Care quality in Rocinha – Rio de Janeiro , Brazil , from the perspective of children caregivers and adult users

1 Departamento de Medicina de Família e Comunidade, Faculdade de Medicina, Universidade Federal do Rio de Janeiro. R. Laura Araújo 36/2o andar, Cidade Nova. 20211-170 Rio de Janeiro RJ Brasil. felipepinto.rio2016@ gmail.com 2 Faculdade de Medicina, Universidade Federal do Rio Grande do Sul. Porto Alegre RS Brasil. 3 Secretaria Municipal de Saúde do Rio de Janeiro. Rio de Janeiro RJ Brasil. A qualidade da Atenção Primária à Saúde na Rocinha – Rio de Janeiro, Brasil, na perspectiva dos cuidadores de crianças e dos usuários adultos


Introduction
According to Starfield 1 , Primary Health Care (PHC) can be defined as the first level of access of a health system ("first contact access"), characterized mainly by its essential attributes, which are longitudinality, comprehensive healthcare and coordination of care within the very health system.PHC services can also rely on complementary characteristics such as family and community orientation and cultural competence, which are its derivative attributes.In addition, countries with a greater focus on PHC (such as the United Kingdom, France, Spain, Portugal and Canada) have better health indicators with lower health investments compared to less oriented countries (such as the U.S.) 2 .
In Brazil, the challenge of increased access 2 of large urban centers has been overcome since 2010, with successful examples of expansion to more than 50% of the resident population of some capitals such as Belo Horizonte, Florianópolis, Curitiba and, recently, Rio de Janeiro 3 .This challenge encompasses the implementation in the middle class.Macinko & Harris 4 state that "the future of the Family Health Strategy (ESF), its sustainable expansion into urban centers and middle classes and its effective integration with secondary and tertiary care will require continued engagement with health service providers, ongoing funding and technical and intellectual investments -all ultimately relying on political support."On the other hand, studies point to the heterogeneity of the quality of care provided by the ESF, which offers diversified portfolios of health services and actions to respond to the attribute of the sometimes insufficient comprehensiveness [5][6][7][8] .Some of these findings highlight better performance in mother and child health outcomes [9][10][11][12][13] , others point to reduced hospitalizations due to PHC-sensitive causes [14][15][16][17] , while others show a clinically insufficient performance.
As of 2009, the municipality of Rio de Janeiro implemented a Primary Health Care Reform (RCAPS) 4 and progressively expanded access to its resident population, from 3.5% to about 60% coverage in late 2016.In absolute numbers, about four million people from Rio are monitored.It is the second largest city in Brazil in number of people covered by Family Health Teams.To assist in the escalation of teams and in the coordination of care, electronic records have been implemented in the facilities since 2011 and are now compatible with the national medical records, the e-SUS, which allows the calculation of sev-eral clinical and management support indicators from the records of individual users.In addition, to support integration between PHC, surveillance and health promotion, other innovations in health information and communication technologies were developed by the municipality, among them the use of social media and blogs of the Family Health Teams, which provide greater transparency to the actions and services developed in the daily work of professionals 18 .
Access was improved with the construction of new health units and the refurbishment of old facilities, and the establishment, in 2012, of the Family and Community Medicine Residency Program of the very Municipal Health Secretariat 19 .This program was initially implanted in the district of Rocinha and has been helping the training of specialists doctors and providing greater resolution of health actions.In addition to being a pioneer in the implantation of medical residency, the Rocinha district was also one of the first places to achieve 100% coverage of Family Health Teams in the year 2010, and was chosen by authors for a comparative analysis with other areas of the South region of the city of Rio de Janeiro.As a result, the objective of this article is to evaluate the extent of PHC attributes, from the experience of users, both adults and children caregivers, comparing the territory served by the Rocinha health facilities with other areas of health district 2.1.

Methodology
This is a cross-sectional study with independent random samples of service users for each of the ten planning areas (AP) of the city of Rio de Janeiro.This paper delimited its analysis, considering only the sanitary district called "AP 2.1", which corresponds to the southern region of the city, consisting of 18 districts and with a population of 638,050 inhabitants in 2010 20 .One of these districts is the Rocinha (69,356 inhabitants), a set of subnormal clusters areas and census tracts 21 also known as "Favela da Rocinha".It is recognized as one of the biggest favelas in the world and its occupation dates back to the 1930s.After expressive expansion, including strong migrant movement from the Brazilian Northeast, it receives the first Health Facility in the 1980s, namely, CMS Dr. Albert Sabin.
In 2015, the Rocinha district had 25 family health teams (Figure 1), with a total of 63,454 inhabitants (November/2015) and an average of 2,538 residents per team (2,483 is the median).On the other hand, there were 28 teams in the other districts of AP 2.1, totaling 90,913 dwellers, with an average of 3,247 registered people per team (3,290 is the median).
Comparing the district of Rocinha and other districts, a minimum difference of 0.5 was accepted in the mean general score between the areas, and a significance level of 5% and a statistical power of 80% were used for children, and 90% for adult users.The complex sample structure was also incorporated into the sample calculation using the fit factor with an intraclass correlation coefficient (ICC) of 0.01.In AP 2.1, the total sample in 2014 was n = 802, of which 369 children and 433 adults.Children under 12 years of age were included and adults 18 years of age and over were eligible to participate in the survey.In addition, the health facility should have existed for at least six months, and each user, at the time of the interview, should have performed at least one medical consultation prior to the date of application of the tool.Those with physical and mental conditions that prevented them from answering the questionnaire were excluded.
Following authorization of the municipal manager and AP coordination, previously trained interviewers contacted the facility's coordination and scheduled the visit.Individuals were invited to participate consecutively in the study at the health unit.All those who accepted signed an Informed Consent Form.Two questionnaires were applied: a) Primary Care Assessment Tool -PCAT-Brazil 22,23 , a questionnaire that measures the level of health services' orientation to PHC (through seven previously defined attributes); and b) a structured questionnaire with sociodemographic variables and referred morbidity.Interviewers were duly trained with the use of an "Interviewer's Handbook".PCAT-Brazil allows the calculation of scores for each PHC attribute and a general score on a scale of 0 to 10. Scores above 6.6 indicate high quality health care in the respective item / attribute.
In relation to the statistical analysis, the mean scores of each attribute were calculated, in addition to the general and essential mean scores for Rocinha and other districts, following the criteria for calculation according to the tool's manual.To compare the strata "district of Rocinha" vs. "other districts of AP 2.1", the t-test was used for two independent samples, both for children users and adult users.In the analyzes that included the whole sample, whether child user or adult user, the structure of the sampling plan was considered, which allows to incorporate adjustments in variability estimates, considering 5% for the levels of statistical significance.The calculated estimates were shown by mean score and the respective 95% confidence interval.
The following software were used throughout the study: (i) the Teleform 24 program, version 10.5, for the design of the questionnaires, the reading of the questionnaire images and data validation; Data Analysis and Statistical Software (STATA), version 12 25 ; and the Statistical Analysis System (SAS), version 9.4 26 , for collected database analysis, review, exploratory data analysis and statistical inference.
The study was approved by the Ethics Committee of the Municipal Health Secretariat of Rio de Janeiro (SMS-RJ) and followed the principles of CNS Resolution Nº 466/2012.Interviews were carried out by handing out the letter of presentation of the study to users or caregivers, as well as reading and signing the Informed Consent Form (TCLE).

Primary Care Assessment Tool
The mean time of each interview in the case of the child questionnaire was 28 minutes and 32 minutes in the case of adults.The main responsible for the child, who answered the tool was the father or mother (about 80% of the cases, with an average age of 30 years) and grandparent (in 6% of situations) (Table 1).Regarding gender and skin color, in Rocinha, most children were male and non-white, whereas in the other AP 2.1 districts, white boys prevailed.Among adults, women predominated (about 80%) in both groups.In the Rocinha district, half of the people were married or had a partner, with an average of three children and schooling of around five years of study.Among the other areas, 38.31% had a partner and about nine years of study.
Nurseries or schools were attended by only 49.69% of the children and a little over 50% had SUS card in the Rocinha community.As for the Bolsa Família (Family Grant) Federal Government Card and its equivalent of the municipality of Rio de Janeiro, the Família Carioca ("Rio de Janeiro Native Family") card, 28.75% and 10.00%, respectively, benefited of these social programs.These data are corroborated when the employment issue was evaluated, in which information evidenced that only slightly more than 50% of those responsible for the children were employed or received Social Security benefits.
When asked about the choice of service, 30-36% stated that it had been defined by the Municipal Health Secretariat, which is in accordance with the form of registration proposed by the municipality, through territorialization, whether for a Municipal Health Center or a Family Health Clinic.From the data shown in Table 1, it is believed that, over the years, a link has been created between the facility and the people consulted, since most of them have reported using the establishment for over a year.
In addition, 20% of the children's caregivers stated that they had health problems and 50-60% of adults in the areas surveyed monitor their health status at the facilities.Half of children's medical appointments are pre-scheduled, and for adults, level is 65.73%.The general evaluation of the last consultation is positive, with more than 80% declaring they were satisfied or very satisfied.Finally, when enquired on whether they had private health plan, fewer than 10% confirmed.
Table 2 shows the mean scores obtained from the attributes with a 95% confidence interval in the experience of adult and children users in AP 2.1 Primary Health Care services, comparing the district of Rocinha with the other areas of this health district.The essential and general scores were similar for children users and higher for adult users, when comparing Rocinha vs. the other districts at hand.Among children, the only attribute with statistical significance (p-value < 0.10) was the "community orientation", which is best evaluated among users of the Rocinha district.This same realm had similar results among adults.However, two other attributes -for adult users -access and longitudinality -obtained higher performance in this same district (p-values < 0.05).In this age group, the mean score obtained was 7.32 [CI: 6.88; 7.75] among the underlying items of "longitudinality".This evidences a good quality of primary care in the follow-up of adults, especially among the most prevalent chronic diseases, namely, hypertension and diabetes.
On the other hand, attributes that contributed negatively (with scores below six) and must be improved were those related to access and coordination of care (children) and "access", "comprehensiveness -services available", "comprehensiveness -services provided" (adults).A careful review of the portfolio of services provided 27 in PHC by AP 2.1 (non-tabulated data) shows that there has been a delay in the implementation of various actions such as alcohol detoxification and intrauterine device insertion (IUD).
In relation to the attribute of longitudinality mentioned above, aggregate primary source indicators from electronic medical records allow us to infer improved quality health care since 2013.The proportion of consultations performed by the family doctor who monitors each family is an indicator of longitudinality of care, and the target was established as an interval [70%, 90%], since it is believed that periods of absence of the professional on vacation are necessary, his/her replacement by another colleague to participate of external events and congresses, as well as other possible intercurrences.The positive trend of this indicator, when comparing two groups, namely, the district of Rocinha vs. the other AP 2.1 dis- tricts, shows that, from 2015, the former's performance exceeds the latter, and both remain within the lower limit of the target from the first quarter of 2015 (Graphic 1).
In AP 2.1, of the total number of people consulted by doctors, 83.4% answered the main reason for going to the health facility (whether scheduled or spontaneous).Among responses, we highlight the reasons associated with routine follow-up and consultation, conducting examinations at the facility and, as a main complaint, hypertension, demonstrating consistency with the results found for access and longitudinality attributes (Figure 2).Source: Evaluation study on the level of primary health care orientation from the experience of users of the Family Clinics in the city of Rio de Janeiro.Caption: (*) Non-white: "black", "yellow", "brown" and "indigenous" were gathered in one group.SSE -Sample Standard Error.

Discussion
Among children, the overall mean score obtained (6.77), higher than 6.60 recommended by PCA-Tool-Brazil as a cutoff point for defining good health care (even within the confidence interval), suggests that health district 2.1 has been able to develop quality PHC for this age group.While mean coverage of this area is 24.2% (91.5% in Rocinha and 16.0% in other districts), data sug-  gest that local level management has developed actions and strategies to strengthen the 53 teams.Results were higher than those observed in the western region of São Paulo, Vitória da Conquista/BA and Montes Claros/MG [29][30][31] .With regard to adults, the general mean score obtained (6.20) is in a good health care path, higher than to several national locations that applied the same methodology, such as the Alfenas/MG 32 micro-region and the municipality of Porto Alegre 33 .
The fact that Rocinha achieved better performance in several attributes, besides the greater PHC population coverage can be explained by the consolidation of the  34 , one factor that has hampered users' access in the Rocinha community is location in border areas of each of the facilities, exactly when families move to other "neighborhoods of the Rocinha".Aragão 35 argues that this community is an important place of internal mobility, which is the synthesis of the metropolis' spatial mobility.Therefore, a solution for cases where a neighborhood has already achieved close to 100% of its resident population would be the combination of territory / micro-areas with lists of users by doctor, such as those used in European countries 36 .Thus, geographic accessibility would be facilitated, eliminating barriers to primary care, given the difficulty of getting children and elderly people to walk up alleyways and steep stairs of the Rocinha.
The overall score was 6.77 (children) and 6.20 (adults, p-value = 0.010).The best performance among children is related to the greater tradition of physicians of the municipal health network in mother and child health 37,38 , as a set of actions and activities has been geared to this group since the 1970s and 1980s.Furthermore, there are several performance-related payment indicators at the SMS 39 , which may be contributing to the targeting of PHC services.Future studies should be developed to compare these indicators and the distribution of physicians by specialty of practice, considering that less than 20% of professionals have a Family and Community Medicine specialist title.

Final considerations and recommendations
We recommend the strengthening of the Family and Community Medicine Residency Program within a political-pedagogical project that enhances the full development of the SMS service portfolio through contents and PHC-relevant clinical practices.In parallel, the in-service training of preceptors and the participation of experienced faculty in the SUS are also another desirable action to qualify undergraduate and graduate students and ensure academic sustainability and motivation for the search for updated knowledge in PHC services.Another recommendation is the adoption of a list of patients by doctor to facilitate access and longitudinality, especially in urban environments with high geographic mobility.
Another suggested action would be the systematic use of PCAT-Brazil in a reduced version (with fewer items) for the evaluation of the quality of services provided to adult users and children, as one of the indicators of the management agreement.Its implementation would allow the semiannual monitoring of actions and activities underlying each PHC structure and process attribute, in addition to allowing comparison with other national and international regions.
The challenges of developing quality PHC in districts like Rocinha are constant.It suffices to highlight its resident population of 70,000 inhabitants, greater than 92% of Brazilian municipalities, and without taking into account the great internal mobility among families who move to live with relatives in the neighborhood each year, which further increases the floating population that uses public services.Thus, the management of a list of registered and monitored patients is another recommended aspect for a good development of local health activities.

Collaborations
LF Pinto, P Travassos, R Pessanha elaborated the structure and the calculations of scores for the analysis of data.OP D'Avila carried out the survey of the bibliographical references and the critical reading of the paper.L Hauser, E Harzheim, MR Gonçalves performed the critical review of the final version of the paper.

Figure 1 .
Figure 1.Map of the Health Planning Areas of the City of Rio de Janeiro (with emphasis on AP 2.1) and map of the 25 Family Health Teams of the community of Rocinha -2016.Source: Own elaboration from the Statistical Journals and Maps of Primary Health Care (CEMAPS) of the city of Rio de Janeiro 27 .

Table 1 .
Characterization of children and adult users of PHC services in the district of Rocinha and other AP 2.1 areas -Municipality of Rio de Janeiro -2014.

Table 2 .
Mean scores (#) and confidence intervals (CI 95%) of Primary Health Care attributes in the experience of adult users and responsible for children.AP 2.1: Rocinha district vs. other districts -Municipality of Rio de Janeiro -2014.
Family and Community Medicine Medical Residency Program of the SMS-RJ in place in two (Maria do Socorro Silva e Souza Family Clinic and Albert Sabin Municipal Health Center) of the three facilities since 2012 and, as of 2016, also at the Rinaldo Delamare Family Clinic.The first graduation of resident Chart 1. Proportion of patients medical consultations by own family doctor Rocinha x other AP 2.1 districts -Municipality of Rio de Janeiro, 2013-2015.Source: PHC Electronic Medical Record, AP 2.1/SUBPAV/SMS-RJ.Figure 2. Reason for last medical consultation among adult users.