Indicators for teenager ’ s oral health ’ s surveillance

The existence of a few indicators that could guide the evaluation of oral health surveillance in the primary health care attention, mainly in adolescence life cycle, raised the realization of this study. To develop indicators to this end, it was conducted: document analysis to guide the development of a logic model and selection of data to compose indicators. This selection and validation of the logic model were performed by a group of four experts that, from the perspective of the modified Delphi method, analyzed if the model illustrated the activities, results and expected impact of a primary oral health service to enable the adolescents oral health surveillance and assigned points (0-10) to each data proposed. Then, those data judged important by the consensus of experts (média≥7; standard deviation <3) were used to construct indicators. After individual analysis and group discussions, the logical model and 36 of the 48 data, initially proposed, were consensually important, resulting in 26 indicators. The indicators matrix intends to be a situational diagnostic tool to assess, plan and manage health actions to adolescents, but it can be used in other life cycles by its adaptation.


Introduction
The purpose of the Health Information Systems (SUS) is to assess the territory´s health situation to support better decisions for health policy, planning, management, monitoring and evaluation of health programs; quantify/determine the volume of financial resources to be transferred to each service; as well as support epidemiological analysis and assessment [1][2][3] .
However, there are critical points regarding to some SIS in Brazil that need to be overcome in order for these SIS achieve their purpose.One of these nodes is the limitation of offer information needed by managers to guide priority actions due to biologists and fragmented vision about the health/disease process, still hegemonic within the SIS.This reflected in the predominance of [1][2][3][4][5] disease indicators.
In this way, overcoming the limitations of the information must resound the ressignification of health where are present other dimensions including indicators that signals the real situation of the studied territory regarding the health-disease process.In this sense, the indicators related to issues that permeate National Health Humanization Policy (PNH) enable not only size changes in health-disease frameworks, but also include issues involved in the health work process 6 .
The PNH proposes developing relational technologies and sharing of management practices and implement processes for monitoring and evaluation, emphasizing knowledge generated in the Unified Health System (SUS) and successful collective experiences.As a consequence, the capacity of intervention of the Health System on the sanitary reality will be amplified and improved, providing more subsidies for the concretization of the right to health 7 .Regarding to oral health, regardless of the level of health care attention, analysis and use of information are still precarious.Historically, oral health information contained in health information systems were mainly consolidated by information of outpatient production and few indicators proposed by the Pact for Basic Care 8 .In this sense, the Performance Index of the Unified Health System (IDSUS), a synthetic indicator benchmarking built to enable a contextualized evaluation of SUS´s performance presents only three oral health indicators and all of them refer to primary health care: estimated population coverage by the basic oral health teams; the collective action average of supervised tooth brushing and tooth extractions ratio in relation to individual preventive and curative clinical procedures 9 .This situation hinders the implementation of a health surveillance model attention as advocated by the SUS and an evaluation, not just in a normative way, of the effectiveness of oral health at the local level.In spite of advances , with the insertion of Oral Health Team in the Family Health Strategy and the establishment of a Brazilian Oral Health Policy (PNSB) 10 , the results are not yet visible in the structuring of health services and do not promote, as a matter of fact, significant changes in oral health care model 11,12 .
The existence of a few indicators that could guide the monitoring and evaluation of oral health actions at the local level and, potentially, to promote the implementation of the oral health surveillance model attention has raised the development of this study.
It was decided to prioritize adolescents from 15 to 19 years of age, since it is common for this group not to seek the health unit and tend to underestimate their health risk behaviors, since they generally feel invulnerable or minimally susceptible to them.However, when well-targeted, they are able to perpetuate healthy behaviors throughout life 13 .
In addition, despite a reduction in caries prevalence among teenagers, the results of the latest national survey of oral health -SB Brazil 2010 -indicated that 18% of 12-year-old adolescents have never been to the dentist, untreated caries index of 44.5% among 15 to 19 years-old adolescents and 39% of them reported some difficulty to carry out activities related to mouth 14 .
Based on the above the aim of this study was to construct a matrix of indicators to support the construction of an Adolescent Oral Health Information System (SISBA).

Method
This is a development study that aims the systematization of existing knowledge and the development of an intervention or of a measuring instrument 15 .In this case, the measuring instrument is a matrix of indicators that can assess oral health services at the local level.Therefore, the evaluation of health services is the purpose of this study.
The systematization of knowledge took place initially by the formulation of a logical model for the services related to the oral health of adolescents (15-19 years) of primary health care from the perspective of health surveillance.The logical model defines how the service should be-have in order to achieve the expected results in a given organizational and policy context 16 .Thus, the model of this research aims to illustrate the resources, activities and results required by Primary Care Oral Health Teams Whose mission is to promote health, prevent disease and injuries and reduce morbidity.
To guide the construction of this model, it was carried out a literature and documental review of the National Health Humanization Policy 7 , the Basic Care Notebook nº17 8 , Brazilian Oral Health Policy 10 , rulings by the Brazilian Ministry of Health 267/2001 17 and articles related to the subject investigated.
From the logical model it was identified criteria and data that could be used to construct indicators to integrate SISBA.These criteria and data were distributed in components and sub-components (proximal and distal) of an evaluation matrix.This matrix built by the researchers was submitted to a content validation process by four experts.The Group of experts was formed by teachers of undergraduate degree in dentistry and graduate studies in collective health of a federal public University with experience in public health services and publications in the area of evaluation of oral health services.The experiences are related to coordination of epidemiological national and state surveys, insertion in the coordination of oral health of the State Secretariat of health and development of research and extension actions on primary and secondary oral health in municipal scope.Thus, the principle for the selection of experts was the concrete empirical knowledge about oral health services, the academic experience and experience in services in management or assistance.
The group of experts was personally invited to participate and received by e-mail information about the study protocol for the construction of the SISBA evaluation matrix.Such matrix should be analyzed based on the following guiding question: to assess the oral health care of adolescents in primary health care, which criteria/data should be used to compose a health information system?
The evaluation matrix was composed from components and sub-components (keywords that aggregate a set of activities of the logical model) and criteria (the attribute structure, process or result used to measure the components) 18 , in addition to the data required for definition of the criteria.To every one of the criteria was requested to experts the proposition of a grade ranging from zero (maximum disagreement as to the inclusion of the criterion/data in the matrix) to 10 (maximum agreement about its inclusion).
For validation of the evaluation matrix, it was opted for the "Delphi modified" method, which consists in the inclusion of at least one round of face-to-face discussion between experts 1 , through association with the technique of consensus conference 16 .The study took a first round with the application of the traditional Delphi technique, in which the experts evaluated individually the proposed matrix of SISBA, assigning each item of the matrix a value from zero (0) to 10 (ten).In addition, it was possible to include new criteria and their respective values 19 .
After the evaluation, the experts sent the matrix and their comments by email to researchers so that they proceed with the calculation of the average (importance attributed to each criterion/ data) and standard deviation (SD) (the degree of consensus of the experts as to the relevance of the criteria/data).
Secondly, the nominal group was performed, as advocated in the modified Delphi method.Therefore, there was a discussion about the relevance of the logical model and, then, of the criteria and data of the matrix, exposing visually, at the same time, to the experts the average and standard deviation calculated.Would also be discussed the "new" criteria; however there was no proposition by experts.
After the discussion, this matrix was forwarded by e-mail to an individual reassessment by confirmation/assignment of notes.Then the experts returned this reassessment for the calculation of the averages and the DP score assigned.The criteria/data with average ≥ 7 (criterion/important data) and DP < 3 (consensus of experts) were kept in the matrix, and the other removed 16 .
The four experts invited to the study participated in all phases of research and had a deadline of two weeks for evaluation of pre and post nominal group matrix.
After this phase of validation of the criteria and data, the group of researchers met to discuss and build indicators for evaluating and monitoring issues related to oral health care model in the perspective of National Oral Health Policy and the National Health Humanization Policy.The indicators defined primed for simplicity of understanding, validity, and availability 18 .In this way, the Group took such characteristics for selection/creation of indicators.

Results
The components of the logic model were built based on the pillars of basic care, Care coordination and longitudinality, Accessibility and Completeness of Attention 8,20 .Regarding the subcomponents, strategic management stands out, which is usually not discussed in the perspective of integrality of attention.However, take care and manage the health work process make up a single reality, since there is no way to change the modes to meet population health service without also change the logistics of work processes, the dynamics of team interaction, mechanisms for planning, decision-making, participation and assessment 21 .
The representation of the context through the National Health Humanization Policy (PNH) as the components and sub-components of the model were assigned as adequate by the experts.The PNH, as a transversal policy to all SUS policies and programs, would have its principles and precepts (user embracement, participative management, ambience, expanded and shared clinic, worker valorization and protection of the Rights of Users) as guiding principles of all policies Health, including the Smiling Brazil (Brasil Sorridente) -PNSB 7.8 .
Each of the components of the logical model showed activities consistent with their implementation in the daily routine of the Basic Health Units, with a view to obtaining results that will impact on the reduction of oral morbidity, quality of life improvement and empowerment (Figure 1).The logical model presented to the experts had its validity validated, since they identified plausibility among its constituent elements.Thus, it was possible to construct a coherent logical model of health surveillance, which includes health as a social product, derived from the relationships present in a given political, economic, cultural and ideological scenario 22 .
Regarding the results of the matrix judgment, these are presented according to the two evaluation moments performed by the experts.In the first moment of evaluation have been proposed 48 items that would respond to the proximal logical model subcomponents.Of this total, 36 considered important in the evaluation of experts by consensus (average ≥ 7 and d. p < 3) as shown in Table 1.
In this first evaluation, there was data whose experts judged measure questions already measured by another element of the array, so, although valid, received low-scoring (adolescents residing in the area assigned, references to the care of patients with special needs).Others considered valid, but difficult to measure (first dental appointment, queries to complete treatment, self-declaration of using drugs by the adolescents).However, there were data that, according to the evaluators, did not measure what was proposed, classified as non-valid (professionals with more than one year in the unit, SIS feeding, suspension of the transfer of funds).Data entered into the subcomponent sanitation and environment that could be picked up on other information systems and exceeded the governability of Basic Health Unit (UBS) received low scores (garbage collection, sewage network coverage, presence of fluoridated water and concentration of fluoride in the water).
In turn, in the second round of evaluation, 23 data were considered to be consensually important.Specifically, there was the reaffirmation of the exclusion of the first dental appointment data and queries for completion of treatment, as well as the full exclusion of the data contained in the criteria garbage collection, sewage network, water supply; Monthly supply of SIS; Suspension of funding and Establishment of interpersonal relationship for the reasons already exposed.
Still, there was consensus about the exclusion of other criteria in full: 1-articulation between levels of care; 2-Referrence and counter reference to the CEO; 3-specification of demands sent to the CEO; 4-Capturing user needs; 5-Professional training; 6-Precariousness of labour relations.
Regarding the first three criteria, it was evaluated, respectively, that the number of references to the CEO would already be included in the criterion articulation between the services; the relevant for measuring the institution of reference and counter-reference would be the number of references itself and not the time interval in which these occurred; the data relating to dental specialties of CEO, although important, were removed by also being referred to in criterion articulation between the services and the data referring to the treatments on the Psychosocial Care Centers (CAPS) were removed, because even though it specify a possible user need, not necessarily would identify activities or results related to oral health teams.
With regard to the Capturing users needs, it was discussed that there would be a low discriminatory power in situations of low frequency event (self-declaration of drugs) and that the number of diagnosis of eating disorders conducted by nutritionist and/or doctor arising from the referral by the Dentist (CD) would be included in the criterion articulations between the services.
The last two criteria were excluded because they were judged as not valid.It was argued that the effective employment bonds do not, necessarily, be related to greater commitment to the work and, therefore, would not be a factor of professional motivation.With regard to professional training, it would not be congruent with an information system in the perspective of surveillance.This is possibly related to the prevalent view that information systems are characteristic

Discussion
The SISBA aims to constitute a situational diagnosis tool for the planning and programming of health actions aimed at teenagers, but with a good adaptation can subsidize the construction of systems to other life cycles.However, your main purpose is to provide an assessment on the effectiveness of the model health monitoring in the context of local health units and, therefore, the experience of the principles and values of the PNH in health care and in the management of care.The health surveillance constitutes a model of analysis that uses the territory as a space of reference, highlighting the importance to consid-er the heterogeneity of the population as to their needs and access to health services 23 .The definition of adolescence as a priority of the SISBA cycle related to the global context of demographic and epidemiological transition characterized by the decrease of fertility rates, increased life expectancy and a higher incidence of chronic diseases/contagious face and appearance of the harms to health as being responsible for significant morbidities 24 population.In this sense, one can infer some increased costs of public health assistance, if there is a longevity associated with quality of life 25 .We must promote and develop health promotion policies targeted both the ageing population as it possibly age.In this sense, the cycle of adolescence would be adapt to the practices of promotion of healthy habits for active ageing, cognitive and motor development characteristic of this phase promotes susceptibility to social behavior changes and your lifelong conservation 13,26 .So, schedule actions for the resolution of the accumulated needs in adolescents configured in a matter of public health.Oral health, notes the need to facilitate strategies to combat poor adolescents access to dental services, especially at the age of 15 to 19 years, characterized as a second phase of adolescence.According to data from the SB Brazil 2010, 65.1% of teenagers between 15 and 19 years autoreferiram need for dental treatment, 24.7% reported toothache in the 6 months prior to the survey and 13.6% of those teens never consulted with the dentist.It also observed that the 12 years, 43.5% of the people are free of dental caries in permanent dentition, while the 15 to 19 years, this percentage is 23.9% 14 .
The second phase of adolescence builds up larger assistance needs in relation to the first phase.This, possibly, occurs by difficulty of General access to dental care services that culminates in an increasing morbidity over the life of the individual but also to the hegemonic assistance model.In Brazil, for many decades, predominated in the public service the dental care model curativista and mutilator.In this panorama, a care model called Incremental System geared to schoolchildren in the age group of six to 14 years, which lasted for more than 40 years.In this way, one can say that the other population groups were underserved public dental policy, being restricted to emergency calls and not conservatives 27 .
In order to exercise, in fact, actions based on the Health Surveillance model, democratic and participatory practices are required, in the form of teamwork, directed to populations for which responsibility for oral health care assumed, considering the dynamics in the Territory in which these populations live.In addition, it is necessary to institute an information-valued culture in organizations to verify the implementation and implementation of this model in health work processes.One of the ways to consider the dynamicity of the territory is to use epidemiology as a situational diagnostic tool for planning health actions in 28 health.Under such aspect, the epidemiology would be a technology, according to the design of Mehry 29 , which could increase the scope of the organizational mission of health care, health care.For this, the information produced should focus on the Health Sciences 'reference' , transposing the genesis of information immersed in the 'reference' Disease Sciences in order to contemplate the complexity of specific processes of health/ disease/care 31 .
Factors related to the work process from the perspective of health surveillance referred to the SISBA.These factors relate to implementation of a health care network, modus operandi of assistance (actions developed by the capture of the demand analysis of the services performed and epidemiological surveys) and management services.Chart 1. continuation the health field 31 .With regard to the MOS, the SISBA includes indicators to check the modification of a model of attention curativista to the preventivista, the breadth of access to this attention, the actions taken by the service (both in your physical space as social equipment by the community) for the raising demands and for the assistance itself.
Regarding the establishment of a network of the search SISBA to evaluate specific points of oral health care Network, notably, the articulation between the APS and Secondary attention represented by the CEO.This is because these are more technological density levels demanded by Brazilians.However, even not including indicators related to other points of attention (tertiary and Quaternary), the SISBA may raise evaluations elsewhere in operating the network structure (support; logistics systems; governance system) 24 .This is because finding a poor articulation between the APS and the services, you must get the whys and certainly, other factors should investigated.In fact, in an assessment it is necessary to select the indicators to be monitored so that these signals the possible problems the effectiveness and efficiency of the service in the midst of the impracticality of periodically reviewing a large number of indicators.
SISBA indicators relate the reference and contrarreferência (01), organization of demand (06), users' Satisfaction (01), Self-perception in oral health (01), epidemiology (03), oral health care (11), multiprofessional Teams (01) and (02).These issues are widely cited in the literature as relevant to an assessment of services in support of quality, but are not encompassed by national SIS used to assess oral health services 32,33 .Nevertheless, 26 indicators selected to compose the SISBA, 11 have your construction based on primary data need to be collected by the service.
However, many of the indicators SISBA are built based on data recorded routinely for oral health teams in the information systems of the SUS.However, these data are not used as a subsidy to build guiding work process indicators and, consequently, as management tools and management.In this sense, Bueno et al. 32 to propose indicators to support an assessment of oral health services of Cambé (Paraná), of 13 indicators validated, eight had as information sources national SIS.It should stressed that this study aimed to develop and validate indicators for evaluating oral health service specific municipal and not compose indicators for basic care in a generic way.Such aspect is relevant, because it denotes the difference in the composition of the groups selected to validate the indicators.
In the case of SISBA, the composition encompassed acting professionals in attendance, since there would be no time for definition of param-eters and goals where the involvement of directly involved in service is essential.Already Bueno et al. 32 included in workshops for logical model validation and array of indicators, professionals in the city of Salvador in performance in assistance and coordination.In the same sense, Colussi and Calvo 30 to develop a model to assess the quality of the basic buccal health attention and test your applicability in Santa Catarina municipalities of different sizes, also involved insertion service professionals (08 dentists with expertise in State management, in teaching or in research in Santa Catarina for over four years, with experience in health assessment).
As for the SISBA, it believed in your validity in assessing the oral health care of adolescents in primary health care, once the indicators presented significant the importance values (average) and concurrence (standard deviation) of the evaluators.Of 48 posts data to trial of 12 experts, submitted after the second evaluation round, average 10 (very important) and standard deviation zero (total consensus).The smallest average and standard deviation were relating to data: teenagers who left treatment (average: 7.5; standard deviation: 2.38) and (meetings with users (average: 7.5; standard deviation: 2.89).Even the scores were lower due to the difficulty of assessing the abandonment of treatment and low frequency of meetings with user participation.Thus, the data considered important, more difficult to measure.Therefore, the array of SISBA offers the potential to provide an assessment in data reliability from the relevance of the composition of the Group of experts and of the degree of agreement of the same obtained in the study.
With regard to the argument of the infrequent use of the information, Martino 34 shows that the municipalities in your most do not use indicators, other than those agreed upon by the Ministry of health and State departments, expressing a practice of using information for planning, control and evaluation of the actions of oral health has not assimilated.Thus, infers that the use of indicators to occur by governmental requirements and not on the initiative of the services.
Amid the need to elucidate how the oral problems interfere with the growth and development of adolescents, to establish strategies to combat these problems and to establish parameters of oral health, the development of technologies such as the SISBA is essential, since it seeks to enable a decentralization of local information for the strategic planning and programming of actions considering the characteristics and peculiarities of the territory and your population assigned.
However, the SISBA seeks to break away from the prospect of SIS epidemiological essentially requiring a change of perception about the several purposes that an SIS may have for improving the work process.Including, the SISBA requires modifications to the infrastructure of the UBS, seen that demand the use of information technology (hardware, software, internet).This implies that the professionals have knowledge, skills and affinity with the field of information technology so that they can feed the system, consolidate the data and analyze it.However, these issues already discuss in Brazil.In this regard, initiatives such as the SISAB 35 provide the supply of microcomputers to UBS, while permanent education policy 36 assumes work process improvements including the use of information and communication technologies.
The challenge of SISBA is the ability to use your in any locale, giving Brazilian external validity.This is possible, to the extent that your array of indicators built based on guiding Machado of PNSB.Therefore, depending on the reality of the territory that will applied, you can add or reduce indicators.The criteria for this should be the agreement of these indicators with the actors involved in the process of work considering, among other factors, your validity and feasibility 32 .
Even the argument above relates to a limitation of the study is the non-application of the array of SISBA to verify your applicability on the spot.However, this was not the objective of this work which consisted essentially in build a logical model illustrating how should be the operation of a service of oral health basic attention focused on adolescent oral health surveillance and, under this approach, propose indicators to check how much the service would be approaching this model of attention.However, amid the challenge of the legitimacy of the SISBA, it is necessary an evaluative research about your services and deployment prior to this analysis, develop workshops where the SISBA can deployed to compromise the standards and goals of each indicator with the professionals of these services.Therefore, this study aims to conduct other studies showing that research strategies and valuation, in fact, have a procedural character.
The institutionalization of the SUS card use can be a facilitator in the implementation of the SISBA, including contributing to avoid duplicity of information 37 .At the local level, the SISBA will contribute to the monitoring of oral health services and for the use of information by professionals, as a tool for assessing and planning the health teams.Your bookmarks can used to evaluate the impact of actions implemented by the health teams for building and analyzing a local historic series.Distal level, compete for the implementation of the right to health, in particular, the adolescents and the equity of health policies.This is because Brazil has the challenge of instituting policies, programs and actions to the groups once excluded, in order to minimize social inequalities in health.

Collaborations
FCA Machado and GCA Souza participated in the conception, design, analysis, interpretation of data, article and review, LRA Noro participated in the analysis and interpretation of data, article writing and critical review.

Figure 1 .
Figure 1.Logical model of oral health care of the adolescent in the family health strategy.
participating in the supervised brushing dental collective action divided by the total number of adolescents in the area x 100 (every six months)
mental, worker's health together) nor of surveillance related to the health-Disease itself (health surveillance).The latter related to health service available that would act as a social determinant.After consolidated and validated criteria, were defined 26 indicators presented in Chart 1.

Table 1 .
Criteria and data organized according to the components and subcomponents deemed consensually important for subsidizing the construction of indicators to compose SISBA.

Table 1 .
continuation Chart 1. Indicators, objectives, sources and methods of calculation defined by consensus to compose the SISBA, organized according to the proximal subcomponents and criteria of the logical model.
1 Non-invasive procedures: cariostatic application for tooth, Topical Application of Fluoride individual, plaque disclosure, provisional restoration.1CEO:Center of Dental Specialties; 2 CAPS: Center for Psychosocial Care; 3 ACS: Community Health Agent; 4 OIDP: Oral Impact on Daily Performance -Checking for difficulty in performing activities to: eat, talk, smile, study, sleep, maintain mood, socially relate, perform mouth hygiene due to a problem in the mouth, tooth or prosthesis, and attributed motive to this difficulty.This information should be collected before and at the end of treatment; 5 ESF: Family Health Team; 6 SIAB: Basic Attention Information System.
Outpatient Information System; 2 SIAB: Basic Attention Information System; 3 OHT: Oral Health Team; 4 IBGE: Brazilian Institute of Geography and Statistics; 5 PMAQ: National Program for Improving Access and Quality of Primary Care; 6 ACS: Community Health Agent; 7 OIDP: Oral Impact on Daily Performance; 8 ESF: Family Health Team.