Assessment of compliance with malaria treatment monitoring and cure verification activities *

* Extracted from the thesis: “Avaliação das atividades de monitoramento do tratamento e verificação de cura do Programa de Controle da Malária na Região Amazônica”, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, 2018. 1 Universidade Federal do Acre, Centro de Ciências da Saúde, Rio Branco, AC, Brazil. 2 Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Ribeirão Preto, SP, Brazil. 3 Universidade de São Paulo, Escola de Enfermagem, Departamento de Enfermagem em Saúde Coletiva, São Paulo, SP, Brazil. 4 Universidade Federal de São Paulo, Escola Paulista de Enfermagem, Departamento de Saúde Coletiva, São Paulo, SP, Brazil. ABSTRACT Objective: To assess compliance with treatment monitoring and cure verification activities by Malaria Control Program professionals. Method: This is an evaluation research carried out through systematic observation, with the aid of a Likert-type scale form, adopting a numerical score to assess the fulfillment of activities. Data collection was carried out in the Amazonian municipality of Cruzeiro do Sul in Acre State. Data were analyzed using descriptive statistics. Results: Fifteen endemic disease control agents, five nurses and five microscopists were observed in the performance of their functions in the program. Treatment monitoring and cure verification activities obtained the respective total compliance percentages of 72.0% and 12.1%. Microscopists, assessed in 9 activities, obtained a higher percentage of compliance with activities, while nurses and endemic disease control agents had a partial compliance rate or did not perform certain activities. Conclusion: Malaria Control Program performs below the recommended level, not meeting the established gold standard, which may mean maintaining or increasing malaria cases.


ancoACBrazil
www.scielo.br/reeusp Rev Esc Enferm USP • 2020;54:e03655
237EBE2A6D6816AF708BDABBCD03EDA910.1590/S1980-220X2019005303655Received: 02/25/2019 Approved: 03/05/2020DESCRIPTORS MalariaTreatment OutcomePublic Health NursingPublic Health Surveillance
Objective: To assess compliance with treatment monitoring and cure verification ac ivities by Malaria Control Program professionals.Method: This is an evaluation research carried out through systematic observation, with the aid of a Likert-type scale form, adopting a numerical score to assess the fulfillment of activities.Data collection was carried out in the Amazonian municipality of Cruzeiro do Sul in Acre State.Data were analyzed using descriptive statistics.Results: Fifteen endemic disease control agents, five nurses and five microscopists were observed in the performance of their functions in the program.
reatment monitoring and cure verification activities obtained the respective total compliance percentages of 72.0% and 12.1%.Microscopists, assessed in 9 activities, obtained a higher percentage of compliance with activities, while nurses and endemic disease control agents had a partial compliance rate or did not perform certain activities.Conclusion: Malaria Control Pr gram performs below the recommended level, not meeting the established gold standard, which may mean maintaining or increasing malaria cases.

INTRODUCTION

Malaria is endemic in the Amazon region and its historical trajectory is linked to the process of economic development and migration.The first rubber cycle, which occurred between 1879 and 1912, was marked by t e intense migratory movement, especially of the northeastern population, which favored the disease to spread (1) .

Between the 20s and 90s of the 20 th century, several measures were adopted by the government to curb the disease to spread, especially in the Amazon region.The creation of the Brazilian National Public Health Foundation (FUNASA -Fundação Nac

úde Pública),
n 1993, culminated in the outline of several actions.After its extinction, in 2003, the Health Surveillance Department, directly linked to the Ministry of Health, defined new national guidelines for combating malaria through the Malaria Control Program (MCP) (2) .

MCP's main goal is to reduce malaria incidence, its complications and mortality, interrupting its transmission chain.For this objective to be achieved, it is necessary to m

ilize fin
ncial, physical, and human resources.The involvement of health professionals in disease control is important, as the commitment of the different categories of workers is essential (3) .

A worldwide public health problem is addressed, the magnitude of which inserts it into the Sustainable Development Goals (SDGs), with a government agenda to end epidemics of neglected tropical diseases by 2030 (4) and to present contributions to surveillance practices in health in the context of malaria providing subsidies for management action in disease control.

Assessment is a fundamental tool that qualifies decisionmaking by public policy makers and executors, managers, h

lth professionals an
patients, enabling the promotion of adjustments and adequacies to health programs.Thus, the present study seeks to evaluate the compliance with treatment monitoring and cure verification activities by MCP professionals.


METHOD


Type of sTudy

This is an evaluation research, with a quantitative approach focusing on the element "process" of health service assessment.This type of study is characterized by the systematic application of procedur s that allow judging intervention programs, analyzing operational processes in specific contexts (5) .The process is a dimension that covers the relationship between health professionals and their direct actions in patient care (6) .


scenario

The study was carried out in the Amazonian municipality of Cruzeiro do Sul, located in Acre sta

.In the Juruá an
Tarauacá Envira regions, where the municipality is located, 91% of the reported cases of malaria in Acre are concentrated, and where Annual Parasite Index (API) is considered by the Ministry of Health to be high and classified as high risk (API -50/1000).The municipal health network has 22 Family Health Units (FHU), according to the system of the National Health Facility Reg stry.populaTion Endemic disease control agents, nurses and microscopists who make up the MCP team were considered eligible for the study.In total, six FHU were selected.


selecTion criTerion

Th FHUs were chosen according to the number of notifications and because they are located in "hotspots", areas where Malaria transmission is considered intense (7) .Participants included were all of the selected professional categories who were assigned to the FHU and who had worked for at least three months with MCP, an adequate period for verifying the worker's adaptation to job functions, according to the Consolidation of Labor Laws (8) .

All professionals linked to MCP in the uni s were included.The activities performed by twenty-five (05 nurses, 05 microscopists, and 15 endemic disease control agents were observed in five FHUs, and in a selected unit, all five professionals of the program team did not accept to participate i

the study, being considered
s sample loss.


daTa collecTion

Data collection was carried out on December 2017 using the systematic observation technique (9) .Observation was initiated, in loco, during care by the team to patients who used the MCP.This strategy was used to allow greater familiarity between the research and service teams, allowing the record of the actions observed to portray the actual daily life of the program team.

A systematic observation form was prepared in the form of a checklist according to the specific assignments of each professional category inclu

d in the
study and which are provided for in MCP.

The checklist was based on a Likert scale with a focus on treatment monitoring activities and their outcome, considering the attributions of each professional category, extracted from a primary care booklet for epidemiological surveillance and based on MCP "gold standard" (10) .This provides for the establishment of antimalarial therapy within 24 hours after diagnosis, guidance on therapeutic scheme and home visits, one at the beginning of treatment, one during and one at the end.

For curing verification, it is recommended to perform six Cure Slide Verification (CSV ) after the end of treatment (11) .

Thus, the variables (V) related to treatment monitoring and cure verification were grouped by professional category (Chart 1).


daTa analysis and TreaTmenT

To analyze the variables observed in the professio als' work process, the mean of each variable on the Likert-type scale was calculated, which varied from 1 to 3 and represented a performance indicator in relation to each study variable, 1 corresponding to not performing the activity, 2 performing partially and 3 performing completely.The scores obtained in the variables, by professional ca

gory, were
rouped allowing the calculation of the mean of each variable.The data were processed with the aid of Excel®, being represented in graphic form.


eThical aspecTs

This study was approved by the Ethics Comm ttee of Hospital São Paulo of Universidade Federal de São Paulo, approved under Opinion 1.940.017/17.The Informed Consent Form was prepared and presented to the participants, with their consent being the condition for data collection according to Resolution 466/12 of the Brazilian National Health


RESULTS

With regard to the activities performed by nurses, it was found that no activity was performed in a partial or total way; however, the variable referring to home care was the one that came closest to the partial exec tion score.

Figure 1 represents the index of professional nurses (n=5).V7: Provide, together with the family health team and/or the team of community health agents, urgent patient referral for serious medical and hospital assistance; V8: Record medications that patients are taking in the bulletin of the malaria epidemiological surveillance information system; V9: Make an appointment for CSV follow-up, together with the family health team and/or community health agent team.


E demic disease control agents

V1: Identify signs and symptoms of malaria and provide the start of treatment; V2: Follow patients up under treatment; V3: Guide patients on the need to complete treatment; V4: Carry out immediate and adequate treatment according to the treatment tables in this booklet and others that were introduced by the Ministry of Health's malaria treatment manual; V5: Collect CSV aft r completion of treatment and forward for reading according to the local strategy; V6: Receive the CSV results, and if it is positive, repeat treatment.The category of endemic disease control agents (n=15) presented an index as shown in the graph in Figure 3.The variables that demonstrated the best performance were V3, V4, and V6, with means close to full compliance.The first two are related to treatment monitoring and V6 for cure v rification, as shown in figure 3.

The variables related to treatment monitoring obtained a percentage of compliance with the activities of 72%, and those related to cure verification obtained a percentage of compliance of 12.1%.It was noted that there is a significant difference between the two, with cure verification being the activity with the lowest rate of compliance.


DISCUSSION

In assessing the rate of compliance with the activities of the three professional categories included in the study, a significant dif erence was found in their performance in relation to each one of them.

The nurses' performance was assessed in five activities related to monitoring the treatment and verifying the cure for malaria, which were not partially or totally fulfilled, despite the relevance of this professional in the "process of epidemiological surveillance -informationdecision -action during care for individuals, families and communities" (12) .It is emphasized that nursing work must be linked to other professional practices, for the production of health serv ces that meet communities' needs as a whole (12) .

During the observation period, it was identified that there is no supervision of the work of endemic disease control agents by nurses, even though there is a prediction of this activity in the primary care booklet for health surveillance (10) .It is important to highlight the role of the nurse's leadership with the health team, as it qualifies the services and provides www.scielo.br/reeuspRev Esc Enferm USP • 2020;54:e03655 better team performance, in addition to enabling fulfilling patients' needs and meeting institutional goals.The daily practice of nursing care in a setting of multiple activities, which make up the PHC (Primary Health Care) portfolio in Brazil, is challenging.A study carried out in the Brazilian state of Minas Gerais revealed that the overload of nurses in the family health strategy "has an impact on the quality of care provided, causing feelings of frustration and doubt egarding their performance" (13) .

Another relevant aspect that can influence professional performance is the operational context of MCP.In the municipality studied, there are challenges for implementing the actions similar to those found in South Africa in a study carried out in 2014, in which lack of financial resources, staff and political support was identified, making the goals and control plan regarding malaria without operational conditions (14) .

Concerning microscopists' work, it is known that the coordination of health surveillance laboratories is responsible for the quality control of the production of these professionals, who must work in basic laboratories, in health units, directly in microscopic analysis (15) .It is added that the performance of microscopists is influenced by load and working conditions (physical structure), demand for services, availability and quality of inputs, in addition to the nature of interpersonal relationships at work (16) .

When analyzing he set of variables, it is observed that this is the category studied with the greatest number of activities.It can be considered that the fulfillment of actions related to treatment monitoring and cure verification has a good performance, with emphasis on cure verification.However, it is important to highlight that this professional has a predominantly technical procedural work process, as it is restricted to the use of the microscope, which gives it a different nature in r lation to the other categories studied (17) .

The variables related to microscopists' work, in which there is a need for involvement with the team, showed an index of partial realization and non-realization, which reiterates that the focus of their activity is more restric ed to microscopy.Studies on the assessment of the activities of this professional carried out in Ethiopia and Indonesia have shown that the aspect of accuracy in reading slides has been more emphasized in relation to other aspects of the work process (17)(18) .

In the six activities assessed to measure the compliance rate of endemic dise

e control a
ents, there was no record of the total achievement index.Professional agents are relevant in the MCP, and must work in an integrated manner with the health team, developing "disease surveillance, preventi n and control activities and health promotion in accordance with SUS [Sistema Único de Saúde -Brazilian Unified Health System] guidelines and under supervision (19) .

However, the agents' work process can lead to occupational exhaustion.A research on the insertion of agents in a malaria treatment institution, carried out in three sub-Saharan African countries, concluded that well-trained agents' work can present good performance; however, work management is necessary for adoptin strategies that can guarantee performance conditions for these professionals (20) .

Agents are workers in the program who have more opportunities to contact patients.It is up to agents to identify patients to perform an exam, slide coll ction, disease reporting, institution, treatment monitoring and cure verification.In addition to these occasions, in the field work of vector control actions, agents have access to patients' homes, appropriating the local reality, the context of life of other information that interfere with the population's health condition (21) .It is a context of