PRIMARY HEALTH CARE ATTRIBUTES IN BREASTFEEDING CARE

Objective: To analyze the presence and extent of the Primary Health Care attributes in the breastfeeding process based on the experience of the health professionals in the services certified by the Amamenta Brasil Network in comparison with non-certified services. Method: cross-sectional and descriptive study with a quantitative approach, using the PCAToolBrazil version for professionals, which was applied to 53 health professionals, physicians and nurses, from a city in the State of São Paulo, Brazil. Descriptive and inferential statistical analysis was applied, using Student’s t-test and the Mann-Whitney test. Results: the services certified by the Amamenta Brasil Network scored higher on Longitudinality(6.7) and Coordination-information systems (8.3).The professionals who were trained by the Amamenta Brasil Network scored higher on Coordination-information systems(8.4)and on Comprehensiveness available services (7.0).These two groups also gave more positive answers to the other attributes. Conclusion: the services certified by and the professionals who were trained by the Amamenta Brasil Network demonstrated a higher degree of orientation towards Primary Health Care. The data appoint that the better performance on the attributes is related, among other factors, to the professionals’ being better qualified to develop practices that value the promotion, protection and support of breastfeeding, in accordance with the principles of Primary Health Care. DESCRIPTORS: Breast feeding. Primary health care. Professional practice.Maternal and child health. Health evaluation.


INTRODUCTION
In health systems, the health care providers influence and support feeding decisions at critical times, before and after birth, and later when there are challenges to maintaining exclusive and continued breastfeeding. Substantial gaps in knowledge and skills to support breastfeeding are reported in all categories of health professionals though. 1 In that sense, the work Primary Health Care performs in Brazil, initiated during prenatal care and continued shortly after hospital discharge is an opportunity to identify the risks to early weaning and establish intervention measures. Many difficulties emerge in the first months of the child's life to maintain breastfeeding and Primary care is an environment that encourages this practice. 2 The improvement in Brazilian indicators related to child health is attributed to social and economic changes, combined with governmental actions and programs that have expanded the access to and coverage of health services, especially in Primary Health Care (PHC). 3 In the range of the actions to support breastfeeding implemented in Brazil in recent decades, the Brazilian breastfeeding network Amamenta Brazil (RAB) is an innovative proposal in the context of Primary Care. Currently, the network is called the Brazilian Breastfeeding and Feeding Strategy (EAAB), after integration with the National Strategy for the Promotion of Healthy Complementary Food (ENPACS), in 2011. The proposal is aligned with the Continuing Education Policy, in the framework of the critical-reflexive method, focusing on the discussion of the primary care teams about the implications of their work process in the promotion, protection and support of breastfeeding in line with the PHC attributes. 4 In this study, we aim to analyze the care in the services certified by RAB as, when we started the study, the EAAB Strategy was still being implemented in the city, but the strategy maintains the same method and theoretical framework.
PHC is, therefore, a form of organization of the health services that responds to a care model with its own values, principles, and elements, through which the goal is to integrate all aspects of these services, and which is focused on the health needs of population. 5 In its most developed form, PHC is the first contact with the health system and the place responsible for organizing the health care of individuals, their families and the population over time. Primary Health Care seeks to provide a balance between the two goals of a Brazilian health system: improving the health of the population and providing equity in the distribution of resources. 5 Beyond the analysis of the effects produced on the breastfeeding indicators, no studies were identified that look at the structural aspects, the work process and interpersonal relations, which in RAB's proposal constitute the basis for transforming professional practices, based on a critical reflection on actual practices.
Thus, in this research, we aim to analyze the presence and extent of the PHC attributes in the breastfeeding process, based on the health professionals' experience in the services certified by RAB, compared to non-certified services.

METHOD
A cross-sectional and descriptive study was developed in the health services certified as part of the RAB, in comparison with health services not certified by the RAB, which provide care to women and children in the breastfeeding process and are part of the organized and hierarchical system of the Unified Health System (SUS), in a medium-sized city in the interior of the State of São Paulo, Brazil. Health care in the city is divided into Health Districts, containing health services that develop the 4/11 traditional health care model, a basic health service (BHU), and others that work through the Family Health Strategy. The five Health Districts include both types of health facilities.
The sampling plan was carried out considering the health services that had the greatest number of live births in the year 2013 6 and the proposal to compare the health services certified and not-certified by RAB. We selected the two groups of health services (certified and uncertified), constituting a convenience sample. The same numerical representation of health services with regard to the type of care model was respected. These services were numbered from one to ten. For each Health District, one certified and one non-certified health services were chosen.
In each of these services, the health professionals engaged in direct care for women and children during the breastfeeding process were identified, which constituted the inclusion criterion. Twenty-five physicians and 28 nurses were invited to participate in the study, totaling 53 participants. The researcher herself gathered and recorded the information at the time of the interview between January and May 2015. The following exclusion criteria were considered: professionals who were on leave or vacation at the time of data collection, and the impossibility of interviewing them after three consecutive appointments.
The Primary Care Assessment Tool (PCATool) professional version was used, which provides an individual measure of the structure and care process in PHC. 7 This tool was developed by Barbara Starfield, and a group of researchers from the Federal University of Rio Grande do Sul translated and validated the tool in Brazil in 2006. After this validation, the instrument was called Instrumento de Avaliação da Atenção Primária (PCATool-Brazil). 7 This tool is in the public domain, and is available free of charge by the Ministry of Health. 7 In this study, our interest was focused on the structural aspects and the care process in health services. Only the essential attributes of the instrument (First Contact -accessibility, Longitudinality, Coordination -care integration, Coordination -information systems, Comprehensiveness -available services) were used without altering any content. Regarding the attribute Comprehensivenessservices provided, this contains questions that do not address specific aspects of breastfeeding and care services provided to breastfeeding. Regarding the Family Orientation attribute, the questions in this attribute are related to family orientations to discuss health problems, plan the treatment and care provided to sick relatives, which is not the objective of this study. For the Community Orientation attribute, the questions are related to the knowledge of health problems in the community, which is not the objective of this study either. As these attributes were excluded, the Essential and General PHC Scores were not calculated.
The data were stored in an Excel spreadsheet, by means of double data entry to eliminate the possible errors, and analyzed using the statistical program Statistical Package for the Social Science -SPSS ® , version 16.0, license 9791560. For the continuous variables, referring to the sociodemographic and vocational training characteristics, the central trend (mean) and dispersion (standard deviation) measures were calculated. The intergroup means (certified services -uncertified services, trained and untrained professionals) were calculated using Student's t-Test and the Mann-Whitney Test. To use these tests, it is necessary to test if the variances of the two groups are statistically equal and if the data follow a normal distribution. A significance level of 5% (α = 0.05) was considered for all tests. Results were considered statistically significant if p <0.05 with a 95% confidence interval.
The PCATool-Brazil data were statistically analyzed according to the guidelines contained in the instrument manual, where the scores for each of the attributes or their components were calculated by the simple arithmetic mean of the answer scores of the items that compose each attribute or its component on a Likert scale ranging from 1 to 4. The answers are distributed as follows: "definitely yes" (score=4), "probably yes" (score=3), "probably no" (score=2), "definitely no" (score=1), "I do not 5/11 know/do not remember" (score=9). 6 Scores >3 indicate the strong presence and extension of the evaluated attribute, as they respond positively to the attribute. The scores can also be converted on a scale from zero to 10 for the sake of a better visualization of the results, with a cut-off point at > 6.6, as performed in this research. 7 The research followed all the ethical precepts according to National Health Council resolution 466/2012.

RESULTS
Of the 53 health professionals interviewed, 25 (47.2%) were physicians and 28 (52.8%) were nurses. Among the nurses, 24 (85.7%) professionals were female and four (14.3%) were male. Of the physicians, 13 (52%) professionals were female and 12 (48%) male. The average age was 36 years, with a minimum of 26 years and a maximum of 54 years. With regard to vocational training, 31 professionals (58.4%) graduated from public institutions. The year of graduation ranged from 1984 to 2013, and only five participants (9.4%) graduated between 2010 and 2013.
Regarding the workplace in the health services, 79.3% of the study participants work in primary health care units and 52.8% in RAB certified units. As for the Health District variable, 12 (22.6%) professionals work in services that belong to the Central region. Regarding the professional training, 49 participants (92.4%), including physicians and nurses, completed a Post-graduation course between 1993 and 2014, and 27 of them (50.9%) completed post-graduation as from 2010. Among the nurses, 10 participants (35.7%) held specialization degrees in Public Health/Family and Community Health. It is noteworthy that 82.1% of the participants (28) obtained their Post-Graduation degree from private institutions. With regard to the physicians, ten professionals (40%) took a Post-Graduation program in Pediatrics, ten professionals (40%) in Gynecology and Obstetrics and five (20%) completed a Post-Graduation degree in Family and Community Medicine. The length of experience of the professionals (physicians and nurses) in the health service participating in the study ranged from one to 22 years at the service, with 33 professionals (62.2%) working in the service for less than five years. Table 1 shows the attribute scores of the ten health services participating in the research. Among the attributes of PHC, First Contact -accessibility and Coordination -care integration presented a low score; Comprehensiveness -available services presented a borderline score considering the established cutoff point. Longitudinality and Coordination -information systems presented high scores. The comparison of the professionals' attribute scores between the services certified and not certified by the RAB is displayed in Table 2. For the attribute First contact -accessibility, scores remained below the cut-off point in the two groups of services; in the RAB certified services, however, scores for this attribute were higher. Scores for the attribute Coordination -care integration were very close to the cut-off point in the two groups of health services.Scores for the attributes Longitudinality, Coordination -information systems and Comprehensiveness -available services were superior to the cut-off points in the RAB certified health services. It is highlighted that Coordination -information systems was the attribute with the highest scores. Comprehensiveness -available services obtained a borderline score in the two groups analyzed.   In Table 3, data are displayed on the analysis of the attributes among professionals who were trained and not trained for the RAB. The attribute First contact -accessibility obtained a low score for both professionals. When comparing these professionals, higher scores were observed for Coordination -information systems and Comprehensiveness in the group that received training. On the opposite, Longitudinality and Coordination -care integration scored higher in the group without training. The professionals who received training answered more positively concerning the attributes Access, Coordination -information systems and Comprehensiveness though. The data on the calculation of the mean scores between the study groups (certified and noncertified services; trained and non-trained professionals) were considered statistically non-significant results. A statistically significant difference was only found for the component Coordination -Care Integration (p=0.017) among the professionals who received training for the network.

DISCUSSION
In assessing the attributes of PHC, we aimed to identify how health professionals are offering services to women who are breastfeeding their children. Considering that RAB has the potential to modify and improve the way in which health professionals perform care for these women, we understand that this knowledge can influence the other actions in health services.
Among the sociodemographic characteristics, a higher frequency of female professionals was evidenced, and this result may be related to the fact that the care professions are often attributed to the female universe. 8 The attention and orientations directed to the women about the course of breastfeeding are necessary and stimulating factors for the promotion and prevention of possible complications during the breastfeeding process, and their practice should extend from prenatal to postpartum care. 9 The low score for the attribute Access points to the possibility that the health services evaluated here, did not attend to the women's needs. The certified services and the professionals with training for RAB responded more positively to this attribute though. A study involving professionals aimed to evaluate the performance and the structure of PHC as a preferred entry point for the Unified Health System. The results showed that the PHC quality falls short of what is desired for the attribute First Contact

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Access, which evidences the need for multiprofessional action strategies and decentralization of care, as well as for the planning of the professionals' actions. 10 Prenatal care should translate the comprehensiveness of care (care, prevention and health promotion). Similar results were found in a study that presented the reflection about the context of the nurse's role in health services, often with an emphasis on technical procedures, distancing the nurse from individualized care, which was reflected in the low score for the attribute Access -accessibility. 11 Regarding Longitudinality, our findings revealed that among the ten health services studied, RAB certified services indicated a greater follow-up of women, over time, in the health services. This attribute contains care actions that aim to bring the woman as a person at the time of care, in view of aspects about understanding her doubts, being clear about the answers, knowing the woman's history, knowing her as a person (and not as a person with a health problem). Longitudinality implies a therapeutic relationship characterized by the health professional's responsibility and the patient's trust. These characteristics are important for the care follow-up to take place. 11 In the Coordination -care integration attribute, which refers to the relationship between the health service and the specialized service, this study presented a score below the cut-off point in all health services studied. When observing the relative and absolute frequencies of the variables of this attribute, the answers "definitely yes"/"probably yes" occurred more frequently, except for the question about the professional of the health service receiving, from the specialist, information about the patient forwarded. Most professionals answered "certainly not", as the medical professional is often responsible for receiving the counter-referral from the specialized service to which he forwarded that patient, which may have characterized the score below the cut-off point.
In our results, the presence and the extension of the Comprehensiveness -available services attribute were appropriate for the services certified and not certified by the RAB and for the professionals who received the RAB training. This attribute evaluates the range of services available and provided by the primary care service. Actions that the health service has to offer so that users receive comprehensive care, considering the biopsychosocial nature of the health-disease process, as well as promotion, prevention, cure and rehabilitation actions, adapted to the context of this care level. 12 One consideration due on the Comprehensiveness attribute is that it needs to be understood from several, not mutually exclusive angles though, focusing primarily on preventive and health promotion activities, without negatively affecting the health care services. 13 In this sense, a study highlights the importance of care for mother and child and reinforces the nature of care comprehensiveness, as it considers the mother/caregiver at the moment of the consultation, underlining that the mothers recognize and explore the whole opportunity of this encounter with the child, as well as the mother/family to provide care, 3 which supports the findings of this study.
In the region of this study, there are several educational and counseling actions aimed at promoting breastfeeding in health services, and the result of the score of this attribute may be, among others, an indication that the care model the professionals adopt is articulated in such a way that breastfeeding care takes into account the issues that shape it and conform it to the singularities of mother and child.
The Coordination -information systems attribute obtained the highest score in the services certified by the RAB and for the professionals who received training for the RAB, suggesting that these groups more closely approach the breastfeeding care based on the principles of PHC. It is understood from the results that, from these professionals' perspective, the health services participating in this study are well engaged in the aspect of referral and counter-referral with other services, as well as with regard to women's access to their documents and medical records, as this attribute is evaluated by how the service communicates with the system. When the score for this attribute is high, it is understood that the service is well organized and informative in relation to the patient documents and histories. 5

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This study presented some limitations that need to be pointed out: PHC was evaluated only in the professional's view, which tends to make it more positive when compared to the evaluation by the users. 14 In addition, the care provided in the health services was measured only based on health actions for mothers and infants on breastfeeding.
It should be noted, however, that the quality of care results from a complex interaction of factors that involve professional skills, working conditions and user satisfaction. It cannot be assumed that a single study can take on all facets of health care. Most studies in the field present different cuts on the subject, precisely because of the difficulty of incorporating such diverse perspectives.

CONCLUSION
This study showed that certified services and professionals with RAB training, responded more positively to the PHC attributes, demonstrating a greater degree of orientation towards PHC. In addition, among other factors, the better performance of these groups in the attribute scores is related to the professionals' better qualification to develop practices that value the promotion, protection and support to breastfeeding.
It is important to highlight that the results found in this study showed that there are challenges in breastfeeding care, including the need for all PHC professionals to operate beyond the perspective of case management, promoting comprehensive, contextualized care, addressing all aspects related to the care for mothers and babies during breastfeeding. The goal is to incorporate in daily activities the understanding of breastfeeding as a dynamic process with different meanings.
The results of this study indicate that it would be of great public health interest that the actions developed in partnership with the RAB be expanded to the other health services of the city, contributing to the improvement of the breastfeeding practice indicators.
The instrument used in the study was easy to apply and permitted finding results that indicate positive aspects the health services should maintain, identifying interventions in order to strengthen them, besides aspects that require close observation and periodic and systematic evaluation, aiming at the quality of care provided to woman and child.
Thus, the results obtained here contribute to new demands and the development of other studies, in view of the challenge of building more effective and egalitarian programs. A broader approach is required, integrating the actions of the Breastfeeding and Feeding Brazil Strategy, implemented after the beginning of this study, involving and uniting the various actors in the breastfeeding process, in order to reach a balance in the different demands, conceptions and perspectives and, thus, to enable the construction of new concepts and values considered positive for the practice of breastfeeding.