POLICY TRANSFER: PERSPECTIVE OF THE DIRECTLY OBSERVED TREATMENT OF TUBERCULOSIS¹

ABSTRACT

Objective:

to investigate how the policy transfer of the Directly Observed Treatment of Tuberculosis was developed from the perspective of the community health professionals of the Conceição Hospital Group.

Method:

it is a quantitative research of the epidemiological inquiry type, which was based on the application of a validated and self-directed instrument to the health professionals belonging to the 12 Primary Health Care Units to the Community Health Service of the Conceição Hospital Group. For the analysis, the beta regression, the description of the frequencies of the variables, the distribution of the mean, median and the standard deviation were used. In addition, the standardized mean and standardized scores were created.

Results:

109 health professionals participated in the study, most of them female (77.06%), aged between 30 and 59 years old (87.16%) and belonging to the medical category (37.61%). Regarding the three analyzed dimensions of the policy transfer process, it was observed that the Knowledge dimension was the one that had the highest score (77.8%), followed by the dimensions Information (72.7%) and Innovation (67.7%). The need for involvement and participation of the population in the discussions of Directly Observed Treatment, improvement of the infrastructure of the health services and the complexity of the process of accomplishment of this practice were some, among others, important aspects pointed out.

Conclusion:

it is necessary to reformulate and improve the actions related to the operationalization and transfer of the Directly Observed Treatment of Tuberculosis.

DESCRIPTORS:
Tuberculosis; Public health; Public policy; Family health strategy; Health management.

RESUMO

Objetivo:

investigar como se desenvolveu a transferência da política do Tratamento Diretamente Observado da Tuberculose na ótica/para dos/os profissionais de saúde comunitária do Grupo Hospitalar Conceição.

Método:

trata-se de uma pesquisa de abordagem quantitativa do tipo inquérito epidemiológico, que se baseou na aplicação de um instrumento validado e autodirigido para os profissionais de saúde pertencentes às 12 Unidades de Atenção Primária à Saúde do Serviço de Saúde Comunitária do Grupo Hospitalar Conceição. Para a análise,foram utilizados a beta regressão, a descrição das frequências das variáveis, a distribuição da média, mediana e o desvio-padrão. Além disso, foram criados a média padronizada e os escores padronizados.

Resultados:

participaram do estudo 109 profissionais de saúde, a maioria do sexo feminino (77,06%), com idade entre 30 e 59 anos (87,16%) e pertencentes à categoria médica (37,61%). Em relação às três dimensões analisadas do processo de transferência da política, observou-se que a dimensão Conhecimento foi a que obteve maior escore (77,8%), sendo seguida pelas dimensões Informação (72,7%) e Inovação (67,7%). A necessidade de envolvimento e participação da população nas discussões do Tratamento Diretamente Observado, de melhoria da infraestrutura dos serviços de saúde e a complexificação do processo de realização dessa prática foram alguns, dentre outros, aspectos importantes apontados.

Conclusão:

urgem medidas de reformulações e melhorias nas ações vinculadas à operacionalização e transferência do Tratamento Diretamente Observadoda Tuberculose.

DESCRITORES:
Tuberculose; Saúde pública; Política pública; Estratégia de saúde da família; Gestão em saúde

RESUMEN

Objetivo:

investigar cómo se desarrolló la transferencia de la política del Tratamiento Directamente Observado de la Tuberculosis desde la óptica de los profesionales de la salud comunitaria del Grupo Hospitalario Conceição.

Método:

se trata de una investigación de abordaje cuantitativa del tipo averiguación epidemiológica basada en la aplicación de un instrumento validado y autodirigido para los profesionales de la salud pertenecientes a las doce (12) Unidades de Atención Primaria para la Salud del Servicio de Salud Comunitario del Grupo Hospitalario Conceição. Para el análisis se utilizaron la regresión lineal, la descripción de las frecuencias de las variables, la distribución de la media, mediana y el desvío-estándar. Además, se crearon la media estandarizada y los resultados estandarizados.

Resultados:

participaron del estudio 109 profesionales de la salud, la mayoría del sexo femenino (77,06%), con edades entre 30 y 59 años (87,16%) y pertenecientes a la categoría médica (37,61%). En relación a las tres dimensiones analizadas del proceso de transferencia de la política, se observó que la dimensión Conocimiento fue la que obtuvo el mayor resultado (77,8%), seguida por las dimensiones Información (72,7%) e Innovación (67,7%). La necesidad de envolvimiento y participación de la población en las discusiones del Tratamiento Directamente Observado, de la mejoría de la infraestructura de los servicios de salud y la complejidad del proceso de realización de esa práctica fueron algunos de los aspectos importantes señalados, entre otros.

Conclusión:

son urgentes las medidas de reformulaciones y mejorías en las acciones vinculadas con la operacionalización y transferencia del Tratamiento Directamente Observado de la Tuberculosis.

DESCRIPTORES:
Tuberculosis; Salud pública; Política pública; Estrategia de salud de la familia; Gestión en salud

INTRODUCTION

The transfer of public policies is an unexplored and still incipient subject in the Brazilian academic environment.¹ It can be understood as the process in which the “[...] knowledge about policies, administrative arrangements, institutions etc. in one time and/or place is used in the development of policies, administrative arrangements and institutions in another time and/or place.”^2:344

In health domains, this process is configured as a constant activity, related to the most diverse instances, contents and organizational contexts. Observed under this light, the construction of the Brazilian model of the Unified Health System (SUS - Sistema Único de Saúde) was inspired at a given moment by the Dawson Report and by the National Health System, of British origin, in what concerns mainly to the organization of the Primary Health Care,³ among many other examples that we could mention. Although routinely present in health, it is necessary to highlight the current scarcity of systematic studies on the transfer of public policies in this environment,⁴ which stimulates and challenges researchers in the search for new and important scientific evidence in this regard.

When it comes to the transfer of a policy, it is necessary to bear in mind the complexity of a process involving the most diverse actors, levels and governmental arenas (global, national, state, regional, local) as well as the support networks. Variables such as the political, economic, cultural, social context and the availability of financial and human resources are elements, among many others, that can greatly influence this process.⁵

The centrality of this theme is reinforced if we consider that the results of a particular program, for example, may be an immediate reflection of the quality of its implementation, which is directly linked to the way this program was disseminated, transferred and disclosed among its main actors. The systematization, disorganization and disqualification of this stage can result in unprepared professionals and foolhardily unreachable goals.

Thus, considering the importance of the topic, it is proposed to investigate how the policy transfer of the Directly Observed Treatment (DOT) of tuberculosis (TB) was developed from the perspective of the health professionals of the twelve Community Health Units of the Conceição Hospital Group (CHG), in Porto Alegre, state of Rio Grande do Sul. It is known that the capital of Rio Grande do Sul occupies the first places in the ranking of Brazilian capitals with the highest incidence of TB (99.3/100,000 inhabitants in 2014),⁶ and stands out for the low cure rate in the treatment of new cases of bacilliferous pulmonary TB (for example, 57.6% in 2012).⁷

Considering that the correct use of the medicines makes possible a cure percentage of 90% of the cases of the disease,⁸ we have in DOT an important ally in this sense, both regarding the guarantee of medication intake by the patient, as well as favoring the support and adherence to the treatment, reducing the probability of possible drugs resistance.

Therefore, considering the worrying epidemiological scenario of Porto Alegre in relation to TB and the relevance of DOT in the fight against the disease, we were led to investigate some elements of the process of transferring this policy to health professionals, their strengths and weaknesses, potentialities and critical nodes that may interfere in the execution of the policy in the capital of Rio Grande do Sul.

The importance of this study lies not only in the possibility of expanding the scientific evidence on a less widespread theme in the health field, such as the transfer of public policies, but above all in the possibility of obtaining an instrument to management, reformulation and restructuring of TB control local services in Porto Alegre, especially regarding DOT. Without losing sight of the fact that this is an initiative that can be extended to other contexts and similar scenarios, or even adopted as a model for investments in new areas.

METHOD

This is a quantitative study of the epidemiological inquiry type, carried out at the 12 Primary Health Care Units of the CHG Community Health Service (CHS) in Porto Alegre - Rio Grande do Sul (Brazil). They are located in the north of the capital of Rio Grande do Sul, being responsible for health care of the population of this territory. The professionals that make up the CHS/CHG provide care for approximately 105 thousand people.⁹

All the doctors, nurses, assistants, and nursing technicians involved with DOT in Primary Health Care participated in the study. As inclusion criteria in the research, the subjects who consented to their participation and who had training or worked for at least six months with DOT in their units were considered.

The study was based on the application of a validated instrument (called “Evaluation of the Transfer of Policies - Innovation, Information and Knowledge in Tuberculosis - ATP-IINFOC-TB”) and self-directed to health professionals. It has 39 items distributed in three dimensions: nine in Information, 10 in Knowledge and 20 in Innovation. These dimensions were chosen as a theoretical subsidy that perpasses the theme of public policy transfer. The questionnaire items were judged using the modified Likert scale, with the following options: disagree (1), partially disagree (2), indifferent (3), partially agree (4), agree (5).

It should be emphasized that the ATP-IINFOC-TB instrument was not elaborated with the objective of investigating which professional has more information, knowledge or innovates more their practice, but as an investigation subsidy of the variables, processes and elements (information flow, frequency, type of placement, actors involved, type of material used, educational and work strategies, among others) related to the transfer of the DOT policy from the perspective of each of the dimensions in their singularities.

The data collection was carried out between April and May 2014 by the main researcher, after consent of the health services involved in the research and approval of the three Research Ethics Committees (RECs) mentioned below.

The data obtained were organized with the help of Microsoft Excel^® (version 2010) and analyzed using statistical software SPSS^® (version 22) and R (version 3.0.2). Beta regression, description of the frequencies of the variables and distribution of the mean, median and standard deviation were some statistical devices used for the analysis. In addition, the mean and standardized scores were calculated so as to allow an association of the responses obtained in percentage terms with the Likert scale items, respecting the following correlation: disagree (0%); partially disagree (25%); indifferent (50%); partially agree (75%); agree (100%). For explanatory effect, a standardized score with a 80% result for a given item means that the subjects of the research were positioned between the partially agree and agree on the judgment of mentioned item.

This research was approved by three RECs, by the Ribeirão Preto Nursing School of the University of São Paulo (EERP/USP - CAAE 01197312.3.0000.5393), by the Municipal Health Department (SMS - Process nº 001.008442 .12.6) of Porto Alegre and by the Conceição Hospital Group (CHG - CAAE 01649012.9.0000.5530) and it respects all the ethical and legal principles required in studies of this nature. In addition, in order to improve the presentation of the data, results, information and actions developed in the research, it was decided to use the criteria, when applicable, of the STROBE checklist, an international guide developed for this purpose.

RESULTS

A total of 109 health professionals participated in the study, with the majority of females (77.06%), aged between 30 and 59 years old (87.16%) and belonging to the medical category (37.61%), followed by nurses (22.94%), nursing assistants (22.02%) and nursing technicians (17.43%).

For the purposes of analysis and discussion, we selected six items of the questionnaire, three with the highest and three with the lowest scores standardized by dimension (Information, Knowledge and Innovation, respectively), as shown in Charts 1, 2 and 3.

Chart 1
Representation of the highest and lowest standardized scores of the participants' answers by item of the ATP-IINFOC-TB instrument in the Information dimension. Porto Alegre, RS, Brazil, 2014.

	Item	Nº of theitem	Standardized Score
Information Dimension (Items from 1-9)	The DOT has been discussed among professionals/staff that work with TB in the health unit where I work.	2	85.42
	When discussing about DOT, the Tuberculosis Control Program (TCP) coordination (municipal/state) uses clear, concise, and easily understood language.	6	84.80
	The coordination of the Tuberculosis Control Program (TCP municipal/state) has discussed the Directly Observed Treatment (DOT) with the team of the health unit where I work.	1	84.67
	The TCP coordination (municipal/state) uses strategies to motivate and involve the health unit team in which I work regarding DOT.	5	74.52
	There is no integration/interaction between the coordination of the PCT (municipal/state) and the team of the health unit where I work.	4	68.16
	The population participates in discussions about the DOT in the health unit where I work.	3	25.97

Chart 2
Eepresentation of the highest and lowest standardized scores of the participants' answers by item of the ATP-IINFOC-TB instrument in the Knowledge dimension. Porto Alegre, RS, Brazil, 2014.

	Item	Nº of theitem	Standardized Score
Knowledge Dimension (Items from 10-19)	In order to achieve success in DOT it is necessary to incorporate other institutions/actions in addition to the health sector.	19	89.91
	I understand the DOT guidelines.	10	87.85
	The team at the health unit where I work recognizes the importance of DOT.	18	87.27
	The TCP coordination (municipal/state) often offers training on DOT.	14	71.26
	I participate in the training offered by the (Municipal/Regional/State) Health Department on DOT.	15	59.31
	In the health unit where I work, the team considers DOT as a simple routine.	13	54.40

Chart 3
Representation of the highest and smallest standardized scores of participants' answers by item of the ATP-IINFOC-TB instrument in the Innovation dimension. Porto Alegre, RS, Brazil, 2014.

	Item	Nº of theitem	Standardized Score
Innovation Dimension (20-39)	DOT requires the development of an individual care plan for the TB patient.	23	92.36
	At the health unit where I work, the team considers DOT as a practice that qualifies TB patient care.	28	91.44
	In the health unit where I work, the difficulties (access, economic, among others) of patients in DOT are perceived by the health team.	38	84.63
	In the health unit where I work, other strategies are created to promote adherence to DOT beyond those already existing in the program.	31	51.68
	The health unit where I work has an adequate infrastructure to provide patient care in DOT (rooms, equipment, etc.).	21	46.53
	At the health unit where I work, the community resources are used to support the patient's adherence to DOT (support groups, self-help groups, neighborhood leaders, church, and neighborhood association).	32	38.25

In general, health professionals were between the partially agree and agree about the existence of a discussion about the DOT theme between the team and the coordination of the TB control program. On the other hand, they remained between the indifferent and the partially agree on the integration of these actors in the work environment and between the partially disagree and the indifferent, when the subject was the participation of the population in discussions about the DOT.

In the Knowledge dimension, the strength of the evaluation was the recognition of the importance of DOT and of incorporating other institutions in its operationalization, in addition to those related to health, in the lids and operationalization of the policy. On the other hand, the participation in training on the thematic and the complexity of the operational routine of DOT were the critical nodes pointed out by health professionals (Chart 2).

When discussing Innovation, it is observed a tendency to recognize the need to elaborate an individual care plan for the TB patient and the existence of economic and access difficulties, among others, experienced by the patients performing DOT. The item that discusses the creation of new treatment adherence strategies has touched the indifferent in the judgment of the health professionals and the existence of an adequate infrastructure in the unit, the partially disagree, the same regarding the use of community support resources (Chart 3).

In another perspective, the answers of the health professionals were analyzed by category as to the relation of the whole set of elements of the DOT transfer, which were based on each of the dimensions/domains (Information, Knowledge and Innovation) and their respective working realities.

Thus, after final adjustments by the Beta regression, the predicted values for mean and standard deviation (Table 1) were obtained. In this sense, it was observed that the Nursing category presented a lower average in the Information domain (0.6666), the Nursing Technician in the Knowledge (0.6547) and the Doctor in Innovation (0.6595). Both with answers that have been between the options indifferent and partially agree on the Likert scale. When evaluated in their collectivity, the health professionals assigned the lowest standard score to the Innovation category (67.7%), followed by Information (72.7%) and Knowledge (77.8%).

Table 1
Predicted values for the model in relation to the mean and the standard deviation according to domains and professional categories. Porto Alegre, RS, Brazil, 2014.

Domain	Category	Average standardized mean	Deviation
Information	Doctor	0.7096	0.1828
Information	Nurse	0.6666	0.1536
Information	Technician	0.7571	0.1315
Information	Assistant	0.7031	0.1824
Knowledge	Doctor	0.7532	0.1501
Knowledge	Nurse	0.6986	0.2058
Knowledge	Technician	0.6547	0.1739
Knowledge	Assistant	0.7629	0.1316
Innovation	Doctor	0.6595	0.1530
Innovation	Nurse	0.8133	0.1092
Innovation	Technician	0.7679	0.1549
Innovation	Assistant	0.7302	0.1311

DISCUSSION

The results of this study lead us to the understanding that the information barriers, according to health professionals, are not fundamentally related to the process of discussion of the DOT policy between managers/coordinators and health professionals, but, in some way, they are associated with the lack of participation and popular involvement in this process, the impaired integration/interaction between the different levels of management and care (which may compromise the functioning of the care network and the flow of information) and the existence of motivational strategies aimed at working with DOT.

As known, success in the transfer of a public policy and its incorporation in a given context can be influenced by several factors, among which the organizational model adopted and the precariousness of the support in the development of the actions, the failure in the communicative process and in the dissemination of information and government motivations that do not always see politics as a priority, among others.¹¹ If we consider the perspective of a policy transfer in which information is converted into knowledge and subsequently into innovations in the work environment, in fact, the motivational factor, whether individual or institutional, has great weight in this course.

For example, the ability to reconstruct, adapt, re-contextualize and reassemble acquired knowledge according to local needs and specificities becomes a key element of the DOT policy transfer process¹² and tends to be strengthened by stimulus and encouragement. Therefore, when health professionals get close to the indifference, raising doubts about the use of motivational strategies for the coordination of the tuberculosis program, precedents are opened to consider the possibility of disrupting this constructivist and innovative logic, with repercussions on its productive chain, on creative practice and on the TB control itself.

In addition, the policy transfer tends to also be impacted by a poor integration between the managers/coordinators of disease control programs and the team of professionals who operationalize the policy, with consequences that can compromise from the diffusion of the information to the innovative process of achieving the desired results, since the achievement of the established goals, including those for the TB control, goes through a process of planning of actions that requires not only the participation and integration of the management and professionals of SUS from different levels of the government, but also from the civil and the academic society, considered as fundamental in relation to the entire evaluation and continuity process.¹³

In addition, thinking about the transferring of a public policy, in our case the DOT, implies recognizing the specificities and the local reality of the scenarios of its implementation. Thus, the popular participation and, particularly, the social control, are fundamental pieces when the subject involves the necessary contextual adaptation, making possible the existence of a more inclusive, participatory and qualified process from its formulation to the decision making.¹³

When analyzing the Knowledge domain, it is possible to observe that the incorporation of other institutions/actions, besides the health sector as a way to obtain success in DOT, stood out among the other items, presenting the highest score of this dimension. In fact, the success of the treatment requires care based on the concept of integrality, in this sense, intersectoral measures; the issue of bonding and accountability are unparalleled strategies for strengthening this type of care in the context of the Primary Health Care.¹⁴

It is possible to observe that the weaknesses and critical nodes in this dimension of analysis are not necessarily linked to the lack of recognition of the importance or even understanding of the guidelines governing such policy, since these items have also presented considerable scores, but materialized in the question of the participation of professionals in training on the subject and in the conception of DOT as a simple work routine.

There is evidence that the lack of training of health professionals can be a considerable barrier in the transfer of the DOT policy at the local level and as an impact factor not only in the management of care, but also in the sphere of knowledge and in the construction of a distorted view of the subject.¹⁵ In addition, the lack of training and permanent education, perceived as disincentive and devaluation, added to the deviation of role and work overload, among other factors, tend to generate feelings of impotence and frustration with important impact in the work context,¹⁵ certainly, also in the motivational component and in the effectiveness of the policy.

The tuberculosis DOT, although a theoretical trivial routine, presents a certain degree of difficulty when we consider, among others, the issues mentioned above. Another point concerns the fact that the treatment is not limited to simply monitoring the medication intake by the health professional, but it also involves other aspects such as qualified listening, strengthening of ties with the team and also the monitoring of adverse reactions, among others.¹²

Regarding this last aspect, from the point of view of Innovation, its possible to observe the recognition by the health professionals of the importance of elaborating an individual care plan for the TB patient. In fact, a unique, personalized approach strengthened by listening and effective bond with TB patients and their families not only works as a possibility to better identify needs and to plan interventions, but also as a strategy for patient empowerment and an important assumption to promote health care based on the National Humanization Policy.¹¹ In addition, the prolonged course of the disease makes this plan a very valuable tool for its management, while requiring an effective, cooperative and interdependent health system.¹⁶

The barriers, when one thinks of innovating in DOT, in the conception of health professionals, are not bound to the recognition of this practice as a measure that qualifies care for the patient, but in the existence of perceived barriers and difficulties related to the patient (be they economic and access factors), to the deficiencies in the creation of new treatment adherence strategies, and especially inadequate health services infrastructure. There are indications that DOT is, in fact, recognized as an important practice by health professionals, but the lack of time for its practice and the lack of human resources, materials and transportation, decisively influences its operationalization.¹⁷

The effective adherence to the TB treatment is an interesting challenge that involves strengthening the bond between the health team and the patient. At this occasion, the individual needs and peculiarities are recognized, the best strategies for access to treatment are drawn up, mutual cooperation is generated and the chances of abandonment are reduced. The success of the treatment will be the result, among other factors, of the way in which this bond is established, the embracement by the health team and the guarantee of access.¹⁸ Therefore, innovative practices of adherence to DOT, in order to be effective, will also need to invariably consider these aspects, as well as the infrastructural and organizational context of the health services, since the lack of patient follow-up tends to increase the possibility of withdrawal from the tuberculosis medication treatment.¹⁹

Thus, it is believed that the high dropout rate in Porto Alegre (27.14%),⁷ may in some way also be associated with the absence or deficiency in the innovative process regarding the TB control actions, specifically those regarding DOT. Thus, it is possible to think of several qualification strategies of this process, such as, for example, health education for users of supervised treatment, not only as a source of information about the disease, but also as an opportunity to receive professional support, reduction of the stigma and effective use of the medication.²⁰

Other alternatives may also be linked to the incentive for supplying basic food baskets and support groups, with an impact on membership and, consequently, on the reduction of the dropout in the capital of Rio Grande do Sul, which is still above the 5% recommended by the Ministry of Health.²¹

Regarding the three dimensions as a whole, the results demonstrate that a careful look at the elements that integrate the dimension of Information and the way in which they are worked in the process of transfer of DOT to the Nurses is necessary. Similar logic applies to those in the Knowledge dimension and the Nursing Technicians category, as well as the Innovation dimension and the Medical category.

In general, the DOT transfer process carried out in full with all the categories of professionals needs to be revised in terms of the Innovation and Information dimensions, since they were the ones with the lowest and most worrying standardized scores, pointing to the need for reformulations and improvements. There is no doubt that information is a basic axis in the DOT consolidation, since the way health professionals are informed about the importance and necessity of DOT and the adoption of other TB control strategies can decisively influence the success or failure in the process of transferring that policy.¹¹

In addition, in order for DOT to consolidate itself as a transferred policy in the operational perspective of the World Health Organization, it is important that health professionals innovate their practices, which means going beyond the reproduction of the norms instituted, proposing changes that are based on their professional experience²² and on the recognition that the heterogeneity of each location, demanding adjustments to the policies transferred. This fact becomes perfectly possible to be realized, since there is no obligation to adopt a policy in its entirety, detail by detail, which, in turn, opens precedents for the new and for the necessary.²

CONCLUSION

The experience shows the need for qualification of important and basic points that may jeopardize the transfer cycle of the Directly Observed Treatment of Tuberculosis policy and its operationalization. Thus, it is possible to mention the impaired integration of the different levels and actors of the health network, the fragility in the motivational component, the lack of capacity and permanent education on the subject, the declared infrastructure deficit of the services, the complexity of the work process with the policy, among others.

Structural aspects related to information, knowledge and innovation within the scope of DOT (for example, the popular participation in the discussions related to this policy, the need for a greater supply of training for health professionals, the creation of new adherence strategies, etc.) need to be rethought and exercised in a new perspective among the health professionals, considering, therefore, their individual needs, their collective peculiarities and their heterogeneous working contexts. In order to do so, it is also necessary to promote a qualification of the services and the logistics of providing it and strengthen the political and managerial will in the treatment of tuberculosis, a disease that is known to be neglected.

It is expected that the present study may serve as an important subsidy, initially, as scientific evidence on the subject of public policy transfer, but also for the decision making and implementation of structural changes and in the work process of the health services, and especially for the qualification in the provision of care to the TB patient. It is also suggested that further studies are performed, given the importance of the topic.

• 1
  Article extracted from the thesis - The planning and execution of the policy transfer of the Directly Observed Treatment of Tuberculosis in the city of Porto Alegre - RS presented to the Public Health Nursing Program of the Mother-Child and Public Health Department, Escola de Enfermagem de Ribeirão Preto (EERP) Universidade de São Paulo (USP), in 2015.

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Publication Dates

• Publication in this collection
  09 Aug 2018
• Date of issue
  2018

History

• Received
  07 Apr 2017
• Accepted
  08 Nov 2017