Growth surveillance in the context of the Primary Public Healthcare Service Network in Brazil : literature review Vigilância do crescimento no contexto da Rede Básica de Saúde do SUS no Brasil : revisão da literatura

Objectives: to identify and analyze the scientific literature on child growth monitoring in the context of the primary public healthcare service network in Brazil, focusing on the main problems detected in studies. Methods: the review was based on searches ofSciELO, Lilacs and PubMed databases to identify articles published between 2006 and 2014. The articles were categorized according to the analytical categories of structure (items needed to carry out primary activities) or work processes (set of activities and procedures used in the management of resources). Results: of the 16 articles included in this review, only six dealt with structure and, in these, thetraining of professionals and availability of protocols were the most frequently identified problems. Processes, addressed in 15 articles, highlighted the underutilization of Child Health Handbook to record growth measurements and the adoption of guidelines on the basis of notes taken. Conclusions: the difficulties found demonstrate the everyday circumstances of the public health service which have a detrimental effect on growth surveillance.


Introduction
Child growth monitoring is one of the guiding principles of basic health measurement and its main purpose is to assess the adequacy of growth and to identify deficiency at an early stage, before the child reaches the status of undernutrition. 1,2The main benefits of growth monitoring are reductions in undernutrition, morbidity and mortality among young children. 3This action provides a necessary basis for the evaluation of health conditions, as well as a reduction in child morbidity and mortality. 1n Brazil, in the context of Primary Health Care, child growth monitoring and development occurs through childcare consultation.This consultation becomes effective when routines are established and assistance is offered on a regular, systematic, comprehensive and individualized basis.This surveillance during routine visits not only provides access to services, but also consolidates ties, promotes acceptance and contributes to comprehensive care.It also enables the identification of major health problems, as well as the provision and evaluation of health care services. 4,5n childcare consultation, effective monitoring requires a good level of record-keeping in terms of monitoring tools, high coverage rates, regular attendance and accurate measurements.The training of professionals and maternal education in health care are basic conditions for the good performance of health actions. 6However, the reality diverges from the recommendations of the Ministry of Health, with deficiencies in terms of both the involvement of professionals and growth surveillance. 7,8ecently published review articles have enhanced the scientific literature on topics related to food and nutrition actions in the Primary Health Care System.These studies focus mainly on the profile of research groups and actions related to food and nutrition within the Family Health Strategy, 9 scientific nutrition production in the Primary Health Care System, 10 scientific knowledge produced by the Child Health Record as a child health surveillance instrument, 11 the factors that hinder the proper use of the Child Health Record by health professionals 12 and the use of the Child Health Record with an emphasis on growth and development. 13iven the absence of reviews with a specific focus on failures and difficulties regarding growth monitoring, this aim of the present study was to reveal shortcomings in the development of this action as a way of promoting changes in its operation.
The present study thus aimed to identify and analyze the scientific literature on child growth monitoring in the context of the primary public healthcare service network in Brazil, focusing on the main problems detected in the studies.

Methods
A literature review was carried out with the following question in mind: what scientific production was there on child growth monitoring within the (Unified Health System) SUS health network in Brazil from 2006 to 2014?The study was based on searches ofthe Scientific Electronic Library Online (SciELO), the Latin American and Caribbean Health Sciences (Lilacs) and the National Library of Medicine, United States (PubMed) databases.The search considered articles published between 2006 and the search date (5/24/2015) in English, Portuguese and Spanish.The period beginning in 2006 was chosen because 2005 was the year the Child Health Handbook was created 14 and 2006 the year of publication of the new growth curves of the World Health Organization, 15 an important milestones in health surveillance actions.
The decision on the inclusion of items involved two stages: i) screening by reading titles and abstracts, ii) reading methods section or the full text.In the screening stage, publications other than articles, studies conducted outside Brazil, review articles, intervention studies and qualitative research were excluded.In the stage involving reading the methods section or the full text, it was decided to include observational studies conducted in Brazil in the context of the basic SUS health network which deal with the monitoring of growthin children aged 0-5 years.At this stage, studies that did not include children under five years of age, studies not performed within the basic SUS health network, studies not focused on infant growth surveillance and studies that only used compound parameters in their analysis (without defining specific aspects of infant growth surveillance) were excluded.The literature search, the selection of studies and classification of items as included or excluded were performed by two reviewers independently.Discrepancies between reviewers were resolved by consensus.
Articles were categorized according to analytical categories: structure (items needed to carry out primary health activities: infrastructure, equipment, materials and supplies, human resources) or processes (sets of activities and procedures employed in the management of resources: management, specific activities related to growth monitoring, healthy eating promotion, prevention and control of nutritional disorders, nutritional care for risk groups).For both categories, articles were entered into Excel spreadsheets for analysis of the evaluation parameters that the authors used in their studies.Parameters were quantified according to their use frequencies.
Articles included in the review were characterized according to author and year of publication, objectives, study setting, subjects (population, professionals, documents/records), study samples, and main results.

Results
The search strategy identified 1745 documents, not including duplicates or triplicates, in the databases, 1729 of which did not meet the eligibility criteria, resulting in 16 articles for analysis.The process of selection of articles can be seen in Table 1.
The evaluation of the structure of health units in relation to feeding and nutrition actions (activities such as food and nutrition surveillance, healthy eating promotion, prevention programs and control of nutritional disorders, monitoring of government programs) was considered in only six articles 20- 23,25,28 revealing recurrent problems such as lack of training/knowledge of health professionals to develop activities targeting growth surveillance as well as lack of protocols for these purposes.Some results also show difficulties related to the infrastructure of units or premises for consultations (Table 3).
Results related to working process (Table 4) were considered in 15 [16][17][18][19][20][21][22][24][25][26][27][28][29][30][31] of the 16 articles and the most commonly cited problems were those related to recording growth parameters, particularly the growth curves of the Child Health Record and those concerning the adoption of guidelines on the basis of notes included in the Child Health Record, including those related to growth curves. Failue to assess anthropometric parameters in consultations, especially height, also stands out as a recurring result in several studies.

Discussion
It can be inferred from the findings of this review that publications related to growth surveillance in the primary public healthcare service network in Brazil are still insufficiently numerous and geographically uneven.Two literature reviews focusing on scientific production in the field of nutrition showed similar results, as they did with regard to evaluative research on growth surveillance and child health care. 9,10It is argued that these disparities are related to the concentration of graduate programs and research groups in the most developed regions of the country, as well as to differences in investment in research.There is therefore a need to highlight the importance of maintaining strategies that allow a better distribution of scientific production in the country, such as the National Policy for Science, Technology and Innovation in Health, which, from 2004 onwards, established mechanisms to overcome regional research inequalities, with the funding of resources to the order of 30% for projects whose executive institutions are located in the least developed regions of the country. 10The results presented here show that the situation is worst in the North region, while the Northeast region, with scientific production similar to that of the Southern region, still has room for improvement.
In relation to results systematized from studies included in this review, basic aspects in health care priorities were neglected. 1,32Since 2006, children's health was officially established as a strategic part of National Primary Care Policy. 33These issues are related to both structural conditions and to working      processes, which are essential for the good performance of services and improvements in thehealth status of the population. 34n Northeast and South Brazil, a study that compared the traditional model of primary care to the model adopted by the Family Health Strategy found, among others, issues related to precariousness and improvisation in the structures of health units. 34he authors therefore pointed out that primary health care in Brazil is marked by restrictions that compromise service performance and hence impact public health.In the state of Bahia, a recent study with a similar focus,produced similar results. 35This is recognized by health professionals, according to the results of a study conducted in the Distrito Federal that indicated dissatisfaction with the physical structure. 36In the specific case of monitoring growth, a worldwide study foundsimilar deficiencies, including lack of anthropometric equipment. 37These results are similar to those regarding infrastructure problems in this review, pointing to a shortage of structure at health facilities that may have a negative impact on growth monitoring and system performance.
Deficiencies regarding the training of health team members have beenreported to be one of the major limiting factors in the structure of nutritional assistance during prenatal care in the municipality of Rio de Janeiro. 38A study carried out in Northeast Brazil reported that the number of health professionals in the Family Health Strategy trained in Public Health has decreased. 39Focusing on Latin America, other researchers have highlighted the shortage of nurses with specific skills to work in primary health care. 40Studies conducted in the cities of Vitória 41 and Campina Grande 36 have highlighted the importance of training courses for actions performed by primary health professionals.In these studies, when asked about training courses they attended, health professionals reported that the topic of child health was not one of those most commonly mentioned.Another study that examined the history of the Family Health Strategy over the 12 years of implementation, showed that training, qualification and continued education of nurses and other professionals of the Family Health Strategy must be a state policy priority. 42These results and those previously obtainedpoint to the need for training of health professionals, includingin the field of child growth monitoring.
In terms of growth monitoring, there isneed for continuous training in anthropometry as a way ofpromoting learning and professional development and ensuring that health surveillance objectives are met. 43Standardization of measurement procedures and calibration of evaluators are essential to minimize systematic errors (accuracy guarantee), 43,44 which, even if slight, can lead to significant distortions in the nutritional diagnosis. 25The anthropometry training program recently published by researchers can be recommended for these purposes. 43he use of protocols is critical for standardization of child growth surveillance. 20The unavailability of or failure to use protocols, in combination with the results outlined here, have been pointed out in previous studies in the context of the Family Health Strategy. 34,45,46Managers and health professionals should thus be aware of the Technical Standard of the Ministry of Health's Food and Nutrition Surveillance System. 47The lack of qualification and the non-use of protocols may compromise diagnosis of nutritional status, identification of risks and optimization/systematization of care. 20,25here is therefore a need to know which factors negatively influence the structural conditions of health units, despite the regulatory and legislative aspects stipulated by law.Ordinance Nº 24.88 of October 21, 2011, which regulates NationalPrimary Care Policy, thus also stipulatesthe professional assignments, environments, equipment and materials that must be present in each health unit if the set of proposed actions is to be adequately accomplished. 33n relation to child growth surveillance, there is need for adequate physical spaces and good quality equipment, with recommended maintenance and calibration.9 In terms of working processes, problems relating to height measurement can be associated with more recent incorporation of height x age curves, as proposed by the 2007 Child Health Record. 11To this should be added: 1) lack of training and/or motivation of health professionals; 2) lack of appropriate and/or maintenance of measuring instruments; 3) little recognition or ignorance on the part of health professionals of the importance of adequate linear growth, with a detrimental effect on the situation of Brazilian children and prevention by way of timely intervention. 25,50ontinuous recording of anthropometric data is as important as measurement and dependent on it.Similar to results found here, recent articleshave discovered major shortcomings in the records of anthropometric measurements included in the Child Health Record child health surveillance tool. is recommended that anthropometric data be recorded during all consultations regardless of the child's condition, such as nutritional risk, as this is the most appropriate way to monitor child growth in the primary health care. 1,32Continuous care, ensuring the follow-up of the growth monitoring schedule, as proposed in the Appointments Agenda for Comprehensive Child Health and Reduction of Infant Mortality, 32 enables data to be shared among professionals and provides indispensable and extended follow-up of the full care offered and helps identify situations of risk. 1,12,32ne of the main problems that researchers found with analysis of the information contained in Child Health Recordsby literature review was that the anthropometric data records are not transferred to the curves and that guidance to parents based on the notes recorded was insufficent, 11 as found in the present study also.Another literature review found the main factors explaining the difficulty health professionals experienced using the Child Health Recordsproperly, in such a way that they could be applied to barriers to the development of growth monitoring actions, to belack of training in the use of this instrument, insufficient time, unavailability of the instrument in health services, non-use of the instrument by all members of the healthcare team, and lack of awareness of its importance on the part of mothers/families. 12Another possible difficulty may be the fact that recommendations for the use of the Child Health Record 14 may be out of date and not reflect changing versions.
Thus, despite evidence indicating the importance of the Child Health Record for health professionals, it was also found that the latter face various difficulties in its use and that investment in qualification is needed to minimize these limitations 11,12,50 Such issues have also been highlighted in literature on evaluative analysis of Primary Health Care. 6,35,51In relation to growth monitoring, therefore, two aspects may be highlighted: i) the use and interpretation of growth curves is one of the major difficulties faced by professionals, 11,12 as found in research involving 178 countries, 37 ii) the lack of expertise on the part of professionals in implementation ofhigh-quality actions, 11,12 as reflected in the need for training and standardization of pediatric practices found in research involving 11 European countries. 52To meet the challenge of professionaltraining, researchers from UNICEF presented recommendations in an article published for this purpose. 2he difficulties found regarding working processes also reflect the challenges related to the development of the Food and Nutrition Surveillance System.This system has been relegated to the sidelines and lacks analytical or universal features. 53oreover, it has not been prioritized in evaluative research on its functioning. 9The results of two recent surveys thus indicatea low percentage of system utilization and coverage in the states of Rio Grande do Sul 54 and São Paulo. 55espite the low operational cost of child growth monitoring, which classifies it as a feasible health care technology, 56 the daily life of public health services in Brazil seems to be different.It has been suggested that growth monitoring may improve the utilization of health services, which, in turn, along with maternal education regarding food and nutrition, has a positive effect on nutritional status and health.However, it has been stressed that,for growth monitoringto have effect on nutritional status, the action must involve nutritional counseling and be part of a comprehensive program.In addition, the impact is conditioned by coverage, intensity of contact, performance of professionals, adequacy of resources and involvement of families. 2,3With regard to family involvement, the shared responsibility of families and health professionals for use and accurate completion of the Child Health Record should be emphasized. 13,57There is therefore a need to ensure the structural and procedural conditions that are basic requirements for growth monitoring and the multiple factors that should be considered for actionsto have the desired effects.
The results of the present review suggest limitations regarding the geographical concentration of studies and generalizations should be made with the greatest of care.Studies should therefore be conducted in the Center West, South and North regions of Brazil to establish comparisons between geographical realities and different resources.Likewise, the impossibility of generalizing the design of some of the systematic studies suggests the need for research that better guarantees representation.Despite these restrictions, the relevance of the results comes from the evidence provided on the problems faced whenmonitoring the growth of Brazilian children that underline the need for changes aimed at better implementation of primary health care.
It was concluded that there are few studies of growth surveillance in the context of theprimary public healthcare service network in Brazil and that these tend to be concentrated in certain geographical regions.However, when the results of 16 studies are used, the main obstacles in terms of structure and working processes to growth monitoring programs in primary care are highlighted.In terms of structure, Figueroa Pedraza D deficiencies in training/knowledge of professionals, availability of protocols and physical infrastructure were the main barriers described.In the case of working processes, the main difficulties found were height measurement, recording of growth parameters and use of the Child Health Record to guide parents or provide monitoring using growth curves.Thisis the everyday reality of public health services, although growth surveillance is a cost-effective and feasible action with proven benefits for health services and for the population.There is, therefore, a need for more comprehensive research to establish a more consistent overview of the national reality based on the preliminary results of the present study, to improve and expand knowledge and practices regarding childcare.
Figueroa Pedraza D Figueroa Pedraza D

Table 1
Studies excluded and included in the review of child growth monitoring in the context of the Primary Public Healthcare Service Network in Brazil.Publications from 2006 to the date of the search (24/05/2015).
Reading stage of the methods section or in full -Studies that did not include children under five years 467 -Studies not carried out in the basic SUS health network 601 -Studies not focused on child growth monitoring 314 -Studies that included only compound parameters 02

Table 2
Characteristics of articles on child growth monitoring in the context of the Primary Public Healthcare Service Network in Brazil: general characterization.Publications from 2006 to the date of the search (24/05/2015).
BFHU= Basic Family Health Unit; BHU= Basic Health Unit; CHR= Child Health Record; FHP= Family Health Program; FHS= Family Health Strategy.

Table 2
Characteristics of articles on child growth monitoring in the context of the Primary Public Healthcare Service Network in Brazil: general characterization.Publications from 2006 to the date of the search (24/05/2015).
BFHU= Basic Family Health Unit; BHU= Basic Health Unit; CHR= Child Health Record; FHP= Family Health Program; FHS= Family Health Strategy.

Table 2
Characteristics of articles on child growth monitoring in the context of the Primary Public Healthcare Service Network in Brazil: general characterization.Publications from 2006 to the date of the search (24/05/2015).

Table 3
Characteristics of articles on infant growth surveillance in the context of the Primary Public Healthcare Service Network in Brazil: main results of studies focused on structure.Publications from 2006 to the date of the search (24/05/2015).

Table 3
Characteristics of articles on infant growth surveillance in the context of the Primary Public Healthcare ServiceNetwork in Brazil: main results of studies focused on structure.Publications from 2006 to the date of the search (24/05/2015).

Table 4 Characteristics
of articles on child growth monitoring in the context of the Primary Public Healthcare Service Network in Brazil: main results of studies focused on working processes.Publications from 2006 to the date of the search (24/05/2015).

Table 4
Characteristics of articles on child growth monitoring in the context of the Primary Public Healthcare Service Network in Brazil: main results of studies focused on working processes.Publications from 2006 to the date of the search (24/05/2015).