Evaluation of Primary Healthcare from the perspective of child caregivers: an integrative review

ABSTRACT

Objective

To identify the quality evaluation of Primary Healthcare services in the literature from the perspective of child caregivers through applying the PCATool, children’s version.

Method

An integrative review performed in the MEDLINE, CINAHL, LILACS, BDENF and Web of Science databases.

Result

Seventeen (17) articles were selected. All included studies were descriptive (100%) and had evidence level IV (100%). The affiliation degree component (average = 7.72) of the longitudinality attribute, the utilization component (average = 7.14) of the first contact access attribute, and the information system component (average = 6.63) of the coordination attribute presented high average scores (≥6.6), while the other attributes and components obtained low average scores (<6.6).

Conclusion

Although management of Primary Healthcare services has consistently applied efforts to improve their performance and quality in providing and delivering care to the population, it has been observed that problems related to the process and structure of these services still persist given that most of the attributes were poorly evaluated.

Primary Health Care; Child; Caregivers; Health Evaluation; Child Health; Review

RESUMO

Objetivo

Identificar na literatura a avaliação da qualidade dos serviços de Atenção Primária à Saúde sob a ótica de cuidadores de crianças por meio da aplicação do PCATool, versão infantil.

Método

Revisão integrativa realizada nas bases de dados MEDLINE, CINAHL, LILACS, BDENF e Web of Science.

Resultados

Foram selecionados 17 artigos. Todos os estudos incluídos eram descritivos (100%) e possuíam nível de evidência IV (100%). O componente grau de afiliação (média=7,72), do atributo longitudinalidade, o componente utilização (média=7,14), do atributo acesso de primeiro contato, e o componente sistema de informação (média=6,63), do atributo coordenação, apresentaram média dos escores alta (≥6,6), enquanto os demais atributos e componentes obtiveram média dos escores baixa (<6,6).

Conclusão

Embora a gestão dos serviços de Atenção Primária à Saúde tenha aplicado constantemente esforços para melhorar seu desempenho e qualidade na oferta e prestação da assistência à população, observou-se que problemas relativos ao processo e estrutura destes serviços ainda persistem, tendo em vista que a maioria dos atributos foi avaliada insatisfatoriamente.

Atenção Primária à Saúde; Crianças; Cuidadores; Avaliação em Saúde; Saúde da Criança; Revisão

RESUMEN

Objetivo

Identificar en la literatura la evaluación de la calidad de los servicios de Atención Primaria de Salud bajo la óptica de los cuidadores de niños mediante la aplicación del PCATool, versión infantil.

Método

Revisión integrativa llevada a cabo en las bases de datos MEDLINE, CINAHL, LILACS, BDENF y Web of Science.

Resultados

Fueron seleccionados 17 artículos. Todos los estudios incluidos eran descriptivos (100%) y tenían nivel de evidencia IV (100%). El componente grado de afiliación (promedio=7,72), del atributo longitudinalidad, el componente utilización (promedio=7,14), del atributo acceso de primer contacto, y el componente sistema de información (promedio=6,63), del atributo coordinación, presentaron promedio alto de los scores (≥6,6), mientras que los demás atributos y componentes obtuvieron promedio bajo de los scores (<6,6).

Conclusión

Si bien la gestión de los servicios de Atención Primaria de Salud hayan aplicado constantemente esfuerzos hacia mejorar su desempeño y calidad en la oferta y prestación de la asistencia a la población, se observó que problemas relacionados con el proceso y estructura de dichos servicios todavía persisten, a la vista de que la mayoría de los atributos fue evaluada insatisfactoriamente.

Atención Primaria de Salud; Niño; Cuidadores; Evaluación en Salud; Salud del Niño; Revisión

INTRODUCTION

Primary Healthcare (PHC) is the first level of care provided to populations and is a fundamental part of the health systems of high and low income countries¹-², since it provides services without access restriction and it has an ability to address most of the population’s health needs, offering disease and injury prevention, as well as health promotion and care actions¹,³.

It is considered important to improve the quality of PHC in order to build stronger health systems⁴. International studies indicate that PHC contributes to better health¹-²,⁴-⁶, equity⁴-⁶ and cost reduction outcomes¹,³-⁶. Therefore, it is essential to evaluate PHC services through the presence and extension of their attributes in order to reorganize the actions for more qualified healthcare⁷.

The Primary Care Assessment Tool (PCATool) is the most used instrument to evaluate PHC in Brazil, considering that this tool is the closest to the Family Health Strategy (FHS), proposed by the National Primary Healthcare Policy⁸. The PCATool was developed and validated by Barbara Starfield and colleagues⁹-¹⁰, and identifies whether health services and PHC are oriented according to their essential and derived attributes⁶-⁷. The essential attributes are: first contact access, longitudinality, comprehensiveness and coordination of care¹¹-¹², which are named after their need to provide primary care¹³. In turn, the derived attributes are: family orientation, community orientation and cultural competence¹¹-¹², which qualify PHC and expand the interaction of individuals/community with health services¹³. It is noteworthy that the derived cultural competence attribute was excluded in the Brazilian version, since a dimension with three or more representative questions was not consolidated in the factorial analysis¹³.

An evaluation of PHC quality from the perspective of child caregivers through the PCATool (children’s version) has been the subject of several national studies¹⁴-¹⁷, however there is no integrative literature review on the subject yet. Therefore, this study was proposed, aiming to emphasize the Brazilian reality. Its results will make it possible to identify how much the PCATool (children’s version) has been used and which essential and derived attributes achieved good and poor performance according to child caregivers. Recognition of essential attributes or derivatives that did not achieve good performance from the perspective of child caregivers may contribute to proposing interventions that can modify this situation, being an important ally in child health to improve quality of life, reduce child mortality, preventable diseases and preventable hospitalizations.

Given the above, the aim of this study was to identify the evaluation of the quality of PHC services in the literature from the perspective of child caregivers through applying the PCATool, children’s version.

METHOD

STUDY DESIGN

This is an integrative review (IR), with the following steps being adopted to conduct it: identifying the theme and formulating the research question; setting inclusion and exclusion criteria; categorizing studies; evaluating the sample studies; interpreting the results; and then synthesizing the main findings found in the studies¹⁸.

The research question was formulated according to the PICo strategy, namely: Participants – P; Interest – I; Study context – Co¹⁹, and the following structure was considered: P – children; I – evaluation of health services; Co – Primary healthcare. Thus, the following question was elaborated: “What is the evaluation of the quality of PHC services from the perspective of child caregivers, as verified through application of the PCATool, children’s version?”

DATA COLLECTION

The search was performed in April 2018, in the databases: Medical Literature Analysis and Retrieval System Online via National Library of Medicine National Institutes of Health (MEDLINE via PubMed); Web Of Science (WOS); Cumulative Index to Nursing and Allied Health Literature (CINAHL); Latin American and Caribbean Health Sciences Literature (LILACS) via the Virtual Health Library (VHL) and the Base de Dados de Enfermagem (BDENF) via the VHL. The controlled and uncontrolled descriptors were selected from the Health Sciences Descriptors (DeCs), Medical Subject Headings (MeSH) and CINAHL Terminology (Emtree) (Chart 1).

Chart 1
– Controlled and uncontrolled descriptors and search expressions used in databases according to the PICo strategy – Teresina, PI, Brazil, 2018.

MeSH
P	Controlled descriptor	Child
I	Uncontrolled descriptor	Services Assessment
Co	Controlled descriptor	Primary Health Care
Search Expression MEDLINE via PubMed	((Child[MeSH Terms]) AND (Service Assessment) AND (Primary Health Care[MeSH Terms]))
MeSH
P	Controlled descriptor	Child
I	Uncontrolled descriptor	Health Services Evaluation
Co	Controlled descriptor	Primary Health Care
Search Expression Web of Science	((TS=(Child) AND TS=(Health Services Evaluation) AND TS=(Primary Health Care))
List CINAHL
P	Controlled descriptor	Child
I	Controlled descriptor	Evaluation Research
Co	Controlled descriptor	Primary Health Care
Search Expression CINAHL	(MH “Child”) AND (MH “Evaluation Research”) AND (MH “Primary Health Care”)
DeCS
P	Controlled descriptor	Criança
	Uncontrolled descriptor	Crianças
I	Controlled descriptor	Pesquisa sobre Serviços de Saúde
	Uncontrolled descriptor	Pesquisa sobre Prestação de Cuidados de Saúde; Pesquisa nos Serviços de Saúde; Avaliação de Serviços de Saúde; Avaliação dos Serviços de Saúde; Avaliação dos Serviços.
Co	Controlled descriptor	Atenção Primária à Saúde
	Uncontrolled descriptor	Atenção Primária de Saúde; Atenção Básica; Atenção Básica à Saúde; Atenção Básica de Saúde; Atenção Primária; Atenção Primária em Saúde; Cuidados de Saúde Primários; Cuidados Primários à Saúde; Cuidados Primários de Saúde.
Search Expression LILACS via the Virtual Health Library	((tw:(criança)) OR (tw:(crianças))) AND ((tw:(pesquisa sobre serviços de saúde)) OR (tw:(pesquisa sobre prestação de cuidados de saúde)) OR (tw:(pesquisa nos serviços de saúde)) OR (tw:(avaliação de serviços de saúde)) OR (tw:(avaliação dos serviços de saúde)) OR (tw:(avaliação dos serviços))) AND ((tw:(atenção primária à saúde)) OR (tw:(atenção primária de saúde)) OR (tw:(atenção básica)) OR (tw:(atenção básica à saúde)) OR (tw:(atenção básica de saúde)) OR (tw:(atenção primária)) OR (tw:(atenção primária em saúde)) OR (tw:(cuidados de saúde primários)) OR (tw:(cuidados primários à saúde)) OR (tw:(cuidados primários de saúde)))
Search Expression BDENF via the Virtual Health Library	((tw:(criança)) OR (tw:(crianças))) AND ((tw:(pesquisa sobre serviços de saúde)) OR (tw:(pesquisa sobre prestação de cuidados de saúde)) OR (tw:(pesquisa nos serviços de saúde)) OR (tw:(avaliação de serviços de saúde)) OR (tw:(avaliação dos serviços de saúde)) OR (tw:(avaliação dos serviços))) AND ((tw:(atenção primária à saúde)) OR (tw:(atenção primária de saúde)) OR (tw:(atenção básica)) OR (tw:(atenção básica à saúde)) OR (tw:(atenção básica de saúde)) OR (tw:(atenção primária)) OR (tw:(atenção primária em saúde)) OR (tw:(cuidados de saúde primários)) OR (tw:(cuidados primários à saúde)) OR (tw:(cuidados primários de saúde)))

Primary studies which evaluated PHC services from the perspective of child caregivers through applying the PCATool – children’s version, without time/period determination, in Portuguese, English and Spanish, and which were available in full in the database were included. Exclusion criteria comprised: literature reviews, secondary studies, letters, editorials, experience reports, case studies, PCATool validation studies, primary studies whose participants were adults, conglomerates, health professionals and/or other subjects who were non-caregivers/family members of children.

First, 1,525 publications were located, being 438 in MEDLINE, 329 in LILACS, 48 in BDENF, 41 in CINAHL and 669 in WOS. Identification and selection were independently performed by two reviewers, taking into consideration the research question and the established inclusion criteria. All titles and abstracts were initially read, and 1,486 were discarded. It is noteworthy that 12 articles were repeated among the databases, which were only counted once. A complete reading of the remaining 27 studies was subsequently performed; 10 articles were excluded after the complete reading because they did not meet the inclusion criteria. Thus, the sample consisted of 17 articles (Figure 1).

Figure 1
– Flowchart adapted from the integrative review article selection process.

An instrument prepared by the authors was used to extract information from the studies included in the review, containing information about: the authorship; publication year; database; purpose, design and study participants; level of evidence; and evaluated PHC attribute/component and its average score. The level of evidence adopted by this IR was stratified into: Level I – meta-analysis of multiple controlled studies; Level II – individual experimental studies (randomized controlled trial); Level III – quasi-experimental studies (non-randomized clinical trial, pre and post-test single group, time series or case control); Level IV – non-experimental studies (descriptive, correlational and comparative research, qualitative research and case studies); Level V – program evaluation data and data obtained systematically; Level VI – expert opinions, experience reports, consensus, regulations and laws²⁰.

DATA ANALYSIS AND PROCESSING

The critical analysis and qualitative synthesis of the selected studies were performed descriptively. Two categories were created in order to discuss the findings which have the purpose of demonstrating strengths and aspects that need improvement to achieve more qualified and resolute primary healthcare, presenting the attributes that reached high and low mean scores. It is noteworthy that a high PHC score is considered to be those that obtain a value greater than or equal to 6.6¹².

RESULTS

CHARACTERIZATION OF THE REVIEW STUDIES

All studies in this review (17 – 100%) were descriptive, 14 (82.4%) were available in the LILACS database, and the number of participants ranged from 34 to 3,145 child caregivers (Chart 2).

Chart 2
– Characterization of productions included in the integrative literature review – Teresina, PI, Brazil, 2018.

Article code. Lead author, year. (Database)	Design (Level of evidence)	Study objective	Study participants
A01. Leão CDA(14), 2011. (LILACS)	Descriptive and quantitative (IV)	To evaluate the attributes of primary healthcare in child healthcare offered by FHS teams compared to other child health services in Montes Claros (MG).	272 child caregivers.
A02. Furtado MCC(15), 2013. (LILACS)	Descriptive and quantitative (IV)	To analyze the presence and extent of Primary Care attributes and the degree of affiliation of children under 1 year of age in the Family Health Unit.	44 mothers of children under 1 year.
A03. Araújo JP(16), 2014. (LILACS/ CINAHL/WOS)	Descriptive and quantitative (IV)	To identify the extent of family orientation and community orientation attributes in child healthcare in primary care services.	548 family members and/or caregivers of children under 12 years old.
A04. Mesquita Filho M(21), 2014. (LILACS/WOS)	Descriptive and quantitative (IV)	To evaluate the attributes of primary healthcare for children and to know associated factors.	419 caregivers of children from 0 to 24 months old.
A05. Oliveira VBCA(22), 2015. (LILACS/WOS)	Descriptive and quantitative (IV)	To compare the care model of Traditional Basic Units (BHU) with the FHS units.	482 family members responsible for children.
A06. Silva AS(17), 2015. (LILACS/WOS)	Descriptive and quantitative (IV)	To evaluate the attributes of primary healthcare regarding access; longitudinality; comprehensiveness; coordination; family orientation and community orientation in the FHS, triangulating and comparing the point of view of social actors involved in the care process.	527 adult users, 34 health professionals and 330 responsible for children up to 2 years old, related to 33 family health teams in 11 municipalities.
A07. Fracolli LA(23), 2015. (WOS)	Descriptive and quantitative (IV)	To evaluate the presence and extension of attributes of Primary Healthcare in the FHS in the city of Quatá-SP.	34 caregivers of children under 2 years.
A08. Oliveira VC(24), 2015. (LILACS)	Descriptive and quantitative (IV)	To evaluate and compare the presence and extension of the longitudinality attribute in the BHU and FHS services in the municipality of Colombo, state of Paraná.	482 relatives of children from 0 up to 1 year-old.
A09. Daschevi JM(25), 2015. (LILACS)	Descriptive and quantitative (IV)	To evaluate the principles of family and community orientation of primary healthcare for children in basic health units of Londrina, Paraná.	609 parents or primary caregivers of children under 12 years old.
A10. Souza GT(26), 2015. (LILACS)	Descriptive and quantitative (IV)	To evaluate the coordination principles of primary healthcare for children in 39 Basic Health Units in the urban area of Londrina, Paraná.	609 parents or primary caregivers children under 12 years old.
A11. Silva AS(27), 2016. (MEDLINE/ WOS)	Descriptive and quantitative (IV)	Evaluate care for children under 2 years of age provided in the FHS.	586 responsible adults/caregivers of children from 0 to 2 years old, however only 330 were considered who unanimously pointed to the FHS as a regular source for child health care.
A12. Harzheim E(28), 2016. (LILACS/ MEDLINE)	Descriptive and quantitative (IV)	To evaluate the limits and possibilities of advances in primary healthcare in the city of Rio de Janeiro from the experience of both adult and children users.	3,145 caregivers responsible for children and 3,530 adults.
A13. Reichert APS(29), 2016. (LILACS)	Descriptive and quantitative (IV)	To identify the principle of family and community orientation in Family Health Units regarding the healthcare of children under 10 years.	344 family members and/or caregivers of children under 10 years.
A14. Diniz SGM(30), 2016. (LILACS)	Descriptive and quantitative (IV)	To evaluate the presence and extension of the comprehensive attribute in child healthcare in the context of the FHS.	344 family members of children.
A15. Santos NCCB(31), 2016. (LILACS/WOS)	Descriptive and quantitative (IV)	To evaluate the family orientation and community orientation attributes according to three PHC models.	1,484 family members and/or caregivers of children under 10 years attended in different PHC models.
A16. Wolkers PCB(32), 2017. (WOS)	Descriptive and quantitative (IV)	To evaluate and compare the quality of primary care offered to children with type 1 diabetes mellitus among the types of public healthcare services in the experience of their primary caregivers.	55 caregivers of children with type 1 diabetes mellitus.
A17. Morais JMO(33), 2017. (LILACS/BDENF)	Descriptive and quantitative (IV)	To identify the following of the principle of primary care, first contact access in basic family health units in the healthcare of children from 0 to 9 years old.	363 female mothers or grandparents of children between 0 and 9 years old.

• Note: (n=17).

The degree of affiliation component (mean = 7.72) of the longitudinality attribute; the utilization component (mean = 7.14) of the first contact access attribute; and the information systems component (average = 6.63) of the coordination attribute presented high average scores (≥6.6), while the other attributes and components obtained low average scores (<6.6) (Chart 3).

Chart 3
Mean evaluation scores for primary healthcare attributes and mean PCATool (children’s version) scores of studies included in the review – Teresina, PI, Brazil, 2018.

Evaluated Attribute/Component	Articles																	Average Scores
	A01	A02	A03	A04	A05§	A06*	A07	A08¢	A09	A10	A11*	A12	A13	A14	A15@	A16	A17#
Degree of Affiliation	-	-	-	-	-	-	9.31	-	-	-	-	7.54	-	-	-	7.76	6.28	7.72
First Contact Access	5.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.40
First Contact Access – Utilization	-	3.6	-	-	6.54	7.99	9.22	-	-	-	7.99	7.88	-	-	-	6.29	7.57	7.14
First Contact Access – Accessibility	-	3.4	-	4.7	3.88	4.87	6.75	-	-	-	4.87	4.72	-	-	-	4.84	5.83	4.87
Longitudinality	8.2	3.4	-	7.8	4.37	6.66	8.54	4.4	-	-	6.66	6.14	-	-	-	7.21	-	6.34
Coordenation	6.3	-	-	5.0	-	-	-	-	-	-	-	-	-	-	-	-	-	5.65
Coordination – Care Integration	-	3.7	-	-	6.67	6.88	7.6	-	-	7.393	6.88	6.01	-	-	-	5.18	-	6.29
Coordination – Information Systems	-	3.5	-	-	5.74	6.98	8.89	-	-	7.62	6.98	6.63	-	-	-	6.71	-	6.63
Comprehensiveness – Available Services	-	2.3	-	-	5.44	5.18	6.78	-	-	-	5.18	5.76	-	5.2	-	2.23	-	4.76
Comprehensiveness – Basic Services Available	5.6	-	-	5.6	-	-	-	-	-	-	-	-	-	-	-	-	-	5.60
Comprehensiveness – Complementary Services Available	4.9	-	-	2.9	-	-	-	-	-	-	-	-	-	-	-	-	-	3.90
Comprehensiveness – Services Provided	8.0	3.8	-	5.6	-	6.5	9.39	-	-	-	6.5	5.44	-	5.4	-	5.43	-	6.23
Family Orientation	4.3	3.2	4.4	4.7	4.70	5.1	7.29	-	5.082	-	5.1	5.43	3.7	-	4.90	3.86	-	4.75
Community Guidance	5.6	3.4	5.1	5.4	3.70	5.69	7.72	-	5.462	-	5.69	5.09	5.7	-	5.53	0.90	-	5.00
Essential score	6.9	3.1	-	5.3	-	6.44	7.62	-	-	-	6.44	6.30	-	-	-	5.78	-	5.99
Derived score	5.0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.00
Overall score	6.4	3.0	-	5.2	-	6.21	7.60	-	-	-	6.21	6.09	-	-	-	5.06	-	5.72

DISCUSSION

ATTRIBUTES WHICH PERFORMED WELL

This category included: utilization component, first contact access attribute; degree of affiliation component of the longitudinality attribute; longitudinality attribute; and care integration components and information systems of the coordination attribute.

Of the four studies²³,²⁸,³²-³³ which assessed the degree of affiliation, three²³,²⁸,³² (75%) had a high score, showing that the primary care service is recognized as a reference for health care by users of the health system, considering that the degree of affiliation is configured as recognition of that health service/professional as the main source to promote the user’s healthcare³³. It is noteworthy that some problems related to the lack of resoluteness of the service and the difficulty of accessibility may influence the degree of affiliation³³.

The first contact access attribute is divided into two components: accessibility and utilization²³, where the first concerns the availability of the service to the user and the ability to meet the demands (routine, spontaneous demand, of acute illness or acute chronic problems), while the second relates to how much the user prioritizes the use of a particular health service¹⁷. It is noteworthy that although the attribute is composed of two components, only the utilization component achieved a good evaluation in 62.5% of the primary articles that evaluated it. Thus, it is understood that PHC is the main alternative when the child needs healthcare.

The longitudinality attribute was well evaluated in 60% of the articles¹⁴,¹⁷,²¹,²³,²⁷,³² that measured it. This attribute is considered as being central to PHC²⁷, as it represents the continuity of user care over time and permanently²⁸. It is important to highlight that the presence of longitudinality in child care provides benefits such as: prescription of more agile prevention actions, reduction of unnecessary referrals, better understanding of the individual’s health/disease process and more accurate diagnoses and treatments, impacting on a reduction in health system costs²²,²⁷. Some factors may negatively influence this attribute, such as: health teams with high turnover among professionals and lack of training of professionals²⁴.

The coordination attribute refers to the guarantee of care continuity from the perspective of an articulated network of health services¹⁴,²¹, as well as the opportunity to identify problems that need permanent monitoring²¹. Its components, care integration and information systems received satisfactory evaluation in 62.5% and 75% of the articles, respectively.

Care integration refers to the availability of access to specialized services by users, however, items that question counter-reference are still poorly evaluated by users¹⁷. In other words, communication between basic and specialized services still does not occur in an effective way²⁶, indicating the need to integrate care networks in order to optimize access and use of health resources by the population.

Regarding the information system component, it is noteworthy that its positive evaluation evidences responsible monitoring of users by professionals for recording important information about the child’s health. The use of these records enables monitoring the health status of the population, which allows improvement and evaluation of health-related indicators. However, a study highlights that these information records and users’ access to them are either not occurring or occurring ineffectively²².

ATTRIBUTES WHICH DID NOT ATTAIN GOOD PERFORMANCE

Attributes and components which did not achieve good performance were inserted in this category, demonstrating the need for improvement in their presence and extension in order to achieve more qualified and resolute PHC for children, which are: first contact access attribute and its accessibility component; coordination attribute; comprehensiveness attribute and its available service components (subdivided into basic services available and complementary services available) and services provided; and family orientation and community orientation attributes.

Regarding the accessibility component of the first contact access attribute, 88.9% of the articles had a low score, which demonstrates weakening in the initial healthcare process, meaning when the user tries to access health services²⁷. In order to justify this problem, factors are highlighted, such as: difficulties in scheduling appointments for the same day²³,²⁷ or when necessary²⁷, getting quick professional telephone assistance²³,²⁷ and long waiting at reception to get an appointment or receive care²³. It is emphasized that the attribute first contact access is complex, considering that it is related to the individual/community and organizational characteristics of health services. Adopting innovative management policies is evidenced to ensure greater accessibility to users and to provide health services which meet their main needs²⁸.

The coordination attribute was evaluated by two¹⁴,²¹ articles, receiving low scores in both. Thus, there is evidence of the still fragmented children’s healthcare in basic services, mainly due to factors which interfere with coordination such as the high turnover of physicians in primary care services and inadequate training in the public health area²¹. It is noteworthy that the negative evaluation of this attribute implies fragility in the care continuity, and consequently care fragmentation, which should be comprehensive and integrated. Thus, it is understood that coordination is an attribute of great relevance to others²⁶, and that comprehensiveness becomes unviable without it³⁰.

The attribute of comprehensiveness and its components were poorly evaluated in most studies, which indicates a barrier to implementing comprehensive care³⁰. From this perspective, the health needs of children and their families should be recognized, and PHC services should have the resources to meet them¹⁵.

Some factors were cited by the studies to explain low scores, such as the unavailability of services that address the drug phenomenon, mental health, visual assessment, and HIV counseling and detection¹⁵,²⁷,³⁰. In addition, a compromise in comprehensiveness may result from overvaluation and searching for services with higher technological densities in the Brazilian health system. In this sense, it is considered essential that professionals and managers identify the health needs of the population and coordinate care in order to provide equitable actions and services³².

The family orientation and community orientation attributes presented unsatisfactory assessments in 92.3% of the studies, which indicates the need to promote health actions that envisage both the individual and their family²⁹,³¹, and cover the community in health actions in order to make changes in the environment in which they live²⁵.

The derived attribute of family orientation considers the family as a care subject, recognizing and meeting their needs¹⁷,²⁹. It is recognized that knowing the context in which the individual/family live provides the professional new care possibilities and more resolute care committed to meeting health needs³¹-³². Thus, comprehensiveness can be compromised if family orientation is ineffective³².

For community orientation, the results show a lack of participation and social control by the population studied in the articles¹⁷, which portrays the importance of knowing the health needs of the community through knowing the context in which families are inserted, and that health actions should take into account the epidemiological profile of the community¹⁶. A weakness of this attribute may compromise planning and evaluation³², as the developed actions may not be recognized as a priority need by the community.

CONCLUSION

Although the management of PHC services has been making efforts to improve its performance and quality in providing and delivering care to the population, problems related to the process and structure of these services still persist, considering that most of the attributes were evaluated unsatisfactorily. Items scored in the “accessibility” component, for example, are barriers to childcare because they are only available during business hours and during the week. In addition, the weakness in the referral and counter-referral process makes it difficult the dialogue between the different levels of care.

It is noteworthy that the items of the services provided component address guidance regarding childcare, especially safety, yet this component was poorly evaluated, showing an absence of and/or insufficient guidance needed for preventing accidents and basic care actions. However, the instrument does not have questions about childcare consultation, in which the growth and development of children under 2 years are verified and monitored, which enables identifying problems in a timely manner.

The family and community context in which the child lives need to be included and valued by health professionals, so that care is tailored to their needs which are diverse and different for each child. From this perspective, the importance of professionals developing communicative and investigative skills with their clientele is highlighted, as these attributes were poorly evaluated.

Despite the persistence of the mentioned barriers, the caregivers and/or guardians of the researched children reported a strong degree of affiliation with PHC services, indicating that they are the main reference for health care, as they seek the basic units when they need (utilization) and have a strong bond with professionals, as children are followed over time (longitudinality).

Therefore, the studies showed the importance of PHC for childcare and the need to develop strategies which promote improving the quality of offered services and an extension of the service hours, as well as executing activities such as care guidelines.

Legend: * articles derived from the same study; # performed an arithmetic mean between the scores found in the eight FHS units; § performed the average of the scores per item and the average between the FHS and BHU stratified scores; @ the mean between the FHS, BHU and Mixed BHU stratified scores is averaged; ¢ average between FHS and BHU stratified scores.

Note: (n=17).

REFERÊNCIAS

• ¹
  Kuang L, Liang Y, Mei J, Zhao J, Wang Y, Liang H et al. Family practice and the quality of primary care: a study of Chinese patients in Guangdong Province. Fam Pract. 2015;32(5): 557-63. DOI: https://doi.org/10.1093/fampra/cmv064
  » https://doi.org/10.1093/fampra/cmv064
• ²
  Mei J, Liang Y, Shi L, Zhao J, Wang Y, Kuang L. The Development and Validation of a Rapid Assessment Tool of Primary Care in China. Biomed Res Int. 2016;2016(ID6019603): 1-13. DOI: http://dx.doi.org/10.1155/2016/6019603
  » http://dx.doi.org/10.1155/2016/6019603
• ³
  Silva AN, Silva SA, Silva ARV, Araújo TME, Rebouças CBA, Nogueira LT. Primary care assessment from a male population perspective. Rev Bras Enferm. 2018;71(2):236-43. DOI: http://dx.doi.org/10.1590/0034-7167-2016-0651
  » http://dx.doi.org/10.1590/0034-7167-2016-0651
• ⁴
  Aoki T, Inoue M, Nakayama T. Development and validation of the Japanese version of Primary Care Assessment Tool. Fam Pract. 2016;33(1):112-7. DOI: https://doi.org/10.1093/fampra/cmv087
  » https://doi.org/10.1093/fampra/cmv087
• ⁵
  Wang W, Shi L, Yin A, Mao Z, Maitland E, Nicholas S et al. Primary care quality among different health care structures in Tibet, China. Biomed Res Int. 2015;2015(ID206709):1-8. DOI: http://dx.doi.org/10.1155/2015/206709
  » http://dx.doi.org/10.1155/2015/206709
• ⁶
  Hoa NT, Tam NM, Peersman W, Derese A, Markuns JF. Development and validation of the Vietnamese primary care assessment tool. PLoS One. 2018;13(1):e0191181. DOI: https://doi.org/10.1371/journal.pone.0191181
  » https://doi.org/10.1371/journal.pone.0191181
• ⁷
  Ferreira T, Paula CC, Kleinubing RE, Kinalski DDF, Anversa ETR, Padoin SMM. Evaluation of the quality of primary health care for children and adolescents with HIV: PCATool-Brasil. Rev Gaúcha Enferm. 2016;37(3):e61132. DOI: http://dx.doi.org/10.1590/1983-1447.2016.03.61132
  » http://dx.doi.org/10.1590/1983-1447.2016.03.61132
• ⁸
  Fracolli LA, Gomes MFP, Nabão FRZ, Santos MS, Cappellini VK, Almeida ACC. Primary health care assessment tools: a literature review and metasynthesis. Ciênc Saúde Coletiva. 2014;19(12):4851-60. DOI: http://dx.doi.org/10.1590/1413-812320141912.00572014
  » http://dx.doi.org/10.1590/1413-812320141912.00572014
• ⁹
  Shi L, Starfield B, Xu J. Validating the adult primary care assessment tool. J Fam Pract. 2001;50(2):161-4.
• ¹⁰
  Cassady CE, Starfield B, Hurtado MP, Berk RA, Nanda JP, Friedenberg LA. Measuring consumer experiences with primary care. Pediatrics. 2000;105(4 Pt 2):998-1003.
• ¹¹
  Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia [Internet]. Brasília; 2002 [citado 2018 fev. 06]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/atencao_primaria_p1.pdf
  » http://bvsms.saude.gov.br/bvs/publicacoes/atencao_primaria_p1.pdf
• ¹²
  Brasil. Ministério da Saúde. Manual do instrumento de avaliação da Atenção Primária à Saúde: Primary Care Assessment Tool - PCATool – Brasil [Internet]. Brasília; 2010 [citado 2018 fev. 06]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/manual_avaliacao_pcatool_brasil.pdf
  » http://bvsms.saude.gov.br/bvs/publicacoes/manual_avaliacao_pcatool_brasil.pdf
• ¹³
  Harzheim E, Starfield B, Rajmil L, Álvarez-Dardet C, Stein AT. Consistência interna e confiabilidade da versão em português do Instrumento de Avaliação da Atenção Primária (PCATool-Brasil) para serviços de saúde infantil. Cad Saúde Pública. 2006;22(8):1649-59. DOI: http://dx.doi.org/10.1590/S0102-311X2006000800013
  » http://dx.doi.org/10.1590/S0102-311X2006000800013
• ¹⁴
  Leão CDA, Caldeira AP, Oliveira MMC. Atributos da atenção primária na assistência à saúde da criança: avaliação dos cuidadores. Rev Bras Saude Mater Infant. 2011;11(3):323-34. DOI: http://dx.doi.org/10.1590/S1519-38292011000300013
  » http://dx.doi.org/10.1590/S1519-38292011000300013
• ¹⁵
  Furtado MCC, Braz JC, Pina JC, Mello DF, Lima RAG. Assessing the care of children under one year old in Primary Health Care. Rev Latino Am Enfermagem. 2013;21(2):554-61. DOI: http://dx.doi.org/10.1590/S0104-11692013000200012
  » http://dx.doi.org/10.1590/S0104-11692013000200012
• ¹⁶
  Araujo JP, Viera CS, Toso BRGO, Collet N, Nassar PO. Assessment of attributes for family and community guidance in the child health. Acta Paul Enferm. 2014;27(5):440-6. DOI: http://dx.doi.org/10.1590/1982-0194201400073
  » http://dx.doi.org/10.1590/1982-0194201400073
• ¹⁷
  Silva SA, Baitelo TC, Fracolli LA. Primary Health Care Evaluation: the view of clients and professionals about the Family Health Strategy. Rev Latino Am Enfermagem. 2015;23(5): 979-87. DOI: http://dx.doi.org/10.1590/0104-1169.0489.2639
  » http://dx.doi.org/10.1590/0104-1169.0489.2639
• ¹⁸
  Mendes KDS, Silveira RCCP, Galvão CM. Integrative literature review: a research method to incorporate evidence in health care and nursing. Texto Contexto Enferm. 2008;17(4):758-64. DOI: http://dx.doi.org/10.1590/S0104-07072008000400018
  » http://dx.doi.org/10.1590/S0104-07072008000400018
• ¹⁹
  Karino ME, Felli VEA. Enfermagem baseada em evidências: avanços e inovações em revisões sistemáticas. Cienc Cuid Saúde. 2012;11 Supl.:11-5. DOI: http://dx.doi.org/10.4025/cienccuidsaude.v11i5.17048
  » http://dx.doi.org/10.4025/cienccuidsaude.v11i5.17048
• ²⁰
  Stetler CB, Morse D, Rucki S, Broughton S, Corrigan B, Fitzgerald J, et al. Utilization-focused integrative reviews in a nursing service. Appl Nurs Res. 1998;11(4):195-206. DOI: https://doi.org/10.1016/S0897-1897(98)80329-7
  » https://doi.org/10.1016/S0897-1897(98)80329-7
• ²¹
  Mesquita Filho M, Luz BSR, Araújo CS. A Atenção Primária à Saúde e seus atributos: a situação das crianças menores de dois anos segundo suas cuidadoras. Ciênc Saúde Coletiva. 2014;19(7):2033-46. DOI: http://dx.doi.org/10.1590/1413-81232014197.17322013
  » http://dx.doi.org/10.1590/1413-81232014197.17322013
• ²²
  Oliveira VBCA, Veríssimo MLOR. Children’s health care assistance according to their families: a comparison between models of Primary Care. Rev Esc Enferm USP. 2015;49(1):30-6. DOI: http://dx.doi.org/10.1590/S0080-623420150000100004
  » http://dx.doi.org/10.1590/S0080-623420150000100004
• ²³
  Fracolli LA, Muramatsu MJ, Gomes MFP, Nabão FRZ. Avaliação dos atributos da Atenção Primária à Saúde num município do interior do Estado de São Paulo - Brasil. Mundo Saúde [Internet]. 2015 [citado 2018 maio 16];39(1):54-61. Disponível em: https://www.saocamilo-sp.br/pdf/mundo_saude/155569/A05.pdf
  » https://www.saocamilo-sp.br/pdf/mundo_saude/155569/A05.pdf
• ²⁴
  Oliveira VC, Veríssimo MLOR. A prática da longitudinalidade no atendimento à saúde da criança: comparação entre modelos assistenciais distintos. Cogitare Enferm [Internet]. 2015 [citado 2018 maio 16];20(1):45-52. Disponível em: https://revistas.ufpr.br/cogitare/article/view/35233
  » https://revistas.ufpr.br/cogitare/article/view/35233
• ²⁵
  Daschevi JM, Tacla MTGM, Alves BA, Toso BRGO, Collet N. Avaliação dos princípios da orientação familiar e comunitária da atenção primária à saúde da criança. Semina Cienc Biol Saúde. 2015;36(1):31-8. DOI: http://dx.doi.org/10.5433/1679-0367.2015v36n1p31
  » http://dx.doi.org/10.5433/1679-0367.2015v36n1p31
• ²⁶
  Souza GT, Alves BA, Tacla MTGM, Collet N, Toso BRGO. Avaliação do princípio da coordenação na atenção primária à saúde da criança em Londrina-PR. Semina Cienc Biol Saúde. 2015;36(1):39-46. DOI: http://dx.doi.org/10.5433/1679-0367.2015v36n1p39
  » http://dx.doi.org/10.5433/1679-0367.2015v36n1p39
• ²⁷
  Silva SA, Fracolli LA. Evaluating child care in the Family Health Strategy. Rev Bras Enferm. 2016;69(1):54-61. DOI: http://dx.doi.org/10.1590/0034-7167.2016690107i
  » http://dx.doi.org/10.1590/0034-7167.2016690107i
• ²⁸
  Harzheim E, Pinto LF, Hauser L, Soranz D. Assessment of child and adult users of the degree of orientation of Primary Healthcare in the city of Rio de Janeiro, Brazil. Ciênc Saúde Coletiva. 2016;21(5):1399-408. DOI: http://dx.doi.org/10.1590/1413-81232015215.26672015
  » http://dx.doi.org/10.1590/1413-81232015215.26672015
• ²⁹
  Reichert APS, Leôncio ABA, Toso BRG, Santos NCCB, Vaz EMC, Collet N. Family and community orientation in children’s primary healthcare. Ciênc Saúde Coletiva. 2016;21(1):119-27. DOI: http://dx.doi.org/10.1590/1413-81232015211.05682014
  » http://dx.doi.org/10.1590/1413-81232015211.05682014
• ³⁰
  Diniz SGM, Damasceno SS, Coutinho SED, Toso BRGO, Collet N. Evaluating comprehensiveness in children’s healthcare. Rev Gaúcha Enferm. 2016;37(4):e57067. DOI: http://dx.doi.org/10.1590/1983-1447.2016.04.57067
  » http://dx.doi.org/10.1590/1983-1447.2016.04.57067
• ³¹
  Santos NCCB, Toso BRGO, Collet N, Reichert APS. Family-centeredness and community orientation according to three child health care models. Acta Paul Enferm. 2016;29(6):610-7. DOI: http://dx.doi.org/10.1590/1982-0194201600086
  » http://dx.doi.org/10.1590/1982-0194201600086
• ³²
  Wolkers PCB, Macedo JCB, Rodrigues CM, Furtado MCC, Mello DF. Primary care for children with type 1 diabetes mellitus: caregiver perspectives. Acta Paul Enferm. 2017;30(5):451-7. DOI: http://dx.doi.org/10.1590/1982-0194201700066
  » http://dx.doi.org/10.1590/1982-0194201700066
• ³³
  Morais JMO, Morais FRR, Santiago CMC. Acesso de primeiro contato na Atenção Primária à Saúde para crianças de 0 a 9 anos. Rev Online Pesquisa Cuid Fundam. 2017;9(3):848-56. DOI: http://dx.doi.org/10.9789/2175-5361.2017.v9i3.848-856
  » http://dx.doi.org/10.9789/2175-5361.2017.v9i3.848-856

Publication Dates

• Publication in this collection
  13 Dec 2019
• Date of issue
  2019

History

• Received
  13 July 2018
• Accepted
  11 Apr 2019