HEALTH SERVICES IN TUBERCULOSIS CONTROL: FAMILY FOCUS AND COMMUNITY ORIENTATION

O objetivo deste estudo foi avaliar, na percepção dos doentes, o desempenho dos Serviços de Saúde responsáveis pelo controle da tuberculose (TB) em relação às dimensões enfoque na família e orientação para a comunidade. Como método, foi usada a pesquisa avaliativa transversal com 108 doentes de TB. Utilizou-se questionário elaborado por Starfield e Macinko, adaptado para a atenção à TB por Villa e Ruffino-Netto. Os resultados apontam que, na primeira dimensão, os profissionais de saúde (PS) demonstram preocupação em relação aos sinais/sintomas dos pacientes e, em menor grau, sobre outros problemas de saúde dos familiares, comprometendo a integralidade do cuidado. Na segunda dimensão, os PS mostram pouca preocupação quanto à busca ativa dos casos, deficiência na capacitação de PS, baixa taxa de contatos examinados. Conclui-se pela necessidade de ampliar a visão epidemiológica dos PS, cuja atenção está focalizada no doente, com poucas ações preventivas sobre a família/comunidade, o que evidencia ser imprescindível maior aproximação entre PS/doentes/familiares/comunidade.

It is worth highlighting that, during the last decade, Brazil experienced great changes in health system organization.Primary care received special attention because of the introduction of innovative and strategic programs to change the care model in the Unified Health System -SUS (2) .
Establishing new dimensions like family focus and community orientation in primary care services is necessary to support changes in quality and strengthen commitment and involvement among HP, patients, family and community.Thus everybody can feel like "active subjects" in the search for better living conditions.
In 1992, the World Health Organization (WHO) declared tuberculosis (TB) an emergency in the world.
According to its estimates, one third of the world population is infected with M tuberculosis.Of those, eight million will develop the disease and two million will die every year.Currently, Brazil is ranked 16 th in a ranking of 22 countries concentrating 80% of global TB cases (1) .
Studies show the need to create alternatives for TB control focused on participatory, collective and comprehensive health practice, connected to the Strategies.This focus compulsorily involves a Health Surveillance system that prioritizes the surveillance of the space/population/family/community where the disease occurs, instead of classic, patient-focused surveillance (3)(4) .

MATERIAL AND METHOD
This is an evaluative, quantitative, crosssectional research, using the Primary Health Care (PHC) dimensions as theoretical framework (5) .TB The Primary Care Assessment Tool (PCAT) was used (5) .This instrument was adapted and validated in Brazil for TB care (6) .In a broader study, eight PHC dimensions were considered.In this study, the following dimensions were assessed: Family focus

Characterization of TB patients
Of the 108 interviewed patients in the city, 83.3% undergo supervised treatment, of those 77.8% in the municipal reference outpatient clinic, and only 22.2% in UBS.Of the total, 65.7% are male, 66.7% have primary education (complete or incomplete), 55.6% live in owned houses and 98.1% live in masonry houses.As to socioeconomic characterization, more than 95% have piped water, refrigerator, electricity, bathroom at home and TV, 50% have car and 65%, telephone.

Family focus dimension -regards patients
in their daily environment, taking into consideration that health needs assessment should consider the family context and any health threat, besides coping with limited family resources (5) .
Figure 1 presents the frequency distribution of answers regarding care provided by HP to TB patients and their relatives.
It is observed in Figure 1 that health professionals always ask information about patients' and family's life circumstances, about diseases in the family, and cough or fever, with frequencies of 63, 65 and 69%, respectively.These percentages reflect, in a way, the concern with patients and/or their relatives.
As  In Figure 2, it is observed that variable V3 had the highest score, 4.23.This score presents a statistically significant difference with variables V5, V6, V7 and V8.It is also observed that there is no statistically significant difference among the variables V3, V4, V2 and V1.On the other hand, it is observed that the V8 variable had the lowest score, that is, 2.11, statistically significant different from the other variables of this dimension.

The community orientation dimension
implies the acknowledgment that all health needs of the population occur in a specific social context, w h i c h s h o u l d b e k n o w n a n d t a k e n i n t o consideration (5) .The variables V4 and V5 had equal scores.health system to deal with different realities and prioritize regions with a higher incidence of the disease (7) .

DISCUSSION
As to the family focus dimension, on the whole, health professionals are concerned with patients' signs/symptoms and, to a lesser extent, with family life circumstances and diseases, evidencing little concern with other health problems of the family.
The search for respiratory symptomatic (RS) patients in TB control is complex and requires knowledge beyond technical/specific abilities.The family approach surpasses the biological knowledge.
It is characterized by a sequence of activities that includes contact at home; orientation about the disease, signs and symptoms; ways of transmission; identification of RS; orientation on sputum collection; forwarding and reception of the material by the Basic Health Unit (UBS); flow of examinations to the laboratory; receiving results by the unit and users, and forwarding diagnosed cases for follow-up in outpatient clinics (8) .
A study carried out in São José do Rio Preto points out data about service organization, and shows their lack of systematization in control monitoring of TB patients' contacts.Care is still patient-centered, with limited actions towards contacts and little valorization of preventive actions (9) .
Shared commitment, involving health services, patients and family, is required for TB treatment success, through agreements that consider needs of all parts involved (10) .Patients and relatives should become protagonists of their own treatment and active subjects in decision-making on their therapeutic project (11) .
Including relatives in treatment is an extremely important action and should be considered HP involvement in actions to search for RS is considered their form of participating in planning and putting this activity in practice (12) .
Low problem solving capacity was also observed in Ribeirão Preto, from 1998 to 2006 (in this period, the percentage of baciloscopies carried out varied from 15 to 26% of the expected) and the detection of new cases varied from 40 to 80.5%.
These data suggest the basic health network is not searching for RS in the community (12) .
Also in Ribeirão Preto, a study carried out with a group of nurses showed they believed HP's way of acting, as to RS, is directly related to the way care is delivered to patients.The active search for RS in the community occurs in a limited way or through specific demands (12) .
The need to introduce new work strategies in the care model, to remodel the "old" and develop a "new" system is highlighted (13) .The traditional care model needs to be replaced by a modern model, incorporating patients' expectations, with active involvement of families and organized sectors of the community with a view to a greater inclusion of social actors in the disease's treatment, the most comprehensive dimension for the conception of the health promotion model (14) .
Health services (HS) are organized to provide care in severe conditions, leaving chronic diseases in second place.Seventy-five percent of the diseases that occur in Brazil are related to chronic conditions (13) .
In families facing chronic health conditions, bonding between HS and family should be prioritized.
Although TB is a chronic disease, the need to train human resources suitable to achieve these aims is emphasized.
The factors most commonly associated to low effectiveness are HS's lack of organization, bad social conditions and low treatment adherence.TB control should be understood beyond a biomedical intervention and address considering patients' perspective and the context of the health practices (15)   .
The participation of the organized civil society the performance of the community sector is beyond discussion and indispensable (16) .

FINAL CONSIDERATIONS AND CONCLUSIONS
The performance of the city in the family focus dimension showed that HP are concerned with patients' signs and symptoms and, to a lesser extent, with other health problems of their relatives, endangering comprehensive healthcare.Regarding the community orientation dimension, it is observed that HP are less concerned with the active search for cases.In the variable that requires patient observation of advertisements, scores were high, however, the same does not happen for the offering of services provided by HP.
It is important to mention that poor HP training, few RS and examined contacts, and the need for intervention strategies to improve the quality of the services offered to patients are aspects worth highlighting.
community reality and able to surpass the borders of the health units (UBS).The family focus and community orientation dimensions are a new paradigm in SUS, and are essential for the reorganization of the services and in the Family Health patients from São José do Rio Preto, a city in the Northwest of São Paulo, Brazil, with 450 000 inhabitants, were inquired.The study sample consisted of 108 patients, under follow-up in the Tuberculosis Control Program (TCP) at the health units, from June 2006 to July 2007.
Interviewees answered questions according to a pre-established, Likert-type scale, ranging from 0 to 5 (0 was attributed to the answer "I do not know" or "it does not apply" and values from 1 to 5 registered the degree of preference or concordance relation with the statements).Before data collection, explanatory scripts were used to clarify patients about the questionnaire's answering scale.Interviewers explained interviewees about answers' numerical meaning (1 to 5 scores), for instance: never = 1; seldom = 2; sometimes = 3; often = 4; always = 5.Interviewers were trained before applying the instrument (questionnaire).Exploratory analysis was used to measure the categories of answers to the questionnaire questions, as well as to verify possible inconsistencies in databases.Each indicator was developed through the total scores (categories) of patients' answers, divided by the total number of interviewed patients, resulting in a mean value.Descriptive statistics was used for data analysis.The research project was approved by the Research Ethics Committee of the University of São Paulo at Ribeirão Preto College of Nursing, according to the guidelines of Resolution 196/96 CNS (National Health Council).

Figure 2 -
Figure 2 -Distribution of the confidence intervals of the variables regarding TB patients' answers, as to the family focus dimension, São José do Rio Preto, SP, 2007

Figure 3
Figure 3 presents the frequency distribution a s t o t h e k i n d o f c a r e p r o v i d e d b y h e a l t h professionals with respect to the community orientation dimension.

Figure 3 -
Figure 3 -Distribution of TB patients' answers as to the family focus dimension variables.São José do Rio Preto, SP, 2007 studies have been carried out in the same city, addressing these epidemiological factors, focusing on the organization of the health services and structuring of the TCP.Through secondary data sources, it was observed that, despite the satisfactory socioeconomic indicators, the risk of getting TB is two times higher in the area with worse socioeconomic levels.This shows the need to change the current medical care standard, human resources training and to redirect public policies.Identifying areas with different TB risks allows the municipal in all cases.The TCP team should work jointly with the UBS and PSF/PACS (Family Health Program/ Community Health Agents Program) teams.In the community orientation dimension, activities that depend on patients (i.e.: observing what is offered in terms of advertisement/posters/ educational material) presented high scores.The same did not occur with the responsibility to offer services, such as RS active searching the community for sputum collection and requiring community participation to discuss TB-related health problems.
and non-governmental organizations is essential in TCP activities.Social movements should work to benefit from training opportunities.There have been advances, such as the creation of the Brazilian Partnership Against Tuberculosis, by the Ministry of Health, in 2004, proposed by the Stop TB Partnership in Geneva.Besides this, there is a broad discussion of TB control strategies in Brazil, taking into consideration articulation, intersectoriality, interdisciplinarity and participation of civil society.In the current context of the fight against TB in Brazil,
to the supply of reservoir for sputum examination, knowledge about relatives, if HP talk with them about the disease or treatment or about other health problems, "always" was answered in 60 (the Ministry of Health -MS-suggests 100%), 48, 46, 46 and 16% of cases, respectively.Health professionals talk little about other health problems, compromising the comprehensive aspect of health care.Figure 1 -Distribution of TB patients' answers regarding the family focus dimension variables.São José do Rio Preto, SP, 2007 Rev Legend: V1.Do health professionals (HP) ask about your family's life circumstances?V2.Do HP ask about diseases in the family?V3.Do HP ask if relatives have cough or fever?V4.When you got TB, did HP supply reservoirs for sputum examination to all your family members?V5.Do HP know your relatives?V6.Do HP talk to your relatives about TB? V7.Do HP talk to relatives about TB treatment?V8.Do HP talk to relatives about other health problems?