FAMILY PERSPECTIVE ON A FAMILY CARE PROGRAM

Este estudio tiene como objetivo analizar la evaluación del usuario sobre la atención a la salud de la familia, con la finalidad de verificar las dificultades y potencialidades para transformar el modelo de atención a la salud. Se trata de un estudio de caso cualitativo, realizado en una Unidad de Salud de la Familia, en San Sebastián, Brasilia-DF, Brasil, cuya recolección de datos consistió en la observación del proceso de trabajo desarrollado por el equipo y grupos focales con usuarios. Los datos analizados, utilizando la técnica del Discurso del Sujeto Colectivo, demostraron que las acciones de prevención y promoción de la salud y la relación de profesionales y usuarios fueron evaluadas positivamente; y, el acceso a los servicios de salud, a los medicamentos y a los profesionales fue evaluado negativamente. Las acciones desarrolladas no garantizan la atención integral de la salud de la familia y señalan la necesidad de revisar las estrategias de organización del servicio, sobre todo las que posibiliten la participación de la comunidad para resolver sus necesidades.


LA ATENCIÓN A LA SALUD DE LA FAMILIA EVALUADA POR EL PROPIO USUARIO
Este estudio tiene como objetivo analizar la evaluación del usuario sobre la atención a la salud de la familia, con la finalidad de verificar las dificultades y potencialidades para transformar el modelo de atención a la salud.Se trata de un estudio de caso cualitativo, realizado en una Unidad de Salud de la Familia, en San Sebastián, Brasilia-DF, Brasil, cuya recolección de datos consistió en la observación del proceso de trabajo desarrollado por el equipo y grupos focales con usuarios.Los datos analizados, utilizando la técnica del Discurso del Sujeto Colectivo, demostraron que las acciones de prevención y promoción de la salud y la relación de profesionales y usuarios fueron evaluadas positivamente; y, el acceso a los servicios de salud, a los medicamentos y a los profesionales fue evaluado negativamente.Las acciones desarrolladas no garantizan la atención integral de la salud de la familia y señalan la necesidad de revisar las estrategias de organización del servicio, sobre todo las que posibiliten la participación de la comunidad para resolver sus necesidades.DESCRIPTORES: atención primaria de salud; salud de la familia; satisfacción de los consumidores

INTRODUCTION
The Family Health Strategy (ESF) is a priority approach for the reorganization of primary care based on the Brazilian National Health System (SUS) principles.This strategy should be implemented using management and health practices that are equitable and involve the community, provided by a multidisciplinary team and delivered to populations in defined linked areas with the use of highly effective and complex, low-density technologies (1) .It should be integrated to a network of services to assure comprehensive care to individuals and their families and provide referral and counter-referral from the primary care level to more complex levels of attention.
In the Federal District, Brasília, the Family Health Strategy is currently known as the Healthy Family Program (in Portuguese, PFS).Ten years after its implementation, as seen nationwide, PFS has been meeting significant challenges locally.Difficult access to care, discontinued attention and lack of comprehensive care are some of the problems faced, calling for a profound reevaluation of this complex program (2)(3)(4) .
It is thus crucial to evaluate the PFS as part of a process of critically assessing the services provided based on the participation of the involved actors, especially those users who can more clearly and reliably articulate their opinions on care delivered to them (2,(5)(6)(7)(8)(9) .In this sense, the evaluation made by the very population attended by PSF team aims at providing input for rethinking professional practices and implementing actions for the improvement of service organization.
Studies as such have incorporated into the evaluation process a subjective dimension that allows to assessing quality of PSF services, including user's satisfaction assessment (6)(7)(8)(9) .However, it should be noted that most studies have adopted mechanist and functionalist approaches, overlooking priority issues for service evaluation (7)(8)(9) .
Acknowledging these limitations and the special need to broaden the analyses and go beyond the simple appraisal of PSF user's satisfaction, an evaluation process has been proposed to explore cultural and behavioral changes: representations of the health-disease process, appropriate care practices and health management strategies (8)(9) .Also, it should further examine the meaning of family, which is regarded as a social agent of change from a wider perspective.
Hence, this evaluation should allow users to actually expressing their subjective views about the care service (7)(8)(9)(10)(11) , giving them an opportunity to freely discuss their feelings and perceptions about several different dimensions: general needs (deficiencies, health-related necessities); cognitive (perception about care service); relational (respect, listening, reception); organizational (access to services, drugs, providers); and professional (quality and competence) (8)(9) .
The purpose of the present study was to provide input to consider the inclusion of user subjectivity in the assessment of health service quality and to examine family care from the user's perspective to identify critical challenges and potential capacities for improving care and ultimately reorganizing the care model.

USER SATISFACTION: A BRIEF REVIEW
Since 1960s in Europe and the US and mid-1990s in Brazil, user satisfaction approach has been applied in health evaluation studies (12-13)   .This approach focuses on the different dimensions involved in health care, from doctor-patient relationship to the quality of facilities and care delivered by health providers.
The concept of quality has enabled to better define measurement variables of service quality with the inclusion of a non-specialized outlook; i.e., users' view (13)   .Several models have been designed for user satisfaction assessment and most are based on the assumptions of user perceptions concerning their expectations, values and needs at the different dimensions of health care (12)(13) .
When forming their opinion about services, users take into consideration one or more combinations of the following aspects: an ideal service; a notion of care service they ought to have; their past experiences in similar services; and a minimum subjective level of service quality to be achieved to be acceptable (12)(13) .
Recognizing the inherent complexity of user's assessment process of service quality, the World Health Organization (WHO) introduced a surrogate for the concept of satisfaction: responsiveness.This proposed concept intends to examine how governmental actions meet people's expectations and demands (12) and is based on the assumption that health systems should promote and maintain people's health, treat them with dignity and facilitate their involvement in decision making regarding their health care, treatment and other management.
Family perspective on a family… Shimizu HE, Rosales C.
More recently, due to a concern to actually take into consideration users' status in health services and systems and, more importantly, to allow them to express their status, the concept of humanization was included in the design of health services evaluation studies (10)(11)(12) .This concept focuses on human, A two-step data collected was carried out.
First, data was collected from a focus group discussion.
There were two sessions, on average an hour and half each, where a coordinator and an observer met with members of 10 families who attended the PSF for at least a year and lived in the five microareas studied.The focus group participants were selected by drawing and had the following profile: 60% were females, 40% males; 50% had complete and 50% had incomplete elementary schooling; 60% were homemakers, 30% unemployed and 10% were retired.
The focus group discussions were guided based on the following statements: "Tell us how you perceive the PFS"; and "Tell us about the pros and cons of care provided at the PFS".The discourse of the collective subject (DCS) approach was applied in the analysis (14)   .Key expressions of central ideas were first identified in each speech and then central ideas Ethics Committee and all subjects signed a free informed consent form after the objectives, methods, risks and benefits of the study were discussed.

RESULTS AND DISCUSSION
DCS 1 showed that users, when referring to PFS, first focused on the health representation.This representation should be well understood as it guides users' attitudes and practices toward health care (8)(9) .In fact, while health providers have been promoting a change in the way people take care of their health, many efforts still focus on the biomedical model with a strong mechanist or at most systemic emphasis that affects health practice (15) .Such approaches fail to facilitate the complex human processes of life, health, care, cure and death.
Family perspective on a family… Shimizu HE, Rosales C.
There is a need to advance actions of health prevention and promotion as well as to reinforce the idea of health as a social right based on the utilization of all technologies available for health prevention, promotion, treatment and rehabilitation (16) .
DCS 2 illustrated the family representation, which is the main goal of PFS team work.Users described the family as a core social institution traditionally formed by a father, a mother and children and its role is to provide affection, care and help to its members.However, it has changed due to recent trends of reduced family size, fragile marital bonds and multiple arrangements other than that of the conventional nuclear family.This is above all a result of single-parent families commonly headed by single women.These trends have raised questions about the centrality and future of the families in modern societies as well as their responsibilities and social roles.
Focusing on the family is a breakthrough toward changing the health care model.Yet it calls that providers take an in-depth, contextualized approach.To begin with, family should not be regarded as a biological, natural or set body but rather a product of historical forms of human organization.In addition, the family can be approached in multiple ways and the health team should find the best approach that will allow them to take on roles that can communicate with each other and be complementary to produce a comprehensive care (17) .

Users evidenced their representations about PFS team providers in DCS 3:
The health team is also our family because they help us when we find ourselves in a predicament.Nursing staff provide us medicines, care, and cleans us and takes us to the toilet.This is all very important.However, there is god, there is the family and there is the doctor.In regard to the work developed at the PSF unit, DCS 4 evidences it is intended to the management of low-technology medical conditions.
During the study observation it was verified that the work team spends most of its time in internal medicine, prenatal, growth and development visits which are prescheduled and organized on free demand.These visits are short, lasting no more than 15 minutes, and focus on complaints with little room for discussion between users and providers.Besides, there are also groups of high blood pressure and diabetes patients who have an opportunity of undergoing procedures for disease management.
Home visits, particularly paid to those patients with special needs, were positively evaluated.It was observed that health workers pay home visits, identify family problems and then discuss them with the team.
They are welcome in the community and people tell them their problems and seek clarification about their care.
Users also positively evaluated lectures and disease prevention campaigns.It was found that lectures addressing hygiene care, healthy eating, environment and waste management, family planning and newborn care are delivered in simple language but attendance is low and educational resources are poor.Users had a positive attitude toward disease Family perspective on a family… Shimizu HE, Rosales C.
prevention campaigns since they perceived it as an important opportunity of health management.
These findings indicate that PSF actions aim at managing health problems with low technology; they take most of the providers' time, especially the doctor's; and there are also educational and group management activities, which are highly important for improving primary care.However, it becomes clear that, for improving care quality, quality actions with effective involvement of users and based on the assessment of their actual needs and demands are required.
In DCS 5 users pointed out flaws in the program organization: Here at PSF we are not seen on the same day but we make an appointment to be seen later.But  With respect to program organization, it was pointed out difficult access to care chiefly because of bureaucracy obstacles to get to be seen.Everyday about 10 patients with scheduled visits are not seen.
Several users had their visits rescheduled for a month later, some complained they had to come for the third time to wait for an opening.A large number of users also tried to get home visits and others complained of long wait at the unit and other services of higher complexity.
Another issue pointed out in DCS 5 was difficult access to drugs.It evidences that the Brazilian Ministry of Health drug aid program for promoting comprehensiveness has not been adequately meeting people's needs.
In addition, DCS 5 shows users have difficult access to testing.Apparently the difficulty to manage health conditions requiring high technology has made users believe they need a hospital in their area.This belief prevents users from appreciating PSF and health prevention and promotion actions as well.And, lastly, users reported difficult access to providers as there were too many people to be seen.

Access to many services (visits and tests)
and drugs is limited.There is a clear need for PFS to improve the program's comprehensiveness with sustained coordination of family-related health practices (not seen at the unit) to ensure the required delivery of continuous, global services and providers and organizations, all articulated in time and space.
Comprehensive care necessarily requires the integration of services through care networks considering the interdependence of actors and organizations as they do not have by themselves all resources required for managing users' conditions during their life cycles (18) .DCS 6 focus on the relationship between providers and users: I was welcomed at PSF and very all served, they all treat me well.This team is very good in welcoming and providing people care, affection and attention.The doctor is excellent, I like him a lot.I cannot complain and I appreciate a lot their care. ( Users revealed that the team providers are kind and affectionate in both reception and care. Humanization of care was assimilated as a core component of work.This concept brings in the notion of dignity and respect to human life, underscoring the ethical dimension of the relationship between patients and health providers (19) .
In DCS

FINAL CONSIDERATIONS
The study findings show that representation of health as absence of disease based on the individual and ethical dimensions of care and user's rights and empowerment.Although new and not yet strong, this proposal calls for the inclusion of a healthrelated social/cultural dimension in the evaluation process, especially in qualitative studies.METHODSIt was opted to conduct a qualitative study as it allows capturing subjects' perceptions, beliefs and values on an array of situations routinely experienced at PSF.The PFS unit in the city of São Sebastião, Federal District, was studied since it met the inclusion criteria: large staff in the metropolitan area; at least six months of operation; and primary care team available (one doctor, one nurse, three nursing assistants and five health workers).
were singled out and grouped.Each group was named and a summary central idea was designated.Finally, DCS were constructed for each group as shown above.The second step of data collection included non-participant observation of the work process developed at the PSF unit.Two trained investigators collected the data and recorded it on a log book.The following aspects were observed over a two-week period (30 hours): user's reception, screening, medical and nursing visits, procedures, home visits, campaigns and educational lectures.Over the first week, there were 20 hours of observation (morning and afternoon), and over the second week, 10 hours (morning and afternoon).The study investigators deemed this amount of observation time sufficient as it provided information on how the work was developed at that service.This step was intended to assess the quality of care, the relationship between providers and users, access to care service and management effectiveness.To further explore the reality of care, i.e., PSF everyday operation, this data was crossexamined with DCS.The study was approved by the Federal District Local Health Department (SES/DF) Research

Family perspective on a
family… Shimizu HE, Rosales C. Rev Latino-am Enfermagem 2008 setembro-outubro; 16(5):883-8 www.eerp.usp.br/rlaebiomedical model still prevails among health services users.It evidences a need of PFS to strongly focus on a broader concept of health, which includes the understanding of basic human biological, psychological and social needs for health promotion.As for health practices developed at PFS, they focus on the management of health conditions requiring low technology.Users positively evaluated health prevention and promotion actions including home visits, educational lectures and disease prevention campaigns.These are valuable tools but more creative strategies are needed for improving care quality.Users' satisfaction regarding service organization is very low, mostly because of difficult access to services, drugs and providers, which are key for health management.Care provided was perceived as humanized, caring and respectful, which indicated that bonds can be developed between providers and users as they are crucial for family care.In conclusion, PSF has made some advances in family care but its actions need to be redirected for bringing about change to the care model, with an effective involvement of users for meeting their needs.People's empowerment should be sought in the process of program management as a requisite for quality policy and technical actions and the development of a cultural identity in the community, opening up new horizons for gaining the right to a healthy lifestyle.