Child Health Handbook in Primary Care: perspectives of family health professionals and mothersABSTRACT
Objective: To understand the use of the Child Health Handbook in Primary Care from the perspective of family health professionals and mothers.
Method: Qualitative research, grounded in Symbolic Interactionism, with 25 family health professionals and 11 mothers, in a city in Northeast Brazil. The data were collected in the months of September and October 2020, through semi-structured interviews and submitted to inductive thematic analysis.
Results: The following thematic units were developed: “Use of the Child Health Handbook in Primary Care: the role of nursing”, which revealed nurses as the professionals who most frequently observe and fill out the records in the handbook and guide mothers; and “Obstacles to the use of the Child Health Handbook in Primary Care”, which highlighted the weaknesses in academic training and the unavailability of the handbook as obstacles to its use.
Conclusion: Nurses play a central role in monitoring child development using the Child Health Handbook in Primary Care. The work of nurses, as important members of the multiprofessional team, has the potential to give new meaning to this instrument for other professionals, and for mothers, positively impacting child development.
Descriptors:
Nursing; Public health surveillance; Child development; Primary health care; Symbolic interactionism
RESUMO
Objetivo: Compreender o uso da Caderneta da Criança na Atenção Primária sob o olhar dos profissionais de saúde da família e das mães.
Método: Pesquisa qualitativa, ancorada no Interacionismo Simbólico, com 25 profissionais de saúde da família e 11 mães, em município do Nordeste brasileiro. Os dados foram produzidos nos meses de setembro e outubro de 2020, mediante entrevista semiestruturada e submetidos à análise temática indutiva.
Resultados: Foram elaboradas as unidades temáticas: “Utilização da Caderneta da Criança na Atenção Primária: o protagonismo da enfermagem”, que desvelou os enfermeiros como profissionais que mais observam e preenchem os registros na caderneta e orientam as mães; e “Obstáculos para utilização da Caderneta da Criança na Atenção Primária”, que evidenciou as fragilidades na formação acadêmica e a indisponibilidade da caderneta como obstáculos para sua utilização.
Conclusão: Os enfermeiros são protagonistas na vigilância do desenvolvimento a partir da utilização da Caderneta da Criança na Atenção Primária. A atuação do enfermeiro, que é um importante membro da equipe multiprofissional, tem potencial para ressignificar esse instrumento pelos demais profissionais da equipe e pelas mães, repercutindo, de forma positiva, no desenvolvimento infantil.
Descritores:
Enfermagem; Vigilância em saúde pública; Desenvolvimento infantil; Atenção primária à saúde; Interacionismo simbólico
RESUMEN
Objetivo: Comprender el uso del Manual del Niño en Atención Primaria desde la perspectiva de los profesionales de la salud de la familia y de las madres.
Método: Investigación cualitativa, anclada en el Interaccionismo Simbólico, con 25 profesionales de la salud de la familia y 11 madres, en una ciudad del Nordeste brasileño. Los datos fueron producidos en septiembre y octubre de 2020, a través de entrevistas semiestructuradas y sometidos a análisis temático inductivo.
Resultados: Se desarrollaron unidades temáticas: “Uso del Manual del Niño en Atención Básica: el papel de la enfermería”, que reveló al enfermero como el profesional que más observa y completa los registros del manual y orienta a las madres; y “Obstáculos para el uso del Manual del Niño en Atención Primaria”, que destacó las debilidades en la formación académica y la falta de disponibilidad del manual como obstáculos para su uso.
Conclusión: Los enfermeros son protagonistas en el seguimiento del desarrollo a través del uso del Manual del Niño en Atención Primaria. El papel del enfermero, miembro importante del equipo multidisciplinario, tiene el potencial de dar un nuevo significado a este instrumento para los demás profesionales del equipo y para las madres, impactando positivamente en el desarrollo infantil.
Descriptores:
Enfermería; Vigilancia de la salud pública; Desarrollo infantil; Atención primaria de salud: Interaccionismo simbólico
INTRODUCTION
Health care workers are important agents for the full development of childhood. Early interaction with children and their families will provide workers with the opportunity to contribute to promoting child’s health, healthy nutrition, strengthening bonds, early and appropriate stimulation1, as well as Child Development Surveillance (CDS).
CDS is characterized as a process based on flexibility, longitudinality and continuity. Through it, professionals identify children with possible developmental issues and, if necessary, refer them to specialized services, health education and family-centered care, with the aim of promoting child development2).
For CDS to be effective, professionals should include the following components into their practice: listening attentively to caregivers’ concerns about the child's development; obtaining, documenting and maintaining a developmental history; making accurate observations of the child; recognizing risk and protective factors; keeping a clear and accurate record of the process and findings; and discussing viewpoints and findings with professionals from other areas who care for children2.
The multiprofessional team working in Family Health Units (FHU) is committed to developing actions that promote and protect health, prevent injuries, treat, rehabilitate and maintain health across different social settings and throughout the entire life cycle3. This interdisciplinary practice can bring significant benefits to CDS, since different professional competencies can work together to provide comprehensive care in view of the complexity of child growth and development4.
To operationalize the monitoring of child growth and development, the National Policy for Comprehensive Child Health Care (Política Nacional de Atenção Integral à Saúde da Criança - PNAISC), published in 2015, recommends implementing and using the Child Health Handbook (CH) by all individuals involved in care. This tool consists of two parts, the first containing information intended for the caregiver/family member on aspects related to the child’s rights and care; and the second part for records of child monitoring by professionals5. Thus, by providing the opportunity to fill in data and communication between professionals and families, the CH acts as a guiding thread for comprehensive child care6.
A scoping review analyzed 129 studies that addressed the CH in Brazil and identified in filling out all aspects assessed, except in the vaccination section. This is justified by various reasons, such as characteristics of the child, family, and caregivers, as well as health professionals who can influence its use and adequate completion7. The use of the CH is still inconsistent and neglected by those responsible for caring for the child in PHC, resulting in disruption in the monitoring of each stage of child development8.
There are gaps in the completion of almost all items of the CH, except for vaccination, and there are different factors that interfere with the use of the tool, such as: contextual factors (availability of the CH), the characteristics of the infants (such as sex, age, prematurity and frequency of childcare consultations), family members and caregivers (age, educational level, income, number of children, employment, participation in prenatal care, reading ability and present the CH at consultations) and health workers (work environment, specialty, communication at work, knowledge about the tool and ability to request, guide and complete the handbook)7.
The deficiencies in filling out the CH highlighted in the literature7-9 point out the need for actions that strengthen the use of this development monitoring tool in PHC, by all family members of the health team.
It is crucial to understand how the use of the CH by health professionals occurs during childcare, based on the perceptions of Family Health Strategy (FHS) workers and mothers of children under three years old, to understand the meanings that permeate the use of the Child Health Handbook in PHC and, from this, propose health actions that promote longitudinal child care. Thus, the importance of developing this research is justified, which aims to explore the question: how is the use of the Child Health Handbook according to the perspective of family health professionals and mothers?
Therefore, this study aims to understand the use of the Child Health Handbook in Primary Care, from the perspective of family health professionals and mothers.
METHOD
Study design
This is an exploratory study with a qualitative approach, anchored in Symbolic Interactionism (SI), which explores reality through the analysis of individual actions and interactions. SI is not limited to a single cause to understand human decisions in situations, such as the use of CH, but seeks to understand the story behind the actions. SI recognizes the dynamic and interpretative nature of human beings, influenced by social interactions and individual experiences over time10.
The Consolidated Criteria for Qualitative Research Reports (COREQ) was adopted as an auxiliary tool for preparing the study report.
Location
The study was conducted in Family Health Units (FHU) in João Pessoa, Paraíba, Brazil. The municipality has a territorial area of 210.044 km², an estimated population, in 2021, of 825,796 people and a Municipal Human Development Index (MHDI) of 0.76311. Its Primary Care Network is composed of 199 Family Health Teams (FHT), distributed in Family Health Units (FHU), in addition to five Basic Health Units, 34 teams from the Expanded Family Health and Primary Care Center, among other strategies and teams12.
Participants and Selection Criteria
25 professionals from eight FHTs were invited to participate in the study, including nurses, physicians, dentists, community health agents, nursing technicians and dental assistants. Additionally, 11 mothers of children under three years of age participated, who could be from the same FHT as the professional(s) interviewed. There were no withdrawals or refusals by mothers or health professionals to participate in the study.
The selection of participants for the study was intentional, considering the object of study and compliance with the eligibility criteria. For health professionals, the inclusion criteria required that they be linked to the FHU for at least six months and be involved in the care of children under three years old. As for mothers, the criteria included being over 18 years of age, being the mother of a child under three years old and being registered with the FHU. Professionals on vacation or leave during the data collection period were not included, nor were mothers visiting the FHU for the first time, who did not have a CH, and/or who had impaired cognitive function.
Data collection
The production of empirical data was carried out in September and October 2020. Initially, after obtaining the necessary authorizations to conduct the research, contact was made with the manager of each FHU to present the study and provide the documentation required for its implementation. After obtaining authorization from the health unit management, the main researcher contacted the professionals of the FHT and invited them to participate in the study, Being the only previous relationship between the researcher and the participant. Once these professionals agreed, the interviews were scheduled to occur immediately after the end of the user services to avoid interference in their work routines. The interviews were conducted in the service room or in another private area of the FHU, as suggested by the participants, to ensure greater comfort and privacy.
The interviews with the mothers occurred while they were waiting for their child’s consultation in the waiting room. Using simple and understandable language, the study was explained, and the invitation to participate was extended. It was ensured that the interview would not interfere with the order of their child’s consultation. After the mother's acceptance, the interview began in the waiting room. Despite being a shared space with a lot of movement, two chairs were reserved further away from the public to minimize external interference. No interview needed to be interrupted early for a consultation with the team.
During the data collection period, which took place amid the Covid-19 pandemic, all safety protocols recommended by local authorities were strictly followed. Additionally, biosafety measures were adopted to prevent the spread of the new coronavirus during the interviews, which were conducted in person.
Data production involved the use of field notes and semi-structured interviews, with specific scripts prepared for healthcare professionals and mothers. The script for professionals was composed of the following questions: “How do you use the Child Health Handbook in your professional practice?”, “How do you evaluate the use of the handbook by Primary Health Care professionals?”. The interview script for the mothers presented the following question: “How is your child’s handbook used by family health professionals?”. In the process of preparing the scripts and applying them at the beginning of data production, in the first three interviews, adjustments were necessary in the questions, to not induce the participants’ responses and to promote a deeper understanding of the phenomenon, as well as to add secondary questions, since this was a semi-structured interview.
The interviews were conducted by an experienced researcher in the data collection technique, who is also a nurse specialized in child health. The interviews were recorded and lasted an average of 20 minutes. The interviews were concluded when the data set reached the study’s objective, achieving theoretical saturation13. There was no repetition or return of interviews to the participants.
To ensure data reliability and saturation, after the interviews were conducted, all interviews were fully transcribed and checked by another researcher (pair analysis), both with experience in qualitative studies. The transcriptions were discussed between the researchers to make decisions regarding the completion of the data production stage.
Data analysis
The data set was analyzed using Inductive Thematic Analysis, which suggests a recursive approach between its phases, as necessary: familiarization with the theme, transcriptions and repetitive readings of the data set were performed, and the initial data were noted; generation of initial codes, codes were assigned to the entire data set to highlight relevant aspects found; search for themes, codes were grouped into potential themes, and relevant extracts were combined to form overarching themes; review of themes, themes were refined, and a thematic analysis map was outlined; definition of themes, the essence of each theme was identified, along with the set of themes, and it was determined which aspects of the data each theme addresses; final textual production, a concise, coherent, logical and non-repetitive report of the data was produced, with treatment and interpretation of the results in light of the relevant literature and the adopted theoretical framework14.
To prepare the final thematic map recommended in the inductive analysis, the concept mapping software Cmap Tools, version 6.04, was used.
Ethical aspects
The research followed ethical recommendations and is linked to the research project entitled XXX (information temporarily removed to ensure double-blind review) which has a favorable opinion from the Research Ethics Committee no. 3,156,449, Ethical Appreciation Certificate (CAAE) 97362718.1.0000.5188. All study participants provided their signature on the Informed Consent Form (ICF). To ensure anonymity, participant data extracts were coded as follows: “C” for caregivers/mothers, “N” for nurses, “P” for physicians, “D” for dentists, “NT” for nursing technicians, “DA” for dental assistants, and “CHA” for community health agents, followed by a number corresponding to the chronological order of the interviews, for example: C1, [...] and N1/P1/D1/NT1/DA1/CHA1, [...].
RESULTS
The study involved 25 PHC professionals, including seven nurses, six dentists, four physicians, five community health agents, two nursing technicians, and a dental assistant. Most of the participants identified themselves as female, with ages ranging from 24 to 65 years, and experience in PHC ranging from 10 months to 32 years.
Additionally, 11 mothers participated in the study, aged between 19 and 40 years. Regarding marital status, seven were single, three were married and one was in a stable union. Regarding education level, eight had completed high school, two had incomplete high school and one had higher education. In terms of occupation, six were housewives, two were students and three were employed. Most of the mothers had one child, and the children's ages ranged from 3 to 21 months.
During the analysis of the data corpus, a thematic map was created to clearly demonstrate the story told by the data (Figure 1), in an attempt to not limit the presentation of extracts, codes and themes developed. Furthermore, based on the initial data coding, the following thematic units were also outlined: “Use of the Child Health Handbook in Primary Care: the role of nursing” and “Obstacles to the use of the Child Health Handbook in Primary Care”.
Map with data codes constructed through inductive thematic analysis. João Pessoa, PB, Brazil, 2020.
Use of the Child Health Handbook in Primary Care: the role of nursing
The CH should be monitored and filled out by all those responsible for the child's care, however, some family health professionals use this tool minimally or neglect it, considering it to have a symbolic meaning exclusively for nursing.
No, I have already used the Child Handbook, the ones who use it most are the nursing staff to monitor vaccinations and things like that. Dentistry is not using it, I don't use it. We use individual medical records here, it is a form and it is kept in the user's medical record. (D6)
[...] Nursing does (use the handbook). However, physicians and dentists do not. I believe that nurses use it. At least, I see them taking the handbook and writing everything down. (D1)
[...] Nursing is the one that uses it the most, I believe that it is mostly nurses who use the child handbook. (NT2)
[...] The nurse performs childcare and records everything in the handbook, but I notice that other health team professionals, such as the physician and dentist, do not use this tool [...] it is always more focused on the nurse. (N1)
According to data extracts, PHC nurses attribute to the handbook a symbol of a support tool in childcare, based on the recording of data obtained during the child’s consultation, as well as by observing the available records.
[...] I record everything: weight, height, head and abdominal circumference, and vaccination data. I observe the interaction with the mother, breastfeeding, the father's involvement in the consultation; I also praise when the father comes and encourage that participation. All the data I can note in the child’s handbook, I try to fill in. This new handbook has some subjective aspects, like what we observe regarding the mother-child interaction, signs of mistreatment, or signs of violence. (N4)
[...] I record all the information that the handbook asks me to, I mark it, assessing the child's development according to the age group. I mark if the child walked, if he/she talked, the interaction with the mother, whether we observed something different, the vaccination status, to see if it’s up to date, and the child’s growth and development... weight, height. (N5)
The nurse informs the mothers about the data recorded in the CH, such as the growth charts, and provides guidance on the importance of handling it.
[...] When we come for the consultation, she (nurse) keeps us informed about everything. She explains how the chart works, that it’s important to see the child’s weight, and explains everything very clearly. (C3)
[...] I received guidance from the nurse here at the FHU (Family Health Unit) when I received it for the first time. She explained everything clearly, what it was for and how to use it. (C10)
[...] I always explain to the mothers all the data in the handbook, what I’m writing down, especially the charts, so they understand, because it’s not just about us marking those points and drawing the growth line, but also helping the mother understand why, when the child is normal, and when they are outside of the normal range. (N4)
The use and filling of the handbook mainly occur during child health consultations by the PHC nurse.
[...] Here at the FHU, physicians cannot do childcare because they provide general care, and so, many times, they (mothers) do not bring the handbook to us, they only bring it when it is time to go to the nurse who has a scheduled childcare day. (P1)
[...] In childcare appointments, mostly, that’s when I use it the most because, unfortunately, the mothers don’t have the habit of bringing the child’s handbook, but in the child health consultations, I make it a requirement. (N4)
Another nursing professional who prioritizes the use of the Child Health Handbook in their care practice is the nursing technician in the vaccination room.
Here (vaccination room), we never forget to record in the child’s handbook, never, because that’s what proves the child got the vaccine, and for them to get the second dose, they need to have received the first one. But the difficulty here is that there are many records. We don’t just record in the child’s handbook; we record in the procedure, the vaccine exit, in a book-so we have a lot of records-but we can forget all of them, except the one for the child! That’s impossible to happen, it’s something that absolutely cannot happen, because if it does, the child may end up getting two doses of a vaccine they didn’t need. (NT1)
Obstacles to the use of the Child Health Handbook in Primary Care
Although the findings demonstrate the prominent role of nursing in the use of CH, healthcare professionals listed the reasons that hinder the use of the tool in their care practice, which are related to the gaps in academic training for the appropriate and timely use of CH, as well as the excessive routine and workload at the FHU.
[...] When I am with a student in the preceptorship, I always emphasize this (the use of the handbook), but I had a training where this wasn’t given due importance. (N2)
[...] In college, public health classes were focused on popular health education..., and not on the child health handbook. So, dentistry is very separate from the child's handbook. The problem is in the undergraduate course, because what we learn in public health we try to put into practice in our daily lives. This is where the welcoming, the importance of home visits, pregnancy day, discussion groups, health promotion, all of that, except for the child's health handbook. (D3)
[...] I think the difficulty is the demand for dentistry. The demand is very high, sometimes there are too many users for too little time. So, I believe it's a matter of time. (DA1)
[...] There are really professionals who don’t use it properly (the handbook), they don’t fill in the growth curve data properly because it takes some time to create the curve and interpret it. (P2)
Furthermore, the shortage of health handbooks in healthcare services is still a reality that, according to the data extracts, is one of the main obstacles to the use of this tool. Due to the lack of distribution of the CH in maternity wards and its unavailability in PHC, occasionally maternity wards provide mothers and children with a limited card, where some health information is recorded.
[...] We are having difficulty with health handbooks, it's very complicated. In the past, children would leave the maternity ward with a health handbook, but today it is a bit complicated. Children arrive for vaccinations and only have that little piece of paper from the maternity ward, not a health handbook. (N3)
[...] Sometimes the health handbook is not available, I don't know if it is due to poor management or if the Ministry doesn't provide it. Providing the health handbook is important, and if you don't have the health handbook, you can't monitor the situation properly. The availability of the health handbook is one of the biggest difficulties. (P2)
It is also noted that recording information in the CH and in the family medical record has the meaning of a bureaucratic activity for these social actors. Due to this symbolism given to the health handbook, some professionals see recording in the health handbook as a “waste of time” and prioritize making notes on the form contained in the family medical record.
[...] It’s very bureaucratic, and what is bureaucratic is work because you have to record on each little sheet. There’s a page for height, a page for weight, and you must record the date, weight, and head circumference. So, everything bureaucratic takes work. I believe that’s the reason for the difficulty. (N7)
[...] I know there’s a dental chart (in the handbook), but we also have the dental chart in the form in our files, so to avoid doing it twice, we fill it in on our municipal dental form, but it’s basically the same thing. (D1)
In addition to the difficulties arising from the service itself, professionals point out that mothers forget to take the CH to the child’s consultation or lose this document. They also report corrections in the handbook. The symbolic meaning of the CH for mothers is reflected in their behavior.
[...] Sometimes, the cultural level of the population is a problem. They (children and mothers) come to the consultation and forget the vaccination card at home. They don't bring it with them all the time, making the consultation harder. (P2)
[...] Because it’s paper, because it’s a physical object, sometimes it gets lost at home, so they don’t bring it. They only go looking for it when it’s time for the vaccine and then it’s left there in the corner and forgotten, sometimes it’s very worn out, it’s falling apart. The difficulty is because it’s a physical object. (D6)
[...] Generally, the vaccine is up to date, but there are cases when we ask for it (the vaccination card) and even the mother herself forgets that she has one or two vaccines overdue, without even remembering those who don't know where the vaccination card is. (CHA5)
For mothers, the multiple activities involved in caring for their children and the house are an obstacle to using it.
For me, it's a lack of time because I have to take care of the child, the house, everything. (C7)
For me to look and read, it takes time, and I don't have much time. The time I have is when she [the daughter] is sleeping, which is rare. (C11)
To deal with these challenges, some essential strategies were identified, including training on CH and awareness-raising initiatives aimed at PHC workers, in order to reframe the symbols attributed to the CH.
[...] We haven’t received training (on the CH), I never had one, it was 'by chance.' One thing I don’t like about primary care is this, the fact that they place us here and require information, things we’re often not trained for [...]. The importance of the handbook needs to be conveyed by qualified people, showing how to handle the handbook because we deal with it and observe that graph, but we don’t have expertise in the subject. I need to understand this handbook better. Once we are trained, we understand it better and value it more. (N2)
[...] I think there could be actions for both the mothers, promoted by the FHU, and for the FHU professionals. Actions about the handbook, informing how important it is for the child's development because we must use it not just to plot the height and weight on the graph, but also to use that part for developmental milestones, for example, that the child should be exclusively breastfed up to six months. There are mothers who don’t know that, you know?! Then they give other food to the child, give water, and that’s not right. So, we should promote actions on the proper use of the handbook. (P4)
DISCUSSION
The empirical data revealed that the CH is used mainly by the nurse, a professional member of the PHC team. This prominent role is a socially constructed symbol and recognized by the healthcare team. Thus, considering the practice of vigilant care based on the use of the CH, the nurse was revealed as the protagonist in the CDS. From the mothers’ perspective, the symbol attributed to the CH is reflected in the way they act, forgetting the handbook or reporting a lack of time to read and use the tool.
The different meanings of the CH for PHC professionals can influence their decision to use it or not during childcare. These meanings come from the interactive process between people and the handbook, resulting in the attribution of meanings to this tool. This interaction, which can be both symbolic and non-symbolic, is a process that involves the interpretation of actions, since symbolic meanings can be developed in different ways by people. Therefore, the meanings attributed to objects are not intrinsic to them, but arise from human interaction and interpretation10.
Despite the different meanings attributed to the CH, it is a CDS tool, which suggests the adherence to specific strategies and assessments, with the ability to visualize early factors that interfere in the acquisition of new skills, so that the interventions performed can enhance development15. The CH also offers the opportunity to monitor the physical, affective, psychomotor, social and emotional performance of the child, through notes made by caregivers and health, education and social assistance professionals16.
As a monitoring tool, CH offers numerous possibilities for childcare based on promoting healthy development and preventing harm, in line with the principles of primary care. On the other hand, when CH is neglected by the professionals monitoring the child, this care is weakened and may leave gaps in child health. The symbol attributed to CH by professionals has an impact on their way of acting, that is, the care provided to the child.
The nurse’s leading role is also revealed when this professional observes the completion of data collected in other consultations, developing care guided by health surveillance and longitudinal care. In consultations with children, the nurse plays a fundamental role in the care provided in healthcare services and is seen by parents as a positive source of support by offering important information about the care of their children and encouraging their involvement17.
According to a systematic review, primary care nurses are the professionals most likely to implement Maternal and Child Health in their services, a tool similar to CH, used to record health information about children and/or mother18.
It was evident that other professionals in the family health team participating in the study do not perceive themselves as responsible for using the handbook, making it an intrinsic object of the care provided by nurses to children, signaling the prominent role of this professional. A study conducted in Australia with 202 parents revealed that nurses and midwives were more likely to use the child health record tool (59.4%), compared to pediatricians (34.1%), general practitioners (33.7%) or other professionals (7.9%)19. This finding, although recognizing the significant contribution of nursing in the use of the handbook or similar tools used in other countries, limits the possibilities for continuity and interdisciplinary care.
The filling out of health information in the CH corresponds to an essential legal document for care based on continuity and monitoring of development. When a healthcare worker does not handle the handbook in childcare, they not only absolve themselves of their responsibility regarding health information but also infringe upon the child’s fundamental rights20.
Considering the continuity of care recommended by the CH, it is essential that it be present in all child health care meetings and by all members of the FHT. This requires expanded and multiprofessional work in child care, enabling them to provide effective care using the CH for monitoring child development15. In this context, nurses stand out due to their duties and responsibilities regarding the health of children and their families. Thus, they need to have skills and broad knowledge of the aspects involving child health to ensure adequate and comprehensive monitoring21.
Nurses are also responsible for instructing mothers about the records in the health handbook and highlighting the importance of its use, thus reaffirming their commitment to the main document for monitoring child health. In this regard, a study conducted in João Pessoa-PB involving mothers and/or caregivers of children under three years of age found that most did not receive information about the CH, but that doctors and nurses showed the records present in the instrument during childcare consultations, thus compromising the family’s constructive collaboration in the CH22. The participants’ reports revealed the CH as a symbolic tool related to the childcare consultation carried out by the nurse, which limits the meaning of the CH and the spaces where it should be present.
Health education for mothers about the CH is essential in all consultations, as this allows them to recognize the importance of the handbook as a vital document for child health, valuing its use and requiring health professionals to fill it out properly23. The lack of guidance for mothers is directly related to inadequate completion of the CH17. Guidance is crucial and can be the necessary impetus for the (re)signification of the tool by both mothers and healthcare professionals.
According to the SI theory, interaction between people and self-reflection are intrinsically linked and generate social action. When the nurse guides the mother about the CH, this serves as a stimulus for her, which can influence the way she perceives and uses this tool, alleviating the lack of care with the CH, as evidenced in the data excerpts. This process of reaction and adaptation on the part of the mother can also become a stimulus for the nurse, leading to a change in behavior and the initiation of new practices10.
Some obstacles to the use of the CC faced by the entire PHC team were identified, such as weak academic training, dissatisfaction and the limited interaction with the CH in the training process. It is crucial to emphasize that dealing with the lack of adequate records in the handbook requires special attention to the training of healthcare professionals, so that they understand the importance of this tool for health surveillance. The lack of knowledge of professionals about the handbook, possibly related to deficiencies in their training, hinders the effective use of this resource in child care7.
Assuming that the quality of education in undergraduate courses will shape the profile of future workers and considering that it is during training that the first opportunities to learn about the handbook should arise, it is necessary to carefully examine the curricula of courses in the health area. This aims to integrate, more effectively, health education about this crucial tool for monitoring and promoting child health.
According to the principles of interactionism, individual actions assume a symbolic character when they acquire meaning for those who perform them and are shaped by previous experiences10. Besides the period of graduation, which is an opportune moment to ensure the symbolism of using the handbook by the nurse, it is also essential that this symbol be strengthened through ongoing education actions in the work process, considering that this important instrument and health policies may undergo adjustments.
Other obstacles to the use of the handbook in PHC were routine and workload. Regarding the routine of the nurse, a professional who stands out in the use of the CH, in addition to the burden of bureaucratic, administrative and direct care tasks, nurses face the concentration of responsibilities, considering these circumstances as extreme situations or significant challenges in the context of child health care24.
The decision to use the CH was sometimes limited by its unavailability in childcare settings. A similar situation was observed in a study involving different cities in northeastern Brazil, when it was identified that most of caregivers indicated that they did not receive the CH due to the lack of this resource25. This highlights a national public health problem, which may be negatively influencing the value of the use of this document, both by professionals and mothers, and contributing to the fragmentation of childcare.
The situation described in Brazil contrasts with the mandatory provision of the CH to all children born in public and private maternity hospitals in the country6, raising essential reflections on the quality of care and resources allocated to child health in the country. Therefore, when the CH is not available in health services, this interaction is hindered, resulting in a lack of symbolic action. This situation can partly explain the lack or inappropriate use of the CH by some professionals in the Health Care Network (HCN) and by families.
Regarding the use of the handbook by mothers, reports indicate that they often do not take the instrument to consultations and do not use it due to lack of time. When used correctly, the CH becomes an accessible and easy-to-use medical record, containing relevant data about the child. Therefore, it is essential that caregivers are instructed on the importance of taking the Ch with them to every consultation26, as this allows professionals to record information appropriately and monitor the child's growth and development. According to the premises of the SI, the interaction between the individual (the child’s caregiver) and the object (the CH) is crucial to understanding the decision and action of using this tool. Interaction plays a fundamental role, as it guides the individual’s actions10.
It is noteworthy that the obstacles to the use of the handbook involve the entire FHT; despite this, the nurse stands out maintaining a position of resistance, ensuring that they are the main professional, that is, the protagonist in the use of the CH, as corroborated by all team members. This highlights their relevant role in promoting CDS.
To overcome the obstacles related to the use of the CH, professionals point out the relevance of Permanent Health Education (PHE) and awareness-raising actions to foster closer engagement with the handbook and, consequently, its use. In this regard, it is evident that there is still a lack of training and actions on PHE in services aimed at CH, highlighting the need to include this topic in PHE processes to include this tool as a guide for health practices7.
The findings point to the relevance of PHE actions for the use of PHE, including all HCN workers and mothers. For PHE to become an effective instrument for surveillance, communication, education and health promotion, it is essential that everyone understands and uses it as a significant symbol of comprehensive childcare, as well as ensuring its printing and distribution are prioritized by the three levels of government.
In this context, education plays a key role in transforming the perception of PHE and the way it is addressed in PHC. According to the principles of SI, human decisions and behaviors are influenced by interactions with social objects and the sharing of perspectives10. Therefore, the findings of this study fill gaps in knowledge and are innovative, as they show that highlighting nurses through their experiences with CH can become important educators to foster the (re)signification of this as a CDS instrument.
The limitations of this research are related to the participant selection process and their specific geographic location. The study was conducted exclusively in the PHC unit of a capital city in the Brazilian Northeast, and it is difficult to expand the results to different levels of care and to other settings in Brazil. Furthermore, given the restrictions imposed by the pandemic, the researcher was unable to return to the service to collect feedback from participants on the results. Future studies are suggested to investigate the use of the CH by nurses in all points of the HCN, covering the various realities across the country.
Despite the limitations, it is expected that this research will motivate managers to plan strategic actions involving different sectors, aiming to improve the quality of child health services and raise awareness among all families and workers (health, education and social assistance) about the use of CH in the HCN, so that it becomes an intersectoral, interdisciplinary and development surveillance tool, capable of outlining the child’s history.
CONCLUSÃO
From the perspective of the professionals of the FHT and mothers, this study identified the leading role of nurses in CDS and in ensuring continuity of care in PHC, when using the CH. For nurses, this handbook consists of a significant symbol in their care, leading them to review existing records, enter new information about the child’s health and provide guidance to mothers on the importance of using the handbook. These actions align with the principles of childcare and the objectives of the CH.
However, the team faces several challenges when using this tool, such as gaps in the training process regarding the use of the CH, excessive workload, unavailability of the document in health services, recording of children’s information in both the handbook and medical records, mothers forgetting to bring the handbook to the child’s consultations and corrections or loss of the document. To overcome these obstacles, important resources mentioned include training and raising awareness about the relevance of the handbook for continuous and comprehensive care.
For mothers, the symbolic meaning of the CH is that it is an important tool in caring for their children, and they value the explanations provided by nurses about the recorded data and its interpretation. However, they mention limitations in using the handbook, due to lack of time because of their household responsibilities and caring for their children, forgetting to bring the handbook to appointments, and the perception that reading and using the handbook requires too much time. Therefore, promoting interaction between the caregiver and the CH is essential for its symbolic meaning to be (re)constructed and, thus, the CH to be effectively implemented in childcare.
In this perspective, there was convergence in the symbols attributed to the CH by both mothers and professionals regarding the importance of the tool in comprehensive childcare and the difficulties in its use, such as the absence of the instrument, lack of time, and work overload.
It is believed that the essential role of the nurse, as an important member of the multiprofessional team, in using the handbook will drive the (re)signification of this tool by other PHC workers and mothers, just as it will positively reflect on the quality of life and the full development of the child.
ACKNOWLEDGMENTS
The present work was conducted with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES) - Funding Code 001.
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Source: author *Community Health Agent; **Dental Assistant.