Avaliação da atenção primária no controle da hanseníase: validação de instrumentos e análise do desempenho de municípios endêmicos do Estado de Minas Gerais Belo Horizonte

Abstract

The present study aims to evaluate the performance of endemic municipalities of Minas Gerais in leprosy care by means of a methodology for assessing the degree of orientation of primary health care in executing leprosy control actions. This is a survey that has two stages, the first being a methodological study for developing and validating a measuring instrument and the second stage being an evaluative survey, conducted in three municipalities of Minas Gerais, to measure the presence and extent of primary health care (PHC) attributes in disease control. The methodological study was conducted in four steps: (1) Construction of the "Instrument for assessing the performance of primary care in efforts to leprosy control" in four versions designed for managers, health care professionals (doctors and nurses), community health agents (CHA) and users; 2. Face and content validity by specialists; 3. Implementation of the pre-test in the municipality of Betim during June and July 2012; 4. Construct validity, reliability and credibility data collection survey was conducted in the municipalities of Almenara, Teófilo Otoni and Governador Valadares, between July and December 2012. The participants were: 380 CHA, 124 doctors and nurses, 14 managers and 31 users. For the construct validity, exploratory factor analysis was used; the measurement of internal consistency of the items was determined by Cronbach's alpha and the stability over time using the Wilcoxon and Intra-Class Correlation Coefficient (ICC) test. In evaluation research, general, essential and derived scores were assigned, for each attribute of PHC (first contact, access, continued care, comprehensiveness of available and provided services, coordination, family orientation, community orientation and professional orientation). The mean scores above 6.6 correspond to high orientation of PHC services for executing leprosy control actions (LCA). Statistical Package for the Social Sciences (SPSS) for Windows version 17 was used for statistical analysis: descriptive statistics (measures of central tendency, position and dispersion) and analytics (Kruskal-Wallis and Mann-Whitney tests). We adopted a 5% critical level for rejection of the null hypothesis. Results of methodological study: the instrument designed for CHA has demonstrated construct validity, reliability and test-retest stability, and is considered reliable and valid for assessing the performance of PHC in the leprosy care. The other versions showed construct validity in the mirror version of CHA and measures of acceptable reliability. The results of evaluative research were presented in each scenario. Almenara: all the informants assigned scores above 6.6 on the scale of general guidance and essential PHC services for the implementation of LCA. However, managers, users and CHA identified weaknesses in the attributes that constitute to the derived score (family, community and professional orientation). There were no statistically significant differences between informants in the assessment of general and essential performance derived from APS in leprosy care. Teófilo Otoni: In relation to the overall score, 42.9% of managers; 43.6% of doctors and nurses; 71.5% of CHA rated the service as strongly oriented towards the achievement of LCA in PHC. Professionals were the only informants who identified weaknesses in derived score (mean = 5.7). There were statistically significant differences between informants in the assessment of general and essential performance derived from the PHC in leprosy care and access, continued care and community orientation attributes. Governador Valadares: In relation to the overall score, 60% of managers; 70.4% of Avaliação da atenção primária no controle da hanseníase: validação de instrumentos e análise do desempenho de municípios endêmicos do Estado de Minas Gerais 11 doctors and nurses; 70.3% of CHA and 42.9% of users rated the service as strongly oriented towards the achievement of LCA in PHC. The key score showed an average above 6.6 and only the derived score rated negatively by the users qualifies for the attention of PHC. There was no statistically significant difference between the informants in the assessment of general, essential and derived scores. However, it was found that average score is significantly different when compared to scores of attributes such as first contact; access; continued care; comprehensiveness of available services; family orientation; community and professional orientation. It was found that statistically, there is a significant difference in overall score between the municipalities included in the study, and that, Almenara has received majority of the orientation of PHC in order to execute LCA, followed by Governador Valadares and lastly, Teófilo Otoni. We conclude that the tools developed in this research may be appropriate to evaluate the performance of PHC in the development of LCA, but it is necessary to conduct further studies to test the psychometric properties. In each scenario the attributes that need to be strengthened to empower the performance of PHC in leprosy control were identified.