Assessment in the primary care of the State of São Paulo, Brazil: incipient actions in sexual and reproductive health

ABSTRACT OBJECTIVE The objective of this study is to assess performance in sexual and reproductive health of primary health care services of the Brazilian Unified Health System, in the State of São Paulo, Brazil. METHODS An evaluative framework was built for sexual and reproductive health with the categorization of 99 indicators in three domains: sexual and reproductive health promotion (25), sexually transmitted infections/AIDS prevention and care (43), and reproductive health care (31). This framework was applied to assess the services responses to the questionnaire of Quality Evaluation of Primary Health Care in the Municipalities of São Paulo State (QualiAB), in 2010. Percentages were calculated for positive responses to indicators and performance in the sexual and reproductive health dimension, according to domains, and their contribution to the overall score in sexual and reproductive health (Friedman), relative participation (Dunn), and correlation (Spearman) was verified. RESULTS Overall, 2,735 services participated in the study. They were located in 586 municipalities (distributed throughout the 17 regional health departments of São Paulo), of which 70.6% had fewer than 100,000 inhabitants. The overall average performance of these services for sexual and reproductive health is 56.8%. The actions are characterized by: prenatal with adequate beginning and exams, better organization for immediate rather than for late postnatal care, and selective reproductive planning for some contraceptives; prevention based on specific protection, limitations in the prevention of congenital syphilis, in the treatment of sexually transmitted infections, and in the screening of cervical and breast cancer; specific educational activities, with a restricted vulnerability approach, focus on sexuality over reproduction. The domain of reproductive health has greater participation in the overall score, followed by prevention/care and promotion. The three domains are correlated; the domain of prevention/care has the highest correlation with the other ones. CONCLUSIONS The implementation of sexual and reproductive health in primary health care in the services studied is incipient. The revision of the purpose of the work, the dissemination of technologies, and the investing in permanent education are needed. The evaluative framework built can be used by the sexual and reproductive health program services and management in primary health care, thereby contributing to their actions.


INTRODUCTION
Primary health care (PHC) services are considered relevant to sexual and reproductive health (SRH) of individuals and population groups. The Program of Action of the IV International Conference on Population and Development 33 and the Platform of Action of the IV World Conference on Women 32 , international milestones in the definition and visibility of SRH, point to PHC as a priority level. In Brazil, PHC is strategic to make SRH policies effective in the Brazilian Unified Health System (SUS) 12,22 .
The policy recommendations and delineation of the SRH programs are related to the attributes and purposes of the work in PHC 3,15,29 . Considered as "first and basic care", PHC is characterized by its technological dimension 15 , the articulation of low-complexity material technologies and highly complex technical and organizational process technologies 29 , with the capacity to promote higher equality and efficiency to the health care system and a positive impact on the health of the population 30 . Oriented towards comprehensivenes 3 , it develops actions for health promotion, disease prevention, recovery, and rehabilitation. Because of its proximity to the territory -area of sanitary responsibility and geopolitical space 25 , headquarters of the life of subjects, with its needs and projects -, PHC is the preferable scenario of care practices 3,25,29,30 . Issues related to sexuality and reproduction trigger individual demands and requests from other sectors for PHC services; they have epidemiological relevance and are of collective interest for health education in the community 13,22 .
The constitution of the SRH field refers to expanded notions of health and sexual and reproductive rights, influenced by population and development policies, and the participation of social movements about sexuality and gender relations 7 . Reproductive health is considered the complete well-being of the reproductive functions and processes; its care includes methods, techniques, and services that contribute to the reproductive well-being and the prevention and resolution of problems. Sexual health aims to improve the quality of life and personal relations. It is not limited to reproductive counseling and assistance to persons with sexually transmitted infections (STI) 7 .
Brazil, a signatory of international conferences on rights in SRH 32,33 , has elaborated policies, programs, protocols, and recommendations related to the attributions of PHC to make SRH effective in the SUS, which guided this evaluative study 9 . Examples include the National Policies on STI and AIDS 16  Implementation of SRH care in PHC presents challenges such as: lack of discussion on this topic in health training 1 ; difficulties in how professionals address this issue with users 13,22 ; limited understanding of the SRH contents as basic health actions 22 ; low integration between services 34 ; focus on higher-risk groups over population strategies 34 ; and little technological definition of prevention actions for STI and AIDS 12 , characterized by the individual values of professionals and conservatism 12 . In Brazil and in the State of São Paulo, proposals to overcome these challenges include publications, seminars, permanent education activities, and monitoring of the actions in PHC services 18,22,26

METHODS
This study was developed as a health assessment with the creation of an evaluative framework for the SRH dimension in PHC. The answers to the questionnaire QualiAB, filled online by managers and services teams, in 2010, were used as source of data. The questionnaire was elaborated in evaluative research 5 , validated in 2007, and referenced by the health work theory -which considers health practices as technical and political intervention in reality 15 . The QualiAB is applicable to services of different organizational arrangements and it covers the various tasks of the PHC, enabling the assessment of specific themes 5 .
In 2010, the QualiAB was adopted as a tool to support the PHC management of the State Health Department (SES/SP) 5 . Adherence was open for all the municipal managers to register their services in the QualiAB system, and its dissemination predominantly focused on municipalities that had the Program of Primary Health Care Articulators, aimed at municipalities with less than 100,000 inhabitants 2 .
The evaluative framework for the SRH dimension consisted of the selection of answers to the questions of the QualiAB related to SRH, regarded as indicators and categorized according to the purposes of SRH promotion, STI/AIDS prevention and care, and reproductive health care (Table 1).
In order to characterize the practices of the services, the answers to the indicators generated a binary system (1 for what the service does; 0 for what it does not do). In each service, the answers to the indicators making up each subdomain were added; the total number of indicators making up the subdomain was the denominator for the value obtained, with the result varying between zero and 100. This procedure was repeated for each domain and for the SRH dimension, as a whole. Friedman test was used to compare the subdomains and domains in order to verify their contribution to the score created for the SRH dimension. A histogram was designed to show the distribution of services in the score for the SRH dimension. The relative participation of each domain or subdomain for the entire SRH dimension was subsequently obtained using Dunn's nonparametric multiple comparisons

RESULTS
From the 645 municipalities in the State of São Paulo, 586 (90.8%) were part of the QualiAB assessment, with the registration of 2,844 services, of which, 2,735 services (95%), distributed throughout the 17 Regional Health Departments of SES/SP, responded to the QualiAB 5 . According to population data of 2010, 55.6% of the participating services are located in municipalities with less than 50,000 inhabitants, 15.1% between 50,000 and 100,000, 12.7% between 100,000 and 200,000, 11.6% between 200,000 and 500,000, and 5.1%, with more than 500,000 inhabitants (IBGE, 2010) 5 . The coverage estimate achieved by the QualiAB is imprecise, because of consistencies in the existing records and their poor updating. Considering the number of 4,222 basic health units and 341 health centers, amounting to 4,563 basic services, registered in the National Register of Health Establishments in July 2010, the proportion of response to the QualiAB is 59.9% of the existing services.
Of the participating services, 56.6% are located in the urban periphery, 33.9% in the urban center, and 9.5% in the rural area. The distribution by organizational arrangement consists of 43.7% of Family Health Units (FHU), 32.0% of Basic Health Units (BHU), with or without specialties, 8.5% of BHU with Program of Community Health Agents (PCHA), 5.6% of BHU with family health team, 4.5% of BHU with specialties, 0.7% of upfront units, and 5.0% of other types.
The SRH actions developed in the PHC and the average performance of the group of services are presented in the domains of SRH promotion, STI/AIDS prevention and care, and reproductive health care (Table 2).
For SRH promotion, isolated activities are predominant in the actions of health education developed in the community and unit: campaigns restricted to the health service and sector, based on the transmission of information. Addressing the body and reproductive functions takes precedence over the discussion on rights and sexuality. Situations of vulnerability, such as alcohol abuse and violence, are more present in educational activities in the community than they are followed up in the units.
Regarding STI/AIDS prevention and care, specific protection actions, such as vaccination against hepatitis B and distribution of condoms to the general population, are among the main preventive measures, despite the scarce availability of female condoms. Educational activities for STI/AIDS prevention are more often in the units than in the community. Women are the main target audience, comparing adults and adolescents. There are limitations of screening for cervical-uterine cancer, because of the low criteria compliance and irregular offer of Pap smear. Syphilis and HIV diagnosis, during prenatal care, is compromised by improper collection of exams. Treatment of STI cases has limitations because of the insufficient adoption of syndromic treatment and the predominance of a diagnostic confirmation approach, requiring greater professional expertise and bringing risks to the adherence of the user. Use of condoms and serological testing are frequently advised. There are limitations in the availability of medications for STIs, the application of benzathine penicillin, and the treatment of pregnant women with syphilis and their partners. The nonexistence of cases of congenital syphilis is reported only in part of the units. Health surveillance activities, such as exam assessment, happen partially. The most frequently recorded information, such as vaccinations and collection of Pap smear, refers to productivity.
In reproductive health care, reproductive planning is a frequent activity in women' s health care, with a higher occurrence of health educational activities in the units than in the community. The availability of male condoms and oral contraceptives is high. The offer of surgical methods is frequent. On the other hand, female condoms and emergency contraception are scarcer. Most services offer prenatal as a scheduled activity, with admission of pregnant women in the first trimester and performance of the recommended tests. Health education actions for pregnant women are present in most units, some with groups for adolescents. Time and place of immediate postpartum appointment scheduling are usually more appropriate, than for late postpartum. The surveillance of no-show patients is more common for pregnant women when compared to puerperal women. Breast cancer approach often integrates the actions planned for women's health; however, it rarely meets the criteria for mammogram referral. Men's health actions include prevention of prostate cancer in many services.
The overall average performance of the services of PHC for the SRH dimension in São Paulo State is 56.8%; no service has an average higher than 91.9%. The distribution of services in the score for SRH originated a histogram that approaches the normal curve, which indicates the evaluation adequacy and allows the discrimination and description of the performance of the services using the arithmetic mean. Despite considerable variance, the analysis is significant because of the high number of indicators and participating services. Friedman test shows that reproductive health care is the domain with the highest contribution to the SRH dimension, followed by STI/AIDS prevention care and SRH promotion ( Figure 1).   The emphasis of reproductive health care and the relative contribution of the other domains are confirmed by Dunn's comparison, which shows the average difference of each domain of the SRH dimension in relation to the other ones. The comparison between the subdomains shows the distance between their participation in the composition of the domains. The average difference is attributed to the frequency of the actions performed ( Figure 2).

Grouping of indicators
The correlation between all domains and subdomains comprising the SRH dimension is positive. The domain of STI/AIDS prevention and care is the only one with correlation greater than 0.6 with the other domains. The same happens with the subdomain of STI/AIDS prevention and diagnosis, which presents correlation greater than 0.5 with the other subdomains (except health care of reproductive and sexually related organs) ( Table 3).

DISCUSSION
Concerning the purposes of work in health care 3,29 , the greatest contribution of the domain of reproductive health care for the average performance in SRH reflects the role of tradition in the women's health area in PHC. It reveals the power relations that characterize the care in this group 10,17 , notably regarding the protection of the maternal and child health and female body control 10,28 . The differences in the actions researched and the order of participation between the subdomains -prenatal and postnatal care, health care of reproductive and sexually related organs, and reproductive planning -possibly express an unequal recognition of these practices by both the health sector and the society. Actions seeking maternal and child mortality reduction and screening for neoplasms are regarded as more important than the ones seeking to guarantee reproductive choices in sexuality 8,10,28,31 . Training and know-how in technologies involved in each type of action are different: biomedical actions are more present than those of health communication and education actions 11,31 , with an appropriate offer of exams, compared to groups during prenatal care, for example. Actions commonly happen in the unit rather than in the community. There is a polarization between reproduction and sexuality 28 , as well as inadequacy in how sexual and reproductive rights and gender relations 10 are addressed indicated by the limitation in the supply of female condoms and emergency contraception.
The domain of STI/AIDS prevention and care occupies the second position in the SRH dimension. The achieved performance is related to PHC assignments in SRH and reflects challenges in its implementation: separation between reproduction and sexuality 28 , stigma related to STI/AIDS 8,27 , and difficulties to conduct care actions guided by the vulnerability and human rights framework 4,12,27 . A greater incorporation of measures for STI/AIDS prevention and diagnosis rather than for care expresses the historical demand for prevention actions in PHC 26 , as well as low recognition of STI care as its responsability 26 . Consequently, training and adoption of technological tools 14,15,26 are necessary. The actions of health surveillance and information are a relatively high performance subdomain, with emphasis on data record related to production. However, these data require critical analysis, given the high frequency in the number of collection of Pap smear, in contrast with the low criteria compliance to prescribe the exam.
The lower number of actions of the domain of SRH promotion expresses both the challenge concerning the specific object and the practices of health promotion 3,4,31 , despite the fact they are PHC responsibility. The promotion of health requires work with social participation, approximation to the territory 25 , health education and communication methodologies 11,31 , interdisciplinarity, and intersectoriality 11 . Some particularities of SRH require understanding complex concepts -such as sexual and reproductive rights 7 , vulnerability 4 , and gender relations 7,10 -, besides the need to adopt suitable technological tools 15,26 . There is also disarticulation between reproduction and sexuality 28 and the predominance of informational over participatory strategies 11,31 . The difference between the educational activities about violence or alcohol and drug use and the follow-up of these cases shows the scarcity of tools for this operation 15 .
The positive correlation between the domains and subdomains of the SRH dimension shows that each one is related to the others, revealing the importance of comprehensiveness 3 in the SRH care in PHC. The higher correlation of the domain of STI/AIDS prevention and care and, particularly, the subdomain of STI/AIDS prevention and diagnosis (in relation to the other domains and subdomains, respectively) show that both are good indicators for SRH. This characteristic can contribute to a better understanding of how they are implemented in the services. In addition, when taken as an investment and technological proposition focus, these indicators can foster improvements in SRH care practices in PHC. It can be assumed that work with STI/AIDS requires staff prepared to work with sensitive issues 8,27 capable of addressing complex knowledge and techniques 14,15,26 . This can contribute to the handling of other objects in the health work, which require an approach that take into consideration user autonomy 10,11 , and situations of vulnerability 4,27 , as well as the establishment of interfaces between prescriptive measures and the projects of persons -combining technical attainment and practical success 3 .
The average performance of units of 56.8% for the SRH dimension exposes a discrepancy between what is accomplished by the services and what is proposed for PHC 22,32,33 in order to achieve population impact 30 . The amount of assignments is a great challenge for PHC, and therefore reduction of expectations could be proposed. However, there are public policies and a SRH program for PHC in Brazil and in the State of São Paulo, which consider SRH actions essential and a responsibility of PHC [16][17][18][19][20][21][22][23][24] . Moreover, the very characteristics of PHC, including the articulation of health work purposes 3,29 and proximity to the territory 25 , make SRH its object 13,22 .
The performance and integration of SRH actions, conducted by PHC services, are indicators of the implementation of the SRH program in PHC. Thus, the analysis of the results points to an incipient implementation. This is due to inadequate recognition of SRH as an object of PHC -not only in its extent, but above all, in the comprehensiveness of SRH -, and the need for review, improvement, and expansion of the incorporation of technologies to handle SRH in PHC practice.
Regarding the limitations of this study, the assessment focused predominantly on organizational components, which are necessary, yet not sufficient to appreciate quality. The use of previously collected data precluded the inclusion of some objects of the SRH dimension, such as men's health actions and the issue of sexual diversity. The findings cannot be extended to all PHC services in São Paulo: the sample was not done randomly, but rather from the adherence of managers; municipalities with large population were under-represented; the city of São Paulo did not participate in the study. On the other hand, the total number of the participating services was high and there was a significant participation of small municipalities, reflecting both the political and administrative structure of São Paulo, as 81.2% (524) of municipalities have less than 50,000 inhabitants (IBGE, 2010) and the support of the Program of Primary Health Care Articulators 2 , addressed to small municipalities. The articulation with the SES/SP program, previously mentioned, facilitated the return of results and favored the responsiveness to the recommendations following it 5 .
Methodological possibilities were also present; with emphasis on the construction of a viable assessment, integrating a general questionnaire about PHC with easily understood explanations and recommendations, which may contribute to improving the organization of the work with SRH in PHC. Additionally, the study provided a review and update of the SRH dimension in the new 2016 version of the questionnaire QualiAB. The need to improve PHC in Brazil is well-known. The diversity of evaluative approaches -as represented by the tools QualiAB, Autoavaliação para a Melhoria do Acesso e da Qualidade da Atenção Básica (AMAQ), Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ), and Primary Care Assessment Tool (PCATool-Brasil) -contribute to this improvement 6 .

CONCLUSIONS AND CONTRIBUTIONS FOR THE SRH PROGRAM IN PHC
Considering PHC as strategic for SRH is a challenge. This study makes possible the proposition of a theory for the SRH program in PHC, taking into account the action purposes, and presenting priority activities and useful tools for the work. The evaluative framework for SRH in PHC, which, from the assessment of empirical data, was a mediator in the construction of this theory, can be used as a tool, particularly for work planning or future assessments.
With this evaluation framework, the task of assessing practices displaying different characteristics regarding purpose, technology, definition, and tradition in PHC has been fulfilled. It resulted in the creation of an assessment presenting variability of indicators, robust domains and subdomains, and discrimination between services in what concerns performance in SRH actions. These attributions, as well as the insertion of the SRH dimension in a general questionnaire about PHC, make this a viable and replicable assessment.
In addition, this assessment shows completeness and usefulness by a combined elaboration of explanations, judgment, and recommendations.
To affirm that the implementation of SRH actions in PHC of the São Paulo State is incipient -namely, beginning, and therefore still inadequate and insufficient -also means to bet on changes and improvements, which is a possibility inherent in everything that is new. The results and analysis of this assessment may contribute to this process both in the organization of the work in the services and in the management of SRH program in PHC. It is worth mentioning that this assessment allows for a thorough understanding and discussion of the care practices for SRH developed by PHC, the performance of the services, and also the awareness of the domain of STI/AIDS prevention and care as a core indicator for assessments of SRH and a possible focus of technological proposition. Recommendations for the SRH program in the SUS's PHC of São Paulo State highlight the need to comprehend SRH in PHC, as well as review the work purposes, and by taking into account the distribution of the performance of the services, investments in training and design of tools should be considered.