Studies on the Child Handbook in Brazil: a scoping review

ABSTRACT OBJECTIVE To systematically identify and map studies involving the Caderneta da Criança (Child Handbook - CH) in Brazil. METHODS A scoping review using the methodology proposed by the Joanna Briggs Institute. The databases PubMed, Biblioteca Virtual em Saúde (BVS), Biblioteca Digital Brasileira de Teses e Dissertações, Periódicos Capes and Google Scholar were consulted. Primary and secondary studies that mentioned the use of CH were included, without restrictions regarding design, year of publication or population, published in Portuguese, English or Spanish and gray literature (theses and dissertations). RESULTS A total of 129 studies were included, mostly descriptive, published as scientific papers. The Northeast region, the population of caregivers of children and the Primary Care scenario were observed in most studies; 47% of the studies used the CH as a source of data, the majority on vaccination. Despite the different criteria to define adequacy of completing the CH, the studies identified weaknesses in filling out all of its items, except for immunization. The utilization and/or completion of the CH were linked to various factors, including the availability of the CH, characteristics of the children (such as sex, age, prematurity and well-child appointments), attributes of the family members and caregivers (such as age, education, income, parity, work status, prenatal care, reading, note-taking and bringing CH to appointments) and features of the professionals (such as workplace, medical specialty, communication style, knowledge about the CH, requesting, guiding and note-taking). CONCLUSIONS The results reinforce the need to better understand which factors affect the distribution of the CH in the population, as well as pointing to the need for understanding its use and completion by the different care points. The need for intervention studies to improve the implementation of this tool and to include training on the use of the CH in the context of continuing health education becomes evident.


INTRODUCTION
The world's progress in reducing child mortality is remarkable 1 . At this time, efforts are being directed not only to reduce mortality, but also to promote the full development of all children 2 . Thus, educational actions with families, monitoring and recording data on the child's health, and the integration of actions between services are essential 3 .
Instruments for recording information, such as health records, have been used in more than 163 countries with the aim of improving maternal and child health 4,5 . A systematic review identified that health records for pregnant women and children are effective in improving health outcomes 6 . These records have a positive impact on promoting care-seeking behaviors, improving knowledge and care practices, encouraging home care for childhood illnesses, reducing child mortality and morbidity and facilitating ongoing care.
In Brazil, the Children's Card was created in 1984 by the Ministry of Health (MoH), replacing the Vaccination Record, to include the monitoring of growth and child development (CD) of children aged 0 to 5 years 7,8 . This instrument underwent several updates, and in 2005, the Child Health Handbook (CHH) was created as a tool for comprehensive monitoring of child health. In 2021, the Caderneta da Criança (Child Handbook -CH) was launched, aimed at all children born in Brazilian territory, which provides for the monitoring of children aged 0 to 10 years. This new version was designed to be used by families and healthcare providers and other child care services, such as those in education and social assistance, facilitating the integration of actions 9,10 . The first part of the CH is directed at families, and the second part is for professional records for child monitoring, including a tool for autism screening 10 .
The CH is the main tool for monitoring healthy growth and development according to the National Policy of Comprehensive Healthcare for Children (PNAISC) 3 . Despite its potential, and being a nationwide action established by the MoH, studies have highlighted the inadequate use and completion of the CH, with no consensus regarding the factors associated with this use or interventions that can improve it 11,12 . Therefore, this review aims to map the studies on the MoH's CH that have analyzed its use, barriers and facilitators, and interventions aimed at its use, in order to provide information for its effective implementation.

Study Design
A scoping review was carried out, which is a systematic method for mapping the scientific production on a given topic with the aim of identifying concepts and research gaps 13 , using the methodology of the Joanna Briggs Institute 13 . The following question was considered, based on the PCC acronym (population, concept and context): What is the scientific production on the use of the CH by healthcare professionals, managers, family and caregivers in Brazil? The research protocol was published in the Zenodo repository (https://sandbox.zenodo.org/record/891923#.YQhK445KhPY).

Eligibility Criteria
Primary and secondary studies that mentioned the use of the CH in the Brazilian context, regardless of study design, publication year, or population, published in Portuguese, English, or Spanish, were included. Grey literature such as theses and dissertations were included, while conference abstracts and undergraduate course papers were excluded. Studies that did not explicitly state that the instrument used referred to CH were only included if the study description left no doubt that it was the MoH instrument.
After mapping terms related to the research question and discussions among specialists, a search strategy was built for PubMed and subsequently adapted by two librarians for other research platforms. Supplementary Table 1 a shows the dates, terms, databases, and strategies used.
Screening of titles and abstracts and reading of full texts were performed by two independent reviewers using the Rayyan 14 platform, and disagreements were resolved by a third reviewer. In both stages, a sample of studies was selected at the beginning of the process for calibrating of the inclusion and exclusion criteria.

Data Extraction
The data extraction process involved the development of a spreadsheet (Supplementary Table 2 b ) and three articles were selected for calibration. The studies were independently extracted by two reviewers and disagreements were resolved by a third. The following information was collected: (i) study characteristics, (ii) results, (iii) barriers and facilitators to the use of the CH, and (iv) limitations related to the CH. For each included study, the approach to the CH was identified: (i) data source (studies that collected information of interest to the authors about the child, through CH, for example, immunization data); (ii) object of study (the objective was to study the CH, for example, its completion and associated factors); (iii) citation in results (only cited CH in the results); and (iv) data collection instrument (used some CH instrument for data collection, such as the CD surveillance instrument).

Compilation and Analysis of Results
(i) Characterization of studies: study type -1 (primary/secondary) and 2 (scientific articles/literature review articles/dissertations/theses) -; study design (as described by the authors); approach to CH; nomenclature given to the CH by the authors (adopted by the MoH/no and authors explicitly stated in the references that it was the MoH's CH/no); publication year; region of Brazil (North/Northeast/Central-West/Southeast/ South); population (family members or caregivers/healthcare professionals/both/ others); scenario (Primary Health Care -PHC/medium and high complexity services -MAC/community/education/social assistance/more than one scenario); and location (primary health unit -UBS)/domicile/vaccination campaign/outpatient/school/hospital/ more than one location/others).
(ii) Results: the results of studies that used CH as a data source were briefly described, and those that used CH as an instrument for data collection, as an object of study, or that mentioned CH in the results were detailed (barriers and facilitators to CH use and limitations related to CH). The last two were presented together as they had similar results.

RESULTS
A total of 2,206 records were retrieved after removing duplicates (

Characterization of Studies
Ninety-two studies (71.3%) were articles published in scientific journals, including eight literature reviews; 30 were dissertations (23.3%) and seven were theses (5.4%) (  11,12,62,[132][133][134][135][136][137][138][139][140] , and 3 .1% used both 34,43,68,141 . Sixty studies (47.5%) used CH as a data source and 47 (36.4%) used it as a study object. In 11 (8.5%), CH was mentioned only in the results, and in four (3.1%), it was used as an instrument for data collection ( Table 1). The remaining 7 refer to an article and six dissertations that used more than one approach to CH. Six of them use CH as a data source and also as an instrument for data collection (n = 3) 23,29,57 , object of study (n = 1) 16 or citation in the results (n = 2) 21, 24 . In a dissertation 141 , the CH is cited in the results and is also an object of study (Table 1).

Data Source
The main data extracted from the CH were related to vaccination (62.3%, n = 38) 20 Table 2).

Completion of the CH
The studies pointed out weaknesses in filling out all items of the CH 11,12,23,57,113,132,138,139 .
Considering different criteria to define adequacy, the completion of the items varied between 18.9% and 70% 16 . Poorer prevalences or absence of records were attributed to iron and vitamin A supplementation, as well as auditory, ocular, and oral health 22,33,60,63,82,84,141 .
CH is more commonly used in outpatient care, not being highly valued in the hospital setting 33,90,113,129 . Although healthcare professionals recognize that the lack of CH records and discontinuation of CH use can hinder the monitoring of the child's health 127,130,139 , they mainly understand CH as an instrument for recording vaccination and growth 80,90,96,107,127,129 . In the statements of these professionals, CH also appears as something that allows and guides the child monitoring by different services 90,99,129 and stimulates communication with family members 78,90,96,98,127 ; however, these uses are not observed in practice 18,60,90,93,96,107,127,129,132,140 . Community health workers (CHW) are seen as a strategic point for working with CH 7 , but they do not feel valued by the population, as they observe resistance from mothers when requesting the CH for consultation 94 . A study that aimed to describe the practices of home visits by CHW according to region and location of UBS identified that the Northeast region had the highest percentages of verification of the "vaccination card" (51%) 126 .
Healthcare professionals claim that there is a lack of interest and little engagement of family members and caregivers in CH use -as they do not read or bring the CH to the appointments 90,91,94,96,112,129,132,137,139,140 -, but they believe that CH enables mothers to understand their child's health 127 . They also argue that family members should require the completion of CH 90 , co-responsibilizing themselves for its use 90,99 . On the other hand, they recognize that caregivers' non-use of CH may be related to not receiving guidance for it 91
However, some studies have identified that 52% of mothers were instructed to bring the CH to appointments 94 , from 70% to 86.5% of healthcare professionals requested CH during the appointment 21,25,35 , 49% of the professionals took notes on CH during the appointment 94 , and 25% of family members and caregivers perceived indifference from the doctor regarding the CH 84 . According to family members and caregivers, not receiving guidance from healthcare professionals regarding CH 53,138 and the difficulty in understanding the information contained therein 96,132,138 are factors associated with reduced use of the CH by these actors.
Box represents the factors related to the use and/or completion of the CH.

Intervention Studies
In the four intervention studies identified 93,94,112,122 , the strategies to expand the use of the CH include collective monitoring using the CH 93 , reminders added to the child's medical record for the professional to complete the CH 122 , and the creation of spaces for dialogue about the CH 112 . One of the studies 94 warns that training may not have the expected impact, and it is necessary to plan strategies to reach the target audience and involve managers.
Lack of adequate space, support and organization, work overload and lack of participation of healthcare professionals were barriers to these actions 93,94,112,122 .

Data Collection Instrument
One study used the weight-for-age curve to evaluate the nutritional status of children aged 6 to 60 months using two methodologies (Waterlow criteria = 42.9% and CH chart = 35.6%), concluding that the prevalence of children with nutritional problems was similar and high 29 .
Six studies used the CH's surveillance instrument of CD 19,23,28,46,57,89 . One study evaluated the neuropsychomotor development of children aged 0 to 18 months 28 using the CH milestones, showing that 53% of them presented all the expected milestones for their age. Another study 46  (v) the CH instrument advances CD milestones that should be required at later age groups, leaving doubts regarding the child's classification 46,89 ; and (vi) vague explanation and imprecise language in the design of the CH instrument 46,128 .

DISCUSSION
As far as we know, this is the first scoping review that compiles all scientific production published between 1990 and July 2021 on the CH in Brazil. A significant number of studies were identified (n = 129), and almost half of them used the CH as a data source, mainly for vaccination data. The other half took the CH as an object of study, citing it in the results or using it as a data collection instrument. In this case, the main outcomes investigated were the completion and factors associated with completing the CH, in which weaknesses were identified in completing all items, except for vaccination. Contextual characteristics related to children, family members and caregivers, as well as professionals, were related to the use and/or completion of the CH. That is, as the CH is properly filled out, the possibilities of its use in analysing different health outcomes increase. The use of an inappropriate nomenclature demonstrates that the authors may be limiting the CH to its initial use 11,80,141 of recording vaccination, and this view seems to be perpetuated and transmitted to caregivers, not favoring the change to an expanded view of the CH. The CH is also an instrument intended for empowering families to care for their children, but these actors have not been sufficiently involved in the care process. Despite these barriers, Brazilian studies indicate a positive association between the use of the CH and better outcomes, such as the child's nutritional status 86 and CD 142 .
Almost half of the studies were conducted in the Northeast region. A national study on home visits identified higher percentages of verification of the "vaccination cards" (51%) and weighing of children (41.3%) in this region 126 , which may indicate that child health monitoring activities are a priority in the scope of the Northeastern PHC. PHC was the scenario for most of the studies, in line with its role as the coordinator of care in health care networks 143 . Consequently, the UBS were the preferred locations for conducting studies, as a viable and cost-effective alternative for research on child health. It is worth highlighting the use of vaccination campaigns as an alternative for carrying out surveys on health, nutrition, and CD in Brazil 146,148 . However, little emphasis was given to the role of other points of care 139 , such as maternity wards, which are crucial in the distribution and initial completion of the CH.
The interest in studying the use of the CH seems to have started in 2005, coinciding with the launch of the CHH, when the document began to be used as an instrument for surveillance and comprehensive monitoring of child health more emphatically. The main outcome investigated by studies that used the CH as an object of study or cited it in their findings was its completion and factors associated with completion. It is, therefore, the obtaining of a diagnosis on the use of this tool, which can help in defining strategies to improve the currently restricted scenario of its use. However, the need for the inclusion of the CH theme in processes of continuing education for the incorporation of this instrument as a guide for health practices is clear 11,21,35,53,[77][78][79]88,90,95,99,113,127,128,[130][131][132]137,139,141 . Also, the production in the field of implementation research is small, and few studies advance in proposing intervention models to solve the problem 93,94,112,122 .
The incorporation of CD surveillance into the work process of PHC using the CH is yet another challenge 122,136 . The proposal to carry out a physical examination of the child and identify CD risk factors (biological, social, and environmental), as well as observing developmental milestones, make the CH a tool to support professionals in CD surveillance 144 . Therefore, studies that aimed to validate the CH's CD milestones as a screening tool should be interpreted with caution since the purpose of the MoH is to use these milestones along with other information to identify children with possible delays. Thus, more studies are needed considering all the aspects raised in the CH for CD surveillance and its purpose of global CD assessment.
The scope of the bibliographic search conducted and the inclusion of grey literature are strengths of this review. On the other hand, the exclusion of conference abstracts and undergraduate course papers, as well as limited consultation to the first ten pages of Google Scholar and the non-availability of CH reports from studies funded by the MoH may be considered limitations.
The CH, in its multifunctionality, can be a formative tool and support for professionals working in child health and guidance to caregivers, and the data generated with its completion can contribute to the development of public policies involving early childhood. Nevertheless, the findings of this review reinforce the need to better understand which factors affect the distribution of the CH to the population and how to improve this process. They also point to the need to understand its use and completion by the different points of care and sectors, in the different Brazilian contexts. The need for studies that evaluate training models for healthcare professionals to use the CH in the context of continuing health education and interventions that encourage caregivers to use the CH is evident. Thus, researchers, policymakers, managers, healthcare professionals, and other sectors should seek in the CH a way to effectively systematize and monitor child health care, strengthening this important strategy inserted in policies to promote healthy growth and development and reduce child morbidity and mortality.