Modeling of Food and Nutrition Surveillance in Primary Health Care

Modelização da Vigilância Alimentar e Nutricional na Atenção Primária em Saúde

ABSTRACT

Objective:

To describe the modeling stages of food and nutrition surveillance in the Primary Health Care of the Unified Health Care System, considering its activities, objectives, and goals

Methods:

Document analysis and semi-structured interviews were used for identifying the components, describe the intervention, and identify potential assessment users.

Results:

The results include identification of the objectives and goals of the intervention, the required inputs, activities, and expected effects. The intervention was then modeled based on these data. The use of the theoretical logic model optimizes times, resources, definition of the indicators that require monitoring, and the aspects that require assessment, identifying more clearly the contribution of the intervention to the results

Conclusion:

Modeling enabled the description of food and nutrition surveillance based on its components and may guide the development of viable plans to monitor food and nutrition surveillance actions so that modeling can be established as a local intersectoral planning instrument.

Keywords:
Health planning; Models theoretical; Monitoring; Nutritional surveillance; Primary health care.

RESUMO

Objetivo:

Descrever as etapas de modelização da vigilância alimentar e nutricional na Atenção Primária em Saúde no Sistema Único de Saúde, considerando suas atividades, objetivos e metas.

Métodos:

Foram utilizadas as técnicas de análise documental e entrevistas semi-estruturadas para identificar os componentes, descrever a intervenção e identificar os potenciais usuários da avaliação.

Resultados:

Foram identificados os objetivos e metas da intervenção, os insumos necessários, as atividades e os efeitos esperados. A partir dessas informações, a intervenção foi modelizada. A utilização do modelo lógico teórico otimiza tempo, recursos, definição de indicadores a serem monitorados e aspectos a serem avaliados, identificando com mais clareza qual a contribuição da intervenção para o alcance dos resultados.

Conclusão:

A modelização possibilitou descrever a vigilância alimentar e nutricional a partir de seus componentes e poderá orientar a elaboração de planos viáveis de monitoramento das ações da vigilância alimentar e nutricional para sua efetivação como um instrumento de planejamento intersetorial em nível local.

Palavras-chave:
Planejamento em saúde; Modelos teóricos; Monitoramento; Vigilância alimentar e nutricional; Atenção primária à saúde

INTRODUCTION

Given the everlasting and intense social and regional inequalities in Brazil, many public policies of different sectors and governmental spheres target social inclusion. Historically, Brazilian social policies aimed at individuals and families, in a focused and assistive manner, intervening little on structural aspects and effectively ensuring social rights by universal policies. Moreover, management instances lack consistent information to support their structuring, implementation, and development processes^1,2.

Despite the significant advances achieved by the universalization and decentralization of the Sistema Único de Saúde (SUS, Unified Health Care System) in 1990, some interventions still fail because consistent information to support decision making is scarce^3,4.

The effective implementation of the sanitary model of health surveillance, which recommends evidence-based planning and management to solve the most common and important health problems in population groups, faces numerous challenges. These problems, identified in the routine of local health services, should feed the database of the National Health Surveillance Systems, which contribute to consolidate SUS administrative decentralization^5,6.

In this context, food and nutrition surveillance stands out as one of the guidelines of the Política Nacional de Alimentação e Nutrição (PNAN, National Food and Nutrition Policy), an important instrument for monitoring and assessing social policies, especially those related to the Human Right to Adequate Food, Food and Nutrition Security (FNS), and health sector policies, such as the Política Nacional de Atenção Básica (National Primary Health Care Policy) and the Política Nacional de Promoção da Saúde (National Health Promotion Policy)^7-10.

The food and nutrition surveillance configuration adopted by Brazil was similar to that adopted by other developing countries, where the monitoring of the nutritional status of groups of higher biological (mother-child dyad) and social (the poor) vulnerability was prioritized in detriment of the monitoring of economic indicators of food intake, production, and supply for the areas of agriculture and economy¹¹.

By monitoring the population's food intake and nutritional status to provide "continuous data about the food and nutrition conditions and its determinants"⁹ food and nutrition surveillance aims to provide data to help the decision making of the individuals responsible for creating policies, planning, and managing programs that aim to improve the population's food intake patterns and nutritional status^7-10. Timely, quality, and representative monitoring of the population's food and nutrition profile would allow identifying the scope of these policies to improve their execution, establish courses of action, and provide an account, to the society, of the huge resources invested towards social participation and accountability^6-13.

Food and nutrition surveillance was operationalized in SUS Primary Health Care (PHC) through the routine activities of the Family Health Strategy. It should cover all the population treated at this level of care, which includes all age groups, from pregnancy to senility^7-9. The information about individuals' eating behavior and nutrition status should feed the electronic database of the Sistema de Vigilância Alimentar e Nutricional (Sisvan, Food and Nutrition Surveillance System), consisting of one nutritional and one food surveillance subsystems, whose expansion and optimization were defined as priorities by PNAN^7-10,13,14.

From its implementation, Sisvan has presented problems that hinder its operationalization and use, that is, its ability to provide quality and timely information for the creation of effective public policies. The most visible problems regard structural aspects, such as inappropriate human and material resources: few professionals and high turnover, inappropriate professional qualification to obtain reliable data, and inadequate number of anthropometric, information technology, and Internet devices^13,15-19. Consequently, Sisvan has low population coverage, being limited to mother-child dyads and beneficiaries of social programs^13,20-22.

The need to expand food and nutrition surveillance coverage and improve the quality of the generated data reinforce the importance of institutionalizing assessment and monitoring as essential stages of public policies' cycle and justify studies that assess the different stages of an intervention^4,6.

However, it is only possible to choose a stage to assess after modeling the intervention, which is the first stage of a theory-based assessment study²³, since the approaches and methods used for each assessment will depend on the complexity of the intervention, the questions that the study aims to answer, and the maturation stage of the intervention²⁴.

The modeling of an intervention attempts to briefly and schematically describe how a complex system of actions intends to reach its objectives. For this purpose, it exposes the links between the expected effects of an intervention and its relationship with the employed resources and activities, thereby guiding the assessment and monitoring process in any intervention phase, from planning to result achievement, passing through the implementation process²⁴.

Given the aforementioned information, this article aims to describe the food and nutrition surveillance modeling in PHC by creating Theoretical Logic Models (TLM) that expose the relationships of causality between the structure, processes, and results expected by the regulatory instruments defined at the federal level to produce timely and quality information continuously for intersectoral decision making in the health sector from the FNS perspective^3,4,6,24-26.

METHODS

Description of the objectives and premises of the intervention is one of the first stages of a theory-based assessment study²³, and it is usually presented in the form of logic models, which can be of three types: causal, theoretical, and operational^24,26,27.

The causal logic model describes the causes of the problem on which the intervention intends to act. The TLM tries to analyze the plausibility of the relationships of causality between structure, processes, and results, aiming to reach the intervention objectives, established in its regulatory and organizational instruments. It also allows analyzing the plausibility of the intervention's strategy and logic. Finally, the operational logic model tries to establish how the TLM is implemented at the local level, considering the particularities of each context. Thus, it is a TLM development based on its validation in different contexts^24,23.

This study describes two TLM. The first, food and nutrition actions in PHC, and as its development, a TLM proposal of food and nutrition surveillance, to deepen the discussion about the processes conducted in the PHC context to obtain the population's food and nutritional diagnosis.

Food and nutrition surveillance was modeled in three stages: 1) identification and description of the official documents and literature available about the intervention; 2) description and delimitation of the intervention, its activities, target population, objectives, and goals; and 3) identification of the assessment users and other potential stakeholders.

Identification and description of official documents and the literature available about the intervention was based on an extensive literature review, systematically searching the Biblioteca Virtual em Saúde (Bireme, Virtual Health Library), which includes the databases Medical Literature Analysis and Retrieval System Online (MedLine), Literatura Latino-Americana e do Caribe em Ciências da Saúde (Lilacs, Latin American and Caribbean Literature on Health Sciences) and Scientific Electronic Library Online (SciELO). The following English and Portuguese descriptors were used: "Segurança Alimentar e Nutricional" (Food and Nutrition Security), "Vigilância Nutricional" (Nutritional Surveillance), "Vigilância Alimentar" (Food Surveillance), "Atenção Primária à Saúde/Atenção Básica" (Primary Health Care/Primary Care), "Sistema de Informação" (Information System), "Planejamento em Saúde" (Health Planning), "Programas e Políticas de Nutrição e Alimentação" (Food and Nutrition Programs and Policies).

The search, conducted in June 2014, returned 447 publications, of which 160 were articles, 102 were official documents, 39 were theses, and 146 were other types of documents, such as congress annals, monographies, and reports. Based on their relationship with the subject, 46 articles, 61 official documents of the Brazilian government, and 8 theses were selected. Many publications appear in more than one search, so they were considered only once. Official documents from other countries were not included.

The concept of intervention and the items that compose the TLM guided the construction of content analysis categories for document analysis²⁸, from which food and nutrition surveillance legislation and regulatory publications, listed chronologically in Chart 1, were analyzed. References of the selected documents were also consulted, as well as interministerial decrees, in order to identify intersectoral articulations with education, agriculture, food and nutrition security, and social assistance. The food and nutrition surveillance goals were described in Chart 1, which contain the National Health Plans, offering elements related to the political and organizational context of food and nutrition surveillance in Brazil.

Chart 1
Legal milestones and regulations of the Ministry of Health for Food and Nutrition Surveillance

Key informants were interviewed to describe and delimit the intervention, its activities, target population, objectives, and goals, identifying the users of a probable assessment and other potential stakeholders; to analyze documents; and to review the literature.

This stage was conducted by the same research group in another study from the first semester of 2012, which assessed the degree of Sisvan web implementation in Minas Gerais (CAAE nº 0032.0.238.000-11) using yet unpublished survey results. In the qualitative stage, 56 municipalities were selected, two by the Regional Health Superintendence, one with the highest and another with the lowest degree of Sisvan web implementation, classified according to an electronic questionnaire sent previously and answered by 432 of the 853 municipalities of the state. Of the 56 municipalities that met the inclusion criteria for the 28 Regional Health Superintendence, 26 municipalities of 13 Regional Health Superintendence authorized the study. Thus, we identified and contacted the professionals responsible for entering data in the Sisvan web of 26 municipalities to administer a semi-structured interview, conducted in loco, to check how they perceived the operational characteristics of Sisvan web through technical parameters of usability, information architecture, and accessibility.

Although these interviews presented the limitation of revealing only a part of the local food and nutrition surveillance, they were useful for contextualizing the intervention in a real situation, in which the problems that affect its execution could be identified and analyzed, contributing to the creation of theoretical suppositions and exposing rival theories. They also contributed to the identification of individuals potentially involved in the intervention and assessment, and to its modeling.

Once the interviews were finished, the content was transcribed, and after successive readings, the material was organized into analytical categories, complementing document analysis²⁸. Based on the described data collection techniques, the intervention modeling stage began^24-26. By considering food and nutrition surveillance an intervention, we intend to describe it as an organized action system that includes the actors involved in planning, organizing, and carrying out the activities; a structure that covers the set of resources and rules beyond the actors' control as it contains a political, ideological, and normative component; and the objectives and goals of the intervention actions, in this case, to supply continuous and quality information on the nutritional status and food intake of the territorial population. The TLM tried to schematically represent all components of the intervention - problem, objectives, inputs, activities, and expected results in the short, medium, and long term, exposing its work and operational aspects²⁴.

RESULTS

To consider food and nutrition surveillance an intervention means to recognize it as a system of organized actions that should produce periodical information about the food and nutritional conditions of individuals and populations, and its determinants, allowing monitoring the food and nutrition transition. These data would be useful for defining health promotion and care actions under the light of SUS and FNS principles^5-10.

Food and nutrition surveillance is, thus, understood as an intervention that allows monitoring and assessing FNS-related social policies^11-13. The data produced locally by PHC are useful for managers of the health sector, and through the intersectoral articulation of this with other sectors such as education, agriculture, social assistance, habitation, supply, social security, and labor, among others, to make decisions that enable achieving Food and nutrition surveillance^7-10,13.

The identified food and nutritional surveillance objectives were the organization of the necessary inputs and activities to: 1) supply continuous and updated data about the food and nutritional situation of municipal and state PHC users; 2) identify geographic areas, social segments, and population groups at risk of nutritional problems; 3) promote an early diagnosis of nutritional problems, whether underweight or excess weight, enabling actions that prevent the consequences of these problems; 4) enable monitoring and assessing the nutritional status of families that benefit from social programs; and 5) offer subsidies for the formulation and assessment of public policies that aim to improve the food and nutritional situation of the Brazilian population.

To implement and supervise food and nutrition actions at the local level, the municipal manager should designate a coordinator, preferably a dietitian. This coordinator, responsible for planning and organizing food and nutrition actions, should articulate with other PHC coordinators to organize the necessary structure and the work of the professionals in Family Health Strategy teams to make the food and nutritional diagnosis of individuals and population groups in the attached territory. Based on food and nutrition actions, individual user data would be collected (clinical, biochemical, anthropometric, and food intake) and immediately processed and analyzed by Sisvan web and other Sistema de Informação em Saúde (SIS, Health Information Systems), which would provide complementary information about the life and health conditions of individuals and specific population groups^9,13-22,29.

With Sisvan and SIS data, it is possible to carry out a health situation analysis to serve as a basis for the local health planning and programming, considering the assistance and nutritional care actions, including referral and counter-referral; prevention of the most common nutritional diseases and disorders and health promotion focusing on the determinants of nutritional, life, and health conditions^5,6,29. For this purpose, the methodological principles of situational strategic planning are recommended, defining the objectives, goals, actions, and activities to face the most important problems, and defining the individuals in charge, deadlines, and resources to advance the intersectoral work^1,3,30.

Expansion of Sisvan population coverage and qualification of its actions are PNAN guidelines. For the first, the Ministery of Health recommended the "Nutritional Calls" along with the national immunization campaigns; the second regarded the inclusion of a dietitian in the Núcleo de Apoio à Saúde da Familia (NASF, Family Health Support Centers) as a way to strengthen the actions performed by Family Health Strategy teams related to it, including the provision of trainings^{7-10,14,29,31}.

Each technical component uses inputs to carry out management activities or activities directed at individuals, families, and community, to obtain immediate results (product), medium-term results (results), and long-term results (impact)²⁴ to advance in the search for FNS assurance.

These components are described and systematized in the TLM of the food and nutrition actions in PHC, detailed in Figure 1, developed by analyzing the literature and Ministery of Health regulation instruments, such as the 2008 "Cartilha de Protocolos do Sistema de Vigilância Alimentar e Nutricional na assistência à saúde" (Compendium of Protocols of the Food and Nutrition Surveillance System in Health Care) and the 2009 "Matriz das Ações de Alimentação e Nutrição na Atenção Básica em Saúde" (Matrix of Food and Nutrition Actions in Primary Health Care).

Figure 1
Theoretical and Logical Model of Food and Nutrition Actions in Primary Health Care.

By considering food and nutrition surveillance one of the components of food and nutrition actions and the focus that should be given to the food and nutrition surveillance implementation process in PHC, a specific TLM was created specifically for food and nutrition surveillance. This TML involves planning and management of food and nutrition actions, and food and nutrition diagnosis, which were specifically systematized and described in Figure 2.

Figure 2
Theoretical Logic Model of Food and Nutrition Surveillance in Primary Health Care.

The following were identified as potentially involved in the intervention, and thus, possible users of a food and nutrition surveillance implementation assessment in PHC: (a) the municipal technical references of food and nutrition surveillance, responsible for the planning and management of food and nutrition actions and for analyzing and disclosing information about the food and nutritional status of the population, which were named food and nutrition surveillance managers; (b) the health professionals involved in data collection and digitization; (c) professionals of different sectors related to FNS; (d) the technical references of food and nutrition surveillance at the regional level, also named food and nutrition surveillance managers in this management level; (e) the population of ascribed territories.

Chart 2 details the identified potential users, their role in food and nutrition surveillance, their interest and role in the assessment, and their role in using the findings.

Chart 2.
Potential users of an assessment of food and nutrition surveillance implementation in primary health care.

DISCUSSION

The expected product from food and nutrition surveillance modeling is the full description of the intervention²⁴ and its schematic representation in the form of TLM. The purpose of these products is to reveal the chain of predicted effects to reach the objectives of making quality information available in a timely manner about the nutritional status and food intake of the territorial population.

In addition to describing the intervention, the study identified its objectives, goals, and individuals potentially interested in the assessment. For Champagne et al.²⁴, one intervention can be conceived as an organized system of action that involves, within a structure, actors that perform certain processes to reach defined objectives. With this perspective, food and nutrition surveillance ultimately tries to improve the population's life and health conditions by providing updated, timely, and quality information for manager decision making^9,10,13,15.

Regarding food and nutrition surveillance, the scope of action of the health sector, particularly primary health care, responsible for the reorganization of the Health Care Networks, refers to the identification of the population's health needs to better guide intersectoral policies and actions that affect its determinants and requirements²⁹. In addition to identifying health needs, it is PHC role to refer to secondary and tertiary care the cases that require individual diagnosis and treatment (referral), and to monitor and follow these individuals in the service routine (counter-referral)^29,31.

The description of food and nutrition surveillance based on regulations and literature review allowed identifying the limited expansion of food and nutrition surveillance coverage to population segments other than the beneficiaries of social programs, pregnant women, and children^15,16,20-22. The absence of monitoring of other life stages, such as adolescence, adulthood, and old age, limits its field of action as an instrument to monitor nutritional problems related to overweight, obesity, and specific nutritional deficiencies, which have been the most prevalent and challenging to SUS³¹.

In addition to expanding the coverage to adolescents, adults, and older adults, it is essential to qualify food and nutrition surveillance actions, aspects that have been incorporated in the goals of sectoral and intersectoral planning^6-10,14. The goals defined by the federal sphere must guide the local actions, in consonance with the particularities and needs identified by analyzing the health situation. Hence, they show the priorities and political options adopted by the Brazilian government over the years. The study identified the absence of goals related to health promotion, hardly measurable by quantitative methods, and that require assessments of social changes^4,5,30. Although these aspects have been considered important in the analyzed documents, there are no planned goals and indicators for their measurement. This is an important aspect that still requires strengthening.

It is important to point out the essential role of food and nutrition surveillance as a pillar for the food and nutritional monitoring of the population, as an instrument to be prioritized as much as the large nationwide surveys. Although the latter are more reliable, accurate, and allow the establishment of causal relationships, they are more expensive and complex, so conducted less frequently. Food and nutrition surveillance inserted in the services has lower information quality and reliability, but aids timely decision making at the local level because it is produced continuously and can cover a high percentage of the population^7,9.

In this perspective, the large surveys are more useful for the central levels of management and for the definition of macroeconomic policies. At the local level, the use of SIS for organizing the services and intersectoral planning is essential to guarantee the effort of the services to increase their coverage and qualify actions^1,3.

Based on the perspective of the usefulness of the assessment results to improve the execution of the intervention, it is necessary to identify and involve individuals potentially interested in the assessment to potentiate their commitment to use the findings^24-26. They will be involved in the stages of making pacts with respect to the assessment objectives and creation of the matrix of criteria that will guide the assessment^25,26.

Specifically, the managers will help to identify and describe the available structure (financial, physical, human, and material resources) to carry out food and nutrition surveillance actions, its organization, and the data analysis and disclosure processes, while the professionals will help describe the operationalization of routine activities of data collection and subsequent digitization in the system. The territorial population may disclose its expectation and needs regarding food and nutrition actions and surveillance. Validation of the TLM in different contexts is an expected development of intervention modeling from the perspective of theory-based assessment²³.

FINAL CONSIDERATIONS

In the search for expanding the population coverage and qualification of the actions performed, one may say that food and nutrition surveillance description approaches the dimensions of planning, management, and food and nutritional diagnosis, focusing on activities using the available inputs and the main products regarding the food and nutrition surveillance objectives, which is to supply information for action.

Based on the created logic models that describe food and nutrition surveillance, the expected developments are the involvement of the stakeholders identified in theoretical logic model validation, followed by the logical analysis of the intervention, which will allow the identification of the plausibility of the proposed causal relationships.

The strengthening of the intervention functioning theory stemming from all these stages will allow reviewing the developed logic models in an interactive process marked by cycles that update the intervention functioning based on the emergence of new evidence. One limitation is the difficulty of presenting the whole intervention complexity in one single schematic representation.

The discussion about logic models seems to increase the knowledge of all those involved with the intervention, to contribute to the orientation of different types of assessments about any of the food and nutrition surveillance phases, and to guide future matrices to monitor food and nutrition surveillance processes in PHC. This, undoubtedly, is a useful and timely instrument to help decision making even before the assessment itself is conducted. It may be useful to management instances and service professionals, in addition to instances of social control. The TLM optimizes time, resources, definition of indicators that require monitoring, and aspects that require assessment, identifying more clearly the contribution of the intervention to achieve the results and what other components contribute to this achievement.

Identifying the difficulties and potentialities found locally to increase population coverage and qualify food and nutrition actions is essential for proposing concrete actions that bring the political discourse closer to the reality of Brazilian municipalities and change food and nutrition surveillance into a management instrument for intersectoral planning.

ACKNOWLEDGMENT

We thank Conselho Nacional de Desenvol-vimento Científico e Tecnológico for the doctoral grant and Fundação de Amparo à Pesquisa do Estado de Minas Gerais for sponsoring the study

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  CONTRIBUTORS SAS VITORINO helped to conceive and design the study, and to write the article. MM CRUZ helped to conceive the study, reviewed the article, and approved the final version for publication. DC BARROS helped to conceive the study, reviewed the article, and approved the final version for publication.

Publication Dates

• Publication in this collection
  Jan-Feb 2017

History

• Received
  24 Apr 2015
• Reviewed
  19 Sept 2016
• Accepted
  19 Oct 2016