INTRODUCTION

The enslavement of people of African descent that lasted about 380 years in Brazil was characterized by a period of extreme violence and genocide of these people ¹. Even 133 years after Law No. 3353 of May 13, 1888, abolished slavery, there has been no effective social reparation or mitigation of racial hierarchy ¹, which contributed to the process of stigmatization, a result of the socio-historical racism that shapes the construction of the country, still remains today.

As a resistance to the exploitation suffered during the years of slavery, the quilombola territories arose. Such territorial structures, grouped mostly African peoples and their enslaved descendants who rebelled against the prevailing system, indigenous peoples and some white Europeans excluded from the system ^2).

Currently, Fundação Cultural Palmares records ³, indicate that 61% of the quilombola communities are located in the Northeast Region of Brazil, 33 of them in Rio Grande do Norte. These quilombola communities are vulnerable to various social impacts, with high levels of poverty, illiteracy, unemployment, lack of sanitation, electricity, and access to health services, contributing to the permanence of high rates of social and collective vulnerability ³

In this way, the policies to promote equity in health are conFigured as a set of actions and health services that aim to ensure resolute access, in a timely manner and with quality ^4). Among these policies, the National Policy for the Integral Health of the Black Population (NPIHBP), as well as the National Policy for the Integral Health of the Rural and Forest Populations (NPIHRFP) highlight the need to attend to the specific health needs of the remaining quilombo population, since they express living conditions marked by the process of exclusion of the black Brazilian population and, especially, are present in rural areas ^4,5).

However, research has shown weaknesses in the execution of interventions that allow access to public policies by this population ^6). Among them, access to Primary Health Care is not only due to the geographical barriers in rural areas, but also to the shortage of professionals willing to experience the rural context, the lack of knowledge about the reality and specificities, as well as the racial discrimination stigmatization that surrounds vulnerable populations ⁷.

It is observed that the investments made in PHC, easily evidenced by the expansion of Family Health Strategies (FHS) and Basic Health Units (BHU), are far from this population, which goes against what is established in the National Policy of Primary Care (NPPC) and in the NPIHRFP, which advocate universal care without distinction of gender, race/color, ethnicity, and sexual orientation ^5)(8)(9

For Bárbara Stafield^10), the assistance in the context of PHC should be guided by observing the attributes of access to the first contact with the service, longitudinality, integrality and coordination of care, following three attributes. Considering the attributes pre-established by PHC in the context of quilombola communities, the normative evaluation in health is characterized as an important tool for analysis of the social complexity of this population group, and can show what NPPC and NPIHRFP recommend about the actions performed in quilombola communities ^11).

Given the above, it is considered relevant studies that expand the discussion about the assistance provided by PHC in quilombola communities from the precepts established by the Unified Health System (UHS). The use of normative assessments applied to professionals who experience this reality is conFigured as a powerful ally in the construction of actions, which strengthen from a value judgment, the measures that ensure the performance and capacity of health care offered to this community.

In this sense, the objective of the present study is to evaluate the degree of implementation of the attributes of primary health care (PHC) as an indicator of the quality of care provided to quilombola communities in the state of Rio Grande do Norte.

METHOD

This is a study to evaluate the quality of primary health care attributes with a focus on the assistance provided to quilombola communities, which is characterized as an initial tool for the recognition of a certain reality that results in future interventions.

The scenario of this study was 33 quilombola communities distributed in 24 municipalities of the state of Rio Grande do Norte that are registered and recognized by the Palmares Cultural Foundation ³.

The target sample of this study was composed of doctors, nurses and nursing technicians or assistants who work in the Family Health Strategies (FHS) and Primary Care Teams (PCT) working in quilombola communities. In this sense, all 99 professionals responsible (doctors and nursing staff) for care in quilombola communities that are registered and recognized by the Palmares Cultural Foundation, distributed in 24 municipalities in the state of Rio Grande do Norte (RN), were invited to participate in the study. However, with the absence of responses from some professionals, the study had the participation of 51 professionals, 10 doctors, 25 nurses, and 16 nursing technicians.

The research sample was approximately 52% representative. Furthermore, it was possible to observe that in the municipalities of Bom Jesus, Ielmo Marinho, Ipanguaçu, Parelhas, Patu and Touros (Baixa do Quinquim) 100% of responses from registered professionals were obtained, on the other hand, the municipalities of Bom Jesus (Sítio Pavilhão), Portalegre (Sitio Arrojado/Engenho Novo and Sitio Pega) and São Tomé did not obtain any response from registered professionals.

For data collection, an instrument called Primary Care Assessment (PCATool/2020) version Brazil ¹⁰, was used, adapted to the reality of Primary Health Care in quilombola communities. The PCATool aims to measure the degree of implementation of PHC attributes in health care services ^10,11.

Data collection occurred between September and October 2021. To carry it out, the professionals were previously contacted by email or phone that were requested to the PHC coordination of each municipality in order to present information about the research. After that, the evaluative questionnaire was sent via Google Forms.

The overall score was calculated by adding the scores of all the components that form the essential attributes and the derived attributes (first contact access - accessibility, longitudinality, coordination - integration of care, coordination - information system, completeness - services available, completeness - services provided, family orientation, and community orientation), divided by the total number of components¹⁰.

According to the score achieved, the actions were judged as to their implementation through the criteria recommended by Ferreira and Silva (2014)¹², which was adapted for this study, as follows: not implemented (from 0 to 25%); incipiently implemented (from 26% to 50%); partially implemented (from 51% to 75%); fully implemented (from 76% to 100%).

Since this is a research involving human beings, the requirements proposed by the National Health Council were met, through Resolution No. 510/2016 ¹³. It is important to reiterate that the research was only conducted after approval by the Research Ethics Committee (CEP/CENTRAL) of the Federal University of Rio Grande do Norte, according to opinion 4.895.214.

RESULTS

Table 1 shows the characterization of the professional respondents. Regarding gender, 74.51% (n=38) are women and 25.49% (n=13) are men. Regarding the time they have been working in the quilombola community, it was possible to observe that 49.02% (n=25) have worked for one year, followed by 35.29% (n=18) who have worked from 2 to 5 years, and 3.92% who have worked more than 11 years in the community. It was also found that the professionals working with this 49.02% (n=25) are nurses, 31.37% (n=16) are nursing technicians and 19.61% (n=10) are doctors.

Table 1. Characteristics of primary health care professionals responsible for assistance in quilombola communities, Rio Grande do Norte, Brazil, 2021. (n=51). 

Source: Research data.

From the data analysis performed, it was identified that the PHC actions in quilombola communities in Rio Grande do Norte were classified as fully implemented (82.2%), considering the dimensions Capacity (77.92%) and Performance (85.56%). When observing the derived attributes: longitudinality (92.94%), coordination - information systems (80.88%), integrality - available services (85.91%), family orientation (87.45%), and community orientation (92.16%), it is noted that these dimensions were also fully implemented. Only the dimensions accessibility (74.51%) and coordination - integration of care (56.86%), were considered as partially implemented, as can be seen in Table 2.

However, it is worth noting that although most attributes have been fully implemented when considering the overall assessment, some items are still only partially implemented or implemented in an incipient way.

Table 2. Degree of PHC attributes in quilombola communities in Rio Grande do Norte, Brazil, 2021. 

Table 2 (cont.). Degree of PHC attributes in quilombola communities in Rio Grande do Norte, Brazil, 2021. 

Souce: Research data.

Finally, Table 3 presented the number of items per level of implementation (Not implemented, Incipient, Partially implemented and Fully implemented) according to the dimensions Capacity (Accessibility, Longitudinality, Coordination - Integration of Care and Coordination - Information Systems) and Performance (Completeness - Services Available, Family and Community Orientation). It was possible to observe that of the 19 items evaluated in the Capacity dimension 5.26% (n=01) were not implemented, 10.53% (n=02) were implemented in an incipient way, 21.05% (n=04) were partially implemented and 63.16% (n=12) were totally implemented, while of the 22 items evaluated in the Performance dimension it was noted that 4.55% (n=01) were implemented incipiently and 95.45% (n=24) were totally implemented. Overall, 2.44% (n=01) of the items were not implemented, 6.81% (n=03) were implemented incipiently, 9.09% (n=04) were partially implemented, and 81.82% (n=36) were fully implemented.

Table 3. Distribution of items and degrees of implementation of PHC attributes in quilombola communities in Rio Grande do Norte, Brazil, 2021. 

Source: Research data.

DISCUSSION

From this evaluation study, it was possible to carry out a situational diagnosis of PHC actions in quilombola communities in Rio Grande do Norte, identifying the weaknesses and potentialities in the provision of health care to these communities.

With regard to the accessibility dimension, it can be seen that it was classified as partially implemented (74.51%). Similarly, items A3, A4 and A6 in this dimension were also classified as partially implemented, while item A7 was classified as implemented in an incipient way. These items deal, respectively, with the structure of the service, the presence of internet and the barriers that are encountered by professionals on their way to the quilombola communities, which shows that these aspects still need more attention for the effectiveness of the care provided to these communities.

Although the terms access and accessibility are often used synonymously, these concepts have different meanings. Accessibility refers to the supply-side characteristics that enable people to reach services, while access is the way people perceive accessibility ⁹. Thus, it is understood that accessibility is characterized by the supply of services and the ability to meet the health needs of a given population, whenever they are needed in an easy and convenient manner.

These aspects demonstrate the variety of conditions that still need more attention for PHC to work effectively as the first contact service for the quilombola communities.

Regarding the longitudinality attribute, it was observed that it was classified as fully implemented (92.94%), as well as all items that compose it. Longitudinality is characterized by the continuity of care and the professional-patient relationship throughout the user's life, regardless of the absence or presence of disease. Thus, it is noted that this attribute is closely related to the bond.

The way in which a link is established with the community is a determining factor in the quality of the service provided by PHC. The relationships established between professionals and users are conFigured as a strong mechanism capable of making health services a satisfactory and usual source of attention to the population's needs. This relationship generates a feeling of trust on the part of users and accountability on the part of professionals who are part of this process ¹⁴.

When the coordination - care integration dimension is considered, it is noted that, like the accessibility dimension, this attribute was only partially implemented (56.86%). It is worth remembering that the dimension in question is characterized by the guarantee of continuity of care within a network of services, i.e., it is through this dimension that responses to the set of health needs presented by the population are organized ¹⁵. As discussed by Madureira (2015) ¹⁵, This attribute is essential for PHC to occupy a fundamental role in the health system. However, the Brazilian Unified Health System (UHS) still faces the great challenge of qualifying the PHC to perform this function of care coordination and thus provide users of the UHS with adequate responses to their needs ⁹.

Regarding each of the items that make up this dimension, it is noted that only one was classified as fully implemented (Item CI - 94.12%). This item refers specifically to discussions about the referral of the user to other services in the health network, which indicates that the teams seem to inform users about the specialized services that make up the network and their purpose. However, the results also show that although there is an initial communication between professionals and users, this dialogue seems to lack continuity, considering that item C2, which concerns the discussions that are held with the user after the consultation with the specialist, was classified as partially implemented (66.67%).

The difficulty in accessing other services in the health network is not a problem restricted to the quilombola communities in the state of Rio Grande do Norte. Previous studies have already shown that there is underutilization of health services by this population, and this occurs, in large part, due to the remoteness of quilombola communities from urban centers ¹⁶.

In addition, in order for care coordination to exist, it is also necessary to transfer information about users' health problems, which demands the existence of a longitudinal follow-up chart and an effective system of reference and counter-reference. This statement made by Madureira¹⁵ leads to another attribute investigated in this research, coordination - information systems, through which we sought to investigate the use of medical records, access to medical records, and whether there is a record of useful information for the continuity of health care. This attribute was rated as fully implemented (80.88%), which indicates that the professionals who participated in the study seem to make proper use of this work tool.

The importance of the use of the medical record by health teams is emphasized, given that an essential part of coordination is the availability of information covering health problems and access to health services. According to Starfield ¹¹, Coordination challenges can arise when, within the primary care setting, users are seen by different team members and information about them is generated in different places. Thus, the medical record is the main document for recording information about the user and the care provided to him or her ¹⁷.

However, despite the full implementation of this dimension, we cannot fail to highlight the fact that item D3 (Your service already has an electronic medical record in the quilombola community) had an incipient implementation (39.22%). This indicates that a large part of the teams still do not use the digital health record, bringing up again one of the limitations that are experienced in the quilombola communities: lack of internet access.

Far from being trivial, the use of electronic medical records can have significant impacts on the care of the quilombola community. An investigation conducted in the municipalities of Aracaju, Belo Horizonte, Florianópolis, and Vitória on the implementation of the FHS with a focus on integration with the care network found that among the facilitating conditions for the integration of services were the implementation of the computerized system for scheduling and regulation of medical appointments and specialized exams (SISREG), and the existence of electronic medical records with online access ⁹.

One can see, in view of the above, that the investment in Information and Communication Technology - ICT, such as the computerization of medical records, is an important initiative that can be considered pro-coordination. However, if it is already a challenge to implement these systems in urban centers, the difficulties become even more evident when it comes to quilombola communities, due to the lack of internet access in these places. A recent survey conducted with quilombola communities in the Northeast of Brazil showed that 29% of the homes do not have Internet access. Among the families that do have internet at home, a large part of them have difficulties to pay the monthly expenses with the service. In addition, only 11% of families living in quilombola communities have a computer, the others use cell phones with limited data plans to access information, study, work, access religious and cultural content, and connect to the community ¹⁸.

With regard to the attribute comprehensiveness - available services, it was observed that this was classified as fully implemented (85.01%). This result is similar to that found in the research conducted by Sala et al. (2011), which assessed the level of implementation of comprehensiveness from the perspective of users of health units in the city of São Paulo ¹⁸.

As stated by Silva, Miranda and Andrade¹⁹, Different meanings can be attributed to the term integrality that are not necessarily mutually exclusive. Among them, integrality can be understood as a practice of considering the whole in the knowledge about diseases, so as to enable the treatments given to subjects to be guided by a comprehensive view of their needs. Moreover, the aforementioned authors point out that another interpretation of the term considers integrality as a way to organize professional practices and services, considering that they should be able to perform a broad understanding of the needs of the population they serve.

These definitions are aligned with the notion of integrality adopted in this research, which considers this attribute as the recognition of the broad spectrum of needs of an individual, which implies offering preventive and curative services and ensuring access to all types of services for all age groups through referral, when necessary. In integrality, promotion, prevention, and treatment are integrated in the professional practice, which assumes an approach focused on the individual, his family, and his context, being essential the interdisciplinary work of the health teams. Thus, one can understand that in the day to day of health services, integrality is expressed through the ability of professionals to respond to the suffering of users and, in a coordinated way, identify and offer, for each unique situation, preventive actions ¹⁸.

However, despite the full implementation of this attribute, some items are still incipiently implemented (E3), and partially implemented (E8 and E9). Regarding item E3 (Verify if the quilombola family can participate in any social assistance program or social benefits - e.g. Bolsa Família Program, Social Tariff), it is possible that its implementation was incipient because the sample of this study was mostly made up of doctors, nurses, and nursing technicians and, in general, issues related to ensuring the rights of users end up being the responsibility of the social service professional. Items 8 (Identification of hearing problems in the quilombola community) and 9 (Identification of visual problems in the quilombola community) may have been partially implemented due to the absence of means and/or professionals that can assess these dimensions of health in the quilombola communities, which demonstrates the need to expand the services offered in the PHC.

In turn, the attribute family orientation was classified as fully implemented (87.45%). This attribute consists in considering the family as the subject of health care, assuming the importance of the diagnosis, the family needs and characteristics according to the physical, economic, cultural and social situation in which they live and are inserted. In short, family orientation is the consideration of the family and the family environment in the care provided.

Family orientation is an attribute that is materialized from the comprehensiveness of the integrality principle that offers support for the consideration of the person within his/her environments ¹¹. The bond with the family at home allows PHC workers to identify opportunities for new care, guiding their actions by the social health indicators of the population. Through qualified listening, professionals can plan strategies to respond to the particular characteristics and needs of families, not restricting themselves to technical knowledge only ²⁰.

Given the results found, it is inferred that the professionals participating in this study seem to take into account the particular characteristics of the families assisted in the provision of health care. These data go against what was observed in a previous study conducted with users of a health service, which found that the attribute family orientation received very low percentages of positive responses in most of the items that make up the dimension ²⁰

It is considered that one of the primary points for the effectiveness of family counseling are home visits, which are important and indispensable for the consolidation of horizontal relations between PHC professionals and families in the dynamics of care. In the home context, professionals get to know the family reality, employment, housing, and sanitation conditions, facilitating the planning of the work that will be developed for health prevention and promotion ²¹.

In this sense, it is considered that one of the possibilities of PHC action with regard to family counseling is to favor family counseling spaces in order to promote important information about genetic aspects that are directly associated with the health conditions of the black population ¹⁶.

Finally, the attribute community orientation, similar to what was observed for family orientation, was classified as fully implemented (92.16%), as well as all items that make up this dimension. Community orientation refers to the understanding that the health needs of the population are directly related to their social context and that the recognition of these needs presupposes that health teams know the area where they work.

It is considered a positive finding of this study that the family and community orientation dimensions were classified as fully implemented, considering that in previous studies these dimensions were negatively evaluated by users of different health services ²¹.

In this context, it is crucial the training of health professionals, who must be aware of the health and social specificities that are experienced by the black population, specifically quilombola communities living in rural contexts. Professional training, when disconnected from the reality of living and health conditions of the population, results in a lack of preparation to deal with patients with different sociocultural characteristics, which is an obstacle to the full implementation of PHC attributes in quilombola communities.

Given the above, this study reaffirms its relevance, because by recognizing the health conditions that are imposed on quilombola communities in Rio Grande do Norte, it is possible to improve the health care provided to this population, considering the positive aspects in order to strengthen them, and identifying what still needs to be transformed. It is understood that the search for change in the reality of quilombola communities is necessary, and this can occur through engagement in struggles that aim to comply with the laws and social policies that ensure comprehensive health care for this population.

Entretanto, apesar das contribuições do presente estudo, o mesmo não é isento de limitações.

The low number of responses from professionals is considered a limitation of this research, which may, in some way, have impacted the results. We initially estimated a sample of 99 professionals, 33 from each area (physicians, nurses and nursing technicians), however, in the end, only 51 participants responded to the study, most of whom were nursing professionals. This is an important fact to be highlighted, as it makes the results predominate the perspective of a single category, being relevant that future studies seek to balance the number of participants per professional category, in order to have a broader view of the problem investigated.

CONCLUSION

From the results of the data of this study it was possible to infer that most of the attributes of PHC are classified as fully implemented in quilombola communities in Rio Grande do Norte, however, it could also be observed that some points still need to be improved, specifically those related to the physical structure of services, access to the Internet and the conditions of locomotion and transportation of both users and professionals.

It is worth noting that almost all attributes and items that were classified as partially implemented or implemented in an incipient way, point to problems that do not depend only on the multiprofessional team to be solved. For the attributes of PHC to be fully implemented in the investigated quilombola communities it is necessary, first of all, to count on government investment in order to solve the difficulties that were identified.

To deal with issues related to quilombola communities in Brazil is to bring to the center of the debate problems that range from vulnerabilities to ethnic, cultural, and historical resistance of a people marked by conflicts and dilemmas. History has not infrequently relegated the black population to a trajectory of prejudice, discrimination, injustice, inequality, and inequity, which has reinforced processes of social exclusion, depriving the black population of better opportunities and living conditions. In this sense, studies focused on the health of this population should be increasingly present in the academic and scientific sphere, in order to ensure the promotion of equality aimed at the development and strengthening of specific public policies, as well as highlighting the process of inequality of this population, historically neglected.