ADMINISTRACIÓN - GESTIÓN - CALIDAD

 

Perception of users and health professionals about the quality of care provided to patients with AIDS

Percepção de usuários e profissionais de saúde sobre a qualidade dos cuidados prestados a pacientes com AIDS

Percepción de los usuarios y los profesionales de la salud acerca de la calidad de la atención prestada a los pacientes con AIDS

 

 

da Silva, Richardson Augusto Rosendo*; Torres, Gilson de Vasconcelos**; da Silva, Ilisdayne Thallita Soares***; Nelson, Ana Raquel Cortês****; Lucena, Indira de Araújo****; Costa, Danyella Augusto Rosendo da Silva*****

*PhD in Health Sciences. Adjunct Professor III of the Undergraduation Course and Graduate Program (Master degree and Ph.D.) in Nursing from the Departament of Nursing, Federal University of Rio Grande do Norte/UFRN. Natal, (RN). E-mail: rirosendo@yahoo.com.br
**Post-PhD in Nursing. Full Professor from the Departament of Nursing, UFRN
***Nurse. Temporary Professor from the Undegraduate Nursing Course at the Faculty of Health Sciences in Trairi/ Federal University of Rio Grande do Norte
****Nursing Student from UFRN
*****Master in Nursing from the Graduate Nursing Program, Federal University of Rio Grande do Norte/UFRN. Federal Institute of Education, Science and Technology of Rio Grande do Norte (IFRN), Natal, RN, Brazil.

 

 

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ABSTRACT

Objective: Identify the perception of users and health professionals about the quality of care for patients with AIDS.
Material and methods: Quantitative study, conducted at the outpatient clinic of a public hospital in northeastern Brazil. Participated in the survey 626 patients and 34 health professionals. Data were collected through structured between August 2009 to July 2010, and analyzed using descriptive and inferential statistical form. The research was approved by the Ethics Committee under C.A.A.E. n^o. 0063.0.051.000-07.
Results: It was identified that the majority of users (85,6%) showed dissatisfaction, while most of the professionals interviewed (58,8%) are satisfied with the care provided in the service searched.
Conclusions: It is opinion mister consider both users of health professionals in the assessment of health services

Key words: Acquired Immunodeficiency Syndrome; Health Services Evaluation; Patient Satisfaction; Quality of Health Care.

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RESUMO

Objetivo: Identificar a percepção de usuários e profissionais de saúde sobre a qualidade dos cuidados prestados a pacientes com AIDS.
Material e métodos: Estudo quantitativo, realizado no serviço ambulatorial de um hospital público do Nordeste do Brasil. Participaram da pesquisa 626 pacientes e 34 profissionais de saúde. Os dados foram coletados através de formulário estruturado entre agosto de 2009 a julho de 2010, e analisados pela estatística descritiva e inferencial. A pesquisa obteve aprovação do Comitê de Ética sob o C.A.A.E n^o. 0063.0.051.000-07.
Resultados: Identificou-se que a maioria dos usuários (85,6%) mostrou insatisfação, enquanto que a maior parte dos profissionais entrevistados (58,8%) está satisfeita com os cuidados prestados no serviço pesquisado.
Conclusões: Faz-se mister considerar a opinião tanto dos usuários quanto dos profissionais de saúde na avaliação dos serviços de saúde

Palavras chave: Síndrome de imunodeficiência adquirida; Avaliação de serviços de saúde; Satisfação do paciente; Qualidade da assistência à saúde.

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RESUMEN

Objetivo: Identificar la percepción de los usuarios y los profesionales de la salud acerca de la calidad de la atención para los pacientes con SIDA.
Material y métodos: Estudio cuantitativo, realizado en el ambulatorio de un hospital público en el noreste de Brasil. En la encuesta participaron 626 pacientes y 34 profesionales de la salud. Los datos fueron recolectados a través de un formulario estructurado entre agosto 2009 y julio 2010, y se analizaron de forma estadística descriptiva e inferencial. La investigación fue aprobada por el Comité de Ética en virtud del CAAE. n.^o. 0063.0.051.000-07.
Resultados: Se identificó que la mayoría de los usuarios (85,6%) mostraron insatisfacción, mientras que la mayoría de los profesionales entrevistados (58,8%) están satisfechos con la atención recibida en el servicio buscado.
Conclusiones: Es preciso considerar la opinión tanto de los usuarios como de los profesionales sanitarios en la evaluación de los servicios de salud.

Palabras clave: Síndrome de Inmunodeficiencia Adquirida; Evaluación de Servicios de Salud; Satisfacción del Paciente; Calidad de la Atención de Salud.

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Introduction

The Acquired Immunodeficiency Syndrome (AIDS) raises a great concern because of its severity, global spread, doubts and difficulties in its control. In spite of this, there was several advances in this field that have contributed to improving both the quality and the quantity of years lived by those who are affected by this infection ⁽¹⁾.

Within the Brazilian policy on AIDS, one should highlight the free and universal distribution of antiretroviral drugs, which constitutes one of the determining factors for reducing morbimortality from HIV infection and illness caused by AIDS ^(2-3). This policy has helped the Brazilian response to the AIDS epidemic to earn recognition worldwide, turning Brazil into an international leadership ⁽⁴⁾.

Combined Antiretroviral therapy (ART) adopted in the treatment of AIDS showed to be effective in relation to the decrease in opportunistic infections and the increase in life expectancy, which provided a improvement in the quality of life of these people and led the AiDs to acquire a nature of chronic disease ⁽⁵⁾.

The need for health resulting from AIDS requires an ongoing outpatient care to perform the immunological, pharmacological and clinical follow-up of patients living with the disease. This type of care has contributed to changing the pattern of the disease, thus minimizing hospital admissions and bringing results of great significance for the treatment of patients ⁽⁶⁾.

Accordingly, the quality of outpatient care is one of the main determining elements of the expected results and impacts of the actions aimed at meeting people with AIDS ⁽⁷⁾.

In this context, this study sought to identify the perception of users and health professionals about the quality of care provided to patients with AIDS.

This study is significant insofar as it brings subsidies to discuss strategies that may give support for the improvement of the outpatient care of people who coexist with AIDS, in addition to presenting indicators of perception of the quality provided able to bring benefits to the institution and users of the surveyed service.

 

Material and method

This study is configured as evaluative research, with a quantitative approach, developed in the outpatient unit of the Giselda Trigueiro Hospital (HGT, as per its acronym in Portuguese), reference to the treatment of AIDS, situated in the capital of Rio Grande do Norte, Brazilian Northeast.

The population was composed of all patients with AIDS, identified, registered and treated in the study period in the aforesaid hospital and all the professionals who meet these customers. The probabilistic sample without replacement was calculated using the estimation for finite populations with sampling error of 5% and a confidence level of 95% (Z∞=1,96), thus constituting a sample of 626 patients and 34 professionals. The selection of participants was obtained by convenience sampling of consecutive type.

The project was approved by the Research Ethics Committee on human beings of the Federal University of Rio Grande do Norte, under the Certificate of Presentation for Ethical Consideration (C.A.A.E., as per its acronym in Portuguese) n^o 0063.0.051.000-07.

In order to select patients, the following inclusion criteria were complied with: having confirmed the medical diagnosis of AIDS, being over 18 years of age, being a user followed-up in the service for at least six months and being submitted to consultation in the outpatient clinic of HGT.

Regarding the professionals, the following inclusion criteria were complied with: having signed the Free and Informed Consent Form and being part of the multiprofessional team that meets patients with AIDS. The data collection took place from August 2009 to July 2010.

As data collection instrument, a form with structured questions was used, validated by pilot study, addressing issues relating to the operation of HGT and services offered. To that end, 11 indicators of perception of the quality provided were established, namely: physical structure; respect for the privacy of users; professionals/users relationship; opportunity given to users to make complaints; support offered by the service; punctuality of health professionals; guidance received on the treatment; reception; convenience of opening hours; availability of antiretroviral drugs (ARV) and laboratory examinations; and ease of access to services.

Each indicator had gradations ranging from 1 to 5 points, corresponding respectively to the following scores: very bad (1 point), bad (2 points), regular (3 points), good (4 points) and excellent (5 points), with the minimum value assigned to the total sum of all indicators being 11 and the maximum value being 55 points.

The choice of these indicators was based on discussions with users and health professionals, as well as on the literature itself relevant to the theme ^(7-9).

Working on the assumption that the indicators of perception of the quality provided chosen have influence on the satisfaction and dissatisfaction of the quality of health care, it was decided to create a new variable resulting from the total sum of the 11 indicators, defined as the dependent variable (quality of care provided) and categorized as satisfactory and unsatisfactory. The evaluation whose total sum was below 70% (11 to 38 points) was considered unsatisfactory, and it was considered satisfactory when was equal to or greater than 70% (39 to 55 points).

The interviews were answered in a private room within the hospital itself, in an individual way and free of interruptions, seeking to maintain the privacy of the interviewees, previously explaining the objective of the research and requesting the signature of the FICF, in compliance with the Resolution of the Brazilian National Health Council for accomplishment of research with human beings, ensuring anonymity of the interviews, as well as the withdrawal at any time of the research.

After this step, the obtained results underwent a review process in a paired way among the authors, with a view to ensuring an agreed judgment, thus seeking a greater accuracy. Subsequently, the collected results were organized in electronic database through typing into a spreadsheet in the Microsoft Excel^® application, where the diagnoses were recorded. Concerning the analysis of the data, the statistical program Statistical Package for Social Sciences (SPSS) was used, which generated descriptive values and the p-value of the Kolmogorov-Smirnov normality test, with the purpose of checking whether the distribution of data follows a normal distribution.

With the intention of performing a descriptive and inferential statistical treatment, the scores of the indicators previously considered in an individual way were regrouped, reclassified and transformed into only two categories - unsatisfactory (1 - very bad, 2 -bad and 3 - regular) and satisfactory (4 - good and 5 - excellent), targeting the crossing and the statistical tests among the dependent variable, the quality of care provided and the aforementioned 11 indicators.

Through the SPSS 20.0 program, descriptive analyses with absolute and relative frequencies were performed, with crossing of variables in 2x2 contingency tables, with Chi-square test (X²) and Spearman correlation (r > 0,75=strong; r < 0,75 to 0,50=average; r < 0,50=weak), and adoption of level of statistical significance of p-value <0,05. At this step, the results were tabulated and presented in a table.

 

Results

When analyzing the set of 11 indicators used to identify the perception of users and health professionals about the quality of care provided to patients with AIDS, the service was considered unsatisfactory by 85,6% of users and by 41,2% of professionals, with significant difference (p=0,000) and strong correlation (r=0,865) among the analyzed indicators (Table 1).

 

 

When analyzing the set of 11 indicators used to identify the perception of the quality of care provided to patients with AIDS, the service was considered unsatisfactory by 85,6% of users and by 41,2% of professionals, with significant difference (p=0,000) and strong correlation (r=0,865) among the analyzed indicators (Table 1).

It was found a difference on the evaluation of the following the indicators of perception of the quality provided: profesionals/users relationship; support offered; punctuality of health professionals and guidance on the treatment. Nevertheless, one should observe a similarity at the moment of evaluating the following indicators: physical structure; respect for privacy; opportunity to make complaints; reception; convenience of opening hours; availability of ARV and laboratory examinations; and ease of access (Table 1).

According to the opinion of users, the dissatisfaction was prevalent in seven indicators: physical structure; respect for the privacy of users; professionals/users relationship; opportunity given to users to make complaints; support offered by the service; punctuality of health professionals and guidance received on the treatment, showing a significant difference (p=0,000) and correlations ranging from moderate to strong with regard to the quality of care provided (Table 1).

Among the four indicators that showed a small percentage in favor of the perception of satisfaction: reception; convenience of opening hours; availability of antiretroviral drugs and laboratory examinations; and ease of access to services, there were no significant difference (p<0,005) and moderate correlations with regard to the quality of care provided (Table 1).

According to the opinion of professionals, the perception of satisfaction was prevalent in eight indicators: support offered by the service; convenience of opening hours; reception; guidance received on the treatment; punctuality of health professionals; availability of antiretroviral drugs and and laboratory examinations; professionals/users relationship; and ease of access to services, showing a significant difference (p=0,000) and strong correlations with regard to the quality of care provided (Table 1).

Among the three indicators that showed prevalence of the perception of dissatisfaction: physical structure; respect for the privacy of users; and opportunity to make claims, there were no significant difference (p<0,005) and correlations ranging from moderate to strong with regard to the quality of care provided (Table 1).

 

Discussions

With respect to ease of access to the service, it was found a positive perception about the quality of care provided to patients with AIDS, which is expressed by means of the satisfaction on the part of the interviewed users and professionals.

The health care of people who coexist with AIDS should be provided in a continuous way, implementing strategies for improving the access to health services, in order to prevent the occurrence of abandonment, and should be started immediately, even before the diagnosis of infection, and include the follow-up during the entire course of the disease ⁽¹⁰⁾. In this sense, health services have an important role, given that by extending access, they become boosters of the quality of life of people who coexist with AIDS ⁽¹¹⁾.

The access to an early diagnosis and the treatment implemented before the onset of signs and symptoms of the disease may contribute to a better prognosis of AIDS infection. Thus, there is need for a deeper gaze on the part of the political power, health professionals and society at large toward the people affected by AIDS, in the sense of easing the access and accessibility of these patients to the service in such a way as to promote an effective follow-up, with a view to providing a more comprehensive and qualitative health care ⁽¹²⁾.

In the case of the reception, it was also considered favorable by the majority of the users and professionals of the service.

Reception brings with it a positive impact on the acceptance of the diagnosis for patients living with AIDS. This health care technology places the subject as the major element of health care, stimulating the health service to appreciate and share experiences in such a way as to promote the meeting between people, in a process permeated by dialogue and negotiation ^{(12, 13)}.

The attitude of understanding and reception assumed by the health team during the health care actions provided to people with AIDS, whether at the reception desk, the medical office, or even in the moment of scheduling consultations and dispensing medicinal drugs, contributes to a better attendance and treatment, besides encouraging adherence to therapy ⁽¹⁴⁾.

In the present study, one should observe a prevalent satisfaction with regard to the indicator "availability of antiretroviral drugs and laboratory examinations". A similar result was found in a research on the evaluation of the quality of the SUS outpatient services that treat adults who coexist with HIV/AIDS in Brazil. This evaluation found that the availability of count for the TCD4+ lymphocyte and the viral load is high on the part of the screening services, with 80,9% and 77,8%, respectively, and the waiting time for the majority of the laboratory examinations is less than fifteen days. Regarding the availability of antiretroviral drugs, the dispensing of these medicinal drugs is conducted, in 73,1% of cases, on the same day of the first prescription ⁽⁷⁾.

One of the best known facets of the Brazilian program on HIV/AIDS is the free and universal distribution of antirretroviral drugs for the treatment of the infection within the public health network, accounting for significant changes in the profile of this epidemic ⁽⁴⁾.

The advances in research have contributed to increase the survival of patients living with the disease and improve the quality of life of these people. Currently, there are several cases in which the patients with AIDS spend years without manifesting the disease, unlike a few years ago in which the diagnosis had association with death. This clinical picture is, overwhelmingly, a product of the effectiveness of the treatment, which, in Brazil, is considered as a reference in the current days ⁽¹⁵⁾.

The poor physical structure in the public health network reaches even large-size institutions, such as the case of the researched service, which is highlighted by users and health professionals as the most criticized indicator in this study. Another study held in the same institution showed that the discomfort and the inappropriateness of the physical infrastructure were considered as major limitations for the full professional performance ⁽¹⁶⁾.

The place where the health care actions are provided should have minimum facilities to ensure an environment capable of providing greater comfortability, thus allowing well-being for both the user and the profesional ⁽¹⁷⁾.

With respect to the indicator "guidance on the treatment", one should observe a discrepancy of opinion among the interviewees, since it is considered unsatisfactory by users and satisfactory by professionals. Interpersonal communication is configured as a human means of interaction, i.e., exchange and transmission of meanings. In a study conducted in HGT, seeking to understand communication aspects involved in the interaction of the professional with the user who coexists with AIDS, it was observed that professionals consider the verbal communication as crucial for the user to become able to understand the guidance and information required for a good adherence to medical treatment ⁽¹⁸⁾.

For this purpose, in this process, it is essential that professionals make use of an appropriate language, with clear and accurate written and verbal information about prescription, highlighting the importance of the medicinal drugs to the health of patients living with AIDS, thus contributing to a better adherence to the established therapy ^(15,19).

The team-patient relationship has a function as important as the medicinal drugs for the treatment of the illness. In this study, this indicator was considered unsatisfactory by a portion of the users, but satisfactory by the professionals of the service. AIDS is a disease that requires constant visits to health services for holding controls, submission to various types of examinations, and accomplishing prolonged treatments, which are factors that produce negative repercussions on the quality of life of these people

In this context, professionals stimulate behavior changes through the trust established in the professional-patient relationship, when they assume positive attitudes during the health care to people who coexist with AIDS.

The health practitioner often becomes the unique resource for which the patient can send their complaints. Therefore, the way in which this worker listens to the complaint may imply the follow-up or not of the treatment. Although this does not show a solution to the exposed problem, the main generator of distress takes place when the patient perceives that the professional does not take the complaint into consideration and does not reveal concern to try to understand it.

Concerning the indicator "support offered", this was considered the most satisfactory indicator for the professionals, but it was unsatisfactory for the users.

The moment to deal with the AIDS diagnosis implies great consequences to the person affected by the illness, generating several feelings, such as helplessness and difficulty in facing this phase of life ⁽¹⁴⁾.

Accordingly, the support offered by the professional is important for the patient to deal with the several situations permeating AIDS, which has positive influence on the acceptance of the diagnosis on the part of the person affected by this infection ⁽¹²⁾.

It is worth emphasizing that the health care team should have knowledge of the vulnerabilities of patients, in order to consequently develop an intervention space that encourages adherence to treatment, through supportive strategies to these individuals, in such a way as to contribute to the improvement of their well -being and quality of life ⁽¹⁰⁾.

 

Conclusions

In general, the obtained results showed satisfaction with the perception about the quality of care provided to patients with AIDS on the part of health professionals, and dissatisfaction according to the evaluation of the interviewed users, demonstrated by significant prevalence and strong correlation of indicators used in this study. It was found a difference on the evaluation of the following indicators of perception of the quality provided: professionals/users relationship; support offered; punctuality of health professionals; and guidance received on the treatment. Nevertheless, one should observe a similarity in the following indicators: physical structure, respect for privacy, opportunity to make complaints, reception; convenience of opening hours; availability of ARV and laboratory examinations; and ease of access to services.

It is believed that the results of this research, if used by managers and professionals, may contribute to the improvement of the quality of care provided to patients with AIDS in the researched health service, and even in other services, in a conception of transformation underpinned by the opinion of users and health professionals, seeking minimum working conditions able to give support to a more humanized health care process.

 

 

Received: July 7, 2014
Accepted: September 20, 2014

 

 

References

1. Ilias M, Carandina L, Marin MJS. Adesão à terapia antirretroviral de portadores do vírus da imunodeficiência humana atendidos em um ambulatório da cidade de Marília, São Paulo. Rev baiana saúde pública. 2011 Abr/Jun;35(1):471-84. Disponível em: http://inseer.ibict.br/rbsp/index.php/rbsp/article/viewFile/319/pdf.         [ Links ]

2. Potrich T, Paula CC, Padoin SMM, Silva CB. Cuidado familiar na adesão à terapia antirretroviral em crianças com HIV/AIDS. Cogitare enferm. 2012 Abr/Jun;18(2):379-86. Disponível em: http://www.revenf.bvs.br/scielo.php?script=sciarttext&pid=S1414-85362013000200025.         [ Links ]

3. Sousa AM, Lyra A, Araújo CCF, Pontes JL, Freire RC, Pontes TL. A política de AIDS no Brasil: uma revisão de literatura. J Manag Prim Health Care. 2012;3(1):62-6. Disponível em: http://www.jmphc.com/ojs/index.php/01/article/view/38/34.         [ Links ]

4. Grangeiro A, Silva LL, Teixeira PR. Resposta à aids no Brasil: contribuições dos movimentos sociais e da reforma sanitária. Rev panam salud pública. 2009;26(1):87-94. Disponível em: http://www.scielosp.org/pdf/rpsp/v26n1/13.pdf.         [ Links ]

5. Kramer AS, Lazzarotto AR, Sprinz E, Manfroi WC. Alterações metabólicas, terapia antirretroviral e doença cardiovascular em idosos portadores de HIV. Arq Bras Cardiol. 2009; 93(5):561-568. Disponível em: http://www.scielo.br/scielo.php?pid=S0066-782X2009001100019&script=sciarttext.         [ Links ]

6. Ribeiro AC, Paula CC, Neves ET, Padoin SMM. Perfil clínico de adolescentes que têm AIDS. Cogitare enferm. 2010 Abr/Jun;15(2):256-62. Disponível em: http://ojs.c3sl.ufpr.br/ojs2/index.php/cogitare/article/view/17858.         [ Links ]

7. Ministério da Saúde (BR) Programa Nacional de Doenças Sexualmente Transmissíveis e AIDS. Avaliação da qualidade dos serviços ambulatoriais do SUS que assistem adultos vivendo com HIV/Aids no Brasil. Relatório da Aplicação de 2010 e Comparação com o resultado de 2007. Brasília: Ministério da Saúde; 2011. (cited 2014 jun 2). Disponível em: http://sistemas.aids.gov.br/qualiaids/(Produto 1. Relatório Final da aplicação do Qualiaids 2010).pdf.         [ Links ]

8. Nemes MIB, Melchior R, Basso CR, Castanheira ERL, Alves MTSSB. The variability and predictores of quality of AIDS care services in Brazil. BMC Health Services Research 2009;9:51-58. Disponível em: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2671500/.         [ Links ]

9. Nemes MIB, Castanheira ERL, Helena ETS, Melchior R, Caraciolo JM, Basso CR, et al. Adesão ao tratamento, acesso e qualidade da assistência em Aids no Brasil. Rev Assoc Med Bras 2009;55(2):207-12. Disponível em: http://www.scielo.br/scielo.php?pid=S0104-42302009000200028&script=sciarttext.         [ Links ]

10. Schilkowsky LB, Portela MC, Sá MC. Fatores associados ao abandono de acompanhamento ambulatorial em um serviço de assistência especializada em HIV/aids na cidade do Rio de Janeiro, RJ. Rev bras epidemiol. 2011 ;14(2): 187-97. Disponível em: http://www.scielo.br/scielo.php?pid=S1415-790X2011000200001&script=sci abstract&tlng=pt.         [ Links ]

11. Meirelle BHS, Silva DMGV, Vieira FMA, Souza SS, Coelho IZ, Batista R. Percepções da qualidade de vida de pessoas com HIV/AIDS. Rev RENE. 2010 Jul/Set;11(3):68-76. Disponível em: http://www.revistarene.ufc.br/vol11n3_pdf/a07v11 n3.pdf.         [ Links ]

12. Campos LA. As diferentes facetas no tratamento do HIV/AIDS: uma análise de representações sociais de enfermeiros (dissertação). Rio de Janeiro (RJ): Universidade do Estado do Rio de Janeiro; 2010.         [ Links ]

13. Pinho LB, Hernández AMB, Kantorsk LP. O discurso sobre o acolhimento e a acessibilidade nos serviços comunitários de saúde mental. Cogitare enferm. 2009 Out/Dez;14(4):612-9. Disponível em: http://www.revenf.bvs.br/scielo.php?script=sciarttext&pid=S1414-85362009000400002&lng=es&nrm=iso&tlng=pt.         [ Links ]

14. Botti ML, Leite GB, Prado MF, Waidman MAP, Marcon SS. Convivência e percepção do cuidado familiar ao portador de HIV/AIDS. Rev enferm UERJ. 2009 Jul/Set; 17(3):400-5. Disponível em: http://www.facenf.uerj.br/v17n3/v17n3a18.pdf.         [ Links ]

15. Almeida EL, Araújo GBS, Santos VA, Bustorff LACV, Pereira AVL, Dias MD. Adesão dos portadores do HIV/AIDS ao tratamento: fatores intervenientes. REME revmin enferm. 2011 Abr/Jun;15(2): 208-16. Disponível em: http://www.enf.ufmg.br/sitenovo/modules/mastoppublish/files/files4e662b005a6b3.pdf.         [ Links ]

16. Silva RAR. Cartografia da percepção de mães e profissionais sobre a atenção à Saúde de crianças/adolescentes soropositivos no município de Natal-RN (dissertação). Natal: Universidade Federal do Rio Grande do Norte; 2006.         [ Links ]

17. Esher A, Santos EM, Margarinos-Torres R, Azeredo TB. Construindo critérios de julgamento em avaliação: especialistas e satisfação dos usuários com a dispensação do tratamento do HIV/Aids. Ciênc saúde coletiva. 2012;17(1):203-14. Disponível em: http://www.scielo.br/scielo.php?pid=S1413-81232012000100022&script=sciabstract&tlng=pt.         [ Links ]

18. Carvalho ALS, Gico VV. Communicational aspects in health care. Fiep Bulletin 2009;79:12-16.         [ Links ]

19. Navarro AMA, Bezerra VP, Oliveira DA, Moreira MASP. Alves MSCF, Gurgel SN. Representações sociais do HIV/AIDS: percepção dos profissionais da atenção primária à saúde. (periódico da Internet). Rev pesqui cuid fundam (periódico online). 2011 (acesso em 2013 ago 10) (Ed.Supl.):92-99. Disponível em: http://seer.unirio.br/index.php/cuidadofundamental/article/viewArticle/1966.         [ Links ]