Implementação da Estratégia Nacional para Alimentação Complementar Saudável (ENPACS): proposta de um modelo de avaliação em nível municipal
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Data
2014-02-28
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Universidade Federal de Viçosa
Resumo
No cenário das ações para redução da morbimortalidade infantil surge a Estratégia Nacional para Alimentação Complementar Saudável (ENPACS), lançada no Brasil para promover o aleitamento materno e a alimentação complementar saudável como atividade de rotina nos serviços de saúde, em nível de Atenção Primária, em todo o país. O valor dessa iniciativa pública se iguala ao da necessidade de avaliações do processo de sua implantação e implementação, além do seu impacto sobre os indicadores nutricionais, tendo em vista a incipiência da experiência brasileira em avaliação de políticas e programas públicos da esfera estatal. Neste sentido, este estudo teve como objetivo avaliar o processo de implantação e implementação da Estratégia Nacional para Alimentação Complementar Saudável (ENPACS) no município de Viçosa-MG. Ademais, buscou-se também subsidiar os processos de tomada de decisão em políticas e programas de alimentação e nutrição, contribuindo com a produção de conhecimentos referentes ao desenvolvimento e aplicação de um modelo adaptado para o processo de investigação avaliativa da ENPACS, que poderá ser utilizado e, ou servir de base para estudos futuros. Trata-se de um estudo de caso, onde se pretendeu avaliar a ENPACS num contexto local, no período de outubro de 2012 a dezembro de 2013. Foram envolvidos no estudo cuidadores (mães, pais, avós ou outros membros da família que fossem os responsáveis diretos pelo cuidado do menor) de crianças menores de cinco anos cadastradas e moradoras em áreas de abrangência da Estratégia Saúde da Família (n=395); agentes comunitários de saúde (n=79); enfermeiros coordenadores de equipes de Estratégia Saúde da Família (n=8); profissionais capacitados na ENPACS (n=5); gestores municipais atuais e do período de implantação da Estratégia no município (n=2); coordenadores do Serviço de Nutrição e de Estratégia Saúde da Família municipal (n=2). Para a avaliação da implantação e implementação da ENPACS foi proposto um modelo composto de duas etapas, construído considerando-se a configuração da Estratégia, que abarca atividades educativas para a alimentação complementar saudável e o monitoramento dos marcadores de consumo alimentar, realizado por meio do Sistema de Vigilância Alimentar e Nutricional web – Sisvan web. Na primeira etapa, utilizou-se a Avaliação Centrada nos Objetivos da ENPACS, que pretendeu verificar em que medida a Estratégia atingiu seus objetivos, conforme proposições de Bryce et al. (2004). Na segunda etapa utilizou-se a Avaliação Centrada nos Participantes para verificar junto aos gestores, profissionais de saúde das ESF’s e responsáveis pelas crianças menores de 5 anos, as restrições administrativas e ocupacionais, a experiência e percepções sobre a importância da ENPACS para a saúde das crianças, utilizando-se de entrevistas e grupos focais. Os dados quantitativos foram tabulados no Excel 6.0 e SPSS 10.0, o que permitiu a formação dos escores e elaboração do diagrama e das frequências. A análise das falas foi realizada por meio do método de análise de conteúdo, modalidade temática (BARDIN, 1977). Os resultados apontaram a existência de uma grande demanda numérica de crianças em idade correspondente ao público do programa, bem como a ocorrência de desvios nutricionais nas crianças de seis meses a dois anos de idade. A análise do número de cuidadores que responderam ao formulário de marcadores do consumo alimentar de menores de dois anos de idade revelou que o Sisvan-web foi alimentado somente em 2010, todavia, apenas com informações referentes à alimentação nos primeiros seis meses de vida, totalizando um número de crianças muito abaixo do esperado. 53,19% das crianças menores de 6 meses haviam sido acompanhada no mês anterior à entrevista conforme o preconizado pelo Ministério da Saúde para esta faixa etária; entretanto, 53,19 % destes mesmos cuidadores referiram não ter recebido orientação sobre aleitamento materno no mesmo período. 52,41% dos cuidadores avaliaram as orientações recebidas como insuficientes. Não foi possível verificar o impacto da ENPACS no município por insuficiência de dados. De forma geral, a metodologia de implantação da ENPACS no município em estudo foi bem avaliada pelos profissionais que participaram da oficina de implantação no ano de 2010, contudo, sua atuação restringiu-se ao nível ambulatorial. Em 46,84% das equipes o acompanhamento de rotina das crianças é realizado mensalmente e em 100% as atividades restringem-se à avaliação antropométrica. As fragilidades apontadas pelos profissionais são: vinculação profissional e educação continuada. O desconhecimento da ENPACS demonstrado por 75% dos gestores e coordenadores reflete-se na ausência de respostas afirmativas dos agentes comunitários e também nas ações de saúde desenvolvidas para crianças de primeira infância no município. Em geral, os cuidadores avaliam de forma positiva as ações desenvolvidas para crianças menores de 2 anos; porém, o mesmo não ocorreu em relação à qualidade da consulta. Decorridos três anos, a implantação e implementação da ENPACS no município estudado não ocorreram de forma efetiva. Conforme evidenciaram os parâmetros avaliados, há deficiência no seu processo de implantação e implementação, revelando um descompasso entre o nível operacional e as instâncias gestoras superiores, onde os diferentes graus de adesão dos atores sociais aos objetivos e à metodologia da estratégia por si só, já sinalizam o enfraquecimento dos esforços dispendidos para sua efetivação.
In the scenario of the actions to reduce infantile morbimortality, the National Strategy for Complementary Healthy Feeding (ENPACS) is launched in Brazil in order to promote breastfeeding and complementary healthy feeding as routine practice in health services, in terms of Primary Care, throughout the country. The value of this public initiative equalizes the need for evaluation of its implantation and implementation process, besides its impact on nutritional indicators, as taking into account the incipiency of the Brazilian experience in evaluation of public policies and programs within state ambit. Thus, this study was carried out to evaluate the implantation and implementation process of the National Strategy for Complementary Healthy Feeding (ENPACS) in Viçosa municipality - MG. Furthermore, it was also sought to subsidize the decision-making processes in policies and programs concerning to alimentation and nutrition, as contributing to production of the knowledge concerning to development and application of a model adapted to evaluative research process of the ENPACS that can be used and, or serve as basis for future studies. This is a case study, where the intention was to evaluate the ENPACS in local context over the period from October 2012 to December 2013. The study embraced the caretakers (mothers, fathers, grandparents or other family members who were directly responsible for the care of the child) of the registered children under five years and residents in areas embraced by the Strategy for Family Health (n = 395). In addition, the following agents were also involved: community health workers (n=79); nurses coordinating the teams of the “Strategy for Family Health” (n = 8); professionals trained in ENPACS (n =5); either current municipal managers and those who acted during the Strategy implantation period in municipality (n=2); coordinators of the Nutrition Service and municipal Strategy for Family Health (n=2). For evaluation of the implantation and implementation of ENPACS, a model was proposed. This model was composed by two stages and was built by considering the configuration of the Strategy that includes either educational activities for complementary healthy feeding and the monitorship of the dietary intake markers accomplished through Sistema de Vigilância Alimentar e Nutricional web – Sisvan - web. In the first step, the Evaluation Centered on Objectives of the ENPACS was used in order to ascertain the extent the Strategy achieved its objectives, according to propositions by Bryce et al. (2004). In the second step, the Evaluation Centered on Participants was used in order to verify, with the managers, health professionals of the Strategy for Family Health (ESF's) and guardians of the children under 5 years old, the administrative and occupational restrictions, the experience and perceptions concerning to importance of the ENPACS for the health of the children, by using interviews and focus groups. The quantitative data were tabulated in Excel 6.0 and SPSS 10.0, which allowed the formation of the scores and the elaboration of the diagram and frequencies. The analysis of the speeches was performed by using the content analysis method, thematic modality (BARDIN, 1977). The results indicated the occurrence of a large numerical demand of children at age corresponding to the public of the program, as well as the occurrence of nutritional problems in children at age range from six months to two years. The analysis of the number of caregivers who responded to the formulary of markers of the food intake in children under two years of age showed that Sisvan - web was fed only in 2010, however, only with information referring to food at the first six months of life, as totaling a number of children much lower than expected. The age range of the children younger than 6 months (53.19%) was monitored on the month before interview, as recommended by the Ministério da Saúde; however, 53.19 % of the same caregivers reported having received no guidance on breastfeeding over the same period. A total of 52.41 % caregivers evaluated the guidance as insufficient. It was not possible to verify the impact of the ENPACS upon municipality due to insufficient data. In general, the methodology of the ENPACS implementation in the municipality under study was well evaluated by professionals who participated in the establishment workshop in year 2010; however, its performance was limited to ambulatory level. In 46.84 % of the teams, the routine monitoring of the children is held monthly and 100 % activities are restricted to the anthropometric assessment. The weaknesses identified by professionals are: professional binding and continuing education. The non-acquaintance of ENPACS demonstrated by 75% of the managers and coordinators is reflected on absence of affirmative responses of the community agents and also on health care developed for young children in the municipality. In general, caregivers evaluate positively the actions developed for children under 2 years of age; however, this did not occur in relation to the quality of the query. After three years, the deployment and implementation of the ENPACS in the municipality under study did not occur effectively. As evidenced by the parameters under evaluation, there is deficiency in its implantation and implementation process, as revealing a mismatch between the operational level and superior management levels, where different degrees of the actors’ adhesion to the objectives and methodology of the strategy signalize the weakening of the efforts spent for their effectiveness.
In the scenario of the actions to reduce infantile morbimortality, the National Strategy for Complementary Healthy Feeding (ENPACS) is launched in Brazil in order to promote breastfeeding and complementary healthy feeding as routine practice in health services, in terms of Primary Care, throughout the country. The value of this public initiative equalizes the need for evaluation of its implantation and implementation process, besides its impact on nutritional indicators, as taking into account the incipiency of the Brazilian experience in evaluation of public policies and programs within state ambit. Thus, this study was carried out to evaluate the implantation and implementation process of the National Strategy for Complementary Healthy Feeding (ENPACS) in Viçosa municipality - MG. Furthermore, it was also sought to subsidize the decision-making processes in policies and programs concerning to alimentation and nutrition, as contributing to production of the knowledge concerning to development and application of a model adapted to evaluative research process of the ENPACS that can be used and, or serve as basis for future studies. This is a case study, where the intention was to evaluate the ENPACS in local context over the period from October 2012 to December 2013. The study embraced the caretakers (mothers, fathers, grandparents or other family members who were directly responsible for the care of the child) of the registered children under five years and residents in areas embraced by the Strategy for Family Health (n = 395). In addition, the following agents were also involved: community health workers (n=79); nurses coordinating the teams of the “Strategy for Family Health” (n = 8); professionals trained in ENPACS (n =5); either current municipal managers and those who acted during the Strategy implantation period in municipality (n=2); coordinators of the Nutrition Service and municipal Strategy for Family Health (n=2). For evaluation of the implantation and implementation of ENPACS, a model was proposed. This model was composed by two stages and was built by considering the configuration of the Strategy that includes either educational activities for complementary healthy feeding and the monitorship of the dietary intake markers accomplished through Sistema de Vigilância Alimentar e Nutricional web – Sisvan - web. In the first step, the Evaluation Centered on Objectives of the ENPACS was used in order to ascertain the extent the Strategy achieved its objectives, according to propositions by Bryce et al. (2004). In the second step, the Evaluation Centered on Participants was used in order to verify, with the managers, health professionals of the Strategy for Family Health (ESF's) and guardians of the children under 5 years old, the administrative and occupational restrictions, the experience and perceptions concerning to importance of the ENPACS for the health of the children, by using interviews and focus groups. The quantitative data were tabulated in Excel 6.0 and SPSS 10.0, which allowed the formation of the scores and the elaboration of the diagram and frequencies. The analysis of the speeches was performed by using the content analysis method, thematic modality (BARDIN, 1977). The results indicated the occurrence of a large numerical demand of children at age corresponding to the public of the program, as well as the occurrence of nutritional problems in children at age range from six months to two years. The analysis of the number of caregivers who responded to the formulary of markers of the food intake in children under two years of age showed that Sisvan - web was fed only in 2010, however, only with information referring to food at the first six months of life, as totaling a number of children much lower than expected. The age range of the children younger than 6 months (53.19%) was monitored on the month before interview, as recommended by the Ministério da Saúde; however, 53.19 % of the same caregivers reported having received no guidance on breastfeeding over the same period. A total of 52.41 % caregivers evaluated the guidance as insufficient. It was not possible to verify the impact of the ENPACS upon municipality due to insufficient data. In general, the methodology of the ENPACS implementation in the municipality under study was well evaluated by professionals who participated in the establishment workshop in year 2010; however, its performance was limited to ambulatory level. In 46.84 % of the teams, the routine monitoring of the children is held monthly and 100 % activities are restricted to the anthropometric assessment. The weaknesses identified by professionals are: professional binding and continuing education. The non-acquaintance of ENPACS demonstrated by 75% of the managers and coordinators is reflected on absence of affirmative responses of the community agents and also on health care developed for young children in the municipality. In general, caregivers evaluate positively the actions developed for children under 2 years of age; however, this did not occur in relation to the quality of the query. After three years, the deployment and implementation of the ENPACS in the municipality under study did not occur effectively. As evidenced by the parameters under evaluation, there is deficiency in its implantation and implementation process, as revealing a mismatch between the operational level and superior management levels, where different degrees of the actors’ adhesion to the objectives and methodology of the strategy signalize the weakening of the efforts spent for their effectiveness.
Descrição
Palavras-chave
Nutrição, Alimentação e saúde, Crianças - Nutrição, Avaliação de programas, Métodos de avaliação, ENPACS
Citação
EINLOFT, Ariadne Barbosa do Nascimento. Implementação da Estratégia Nacional para Alimentação Complementar Saudável (ENPACS): proposta de um modelo de avaliação em nível municipal. 2014. 126 f. Dissertação (Mestrado em Ciência da Nutrição) - Universidade Federal de Viçosa, Viçosa. 2014.