Family Health Strategy and More Doctors Program in Rural Area of Porto Velho, Brazil: A Qualitative Analysis under the Nurse’s Perspective

The Family Health Strategy (FHS) together with the implementation of the More Doctors Program (MDP) has an effective contribution to the strengthening of Primary Health Care (PHC) and the consolidation of the Unified Health System (SUS), which has intended to meet the health needs of the population in need of care less complex. Thus, this study aims to analyze the Family Health Strategy and the Program More Doctors implanted in the Rural Municipality of Porto Velho, Rondônia, from the perspective of nurses. This is a qualitative research, descriptive exploratory performed in the field, based on the assessment the perspective of nurses working in the FHS, which are favored by the MDP. The data collection was carried out through a questionnaire,Primary Care Assessment Tool (PCA Tool), in its version validated in Brazil entitled PCA Tool- Brazil (BRAZIL, 2010). This instrument is widely used by national research that evaluates the quality of primary care. For the construction of the database was used Microsoft Word software. For qualitative data, the collection was carried out through interviews recorded by a script containing open questions. The response were discussed based on the content analysis technique proposed by Bardin (2011). The results achieved indicate that the MDM enabled the structuring of teams that were incomplete in the rural area of the town, however presents numerous challenges in the organization of the work process and the understanding of program objectives.


INTRODUCTION
One of the best ways to be a progression of public policies for the health sector is to have mechanisms that constantly provide information to improve and or expand the proposed actions aimed at citizens' quality of life covering as much of the Brazilian territorial extension with due doctor. In Brazil, there are 40 700 Family Health Units (USF) operating in all states. Work in these health posts more than 39,100 family health teams -FHS, which represents an increase of 135% compared to 2002 when 16 700 teams were registered. The number of community health agents (CHA) also rose 49%, from 175,400 in 2002 to 265,200 in 2015. There was also an increase of 459% in the number of oral health teams from 4.2 thousand in 2002 to 23 800 teams today (BRAZIL, 2015). In 1996, the FHSwas established in Porto Velho, the adequacy of the program teams of Community Health Agents (PACS), existing in the urban east area and the rural area of Porto Velho. In the rural area of the city, now the city has 22 family health teams, distributed in 20 Basic Health Units in 20 locations (Santos et al, 2012). In 2013, Brazil had a need for medical widely discussed by international bodies. The national average was 1.8 doctors / thousand inhabitants. Reality in contrast countries such as Argentina, Uruguay and Spain, which have 3.2, 3.7 and 4.0 doctors / thousand inhabitants, respectively. Nationally, 22 Brazilian states presented themselves below the national average, with less than 1 / thousand inhabitants, they Acre, Amapá, Maranhão, Pará and Piauí (BRAZIL, 2015). Based on this reality, the Most medical program for Brazil aims to strengthen primary care, in which through intergovernmental partnerships, directs medical professionals to the reduction of the assistance gaps, to ensure improved access to users of the Unified System Health throughout the Brazilian territory (PAHO, 2016). As a supervisor and coordinator of the team, the nurse professional, has a huge and important responsibility regarding the organization of actions and health services to the community, which is responsible for the organization of the whole team work process. Enlarge care with primary health care to the entire Brazilian population is a prerequisite for the improvement of various health indicators and, more than that, for the very consolidation of the Unified Health System -SUS-(BRAZIL, 2012).
According to Castro (2012), the implementation of the Family Health Strategy in 1994, adopted by the Ministry of Health in Brazil, promotes the expansion of PHC. From what was presented, it emerges as guiding question of research: What is the vision of the nurse as a member of the multidisciplinary team of the Family Health on the implementation of More Medical program in rural Porto Velho? In this sense the opinion of nurses about health services and above all, the process to develop, it is extremely important when seeking the quality of service provided to users. Thus one can not ignore the perception of this professional who deals directly with the structural reality, planning, management and involving directly and indirectly in their work process and assistance to the user's health. So analyze the health strategies of the family and most medical program in the rural area of the old port from the perspective of the nurse is the best way to constantly find reliable data in order to expand and improve such tactics for implementation of various actions for health of the family. Through this context, this study is justified by the opportunity to know the quality of primary health care in rural Porto Velho, after twenty years of implementation of the FHS and four years of implementation of the More Doctors program, through the present research science with a focus on nurse vision. Thus, this study aims to analyze the quality of the Family Health Strategy and the Program More Doctors implanted in the rural municipality Porto Velho, Rondônia, from the perspective of nurses. In addition to secondary objectives as: To describe the profile of nurses of Health teams Porto Velho family; Unveiling the understanding of these professionals about the More Doctors program (MDP); identify the challenges that lay ahead for the effective implementation of the Family Health Strategy in the rural area of Porto Velho, in the FHS nurses' perspective.

II.
METHODOLOGY This is a qualitative research, descriptive exploratory performed in the field, based on the assessment the perspective of nurses working in the FHS, which are favored by the Program More Doctors in Rural areas of the city of Porto Zone Velho, RO. This research consisted of an offshoot of a mother project entitled Health Strategy Quality assessment and Family Program More Doctors in the city of Porto Velho, Rondônia: the perspective of the medical professional, whose aim is to assess the quality of health strategy Family and program More Doctors in Porto Velho, Rondônia, in the doctor's perspective. The study excluded all professional nurses who were not properly registered as Health team of nurse supervisors family or were replacing interim holder nurse of UBS staff in addition to those who for whatever reason could not or did not feel the urge to participate in the data collection for the study. It was used in data collection an adaptation of the instrument Primary Care Assessment Tool (PCA Tool), in its version validated in Brazil entitled PCA Tool-Brazil. This instrument is widely used by national surveys that assess the quality of care provided by Family Health Teams. The PCAToolwas considered the most complete and suitable to measure the attributes needed to APS, to accept the assessment framework and procedural characteristics of primary care services and be available in different formats. Adaptations in the original PCATool instrument were necessary when the validation process for Brazil, which took into account the cultural characteristics of the population and the national health system (PAULA et al, 2016). Nine (09) open questions related to the work process, instruments and development of USF Rural Zone and the arrival of the Program More Doctors were conducted semistructured interviews, by appointment with the professionals of health facilities in which they were used. The collection was carried out through interviews recorded in digital device (mobile phone) in order to preserve the accuracy of the information obtained. Before the interviews, the collection procedures were exposed, and resolved the doubts of respondents on the issues concerning the questionnaire was left to the interviewee at ease to answer questions both through digital means and in writing.
Of the seven (07) interviews scheduled in one case the scheduled professional after the first contacts demonstrated a lack of interest by not confirm and or respond to various types carried out communications, phone calls, emails and text messages to concretize the interview stage demonstrating thus be unavailable for us to meet, even after confirming the participation in the research process. Six (06) professionals were approached which, however, in this study had two more (02) losses due to factors beyond our will: One of professionals fell ill during the interview and can not complete the same; in another unit the professional was not effective because it was replacing the holder and even recording could not be considered by the lines have less than six months ahead of the unit provided service. So we completed four successful approaches. Among these four (04) interviews, we have the longest 39 minutes 57 seconds, and the shorter with 8 minutes and 22 seconds. The analysis method of qualitative data in this study, we used the thematic modality that defines a set of communication analysis techniques aimed at achieving, by systematic procedures and Description of the objectives of the content of messages, indicators (quantitative or not) that allow the inference knowledge relating to the conditions of production / reception of messages (Bardin, 2011). Content analysis in a research involves research techniques which allow, in an orderly manner, the description of the messages and attitudes linked to the context of the subject's assertion researched and deductions on the collected data (Cavalcante et al, 2014). Bardin (2011), the construction of the collected data is to find the core meanings that compose a communication frequency and whose presence means something to the purpose of the study. Thus, the following three hases to develop: 1. Pre-analysis is the stage of the organization, ie a first contact with the transcript content. superficial reading of the testimonies collected in the interview. 2. Exploration of material: made cutouts of the statements in record units expressed in words and ideas the form of categorization that reach the understanding of the study. 3. Processing of data and interpretation: the material was subjected to qualitative analysis, making received treatment -if valid and meaningful for the study as comparison with the literature.

International Journal of Advanced Engineering Research and Science (IJAERS)
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III. RESULTS AND DISCUSSION
The study included four professional nurses from four different USF Rural Porto Velho Zone, two of which are female and two male, with ages ranging 31-36 years working in the FHS -Strategy and Health between 1-7 years, these post-graduates, and are duly registered as a professional nurse in the FHS. The speeches made during the interviews allowed the construction of four thematic categories: nursing work process in USF rural area; Professional nursing vision of primary health care; More medical program's contribution to primary health care; Weaknesses and strengths identified by the strategy nurses and family health in the Rural Area of PVH -RO.

Category 1 -Nursing Work Process In Rural Area USF
Based on the lines, emerged the category dealing with the work process that the nurse holds in USF Rural Area of Porto Velho -RO, since activities and assignments are used described in specific clinical protocols to meet the Basic Health Units, effecting what is in their power to bring health community it is inserted, as expressed speech cited.
" [...]   It is believed that all the work in the health area should be vested by procedures that have worked and or experienced should realize confirm good practices in prevention and maintenance and recovery of health, for this to occur should know and apply knowledge arising, for example: the BANP, protocols and guidelines. The professional nurse has another important role in USF for the materialization of a health care more acceptable and worthy to be provided to its customers. This being the performing nursing consultations as a way to better understand the health history of the person who will be provided assistance. This was a point this speech below. and families enrolled in their team, perform nursing consultations, procedures, group activities as protocols, provided by the Ministry of Health (BRAZIL, 2012). It is known that the reality faced by professionals working in the rural area is difficult because there are problems arising from the lack of constant and uninterrupted public policy. As well as the lack of planning to be a minimum of materials and equipment to develop continuing education for staff.

Category 2 -Vision Professional Nurses On Basic Health Warning
The subjects of the study show, from the speeches made during the interviews, the professional nurse vision that acts in the countryside presents on Primary Health Care, expressing that to have good health it is necessary that first there is the prevention of diseases, using health education as the main tool, and foster care for small injuries are healed at primary level, as expressed the lines below.
"  Roecker and Marcon (2011), the same affinity that health education, exercised in the FHS, should be a very important activity, both for professionals and for the community because the goals the FHS will only be achieved through educational practices aimed at enhancing the health of individuals. However, it is necessary for the team to plan and organize with user participation activities that involve the entire population in different life cycles . Based on that primary care is proposed, it agrees with the view that nurses reported in this study. Thus the basic attention is the first user access to the health system, which according to their health status, this can be resolved on the first contact or directed to other levels of care. The speech below describes.
"Well, the attention is the health sphere, where citizens should be brought into the public health system. Where theoretically he should have solved about 80% of the problems [...] "Nurse USF 3 Continually check that the Primary Care (AB) is a joint health action at individual and collective level, following the principle that involves the promotion, protection and community health recovery, aiming that at this moment are about healed of 80% of public health problems. Developing a comprehensive care to alter the health status of the individual according to the determinants and health conditions (BRAZIL, 2013). So follow a schedule of service in a rural primary care unit will not always be easy, as these come to meet beyond their enrolled area, in this direction the team should be prepared to meet spontaneous demand, as these units are only references to these individuals in search of health care. As speaks next.
" Good, Basic attention she's related to primary care. Staff should act in the fight against diseases, and the prevention, promotion and recovery of health, that particular locality. The important thing is that the team can meet local demand and also spontaneous demand as we try to meet, because people sometimes comes from a locality as the BR, local far [...] "Nurse USF 4 As expressed in the speeches, , points out the need to schedule follow-up on the agendas of professionals from UBS. It is also essential that the units are open and ready to receive the patient who previously did not schedule your query by casualties account and or unforeseen. It defines that the primary health care are basic health units or family health strategy, which craves that this be the first counted user with the Unified Health System (SUS). The secondary and tertiary attention consist of hospitals and outpatient unit, in which the same user will receive a more specific health care (BRAZIL, 2012). In the countryside is no different, because the contact of community health workers to the population of its coverage area allows the nurse, doctor and other staff of professionals can intervene in the health and population of the disease, ie through home visits , active surveillance, health education and other activities that can be undertaken by staff of the Family health Strategy. You can see then that the implementation of MDP added new experiences and practices in the care of health, which contributes to the improvement of APS, also offering support finds in the organization and provision of services, thus facilitating the development of activities that UBS .

Category 3 -Program's Contribution
"Yes, the more medical program was instrumental in the formation of the team [...]" Nurse USF 4 It's known that more than three years of MDP deployment in the country, which is widely reported by official data from the Ministry of Health indicate an increase in APS coverage throughout Brazil, as program physicians are becoming adders for FHS, thereby strengthening health actions at this level of attention (ANDRADDE, 2017). The Pan American Health Organization (2015), reports that the MDP even exposing difficulties methodological, there is strong evidence of management that indicate that the expansion of the Strategy and Health through its teams can reduce child mortality and hospitalization for the simple fact to pay Primary increasingly strengthened. However, it is observed in the reports that the MDP is seen as positive for Primary because in some locations would have the doctor on your team without the presence of the program. Thus the presence of this professional contributes to implementing preventive and curative actions, in addition to this team member take the pledge of allegiance, agreed in advance by the ministry of health, facilitating the development of the team's activities and improving care.

Category 4 -Weaknesses and Strengths Pointed out by Nurses of Strategy and Family Health in Rural Area
Pvh -Ro The statements show that there are many difficulties faced not only for the nurse, but also for the team in general, because the lack of equipment, materials, supplies and medications needed undertakes all the work of the team. Occurring thus offering poor care for the resident population of these regions, which already have by nature the difficulty of access. The following reports describe this category.
"The difficulty is not having adequate space, another difficulty is the issue of ACS that are often accommodated [...]" Nurse of USF1 However it is considered that working in an environment where there is a good physical structure influences nursing practice, promoting its realization with the required technical quality. Upon the existence of an appropriate framework with regard to the comfort promotes more humane working conditions for the team, also favoring the best quality of care to the user's health (Pedrosa et al, 2011). In relation to the ACS Peixoto et al (2015) reports that it aims to carry out active and passive surveillance of the problems related to the community, because they usually occur mostly within the home. Thus the ACS identifies the people in your community and health disorders present in family, neighborhood and friendship. So it is the improvement of its projection and its status becomes meaningful and relevant importance within the team that is inserted. Upon this, the next step moves through the nurse who is recognized by the capacity and ability to understand the human being in general, the ability to provide a friendly service and understand the social differences promoting the interaction and collaboration between users, the team health, regardless of their economic, cultural or social conditions, optimizing care interventions. However without proper performance of the ACS user demand compliance with established disease (BACKES, 2010). It comes to the structure of the relevant equipment to the work developed by these professionals requires a constant and usual apparatus to make predictions and identify the existing conditions in the communities. The comment below expresses the reality of some current difficulties in the countryside of Porto Velho.
"Lack of sonar equipment, lighting focus to prevention, lack of medication." Nurse USF 2 It is thus explicitly as Moura et al (2010), the shortage of equipment, educational materials and medicines, involved in the quality of care to users, as it may hinder the realization of health promotion activities, jeopardizing the continuity of care. Taking into consideration that the Family Health Strategy has as one of its main lines of action to promote health and disease prevention. Under these difficulties also points up the challenge of having a full team, as one of the professionals mentioned that since he started working in the unit did not have the opportunity to assist the community with a full team. The speech is then characterized situation.
" Nurse USF 4. One might say that interpersonal relationships are important to understand the care in health professional practice, as this strengthens increasingly the process of working on a team in the FHS, in which empathy also consisti in a key element, making the subject understandable at the time of a positive or negative judgment (FORMOZO et al, 2011). With so many challenges pointed out by nurses interviewed stands out in speech after the presence of the doctors of the Program More Doctors, as they become the basis to encourage teams of locations the countryside.
"The ease of development of my team is geared to physicians Program More Doctor." Nurse. USF 1 The Program More Doctors strengthens primary care, enabling people to locations difficult to access pose a health service with a high satisfaction level with the present relationships between the community and the team (PAHO, 2012). It is known that due to the great need to provide doctors to areas of vulnerability, the Federal Government took the initiative to deploy more medical Program, this was possible to have immediate, emergency and more sustainable answers is to provide doctors to care services Basic (BRAZIL, 2015). In accordance with the report of Operational Audit of the Court of Audit (TCU), it demonstrated that after implementation of MDP listens growth of 33% in the number of consultations and 32% in home visits, indicating the increase in supply health service (SANTOS, 2015). By the lines it is observed that it is difficult for nurses to develop an effective attention to the population due to lack of resources to enable the professional to perform its function with excellence. But even with the obstacles the interpersonal relationship of the staff and the community is what keeps the teams and the operation of the Family Health Strategy in these locations.

IV.
FINAL CONSIDERATIONS The study achieved the objective of analyzing the ESF and the MDP from the perspective of nurses, for in the course of the interviews it is clear that the ESF is stagnant, that despite the implementation of PMM who came to meet the need for doctors in remote locations It culminated in the structuring of many teams, but the problems arising from political and administrative issues hinder the Primary termination.
However according to the expressions of respondents, the MDP provided a high satisfaction of professional nurses with the inclusion of these medical teams in the localities of the countryside, given that the municipality had great difficulty in entering this professional by their own means. For them, the program's doctors strengthen the actions taken by the teams, and demonstrate that actually are involved and committed to what they propose the strategy.
On the provision of assistance and the progress of the UBS service was unanimous declarations in the case of difficulties in carrying out the work process, as there is shortage of other human resources, materials, medicines, and poor physical infrastructure, hindering the progress of the service. It was appointed although the reference and counter reference also reveals itself as a major obstacle to the day to day work of the teams, because the lack of a network of computers connected to the Internet prevents the user from scheduling tests, procedures and or consultation with expert in the urban center, leaving the user waiting indefinitely scheduling, unlike what happens in the units of capital, in which users leave already regulated. The analysis of the speech revealed a point considered primary optics of the nurse in the ESF, as it became clear that are professional self-sacrificing for their work, which with all the difficulties tend to persevere in the mission to fulfill its role of promoting health, linked with the interpersonal relationship. These relationships created and narrowed with the community and with teammates, is strengthened at the time of difficulties faced by the teams of the units.
The FHS and the MDPare proposed under construction representing the aspirations of the population in various corners of our country, but needs to be constantly re-evaluated and improved. And this is only possible if taken into account the points made by the teams that deal directly with these people who star in a poor part of our society, technicians, doctors and especially nurses who with his holistic view recognize the demands presented by these communities Rural Porto Velho Zone.
In this research we found setbacks in getting answers from the professionals to the interviews, and we have accomplished just taking losses because some did not fit the inclusion criteria. Through the lines, we observed that some professionals responded succinctly demonstrating discredit not specifically to the survey, but the theme and worked their lived realities.
The results presented here, contribute to the strengthening of the theme within the municipality as well as brings up the need to rescue the Family Health theme, Primary Care and Program More Doctors, aiming to broaden the debate between the actors directly and indirectly involved.
The research also helps to be able to analyze how they are being offered health services of the localities of the Rural Zone of Porto Velho. This being an analytical tool for the people, for health professionals and especially for municipal managers, causing them to know the reality faced by the teams and users. In addition to making online study to obtain knowledge in academia in health, aiming to expand research in looking for improvements to primary health care.