- Email: [email protected]
Assessing the potential effectiveness of oral health promotion strategies in primary health care in Brazil
p u b l i c h e a l t h 1 4 7 ( 2 0 1 7 ) 4 7 e5 0
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Short Communication
Assessing the potential effectiveness of oral health promotion strategies in primary health care in Brazil A.D. Silveira Filho a, S.J. Moyses a, D.C. Silveira b,c,*, S.A. Ignacio a, S.T. Moyses a (Programa de Pos-Graduac¸a ~o), Curitiba, PR, Brazil Pontifı´cia Universidade Catolica do Parana JFK Neuroscience Institute, Edison, NJ, USA c Seton Hall University, South Orange, NJ, USA a
b
article info Article history: Received 16 May 2016 Received in revised form 27 January 2017 Accepted 30 January 2017
Introduction Tackling the social determinants of diseases in primary health care by promoting health, better quality of life, and disease prevention defines the so called ‘New Public Health’ movement in Brazil.1,2 The Brazilian Unified Health Care System, forged on this movement, aims to guarantee the right to health to all individuals adopting the principles of universality, equity, integrality, decentralization, and regionalization of health services under social control, with primary health care as their main strategy.3 The Brazilian primary care,3 health promotion,4 and oral health5 policies aim at ensuring a holistic health care network by providing social initiatives and intervening on risk factors with strategic programmatic actions.3e5 Based on this approach and following international health promotion initiatives, oral health teams aim to develop actions on health promotion,
disease prevention, diagnosis, treatment, monitoring, rehabilitation, and health maintenance for everyone.3e5 Oral health promotion strategies must be developed based on health promotion pillars and values, combining a common risk factors approach and focusing on the social determinants of health/ disease.6,7 Therefore, the potential effectiveness of oral health promotion strategies depends on the extent to which they include these pillars and values regarding planning, implementation and sustainability of actions. Regardless of increasing numbers of oral health teams working in primary health care in Brazil through the expansion of the Brazilian family health strategy, evidence concerning the effectiveness of primary health care and oral health promotion strategies remains unclear.8 The main goal of this research was to determine the effectiveness of oral health promotion strategies developed by professionals in primary health care, which were mapped by the Brazilian National ticas Study of Health Promotion Practices (Estudo Nacional de Pra ~o da Sau´de e ENPROSA), conducted by the Brazilian de Promoc¸a Center for Surveillance on Oral Health/Ministry of Health.
Applying the oral health promotion evaluation toll The secondary database of the ENPROSA was used in this study, which encompassed oral health promotion strategies that were developed in primary health care in 26 Brazilian State capitals and the Federal District. Information was obtained from a sample of 1819 dental surgeons (75.3% female
* Corresponding author. JFK Neuroscience Institute, Edison, NJ, USA. E-mail address: [email protected] (D.C. Silveira). http://dx.doi.org/10.1016/j.puhe.2017.01.028 0033-3506/© 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
48
p u b l i c h e a l t h 1 4 7 ( 2 0 1 7 ) 4 7 e5 0
and 24.7% male) of a total population of 2069 professionals working for at least one year in primary health care services at Basic Health Units. To collect the data in each city during the ENPROSA, dental surgeons were requested to choose one oral health promotion strategy which they were directly involved and that had been implemented for at least one year in their local area. This approach was an attempt to target one specific strategy that the participant had previous experience with. The selected oral health promotion strategy was further evaluated using the Oral Health Promotion Strategy Effectiveness Evaluation Tool proposed and validated by Kusma et al.6,7 This tool aimed to evaluate the potential of effectiveness of oral health promotion strategies conducted by primary health care dental teams using 23 indicators related to descriptors linked to the health promotion pillars (equity, participation, sustainability) and values (governance, autonomy, empowerment, intersectorality) organized into three dimensions: oral health, public health policies, and human and social development (Table 1).6,7 Each indicator (Table 1) uses statements in an attempt to measure whether the strategy being evaluated includes or not the health promotion pillars and values, therefore determining its ability to promote oral health. For each indicator, the answers are ordered in a Likert-type scale with values ranging from 1 to 5. A final score is then obtained ranging from 23 to 115. The higher the score, the more the strategy covers the health promotion pillars and values and, therefore, presumably provides the greatest potential for promoting oral health. Values ranging from 23 to 74 are indicative of strategies that are not in alignment with the health promotion pillars and values, having little potential effectiveness for promoting oral health, whereas values between 75 and 115 are characteristic of strong strategies, which include the aforementioned pillars and values, and present the greatest potential for promoting oral health in primary health care. Data from this study were analyzed using IBM SPSS v. 22.0 software. Initially, data were tested for consistency. Then, they were analyzed regarding frequency of distribution, subtotals and final scores of all three dimensions. The demographic data, city of origin and state, behavior of the descriptors regarding inclusion or not of the pillars and values of the oral health were analyzed to assess the potential effectiveness of the oral health promotion strategies. The Student t test was used for independent variables, including sex and model of attention (with correction of AspinWelch). One-way ANOVA, post hoc analysis, GameseHowell test were used to look for statistically significant differences between variables such as cities and regions of Brazil. The Pearson Correlation Coefficient was used to measure the degree of association between variables such as age and time working in the Brazilian Unified Health Care System as well as each of the dimensions being analyzed. The value of P < 0.05 was used to determine statistically significant differences.
Oral health promotion in primary health care The mean score obtained by the analyzed oral health promotion strategies developed in primary health care was 71.3 (95% confidence interval [95% CI] 70.4e72.1; P 0.42).
Moreover, the majority (54.9%) of the evaluated strategies were not in alignment with the health promotion pillars and values, having little potential for promoting oral health. The final scores showed great variability among the 26 Brazilian capitals and the Federal District, suggesting an important role of the geographical, social, and political context on the results. Individually, the capitals Rio de Janeiro ~o Pessoa, in the Southeastern and Northeast of Brazil, and Joa had the highest final scores regarding their experiences of m, in the promoting oral health, whereas Boa Vista and Bele North, had the lowest scores. As a whole, higher scores were observed in the richest Southeastern and Southern regions of Brazil, which are known to have more organized health services. The lowest scores were seen in the Central-Western and Northern regions. The oral health promotion strategies developed by teams from the Family Health Strategy were shown to have the greatest alignment with the pillars and values of health promotion (mean score ¼ 73.3; 95% CI 72.4e74.2) compared to those developed by teams working in the traditional health care model (mean score ¼ 64.7; 95% CI 62.9e66.6). The family health strategy, based on a multidisciplinary practice, is the main innovative approach to promote the primary health care model in Brazil.3 This finding reinforces the importance of this approach to organize and guide the Brazilian national health systems.9 The degree of association and correlation regarding the dimensions oral health, public health, and social and human development were analyzed to identify the set of indicators of each of the three dimensions of the instrument used most contributed to the results. The strength of the oral health dimension is related to whether the evaluated strategy takes into account epidemiological information on its planning and development (descriptor #4, r ¼ 0.75). The strongest indicator in the public health dimension was the local planning performed by the primary care health unit (descriptor #9, r ¼ 0.64). The autonomy of the primary health care teams to work locally based on a broad understanding of individuals in different social contexts may lead to a greater consistency of oral health promotion strategies and ensure oral health care for those most vulnerable.10 In the human and social development dimension these findings suggest the importance of encouraging social participation and developing oral health promotion strategies (descriptor #4, r ¼ 0.67). Our results highlight the need for critical thinking about health care practices in primary health care to promote the community values and ensure proper implementation of the principles of the Unified Health System in Brazil. In conclusion, our results showed significant differences in oral heath promotion among distinct Brazilian regions with highest scores seen in the richest Southeastern and Southern regions where the pillars and values of health promotion strategies were followed. The lowest scores were seen in the Central-Western and Northern regions, which are much poorer regions. These findings indicate that promoting equity through our national health policies is important to provide equal access to health for everyone. This study also reinforces the value of an evaluative tool that analyzes the effectiveness of oral health promotion practices to provide meaningful changes in primary health care. Finally, our findings reaffirm
p u b l i c h e a l t h 1 4 7 ( 2 0 1 7 ) 4 7 e5 0
49
Table 1 e Dimensions and descriptors of the Oral Health Promotion Strategy Effectiveness Evaluation Tool.6 Oral health dimension #1 #2 #3 #4 #5
The oral health promotion (OHP) strategy recognizes and acts on the social determinants of oral health (SDH). The OHP strategy recognizes and acts on common risk factors for oral and general health. The OHP strategy investigated the epidemiological profile of oral conditions and diseases before their onset and this investigation had an influence on its planning and development. The OHP strategy leads to improvement of previous epidemiological profile when compared with the current profile. Changes in the epidemiological profile that occurred after the development of the OHP strategy are recognized and helped to determine new goals.
Public policies dimension #1
The OHP strategy recognizes, prioritizes, and develops actions to help more vulnerable social groups and/ or families at risk in their region. #2 The OHP strategy develops practices that ensure the fair participation of the target population. #3 The OHP strategy involves the participation of different health care professionals (professionals other than those from the oral health team) who work in the region. #4 Different professional positions (managers and technicians), institutions and community leaders participate cooperatively in the development of the OHP strategy. #5 The OHP strategy is in contact with other initiatives developed in the region to promote health care. #6 The OHP strategy is recognized and supported by health care managers at local and municipal levels. #7 The OHP strategy provides for the allocation of specific resources (human, financial and infrastructural) required for its development. #8 The OHP strategy provides for and performs process evaluations and results throughout its development. #9 The OHP strategy and its results are recognized and agreed upon during the local planning performed by the Primary Care Health Unit. #10 The OHP strategy and its results are recognized and discussed by the Local Health Care Board. Human development and social dimension #1 The OHP strategy takes into consideration and respects the values of the local community for its planning and development. #2 During its implementation and evaluation, the OHP strategy makes it possible for the local community/ target population to participate in terms of defining its priorities and goals. #3 The OHP strategy makes it possible for the target population to evaluate and discuss the results generated by its actions. #4 The OHP strategy allows changes to be made in its administrative process based on suggestions given by the participant population. #5 The OHP strategy is widely disclosed to the local community. #6 The OHP strategy shares functions/roles of leadership among the various individuals involved. #7 The OHP strategy encourages the development of training programs for social actors from the community. #8 The OHP strategy offers mechanisms to maintain the results and benefits obtained.
the importance of the Unified Health System in Brazil as a social policy that supports and promotes welfare to all citizens.
Author statements Ethical approval The Research Ethics Committee at the Pontifical Catholic in Curitiba (PR) approved this study. University of Parana Informed consent was obtained from each participant in accordance with the Declaration of Helsinki.
Funding The National Health Fund from the Ministry of Health in Brazil funded this study. The sponsors had no involvement in the study design, data collection or write up.
Competing interests None declared.
references
1. Heidmann ITSB, Almeida MCP, Boehs AE, Wosny AM, Monticelli M. Health promotion: historic trajectory of its conception. Texto Contexto Enferm Florian opolis 2006;15(2):352e8. 2. McQueen DV, Jones CM, editors. Global perspectives on health promotion effectiveness. Atlanta (GA): Springer; 2007. p. 3e11. 3. Sampaio LFR, Silveira Jr AD. National primary health care policy, rio da Sau´de; pact series for health, vol. 4. Brası´lia (DF): Ministe 2006. p. 1e60. 4. National health promotion policy. Nov 11, 2014. Portaria No. 2.446. 5. Costa H, Solla J, Suassuna A, Pucca Jr G. Guidelines of the rio da Sau´de; national oral health policy. Brası´lia (DF): Ministe 2004. p. 1e16. 6. Kusma SZ. Effectiveness evaluation of oral health promotion strategies: a tool validation. Curitiba: PUCPR; 2010. In: http:// www.biblioteca.pucpr.br/tede/tde_busca/processaPesquisa.php? listaDetalhes%5B%5D¼1972&processar¼Processar. s ST, Moyse s SJ. Health promotion: 7. Kusma SZ, Moyse perspectives for evaluation of oral health in primary healthcare. Cad Saude Publica 2012;28(Suppl. 1):S9e19.
50
p u b l i c h e a l t h 1 4 7 ( 2 0 1 7 ) 4 7 e5 0
8. Pucca Jr GA, Costa JFR, Chagas LD, Silvestre RM. Oral health policies in Brazil. Braz Oral Res 2009;23 (Suppl. 1):9e16. 9. Starfield B. Primary care: balancing health needs, services and technology. New York: Oxford University Press; 1998. p. 1e438.
s ST, Bisinelli JC, Moyse s SJ. Oral 10. Nascimento AC, Moyse health in the family health strategy: a change of practices or semantics diversionism. Rev Saude Publica 2009;43(3):455e62.
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Short Communication
Assessing the potential effectiveness of oral health promotion strategies in primary health care in Brazil A.D. Silveira Filho a, S.J. Moyses a, D.C. Silveira b,c,*, S.A. Ignacio a, S.T. Moyses a (Programa de Pos-Graduac¸a ~o), Curitiba, PR, Brazil Pontifı´cia Universidade Catolica do Parana JFK Neuroscience Institute, Edison, NJ, USA c Seton Hall University, South Orange, NJ, USA a
b
article info Article history: Received 16 May 2016 Received in revised form 27 January 2017 Accepted 30 January 2017
Introduction Tackling the social determinants of diseases in primary health care by promoting health, better quality of life, and disease prevention defines the so called ‘New Public Health’ movement in Brazil.1,2 The Brazilian Unified Health Care System, forged on this movement, aims to guarantee the right to health to all individuals adopting the principles of universality, equity, integrality, decentralization, and regionalization of health services under social control, with primary health care as their main strategy.3 The Brazilian primary care,3 health promotion,4 and oral health5 policies aim at ensuring a holistic health care network by providing social initiatives and intervening on risk factors with strategic programmatic actions.3e5 Based on this approach and following international health promotion initiatives, oral health teams aim to develop actions on health promotion,
disease prevention, diagnosis, treatment, monitoring, rehabilitation, and health maintenance for everyone.3e5 Oral health promotion strategies must be developed based on health promotion pillars and values, combining a common risk factors approach and focusing on the social determinants of health/ disease.6,7 Therefore, the potential effectiveness of oral health promotion strategies depends on the extent to which they include these pillars and values regarding planning, implementation and sustainability of actions. Regardless of increasing numbers of oral health teams working in primary health care in Brazil through the expansion of the Brazilian family health strategy, evidence concerning the effectiveness of primary health care and oral health promotion strategies remains unclear.8 The main goal of this research was to determine the effectiveness of oral health promotion strategies developed by professionals in primary health care, which were mapped by the Brazilian National ticas Study of Health Promotion Practices (Estudo Nacional de Pra ~o da Sau´de e ENPROSA), conducted by the Brazilian de Promoc¸a Center for Surveillance on Oral Health/Ministry of Health.
Applying the oral health promotion evaluation toll The secondary database of the ENPROSA was used in this study, which encompassed oral health promotion strategies that were developed in primary health care in 26 Brazilian State capitals and the Federal District. Information was obtained from a sample of 1819 dental surgeons (75.3% female
* Corresponding author. JFK Neuroscience Institute, Edison, NJ, USA. E-mail address: [email protected] (D.C. Silveira). http://dx.doi.org/10.1016/j.puhe.2017.01.028 0033-3506/© 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
48
p u b l i c h e a l t h 1 4 7 ( 2 0 1 7 ) 4 7 e5 0
and 24.7% male) of a total population of 2069 professionals working for at least one year in primary health care services at Basic Health Units. To collect the data in each city during the ENPROSA, dental surgeons were requested to choose one oral health promotion strategy which they were directly involved and that had been implemented for at least one year in their local area. This approach was an attempt to target one specific strategy that the participant had previous experience with. The selected oral health promotion strategy was further evaluated using the Oral Health Promotion Strategy Effectiveness Evaluation Tool proposed and validated by Kusma et al.6,7 This tool aimed to evaluate the potential of effectiveness of oral health promotion strategies conducted by primary health care dental teams using 23 indicators related to descriptors linked to the health promotion pillars (equity, participation, sustainability) and values (governance, autonomy, empowerment, intersectorality) organized into three dimensions: oral health, public health policies, and human and social development (Table 1).6,7 Each indicator (Table 1) uses statements in an attempt to measure whether the strategy being evaluated includes or not the health promotion pillars and values, therefore determining its ability to promote oral health. For each indicator, the answers are ordered in a Likert-type scale with values ranging from 1 to 5. A final score is then obtained ranging from 23 to 115. The higher the score, the more the strategy covers the health promotion pillars and values and, therefore, presumably provides the greatest potential for promoting oral health. Values ranging from 23 to 74 are indicative of strategies that are not in alignment with the health promotion pillars and values, having little potential effectiveness for promoting oral health, whereas values between 75 and 115 are characteristic of strong strategies, which include the aforementioned pillars and values, and present the greatest potential for promoting oral health in primary health care. Data from this study were analyzed using IBM SPSS v. 22.0 software. Initially, data were tested for consistency. Then, they were analyzed regarding frequency of distribution, subtotals and final scores of all three dimensions. The demographic data, city of origin and state, behavior of the descriptors regarding inclusion or not of the pillars and values of the oral health were analyzed to assess the potential effectiveness of the oral health promotion strategies. The Student t test was used for independent variables, including sex and model of attention (with correction of AspinWelch). One-way ANOVA, post hoc analysis, GameseHowell test were used to look for statistically significant differences between variables such as cities and regions of Brazil. The Pearson Correlation Coefficient was used to measure the degree of association between variables such as age and time working in the Brazilian Unified Health Care System as well as each of the dimensions being analyzed. The value of P < 0.05 was used to determine statistically significant differences.
Oral health promotion in primary health care The mean score obtained by the analyzed oral health promotion strategies developed in primary health care was 71.3 (95% confidence interval [95% CI] 70.4e72.1; P 0.42).
Moreover, the majority (54.9%) of the evaluated strategies were not in alignment with the health promotion pillars and values, having little potential for promoting oral health. The final scores showed great variability among the 26 Brazilian capitals and the Federal District, suggesting an important role of the geographical, social, and political context on the results. Individually, the capitals Rio de Janeiro ~o Pessoa, in the Southeastern and Northeast of Brazil, and Joa had the highest final scores regarding their experiences of m, in the promoting oral health, whereas Boa Vista and Bele North, had the lowest scores. As a whole, higher scores were observed in the richest Southeastern and Southern regions of Brazil, which are known to have more organized health services. The lowest scores were seen in the Central-Western and Northern regions. The oral health promotion strategies developed by teams from the Family Health Strategy were shown to have the greatest alignment with the pillars and values of health promotion (mean score ¼ 73.3; 95% CI 72.4e74.2) compared to those developed by teams working in the traditional health care model (mean score ¼ 64.7; 95% CI 62.9e66.6). The family health strategy, based on a multidisciplinary practice, is the main innovative approach to promote the primary health care model in Brazil.3 This finding reinforces the importance of this approach to organize and guide the Brazilian national health systems.9 The degree of association and correlation regarding the dimensions oral health, public health, and social and human development were analyzed to identify the set of indicators of each of the three dimensions of the instrument used most contributed to the results. The strength of the oral health dimension is related to whether the evaluated strategy takes into account epidemiological information on its planning and development (descriptor #4, r ¼ 0.75). The strongest indicator in the public health dimension was the local planning performed by the primary care health unit (descriptor #9, r ¼ 0.64). The autonomy of the primary health care teams to work locally based on a broad understanding of individuals in different social contexts may lead to a greater consistency of oral health promotion strategies and ensure oral health care for those most vulnerable.10 In the human and social development dimension these findings suggest the importance of encouraging social participation and developing oral health promotion strategies (descriptor #4, r ¼ 0.67). Our results highlight the need for critical thinking about health care practices in primary health care to promote the community values and ensure proper implementation of the principles of the Unified Health System in Brazil. In conclusion, our results showed significant differences in oral heath promotion among distinct Brazilian regions with highest scores seen in the richest Southeastern and Southern regions where the pillars and values of health promotion strategies were followed. The lowest scores were seen in the Central-Western and Northern regions, which are much poorer regions. These findings indicate that promoting equity through our national health policies is important to provide equal access to health for everyone. This study also reinforces the value of an evaluative tool that analyzes the effectiveness of oral health promotion practices to provide meaningful changes in primary health care. Finally, our findings reaffirm
p u b l i c h e a l t h 1 4 7 ( 2 0 1 7 ) 4 7 e5 0
49
Table 1 e Dimensions and descriptors of the Oral Health Promotion Strategy Effectiveness Evaluation Tool.6 Oral health dimension #1 #2 #3 #4 #5
The oral health promotion (OHP) strategy recognizes and acts on the social determinants of oral health (SDH). The OHP strategy recognizes and acts on common risk factors for oral and general health. The OHP strategy investigated the epidemiological profile of oral conditions and diseases before their onset and this investigation had an influence on its planning and development. The OHP strategy leads to improvement of previous epidemiological profile when compared with the current profile. Changes in the epidemiological profile that occurred after the development of the OHP strategy are recognized and helped to determine new goals.
Public policies dimension #1
The OHP strategy recognizes, prioritizes, and develops actions to help more vulnerable social groups and/ or families at risk in their region. #2 The OHP strategy develops practices that ensure the fair participation of the target population. #3 The OHP strategy involves the participation of different health care professionals (professionals other than those from the oral health team) who work in the region. #4 Different professional positions (managers and technicians), institutions and community leaders participate cooperatively in the development of the OHP strategy. #5 The OHP strategy is in contact with other initiatives developed in the region to promote health care. #6 The OHP strategy is recognized and supported by health care managers at local and municipal levels. #7 The OHP strategy provides for the allocation of specific resources (human, financial and infrastructural) required for its development. #8 The OHP strategy provides for and performs process evaluations and results throughout its development. #9 The OHP strategy and its results are recognized and agreed upon during the local planning performed by the Primary Care Health Unit. #10 The OHP strategy and its results are recognized and discussed by the Local Health Care Board. Human development and social dimension #1 The OHP strategy takes into consideration and respects the values of the local community for its planning and development. #2 During its implementation and evaluation, the OHP strategy makes it possible for the local community/ target population to participate in terms of defining its priorities and goals. #3 The OHP strategy makes it possible for the target population to evaluate and discuss the results generated by its actions. #4 The OHP strategy allows changes to be made in its administrative process based on suggestions given by the participant population. #5 The OHP strategy is widely disclosed to the local community. #6 The OHP strategy shares functions/roles of leadership among the various individuals involved. #7 The OHP strategy encourages the development of training programs for social actors from the community. #8 The OHP strategy offers mechanisms to maintain the results and benefits obtained.
the importance of the Unified Health System in Brazil as a social policy that supports and promotes welfare to all citizens.
Author statements Ethical approval The Research Ethics Committee at the Pontifical Catholic in Curitiba (PR) approved this study. University of Parana Informed consent was obtained from each participant in accordance with the Declaration of Helsinki.
Funding The National Health Fund from the Ministry of Health in Brazil funded this study. The sponsors had no involvement in the study design, data collection or write up.
Competing interests None declared.
references
1. Heidmann ITSB, Almeida MCP, Boehs AE, Wosny AM, Monticelli M. Health promotion: historic trajectory of its conception. Texto Contexto Enferm Florian opolis 2006;15(2):352e8. 2. McQueen DV, Jones CM, editors. Global perspectives on health promotion effectiveness. Atlanta (GA): Springer; 2007. p. 3e11. 3. Sampaio LFR, Silveira Jr AD. National primary health care policy, rio da Sau´de; pact series for health, vol. 4. Brası´lia (DF): Ministe 2006. p. 1e60. 4. National health promotion policy. Nov 11, 2014. Portaria No. 2.446. 5. Costa H, Solla J, Suassuna A, Pucca Jr G. Guidelines of the rio da Sau´de; national oral health policy. Brası´lia (DF): Ministe 2004. p. 1e16. 6. Kusma SZ. Effectiveness evaluation of oral health promotion strategies: a tool validation. Curitiba: PUCPR; 2010. In: http:// www.biblioteca.pucpr.br/tede/tde_busca/processaPesquisa.php? listaDetalhes%5B%5D¼1972&processar¼Processar. s ST, Moyse s SJ. Health promotion: 7. Kusma SZ, Moyse perspectives for evaluation of oral health in primary healthcare. Cad Saude Publica 2012;28(Suppl. 1):S9e19.
50
p u b l i c h e a l t h 1 4 7 ( 2 0 1 7 ) 4 7 e5 0
8. Pucca Jr GA, Costa JFR, Chagas LD, Silvestre RM. Oral health policies in Brazil. Braz Oral Res 2009;23 (Suppl. 1):9e16. 9. Starfield B. Primary care: balancing health needs, services and technology. New York: Oxford University Press; 1998. p. 1e438.
s ST, Bisinelli JC, Moyse s SJ. Oral 10. Nascimento AC, Moyse health in the family health strategy: a change of practices or semantics diversionism. Rev Saude Publica 2009;43(3):455e62.