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The offering of integrating and complementary practices by multiprofessional teams: a study of associated factors, as of the PMAQ-AB third cycle

ABSTRACT
This study aimed to identify the factors associated with the provision of integrative and complementary practices used by multidisciplinary teams (MT) in the state of Bahia - Brazil. This is an exploratory, cross-sectional, quantitative, and descriptive study, based on the results of the external evaluation of the third cycle of the 2017 Primary Care Quality Improvement and Assessment Program (PMAQ) held in 171 municipalities in the state. To identify the factors associated with the outcome variable (the offering of ICHP), two levels of independent variables were used: distal level (clinical-care subdimension) and proximal level (technical-pedagogical subdimension). It could be observed that the offering of ICHP in the state of Bahia presented heterogeneity. The most frequently ICHP offered in the state were Music Therapy and Shantala massage. In the technical-pedagogical subdimension, it could be observed that the offering of ICHP had statistical significance in the following variables: pedagogical activities offered; the MT carried out monitoring and analysis of indicators related to their work process; and the MT that supported and developed strategies to promote body practices and physical activities in the territory. It can be concluded that the offering of ICHP was identified in teams that best organized and qualified their health work processes, prioritizing the arrangement of Matrix Support and Permanent Education actions.

Keywords: Complementary Therapies; Unified Health System; Primary Health Care; Family Health Strategy; Multiprofessional Team.

Introduction

The Declaration of Alma-Ata1 was essential for Primary Health Care (PHC) when it recommended, at the International Conference on Primary Health Care, that municipal administrations begin their processes of structuring and operationalizing strategies that would enable the inclusion of traditional and alternative medicines, known as integrative and complementary practices (ICHP), in public health services in Brazil.
According to Starfield2, PHC is configured through attributes, integrating a comprehensive concept, offering a system gateway for health needs and problems, centered on the family, with coordinated and longitudinal care, focused on the community3.
The current Multiprofessional teams were initially referred to as the Family Health Support Center (Núcleo de Apoio à Saúde da Família - NASF) and were institutionally created in 2008 by Ordinance GM/MS No. 154 of June 24, 2008 (revoked by Ordinance GM/MS No. 2,488 of October 21, 2011)4. The NASFs sought to expand the level of resolution and scope of Primary Care (PC) actions by supporting, primarily and in a shared and integrated manner, the Family Health teams (eSF) and, later, also the Primary Care teams (eAB). In 2011, the PNAB was updated, which strengthened the matrix support policy. Based on the guidelines established with the approval of the latest version of the National Primary Care Policy (PNAB)5, in September 2017 they became known as the Expanded Family Health and Primary Care Center (NASF-AB). It is important to note that, in this study, what was previously known as NASF or NASF-AB will be referred to as multidisciplinary teams (MT).
The work process of multidisciplinary teams is guided by both the Basic Care (BC) guidelines and the theoretical and methodological framework of the Matrix Support6 within BC, operating from the clinical-care and technical-pedagogical support dimensions, together with the reference teams within the PHC, namely eSF and eAB. It is guided by a work logic focused on sharing and matrixing among teams, in the search for producing care that is strengthened by the link with the territory and guided by the longitudinally and comprehensiveness of care7.
In this sense, it is clear that integrative and complementary health practices (ICHP), which were officially included in the Unified Health System (SUS) in 20068 through the National Policy of Integrative and Complementary Practices (PNPIC), dialogue with the guiding elements of the work process of multidisciplinary teams, as they are based on a humanized care model focused on comprehensiveness, with a broader view of the health-disease process and global promotion of human care, especially self-care9.
This study used the concept of integrative and complementary health practices guided by the PNPIC concept, which translates them as health practices, guided by humanization and comprehensiveness, with a focus on mindful listening, therapeutic connection, and the integration of the human being with the environment and society9. According to the policy, the ICHP encompass both complex medical systems (Medical Rationalities) and therapeutic resources.
The PNPIC currently includes 29 types of practices, all duly recognized and incorporated into the aforementioned policy10,11, thus promoting an expansion in the scope of ICHP offerings in the SUS, strengthening its insertion within the scope of PHC, especially in the eSF. It is worth noting that the process of institutionalization in PHC implies federal incentives for municipalities, matrix support and continuing education actions, in addition to investment in professional training through government induction12.
The insertion of ICHP in PHC occurs through the provision of care practices and matrix support actions in ICHP among professionals linked to the eSF and multidisciplinary teams13, in addition to other services in the health care network. In a qualitative study of municipal experiences12, it could be observed that the potential for expansion of ICHP in the SUS, widely known as Traditional and Complementary Medicine (TCM), is greater via MT, since these professionals act as references for matrix support in ICHP, operating in the logic of specialized support through the provision of individual and collective care, such as activities of specific groups, health promotion actions and continuing education with the teams12. Professionals working in the units, which were the subject of another research, were the main actors who contributed to the process of expanding ICHP in the SUS, based on their own investments for training in practices, without any financial support from local management, which ends up hindering the dissemination and sustainability of the policy, going against the SUS comprehensiveness and universality guidelines14.
It is important to consider and implement measures that collaborate with the implementation of the offering of ICHP in the SUS, in a democratic, participatory and co-responsible manner among the parties involved. Furthermore, the importance of using ICHP in other countries and in confronting the COVID-19 pandemic is highlighted. A systematic review presented the importance of ICHP in fighting COVID-19 by individuals with effects both on mental health and also on physical symptoms15.
There are knowledge gaps regarding the supply and types of practice16 and in relation to ways of organizing and including ICHP in the SUS, both in PHC and in matrix support services for Primary Care17.
The World Health Organization (WHO)18, in its 2014-2023 document on traditional medicine, also reinforces the importance of encouraging countries to consider the potential contribution of TCM as integrated into health systems, indicating a set of priority actions, as well as establishing and developing policies and regulations that promote the safe and effective use of TCM by the population.
This study aimed to identify the factors associated with the provision of integrative and complementary health practices by multidisciplinary teams in the state of Bahia, in Brazil. This research is based on the results of the external evaluation of the third cycle of the Program for Improving Access and Quality of Primary Care (Programa de Melhoria do Acesso e da Qualidade da Atenção Básica - PMAQ), which took place in 2017.

Methodology

To contribute to the analysis and discussion of the results presented herein, the following theoretical frameworks were used: assumptions of comprehensive primary health care2, integrative and complementary health practices in PHC, and conceptual bases of matrix support6,19 for the organization of health work in PHC.

Study type, location, and period

This is an exploratory, cross-sectional study with a descriptive and analytical quantitative approach. This research included the implemented multidisciplinary teams that participated in the external evaluation of the third cycle of the Primary Care Quality Improvement Program (PMAQ), conducted in 2017, based on the guidelines established in the program ministerial ordinance20.

Data collection, systematization, and analysis

The study used secondary data from the third cycle of external evaluation of the PMAQ, collected in 2017. Data were extracted from Module IV (Interview with a professional from the multidisciplinary teams and verification of documents at the Basic Health Unit (BHU), which aimed at evaluating the work process of these teams and the organization of care for users based on a set of variables listed in the external evaluation instrument of the PMAQ21. This module corresponded to the existing multidisciplinary teams that had joined the program. The selection of variables for this module was based on the theoretical framework listing the descriptions and categories that helped identify the factors associated with the offering of ICHP by the multidisciplinary teams. It is worth noting that the data from Module IV can be accessed from the Ministry of Health/MS website (www.saude.gov.br/pmaq).
Initially, a descriptive (absolute and relative frequencies) analysis was performed by type of ICHP offered, according to the Regional Health Center (Núcleo Regional de Saúde - NRS)22,23 (hereinafter referred to as the health macro-region). To analyze the factors associated with the outcome variable (offering of ICHP by the MT), the independent variables were grouped in two levels: a distal level (related to the clinical-care subdimension), and a proximal level (related to the technical-pedagogical subdimension, involving the MT work process).
The clinical care subdimension included five variables, namely: assessment of complex cases and risk classification; increased resolution related to the greater diversity of actions offered in the PC; support and development of care strategies for people with chronic diseases; support and development of mental health care actions; and use of protocol for welcoming spontaneous demand or line of care that includes ICHP. In the technical-pedagogical subdimension, a set of 19 variables relevant to this analysis was identified (Table 1).
In the exploratory phase, a bivariate analysis was performed, correlating each of the independent variables with the outcome variable, by hierarchical level (distal and proximal). All variables presenting a statistically significant association (p ≤ 0.20) were analyzed by logistic regression, obtaining the Crude and Adjusted Odds Ratio. Version 13 of the Stata® statistical program was used to run the data analysis. The QGIS® program was used to show the territorial distribution of the municipalities that have multidisciplinary teams offering ICHP in the state of Bahia. The results are presented in tables, graphs, and maps.
This research did not require submission to the Research Ethics Committee (Comitê de Ética em Pesquisa - CEP), as it used secondary data from the external evaluation database of the third cycle of PMAQ, available for public access (https://aps.saude.gov.br/ape/pmaq/ciclo3/).


Results

The territorial distribution of municipalities with multidisciplinary teams offering ICHP in 2017 showed that from the 417 municipalities in the State of Bahia, 171 of them had multidisciplinary teams offering ICHP (41% of municipalities). The offering was heterogeneous, with a greater concentration in the Center-East, South and East Regional Health Centers (NRS) and greater dispersion in the Northeast and West NRS (Figure 1).
Table 1 shows that the ICHP most offered by multidisciplinary teams in Bahia were Music Therapy, Shantala, Traditional Chinese Medicine/Auriculotherapy, and Art Therapy, while Thalassotherapy had the lowest frequency in the state (0.1%). It is worth noting that Thalassotherapy is a practice that integrates Anthroposophical Medicine, a medical rationale contained in the PNPIC.
It is important to note that the only practice that was not offered in any macro-region was the ‘Rio Aberto’ System, which is a system of psycho-body techniques integrating various practices for the development of wisdom about the body with a view to aligning the body, mind, and spirit. However, this practice is not directly included in the PNPIC. The Center-East NRS offered many practices, followed by the East and South NRS, respectively. The lowest offer in the state was observed in the Far South and West NRS (Table 1).
It can be observed that in the East NRS, where the state capital and metropolitan region are located, the Traditional Chinese Medicine/Auriculotherapy (20%) was the most offered ICHP by multidisciplinary teams, followed by Do-in/Shiatsu/Massage Therapy/Reflexology (14.7%), and Music Therapy (13.7%). Regarding Medical Rationalities (known as Complex Medical Systems), it was noted that Traditional Chinese Medicine/Auriculotherapy was more common in the South, East, and Central-East NRS (Table 1).
Table 2 shows the offering of ICHP by multidisciplinary teams, according to the dimensions of the teams\' work process. The offering of ICHP at the distal (clinical care) level shows that the highest percentages were concentrated among multidisciplinary teams that performed complex case assessment and risk classification (96.53%; p=0.018) and that supported and developed mental health care actions (100%; p=0.004). The other variables at this level did not present significant results.
At the proximal (technical-pedagogical) level, when only the offering of ICHP was analyzed, it was possible to observe multidisciplinary teams that: had their activities monitored and evaluated by the coordination/reference (96.48%; p=0.031); received provision of pedagogical activities by the coordination (86.43%; p=0.000); carried out a diagnosis of the territory that revealed the need for professionals to compose the multidisciplinary team (86.67%; p=0.042); received courses offered by management that were appropriate to the needs of professionals in multidisciplinary teams to work in Primary Care (78.71%; p=0.000); carried out planning that was articulated with the planning of eAB (81.68%; p=0.000); monitored/analyzed work process indicators (92.57%; p=0.001); and supported and developed strategies with PHC teams to promote body practices and physical activity in the territory (99.50%; p=0.000). The other variables did not present statistically significant percentages (Table 2).
In the logistic regression (Table 3) in the clinical-care subdimension, it was observed that the chance of offering ICHP (OR 3.04; 95%CI 1.16 – 7.94) was greater in multidisciplinary teams that performed complex case assessment and risk classification, when compared to teams that did not. In those multidisciplinary teams with greater diversity of actions offered in PC, the chance of offering ICHP (OR 2.42; 95%CI 0.75 – 7.82) was greater when compared to teams with less diversity, although this variable did not present a significant p value.
Still on Table 3, statistical significance was found in some of the variables in relation to the technical-pedagogical subdimension. It was observed that the chance of offering ICHP (OR 3.14; 95%CI 1.80 – 5.49) was greater when the coordination offered pedagogical activities to the multidisciplinary teams, compared to those that did not. This chance was also more evident, being greater (OR 2.75; 95%CI 1.68 – 4.49) when the management offered courses suited to the needs of the professionals in the multidisciplinary teams to work in Primary Care, when compared to those management teams that did not offer any type of course.
It was observed that multidisciplinary teams that monitored and analyzed work process indicators were more likely to offer ICHP (OR 3.05; 95%CI 1.53 – 6.09) when compared to teams that did not. Nevertheless, multidisciplinary teams that supported and developed strategies to promote body practices and physical activity in the territory with eAB were 97% more likely to offer ICHP (OR 23.97; 95%CI 3.09 – 185.71) when compared to those that did not develop such strategies (Table 3).
The final model demonstrated that the chance of offering ICHP was greater in teams where the coordination (management of multidisciplinary teams at the municipal level, which may be the PC coordination or the coordination of multidisciplinary teams) offered pedagogical activities for these multidisciplinary teams (OR 2.63; 95%CI 1.24 - 5.58; p = 0.012); multidisciplinary teams monitoring and analyzing indicators related to their work process (OR 3.07; 95%CI 1.72 - 5.46; p = 0.000); and multidisciplinary teams supporting and developing eAB strategies to promote body practices and physical activities in the territory (OR 18.33; 95%CI 2.26 - 148.52; p = 0.006) (Table 4).

Discussion

Unlike the most common practice in the entire state of Bahia, it was observed that, in the East NRS, where the state capital is concentrated, Traditional Chinese Medicine/Auriculotherapy was the ICHP most offered by multidisciplinary teams, contributing to studies24,25 highlighting the expansion of acupuncture procedures in the SUS, after the legitimization of the use of this practice by other qualified health professionals, in addition to the medical category.
In one of such studies25, multidisciplinary teams are presented as an important strategy for the inclusion of non-medical professionals specializing in acupuncture in the SUS and especially in the PHC, as they function as a matrix team for the supported reference teams (eSF and eAB). Based on these findings, it is possible to demonstrate the contributions of multidisciplinary teams in the expansion of more effective and qualified care offers within the PHC. These teams’ strategy promotes the expansion of ICHP in PHC, based on matrix support actions, health promotion, as well as collective actions12, in addition to collaborating with shared care between teams and expanded clinic26.
By analyzing the map, it could be noted that the offering of ICHP was concentrated in the NRS surrounding the state capital, an area where a greater number of municipalities with multidisciplinary teams is also observed. This condition contributes to greater accessibility to these practices within PHC. This finding cannot be observed in regions further away from the capital, which tend to prioritize a model focused on contemporary Western medicine, the hegemonic medical rationale in Brazil, which operates fragmented, doctor-centered care practices based on the Cartesian model. These findings contribute to a recent study14 addressing remote accessibility based on the regional location of some health services.
Another significant result of the offering of ICHP was related to the number of multidisciplinary teams that supported and developed mental health care actions. This finding corroborates a study27 that pointed out the existence of similar aspects between PHC, psychosocial care, and the use of ICHP, among which: the counter-hegemonic and questioning nature of the biomedical model; the conceptions of objects, means, and ends of the care offered; the focus on family, community and user-centered approach; the dialogical and participatory relationships; the various care practices that induce self-healing with a de-medicalizing nature; the holistic approach, and the prevention and health promotion actions.
The ICHP offers proved to be significant when the coordination or reference developed pedagogical activities with the multidisciplinary teams, showing that continuing education actions, made possible by the municipal management initiative, encouraged and enable an expansion of the scope of care provision from a care network perspective, as shown in the study by Tesser and Sousa27.
It is noteworthy that actions involving Continuing Education in Health (Educação Permanente em Saúde - EPS) were strengthened when shared care tools are used, which favor the exchange of knowledge and practices among professionals, implementing spaces for discussion, analysis, and reflection of practices in the daily work28, in line with the organizational arrangements of matrix support and the expanded clinic. However, the findings of this study corroborate another study pointing to the existence of weaknesses in the performance of multidisciplinary teams in relation to the promotion of EPS activities with the matrix teams29.
On the other hand, it was also observed that the ICHP offered were more frequent in those teams that received management-provided courses that were appropriate to the needs of the professionals in the multidisciplinary teams. Sousa and Tesser12 discuss the importance of continuing education actions, through training and specializations, which seeks to add value to and enhance the expertise, skills, and competencies acquired by ICHP professionals within the scope of the SUS.
Continuing education actions are relevant; however, it is important to emphasize that permanent education seeks to approach the real needs of the territory and health services, even though the activities end up being developed based on a knowledge transmission logic that is more vertical and less dialogic, problematizing and transforming of practices29. It could also be observed that the training of professionals working in multidisciplinary teams presents weaknesses regarding the dimensions of the matrix support and components of their work process.
Another relevant finding was that multidisciplinary teams performing a diagnosis of the territory to support the composition of their teams presented greater chance of offering ICHP, thus demonstrating the importance of collecting information relevant to the diagnosis and analysis of the territory being supported. Other elements can further contribute to this territorial diagnosis, such as the epidemiological and social context, the panorama of the care network and its health needs7.
About monitoring and evaluation, it was found that the multidisciplinary teams that had their activities monitored and evaluated by the coordination/management reference, and those that monitored and analyzed their work process indicators, presented a higher prevalence of offering ICHP. Using monitoring and evaluation instruments can help redirect practices based on new proposals and readjustment of interventions7, from a broader perspective of care, adjusting to the planning of actions in an integrated manner between multidisciplinary teams and the supported reference teams.
By analyzing the health promotion actions, a significant offer of ICHP could be observed by multidisciplinary teams that supported and developed strategies to promote body practices (PC) and physical activity (PA) in a shared manner with PHC teams. This finding confirms the research30 that points to a significant increase in the offering of body practices and physical activity in PC services; however, it also reinforces the importance of PHC teams, especially eSF and multidisciplinary teams, seeking to expand the scope of these offers, from a multidisciplinary perspective, with a view to comprehensive care. It is worth noting that ICHP have been integrated into the SUS based on the concept of health promotion and disease prevention, including PC and PA31.
Considering that ICHP seek to establish a broader and holistic understanding of the health-disease process by encouraging the empowerment of individuals, such practices are strategic resources for implementing health promotion actions17, even though there are significant challenges for expanding the access to ICHP in SUS services.
The results of this study presented a positive influence of the work of multidisciplinary teams in the offering of ICHP based on the logic of matrix support. The greater the diversity of actions offered by these teams in Primary Care, the greater the chance of offering ICHP. Matrix support by multidisciplinary teams, as an institutional model and arrangement, provides the exercise of interdisciplinary practices17 and the sharing of knowledge among the various professional training centers, through individual and shared care tools, which will aid in dealing with complex cases.
Considering the new PNAB32 and the new financing model, based on the Previne Brasil Program33, it is noted that multidisciplinary teams, as a PC strategic project, no longer have financial resources exclusively allocated to the cost of these teams in the territory, nor health indicators allocated to these teams, and it is the discretion of the municipal managers to think about the composition and structuring of these multidisciplinary teams. From this perspective, it is necessary to think and reflect on the future of these teams as an important strategy to expand and qualify the care offered, increasing the resolution of Primary Care and, thus, jointly promoting reflections on the offering of ICHP.
Although this study is based on data from 2017, the topic is still relevant, given that the study addresses an object that requires a greater increase in scientific production to encourage the evaluation of the policy supporting ICHP, and such results should serve as a mirror for current and future evaluations.


Conclusion

The results presented herein showed a greater offering of ICHP by multidisciplinary teams that: received offers of pedagogical activities from the management/coordination team; that monitored and analyzed the indicators of their work process, and that supported and developed strategies to promote body practices and physical activities in the territory in a shared manner with the PHC teams. In addition, it was possible to identify that the main ICHP offered in the state of Bahia were: Music Therapy, Shantala and Do-in/Shiatsu/Massage Therapy/Reflexology, followed by TCM/Auriculotherapy.
Based on such evidence, the authors emphasize the importance of prioritizing and investing (both technically and financially) in the arrangement of matrix support, which is operationalized through clinical-care actions and technical-pedagogical support, strengthening continuing education actions and the organization of the work process, in a dialogical relationship between the eSF and eAB matrix teams and the multidisciplinary matrix teams.
The limitations of this study may be related to the fact that the teams participating in PMAQ-AB were selected by the municipal administration and all data collection from this evaluation process occurred through the transfer of financial resources to the municipalities participating in the program.
Finally, the authors emphasize the essential aspect of developing new research, especially after the new coronavirus/Covid-19 pandemic and the new PHC financing model, which can contribute to the findings of this study, enhancing and strengthening the offering of ICHP in the SUS, with an emphasis on PHC services. The results found here can contribute to the discussion on the promotion for the implementation of national and state ICHP policies, especially the current and recently institutionalized state policy, as well as encouraging the debate for the social construction of legislation that strengthens and contributes to the development and institutionalization of the ICHP policy in Brazil.

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32. Brazil. Ministério da Saúde. Ordinance No. 2,436, of September 21, 2017 Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Brasília, DF: Ministério da Saúde, 2017. [internet]. [Accessed on 2021 May 08]. Available from: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html

33. Brazil. Ministério da Saúde. Ordinance No. 2,979 of November 12, 2019. Institui o Programa Previne Brasil, que estabelece novo modelo de financiamento de custeio da Atenção Primária à Saúde no âmbito do Sistema Único de Saúde, por meio da alteração da Portaria de Consolidação nº 6/GM/MS, de 28 de setembro de 2017. Diário Oficial da União, 2019.