Professional and Community Satisfaction with the Brazilian Family Health Strategy, Brazil

Abstract

Objective

To analyze the strengths and limitations of the Family Health Strategy (ESF) from the perceptions of healthcare professionals and community.

Methods

Between June-August 2009, in the city of Vespasiano, Minas Gerais State, Southeastern Brazil, a questionnaire was applied to evaluate the ESF with 77 healthcare professionals and 293 caretakers of children under five. Health professional ESF training, community access to care, patient communication, and delivery of health education and pediatric care were of main interest in the evaluation. Logistic regression analysis was used to obtain odds ratios (OR) and 95% confidence intervals (CI).

Results

The majority of health care professionals reported their program training was insufficient in quantity, content and method of delivery. Caretakers and professionals identified similar weaknesses (services not accessible to the caretakers, lack of healthcare professionals, poor training for professionals) and strengths (community health worker-patient communications, provision of educational information, and pediatric care). Recommendations for improvement included: more doctors and specialists, more and better training, and scheduling improvements. Caretaker satisfaction with the ESF was found to be related to perceived benefits such as community health agent household visits (OR 5.8, 95%CI 2.8;12.1), good professional-patient relationships (OR 4.8, 95%CI 2.5;9.3), and family-focused health (OR 4.1, 95%CI 1.6;10.2); and perceived problems such as lack of personnel (OR 0.3, 95%CI 0.2;0.6), difficulty with access (OR 0.2, 95%CI 0.1;0.4), and poor quality of care (OR 0.3, 95%CI 0.1;0.6). Overall, 62% of caretakers reported being generally satisfied with the ESF services.

Conclusions

Identifying the limitations and strengths of the ESF from the healthcare professional and caretaker perspective may serve to advance primary community healthcare in Brazil.

Introduction

Dramatic changes made to Brazil's Unified Health System (SUS) in the 1990s led to the creation of a public, federal, decentralized, participatory and comprehensive health system.¹⁰ One federal program receiving particular recognition for its contributions to reducing child mortality in Brazil is the family health strategy (ESF).¹⁴ The ESF was designed to deliver primary healthcare services through multidisciplinary health teams comprised of a physician, a nurse, a nurse assistant, and several community health workers (CHWs).¹³ The teams provide health promotion, disease prevention, treatment and rehabilitation at ESF health units at the municipality level and extend these services to the household level via regular household visits.

Epidemiological studies reported the impact ESF has on reduced infant mortality in Brazil.^{1,10,12,18,19} Under-five mortality due to diarrhea decreased from 12% in 1990 to 5% in 2002, following expansion of the ESF.¹⁰ A health system's performance is often evaluated using epidemiological data instead of the perceptions or satisfaction levels of the patients or health workers involved in the system.^2,24 Limited research has examined the perceptions of the ESF's services for child health, particularly from the perspective of the professionals delivering these services and the caretakers of children receiving care. Studying the perspectives of individual users is important for improving health systems,^5,8 especially those of caretakers of children under five years, as they are frequent users of health system services for their vulnerable children. Valuable insight to a health systems' overall performance can be obtained from the users and providers.^4,5,20,22 An important challenge to achieving the Millennium Development Goals in developing countries, as noted by Willis-Shattuck et al,²⁷ is the absence of a properly trained and motivated workforce. Evaluating the potential factors influencing health worker retention is critical for improving health systems.^13,17 In a study from the state of Ceará, Northeastern Brazil, health worker integrity was cited as a key element to the observed improvements in community health.²⁵ Patient or community satisfaction with ESF services can be used to identify areas for programmatic improvement.^2,4,11,12 In our previous work, patient satisfaction with the health agent and ESF unit were associated with perceived access to the unit and frequency of agent home visits.¹⁶ Positive relationships between the community and ESF professionals are important in the primary care setting because of its long-term orientation centered on prevention.^2,15,17

This study aimed to analyze the strengths and limitations of ESF services, through the perceptions of healthcare professionals and community.

These analyses may provide key findings through which Brazilian policy makers and researchers in the field of health care quality can utilize user and professional perceptions as indicators of population health and program strengths and limitations.

Methods

The ESF was officially implemented in the state of Minas Gerais, Southeastern Brazil in 2004-2005. The municipality of Vespasiano was the first city in Minas Gerais to adopt the ESF as the main strategy for primary health care in 1999 (pers. comm. Dr. Hérica Soraya Albano, Vespasiano's Municipal Secretary of Health). Because Vespasiano had the longest history with the ESF in Minas Gerais, we chose Vespasiano as our study site to investigate the caretaker and Professionals' satisfaction with the ESF in a city with commitment and experience with the ESF. The coverage of the ESF in Vespasiano was 34% in 2009. We collected perceptions from each healthcare Professional team member (doctors, nurses, nurse assistants, and CHWs) from June to August of 2009, on their program training, challenges encountered in the work environment, and the Professionals' overall evaluation of the ESF services. We also collected perceptions from caretakers of children under-five years during the same time period on their experience with overall ESF services. In a sub-analysis, we explored the use of and satisfaction with ESF diarrhea care and prevention services among caretakers because such activities may have an important role in preventing mortality due to diarrhea among children under-five.^18,19

The sample population was comprised of primary caretakers of children served by the ESF program and professionals working at the ESF units in the city of Vespasiano, Minas Gerais State, Southeastern Brazil. Vespasiano was selected as the study site because Vespasiano had the longest history with the ESF in Minas Gerais State. Another reason for selecting Vespasiano was that it was the appropriate size, unlike a larger city, to randomly sample the entire municipality and all the ESF professionals with our resources, community, municipality and research support. We chose diarrhea as a model disease to study the ESF's efforts in child health because it is a common yet potentially fatal disease of children under-five years^18,19 and serves as a concrete service with which to specifically evaluate the program.

Primary caretakers of children < 5 years were recruited by random selection in between June and August of 2009. They were chosen because they are frequent users of health system services for their vulnerable children. Respondents were identified from all ten of the ESF units in Vespasiano. Lists of all households were obtained from the units themselves, and 310 households were selected using proportionally allocated stratified random sampling, stratified by ESF unit.¹⁵ The sample size was calculated to obtain a precision of 0.055 around an estimate of user satisfaction with the ESF. Of 310 selected households, 253 of eligible households agreed to participate (82% response rate).

The participants in the health professional study included a convenience sample of healthcare professionals (18 years and older) that were working for the ESF during the study period. We chose the ESF Professionals because the caretakers interact with these representatives of the ESF system. Of the 85 eligible professionals identified and contacted, eight doctors, eight nurses, nine nurse assistants and 52 community health workers (CHW) agreed to participate (91% response rate).

The interviews were conducted in Portuguese using a semi-structured questionnaire, either at the ESF health units or the Professionals' home, by trained local medical students unaffiliated with the ESF. The Vespasiano ESF was not involved in the study conception, design, or analysis except to provide lists of caretakers from which random sampling frames were constructed and encouraging CHW to accompany study staff to the caretaker's home. CHW did not participate or were present during data collection. Study questions not developed independently by the survey authors were referenced from the Integrated Health Facility Assessment Survey.¹⁶ These questions were related to health service quality, health provider communication practices, and problems encountered on the job, as well as diarrhea services and health-seeking behaviors in the community. Each interview took approximately 30 minutes to complete. Caretakers were asked these four satisfaction questions: “In general, how does the ESF in Vespasiano benefit you and your family?”; “Have you had any problems with the ESF in Vespasiano that you would like to share with us?”; “How satisfied are you with services provided at the ESF unit?”; and “Do you have any other information on the ESF you would like to share with us?”.

All surveys were double-data entered by two different data operators and cleaned using EpiInfo version 3.5.1 and Microsoft Access 2007. Open-ended responses were stratified by Professional category and translated from Portuguese to English by the authors. For open-ended responses, we used a post-hoc coding approach, where we attached codes to the participant answers to the open-ended questions and counted the types of responses we received.All quantitative statistical analysis procedures were completed using EpiInfo version 3.5.1 and SPSS/PASW Statistical Software (V. 17.0 and 18.0). Binary logistic regression models were created with an enter method of entry. A p <0.05 was considered significant.

We compared specific problems and challenges cited by professionals and caretakers to identify common challenges encountered by all participants in the ESF system. Professionals were asked specifically about these issues, while caretakers' responses were extracted from open-ended responses, which led to smaller percentages of caretakers' responses because all caretakers did not address all topics. We asked all participants about their ESF training experiences to evaluate the ESF practices for health professional capacity strengthening. We also asked those who received training if they found the training useful for their work at the ESF and whether they had any suggestions to improve the training system. From the open ended suggestions provided by each health professional for improving the training system, we used a post-hoc coding approach, where we attached codes to the participant answers to the open-ended questions and counted the types of responses we received. We then grouped common responses related to training quantity, topics, methods, and quality.

To evaluate whether specific benefits and problems were associated with overall caretaker satisfaction with the ESF, the coded open-ended responses of specific benefits and problems (exposures) were compared with a specific closed-ended response on overall caretaker satisfaction with the ESF.¹⁵ We ran two logistic regression models to assess which benefits and problems were significant predictors of caretaker satisfaction.

The two studies followed the Declaration of Helsinki set of principles and were approved by the Institutional Review Boards of Emory University (IRB00020524, 2009, Atlanta, GA, USA) and the Faculdade da Saúde e Ecologia Humana- FASEH, Vespasiano, MG, Brazil (IRB process N° 330/ 2009). Written informed consent was requested of each subject before each interview.

Results

About 53% of respondents were 30 years or younger (19 to 63 years); females comprised 95% of respondents. A majority of nurses (87%) and CHWs (94%), compared to doctors (63%) and nurse assistants (67%), reported having less than five years of experience working in the healthcare setting before entering the ESF. A significantly (p = 0.02) greater percentage of the CHW (75%) reported working at the ESF for more than a year compared to other professionals combined: doctors (50%), nurse assistants (33%), and nurses (63%). The majority of the caretakers were female (94%) and the mean age was 34 years (SE 0.73 years).

We chose similar questions from both surveys to compare responses on caretaker and health professional satisfaction levels and perceptions of the ESF (Table 1). More professionals than caretakers said they believed the ESF was accessible to the communities they served (68% versus 46%); 75% of doctors, 88% of nurses, 56% of nurse assistants, and 65% of CHW thought that they believed the ESF was accessible to the communities they served. 34% of caretakers “sometimes” thought the ESF was accessible (data not shown). While very few caretakers surveyed reported that they had ever received any advice (18%) or participated in educational activities (2%) on diarrhea treatment, nearly all professionals reported that they normally give caretakers of children advice (97%) or CHW hold educational activities (67%) on diarrhea treatment. Specifically, 100% of doctors, 100% of nurses, 100% (9/9) of nurse assistants, and 96% of CHW gave advice about diarrhea treatment. Few caretakers reported receiving written information on diarrhea prevention, and few CHW reported having given written information in the last year. No particular ESF unit stood out as having higher information distribution rates than others (data not shown). The Child Health Booklet had high usage rates among both professionals and caretakers: most caretakers (81%) regularly use the booklet (for monitoring child growth or keeping track of child vaccination records), and most professionals (72%) have been trained on the booklet (Table 1); 67% of doctors, 67% of nurses, 43% of nurse assistants, and 77% of CHW were trained on the Child Health Booklet. There were discrepancies between caretakers and professionals in the particular activities around diarrhea, especially advice about diarrhea treatment and the distribution of written information about diarrhea. However, the two groups had similar levels of high to very high overall satisfaction with the ESF's diarrhea services (professionals 87%, caretakers 85%); 88% of doctors, 100% of nurses, 100% of nurse assistants, and 83% of CHW were satisfied with the ESF diarrhea services.

Table 1.

Caretakers and Professionals' reported experiences with the Family Health Strategy (ESF) services and activities. Vespasiano, Southeastern Brazil, 2009.

	Caretakers		Professionals
	n	%	n	%
Accessible to the community	n =242		n =77
Yes	110	45.5	52	67.5
Receive/give advice about diarrhea treatment	n =252		n =77
Any advice	44	17.5	75	97.4
Educational activities about diarrheaa	n =252		n =51
Caretakers ever participated; CHW presented in past year	5	2.0	34	66.7
Written information about diarrheaa	n =252		n =52
Caretakers have received; CHW presented in past year	44	17.5	2	3.9
Child Health Booklet	n =236		n =66
Caretakers use booklet,b Professionals received training on booklet	191	80.9	47	71.2
Satisfaction with ESF diarrhea servicesc	n =103		n =77
Yes	88	85.4	67	87.0

CHW: Community Health Worker

^aQuestions on having ever given educational activities and written info on diarrhea were only asked to community health agents.

^b“Use” includes monitoring of child growth and vaccination records.

^cThe N is relatively small for caretakers because not all have ever sought diarrhea treatment with ESF. Variable for caretakers combines questions of caretaker satisfaction levels with services for controlling diarrhea at ESF unit, and caretaker satisfaction levels with advice given by community health agent.

The most common problem cited by caretakers was “lack of health professionals,” a sentiment shared by a similar number of nurses and a smaller percentage of CHW and nurse assistants but, interestingly, not doctors (Table 2). More than 3/4 of the health professionals in all categories reported that the “ESF was difficult to access”, in terms of length of travel time for professionals, while 1/4 of caretakers reported this issue. The same discrepancy between professional and caretaker opinions on lack of resources also suggests different expectations among professionals and caretakers on what resources should be available. Around half the professionals reported that “poor quality” was a problem, which includes “lack of training;” less than a quarter of caretakers felt that “poor quality of care” was a problem. The caretakers cited challenges, related to “poor infrastructure” and “limited resource availability,” as major issues that may be limiting their delivery and utilization of care.

Table 2.

Professional and caretakers' perceptions of challenges and problems with the Family Health Strategy (ESF) services. Vespasiano, Southeastern Brazil, 2009.

Challenge (Yes)a	Doctor		Nurse		Nurse assistant		Community health worker		All professionals		Caretakers
	n	%	n	%	n	%	n	%	n	%	n	%
Not enough health care professionals	0	0	3	38.0	2	22.0	9	17.0	14	18.0	89	35.0
Difficult to access	6	75.0	6	75.0	7	78.0	38	73.0	57	74.0	53	21.0
Lack of resourcesb	6	75.0	8	100.0	6	67.0	37	71.0	57	74.0	41	16.0
Poor qualityc	5	63.0	3	38.0	4	44.0	27	52.0	39	51.0	40	16.0
Total	8		8		9		52		77		253

^aCombination of “no” and “don't know” complete remaining responses; caretaker responses coded from open-ended responses

^bIncludes medication, equipment, and staff

^cIncludes lack of training for professionals and poor care for caretakers

Almost all professionals (92%) had received some form of ESF training (both formal and informal) in their first 12 months working at the ESF, mainly through lectures (96%) and/or individual orientation by co-workers (93%, data not shown). A high proportion of professionals (97%) perceived that their training was useful for their work in the program.

Almost all participants suggested increasing the number of trainings provided (quantity) and expanding on the content of the training (topics) to include topics specific to issues encountered in their communities or health units (Table 3). Professionals recommended moving the trainings to the units or arranging transportation to the training sites and providing take-home materials after the sessions to improve the way the trainings are provided. They made suggestions to improve the quality of the sessions, such as reducing the number of people per session for better organization and standardizing the language for all professionals to follow.

Table 3.

Suggestions to improve current Family Health Strategy health care professional training, by professional category and training theme. Vespasiano, Southeastern Brazil, 2009.

Themea	Doctor	Nurse	Nurse assistant	Community health worker
Quantity	Need more (e.g. trimester meetings)	N/A	Need more (e.g. weekly meetings)	Need more
Topics	Address unit-specific issues	Address community and unit-specific issues	Provide training in: pharmacy skills; environmental issues; relevant research topics	Address community-specific issues Provide training in: disease pathology; first aid; health of elderly; maternal and child health; diarrhea; sexually transmitted diseases; patient communication; vaccines; treatments
Methods	Provide lectures from specialized professionals (e.g. from the medical school) Request evaluations of training sessions from each trainee	Provide individual training when needed (especially for CHW)	Provide handouts/ materials Arrange transportation to training sites Have light snacks available	Provide special training for new CHWs Provide handouts-Need more videos, lectures, and practical training (workshops) Offer training at units Divide training by unit Provide training on how to use health promotion materials
Quality	Good	Make training more dynamic Need greater consistency of information Use language all can understand	Slow down pace of lectures Need better organization (less people/ session)	Slow down pace of lectures Need more investment in CHW capacity-strengthening Information should be up to date

^aResponses extracted from open-ended questions and assigned to themes identified by the investigator. N/A: No comment. CHW: Community Health Worker

Caretakers reported on several strengths of the program and provided recommendations for improvements (Figure 1A). The most commonly cited benefits were availability of staff, ease in scheduling appointments, and the home visits by CHWs. Provision of pediatric care and information on health issues were also mentioned by around 10% of caretakers. We also asked about common problems with the ESF and the four main problems raised by caretakers were lack of personnel (35%), difficulty with access (21%), poor quality of care (16%), and lack of resources (16%) (data not shown, n = 253). Caretakers reported specific places where improvements in the ESF care could be improved (Figure 1B). The most common responses were that the ESF needed more doctors and specialists. Other common recommendations were to make the scheduling process easier, improve attention from ESF staff, and to give out more educational information. Many of the recommendations paralleled benefits cited by the caretakers. These areas, specifically the scheduling process, home visits and doctor-patient relationships, and information given to the caretakers, were identified as strengths of the ESF program and areas where improvements could capitalize on areas of program strength.

Figure 1.

A) Bars represent the number of caretakers who mentioned the row topic as a benefit of the ESF services. “Other” responses included availability of exam options, fast lab results, an easy system, availability of medications, good treatment by staff, focus on prevention, chronic disease care, vaccinations, prenatal care, and general improvement in the ESF.

B) Bars represent the number of caretakers who mentioned each topic as a recommendation to improve the ESF program. “Other” responses include: better staff training, more medicines, better unit facilities, more home visits from agent, better process for urgent care, better quality, better professional-patient relationships, and better overall structure.

Caretakers; cited benefits of the Family Health Strategy (ESF) and recommendations for improving the ESF in Vespasiano, Southeastern Brazil, 2009.

In general, 62% of caretakers reported being “satisfied” or “very satisfied” with the services of the ESF and 10% of caretakers reported being “dissatisfied” with the ESF. The first logistic regression model showed the association between the open-ended benefits and overall satisfaction with the ESF, while adjusting for other benefits, education and income (Table 4). Caretakers who cited household visits as a benefit of the ESF were almost five times more likely to be satisfied with the ESF than caretakers who did not mention household visits. Caretakers who discussed the positive relationships and family-focused care they received from health professionals were four times more likely to be satisfied than caretakers who did not mention positive relationships or family-focused care. The second model, examined the association between open-ended problems and overall satisfaction, while adjusting for other problems, education and income. Caretakers who cited a lack of personnel were a third less likely to be satisfied than caretakers who did not cite lack of personnel. Caretakers who cited difficulty of access and poor quality of care were a fifth and a fourth less likely to be satisfied, respectively, than caretakers who did not cite difficulty of access or poor quality of care. Prevention services and lack of resources were not significantly related to overall satisfaction with the ESF.

Table 4.

Predictors of caretaker satisfaction with the Family Health Strategy (ESF) in Vespasiano, MG, Southeastern Brazil, 2009.

Variable	OR	95%CI	p
Adjusted Model 1. Benefits
Benefitsa (n=253)
Household visitsb	5.783	2.770;12.075	<0.0001
Good professional-patient relationshipb	4.806	2.484;9.296	<0.0001
Family-focused healthb	4.059	1.619;10.179	0.003
Prevention services	1.298	0.595;2.831	0.572
Adjusted Model 2. Challenges
Problemsa (n=253)
Lack of personnelb	0.346	0.191;0.626	<0.0001
Difficulty with accessb	0.206	0.103;0.412	<0.0001
Poor quality of careb	0.266	0.124;0.573	0.001
Lack of resources	0.828	0.381;1.800	0.634

^aIn Model 1, all benefits were adjusted for each other. In Model 2, all problems were adjusted for each other. In both models, education and income were adjusted for all variables and were not significant.

^bp < 0.05

Discussion

Areas of discrepancy between caretaker and professional perceptions were important factors in patient satisfaction. Professionals and caretakers often encountered similar challenges that may be hindering the program's capacity to meet the healthcare needs of the caretaker. Recommendations from healthcare professionals and caretakers on improvements to training and program services were also important areas for improvement of the ESF. Despite the limitations encountered within the program structure, 62% of caretakers reported being “satisfied” or “very satisfied” with the services of the ESF and 10% of caretakers reported being “dissatisfied” with the ESF, indicating that the program was evaluated fairly positively. Our study supports studies that recognize the important role the program may have in promoting child health in Brazil.^1,3,10,18,19

Differences between caretaker and Professional perceptions of the ESF were greatest in three areas: the ESF was accessible to the caretaker; health care professionals were lacking; and the rates at which caretakers received advice or educational activities on child diarrhea treatment. This difference may be due to caretakers' experiences of waiting in long lines, difficulty getting appointments^7,20 (data not shown), and over-reporting of giving health advice or educational activities by CHWs. Similarities in perceptions of the ESF were found in satisfaction with ESF diarrhea services and usage of the Child Health Booklet. Professionals also shared challenges: difficulty of access to the unit and to households, lack of resources, and poor quality of training. These work challenges have been cited by ESF Professionals in other municipalities.^6,10,13,17 Perceptions of limited resources and poor infrastructure could be explained by the relatively recent implementation of the program in the municipality^13,22 (e.g. transportation to distant ESF units may be lacking).

Both caretakers and professionals had recommendations for improving the ESF in structuring and providing health services to serve their communities: improvement of health care services^4,5,23 and worker retention, job satisfaction, and motivation^9,21,28 responsible for an overall strong health system.^9,25 In a review of the literature, Willis-Shattuck et al²⁷ cited health worker retention as a key factor in strengthening health systems in developing countries. Job satisfaction and motivation play a key role in retaining health professionals without regard to financial considerations.^17,27 Many recommendations stemmed from areas of discrepancy between professional and caretaker perceptions and were significant factors in patient satisfaction (Table 4). Professionals were more likely to think that ESF services were accessible to the caretaker; on the other hand, caretakers found it difficult to access services and that problem made caretakers significantly less likely to be satisfied (OR 0.2, 95%CI 0.1;0.4, Table 4). Similar results were found in the perception that there weren't enough health care professionals (OR 0.3, 95%CI 0.2;0.6), and the perception of poor quality of care (OR 0.3, 95%CI 0.1;0.6, Tables 2 and 4). These problems all significantly decreased the likelihood that caretakers were satisfied with the ESF. Areas of correspondence between the perceptions of professionals and caretakers were significantly related to increased patient satisfaction, as seen in household visits (OR 5.8, 95%CI 2.8;12.1), attendance (OR 4.8, 95%CI 2.5;9.3), and family-focused health (OR 4.1, 95%CI 1.6;10.2). By increasing correspondence between caretaker and professional perceptions and expectations, patient satisfaction may be increased, which in turn will increase medical compliance and more effective utilization of care.^20,26 Our study is among a few group of publications that have examined areas of correspondence and discrepancies between the identified perceptions of the users and ESF professionals. Despite the limitations involved with comparing the perceptions of the two groups simultaneously, our results point to the critical need for increased identification and evaluation of caretaker's and ESF professional's perceptions of public health programs like the ESF in order to use the findings to construct appropriate recommendations for program development.

Our study had strengths and limitations. By inviting all the professionals of Vespasiano (n = 85) to participate (response rate 91%), we increased our likelihood of obtaining a large sample population and collecting a wide and representative range of perceptions from all four ESF professional types. Random sampling of caretakers allowed us to make generalizations about ESF caretakers in the municipality.¹⁵ Our methods involved novel approaches not applied in other studies, including the application of modeling procedures to examine caretaker satisfaction, comparison of the perceptions of the caretakers and professionals and random sampling to identify the sample of caretakers for the study. In addition, we attempted to reduce potential interviewer bias by providing standardized training to all interviewers on applying the survey and probing for open ended data before the start of the study. However, one disease marker, diarrhea, instead of several disease markers, was evaluated. We could not assess the influence of duration of the professional's work with the specific ESF unit on their satisfaction because we lacked these data and sample size for an adequate analysis. The data presented here are based on self-reports from the participants, which raises a concern for potential respondent bias. Because the context and phrasing of the questions between caretakers and professionals differed, we were not able to statistically compare these two populations, but instead can only make general comparisons. Our study objectives, however, were designed to evaluate perceptions of the services provided and to a lesser extent the actual delivery of these services.

While our study examined a local scenario, some of our findings may be generalized to the perceptions of other ESF professionals in Brazil. Key differences in ESF experiences between municipalities may involve different disease profiles, institutional capacities, and public administration within each area.^13,22 These differences should be considered in multi-site evaluation studies. By interviewing the majority of the ESF professionals in Vespasiano, similar perceptions were reported across the participants regardless of the health unit where they worked (which had their own differences and needs to consider), suggesting that our results may also reflect the perceptions of other ESF professionals in Brazil. Many caretaker responses were similar across the units where they received care and because our findings have been supported at least partially by studies outside Vespasiano,^{6,10,12,13,17} these responses may also reflect the perceptions of other users of the ESF in Brazil. Because the survey pool (primary caretakers of children < 5 years in Vespasiano served by the ESF) was randomly sampled, the resulting data were generalizable to the entire population of ESF caretakers throughout the municipality. The analyses of this study can serve as a basis for future research across municipalities.

Our findings allow for the development of measures to improve on the challenges confronting ESF health teams while promoting key activities that may be contributing to patient satisfaction and reductions in the incidence and severity of some of the major diseases affecting the Brazilian pediatric population.