O cuidado das condições crônicas na atenção primária à saúde: o imperativo da consolidação da estratégia da saúde da família

Health conditions can be defined as circumstances in people’s health which are more or less persistent and which require reactive or proactive, episodic or continuous and fragmented or integrated social responses from health care systems, health professionals and health care users. The finding that the classic typology of communicable diseases and noncommunicable diseases cannot support the organization of health care systems led to the proposal of health conditions, which was developed in the late 1990s by scholars linked to the chronic care model(1,2) and then adopted by the World Health Organization(3). Knowing such conditions allows to know them better and thus be able to prevent possible diseases through health promotion strategies. The study of the typology of health conditions is based on the way health professionals, health care users and health care systems are engaged to respond socially to the demands, whether in a reactive, episodic and fragmented way, or in a proactive, continuous and integrated way. Such typology is mainly based on some key variables contained in the concept of health condition: the first refers to the duration of the health condition – short or long; the second is the way health professionals, health care systems and health care users fight such conditions – an episodic, reactive and fragmented approach focused on diseases and complaints or a continuous, proactive and integrated approach focused on people and families through more or less permanent care contained in a plan of care prepared by the health team and the users together. It should be noted that chronic condition is not the same as chronic disease. All chronic diseases (diabetes, cardiovascular diseases, cancers, chronic respiratory diseases, chronic musculoskeletal diseases, and others) are chronic conditions. But this concept also encompasses persistent infectious diseases (leprosy, tuberculosis, HIV/AIDS, certain viral hepatitis, and others), maternal and perinatal conditions (follow-up of pregnant women and perinatal, postpartum and newborn care); conditions linked to the maintenance of health throughout life cycles (child care, adolescent care and older person care); long-term mental disorders; continuous physical and structural disabilities (amputations, blindness, persistent motor deficits, and others); metabolic diseases; non-acute oral diseases; and health conditions characterized as illnesses, which refer to the way people perceive their disease, that is, the subjective response of individuals and/or their network of relationships to a particular disease(4,5). The model of care for acute events has failed to respond to health situations dominated by chronic conditions, which has led different countries and several institutions to seek models of care for chronic conditions. Several models of care for chronic conditions have been reported in the international literature(6). The most significant models are the chronic care model (CCM), the seminal model, and the risk pyramid model (RPM). The CCM, proposed in the United States of America(2), works best in public and universal health care systems(7) and is composed of six elements subdivided into two main fields: the health care system and the community. In the health care system, changes must be made to the organization of health care, to the service delivery system design, to decision support, to clinical information systems and to self-management support. In the community, the changes are centered on the integration between health care services and community resources. These six elements present interrelationships that allow the development of informed and active users and a prepared and proactive health team to produce better health and functional outcomes for the population. The second major international impact model, the risk pyramid model (RPM), is based on population risk stratification. This determines self-care and professional care intervention strategies. Professional care, depending on the risks, determines the clinic management technology to be used: health condition management or case management(8). International evidence on health care models and the uniqueness of the Unified Health System (Sistema Unico de Saude – SUS) led to the development of a chronic condition care model (CCCM) that could be applied to the Brazilian public health system(9). The basis of the CCCM is the CCM, but this model of origin has been expanded to incorporate two other models, the RPM and the model of social determinants of health(10), to adapt to the requirements of a public and universal health care system such as the SUS. The CCCM is built on three columns: one column features the total population divided into subpopulations by risk strata; another column features the different levels of social determinants of health: intermediate, proximal and individual determinants; and the third column features the five levels of health interventions on determinants and their populations: promotional interventions (level 1), preventive interventions (level 2) and clinic management interventions on established chronic conditions (levels 3, 4 and 5). With regard to its application in primary health care, a rigorous evaluation research was carried out in the municipality of Santo Antonio do Monte, Minas Gerais, Brazil. The intervention took place from June 2013 to December 2014 and focused on four target groups: individuals with hypertension, individuals with diabetes, pregnant women and children under two years old(11). The results of both the quantitative and qualitative analyses were very positive. Another evaluation showed positive effects of CCCM on the organization of a network of primary health care and specialized outpatient care(12). Given the relevance of this subject, the present issue of the Brazilian Journal in Health Promotion (Revista Brasileira em Promocao da Saude – RBPS) complements this dialog by featuring three original articles on chronic conditions in different contexts of Public Health and their impact on the life of patients. The main findings of these studies focus on: physical activity as a means of reducing cardiovascular risk in hypertensive older patients(13), the association of vitamin D deficiency and its consequences in patients with type 1 diabetes(14), and, finally, feelings of rejection, sadness and anguish arising from an unwanted pregnancy and the great impact on the psychological life of adolescents(15). RBPS fulfills, once again, the function of bringing to researchers and readers themes of great value and scientific interest in the health promotion field.