Introduction

Basic Health Units (BHU) are the main gateway to users, as well as centers for communication with the entire Healthcare Network. Services provided by them are all free of charges, since they are part of the Brazilian Unified Health System (SUS). Oftentimes, users are treated in units located near their residences, and study or working place. BHUs provide medical and dental care, referrals to specialties, wound dressings, free medication, laboratory test collections and vaccinations.

There has been decreased adherence to immunization among adult patients in recent years due to routine mishaps, such as divergent schedules (units and users), lack of information about services provided to users, as well as somatization of myths and beliefs created in social media and in popular culture.

Educational actions were implemented in the waiting room of a BHU as strategy to increase patients’ adherence to vaccination and to provide information about the herein addressed topic. The strategy focused on helping users to understand the importance of getting vaccinated through guidelines that even comprise a game based on questions and answers, as well as folders and explanatory posters on the importance of vaccination.

Thus, the aim of the current technical report was to answer the following guiding question: “How does health education provided to patients in the waiting room of BHUs contribute to their adherence to vaccination?”. The present study was divided into four sections, besides the introduction. The first section presents the theoretical-empirical review of the study; the second one shows the adopted empirical method; the third section addresses the survey and result analysis, whereas the fourth, and final, section accounts for the final considerations.

Theoretical Background

SUS comprises different complexity levels divided into Primary (PHC), Secondary and Tertiary Health Care. PHC focuses on guiding, responding to and meeting the needs of the population through the Family Health Strategy (FHS), by prioritizing integral and continuous health promotion, protection and recovery actions (^{GIOVANELLA et al., 2009}; ^{OLIVEIRA; PEREIRA, 2013}).

The National Immunization Program (PNI - Programa Nacional de Imunizações), which contributes to reduce morbidity and mortality rates associated with communicable diseases, lies within the scope of BHUs. PNI has shown increased complexity over the years, since different vaccines were introduced in its routine calendar within a short period-of-time. Furthermore, vaccination coverage performance in Brazil is comparable to that of developed countries (^{LIMA; PINTO, 2017}; ^{SATO, 2015}; ^{SILVA JUNIOR, 2013}).

Although the country presents good vaccination coverage, surveys have shown inequality among municipalities, due to several crises that have influenced, and remain influencing, population’s understanding about, and acceptance of, vaccine application. Many variables drive the population into having different, negative opinions about the importance of vaccination. Among them, one finds demographic, socioeconomic, religious, scientific and political issues, lack of confidence due to past experiences, and even fear of needles and pain (^{CHAVES; ROSS, 2014}; ^{DOMINGUES; TEIXEIRA, 2013}; ^{MIZUTA et al., 2019}).

Given the need of contemplating health promotion, protection and recovery actions, strategies and tools are used in health services, on a daily basis, to develop humanized and comprehensive care. These strategies comprise activities associated with Health Education, which is understood as alternative to help transforming and empowering individuals about their health. It is extremely important taking into consideration popular knowledge and the context it is inserted in, at the time to develop health education actions (^{CHAVES; ROSS, 2014}; ^{MALLMANN et al., 2015}).

Thus, waiting rooms are a valuable strategy used to carry out educational actions, since they are large spaces where one can have access to a large number of users at the same time. Interventions can be structured based on dialogues among scholars, health professionals and users, who can address several topics - from local needs to issues of national or global importance - in order to promote self-care encouragement and approximation between community and health services (^{CALIXTO et al., 2018}; ^{ZAMBENEDETTI, 2012}).

Methodology

The current study was carried out in a BHU in Western São Paulo City; the BHU belongs to the Downtown Coordination and to the Technical Health Supervision of Santa Cecília. It is a municipal unit that adopts a mixed model of actions, namely: Traditional BHU and Family Health Strategy (FHS). It is worth emphasizing that primary and secondary level programs are installed in the same building, namely: the Elderly Companion Program (PAI - Programa Acompanhantes de Idosos), the Multidisciplinary Home Care Team (EMAD - Equipe Multidisciplinar de Atenção Domiciliar) and the Street Clinic. In addition to the aforementioned programs, other secondary level services are also provided by the investigated BHU, namely: Outpatient Medical Assistance (AMA - Assistência Médica Ambulatorial) and the Elderly Health Reference Unit (URSI - Unidade de Referência à Saúde do Idoso).

The current reseach is a qualitative study based on activities developed by Physical Therapy undergraduate students from a private university in the Metropolitan Area of São Paulo, who were attending internship in Public Health at the aforementioned UBS - the group comprised 8 students and 1 preceptor. Health guidelines were provided during the Waiting Room development period, based on a game formed by questions and answers, and on folders and explanatory posters about the importance of vaccination.

Orientations were provided for four non-consecutive days; they were based on collective or individual approaches that have lasted 5 minutes (each), on average. On the other hand, the total performance time of the research group was 5 hours a day. This methodology was applied from April to May 2019.

A table comprising numbers ranging from 0 to 100 was developed on A4 sheet to survey the number of users participating in the waiting room activity - a number was assigned for each instructed user. The National Health Card (CNS - Cartão Nacional de Saúde) was also used to collect data such as participants’ date of birth and sex. With respect to the investigation on participants’ adherence to vaccination, each user was directed to the vaccination room and they carried a card with the following question: What were the administered vaccines? The card was delivered at the end of each orientation session. All patients were accompanied by a student and the question on the card was filled in by the nursing team. At the end of the immunization process, the card was delivered to the student accompanying the patient. Activity flowchart was developed in Bizagi software (Figure 1) to enable better visualization.

Source: Elaborated by the author.

FIGURE 1 Activity flowchart for the implementation of health education actions. São Paulo, Brazil, 2019.  

Results

In total, 201 users were instructed based on the herein proposed intervention: 65% were women (n=131) and 35% were men (n=70). Participants’ mean age was 59 years and median age was 63 years. The youngest participant was 19 years old, whereas the oldest one was 94 years old. Graph 1 enables analyzing the results based on the number of individuals instructed per day and on the number of patients vaccinated after receiving health education instructions. In total, 64 individuals were vaccinated.

Source: Database

GRAPH 1 Users instructed per day and number of vaccinated individuals after receiving Health Education instructions. (n=201). São Paulo, Brazil, 2019.  

In total, 80 vaccine doses were applied to participants; dT (Diphtheria and Tetanus), Yellow Fever, Hepatitis B, Influenza and Triple Viral (Measles, Mumps and Rubella - MMR) were the most applied ones. Data are shown in Graph 2.

Source: Database.

GRAPH 2 Doses and types of vaccines applied after Health Education instructions. (n=201). São Paulo, Brazil, 2019.  

Conclusion

It is important emphasizing that health education actions focused on highlighting the importance of vaccination, based on the waiting room methodology, had not been carried out before the current study. Thus, it was not possible measuring comparative results expressed in numbers.

However, the current study has shown positive results, both for users’ participation in the proposed activities and for adherence (32%) of individuals instructed to immunization. This outcome has shown the methodological strategy’s effectiveness and implementation feasibility.

The study has also emphasized the multidisciplinary work, in the present case, between Physical Therapy and Nursing, as well as highlighted the important role played by Physical Therapy based on actions focused on health prevention, promotion and education in Primary Care.

Given the contribution of the current study to the literature and to health professionals’ daily practice, it is worth carrying out further studies to find comparative parameters and to determine the age group that mostly rejects vaccination, in order to produce more effective tools for the target public, as well as to optimize resources and increase patients’ adherence to vaccination.