Challenges in schistosomiasis control in Sergipe , Brazil : from 2013 to 2018

This study aimed to analyze the performance of the Schistosomiasis Epidemiological Surveillance System in Sergipe, Brazil. This study used a mixed methodology, with a quantitative approach and the application of semi-structured interviews, directed to professionals of Health Surveillance and Primary Care in seven regional health departments headquarters in Sergipe, as well as information obtained in Sistema de Informação do Programa de Controle da Esquistossomose (SISPCE), Sistema de Informação sobre Research, Society and Development, v. 9, n. 10, e3679108802, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i10.8802 2 Mortalidade (SIM) and Sistema de Informação de Agravos de Notificação (SINAN). Interviews were applied from March to October 2018 and secondary data obtained in the information systems corresponded to the period between 2013 and 2018, when structure and process indicators were compared with result indicators. The main critical point was the lack of implementation of the Schistosomiasis Control Program (PCE) in the entire endemic area, lack of interaction between Epidemiological Surveillance and Primary Care, deficiencies in the management and execution of field actions. Failures in the implantation in the PCE, in the structure and process of the Surveillance System, in addition to the need for greater integration between the professionals of the Epidemiological Surveillance and other health sectors, negatively influence the results of the PCE, and may have similar causes and results in the others endemics of the state.

1981, only Regional of Nossa Senhora da Glória had 100% of the component as indemnity municipalities.
The study scenario comprised all six municipalities that host regional health endemic for Schistosomiasis. For the primary data, they were obtained through interviews with managers, doctors and other patient care professionals. The interviews took place with the application of semi-structured questionnaires, from the second semester of 2017 from the first semester of 2018.
The questionnaires were prepared according to the triad precepts: structure, process and results, proposed by Donabedian (1990) (Donabedian, 1990) for health evaluation, which contained questions regarding some variables related to management and epidemiology.
During health and endemic agents' interviews, other municipalities in the endemic area participated in addition to the regional headquarters. Questionnaires were applied to Municipal Endemic Coordinators, Municipal ES Coordinators, doctors and nurses from the Family Health Program (PSF), endemic supervisors (field supervisors), community health agents and endemic agents. Other health professionals were also interviewed as part of the health surveillance process in Sergipe, totalizing one manager from each of the six endemic regional headquarter, 09 health professionals (including doctors and nurses) and 58 agents (between community health and endemic agents). Community health agents are those who carry out activities related to the PSF and endemic agents are responsible for performing functions with the teams that treat endemic diseases within the Municipal Epidemiological Surveillance.
The inclusion criteria of municipalities were: belonging to different regional health departments in the state; be the headquarters of the regional department or the one with the largest population within the regional health department; and belong to one of the endemic areas for Schistosomiasis.  (Demográfico, 2010).
To analyze the Schistosomiasis Surveillance System performance, regarding attributes related to quality (simplicity, flexibility, acceptability and stability), questionnaires were applied only to managers and coordinators who directly participated in the activities of Epidemiological Surveillance System in regional health centers and those responsible for Basic Health Units (BHU). Development, v. 9, n. 10, e3679108802, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i10.8802 8 To evaluate the structure, the sum of means found for the System subject and object was performed. The Subject was the interviewee's perception of human resources, material and activity flow in the Surveillance System (SS). In the information about the Process, attributes recommended by the CDC / USA were evaluated, as well as the guidelines suggested by the WHO, which were simplicity, acceptability, flexibility and stability (CDC -Center for Desease Control and Prevention, 2001).
General elements of structure, process and usefulness of the system were assessed by means of a score given to each evaluated attribute. Thus, the following values were assigned: 1) Subject: 0 to 3 (insufficient); 4 to 7 (little enough) and 8 to 11 (sufficient), with a total value of 11 points. 2) Object: 0 to 1 (insufficient), 2 to 4 (little enough) and 5 to 6 (sufficient).
Questionnaires were based on the models applied by Menezes, Carmo and Samico (2012) (Menezes et al., 2012) and three different models were used with specific questions for the interviewee's activity within the ES: Model 1 -Managers (secretaries, managers, coordinators and directors); Model 2 -Doctors, Nurses, Social Workers; and Model 3 -Community Health Agents, Endemic Agents, Laborers, Digitizers and other employees. stages: organization, transcription and tabulation. The content obtained in the interviews, by observation and discussion with the regional professionals and managers, was organized in stages: organization, transcription and tabulation.
Data obtained through the Information Systems and interviews were compiled in a 2010 Microsoft Office Excel Program. Nominal and ordinal qualitative variables were obtained through a uni-varied descriptive analysis, proceeding to an extracted data categorization, obtaining the respective frequencies and percentages of categorical variables.
For quantitative variables, data analysis was performed with the calculation of means and standard deviation.
The percentage of stratified patients corresponded to the sum of the infected population observed through active search (Schistosomiasis Control Program -SCP) and spontaneous demand (Primary Care -PC), divided by the total of treatments performed.
To calculate prevalence, the population registered through the AB was excluded due to the absence of a total number of those examined. Regarding structure, items percentages were calculated in accordance with the observed in each questionnaire domains. In all analyzes, missing values were disregarded for the statistical calculation. Computed scores had a maximum score equal to 100 and a minimum score equal to zero. Research, Society and Development, v. 9, n. 10, e3679108802, 2020 (CC BY 4.

Results
Schistosomiasis transmission from 2013 to 2018 was present in six of the regional health regions of the state, occurring mainly in the coastal area, except in the regional area of Nossa Senhora da Glória, for being harmless ( Figure 2). Research, Society and Development, v. 9, n. 10, e3679108802, 2020 (CC BY 4. The percentage of individuals treated in 2015 (81%) and 2017 (90%), respectively, was obtained by the ratio between the infected population and the total treatment performed in the year. The PCE was inactive in 18 of the 51 endemic municipalities, that is, they were municipalities that had not performed an active search for at least one year (Table 2). In these municipalities, patients came exclusively from Primary Care.
Research, Society and Development, v. 9, n. 10, e3679108802, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i10.8802  Regarding the number of deaths due to endemic diseases in Sergipe (dengue, Leishmaniasis, Chagas disease and Schistosomiasis), there was a predominance of Chagas disease and Schistosomiasis throughout the historical series ( Figure 4). During the studied period the mortality rate in Sergipe was 0.86/100,000 inhabitants (Brasil, 2014). In the questionnaires answers regarding structure, the assessment was considered to be insufficient (average 14.2), having as factors that most influenced the interviewees perception: lack of physical and personal organization, especially the turnover of endemic professionals and the lack of integration between the SCP, PC and other health, education and infrastructure sectors in the municipalities.
The elements (human and material resources) and object (population served) were considered insufficient, being reported on open questions: the lack of articulation among several sectors of municipal surveillance; the lack of integration between the teams of community health agents and endemic patients; poor visibility of the endemic disease, especially among managers; and accommodation of health professionals and the population in the face of endemic diseases that affect the cities studied (Table 3). Of the attributes analyzed, simplicity and flexibility were those with the lowest evaluation (Table 4). Simplicity referred to the structure in terms of ease in operation, which should be a simple operation system and flexibility to adapt, using strategies to detect cases, active or passive search (spontaneous demand). Acceptability, defined by the CDC (2001) as the willingness of individuals and organizations to participate in the surveillance system, and stability, as the actions feedback, was the best-rated attribute.
Coordinators, directors and managers in general had a previous level of management experience, but the average number of months in the job was less than one year. Although the answers indicate 100% of the implanted SCP, there was only information from the headquarters (Table 5).
Research, Society and Development, v. 9, n. 10, e3679108802, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i10.8802 Doctors and other health professionals such as nurses, social workers and veterinarians, reported that some of them were not hired for the Family Health Strategy (FHS) Program. Most of them did not receive information about endemic diseases, as there were no meetings for this purpose. The average number of months in the job, in general, was less than one year (Table 6). The consolidation of the answers given by endemics and / or health agents from the FHS showed that the majority had high school education and received training for the function they performed (Table 7). Epidemiological information were provided written and, in the interviews, was reported that they received most of the information during training.
Notifications should be carried out by typists trained for this purpose, within the surveillance sectors from the municipal departments. However, in the questionnaire applied to endemic diseases agents, the majority replied that they always made the notifications. They also reported that the population's participation in preventive measures was low. Source: Authors' source (2020).

Discussion
The Regarding ESS dynamics developed in Sergipe, Schistosomiasis surveillance was used as a reference due to the fact that the state has the highest prevalence for the disease in the country, according to the last National Survey concluded in 2018 (Katz, 2018).
In agreement with studies on Schistosomiasis distribution in Sergipe, the occurrence in the coastal strip (A. D. dos Santos, Santos, dos Santos, Barreto, & de Araújo, 2016;C. V. V Rollemberg et al., 2015) is observed especially in the most deprived areas of large cities or regional headquarters (de Melo et al., 2011).
In this study the high prevalence found, with an average of 7.5%, was very close to the data found in the National Survey of Schistosomiasis Mansoni and Geo-helminthiasis Prevalence. Among states with municipalities up to 500 thousand inhabitants, Sergipe had the highest prevalence (10.67%), followed by Pernambuco (3.77%) and Alagoas (3.35%), much above the 1% national average (Katz, 2018).  Saúde, 2014;Souza et al., 2007;Tranquillini et al., 2011).
Between 2016 and 2018, more than 20 municipalities did not report data to the Information Systems (SISPCE and / or SINAN). This hindered all analyzes necessary for epidemiological delimitation. This also reflects a negligence towards this parasitosis, demonstrated in the high number of deaths compared to that found in the other endemic diseases that affect Sergipe.
Through the questionnaires, an overview of the structure, process and results achieved from 2013 to 2018 was observed. The structure may have represented the major cause of the system problems, since it is the basis for all actions execution. This variable, among all the others, is the one with the easiest observation (Quinino, Costa, Aguiar, Wanderley, & Research, Society and Development, v. 9, n. 10, e3679108802, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i10.8802 22 Barbosa, 2009). The process, as the sum of all actions (diagnosis, treatment, prevention and health education), is considered by Donabedian (1990) (Donabedian, 1990)  In all interviews and direct observations, it was clear that the population was not included in the surveillance process of endemic diseases that affect municipalities. This aspect is somewhat different with regard to Dengue, in which there is a greater mobilization involving the population, although the number of deaths from this disease is lower when compared to Schistosomiasis. This may possibly occur with Dengue due to the imminent risk of an epidemic and rapid evolution to death (Barata, 2013). In endemics schistosomiasis, Leishmaniasis and Chagas disease, there is a general lack of motivation for the inclusion of the population in the process, even though the human being factor is the main component for prevention.
Another striking point observed was the lack of integration of the Family Health Program in Primary Care with the Endemic Teams. The reduced number of human resources aimed at controlling endemic diseases, the lack of material resources such as transportation, laboratories and materials, combined with the manager's lack of effort to integrate health professionals in the performance of activities, contributes to little effectiveness and efficiency in the Control Programs activities. The lack of integration between the sectors hinders the flow of information, damaging the feedback due to the constant inconsistencies such as lack of updated data, delay in obtaining resources, reduction of human resources, especially when there is a need for quick responses in some situations, in addition to information duplication in the systems. Another factor that can negatively interfere in the surveillance actions is the high turnover of professionals (Gonçalves et al., 2014), as the delay in adaptation generates a lack of feedback from the system, failure of data analysis, lack of epidemiological situation disclosure, lack of follow-up patient and lack of actions continuity (Vieira & Calvo, 2011).
An average of 31 (61%) endemic municipalities carrying out SCP activities annually and 18 (35%) without conducting an active search was another factor that possibly justified the disease maintenance and the failure to control it, demonstrating that decentralization has not been showing results satisfactory with regard to endemic diseases in Sergipe. This can be attributed to the lack of material and human resources, as observed, also, in the situation of Chagas' disease without the inclusion of work in actions to control endemic diseases in the municipalities. All of these factors may led to little improvement in control and surveillance actions for the population . Actions are carried out without planning, especially with Schistosomiasis, as the municipalities work within their limitations, reproducing actions year after year and underestimating the data produced that could better guide control and surveillance activities.
When comparatively analyzing the questionnaires and data obtained in the information systems, it was identified that both managers and other professionals interviewed perceive the dynamics of surveillance as: a supremacy of the medical part, centered almost exclusively in the patient and, in the foreground, in communicable endemic or rapid progression diseases such as dengue; and health promotion centered on treatment, drawing attention to the large number of patients coming from Primary Care as a result of a deficient SCP implantation in endemic areas. These factors were also observed by Santos et al. (2012) (S. S. B. da S. Santos et al., 2012 in an evaluation on the decentralized management capacity in the state of Bahia. In the Schistosomiasis transmission network, which consists of a sick patientenvironment-healthy patient, the treatment has been the most prominent aspect to receive more attention. All other factors are neglected, either due to insufficient human and material resources or to the need for interaction between other areas, mainly infrastructure and education (Barata, 2013). It was also noted that there was little or no interest in the integration between administrative sectors through municipal managers.
In the structure analysis of the six studied regions, half of them had little enough structure and the other half was considered structurally adequate to develop Schistosomiasis surveillance activities. This factor may have been influenced by the public interviewed, since the answers coming from perception, professional training and qualification are of fundamental importance (Almeida, 1998). However, in the subjective questions, it was observed that managers' actions and responses were often softened due to their position fragility, limiting the final process to treatment and underestimating the data produced, even though it was a fundamental source for a good operational quality of endemic control actions.
Regarding the attributes, simplicity and flexibility were the best scored, with both leading to new strategies. System attributes are also subject to perception bias due to professionals training, time in office, relationships between technicians and managers.
Underreporting and the large number of municipalities that did not carry out an active search are reflective of the high managers' turnover and little integration among professionals.
However, flexibility was the most scored attribute though, according to Aquino (2006) (Aquino, 2006), and flexibility is impaired when there is not a good staff adaptation and integration with the basic network, going against the results of the present study. The little knowledge about SCP scope, the lack of control actions planning on the municipal agenda and low priority given to Schistosomiasis may explain the high prevalence and deaths maintenance in the state. The results found showed that, even with the municipalization of endemic control, periodic evaluations of these actions are necessary in order to detect weaknesses in the System, thus finding new strategies for endemic control and surveillance approaches, enabling to achieve a satisfactory result.
According to the SES/SE Endemic Nucleus, an endemic assessment process in Sergipe started in 2016, when this nucleus prepared an assessment questionnaire, in an attempt to obtain more efficient and quick information, to facilitate the analysis of epidemiological situation of the municipalities. However, only the fields related to Dengue were properly filled out and used.
Although health data and indicators are constantly used, analyzed and disseminated, both by state department and research institutions (A. D. dos Silva et al., 2015), the information obtained has little guidance or is used for the qualification of health surveillance services and actions.

Conclusion
The evaluation of a Health System is complex and must occur on an ongoing basis, becoming a work routine with the participation of all those involved, initially maintaining a structured and functional database. This study indicated that, even in municipalities and regional health in Sergipe, in which data and indicators were analyzed and disseminated, the information obtained had little guidance or was used in surveillance actions or in services qualification.
PCE, as well as other programs to control endemic diseases, compose a small portion in relation to the range of Surveillance System attributions, and an environment global view, regarding health aspects, is essential. This study suggests the adoption of models containing information from municipality routine or locality.