Presentation: Actions for the prevention and control of type 2 diabetes (T2DM) are priorities within primary health care, from the dispensing of specific medications to non-pharmacological actions such as physical activity and nutrition that are part of the line of care. Thus, the ideal treatment for T2DM is to associate pharmacological intervention with an effective healthy lifestyle change, especially with dietary education and the practice of physical activity. The inclusion of these prevention and management actions (PMA) in primary health care is essential for improving the care of users in the Unified Health System (SUS). The study aimed to describe prevention and management actions and their components in primary health care settings in the State of Amazon, Brazil.

Development: Data were collected as part of the Study of Health in Primary Care of the Amazon Population (SAPPA). SAPPA is a cross-sectional study carried out in 6 cities from Amazon, Brazil. The ethical approval (registration: 4.318.325) was granted by the Research Ethics Committee with humans of the Amazon Federal University. All participants signed consent forms. UBS in each municipality were chosen using a random selection tool. Managers were invited to complete a questionnaire containing demographic data and information regarding T2DM prevention and management. Managers were asked to identify PMA currently being used in their specific UBS unit. The questions focused on planning and implementation phases from each action delivered to diabetic users. To evaluate the development and implementation of prevention or management of T2DM was used the RE-AIM method (Reach, Effectiveness, Adoption, Implementation and Maintenance). Reach: We assessed reach using data from the target population and the participation rate of the population. We analyzed separately the data on kids, people aged 18 to 60, and people aged 60 or older. To calculate the participation rate, the denominator was the number of users registered at the specific UBS, and the numerator was the number of participants. Additionally, for each action, the managers were asked about inclusion criteria and strategies used to publicize each action. Efficacy/Effectiveness: Questions from effectiveness included the main aim from each action, the use of strategies to measure results, the frequency of evaluation, attendance control of participants and fidelity checks, and if they tracked reasons for withdrawal. Adoption: The questions involved a description of who delivered the program and who managed them.  Implementation: We asked managers to describe the core actions content, provide information on the duration of each session, and frequency of sessions, where the actions/program were delivered and the provenance of the resources. Maintenance: The maintenance was measured using the time of implementation of actions, and if the action was still being offered.  Descriptive statistics were used to describe the characteristics of participants. Categorical variables were summarized using counts and percentages; quantitative variables were summarized using means and standard deviations or medians and inter-quartile ranges, as appropriate.

Results: Between August 2020 and June 2021, 18 managers from primary care units took part in this research from 6 rural Amazon cities. Managers were predominantly women (n=14), mean age 39±8,1 year old and nurses (n=11; 57,9%). Other professionals were administrator (n=3), physiotherapist (n=1), social workers (n=2), biological science (n=1), literature degree (n=1), and 73,7% had a post-graduate degree. The length of professional experience varied between 1 until 15 years (range more prevalent 3-6 years). And 58% were in office for less than a year.  Seventeen actions were identified during study collections. Only one UBS informed there was more than one action/program (2 action/program) currently occurring and two of them there were no diabetes PMA. Managers described 6 prevention actions, while 11 were focused on prevention and management of T2DM. To best reflect the aims of the study, the results are presented following the RE-AIM framework. Reach: A total of 672 users were enrolled in some PMA, representing 67,5% of the total diabetic population registered in the UBS. Children's participation represented 2,7% of the total sample. Considering the number of children registered in the UBS, on average, 25% were enrolled in 3 different actions. Adults were included in 15 actions, representing 52% of the total sample, and the participation rate was 32,7%. People aged 60 or older represented 45% of the participants and the participation rate was 27,5%. Related to recruitment, 9 managers reported the existence of some criteria as being diabetic, presence of hypertension, obesity, or being older.  Recruitment strategies were predominantly health professional indication (76,5%) and person to person (88,2%). Effectiveness: The principal verbs used by managers to describe the primary aim of actions were “guide” and “prevent”. Effectiveness for diabetes PMA outcomes was measured in 76,5% by implementation team feedback, 35,3% user feedback, 53% UBS unit team feedback, 41,2% capillary blood glucose measurement, 29,4% HbA1c and/or fasting blood glucose measurements and occurred weekly (41,2%) and monthly (41,2%), predominantly. Among prevention actions, the main mechanisms for evaluation were implementation team, user, and UBS unit team feedbacks. 76,5% of the actions had frequency controlling of participants during the development, but only 41,1% measured fidelity checks and of these, 57% investigated the reasons for withdrawing. Adoption: a total of 310 health professionals participated in diabetes PMA in primary health care settings in the State of Amazon from planning to implementation, including 31 nurses, 39 health technicians, 27 physicians, 174 community health agents, 4 physical educational professionals, 3 physiotherapists, 3 nutritionists, and 29 (others) with 100% of the efforts coordinated by nurses.  Implementation: all (100%) actions used lectures as a method of knowledge transference approach. Furthermore, 58,8% used individual user guidance, and 47% used participant group discussions.  Related to targets from diabetes PMA, 10 (58,8%) actions included physical activity and nutritional behaviors. Only one mentioned weight loss orientation and two actions targeted medication adherence. Blood measures were mentioned in 23,5%. There were no practical activities including effective lifestyle changes, with healthy nutrition and physical exercise. The actions occurred weekly (n=6; 35,3%), monthly (n=6; 35,3%) or fortnightly (n=3; 17,7%), lasting from 30 (n=5) to 60 min (n=6). Six actions didn’t have a fixed duration occurrence. The vast majority of meetings took place at the UBS (n=12), and only 5 actions involved community spaces such as (gym, church, association, school). Ten (58,8%) actions were government-supported and 5 (29,4%) required that all material resources come from each participant. One action didn’t have any funding.  Maintenance: eight (47%) actions occurred for a period longer than 4 years and 3 (17,6%) from 1 to 4 years. Five managers didn’t answer or didn´t know this information. One action was no longer offered during the collection period.

Final considerations: This study identified prevention and management actions developed in primary health care. The actions methodology was based on lectures, majority, and with a greater focus on physical activity and nutrition orientation. However, there were no practical activities included as a real strategy to induce lifestyle changes and measures of effectiveness were user, implementation team, and UBS team feedback.

The lack of specialized professional training added to the high turnover of the team, and the absence of a multidisciplinary team, in addition to the difficulty of incorporating specific care for chronic diseases, negatively impact the assistance received by users in primary care. Despite that, primary health care has an important role in chronic diseases care in the Amazon State.