3.2 Qualitative Results
Based on the analysis of the interview material, eight categories of description were created with the coding process, which are described below.
Category 1 – Process of data collection is perceived as technically simple, but still challenging in the overall process.
Each municipality in Brazil has autonomy to decide on the process of collecting and processing data for the Sisvan system. Some municipalities are organized with a specific coordination for food and nutritional surveillance while others are not. This, as well as the existence of local health information systems influences on the way data is collected. There was mention of lack of uniformity within the same municipality (given the organization and structure of each health unit), as well as low data collection and general challenges regarding the data collection process. At the same time, the system is described as intuitive and simple to use, with instant return of data.
“At the moment I pass it on to the system, there’s a first analysis, which I will see if there’s any serious disparity. Then since it’s online this data goes automatically to the ministry of health. So if today I enter data and tomorrow I want a report on these data, I have it. It’s instantaneous.” (6)
On the other hand, challenges related to data collection, low coverage, lack of interest from professionals or even the decentralization of the systems are mentioned as having an effect on the results, which shows there is still room for improvement.
“Each municipality decides for themselves, so each one does it one way, fills it out as they want it. There are towns that work really well and others don’t.” (3)
Besides the nutritional status indicators (measurements of height and weight), the Sisvan accompanies food consumption, which is a form with a 24-hour recall, with yes and no questions regarding the food habits for children less than 6 months, 6 to 23 months and children over 2 years old, teenagers, adults, pregnant women and elderly. The food consumption form has been described as easy, although seen as a challenge among the participants, presenting very low coverage and a burden to professionals to fill out.
“The questionnaire on nutritional intake, which is part of the Sisvan, needs to be used more. There still is a resistance to use the questionnaire on nutritional intake because it requires more time to do those questions.” (7)
Category 2 – Sisvan as a guide for programs and policies requires a cross-sectional approach and identification of problematic issues.
It is clear that the system is characterized as a tool to visualize and monitor the current status of the population attended by the Primary Health care units. The perception of the Sisvan’s objective to serve as a guide for policy making is evident, although more articulation between the different instances (municipal, state and federal) could aid the municipalities to create or adapt more local programs with the generated data.
“I think it provides information for municipalities, state, and national. The transformation, our work begins here in our town, at the primary care. So I think each sector is responsible.” (2)
Data generated by the system are seen as an important asset both locally as beyond the municipality and the health sector. Even if they presented challenges in terms of transposing this data into programs and policies, it is clear that there’s a concern in generating results with the information provided by the Sisvan, as well as collecting precise data which can be used by third parties. The challenge is the lack of time or priority given to the local usage of the collected data. Partnerships with the academic sector, for example, is a possibility for these municipalities to be able to reflect and analyze the results. A third-party with more resources can assist the health units and departments in this matter and would fill the gap some of them perceive of this lack of local analysis and usage of the results.
“With the University for example, we started doing inter-sectorial work, and we ask as a counterpart, this study of these data the town is producing. So we have a better view of what’s going on.” (2)
Category 3 – Perceived local ownership of data influenced by decentralization of health system.
The Sisvan is regarded by the participants as key for municipalities to monitor the populations’ nutritional status and articulate to existing or new programs and public health practices. There is a common view of the system as a local tool for health unit managers to diagnose and have the necessary information for priority settings and interventions. It was possible to detect in the interviews a direct link made from Sisvan generated data to individual accompaniments, which is an indication that local ownership of data does takes place. By local ownership here it is meant the collective process in which local actors determine and influence in the production of health agendas based on produced data [24, 25].
“I see as a main characteristic or function of the system to allow for anyone to look at this nutritional situation diagnosis to plan actions related to and focused on health issues related to that specific unit or municipality.” (3)
“it was based on this analysis that we were able to justify the implementation of a program to treat obesity. Because it demanded resources, inter-sectorial work, we involved different departments.” (2)
Local management can benefit from analyzing their own collected data, although it does not appear to happen frequently and local analysis depends on how each individual health unit or even the municipality is organized. The process of actively using this data locally still has room for improvement, since it is not frequent for individual health units or managers to monitor their local needs.
“So the health teams many times do not have time to look at this data because we know how demanding is the health teams’ routine.” (7)
Participants describe the system as giving the possibility of a local diagnosis for a specific region or health unit but this is counterbalanced with the difficulties found in the day to day operations of the primary health care centers, which are burdened with other responsibilities that overshadow the nutritional surveillance development.
“The professionals they screen the materials, the documents to fill out. So they fill out those they believe are most important, more demanded by the management staff, and they leave out the ones that are not so demanded, in part, or think it’s less interesting.” (5)
The local ownership of the generated data is also related to the effects of the decentralized health care setting, in which each municipality is organized in a different way and has the ability to plan and demand information according to the way the health departments are structured.
Category 4 – Sisvan is an embedded part of the National Health Information System
Participants perceived a greater relationship between the nutritional surveillance to the other health information systems present in the primary health care setting. There is an ongoing interoperability, which allows transfer of information between the information systems available in the basic health units, where the data is collected.
“...the path I think is to increasingly have an integration of data which I think it’s essential, thinking also on the local manager, because it avoids double work, and gives a return both general and specific.”(8)
Even though some municipalities use other information systems within the health units that are not the national Sisab platform, they integrate the systems so that all collected data migrates to the e-sus system (which is the national information system within the Primary Care, as an attempt to digitalize and qualify the work process. Municipalities can use their own system of information, given data are later entered into the main database). This, on the other hand, brings some challenges as well and potential “data loss”.
Eventually, the Sisvan appears as a system that can aggregate data from all other information systems, which can bring benefits in terms of data analysis, if used in its potential.
“Today the Sisvan is really for a management of all this information from various systems or these accompaniments that take place in the basic health units in the municipalities”. (9)
Category 5 – Existing integration into the Primary Health Care and Family Health Strategy is evident, but at the same time reveals challenges and difficulties of daily routine.
The Primary health care system in Brazil has advanced greatly in the last years, especially with the expansion of the Family Health Strategy, which makes the bridge between the population and the health units, and the cash transfer social programs . The Family Health Strategy (FHS) works in teams, composed of a minimum of one doctor, one nurse, one auxiliary nurse and Community Health Agents. These teams were expanded in the year 2000  with a new structure to include a multidisciplinary team with dentists, nutritionists, psychologists, social workers and others – which compose the Nucleos de Apoio à Saude da Familia – NASF (Family Health Support Nucleus). These nucleus are responsible for several health units and have a rotation schedule, depending on the municipality, the population size and local organization. The Sisvan system appeared as a routine process within the primary health care units and in some cases, the NASF teams were pointed as being the ones responsible for the data collection, given a nutritionist is part of the groups.
“It’s done in the basic health unit, so every user that comes to the health unit in the consultation, they do the anthropometric measurement and food consumption through the Sisvan-web” (5)
The PSE Program (Programa Saúde na Escola or School Health program), established in 2007 also appears to be articulated to the Sisvan system, for measuring teenagers and young children. This integration to the Primary health care system, at the same time that it characterizes the system as routine, also demonstrates challenges which are common to all information systems and services, such as a work overload for the health professionals and the impossibility of using the Sisvan to all its potential.
“No one wants to feed any system, especially one such as this one, that doesn’t result in a gratification for the employee because then they don’t want it” (1)
“You end up piling up functions, so you don't stay directed towards the Sisvan. So for example, I’m a nurse, so I’m working with the Sisvan, the Bolsa, child formulas, obesity treatment, we aggregate activities and responsibilities”. (2)
Category 6 – Intertwining relationship between the Sisvan and Bolsa Familia.
The Family Allowance program and the Sisvan appear to be mistaken for each other, but at the same time, are regarded as two different entities that dialogue only at a system level. The Sisvan’s first digital version in 2003, Sisvan-web, was developed based on an existing structure for the cash transfer program Bolsa Alimentação (Food Allowance), a precursor of the Family Allowance (Bolsa Família) program. So when the Family Allowance was launched in 2004 and the nutritional status evaluation was a conditioning factor in health prevention to receive the benefit, the Sisvan was chosen as the management tool to gather this data . The fact that a high percentage of the coverage of the Sisvan today is from data coming from the Bolsa Familia program is still due to a priority given to the measurement of the population receiving the benefits. This will have a repercussion as well on the representativeness of the generated data.
“So it ends up being that priority group which has information on food and nutritional surveillance, children, pregnant women and the beneficiaries from the Bolsa Familia, which is the conditionality of the benefit.” (7)
Another factor which appears to influence this preference to the Bolsa Familia population is the immediate and palpable result of this process.
“When they do the Bolsa Familia [measurement], they finish doing that and they already have an answer, because you fill it out, the family receives money. So they see a physical answer for that work they did. The Sisvan, its answer is not tangible, that’s why they consider it less important.” (6)
Category 7 – Role of the State and Ministry levels of supervision and guidance has shortcomings.
As the data collection takes place within the local municipal primary care setting, the States and Federal Ministry of Health play a guiding and supporting role in the process of collection and data analysis.
“In the process of collecting data, the role [of the ministry] is to induce. To show look, professionals, managers, we established a new tool, provided a new resource within the system, use it, doing the trainings, the disclosure notes, mechanisms of promotion to these professionals, and also solving doubts related to the use of the system.” (9)
The State entities work as a “buffer” zone between the municipalities and the federal coordination of the system. State authorities also have a role of guiding and supervising the municipal data collection, although in a more in-person manner, emphasizing the importance of local authorities taking ownership of the information to guide policies and programs on a local level. However, this function played by the higher instances in the system’s process also has flaws, as lack of guidance and proper training.
“There’s no guideline, within the ministry of health, or the health departments, of who should fill this out. It’s a system that is thrown out there and do whatever you want with it.” (3)
Category 9 – First stage of the Covid-19 pandemic has direct effect on system’s coverage and role.
All participants mentioned direct effects of the 2020 Covid-19 pandemic in their work, especially in terms of the data collection taking place within the primary health care setting. Since the measurements for the Sisvan are done within the health units and the population is not attending routine care, this will have a direct repercussion in the coverage. However, there has been a decision from the Ministry of Health to suspend the measurements for the first part of the year, so families are not penalized (Ministry Social Development, 2020) with the lack of cash transfer (in the case of the Family Allowance measures).
“Data will decrease, now in 2020 we’ll have much less data, both from Bolsa Familia as the Sisvan, because people are not going to the health units.” (3)
“One of the actions in our town to fight the virus was the suspension of routine consultation. We kept the prenatal visits, high blood pressure and diabetic patients, but the routine consultations we did this was all suspended. Measurements for the Bolsa, all this was cancelled, it was all was affected. We no longer do health promotion.” (2)
On the other hand, the role of the nutritional surveillance system is seen as of great importance once the pandemic in Brazil diminishes, in order to accompany those families that have been economically affected during the crisis.
“there will be an impact on the anthropometric data and the Sisvan will be able to map this. In a later period, in children we’ll probably see an increase in terms of low weight, but it’s a way to monitor this and identify priority groups for intervention.” (8)
From the analysis of these categories, two great “forms of thought”  were derived, which describe the way the interviewees interpret the nutritional surveillance system. The two themes which constitute the experiential description of the phenomenon are:
Sisvan is perceived as a path, or process, to generate data which can become action that transforms health
The surveillance system was ultimately characterized as a “course of action”. And this course can generate direct and positive results in terms of public health care to both individuals and collective entities or it can be just a routine data collection, which serves to fill a larger system of data that is used for diagnosis. In both cases, the Sisvan is seen as a “path”, not an end in itself, which is a means to improve nutrition and health conditions. However, as a process, the system also has room for improvement, since it is in constant use and analysis. Challenges were presented in terms of data usage, analysis and the structuring and functioning of the system.
Sisvan is part of a greater structure of care, that goes beyond nutrition
Once the system is integrated within the Primary health care setting, within the health information system, it acquires relations to other programs, strategies and actors which define its role of not only a monitoring tool for the determining factors of nutritional status and habits of the population but also as one more fiber of the national health care fabric. This integration into a greater structure also imposes a demand for more articulation between several instances to generate results in the health setting.
3.3 Triangulation of Results
This part of the analysis was focused on determining key themes from both methods which could approached and tested for convergence or dissonance, according to the triangulation protocol developed by Farmer et al., 2006. The main topics that were found to be present in both methods (quantitative and qualitative) are: “low coverage of data”; “high prevalence of data from the Bolsa Familia program”; “uniform data collection in municipalities”; “system as part of the primary care with capillarity in all regions”. These were assessed based on their convergence, agreement or dissonance  and the major results of this process is described in Table 3, below:
– Summary of Triangulation of Results
Low Coverage of data
System present in all Brazilian states, but 44% of the states had coverage of less than 30% in 2018.
Coverage addressed by interviewees as a flaw and influencing factor in the diagnosis of results.
A partial agreement was determined between the two analysis. This is characterized by the fact that even though low coverage of data was detected in both methods, being an influencing factor in the diagnosis of results, in the qualitative study, low coverage was also stressed as being a characteristic of the food consumption part of the Sisvan, which was not contemplated in the quantitative analysis of this study.
High prevalence of data from the Family Allowance program
Data originating from the Bolsa Familia system constituted 91,8% of the data in 2014 and 74,6% in 2018.
The Family Allowance program appeared to be identified as a different system but with interconnecting relationship, especially at the data collecting process.
There was agreement between both analysis regarding this theme. It is clear that the Family Allowance program plays an important part as a booster for the high accompaniment of children within the system, but this could have an influence on the type of generated data (convenient sampling).
System as part of the primary care with capillarity in all regions
As of 2015, only one region of the country had lack of data in the system. In 2018, all but one of the 5.570 municipalities of the country had entered anthropometric data for children.
It is clear that data collection takes place within the PHC system and that the municipalities have engendered the data collection process within the routine of the health units.
A partial agreement was found between the two methods regarding this theme. Data collection is routine among municipalities, generating nation-wide data but an in-depth analysis of the quantitative per state would demonstrate in more details the relationship between the coverage of the PHC for example and the Sisvan. For there isn’t a uniform data collection process within each state, which would need to be further investigated to find converging points and the influencing factors within the PHC system.