Surveillance of the territory in health in primary care: the contribution of the Community Health Worker in the continuity of care

ABSTRACT This study aimed to identify weaknesses in the work process of the Community Health Workers (CHW) and their perception of importance given by them to the actions in territorial surveillance for the work of the health team, together with a process of awareness and training of the CHW on the subject. For this purpose, a data cross-referencing of two information systems (electronic medical record and family register) was carried out and a questionnaire was applied to the CHW, with subsequent educational process with these actors on the theme, based on the fragilities identified. The results show that the CHW are aware of the importance of their work on the subject studied, but that the specific assignments of the category were not fulfilled in their fullness, an observation mainly done in the cross-referencing data. The sensitization process seems to have helped them to identify weaknesses in their work process. It is thus perceived that the territorial surveillance seems to be present in the discourse of the CHW, but the daily practice shows weaknesses in their work process and communication with the rest of the team, aggravated by the existence of disconnected information systems.摘要 本研究旨在识别社区卫生工作者（Community Health Workers, CHW）工作流程中的短板，调研CHW对自身在卫生团队地域监测相关工作中所承担行动的重要性的认知，并针对该主题开展面向CHW的认知提升与培训工作。为此，本研究对电子病历（electronic medical record）与家庭登记系统（family register）两个信息系统开展数据交叉比对，并向CHW发放问卷；随后基于已识别的薄弱环节，针对该主题面向上述工作人员开展教育干预。研究结果显示，CHW已明晰自身在本研究主题相关工作中的重要性，但该岗位的具体职责并未得到全面落实，这一结论主要基于交叉比对数据得出。由此可见，CHW在工作表述中均提及地域监测工作，但日常实践中其工作流程及与团队其他成员的沟通仍存在短板，而信息系统互不联通的现状进一步加剧了这一问题。