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MODELING OF FOOD AND NUTRITION SURVEILLANCE | 109

Rev. Nutr., Campinas, 30(1):109-126, jan./fev., 2017 Revista de Nutrição

https://doi.org/10.1590/1678-98652017000100011

1 Fundação Oswaldo Cruz, Escola Nacional de Saúde Pública, Programa de Pós-Graduação em Saúde Pública. R. LeopoldoBulhões, 1480, sala 613, 21041-210, Manguinhos, Rio de Janeiro, RJ, Brasil. Correspondência para/Correspondence to: SASVITORINO. E-mail: <[email protected]>.

ORIGINAL | ORIGINAL

Modeling of Food and NutritionSurveillance in PrimaryHealth Care

Modelização da Vigilância Alimentar

e Nutricional na Atenção

Primária em Saúde

Santuzza Arreguy Silva VITORINO1

Marly Marques da CRUZ1

Denise Cavalcante de BARROS1

A B S T R A C T

Objective

To describe the modeling stages of food and nutrition surveillance in the Primary Health Care of the UnifiedHealth Care System, considering its activities, objectives, and goals.

Methods

Document analysis and semi-structured interviews were used for identifying the components, describe theintervention, and identify potential assessment users.

Results

The results include identification of the objectives and goals of the intervention, the required inputs, activities,and expected effects. The intervention was then modeled based on these data. The use of the theoretical logicmodel optimizes times, resources, definition of the indicators that require monitoring, and the aspects thatrequire assessment, identifying more clearly the contribution of the intervention to the results.

Conclusion

Modeling enabled the description of food and nutrition surveillance based on its components and may guidethe development of viable plans to monitor food and nutrition surveillance actions so that modeling can beestablished as a local intersectoral planning instrument.

Keywords: Health planning. Models theoretical. Monitoring. Nutritional surveillance. Primary healthcare.

110 | SAS VITORINO et al.

Rev. Nutr., Campinas, 30(1):109-126, jan./fev., 2017Revista de Nutrição

https://doi.org/10.1590/1678-98652017000100011

R E S U M O

Objetivo

Descrever as etapas de modelização da vigilância alimentar e nutricional na Atenção Primária em Saúde noSistema Único de Saúde, considerando suas atividades, objetivos e metas.

Métodos

Foram utilizadas as técnicas de análise documental e entrevistas semi-estruturadas para identificar oscomponentes, descrever a intervenção e identificar os potenciais usuários da avaliação.

Resultados

Foram identificados os objetivos e metas da intervenção, os insumos necessários, as atividades e os efeitosesperados. A partir dessas informações, a intervenção foi modelizada. A utilização do modelo lógico teóricootimiza tempo, recursos, definição de indicadores a serem monitorados e aspectos a serem avaliados,identificando com mais clareza qual a contribuição da intervenção para o alcance dos resultados.

Conclusão

A modelização possibilitou descrever a vigilância alimentar e nutricional a partir de seus componentes e poderáorientar a elaboração de planos viáveis de monitoramento das ações da vigilância alimentar e nutricional parasua efetivação como um instrumento de planejamento intersetorial em nível local.

Palavras-chave: Planejamento em saúde. Modelos teóricos. Monitoramento. Vigilância alimentar e nutricional.Atenção primária à saúde.

I N T R O D U C T I O N

Given the everlasting and intense socialand regional inequalities in Brazil, many publicpolicies of different sectors and governmentalspheres target social inclusion. Historically,Brazilian social policies aimed at individuals andfamilies, in a focused and assistive manner,intervening little on structural aspects and

effectively ensuring social rights by universalpolicies. Moreover, management instances lackconsistent information to support their structuring,

implementation, and development processes1,2.

Despite the significant advances achievedby the universalization and decentralization of the

Sistema Único de Saúde (SUS, Unified Health CareSystem) in 1990, some interventions still failbecause consistent information to support

decision making is scarce3,4.

The effective implementation of thesanitary model of health surveillance, whichrecommends evidence-based planning andmanagement to solve the most common andimportant health problems in population groups,faces numerous challenges. These problems,

identified in the routine of local health services,should feed the database of the National HealthSurveillance Systems, which contribute toconsolidate SUS administrative decentralization5,6.

In this context, food and nutritionsurveillance stands out as one of the guidelinesof the Política Nacional de Alimentação e Nutrição(PNAN, National Food and Nutrition Policy), animportant instrument for monitoring andassessing social policies, especially those relatedto the Human Right to Adequate Food, Food andNutrition Security (FNS), and health sector policies,such as the Política Nacional de Atenção Básica(National Primary Health Care Policy) and thePolítica Nacional de Promoção da Saúde (NationalHealth Promotion Policy)7-10.

The food and nutrition surveillanceconfiguration adopted by Brazil was similar to thatadopted by other developing countries, where the

monitoring of the nutritional status of groups ofhigher biological (mother-child dyad) and social(the poor) vulnerability was prioritized in

detriment of the monitoring of economicindicators of food intake, production, and supplyfor the areas of agriculture and economy11.



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By monitoring the population’s food intakeand nutritional status to provide “continuous dataabout the food and nutrition conditions and its

determinants”9 food and nutrition surveillanceaims to provide data to help the decision makingof the individuals responsible for creating policies,

planning, and managing programs that aim toimprove the population’s food intake patternsand nutritional status7-10. Timely, quality, and

representative monitoring of the population’s foodand nutrition profile would allow identifying thescope of these policies to improve their execution,

establish courses of action, and provide anaccount, to the society, of the huge resourcesinvested towards social participation and

accountability6-13.

Food and nutrition surveillance wasoperationalized in SUS Primary Health Care (PHC)through the routine activities of the Family Health

Strategy. It should cover all the population treatedat this level of care, which includes all age groups,from pregnancy to senility7-9. The information

about individuals’ eating behavior and nutritionstatus should feed the electronic database of theSistema de Vigilância Alimentar e Nutricional(Sisvan, Food and Nutrition Surveillance System),consisting of one nutritional and one foodsurveillance subsystems, whose expansion and

optimization were defined as priorities by PNAN7-

10,13,14.

From its implementation, Sisvan haspresented problems that hinder itsoperationalization and use, that is, its ability toprovide quality and timely information for thecreation of effective public policies. The mostvisible problems regard structural aspects, suchas inappropriate human and material resources:few professionals and high turnover, inappropriateprofessional qualification to obtain reliable data,and inadequate number of anthropometric,information technology, and Internet devices13,15-19.Consequently, Sisvan has low populationcoverage, being limited to mother-child dyads and

beneficiaries of social programs13,20-22 .

The need to expand food and nutritionsurveillance coverage and improve the quality ofthe generated data reinforce the importance ofinstitutionalizing assessment and monitoring asessential stages of public policies’ cycle and justifystudies that assess the different stages of anintervention4,6.

However, it is only possible to choose astage to assess after modeling the intervention,which is the first stage of a theory-basedassessment study23, since the approaches andmethods used for each assessment will dependon the complexity of the intervention, thequestions that the study aims to answer, and thematuration stage of the intervention24.

The modeling of an intervention attemptsto briefly and schematically describe how a

complex system of actions intends to reach itsobjectives. For this purpose, it exposes the linksbetween the expected effects of an intervention

and its relationship with the employed resourcesand activities, thereby guiding the assessment andmonitoring process in any intervention phase,

from planning to result achievement, passingthrough the implementation process24.

Given the aforementioned information,this article aims to describe the food and nutrition

surveillance modeling in PHC by creatingTheoretical Logic Models (TLM) that expose therelationships of causality between the structure,processes, and results expected by the regulatoryinstruments defined at the federal level to producetimely and quality information continuously forintersectoral decision making in the health sectorfrom the FNS perspective3,4,6,24-26.

M E T H O D S

Description of the objectives and premisesof the intervention is one of the first stages of atheory-based assessment study23, and it is usuallypresented in the form of logic models, which canbe of three types: causal, theoretical, andoperational24,26,27.



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The causal logic model describes thecauses of the problem on which the interventionintends to act. The TLM tries to analyze theplausibility of the relationships of causalitybetween structure, processes, and results, aimingto reach the intervention objectives, establishedin its regulatory and organizational instruments.It also allows analyzing the plausibility of theintervention’s strategy and logic. Finally, theoperational logic model tries to establish how theTLM is implemented at the local level, consideringthe particularities of each context. Thus, it is aTLM development based on its validation indifferent contexts24,23.

This study describes two TLM. The first,food and nutrition actions in PHC, and as itsdevelopment, a TLM proposal of food andnutrition surveillance, to deepen the discussionabout the processes conducted in the PHC contextto obtain the population’s food and nutritionaldiagnosis.

Food and nutrition surveillance wasmodeled in three stages: 1) identification anddescription of the official documents and literatureavailable about the intervention; 2) descriptionand delimitation of the intervention, its activities,target population, objectives, and goals; and 3)identification of the assessment users and otherpotential stakeholders.

Identification and description of officialdocuments and the literature available about theintervention was based on an extensive literaturereview, systematically searching the BibliotecaVirtual em Saúde (Bireme, Virtual Health Library),which includes the databases Medical LiteratureAnalysis and Retrieval System Online (MedLine),Literatura Latino-Americana e do Caribe emCiências da Saúde (Lilacs, Latin American andCaribbean Literature on Health Sciences) andScientific Electronic Library Online (SciELO). Thefollowing English and Portuguese descriptors wereused: “Segurança Alimentar e Nutricional” (Foodand Nutrition Security), “Vigilância Nutricional”(Nutritional Surveillance), “Vigilância Alimentar”(Food Surveillance), “Atenção Primária à Saúde/

Atenção Básica” (Primary Health Care/PrimaryCare), “Sistema de Informação” (InformationSystem), “Planejamento em Saúde” (HealthPlanning), “Programas e Políticas de Nutrição eAlimentação” (Food and Nutrition Programs andPolicies).

The search, conducted in June 2014,returned 447 publications, of which 160 werearticles, 102 were official documents, 39 weretheses, and 146 were other types of documents,such as congress annals, monographies, andreports. Based on their relationship with thesubject, 46 articles, 61 official documents of theBrazilian government, and 8 theses were selected.Many publications appear in more than onesearch, so they were considered only once. Officialdocuments from other countries were notincluded.

The concept of intervention and the itemsthat compose the TLM guided the constructionof content analysis categories for documentanalysis28, from which food and nutritionsurveillance legislation and regulatory publications,listed chronologically in Chart 1, were analyzed.References of the selected documents were alsoconsulted, as well as interministerial decrees, inorder to identify intersectoral articulations witheducation, agriculture, food and nutrition security,and social assistance. The food and nutritionsurveillance goals were described in Chart 1,which contain the National Health Plans, offeringelements related to the political and organizationalcontext of food and nutrition surveillance inBrazil.

Key informants were interviewed todescribe and delimit the intervention, its activities,target population, objectives, and goals,identifying the users of a probable assessmentand other potential stakeholders; to analyzedocuments; and to review the literature.

This stage was conducted by the sameresearch group in another study from the firstsemester of 2012, which assessed the degree ofSisvan web implementation in Minas Gerais(CAAE nº 0032.0.238.000-11) using yet



https://doi.org/10.1590/1678-98652017000100011

Chart 1. Legal milestones and regulations of the Ministry of Health for Food and Nutrition Surveillance.

1 of 3

1990

1997

1999

2004

2005

2006

Decree n° 1.156 – 31/08/1990. Institutes the Sisvan in the Ministry of Health and

creates the National Executive Working Group.

Law n° 8.080 – 19/09/90. Establishes the conditions for health promotion, protection,

and recovery, and the organization and functioning of the corresponding services.

Decree n° 080-P – 16/10/90. Institutes the Sisvan Helping Committee and its

attributions.

Decree n° 1.882 – 18/12/1997. Establishes a minimum salary for Primary Health Care

and its composition.

Decree nº 710 – 10/06/1999. Aproves the National Food and Nutrition Policy. Its third

guideline covers Sisvan expansion and optimization to extend coverage to the whole

country and population segments from Primary Health Care.

Decree nº 1.172 – 15/06/04. Regulates NOB SUS nº 01/96 regarding the jurisdictionsof the federal, state, municipal, and Federal District governments in the area of healthsurveillance, and defines the funding system and other measures.

Decree nº 2.246 – 18/10/04. Institutes and discloses basic guidelines for theimplementation of food and nutrition surveillance actions in the scope of SUS primaryhealth care actions throughout the country.

Interministerial Decree nº 2.509 – 18/11/2004. Articulation between the Ministries ofHealth and Social Development. Establishes the attributions and norms for providingand monitoring health actions related to the requirements for families to participatein the Programa Bolsa Família (Cash Transfer Program).

Decree nº 2.607 – 10/12/2004. Approves the 2004-2007 National Health Plan. Goalsfor promoting a healthy diet and fighting malnutrition. Monitor the fortification ofwheat flour and cornmeal 2004-2007 in the 27 federal units; Monitor the food andnutrition situation in roughly 60% of the municipalities; annually providemicronutrients to at least 70% of the population at risk.

Decree nº 729 – 13/05/2005. Institutes the National Program of Vitamin ASupplementation, among other measures.

Decree nº 730 – 13/05/2005. Institutes the National Iron Supplementation Program,which aims to prevent iron-deficiency anemia, among other measures.

Decree nº 2.362 – 01/12/2005. Restructures the National Program to Prevent andControl Iodine Deficiency Disorders, called Pro-Iodine.

Decree nº 2.608/GM – 28/12/05. Defines maximum financial resources available forhealth surveillance to encourage the structuring of surveillance actions to preventnoncommunicable diseases and problems by state and state capital departments ofhealth.

Decree nº 399/GM – 22/02/06. Discloses the 2006 Health Pact – Consolidation ofSUS and approves its operational guidelines (Pact for Life, Pact to Defend SUS, andPact of SUS Management)

Decree nº 648 – 28/03/06. Approves the National Primary Health Care Policy,establishing the review of the guidelines and norms for the organization of primaryhealth care for the Program Family Health and Program of Community Health Agents.Implementation of food and nutrition surveillance from this level of care.

Decree nº 687 – 30/03/06. Approves the National Health Promotion Policy.

Decree nº 148 – 27/04/2006. Establishes norms, criteria, and procedures to supportthe management of the Programa Bolsa Família and Cadastro Único de ProgramasSociais do Governo Federal (Single Register of Social Programs of the FederalGovernment) at the municipal level, and creates the Decentralization ManagementIndex of the Program.

Final Report of the Inter-agency

Health Information Network about

Sisvan indicators, 1999.

Food and Nutrition Surveillance:Basic instructions for health servicedata and information collection,processing, and analysis, 2004.

Sisvan Informatization – part I(Implementation of Sisvan Modulefor Managing the Programa BolsaFamília).

Primary Health Care Periodicals nº 12.Obesity. Ministry of Health, 2006.

PeriodTechnical norms and manuals basic

health textsLegislation



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2 of 3

2006

2007

2008

2009

2010

Interministerial Decree nº 1.010 – 08/05/06. Institutes the guidelines for promoting a

healthy diet in public or private kindergartens and elementary and high schools

throughout the country.

Decree nº 1.097 – 22/05/06. Defines the Process of Covenanted and Integrated

Programming of Health Assistance in the scope of SUS.

Law nº 11.346 – 15/09/06. Creates the Sisan, to ensure the Human Right to Adequate

Food, among other measures.

Decree nº 6.286 – 5/12/2007. Institutes the Health at School Program, whose health

actions should be developed together with the primary public education network

following SUS principles and guidelines, including nutritional assessment of

schoolchildren, among other actions.

Decree 154 – 24/01/2008. Creates the NASF.

Decree nº 325/GM – 21/02/08. Establishes priorities, objectives, and goals for the

2008 Pact for Life, the indicators for monitoring and assessing the Pact for Health,

and the instructions for their pact.

Decree nº 1.424 – 10/07/2008. Establishes the fund to fund annual transfer to structure

and implement the food and nutrition actions in the scope of the state and municipal

departments of health based on the National Food and Nutrition Policy.

Decree nº 321 – 29/09/2008. Regulates the management of the Programa Bolsa Fa-

mília requirements.

2009-2011 National Health Plan. Published in 2009. Sisvan – related goals: Expand

food and nutrition surveillance in all municipalities, especially with respect to food

intake. Insertion of food and nutrition actions in NASF. Expand the population covered

by Sisvan from the 4.7% in 2007 to 10% in 2011; increase the prevalence of exclusive

breastfeeding in the first six months of life from 40% in 2007 to 50% until 2011;

reduce protein-energy malnutrition (underweight) in children aged less than five years

from the 5.8% in 2007 to 4.0% until 2011; maintain the elimination of iodine

deficiency disorders throughout the country (<5% of the population); reduce iron-

deficiency anemia in women of childbearing age from 29% to 24%, and in children

aged less than two years, from 24% to 19%.

Decree nº 1.630 – 24/06/2010. Establishes the fund to fund annual transfer to structure

and implement the food and nutrition actions of the state and municipal departments

of health based on the National Food and Nutrition Policy.

Decree nº 3.462 – 11/11/2010. Establishes criteria for feeding the National Health

Care Information System databases.

Decree nº 649 – 26/11/2010. Institutes the Centers for Food and Nutrition

Collaboration of the Ministry of Health to help establish the guidelines and strategies

that optimize the National Food and Nutrition Policy actions.

Decree nº 4.279 – 30/12/2010. Establishes guidelines for the organization of the

Health Care Network in SUS scope.

Management Report of the Food and

Nutrition Coordination Office of the

Ministry of Health for 2003-2006.

Primary Health Care Periodicals nº 20.

Micronutrient deficiencies. Ministry

of Health, 2007.

Sisvan Informatization – part II

(Implementation of Sisvan web).

Sisvan protocols for health assistance,

2008.

Matrix of food and nutrition actions

in primary health care, 2009.

Collection of norms for social control

in SUS, 2009.

Food and Nutrition Indicators, 2009.


Child ’s Health: Child nutrition,

breastfeeding, and complementary

foods. Ministry of Health, 2009.


Health at School. Ministry of Health,

2009.

Instruction Manual of the Programa

Bolsa Família in Health, 2010.

Management Report of the Progra-

ma Bolsa Família in Health for 2005

to 2010.



Ministry of Health for 2007-2010.

Primary Health Care Periodicals nº 27

0150 NASF Guidelines: Family Health

Support Center. Ministry of Health,

2010.





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3 of 3

2011

2012

2013

2014

National Health Plan 2012-2015. Published in 2011. Establishes as goals related to

Sisvan: To increase by 25.0% the Sisvan coverage; to reduce protein-energy

malnutrition (underweight) in children aged less than five years by 10.0%, going

from 4.4% in 2011 to 4.0% in 2015; to reduce chronic malnutrition (stunting) in

children aged less than five years by 15%, going from 13.5% in 2011 to 11.5% in

2015; to reduce by 25% the intake of salt by the Brazilian population, going from

12g/person/day in 2008/2009 to 9g/person/day until 2015.

Decree nº 7.508 – 28/06/2011. Regulates Law nº 8.080/1990, to establish SUS

organization, health planning, health assistance, and inter-federative articulation.

Decree nº 2.029 – 24/08/2011. Institutes Household Care in SUS scope, defining

actions for household care in primary, outpatient, and hospital care.

Decree nº 2.488 – 21/10/2011. Approves the National Primary Health Care Policy,

establishing the review of guidelines and norms for the organization of primary health

care for the Family Health Strategy and the Program of Community Health Agents.

Decree nº 2.685 – 16/11/2011. Establishes the annual fund to fund transfer for

structuring and implementing food and nutrition actions in the scope of the state

and municipal health departments based on the National Food and Nutrition Policy.

Decree nº 2.715 – 17/11/2011. Updates the National Food and Nutrition Policy.

Decree nº 3.156 – 27/12/2011. Enables the municipalities that will receive financial

resources for structuring the food and nutrition surveillance in primary health care

units with primary health care teams adhering to homologated.

Decree nº 3.157 – 27/12/2011. Homologates municipalities to receive incentive to

pay for the health promotion actions of the Health Academy Program and homologates

the municipalities that will receive financial resources to structure food and nutrition

surveillance in these centers.

Plan of strategic actions for fighting

chronic noncommunicable diseases

in Brazil 2011-2022.

Instructive Program Health at School,

2011.

Instructions for collecting and

analyzing anthropometric data in

health services, 2011.



Ministry of Health. 2011

Intersectoral Strategy to Prevent and

Control Obesity: Recommendations

for states and municipalities. Caisan,

2014.



Note: Sisvan: Sistema de Vigilância Alimentar e Nutricional; NOB: Norma Operacional Básica; SUS: Sistema Único de Saúde; GM: Gabinete do

Ministro; NASF: Núcleo de Apoio à Saúde da Familia; Caisan: Câmara Interministral de Segurança Alimentar e Nutricional.

unpublished survey results. In the qualitativestage, 56 municipalities were selected, two bythe Regional Health Superintendence, one withthe highest and another with the lowest degreeof Sisvan web implementation, classifiedaccording to an electronic questionnaire sentpreviously and answered by 432 of the 853municipalities of the state. Of the 56 municipalitiesthat met the inclusion criteria for the 28 RegionalHealth Superintendence, 26 municipalities of 13Regional Health Superintendence authorized the

study. Thus, we identified and contacted theprofessionals responsible for entering data in theSisvan web of 26 municipalities to administer asemi-structured interview, conducted in loco, tocheck how they perceived the operationalcharacteristics of Sisvan web through technicalparameters of usability, information architecture,and accessibility.

Although these interviews presented thelimitation of revealing only a part of the local foodand nutrition surveillance, they were useful for



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contextualizing the intervention in a real situation,in which the problems that affect its executioncould be identified and analyzed, contributing to

the creation of theoretical suppositions andexposing rival theories. They also contributed tothe identification of individuals potentially

involved in the intervention and assessment, andto its modeling.

Once the interviews were finished, thecontent was transcribed, and after successive

readings, the material was organized intoanalytical categories, complementing documentanalysis28. Based on the described data collection

techniques, the intervention modeling stagebegan24-26. By considering food and nutritionsurveillance an intervention, we intend to describeit as an organized action system that includes theactors involved in planning, organizing, andcarrying out the activities; a structure that coversthe set of resources and rules beyond the actors’control as it contains a political, ideological, andnormative component; and the objectives andgoals of the intervention actions, in this case, tosupply continuous and quality information on thenutritional status and food intake of the territorialpopulation. The TLM tried to schematicallyrepresent all components of the intervention –problem, objectives, inputs, activities, andexpected results in the short, medium, and longterm, exposing its work and operationalaspects24.

R E S U L T S

To consider food and nutrition surveillancean intervention means to recognize it as a systemof organized actions that should produceperiodical information about the food andnutritional conditions of individuals andpopulations, and its determinants, allowingmonitoring the food and nutrition transition.These data would be useful for defining healthpromotion and care actions under the light of SUSand FNS principles5-10.

Food and nutrition surveillance is, thus,understood as an intervention that allowsmonitoring and assessing FNS-related socialpolicies11-13. The data produced locally by PHC areuseful for managers of the health sector, andthrough the intersectoral articulation of this withother sectors such as education, agriculture, socialassistance, habitation, supply, social security,and labor, among others, to make decisionsthat enable achieving Food and nutritionsurveillance7-10,13.

The identified food and nutritionalsurveillance objectives were the organization ofthe necessary inputs and activities to: 1) supplycontinuous and updated data about the food andnutritional situation of municipal and state PHCusers; 2) identify geographic areas, socialsegments, and population groups at risk ofnutritional problems; 3) promote an earlydiagnosis of nutritional problems, whetherunderweight or excess weight, enabling actionsthat prevent the consequences of these problems;4) enable monitoring and assessing the nutritionalstatus of families that benefit from socialprograms; and 5) offer subsidies for theformulation and assessment of public policies thataim to improve the food and nutritional situationof the Brazilian population.

To implement and supervise food andnutrition actions at the local level, the municipalmanager should designate a coordinator,preferably a dietitian. This coordinator, responsiblefor planning and organizing food and nutritionactions, should articulate with other PHCcoordinators to organize the necessary structure

and the work of the professionals in Family HealthStrategy teams to make the food and nutritionaldiagnosis of individuals and population groups in

the attached territory. Based on food and nutritionactions, individual user data would be collected(clinical, biochemical, anthropometric, and foodintake) and immediately processed and analyzed

by Sisvan web and other Sistema de Informaçãoem Saúde (SIS, Health Information Systems),which would provide complementary information



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about the life and health conditions of individualsand specific population groups9,13-22,29.

With Sisvan and SIS data, it is possible tocarry out a health situation analysis to serve as a

basis for the local health planning andprogramming, considering the assistance andnutritional care actions, including referral and

counter-referral; prevention of the most commonnutritional diseases and disorders and healthpromotion focusing on the determinants of

nutritional, life, and health conditions5,6,29. For thispurpose, the methodological principles ofsituational strategic planning are recommended,defining the objectives, goals, actions, andactivities to face the most important problems,and defining the individuals in charge, deadlines,and resources to advance the intersectoralwork1,3,30.

Expansion of Sisvan population coverageand qualification of its actions are PNANguidelines. For the first, the Ministery of Healthrecommended the “Nutritional Calls” along withthe national immunization campaigns; the secondregarded the inclusion of a dietitian in the Núcleode Apoio à Saúde da Familia (NASF, Family HealthSupport Centers) as a way to strengthen theactions performed by Family Health Strategyteams related to it, including the provision oftrainings7-10,14,29,31.

Each technical component uses inputs tocarry out management activities or activitiesdirected at individuals, families, and community,to obtain immediate results (product), medium-term results (results), and long-term results(impact)24 to advance in the search for FNSassurance.

These components are described andsystematized in the TLM of the food and nutritionactions in PHC, detailed in Figure 1, developedby analyzing the literature and Ministery of Healthregulation instruments, such as the 2008 “Cartilhade Protocolos do Sistema de Vigilância Alimentare Nutricional na assistência à saúde” (Compendiumof Protocols of the Food and Nutrition Surveillance

System in Health Care) and the 2009 “Matriz dasAções de Alimentação e Nutrição na AtençãoBásica em Saúde” (Matrix of Food and NutritionActions in Primary Health Care).

By considering food and nutritionsurveillance one of the components of food and

nutrition actions and the focus that should begiven to the food and nutrition surveillanceimplementation process in PHC, a specific TLM

was created specifically for food and nutritionsurveillance. This TML involves planning andmanagement of food and nutrition actions, and

food and nutrition diagnosis, which werespecifically systematized and described inFigure 2.

The following were identified as

potentially involved in the intervention, and thus,possible users of a food and nutrition surveillanceimplementation assessment in PHC: (a) the

municipal technical references of food andnutrition surveillance, responsible for the planningand management of food and nutrition actions

and for analyzing and disclosing informationabout the food and nutritional status of thepopulation, which were named food and nutrition

surveillance managers; (b) the health professionalsinvolved in data collection and digitization; (c)professionals of different sectors related to FNS;

(d) the technical references of food and nutritionsurveillance at the regional level, also named foodand nutrition surveillance managers in this

management level; (e) the population of ascribedterritories.

Chart 2 details the identified potentialusers, their role in food and nutrition surveillance,

their interest and role in the assessment, and theirrole in using the findings.

D I S C U S S I O N

The expected product from food andnutrition surveillance modeling is the fulldescription of the intervention24 and its schematic



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Chart 2.Potential users of an assessment of food and nutrition surveillance implementation in primary health care.

State Manager

Regional manager of food

and nutrition surveillance

Municipal manager of

food and nutrition

surveillance

Municipal health

professionals

Professionals responsible

for entering data into the

system

Professionals/managers of

other sectors (education,

social assistance,

agriculture)

Population of the attached

territory

Responsible for the

organizational guidelines

in the state, encouraging

planning, and inducing

implementation

Responsible for supporting

the municipal manager

with respect to the

planning and management

of local actions

Responsible for analyzing

and disclosing information

at the regional level

Responsible for planning

and managing local actions

Responsible for analyzing

and disclosing information

Carry out data collection

activities, support food


implementation in health

services

Responsible for entering

data into the system,

support food and

nutrition surveillance

implementation in health

services

Responsible for using

food and nutrition

surveillance information

to define actions of the

respective sectors

regarding the health

needs of the population

Are the target population

for the food and nutrition

diagnosis actions

To increase the knowledge

and involvement of the

health sector and inter-

sector; improve the

intervention

To identify potentialities

and weaknesses to

improve the intervention,

and to increase knowledge

about the intervention

To identify potentialities

and weaknesses to

improve the intervention,

and to increase knowledge

about the intervention

To assess practices,

opportunity to expose the

operational difficulties

experienced during the

service routine

To deepen knowledge

about the intervention,

increase the amount of

quality data for

intersectoral articulation

To improve the

intervention and increase

access to and quality of

health services

To institutionally support

and encourage assessment

and monitoring

To contribute to the

definition of the focus of

assessment

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support for conducting

the study

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criteria

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describe the available

structure and create

assessment criteria

To supply information

about the

operationalization of

practices in service routine

To supply information

about the

operationalization of

practices in service

routine, participate in the

discussions about the

intervention

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intervention by requiring

quality food and nutrition

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from an intersectoral

perspective

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assessment focus; supply

information about the

functioning of the

intervention; To talk about

their expectations and

needs for the intervention

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service)

Potential assessment user Role in the intervention Interest in assessment

To correct directions, de-

fine state policies, induce

municipal assessments

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management of food


To improve local

management of food and

nutrition surveillance

actions

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practices, support the

adjustment of protocols

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service practices, and to

mobilize articulation

efforts

To commit to the use of

food and nutrition

surveillance data for

decision making in their

respective sectors; to

increase intersectoral

planning

To ask public

management to correct

directions

Role in the assessment Role in using the findings

representation in the form of TLM. The purposeof these products is to reveal the chain ofpredicted effects to reach the objectives of making

quality information available in a timely mannerabout the nutritional status and food intake ofthe territorial population.



https://doi.org/10.1590/1678-98652017000100011

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https://doi.org/10.1590/1678-98652017000100011

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https://doi.org/10.1590/1678-98652017000100011

In addition to describing the intervention,the study identified its objectives, goals, andindividuals potentially interested in theassessment. For Champagne et al.24, oneintervention can be conceived as an organizedsystem of action that involves, within a structure,actors that perform certain processes to reachdefined objectives. With this perspective, foodand nutrition surveillance ultimately tries toimprove the population ’s life and healthconditions by providing updated, timely, andquality information for manager decisionmaking9,10,13,15.

Regarding food and nutrition surveillance,the scope of action of the health sector,particularly primary health care, responsible forthe reorganization of the Health Care Networks,refers to the identification of the population’shealth needs to better guide intersectoral policiesand actions that affect its determinants andrequirements29. In addition to identifying healthneeds, it is PHC role to refer to secondary andtertiary care the cases that require individualdiagnosis and treatment (referral), and to monitorand follow these individuals in the service routine(counter-referral)29,31.

The description of food and nutritionsurveillance based on regulations and literaturereview allowed identifying the limited expansionof food and nutrition surveillance coverage topopulation segments other than the beneficiariesof social programs, pregnant women, andchildren15,16,20-22. The absence of monitoring ofother life stages, such as adolescence, adulthood,and old age, limits its field of action as aninstrument to monitor nutritional problems relatedto overweight, obesity, and specific nutritionaldeficiencies, which have been the most prevalentand challenging to SUS31.

In addition to expanding the coverage toadolescents, adults, and older adults, it is essentialto qualify food and nutrition surveillance actions,aspects that have been incorporated in the goalsof sectoral and intersectoral planning6-10,14. Thegoals defined by the federal sphere must guide

the local actions, in consonance with theparticularities and needs identified by analyzingthe health situation. Hence, they show thepriorities and political options adopted by theBrazilian government over the years. The studyidentified the absence of goals related to healthpromotion, hardly measurable by quantitativemethods, and that require assessments of socialchanges4,5,30. Although these aspects have beenconsidered important in the analyzed documents,there are no planned goals and indicators for theirmeasurement. This is an important aspect thatstill requires strengthening.

It is important to point out the essentialrole of food and nutrition surveillance as a pillarfor the food and nutritional monitoring of thepopulation, as an instrument to be prioritized asmuch as the large nationwide surveys. Althoughthe latter are more reliable, accurate, and allowthe establishment of causal relationships, they aremore expensive and complex, so conducted lessfrequently. Food and nutrition surveillanceinserted in the services has lower informationquality and reliability, but aids timely decisionmaking at the local level because it is producedcontinuously and can cover a high percentage ofthe population7,9.

In this perspective, the large surveys aremore useful for the central levels of managementand for the definition of macroeconomic policies.At the local level, the use of SIS for organizingthe services and intersectoral planning is essentialto guarantee the effort of the services to increasetheir coverage and qualify actions1,3.

Based on the perspective of the usefulnessof the assessment results to improve the executionof the intervention, it is necessary to identify andinvolve individuals potentially interested in theassessment to potentiate their commitment to usethe findings24-26. They will be involved in the stagesof making pacts with respect to the assessmentobjectives and creation of the matrix of criteriathat will guide the assessment25,26.

Specifically, the managers will help toidentify and describe the available structure



https://doi.org/10.1590/1678-98652017000100011

(financial, physical, human, and materialresources) to carry out food and nutritionsurveillance actions, its organization, and the dataanalysis and disclosure processes, while theprofessionals will help describe theoperationalization of routine activities of datacollection and subsequent digitization in thesystem. The territorial population may disclose itsexpectation and needs regarding food andnutrition actions and surveillance. Validation ofthe TLM in different contexts is an expecteddevelopment of intervention modeling from theperspective of theory-based assessment23.

F I N A L C O N S I D E R A T I O N S

In the search for expanding the population

coverage and qualification of the actionsperformed, one may say that food and nutritionsurveillance description approaches the

dimensions of planning, management, and foodand nutritional diagnosis, focusing on activitiesusing the available inputs and the main products

regarding the food and nutrition surveillanceobjectives, which is to supply information foraction.

Based on the created logic models that

describe food and nutrition surveillance, theexpected developments are the involvement ofthe stakeholders identified in theoretical logicmodel validation, followed by the logical analysisof the intervention, which will allow theidentification of the plausibility of the proposedcausal relationships.

The strengthening of the interventionfunctioning theory stemming from all these stageswill allow reviewing the developed logic modelsin an interactive process marked by cycles thatupdate the intervention functioning based on theemergence of new evidence. One limitation is thedifficulty of presenting the whole interventioncomplexity in one single schematic representation.

The discussion about logic models seemsto increase the knowledge of all those involved

with the intervention, to contribute to theorientation of different types of assessmentsabout any of the food and nutrition surveillancephases, and to guide future matrices to monitorfood and nutrition surveillance processes in PHC.This, undoubtedly, is a useful and timelyinstrument to help decision making even beforethe assessment itself is conducted. It may beuseful to management instances and serviceprofessionals, in addition to instances of socialcontrol. The TLM optimizes time, resources,definition of indicators that require monitoring,and aspects that require assessment, identifyingmore clearly the contribution of the interventionto achieve the results and what other componentscontribute to this achievement.

Identifying the difficulties and potentialitiesfound locally to increase population coverage andqualify food and nutrition actions is essential forproposing concrete actions that bring the politicaldiscourse closer to the reality of Brazilianmunicipalities and change food and nutritionsurveillance into a management instrument forintersectoral planning.

A C K N O W L E D G M E N T

We thank Conselho Nacional de Desenvol-vimento Científico e Tecnológico for the doctoral grantand Fundação de Amparo à Pesquisa do Estado de

Minas Gerais for sponsoring the study.

C O N T R I B U T O R S

SAS VITORINO helped to conceive and designthe study, and to write the article. MM CRUZ helpedto conceive the study, reviewed the article, andapproved the final version for publication. DC BARROShelped to conceive the study, reviewed the article, andapproved the final version for publication.

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Received: April 24, 2015Final version: September 19, 2016Approved: October 19, 2016

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