Instruments for evaluating the quality of services in chronic diseases: scoping review

Sousa, Gutembergue Santos de; Silva, Fabiane Verônica da; Longhi, Fabiana Gulin; Cortela, Denise da Costa Boamorte; Silva, Pãmela Rodrigues De Souza; Ferreira, Silvana Margarida Benevides

doi:10.1590/1518-8345.7168.4293

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Revista Latino-Americana de Enfermagem

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Review Article • Rev. Latino-Am. Enfermagem 32 • 2024 • https://doi.org/10.1590/1518-8345.7168.4293 copy

Instruments for evaluating the quality of services in chronic diseases: scoping review^* * *Paper extracted from doctoral dissertation “Validação de instrumento para avaliação das ações de controle da hanseníase em crianças e adolescentes”, presented to Universidade Federal do Mato Grosso, Faculdade de Enfermagem, Cuiabá, MT, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

to map the scientific literature on the validity of instruments for evaluating the quality of services provided in primary health care for chronic diseases related to systemic arterial hypertension, diabetes mellitus, leprosy and tuberculosis.

Method:

scoping review, following the Joanna Briggs Institute method and described in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. 13 databases and gray literature were included. The selection of studies was carried out after removing duplicates and individual and paired evaluation. The data was extracted based on an elaborate script and presented in tables and charts.

Results:

the analysis of 28 selected studies showed that the majority were from Brazil, followed by China and Malaysia. Almost half of the validated instruments were generic, and the specific ones covered the evaluation of diabetes mellitus and leprosy. The types of validation carried out were content and construct.

Conclusion:

there is a need to construct specific instruments due to the scarcity of studies on the process of validating instruments for evaluating the quality of services provided by primary health care for chronic diseases.

Descriptors:
Validation Study; Evaluation of Research Programs; Surveys and Questionnaires; Chronic Disease; Health Services Research; Methods

Highlights:

(1) Validated instruments for evaluating services in chronic diseases.

(2) Possibility of carrying out new studies on adaptations of PCAT and PACIC.

(3) No evaluation was identified for minors under 18 years of age with chronic diseases.

(4) Use of a generic instrument to evaluate specific chronic diseases.

Data base	Search strategy
PubMed	((“Health Personnel”[Mesh] OR “Health Personnel”) OR (“Health Manager”) OR (“Patients”[Mesh] OR Patients OR Patient)) AND ((“Validation Study” OR “Validation Studies” OR “Validation Tool” OR “Validation Tools” OR “Validation Instruments” OR “Validation Instrument”) AND ((“Health Evaluation”) OR (“Quality of Health Care”[Mesh] OR “Quality of Health Care”))) AND (“Primary Health Care”[Mesh] OR “Primary Health Care” OR “Primary Healthcare” OR “Primary Care”)
CINAHL	(((MH “Health Personnel”) OR “Health Personnel”) OR ((MH “Patients”) OR (Patient OR Patients))) AND ((MH “Validation Studies”) OR (“Validation Study” OR “Validation Studies” OR “Validation Tool” OR “Validation Tools” OR “Validation Instruments” OR “Validation Instrument”)) AND ((“Health Evaluation”) OR ((MH “Quality of Health Care”) OR “Quality of Health Care”)) AND ((MH “Primary Health Care”) OR “Primary Health Care”)
EMBASE	(‘health care personnel’/exp OR ‘health care personnel’ OR ‘patient’/exp OR patient) AND (‘validation study’/exp OR ‘validation study’) AND (‘health care quality’/exp OR ‘health care quality’ OR ‘health evaluation’) AND (‘primary health care’/exp OR ‘primary health care’)
Scopus	TITLE-ABS-KEY ((“Health Personnel” OR “Health Manager” OR Patient) AND (“Validation Study” OR “Validation Studies” OR “Validation Tool” OR “Validation Tools” OR “Validation Instruments” OR “Validation Instrument”) AND (Evaluation OR “Quality of Health”) AND (“Primary Health Care” OR “Primary Healthcare” OR “Primary Care”))
Web of Science	(“Health Personnel” OR “Health Manager” OR Patient) AND (“Validation Study” OR “Validation Studies” OR “Validation Tool” OR “Validation Tools” OR “Validation Instruments” OR “Validation Instrument”) AND (Evaluation OR “Quality of Health”) AND (“Primary Health Care” OR “Primary Healthcare” OR “Primary Care”)
PsycINFO	(“Health Personnel” OR “Health Manager” OR Patient) AND (“Validation Study” OR “Validation Studies” OR “Validation Tool” OR “Validation Tools” OR “Validation Instruments” OR “Validation Instrument”) AND (Evaluation OR “Quality of Health”) AND (“Primary Health Care” OR “Primary Healthcare” OR “Primary Care”)
Infolep	(“Validation Study” OR “Validation Studies” OR “Validation Tool” OR “Validation Tools” OR “Validation Instruments” OR “Validation Instrument”)
Cochrane Library	(“Patients” OR “Health Personnel” OR “Health Manager”) AND (“Validation Study” OR “Validation Studies” OR “Validation Tool” OR “Validation Tools” OR “Validation Instruments” OR “Validation Instrument”) AND (“Quality of Health Care” OR Evaluation) AND (“Primary Health Care”) = in Title Abstract Keyword
CAPES Catálogo de Tteses e Dissertações	Validação AND Avaliação AND “Atenção Primária à Saúde”
DART - EBSCO Open Dissertation	(“Health Personnel” OR “Health Manager” OR Patient) AND (“Validation Study” OR “Validation Studies” OR “Validation Tool” OR “Validation Tools” OR “Validation Instruments” OR “Validation Instrument”) AND (“Primary Health Care” OR “Primary Healthcare” OR “Primary Care”)
Networked Digital Library of Theses and Dissertations (NDLTD)	(“Health Personnel” OR “Health Manager” OR Patient) AND (“Validation Study” OR “Validation Studies” OR “Validation Tool” OR “Validation Tools” OR “Validation Instruments” OR “Validation Instrument”) AND (Evaluation OR “Quality of Health”) AND (“Primary Health Care” OR “Primary Healthcare” OR “Primary Care”)
BDTD - Biblioteca Digital Brasileira de Teses e Dissertações - IBICT - Instituto Brasileiro de Informação em Ciência e Tecnologia	Validação AND Avaliação AND “Atenção Primária à Saúde”
ACS Guide to Scholarly Communication	(“Health Personnel” OR “Health Manager” OR Patient) AND (“Validation Study” OR “Validation Studies” OR “Validation Tool” OR “Validation Tools” OR “Validation Instruments” OR “Validation Instrument”) AND (“Primary Health Care” OR “Primary Healthcare” OR “Primary Care”)

Variables	n*	%^†
Type of publication journal
National	06	21.4
International	22	78.6
Country where the study was carried out
Germany	02	07.1
Brazil	07	25.0
China	03	10.7
France	02	07.1
Netherlands	02	07.1
Malaysia	03	10.7
Others^‡	09	32.3
Chronic disease evaluated by the survey instrument
Generic instrument^§	13	46.4
Hypertension	03	10.7
Diabetes	05	17.9
Leprosy	05	17.9
Tuberculosis	02	07.1
Population studied
< de 18 years old	00	00.0
> de 18 years old	19	68.0
Health professionals	07	25.0
Managers	02	07.0
Type of validity adopted ^\|\|
Cross-cultural adaptation	14	50.0
Content validity	19	67.9
Face validity	06	21.4
Semantic validity	18	64.3
Construct validity	23	82.1
Calculation of the internal consistency of the instrument
Yes	26	92.9
No	02	07.1
Calculation of instrument reliability
Yes	13	46.4
No	15	53.6
Type of scale adopted
Dichotomous	01	3.6
3-point Likert	01	3.6
4-point Likert	04	14.3
5-point Likert	16	57.1
Others^¶	06	21.4
Identified instruments
PACIC** adaptations	08	28.5
PCAT^†† adaptations	08	28.5
Other miscellaneous instruments	12	43.0

Chronic disease	Main findings
Diabetes	Instruments originally developed20Wei X, Barnsley J, Zakus D, Cockerill R, Glazier R, Sun X. Assessing continuity of care in a community diabetes program: initial questionnaire development and validation. J Clin Epidemiol. 2008;61(9):925-31. https://doi.org/10.1016/j.jclinepi.2007.12.010 https://doi.org/10.1016/j.jclinepi.2007.... ^),(25Bélanger A, Hudon C, Fortin M, Amirall J, Bouhali T, Chouinard MC. Validation of a French-language version of the health education impact Questionnaire (heiQ) among chronic disease patients seen in primary care: a cross-sectional study. Health Qual Life Outcomes . 2015;13:64. https://doi.org/10.1186/s12955-015-0254-0 https://doi.org/10.1186/s12955-015-0254-... and cross-culturally adapted19Abdul-Razak S, Ramli AS, Badlishah-Sham SF, Haniff J; EMPOWER-PAR Investigators. Validity and reliability of the patient assessment on chronic illness care (PACIC) questionnaire: the Malay version. BMC Fam Pract. 2018;19(1):119. https://doi.org/10.1186/s12875-018-0807-5 https://doi.org/10.1186/s12875-018-0807-... ^),(30Maindal HT, Sokolowski I, Vedsted P. Adaptation, data quality and confirmatory factor analysis of the Danish version of the PACIC questionnaire. Eur J Public Health. 2012;22(1):31-6. https://doi.org/10.1093/eurpub/ckq188 https://doi.org/10.1093/eurpub/ckq188... ^),(37Abdul-Razak S, Ramli AS, Badlishah-Sham SF, Haniff J; EMPOWER-PAR Investigators. Validity and reliability of the patient assessment on chronic illness care (PACIC) questionnaire: the Malay version. BMC Fam Pract . 2018;19(1):119. https://doi.org/10.1186/s12875-018-0807-5 https://doi.org/10.1186/s12875-018-0807-... .
	Presented continuity of care19Abdul-Razak S, Ramli AS, Badlishah-Sham SF, Haniff J; EMPOWER-PAR Investigators. Validity and reliability of the patient assessment on chronic illness care (PACIC) questionnaire: the Malay version. BMC Fam Pract. 2018;19(1):119. https://doi.org/10.1186/s12875-018-0807-5 https://doi.org/10.1186/s12875-018-0807-... ^),(25Bélanger A, Hudon C, Fortin M, Amirall J, Bouhali T, Chouinard MC. Validation of a French-language version of the health education impact Questionnaire (heiQ) among chronic disease patients seen in primary care: a cross-sectional study. Health Qual Life Outcomes . 2015;13:64. https://doi.org/10.1186/s12955-015-0254-0 https://doi.org/10.1186/s12955-015-0254-... , prevention and health promotion20Wei X, Barnsley J, Zakus D, Cockerill R, Glazier R, Sun X. Assessing continuity of care in a community diabetes program: initial questionnaire development and validation. J Clin Epidemiol. 2008;61(9):925-31. https://doi.org/10.1016/j.jclinepi.2007.12.010 https://doi.org/10.1016/j.jclinepi.2007.... ^),(30Maindal HT, Sokolowski I, Vedsted P. Adaptation, data quality and confirmatory factor analysis of the Danish version of the PACIC questionnaire. Eur J Public Health. 2012;22(1):31-6. https://doi.org/10.1093/eurpub/ckq188 https://doi.org/10.1093/eurpub/ckq188... and care37Abdul-Razak S, Ramli AS, Badlishah-Sham SF, Haniff J; EMPOWER-PAR Investigators. Validity and reliability of the patient assessment on chronic illness care (PACIC) questionnaire: the Malay version. BMC Fam Pract . 2018;19(1):119. https://doi.org/10.1186/s12875-018-0807-5 https://doi.org/10.1186/s12875-018-0807-... as phenomena of interest.
	Target audience and study participants were adult population25Bélanger A, Hudon C, Fortin M, Amirall J, Bouhali T, Chouinard MC. Validation of a French-language version of the health education impact Questionnaire (heiQ) among chronic disease patients seen in primary care: a cross-sectional study. Health Qual Life Outcomes . 2015;13:64. https://doi.org/10.1186/s12955-015-0254-0 https://doi.org/10.1186/s12955-015-0254-... , adult and elderly population19Abdul-Razak S, Ramli AS, Badlishah-Sham SF, Haniff J; EMPOWER-PAR Investigators. Validity and reliability of the patient assessment on chronic illness care (PACIC) questionnaire: the Malay version. BMC Fam Pract. 2018;19(1):119. https://doi.org/10.1186/s12875-018-0807-5 https://doi.org/10.1186/s12875-018-0807-... ^,37Abdul-Razak S, Ramli AS, Badlishah-Sham SF, Haniff J; EMPOWER-PAR Investigators. Validity and reliability of the patient assessment on chronic illness care (PACIC) questionnaire: the Malay version. BMC Fam Pract . 2018;19(1):119. https://doi.org/10.1186/s12875-018-0807-5 https://doi.org/10.1186/s12875-018-0807-... and health professionals20Wei X, Barnsley J, Zakus D, Cockerill R, Glazier R, Sun X. Assessing continuity of care in a community diabetes program: initial questionnaire development and validation. J Clin Epidemiol. 2008;61(9):925-31. https://doi.org/10.1016/j.jclinepi.2007.12.010 https://doi.org/10.1016/j.jclinepi.2007.... ^),(30Maindal HT, Sokolowski I, Vedsted P. Adaptation, data quality and confirmatory factor analysis of the Danish version of the PACIC questionnaire. Eur J Public Health. 2012;22(1):31-6. https://doi.org/10.1093/eurpub/ckq188 https://doi.org/10.1093/eurpub/ckq188... .
	Used the convergent/divergent construct validity technique20Wei X, Barnsley J, Zakus D, Cockerill R, Glazier R, Sun X. Assessing continuity of care in a community diabetes program: initial questionnaire development and validation. J Clin Epidemiol. 2008;61(9):925-31. https://doi.org/10.1016/j.jclinepi.2007.12.010 https://doi.org/10.1016/j.jclinepi.2007.... ^),(25Bélanger A, Hudon C, Fortin M, Amirall J, Bouhali T, Chouinard MC. Validation of a French-language version of the health education impact Questionnaire (heiQ) among chronic disease patients seen in primary care: a cross-sectional study. Health Qual Life Outcomes . 2015;13:64. https://doi.org/10.1186/s12955-015-0254-0 https://doi.org/10.1186/s12955-015-0254-... ^),(37Abdul-Razak S, Ramli AS, Badlishah-Sham SF, Haniff J; EMPOWER-PAR Investigators. Validity and reliability of the patient assessment on chronic illness care (PACIC) questionnaire: the Malay version. BMC Fam Pract . 2018;19(1):119. https://doi.org/10.1186/s12875-018-0807-5 https://doi.org/10.1186/s12875-018-0807-... .
	Presented Cronbach’s alpha greater than 0.819Abdul-Razak S, Ramli AS, Badlishah-Sham SF, Haniff J; EMPOWER-PAR Investigators. Validity and reliability of the patient assessment on chronic illness care (PACIC) questionnaire: the Malay version. BMC Fam Pract. 2018;19(1):119. https://doi.org/10.1186/s12875-018-0807-5 https://doi.org/10.1186/s12875-018-0807-... ^),(25Bélanger A, Hudon C, Fortin M, Amirall J, Bouhali T, Chouinard MC. Validation of a French-language version of the health education impact Questionnaire (heiQ) among chronic disease patients seen in primary care: a cross-sectional study. Health Qual Life Outcomes . 2015;13:64. https://doi.org/10.1186/s12955-015-0254-0 https://doi.org/10.1186/s12955-015-0254-... ^),(30Maindal HT, Sokolowski I, Vedsted P. Adaptation, data quality and confirmatory factor analysis of the Danish version of the PACIC questionnaire. Eur J Public Health. 2012;22(1):31-6. https://doi.org/10.1093/eurpub/ckq188 https://doi.org/10.1093/eurpub/ckq188... ^),(37Abdul-Razak S, Ramli AS, Badlishah-Sham SF, Haniff J; EMPOWER-PAR Investigators. Validity and reliability of the patient assessment on chronic illness care (PACIC) questionnaire: the Malay version. BMC Fam Pract . 2018;19(1):119. https://doi.org/10.1186/s12875-018-0807-5 https://doi.org/10.1186/s12875-018-0807-... .
	The instruments presented psychometric properties considered valid, being suitable for use in scientific studies19Abdul-Razak S, Ramli AS, Badlishah-Sham SF, Haniff J; EMPOWER-PAR Investigators. Validity and reliability of the patient assessment on chronic illness care (PACIC) questionnaire: the Malay version. BMC Fam Pract. 2018;19(1):119. https://doi.org/10.1186/s12875-018-0807-5 https://doi.org/10.1186/s12875-018-0807-... ^)-(20Wei X, Barnsley J, Zakus D, Cockerill R, Glazier R, Sun X. Assessing continuity of care in a community diabetes program: initial questionnaire development and validation. J Clin Epidemiol. 2008;61(9):925-31. https://doi.org/10.1016/j.jclinepi.2007.12.010 https://doi.org/10.1016/j.jclinepi.2007.... ^),(25Bélanger A, Hudon C, Fortin M, Amirall J, Bouhali T, Chouinard MC. Validation of a French-language version of the health education impact Questionnaire (heiQ) among chronic disease patients seen in primary care: a cross-sectional study. Health Qual Life Outcomes . 2015;13:64. https://doi.org/10.1186/s12955-015-0254-0 https://doi.org/10.1186/s12955-015-0254-... ^),(30Maindal HT, Sokolowski I, Vedsted P. Adaptation, data quality and confirmatory factor analysis of the Danish version of the PACIC questionnaire. Eur J Public Health. 2012;22(1):31-6. https://doi.org/10.1093/eurpub/ckq188 https://doi.org/10.1093/eurpub/ckq188... ^),(37Abdul-Razak S, Ramli AS, Badlishah-Sham SF, Haniff J; EMPOWER-PAR Investigators. Validity and reliability of the patient assessment on chronic illness care (PACIC) questionnaire: the Malay version. BMC Fam Pract . 2018;19(1):119. https://doi.org/10.1186/s12875-018-0807-5 https://doi.org/10.1186/s12875-018-0807-... .
Leprosy	The instruments were adapted from the original instrument called Primary Care Assessment Tool42Villa TCS, Ruffino-Netto A. Performance assessment questionnaire regarding TB control for use in primary health care clinics in Brazil. J Bras Pneumol. 2009;35(6):610-2. https://doi.org/10.1590/S1806-37132009000600014 https://doi.org/10.1590/S1806-3713200900... ^)-(45Lanza FM, Vieira NF, Oliveira MMC, Lana FCF. Evaluation of the Primary Care in leprosy control: proposal of na instrument for users. Rev Esc Enferm USP. 2014;48(6):1054-61. https://doi.org/10.1590/S0080-623420140000700013 https://doi.org/10.1590/S0080-6234201400... .
	The studies were carried out in the adult population40Zeugfang D, Wisetborisut A, Angkurawaranon C, Aramrattana A, Wensing M, Szecsenyi J, et al. Translation and validation of the PACIC+ questionnaire: the Thai version. BMC Fam Pract . 2018. https://doi.org/10.1186/s12875-018-0801-y https://doi.org/10.1186/s12875-018-0801-... ^),(44Lanza FM, Vieira NF, Oliveira MMC, Lana FCF. Instrumento para avaliação das ações de controle da hanseníase na Atenção Primária. Rev Bras Enferm. 2014;67(3):339-46. https://doi.org/10.5935/0034-7167.20140044 https://doi.org/10.5935/0034-7167.201400... , with Community Health Agents43Lanza FM, Vieira NF, Oliveira MMC, Lana FCF. Validação do instrumento de avaliação do desempenho da atenção primária nas ações de controle da hanseníase (PCAT - hanseníase): versão profissionais. HU Rev. 2019;44(3):311-23. https://doi.org/10.34019/1982-8047.2018.v44.25618 https://doi.org/10.34019/1982-8047.2018.... , with health professionals42Villa TCS, Ruffino-Netto A. Performance assessment questionnaire regarding TB control for use in primary health care clinics in Brazil. J Bras Pneumol. 2009;35(6):610-2. https://doi.org/10.1590/S1806-37132009000600014 https://doi.org/10.1590/S1806-3713200900... and with managers45Lanza FM, Vieira NF, Oliveira MMC, Lana FCF. Evaluation of the Primary Care in leprosy control: proposal of na instrument for users. Rev Esc Enferm USP. 2014;48(6):1054-61. https://doi.org/10.1590/S0080-623420140000700013 https://doi.org/10.1590/S0080-6234201400... .
	Semantic validity and evaluation of questions regarding clarity, understanding and adequacy of items were carried out40Zeugfang D, Wisetborisut A, Angkurawaranon C, Aramrattana A, Wensing M, Szecsenyi J, et al. Translation and validation of the PACIC+ questionnaire: the Thai version. BMC Fam Pract . 2018. https://doi.org/10.1186/s12875-018-0801-y https://doi.org/10.1186/s12875-018-0801-... ^),(42Villa TCS, Ruffino-Netto A. Performance assessment questionnaire regarding TB control for use in primary health care clinics in Brazil. J Bras Pneumol. 2009;35(6):610-2. https://doi.org/10.1590/S1806-37132009000600014 https://doi.org/10.1590/S1806-3713200900... ^)-(45Lanza FM, Vieira NF, Oliveira MMC, Lana FCF. Evaluation of the Primary Care in leprosy control: proposal of na instrument for users. Rev Esc Enferm USP. 2014;48(6):1054-61. https://doi.org/10.1590/S0080-623420140000700013 https://doi.org/10.1590/S0080-6234201400... .
	The instruments had their construct evaluated through factor analysis43Lanza FM, Vieira NF, Oliveira MMC, Lana FCF. Validação do instrumento de avaliação do desempenho da atenção primária nas ações de controle da hanseníase (PCAT - hanseníase): versão profissionais. HU Rev. 2019;44(3):311-23. https://doi.org/10.34019/1982-8047.2018.v44.25618 https://doi.org/10.34019/1982-8047.2018.... or the mirror validity technique with another instrument42Villa TCS, Ruffino-Netto A. Performance assessment questionnaire regarding TB control for use in primary health care clinics in Brazil. J Bras Pneumol. 2009;35(6):610-2. https://doi.org/10.1590/S1806-37132009000600014 https://doi.org/10.1590/S1806-3713200900... ^),(44Lanza FM, Vieira NF, Oliveira MMC, Lana FCF. Instrumento para avaliação das ações de controle da hanseníase na Atenção Primária. Rev Bras Enferm. 2014;67(3):339-46. https://doi.org/10.5935/0034-7167.20140044 https://doi.org/10.5935/0034-7167.201400... ^)-(45Lanza FM, Vieira NF, Oliveira MMC, Lana FCF. Evaluation of the Primary Care in leprosy control: proposal of na instrument for users. Rev Esc Enferm USP. 2014;48(6):1054-61. https://doi.org/10.1590/S0080-623420140000700013 https://doi.org/10.1590/S0080-6234201400... .
	The reliability of the instrument was calculated through test/retest40Zeugfang D, Wisetborisut A, Angkurawaranon C, Aramrattana A, Wensing M, Szecsenyi J, et al. Translation and validation of the PACIC+ questionnaire: the Thai version. BMC Fam Pract . 2018. https://doi.org/10.1186/s12875-018-0801-y https://doi.org/10.1186/s12875-018-0801-... ^),(42Villa TCS, Ruffino-Netto A. Performance assessment questionnaire regarding TB control for use in primary health care clinics in Brazil. J Bras Pneumol. 2009;35(6):610-2. https://doi.org/10.1590/S1806-37132009000600014 https://doi.org/10.1590/S1806-3713200900... ^)-(45Lanza FM, Vieira NF, Oliveira MMC, Lana FCF. Evaluation of the Primary Care in leprosy control: proposal of na instrument for users. Rev Esc Enferm USP. 2014;48(6):1054-61. https://doi.org/10.1590/S0080-623420140000700013 https://doi.org/10.1590/S0080-6234201400... .
	The instruments presented psychometric properties considered valid, being suitable for use in scientific studies40Zeugfang D, Wisetborisut A, Angkurawaranon C, Aramrattana A, Wensing M, Szecsenyi J, et al. Translation and validation of the PACIC+ questionnaire: the Thai version. BMC Fam Pract . 2018. https://doi.org/10.1186/s12875-018-0801-y https://doi.org/10.1186/s12875-018-0801-... ^),(42Villa TCS, Ruffino-Netto A. Performance assessment questionnaire regarding TB control for use in primary health care clinics in Brazil. J Bras Pneumol. 2009;35(6):610-2. https://doi.org/10.1590/S1806-37132009000600014 https://doi.org/10.1590/S1806-3713200900... ^)-(45Lanza FM, Vieira NF, Oliveira MMC, Lana FCF. Evaluation of the Primary Care in leprosy control: proposal of na instrument for users. Rev Esc Enferm USP. 2014;48(6):1054-61. https://doi.org/10.1590/S0080-623420140000700013 https://doi.org/10.1590/S0080-6234201400... .

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[1] Corresponding author: Gutembergue Santos de Sousa E-mail: gutenf@yahoo.com.br https://orcid.org/0000-0003-3672-4388