Evaluation of the COVID-19 testing strategy in PHC of a high-vulnerability health district in Brazil, 2020-2022 | BMC Public Health | Full Text

Jun 06, 2025

BMC Public Health volume 25, Article number: 2101 (2025) Cite this article

Metrics details

Considering the potential role of primary health care (PHC) in the response to COVID-19, a formative evaluation (FE) was carried out between December 2021 and February 2022 to understand its work process against COVID-19 in a high-vulnerability health district in Brazil, identifying the difficulties in carrying out tests and the best practices for the implementation of the intervention “Expansion of testing, quarantine, e-health and telemonitoring strategies to combat COVID-19 in Brazil” (TQT).

FEs are used to guide the implementation of health interventions. This FE was based on a situational diagnosis of the territories and PHC health units of the health district under study, with approximately 400,000 inhabitants, in which the TQT Project would later be implemented. A qualitative study was conducted based on 22 semistructured interviews and three focus groups (FGs) involving 19 PHC professionals. The interviews and FGs were analysed in terms of their thematic content.

There was a lack of coordination in implementing actions; COVID-19 testing was concentrated in a few PHC units, generating work overload and weakness of other health programs in these units; the health units’ physical structure was inadequate, and human resources were insufficient; and no criteria were identified for defining the number of tests offered per day per unit.

The FE identified barriers to testing and supported the design of the TQT, including the adaptations needed to implement actions. The concentration of testing in a few units is an important barrier to access; it is suggested that testing actions should be deconcentrated in as many health units as possible.

Peer Review reports

Despite the potential response of primary health care (PHC) in the context of the coronavirus COVID-19 pandemic, the incorporation of actions at this level of care has been heterogeneous, even among countries with universal systems. There have been delays in including PHC actions in some countries, and coordination and funding are needed [1]. PHCs must act beyond a space for triage and follow-up of minor cases when dealing with health crises. Active monitoring, emphasising the territory, strengthening telehealth care, and protecting health professionals are structural issues in dealing with the pandemic [2]. Health promotion and prevention are of fundamental importance in controlling pandemics, strengthening community guidance, discussing prevention strategies, and addressing home isolation [3].

Investment at this level of care can reduce hospital admissions for PHC-sensitive causes, including COVID-19 [3]. In Brazil, the constant challenges in financing and implementing the Unified Health System (SUS, in Portuguese, Sistema Único de Saúde), especially the changes in PHC financing, have shown that PHC has not been sufficiently strengthened to address the pandemic and its consequences [3]. Its distribution and capillarity throughout the national territory and the training of health professionals to apply rapid tests for other diseases can contribute to the decentralisation and expansion of rapid tests for COVID-19, considering its role in the active search for cases and contacts, adoption of quarantine and isolation strategies, care for mild symptomatic patients and articulation with other points in the health network [4,5,6,7].

To understand the work process of PHC units in coping with COVID-19 in a health district (HD) with high socioeconomic vulnerability in a capital city in Northeast Brazil, this article presents the main results of a formative evaluation (FE) that helps define the best practices for implementing the intervention “Expansion of testing, quarantine, e-health and telemonitoring strategies to combat COVID-19 in Brazil” (TQT Project).

Formative evaluation (FE) is usually carried out when developing a new program to promote adjustments that ensure its viability and acceptance [8,9,10,11]. Widely used in the development of projects in the field of education [8], it can be used to guide the implementation of any intervention [10, 11], including those of the health field, such as clinical improvement [11] or the development of health information technologies [12]. It uses qualitative methods, whether associated with quantitative techniques, and its results are shared with the strategy implementation team to incorporate the stakeholders’ views into the intervention design [11].

This FE was carried out in the most populous of 12 HD of a Northeast Brazilian capital, with a population of more than 2 million inhabitants in 2020. The HD under study had PHC coverage of 47.8% and a Family Health Strategy coverage of 38% in 2020. The FE was based on a situational diagnosis of the territories and PHC health units of the HD, with a population of approximately 400,000 inhabitants, in which the TQT Project would later be implemented.

It sought to include the point of view of the different social agents who would be part of the study, including the population of the territories, in defining priorities and planning actions. It was based on document analysis (Table 1), meetings with professionals, semistructured interviews, and focus groups in two phases: preparatory (document analysis and meetings with professionals and managers of PHC units) in early December 2021, which guided the second phase (interviews and focus groups), between the middle of December 2021 and March 2022, with professionals and users of 22 PHC units. The municipal documents cited in this paper are listed in Table 1, D1 to D7. The FG and interview scripts were developed specially for this study, and can be accessed in the supplementary material. The period in which the second phase of the FE was carried out coincided with the increase in cases of COVID-19 related to the Omicron variant in Brazil. At that time, all health professionals in public service and approximately 70% of the population were fully vaccinated once the national vaccination plan in Brazil began in January 2021.

The health crisis context was considered during all stages of the study while maintaining individual protection measures, hygiene, and physical distancing.

The convenience sample covered different ethnicities, social conditions, genders, and age groups. The health unit managers appointed the professionals interviewed, who should have had at least one year of experience in the unit and involvement in activities to combat COVID-19. This strategy aimed to involve the health professionals who were most engaged in actions to tackle COVID-19. However, it may have led to the participation of professionals more aligned with the policies defended by the municipal administration. The criterion of at least one year of work experience in each unit was established to identify professionals with experience in implementing testing strategies adopted by the municipality over the past year. This criterion aimed to exclude recently hired participants who would not have sufficient knowledge to accurately describe how the testing process had been conducted during the COVID-19 pandemic. The interviews with users were not included in the results of this study.

Three focus groups (FGs) were held, consisting of at least two health professionals and the manager of two units where testing was performed, with a means of 6 participants per FG. In the text, FG are identified as FG01 to FG03.

Semistructured interview scripts were drawn for health professionals, taking into account their specificities, identification, perceptions of testing, work processes in dealing with the pandemic, relationships with the care network, conceptions and practices of prevention, diagnosis, and care concerning COVID-19, and means of communication between the health unit and the community. Another script was drawn to conduct focus groups to understand the procedures and logistics for attracting users of the health services included in the study. So, the interviews sought to identify how the work process for dealing with COVID-19 was carried out, as well as the facilities and difficulties in each unit to implement specific adequations to improve the TQT Project, while the focus groups confronted the different testing strategies used and identified the best practices in testing and caring for COVID-19 in PHC.

FG and interviews were recorded, transcribed, reviewed, coded, and anonymised to avoid identifying the participants. The health units were named UBS01 to UBS22 (in Portuguese, Unidade Básica de Saúde). The samples were then subjected to content analysis [13], composed of three phases: pre-analysis (organisation of the material; systematisation of preliminary ideas), analysis and exploration of the material (coding phase, based on the predefined categories in Table 2) and treatment of the results and interpretation. Content analysis seeks to promote an understanding of the phenomenon. The variables were decoded using NVivo Pro 11® software. The following criteria were considered for analysis: a) profile of the study participants, b) receptiveness, c) diagnosis/testing, d) case follow-up, and e) follow-up in the care network (Table 2).

The empirical evidence highlights the need to look at these results from the theoretical perspective of the health work process. New health needs have been incorporated, modifying the object of practice and implying new arrangements within health units. The theory of the health work process [14, 15], the concepts of work agents (health professionals), objects (health needs), and means or instruments of work (knowledge, tools, relationships between professionals and service users and between professionals and each other) were used to prepare this article [15].

This study was conducted according to guidelines from the Brazilian Research Ethics Commission Resolution (numbers 466/2012 and 510/2016). The protocol was approved by the research ethics committees of the WHO (CERC.0128B) and the local Brazilian Institutional Review Board (protocol identification number 53844121.4.1001.5030).

A total of 22 health professionals were interviewed, most of whom were nurses (54.5%), women (95.5%), and 72.7% were black and brown, with an average age of 44.1 years, ranging from 28–62 years. A total of 19 health professionals participated in the three focus groups, 36.7% of whom were nurses, 26.3% were managers, and 21.1% were dentists, most of whom were women (78.9%), black and brown (84.2%), with an average age of 42.94 years, ranging from 29–60 years (Table 3). Of these, only one nurse and one dentist also took part in the interviews, resulting in a total of 43 health professionals who took part in the study.

The municipality has established criteria for case definition, notification procedures, clinical and laboratory diagnosis, clinical management, prevention, and control measures. A form was drawn to investigate cases of the new coronavirus and a protocol for reception, defining how to address respiratory symptoms and the flow of care in PHC [D1]. The municipality’s regulations listed actions inherent to ACS in preventing and controlling COVID-19, specific guidelines for oral health, the Expanded Family Health and Primary Care Support Center (NASF-AB, in Portuguese, Núcleo de Atenção à Saúde da Família), and specific program activities. Mild cases should be treated and guided at the UBS, whereas severe cases should be stabilised and referred by mobile emergency care services [D1].

In the HD, it took much work to establish double entry in terms of physical structure since most units had a single door, making it impossible to provide differentiated access for respiratory symptoms and routine services. Elective dental care was suspended between March and June 2020, while emergency care was maintained [D2]. Medical and nursing care focused mainly on pregnant women, individuals with comorbidities, and children.

The initial reception at the front door was carried out by nurses, dentists, auxiliary staff, and ACS, followed by screening and referral to the appropriate service. The difficulties were related to the lack of personal protective equipment (PPE) and COVID-19 tests at the start of the pandemic, fear, a lack of knowledge, and uncertainty about the disease. Some professionals initially felt unsafe participating in COVID-19-related actions, but everyone became involved over time. Professionals over the age of 60, pregnant women, or those with comorbidities were teleworked.

The program “Municipality Protects – Primary Healthcare against COVID-19” (Municipality Protects), launched on 17/06/2020, promoted the reorganisation of the functioning of PHC via telemedicine to avoid a large flow of people in health units and allowed access to essential services [D3]. The changes to the work process in PHC to implement this program were guided by a technical note [D4]. The program’s objectives were as follows: 1. to protect and care for individuals and communities impacted by the pandemic; 2. to trace contacts and block transmission of the disease; 3. to monitor cases; 4. to welcome the population and their medical care needs, even if not associated with COVID-19; and 5. to protect and support health workers during the pandemic [D4].

Based on the identified problems, the TQT project proposed visiting the units to identify spaces for installing external structures for testing, as well as planning an adequate supply of PPE for professionals.

According to municipal regulations, “[...] diagnosis depends on clinical-epidemiological investigation, physical examination, and laboratory tests [...]” ([16], p. 4). The laboratory diagnosis of suspected cases was initially done in reference collection units (RCUs) [D1]. It was not recommended to be carried out in PHC [D5], where the clinical-epidemiological diagnosis was carried out based on flu-like symptoms and a history of close contact with laboratory-confirmed COVID-19 cases for which it was not possible to carry out a specific laboratory investigation [D6].

In cases of homeless people, if the suspicion was confirmed, they were guaranteed shelter through the Department of Social Promotion, Combating Poverty, Sports and Leisure, or housing assistance [D3].

Initially, the testing actions took place via a joint effort strategy in tents in higher-case neighbourhoods. Antibody tests (IgM and IgG) and rapid antigen tests were used on symptomatic individuals, with a limited supply of 150 daily tests in each tent. The results were sent via cell phone text messages. Several professionals interviewed participated in these testing sessions, especially dentists when elective dental appointments were suspended. Masks and food baskets were also distributed with this strategy [D7].

In 2022, testing actions were distributed throughout the municipality’s 12 HDs, with PHC units offering the service being publicised daily on social media (Instagram). The rapid antigen test was the most widely used method, and the actions were concentrated: 31.8% of the UBS performed or had already performed COVID-19 tests, with a higher concentration in the UBS with the Family Health Strategy (ESF, in Portuguese, Estratégia Saúde da Família) (Table 4).

To address these testing-related issues, the TQT project proposed expanding testing access across all primary healthcare units in the area where the study was implemented. Additionally, a rapid testing module using antigen tests was added to the digital platform, ensuring immediate result availability for patients and the issuance of a signed test report by professionals within 48 hours after result verification.

Most professionals opposed the strategy of concentrated testing, saying that it created a work overload:

[...] These units could not do anything more, practically, than test and attend to COVID. (Interview UBS03, doctor, 36 years old, female, black)

There was a delay or weakness at the central level in coordinating the implementation of testing actions.

There was no definition [...] The municipality leaves it up to the teams to get together and decide. [...] While the dentists were testing, they tested 20 a day. [...] the municipality has invented a protocol, which nobody knows about, that they can test only one [person] per hour because they have to lower the aerosol. One per hour, four per shift, you cannot test anyone.” (Interview UBS03, doctor, 36 years, female, black)

This delay caused tension within the teams due to the lack of guidance on the number of tests to be carried out. The number of tests was determined at each PHC unit according to the internal protocol for testing and the capacity for medical care after the test.

There were six per shift, with two more free, already requested. (FG03, UBS06, Dentist, 30 years old, female, black)

Thirty tests (Interview UBS18, Nursing technician, 61 years old, female, black)

100 tests. We were doing 110, 90. (FG03, UBS01, nurse, 43 years old, male, brown)

This issue led to a conflict between the health teams participating in a focal group (FG03): while one unit performed less than 20 tests daily, the other performed approximately 100. The procedures adopted between one testing strategy and another (waiting time and sanitising the room) differed, as did how medical care for positive cases was conceived. First, medical care for the user with a positive test was described as a “pandemic medical appointment or consultation” only to identify symptoms, prescribe medication, and guide the patient. On the other hand, the doctors on UBS06 considered each visit a family health routine consultation, which implies considering the expanded concept of health. However, this could mean more time with the patient in the doctor’s office, resulting in longer waiting times for users with positive cases of COVID-19, expecting medical appointments.

[...] when I go for a consultation, when I’m not in the pandemic, I’m at a family health consultation [...] I have to do all the nutrition and medication stuff. The moment I am in the pandemic, when the patient leaves the room positive [for COVID-19], I know what his symptoms are; he has rhinitis, [...] he has a headache. He has a runny nose, and his throat hurts. I’m not going to keep asking him [about other aspects of his life] (FG04, UBS01, Doctor, 42 years old, female, brown)

The age group to be tested also generated doubts and different attitudes on the part of the teams. In children, the decision to test seemed to be linked to parental acceptance, the risk of the condition worsening, and epidemiological purposes.

[...] under the age of two. [...] For example, for babies, there’s always a question that the team decides on the spot. The parents decide whether it is worth it or not. [...] Epidemiologically, we establish: so if you are, [...] the child probably is. [...]. (FG04, UBS01, nurse, 43 years old, male, brown)

There was a reduction in routine actions and services at the UBS to focus on COVID-19 testing.

We had to turn the unit over to testing practically. Therefore, the ESF itself did not exist (...). If you have testing at the unit (...), the flow is completely changed. (Interview UBS12, Dentist, 38 years old, female, brown)

The professionals considered the physical structure of most of the units inadequate, and there were insufficient human resources to adapt the PHC units to the operational testing requirements.

[...] we do not have the human resources for this. We have to work around the schedule to meet the unit’s demands. [...] If we had the testing, we would not have the vaccine. [...] we do not have this kind of structure, so how will we make sure we do not cross this public? [...] (Interview, UBS05, nurse, no age information, female, white)

[...] Many people had to leave because they got COVID-19. Many people got sick. [...] The risk group, which does not meet the demand for COVID [...], this whole process [...] impacted the team. (FG04, UBS01, Manager, 57 years old, female, brown)

Some attitudes of resistance to adhering to the testing work were highlighted.

[...] some professionals do not feel comfortable testing, and we have respected that [...] when the rules came down that everyone must test, technicians, nurses, doctors or dentists, and if someone does not test, it is as if the team is taking over for them. [...] it is a pact between colleagues.” (FG04, UBS01, nurse, 43 years old, male, brown)

The statements that opposed testing in PHC units were justified by technical issues related to inadequate space, insufficient human resources, and a lack of training. The need for more training and capacity building stood out. Most professionals reported having undergone training on their initiative. Training for COVID-19 testing, which was restricted to units that carried out testing, was practical and was carried out by professionals from the municipal Central Laboratory (LACEN, in Portuguese, Laboratório Central), usually before testing began in the unit.

The TQT conducted training and continuous education throughout the entire intervention process, starting with pre-planned training topics but also incorporating subjects based on professionals’ reports.

There were situations associated with pressure on the services to test for work-related reasons, often frustrated by the lack of available tests and/or criteria for testing.

Most people, when they seek testing, [...] it is more for work reasons.” (FG04, UBS06, Dentist, 30 years old, female, black)

[...] people want to know more about protecting someone. Or the labour issue. [...] this is an apparent demand from people. (FG04, UBS01, nurse, 43 years old, male, brown)

[...] the problem is when it is negative. Because they do not take the paper that it is negative, the company is left with the question of whether or not to accept it because there is no way of proving it, only after the test results return. (FG04, UBS06, nurse, 36 years old, male, white)

The insufficiency of the public network (low number of testing units and quantity of tests), coupled with a lack of planning, with testing points defined without much notice, left the population and professionals disoriented.

[...] there’s no prior information [...] it arrives at the last minute. [...] (Interview, UBS17, doctor, 28 years old, female, brown)

Another aspect identified was the lack of information for case surveillance:

I: And if you wanted to know the number of cases in the area, do you have any place to look for this information? The number of hospitalisations in the area, deaths...

- No, nothing. (Interview, UBS03, doctor, 36 years old, female, black)

A system developed by the Municipal Health Secretariat was mentioned, which would be used to monitor cases but was not used in practice due to some flaws.

[...] this system was very bad [...] you did not know where the person had tested it, did not have any information that you were going to call, and could not copy the data to put it in a table. [...] (Interview, UBS03, doctor, 36 years old, female, black)

Because of the testing concentration in a few UBS in the municipality, the health professional’s perception of work overload and the implications for other programs offered, the TQT project implemented the testing strategy in all PHC units. A digital platform was developed encompassing the management and surveillance of suspected and confirmed COVID-19 cases. This platform was designed with distinct interfaces for healthcare professionals and community members. For healthcare professionals, it included: situation analysis with the distribution of positive cases, contacts, and deaths by geographic area within the territory covered by the primary healthcare team; case monitoring management, allowing the registration of symptoms of monitored users and facilitating coordination with other levels of the healthcare network; and access to test results. For community members, the platform provided access to test results, vaccination monitoring, contact with primary healthcare centres, and educational videos and messages.

Patients without signs of severity should be isolated at home with remote monitoring every 48 hours by health unit professionals. Patients could be discharged safely or, in the event of complications, referred to an Emergency Care Unit (UPA, in Portuguese, Unidade de Pronto Atendimento) [D4]. The Municipal Health Secretariat provided at least one tablet for each health team through a project to address the pandemic focus on primary health care. The health units carried out telemonitoring of cases by telephone or via the WhatsApp business app [D4].

Professionals reported following the Municipal Health Secretariat guidelines for monitoring cases, and telemonitoring was delegated to professionals working remotely. After vaccination, this activity became part of the schedule of health actions under the responsibility of all PHC team professionals.

In the event of a referral to a UPA, the patient should carry a referral and counter referral form and a copy of the notification form. All units reported receiving patients and referring them for COVID-19 testing, with a medical request, when the unit did not do this. In general, the units did not receive feedback on the referral for testing, except when the user returned to the service.

In the TQT project, any user within the coverage area could undergo testing at the project’s designated units. The test was made available on the digital platform, and telemonitoring was conducted by members of the user’s reference unit team.

Communication between health units and users was mainly conducted face-to-face. The professionals reported that communication/dissemination of information about the services was the prerogative of the Municipal Health Secretariat.

We do not do the dissemination. It is the City Hall that does it. The prefecture publicises the points, and the patients seek them out according to demand [...] I felt there was a lack of communication between the prefecture and the professionals. [...] The health unit does not have an Instagram; it does not have a Face [Facebook], but they use the mural to inform the community. (Interview, UBS17, doctor, 28 years old, female, brown)

The TQT digital platform also incorporated a chatbot to provide information on COVID-19, testing, and symptom registration for monitored users to enhance communication efficiency between users and primary healthcare units. Web-based communication strategies and social media were prioritized to ensure patient and healthcare team safety while reducing community transmission. Additionally, existing social infrastructure and communication strategies within the communities, such as community radio stations and sound trucks, were utilized due to their broad reach.

The study population was composed mainly of black and brown women, corroborating the predominant ethnicity in the municipality and women’s participation in health careers. In general, women are more exposed to illness, both in the professional and domestic spheres, and the physical distancing imposed by the pandemic has aggravated situations of violence, reduced access to reporting services, and increased barriers to accessing health services. In addition, women have taken on an increased workload because of their responsibility and lack of sharing household chores, which affects their physical and mental health [16].

A study that assessed the quality of PHC in a municipality in the state of Minas Gerais, Brazil, during the first six months of the pandemic reported low performance. The explanation, in this case, may be related to the disruption of local health services due to the federal government’s decision-making in the pre-pandemic period, with a reduction in the number of ACSs, flexible working hours and changes related to the NASF and PHC funding [17]. In Brazil, health is a right of all citizens and a state’s duty, but financing is always a challenge for SUS maintenance, and the PHC has not been sufficiently strengthened to address the pandemic and its consequences by the Federal government [3].

In general, there is a need to reorganize the work process and care flows so that professionals, whether they are ACS professionals [18], NASF professionals [19], or nurses [20], can carry out their activities. The use of PPE, telehealth, new ways of building and maintaining links, reorganization of the work setting [19], reduction or suspension of home visits and group activities [21], increased workload and administrative activities [21, 21], and increased emotional distress, with feelings of anguish, fear, insomnia, sadness, anxiety, and the loss of relatives, friends, patients or coworkers [21], are aspects highlighted by studies related to the reorganization of the work process in PHC during the COVID-19 pandemic.

Despite the denialism of the president of Brazil, the response organization in the municipality under study followed WHO guidelines and scientific knowledge. It was initially based on nonpharmacological measures and guidelines for changes in the work process of PHC teams, especially regarding new technologies and procedures [D4]. However, given that the disease was initially unknown, the regulations were often published late in relation to the need to adapt the services, so the decision-making process was left to the teams themselves, adapted later when necessary.

The problems at the start of the pandemic in the municipality were similar to those seen in other countries, with insufficient PPE, the emotional commitment of professionals related to fear, lack of knowledge about the disease, the severity and lethality of cases, and uncertainty. Testing actions were quite limited, either quantitatively or qualitatively (using antibody tests), with joint efforts, called testing blitzes, being carried out in locations with a relatively high concentration of cases to treat symptomatic patients.

The strategy varied over time. When testing began to be carried out in PHC units, it was concentrated mainly in those with ESF, which meant that the teams’ work process was compromised from its object, which was originally related to the expanded concept of health. Family health teams were then asked to develop more restricted actions and incorporate new knowledge and tools, especially related to communication technology, telehealth, or e-health. The use of health information and communication technologies and telehealth in PHC has been a strong ally in establishing care, promoting health, and addressing the COVID-19 pandemic [22]. The TQT was implemented with a monitoring and implementation committee that included managers from the municipal and district health departments. This approach allowed for the incorporation of perspectives not only from researchers but also from managers and healthcare professionals.

When the UBS01 doctor explains the difference between a “pandemic” consultation and a “family health” consultation, she highlights the different conceptions of the object of health work and its implications for the work process of PHC teams [14, 15]. On the other hand, the fact that the health family team at UBS06 did not proceed with this distinction with respect to the time of the consultations during the pandemic period resulted in a limited number of tests offered at that health unit, corresponding to 10% of those at UBS01. These questions were discussed with the healthcare professionals during the training made by TQT project team.

The health administration needs to regulate these changes in the work process. As this is a matter of planning and managing services, each unit cannot decide alone. How many tests per shift will a PHC unit that will prioritise the testing strategy be able to do? How many professionals and which professional categories will be involved? What services will no longer be offered or limited for this to happen? Where can the demand for this service be redirected? The number of tests provided at the units varied from 10–100 daily. There was unnecessary overload and tension in this situation due to a lack of management intervention. On the other hand, regulations must be adapted to technical and scientific knowledge and local reality. TQT project ensured that tests were offered to everyone, facilitating access and distributing the work between all units. It has also reduced geographical and economic barriers to access to testing, given the availability of tests closer to users’ homes.

The inadequate physical structure of health units (small, unventilated rooms) made it difficult for them to adapt to the reality imposed by the pandemic. There is also a need for more human resources, especially when faced with the illness of frontline professionals. These issues have been highlighted in other studies on PHC in the context of the COVID-19 pandemic [20]. The TQT supported the testing strategy by equipping healthcare units with an external structure that enabled COVID-19 testing to be conducted outside the facilities.

The incorporation of new tools, whether soft (relational), soft-hard (technical knowledge and expertise), or hard (equipment) technologies [23], had an effect on the work process, compromising the supply of services. Given the characteristics of the forms of transmission of COVID-19, dentistry was initially configured as one of the professions most at risk for professionals and service users. In the municipality studied, dental care was suspended until June 2020, a measure adopted in several countries [24]. Dentists were assigned various functions inside the UBS or other health units during this period. A group of four dentists was the central workforce mobilized to form the Workers’ Support Service Center (NAAT, in Portuguese, Núcleo de Apoio à Saúde do Trabalhador), a service focused on the health care of workers linked to the Municipal Health Secretariat that operated between May 2020 and November 2021 [25].

The TQT project provided a grant to selected professionals in the health teams to perform research-related tasks such as reporting and leading the team in new actions. This ensured a referral in each unit and encouraged participation. On the other hand, sometimes those who did not receive the grant felt that they did not need to develop the same responsibilities.

Other programs and/or care guidelines have been compromised or weakened by the necessary availability of professionals to carry out actions aimed at dealing with COVID-19 or by the targeting of PHC actions to specific groups. This problem was, in part, resolved with the testing offer in all PHC units, reducing the work overload.

This situation leads to the late diagnosis of diseases or their nontreatment, as well as the recrudescence of previously controlled diseases and an increase in acute conditions [26]. In this way, services must be organized to guarantee care for the health needs damaged during the pandemic, represented by care for users whose health conditions have worsened. In the return to a “normal” offer of services in the PHC units, this situation must be considered, trying to identify people with worsened conditions by active search for cases.

The changes in the work process organization in PHC were regulated by a specific project (“Municipality Protects”), emphasizing telemedicine actions and guaranteeing a tablet for each family health team. The telemonitoring of cases was initially concentrated on professionals working remotely, such as those in their 60s, those with comorbidities, and pregnant women. After vaccination, however, all professionals carried out activities to address the pandemic, such as reception, screening, testing, guidance, and telemonitoring. In the TQT project, telemonitoring was carried out by members of the health unit teams themselves.

The main barriers to access testing identified in a literature review [27] were the cost of testing, low level of health literacy, low trust in the health system, reduced availability and accessibility to testing sites, stigma, and consequences of testing positive. Possible strategies for reducing barriers include free testing, raising awareness about the importance of testing, presenting different testing options and types of testing sites (drive-through, walk-up, at home), ensuring transportation, and wage or housing support for self-isolation [27]. Behavioural barriers have also been related to COVID-19 testing, even in health systems where they are offered free of charge and widely available, such as in Australia [28] and England [29]. Information barriers, such as not knowing where and when to test [29], are among the most important. Although strategies such as disseminating videos with appropriate language on social networks can reduce this type of barrier, increased information is only sometimes related to greater adherence to testing [28]. The difficulties can be even more significant in countries that had a more limited supply of tests during that period, such as Brazil.

Before the pandemic, the shortage of human resources aggravated what happened in several places, with many professionals falling ill, generating overload and further illness among colleagues. The very dynamics of carrying out the research were affected. Several interviews had to be rescheduled at the last minute because the professional had symptoms or tested positive. Anyway, the research team tried to maintain the activities and used masks, physical distancing and other preventive measures to protect themselves. And also tried to ensure the best possible conditions for the development of research activities.

Another relevant aspect was the need for more training. To carry out the rapid antigen test, considering that the units already performed rapid tests for other diseases, practical education was implemented at the unit itself by professionals from the municipal laboratory. This was the only training mentioned by the professionals. In this sense, initial training sessions were held, covering all healthcare professionals involved. These sessions were remote and conducted by the TQT project team and also invited specialists. Other initiatives were conducted during all the TQT interventions, with periodic training for managers and health professionals.

The lack of information limits the ability of actions to follow up with cases and contacts. If an individual was referred by a PHC unit and tested positive at another healthcare unit, the case was not notified to the initial care unit or the unit in their area. These problems related to the functioning of the epidemiological surveillance system possibly contributed to limitations in controlling the pandemic during that period. Countries that have invested in health surveillance actions and strategies (testing and monitoring cases and contacts) have managed to control the pandemic better [30, 31]. TQT project developed surveillance strategies with a digital platform with testing, case and contact tracing, telemonitoring, active surveillance and a real-time dashboard.

In the media, it seemed necessary to incorporate social networks such as Instagram, Facebook, and WhatsApp, as well as invest in health education actions and disseminate knowledge about the disease to consolidate the PHC team as a reliable source of information. It was also implemented by the TQT project.

The COVID-19 pandemic has had an impact on all health services. Despite having the potential to contribute to tackling the pandemic, PHC was weakened in Brazil due to changes that occurred in the pre-pandemic period, including in its funding, and was not initially prioritized. When the testing strategy in the municipality began to involve PHC units, those that concentrated the actions reduced the supply of other services. The difficulties in implementing testing in PHC units were inadequate infrastructure, insufficient human resources, and changes in the work process of health teams, with repercussions for the general health conditions of the population. The model of care based on the ESF ceased to exist during several moments of the pandemic, especially for the PHC units offering COVID-19 tests, as explained in the results.

At various times, the researchers witnessed PHC units with crowds in external and internal areas, especially for testing and vaccination.

The need to prove their positive or negative status for COVID-19 to employers is one of the main reasons for seeking testing; however, this is not a criterion for testing in the municipality, and it is essential to include this possibility in the testing protocols of the TQT project.

The FE identified barriers to testing, and its findings helped design the intervention, including the need to adapt the units’ physical structure to implement the TQT project’s actions. The concentration of testing actions in a few units is an essential barrier to access, and these actions are recommended to be carried out in as many PHC health units as possible.

We should also highlight the limitations of the study. The use of a convenience sample of healthcare professionals indicated by the PHC unit manager and the time when the research had begun (during the omicron peak in Brazil and when quite 80% of the population had received at least one vaccine dose and about 70% had received the initial COVID-19 vaccine protocol) probably have interfered in the results and the epidemiological situation. We should also consider the memory bias about the situation at the beginning of the pandemic in early 2020. Anyway, these limitations did not negatively influence the propositions for TQT project implementation.

Finally, it should be emphasised that not all of the strategies implemented in the TQT project have been incorporated by the Municipal Health Secretariat into its testing strategy, whether for financial, administrative, political or even timing reasons.

The FE identified essential barriers to TQT implementation and promoted adjustments that ensured its viability and acceptance. Sharing the results with the strategy implementation team during the operationalization of the FE was important for incorporating stakeholders’ views into the intervention design early and adapting the structure and human resources to ensure the viability of the intervention.

On the basis of the results of the formative research, several strategies were implemented: testing was offered in more health units to increase the population’s access to tests for the SARS-CoV-2 virus; training of professionals; development and use of a digital platform with a real-time situation dashboard; notification control; availability of test results to users; telemonitoring; tracking; and greater availability of PPE.

The FE occurred during the Omicron variant peak, and it was essential to consider the safety of all research participants and research team members.

Most of the researchers needed to familiarise themselves with the health district area. As we were working in a highly socially vulnerable area, some PHC units are located in areas of urban violence, and a careful attitude was necessary to avoid violence among the research team. Some strategies, such as planning visits with the managers of PHC units, using institutional vehicles for the transportation of the research team, and avoiding visiting PHC units in urban violence areas on holidays eves and days with little movement, were adopted.

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Community health agents, in Portuguese, Agentes Comunitários de Saúde

Coronavirus disease 2019

Family Health Strategy, in Portuguese, Estratégia Saúde da Família

Formative evaluation

Focus group

Health district

Expanded Family Health and Primary Care Support Center, in Portuguese, Núcleo Ampliado de Saúde da Família e Atenção Básica

Primary health care

Personal protective equipment

Unified Health System, in Portuguese, Sistema Único de Saúde

Project “Expansion of testing, quarantine, e-health and telemonitoring strategies to combat COVID-19 in Brazil”

PHC health unit, in Portuguese, Unidade Básica de Saúde

Prado NM de BL, Rossi TRA, Chaves SCL, Barros SG de, Magno L, Santos HLPC dos, Santos AM dos. The international response of primary health care to COVID-19: document analysis in selected countries. Cad Saúde Pública. 2020. https://doi.org/10.1590/0102-311X00183820.

Fernandez MV, Castro DM de, Fernandes L da MM, Alves IC. Reorganizar para avançar: a experiência da Atenção Primária à Saúde de Nova Lima/MG no enfrentamento da pandemia da Covid-19. APS em Revista. 2020. https://doi.org/10.14295/aps.v2i2.84.

Cirino FMSB, Aragão JB, Meyer G, Campos DS, Gryschek ALFPL, Nichiata LYI. Desafios da Atenção Primária no contexto da Covid-19: a Experiência De Diadema, SP. Rev Bras Med Fam Comunidade 2021. https://doi.org/10.5712/rbmfc16(43)2665.

Sarti TD, Lazarini WS, Fontenelle LF, et al. Qual o papel da Atenção Primária à Saúde diante da pandemia provocada pela Covid-19? Epidemiol e Serv saude Rev do Sist Unico Saude do Bras. 2020. https://doi.org/10.5123/s1679-49742020000200024.

Article Google Scholar

Farias LABG, Colares MP, Barretoti FKA, Cavalcanti LPG. O papel da atenção primária no combate ao Covid-19: impacto na saúde pública e perspectivas futuras. Rev Bras Med Fam Comunidade. 2020. https://doi.org/10.5712/rbmfc15(42)2455.

Article Google Scholar

Medina MG, Giovanella L, Bousquat A, Mendonça MHdeM, Aquino R. Atenção primária à saúde em tempos de Covid-19: o que fazer? Cad Saude Publica. 2020. https://doi.org/10.1590/0102-311X00149720.

Teixeira MG, Medina MG, Costa MCN, Barral-Netto M, Carreiro R, Aquino R. Reorganização da atenção primária à saúde para vigilância universal e contenção da Covid-19. Epidemiol Serv Saúde. 2020. https://doi.org/10.5123/S1679-49742020000400015.

Article PubMed Google Scholar

Scriven M. The methodology of evaluation. In: Gagné R, Scriven M, editors. Perspectives in curriculum evaluation. Chicago: Rand MacNally; 1967. p. 39–83.

Google Scholar

Wyllie A, Casswell S. Formative evaluation of a policy-orientated print media campaign. Health Promot Int. 1992. https://doi.org/10.1093/heapro/7.3.155.

Article Google Scholar

Tessmer M. Formative evaluation alternatives. Perform Improv Q. 1994. https://doi.org/10.1111/j.1937-8327.1994.tb00613.x.

Article Google Scholar

Elwy AR, Wasan AD, Gillman AG, Johnston KL, Dodds N, McFarland C, Greco CM. Using formative evaluation methods to improve clinical implementation efforts: description and an example. Psychiatry Res. 2020. https://doi.org/10.1016/j.psychres.2019.112532.

Article PubMed Google Scholar

Cresswell K, Williams R, Sheikh A. Developing and applying a formative evaluation framework for health information technology implementations: a qualitative investigation. J Med Internet Res. 2020. https://doi.org/10.2196/15068.

Article PubMed PubMed Central Google Scholar

Bardin L. Análise de conteúdo, vol. 70. São Paulo: Edições; 2016.

Google Scholar

Mendes-Gonçalves RB. Práticas de saúde e tecnologia: contribuição para a reflexão teórica. Brasília: Organização Pan-americana de Saúde; 1988.

Google Scholar

Mendes-Gonçalves RB. Práticas de Saúde: processos de trabalho e necessidades. São Paulo: Centro de Formação dos Trabalhadores em Saúde da Secretaria Municipal da Saúde; 1992.

Google Scholar

Reis AP dos, Góes EF, Pilecco FB, Almeida M da CC de, Diele-Viegas LM, Menezes GM de S, Aquino EML. Desigualdades de gênero e raça na pandemia de Covid-19: implicações para o controle no Brasil. Saúde Em Debate. 2020. https://doi.org/10.1590/0103-11042020E423.

Nascimento MC do, Silva SA da, Oliveira AAM de, Moura HSD, Araújo JST de, Delpino FM, Soares D de A, Fronteira ISE, Sawada NO, Arcêncio RA. Quality of primary health care during the COVID-19 pandemic: evaluation by users affected by the disease. O Mundo Da Saúde. 2022. https://doi.org/10.15343/0104-7809.202347e14272022P.

Maciel FBM, Santos HLPC dos, Carneiro RA da S, Souza EA de, Prado NM de BL, Teixeira CF de S. Agente comunitário de saúde: reflexões sobre o processo de trabalho em saúde em tempos de pandemia de Covid-19. Ciênc Saúde Colet. 2020. https://doi.org/10.1590/1413-812320202510.2.28102020.

da Silva DB, da Silva NM. Reflections of the covid-19 pandemic in the process of occupational therapeutic in primary health care. Rev Interinst Bras Ter Ocup. 2022. https://doi.org/10.47222/2526-3544.rbto50073.

Article Google Scholar

Felix RS, Pinheiro VR de M, Neves Junior TT das. Percepções dos enfermeiros sobre as condições de trabalho e infraestrutura das unidades de atenção primária em saúde. Tempus Actas de Saúde Colet. 2023. https://doi.org/10.18569/tempus.v16i4.3062.

Prats GL. Os impactos da pandemia da COVID-19 no trabalho e saúde dos agentes comunitários de saúde. In: Pantheon - Federal University of Rio de Janeiro Institutional Repository. Faculty of Business Administration and Sciences of the Federal University of Rio de Janeiro (FACC/UFRJ). 2021. http://hdl.handle.net/11422/18754. Accessed 22 Jan 22.

Fernandes GA de S, Oliveira TF de, Dias CI da S, Silva ALA da, Belian RB, Claudino LMZ. Uma prática para (re)organização do processo de trabalho em Saúde da Família: o telemonitoramento em saúde no contexto da Covid-19. APS em Revista. 2022. https://doi.org/10.14295/aps.v4i2.236.

Merhy EE. Saúde: a cartografia do trabalho vivo. 2nd ed. São Paulo: Hucitec; 2005.

Google Scholar

COVIDental Collaboration Group. The COVID-19 pandemic and its global effects on dental practice. An International survey. J Dent. 2021. https://doi.org/10.1016/j.jdent.2021.103749.

Article Google Scholar

Mendonça TT de. Acessibilidade ao núcleo de apoio e atendimento ao trabalhador durante a pandemia de COVID-19. In: Plataforma Sucupira. Coordination of Higher Education Personnel (CAPES, Brazil). 2023. https://sucupira-legado.capes.gov.br/sucupira/public/consultas/coleta/trabalhoConclusao/viewTrabalhoConclusao.jsf?popup=true&id_trabalho=13791090#. Accessed 26 Feb 24.

Ramos TC da S, Silva TF da. Work in primary health care and the Covid-19 pandemic: an experience report. Res Soc Dev. 2021. https://doi.org/10.33448/rsd-v10i3.13396

Embrett M, Sim SM, Caldwell HAT, Boulos L, Yu Z, Agarwal G, Cooper R, Aj AJG, Bielska IA, Chishtie J, Stone K, Curran J, Tricco A. Barriers to and strategies to address COVID-19 testing hesitancy: a rapid scoping review. BMC Public Health. 2022. https://doi.org/10.1186/s12889-022-13127-7.

Article PubMed PubMed Central Google Scholar

Bonner C, Batcup C, Cvejic E, Ayre J, Pickles K, Copp T, et al. Addressing behavioral barriers to COVID-19 testing with health literacy-sensitive ehealth interventions: results from 2 national surveys and 2 randomized experiments. JMIR Public Health Surveill. 2023. https://doi.org/10.2196/40441.

Article PubMed PubMed Central Google Scholar

Graham MS, May A, Varsavsky T, Sudre CH, Murray B, Kläser K, et al. Knowledge barriers in a national symptomatic-COVID-19 testing program. PLOS Glob Public Health. 2022. https://doi.org/10.1371/journal.pgph.0000028.

Article PubMed PubMed Central Google Scholar

Rossi TRA, Soares CLM, Silva GA, Paim JS, Vieira-da-Silva LM. A resposta da Coreia do Sul à pandemia de COVID-19: lições aprendidas e recomendações a gestores. Cad Saúde Pública. 2022. https://doi.org/10.1590/0102-311X00118621.

Article PubMed Google Scholar

Barros SG de, Cruz DN, Souza JC, Silva LA, Guimarães MC da S, Rezende MM, et al. Vigilância e elevada cobertura vacinal: como Portugal superou o colapso e retomou o controle da pandemia. Ciênc Saúde Colet. 2023. https://doi.org/10.1590/1413-81232023285.10732022

Download references

We thank the Municipal Health Secretariat, health professionals, community health workers, and local communities for supporting this project. We also thank the Brazilian Ministry of Health, UNITAID, and the World Health Organization (WHO) for supporting this project.

This work was supported by UNITAID - Innovation in Global Health [Public notice COVID-19 UNITAID/2021].

Faculty of Dentistry, Federal University of Bahia, Rua Araújo Pinho, 62, Canela, Salvador, Bahia, CEP: 40.110-912, Brazil

Sandra Garrido de Barros, Ana Clara de Rebouças Carvalho & Denise Nogueira Cruz

Collective Health Institute of Federal University of Bahia, Salvador, Bahia,, Brazil

Sandra Garrido de Barros, Camila Ramos Reis, Laio Magno, Inês Dourado & Ligia Maria Vieira-da-Silva

State University of Bahia, Salvador, Bahia, Brazil

Thais Regis Aranha Rossi, Sisse Figueiredo de Santana & Laio Magno

You can also search for this author inPubMed Google Scholar

You can also search for this author inPubMed Google Scholar

You can also search for this author inPubMed Google Scholar

You can also search for this author inPubMed Google Scholar

You can also search for this author inPubMed Google Scholar

You can also search for this author inPubMed Google Scholar

You can also search for this author inPubMed Google Scholar

You can also search for this author inPubMed Google Scholar

You can also search for this author inPubMed Google Scholar

SGB: methodology, investigation, data curation, formal analysis, writing - original draft; TRAR: conceptualization, project administration, formal analysis, writing – review & editing; ACRC: methodology, investigation, data curation, formal analysis, writing - original draft; DNC: methodology, investigation, data curation, formal analysis, writing - original draft; SFS: investigation, data curation, formal analysis; CRR: investigation, data curation, formal analysis; LM: conceptualization, project administration, writing – review & editing; ID: funding acquisition, project administration, writing – review & editing; LMVS: methodology, formal analysis, writing – review & editing.

Correspondence to Sandra Garrido de Barros.

The project was approved by the ethics and research committee of the Institute of Collective Health at the Federal University of Bahia, under the number 53844121.4.1001.5030, and has been performed in accordance with the ethical standards of the Declaration of Helsinki and its later amendments or comparable ethical standards. All the participants agreed to take part by signing the Free and Informed Consent Form.

Not applicable.

The authors declare no competing interests.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

de Barros, S.G., Rossi, T.R.A., de Rebouças Carvalho, A.C. et al. Evaluation of the COVID-19 testing strategy in PHC of a high-vulnerability health district in Brazil, 2020-2022. BMC Public Health 25, 2101 (2025). https://doi.org/10.1186/s12889-025-23229-7

Download citation

Received: 28 November 2024

Accepted: 19 May 2025

Published: 05 June 2025

DOI: https://doi.org/10.1186/s12889-025-23229-7

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative