Adherence, non-adherence, and abandonment of child follow-up: Mixed methods approach


Bianca Machado Cruz Shibukawa1Gabrieli Patrício Rissi1Roberta Tognollo Borota Uema1Maria de Fátima Garcia Lopes Merino1, Ieda Harumi Higarashi1


State University of Maringá 




Objective: To analyze the adherence, non-adherence, and abandonment of the follow-up of children referred to the high-risk reference centers of the Paraná Mothers’ Network. Method: A convergent parallel mixed study. The study locus will be represented by the high-risk outpatient clinics of the Paraná Mothers’ Network of a Regional Health Area in the state of Paraná. The population will be of children referred to the outpatient clinics from January 2015 to December 2019, the relatives of children who attended, did not adhere and/or abandoned the follow-up in these centers, as well as city’s managers and professionals working in the regional headquarters of this Regional Health Area. The analysis of the quantitative data will be performed through spatial autocorrelation. It is intended to use exploratory analysis of spatial data to determine the existence of Global Spatial Autocorrelation and Local Spatial Autocorrelation Index. The interview data will be analyzed on the DSCsoft software, following the precepts proposed by the Collective Subject Discourse.

Descriptors: Child Health; Patients Dropping Out Treatment; National Health Programs; Evaluation of Health Programs and Projects; Maternal and Child; Health Services.




In Brazil, we saw a long path of public policy implementation aimed at maternal and child health, until 2011, when the Women and Children Health Care Network was created, which was called Rede Cegonha. It presented as a motto the guarantee of the reproductive right of women, with safety and quality, in addition to following-up the child from birth until two years of age, thus aiming to reduce maternal and child mortality(1).

Following this perspective, in 2012, in the state of Paraná, the Paraná Mothers’ Network (Rede Mãe Paranaense, RMP) is founded with the objective of improving maternal and child care and reducing the morbidity and mortality rates of this population. Its functional bases are founded in the risk stratification of pregnant women and children, referral and counter-referral defined flows, as well as the division of work among the primary, secondary, and tertiary levels of health care(2)

RMP users can be stratified into three groups: usual risk, intermediate risk, and high risk. Children stratified as “high risk”, the focus of this study, are those who have characteristics which were already strongly linked to greater risks of child morbidity and mortality, namely: prematurity, low birth weight, perinatal asphyxia, hyperbilirubinemia with exchange transfusion, congenital malformations, chromosomopathies, genetic diseases, positive neonatal screening, vertically transmitted diseases, severe malnutrition, delayed neuropsychomotor development, and repeated intercurrences with clinical repercussion(2).

The children stratified as high risk need to undergo a follow-up on growth and development, both in primary care and in high-risk outpatient facilities, which have the responsibility of offering multi-professional and specialized care, as well as to provide for all the exams needed for each child(2).

Immediately after its implementation, there has been a drop in the child mortality rates in the entire state; however, in the last years, the rates have increased again, outlining a movement contrary to that expected, given the technical, scientific, structural, and assistance contributions offered by the network(2).

Faced with this paradoxical scenario, the need was perceived to seek to perform this evaluation of the adherence, non-adherence, and abandonment of child follow-up since, for the proper functioning of the program and so that it can attain its objectives, it is fundamental to guarantee the effective participation of the users throughout the recommended follow-up, until discharge3)

Given the above, the following objective was established: to analyze the adherence, non-adherence, and abandonment of the follow-up of children referred to the high-risk reference centers of the Paraná Mothers’ Network.




A concomitant, convergent, and parallel study of mixed methods. The study locus will be two high-risk outpatient facilities, which were chosen for being responsible for serving an entire Regional Health Area of Northeast Paraná, which includes 30 cities. The population encompasses the total of children referred to the RMP centers in the period from January 2015 to December 2019, children’s family members who attended, did not adhere and/or abandoned follow-up in these centers, as well as managers of the 30 municipalities that compose the Regional Health Area, and professionals responsible for the RMP working in the Regional Health Area headquarters.

As inclusion criteria, for the family groups, the following were established: being responsible for taking the child to the consultation, accepting participating in the research and having it concluded, not having adhered or having abandoned the follow-up in the last six months prior to the initial data collection, in order to preserve the memory/recall of the facts. No exclusion factors were established. 

For the selection of the managers, it was established that each municipality will indicate a representative, according to a single inclusion criterion: participating in the meetings of the Regional Health Area driving group, as it is in these meetings that the network’s strategies are discussed and aligned. No exclusion factors were established.  

For the selection of the collaborators responsible for the RMP in the scope of the Regional Health Area headquarters, the following eligibility criteria were defined: all the team members who have worked for a minimum of one year in the network and who agreed to participate in the study. No exclusion factors were established.

 All the children included in the study will be evaluated regardless of the final date of the follow-up, that is, children included in December 2019 will be followed-up until December 2020, or until they abandon follow-up. Quantitative and qualitative data collection will occur simultaneously, according to the assumptions of the mixed methods: concomitant, convergent and parallel. To assure methodological quality, the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) tool will be used for the quantitative part, and the Consolidated criteria for reporting qualitative research (COREQ), for the qualitative part.

The quantitative instrument includes the year of follow-up, municipality of origin, and outcome (adherence, non-adherence, and abandonment). The health coverage data (percentage of coverage per municipality of interest) will be obtained through the National Registry of Health Facilities. As for the sociodemographic data of the population (schooling, income, gender, and area of residence), they will be obtained from the Atlas of Human Development of the municipalities, prepared by the United Nations Development Program. 

The qualitative stage will consist of recorded interviews, previously scheduled with the population that accepts to participate in the study, following the methodological basis of the collective subject discourse, which aims to put discourses together, as a puzzle, to express a certain phenomenon. It is intended to conduct the collection along with three collective subjects, namely: family members’ group, managers’ group, and the group of collaborators responsible for the RMP the study Regional Health Area.

To identify which sociodemographic and ESF coverage indicators had a greater geospatial impact on the distribution of the adherence, non-adherence, and abandonment table, a spatial regression multivariate analysis will be conducted by means of the R software.

For spatial autocorrelation, the intention is to use exploratory spatial data analysis to determine the existence of Global Spatial Autocorrelation (Moran’s I) and the Local Index of Spatial Autocorrelation (LISA). The data from the interviews will be transcribed in full and inserted in the DSCsoft software, and they will be analyzed following the six steps proposed by the Collective Subject Discourse.

Given the ethical-legal issues referred to by the National Health Council, this research was approved by the Research Ethics Committee of the State University of Maringá under CAAE: 24906719.9.0000.0104





The expectation is to identify the main reasons leading to adherence, non-adherence, and abandonment of the follow-up of children referred to the high-risk reference centers of the RMP.

The aim of this study is to provide an overview of the actual functioning of RMP, with a view to subsidizing improvements in care and in the patient retention rates. In addition, it is expected that the results can subsidize the professionals and health secretaries on planning the actions that favor the adherence of the families to child follow-up.

For children and families, it is expected that, upon the improvements provided for in the RMP, they may obtain easier access to the high-risk services, as well as the improvement in adherence to follow-up, aiming to guarantee the health of the at-risk child population.





1. Brasil. Ministério da Saúde. Portaria 1.459, de 24 de junho de 2011. Institui, no âmbito do Sistema Único de Saúde a Rede Cegonha. Diário Oficial da União 24 jun 2011; Seção 1.


2. Secretaria de Estado do Paraná. Linha Guia Rede Mãe Paranaense. Curitiba, PR: Secretaria de Estado do Paraná, 2018.


3. Sampaio LM, Reis AP, Neves GAO, Andrade DL. Street network: importance of prenatal follow-up and linking of pregnant to reference maternity. Cienc Cuid Saude [Internet]. 2018 [cited 2020 jul 25]; 17(1):1–7. Available from:  doi: 10.4025/cienccuidsaude.v17i1.38384  



Received: 07/28/2020

Revised: 10/09/2020