Perception and use of the Child's Health Handbook by professionals and mothers: an interactionist approach*

Objective: to understand the perception of health professio - nals and mothers about the Children’s Handbook. Methods: qualitative study, developed in Family Health Units, with 25 professionals and 11 mothers of children under three years old by means of semi-structured interviews. The empirical material was submitted to Inductive Thematic Analysis and interpreted in the light of Symbolic Interactionism. Results: Child Health Handbook was seen as a multi-professional and intersectoral tool that allows continuity of care, guides the professional’s conduct and the care of the child’s family. Ho - wever, it was still seen as a vaccination card. As for use, weak nesses were mentioned during home visits and in professio - nals’ records. In addition, mothers only used it when they took the child to the health service. Conclusion: professionals and mothers presented distinct opinions about the Child Health Notebook. Some considered it as an extension of the medical record and others as a tool like the child’s card, being used by specific professionals and at specific times. Contributions to practice : the data reveal meanings and perceptions of the health team and mothers about the Child’s Health Handbook and its use, bringing contributions to the scientific knowledge on the subject. Descriptors : Objetivo :


Introduction
In Brazil, the National Policy for Comprehensive Care of Child Health advocates surveillance and encouragement of early childhood development by Primary Health Care (PHC). At this level of care, with the adoption of the Family Health Strategy (FHS) as an important model of health care, the Family Health Team (FHT) becomes the main responsible for monitoring growth and development of children through the Child's Health Handbook (1) .
The Children's Health Handbook is based on the theoretical concepts of health promotion and comprehensive care, it understands the rights and duties of children and parents as well as the care for the child so that he/she grows and develops in a healthy way. It contains guidelines and spaces for recording data on birth, breastfeeding, healthy complementary feeding, vaccination, growth and development, oral health, danger signs for serious diseases, accident and violence prevention, and information on access to social and education programs (2)(3) . To accomplish what is proposed, it is essential that this tool is used by different agents of care and at all points of the childcare network (4) , especially in the PHC.
The Family Health Team, composed of a physician, nurse, nursing assistant/technician, Community Health Agent, dentist, endemic disease control agent, and oral health assistant/technician, has expanded capacity to produce comprehensive care to the child (2,5) . For this, the team must be responsible for monitoring and providing guidance focused on child growth and development and for recording information in the Child's Health Handbook (6) .
In addition to the FHS professionals, it is essential to be used by caregivers to ensure the monitoring of the child's health. The child health record documents, when used by parents, present benefits for the knowledge and practice of care, impacting the child's health and development (7) . Supporting caregivers' understanding of the records in the Child's Health Han-dbook is paramount to improve communication and ensure its implementation in health services (8) .
It is noteworthy that, in low-and middle-income countries, in 2016, 5.6 million children under five years of age died from preventable causes, which goes against the third Sustainable Development Goal, which calls for the end of preventable deaths of children in this age group by 2030 (9) . To this end, child health records are a simple intervention capable of mitigating morbidity and mortality by promoting continuity of care.
On the other hand, the child's records are still deficient. In Brazil, the evaluation of child development is compromised due to flaws in the registration of the Child's Health Handbook (6,10) . When analyzing 420 booklets of children under five years of age, a survey revealed that only 25.5% were satisfactorily filled and that the rate of neuro-psychomotor development record was one of the lowest, 18.1% (10) .
A similar reality was evidenced in research developed in Kenya, which, when evaluating the knowledge of mothers and health professionals about maternal and child health booklets, found that there was no adequate completion of the child development milestones in the 78 booklets analyzed, despite 80.8% of professionals claiming to fill in the neuro-psychomotor development data (11) .
It is urgent to understand the real meaning of the booklet, because, to assume its role as a tool that helps in the work process of the FHS and in the family's daily life, it must be perceived as a meaningful object. In this regard, the Symbolic Interactionism states that the meaning of things arises because of the interaction that each one maintains with them (12) .
In this sense, the following question was posed: what is the perception of the professionals of the Family Health Strategy and of the mothers about the Child's Health Handbook as a tool for Child Development Surveillance, according to the principles of Symbolic Interactionism? How is it being used by professionals and mothers? Therefore, the objective was to understand the perception of health professionals and mothers about the Children's Handbook. Thus, the originality of this research stems from the approach of all Family Health team professionals and mothers, being unprecedented in the national literature.

Methods
Qualitative research anchored in the assumptions of Symbolic Interactionism and developed according to the precepts of the Consolidated Criteria for Reporting Qualitative Research (COREQ). Symbolic interactionism seeks to analyze the meanings attributed to people, relationships, and objects, which are modified according to social interactions (13) .
Data collection was carried out in two integrated Family Health Units (FHU), totaling eight FHS of a capital city in the Northeast region of Brazil, and FHS professionals participated in the investigation, including nurses, physicians, dentists, , oral health assistants, and mothers of children enrolled in the FHS.
The eligibility of participants occurred by intentionality. For professionals, the inclusion criteria were assisting a child under three years of age and having been employed or contracted by the FHS for at least six months, an appropriate time for interaction between professionals and family members, and child follow-up in the Child's Health Handbook. For mothers, the criteria were: age of majority, being the main caregiver of a child under three years of age and having a record at the FHU. It is noteworthy that the focus on children under three years of age, a period called early childhood, is due to the importance of comprehensive and integrated care at this stage of life, as it is the noblest period for the development of brain functions and the promotion of healthy growth and development (14) , besides being a phase of greater opportunities for successful intervention, if any change in development is detected.
Professionals who were on vacation or leave of any kind during the data production period were not included, as well as mothers who were at the FHU for the first time, those who did not have the Child's Health Handbook and/or those with impaired cognitive function.
Data production occurred in September and October 2020. Initially, we approached the field and the FHS professionals to present the research objectives, invite them to participate in data collection and, after their acceptance, agree on a date for the interviews. These took place after the assistance to users, without the presence of third parties, in the interviewee's care room or in another environment of the FHU able to ensure privacy and convenience.
Data production with the mothers took place while they were waiting for the child's appointment in the waiting room of the FHU. They were guaranteed privacy and the non-interference of the interview in the sequence of care, and, after their consent, the interview was initiated.
The semi-structured interview was used with the support of two scripts, one for the professionals and the other for the mothers. Both contained two parts: characterization of the participants and guiding questions. The first script presented questions related to the professionals: tell me what you understand about the Child's Health Booklet as a tool for monitoring child development; how do you use it in your professional practice? How do you evaluate the use of the booklet by the FHS team? The second script contained questions for mothers: Tell me what you understand about the Child's Health Handbook; How do you use it? How is your Child's Health Handbook being filled out by health professionals?
All interviews were conducted face-to-face at the FHU and, due to the pandemic context of CO-VID-19, biosafety and prevention measures were adopted, such as: wearing a mask, offering 70% alcohol, and distance between the researcher and the participant.
The interviews were audio-recorded on portable digital media and lasted an average of 20 minutes, with no repetition of interviews. Then, the audios were transcribed in full, which favored the familiarization with the data and the deepening of the subsequent interview. Data production was terminated by theoretical saturation, i.e., when the corpus presented thematic recurrence and enabled the achievement of the proposed objective (15) . It is noteworthy that the transcripts were not returned to the participants.
The data corpus was submitted to Inductive Thematic Analysis. In this approach, the themes constructed arise from the coding process, which does not aim to fit into a preceding framework of codes or into the analytical preconceptions of the researcher. To this end, the six phases were carried out: familiarization with the theme from the transcripts of the interviews, reading and re-reading the materials, subsequently carrying out a draft of ideas about what the data suggested and what was interesting about them; generation of initial codes with the identification of the interesting aspects of the data, and the initial codes were generated and grouped; search for themes, which consisted of sorting the codes, classifying them into potential themes; review of the themes, in which all the selected extracts were read in the potential themes, some being relocated and others unified, providing the refinement and delineation of the thematic map; definition and naming of the themes, identifying the essence of each theme and determining which aspect of the data each theme captures; production of the analysis report with a concise, coherent, logical, non--repetitive and interesting description about the story told by the data (16) .
This study is linked to a universal project approved in the Research Ethics Committee under Opinion no. 3,156,449/2019. In addition, the ethical requirements were respected, according to Resolution No. 466/12, and all participants read and signed the Informed Consent Form, in two copies. To preserve anonymity, each participant was named by an alphanumeric code, with the letter 'C' referring to caregivers/mothers; 'N', to nurses; 'P', to physicians; 'D', to dentists; 'NT', to Nursing technicians; 'OA' , to oral health assistants or 'CHW' to Community Health Workers, followed by the Arabic numeral corresponding to the order of the interviews: C1/N1/P1/D1/NT1/OA1/ CHW1, (...).

Results
Twenty-five FHS professionals and 11 mothers participated in the data collection. No participant refused to participate in the research or dropped out. Among the professionals, there were seven nurses, six dentists, four physicians, five CHWs, two nursing technicians, and one oral health assistant. The majority were female, whose ages ranged from 24 to 65 years, and the time they had worked in the FHS from ten months to 32 years. As for the mothers, they were between 19 and 40 years old, most were housewives, had completed high school, and had only one child. Regarding marital status, seven were single, three were married, and one was in a stable union. Since all the participating caregivers are the children's mothers, the word 'mothers' will be used to refer to them.
From the analytical process, two themes were built: Perceptions of professionals and mothers about the Child's Health Handbook and its meanings; Weaknesses in the use of the Child's Health Handbook.

Perceptions of professionals and mothers about the Child's Health Booklet and its meanings
The Child Health Handbook is a fundamental document for monitoring child health. It was considered an easy-to-handle tool, which allows for vaccination records, monitoring of growth and development, prevention of diseases, and health promotion: On the other hand, some participants, such as CHWs and mothers, understand it only as a tool for recording vaccines, calling it a 'vaccination record card' or 'vaccination handbook': The vaccination record card is an indispensable document in the life of the mother to control the children's vaccines, because it works preventively in relation to diseases (CHW5). I consider it as a vaccination card, even because I only take it for that (C11).
The handbook was considered an extension of the medical record, being an important source of information on the child's health for the different professionals in the health care network. In addition, it has a multi-professional and intersectoral character and enables the continuity of care when used in meetings between professionals, children, and families:

Discussion
The perceptions of professionals and mothers about the Child's Health Handbook show to be interconnected to their previous experiences with this tool. The meaning attributed to it was reflected in its use or not. According to Symbolic Interactionism, human beings attribute different meanings to objects and things depending on their interaction with them (13) . Thus, a single object can present different values.
The Child Health Handbook was perceived as an enlightening, timely and easy-to-use tool, important for comprehensive care and surveillance of the child's health, since it enables the monitoring of growth, development and vaccination status and favors disease prevention and health promotion. This result corroborates research developed with children's caregivers, which evidenced the handbook as an accessible medical record, with rich information and simple to handle (17) .
In contrast, the child health record tools are sometimes not fully understood. A PHC survey of 403 parents and 62 health professionals found that parents perceived the usefulness of the Child Health Booklet primarily as a reminder for vaccination (100%) and for monitoring child growth (91.6%). However, this tool was poorly recognized for health records (17%), checking developmental stages (4.7%), communicating with health care professionals (1.4%), and encouraging childcare (1.4%) (18) .
In Brazil, the Child Health Handbook is associated with the vaccination card and its function is emphasized to the record of vaccines, revealing that the previous experiences of mothers and professionals did not provide an opportunity to give this tool a new meaning. This understanding is a pressing reality, because the FHS and the mothers can limit the use and, consequently, compromise their role in the surveillance of child development.
The pun of the terms 'child's card' and 'handbook' was also identified in another research conducted with FHS nurses, which highlighted that the term 'card' should be disused, since the old tool contained only the vaccination schedule and a chart for monitoring child growth and development and had no information for caregivers (19) .
With the replacement of the card by the Child Health Handbook in 2005, and after successive updates, the tool gains a meaning of integrality and presents an expanded look at the child, providing an opportunity for a longitudinal and resolutive care (19) . Some interviewees considered the booklet as an extension of the medical record and stressed the importance of being used by all professionals and by all sectors of the care network.
The identification of interprofessional and intersectoral aspects of the handbook draws attention, since the expansion of dialogue between health, education and social assistance policies is a recent achievement (3) . To favor the collective use, it emphasizes the partnership between parents, the community, and health, education, and social assistance professionals, as well as the record of all information on childcare (19)(20) .
According to the interactionist principles, the action-interaction between professionals and families is fundamental to promote the use of the Child's Health Handbook, since family members establish actions of unique care and their interaction with the professional provides an opportunity to exchange perspectives, which modifies their actions and may lead to the use of the tool (21) .
Another highlighted point was the ability of the booklet to guide the care offered to the child, because when properly filled out, it ensures information about the child's condition and enables longitudinal care. In Brazil, the main tool for providing longitudinal care is the Child´s Health Handbook. It is pointed out that such longitudinally is an attribute of PHC that presupposes the continuity of care, permanently, through the link and accountability between professionals and users over time, reducing the risks of health complications arising from the ignorance of life stories and the lack of coordination of care (22) .
As in Brazil, in Indonesia, a document is used for monitoring the child's health, the Maternal and Child Health Handbook, which, in addition to monitoring the child, integrates the pregnant woman's health records and should be used both at home and in health services. According to Indonesian research, the tool favors the continuity of childcare, family support, and the reduction in the number of children with low weight and height (23) .
The monitoring of the child through the records in the booklet by the FHS can bring benefits to the child population, considering that its monitoring occurs primarily in the PHC (2) . The use of the tool is a premise for health promotion and comprehensive care in childhood. However, the data presented here reveal that, by presenting divergent meanings, the use of the booklet occurs in different ways.
Even knowing the importance of the handbook, dentists said they did not use it during childcare, resulting in neglect of care, since the records in the booklet represent a form of care. In this direction, research that analyzed 367 handbooks showed that only 0.8% showed some record in the dental chart, being the field with the worst rate of completion (24) .
It is revealed that having knowledge about the booklet does not necessarily imply that it is a meaningful object and that it will be used. In this, the precepts of Symbolic Interactionism are elucidated, since some professionals acted based on the meaning attributed to the handbook (13) , which deviates from the sense of collectivity proposed by the Ministry of Health.
On the other hand, dentists emphasized the work of nursing with the Child's Health Handbook. To understand this divergence of values among the members of the FHS, it is necessary to reflect on the training process of health workers, who still have limited training, setting weaknesses in the effectiveness of care (25) . On the other hand, nurses' training is holistic and focused on the principles of the Brazilian Unified Health System, being a facilitating aspect in their work process (26) .
Although Nursing was highlighted, the Child's Health Handbook was also used by other FHS professionals, such as the CHW. Considering that the practice of home visits and health education are basic actions of these professionals, their role is essential for child follow-up through the booklet. However, the action was limited to the observation of the vaccination schedule and the scheduling of childcare contained in the booklets of children under three years of age. This may reflect the knowledge and meaning attributed to the tool.
Thus, the perception and use of the booklet by the CHWs are below their purposes, since the document is intended for child monitoring, to ensure the continuity of care and the correct recording of health data since birth (2) . Moreover, these professionals have not perceived the recording of information as a possible activity in their practice, a situation that contributes to the discontinuity of care and may be related to the fact that they do not recognize themselves as responsible for filling the handbook (27) .
Despite the recommendations for appropriation and use of the Child's Health Handbook by all those involved in childcare, guidance on how it should be used is still scarce. In the case of CHWs, for example, they are workers who have vast opportunities to promote health surveillance through the tool; however, there seems to be no guidance for recording in the tool during home visits. The lack of a protocol hinders the proper use of the booklet by the multidisciplinary team and family members.
Besides the professionals, another agent of care that must deal with the Child's Health Handbook in their daily lives, perhaps the most important, is the caregiver and/or the child's mother (3) . In this investigation, mothers attributed a meaning to the tool when they reported that their doubts were solved by reading the available contents, enhancing autonomy in care. Despite this, mothers did not perceive themselves as responsible for filling it out and used it only occasionally.
In this context, data from a survey developed with 202 parents of children under five years of age pointed out that the parents' commitment to take the child's health record book to routine consultations, as well as reading the information and filling it out, was influenced by the way health professionals referred to it during childcare. Thus, parents were less likely to read the document when they perceived that the physician was less interested in using it. In turn, parents who perceived the professionals' willingness to use and refer to the tool were more likely to use it for routine checks (28) .
The mothers' interest in the Child's Health Handbook may reflect their experiences during the care offered to the child in the FHS. As they sometimes do not perceive the use of this tool in practice and do not receive proper guidance on its use, it is inconsistent to want mothers to identify it as a meaningful object. According to the Symbolic Interactionism, the way an individual acts awakens attitudes in the other (13) , thus, the professional, when using the handbook for health promotion, can involve the mother in reading, evaluating, and filling the tool. However, research developed at different levels of health care in Brazil reinforced the precariousness of maternal guidance on the Child´s Health Handbook aimed, presenting values between 57.4% and 77.3% of mothers who did not receive information about the booklet (29)(30) . Moreover, the scarce guidance of parents by health professionals regarding the child's monitoring tool was the main reason for its irregular use (18) .
This may result from the professionals' limited understanding of the family's participation in filling out the handbook. Moreover, it is perceived that its collective use is still incipient, and it is necessary that FHS professionals and mothers awaken to the shared responsibility.
The weaknesses in its use as a collective tool may reflect the meanings attributed to it. In the light of Symbolic Interactionism, the attitudes of human beings are related to the meanings they attribute to a certain object. These meanings are social products that arise from interaction and lead the individual's behavior. Therefore, knowing these meanings may favor the understanding of human action (13) .

Study limitations
The interviews with the mothers in the FHU environment may have caused fear and intimidation, since they were linked to the service. Another limitation refers to the non-inclusion of the unit managers, since it would have been crucial to know their perception about the Children's Health Handbook, since one of their attributions is to follow up, guide, and monitor the work processes of the teams that work in the unit under their management.

Contributions to practice
Relevant contributions to the advancement of scientific knowledge regarding the Child's Health Handbook were presented when revealing the meanings and perceptions of the team and mothers about the tool and how it is used in the FHS. It was possible to glimpse issues that precede the underuse of the booklet, revealing subjective dimensions, as proposed by qualitative research.

Conclusion
The professionals of the Family Health Team and the mothers had different perceptions about the Child Health Handbook. Some perceived it as an extension of the medical record and others understood it as a tool similar to the child's card, being used by specific professionals and in specific moments. It was identified that knowledge does not necessarily equate to its symbolic meaning for the individual, since almost all participants recognized the importance of the Child Health Handbook, but did not use it as a collective and interprofessional tool in childcare.