we used data from the second pmaq - ab external assessment , financed by the ministry of health and carried out between 2013 and 2014 . we analyzed variables from modules i and ii of the pmaq - ab in relation to a universe of 29 757 pc teams . the variables were organized in categories to provide an overview of the incorporation of ict in primary care provided by brazilian public health system . to evaluate the quality of women 's health care , we used variables from modules i and ii from the second pmaq cycle . they were selected on the basis of criteria used by the ministry of health in eab ( basic healthcare team ) certification , which attributed a weight  to each of the variables . for questions on women 's health , weights between 0.0000 and 0.2143 were attributed . an index , called the iasm ( brazilian portuguese acronym for aspects of women 's primary care index ) , was created from the sum of each of the 17 values expressing the quality of women 's care . the index was then dichotomized taking the value of  adequate  ( value 1 ) , when the index was 13 and above , and  inadequate  ( value 0 ) , when the index was 12 points or less . these variables were selected on the basis of the criteria employed by the ministry of health to assess the quality of aspects of women 's primary care ( brasil ministrio da sade , 2015 ) . variables from module i refer to the capacity of the pcu to provide rapid testing for syphilis , pregnancy , and human immunodeficiency virus ( hiv ) infection , besides the free supply of iron sulfate . in module ii , variables refer to health promotion and education , focusing on cervical and breast cancer prevention , and family planning . other variables were selected on the basis of pregnant women 's care and the early diagnosis of complications during pregnancy , monitoring through the use of the pregnant card , and the capacity of the team to receive laboratory results in a timely manner . furthermore , variables indicative of cervical cancer active search , final cytopathological examination , breast cancer , and prenatal care were selected . finally , the selection was completed with childbirth care follow - up such as home visits by community agents , nurses , and doctors . independent variables referring to ict incorporation were selected from modules i and ii of the pmaq - ab . the selection of independent variables included aspects of the following analytical ict categories : infrastructure , connectivity , information systems implementation , and use of information . in the first category ( ict infrastructure ) , we used variables relating to computers , televisions , printers , and peripheral devices in working conditions . in the second category ( connectivity ) , we used variables relating to internet access , telephone and smartphone availability , internet access in medical and nursing offices , and sufficient bandwidth . these variables are present in module i. the third category ( implementation and usage of the systems ) from modules i and ii included ehr implemented by the team and integration with other points of the health care network , the existence of telehealth and its resources in the unit , and the use of referral centers . the fourth category ( usage of information ) also came from module ii : information made available by management and support for the teams in health situation analysis , as well as team execution of monitoring , indicator analysis , and women 's health information registration related to prenatal care , and breast and cervical cancer care . in the analysis of ict incorporation , 4 ict categories were created . each category was assigned a value to represent the degree of technology incorporation by the pct . ( presence of 80% of the variables ) ,  average  ( 50%-80% ) , or  low  ( < 50% ) , allowing us to gauge the extent of ict incorporation process . statistical analysis was performed in 2 phases : descriptive and inferential . first , we calculated the frequency of all ict variables and those referring to women 's health . to verify associations between the incorporation of ict and the quality of aspects of women 's primary care , multiple logistic regression analysis was initially performed , with the iasm as the dependent variable . throughout the analysis , the value of  inadequate  was used as a reference category . first , the association of the variables comprising the indexes of each category with the iasm was verified . this analysis sought to determine the degree of association of each component with the quality of care index . subsequently , the association of the iasm with the independent variables by each category 's levels ( low / medium / high ) was verified . statistical analyses adopted a statistical significance level of 5% ( p  .05 ) and a confidence interval of 95% , with calculation of the respective odds ratio ( or ) to indicate the magnitude of the associations . after logistic regression , calibration of the models created was evaluated using hosmer and lemeshow 's goodness - of - fit test . in all cases , this study was approved by the research ethics committee of ufmg ( number 1.275.911 ) . we used data from the second pmaq - ab external assessment , financed by the ministry of health and carried out between 2013 and 2014 . we analyzed variables from modules i and ii of the pmaq - ab in relation to a universe of 29 757 pc teams . the variables were organized in categories to provide an overview of the incorporation of ict in primary care provided by brazilian public health system . to evaluate the quality of women 's health care , we used variables from modules i and ii from the second pmaq cycle . they were selected on the basis of criteria used by the ministry of health in eab ( basic healthcare team ) certification , which attributed a weight  to each of the variables . for questions on women 's health , weights between 0.0000 and 0.2143 were attributed . these variables were then arranged in decreasing order , with selection of those with  weight  equal to or greater than 0.1010 ( brasil ministrio da sade , 2015 ) . an index , called the iasm ( brazilian portuguese acronym for aspects of women 's primary care index ) , was created from the sum of each of the 17 values expressing the quality of women 's care . the index was then dichotomized taking the value of  adequate  ( value 1 ) , when the index was 13 and above , and  inadequate these variables were selected on the basis of the criteria employed by the ministry of health to assess the quality of aspects of women 's primary care ( brasil ministrio da sade , 2015 ) . variables from module i refer to the capacity of the pcu to provide rapid testing for syphilis , pregnancy , and human immunodeficiency virus ( hiv ) infection , besides the free supply of iron sulfate . in module ii , variables refer to health promotion and education , focusing on cervical and breast cancer prevention , and family planning . other variables were selected on the basis of pregnant women 's care and the early diagnosis of complications during pregnancy , monitoring through the use of the pregnant card , and the capacity of the team to receive laboratory results in a timely manner . furthermore , variables indicative of cervical cancer active search , final cytopathological examination , breast cancer , and prenatal care were selected . finally , the selection was completed with childbirth care follow - up such as home visits by community agents , nurses , and doctors . independent variables referring to ict incorporation were selected from modules i and ii of the pmaq - ab . the selection of independent variables included aspects of the following analytical ict categories : infrastructure , connectivity , information systems implementation , and use of information . in the first category ( ict infrastructure ) , we used variables relating to computers , televisions , printers , and peripheral devices in working conditions . in the second category ( connectivity ) , we used variables relating to internet access , telephone and smartphone availability , internet access in medical and nursing offices , and sufficient bandwidth . these variables are present in module i. the third category ( implementation and usage of the systems ) from modules i and ii included ehr implemented by the team and integration with other points of the health care network , the existence of telehealth and its resources in the unit , and the use of referral centers . the fourth category ( usage of information ) also came from module ii : information made available by management and support for the teams in health situation analysis , as well as team execution of monitoring , indicator analysis , and women 's health information registration related to prenatal care , and breast and cervical cancer care . in the analysis of ict incorporation , 4 ict categories were created . each category was assigned a value to represent the degree of technology incorporation by the pct . values were defined as  high  ( presence of 80% of the variables ) ,  average  ( 50%-80% ) , or  low  ( < 50% ) , allowing us to gauge the extent of ict incorporation process . first , we calculated the frequency of all ict variables and those referring to women 's health . to verify associations between the incorporation of ict and the quality of aspects of women 's primary care , multiple logistic regression analysis was initially performed , with the iasm as the dependent variable . throughout the analysis , the value of  inadequate  was used as a reference category . first , the association of the variables comprising the indexes of each category with the iasm was verified . this analysis sought to determine the degree of association of each component with the quality of care index . subsequently , the association of the iasm with the independent variables by each category 's levels ( low / medium / high ) was verified . statistical analyses adopted a statistical significance level of 5% ( p  .05 ) and a confidence interval of 95% , with calculation of the respective odds ratio ( or ) to indicate the magnitude of the associations . after logistic regression , calibration of the models created was evaluated using hosmer and lemeshow 's goodness - of - fit test . in all cases , this study was approved by the research ethics committee of ufmg ( number 1.275.911 ) . analysis of the 29,757 pcts assessed in the pmaq-2nd cycle indicates that , in terms of ict infrastructure , most of them have equipment and basic peripheral devices : 73.7% and 61% of the units have functioning computers and tvs , respectively ; and 57.1% have a printer . as for peripheral devices , which are important in interactive processes , only 11.6% and 16.1% have a microphone and a webcam in working condition , respectively ( table 1 ) . the connectivity available to the pcts , via the internet and the provision of sufficient bandwidth to perform their activities , is at approximately 55% of the units . however , the number of medical or nursing offices with internet - connected computers is roughly 1/5 of the units ( 18.7% and 21.8% , respectively ) ( table 1 ) . regarding the implantation of information systems , it was noted that only 13.9% of the pcts have access to ehrs and 11.2% are integrated with other points of the care network . thirty percent of the teams reported using telehealth resources , mainly for in - service training ( 32.7% ) and education of professionals ( 21.4% ) . the referral of primary care users via the referral center is performed by 86.3% of the teams ( table 1 ) . it was noted that the use of process information by the basic health care team category demonstrates greater frequency ( > 60% ) for most of its variables . however , regarding issues on the registration of women eligible for mammography , in the referral of higher - risk users to other points of the care network , in the event of abnormal cytopathology or mammography examinations , the percentage of positive responses is lower ( 53.6% , 56.4% , and 47.1% , respectively ) . it is worth highlighting that the monitoring and analysis of health information and indicators are carried out by 88.6% of the teams ( table 1 ) . aspects of women 's health care were analyzed on the basis of variables from primary care applied to prenatal and postnatal care , breast cancer , and cervical cancer . in terms of prenatal and postnatal care , the pcts carry out many of the established activities such as active research ( 82.8% ) , the use of pregnant card in the monitoring of pregnant women ( 97.8% ) , and receipt of pregnant women 's examinations in a timely manner ( 96.6% ) . however , other recommended actions demonstrate lower percentages : the use of protocols to enroll pregnant women into the system for early diagnosis of complications during pregnancy ( 54.4% ) , and appointments at specially assigned times on any day of the week to ensure postnatal monitoring up to 10 days after childbirth ( 45.7% ) . rapid testing for syphilis , pregnancy , and hiv is at 31.8% , 34.1% , and 33.4% , respectively . educational activities and health initiatives regarding family planning are carried out by 72.0% of the pcts ( table 2 ) . abbreviations : acs , community health agent ; hiv , human immunodeficiency virus ; iasm , women 's primary care index ; pct , primary care team . total of pcts = 29 797 . in the prevention and monitoring of breast and cervical cancer , we observed that the pct performed most of the recommended actions : 91% perform cytopathology pelvic examinations in the unit ; 76.3% and 66.5% , respectively , carry out active searches in cases of cervical and breast cancer ; and 74.7% of teams implement active searches in late cytopathology examinations . educational activities and health promotion initiatives on cervical and breast cancer are offered by 78.4% of the teams ( table 2 ) . in relation to the index created iasm , based on the sum of the variables described earlier , we find that only 27.2% ( n = 8088 ) of the teams achieved a score of  adequate  ; that is , they performed 80% or more of the selected activities ( table 2 ) . in analysis of the association of the ict categories and the iasm quality of care measure , we noted a statistically significant association between ict infrastructure resources and the quality of care provided , particularly concerning printer availability ( or = 1.70 ) , tv ( or = 1.39 ) , and computer ( or = 1.30 ) ( table 3 ) . abbreviations : ci , confidence interval ; or , odds ratio adjusted ; pct , primary care team . dependent variable : reference category : inadequate ; independent variables : reference category : low level . the association between connectivity and the iasm is observed in the cases where there is internet in medical offices ( or = 1.60 ) and access to smartphones ( or = 1.64 ) ( table 3 ) . regarding system implantation , there is a statistically significant association in relation to the existence of ehrs and the quality of care ( or = 3.05 ) . the presence of telehealth is associated with quality of care ( or = 1.28 ) and its use is applied only in the case of forming a second opinion ( or = 1.41 ) and use of telehealth ( or = 1.50 ) . the use of the telehealth 0800 telephone line is associated with quality of care ( or = 1.34 ) , as well as the use of records from e - sus ( 1.29 ) . referral of primary health care users via the referral center is also associated with the quality of care ( or = 1.42 ) ( table 3 ) . concerning the use of information , all analyzed variables presented statistically significant association with the iasm , with the exception of activities related to the registration of higher - risk pregnant women . in this case , it is possible that this variable is a confounding factor , considering that the teams ' planned activity according to pregnant women and risk is strongly associated with the quality of care ( or = 1.84 ) and may already contain information on this risk ( table 3 ) . the assessment of ict categories points to a low - degree incorporation for infrastructure ( 47.1% of low - degree incorporation ) , connectivity ( 81.0% ) , and system implantation ( 90.9% ) . with regard to the information usage , the degree of ict incorporation is about evenly distributed between medium - degree incorporation ( 42.7% ) and high - degree incorporation ( 38.4% ) ( table 4 ) . dependent variable : reference category : inadequate ; independent variables : reference category : low level . on analyzing associations between the degrees of incorporation of ict categories that may be contributing to better women 's care , it is noted that in all ict categories there was a statistically significant association between infrastructure , connectivity , information usage and systems , and the quality of care provided . there is a strong association between information usage and the iasm ( or = 3.78 and or = 12.31 for medium and high degrees of ict , respectively ) . besides this , for the other categories , the high degree of ict incorporation increases the chances of better women 's health care quality : connectivity ( or = 1.22 ) , infrastructure ( or = 2.03 ) , and implementation of information systems ( or = 4.36 ) ( table 4 ) . the results of the study indicate a relative unevenness regarding the incorporation of ict in brazil , despite the implementation of projects aimed at stepping up the process of ict incorporation in public pcus . in brazil , the national broadband plan ( the result of a partnership between the ministry of health and the ministry of communications ) is ongoing , with the aim of installing high - speed internet in 12 000 pcus , as well as the pcus retraining program by the ministry of health , which has invested in the provision of computers and internet , and in the implantation of ehr ( brasil ministrio da sade , n.d .- a , n.d .- b ) . in particular , the proposal to implement the e - sus project has become a significant initiative that has also driven the incorporation of ict in brazil 's primary care . the e - sus project substitutes the former primary health care information system that did not have the individualized registration of attended patients . the new system registers activities carried out in primary health care , individual consultations , and even more advanced options , such as electronic medical records ( brasil ministrio da sade , 2014 ) . despite these initiatives , it is worth mentioning the limited dissemination of ict resources , for example ( only 13.9% of teams use ehrs and only 11.2% are linked to the national network ) . these data serve to illustrate brazil 's challenges in relation to ict incorporation , in comparison with international experiences . difficulties in computerizing medical care are well - documented , but some countries have achieved significant progress in this regard . in 2015 , in finland , 75% of pcus had electronic records ( world health organization , 2016 ) . in canada , 49% of primary care doctors reported using an ehr , in 2010 ( greiver et al . , 2013 ) . in 2011 , in the united states ( black et al . , 2011 ) , usage of an her was observed in 35% of outpatient care medical offices . for instance , there is the low effective penetration of the national telehealth program , established in brazil since 2007 , given that its resources are used by only 30% of pcts . in latin america , there are very few countries that have a structured national telehealth project with brazil , along with mexico , standing out ( organizacin panamericana de la salud , 2016 ) . another aspect refers to the use of the referral center in referring patients to other points in the health care network , which is significant in that it contributes to the establishment of collaborative networking , as well as the pcus reporting the use of information for the planning and monitoring of actions . the current program of women 's care , in which there is continuous monitoring , was based on a continuous process of information usage . the program established minimum quantitative criteria for obstetric care , aimed at indirectly improving the quality of care ( brasil ministrio da sade , 2002 ) . this aspect of the implemented program provides interesting opportunities in the search for a correlation between ict incorporation and the quality of care . the women 's health care program establishes well - defined quality criteria , particularly aspects addressed in this article . this program has been monitored over time through official information systems . in this context , our study showed a strong correlation between the use of information and the quality of women 's healthcare care provided . among the 4 categories analyzed ( infrastructure , connectivity , system implementation , and the use of information ) , it was the last one that stood out . the category regarding information usage could contribute greatly to an improvement in the quality of health care the women 's health care program was a pioneering initiative in brazil 's public health , in establishing a minimum protocol of actions to be implemented during the follow - up of pregnancies . the information system established by the program was the management tool that enabled the monitoring of program compliance , achievement of goals , and the direct follow - up of mother and child health statistics within the national context . through the proposed process indicators , the monitoring of results is another important management tool , capable of generating program and strategy actions , based on the profile of the target population ( andreucci & cecatti , 2011 ) . despite this effort , the created index ( iasm ) shows that only 27.2% of the teams demonstrated a level deemed adequate from the perspective of the women 's health care provided , based on the variables related to the generation and use of information . in the analysis of the association between the quality of certain aspects of women 's care provided and the ict incorporation process , in the 4 categories analyzed , a strong association was noted . teams that have a medium or high degree of ict incorporation are more likely to provide better women 's care , this being a progressive gradient . the information usage category demonstrates the most notable association , more so than the others . in other studies on ict incorporation , the dimension related to information usage is also the one most consolidated in brazil ( giovanella et al . , 2015 ; price et al . , 2013 ) . it should be noted that this analysis focused on aspects of ict that were assessed by the pmaq - ab . therefore , it is possible that there are information and/or selection bias problems in the study . the creation of an index to assess some aspects of quality of women 's health care may also result in bias in the association analysis . despite these limitations , this study allowed us to identify relevant issues in the provision of ict in terms of structure , connectivity , information systems implementation , and information usage . although the relationship between ict incorporation and the quality of primary health care is not yet well established in the literature ( black et al . , 2011 ; ludwick & doucette , 2009 ; mitchell et al . , 2001 ; scochi , 1994 ; tanaka , 1995 ; vasconcellos et al . , 2008 ) , this study 's findings indicate a positive association between all the analyzed categories and the quality of certain aspects of women 's primary health care . as such , we reiterate the need for further assessments of the policies implemented in the area , with the aim of improving access and quality in brazil 's primary health care .
the use of information and communication technology ( ict ) is on the increase in the health systems , representing a means of improving the quality of health care . 
 this study analyzed the ict incorporation in primary care in brazil and identified the different aspects that may be associated with better quality in the care provided , in relation to certain aspects of women 's care . 
 we noted an unevenness regarding ict incorporation in brazil . 
 however , the findings indicate an association between ict and certain aspects of the quality provided in women 's health care , which reinforces the need for further studies on this type of evaluation .