Print version ISSN 1414-3283
Interface (Botucatu) vol.3 no.se Botucatu 2007
Building an Educational Program together health community agents
Construindo um programa de educação com agentes comunitários de saúde
Construyendo un programa de educación con los agentes comunitarios de salud
Lúcia Rondelo DuarteI; Débora Schimming Jardini Rodrigues da SilvaII; Sandra Helena CardosoIII
IEnfermeira; doutora em Ciências Biológicas - Enfermagem; professora, departamento de Enfermagem, Faculdade de Ciências Médicas, Pontifícia Universidade Católica de São Paulo. Sorocaba, SP. <firstname.lastname@example.org>
IIEnfermeira, Hospital Santa Lucinda, Pontifícia Universidade Católica de São Paulo. Sorocaba, SP. email@example.com
IIIEnfermeira, Centro Cirúrgico, Hospital Evangélico de Sorocaba, Associação Evangélica Beneficente. Sorocaba, SP. <firstname.lastname@example.org>
Translated by Karen Rondelo Duarte
Translation from Interface - Comunicação, Saúde, Educação, Botucatu, v.11, n.23, p. 439-447, Sept./Dec. 2007.
Aiming at contributing inputs to the learning process of community health agents from Family Health Strategy, this study has sought to devise an Educational Program to qualify seven community agents from the Family Health Unit on Habiteto, a neighborhood in the Brazilian city of Sorocaba. Speeches on the perception these agents have of their work, their difficulties and proposals were captured and analyzed within the framework of the "Collective Subject Speech". Results showed the group's learning needs, and guided the devising and implementation of the Educational Program, which adopted the "Problem-Based Education" model. This knowledge was built by the agents through a problem-focused reality, debating, searching for solutions, and implementing intervention projects. They noticed that being a community health agent means, above all, to struggle and harness community forces for purposes of defending health & education public services and for improving social health determinants.
Key words: Health agents. Problem-based education. Community. Family Health.
Com a preocupação de subsidiar a formação de agentes comunitários de saúde da Estratégia de Saúde da Família, este estudo teve como propósito construir um Programa de Educação para capacitar um grupo de agentes comunitárias de unidade de saúde da família de Sorocaba, São Paulo. Os discursos a respeito das percepções que essas agentes têm sobre o seu trabalho, suas dificuldades e propostas foram captados e analisados segundo o referencial do Discurso do Sujeito Coletivo. Os resultados mostraram as necessidades de aprendizagem do grupo e nortearam a construção e implementação do Programa de Educação para o qual adotou-se o modelo da Educação Problematizadora. O conhecimento foi construído pelas agentes de saúde com base na problematização da realidade, debatendo, buscando soluções e implementando projetos de intervenção. Elas puderam perceber que ser agente comunitário de saúde é, sobretudo, lutar e aglomerar forças em sua comunidade na defesa dos serviços públicos de saúde e educação e da melhoria dos determinantes sociais de saúde.
Palavras-chave: Agentes de saúde. Educação problematizadora. Comunidade. Saúde da Família.
Con la preocupación de subvencionar el proceso de apredizaje de los agentes comunitarios de salud de la Estrategia de Salud de la Familia, este estudio tuvo como objetivo elaborar un programa de educación para capacitar a grupo de agentes comunitarias de unidad de salud familiar de Sorocaba em el estado de São Paulo, Brasil. Las percepciones que tales agentes tienen sobre su trabajo, sus dificultades y propuestas fueron captadas y analizadas según el modelo del Discurso del Sujeto Colectivo. Los resultados mostraron la necesidad de apredizaje del grupo y orientaron la formación e implantación del programa de educación para el cual se adoptó el modelo de la Educación Problematizadora. El conocimiento fue construido por las agentes de salud a partir de la problemática de la realidad debatiendo, buscando soluciones e implantando proyectos de intervención; pudiendo percibir que ser agente comunitario de salud es, sobre todo, luchar y unir fuerzas em su comunidad para la defensa de los servicios públicos de la salud, de la educación y de la mejoría de los determinantes sociales de salud.
Palabras clave: Agentes de salud. Educación problematizadora. Comunidad. Salud de la familia.
The Family Health Strategy (FHS) was created by the Ministry of Health to reorganize the welfare practice in Brazil, with the purpose to promote the health of families based on a new dynamic (Pedrosa & Telles, 2001; Brasil, 2000).
By the taking the family as the focus of the physical and social space, this new strategy is providing the health team an broaden comprehension of the health-illness process, creating the opportunity to the interdisciplinary action, that binds the social sciences to health issues, demography, epidemiology, among others (Trad & Bastos, 1998).
This welfare model prioritizes the multidisciplinary work, involving doctors, nurses, nursing assistants and community agents, on which all must identify themselves with a caring proposition that requires creativity and initiative for community and group works (Brasil, 1997).
The Community Health Agents (CHA) have a very specific role that differs them from the other members of the team. First of all, they are people that live within the reality and health practices of the neighborhood where they live and work; therefore, they have identification with the culture, language and customs of their own community (Nunes, 2002).
The community agents know deeply the local reality because they are part of the community. They know the values, language, dangers and opportunities. They represent a very special possibility on bringing to the inside of the health teams the people's view. A look that reveals necessities from a different point of view and that, therefore, opens the doors for a new universe of intervention. (Feuerwerker & Almeida, 2000, p.23).
These peculiarities can waken on the agents the interest for social movements for the pursuit for better living conditions, such as: education, basic sanitation, leisure, work, income and others (Souza, 2000). The Ministry of Health supports and stimulates this idea by giving specific attributions to the CHA, such as: translating to the health teams the social dynamic of the community, its needs, potentialities and limitations; identify the existing partners and resources on the community that can be optimized by the teams; besides promoting the community's education and mobilization, targeting the development of collective sanitation actions and environmental improvement (Tavares, 2002).
All this attributions require the CHA to have a natural leadership on the community, reasoned on their capacity to communicate with people, to stimulate the co-responsibility on the improvement of life and health quality of the population.
However, this natural leadership, present on official documents as an attribute, is not real; it is a presupposition that lacks fundament. Consequently, transforming the health agents in proactive persons must be the central objective of the training programs.
The community health agents must then be trained about the different aspects of the health-illness process. Besides the biomedical knowledge, it must be incorporated on their formation other knowledge that favors the interaction of these agents with the families, as well the identification of their needs.
The comprehension of the health-illness process in all its dimensions (biologic, social, political, economic and cultural) is important to the adequate planning of the health actions based on the reality that families are found at (Nunes, 2002).
However, the education of these health professionals, in many schools, is guided on the traditional and Flexnerian model of the medical schools that strongly focuses on the biological aspects fragments the knowledge and reproduces a compartmentalized, technical and repairing practice (Saupe & Wendhausen, 2003). This practice doesn't contemplate the participation of the users, families and community on their own healing process, nor does stimulate the community participation for the transformation of the health determinants.
The majority of the workers from the Family Health Strategy is educated on this model e these are the professionals that are teaching the community agents, inspired by this biomedical model of health.
Base on this assumption, we made a study with the concern to promote a capacitating and educational process of the community health agents so they can effectively exercise their attributions.
With the objective to contribute for a better development of the abilities and potentialities of the community health agents, prioritizing their needs and the community's, we built and developed with them an educational project to teach how to teach, on a problem-based educational practice.
The problem-based education recognizes the students as the direct responsible for the building of their knowledge, developing their power of world comprehension, establishing an authentic form of thinking, where the ideas are shared (Freire, 1987).
The study, approved by the Ethics Committee of the Center of Medical and Biological Sciences of the Pontifícia Universidade Católica from São Paulo (PUC-SP), and sponsored by the National Council for Scientific and Technological Development (CNPq), was done with community health agents of the Family Health Strategy from the Habiteto neighborhood, city of Sorocaba, state of São Paulo, Brazil. It is a new neighborhood, on the city's periphery, that reunites families taken from areas of risk.
Initially, there were done individual interviews, semi-structured, with the seven community health agents that act on the Family Health Unity (FHU) of the Habiteto neighborhood. The interviews' script, elaborated according to the theoretical framework of the "Collective Subject Speech" (Lefévre et al., 2003), addressed the CHA's perception about their work, difficulties and what they would like to do for their community.
The interviews were recorded in audio and transcript. After that, it was organized a board for each one of the applied questions, containing the subjects, their respective key-expressions and central ideas. The central ideas were organized in categories, and for each category, it was formulated a collective speech, totaling 19 speeches.
The collective speeches showed the need for capacitating the community agents and resulted on the joint construction of the educational program, that had as its general objective to capacitate them to face the difficulties felt on their community work, so that:
· They recognize and exercise their roles as leaders of the community;
· The stimulate the community organization and participation;
· They bring, in a partnership with the community, solutions for the improvement of the quality of life of the attended families.
Eight meetings were made, in alternated weeks, on the afternoon, during 2 and a half hours each one. The chosen place was the PUC-SP campus in Sorocaba.
The themes discussed on the meetings were: Relaxation Therapy, Self-Esteem, Community Resources, Community Participation, Communication and Leadership, Building a Discussion Group on the Community, and Making an Educational Activity on the Community.
The Collective Speech of the community health agents from the Habiteto neighborhood
The community health agents (CHA) described their work with activities such as: systematically visiting the families under their responsibility; investigate the existence of situations of risk on each visit, orient to the prevention of diseases and for the needs found; take the problems found to be discussed with the family health unity team, and serve to the community, teaching what they learned. They point out that it is a preventive, team work and that they receive training for the orientations that they must transmit on the households.
Among the CHA's attributions, determined by the Health Ministry, were pointed out by the interviewees, the identification of situations of risk, forward patients to the Unity of Basic Health (UBH) and the orientation for the health promotion and protection.
The activities of identifying partners and community resources, as well the community mobilization for the accomplishment of favorable environments and conditions to health were not cited. The community mobilization is fundamental to the work of health promotion in communities with social problems from the Habiteto neighborhood. Although a leadership profile is expected, on our study the community health agents exercised community leadership during the education program, based on the problematization of reality, on the debate and on the pursuit of solutions.
The work instruments that appeared on the speeches were: the interview, the home visit and the families' registration. However, the mapping of the community and community meetings were not described by the CHA.
The struggle to modify the health determinants such as: work, salary, housing and basic sanitation, among others doesn't appear on the community agents' speeches about their work on the Family Health Strategy. The preventive orientation work, so emphasized by the agents, is individualized and focused on the prevention of specific risks.
The speech about the difficulties faced is emphatic when referred to hygiene. It's the main concern of most (six) community health agents. Besides considering that there are many families living in precarious conditions of hygiene, they believe that is a delicate and offensive subject to be addressed to the residents.
The CHA's difficulty on addressing hygiene is evident, there's the fear of not being well accepted by the families anymore. They say that addressing this subject must be careful and they suggest the making of lectures, meetings or theater as more adequate strategies. They consider that the bond of trust and friendship that they maintain with the families makes the addressing of this subject difficult and that the nurse, for not residing in the neighborhood, would be the more adequate professional of the family health team to do these orientations. This speech gives clues about the limitations felt on the management of the hygiene subject with the families.
When talking about her difficulties, one CHA referred to the need to listen to what the families have to say, since there are problems whose solutions she can't resolve, and, in this case, can only listen to. Guided by the medical biological referential, the health professionals feel impotent when facing the misery, unemployment, lack of hygiene, hunger. These are the problems, for which there's no immediate cure, but are so serious that must be taken care of.
To listen to what the community has to or need to say is to shelter them; the sheltering is a form of care, maybe the first step to broaden the dialogue that can generate possibilities and opportunities.
The poverty and hunger, faced by many families on the Habiteto neighborhood, worries the CHA. They appear on the speech of four community agents when questioned about what they would like to do for the community. However, they believe that these are problems that escape their field of expertise.
The community agents demonstrated impotence and frustration when facing the social and hygiene problems. These are the biggest "critical knots" of the Habiteto neighborhood.
Although hygiene has been the greatest difficulty faced and hunger the greatest issue to be solved, no speech linked them both. They were approached as isolated issues.
Thinking hygiene without considering how the Habiteto neighborhood residents live life, as well thinking about educating them, adopting practices that only retransmit the knowledge, does not promote the transformations needed on the community.
The popular education does not intend to create educated subordinated people: people that are clean, polite, alphabetized, drinking boiled water, eating soy flour, shitting in septic tanks... It intends to participate on the effort to the organization of the political work that, step by step, opens the path to the conquest of their freedom and their rights (Vasconcelos, 1998, p.43).
Even feeling impotent and frustrated with the gravity of these problems, on of the CHA manifested the desire to improve the self-esteem of the residents. Besides that, another agent believes that there's the need to offer more areas of diversified leisure for the community. Solving the hunger problem is the "dream" of one CHA, who thinks that the best way to do it would be by helping the families to acquire financial independence, and not depending on others.
The "dream" speech of the CHA, related to the problems of the community that they are part of, refer to a holistic view that permeates the world view of these health workers, and provides conditions to better identify the paths to go through. But it is not enough, because they don't know how to broaden the possibilities of educative actions, like struggling to transform the social health determinants, and how to mobilize the community to the achievement of better conditions.
This unknowing on how to work with the community is the result of an education that talks "to" the people and not "with" them. Because of that, during the process of building and implementing of the capacitating program, we stimulated the participation of the community agents to develop the autonomy and comprehension of the individual and collective responsibility on the leaning process (Freire, 1987).
Building the educational program
We strived, on each meeting, to develop the criticity of the agents, bringing them a wider comprehension of the health-illness process. We delegated activities to be developed, between meetings, extending the themes approached on the classroom to their daily routine, stimulating the cooperation and involvement of the others members of the team and community.
By detecting the group's difficulty on broaden the possibilities of educational actions, we used, on every meeting, creative-participative dynamics and strategies that could be applied with the community, as well as materials and resources of easy access.
The knowledge was being built based on the problematization of the reality brought by them, debating and searching solutions within their own reality and implementing intervention projects. Besides that, culture and language of the community, as well their possibilities, were respected and used.
One of the developed activities during the capacitating program was the identification of the most relevant problems that occur on the micro-area of each agent and its possible solutions. The problems found were: alcoholism, low education, teenage pregnancy, and arterial hypertension. The agents were supposed to present projects for the resolution of these issues that involved partners, local resources and community participation.
Among the elaborated projects, it deserves to be highlighted the project to incentive schooling, which its initial focus was to lower unemployment. The change of focus happened when the agents sought a partnership with the Municipal Secretary of Citizenship and the local school direction, finding out that the issue of unemployment is due to, in part of, lack of schooling.
The Habiteto residents, for being from a poor area, have preference to positions offered by the Sorocaba City Hall. However, the positions available were not filled due to the low education of the applicants. On the other hand, the local school offered technical, language and high school equivalence courses, but couldn't put together classes because of the lack of applicants due to poor divulgation, or lack of interest.
Developing this work, the agents noticed the importance of partnership and communication between these services and started to publicize the classes offered by the school. As a result, they manage to graduate a high school equivalence class and, consequently, promote the schooling and self-esteem of the Habiteto residents.
During the period when we interacted with the agents, we noticed on them significant changes, like an improvement of self-esteem and the will to be more daring. These facts were probably result of the methodology and strategies that we applied, the bond of affection that was established between us, as well the concern on using the previous experience of our apprentices and bringing them to comprehend the responsibility of each one of them during the teaching-learning process and on the leadership that they must exercise on the community. A leadership that must be built by the agents day by day, by facing the problems of the community and on the collective search for solutions.
In the beginning of the educational program, the CHA presented as their main complaint, the lack of hygiene of the community. Little by little, this view began to be deconstructed until the point where they could understand that the problem with hygiene might be associated with other issues: low self-esteem, unemployment, poverty, depression, among others. Their "view" was broadened to beyond the biological and hygienist aspects and contemplated, as well, emotional and social issues, that interfere on the health-illness process.
A concrete proof of this focus was the work developed by the agents in the sense on re-integrating the Habiteto families to schooling and, consequently, to facilitate their access to the job market. Besides being able to fill a high school equivalence class on the neighborhood, two agents went back to school.
One CHA, that in the beginning made hopelessness statements about the community, after the end of the works, gave a very hopeful and excited testimony.
Another revelation was one of the agents that, during the meetings, was shy and talked very little, but on one of the classroom dramatizations, surprised us by the eloquence of her acting. By developing the last activity of the Educational Program, "making an educational activity on the community", this agent established a partnership with the Pastoral do Menor (a program for street kids) and organized a theater group with the kids from the Pastoral do Menor, to discuss on the community the issue of teenage pregnancy.
The work of this agent showed us that she assimilated and applied on her daily routine the work on a partnership, the utilization of community resources and the stimulation to the formation of other community leaders, subjects that were addressed during the capacitating program.
The analysis of the Collective Subject Speeches of the community health agents from the Habiteto neighborhood pointed out to a capacitating program that stimulated, on the health agents, the full development of their attributions, specially the ones listed below:
- the facilitation of the community leaders expression
- the incentive to the participation of the community
- the promotion of community meetings that focus on the perceived problems
- the identification of the community potentials
- the recognition of partners and resources that exist on the community
- the educational action of problematization
These activities are part of the work of the community health agent, according to the Ministry of Health, but were not addressed on the speeches, although they are appropriate to face the problems lived by the community in question.
In the beginning of the capacitating program, most agents showed dismay and impotence facing the social problems of the Habiteto families. By the end of the meetings, they showed optimism and hope, because they noticed that their objectives and dreams could be accomplished as long as they invested on new focuses and strategies.
With the implementation of the Educational Program, we saw that the practice of the CHA, that initially was strongly influenced by biological issues, was gradually redirected, having as its focus a broadened view of the health-illness process. Partnerships were established, community meetings were made, community leaderships and resources were found and optimized. Dynamic and participation strategies were adopted on the work with the community, stimulating their participation.
The larger and different attention for the families on situations of risk, like the ones from Habiteto, is a necessity within the social exclusion where they live. Their members, weakened by poverty, have an enormous difficulty to adequately implement health care.
Promoting meetings so these people can reflect about their lives, identify their needs and act collectively to solve them is the biggest challenge of the community health agents and of the health teams from the Habiteto neighborhood. Being a community health agent is, above all, to struggle and join forces on their community in the defense of the health and education public services, and on the improvement of the social health determinants. And being a agent of change and of encouragement to the community participation (Brasil, 2000).
We believe that there must be a constant movement to ensure, to the community health agents, a permanent education so they can fully develop their capabilities, stimulating them to make a community work with participation that is reflective and transforming. The methodology of problem-based education proved to be powerful to the achievement of this purpose.
The authors Lúcia Rondelo Duarte, Débora Schimming, Jardini Rodrigues da Silva and Sandra Helena Cardoso participated, equally, on all steps of the elaboration of this article.
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