COMMUNI TY HEALTH AGENT: A LI TERATURE REVI EW
Ana Cláudia Gar abeli Cav alli Klut hcov sk y1 An gela Mar ia Magosso Tak ay an agu i2
Klut hcovsky ACGC, Takayanagui AMM. Com m unit y healt h agent : a lit erat ure review. Rev Lat ino- am Enferm agem 2 0 0 6 n ov em br o- dezem br o; 1 4 ( 6 ) : 9 5 7 - 6 3 .
St u dy of t h e r ev iew lit er at u r e r egar din g br azilian Com m u n it y Healt h Agen t . Th e m et h odology w as descr ipt iv e and ex plor at or y st udy , using t he LI LACS dat abase ( 1982 t o m ar ch/ 2005) and MEDLI NE ( 1966 t o 2005) . The analysis result ed 153 publicat ions, from w hich 97 had been excluded. About t ype of product ion, of t h e 5 6 r efer en ces ( 1 0 0 % ) , 5 3 , 6 % w er e book s, 3 2 , 1 % per iodic ar t icles, 7 , 1 % Mast er ’s Th eses an d r em ain s 7,2% , doct or al disser t at ions and specializat ion m onogr aphs. I t w as obser v ed t hat 59% of t he r efer ences had been enclosed in t he dat abase in 2000. Consider ing only per iodic ar t icles, specializat ion m onogr aphs, Mast er ’s Th eses an d doct or al disser t at ion s, an am ou n t of 2 6 st u dies, t h e ex per im en t al design pr edom in at ed ( 7 3 % ) , b ein g t h e ob j ect iv es m ost f r eq u en t : ch ar act er izat ion of t h e ag en t s an d t h eir f u n ct ion s, p r ocess w or k an d r esult s. The dat a suggest incr easing int er est on t he subj ect , how ev er , t hese w or ker s st ill consist a populat ion lit t le st udied.
DESCRI PTORS: com m unit y healt h agent ; fam ily healt h pr ogr am ; r ev iew lit er at ur e
AGENTE COMUNI TARI O DE SALUD: UNA REVI SI ÓN DE LI TERATURA
Est u dio de lit er at u r a de r ev isión sobr e Agen t e Com u n it ar io de Salu d br asileir o. La m et odología er a est udio descript ivo y explorat ório, en base de dat os LI LACS ( 1982 a 2005) y MEDLI NE ( 1966 a 2005) . El análisis r esult ó 153 publicaciones, 97 excluidos. De las 56 r efer encias ( 100% ) , 53,6% er an los libr os, 32,1% ar t ículos de periódicos, 7,1% eran disert aciones de m aest ría y del rest o 7,2% , las t esis de doct orado y m onografías de especialización. El 59% de las referencias habían sido incluidos en la base de dat os en 2000. Considerando los ar t ículos per iódicos, las m onogr afías de especialización, disser t aciones de m aest r ía y t esis de doct or ado ( 2 6 est udios) , el diseño ex per im ent al pr edom inó ( 7 3 % ) , siendo los obj et iv os m ás fr ecuent es: car act er ización de los agent es y de sus funciones, ev aluaciónes del pr oceso y de los r esult ados del t r abaj o. Los dat os sugier en int er és de aum ent o en el t em a, est os t r abaj ador es t odav ía consist en una población poco est udiada.
DESCRI PTORES: agent e com unit ar io de salud; pr ogr am a salud de la fam ilia; lit er at ur a de r ev isión
O AGENTE COMUNI TÁRI O DE SAÚDE: UMA REVI SÃO DA LI TERATURA
Est e é um est udo de revisão da lit erat ura sobre o Agent e Com unit ário de Saúde brasileiro. A m et odologia usada foi o est udo explorat ório- descrit ivo, ut ilizando- se o banco de dados LI LACS ( de 1982 at é 2005) e MEDLI NE ( 1966 a 2005) . A análise result ou em 153 publicações, sendo 97 excluídas. Quant o ao t ipo de produção, das 56 r ef er ên cias ( 1 0 0 % ) , 5 3 , 6 % er am liv r os, 3 2 , 1 % ar t igos de per iódicos, 7 , 1 % disser t ações de m est r ado e os r est ant es, 7, 2% , t eses de dout or ado e m onogr afias de especialização. Obser v ou- se que 59% das r efer ências for am in clu ídas n a base de dados a par t ir de 2 0 0 0 . Con sider an do- se ar t igos de per iódicos, m on ogr afias de especialização, disser t ações de m est r ado e t eses de dout or ado, no t ot al de 26 est udos, houv e pr edom ínio do delineam ent o ex per im ent al ( 73% ) , sendo os obj et iv os m ais fr eqüent es: car act er ização dos agent es e de suas funções, avaliação do processo e result ados do t rabalho. Os dados sugerem int eresse crescent e sobre o t em a, em bor a os agent es sej am ainda um a população pouco est udada.
DESCRI TORES: agent e com unit ár io de saúde; pr ogr am a saúde da fam ília; lit er at ur a de r ev isão
¹ MD, M.Sc. in Nursing. Facult y, Cent ral- West ern St at e Universit y, Guarapuava- PR, e- m ail: anafabio@brt urbo.com .br. ² Associat e Professor, Universit y of São Paulo at Ribeirão Pret o College of Nursing, WHO Collaborat ing Cent re for Nursing Research Developm ent , e- m ail: am m t akay@eerp.usp.br.
I NTRODUCTI ON
I
n West er n ed u cat ion , h ealt h an d d isease concept ions were st rongly influenced by t he biologicalpar adigm , in w h ich t h e h ealt h con cept is based on
t he absence of disease, and at t ent ion is dir ect ed at
t h e in div idu al an d t h e disease, w it h t h e h ospit al as
t he dom inant unit and t he predom inance of specialized
m edical care, t hus disaggregat ing global at t ent ion on
t he hum an being( 1).
I n Br azil, t h er e is an on g oin g p r og r essiv e
exhaust ion of t his privat e m edical care m odel, m ainly
from t he end of t he 1970’s onwards. During t he second
h al f o f t h e 1 9 8 0 ’s, t h e d em o cr at i c t r an si t i o n w as
co n so l i d a t e d t h r o u g h a n i n st i t u t i o n a l r e o r d e r i n g
m ovem ent t hat culm inat ed in t he Federal Const it ut ion
of 1 9 8 8 , t h e Or g an ic Healt h Law of 1 9 9 0 an d t h e
cr eat ion of t he Single Healt h Syst em ( SUS)( 2- 3).
I n or der t o com ply w it h Feder al Const it ut ion
det er m inat ions about t he basic pr inciples of t he SUS
in t er m s of t r adit ional healt h ser v ice or ganizat ion, in
1991, t he Minist ry of Healt h im plant ed t he Com m unit y
Healt h Agen t Pr ogram ( CHAP) all ov er t h e cou n t r y,
as a pr oposal t o change t he t r adit ional public healt h
car e par adigm( 2, 4).
How ev er, w h en con sid er ed sep ar at ely, t h e
CHAP is a select iv e pr im ar y car e pr oposal, cr eat in g
incr easing healt h ser v ice dem ands. Hence, in 1 9 9 4 ,
t h e Min ist r y of Healt h lau n ch ed t h e Fam ily Healt h
Program ( FHP)( 2), underst ood as a st rat egy in t he SUS
basic healt h car e m odel, in w hich t he fam ily healt h
t eam cor r esp on d s t o on e of t h e car e p oin t s in t h e
m unicipal healt h sy st em net w or k( 5).
Com m unit y healt h agent s ( CHA) can be part
of an FHP t eam or t he CHAP, w hich is consider ed a
par t of t he FHP or a t r ansit ion pr ogr am t ow ar ds t he
FHP, in t hose cit ies where only t he CHAP exist s( 6).
A c c o r d i n g t o t h e M i n i s t r y o f H e a l t h ,
c o m m u n i t y h e a l t h a g e n t s a r e p r o f e s s i o n a l s s u i
generis. They should live in t he com m unit y it self, have
a m ore social t han t echnical profile, be over 18, wit h
full- t im e availabilit y t o perform t heir act ivit ies. Am ong
ot her t ask s, t hey should w or k w it h fam ilies w it hin a
d ef in ed g eog r ap h ical b ase an d r eg ist er an d f ollow
t hese fam ilies( 7).
The CHA’s m ain inst r um ent s ar e int er v iew s,
hom e visit s, fam ily regist ers, com m unit y m apping and
com m unit y m eet ings( 3 ).
Th e CH A a r e r e s p o n s i b l e f o r a n a l y z i n g
com m unit y needs; being act iv e in healt h pr om ot ion
an d disease pr ev en t ion act ion s, especially in v olv in g
childr en, w om en, adolescent s, elder ly and phy sically
and m ent ally - im pair ed per sons; par t icipat ing in basic
h y g i en e an d en v i r o n m en t al i m p r o v em en t act i o n s;
part icipat ing in healt h t eam m eet ings and ot her healt h
ev ent s w it h t he com m unit y( 3).
H i s t o r i c a l l y, t h e CH A r e p r e s e n t t h e l i n k
bet ween t he professional t eam and t he com m unit y( 8),
wit h t he role of t ranslat ing t he scient ific t o t he popular
u n i v er se, o f f aci l i t at i n g p eo p l e’ s access t o h eal t h
s e r v i c e s . S o m e t i m e s , h o w e v e r, t h e y f a c e t h e
p op u lat ion ’s r esist an ce t o or ien t at ion s, as w ell as
difficu lt ies t o r elat e w it h com m u n it y m em ber s or in
t he w ork process inside t he healt h t eam( 9- 10).
Desp it e d if f icu lt ies, t h e b en ef it s t h e CHA’s
work all over t he count ry have brought t o t he Brazilian
p op u lat ion ’s h ealt h ar e u n d en iab le, w it h d ecr eased
m or t alit y and m or bidit y lev els and im pr ov ed r at es in
som e healt h act ions, accom panied by t he com m unit y’s
valuat ion of t heir work( 9- 11).
Nowadays, a large num ber of CHA are act ive
in Brazil. I n Decem ber 2005, t here were 208,104 CHA,
i. e. 58. 4% of t he est im at ed nat ional populat ion w as
followed by CHA, calculat ing 575 persons per agent( 12).
Th u s, t h i s st u d y i s j u st i f i e d b y t h e l a r g e
n u m b er of CHA p r of ession als act iv e in Br azil; t h e
nat ure of t heir work; t he Healt h Minist ry’s great st im ulus
t o r eor ganize basic car e t hr ough t he ex pansion and
im plan t at ion of n ew FHP t eam s in cit ies, w h er e t h e
CHA are fundam ent al act ors; besides t his professional’s
growing presence in t he nat ional healt h syst em .
The guiding quest ion of t his st udy is t o find
ou t t o w h at ex t en t an d h ow scien t if ic r esear ch h as
look ed at CHA pr ofessionals as r esear ch subj ect s, or
st udied aspect s r elat ed t o t heir w or k .
Giv en t he im por t ance of t hese pr ofessionals,
em phasized by t he Healt h Minist r y it self, w e believ e
t hat sever al st udies r elat ed t o t he CHA have alr eady
been r ealized.
Th is st u d y aim ed t o car r y ou t a lit er at u r e
r ev iew( 13) on Br azilian CHA, w it h r espect t o t he t y pe
of product ion and year of publicat ion, different j ournals
p u b lish in g t h e scien t if ic ar t icles, t y p es of r esear ch
design and t heir obj ect iv es.
METHODOLOGY
Th i s st u d y i s a l i t er a t u r e r ev i ew( 1 3 ) a b o u t
To s t a r t t h e r e f e r e n c e s e a r c h , f i r s t , w e
accessed t he sit e www.birem e.br and, aft er consult ing
t he Healt h Science Descr ipt or s ( DeCS) , w e ident ified
t h e f o l l o w i n g d escr i p t o r s: Ag en t e Co m u n i t á r i o d e
Saúde, Agent e Com unit ario de Salud and Com m unit y
Healt h Agent , t hus including publicat ions in Port uguese,
Spanish and English.
Next , using t he sam e sit e, on March 3rd 2005,
we accessed t he dat abases of t he Lat in Am erican and
Car ibbean Healt h Science Lit er at ur e ( LI LACS) , since
1982 ( st art dat e of t he syst em ’s dat a collect ion) ; and
t h e Na t i o n a l Li b r a r y o f Me d i ci n e, r e sp o n si b l e f o r
MEDLI NE, since 1966, using t he descr ipt or w or ds in
t h e r esp ect i v e l an g u ag es (Ag en t e Co m u n i t ár i o d e
Saúde, Agent e Com unit ario de Salud and Com m unit y
Healt h Agent ) , in singular and plural, in t he field w ords
in t he t it le.
I n LI LACS, w e found 1 2 7 r efer ences, w hich
w er e pr int ed out . Som e of t hem display ed t he t it le,
year and place of publicat ion, while ot hers also included
t h e a b s t r a c t . Re p e t i t i o n s ( 2 9 r e f e r e n c e s ) a n d
publicat ions t hat were not relat ed t o Brazilian CHA ( 42
references) were excluded, result ing in 56 references,
50 of which were Brazilian and six int ernat ional.
I n MEDLI NE, 26 references were found, which
w er e excluded fr om t his st udy because t hey r efer r ed
t o healt h agent s from ot her count ries ( 24 references) ,
o r b e ca u se t h e y h a d a l r e a d y b e e n ca t a l o g u e d i n
LI LACS ( 2 r ef er en ces) .
Th e 5 6 ( 1 0 0 % ) r ef er en ces o b t a i n ed f r o m
LI LACS, w h i ch co n st i t u t ed o u r sam p l e, w er e f i r st
cat alogued and analy zed accor ding t o t he pr oduct ion
t y pe and y ear of publicat ion.
A lar ge m aj or it y of r efer ences t o book s and
book chapt er s did not cont ain an abst r act , but only
t he t it le, y ear and place of publicat ion. Hence, only
j ou r n al ar t icles, sp ecializat ion cou r se m on og r ap h s,
m a s t e r ’ s t h e s e s a n d d o c t o r a l d i s s e r t a t i o n w e r e
a n a l y z e d a c c o r d i n g t o t h e d i f f e r e n t t y p e s o f
m et hodological appr oaches and r esear ch obj ect iv es.
Th i s i n f o r m a t i o n w a s o b t a i n e d b y a n a l y zi n g t h e
av ailable abst r act s.
We f aced a n u m b er o f d i f f i cu l t i es i n d at a
collect ion: t he non av ailabilit y of som e abst r act s, as
w ell as t he fact t hat som e abst r act s did not cont ain
inform at ion about t he m et hodological approaches and
obj ect ives, relat ed t o art icles as well as m onographs,
t h eses an d d isser t at ion s. Desp it e t h ese d if f icu lt ies,
w e collect ed t h e d esir ed in f or m at ion ab ou t a lar g e
m aj or it y of t he abst r act s.
D a t a w e r e t r e a t e d t h r o u g h a b so l u t e a n d
per cen t age f r equ en cy an aly sis.
RESULTS AND DI SCUSSI ON
I n t h i s l i t e r a t u r e r e v i e w a b o u t CH A, w e
an aly zed 5 6 r ef er en ces, 5 0 of Br azilian an d six of
int ernat ional origin, which const it ut ed our final sam ple.
Table 1 sh ow s t h e dist r ibu t ion accor din g t o
pr oduct ion t y pe.
Table 1 - Dist ribut ion of CHA references according t o
p r od u ct ion t y p e in t h e LI LACS d at ab ase, b et w een
1982 and 2005
e p y t n o i t c u d o r
P N %
s r e t p a h C k o o B r o s k o o
B 30 53.6
s e l c it r A l a n r u o
J 18 32.1
s e s e h T s ' r e t s a
M 4 7.1
s h p a r g o n o M n o it a z il a i c e p
S 2 3.6
s n o it a t r e s s i D l a r o t c o
D 2 3.6
l a t o
T 56 100
The above t able shows t hat t he m ost frequent
r ef er en ces w er e b ook s or b ook ch ap t er s ( 5 3 . 6 % ) ,
f ollow ed b y j ou r n al ar t icles ( 3 2 . 1 % ) an d m ast er ’s
t heses ( 7. 1% ) .
Wit h respect t o t he books and book chapt ers,
19 of t he 30 r efer ences w e found w er e published by
t h e Healt h Min ist r y, an d f iv e b y t h e Pan Am er ican
H e a l t h Or g a n i z a t i o n , w h i c h d e m o n s t r a t e s t h e s e
g o v er n m en t a l en t i t i es’ i n t er est i n t h e t h em e a n d
collab or at ion .
On t h e o t h e r h a n d , o n l y e i g h t ( 1 4 . 3 % )
r ef er en ces r esu l t ed f r om g r ad u at e ( sp eci al i zat i on ,
m ast er ’s and doct or al) cour se r esear ch.
As t o product ion year, t he 56 references were
dist ribut ed as shown in Figure 1.
Pot informed
Figu r e 1 - Dist r ibu t ion of CHA r efer en ces accor din g
t o pu blicat ion per iod in t h e LI LACS dat abase, f r om
As t o t h e y ear of pu blicat ion , w e f ou n d 1 1
r efer ences ( 19.6% ) unt il 1994, t he fir st of w hich w as
p r od u ced in 1 9 8 9 . Th is cor r esp on d s t o an av er ag e
rat e of t w o publicat ions per year. Sim ilar rat es w er e
found bet w een 1995 and 1999. Fr om 2000 t o 2004,
w e f ou n d 3 3 r ef er en ces ( 5 9 % ) , i. e. an av er ag e of
6 . 6 p er y ea r, w h i ch a p p r o x i m a t el y r ep r esen t ed a
t h r e e f o l d i n c r e a s e i n t h e n u m b e r o f a n n u a l
p u b l i cat i o n s i n co m p ar i so n w i t h t h e t w o p r ev i o u s
p er iod s, r ev ealin g t h at p u b licat ion s ab ou t CHA ar e
m ain ly con cen t r at ed in t h e last f iv e y ear s. I n f act ,
t his finding is pr ov ed w hen w e analy ze t he hist or y of
t he CHAP and t he FHP in Br azil fr om t he end of t he
1 9 9 0 ’s on w ar d s.
Mo r e o v e r, a s o b s e r v e d , t h e i n c r e a s e i n
r e se a r ch a b o u t t h i s t h e m e h a s o ccu r r e d i n n o n
-geom et r ical pr opor t ion s, pr obably du e t o t h e gr eat
e x p a n si o n o f t h e CHAP a n d t h e FHP i n d i f f e r e n t
Brazilian cit ies, m ainly in recent years, confirm ing t he
Healt h Minist ry’s int ent ion t o t urn t he FHP not m erely
int o anot her program , but int o a st rat egy t hat at t em pt s
t o change t he t r adit ional healt h car e m odel.
Table 2 - Dist ribut ion of art icles published about CHA
a cco r d i n g t o t h e i n d e x e d j o u r n a l i n t h e LI LACS
dat abase, fr om 1982 t o 2005
t he m et hodological appr oaches t hey adopt ed. Result s
are shown in Table 3. This it em could not be assessed
i n t h e 3 0 r e f e r e n ce s r e l a t e d t o b o o k s a n d b o o k
ch apt er s, becau se m ost of t h em did n ot in clu de an
abst ract , but only t it le, year and place of publicat ion.
Tab le 3 - Dist r ib u t ion of CHA r ef er en ces ( ar t icles,
m on ogr aph s, t h eses an d disser t at ion s) accor din g t o
t h e adopt ed m et h odology, in t h e LI LACS dat abase,
from 1982 t o 2005
s l a n r u o
J N %
a c il b ú P e d ú a S e d s o n r e d a
C 5 27.7
e t a b e D m e e d ú a
S 3 16.5
e t a b e D a r a p e d ú a S m e o ã ç a g l u v i
D 2 11.0
m u r a it n e i c S a t c
A 1 5.6
a v it e l o C e d ú a S e d s o n r e d a
C 1 5.6
m e g a m r e f n E e r a t i g o
C 1 5.6
o ã ç a c u d E , e d ú a S , o ã ç a c i n u m o C e c a f r e t n
I 1 5.6
li t n a f n I -o n r e t a M e d ú a S e d a r i e li s a r B a t s i v e
R 1 5.6
í u a i P o d a c il b ú P e d ú a S e d o ã ç a i c o s s A a d a t s i v e
R 1 5.6
m e g a m r e f n E e d a h c ú a G a t s i v e
R 1 5.6
a c il b u P d u l a S e d a n a c i r e m a n a P a t s i v e
R 1 5.6
l a t o
T 18 100
A c l o s e r l o o k a t t h e a r t i c l e s p u b l i s h e d
accor ding t o j our nal t y pe show s t hat t he 18 ar t icles
f ou n d in ou r su r v ey w er e pu blish ed in 1 1 dif f er en t
j ournals, eight of which cont ained j ust one art icle about
ou r cen t r al r esear ch t h em e. Th e f ollow in g j ou r n als
pr esen t ed t h e lar gest n u m ber of pu blicat ion s abou t
t h e t h em e: Cad er n o s d e Saú d e Pú b l i ca, w i t h f i v e
art icles ( 27.7% ) ; Saúde em Debat e, wit h t hree art icles
( 16.5% ) and Divulgação em Saúde para Debat e, wit h
t w o publicat ions ( 11.0% ) ( Table 2) .
We a n a l y ze d t h e 1 8 j o u r n a l a r t i cl e s, t w o
specializat ion m onogr aphs, four m ast er ’s t heses and
t w o doct or al disser t at ions, t ot aling 26 st udies, as t o
n g i s e d l a c i g o l o d o h t e
M N %
l a t n e m i r e p x
E 19 73.0
n o it c e lf e r l a c it e r o e h
T 3 11.6
t r o p e r e c n e i r e p x
E 1 3.8
e l b a li a v a t o n t c a r t s b a r o d e m r o f n i t o
N 3 11.6
l a t o
T 26* 100
* excluding books and book chapt ers
The analysis of t hese dat a r evealed t hat t he
m ost frequent ly used m et hodology was experim ent al,
adopt ing an em pir ical pr ocedur e for dat a collect ion,
including group com parisons, follow- up st udies or case
st udies( 14).
We f o u n d n o r ev i ew st u d i es. Th i s ca n b e
ex plained by t he fact t hat com m unit y healt h agent s
have only recent ly been int roduced as healt h workers
in Br azilian public healt h.
I n t hree st udies ( 11.6% ) , abst ract s were not
av ail ab l e or, w h en av ai l ab l e, t h ey d i d n ot con t ai n
infor m at ion about t he adopt ed m et hodology.
N i n e t e e n s t u d i e s u s e d e x p e r i m e n t a l
m e t h o d o l o g y, se v e n ( 3 6 . 8 % ) o f w h i ch l o o k e d a t
co m m u n i t y h ea l t h a g en t s, a n d sev en ( 3 6 , 8 % ) a t
agent s and ot her subj ect s ( five st udies involving users,
one including m edical st udent s and one Basic Healt h
Un i t h e a d s, p h y si ci a n s a n d n u r se s) . Tw o st u d i e s
l o o k ed a t u ser s, o n e o f w h i ch a l so i n v o l v ed CHA
in st r u ct or s/ su p er v isor s.
I n t hr ee st udies, t he abst r act did not clar ify
t he r esear ch subj ect .
We f o u n d t h r ee st u d i es t h a t a d o p t ed t h e
r ef lex iv e m et h odology, on e of w h ich w as r elat ed t o
t he CHA hir ing m ode, anot her t o t heir incor por at ion
int o t he public healt h syst em and t he t hird t o t he use
o f h u m a n r e s o u r c e s f r o m t h e p e r s p e c t i v e o f
const r uct ing t he SUS.
Table 4 pr esen t s t h e obj ect iv es of j ou r n als
ar t icles, specializat ion m on ogr aph s, m ast er ’s t h eses
and doct or al disser t at ions. Due t o abov e m ent ioned
r eason s, t h is it em cou ld n ot be an aly zed in t h e 3 0
Tab le 4 - Dist r ib u t ion of CHA r ef er en ces ( ar t icles,
m onogr aphs, t heses and disser t at ions) , accor ding t o
r esear ch ob j ect iv es, in t h e LI LACS d at ab ase, f r om
1982 t o 2005
h as been con sider ed as “ a fu n dam en t al st r at egy t o
r e c o m p o s e t r a i n i n g , c a r e , m a n a g e m e n t , p o l i c y
for m ulat ion and social cont r ol pr act ices in t he healt h
sect or...”( 15).
One of t he st udies looked at t he agent s’ social
r e p r e s e n t a t i o n s w h i c h t h e y e i t h e r e l a b o r a t e d
t hem selv es or w hich user s pr oduced about t he CHA,
a n d a l s o a n a l y z e d t h e CH A’s a n d u s e r s ’ s o c i a l
r e p r e se n t a t i o n s a b o u t p sy ch o so ci a l a sp e ct s a n d
pr of ession al pr act ices.
Fu r t h e r m o r e , a b o u t t h e a g e n t s ’
char act er izat ion, one st udy sought t o under st and t he
CHA’s profile in a m et ropolit an region, wit h a view t o
m a k i n g v i a b l e t h e p o p u l a t i o n ’ s a cce ss t o h e a l t h
ser v ices t hr ough t w o t y pes of pr act ices in car r y out
t h e pr oposed policies: on e pr edom in an t ly t ech n ical,
b y m ean s of access t o h ealt h ser v ices in all car e
st ag es, an d an ot h er p olit ical p r act ice, t h r ou g h t h e
conquest of civ il r ight s.
As t o t h e CHA’s w o r k p r o ce ss ( 2 3 . 1 % o f
r e f e r e n ce s) , t h r e e st u d i e s a i m e d t o a n a l y ze t h e
act ions t hey developed in t he healt h syst em . Anot her
at t em pt ed t o under st and t he com m unicat ion pr act ice
bet ween FHP agent s and users, as a work inst rum ent
t o im pr ov e healt h car e.
I n t he sam e sense, one st udy about t he CHAP
discu ssed t h e det er m in an t an d con dit ion in g f act or s
t o in cor p or at e t h e ag en t s in t o t h e Br azilian p u b lic
healt h syst em . A research carried out in t wo cit ies in
t h e No r t h e a st o f Br a zi l a sse sse d t h e u se o f t h e
I nt egrat ed St rat egy for t he Managem ent of Prevalent
Ch ildh ood Diseases by CHA.
Five st udies ( 19.3% ) evaluat ed result s of CHA
act iv it ies ( in t h e CHAP an d FHP) , in clu din g: u se of
h ealt h ser v ices, popu lat ion ’s k n ow ledge abou t CHA;
effect s on healt h pract ice m odificat ions; m ean num ber
of visit s/ m ont h per fam ily; hospit alizat ion rat e am ong
children under five years old; use of oral rehydrat ion
solu t ion ; diar r h ea con t r ol; deat h s of ch ildr en u n der
one year old; basic vaccinat ion cover age; pr evalence
of height / age deficit and incidence of low birt h weight .
One art icle discussed t he agent s’ inst it ut ional
relat ion and report ed on t he need t o hire out sourced
w or ker s for dir ect social ser vice deliver y of collect ive
in t er est .
Th e d e c e n t r a l i z a t i o n o f h e a l t h p r o v o k e d
ch an ges in t h e w ay h ealt h pr of ession als ar e h ir ed,
m ainly due t o t he ex pansion and im plem ent at ion of
h ealt h pr ogr am s, w h ich cr eat ed a lar ge in cr ease in
pr ofessional hir ing. Thus, m any cit ies st ar t ed t o use
s e v i t c e j b
O N %
n o it c n u f r i e h t d n a s t n e g a f o n o it a z i r e t c a r a h
C 6 23.1
s s e c o r p k r o w ' s t n e g a f o t n e m s s e s s
A 6 23.1
s e it i v it c a d e m r o f r e p f o t n e m s s e s s a tl u s e
R 5 19.3
n o it a l e r l a n o it u t it s n i ' s t n e g
A 1 3.8
s t c e p s a l a c i h t e f o s i s y l a n
A 1 3.8
n o it a t n a l p m i e c i v r e s f o n o it p i r c s e
D 1 3.8
s n o it i d n o c k r o w d n a h tl a e h n o h c r a e s e
R 1 3.8
n o it c a f s it a s r e s u d n a t n e m e g d e l w o n k c
A 1 3.8
e l b a li a v a t o n t c a r t s b a r o d e m r o f n i t o
N 4 15.5
l a t o
T 26 100
I n a t ot al of 26 st udies, Table 4 show s t hat
t h e m ost f r eq u en t ly d ef in ed ob j ect iv es f or j ou r n al
ar t icles, specializat ion m on ogr aph s, m ast er ’s t h eses
an d doct or al disser t at ion w er e r elat ed t o t h e CHA’s
act iv it y, including t he w or k pr ocess ( 23. 1% ) , r esult s
o f t h ei r act i v i t i es ( 1 9 . 3 % ) , d escr i p t i o n o f ser v i ce
im plant at ion ( 3, 8% ) and ack now ledgem ent and user
sa t i sf a ct i o n ( 3 . 8 % ) , t o t a l i n g 5 0 % . Th i s r e su l t i s
followed by publicat ions whose obj ect ives were relat ed
t o t h e CHA’s co n d i t i o n , w h et h er i n t er m s o f t h ei r
c h a r a c t e r i z a t i o n a n d f u n c t i o n ( 2 3 . 1 % ) , t h e i r
inst it ut ional relat ion ( 3.8% ) and t heir healt h and work
condit ions ( 3.8% ) , t ot aling 30.7% .
The analysis of research abst ract s t hat aim ed
t o an aly ze t h e ch ar act er izat ion of agen t s an d t h eir
f u n ct i o n ( 2 3 . 1 % ) sh o w ed t h at o n e o f t h e st u d i es
at t em pt ed t o con st r u ct t h e agen t s’ iden t it y in t h eir
work, wit h respect t o int erpret at ion conflict s and power
relat ions est ablished am ong FHP users, based on t hree
perspect ives: t he agent s’ official t raining, t he ident it y
ag en t s t h em selv es p r od u ce ab ou t t h em selv es an d
t h eir p r act ice, an d t h e id en t it y t r an sm it t ed b y t h e
com m u n it y.
Tw o s t u d i e s t r i e d t o u n d e r s t a n d t h e
p h en om en on of r elig iou sn ess, sp ir it u alit y, p er son al
beliefs and values, expressed t hrough daily st rat egies
and pract ices relat ed t o healt h, associat ing t hem wit h
lear n in g an d ob t ain ed k n ow led g e, also t ak in g in t o
account healt h educat ion. Anot her st udy em phasized
w or k shops in t he cont ex t of a per m anent educat ion
p r oj ect d ev elop ed w it h CHA, p r ob lem at izin g som e
m anifest at ions by t he subj ect s involved in t he t raining
p r o cess.
Healt h ed u cat ion h as b een d iscu ssed f or a
l o n g t i m e i n a c a d e m i c m e a n s a s w e l l a s p u b l i c
d i f f e r e n t f o r m s o f h i r i n g . Th e H e a l t h Mi n i s t r y
est ab lish ed a com m it t ee t h at d ef in es st r at eg ies t o
reduce t he precariousness of healt h work in t he SUS.
H e a l t h p r o f e s s i o n a l s ’ w o r k r e l a t i o n s s h o u l d b e
g u ar an t eed , w it h all d u e lab or an d social secu r it y
r i g h t s , a s w e l l a s t h e d e m o c r a t i z a t i o n o f w o r k
r elat ions( 16).
On e ar t icle d i scu ssed t h e et h ical q u est ion
about t he r ight t o pr ivacy in r elat ions bet w een user s
a n d CHA, w i t h r e sp e ct t o a cce ss t o ce r t a i n u se r
infor m at ion, such as disease diagnoses for ex am ple.
Anot her ar t icle descr ibed t he im plant at ion of
p r im ar y h ealt h car e w or k in Rio d e Jan eir o slu m s,
where CHA were responsible for a specific populat ion.
On e r e s e a r c h a b o u t h e a l t h a n d w o r k
con dit ion s, in v olv in g f if t een CHA, aim ed t o iden t if y
ep i d em i ol og i cal an d cl i n i cal asp ect s t h at cou l d b e
associat ed w it h t he r isk of ex posur e t o pest icides.
Despit e t h e im por t an ce of u ser sat isf act ion
i n h e a l t h s e r v i c e s a n d a c t i o n s , o n l y o n e s t u d y
at t em pt ed t o ident ify if CHAP users acknowledged t he
role and im port ance of t he CHA’s act ivit ies, as well as
user s’ sat isfact ion about t hese agent s’ w or k .
FI NAL CONSI DERATI ONS
The result s of t his st udy show a large rise in
publicat ions about CHA in r ecent y ear s, m ainly aft er
t he y ear 2000. Especially book s, book chapt er s and
j ou r n al ar t icles in cr eased , p ossib ly d u e t o g r eat er
int erest in t his professional, considering t hat t he Healt h
M i n i s t r y h a s e n c o u r a g e d t h e e x p a n s i o n a n d
im plant at ion of new FHP t eam s all over t he count ry.
Li t e r a t u r e r e v i e w s c a n c h a r a c t e r i z e t h e
t r aj ect or y follow ed t o achieve cur r ent know ledge and
gu ide n ew r esear ch pr oj ect s( 1 7 ). Th u s, w e obser v ed
t en den cies in st u dies abou t CHA, em ph asizin g t h eir
act iv it ies, w het her by analy zing t he w or k pr ocess or
by assessing t he result s of t heir act ivit ies, as well as
char act er izing agent s and t heir funct ions.
More st udies should look at CHA, considering
t he agent s as person, t heir dilem m as, difficult ies and
achiev em ent s, i. e. fact or s t hat can be influenced by
t he peculiar nat ure of t heir work or not .
Ot her im port ant research is relat ed t o polem ic
and essent ial issues in healt h w ork m anagem ent and
healt h educat ion, such as t he hiring of SUS workers;
f u n ct ion p lan s, car eer s an d w ag es an d p er m an en t
educat ion in t he SUS( 16), m ainly at m unicipal level.
Alt hough we could not analyze t he qualit y of
publicat ions in t his review, we believe t hat t his st udy
a l l o w e d u s t o c h a r a c t e r i z e h o w r e s e a r c h a b o u t
Br azilian CHA has been conduct ed.
I n view of t he short t im e t hese professionals
hav e been inser t ed in t he healt h ar ea, m any st udies
m ust be looking at com m unit y healt h agent s, and t he
num ber of publicat ions m ay increase in t he next years.
We h ope t h at , despit e it s lim it at ion s, t h is lit erat u r e
r eview m ay encour age new st udies about CHA.
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