THE POTENTI AL OF AN I NSTRUMENT TO I DENTI FY SOCI AL VULNERABI LI TI ES AND
HEALTH N EEDS: COLLECTI VE HEALTH KN OW LEDGE AN D PRACTI CES
Eu n ice Nak am u r a1 Em ik o Yosh ik aw a Egr y2 Célia Mar ia Siv alli Cam pos3 Lúcia Yasuk o I zum i Nichiat a3 Anna Mar ia Chiesa4 Ren at a Fer r eir a Tak ah ash i5
Nak am ur a E, Egr y EY, Cam pos CMS, Nichiat a LYI , Chiesa AM, Tak ahashi RF. The pot ent ial of an inst r um ent t o id en t if y social v u ln er ab ilit ies an d h ealt h n eed s: collect iv e h ealt h k n ow led g e an d p r act ices. Rev Lat in o- am En fer m agem 2 0 0 9 m ar ço- abr il; 1 7 ( 2 ) : 2 5 3 - 8 .
Ob j ect iv es: t o an aly ze an in st r u m en t t h at aim s t o u n d er st an d t h e h ealt h - d isease p r ocess, it s p ot en t ial t o ident ify social vulner abilit ies and healt h needs t o enable t he m ost appr opr iat e int er vent ions in a given t er r it or y. Pr ocedu r es: an aly sis of t h e dat a collect ion in st r u m en t – com posed of closed an d open qu est ion s t o iden t ify d if f er en t p r of iles of social r ep r od u ct ion ( w ay s of w or k in g an d liv in g ) – u sed in t h e Pr oj ect of Ped ag og ical Dev elopm ent and act iv it ies r epor t ed by st udent s at a Collect iv e Healt h Nur sing depar t m ent . Conclusions: t he inst r um ent enables healt h car e pr ofessionals, especially t hose fr om Collect iv e Healt h Nur sing, t o ident ify social vulner abilit ies and healt h needs, and guide int er vent ions in differ ent cont ext s, accor ding t o t he healt h pr om ot ion per spect ive. Thus, it r eveals pot ent ial t o t r ansfor m cur r ent healt h pr act ices, dynam ism and const ant innovat ion of t hese pr act ices in differ ent cont ex t s, accor ding t o t he “ r adicalit y ” t hat is char act er ist ic of Collect iv e Healt h.
DESCRI PTORS: needs assessm ent ; social vulner abilit y; nur sing; public healt h; deliver y of healt h car e; educat ion
EL POTENCI AL DE UN I NSTRUMENTO PARA EL RECONOCI MI ENTO DE
VULNERABI LI DADES SOCI ALES Y NECESI DADES DE SALUD: CONOCI MI ENTOS Y
PRÁCTI CAS EN SALUD COLECTI VA
Est e est udio t uv o com o obj et iv os analizar un inst r um ent o de lect ur a del pr oceso salud enfer m edad y ev aluar su p o t en ci a l p a r a el r eco n o ci m i en t o d e v u l n er a b i l i d a d es so ci a l es y n ecesi d a d es d e sa l u d , p o si b i l i t a n d o int er v enciones m ás adecuadas en un dado t er r it or io. Los pr ocedim ient os usados se const it uy er on de análisis del inst r um ent o de r ecolección de dat os – com puest o por pr egunt as cer r adas y abier t as par a el r econocim ient o de los difer ent es per files de r epr oducción social ( for m as de t r abaj ar y de v iv ir ) – ut ilizado en el Pr oy ect o de Desar r ollo Ped ag óg ico y d e in f or m es d e las act iv id ad es d esar r ollad as p or alu m n os d el Dep ar t am en t o d e Enfer m er ía en Salud Colect iv a de la Escuela de Enfer m er ía de la Univ er sidad de San Pablo( USP) . Se concluy e que el inst r um ent o analizado posibilit a a los pr ofesionales de la salud, par t icular m ent e de Enfer m er ía en Salud Colect iva, r econocer vulner abilidades sociales y necesidades de salud, or ient ando sus int er venciones en difer ent es cont ex t os, según la per spect iv a de la pr om oción de la salud. Rev ela, así, un pot encial t r ansfor m ador de las p r áct icas d e salu d v ig en t es, car áct er d in ám ico y d e r en ov ación con st an t e d e esas p r áct icas en d if er en t es cont ex t os, según la “ r adicalidad” pr opia de la Salud Colect iv a.
DESCRI PTORES: ev alu ación de n ecesidades; v u ln er abilidad social; en f er m er ía; salu d pu blica; pr est ación de at ención de salud; educación
O POTENCI AL DE UM I NSTRUMENTO PARA O RECONHECI MENTO DE VULNERABI LI DADES
SOCI AI S E N ECESSI DADES DE SAÚDE: SABERES E PRÁTI CAS EM SAÚDE COLETI VA
Est e est udo t ev e com o obj et iv os analisar um inst r um ent o de leit ur a do pr ocesso saúde- doença, seu pot encial par a o r econhecim ent o de v ulner abilidades sociais e necessidades de saúde, possibilit ando int er v enções m ais adequadas num dado t er r it ór io. Os pr ocedim ent os usados const it uír am - se de análise do inst r um ent o de colet a de dados – com post o por quest ões fechadas e aber t as par a o r econhecim ent o dos difer ent es per fis de r epr odução social ( for m as de t r abalhar e de v iv er ) – ut ilizado no Pr oj et o de Desenv olv im ent o Pedagógico e de r elat ór ios das at iv idades desen v olv idas por alu n os do Depar t am en t o de En f er m agem em Saú de Colet iv a da Escola de En f e r m a g e m d a USP. Co n cl u i - se q u e o i n st r u m e n t o a n a l i sa d o p o ssi b i l i t a a o s p r o f i ssi o n a i s d e sa ú d e , par t icu lar m en t e da En f er m agem em Saú de Colet iv a, r econ h ecer v u ln er abilidades sociais e n ecessidades de saúde, or ient ando suas int er v enções em difer ent es cont ex t os, segundo a per spect iv a da pr om oção da saúde. Rev ela, assim , p ot en cial t r an sf or m ad or d as p r át icas d e saú d e v ig en t es, car át er d in âm ico e d e r en ov ação const ant e dessas pr át icas em difer ent es cont ex t os, segundo a “ r adicalidade” pr ópr ia da Saúde Colet iv a.
DESCRI TORES: det er m in ação das n ecessidades de cu idados de saú de; v u ln er abilidade social; en f er m agem ; saú de pú blica; assist ên cia à saú de; edu cação
Esco l a d e En f er m a g em d a Un i v er si d a d e d e Sã o Pa u l o, Br a zi l : 1So ci a l Sci en t i st , Ph . D. i n An t h r o p o l o g y, Resea r ch er Pr o d o c/ Ca p es, e- m a i l : eunice_nakam ura@hot m ail.com ; 2RN, Ph.D. in Public Healt h, Full Professor, e- m ail: em iyegry@usp.br; 3RN, Ph.D. in Nur sing, Facult y, e- m ail: celiasiv@usp.br, izum i@usp.br; 4RN, Ph.D. in Public Healt h, Associat e Professor, e- m ail: am chiesa@usp.br; 5RN, Ph.D. in Nursing, Associat e Professor, e- m ail: rft akaha@usp.br.
I NTRODUCTI ON
A
bou t 3 0 y ear s ago, Collect iv e Healt h w as est ab lish ed as an ar ea of k n ow led g e an d scop e ofpr act ices, as fr om cr it icism against t he pr edom inant
m ed i ca l m o d el . I t s h i st o r i ca l d ev el o p m en t m a i n l y
o ccu r r ed i n Lat i n Am er i can co u n t r i es, w i t h st r o n g
in f lu en ce f r om Lat in Am er ican Social Ep id em iolog y,
w hich em phasizes t he hist or ical and social nat ur e of
t he healt h- disease pr ocess and it s det er m inant s. This
a r e a o f k n o w l e d g e , o f La t i n Am e r i ca n o r i g i n , i s
p a r t i cu l a r l y ch a r a ct e r i ze d b y t h e d e f e n se o f t h e
con n ect ion b et w een p u b lic an d eq u it ab le u n iv er sal
h eal t h sy st em s, b ased o n t h e t r i h ed r al “ i d eo l o g y,
k now ledge and pr act ice”( 1).
The st r ong connect ion bet w een t hink ing and
act ion t urned Collect ive Healt h int o an expressive field
for changes t hat occurred in t he healt h area, especially
in Br azil in t he 1980s. On t he ot her hand, it r equir ed
a m or e pr ecise def in it ion of con cept ion s an d h ealt h
pr act ices accor din g t o t h e collect iv e h ist or ically an d
socially det er m ined nat ur e of t heir obj ect .
Since t he im plem ent at ion of t he Single Healt h
Sy st em ( SUS) by t h e Feder al Con st it u t ion of 1 9 8 8 ,
t h e pot en t ial con n ect ion bet w een n ew con cept s an d
h e a l t h p r a c t i c e s h a s b e e n o n e o f t h e i m p e l l i n g
elem en t s of t h e d esir ed ch an g e in car e m od els( 2 ). How ever, t her e is an im por t ant obst acle r egar ding t he
ad eq u at e ed u cat i o n o f p r o f essi o n al s f o r Co l l ect i v e
Healt h pr act ice.
Am ong t he sever al ar eas t hat com pose Healt h
Sciences, Nursing has focused on issues present ed in
t he Collect iv e Healt h ar ea, dev eloping a specific ar ea
of k now ledge, r eflect ing and pr oposing, at t he sam e
t im e, new possibilit ies for pr ofessional educat ion and
p r act ice, esp ecially b ecau se it is an ar ea in w h ich
int er v ent ion and car e ar e essent ial act iv it ies.
N o t b y c h a n c e , k n o w l e d g e i n Co l l e c t i v e
Healt h Nu r sin g h as b een d r iv en b y d eep en in g t h e
t h e o r e t i c a l a n d m e t h o d o l o g i c a l f r a m e w o r k s a n d
br oadening t he spect r um of inst r um ent s t o st udy t he
r eal i t i es an d h eal t h - d i sease p r o cesses o f d i f f er en t
social g r ou p s, t h u s con t r ib u t in g t o t h e q u alif icat ion
of h ealt h pr act ices.
Th eo r et i cal - m et h o d o l o g i cal ad v an cem en t s,
o b ser v ed i n t h e ar ea, h av e n o t b een su f f i ci en t t o
pr ev ent gaps in t he t r ansfor m at ion and innov at ion of
healt h pr act ices, w hich seem t o be m ainly r elat ed t o
t he lack of analyses on professional educat ion focused
on Collect iv e Healt h pr act ices.
Analy sis of t hese pr act ices im plies r eflect ion
o n t h e n a t u r e a n d s p e c i f i c i t y o f t h r e e b a s i c
com p on en t s: t h e ob j ect , t h e w or k in st r u m en t s an d
act ivit ies or t he w or k per se. These ar e pr act ices t hat
p r esu p p o se sp eci f i c k n o w l ed g e g u i d i n g h eal t h car e
accor ding t o t he populat ion’s healt h needs. Thus, t hey
s h o u l d b e b a s e d o n c o m p e t e n c e s t h a t v a l u e
c o m m i t m e n t “ w i t h p r o t e c t i o n o f l i f e a n d t h e
com m u n it y ’s h ealt h ”( 1 ). Tak in g h ealt h n eed s as t h e obj ect of an aly sis, a f ir st st ep w ou ld be t o an aly ze
h e a l t h p r a ct i ce s a n d t h e i r d e t e r m i n a n t s t h r o u g h
appr opr iat e inst r um ent s so as t o gr asp and t r ansfor m
t h em .
Thus, t his art icle aim s t o analyze t he pot ent ial
of an inst r um ent – bot h in t eaching Collect ive Healt h
Nur sing and healt h car e – t o acknow ledge t he healt h
needs of individuals and fam ilies fr om differ ent social
gr oups in a giv en ar ea, w ho in t ur n should be t ak en
as t he obj ect of healt h pr act ices, so as t o put t hese
pr act ices in t o oper at ion w it h a v iew t o m eet in g t h e
n eed s t h at f i r st o r i g i n at ed i n t h e ci r cu l ar r el at i o n
bet w een healt h needs and healt h car e.
This cont ribut ion – in t he t eaching dim ension
– is consist ent w it h t he need for inst r um ent s in t he
t e a ch i n g w o r k p r o ce ss t h a t a r e a b l e t o i m p r o v e
ed u cat ion of f u t u r e h ealt h w or k er s w it h a v iew t o
ch an g in g t h e h ealt h car e m od el, w h ich h as m ain ly
t ak en d isease as ob j ect of h ealt h p r act ices in t h e
i n d i v i d u a l s c o p e( 2 ). Re g a r d i n g t h e h e a l t h c a r e dim ension, t he w or k inst r um ent analyzed in t his st udy
per m it s t he ident ificat ion of healt h needs t hat br oaden
t h e o b j e c t o f h e a l t h p r a c t i c e s b e y o n d t h a t
p r ed o m i n a n t l y i d en t i f i ed w i t h a l r ea d y est a b l i sh ed
i n d i v i d u a l p r o b l e m s o r n e e d s r e s t r i c t e d t o p r e
-det er m in ed pr ogr am s( 4 ).
Pr o c e d u r e s : a n a l y s i s o f t h e i n s t r u m e n t o f t h e
Ped ag og ical Dev elop m en t Pr oj ect f or t h e ed u cat ion
of pr ofessionals in Collect iv e Healt h Nur sing
On e o f t h e g o a l s o f t h e Co l l ect i v e Hea l t h
Nu r sin g Depar t m en t ( PHN) at t h e Un iv er sit y of São
Pa u l o Sch o o l o f N u r si n g ( EEUSP) , b a se d o n t h e
t h eor et i cal- m et h od ol og i cal r ef er en ce f r am ew or k of
S o c i a l Ep i d e m i o l o g y, h a s b e e n t o o r i e n t i t s
u n d e r g r a d u a t e s t u d e n t s t o i d e n t i f y o b j e c t i v e
det er m in an t s of t h e h ealt h - disease pr ocess an d, at
t he sam e t im e, under st and t he subj ect iv e aspect s of
t h i s p r o c e s s t h r o u g h t h e m e a n i n g s a n d
t heir pr ocess of illness. I n addit ion, one of t he m ain
concer ns in educat ion has been t he r eflect ion about
t he nur sing w or k pr ocess, t he r elat ion of nur ses w it h
t h e dif f er en t social h ealt h act or s an d t h e m ean in gs
at t r ibut ed t o t he healt h w or k and pr act ices w it h a view
t o b e t t e r o r g a n i z i n g t h e m i n t h e f a c e o f t h e
popu lat ion ’s differ en t r ealit ies.
Wit h t his in m ind, a gr oup of facult y m em ber s
o f t h i s d e p a r t m e n t e l a b o r a t e d a Pe d a g o g i c a l
D ev el o p m en t Pr o j ect*, ai m i n g t o cr i t i cal l y m o n i t o r healt h( 5) based on r esear ch and, at t he sam e t im e, on lear n in g t o delim it h ealt h pr oblem s an d n eeds in a
given t er r it or y so as t o pr opose int er vent ion st r at egies
in par t icular r ealit ies.
The Pr oj ect aim s “ ( ...) t o descr ibe t he healt h
s i t u a t i o n i n t h e t e r r i t o r y, w i t h i n t h e l i m i t s o f a
p e d a g o g i c a l w o r k , s p e c i f i c a l l y f o c u s e d o n m o r e
gener al aspect s of t he com m unit y t hat occupies t he
scope ar ea, seek ing t o ident ify t he pr ofiles of social
r epr oduct ion ( w ays of living and w or king) and pr ofiles
o f h eal t h - d i sease o f f am i l i es r esi d en t i n a sam p l e
j oint ly delim it ed w it h t he Basic Healt h Unit ( BHU) ”* *. To ach iev e t h e pr oposed goal, t h e follow in g
t heor et ical- m et hodological and oper at ional r efer ences
were adopt ed: a) concept ion of epidem iological profiles( 6) t o ident ify hom ogeneous groups in t he populat ion; b)
from t he m et hodological point of view, we believe t hese
concept ions support t he syst em at izat ion t o apprehend
t he Collect iv e Healt h obj ect , guide t he descr ipt ion of
part icularit ies of t he healt h sit uat ion in t he elect ed BHU
area t o carry out healt h surveys and act ions t o m onit or
t he populat ion’s healt h condit ions; c) underst anding t hat
assum ing r esponsibilit y for t he healt h of r esident s in
t he area im plies in cont rolling, m onit oring and
following-up t he healt h of all resident s by t he public healt h sect or
t hrough t he charact erizat ion of different epidem iological
profiles and t he possibilit y of int ervent ion in t hem . Thus,
t h ei r w o r k , l i f e a n d h ea l t h co n d i t i o n s h a v e t o b e
m onit ored t hrough an int erdisciplinary act ion bet ween
and across sect ors, which is how Healt h Surveillance( 6) o p er a t es; d ) f r o m t h e p ed a g o g i ca l p o i n t o f v i ew ,
a p p r e h e n d i n g t h e st u d i e d r e a l i t y b a se d o n t h e se
co n ce p t i o n s e n a b l e s st u d e n t s t o u n d e r st a n d t h e
co l l ect i v e i n t er v en t i o n p r o p o sal i n co n t r ast t o t h e
t r a d i t i o n a l e d u ca t i o n a l e x p e r i e n ce f o cu se d o n
int ervent ions in t he individual body.
I f, on t he one hand, t he educat ional pr oj ect ,
it s obj ect iv es and t heor et ical assum pt ions innov at ed
t he t eaching- lear ning pr ocess, especially in Collect iv e
Healt h Nur sing, on t he ot her hand, t he inst r um ent it
u sed d eser v es a m or e d et ailed an aly sis, esp ecially
r eg a r d i n g i t s t ech n o l o g i ca l p o t en t i a l a n d p o ssi b l e
co n t r i b u t i o n t o e x p a n d k n o w l e d g e a n d t r a n sf o r m
pr act ices in t he Collect iv e Healt h ar ea.
This inst r um ent is used her e as w ork t ool or
t echnology used t o ident ify, m anipulat e or t r ansfor m
healt h needs and t heir det er m inant s, t hus at t ending
t o i t s co l l ect i v e ch ar act er an d , at t h e sam e t i m e,
en ab lin g t h e ad op t ion of p r oced u r es t h at allow f or
t he also collect iv e w or k in healt h( 1).
Th e o b j e ct o f a n a l y si s i s, t h e r e f o r e , t h e
inst rum ent used for dat a collect ion in t he educat ional
pr oj ect : a quest ionnair e com posed of closed and open
q u est ion s t o id en t if y t h e d if f er en t p r of iles of social
r epr oduct ion – w ays of living and w or king. Repor t s of
act iv it ies dev eloped by st udent s at t ending t he cour se
“ Fu n d a m e n t a l s a n d Pr a ct i ce s i n Co l l e ct i v e He a l t h
Nu r sin g” du r in g t h e f ir st sem est er of 2 0 0 6 in t h r ee
BHUs ( Jar dim São Jor ge, Jar dim Boa Vist a an d Vila
Dalv a) under t he But ant ã Healt h Super v ision, Healt h
Coor d in at ion of t h e Mid w est r eg ion , São Pau lo, SP,
w er e also analyzed. Based on t he or iginally pr oposed
inst r um ent , t he analysis also consider ed an adapt at ion
car r ied ou t in f ield act iv it ies in 2 0 0 6 , accor d in g t o
part icularit ies of each area present ed in t hose report s.
Th e com p lex it y of t h e h ealt h - d isease p r ocess: t h e
ident ificat ion of social v ulner abilit ies and populat ions’
h ealt h n eeds
S t u d i e s a d d r e s s i n g t h e m o n i t o r i n g o f
Collect iv e Healt h con dit ion s t en d t o m ain ly con sider
t he w ays of social int eract ion of a cert ain populat ion( 5). Th ese w ay s of social in ser t ion d if f er in t h e sev er al
populat ions and define condit ions of par t icular social
v u ln er ab ilit ies, w h ich in t u r n lead t o social g r ou p s’
differ ent healt h needs( 7- 8).
Th e associat ion bet w een t h e con cept ion s of
social vulnerabilit ies and healt h needs in t he collect ive
p er sp ect i v e ar e cl o ser t o t h e So ci al Ep i d em i o l o g y
view , in w hich t he healt h- disease process is considered
a co m p l e x p h e n o m e n o n , so ci a l l y d e t e r m i n e d a n d
* Pr oj ect st r uct ur ed by facult y m em ber s fr om t he Collect ive Healt h Nur sing Depar t m ent at t he Univer sit y of São Paulo School of Nur sing, based on t he pedagogical r esear ch pr oj ect st r uct ur ed by t he facult y r esponsible for t he under gr aduat e cour se subj ect in 2001, depar t ing fr om a r esear ch pr oj ect elabor at ed t o guide t he developm ent of pedagogical act ivit ies in t he sam e subj ect in 1999.
* * Soar es CB, Cam pos CMS, Helene LF, I zum i L, Maeda L. Pr oj et o de Desenvolvim ent o Pedagógico.
m o d u l a t e d b y b i o l o g i ca l , p sy ch o l o g i ca l , cu l t u r a l ,
econ om ic an d polit ical con dit ion s. Accor din g t o t h is
perspect ive, t he root s of healt h- disease processes are
linked t o ways of social groups’ insert ion in t he world
of work, especially in t heir ways of working, which give
rise t o part icularit ies found in t heir living condit ions( 5,9). Th u s, “ ( …) t h e u lt im at e cau se of t h e h ealt h - disease
p r ocess b eh av ior sh ou ld b e sou g h t in t h e w ay t h e
societ y is organized t o const ruct social life. ( …) Social
o r g a n i z a t i o n i s a n e s s e n t i a l d e t e r m i n a n t o f
m a n i f est a t i o n s o f p o p u l a t i o n s’ q u a l i t y o f l i f e an d ,
consequent ly, of differ ent healt h needs”( 10).
Th u s, h ealt h an d disease pr ocesses ar e t h e
sy n t h esis of t h e set of d et er m in at ion s t h at en d u p
r e s u l t i n g i n d i f f e r e n t i a t e d v u l n e r a b i l i t i e s o r
pot ent ialit ies. We underline t he perspect ive adopt ed in
t h i s st u d y o f so ci al v u l n er ab i l i t y, u n d er st o o d as a
dim en sion of ex clu sion , discr im in at ion or w eak en in g
processes of social groups, regarding t heir capacit y t o
cope wit h such condit ions. The t erm social vulnerabilit y,
or igin at ed in t h e ar ea of in t er n at ion al adv ocacy f or
Hum an Right s, originally refers t o legally or polit ically
v u ln er ab le g r ou p s or in d iv id u als in t h e p r om ot ion ,
prot ect ion or assurance of t heir civil right s( 11). I t is linked t o social inequit y and inequalit ies, ex pr essed t hr ough
processes of pot ent ial illness or no illness, and coping
relat ed t o individuals, groups and com m unit ies. I n t his
concept ion, vulnerabilit y is not rest rict ed t o individual
vulnerabilit y but also involves t he collect ive, requiring
healt h pr act ices char act er ized by t he dev elopm ent of
act ions t hat include “ social response”, t he part icipat ion
of different social act ors in t he j oint search for st rat egies
able t o m eet healt h needs( 12).
Healt h n eed s ar e n ot r est r ict ed t o m ed ical
needs, healt h ser v ices or healt h pr oblem s ( diseases,
sufferings or risks) . I n fact , t hey are relat ed t o needs
or vulnerabilit ies t hat express ways of life and ident it ies,
ex p r essed in t h e q u est ion “ w h at is r eq u ir ed t o b e
h e a l t h y ?” , w h i c h t h e r e f o r e i n v o l v e s “ n e c e s s a r y
condit ions t o enj oy healt h”( 1). The scope and com plexit y of t hese obj ect ives of Collect ive Healt h pract ice require
pr ofessional com pet ence and specific inst r um ent s t o
appr opr iat ely answ er t o it s collect iv e char act er.
An inst r um ent t o guide Pr ofessional Collect iv e Healt h
pr act ice
I n t his analysis, in t aking t he concept s of social
vulnerabilit ies and social needs as obj ect s of Collect ive
Healt h pract ices, it is essent ial t o delim it t he discussion
regarding how t hese pract ices are put in pract ice. Once
t hese needs are ident ified, a challenge is also im posed,
which is t o elaborat e int ervent ion act ions in t he healt h
sect or able t o connect principles of universalit y, equit y
and int egr alit y, r ecom m ended by SUS( 13).
The est ablishm ent of Collect iv e Healt h as an
ar ea of k n ow led g e an d scop e of p r act ices lead s t o
t h e r esu m p t ion of som e essen t ial con cep t s f or t h e
co n st r u ct i o n o f w h at co u l d b e cal l ed “ m ap p i n g o f
p r a x i s”( 1 ). Th ese co n cep t s a r e: h ea l t h n eed s, t h e s u b j e c t a n d h e a l t h p r a c t i c e s , c o n n e c t e d i n t h e
u n d er st a n d i n g o f h ea l t h n eed s a s a p o ssi b i l i t y o f
subj ect s being healt hy and acknow ledged in t he int er
-subj ect iv e r elat ion bet w een healt h pr ofessionals and
p o p u l a t i o n , r e o r g a n i zi n g a ct i v i t i e s a n d r e cr e a t i n g
t ech n olog ies.
This is t he Collect iv e Healt h( 1) “ r adicalit y ” in view of it s em ancipat ion assum pt ions, dem ocr acy and
s u b j e c t s ’ a u t o n o m y, w h i c h i n t u r n a r e i t s m a i n
ob st acles, esp ecially in t er m s of p r of ession al sk ills
n eed ed f or t h e d ev elop m en t of p r act ices b ased on
such assum pt ions. These obst acles w ill be gr eat er as
t he concept of fairness is associat ed t o t he possibilit y
o f a p p r eh en d i n g d i f f er en t h ea l t h n eed s a n d t h ei r
ex pr ession by au t on om ou s su bj ect s.
The com pet ences ex pect ed fr om a Collect iv e
Healt h Pr of ession al, p r esen t ed h er e as a p r ob lem ,
ar e addr essed based on t he analysis of t he inst r um ent
used in t he Pedagogical Developm ent Proj ect , in w hich
t eaching and w or k ar e int egr at ed
Th i s i n s t r u m e n t c o n s i d e r s i m p o r t a n t
d i m e n s i o n s o f o b j e c t i v e r e a l i t y, n a m e l y t h e
e s t a b l i s h m e n t o f a f a m i l y, w a y s o f w o r k i n g ( o r
p r o d u ct i o n ) a n d w a y s o f l i f e ( o r co n su m p t i o n ) o f
d i f f e r e n t s o c i a l g r o u p s , w i t h t h e i r p o t e n t i a l f o r
st r en g t h en i n g a n d ex h a u st i o n , t o u n d er st a n d t h e
v ulner abilit y of differ ent social gr oups t o illness in a
giv en r ealit y.
Based on t he analy sis of t he inst r um ent and
r epor t s of act iv it ies dev eloped by st udent s at t ending
t he cour se “ Fundam ent als and Pr act ices of Collect iv e
H e a l t h N u r s i n g ” , a s e t o f i n d i c a t o r s r e l a t e d t h e
char act er ist ics of fam ilies, t heir w ay s of w or k ing and
liv ing, ident ified m or bidit y and coping st r at egies, and
p er cep t ion s r elat ed t o t h e h ealt h - d isease p r ocess.
These indicat or s per m it t ed k now ing t he pot ent ials of
st r engt hening and t hose r elat ed t o t he ex haust ion of
s o c i a l g r o u p s , d e f i n i n g a f r a m e w o r k o f s o c i a l
fam ily com posit ion, it is possible t o charact erize fam ily
ar r angem ent s, or igin of it s m em ber s, educat ion and
gener at ional r elat ions in t he differ ent gr oups.
A s t o w a y s o f w o r k i n g , t w o g r o u p s o f
i n d i c a t o r s s t o o d o u t : 1 ) p a i d w o r k ( a c t i v i t y
ch ar act er ist ics, occu p at ion , w eek ly w or k in g h ou r s,
t im e spent on daily com m ut ing) and 2) fam ily incom e
( benefit s r eceiv ed in addit ion t o w or k , per cent age of
fam ily in com e spen t on basic ex pen dit u r e lik e food,
r ent , ut ilit ies, t elephone, clot hing) .
I n t er m s of w ays of life, t he follow ing gr oups
of indicat or s ar e highlight ed: 1) housing ( ow ner ship,
adequ acy of v en t ilat ion an d n at u r al ligh t in g, gr ow t h
or dev elopm ent of m old, pr edom inant floor m at er ial,
n u m b er of r oom s, n u m b er of r esid en t s) ; 2 ) access
( t o b a si c se r v i ce s l i k e w a t e r, e l e ct r i ci t y, g a r b a g e
collect ion , sew ag e an d leisu r e act iv it ies) ; 3 ) social
p a r t i ci p a t i o n ( i n g r o u p s, a sso ci a t i o n s, u n i o n s a n d
polit ical part ies) ; 4) percept ion of vulnerable sit uat ions
( l a n d sl i d e , f l o o d , v i o l e n ce , r o a d t r a f f i c a cci d e n t ,
co n t a m i n a t i o n b y g a r b a g e , se w a g e a n d st r e a m s,
cont act w it h vect or s, developm ent of alcohol and dr ugs
a d d i c t i o n , i n v o l v e m e n t i n p r o b l e m s w i t h d r u g
t r af f ick in g ) .
The social gr oup’s pr ofiles of healt h- disease
and har m w hich fam ily m em ber s ar e ex posed t o ar e
i d e n t i f i e d a s t h e r e su l t o f t h e cl a sh b e t w e e n t h e
p o t en t i a l s o f st r en g t h en i n g a n d ex h a u st i o n t h ese
f a m i l i e s a r e su b m i t t e d t o . Th i s r e su l t i s i n f e r r e d
t h r ou gh qu est ion s t h at addr ess: 1 ) r epor t ed h ealt h
pr ob lem s ( gen er al pr oblem s, pr oblem s w it h alcoh ol
a n d o t h e r d r u g s, m e n t a l p r o b l e m s a n d p h y si ca l
im p air m en t p r ob lem s) ; 2 ) r ep or t ed h osp it alizat ion s
( last 12 m ont hs) ; 3) m onit or ing of pr event ive exam s
( last Pap sm ear an d m am m ogr aph y ) ; 4 ) adh er en ce
t o h e a l t h se r v i ce p r o g r a m s a v a i l a b l e i n t h e a r e a
( fr equency of cont act w it h healt h ser v ices r elat ed t o
t h e r epor t ed m or bidit ies) .
Th e o p e n q u e s t i o n s t h a t c o m p o s e t h e
inst rum ent focus on t he apprehension of t he subj ect ive
d i m e n s i o n o f h e a l t h - d i s e a s e p r o c e s s e s , i n t h e
concept ions and ex per iences of int er v iew ed fam ilies,
r e v e a l i n g p a r t i cu l a r m e a n i n g s o f w h a t a h e a l t h y
per son is, car e st r at egies ( w h o play s t h e car egiv er
role, how t he relat ion caregiver/ pat ient is est ablished)
and possibilit ies of accessing healt h ser v ices.
Th e c o m p l e m e n t a r y a n a l y s i s o f t h e s e
i n d i c a t o r s , r e s u l t o f o b j e c t i v e a n d s u b j e c t i v e
d i m e n si o n s o f f a m i l i e s’ r e a l i t y ca p t u r e d f r o m t h e
pr oposed inst r um ent , has enabled j oint w or k bet w een
w or k er s at t h e BHU, st u den t s an d f acu lt y f r om t h e
Collect iv e Healt h Nur sing depar t m ent in t he planning
o f s p e c i f i c i n t e r v e n t i o n s f o r a s e t o f p a r t i c u l a r
v u l n e r a b i l i t i e s a n d h e a l t h n e e d s i d e n t i f i e d i n t h e
differ en t social gr ou ps.
CONCLUSI ONS
Th e a n a l y ze d i n st r u m e n t a i m s t o i d e n t i f y
d e t e r m i n a n t s o f t h e h e a l t h - d i se a se p r o ce ss a n d
u n d er st an d t h e con cep t ion s an d ex p er ien ces social
gr oups hold r egar ding t heir pr ocess of becom ing ill.
I t e n a b l e s h e a l t h p r o f e s s i o n a l s , a n d e s p e c i a l l y
Collect iv e Healt h Nu r sin g st u d en t s in v olv ed in t h e
Ped ag og ical Pr oj ect , t o id en t if y v u ln er ab ilit ies an d
h e a l t h n e e d s, a n d a t t h e sa m e t i m e g u i d e t h e m
r e g a r d i n g d i f f e r e n t i n t e r v e n t i o n s i n t h e d i f f e r e n t
c o n t e x t s t h e y a c t i n . I n t h i s p e r s p e c t i v e , t h e i r
cont r ibut ions and t hose r elat ed t o t he inst r um ent used,
f o r p r o f essi o n al ed u cat i o n an d g u i d an ce o f h eal t h
pr act ices, ar e link ed t o it s possible r elat ion w it h t he
assu m pt ion s of Collect iv e Healt h .
Th e i n s t r u m e n t s o f i d e n t i f i c a t i o n a n d
m onit oring of healt h needs can be classified according
t o d i f f e r e n t p e r s p e c t i v e s a d o p t e d , a c c o r d i n g t o
pr ior it ies, t ar get s or goals and healt h pr om ot ion t o:
1 ) iden t if y t h e m ost n eeded or t h e t ar get au dien ce
f o r Co l l e c t i v e H e a l t h p o l i c i e s a c c o r d i n g t o
ep i d em i o l o g i cal cr i t er i a; 2 ) g u ar an t ee t h at h eal t h
s e r v i c e s a r e m o r e e f f i c i e n t i n a t t e n d i n g t h e
p o p u l at i o n ’ s h eal t h n eed s o r 3 ) r eg ar d l ess o f t h e
ident ificat ion of pr oblem s, value a pr oact ive appr oach,
focused on t he populat ion’s par t icipat ion and on t he
possibilit y of it s aut onom y in t he generat ion of it s ow n
h ealt h r esou r ces. Despit e t h e dif f er en ces, t h e t h r ee
ap p r oach es sh ou ld com p ose an in t eg r at ed sy st em ,
per m it t ing t hat dat a necessar y for differ ent pur poses
ar e ident ified at differ ent lev els and t hr ough specific
inst r um ent s and m et hods( 15).
The inst r um ent analyzed and pr esent ed in t his
art icle is close t o t he perspect ive of healt h prom ot ion
as it seeks t o ident ify vulnerabilit ies and healt h needs
o f d i f f er en t so ci a l g r o u p s i n t h e p o p u l a t i o n , t h ei r
pot ent ials of st r engt hening and ex haust ion based on
t h e ch a r a ct er i st i cs o f t h ei r i n ser t i o n i n t h e so ci a l
r epr oduct ion. Mor eover, in per m it t ing com plem ent ar it y
bet w een obj ect iv e aspect s of r ealit y an d su bj ect iv e
concept ions of t he populat ion it self, it also values t he
differ ent m eanings at t r ibut ed t o w ay s of life, healt h
an d su f f er in g .
Th u s, i t r ev eal s i t s p o t en t i al t o t r an sf o r m
current healt h pract ices and guide st udent s and healt h
pr ofessionals t o adopt pr act ices m or e consist ent w it h
t h e a s s u m p t i o n s o f t h e Co l l e c t i v e H e a l t h a r e a ,
especially t h e con cept s of collect iv e, equ it y, alt er it y
an d au t on om y. I t also en ab les t h e con n ect ion an d
r e d e f i n i t i o n o f t h r e e b a si c co m p o n e n t s o f h e a l t h
pr act ices – t he obj ect , t he inst r um ent and act ivit ies –
st r e ssi n g t h e d y n a m i c n a t u r e o f t h e t h e o r e t i ca l
-m e t h o d o l o g i ca l -m o d e l i t i -m p l i e s a cco r d i n g t o t h e
dynam ics of t he Collect ive Healt h ar ea: “ a space m or e
open t o new par adigm s in t he face of healt h needs,
h u m a n r i g h t s , a n d e m a n c i p a t o r y p r o c e s s e s o f
dem ocr at izat ion of social life”( 1).
I t i s t h i s d y n a m i c m o d e l , co u p l e d t o t h e
p ossib ilit y of con st an t r en ew al of h ealt h p r act ices,
accor d in g t o t h e con t ex t social g r ou p s liv e in , t h at
seem s t o cont ain t he “ r adicalit y ” of Collect iv e Healt h
and of a t heor et ical- m et h odological m odel based on
t he per spect ive of t he ot her, his( er ) vulnerabilit ies and
healt h needs( 1). This m odel also cont ains t he pot ent ial “ r a d i c a l i t y ” o f t h e p r o f e s s i o n a l e d u c a t i o n a n d
t r a n s f o r m a t i o n o f h e a l t h p r a c t i c e s , n o l o n g e r
exclusively focused on biom edical know ledge, but also
open t o ot her k inds of k now ledge.
One of t he gr eat challenges for t he pr ocess
of pr ofessional educat ion in Collect iv e Healt h seem s
t o b e t h e p o s s i b i l i t y o f f o r m u l a t i n g s p e c i f i c
co m p et en ces i n t h i s ar ea, b ased o n t h e i d eal co
-m an age-m en t( 1 6 ), in v iew of in t er v en t ion s gu ided by con f r on t in g ack n ow ledged sit u at ion s of v u ln er abilit y
an d h eal t h n eed s o f t h e p o p u l at i o n , co n n ect ed t o
p r i n c i p l e s o f u n i v e r s a l i t y, e q u i t y a n d i n t e g r a l i t y
r ecom m en ded by t h e SUS.
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