EDUCATI VE PRACTI CE OF COMMUNI TY HEALTH AGENTS
ANALYZED THROUGH THE CATEGORY OF PRAXI S
Car la An dr ea Tr apé1 Cássia Baldini Soar es2
Trapé CA, Soar es CB. Educat ive pr act ice of com m unit y healt h agent s analyzed t hr ough t he cat egor y of praxis. Rev Lat ino- am Enfer m agem 2 0 0 7 j aneir o- fev er eir o; 1 5 ( 1 ) : 1 4 2 - 9 .
This st udy aim ed t o: analy ze t he concept ions of healt h educat ion t hat guide educat ional pr act ices of com m unit y healt h agent s in t he Fam ily Healt h Pr ogr am of t he But ant ã Healt h Coor dinat ion, São Paulo, Br azil, and analy ze t he char act er of t hese educat ional act iv it ies. Dat a w er e collect ed t hr ough focus gr oups and in-dept h sem i- st r uct ur ed int er v iew s w it h 3 9 agent s. The analy sis pr ocedur es follow ed t he r ecom m endat ions of t hem at ic cont ent analysis, and praxis was t he analyt ical cat egory. Regarding t heoret ical act ivit y as a com ponent of pr ax is, w e f ou n d t h at m ost h ealt h edu cat ion con cept ion s w er e based on t h e t r an sm ission of n or m at iv e in f or m at ion lear n ed f r om h ealt h t ech n ician s. Th is t h eor et ical act iv it y en d ed u p gu id in g a p r act ical act iv it y t ypical of r epet it ive pr axis, in w hich t he agent s do not par t icipat e in t he healt h w or k planning pr ocess and do not dom inat e t he “ ideal obj ect ” , r epr oducing t asks planned by ot her s.
DESCRI PTORS: healt h educat ion; com m unit y healt h agent ; Fam ily Healt h Pr ogr am
LA PRÁCTI CA EDUCATI VA DE LOS AGENTES COMUNI TÁRI OS
DE SALUD A LA LUZ DE LA CATEGORI A PRAXI S
Est e est udio t uv o com o obj et iv os: analizar las concepciones de educación en salud que or ient an las práct icas educat ivas de los agent es com unit arios de salud en el Program a de Salud de la Fam ilia de la Coordinación de Salud de la Alcaldía m enor de But ant ã en la ciudad de São Paulo, Br asil; y analizar el car áct er de esas act ividades educat ivas. La colect a de dat os ocur r ió por m edio de gr upos focales y ent r evist as individuales con 3 9 agent es. Los pr ocedim ient os de análisis siguier on las r ecom endaciones del análisis t em át ico, t eniendo la praxis com o cat egoría de análisis. En relación a la act ividad t eórica, com ponent e de la praxis, se const at ó que gran part e de las concepciones de educación en salud se basaba en la t ransm isión de inform aciones norm at ivas aprendidas con los t écnicos de salud. Esa act ividad t eórica acabó por guiar una act ividad práct ica caract eríst ica de la praxis reit erat iva, en que los agent es no part icipan del planeam ient o del proceso de t rabaj o en salud y no dom inan el “ obj et o ideal” , r epr oduciendo t ar eas planeadas por ot r os.
DESCRI PTORES: educación en salud; agent e com unit ar io de salud; pr ogr am a salud de la fam ilia
A PRÁTI CA EDUCATI VA DOS AGENTES COMUNI TÁRI OS
DE SAÚDE À LUZ DA CATEGORI A PRÁXI S
Est e est u do t ev e com o obj et iv os: an alisar as con cepções de edu cação em saú de qu e n or t eiam as prát icas educat ivas dos agent es com unit ários de saúde do Program a de Saúde da Fam ília da Coordenadoria de Saúde da Subprefeit ura do But ant ã da cidade de São Paulo, e analisar o carát er dessas at ividades educat ivas. A colet a de dados ocorreu por m eio de grupos focais e ent revist as individuais com 39 agent es. Os procedim ent os de an álise segu ir am as r ecom en dações da an álise t em át ica, t en do a pr áx is com o cat egor ia de an álise. Em relação à at ividade t eórica, com ponent e da práxis, const at ou- se que grande part e das concepções de educação em saúde se paut av a na t r ansm issão de infor m ações nor m at iv as apr endidas com os t écnicos de saúde. Essa at ividade t eórica acabou por guiar um a at ividade prát ica caract eríst ica da práxis reit erat iva em que os agent es não part icipam do planej am ent o do processo de t rabalho em saúde e não dom inam o “ obj et o ideal” , reproduzindo t ar efas planej adas por out r os.
DESCRI TORES: educação em saúde; agent e com unit ár io de saúde; pr ogr am a saúde da fam ília
1
RN, M.Sc. in Public Healt h Nursing, Technician, e- m ail: carlaens@usp.br; 2 RN, PhD in Educat ion, Facult y, e- m ail: cassiaso@usp.br, Universit y of São Paulo College of Nursing
I NTRODUCTI ON
T
h is st u d y look s at h ealt h ed u cat ion as a so ci a l p r a ct i ce ca r r i e d o u t b y Co m m u n i t y He a l t hAgent s ( CHA) , who are perceived as agent s of change
i n v i e w o f t h e i m p l a n t a t i o n o f t h e Fa m i l y He a l t h
Pr ogr am ( FHP) . Healt h educat ion is one int er v ent ion
inst r um ent , r ecom m ended and ack now ledged by t he
Br azilian Healt h Minist r y t hr ough Law 10. 507, w hich
cr eat es t h e p r of ession of CHA. Com m u n it y Healt h
A g e n t s ’ a c t i v i t i e s a r e c h a r a c t e r i z e d b y d i s e a s e
p r e v e n t i o n a n d h e a l t h p r o m o t i o n , d e v e l o p e d
according t o t he guidelines of t he Single Healt h Syst em
( SUS) and under a local m anager ’s super v ision( 1). This st udy st ar t s fr om docum ent at ion about
CHA in t h e St at e of São Pau lo, j oin ed f r om 1 9 8 1
onw ar ds t hr ough t he DEVALE Pr oj ect ( Pr oj ect for t he
Ex pansion of Basic Healt h and Sanit at ion Ser v ices in
Rur al Ar eas) , w hich w as par t of t he PI ASS Pr ogr am
( Pr o g r a m f o r t h e I n t e r i o r i z a t i o n o f H e a l t h a n d
Sanit at ion Act ions( 2).
PI ASS, developed in t he m id- 1970’s, was one
of t h e m ost ex p r essiv e Healt h Cov er ag e Ex t en sion
Pr o g r a m ( PEC) . Gu i d e d b y N o r t h A m e r i c a n
Com m unit y Medicine concept ions, t he program aim ed
t o m it igat e, t hr ough focal act ions, conflict s der iv ing
fr om social inequalit ies( 3).
Com m unit y act ion at t em pt ed t o act on already
in st alled h ealt h pr oblem s, r est r ict in g act ion s t o t h e
consum pt ion sphere, wit hout int ervent ions t hat would
r each t h e labor w or ld. I t w as based on com m u n it y
p a r t i c i p a t i o n , w i t h t h e c l e a r i n t e n t t o p r o v i d e
orient at ions recom m ended by healt h st aff, leaving t he
f i n a l s a y u p t o t h e t e c h n i c i a n . Mo r e o v e r, t h e
p o p u l a t i o n ’ s p a r t i ci p a t i o n w a s r eq u est ed t o so l v e
p r ob lem s b ased on lim it ed local r esou r ces, t o t h e
d et r im en t of st r u ct u r al t r an sf or m at ion s t h at w ou ld
adequat ely at t end t o t he healt h needs of t he social
gr oups t hat com pr ised a giv en com m unit y( 3). At t he end of t he 1960’s, com m unit y act ion
p r og r am s an d t h e Com m u n it y Med icin e m ov em en t
w er e br ought t o Lat in Am er ica and t o Br azil, m ainly
t hrough t he Pan Am erican Healt h Organizat ion ( PAHO)
and Nor t h Am er ican pr iv at e foundat ions( 3).
Th e cr ea t i o n o f t h i s k i n d o f p r o j ect s w a s
associat ed wit h t he UN ( Unit ed Nat ions) resolut ion t hat
called u pon r ich cou n t r ies t o pr om ot e h elp t o poor
count ries aft er World War I I , as a st rat egy t o rem ove
t he danger of East ern European com m unist ideologies’
e x p a n s i o n . Th u s , t h e U S p r o m o t e d t e c h n i c a l
assist ance pr oj ect s for count r ies at t he per ipher y of
capit alism , m ainly from Lat in Am erica, including Brazil,
dev eloping count less ex per iences. I n pr inciple, t hese
w e r e f o cu se d o n r u r a l a n d sm a l l si t e s a n d w e r e
addr essed in differ ent st udies( 4).
Th i s p r i n ci p l e w a s st r en g t h en ed f r o m t h e
1970’s onwards by m eans of t he capit alist crisis, whose
an sw er w as t h e econ om ic, p olit ical an d id eolog ical
proj ect of neoliberalism . Through t he fight against t he
St at e of Social Well- Being, global capit al gained t he
a d h e r e n c e o f a S t a t e t h a t e s t a b l i s h e d o f f i c i a l
r at ion alized pu blic h ealt h car e m odels at a m in im al
cost , allow ing t he pr ivat e sect or t o explor e healt h as
a com m er cial good( 5).
“ I n v iew of t h is p ict u r e, it is im p or t an t t o
consider t he m eanings incr easingly at t r ibut ed t o t he
right t o healt h, in a scenario in which t he arrangem ent
bet ween t he public and privat e sect or are not always
g u i d e d b y a n i n cl u si v e e t h i ca l r a t i o n a l i t y, w h e r e
m iserabilit y and so- called social vulnerabilit y sit uat ions
def in e t h e pr iv ileged pr oj ect of social policies ( . . . ) .
[ an d w h er e] t h e w ay san it at ion policies ar e f u n ded
a n d o p e r a t i o n a l i z e d a p p o i n t s t h e p u b l i c - p r i v a t e
ar t icu lat ion , ex em pt in g t h e St at e fr om it s r ole as a
guar ant or of r ight s”( 6).
H e n c e , t h e FH P e n d e d u p b e i n g a
com p en sat or y p r og r am , in a con t ex t w h er e p u b lic
services were t ransform ed int o Social Organizat ions( 7). I t is not “ difficult t o associat e t his care m odel wit h t he
fam ily/ com m unit y m edicine m odel. I t is obvious t hat ,
i n or d er t o of f er t h e essen t i al m i n i m u m p ack ag e,
sp e ci a l i st s a r e n o t n e ce ssa r y, n o t e v e n i n b a si c
specialt ies, n or in v est m en t s in t h e qu alificat ion an d
m oder nizat ion of t he ser v ice net w or k ( ...) ”( 8). Based on t he prem ise t hat CHA inst it ut ionally
par t icipat e in t h e con cr et izat ion of t h is pr oj ect an d
ca n t h er ef o r e d ev el o p ed u ca t i v e a ct i o n s t o m a k e
indiv iduals and fam ilies account able for t he solut ion
of t heir healt h problem s, t his st udy aim ed t o: analyze
t he educat ion, healt h and healt h educat ion concept s
t h at g u id e CHA’s ed u cat iv e p r act ices; an aly ze t h e
char act er of educat iv e act iv it ies car r ied out by CHA
f r om t h e Healt h Coor din at ion Of f ice of t h e Bu t an t ã
Mu n icipal Gov er n m en t .
THEORETI CAL CONSI DERATI ONS
Pr ax is appear s as a pot ent analy t ic cat egor y
a ccu m u l a t e d k n o w l e d g e ( e x p e r i e n ce / t r a i n i n g f o r
w or k / in t en t ion alit y of com m u n it y h ealt h ag en t s as
a g e n t s i n t h e h e a l t h w o r k p r o c e s s ) a n d t h e
concr et izat ion of t his pr oj ect .
Pr a x i s r e f e r s t o t h e h u m a n a c t i o n t h a t
t ransform s nat ure, based on t he t heory t hat exist s t o
guide t he act ion, t hat is, “ pr ax is pr esent s it self as a
m at erial and t ransform ing act ivit y t hat is adj ust ed t o
obj ect ives. Out side praxis, t here is t heoret ical act ivit y,
which is not m at erialized, t o t he ext ent t hat it is purely
spirit ual. But , on t he ot her hand, praxis does not exist
as a p u r el y m at er i al act i v i t y, t h at i s, w i t h o u t t h e
pr oduct ion of goals and k now ledge t hat char act er ize
t heor et ical act iv it y ”( 9).
What charact erizes act ual hum an act ivit y is t he
aw ar eness of act ions, w hich ar e dir ect ed t ow ar ds an
obj ect in order t o t ransform it and whose final result
t r ies t o get near t he ideal r esult . Thus, pra x is, as a
m at erial pract ical act ivit y guided by conscience ( t heory)
in order t o t ransform nat ure on t he basis of an int ent ional
proj ect , is different iat ed from general act ivit y( 9). Theory can present it self as t heoret ical act ivit y
t o t h e e x t e n t t h a t i t t r a n s f o r m s p e r c e p t i o n s ,
concept ions or concept s, t hat is, when bot h obj ect ives
an d k n ow led g e ar e p r od u ced . How ev er, t h eor et ical
act ivit y alone does not t ransform realit y, as “ it s act ivit y
i s n o t o b j e ct i f i e d o r m a t e r i a l i z e d ”( 9 ). Th i s i s a n im per at ive char act er ist ic of pr axis and, t her efor e, w e
cannot t alk about t heor et ical pr ax is.
Th e or e t ica l a ct iv it y is d ist in g u ish ed f r om p r a c t i c e i n t e r m s o f o b j e c t , g o a l s , m e a n s a n d
inst rum ent s. I f t he obj ect of pract ical act ivit y is nat ure,
societ y or m en, it s goal is t he t r ansfor m at ion of t he
nat ural or social world, and t he result is a new m at erial
r ealit y; in t h eor et ical act iv it y, t h e ob j ect in clu d es
per cept ions, concept s, t heor ies and r epr esent at ions,
and t he goal is t o producet heories t hat explain current
r eal i t y or o u t l i n e g o al s t h at i d eal l y an t i ci p at e t h e
t r a n s f o r m a t i o n o f r e a l i t y, w i t h o u t i t s a c t u a l
occu r r en ce( 9 ).
On t h e ot h er h an d , t h e w ay con scien ce is
pr esen t in t h e su bj ect ’s pr act ical act iv it y con figu r es
different praxis levels. Thus, a dist inct ion can be m ade
bet ween creat ive and im it at ive praxis. “ Praxis appears
eit her as im it at ive praxis, t hat is, in conform it y wit h a
pr ev iou sly est ablish ed law , an d w h ose ex ecu t ion is
r epr oduced in m ult iple pr oduct s t hat show analogue
charact erist ics, or as innovat ive, creat ive praxis, whose
creat ion does not fully adapt t o a previously est ablished
law and culm inat es in a new and unique product ”( 9). I m i t a t i v e p r a x i s f a v o r s t h e q u a n t i t a t i v e
m u lt ip licat ion of a q u alit at iv e ch an g e p r ov ok ed b y
cr eat iv e pr ax is. As m an does n ot liv e in an et er n al
cr eat iv e st at e, since he only finds him self obliged t o
cr eat e w hen confr ont ed w it h som e need, he r epeat s
w h ile h e d oes n ot cr eat e. How ev er, t h is r ep et it ion
needs t o be t ransit or y, as it is by cr eat ing t hat m an
t r ansfor m s t he w or ld and t r ansfor m s him self( 9). Due t o t he unit y bet ween t he conscience t hat
proj ect s and t he hand t hat carries out t he proj ect , in
a w ay, cr eat iv e prax is erase t he differ ence bet w een
m anual and int ellect ual w or k( 9).
How ever, hist or ically, t his cr eat ive charact er
of w or k , r ep r esen t ed b y h an d w or k , w as g r ad u ally
r e p l a ce d b y m e ch a n i z e d w o r k , d u e t o ca p i t a l i st
s o c i e t y ’ s r e q u i r e m e n t s t o i n c r e a s e p r o d u c t i o n .
Technical developm ent it self gave rise t o t he growing
d i v i si o n an d sp eci al i zat i o n o f w o r k . “ [ Hen ce] , t h e
char act er ist ic t r ait s of cr eat iv e pr ax is disappear fr om
[ m an ’s] w or k ( . . . ) . Wor k er s’ div ided, u n ilat eral an d
m o n o t o n o u s a ct i v i t y w a s p r e v i o u sl y d e t e r m i n e d ,
w it hout t heir par t icipat ion. That is, not only t he goal
of his act iv it y, t he ideal obj ect he has t o pr oduce is
f ix ed in an an t icipat ed an d com plet e w ay, bu t also
a n y a n d a l l s t e p s h e w i l l p e r f o r m , w i t h o u t t h e
possibilit y of dev iat ions”( 9).
METHODOLOGI CAL PROCEDURES
We car r ied out a qualit at ive and ex plorat or y
research. The st udy was carried out at regional Basic
Healt h Un it s ( BHU) u n d er t h e r esp on sib ilit y of t h e
But ant ã Municipal Gov er nm ent ’s Healt h Coor dinat ion
Office* , which cov ers t he ext rem e West of São Paulo
Cit y, j oining a populat ion of 359,656 inhabit ant s on a
g e o g r a p h i c a l a r e a o f 5 6 . 1 k m2, d i v i d e d i n f i v e Adm in ist r at iv e Dist r ict s.
This r esear ch focused on t he follow ing unit s
- BHU Jardim Boa Vist a wit h 36 CHA, BHU Vila Dalva
w it h 3 0 ACS, BHU Jd . São Jor g e w it h 3 6 CHA an d
But ant ã School Healt h Cent er ( BSHC) w it h 12 CHA
-t h e on ly u n i-t s -t h a-t cou ld h av e CHU a-t -t h e -t im e of
st u d y.
Th e st u dy popu lat ion in clu ded all 1 1 4 CHU
u n der t h e r espon sibilit y of t h e Coor din at ion Of f ice,
3 9 of w h om v olu n t eer ed t o p ar t icip at e. Dat a w er e
co l l ect ed i n Ju n e, Ju l y an d Au g u st 2 0 0 4 , t h r o u g h
i n d i v i d u a l i n t e r v i e w s w i t h t w o a g e n t s f r o m e a ch
service and t hrough group int erviews - one group wit h
five CHA from BHU Boa Vist a, one group of six from
t he BSHC, one group of t en from BHU São Jorge and
anot her gr oup of t en CHA fr om BHU Vila Dalv a.
I n com pliance wit h t he et hical det erm inat ions
of Law 196/ 96, t he proj ect was approved by t he São
Pau lo Mu n icip al Gov er n m en t Et h ics Com m it t ee. All
in t er v iew ees sig n ed a Fr ee an d I n f or m ed Con sen t
Term , aut horizing t he research and dat a dissem inat ion.
Gr oup int er v iew s w er e select ed on t he basis
of considerat ions by focus group specialist s who adopt
a n e m a n ci p a t o r y a p p r o a ch( 1 0 ). I n t h i s se n se , w e sensit ized t he CHA, asking t hem t o reflect on sit uat ions
t hey experienced in school t hat had som e m eaning in
t heir lives. The addressed t hem es included in t his art icle
w er e: CHA’s concept of educat ion, healt h and healt h
educat ion, how healt h educat ion is done in pract ice.
I n div idu al in t er v iew s w er e h eld w it h agen t s
who had not part icipat ed in t he group discussion, using
a sem ist r u ct u r ed scr ip t w it h t h e f ollow in g t h em es:
h ealt h ed u cat ion con cep t , d escr ip t ion of ed u cat iv e
act iv it ies, descr ipt ion of t eam super v ision.
I n div idu al in t er v iew s an d gr ou p discu ssion s
w er e r eco r d ed w i t h t h e p ar t i ci p an t s’ co n sen t an d
t ranscribed, aft er which t hey were analyzed. Them at ic
dat a analy sis w as applied accor ding t o t he follow ing
s t e p s( 1 1 - 1 2 ): r e c o r d i n g o f i n d i v i d u a l a n d g r o u p int er v iew s; t r anscr ipt ion of t he full int er v iew s by t he
researcher or wit h t he help of anot her person; several
readings of each individual or group int erview, wit h a
view t o apprehending and int erpret ing t hem as closely
as possible t o t h e or igin al discou r se; elabor at ion of
in t er v iew car ds, w r it in g dow n in t h e m ar gin of t h e
t ex t t hem es and sub- t hem es accor ding t o pr ev iously
for m ulat ed qu est ions and pr oblem s, as w ell as new
t h e m e s a n d s u b - t h e m e s t h a t e m e r g e d d u r i n g
successiv e r eadings; fr agm ent at ion of st at em ent s t o
const r uct unit s of m eaning or t hem es, at t em pt ing t o
perceive ot her em pirical and analyt ic cat egories based
o n t h e r e p o r t s , w i t h a v i e w t o o r g a n i z i n g a n d
in t er pr et in g t h eir con t en t s; con t en t an aly sis, based
on t h e t h eor et ical pr em ises an d an aly t ic cat egor ies
t hat had been previously est ablished or em erged from
t he em pir ical m at er ial.
The healt h ser v ices ar e ident ified as UBS I ,
UBS I I , UBS I I I and UBS I V, r espect ing t he or der in
which t he groups were held. The t ext s of t he individual
int erviews are ident ified by t he let t er I and a num ber
t hat also r efer s t o t he or der in w hich t he int er v iew s
w er e held, consider ing t he set of unit s.
RESULTS AND DI SCUSSI ON
Th eor et ical act iv it y : h ow com m u n it y h ealt h ag en t s
con ceiv e h ealt h edu cat ion
Th e lar g est p ar t of t h e ag en t s’ d iscou r se,
obt ained t hrough t he focus groups as well as individual
in t er v iew s, r ev eals t h at t h e h ealt h ed u cat ion t h at
per m eat es t heir w or k is guided by t he t r ansm ission
o f i n f o r m a t i o n a n d r e c i p e s t o a c h i e v e h e a l t h ,
c h a r a c t e r i z i n g a p r e s c r i p t i v e a n d n o r m a t i v e
act iv it y. Consequent ly, less st at em ent s ex plained t he
healt h educat ion concept as t he result of a const ruct ion
g u i d e d b y r e s p e c t f o r u s e r s ’ k n o w l e d g e a n d
e x p e r i e n c e s , c o n s i d e r i n g t h e i r k n o w l e d g e a n d
per cept ions about t heir healt h.
Prescript ive healt h educat ion is configured as
a t r an sm ission pr ocess of pr escr ipt ion s t o pr eser v e
o r a cq u i r e h e a l t h . Th e su b j e ct s o f t h e e d u ca t i o n
pr ocess ar e consider ed as a passiv e “ t ar get public”,
an obj ect t hat is supposed t o accept t he t echnicians’
g u id elin es, w h o p ossess scien t if ic k n ow led g e. CHA
appear as pseudo- t echnicians, because t hey end up
r e p r o d u c i n g t h e s e g u i d e l i n e s w i t h o u t a c t u a l l y
m ast er ing t he k now ledge t hat engender s t hem .
Th e m o s t f r e q u e n t p r e s c r i p t i v e h e a l t h
edu cat ion st at em en t s f it in t o t h e t h em e “ edu cat in g
m eans providing focal inform at ion about healt h care”.
[ Healt h educat ion m eans] Talking about a disease,
t alking about how t o t reat a disease, being capable of saying how
t he person should proceed, you know? The sick person, what ever,
som ebody wit h a heart problem , you’ll say how t his person should
proceed, advise about cert ain diseases, you know... ( UBS I ) .
Ot h e r t h e m e s l i k e “ e d u c a t i n g m e a n s
f r ig h t en in g u ser s f or t h em t o p r ev en t t h e d isease”
w er e also r epr esen t ed.,
That person did not t ake m edicat ion for pressure, for
hypert ension, she didn’t do anyt hing, she didn’t m easure her
blood pressure, she didn’t care so t hen I had t o scare her, I had
t o use t hreat s but I m anaged... ( laughs) . ( UBS I I I )
Th e s a m e p r e s c r i p t i v e c h a r a c t e r w a s
r e p r o d u c e d i n t h e t h e m e s : “ e d u c a t i n g m e a n s
p r o m o t i n g ch a n g e s i n h a b i t s” , “ h e a l t h e d u ca t i o n
m e a n s r e p e a t i n g t h e i n f o r m a t i o n se v e r a l t i m e s”,
This shows t hat healt h educat ion concept ions
are relat ed t o t he goal of changing behaviors, whet her
by using convincing devices, which dem ands repeat ed
infor m at ion t r ansm ission, or by adopt ing fr ight ening
st r at eg ies.
This underst anding of educat ive work is rat her
sim ilar t o Local Healt h Sy st em ( SI LOS) ( SI LOS)( 1 3 ) ed u cat i o n , w h i ch i s ch ar act er i zed b y b l am i n g t h e
per son f or get t in g ill, m ak in g t h em r espon sible f or
con t r ollin g t h e disease. Th is is aim ed at im pr ov in g
people’s life sit uat ion based on indiv idual r esour ces,
w it hout cont est ing t he st ruct ure and dynam ics of t he
product ion m ode, which engender t he root s of healt h
p r ob lem s.
Thus, t he goals of healt h educat ion would be
t o : a ) p u r g e , e x t r a ct b e l i e f s a n d i d e a s t h a t a r e
unfav or able t o t he behav ior ex pect ed by hegem onic
a c a d e m i c k n o w l e d g e ; b ) s t a n d a r d i z e , o r d e r
in d iv id u als’ lif e accor d in g t o p r ev iou sly est ab lish ed
st an d ar d s, w i t h o u t co n si d er i n g su b j ect s’ p r ev i o u s
k n ow ledge an d ex per ien ces or dif f er en ces in social
i n ser t i o n ; c) l eg i t i m i ze i n st i t u t i o n al p r act i ces an d
cont ent s, w hose k now ledge is consider ed v alid( 14). I n t his perspect ive, educat ion is pract iced as
t he delegat ion of responsibilit ies t o t he individual and
as an act ion t hat com plem ent s m edical act ion, wit h a
view t o lowering t he cost s of social policies. The way
healt h educat ion is conduct ed ends up at t ribut ing t he
c a u s e o f h e a l t h a c t i o n s ’ f a i l u r e t o i n d i v i d u a l s ’
“ ignor ance” and “ lack of aw ar eness”( 14).
Thus, t o ov er com e t his “ lack of awar eness”,
v e r y o f t e n , s t r a t e g i e s a r e u s e d t o r e i n f o r c e
or ient at ions and cont r ol on indiv iduals’ bodies( 15), in l i n e w i t h c a m p a i g n i s t p u b l i c h e a l t h( 1 6 ). Po p u l a r knowledge is oft en denied and scient ific knowledge is
i m p o s e d , i g n o r i n g s o c i a l g r o u p s ’ c a p a c i t y t o
a ck n o w l e d g e t h e i r p r o b l e m s a n d a ct i n o r d e r t o
t ransfor m r ealit y, m ak ing t echnicians r esponsible for
st andar dizing life( 14).
On t he ot her hand, w e should also heed t o
at t it udes t hat char act er ize t he ot her ex t r em e, w hich
con sid er s t h at on ly p op u lar k n ow led g e is v alid , in
w h i ch t h e p r o f e ssi o n a l u n cr i t i ca l l y a d a p t s t o t h e
“ com m unit y ’s cult ural r ealit y ”, w it hout conflict s. This
can serve t o j ust ify t he use of cheap st rat egies, based
on local resources, underm ining t he populat ion’s fight
t o conquer it s right s( 14).
Anot her point t o be addressed is t hat healt h
e d u ca t i o n , b y l o o k i n g a t d i se a se p r e v e n t i o n a n d
t r e a t m e n t , a t t e n d s t o t h e i n t e r e s t s o f c a p i t a l ,
t r ansfor m ing t he populat ion’s legit im at e healt h needs
in t o pr odu ct s ( ph ar m aceu t ical an d dr u gs in du st r y ) .
Th is ev id en ces a con t r ad ict or y m ech an ism , i. e. on
t h e o n e h a n d , t h e m e d i c a l a n d d r u g s i n d u s t r y
em ph asizes t h e n eed t o con su m e t h ese pr odu ct s in
or der t o be healt hy and, on t he ot her, people facing
social r epr oduct ion difficult ies do not m anage t o get
access t o t hese goods( 14).
This concept ion is opposed t o t he concept ion
of educat ion as a collect ive const ruct ion of t he healt h
educat ion pr ocess w hich, inst ead of r epr oducing t he
dom inant ideology, at t em pt s t o break wit h “ t he m odes
o f h u m a n r e l a t i o n s t h r o u g h w h i c h w e w e r e
p r og r am m ed f or w or k an d lif e ( as if t h is w er e t h e
nat ural order of t he world) ( ...) This gives rise t o t he
p o s s i b i l i t y o f p o p u l a r h e a l t h e d u c a t i o n , i n t h e
const r uct ion of a hist or ical subj ect t hat , r ecognizing
h i m - / h e r s e l f a s a g e n e r i c i n d i v i d u a l u n d e r
d ev elop m en t , is cap ab le of ad op t in g t h e d iscou r se
t h at m o u l d s h i m / h er t o t h e si t u at i o n o f “ h el p ed ”,
“ ex clu d ed ”, “ d isp ossessed ” an d t ak in g an op p osit e
p osit ion , cr eat in g a n ew d iscou r se, w h er e ( s) h e is
co n st i t u t ed a s a n ew su b j ect . I n t h i s co l l ect i v el y
co n st r u ct e d p r o ce ss, b o t h p r o f e ssi o n a l s a n d t h e
populat ion t ake part ( ...) ”( 14).
I n t h i s s e n s e , w e f o u n d t h e f o l l o w i n g
s t a t e m e n t s i n t h e f o c u s g r o u p s a n d i n d i v i d u a l
in t er v iew s: “ h ealt h edu cat ion m ean s t o r espect t h e
ot her person’s cult ure, realit y and lim it s”, “ t o int ervene
i n t h e l i f e si t u a t i o n ” , “ t o d i scu ss ci t i zen sh i p ”, “ t o
q u est ion st an d ar d s t r an sm it t ed b y t h e m ed ia”, “ t o
enable t he populat ion t o par t icipat e in t he educat iv e
pr ocess”, “ t o adv ise abou t h ow t o u se t h e ser v ice”.
A n o t h e r f r e q u e n t t h e m e w a s “ t o m o b i l i z e t h e
populat ion in or der t o seek t heir r ight s”.
( ...) w hen I st ar t ed, m y view of com m unit y healt h
agent was t hat I would be working wit h fam ilies t o dissem inat e
healt h prevent ion. To get t here: “ you have t o t ake t his or t hat
m edicat ion” . That w as m y v iew as an agent w hen I st ar t ed
working. Today, I see it , no, different ly, t hat besides going t here
and prom ot ing healt h, I have t o help t his com m unit y t o seek t he
right s t hey are offered ( ...) . ( UBS I I I )
These st at em ent s show t hat t he goal of t he
e d u c a t i v e p r o c e s s i s n o t r e s t r i c t e d t o d i s e a s e
pr ev ent ion, but also cov er s t he spher e of r ight s and
t he const r uct ion of cit izenship, at t em pt ing t o discuss
t h e r oot s of h ealt h pr oblem s in lin e w it h a polit ical
and dialogic pr ocess t hat allow s for r eflect ions about
neighborhood and consum pt ion. The relat ions bet ween
healt h and work t hat act ually det erm ine form s of living
ar e n ot addr essed.
An y w a y, i n t h i s p e r s p e c t i v e , e a r l i e r
experiences are t aken int o account and t he populat ion
par t icipat es act iv ely in t he educat iv e pr ocess, in line
w i t h e m a n c i p a t o r y e d u c a t i o n( 1 8 ). Th e c o u n t e r -ideological charact er of t his educat ion is also verified,
t o t he ext ent t hat it opposes t he st andards t ransm it t ed
by t he m edia wit h respect t o “ what one should do t o
be healt hy ”.
Thus, we observe t hat t he t heoret ical act ivit y
( educat ion, healt h and healt h educat ion concept ions)
t h a t g u i d e s t h e CH A’s p r a x i s i s c o n t r a d i c t o r y,
som et im es p r og r essiv e, t r an sf or m in g t h e d om in an t
or der and cont est ing t he r ealit y of social inequalit y,
so m et i m es d i sp l ay i n g p r ed o m i n an t l y co n ser v at i v e
charact erist ics, in response t o t he int erest s of capit al
and r epr oducing dom inant ideology.
Pr ax is: w hat com m unit y healt h agent s do
Th e n a t u r e o f a g e n t s ’ p r a c t i c a l a c t i v i t y
accom p an ied t h e oscillat ion in t h eor et ical act iv it y,
som et im es appear ing as cr eat iv e and som et im es as
im it at iv e pr ax is. The lat t er pr edom inat ed, as show n
by t he act ivit ies agent s m ent ioned in t he focus groups
as w el l as i n i n d i v i d u al i n t er v i ew s, i n w h i ch t h ey
r epor t ed daily w or k sit uat ions.
Th e p r act i ces t h at ch ar act er i ze a cr eat i v e
praxis appeared in t he following t hem es: “ doing healt h
ed u cat ion m ean s t o b r oad en t h e ser v ice’s v iew on
t he populat ion’s healt h needs”, “ doing healt h educat ion
m eans r ealizing int er sect or ial act ions”, “ doing healt h
educat ion m eans being a reference point t o t ransform
t h e h eal t h si t u at i o n ” an d “ d o i n g h eal t h ed u cat i o n
m eans hav ing leader ship t o t r ansfor m r ealit y ”.
We ( ...) are the leaders there in the com m unity, because
t he associat ion it self does not part icipat e in m any t hings t hat
are happening t here, in t he But ant ã region...( ...) Som et im es, we
t ak e par t in m eet ings t h e r esident s’ associat ion som et im es
doesn’t even know about , and t hey should be, it is im port ant , and
t hey aren’t . ( ...) . I really see us occupying t his part of leadership
in t h e com m u n it y . . . b ecau se, in m y v iew , w e see t o t h e
environm ent , we see t o children’s educat ion, t o adolescent s... t o
im prove t he com m unit y, we cont act zoonoses because of t he
r at s, t h e m u n icip al g ov er n m en t , ev er y t h in g . . . We see t o
everyt hing ... The associat ion j ust has t he nam e ...( UBS I V) .
I n t h i s co n t e x t , t h e a g e n t s a t t e m p t e d t o
expand t he essent ially curat ive pract ices, wit h a view
t o including st rat egies t o dem onst rat e displeasure and
opposit ion t owards t he m arginal living sit uat ion of t he
resident s in t he areas t hey at t end. Hence, t hey oft en
recovered t heir leading role in m obilizat ion processes,
as t he curriculum of m ost agent s in t his st udy cont ained
som e form of engagem ent in groups and associat ions.
The pr oposed t r ansfor m at ions abided by t he
sph er e of liv in g con dit ion s, w it h ou t an y st at em en t s
t hat act ually at t em pt ed t o cont est t he social st ruct ure.
Thus, t he agent s’ praxis does not seem t o const it ut e
a polit ical, but m er ely a pr oduct iv e act iv it y. “ Hence,
pr oduct iv e pr ax is is t he fundam ent al pr ax is because,
i n i t , m a n d o e s n o t o n l y p r o d u c e a h u m a n o r
hum anized world, in t he sense of a world wit h obj ect s
t hat sat isfy hum an needs and can only be pr oduced
t o t h e e x t e n t t h a t h u m a n g o a l s o r p r o j e ct s a r e
ex pr essed in t h em , bu t m an also pr odu ces h im self,
form s or t ransform s him self ( ...) . [ Then] , social praxis
i s t h e g r o u p o r so ci al cl ass act i v i t y t h at l ead s t o
t r an sfor m at ion s in t h e or gan izat ion an d dir ect ion of
societ y, or t o cer t ain ch an g es t h r ou g h t h e St at e’s
a c t i v i t y. Th i s f o r m o f p r a x i s i s a c t u a l p o l i t i c a l
act iv it y ”( 9).
This obser vat ion r eveals t o be coher ent w it h
discussions by ot her aut hors( 19) who, in analyzing t he ch ar act er of t h e edu cat iv e pr ocess t o t r ain n u r sin g
auxiliaries t hrough t he Large Scale Proj ect , also found,
on t he one hand, em phasis on t he t echnical charact er
of p ed ag og i cal t r ai n i n g an d , on t h e ot h er, l i m i t ed
polit ical com pr ehension of t he educat iv e pr ocess.
Pr oduct ion- or ient ed pr ax is is oft en r est r ict ed
t o t he realizat ion of t asks, charact erizing an im it at ive
praxis t hat , in t his st udy, corresponded t o t he pract ical
act ivit ies evidenced by discour se in t he focal gr oups,
st at ing t hat “ doing healt h educat ion m eans being t he
h ealt h u n it ’s ey es in t h e com m u n it y ”, “ doin g h ealt h
educat ion is a life m ission t o help t he ot her ”, “ doing
h e a l t h e d u c a t i o n m e a n s h i d i n g t h e s e r v i c e ’ s
lim it at ion s”.
And, t hese days, we are hiding t he lim it at ions here at
t he unit , everyt hing t hat ’s necessary “ will happen” , you see?
When som e adm inist rat ive work is needed, m aking an envelope,
inst ead of t he t echnical assist ant w ho m akes t w ice as m uch
m oney as we do, we are doing his work, he leaves us t here at t he
desk t o go for a walk, read a m agazine while you at t end t he public,
if you do som et hing wrong it ’s ‘because t he agent did it ’. ( UBS I )
I m it at iv e p r ax is w as also q u it e p r esen t in
r ep o r t s a b o u t t h e si t u a t i o n s a g en t s ex p er i en ced ,
sh ow in g t h at in t er v en t ion s w er e aim ed at d isease
cont ext , and t hat even conflict solving proposals were
p er m eat ed b y m or alizin g act ion s, u sin g con v in cin g
and fr ight ening st r at egies.
Thus, a large part of agent s’ act ivit ies seem s
t o be inst r um ent al, const it ut ing an im it at iv e pr act ice
in which t he subj ect act s on realit y by repeat ing t asks
in or der t o adapt t o t his r ealit y. Besides m ak ing up
f or ser v ice lim it at ion s, t h ese t ask s can be su m m ed
u p as “ b r i n g i n g an d t ak i n g ” i n f o r m at i o n f r o m t h e
c o m m u n i t y t o t h e B H U a n d v i c e - v e r s a , w h i c h
cor r espond t o a lar ge par t of agent s’ w or k. This w as
also found in anot her st udy( 20), which observed t hat a c o n s i d e r a b l e p a r t o f a g e n t s ’ w o r k i s t o “ t a k e
m e s s a g e s ” , s u c h a s a p p o i n t m e n t d a t e s , t o t h e
popu lat ion .
Mo r e o v e r, p r a ct i ca l a ct i v i t i e s a l so h a v e a
m e s s i a n i c c h a r a c t e r o f h e l p i n g o t h e r p e o p l e ,
ex p lain in g t h e id eolog ical n at u r e of t h e t h eor et ical
act iv it y t h ey ar e based on . We also fou n d im it at iv e
pr ax is w hen agent s do not int ent ionalize t he goal of
t heir work, a consequence of t he social and t echnical
division t hat is charact erist ic of alienat ion. Thus, agent s
feel pow er less w h en t h ey assu m e t h e r espon sibilit y
o f a t t en d i n g t o a l l co m m u n i t y d em a n d s. W i t h o u t
knowing how t o cope wit h t his sit uat ion, t he CHA use
con v in cin g an d f r igh t en in g st r at egies t h at con dit ion
t he populat ion t o follow t heir adv ice.
FI NAL CONSI DERATI ONS
We found t hat agent s’ pract ice as well as t he
u n der ly in g t h eor et ical act iv it y possess con t r adict or y
char act er ist ics, v ar y ing bet w een m or e t r ansfor m at iv e
an d m o r e co n ser v at i v e ch ar act er i st i cs. Th e l at t er
p r e d o m i n a t e d , r e p r e s e n t e d b y t h e p r e s c r i p t i v e
co n cep t i o n s o f h ea l t h ed u ca t i o n a n d b y i m i t a t i v e
p r ax is.
However, som e agent s m anage t o accom plish
creat ive praxis t o t he ext ent t hat t hey illum inat e t heir
pract ices w it h t heoret ical concept ions t hat go beyond
t h e t e c h n i c a l p o l e a n d , t h e r e f o r e , e x c e e d t h e
b i o m ed i cal ch ar act er o f h eal t h an d co n st i t u t e t h e
f o u n d at i o n s f o r act i o n s t h at t r an sf o r m t h e h eal t h
r ealit y, ev en if in t he consum pt ion spher e.
Th e ov er com in g of im it at iv e pr ax is t ow ar ds
cr eat i v e p r ax i s can b e ach i ev ed b y q u al i f y i n g t h e
agent s - by t r aining cour ses as w ell as by in- ser v ice
supervision. Qualificat ion can act on educat ion, healt h
an d h ealt h ed u cat ion con cep t ion s accor d in g t o t h e
collect ive healt h reference fram ew ork, w it h a view t o
e q u i p p i n g su b j e ct s f o r so ci a l p r a ct i ce b a se d o n
h ist or ical r ealit y. Th is b en ef it s it s con t est at ion as,
alt h ou g h ed u cat ion is n ot a st r u ct u r in g elem en t of
p r o d u c t i o n r e l a t i o n s , i t i s m a n i f e s t e d a s a
super st r uct ur al com ponent , capable of equipping t he
subor dinat e classes t o under st and t he det er m inant s
of t he healt h- disease pr ocess. Thus, pr act ical act ivit y
is no longer t he m ere repet it ion of t asks, but becom es
a n e d u ca t i v e p r i n ci p l e f r o m t h e p e r sp e ct i v e o f a
t r an sf or m at iv e pr ax is.
I t sh o u l d b e em p h asi zed t h at t h e t ask o f
q u a l i f y i n g a g e n t s f u n d a m e n t a l l y d e p e n d s o n t h e
concr et izat ion of t he Single Healt h Sy st em int o car e
m odels t hat overcom e t he t ricks of alienat ion in work.
I n ot h er w or d s, t r ain in g sh ou ld also in clu d e t h ose
r esp on si b l e f or i m p r ov i n g t h e h eal t h w or k f or ce i n
general and t he agent s in par t icular. Thus, im it at iv e
pr ax is cou ld be ov er com e, m ov in g t ow ar ds cr eat iv e
pr ax is, by qu alif y in g all h ealt h pr of ession als’ w or k ,
im proving t he concept ions and operat ive knowledge
-about educat ion, healt h and healt h educat ion, from a
collect ive healt h perspect ive - t hat illum inat e t he cut t ing
of t he obj ect and inst rum ent alize pract ice, in order t o
suppor t social gr oups in t he pr ocess of t r ansfor m ing
healt h realit y and const ruct ing full cit izenship.
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