POTENTI ALI TI ES I N I NTEGRAL CARE: UTERI NE CERVI CAL CANCER PREVENTI ON
ACCORDI NG TO THE USERS OF THE FAMI LY HEALTH STRATEGY
Michele Mandagar á de Oliv eir a1 I one Car v alho Pint o2 Valér ia Cr ist ina Chr ist ello Coim br a3
Oliveira MM, Pint o I C, Coim bra VCC. Pot ent ialit ies in int egral care: ut erine cervical cancer prevent ion according t o t he user s of t he fam ily healt h st rat egy. Rev Lat ino- am Enfer m agem 2007 m aio- j unho; 15( 3) : 426- 30.
This st udy aim ed t o analyze t he int egral care in t he ut erine cervical cancer prevent ion pract ices in t he con cept ion of u ser s of t h e Fam ily Healt h St r at egy t h r ou gh an ex plor at or y an d descr ipt iv e r esear ch w it h a qualit at ive approach. A t ot al of 14 users who perform ed t he Pap sm ear in Decem ber 2002 in four Fam ily Healt h Unit s affiliat ed t o Higher Educat ion inst it ut ions w er e select ed for t he st udy. Dat a w er e collect ed bet w een Apr il and June 2003. We found t hat t he users analyze and assess t he praxis by issuing a value j udgm ent about t he car e t hey r eceiv e, m ainly in t er m s of light ( r elat ional) t echnologies. Concluding, hum anized pr act ices pr ovided by professional/ t eam favor int egral care, st rengt hening t he bond bet ween users and healt h services, as well as healt h pr om ot ion.
DESCRI PTORS: com pr ehensiv e healt h car e; v aginal sm ear s; fam ily healt h
POTENCI ALI DADES EN LA ATENCI ÓN I NTEGRAL: PREVENCI ÓN DE CÁNCER DE CUELLO
UTERI NO DE ACUERDO CON LAS USUARI AS DE LA ESTRATEGI A SALUD DE LA FAMI LI A
El obj et iv o de est e est udio fue analizar la at ención int egr al dent r o de las pr áct icas de pr ev ención de cáncer de cuello ut er ino baj o la concepción de las usuar ias de la Est r at egia Salud de la Fam ilia. I nvest igación d e t ip o ex p lor at or io y d escr ip t iv o con en f oq u e cu alit at iv o. Fu er on seleccion ad as cat or ce u su ar ias q u ien es realizaron el exam en de Papanicolao durant e el m es de diciem bre de 2002, en cuat ro Servicios de Salud de la Fam ilia v inculados a I nst it uciones de Enseñanza Super ior . La r ecolección de dat os fue r ealizados ent r e abr il y j unio de 2003. Los result ados dem uest ran que las usuarias analizan y evalúan la at ención recibida form ando su opinión, en especial, con relación a las t ecnologías leves ( de relación) . Se concluye que las práct icas hum anizadas con r esponsabilidad pr ofesional/ equipo favor ecen al cuidado int egr al, for t aleciendo el vínculo ent r e las usuar ias con los ser vicios y la pr om oción de la salud.
DESCRI PTORES: at ención int egr al de salud; fr ot is v aginal; salud de la fam ilia
POTENCI ALI DADES NO ATENDI MENTO I NTEGRAL: A PREVENÇÃO DO CÂNCER DO COLO
DO ÚTERO NA CONCEPÇÃO DE USUÁRI AS DA ESTRATÉGI A SAÚDE DA FAMÍ LI A
O obj et iv o dest e est udo foi analisar o at endim ent o int egr al nas pr át icas de pr ev enção do câncer do colo do út er o na concepção de usuár ias da Est r at égia Saúde da Fam ília. Foi r ealizada pesquisa ex plor at ór ia e d escr it iv a com ab or d ag em q u alit at iv a d os d ad os. For am selecion ad as q u at or ze u su ár ias q u e r ealizar am o ex am e Papan icolaou n o m ês de dezem br o de 2 0 0 2 em qu at r o Un idades de Saú de da Fam ília, v in cu ladas a inst it uições de nível super ior . Os dados for am colet ados no per íodo de abr il a j unho de 2003. Com o r esult ado f oi obser v ado qu e as u su ár ias an alisam e av aliam a pr áx is em it in do j u ízo de v alor à assist ên cia r ecebida, pr incipalm ent e, no que se r efer e às t ecnologias lev es ( r elacionais) . Conclui- se que pr át icas hum anizadas com r esponsabilização pr ofissional/ equipe fav or ecem cuidado int egr al for t alecendo o v ínculo das usuár ias com os ser v iços de saúde e a pr om oção da saúde.
DESCRI TORES: assist ência int egr al à saúde; esfr egaço v aginal; saúde da fam ília
1
Professor, Federal Universit y of Bahia, Brazil College of Nursing, PI CDT grant holder, Doct oral St udent , e- m ail: m ioliveira76@yahoo.com .br; 2 PhD Professor, e- m ail: ionecarv@eerp.usp.br; 3 Professor, Federal Universit y of Pelot as College of Nursing, Brazil, Doct oral St udent Universit y of São Paulo at Ribeirão Pret o College of Nursing, WHO Collaborat ing Cent er for t he Nursing Research Developm ent , Brazil, e- m ail: valcris@eerp.usp.br
I NTRODUCTI ON
S
pecific Ut er ine Cer v ical Cancer Pr ev ent ion( UCCP) m easu r es w er e st r en g t h en ed i n t h e ear l y
1980s wit h t he creat ion of t he I nt egral Wom en’s Healt h
Ca r e Pr o g r a m ( I W HAP) , l a u n ch ed i n 1 9 8 3 , w h i ch
pr ior it ized int egr al car e t o w om en’s healt h( 1).
Nowadays, t he UCCP int egrat es Prim ary Care
act ions direct ed at specific populat ion groups, insert ed
in t h e Pr im ar y Car e Or g an izat ion Man u al( 2 ), an d is
r ecom m en d ed as on e of t h e act ion s of t h e Fam ily
Healt h St r at egy ( FHS)( 3).
This st udy present s part of t he result s of one
o f t h e a u t h o r ’s Ma st e r ’s t h e si s a b o u t t h e UCCP.
I n t egr al car e is discu ssed in t er m s of t h e dif f er en t
t echnologies t hat per m eat e t his pr act ice.
Th e discu ssion is based on t h e assu m pt ion
t hat int egr al car e per ceiv es and deliv er s car e t o t he
w om an’s healt h as a w hole, solv ing t he need t hat is
m anifest ed, specifically considering t he use of light –
light heav y – heav y t echnologies in UCCP pr act ices.
I nt egr al car e can be pr om ot ed at t he ex act m om ent
t he user com es t o t he healt h service for a pap sm ear
or ev en at her hom e, dur ing t he Com m unit y Healt h
Agent ’s v isit ( CHA) .
I nt egral care is t he second essent ial guideline
o f t h e SUS ( Si n g l e Heal t h Sy st em ) an d i n d i cat es
pr ior it y for pr ev ent iv e act ions w it hout im pair ing car e
ser v ices( 4 ).
Light t echnologies in healt h w or k oper at e by
cr e a t i n g t h e i r o w n w a y o f g o v e r n i n g p r o ce sse s,
con st r u ct in g it s ob j ect s, r esou r ces an d in t en t ion s,
act ing in a cert ain way, in t he int ercessor space, when
t he w or k er and t he user m eet for t he pr oduct ion of
goods- r elat ion sh ips( 5 ).
Th i s w o r k er / u ser m eet i n g h a p p en s i n t h e
in t er cessor sp ace t h at r ev eals q u est ion s ab ou t t h e
healt h product ion processes ( healt h- disease and work
pr ocesses) . I n ev er y place t h is m eet in g occu r s, t h e
t ech n ology of r elat ion sh ip is u sed, t h at is, in ev er y
place t his t echnological pr ocess occur s, liv e w or k is
in act ion , w h ich aim s at t h e pr ocess of list en in g t o
needs, wit h a view t o exchanging inform at ion, m ut ually
r e c o g n i z i n g r i g h t s a n d o b l i g a t i o n s a n d m a k i n g
decisions t hat allow for int er v ent ions( 6).
Wo r k i n g w i t h a m u l t i p r o f essi o n a l t ea m i n
w om an ’s h ealt h car e is an appr opr iat e appr oach in
int egr al car e. How ever, an efficient t eam w or k is not
easy t o r each, and t he m ost obv ious challenges ar e
com m unicat ion and infor m at ion t r ansfer ence, needed
for int egr al car e( 7).
UCCP pr act ices dir ect ed at pr ov idin g h ealt h
ed u cat ion , st im u lat in g self car e, r ealizin g t h e p ap
s m e a r e x a m , p r o v i d i n g m e d i c a l a n d n u r s i n g
consult at ions in t he wom an’s healt h area and m aking
t h e u ser r et u r n t o pick u p t h e r esu lt , ar e dif f er en t
m o m e n t s o f t h e s e r v i c e / p r o f e s s i o n a l / u s e r
r elat ion sh ip . Th e u se of d if f er en t t ech n olog ies in a
w o r k t h a t i s d o n e l i v e , w h e t h e r r e l a t i o n a l o r
st r uct ur ed, cont r ibut e t o an int egr al pr act ice( 8).
Ex pan din g t h e discu ssion , w e per ceiv e t h at
b o t h t ech n o l o g i es ca n o ccu r a t si m i l a r m o m en t s.
How ev er, t h e p r of ession al w h o h as a w or k p r ocess
based on a m ore com prehensive perspect ive of healt h
and a different iat ed view of praxis, will use t he different
t ech n ologies deliv er in g in t egr al car e w it h a v iew t o
t he hum anizat ion of car e and car e qualit y.
On c e s t a n d a r d i z e d , t h e w e l c o m i n g , f o r
inst ance, w ill escape fr om t he r elat ional per spect iv e,
an d w ill becom e h ar den ed by t h e im posit ion of t h e
professional/ t eam ’s knowledge, t hat is, in t he pract ice
of dead w or k .
However, what can be perceived is t hat m any
fam ily healt h pr ofessionals/ t eam s ar e m ov ing in t he
direct ion of int egral healt h pract ice, even when facing
r e m a i n i n g o b st a cl e s f r o m t h e b i o m e d i ca l m o d e l ,
focused on t he specific com plaint and on t he disease.
I n v i ew o f t h ese asp ect s, t h e ai m o f t h i s
research is t o analyze int egral care in ut erine cervical
cancer pr ev ent ion pr act ices accor ding t o FHS user s.
METHOD
A d escr ip t iv e an d ex p lor at or y st u d y w it h a
qualit at iv e appr oach w as per for m ed. Dat a collect ion
f ollow ed t h e log ic of t h e sem ist r u ct u r ed in t er v iew .
Users who were subj ect t o t he pap sm ear in Decem ber
2002 were select ed for t he st udy. Dat a were collect ed
bet w een Apr il and June 2003.
W in t er v iew ed 1 4 w om en at t en d ed in f ou r
Fam ily Healt h Un it s, w h o accept ed t o par t icipat e in
t h e st u d y. Th ese f am ily h ealt h u n it s w er e select ed
b e c a u s e o f t h e i r l i n k a g e t o a h i g h e r e d u c a t i o n
in st it u t ion in Ribeir ão Pr et o, São Pau lo, Br azil. Th e
u se r s a r e i d e n t i f i e d b y t h e i r se l f - d e n o m i n a t i o n s:
Tranquilit y, Love, Passion, Com m unicat ion, Calm ness,
Fear, Joy, Sad n ess, Em ot ion , Sen sib ilit y, Qu iet u d e,
RESULTS AND DI SCUSSI ON
When analyzing t he UCCP pract ice, w e could
observe t hat t he user who com es t o a healt h service t o have a pap sm ear will probably be advised/ at t ended
by a m ult idisciplinary t eam from her arrival up t o her depar t ur e fr om t he FHS. UCCP pr act ice w ill pr obably
use all light / light - heavy/ heavy t echnologies, alt hough it w ill be in gener al car e t hat car e w ill be qualified,
fr om t he t echnician’s as w ell as fr om t he user ’s ow n point of view .
I n t he select ed st at em ent s, we could observe
t h at t h e u ser h er self p er ceiv es an d ev alu at es t h e praxis, m aking a value j udgm ent at t he m om ent she
r epor t s t hat “ it was good”, and t his value j udgm ent , w h et h er p osit iv e or n eg at iv e, is im p or t an t f or t h e
const r uct ion of int egr al pr act ices in healt h ser v ices. The healt h sy st em user, t hr ough com m unit y
part icipat ion in social cont rol, has t he com pet ence t o ev aluat e and int er v ene, m odify ing t he healt h sy st em
it self( 9).
The st at em ent s also indicat e t hat t he user s
recognize t he t echnological differences t hat perm eat e
t he ent ir e pr ocess of pr ev ent ion pr act ices r elat ed t o t h e p r o f e ssi o n a l / t e a m - u se r m e e t i n g , i n t e r m s o f
edu cat ion in h ealt h , t h e pap sm ear, t h e r esu lt an d t r eat m ent , if necessar y.
I didn´ t feel em bar r assed her e, I got com for t able,
relaxed, didn’t feel a t hing, t he speculum is a lit t le uncom fort able,
but it is bearable ( …) I felt com fort able, we are always afraid of
t he result , but t hanks God, I got one of t hese com m on t hings,
wit h a lit t le oint m ent it got bet t er ( …) . There is room t o change
clot hes, t o put on t he apron ( …) ( Com m unicat ion) .
I t c a n b e p e r c e i v e d i n Co m m u n i c a t i o n ’ s
st at em ent t hat her sat isfact ion is relat ed t o t he physical e n v i r o n m e n t , r e g a r d i n g so m e ca r e t a k e n i n t h e
or ganizat ion of t he r oom , pr ov iding t he w om an w it h a feelin g of r espect abou t car e for h er body, w h ich
f o r t h e u s e r w a s t r a n s l a t e d a s t r a n q u i l i t y a n d a cce p t a b i l i t y o f t h e p l a ce , o f t h e p r o f e ssi o n a l ’ s
pr esence and of t he collect ion of t he pap sm ear. Th e n e c e s s a r y r e q u i r e m e n t s f o r t h e
or g an izat ion of t h e UCCP r oom in clu d e a p lace t o
change clot hes, highlight ing t he im port ance of aprons or sh eet s t o cov er t h e u ser, b esid es t h e p r ev iou s
organizat ion of t he m at erials used in t he collect ion( 10). Th i s ca r e ca n b e i n t e r p r e t e d a s t e ch n o l o g y t h a t
int er fer es in car e qualit y in int egr al car e.
Th e h e a l t h p r o f e ssi o n a l s ca n p r e se n t t h e
r oom , t h e m at er ials u sed in t h e ex am an d ex p lain t h e i m p o r t a n ce o f t a k i n g t h e p a p sm ea r, b o t h i n
individual consult at ions and during healt h educat ion( 11).
I t was very good, I always m ake appoint m ent s wit h
t he Dr., she collect ed t he exam . The Dr. explains t hings t o m e,
she also exam s t he breast s and t ells m e t o do t he exam at hom e,
always aft er m y period, even t eaches m e how t o do it . Generally,
t hey t alk explaining how t hey are going t o do t he exam and when
t hey will put t he speculum , t hey use t he lit t le brush and t hat
t hey are already put t ing it in t he lam ina, I rem em ber she said
t hat t here was a lit t le infect ion and she put a rem edy ( Happiness) .
H a p p i n e s s ’ r e p o r t r e v e a l s t h e u s e r ’ s sat isfact ion wit h care at t he m om ent of t he pap sm ear,
p r esen t in g asp ect s r elat ed t o t h e u se of r elat ion al
t echnologies in synchronicit y wit h heavy t echnologies, when t he user m ent ions healt h educat ion, t he m om ent
a n d t h e st e p s o f t h e p a p sm e a r, a s w e l l a s t h e im m ediat e solut ion for t he det ect ion of a local problem
and it s t r eat m ent .
Th e u s e r s ’ e v a l u a t i o n , m a k i n g a v a l u e
j udgm ent on t he received care, present s pot ent ialit ies r elat ed t o t h e car e of f er ed in t h e r esp ect iv e FHS,
a ck n o w l e d g i n g t h e FHS a s a h e a l t h se r v i ce t h a t appears in t he scenario of t he healt h organizat ion and
t h at al l o w s f o r t h e i n st i t u t i o n al r ep r esen t at i o n o f
ser v ices t hat pr opose differ ent iat ed and high- qualit y pr of ession al pr act ices.
I t was good! ( ...) I was well at t ended, did t he prevent ion
exam , t he physician t alked t o m e, explained t he why of t he exam ,
t hat we have t o keep doing it , she passed confidence, t alks,
m aking m e feel really com fort able, so it was a really good t hing
(Love).
The care was not 10% but 100% , because I was like all
em barrassed for having gone all by m yself t o t he doct or, face t o
face asking quest ions about your life, but you st art t o t alk, j ust
like confessing t o t he reverend ( …) , at t he beginning of t he exam
I was em barrassed, but he was t here in front of m e not only as a
doct or, but as a friend! He is a very nice person and very at t ent ive
as a physician, ( …) he is not like t hose people you go t o for a
consult and are badly at t ended. I n t he FHS, I was well at t ended
bot h by t he nurses and by t he physician ( Joy) .
I was well at t ended, never had problem s t here ( ...) .
There are less people t here, t hey give bet t er care, t he agent s and
t he doct or ar e closer t her e t han at t he healt h st at ion, t hey
rem em ber our nam es, t here are less barriers, is like fam ily really
( Tr anquilit y ) .
The care here is m uch bet t er, if you have som et hing,
t hey say, I ´ ll t ry t o fit you in, ot herwise t hey go t o your hom e ( …)
( Passion) .
Th e u ser s t alk ed ab ou t t h e g ood car e t h e professionals delivered, relat ing it t o t he charact erist ics
su g g est s t h at p op u lar k n ow led g e r ecog n izes t h ese
t echnologies as char act er ist ics “ inher ent t o t he good p r of ession al”
I n a previous st udy, it was observed t hat t he
p r op or t ion of p ap sm ear s is h ig h er am on g w om en
w ho hav e been r egist er ed at FHS unit s for a longer t im e, which suggest s an associat ion bet ween t he pap
sm ear an d gr eat er bon din g w it h t h e ser v ice by t h e
user s( 12).
Bonding, w elcom ing, list ening ar e per ceiv ed,
an aly zed an d ev alu at ed by t h e u ser s, w h ich is w h y
t h ey em i t a v al u e j u d g m en t , d i f f er en t l y f r o m t h e evaluat ion of professional pract ice, wit h regard t o t he
deficit of r elat ional t echnologies.
The lack of list ening and welcom ing int erferes n e g a t i v e l y i n t h e r e l a t i o n sh i p s o f b o n d i n g ( u se r
-professional- service) , and can cont ribut e t o t he users’ d i ssat i sf act i o n w i t h t h e p r o p o sed car e, as can b e
ob ser v ed b elow .
They said t hey would collect t he exam , and I said ah,
but I am not prepared, ( …) , t hen he called anot her doct or, t hen t he
ot her one said you will have t o do t he exam , t here is no need t o be
em barrassed, every wom an goes t hrough it ( …) I found it bad
because for m e it didn’t help at all ( Calm ness) .
I solat ed act ions by som e healt h professionals
t end t o affect t he whole, t hat is, considering t he whole, as t h e t eam ’s p er f o r m an ce i n t h e co n st r u ct i o n o f
qualit y care, t o which t he FHS is com m it t ed.
There is a need t o reflect about FHS pract ices,
a b o u t t h e co m m i t m e n t a n d r e sp o n si b i l i t y o f t h e p r o f e s s i o n a l / u s e r t o t h e t r a n s f o r m a t i o n o f t h e
biom edical care m odel t o a t echno- care user- cent ered
m odel t hat allow s for int egr al pr act ices( 7).
The healt h t eam needs t o be at t ent ive t o t he
u ser s’ com p lain t s, d ou b t s an d an x iet y, t h at is, t h e h ea l t h p r o f essi o n a l m u st d ev el o p t h e ca p a ci t y o f
int er act ion and ex change, needs t o be able t o list en and t alk, avoiding t echnical or scient ific t erm s, so t hat
t he user under st ands and also feels under st ood and
car ed for, as a for m t o encourage her t o cont r ol her fear and em bar r assm ent( 11).
A h u m an ized p r act ice, w h ich d ev elop s t h e int er act ion capacit y and act s not only w it h t echnical
pr epar edness, but also w it h int uit ion and sensit iv it y, w ould cer t ainly cont r ibut e t o t he qualit y of t he car e
delivered t o t he wom en, during t he realizat ion of t he pap sm ear( 11).
The t echnologies end up com plem ent ing each other, in term s of care integrality. The users perceive this
integral and quality care and get involved with the team , with the service activities and with health prom otion.
( ...) it is good t o prevent and especially in here, I know
t here are regions, depending on where you live, each person is
at t ended in her own neighborhood, but I like it here, it is very
good ( Happiness)
They at t end m e wonderfully well! ( …) The at t ent ion,
polit eness, r espect , w e ar r iv e and t hey com e w it h affect ion,
sm iling ( Passion) .
Being polit e, t hey are not rude, t hey at t end you wit h
pat ience and a lot of pat ience, t hey list en t o what we say ( Fear) .
Th e im p lem en t at ion of t h e FHS is a g r eat challenge for t he professionals, for t he populat ion and
for t he m anagers who need t o break wit h est ablished
power pract ices at t he services. The part icipat ion and com m it m ent of all act ors is needed. Group discussions
of healt h educat ion wit h t he users of t he FHS can help in t he const r uct ion of int egral car e in t he UCCP.
Gr ou p discu ssion s of h ealt h edu cat ion w it h users of t he FHS can help in t he const ruct ion of int egral
car e in t he UCCP because bot h bonding and m ak ing t hem co- responsibles for t heir healt h are st rengt hened
by dialogue( 13).
Th er ef o r e, t h e h eal t h p r o f essi o n al s/ t eam s
n eed t o at t en d t h e u ser s accor d in g t o t h e in t eg r al
car e view , including healt h educat ion( 14), w it h a v iew t o f acin g t h e ch allen ge an d copin g, st ill at pr im ar y
h ealt h car e lev el, w it h t h e p r ecociou s d et ect ion of u t er in e cer v ical can cer.
CONCLUSI ONS
Healt h car e or ganizat ion in accor dance w it h
t he r eor ient at ion pr oposal of t he car e m odel and t he qualificat ion of prim ary healt h care, aim s t o facilit at e
t he access t o t he basic needs, gr eat er cov er age and car e q u alit y. Th er ef or e, t h e UCCP p r act ices can b e
qualified in t he FHS pr ov ided t hat t he pr ofessionals/ t eam s p r om ot e in t eg r al car e r ecom m en d ed b y t h e
SUS.
UCCP pract ices in t he FHS need t o be qualified
b y m a n a g er s, b y p r o f essi o n a l s/ t ea m a n d a l so b y user s, because int egr al and qualit y pr act ices need t o
be conduct ed in all dir ect ions of car e.
The users of t he FHS, however, can and should t a k e p a r t i n t h i s p r o p o s a l o f r e s p o n s i b i l i t y a n d
com m it m en t t o in t eg r al car e, sin ce t h ey r ecog n ize and evaluat e t he praxis as users of t he healt h syst em .
The user s need t o par t icipat e act iv ely in it s
social con t ex t , in t h e sear ch f or an d assu r an ce of
i n t e g r a l c a r e , s i n c e t h e y a r e c i t i z e n s a n d c o
REFERENCES
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