RESUmo
Esta relexão teve como objeivo compre
-ender a Epidemiologia como referencial teórico-metodológico para a práica da En
-fermagem em Saúde Coleiva. O método de pesquisa foi uma invesigação bibliográica, com a análise de arigos e livros de estudio
-sos que apontam as possibilidades e limites das Epidemiologias clássica, social e críica, com intuito de aproximar suas concepções à práica do enfermeiro. Discute-se que a ar
-iculação dos conhecimentos advindos das supracitadas visões de Epidemiologia possi
-bilita a construção de intervenções de Enfer
-magem para a transformação de realidades de saúde. A Epidemiologia Críica ampara
--se no reconhecimento dos processos pro
-tetores e de desgastes determinantes do processo saúde-doença vividos por grupos de classes sociais disintas. Assim, cabe ao enfermeiro planejar a intervenção em saú
-de para além do adoecimento i-deniicado, propondo intervenções compromeidas com a mudança de processos históricos e sociais, nas dimensões singular, paricular ou estrutural, que acabam por determinar o processo saúde-doença em indivíduos ou grupos.
dEScRitoRES Epidemiologia Saúde pública Processo-saúde-doença Cuidados de enfermagem
Epidemiology as a theoretical-methodological
framework in the nurses’ working process
R
ef
lec
ti
o
n
AbStRAct
The objecive of this relecion was to un
-derstand epidemiology as the theoreical-methodological framework for collecive health nursing pracice. This study is a bibliographic invesigaion which analyzed aricles and books that point out the strengths and weaknesses of classic, social and criical epidemiology, with the purpose to examine their concepts in regards to nursing pracice. The connecions between the knowledge obtained from the above
-menioned views of epidemiology which allow the creaion of nursing intervenions to change health realiies are discussed. Criical epidemiology is supported by the recogniion of the protecing processes and wearing determinants of the health-disease process experienced by diferent social classes. Hence, nurses should plan health intervenions aiming beyond the ideniied illness, proposing intervenions commited to changing historical and social processes, taking into account the unique, paricular or structural dimensions that eventually determine the health-disease process in individuals or groups.
dEScRiPtoRS Epidemiology Public health
Health-disease process Nursing care
RESUmEn
Relexión que objeivó comprender la Epi
-demiología como referencial teórico-meto
-dológico para la prácica de Enfermería en Salud Coleciva. Se realizó una invesiga
-ción bibliográica, con análisis de arículos y libros de expertos que sugieren las posi
-bilidades y límites de las Epidemiologías clásica, social y críica, con la intención de aproximar sus concepciones a la prácica del enfermero. Se discute que la ariculación de los conocimientos devenidos de las citadas visiones de Epidemiología posibilita la cons
-trucción de intervenciones de Enfermería para la transformación de realidades de sa
-lud. La Epidemiología Críica se ampara en el reconocimiento de procesos protectores y desgastes determinantes del proceso salud-enfermedad experimentados por grupos de disintos estratos sociales. Corresponde al enfermero planiicar la intervención en sa
-lud más allá del padecimiento ideniicado, proponiendo intervenciones compromei
-das con cambios de procesos históricos y so
-ciales, en dimensiones singulares, paricula
-res o estructurales, que lleven a determinar el proceso salud-enfermedad en individuos o grupos.
dEScRiPtoRES Epidemiología Salud pública
Proceso-salud enfermedad Atención de enfermería
Adeli Regina Prizybicien de medeiros1, Liliana müller Larocca2, marta maria nolasco chaves3,
marineli Joaquim meier4, marilene Loewen Wall5
A epidemiologiA como referenciAl teórico-metodológico no processo de trAbAlho do enfermeiro
lA epidemiologíA como referenciAl teórico-metodológico en el proceso de trAbAjo del enfermero
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framework in the nurses’ working process
Medeiros ADP, Larocca LM, Chaves MMN, Meier MJ, Wall ML
intRodUction
Since the 1990s, with the passing of Law 8.080/90, Ep
-idemiology has been acknowledged as an important theo
-reical framework to ground health acions that posiively improve the health of the Brazilian populaion(1).
Tradiionally deined as the science that studies the distribuion of diseases and their respecive causes in hu
-man populaions, the knowledge base of epidemiology increased in the 20th century, when scieniic knowledge
was consolidated and largely supported public and collec
-ive health pracices.
Its origin dates back to the ideas expressed by Hip
-pocrates and other scholars of the ancient world. The dis
-tribuion of diseases among populaions, however, started to be measured beginning in the 19th century when inves
-igaions concerning transmissible diseases improved sci
-eniic knowledge(2).
In mid 20th century, in London, cholera cases reached
epidemic levels and the physician and re
-searcher John Snow, ater careful invesiga
-ion applying scieniic logic to observa-ional research, concluded that the miasmaic hy
-pothesis concerning epidemic origins should be refuted. At the same ime, Florence Nighingale (1820-1910) studied mortality due to postoperaive infecion in soldiers during the Crimean war, conirming the clin
-ical studies of Semelweiss on a larger scale; Semelweiss associated postpartum infec
-ion with the presence of microbes(3).
In this 19th century context, Classical Epi
-demiology was strengthened as a discipline in Europe, notably with the objecive to ef
-fecively control epidemic outbreaks and
their impact on the European economy, at the ime in full consolidaion of the industrial revoluion. The aspects of analyzed phenomena, with an emphasis on eiological causes and risk factors, straiied the populaion into cate
-gories, providing the State with minimal informaion with a causal and posiivist view of health, which marked the quaniicaional nature of Classical Epidemiology(4).
Historically, Epidemiology has not always targeted the collecive as the object of its study(5). The biologicist con
-cepion endured for a long period and inluenced the con
-situion of epidemiology as a discipline, which contribut
-ed to relecion within epistemological treading diferent paths, without the necessary connecion and interface with social sciences(6).
Such a fact is evidence that epidemiological science is disconnected from the collecive perspecive as it con
-ceives populaion as a mere sum of individuals and resorts to a single clinical discourse to seek acknowledgment and legiimacy(5).
Some disinct models, focused on individual acions (vaccinaion, health educaion) and also directed to so-called risk groups, were conceived to overcome classical causality in an atempt to privilege the collecive dimen
-sion of the health-disease phenomenon(7).
Epidemiology, in contrast from Clinics, uses a pre
-dominantly inducive mode of reasoning: it departs from occurrences in populaions and, ater grouping and nec
-essary analysis, results in inferences applicable to other populaions exposed to the same condiions. In Clinics, however, the risk of becoming sick is applicable to the technical object, which does not have a collecive nature and does not refer to populaions (or only remotely does so) but to individuals(5).
The causes of disease, however, most frequently go beyond the ield of applicaion in Clinics, and this is why there is a need for knowledge that goes beyond the iden
-iicaion of signs and symptoms to classifying illnesses. This understanding enables us to recognize the collecive face of the health-disease coninuum in the individual and contributes to a broadened, non-reducion
-ist view of its determinants, because it seeks explanaions for disease out of the individu
-al morbid enity(5).
From this perspecive, Epidemiology, in its social and criical approaches, is an essenial science to provide and interpret informaion that enables the analysis of phenomena in the poliical-economic-social context in a given historical ime. The con
-creizaion of changes proposed, however, depends on the minds and hands of those involved, as well as the interacion of these with the remaining social processes(4).
The diferent ways of thinking about health are organized in disinct pracices: Public Health and Collecive Health. Public Health(8) is consolidated as the control of diseases in the
society and is based on the concepions of the Tradiional Epidemiology and Muli Causality Theory, with empirical concepts of health and disease, reduced to the phenom
-enal plan and individualized to the biological cause. The methodology of intervenion, in this context, is empirical-analyical, based on structural-funcionalist posiivism, whose guiding axis is the State’s interests(9).
Collecive Health is consolidated as a ield that produc
-es knowledge through the interpretaion of transforma
-ions, paricularly those occurring in Lain-American soci
-ety, in the search for explanaions of diseases that afect low-income social classes. Its philosophical principle is Dialecical and Historical Materialism and is grounded on the Theory of Social Determinaion of Health and Disease. The methodology of intervenion is based on Dialecical and Historical Materialism and on the understanding that objecive reality is determined by its diferent dimensions: singular, paricular and structural(10).
since the 1990s, with the passing of law 8.080/90, epidemiology has been acknowledged
as an important theoretical framework
to ground health actions that positively
improve the health of the brazilian
In this context, the human being is a social agent ca
-pable of transforming reality rather than a mere receptor of environmental inluences(10). Collecive health(9) should
defend the interests of the populaion considering the ur
-gent socio-sanitary situaions of exploited peoples when choosing intervenions.
The methodologies proposed by Social Epidemiology and Criical Epidemiology are further discussed as well as the possibiliies of nurses intervening in health in the light of these concepions.
UndERStAndinG tHE diFFEREnt concEPtionS oF SociAL
EPidEmioLoGY And cRiticAL EPidEmioLoGY
The desire for beter quality of life inluenced the development of diferent concepions concerning the health-disease coninuum associated with disease causa
-ion, which contributed to the achievement of the right to health as a social right of ciizens(11).
In acknowledging the social determinants of health and disease, Epidemiology presents itself as a social the
-ory that explores the structuring-destructuring-restruc-turing of processes that generate the populaion’s health
needs in order to reorient health pracices and heed such needs. This model contributed to evidence for the com
-plexity of health problems ideniied in the collecive, as well as the relaionship of producion and consumpion processes to the set of health problems(12-13).
Social Epidemiology(14) is essenial to complying with
the principle of integrality established within the Brazilian Uniied Health System (SUS) because it is able to connect the singular, paricular and structural dimensions related to the objecive reality of the individual and the collecive, contribuing to the understanding of phenomena and the planning of acions that enable the transformaion of health contexts.
Criical Epidemiology, in turn, in addiion to being organized around social determinaion and a dialecical view of the health-disease coninuum, is focused on the resurgence of the concept interculturality, which refers to
the integraion of the individual with exising interpreta
-ive and social homogeneity from a dialecical and demo
-craic perspecive, aiming for an epidemiological acion no longer centered on factors, unicultural individuals, and funcionalist acions(15).
Both approaches are philosophically grounded in Dia
-lecical Historical Materialism. The irst is a theoreical path that points to the dynamics of reality in society, while
dialecic refers to a method of approaching reality seen as something in constant transformaion(16).
As a form of Nursing pracice supported by Collecive Health, grounded on the Dialecical Historical Materialism,
we highlight the Praxis Intervenion Theory in Collecive Health Nursing, which is a theoreical and methodological framework for nursing intervenion in collecive health(10).
This theory proposes understanding the objecive reality of the health-disease coninuum of a given collecive, or expressed by an individual, through the ideniicaion of socially constructed historical processes in the singular, paricular and structural processes. Hence, it seeks to un
-derstand the associated processes of protecion and wea
-riness, idenifying contradicions between or within them. Such relecion promotes a criical understanding of pro
-cesses expressed in objecive reality and the planning of intervenions that enable the transformaion of reality and also contribute to structure policies in the health sector(14).
The ive stages proposed by the Praxis Intervenion Theory in Collecive Health Nursing for collecive health intervenion includes apprehension and interpretaion of objecive reality. Then a project, which should take into account the prioriies listed according to the vulnerabili
-ies found, is developed; intervenion is then implement
-ed to change the dialecic contradicions that were found in reality. Finally, objecive reality is reinterpreted, that is, the new reality and its contradicions are assessed, to re
-evaluate the previous stage in order to coninue interven
-ing and chang-ing processes that determine such reality. Nursing care is based on three principles of dialecic during the stages of idenifying, interpreing and inter
-vening, which are: law of the struggle of opposites; law of transformaion of quanitaive into qualitaive changes; and law of the negaion of the negaion. The irst law refers to the constant contraposiion among the various dimen
-sions, or within the dimension itself that composes each phenomenon. Relecing on contradicions is intended to idenify vulnerable points and evaluate the governability of the professional to change that reality. The second law, in turn, can be perceived in the intervenion, when quan
-itaive changes originate qual-itaive changes. And inally, the law of the negaion of the negaion is applied at the point when the professional perceives reality is qualitaive
-ly changed, thus, previous reality is then negated, giving place to a new reality, which even though it sill presents marks of the previous reality, is now diferent(17).
The process of ideniicaion should describe in detail the strengths and weak points of the health service—in this case, in the Collecive Health ield— in terms of its objecives, available work force, organizaion and infra
-structure, exising programs, supervision, connecion with other services, informaion systems, care tools, and descripion of the epidemiological proile, also including informaion concerning the work performed by the health staf. Previously standardized data collecion methods are required(14).
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Medeiros ADP, Larocca LM, Chaves MMN, Meier MJ, Wall ML
individuals’ data or a characterizaion of the community/ populaion, in order to understand processes of protec
-ion and faigue in historical and social contexts. Such processes are deined by the way people are included in social producion-reproducion and work-consumpion processes. Based on this understanding, the various ways of organizing groups according to the social class to which individuals belong are ideniied when exploring possi
-biliies of social reproducion in society. In this reality, we consider that the whole is not merely the sum of individ
-uals because there is a complex dynamic that shapes it, which is greater that the mere sum of parts. The later is perceived in a deeper analysis as proposed by the Praxis Intervenion Theory in Collecive Health Nursing.
Social reproducion is the movement of producion and consumpion that takes place according to a given collecive. Awareness and organizaion are constructed in this movement and contribute to the transformaion of the relaionship of the human being with nature. The eco
-nomic dimension, culture, poliical organizaion and the relaions of preservaion and faigue are implicit in this movement. These relaions are represented in the epide
-miological proile of a given collecive; even though they are not directly perceived, they should be acknowledged when one relects upon the processes that generate pro
-tecion or faigue for individuals or the populaion(15).
The view of totality, one of the theoreical bases of Criical Epidemiologic, allows the proposiion of a discus
-sion concerning interculturality, which assumes that the relaionships among the various cultures is supporive, without one absorbing the other, and enables the devel
-opment of health intervenions that breaking with the existent interpretaive and social homogeneity, promot
-ing advancement within a dialecic and democraic under
-standing that strengthen emancipatory health acions.
FinAL conSidERAtionS
Relecing on the history of Epidemiology as science is an important opportunity for nurses to acquire the tools of a theory of knowledge because it enables them to de
-velop a diferent point of view that considers the process of organizaion of health policies.
Being included in the dynamic process that challenges collecive health is currently a pressing need that requires an epistemological foundaion concerning the science of Epidemiology—an essenial theoreical foundaion for the accurate interpretaion of objecive reality— as well as the proposiion of professional pracices in the face of poliical and health models, aiming to improve the use of Epidemiological science as a tool for the nurses’ work process.
The development of Nursing knowledge needs to share validaion of epidemiological knowledge so as to efecively contribute to consolidaing the Brazilian Uni
-ied Health System and reducing social inequaliies. By breaking with the view that reality is reduced to a single plan that we can observe directly, nurses will be able to understand generaive processes, explore contra
-dicions exising in the dimensions of that reality, and paricipate in a more decisive way, in the deiniion of policies in the health sector and regulaions concerning their own pracice.
Such a perspecive can be efected through pracice, whether in health intervenion or during the nurses’ edu
-caion, which focuses on the ideniicaion of determinant processes that are generated in the diferent dimensions of reality, as opposed to the understanding that endorses reality as its appears to us, focused on the signs, symp
-toms and complaints presented by individuals.
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