Luciana da Silva Pinheiro; Thais Cristina Souza de Medeiros; Cecilia Nogueira Valença; Debora Kaynara Ferreira Dantas; Maria Aparecida Paulo dos Santos
BACKGROUND: For acting at the level of the community and mediating between it and health services, the role of community health agents (CHA) is essential. For this reason, this occupational group needs satisfactory quality of life and working conditions to ensure their well-being and improve the quality of their work. On these grounds, the present study is justified as a means to reflect on the work process of this occupational group and enable suggestions for improvements.
OBJECTIVE: To discuss strategies to improve CHA’s quality of life and work.
METHODS: Exploratory study with qualitative analysis conducted with CHA in Currais Novos, Rio Grande do Norte, Brazil.
RESULTS: Strategies suggested to improve quality of life and work focused on mental and physical aspects and the essential resources needed for work.
CONCLUSION: Discussions and sound grounds are needed for initiatives to improve the living and working conditions of CHA and thus achieve a positive impact on this population of workers, and consequently also on their daily actions.
Keywords: community health workers; Family Health Strategy; Unified Health System; quality of life.
INTRODUÇÃO: O agente comunitário de saúde (ACS) tem papel fundamental ao atuar nas comunidades, interligando os serviços de saúde à população. Nesse contexto, é importante que esses profissionais tenham qualidade de vida e trabalho, para que possam ter bem-estar e ao mesmo tempo proporcionar maior qualidade na prestação de suas atribuições. Dessa forma, a pesquisa justifica-se como uma forma de repensar o processo de trabalho dessa categoria, possibilitando traçar propostas de melhorias.
OBJETIVO: Discutir estratégias de melhorias da qualidade de vida e trabalho aos ACSs.
MÉTODOS: Trata-se de um estudo exploratório de abordagem qualitativa, realizado com os ACSs que atuam na cidade de Currais Novos, Rio Grande do Norte.
RESULTADOS: Foi possível evidenciar que as estratégias relacionadas à qualidade de vida e ao trabalho referem-se aos aspectos mentais e físicos, assim como aos recursos básicos para o desenvolvimento do trabalho.
CONCLUSÃO: Há necessidade de discutir e dar sustentação para a implementação de melhorias das condições de vida e trabalho dos ACSs, produzindo um impacto positivo nesses profissionais e, consequentemente, nas ações desempenhadas por eles em seu exercício diário.
Palavras-chave: agente comunitário de saúde; estratégia saúde da família; Sistema Único de Saúde; qualidade de vida.
The priority for the Family Health Strategy (FHS) is to reorganize primary care in Brazil according to the Unified Health System (Sistema Único de Saúde–SUS) principles. The Ministry of Health, state and municipal managers consider FHS a means to expand, ensure the quality of and consolidate primary care, to thus improve its capacity to deal with individual and collective health1.
FHS teams are composed of several categories of health workers, including community health agents (CHA). Although this category was created by the Ministry of Health in 1991 through the Community Health Agent Program, its activities date back to the beginning of the 1980s. A pioneer initiative in the Brazilian Northwest region, this Program was formulated and implemented by the Ministry of Health as an attempt to reduce high child and maternal mortality rates and improve the quality of the health of communities2.
Regulated by the Law no. 13,595, from 5 January 2018 — which amended the Law no. 11,350, from 5 October 2006 — CHA perform their activities exclusively within SUS3,4. This category gained in relevance within the field of family health and plays a strategic role within primary care, given the shortage of professionals and difficulties in the population’s access to health services5.
The text of the law shows that CHA have considerable influence on the development, promotion and maintenance of healthy behaviors. As article 3 states:
Community Health Agents are entitled to perform activities related to the prevention of diseases and health promotion within the Popular Health Education framework through household- or community-based, individual or collective actions developed in accordance to the SUS guidelines which regulate preventive health and primary care to improve the access of the targeted communities to information, health, social promotion and citizenship protection actions and services, under the supervision of municipal, district, state or federal managers.
CHA are charged of demographic and sociocultural diagnosis; of describing household visits in detail, including collection and recording of data relative to their tasks, exclusively aiming at the control and planning of health actions; mobilizing the community and enhancing its participation in health and socio-educational public policies; following up social programs in partnership with Social Work Reference Centers; and performing regular and periodic household visits to follow up the entire population in their area of coverage along the various stages of life3.
In addition to the aforementioned tasks and responsibilities, changes in the National Policy of Primary Care (Política Nacional de Atenção Básica–PNAB) guidelines charge CHA also of blood pressure and capillary glucose measurements and clean wound dressings. While these new tasks will begin after legal authorization is granted and CHA receive the due training4, they show that this category plays a significant role in the organization and efficiency of activities at healthcare units.
Also new are some professional demands, as enunciated in the Law no. 13,595, from 5 January 20183, which lists the requirements for CHA, as e.g. having concluded secondary school and a 40-hour introductory training course. Complete elementary school is not required from CHA who started practice before 5 October 2006; similarly, complete secondary school is not required from those who started in the job before January 2018. Changes introduced in PNAB, with consequent modification of the Law no. 11,350, from 5 October 2006 — which describes tasks and responsibilities, working hours and conditions, required professional training and technical and continuing training — suggest that CHA are subjected to an excessive workload, while their occupation is poorly recognized.
CHA play an essential role at Health Basic Units (HBU) by mediating between facilities and service users. Discussing strategies to improve the quality of life and work of CHA is relevant for their professional performance, since these factors are associated with their well-being, pleasure and motivation to commit to their tasks.
Several aspects should be considered in initiatives to improve the quality of life of workers. In strategies designed for CHA, actions should target both mind and body, including exercise and healthy lifestyles, in addition to a broad scoped approach to occupational health to meet their needs and prevent and/or minimize work-related health problems.
In regard to work as such, basic strategies might result in richer working environments and higher levels of job satisfaction. Some possibilities include: recognition from public authorities and managers, investing in improving actions, financial investment, availability of the basic equipment needed for tasks, promoting social relationships and the productivity of healthcare facilities, good communication between staff members and organization of the work process.
CHA are aware of the needs of the population in their area of coverage, and should be included in permanent education initiatives to support their work in health promotion, social mobilization to deal with social determinants of health, and strategic actions targeting health problems among the population6.
Although several studies addressed the management of CHA work and their quality of life, difficulties still remain in the formulation and implementation of policies to make the value of this occupational group become more visible7.
The aforementioned considerations provide the justification for the present study, which seeks to promote a reflection on the work process of CHA based on their self-perception, with emphasis on significant aspects of their daily work. We suggest some improvements to make the quality and value of this unique members of primary care services become more visible, in addition to identifying factors which interfere with their quality of life and work.
The present was an exploratory study with qualitative analysis. Exploratory studies are a modality of empirical research which aim is to pose questions or identify problems to transform or clarify notions or make investigators familiar with the targeted environment, fact of phenomenon8.
In exploratory studies, systemic procedures are applied to empirical observations or data analysis. Quantitative and qualitative descriptions of the study subject are continuously obtained, and the investigator is called to conceptualize interrelationships among the properties of the analyzed phenomenon, fact or environment. Methods for data collection include content analysis, interviews and participant observation, among others9.
The qualitative approach involves an inseverable bond between the real world and the subjectivity of individuals that cannot be expressed by numbers. Interpreting events and attributing meanings are essential aspects which do not require any statistical method or technique, but the source of data is the natural environment and the interviewer plays a key-role10.
Subjects eligible for the present study were all CHA allocated to HBU in the urban area of Currais Novos, Rio Grande do Norte, Brazil, who had had performed internships supervised by School of Health Sciences of Triari, Universidade Federal do Rio Grande do Norte (FACISA/UFRN). These HBU were selected due to previous institutional contacts which facilitated the investigators’ access to the study subjects.
There are 17 HBU in Currais Novos, 14 of which in the urban area, being that only five of the latter had been the seat of FACISA internships. Four CHA are allocated to each HBU, to a total of 20.
Data collection took place in June and July 2015 by means of a questionnaire administered in semi-structured interviews, with open-ended items, to answer the following overall question: in the CHA’s view, what strategies would improve their quality of life and work? The interviews are not mere chats, but dialogues with a definite aim: to collect data relevant for studies by inquiring informants8.
We included CHA with one year in the job at least. Exclusion criteria were: being absent from work during the period of data collection and withdrawing consent.
The narratives in interviews were transcribed and subjected to thematic content analysis, which included the following steps: pre-analysis; survey of narratives and treatment of results; interference; and interpretation of the data10.
Data collection began after the participants agreed to participate and signed an informed consent form, as required by the National Health Council Resolution no. 466/2012. The study was approved by the research ethics committee of FACISA, CAAE: 43945315.8.0000.5568.
Understanding simple subjects who perform complex activities within SUS is necessary, yet, to protect the participants’ anonymity, they were attributed nicknames based on observed characteristics.
RESULTS AND DISCUSSION
While there are many definitions of quality of life, it is a subjective and multidimensional notion.
Upon being inquired about strategies to improve their quality of life and work, the participants initially mentioned some ways to improve psychological and physical aspects. They acknowledged their role as mediators between health services and the population by providing information on health. Their occupation requires CHA to be in good health, so that they might be able to convey a positive image of that they are attempting to promote, and also to perform their work with the community better.
“As we are health agents, we go door to door, and we can’t look unhealthy, because we’re bringing this, information and better health, to the population.” (CHA Truthful)
Self-care is influenced by social, cultural, environmental and professional factors. It further includes aspects considered to be necessary, such as physical, emotional and social balance in the competences required in daily practice10.
Health workers might provide information to the people under their care exclusively based on their theoretical knowledge. However, they do not apply such knowledge to their own care. When workers do not take care of themselves, the care they provide to others becomes impaired6.
This is an essential aspect to which health workers should pay attention, because it leads to the need to reflect on the awakening, or even rescue, of self-care to achieve fulfilment in the practice of their profession and a feeling of greater personal accomplishment.
Among the various factors the participants mentioned as influencing their quality of life, the psychological impacts of absorbing the population problems served to ground strategies to improve their quality of life:
“One of the strategies that, in my opinion, is very interesting, is to have the community health agents who feel more affected see a psychologist. I believe it would be interesting if the city government would pay some attention to this, because we absorb a lot and for ethical reasons, we can’t let go like that, can we? We can’t talk [about this] to no one. It’s a strategy that would be worth for the public administration to look into.” (CHA Sensible)
“To improve the quality of life, like that, seeing a psychologist, not only once, but a true follow-up. There was one at the Secretariat of Health, a training session, he came only once, and that was it. It should be available as part of the routine.” (CHA Hopeful)
Given that a considerable proportion of participants mentioned this option, considering management investment in psychological support within the occupational health setting is relevant as a means for prevention of diseases or mental health problems.
As a function of the just mentioned findings, having multiprofessional teams trained to provide care to health workers is essential, which could be done at HBU, i.e. at an environment quite close to the target population.
This modality of intervention would benefit the health and work of CHA, for instance, by preventing or reducing anxiety and more serious disorders, such as depression resulting from the high load of problems this population of workers have to absorb in their daily practice.
Another interesting option is for public authorities to make leisure activities available to promote rest, relief and pleasure, thus neutralizing tensions arising from the mental load.
In regard to their physical health, particularly tiredness and body pain arising from their tasks, the participants observed that relaxation techniques and exercise supervised by experts are useful to improve their physical fitness:
“Something else I’d rate interesting, mainly as concerns our performance at work: a physical therapist. Even because, just to practice, so to speak, some technique to improve performance, stretching, relaxation at the end of the day, or at the beginning, that famous workplace fitness, right? Health-care personnel work too much, and I don’t see them stopping to do that.” (CHA Truthful)
Supervised by duly trained professionals, workplace fitness programs are increasingly used as a means for prevention and treatment of work-related musculoskeletal disorders. They consist of brief exercising in the workplace, mainly including stretching, relaxation and body awareness exercises, while keeping balance in the body parts involved in job tasks. Thus workplace fitness programs contribute to improve the quality of life of workers9.
The effects of workplace workouts might extend beyond the few minutes they take, because depending on how the supervising professionals provide orientation on the exercises as such and on health in general, workers might acquire sufficient knowledge to exercise anytime, anywhere, at and outside the workplace11.
Reinforcing these ideas, the participants revealed awareness of the fact they should actively administer their time and set themselves to do something for the sake of their physical health, such as developing positive habits and behaviors leading to better disposition to work:
“I believe, so, in terms of improving my quality of life. So, one has to have time for the gym, walking, exercising... Because one feels, we get very tired, so, if we’d do some exercise, it would be very helpful.” (CHA Smiling)
Still in regard to physical aspects, the participants complained of their levels of exposure to sun, and stated they needed continuous monitoring to avoid health problems:
“We mainly need skin doctors to perform examinations in the consulting room.” (CHA Determined)
As a function of their high levels of sun exposure, professional monitoring of the skin is relevant for preventing skin cancer and other diseases. In addition to consultations with dermatologists, CHA should also consider other approaches for protection against daily sun exposure. Photoprotection might serve to reduce their exposure to sun and thus avoid its harmful effects12. Sunscreen, adequate clothes and accessories, such as hats and caps, and safe exposure to sun are essential components of photoprotection13.
The Ministry of Health recommends the following as basic work equipment for CHA: uniforms, name tags, primary care information forms, scales, chronometers, thermometers, tape measure and educational materials. Other resources indispensable for CHA work, such as personal protective equipment (PPE), are often unavailable. As a result, CHA are exposed to the sun more than 5 hours daily, at critical times of the day, which characterizes a high-risk situation.
To effectively prevent and reduce the incidence of skin cancer, from the strategic point of view, workers should not restrict themselves to merely requesting PPE, but should also become aware of the relevance of making continuous use of it:
“The issue about appropriate uniforms, which included appropriate boots, because we walk a lot, especially in my area, which only has unpaved, dirt roads. Boots would be adequate for work, a long sleeve shirt, a hat, or anything that protects against the sun, which I believe causes skin cancer.”(CHA Sensible)
The locations CHA visit often pose difficulties, for instance, poor physical conditions for moving around, improper sanitation, high risk of contamination and of poisonous animal bites. Appropriate uniforms including adequate footwear might make the working conditions of CHA safer.
For this reason, free provision of PPE is recommended as a safety strategy, i.e. to protect workers from the hazards to which they are exposed.
Regulatory Standard (RS) 6, which deals with PPE, defines it as “any individual device or product used by workers to protect them from hazards liable to threaten their health and safety in the workplace”14.
Still in regard to the hazards to which CHA are exposed, NR 21 reaffirms the need for protection when working outdoors: “special measures will be required to protect workers against excessive sun exposure, heat, cold, humidity and inconvenient winds”15.
Compliance with the laws relative to workers’ rights through appropriate and safe resources has paramount importance to ensure they enjoy high-quality work.
As concerns the activities at HBU, the participants observed that efficacious communication, together with planning of actions, represents an essential strategy to ensure the success of their and their team work:
“I believe that carrying out actions, having continuous meetings is important... To have good communication between all those involved in the job, from the secretary to the unit and the professionals, to avoid flaws upon communicating the information we must transmit to the community. These actions must be planned beforehand to comply with the schedule, follow a sequence, with no hurries due to deadlines or rushes...” (CHA Committed)
“The act of communication stands out as a process of sharing and of help between health workers and the service users to whom they provide care in a way a process to help individuals and their families is established”16.
In regard to their task schedule, the staff must prepare operational monthly time allotment plans, describing activities which will take one day, one week or the entire month, as well as political-organizational plans, which reflect the obligations they have toward the community and managers17.
In the management of any institution, communication is an active factor to ensure that activities are efficient, and it should be permanent for the information and insights necessary for the development of tasks to be conveyed, and above all to promote cooperation and job satisfaction18.
As concerns the execution of their tasks, the participants acknowledged that the quality of the work done depends on the availability of basic resources:
“Quality... if we’d have appropriate tools to work.” (CHA Generous)
“One further thing would be abundance of basic resources for work.” (CHA Sensible)
Upon discussing the recognition received by their occupational group, the participants observed the public authorities need to think over aspects related to financial incentives and provide training as resources to elicit motivation for high-quality performance at work:
“Financial incentives for us to feel more and more encouraged to work as community health agents.” (CHA Sensible)
“I believe that agents should receive training. As a fact, we need that, even because we need to be informed so that we can transmit information to other people.” (CHA Friendly)
As a function of the activity profile of CHA, more organized learning approaches are indispensable, which fact points to the need to implement training programs associated with educational interventions. Such training must be suited to the actual practices developed in the area of coverage and consider scientific, technological and political changes occurring within the field of health19.
Continuing education is considered a means to correct distortions acquired during early training. It contributes to continuous updating in regard to social innovations and transformations, and reflects in changes in the way of thinking, feeling and acting of the new generations19:
“Continuing training , this is to say, staff aware of changes, updating. Who might, thus, push forward the job of health agents, because health agents often become too mechanical and do not improve... If there was some promotion at this level, the quality of the work done by health agents would improve a lot, and would also afford self-esteem... This would probably make a difference to them, and they’d be more qualified for their job, and would also be more appreciated by the management.” (CHA Committed)
“A course to gain access to a job here, I never got that to this day... One of the possible strategies is to teach a course for community health agents, with that our knowledge would increase, and consequently the care provided to the population would improve.” (CHA Sensible)
The participants observed that the lack of introductory courses upon entering the occupation made it difficult for them to adjust to the work process. From the strategic perspective, attention to early training is relevant to enable CHA to perform their job, and to then provide continuing education opportunities for them to strengthen and expand their knowledge.
The Law no. 13,595, from 5 January 2018, suggests implementing technical courses for CHA and epidemics combat agents. These might be fully or partially in-person courses and should comply with the guidelines formulated by the National Education Council3.
The virtual learning environment suited to meet SUS needs (AVASUS) created by the Ministry of Health launched in 2016 a course with modules designed for CHA to understand their own relevance, the actions they perform and their role in the process to improve the quality of the health services provided to the population. Including topics related to health public policies, social control, territorialization, health promotion and disease prevention actions, this course is highly relevant for the continuing education of CHA.
Good relationships between individuals are necessary for teamwork. According to the participants, a course on human relationships would be efficacious for this purpose:
“I believe we need training in human relationships to improve our relationships. I have no problems with the population assigned to me, I mean, with coworkers, to understand we’re all different from each other. And this because we spend most of our lives at work, so I believe it would be very interesting and would improve things a lot.” (CHA Sincere)
Successful teamwork requires sharing, active listening, empathy, self-knowledge, acceptance and openness to get to know others and allow oneself to know6.
Acknowledging the relevance of satisfactory interactions among workers results in more thorough understanding, satisfaction of all the involved parties and harmony in the environment.
Therefore, the strategies mentioned by the participants are essential to achieve respect and appreciation of individuals and workers, thus potentiating their work process, increasing the productivity of health services and improving interpersonal interactions and personal and job satisfaction.
We conclude that the participants were aware of the need and eager for strategies to improve their quality of life and work. They stressed that such strategies should be applied into practice as a function of the relevance of professional recognition and appreciation.
The strategies mentioned primarily focus on mental and physical healthcare, including long-term follow-up by healthcare providers, relaxation techniques, exercising and leisure, among others. Effective availability of basic resources, management recognition, good staff relationships, communication and organization were described as some of the bases to improve their work process.
The present study contributes to raise the awareness of managers and family healthcare providers on the relevance of CHA work and of providing appropriate working and living conditions to this occupational group. In addition, the present study contributes to the technical-scientific knowledge on collective health.
Discussions and sound grounds are needed are needed for initiatives to improve the living and working conditions of CHA, which will result in a positive impact on this population of workers, and consequently also on their daily actions and on the quality of primary care.
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17 de Setembro de 2018.
Aceito em 22 de Abril de 2019.
Fonte de financiamento: nenhuma