Treatment adherence under the foucauldian perspective: knowledge/powers in tuberculosis control manuals in Brazil

Zago, Priscila Tadei Nakata; Maffacciolli, Rosana; Riquinho, Deise Lisboa; Kruse, Maria Henriqueta Luce; Rocha, Cristianne Maria Famer

doi:10.1590/1983-1447.2022.20210075.en

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Revista Gaúcha de Enfermagem

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Original Article • Rev. Gaúcha Enferm. 43 • 2022 • https://doi.org/10.1590/1983-1447.2022.20210075.en copy

Treatment adherence under the foucauldian perspective: knowledge/powers in tuberculosis control manuals in Brazil

Adhesión Terapéutica bajo la mirada foucaultiana: conocimientos/poderes en Manuales de Control de Tuberculosis en Brasil

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective

Investigate which knowledge emerges in the Tuberculosis Control Manuals and how power relations are established for treatment adherence.

Method

Documentary and qualitative research on five Manuals published between 2002 and 2019, available on the Ministry of Health’s Website, based on Michel Foucault’s theoretical and methodological framework.

Results

1. Knowledge: emerges as human resource training; health surveillance actions; medicalization; and multifunctionality of nurses in addressing the social determinants of tuberculosis. 2. Power relations: occur through articulation between different subjects and establish disciplines on the body and the behavior of the person undergoing treatment.

Conclusions

Certain knowledge/powers constitute the actions of treatment adherence to tuberculosis treatment and normalize the “correct/true” way of conducting disease control. Such behaviors refer to self-responsibility, autonomy and empowerment of the subject and do not consider the countless conditions of vulnerability existing in the history of people with tuberculosis.

Keywords
Tuberculosis; Treatment adherence and compliance; Health promotion; Address; Politics

Emergence of different knowledge capable of Adherence	Excerpts from the analyzed Manuals
The training of human resources in the health area appears as the only knowledge necessary for the control of tuberculosis(1010. Ministério da Saúde (BR). Secretaria de Políticas de Saúde. Departamento de Atenção Básica. Manual técnico para o controle da tuberculose: cadernos de atenção básica [Internet]. 6. ed. Brasília, DF: Ministério da Saúde ; 2002 [cited 2020 Dec 10]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/manual_tecnico_controle_tuberculose_cab6.pdf http://bvsms.saude.gov.br/bvs/publicacoe... ).	“The training of health professionals is the crucial issue for these objectives to be achieved, since the other necessary conditions are already created, highlighting the updating of technical knowledge and the availability of financial resources, [...] perfectly possible […] to control tuberculosis”(1010. Ministério da Saúde (BR). Secretaria de Políticas de Saúde. Departamento de Atenção Básica. Manual técnico para o controle da tuberculose: cadernos de atenção básica [Internet]. 6. ed. Brasília, DF: Ministério da Saúde ; 2002 [cited 2020 Dec 10]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/manual_tecnico_controle_tuberculose_cab6.pdf http://bvsms.saude.gov.br/bvs/publicacoe... -55. Moraes DR, Castiel LD. O salutarismo de Robert Crawford e as atualizações do autoritarismo sanitário nosso de cada dia. RECIIS. 2019;13(1):122-33. doi: https://doi.org/10.29397/reciis.v13i1.1731 https://doi.org/10.29397/reciis.v13i1.17... ).
Performing actions within the scope of territorially based health surveillance(1111. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Vigilância em saúde: dengue, esquistossomose, hanseníase, malária, tracoma e tuberculose [Internet]. Brasília, DF: Ministério da Saúde ; 2008[cited 2020 Dec 10]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/cab_n21_vigilancia_saude_2ed_p1.pdf http://bvsms.saude.gov.br/bvs/publicacoe... ) is seen as fundamental in TB control.	“In order to qualify health care based on the principle of integrality, it is essential that work processes are organized with a view to facing the main health-disease problems of communities and with health promotion and surveillance actions […]”(¹¹:⁵).
The discovery of new drugs emerges as necessary for the elimination of the disease(1212. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Manual de recomendações para o controle da tuberculose no Brasil [Internet]. Brasília, DF: Ministério da Saúde ; 2011 [cited 2020 Dec 10]. Available from: https://www.nescon.medicina.ufmg.br/biblioteca/imagem/manual_recomenda%C3%A7oes_controle_tuberculose.pdf https://www.nescon.medicina.ufmg.br/bibl... ).	“[...] there is still no perspective of obtaining its elimination as a public health problem in the near future, unless new vaccines or medicines are developed”(^12:17).
Strengthening adherence depends on how much the professional is able to develop their activities in a systematic way, according to a specific protocol(1313. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Tratamento diretamente observado (TDO) da tuberculose na atenção básica: protocolo de enfermagem [Internet]. Brasília, DF: Ministério da Saúde ; 2011 [cited 2020 Dec 10]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/tratamento_diretamente_observado_tuberculose.pdf http://bvsms.saude.gov.br/bvs/publicacoe... ).	“This publication is therefore dedicated to the systematization of the work of those professionals who have the fundamental role of guaranteeing the supervision of the entire treatment and avoiding intercurrences that favor abandonment […] ensuring patient adherence and successful treatment”^(13:11).
The need to face SDH emerges as a new fact to be considered for TB control(11. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Manual de recomendações para o controle da tuberculose no Brasil [Internet]. Brasília, DF: Ministério da Saúde; 2019 [cited 2020 Dec 10]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/manual_recomendacoes_controle_tuberculose_brasil_2_ed.pdf https://bvsms.saude.gov.br/bvs/publicaco... ).	“The new strategy […] brings the confrontation of social determinants and […] the use of social protection as a support tool […] Brazil has been seeking in intersectoral articulations the response to the centered epidemic […] on those living in a situation of extreme poverty […]”(^1:23).
The classification and systematization of a certain way of knowing about tuberculosis	Excerpts from the analyzed Manuals
Some recommendations aim to classify in order to systematize a way of conducting care in TB treatment.	“[…] organization of records and information of users under investigation and under treatment for tuberculosis, namely: registration of respiratory symptoms, patient registration and treatment, tuberculosis notification, contact registration [...] and follow-up form of daily medication”(^13:91).

Power as an action of government bodies	Excerpts from the analyzed Manuals
Actions for Adherence to TB occur through the determination of attributions to the three governmental health bodies - municipal, state and federal - according to the regionalization and hierarchy of the Unified Health System(11. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Manual de recomendações para o controle da tuberculose no Brasil [Internet]. Brasília, DF: Ministério da Saúde; 2019 [cited 2020 Dec 10]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/manual_recomendacoes_controle_tuberculose_brasil_2_ed.pdf https://bvsms.saude.gov.br/bvs/publicaco... ).	“The Ministry of Health is the body of the Federal Executive Branch responsible for the organization and elaboration of plans and public policies aimed at the promotion, prevention and health care of Brazilians […]”^(1:281). “In certain states and municipalities, the administrative structure includes an intermediate level defined as “regional health”. For such cases, this structure should promote greater proximity between the central state level and the local levels […]”^(1:283).
Power relations and disciplines established between the professional and the person undergoing treatment	Excerpts from the analyzed Manuals
Nurses’ actions occur as a duty of the professional category, which must comply with certain rules(1313. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Tratamento diretamente observado (TDO) da tuberculose na atenção básica: protocolo de enfermagem [Internet]. Brasília, DF: Ministério da Saúde ; 2011 [cited 2020 Dec 10]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/tratamento_diretamente_observado_tuberculose.pdf http://bvsms.saude.gov.br/bvs/publicacoe... ).	“The role of the tuberculosis control program nurse is to organize and comply with the recommendations of the Ministry of Health [...]. The diagnosis of tuberculosis in health services is implicit in the duties of this professional, according to protocols or other technical regulations established by the municipal manager or the Federal District, observing the legal provisions of the profession, performing nursing consultations, requesting additional tests and prescribing medications”^(13:36).
The nurses’ actions are performed according to an extensive list of interventions (previously established) both in the body and in the behavior of the person undergoing treatment(1010. Ministério da Saúde (BR). Secretaria de Políticas de Saúde. Departamento de Atenção Básica. Manual técnico para o controle da tuberculose: cadernos de atenção básica [Internet]. 6. ed. Brasília, DF: Ministério da Saúde ; 2002 [cited 2020 Dec 10]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/manual_tecnico_controle_tuberculose_cab6.pdf http://bvsms.saude.gov.br/bvs/publicacoe... ).	“[…] guide the patient regarding the collection procedure: when waking up in the morning, wash mouth without brushing teeth, inhale deeply, hold breath for a moment and spit up after forcing a cough. Repeat this operation until get two sputum eliminations, preventing it from running down the outside wall of the bowl; guide the patient to wash hands after this procedure. […]”^(10:14).
The organization/operationalization and monitoring of Directly Observed Treatment (DOT) is the main discipline established for Adherence(1313. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Tratamento diretamente observado (TDO) da tuberculose na atenção básica: protocolo de enfermagem [Internet]. Brasília, DF: Ministério da Saúde ; 2011 [cited 2020 Dec 10]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/tratamento_diretamente_observado_tuberculose.pdf http://bvsms.saude.gov.br/bvs/publicacoe... ).	“Directly observed treatment control consists of the application of means that allow the nurse to monitor the evolution of the disease through the analysis of the follow-up form of the daily medication intake[…]. The nurse must pay attention to: […] perform frequent and systematic assessment of the instruments for registering tuberculosis cases in the health unit […]; check the name and dose of the drugs prescribed for the patient and his/her weight; make sure the patient is regularly taking the medication^(13:96).

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[1] Corresponding author:
Priscila Tadei Nakata Zago Email: priscilanakata@gmail.com