Physical therapist insertion in the Family Health Strategy team: the users’ view

Introduction : The Family Health Strategy program (FHS) was created with the aim to strengthen primary care through multidisciplinary practices, focused of health care to the family and community. In this sense, the incorporation of other professionals, other than provided in the minimum composition, such as the physical therapist, may contribute to enhance the comprehensiveness of health care. Objective : To know how the user perceives the need of a physical therapist in the FHS. Methodology : This is a qualitative research of 60 users of a Family Health Center in a city in western Santa Catarina. Data collection was performed at users’ homes by means of an interview. It contained questions about users’ knowledge on physiotherapy and the need to include this professional in the FHS team. Data were analyzed using thematic content analysis. Results : Regarding the users’ knowledge about the physical therapist, we could observe that users perceive this professional as the one who works in rehabilitation. As for the need for the physical


Introduction
Primary care is the gateway to the Unified Health System (SUS in Portuguese) and the starting point for the structuring of local health systems.To organize it, it was created in 1993 the Health Family Program in order to reorient the health care model, establishing new working dynamics in basic health units, in which the family and their social space become the center of the service.In 2006, this program received a new name: Family Health Strategy (FHS), and now it is a permanent guideline to reorganize health services in Brazil in order to implement the principles and guidelines of SUS and to strengthen primary care (1,2).
The FHS proposes the registration of the population according to the neighborhood, situational diagnosis, actions directed to health problems affecting the community and actuation focused in the neighborhood, family and community, in an interdisciplinary and multidisciplinary way.The multidisciplinary team (family health team) must include, at least, doctor, nurse, nursing assistant or technician, dentist, dentistry assistant and dental hygiene technician and it is responsible for three to four thousand inhabitants.In addition, it is required that community health workers (CHW) assist 100% of the population registered, with a maximum of 750 inhabitants per CHW (2).
As noted, the physical therapist is not included in the minimum composition of the family health team, although since 2008 it has been among professionals recommended to integrate the Centers of Support for Family Health (NASF) teams.The NASF were created by Decree No. 154, in 24 January 2008 by the Ministry of Health with the aim to improve the primary care services and to incorporate professionals from different areas of knowledge to the Family Health Team (3).
The role of the physical therapist in primary care still represents a challenge, because this profession has been structured focused in rehabilitation, which was reinforced by traditional and fragmented pedagogical models that do not train professionals to work in the SUS.This is justified, partially, by the fact that this profession has been kept away from primary care, which is, even today, one of the limitations for working in the FHS.
The rapprochement between physical therapy and public health aims to improve the field of practice of this profession and to organize new knowledge that can contribute to the promotion of health and quality of life of the population.The pursuit of insertion of physical therapy in primary care cannot be restricted to the purposes of expanding the physical therapists job market; above all, it must be based on social responsibility inherent in all health care professions (4).
Research has shown that the performance of the physical therapist in primary care has been facing difficulties with regard to the implementation of health promotion practices, due to the training model, to the small number of physical therapists working in the family health and to the great user demand for rehabilitation, among other factors (5, 6, 7).
In this sense, studies that address the performance of the physical therapist in the primary care setting, especially those focused on listening to users, can be important tools for the reorganization, planning of actions and for the insertion of that professional in this context.The objective of this study is to know how the user perceives the need for physical therapists in the FHS.

Methodological procedures
Whereas the field of health is set up by a multifaceted reality, we chose, for this study, a qualitative approach, which seeks to understand the complexity of particular and specific phenomena, facts and processes of certain groups (8).
The analytical and systematic path of the qualitative research enables the objectification of a kind of knowledge that has as raw material opinions, beliefs, values, representations, relationships and human and social actions in the perspective of the actors under subjectivity (9, p. 626).
In this study, we adopted the conception that, since the FHS is a guideline for the organization of primary care, it requires a re-signification of the user, who should be seen as a historical subject, possessor of socially constructed knowledge, which is as important as the knowledge of health professionals (10) .We conducted an interview with 60 users, 33 women and 27 men of different ages, registered in the System of the Primary Care Information (SIAB) of a Family Health Center (FHC) from a municipality in western Santa Catarina.
Data collection was carried out through home visits, during which users answered a semi-structured interview that aimed to identify their sociodemographic and family characteristics, and also their knowledge about physical therapy and their perception regarding the need to insert the physical therapist in the FHS.It was initially asked the user whether they have already done physical therapy or observed a family member in treatment.When the answer was positive, we would perform the interview, which lasted around 45 minutes, and was recorded with a digital recorder and transcribed in full.
During the initial approach, the study participants were informed about the objectives and procedures of the research, and have the preservation of their identity guaranteed.Those who agreed to participate in the study were asked to sign a Free and Informed Consent Form, according to the Guidelines Regulating Research Involving Human Subjects of the National Health Council, Resolution 196/96 and to the Ethics Research Committee of Unochapeco University.
Interviews were conducted by three researchers previously instructed in varying shifts, during weekdays for two months.Before the research, we carried out a pilot test with 10 users to verify the adequacy of the interview script.
The analysis of a qualitative research object, when properly interpreted, achieves the possibility of building knowledge and gathers all the requirements and instruments to be considered and valued as a scientific construct (9, p. 626).Thus, the thematic content analysis comprises three steps to be followed: a) pre-analysis; b) exploration of material; c) processing of the results and interpretation.
In the pre-analysis, the material is organized with successive readings, as this determines in which field researchers should concentrate their attention, deepening the readings.The analytical description phase is the moment in which material is subjected to a thorough study, guided, in principle, by the assumptions and theoretical frameworks.It also comprises coding and classification procedures, and later establishment of categorization.In the interpretation phase the text is written based in the empirical materials and links are established, deepening the connection of ideas and producing the discussion of the analytical categories listed (11).
The Research Ethics Committee of Unochapeco (Opinion No 301/10) approved the project that originated this study.

Results and discussion
Regarding the profile of users surveyed, there was prevalence of women, with 33 female and 27 male participants; 30 were married, 19 had a university degree and 23 had a monthly income ranging from 1 to 3 minimum wages.From the analysis of the obtained statements, the categories and subcategories were identified, as shown in Table 1.
in the creation of rehabilitation centers and in the recognition of physical therapy as a profession necessary for health (12).Since the actions and interventions of the physical therapist in the health status of the individual or population have been so directed to the rehabilitation, at a given time, the role of the physical therapy seems to have been understood as a synonym for (only) rehabilitative care (13).
Currently, although physical therapists work in public health, especially in-group activities, and this profession integrates the NASF team, this conception of rehabilitation is still deeply rooted in the knowledge that users have about the physical therapy, as it can be seen in these statements: It is the art of rehabilitating body movements, which are worn or have suffered fractures and need to recover the movements.It is also used for accidents, bedridden, to strengthen the muscle tone of patients with lung diseases (L.M. P., 22 years old).

It is a profession that aims at rehabilitation of the body, when it has a musculoskeletal problem (M. S., 31 years old).
It is a professional targeted to rehabilitate people's bodies, to improve movements and to reduce pain (M. S. C., 36 years old).
It is noticed that users do not conceive the role of physical therapy in developing health promotion actions in primary care.This perception is reinforced by referrals made by other health professionals, since most of the time, the work of the physical therapist is only required after the disease or injury is already present.
It is noted here that there is a great challenge for physical therapy, which is breaking this paradigm of rehabilitation professional, since in other studies this reality has also been highlighted.Novais and Brito (14), in analyzing the perception of users and health professionals about the physical therapist working in primary care, noted that the physical therapist, for most interviewees, was linked to a professional directly related to rehabilitation, which is a characteristic of the profession.
In a study of Carvalho and Caccia-Bava (15), conducted with 275 users of the FHS in Ribeirao Preto, it was observed that physical therapy was considered by more than 50% of respondents as a synonym for rehabilitation or treatment, and that its field of work is mainly the hospital, with no role in educational

Professional primarily working in rehabilitation
Professional working also in primary care

Insertion of the physical therapist in the FHS
Facilitating the users access to physical therapy services Improving comprehensive care in the FHS

Professional primarily working in rehabilitation
In Brazil, the physical therapist field of work was established due to the increasing number of work accidents resulting from industrialization and by the poliomyelitis epidemic that occurred from the 1930s to the 1950s.The large number of people unable to work and with sequelae, regardless of class (in the case of poliomyelitis), has become a concern for society and a stimulus to medical expertise, resulting activities.The authors also reported that 98% of users stated that healthy people do not need physical therapy services; however, 38% of study participants recognized the basic health unit as the physical therapist field of work, which is a positive aspect, considering that the insertion of this professional in that environment is recent.In addition, respondents supported the inclusion of the physical therapist in primary care as a possibility to provide benefits to the community by contributing to the prevention of diseases and sequelae.
It is known that one of the critical issues that will help to overcome this stigma of rehabilitation professional involves the professional training model.As Silva and Silveira ( 16) highlighted, the training of physical therapists is still centered in the biomedical and technicist model, with little discussion of issues related to the humanization of care and the SUS.This training results in this professional unpreparedness when inserted in the health team (16).In addition, the training directed towards the private labor market, focusing on rehabilitation, does not widen the access of physical therapy for the population.On the contrary, this fact, according to Bispo-Junior (17), increases the lack of physical therapists to work in primary and secondary care levels.
Although most users had the view that the physical therapist operates basically in rehabilitation, some have shown a different view of the role and of the work of the physical therapy, as described below.

Professional working also in primary care
In contrast to what was presented up to this point, some users have recognized the role of physical therapy in primary care.Maybe because they had already had previous contact with this service or because they had heard about the actions of this professional, especially those related to group consultations, carried out by academics of physical therapy from the local university or by physical therapists linked to NASF.In this sense, users have defined physical therapy as a profession that, besides acting in rehabilitation, also acts in disease prevention and health promotion, as the following statements illustrate: It is the profession working with improving body movement, preventing diseases such as RSI and WRMD, among others (M. A. S., 44 years old).

It is the profession that studies the human body and how to improve health through physical activity. It also prevents diseases (R. A. S., 27 years old).
Physical therapy has been entering in primary care, especially by the development of interventions in groups, home visits, among other strategies to maintain health, the disposition and the household welfare (18).Barbosa et al. (19), in a survey conducted in Minas Gerais, reported that the actions developed by physical therapists in NASF were activities in primary prevention groups with populations of women, pregnant women and adolescents; in secondary prevention groups with hypertensive patients; and posture groups, with people feeling pain.The role of the physical therapist in primary care goes (or should go) beyond rehabilitation, including need diagnosis and demand organization; search of partnerships for intervention and for coping health problems; referral to the reference clinics for specialized treatment when not available in the unit; individual care, at the unit and at home; organization of groups to kinesiotherapy practices/ physical activity; participation in the development and implementation of integrated public policies aimed at improving the quality of life in the planning of urban and rural spaces (20).
There is need for a change in the physical therapist model of work, especially due to the pursuit of strengthening and consolidation of the profession in the FHS team.In this sense, it is necessary the expansion of the social role of the physiotherapist, supported by actions aimed at comprehensive care, resolute care, welcoming and bonding and by the ability of the physical therapist to contribute to the production of health and not only of recovery (21).
Costa et al. (22), in investigating the users' perception about the role of physical therapy in the FHS, observed that from the viewpoint of those subjects, physical therapy promoted positive impacts on health and quality of life of families, especially in home care, an environment in which affection and bonding between professional/patient/family were highlighted.The authors stressed also that the practice of physical therapy must overcome the recovery/care approach, taking into account the principles of the FHS, with actions aimed also to health promotion and disease prevention.This opinion is corroborated by the statements of the participants in this study:

It is a profession in which people recover movements and improve their quality of life (E. S., 27 years old).
In my view, it is a profession aimed at improving the health and movements, taking care of us (M.S., 42 years old).
In this perspective, the change in professional training, with the gradual replacement of recovery/ rehabilitative emphasis by health promotion and disease prevention, is presented as a prerequisite to the implementation of a new working model, in which the physical therapist meets the needs of the current health system, which were established since 2002, with the National Curriculum Guidelines for teaching in health (23,4).
Almost all users considered necessary to include the physical therapist in the FHS team.However, according to respondents, this inclusion would be justified because it would facilitate access to rehabilitation care and would diversify the professionals working in the FHS, as we can see in the following analytical categories discussed.

Facilitating the users access to physical therapy services
When asked about the insertion of the physiotherapist in the FHS, users considered it necessary.However, respondents indicated that this inclusion would improve their access to physical therapy services within the tertiary care, since the displacement, as well as financial and physical conditions are the main hindering factors to such access.The statements below show this perception: Because many people can't move around, because of their illness, they are already worn, so it is difficult even to go to the center to seek care in clinics (L.K., 60 years old).Then we wouldn't need to go there to receive care, the access would be easier if it was here, at the health center (M.G. M., 38 years old).Many people cannot afford treatment and if it was close to home for those in need, it would help a lot (A.K. N., 41 years old).
Most respondents have an income between one and three minimum wages, as mentioned and, in these cases, they have pointed out that when appointed for rehabilitation treatment by SUS, they need to travel by bus to the city center, which impairs the rehabilitation process.In this sense, the group of users interviewed believed that there should be a physical therapy sector inside the health unit.With the implementation of the NASFs in the city, we believed that there may be changes in this perception.
A study revealed that the home care performed by physical therapists was considered by users and caregivers as a guarantee of access to physical therapy for those who are unable to move around (24).
Another important element to highlight is that the neighborhood in which the study was conducted.It has large agricultural industries in the food sector of animal origin, and most of the residents of this neighborhood work in these companies performing repetitive movements, which generates a risk for the development of musculoskeletal disorders related to work and, consequently, an increased demand for rehabilitation.It is known that the increased demand for physical therapy services comes from the need for functional rehabilitation (25).Furthermore, the physical therapist is perceived by users and even by health team members as responsible for the rehabilitation and treatment of people with musculoskeletal injuries and disabilities (26).
These factors seem to contribute to the users' view that the physical therapist's work in the FHS is based in rehabilitation, since they mention that improving access to physical therapy would benefit people who have difficulty with mobility, with sequelae of diseases already present in individuals.The unmet demand for rehabilitation care needs attention, which influences the look that users have on the need for physical therapist inclusion in the FHS.
As stated by Bispo-Junior (4), the great need of rehabilitation practices in primary care is also considered a limitation for the development of preventive actions or health promotion, since, the insertion of the professional in the team is mostly organized only from rehabilitation demands present in the territory.
Since it is a relatively recent possibility, the physical therapy performance in primary care faces some difficulties in adapting to the promotion of health.Some research related to physical therapy in primary care have shown that its activity has been restricted to rehabilitation, either due to the great demand of this practice, or due to the small number of physical therapists working in family health or even by the fact that the educational and preventive practices still are not effectively taken as priority (5, 6).
Moreover, Costa et al. (22) reported that the FHS users served in the household by physical therapists highlighted the importance of this home care, since it ensures access to physical therapy treatment for poor people and to those having transport difficulties, thus improving the quality of life of the family group.However, the authors point out that the role of the physical therapist in the family health should not be limited only to curative care, but it should aim to share the FHS and SUS objectives in the pursuit of comprehensive care.
The area of physical therapy has been involved in discussions around the challenges imposed by the organization of health systems, but there is a pressing need for re-signification of physical therapy's intervention object, in a view to approach the field of public health as a basis for reorientation of the focus of care, practice and training.

Improving comprehensive care in the FHS
Under the user's view, the participation of physical therapy in the health team would be important for the comprehensive care, as evidenced in the featured testimonials: Because all professionals who care for our health should be at the health unit, including physical therapy (R. H., 42 years old).It is very important to have the physical therapist in our health unit, because the same way there are doctors and nurses, there should also be physical therapists to take care of our health (N.S., 25 years old).
The users' testimonials show the need for the physical therapist to participate in the development of comprehensive health care.On that point, Formiga and Ribeiro (7) emphasize that the FHS, with the enhancement of assistance provided to families, enabled teams to identify new health needs, giving rise to other demands on care and, thus demonstrating the need of including other professional categories in order to ensure the comprehensiveness of health care.
The primary health care is characterized by a set of health actions covering the promotion and health protection, disease prevention, diagnosis, treatment, rehabilitation, reduction of injuries and health maintenance in order to develop a comprehensive care that improve health status and autonomy of individuals and the determinants of health and health conditions of communities.Thus, to ensure the expansion of the range and scope of the primary health care actions, comprehensiveness and resolute assistance, the presence of different professionals, with a high degree of articulation between them, is essential for the treatment, rehabilitation and management of various care technologies that promote the autonomy of users and communities.However, health actions should be shared in an interdisciplinary process, thus increasing the capacity of health care of the entire team for the management of comprehensive care to users.
Souza et al. (27) highlight the need for greater presence of the physical therapist in primary care for the development of therapeutic projects, providing a comprehensive and effective care.Therefore, according to the authors, it is necessary to discuss the current public policies and to increase the knowledge of users and FHS professionals about the practice of physical therapy.Whereas the FHS requires a multidisciplinary work (2), the inclusion of physical therapy in this scenario needs to be accomplished from a performance integrated with the team, through health promotion activities and disease prevention, based in interdisciplinarity (28).
Thus, besides inserting the physical therapist in the family health teams, it is necessary that this integration occurs through intersection, both of activities, as between professionals, aiming at a comprehensive health practice (29).In this sense, it is crucial the reorientation of training models, ensuring the inclusion of content and practices linked to the FHS, focused on teamwork.
It is noteworthy, in this logic, the observation made by Formiga and Ribeiro (7) when they mentioned that the role of the physical therapist in primary care is a building process, therefore some difficulties still need to be faced.For these authors, the academic training of the physical therapist needs to be directed to primary health care, because "some specific of physical therapists or multidisciplinary assignments proposed by NASF still are not being developed within the training" (7, p. 121).In addition, the authors highlight the importance of continuous training for professionals of the family health teams and of NASF, as well as of the awareness of users as the purpose of the physical therapist's role in primary care.

Final considerations
From the listening and reflection process undertaken in this study, it is noted that users realize that the insertion of the physical therapist in the FHS is required, though their view reveals an understanding of the profession essentially linked to rehabilitation and therefore to the disease context.We proposed that this perception stems from a training model that is still traditional and fragmented, disconnected from the proposed multidisciplinary and interdisciplinary approach, guided by the principle of comprehensive care in order to promote health.
From the analysis of the research findings, it is inferred that users, despite recognizing the relevance of the physical therapist in primary care, expressed, repeatedly, an expectation of therapeutic care in relation to it.This expectation is probably influenced by the perceptions and by the concrete practices of family health teams and physical therapists themselves.It is also considered that the hegemonic model of training still has been characterized by traditional pedagogical projects, based on fragile curricular approach with collective health and incipient integration of students in the SUS.
We emphasize that these aspects are important challenges to be overcome so that the stigma of rehabilitation professional is not perpetuated as the essence of the profession.In this sense, we highlight the relevance of the various arrangements of reorientation of professional training developed by the Ministries of Health and of Education and that are inciting different initiatives, which can constitute the core of significant changes in the training and, consequently, in the care model.
It is stood out, from this perspective, the importance of a continuation of the studies to further investigate this debate, widening the discussion on the role of physical therapy in the FHS.