Medical training and nurses of Family Health strategy on worker health aspect

Considering the worker’s health one of the Unified Health System (SUS) tasks, the Primary Health Care (PHC) and the Family Health Strategy (FHS) play an important role in the development of health actions in the field health-work. In Brazil, where the number of informal and domiciled jobs is high, the FHS becomes a reference in the workers’ health actions. Therefore, if the FHS is not attentive to the relation between professional occupation and disease, several diseases that affect workers can overload the system without obtaining a cure. The aim of this study is to evaluate doctors and nurses recognition of the Family Health Strategy on occupational diseases in Aparecida de Goiânia. This is a qualitative descriptive study and the data analysis was done by content analysis. The setting for this study contemplates FHS units in the municipality of Aparecida de Goiânia, Goiás. There were 8 Basic Health Units and 16 health professionals were interviewed. The data was collected in the participants of the interview workplaces, from February through April, 2013, after being approved by the Ethics and Research Committee. The discourses were analyzed according to Minayo (2007), using thematic analysis. The interviews were recorded and later transcribed for analysis. Among the 16 professionals interviewed we observed that only 3 (18.75%) received professional training on occupational health in their Institution, however the aim of the courses were towards situations of biological hazards and not about workers care. Practitioners reported lack of knowledge in the occupational health area, and also observed that the area is still undervalued and underexplored in the academic and professional fields, and even by the Municipality health management. Evaluating the academic education it is possible to observe the inadequacy of the subject workload, where professionals reported the lack of knowledge in the area and the low workload of the subject in the academic field. Conclusion: There is a need to raise awareness and interest of the municipality health managers and the health professionals, doctors and nurses, towards the relations work-health-disease and the need to capacitate these professionals, in order to assist the workers in a better way.


INTRODUCTION
The Family Health Strategy (FHS) emerges as a proposal of the Brazilian Ministry of Health seeking to restructure primary care focused on the family, within their physical and social environment.Among the basic tasks of the physician and the nurse, we may cite: to provide comprehensive care to individuals; to perform basic actions of epidemiological and health surveillance; to perform practical activities in the areas of children, adolescent, women, worker, adult and the elderly care (1,2) Thus, the Primary Health Care (PHC) and the FHS are seen as organizing axes and system gateway, assuming an important role in the development of actions in the health/work area.However, more than 20 years of the Unified Health System (SUS) still report difficulties in making health-work-environment actions part of the routine of Primary Health Care services (1,3) .
Thus, the need for the Brazilian Ministry of Health to seek the help of educational institutions emerges, in order to define the most adequate professional profile for their needs.This need has been reinforced by demand, by SUS, by professionals trained to plan health care and surveillance activities at workplace, at all levels of care (4) Especially in Brazil, where there are large numbers of informal and home workers, the FHS becomes a reference in occupational health actions.Thus, if the FHS is not attentive to the relationship between professional activity and illness, several diseases that affect workers can overload the system without healing (5) .
Although Primary Care is considered priority for workers' health actions in SUS, we still lack policy implementation and adequate training of health professionals with knowledge and tools necessary for the development of these actions (4) In this context, we proposed this study, which aims to investigate the knowledge of physicians and nurses from the FHS of Aparecida de Goiania-GO about occupational diseases and academic training on the topic, highlighting the perception of professionals about the care provided to FHS workers, and the difficulties and limitations found to perform activities in this area.

METHOD
This is a descriptive and exploratory qualitative study conducted in FHS units in the city of Aparecida de Goiania -GO, which assessed 16 professionals with university degree, eight physicians and eight nurses.The collection of research information was carried out through semi-structured interviews in their workplaces from February to April 2013, after Research Ethics Committee approval, protocol #186/12 according to Resolution 466/12 of the National Health Council. (6)he guiding questions of this study were: "What are the health disorders related to FHS worker's activities?"; "Do these professionals understand the importance of reporting patient occupational activity on their chart?";"Is there some kind of training within the institution that deals with this area of knowledge?".
The interview of participants was conditional by signing the Consent Form (CF), authorizing data collection and their use.Data were analyzed through content analysis, in the thematic analysis (7) .A total of five thematic categories were developed, which facilitate the understanding and interpretation of interviews: professional experience; use of occupational information; knowledge about occupational diseases; and professional training in the workers' health area.
The coding of the interviews was done through the application of qualitative data analysis, Atlas Ti (Analysis of Qualitative Data), in order to allow the analysis and presentation of results, enabling the construction of semantic networks.Semantic networks comprise the categories constructed by the participants' statements and the threads that emerged from this analysis (8) The information provided by participants is confidential and the names of those interviewed are kept confidential.They were identified as follows: N1, N2, N3 and so on.The data have academic and publishing purpose.

RESULTS
The study included 16 FHS professionals, eight physicians and eight nurses.The work experience of these professionals in the FHS was about two years (minimum of one month and a maximum of nine years).From the professionals interviewed, three (18.75%)underwent professional training in occupational health within their working institution, the remaining 81.25% (13) have not undergone training in this area.We also observed the time of academic training of these professionals, ranging from six months to 30 years.
From the discourses, five thematic categories were organized, which facilitated the understanding and interpretation of interviews: professional experience; use of occupational information; knowledge about occupational diseases; and professional training in the workers' health area.
The category most frequently cited by participants was "professional experience to workers' health", the sense measured from the participants' statements from this category highlighted the FHS experience of the healthcare professional caring for workers.
According to participants' statements, there was inexperience in the WH area and even in public health, some participants reported the lack of activities aimed at this audience inside the units and also show the difficulty in understanding the patient as worker and understand the influence of work on their health, as it can be seen from the interview segment below: (I have little experience, since I work in the screening to develop the programs, so I just have little contact with these complaints, then directly with the patient, with the worker, it is little, because we do not associate, because most of the population who we care for have a job [...] (N8)).
Box 1 shows schematically the aforementioned situations and illustrate the participants' perceptions: The measured direction of the interviewees' statements on the category "practical action" revealed the perception of professionals about the care provided to the worker.It is observed by the statements that some participants understand the worker as being the FHS worker.Those who recognize the individual as a worker, believe they are involved in the formal sector of the economy: in companies, factories and industries, missing thus the unemployed, selfemployed and the informal workers.And yet, they often stated about the difficulty and lack of training to meet the workers' need.

([...] I think we should have a training course to empower us to open our eyes so that we may be these professionals in the family health strategy [...] (N8)).
The category "use of occupational information" pointed through the statements of the participants regarding the practice of occupational history, where participants demonstrated a degree of procedural knowledge in diagnosis performance seeking patient work information during the anamnesis.

([...] So, I think it's very important we always do this association. Just as important as it is family history, occupational history is also an important part of life. Most of the time he/she is at work right, not at home. So, to associate the two, I think to close a diagnosis… it is very important [...] (N7)).
Only two participants said they did not often ask about the occupation of the patient, but recognize the importance of this data to guide and direct the patient.
Box 2 shows the aforementioned situations and feelings raised by the participants when talked about the "Care for the worker" and "use of occupational information".The direction measured by the interviewees' statements on the category "Knowledge of occupational diseases", revealed the understanding of professionals on occupational diseases.However, it is observed that even after statements on the importance of professional activity in the patient's health, these do not know how to conceptualize occupational diseases and many associate this difficulty by deficits in professional training.

([...] I think we would have to have more time for us to study about it and be able to associate some diseases that we treat as non-occupational that usually are [...] (N13)).
The category "Professional training on Worker's Health area" revealed in the statements of participants to the training as physician and nurse, if during the academic period there was contact with worker's health and how the workload is distributed.The observed reports revealed hours available for the topic and how the WH area is still undervalued and unexplored by the academic and professional area.

(I think it's a very little explored area and people have a lot of prejudice [...] So I did not like it, but that is an area that has grown but is still very undervalued. Both by patients and by own medical professionals from our area [...] (N7)).
Some "natural categories" were highlighted during the interview, often appearing in the discourse of participants.These categories were not covered previously by the proposed theoretical framework, but they have become important for understanding the answers listed by participants.These categories are: difficulties and professional training.
The category "difficulty and limitations of WH in the FHS" revealed through the discourses, the lack of public awareness, which seeks for care when they have some kind of injury, lack of knowledge in the WH area by professionals, as well as lack of reference to the worker and ignorance on the part of the professionals' flow from the municipality.
The category "professional training" presents the need for these professionals to deepen more in the health/work area, understanding the influence of work on the health of the individual.The professionals recognize the need to seek specific knowledge and suggest courses in this area.
Using the software Atlas IT, a diagram can be produced, representing a semantic network formed from the category "Knowledge of occupational diseases" in the interviews, this figure shows two central semantic units: difficulty and practice of care.The sentence "associated with" used by the software indicates close association between the categories.So if the software finds it in every interview, there are close association between categories, it will show association due to the proximity that were found.
We highlight that the category "difficulty" is associated with the categories of knowledge of diseases and professional training, this means that there is a close relationship between the categories in the participants' answers.That is, whenever the interviewees were about difficulties, they showed some knowledge of occupational diseases and mentioned the need for professional training and professional experience they have accumulated or they needed.The segments of the interviews below exemplify this: (So, here in the unit we are not prepared to provide care related to work or occupation.The girls do not even know, they come ask me, all [...] I think we, the health team (FHS) should look closely at it, which I think is a problem that we have had a lot and that is unresolved and the patient cannot be followed up, cannot return to close a diagnosis [...] (N7)).
(I guess I needed a course, an update on that, we could help many people.There are some specific diseases that we could focus more and decisions that would help many people [...] (N5)).
Similarly, what happened to the category "practice of care" being related again by professionals to the need for professional training and professional experience, demonstrating the lack of experience in the practice of worker care.So when the interviewee mentioned his/her practice of care referred to the accumulated experience in their life histories demonstrating little contact with occupational di-seases, reflecting on the need for training in this area.
The participants made some suggestions for the implementation of actions for workers in the Basic Health Units (BHU), demonstrating the concern to improve care, showing the need of professional qualification.Other suggestions were included as: improving approach and hours of academic discipline, awakening the interest of the city management and health professionals to the experience of the health-work area.

DISCUSSION
Despite the length of FHS professionals training, they have difficulties in recognizing occupational diseases.Some authors have reported about the difficulty faced by the PHC professionals, which can lead to functional disabilities and overwhelm the health care system.In a study conducted in Spain, the authors reported that 83% of occupational diseases are not recognized in official records and also claim that if health PHC professionals do not recognize and do not treat the diseases resulted from work, these will not improve and may progress to disability and functional limitations. (9)In another study conducted in Spain in 2008, it was found that the occupational diseases with higher incidence and prevalence are also the issues most attended by the family doctor, who would correspond to professionals working in PHC in Brazil.Also, the information on occupational diseases are precarious and despite being known national and internationally, this reality affects several other countries and are still poorly known.
In the UK, for example, one study has shown the importance of professional training in health and work areas for professionals of PHC, improving recognition ability of some occupational diseases and therefore, treating them properly, not allowing the aggravation of the problem. (10)n Brazil, it was found that PHC professionals of João Pessoa (PB) had difficulties to notify occupational accidents (OA) and occupational diseases, the study shows that these professionals know the importance of reporting the accident, but many do not know the flow of care to the city workers, reflecting the difficulty for the implementation of occupational health policy. (11)

(I think I need training. An update on this topic. We could help many people. There are some specific diseases that could be more focused and our performance would help many people [...] (N5)).
With this difficulty to notify occupational accidents, there is an increase of underreporting of cases of OA and occupational diseases may lead to a distancing from reality, hindering the development of preventive strategies, assistance and resource management.Thus, the assistance provided by the PHC need more direction, reinforcing the need for occupational health training programs, not only for the best care of the worker, but for identification, intervention and prevention of work--related diseases. (5,12,13)ome authors relate this ability in identifying and reporting occupational diseases to academic training.In or-der for PHC professionals to be able to address problems related to occupational health, they must have more training in occupational health area, which would help in their professional activity.A Spanish study reports the importance of acquiring this knowledge in undergraduate studies and extended for graduate and professional training courses. (9)s for the academic experience, most professionals reported no familiarity with this knowledge area during their training and lack of experience to care for the worker patient.The undergraduate medical course should provide minimum competencies for professional understand the relationship between work and health of workers. (4)In another study assessing the design of nursing students on workers' health, the students stressed the importance of health education, accident prevention, direct assistance, the formation of support groups as predominant nursing activities. (14)he distance of health professionals about health and work issues are often one of the factors hindering the development of WH action. (15)It was shown in a study that practical knowledge in WH increases the confidence of the generalist professional, being important to awaken the search for knowledge and training for these professionals. (16)This need for training and continuing education in WH becomes more evident when the professionals recognize that they perform some orientations, but that they could be more qualified, bringing greater benefit to the population. (15)

(I think we do not have, we realize we don't have appropriate training. We know many things, the orientations that we give when it comes to a patient with this complaint, it is very generalist, I think we should have a more specif ic knowledge, as you asked me that question today, I think we should have a course to empower us to open our eyes for us to receive more training [...] I think we're falling short in this side [...] in reality we do not know what are our rights. We lack of it in our training, lack this in our day-to-day. we search many things to know, because we are workers, we also should know our rights and we just do not know so much and do not know to inform them. I think it's a failure on our part because we don't go after it, and on the part of the management for not offering this training [...] (N8)).
The National Policy of Permanent Education (PNEP) defines that the training of professionals should be based on the need for health services, through a strategic analysis and the study of the local determinants of each region. (17)However, some participants said that the skills that have been made in the city were in accordance with the Notebook 5, part of the Primary Care notebooks and folders assigned by the Worker's Health Reference Center (CEREST) connected to the Municipal Health Department of Goiania.
In addition to the academic experience, the training activities and continuing education, we observe the perception of professionals about the care provided to the worker and while acknowledging the importance of developing occupational health actions in the unit, they showed difficulties to perform it due to lack work experience, the difficulty of understanding the role that work plays in the health of the individual and the difficulty of relating to patients' complaints with occupational activity.Some participants reported they made no questions about the profession of the patient, which can sometimes hinder proper assistance with directions and treatment, preventing future sequels and functional limitations.
A study conducted at the UFMG1 reports the positive aspect of the application of occupational health in the medical area, but stated that many students finish the course without mastering basic knowledge to everyday practice.They also pointed to the awakening of the student as a health worker during the discipline, before taking the class, only 66.36% saw themselves as workers and after its end, 79.72% of students have considered themselves as workers. (4)n the UK, it was found the perception of physicians, nurses and health managers of the PHC about the conduction of occupational health actions, which identified deficiencies in training and the lack of training of these professionals, who reported they were not prepared to deal with issues relating to occupational health, the results of this study demonstrated the need to invest in continuing education in this area. (18)rom this study we observed that the worker's health actions are part of the needs arising from professional practice in primary care and that PHC professionals need training that encompass the reality of population.

CONCLUSION
This study demonstrates different perceptions of health professionals in the Workers' Health area and emerging issues about the lack of professional experience on the practice of care and academic experience by these professionals related to the health/work areas.
We observed that professionals realize the importance of actions aimed at assisting the worker, but they do not have academic and or professional experience to understand the influence of work on patient's health, making their interventions difficult.Thus, we observed the need to start discussions related to health/work areas, not only in specialization courses, but mainly in undergraduate courses.Also, the need for continuing education in order to address our population's reality, improving the care provided to workers.

Box 2 -
Perceptions reported by health professionals of the Family Health Strategy (2013.1)about the worker primary care and feelings aroused in these circumstances:

Figure 1 -
Figure 1 -Semantic representation of relations of the Knowledge category of occupational diseases.