Social representations of the health care of the Mbyá-Guarani indigenous population by health workers 1

ABSTRACT Objective: to analyze the social representations of health care of the Mbyá-Guarani ethnic group by multidisciplinary teams from the Special Indigenous Health District in the south coast of Rio Grande do Sul state (Distrito Sanitário Especial Indígena Litoral Sul do Rio Grande do Sul), Brazil. Method: a qualitative method based on the theory of social representations was used. Data were collected via semi-structured interviews with 20 health workers and by participant observation. The interviews were analyzed with ALCESTE software, which conducts a lexical content analysis using quantitative techniques for the treatment of textual data. Results: there were disagreements in the health care concepts and practices between traditional medicine and biomedicine; however, some progress has been achieved in the area of intermedicality. The ethnic boundaries established between health workers and indigenous peoples based on their representations of culture and family, together with the lack of infrastructure and organization of health actions, are perceived as factors that hinder health care in an intercultural context. Conclusion: a new basis for the process of indigenous health care needs to be established by understanding the needs identified and by agreement among individuals, groups, and health professionals via intercultural exchange.

Indigenous health care for the different ethnic groups that compose the indigenous health care subsystem has been characterized by therapeutic plurality, which is the simultaneous use of several health practices, and this is supported by the health professionals (2) . Indigenous people involved in health care services have several designations, including pajes, healers, shamans, chanters, kuiãs, and karaís.
These leaders often have political and religious duties.
The health care they provide involves various practices, including the use of medicinal plants and various healing rituals that reflect the health concepts associated with complex systems that are configured in the polysemic concept known as traditional indigenous medicine (3) .
Since 2002, the World Health Organization (WHO) has encouraged countries to incorporate traditional medicine (TM), particularly in primary care, to increase the access of health agents to populations with cultural differences (3)(4) . TM involves several social care systems within the field of medicine; in the broad sense, these health practices are established holistically as socially coordinated responses to human diseases (3,5) . For these reasons, the comprehensiveness of care of indigenous populations involves a dimension of interculturalism that brings with it the idea of cultural diversity and the relationships between different cultures or, more specifically, between individuals belonging to different cultures (6) .
Despite the normative advances of the NPHCIP, in practice it has not yet been possible to consolidate the strategies that value the diversity of opinions and health care systems by addressing ethnic and cultural issues (7) . Above all, it is recognized that the implementation of the principles of differentiated care, which are clearly defined in official documents, requires that multidisciplinary teams understand the lifestyle of indigenous peoples, their social organization, representations of the health-disease process, and cultural specificities, among other factors (8) . Furthermore, it is known that health care services still ignore social involvement, thereby limiting the opportunity for dialogue between Western medical practice and traditional medicine; the latter could contribute to the development of a local health system adequate to the reality of indigenous peoples (8)(9) .
The unpreparedness of managers who establish these policies and health professionals who carry them out to address indigenous issues in the perspective of interculturalism is evident (10)(11)(12) . One www.eerp.usp.br/rlae 3 Falkenberg MB, Shimizu HE, Bermudez XPD.
reason for this is that the university model, which is intended to train professionals in the biomedical and medicalized model, is considered hegemonic, superior, and irreplaceable (13)(14) .
This study addresses various concepts of health,  (15)(16) . They are always a result of interactions and information exchange and assume specific shapes and configurations as a result of the specific balance between processes of social influence. Social representations are intended to make something unfamiliar into something familiar and are characterized by a constructive process of anchoring and objectification (15) . Anchoring corresponds to the incorporation of new elements of an object into a system of categories that are familiar and functional to individuals, and objectification aims to make concrete what is abstract, i.e., to transform a concept into an image of something, removing it from its scientific conceptual framework (15) . produced within a given context (12) .

Results
The   The first axis, which includes categories 1 and 3,    The contents of the statements above indicate the significant inconsistencies between the ideal service organization models established by the creation of the subsystem and the implementation of NPHCIP and the actual models adopted in everyday work. All subsystems that circulate and intertwine in a complex cultural system, including traditional medical systems, are related to a world view, as observed in this study, and to a corresponding ethos of its people (17) . In this sense, the world view is a cognitive and existential attribute that allows certain people to develop a representation of a simple reality, including its concept of nature, self, and society. The ethos is a moral and aesthetic attribute that reflects the nature and quality of life of a people, and its organization is the underlying attitude towards itself and its world reflected by life (17) .

Discussion
Another objectification identified in the formation of social representations of traditional medicine was religion. Geertz (17)  to the detriment of indigenous knowledge, which is often considered to consist of ineffective beliefs (18) . This contrast causes tension among health workers because they feel guilty for interfering in this world but also gratified for helping those in need. The attempt to find a balance is ongoing, with most workers striving not to interfere too much but obliged to fulfill their duties as biomedicine workers.
In this perspective, each of these two medical systems, traditional medicine and biomedicine, is part of a specific cultural dimension that coexists within the Mbyá world, leading to a relationship that triggers the formation and sharing of social representations of care among IHMT workers and to a consensual, confined, and redefined world of health care (15) .
We also found that the coexistence of these two medical systems has prompted the health teams to work cooperatively over time to seek solutions to practical daily issues. This cooperation, known as intermedicality, aims to facilitate the interaction between knowledge based on biomedicine and nonmedical knowledge (2) . These cultural competencies are required by workers to minimize the conflicts between different cultures (13) . which creates poor living conditions as well as limited access to land, drinking water, electricity, and health (19) .
These problems are due to increasing aggression from interethnic contact, designated interethnic friction; such aggression has resulted in the elimination or reduction of indigenous lands and slowness in their demarcation.
Furthermore, this condition has caused families to lose their traditional habits (19) , particularly those concerning diet, and to consume industrialized products that are available due to external influences.