Tuberculosis control from the perspective of health professionals working in street clinics

ABSTRACT Purpose: to present the opinion of professionals about street dwellers undergoing treatment of tuberculosis and identify strategies of control of tuberculosis in this population. Method: an exploratory and descriptive study involving 17 health professionals working in street clinics. A semi-structured study composed of closed questions and a guiding question. The statements were analyzed using the discourse analysis technique, resulting in the identification of two analytical categories: 1. Meanings attributed to street dwellers with tuberculosis, and 2. Control of tuberculosis in homeless people. Results: the analysis identified situations that limited adherence to tuberculosis treatment, including the reasons for staying in the streets, living conditions, and risk factors (dependence on alcohol and other drugs, short-sightedness, constant relocations, and lack of perspectives). Street dwellers were knowledgeable about the disease. Furthermore, there were difficulties in solving several problems of people living in the streets, including living conditions and lifestyle, social stigma, relocations, drug abuse, and lack of life project. Conclusion: coping with the complexity of situations related to living in the streets limits to the work of health professionals because these situations go beyond health care and require intersectoral actions.


Introduction
Street people belong to a social group that makes temporary or permanent use of public places as living spaces. These people are socially excluded, cannot satisfy basic needs, and live in the line of indigence or absolute poverty (1) . In 2015, 15,905 people were in a street situation in the city of São Paulo, of which 82% were men, 51.9% were aged 18 to 49 years, and 24.4% were older than 50 years. Approximately 50% of this population (7,335) lived exclusively on the streets, primarily downtown, and the remaining population lived on the streets but slept in shelters (2) .
The living conditions and social exclusion of this group increase its vulnerability, especially regarding the health-disease process. For this reason, in 2011, the Ministry of Health defined guidelines for the organization, operation, and training of street clinic teams to thoroughly meet the unique needs of this population (3) .
Street people are more vulnerable to tuberculosis (TB) because of social and health conditions, and the risk of illness in this population is 48 to 67 times higher than that in the general population. Nutritional deficiencies, use of alcohol and other drugs, sleep deprivation, lack of safety, HIV infection, old age, and limited access to health care impair immune function and increase the likelihood of developing TB (4)(5) .
The rate of TB in this group, corresponding to 2,445.8 cases per 100,000 inhabitants in the city of São Paulo in 2015, is approximately 48 times higher than that in the general population (51.1 cases per 100,000 inhabitants)*. As a neglected disease with limited social visibility, TB represents an aggravation of the health-disease process. Therefore, the control of TB in this social group is challenging because of their living conditions and lifestyle. Studies on TB in homeless people evaluated adherence to treatment (6) , outbreaks and risks (7)(8)(9)(10)(11) , and care actions (5) .
In view of the specificities and challenges for controlling TB in street dwellers, the objective of this study is to present the opinions of health professionals about homeless people undergoing TB treatment and identify strategies for disease control in this group.

Results
Most interviewed professionals were women (n = 14), aged 30-39 years (n = 7), 50-59 years (n = 7), or >60 years (n = 3). Eight professionals were single, six were married, and three were divorced. The educational level included complete higher education (n = 6), www.eerp.usp.br/rlae  Establishing a bond with street dwellers with TB is essential for treatment. In general, the indigents were resistant to interaction on the first contact; however, over time, they accepted the approach of the professionals and began to interact: It is not from one day to the other, we gain space gradually. In the first day, you go by and say 'Good

Discussion
The speeches of the interviewed professionals revealed some characteristics of street dwellers, including the abuse of alcohol and other drugs, constant relocations, short-sightedness, and lack of self-esteem, and these characteristics compromise health care and adherence to treatment of TB. Similar reasons were found in studies conducted in other regions (5,(13)(14) .
These Health care is usually of minor concern for homeless people because survival is a primary necessity as a result of the lack of resources for treatment and continuous exposure to violence (17) . In addition, the indicated that they significantly helped increase access to health services, early diagnosis and treatment, and follow-up until a cure was achieved (5) .
Teamwork is fundamental in health care because of the singularities and complexities of street dwellers, evidencing that the articulation between different areas of knowledge, care practices, and subjects results in the development of interventions appropriate to the needs of this group (19) . The care model used in street clinics increased the access to health care and allowed adequate and personalized care to socially marginalized people, who recognized this modality as a reference health service (20) .
In addition, the characteristics and behavior of street people make them susceptible to social stigma to health services for supervised treatment or medical consultation (24) . health services is not enough to guarantee adherence to treatment. The factors considered essential were the understanding of the health-disease process as a social phenomenon, acknowledgment of the health needs in coping with TB with a focus on patient acceptance, and the responsibility of health professionals in caring for this social group.
The health condition of this population is a cause for concern and a significant challenge in view of the scope, increase in the rate of morbidities, and high number of adversities, which requires the promotion of intersectoral actions because this problem involves political, economic, cultural, and social factors (25) . In this respect, the Theory of Social Determination of the Health-Disease Process has significantly contributed to understand and treat TB in street dwellers because it is necessary to abandon the health care models that disregard this process as a social phenomenon and do not correlate their occurrence with social factors.
The limitations of the present study were the collection of data in only one PHCU, which limited the sample size. In addition, the activities that targeted this population are only part of the work carried out by the street clinics of São Paulo.

Conclusion
According to the opinions of the interviewed professionals, health care for homeless people is a socially relevant issue because their living conditions, marked by many adversities, including risk factors and limitations in access to health services and treatment, making them more vulnerable to illness, discontinuation of treatment, and death from TB. Therefore, the actions of health professionals trained to meet the needs of this group may help control the disease. However, TB in this group is a health problem and a challenge for health managers and professionals and consequently needs to be addressed appropriately to subsidize the formulation, implementation, and use of health technologies consistent with the reality of street people.
Therefore, the findings of this study should raise awareness about this mode of care with a focus on TB.
It is important to highlight the contribution of the study to the professional practice of nurses, expanding their field of practice, and considering that these professionals improve the health care to people living in the streets.
For this purpose, it is necessary to increase awareness about this topic and invest in training professionals capable of dealing with a complex reality involving biopsychosocial and spiritual factors associated with the condition of living in the streets.