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Health necessities in primary attention: the perception of professionals acting in permanent education

Abstracts

OBJECTIVE: To know the concept of necessities in health, according to the perception of the mentors who integrate a team of Permanent Education in Primary Attention of Health, in a social organization. METHODS: It was used the semi-structured interview with five mentors linked to the constant Education of that Institution; the findings were categorized and analyzed according to the Taxonomy of Health Necessities, using the Social Determination Theory of the Health-Disease Process. The five mentors of the team of preceptors of a social organization in the Sao Paulo's Eastern zone participated of the inquiry. RESULTS: The participants examined the four categories proposed by the taxonomy, besides analyzing the identification of the necessities and its fulfillment. CONCLUSION: The professionals think that the populations' health necessities are not attended due to: 1) life conditions, 2) public policies, and 3) mentors' world vision.

Health services needs and demand; Primary health care; Education; Continuing


OBJETIVO: Conhecer o conceito de necessidades em saúde, segundo a percepção dos preceptores que integram uma equipe de Educação Permanente na Atenção Primária em Saúde de uma organização social. MÉTODOS: Utilizou-se entrevista semiestruturada com cinco preceptores vinculados à Educação permanente dessa Instituiçao e os achados foram categorizados e analisados, conforme a Taxonomia de Necessidades de Saúde e a luz da Teoria da Determinação Social do Processo Saúde-Doença. Os cinco profissionais da equipe de preceptoria de uma organização social da zona Leste paulistana participaram da pesquisa. RESULTADOS: Os participantes abordaram as quatro categorias propostas pela taxonomia, além de discorrerem sobre a identificação das necessidades e sua satisfação. CONCLUSÃO: Os profissionais acreditam que as necessidades de saúde da população não são atendidas em razão de questões relacionadas às condições de vida, políticas públicas e visão de mundo dos profissionais.

Necessidades e demandas de serviços de saúde; Atenção primária à saúde; Educação Continuada


OBJETIVO: Conocer el concepto de necesidades de la salud, según la percepción de los instructores que integran un equipo de Educación Permanente en la Atención Primaria de la Salud de una organización social. MÉTODOS: Se utilizó la entrevista semiestructurada con cinco instructores vinculados a la Educación permanente de esa Institución; lo encontrado fue categorizado y analizado, conforme la Taxonomía de Necesidades de la Salud utilizando la Teoría de la Determinación Social del Proceso Salud-Enfermedad. Los cinco profesionales del equipo de instructores de una organización social de la zona Leste paulistana participaron de la investigación. RESULTADOS: Los participantes examinaron las cuatro categorías propuestas por la taxonomía, además de analizar la identificación de las necesidades y su satisfacción. CONCLUSIÓN: Los profesionales piensan que las necesidades de la salud de la población no son atendidas debido a cuestiones relacionadas a: 1) condiciones de vida, 2) políticas públicas, y 3) visión de mundo de los profesionales.

Necesidades y demandas de servicios de salud; Atención primaria de salud; Educación Continua


ORIGINAL ARTICLE

Health necessities in primary attention: the perception of professionals acting in permanent education*

Necesidades de salud en la atención primaria: percepción de profesionales que actúan en la educación permanente

Patricia Tavares dos SantosI; Maria Rita BertolozziII; Paula HinoIII

INursing Tutor in Adult Health in Santa Marcelina Primary Health Care - São Paulo (SP), Brazil

IIFull professor at the Collective Health Nusing Department, Escola de Enfermagem da Universidade de São Paulo - USP - São Paulo (SP), Brazil

IIIPost-doctoral student, Escola de Enfermagem da Universidade de São Paulo - USP - São Paulo (SP), Brazil. Fellowship holder CNPq

Corresponding Author

ABSTRACT

OBJECTIVE: To know the concept of necessities in health, according to the perception of the mentors who integrate a team of Permanent Education in Primary Attention of Health, in a social organization.

METHODS: It was used the semi-structured interview with five mentors linked to the constant Education of that Institution; the findings were categorized and analyzed according to the Taxonomy of Health Necessities, using the Social Determination Theory of the Health-Disease Process. The five mentors of the team of preceptors of a social organization in the Sao Paulo's Eastern zone participated of the inquiry.

RESULTS: The participants examined the four categories proposed by the taxonomy, besides analyzing the identification of the necessities and its fulfillment.

CONCLUSION: The professionals think that the populations' health necessities are not attended due to: 1) life conditions, 2) public policies, and 3) mentors' world vision.

Keywords: Health services needs and demand; Primary health care; Education, Continuing

RESUMEN

OBJETIVO: Conocer el concepto de necesidades de la salud, según la percepción de los instructores que integran un equipo de Educación Permanente en la Atención Primaria de la Salud de una organización social.

MÉTODOS: Se utilizó la entrevista semiestructurada con cinco instructores vinculados a la Educación permanente de esa Institución; lo encontrado fue categorizado y analizado, conforme la Taxonomía de Necesidades de la Salud utilizando la Teoría de la Determinación Social del Proceso Salud-Enfermedad. Los cinco profesionales del equipo de instructores de una organización social de la zona Leste paulistana participaron de la investigación.

RESULTADOS: Los participantes examinaron las cuatro categorías propuestas por la taxonomía, además de analizar la identificación de las necesidades y su satisfacción.

CONCLUSIÓN: Los profesionales piensan que las necesidades de la salud de la población no son atendidas debido a cuestiones relacionadas a: 1) condiciones de vida, 2) políticas públicas, y 3) visión de mundo de los profesionales.

Descriptores: Necesidades y demandas de servicios de salud; Atención primaria de salud; Educación Continua

INTRODUCTION

In the development of their daily practice, health professionals have human care as their main focus. Thus, alternatives for problem solving should be constantly searched for, meeting the health needs presented in different forms that change depending on the social structures, the life styles, the scientific and technological developments, among others.

From this statement, we have used as the study object the category Need based on the theoretical reference of the Social Determination Theory of the Health-Disease Process, which is present in the collective thinking of the different social groups and must encompass the structural processes of the society, the profiles of social reproduction with its corresponding potentialities, wears and the understanding of the biological phenomena that form the health-disease typical standards of these groups and their individuals(1).

Thus, the health needs go beyond the issues related to disease problems and the demand of medical services, encompassing the vulnerabilities that "express modes of life and identities", involving the necessary conditions to be healthy(2).

Although the health-disease process is collective, their manifestations occur in individual bodies, and there should also be an understanding on the health needs(3). These are socially built and determined, however, they can only be "apprehended in their individual dimension, expressing a dialectic relationship between the individual and the society"(4).

Thus, the idea that the needs are individual and isolated is refused, since they emerge to change the harmful processes coming from the relations of social production and reproduction(3). So the needs and their answers can change depending on the historical and social context(5).

Although health needs start in individuals, they may or may not identify and express them in the health service, which, in turn, can decode the need as a demand to be met. However, the actions and practices of the services do not always meet the demands of the users(5).

Listening to the needs of health service users allow professionals to increase their ability to strengthen the interventions regarding the problems brought by the population(6). To that end, they must consider that the work processes should aim to meet the health needs of the social groups from a certain place(7).

Health systems acknowledge and legitimate some health needs above others and this can lead to the creation of new needs. Thus, "we consider as health problems only the needs that reach a certain level of legitimizing, normalization and consensus"(8).

Meeting the needs imply the introduction of work processes that are carried out in the scope of determiners and outcomes(9).

Professionals should be clear about the concept of health needs because they should be part of the universal contract of health workers(10). With this regards, it is believed that public health policies should be made towards the universal right(9).

Conceptualizing, identifying and classifying health needs are very important to give tools to health professionals working in the area of Collective Health to get closer to the phenomenon and to plan their actions to meet the health needs of the population.

Interventions should produce "increasing levels of autonomy in the 'ways they go on with life'" in subjects and in the group. This demands that users trust the services and the health professionals(10).

Health professionals are not always ready to deal with the users' health needs, to promote the autonomy of subjects, showing the importance of spaces for permanent education where they can discuss and deepen their knowledge on the theme to improve care provided.

To make discussions on health needs feasible and to help organize the work process, through the construction of new knowledge, permanent education professionals should embrace the theme.

The Social Organization, setting of this study, uses medical and nursing tutoring as its permanent education strategy. These professionals, connected with Permanent Education have the objective of helping doctors and nurses perfect individual and collective health care through the reflection on their routines, to introduce new practices and to value professionals, offering continuous space for listening and circulating information.

Tutors, because of their role as educators, can promote discussion on the concepts of health needs with the professionals that provide direct care to users to enable changes in health care practices. To that end, it is important to know these professionals' concepts on the theme of health care.

Considering that the options regarding health needs are important to meet the demands of the population with quality and effectiveness, the purpose of the present study is to know the concept of health needs according to the perceptions of tutors that are part of a team of Permanent Education in Primary Health Care of a Social Organization.

METHODS

Qualitative exploratory study. The setting was the Coordination of Primary Health Care of a Social Organization, connected to a philanthropic entity that has been working with primary health care for 13 years with the introduction of the Family Health Strategy (ESF) in the east side of the city of São Paulo. In 2007, the entity signed with the Municipal Health Secretariat the contract to manage Primary Care in a micro region with 15 health units with ESF, 12 units without ESF, and three of them were Outpatient clinics, a center of dental Specialties and an Integrated Center of Rehabilitation.

We chose to carry out the study in this institution because one of the authors of the present article worked there. This made data collection easier, and it also made it possible to deepen the analytical apprehension of the study place.

The subjects of the study were five health professionals, called tutors, that were connected with the Permanent Education of the Institution mentioned.

Semi-structured interviews were carried out as part of the methodology of the study. The first part had identification questions and the second part had the following guiding questions: "What are health needs for you?" and "Do you believe that the health needs of the population are met?" The interviews were recorded and fully transcribed by the researcher.

The instrument had both positive and negative answers. In the first case, we asked study subjects to detail how they considered that needs were met.

The analysis on the perceptions of the health needs was based on the theoretical reference of the Social Determination Theory of the Health-Disease Process and the meanings on the health needs category that were assessed based on Taxonomy proposed by Matsumoto and Cecílio, that organize the needs into four groups(6-11):

- Good conditions of life: these needs can be both related to the "physiological" needs such as food, sanitation, housing, as well as the more "complex" needs such as safety and affection. And they can be interpreted from the perspective of the Natural History of the Disease or by the Social Determination of the Health Disease Process(6).

- Access to the consumption of health technologies that can improve and prolong life: it has to do with the need for access to soft technologies (relational skills), hard-soft (programmed and practical actions) and hard related (equipment, infrastructure). The hierarchical importance of the offer and consumption of these technologies will depend on the real needs of each user(6).

- Creation of affective bonds: the formation of bonds between users and the community, and the team and a professional form this category. Here, bond is understood as "the meeting of subjectivities that are continuous in time, personal and inalienable"(6).

- Increasing levels of autonomy: it refers to subjects' needs to be autonomous, that is, to have the possibility to reconstruct and give a new meaning to the senses of their lives and their form of living, also encompassing the struggle to meet their needs(6).

In addition to the categories proposed by this Taxonomy, another two categories have emerged from the analysis of the statements: the first refers to the forms of identification of the health needs and the second to meeting these needs.

As for the ethical aspects, subjects were invited to take part voluntarily in the study as explained in the Written Consent. The study has been approved by the Research Ethics Committee at Escola de Enfermagem da Universidade de São Paulo (Approval No 783/2008).

RESULTS

All members of the tutoring team took part in the study, with the exception of a member of the team who was the study author, formed by four female individuals and a male individual with mean age of 38 years, ranging from 25 and 56 years, most came from the outskirts of São Paulo, three were single and two were married. Time after under graduation ranged from 4 and 26 years. Complementary education varied: physicians specialized in GP, Gynecology, Obstetrics, and Pediatrics and the nurses in Family Health and Obstetrics. They were all tutors since the center had been established in November 2007, and they were hired according to the Consolidation of Work Laws.

Additionally to the four categories previously mentioned, the following two categories were extracted, based on the speech of the subjects:

Identification of the health needs

The health needs can be seen according to the perception of the user and the health professional. One of the individuals pointed out these two aspects.

"(...) it (the need) can be seen according to two aspects. Yes, one is that of the health professional and the other is that of the community, the individual, people themselves about their own life". E1

According to the individuals, the needs can be identified directly or indirectly, by users themselves, at the time of care, or by observations in the territory.

"When I go to a community or when I visit a home, I identify, looking at the environment they live, (...), in which they are inserted, the family context (...)." E1

Needs for Good conditions of life

Some statements approached the needs, relating them with socioeconomic and cultural conditions.

"To live well regarding family life (...). Social well being, have a complete social life, leisure, work. In this sense(...), social relationship (...), sometimes, alcoholism, so this will somehow influence the treatment of children and their final health". E3

One of the individuals pointed out that the needs should be apprehended beyond the disease, valuing health promotion.

"(...) what are their needs so that health is fostered in their lives; I am not going to focus only in the disease (...)" E1

Another aspect pointed out was the need for an intersection between several social equipment, as well as political will to meet good conditions of life.

"I think the person running the country should give conditions, not to give it as a gift, but give conditions to individuals so that they can develop themselves, they can earn a living, so they can take better care of themselves, that's it". E4

One of the statements highlighted that the aspects related with good living conditions are really important, but it mentioned that alone they are not enough to lead to good health, indicating the intersection with other needs.

"(...) even those patients with a better social level, you will find those that are not living well regarding their diet, leisure, type of leisure, I think that's it". E3

Need to have access to all health care technologies that can improve or prolong life

As for soft technologies, interviewees pointed out the communication between professionals and users.

"The provider could not refer properly, he said (...) not saying it directly. And what he (user) wanted was a simple and objective answer: where do I do my examination?"E5

Regarding hard -soft technologies, programmed actions, medical and nursing knowledge are mentioned.

"(...) when I don't do an early diagnoses of tuberculosis, when I see a puerpera die, when I see children younger than 2 with malnutrition, when I don't have an access (...) correct information (...) I am not meeting the health needs of the population". E1

Last, they have pointed out the access to medications and health equipment as needs for soft-hard technologies.

"(...) there are medications, the health care center (UBS) and the professionals that are in the health care center (...) maybe there should be more health care units, more hospitals would also be helpful". E2

Need to have a bond with a professional or team

In their speech, one of the subjects understood that, to identify and meet users' needs there must be empathy and respect to the conceptions of life, this implies listening and the formation of a bond.

"For me, when individuals see their needs, it is different from when I look at it, I have to look according to the whole aspects of their lives, the sociocultural and family context they live in". E1

Need to have autonomy in the way they go on with their lives

In their statements, one of the individuals pointed out that the lack of access to consumer's good, material, education and cultural heritage can prevent users to identify their health needs in a broader way, leading, many times, to a debt in their autonomy, narrowing the possibilities to "go on with their lives"

"Not everybody knows that you have to eat well, move in an appropriate way, work right, and try to look for what is best to you (...)." E4

Meeting health needs

The last category emerged after exhaustive reading of the statements and it approaches professionals' perceptions regarding the theme.

Most of the health professionals interviewed indicated that users' health needs were not met. They also highlighted that meeting the needs does not depend only on the will of professionals, but also on intersectoral actions.

" (...) it is because it's no use wanting to do, you want it, and I see that doctors also want it, the problem is that they don't have the conditions. (...)". E4

However, there is only one statement that encompasses the perception that a great deal of the needs are met, especially the needs of access to health technologies.

"I think so. Now, here in São Paulo? I think that at least 80% of the health needs can be considered as met". E2

DISCUSSION

Need identification

The outcomes of the study indicated that there are different forms of identifying the health needs, either according to the professional/user point of view or the identification technique.

One of the statements of the subjects pointed out that needs can be identified both in the health professionals' and users' perspectives. As for the view of professionals, the needs can be identified by direct contact with the user and observation of the territory.

The health needs may or may not be felt depending on the social conditions and the prevailing ideology, as well as its expression, that is, the demand is also related with that(4). Therefore, if the needs and demands are connected with social and ideological contexts, their identification will also be.

The statements of individuals approached the theme of need within different perspectives, the individual atomistic: in which the needs are only a condition that require a service, and that of the Social Determination of the Health-Disease Process: which takes into consideration the socioeconomic conditions, ethnic group, gender, generation "which condition the development of the capacities of each person"(4).

Professionals should be able to identify, quantify and value the needs, as well as to program actions to meet their needs(12). However, a study to validate an instrument to identify needs pointed out that teams found it hard to identify and systematize actions that responded to the real needs of the population(2).

One of the individuals pointed out home visits as a strategy to identify needs. This activity enables professionals from the team to identify "family arrangements and health problems faced", making them closer to the actual health needs of that group(13).

None of the individuals mentioned the use of epidemiological data as a way to identify health needs.

Epidemiological investigations are very important to recognize the health-disease profile of the population, since they bring quantitative data on their morbidity and mortality. However, epidemiological data do not capture subjective data such as aspects concerning quality of life of individuals and the group(14). Therefore, it is necessary to combine objective and subjective data to better capture the health needs.

Last, users' perspective is seen when they express their needs when they look for health services to have access to technologies that can improve or prolong their lives(6).

Need for good conditions of life

The category was broadly approached by the interviewees, who considered it an important health need. Individuals listed the needs for good conditions of life in a concrete way; they mentioned lack of good diet, proper housing, sanitation, access to culture and leisure, adequate work conditions, and others that were related to the insertion of individuals in the capitalist mode of production which determines the health-disease process of individuals and the group. Additionally, they pointed out that family and social bonds, safety and affection are also important to reach good conditions of life.

A similar result was reported in a study carried out in Chapecó- SC, in which professionals of family health teams transformed at first the needs for good conditions of life in actual demands such as: offer transport ticket for users undergoing tuberculosis treatment. Later, these professionals realized that the needs for good conditions of life were more complex, they went beyond proper diet, education and housing, individuals also needed to have safety, affection and life projects(15).

Another relevant data, seen in one of the statements was that the access to material goods does not guarantee alone good conditions of life regarding the quality of diet and leisure, that is, having financial conditions does not guarantee quality of life.

In some statements there was, directly or indirectly, the feeling of powerlessness of professionals regarding social and economical issues. This powerlessness was also identified in a study that states that the feeling is present in the routine of professionals, because they can't perform everything that is necessary. They also feel productive when they can articulate responses and help people(15).

Improvement in the conditions of life will never occur completely in the services, as much as professionals are committed and competent because it depends on the articulation among the several social sectors(6).

One of the individuals point out intersectoral actions as a strategy to improve conditions of life of the population. Several authors(6,11,14) defend these actions so that the services form an articulated social action network to "identify the problems and to provide integrated solutions"(14).

Need to access technologies that improve and prolong life

This category raises the discussion on the differences between access and accessibility. Access, has to do with the timely use of the services to obtain timely outcomes. Accessibility is different; it refers to the possibility of getting to the health center. This will depend on social, cultural and political aspects for the provision of the services(16).

All individuals from the study considered the access to technologies as a health need. They have mentioned three types of technologies: soft, hard-soft and hard(17).

Soft technologies have to do with relational processes between workers and users, encompassing the "moments of talking, listening, and interpreting if the intentions people observe in this meeting are accepted"(17).

One of the individuals reports a situation in which there was lack of communication between the receptionist of a unit and a user, whose information was conveyed in an inappropriate and disrespectful manner. This report corroborates with the study when it states that professionals find it hard to manage soft technologies, especially regarding psychological health needs(15).

A study on the physician-patient relationship carried out in Florianópolis-SC, states that physicians feel unprepared to deal with relational issues because their training was centered in clinical aspects with a few opportunities to develop relational skills and understand individuals through the contact with determiners in the health-disease process(18).

Hard-soft technologies concern the ways of thinking and coordinating health actions based on well-structured, organized and filed knowledge(17). The research individuals approached the importance of medical and nursing knowledge and also of the performance of programmed actions.

In the institution where the study was carried out, the use of guides and protocols is widespread. The presentation and discussion of these protocols, guides and of the institutional guidelines and the Municipal Health Secretariat are objects of the work of the tutors together with the clinical knowledge.

As for hard technologies, some examples are the physical structure of the services, the equipment and the consumption materials(17).

All individuals mentioned hard technologies as health needs, approaching the need for offering more services, access to lab and image tests, as well as medications.

Another essential point is the lack of physicians in the ESF in the city of São Paulo. In the place tutors work there is a large turnover of professionals, making care to the population, and the educational work of these tutors difficult because they cannot assess longitudinally the outcomes of their work.

It is believed that, to obtain technological quality in the work, the three types of technology should be arranged in a proper way(17).

As for the professional-user bond, this "implies having relationships so close and clear that we sensitize with the suffering of the other, of that population (...)". This aspect is considered as an important potentiating factor for changes in health practices(11).

Need to have a bond with a professional or team

The need for a bond was not frequent in the statement of study individuals. A possible reason for that is the fact that tutors do not provide direct care, they meet users randomly and for a short period, thus, it is difficult to build a bond.

One of the individuals pointed out the need for listening to users' stories, to understand their family structure, that is, treat them as subjects in order to better capture their family, their needs and give them an answer. This listening requires personal and technical skills of the professional to favor users to preserve their autonomy, helping them face adverse situations(19).

Need to have autonomy in the way they go on with their lives

The category has to do with the ability of making choices. Professionals have the possibility to give support to individuals to make choices that improve their ability to adjust and survive(11). Regarding this need, it was marked in the interviews that issue of the access to consumer goods as a limiting factor to obtain growing levels of autonomy.

This finding is different from the study carried out in São Paulo with professionals of the Health Care Plan, where most of them mistook autonomy with self-care, forgetting to value the individual regarding their subjectivity and history(11). This conception prevents the formulation of a therapeutic project that encourages the development of the autonomy(11).

One of the individuals of the research believes that it is a role of the government to explain users their rights and the health services available to meet their needs. However, the government is increasingly more absent, although it designs public policies, it does not execute them, following a neoliberal trend to establish the Minimal State(7).

The knowledge on the rights and duties offer instruments for users to try to have their need met and to develop their autonomy.

To develop their autonomy, users depend on the combination of individual support techniques, such as medications and access to information, as well as techniques with a social nature such as work qualification and socialization(11).

These aspects appear on the statements of tutors which highlight the importance of access to information, good working conditions, and the development of citizenship.

Meeting the needs

Tutors believe that the health needs of the population are not met, especially because meeting the needs does not depend only on the intentions of the professionals, but rather on the political and intersectoral actions.

A study on the health needs in Maringá-PR showed that, in the work with families, the most common and most difficult needs to be met are the socioeconomical and it does not depend on the will of professionals, but also on the public policies to prevent poverty, chronic unemployment and violence(20).

Additionally, it points out that health professionals focus their look on the disease, on the biological side, which limits the look on the needs and thus, on meeting these needs.

Health professionals do not change the way they relate with the work object, the suffering of individuals and the community, the organization and financial changes in the institutions will not be enough to meet the needs of the population(21).

But, one of the tutors believe that, a great part of the needs are met, referring to hard technological needs such as hospitals and health care units, comparing the city of São Paulo with others where this equipment is lacking. It is believe that to meet these needs the medical staff should be complete.

FINAL REMARKS

Tutors pointed out as forms of identification of the health needs observing the territory and the direct contact with users. The four categories identified were Taxonomy of the Health Needs adopted for data analysis, and another two emerged after exhaustive reading of the statements.

As for the need for good conditions of life, this was pointed out as important, however difficult to be met, as it is related with the socioeconomic context. Concerning the need for access to technologies, tutors highlighted professional-user communication, professional knowledge and access to inputs. Different from the previous categories, the need for a bond was vaguely approached, maybe because these professionals were not very close to the users. In the category that explored the need for autonomy, the relationship between the socioeconomic and cultural conditions and the development of the autonomy was demonstrated. Last, most tutors believe that the needs of the population are not met because of the issues related to the conditions of life, public policies and the way professionals see the health-disease process.

As tutors, because of their roles as educators, may influence professionals that work in the direct care of users, once their perceptions on the health needs is known, it would be relevant to study the way these professionals approach the theme of needs in their educational activities and its impact in the planning of health actions.

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  • 16. Souza ECF, Vilar RLA, Rocha NSPD, Uchoa AC, Rocha PM. Acesso e acolhimento na atenção básica: uma análise da percepção dos usuários e profissionais de saúde. Cad Saúde Pública = Rep Public Health. 2008;24(Supl 1):S100-10.
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  • 19. Morais GSN, Costa SFG, Fontes WD, Carneiro AD. Comunicação como instrumento básico no cuidar humanizado em enfermagem ao paciente hospitalizado. Acta Paul Enferm.  2009;22(3):323-7.
  • 20. Waidman MAP, Elsen I. Famílias e necessidades... revendo estudos. Acta Sci Health Sci. 2004;26(1):147-57.
  • 21. Merhy EE. O SUS e um dos seus dilemas: mudar a gestão e a lógica do processo de trabalho em saúde (um ensaio sobre a micropolítica do trabalho vivo). In: Fleury S. Saúde e democracia: a luta do CEBES. São Paulo: Lemos; 1997.
  • Autor Correspondente:
    Paula Hino
    Av.: Dr. Enéas de Carvalho Aguiar, 419 - Cerqueira César
    São Paulo - SP- Brasil - Cep: 05403-000
    E-mail:
  • *
    Trabalho de conclusão de curso para obtenção do título de especialista em Saúde Coletiva com enfoque em Programa de Saúde da Família Escola de Enfermagem da Universidade de São Paulo - USP - São Paulo (SP), Brasil.
  • Publication Dates

    • Publication in this collection
      13 Jan 2011
    • Date of issue
      2010

    History

    • Received
      18 May 2009
    • Accepted
      17 Aug 2010
    Escola Paulista de Enfermagem, Universidade Federal de São Paulo R. Napoleão de Barros, 754, 04024-002 São Paulo - SP/Brasil, Tel./Fax: (55 11) 5576 4430 - São Paulo - SP - Brazil
    E-mail: actapaulista@unifesp.br