Acessibilidade / Reportar erro

INVISIBILITY OF SOCIAL VULNERABILITY AND SOCIAL RIGHTS TO A COMPREHENSIVE HEALTH CARE IN CHILE

(IN)VISIBILIDADE DA VULNERABILIDADE SOCIAL E DO DIREITO AO CUIDADO INTEGRAL DA SAÚDE NO CHILE

ABSTRACT

Objective:

To estimate the magnitude of perception of invisibility of social vulnerability and its impact on the access to universal and specific services of the Comprehensive Childhood Protection System in Chile.

Method:

Cross-sectional study in 50 vulnerable dyads, who were registered in a family health care center (Metropolitan Region, Chile; 2012). After the informed consent, mothers were interviewed using a structured questionnaire. A correspondence analysis model was applied.

Results:

The invisibility of social vulnerability estimated for mothers (92.0%) and children (86.0%), and a better access was observed to universal services by children and to specific services by mothers.

Conclusion:

The invisibility of vulnerability limits the opportunities of social protection for disadvantaged groups. Therefore, public policy does not correct social inequalities, which deserve attention by the public health managers in Chile.

DESCRIPTORS:
Social vulnerability; Public policy; Risk groups; Health inequalities; Comprehensive health care

RESUMO

Objetivo:

estimar a magnitude da percepção da invisibilidade da vulnerabilidade social e suas consequências no acesso aos serviços universais e específicos do Sistema de Proteção Integral à Infância no Chile.

Método:

estudo transversal em 50 díades vulneráveis, registrados em um centro de saúde familiar (Região Metropolitana, Chile; 2012). Depois do consentimento informado, as mães foram entrevistadas usando um questionário estruturado. Um modelo de análise de correspondência foi aplicado.

Resultados:

a invisibilidade da vulnerabilidade social foi estimada para mães (92.0%) e filhos (86.0%), observando-se um melhor acesso aos serviços universais pelas crianças e aos específicos pelas mães.

Conclusão:

a invisibilidade da vulnerabilidade limita as oportunidades de proteção social a grupos em desvantagem. Consequentemente, a política pública não corrige as desigualdades sociais, que merecem a atenção dos gestores da saúde pública chilena.

DESCRITORES:
Vulnerabilidade social; Política social; Grupos de risco; Desigualdades em saúde; Assistência integral à saúde

RESUMEN

Objetivo:

estimar la magnitud de la percepción de la in-visibilidad de la vulnerabilidad social y sus consecuencias en el acceso a servicios universales y específicos del Sistema de Protección Integral de la Infancia en Chile.

Método:

estudio transversal en 50 díadas vulnerables, registradas en un centro de salud familiar (Región Metropolitana, Chile; 2012). Después de la firma de consentimiento informado, las madres fueran entrevistadas usando un cuestionario estructurado. Se aplicó un modelo de análisis de correspondencias.

Resultados:

la in-visibilidad de la vulnerabilidad social fue estimada para madres (92.0%) y hijos (86.0%), observándose un mejor acceso a los servicios universales a los infantes y específicos a las madres.

Conclusión:

la in-visibilidad de la vulnerabilidad limita las oportunidades de protección social a grupos desventajados. Como consecuencia, la política pública no corrige las desigualdades sociales, que merecen atención de los gestores de la salud pública chilena.

DESCRIPTORES:
Vulnerabilidad social; Protección social en salud; Grupos de riesgo; Inequidad en salud; Atención integral de salud

INTRODUCTION

Social vulnerability is an inequality indicator associated with insecurity, exclusion, uncertainty, lack of protection, susceptibility to health damage, and unequal access to health care. It is a state to which social determinants of the overall context converge, being a substrate for health problems.11. Sarti S, Alberio M, Terraneo M. Health inequalities and the welfare state in European families. J Sociol Soc Welfare. 2013; 40(1):103-30.

2. Feito L. Vulnerabilidad. An. Sist. Sanit. Navar. 2007; 30(Supl 3):7-22.

3. Barata R, Almeida M, Cassanti AC. Social vulnerability and health status: a household survey in the central area of a Brazilian metropolis. Cad Saúde Pública. 2011; 27(Supl 2):s164-75.

4. Devaney J. Inter-professional working in child protection with families with long-term and complex needs. Child Abuse Review. 2008 Jul; 17(4):242-61.
-55. Juárez-Ramírez C, Márquez-Serrano M, Salgado de Snyder N, Pelcastre-Villafuerte BE, Ruelas-González MG, Reyes-Morales H. La desigualdad en salud de grupos vulnerables de México: adultos mayores, indígenas y migrantes. Rev Panam Salud Pública. 2014; 35(4):284-90. Deteriorating health is main consequence of adverse social conditions accumulated during life, as high-level risk and physical and psychological damage are generated compared to population groups who do not present the social vulnerability condition.11. Sarti S, Alberio M, Terraneo M. Health inequalities and the welfare state in European families. J Sociol Soc Welfare. 2013; 40(1):103-30.,55. Juárez-Ramírez C, Márquez-Serrano M, Salgado de Snyder N, Pelcastre-Villafuerte BE, Ruelas-González MG, Reyes-Morales H. La desigualdad en salud de grupos vulnerables de México: adultos mayores, indígenas y migrantes. Rev Panam Salud Pública. 2014; 35(4):284-90. Health vulnerability is understood as the deprotection that people face due to lack of personal, family, social, and financial resources.55. Juárez-Ramírez C, Márquez-Serrano M, Salgado de Snyder N, Pelcastre-Villafuerte BE, Ruelas-González MG, Reyes-Morales H. La desigualdad en salud de grupos vulnerables de México: adultos mayores, indígenas y migrantes. Rev Panam Salud Pública. 2014; 35(4):284-90.-66. Yablonski J, Bell B. Vulnerable children and youth studies. 2009; 4(S1):77-80. In these scenarios, primary health care (PHC) requires relevance as a capital of vulnerable groups, due to the territorial distribution and universal accessibility of public health centers, being a strategy that allows to prevent and mitigate health risks.55. Juárez-Ramírez C, Márquez-Serrano M, Salgado de Snyder N, Pelcastre-Villafuerte BE, Ruelas-González MG, Reyes-Morales H. La desigualdad en salud de grupos vulnerables de México: adultos mayores, indígenas y migrantes. Rev Panam Salud Pública. 2014; 35(4):284-90.,77. De Pietri D, Dietrich P, Mayo P, Carcagno A, De Titto E. Indicadores de accesibilidad geográfica a los centros de atención primaria para la gestión de inequidades. Rev Panam Salud Pública. 2013; 34(6):452-60.

In countries with high rates of inequality, as in the case of Chile, compensatory policies have been implemented for social protection of people exposed to social inequalities and vulnerability.55. Juárez-Ramírez C, Márquez-Serrano M, Salgado de Snyder N, Pelcastre-Villafuerte BE, Ruelas-González MG, Reyes-Morales H. La desigualdad en salud de grupos vulnerables de México: adultos mayores, indígenas y migrantes. Rev Panam Salud Pública. 2014; 35(4):284-90.,88. Majamaa K. Dismissed intergenerational support? New social risks and the economic welfare of young adults. J Youth Stud. 2011; 14(6):729-43.-99. Jackson SF, Birn A-E, Fawcett SB, Poland B, Schultz JA. Synergy for health equity: integrating health promotion and social determinants of health approaches in and beyond the Americas. Rev Panam Salud Pública. 2013; 34(6):473-80. The concept of inequality covers a broad spectrum of differences and disparities in the circumstances in which people live.1010. Woodhead M, Doman P, Murray H. What inequality means for children. International J Children's Rights. 2014 Jul; 22(3):467-501. The effectiveness of these policies depends, among others, on perception and detection of vulnerability by health professionals in the health care system, as well as integrated and synergic management capacity of public institutions in transferring the services to vulnerable people and groups.55. Juárez-Ramírez C, Márquez-Serrano M, Salgado de Snyder N, Pelcastre-Villafuerte BE, Ruelas-González MG, Reyes-Morales H. La desigualdad en salud de grupos vulnerables de México: adultos mayores, indígenas y migrantes. Rev Panam Salud Pública. 2014; 35(4):284-90.,88. Majamaa K. Dismissed intergenerational support? New social risks and the economic welfare of young adults. J Youth Stud. 2011; 14(6):729-43.-99. Jackson SF, Birn A-E, Fawcett SB, Poland B, Schultz JA. Synergy for health equity: integrating health promotion and social determinants of health approaches in and beyond the Americas. Rev Panam Salud Pública. 2013; 34(6):473-80.,1111. Orton L, Lloyd-Williams F, Taylor-Robinson D, Moonan M, O'Flaherty M and Capewell S. Prioritising public health: a qualitative study of decision making to reduce health inequalities. BMC Public Health. 2011 Jan; 11(1):821-9. In the social protection policy, it was defined in the objective of process integration that institutions and their work teams are responsible for managing implementation, financing, and regulation of services.55. Juárez-Ramírez C, Márquez-Serrano M, Salgado de Snyder N, Pelcastre-Villafuerte BE, Ruelas-González MG, Reyes-Morales H. La desigualdad en salud de grupos vulnerables de México: adultos mayores, indígenas y migrantes. Rev Panam Salud Pública. 2014; 35(4):284-90.,1212. Organización Panamericana de la Salud, Organización Mundial de la Salud. La renovación de la atención primaria en las Américas. Edición OPS/OMS [Internet]. 2007 [cited 2010 Dec 10]. Available from: http://www.paho.org/spanish/AD/THS/OS/APS_spa.pdf
http://www.paho.org/spanish/AD/THS/OS/AP...
This is a condition that has required ability for contextualized responses and new forms of institutional organization.55. Juárez-Ramírez C, Márquez-Serrano M, Salgado de Snyder N, Pelcastre-Villafuerte BE, Ruelas-González MG, Reyes-Morales H. La desigualdad en salud de grupos vulnerables de México: adultos mayores, indígenas y migrantes. Rev Panam Salud Pública. 2014; 35(4):284-90.,1212. Organización Panamericana de la Salud, Organización Mundial de la Salud. La renovación de la atención primaria en las Américas. Edición OPS/OMS [Internet]. 2007 [cited 2010 Dec 10]. Available from: http://www.paho.org/spanish/AD/THS/OS/APS_spa.pdf
http://www.paho.org/spanish/AD/THS/OS/AP...
Collaboration between health services and local government institutions is considered to be the best way of obtain effectiveness and efficiency of health resources for poor people, as it has been based on collaboration between institutions and work integration between disciplines.1111. Orton L, Lloyd-Williams F, Taylor-Robinson D, Moonan M, O'Flaherty M and Capewell S. Prioritising public health: a qualitative study of decision making to reduce health inequalities. BMC Public Health. 2011 Jan; 11(1):821-9.-1212. Organización Panamericana de la Salud, Organización Mundial de la Salud. La renovación de la atención primaria en las Américas. Edición OPS/OMS [Internet]. 2007 [cited 2010 Dec 10]. Available from: http://www.paho.org/spanish/AD/THS/OS/APS_spa.pdf
http://www.paho.org/spanish/AD/THS/OS/AP...

Previous reports showed disparities between professionals' perceptions about social vulnerability of pregnant women (8.6%) and data obtained from the Social Protection Records (91.4%).1313. Arcos E, Muñoz LA, Sánchez X, Vollrath A, Latorre C, Bonatti C, et al. Vulnerabilidad social en mujeres embarazadas de una comuna urbana de la Región Metropolitana. Rev Med Chile. 2011; 139: 739-47. At the same time, poor women are perceived by themselves as invisible, hopeless, and socially excluded, and such perception affects their possibilities of self-determination, autonomy, and enjoyment of the welfare rights.1414. Muñoz LA, Sánchez X, Arcos E, Vollrath A, Bonatti C. The motherhood experience in the context of social vulnerability: a comprehensive approach to social phenomenology. Rev Latino-Am Enfermagem. 2013; 21(4):913-9. Reports of socioeconomically disadvantaged women show that they have unequal access to the health care provided by the network of health institutions and social protection.11. Sarti S, Alberio M, Terraneo M. Health inequalities and the welfare state in European families. J Sociol Soc Welfare. 2013; 40(1):103-30.,1515. Lunecke A. Violencia urbana, exclusión social y procesos de guetización: La trayectoria de la población Santa Adriana. Rev Invi. 2012; 26: 287-313.-1616. Plaza S, Padilla B, Ortiz A, Rodrigues E. The value of grounded theory for disentangling inequalities in maternal-child healthcare in contexts of diversity: a psycho-sociopolitical approach. Psychosocial Intervention. Intervención Psicosocial [Internet]. 2014 [cited 2014 Ago 7]; 23(2): 125-33. Available from: https://repositorio.iscte-iul.pt/handle/10071/8678
https://repositorio.iscte-iul.pt/handle/...
The literature on social policies warns that there is an inability to make visible the social vulnerability, which is accompanied by a weakening in the coverage of social services to the citizens.88. Majamaa K. Dismissed intergenerational support? New social risks and the economic welfare of young adults. J Youth Stud. 2011; 14(6):729-43.

In present study, the question was related to the visibility and opportunity situations of access to the services by dyads (mothers and infants), in conditions of extreme vulnerability and psychosocial risk, who were treated in a family health center of an urban community in the Metropolitan Region of Santiago, Chile. The aim of this study was to estimate the magnitude of perception of invisibility of social vulnerability and its consequences in the access to the universal and specific services of the Comprehensive Childhood Protection System, Chile Grows With You (Chile Crece Contigo, ChCC). Programs for universal social transfers, which are conditioned and focused on socially vulnerable children, are the fundamental axis of public policies directed to mitigate the inequality effect and reduce children vulnerability.1717. Tassara C. Políticas públicas de protección social y lucha contra la pobreza en Colombia: logros y desafíos. Papel Político. 2015 Jul; 20(2):1-29.

18. Barrientos A, Byrne J, Peña P, Villa J. Social transfers and child protection in the South. Child Youth Services Rev [Internet]. 2014 Dec [cited 2016 Jun 4]; 47 :106-12. Available from: http://www.sciencedirect.com/science/article/pii/S0190740914002606
http://www.sciencedirect.com/science/art...
-1919. Sabates-Wheeler R, Devereux S. Sustainable graduation from social protection programmes. Development Change. 2013 Jul; 44(4):911-38. There is a growing debate focused on the need to generate knowledge about the effectiveness of the social protection policy to reduce social vulnerability, especially in the opportunities for access to their services.66. Yablonski J, Bell B. Vulnerable children and youth studies. 2009; 4(S1):77-80.,1818. Barrientos A, Byrne J, Peña P, Villa J. Social transfers and child protection in the South. Child Youth Services Rev [Internet]. 2014 Dec [cited 2016 Jun 4]; 47 :106-12. Available from: http://www.sciencedirect.com/science/article/pii/S0190740914002606
http://www.sciencedirect.com/science/art...

METHOD

A descriptive cross-sectional study (non-experimental design) was conducted in a family health center of an urban community in Chile (Metropolitan Region of Santiago of Chile; 2012). Mothers and infants in extreme social vulnerability condition (<4,213 points) participated in the study. The inclusion criteria were as follows: history of prenatal control in women during pregnancy in the public health network, with percentile 5 in the social vulnerability stratification scale as measured by the Social Protection Record (SPR) scale, and their infant children, with health control only in the family health center of an urban community. During that period, 287 pregnant women were admitted to the obstetric control center. They met the inclusion criteria (71) or were not considered (21) for the following reasons: address change, non-acceptance to participate in the study, were not found at home, or the address and contact data were incorrect. Therefore, 50 mothers and their children were the final universe.

Variables on the women and their infants were studied regarding visibility of social vulnerability as recorded by professionals who conducted the health controls and biosociodemographic aspects (age, marital status, education, history of their biomedical, obstetric and psychosocial condition as identified during the prenatal control and after delivery). In children, biomedical birth parameters and history of the biomedical and psychosocial conditions were identified during child health control. This information was obtained from the clinical records and institutional databases of the health center. Information on the opportunity for access to universal services for mothers (15) and their children (7) during the child health control was obtained from secondary sources. Information on access to specific services was also obtained. The primary data were obtained by the investigators through a standard face-to-face interview, which was performed at home or in the health center. When mothers did not recall the information on the services received from the ChCC system, they were checked in the secondary data sources mentioned above. The study objectives were explained to the mothers, and anonymity and confidentiality were assured according to the criteria established by the Scientific Ethics Committee (School of Nursing, Universidad Andrés Bello, L1/CECENF/87). The mothers signed the informed consent form voluntarily.

Crude and refined databases were configured for processing and statistical analysis of the data. Critical analysis of the data was based on the SPSS (v. 20.0) computer program. Data were analyzed from position and dispersion descriptive statistics according to the variable nature. A correspondence analysis model was applied with regard to delivery of social services, and intending to form homogeneous groups from a set of relevant variables.

RESULTS

The invisibility of social vulnerability affected both pregnant women (92.0%) and their children (86.0%) in the access to the health control center. Visibility of psychosocial risk was greater because the health professionals used a standardized screening questionnaire (mothers: 34.0%; infants: 30.0%), which further increased its detection when the investigators reviewed the screening results and clinical records (Table 1).

Table 1
Invisibility of vulnerability and visibility of psychosocial risk in 50 vulnerable dyads, according to the status of female household leadership, 2012

As a consequence, invisibility of psychosocial risk also existed in mothers and infants, with a greater proportion in mothers who were household heads, relative to women who did not have that condition (Table 1). The children's situation is similar to that of mothers. In addition, only 52.2% of women reported having received information about the public policy for comprehensive protection of children, but none about the social protection network.

Regarding dyads' profile, one in two pregnant women were household heads, and this condition showed more adverse biopsychosocial determinants, compared to the group without this condition. Differences were observed between groups regarding age when the women became pregnant, education, and paid work activity (Table 2). They did not have the presence of the father in one of every two families with female household leadership. From the perspective of the reproductive health care, the women were admitted to the center before the first 20 gestation weeks (91.3%), facilitating compliance with delivery of ChCC services in the prenatal period. It is noteworthy to mention that pregnancy was not planned in two out of three (65.2%) women, and this situation represents problems in their access to the fertility control services.

Table 2
Biosociodemographic and obstetric profile of 46 pregnant women with in-visible social vulnerability, according to the condition of female household leadership, 2012

Regarding 25 women with invisible vulnerability and psychosocial risk, as detected by screening and records in the clinical file, depressive symptoms (64.3%) and insufficient family support (50%) were the most frequently mentioned determinants. The latter condition increased in women who were household heads, where two out of three of them reported this type of determinant. One in every four women mentioned having experienced domestic violence.

About 43 infants whose vulnerability was invisible, the birth parameters were very similar in both groups. Attention was called by the high proportion of neonates (two of three) and low proportion of women who indicated encouragement to maternal attachment during labor (Table 3). The health control was updated in nine of ten infants at the time of the interview and most mothers (86.0%) reported a breastfeeding duration over six months. About half of the mothers were main children caregivers (44.2%). Rates of underdevelopment (11.6%) and psychomotor retardation risk (9.3%) were calculated for infants (Table 3).

Table 3
Profile of 43 infants with invisible vulnerability according to mother household leadership status, 2012

As detected by screening and access to revising the clinical records, the main problems of the family environment in infants with invisible vulnerability and psychosocial risk were as follows: history of mental health problems in the family group (female household heads: 100%; total: 91.7%) and use of addictive substances (20 and 16.7%, respectively), were found in infants with invisible vulnerability and psychosocial risk.

In this invisibility context, establishing the consequences for mothers and children in terms of their access to the universal and specific services, as established by the ChCC, was important. Tables 4 and 5 show a better access to universal than to specific services by both mothers and infants. In addition, coverage of universal services for infants was more effective than for mothers, but coverage of specific services for mothers was more effective than for infants (Tables 4 and 5).

Table 4
Universal and specific services received by 46 mothers with invisible vulnerability, 2012

Table 5
Universal and specific services received by 43 infants with invisible vulnerability, 2012

In the model of multiple correspondence analysis, the mother and infant variables were analyzed separately in two dimensions: dimension 1) biosociodemographic background and psychosocial risk history; and dimension 2) access to the ChCC services. In both cases, a high concentration of points was observed in the central area between both axes, revealing little dependence between the categories of both dimensions in the case of both mothers and infants. In short, the graph with all points of the categories provided little explanation on the behavior of the biosociodemographic and psychosocial history, regarding the services transferred to mothers and their children by the social protection system.

DISCUSSION

Evidence indicates the relationship between adverse social determinants with higher maternal stress and depression levels during pregnancy and postpartum. Consequently, it also indicates higher incidence of prematurity and higher rates of child development delay, which affects the behavior and trajectories of individuals forever.2020. Organización Mundial de la Salud. Subsanar las desigualdades en una generación. Alcanzar la equidad sanitaria actuando sobre los determinantes sociales de la salud, [Internet]. 2008 [cited 2010 Jan 10]. Available from: http://apps.who.int/iris/bitstream/10665/44084/1/9789243563701_spa.pdf
http://apps.who.int/iris/bitstream/10665...
The history of unplanned pregnancies (66.0%) represents a family planning that was not treated in vulnerable women. The literature indicates that women with unplanned pregnancy have higher levels of depression, unsafe abortion, domestic violence, less healthy practices during pregnancy and delivery, as well as higher frequency of low birth weight, neglect in child care, abuse, and increased drug addiction. In these cases, it is considered that early admission of women to the health control service, especially household head women, is a factor of protection against health disparities and inequalities, as it offers better access to the universal and specific services. However, our results showed that provision of these services was not 100%.2121. Franco L, Mora G, Mosquera AL, Calvo D. Planificación familiar en mujeres en condiciones de vulnerabilidad social. Rev Univ Ind Santander Salud. 2011; 43(3):240-8.-2222. McCourt C. What is the value of applying social theory to maternity care? Texto Contexto Enferm [Internet]. 2014 [cited 2014 Ago 18]; 23(1):9-10. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072014000100009
http://www.scielo.br/scielo.php?script=s...

As for the situation of poor household head women, it was noted that they have access to the informal labor market, with lower wages and without social security, wich makes them more vulnerable and dependent on the family support networks and public financial and social security.2626. Ozawa M, Yongwoo L. The net worth of female-headed households: a comparison to other types of households. Family Relations. 2006; 55(1):132-45. It was also highlighted that children who live in households headed by women are the most vulnerable members in the society. They also have more economic and health disadvantages and, therefore, their development depends partly on the impact of social welfare policies.2727. Robert H. D. The Impact of state minimum wages on child poverty in female-headed families. J Poverty. 2008; 12(2):155-74.

Explanations for the best performance of the provision of universal services, especially for children, rely on the conscious family health culture, relative to prenatal and child health control, and the wealth of experience-knowledge and skills of nurses, relative to the compliance with program goals.2828. Bertolozzi MR; Nichiata L, Takahashi R, Ciosak S, Hino P, Val L, et al. The vulnerability and the compliance in collective health. Rev Esc Enferm. 2009; 43(spe2): 1326-30.-2929. da Silva TMR, Alvarenga MRM, Campos Oliveira MA. Evaluation of the vulnerability of families assisted in primary care in Brazil. Rev Latino-Am Enfermagem. 2012; 20(5):935-43.

In the public policy for child protection, attention is focused on vulnerable children to repair the equity gaps to which they are exposed since their birth. The implications of low provision of specific services for vulnerable children, is translated into unprotection and insecurity that limits their opportunities for maturation of the neurosensory system, especially in children included in a psychosocial risk environment and/or in those with evidence of development delay. In this study, data on the access to specific services show the incapacity of institutional response, and therefore a debt relative to the effective support by the State for equity of the most vulnerable children so that they have a dignified and secure life since their birth. This increases the institutionalized reproduction of inequality, and marginalization until adult life.3030. Muñoz A, Bertolozzi MR. Can the vulnerability concept support the construction of knowledge in collective health care? Cienc Salud Colectiva. 2007; 12(2):319-24.

31. Ortega-Bolaños J, Bula-Escobar J. El cuerpo como escenario de vulnerabilidad social en salud. Rev. salud pública [Internet]. 2012 [cited 2014 Agosto 12]; 14(6):131-40.
-3232. León-Torres MS. Niños, niñas y mujeres: una amalgama vulnerable. Rev Latinoam Cienc Soc Niñez Juv. 2014; 12(1):105-19.

It has been repeated that this situation can be overcome if the reductionist view the "biomedical" approach is supplemented. From this view, people's options have no space, because they are subject to the expectations and prescriptions of others. This situation can be also overcome if the quality of information on social protection policies delivered to the target population is improved, so that they take the initiative and control in the access to the services.3030. Muñoz A, Bertolozzi MR. Can the vulnerability concept support the construction of knowledge in collective health care? Cienc Salud Colectiva. 2007; 12(2):319-24.,3232. León-Torres MS. Niños, niñas y mujeres: una amalgama vulnerable. Rev Latinoam Cienc Soc Niñez Juv. 2014; 12(1):105-19. In this study, best provision of specific services was observed (82.5% and 83.3%, respectively) when the ChCC system and its services were explained to the women.

The magnitude of invisibility of social vulnerability observed in the present study and its consequences for the right to comprehensive health care, reinforces the need to consider the concepts of social vulnerability and exclusion, as well as to understand the value of interdisciplinary work in the nursing practices.2323. Yanikkerem E, Ay S, Piro N. Planned and unplanned pregnancy: effects on health practice and depression during pregnancy. J Obstet Gynaecol Res. 2013 Jan; 39(1):180-7.,3333. Parton N. Child protection and safeguarding in England: changing and competing conceptions of risk and their implications for social work. Br J Soc Work [Internet]. 2011; 41(5):854-75.

34. Bellato R, Pereira W. Direitos e vulnerabilidade: noções a serem exploradas para uma nova abordagem ética na enfermagem. Texto Contexto Enferm [Internet]. 2005 [cited 2014 Agosto 16]; 14(1):17-24. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072005000100002
http://www.scielo.br/scielo.php?script=s...
-3535. Amorim A, Assis M, Santos A, Jorge M, Servo M. Practices of the family health team: advisors of the access to the health services? Texto Contexto Enferm [Internet]. 2014 [cited 2015 Aug 03]; 23(4):1077-86. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072014000401077
http://www.scielo.br/scielo.php?script=s...
Formalizing the construction of meaningful learning and skills in recognition of complex social phenomena is urgent, as they are essential for a humanized, comprehensive, and quality care that can reduce health disparities and inequalities. The previous attitudes will allow nursing professionals to progress in the understanding, empathy, and sensitivity, going beyond a health control, as they promote interaction among caregivers and making visible the vulnerability and reasons to act with a conscious relevance.22. Feito L. Vulnerabilidad. An. Sist. Sanit. Navar. 2007; 30(Supl 3):7-22.,1111. Orton L, Lloyd-Williams F, Taylor-Robinson D, Moonan M, O'Flaherty M and Capewell S. Prioritising public health: a qualitative study of decision making to reduce health inequalities. BMC Public Health. 2011 Jan; 11(1):821-9.,3636. Barra DCC, Lanzoni GMM, Maliska ICA, Sebold LF, Meirelles BHS. Human living process and nursing from the vulnerability perspective. Acta Paul Enferm. 2010; 23(6): 831-6.-3737. Acosta D, Gomes L, Fonseca A, Gomes G. Violence against women commited by intimate partners: (in)visibility of the problem. Texto Contexto Enferm [Internet]. 2015 [cited 2015 Aug 03]; 24(1):121-7. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072015000100121
http://www.scielo.br/scielo.php?script=s...
In order to increase the certainty of compliance with the public policy, integrating the concept that users in social disadvantage are subjects with unrestricted right to universal access to the services of the social protection system is necessary, especially at the primary level of health care.2929. da Silva TMR, Alvarenga MRM, Campos Oliveira MA. Evaluation of the vulnerability of families assisted in primary care in Brazil. Rev Latino-Am Enfermagem. 2012; 20(5):935-43.,3131. Ortega-Bolaños J, Bula-Escobar J. El cuerpo como escenario de vulnerabilidad social en salud. Rev. salud pública [Internet]. 2012 [cited 2014 Agosto 12]; 14(6):131-40.

CONCLUSION

An elevated magnitude of invisibility of social vulnerability was found in mothers and children attended in the public primary healthcare system, showing the system inability to make itself visible. As a consequence, mothers and infants with extreme social vulnerability had partial access to the services from the public policy of social protection. It is of vital importance that the persons responsible for the public policy, especially nurses, promote the opportunities provided by the State to reduce the health inequalities and disparities among vulnerable children and women.

ACKNOWLEDGEMENTS

The authors thank the logistical support provided by the work team of the Inequality Network, Latin American Institute (Free University of Berlin, Germany).

REFERENCES

  • 1
    Sarti S, Alberio M, Terraneo M. Health inequalities and the welfare state in European families. J Sociol Soc Welfare. 2013; 40(1):103-30.
  • 2
    Feito L. Vulnerabilidad. An. Sist. Sanit. Navar. 2007; 30(Supl 3):7-22.
  • 3
    Barata R, Almeida M, Cassanti AC. Social vulnerability and health status: a household survey in the central area of a Brazilian metropolis. Cad Saúde Pública. 2011; 27(Supl 2):s164-75.
  • 4
    Devaney J. Inter-professional working in child protection with families with long-term and complex needs. Child Abuse Review. 2008 Jul; 17(4):242-61.
  • 5
    Juárez-Ramírez C, Márquez-Serrano M, Salgado de Snyder N, Pelcastre-Villafuerte BE, Ruelas-González MG, Reyes-Morales H. La desigualdad en salud de grupos vulnerables de México: adultos mayores, indígenas y migrantes. Rev Panam Salud Pública. 2014; 35(4):284-90.
  • 6
    Yablonski J, Bell B. Vulnerable children and youth studies. 2009; 4(S1):77-80.
  • 7
    De Pietri D, Dietrich P, Mayo P, Carcagno A, De Titto E. Indicadores de accesibilidad geográfica a los centros de atención primaria para la gestión de inequidades. Rev Panam Salud Pública. 2013; 34(6):452-60.
  • 8
    Majamaa K. Dismissed intergenerational support? New social risks and the economic welfare of young adults. J Youth Stud. 2011; 14(6):729-43.
  • 9
    Jackson SF, Birn A-E, Fawcett SB, Poland B, Schultz JA. Synergy for health equity: integrating health promotion and social determinants of health approaches in and beyond the Americas. Rev Panam Salud Pública. 2013; 34(6):473-80.
  • 10
    Woodhead M, Doman P, Murray H. What inequality means for children. International J Children's Rights. 2014 Jul; 22(3):467-501.
  • 11
    Orton L, Lloyd-Williams F, Taylor-Robinson D, Moonan M, O'Flaherty M and Capewell S. Prioritising public health: a qualitative study of decision making to reduce health inequalities. BMC Public Health. 2011 Jan; 11(1):821-9.
  • 12
    Organización Panamericana de la Salud, Organización Mundial de la Salud. La renovación de la atención primaria en las Américas. Edición OPS/OMS [Internet]. 2007 [cited 2010 Dec 10]. Available from: http://www.paho.org/spanish/AD/THS/OS/APS_spa.pdf
    » http://www.paho.org/spanish/AD/THS/OS/APS_spa.pdf
  • 13
    Arcos E, Muñoz LA, Sánchez X, Vollrath A, Latorre C, Bonatti C, et al. Vulnerabilidad social en mujeres embarazadas de una comuna urbana de la Región Metropolitana. Rev Med Chile. 2011; 139: 739-47.
  • 14
    Muñoz LA, Sánchez X, Arcos E, Vollrath A, Bonatti C. The motherhood experience in the context of social vulnerability: a comprehensive approach to social phenomenology. Rev Latino-Am Enfermagem. 2013; 21(4):913-9.
  • 15
    Lunecke A. Violencia urbana, exclusión social y procesos de guetización: La trayectoria de la población Santa Adriana. Rev Invi. 2012; 26: 287-313.
  • 16
    Plaza S, Padilla B, Ortiz A, Rodrigues E. The value of grounded theory for disentangling inequalities in maternal-child healthcare in contexts of diversity: a psycho-sociopolitical approach. Psychosocial Intervention. Intervención Psicosocial [Internet]. 2014 [cited 2014 Ago 7]; 23(2): 125-33. Available from: https://repositorio.iscte-iul.pt/handle/10071/8678
    » https://repositorio.iscte-iul.pt/handle/10071/8678
  • 17
    Tassara C. Políticas públicas de protección social y lucha contra la pobreza en Colombia: logros y desafíos. Papel Político. 2015 Jul; 20(2):1-29.
  • 18
    Barrientos A, Byrne J, Peña P, Villa J. Social transfers and child protection in the South. Child Youth Services Rev [Internet]. 2014 Dec [cited 2016 Jun 4]; 47 :106-12. Available from: http://www.sciencedirect.com/science/article/pii/S0190740914002606
    » http://www.sciencedirect.com/science/article/pii/S0190740914002606
  • 19
    Sabates-Wheeler R, Devereux S. Sustainable graduation from social protection programmes. Development Change. 2013 Jul; 44(4):911-38.
  • 20
    Organización Mundial de la Salud. Subsanar las desigualdades en una generación. Alcanzar la equidad sanitaria actuando sobre los determinantes sociales de la salud, [Internet]. 2008 [cited 2010 Jan 10]. Available from: http://apps.who.int/iris/bitstream/10665/44084/1/9789243563701_spa.pdf
    » http://apps.who.int/iris/bitstream/10665/44084/1/9789243563701_spa.pdf
  • 21
    Franco L, Mora G, Mosquera AL, Calvo D. Planificación familiar en mujeres en condiciones de vulnerabilidad social. Rev Univ Ind Santander Salud. 2011; 43(3):240-8.
  • 22
    McCourt C. What is the value of applying social theory to maternity care? Texto Contexto Enferm [Internet]. 2014 [cited 2014 Ago 18]; 23(1):9-10. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072014000100009
    » http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072014000100009
  • 23
    Yanikkerem E, Ay S, Piro N. Planned and unplanned pregnancy: effects on health practice and depression during pregnancy. J Obstet Gynaecol Res. 2013 Jan; 39(1):180-7.
  • 24
    Mallard SR, Houghton, LA. Socio-demographic characteristics associated with unplanned pregnancy in New Zealand: implications for access to preconception healthcare, Aust N Z J Obstet Gynaecol. 2013 Oct;53(5):498-501.
  • 25
    Baker M. Working their way out of poverty? Gendered employment in three welfare states. J Comp Fam Stud. 2009; 40(4):617-34.
  • 26
    Ozawa M, Yongwoo L. The net worth of female-headed households: a comparison to other types of households. Family Relations. 2006; 55(1):132-45.
  • 27
    Robert H. D. The Impact of state minimum wages on child poverty in female-headed families. J Poverty. 2008; 12(2):155-74.
  • 28
    Bertolozzi MR; Nichiata L, Takahashi R, Ciosak S, Hino P, Val L, et al. The vulnerability and the compliance in collective health. Rev Esc Enferm. 2009; 43(spe2): 1326-30.
  • 29
    da Silva TMR, Alvarenga MRM, Campos Oliveira MA. Evaluation of the vulnerability of families assisted in primary care in Brazil. Rev Latino-Am Enfermagem. 2012; 20(5):935-43.
  • 30
    Muñoz A, Bertolozzi MR. Can the vulnerability concept support the construction of knowledge in collective health care? Cienc Salud Colectiva. 2007; 12(2):319-24.
  • 31
    Ortega-Bolaños J, Bula-Escobar J. El cuerpo como escenario de vulnerabilidad social en salud. Rev. salud pública [Internet]. 2012 [cited 2014 Agosto 12]; 14(6):131-40.
  • 32
    León-Torres MS. Niños, niñas y mujeres: una amalgama vulnerable. Rev Latinoam Cienc Soc Niñez Juv. 2014; 12(1):105-19.
  • 33
    Parton N. Child protection and safeguarding in England: changing and competing conceptions of risk and their implications for social work. Br J Soc Work [Internet]. 2011; 41(5):854-75.
  • 34
    Bellato R, Pereira W. Direitos e vulnerabilidade: noções a serem exploradas para uma nova abordagem ética na enfermagem. Texto Contexto Enferm [Internet]. 2005 [cited 2014 Agosto 16]; 14(1):17-24. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072005000100002
    » http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072005000100002
  • 35
    Amorim A, Assis M, Santos A, Jorge M, Servo M. Practices of the family health team: advisors of the access to the health services? Texto Contexto Enferm [Internet]. 2014 [cited 2015 Aug 03]; 23(4):1077-86. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072014000401077
    » http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072014000401077
  • 36
    Barra DCC, Lanzoni GMM, Maliska ICA, Sebold LF, Meirelles BHS. Human living process and nursing from the vulnerability perspective. Acta Paul Enferm. 2010; 23(6): 831-6.
  • 37
    Acosta D, Gomes L, Fonseca A, Gomes G. Violence against women commited by intimate partners: (in)visibility of the problem. Texto Contexto Enferm [Internet]. 2015 [cited 2015 Aug 03]; 24(1):121-7. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072015000100121
    » http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072015000100121

Publication Dates

  • Publication in this collection
    2016

History

  • Received
    18 Dec 2015
  • Accepted
    30 June 2016
Universidade Federal de Santa Catarina, Programa de Pós Graduação em Enfermagem Campus Universitário Trindade, 88040-970 Florianópolis - Santa Catarina - Brasil, Tel.: (55 48) 3721-4915 / (55 48) 3721-9043 - Florianópolis - SC - Brazil
E-mail: textoecontexto@contato.ufsc.br