versão impressa ISSN 0104-1169
Rev. Latino-Am. Enfermagem v.14 n.6 Ribeirão Preto nov./dez. 2006
Community health agent: a literature review
Ana Cláudia Garabeli Cavalli KluthcovskyI; Angela Maria Magosso TakayanaguiII
IMD, M.Sc. in Nursing. Faculty, Central-Western State University, Guarapuava-PR, e-mail: email@example.com
IIAssociate Professor, University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, e-mail: firstname.lastname@example.org.
Study of the review literature regarding brazilian Community Health Agent. The methodology was descriptive and exploratory study, using the LILACS database (1982 to march/2005) and MEDLINE (1966 to 2005). The analysis resulted 153 publications, from which 97 had been excluded. About type of production, of the 56 references (100%), 53,6% were books, 32,1% periodic articles, 7,1% Master's Theses and remains 7,2%, doctoral dissertations and specialization monographs. It was observed that 59% of the references had been enclosed in the database in 2000. Considering only periodic articles, specialization monographs, Master's Theses and doctoral dissertations, an amount of 26 studies, the experimental design predominated (73%), being the objectives most frequent: characterization of the agents and their functions, process work and results. The data suggest increasing interest on the subject, however, these workers still consist a population little studied.
Descriptors: community health agent; family health program; review literature
In Western education, health and disease conceptions were strongly influenced by the biological paradigm, in which the health concept is based on the absence of disease, and attention is directed at the individual and the disease, with the hospital as the dominant unit and the predominance of specialized medical care, thus disaggregating global attention on the human being(1).
In Brazil, there is an ongoing progressive exhaustion of this private medical care model, mainly from the end of the 1970's onwards. During the second half of the 1980's, the democratic transition was consolidated through an institutional reordering movement that culminated in the Federal Constitution of 1988, the Organic Health Law of 1990 and the creation of the Single Health System (SUS)(2-3).
In order to comply with Federal Constitution determinations about the basic principles of the SUS in terms of traditional health service organization, in 1991, the Ministry of Health implanted the Community Health Agent Program (CHAP) all over the country, as a proposal to change the traditional public health care paradigm(2,4).
However, when considered separately, the CHAP is a selective primary care proposal, creating increasing health service demands. Hence, in 1994, the Ministry of Health launched the Family Health Program (FHP)(2), understood as a strategy in the SUS basic health care model, in which the family health team corresponds to one of the care points in the municipal health system network(5).
Community health agents (CHA) can be part of an FHP team or the CHAP, which is considered a part of the FHP or a transition program towards the FHP, in those cities where only the CHAP exists(6).
According to the Ministry of Health, community health agents are professionals sui generis. They should live in the community itself, have a more social than technical profile, be over 18, with full-time availability to perform their activities. Among other tasks, they should work with families within a defined geographical base and register and follow these families(7).
The CHA's main instruments are interviews, home visits, family registers, community mapping and community meetings(3).
The CHA are responsible for analyzing community needs; being active in health promotion and disease prevention actions, especially involving children, women, adolescents, elderly and physically and mentally-impaired persons; participating in basic hygiene and environmental improvement actions; participating in health team meetings and other health events with the community(3).
Historically, the CHA represent the link between the professional team and the community(8), with the role of translating the scientific to the popular universe, of facilitating people's access to health services. Sometimes, however, they face the population's resistance to orientations, as well as difficulties to relate with community members or in the work process inside the health team(9-10).
Despite difficulties, the benefits the CHA's work all over the country have brought to the Brazilian population's health are undeniable, with decreased mortality and morbidity levels and improved rates in some health actions, accompanied by the community's valuation of their work(9-11).
Nowadays, a large number of CHA are active in Brazil. In December 2005, there were 208,104 CHA, i.e. 58.4% of the estimated national population was followed by CHA, calculating 575 persons per agent(12).
Thus, this study is justified by the large number of CHA professionals active in Brazil; the nature of their work; the Health Ministry's great stimulus to reorganize basic care through the expansion and implantation of new FHP teams in cities, where the CHA are fundamental actors; besides this professional's growing presence in the national health system.
The guiding question of this study is to find out to what extent and how scientific research has looked at CHA professionals as research subjects, or studied aspects related to their work.
Given the importance of these professionals, emphasized by the Health Ministry itself, we believe that several studies related to the CHA have already been realized.
This study aimed to carry out a literature review(13) on Brazilian CHA, with respect to the type of production and year of publication, different journals publishing the scientific articles, types of research design and their objectives.
This study is a literature review(13) about Brazilian community health agents.
To start the reference search, first, we accessed the site www.bireme.br and, after consulting the Health Science Descriptors (DeCS), we identified the following descriptors: Agente Comunitário de Saúde, Agente Comunitario de Salud and Community Health Agent, thus including publications in Portuguese, Spanish and English.
Next, using the same site, on March 3rd 2005, we accessed the databases of the Latin American and Caribbean Health Science Literature (LILACS), since 1982 (start date of the system's data collection); and the National Library of Medicine, responsible for MEDLINE, since 1966, using the descriptor words in the respective languages (Agente Comunitário de Saúde, Agente Comunitario de Salud and Community Health Agent), in singular and plural, in the field words in the title.
In LILACS, we found 127 references, which were printed out. Some of them displayed the title, year and place of publication, while others also included the abstract. Repetitions (29 references) and publications that were not related to Brazilian CHA (42 references) were excluded, resulting in 56 references, 50 of which were Brazilian and six international.
In MEDLINE, 26 references were found, which were excluded from this study because they referred to health agents from other countries (24 references), or because they had already been catalogued in LILACS (2 references).
The 56 (100%) references obtained from LILACS, which constituted our sample, were first catalogued and analyzed according to the production type and year of publication.
A large majority of references to books and book chapters did not contain an abstract, but only the title, year and place of publication. Hence, only journal articles, specialization course monographs, master's theses and doctoral dissertation were analyzed according to the different types of methodological approaches and research objectives. This information was obtained by analyzing the available abstracts.
We faced a number of difficulties in data collection: the non availability of some abstracts, as well as the fact that some abstracts did not contain information about the methodological approaches and objectives, related to articles as well as monographs, theses and dissertations. Despite these difficulties, we collected the desired information about a large majority of the abstracts.
Data were treated through absolute and percentage frequency analysis.
RESULTS AND DISCUSSION
In this literature review about CHA, we analyzed 56 references, 50 of Brazilian and six of international origin, which constituted our final sample.
Table 1 shows the distribution according to production type.
The above table shows that the most frequent references were books or book chapters (53.6%), followed by journal articles (32.1%) and master's theses (7.1%).
With respect to the books and book chapters, 19 of the 30 references we found were published by the Health Ministry, and five by the Pan American Health Organization, which demonstrates these governmental entities' interest in the theme and collaboration.
On the other hand, only eight (14.3%) references resulted from graduate (specialization, master's and doctoral) course research.
As to production year, the 56 references were distributed as shown in Figure 1.
As to the year of publication, we found 11 references (19.6%) until 1994, the first of which was produced in 1989. This corresponds to an average rate of two publications per year. Similar rates were found between 1995 and 1999. From 2000 to 2004, we found 33 references (59%), i.e. an average of 6.6 per year, which approximately represented a threefold increase in the number of annual publications in comparison with the two previous periods, revealing that publications about CHA are mainly concentrated in the last five years. In fact, this finding is proved when we analyze the history of the CHAP and the FHP in Brazil from the end of the 1990's onwards.
Moreover, as observed, the increase in research about this theme has occurred in non-geometrical proportions, probably due to the great expansion of the CHAP and the FHP in different Brazilian cities, mainly in recent years, confirming the Health Ministry's intention to turn the FHP not merely into another program, but into a strategy that attempts to change the traditional health care model.
A closer look at the articles published according to journal type shows that the 18 articles found in our survey were published in 11 different journals, eight of which contained just one article about our central research theme. The following journals presented the largest number of publications about the theme: Cadernos de Saúde Pública, with five articles (27.7%); Saúde em Debate, with three articles (16.5%) and Divulgação em Saúde para Debate, with two publications (11.0%) (Table 2).
We analyzed the 18 journal articles, two specialization monographs, four master's theses and two doctoral dissertations, totaling 26 studies, as to the methodological approaches they adopted. Results are shown in Table 3. This item could not be assessed in the 30 references related to books and book chapters, because most of them did not include an abstract, but only title, year and place of publication.
The analysis of these data revealed that the most frequently used methodology was experimental, adopting an empirical procedure for data collection, including group comparisons, follow-up studies or case studies(14).
We found no review studies. This can be explained by the fact that community health agents have only recently been introduced as health workers in Brazilian public health.
In three studies (11.6%), abstracts were not available or, when available, they did not contain information about the adopted methodology.
Nineteen studies used experimental methodology, seven (36.8%) of which looked at community health agents, and seven (36,8%) at agents and other subjects (five studies involving users, one including medical students and one Basic Health Unit heads, physicians and nurses). Two studies looked at users, one of which also involved CHA instructors/supervisors.
In three studies, the abstract did not clarify the research subject.
We found three studies that adopted the reflexive methodology, one of which was related to the CHA hiring mode, another to their incorporation into the public health system and the third to the use of human resources from the perspective of constructing the SUS.
Table 4 presents the objectives of journals articles, specialization monographs, master's theses and doctoral dissertations. Due to above mentioned reasons, this item could not be analyzed in the 30 book and book chapter references.
In a total of 26 studies, Table 4 shows that the most frequently defined objectives for journal articles, specialization monographs, master's theses and doctoral dissertation were related to the CHA's activity, including the work process (23.1%), results of their activities (19.3%), description of service implantation (3,8%) and acknowledgement and user satisfaction (3.8%), totaling 50%. This result is followed by publications whose objectives were related to the CHA's condition, whether in terms of their characterization and function (23.1%), their institutional relation (3.8%) and their health and work conditions (3.8%), totaling 30.7%.
The analysis of research abstracts that aimed to analyze the characterization of agents and their function (23.1%) showed that one of the studies attempted to construct the agents' identity in their work, with respect to interpretation conflicts and power relations established among FHP users, based on three perspectives: the agents' official training, the identity agents themselves produce about themselves and their practice, and the identity transmitted by the community.
Two studies tried to understand the phenomenon of religiousness, spirituality, personal beliefs and values, expressed through daily strategies and practices related to health, associating them with learning and obtained knowledge, also taking into account health education. Another study emphasized workshops in the context of a permanent education project developed with CHA, problematizing some manifestations by the subjects involved in the training process.
Health education has been discussed for a long time in academic means as well as public institutions. More recently, Permanent Health Education has been considered as "a fundamental strategy to recompose training, care, management, policy formulation and social control practices in the health sector..."(15).
One of the studies looked at the agents' social representations which they either elaborated themselves or which users produced about the CHA, and also analyzed the CHA's and users' social representations about psychosocial aspects and professional practices.
Furthermore, about the agents' characterization, one study sought to understand the CHA's profile in a metropolitan region, with a view to making viable the population's access to health services through two types of practices in carry out the proposed policies: one predominantly technical, by means of access to health services in all care stages, and another political practice, through the conquest of civil rights.
As to the CHA's work process (23.1% of references), three studies aimed to analyze the actions they developed in the health system. Another attempted to understand the communication practice between FHP agents and users, as a work instrument to improve health care.
In the same sense, one study about the CHAP discussed the determinant and conditioning factors to incorporate the agents into the Brazilian public health system. A research carried out in two cities in the Northeast of Brazil assessed the use of the Integrated Strategy for the Management of Prevalent Childhood Diseases by CHA.
Five studies (19.3%) evaluated results of CHA activities (in the CHAP and FHP), including: use of health services, population's knowledge about CHA; effects on health practice modifications; mean number of visits/month per family; hospitalization rate among children under five years old; use of oral rehydration solution; diarrhea control; deaths of children under one year old; basic vaccination coverage; prevalence of height/age deficit and incidence of low birth weight.
One article discussed the agents' institutional relation and reported on the need to hire outsourced workers for direct social service delivery of collective interest.
The decentralization of health provoked changes in the way health professionals are hired, mainly due to the expansion and implementation of health programs, which created a large increase in professional hiring. Thus, many cities started to use different forms of hiring. The Health Ministry established a committee that defines strategies to reduce the precariousness of health work in the SUS. Health professionals' work relations should be guaranteed, with all due labor and social security rights, as well as the democratization of work relations(16).
One article discussed the ethical question about the right to privacy in relations between users and CHA, with respect to access to certain user information, such as disease diagnoses for example.
Another article described the implantation of primary health care work in Rio de Janeiro slums, where CHA were responsible for a specific population.
One research about health and work conditions, involving fifteen CHA, aimed to identify epidemiological and clinical aspects that could be associated with the risk of exposure to pesticides.
Despite the importance of user satisfaction in health services and actions, only one study attempted to identify if CHAP users acknowledged the role and importance of the CHA's activities, as well as users' satisfaction about these agents' work.
The results of this study show a large rise in publications about CHA in recent years, mainly after the year 2000. Especially books, book chapters and journal articles increased, possibly due to greater interest in this professional, considering that the Health Ministry has encouraged the expansion and implantation of new FHP teams all over the country.
Literature reviews can characterize the trajectory followed to achieve current knowledge and guide new research projects(17). Thus, we observed tendencies in studies about CHA, emphasizing their activities, whether by analyzing the work process or by assessing the results of their activities, as well as characterizing agents and their functions.
More studies should look at CHA, considering the agents as person, their dilemmas, difficulties and achievements, i.e. factors that can be influenced by the peculiar nature of their work or not.
Other important research is related to polemic and essential issues in health work management and health education, such as the hiring of SUS workers; function plans, careers and wages and permanent education in the SUS(16), mainly at municipal level.
Although we could not analyze the quality of publications in this review, we believe that this study allowed us to characterize how research about Brazilian CHA has been conducted.
In view of the short time these professionals have been inserted in the health area, many studies must be looking at community health agents, and the number of publications may increase in the next years. We hope that, despite its limitations, this literature review may encourage new studies about CHA.
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Recebido em: 7.7.2005
Aprovado em: 22.5.2006