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Potentialities in integral care: uterine cervical cancer prevention according to the users of the family health strategy

Abstracts

This study aimed to analyze the integral care in the uterine cervical cancer prevention practices in the conception of users of the Family Health Strategy through an exploratory and descriptive research with a qualitative approach. A total of 14 users who performed the Pap smear in December 2002 in four Family Health Units affiliated to Higher Education institutions were selected for the study. Data were collected between April and June 2003. We found that the users analyze and assess the praxis by issuing a value judgment about the care they receive, mainly in terms of light (relational) technologies. Concluding, humanized practices provided by professional/team favor integral care, strengthening the bond between users and health services, as well as health promotion.

comprehensive health care; vaginal smears; family health


O objetivo deste estudo foi analisar o atendimento integral nas práticas de prevenção do câncer do colo do útero na concepção de usuárias da Estratégia Saúde da Família. Foi realizada pesquisa exploratória e descritiva com abordagem qualitativa dos dados. Foram selecionadas quatorze usuárias que realizaram o exame Papanicolaou no mês de dezembro de 2002 em quatro Unidades de Saúde da Família, vinculadas a instituições de nível superior. Os dados foram coletados no período de abril a junho de 2003. Como resultado foi observado que as usuárias analisam e avaliam a práxis emitindo juízo de valor à assistência recebida, principalmente, no que se refere às tecnologias leves (relacionais). Conclui-se que práticas humanizadas com responsabilização profissional/equipe favorecem cuidado integral fortalecendo o vínculo das usuárias com os serviços de saúde e a promoção da saúde.

assistência integral à saúde; esfregaço vaginal; saúde da família


El objetivo de este estudio fue analizar la atención integral dentro de las prácticas de prevención de cáncer de cuello uterino bajo la concepción de las usuarias de la Estrategia Salud de la Familia. Investigación de tipo exploratorio y descriptivo con enfoque cualitativo. Fueron seleccionadas catorce usuarias quienes realizaron el examen de Papanicolao durante el mes de diciembre de 2002, en cuatro Servicios de Salud de la Familia vinculados a Instituciones de Enseñanza Superior. La recolección de datos fue realizados entre abril y junio de 2003. Los resultados demuestran que las usuarias analizan y evalúan la atención recibida formando su opinión, en especial, con relación a las tecnologías leves (de relación). Se concluye que las prácticas humanizadas con responsabilidad profesional/equipo favorecen al cuidado integral, fortaleciendo el vínculo entre las usuarias con los servicios y la promoción de la salud.

atención integral de salud; frotis vaginal; salud de la familia


ORIGINAL ARTICLE

Potentialities in integral care: uterine cervical cancer prevention according to the users of the family health strategy

Michele Mandagará de OliveiraI; Ione Carvalho PintoII; Valéria Cristina Christello CoimbraIII

IProfessor, Federal University of Bahia, Brazil College of Nursing, PICDT grant holder, Doctoral Student, e-mail: mioliveira76@yahoo.com.br

IIPhD Professor, e-mail: ionecarv@eerp.usp.br

IIIProfessor, Federal University of Pelotas College of Nursing, Brazil, Doctoral Student University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Center for the Nursing Research Development, Brazil, e-mail: valcris@eerp.usp.br

ABSTRACT

This study aimed to analyze the integral care in the uterine cervical cancer prevention practices in the conception of users of the Family Health Strategy through an exploratory and descriptive research with a qualitative approach. A total of 14 users who performed the Pap smear in December 2002 in four Family Health Units affiliated to Higher Education institutions were selected for the study. Data were collected between April and June 2003. We found that the users analyze and assess the praxis by issuing a value judgment about the care they receive, mainly in terms of light (relational) technologies. Concluding, humanized practices provided by professional/team favor integral care, strengthening the bond between users and health services, as well as health promotion.

Descriptors: comprehensive health care; vaginal smears; family health

INTRODUCTION

Specific Uterine Cervical Cancer Prevention (UCCP) measures were strengthened in the early 1980s with the creation of the Integral Women's Health Care Program (IWHAP), launched in 1983, which prioritized integral care to women's health(1).

Nowadays, the UCCP integrates Primary Care actions directed at specific population groups, inserted in the Primary Care Organization Manual(2), and is recommended as one of the actions of the Family Health Strategy (FHS)(3).

This study presents part of the results of one of the author's Master's thesis about the UCCP. Integral care is discussed in terms of the different technologies that permeate this practice.

The discussion is based on the assumption that integral care perceives and delivers care to the woman's health as a whole, solving the need that is manifested, specifically considering the use of light light heavy heavy technologies in UCCP practices. Integral care can be promoted at the exact moment the user comes to the health service for a pap smear or even at her home, during the Community Health Agent's visit (CHA).

Integral care is the second essential guideline of the SUS (Single Health System) and indicates priority for preventive actions without impairing care services(4).

Light technologies in health work operate by creating their own way of governing processes, constructing its objects, resources and intentions, acting in a certain way, in the intercessor space, when the worker and the user meet for the production of goods-relationships(5).

This worker/user meeting happens in the intercessor space that reveals questions about the health production processes (health-disease and work processes). In every place this meeting occurs, the technology of relationship is used, that is, in every place this technological process occurs, live work is in action, which aims at the process of listening to needs, with a view to exchanging information, mutually recognizing rights and obligations and making decisions that allow for interventions(6).

Working with a multiprofessional team in woman's health care is an appropriate approach in integral care. However, an efficient team work is not easy to reach, and the most obvious challenges are communication and information transference, needed for integral care(7).

UCCP practices directed at providing health education, stimulating self care, realizing the pap smear exam, providing medical and nursing consultations in the woman's health area and making the user return to pick up the result, are different moments of the service/professional/user relationship. The use of different technologies in a work that is done live, whether relational or structured, contribute to an integral practice(8).

Expanding the discussion, we perceive that both technologies can occur at similar moments. However, the professional who has a work process based on a more comprehensive perspective of health and a differentiated view of praxis, will use the different technologies delivering integral care with a view to the humanization of care and care quality.

Once standardized, the welcoming, for instance, will escape from the relational perspective, and will become hardened by the imposition of the professional/team's knowledge, that is, in the practice of dead work.

However, what can be perceived is that many family health professionals/teams are moving in the direction of integral health practice, even when facing remaining obstacles from the biomedical model, focused on the specific complaint and on the disease.

In view of these aspects, the aim of this research is to analyze integral care in uterine cervical cancer prevention practices according to FHS users.

METHOD

A descriptive and exploratory study with a qualitative approach was performed. Data collection followed the logic of the semistructured interview. Users who were subject to the pap smear in December 2002 were selected for the study. Data were collected between April and June 2003.

W interviewed 14 women attended in four Family Health Units, who accepted to participate in the study. These family health units were selected because of their linkage to a higher education institution in Ribeirão Preto, São Paulo, Brazil. The users are identified by their self-denominations: Tranquility, Love, Passion, Communication, Calmness, Fear, Joy, Sadness, Emotion, Sensibility, Quietude, Precious, Nostalgia and Happiness.

RESULTS AND DISCUSSION

When analyzing the UCCP practice, we could observe that the user who comes to a health service to have a pap smear will probably be advised/attended by a multidisciplinary team from her arrival up to her departure from the FHS. UCCP practice will probably use all light/light-heavy/heavy technologies, although it will be in general care that care will be qualified, from the technician's as well as from the user's own point of view.

In the selected statements, we could observe that the user herself perceives and evaluates the praxis, making a value judgment at the moment she reports that "it was good", and this value judgment, whether positive or negative, is important for the construction of integral practices in health services.

The health system user, through community participation in social control, has the competence to evaluate and intervene, modifying the health system itself(9).

The statements also indicate that the users recognize the technological differences that permeate the entire process of prevention practices related to the professional/team-user meeting, in terms of education in health, the pap smear, the result and treatment, if necessary.

I didn't feel embarrassed here, I got comfortable, relaxed, didn't feel a thing, the speculum is a little uncomfortable, but it is bearable (…) I felt comfortable, we are always afraid of the result, but thanks God, I got one of these common things, with a little ointment it got better (…). There is room to change clothes, to put on the apron (…) (Communication).

It can be perceived in Communication's statement that her satisfaction is related to the physical environment, regarding some care taken in the organization of the room, providing the woman with a feeling of respect about care for her body, which for the user was translated as tranquility and acceptability of the place, of the professional's presence and of the collection of the pap smear.

The necessary requirements for the organization of the UCCP room include a place to change clothes, highlighting the importance of aprons or sheets to cover the user, besides the previous organization of the materials used in the collection(10). This care can be interpreted as technology that interferes in care quality in integral care.

The health professionals can present the room, the materials used in the exam and explain the importance of taking the pap smear, both in individual consultations and during health education(11).

It was very good, I always make appointments with the Dr., she collected the exam. The Dr. explains things to me, she also exams the breasts and tells me to do the exam at home, always after my period, even teaches me how to do it. Generally, they talk explaining how they are going to do the exam and when they will put the speculum, they use the little brush and that they are already putting it in the lamina, I remember she said that there was a little infection and she put a remedy (Happiness).

Happiness' report reveals the user's satisfaction with care at the moment of the pap smear, presenting aspects related to the use of relational technologies in synchronicity with heavy technologies, when the user mentions health education, the moment and the steps of the pap smear, as well as the immediate solution for the detection of a local problem and its treatment.

The users' evaluation, making a value judgment on the received care, presents potentialities related to the care offered in the respective FHS, acknowledging the FHS as a health service that appears in the scenario of the health organization and that allows for the institutional representation of services that propose differentiated and high-quality professional practices.

It was good! (...) I was well attended, did the prevention exam, the physician talked to me, explained the why of the exam, that we have to keep doing it, she passed confidence, talks, making me feel really comfortable, so it was a really good thing (Love).

The care was not 10% but 100%, because I was like all embarrassed for having gone all by myself to the doctor, face to face asking questions about your life, but you start to talk, just like confessing to the reverend (…), at the beginning of the exam I was embarrassed, but he was there in front of me not only as a doctor, but as a friend! He is a very nice person and very attentive as a physician, (…) he is not like those people you go to for a consult and are badly attended. In the FHS, I was well attended both by the nurses and by the physician (Joy).

I was well attended, never had problems there (...). There are less people there, they give better care, the agents and the doctor are closer there than at the health station, they remember our names, there are less barriers, is like family really (Tranquility).

The care here is much better, if you have something, they say, I'll try to fit you in, otherwise they go to your home (…) (Passion).

The users talked about the good care the professionals delivered, relating it to the characteristics of the light technologies (welcoming, bonding, listening, attention and affective closeness), which suggests that popular knowledge recognizes these technologies as characteristics "inherent to the good professional"

In a previous study, it was observed that the proportion of pap smears is higher among women who have been registered at FHS units for a longer time, which suggests an association between the pap smear and greater bonding with the service by the users(12).

Bonding, welcoming, listening are perceived, analyzed and evaluated by the users, which is why they emit a value judgment, differently from the evaluation of professional practice, with regard to the deficit of relational technologies.

The lack of listening and welcoming interferes negatively in the relationships of bonding (user-professional-service), and can contribute to the users' dissatisfaction with the proposed care, as can be observed below.

They said they would collect the exam, and I said ah, but I am not prepared, (…), then he called another doctor, then the other one said you will have to do the exam, there is no need to be embarrassed, every woman goes through it (…) I found it bad because for me it didn't help at all (Calmness).

Isolated actions by some health professionals tend to affect the whole, that is, considering the whole, as the team's performance in the construction of quality care, to which the FHS is committed.

There is a need to reflect about FHS practices, about the commitment and responsibility of the professional/user to the transformation of the biomedical care model to a techno-care user-centered model that allows for integral practices(7).

The health team needs to be attentive to the users' complaints, doubts and anxiety, that is, the health professional must develop the capacity of interaction and exchange, needs to be able to listen and talk, avoiding technical or scientific terms, so that the user understands and also feels understood and cared for, as a form to encourage her to control her fear and embarrassment(11).

A humanized practice, which develops the interaction capacity and acts not only with technical preparedness, but also with intuition and sensitivity, would certainly contribute to the quality of the care delivered to the women, during the realization of the pap smear(11).

The technologies end up complementing each other, in terms of care integrality. The users perceive this integral and quality care and get involved with the team, with the service activities and with health promotion.

(...) it is good to prevent and especially in here, I know there are regions, depending on where you live, each person is attended in her own neighborhood, but I like it here, it is very good (Happiness)

They attend me wonderfully well! (…) The attention, politeness, respect, we arrive and they come with affection, smiling (Passion).

Being polite, they are not rude, they attend you with patience and a lot of patience, they listen to what we say (Fear).

The implementation of the FHS is a great challenge for the professionals, for the population and for the managers who need to break with established power practices at the services. The participation and commitment of all actors is needed. Group discussions of health education with the users of the FHS can help in the construction of integral care in the UCCP.

Group discussions of health education with users of the FHS can help in the construction of integral care in the UCCP because both bonding and making them co-responsibles for their health are strengthened by dialogue(13).

Therefore, the health professionals/teams need to attend the users according to the integral care view, including health education(14), with a view to facing the challenge and coping, still at primary health care level, with the precocious detection of uterine cervical cancer.

CONCLUSIONS

Health care organization in accordance with the reorientation proposal of the care model and the qualification of primary health care, aims to facilitate the access to the basic needs, greater coverage and care quality. Therefore, the UCCP practices can be qualified in the FHS provided that the professionals/teams promote integral care recommended by the SUS.

UCCP practices in the FHS need to be qualified by managers, by professionals/team and also by users, because integral and quality practices need to be conducted in all directions of care.

The users of the FHS, however, can and should take part in this proposal of responsibility and commitment to integral care, since they recognize and evaluate the praxis as users of the health system.

The users need to participate actively in its social context, in the search for and assurance of integral care, since they are citizens and co-participants in the service.

Recebido em: 29.9.2006

Aprovado em: 24.1.2007

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Publication Dates

  • Publication in this collection
    12 July 2007
  • Date of issue
    June 2007

History

  • Received
    29 Sept 2006
  • Accepted
    24 Jan 2007
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