versión On-line ISSN 1518-8345
Rev. Latino-Am. Enfermagem v.15 n.6 Ribeirão Preto nov./dic. 2007
Ana Carolina Dias VilaI; Vanessa da Silva Carvalho VilaII
IRN, MS in Environmental Sciences and Health, Professor University Salgado de Oliveira, Brazil, e-mail: firstname.lastname@example.org
IIRN, PhD in Nursing, Assistant Professor I da Goiás Catholic University, Brazil
This literature review aimed to identify the concept of Health Education used by researchers in Collective Health; to present the main trends and pedagogical references defended in these studies and to exemplify studies constructed with the objective to promote health education by means of participant strategies with the community's involvement. After reading and analyzing 22 articles searched in the Scientific Electronic Library Online that answered the study questions, the following categories of analysis were constructed: Health Education in Brazil - conceptual aspects; pedagogical practices in education and health; health education applied to professional practices. Health education is an essential field to the development of a society and educative practices are opportunities to apply knowledge directed to social growth. The importance of educational proposals based on the reflection, critique, involvement and awareness is perceived, as well as the importance of implementing new educative programs to meet the population's needs.
Descriptors: health education; public health; nursing
Collective health can be considered a field of scientific knowledge of interdisciplinary nature that "looks at social health needs, with distinct knowledge, disciplines, material and non-material technologies as work instruments, and interventions focused on social groups and on the environment as activities"(1). It consists in the "art and science of preventing diseases and disabilities, prolonging life and promoting physical and mental health in the face of the community's organized efforts(2-3). In Brazil, this field of knowledge is based on health promotion and prevention, aiming at a better quality of life to the population.
During curriculary training supervision in a Nursing course in Collective Health, I could observe the reality of care delivered to the clientele at a municipal integral health care unit responsible for outpatient care in the clinical and pediatric areas, as well as emergency care to a defined geographical area. These clients' needs were observed during this period, especially regarding aspects related to the care flow chart information, necessary health care, as well as the nurse's distancing and even absence, not participating in the carel activities of his(er) competence such as: nursing consultation, diabetics, hypertensive patients, pregnant women, adolescents and elderly orientation groups. It is important to highlight that lack of information generates a poor interpretation of the prescribed treatment, of the care necessary for rehabilitation, in sum, that it promotes ineffective treatment.
In this sense, a demand for care regarding Health Education to individuals in this community was verified, displaying lack of preparedness, non-prioritization of education in health as an intervention strategy for the construction of knowledge and, consequently, for the improvement of health care to the individuals and community attended in this scope area.
Education in Health must be a priority among nursing activities, especially in a care site so close to the community. The nurse professional is apt and trained to deliver care to the patient and his(er) family, attend them in all their existential dimensions, taking into account healing, preventive and educative needs in health care.
In this perspective, this study was developed to answer the following questions: what is education in health? Which pedagogic reference frameworks in education and health are discussed by researchers in Collective Health? Which studies can exemplify trends of educative practices in health in the community?
This study will contribute to elucidate the concept of Education in Health, as well as to identify the reference framework used by these studies, which can contribute to the planning and implementation of educative programs able to actually attend to the community's needs.
First, scientific production on Education in Collective Health was surveyed in periodicals indexed in the Scientific Electronic Library Online (SciELO), which comprehends the selected collection of Brazilian scientific journals. Through this bibliographic search, it was evidenced that, among the journals indexed in the database, the following stood out in terms of publications on this theme: Journal of Public Health; Reports in Public Health and Latin American Journal of Nursing.
These periodicals were selected because they are nationally and internationally relevant, with classification A, B and C international by the Qualis system - Periodicals, Annals and Journals classification. The Qualis system is the result of the classification process of vehicles used by graduate programs for the dissemination of their faculty and students' intellectual production. This system was created by the Coordination for the Improvement of Personnel of Superior Level (Capes) to meet specific graduate evaluation needs. The scientific periodicals fit in categories that indicate quality - A, B and C and circulation scope (international, national or local).
Thus, the period defined for the search is related to the date of the periodical's first publication in the electronic library until 2005. Articles with the following key words were selected: education in health, collective health, education and health and education in nursing. Initially, 160 scientific articles were surveyed, as described in Table 1.
From this initial search, the following inclusion criteria were defined: studies related to education in Collective Health, pedagogical trends used by health professionals, studies that denote pedagogical practices in Education and Health. From the reading of abstracts of these articles, 75 were selected for analysis of the full version, resulting in the final selection of 22 articles, which were the references guiding this study, as described in Table 2.
Articles that did not address education in health in terms of the Collective Health reference framework were excluded. From the reading of these articles, the bibliographic analysis categories regarding knowledge production on Education in health were built as a reference framework for Collective Health. These categories are: education in health in Brazil - conceptual aspects; pedagogical practices in education and health; education in health applied to professional practice. These are presented and discussed below.
EDUCATION IN HEALTH IN BRAZIL - CONCEPTUAL ASPECTS
From the critical review of the surveyed studies, it was evidenced that education in health is understood as a multifocused field to which several conceptions converge, both in education and health, which reflect different understandings of the world, the human being and society. It is an instrument that allows individuals to understand what happens in society, broadening their view of the world they are inserted in. By stimulating education and health, it is possible to transform, develop ideas, create means and support the growth and development of a society(4-6).
Education in health is understood as a means to exchange information and to develop a critical view of health problems and not as a limited process of information transformation(4); it can be perceived as a social fact that involves subjective factors and aspects; it can be considered a social practice, because it is attitude, performance, experience, something that happens at each instant.
Education in health aims to elicit the involvement of the community in health programs, include public policies, promote conceptual transformations in the understanding of health, relate liberating proposals, committed to the development of solidarity and citizenship, towards actions whose essence is the improvement of quality of life. Educating is characterized by the need of the educator to master scientific, technical, pedagogic, investigative, interdisciplinary and cultural knowledge(7). Practicing education in health is practicing socialization, because it is something produced for the social, for an action focused on the human activity.
In the nursing context, practicing education in health is to provide the individual with conditions so that s(he) (her)himself seeks, exposes, questions, lives, experiments, creates, contributes, rescues, acquires his(er) place in society, reaches objectives and ideals and makes dreams come true. It is to acknowledge man as a subject responsible for his own reality(5). This is not a very easy task because it requires dedication, perseverance and desire by the educator and of learner, but it certainly is a very pleasurable task.
Nursing must be seen as a social practice directed to the communitarian and human side; a tie that interconnects individual-society-health-environment. The nurse is closely linked to the practice and educative interventions because s(he) is increasingly prepared to develop his/her role as an educator.
PEDAGOGICAL PRACTICES IN EDUCATION AND HEALTH
Regarding educative practices in health, researchers report that they are a space of production and implementation of knowledge destined to human development and must favor the teaching-learning process through the adoption of pedagogical reference frameworks that promotes the subjects' critical and participative reflection(6).
Among the pedagogical practices discussed in literature, the traditional or conditioned pedagogy and the critical or renewed pedagogy(6) are highlighted. In the traditional or conditioned pedagogy, actions are focused on the teacher's knowledge. The teacher assumes the function of surveilling the students, correcting tests and teaching the subject. The teacher is seen as the maximum authority in the classroom, the only one conducting the process. In this pedagogical practice, the learner receives the knowledge passively, becoming the depository of information provided by the educator. This practice is also denominated "banker education". Educating for filing what is deposited, that is, "it is assumed that the more one gets, the more one knows"(8).
Critical or renewed pedagogy, also known as "problematization pedagogy and/or pedagogy of freedom", has its origins in the popular education movements that occurred in the 1950s. It defines education as an activity in which teachers and students are mediated by the reality they learn and from which they extract the learning content, reach a level of awareness of this reality, which allows for social transformation. Liberating education questions the reality of the human being's relations with nature and with others towards transformation(4,9-11).
Problematizing education works with the construction of knowledge from experiences, based on learning by discovery processes, as opposed to those of reception(12). From self-knowledge and self-reflection, the individual becomes more aware of his(er) responsibility and acts, which certainly facilitates learning(5). In this sense, learning occurs through a motivated action; what is learned is not a consequence of imposition or memorization, but of the critical level of knowledge, which one reaches by the understanding, reflection and critical process.
The studies analyzed indicate that the educative practices guided by the problematizing pedagogy are the most adequate for education in health because, besides valuing the learner's knowledge, it also gives him(er) means to transform his(er) reality and h(er)imself, respects the clientele's right to information in order to establish a more active participation in health actions(7).
Education must help the learner to achieve awareness and a critical attitude towards a change of reality, must be considered as a part of quality of life and cannot be segmented: either one obtains a total transformation of h(er)imself and h(er)is project of life or nothing is transformed.
Educating does not mean simply transferring knowledge, but consists in the educative process that considers the representations of society and man who wants to acquire education. Through education, new generations acquire other cultural values. Education based on reflection, dialogue and exchange of experiences between educator/learner and professional/client, allows both to learn together through an emancipating process.
As an example of the need to insert problematizing education in the formation of health professionals, the article entitled - Londrina State University's nursing course in the construction of a new pedagogic proposal(13) is highlighted. This study aimed to recall the history of Londrina State University's Nursing Curriculum since its implementation, in 1972, until the current one, implemented in 2000. The author reports that the nursing curriculum of this institution went through five changes across its implementation, all of them due to quality improvements in teaching and health care delivered to the population.
The current curriculum is highlighted in the article characterized as "Integrated Curriculum", based on the critical-social conception and on the problematizing pedagogy. The author emphasizes that the adoption of this pedagogical reference came to break with traditional teaching, based on the reproduction of concepts, and met the need to form a new nurse profile with a holistic and not fragmented view of the human being, capable of acting in the care, management, teaching and research areas.
As a result of this integrated change process, a new pedagogic proposal is highlighted, based on the certainty that the student is the active subject in the knowledge construction process, in which the teacher's role is to conduct the teaching and learning processes by continuously challenging the student's rationale, by integrating new knowledge to previous experiences.
It is perceived that this work involved discussions on principles, values and beliefs that guide the nurse's education to meet demands of the work and job market, without losing the capacity to criticize, reflect and act(14).
Other studies also discuss curricular issues that involve education of health professionals, using problematizing education as the teaching method to form critical and reflective professionals, capable of dealing with the social reality they experience(11).
EDUCATION IN HEALTH APLIED TO PROFESSIONAL PRACTICE
Three studies were selected(4,14-15) as examples of potential Educative Actions in Health, which denote the importance of searching participative reference frameworks, using a pedagogy that allows the individual/community to describe their critical, dialogued, reflective and constructive awareness, based on collective educative work(8).
The first study selected was Communitarian intervention and reduction of women's vulnerability to STD/AIDS in São Paulo(14). It is a community-based intervention study that aimed to develop and evaluate a set of STD and AIDS preventive actions focused on the vulnerability of low-income female population.
The study was carried out in São Paulo and involved actions like: training of health professionals from the local outpatient clinic; availability of preservative resources (female and male); performance of educative groups; distribution of educative materials and communitarian radio programs.
The study counted with community participation, including women, men, adolescents and health professionals. The authors appointed the following results: greater search for STD and AIDS prevention, great possibility of developing strategies linked to sexual and reproductive health and the realization of education in collective health through community participation.
The educative activities were scheduled according to the community's availability. The themes discussed during the work were: sexuality and STD, pregnancy and contraception. The authors perceived that the strategies corresponding to the demands and specific interests of the local culture were more successful regarding educative and preventive actions. In addition, the work overload of the local outpatient clinic's health professionals was a limiting factor for a sustainable preventive action. Through this study, the involved health team and community perceived the great impact of educative and participative practices inside the community and that through education, each person's participation and interest, it is possible to transform and educate the population.
The second study entitled Educative booklet for maternal orientation regarding the preterm baby(4) aimed to develop didactic-institutional material, of easy understanding, focused on maternal training in order to prepare the mother for hospital discharge of the preterm baby.
The authors used the participative methodology, which favored the exchange of experiences, questions, information and humanization in the group. Two nurses, two nurse auxiliaries and four mothers of premature babies, hospitalized in the hospital unit, participated in the study.
Four meetings with the study participants were realized, in which a proposal to create an informative-educative booklet was discussed and suggestions on the material were given. They decided on the creation of the illustrated educative booklet, of easy understanding, which could be taken home and would address issues such as: baby's daily care, feeding, hygiene, special care and family relationship.
The use of the participative and critical methodology allowed the study participants to exchange experiences, expose doubts and share problems experienced in their routine. The final version of the educative booklet was evaluated by the participants and was a creative instrument to help in the educative activities in health directed to the clientele. It is perceived that this experience favors the development of educative activities in health in an informal, creative way, coherent with the community's needs(4).
The third study selected was Promoting play in the infant hospitalization context as a health action(15). It aimed to explore the meaning of promoting play in infant hospitalization for health professionals who work directly or indirectly with this proposal.
The authors consider infant hospitalization a potentially traumatic experience, which distances children from their routine, from the family environment, and confronts them with pain, a physical limitation that generates feelings of guilt, punishment and fear of death.
The study was carried out in three hospitals with pediatric hospitalization, located in different Brazilian regions (Northeast, Southeast and South). A total of 33 professionals were interviewed, involved with recreational activities in these institutions.
As to the organization of play, the three hospitals were concerned with the use of recreational activities; two already used them as a form of therapeutic intervention whereas, in one institution, there were no actions interconnected with the promotion of recreational activities. The professionals reported that the institution was going through a process of focusing on recreational actions.
Regarding the meaning of recreational promotion, authors relate play as something pleasurable, which brings joy and rescues the condition of being a child; identify playing as a facilitator for interaction between health professionals, children and caregivers; analyze it as a more democratic space in which individual experiences are valued. There are possibilities of choices and the child's free expression. The authors see playing as a therapy, as it is presented as a possibility of elaborating experiences related to hospitalization, allowing one to reduce anxiety and reorganize feelings.
The authors appoint the possibility of promoting play in the space of infant hospitalization as a facilitator of an interaction dynamics that resignifies the traditional model of intervention and care delivery to hospitalized children.
The study shows play as a form of therapeutic recreation, which benefits the child and acts as a communication and education vehicle that offers information related to the disease and treatment, in a language accessible to the patient and family. Moreover, it identifies the promotion of playing as a facilitator of interaction and professional-child-family bonding.
As nurses, we acknowledge that studies related to educative practices in health are important, and that promoting education in health is possible, since good health professionals are inserted in the job market, promoting humanized and differentiated care; are getting prepared and are studying to practice education.
These studies contribute to reflect on our practical conducts, rethink what kind of professionals we are and our role regarding our client. We cannot forget that promoting health in education demands technical-scientific knowledge, commitment, involvement, favorable work conditions, time by the professional and community and continuity of actions, because we are dealing with human beings, individuals capable of overcoming their problems and search for solutions. When we practice education in health, all of us (professionals, family, community and students) obtain gains.
Through this study, concepts, research, pedagogical reference frameworks, examples and potential proposals for the promotion of education in health were found. It was perceived how Education in health and pedagogical practices have been implemented in the professional practice in Brazil; and how the health professional is increasingly more prepared and apt to practice education in health.
Based on the theoretical reference framework analyzed, the need for new educational proposals is highlighted, based on critical perception, reflective analysis, dialogue, involvement, respect and awareness. The perception is that new studies are necessary to contribute to the implementation of educative programs that attend to the whole community, curricular change proposals that adopt the participative and problematizing reference framework, new research related to education in health, since they will certainly contribute to mediate the relation between theory and health professionals' practice.
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Recebido em: 8.6.2006
Aprovado em: 16.8.2007