Health promotion on amazonic riverside population: experience report

Abstract:

PURPOSE:

to report the health promotion actions conducted on riverside communities by the expeditionary teams of "FOB-USP in Rondônia" project.

METHODS:

this is a cross-sectional, observational study, which consists in an experience report of interdisciplinary expeditions to the Tabajara-RO, Calama-RO, Demarcação-RO and Rio Preto-RO communities. Data collection has occurred by means of medical records, annotations on field diaries and participant observation. The adopted approach to guide the development of this paper lies on the work of the team during the clinical care and community attention moments.

RESULTS:

1042 riverside patients were assisted, being covered also educative and human aid actions the communities have shown as main income sources fishing and subsistence agriculture. Sewer is collected in septic tanks in the open Water comes from rivers or artesian wells. The houses in all of the communities are mostly made of wood. In regards to clinical procedures, 974 in the speech, language and hearing sciences area, being the most common complaint on the hearing area, and 854 dental procedures being mostly performed dental extractions and restorations. Educative actions were taken in all of the communities.

CONCLUSION:

1828 procedures were performed, of which 1100 were clinical and 728 were educative. Access conditions have proven to be precarious and health problems linked to the speech, language and hearing sciences and dental areas were presented as complaints, with dental caries and periodontal disease as main concerns. Need for improvement on access to essential services for the riverside populations has been demonstrated, maintaining regular and continuous care for the implementation of effective educative and health promotion activities.

Keywords:
Speech, Language and Hearing Sciences; Dentistry; Health Promotion; Health Education; Disease Prevention

Resumo:

OBJETIVO:

relatar as ações de promoção de saúde realizadas em comunidades ribeirinhas pelas equipes expedicionárias do projeto "FOB-USP em Rondônia".

MÉTODOS:

trata-se de um trabalho transversal observacional, que consiste em um relato de experiência de expedições interdisciplinares às comunidades de Tabajara-RO, Calama-RO, Demarcação-RO e Rio Preto-RO. A coleta de dados ocorreu por meio dos prontuários, anotação em diários de campo e observação participante. O enfoque adotado para guiar o desenvolvimento do presente trabalho está no trabalho da equipe, nos momentos de atendimento clínico e comunitário.

RESULTADOS:

foram atendidos 1042 ribeirinhos abrangendo ações assistenciais e educativas. As comunidades exibiram como principal fonte de renda a pesca e a agricultura de subsistência. O esgoto é coletado por fossas sépticas ou a céu aberto. A água provém dos rios ou poços artesianos. As casas em todas as comunidades, em sua maioria, são de madeira. Quanto aos procedimentos clínicos, foram realizados 974 fonoaudiológicos, sendo as principais queixas na área de audiologia, e 854 odontológicos com maior realização de exodontias e restaurações. Ações educativas foram realizadas em todas as comunidades.

CONCLUSÃO:

foram realizados 1828 procedimentos, dos quais 1100 foram clínicos e 728 educativos. As condições de acesso mostraram-se precárias e as alterações de saúde referentes às áreas fonoaudiológica e odontológica apresentaram-se como queixas e alterações auditivas e cárie dentária (principalmente) e doença periodontal. Verificou-se a necessidade de aprimorar o acesso das populações ribeirinhas a serviços essenciais, mantendo-se atendimentos regulares e contínuos, para a realização de atividades de educação e promoção de saúde com efetividade.

Descritores:
Fonoaudiologia; Odontologia; Promoção da Saúde; Educação em Saúde; Prevenção de Doenças

Introduction

The term Health Promotion (HP) has been covered, in several contexts along the years, when discussing questions about the health sector for obtaining better quality of life. The definition of HP has broader meaning than prevention, since adopted measures are not directed to a specific illness or disorder, but to help improve health and well-being, emphasizing change on life and work conditions on a population¹. Therefore, HP has for support the factors related to the aspects which permeate the quality of life such as: an adequate standard for feeding and nutrition, housing and sanitation; good work conditions; access to education; clean physical environment; social support for families and individuals; responsible lifestyle; and an adequate spectrum of health care services. This way, such actions return to the collectivity having the population empowerment as one of its pillars², allowing for healthy expansion for the subject personality individually, and also their condition to become politically organized and take part in social changes among the society³.

In this context, given Brazil's territorial extension, it is possible to find populations residing not only in urban or rural areas, but also along the margin of rivers, the so-called riverside communities. The term riverside people applies to any population who live on the margin of rivers. Riverside people are isolated not only from general culture, but also from access from written, TV and radio medias, and from other denizens of the community as well, since the distance between residences can be higher than 2000 meters. On interaction terms, the rivers acts as a constrictor, contact source, barrier and environmental bridge, creating and restricting interaction possibilities, mainly for children ^{4 5}.

Nowadays, health care is given to this population by means of the National Basic Health Care Policy (Política Nacional de Atenção Básica), implemented in the country by the orders MS/GM No. 2.488 and 2.490, both from 2011, geared towards the implantation and operationalization of health activities, as well as to define the amount of funding to the Riverside Family Health Teams (Equipes de Saúde das Famílias Ribeirinhas - ESFR) and expenses of the Basic Riverside Health Units (Unidades Básicas de Saúde Fluviais - UBSF), specially in the Amazon area⁶.

"FOB-USP em Rondônia" is a university extension project which seeks to develop prevention, educative and rehabilitation actions in the areas of Speech, Language and Hearing Sciences and Dentistry. Three times a year, a team composed of students attending graduation and post-graduation, workers and teachers from a public university in the state of São Paulo, travel to the area, being based on the Unique Health System (Sistema Único de Saúde - SUS) directives, in parallel to the previously mentioned policies, however, it is not directly related to them. Up until the realization of the expeditions here presented, the guidelines for national health care for these families were undertaken in according to the SUS's general operational directives (specifically because of the regionalization), being subject to actions proposed and developed by the health professionals from the Health Secretary of the city of Porto Velho.

The riverside communities that received the actions from the extension project "FOB-USP em Rondônia" are located near the city of Porto Velho, in the north region of the state of Rondônia, in the margins of the rivers Machado and Rio Preto, both tributary to Madeira River (Baixo Rio Madeira region)

This project has taken place effectively since 2002, in the city of Monte Negro and riverside communities of the Madeira River, supported by the tripod teaching, research and extension⁷.

The university extension activities have been occurring along the time previously mentioned and have allowed synthesizing the educative, cultural and scientific process, thus enabling a dialog between students, professors and communities. As a result of the interaction of such factors, new knowledge have been produced, it is evident the construction between scientific and popular wisdoms, it can be affirmed that the university extension possess change empowering characteristics both for the involved communities and to the personal and professional lives of the students and professors who are involved⁸.

Considering the shortage of studies directed to the general health conditions of the riverside communities and the importance of such studies to guide and establish public policies for this specific population, this study has the objective to report the health promotion actions taken on these communities by the expeditionary teams on the previously mentioned project.

Methods

This is a cross-sectional, observational study, which consists in an experience report of the expeditions to the riverside community of Tabajara (July/2009), and to the communities of Calama, Demarcação and Rio Preto (July/2010), in the state of Rondônia.

The teaching, extension and research project that has allowed this study was submitted to appreciation on the Ethics on Research with Human Beings of the Dentistry School of Bauru (FOB-USP), being approved under the report 488.199 No. CAE 22168513.0 0000.5417.

The expeditions were part of the university extension activities, which took place under the subject "Collective Health: Actions of the Origin Institution in Rondônia II" and "Extension and Research: Practice in Rondônia II"offered to the graduation and post-graduation courses in the Speech Language and Hearing Sciences and Dentistry areas. The described activities were realized by 12 expedition members, being 8 active in July/2009 (2 Speech, Language and Hearing Sciences students, 4 Dentistry students, one post-graduation student in dentistry and one Speech, Language and Hearing Sciences professor) and 4 on July/2010 expedition (2 post-graduation in Speech, Language and Hearing Sciences students and 2 post-graduation in Dentistry students).

The residents of the visited riverside communities who sought medical care with the expeditionary team took part on this work. Assistance (Clinical care on language, hearing, surgery, cosmetic and preventive dentistry) and educative (open dialogs and supervised tooth-brushing) activities were performed in the areas of Speech, Language and Hearing Sciences and Dentistry, as well as education on general health (by means of open dialogs).

Even being this study not an actual analysis of the life conditions of these populations and their needs and demands on health, some characteristics were highlighted by means of the Participant Observation technique⁹. This technique is possible due to the occurrence of direct contact with the target population of the research, and it allows the acquisition of data on the reality of the individuals in their social context. The relevance of the technique is given due to the capture of a myriad situations or phenomena that are not obtained by means of questioning, once they are observed in reality itself. Two main questions are relevant on the adoption of such methodological procedure; one of them is empathy capacity of the expeditionary/investigator and the other, the acceptance of the researched group. The choice for this technique was due to the fact that the expeditionary/investigator is a new element in this territory, searching then the interaction with the community and same-level discussion of knowledge, making use of the knowledge already possessed by the local population

Assistance actions data was taken from the records of patients who were treated by the expeditionary team, data was raised about the area of treatment, anamnesis and procedures that they were undergone.

The actions were aimed to reach the highest possible number of people. It was based on data annotation in field diaries. The focus adopted to guide the development on this current work was on the work of the team, on clinical and communitary care moments, both home and in Health Unities, where it was possible to observe the reception of the team from the community, the care practices used, as well as the possibility of development of the health promotion activities.

Descriptive analysis of data was realized (procedures and educative actions), which were grouped according to each community (short characterization of life conditions, needs, and educative and assistance actions performed).

Results

Characterization of communities

Riverside communities of Tabajara, Calama, Rio Preto and Demarcação are located on the countryside of Rondônia state. Such communities present as main income sources fishing and subsistence agriculture. Sewer is collected in septic tanks or in the open. Water is provided from rivers or artesian wells and consumed without treatment. Houses are built from wood or mixed materials, few are built from masonry. By not being considered cities, data from these locations were not found on official sources, and have been obtained by means of local administrators.

Tabajara District

Tabajara community is located at the margins of Machado River, about 400 km from the capital Porto Velho and was home to around 400 inhabitants. There was a single public phone and electricity was a recent arrival, however, very expensive for the population.

Locally there were few commercial establishments and few city officials (a nurse, teachers and school workers). There was one public city elementary school with around 50 students and 2 teachers; one health unity with weekly nursing care, but with precarious infra-structure. It was acknowledged that, when there was need for health care, those with financial means would go to other locations and those without would use herbs and medicinal plants.

Calama District

Calama is a district of Porto Velho, located at the margins of Madeira River, with approximately 3,400 inhabitants, including the communities of Demarcação, Rio Preto, Papagaio, Maici, Ilha Nova and Ilha de Assunção. Access is possible via boat, taking around 12 hours of travel (around 300km far from the capital Porto Velho).

The district had 3 diesel-powered generators to power almost all of the houses. The community contained two basic health unities with nurses, nursing auxiliaries and communitary health agents, medical doctors and dentists presence only occurred when these from Porto Velho to the community (professionals from Estratégia Saúde da Família - Family Health Strategy) or by means of university extension projects or non-governmental organizations (NGO). The riverside Family Health Strategy team (FHS) from Porto Velho was supposed to visit the district every fifteen days, however, according to community locals, that were not what occurred, and the population used to be without medical and dental assistance for long periods. There were two state schools; however they did not provide high school education, thus the young locals who wished to continue their studies were forced to move to Porto Velho. The basis for their economy, besides fishing and subsistence agriculture - common to the other communities, was açaí extraction, public work and local commerce.

Rio Preto Community

Rio Preto is 3 hours away from Calama and was home for around 25 families. These families lived in tracts (plots of land) very far away from each other. Also in the community the wasn't any kind of essential service such as health service or any way to acquire industrialized products, with their food coming from fishing, livestock animals and agriculture, mostly from cassava.

The community owned a school with a single classroom and one teacher for all elementary levels, known as multilevel school. The 28 enrolled children traveled kilometers to attend to school. According to reports from the teacher and the children, most of the time there was no food, which compromised the quality of learning and raised school evasion. It was observed a high level of illiteracy, both from children who attended to school and adults.

Demarcação Community

Demarcação is around 3 hours from Calama (in direction opposed to Rio Preto) and was home to around 50 families. The community possessed electricity from a generator and good organizational structure, with access to some industrialized products. Economy was based on fishing, cassava agriculture and the production of its derivatives.

There was one elementary school, well-structured, and one health unity which, however, was not working (due to lack of professionals to care for the population). There was a folk healer, with knowledge about medicinal herbs (used by the population to treat diseases), but it was not possible to find him, as he was out of the community giving consultations.

Assistance Activities

Health assistance activities were performed on the areas of Speech, Language and Hearing Sciences and Dentistry which totaled 1.100 procedures. The performed procedures are presented on Tables 1 and 2

Table 1:
Speech, language and hearing sciences procedures taking place on riverside communities, 2009 and 2010

Table 2:
Dentistry procedures taking place on riverside communities, 2009 and 2010

At Tabajara community it was possible to perform reading workshops with all the interested children, with goals to provide educative activities in a recreational and pleasant way, encouraging the process of reading and writing. On the other communities, on the fact that there were less expeditionary members, it was not possible the development of these activities, however, there were individual and/or group activities developed over the aspects found on the language assessments performed.

The major source of speech, language and hearing sciences area complaints found on these communities were related to hearing. In light of the reports and audiometric configurations, it can be said that the majority of the complaints were related to noise exposure (chainsaw and boat engine). Beyond that, it was seen a high level of malaria cases, in which the residents were unable to tell how many times they have been infected, being that the treatment was always done with quinine. It was also observed that many of the children and adults performed the cleaning of the External Acoustic Meatus (EAM) using chicken's feathers. The risk of such habit has been explained during the actions of education on general health, enlightening the communities on negative effects of cleaning the EAM with chicken's feathers or other daily objects like hairpins and sticks can bring to hearing and general health.

In what refers to the oral language screenings, the existence of language delays with phonetic, phonologic and semantical alterations was found. On written language, learning difficulties were found. Parents and/or guardians, as well as teachers, were advised about the achieved results.

In regards to dentistry procedures, it was verified the execution of atraumatic restorations instead of restorations using the compressor, being the available electric energy not enough to allow the work with dental drills on the communities. The only exception being on Calama District where there was a possibility to use the compressor on the first morning of work, however on the other days of care atraumatic restoration treatments were performed due to the fact of the compressor having burned out due to the oscillations on the energy grid. Furthermore, at Rio Preto community, of all of the procedures performed, it could be seen a lower number of surgical procedures (6.12%) and a higher percentage of restoration procedures (13.25%), this fact seems to be related to the lower occurrence of dental caries in this community.

At Tabajara community, even with the recent arrival of electric energy, there were no power outputs to plug the compressor. Beyond that, when the expedition arrived, there were reports that months before there was a practical dentist who had spent by months caring for the population, performing extraction procedures, in other words, surgical removal of dental element, which could explain the higher percentage of restoration (43.31%) and preventive (36.31%) procedures in relation to surgical (20.38%) procedures.

In relation to oral health, Precarious health conditions were verified, being observed extensive dental caries, precocious dental loss, lack of knowledge about self care and difficulty to access preventive products, as toothpaste and fluoride solutions. However, at Rio Preto community, it was seen that most of the people who received treatment presented better conditions of oral health, but with higher occurrence of dental abrasion.

Educative activities

The actions of education on health were realized on all of the visited communities, with themes focused on healthy feeding, pregnancy, child development, breastfeeding, oral hygiene, hearing, voice, oral habits, child language development and writing, being these themes suggested by the participating observers after identification of the needs of the communities by means of conversations with the local administrators, nurses and teachers. The matters were addressed by means of open discussions during the consultation waiting lines. At school, the actions were developed by means of class room interventions, toothbrush distributions and orientation on oral health with the teachers to allow them to guide their students about brushing, giving continuity to the work started by the team.

The matters were addressed by means of open discussions during the consultation waiting lines. At school, the actions were developed by means of class room and school yard interventions; there were toothbrush distributions and orientation on oral health with teachers and students. After this, the expeditionary team worked privately with the teachers to allow them to guide their students about brushing, giving continuity to the work started by the team.

At Table 3are shown the number of people who received care during the educative activities provided at the visited communities.

Table 3:
Population assisted on educative actions taking place on riverside communities, 2009 and 2010

Discussion

The National Basic Health Care Policy establishes the action of Family Health Teams on Legal Amazonian riverside communities who should help the users of the health system on solving their problems⁴. The project undertaken, on this present study, goes in accord to this policy, however it is not attached to it, by means that it is not a direct government action, but rather a teaching/research/extension project from a public university on southeast Brazil.

In all of the visited communities lack of resources for any technical-scientific health treatment were observed, persisting the use of home knowledge and medicinal herbs to heal health problems. The use of medicinal herbs is a traditional practice of the Brazilian population. Studies point that the existing data, up to late 20th century, was still insufficient to provide an accurate evaluation on the efficacy and safety of most of the medicinal plants¹⁰. However, World Health Organization recommends world diffusion of the required knowledge for rational medicinal plant use, and, with this in mind, the Ministry of Health released in 2009 the National Medicinal Plants and Phytotherapics Program with goals to spread this therapy in a safe way and according to the norms of the National Agency of Sanitary Vigilance (Agência Nacional de Vigilância Sanitária - ANVISA). This program, more than encouraging the production and distribution of medicinal plants and phytotherapics bu the current health system, guarantees budget for new forms of research on the efficacy of these resources on other pathologies¹¹.

In regards to education, in Rio Preto, the most distant community and the one who presented the worst structural conditions, there was an only school, which practiced a multilevel class system. This kind of organization exists mostly in the rural environment, aiming to offer opportunities of education for children residing in such places¹². It is to be highlighted that on the historical development of Brazilian's Education system, the population's whereabouts constitutes an intensifier element on inequality of offers of opportunities of scholarship, being that the closer from the urban centers, bigger are the opportunities of education for the population¹³.

Another point that called for attention on this school was the lack of food for the students, which can worsen even more the educational process for them. The access to adequate feeding, and other factors such as habitation, material resources and stimulation were objects of study on several researches ^{14 16}, being pointed as unfavorable developmental and learning factors when not presented in an adequate manner.

It is know that the illnesses in a population are associated to their way of life and to their social, cultural and environmental universes. Health conditions and everything to which they relate are phenomenon culturally built and interpreted¹⁷.

I all of the communities it was observed that the children and teenagers lacked information about their full names, age and/or date of birth. In regards to hearing, the complaints and audiometric configurations were related to noise exposure (chainsaw and boat engine). This data corroborates the literature which points that beyond cognitive difficulties, work activities performed in noisy environments can cause other kinds of harm, like tinnitus^{18 19}. The audiometric findings can be related also to the ototoxicity of the quinine, even without direct complaint from the riverside population²⁰, due to the high exposure to malaria in the region. Malaria transmission is concentrated in 99.9% of Legal Amazon, which houses the state of Rondônia. This, by turn, is responsible for approximately 15.5% of malaria cases²¹. Sill in regards to hearing, it was observed that the use of chicken feathers to clean the EAM is a common habit on these communities. Studies point the risk of the use of objects to clean the EAM as being a risk factor on complications such as laceration of the meatus, membrane perforation, otomycosis and otitis^{22 23}.

In relation to oral health, the better conditions observed at Rio Preto community can be related to the high consumption of coarse cassava flour by this the population of this place and to the low consumption of industrialized sweet products, unlike the other communities that, despite the difficulties, had more access to these products, being verified a higher occurrence of dental caries and dental loss. It was evidenced that fish was the main source of protein for the riverside people²⁴, however the access to consumption of industrialized food has increased, mostly on the more populated communities. Industrialized products posses a high caries-inducing potential, due to the concentration of sugars, mostly sacarose, and more than that, many times the high concentrations of sugars specified on the packaging is below the one found in most food, mostly those for children²⁵.

Other factors that can be associated to the high prevalence of dental caries in the visited communities are the difficult access to dental health service, the lack of orientation on oral health care and socioeconomic condition.

It was sought by means of Health Education actions, the engaging of the user on the accountability over their own health and by the health of the community to which they belong, this way, the process of health-disease can be better understood by means of the participation of the user²⁶. The adverse conditions and almost complete lack of health services of medium and high complexity, added to geographic isolation and lack of professionals, many times causes the non fulfillment of the right to health and universality of care^{8 27}.

An important aspect to be noted is that, when performing education on health at the communities, it' is valid to use as starting point the previous knowledge of said population in their work environment, social life and struggle for survival and to transform reality, this valuation of the pupils' local culture allows them to feel at home and maintain their initiatives, within a process of cultural interaction and experiences exchange for the shared construction of knowledge. This educative process is based on problematization, bringing up aspects of life which disturb and discussing to find possible solutions for their problems²⁸. This way, when performing education on health activities on riverside communities there was a concern on listening and respecting their understanding about the health-disease process.

Results were also seen on the expeditionary team helping on social and individual formation as humans, citizen, professional and professional citizen formation, on actions with the low income communities, in partnership with the leadership and institutions of these communities and social movements, identification of opportunities, demands, needs and common problems with goals on the integration and autonomy process of these communities, and not being charactered as an assistencialist action, partnership with public authorities and civil society.

At the Amazonian region, especially at the riverside communities, it is noted that in front of geographic, cultural and social characteristics, there are many challenges to promote health. To reach universality of care and the fulfillment of health rights, some difficulties such as lack of health professionals, the precarious sanitation conditions, the long distances and transport and communication difficulties can be punctuated⁶. This way, the university extension presents itself as a door who allows the contact of students and professionals with populations who live in geographically isolated areas⁸.

Conclusion

1828 procedures were performed, of which, 1100 were clinical and 728 educative, on speech, language and hearing ciences and dentistry, at Tabajara, Calama, Rio Preto and Demarcação communities during the period in which the teams were on these communities. Access conditions have shown to be precarious and noted present health alterations referred the speech, language and hearing sciences and dentistry areas were shown due to the prevalence of dental caries and periodontal disease such as the presence of complaints about hearing alterations.

It is concluded by this work, that there is a need to improve access of the populations who live in riverside communities to essential services, especially those of health in a continuous and regular way, in order to accomplish actions of education and health promotion effectively. Beyond that, it was verified the need of implementation of broad social and health policies with aim to act on the determining and conditioning process of health disease in a way to provide improvements on the health of these populations.

It should be said that, based on the encountered need, starting from 2013, the teaching/extension/research project that allowed this study, started a yearly expedition program to these locations, with goals to offer clinical and education care, so to provide a better quality of life to the riverside population on these locations and also possibility of in-depth study of their health conditions and needs.

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• Financial disclosure: University of São Paulo

Publication Dates

• Publication in this collection
  Oct 2015

History

• Received
  04 Nov 2014
• Accepted
  19 Apr 2015