Ageism in the work context of the family health strategy: projection of knowledge on Morin’s dialogic tetragrammaton

This is a theoretical study that aims to articulate contributions on ageism with the dialogic tetragrammaton of interactions, proposed by Morin, in the context of work in the Family Health Strategy and Primary Health Care. To accomplish this, a symbolic projection of knowledge about ageism was carried out, organized in four acts: order, dispersion, interaction, and reconnection. We concluded that this theoretical exercise can be transmuted to the daily work in health care, and that understanding the existence of the dialogic tetragrammaton, which acts in life simultaneously in antagonistic, concurrent and complementary ways, can stimulate critical, creative and complex thinking in favor of knowledge and practices that take the complexity of ageism into account.


Introduction
Ageism refers to stereotypes (thoughts), prejudices (feelings) and discrimination (actions, acts) directed towards people on the basis of their age 1 . It is a complex phenomenon with multiple dimensions and determinants 2 .
Regarding its dimensions, ageism can be institutional, interpersonal or self-directed. Institutional ageism refers to the laws, rules, social norms and structures, policies and practices of institutions that restrict opportunities because of age. Interpersonal ageism, in turn, arises in social interactions between two or more individuals, while self-directed ageism occurs when ageism is internalized and turned against oneself 1,2 .
The determinants of ageism, in turn, are: age, gender, level of schooling, anxiety or fear of death, personality traits, contact with older age groups (mainly between grandfather and grandson and intergenerational friendships), knowledge of the ageing process, proportion of older adults in the city/state/country, life expectancy, mental and physical health, among others 1,2 .
The neoliberal political panorama in the Brazilian society reveals a context of uncertainties regarding the ageing process, which can induce restrictions of rights, amplify vulnerable situations, and promote more illness. It is necessary to recover the leading role in the mobilization of critical reflections in order to face persistent problems deriving from recurrent crises that increase inequalities and social discrimination 3 .
Since its genesis, the Brazilian National Health System (SUS) has contradicted neoliberal interests that were in expansion and that threatened both the health agendas and the demands of social movements, which fought against different forms of racist, sexist, ageist oppressions and for dignity in the workplace, criticizing the social and political determinants of exclusion 4 .
Thus, in view of the current political conditions, we run the risk of deepening neoliberalism as long as there is only a passive hope of overcoming the minimal state without considering different coping scales. It is important to invest in attitudinal and ethical intergenerational processes to reconfigure citizenship, mainly processes related to work, which occupies a central position in the life of ageing people 5 .
According to Neves et al. 6 (p. 327), "The work theme is multifaceted in the literature, being approached and discussed within different research lines and by different scholars". The authors reaffirm different views concerning its meaning and role, mainly as "one of the fundamental values of the human being that still plays an important role in their self-fulfillment and subjectivity, contributing to the development of their identity" 6 (p. 327).
The work environment is a setting for the performance of social functions that, although accomplished on an everyday basis, maintain the sensation of social recognition in (and through) work. Thus, the status of older worker can represent a prestigious social role or a stigma in a society or institution that privileges the new or the novelty 7  Considering that work is essential to human survival, to personal development and to socialization in circuits of belonging, the intellectual or material product of work "is valued because it enables to come closer to youth and get away from inactivity, a characteristic that is socially attributed to ageing" 8 (p. 155).
Perceptions about work are influenced by transformations occurring in and out of institutions. Furthermore, their meanings are different across subjects, professional occupation categories, and age groups 9 . Therefore, work is considered an instrument to distance people from ageist stereotypes constructed and reproduced in everyday life.
The Family Health Strategy (FHS) is a complex framework of reorganization of the services and reorientation of professional practices in conformity with the principles and guidelines of SUS. As such, it is a strategic context to explore the determinants of ageism in the singularities of its teamwork process, in user centrality, and in the complexity of situations experienced due to demands for efficient actions deriving from a set of plural knowledge forms 10 .
The challenge of dialogic and multidimensional thinking involves reflections on the plurality of different threads that, together, sew the darned fabric -a complexus (whole) -in such a way that "everything [...] is intersected and intersects again, is weaved and weaves again, to form the unity of complexity" 11 (p. 147), without disregarding the diversity of each complexity (part) that weaved it.
The present essay stimulates thinking about ageism beyond the apparent order and clarity of things, using complex thought as the framework for understanding it, valuing uncertainties, contradictions and disorder 11 . Therefore, our proposal articulates multiple facets of the same phenomenon, in opposition to limitations deriving from the simplification promoted by the separation of disciplines, similarly to what Lima and Guimarães 12 accomplished when they problematized the Psychosocial Care Network under the lenses of complexity.
Morin 13 suggests a stratagem to institute a way of thinking capable of overcoming the reduction caused by the isolation that mutilates the dimensions of phenomena. Called "dialogic tetragrammaton of interactions", it combines a symbolic universe/game -"between forces of reconnection and forces of separation, forces of organization and forces of disorganization, forces of integration and forces of disintegration" 13 (p. 88) -through a didactic representation that recognizes the unity and plurality of analyzed realities.
In this sense, the apparent linear causality of phenomena would be replaced by a hermeneutic (circular) causality, conceiving a dialog between complementary and antagonistic approaches, aiming at integrating their parts into a whole and this whole in the inside of its parts, in four elements: order, dispersion, interaction, and reconnection. In short, an arrangement that considers the context and the local and macrosocial (global) relation, integrating the thinker (observer) into their observation 14 .
This theoretical-philosophical article is part of a Doctoral dissertation submitted to the Postgraduate Program in Family Health in Northeastern Brazil, of the Northeast Education Network in Family Health (RENASF) -Federal University of Rio Grande do Norte (UFRN). It aims to articulate ageism with the dialogic tetragrammaton of interactions proposed by Morin, by means of Complexity Theory, in the context of work in FHS and Primary Health Care (PHC), through a symbolic projection of knowledge.
To achieve this, the essay is organized in four acts that articulate the aspects: order, representing stability; dispersion, discussing antagonisms; interaction, explaining approximations; and reconnection, clarifying connections.

Order
Order represents totality, the whole, the social organization (structure), singleness, unity. However, such singleness contains, simultaneously within itself, multiplicity, which should not be dissolved by simplification; rather, it should involve dialectics in a hologram where the whole is in the part, which, in turn, is in the whole 11 . In this order, represented here by healthy aging, there is a balance between separation forces, which tend towards dispersion, and attraction forces, which connect the elements with this unity (universe) 14 .
Considering that aging is a silent verb and that longevity has been occupying an increasingly significant space in different social strata, leading people to reflect because of the need to adapt to this new reality, the way of perceiving the aging process is not unique for all people. Ageing can be a positive experience when it is accompanied by continuous opportunities to improve quality of life as people grow older 15 .
Capitalist societies value work in the life of human beings, in the perspective of extraction of surplus value. In this logic, the worker sells their labor as a commodity to ensure their own subsistence and/or that of their family. As one works, one ages, not always with autonomy to choose the best way to live or to work 16,17 .
The ageing process of the working subject occurs in two non-exclusive ways: ageing in relation to work, where transformations deriving from senescence affect the performance of daily work activities, and ageing deriving from work, where the working conditions (physical infrastructure, materials) and the organization of work (division, hierarchy, norms, productivism, rhythm, goals, interpersonal relationships) act on the ageing process 18 .
It is important to highlight that ageing, which occurs throughout the entire professional life and during the whole work cycle, contains in its logic (essence, unity) elements tending towards separation, making it difficult for young people to enter the job market and for older people to remain in it or find a new job if they are fired 19 .
By enabling man to search for and fulfil their life objectives and professional goals, as well as the support of the family -in a society that either recognizes their skills, competencies and attitudes or not -, work is "a founding category of the human being, as they can only exist by working" 6 (p. 328).
Furthermore, the presence, in the social structure (order) of healthy aging, of age-related stereotypes, prejudices and discrimination, promotes disorder, breaking the comfort of stability and producing elements in dispersion: situations that promote ageism. Thus, the world (of ageism) can only come from a rupture, through separation; therefore, it exists based on the relation between what is/was separated 13 .
Hence, in this symbology, dispersion refers to barbarianism, to the problem situation, to vicious circuits, deconstruction, forces of disintegration and misunderstanding, although this very disintegration will come to cause a reorganization of the universe 13,14 .

Disorder
The dispersion forces that promote ageism (thought, feeling, attitude/action), causing distinction, differentiation, segregation and specification, affect both older and younger individuals, harming people's health and social cohesion, as they intensify other forms of social depreciation, like sexism and racism 1,2 . The way in which each person thinks about their ageing process affects their own wellbeing as they grow old. Globally, one in two people are ageist against older citizens, while in Europe the opposite occurs, as ageism against younger people is more common 1,19 .
Nowadays, the world of labor is marked by the prevalence of fragmentation, hierarchical work relationships and individualized work by professional. Other predominant aspects are the resistance of a technical-scientific rationality, inequalities between specialties, and the social importance attributed to each one 9 .
Siqueira-Brito et al. 20 explain that, in ageism, age is the decisive factor for prejudice. Thus, age discrimination is one of the driving forces of ageism. Understanding the human ageing process contributes to reduce prejudice. As more and more people show negative attitudes towards aging, ageism is intensified. On the other hand, in contrast, as fewer people perform derogatory acts, ageism is weakened 21 .
The attitudes of a person or group of persons towards something can be favorable or unfavorable and are influenced by past experiences, feelings, cognition and affection, which, in turn, shape behavior. Thus, perceptions and attitudes (discriminatory or appreciative) towards older people (and/or younger people) are influenced by personal and relational social constructs [21][22][23] .
Organizational or institutional ageism can be understood as a set of negative or positive attitudes towards ageing, appreciating or depreciating the labor of older people, favoring or disfavoring their inclusion, exclusion or permanence in certain functions or positions within an institution [21][22][23] .
Stereotype refers to general opinions formulated by people based on a pre-definition of someone or something (regarding their behavior, culture, economic condition, appearance, etc.) influenced by sociability experiences. It is a way of labelling people or things without in-depth knowledge about the people or the things that are stereotyped, labelled 23 .
Prejudice, in turn, is a preconceived and derogatory value judgment of people, values, beliefs, feelings and behavioral tendencies. It results from contempt and intolerance concerning other points of view, often followed by manifestations of hostility. The subject believes their way of being and seeing people and things is true, refusing ideas that do not fit their values and truths 22,23 .
Finally, discrimination means differentiation, segregation, distinction, the design of a prejudiced action/attitude (stereotyped or not) grounded on preconceived ideas about someone's social aspects (race, color, religion, age, etc.). Discriminatory attitudes promote the social exclusion of the discriminated people, who feel marginalized in the social circuits to which they belong due to the negative treatment they receive 23 .
The dispersions of ageism in the work context are perceived differently by older and younger workers, according to Silva et al. 24 . However, younger people have the perception that ageism reduces their endeavor in the institutions where they work and contributes to intensify economic insecurities in the middle and long run 2,25 .
In view of what has been discussed so far, separation -related to ageism and contextualized in FHS/PHC -is present in the daily routine of older health professionals/workers, and is felt, experienced and mentioned by users as well, as Buno and Bulgarelli 26 have shown. Thus, age-related perceptions and attitudes moderate the denial or affirmation of recognition, leading or not to ageism in the work context.
We highlight that human society and health systems, including the ones guided by FHS/PHC, are constantly being created, deconstructed and reconstructed, due to the need of dealing with the unexpected and with provisional certainties. This ruptures linear ideas and processes of cause and effect, product and producer, as everything that is produced comes back in a self-constitutive, self-organized and self-producer cycle 12 .
Family health units play an important role in the offer of spaces for socialization and belonging that enable users and professionals to discuss the ageing process and the determinants and conditionings of ageism, contributing to health promotion and wellbeing in this life cycle 8 .
The complexity of ageism in the FHS/PHC field must be considered and investigated by empirical studies that explore the trajectory of age-related discrimination, identify discriminatory attitudes, intentions and behaviors, provide subsidies to mitigate derogatory effects (towards older and/or younger people), and amplify previous research on age-related discrimination, in different professional categories, to value age diversity in the workplace 27 .

Interaction
In the universe, the process of interaction between particles happens through collisions and destructions and also through associations and unions, in the relationship between disperse, separated, but not isolated elements 14 . The symbolic projection of the elements of ageism in this stage/act involves studying social interactions and investigating each context/setting. Therefore, the use of instruments to measure ageism is pertinent to diagnose what must be considered in terms of interventions to minimize it, stimulating equal opportunities in the workplace for all ages 9,21 .
Sato et al. 17 emphasized that further studies are needed to shed light on workers' demands and give greater visibility to the interactions between ageing and work. In the same direction, França et al. 21 argued that investigations about actions to combat ageism are scarce, especially studies on prejudiced attitudes against older workers, and that this type of research should include instruments capable of identifying ageism in institutions and what can be done to reduce it.
In FHS/PHC, interpersonal interactions/relations in the workplace are combined in the commitment to search for comprehensive, longitudinal, equitable and efficient care, by means of humanized practices that develop health promotion/education actions, and prevention, diagnosis, treatment and recovery of health problems 28 .
In this interactive complex, the work process is organized in multiprofessional teams that know the families in the catchment area, identify the health problems and risk situations that affect families/communities, and perform a local planning in concrete settings based on intersectorality, creating bonds between health workers/professionals and users through mutual accountability in the resolution of the identified problems 28 .
As the work teams are heterogeneous, their action must include interdisciplinary approaches, amplifying the perception of their complexity and organizing care based on problematization and critical thinking, so that they can go beyond what is instituted as the unique knowledge/thought. Such posture enables a constant exercise of interrogation about what is evident, apparent, valuing each limit of thought and its uncertainties 29,30 .
Thus, according to Bastos et al. 31 , it is necessary to overcome bureaucratic inertia and excessively hierarchized interactions, which hamper praxis in the health services, to rethink the roles of each social actor, the power relations between them and the instituted interests, innovating based on the frameworks of institutional and interprofessional interdisciplinarity. Thus, it will be possible to enhance adherence and construct collaborative and collective actions, in order to face any type of prejudiced manifestations.
In the context of FHS/PHC, individual and collective activities of health promotion and education represent opportunities to raise people's awareness about the importance of stimulating perception, understanding and discussion of the dimensions, determinants and ways of combating ageism against older and younger individuals 32 .
In light of the fact that ageism is connected with social exclusion (discrimination), nothing more adequate than combating an attitude (of separation) with another attitude (of reconnection) inspired by complexity. According to Cruz et al. 30 , this premise allows to leave the inertia position through an interactive, intentional and attitudinal posture, a force dependent on the formation of a professional and personality profile that is willing to face the challenge posed by change processes with resilience, confidence, patience, intuition, and capacity to act in the face of adversity.
Likewise, in this scenario, the discussion about interprofessionality enables to understand integrated and collaborative healthcare practices as a response to users' demands and to the fragmentation of professional practices that predominates in the area of Health. Thus, the act of doing together based on integration of knowledges and sharing of practices is permeated by conciliatory and contradictory feelings, including disputes of power and status, which can facilitate or hinder collaboration and reciprocity 33,34 .
Hence, interprofessional work emerges as a complex arrangement -influenced by relational, procedural, organizational and contextual factors -deriving from the materialization of interprofessionality, conceived as a collaborative practice between professionals from the same institution or from different organizations 35 .
Complexity, as an epistemology, has in its essence different pillars that involve searching for interpretations about the meaning of the complex under analysis and of its foundations. Simultaneously to dispersion forces, reconnection forces emerge in the initial agitation, so that the strongest interactions/attractions aim to ensure the formation/cohesion of a new unity (order) in the universe. The apex of these reconnections happens through the occurrence of new separations, antagonisms and conflicts, attesting that each circuit that leads to death is, at the same time, a life cycle 13,14 .

Reconnection
The last act, represented here as reconnection, signals an ethical posture of resistance to separation. If dispersion was characterized as barbarianism, here we have civilization, with contextualized, interdisciplinary, multidimensional and interprofessional approaches that respect and value the reconnection of different knowledges to think and act in practice with attitudes against ageism 36,37 . It refers to reconnecting through separation, in a pathetic fight of reconnection against dispersion and death. For this mission, in this situation, it is fundamental to develop fraternity and love 14 .
But, Morin 14 asks, what should we reconnect after separation? There is an emptiness, a gap between intention and actions, in such a way that each action increasingly escapes the will of its actor as we enter the game of interactions with the environment in which we intend to intervene. This increases the risk of failure, distortion of meaning, where the action's effects are influenced by the conditions of the context where the situations occur.
Concerning the intention of the act, when we consider the context of each attitude, ecology of action introduces uncertainty and contradiction in ethics. Thus, the forces of reconnection are a minority group in relation to the forces that destroy, annihilate and disperse. However, these are the forces that (re)create life; otherwise, the world would be nothing but dispersion 11,13,14 .
Understanding that the intention of an ethical reconnection sprouts from a source within the individual, like the injunction of a duty, it is in the spirit of people that reconnections occur, based on responsibility, intelligence, initiative, solidarity and love 13 . Therefore, two theories deserve to be discussed here to aid the interpretation of the cement of this reconnection (love), as a criticism against action settings and philosophy of action: the theory of recognition 38 and the theory of gift 39 .
In the typology proposed by Honneth 38 , social recognition happens after human interactions are experienced in three dimensions, as a struggle to obtain: confidence, after experiences of love and affection, in the sphere of intimacy; respect, deriving from the dignity of achieving equal rights; esteem, through the appreciation achieved in democratic solidarity and social division of knowledge and work. These dimensions are also present in the social and work circuits of FHS/PHC [40][41][42] .
The empirical studies that articulate ageism with the theory of recognition are still in their early days, and it is necessary to conduct investigations that are able to assimilate divergences and similarities of results in different organizational contexts. The discussion about prejudiced conceptions and attitudes contributes to construct a harmonious work environment capable of valuing intergenerational diversity [43][44][45][46][47] .
The contribution of recognition theory to the analysis of ageism and its possible modulators attests critical diagnoses of disrespect, oppression and injustice, supporting the search for consolidated evidence to promote social transformations 41,42 . In addition, in the interdisciplinary and interprofessional teams of FHS/PHC, workers, through interactive movements, look for different types of recognition, concerning aspects like professional capacity, personal working skills, recognition of the professional category's value, attitude in the face of problem situations, intergenerational interaction, among others 41,48 .
Therefore, in the work context of FHS/PHC, the sphere of affectivity refers to professional relationships, in affection exchanges capable of building bonds; justice, social order and respect refer to the team's relation to the service, including the institutional mission, norms, rules and agreements, the employment regime and the agreed remuneration, among others; and solidarity corresponds to the relationships that attribute social value and social place, respecting the peculiarities of the work developed by the individual and collective diversity of workers from different professional categories, achieving recognition through self-esteem 41 .
Furthermore, based on this theory, social situations are categorized a priori as perceptions that deny recognition (distrust, disrespect and low esteem), attesting elements associated with situations involving discrimination, prejudice and stigma, and conceptions that affirm recognition (trust, respect, esteem) 38 .
Amaral et al. 48 have found that communication and professional identity are two of the categories that express critical nodes of the work process, validated by primary care professionals. Thus, the promotion of reflections on practice, potentializing democratic hearing spaces, is a pertinent device to problematize and develop ethical postures in order to survey and face subtle or explicit manifestations of ageism. Morin 13,14 states that human societies, simultaneously antagonistic and sympathetic, organize themselves in union through discord (conflict-negotiation) or through concord (agreement) in the dialogism of creation-support-destruction. Such ambiguity is present in the principles of community reconnection in view of the balance of rivalries external and internal to social groups.
To the formation of the social bond, symbol of union, of connection, we consider the relational nature of social phenomena, valuing the complexity of sentimental, moral and cognitive motives bore by the protagonists of the interaction. Hence, the phenomenon of the gift (give-receive-reciprocate) emerges as a collective rule and an affective condition in the rituals (free and obligatory) that create healthy social pacts. Here, social reconnection through alliances will emerge from collective significations mutually recognized in interactions/relationships between close and anonymous people 39,49 .
Because the gift system mobilizes affectivities, it motivates reconnection, evoking friendship, reciprocity and desire in relation to the world. In this sphere, a loving feeling can start an approximation between disperse elements -that used to be separated and now walk, through interaction, towards connection -using words and gestures, in the freedom of donating themselves to the act of bonding 39,49 .
There is an ideological clash between people who prefer the world's constant mercantilism, inspired by neoliberalism -where ideas, desires, objects and people have a cost/price (surplus value) in the search for power and prestige -, and those who fight for sympathetic, ludic and loving achievements. Society needs to be seen as something bigger than the instrumental sum of people and groups 39,49 .
Considering, like Morin 14 , that every ethical act is also an act of reconnection and expression of the autonomy of individuals responsible for their own people and for others, we recommend the development of positions and attitudes in counter-hegemonic spaces that value alterity, aiming to fit it in with modes of social, existential and ecological coexistence grounded on respect for the diversities of social life.
Inouye 27 mentions various challenges to the creation of an anti-ageist health system, such as training/qualifying health professionals in all care settings/spaces; rethinking/readjusting implicit/negative attitudes related to ageism; organizing coordinated interprofessional care; stimulating goal-oriented health care centered on older adults; combating barriers to access/accessibility; strengthening the digital inclusion of older adults; considering sociocultural, anxiety and distrust aspects; involving older people, their families, caregivers and health professionals in the search for solutions; and improving communication and the monitoring of treatment and adherence conducts for periodical follow-ups.
Thus, in the concreteness of ethical and responsible reconnection acts, ageism must be faced in every dimension, by the formulation/application of legal/political measures that approach age-related inequalities, protecting human rights 37,50,51 ; by educational actions that enhance knowledge, skills and competencies to stimulate greater empathy concerning weaknesses and strengths involved in the ageing process 36,37,52 ; and by the implementation of intergenerational interventions for mutual understanding and collaboration between generations [43][44][45][46] .
To conclude, we believe that ageism in the context of FHS/PHC has not been thoroughly discussed in the literature. This essay does not intend to exhaust the matter; rather, we intend to arouse interest in this debate so that further studies are carried out, mainly empirical research, providing additional contributions to the field of Collective Health.

Final remarks
The article articulated aspects related to ageism with complexity theory -in the stages: order (universe); dispersion (separation); interaction (attraction); and reconnection (organization) -, associating knowledge on ageism with Morin's dialogic tetragrammaton of interactions, through a symbolic projection contextualized in the sphere of work in FHS and PHC.
We believe that this theoretical exercise can be transmuted to the daily work in health contexts, and that understanding the existence of order, dispersion, interaction and reconnection -which act simultaneously in life in an antagonistic, concurrent and complementary way -can stimulate critical, creative and complex thinking in favor of knowledge and practices that take the complexity of ageism into account.
In this sense, strategies that involve articulations between teaching, services and community represent an opportunity to trigger reconnection movements, revisiting common sense and discourses associated with age-related stereotypes and prejudices to reduce age discrimination. Interventions amplify students' formative itinerary by problematizing the complexity of ageism and discussing the importance of intergenerational contacts.
Therefore, in consonance with the pedagogical proposal of professional masters' and doctoral programs set in the SUS, students' projects of theses and dissertations must invest in providing knowledge that is socially relevant, catalyzing health teams' in-service qualification processes and implementing (approximating) encounters (interactions) to raise awareness and to conduct in-depth studies (reconnections) about ageism in work and life.
To include aspects of complexity, the acts of reconnection depend on integration into their opponents, as the currents of rupture, dispersion and separation (hate) are becoming stronger, imprisoning and denying people their right to fly and shine, even if it is like the stars -in Morin's allegory -, which feed their own shine with the fire that consumes them, dying of life. May this radiant agony illuminate other disperse stars and stimulate them to fuel their vital energy with ethics, friendship and love.