Perceptions, experiences and perspectives on school health and the School Health Program: the teachers’ viewpoint on the municipal health network of Belem-PA

Fabricio Moraes Pereira Wilkelly Alves de Lima Adalberto Lírio de Nazaré Lopes Liliane Silva do Nascimento About the authors

Abstract

Health at school is the subject of relevant discussions on health promotion. This study aims to understand the reach of the actions resulting from the School Health Program in municipal public schools in Belem-PA, from the perspective of teachers. It is a descriptive-observational study, with analysis of interviews with 22 teachers of municipal public basic education. Field research took place from April to June 2018. A content analysis was carried out, proposed by Bardin, generating four thematic units. Of those interviewed, 50% were unaware of the referred program or the operation of it. It was possible to perceive different modes of interaction between the program's actuators, from the most punctual and inefficient to the most contextualized and integrative. The study of social health determinants is necessary to better understand the processes and needs of these actions in the municipal school environment, with emphasis on issues of basic sanitation, food insecurity, violence and drugs. There is a need for self-recognition of the teacher as a health educator, in order to make them intrinsic health promoters in their pedagogical practices. The school's articulation with the school community can serve as an input for greater integration and stimulation of social control practices.

Keywords:
school health services; public policy; intersectoral collaboration; qualitative research; Public Health

Resumo

A saúde na escola é tema de discussões relevantes no tocante à promoção da saúde. Este estudo objetiva compreender o alcance das ações resultantes do Programa Saúde na Escola em escolas públicas municipais de Belém-PA, na perspectiva dos professores. Trata-se de estudo descritivo-observacional, com análise de entrevistas com 22 professores da educação básica pública municipal. A pesquisa de campo ocorreu no período de abril a junho de 2018. Foi realizada análise de conteúdo, proposta por Bardin, gerando quatro unidades temáticas. Dos entrevistados, 50% desconheciam o referido programa ou seu funcionamento. Foi possível perceber diferentes modos de interação entre os realizadores das ações do programa, desde os mais pontuais e ineficientes aos mais contextualizados e integrativos. O estudo dos determinantes sociais de saúde se faz necessário para compreender melhor os processos e necessidades dessas ações no âmbito escolar municipal, com destaque para questões de saneamento básico, insegurança alimentar, violência e drogas. Há necessidade de autorreconhecimento do professor enquanto educador em saúde, a fim de torná-los intrínsecos promotores de saúde em suas práticas pedagógicas. A articulação da escola com a comunidade escolar pode servir de insumo para maior integração e estimulação das práticas de controle social.

Palavras-chave:
serviços de saúde escolar; políticas públicas; colaboração intersetorial; pesquisa qualitativa; Saúde Pública

Introduction

The milestones of health school ascend to the participation of education and health professionals in looking of their practice, in light of their well-established guidelines, promoting discussions, referrals beyond the legislation and, thus, contributing to the promotion of quality of life, social control, inclusion and other factors that converge in the school, where the teacher figure ends up showing (BRASIL, 2007; DESSEN; POLONIA, 2007DESSEN, M. A.; POLONIA, A. da C. A família e a escola como contextos de desenvolvimento humano. Paideia, Ribeirão Preto, v. 17, n. 36, p. 21-32, abr. 2007.; GUIMARÃES; AERTS; CÂMARA, 2012GUIMARÃES, G.; AERTS, D.; CÂMARA, S. G. A escola promotora da saúde e o desenvolvimento de habilidades sociais. Diaphora, v. 12, n. 2, p. 88-95, ago-dez. 2012.; BRASIL, 2017).

The teacher is inserted in an unique context, as, in the past, he was considered an essential element for society, while recently he is in search of social recognition and professional valuation, even questioning his role as a enabler for health promotion in schools (LEMOS, 2005LEMOS, J. C. Cargas psíquicas no trabalho e processos de saúde em professores universitários. 137f. Tese (Doutorado em Engenharia de Produção) - Universidade Federal de Santa Catarina, Centro Tecnológico, Florianópolis, 2005.; MARIANO; MUNIZ, 2006MARIANO, M. do S. S.; MUNIZ, H. P. Trabalho docente e saúde: o caso dos professores da segunda fase do ensino fundamental. Estudos e Pesquisas em Psicologia, Rio de Janeiro, v. 6, n. 1, p. 76-88, 2006.; MOREIRA; VÓVIO; DE MICHELI, 2015MOREIRA, A.; VOVIO, C. L.; MICHELI, D. Prevenção ao consumo abusivo de drogas na escola: desafios e possibilidades para a atuação do educador. Educ. Pesqui., São Paulo, v. 41, n. 1, p. 119-135, mar. 2015.).

School health is a theme that involves transdisciplinarity, in essence, and that emerges in the natural intersectoriality between the fields of education and health. Although there is no specificity in this theme, the National Curriculum Guidelines for Basic Education reiterate its transversality, in the National Curriculum Parameters (NCPs), and configure a great advance and synthesis in the educational demands at the national level (BRASIL, 1997; 1998; 2013). At the local level, the municipality of Belém, in the state of Pará, has its own resolution regarding its educational guidelines, such as the organization of elementary education in the system of cycles and totalities of education (BELÉM, 2008; 2011). In this sense, recognizing the teacher as one of the protagonists in the transforming and promoting role of health is of great importance in their teaching practice, their political role and their own professional valuation (FREIRE, 2002FREIRE, P. Pedagogia da autonomia: saberes necessários à prática educativa. 25. ed. São Paulo: Paz e Terra, 2002.; MOREIRA; VÓVIO; DE MICHELI, 2015MOREIRA, A.; VOVIO, C. L.; MICHELI, D. Prevenção ao consumo abusivo de drogas na escola: desafios e possibilidades para a atuação do educador. Educ. Pesqui., São Paulo, v. 41, n. 1, p. 119-135, mar. 2015.).

From the perspective of teachers in the municipal public education system in Belém, it is relevant to understand the realities of their school communities in order to obtain parameters for the functioning of this intersectoriality. Thus, this research seeks to understand the scope of actions resulting from the School Health Program (SHP) in municipal public schools in Belém do Pará, from the perspective of teachers, in addition to evaluating the implementation of this intersectoral policy, identifying the school health problems that afflict the students in question and perceive the role of teachers as potential health educators.

Methodology

The project was submitted to the Research Ethics Committee of the Institute of Health Sciences of the Federal University of Pará (UFPA), within the criteria of CONEP Resolution nº 466/12, being approved under CAAE 83728718.9.0000.0018, opinion nº 2.603.475. The Informed Consent Form was presented to each participant, explaining the possible risks of the research and the cancellation of their participation, without any burden of any kind.

This is a descriptive-observational study with a qualitative approach, which uses the method of content analysis proposed by Bardin (2009BARDIN, L. Análise de conteúdo. Lisboa, Portugal: Edições 70, 2009.), carried out in the following steps: pre-analysis, exhaustive exploration of the material, data processing, inference and interpretation of the data. In the analysis, four thematic units were originated.

About the research site, Belém do Pará can be characterized as follows: it is located in the northeast of the state, 120 km from the sea and 160 km from the equator. It has approximately 1,059,406 km² of land area, with approximately 1,393,399 inhabitants (IBGE, 2012; BELÉM, 2018).

Its division into eight administrative districts (figure 1) guided the proposal to divide the incursions into schools agreed upon in the SHP in order to maintain proportionality according to the number of schools per district, being selected by lottery: one school per district, in DAMOS, DABEL, DAICO, DAOUT, DASAC and DAENT districts; two in the DABEN district; and three schools in the DAGUA district, totalizing 11 schools. It was chosen to interview two teachers per school, covering different shifts (morning, intermediate, afternoon or night), obtaining a greater range of information in the most varied age groups.

The inclusion criteria of the research participants were related to the fact that they are teachers working in the classroom, in any activity shift or performance level. Exclusion criteria were related to teachers who were working in ambient classrooms (Library, Special Educational Service, Multimedia), teachers on some type of license or who were readapted from their classroom functions.

Figure 1
Map of Belém divided by administrative districts

A pilot study was carried out with participants in conditions equivalent to the research criteria adopted, adapting the research instruments to the reality faced in schools in the region and the teachers' level of knowledge.

A questionnaire with the following questions was adapted to the open semi-structured interview script: “1- Do you know the School Health Program? (If yes, go to 2a; If negative, go to 2b); 2a- What are your perspectives regarding the program?; 2b- For you, what would the School Health Program be?; 3- Could you explain if or how the program activities take place here at the school?; 4- In general, could you mention the main health problems that affect students at your school?; 5- Could you mention the main public health problems that affect the school community?; 6- At any point, was anything discussed about the actions of the SHP in your school?; 7- Have you ever promoted or participated in any type of health-related practice in your school? If so, could you report your experience?”. The incursions into schools took place from April to June 2018. The interviews were carried out in a separate room or in the teachers' room, occasionally, with an interviewer and interviewee.

Results and Discussion

Among the 22 research participants, 17 were female (77.3%) and five male (22.7%). It was noticed, in this aspect, that the female participants were more accessible, while there were two males withdrew from participating in the interviews, so that they were replaced by two female participants. Regarding education, 12 participants (54.5%) had a degree with specialization, five (22.7%) had more than one degree with specialization, three (13.6%) had a master's degree and two (9.1 %) had only a degree or training in teaching.

Participants' ages ranged between 30 and 55 years, with a mean of 43.4 years of age. The total length of service was between 8-31 years of work, with an average of 19.9 years, while the length of service in the municipality ranged between 2-22 years, with an average of 13 years of service. The number of schools in which they work ranged from 1-4, with an average of two schools. The number of attended classes ranged from 1-33, with an average of 9.7 classes. The workload ranged from 100-350 total monthly hours of work, with an average of 239.3 hours, among those who work only in the municipality (50%) and those who also work in another sphere or in the private network (50%). Despite not being an inclusion criterion, there were only interviews with teachers under the statutory working regime.

Half of the interviewees were categorically unaware of the SHP, even in schools where there were actions related to the program. Lack of knowledge of actions relevant to the program may be related to the quality of communication and transmission of information at school, with greater attention being paid to its interlocutors.

Access to information and communication is crucial in the instrumentalization of subjects in decision-making processes (SILVA; CRUZ; MELO, 2007SILVA, Alessandra Ximenes da; CRUZ, Eliane Aparecida; MELO, Verbena. A importância estratégica da informação em saúde para o exercício do controle social. Ciência & Saúde Coletiva, Rio de Janeiro, v. 12, n. 3, p. 683-8, jun. 2007.). In the research in question, the actions of the SHP were reported to the school management body. The Municipal Education Department (SEMEC), in partnership with the Municipal Health Department (SESMA), throughout 2018, held four periodic meetings with coordinators of the agreed schools where information should be disseminated with their respective teaching bodies. This informational noise interferes in the teacher's performance in relation to activities developed at school.

Evaluation of the SHP in the context of municipal schools in Belém

Assessment processes guide the analysis of knowledge production when there is a need to value it, regardless of purpose. However, these processes are related to decision making and applicability in management systems. With regard to health assessment, it is possible to infer the optimization of processes in complex performance systems (TANAKA; TAMAKI, 2012TANAKA, O. Y.; TAMAKI, E. M. O papel da avaliação para a tomada de decisão na gestão de serviços de saúde. Ciência & Saúde Coletiva, Rio de Janeiro, v. 17, n. 4, p. 821-828, abr. 2012.).

About the actions described by the interviewees, we have different approaches. From the more traditional ones, as below:

P14. Workshops or lectures with families take place. They are very punctual. There have already occurred, here, about [...] Meningitis. It has already happened on the dental issue and verminosis. So, there are lectures with families and individual care for children. They are examined by doctors who come to the school and receive medication.

P15. Generally, lectures are proposed to work with the family on the issue of health care.

P18. There was last year[...], some actions that last a couple of days, in dentistry. But, as the school is small, sometimes they organize to make everyone in one afternoon.

Health education is historically based on the biomedical/hygienist model and preserves traditional teaching methodologies, despite the recent movement of approximation of active teaching-learning methodologies (FARIAS; MARTIN; CRISTO, 2015FARIAS, P. A. M. de; MARTIN, A. L. de A. R.; CRISTO, C. S. Aprendizagem ativa na educação em saúde: percurso histórico e aplicações. Revista Brasileira de Educação Médica, Rio de Janeiro, v. 39, n. 1, p. 143-158, mar. 2015.). The health education model based on lectures and specific health actions does not contribute to significant learning for those involved, going against the grain of health promotion, a reflection of traditional training, bringing to the discussion the training of health professionals for the construction of autonomy community (FREIRE, 2002FREIRE, P. Pedagogia da autonomia: saberes necessários à prática educativa. 25. ed. São Paulo: Paz e Terra, 2002.; 2005; BESEN et al., 2007BESEN, C. B. et al. A estratégia saúde da família como objeto de educação em saúde. Saúde e Sociedade, São Paulo, v. 16, n. 1, p. 57-68, abr. 2007.).

In the field observation, SHP actions were registered, promoted by SESMA, in two schools, which corroborate the aforementioned view. In one of them (figure 2), students from three classes (8th and 9th grades) and Family Health Strategy professionals gathered in the cafeteria to lecture on the issue of sexually transmitted infections (STIs), leprosy and geohelminthiasis. On that occasion, the teachers of the referred groups were able to follow the action, which lasted a few hours in the afternoon.

Even though there was minimal student participation, the dispersion of them was notorious due to the conditions in which the lectures were being held. The criticism of specific actions of this type is ratified, where the lack of better planning led to an activity with a low educational potential in terms of teaching and health promotion.

Figure 2
Health education action through lectures

Regarding the approach to leprosy and geohelminthiasis, information was delivered to students, aimed at parents, in order to assist in the epidemiological surveillance of these diseases and direct medicalization actions.

This posture must be criticized for the specific factor in which it presents itself, not prioritizing the integrality of actions and requiring a reorientation of the care model (ALVES, 2005ALVES, V. S. Um modelo de educação em saúde para o Programa Saúde da Família: pela integralidade da atenção e reorientação do modelo assistencial. Interface (Botucatu), v. 9, n. 16, p. 39-52, fev. 2005.). These types of actions do not have the expected effects when compared to actions that relate dynamics and methodologies in which the student actively participates, in addition to involving faculty and school managers in the actions (MORAES NETO; SANTOS; ALMEIDA, 2009MORAES NETO, A. H. A. de; SANTOS, C. de P.; ALMEIDA, J. C. de A. Uma reflexão sobre as parasitoses intestinais em comunidades de baixa renda do norte do Estado do Rio de Janeiro, Brasil. Revista Práxis, Volta Redonda, v. 1, n. 2, p. 71-74, ago. 2009.).

There are, then, more diversified strategies, using different methodologies:

P03. Initially, there was a theater to present the program. Then came another moment of care in the library, with a medical team, a nurse [...]. But I had no direct contact with the team.

P04. They asked the children to write an essay about tuberculosis [...]. I really liked their dynamics that they not only spoke, but they brought that “television” [...] that keeps rotating and passing the figures. They put pictures on the floor, and together with these pictures from the beginning to the end of tuberculosis, and they had the little feet that the children had to follow the path and each step they took was a stage of the disease, and until they reached the last picture they they were well, like, shocked because it was a lung that was practically in terminal stage due to tuberculosis, and the figure was really ugly, and they were impressed and from then on they had even more that concern, anything, about the sneeze issue , that sometimes we sneeze and there is no question of putting your hand in your mouth and they started to take all this care, and I thought it was cool for that.

P06. Last week we had a health work at the school with the students, on the issue of vaccination, right? [...] Some mothers were called, to be dealing with the subject of vaccinations, with some students.

P10. Through the university, usually through the UFPA or UEPA, professors who bring their students here to do some kind of work with the classes in relation to hygiene, sexually transmitted diseases and other related matters.

As a health education mechanism, the option for active learning methodologies that approach the reality of the school community aims to contribute to the effectiveness of health promotion. Practices molded to popular health education have subsidized this process, making students and their families more present in the school environment, encouraging social control (DESSEN; POLONIA, 2007DESSEN, M. A.; POLONIA, A. da C. A família e a escola como contextos de desenvolvimento humano. Paideia, Ribeirão Preto, v. 17, n. 36, p. 21-32, abr. 2007.; GOMES; MERHY, 2014GOMES, L. B.; MERHY, E. E. A educação popular e o cuidado em saúde: um estudo a partir da obra de Eymard Mourão Vasconcelos. Interface (Botucatu), v. 18, n. supl. 2, p. 1427-1440, 2014.; FARIAS; MARTIN; CRISTO, 2015FARIAS, P. A. M. de; MARTIN, A. L. de A. R.; CRISTO, C. S. Aprendizagem ativa na educação em saúde: percurso histórico e aplicações. Revista Brasileira de Educação Médica, Rio de Janeiro, v. 39, n. 1, p. 143-158, mar. 2015.).

Although there are proposals that use appropriate methods, the so-called "pedagogy of fear" was observed, a practice still present in health education actions aimed at preventing drug use and STIs, in which professionals rely on impactful information and illustrations as a way of explaining extremes in these conditions. This can alienate the interlocutor instead of dealing with the construction of skills to manage and face the risks associated with these situations (BRASIL, 1997). In this perspective, we have different aspects of the professionals' actions with regard to the health actions proposed by the SHP, in addition to partnerships that go beyond the health sector, such as with projects coming from universities and collaborators.

The social determinants of health and the school community

Health education is a challenge that must go beyond mere information about bodily changes, hygiene practices, among others. The interlocutors must feel that they participate in this teaching-learning process. For this, it is necessary that the concept of health transcends that of disease and is understood as a changeable process according to social determination and the different risks to which the population is exposed according to their realities (CANGUILHEM, 2009CANGUILHEM, G. O normal e o patológico. Rio de Janeiro: Forense Universitária, 2009.; ALVES; AERTS, 2011ALVES, G. G.; AERTS, D. As práticas educativas em saúde e a Estratégia Saúde da Família. Ciência & Saúde Coletiva, Rio de Janeiro, v. 16, n. 1, p. 319-325, jan. 2011.).

Social determinants of health can be defined as the living conditions of populations in which certain social positions provide greater access to resources. In this perspective, disadvantaged populations are more vulnerable, as they are more exposed to inequities in the various fields that make up society (BUSS; PELLEGRINI FILHO, 2007BUSS, P. M.; PELLEGRINI FILHO, A. A saúde e seus determinantes sociais. Physis: Rev. Saúde Coletiva, Rio de Janeiro, v. 17, n. 1, p. 77-93, abr. 2007.). Geographically, the municipal schools of Belém are located, for the most part, on the outskirts of the city. In fact, all the schools that contributed to this work ratify this distribution. Therefore, the target audience of these schools is based on participants who live in these conditions, which will be discussed below.

Education and health promotion strategies must take into account the social determinants of health, which influence the daily life of the school community. Here are some relevant lines, in this regard:

P03. Around here it floods so much that the cars, sometimes, we put it here inside the school [...]. So, public health is exactly the issue of sanitation, which is a very large “S”, right?

P07. I think the issue of garbage, this is very aggravating here at the school, which is at the school's doorstep. The community itself comes from far away and brings garbage and puts it right behind the school.

P09. Here at school we have a very big problem with that one, how is it? African snail! There are times of the year when the school gets infested! And we have to be telling the children not to get it, because we know that it transmits diseases.

P14. From what I follow, I see that there are many problems related to lack of sanitation. So, as I told you, mycoses, pediculosis, verminosis are very frequent. Problems caused by poor hygiene, which are stomach pain, vomiting, diarrhea, and skin infections.

In the first excerpt, the interviewee mentions a political campaign slogan of the current mayor of Belém, about the “S” for sanitation, which would be one of the priorities in his government. Basic sanitation in Brazil is irregular, basically due to planning failures, problems in the destination of investments in the sector and lack of sustainability in the final projects. In Belém, the situation is even more complex, considering that the city's planning is closely linked to the tidal dynamics, the difficulty of rainwater drainage and the large amount of solid waste present in the urban perimeter (LEONETI; PRADO; OLIVEIRA, 2011LEONETI, A. B.; PRADO, E. L. do; OLIVEIRA, S. V. W. B. de. Saneamento básico no Brasil: considerações sobre investimentos e sustentabilidade para o século XXI. Revista de Administração Pública, Rio de Janeiro v. 45, n.2, p. 331-348, abr. 2011.; LIMA et al., 2012LIMA, R. J. da S. et al. Análise da distribuição espaço-temporal da leptospirose humana em Belém, Estado do Pará, Brasil. Rev. Pan-Amaz Saúde, Ananindeua, v. 3, n. 2, 33-40, jun. 2012.).

The inadequate disposal of solid waste in Belém is quite visible, which can be found on public roads or thrown into the drainage channels that permeate the city. Added to a service for cleaning public roads and collecting waste that do not meet the real need of the municipality, in this respect, especially in peripheral neighborhoods, where this service is incipient or non-existent (ARAÚJO; SOUSA; LOBATO, 2010ARAÚJO, M. L. de; SOUSA, S. N. de; LOBATO, V. C. Análise da disposição do lixo na cidade de Belém-PA: o caso do lixão do Aurá. ParaOnde!?, v. 4, n. 1, s/p, jan-jun. 2010.), this issue ends for being a problem that converges directly in municipal schools due to their locations.

The third speech refers to the problem of the “African snail”. Some gastropod molluscs are obviously of public health interest, given their potential as an intermediate host for some worms, such as the schistosome (MORAES et al., 2014MORAES, C. N. et al. Correlação de criadouros de Biomphalaria sp., hospedeiro do Schistosoma mansoni, em área de baixa infraestrutura sanitária no distrito de Mosqueiro, Belém, Pará. Hygeia, Uberlândia, v. 10, n. 18, p. 216-233, jun. 2014.). Although biological identification was not performed, some specimens could be registered together with the presence of eggs (figure 3). During the period in which the research was carried out at this school, there was no infestation of these gastropods, as reported.

Figure 3
Gastropod mollusc (left) and eggs (right) found at school

From this perspective, health education and environmental education are strong weapons for the rise of social control over basic sanitation issues in municipalities (MOISÉS et al., 2010MOISÉS, M. et al. A política federal de saneamento básico e as iniciativas de participação, mobilização, controle social, educação em saúde e ambiental nos programas governamentais de saneamento. Ciência & Saúde Coletiva, v. 15, n. 5, p. 2581-2591, ago. 2010.).

About the insertion of students in contexts of violence, we can see:

P10. The school is located in a place where violence and trafficking are quite common. Over the years, we've lost some students, or alumni, to these drugs, and we've even had cases of alumni murdered because of involvement or alleged involvement in trafficking or robberies, and so on.

P19. The main one, here at the school, is: drugs and violence, within the school and domestic violence. Many students who come here are victims of violence, bullying. But one of the biggest problems is drugs! On all shifts!

P20. We check here, the school has drug problems too, which is another type, right? It's a disease too, the issue of drug addiction! We check this a lot at night, at night, but it has already been detected in other shifts.

The issue of violence and drug use is recurrent in schools. The different contexts and social determinants that are involved in these topics permeate the school environment due to the inherent training of the student, usually a teenager, who is in a moment of self-assertion construction and susceptible to the modulation of their personal choices based on group behaviors (BRASIL, 1997).

Regarding the different types of violence, we have, as risk factors, early exposure to violence, legal drugs, a culture of violent response to conflict, the inefficiency of justice and police force, exposure through the media, among others. However, we must highlight as fundamental among the risk factors: poverty, social inequality and marginality. It is notorious that cases of intentional urban violence are more frequent in lower socioeconomic groups, being both provocateurs and victims in this process. (GUERRERO et al., 2011GUERRERO, R. et al. Violência e saúde: o desafio de um problema social nas Américas. In: GALVÃO, L. A. C.; FINKELMAN, J.; HENAO, S. Determinantes ambientais e sociais da saúde. OPAS: Editora Fiocruz, 2011. p. 497-512.).

On drugs, the dialogue between peers must be taken into account. The dissemination of the truculent repression of consumption and commercialization has not generated a satisfactory effect. It is necessary to recognize its power and influence on economic models and social organization, both legal and illegal (BRASIL, 1997). The greatest effects, in relation to the fight against drugs, are in the way of dealing with the subject in the school context. Moralizing, prohibiting or discriminating are ways to distance young people from dialogue, educational and health-promoting actions. The more spaces young people can occupy for qualified and non-discriminatory discussions, sharing experiences in groups, the greater the chances of there being real problematization and identification with daily life (BARROS; COLAÇO, 2015BARROS, J. P. P.; COLAÇO, V. de F. R. Drogas na escola: análise das vozes no jogo social. Educação & Realidade, Porto Alegre, v. 40, n. 1, p. 253-273, mar. 2015.; MOREIRA; VÓVIO; DE MICHELI, 2015MOREIRA, A.; VOVIO, C. L.; MICHELI, D. Prevenção ao consumo abusivo de drogas na escola: desafios e possibilidades para a atuação do educador. Educ. Pesqui., São Paulo, v. 41, n. 1, p. 119-135, mar. 2015.).

In this sense, public policies that aim to reduce economic and social inequalities, especially those aimed at combating extreme poverty, can initiate new paths with regard to intersectoral policies and actions, promoting greater contribution to social control (SILVA, 2005SILVA, M. O. da S. e. Os programas de transferência de renda e a pobreza no Brasil: superação ou regulação? R. Pol. Públ., v. 9, n. 1, p. 251-278, jul-dez. 2005.; GUERRERO et al. ., 2011GUERRERO, R. et al. Violência e saúde: o desafio de um problema social nas Américas. In: GALVÃO, L. A. C.; FINKELMAN, J.; HENAO, S. Determinantes ambientais e sociais da saúde. OPAS: Editora Fiocruz, 2011. p. 497-512.).

Here are other lines:

P01. I have a student who is overweight[...]. Sometimes, they don't have the habit of having a healthy snack at school, so that's a worrying factor, as sometimes they buy snacks, popcorn, stuff, and bring it to school. Do not take advantage of the snack that is provided by the city, in this case.

P08. We see our students who arrive, like this, with lack of food, understand? They are a little bit, like, malnourished.

P13. So, I think that health is totally linked to food. Here, we know that we live in a very area... I'm not going to say that everyone is miserable, but it is quite complicated financially, and I think that everything that comes interferes because of that. We see, like, many children here at school who come because of the coffee. It is true! We think we're just making this speech, but it's true! There are children who come just to eat!

P17. Precisely I don't know how to tell you, but from the biological look we have, we notice mainly that they eat a lot of junk food.

In the excerpts above, risk factors for poor diet or secondary malnutrition are shown, which ends up revealing a reality at different levels of inequities with regard to food and nutrition security (GUBERT; PEREZ-ESCAMILLA, 2018GUBERT, M. B.; PEREZ-ESCAMILLA, R. Insegurança alimentar grave municipal no Brasil em 2013. Ciência & Saúde Coletiva, Rio de Janeiro, v. 23, n. 10, p. 3433-3444, out. 2018.). The demographic profile must be considered as well as the mother's access to quality food, employment and time available at a more household level, food costs, care policies, social support networks, basic sanitation, health services, in local level, among several other determinants that modulate the relationship of these students with food and their ways of eating (KEPPLE; SEGALL-CORRÊA, 2011KEPPLE, A. W.; SEGALL-CORREA, A. M. Conceituando e medindo segurança alimentar e nutricional. Ciência & Saúde Coletiva, Rio de Janeiro, v. 16, n. 1, p. 187-199, jan. 2011.).

In one of the schools, an interesting scene could be registered in this regard: when the guardians take early childhood education students to the classroom, they also take part of the lunch (figure 4) and leave it on the cafeteria bench for the employees of the kitchen store in the refrigerator.

Figure 4
Drinks taken by the guardians of students from one of the surveyed schools

Although there is school lunch, some guardians opt for lower quality inputs, due to their economic value, a culture of practicality or perhaps lack of familiarity with less processed foods and lack of time for more elaborate and more nutritious preparations, consequently. This is followed by the issue of food insecurity, modulated by financial instabilities, access to food supplies and lack of public policies, where school meals represent the main meal of the day for needy students, contributing to school attendance (BEZERRA, 2009BEZERRA, J. A. B. Alimentação e escola: significados e implicações curriculares da merenda escolar. Revista Brasileira de Educação, Rio de Janeiro, v. 14, n. 40, p. 103-115, jan-abr. 2009.; KEPPLE; SEGALL-CORRÊA, 2011KEPPLE, A. W.; SEGALL-CORREA, A. M. Conceituando e medindo segurança alimentar e nutricional. Ciência & Saúde Coletiva, Rio de Janeiro, v. 16, n. 1, p. 187-199, jan. 2011.).

The quality of life of the poorest populations on the continent undergoes a complication that follows the lack of opportunities in a political and economic system that does not have social justice and the reduction of health inequities as pillars. Health problems, food insecurity, poor access to health and safety services end up intensifying as population growth rises (NOYOLA; HELLER; OTTERSTETTER, 2011NOYOLA, A.; HELLER, L.; OTTERSTETTER, H. Os desafios para a universalização do saneamento básico. In: GALVÃO, L. A. C.; FINKELMAN, J.; HENAO, S. Determinantes ambientais e sociais da saúde. OPAS: Editora FIOCRUZ, 2011. p. 369-384.).

Basic education teacher: inherent health educator

Teaching is one of the most challenging occupations, in which the teacher needs to be dedicated, changeable and aware of the different interpersonal, social and political relationships in which they are inserted together with the social function of the school and its own, even though there are difficulties in this process (TUNES; TACCA; BARTHOLO JÚNIOR, 2005TUNES, E.; TACCA, M. C. V. R.; BARTHOLO JUNIOR, R. dos S. O professor e o ato de ensinar. Cadernos de Pesquisa, São Paulo, v. 35, n. 126, p. 689-698, dez. 2005.; GATTI, 2013GATTI, B A. Educação, escola e formação de professores: políticas e impasses. Educar em Revista, Curitiba, v. 50, p. 51-67, out-dez. 2013.).

In this horizon, there are three strands of thought about the excerpts collected in the research, regarding the participation of the interviewed teachers in actions or practices related to health, in the schools where they work. One of them points to the lack of self-recognition as a potential health educator:

P07. There was no action, like that, or work, activity that we have done. I think not.

P08. No. That's what I said, that I miss this prevention, this clarification.

P10. Not that I remember now.

P15. No. Does my classes count?

The public school system entails multiple demands, professional devaluation, scarce planning and reflection time, and lack of articulation between teachers, pedagogical coordinators and principals. The work of health promotion can be perceived as an additional demand for teachers, who sometimes feel that they do not have the support of school management and that they have few pedagogical resources for actions of this kind. This may also explain the low teaching support for actions promoted in this context by partners such as the Health Department or Universities (PARO, 2012______. Trabalho docente na escola fundamental: questões candentes. Cadernos de Pesquisa, São Paulo, v. 42, n. 146, p. 586-611, ago. 2012.; UCHÔA, 2012UCHÔA, R. de C. M. de F. O Programa Saúde na Escola sob o olhar dos Gestores, Educadores e Participantes: Um estudo no município de Manaus. 2012. 60 f. Dissertação (Mestrado em Ciências da Saúde) - Universidade Federal do Amazonas, Manaus, 2012.; MOREIRA; VÓVIO; DE MICHELI, 2015MOREIRA, A.; VOVIO, C. L.; MICHELI, D. Prevenção ao consumo abusivo de drogas na escola: desafios e possibilidades para a atuação do educador. Educ. Pesqui., São Paulo, v. 41, n. 1, p. 119-135, mar. 2015.).

Thus, the very fact that teacher education has historically been based on a traditional model of education, with vertical practices, configures a factor in the distancing of teachers with non-mandatory teaching methods. And, in addition to the teacher, sometimes other support professionals for teachers, such as the management body, agree with this outdated structural model (FREIRE, 2002FREIRE, P. Pedagogia da autonomia: saberes necessários à prática educativa. 25. ed. São Paulo: Paz e Terra, 2002.; PARO, 2010PARO, V. H. Educação, política e a administração: reflexões sobre a prática do diretor de escola. Educação e Pesquisa, São Paulo, v. 36, n. 3, p. 763-778, set-dez. 2010.).

Another aspect, although there is potential recognition, delegates health knowledge to the field of Natural and Biological Sciences or to the health sector itself:

P01. Here, what I've already done with them, we work in the classroom teaching some hygiene issues, health issues, even physical, mental, and other characteristics, we don't go into it very deeply because I'm not in the area.

P02. I think that as a teacher it is part of my profession to guide students, so, even though I am not a health care professional, I always try to guide them by asking them to wash their hands, [...].

P14. I can tell you that, here, related to the contents of natural sciences, we talk and get in touch with the families.

P22. We have the science content that ends up working on this part, more theoretically, but then the action doesn't have much.

In both cases, this distance can be considered as a consequence of professional training and deficient transdisciplinary practices. The cross-cutting themes appear on the national scene, effectively, in the late 1990s and systematize some themes to be worked on by all teachers, in order to insert them into the socio-political-cultural context of students (BRASIL, 1997; 1998). In this sense, the lack of interaction between the health sector, school education and teacher education contribute to the avoidance of confronting health-related issues in teaching practice. Thus, studies indicate that the role of teachers ends up restricted to common sense or to the biomedical/hygienist conception, without deepening the content (GUSTAVO; GALIETA, 2017GUSTAVO, L.; GALIETA, T. Da saúde de ontem à saúde de hoje: a formação de professores desde a história natural às ciências biológicas no Brasil. ALEXANDRIA: R. Educ. Ci. Tec., Florianópolis, v. 10, n. 2, p. 197-221, nov. 2017.).

So, the third aspect concerns teachers who recognize the value of their praxis, inserting health into their planning in a natural way:

P15. In my classes, I do, through informative texts, documentaries. I work a lot with them, well, in all areas: dentistry, health care, even. It's in our work proposal.

P17. Yes, normally I always work activities, especially during holidays and carnival. I always enjoy working on the issue of preventing STDs and the issue of contraceptive methods, right, condoms as the most effective way to fight STDs and unwanted pregnancies[...]. Always with really stronger images, which is for them to see what the disease really is like, and for them not to want to acquire something like that, to come back from the party they went to to have fun with something like that.

P20. I think that when we work on the issue of garbage, the issue of recycling, the issue of preserving the environment, we are talking about health, right? Because we are talking about a direct intervention in health, well-being, living conditions.

The ability to promote transdisciplinarity in teaching practice is extremely important to situate the different social contexts in which teachers and students are inserted. Permanent and continuing education are key elements in the acquisition of new perspectives on teaching activities (BRASIL, 1997; 1998).

Of the three excerpts selected to represent the third interpretive strand, two are from Geography and Science professors. This corroborates the mentions of health themes in the local curricular guidelines of the city of Belém, and demonstrates the intrinsic responsibility of these professionals to curricular entities established with regard to environmental education and health programs and actions, with Physical Education teachers, in the latter (BELÉM, 2015; KRASILCHIK, 2016KRASILCHIK, M. Prática de ensino de biologia. 4. ed. São Paulo: Editora da Universidade de São Paulo, 2016.).

The inseparability of care in the health-education binomial

This thematic unit recognizes the role of health surveillance of education professionals, from teachers to others, with the explanation of injuries perceived by teachers and practices that promote health in a more specific way. From the interviews, we listed the main student injuries perceived by the teachers, in decreasing order of occurrence: problems with hygiene, flu or virus, vision, food, skin, teething, lice, low resistance, chickenpox, self-mutilation, pigeons and worms.

The issue of hygiene can be seen as the most cited, which goes back to the correlation of health advances since the beginning of the 20th century with schools, permeating the hygienist molds in the process (GUSTAVO; GALIETA, 2017GUSTAVO, L.; GALIETA, T. Da saúde de ontem à saúde de hoje: a formação de professores desde a história natural às ciências biológicas no Brasil. ALEXANDRIA: R. Educ. Ci. Tec., Florianópolis, v. 10, n. 2, p. 197-221, nov. 2017.). The school environment, in addition to the workplace of education professionals, is where students spend a good part of their days, socializing and interacting with their peers and mentors. In this perspective, there follows an interesting record observed in one of the schools surveyed, with regard to the health information process within the school (figure 5).

Figure 5
Individual notices of notification of student health problems on a notice board in the teachers' lounge

This initiative is of great value, as it informs all teachers of the grievances, elucidating and updating progress in improving the health status of the students in question. It is noteworthy that this initiative was the only one of its kind found among the surveyed schools. In this perspective, school management has merit for disseminating relevant information about the health situations of students, enabling prior teacher planning for a given situation (SILVA; CRUZ; MELO, 2007SILVA, Alessandra Ximenes da; CRUZ, Eliane Aparecida; MELO, Verbena. A importância estratégica da informação em saúde para o exercício do controle social. Ciência & Saúde Coletiva, Rio de Janeiro, v. 12, n. 3, p. 683-8, jun. 2007.; PARO, 2010PARO, V. H. Educação, política e a administração: reflexões sobre a prática do diretor de escola. Educação e Pesquisa, São Paulo, v. 36, n. 3, p. 763-778, set-dez. 2010.).

When we came across the following excerpts, we raised some important points:

P03. I realize that there are children, I have the habit of looking at their little eyes, I have a daughter too and I see, I like to be looking and I see apparently anemic children and I believe it is due to feeding, too, because I do a survey what they eat at home for lunch, and bologna and açaí is a very big food base for them.

P08. And we know that it's not just the profession, it's not just the teacher. We women are accumulating, in the society we live in today, various roles. In search of equality, [...] we accumulate the role of woman, mother, daughter, wife, teacher, worker. And then, besides the work inside the house, there is the work outside.

P14. In this case, I [will get in touch] with the families of this year, to work on the lice in the room, in relation to brushing their teeth, as they do not have the habit of brushing their teeth, in relation to the habits of basic hygiene such as bathing, cleaning and cutting nails, haircuts and controlling rats and insects at home.

In the history of education in the country, there is the contribution of women to the expansion of teaching. There was an intrinsic extension of her role as mother to educator and reconciled the traditionally cultivated domestic functions of women, who, ever earlier, were forced to fill primary teaching positions at low wages. The essentially female precocious provision of the profession is even pointed out as determinant by the social discredit and low salaries of the profession (TAMBARA, 1998TAMBARA, E. A. C. Profissionalização, escola normal e feminilização: magistério sul-rio-grandense de instrução pública no século XIX. História da Educação, Pelotas, v. 2, n. 3, p. 35-57, jan-jun. 1998.; TANURI, 2000TANURI, L. M. História da formação de professores. Revista Brasileira de Educação, Rio de Janeiro, v. 14, p. 61-88, ago. 2000.).

In this context, health care, a concept that has been extensively developed in nursing, establishes the role of women in the process. Historically, too, the role of the nurse is marginalized and inferior. Drawing a parallel with the educational area, it is clear that the scenario is not so different, safeguarding the obvious differences in performance (LIMA, 1998LIMA, R. de C. D. A enfermeira: uma protagonista que produz o cuidado no cotidiano do trabalho em saúde. 244f. Tese (Doutorado em Enfermagem) Universidade Estadual de Campinas, Faculdade de Ciências Médicas, 1998.; FRANCO; MERHY, 2012FRANCO, T. B.; MERHY, E. E. Cartographies of Work and Healthcare. Tempus, Brasília, v. 6, n. 2, p. 151-63, abr. 2012.).

Although the stigmatized role of women is currently undergoing significant changes with regard to empowerment and conquering spaces in the labor market, among other sectors, the reverberation of the wounds of macho society on them is undeniable (OLIVEIRA; RODRIGUES, 2018OLIVEIRA, P. A.; RODRIGUES, M. M. O papel da mulher na divisão sexual e social do trabalho. Revista Serviço Social em Perspectiva, Montes Claros, Ed. Especial, p. 45-58, mar. 2018.). Along with this, we have the issue of bringing the family closer to the school. This essential element, which undergoes grandiose configuration changes, according to the social strata, must maintain a partnership with teachers and school managers, being decisive in terms of maintaining social control and perspectives for changing the scenario (SILVA, 2005SILVA, M. O. da S. e. Os programas de transferência de renda e a pobreza no Brasil: superação ou regulação? R. Pol. Públ., v. 9, n. 1, p. 251-278, jul-dez. 2005.).

Final considerations

Given the above, the relevant participation of teachers and the education sector in health promotion processes is evident. Although there were meetings with members of the school management body to discuss the SHP and the corresponding actions, it was clear that the faculty had little or nothing to participate in the proposed actions due to the lack of information and communication about them.

Regarding the actions proposed in schools, there are examples from specific and out-of-context events, which go the opposite of what is recommended in this specific policy and in the Unified Health System (SUS), to those that use methodologies with real potential to lead to health promotion to the school community. The relevance of the study of social determinants of health can explain several situations that impact the school community in different ways, including ratifying problems considered old, but still continuing in the school preamble, such as the issue of food insecurity, violence, drugs and the precarious sanitation conditions.

The role of the basic education teacher as a health educator turns out to be innocuous, as long as there is no recognition in this situation. However, for this to occur satisfactorily, it is necessary that it is always updating itself and enabling it to apply increasingly effective teaching-learning methods.

Finally, the greater participation of women and the greater care that they, as teachers, manage to give to students are remarkable. Attentive and with the family, health promotion can occur through communication with those responsible, attracting the community into the school space and following what is done at school, encouraging the exercise of social control.1 1 F. M. Pereira: elaboration and design of the study; acquisition, analysis and interpretation of data; writing and reviewing the manuscript. W. A. de Lima: analysis and interpretation of data; writing and reviewing the manuscript. A. L. de N. Lopes: analysis and interpretation of data; writing and reviewing the manuscript. L. S. do Nascimento: elaboration and design of the study; manuscript review

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Publication Dates

  • Publication in this collection
    15 Nov 2021
  • Date of issue
    2021

History

  • Received
    03 May 2019
  • Accepted
    14 Apr 2020
  • Reviewed
    28 Mar 2021
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