Community Health Agents: health promotion skills for adolescents

Objective: to identify the domains developed by Community Health Agents in health pro- motion skill towards adolescents. Method: qualitative study conducted with 16 Community Health Agents, based on the methodological framework of professional skills. Results: two categories and nine domains of health promotion skills emerged: Knowledge (Concept; Health determinants and conditioning factors; Main population health problems and coping; Intersectoriality); and Skill (Identifying the relationship between health problems; Conduct-ing educational activities; Organizing discussion groups; Proposing and implementing inter- sectoral actions and establishing articulation with social facilities; Supporting social literacy actions). Final consideration : it was noted that there were some domains of skills in health promotion of Community Health Agents among adolescents, but there is a need for continuing education regarding the approach, for these professionals, in relation to knowledge and skills of health promotion.


INTRODUCTION
Adolescence is a period of life characterized by biopsychosocial transformations that can impact on personal, cognitive and social development, placing them in a unique setting for health promotion. Given the singularities and vulnerabilities imposed by this phase, there is a need for health contributions to a qualified approach to this public (1) .
The peculiarities inherent to adolescence fostered the consolidation of public health policies that recognized the right to health and citizenship of these subjects and provided their protagonism through their effective participation in health programs. In accordance with the principles established by Brazilian Unified Health System (SUS -Sistema Único de Saúde), Family Health Strategy (FHS) was propagated as a proposal for reorienting health services (2) .
Among the members that make up FHS (nurse, nursing technician, physician, Community Health Agents (CHAs), dentist and dental hygiene technician), CHAs stand out for the work done with the families of their responsibilities, as they are responsible by the dialogue between the families and the health team (2) . They are characterized as managers of health promotion strategies (3) and transformers of the reality of communities (4) .
In this sense, the Ministry of Health proposed ordering the training of these professionals based on professional skills. Professional skills are expressed in knowledge, skills and attitudes that generate criticism, reflection, commitment and sensitivity. Therefore, five skills order the performance of CHAs' work process, namely: integration of the health team with the local population; planning and evaluation of health actions in conjunction with the team; health promotion, aiming at improving the population's quality of life; prevention and monitoring of environmental and health risk; prevention and monitoring of specific groups and morbidities (5) .
It is emphasized that each of these skills has domains of knowledge and skills that are expected for the work of CHAs. Among these skills, we highlight the skill of health promotion, as it encourages the adoption of healthy lifestyles and health conscious and committed citizens, an important focus when it comes to the vulnerabilities that adolescents may be inserted into (5) .
A study on the perceptions and practices of CHA in actions with adolescents, points out that these professionals characterize them based on knowledge and common sense. In practice, they use listening and refer them to health facilities, seek confidence and establish ties in meetings (6) . They refer to the need for qualification so that they can get closer to educational and assistance activities with adolescents. Health promotion actions are still developed contingently and restricted to the prevention and monitoring of adolescents in some health condition through other programs (prenatal care, cancer prevention and family planning) (7) .
Given the above, there are gaps in the understanding of CHAs regarding their health promotion skills (knowledge and skills). In this sense, the question arose: which domains are being contemplated by CHAs in the health promotion skill among adolescents?
This study is relevant because it allows reflections on the role of nursing, as it is responsible for the training and skills of these professionals and identity construction, which enable the CHA to effectively act in health promotion.

OBJETIVE
This study aims to identify the domains developed by Community Health Agents in health promotion skill towards adolescents.

Ethical aspects
The guidelines and regulatory standards for research with human beings, according to Resolution 466/12 of the Brazilian National Health Board (Conselho Nacional de Saúde)/Ministry of Health, were followed. Participants were informed about the purpose of the study and signed the Informed Consent Form, ensuring anonymity. There were minimal risks to participants, such as discomfort, but was reduced by debating the social relevance of the study. The review and approval of the Research Ethics Committee was issued by Universidade Regional do Cariri Committee and CAAE (Certificado de Apresentação para Apreciação Ética -Certificate of Presentation for Ethical Consideration).

Theoretical-methodological framework
Professional skills were developed in order to qualify workers for the effective performance of their duties. In the context of health promotion, it was necessary to present the skills recommended by the Ministry of Health (knowledge and skills) to guide the work of CHAs (Chart 1).
The domains of health promotion skill provide frameworks for the development of skills and knowledge inherent in health promotion. CHAs, as health promoters, should incorporate such skills.

Knowledge
Health Promotion: concept and strategies; -Ways to learn and teach in popular education; -Health-disease process and its determinants and health conditions; Popular culture and its relation to the educational processes; -Social risk conditions: violence, unemployment, unprotected childhood, migratory processes, illiteracy, lack or insufficiency of basic infrastructure, others; -Participation and social mobilization: factors that facilitate and/or hinder collective action; -Health indicators; -Concepts operated in contemporary civil society: social movements of struggle and defense of citizenship.
-Main health problems of the population and coping with these; -Leadership: concept, types and processes of constitution of popular leaders; -Intersectorality; -People with special needs: approach, social inclusion and legal rights; -Information, education and communication: concepts, differences and interdependencies; -Health of children, adolescents, adults and the elderly. Statutes of children, adolescents and the elderly.
To be continued of Community Health Agents: health promotion skills for adolescents Santos RL, Dias MSA, Pinto AGA, Cavalcante EGR, Machado MFAS.

Type of study
Descriptive study with qualitative approach conducted with CHA, linked to a municipality in the Northeast, countryside of Ceará, Brazil.

Methodological procedures
For this study, the following steps were performed: I -Contact with the municipal health department to obtain consent and access to the FHS; II -Selection of FHS teams located in both urban and rural areas; III -Access to the FHS and scheduling with the participants. The selection of the teams, for eligible participants, was made by lottery for unintentional selection of participants. Thus, among the urban area FHS teams, two were drawn. Similarly, it occurred for the selection of participants linked to rural FHS teams considering that the study contemplated different realities of professional practice. Thus, they participated in the CHA study of urban and rural areas, following the steps described.
Participants were identified by the increasing order number of data processing and this made it possible to preserve anonymity (CHA1, CHA2, CHA3 etc.). Inclusion criteria were CHA linked to FHS; working for at least one year. Exclusion criteria were CHAs that were absent from the health service during the data collection period. The semi-structured interview was used as a data collection instrument and presented aspects related to the perception of CHAs about their work practice among adolescents.

Study setting
The study took place in the city of Barbalha, Ceará, Brazil. Four FHS teams were drawn (two from the urban area and two from the rural area), totaling 19 CHA. However, two were on vacation and one on sick leave during the data collection period. Therefore, this study composed 16 CHA. All participants were female, mostly in the predominant age group of 36 and 46 years (seven CHA). The minimum age was 25 years and a maximum of 57 years, working in the profession between 14 and 19 years (six CHA), with a minimum of eight years and maximum 30 years in this profession.

Collection and organization of data
The interviews took place after scheduling by the researcher herself, from January to February 2016, according to the availability of participants, in a space reserved for the FHS itself and individually. Each interview lasted an average of 28 minutes. The speeches supported the elaboration of the analytical categories of the study, characterized by the domains of health promotion skill.

Data analysis
The study analysis followed Bardin's guidelines (8) , supported by the theoretical and methodological framework of the Ministry of Health's skills and other studies relevant to the theme. In this sense, the analysis of participants' discourses was divided into three phases: pre-analysis, material exploration and inference and interpretation. The analyzed data are presented in categories evidenced according to the highlighted domains in the health promotion activities among adolescents.

RESULTS
The categories composed by the domains of health promotion skill performed by CHAs are presented. From the participants' statements, the following health promotion knowledge domains can be highlighted: Concepts; Health-disease process and its determinants and health conditions; Main health problems of the population and their coping; and Intersectoriality.
Regarding the domains of health promotion skills of CHA, the following are evidenced: Identifying the relationship between health problems and living conditions of the population; Performing educational activities; Organizing discussion groups; Proposing and implementing intersectoral actions and establishing articulation with social facilities; and Supporting social literacy actions for adolescents.

Health promotion knowledge of Community Health Agents: concepts
CHAs understand the concept of knowledge-based health promotion, which is associated with disease prevention. In the report, the CHAs perceive themselves as part of the FHS and point out the practices they perform in this care model:

Health promotion knowledge of Community Health Agents: health-disease process and its determinants and health conditions
Components of health promotion such as quality of life, manifested by access and elements of health (sanitation, economic and social conditions) were pointed out. In addition to the persistence of CHAs in aggregating information and quality of life. The attempt to articulate health promotion to the knowledge of the health-disease process and the determinants and conditioning factors of health was noticed.
Health promotion is quality of life. Health is not just the absence of disease, the pathology itself. In our work, the quality of life must be first: sanitation, quality water, access, [.

Health promotion knowledge of Community Health Agents: main population health problems and coping
CHAs recognize Zika and Chikungunya as harms in the wider community. Specifically regarding adolescent health, the most common problems were Sexually Transmitted Infections (STIs), although for coping, the transmission of health information and educational lectures were limited as a preventive possibility.

Health promotion knowledge of Community Health Agents: intersectoriality
CHAs expressed the approach of sectors of the community, such as school and church, that occurred voluntarily or were invited for educational activities. They also worked with adolescents from Health at School Health (PSE -Programa Saúde na Escola) and used this space due to the availability of structural and material resources.
We look for the direction of the school and those of the age group, like adolescents. Next to PSE. (CHA 4) We go to school: because we have an auditorium, a data show, so we get together. Health and education came together. (CHA 10)

Health promotion skills of Community Health Agents: identifying the relationship between health problems and living conditions of the population
CHAs pointed out that with the resurgence of Dengue and Zika virus, they use the skill to guide health protection measures, specifically cleaning, conditioning and disposal of waste for vector control. They explained about the problems of drug addiction and prostitution, which affect adolescents in the community, although they did not highlight the vulnerabilities that are linked to these problems.
He lectures talking about the problems, as today there is Dengue, Zika, about hygiene ... we get to the health center and speak. (CHA13) Since dengue appeared, the problem of waste, then we also talk. And drug and prostitution care. (CHA 11) Health promotion skills of Community Health Agents: carrying out educational activities CHAs expressed that they performed practices with adolescents, whether or not articulated with PSE, collectively or individually. These were conducted through home visits and lectures in schools or the health unit. The most mentioned topics were teenage pregnancy, family planning, drug use, the need for home and environmental hygiene.

It is in home visits and in schools; We do work guiding pregnancy, adolescence, such as drugs, home hygiene and environmental. The age group we work for is from 12 to 16 years old. (CHA 4)
We talk about prevention, family planning, ... it's about unplanned pregnancy, STD. (CHA 1)

Health promotion skills of Community Health Agents: organizing discussion groups
CHAs pointed out difficulties in this action and sometimes were not developed due to lack of planning, demotivation or due to work break, due to the state of strike of professionals linked to FHS. Report that educational practices, through lectures, resulted in little or no participation of adolescents and have difficulty knowing how to approach adolescents, especially those on drug addiction or considering a particular problem.
They are often planned. Others are last minute. We try and try to give a lecture and they don't want to, they are afraid. (CHA 1)

In my area, I am in deficit in this sense there. We worked a lot in a team, but with the strike going on, it discouraged our work. (CHA 9)
It is very difficult to reach out and approach the adolescent. Because an adolescent problem, I don't get involved [...] because of drugs. I find it complicated to work with adolescents. (CHA 15) Also in this domain, there was a report of punctual activity with the adolescent, which was related to continuing education in a complementary course with this target audience. However, this activity was not continuous in the work process.
We never work directly alone with adolescents. I particularly never saw it. I already did with another health worker because it was a course to complete the course load

Health promotion skills of Community Health Agents: proposing and implementing intersectoral actions and establishing articulation with social facilities
CHAs cited rapprochement, respectively, with the Psychosocial Care Center (CAPS -Centro de Atenção Psicossocial) and the school or church, in the perspective of responding to the demands in the community, especially related to the problem of drug use.

DISCUSSION
In the health promotion knowledge domain, CHAs understand as a synonym for disease prevention and/or a good quality of life. The latter was related to the sense that promoting health is the quality of life of individuals, rather than understanding how terms are interrelated. In this sense, a limitation is inferred from the broad concept of health promotion conceived since the VIII Brazilian National Health Conference.
The definition of health promotion is anchored in the adoption of behaviors that value the individual's well-being and potential for optimal health (9) . The definition of the term "Quality of life" is broad and the main characteristic is its association with the subjects' surroundings (10) . Prevention is an intervention strategy to prevent the onset of specific diseases. While health promotion extends prevention and is based on enhancing the health of individuals and social transformations. There are similarities between both terms (11) , but they are concepts that should be understood as distinct.
This difficulty, reported by the study participants, may reflect the lack of continuing education in the service. Thus, one can affirm the need for strategies that value the training of community health agents, focusing on learning health promotion and consequently, strengthening the community action of their skills with adolescents.
In this sense, a study obtained results consistent with this research, by highlighting the challenges in the reorientation of the care model and the need for vocational training and pointing to the centralization of educational practice in the daily work of CHAs, which was limited to the transmission of information. Therefore, it requires the incorporation of training, assistance and institutional practices to broaden the conception of health promotion (12) .
Regarding the domain process health-disease-care-quality of life and its determinants and health conditions, it was noted that CHAs described components inherent to access to health (sanitation, economic and social conditions). In addition to the persistence of CHA in aggregating information and quality of life, there was an attempt to articulate health promotion with knowledge of the health-disease process and the determinants and conditioning factors of health. This finding is similar to another study in which CHAs aggregate the approach not only to disease but also determinants of health problems to contribute to the adolescent health-disease process (7) .
In the area of identifying the main health problems of the population (group of adolescents) and coping, CHAs recognized sexually transmitted infections, drug addiction and pregnancy. They believe that information can be a promoter in disease prevention, although they did not express the planning or interventions needed to address the problems diagnosed with adolescents.
This finding corroborates a study conducted in South Africa, which points out that if health professionals have poor information or when there is no planning, among the health team for health organization and interventions; health care may be compromised (13) .
In the United Kingdom, a study was developed to understand educational strategies that can be enhanced in the work of these professionals. These strategies should be explored in the perception of health promotion and be guided by the perspective of informing adolescents about what is healthy and not only about diseases, breaking vertical practices, highlighting the technical knowledge of health professionals (14) . Thus, the study prescribes the need to strengthen competence in empowerment so that these health professionals can promote the effective participation and changes in attitudes of adolescents.
Other common community issues were also reported by participants, such as prevention of arboviruses (Zika and Chikungunya); but they did not mention the team action plan. It is noticed that the incorporation of these themes are consistent with the local reality and present in the practices.
The intersectoriality domain ratifies the articulation with other health equipment, such as CAPS, and even though they used spaces, from the community itself as a school and church; to facilitate health promotion actions with adolescents by developing themes relevant to this phase.
School space and churches were also present contexts in a study with adolescents. The use of these spaces was provided by 7 of Community Health Agents: health promotion skills for adolescents Santos RL, Dias MSA, Pinto AGA, Cavalcante EGR, Machado MFAS.
the expansion of public policies involving sexual and reproductive health that favored the participation of adolescents in the school context and in churches (15) . In fact, permanent articulation needs planning and systematization of these actions. The training process must include health promotion in the daily health services of SUS (16) .
In the performance of CHAs, it is clear that in the domain Ability to identify the relationship between health problems and living conditions of the population returned to the problem of arboviruses and the relationship of the community with the environment. Thus, they explored the home context, through home visits, to interact with the adolescents and guide or refer them to the health unit, when necessary.
Also in this domain, they highlighted vulnerabilities of adolescents such as drug addiction and prostitution, which is a condition present in their micro areas, but did not relate the care provided. In addition to the reported vulnerabilities, a study shows that living in rural areas may make adolescents vulnerable, especially to pregnancy, thus recognizing the importance of social determinants for this clientele (17) . The actions of CHAs in adolescent care view the importance of training, especially in emerging issues such as alcohol, drugs and sexuality (7) .
Regarding the domain that perform educational activities in the available spaces of the community, it was found that they used the home, school and health unit and addressed diverse themes. However, this action is based on a traditional approach and restricts the use of lectures, although they recognize that they are unattractive and need educational materials. The CHAs' speeches on the need and interest in educational activities with adolescents was also identified in a study that highlighted the need to make serial folders and albums and other educational tools to help them demonstrate the content, in addition to need for personal qualification (7) . This requires the approach of new approaches, technologies and teaching-learning methodologies that enable and qualify the dialogue and listening of these groups.
Another skill evidenced in the speeches of the professionals in this study was in relation to the domain to organize discussion groups. In this, they reported on the difficulties in continuing this action related to lack of time, overload or lack of motivation in the face of working conditions and the need for planning. Moreover, the difficulty in articulating educational practices and fear resulting from drug-related violence that marginalizes society; were evidenced. This finding is consistent with a study that pointed to demotivation in CHAs' work performance due to increased workloads, dissatisfaction with remuneration, unhealthy conditions, overwork and devaluation by the population or health team. This feeling may interfere in the performance of activities of these professionals (18) .
The genesis of weaknesses in addressing adolescent health may be related to the precariousness of the training that CHAs received to perform their functions. These professionals need to guide the exercise of their activities in health promotion strategies that impact on health care and the health-disease process, an assumption supported by SUS itself (19) .
Regarding the proposing and implementing intersectoral actions and establishing articulation with social equipment domain, CHAs stated approximation with CAPS, school or church. Intersectoral action articulated with social facilities favors learning and solving needs among the actors involved (1) .
CHAs' skills to support adolescent social literacy actions infers that they encourage PRO-JOVEN project and programs such as PROERD, in the perspective that adolescents continue their studies. This ability points to the ability to communicate with families, recognizing their health needs and identifying efficient public policies to meet those needs (20) .
In analysis of the skill profile proposed by the Ministry of Health for health promotion skill, in the statements of CHAs, there were weaknesses in evidence about health indicators, education and communication. Ways of learning and teaching in popular education, popular culture and their relationship to educational processes; were not evidenced in this area.
Other developments such as concepts operated in contemporary civil society, the right to human diversity, leadership and even people with special needs (approach, measures to facilitate social inclusion and legal rights, statutes of children, adolescents and the elderly) were not mentioned in the study.

Study limitations
The limitation of this study was the need to approximate the studied phenomenon to adolescents and compare the findings. Therefore, this study points to the expansion of research so that further investigations are carried out, with other designs and approaches, to explore the application of the domains of skill with CHA and even understand how the professional training of these workers by professional skills happens.

Contributions to nursing, health and public policies
This research contributes to nursing, health and public policies, by noting the importance of the formation of CHAs regarding the health promotion skills domains proposed by the Ministry of Health, since nurses are primarily responsible for the training of such professionals. Another contribution is the need for nurses to use new health technologies that incorporate the qualification of these professionals in their work with adolescents. CHAs are hybrid characters in the context of health policies, and nurses are fundamental in their formation in a defined and specific way. It is recognized the importance of (re)discussing the ordering process in the formation of CHAs, in the current public policy setting, under the logic of the potentialities of the current health care model.

FINAL CONSIDERATIONS
The CHA speeches revealed the presence of the following knowledge domains of health promotion skills of the Ministry of Health: concepts; health-disease process and its determinants and conditioning factors; Main health problems of the population and coping and Intersectoriality.
As for the domains of skills were found: Identifying the relationship between health problems and living conditions; Performing educational activities; Organizing discussion groups; Proposing and implementing intersectoral actions and establishing articulation with social facilities; and Supporting social literacy actions for adolescents. These domains imply the performance of health promotion activities of these professionals with adolescents. However, there are weaknesses in the ordering of training of professionals and, consequently, challenges to the promotion of effective health, as other domains of skill were not highlighted.
Skills in health promotion of CHAs domains need discussions for the effective appropriation to the working practices of these professionals. Thus, it is necessary to approximate these conceptions to the perspectives required by SUS.
Continuing education for these professionals is also important. Intersectoral articulation can still be worked on, since this articulation is not only the responsibility of the health sector and needs permanent links.