Implementation of the National Policy for Comprehensive Attention to Men’s Health: challenges experienced by nurses

ABSTRACT

Objective

To analyze the challenges experienced by nurses in the implementation of the National Policy for Comprehensive Attention to Men’s Health.

Method

Descriptive, qualitative study, carried out with nurses working in Primary Health Care in a city in the state of Bahia, Brazil. Individual interviews were carried out and then analyzed using the Discourse of the Collective Subject, in the light of the guidelines of the National Policy for Comprehensive Attention to Men’s Health.

Results

A total of 40 nurses participated. The challenges for the implementation of the policy are related to the inoperability of government actions, weaknesses in municipal management, underfunding and discontinuity of actions.

Conclusion

Nurses face complex macro-management challenges in the implementation of the National Policy for Comprehensive Attention to Men’s Health in Primary Health Care.

Nursing; Men’s Health; Health Policy; Primary Health Care; Health Care (Public Health

RESUMO

Objetivo

Analisar os desafios vivenciados por enfermeiras na implementação da Política Nacional de Atenção Integral à Saúde do Homem.

Método

Estudo descritivo, qualitativo, realizado com enfermeiras que atuam na Atenção Primária à Saúde em um município da Bahia, Brasil. Realizou-se entrevista individual, analisada pelo método do Discurso do Sujeito Coletivo, à luz das diretrizes da Política Nacional de Atenção Integral à Saúde do Homem.

Resultados

Participaram 40 enfermeiras. Os desafios para a implementação da política concentram-se na inoperância das ações governamentais, fragilidades da gestão municipal, subfinanciamento e descontinuidade das ações.

Conclusão

As enfermeiras enfrentam desafios complexos de macrogestão na implementação da Política Nacional de Atenção Integral à Saúde do Homem na Atenção Primária à Saúde.

Enfermagem; Saúde do Homem; Política de Saúde; Atenção Primária à Saúde; Atenção à Saúde

RESUMEN

Objetivo

Analizar los desafíos vividos por las enfermeras en la implementación de la Política Nacional de Atención Integral a la Salud del Hombre.

Método

Se trata de un estudio descriptivo y cualitativo realizado con enfermeras que trabajan en la Atención Primaria de Salud en un municipio de Bahía, Brasil. Se llevaron a cabo entrevistas individuales y se analizaron con el método del Discurso del Sujeto Colectivo, a la luz de los lineamientos de la Política Nacional de Atención Integral a la Salud del Hombre.

Resultados

Participaron 40 enfermeras. Los retos para la aplicación de la política se concentran en la inoperancia de las acciones gubernamentales, la debilidad de la gestión municipal, la infrafinanciación y la discontinuidad de las acciones.

Conclusión

Las enfermeras se enfrentan a complejos retos de macrogestión para implementar la Política Nacional de Atención Integral a la Salud del Hombre en la Atención Primaria Sanitaria.

Enfermería; Salud del Hombre; Política de Salud; Atención Primaria de Salud; Atención a la Salud

INTRODUCTION

Men’s health has become a worldwide concern¹ - ³ . Nevertheless, data from Brazil in 2016 showed that women lived, on average, 7.4 years longer than men and had a life expectancy of around 78.7 years, while men had a life expectancy of 71.3 years. In addition, it was observed that the indicators of morbidity and mortality were higher in the male population, with emphasis on external causes⁴ - ⁵ .

Therefore, in 2009, the Brazilian Ministry of Health approve the National Policy for Comprehensive Attention to Men’s Health (PNAISH), which appointed Primary Health Care (PHC) as the fundamental space for the promotion of men’s care, the implementation of financial incentive and the inclusion of the male audience in health actions, with the objective of transforming the panorama of men’s health in Brazil⁶ - ⁷ .

The main objective of the PNAISH is to promote actions to expand men’s access to health services, especially to PHC, considering the different organizational arrangements and operational and technological capacity of the networks in the local health systems. This policy considered masculine singularities and masculinities in their diverse socio-cultural contexts. Its central guidelines are the understanding of men’s health as a set of actions aimed at promotion, prevention, assistance, and recovery throughout the national territory⁸.

In a context in which PHC is the preferred gateway to the Unified Health System (SUS), the inclusion of nurses in multidisciplinary teams has a singular importance, as their work in the promotion of practices that coordinate clinical assistance and administrative management contribute to the daily provision of care. These professionals sometimes act as team leaders, and are responsible for coordination, supervision, monitoring, continuing education and research actions, contributing to the approval and implementation of the actions of the PNAISH at all levels, whether at central or municipal level⁹.

In this scenario, it is possible to see that the work of nurses in PHC is essential for the implementation of public health policies, given that their professional practice in this context includes resource management, administrative processes, teaching-learning actions, implementation of permanent and continuing education related to male health, as well as direct actions in the assistance to this population throughout their life cycle, whether in individual consultations or collective interventions. Thus, there are competences and skills that can be easily identified in the professional profile of nurses working in PHC, such as decision-making, reception skills, promotion of bonds, accountability, flexibility, creativity, scientific knowledge, clinical expertise, commitment and negotiation skills, which makes them a significant contribution to the advancement of PNAISH in Brazil¹⁰.

Thus, when well-positioned and in favorable conditions to act, nurses use their strategic vision and mobilization skills to achieve teamwork, which may facilitate the implementation of actions aimed at the management/provision of care to users, with a focus on the Family Health Strategy (FHS)¹⁰.

However, the analysis of the context and of the health-disease process of the male population shows a need to include this public in strategic actions to promote health and prevent diseases and injuries, considering their specificities. This requires health professionals to have a broad perspective towards comprehensiveness. However, actions on men’s health are still poorly structured, which can lead to difficulties in the implementation of actions focused on this population, such as the implementation of a health policy in daily health work⁶.

Thus, the PNAISH is considered a strategic proposal to bring the male public closer to health care and include them in preventive health care. However, it is important to point out the difficulties found by PHC professionals to implement the policy. Several factors are involved in the implementation of the policy, such as planning in macro-management and transposing planning to care activities in micro-management, which can generate challenges for professional nursing practice⁹ , ¹¹ - ¹² . In addition, the Ministry of Health has identified an unfavorable scenario in Brazil when it comes to advances in the implementation of the policy in the country, which involves, among other factors, gender issues that influence the relationship of men with health services⁹ , ¹² .

Despite this panorama, there are still gaps in the scientific knowledge of nursing when it comes health care and provision of care to the male audience. Original studies addressing the implementation of the PNAISH are limited, which justifies this study and makes it relevant for nursing training and practice.

Given the above, this study was guided by the research question: What are the challenges experienced by nurses in the implementation of the PNAISH? This article aimed to analyze the challenges experienced by nurses in the implementation of the PNAISH.

METHOD

STUDY TYPE AND SCENARIO

This is a Brazilian, descriptive, qualitative study, carried out with 40 nurses working in PHC, specifically in the FHS, in seven Primary Care Center (PCC) and 26 Family Health Centers (FHC), in a city in the state of Bahia, Brazil.

SELECTION CRITERIA

Nurses who worked providing direct assistance to users were included in the research. Nurses who were in training, were taking professional vacation or were in their curricular internship in Nursing were not included. In the total sample, four professionals refused to participate in the research, two arguing that they did not have knowledge or proximity with the theme, one for lacking time to answer the questions and the last professional did not want to reveal the reason for the refusal.

DATA COLLECTION

For data collection, a survey of the health centers in the city was carried out with the help of with the Municipal Health Secretariat, through the Nursing Division. This data collection occurred between August and December 2017 and between March and June 2018. Subsequently, an in-depth individual interview was conducted, guided by a semi-structured instrument composed of closed questions addressing the professional, social and economic characteristics and open questions about the central problem of the study, namely: Tell us your professional experience with men’s health care? Tell us how PNAISH has been implemented in your territory? A pilot test was previously applied to the research group and then to three participants. The data collected in the pilot tests were not included in the sample of this study and the final sample did not include any repeated interviews.

The interviews were recorded using a professional recorder and were later transcribed in full and presented to the participants for their approval, according to the guidelines proposed by COREQ, which guided the entire study. The selection of participants was consecutive and intentional. The researchers of the study had previous proximity with the subject of the study. The responsible researcher is a male professional, with a master’s degree in nursing, who has worked as a teacher and provided health education actions in health services and training of human and academic resources in the area. The other members of the research team had an undergraduate degree in Nursing and training in research and in the method used.

The interviews occurred in a private environment in the health center, at times when nurses were not providing care to users, as previously scheduled. The participants were approached face to face. Only the researchers and the participant were present at the time of the interview. The average duration of the interviews was 60 minutes. Field notes were made after the interviews, but were not included as empirical material for analysis. The collection process only began after a visit to the centers to present the research. The participants were invited to participate in the research and signed the Informed Consent Term (TCLE).

The empirical corpus was constructed with the use of theoretical sampling derived from the data. The distinct territorial characteristics experienced by the nurses were taken into account, which led the researchers to deepen their investigations looking for evidence on the co-occurrences, convergences and complementarities in the discourses. From the derived data, 10 theoretical codes were analyzed. As necessary, the participants had access to the transcribed interviews, gave their opinion on the results and had access to their presentation at a thematic event held by the municipal health department.

DATA ANALYSIS AND TREATMENT

The data collected were organized, systematized and processed in the NVIVO10 Software for qualitative analysis. The sample consists of socio-demographic data, and professional and empirical data that are the object of the study’s central investigation. The analysis was guided by Discourse of the Collective Subject (DSC) method, which rescues the constructs of Social Representations, marked by representative recognition in the individual dimension, in coordination with the collective dimension. Therefore, data is grouped into general semantic categories, associating opinions of similar meanings present in different testimonies¹³. The participants were identified through the description of the method, namely: “DSC of nurses working in the FHS”.

Therefore, the DSC, through its methodological constructs called Key Expressions, Central Ideas and Anchorages, enable the synthesis of discourses that can represent the collectivity in an individual¹³. The findings were analyzed from the perspective of the theoretical/normative reference of PNAISH in its principles and guidelines⁸. The data were in line with the conclusions, converging with the assumption of the study and the problems found in the discourses.

ETHICAL ASPECTS

The study was linked to the matrix research project called: Attention to men’s health in a setting in the Northeast Region of Brazil, approved by the Research Ethics Committee (REC) under opinion number: 1.208.304, along with the subproject entitled: Nursing in men’s health care: challenges of implementing actions in Family Health Strategy, also approved by REC, under opinion 996.821, both managed with their own financing.

The ethical recommendations for conducting studies involving human beings were followed throughout the research development process, in compliance with the guidelines of Resolution No. 466 of 2012 of the National Health Council, as well as Resolution No. 580 of March 22, 2018, which regulates the provision in item XIII.4 of CNS Resolution No. 466, and establishes ethical particularities for research with human beings in SUS institutions. To this end, autonomy to participate in the study, confidentiality of information and anonymity of the interviewees were maintained. The participants were described according to the methodological presentation of the DSC, being identified as: DSC of nurses working in FHS .

RESULTS

All the study participants were female, cisgender, heterosexual and married, self-identified as brown and were between 25 and 48 years old. The participants had worked in health centers for more than a year and had a total training time between 2 and 16 years. As for graduate academic training, most nurses were specialists in public health and/or family health, followed by attention to urgencies and emergencies. Most had one employment bond.

The Discourse of the Collective Subject revealed that the challenges for the implementation of the PNAISH are associated with the ineffectiveness of governmental actions, the weaknesses in municipal management, underfunding and, consequently, the discontinuity of actions.

Nurses’ discourse revealed the ineffectiveness of federal government actions, which generates challenges for the implementation of the policy. Discourses highlighted the limitations of strategies to expand the access of men to health services and increase the incentive and professional training for meeting male demands, absence of guidance protocols, low dissemination and lack of commitment and non-prioritization of men’s health care by the government. The results will be presented in Charts 1 , 2 , 3 and 4 below.

Chart 1
Discourse of the Collective Subject of nurses working in Family Health Strategy on the ineffectiveness of governmental actions, Bahia, Brazil, 2020.

Key expressions: [...] Access of men... strategy to attract patients... there is no manual... [...]	Men’s health policy is positive because it seeks to address the problems that specifically affect the male population, as a proposal for health promotion and disease prevention. However, its strategies need to be improved in order to facilitate the access of men to the services offered in health center, but this has still not happened. There is no incentive from the government for health professionals to develop strategies for attracting men, nor an instrument for the development of consultations and specific promotion actions for the male audience. There is an absence of Ministry of Health manuals that provide specific guidelines, and the dissemination of the policy is still weak or almost nonexistent. There is a lack of commitment of the federal government to prioritize and strengthen the presence of men in the services before they become ill (DCS, nurses who work on the FHS).
Central ideas: [...] strengthening actions... dissemination is very weak... something that guides us [...].
Anchorage: [...] the federal government also needs to be committed [...].

Source: Research data.

Chart 2
Discourse of the Collective Subject of nurses working in Family Health Strategy on the weaknesses in municipal management, Bahia, Brazil, 2020.

Key expressions: [...] they only order.... implement... request [...].	I work directly in care at the health center, I know the needs of the population and the demands of the area, but the managers who are at the top, whether municipal, such as the health secretary, or coordinators, only send the assignments to be fulfilled, implemented and then charge us, but do not ensure that the actions take effect. They do not provide the necessary support to be successful in the actions, nor do they follow up on how they can be implemented. In addition, they are not concerned with working together with the health team to promote this policy and observe the needs of men up close, which could improve access and assistance. I do not have an adequate structure to develop the policy actions, such as educational actions, locomotion, with the provision of transportation for the team to go to the coverage area in the community, so I have to use my own vehicle, and expose myself to dangers, due to the risk areas in my territory (DCS, nurses who work in FHS).
Central ideas: [...] assignments to be fulfilled... do not ensure that they are carried out... do not provide the necessary support [...].
Anchorage: [...] I don’t have an adequate structure to develop the policy’s actions [...].

Source: Research data.

Chart 3
Discourse of the Collective Subject of nurses working in Family Health Strategy on the underfunding for the implementation of PNAISH, Bahia, Brazil, 2020.

Key expressions: [...] financial resources... transportation... investment... campaigns [...].	The government needs to invest financial resources to attract men to the health center. It is the manager’s responsibility to demand these resources, because, as a nurse, it is not my competence. There is a lack of resources to carry out health education actions and disseminate services and health campaigns on social networks and radio programs. Without these benefits, the development of constant actions on health care awareness becomes difficult (DCS, nurses who work on FHS).
Central ideas: [...] lack of resources [...].
Anchorage: [...] as a nurse, it is not my competence... without these benefits in this center [...].

Source: Research data.

Chart 4
Discourse of the Collective Subject of nurses working in Family Health Strategy on the discontinuity of actions for the implementation of PNAISH, Bahia, Brazil, 2020.

Key expressions: [...] negative... no priority is given [...].	Health policies are implemented, but depending on the target audience, the government does not give them the same priority, which becomes negative, as actions lose continuity and are forgotten. This is a reality that I observe for PNAISH. The actions must not only be implemented, but government officials and managers must press for the policy to be continued. They must actually participate and follow up, provide the necessary support, because if this does not happen, how will the policy work? Only in the Blue November campaign that the government provides everything, such as exams, screening, places for medical appointments, referral to specialized centers and adequate support to the demands, but on other days men need to schedule, wait for medical regulation to make a referral in case there is a bigger problem like the identification of a cancer and it all takes a long time. Actions need to happen all year round, not just in a month (DCS, nurses who work on FHS).
Central ideas: [...] in blue November, the government provides everything [...]. [...] actions need to happen all year round [...].
Anchorage: [...] losing continuity... being forgotten [...].

Source: Research data.

The collective discourse pointed to weaknesses in municipal management as a challenge faced for the implementation of the PNAISH, comparing the willingness and work of nurses who recognize the male demands in the territory to the practices of municipal management, that establishes goals but does not provide conditions and resources for their achievement. Another factor highlighted is the lack of infrastructure, such as the lack of vehicles for locomotion of the teams and development of activities outside the center.

The underfunding of the public health system was pointed out by nurses as an important challenge for the implementation of the PNAISH. The allocation and distribution of the financial resources necessary to guarantee the attention to men’s health is not the competence of the professionals within the scope of the FHS, which compromises the development of actions, the dissemination, and even the necessary locomotion for activities in the territory covered by the services.

The discontinuity of actions was a challenging factor for nurses. The discourse points out that PNAISH has not been prioritized and has been overlooked by government officials, which has had a direct impact on the continuity of actions, causing them to stop happening in the daily work in health services. Nurses report that the implementation process is not followed, nor monitored, and the necessary support is not provided. In addition, the discourse emphasizes that actions aimed at men’s health are limited to the prevention and treatment of prostate cancer, through screening actions, carried out in the campaign “Blue November”, but are not extended to other contexts and other periods of the year.

DISCUSSION

The limitations of this study are associated with the application of a single technique to produce empirical data, which may have reflected on the findings that were apprehended, in contrast to the combination of different methods. In addition, other nursing professionals who work in FHS, such as nursing technicians and assistants were not included, which means there are nuances yet to be explored in future studies. Finally, the inclusion of nursing professionals who work in management and technical area in men’s health could reveal other aspects that could complement the data presented.

In this study, the findings represent an analytical presentation of the challenges experienced by nurses in the daily routine of their professional practice in PHC regarding the implementation of the PNAISH.

The nurses’ discourse reveals the obstacles in the promotion of care practices that reach and involve men in the scope of PHC, pointing out the challenges of implementing the PNAISH. It also pointed to the direction of the policy, as a promoter of access, in a setting that is still insufficient for the transformation of the complex issues that surround this public in the context of health care and care production, due to aspects of the social construction of masculinities.

Three contextual elements regarding the difficulties for the insertion of men in health care can be highlighted: the context of men themselves and the construction of their masculinities; another, related to the professional dimension, marked by the low capacity to transpose the principles of politics into actions; and, finally, the organizational nature of the services and to the gendered division of health actions and services, as already show in another study¹⁴.

Still, considering this policy as a necessary normative instrument, its concreteness is not enough to transform reality. Symbolically, the singularity of the noun “man”, contained in the title of the document, reflects the lack of recognition of the diversity of construction and exercise of masculinities, contrasting with the body of the text, in which another understanding is presented⁷. Another guideline of the PNAISH is the co-responsibility of civil society organizations in government actions, considering health as a means of exercising citizenship⁸. Above all, the findings of this study reveal the invisibility of this social integration in health actions, which also affect the social recognition of the relevance of this health policy.

Although the relevance of the policy is recognized, nurses pointed out the limitations of management actions, which affect the work process. The collective discourse shows the lack of political will for the implementation of the PNAISH, which requires efforts of different orders, considering the structural aspects and the associated costs.

Another study analyzed the implementation of the PNAISH in a state capital in Brazil and revealed that the management process is fragmented and is characterized by the instability of the actors involved in the implementation of this policy. It also identified the proposition of nonspecific actions, without epidemiological justification, or actions planned without an adequate understanding of the local reality and situational diagnosis, which was reflected in the inability to transform the health scenario of the male population¹⁵. Another aspect worth highlighting is the lack of an instrument that allows nurses to guide men’s health care within the scope of the FHS, which weakens the care offered to this public. Another study highlights the lack of professional qualification to meet the demands related to men’s health, which can contribute to their low search for PHC services¹⁶.

Still, when analyzing male morbidity and mortality, it can be seen many problems could be avoided if men regularly consulted health professionals and adopted preventive health care measures, such as healthy attitudes and habits. Thus, it is known that the distance of men from these practices has significantly increased costs for the SUS and has been an emotional and physical burden for the users and their family members¹⁷ - ²⁰ .

Despite this, the importance of nursing professionals has been noted, as they are indispensable professionals in the care for the male audience and are responsible for educational, prevention and health promotion activities, with the possibility of synthesizing the magnitude of the actions and their functionality and practical application, in an attempt to improve public health services⁹. However, the nurses pointed out that there is a shortage of financial resources for implementing planned actions, as well as precarious conditions for the performance of their professional functions, such as a lack of vehicles for the locomotion of the teams in the health services where they work.

This lack of specific financial resources has been a determining factor for the discontinuity of actions and the difficulties in the process of implementation of this men’s health policy. Still, the interviewees considered that this justification reflected an inadequate understanding of the nature of the health system, especially primary care, since there are resources that could enable the effective expansion of access and promotion of male care as proposed in the guidelines¹⁵. In this sense, the repercussions of underfunding in health services and inadequate strategies in policies and public actions aimed at the male public have been reflected in the disparities in morbidity and mortality indicators between men and women in Brazil, which are up to four times greater higher among men²¹.

According to the discourse of nurses, the municipal management model was vertical, centered on numerical indicators and little participatory and constructive, revealing a distant work on the part of managers and coordinators. Findings characterizing the care provided to men in FHS in different Brazilian regions have demonstrated an incompatibility between the expectations of managers about the male reasons for seeking services and the real demands expressed by this the population, which shows a fundamental gap between services and users and explains the weak involvement of these subjects in the different care actions and practices offered in these spaces²² - ²³ .

However, based on this scenario, it is possible to observe the potential of health teams to manage their micropolitics in their areas of operation, using tools for managing the work process and expanding and strengthening devices such as reception, bonding, accountability, territorialization, matrix support, strategic situational planning, among others. The potential of bonding and reception in the reorientation of health practices and the insertion of men as subjects of care has been evidenced in the field of professional nursing practice. These factors enable an understanding of the value of the work of health professionals, who work in services that usually attract few men, such as primary care, as they meet the health needs of this public²⁴ - ²⁵ .

It is necessary to politically (re)think men’s health towards a more comprehensive participation of nursing professionals, considering the subject according to the problematization of their health condition and enabling a social action that is appropriate to their circumstances and vulnerability, seeking to break with the barriers to the exercise of a healthy and less harmful and toxic masculinity².

Regarding the discontinuity of actions, it is possible to observe a discourse that reveals different nuances, reflecting a professional nursing practice still restricted to the logic of implementation of health programs. This problem creates barriers to the improvement of information systems, which could monitor and/or direct men’s health actions in Brazil, another guideline contained in the PNAISH⁸ , ²⁶ .

Regarding this challenge, another aspect highlighted was the restriction of male health care to specific actions and campaigns, such as the blue November, dedicated to prostate cancer screening. Scholars analyzed the actions of the “Blue November” and unveiled the disputes underlying this campaign and the role and contribution of medical practice in the design of a model of human health care reduced to sporadic and curative actions, without an effective contribution to a comprehensive men’s health²⁷ - ²⁹ .

It is also important to ponder the data revealed in the discourse due to gender relational issues, given that the information was given by female nurses, who shape their view of men and health care based on their own constructions³⁰. The gender is also relevant when it comes to the work developed by female nurses regarding men’s health care. Therefore, it needs to be incorporated⁷.

It is necessary to advance in the relational perspective of gender and masculinities, along with other structural markers that intersect and influence the organization and planning of health care, to rethink the way services and professionals, especially nursing professionals, are organized to reach users, assuming, in this case, men as central to the production of care.

Therefore, the political scenario of fiscal austerity jeopardizes the right to health, as it compromises the already precarious access of men to health services, considering that the scarcity of resources prevents the expansion of the services, the continuity of care and the comprehensiveness of health care, which amplifies the vulnerability that these subjects already experience in their ways of managing their own lives.

CONCLUSION

The collective discourse of nurses pointed to a myriad of obstacles to men’s right to health. These barriers are challenges to the implementation of the PNAISH, as they refer to the operational aspects of the policy in the health system. These aspects were related to the lack of commitment of the State regarding the promotion of men’s health as a guideline for the organization of care, to the technical capacity in the different areas of SUS management or even to the unavailability and misallocation of financial resources for the implementation and consolidation of practices and services that can welcome the male population and respond to their needs.

It is essential to consider that in addition to the need to overcome the challenges identified, the implementation of PNAISH and the promotion of men’s health involves rethinking conventional care practices, which were formerly still focused on medication and restricted to traditional health centers and services. In this sense, the policy itself is a device capable of giving visibility and producing encounters that are affective, effective and can transform subjects, whoever they are, wherever they are.

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Publication Dates

• Publication in this collection
  16 July 2021
• Date of issue
  2021

History

• Received
  29 June 2020
• Accepted
  08 Jan 2021