THE POTENTIAL OF AN INSTRUMENT TO IDENTIFY SOCIAL VULNERABILITIES AND HEALTH NEEDS: COLLECTIVE HEALTH KNOWLEDGE AND PRACTICES

Este estudo teve como objetivos analisar um instrumento de leitura do processo saúde-doença, seu potencial para o reconhecimento de vulnerabilidades sociais e necessidades de saúde, possibilitando intervenções mais adequadas num dado território. Os procedimentos usados constituíram-se de análise do instrumento de coleta de dados – composto por questões fechadas e abertas para o reconhecimento dos diferentes perfis de reprodução social (formas de trabalhar e de viver) – utilizado no Projeto de Desenvolvimento Pedagógico e de relatórios das atividades desenvolvidas por alunos do Departamento de Enfermagem em Saúde Coletiva da Escola de Enfermagem da USP. Conclui-se que o instrumento analisado possibilita aos profissionais de saúde, particularmente da Enfermagem em Saúde Coletiva, reconhecer vulnerabilidades sociais e necessidades de saúde, orientando suas intervenções em diferentes contextos, segundo a perspectiva da promoção da saúde. Revela, assim, potencial transformador das práticas de saúde vigentes, caráter dinâmico e de renovação constante dessas práticas em diferentes contextos, segundo a “radicalidade” própria da Saúde Coletiva.


O POTENCIAL DE UM INSTRUMENTO PARA O RECONHECIMENTO DE VULNERABILIDADES SOCIAIS E NECESSIDADES DE SAÚDE: SABERES E PRÁTICAS EM SAÚDE COLETIVA
Este estudo teve como objetivos analisar um instrumento de leitura do processo saúde-doença, seu potencial para o reconhecimento de vulnerabilidades sociais e necessidades de saúde, possibilitando intervenções mais adequadas num dado território.Os procedimentos usados constituíram-se de análise do instrumento de coleta de dados -composto por questões fechadas e abertas para o reconhecimento dos diferentes perfis de  which emphasizes the historical and social nature of the health-disease process and its determinants.This area of knowledge, of Latin American origin, is particularly characterized by the defense of the connection between public and equitable universal health systems, based on the trihedral "ideology, knowledge and practice" (1) .
The strong connection between thinking and action turned Collective Health into an expressive field for changes that occurred in the health area, especially in Brazil in the 1980s.On the other hand, it required a more precise definition of conceptions and health practices according to the collective historically and socially determined nature of their object.
Since the implementation of the Single Health System (SUS) by the Federal Constitution of 1988, the potential connection between new concepts and health practices has been one of the impelling elements of the desired change in care models (2) .
However, there is an important obstacle regarding the adequate education of professionals for Collective Health practice.
Among Analysis of these practices implies reflection on the nature and specificity of three basic components: the object, the work instruments and activities or the work per se.These are practices that presuppose specific knowledge guiding healthcare according to the population's health needs.Thus, they should be based on competences that value commitment "with protection of life and the community's health" (1) .Taking health needs as the object of analysis, a first step would be to analyze health practices and their determinants through appropriate instruments so as to grasp and transform them.
Thus, this article aims to analyze the potential of an instrument -both in teaching Collective Health Nursing and health care -to acknowledge the health needs of individuals and families from different social groups in a given area, who in turn should be taken as the object of health practices, so as to put these practices into operation with a view to meeting the needs that first originated in the circular relation between health needs and health care.
This contribution -in the teaching dimension -is consistent with the need for instruments in the teaching work process that are able to improve education of future health workers with a view to changing the health care model, which has mainly taken disease as object of health practices in the individual scope (2) .Regarding the health care dimension, the work instrument analyzed in this study permits the identification of health needs that broaden the object of health practices beyond that predominantly identified with already established individual problems or needs restricted to predetermined programs (4) .
Procedures With this in mind, a group of faculty members of this department elaborated a Pedagogical Development Project * , aiming to critically monitor health (5) based on research and, at the same time, on learning to delimit health problems and needs in a given territory so as to propose intervention strategies in particular realities.
The Project aims "(...) to describe the health situation in the territory, within the limits of a pedagogical work, specifically focused on more general aspects of the community that occupies the scope area, seeking to identify the profiles of social reproduction (ways of living and working) and profiles of health-disease of families resident in a sample jointly delimited with the Basic Health Unit (BHU)" ** .
To achieve the proposed goal, the following theoretical-methodological and operational references were adopted: a) conception of epidemiological profiles (6) to identify homogeneous groups in the population; b) from the methodological point of view, we believe these conceptions support the systematization to apprehend the Collective Health object, guide the description of particularities of the health situation in the elected BHU area to carry out health surveys and actions to monitor the population's health conditions; c) understanding that assuming responsibility for the health of residents in the area implies in controlling, monitoring and followingup the health of all residents by the public health sector through the characterization of different epidemiological profiles and the possibility of intervention in them.Thus, their work, life and health conditions have to be monitored through an interdisciplinary action between and across sectors, which is how Health Surveillance (6) operates; d) from the pedagogical point of view, This instrument is used here as work tool or technology used to identify, manipulate or transform health needs and their determinants, thus attending to its collective character and, at the same time, enabling the adoption of procedures that allow for the also collective work in health (1) .
The object of analysis is, therefore, the The complexity of the health-disease process: the identification of social vulnerabilities and populations' health needs

Studies addressing the monitoring of
Collective Health conditions tend to mainly consider the ways of social interaction of a certain population (5) .
These ways of social insertion differ in the several populations and define conditions of particular social vulnerabilities, which in turn lead to social groups' different health needs (7)(8) .
The association between the conceptions of social vulnerabilities and health needs in the collective perspective are closer to the Social Epidemiology view, in which the health-disease process is considered a complex phenomenon, socially determined and modulated by biological, psychological, cultural, economic and political conditions.According to this perspective, the roots of health-disease processes are linked to ways of social groups' insertion in the world of work, especially in their ways of working, which give rise to particularities found in their living conditions (5,9)   .Thus, "(…) the ultimate cause of the health-disease process behavior should be sought in the way the society is organized to construct social life.(…) Social organization is an essential determinant of manifestations of populations' quality of life and, consequently, of different health needs" (10) .
Thus, health and disease processes are the synthesis of the set of determinations that end up resulting in differentiated vulnerabilities or potentialities.We underline the perspective adopted in this study of social vulnerability, understood as a dimension of exclusion, discrimination or weakening processes of social groups, regarding their capacity to cope with such conditions.The term social vulnerability, originated in the area of international advocacy for Human Rights, originally refers to legally or politically vulnerable groups or individuals in the promotion, protection or assurance of their civil rights (11)   .It is linked to social inequity and inequalities, expressed through processes of potential illness or no illness, and coping related to individuals, groups and communities.In this conception, vulnerability is not restricted to individual vulnerability but also involves the collective, requiring health practices characterized by the development of actions that include "social response", the participation of different social actors in the joint search for strategies able to meet health needs (12) .
Health needs are not restricted to medical needs, health services or health problems (diseases, sufferings or risks).In fact, they are related to needs or vulnerabilities that express ways of life and identities, expressed in the question "what is required to be healthy?",which therefore involves "necessary conditions to enjoy health" (1) .The scope and complexity of these objectives of Collective Health practice require professional competence and specific instruments to appropriately answer to its collective character.

An instrument to guide Professional Collective Health practice
In this analysis, in taking the concepts of social vulnerabilities and social needs as objects of Collective Health practices, it is essential to delimit the discussion regarding how these practices are put in practice.Once these needs are identified, a challenge is also imposed, which is to elaborate intervention actions in the health sector able to connect principles of universality, equity and integrality, recommended by SUS (13) .
The establishment of Collective Health as an area of knowledge and scope of practices leads to the resumption of some essential concepts for the construction of what could be called "mapping of praxis" (1) .These concepts are: health needs, the These indicators permitted knowing the potentials of strengthening and those related to the exhaustion of social groups, defining a framework of social vulnerabilities (14) and, consequently, a set of health needs particular to these groups (8) .With regard to family composition, it is possible to characterize family arrangements, origin of its members, education and generational relations in the different groups.
As to ways of working, two groups of indicators stood out: 1) paid work (activity characteristics, occupation, weekly working hours, time spent on daily commuting) and 2) family income (benefits received in addition to work, percentage of family income spent on basic expenditure like food, rent, utilities, telephone, clothing).
In terms of ways of life, the following groups of indicators are highlighted:

CONCLUSIONS
The analyzed instrument aims to identify determinants of the health-disease process and understand the conceptions and experiences social groups hold regarding their process of becoming ill.The instruments of identification and monitoring of health needs can be classified according to different perspectives adopted, according to priorities, targets or goals and health promotion to: 1) identify the most needed or the target audience for Collective Health policies according to epidemiological criteria; 2) guarantee that health services are more efficient in attending the population's health needs or 3) regardless of the identification of problems, value a proactive approach, focused on the population's participation and on the possibility of its autonomy in the generation of its own health resources.Despite the differences, the three approaches should compose an integrated system, permitting that data necessary for different purposes are identified at different levels and through specific instruments and methods (15) .
The instrument analyzed and presented in this open to new paradigms in the face of health needs, human rights, and emancipatory processes of democratization of social life" (1) .
It is this dynamic model, coupled to the possibility of constant renewal of health practices, according to the context social groups live in, that seems to contain the "radicality" of Collective Health and of a theoretical-methodological model based on the perspective of the other, his(er) vulnerabilities and health needs (1) .This model also contains the potential "radicality" of the professional education and transformation of health practices, no longer exclusively focused on biomedical knowledge, but also open to other kinds of knowledge.
One of the great challenges for the process of professional education in Collective Health seems to be the possibility of formulating specific competences in this area, based on the ideal comanagement (16) , in view of interventions guided by confronting acknowledged situations of vulnerability and health needs of the population, connected to principles of universality, equity and integrality recommended by the SUS.
: analysis of the instrument of the Pedagogical Development Project for the education of professionals in Collective Health Nursing One of the goals of the Collective Health Nursing Department (PHN) at the University of São Paulo School of Nursing (EEUSP), based on the theoretical-methodological reference framework of Social Epidemiology, has been to orient its undergraduate students to identify objective determinants of the health-disease process and, at the same time, understand the subjective aspects of this process through the meanings and representations diverse social groups hold regarding their process of illness.In addition, one of the main concerns in education has been the reflection about the nursing work process, the relation of nurses with the different social health actors and the meanings attributed to the health work and practices with a view to better organizing them in the face of the population's different realities.
apprehending the studied reality based on these conceptions enables students to understand the collective intervention proposal in contrast to the traditional educational experience focused on interventions in the individual body.If, on the one hand, the educational project, its objectives and theoretical assumptions innovated the teaching-learning process, especially in Collective Health Nursing, on the other hand, the instrument it used deserves a more detailed analysis, especially regarding its technological potential and possible contribution to expand knowledge and transform practices in the Collective Health area.
used for data collection in the educational project: a questionnaire composed of closed and open questions to identify the different profiles of social reproduction -ways of living and working.Reports of activities developed by students attending the course "Fundamentals and Practices in Collective Health Nursing" during the first semester of 2006 in three BHUs (Jardim São Jorge, Jardim Boa Vista and Vila Dalva) under the Butantã Health Supervision, Health Coordination of the Midwest region, São Paulo, SP, were also analyzed.Based on the originally proposed instrument, the analysis also considered an adaptation carried out in field activities in 2006, according to particularities of each area presented in those reports.
The potential of an instrument to identify social… Nakamura E, Egry EY,Campos CMS, Nichiata LYI, Chiesa AM, Takahashi RF.Rev Latino-am Enfermagem 2009 março-abril; 17(2):253-8 www.eerp.usp.br/rlae* Project structured by faculty members from the Collective Health Nursing Department at the University of São Paulo School of Nursing, based on the pedagogical research project structured by the faculty responsible for the undergraduate course subject in 2001, departing from a research project elaborated to guide the development of pedagogical activities in the same subject in 1999.** Soares CB, Campos CMS, Helene LF, Izumi L, Maeda L. Projeto de Desenvolvimento Pedagógico.São Paulo: Departamento de Enfermagem em Saúde Coletiva da Escola de Enfermagem da USP; 2002.Document elaborated for the course subject Fundamentals and practice in Public Health Nursing.
subject and health practices, connected in the understanding of health needs as a possibility of subjects being healthy and acknowledged in the intersubjective relation between health professionals and population, reorganizing activities and recreating technologies.This is the Collective Health(1) "radicality" in view of its emancipation assumptions, democracy and subjects' autonomy, which in turn are its main obstacles, especially in terms of professional skills needed for the development of practices based on such assumptions.These obstacles will be greater as the concept of fairness is associated to the possibility of apprehending different health needs and their expression by autonomous subjects.The competences expected from a Collective Health Professional, presented here as a problem, are addressed based on the analysis of the instrument used in the Pedagogical Development Project, in which teaching and work are integrated This instrument considers important dimensions of objective reality, namely the establishment of a family, ways of working (or production) and ways of life (or consumption) of different social groups, with their potential for strengthening and exhaustion, to understand the vulnerability of different social groups to illness in a given reality.Based on the analysis of the instrument and reports of activities developed by students attending the course "Fundamentals and Practices of Collective Health Nursing", a set of indicators related the characteristics of families, their ways of working and living, identified morbidity and coping strategies, and perceptions related to the health-disease process.
It enables health professionals, and especially Collective Health Nursing students involved in the Pedagogical Project, to identify vulnerabilities and health needs, and at the same time guide them regarding different interventions in the different contexts they act in.In this perspective, their contributions and those related to the instrument used, for professional education and guidance of health practices, are linked to its possible relation with the assumptions of Collective Health.
article is close to the perspective of health promotion as it seeks to identify vulnerabilities and health needs of different social groups in the population, their potentials of strengthening and exhaustion based on the characteristics of their insertion in the social reproduction.Moreover, in permitting complementarity between objective aspects of reality and subjective conceptions of the population itself, it also values the possibility of expression of subjects involved and of The potential of an instrument to identify social… Nakamura E, Egry EY, Campos CMS, Nichiata LYI, Chiesa AM, Takahashi RF.Rev Latino-am Enfermagem 2009 março-abril; 17(2):253-8 www.eerp.usp.br/rlaedifferent meanings attributed to ways of life, health and suffering.Thus, it reveals its potential to transform current health practices and guide students and health professionals to adopt practices more consistent with the assumptions of the Collective Health area, especially the concepts of collective, equity, alterity and autonomy.It also enables the connection and redefinition of three basic components of health practices -the object, the instrument and activitiesstressing the dynamic nature of the theoreticalmethodological model it implies according to the dynamics of the Collective Health area: "a space more