Perception of health and education professionals on the School Health Program

This article consists of a case study that aimed to identify health and education professionals’ perceptions of the School Health Program (PSE) actions in a suburban territory of Baixada Santista, São Paulo. Three educational counselors from two schools, a PSE articulator, a therapeutic companion, a psychologist, two nurses, and a community health worker were interviewed. The transcribed inter-views were submitted to lexographic analysis and descending hierarchical classification in the software IRaMuTeQ-R. They were later analyzed based on the theoretical references on the PSE, school health, and intersectoriality. The results showed that the PSE actions focus on the matrix support meeting, referrals, vaccination verification, oral health, and eye health. The inadequate continuing training, poor knowledge of the PSE policy, and overwork compromise the full consideration of the program’s objectives, which, traversed by the pandemic, escalated the challenges faced by professionals. There is potential to be explored by the meeting of health and education. However, challenges involving these sectors, the traditional management rationale, the biological approach, and social participation should be overcome to advance towards intersectoral proposals to promote health and well-being.


Introduction
The School Health Program (PSE) was established by Decree Nº 6.286 of December 5, 2007, within the Ministries of Health and Education, to promote, prevent and pay attention to the health issues of students in the public network.The PSE aims to promote health and a peace culture by strengthening Health and Public Education, linking the Unified Health System (SUS) actions with those of primary public education broadly (community, equipment, and local resources); assisting in the comprehensive education of students; establishing a social care resource that promotes citizenship and the exercise of human rights; supporting coping with health problems that can compromise school performance; designing a line of communication between health units and schools; and consolidating community participation in education and health policies 1 .
Health Education learning has been increasingly used to improve the population's quality of life today, emerging as a priority in new State policies and programs geared to the public in social vulnerability, facilitating universal access to health and education through a free service network.In this format, the National Education and Health policy, through the PSE, supports the development of Education, Risk Prevention, and Health Promotion (HP) actions in the demands arising from the territorial mapping, in which the State can better manage and prevent risks to public health by identifying people's living conditions under a vigilant aspect.In this sense, the school, as a participant in the program, is increasingly involved with social problems and summoned to act for the well-being of the population 2 .
Thus, the PSE proposes strategies to address the locality's problems through intersectoriality and by sharing responsibilities between sectors, which are accustomed to isolation and may thus have the opportunity to strengthen the link between Health and Education.Health and Education professionals consider the program paramount and recognize the benefits for quality of life arising from the inclusion of health in schools, positively interfering with education and improving people's access to health services 3 .
From this perspective, the PSE proposes to strengthen the link between schools and PHC Units (UBS) with the planning and implementation of joint actions, in which the school is established as a powerful setting for intersectoral work and construction of learning that guides decisions and attitudes for a better quality of life 4 .Therefore, the PSE is an opportunity to re-signify the school and change the social determinants to produce citizenship and empowerment through presentation, knowledge, discussion, and implementation of HP ideals, overcoming theory, and experiencing the health policy proposal 5 .
Given the proposed conjunction between health and education to promote actions that consider the comprehensiveness of the students offering subsidies for their full development, it is crucial to reflect on the perceptions of the professionals involved in this dynamic to understand it and verify the effectiveness of the actions proposed by the program and those implemented.The importance of this research lies in revealing the perceptions of health and education workers about the PSE, thus understanding the intersectoral work process through the lens of the prominent figures responsible for its implementation in a suburban territory of a city on the coast of São Paulo.

Material and methods
This qualitative case study 6,7 involved the participation of Health and Education professionals in the matrix support meetings at the Family Health Unit (USF) in the territory since 2019 and who worked in the PSE context in a suburban territory of Baixada Santista, located in a municipality with a Human Development Index (HDI) of 0.840 8 .
The municipality uses the matrix support meeting as the primary PSE strategy, which produces health for the socialization and referral of cases received in the health units with mental health, in a new rearrangement, including education, through the participation of the schools.The data collection tool employed was interviews to collect true information, discussing and interacting on the subject through a freer route, following a semi-structured roadmap of questions, which allows the interviewer's adaptations from a basic, but flexible scheme 9 .
Nine women aged between 34 and 54 participated: three education professionals, Educational Advisors (EA); and six health professionals -one PSE articulator, one therapeutic companion of the Child Psychosocial Care Center (CAPSI), two nurses from the USF, one psychologist from the Family Health Care Center (NASF), and one Community Health Worker (ACS) from the USF.
An individual semi-structured interview was held through videoconferencing.The content was recorded for later transcription.Each interview lasted, on average, forty minutes, and the total collection time was five and a half hours.The approach to the professionals was carried out after the researcher communicated with the managers via cell phone contact between March and April 2021.
The interviews were transcribed after data collection.The free IRaMuTeQ software was adopted for data processing, anchored to the R statistical software.This data processing tool performs textual statistical analyses.The present research used the results presented by the IRaMuTeQ of the Descending Hierarchical Classification (DHC) or Reinert's method, which classifies the text segments according to their vocabularies, dividing sets based on the frequency of reduced forms (lemmatized words) to obtain classes of Elementary Context Units (ECU) that comprise the words grouped by the software by similarity and difference 10 .
The lexical analysis of the software presented five classes, which were analyzed

Results and discussion
Data processing by the IRaMuTeQ-R software in the textual statistics analysis option returned 30,240 words in the textual corpus, with a mean frequency of 3,360 per text, 3,317 forms, and 816 different words (hapax).In the specificity analysis, the chosen variables considered the active and complementary forms, selected by the variable *p (person), with a minimum frequency of ten.IRaMuTeQ generated a report classifying 864 ECUs, considering 78.24% of the material relevant; the safety rating follows the standard of at least 70% of the material.In the results, the ECU number is in the title of each class.The organization generated by the program grouped the words into five classes linked by axes represented in the dendrogram.With the results from the DHC, we verified the most critical frequencies and, when interpreting the corpus, defined the thematic categories that emerged from this combination.Thus, enhancing the investigation through inferences, we attempted to understand the messages hidden behind the frequency of the appearance of words 11 .The researcher named these categories by interpreting the words grouped in the classes and the ECUs presented by the software.IRaMuTeQ performed the textual analysis, and its results were analyzed from the theoretical frameworks of current studies on school health and intersectoriality.The dendrogram in figure 1 illustrates the classes/categories deriving from the interview content segmentation performed by the IRaMuTeQ software.The classes show excerpts from the statements of the research participants identified with the letter P and a number from one to nine, and also by their work field -health or education.They will be presented below per the sequence shown in figure 1 (dendrogram):

PSE overview
The PSE overview class, with 20.71% of the segments used, has the following most representative words: 'resource, Santos, expectation, meaning, comprehensive, political, and planning'.They refer to how the research subjects recognize the program and understand how it works.
The PSE was the device that systematized the meeting of Health and Education in the territory through the participation of Education in the matrix support meetings on mental health held at the USF, in which cases usually brought by schools were discussed, unfolding in agreed referrals by the professionals, recognized as a device for the PSE's work and a tool to draw the Health and Education sectors closer, facilitating the entry of students into health.
This Health and Education meeting was an essential advantage, but with some trepidation.Professionals needed to be more explicit about their roles in working with the program.They linked the operation to specific demands related to vaccination and referrals to pediatrics or other specialties, historically marked by a sectoral and fragmented structure in the proposals of health and education policies 3 .

In the beginning, I thought about what it will be like, the experience of working with professionals from another sector. Because you keep thinking about health and education, how you will be received, how health will receive us. (P8 Educação).
The main actions of the program start from a proposal at the central level and not from the territory.The Municipal Intersectoral Working Group (GTI-municipal) meets and outlines action strategies, and the articulator disseminates health and education.However, these can and should start from the demands of the territory.
Territoriality is one of the principles underpinning the PSE, which translates into effectively constructing spaces for social interaction arising from this partnership with the Family Health Strategy (ESF) and schools.The involvement of local stakeholders in health actions, through their interpretations and resignifications, potentially alters the ability to transform reality 5 .
The PSE has some actions.It has a centralization and some coordination offices in Santos.At Alemoa, it is the mental health matrix support meeting; that is, it is a meeting in which representatives of the territory's schools, UBS, and representatives of adult and child CAPS also participate.(P2 Saúde).

Indeed, the definitions of PSE actions and priorities were made at a central level. I'm curious whether autonomy had been given to the territories, for example. (P6 Saúde).
Coordinated jointly by the Health and Education Secretariats, the PSE represents the intersectoral relationship mediation in the health articulator figure.Professionals recognize them as responsible for announcing the schedule of matrix support meetings, disseminators of the significant proposed actions, and an element of assistance in implementing the program, providing the necessary mediation of this meeting between health and education, which is only sometimes peaceful.
[...] we, from Education, attempted to work together whenever necessary with health.However, we need this help from the PSE most of the time.(P8 Educação).
The lack of structure for implementing the interministerial policy is a latent threat, compromising the proposals' effectiveness.
Human and material resources are listed as scarce, and the articulator's figure is the most remembered.The municipality has 86 schools, 32 UBS, and only three articulators to coordinate the PSE, all in the Health sector.
The lack of planning is also seen as an obstacle to the program's implementation 12 .The difficulties in developing the intersectoral actions consider, among others, narrowing the concept of health, professional training focused on the logic of the specialty that limits the work of professionals to their area, and the work overload within their sectors hampering the overcoming of deep-seated conservatism in daily practices 13 .
We have exciting policies, projects, and ideas.However, we need the people to address all this, resources, obviously material resources, of how we could have resources directed towards this.We don't have them.(P2 Saúde).
[...] we need more people to work with.Organizing all this requires people.All this can only be done with people.We need more people to handle all this.(P2 Saúde).

Health-Education Intersectoral Relationship
The Health-Education Intersectoral Relationship class represents 19.53% of the corpus, and its most important words are 'education, health, intersectoral, experience, to work, effective, sector, professional, and implement'.This category highlights the factors considered in the program's intersectoral work dynamics.
The interaction between UBS/USF and schools supports a new perspective on school health, sharing attributions and responsibilities in an intervention aligned with and established per the student's real health demands.This relationship and the influential contributions of health education are affirmed as new possibilities, such as those addressed in the HP proposals, which transcend the biological vision, expanding to a comprehensive and social overview of the subjects 14 .
The experience of working with professionals from another sector is deemed positive; advantages such as knowing the reality of the other service, establishing a support network to review the cases, and sharing knowledge and responsibilities are the potential of this articulation.However, disparities and discomfort, verticalization, and power relationships are perceived in the expectations of education vis-à-vis health, decision-making, and referrals.
The composition of the PSE in the territory is predominantly from the Health sector; Education, represented only by the EOs, was inserted in the matrix support space, which is a health production; the meetings are at the USF, a health equipment, thus giving greater importance to the sector.This situation confirms the remnants of the partnership between the Ministries of Health and Education, which shows imbalances and contradictions in the program's operation led by the health sector in issues ranging from the adherence of municipalities to the distribution of power, funding and responsibilities of actions 15 .The most significant repercussion of HP actions in schools must be based on the collaboration of Health and Education rather than on the transfer of the implementation of tasks between the sectors 16 .
In the same way, discrediting Education's intervention capacity enhances the expected solution of students' problems through health care and frustration when cases are not attended to and referred.It is common to expect miraculous resolutions by the Health sector as if the work of these professionals could solve all problems 17 .
In the experience of working with professionals from another sector, we told a little of our history of Health to Education.We heard the Education's difficulty because pointing out what education should do is easy.(P5 Saúde).

The experience of working with professionals from another sector takes work. Health only sometimes
gives the return that Education expects and that we need.They still need to walk together; Health and Education must still walk together.We are very far from that.(P7 Educação).
Despite keeping dialogue in the monthly meetings, Health and Education still need more time to interact and consider all the aspects that intersectoral work requires.The training that decreased over time mainly addressed the application of health actions to the school public and the flow of referrals from the PSE.While criticizing the lack of knowledge of the program, the professionals do not recognize themselves as an integral part, disfavoring the authorship of actions based on the territory's reality.
Initial and continuing education processes are essential for implementing planned actions and are foreshadowed in health and education policies, where the ministries are responsible for formulating proposals 1 .

The school and we in Health never sit down to talk about what can be done and about articulating PSE actions: this still needs to be done. There is no conversation between health and education.
(P1 Saúde).

[...] the suggestion for practical intersectoral work between Health and Education is the greater awareness of professionals regarding the PSE. (P9 Educação).
Intersectoriality cannot be seen as a sole responsibility of a sector or professional.Establishing a support network and listening to professionals and sectors are necessary so that the work developed overcomes the care model and solves the problems experienced by the population.Noteworthy is that intersectoral partnerships with this objective are specific, occasional, and not systematically planned 16 .

PSE reflections in the community
The PSE reflections in the community class brings with it the unfolding of the most notable cases discussed in the matrix support meetings.Represented by 17.6% of the classified segments, it was established mainly around the words 'mother, son, perspective, link, appear, depression, observe', and others.They provide clues about the main stakeholders targeted by the program, the actions preceding the immersion, and the incidence of mental health cases.
It is interesting to see how several professionals reported the same case, perceived similarly, and exemplified as a successful result of intersectoral work.Within this context, the ACS figure emerges strongly in providing critical information due to the proximity of people in the community.Education also contributes significantly to the anticipation of issues and the unveiling cases that are not apparent in visits and health care.

[...] during the matrix support meeting, the school brought up the issue of absences and wounds and, as Health already monitored the family, it also brought up the issue of depression: the mother was pregnant and had had post-natal depression. She would possibly have it again and did [...]. (P1 Saúde).
Professionals perceived the territory as a place of extreme vulnerability, with factors such as violence, drug trafficking, and pollution directly affecting people's health.Complex cases established and affected by social factors manifest in health issues and behaviors revealed mainly in the school environment.Despite identifying these risk factors, any directed action beyond the individual referrals agreed upon in the matrix support meetings was not reported.
It is common to struggle developing actions corresponding to the broad concept of health, as problems tend to be individualized and detached from the factors attached to their (re)production, which can lead to reinforcing the medicalization of learning and behavioral issues 13 .
The program is recognized as a healthcare facilitator, enabling access through school referrals.The USF and the schools are the only facilities in the territory.From there, referrals are made to other locations, and CAPSI is almost 3 km away.Despite this complicating factor, the lack of parental commitment hinders adherence to referred students' care, monitoring, and treatment.
The PSE calls on individuals to assume the leading role and responsibility for their health, forming subjects with skills aimed at health protection and active resolution of community problems, not evidencing other factors when there is no adherence to the proposed referral/treatment, highlighting the blaming of the family 2 .

After the referral for each situation, things start to complicate a little, first because the family needs to get involved and have the commitment and responsibility to take the child. (P8 Educação).
Despite the emptiness felt by Health and Education professionals with suspended matrix support meetings during the pandemic, the PSE continued to work, helping schools in the active search, referrals to specialties, the follow-up and monitoring of COVID-19 cases, and the protocols for returning to face-to-face activities.
The pandemic has profoundly affected the community and the routine of services; the school started to develop remote activities and was in charge of the distribution of essential food baskets to the families of the students, and the USF, to meet a much greater demand due to the COVID-19 cases.
Mental health issues were the main demands observed during this period.Moreover, meetings between professionals occurred remotely in some network meetings, and communication continued during social distancing.Furthermore, partnerships were established for servicing specific cases.

Unfortunately, the anxiety, depression, and self--harm rate among young people also increased. So, these demands made me also articulate PSE actions remotely, involving CAPSI and mental health. (P5 Saúde).
It was the COVID protocols, which the school already knows, and this fundamental point of the relationship with groups for hybrid teaching.It was crucial for the school not to make the mistake of mixing students up.(P7 Educação).

Referrals
This class addresses the aspects that involve referrals from matrix support meetings.It comprises 19.53% of the segments classified mainly around the words 'referral, refer, child, PSE, year, Specialized Rehabilitation Center (CER), attempt, evaluation, service', and others.They address the program's main demands, presenting and discussing cases, the professionals and services involved, feedback, actions, successes, and challenges.
Initially, the PSE was understood as a set of protocols for referring children from the school to the UBS/USF and defining some actions.The first understanding is that this Health-Education integration would solve specific complaints, but, throughout the process, with the participation of all professionals, it was considered as a perspective of a more comprehensive approach to cases.
A calendar was prepared with the PSE with the monthly matrix support meetings' dates and shared with the schools early in the year.These took about six cases of students with some needs, usually learning difficulties and suspected disorders or disabilities.From there, the cases were presented and discussed in the meetings, and professionals could add information and their perceptions about that child; referrals that could be for a sports activity, a visit to a pediatrician, and a referral to CAPSI or CER were removed.
The school brought difficulties, problems, or some perception that that child had a severe issue to the matrix support meeting.(P3 Saúde).
The meeting is a crucial moment for professionals, as it defines the course for each situation.However, there is an apparent expectation from Education that cases are considered and referred to medical specialties or therapies, expanding that child's support network to others other than school.Moreover, the Health sector perceives a lack of acceptance of some cases, delaying the referral of that child.On the other hand, Health professionals complain about the high school demand.They cannot always provide immediate care to students who arrive at the USF through referral, which usually occurs in cases of fever, skin problems, diarrhea, and suspected contagious diseases.Health professionals, in turn, are concerned with the issue of the expected medicalization, reports, or unnecessary referrals that create labels or derive from the intention to control behaviors.However, some bureaucratic issues require reporting to the school, for example, so the student is entitled to an inclusion mediator and assisted by a professional who monitors and meets special needs in the teaching and learning routine.
With a control bias, the program projects the capacity of leading professionals to prevent and solve problems from the most diverse social orders.Medical power is often established through medicalization.
Embracing the improved productivity through policies that articulate sectors and with a direct impact on the life of the population is established more in ideology than in practice, as it uses the same conservative practices to meet the needs generated by this same system that centralizes health actions in the State 18 .The medicalization event in the school setting creates unnecessary referrals for health, unfolding in growing diagnoses of mental and behavioral disorders, revealing a school that seeks normalization and does not tolerate differences 4 .
A new structure would be necessary for the balanced conduction of the PSE and the joint construction of the work to work with the program's policy to bypass control and monitoring actions, realigning the possible expectations of solving problems through the work of professionals and the community.The State should take charge of resolving what transcends the team's capacity 18 .
The difficulties in implementing the PSE are affected by the institutions' policy, focused on prescriptive and disjointed actions, using traditional techniques and methods, with difficulties in intersectoral articulation and lack of social participation 19 .
[...] this matrix support meeting is very far away because we from Education assume the problems, but Health thinks it is always too early to diagnose something.They often need to give the feedback we expect.(P7 Educação).
Not everything will be resolved with the psychologist, who collaborates with the PSE implementation, leading to a healthy discussion about the risk of overmedicalizing children and controlling children excessively.(P6 Saúde).
One of the consequences of the matrix support meetings is referrals to CAPSI, CER, and medical specialties.The main objection is children's delayed care by these services due to the lack of professionals and scarce equipment.Thus, solving these issues escapes the reach of professionals, giving the impression of frustration and the need for continuity of the work started.Despite the great demand and lagging human resources, as the CAPSI participates in this dialogue at the matrix support meeting, it already performs screening, guarantees the reception for referrals, and offers concrete feedback, with the professionals recognizing the effectiveness and importance.
[...] We indeed have demands.Children with difficulties have a lot, and sometimes they go on a waiting list for an evaluation at the CER, which is usually where they are referred to, and sometimes wait a whole year to see the expert [...].(P1 Saúde).
Sometimes, we have the issue of the vaccination card, where the school surveys the number of children vaccinated and those who are not.We also have a spreadsheet prepared by the PSE where the school gives feedback.(P8 Educação).
Among the other actions provided for in the PSE, vaccination establishes the school's partnership with the USF, a mandatory requirement when registering schools in the municipality.These data are shared with the PSE articulation.The PSE coordination proposes some actions throughout the year but gives autonomy to develop others from the territory.However, this could be more transparent for professionals.At the end of each year, the PSE sends a spreadsheet to survey which actions have been carried out.

Access to Health
The class Access to Health, formed mainly around the words 'ACS, month, occur, come, schedule, ask, nurse, and UBS', appears with the representation of 20.86% of the classified corpus and describes the main ways in which the families access or are accessed by health, emphasizing the importance attributed by the group to the figure of the ACS in this relationship with the community.
The ACS facilitates entry into health services, as it mediates the approach of the community with the ESF teams, performing their work in the territory where they reside, making home visits to households, collecting information about their living and health conditions, guiding and supporting on health issues regarding the workgroup 20 .
The matrix support meeting takes place once a month; usually, the school sends us an email telling us which children need to be discussed at the matrix support meeting, and we survey to see whether the ACS monitors these children.(P1 Saúde).
The ACS is recognized as the element that brings a more humanized view of the family with access to a more direct report because of the proximity and familiarity.These professionals bring in their statements people's requests for help, and despite being valued by the group, they carry in their statements the frustration of unresolved cases and the impression that sometimes their report is not convincing enough to mobilize more effective actions to serve the community.
This professional experiences the paradox of a double role, as he/she lives and works with the population of the same territory.His/her actions can generate expectations that directly interfere with the relationships established with the community and work team -while allowing, in a very peculiar way, the construction of bonds that need to be managed in the dimension of care practices 21 .

If children have a problem, we advisers refer them, and we have the ACS, which also makes a legal partnership with the school. So, we have access; the ACS brings the children's reality into the community. (P7 Educação).
It's because something is happening.So, in some cases, the ACS talks and sees them, and it seems they are discredited.They think that this is not quite the case, that this is not the understanding.(P4 Saúde).
Besides ACS' actions, undertaking intersectoriality as a form of action that breaks down resistance alliances.It involves priority people of the territory to address their problems in an integrated way.Capacity is chosen for professionals and the population searching for solutions that agree with their reality.In this context, the community becomes the subject and not the object of actions, actively participating, collaborating with public organizations, protecting their health, and ensuring social participation 22 .

Final considerations
The professionals' perceptions showed that the program established the approximation of the Health and Education sectors, configuring the main action with the mental health matrix support meetings with the participation of schools.The other actions conducted in the territory derive from the GTI-municipal.They are implemented by professionals in specific practices that involve vaccination, eye and oral health actions, anthropometric assessment, and others.
While seen as power, this dynamic is also seen as a hurdle, leading to an ambiguous perception.The shared responsibilities in the presentation of cases, the exchange of information, and the possibility of finding support are pointed out as the main advantages of working with the PSE.
Intersectoriality is perceived as a fundamental methodology that strengthens the relationship between sectors.However, its concept appears limited to the advantages of working together, such as the discrete notion of the health concept, without considering the local context to propose actions and community participation.
The pandemic compromised the program's progress, further segmented the actions, removing professionals and delegating tasks to the counterpart PSE, whether of information about students or responsibility for health protocols and monitoring COVID-19 cases in schools.
Professionals perceive the PSE as the superficial knowledge they present about this public policy and its guidelines.The territorial organization is still configured in traditional school health practices, with campaigns and health monitoring applied to students.There was no mention of considering the Political-Pedagogical Project of schools in recognition of the territory or as a basis for planning actions.
The PSE adds a potential possibility of HP that can transcend the biological overview and sanitary actions.Thus, it is necessary to overcome the traditional logic of management, offering training to expand the necessary concepts that translate into practices to create opportunities for democratic, intersectoral relationships and favor community participation with actions that emerge from the analysis of the local context, are inserted in the pedagogical projects of the schools and facilitate, thus, care, prevention, and HP.

Collaborators
Baroni JG (0000-0001-7006-0349)* contributed to the elaboration, conception, design of the study, analysis and interpretation of data, elaboration of the text, and critical review of the content.Silva CCB (0000-0001-9250-6065)* contributed to the elaboration, conception, planning, and analysis of the manuscript; and for the elaboration and review of the critical version of the content.s *Orcid (Open Researcher and Contributor ID).