UNDERSTANDING THE WORK PLAN OF COMMUNITY HEALTH AGENTS IN THE CITY OF VIÇOSA, MINAS GERAIS

Abstract

The Community Health Agent (CHA) is identified by the community as responsible for creating the link between it and the staff of the Family Health Strategy (FHS), interaction estimated by the work of the CHA. The aim of this study was to understand the perception of the CHA on the planning work. It was used qualitative and descriptive approach to data collection by the method of Focus Group (FG). For data analysis, discourse analysis was used. Intentionally, 16 CHA of 14 Basic Health Units of Vicosa, were invited to join the GF. Six CHA accepted to participate and constituted the research sample. The data showed that there is an imbalance between the desire of the CHA to satisfactorily carry out the activities and meet the expectations of families. Imbalance influenced by precarious working conditions and lack of planning, leading to poor performance of the CHA. It was concluded that the lack of planning work of the CHA generated dissatisfaction among them in relation to the work carried.

Keywords

Education; Health Education; Questionnaires

Introduction

Planning something means taking actions that aim at reaching better results and it involves acknowledging difficulties, threats and risks; thinking about the future, setting goals and finding means to achieve them. Thus, those are features that distinguish men from other living beings. Planning plays the role of diagnosing reality and changing it.

The health care process brings along the idea of serving. It is often related with achieving results that change a certain reality by heading the work process towards the aims and goals, taking under consideration the complexity of linking different resources that include cognitive, organizational, political, subjective, financial and other aspects.

Managing the planning cycle demand four stages:Planning (defining goals; formulating strategies; analyzing the reality; identifying opportunities and threats; empowering alliances);

Organizing and developing (making resources available; acquiring physical space and equipment; replacing consumables and managing competences);

Performing/directing (making decisions; performing planned actions and adapting to the action context);

Controlling and evaluating (analyzing the impact from putting the planned action in practice; checking if the objectives were achieved; checking efficiency strategies ; suggesting improvements for efficiency and effectiveness)[emphasis added].1

The planning process involves defining goals and formulating strategies; this is the way to accomplish the aims. Competence management is taken under consideration in the organization and development stage since it prepare those involved with the success of the taken actions.1

Similarly, the authors highlight that:

Performing/Directing incorporates the decision-making process and the performance of programmed actions. It is done by permanently focusing on the opportunity to put the projects in practice and adapt them to the context where the action will effectively take place.

Controlling/Evaluating refers to guaranteeing that the taken actions were performed as they were programmed [emphasis added].1

Therefore, the managing challenge in FHS (Family Health Strategy) means involving different social actors from the health context in the work process by approaching workers to results from their work.1 The work process starts by identifying and analyzing FHS problems, pointing priorities, defining actions to overcome problems and identifying the necessary resources to overcome them.2

Therefore, local planning must be a flexible and participative process to allow knowledge exchange between FHS and the community.3 Thus, the work is performed by a multidisciplinary team that holds at least one physician, one nurse, one nursing assistant and four to six Community Health Agents (CHA). CHAs must live in the community and have at least completed elementary school .3

The requirement for CHAs to live in the community is linked to the fact that they need to share the same values and interests of the local population, since it leads to collective identity. Thus, this identifier trace allows CHAs to develop and perform disease prevention and health promotion within the community by legitimizing and providing human and cultural effectiveness during their professional performance.4

Thus, it is worth training the professionals before they start their activities. However, this is not the reality in most regions throughout the country. Professionals count only on the common sense during their daily activities – it looks like they are in a game of attempts, hits and errors.5 Thus, it is demanding to rethink the whole health care process through concrete conditions – mainly CHAs’ work conditions –   that allow the work of Health Professional teams.

The present study aims to analyze and to understand CHAs’ work plan in Viçosa County. It was necessary to understand the difference between prescribed task and real task in order to achieve this goal. Subsequently, it is then possible proceeding with the discussion about CHAs’ work plan.

Literature Review

Focus Group

The focus group has been widely used as methodological strategy to deepen the understanding on health professionals’ daily activities.6

It is presented as a widely used method by researchers from the health field for data collection; it emphasizes the easiness to approach themes that would be hardly explored in individual interviews as well as encourages the debate and reinforces the low cost of the technique.7

Therefore, when the focus group is applied, it is demanding to take different subjects into consideration and their concepts must be understood as well as the fact that they are linked to social contexts the analyzed phenomenon is inserted in. Thus, the focus group aims to gather detailed information about a specific theme defined by the group’s researcher, coordinator or moderator and to understand the participants’ perception about a theme, product or service.6

The room where the FG will happen must be well programmed in order to avoid external interference which may compromise the discussion in the group .6 7 8

These authors state that FG may be used as a way to get to know participants’ opinions and it is done according to the researcher’s intentions, since he or she is the one who directs the themes to be discussed, based on a pre-established script.

Essentially, FG consists of promoting the interaction between the participants and the researcher. It must be formed of small groups of people who have no close contact to each other or work bonds, but who actually have common features. FG must not last for more than two hours, so the discussions do not assume personal features.7

The environment must be carefully prepared so the external noises do not distract the participants. The authorization from the involved ones, for audio and video recording, is demanding. It is common to have rapporteurs or observers in the room to write down the main events and observe nonverbal communication within the environment; besides the researcher, who is often moderating the discussion.8

In summary, the adoption of focus group as a way to find out the reality of certain groups and their perceptions may lead to health research advancements and to the elaboration of new group interview methods, fact that turns FG into an effective work strategy for caseworkers.

FG planning and participants’ features

It is demanding to select participants by having in mind the clear determination of their social group before the FG. However, FG does not aim to identify how often a certain behavior or opinion takes place, but to understand the different opinions or actions towards some issues.8According to the authors it is worth avoiding people from the same acquaintanceship or even with contrasting features, in the same group.8

Choosing the place is also a concern. It is suggested that the room must be free from interferences and big enough to host all invited participants. Therefore, it is highlighted that the place booked to the FG event must be “neutral ground” and easily accessed by the participants.7 6

The authors still highlight that chairs in the room must be arranged in a circle to help viewing the participants in order to achieve better interaction and “confrontation”, fact that allows different opinions about some situations.

According to the current study, FG was also important to understand interviewees’ perception about the programmed and performed tasks.

Programmed and Performed Tasks

Before start reflecting about the programmed and performed tasks, it is important questioning the work process in order to understand it. The process has three elements: the activity adjusted to a means (the work itself); the object of work (the matter applied to the work) and the instruments or means of work.9

Some elements must be systematically analyzed in the healthcare process, because they involve the reciprocal relation among these elements: their object of work; their instruments; the mean of the work and the agents who will perform it.9

The task is the visible face of the programmed work, “it is understood as something that is put to workers or what is expected to be done by them”. According to the authors, the task precedes the activity: “it explicitly or implicitly conveys a model of individual; […] and requires double mental elaboration activities from them”.10

Similarly, the authors describe the fundamental aspects of the activity:

[…] meaning, mediation strategies, contradictions ontological role, think-act-feel integration.

Moreover, the activity has an integrating and unifying character as it organizes and structures the situations of work elements and constitutes the mediation developed by workers to overcome the contradictions externally imposed to them.10

The ergonomic line, created in French-speaking countries, names the activity as “ergonomics” and divides the work in two faces: the task, which is the programmed work; and the activity, which is the real work. According to the authors, their sides are not opposed.11

The following elements feature the programmed work:

The aims and results to be achieved in terms of productivity, quality and term;

The predicted methods and procedures;

The orders given by the hierarchy (written or verbally) and the instructions to be followed;

The protocols and technical/safety rules to be followed;

The technical means made available – prescription element frequently despised;

The predicted manner of the division of labor;

The predicted temporal conditions;

The socioeconomic conditions (qualification, wage) [emphasis added].11

By following such perspective, it is noticed that tasks and activities are developed by work plan. Therefore, it is found that planning is the way to help workers understanding their work’s goal and how to develop it.

Thus, it is important defining work and work process:

Work, in general, is the group of procedures followed by men to produce an object, to transform it and to obtain a certain product that supposedly has some use.

[…]

The more complex the work process is, and the less systematized, the harder will be the reflection about it.

These are features frequently found […] in FHS. Therefore, it is fundamental that professionals working with it develop the skills to apply instruments that allow the critical reflection about and the transformation of their work processes.12

Thus, work process means meeting demands and expectations of men, according to their social organization in a certain time in history.12

It is worth understanding easily perceived organizational culture features.12 Such features are called formal and open aspects; other aspects are hard to perceive and are classified as informal and hidden. Thus, it is possible to point out that visible elements are the operational aspects such as the activities, for instance:

Organizational Structure; Titles and job descriptions; Goals and strategies; Technology and Operational Practices; Personnel Policies and Guidelines; Methods and Procedures; Physical and Financial Productivity Measures.13

By taking such elements under consideration, the authors state that organization is perceived as a complex system structured to motivate and increase productivity; therefore, it must be constantly observed, analyzed and improved.

Healthcare workers face challenges at the time to organize tasks and activities. Thus, the present study showed how CHAs reason about their work plan in BFHUs (Basic Family Health Units) in Viçosa County.

Methodology

Research Featuring

The research is a qualitative study based on the descriptive approach and it aims to describe CHAs’ perception about work planning in BFHUs in Viçosa, Minas Gerais State.

Study Site

The study was performed in BFHUs in Viçosa County, Zona da Mata of Minas Gerais State. The city holds 73.333 inhabitants, according to the Primary Care Department.14

In 1999, the year the Health Units were launched, there were 59.024 inhabitants and two FHSs with 10 CHAs. The estimate covered population was 5.750 inhabitants. In 2013, there were 86 CHAs distributed among 13 Family Health teams, with estimate covered population 49.450 inhabitants, approximately 67.43% of the local population.

The 86 CHAs were distributed among 14 BFHUs, in different neighborhoods, in Viçosa County: Amoras (five CHAs); Bom Jesus (seven CHAs); João Braz/Violeira (five CHAs); Nova Era (seven CHAs); Nova Viçosa/Posses (eleven CHAs); Novo Silvestre (three CHAs); São José do Triunfo (five CHAs); Barrinha (ten CHAs); São Sebastião (seven CHAs); Cachoeirinha (two CHAs); Silvestre (six CHAs); Santa Clara (seven CHAs); Santo Antônio I (five CHAs) and Santo Antônio II (six CHAs).

By considering the presented aspects, it is highlighted that the study was performed in 14 BFHUs in Viçosa County.

Population and Sample Featuring

The 14 BFHUs in Viçosa, MG and their 86 CHAs were featured as the studied population; one CHA was selected at each BFHU, except for the Units that had more than one team; two CHAs were selected in  double team units, thus totaling 16 CHAs. Two Focus Groups were organized to better explore CHAs’ contributions, the groups were comprised by eight participants each and they were distributed at different times. Such procedure ensured that the invited CHAs – from the BFHUs with two of them – could be distributed at different times to preclude intimidation and discomfort at the time to discuss questions that influence the lack of work planning in the Unit.

These 16 CHAs were selected because they had been working in the BFHUs for a shorter time. However, only four CHAs participated in the first FG and two, in the second and it set the study’s sample.

All the selected CHAs were female and had been working in BFHUs for four months to three and a half years. The participants did not know each other, because they worked in neighborhoods distant from each other; they authorized video and audio recording, and signed the Informed Consent Form (ICF). The researcher was in charge of keeping participants anonymous during data presentation.

The present study was authorized by the Ethics Committee of Research (ECR), Legal Opinion: 295.361, from June 03^rd 2013, and it was funded by CNPq (Brazilian National Council for Scientific and Technological Development).

Data collection instruments applied in the research

The previously described Focus Group was used as data collection method, since it is a qualitative and descriptive research. The technique allows discussions among participants and in the mean time leads researchers to insights concerning patients’ interaction.7

FG may still be considered as a situational diagnosis technique used to show CHA’s perceptions about their work plan.8

Focus Group conduction

Two FGs,1 hour and 20 minutes long, were performed and their duration included meal-break time. The first FG was composed of 4 CHAs (n=4) and the second FG of two (n=2). Video presentations, with reports about CHA’s work in Viçosa and other cities were used during the focus groups’ conduction. Yet, magazines, statements and editorial cartoons about motivation and health care were used to encourage the discussion and the participation by CHAs.

The initial discussion themes were: the pros and cons of the profession; tasks; relationship; work conditions; motivation; communication between community and team and training.

Besides the researcher, who was the moderator, three rapporteurs who did not know the CHAs were in the room. The experience in this study field and the familiarity with the research subject – work planning – were considered at the time to choose the rapporteurs. The presence of rapporteurs did not change the group’s dynamics; instead, it helped the verbal and nonverbal communication. They took notes of and observed participants’ reports.

The speeches in the focus groups were audio and video recorded, and then they were fully transcribed.

Data analysis instruments

Qualitative data processing was done through discourse analysis and it considered the discourse to be a social identity product.

The analysis of the found answers allowed understanding the implicit and explicit language and it took each CHA’s experience and understanding on how they perceive the developed work into account.

Results and Discussion

Initially, CHAs were requested to make their own nametags with their names or nicknames on it and to choose a picture able to depict a personal feature as well as a statement, among those chosen by the moderator, to represent their daily routine and put it on a table. These activities were a way to minimize the possible negative impact of having CHAs in an uncommon place with people they did not know.

When Agent “P”^a started her speech about personal and work featuring, she chose the picture of a pet, stating that she likes animals. Her statement: “We get strength, courage and confidence in every experience, so we truly stop to face fear”.15 When she explained why she chose that statement, it was identified that CHAs go through situations they are not prepared to deal with such as the contact with drug users and mental disorder patients.

______________

a The identification by letters of the alphabet is used to keep the interviewee’s anonymous.

Conflicts and lack of ability in the development of activities involving families were observed when they face unusual situations, as it is shown in the following statement by “Agent P”:

he has been walking around the neighborhood armed […], he already tried to kill his daughter and mother[…] but there was a moment when I stopped to think, oh my, sometimes I am walking here on the street, what if he comes here out of nowhere and kills me? […] the wage I get, let’s say, it is not worth my life, not even if I got a lot of money, it would not be worth more than my life (Speech by Agent P).

ele tá andando armado pelo bairro […], já tentou matar a filha a mãe […] mas teve um momento assim que eu parei para pensar, nossa, as vezes eu tô andando aqui na rua, e se ele vier aqui e do nada ele me matar. […] o salário que eu ganho, tipo assim, não vale a minha vida, nem se eu ganhasse muito não valeria a minha vida (Fala do Agente P).

The report by this CHA shows the professional difficulty to deal with drug users and people with mental disorders. It reinforces the lack of training these professionals deal with when living these populations’ reality. However, such attitude is expected from CHAs, since they must deal with individuals and their families in a daily basis because they give health assistance in the community.

The statement in Agent “P” speech, when she showed wage dissatisfaction, was supported by other participants. Thus, the polyphony is identified through CHAs’ social position and there are several voices behind in her speech, since she was not alone. She was followed by five other participants and it depicts a collective subject.

Regarding the social position of the speech, the construction of a professional identity is influenced by several conceptions and experiences, an individual is not homogeneous, but actually it comprises a social group that has voice and attitude.16

According to the aforementioned, it was identified that professionals with higher incomes are those who perform the technical procedures and treat the users’ diseases, so they become more socially and financially valued.17 Regarding the CHAs’ case, they try to strengthen their speech stating that disease prevention is part of the care given to the assisted families. The difference between technical care and CHAs’ attendance was noticed:

Care is emphasized in its technical scope and brought to discussion based on the relationship between community health agents and the community itself. It means that technical procedures are the possible way to offer care to others, whereas relational procedures such as listening and perceiving are not health technologies.17.

The discussion in the FG headed towards identifying problems that make it difficult to perform the programmed tasks and to present real activities that do not meet the families’ interests, as it is noticed in the following statement:

We do not get a good wage, then, we do not have to work a lot (Part of the audio transcription of the Focus Group, Agent F).

A gente ganha pouco então temos que trabalhar pouco.

If we accepted to earn this wage, we will do it, but… (Speech by Agent P).

Se a gente aceitou receber esse salário, a gente faz, mas…

The financial issue is even more critical when one compares CHAS’ wage and that of other FHS members.17

During the FG, it was possible to point out the institutional voice with the verb which was highlighted during the FG: “it was already told that the unhealthy work payment will be cut, because it was said that we do not have access to patients” (speech by Agent F) (já disseram que vão cortar a insalubridade, porque disseram que a gente não tem acesso aos doentes). The voice of the social and collective subject was also highlighted: “and we are the first ones to go to their houses” (Speech by Agent F) (sendo que nós somos as primeiras pessoas que vai na casa).

The polyphony is noticed when analyzing the discourses, since it groups several voices into one discourse (the institutional voice, the social and collective subjective).16 This polyphony is found in the current study and shows that when CHAs think about their jobs, they cannot set the best way to act; they are influenced by the institution and the population they assist. Thus, the suffering and anguish resulting from these interferences lead to lack of emotional conditions that stop CHAs’ from defining priorities.

CHAs report that duty fulfillment leads to work overload. It is known that when work is bad organized, the immediate consequence is overload because it causes workers’ physical and mental exhaustion. It can be observed in the following speech by Agent B:

Home visit, only in our area, but consultations and such things, also people from other areas […] I mean, if a person from the other area shows up, we have to give assistance […] then it is a real fast pace […] it hinders us to perform our work, and people tell us: oh, you have not been to my house anymore. And that is because we stay most of the time in the FHS (Speech by agent B) [emphasis added].

Visita domiciliar, somente da nossa área mesmo, mas a questão das consultas, essas coisas assim, das outras áreas também […] assim, se chega uma pessoa da outra área a gente tem que dar assistência […] então é correria mesmo. […] impede né de fazer o trabalho da gente, e o pessoal cobra da gente: ah você não vai mais na minha casa. Isso porque a gente fica a maior parte do tempo lá na FHS.

The lack of clear delimitation on duties and the CHAs’ roles have been distorted, that is why they feel overloaded.5 It also has to do with the changes in and the precariousness of the work environment, such as lack of human resources to perform management activities – mainly in health care – as it is noticed in the following transcription:

There is no administrative assistant there either; we need to keep on taking turns, each one stays at the reception in a different day […] there is a cleaning assistant, but when he was on vacation we have already cleaned, every Friday, everyone together (Speech by Agent M).

Lá também não tem auxiliar administrativo, a gente tem que tá revezando, cada dia é um que fica na recepção […] lá tem auxiliar para limpeza, mas de férias a gente fez sim, toda sexta feira, juntava todo mundo.

Although there is not much awareness about what must be done or about the requests that transcend what is expected for the job, CHAs live other issues in their daily work; one of these issues is psychological harassment. Even though it is not a current phenomenon, the psychological harassment has been a common diagnosis in CHAs’ work environment. The psychological violence episodes were clearly identified in the speeches by CHAs “B” and “F”.

[…] there is fear, a little, but we need it, right? But people are afraid to be too much exposed and lose their jobs (Speech by Agent B).

 […] tem medo, é pouco, mas a gente precisa né, mas assim, o pessoal fica com medo de, de querer se expor demais e perder o emprego.

[…] the threats are big […] they say that health agents, this law that protects us will end, that the mayor does not like FHS, that it will be closed, so we always hear that […] just like in a meeting we had, they said that who was not satisfied could leave because the list is long (emphasis added). (Speech by agent F).

[…] as ameaças são grandes […] falam que o agente de saúde, essa lei que nos protege vai acabar, que o prefeito não gosta de PSF que vai fechar, então sempre chega isso […] igual em uma reunião que tivemos, falaram que quem não estiver satisfeito pode sair porque a lista tá grande (emphasis added).

The psychological harassment and the threats suffered by CHAs could be identified in their behavior during the FG. The feelings were shown in different voice tones, sometimes silence in the group was common and there were moments of euphoria.

The sound structures show situations lived at a specific moment, i.e., if they feel threatened they would speak in low voice; if they are angry, they would raise their voices; if they are happy, they would smile.18 This may be noticed in the groups at moments when what was said by the participants could not be heard and; at other moments; there was euphoria when some questioning was noticed.

It is possible noticing the use of “power and coercion” in the institutional voice represented by CHAs in the statement highlighted above. 18 19

[…] the body only becomes a useful power if it is a productive body and a submissive body at the same time. This subjection is not obtained only by violence, tools or ideology; it does may be the direct and physical use against strength act over material elements without however be violent; be calculated, organized, technically thought; be subtle, not using any weapons or terror, and continue to be physical. […] These is a source of it; use it, value it or impose some of their ways of action. But itself, in its mechanisms and effects, it is situated in a completely different level. It is about some sort of microphysics power brought into play by apparatus and institutions, but which field of validity is put somehow between these big operations and the bodies themselves, and their materiality and strength. [emphasis added].19

The lack of professional recognition and the respect from fellow workers and from the population that – according to the CHAs’ speech – often offend them. Such fact may be proved in the speeches by CHAs “F” and “M”.

[…] for example, when you need anything at the secretariat, you have no support from anyone, you call someone at the coordination, oh you have to talk to another person. […] If you hear at the FHS, what a bunch of vagabond women! Because there is no tape to measure sugar blood level for almost 2 years, so they think it is agents’ fault, if the physician goes out at half past nine, the agents are worthless! They should put fire on you; it is just like that. […] They swear and almost bit on us (Speech by Agent F) [emphasis added]

[…] por exemplo, na hora que você precisa de qualquer coisa na Secretaria, você não tem respaldo de ninguém, liga pra um na coordenação, ah você tem que falar com fulano. […] Se ouvir dentro da FHS, bando de mulher vagabunda! Por que não tem a fita de fazer glicemia vai fazer 02 anos, pra medir a glicose, então eles acham que a culpa é das agentes, se o médico sai as nove e meia, as agentes que não valem nada! Tem que botar fogo em vocês, é desse jeito. […] Eles xingam e só faltam bater na gente [grifo nosso].

[…] when I started, the families would not attend me at the houses, many at my area have health insurance, Agros, and they said CHAs never did anything for them (Speech by Agent M).

[…] quando comecei as famílias não me atendiam nas casas, muitos da minha área têm plano de saúde, Agros, e diziam que o ACS nunca fizeram nada por eles.

Users did not recognize the professional devaluation of CHA’s work because they do not act directly in the improvement of the quality of life of this population.20 Problems faced by them were structural. Thus, the professionals depended on economic and social policies for intervention. This work devaluation takes place in institutional and community environments and it leads to some sort of suffering and anguish among CHAs, since they cannot give the immediate answer demanded by the population. These professionals start seen themselves as being responsible for such demands.21

I am the person who is there to help you. […] When I deliver a prescription, or I pass by, they say: we are glad you came, you are here. You know: oh! You got it! (Speech by Agent T).

Eu sou a pessoa que tá ali para ajudar. […] quando eu vou entregar uma receita, ou eu passo lá, elas falam: que bom que você veio, que você tá aqui. Sabe: ah! você conseguiu!

When you can solve something, a consultation you get for the families, some attendance, hardly ever the families get it quickly, sometimes with your knack, your effort, oh! I go there, talk to the coordinator, you can solve everything, oh my, you get, you see the family like that, like they are happy and thankful, you know? So there are some people who recognize it, then, I think that it is positive, I think, we feel useful, you know. (Speech by Agent B).

Quando você consegue resolver, uma consulta que você consegue para a família, algum atendimento, poucas vezes assim a família consegue rápido, as vezes com seu jeitinho, com seu esforço, ah! Vou lá converso com a coordenadora, tudo você consegue resolver, nossa, você fica, você vê a família assim, como que fica feliz fica agradecida sabe! Então tem uns que reconhecem, então assim, acho que isso é um ponto positivo, eu acho, a gente se sente útil, sabe.

I cannot tell if there at ESP, for nurses, physicians, if I have any value, but in my micro area I have so much value, at least for users, families, they value me a lot and I get very happy with that (Speech by Agent M).

Não sei dizer se lá na FHS, da enfermeira, do doutor, se eu tenho algum valor, mas na minha micro área eu tenho muito valor, pelo menos assim, dos usuários, das famílias eles me valoriza bastante e eu fico muito feliz com isso.

[…] the families recognize our work, they thank us (Speech by Agent A).

[…] a família reconhece nosso trabalho, agradece.

The lack of training compromises the communication with the community. Although CHAs know the local reality of health service users in the BFHU, they may not provide much guidance about health, mainly because users consider that the preventive information are already known, as it was reported by Agent “A”. It once again shows that health education must be an improvement process for users’ health awareness and not just information transfer in order to change behaviors, although respecting popular knowledge:

You have to walk, cannot eat too much salt, cannot smoke, we say it, but they already know and do it anyways (Speech by Agent A).

Tem que fazer caminhada, não come muito sal, não pode fumar, a gente fala, mas eles já sabem e fazem assim mesmo.

The health process brings up the discussion about hiring when actually it should be focused on the improvement of people’s health conditions. Therefore, there is the demand for establishing an efficient communication between those who give the information and those who get it. It necessarily promotes changes in work routines by valuing communication and providing the team with a strategic view.22

Although involvement and communication are essential for the effectiveness of health care services, such approach may result in moments of dissatisfaction with the work environment. The lack of privacy, for example, was another complaint by CHAs. It was found that such situation was frequent due to the dwelling proximity of CHAs with the assisted population. The speech by Agent “F” reports it:

We work Monday to Monday, because we live in the neighborhood, sometimes I am at home, lying down, someone knocks, calls, how will you mistreat someone? Will you mistreat someone who is feeling sick? Then someone calls my mobile at five in the morning: what time will the consultation be? (Speech by Agent F)

A gente não trabalha de segunda a segunda não, porque a gente mora no bairro, às vezes eu tô em casa, deitada, chama, bate um, como que você vai destratar uma pessoa? Vai destratar uma pessoa que tá passando mal, então liga no meu celular às cinco da manhã: que horas que vai sair a consulta?

The health agents have a hard time setting limits to the provided assistance, since they feel like being part of the problem because they live in the community.5 20

Therefore, authors state that:

As members of the community, CHAs live situations similar to those by the users with regards to the service. They identify themselves with the health and life conditions of the population they assist. Such social class identification allows understanding the community’s conditions and socio-cultural values as well as its demands.21

Besides living in the community, it is demanding to develop some skills and competences to work as CHA in family disease prevention counselling. During the FG, it was observed that CHAs were not able to provide high quality assistance due to the lack of training; it is evidenced in the speeches by Agents “B”, “A”, “M” and “P”:

[…] we get in to work, get approved in the public exam and everything, but we have no previous preparation, we go without knowing anything, if there is no person with a goodwill in there, who can help you, you get lost […] you saw more or less how it works, you get your bag, go out and see what people need […] that is why I think it should have, so you do not get so lost. (Speech by Agent B).

[…] a gente entra para trabalhar, passa num concurso tudo, mas não tem um preparo antes, vai assim sem saber de nada, se não tiver uma pessoa de boa vontade ali dentro, assim, que possa te ajudar você fica perdida […] viu mais ou menos como que funciona, você pega sua pastinha e sai e vai ver o que que a pessoa precisa […] por isso eu acho que deveria ter para você não ficar tão perdida.

[…] lack of training, because a new campaign appears, a problem, right? Then there should be training […] in the vaccine campaign, we did not know exactly to say the age group (Speech by Agent A).

[…]falta de treinamento, porque surge uma campanha nova, um problema, né, então tinha que ter um treinamento […] na campanha de vacina, a gente não sabe dizer direito, faixa etária.

My nurse gave me a file with all the families we have in my micro-area and said “you can go” […] with no uniform or anything, therefore I knocked at a house, the woman looked from the window, like, where is your uniform? You are not wearing an uniform, nametag, nothing, how am I supposed to know you are a Health Agent? […] I have the shirt, but the nametag has not arrived yet (Speech by Agent M).

A minha enfermeira, me deu uma pasta com todas as famílias que a gente tem na minha micro-área e falou pode ir[…] sem uniforme sem nada, portanto eu bati numa casa, a mulher olhou da janela assim, cadê seu uniforme, não tá de uniforme, crachá não tá de nada, como que eu vou saber que você é Agente de Saúde? […] a blusa eu tenho, mas o crachá não chegou até hoje.

We always talk to each other there, at that time, from 7 o’clock to half past eight while we are having breakfast, organizing the paperwork, what I have no doubt about, I explain, what I know I pass forward. Regarding attendance to the population, always when I can guide, if I know something, even if it is not about FHS, these things, talking, straight talk all the time, that is very good (Speech by Agent P) [emphasis added]

Lá a gente sempre conversa uma com a outra, nesse horário assim, de 7 horas até 8 e meia que a gente tá tomando café, organizando a papelada, o que eu não tenho dúvida eu ‘exprico’, o que eu sei eu passo para os outros, e referente também ao atendimento à população, sempre que eu posso tá orientando assim, se eu souber alguma coisa assim até além que não seja da FHS assim essas coisas, conversando, então assim, diálogo direto, o tempo todo e isso é muito bom [grifo nosso].

The teaching-learning instruments that favor popular and technical knowledge and are indispensable for health promoting, are not available to these professionals.5

CHAs were asked if they understood their function in the work team; if the roles are well defined. These questions helped identifying that duty changes were a common practice in the evaluated BFHUs.  CHAs’ professional activities involved medical prescription transcription and Agent “A” reported it as an inadequate behavior:

Oh, there at ours not anyone can do it, the nurse does it sometimes, the head nurse, and there is an agent there, the physician, it is only her responsibility, it is more work for her and it is known by them up there, at the secretariat, it is not hidden […] it is not anything, if it is not already written in the records that the person uses that, that medication cannot be prescribed […] if we do not understand what medication it says, we are not supposed to do it, only the ones we already know […] we must be safe (Speech by Agent A).

Ah, lá no nosso não é todo mundo que pode fazer não, a enfermeira as vezes faz, a enfermeira chefe mesmo, e tem uma agente lá, o médico, é só responsabilidade dela assim é mais serviço para ela e isso tem o conhecimento lá de cima, da Secretaria, não é escondido né […] não é qualquer, se não tiver no prontuário já relatado que a pessoa usa aquilo, aquele medicamento não pode […] se não entender qual medicamento que é não é para fazer, só os que já sabe,[…] tem que ter segurança.

The study identified the nurse who coordinates FHS and determines how tasks and activities will be performed, without sharing the priorities with the CHAs.

They justify such conduct by stating that it accelerates physician’s work; however, it compromises CHAs’ work. These are the informal and hidden aspects of their work12 and they are easily proved by the speech by Agent “M”:

No, no, the doctor likes, I think, because she has a longer time of work, she suggested to do it and is doing it herself, and the nurse does too (Speech by Agent M).

Não, não é o doutor que gosta, assim eu acho, porque ela tem mais tempo de serviço, ela mesmo que se propôs e tá fazendo e a enfermeira também faz.

Every work process involves one or several individuals who take actions and establish goals.

Overall, work processes often have their activities performed by only one individual, although it rarely happens in the whole work process. Then, it is about a single person performing an activity or a certain group of activities. However, collective, conjoint or complementary activities from several individuals are found in work processes. Thus, it is usually recalled as group work or team work.22

Inadequacy reproduction and power abuse were institutionalized and it became a natural aspect in the herein studied activity, it can be noticed in the participant’s speech.

Power and domination are connected to specific social domains:

[…] the elites and professional institutions and the rules and routines make the basis of everyday discursive power reproduction in these domains and institutions. The victims or targets of this power are usually the public or citizens in general, the “masses”, the clients, the subjects, the audience, the students and other groups that are dependent on institutional and organizational power.18

CHAs’ daily activities were not planned, and actions ended up being done by improvise, as shown in the speech by Agents “A” and “M”.

[…] when I plan everything goes wrong. […] not only with the nurse, but also Agents, they could meet and discuss the problems of the week (Speech by Agent A).

 […] quando planejo dá tudo errado. […] não só com a enfermeira, mas as Agentes também, podia reunir para discutir os problemas da semana.

We have a meeting once a month with the nurse there (Speech by Agent M).

Temos reunião lá uma vez por mês com a enfermeira.

Lack of training may be one of the determinant factors for the improvising in CHAs activities and it is reinforced by political and management issues.

In CHAs’ perception there are still several factors that discourage and demotivate work planning, such as: low wage, threats, fear to lose the job, job instability, lack of privacy, lack of dialogue among CHAs, lack of dialogue with the coordination, unawareness of duties, cleaning activities in BFHU, attendance at the reception or pharmacy, accountability by families for the lack of medication and exams, insufficient instruments to perform the tasks, lack of identification, lack of training, excess of bureaucracy, lack of sense of team work, tasks accumulation, the activities performed at home, prescription transcription; inadequate room, lack of team planning, staff turnover and work overload.

The descriptive analysis of discouraging and demotivating factors regarding work planning suggest that there are professional technical problems such as the lack of communication among FHSs, task accumulation, unawareness of duties, lack of human resources to perform management activities and prescription transcription performed by CHAs – the last one is the physicians’ duty and in some cases it is possible to be done by nurses. Thus, the lack of planning negatively interferes in the development of CHAs’ daily tasks and it impairs the communication with the community and the definition of priorities. Lack of privacy is featured as a personal character issue which hinders motivation for performing tasks and activities in an organized and planned way. It was possible to identify political and management problems that also interfere in the performance of CHAs’ activities such as staff turnover, inadequate room, job instability, threats and accountability of CHAs by some users due to the lack of time for consultations and exams, which, besides hindering the good performance of professionals, demotivates and leads to suffering.

Conclusion

The inexistence of planning helps the ineffectiveness of services performed by CHAs. The lack of planning and ability to deal with drug users and patients with mental disorders made the performance of programmed tasks difficult. CHAs were demotivated by work overload and by the lack of training to perform daily tasks.

Groups and families priorities are not discussed as team work. An unbalance was observed between CHAs’ will to nicely perform their activities and the impossibility to fulfill families’ expectations due to work condition precariousness and lack of planning. It then even worsens CHA’s bad performances.

However, adopting planning is a strategic issue to CHAs’ work organization. Implementing planned and discussed routines could help guaranteeing community’s participation in the social control of services performed by ESP. Such fact may be a challenge for the cities, but it will improve the effectiveness of actions taken by health professionals, especially by the Family Health Strategy.

The adoption of focus groups by studies about the herein discussed subject appears as an important instrument for social workers in the analysis and understanding of CHAs’ work plan.

The FG method led to the comprehension of strategies used by professionals during the performance of their work and the difficulties faced in their professional routine.

Thus, BFHUs’ health teams need to improve training to their technical and management board and to professionals who could help developing a social assistance network such as Social Workers, whose duties, among other, are: “investigate, formulate, manage, perform; evaluate and monitor social policies, programs and projects in health fields […]. Perform […] training […] favor users’ access to social rights”.22

It was possible finding that the focus group amplified the interaction between the researcher and the participants and it allowed to more effectively explore the discussed themes.

Acknowledgements

Thanks to CNPq for the financial support given through the concession of scholarships.

References

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Authors

Gracilene Maria Almeida Muniz Braga: Master/Federal University of Viçosa-MG (Professor – Department of Social Service – EMESCAM)

Simone Caldas Tavares Mafra: Doctor/ Federal University of Viçosa-MG (Professor – Department of Home Economics – UFV)

Emília Pio da Silva: Doctor/ Federal University of Viçosa-MG (Post-doc Scholarship)

Andreia Patrícia Gomes: Doctor/ Federal University of Viçosa-MG (Professor – Department of Medicine – UFV)

Mônica Santos Souza Melo: Doctor/ Federal University of Viçosa-MG (Professor – Language Department – UFV)