Abstract

Community Health Workers (CHWs) are a link between Family Health Strategy (FHS) professionals and the community. This study aims to analyze health care professionals’ perceptions and health management about CHWs’ role in caring for dependent elderly people. A qualitative study was carried out, from a hermeneutic-dialectic perspective, with 38 professionals working in elderly people’s health in cities in the five regions of Brazil. The results identified CHWs as facilitators of access to elderly people dependent on the health care network, gaps in continuing education and the reduced number of these professionals to meet the demand in primary care. Respondents attributed great importance to CHW’s performance, valued their participation in FHS, but pointed out a lack of knowledge and difficulties to supply the adequate amount in health care services and in assistance of elderly people with dependence and family. It is concluded that health professionals and managers consider CHWs to be a great workforce and essential to the dependent elderly people and their caregivers. The number of CHWs is insufficient in relation to FHS, and there is a lack of training to deal with various types of dependence.

Key words:
Community health worker; Family health strategy; Health personnel; Frail elderly; Qualitative research

Introduction

Community health workers (CHWs) are workers at the Brazilian Unified Health System (SUS - Sistema Único de Saúde) who started their activities in the Brazilian National Program of Community Health Workers (PNACS - Programa Nacional de Agentes Comunitários de Saúde), which, after a year, became known as the Community Health Workers Program (PACS - Programa de Agentes Comunitários de Saúde)¹1 Silva TL, Soares AN, Lacerda GA, Mesquita JFO, Silveira DC. Política Nacional de Atenção Básica 2017: implicações no trabalho do Agente Comunitário de Saúde. Saúde Debate 2020; 44(124):58-69.. The profession was regulated in 2002 and its duties are provided for in Ordinance 2.4361 of September 2017, which approves the new Brazilian National Policy for Primary Care (PNAB - Política Nacional de Atenção Básica)¹1 Silva TL, Soares AN, Lacerda GA, Mesquita JFO, Silveira DC. Política Nacional de Atenção Básica 2017: implicações no trabalho do Agente Comunitário de Saúde. Saúde Debate 2020; 44(124):58-69.^,22 Brasil. Ministério da Saúde (MS). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2017; 22 set..

PNACS started in the late 1980s, inspired by successful experiences in some states in northeast Brazil, the Federal District and São Paulo³3 Brasil. Ministério da Saúde (MS). Agente Comunitário de Saúde [site da Internet]. Brasília: MS; 2020 [acessado 2020 Jun 10]. Disponível em: https://www.saude.gov.br/acoes-e-programas/saude-da-familia/agente-comunitario-de-saude. People from underserved communities, especially women, were assigned to assist in promoting health in their respective territories. CHWs strengthened the community’s connection to health services and supported disadvantaged populations, as is the case with similar programs in other countries⁴4 Butcher N, Sittherb A, Velavanc J, Johnd E, Thomase MC, Grills N. Evaluation of community health worker training course effectiveness in India. Christ J Glob Health 2016; 3(2):18-26.^,55 Giovanella L, Almeida PF. Atenção primária integral e sistemas segmentados de saúde na América do Sul. Cad Saude Publica 2017; 33(Supl. 2):e00118816..

The Family Health Program (FHP), later Family Health Strategy (FHS), started to add CHW functions both in Basic Health Units (BHU) and in Family Health teams (FHSt). Among its attributions, the link between the demands of community and health services located in its area of emphasis stands out⁶6 Faria CCMV, Paiva CHA. O trabalho do agente comunitário de saúde e as diferenças sociais no território. Trab Educ Saúde [periódico na Internet] 2020 [acessado 2020 Abr 24]; 18(Supl. 1):e0025183. Disponível em: https://www.scielo.br/pdf/tes/v18s1/1678-1007-tes-18-s1-e0025183.pdf
https://www.scielo.br/pdf/tes/v18s1/1678... ^,77 Guanaes-Lorenzi C, Pinheiro RL. A (des)valorização do agente comunitário de saúde na Estratégia Saúde da Família. Cienc Saude Colet 2016; 21(8):2537-2546..

In health systems in several countries, there are workers whose role is similar to that of Brazilian CHW. Despite the different names, the term Community Health Workers identifies them in the international literature⁴4 Butcher N, Sittherb A, Velavanc J, Johnd E, Thomase MC, Grills N. Evaluation of community health worker training course effectiveness in India. Christ J Glob Health 2016; 3(2):18-26.^,55 Giovanella L, Almeida PF. Atenção primária integral e sistemas segmentados de saúde na América do Sul. Cad Saude Publica 2017; 33(Supl. 2):e00118816.^,88 Komaromy M, Ceballos V, Zurawski A, Bodenheimer T, Thom DH, Arora S. Extension for Community Healthcare Outcomes (ECHO):a new model for community health worker training and support. J Public Health Policy 2018; 39(2):203-216.. Regardless the countries of origin, these professionals show common traits, playing a strategic role with populations in rural areas, remote or in vulnerable situations. Its importance is recognized in the dialogue with the community, strengthening and consolidating health programs in different countries⁴4 Butcher N, Sittherb A, Velavanc J, Johnd E, Thomase MC, Grills N. Evaluation of community health worker training course effectiveness in India. Christ J Glob Health 2016; 3(2):18-26.^,88 Komaromy M, Ceballos V, Zurawski A, Bodenheimer T, Thom DH, Arora S. Extension for Community Healthcare Outcomes (ECHO):a new model for community health worker training and support. J Public Health Policy 2018; 39(2):203-216..

In South American countries, except Uruguay, professionals who resemble Brazilian CHW are official members of multidisciplinary teams, working for remuneration or voluntarily⁵5 Giovanella L, Almeida PF. Atenção primária integral e sistemas segmentados de saúde na América do Sul. Cad Saude Publica 2017; 33(Supl. 2):e00118816.. Portugal, France, Spain, England, United States, Canada, India, Kenya, Uganda, Ghana, and South Africa also include these professionals⁴4 Butcher N, Sittherb A, Velavanc J, Johnd E, Thomase MC, Grills N. Evaluation of community health worker training course effectiveness in India. Christ J Glob Health 2016; 3(2):18-26.^,88 Komaromy M, Ceballos V, Zurawski A, Bodenheimer T, Thom DH, Arora S. Extension for Community Healthcare Outcomes (ECHO):a new model for community health worker training and support. J Public Health Policy 2018; 39(2):203-216.^,99 Torres S, Labonté R, Spitzer DL, Andrew C, Amaratunga C. Improving health equity: the promising role of community health workers in Canada. Healthc Policy 2014; 10(1):73-85., who work with a pre-established number of families, on a defined geographical basis¹⁰10 Prentiss T, Tamler I, Plum A, Parke D, Zervos J, Tanniru M, Sears MH, White M, Wisdom K, Kaljee L. Community health workers as innovators: methods and results from a tele-education pilot for community health workers in Detroit, Michigan. In: Anais do 50º Hawaii International Conference on System Sciences (HICSS); 2017; Honolulu. p. 3273-3282..

In Brazil, in 2017, the new PNAB²2 Brasil. Ministério da Saúde (MS). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2017; 22 set. suppressed the minimum number of CHW per team, in contrast to the previous standard of four CHW per team, and there may be up to one CHW per team. Additionally, it also excluded from the text the forecast of the workload of up to eight hours/week for training these professionals²2 Brasil. Ministério da Saúde (MS). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2017; 22 set..

According to the education and health promotion principles, CHWs are professionals who live with the singularities of families, knowing the living conditions and social relationships in communities¹¹11 Loureiro LH, Diogo MA, Mendes TB, Machado TBFV, Marcellini PS, Tonini T. O trabalho e a formação do agente comunitário de saúde. Rev Práxis 2017; 9(17):103-111.^,1212 Melo MB, Quintão AF, Carmo RF. O Programa de Qualificação e Desenvolvimento do Agente Comunitário de Saúde na perspectiva dos diversos sujeitos envolvidos na atenção primária em saúde. Saúde Soc 2015; 24(1):86-99.. Among its functions, participating in territory mapping, family registration and home visits allows to know the community reality and identify populations at risk¹³13 Braga GMAM, Mafra SCT, Silva EP, Gomes AP, Melo MSS. Percepção do trabalho do agente comunitário de saúde pelos usuários atendidos nas unidades básicas de saúde da família de Viçosa, MG: tarefas realizadas e normas prescritas. Oikos 2016; 27(1):79-95..

As the population’s life expectancy and aging grew, assistance and social challenges were addressed to CHWs. Demographic, epidemiological and health changes have resulted in the expansion of chronic and complex diseases, which make elderly people increasingly fragile and dependent, demanding more organized and resolved health care networks¹²12 Melo MB, Quintão AF, Carmo RF. O Programa de Qualificação e Desenvolvimento do Agente Comunitário de Saúde na perspectiva dos diversos sujeitos envolvidos na atenção primária em saúde. Saúde Soc 2015; 24(1):86-99..

Indeed, increased longevity requires involvement of the entire FHSt in elder care. In this regard, the longitudinal contact and proximity of CHWs to homes express a potent space for carrying out care, especially for dependent elderly people¹⁴14 Andrade IA, Guimarães CP, Martins LC, Moreira JC. Capacitação em saúde do idoso para os agentes comunitários de saúde da UBS Citrolândia em Betim-MG: relato de uma prática intervencionista. Sinapse Múltipla 2017; 6(2):267-272..

It is believed that the guidelines in force at PNAB that reduced the number of CHWs per team may compromise care coverage of families, in addition to weakening the continuing education and training actions of CHWs. This makes it difficult to meet the population’s needs, including dependent elderly people, who require articulate and resolute attention. In this context, CHWs play a strategic role in view of their proximity to families in the territory. However, there is a gap in scientific production on the relevant CHWs’ role with dependent elderly people, which justifies focusing, in this investigation, health professionals’ and managers’ perspectives on CHWs’ actions and roles with the frail elderly population.

Given the above, this article aims to analyze primary care and health management professionals’ perceptions in about CHWs’ role in caring for dependent elderly people.

Methods

A qualitative study was carried out with support in hermeneutics-dialectics. An understanding of the problem was sought, taking into account objective, subjective aspects, beliefs and meanings of managers and health professionals in relation to CHWs’ role in the context of care for dependent elderly people and their families.

Hermeneutics-dialectics, as a theoretical-methodological lens, makes it possible to establish a reflective process¹⁵15 Habermas J. Dialética e Hermenêutica. Porto Alegre: LPM; 1987., to understand the communication between people and their connections with the environment. In this perspective, everyday life and common sense are elements of investigation. Languages permeate the experiences and interactions instruments that lead to understanding the characteristics of the universe under investigation¹⁶16 Gadamer HG. Verdade e método: traços fundamentais de uma hermenêutica filosófica. Petrópolis: Vozes; 1999.. A researcher does not use personal conceptions, which makes it possible to read the meanings that emerge from the reflective movement.

By associating hermeneutics and dialectics¹⁷17 Minayo MCS. Hermenêutica dialética como caminho do pensamento social próprio. In: Minayo MCS, Deslandes SF, organizadores. Caminhos do pensamento: epistemologia e método. Rio de Janeiro: Fiocruz; 2013. p. 83-107., consensus and dissent lead to a broader world view, allowing research to deepen in context and reveal the multiple phases of a complex reality permeated by values, beliefs and subjectivities¹⁸18 Gomes MHA, Silveira C. Sobre o uso de métodos qualitativos em Saúde Coletiva, ou a falta que faz uma teoria. Rev Saude Publica 2012; 46(1):160-165.^,1919 Taquette SR. Análise de dados de pesquisa qualitativa em saúde. In: Atas do V Congresso Ibero-Americano em Investigação Qualitativa - CIAIQ; 2016; Porto, Portugal. p. 524-533.. This combination of methods synthesizes comprehensive and critical processes, because the same reason that understands, clarifies and gathers, also challenges, dissociates and criticizes¹⁵15 Habermas J. Dialética e Hermenêutica. Porto Alegre: LPM; 1987..

The contributions of this approach to understanding the particularities and concepts attributed to CHWs’ performance with elderly people by respondents was verified with support in experiences, conflicts, experiences and interlocutions maintained in the professional and community scope.

Data collection took place from June to September 2019, in eight cities in the five regions of Brazil: Araranguá, Brasília, Fortaleza, Manaus, Porto Alegre, Belo Horizonte, Rio de Janeiro, and Teresina.

Thirty-eight professionals from primary care and health management participated, 22 of whom were female and 16 were male, with an average age of 43 years, who worked in the elderly people’s health field in the eight cities, with the following training: physicians (8), nurses (18), social workers (3), physical educator (1), physiotherapist (1), dentists (2), neuropsychologist (1), biologist (1), nursing technician (1), pedagogue (1) and CHW (1).

Health professionals active, for at least a year, were invited in BHU and in municipal programs that support elderly people and their families were included. As managers, those responsible for the bodies that coordinate the elderly people’s health in those cities were invited, such as health departments or managers of specific programs. In general, study participants had specializations, previous experiences or continuing education courses that enabled them to work in the context of elderly’ health. The study excluded those who were on vacation, away from work or who missed work on the day of collection.

For the sample composition, professionals and managers were identified at BHU and at the municipal health departments of the respective cities, who were invited in person or by telephone to participate in the interviews. Interviews were conducted at the participants’ workplaces by experienced researchers. Therefore, the sample was carried out intentionally, which is demonstrated by cities in the Table 1.

Semi-structured interviews were directed to each type of professional, with questions that started addressing identification data and length of experience in service. They went deeper to identify interviewees’ perceptions of elderly people with social, physical, mental and cognitive dependence, facilities and difficulties to welcome, accompany or refer elderly people and their families with different types of dependence, and initiatives to support elderly people and families.

The interview questions were prepared by the researchers who worked together in the investigation, who participated in the local teams, carried out the interviews with permission of audio recording and were transcribed in full. Notes recorded in the field diary also supported data collection, which ended from the principle of saturation²⁰20 Nascimento LCN, Souza TV, Oliveira ICS, Moraes JRMM, Aguiar RCB, Silva LF. Saturação teórica em pesquisa qualitativa: relato de experiência na entrevista com escolares. Rev Bras Enferm 2018; 71(1):228-233., when new ideas related to the topic under discussion no longer emerged.

In line with the presuppositions of hermeneutics-dialectics, the three steps recommended by Minayo¹⁷17 Minayo MCS. Hermenêutica dialética como caminho do pensamento social próprio. In: Minayo MCS, Deslandes SF, organizadores. Caminhos do pensamento: epistemologia e método. Rio de Janeiro: Fiocruz; 2013. p. 83-107. - ordering, classification and final data analysis were followed. Ordering includes transcribing interviews, reading empirical material and organizing the contents that emerge from the text in sets of meanings. Classifying the indicators denotes the elaboration and grouping of the sets of meanings in specific themes of the object of study. Analysis consisted of creating an organization flowchart to visualize the themes.

Although the interview script did not include specific questions about CHWs’ role in the context of dependent elderly people’ health, the focus of analysis in this article fell on the 14 statements of managers and 18 of health professionals who deal with this subject. Thus, given frequency and relevance, data made the study’s objective emerge. The material, after being organized and analyzed, was presented in two themes.

Data were interpreted in the light of hermeneutics-dialectics¹⁵15 Habermas J. Dialética e Hermenêutica. Porto Alegre: LPM; 1987.^,1717 Minayo MCS. Hermenêutica dialética como caminho do pensamento social próprio. In: Minayo MCS, Deslandes SF, organizadores. Caminhos do pensamento: epistemologia e método. Rio de Janeiro: Fiocruz; 2013. p. 83-107., the literature on CHWs’ role and approaches related to elderly people’s health²2 Brasil. Ministério da Saúde (MS). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2017; 22 set.^,33 Brasil. Ministério da Saúde (MS). Agente Comunitário de Saúde [site da Internet]. Brasília: MS; 2020 [acessado 2020 Jun 10]. Disponível em: https://www.saude.gov.br/acoes-e-programas/saude-da-familia/agente-comunitario-de-saude^,2121 Brasil. Ministério da Saúde (MS). Diretrizes para capacitação de agentes comunitários de saúde em linhas de cuidado. Brasília: MS; 2016.. At the end, the research team synthesized the findings, dialoguing with the identified themes and comparing them to the theoretical-methodological framework, to the objectives and assumptions previously established.

To protect participants’ identities, we chose to name them by means of letters and numbers. Letters HP refer to health professional and letter M refers to manager. The numbers correspond to the number of participants, such as, for example, HP1 means health professional number 1, M1 is manager 1, and so on.

This article is part of a study entitled Estudo situacional dos idosos dependentes que residem com suas famílias visando a subsidiar uma política de atenção e de apoio aos cuidadores, coordinated by a team belonging to the Department of Studies on Violence and Health Jorge Careli of the Brazilian National School of Public Health, Fundação Oswaldo Cruz. The project was approved by the Research Ethics Committee of Fundação Oswaldo Cruz.

Results and discussion

Health professionals’ perceptions, be they of care or management, about CHWs’ performance, expressed in the interviews, were mapped and synthesized, converging to the formulation of two thematic categories: “CHWs as facilitators of access to elderly people dependent on the health care network” and “Gaps in continuing education of CHWs on assistance to dependent elderly people”.

CHWs as facilitators of access to elderly people dependent on the health care network

The approximation of CHWs with the community in which they operate and reside facilitates the knowledge of these professionals regarding families’ social and health problems. In this logic, CHWs’ praxis occurs in the capillarity of the first level of health care, materializing in easy access to elderly people and their families, in involvement with the family dynamics of elderly people, establishing formation of bonds, a ‘bridge’. This dynamic goes beyond permeability with residents, as it also stems from knowledge of the ethical and safety codes that govern the territory in which they operate²²22 Assis AS, Castro-Silva CR. Agente Comunitário de Saúde e o idoso: visita domiciliar e práticas de cuidado. Physis [periódico na Internet]. 2018 [acessado 2018 Out 23]; 28(3):0103-7331. Disponível em: https://www.scielo.br/pdf/physis/v28n3/0103-7331-physis-28-03-e280308.pdf
https://www.scielo.br/pdf/physis/v28n3/0... .

This theme attests that the CHW is seen as a bridge between health professionals, the service and the assisted community. This idea of bridge, referred to frequently by participants, refers to link, chain and bond²³23 Costa SM, Araújo FF, Martins LV, Nobre LLR, Araújo FM, Rodrigues CAQ. Agente Comunitário de Saúde: elemento nuclear das ações em saúde. Cien Saude Colet 2013; 18(7):2147-2156.. This perception occurs based on health care model reorientation that assumes the understanding of territory as a living space, where people demonstrate singularities, ways of living and socio-cultural arrangements to face illnesses⁶6 Faria CCMV, Paiva CHA. O trabalho do agente comunitário de saúde e as diferenças sociais no território. Trab Educ Saúde [periódico na Internet] 2020 [acessado 2020 Abr 24]; 18(Supl. 1):e0025183. Disponível em: https://www.scielo.br/pdf/tes/v18s1/1678-1007-tes-18-s1-e0025183.pdf
https://www.scielo.br/pdf/tes/v18s1/1678... .

In participants’ statements, the importance of home care performed by health teams with CHWs emerges, establishing itself as a point of care in the health care network and supporting the concept of home visit (HV) as a means to carry out care centered on singularities and contexts of life²⁴24 Muniz EA, Freitas CASL, Oliveira EM, Lacerda MR. Atenção domiciliar ao idoso na estratégia saúde da família: perspectiva sobre a organização do cuidado. Rev Enferm UFPE [periódico na Internet]. 2017 Jan [acessado 2020 Maio 23]; 11(Supl.1):296-302. Disponível em: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/viewFile/11908/14391
https://periodicos.ufpe.br/revistas/revi... . It is worth expressing that the realization of HV strengthens the elderly people’ sense of belonging to health services.

It is important to point out teaching-service integration, reiterating SUS as a “practice scenario” essential to training, highlighting the mediation of CHWs in academic pathways and in the constitution of intersectoriality, with access of dependent elderly people to the multidisciplinary actions of health services²⁵25 Morosini MV. Educação e trabalho em disputa no SUS: a política de formação dos agentes comunitários de saúde. Rio de Janeiro: EPSJV; 2010..

In the perspective of approaching health system users, CHWs act as articulators in FHS. Most of them, coming from communities, show socio-cultural characteristics that bring them closer to users, in addition to allowing contextualization of the problems in the territory²⁶26 Filgueiras AS, Silva ALA. Agente Comunitário de Saúde: um novo ator no cenário da saúde do Brasil. Physis [periódico na Internet]. 2011 [acessado 2020 Maio 23]; 21(3):899-916. Disponível em: https://www.scielo.br/pdf/physis/v21n3/08.pdf
https://www.scielo.br/pdf/physis/v21n3/0... .

Still in the sense of getting closer to the community, CHWs embrace, listen and monitor elderly people in their homes, offering greater comfort and seeking to resolve the demands²⁷27 Magalhães KA, Giacomin KC, Santos WJ, Firmo JO. A visita domiciliária do agente comunitário de saúde a famílias com idosos frágeis. Cien Saude Coletiva [periódico na Internet]. 2015 [acessado 2020 Jan 23]; 20(12):3787-3796. Disponível em: https://www.scielosp.org/article/csc/2015.v20n12/3787-3796
https://www.scielosp.org/article/csc/201... .

Litzelman et al.²⁸28 Litzelman DK, Inui TS, Griffin WJ, Perkins A, Cottingham AH, Schmitt-Wendholt KM, Ivy SS. Griffin W. Impact of community health workers on elderly patients' advance care planning and health care utilization: moving the dial. Med Care 2017; 55(4):319-326. report results in emergency care and hospitalization decrease in the state of Indiana, United States of America, where elderly people participate in discussions and decisions about their care with local CHWs, at home, through care planning. This shows the importance of bringing this professional closer to health system users. The study highlights the need for a strategy to increase the number of countries with this same target, as pointed out by the World Health Organization, by establishing programmatic and financial recommendations for programs that include the figure of CHWs²⁹29 Tulenko K, Møgedal S, Afzal MM, Frymus D, Oshin A, Pate M, Quain E, Pinel A, Wynd S, Zodpey S . Community health workers for universal health-care coverage: from fragmentation to synergy. Bull World Health Organization 2013; 91:847-852..

Like India, CHWs establish a link between community leaders and those of religious organizations for health care performance, favoring access for underserved and remote communities across the country to primary care. In this perspective, this action provides changes in health-related behavior, with repercussions on the expansion of health care for these populations, as well as the positive impact on health across India³⁰30 Butcher N, Grills N. Impacts of community lay-leader health worker training & practice (Uttarakhand, India). Christ J Glob Health 2017; 4(2):43-52..

Australian researchers have observed, from examples of successful government programs in low and middle income countries, that CHWs are effective. Thus, they decided to assess the scope, the value of this type of program in Australia and the challenges in integrating these workers into the health system. They verified the relevance of their performance in improving equity and access of the less favored population to Primary Health Care (PHC), facilitating access to health services and information, which becomes even more important considering the growing number of chronic diseases³¹31 Javanparast S, Windle A, Freeman T, Baum F. Community health worker programs to improve healthcare access and equity: are they only relevant to low- and middle-income countries? Int J Health Policy Manag 2018; 7(10):943-954..

From the perspective of healthcare and management professionals, CHWs’ performance offers an improvement in health conditions and advances in the actions recommended in PNAB. Thus, the interlocution of these workers with the community is seen as a positive aspect in conditions related to communication and health education.

CHWs’ role refers to important aspects in the context of the health of dependent elderly people, since it increases the uptake of this population to access primary care (active search), enables risk stratification, the identification of diseases and brings the demands of elderly people to BHUs³²32 Brito LP. O agente comunitário em saúde: um cuidador ou um apoiador institucional? [dissertação]. Brasília: Universidade de Brasília; 2015..

Not every “gather” of dependent elderly people’ health needs contains a resolving outcome; often, it can become repressed due to SUS organizational processes, such as regulation, and the obstacles to overcome the complexity levels of health care²⁷27 Magalhães KA, Giacomin KC, Santos WJ, Firmo JO. A visita domiciliária do agente comunitário de saúde a famílias com idosos frágeis. Cien Saude Coletiva [periódico na Internet]. 2015 [acessado 2020 Jan 23]; 20(12):3787-3796. Disponível em: https://www.scielosp.org/article/csc/2015.v20n12/3787-3796
https://www.scielosp.org/article/csc/201... .

In contrast, there are difficulties with reducing the number of CHWs per team², which implies fragmentation and incompleteness of care for dependent elderly people, family and or caregiver³³33 Silva TL, Soares AN, Lacerda GA, Mesquita JFO, Silveira DC. Política nacional de atenção básica 2017: implicações no trabalho de agente comunitário de saúde. Saúde Debate [periódico na Internet]. 2020 [acessado 2020 Jan 23]; 44(124):58-69. Disponível em: https://www.scielosp.org/article/sdeb/2020.v44n124/58-69/pt/
https://www.scielosp.org/article/sdeb/20... . Facts of this nature were identified in the statements of professionals from Araranguá and Belo Horizonte:

The reduction in the number of workers per team came into force with the new PNAB in 2017. This legal determination weakens the daily assistance coverage of CHWs in their territories, compromising compliance with the home visit agenda, moment when health problems and dependent elderly people’s needs are raised. From then on, CHWs schedule appointments and consultations with the professionals of their teams, who, in turn, make referrals and referrals to specialized health levels.

The relationships of proximity and dialogue maintained by CHWs and professionals in care and management, in an attempt to mediate and bring elderly people and family members closer to health services, try to offer greater resolution to aspects that are often not revealed within of dependent elderly people’ homes and families.

Many caregivers, as they are alone and do not have the support of other family members or neighbors, see CHWs as a support that enables the search for care, obtaining medication or, simply, a friendly ear to relieve the suffering and limitations of elderly people or their own.

The creation of El libro Blanco de la Dependência, in Spain, in 2004, it exemplifies the ample care for dependent elderly people, considering the integral health of this population within health care network. Thus, it establishes several axes of action and highlights the support to elderly people and caregivers at home with a form of respect, protection, comfort and improvement of quality of life and health³⁴34 Minayo MCS. O imperativo de cuidar da pessoa idosa dependente. Cien Saude Colet 2019; 24(1):247-252.^,3535 Instituto de Mayores y Servicios Sociales (IMSERMO). Libro Blanco de Atención a las personas en situación de dependencia en España. Madrid: IMSERMO; 2004 [acessado 2018 Jul 12]. Disponível em: https://www.imserso.es/InterPresent2/groups/imserso/documents/binario/libroblanco.pdf. PACS can seek inspiration in this strategy to act in the direction of a more comprehensive care for these families, based on the support of public policies and a training of CHWs directed to elderly people’s health.

Gaps in continuing education of CHWs on assistance to dependent elderly people

In professionals’ statements, there was an understanding of the desire to have, in their teams, qualified CHWs, holders of knowledge and skill to use means in health education, favoring their performance with dependent elderly people.

Studies²²22 Assis AS, Castro-Silva CR. Agente Comunitário de Saúde e o idoso: visita domiciliar e práticas de cuidado. Physis [periódico na Internet]. 2018 [acessado 2018 Out 23]; 28(3):0103-7331. Disponível em: https://www.scielo.br/pdf/physis/v28n3/0103-7331-physis-28-03-e280308.pdf
https://www.scielo.br/pdf/physis/v28n3/0... ^,3636 Fortes KMGS, Moura MEB, Nunes BMVT, Landim CAP, Lago EC. Formação do Agente Comunitário de Saúde da família na atenção ao idoso. Rev Enferm UFPE 2016; 10(Supl. 1):211-217. state that CHWs’ practices are based on welcoming and qualified listening, which strengthens the relationship with elderly people and, remember, that CHWs’ performance in caring for the elderly population comes from the Brazilian National Health Policy for Elderly people (Política Nacional de Saúde da Pessoa Idosa) guidelines. Among other guidelines, this policy values the training and education of SUS professionals to work with this population, which brings value to CHWs’ work, contributing to training these professionals regarding aging.

Silva et al.³⁷37 Silva DM, Silva MAC, Oliveira DS, Alves M. Cotidiano de agentes comunitários de saúde com idosos segundo o referencial de certeau. Cogitare Enferm 2017; 22(4):e50436. and Medeiros et al.³⁸38 Medeiros KKAS, Pinto Júnior EP, Bousquat A, Medina MG. O desafio da integralidade no cuidado ao idoso, no âmbito da Atenção Primária à Saúde. Saúde Debate 2017; 41(3):288-295. point out that the challenges surrounding care for dependent elderly people and social inequalities in health amplify situations of vulnerability. In this regard, participants join forces to alleviate this dependence and neglected care, promoting health actions in line with the purposes of active aging.

Rahmawate and Bajorek³⁹39 Rahmawati R, Bajorek B. A community health worker-based program for elderly people with hypertension in Indonesia: a qualitative study, 2013. Prev Chronic Dis 2015; 12:e175. explore CHWs’ role in a program to support hypertensive elderly people living in a rural community in Indonesia. These professionals stood out as “health care guardians”. After being trained, they assisted in hypertension monitoring, supported professionals of a health unit in blood pressure measurement, guidance on physical activity and healthy eating. Elderly people and health professionals have evidenced many health benefits for those assisted by CHWs’ work, in addition to the feeling of protection and support from peers.

There is an alignment of the actions of Brazilian CHWs described by professionals and managers with the principles of integrality and intersectoriality⁴⁰40 Heimann LS, Ibanhes LC, Boaretto RC, Castro IEN, Telesi Júnior E, Cortizo CT, Fausto MCR, Nascimento VBN, Kayano J. Atenção primária em saúde: um estudo multidimensional sobre os desafios e potencialidades na região metropolitana de São Paulo (SP, Brasil). Cienc Saude Colet [periódico na Internet]. 2011[acessado 2020 Jan 23]; 16(6):2877-2887. Disponível em: https://www.scielo.br/pdf/csc/v16n6/25.pdf
https://www.scielo.br/pdf/csc/v16n6/25.p... , prioritizing the dependence of elderly people, which supports the interviewees’ statements:

Permanent health education is crucial to offer quality actions. This should be based on knowledge of the political guidelines, statutes and manuals⁴¹41 Brasil. Ministério da Saúde (MS). Política Nacional de Educação Permanente em Saúde: o que se tem produzido para o seu fortalecimento? Brasília: MS; 2018.^,4242 Peixoto LS, Gonçalves LC, Costa TD, Tavares CMM, Cavalcante ACD, Cortez EA. Educação permanente, continuada e em serviço: desvendando seus conceitos. Enferm Global 2013; 12(29):324-340., in addition to legal and ethical provisions. Melo et al.⁴³43 Melo EA, Mendonça MHM, Oliveira JR, Andrade GCL. Mudanças na Política Nacional de Atenção Básica: entre retrocessos e desafios. Saúde Debate [periódico na Internet]. 2018 Set [acessado 2020 Maio 23]; 42(1):38-51. Disponível em: https://www.scielo.br/pdf/sdeb/v42nspe1/0103-1104-sdeb-42-spe01-0038.pdf
https://www.scielo.br/pdf/sdeb/v42nspe1/... affirm that, when understanding SUS as a training space, PNAB 2011 predicted that up to 8 hours/week of FHS professionals would be used for training activities, continuing education, matrix support and on call in the emergency network. This wording did not last in the current PNAB¹1 Silva TL, Soares AN, Lacerda GA, Mesquita JFO, Silveira DC. Política Nacional de Atenção Básica 2017: implicações no trabalho do Agente Comunitário de Saúde. Saúde Debate 2020; 44(124):58-69.^,22 Brasil. Ministério da Saúde (MS). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2017; 22 set..

PNAB reformulation weakens continuing education for the greater purpose, which is the reconfiguration of praxis in search of solutions to the problems that emanate from it. Thus, it is also perceived, as discontinuity, a lower valuation of continuing education, a key part for the work in primary care (PC)⁴²42 Peixoto LS, Gonçalves LC, Costa TD, Tavares CMM, Cavalcante ACD, Cortez EA. Educação permanente, continuada e em serviço: desvendando seus conceitos. Enferm Global 2013; 12(29):324-340.. A manager’s statement shows how important it is to internalize the concepts of continuing education in health work:

Filgueiras and Silva²⁶26 Filgueiras AS, Silva ALA. Agente Comunitário de Saúde: um novo ator no cenário da saúde do Brasil. Physis [periódico na Internet]. 2011 [acessado 2020 Maio 23]; 21(3):899-916. Disponível em: https://www.scielo.br/pdf/physis/v21n3/08.pdf
https://www.scielo.br/pdf/physis/v21n3/0... point out that these professionals facilitate approximation between health services and community, as well as helping to expand access to health information and practices. Studies⁴4 Butcher N, Sittherb A, Velavanc J, Johnd E, Thomase MC, Grills N. Evaluation of community health worker training course effectiveness in India. Christ J Glob Health 2016; 3(2):18-26.^,4444 Perry HB, Zulliger R, Rogers MM. Community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness. Annu Rev Public Health 2014; 35:399-421. demonstrate that CHWs’ work can be effective in improving population’s health in low, middle and high income countries. However, CHWs cannot reach their full potential to act in the community, with different populations and age groups, without a continuous training process.

Understanding the importance of CHW’s performance by health managers and professionals, in the perspective of dialectics, comes from the comparative act, when they confront actions and attributions of each one. In this regard, CHWs recognize the need for a broader and deeper training that privileges elderly people’s health and dependency, so that they can act with greater property and offer more resolution to this population.

The Guidelines for Training CHW in Care Lines²¹21 Brasil. Ministério da Saúde (MS). Diretrizes para capacitação de agentes comunitários de saúde em linhas de cuidado. Brasília: MS; 2016. are based on axes for providing a care service that is more directed to the target audience, proposing to meet regional, local demands and health priorities. They choose imperative points to be effective in PHC, this being the level that orders and coordinates care in the intricacies of the health care network.

CHW’s training in elderly people’ health is seen by participants as an essential strategy so that CHWs can act based on the Brazilian health policies that regulate the organization of health services and improvement of the population’s living and health conditions. In such a way, it will be able to act in health care promotion for elderly people through articulation between actions of education and mediation in health, principles of popular education, problematization of reality and active participation in the community. Therefore, CHWs will be able to increasingly encourage emancipatory relationships between the different health professionals working with the elderly population, developing integrated actions in PC teams and strengthening the care coordination principles.

Final considerations

The findings reveal a positive view and relevance of CHWs’ work in health teams, especially in FHSt. Health actions aimed at elderly people, especially dependents, need CHWs’ performance, as these professionals represent a link between the family, the FHSt and other services in the municipal health network.

Participants’ statements demonstrate that thanks to CHWs’ intensive adherence to the families registered in their assigned areas, FHSt have a permanent vision for this clientele, especially the elderly, fragile and dependent population.

As they are closer to families, CHWs identify dependent elderly people’s needs and facilitate their access to the health care network. Professionals recognize, however, that the reduced number of CHWs per team as well as the compromise of the workload destined to the training and continuing education of these workers are responsible for the fragility of the assistance coverage’s work. This compromises the entire line of care for dependent elderly people, either in PC or in accessing other levels of health care.

Another evidence reported by participants on CHWs’ performance in their territories refers to the support provided to informal caregivers. They recognize in them a support that enables the search for care, obtaining medication or an attentive listening capable of relieving the suffering and limitations of elderly people and caregivers.

Concerning CHWs’ performance in relation to fragile elderly people, participants pointed out a need for changes in Brazilian legislation that guarantee the expansion of the number of CHWs per team. Another demand is the allocation of hours for training and qualification of these human resources to work with the elderly population, with emphasis on dependents.

The aged population, which increases the number of older elderly people, CHWs are of great importance and need to be increasingly prepared to meet the basic needs and assistance demands of this clientele.

This investigation also contributes in the public health field in the sense of filling gaps in knowledge in the national and international scientific literature regarding the object of study analyzed given the lack of publications on CHWs’ role caring for dependent elderly people, which gives a character of originality to the text.

As a limitation, it was found that, although the idea that CHWs are considered important in caring for elderly people in PHC emerged from the statements, the interview questions did not address this specific topic, which may have suppressed the opinion of some participants on this theme. On the other hand, many professionals and managers interviewed, from most cities, issued relevant opinions on CHWs’ performance regarding elderly people’s health.

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