Abstract

This article analyzes the inclusion of the aging and interprofessional education topics in the education of Family Health Strategy (ESF) and Family Health Support Center (NASF) professionals by analyzing their courses’ pedagogical projects. The article is based on a qualitative documentary research held in the state of Rio Grande do Norte, Brazil. The pedagogical projects were analyzed based on the content analysis method using the thematic analysis procedure in two predetermined recording units: (i) professional competencies and (ii) curricular structure. As part of the results, none of the courses investigated in this study offer an interprofessional health education addressing deeper aging discussions.

Keywords:
Aging; Elderly health; Interprofessional education; Professional health education; Family health

Introduction

To the detriment of political and social achievements, as well as of science and technology advances, increase in life expectancy and in the proportion of elderly people (≥ 60 years old) has become a global phenomenon¹1. Coyle CE, Mutchler JE. Aging with disability: advancement of a cross-disciplinary research network. Res Aging. 2017; 39(6):683-92.. In Brazil, there has been a decrease in birth rate and an accentuated increase in elderly people, which will intensify in the next decades²2. Ferreira LMBM, Jerez-Roig J, Andrade FLJP, Oliveira NPD, Araújo JRT, Lima KC. Prevalência de quedas e avaliação da mobilidade em idosos institucionalizados. Rev Bras Geriatr Gerontol. 2016; 19(6):995-1003..

An increase in morbidities and functional inabilities, and a decrease in independence and autonomy, as well as an increase in the number of hospitalizations in intensive care units, are incorporated into the accelerated aging process of the population³3. Alves KL, Alves MRR, Sá CMCP, Xavier Junior JA, Barros KC, Alves LMRR, et al. Nursing professional’s working load given to the elderly at the intensive unit care. Int Arch Med. 2017; 10(44):1-8.. Faced with this demographic transition, it is necessary to invest in Brazilian National Health System (SUS) in order to provide answers to the elderly needs^4,5.

SUS aggregates healthcare management, social participation and education actions, being defined as an intersectoral and interprofessional space⁶6. Peduzzi M. O SUS é interprofissional. Interface (Botucatu). 2016; 20(56):199-201.. In this sense, the importance in strengthening education and interprofessional work to qualify a comprehensive elderly healthcare is highlighted, being an alternative response to health issues suffered by this part of the population^7,8.

The interprofessional education’s and the Brazilian public health’s principles are aligned⁹9. Costa MV, Vilar MJ, Azevedo GD, Reeves S. Interprofessional education as an approach for reforming health professions education in Brazil: emerging findings. J Interprof Care. 2014; 28(4):379-80., based on a significant interactive education and on the exchange of knowledge among different professionals^10,11. Besides being better prepared to work in teams and according to SUS’ principles based on comprehensive care through interprofessional education, students and future health professionals become more agile to deal with difficulties in the daily work routine¹²12. Batista NA, Batista SHSS. Educação interprofissional na formação em saúde: tecendo redes e práticas de saberes. Interface (Botucatu). 2016; 20(56):202-4..

Over the last decades, interprofessional education has gained ground as an important component to education and healthcare transformation under the perspective of a collaborative and effective work development^11,13. However, in Brazil, the prevailing health education model is still characterized as uniprofessional, focused on isolated disciplines, in the fragmentation of care and of biomedical practice, diverging from SUS’ and the National Curricular Guidelines’ recommendations for health courses¹⁴14. Silva JAM, Peduzzi M, Orchard C, Leonello VM. Educação interprofissional e prática colaborativa na atenção primária à saúde. Rev Esc Enferm USP. 2015; 49 Esp 2:16-24..

Additionally, in elderly healthcare, organizing health networks coordinated by primary healthcare teams is necessary, but particularly by Family Health Strategy (ESF) and Family Health Support Center (NASF) professionals¹⁵15. Belas IA, Rocha JHA, Silva FM, Lustosa JVB, Carneiro WS, Valença AMG, et al. Articulated actions of the family health strategy teams and their centres of support in the state of Piauí, Brazil. Int Arch Med. 2017; 10(5):1-8.. Attempts to organize the primary healthcare in Brazil date back to 1920, with the creation of different proposals in different regions of the country¹⁶16. Arantes LJ, Shimizu HE, Merchán-Hamann E. Contribuições e desafios da Estratégia Saúde da Família na atenção primária à saúde no Brasil: revisão da literatura. Cienc Saude Colet. 2016; 21(5):1499-509.. However, efforts to strengthen primary healthcare only began in the 1990s through SUS’ decentralization process, with guaranteed transfer of federal resources to states and cities.

Still in the 1990s, specifically in 1994, the Brazilian Ministry of Health created Family Health Program (PSF), which derives from Community Health Agents Program (PACS), founded in 1991 with the objective of reorienting the care model based on primary healthcare and in compliance with SUS’ principles¹⁷17. Andrade RS, Caldas LBSN, Falcão MLP, Goes PSA. Processo de trabalho em uma unidade de saúde da família e a educação permanente. Trab Educ Saude. 2016; 14(2):505-21.. Based on health promotion and protection, as well as prevention of aggravations, either individually or collectively, PSF became SUS’ structuring axis, being called Family Health Strategy (ESF) in 2006¹⁸18. Miranda GMD, Mendes ACG, Silva ALA, Santos Neto PM. A ampliação das equipes de saúde da família e o Programa Mais Médicos nos municípios brasileiros. Trab Educ Saude. 2017; 15(1):131-45..

According to National Primary Care Policy (PNAB), instituted on October 21, 2011 through Directive no. 2488 of the Brazilian Ministry of Health, ESF is SUS’ main gateway and the main means of communication between users and healthcare networks. Care provided by ESF’s team of professionals at home or in primary care units values the subjects’ singularity and life stories, building bonds between users and health services¹⁹19. Lima RRT, Castro JL. Estudo acerca do perfil: uma contribuição para as políticas de valorização profissional. In: Castro JL, Vilar RLA, Oliveira NHS. As trilhas e os desafios da gestão do trabalho e da educação na saúde. Natal: Una; 2016. p. 129-47..

In order to strengthen even more the primary healthcare in Brazil and expand ESF professionals’ scope of action, the Brazilian Ministry of Health created NASF in 2008 through Directive no. 154. NASF and ESF professionals coordinate the health system based on primary healthcare, providing a comprehensive care to other levels of the service. Additionally, with the matrix support, these professionals aim at breaking vertical and hierarchized work practices²⁰20. Shimizu HE, Fragelli TBO. Competências profissionais essenciais para o trabalho no Núcleo de Apoio à Saúde da Família. Rev Bras Educ Med. 2016; 40(2):216-25..

Regarding elderly health, comprehensive care under the ESF scope requires a group of professionals that goes beyond doctors, such as community health agents, dental surgeons, nurses, nursing technicians, oral health technicians and NASF professionals⁶6. Peduzzi M. O SUS é interprofissional. Interface (Botucatu). 2016; 20(56):199-201.. These professionals should work based on collaborative practice and promote actions in favor of an active aging²¹21. Costa T, Torres GV, Oliveira RA, Costa MV, Dantas BAS, Miranda JMA, et al. Changes in the quality of life of an elderly group of the Family Health Strategy. Int Arch Med. 2016; 9(381):1-9..

Therefore, in order to identify if the professional health education is as expected in providing care to the elderly population, this article is aimed at analyzing the inclusion of the aging and interprofessional education topics in the education of ESF and NASF professionals.

Methodology

Research characterization

This article results from a qualitative documentation research conducted in the Brazilian northeastern state of Rio Grande do Norte (RN). The Northeast is the second region of the country with the largest number of elderly people, comprising approximately 29% of the entire Brazilian elderly population²²22. Andrade LM, Sena ELS, Pinheiro GML, Meira EC, Lira LSSP. Políticas públicas para pessoas idosas no Brasil: uma revisão integrativa. Cienc Saude Colet. 2013; 18(12):3543-52.. Additionally, according to the demographic census conducted in 2010 by Brazilian Institute of Geography and Statistics (IBGE), 10.8% of RN’s population is comprised of ≥ 60-year-old people²³23. Instituto Brasileiro de Geografia e Estatística. Censo Demográfico 2010 [Internet]. Rio de Janeiro: IBGE; 2010 [citado 11 Ago 2017]. Disponível em: Disponível em: http://www.ibge.gov.br/estadosat/temas.php?sigla=rn&tema=censodemog2010_snig .
http://www.ibge.gov.br/estadosat/temas.p... .

In order to achieve the research’s objective, the pedagogical projects of the courses that comprise the ESF and NASF teams of professionals (Chart 1) were searched and analyzed.

Data collection

The research data were collected by analyzing the pedagogical projects of the courses related to the professions listed in Chart 1. Initially, seventy courses registered in the Brazilian Ministry of Education’s information systems were identified, taught in public and private education institutions of RN (Table 2). In order to identify mid-level courses, National Information System for Professional and Technological Education (SISTEC) was consulted, and in order to identify higher-level courses, Regulatory System of Higher Education (e-MEC) was consulted.

Subsequently, the pedagogical projects were analyzed with the coordination of the identified courses by accessing their institutional web pages, by e-mail or in person. Consequently, an analysis of 57 pedagogical projects was provided (Chart 2). The entire data collection process was held from June to August 2016.

Data analysis

The pedagogical projects were analyzed based on the content analysis method, in the thematic modality, contemplating the pre-analysis, material exploration and data interpretation phases. According to Minayo²⁴24. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 13a ed. São Paulo: Hucitec; 2013., in qualitative researches, content analysis is used to support subjective text interpretation. The topic, on the other hand, is a significant element identified by analyzing a given textual content, denotating reference amounts and behavior models present in the discourse, which will contribute to the formulation of thematic units²⁴24. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 13a ed. São Paulo: Hucitec; 2013..

In this sense, the aging and interprofessional education topics, defined as this study’s object, were analyzed in two predetermined recording units: professional competencies and curricular structure. We decided to analyze these topics in both recording units because, according to the National Education Guidelines and Framework Law²⁵25. Presidência da República (BR). Lei 9.394, de 20 de dezembro de 1996. Estabelece as diretrizes e bases da educação nacional [Internet]. Brasília: Casa Civil; 1996 [citado 11 Ago 2017]. Disponível em: http://www.planalto.gov.br/ccivil_03/leis/L9394.htm., the competencies consist on the ability to mobilize, articulate and practice the necessary values, skills and knowledge for the efficient development of the required activities for the job.

Additionally, these competencies can be provided through specific topics in the curricular structure of each education. Therefore, the recording units defined herein that must be included in the pedagogical projects significantly influence each health professional’s knowledge and practice. Data were analyzed from September to November 2016.

Ethical aspects

Since this is a documentation research of public domain documents, it was not necessary to submit the research project for the Research Ethics Committee’s appreciation and opinion, according to the guidelines or Resolutions no. 466/2013 and no. 510/2016 of the National Health Council.

Results

Firstly, some information about the courses and education institutions who took part in this study will be described to facilitate understanding of the results. We identified 70 courses for the 17 professions involved in ESF and NASF. These courses were offered by 16 education institutions, most of them (82%) private. Furthermore, 62% of the total number of education institutions are focused in the metropolitan region of the city of Natal, capital of the state.

It is worth highlighting that 81% of the Nursing courses, 80% of the Pharmacology courses, 83% of the Physiotherapy courses, 86% of the Psychology courses and 81% of the Social Work courses that prepare professionals who comprise the ESF and NASF teams are offered by private institutions. Among all the 70 courses, 57 (81%) of them provided their pedagogical projects for this research.

However, the pedagogical projects of 13 courses (19%) were not analyzed for two reasons: they were not published on the education institution’s web page or the education institutions refused to provide them. Therefore, the pedagogical project of the Arts and Education course (visual arts educator) was not analyzed because the only institution that offers this undergraduate course in the state did not provide the institutional document.

Based on the operationalization of the analyses of the professional competencies and curricular structures described in the pedagogical projects in light of the aging and interprofessional education topics, two analytical categories emerged: uniprofessional education and aging secondarization.

Category 1: uniprofessional education

The professional health education described in the analyzed pedagogical projects is in line with the education model described in the National Curricular Guidelines, aiming at a generalist, humanistic, critical and reflective education of future health professionals, according to the following excerpts:

However, none of the pedagogical projects provide for the development of competencies so that professionals are able to work towards the elderly population’s health needs, particularly regarding interprofessional practice providing comprehensive care and development of autonomy, protagonism and interdependence of the aging subject.

We also noticed none of the courses offer curricular components that deal with aging in an interdisciplinary and interprofessional way, as shown by the following excerpts:

Since the pedagogical projects of the courses mentioned above does not provide for the development of competencies to work in interprofessional elderly healthcare, we believe this justifies the lack of content that enables this development.

In these situations, professional education in elderly healthcare is exclusively based on the assistance of chronic degenerative diseases and on the identification and prevention of health damages. Additionally, this is a uniprofessional education, i.e. isolated among students from the same course.

Category 2: aging secondarization

In some situations, such as in the Community Health Agent Technician and Nursing Technician courses, both from a private institution in the metropolitan region of Natal; Social Work course of a private institution in a city of RN; and Nursing courses of two education institutions (one public and one private) in the metropolitan region of Natal and of one public institution located in a city of RN, the aging and elderly health topics are jointly dealt with other life cycles (children, teenager and adult health).

In other situations, such as in the Medicine course of a public institution in a city of RN; Physiotherapy course of a private institution in the metropolitan region of Natal; and Physiotherapy, Nutrition, Medicine, Psychology and Occupational Therapy courses of another private institution also in the metropolitan region of Natal, the aging and elderly contextualization is reduced to biological and physiological aspects.

Despite this predominance in secondarizing or simplifying the aging discussion, there are curricular components contrary to this mainstream. The pedagogical project of the undergraduate Physiotherapy course of a public institution in the metropolitan region of Natal, for example, has a curricular component called Gerontology. Its main objective is to provide students and future health professionals with a multidimensional understanding of aging. However, this curricular component is not required in the physiotherapist education yet and is uniprofessional.

It is worth highlighting that the education institution mentioned in the previous paragraph also offers the curricular component Health and Citizenship. In this curricular component, undergraduate health students are inserted into primary healthcare services, with or without ESF, in order to understand, through interprofessional education and questioning the pedagogical method, the social demands of the population that uses SUS. However, there is no discussion of aging-related issues.

Another example refers to the Medicine course in the city of Caicó, in RN. Its curricular structure is organized by knowledge nuclei made up of different curricular components. Among these knowledge nuclei, there is one specific to elderly healthcare called Geriatrics.

This nucleus covers physiological, epidemiological and social issues of the aging and demographic transition processes experienced in Brazil. It also covers the topic related to the elderly population’s health promotion, but uniprofessionally.

Discussion

In health work, professional education is a permanent discussion. From 1990 to 2010, for example, most of the scientific productions (71.2%) related to work and education in health were related to the qualification of human resources to work in SUS²⁶26. Pinto ICM, Esperidião MA, Silva IV, Soares CM, Santos L, Fagundes TLQ, et al. Trabalho e educação em saúde no Brasil: tendências da produção científica entre 1990 - 2010. Cienc Saude Colet. 2013; 18(6):1525-34.. Besides the scientific production, we can also observe a relative expansion in health professional education courses in the Brazilian educational system²⁷27. Teixeira CF, Coelho MTAD, Rocha MND. Bacharelado interdisciplinar: uma proposta inovadora na educação superior em saúde no Brasil. Cienc Saude Colet. 2013; 16(6):1635-46..

However, the regional concentration of health teaching institutions, particularly in metropolitan regions, as well as the disorderly proliferation of courses, mostly higher education ones, has resulted in the education of professionals with an inadequate profile to provide support to the population’s health needs²⁸28. Pierantoni CR, França T, Magnago C, Nascimento DN, Miranda RG. Graduações em saúde no Brasil: 2000-2010. Rio de Janeiro: IMS, UERJ; 2012.. Health teaching institutions tend to hypervalue specific areas, limiting the education of professionals to specific knowledge, without acknowledging the health needs’ scope and complexity⁶6. Peduzzi M. O SUS é interprofissional. Interface (Botucatu). 2016; 20(56):199-201.. In this sense, a great challenge to the National Policy for Health Work and Education Management emerges: strengthening the dialog between education institutions and health services in order to provide an interprofessional education according to social transformations and SUS’ demands^9,29.

The gap in the interaction between health and education is even bigger when the relationship between elderly health and professional education is highlighted. On the one hand, a strong dependence of elderly people on health services, particularly of long-lived elderly (≥ eighty years old), is evidenced. In the current scenario, they represent the age range that grows the most among the elderly population³⁰30. Menezes TMO, Lopes RLM. Significados do vivido pela pessoa idosa longeva no processo de morte/morrer e luto. Cienc Saude Colet. 2014; 19(8):3309-16..

This dependence tends to increase in the next years³¹31. Veras RP. Envelhecimento populacional e as informações de saúde do PNAD: demandas e desafios contemporâneos. 2007; 23(10):2463-6., resulting from the demographic transition process occurring not only in Brazil but also in other developing countries, such as Russia, India and China, particularly in a context of significant social inequality^32,33. On the other hand, in the health courses’ pedagogical projects, contextualization of the human aging process is still not significant. It is uniprofessional and often incoherent with professional practice.

Professional health education plays an important role in society, considering students of the existing courses will be future workers who will provide healthcare to the population³⁴34. Ribeiro IL, Medeiros Júnior A. Graduação em saúde, uma reflexão sobre ensino-aprendizado. Trab Educ Saude. 2016; 14(1):33-53.. Consequently, elderly healthcare requires specific competencies to contextualize the aging process and the development of interprofessional work³⁵35. Lima RRT, Castro JL, Lima KC. Saúde do idoso e formação profissional: como ocorre essa relação em uma instituição de ensino superior? Saude Redes. 2016; 2(1):1287-9..

In this sense, integrating the teaching process into the daily health service routine, particularly in primary care, is necessary to increasingly align professional practice to the population’s needs, in this case, the elderly population’s health needs. Besides integrating teaching and service into an aging-based health education, ensuring the development of interprofessional work and teaching practices is also necessary. In order to improve elderly care, it is necessary to trust the interprofessional teams’ power⁸8. Arruda LS, Moreira COF. Colaboração interprofissional: um estudo de caso sobre os profissionais do Núcleo de Atenção ao Idoso da Universidade Estadual do Rio de Janeiro (NAI/UERJ), Brasil. Interface (Botucatu). 2018; 22(64):199-210..

However, none of the courses investigated in this study contemplates a deeper discussion related to the aging topic in an interprofessional way. This fact can be connected to the education institutions’ disruption with the social dynamics and consequently with the health services’ dynamics, as well as to the teachers’ lack of interest in changing their teaching practices.

Teachers’ awareness to develop competencies incorporated into the elderly population’s health in the future health workforce education in the United States, for example, is still a critical node³⁶36. Ford CR, Brown CJ, Sawyer P, Rothrock AG, Ritchie CS. Advancing geriatric education: development of an interprofessional program for health care faculty. Gerontol Geriatr Educ. 2015; 36(4):365-83.. However, in order to confirm if this situation is similar to the Brazilian reality and that of the place where this study was held, it is necessary to conduct other researches to extrapolate the documentation analysis, assessing the perception of students and teachers on the pedagogical methods used in professional education focused on aging. Investigating the perception of elderly people regarding care provided by health professionals who work in SUS is also necessary.

In order to avoid elderly healthcare from being restricted and endowed with stigmas and prejudices against aging, it is necessary to encourage changes in the educational model³⁷37. Golden GM, Gammonley D, Hunt D, Olsen E, Issenberg B. The atitudes of graduate healthcare students toward older adults, personal aging, health care reform, and interprofessional collaboration. J Interprof Care. 2014; 28(1):40-4.. This change should be based on interprofessional education focused on comprehensive care and active aging, so that professionals are multiplier agents and encourage elderly people to live an autonomous, independent and participatory life³⁸38. Lima KC. Educação em saúde para o envelhecimento ativo. In: Nacif PGS, Queiroz AC, Gomes LM, Rocha RG, organizadores. Coletânea de textos CONFINTEA Brasil+6: tema central e oficinas temáticas. Brasília: Ministério da Educação; 2016. p. 252-8..

Therefore, it is necessary to implement mandatory curricular components in the education of health professionals, which discuss aging interprofessionally. This curricular components should be based on the understanding of a broader dimension on human aging, involving economic and social aspects, not only curing diseases.

Non-compliance with these requirements will result in the continuity of this health work fragmentation, being increasingly divergent from what is recommended by health policies in Brazil. Among these policies, the National Health Policy for the Elderly establishes that elderly healthcare should follow SUS’ principles and be organized by ESF and NASF in order to comply with this population’s needs³⁹39. Uchimura KY, Bosi MLM. Habilidades e competências entre trabalhadores da Estratégia Saúde da Família. Interface (Botucatu). 2012; 16(40):149-60..

Final remarks

Even being limited to the curricular content, this research evidenced that uniprofessional education is a prevailing reality in the investigated courses, where students are inserted in an education model that does not contribute to the changes required by elderly healthcare. However, the research indicates important elements for a critical reflection and to build a permanent agenda that enables changes in the way aging is approached in the education of professionals inserted in the ESF and NASF teams. This approach must be interprofessional and consider the social aspects underlying the aging process under the perspective of comprehensive care and collaborative work.

Curricular transformations are only one step to achieve the desired professional profile in elderly healthcare, since they influence but do not determine how practices occur. The concluding study shows the need to mobilize agents from education institutions and health services to discuss and collectively build pedagogical projects that promote the education of health professionals in light of an active aging, interprofessional education and SUS’ principles.

Finally, due to the growing increase in the Brazilian elderly population that can consequently result in an increase of this age group in SUS’ services, if the elderly population’s peculiarities are not duly understood and broadly discussed in the education and practice of health professionals, it will not be possible to ensure a comprehensive care to elderly people.

Acknowledgements

We would like to thank the education institutions of the state of Rio Grande do Norte for providing the pedagogical projects for this study.

References

Publication Dates

History