Abstract

Introduction

Uruguay implemented the Equity Plan in 2008 with the purpose of ensuring the exercise of citizens’s rights and especially those in a situation of socio-economic vulnerability¹1. Presidencia de la Republica. Plan de equidad [Internet]. Montevideo: Ministerio de Desarrollo Social; 2008 [citado 3 Feb 2019]. Disponible: http://www.mides.gub.uy/innovaportal/file/913/1/plan_equidad_def.pdf .
http://www.mides.gub.uy/innovaportal/fil... , ²2. Ministerio de Desarrollo Social. Dirección Nacional de Evaluación y Monitoreo. División Evaluación. Programa Uruguay Trabaja. Edición 2009. Resultados Evaluación. Informe Final. Montevideo: Ministerio de Desarrollo Social; 2011. .

The Equity Plan intended to weave a social assistance and integration network through the definition of policies associated with protected work, including the Uruguay Trabaja (UT) Program, seeking to contribute to social integration through socio-educational strategies and improvement of their employability³3. Ministerio de Desarrollo Social. Programa Uruguay Trabaja, dirección de trabajo ciudadano. Montevideo: Publicación MIDES; 2009. . It is a time-limited program (9 months) aimed at people over 18 years old who have been unemployed for a long time, without complete basic secondary education, belonging to households living in extreme poverty measured by the index of critical needs⁴4. Amarante V, Arim R, Vigorito A. Metodología para la selección de participantes en el Plan de Atención Nacional a la Emergencia Social. Montevideo: Ministerio de Desarrollo Social; 2005. . Participants must perform 30 hours of temporary work activities with social value and training, receiving an approximate amount of US $ 112 per month.

The incorporation of dental care in the program was defined due to its possible impact in overcoming barriers to the inclusion of people in the labor market, a topic still lacking sufficient evidence⁵5. Shingal S, Correa R, Quiñonez C. The impact of dental treatment on employment outcomes: a systematic review. Health Pol. 2013; 109:88-96. , ⁶6. Singhal S, Mamdani M, Mitchell A, Tenenbaum H, Quiñonez C. An exploratory pilot study to asses self-perceived changes among social assistence recipients regarding employment prospects after receiving dental treatment. BMC Oral Health. 2015; 15:138. . Oral health care is broader than the one proposed by the comprehensive benefit program (PIAS) for adult users of the National Integrated Health System⁷7. Intendencia de Montevideo. Programa de Salud Bucal. Acuerdos de trabajo Programa Uruguay Trabaja. Montevideo; 2012. . Participants receive social support from leaders of Civil Society Organizations (CSOs) that operationalize the policy, manage the access of participants to the benefits of the program and link with dentists.

Dental care can be provided in municipal health services in Montevideo near their homes or workplaces. The weekly attention outside working hours has no direct cost to the users. The Ministry of Social Development funds it on a per capita basis, being carried out during the annual edition of the program.

Despite the fact that the program offers the opportunity of a wider range of dental services, 30% of people abandon dental treatment⁸8. Blanco S. Motivos de abandono ao tratamento odontológico nos indivíduos que participam do programa “Uruguay Trabaja”, Montevideu, 2008-2012 [tese]. Rio Grande do Sul: Universidade Federal do Rio Grande do Sul; 2012. .

Different authors in the literature seek to explain the reasons for dropping out dental treatment: personal situations (family, pregnancy, diseases)⁹9. Curtis B, Evans RW, Sbaraini A, Schwarz E. Geographic location and indirect costs as a barrier to dental treatment: a patient perspective. Aust Dent J. 2007; 52(4):271-5. , ¹⁰10. Skaret E, Raadal M, Kvale G, Berg E. Factors related to missed and cancelled dental appointments among adolescents in Norway. Eur J Oral Sci. 2000; 108(3):175-83. ; forgetting appointments¹¹11. Ferreira MB, Lopez AC, Lion MT, Lima DC, Nogueira DA, Pereira AA. Absenteismo em consultas odontológicas programáticas na estratégia saúde da família. Rev Univ Vale do Rio Verde. 2016; 14(1):411-9.

12. Almeida GL, Garcia LFR, Almeida TL, Bittar TO, Pereira AC. Estudo do perfil socioeconômico dos pacientes e os motivos que os levaram a faltar em consultas odontológicas na estratégia de saúde da família em uma distrital de Ribeirão Preto /SP. Cienc Odontol Bras. 2009; 12(1):77-86. - ¹³13. Melo ACBV, Braga CC, Forte FDS. Acessibilidade ao serviço de saúde bucal na atenção básica: desvelando o absenteísmo em uma Unidade de Saúde da Família de João Pessoa - PB. Rev Bras Cienc Saude. 2011; 15(3):309-18. ; time (duration of treatment, transfers, coincidence with work schedule)¹⁴14. Gonçalves CA, Vazquez FL, Ambrosano GMB, Mialhe FL, Pereira AC, Sarracini KLM, et al. Estratégias para o enfrentamento do absentismo em consultas odontológicas nas Unidades de Saúde da Família de um município de grande porte: uma pesquisa-ação. Cienc Saude Colet. 2015; 20(2):449-60.

15. Lahti S, Hausen HW, Vaskilampi T. The perceptions of users about barriers to use of free systematic oral care among Finish pre-school children – a qualitative study. Acta Odontol Scand. 1999; 57(3):139-43. - ¹⁶16. Rocha C, Bercht S. Estudo do abandono do tratamento odontológico em um serviço publico de Porto Alegre: o Centro de Saúde Murialdo. Rev Fac Odontol Porto Alegre. 2000; 42(2):25-31. ; fear, previous frustrating experiences, poor relationship with professionals¹⁷17. Albuquerque O, Abegg C, Rodrigues CS. Percepção de gestantes do Programa Saúde da Família em relação a barreiras no atendimento odontológico em Pernambuco, Brasil. Cad Saude Publica. 2004; 20(3):789-96. , ¹⁸18. Bedos C, Brodeur JM, Levine A, Boucheron L, Richard L, Benigeri M, et al. The dental care pathway of welfare recipients in Quebec. Soc Sci Med. 2003; 57(11):2089-99. ; factors related to organization of services¹⁹19. Marshman Z, Porritt J, Dyer T, Wyborn C, Godson J, Baker S. What influences the use of dental services by adults in the UK? Community Dent Oral Epidemiol. 2012; 40(4):306-14. , ²⁰20. Daly B, Newton TJ, Batchelor P. Patterns of dental service use among homeless people using a targeted service. J Public Health Dent. 2010; 70(1):45-51. ; costs²¹21. Molarius A, Engström S, Flink H, Simonsson B, Tegelberg A. Socioeconomic differences in self-rated oral health and dental care utilisation after the dental care reform in 2008 in Sweden. BMC Oral Health. 2014; 14:134.

22. Locker D, Maggirias J, Quiñonez C. Income, dental insurance coverage, and financial barriers to dental care among Canadian adults. J Public Health Dent. 2011; 71(4):327-34. - ²³23. Roberts-Thompson KF, Stewart J, Giang Do L. A longitudinal study of the relative importance of factors related to use of services among young adults. Community Dent Oral Epidemiol. 2011; 39(3):268-75. ; but they do not approach the phenomenon of abandonment as a contextualized social practice.

Due to the importance of dental care for participants’ social integration, the objective of this study was to analyze the phenomenon of abandoning the dental treatment that affects the individuals participating in UT Montevideo - 2010-2012 editions, from the perspective of its referents and participants.

The phenomenon of abandonment will be analyzed from the theoretical contributions of Bourdieu’s constructivist structuralism, particularly the concept of habitus; framed in a comprehensive view of the social world. The protagonists of UT as social agents occupy positions (depending on their available capitals) in the system of social world relations. They develop practices in relation to oral health care, which are part of an experienced and incorporated history regarding the conditions of their existence. The concept of habitus allows us to think up to what extent the new healthcare practices can be incorporated as action strategies by UT participants during the program²⁴24. Bourdieu P. Cosas dichas. Barcelona: Gedisa; 1993. , ²⁵25. Bourdieu P. El sentido práctico. Madrid: Taurus; 1980. .

Castel’s theoretical contributions are also used, as they relate to the individualization of social protection trends, developed in France by international organizations that were later replicated in Latin America, through temporary focused programs aiming towards social insertion objectives²⁶26. Castel R. El ascenso de las incertidumbres. Trabajo, protecciones, estatuto del individuo. Buenos Aires: Fondo de Cultura Económica; 2010.

27. Castel R. La inseguridad social. ¿Qué es estar protegido? Buenos Aires: Manantiales; 2004. - ²⁸28. Castel R. La metamorfosis de la cuestión social. Una crónica del asalariado. Buenos Aires: Paidos; 1997. .

Methodology

The present work assumes the modality of a case study, using a qualitative approach whose object of research is the UT dental care program as it was carried out in municipal health centers.

The data collection was developed in two moments: 1. Identification of the universe of persons who dropped out from dental care, using the reports of the care providers and the CSOs that participated during the study period (2010-2012); 2. Performing interviews with participants and referents.

In order to select the participants to be interviewed, it was created a data bank of the people (n = 693) that was part of the 2010-2012 editions of UT. The study then filtered the data bank to select the people who dropped out (n = 340). Since the program editions are developed annually, the ‘abandonment situation’ was conceptualized when a person received assistance at least once and did not continue the treatment until the beginning of the next group. The sample selection of the interviewees was randomly carried out from the abandonment data bank, identifying a ‘typical case’ characterized by belonging to any of the program’s editions, being a woman and of the oldest age group.

Those CSOs who had participated in UT were selected, choosing the referents that should have performed the follow-up of protagonists in at least one of the program’s editions (n = 27).

The interviews were conducted by one researcher, following a pre-tested pattern ( Chart 1 ).

An active and methodical listening was carried out during the interviews²⁹29. Bourdieu P. La miseria del mundo. Buenos Aires: FCE; 1999. . We conducted ten interviews with the participants (eight in their homes and two in private rooms inside the health services). The interviews of seventeen referents were carried out inside health facilities, while the rest was done in the referents’ workplace.

The size of the samples was defined using the saturation criterion, when the narrative contents of the subjects supplies scarce additional input to the objectives proposed in the research, becoming repetitive³⁰30. Turato ER. Tratado de metodologia da pesquisa clínico-qualitativa: construção teórico-epistemológica, discussão comparada e aplicação nas áreas da saúde e humanas. 3a ed. Petrópolis, RJ: Vozes; 2008. .

Regarding the record of communications, it was carried out a systematic, repeated, exhaustive and fluctuating reading of the contents of the interviews of the participants and the referents as well as a content analysis based on Bardin, including the stages of pre-analysis, exploration of the material, treatment of results and interpretation³¹31. Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011. .

The study was approved by the Research Ethics Committee of the Faculty of Dentistry of the University of the Republic (091900/000270/10) and by the Research Committee of the Faculty of Dentistry (COMPESQ / FO) of the Federal University of Rio Grande do Sul (UFRGS).

Results and discussion

From the analysis of the interviews, three emerging categories were organized to understand the phenomenon of abandonment ( Chart 2 ).

The abandonment of the treatment associated with UT Program

UT is a demanding program. For 9 months, protagonists must reorganize their daily lives by incorporating workdays of 6 hours plus dental care. The participants, mostly women (70%), are responsible for caring for their families. Family chores are essentially unpaid female activities (14 hours per week for child care). This has relevant gender consequences, because when female members of the families are the main providers of well-being, they must either exclude themselves from the labor market, or face greater difficulties than their male counterparts in reconciling productive and reproductive work³²32. Aguirre R. El futuro del cuidado. In: Arriagada I, editor. Futuro de las familias y desafíos para las políticas. Santiago de Chile: NU-Cepal; 2008.

33. Batthyány K, Genta N, Perotta V. El aporte de las familias y las mujeres al cuidado no remunerado de la salud en el Uruguay. Santiago de Chile: CEPAL; 2015. (Serie Asuntos de Género n° 127). - ³⁴34. Batthyány K. Género, cuidados familiares y uso del tiempo [Internet]. Montevideo: Departamento de Sociología, Facultad de Ciencias Sociales, Universidad de la República; 2013 [citado 3 Feb 2019]. p. 177-98. Disponible: http://cienciassociales.edu.uy/departamentodesociologia/wp-content/uploads/sites/3/2013/archivos/Karina%20Batthy%C3%A1ny%20G%C3%A9nero,%20cuidados%20familiares%20y%20uso%20del%20tiempo.pdf .
http://cienciassociales.edu.uy/departame... .

Family tasks cause absenteeism to dental care appointments. The abandonment is a process developed upon from the repeated absences and one of the tasks of the referents is to be attentive to their motives.

The program imposes a new pivotal time organization representing the work whose “... temporary requirements and priorities sacrifice the rest of social activities”³⁵35. Torre RR. Discursos sociales del tiempo [Internet]. Madrid: Universidad Complutense de Madrid; 2003 [citado 3 Feb 2019]. Disponible: http://www.ucm.es/data/cont/docs/183-2013-05-10-Ram%C3%B3n%20Ramos%20Torre.pdf
http://www.ucm.es/data/cont/docs/183-201... . Given the oral clinical situation, the average number of consultations is 12 sessions per participant; “programmed dental care” requires long-term commitments, confirming the need to overcome day-to-day survival strategies³⁶36. Berger P, Luckmann T. La construcción social de la realidad. Madrid: Amorrortu Ediciones; 2011. .

During the job searching workshops in the course of the program, the referents point out the importance of dental care for the improvement of employability.

It is not easy to include the assistance in the life projects that are promoted. Sometimes the time available to deploy the processes of reflection and creation of habits and competences, of secondary socialization or “asocial sociability” as the Castel denominates it (relational configurations “more or less evanescent” that are registered intermittently or temporarily in the institutions and that place the subjects in “weightlessness situation”) are not enough²⁸28. Castel R. La metamorfosis de la cuestión social. Una crónica del asalariado. Buenos Aires: Paidos; 1997. . Sometimes people end up incorporating them only once the program has finished.

The abandonment associated with dentists

Once in the services, the patient-professional relationship is put into play. The previous bond has been frequently specific for pain relief, or diagnosis for the compulsory health card, evidencing the power of the profession to decide aspects of labor insertion, but not to solve the problems that are detected.

In Uruguay it is demanded to have a ‘clean’ mouth (as a criterion of normality) to obtain a 2-year health card (Law 9696, Decree 651/90). When restoration is not accessible, the way of cleaning the mouth is extraction. The model of attention generates a mutilation and does not repair it. The dentists are invested as arbiters of health for the working class, based on their qualified knowledge, building a concrete power over people’s life, ordering what they should do as part of the medicalization processes of modern society in which the State “Sees, announces, but does not intervene”³⁷37. Foucault M. Historia de la medicalización. Educación Médica y Salud. 1977; 11(1):3-25.

38. Foucault M. La crisis de la medicina o la crisis de la antimedicina. Educ Med Salud. 1976; 10(2):152-69. - ³⁹39. Foucault M. El nacimiento de la clínica: una arqueología de la mirada médica. Perujo F, traductor. 3a ed. México: Editorial Siglo XXI; 1989. . In a broad sense, medicalization of social life is understood as the extension of the domain in which medicine happens to intervene, and which in the past exhibited a degree of exteriority with respect to its interference⁴⁰40. Mitjavila M. Espacio político y espacio técnico: las funciones sociales de la medicalización. Cuad CLAEH. 1992; (62):37-45. , ⁴¹41. Portillo J. La medicina: el imperio de lo efímero. In: Portillo J, Rodríguez J. La medicalización de la sociedad. Montevideo: Nordan editorial; 1993. p. 17-36. . Dentistry (as part of medicine) is then also a biopolitical strategy of the modern State⁴²42. Murguia A, Ordorika T, Lendo LF. The study of processes of medicalization in Latin America. Hist Cienc Saude Manguinhos. 2016; 23(3):635-51. .

Although the dentists in UT put on hold their traditional role of exclusively relieving pain and mutilating, the new situation carries with it the prejudices of the participants and the professionals in the consultation. Among the dropouts, there is distrust of the professionals when they are young, because they do not have enough experience, or when they are women because they are not strong enough.

The professional role is based on the confidence of patients, and although “reliability” is given to the abstract system of dental care, the flesh-and-bone potentially fallible individuals represent them, those who operate in it and in them it is necessary to trust upon⁴³43. Saliba NA, Nayme JGR, Moymaz SAS, Cecilio LPP, Garbin CAS. Organização da demanda de um Centro de Especialidades Odontológicas. Rev Odontol UNESP. 2013; 42(5):317-23. .

Additionally, women-dentist carry the gender biases derived from the remnants of a clinical practice focused on extractions for adults performed by a man-dentist and using force (a traditionally masculine attribute). Since the clinical practice is more conservative and the workforce is mostly femenine, the changes that may be generated in the exercise and in professional social representations have not yet been sufficiently examined⁴⁴44. Inglehart MR. Interactions between patients and dental care providers: does gender matter? Dent Clin North Am. 2013; 57(2):357-70. , ⁴⁵45. Mackay JC, Quiñonez CR. The feminization of dentistry: implications for the profession. J Can Dent Assoc. 2012; 78:1-7. .

The dentists have biases in their care process, related to the participants’ social status. A referent affirms: ... there is a “hidden” situation of prejudice, “you arrived in this state and ... now you are worried because I have to care for you” (R10).

The moralizing attitude can be an expression of the authority of professional power that some dentists may particularly feel when they treat the poorest populations. This is expressed as a correction of behavior deviated from the central value of health and is based on the social legitimacy of their actions as health professionals⁴⁶46. Mitjavila M. El saber médico y la medicalización del espacio social. Montevideo: Universidad de la República; 1998. .

When dentists understand poverty as an individual characteristic depending on personal responsibility of the poor, and not from a structural perspective, they have less empathy with patients⁴⁷47. Loignon C, Landry A, Allison P, Richard L, Bedos C. How do dentists perceive poverty and people on social assistance? A qualitative study conducted in Montreal, Canada. J Dent Educ. 2012; 76(5):545-52. . Dentists can experience caring in poor areas with high levels of frustration and impotence because there are procedures that the system will not cover, because they are not lucrative or because of organizational difficulties due to the patients’ absenteeism⁴⁸48. Bedos C, Loignon C, Landry A, Richard L, Allison PJ. Providing care to people on social assistance: how dentists in Montreal, Canada, respond to organisational, biomedical, and financial challenges. BMC Health Serv Res. 2014; 14:1-9. , something that may generate lower quality assistance⁴⁹49. Harris RV. Do poor areas get the services they deserve? The role of dental services in strucutral inequalities in oral health. Community Dent Health. 2016; 33(2):164-7. , ⁵⁰50. Pourat N, Andersen RM, Marcus M. Assesing the contribution of the dental care delivery system to oral health care disparities. J Public Helth Dent. 2015; 75(1):1-9. or even exclusion strategies⁵¹51. Pegon–Machat E, Tubert-Jeannin S, Loignon C, Landry A, Bedos C. Dentist experience benefiting from a public insurance program. Eur J Oral Sci. 2009; 117(4):398-406. .

The protagonists bring explanations of the world and knowledge that constitute the bases that guide their expectations. The expectations may be different from those proposed by professionals, especially from more normative positions.

This new role requires professional vocational care and listening, strengthening the soft technologies of the management of health services⁵²52. Costa CB. Saúde bucal na estratégia de saúde da família: avanços e desafios na produção do cuidado odontológico [dissertação]. Florianópolis: Universidade Federal de Santa Catarina; 2015.

53. Pinheiro PM, Oliveira LCD. A contribuição do acolhimento e do vínculo na humanização da prática do cirurgião-dentista no Programa Saúde da Família. Interface (Botucatu). 2011; 15(36):185-98.

54. Franco TB, Merhy EE. El reconocimiento de la producción subjetiva del cuidado. Salud Colect. 2011; 7(1):9-20. - ⁵⁵55. Teixeira MCB. A dimensão cuidadora do trabalho de equipe em saúde e sua contribuição para a odontologia. Cienc Saude Colet. 2006; 11(1):45-51. . Having a good relationship with professionals is very important for the participants; receiving orders, not being recognized or listened to, generates limitations to establish a bond that facilitates the continuity of assistance.

Many times, a strategy that allows coping with the situation consists in the support of the groupmates that offers the contention to sustain an unknown experience. “But, OK, it was good, because if you’re waiting, waiting with a partner becomes more ... bearable” (P9).

These attitudes contribute to develop forms of recognition and mutual pride that enhance the solidarity of the group⁵⁶56. Honneth A. La lucha por el reconocimiento. Barcelona: Grijalbo Mondadori; 1997. .

Dialogue is needed to agree upon both the treatment plan and schedule. The participants should have the possibility to state what they consider best for their lives, for example, when the patient prefers an extraction, while the dentist does not, or vice versa.

The texts of the participants reflect the tension resulting from the encounter between professional knowledge and patient’s freedom. It is necessary to overcome the paternalistic model by a decision model already enshrined in Uruguayan legislation, which places the patients as agents with rights, as well as a broad autonomous decision-making capacity over the diagnostic and therapeutic procedures offered to them⁵⁷57. Lázaro J, Gracia D. La relación médico-enfermo a través de la historia. An Sist Sanit Navar. 2006; 29(3):7-17. , ⁵⁸58. Sáenz SJ. Perspectivas en la relación odontólogo-paciente: un vínculo entre personas. Rev Fac Odontol Univ Nac Cuyo. 2013; 7:2-18. .

The model of medicalization produces a conversion of health problems into strictly political problems related to public hygiene through the revaluation of the body (as workforce) and moralization, as a social control of deviance. “Medicine” [and in this case dentistry] appears “as an instituted and instituting space for broader social relationships”⁵⁹59. Ortega E. El servicio social y los procesos de medicalización de la sociedad uruguaya en el período neobattlista. Montevideo: Trilce; 2008. (p.28) that are not directly related to the disease and its healing process or management of the disease. According to Menéndez⁶⁰60. Menéndez E. Relaciones sociales de cura y control. Notas sobre el desarrollo del modelo médico hegemónico. Rev Paraguaya Sociol. 1984; 21(61):153-70. , “the process of medicalization involved the ideological and technical appropriation of the health/disease processes and their constant application to new forms of social behavior”(p.165). This phenomenon generated “a split between medical knowledge and popular knowledge”, legitimizing health control⁵⁹59. Ortega E. El servicio social y los procesos de medicalización de la sociedad uruguaya en el período neobattlista. Montevideo: Trilce; 2008. (p. 28).

This encounter between dentists and patients can be an opportunity to develop a “live” professional work process (creative and innovative) that surpasses the forms of work oriented exclusively by a productive and mechanistic management⁶¹61. Lazzarato M, Negri A. Trabalho imaterial: formas de vida e subjetividade. Rio de Janeiro: DP & A; 2001. , ⁶²62. Lazzarato M. Políticas del acontecimiento. Buenos Aires: Tinta Limón; 2006. .

The abandonment of the treatment associated with the socialization process

The daily routine of the participants and the disagreement with the professionals can activate a process of distancing from the dental services that the participants call “abstaining from doing” (P5). When consulted, they recognize that oral health care was not a priority during their childhood.

There is evidence that early childhood is a sensitive period and that it influences health trajectories throughout life⁶³63. Heilmann A, Tsakos G, Watt RG. Oral health over the life course. In: Burton-Jeangros C, Cullati S, Sacker A, Blane D, organizadores. A life course perspective on health trajectories and transitions [Internet]. Cham: Springer; 2015 [citado 3 Feb 2019]. p. 39-59. Disponible: https://www.ncbi.nlm.nih.gov/books/NBK385369/
https://www.ncbi.nlm.nih.gov/books/NBK38...

64. Marmot M, Bell R. Social determinants and dental health. Adv Dent Res. 2011; 23(2):201-6. - ⁶⁵65. Listl S, Watt RG, Tsakos G. Early life conditions, adverse life events, and chewing ability at middle and later adulthood. Am J Public Health. 2014; 104(5):55-61. .

During the process of “primary socialization”, the family as a significant group mediates the social world both from a cognitive and emotional point of view, guiding attitudes - among them those referring to oral health - that will reflect the identity of that individual³⁶36. Berger P, Luckmann T. La construcción social de la realidad. Madrid: Amorrortu Ediciones; 2011. .

The participants recognize how the deterioration of the mouth can interfere in their relationship with others, albeit being necessary to differentiate to which “others” they relate. The referents warn that in the closer environment where the participants move, and even in the informal jobs they can get, oral health does not represent a problem for the person, since the process of primary socialization occurs not only from the family perspective with an “idiosyncratic coloration”, but from the broader perspective of the class to which the family belongs³⁶36. Berger P, Luckmann T. La construcción social de la realidad. Madrid: Amorrortu Ediciones; 2011. . With “certain others” such as teachers, technicians, persons from less closer social circles, the appearance can be perceived as a lack or limitation to the exchange. According to the referents, this duality must be worked on “and it must be made explicit” (R2).

It is as part of the processes of secondary socialization that new attitudes are produced and reproduced. This process of internalizing new institutional sub-worlds leads to opening to the family world, although strong biographical impacts will be needed in order to disintegrate reality as it was internalized in childhood³⁶36. Berger P, Luckmann T. La construcción social de la realidad. Madrid: Amorrortu Ediciones; 2011. . In the institutional world as presented by the referents, oral health can assume new meanings and produce a shift and a commitment to this reality, incorporating new attitudes.

In the broader social space, oral health conditions mean that the protagonists often do not smile or hide and must manage the tension that is generated in social contacts, avoiding being discredited. To be discovered, or its possibility, discourages them.

In different social spaces, stigmatization may arise. People, knowing that they may be subject to a subsequent discredit, try to hide what discredits their own image in public life (concealment) and internally feel marked and ashamed by these stereotypes⁶⁶66. Goffman E. Estigma. La identidad deteriorada. Buenos Aires: Amorrortu; 2001. .

The body, marked by the status of the mouth, places people in the hierarchy of classes, being a sign of their status, perhaps the most intimate - that cannot be dissociated from the person who inhabits it⁶⁷67. Boltanski L. As classes sociais e o corpo. 2a ed. Rio de Janeiro: Geral; 1984. and, as the referents say: “it reflects how life has treated them “(R14).

This body-made-history constitutes the habitus, defined by Bourdieu²⁴24. Bourdieu P. Cosas dichas. Barcelona: Gedisa; 1993. as the matrix of the world is perceived, conditioning the repertoire of the individual’s practices and explaining the behaviors of the UT participants in relation to their possibilities of attending to and sustaining dental care.

The mouth, as a physical crossroads of the body, produces and reproduces practices, combining functions and forms in the diet (what to eat and drink, the way of eating, the time to eat), in the aesthetics (tastes, flavors, beauty) in the expression of affection (smiling, kissing), hygiene and care⁶⁸68. Bourdieu P. Respuestas: por una antropología reflexiva. México: Grijalbo; 1995. . The differentiated forms of consumption (whether in terms of hygiene or personal care) originated by the position in the economic space adjust the aspirations to objective opportunities, with the conviction that they will not have more than they deserve²⁹29. Bourdieu P. La miseria del mundo. Buenos Aires: FCE; 1999. .

There are unthinkable practices, perceived as they were excluded from their life.

The habitus tends to guarantee conformity with the practices that are usually experimented. This built-in history, the basis from which reasonable practices are produced, gives persistence and predictability to social life. This could explain the lack of mobilization by something that they believe it does not belong to them. For example, health check-ups, appearing only as a standard to be complied with, emanated from professional discourse.

According to Boltanski⁶⁷67. Boltanski L. As classes sociais e o corpo. 2a ed. Rio de Janeiro: Geral; 1984. the members of the lower classes do not pay attention to their bodies, expecting mainly that the body should function. For the upper classes the disease is inscribed in time and can adopt a preventative attitude, willing to submit themselves to rules that seek to preserve them from the disease. In the lower classes, the immediateness in the management of time can lead to “energetic remedies” such as tooth extraction, (perhaps painful, but immediately attenuating the suffering) that can be the solution to their problems. The idea of prevention, in short, is based on a problematization of the future (notion of risk) that does not coincide with the immediateness of their lives⁶⁹69. Bentura C. La sutil y aparente “ingenuidad” del concepto de riesgo en el campo de la salud. Rev Fronteras. 2009; 5:21-34. .

However, the habitus, despite being socially conditioned, is not immutable, but rather an open system of dispositions that can be affected by new experiences. The encounter with other social fields generates a practical sense that, as a strategy, allows adapting using personal creativity, to new experiences. One of those experiences is the passage through the UT groups.

Final considerations

The phenomenon of dropout is analyzed in the context of the UT program. In this context some people manage to reach the dental discharge stage while others do not.

We must recognize that much is asked for a 9-months period. The achievements obtained during the course of the accompaniment of the CSOs are fundamental, because UT in dentistry generates competencies that are basically valid during the course of the program. Before UT people did not develop them, not out of negligence, but because that type of care was not available; and once the policy is finalized, these competencies will again disappear within the framework of the universal care provided by the public sector.

To be exposed to new circumstances by the program allowed some protagonists to modify their practices in oral health stemming from self-reflective work, experimented together with their partners, acknowledged by the members and the referents of the group.

Oral care is an opportunity. But there are times when people cannot take advantage of the opportunities because, as stated in the interviews, there are other more urgent priorities such as the survival of the family and children. Lives are complicated, bonding with dentists is weak, or the adaptation to the program process is not enough as it goes against the weight of history and the present of poverty. In that way, part of this population, the most vulnerable, the unemployed, subject to individualized protections, abandon care or just give up, remaining abandoned by the State without social protection once the program ends.

Participants access a transitory right of assistance within a program that pretends to address rights. In order to transform the participants in truly holders of rights, a mechanism must be created that guarantees a transition, a bridge towards dental care in the health sector that provides them with comprehensive benefits once the promoted employment assistance program has been completed. It must also have the necessary breadth to respect that right that today does not integrate the universal policy of the National Integrated Health System, as far as dentistry is concerned.

Social integration is more than coordination and articulation of resources as it involves changes and transformations of public policies and structures of the system, in particular of the health system.

The universal health matrix should receive people after they transit through social programs, and it should process and respond in quantity and quality to their needs in oral health. It is this one of the political-healthcare problems that this work show as needing to be addressed by the State.

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