Abstract

Introduction

Adolescence, a social construction of our culture, corresponds to a dynamic phase of human development between childhood and adulthood that is variable, even among reference sources ¹1. Secretaria da Saúde do Estado São Paulo. Linha de cuidado para a saúde na adolescência e juventude para o Sistema Único de Saúde no Estado de São Paulo [Internet]. São Paulo: Secretaria de Estado de Saúde; 2018 [citado 25 Jun 2019]. Disponível em: https://cebrap.org.br/wp-content/uploads/2018/11/Linha-de-Cuidado-Adolescencia-Juventude-SUS-SP-1.pdf
https://cebrap.org.br/wp-content/uploads... . According to the World Health Organization ²2. World Health Organization. Adolescent health [Internet]. Genebra: Who; 2019 [citado 30 Jun 2019]. Disponível em: http://www.who.int/topics/adolescent_health/en/
http://www.who.int/topics/adolescent_hea... , adolescence encompasses the age range from ten to 19 years. Correspondingly, the Ministry of Health ³3. Brasil. Ministério da Saúde. Secretaria de Atenção a Saúde. Departamento de Ações Programáticas e Estratégicas. Proteger e cuidar da saúde de adolescentes na atenção básica. Brasília: Ministério da Saúde; 2017. adopts this same chronological parameter, although the Child and Adolescent Statute ⁴4. Brasil. Câmara dos Deputados. Lei nº 8.069, de 13 de Julho de 1990. Dispõe sobre o estatuto da criança e do adolescente e dá outras providencias. Diário Oficial da União. 13 Jun 1990. defines this phase as a period from 12 to 18 years.

Moreover, the chronological criterion used to delimit adolescence became very useful in the biomedical definition of parameters for scientific investigations and public policymaking ⁵5. Senna SRCM, Dessen MA. Reflexões sobre a saúde do adolescente brasileiro. Psicol Saude Doenças. 2015; 16(2):217-29. doi: https://dx.doi.org/10.15309/15psd160208 .
https://dx.doi.org/10.15309/15psd160208... . However, it became insufficient to deal with the concrete and historical subject – the adolescent, from a sociological perspective ⁶6. Peres F, Rosenburg CP. Desvelando a concepção de adolescência/adolescente presente no discurso da saúde pública. Saude Soc.1998; 7(1):53-86. .

Adolescence is a complex phenomenon, product of the interaction between processes of biological and sociocultural development ⁷7. Leal MM, Saito MI. Síndrome da adolescência normal. In: Saito MI, Silva LEV, Leal MM, editores. Adolescência: prevenção e risco. 3a ed. São Paulo: Atheneu; 2014. p. 75-82. . Using this lens, the understanding of adolescence substantiates the idea of a continuous identity construction, considering the relational and definitely contingent character of the identities of individuals and groups ⁸8. Ayres JRCM. Sujeito, intersubjetividade e práticas de saúde. Cienc Saude Colet. 2001; 7(1):63-72. .

Adolescence is therefore engendered in intersubjectivity, being woven into the relationships with the world and constituting its historicity ⁶6. Peres F, Rosenburg CP. Desvelando a concepção de adolescência/adolescente presente no discurso da saúde pública. Saude Soc.1998; 7(1):53-86. – an aspect that “signals the uniqueness in the formative process of individuals and the collective construction of shared beliefs and values in the cultural dimension” ⁹9. 9. Campos GWS, Cunha GT, Figueiredo MD. Práxis e formação Paideia: apoio e cogestão em saúde. São Paulo: Hucitec; 2013. (p. 80). In fact, the ways of walking in life reflect the vulnerability ¹⁰10. Malagón-Oviedo RA, Czeresnia D. O conceito de vulnerabilidade e seu caráter biossocial. Interface (Botucatu). 2015; 19(53):237-49. doi: 10.1590/1807-57622014.0436. of adolescents, facing the complex process of health and illness, in turn accentuated in contexts of inequity and stigma.

Therefore, vulnerability would not be something natural to adolescence, as it would present itself as a perspective of the dialectic of the subject’s way of being/living in the process of becoming ¹¹11. Deleuze G, Guattari F. Mil platôs: capitalismo e esquizofrenia. São Paulo: Editora 34; 1997. v. 4. an adolescent ¹²12. Organiação Panamericana de Saúde. Adolescer, verbo de transição. Brasília: OPAS; 2016. . Thus, adolescents should not be constituted as target population for interventions, but instead as a set of social relations that need a sensitive approach to ethnic, gender, class, etc., since adolescence would be a potentiality ¹¹11. Deleuze G, Guattari F. Mil platôs: capitalismo e esquizofrenia. São Paulo: Editora 34; 1997. v. 4. .

Not surprisingly, any adolescents’ health care pathway is complex, especially from the perspective of comprehensive care ¹1. Secretaria da Saúde do Estado São Paulo. Linha de cuidado para a saúde na adolescência e juventude para o Sistema Único de Saúde no Estado de São Paulo [Internet]. São Paulo: Secretaria de Estado de Saúde; 2018 [citado 25 Jun 2019]. Disponível em: https://cebrap.org.br/wp-content/uploads/2018/11/Linha-de-Cuidado-Adolescencia-Juventude-SUS-SP-1.pdf
https://cebrap.org.br/wp-content/uploads... . In the logic of organization of health care networks ¹³13. Santos AM. Redes regionalizadas de atenção à saúde: desafios à integração e à coordenação do cuidado. Salvador: Edufba; 2018. , the Family Health Strategy (FHS) should also be the primary locus for continuous/coordinated care and professionals at this level of attention would be the subjects with the power to build shared actions in the territory and produce an expanded clinical approach ⁹9. 9. Campos GWS, Cunha GT, Figueiredo MD. Práxis e formação Paideia: apoio e cogestão em saúde. São Paulo: Hucitec; 2013. .

Such perspective places its bets on the kind of care directed towards specific territories and its consequent approximation with the life context of adolescents, the existence of work processes that are porous to interdisciplinary action, intersectoral articulation and the possibility of a perennial space for inter-subjective exchanges capable of producing dialogic relations and promote care networks ¹⁴14. Ayres JRCM, Carvalho YM, Nasser MA, Saltão RM, Mendes VM. Caminhos da integralidade: adolescentes e jovens na Atenção Primária à Saúde. Interface (Botucatu). 2012; 16(40):67-82. , ¹⁵15. Horta NC, Madeira AMF, Armond LC. Desafios na atenção à saúde do adolescente. In: Borges ALV, Fugimori E, organizadores. Enfermagem e a saúde do adolescente na atenção básica. Barueri: Manole; 2009. p. 119-41. . Therefore, the FHS would provide at the same time individualized care for adolescents, as well as the identification of needs that go beyond those clinically demanded and defined by biomedical rationality, further expanding them to aspects that surpass social medicalization ¹⁶16. Tesser CD. Medicalização social: limites biomédicos e propostas para a clínica na Atenção Básica. In: Tesser CD, organizador. Medicalização social e atenção à saúde no SUS. São Paulo: Hucitec; 2010. p.108-30. .

From this perspective, fostering professional competence in adolescent care at the theoretical and technical levels remains a major challenge ¹⁷17. Higarashi IH, Baratieri T, Roecker S, Marcon SS. Atuação do enfermeiro junto aos adolescentes: identificando dificuldades e perspectivas de transformação. Rev Enferm UERJ. 2011; 19(3):375-80. . Moreover, both in the training process during the undergraduate process ¹⁸18. Ceccim RB, Carvalho YM. Ensino da saúde como projeto da integralidade: a educação dos profissionais de saúde no SUS. In: Pinheiro R, Ceccim RB, Mattos RA, organizadores. Ensinar saúde: a integralidade e o SUS nos cursos de graduação na área da saúde. Rio de Janeiro: Lappis; 2006. , as well as in the actions of in-service permanent education ¹⁹19. Santos AM, Nóbrega IKS, Assis MMA, Jesus SR, Kochergin CN, Bispo Júnior JP, et al. Desafios à gestão do trabalho e educação permanente em saúde para a produção do cuidado na estratégia saúde da família. Rev APS. 2015; 18(1):39-49. , there are gaps in the approach to attributes that are inherent to adolescent health and, consequently, it is confronted with professionals lacking the adequate competencies to deal with specific demands of this social group ²⁰20. Lage AMD, Moura LR, Horta NC. Abordagem ao adolescente e ao jovem na atenção primária. In: Souza MCMR, Horta NC, organizadores. Enfermagem em saúde coletiva: teoria e prática. 2a ed. Rio de Janeiro: Guanabara Koogan; 2017. p. 241-58. . This issue also compromises the quality of the FHS as a priority entry point for the population of the assigned territory as a whole ²¹21. Santos AM, Giovanella L, Mendonça MHM, Andrade CLT, Martins MIC, Cunha MS. Práticas assistenciais das Equipes de Saúde da Família em quatro grandes centros urbanos. Cienc Saude Colet. 2012; 17(10):2687-702. .

In this area, aspects related to the training process of health workers for the production of adolescent health care are discussed, taking into account the academic experience and in-service training to qualify the work process within the scope of Primary Health Care.

Method

It is a qualitative study ²²22. Demo P. Pesquisa qualitativa: busca de equilíbrio entre forma e conteúdo. Rev Lat Am Enfermagem. 1998; 6(2):89-104. , researching the meanings attributed to facts, relationships and practices for the production of adolescent health care. The data were produced through interaction with interlocutors at the Municipal Health Department at five Family Health Units (FHU). Four of them were in the urban area, and one in the rural area, in a municipality in southwestern Bahia (796 km from Salvador), a regional health headquarters. Family Health Strategy (FHS) coverage was 82%, with 19 Family Health Teams (EqSF) and two Family Health Support Group (NASF) teams ²³23. Secretaria da Saúde do Estado da Bahia. Portal do Departamento de Atenção Básica [Internet]. Salvador: Secretaria da Saúde do Estado da Bahia; 2018 [citado 2 Fev 2018]. Disponível em: http://www.saude.ba.gov.br/atencao-a-saude/dab/
http://www.saude.ba.gov.br/atencao-a-sau... .

The choice of EqSF was made by a previous survey, through contact with managers from all FHU. The field exploration covered data concerning the professionals’ working time and a brief report of the adolescent care actions developed by the EqSF. The selection covered different contexts of location of the FHU: rural and urban; peripheral and central neighborhoods.

Data production (Table 1) took place between September and November 2017. The study interlocutors (81 subjects) and the respective techniques were composed by: 1) seven managers - semi-structured interviews; 2) seventeen PHC professionals - semi-structured interviews; 3) ten professionals from two Family Health Support Center (NASF) teams - grouped into a focus group; 4) 47 adolescents - subdivided into five focus group sessions (one session for each selected FHU), respectively with twelve, nine, eleven, nine and six adolescents per group.

Moreover, the justification for the choice of different instruments for different groups of interlocutors was due to the methodological strategy that sought the involvement of diversity of subjects – both in quantity and quality - without disjunction ²²22. Demo P. Pesquisa qualitativa: busca de equilíbrio entre forma e conteúdo. Rev Lat Am Enfermagem. 1998; 6(2):89-104. . A greater number of adolescents was eligible for the study and in order to contemplate greater participation, the focus group resource was used also enabling the production of data in a more interactive and problematic context ²⁴24. Trad LAB. Grupos focais: conceitos, procedimentos e reflexões baseadas em experiências com o uso da técnica em pesquisas de saúde. Physis. 2009; 19(3):777-96. , ²⁵25. Gatti BA. Grupo focal na pesquisa em ciências sociais e humanas. Brasília: Líber Livro; 2005. . This feature, too, was used for NASF professionals applying a similar rationale.

On the other hand, managers formed a restricted group and therefore compatible with individualized data production. Similarly, in the professionals’ case, the interview was the chosen technique, due to the need to understand the formative singularities present in the different cores of knowledge. Even though it was a large group, there was representation regarding five FHU and selectable by saturation ²⁶26. Fontanella BJB, Ricas J, Turato ER. Amostragem por saturação em pesquisas qualitativas em saúde: contribuições teóricas. Cad Saude Publica. 2008; 24(1):17-27. .

Subsequently, the interviews and focus group sessions were recorded, fully transcribed and coded with letters and Arabic numbering. The letters M were used for managers, P for FHS professionals, NP for NASF professionals and A for adolescents.

To analyze and interpret ²⁷27. Gomes R. Análise e interpretação de dados de pesquisa qualitativa. In: Souza MC, organizador. Pesquisa social: teoria, método e criatividade. 34a ed. Petrópolis: Vozes; 2015. the interviews and focus groups, the data were sorted according to the general reading of the transcribed material and a primary organization of the different empirical data. The material was sorted and classified, the transcripts were read exhaustively and the context units were selected, grouped and categorized ( Table 2 ). The arguments of the focus groups and interviews were confronted, followed by a comparison between the different discourses in the dialectical confrontation of ideas and positions of the subjects. For the final data analysis ²⁷27. Gomes R. Análise e interpretação de dados de pesquisa qualitativa. In: Souza MC, organizador. Pesquisa social: teoria, método e criatividade. 34a ed. Petrópolis: Vozes; 2015. , the narratives were cross-cut, identifying consensus, mediation, agreement (hermeneutic movement) and controversies, dissent, criticism (dialectical movement) fostering intersubjectivity for the production of comprehensive and critical interpretation ²²22. Demo P. Pesquisa qualitativa: busca de equilíbrio entre forma e conteúdo. Rev Lat Am Enfermagem. 1998; 6(2):89-104. , ²⁸28. Minayo MCS. Hermenêutica-dialética como caminho do pensamento social. In: Minayo MCS, Deslandes SF, organizadores. Caminho do pensamento: epistemologia e método. Rio de Janeiro: Fiocruz; 2002. p. 83-107. .

Finally, the results and discussion were grouped into three thematic categories: I) Deficiencies in the academic formation of health professionals regarding adolescent care; II) Permanent education in health and the invisibility of adolescents; and III) Professional unpreparedness and adolescent perception (Figure 2).

The research was approved by the Research Ethics Committee of the Federal University of Bahia (Opinion 2,250,531). The investigation started with the signing of the Free Informed Consent form - managers, professionals, adolescents (≥18 years) or legal guardian - and the Free and Informed Assent form (adolescents ≤18 years).

Results e discussion

Shortcomings in the academic formation of health professionals regarding adolescent care

To understand these results, this category is based on the perceptions of professionals of the Family Health Strategy.

Thus, doctors and nurses considered their formative process incipient and superficial in the context of adolescent health. This is because, at the undergraduate level, there was no specific curricular component, while the approaches, whenever present in the curriculum were linked to the child’s health. There was also greater emphasis on the topic related to childhood, without a thorough focus on the singularities of adolescent care. Moreover, the topics related to adolescent health did not crosscut other curriculum components either, characterizing a formative gap. The fragments below exemplify such findings:

However, the educational limitations in undergraduate health are historical, as per the process of training on comprehensive care ¹⁸18. Ceccim RB, Carvalho YM. Ensino da saúde como projeto da integralidade: a educação dos profissionais de saúde no SUS. In: Pinheiro R, Ceccim RB, Mattos RA, organizadores. Ensinar saúde: a integralidade e o SUS nos cursos de graduação na área da saúde. Rio de Janeiro: Lappis; 2006. . Regarding adolescent health, for example, there has been the insertion of broader perspectives in the curriculum matrix in some courses ²⁹29. Vitalle MSS, Almeida RG, Silva FC. Capacitação na atenção à saúde do adolescente: experiência de ensino. Rev Bras Educ Med. 2010; 34(3):459-68. , however, they are still insufficient for a professional performance consistent with comprehensive care ³⁰30. Santos AAG, Silva RM, Machado MFAS, Vieira LJES, Catrib AMF, Jorge HMF. Sentidos atribuídos por profissionais à promoção da saúde do adolescente. Cienc Saude Colet. 2012; 17(5):1275-84. .

Not by chance, the professionals interviewed revealed themselves as insecure in clinical conducts, unless the adolescent fit into any of the FHU programmatic actions. In general, the curriculum of health courses does not deal properly with themes related to adolescence, often restricted to a conservative and technical approach to the reproductive process / sexuality ¹⁷17. Higarashi IH, Baratieri T, Roecker S, Marcon SS. Atuação do enfermeiro junto aos adolescentes: identificando dificuldades e perspectivas de transformação. Rev Enferm UERJ. 2011; 19(3):375-80. .

Consequently, care practices are often organized on the basis of programmatic actions, i.e. the set of professionals’ actions is concentrated in certain population groups and/or specific diseases ²¹21. Santos AM, Giovanella L, Mendonça MHM, Andrade CLT, Martins MIC, Cunha MS. Práticas assistenciais das Equipes de Saúde da Família em quatro grandes centros urbanos. Cienc Saude Colet. 2012; 17(10):2687-702. , ³⁰30. Santos AAG, Silva RM, Machado MFAS, Vieira LJES, Catrib AMF, Jorge HMF. Sentidos atribuídos por profissionais à promoção da saúde do adolescente. Cienc Saude Colet. 2012; 17(5):1275-84. to the detriment of comprehensiveness ³¹31. Merhy EE. Integralidade: implicações em xeque. In: Pinheiro R, Ferla AA, Mattos RA. Gestão em redes: tecendo os fios da integralidade em saúde. Rio de Janeiro: Lappis; 2006. p. 97-109. (in the territory and the FHU), contrary to an integral PHC ³²32. Santos AM, Giovanella L, Botelho H, Sousa JC. Desafios organizacionais para fortalecimento da Atenção Primária à Saúde em Portugal. Rev Bras Educ Med. 2015; 39(3):359-69. and an expanded clinic approach ⁹9. 9. Campos GWS, Cunha GT, Figueiredo MD. Práxis e formação Paideia: apoio e cogestão em saúde. São Paulo: Hucitec; 2013. .

In addition, while programs targeting maternal and child groups and the elderly are heavily implemented, actions targeting adolescents remain marginal in government policies ³³33. Lopez SB, Moreira MCN. Quando uma proposição não se converte em política? O caso da Política Nacional de Atenção Integral à Saúde de Adolescentes e Jovens – PNAISAJ. Cienc Saude Colet. 2013; 18(4):1179-86. and in professional practices ²¹21. Santos AM, Giovanella L, Mendonça MHM, Andrade CLT, Martins MIC, Cunha MS. Práticas assistenciais das Equipes de Saúde da Família em quatro grandes centros urbanos. Cienc Saude Colet. 2012; 17(10):2687-702. , ³⁰30. Santos AAG, Silva RM, Machado MFAS, Vieira LJES, Catrib AMF, Jorge HMF. Sentidos atribuídos por profissionais à promoção da saúde do adolescente. Cienc Saude Colet. 2012; 17(5):1275-84. , ³⁴34. Costa RF, Zeitoune RCG, Queiroz MVO, Gómez G, Carmen I, García MJR. Redes de apoio ao adolescente no contexto do cuidado à saúde: interface entre saúde, família e educação. Rev Esc Enferm USP. 2015; 49(5):741-7. . Moreover, health care actions aimed at adolescents are practically nonexistent in PHC services; therefore, internships in services do not provide the undergraduate with the meaningful experience for their academic education and compromises the clinical and relational competence required for qualified care. Nevertheless, the experience as a student, according to interviewees, was limited to the performance of educational activities at school, contrary to the perspective of comprehensive care (both technical and relational), as the following excerpt points out:

The experience of the student in other spaces that transcend the health unit in practices related to ABS is of paramount importance in the formative path, because “the formative process does not happen only at school. It happens in multiple spaces, just as there are multiple learning processes that occur in each of these spaces” ³⁵35. Fagundes NC, Burnham TF. Discutindo a relação entre espaço e aprendizagem na formação de profissionais de saúde. Interface (Botucatu). 2005; 9(16):105-14. (p. 106). In this perspective, the teaching-learning scenarios should not be restricted to formal places of professional practice, but should include “multi-referential spaces”, through the plurality of glances directed to a reality and the languages needed to translate it ³⁶36. Fagundes NC, Burnham TF. Transdisciplinaridade, multirreferencialidade e currículo. Rev FACED. 2001; 5:39-55. . However, such learning spaces cannot be a “dressing” to the set of actions necessary to the teaching process aimed at the production of integral care.

From this perspective, the diversity of teaching-learning scenarios that make up the student’s insertion itinerary enhances the preparation for the comprehensiveness of care, because within the daily actions of the institutions and the community, the ways of creation and appropriation of production, reproduction and reinvention of health and ways of walking in life are expressed ³⁷37. Paro CA, Pinheiro R. Cenários diversificados de aprendizagem na formação em Saúde Coletiva: reflexões a partir dos saberes e práticas da integralidade. In: Pinheiro R, Engel T, Asensi FD, organizadores. Vulnerabilidades e resistências na integralidade do cuidado: pluralidades multicêntricas de ações, pensamentos e a (re)forma do conhecimento. Rio de Janeiro: CEPESC/IMS/UERJ, Abrasco; 2017. p. 278-96. .

Thus, it is necessary to provide to undergraduate students in the health area moments of articulation of concepts, perceptions and sensations to produce knowledge from teaching practices guided by comprehensiveness from a critical and problematic perspective ¹⁸18. Ceccim RB, Carvalho YM. Ensino da saúde como projeto da integralidade: a educação dos profissionais de saúde no SUS. In: Pinheiro R, Ceccim RB, Mattos RA, organizadores. Ensinar saúde: a integralidade e o SUS nos cursos de graduação na área da saúde. Rio de Janeiro: Lappis; 2006. , ³⁷37. Paro CA, Pinheiro R. Cenários diversificados de aprendizagem na formação em Saúde Coletiva: reflexões a partir dos saberes e práticas da integralidade. In: Pinheiro R, Engel T, Asensi FD, organizadores. Vulnerabilidades e resistências na integralidade do cuidado: pluralidades multicêntricas de ações, pensamentos e a (re)forma do conhecimento. Rio de Janeiro: CEPESC/IMS/UERJ, Abrasco; 2017. p. 278-96. , ³⁸38. Pinheiro R, Ceccim RB. Experienciação, formação, cuidado e conhecimento em saúde: articulando concepções, percepções e sensações para enfeitar o ensino da integralidade. In: Pinheiro R, Ceccim RB, Mattos RA. Ensinar saúde: a integralidade e o SUS nos cursos de graduação na área da saúde. Rio de Janeiro: IMS/UERJ, CEPESQ, Abrasco; 2005. p. 13-35. . Nevertheless, it is believed that the reflection on the aspects experienced in theory and practice (intersubjectivity and procedures) can strengthen the formation of future professionals involved with ways of organizing services so that they receptive to adolescents and foster work processes that are attentive and resolute to the demands of this social group. Thus, experiences of fragmented and uncompromised care experienced in undergraduate studies will not be reproduced in the daily work of PHC services, as evidenced in the following statement:

Thus, inadequate training of health professionals regarding adolescent health care has been reproduced in daily life at PHC services. Therefore, by using the FHU as a field of practice and not experiencing comprehensive and diversified actions (clinical and educational) directed towards the adolescent, the students are able to reflect on their future practices, essentially due to the lack of stimulation and / or because not knowing how to do it. As a result, professionals elaborate partial formulations about the adolescent and the modes of care that, in turn, fragment the body “[...] as an instrument of diagnosis, prevention or therapy, with a dual function: as an instrument in its relationship with work: and of object, as the one in which the interventions are done” ¹⁸18. Ceccim RB, Carvalho YM. Ensino da saúde como projeto da integralidade: a educação dos profissionais de saúde no SUS. In: Pinheiro R, Ceccim RB, Mattos RA, organizadores. Ensinar saúde: a integralidade e o SUS nos cursos de graduação na área da saúde. Rio de Janeiro: Lappis; 2006. (p. 71).

In turn, situations experienced in adolescence, such as progressive separation from parents, attachment to new groups, search for self and identity, fluctuations in mood, social attitude, as well as issues related to sexual initiation and other aspects of sexuality ³⁹39. Ferrari RA, Thomson Z, Melchior R. Adolescência: ações e percepção dos médicos e enfermeiros do Programa Saúde da Família. Interface (Botucatu). 2008; 12(25):387-400. , for example, require integrally oriented teaching practices ¹⁸18. Ceccim RB, Carvalho YM. Ensino da saúde como projeto da integralidade: a educação dos profissionais de saúde no SUS. In: Pinheiro R, Ceccim RB, Mattos RA, organizadores. Ensinar saúde: a integralidade e o SUS nos cursos de graduação na área da saúde. Rio de Janeiro: Lappis; 2006. , ³¹31. Merhy EE. Integralidade: implicações em xeque. In: Pinheiro R, Ferla AA, Mattos RA. Gestão em redes: tecendo os fios da integralidade em saúde. Rio de Janeiro: Lappis; 2006. p. 97-109. , ⁴⁰40. Barros MEB. Desafios ético-políticos para a formação dos profissionais de saúde: transdisciplinaridade e integralidade. In: Pinheiro R, Ceccim RB, Mattos RA. Ensinar saúde: a integralidade e o SUS nos cursos de graduação na área da saúde. Rio de Janeiro: IMS/UERJ, CEPESQ, Abrasco; 2005. p. 131-52. .

However, often, higher education courses offer a “package” of technical-scientific content to the detriment of the subjective production of care ⁹9. 9. Campos GWS, Cunha GT, Figueiredo MD. Práxis e formação Paideia: apoio e cogestão em saúde. São Paulo: Hucitec; 2013. , ¹⁵15. Horta NC, Madeira AMF, Armond LC. Desafios na atenção à saúde do adolescente. In: Borges ALV, Fugimori E, organizadores. Enfermagem e a saúde do adolescente na atenção básica. Barueri: Manole; 2009. p. 119-41. , ¹⁸18. Ceccim RB, Carvalho YM. Ensino da saúde como projeto da integralidade: a educação dos profissionais de saúde no SUS. In: Pinheiro R, Ceccim RB, Mattos RA, organizadores. Ensinar saúde: a integralidade e o SUS nos cursos de graduação na área da saúde. Rio de Janeiro: Lappis; 2006. . In addition, students become passive interlocutors during training, and later, on entering the services they are caught by the clipped-reduced-corporate-centered axis ¹⁵15. Horta NC, Madeira AMF, Armond LC. Desafios na atenção à saúde do adolescente. In: Borges ALV, Fugimori E, organizadores. Enfermagem e a saúde do adolescente na atenção básica. Barueri: Manole; 2009. p. 119-41. . One respondent exemplifies this approach to teaching, limited to biomedical issues and ignorant of the complexity of ethical-political dimensions surrounding adolescent health care:

In the opposite direction, several bets have been made towards changes in formation and ways of conceiving the production of interdisciplinary and multi-referential knowledge ³⁵35. Fagundes NC, Burnham TF. Discutindo a relação entre espaço e aprendizagem na formação de profissionais de saúde. Interface (Botucatu). 2005; 9(16):105-14. , ³⁶36. Fagundes NC, Burnham TF. Transdisciplinaridade, multirreferencialidade e currículo. Rev FACED. 2001; 5:39-55. . These changes aim to bridge the gap between the biomedical conception, centered on social medicalization ¹⁶16. Tesser CD. Medicalização social: limites biomédicos e propostas para a clínica na Atenção Básica. In: Tesser CD, organizador. Medicalização social e atenção à saúde no SUS. São Paulo: Hucitec; 2010. p.108-30. , that guides hegemonic medical practice, and health practices guided by a dialectical conception in the production of health care ⁹9. 9. Campos GWS, Cunha GT, Figueiredo MD. Práxis e formação Paideia: apoio e cogestão em saúde. São Paulo: Hucitec; 2013. .

In this sense, it is important that the pedagogical process is reflexive and dynamic. However, the interviewed professionals pointed out that during the academic formative period, there were no experiences with active methodologies and that the adolescent health-related component was based on the transmission of contents, lacking problematization. Such issues show a poor production of health knowledge, especially when the topic is focused on vulnerable populations and/or those populations that are difficult to link to health services ¹1. Secretaria da Saúde do Estado São Paulo. Linha de cuidado para a saúde na adolescência e juventude para o Sistema Único de Saúde no Estado de São Paulo [Internet]. São Paulo: Secretaria de Estado de Saúde; 2018 [citado 25 Jun 2019]. Disponível em: https://cebrap.org.br/wp-content/uploads/2018/11/Linha-de-Cuidado-Adolescencia-Juventude-SUS-SP-1.pdf
https://cebrap.org.br/wp-content/uploads... , ⁴¹41. Silva MAI, Mello FCM, Mello DF, Ferriani MGC, Sampaio JMC, Oliveira WA. Vulnerabilidade na saúde do adolescente: questões contemporâneas. Cienc Saude Colet. 2014; 19(2):619-27. . In this sense, when the educational approach is vertical and focused on content accumulation, with scarce holistic and dialectical approaches to the adolescent health-disease process, there is ample possibility to train professionals focused on the biological core, suffering from limitations to propose creative and dialogical interventions, essentially due to the lack of prior references, resulting in highly medicalizing practices ¹⁶16. Tesser CD. Medicalização social: limites biomédicos e propostas para a clínica na Atenção Básica. In: Tesser CD, organizador. Medicalização social e atenção à saúde no SUS. São Paulo: Hucitec; 2010. p.108-30. . The fragments below summarize this perspective:

Moreover, it is important to highlight that the proposals debated for the transformation of health courses involve the methodological character of teaching or didactic-pedagogical approaches techniques, however, they carry “culturalized” contents. In this way the traces of production and social reproduction remain, regardless of the didactic model ⁴²42. Koifman L, Saippa-Oliveira G. Produção de conhecimento e saúde. In: Pinheiro R, Ceccim RB, Mattos RA, organizadores. Ensinar saúde: a integralidade e o SUS nos cursos de graduação na área da saúde. Rio de Janeiro: IMS/UERJ, CEPESQ, Abrasco; 2005. p. 111-50. .

Continuing health education and adolescent invisibility

To understand these results, this category is based on the perceptions of professionals (FHS and NASF) and managers.

From the perspective of training workers involved with SUS, the National Policy of Permanent Education in Health ⁴³43. Brasil. Ministério da Saúde. Gestão da Educação em Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Política Nacional de Educação Permanente em Saúde. Brasília, DF: Ministério da Saúde; 2009. promoted the transformation of the educational model aimed at the development of actions directed to meaningful learning in daily work as a techno-political issue ⁴⁴44. Ceccim RB. Educação permanente em saúde: desafio ambicioso e necessário. Interface (Botucatu). 2005; 9(16):161-8. . Such a perspective involves changes in relationships, processes; health acts, organizations and people, thus requiring a myriad of synergistic training strategies ⁴⁵45. Brasil. Ministério da Saúde. Política Nacional de Educação Permanente em Saúde: o que se tem produzido para o seu fortalecimento? Brasília: Ministério da Saúde; 2018. .

However, the interviewees (managers and professionals) considered the in-service education activities insufficient, as they are not always implemented; and when they happen, they usually did not cover care with adolescents, as illustrated by the following excerpts:

The reports reinforce the finding of collective mismatch in the production of adolescent health. Worryingly, managers in the role of institutional supporter and service organizer and NASF professionals in the matrix support role did not feel prepared to provide pedagogical support to PHC professionals within the scope of adolescent health. The actions appeared to be a result of individual motivation by some professionals without institutional support and without a support network. Nevertheless, despite some positive initiatives, the incorporation of systematic and institutionalized opportunities for continuing education for professionals is still scarce throughout the country ⁴⁶46. Faria RMB. Os desenhos institucionais da educação permanente: balanço das políticas. In: Pierantoni CR, Viana ALA, organizadores. São Paulo: Hucitec; 2010. p. 123-43. .

Managers pointed out the formative deficiency of professionals as a reason for not approaching adolescent care in permanent education actions, leading them to prioritize themes related to already institutionalized programs, and adolescents going unnoticed in these educational activities. Moreover, they also report the turnover of professionals as a challenge for the implementation of permanent health education actions, hindering the continuity and advancement of the themes, due to the change in the staff that required the repetition of topics that were touched in previous moments.

Despite the difficulty in the development and consolidation of permanent health education as a result of the precariousness of employment relationships and the consequent turnover of professionals, it is understood that, by qualifying the professional for health work, permanent education contributes to the appreciation of the workers, favoring retention.

According to managers and health professionals, topics were being surveyed within health teams so that in-service education activities were congruent with the demands of professionals:

In this sense, although adolescent care is not listed among the themes for educational actions, the method used to define such themes approached the precepts governing permanent health education, as it tried to articulate the construction of proposals encompassing the needs of the subjects. In this context, for educational actions to take into account the need for services, it is necessary that professionals and managers, immersed in the daily life and complexity of their problems, may read reality using theoretical contributions or lenses that broaden the critical look, so that the educational actions are fruitful and can effectively impact the resignification and restructuring of the work process ⁴⁴44. Ceccim RB. Educação permanente em saúde: desafio ambicioso e necessário. Interface (Botucatu). 2005; 9(16):161-8. , ⁴⁷47. Campos KFC, Sena RR, Silva KL. Educação permanente nos serviços de saúde. Esc Anna Nery. 2017; 21(4):e20160317. .

Given the lack of face-to-face in-service education activities, technological tools, such as telehealth, were cited by respondents (professionals and managers) as important facilitators of access to this type of training:

The discourses show clearly that information technologies were valuable instruments in the improvement and updating of health workers. In this sense, the National Telehealth Brazil Program has been used at PHC as a means for continuing education at PHC ⁴⁸48. Guimarães EMP, Godoy SCB, Vilela LCM, Mafaldo JDS. Teleconsutoria e videoconferência como estratégia de educação permanente para as equipes de saúde da família. Cogitare Enferm. 2015; 20(2):376-84. . In addition to training, professionals who participate in telehealth activities have the possibility to build their own knowledge, through the exchange of experiences with professionals from other regions, who experience a different reality in performing the same activity ⁴⁹49. Almino MAFB, Rodrigues SR, Barros KSB, Fonteles AS, Alencar LBL, Lima LL, et al. Telemedicina: um instrumento de educação e promoção da saúde pediátrica. Rev Bras Educ Med. 2014; 38(3):397-402. . This contact with other realities favors the broadening of glances in the qualification of care and the implementation of changes in the work process. In addition, issues related to adolescent health have been addressed in videoconferences ⁴⁸48. Guimarães EMP, Godoy SCB, Vilela LCM, Mafaldo JDS. Teleconsutoria e videoconferência como estratégia de educação permanente para as equipes de saúde da família. Cogitare Enferm. 2015; 20(2):376-84. , ⁴⁹49. Almino MAFB, Rodrigues SR, Barros KSB, Fonteles AS, Alencar LBL, Lima LL, et al. Telemedicina: um instrumento de educação e promoção da saúde pediátrica. Rev Bras Educ Med. 2014; 38(3):397-402. thus favoring the training of PHC professionals.

However, as pointed out by the interlocutors of this study, the use of this distance education resource by health professionals depends on their personal initiative, on resources such as computer and internet, as well as a better organization of the work process to allow a space in the workplace schedule for such activity. These aspects are obstacles that need to be overcome in order to achieve the desired goal in distance education activities ⁵⁰50. Godoy SCB, Guimaraes EMP, Assis DSS. Avaliação da capacitação dos enfermeiros em unidades básicas de saúde por meio da telenfermagem. Esc Anna Nery. 2014; 18(1):148-55. .

Regardless of the use or not of informational devices, permanent health education has as its central element the transformation of professional practices and the work organization itself, through the introduction of mechanisms, spaces and themes that generate self-analysis, implication, self-management, institutional change, thought (disruption with established formulas or models) and experimentation ²⁹29. Vitalle MSS, Almeida RG, Silva FC. Capacitação na atenção à saúde do adolescente: experiência de ensino. Rev Bras Educ Med. 2010; 34(3):459-68. . Likewise, by placing the professional on the agenda of analysis, by permeating the concrete relationships that operate realities, permanent health education enables the construction of fertile collective spaces for the reflection and evaluation of meanings of daily produced acts ⁴⁴44. Ceccim RB. Educação permanente em saúde: desafio ambicioso e necessário. Interface (Botucatu). 2005; 9(16):161-8. .

Moreover, professionals are often captured by the way health care is reproduced and do not reflect on the care provided to adolescents in their daily practice, perpetuating inadequacies in the way health is performed.

Therefore, permanent health education becomes a fertile ground for breaking this alienation of neglected adolescent care, based on meaningful and meaningful learning, which makes the subject question what is posed, thus creating the possibility of transformation of the care produced in their work process.

From this point of view, formal knowledge must enable the self-analysis and self-management of the collectives, as the everyday subjects, agents and agencies are those who must lead the change in reality aimed by educational practices ⁴⁴44. Ceccim RB. Educação permanente em saúde: desafio ambicioso e necessário. Interface (Botucatu). 2005; 9(16):161-8. .

Professional unpreparedness and adolescent perception

To understand these results, this category is based on the perceptions of groups with adolescents in territories covered by the Family Health Strategy.

The lack of preparation of professionals, both in the technical and relational dimension, was denounced by adolescents as an obstacle to the adherence to the proposed actions, as well as to the establishment of the professional-user bond.

Thus, despite being characterized as a lightweight technology ⁵¹51. Merhy EE. Saúde: a cartografia do trabalho vivo. 4a ed. São Paulo: Hucitec; 2014. , the adolescents’ discourse showed that the bond proved to be dependent on structured knowledge, that is, on light-hard technology ⁵¹51. Merhy EE. Saúde: a cartografia do trabalho vivo. 4a ed. São Paulo: Hucitec; 2014. , because trust in the professional was conditioned to the knowledge shown in the act. Thus, the bond is not restricted to good professional-user interaction, but also requires good assistance in face of the problems manifested by users in the effective production of expected and necessary results, thus, credibility in the service will be achieved ⁵²52. Santos AM, Assis MMA, Nascimento MAA, Jorge MSB. Vínculo e autonomia na prática de saúde bucal no Programa Saúde da Família. Rev Saude Publica. 2008; 42(3):464-70. .

The proper preparation of the professional in adolescent care becomes essential not only in the implementation of actions at the individual level, but also at the collective level, because in order to be able to link the adolescent to the activities, they must be interesting and attractive, requiring professional communication skills, confidence, creativity, and the ability to captivate, instigate and hold attention.

However, such requirements are challenging, since inadequate training of professionals is one of the central problems, weakening the performance of educational actions in the logic of popular health education ⁵³53. Vasconcelos EM. Educação popular: de uma prática alternativa a uma estratégia de gestão participativa das políticas de saúde. Physis. 2004; 14(1):67-83. , frequent vertical and imposing approaches that do not favor the leading role and empowerment of the subjects ⁵⁴54. Brasil PRC, Santos AM. Desafios às ações educativas das Equipes de Saúde Bucal na Atenção Primária à Saúde: táticas, saberes e técnicas. Physis. 2018; 28(4):e280414. .

Conclusion

The permanent formative process of managers and health professionals for the production of adolescent care in PHC was unveiled confronting the conservative teaching model, centered on intervention practices and focused on social medicalization. In addition, even newer continuing education strategies such as the COAPES (Organizational Contracts for Public Action Teaching-Health) have encountered resistance because of scarce traditions in intersectoral articulation.

To overcome the status quo related to the hegemonic mode of care production and consequent adolescent invisibility in health services, there is a need of a greater investment in the teaching-learning process of future professionals through curricular matrices, taking into account the multi-referentiality.

In addition, the subjects must continually establish the dialogue between educational institutions, health services and the community, especially, listening to the biggest interests - the adolescents.

Finally, the rationale for PHC should be territorial care, which means changing the biomedical logic that is insistently trying to get adolescents into the FHU (as consumers of procedures), but instead encouraging the team to meet the community, and therefore meeting with the adolescents and young people in the territory. In this sense the main issue is not to make a FHU more attractive, but to make health actions more coherent and appropriate to the needs / lifestyles of adolescents, from the perspective of comprehensiveness of health.

Acknowledgements

To the State University of Bahia (UNEB) and the Professional Master’s Degree in Collective Health, State University of Feira de Santana (UEFS). Our special thanks to the managers, health professionals and adolescents from Guanambi, Bahia, for their willingness to participate in the research.

References

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