Abstract

Introduction

The right to health care is guaranteed in the Brazilian Constitution; it is a duty of the State that should be implemented through public policy¹1 Constituição (1988). Constituição da República Federativa do Brasil. Brasília, DF: Senado Federal; 1988.^,22 Brasil. Ministério da Saúde. Lei nº 8080, de 19 de Setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União. 19 Set 1990.. Public health should be a political and social goal, involving all sectors and services, being guaranteed through government policies and programs³3 Brasil. Ministério da Saúde. Promoção da saúde: Declaração de Alma-Ata, Carta de Ottawa, Declaração de Adelaide, Declaração de Sundsvall, Declaração de Santafé de Bogotá, Declaração de Jacarta, Rede de Megapaíses e Declaração do México. 2a ed. Brasília: Ministério da Saúde; 2001.. A healthy population must include all regions and social classes, which indicates the importance of integrating the efforts of all services and policies⁴4 Organização Mundial de Saúde. Declaração de Adelaide sobre a Saúde em Todas as Políticas: no caminho de uma governança compartilhada, em prol da saúde e do bem-estar. Genebra: WHO; 2010.. Thus, education and health policies should be integrated, especially regarding health promotion activities in schools.

Health promotion in schools is important for the healthy development of the population, since children and adolescents are in the process of being educated and can thus become healthy adults. To promote joint actions between health and education at the primary care level, as well as to reduce the fragmentation of health actions in schools, the School Health Program (SHP)⁵5 Brasil. Ministério da Saúde. Programa de Saúde na Escola [Internet]. Brasília: Ministério da Saúde; 2020 [cited 2020 Nov 24]. Available from: http://portal.mec.gov.br/expansao-da-rede-federal/194-secretarias-112877938/secad-educacao-continuada-223369541/14578-programa-saude-nas-escolas
http://portal.mec.gov.br/expansao-da-red... was created. The SHP is responsible for health care actions including preventing, protecting, promoting and strengthening the ties between the community and health and education networks. The program is based on an agreement between the municipalities and the Federation, which indicate health units, family health teams, and schools at which SHP activities will be developed⁶6 Brasil. Presidência da República. Decreto nº 6.286, de 5 de Dezembro de 2007. Institui o Programa Saúde na Escola - PSE, e dá outras providências. Diário Oficial da União. 5 Dez 2007.^,77 Brasil. Ministério da Educação. Ministério da Saúde. Portaria Interministerial nº 1.055, de 25 de Abril de 2017. Redefine as regras e os critérios para adesão ao Programa Saúde na Escola – PSE por estados, Distrito Federal e municípios e dispõe sobre o respectivo incentivo financeiro para custeio de ações. Diário Oficial da União. 26 Abr 2017..

For this reason, preparing professionals to conduct such program means improving health education in schools⁸8 Domene SMA. A escola como ambiente de promoção da saúde e educação nutricional. Psicol USP. 2008; 19(4):505-17. Doi: https://doi.org/10.1590/S0103-65642008000400009.
https://doi.org/10.1590/S0103-6564200800... . Activities in the school environment have profound repercussions in the local community⁹9 Silveira CC, Meyer DEE, Félix J. A generificação da intersetorialidade no Programa Saúde na Escola. Rev Bras Estud Pedagog. 2019; 100(255):423-42. Doi: https://doi.org/10.24109/2176-6681.rbep.100i255.3807.
https://doi.org/10.24109/2176-6681.rbep.... , making schools a promising environment for promoting health¹⁰10 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Ministério da Educação. Passo a passo PSE: Programa Saúde na Escola: tecendo caminhos da intersetorialidade. Brasília: Ministério da Saúde, Ministério da Educação; 2011.. Therefore, health must be continuously promoted in schools by teachers, encompassing work, lifestyle, and health-related learning¹¹11 Gomes JP. As escolas promotoras de saúde: uma via para promover a saúde e a educação para a saúde da comunidade escolar. Educacao. 2009; 32(1):84-91.. Since school teachers spend most of their time with students, they have a fundamental role in health education. Therefore, health education must identify and find creative solutions to problems, combining what is known with feelings and beliefs to determine how to value life and improve the quality of life¹²12 Boccaletto EMA. Referenciais teóricos e práticas da escola promotora da saúde e qualidade de vida. In: Vilarta R. Saúde Coletiva e atividade física: conceitos e aplicações dirigidos à graduação em educação física. Campinas: IPES Editorial; 2007. p. 85-91.. Apart from the classroom, the community is extremely important because it is the environment in which students live. Thus, communities and schools must interact and form a two-way collaboration, leveraging the resources of both¹¹11 Gomes JP. As escolas promotoras de saúde: uma via para promover a saúde e a educação para a saúde da comunidade escolar. Educacao. 2009; 32(1):84-91.^,1313 Pereira MD, Pereira PLG, Faria RGS, Cordeiro DR, Viegas SMF. Intersectoral actions between health and education: notes on the Health at School Program. Physis. 311(2):e310224. Doi: https://doi.org/10.1590/S0103-73312021310224.
https://doi.org/10.1590/S0103-7331202131... .

The SHP brought together professionals from schools and health units, and the need to perform interdisciplinary work led to a need to coordinate different sectors of the municipality. For interdisciplinarity to occur, good communication must be established between different disciplines, understood here as fields of knowledge. Thus, a shared language and a shared logical and symbolic communication structure are fundamental¹⁴14 Almeida Filho N. Transdisciplinaridade e saúde coletiva. Cienc Saude Colet. 1997; 2(1-2):5-20. Doi: https://doi.org/10.1590/1413-812319972101702014.
https://doi.org/10.1590/1413-81231997210... . Interdisciplinarity requires people who are competent in their fields to dialogue about the problematics of the involved themes and collaborate with other disciplines, which results in discussing concepts, and combining methods and analysis to jointly construct results¹⁵15 Minayo MCS. Interdisciplinaridade: funcionalidade ou utopia? Saude Soc. 1994; 3(2):42-63. Doi: https://doi.org/10.1590/S0104-12901994000200004.
https://doi.org/10.1590/S0104-1290199400... . Interdisciplinary work creates contexts conducive to the collaborative construction of new knowledge, which arises, roughly speaking, from integrating knowledge originally derived from distinct disciplines.

Interdisciplinarity in health promotion ensures that health actions cannot be conducted in isolation or be compartmentalized into traditional academic disciplines, and neither can they involve knowledge associated with an exclusive field (for example, relegating the work of oral health promotion to dentists). Moreover, interdisciplinarity is not just a theoretical issue, but calls for coordination between the actors in their territory of action. Professionals should seek strategies for overcoming challenges to action and seek interdisciplinary meaning in their daily practice, using their specific knowledge to contribute to the common project of health promotion¹⁶16 Menossi MJ, Oliveira MM, Coimbra VCC, Palha PF, Almeida MCP. Interdisciplinaridade: um instrumento para a construção de um modelo assistencial fundamentado na promoção da saúde. Rev Enferm UERJ. 2005; 13(2):252-6., which results in the collaborative construction of new knowledge.

Regularly scheduled projects throughout the year between health teams and schools can produce good results and satisfaction for the workers, which narrows the gap between theory and practice in school-related health actions. A culture of permanent integration between education and health is needed to unite efforts toward joint systematized health action planning¹⁷17 Faria HA, Carvalho GS. Escolas promotoras de saúde: fatores críticos para o sucesso da parceria escola-centro de saúde. Rev Port Saude Publica. 2004; 22(2):79-90.^,1818 Penso M, Brasil KCTR, Arrais AR, Lordello SR. A relação entre saúde e escola: percepções dos profissionais que trabalham com adolescentes na atenção primária à saúde no Distrito Federal. Saude Soc. 2013; 22(2):542-53. Doi: https://doi.org/10.1590/S0104-12902013000200023.
https://doi.org/10.1590/S0104-1290201300... .

Penso et al.¹⁸18 Penso M, Brasil KCTR, Arrais AR, Lordello SR. A relação entre saúde e escola: percepções dos profissionais que trabalham com adolescentes na atenção primária à saúde no Distrito Federal. Saude Soc. 2013; 22(2):542-53. Doi: https://doi.org/10.1590/S0104-12902013000200023.
https://doi.org/10.1590/S0104-1290201300... conducted interviews with health professionals who work with adolescents to assess their perception of the relationship between health and school. They pointed out that, despite the existence of government policies and health-related programs at school, there is still a lack of coordination between managers and professionals at the local level. They also found that health professionals and educators were unprepared to develop health actions in an integrated manner. It was clear that there is a need to establish a culture of permanent integration between these two axes, to join forces in a systematized health action plan that can create a favorable context for interdisciplinary work.

In line with SHP policy, continuing teacher education is needed for health promotion in the classroom, just as pedagogical education is needed for health professionals who work directly with students. Continuing education should begin at the undergraduate level and continue outside regular work hours to ensure the success of interdisciplinary health and education projects in schools. It is also important to provide dedicated space for reflection about health education projects, as well as for the support and education of teachers and health professionals⁶6 Brasil. Presidência da República. Decreto nº 6.286, de 5 de Dezembro de 2007. Institui o Programa Saúde na Escola - PSE, e dá outras providências. Diário Oficial da União. 5 Dez 2007.^,1111 Gomes JP. As escolas promotoras de saúde: uma via para promover a saúde e a educação para a saúde da comunidade escolar. Educacao. 2009; 32(1):84-91.^,1212 Boccaletto EMA. Referenciais teóricos e práticas da escola promotora da saúde e qualidade de vida. In: Vilarta R. Saúde Coletiva e atividade física: conceitos e aplicações dirigidos à graduação em educação física. Campinas: IPES Editorial; 2007. p. 85-91..

To evaluate the effectiveness of health promotion projects, this study employed Bandura’s cognitive-social theory¹⁹19 Bandura A. Social foundations of though and action: a social cognitive theory. Englewood Cliffs: Prentice-Hall; 1986. and the self-regulated learning construct²⁰20 Zimmerman BJ. Becoming a self-regulated learner: which are the key subprocess? Contemp Educ Psychol. 1986; 11(4):307-13. Doi: https://doi.org/10.1016/0361-476X(86)90027-5.
https://doi.org/10.1016/0361-476X(86)900... . The latter indicates that individuals can make choices about themselves and their environment to achieve what they want. Thus, human beings are agents with knowledge of their own lives and are not merely products of their environment. When people are agents, they develop strategies and are proactive; they modify their own circumstances, being self-regulated and self-reflexive. Being an agent means making intentional choices, knowing that one’s actions can change the course of events²¹21 Bandura A. Health promotion from the perspective of social cognitive theory. Psychol Health. 1998; 13(4):623-49. Doi: https://doi.org/10.1080/08870449808407422.
https://doi.org/10.1080/0887044980840742... .

It is assumed that health professionals and educators can act in an interdisciplinary and deliberate manner to equip students to be proactive and modify their health behaviors and circumstances. Health professionals, by working together with schools and developing projects with teachers and students, are a potential tool for change and improvement in the students’ health, helping mold the actions and practices of schools.

Furthermore, teachers, who act more directly with students in the self-regulation model, must also be able to self-regulate. They must be self-reflective agents of their health choices and self-care. Learning to learn is an essential part of the success of the teaching/learning process²²22 Magalhães CR. A autorregulação da aprendizagem em Programa Institucional de Acolhimento e Suporte ao aluno universitário: os professores como parceiros. Cad Educ. 2012; (42):143-67.: since learning to learn requires learning strategies that must be shared between teachers and students, it is important for teachers to learn, study, organize and plan their material to guide student learning. To teach thinking, teachers need to move out of their comfort zones, modify their own learning and then modify their teaching methods, thus becoming reflective teachers who analyze their own reality and that of their students. In order to teach learning to learn, teachers must themselves know how to learn to learn.

Continuing education is a means of preparing teachers to face this reality in the classroom, expanding their teaching strategies. In addition, teachers who undertake continuing education programs in the learning-to-learn methodology have a better foundation for using this strategy in the classroom²³23 Simão AMV. Integrar os princípios da aprendizagem estratégica no processo formativo dos professores. In: Simão AMV, Duarte AM, Da Silva AL, De Sá IA, Sá I. Aprendizagem auto-regulada pelo estudante - perspectivas psicológicas e educacionais. Porto: Porto Editora; 2004. p. 95-106.. Likewise, it is understood that health professionals working in the SHP can also be models of the learning-to-learn process by learning to be healthy and responsible for their self-care.

Set in this context, the research reported here is part of a larger project which aimed to promote self-regulation for health self-care²⁴24 Rosário P, Núñez JC, González-Pienda J. As travessuras do amarelo. Americana: Adonis; 2012. in 5th grade classes in schools participating in the SHP in a municipality of Rio Grande do Sul, Brazil. This article describes the perceptions of education and health professionals about interdisciplinarity in school-based health promotion programs, one of the themes that emerged from focus groups conducted with participants in a self-regulatory continuing education program for self-care and health promotion.

Method

This article presents an exploratory and descriptive qualitative study²⁵25 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 13a ed. São Paulo: Hucitec; 2010. which involved seven municipal schools and their corresponding health units that were already participating in the SHP. Each team was contacted through letters of invitation and telephone contact by the Municipal Departments of Education and Health, with the assumption that pairs of health professionals and 5th grade teachers should be selected for effective participation in the study. A total of 28 participants were expected, including schools’ teachers, educational counselors, and supervisors. Among health professionals, doctors, nurses, nurse technicians, dentists, oral health technicians/assistants, and community health agents were expected to participate. The selected health and education professionals were invited to the pre-program focus group at the Department of Education two weeks before the project began. The participants were invited to the post-program focus group during the penultimate program session, and the focus group was held after the final session. Inclusion criteria were: health professionals from the municipality; being nominated as responsible for the development of educational actions involving healthy eating and oral health in the SHP; 5th grade public school teachers from the municipality.

The in-service continuing education program on self-regulation for self-care and health promotion was held at the municipal Department of Education. Between September and December 2015, a total of six four-hour meetings were held biweekly and were complemented with six hours of remote work, totaling 30 hours. The purpose was to prepare professionals to conduct a self-regulation program for 5th graders in 2016. The continuing education program was coordinated by a pedagogue, a psychologist, a nutritionist, and a dentist, as well as by the study’s researchers. The first author of this article participated in all of the meetings as a participant observer for better rapport with the participants during the focus groups.

For data generation, we used the focus group technique, which determines the participants’ perceptions about health promotion practice in schools before and after the program, for later analysis and evaluation. The focus group aims to gather information from participants on some topic and understand their opinions and attitudes about it. The researcher (moderator), therefore, should be aware of the interaction between group participants to ensure that all topics indicated by the script and the research objectives are discussed²⁶26 Barbour R. Grupos focais. Porto Alegre: Artmed; 2011..

In this study, we used the topic direction method, which includes, besides a script, the formulation of new questions to guide and deepen discussion of the pre-selected topics²⁷27 Flick U. Introdução a pesquisa qualitativa. 3a ed. Porto Alegre: Artmed; 2009.. Based on a pre-established script, the moderator (first author) conducted the discussions with thought-provoking questions to deepen discussion of the topics, in addition to resolving minor questions about the participants’ statements. The objectives for the pre- and post-program focus groups were differentiated and are listed in the table below (Table 1).

There were four focus groups: two were held two weeks prior to the beginning of the continuing education program in September and two were held after the program was completed, following the final session in December. The participants were divided into two groups with a maximum of 14 people to ensure good discussion of the selected topics. The pre-program focus groups involved participants who could attend on the set day and time, which by chance led to one group of health professionals and another of educators. However, for the post-program groups, the participants were assigned to specific groups to ensure similar numbers of health and education professionals in each group. The different teams were split up and assigned to different groups to stimulate different points of view during the discussion.

A total of 26 participants (11 [42.3%] health professionals and 15 [57.7%] education professionals) participated in the focus groups, attending at least one session. To minimize the risk of identifying the participants and their institutions, pseudonyms were used from the beginning of the study through publication of the results. The pairs of partnered health facilities and schools were also assigned their own color. Figure 1 shows the focus group participants, along with their profession and assigned color.

Only five participants were present at each focus group session, both before and after program. The Grey health unit and the Brown school were excluded from this phase of the study because they did not participate in the continuing education program, and this was necessary for subsequent phases of the project. The educators from the Red school withdrew from the study during the program.

The first author participated in three of the four focus groups, and the fourth focus group was conducted by another researcher who had observed the first two sessions. This arrangement was necessary for the post-program focus groups to occur at the same time. The role of the focus group assistant was to make observations about the discussions, as well as to operate the recording equipment. In addition, the assistant guaranteed that the final focus groups would be conducted in a similar fashion. The approximately four and a half hours of recording were fully transcribed.

Thematic analysis²⁸28 Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006; 3(2):77-101. Doi: https://doi.org/10.1191/1478088706qp063oa.
https://doi.org/10.1191/1478088706qp063o... was used for interpretative analysis of the data. The following steps were taken: reading and familiarization with the data; generating the initial coding; searching for themes based on initial coding; reviewing the themes; defining the themes and documenting the results of the analysis²⁸28 Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006; 3(2):77-101. Doi: https://doi.org/10.1191/1478088706qp063oa.
https://doi.org/10.1191/1478088706qp063o... ^,2929 Howitt D, Cramer D. Thematic analysis. In: Howitt D, Cramer D. Introduction to research methods in psychology. 3th ed. Edimburg: Pearson Education Limited; 2011. p. 328-42.. An analysis was performed of the data produced with the focus groups, i.e., the codes and, consequently, the themes emerging from the participants’ discussion²⁸28 Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006; 3(2):77-101. Doi: https://doi.org/10.1191/1478088706qp063oa.
https://doi.org/10.1191/1478088706qp063o... .

Regarding ethical aspects, participants were informed about the justification, objectives and procedures of the study and were invited to sign informed consent forms. There was no financial benefit from participating in the study. This research was approved by UFCSPA Research Ethics Committee (Ethical Approval Nº 46789315.0.0000.5345).

Results and discussion

Thematic analysis of the data collected in the focus groups was performed, identifying codes, themes and subthemes from what participants stated during the discussion. The pre- and post-program groups were analyzed separately and generated independent themes. The pre-program discussion resulted in 22 codes, which after reviewing were consolidated into 17 codes around four themes: (1) health actions at school, (2) health promotion, (3) family and school relations, (4) interdisciplinarity. The post-program discussion led to 27 codes, which were subsequently consolidated into 20, which dealt with the following four themes: (1) health promotion; (2) family and school relations; (3) interdisciplinarity; (4) program assessment.

This article discusses the interdisciplinarity theme, which emerged in both the pre- and post-program data. Figure 2 presents the interdisciplinary theme and its subthemes derived from the analysis, which resulted from the research question. It should be pointed out that all data analysis, whether in the description or discussion of the results, is permeated by the researchers’ and participants’ perceptions about aspects of health promotion in schools and the performance of health and education professionals in this context. The interdisciplinarity subthemes are discussed in two analytical sections, followed by a brief analysis of the implications of our findings.

Pre-program perceptions

Both health and education professionals reported that regular programs were needed for there to be effective results in schools, due to the fact that when programs are not continued, children learn but do not put what they have learned into practice. For health care programs to actually become part of the children’s habits, they should be presented more often. This continuity can be provided by joint and interdisciplinary work between schools and health teams, which has also been reported in other studies¹⁷17 Faria HA, Carvalho GS. Escolas promotoras de saúde: fatores críticos para o sucesso da parceria escola-centro de saúde. Rev Port Saude Publica. 2004; 22(2):79-90.^,3030 Marinho JCB, Silva JA. Modos de organização e implicações das práticas educativas de educação em saúde. Rev Acta Sci. 2015; 17:213-34..

Of the six pairs of education and health professionals represented in the first focus groups, only the Purple pair reported carrying out health programs that could be considered interdisciplinary, mainly due to the complementarity and partnership involved. Their school participates in monthly meetings with the health team, which defines the health projects that will be carried out during that month at the school. The interdisciplinary relationship between the school and health unit seems of paramount importance for developing and implementing health promotion activities with students³⁰30 Marinho JCB, Silva JA. Modos de organização e implicações das práticas educativas de educação em saúde. Rev Acta Sci. 2015; 17:213-34.^,3131 Barros JPP, Luz PCM. Saúde na escola: que discursos circulam entre profissionais de saúde e educação? Rev Artes Educar. 2015; 1(1):115-32. Doi: https://doi.org/10.12957/riae.2015.10340.
https://doi.org/10.12957/riae.2015.10340... . A statement by Mônica demonstrated her pride in working with health professionals:

Although there was a consolidated partnership in the Purple duo, Simone still depicts the school as waiting for the health unit, waiting for interventions: “The school’s doors are open, waiting for interventions”. In addition to the protagonist posture taken by health professionals, the school had a passive attitude toward the SHP, awaiting initiatives by the health unit³⁰30 Marinho JCB, Silva JA. Modos de organização e implicações das práticas educativas de educação em saúde. Rev Acta Sci. 2015; 17:213-34.. This could corroborate the idea that although the health and education professionals in this particular partnership work in an intersectoral manner, joint planning that favors the emergence of truly interdisciplinary actions is still necessary, i.e., planning that transcends the boundaries between the different areas of knowledge and enables the emergence of new knowledge, exactly in the space that emerges between the different disciplines³²32 Berkenbrock-Rosito MM, Haas C. Interdisciplinaridade e transdisciplinaridade: políticas e práticas de formação de professores. Rio de Janeiro: Wak Editora; 2014..

The lack of time, overloaded staff, lack of preparation for building interdisciplinarity and the large bureaucracy involved in health actions at school all impede health and education working together to plan actions¹⁸18 Penso M, Brasil KCTR, Arrais AR, Lordello SR. A relação entre saúde e escola: percepções dos profissionais que trabalham com adolescentes na atenção primária à saúde no Distrito Federal. Saude Soc. 2013; 22(2):542-53. Doi: https://doi.org/10.1590/S0104-12902013000200023.
https://doi.org/10.1590/S0104-1290201300... . Nevertheless, the participants recognized the importance of interdisciplinarity and joint projects between health and education, but warned that they do not happen. The activities are still carried out in a fragmented manner by almost all of the teams that participated in the focus groups, i.e., a series of actions that depend on knowledge traditionally associated with specific fields.

It was observed that different projects are carried out in schools and have good results, although there is little continuity. Projects usually arrive at the schools without prior planning and end up being slotted into the class schedule with time being the only concern; actions that foster interdisciplinarity are not planned for. This highlights the need for better project management by the health and education departments and could indicate a need for joint planning between professionals in these two areas. According to Rocha et al.³³33 Rocha DG, Marcelo VC, Pereira IMTB. Escola promotora da saúde: uma construção interdisciplinar e intersetorial. J Hum Growth Dev. 2002; 12(2):57-63. Doi: https://doi.org/10.7322/jhgd.39686.
https://doi.org/10.7322/jhgd.39686... , schools actually receive a broad range of teams, from primary care and epidemiological surveillance to civil and military police, who address a variety of topics, such as traffic and environmental issues. These projects, however, are disconnected, both from each other and from school practice. The actions are not monitored by any management team, so the lack of coordination causes overlapping content and themes.

The success of the interdisciplinary experience, therefore, depends on the meeting of people who are willing to dialogue and listen to other professionals, who are competent in their own discipline and willing to understand other disciplines, and who are open to constructing new concepts and analyses that lead to interdisciplinary results and actions. Cooperation between professionals from different disciplines should be evident throughout the process¹⁵15 Minayo MCS. Interdisciplinaridade: funcionalidade ou utopia? Saude Soc. 1994; 3(2):42-63. Doi: https://doi.org/10.1590/S0104-12901994000200004.
https://doi.org/10.1590/S0104-1290199400... .

Post-program perceptions

Interdisciplinarity is essential for the SHP, because coordination between health and education teams is important for developing continuing and permanent activities for students. In addition, interdisciplinarity arises from the organization of the two teams who fulfill their work demands and produce planning that facilitates the interaction of school and health to construct new knowledge⁶6 Brasil. Presidência da República. Decreto nº 6.286, de 5 de Dezembro de 2007. Institui o Programa Saúde na Escola - PSE, e dá outras providências. Diário Oficial da União. 5 Dez 2007..

One of the participants, Mariana, reflected on the great difficulty faced by the health unit at the beginning of the SHP, especially regarding the information presented to the health team regarding the program. According to her, the SHP came as a command from municipal management, complete with a list of mandatory health activities that should be conducted in schools. Moreover, health professionals were to seek out educators, sensitize them about the importance of the program and the development of these activities. She pointed out that no professional received clear information about how to proceed or was sensitized to activities’ importance or told how to perform them at school. It seems common for program management to expect that health professionals take the leading role, i.e., they are to seek out the school and initiate the health education projects, providing the space and coordination necessary for interdisciplinarity³¹31 Barros JPP, Luz PCM. Saúde na escola: que discursos circulam entre profissionais de saúde e educação? Rev Artes Educar. 2015; 1(1):115-32. Doi: https://doi.org/10.12957/riae.2015.10340.
https://doi.org/10.12957/riae.2015.10340... , but without an epistemological conception of what defines truly interdisciplinary action.

Mariana pointed out how important self-regulation education was for her and her work team to bring health closer to the school and to really discuss how to carry out health promotion actions. Just the fact that the school recognizes health professionals and understands the importance of the activities performed was a gain for this team, i.e., this is the connection that should have been formed at the beginning of the SHP. This is the interdisciplinary link that health professionals expect to be strengthened through projects:

Participation in interdisciplinary projects, continuing education, and different types of meetings that aim to bring together professionals from different areas encourage dialogue and promote interdisciplinarity among them³⁴34 Velloso MP, Guimarães MBL, Cruz CRR, Neves TCC. Interdisciplinaridade e formação na área de saúde coletiva. Trab Educ Saude. 2016; 14(1):257-71. Doi: https://doi.org/10.1590/1981-7746-sip00097.
https://doi.org/10.1590/1981-7746-sip000... . Several participants mentioned the importance of continuing education for interdisciplinary activities. Angélica argued that the connection between health and education is important, and that everyone involved with students should know what activities will be developed so they can all help the projects meet their objectives:

Ubiratan thought that participating in the continuing education program was important, despite difficulties in developing activities due to lack of a pedagogical connection with the school. Ubiratan’s report agrees with something reported in other studies: health professionals are aware of and highlight the importance of working with education professionals to develop health planning and actions in schools, which makes it clear that, for health to be effectively promoted at schools, it is necessary to build dialogue between the two teams³¹31 Barros JPP, Luz PCM. Saúde na escola: que discursos circulam entre profissionais de saúde e educação? Rev Artes Educar. 2015; 1(1):115-32. Doi: https://doi.org/10.12957/riae.2015.10340.
https://doi.org/10.12957/riae.2015.10340... :

Strengthening the interdisciplinary relationship between health and education should ensure better involvement among professionals. Janne suggested that communication between teams can also avoid work overload, because by organizing each other’s activities and the school curriculum, the professionals understand their own roles and can better organize their work. Since all professionals work toward achieving joint work goals in addition to their routine work, interdisciplinarity can complement the team and assist in its organization, rather than increase the existing workload. Janne reported the importance of continuity in health actions:

Organization and a division of labor are needed for the involved professionals to avoid overload. Since only those who take charge of school activities are able to do so, the others simply delegate the responsibilities they face. This shows the difficulty inherent to teamwork and the bureaucracy involved in the internal demands of the team. There is a great need for permanent coordination between the health and education teams so that systematized health promotion projects can begin through joint planning and be performed by both the health and education teams¹⁸18 Penso M, Brasil KCTR, Arrais AR, Lordello SR. A relação entre saúde e escola: percepções dos profissionais que trabalham com adolescentes na atenção primária à saúde no Distrito Federal. Saude Soc. 2013; 22(2):542-53. Doi: https://doi.org/10.1590/S0104-12902013000200023.
https://doi.org/10.1590/S0104-1290201300... . Some important aspects in building partnerships between schools and health units should be remembered, such as: the health unit must have an active role, including initiative in developing the projects; there should be greater exchange and involvement between health and education; there is a need for a real school health team¹⁷17 Faria HA, Carvalho GS. Escolas promotoras de saúde: fatores críticos para o sucesso da parceria escola-centro de saúde. Rev Port Saude Publica. 2004; 22(2):79-90..

Implications for studies on interdisciplinarity

The continuing education program encouraged participants to think about interdisciplinary relationships and develop health promotion projects at school. Thus, the program presented new possibilities, including the necessary coordination between professionals from different areas around a common pedagogical objective, which corroborates the need for continuing education to build a collective and collaborative concept of health promotion¹³13 Pereira MD, Pereira PLG, Faria RGS, Cordeiro DR, Viegas SMF. Intersectoral actions between health and education: notes on the Health at School Program. Physis. 311(2):e310224. Doi: https://doi.org/10.1590/S0103-73312021310224.
https://doi.org/10.1590/S0103-7331202131... ^,3535 Medeiros ER, Pinto ESG, Paiva ACS, Nascimento CPA, Rebouças DGC, Silva SYB. Facilidades e dificuldades na implantação do Programa Saúde na Escola em um município do nordeste do Brasil. Rev Cuid (Bucaramanga). 2018; 9(2):2127-34. Doi: http://dx.doi.org/10.15649/cuidarte.v9i2.514.
https://doi.org/10.15649/cuidarte.v9i2.5... .

Although the challenge of constructing new knowledge remains, it is not dependent on specific fields but arises from their integration. It is clear that the continuing education program participants perceived that, for health promotion actions to happen in schools, there must be dialogue between professionals from both areas to develop set common goals.

Interdisciplinarity should help professionals promote health beyond the school walls, including students’ families and the school’s community. The participation of different sectors in health promotion should be encouraged, and the continuing education program seems to have been effective in this regard. Thinking about health self-regulation was considered a challenge to actions promoting dialogue between health and education professionals, as well as to joint actions in the school context. Applying self-regulation to children in the classroom, as well as to the involved professionals, is important for a complete cycle of action.

It is necessary for everyone to develop habits of observation, planning, execution and evaluation of their processes, so the educational process and changes of habit will be complete. The continuing education program helped participants understand that everyone can self-regulate, each at their level of development and learning³⁶36 Rosário P, Núñez JC, González–Pienda J. Auto-regulação em crianças sub-10. Projecto Sarilhos do Amarelo. Porto: Porto Editora; 2007.. Thus, exercising self-regulation during the program was a means of developing interdisciplinary thinking about the health promotion projects that can be developed at schools.

Other studies have confirmed that there are still difficulties in the relationship between education and health professionals, especially regarding excessive bureaucracy, lack of time, scarcity and overload of professionals and the lack of preparation for developing joint actions, as well as a lack of motivation to work in the school environment. This shows the need to encourage programs that bring the theory behind policies closer to professional practice¹⁷17 Faria HA, Carvalho GS. Escolas promotoras de saúde: fatores críticos para o sucesso da parceria escola-centro de saúde. Rev Port Saude Publica. 2004; 22(2):79-90.^,1818 Penso M, Brasil KCTR, Arrais AR, Lordello SR. A relação entre saúde e escola: percepções dos profissionais que trabalham com adolescentes na atenção primária à saúde no Distrito Federal. Saude Soc. 2013; 22(2):542-53. Doi: https://doi.org/10.1590/S0104-12902013000200023.
https://doi.org/10.1590/S0104-1290201300... .

The challenges involved in developing continuing educational programs in the SHP context have increased in recent years. Such challenges have a direct impact on interdisciplinary work, regarding the definition of tasks and roles expected from each professional, the lack of financial resources, and the excessive workload necessary to construct a program that depends heavily on the joint work of health and education professionals⁹9 Silveira CC, Meyer DEE, Félix J. A generificação da intersetorialidade no Programa Saúde na Escola. Rev Bras Estud Pedagog. 2019; 100(255):423-42. Doi: https://doi.org/10.24109/2176-6681.rbep.100i255.3807.
https://doi.org/10.24109/2176-6681.rbep.... ^,3737 Medeiros ER, Holanda LMSL, Pinto ESG, Paiva ACS, Medeiros HIB, Silva SYB. Structure of services and material health resources associated with the School Health Program. Rev Bras Enferm. 2020; 73(6):e20190073. Doi: https://doi.org/10.1590/0034-7167-2019-0073.
https://doi.org/10.1590/0034-7167-2019-0... . This demonstrates the importance of interdisciplinarity to overcome problems such as the lack of sharing responsibilities and the centralization of power, as well as to achieve intersectoral action as a public policy³⁸38 Chiari APG, Ferreira RC, Akerman M, Amaral JHL, Machado KM, Senna MIB. Rede intersetorial do Programa Saúde na Escola: sujeitos, percepções e práticas. Cad Saude Publica. 2018; 34(5):e00104217. Doi: https://doi.org/10.1590/0102-311X00104217.
https://doi.org/10.1590/0102-311X0010421... .

When there is interdisciplinary work, there is a tendency for fragmented activities and lack of continuity to disappear. In bringing health units and schools together, their intentions and needs are combined, which leads to better health promotion activities for students. Thus, it seems that continuing actions can lead to positive results, since they are part of a dialogue between different fields that must be articulated around promoting self-regulation.

Final considerations

This study developed a program about self-regulation for self-care and health promotion to enable professionals to work on this issue with students, as well as to bring health and education closer, strengthening interdisciplinary ties that should already exist in the SHP. It was clear that continuing education was needed to create and strengthen the working relationship of the participants, as well as to support the implementation of health education actions in schools. Because the interdisciplinarity being developed through this project is at an early stage and requires much collaboration between health and education professionals, regular continuing education programs should be carried out to assist teams in building new knowledge around a common goal.

Further studies are needed to assess the effects of the program discussed here, which could be conducted through interviews with participants or field intervention follow-up reports to assess its impact on health promotion in the medium and long terms. It should be pointed out that the other themes discussed in the focus groups, which are not addressed here for the sake of brevity, can provide an overview of the participants’ perceptions about the program beyond interdisciplinarity, such as the evaluation and promotion of health and the relationship between family and school. The initiative to create a favorable context for the emergence of interdisciplinary projects in the SHP context (i.e., continuing education in health self-regulation) can lead to permanent coordination between education and health teams that promotes quality of life among school-aged children and young people.

Agradecimentos

The authors would like to thank Luciana Bisio Mattos, Mariana da Silva Bauer, and Maína Hemann Strack for their participation in the elaboration of the research project this study is based on.

References

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