Abstract

This qualitative case study analyzed the meaning of the experience of training the community health worker (CHW) in a city in the south of Brazil, based on the problematizing education approach proposed by the Ministries of Education and Health for a technical course. Interviews were conducted with CHWs who completed the course and health and education managers involved in the development and pedagogical supervision of the course (n=17). The students' portfolios and the course’s Pedagogical Project were analyzed. The textual material was interpreted by content analysis supported by the ATLAS.ti software. The course enhanced the CHWs’ knowledge on how to approach and guide families, improved their communication and interpersonal skills, and broadened their understanding of health by including social determinants of the health-disease process, preparing them to deal with complex problems. This brought security, confidence and tranquility to the work process. The problematizing education approach, which greatly values active teaching-learning-assessment methodologies, promoted learning connected with the experiences of the CHWs. The course also fostered the CHWs’ feeling of belonging to a team. Challenges were observed regarding the understanding/execution of the active methodologies. Research on the training of CHWs and on the assessment of their work, involving the perception of teams and users, is recommended.

Keywords:
Community Health Workers. Education; Continuing. Family Health Strategy. Primary Health Care. Unified Health System.

Introduction

Work in the area of health is marked by the interaction between knowledge, practice and technology, which requires of professionals high-quality training, permanent education, and specific competencies to understand and meet users’ needs (MERHY; FRANCO, 2009MERHY, E. E.; FRANCO, T. B. Trabalho em saúde. In: FIOCRUZ. Dicionário da Educação Profissional em Saúde, 2009. Disponível em: Disponível em: http://www.sites.epsjv.fiocruz.br/dicionario/verbetes/trasau.html . Acesso em: 13 set. 2020.
http://www.sites.epsjv.fiocruz.br/dicion... ; MACHADO; XIMENES NETO, 2018MACHADO, M. H.; XIMENES NETO, F. R. G. Gestão da Educação e do Trabalho em Saúde no SUS: trinta anos de avanços e desafios. Ciênc. saúde coletiva. Rio de Janeiro, v. 23, n. 6, p. 1971-1979, jun. 2018.).

The profession of Community Health Worker (CHW) is recent. Regulated on October 5, 2006 (BRASIL, 2006BRASIL. Lei nº 11.350, de 5 de outubro de 2006. Regulamenta o § 5o do art. 198 da Constituição, dispõe sobre o aproveitamento de pessoal amparado pelo parágrafo único do art. 2o da Emenda Constitucional no 51, de 14 de fevereiro de 2006, e dá outras providências. Diário Oficial [da] República Federativa do Brasil, Poder Executivo, Brasília, DF, 2006. ), this professional has become, within Brazil’s Unified Health System (SUS), an essential worker in the team of the Family Health Strategy (FHS) - the main organization model of Primary Health Care (PHC) in the country. Such importance derives from the fact that they have a broader understanding of health and care, taking into account the territory where the person lives and their reality of life (PAIM , 2011PAIM, J. et al. O sistema de saúde brasileiro: história, avanços e desafios. The Lancet. London, v. 377, n. 9779, p. 1778-1797, 2011. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/artigos/artigo_saude_brasil_1.pdf . Acesso em: 10 jan. 2020.
http://bvsms.saude.gov.br/bvs/artigos/ar... ; LAVOR, 2010LAVOR, A. C. H. O Agente Comunitário: um novo profissional da saúde. In: BRASIL. Ministério da Saúde. Secretaria de Atenção à saúde. Departamento da Atenção Básica. Memórias da saúde da família no Brasil. Brasília, 2010.; SILVA; DALMASO, 2004SILVA, J. A.; DALMASO, A. S. W. Agente de saúde comunitário: o ser, o saber, o fazer. Cad. Saúde Pública , Rio de Janeiro, v. 20, n. 5, p. 1433-1434, set./out. 2004. ). In the organization of PHC, the CHW is, at the same time, an actor in health promotion and a subject who participates in the dynamics of the Health Unit’s catchment area (LOSCO; GEMMA, 2019LOSCO, L. N.; GEMMA, S. F. B. Sujeitos da saúde, agentes do território: o agente comunitário de saúde na Atenção Básica ao imigrante. Interface (Botucatu), Botucatu, v. 23, e180589, 2019. Disponível em: Disponível em: http://www.scielo.br/pdf/icse/v23/1807-5762-icse-23-e180589.pdf . Acesso em: 10 jan. 2020.
http://www.scielo.br/pdf/icse/v23/1807-5... ).

As they are the professionals in the team who first have contact with the families’ reality and health problems, and with the social and environmental issues that influence the population’s health, they create a close connection with the Unit’s users (COSTA , 2013COSTA, S. M. et al. Agente Comunitário de Saúde: elemento nuclear das ações em saúde. Ciênc. Saúde Colet. , Rio de Janeiro, v. 18, n. 7, p. 2147-2156, jul. 2013. ; NASCIMENTO; CORREA, 2008NASCIMENTO, E. P. L.; CORREA, C. R. S. O agente comunitário de saúde: formação, inserção e práticas. Cad. Saúde Pública , Rio de Janeiro, v. 24, n. 6, p. 1304-1313, 2008.). Thus, their responsibilities transcend the health sector and they act in the interface between social work, education and environment, relying, also, on knowledge related to the Human, Social and Political Sciences (REIS; BORGES, 2016REIS, J. R. F.; BORGES, C. F. Contribuições históricas e políticas para a formação de agentes comunitários. Revista Contemporânea de Educação. Rio de Janeiro, v. 11, n. 21, p. 98-120, 2016.).

Understanding the complexity of the CHW’s work process and the need to qualify and value their professional practice, the Ministries of Health and Education have established a framework for technical courses targeted at training CHWs (BRASIL, 2004BRASIL. Ministério da Saúde. Ministério da Educação. Referencial curricular para curso técnico de agente comunitário de saúde. Brasília: Ministério da Saúde, 2004. ). The aim is that they work in accordance with the FHS guidelines without being overburdened, knowing their role and responsibilities (ALMEIDA; BAPTISTA; SILVA, 2016ALMEIDA, M. C. S.; BAPTISTA, P. C. P.; SILVA, A. Cargas de trabalho e processo de desgaste em Agentes Comunitários de Saúde. Rev. Esc. Enferm. USP, São Paulo, v. 5050, n. 11, p. 95-103, 2016. ; MOTA; DOSEA; NUNES, 2014MOTA, C. M.; DOSEA, G. S.; NUNES, P. S. Avaliação da presença da Síndrome de Burnout em Agentes Comunitários de Saúde no município de Aracaju, Sergipe, Brasil. Ciênc. Saúde Colet. , Rio de Janeiro, v. 19, n. 12, p. 4719-4726, dez. 2014.; COSTA , 2013COSTA, S. M. et al. Agente Comunitário de Saúde: elemento nuclear das ações em saúde. Ciênc. Saúde Colet. , Rio de Janeiro, v. 18, n. 7, p. 2147-2156, jul. 2013. ; WAI; CARVALHO, 2009WAI, M. F. P.; CARVALHO, A. M. P. O trabalho do agente comunitário de saúde: fatores de sobrecarga e estratégias de enfrentamento. Rev. Enfermagem. UERJ, Rio de Janeiro, v. 17, n. 4, p. 563-568, out-dez. 2009.). In 2015, by means of Directive 243, the Ministry of Health also instituted the Introductory Course for CHWs, standardizing the minimum number of hours and defining basic curricular components for such training (BRASIL, 2015BRASIL. Ministério da Saúde. Portaria nº. 243 de 25 de setembro de 2015. Dispõe sobre o Curso Introdutório para o Agente Comunitário de Saúde e Agente de Combate às Endemias e seu conteúdo. Diário Oficial [da] República Federativa do Brasil, Poder Executivo, Brasília, DF, 2015. ).

Despite the existence of movements targeted at the qualification of CHWs and the strategic role of this professional in the expansion and consolidation of PHC in Brazil, a systematic review of their work in Brazil has shown that, according to them, their training is insufficient. The weaknesses reported in the review were: excessive standardization of contents, which approach predominantly technical and scientific themes and do not include local reality data; insufficient focus on theoretical and practical aspects that can help them deal with issues related to their work routine (handling of family and social problems); and the reduced number of hours allocated to such activities (ALONSO; BÉGUIN; DUARTE, 2018ALONSO, C. M. C.; BÉGUIN, P. D.; DUARTE, F. J. D. M. Trabalho dos agentes comunitários de saúde na Estratégia Saúde da Família: metassíntese. Rev. Saúde Pública, São Paulo, v. 52, n. 14, p. 1-13, 2018.).

This research analyzes the meaning of the experience of CHW training in a city located in the south region of Brazil, based on the problematizing education proposal present in the theoretical framework for the technical course of the Ministries of Education and Health. It investigated the perspective of students and of managers connected with the Municipal Health Department and educational institutions involved in the implementation, development and pedagogical supervision of the course.

Methodology

This qualitative research with a phenomenological approach (MERLEAU-PONTY, 2006MERLEAU-PONTY, M. Fenomenologia da percepção. São Paulo: Martins Fontes, 2006.) focused, as a case study, on CHW training in a technical course based on the problematizing education proposal. The pedagogical proposal of the course is presented on Box 1.

The study was carried out in a city located in the south region of Brazil, where all the stages of the technical course took place, between 2015 and 2017. Of the 136 CHWs of the city, 45 completed the course, divided into two classes. The research subjects were the CHWs that completed the technical course, who work in the city’s 14 Family Health Units (n=45), health managers from the Municipal Health Department who participated in the implementation and development of the technical course (n=2), and an education manager linked to the educational institutions that monitored the course’s pedagogical development (n=1).

The CHWs were selected intentionally, according to the representativeness of the 14 Health Units where they worked. The inclusion criterion was that they must have completed the technical course. The CHWs who were on vacation or on other types of leave during the interview stage were excluded from the research. As for the managers, their involvement in the course was the reason for inviting them to participate in the study. The selected health managers had been involved in the matter since the agreement for offering the course was made; they also acted as teachers-facilitators. The selected education manager, in turn, participated in the training of the city’s facilitators and provided pedagogical support during the whole course.

Both the teachers-facilitators (responsible for the theoretical encounters) and the supervisors (coordinated the CHWs and supervised the theoretical-practical field activities) worked in the Municipal Health Department and were trained by the partner educational institutions (Hospital Público de Ensino and Instituto Federal de Educação).

Individual semi-structured interviews were performed (Box 2), recorded and transcribed, and the CHWs’ portfolios and the Pedagogical Project of the Course (PPC) were submitted to a documentary analysis. The portfolios were requested of the CHWs when they were invited to participate in the research.

Regarding the interviews performed with CHWs, sample size was determined according to the evaluation of the density of the textual material, allied with the criterion of theoretical saturation, that is, no more interviews were performed when we concluded that new discourses did not add significant information in view of the research objectives (FONTANELLA , 2011FONTANELLA, B. J. B. et al. Amostragem em pesquisas qualitativas: proposta de procedimentos para constatar saturação teórica. Cad. Saúde Pública , Rio de Janeiro, v. 27, n. 2, p. 389-394, fev. 2011.). Overall, 17 interviews were performed, from December 2017 to January 2018. Each interview lasted approximately 40 minutes, totaling 13 hours of recorded material.

The produced material was interpreted by thematic content analysis (BARDIN, 2011BARDIN, L. Análise de conteúdo. São Paulo: Edições 70, 2011.), with the support of the software Visual Qualitative Data Analysis (ATLAS.ti). This analysis followed the stages of pre-analysis (corpus), exploration of the material (crude data codified in themes and then in categories), treatment of the collected data and, finally, interpretation according to the theoretical framework and proposed objectives (BARDIN, 2011BARDIN, L. Análise de conteúdo. São Paulo: Edições 70, 2011.).

The research was approved by the Research Ethics Committee (Opinion no. 2.421.138) and by the city’s Municipal Center of Education and Public Health. To preserve secrecy concerning the participants’ identity in the interviews, each one received a number from E1 to E17 with the following codification: EE - Student Interview (CHW); EGS - Health Manager Interview; EGE - Education Manager Interview. The textual material (portfolios and Pedagogical Project of the Course) was identified in the results as AP (analysis of portfolio) and APPC (analysis of the Pedagogical Project of the Course).

Results

A total of 14 CHW and 3 managers participated in the study (Table 1).

The main themes were identified; subsequently, categories - meaning codification units - emerged. These categories express the form of organization and presentation of the results (Box 3).

Expectations in relation to training: Opportunity of professional education, qualification and technical learning

All the CHWs who were part of the city’s Family Health teams were invited to enroll and participate in the technical course (single selection criterion), but not everyone did. On the one hand, the CHWs expected that the training provided in the course would be more than ‘a qualification’, bringing the possibility of “discovering what it means to be a CHW” (EE5). On the other hand, there was also the perception that the course “would be one more qualification where people go there and say everything we already know” (EE9), “that it wouldn’t be worth taking the course because I’ve been a community worker for a very long time. What am I going to learn in the course?” (EE3). For this reason, some CHWs were not interested in enrolling. “Many CHWs didn’t want to take the course. [...] They said, ‘This won’t make a difference to us. It won’t add anything because we’re already working in the area” (EE4).

The CHWs also reported the expectation that the course would provide learning related to “more tangible things for my work”, like “measuring blood pressure at home” (EE10EE11), “measuring blood glucose”, “being awarded a technical course in Nursing” (EE1), which might bring more respect and recognition to the profession. “[...] my God, we would be much more recognized!” (EE1).

The CHWs recognized that the explanations about the course’s objectives that were given in the first classes were important and made them receptive to learn new things. “[...] we learned many interesting things that we hadn’t even imagined” (EE11).

More than classes, encounters: From ‘sitting down and copying from the blackboard’ to the challenge of shared learning

Understanding that the training was targeted at workers whose professional identity is gradually constituted during the daily work routine - “in-practice training” -, the course valued the CHW’s work experience, in a participatory educational process.

It was a pedagogical proposal that aimed at stimulating the use of active teaching-learning-assessment methodologies that valued the students’ life and work experiences, encouraging a “[...] posture of research, curiosity, reflection, cooperation and solidarity, establishing a relationship with the environment that surrounds them. Such methodologies aid human education and students’ action in the world” (APPC).

This pedagogical strategy of “methodologies that related daily practice to the theoretical knowledge that was presented” (EGS16), “about what you are doing”, valuing the “experiences of the CHWs” (EE9), proved to be a facilitator of learning.

The course was organized in semesters and disciplines, with 1,300 hours distributed over three semesters. The theoretical classes occurred twice a week (16 hours per week/96 hours per semester) and included moments of individual activities, but collective activities in groups predominated. The theoretical classes were participatory and the point of departure was always a film or group reading about a theme of interest to the CHW (initial group dynamics). Then, the triggering discussion about the matter in question started and everybody was free to speak, express their opinions and exchange ideas. After the discussion, the CHWs developed textual productions in groups, workshops, role-plays or parodies. The CHWs were released from their working hours to participate in the theoretical classes. The course’s practical activities, in turn, occurred in the CHW’s work context, with health teams and users-families-communities. The activities ranged from interviews with users and team professionals to discussions, in team meetings, of specific themes approached in the course (APPC).

The methodology was perceived as “non-traditional”: instead of “sitting down and copying from the blackboard” (EE5), it presented “very participatory classes. If anyone had a question, they asked it immediately, everybody together” (EE9). “It wasn’t tiresome, it wasn’t a class where we just read, read, read. [...] we always had the opportunity to speak, talk to each other and express our opinion” (EE10). The workshops and dynamics that provided theoretical knowledge also stimulated the development of “the CHWs’ human skills” (EGS16), which enabled them to “follow” and “internalize the contents” (EE5EE8), and maintained them stimulated and interested in the course.

In the CHWs’ perception, the dynamics, experience reports, knowledge exchanges and role-plays of the work routine allowed them to identify themselves with “day-to-day situations of the Unit” (EE12), making them look “at reality with other eyes” (EE13) and search for “more than one way to solve problems” (AP).

The CHWs realized the power of shared learning in discussion groups with different compositions, where everyone helped each other to understand what was being discussed. It was a “completely new” collective construction to these students, aimed at understanding and discussion, and favoring the emergence of other ideas. “Many things we learned together, it was a joint construction” (EE5).

Popular education principles of exploring creativity and freedom of thought brought a feeling of empowerment to the students, due to the capacity for creation they experienced. “This empowers the student. They see they are capable of many things, even of creating, which is something that we’re not encouraged to develop in life” (EGE17).

In this educational process, the relationship between teachers-facilitators and students cannot be vertical and hierarchical; it should be a horizontal relationship of cooperation and mutual understanding. The overall perception was that the interaction between teachers-facilitators and CHWs was marked by an “exchange of ideas” (EE3), in which the student questioned and contributed their own knowledge and previous experiences and the facilitators also learned with the students: “they said themselves, more than once, that they were learning certain matters together with us” (EE5).

Even shy CHWs developed gradually with each presentation in the classroom, acquiring a “flexibility” that is important for their daily work.

Expressions of an educational process for work and for life

In the CHWs’ perception, the training received in the technical course provided knowledge that facilitated the “approach to the families”, which brought “security and confidence” to their work in primary care, “inside and outside the Unit” (AP).

With the course, the CHWs’ understanding of health was “amplified” (EE7): “aspects of legislation and people’s rights” were included (EE1) and they started to perceive people’s illness “based on social, psychological and workplace problems” (EE1). They realized that “each home is unique” (AP) and learned “where we had to focus our attention, what to observe, ask, look at” (EE12), “what can be behind that disease, that person and bring this here, to the Unit’s professionals, so that we can outline, together, the therapeutic plan” (EE5). Thus, the home visit became “a universe of possibilities” (AP), not “simply a formal visit, you’ll have to look at the entire context, environment issues, social issues, family issues, what is implicated there, what intertwinements in that context are influencing the health-disease process” (EGE17).

Although they have the team to share issues with, the CHWs believe their work is “lonely” (EE14), as they are the ones who are in the person’s home, in close contact with the families. “You are only one person, sometimes, to deal with 500, 600 people, each one with their own problem, and they want you to give a solution” (EE3).

After completing the course, these professionals felt “calmer” (EE3EE14), knowing better how to deal with frustrations and avoiding to “suffer” (EE14), for they understood the limitations of their work (EE2) and stopped feeling guilty when they cannot solve people’s problems by themselves. “[...] I have to share, I have to try and help and not suffer because of the problems” (EE14).

Another aspect that deserves to be highlighted about the importance of this training was the CHWs’ understanding of their role and responsibilities in the FHS team, which was one of the pedagogical aims of the course.

Before taking the course, the CHWs believed their responsibilities were “to enroll users and enable people’s access to the Health Unit”, a “carrier of information” from the service to users (EE5). With the training received in the technical course, the CHWs’ perception of their work was transformed. It started to involve health promotion and education activities for people, families and communities - healthy eating, practice of exercises, caring for their environment, making the community pay attention to certain risk factors there may be in their territory (EE5) -, avoiding practices seen as “paternalistic”, like “going with the person to the doctor, going with them to the hospital for tests”, “doing things for the other” (EE3EE9).

This understanding of their competencies generated in the CHWs the feeling that they are “part of the team” (EE3) and “can speak, express opinions, provide the point of view of the user” (EE8), as “no one is better than anyone” (EE5). The CHWs perceived that their teammates could also see them as “health professionals” and no longer “as a go-between” (EE5), valuing the knowledge brought by the CHW and this professional’s role in the healthcare process.

The knowledge acquired in the course made the CHWs become critical professionals, which affected the very functioning of the services, as they started to use new “work tools” and contribute to “team meetings, to the organization of the Unit’s action plan, to the interaction with the community” (EE3).

To the CHWs, the course provided more than technical gains regarding how to do things in the profession: it improved their interpersonal skills, as they became “better human beings” (EE2), with greater capacity for “being in the other’s shoes” (EE9). “[Before the course] I used to push people away with my way of being, I fought a lot with people” (EE11).

The reflections brought by the course on complex themes - drug users, violence against women, male chauvinism, feminism, social assistance programs - helped the CHWs remove their “prejudices” and “pre-judgment”. Due to this, they felt it easier to deal with people, to “see the other, a human being” (EE2EGS15).

To the managers, it was very gratifying to participate in the students’ growth. Being part of the process also made them learn.

Challenges that marked the educational process: What can qualify a CHW training proposal

Some challenges were part of the development of the course. When the active methodologies were presented to the CHWs in work groups, they had difficulties and felt discomfort. Moreover, the CHWs needed time to adapt to the presence of a teacher-facilitator, as they expected that the educators would have characteristics of teachers who transmit knowledge, reporting that “the person at the front needs to transmit security to those in the back” and that the teachers, sometimes, “seemed not to have prepared the lesson” (EE11). As the activities developed, however, the group gradually assimilated the active methodologies.

Managers and CHWs also perceived situations in which the teachers-facilitators had difficulties in understanding the methodology of the proposed classes - “how to do it”. Due to this, the first classes were disorganized, despite the pedagogical help received from the course management.

The teachers-facilitators’ difficulty affected the course’s teaching experiences. On some occasions, the CHWs perceived that too much time was spent in discussions about certain themes without a conclusion, or that no one understood the objective of using the active methodology.

The supervisors of the CHWs’ work in the Health Units also had difficulties in understanding the activities proposed by the course, which led to situations of conflict between them and the CHWs.

Furthermore, the supervisors should monitor the construction of the CHWs’ portfolios, but that did not always happen. According to some reports, the supervisors “never looked” (EE6) at the portfolios, which generated a feeling of sadness among the CHWs.

The technical course as a mark of an experience and the permanent education perspective

The technical course lasted one year and a half and was an experience that marked its participants. One of the marks of this experience was the graduation ceremony that was held at the end of the course. This moment affected not only the students’ professional life, but also the personal one.

The field activities in different territories was also considered remarkable in the experience.

To the CHWs who were starting in the profession, taking the course enabled them to discover the “passion” the professionals have for their work in FHS, which had not been understood by this group. “To me, it was only one more job I was paid to do. After I took the course, I started feeling this passion for Family Health that I see in people” (EE8).

The managers felt the significant sensations of “mission accomplished, of having supported, contributed in some way, having made the project viable, having believed that the project would be possible”, for even with the difficulties they found along the way, the CHWs’ enthusiasm made them move forward and the project became “very contagious” (EGE17).

The “partnership” among classmates and between them and the teachers-facilitators (EE10), as well as the “knowledge exchange among people” (EE7), marked the training experience.

The CHWs reported they would like to continue with permanent education, so they do not limit themselves to the “mechanical” act of repeating tasks (EE6) or “just speaking about cases”, and continue “exchanging ideas”, “improving” their work (EE3) and “transforming the daily routine” (EE10). Taking the course generated “learning” and opened a “range” of possibilities, awaking desires and perspectives. “I want to start reading Paulo Freire’s work this year [...] I’ll sit the ENEM [National High School Exam], I want to continue studying!” (EE2).

At the end of the course, the CHWs felt “gratitude to teachers and classmates” for having lived this educational experience, marked by learning with “pleasure” and “meaning”, and which brought the will to improve their professional action (EE14).

Discussion

This study analyzed the meaning of the experience of an educational process based on the problematizing education approach in a technical course for Community Health Workers, from the perception of students and managers. We used the theoretical perspective of phenomenology as a study of signification and essences (MERLEAU-PONTY, 2006MERLEAU-PONTY, M. Fenomenologia da percepção. São Paulo: Martins Fontes, 2006.), based on the concepts of perception and experience.

Perception is the way in which things come to us through our senses. The information brought by perception should be in a prominent place, as it enables a more authentic truth compared to what is constructed by thinking, which is frequently more valued. Perception is not a construction; it is a way of feeling the world (MATTHEWS, 2011MATTHEWS, E. Compreender Merleau-Ponty. 2. ed. Petrópolis: Vozes , 2011.). Experience, in turn, according to Larrosa (2002LARROSA, J. B. Notas sobre a experiência e o saber de experiência. Revista Brasileira de Educação, Rio de Janeiro, n. 19, p. 20-28, 2002.), is “what happens to us, what occurs with us, what touches us” (p. 21). People undergo many events throughout life, but not all of them will really touch them and become experiences. Experience is totally individual; the same event can occur to different people, in the same place, at the same time, but each of them may have a distinct, unique, private experience, or they might not have an experience at all (LARROSA, 2002LARROSA, J. B. Notas sobre a experiência e o saber de experiência. Revista Brasileira de Educação, Rio de Janeiro, n. 19, p. 20-28, 2002.). For an experience to exist, therefore, it is necessary that a person exists, as experience is directly related to feelings and sensations. For it to occur, time is also necessary. Time to think, look, hear and feel (PIRES, 2014PIRES, E. G. Experiência e linguagem em Walter Benjamin. Educ. Pesqui., São Paulo, v. 40, n. 3, p. 813-828, jul./set. 2014.).

This study showed experiences generated by an educational process with meanings expressed by the qualification of CHWs’ work. By taking the technical course, the CHWs acquired knowledge and information on how to approach and guide families during home visits, and amplified their understanding of the concept of health. The things they learned brought “more security and confidence” and prepared them to deal with complex situations and frustrations inherent in the work process.

Furthermore, the problematizing education experience in the technical course proved to be powerful to promote the recognition of the CHWs’ responsibilities in the team and in interventions with users. This deserves to be highlighted here because this professional’s responsibilities have not been well dimensioned (ALONSO; BÉGUIN; DUARTE, 2018ALONSO, C. M. C.; BÉGUIN, P. D.; DUARTE, F. J. D. M. Trabalho dos agentes comunitários de saúde na Estratégia Saúde da Família: metassíntese. Rev. Saúde Pública, São Paulo, v. 52, n. 14, p. 1-13, 2018.) - they are broad and poorly delimited (TOMAZ, 2002TOMAZ, J. B. C. O agente comunitário de saúde não deve ser um “super-herói”. Interface comun. saúde educ. Botucatu, v. 6, n. 10, p. 75-94, fev. 2002. ). Assigning excessive functions to the CHW is not uncommon (QUEIRÓS; LIMA, 2012QUEIRÓS, A. A. L.; LIMA, L. P. A institucionalização do trabalho do agente comunitário de saúde. Trabalho, Educação e Saúde, Rio de Janeiro, v. 10, n. 2, p. 257-81, 2012. ). Any action related to families and territory is assigned to them, as well as bureaucratic activities, which, in fact, should be divided among the team’s professionals. In addition, the CHWs’ work scenario is characterized by isolated and fragmented trainings, out of context and without a logical sequence, precisely because their responsibilities lack a clear delimitation and their very function is not understood (TOMAZ, 2002TOMAZ, J. B. C. O agente comunitário de saúde não deve ser um “super-herói”. Interface comun. saúde educ. Botucatu, v. 6, n. 10, p. 75-94, fev. 2002. ; WAI; CARVALHO, 2009WAI, M. F. P.; CARVALHO, A. M. P. O trabalho do agente comunitário de saúde: fatores de sobrecarga e estratégias de enfrentamento. Rev. Enfermagem. UERJ, Rio de Janeiro, v. 17, n. 4, p. 563-568, out-dez. 2009.; MOTA; DOSEA; NUNES, 2014MOTA, C. M.; DOSEA, G. S.; NUNES, P. S. Avaliação da presença da Síndrome de Burnout em Agentes Comunitários de Saúde no município de Aracaju, Sergipe, Brasil. Ciênc. Saúde Colet. , Rio de Janeiro, v. 19, n. 12, p. 4719-4726, dez. 2014.; ALMEIDA; BAPTISTA; SILVA, 2016ALMEIDA, M. C. S.; BAPTISTA, P. C. P.; SILVA, A. Cargas de trabalho e processo de desgaste em Agentes Comunitários de Saúde. Rev. Esc. Enferm. USP, São Paulo, v. 5050, n. 11, p. 95-103, 2016. ).

The recognition of their responsibilities was constructed throughout the course, being stimulated by the education proposal based on Paulo Freire’s theory of problematizing pedagogy (FREIRE, 2006FREIRE, P. Pedagogia do oprimido. São Paulo: Paz e Terra , 2006.; STRECK; REDIN; ZITKOSKI, 2010STRECK, D. R.; REDIN, E.; ZITKOSKI, J. J. Dicionário Paulo Freire. 2. ed. Belo Horizonte: Autêntica, 2010.). To Freire (2006)FREIRE, P. Pedagogia do oprimido. São Paulo: Paz e Terra , 2006., problematizing is based on the reality that surrounds the subject, on their praxis. The subject searches for solutions to the reality in which they live and becomes capable of transforming it through their own action. At the same time, the subject undergoes transformations and gradually identifies new problems, in a continuous process of search and transformation (FREIRE, 1996FREIRE, P. Pedagogia da autonomia: saberes necessários à prática educativa. São Paulo: Paz e Terra, 1996.; BORDENAVE; PEREIRA, 2008BORDENAVE, J. D.; PEREIRA, A. M. Estratégias de ensino-aprendizagem. 29. ed. Petrópolis: Vozes, 2008.).

Community workers and managers perceived the problematizing methodology as an advantage of the course. Students initially felt some discomfort, as they expected the ‘traditional’ teaching methodology - “sitting down and copying from the blackboard” -, in which the student is a mere spectator, remaining in the passive position of absorbing and repeating knowledge transmitted by the teacher, without developing criticism and reflection (MITRE , 2008MITRE, S. M. et al. Metodologias ativas de ensino-aprendizagem na formação profissional em saúde: debates atuais. Ciênc. Saúde Colet. Rio de Janeiro, v. 13, n. 2, p. 2133-2144, 2008.). The course’s active methods and dynamic and participatory classes motivated the CHWs to complete the course. Such methods were strategic to the CHWs’ satisfaction with classroom moments (BARBOSA; MOURA, 2013BARBOSA, E. F.; MOURA, D. G. Metodologias ativas de aprendizagem na educação profissional e tecnológica. B. Tec. Senac, Rio de Janeiro, v. 39, n. 2, p. 48-67, maio-ago. 2013.).

This shows the importance of assuming the political nature of education, stimulating the student’s critical posture, as problems/themes to study are intentionally obtained from the observation of reality, with all its complexities (CYRINO; TORALLES-PEREIRA, 2004CYRINO, E. G.; TORALLES-PEREIRA, M. L. Trabalhando com estratégias de ensino-aprendizado por descoberta na área da saúde: a problematização e a aprendizagem baseada em problemas. Cad. Saúde Pública, Rio de Janeiro, v. 20, n. 3, p. 780-788, maio/jun. 2004.; BERBEL, 1998BERBEL, N. A. N. A problematização e a aprendizagem baseada em problemas. Interface comun. saúde educ., Botucatu, v. 2, n. 2, p. 139-154, 1998. ). This educational approach is supported by the process of learning through discovery, in such a way that students do not receive contents in their final form; rather, they receive problems so that they can make their discoveries and build knowledge, always taking their previous experiences into account. Therefore, education is established on the premise that the student builds knowledge by undergoing experiences of significant learning (CYRINO; TORALLES-PEREIRA, 2004) that promotes changes (STRECK; REDIN; ZITKOSKI, 2010STRECK, D. R.; REDIN, E.; ZITKOSKI, J. J. Dicionário Paulo Freire. 2. ed. Belo Horizonte: Autêntica, 2010.).

Besides promoting knowledge targeted at the profession’s specific responsibilities, the technical course’s pedagogical practice was capable of educating ethical, historical, reflective, transformative and humanized beings (CYRINO; TORALLES-PEREIRA, 2004CYRINO, E. G.; TORALLES-PEREIRA, M. L. Trabalhando com estratégias de ensino-aprendizado por descoberta na área da saúde: a problematização e a aprendizagem baseada em problemas. Cad. Saúde Pública, Rio de Janeiro, v. 20, n. 3, p. 780-788, maio/jun. 2004.). In the reports on the course, the CHWs perceived themselves as better human beings, with greater capacity to include the other’s perspective in the care process. This characterizes empathy, which can influence the quality of the relationship between health professional and user (STRECK, 2016STRECK, D. R. Metodologias participativas de pesquisa e educação popular: reflexões sobre critérios de qualidade. Interface comun. saúde educ. Botucatu, v. 20, n. 58, p. 537-547, 2016.) and enhance the creation of a bond between them. The bond, as a relational technology, plays an important role in the care process because it favors the shift from the disease-centered care model to the person-centered one (PINHEIRO; OLIVEIRA, 2011PINHEIRO, P. M.; OLIVEIRA, L. C. A contribuição do acolhimento e do vínculo na humanização da prática do cirurgião-dentista no Programa Saúde da Família. Interface comun. saúde educ. Botucatu, v. 15, n. 36, p.187-198, jan./mar. 2011.).

The importance given to the active teaching-learning-assessment methodologies throughout the educational process allowed the CHWs to occupy the position of protagonists regarding their learning. Curiosity (CARDOSO , 2017CARDOSO, M. L. M. et al. A Política Nacional de Educação Permanente em Saúde nas Escolas de Saúde Pública: reflexões a partir da prática. Ciênc. Saúde Colet. , Rio de Janeiro, v. 22, n. 5, p. 1489-1500, 2017.) and decision-making were stimulated through action-reflection-action (FREIRE, 2006FREIRE, P. Pedagogia do oprimido. São Paulo: Paz e Terra , 2006.; BERBEL, 1998BERBEL, N. A. N. A problematização e a aprendizagem baseada em problemas. Interface comun. saúde educ., Botucatu, v. 2, n. 2, p. 139-154, 1998. ). Besides hearing, the CHWs also spoke, asked questions, discussed and problematized, building and sharing knowledge, instead of absorbing it in a passive way (BARBOSA; MOURA, 2013BARBOSA, E. F.; MOURA, D. G. Metodologias ativas de aprendizagem na educação profissional e tecnológica. B. Tec. Senac, Rio de Janeiro, v. 39, n. 2, p. 48-67, maio-ago. 2013.).

The discomfort reported by the CHWs and the teachers-facilitators’ difficulty in conducting theoretical activities through active teaching-learning-assessment methodologies represent the challenges of this educational course. In this proposal, the teacher’s role as the single source of information and knowledge is deconstructed, which requires a change in posture towards an educator who guides and facilitates the learning process, conducting reflections with students (BARBOSA; MOURA, 2013BARBOSA, E. F.; MOURA, D. G. Metodologias ativas de aprendizagem na educação profissional e tecnológica. B. Tec. Senac, Rio de Janeiro, v. 39, n. 2, p. 48-67, maio-ago. 2013.). Based on a problem, other developments of the theme emerge, making educator and students have contact with situations or contents that had not been predicted initially, but which will need to be investigated because they are relevant to the understanding of the problem (CYRINO; TORALLES-PEREIRA, 2004CYRINO, E. G.; TORALLES-PEREIRA, M. L. Trabalhando com estratégias de ensino-aprendizado por descoberta na área da saúde: a problematização e a aprendizagem baseada em problemas. Cad. Saúde Pública, Rio de Janeiro, v. 20, n. 3, p. 780-788, maio/jun. 2004.).

It is important to highlight the different expectations that the CHWs had concerning the course. Unlike the isolated trainings with no connection to the CHWs’ work needs, the results showed that the course enabled an “experience” of permanent health education that promotes and produces meanings (CECCIM; FEUERWERKER, 2004CECCIM, R. B.; FEUERWERKER, L. C. M. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis: Revista de Saúde Coletiva, Rio de Janeiro, v. 14, n. 1, p. 41-65, 2004. ; MICCAS; BATISTA, 2014MICCAS, F. L.; BATISTA, S. H. S. S. Educação permanente em saúde: metassíntese. Rev. Saúde Pública , São Paulo, v. 48, n. 1, p. 170-85, 2014.; CARDOSO , 2017CARDOSO, M. L. M. et al. A Política Nacional de Educação Permanente em Saúde nas Escolas de Saúde Pública: reflexões a partir da prática. Ciênc. Saúde Colet. , Rio de Janeiro, v. 22, n. 5, p. 1489-1500, 2017.). This is achieved through the importance given to students’ previous experiences and knowledge, the search for alternative solutions to problems based on the contribution of each professional’s accumulated knowledge, and the connection between theory and the CHWs’ daily work routines (CECCIM; FEUERWERKER, 2004CECCIM, R. B.; FEUERWERKER, L. C. M. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis: Revista de Saúde Coletiva, Rio de Janeiro, v. 14, n. 1, p. 41-65, 2004. ; MERHY; FEUERWERKER; CECCIM, 2006MERHY, E. E.; FEUERWERKER, L. C. M.; CECCIM, R. B. Educación permanente en salud: una estrategia para intervenir en la micropolítica del trabajo en salud. Salud Colectiva, Buenos Aires, v. 2, n. 2, p. 147-160, 2006.; CARDOSO , 2017CARDOSO, M. L. M. et al. A Política Nacional de Educação Permanente em Saúde nas Escolas de Saúde Pública: reflexões a partir da prática. Ciênc. Saúde Colet. , Rio de Janeiro, v. 22, n. 5, p. 1489-1500, 2017.). These positive results in relation to students’ work and life have also been found by Souza (2014SOUZA, K. M. et al. Práticas pedagógicas de Educação Popular em Saúde e a formação técnica de Agentes Comunitários de Saúde no município do Rio de Janeiro, Brasil. Interface comun. saúde educ. Botucatu, n. 18, v. 2, p. 1513-1522, 2014.) when they analyzed the version of the technical course for CHW training that was offered in the city of Rio de Janeiro.

The CHWs investigated in this research expected to learn technical Nursing procedures that could make users recognize them as professionals. This has been a tendency when we think about the CHW’s action (SIMAS; PINTO, 2017SIMAS, P. R. P.; PINTO, I. C. M. Trabalho em saúde: retrato dos agentes comunitários de saúde da região Nordeste do Brasil. Ciênc. Saúde Colet. Rio de Janeiro, v. 22, n. 6, p. 1865-1876, jun. 2017.; NUNES , 2002NUNES, M. O. et al. O agente comunitário de saúde: construção da identidade desse personagem híbrido e polifônico. Cad. Saúde Pública . Rio de Janeiro, v. 18, n. 6, p. 1639-1646, dez. 2002.). Such tendency has been fostered by the update of the National Primary Care Policy (PNAB), in 2017, and by Law no. 13.595, of 2018, which regulated the reformulation of responsibilities, working day, working conditions, professional education level, technical and continued education courses, and payment of transport for CHWs and Endemic Diseases Combat Agents (BRASIL, 2018BRASIL. Lei nº 13.595, de 5 de janeiro de 2018. Altera a Lei nº 11.350, de 5 de outubro de 2006, para dispor sobre a reformulação das atribuições, a jornada e as condições de trabalho, o grau de formação profissional, os cursos de formação técnica e continuada e a indenização de transporte dos profissionais Agentes Comunitários de Saúde e Agentes de Combate às Endemias. Diário Oficial [da] República Federativa do Brasil, Poder Executivo, Brasília, DF, 2018. ).

Even though the individual and collective activities of disease prevention and health promotion through Popular Education are established among the responsibilities of the CHW, both the 2017 PNAB and Law no. 13.595 give new responsibilities to this professional, such as measuring axillary temperature and blood pressure, measuring capillary blood glucose, and providing guidance/support related to drug administration (BRASIL, 2017; BRASIL, 2018BRASIL. Lei nº 13.595, de 5 de janeiro de 2018. Altera a Lei nº 11.350, de 5 de outubro de 2006, para dispor sobre a reformulação das atribuições, a jornada e as condições de trabalho, o grau de formação profissional, os cursos de formação técnica e continuada e a indenização de transporte dos profissionais Agentes Comunitários de Saúde e Agentes de Combate às Endemias. Diário Oficial [da] República Federativa do Brasil, Poder Executivo, Brasília, DF, 2018. ).

This tendency of valuing biomedical knowledge moves the central axis of the CHW’s work from the educational process to care provision, which may significantly change the healthcare provided in territories and the future of the profession that represents the category with the largest number of professionals in primary care (SILVA , 2018SILVA, J. A.; DALMASO, A. S. W. Agente de saúde comunitário: o ser, o saber, o fazer. Cad. Saúde Pública , Rio de Janeiro, v. 20, n. 5, p. 1433-1434, set./out. 2004. ; SIMAS; PINTO, 2017SIMAS, P. R. P.; PINTO, I. C. M. Trabalho em saúde: retrato dos agentes comunitários de saúde da região Nordeste do Brasil. Ciênc. Saúde Colet. Rio de Janeiro, v. 22, n. 6, p. 1865-1876, jun. 2017.).

The CHW’s characteristic, genuine and most important asset is precisely popular knowledge and knowledge of the social dynamics of their community (BORNSTEIN; STOTZ, 2008BORNSTEIN, V. J.; STOTZ, E. N. Concepções que integram a formação e o processo de trabalho dos agentes comunitários de saúde: uma revisão da literatura. Ciênc. Saúde Colet., Rio de Janeiro, v. 13, n. 1, p. 259-268, jan./fev. 2008.). Such modifications bring the concern about a possible emergence of setbacks in Brazil’s healthcare model. The CHW’s professional specificity is that they create the bond with the population and represent the population’s voice inside the health system. It is through the CHW’s work that the relationship between popular knowledge and action is consolidated in act, the community’s cultural questions are valued, and popular and scientific knowledge are integrated (BRASIL, 2009BRASIL. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. O trabalho do agente comunitário de saúde. Brasília: Ministério da Saúde , 2009. 84p. ).

Therefore, we argue that it is necessary to strengthen this professional’s role in SUS, qualifying their actions in the community as a health promotion agent in a model that interacts with people and reduces health inequalities. To achieve this, the CHW’s training, as well as that of all health professionals, should be based on educational processes that ensure what Almeida Filho (2011, p. 1899)ALMEIDA FILHO, N. Higher education and health care in Brazil. Lancet, London, v. 377, p. 1898-1900, June 2011. considered “the ideal SUS workforce - i.e., skilled, evidence-oriented, well-trained professionals who are committed to equity in health”.

Final remarks

The problematizing education proposal of the technical course for CHWs, valuing active teaching-learning-assessment methodologies and students’ life and work experiences, promoted learning related to their communication skills, which facilitated the approach and guidance to families, and learning related to their interpersonal skills, which made them better human beings with greater capacity for empathy. The course also included the social determinants of the health-disease process in the professionals’ concept of health, amplifying their understanding of the concept and preparing them to deal with complex problems, which brought security, confidence, and tranquility to the work process. It enabled the CHWs to think about and perceive their professional responsibilities in the Family Health team beyond the enrolment of families and facilitation of users’ access to the Health Unit, revealing their responsibility in actions related to health education and promotion for people, families and the community. The CHWs started to feel they belonged to the team. The theoretical-practical activities developed in Health Units took the teams out of the comfort zone, enabling all the team’s professionals, not only the CHWs who participated in the course, to rethink the work process that had been established up to that moment.

If, on the one hand, the course’s methodology enabled the CHWs to follow the contents and maintained them stimulated and interested in the course until the end, on the other hand, its understanding and execution were challenging.

Research on the training of CHWs and on the assessment of their work involving the perception of other professionals of the Family Health Strategy team, as well as users, is recommended to ensure effective teamwork and improve the SUS.¹1H. P. R. da Silva: idealization of the research, construction of the theoretical framework, production and analysis of data, writing of the article. R.F.C. Toassi: idealization and coordination of the research, construction of the theoretical framework, production and data analysis, writing and final review of the article.

References

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