Abstract

Objetivo:

to investigate the characteristics of health communication services taking the Municipal Health Department Councils network in Brazil as a basis.

Methods:

this was a quantitative study with an exploratory design conducted in 2014-2015, using non-probability sampling. Four structured questionnaires were used examining four dimensions: 1) structure of the communication advisory service work; 2) profile of the professionals working in these services; 3) the main duties of these advisory services, and 4) possible variants of municipalities not having this specialized service.

Results:

72 of the 122 participating municipalities did not have a communication advisory service and only two network members had communications directorates; work facilities were precarious, professionals had little length of communication advisory service; they did not have job stability and were not members of the health management councils.

Conclusion:

Although they provide direct advice to health secretaries, the working conditions of communication professionals compromise their planning actions.

Keywords:
Public Health Policies; Unified Health System; Health Management; Health Communication

Introduction

Health communication is considered strategic for the quality of decision-making in the Brazilian National Health System (SUS) and for the development of health promotion actions. The working process of the health communication advisory services must go through organizational processes that encompass their physical structure and the profile those who work in them, as well as and above all the definition of a strategic agenda so that they can respond to the demands of the population for permanent improvements in the ways of informing and communicating health actions.

However, , when examining the organizational characteristics of the Municipal Health Departments (SMS) and of the Municipal Health Department Councils (COSEMS), there is an almost total absence of communication advisory services (Ascom). When they do exist, they are generally focused on campaigns to advertise strategic actions defined by the Brazilian Ministry of Health (MS) within its framework of policies.

Pattern reinforces the operational modes of persuasion, recommendation and culpability of the (re)emergence of health conditions in a given segment of society. Such a culture widens the gap between the current model and a new way of organizing information and geared to disease prevention and control. In other words, a proposal of action in which health communication professionals can contribute to the broadening of the debate about the relevance of the use of epidemiology as a producer of knowledge capable of demonstrating, through communication, the meaning of preventing, protecting and promoting health as a right of citizenship.¹1. Cunha JP. Comunicação em vigilância sanitária. In: Campos FE, Werneck GAF, Tonon LM (Org.). Vigilância sanitária [Internet]. Belo Horizonte: Coopmed, 2001 [citado 2018 mar 6]. (Cadernos de Saúde, 4). p. 105-13. Disponível em: Disponível em: http://www.ccs.saude.gov.br/visa/publicacoes/arquivos/cad_saude4.pdf
http://www.ccs.saude.gov.br/visa/publica...

Communication, from the point of view of the the health service manager, can act as a mediator of dialog between public actions, public opinion and the public sphere. In cooperation with the specific communication strategies developed by professionals in this area, communication takes on the purpose greater enlightenment and engagement of society, which Gomes and Maia²2. Gomes W, Maia RCM. Comunicação e democracia. Porto Alegre: Meridiona; Sulina l, 2008. call the "pedagogical practice of enlightenment and mutual understanding".

Habermas³3. Habermas J. Mudança estrutural da esfera pública. 2. ed. Rio de Janeiro: Tempo Brasileiro; 2003. talks about the subjectivity in the public sphere, often seen as an extension of the experience and the private interests of individuals. In view of this, in order for communication to be effective, health service manager self-understanding is required, with the aim of restructuring their strategy of action. The notion that the communication is only the transmission of information from the transmitter to the receiver needs to be superseded, in view of the complexity of communication actions, that demand care, processes, workflows, structure and qualified professionals to act on the front line of dialog with society.

Researches that indicates interrelationships between communication and the health sector is still limited,⁴4. Mendonça AVM. Informação e Comunicação para o Sistema Único de Saúde no Brasil: uma política necessária. In: Sousa MF, Franco MS, Mendonça AVM. Saúde da Família nos municípios brasileiros: os reflexos dos 20 anos do espelho do futuro. Campinas: Saberes Editora; 2014. p. 701-19. whereby both areas take on the joint responsibility for preparing policies, plans and programs geared to communication action, taking as a reference the situation of the population’s health-illness. Taking this stance requires communication professionals to have knowledge, skills and attitudes aimed at achieving the qualified engagement of the population in such interventions, while respecting the population’s culture and values.⁵5. Schiavo R, Leung MM, Brown M. Communicating risk and promoting disease mitigation measures in epidemics and emerging disease settings. Pathog Glob Health. 2014 Mar;108(2):76-94.

A new model therefore needs to be built - reorganizing values, principles and guidelines-, in which communication is participatory and able to indicate to the Municipal Health Departments and Municipal Health Department Councils (COSEMS) the need to prepare strategic plans directed towards building healthy territories and cities. Knowing the context and the situation of the communication advisory services is the starting point for identifying weaknesses and proposing improvements.

The objective of this study was to investigate the characteristics of health communication services, taking the the Municipal Health Department Councils network in Brazil (COSEMS) as a basis.

Methods

This is a quantitative study the design of which is exploratory and explanatory. It used primary data collected by means of electronic questionnaires.

The study population was comprised of Municipal Health Departments (SMS) and Municipal Health Department Councils (COSEMS) from all over Brazil. All SMS were invited to participate in the study by means of invitation letters sent by electronic mail. However, in the face of technological access still being limited in the case of many Brazilian municipalities, it was considered necessary to also include the COSEMS in the survey. All COSEMS were invited via the COSEMS Network. We adopted non-probability sampling of volunteers. The type of sampling is comprised of members of the population who volunteer to participate in the research in a non-random manner.⁶6. Oliveira TMV. Amostragem não probabilística: adequação de situações para uso e limitações de amostras por conveniência, julgamento e quotas [Internet]. Admin On Line. 2001 jul-ago-set [citado 2018 mar 6];2(3). Disponível em: Disponível em: http://www.fecap.br/adm_online/art23/tania2.htm
http://www.fecap.br/adm_online/art23/tan... ^.77. Lakatos EM, Marconi MM. Metodologia do trabalho científico: procedimentos básicos, pesquisa bibliográfica, projeto e relatório, publicações e trabalhos científicos. 7. ed. São Paulo: Atlas; 2013. Thus, the results achieved from this type of sample cannot be extrapolated to the entire universe.⁷7. Lakatos EM, Marconi MM. Metodologia do trabalho científico: procedimentos básicos, pesquisa bibliográfica, projeto e relatório, publicações e trabalhos científicos. 7. ed. São Paulo: Atlas; 2013. The data collection instrument included four questionnaires, available in electronic media and hosted on a University of Brasília (UnB) server. The questionnaires were publicized and available on the portal of the National Council of Municipal Health Departments (CONASEMS) during a period of two years (January 2014 to December 2015). After this collection period in which the questionnaires were returned by the respondents, they were then placed offline.

The questionnaires were adapted based on Romar's Master's⁸8. Romar AAC. Estudo descritivo da área de comunicação: estrutura e principais cenários das Secretarias Estaduais de Saúde [dissertação]. Brasília: Universidade de Brasília; 2014. dissertation following studies coordinated and devoloped by the University of Brasília Center for Studies in Public Health (NESP/Unb) and Laboratory of Health Education, Information and Communication (Ecos/UnB). As the methodology proposed comes from a Master’s dissertation that also included the National Council of State Health Secretaries (CONASS),⁸8. Romar AAC. Estudo descritivo da área de comunicação: estrutura e principais cenários das Secretarias Estaduais de Saúde [dissertação]. Brasília: Universidade de Brasília; 2014. the questionnaires were adapted with regard to the scope of the professionals, their places of work and regional networks, with the aim of expanding the scope of the study.

The adapted questionnaires addressed the specificities of the COSEMS Network and of Municipal Health Departments (SMS) both with and without communication advisory services (Ascom).

The communication advisory services were characterized according to the profile of the adviser physical structure and forms of communication. The adviser profile was evaluated according to the following variables: sex (male, female); schooling (high school, Master’s, degree course, specialization, Ph.D., unknown); qualification (communication, health, other, unknown); employment relationship with SMS (Consolidation of Labor Laws -CLT, High Level Management and Advising-DAS/commissioned position, statutory, statutory/DAS or commissioned position, statutory/position of trust, service provider, other; length of service at SMS (up to four years, more than four years); and length of service in the area of health communication (up to four years, more than four years). Physical structure and forms of communication were evaluated in relation to the presence or otherwise of: communication area links with the health secretary, council president, participation in the collegiate management body, SMS organization chart, exclusive room for the communication service, (camera, computer, notebook, printer, camcorder, DVD recorder, telephone, cell phone, TV), information technology (equipment, software, internet access), access to communication media and tools (subscriptions to newspapers, Internet portals, cable television, other), access to communication media and tools (social networks, internet portals, blogs, among others), a clipping system (with or without evaluation of results/content approach -qualitative and quantitative evaluation of goals).

The Statistical Package for Social Sciences (SPSS) was used for the descriptive statistical analysis. Percentage calculations were performed and mean values were obtained, in addition to the generation of graphs and tables of frequency, as the case may be.

The study project was approved by the Research Ethics Committee of the University of Brasília Faculty of Health Sciences (CEP/FS/Unb), under number 209/13. The participants were informed about the objectives and procedures of the research and the respondents electronically signed the free and informed consent form.

Results

After elimination of duplicated answers, the universe to be analyzed was comprised of 122 municipalities that answered the survey. Of the total of valid responses, 79 (64.8%) stated that they did not have a communication advisory service (Ascom).

Only half of the 20 Municipal Health Department Councils that answered the survey stated they had a communication advisory service: Alagoas, Amazonas, Bahia, Minas Gerais, Pará, Rio Grande do Norte, São Paulo, Rio de Janeiro, Paraná and Rio Grande do Sul. Those COSEMS that reported not having a communication advisory service are: Tocantins, Amapá, Mato Grosso do Sul, Acre, Piauí, Maranhão, Roraima, Rondônia, Mato Grosso and Sergipe. The remaining states did not participate in the study (Figure 1). COSEMS of the Southern and Southeastern regions were best served by communication advisory services.

Characterization of Municipal Health Department communication advisers

The profile of SMS communication adviser is characterized by a predominance of females (25). As to the degree of schooling, the majority of advisers had a degree (21), followed by a group of advisers with specialization (postgraduate) (14), only 1 presented had a Ph.D. (Table 1). The majority of communication advisers stated having qualifications in the area of communication (26).

As regards employment relationship, advisers were mostly (21) employed in commissioned or high level management and advising positions (DAS) (Table 1). Only 13% of municipal municipal advisers with this type of employment relationship had been working for more than four years at the Municipal Health Department (Figure 2).

Average length of service at the institution was 4.4 years (SD=6.7), while the shortest time was less than 1 year, and the longest 36 years. The communication adviser who had 36 years of service reported being a federal civil servant assigned by SUS to the municipality. This particular dataset was considered discrepant and excluded from the analysis, thus reducing the average length of service to 3.7 years. Average length of service in health communication was a little lower: 3.6 years.

Of the respondents, 37 reported that the communication area was directly linked to Municipal Health Secretary and 28 stated that the area of communication did not participate in the collegiate management body (Table 2).

As regards the physical structure, all respondents stated not having a room exclusively for this purpose, besides not having available equipment, information technology, access to media and communication tools, clipping systems and mailing systems. Only one adviser reported that the communication advisory service worked with its own budget, however, this was not in excess of R$ 1,000. 14 ASCOMs had its own communication medium available (Table 2).

Among the respondents, 23 reported having information and communication strategies aimed to give greater visibility to SUS guidelines, and 22 stated having publications focused on health information and communication (Table 2).

Professional training was not promoted in most advisory services (31), and neither planning nor the process of monitoring and evaluation such planning occurred in 40 of the advisory services (Table 2).

Characterization of COSEMS communication advisers

The profile of the COSEMS communication advisers is distributed equally in relation to sex (5 men and 5 women). As regards education level, the majority reported having specialization (postgraduation) (6), and one stated having a PH.D. in Social Communication (this was also the only one with a DAS position). All advisers indicated having qualifications in the area of communication. Regarding the type of employment relationship with COSEMS, the most frequent category was service providers (7), followed by employees working under the Consolidation of Labor Laws (2) (Table 1).

Average length of service at the institution was 2.4 years (SD=1.65), with a variation of 1 year for the shortest and 5 years for the longest. Average length of service in the health communication area was 4.3 years (SD=2.8).

Most participated in the last meeting of the CONASEMS Thematic Communication Center(8) and all responded that the communication area was directly linked to the COSEMS president (Table 2).

Regarding communication area physical structure, all respondents stated not having an exclusive room for this purpose; as well as not having equipment, information technology, access to media and communication tools, clipping systems and mailing systems. They were also were unanimous in affirming that the communication advisory services had no budgets of their own (Table 2).

Even with poor infrastructure, the majority (9) of COSEMS had a page on the Internet, blogs and profiles on social networks such as Facebook and Twitter, among others. COSEMS that did not have a web page stated, however, using social networks as one of their advisory services means of communication (Table 2).

As regards information and communication strategies aimed at giving greater visibility to SUS guidelines, 8 said they used them. With regard to publications focused on health information and communication, half of the respondents (5) stated having such material.

Professional training was not promoted in 8 of the advisory services, while 6 of them had no planning nor monitoring and evaluation of such planning (Table 2).

90% of advisory services had a professional journalist, whereby in 40% of cases this person alone was the advisory service. The average number of employees per team was 5.1 (SD=6.6), the largest team was comprised of 22 employees. The professions of public relations, radio communication and social mobilizer did not appear in any of the communication advisory services interviewed.

A relevant characteristic found in communication advisory teams refers to the employment relationship, which was predominantly of a temporary character, since the majority was comprised of service providers and interns. Out of all COSEMS participating in the survey, only one civil servant worked in the communication advisory service.

Regarding the question "Does COSEMS have a Communication Directorate, the majority of COSEMS that had communication advisory services responded negatively (8). Only COSEMS/SP and COSEMS/BA had this type of directorate in their structure.

Discussion

The absence of a communication advisory service in 64.8% of municipalities that answered the survey and the precarious nature of the structure and employment relationships found reveal the difficulties of health communication in the places evaluated. Among the findings, the question of the employment relationship which, in both cases, is temporary - in SMS, the majority of advisers hold DAS positions, while in COSEMS the majority are service providers - has a direct impact on length of service in municipal health communication advisory services. This fact, allied to the scarcity of training actions observed both in SMS and in COSEMS, may have important consequences on the quality and continuity of the actions.

According Belluzzo,⁹9. Belluzzo RCB. Competências na era digital: desafios tangíveis para bibliotecários e educadores. ETD Educ Temát Digit. 2005 jun;6(2):30-50. makes a communications professional stand out in this century is information competency, whereby they need “elements for the development of skills and abilities to access and use information for the production of knowledge and social development". Thus, these professionals need to be able to contribute as agents the encourage the search for relevant and effective information.⁹9. Belluzzo RCB. Competências na era digital: desafios tangíveis para bibliotecários e educadores. ETD Educ Temát Digit. 2005 jun;6(2):30-50.

Pitta And Magajewsk¹⁰10. Pitta AMR, Magajewsk FRL. Políticas nacionais de comunicação em tempos de convergência tecnológica: uma aproximação ao caso da Saúde. Interface - Comunic, Saúde, Educ. 2000 ago;4(7):61-70. state that a health communication policy must be articulated and consistent with several principles from the field of planning, service management and epidemiology, serving as pillars to (re)organize a model of health attention committed to building equity and satisfying the needs and concrete demands of the country’s citizens. As such, another critical point revealed by the survey refers to the virtual inexistence of planning in Municipal Health Department (SMS) communication areas (93% stated having no planning).

These dimensions are important for reflection on the organizational modes of managing SMS, the managers of which must necessarily must consider the planning of any sectoral action - including communication actions, based on new territories of a socio-spatial nature. These territories are constituted socially by flows, movements, cultural agendas, ways of building health needs and social demands that intertwine in complex ways.¹⁰10. Pitta AMR, Magajewsk FRL. Políticas nacionais de comunicação em tempos de convergência tecnológica: uma aproximação ao caso da Saúde. Interface - Comunic, Saúde, Educ. 2000 ago;4(7):61-70.

The demand for the planning of long-term information and communication actions is growing,¹¹11. Ministério da Saúde (BR). Conselho Nacional de Saúde. Relatório das oficinas de comunicação [Internet]. Brasília: Ministério da Saúde; 2006 [citado 2018 mar 6]. (Série D. Reuniões e Conferências). 104 p. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/relatorio_oficinas_comunicacao.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...

12. Ministério da Saúde (BR). Conselho Nacional de Saúde. Relatório do seminário nacional de comunicação, informação e informática em saúde para o exercício do controle social [Internet]. Brasília: Ministério da Saúde ; 2006 [citado 2018 mar 6]. 78 p. Disponível em: Disponível em: http://conselho.saude.gov.br/biblioteca/livros/relatorioseminario_miolo.pdf
http://conselho.saude.gov.br/biblioteca/... ^-1313. Araujo TCCF. Comunicação em saúde: contribuições do enfoque observacional para pesquisa e atuação. Arq Bras Psicol. 2009 ago;61(2):1-13. in contrast to the offer of actions made by the temporal mandates of political subjects, limited by focal actions, requirements, standards, sometimes attributing guilt. Rather, public health communication must be directed towards social well-being and be guided by the principles and guidelines of SUS.¹⁴14. Araújo IS. Comunicação e Saúde. In: Martins CM (Org.). Educação e saúde. Rio de Janeiro: EPSJV/Fiocruz; 2007.

Furthermore, in view of the total absence of adequate working structure in relation to working space, equipment availability and access to work instruments, there is an urgent need to improve the working conditions and infrastructure of the communication advisory services, in keeping with with the relevant social responsibility services provided by these professionals.

As such, one of the conclusions reached by this study is that communication advisers have dedicated themselves to providing advice of a personal nature, i.e. advice on management by health secretaries, to the detriment of the institutionalization of work processes directed towards individuals, families and communities, in terms of prevention, protection and recovery of their health-disease status. One of the aspects that demonstrate this relationship is the fact that the professionals work in direct relationship with the health secretary, but do not have, however, a seat on the management collegiate bodies.

Also point to the employment instability of these professionals, whose permanence in their jobs depends on the expectation of maintaining political agents in power. This characteristic limits the structural conformation of the communication area as well as its legitimacy within health department spaces. As a consequence, this establishes the lack of need to build an agenda devoted to information and communication focused on promoting health in a specialized manner. This would require the carrying out of situation analyses of real demands, in order to formulate strategic planning aimed at the development of individual and collective competencies aligned with the functions of health communication professionals. When considering the problems indicated by health service managers, Montoro¹⁵15. Montoro T. Retratos da comunicação em saúde: desafios e perspectivas. Interface (Boticatu). 2008 abr-jun;12(25):445-8. highlighted the difficulties linked to the planning of health communication. This activity is limited by logistical deficiencies of communication actions, small number of professional staff, discontinuity of actions, accessory role attributed to communication, difficulties in meeting daily demand, lack of representativeness in participatory bodies and absence of data on the results of the strategies adopted.

The inclusion of these professionals in the organizational structure of the Municipal Health Departments is undoubtedly is one of the strategies to be adopted so that these spaces are established as a place to be recognized by health professionals, managers and other municipal authorities as a specialized technical and strategic area. One of the challenges to achieving higher quality of these services refers to the employment relationship. The unease associated with commissioned positions needs to be reduced so that advisers have greater security in relation to their rights, i.e., it is necessary to establish new forms of employment contracts that guarantee greater stability and strengthen the bond.¹⁶16. Organização Pan-Americana da Saúde. Chagas L, Seclen J. Informe sobre a reunião de trabalho “Discussão sobre o marco referencial e conceitual da Atenção Básica e Saúde da Família no Brasil” [Internet]. Brasília: Organização Pan-Americana da Saúde; 2003 [citado 2018 mar 6]. 11 p. Disponível em: Disponível em: http://www.paho.org/bra/index.php?option=com_docman&view=download&alias=549-informe-sobre-a-reuniao-trabalho-discussao-sobre-o-marco-referencial-e-conceitual-9&category_slug=atencao-primaria-em-saude-944&Itemid=965
http://www.paho.org/bra/index.php?option...

One of the limitations of this study was the small number of municipalities which returned the information filled in. As such, caution is needing with regard to the generalization of the findings to municipalities that did not take part in the study.

It is hoped that the points raised here may assist in the effective construction of a strategic political agenda of health communication within the context of SMS and COSEMS. An agenda that signals the institutional commitments to the strengthening of information and communication processes directed towards health promotion and understood as an ethical -political-formative ideal to be achieved on the way towards healthy, fraternal, democratic and socially just cities.

References

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