ABSTRACT

The objective of this study was to describe the utilization of the ZOPP (Goal-Oriented Project Planning) method in two primary healthcare units, taking into account the development of skills for interprofessional work and the production of a service organization protocol focused on prenatal care. Participant observation method was applied during twelve videotaped sessions. Participants were eight health professionals and two users of the Unified Health System. The method was evaluated positively by bringing nuclear issues to problematization and by the ability to maintain the involvement of the participants, showing flexibility and adequacy, as well as favoring the inseparability between analyzing, planning and implementing actions, which aroused ethical commitments and regained innovative behaviors in the direction of solving problems, strengthening interprofessional collaboration.

KEYWORDS
Prenatal care; Dental care; Method ZOPP

Introduction

The importance of planning in the health sector has been related to the transformations in the forms of assistance, organization of networks and health services systems since the second half of the twentieth century, generating the interest of international bodies in developing methodological proposals that could subsidize administration of health services. In Brazil, the recognition of health as a social right and the guidelines of the Unified Health System (SUS) have boosted the decentralization of health services, creating favorable conditions for the exercise of planning in public organizations¹1 Teixeira CF. Planejamento em Saúde: Conceitos, métodos e experiências. Salvador: Edufba; 2010..

The fragilities of traditional, normative, economistic and technocratic methods, typical of a vision of planning as an instrument of the State in situations of power concentration, have culminated in new planning models, contemplating the various actors involved in power sharing contexts and providing interaction and negotiation²2 Rivera FJU, Artmann E. Planejamento e gestão em saúde: histórico e tendências com base numa visão comunicativa. Ciênc. Saúde Colet. 2010; 15(5):2265-2274..

Faced with health planning conceptions, it is possible to observe two aspects regarding the relationship between the subjects involved and the way in which knowledge and action are available: one, in which there is a clear separation between the people who plan and those who act, and another, in which the one who plans is the one who does³3 Moraes VV. Planejamento participativo como instrumento de aprendizado [dissertação]. Campinas: Universidade Estadual de Campinas; 2006.. The latter has become known as participatory planning, a way of linking knowledge to action, in which all who must act must also take part in the appropriation of theories that guide action, overcoming the tradition of techniques that separate those who plan from those who perform, and that keep the fragmentation of knowledge and practices, the distance between technical and practical knowledge, making it difficult to produce adequate responses to the multidimensional and complex realities present in the health area.

Participatory planning involves the inclusion of users of a given service in the moments of evaluation, proposition and planning. In addition to a democratic exercise, this involvement contributes considerably to the definition of actions with greater feasibility and to the promotion of social protagonism, since it requires openness to cultural change in the face of the fragmentation and vertical segmentation of knowledge, expertise and practices, reducing the asymmetries so common in social relations.

The Zielorientiert Projectplannung (ZOPP) or Goal-Oriented Project Planning method is a social intervention planning technique, created and developed by the German Society for International Cooperation in the 1980s to address the need for more effective actions linked to the closest factors to the causes of the problems, identified through careful listening of those involved and benefited by social projects, such as managers, beneficiary groups and technicians responsible for implementation, for the joint construction of decisions⁴4 Bolay FW. Guia para aplicação: planejamento de projeto orientado por objetivos - método ZOPP. Recife: GTZ; 1993..

In considering that scientific information on the application of the ZOPP method in the health area is scarce, the objective of this article was to produce a dense description regarding the use of the ZOPP method in two Primary Health Care (PHC) units, to collectively construct a Protocol of Attention to the Pregnant Woman (PAG) which best suits the necessities and reality of the users, taking into account the development of competences for the interprofessional work.

Methods

A descriptive study was carried out, whose collection method was a participant observation that allows greater immersion in the field to observe, share experiences and gather information, in order to obtain supposedly hidden or deep answers and meanings, aiming to understand the questions that guide the research.

Two PHC units in the city of Uberlândia, Minas Gerais, which are part of the Family Health Strategy were selected because they presented common characteristics in terms of assisted population, favorable conditions of physical structure, declaration of interest on the part of the professionals and the management and favorable degree of interprofessional collaboration⁵5 Faquim JPS, Frazão P. Percepções e atitudes sobre relações interprofissionais na assistência odontológica durante o pré-natal. Saúde debate. 2016; 40(109):59-69.. It is described, below, the situation, the actors, the processes and the strategies of data collection.

The situation-problem in prenatal care was the difficulty in providing the integral health dental component with a preventive focus on the mother and the baby in the assisted area, a common aspect in the provision of care during the prenatal. In a study in a brazilian metropolitan region, it was verified that only 12% of the puerperal received adequate dental care during the prenatal period⁶6 Santos-Neto ET, Oliveira AE, Zandonade E, et al. Acesso à assistência odontológica no acompanhamento pré-natal. Ciênc. Saúde Colet. 2012; 17(11):3057-3068.. In another research, it was observed that dentists and obstetricians diverged from the scientific literature and from one another on recommendations related to dental care (use of local anesthetics, prenatal fluoride supplementation, dental panoramic x-rays etc.)⁷7 Zanata RL, Fernandes KB, Navarro PS. Prenatal dental care: Evaluation of Professional knowledge of obstetricians and dentists in the cities of Londrina/PR and Bauru/SP, Brazil, 2004. J Appl Oral Sci. 2008; 16:194-200.. Because infections may play an important role in inducing births and prematurity, and periodontal disease could be a risk factor for adverse pregnancy outcomes, health teams should be committed to inter-professional work that seeks to raise the quality of care prenatal care⁸8 Faquim JPS, Oliveira APL, Silva MJB, et al. Inflammation mediators related to periodontal disease and pregnancy outcomes: a call for quality of antenatal care while promising evidences are emerging. Global J Health Sci. 2017; 9(8):169-177..

The use of guidelines of orientation for the care routines of a given service is, therefore, a recommended measure for the development of best practices in health work processes, for the safety of the patient, and for quality of care in health systems⁹9 Paim JS. Atenção à saúde no Brasil. In: Brasil. Ministério da Saúde. Saúde no Brasil: contribuição para a agenda de prioridades de pesquisa. Brasília, DF: Ministério da Saúde; 2004. p. 14-40.. Such protocols are instruments for the management of services, ranging from work organization in a unit and in the territory, user flows, to proposals for networking, evaluation and information system, establishing interfaces between units, levels of attention (medical appointments scheduling, reference and counter-reference) and other sectors¹⁰10 Werneck MAF, Faria HP, Campos KFC. Protocolos de cuidados à saúde e de organização do serviço. Belo Horizonte: UFMG; 2009..

The actors belonged to four categories of professionals (doctors, dentists, nurses and oral health technicians), totaling eight health professionals, as well as two pregnant women users of the SUS who performed prenatal and delivery in the public network of the city and had an average frequency of 96% among all participants.

A training workshop using the ZOPP method, with 12 sessions of average duration of 3 hours and 30 minutes each, was conducted by a professional specialized in the elaboration and management of projects. This workshop used a classroom with removable chairs, blackboard, paper and flip chart, reserved at the Federal University of Uberlândia, and was planned under the principles of Permanent Education in Health, a strategy for the organization of educational processes aimed at health workers based on needs identified by workers in their different contexts, in dialogue with their previous knowledge¹¹11 Haddad J, Roschke MA, Davini MC. Educación Permanente de Personal de Salud. Washington: Organización Pan-americana de la Salud; 1994.. This strategy has been focused primarily on the management-workers relationship, and has rarely been used as a strategy to increase the 'contact surface' and the mutual production of workers and users¹²12 Merhy EE, Feuerwerker LCM. Educação Permanente em Saúde: educação, saúde, gestão e produção do cuidado. In: Mandarino ACS, Gomberg E, organizadores. Informar e Educar em Saúde: análises e experiências. Salvador: UFBA; 2011. p. 5-21..

The purposes of the workshop were: to stimulate cooperation between the different professionals and users in the analysis of the attention to the pregnant woman; to provide criticism under different perspectives related to the health care of the pregnant woman during the prenatal period, preparing professionals and users for the construction of a PAG that would result in a proposal of production of care focused on the needs of the pregnant woman, characterized by interprofessional practice and interdisciplinary approach.

The meetings were planned according to the steps of the method in the following sequence: context analysis; problem analysis (tree of problems); goal analysis (tree of goal); the choice or prioritization of achievable goals; planning (construction of the PAG). The steps are not impenetrable, relating to each other in a process of successive approximations in which moments are highlighted in which the group is dedicated to specific aspects of the problem-situation⁴4 Bolay FW. Guia para aplicação: planejamento de projeto orientado por objetivos - método ZOPP. Recife: GTZ; 1993..

The method predicts the definition of actions based on an exhaustive analysis of the problems, causes and effects and the consequent reversal of the problems in objectives, expected results and actions, assuming that the actions will respond to the problems in a more integral and effective way. The use of different visualization techniques and communicative strategies are essential to promote horizontal participation and to support the construction of a logical framework in which everyone can identify the relationship between actions and expected results, among other aspects of planning (responsible, partners, deadline, indicators, risks, commitments).

At the first moment, the participants were encouraged to analyze the context where they were inserted and the place where the project was being developed. The vision of the problems raised and their interrelationship were shared seeking to identify a central problem and 'trunks and roots' that would identify how the problem manifests itself and relates to other problems as 'cause and effect'. This analysis gave rise to a visual representation called 'tree of problems'. After construction and visualization, the group was proposed to revert problems into objectives, giving rise to the 'tree of goals'.

These two visual tools, the basis for social intervention planning, serve as a 'control panel', as a guide to the search for integrated solutions in a complex context such as health. In order for the work to be effective, prerequisites are necessary such as: ensuring equal participation, identifying the concept of problem accurately, ensuring the direct involvement of participants in the context of action and adopting a flexible and provisional attitude for 'cause and effect' relationships and the search for consensus.

In addition to constructing a critical view about real work situations, this method was formulated as a tool for the improvement of collaborative skills, seeking greater interactivity and involvement of the participants in the work.

After the construction of the problems and goals trees, the selection of the achievable objectives for the project (second moment) was carried out, as well as the construction of the logical framework and a new PAG proposal that responded to the problems raised and was adapted to the reality experienced by the actors.

The data were collected from September 2014 to February 2015, composing around 40 hours of recording with a digital camera with a tripod positioned in a place that made it possible to record as broadly as possible the activities of the group. The researcher participated in the data collection and had an active observer role. After the workshop, the field diary was used. Observations, feelings, perceptions and meanings of the lived experiences were recorded. In order to protect the anonymity, the participants were identified by the abbreviations P1 to P10.

The performance of the method was measured by the degree of agility to bring the pertinent issues to the center of the discussion (focus), allowing their in-depth problematization, and their capacity to maintain participant engagement, relationship building and decision making, considering the expected duration.

In order to capture the performance, the recordings were evaluated, and the most significant parts related to the application of the method were examined more than once for interpretation, allowing a greater degree of accuracy in the gathering of the information¹³13 Belei RA, Paschoal SRG, Nascimento EN, et al. O uso de entrevista, observação e videogravação em pesquisa qualitativa. Cad Educ. 2008; 30:187-99..

The study was approved by the Research Ethics Committee of the Faculty of Public Health of the University of São Paulo (Opinion: 312.904), and all participants signed the Informed Consent Form (ICF).

Results and discussion

In the first meeting, after the arrangements, the ethical considerations and the sharing of expectations, the ZOPP method was presented to the team, addressing the concept of 'problem' and the consensual model as a strategic proposal for decision making, in order to facilitate the analyze of complex situations and plan activities. The meeting generated many expectations according to the following narrative:

In the construction of a participative model to evaluate a specific program, researchers emphasized that the involvement of the team as a whole favors the valorization and integration of professionals, expedites the discussions and allows the agile return of the results once it occurs in the process itself of discussion¹⁴14 Bursztyn I, Ribeiro JM. Avaliação participativa em programas de saúde: um modelo para o Programa de Saúde do Adolescente. Cad Saúde Pública. 2005; 21(2):404-416..

It was discussed the formation of a 'team' as an evolution of a 'work group', showing that a group is a collection of people with diverse interests and some coincident, who have responsibilities in the tasks and enquiries between them, and eventually, divides problems, while a team corresponds to a set of people who have shared interests, responsibilities in the process and plans and complements in different situations.

The conduction sought to facilitate the analysis, collective reflection and cooperative work of the participants, using the methodology chosen and the topics addressed for the development of communication skills and interprofessional cooperation¹⁵15 Matuda CG, Aguiar DML, Frazão P. Cooperação interprofissional e a Reforma Sanitária no Brasil: implicações para o modelo de atenção à saúde. Saúde Soc. 2013; 22(1):173-186.. Building a shared vision collectively guided the planning moments described below.

Also called 'Involvement Analysis', a recognition of the general context and local reality, exposition of the experiences regarding the direct experience of the situation and a reflection on the problematic of the institutional scenario were carried out (main problems, characteristics, potentials, history of the territory and culture) that motivated the team to convene.

At that moment, a mapping of the organizations in the territory, groups of pregnant women, actions aimed at prenatal care, professionals directly involved with the problem-situation was carried out, both within the health units and in the management of the network, searching in a shared way identify the support points and partnerships, potential resistances and potentially available resources.

This phase had an important role in relation to the psychology of group processes. As the method brought together participants who were usually little known, this step was important to raise the knowledge of the actors about each other and to exercise participatory work, before potentially more conflicting reflection and analysis activities took place¹⁶16 Brose M. Metodologia Participativa: Uma Introdução a 29 instrumentos. 2. ed. Porto Alegre: Tomo Editorial; 2010..

Subsequently, participants listed the main problems related to prenatal care, and a reflection on the interrelationships, 'causes and effects' was carried out, providing an analytical picture of the situation.

In order to get the participants to reflect and give their opinion on a certain theme, the problematization was initiated through an issue³3 Moraes VV. Planejamento participativo como instrumento de aprendizado [dissertação]. Campinas: Universidade Estadual de Campinas; 2006.. The questions were asked by the moderator to conduct the discussion.

With this, it was possible to reflect on the difficulties and the level of commitment of the integral attention, of the fragmentation of the knowledge, of problem-solving and intersectoriality of the services and of the health system.

Each participant registered the problems they found in comprehensive care for the pregnant woman. Subsequently, in small groups, they presented the individual points of view, confronting them and rewriting those which had common points. Then, the problems were ordered as: causes, central problem or effects related to the difficulties of multiprofessional approach and little shared routines;

To the demotivation and lack of commitment;

To the concentration of actions in the dentist; and with the activities of the Oral Health Technician (OHT).

In addition to identifying problems, it was sought to strengthen the relationship between participants and teamwork, to prevent participants from becoming active in the role/position to express themselves, to facilitate spontaneity in the expression of personal ideas to consolidate a group conscience, to clarify the method so that all could participate in the same way and guarantee the distribution of the word to avoid the 'concentration of power' or the 'monopoly of truth', since it was possible to perceive those who expressed themselves with greater ease and those who put themselves in a timid and constrained way.

Despite the differences in context and the specificities of the relationship between user and professional required in health care¹⁷17 Merhy EE. Saúde: a cartografia do trabalho vivo. São Paulo: Hucitec; 2002., it can be considered that the encounter between user and professional in planning activities can also allow changes in the conditions in which the production of health care occurs, favoring an approach focused on the needs of the pregnant woman.

This moment made it possible for the participants, especially the users, to freely expose their anguish. It allowed to identify possible solutions with a chance of success, for which the individual, separately, did not have an answer. Different, potentially conflicting and opposing views of reality were observed. The users had the opportunity to expose the greatest difficulties they faced during prenatal care in the network, as well as positive experiences. These informations were important subsidies to think about a proposal that corresponded to the needs of the population.

Among the problems, stand out: difficulties with the attendance of pregnant women in the consultations, lack of knowledge about social rights, including beliefs and fears related to dental consultation:

Advances are recognized in the exercise of social control exercised by organized civil society, despite the still small involvement of health workers and users in the daily management of health services¹⁸18 Penha FC, Magajewski F. Gestão Participativa e Valorização dos Trabalhadores: avanços no âmbito do SUS. Saúde Soc. 2012; 21(supl.1):71-79.. The participation of users, besides adding more legitimacy to the actions and support for the proposals, seeks to ensure the inclusion of new political actors in health and expand the possibility of listening to the needs and organized entities of civil society, giving a greater density to the process of democratization of society.

The visual technique of this stage was the construction of a 'tree of problems' that mapped the problems listed by the team, emphasizing, in the collective view, their main causal relations. The central problem identified by the team was placed in the center of the design representing the trunk. Its causes were represented by the roots; and its effects on the leaves of the tree (figure 1).

Based on the central problem, the causes related to the health unit, the pregnant women and the team, as well as their resulting effects, were listed (figure 2).

Some problems could be worked out in a more exhaustive way, however it was decided to contemplate the discussion at the level acceptable by the group as a common problem, of interest to all, considering the different points of view, the time available for meetings, fatigue, and the limitations of technical and theoretical knowledge.

The 'tree of problem tree' has been transformed into a 'tree of goals', converting each problem into a goal. Thus, a joint negative (problem-based) vision was made for a positive vision, a promising future situation and possible solutions to be sought.

At this moment, it was important to lead the team to focus only on what was considered desirable, that is, the construction of a representation of reality as it should be, without thinking about the project or the viability of the objectives.

This stage of transposing a problem-situation into an objective-situation also had the purpose of reassessing the problems raised, taking into consideration that, in the impossibility of reversing a problem in objective, it was necessary to review and rewrite the problem. Problems with no solution or that had their solution outside the governability of the team needed to be rethought within a hierarchical context or formulated in a more appropriate way, opening up the possibility of alternative solutions.

The visual technique was the construction of a 'tree of goals' that mapped the objectives corresponding to each problem situation, proposing an alternative strategy (figure 3).

The overall objective has guided the identification of the objectives related to the health unit, the pregnant women and the team (figure 4), considering the perception of all the members about the reality and context in which they were inserted.

The 'tree of goals' presented a broad and complex framework, a vision of the future of how reality would be without those problems. The team took full advantage of the dialogue enabled by the method, which reflected in the identification of complexities that extrapolated their scope and their governability, an aspect that may be common during their application when the work team manages to deepen the reflection and maintain the focus of the discussion.

In the second moment, participants reflected on a conscious choice of which objectives, given the complexity of the framework, should be prioritized and attainable through the elaboration and implementation of a PAG.

In order to guide the choices, a discussion was held on the points of support, partnership and potentially available resources. In a consensual reflection, the stage of choice to define the best intervention strategy that would have a chance of success in the processes of change of reality took place, considering the resource limitation, probability of success, relation between the cost of the effort and the potential benefit and mobilization of collaborative practices.

Faced with the choice of objectives and strategies to be implemented, the team proceeded to the planning phase that corresponded to the construction of the logical framework: a tool used to better visualize the planning of actions and the relations that are established between the actions and the objectives. The main elements are: objectives, actions, goals, indicators and constraints. The definition and measurement of the indicators allow the monitoring and evaluation of the project, subsidizing the identification of the necessary corrective measures. Its construction started from the situation analysis and was the result of the comprehension and the choices of actions that can be carried out within the situation and the context.

From these three main visual tools, 'tree of problems', 'tree of goals' and logical framework, began the construction of a PAG that met the priority objectives related to the organization of services under the governability of the multiprofessional team, taking in development of skills for collaborative work.

In the elaboration, the scientific knowledge, the experiences of the professionals, the characteristics of the local reality and the interprofessional collaboration were considered as a tool to improve the quality of the integral care offered to the pregnant women, seeking to overcome the isolated uniprofessional action and the disciplinary approach.

During the workshop sessions, the workers detected cognitive and attitudinal needs on health care networks, collaborative attention and centered on the pregnant woman and the family, multiprofessional action, interprofessional work in PHC, knowledge of other successful experiences in SUS for pregnant women, prenatal care in the state of Minas Gerais, strategies of education in pregnant-centered health (chatting groups), family planning, social rights related to gestation, bonding with the pregnant woman and her family, teenage pregnancy, pregnant drug addicts, among others.

In order to meet these needs, activities were carried out contemplating themes based on the strategy of Permanent Education in Health. Technical references and specialists of the municipal health network and other institutions were activated promoting the greater involvement of supporters in the project.

The protocol covered mainly the flow of the pregnant women and the dynamics of the work process, contemplating four moments: the entrance of the woman with suspicion of pregnancy in the network, the reception in the health unit, the diagnosis of the pregnancy and, subsequently, the flow of the multiprofessional prenatal care within a perspective of interprofessional collaboration. It was emphasized that it should not be used as an instrument for the stiffening of professional practice, but as a source-guide capable of helping shared decisions, recognizing that professionals must be prepared to deal with unforeseen situations, without losing sight of the objectives of a process of integrated work. By accepting ranges and limits, protocols should be periodically reviewed based on the evaluation of the results of their implementation, the progress of scientific and technological knowledge and the health needs of the population that are likely to undergo major changes in a context of demographic and epidemiological transition¹⁰10 Werneck MAF, Faria HP, Campos KFC. Protocolos de cuidados à saúde e de organização do serviço. Belo Horizonte: UFMG; 2009..

A significant moment of the protocol, besides the moments of shared consultation and discussion of cases, was the proposal to carry out a group activity planned in the health units monthly. In it, the professionals set out to work together, with the objective of creating an environment of support and welcome to the pregnant women, create bond, favor inclusion and listening, to consider the diversity of values, perceptions and behaviors, representing another space of interprofessional practice under an interdisciplinary approach.

The ZOPP method was well evaluated by all workshop participants according to the following narratives:

Planning and implementation are articulated in the method; and the potential beneficiaries of the plans and programs should be an active part in the planning process, along with the technical team contributing to increase the chances of success³3 Moraes VV. Planejamento participativo como instrumento de aprendizado [dissertação]. Campinas: Universidade Estadual de Campinas; 2006..

Limits and ranges

The ZOPP method as a planning technique presents important attributes, but also critical points that need to be monitored. For the election of problems, realities and priorities of certain professionals who are more qualified or who have 'greater power' to persuade other participants users and other professionals may predominate. The simplification of the method can make its application mechanical and rigid, impoverishing the synergy of ideas, which requires the leader flexibility and mastery to ensure homogeneous understanding and the exercise of voice to all participants.

It was observed that the visualization techniques confer an important attribute of the method for its performance by facilitating the concentration, the vision of the whole and guaranteeing agility in the resumption of the discussions between the meetings. The skills and competences of the workshop leader were also key to help participants conceptualize the problem and to ensure direct involvement, equal participation and homogeneous understanding, since the team was composed of people with different cognitive accumulations and levels of schooling.

Finally, the importance of the vision and decision of consensus, which at the same time allowed the respect to the different opinions, propitiated advance in the decision making, favoring the communication, establishing a common language in the planning and the monitoring of the project. Feliciano¹⁹19 Feliciano KVO. Aspectos da comunicação nas práticas avaliativas na Estratégia Saúde da Família. Rev Bras Saúde Mater Infant. 2010; 10(Supl.1):s219-s227. draws attention to the need for a non-forced communication committed to a dialogical practice based on the consensual force of the argument.

Final considerations

Given the results, it can be affirmed that the participatory planning method was efficient to allow the visualization of the internal and external factors to the work that compromised the quality of the care to the pregnant woman, enabling the participants to recognize the accumulated knowledge and the value of their actions and complementarities, including user reality.

It proved to be flexible and suitable for the development of competences for collaborative work and the construction of a protocol of service organization in the scope of the PHC. The inseparability between analyzing, planning and implementing actions aroused ethical commitments and recovered innovative behaviors in the routing of problem resolution, strengthening interprofessional collaboration.

The planning and the resources mobilized can assure the accomplishment of the actions. Certain limitations can be overcome by involving participants directly in the context of action, by guaranteeing equal participation and homogeneous understanding, by stimulating the synergy of ideas, by using proper visualization techniques, by accurately identifying problems, by ability and competence of the leader to extract the vision of possible consensus.

With its application, the trust and the willingness for interprofessional collaboration was restored. The relationships of autonomy and interdependence of professional work were re-signified, generating new knowledge about the theme related to the needs of pregnant women. Transformations were triggered in interprofessional relationships and among professionals and users, in the quality of the bonds and in the degree of co-responsibility in the production of care.

The implication of the subjects (workers and pregnant women) as protagonists in the production of changes in the units studied was visible as a result of the changes in attitude and involvement in the process of production of care required for the implementation of the new PAG, an important condition when seeking higher quality in the provision of health services. Pregnant women and professionals felt the protagonists of the project; and new forms of care for pregnant women were instituted. Pregnant women are being counted on as partners in social mobilization, stimulating new therapeutic devices. In the first seven months of implementation of the protocol, there was a general perception of the team that it improved the attention to the pregnant woman and promoted a more collaborative and interprofessional work.

References

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