ABSTRACT

This study aimed to understand the appropriation of Permanent Health Education (PHE) by Primary Health Care (PHC) in Brazil, through an integrative review of the literature. There was a search for texts published in Portuguese, English and Spanish on PHE in PHC in Brazil, between 2007 and 2017, which addressed the concept of PHE, initiatives developed in PHC and/or perception about changes in professional practice. Twenty-seven studies were selected. The thematic content analysis identified four empirical categories: conceptions of PHE; PHE initiatives and their characteristics in the PHC; positive points and facilitators related to PHE initiatives in PHC; and fragile and difficult points. It was observed that the understanding of PHE by health professionals and managers is close to the concept of Continuing Education (CE). Among the PHE initiatives in the services were: development of technological resources; teaching-service approach; and the formation of collective spaces of meaningful learning in the daily work. However, the devaluation of PHE initiatives contributes to its non-effectiveness in PHC and the valuation of CE practices. It is considered necessary to legitimize PHE as a movement and educational policy in the scenario of PHC in Brazil, aiming at improving the quality of management and care.

KEYWORDS
Permanent education; Health policy; Primary Health Care; Health human resource training

Introduction

The concept of permanent education was introduced in Latin America in the face of the inadequacy of vocational training, which focused exclusively on the development of technical skills aimed at productive performance, without the inclusion of knowledge, values and a commitment to political, ethical and social activities¹1 Unesco. Educação: Um tesouro a descobrir - Relatório para a Unesco da Comissão Internacional sobre educação para o século XXI [internet]. São Paulo: Cortez; 1998 [acesso em 2018 jan 20]. Disponível em: http://dhnet.org.br/dados/relatorios/a_pdf/r_unesco_educ_tesouro_descobrir.pdf.
http://dhnet.org.br/dados/relatorios/a_p... ^,22 Guimarães EMP, Martin SH, Rabelo FCP. Educação Permanente em Saúde: Reflexões e desafios. Cienc. enferm. [internet]. 2010 [acesso em 2018 jan 20]; 16(2):25-33. Disponível em: https://scielo.conicyt.cl/pdf/cienf/v16n2/art_04.pdf.
https://scielo.conicyt.cl/pdf/cienf/v16n... .

The insertion of this concept in the health field in Brazil occurred through the Human Resources Development Program of the Pan American Health Organization (PAHO), in the 1980s, and focused on the construction of a new pedagogical framework which would enable greater involvement of the worker in the productive process of health, aimed at improving quality³3 Lemos CLS. Educação Permanente em Saúde no Brasil: educação ou gerenciamento permanente? Ciênc. Saúde Colet. [internet]. 2016 [acesso em 2018 jan 10]; 21(3):913-922. Disponível em: http://www.scielo.br/scielo.php?pid=S1413-81232016000300913&script=sci_abstract&tlng=pt.
http://www.scielo.br/scielo.php?pid=S141... . The intention was the inclusion of a new model based on learning in a relationship with the work process itself to transform health practices⁴4 Campos KFC, Sena RR, Silva KL. Educação permanente nos serviços de saúde. Esc. Anna Nery Rev. Enferm. 2017 ago; 2(4):1-10.^,55 Silva JF. A educação permanente em saúde como espaço de produção de saberes na Estratégia de Saúde da Família [dissertação]. [internet]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca; 2015 [acesso em 2018 jan 20]. Disponível em: https://www.arca.fiocruz.br/bitstream/icict/13461/1/30.pdf.
https://www.arca.fiocruz.br/bitstream/ic... .

The Permanent Health Education (PHE), inserted by the Ministry of Health as a health policy in Brazil through Decrees nº 198/2004 and nº 1996/97, aims to guide the training and qualification of professionals inserted in public services, with the aim of transforming professional practices and the organization of work itself based on the needs and difficulties of the system⁶6 Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Política de Educação Permanente e Desenvolvimento para o SUS: caminhos para educação permanente em saúde. Brasília, DF: Ministério da Saúde; 2004. 68 p. (Série C. Projetos, Programas e Relatórios).

7 Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação em Saúde. Política Nacional de Educação Permanente em Saúde. Brasília, DF: Ministério da Saúde, 2009. 64 p. (Série B. Textos Básicos de Saúde) (Série Pactos pela Saúde 2006; v. 9).^-88 Cardoso ML, Costa PP, Costa DM, et al. A Política Nacional de Educação Permanente em Saúde nas Escolas de Saúde Pública: reflexões a partir da prática. Ciênc. Saúde Colet. 2017; 22(5):1489-1500..

As for the organization and functioning of public and universal health systems, based on the proposal defined at the International Conference on Primary Health Care, held in Alma Ata (1978), Primary Health Care (PHC) became the first level of contact of people with the national health system and the first element of an ongoing process of attention to essential health care, bringing health services as close as possible to people’s lives⁹9 Brasil. Ministério da Saúde. A questão dos recursos humanos nas Conferências Nacionais de Saúde (1941-1992). Cad. RH Saúde. 1993 nov; 1(1):218.^,1010 Oliveira MAC, Pereira IC. Atributos essenciais da Atenção Primária e a Estratégia Saúde da Família. Rev. bras. enferm. 2013 set; 66(1):158-164..

In Brazil, the main practical strategy and reorganization of PHC implemented in 1994 consisted of the Family Health Program (FHP), later called the Family Health Strategy (FHS)¹⁰10 Oliveira MAC, Pereira IC. Atributos essenciais da Atenção Primária e a Estratégia Saúde da Família. Rev. bras. enferm. 2013 set; 66(1):158-164.. The FHS proposes that health care be centered on the family, which places health professionals in direct contact with the population, allowing them to better understand the health needs of the people¹⁰10 Oliveira MAC, Pereira IC. Atributos essenciais da Atenção Primária e a Estratégia Saúde da Família. Rev. bras. enferm. 2013 set; 66(1):158-164..

In this context, PHE, inserted in Brazil as an ethical-political-pedagogical proposal, aims to transform and qualify health care, training processes, health education practices, and encourage the organization of actions and services in an intersectoral perspective also in the FHS scenario. The PHE aims to strengthen PHC practices and the model of health care in force in the Country considering the articulated work between management spheres, educational institutions, the service and the community⁷7 Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação em Saúde. Política Nacional de Educação Permanente em Saúde. Brasília, DF: Ministério da Saúde, 2009. 64 p. (Série B. Textos Básicos de Saúde) (Série Pactos pela Saúde 2006; v. 9).^,1111 Fortuna CM, Matumoto S, Pereira MJB, et al. Educação permanente na estratégia saúde da família: repensando os grupos educativos. Rev. Latino-am Enfermagem [internet]. 2013 jul [acesso em 2018 jan 20]; 21(4):1-8. Disponível em: http://www.scielo.br/pdf/rlae/v21n4/pt_0104-1169-rlae-21-04-0990.pdf.
http://www.scielo.br/pdf/rlae/v21n4/pt_0... .

Under the auspices of the PHC, the FHS focuses on promoting health in the communities, guaranteeing everyone the right to access, equally and integrally, to health services, in accordance with the principles of the Unified Health System (SUS)¹⁰10 Oliveira MAC, Pereira IC. Atributos essenciais da Atenção Primária e a Estratégia Saúde da Família. Rev. bras. enferm. 2013 set; 66(1):158-164.. In addition, it aims to institute a new paradigm in health care, with innovative guidelines in the ways of producing actions and health services, with a perspective of change and conversion of the existing mechanistic and biomedical assistance model¹²12 Menezes RCE, Oliveira MAA, Costa EC, et al. Alimentação e nutrição na atenção básica à saúde: a educação permanente como instrumento de aproximação ensino-serviço. Revista baiana de saúde pública. 2013 out; 37(4):1051-1070..

It should be highlighted that the FHS consists of a powerful space for the consolidation of PHE by performing shared practices in teams using different technologies to care for users, for having an inductive role in the interdisciplinary work of the team, in building a bond between team and users and the reformulation of traditional knowledge and practice in health¹³13 Soratto J, Pires DEP, Dornelles S, et al. Family health strategy: a technological innovation in health. Texto & contexto enfermagem. [internet]. 2015 abr [acesso em 2018 jan 20]; 24(2):584-592. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072015000200584.
http://www.scielo.br/scielo.php?script=s... . In addition, the PHE is directed to the daily updating of the practices according to the theoretical, methodological, scientific and technological contributions available, as well as the joint construction of organizational, inter-institutional and/or intersectoral practices, directed at the policies in which health acts are inscribed¹⁴14 Ceccim RB. Educação Permanente em Saúde: desafio ambicioso e necessário. Interface (Botucatu). 2005; 9(16):161-168..

According to Rovere¹⁵15 Rovere MR. Gestion de la educacion permanente: una relectura desde una perspectiva estrategica. Educ. méd. salud. [internet]. 1993 out [acesso em 2018 jan 20]; 27(4):489-515. Disponível em: http://hist.library.paho.org/Spanish/EMS/16342.pdf.
http://hist.library.paho.org/Spanish/EMS... , Haddad, Roschke and Davini¹⁶16 Haddad JQ, Roschke MAC, Davini MC. Educación permanente de personal de salud. [internet] Washington, D.C.: Organizacion Panamericana de La Salud, 1994 [acesso em 2018 jan 10]. Disponível em: http://hist.library.paho.org/Spanish/DRH/17399.pdf.
http://hist.library.paho.org/Spanish/DRH... and Ceccim and Feuerweker¹⁷17 Ceccim RB, Feuerwerker LCM. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis. 2004; 14(1):41-65., for the development of the training of workers and the organization of the work process in health, it is necessary to consider PHE initiatives, since they are focused on the daily work, in the articulation between the different actors and in a multiprofessional and interdisciplinary perspective.

Differently, training processes based on the conception of Continuing Education (CE) aim to update technical-scientific knowledge through the use of pedagogies of transmission of knowledge¹⁶16 Haddad JQ, Roschke MAC, Davini MC. Educación permanente de personal de salud. [internet] Washington, D.C.: Organizacion Panamericana de La Salud, 1994 [acesso em 2018 jan 10]. Disponível em: http://hist.library.paho.org/Spanish/DRH/17399.pdf.
http://hist.library.paho.org/Spanish/DRH... ^,1717 Ceccim RB, Feuerwerker LCM. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis. 2004; 14(1):41-65.. Initiatives with characteristics of the CE are insufficient to meet the growing demands of the implementation of the SUS, more specifically the PHC, due to its disarticulation with health care practices⁶6 Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Política de Educação Permanente e Desenvolvimento para o SUS: caminhos para educação permanente em saúde. Brasília, DF: Ministério da Saúde; 2004. 68 p. (Série C. Projetos, Programas e Relatórios)..

From that point of view, faced with the proposal of the PHE as a guiding force of the health care model in SUS, aiming to improve the processes of training and reorganization of services provided to the population, this study aimed to understand the appropriation of PHE by primary care in Brazil, through an integrative review of the literature regarding initiatives of PHE developed in Brazil.

Methods

This is a research of integrative review of national and international literature on PHE in PHC in Brazil. This review includes a broad methodological approach as for synthesis reviews, since it allows the combination of data from the theoretical and empirical literature, non-experimental studies and experimental studies¹⁸18 Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein (São Paulo). 2010; 8(1):102-106..

The choice for the accomplishment of the integrative literature review was due to the fact that this approach allows a synthesis of the knowledge about the theme of PHE, mainly regarding its conceptual definition. This brings an understandable panorama of the different concepts found, as well as the fact that it is possible to apply the data found by different methods, in the field of practice.

The review study was elaborated based on the six phases of construction of an integrative review of the literature, proposed by Souza, Silva and Carvalho¹⁸18 Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein (São Paulo). 2010; 8(1):102-106. and Mendes, Silveira and Galvão¹⁹19 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto & contexto enferm. 2008; 17(4):758-764.. In the initial stage, the following central question that guided the study was defined: ‘How has PHE been appropriated by PHC?’. In addition to this, the study was also guided by the specific questions: ‘How is PHE conceptually characterized in the PHC?’, ‘What are the PHE initiatives developed in the PHC?’ And ‘What are the results obtained from PHE initiatives?’.

For the selection of papers, the following inclusion criteria were considered: papers derived from researches (monographs, dissertations, theses, original articles and literature reviews); papers that deal with the concept of PHE and its development in PHC in Brazil; papers whose objectives related to PHE initiatives developed in the PHC; and papers on perceptions regarding the change in professional practice from these initiatives. The survey comprised papers published in the Portuguese, English and Spanish languages, from 2007 to 2017. This cut was defined for contemplating the period of validity of Decree nº 1996/2006 of the National Policy on Permanent Health Education (PNEPS).

Duplicated works, decrees, editorials, opinion articles, as well as documents and abstracts of seminars, congresses, courses and those not found in its entirety were excluded.

The search in the literature and the selection of publications were carried out by two researchers independently, between December 2017 and February 2018. With regard to the databases, the publications were collected from the Virtual Health Library (VHL), which gathers periodicals and scientific journals, such as: Lilacs (Latin American and Caribbean Literature in Health Sciences), Medline (Medical Literature Analysis and Retrieval System online), BBO (Brazilian Bibliography of Dentistry) and BDENF (Nursing Database). The search was also carried out in the following databases: SciELO (Scientific Electronic Library Online); electronic bank of theses and dissertations of BDTD (Digital Library of Theses and Dissertations); Google Scholar; and Scopus (SciVerse Scopus).

The descriptors used for the search were selected from the structured vocabulary Descriptors in Health Sciences (DeCS), in Portuguese, English and Spanish: ‘recursos humanos em saude’, ‘educacao permanente’, ‘educacao permanente em saude’, ‘educacao continuada’, ‘permanent education’, ‘educación permanente’, ‘atençao primaria’, ‘atençao primaria a saude’, ‘primary health care’, ‘atención primaria de salud’. These descriptors were used in the search with the help of Boolean operators (AND and OR).

Although this review aims to highlight the current knowledge about the theme of PHE developed in the PHC in Brazil, the choice by the term ‘continuing education’ was present due to the existing conceptual confusion with the term PHE and, consequently, its use inadequate in scientific texts and articles.

After the gathering phase of publications, the reading of the title and the abstract of the 129 publications were carried out by the two reviewers, independently, considering the defined inclusion and exclusion criteria. Subsequently, all publications were read in full, re-examining inclusion and exclusion criteria. This step helped categorize the information extracted from the publications.

The systematization of the selection of the publications in the bases of the scientific literature is presented in a flowchart (figure 1), with the description of the search stages with the quantitative of publications in each of the bases. The inclusion and exclusion criteria of the 96 publications were considered, until reaching the final number of 27 publications selected for the review.

For the analysis of the included studies, thematic content analysis was used²⁰20 Minayo MCS, organizadora. Pesquisa Social. Teoria, método e criatividade. 18. ed. Petrópolis: Vozes; 2016.. In the pre-analysis stage, the material exploration and treatment of the obtained results and interpretation were carried out. In this stage, the organization of the information and the systematization of the initial ideas were carried out by means of the floating reading of the data, highlighting main elements with the purpose of identifying possible categories of analysis. In the second stage, the exploration of the material was carried out, which consisted in the codification, classification and aggregation of the data and elaboration of the empirical categories responsible for the specification of the theme: conceptions of PHE; PHE initiatives and their characteristics in the PHC; positive points and facilitators related to PHE initiatives in the PHC; and fragile and difficult points.

Results and discussion

From the publications selected for this study, a table was developed (chart 1), showing the characteristics of these publications, according to the year of publication, title, type of publication, main author and database.

From the exploration of the selected material, empirical categories were elaborated to analyze the publications included in this integrative review.

Conceptions of Permanent Health Education

The concept of permanent education, based on the implementation of PHE policy, has undergone modifications in its understanding of practice of services, given the characteristics of each region and the needs for training and professional development. With this, it is believed that it is relevant to know the conceptual contribution of the PHE to the understanding of the current events in the health sector⁴4 Campos KFC, Sena RR, Silva KL. Educação permanente nos serviços de saúde. Esc. Anna Nery Rev. Enferm. 2017 ago; 2(4):1-10..

The results of this study demonstrate distinct paradigmatic perceptions about the design of PHE. An understanding of PHE from critical concepts and the predominance of an understanding that approaches the concept of traditional education.

Of the 27 publications, in 17 (63%) of them, the PHE concept was clearly stated. It was found a critical conception consistent with PHE in the view of some health workers in PHC, such as, for example, education in work as a collective construction of knowledge from the reality of the service.

For Freire²¹21 Freire P. Pedagogia do Oprimido. 14. ed. Rio de Janeiro: Paz e Terra; 2005., critical education is characterized by being dialogic, in which the problematization generates reflection and enables the re-signification and construction of new knowledge. In the field of health, PHE is defined as a pedagogical process that places daily work in health or training under analysis, starting from the presupposition of meaningful learning that allows the health professionals themselves to reflect on the lived reality and the models of health care in which they are inserted, as well as of the problems faced¹⁴14 Ceccim RB. Educação Permanente em Saúde: desafio ambicioso e necessário. Interface (Botucatu). 2005; 9(16):161-168..

It is understood, therefore, that PHE has, in the scenario of practices, the work process as an object of transformation, starting from the critical reflection of the professionals on what is happening in the daily services and seeking solutions together with the team to the problems encountered. However, what is observed in the selected studies is the lack of knowledge about PHE practices, a conceptual confusion between the terms PHE and CE and the perpetuation of actions focused on the CE. Possibly, part of this lack of understanding is due to the period of professional training in undergraduate courses based on the hegemonic medical model, with a strong presence of the culture of a fragmented education in the level of service management in the municipal and state spheres.

It is notable, from the 17 publications that bring the conception of PHE by health workers in PHC, a predominance of a conception of instrumental education, with emphasis on technical actions and updating of knowledge, which approximates the precepts of CE, observed in some of the studies²²22 Silva LAA, Soder RM, Petry L, et al. Educação permanente em saúde na atenção básica: percepção dos gestores municipais de saúde. Rev. gaúch. enferm. [internet]. 2017 mar [acesso em 2018 jan 20]; 38(1):1-8. Disponível em: http://www.scielo.br/pdf/rgenf/v38n1/0102-6933-rgenf-1983-144720170158779.pdf.
http://www.scielo.br/pdf/rgenf/v38n1/010...

23 Weykamp JM, Cecagno D, Vieira FP, et al. Educação permanente em saúde na atenção básica: percepção dos profissionais de enfermagem. Rev. enferm. UFSM. [internet]. 2016 abr [acesso em 2018 jan 20]; 6(2):281-289. Disponível em: https://periodicos.ufsm.br/reufsm/article/view/16754/pdf.
https://periodicos.ufsm.br/reufsm/articl...

24 Tesser CD, Garcia AV, Vendruscolo C, et al. Estratégia saúde da família e análise da realidade social: subsídios para políticas de promoção da saúde e educação permanente. Ciênc. Saúde Colet. 2011; 16(11):4295-4306.

25 Silva CEM. Educação permanente e suas interfaces com as condições sensíveis à atenção primária [dissertação] [internet]. Juiz de Fora: Universidade Federal de Juiz de Fora; 2016. 100 p. [acesso em 2018 jan 20]. Disponível em: https://repositorio.ufjf.br/jspui/bitstream/ufjf/3178/1/charleneestermachadosilva.pdf.
https://repositorio.ufjf.br/jspui/bitstr...

26 Aiub AC. Educação permanente em saúde no processo de trabalho do enfermeiro: concepções e resultados nos municípios pequeno porte da DRS III - Araraquara - São Paulo. [dissertação]. [São Paulo]: Escola de Enfermagem de Ribeirão Preto - Universidade de São Paulo; 2015. 54 p.

27 Pinto MCRL. O enfermeiro como facilitador de processos de educação permanente em saúde: fronteiras e perspectivas da atuação profissional [dissertação] [internet]. São Carlos: Universidade Federal de São Carlos; 2011. 170 p. [acesso em 2018 jan 20]. Disponível em: https://repositorio.ufscar.br/bitstream/handle/ufscar/3238/4121.pdf?sequence=1&isAllowed=y.
https://repositorio.ufscar.br/bitstream/...

28 Raddatz M. Ações de educação permanente em saúde desenvolvidas por equipes de atenção básica em saúde [dissertação] [internet]. Rio Grande do Sul: Universidade Federal de Santa Maria; 2014. 81 p. [acesso em 2018 jan 20]. Disponível em: https://repositorio.ufsm.br/bitstream/handle/1/7405/RADDATZ%2c%20MICHELE.pdf?sequence=1&isAllowed=y.
https://repositorio.ufsm.br/bitstream/ha... ^-2929 Peduzzi M, Guerra DAD, Braga CP, et al. Atividades educativas de trabalhadores na atenção primária: concepções de educação permanente e de educação continuada em saúde presentes no cotidiano de Unidades Básicas de Saúde em São Paulo. Interface (Botucatu) [internet]. 2009 jul [acesso em 2018 jan 20]; 13(30):121-134. Disponível em: http://www.scielo.br/scielo.php?pid=S1414-2832009000300011&script=sci_abstract&tlng=pt.
http://www.scielo.br/scielo.php?pid=S141... .

This conception, that educational actions are linked to specific skills, programmatic and centralizing style, with standardized contents and updating of knowledge according to the specificities of each category, was perceived by active primary care nurses, demonstrated in the research by Silva et al.³⁰30 Silva LAA, Pinno C, Schmidt SMS, et al. A educação permanente no processo de trabalho de enfermagem. Rev. enferm. Cent.-Oeste Min. [internet] 2016 set [acesso em 2018 jan 20]; 6(3):2349-2361. Disponível em: http://www.seer.ufsj.edu.br/index.php/recom/article/view/1027/1168.
http://www.seer.ufsj.edu.br/index.php/re... and also mentioned by the health workers, representative of each professional category and the managerial segment, in the study conducted by Silva and Peduzzi³¹31 Silva JAM, Peduzzi M. Educação no trabalho na atenção primária à saúde: interfaces entre a educação permanente em saúde e o agir comunicativo. Saúde Soc. 2011 out; 20(4):1018-1032. in the city of São Paulo.

In the view of representatives of the municipal management of a study carried out in a region of the Northeast, it is also observed that the specific courses are presented as permanent education actions, which reflects the few theoretical approximation of these managers with the concept of PHE or the indiscriminate use of both concepts (PHE and CE)³²32 Lima SAV, Albuquerque PC, Wenceslau LD. Educação permanente em saúde segundo os profissionais da gestão de Recife, Pernambuco. Trab. educ. saúde (Online) [internet] 2014 maio [acesso em 2018 jan 10]; 12(2):425-441. Disponível em: http://www.scielo.br/scielo.php?pid=S1981-7462014000200012&script=sci_abstract&tlng=pt.
http://www.scielo.br/scielo.php?pid=S198... . Similar results were found in the study that investigated the PHE design of dental managers and surgeons³³33 Formenton YF. Educação Permanente em Saúde: representações sociais de enfermeiros da saúde da família [dissertação] [internet]. São Carlos: Universidade Federal de São Carlos; 2013. 122 p. [acesso em 2018 jan 10]. Disponível em: https://repositorio.ufscar.br/bitstream/handle/ufscar/3254/4941.pdf?sequence=1.
https://repositorio.ufscar.br/bitstream/... , in the study conducted with professionals from the Health Unit (HU) of the city of Rio de Janeiro³⁴34 Gonçalves LC, Cortez EA, Cavalcanti ACD. Permanent Education in relation to Family Health Strategy: a descriptive exploratory study. Online braz. j. nurs. [internet] 2013 out [acesso em 2018 jan 20]; 12(1):593-595. Disponível em: http://www.objnursing.uff.br/index.php/nursing/article/view/4528/html.
http://www.objnursing.uff.br/index.php/n... and in the research developed by Zinn³⁵35 Zinn GR. Educação Permanente em Saúde: de diretriz política a uma prática possível [tese] [internet]. São Paulo: Universidade de São Paulo; 2015. 147 p. [acesso em 2018 jan 20]. Disponível em: http://www.teses.usp.br/teses/disponiveis/7/7140/tde-11052015-154630/pt-br.php.
http://www.teses.usp.br/teses/disponivei... in Sorocaba with managers and professionals of health.

Such confusion or misuse of the concepts of PHE and CE can be also noted in the research carried out by Mishima et al.³⁶36 Mishima SM, Aiub AC, Rigato AFG, et al. Perspectiva dos gestores de uma região do estado de São Paulo sobre educação permanente em saúde. Rev. Esc. Enferm. USP. 2015; 49(4):665-673., in which, in the definition of PHE in the perception of municipal health managers in a region of São Paulo, priority is given to the provision of courses and specific training to health workers.

In the field of health, CE practices are presented in line with the traditional model of education, guided by the technical-scientific knowledge and the updating of knowledge by professional categories, from the transference of content, leading to a fragmentation of health practices¹⁷17 Ceccim RB, Feuerwerker LCM. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis. 2004; 14(1):41-65.^,2121 Freire P. Pedagogia do Oprimido. 14. ed. Rio de Janeiro: Paz e Terra; 2005.^,2929 Peduzzi M, Guerra DAD, Braga CP, et al. Atividades educativas de trabalhadores na atenção primária: concepções de educação permanente e de educação continuada em saúde presentes no cotidiano de Unidades Básicas de Saúde em São Paulo. Interface (Botucatu) [internet]. 2009 jul [acesso em 2018 jan 20]; 13(30):121-134. Disponível em: http://www.scielo.br/scielo.php?pid=S1414-2832009000300011&script=sci_abstract&tlng=pt.
http://www.scielo.br/scielo.php?pid=S141... ^,3737 Silva JAM. Análise das atividades educativas dos trabalhadores da saúde na atenção básica: concepções de educação no trabalho, levantamento de necessidades, público participante e resultados esperados [dissertação] [internet]. São Paulo: Universidade de São Paulo; 2009. 215 p. [acesso em 2018 jan 20]. Disponível em: http://www.teses.usp.br/teses/disponiveis/7/7131/tde-13062008-100234/pt-br.php.
http://www.teses.usp.br/teses/disponivei... . It is worth noting here a reservation about the accomplishment of initiatives focused on the technical-scientific update, since these are not less important, however, constitute only one of the points of change of practices and not the central focus as in PHE actions .

The inadequate appropriation of PHE and CE concepts in the field of practice was also observed in the study by Bomfim et al.³⁸38 Bomfim ES, Oliveira BG, Rosa RS, et al. Educação permanente no cotidiano das equipes de saúde da família: utopia, intenção ou realidade? Rev. pesqui. cuid. fundam. (Online). [internet]. 2017 abr [acesso em 2018 jan 20]; 9(2):526-535. Disponível em: http://seer.unirio.br/index.php/cuidadofundamental/article/view/5464.
http://seer.unirio.br/index.php/cuidadof... , in which health workers (PHC professionals and municipal managers) cite PHE as a public policy, articulated between the need for learning and work and as a process of professional qualification through the formulation of knowledge. In the practice of the health service, it was found a lack of knowledge and lack of this concept, experiencing a different practice that approaches the precepts of a CE.

In addition to this understanding of PHE that most closely approximates the characteristics of a CE, in the study carried out with nurses working in the primary care of municipalities in Rio Grande do Sul, a different way of conceptualizing PHE was found: a direct relationship with the clinic and with the control and prevention of the disease³⁹39 Barth PO, Santos JLG, Ramos FRS. Continuing health care education: concepts and practices of nurses in basic health units. Rev. eletrônica enferm. [internet]. 2014 jul [acesso em 2018 jan 20]; 16(3):604-11. Disponível em: https://www.fen.ufg.br/revista/v16/n3/pdf/v16n3a15.pdf.
https://www.fen.ufg.br/revista/v16/n3/pd... . It was also found in the findings of the research conducted by Gonçalves, Cortez and Cavalcanti³⁴34 Gonçalves LC, Cortez EA, Cavalcanti ACD. Permanent Education in relation to Family Health Strategy: a descriptive exploratory study. Online braz. j. nurs. [internet] 2013 out [acesso em 2018 jan 20]; 12(1):593-595. Disponível em: http://www.objnursing.uff.br/index.php/nursing/article/view/4528/html.
http://www.objnursing.uff.br/index.php/n... , in which the definition of PHE by health professionals appeared the concepts of disease prevention and health education.

Based on the concept of PHE, the reflection on professionals’ practices in health services is fundamental; and when it becomes secondary or does not happen, according to Stroschein and Zocche⁴⁰40 Stroschein KA, Zocche DAA. Permanent education in health services: a study on the experience gained in Brazil. Trabalho, educação e saúde [internet]. 2012 [acesso em 2018 jan 20]; 9(3):505-519. Disponível em: http://www.scielo.br/pdf/tes/v9n3/v9n3a09.pdf.
http://www.scielo.br/pdf/tes/v9n3/v9n3a0... , PHE is not implemented, giving space for the reproduction of individual care practices and ways of thinking rooted in the traditional model of care.

There is, therefore, a constant need for change from the reflections emanating from the daily life of the service itself and from the fact that teaching is intertwined with the shifting and changing reality of actions and services, from spaces and themes capable of generating self-analysis, self-management and institutional change and professional practices that generate processes of thought and transformation of practices¹⁴14 Ceccim RB. Educação Permanente em Saúde: desafio ambicioso e necessário. Interface (Botucatu). 2005; 9(16):161-168..

PHE initiatives and their characteristics in PHC

In order for the realization of the conceptual understanding of PHE in the health field to occur, and more specifically in primary health care, it is necessary, first, to recognize and legitimize it as a movement and educational policy by health workers in the context of their practices. Among the PHE initiatives carried out in the PHC cited in 13 (48.1%) of the 27 selected publications, are, mainly, those related to technological resources, such as distance education and Telehealth; the approximations between teaching and service, such as Pro and Pet-Health; and those related to the daily work, such as the groups of conversation and team meetings.

While checking the strategies used to implement the PNEPS in the PHC, through an integrative review of the literature, Fuzissaki, Clapis and Bastos⁴¹41 Fuzissaki MA, Clapis MJ, Bastos MAR. Consolidação da política nacional de educação permanente: revisão integrativa. Revista de enfermagem UFPE [internet]. 2014 abr [acesso em 2018 jan 20]; 8(4):1011-1020. Disponível em: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/9773.
https://periodicos.ufpe.br/revistas/revi... identified the development of the following initiatives: use of innovative technologies, such as the internet; distance education and Telehealth. Thus, it was also observed in the study on the external evaluation stage of the National Program for Improving Access and Quality of Primary Care (PMAQ-AB), which, according to the professionals of the Family Health Teams, revealed that Telehealth was the PHE activity most accomplished by them in the workplace, followed by on-site courses, exchange of experiences, distance education activities, mentoring, and Telemedicine University Network⁴²42 Pinto HA, Ferla AA, Ceccim RB, et al. Atenção Básica e Educação Permanente em Saúde: cenário apontado pelo Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB). Divulg. saúde debate. 2014 out; 51:145-160..

For Schweickardt et al.⁴³43 Schweickardt J, Lima RTS, Ceccim RB, et al. Educação permanente em gestão regionalizada da saúde: saberes e fazeres no território do Amazonas. Porto Alegre: Rede UNIDA; 2015., the practices of PHE should be based on the use of active methodologies for knowledge construction, not on the transfer of information, in which the student is not the one who listens and memorizes, but one who builds for himself the knowledge that has been emitted in the debates. Corroborating the thinking of Ceccim¹⁴14 Ceccim RB. Educação Permanente em Saúde: desafio ambicioso e necessário. Interface (Botucatu). 2005; 9(16):161-168., PHE consists of daily updating of practices by health professionals according to meaningful learning and through the use of active methodologies and scientific and technological advances.

In this perspective, a major advance of PHE in primary care is Telehealth, which is based on a network of partner services, managed by state health secretariats, educational institutions and health services for the development of strategies for education for work, improvement of the quality of care, expansion of actions offered by these teams, change in care practices and the organization of the work process⁴⁴44 Faria MGA, David HMSL. Enfermagem e educação permanente à distância: o exemplo do projeto Telessaúde Brasil, núcleo Rio de Janeiro. Cogitare enferm. 2010; 15(4):667-673.^,4545 Brasil. Ministério da Saúde. Portaria nº 35, de 4 de janeiro de 2007. Institui no âmbito do Ministério da Saúde, o Programa Nacional de Telessaúde. Diário Oficial da União. 5 Jan 2007..

The teaching-service integration, in turn, consists of a strategy of professional improvement that connects information content and motivation, through the collective construction of knowledge. According to Ceccim and Feuerwerker¹⁷17 Ceccim RB, Feuerwerker LCM. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis. 2004; 14(1):41-65., it is the responsibility of the education institutions and the SUS to problematize work and health and education organizations, through the construction of meanings and practices based on social organization, with the participation of managers, trainers, users and students.

The existence of proposals that integrate teaching and service, such, for example, Pro and Pet-Health and/or the existence of education policies in health institutions, discussion circles and workshops, in the view of some of the authors, constitute important and relevant initiatives for the consolidation of PHE¹²12 Menezes RCE, Oliveira MAA, Costa EC, et al. Alimentação e nutrição na atenção básica à saúde: a educação permanente como instrumento de aproximação ensino-serviço. Revista baiana de saúde pública. 2013 out; 37(4):1051-1070.^,3232 Lima SAV, Albuquerque PC, Wenceslau LD. Educação permanente em saúde segundo os profissionais da gestão de Recife, Pernambuco. Trab. educ. saúde (Online) [internet] 2014 maio [acesso em 2018 jan 10]; 12(2):425-441. Disponível em: http://www.scielo.br/scielo.php?pid=S1981-7462014000200012&script=sci_abstract&tlng=pt.
http://www.scielo.br/scielo.php?pid=S198... ^,3838 Bomfim ES, Oliveira BG, Rosa RS, et al. Educação permanente no cotidiano das equipes de saúde da família: utopia, intenção ou realidade? Rev. pesqui. cuid. fundam. (Online). [internet]. 2017 abr [acesso em 2018 jan 20]; 9(2):526-535. Disponível em: http://seer.unirio.br/index.php/cuidadofundamental/article/view/5464.
http://seer.unirio.br/index.php/cuidadof... ^,4646 Silva KL, Ribeiro HCTC, Pereira LD, et al. Plano diretor de atenção primária como estratégia de educação permanente: perspectiva dos facilitadores. Rev Rene. [internet]. 2012 [acesso em 2018 jan 20]; 13(3):552-561. Disponível em: http://www.periodicos.ufc.br/rene/article/view/3977.
http://www.periodicos.ufc.br/rene/articl... ^,4747 Cardoso IM. "Rodas de Educação Permanente" na atenção básica de saúde: analisando contribuições. Saúde Soc. 2012; 21(1):18-28..

Thus, PHE circles also fit into important learning spaces. For Costa et al.⁴⁸48 Costa RRO, Bosco Filho J, Medeiros SM, et al. As rodas de conversa como espaço de cuidado e promoção da saúde mental. RAS. 2015 jan; 13(43):30-36., the institution of these collective spaces may allow the interaction of different actors to reflect on the reality of the health services in which they are inserted and to elaborate projects, tasks and actions, with the strengthening of autonomy and protagonism.

Such collective learning spaces follow the same logic as the Circle Method, known as the Paideia Method, developed by Cunha and Campos⁴⁹49 Cunha GT, Campos GWS. Método Paidéia para co-gestão de coletivos organizados para o trabalho. ORG & Demo. 2010 jan; 11(1):31-46. and understood as a critical method to the hegemonic managerial rationality that proposes new forms of reconstruction of the co-management of institutions, from the institution of collective spaces with the integration of different actors, guidelines and practices in health.

In the view of the professionals of the Family Health Team participating in the research carried out in the city of Rio de Janeiro by Silva⁵5 Silva JF. A educação permanente em saúde como espaço de produção de saberes na Estratégia de Saúde da Família [dissertação]. [internet]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca; 2015 [acesso em 2018 jan 20]. Disponível em: https://www.arca.fiocruz.br/bitstream/icict/13461/1/30.pdf.
https://www.arca.fiocruz.br/bitstream/ic... , collective spaces, such as the team meeting, are important for the production of knowledge, becoming the daily life of work, a device for structuring, organizing, establishing guidelines and space for decision-making. This was also reported by the PHC health professionals in the studies conducted by Zinn³⁵35 Zinn GR. Educação Permanente em Saúde: de diretriz política a uma prática possível [tese] [internet]. São Paulo: Universidade de São Paulo; 2015. 147 p. [acesso em 2018 jan 20]. Disponível em: http://www.teses.usp.br/teses/disponiveis/7/7140/tde-11052015-154630/pt-br.php.
http://www.teses.usp.br/teses/disponivei... , Raddatz²⁸28 Raddatz M. Ações de educação permanente em saúde desenvolvidas por equipes de atenção básica em saúde [dissertação] [internet]. Rio Grande do Sul: Universidade Federal de Santa Maria; 2014. 81 p. [acesso em 2018 jan 20]. Disponível em: https://repositorio.ufsm.br/bitstream/handle/1/7405/RADDATZ%2c%20MICHELE.pdf?sequence=1&isAllowed=y.
https://repositorio.ufsm.br/bitstream/ha... , Araújo et al.⁵⁰50 Araújo RRM, Moura MEB, Nunes BMVT, et al. Educação permanente em enfermagem na estratégia saúde da família. Rev. pesqui. cuid. fundam. (Online). [internet]. 2013 dez [acesso em 2018 jan 20]; 5(6):64-73. Disponível em: http://www.redalyc.org/html/5057/505750944008/.
http://www.redalyc.org/html/5057/5057509... , Alves et al.⁵¹51 Alves MR, Alves CR, Santos CLS, et al. Educação permanente para os agentes comunitários de saúde em um município do norte de Minas Gerais. Rev. pesqui. cuid. fundam. (Online). 2013 jul [acesso em 2018 jan 20]; 3(6):882-888. Disponível em: http://www.seer.unirio.br/index.php/cuidadofundamental/article/viewFile/2993/pdf_1325.
http://www.seer.unirio.br/index.php/cuid... and in the studies conducted by Silva, Ogata and Machado⁵²52 Silva JAM, Ogata MN, Machado MLT. Capacitação dos trabalhadores de saúde na atenção básica: impactos e perspectivas. Rev. eletrônica enferm. [internet]. 2007 [acesso em 2018 jan 20]; 9(2):389-401. Disponível em: https://www.fen.ufg.br/revista/v9/n2/pdf/v9n2a08.pdf.
https://www.fen.ufg.br/revista/v9/n2/pdf... and Lima, Albuquerque and Wenceslau³²32 Lima SAV, Albuquerque PC, Wenceslau LD. Educação permanente em saúde segundo os profissionais da gestão de Recife, Pernambuco. Trab. educ. saúde (Online) [internet] 2014 maio [acesso em 2018 jan 10]; 12(2):425-441. Disponível em: http://www.scielo.br/scielo.php?pid=S1981-7462014000200012&script=sci_abstract&tlng=pt.
http://www.scielo.br/scielo.php?pid=S198... with managers and health workers.

Positive points and facilitators related to PHE initiatives in PHC

From the reading of the selected publications, it was noted that, in 11 (40.7%) of them, positive points and facilitators related to PHE initiatives were mentioned, with these points acting as a necessary tool for the qualification of workers and the work itself in PHC and the reorganization of work processes.

Facilitators are understood to be the facilities related to contextual factors understood as aspects, circumstances and/or phenomena that contributed to the success of the activity or result⁵³53 Cruz MM. Avaliação de Políticas e Programas de saúde: contribuições para o debate. In Mattos RA, Baptista TWF. Caminhos para análise das políticas de saúde. Rio de Janeiro: Rede Unida; 2011. p. 181-199.. In the case of this review, the facilitator points are those that contribute to the development of PHE initiatives in PHC.

PHE initiatives were perceived by some managers and health professionals as a re-signification of practices and as an improvement in work behavior. In this context, the coping with reality of the health service came about through the significant learning they exercised in their daily work⁵5 Silva JF. A educação permanente em saúde como espaço de produção de saberes na Estratégia de Saúde da Família [dissertação]. [internet]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca; 2015 [acesso em 2018 jan 20]. Disponível em: https://www.arca.fiocruz.br/bitstream/icict/13461/1/30.pdf.
https://www.arca.fiocruz.br/bitstream/ic... ^,1212 Menezes RCE, Oliveira MAA, Costa EC, et al. Alimentação e nutrição na atenção básica à saúde: a educação permanente como instrumento de aproximação ensino-serviço. Revista baiana de saúde pública. 2013 out; 37(4):1051-1070.^,2828 Raddatz M. Ações de educação permanente em saúde desenvolvidas por equipes de atenção básica em saúde [dissertação] [internet]. Rio Grande do Sul: Universidade Federal de Santa Maria; 2014. 81 p. [acesso em 2018 jan 20]. Disponível em: https://repositorio.ufsm.br/bitstream/handle/1/7405/RADDATZ%2c%20MICHELE.pdf?sequence=1&isAllowed=y.
https://repositorio.ufsm.br/bitstream/ha... ^,3535 Zinn GR. Educação Permanente em Saúde: de diretriz política a uma prática possível [tese] [internet]. São Paulo: Universidade de São Paulo; 2015. 147 p. [acesso em 2018 jan 20]. Disponível em: http://www.teses.usp.br/teses/disponiveis/7/7140/tde-11052015-154630/pt-br.php.
http://www.teses.usp.br/teses/disponivei... ^,3636 Mishima SM, Aiub AC, Rigato AFG, et al. Perspectiva dos gestores de uma região do estado de São Paulo sobre educação permanente em saúde. Rev. Esc. Enferm. USP. 2015; 49(4):665-673.^,5050 Araújo RRM, Moura MEB, Nunes BMVT, et al. Educação permanente em enfermagem na estratégia saúde da família. Rev. pesqui. cuid. fundam. (Online). [internet]. 2013 dez [acesso em 2018 jan 20]; 5(6):64-73. Disponível em: http://www.redalyc.org/html/5057/505750944008/.
http://www.redalyc.org/html/5057/5057509... ^,5454 Silva LAA, Bonacina DM, Andrade A, et al. Desafios na construção de um projeto de educação permanente em saúde. Rev. enferm. UFSM [internet]. 2012 dez [acesso em 2018 jan 20]; 2(3):496-506. Disponível em: https://periodicos.ufsm.br/reufsm/article/view/5364/pdf.
https://periodicos.ufsm.br/reufsm/articl... .

The ethical-political awakening of the subjects related to PHE is centered on meaningful learning in the work that consists of qualification and training processes, thought and organized from the health needs, adopting the problematization of the work process with focus on the transformation of the professional practices and the organization of work⁵⁵55 Oliveira FMCS, Ferreira EC, Rufino NA, et al. Educação permanente e qualidade da assistência à saúde: aprendizagem significativa no trabalho da enfermagem. Aquichan. 2011 abr; 11(1):48-65.^,5656 Gomes IEM, Signor E, Arboit EL, et al. Desafios na gestão do trabalho em saúde: a educação na interface com atenção. Rev. enferm. Cent.-Oeste Min. [internet]. 2014 [acesso em 2018 jan 20]; 4(2):1100-1111. Disponível em: http://www.seer.ufsj.edu.br/index.php/recom/article/view/638.
http://www.seer.ufsj.edu.br/index.php/re... .

According to the speeches of health professionals from a municipality in the metropolitan area of Belo Horizonte (MG), PHE initiatives have identified different tools that guide practice in PHC, allowing changes in the organization of work processes and the qualification of professionals⁵⁴54 Silva LAA, Bonacina DM, Andrade A, et al. Desafios na construção de um projeto de educação permanente em saúde. Rev. enferm. UFSM [internet]. 2012 dez [acesso em 2018 jan 20]; 2(3):496-506. Disponível em: https://periodicos.ufsm.br/reufsm/article/view/5364/pdf.
https://periodicos.ufsm.br/reufsm/articl... . They provoke, thus, reflections on the work in the PHC, mainly regarding the practice of the teams and the discussion of the elements of the work process.

For Merhy, Feuerwerker and Ceccim⁵⁷57 Merhy EE, Feuerwerker LCM, Ceccim RB. Educación Permanente em Salud: una estrategia para intervenir en la micropolítica del trabajo em salud. Salud colectiva [internet]. 2006 maio [acesso em 2018 jan 10]; 2(2):147-160. Disponível em: http://www.scielo.org.ar/scielo.php?script=sci_arttext&pid=S1851-82652006000200004.
http://www.scielo.org.ar/scielo.php?scri... and Ceccim¹⁴14 Ceccim RB. Educação Permanente em Saúde: desafio ambicioso e necessário. Interface (Botucatu). 2005; 9(16):161-168., the PHE is a powerful tool, since it allows acting on the micro politics of the work, expanding the spaces of action and articulation of the workers. This would be done in the configuration of practices and in the creation of collective spaces of discussion, in addition to making the public health network a teaching-learning network in the exercise of work.

This teaching-service interrelationship was mentioned as a strategy in the development of the PHE initiatives as it allows the effective exchange between the health services and the University, favoring the qualification of services and research³⁰30 Silva LAA, Pinno C, Schmidt SMS, et al. A educação permanente no processo de trabalho de enfermagem. Rev. enferm. Cent.-Oeste Min. [internet] 2016 set [acesso em 2018 jan 20]; 6(3):2349-2361. Disponível em: http://www.seer.ufsj.edu.br/index.php/recom/article/view/1027/1168.
http://www.seer.ufsj.edu.br/index.php/re... ^,3232 Lima SAV, Albuquerque PC, Wenceslau LD. Educação permanente em saúde segundo os profissionais da gestão de Recife, Pernambuco. Trab. educ. saúde (Online) [internet] 2014 maio [acesso em 2018 jan 10]; 12(2):425-441. Disponível em: http://www.scielo.br/scielo.php?pid=S1981-7462014000200012&script=sci_abstract&tlng=pt.
http://www.scielo.br/scielo.php?pid=S198... ^,3636 Mishima SM, Aiub AC, Rigato AFG, et al. Perspectiva dos gestores de uma região do estado de São Paulo sobre educação permanente em saúde. Rev. Esc. Enferm. USP. 2015; 49(4):665-673..

Facilitating aspects of PHE initiatives mentioned by the participants of the studies by Weykamp et al.²³23 Weykamp JM, Cecagno D, Vieira FP, et al. Educação permanente em saúde na atenção básica: percepção dos profissionais de enfermagem. Rev. enferm. UFSM. [internet]. 2016 abr [acesso em 2018 jan 20]; 6(2):281-289. Disponível em: https://periodicos.ufsm.br/reufsm/article/view/16754/pdf.
https://periodicos.ufsm.br/reufsm/articl... and Zinn³⁵35 Zinn GR. Educação Permanente em Saúde: de diretriz política a uma prática possível [tese] [internet]. São Paulo: Universidade de São Paulo; 2015. 147 p. [acesso em 2018 jan 20]. Disponível em: http://www.teses.usp.br/teses/disponiveis/7/7140/tde-11052015-154630/pt-br.php.
http://www.teses.usp.br/teses/disponivei... refer to self-will, to the stimulation of critical reflection and the search for self-knowledge and professional growth. It is of great relevance that the institutions have the qualification of the professionals as an investment and encourage the implementation of the PHE in the Basic Health Units, favoring the positive perception of the professionals on the PHE, which, therefore, determines their participation in the actions.

The stimulus to the critical reflection of health professionals in their work context is a major challenge of PHE, making it necessary to improve educational methods and systematized and participative processes in the work space²2 Guimarães EMP, Martin SH, Rabelo FCP. Educação Permanente em Saúde: Reflexões e desafios. Cienc. enferm. [internet]. 2010 [acesso em 2018 jan 20]; 16(2):25-33. Disponível em: https://scielo.conicyt.cl/pdf/cienf/v16n2/art_04.pdf.
https://scielo.conicyt.cl/pdf/cienf/v16n... ^,33 Lemos CLS. Educação Permanente em Saúde no Brasil: educação ou gerenciamento permanente? Ciênc. Saúde Colet. [internet]. 2016 [acesso em 2018 jan 10]; 21(3):913-922. Disponível em: http://www.scielo.br/scielo.php?pid=S1413-81232016000300913&script=sci_abstract&tlng=pt.
http://www.scielo.br/scielo.php?pid=S141... ^,5454 Silva LAA, Bonacina DM, Andrade A, et al. Desafios na construção de um projeto de educação permanente em saúde. Rev. enferm. UFSM [internet]. 2012 dez [acesso em 2018 jan 20]; 2(3):496-506. Disponível em: https://periodicos.ufsm.br/reufsm/article/view/5364/pdf.
https://periodicos.ufsm.br/reufsm/articl... ^,5555 Oliveira FMCS, Ferreira EC, Rufino NA, et al. Educação permanente e qualidade da assistência à saúde: aprendizagem significativa no trabalho da enfermagem. Aquichan. 2011 abr; 11(1):48-65..

Another positive point related to PHE initiatives, reported by managers from a region of the state of São Paulo, was the changes in the practice of health worker services. In this a greater concern has appeared with its practice and appreciation of the continuity of what was learned, as well as the need for its application in its daily work³⁶36 Mishima SM, Aiub AC, Rigato AFG, et al. Perspectiva dos gestores de uma região do estado de São Paulo sobre educação permanente em saúde. Rev. Esc. Enferm. USP. 2015; 49(4):665-673.^,5252 Silva JAM, Ogata MN, Machado MLT. Capacitação dos trabalhadores de saúde na atenção básica: impactos e perspectivas. Rev. eletrônica enferm. [internet]. 2007 [acesso em 2018 jan 20]; 9(2):389-401. Disponível em: https://www.fen.ufg.br/revista/v9/n2/pdf/v9n2a08.pdf.
https://www.fen.ufg.br/revista/v9/n2/pdf... .

In the view of Ceccim and Ferla⁵⁸58 Ceccim RB, Ferla AA. Educação permanente em saúde. In: Pereira IB; Lima JCF. Dicionário da educação profissional em saúde. 2. ed. Rev. ampl. Rio de Janeiro: EPSJV; 2008. p. 163-167., training, from the perspective of PHE, can be considered when a new information generates anxiety and questions about how it has worked; and this new information prevents professionals from remaining the way they were before. It characterizes a training capable of generating changes in work practice by inducing a reflective and purposeful attitude by the pupil.

Weak points and difficulties related to PHE initiatives in PHC

Weak points and difficulties in implementing PHE initiatives in PHC were reported by health professionals in 17 (63%) of the selected publications. There were inadequacies in daily work, such as work overload and workforce far from what is required, lack of planning to carry out PHE initiatives, non-appreciation of PHE initiatives by management and inadequate characteristics of the PHE initiatives developed.

In the view of health professionals, the low participation of health workers in PHE initiatives is, often, related to the small workforce and the difficulty of releasing the work²²22 Silva LAA, Soder RM, Petry L, et al. Educação permanente em saúde na atenção básica: percepção dos gestores municipais de saúde. Rev. gaúch. enferm. [internet]. 2017 mar [acesso em 2018 jan 20]; 38(1):1-8. Disponível em: http://www.scielo.br/pdf/rgenf/v38n1/0102-6933-rgenf-1983-144720170158779.pdf.
http://www.scielo.br/pdf/rgenf/v38n1/010... ^,2525 Silva CEM. Educação permanente e suas interfaces com as condições sensíveis à atenção primária [dissertação] [internet]. Juiz de Fora: Universidade Federal de Juiz de Fora; 2016. 100 p. [acesso em 2018 jan 20]. Disponível em: https://repositorio.ufjf.br/jspui/bitstream/ufjf/3178/1/charleneestermachadosilva.pdf.
https://repositorio.ufjf.br/jspui/bitstr... ^,3535 Zinn GR. Educação Permanente em Saúde: de diretriz política a uma prática possível [tese] [internet]. São Paulo: Universidade de São Paulo; 2015. 147 p. [acesso em 2018 jan 20]. Disponível em: http://www.teses.usp.br/teses/disponiveis/7/7140/tde-11052015-154630/pt-br.php.
http://www.teses.usp.br/teses/disponivei... ^,5151 Alves MR, Alves CR, Santos CLS, et al. Educação permanente para os agentes comunitários de saúde em um município do norte de Minas Gerais. Rev. pesqui. cuid. fundam. (Online). 2013 jul [acesso em 2018 jan 20]; 3(6):882-888. Disponível em: http://www.seer.unirio.br/index.php/cuidadofundamental/article/viewFile/2993/pdf_1325.
http://www.seer.unirio.br/index.php/cuid... , with noncompliance with presented schedules, with the performance of activities at inappropriate times and with the overload of the team²³23 Weykamp JM, Cecagno D, Vieira FP, et al. Educação permanente em saúde na atenção básica: percepção dos profissionais de enfermagem. Rev. enferm. UFSM. [internet]. 2016 abr [acesso em 2018 jan 20]; 6(2):281-289. Disponível em: https://periodicos.ufsm.br/reufsm/article/view/16754/pdf.
https://periodicos.ufsm.br/reufsm/articl... ^,2626 Aiub AC. Educação permanente em saúde no processo de trabalho do enfermeiro: concepções e resultados nos municípios pequeno porte da DRS III - Araraquara - São Paulo. [dissertação]. [São Paulo]: Escola de Enfermagem de Ribeirão Preto - Universidade de São Paulo; 2015. 54 p.^,2828 Raddatz M. Ações de educação permanente em saúde desenvolvidas por equipes de atenção básica em saúde [dissertação] [internet]. Rio Grande do Sul: Universidade Federal de Santa Maria; 2014. 81 p. [acesso em 2018 jan 20]. Disponível em: https://repositorio.ufsm.br/bitstream/handle/1/7405/RADDATZ%2c%20MICHELE.pdf?sequence=1&isAllowed=y.
https://repositorio.ufsm.br/bitstream/ha... ^,5050 Araújo RRM, Moura MEB, Nunes BMVT, et al. Educação permanente em enfermagem na estratégia saúde da família. Rev. pesqui. cuid. fundam. (Online). [internet]. 2013 dez [acesso em 2018 jan 20]; 5(6):64-73. Disponível em: http://www.redalyc.org/html/5057/505750944008/.
http://www.redalyc.org/html/5057/5057509... ^,5252 Silva JAM, Ogata MN, Machado MLT. Capacitação dos trabalhadores de saúde na atenção básica: impactos e perspectivas. Rev. eletrônica enferm. [internet]. 2007 [acesso em 2018 jan 20]; 9(2):389-401. Disponível em: https://www.fen.ufg.br/revista/v9/n2/pdf/v9n2a08.pdf.
https://www.fen.ufg.br/revista/v9/n2/pdf... .

Corroborating the results found in the selected publications, Lopes et al.⁵⁹59 Lopes SRS, Piovesan ETA, Melo LO, et al. Potencialidades da educação permanente para a transformação das práticas de saúde. Comun. ciênc. saúde. 2007 abr; 18(2):147-155. emphasize that the difficulties that can arise in the PHE processes are related to the decisions regarding work management, decontextualized in health care planning; dissociation between planning and education and health; lack of definition of health policies and focus of work fragmented by professions. Personnel management and planning of PHE actions are characterized as difficulties to be faced for the development of PHE.

Peduzzi et al.²⁹29 Peduzzi M, Guerra DAD, Braga CP, et al. Atividades educativas de trabalhadores na atenção primária: concepções de educação permanente e de educação continuada em saúde presentes no cotidiano de Unidades Básicas de Saúde em São Paulo. Interface (Botucatu) [internet]. 2009 jul [acesso em 2018 jan 20]; 13(30):121-134. Disponível em: http://www.scielo.br/scielo.php?pid=S1414-2832009000300011&script=sci_abstract&tlng=pt.
http://www.scielo.br/scielo.php?pid=S141... point out that the demand for educational activities originates, for the most part, externally to the service and that it is not part of the demands of the workers, being decontextualized with the internal planning. Or they come, by and large, from municipal managers, who for various interests, opt for immediate educational actions, constantly dissociated from the needs of workers and users⁵5 Silva JF. A educação permanente em saúde como espaço de produção de saberes na Estratégia de Saúde da Família [dissertação]. [internet]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca; 2015 [acesso em 2018 jan 20]. Disponível em: https://www.arca.fiocruz.br/bitstream/icict/13461/1/30.pdf.
https://www.arca.fiocruz.br/bitstream/ic... ^,3030 Silva LAA, Pinno C, Schmidt SMS, et al. A educação permanente no processo de trabalho de enfermagem. Rev. enferm. Cent.-Oeste Min. [internet] 2016 set [acesso em 2018 jan 20]; 6(3):2349-2361. Disponível em: http://www.seer.ufsj.edu.br/index.php/recom/article/view/1027/1168.
http://www.seer.ufsj.edu.br/index.php/re... ^,3535 Zinn GR. Educação Permanente em Saúde: de diretriz política a uma prática possível [tese] [internet]. São Paulo: Universidade de São Paulo; 2015. 147 p. [acesso em 2018 jan 20]. Disponível em: http://www.teses.usp.br/teses/disponiveis/7/7140/tde-11052015-154630/pt-br.php.
http://www.teses.usp.br/teses/disponivei... .

For Fuzissaki, Clapis, and Bastos⁴¹41 Fuzissaki MA, Clapis MJ, Bastos MAR. Consolidação da política nacional de educação permanente: revisão integrativa. Revista de enfermagem UFPE [internet]. 2014 abr [acesso em 2018 jan 20]; 8(4):1011-1020. Disponível em: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/9773.
https://periodicos.ufpe.br/revistas/revi... , because of the lack of planning of the initiatives, they often become superficial. The authors pointed out that, from the perception of the managers, PHE initiatives are initial, and the PNEPS tools are presented in an incipient and insufficient way to change the picture of problems posed on the services, being still far from the daily life of the PHC services³⁶36 Mishima SM, Aiub AC, Rigato AFG, et al. Perspectiva dos gestores de uma região do estado de São Paulo sobre educação permanente em saúde. Rev. Esc. Enferm. USP. 2015; 49(4):665-673..

It is notable, from the selected publications, an important role of the management in the implementation of PHE initiatives, especially in what concerns the organization of work, the planning of activities linked to local difficulties, communications and decision-making, since managers are key players in the continuous organization and improvement of structures and, above all, processes³⁰30 Silva LAA, Pinno C, Schmidt SMS, et al. A educação permanente no processo de trabalho de enfermagem. Rev. enferm. Cent.-Oeste Min. [internet] 2016 set [acesso em 2018 jan 20]; 6(3):2349-2361. Disponível em: http://www.seer.ufsj.edu.br/index.php/recom/article/view/1027/1168.
http://www.seer.ufsj.edu.br/index.php/re... ^,3232 Lima SAV, Albuquerque PC, Wenceslau LD. Educação permanente em saúde segundo os profissionais da gestão de Recife, Pernambuco. Trab. educ. saúde (Online) [internet] 2014 maio [acesso em 2018 jan 10]; 12(2):425-441. Disponível em: http://www.scielo.br/scielo.php?pid=S1981-7462014000200012&script=sci_abstract&tlng=pt.
http://www.scielo.br/scielo.php?pid=S198... ^,3636 Mishima SM, Aiub AC, Rigato AFG, et al. Perspectiva dos gestores de uma região do estado de São Paulo sobre educação permanente em saúde. Rev. Esc. Enferm. USP. 2015; 49(4):665-673.^,5151 Alves MR, Alves CR, Santos CLS, et al. Educação permanente para os agentes comunitários de saúde em um município do norte de Minas Gerais. Rev. pesqui. cuid. fundam. (Online). 2013 jul [acesso em 2018 jan 20]; 3(6):882-888. Disponível em: http://www.seer.unirio.br/index.php/cuidadofundamental/article/viewFile/2993/pdf_1325.
http://www.seer.unirio.br/index.php/cuid... ^,6060 Maciel JAC. A educação permanente em saúde para os cirurgiões-dentistas da estratégia saúde da família: o caso de Sobral, Ceará [dissertação] [internet]. Ceará: Universidade Federal do Ceará; 2016. 114 p. [acesso em 2018 jan 20]. Disponível em: http://www.repositorio.ufc.br/bitstream/riufc/21829/3/2016_dis_jacmaciel.pdf.
http://www.repositorio.ufc.br/bitstream/... .

Corroborating this idea, Araújo et al.⁵5 Silva JF. A educação permanente em saúde como espaço de produção de saberes na Estratégia de Saúde da Família [dissertação]. [internet]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca; 2015 [acesso em 2018 jan 20]. Disponível em: https://www.arca.fiocruz.br/bitstream/icict/13461/1/30.pdf.
https://www.arca.fiocruz.br/bitstream/ic... ^,2929 Peduzzi M, Guerra DAD, Braga CP, et al. Atividades educativas de trabalhadores na atenção primária: concepções de educação permanente e de educação continuada em saúde presentes no cotidiano de Unidades Básicas de Saúde em São Paulo. Interface (Botucatu) [internet]. 2009 jul [acesso em 2018 jan 20]; 13(30):121-134. Disponível em: http://www.scielo.br/scielo.php?pid=S1414-2832009000300011&script=sci_abstract&tlng=pt.
http://www.scielo.br/scielo.php?pid=S141... ^,5050 Araújo RRM, Moura MEB, Nunes BMVT, et al. Educação permanente em enfermagem na estratégia saúde da família. Rev. pesqui. cuid. fundam. (Online). [internet]. 2013 dez [acesso em 2018 jan 20]; 5(6):64-73. Disponível em: http://www.redalyc.org/html/5057/505750944008/.
http://www.redalyc.org/html/5057/5057509... point out difficulties for PHE initiatives in studies with health professionals of the FHS: the use of inadequate methodologies; lack of preparation of the lecturer; repetition of themes; thematic approach away from the reality of services; and the use of inappropriate language.

Other aspects that make it difficult to carry out such actions are the lack of awareness and/or lack of appreciation by the municipal health managers of the initiatives of permanent education and the inadequate profile of the managers, as well as their lack of experience and lack of knowledge of the specificities of the SUS and its guidelines²²22 Silva LAA, Soder RM, Petry L, et al. Educação permanente em saúde na atenção básica: percepção dos gestores municipais de saúde. Rev. gaúch. enferm. [internet]. 2017 mar [acesso em 2018 jan 20]; 38(1):1-8. Disponível em: http://www.scielo.br/pdf/rgenf/v38n1/0102-6933-rgenf-1983-144720170158779.pdf.
http://www.scielo.br/pdf/rgenf/v38n1/010... ^,2626 Aiub AC. Educação permanente em saúde no processo de trabalho do enfermeiro: concepções e resultados nos municípios pequeno porte da DRS III - Araraquara - São Paulo. [dissertação]. [São Paulo]: Escola de Enfermagem de Ribeirão Preto - Universidade de São Paulo; 2015. 54 p..

The culture of not valuing educational actions focused on PHE, considering that these are detached from the work processes and the needs of the service, perpetuates characteristics in these actions of a lack of continuity, not involving all professionals in the initiatives and practices of PHE, distinguishing more practices in the logic of CE.

The lack of definition of health policies associated with the political and institutional context is also a difficulty for implementing PHE initiatives²²22 Silva LAA, Soder RM, Petry L, et al. Educação permanente em saúde na atenção básica: percepção dos gestores municipais de saúde. Rev. gaúch. enferm. [internet]. 2017 mar [acesso em 2018 jan 20]; 38(1):1-8. Disponível em: http://www.scielo.br/pdf/rgenf/v38n1/0102-6933-rgenf-1983-144720170158779.pdf.
http://www.scielo.br/pdf/rgenf/v38n1/010... ^,3232 Lima SAV, Albuquerque PC, Wenceslau LD. Educação permanente em saúde segundo os profissionais da gestão de Recife, Pernambuco. Trab. educ. saúde (Online) [internet] 2014 maio [acesso em 2018 jan 10]; 12(2):425-441. Disponível em: http://www.scielo.br/scielo.php?pid=S1981-7462014000200012&script=sci_abstract&tlng=pt.
http://www.scielo.br/scielo.php?pid=S198... ^,3333 Formenton YF. Educação Permanente em Saúde: representações sociais de enfermeiros da saúde da família [dissertação] [internet]. São Carlos: Universidade Federal de São Carlos; 2013. 122 p. [acesso em 2018 jan 10]. Disponível em: https://repositorio.ufscar.br/bitstream/handle/ufscar/3254/4941.pdf?sequence=1.
https://repositorio.ufscar.br/bitstream/... ^,3636 Mishima SM, Aiub AC, Rigato AFG, et al. Perspectiva dos gestores de uma região do estado de São Paulo sobre educação permanente em saúde. Rev. Esc. Enferm. USP. 2015; 49(4):665-673.^,6161 Bispo Júnior JP, Moreira DC. Educação permanente e apoio matricial: formação, vivências e práticas dos profissionais dos Núcleos de Apoio à Saúde da Família e das equipes apoiadas. Cad. Saúde Pública. 2017; 33(9):1-13.. For Silva et al.³⁰30 Silva LAA, Pinno C, Schmidt SMS, et al. A educação permanente no processo de trabalho de enfermagem. Rev. enferm. Cent.-Oeste Min. [internet] 2016 set [acesso em 2018 jan 20]; 6(3):2349-2361. Disponível em: http://www.seer.ufsj.edu.br/index.php/recom/article/view/1027/1168.
http://www.seer.ufsj.edu.br/index.php/re... and Zinn³⁵35 Zinn GR. Educação Permanente em Saúde: de diretriz política a uma prática possível [tese] [internet]. São Paulo: Universidade de São Paulo; 2015. 147 p. [acesso em 2018 jan 20]. Disponível em: http://www.teses.usp.br/teses/disponiveis/7/7140/tde-11052015-154630/pt-br.php.
http://www.teses.usp.br/teses/disponivei... , such discontinuity of PHE initiatives can often be associated with political issues and interests.

According to the study carried out by Mishima et al.³⁶36 Mishima SM, Aiub AC, Rigato AFG, et al. Perspectiva dos gestores de uma região do estado de São Paulo sobre educação permanente em saúde. Rev. Esc. Enferm. USP. 2015; 49(4):665-673., there is a predominance of a training model based on sporadic and fragmented courses, in which professional education is developed through the provision of qualification and training, supported by biomedical knowledge and based on a methodological approach of unidirectional transmission of information, whose main purpose is to update procedures, protocols and routines, generally based on the recommendations established by the Ministry of Health or State Health Department.

According to the reflection made by Ceccim and Feuerwerker¹⁷17 Ceccim RB, Feuerwerker LCM. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis. 2004; 14(1):41-65., traditional capacities, understood as CE are, sometimes, necessary and must be carried out, but, without losing sight of ‘education that thinks the work’ and the ‘education that thinks of the production of the world’. Thus, it is not only a question of organizing ‘specific courses or programmatic packages’, but of coordinating the training process and PHE in order to enable subjects to take their place in this process of construction.

In addition to the difficulties and challenges related to PHE in the PHC, measures are necessary to address the barriers that impede the implementation of PHE proposals. As mentioned by Lemos³3 Lemos CLS. Educação Permanente em Saúde no Brasil: educação ou gerenciamento permanente? Ciênc. Saúde Colet. [internet]. 2016 [acesso em 2018 jan 10]; 21(3):913-922. Disponível em: http://www.scielo.br/scielo.php?pid=S1413-81232016000300913&script=sci_abstract&tlng=pt.
http://www.scielo.br/scielo.php?pid=S141... , the need for actions aimed at evaluating these PHE processes and the permanent awareness of managers as protagonists, regarding the flexibility of educational actions in the field of practice. From this perspective, it is necessary to carry out evaluation procedures for the consolidation of quality in PHE practices, through instruments that evaluate the PHE in the scope of primary care.

Final considerations

The execution of strategies and actions focused on PHE is fundamental for PNEPS implementation and has been developed in primary health care services. However, many of these initiatives developed for health workers are based on a conception of instrumental education with an emphasis on punctual actions, fragmented and decontextualized with the daily services, which are closer to the concept of CE.

Even if there is a perpetuation of practices aimed at the traditional model, there is considerable progress in the use of technological resources and reflective practices in the daily work routine or that integrate teaching-service in PHE initiatives. These are intended to produce an awakening by health workers to change their practice, thus modifying their professional performance and the qualification of health services – and that is when PHE practices do happen.

To implement the PHE proposal in line with PNEPS guidelines, however, the existing difficulties for its development deal with the lack of tools that help the manager to operationalize what is proposed in the Policy, the need for articulation among the levels of management, the lack of qualified professionals and their accession to educational activities, the lack of planning by unit managers, the turnover of professionals due to the superficial bond with the service, the low popular participation and the work approach fragmented by professions. These are difficulties that need to be addressed and rethought in the sense of effective change.

In order for PHE, within the context of SUS, to be legitimized as a movement and educational policy and for its practices and initiatives to be consolidated by health workers in the scenario of PHC practices in Brazil, it is fundamental, based on the results of this research, the importance of the understanding of the term PHE by health workers, the performance of managers with health professionals, the training of professionals qualified to direct these PHE initiatives, as well as the greater articulation between the service and educational institutions and popular participation. It is believed that the training and development of health workers must take place in a reflexive, participative and continuous way, focused on local needs, services and people, strengthening the bond between managers, educational institution, health professionals and improve the quality of the health system.

References

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