Community health agents and the interface with educational actions

Introduction: Within the mandate of all the professionals who make up the Family Health Strategy, health education is common to all. The Nurse, as part of the team, has a key role in health levels of individuals, families and communities, because the primary purpose of these actions is guided by the maintenance, promotion, restoration of health, prevention of diseases and disorders and psychological contribution to dealing with the consequences that an imbalance in health-disease process can generate on a family or community.


Introduction
The health system in Brazil witnessed various health care models for centuries, being launched by medical assistance and privatized.Such strategies aimed to solve problems and meet health needs, and were based on individual and curative hospital-welfarism, geared primarily for the individual disease.Consequently, the system has not been effective in addressing the health problems of the population [1].
Facing this reality, to transform the process of curative work, the health ministry deployed the Family Health Strategy.The main change on the focus of attention was that the strategies no longer focused exclusively on the individuals and diseases, but on the collectivity.The family became the privileged space of action, with practice based on ethical and moral principles, leading to increased user autonomy, to promote health [2].
In this sense, health promotion is considered as a production strategy of health -ie, as a way of thinking and acting articulated to other policies and technologies developed in the health system in Brazil, collaborating in the preparation of shares that allow social answering the health needs [3].
In this sense, the evolution of public policies and the increasing demand for a better quality of life provided the incorporation of concepts and practices of health.It should be emphasized that educational actions constitute the range of situations which characterize the delivery of services to the population and that the involvement of all the actors is an unequalled condition for the full exercise of public health [4].
Health education was inserted into the twentieth century, precisely in 1924.The public policy of the country consisted of the sanitary model, with special campaigns and programs to eradicate epidemic diseases.It was focused on a specific group of the population through an authoritarian and traditionalist model, with the distribution of printed material in brochures and books [5].This was not effective for health improvement.
In the 80s, with the emergence of the Unified Health System and its guiding principles, health education began to be used as a means of improving the health of the population.It aimed to promote health and prevent diseases, stimulating individuals to take actions to improve theirs and other people´s quality of life.It facilitated social inclusion and promoted the autonomy of people participation in health [6] .
The Family Health Strategy has emerged as a necessary way to redirect primary care practices of health care [7].It focused on prevention and health promotion, by developing educational assistance processes, to improve the ability of self-caring of individuals [8].
Within the mandate of all the professionals who make up the Family Health Strategy, health education is common to all.The Nurse, as part of the team, has a key role in health levels of individuals, families and communities.
The primary purpose of these actions is guided by the maintenance, promotion, restoration of health, prevention of diseases and disorders and psychological contribution to dealing with the consequences an imbalance in health-disease process can generate on a family or community [1][2][3][4][5][6][7][8][9].
It is also responsible to oversee, coordinate and conduct continuing education activities of community health workers and contribute, participate, and engage in continuing education activities of nursing staff and other team members [10].
In this context, for conducting health education actions, the reality of the community, on which the Family Health Strategy is inserted, must be considered.This requires that healthcare staff, who are directly involved in the community, is qualified and trained to perform it.
The Community health agent (CHA) has the task of monitoring the families of a community area, guiding individuals by engaging in educational processes, thereby having the role of educator.The CHA is the link between the Family Health Strategy and the community and provides the association of scientific and popular knowledge [11].In this context, the Community health agent is essential on the implementation of policies aimed at reorientation of the health care model.
The construction of educational practices with the Community health agent is one of the duties of the nurses.This should be made continuously, considering their experience and knowledge, as the starting point of the educational process [12].These practices can performed in the physical space and on the Family Health Strategy held in the community.For this educational process to be satisfactory, dynamic and participatory actions allow the Community health agent to build their own knowledge, based on life experiences [9].
In this context, the work process of teaching different professionals has become a challenge for nurses, especially because it must be considered the individuality and the way that Community health agent build knowledge.The attitudes generated in this process will interfere with the way who perform their teaching practices with the population [13].
Given the information above, considering the importance of the Community health agent to implement initiatives in health education, some questions arose: How nurses perceive health education ?Do they realize the importance of this profession on the construction of these actions?Will there be factors that facilitate or hinder this interaction for building these actions?
To answer these questions, this research aimed to understand the perception of nurses about construction practices in health education along with health workers.

Methods
A descriptive qualitative study conducted in the city of Juazeiro do Norte, Ceará, Brazil, with the sce-narios Units of Family Health said council was held.The study included 17 nurses working in these units.This number was established considering the inclusion criteria: being an effective nurse of the county , being, for at least 6 months at the Health Unit.
Yet considered the process of saturation lines to get to the end of data collection.It is considered that the saturation process of speech occurs when the researcher, after analyzing the information collected from a number of participants, realizes new interviews should depict repetitions of content, bringing some significant additions to the research in view of its objectives [14].
The instrument for data collection was the semistructured interviews conducted between June and September 2013.However, the collection was suspended considering the process of saturation lines.Thus, we observed saturation when focused on the perception of health education in two aspects: prevention and continuing education, with regard to the importance of Community health agent in the construction of educational activities, is focused on the real needs of users and, regarding facilities and difficulties, focused on affordability and lack of material resources.
Data were organized by content analysis using steps Bardin [15], focused on development of categories, grouped by elements and ideas that contain common characteristics and may be prepared before or after the data collection.
The research followed all rules established by Resolution 466/12 of the National Health Council [16] establishing guidelines and regulations governing research involving human subjects.The project was submitted to Brazil platform, being approved under protocol number 195.428 .

Results and discussion
Participated in the study 17 nurses, 13 female.The group ranged from 24 to 47 years old.With respect to the time they finished graduation, there was variation between 1 year and 6 months and 16 years and the time of experience in the Family Health Strategy, 1-9 years.All possessed expertise in the Family Health Strategy or Public Health.
The look of nurses on health education and the participation of health workers is expressed in the topics that follow, represented by the categories: Prevention of disease or continuing education: perceptions of health education, Importance of Community health agent in the construction of educational practices, educational practices along the Community health agent: successful strategies and challenges.

Disease prevention or continuing education: perceptions of health education
According to the National Policy for the Promotion of Health, it is proposed that health interventions broaden their scope, taking as object the problems and needs of health and its determinants and constraints.The organization of care and care involves at the same time, the actions and services that work on the effects of illness and those aiming to space beyond the walls of health facilities and the health care system, focusing on the living conditions and promoting the expansion of healthy choices by individuals and communities in the places where they live and work [3].
In this context, the authors [17] reported that health education is an important instrument to facilitate the training of the community , contributing to the promotion of health.For this, health workers and users need to establish a dialogical relationship guided by the therapeutic listening, respect and appreciation of experiences, stories of life and worldview, knowledge of these educational practices by these workers is necessary, considering the importance of knowing the other's gaze, interact with it and collectively reconstruct knowledge and everyday practices.Thus, we understand the importance of nurses entered this reality, understand about health education.In this sense, this approach of seeking the participants' perceptions about health education, showed up two axes: health education related to disease prevention and the other related to continuing education, revealing a traditionalist vision, but also misguided on health education, as follows : Well, health education is a way to educate the public to prevent, or avoid some types of diseases.It is important for disease prevention (Interviewee 9).

Health education is the continuous and periodic updating of professional or community on preventive aspects of health. The importance is to keep updated professional or community oriented about their health (Interviewee 10).
Apprehends that a perception of health education is still limited to hospitalocentric model and can reveal a decontextualization of professionals who are included in the model, since the model of the Family Health Strategy is intrinsically linked to health promotion.
The traditionalist view that most respondents refers to the biomedical model, dedicated exclusively to the cure of diseases and individual welfare, the educational process focuses on individual behavior change.Health is still seen as the result of choices made by individuals, so is ineffective in solving the health problems of the population.This thought is still dominant in health care, which is directly related to professional [18][19] training.
However, for some authors [20][21], health education should be perceived as an instrument to pro-mote health, and the process of health and illness seen as a mode of social production.The challenge for health professionals is that they should work within the health promotion perspective, seeing that they are involved in a model which seeks the empowerment of the users.
It is noteworthy, therefore, that for this critical awareness, health education should be seen as a process of teaching/ learning , which may contribute to the clarification of the subjects involved in the case, users, allowing them to view and address the determinants of health and illness in a new world view [22].
Thus, a perception of education in restricted shares of the preventative nature provide no behavior change on the decision making. .Professionals are aware of the need to transform this educational process regarding the organization and planning of teaching and learning activities, thereby meeting the perspectives of health promotion [23].
While the public policy focuses on health education as a way of promoting health , education presents difficulties in monitoring the evolution of these practices in preparing future nurses as educators.They are often still focused on biomedical aspects and traditionalist education and promotion strategies need to be incorporated into their theoretical and practical actions for health promotion [24].
In a study conducted in Sweden with health professionals in primary care also showed limited perception of actions that would be focused on health promotion.They were touted as primary, secondary or tertiary prevention, which may reveal a lack of adequate knowledge to integrate into the daily work to promote health effectively [25].
The graduation must act in the formation of trained professionals in a critical and reflective way, so that they can contribute to transform the reality in which they live.Health education needs to be addressed from the beginning of the Graduation, interconnected with other disciplines, so that students can understand the importance and acquire skills to perform it.
Another response often quoted by the participants referred to above, was the misconception of health education as continuing education.According to Guimarães and Aires [26] , this aims to update knowledge and training of health staff , thus enabling a systematic accumulation of information, so that the theories used are applied in routine practice Family Health Strategy, disregarding the reality of community as a starting point in the development of vocational education .
The preparation of nurses as health educators and the proper approach to health education for graduation is essential because it will directly reflect on professional practice and consequently in the way plans, organizes and conducts health education actions directly with the community or assisted with health care professionals, who are more involved in it: the Community health agent .

The importance of the Community health agent in the construction of educational practices
The Community health agent is essential in the implementation of educational practice that mediates the scientific and popular knowledge, to be a member of a multidisciplinary team and be placed in the context of the community, having more contact with the population, and a bond the community and the Family Health Strategy.Accordingly, we sought to understand how nurses perceived Community health agents in the construction of educational activities.
Thus, as illustrated by the statements below, they associate the role of health workers as essential for the construction of educational practices, and holders of the needs of the population, since they fall within the context of community.

Because they are directly in contact with the population, they focus on any subject and if they provide incorrect information, it will hinder the progress of the health care team in a general way (interviewee 1).
He is the main link between the community, a well-trained knowledgeable CHA, will know how to act in the community and will know to bring the community close (Interviewee 3).

The CHA is the link between the community and the staff, it is set in the context of the community, CHAs know more than any of us here the reality of the community they work with. (Interviewee 7).
The CHA is the door to primary care, they attending households investigating problems and providing guidance [...]

they are the first to have contact with the education of the community. (Interviewee 10).
It was evident that the involvement of Community health agent in construction practices is paramount to meet the real needs of users.This relevance can contribute to active participation in these practices when implemented by nurses, which enables the nurse interaction/ user and in turn, the necessary link between them.
The way that Community health agents organize and perform such procedures, directly affects the health of the assisted population, as an orientation taken incorrectly can aggravate or cause health problems in the population.Then the implementation of educational practices with these professionals becomes increasingly crucial, because it values and qualifies their work.Therefore, they will be able to intervene effectively in situations in their daily lives, and become really a link between the community and Family Health Strategy, recognizing their transformative role, bringing together scientific and popular knowledge [27].
Community Health agent knows the reality and the health needs of the population, showing the team at Family Health Strategy.So that interventions are carried out in the community and also provided through these educational practices performed with these professionals.They will play the role on promotion of health through exchange of experiences, home visits, and individual and group strategies [28].
Thus, by being inserted in the community, they identify with the culture, customs and language, promoting the mobilization, developing people's ability to address problems that affect their health, such as lack of sanitation , aiming to develop actions to improve the quality of life [29] .
In view of the above, we realize that when educational practices are implemented with the Community health agent in the context of real problems and needs of the population, they become more participatory, strengthening relationships between nurses and community because the issues raised are being experienced , with the sharing of knowledge, thus intervening in reality of the individuals involved .
However, many educational practices are geared to traditional methods, where there is a concern with the creation of a bond between the community, based on curative practices.The needs of the users may be not considered as a starting point in building these practices, and that this view is totally related to how nurses perceive health education [4].
These actions should promote the participation of individuals, guided by social necessity valuing the reality and experience of the same, with the development of critical awareness, encouraging the voluntary adoption of behavior change , as well as the social commitment of processing [28], which moves away from the traditional model of health education.

Educational practices to the Community health agent: advantages and difficulties
The development of educational practices requires professional qualifications, educational and teaching materials, time to plan them, support of professional staff and governors.The nurses pointed facilities in develop them with the Community health agent, the facilitated access, which most of these professionals are participatory and stakeholders: Working with CHA has many facilities such as availability.They are normally interested, contact is easier and they bring the reality of the community for discussions (Interviewee 10).

They always like to stay on top of issues, ask participate, take questions. (Interviewee 9).
The facility is that we're in day-to-day part of the team, we have daily access to community, they participate, suggest topics (Interviewee 7).
The commitment to share educational practices demonstrated by Community health agents is essential to achieve efficiency and desired goals, namely the exchange of knowledge among professionals.So that the real needs of the community are known, encouraging greater participation and making these activities more effective, enhancing the autonomy of individuals involved in the search for quality health [9].
However, difficulties were highlighted by the research subjects and the lack of materials, space and time to develop and implement these activities, and high demand, which makes the planning and lack of support from governors, as illustrated by the following statements:

It has no material, has a meeting room, is totally different from what we envisioned as scholarly (Interviewee 3).
The difficulty is that I had no training for this, we only goodwill, or receive materials for it (Interviewee 15).It is the lack of basic materials, because sometimes we have to buy the materials to perform these activities because you will not be just talking, [...] because it disperses attention and gets tiresome (Interviewee 2).
Several studies point to difficulties encountered in the implementation of educational practices, lack of educational materials, audiovisual resources, poor infrastructure, lack of physical space and management support, plus the overhead of service; causing problems in the planning of these actions, and the different ways that each Community health agent builds knowledge and exercising the profession .
Promoting health through health education requires, above all, management support , a reality that is not effective and is not limited to Brazil.In a study conducted in Sweden, to investigate about the difficulties facing actions developed on Primary Health, respondents point to the scarcity of resources and priority, for example, vaccination campaigns, and resources to enable initiatives focused on changes behaviors receive less priority [32].
Another problem encountered by nurses working for health education with ACS is the hospital-centered vision of health care, the use of language, often incomprehensible and lack of skills and training to develop specific educational practices with them, that they can develop them qualified and diverse way.In the present study, no participant reported having this type of activity, this practice being exercised only by the knowledge acquired in undergraduate and through experience [4].
However great, the difficulties in the realization of these practices should be considered as more important in their buildings, the methodology to be used, with a view in the educational process of each professional, analyzing the skills of individuals, considering the prior knowledge to debate the issue so that the motivation of the Community health agent is highlighted [33].
In this context, it is understood to be an urgent need to implement activities to qualified health professionals, with emphasis on strengthening the capacity for collective work, to contribute to not lose the concept of comprehensive health care and perform the work education among the population.Therefore, it is necessary to effectively exercise teamwork, since the process of training of health professionals [34][35].
As a tool providing changes in reality, it is worth highlighting the continuing education of health workers, which will enhance the educational actions, reorienting the practice, taking the precepts and principles of the Single Health System and meaningful learning, effecting thus an education that empower users, promoting lifestyle change thereof, as well as of the current health care model, which aims to promote the health of the population [36].
In this sense, recognizing the inserted fact, considering the current model of the Family Health Strategy, it is known that nurses should conduct educational practices from the perspective of health promotion.In other words, actions that should be focused on the determinants and conditions the health-disease process, establishing pedagogical educational activities, which are conditioned by the health needs of the population, considering political and economic aspects.

Conclusion
Health education by the Family Health Strategy, transformed health care in Brazil, which was not able to solve the health problems of the population.However, health promotion must be developed in practice assistance and is still facing hospitalocentric and curative models.
In this sense, it became clear that this is still a perception of limited health education in the prevention of diseases, which may affect the proce-dures adopted to implement these actions.On the other hand, although with this curative vision care, nurses consider for planning actions, the Community health agent reveals a care focused on the real needs of the population.
The Community health agents are closer to the community and meet thereal needs, having access to primary care.They need to be qualified, so that they can perform these practices efficiently, making the most present in the Family Health Strategy and modifying reality community to improve their quality of life.However, it is up to nurses to share knowledge through health education carried out with these professionals.
Thus, it is evident that there is a need for reorientation of health practices.However, this reorientation depends on the vision of nursing professionals in understanding a health education from the perspective of health promotion, as well as greater involvement of management in order to ensure human and material capable of these actions happen, which will provide assistance to the population facing health promotion.This contributes to a better quality of life for individuals and families assisted resources.
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