José Roque Junges

Capital social e a agenda de pesquisa em epidemiologia

Social capital refers to those features of social organization that enable participants to act together and more effectively pursue common goals. A growing body of evidence suggests that societies with high levels of social capital have lower morbidity and mortality rates and higher life expectancy and are less violent. The main goal of this article is to review the relationship between social capital and health. First, the main concepts and criticisms of social capital theory are discussed. Next, commonly used assessment tools are elucidated. Then, the relationship between social capital and health is analyzed. Finally, the article comments on the theorys application to Brazilian reality. If scientific rigor is applied to social capital research, recognizing theoretical and methodological difficulties, it can expand the research agenda and contribute to a better understanding of how to effectively deal with health inequalities.

Politica de humanizacao na atencao basica: revisao sistematica

OBJECTIVE To analyze humanization practices in primary health care in the Brazilian Unified Health System according to the principles of the National Humanization Policy. METHODS A systematic review of the literature was carried out, followed by a meta-synthesis, using the following databases: BDENF (nursing database), BDTD (Brazilian digital library of theses and dissertations), CINAHL (Cumulative Index to nursing and allied health literature), LILACS (Latin American and Caribbean health care sciences literature), MedLine (International health care sciences literature), PAHO (Pan-American Health Care Organization Library) and SciELO (Scientific Electronic Library Online). The following descriptors were used: Humanization; Humanizing Health Care; Reception: Humanized care: Humanization in health care; Bonding; Family Health Care Program; Primary Care; Public Health and Sistema Único de Saúde (the Brazilian public health care system). Research articles, case studies, reports of experiences, dissertations, theses and chapters of books written in Portuguese, English or Spanish, published between 2003 and 2011, were included in the analysis. RESULTS Among the 4,127 publications found on the topic, 40 studies were evaluated and included in the analysis, producing three main categories: the first referring to the infrastructure and organization of the primary care service, made clear the dissatisfaction with the physical structure and equipment of the services and with the flow of attendance, which can facilitate or make difficult the access. The second, referring to the health work process, showed issues about the insufficient number of professionals, fragmentation of the work processes, the professional profile and responsibility. The third category, referring to the relational technologies, indicated the reception, bonding, listening, respect and dialog with the service users. CONCLUSIONS Although many practices were cited as humanizing they do not produce changes in the health services because of the lack of more profound analysis of the work processes and ongoing education in the health care services.OBJECTIVE : To analyze humanization practices in primary health care in the Brazilian Unified Health System according to the principles of the National Humanization Policy. METHODS : A systematic review of the literature was carried out, followed by a meta-synthesis, using the following databases: BDENF (nursing database), BDTD (Brazilian digital library of theses and dissertations), CINAHL (Cumulative Index to nursing and allied health literature), LILACS (Latin American and Caribbean health care sciences literature), MedLine (International health care sciences literature), PAHO (Pan-American Health Care Organization Library) and SciELO (Scientific Electronic Library Online). The following descriptors were used: Humanization; Humanizing Health Care; Reception: Humanized care: Humanization in health care; Bonding; Family Health Care Program; Primary Care; Public Health and Sistema Unico de Saude (the Brazilian public health care system). Research articles, case studies, reports of experiences, dissertations, theses and chapters of books written in Portuguese, English or Spanish, published between 2003 and 2011, were included in the analysis. RESULTS : Among the 4,127 publications found on the topic, 40 studies were evaluated and included in the analysis, producing three main categories: the first referring to the infrastructure and organization of the primary care service, made clear the dissatisfaction with the physical structure and equipment of the services and with the flow of attendance, which can facilitate or make difficult the access. The second, referring to the health work process, showed issues about the insufficient number of professionals, fragmentation of the work processes, the professional profile and responsibility. The third category, referring to the relational technologies, indicated the reception, bonding, listening, respect and dialog with the service users. CONCLUSIONS : Although many practices were cited as humanizing they do not produce changes in the health services because of the lack of more profound analysis of the work processes and ongoing education in the health care services.

Agentes comunitários de saúde: perfil e formação

This research discusses the profile and education of the community health agents. There is no clarity about the kind of professional needed and the appropriate training to the fulfillment of the function. The research is a case study with exploratory methodology and qualitative approach. The data was collected with a focused group, formed by ten agents, intentional selected from those with more time in service in Family Health Strategy teams from the municipality of Santa Maria, Rio Grande do Sul State. The discussions were recorded and transcribed by the researcher. The data was interpreted by content analysis. The results pointed to some important questions concerning the identity of the community health agents: integration on the health team, insertion in the community, profile and education. The profile which emerges from the research, is not different from the one proposed by the Ministry of Health. However, the difference is the professionalization, an initiative assumed by the agent, guided by reality, which he faces in his activity. The gaps, perceived in his formation, cause the agent to construct his professional identity, determined more by the technical aspect of the scientific knowledge than by his social competence as a community agent.

Bioética e saúde coletiva: convergências epistemológicas

This is a theoretical discussion about the epistemological statute of bioethics based on its convergences with public health, linked as scientific areas that came from the context of the second epistemological rupture, which questioned the critique to common sense inherent in modern science. The reapproximation with common sense in the second rupture means considering the determinants of environment and subjectivity in the methodology. Emerging from the second rupture, public health and bioethics include the social and subjective determinants in their analysis, with an enlarged and complex vision of human health and human actions involving environment, life and health. This requires a transdisciplinary focus in their approaches. What is the meaning of these premises for the epistemological statute of bioethics in its convergence with public health? As ethics, bioethics needs to be critical, but not aprioristic. The criticism of bioethics needs to come from the facticity of the social determinants expressed by the health iniquities. The only way to integrate criticism and facticity is hermeneutics, interpreting the significances constructed in the reality and become critical therefrom. This is the epistemological statute appropriate to bioethics in its convergence with public health.

Processos de trabalho no Programa Saúde da Família: atravessamentos e transversalidades

A pesquisa teve o objetivo de compreender os desafios eticos da implantacao do Programa usando a abordagem qualitativa e discussao focal em grupo. A amostra foi intencional, com integrantes das diferentes equipes PSF do municipio de Campo Bom (RS): 3 medicos, 3 enfermeiras, 2 tecnicas e 4 agentes comunitarios de saude. Foram criadas 8 situacoes de discussao sobre diferentes aspectos do PSF. O artigo e um recorte da pesquisa, tendo como objetivo especifico os estrangulamentos nos processos de trabalho do PSF. O referencial teorico sao os conceitos de atravessamento e transversalidade e a proposta da clinica ampliada. Os resultados foram classificados segundo os diferentes atores envolvidos nos processos de trabalho: usuarios, agentes comunitarios de saude, profissionais, gestores e sistema de saude. Os resultados apontam que os estrangulamentos nestes processos tem a sua origem na reproducao de procedimentos e de praticas hospitalares na atencao basica, levando a desconsiderar as dimensoes subjetivas e sociais do processo saude/doenca. A proposta da clinica ampliada poderia ser uma resposta, porque defende que os itinerarios terapeuticos precisam ser frutos de uma pactuacao entre usuario e profissional.The study was performed with the objective to understand the ethical challenges of implementing the Program, using a qualitative approach and focal group discussion. The study included members from different FHP teams in the city of Campo Bom (Rio Grande do Sul, Brazil): three physicians, three nurses, two technicians, and four community health agents. Eight situations were created to discuss different aspects of the FHP. This article is an excerpt of the study, addressing the bottleneck effects in the FHP work process. The theoretical framework included concepts of crossing and transverse and the amplified clinic proposition. The results were categorized according to the individuals involved in the work processes: users of the health system, community health agents, professionals, administrators, and health system. The bottleneck effect in these processes originates in the repetition of primary care procedures and hospital practices, disregarding the subjective and social dimensions of the health/disease process. The amplified clinic proposition could be an answer since it holds that the therapeutic plans should result from an agreement between the health system user and the professional.La investigacion tuvo el objetivo de comprender los desafios eticos de la implantacion del Programa usando el abordaje cualitativo y la discusion focal en grupo. La muestra fue intencional, con integrantes de los diferentes equipos PSF del municipio de Campo Bom (RS): 3 medicos, 3 enfermeras, 2 tecnicas y 4 agentes comunitarios de la salud. Fueron creadas 8 situaciones de discusion sobre diferentes aspectos del PSF. El articulo es una parte de la investigacion, teniendo como objetivo especifico los estrangulamientos en los procesos de trabajo del PSF. El marco teorico es el concepto de transversalidad y la propuesta de la clinica ampliada. Los resultados fueron clasificados segun los diferentes actores que participaron en los procesos de trabajo: usuarios, agentes comunitarios de salud, profesionales, gestores y sistema de salud. Los resultados apuntan que los estrangulamientos en estos procesos tienen su origen en la reproduccion de procedimientos y de practicas hospitalarias en la atencion basica, llevando a desconsiderar las dimensiones subjetivas y sociales del proceso salud/enfermedad. La propuesta de la clinica ampliada podria ser una respuesta, porque defiende que los itinerarios terapeuticos precisan ser fruto de un pacto entre usuario y profesional.

Direito à saúde, biopoder e bioética

The right to health is being more and more affected by the Biopower new configurations, no more only determined by the State, as in Foucault’s analyses, but mainly by the symbolic power of the market. The biotechnological enterprises stir up increasing claims for consuming in health. These products are techno-semiotic agencies of the subjectivity in hea lth, rendering their use as a right. In this situat ion it is important to return to the Right to Health compr ehension of the International Conventions and the Alma-Ata Conference, proving the interdependence between Human Rights in general and the Right to Health in particular, mainly aiming at the social d eterminants of health that define more basic rights . The Human Rights perspective permits the proposal of a public health bioethics, different from the clinical bioethics, more appropriate for considerin g the collective implications of the right to Healt h, not reduced to a mere consumption of technologies. Key-words: Human Rights. Right to Health. Technologies. Biopower. Bioethics. RESUMO O direito a saude esta sempre mais afetado pelas no vas configuracoes do biopoder, cujas intervencoes nao sao mais determinadas unicamente pelo Estado como aparece nas analises de Foucault, mas principalmente pelo poder simbolico do mercado. As empresas biotecnologicas suscitam crescentes demandas de consumo em saude. Estes produtos sao agenciadores tecno-semiologicos da subjetividade em saude, tornando seu consumo objeto de um direito. Nesta situacao e importante voltar a compreensao do direito a saude presente nas convencoes internacionais e na conferencia de Alma-Ata, mostrando a interdependencia entre os direitos huma nos em geral e o direito a saude em particular e, principalmente, apontando para os determinantes sociais da saude que definem direitos mais basicos. A perspectiva dos direitos humanos permite propor uma bioetica da saude publica, diferente da bioetica, v.13, n.29, p.285-95, abr./jun. 2009.The right to health is being more andmore affected by the new biopowerconfigurations, whose interventions areno longer determined only by the State,but mainly by the symbolic power of themarket. The biotechnological enterprisesstir up increasing demands for consumingin health. These products are techno-semiotic agencies of subjectivity in health,and they make their consumptionbecome a right. In this situation it isimportant to return to the understandingof the Right to Health that is present atthe International Conventions and at theAlma-Ata Conference, showing theinterdependence between Human Rightsin general and the Right to Health inparticular, and also the socialdeterminants of health that define morebasic rights. The Human Rightsperspective enables the proposal of apublic health bioethics, which is differentfrom the clinic bioethics and moreappropriate to consider the collectiveimplications of the Right to Health, notreduced to the mere consumption oftechnologies.Keywords: Human Rights. Right tohealth. Technologies. Biopower. Bioethics.O direito a saude esta sempre maisafetado pelas novas configuracoes dobiopoder, cujas intervencoes nao sao maisdeterminadas unicamente pelo Estado,mas, sobretudo, pelo poder simbolico domercado. As empresas biotecnologicassuscitam crescentes demandas deconsumo em saude. Estes produtos saoagenciadores tecnosemiologicos dasubjetividade em saude, tornando seuconsumo objeto de um direito. Nestasituacao e importante voltar acompreensao do direito a saude presentenas convencoes internacionais e naconferencia de Alma-Ata, mostrando ainterdependencia entre os direitoshumanos em geral e o direito a saude emparticular e, especialmente, apontandopara os determinantes sociais da saudeque definem direitos mais basicos. Aperspectiva dos direitos humanos permitepropor uma bioetica da saude publica,diferente da bioetica clinica, maisadequada para pensar as implicacoescoletivas do direito a saude, nao reduzidoa um mero consumo de tecnologias.Palavras-chave: Direitos Humanos.Direito a saude. Tecnologias. Biopoder.Bioetica.

Arranjos familiares e implicações à saúde na visão dos profissionais do Programa Saúde da Família

OBJECTIVE To describe perception of family structures and understanding of a healthy family by Programa Saúde da Família (Family Health Program) team members. METHODS Research with a qualitative approach, employing the focus group technique, and involving the Program professionals from the city of Campo Bom, Southern Brazil, between June and August 2005. Sample was comprised of 12 professionals, including doctors, nurses, nursing technicians and community health agents. The following issues were investigated: the meaning of family; the meaning of the role of family; type of family most frequently cared for by professionals; the meaning of a healthy family; and types of family causing more difficulties of care. The methodological instrument used was content analysis. RESULTS Two main categories were observed: family structures, where a great diversity of arrangements was found; and healthy family, where the predominance of speech is consistent with a multifaceted view on health, involving political, social, economic and cultural aspects. Professionals identify and respect distinct family structures and adapt medical treatment accordingly. CONCLUSIONS Findings reveal that professionals are willing to deal with the different family structures present in their routine.OBJETIVO: Descrever a percepcao dos profissionais de equipes do Programa Saude da Familia sobre as configuracoes familiares e a compreensao de familia saudavel. METODOS: Pesquisa de abordagem qualitativa, empregando tecnica de grupo focal com profissionais do Programa Saude da Familia do municipio de Campo Bom, RS, no periodo de junho a agosto de 2005. A amostra foi composta por 12 profissionais: medicos, enfermeiras, tecnicas de enfermagem e agentes comunitarias de saude. Os temas investigados no roteiro foram: significado da familia, do papel da familia; tipo de familia mais comumente atendida pelos profissionais; significado de familia saudavel; quais familias oferecem maiores dificuldades para a atencao. O instrumental metodologico utilizado foi a analise de conteudo. RESULTADOS: Observaram-se duas categorias principais: arranjos familiares, em que se constatou grande diversidade de arranjos; e familia saudavel: em que o predominio dos relatos esta de acordo com uma visao multifacetada de compreensao de saude, abrangendo aspectos politicos, sociais, economicos e culturais. Os profissionais identificam e respeitam os diferentes arranjos familiares, e adaptam o tratamento ao modelo de familia que se apresenta. CONCLUSOES: Os achados mostram que os profissionais apresentam disposicao para lidar com os multiplos arranjos familiares presentes no seu cotidiano.

A produção científica sobre acesso no âmbito do Sistema Único de Saúde do Brasil: avanços, limites e desafios

A importância do acesso aos servicos de saude para a superacao dos impasses no âmbito da gestao do Sistema Unico de Saude (SUS) motivou a sistematizacao dos seus avancos, limites e desafios por meio de uma revisao da producao cientifica. Este estudo apresenta os principais resultados das pesquisas sobre acesso, tendo como universo de analise 5 revistas cientificas brasileiras de Saude Coletiva, indexadas internacionalmente e disponibilizadas na Scientific Electronic Library Online (SciELO). Contemplaram os criterios de inclusao 25 artigos envolvendo pesquisas qualitativas e relatos de experiencias, escritos em portugues, espanhol e ingles, publicados de 2002 a 2011. Na analise do campo objetal, os resultados evidenciam a nocao de acesso relacionada as seguintes categorias: processos de trabalho; organizacao da rede de atendimento; sistema e modelo de atencao. Centrados na avaliacao das condicoes de acesso, os estudos direcionam as criticas aos aspectos de esgotamento do sistema, sendo a organizacao da rede de atendimento o principal alvo das discussoes, a luz das representacoes sociais dos sujeitos envolvidos, em especial dos usuarios dos servicos. Limites, avancos e desafios sao identificados com enfase nos niveis da micro e mesogestao, isto e, no âmbito dos processos de trabalho e na organizacao da rede, ficando em segundo plano a analise da logica do sistema, definidora do modelo de atencao, que organiza o acesso aos servicos, bem como as respostas as necessidades advindas dos determinantes sociais da saude, das transicoes demograficas e epidemiologicas e do papel do controle social na efetivacao do direito a saude.

Interfaces entre território, ambiente e saúde na atenção primária: uma leitura bioética

Ethic challenges of public health are traversed by micro and macro social determinants, requiring the health service to be focused on the scope and its populations needs. Therefore understanding the interface between territory, environment and health is important. Territory is the space of the daily sociability of the social group who inhabit it, not reduced to administration limits. Health depends both on the micro territory and the macro natural and social environment, since represent the social determinants of life reproduction. So, the first ethic challenge is the construction of an assistance model which integrates primary care and the surveillance knowledge on the health needs of this territory. Another challenge is to build intersectoral actions, politically jointed and compromised to face social determinants and environmental damages that affect the health of population, improving their life quality.Los desafios eticos de la salud publica estan atravesados por determinantes micro y macro sociales, exigiendo que el servicio este enfocado en el territorio de abarcamiento y en las necesidades de su respectiva poblacion. Por eso entender las interfaces entre territorio, ambiente y salud es importante. Territorio es el espacio de las sociabilidades cotidianas del grupo social que lo habita, no reducido a los limites administrativos. Salud depende tanto del micro territorio, cuanto del macro ambiente natural y societario, ya que ambos configuran los determinantes sociales de la reproduccion de la vida. Asi, el primer desafio etico es la construccion de un modelo de asistencia que integre cuidados primarios y los conocimientos de la vigilancia sobre las necesidades en salud de aquel territorio. Otro desafio etico es la construccion de acciones inter-sectoriales politicamente articuladas y acordadas para enfrentar los determinantes sociales y los danos ambientales que afectan la salud de aquella poblacion en el sentido de mejorar su calidad de vida.

Violência urbana e capital social em uma cidade no Sul do Brasil: um estudo quantitativo e qualitativo

OBJECTIVE to study the relationship between reported urban violence and social capital in a medium-sized city in the state of Rio Grande do Sul, Brazil. METHODS the study was carried out with adults living in the urban area of São Leopoldo. For the quantitative analysis, a structured questionnaire was answered by 1 100 individuals older than 20 years of age and in charge of the household at the moment of the interview. Violence was evaluated based on the reports of violent arguments, theft or robbery, drug-related events, and homicides in the neighborhood over the previous six months. Social capital was defined based on the reported degree of trust among neighbors, informal social control, opinions on the actions of government and politicians, and social action in the neighborhoods. For the qualitative analysis, 11 participants residing in the area with the lowest or with the highest social capital answered a semi-structured interview. RESULTS people living in low-trust neighborhoods reported higher rates of homicide (OR = 2.82; 95%CI: 1.67-4.74; P > 0.001) and violent arguments (OR = 2.56; 95%CI: 1.82-3.59; P > 0.001) than people living in high-trust neighborhoods. Violent situations were reported most often in neighborhoods with low social capital, in which a lack of government attention was also reported. CONCLUSIONS in neighborhoods with the highest social capital, the prevalence of reported violence was lower. Priority should be given to public policies that promote social capital for the common good.