Occupational therapy and intersectoral networks: concepts and experiences in debate

Abstract

The formation of networks as a strategy for professional action is a broadly advocated theme within the framework of social policies, which have been historically organized in sectors and need to have their actions reorganized in view of the increasingly complex social demands. Networking is understood as a resource to confront the social question and its consequences, and as a tool for effecting proposals for professional intervention. Occupational therapy can use the creation and/or strengthening of social networks as processes that seek to ensure greater autonomy and social insertion to individuals or groups who are experiencing processes of rupture in their lives. This study aimed to investigate the strategy of forming intersectoral networks between the services that comprise social policies in the municipality of Campinas, state of São Paulo, Brazil, as a possible support tool focusing on the work of occupational therapists. As a method, 13 district coordinators from the social assistance, education and health areas were interviewed and a questionnaire was applied to 17 of the 36 occupational therapists (47%) working in the municipal network. In addition, two institutional networks were observed for four months. Finally, nine occupational therapists participated in a face-to-face meeting to discuss their experience and role in networks. Here, the data from the questionnaires and the group with the professionals are analyzed. In conclusion, considering the centrality of social (re)insertion as an objective of the occupational therapists, in addition to characteristics such as availability and flexibility, the promotion of intersectoral networks is a part of this work; however, this cannot be considered a specific or exclusive professional action.

Keywords:
Social Polices; Intersectoral Collaboration; Professional Practice

Resumo

A formação de redes como estratégia de ação técnica tem se caracterizado como uma temática amplamente defendida no bojo das políticas sociais, as quais são historicamente organizadas em setores e precisam ter suas atuações reorganizadas em vista das cada vez mais complexas demandas sociais. O trabalho em rede é compreendido como um recurso de enfrentamento à questão social e suas consequências, e como ferramenta para efetivação de propostas de intervenção junto à população assistida. A terapia ocupacional pode utilizar da criação e/ou fortalecimento das redes sociais como processos que buscam garantir maior autonomia e inserção social a pessoas ou grupos que vivenciam processos de ruptura em suas vidas. Objetivou-se investigar a estratégia de articulação intersetorial entre os serviços que compõem as políticas sociais em Campinas - SP como possível ferramenta de suporte, enfocando a atuação de terapeutas ocupacionais. Como método, 13 coordenadores distritais das áreas de assistência social, educação e saúde foram entrevistadas e 17 das 36 terapeutas ocupacionais (47%) que atuam na rede municipal responderam a um questionário. Além disso, observou-se duas redes institucionais por quatro meses. Por fim, nove terapeutas ocupacionais participaram de um encontro presencial para discutir sua experiência e papel nas redes. Aqui analisam-se os dados dos questionários e grupo com as profissionais. Conclui-se que, considerando a centralidade da (re)inserção social como objetivo da terapia ocupacional, somada a características como disponibilidade e flexibilidade, o fomento de redes intersetoriais é integrado ao seu trabalho; contudo, essa não pode ser considerada uma ação profissional específica ou exclusiva.

Palavras-chave:
Políticas Sociais; Colaboração Intersetorial; Prática Profissional

Networks and Intersectoriality: How is this relationship woven?

In the contemporary debate on new forms of public policy management, the development of joint actions and the constitution of spaces for collective discussion from the perspective of networking between services of different sectors stand out, notably in social assistance, education and health, with the objective of increasing the effectiveness of actions and optimizing the use of available resources.

From the understanding of social support networks, that is, spaces where people can count on different types of support – having the possibility to share problems and try to find solutions (Mângia & Muramoto, 2007) or “[...] the sum of relationships that an individual perceives as significant or differentiated from the anonymous mass of society” (Ferro, 2015, p. 488) – the networks created between the services operating in the social policies can be included as a form of support for the assisted population. At the same time, from a critical perspective, it is discussed that, in addition to increasing social support to the population - as predominantly addressed in the literature, social support networks can provide life control, especially in the lives of poor people, demonstrating ambivalence in their organization and actions.

Social support networks present a variety of configurations. Gonçalves & Guará (2010) described the following types of network: primary networks or spontaneous protection networks (sustained by the principles of solidarity and mutual support, composed of the family nucleus and friendship and neighborhood relations); social community networks (comprise community organizations, neighborhood associations, and philanthropic organizations, which, based on the principle of active trust, offer services to their micro-localities); social movement networks (formed by social movements, whose objective revolves around the defense of rights and surveillance and the struggle to ensure popular participation); public sector networks (include specialized services resulting from the action of the State through public policies); private service networks (composed of specialized services provided by the private sector to those who can pay for them). Among the social assistance networks, there are thematic, intersectoral, territorial, organizational and interinstitutional networks, and others of hybrid nature, which are both territorial and thematic. For this study, the term intersectoral networks was chosen, that is, networks formed by services from different sectors, both from governmental and non-governmental organizations.

Both the literature and the current discussions, whether in the business, social movement or State contexts, present a broad defense of the importance of networking (Goulart et al., 2010; Gonçalves & Guará, 2010). In the last context, specifically, there is a consensus that services organized in a network have the objective of ensuring social support and rights.

The concept of intersectoriality is quite often associated with networks. According to Inojosa (2001, p. 105), intersectoriality can be understood as “[...] the combination of knowledge and experiences with a view to planning, conducting and evaluating policies, programs and projects with the aim of achieving synergistic results in complex situations”, that is, something quite similar to the proposition of networks. However, it is argued that they are not synonymous, but can be complementary (Bronzo, 2017). This is because networking between different services does not necessarily presuppose changes in the structures, dynamics or characteristics of a particular institution or policy, as services and their workers can connect to each other, without necessarily undergoing changes in their everyday lives. On the other hand, the precept of intersectoriality involves more comprehensive changes concerning institutional processes in the design and content of sectoral policies (Bronzo, 2017).

Authors such as Bronzo (2017) and Monnerat & Souza (2010) approach the intersectoral/interdisciplinary strategy as a new paradigm, in contrast to the specific and partial tradition of modern science and traditional government. Bronzo (2017) also states that new referents, such as networks, used within the scope of intersectoriality, evidence the fragility of traditional government models: hierarchical and self-sufficient. Intersectoriality is configured as one more tool in the confrontation of mismatched and overlapping actions, thus motivating the creation of new propositions and intervention strategies based on dialogue and debate between different points of view. However, it is necessary to enable the materialization of deliberate developments, so that intersectoriality migrate from ideology to practice. In a way similar to networks, this is a topic that has spread quickly and has been appropriated by political discourses, but which has not necessarily unfolded into effective actions. Intersectoriality is a seemingly consensual theme.

Akerman et al. (2014, p. 4297) state that there is a broad defense of intersectoriality, but still without a sufficiently innovative practice capable of influencing the traditional management models. They argue that there is a wide range of definitions and questions about the concept of intersectoriality and, therefore, advocate the term “intersectionalities”, stating that their conformations are subject to history, conjuncture, and the actors involved in the process.

Furthermore, it is necessary to counterpoint the well-intentioned proposition of intersectoral networks: the relationship and predominance of these actions aimed at the poor population. The focus of social policies and programs on the poorest segments of society is historical (Donzelot, 1980). Thus, the large number of publications addressing this theme as a way of coping with the complexity of poverty and its effects is not surprising, as listed in the literature review conducted by Amaral (2015). However, there is concern about the possibility of using this strategy as a way of controlling the lives of the poor population. After all, if this is such an advocated strategy, why is it not for everyone?

Avelar & Malfitano (2018) warn of the need to critically analyze the ambivalence present in the formation of intersectoral networks: in theory, it is possible to observe that such a guideline is seen as a way to promote greater effectiveness in actions and support for the subjects assisted by the social police but, at the same time, mechanisms such as surveillance, control and moral judgment can be observed in network actions, especially with regard to the poor, thus been categories that need to enter the concerns for reflection on the process.

In the essay The Subject and Power, Foucault (1995) discusses the question of pastoral power - a form of control exercised by different figures based on a certain knowledge regime, with institutions becoming one of these pastors in the 18th century. Considering social policies and their institutions, despite their universal character, it is undeniable that health and education policies are used on a larger scale by the poor population, whereas social assistance policies are focused on a population with a specific income. Considering the intersectoral conformation and, depending on how it is carried out in different territories, it is impossible not to notice that this resource is often used to exponentially increase the possibility of power of the institutions involved over those who are the target of their interventions. For instance, as the data of this study show, it is not uncommon to notice exchanges of information that cause an excessive exposure of the life of a certain family - subject to judgments, reprisals, and interference from the technicians who execute the policy.

In addition, it is important to observe the limits placed on public policies, especially on social policies. Lopes et al. (2014, p. 592) highlight four important issues:

In the capitalist State, based on the private valorization of capital and on the sale of labor as a commodity-form in which these structures are intrinsically classist, what are the functions of these policies? What are the objective limits to which these policies are subject, within the range of paradigmatic elasticity of that State, regardless of the actors located ahead of it? What are, therefore, the possible actions in this context and to what extent do these actions define observable and stable changes? How to include the themes of citizenship and social transformations in this analysis in order to build a less socially unfair world?

In view of this plurality, the need for research that can provide theoretical contributions to the theme is advocated in order to favor a leap from what are currently experiments in public management to a real government praxis.

Occupational Therapy and Intersectoral Networks

The need to understand the specificity and/or contributions of occupational therapy to networking emerged from the professional routine of the author, who is a researcher and occupational therapist working in Primary Health Care (PHC). From the experience of the author in this context, sometimes individually in contact with other workers, sometimes in meetings with other occupational therapists, it was often observed the availability and ease of movement of those professionals throughout the different services and/or sectors of social policies.

Lopes et al. (2011) argue that actions directed to the creation and/or strengthening of social networks ensure greater autonomy and social inclusion of people or groups undergoing processes of social rupture. To this end, it is necessary that social actors, for example, professionals, be focused on actions that are based on the territory, guarantee rights, and respect the singularity of individuals.

It is argued that occupational therapy, as a profession that works with the everyday life and social (re)insertion of people, centers its practice on the theme of networks - whether primary or secondary, with the latter including the service network. After all, that is where people transit, where relationships are weaved, and either tighten or loosen. Depending on these relationships, more or less needs are met and more or less rights are accessed and, consequently, guaranteed.

Additionally, it is argued that the historical process of the role played by occupational therapists – from its genesis to the present – inserted in public policies, especially in social policies, influences the possibility of transit of this professional category in the service intersectoral networks.

According to Lopes (1999), occupational therapy became an institutionalized profession in the early 20th century, in the so-called first-world countries, especially in Canada, the USA, and the UK. Lopes also informed that, based on Antônio Gramsci’s theory, occupational therapists fell into the category of “consensus workers”, so called because of the role they perform within social area services (Lopes, 1999). Still according to Lopes, it is worth noting that the predominance of female workers occurred precisely because of the moral question embedded in consensus work, that is, characteristics such as docility and maternal instinct were seen as inherent in women and appropriate for the type of care provided, in addition to their charitable character.

Bezerra (2011) analyzed occupational therapy historically and explained the comings and goings of this category regarding its legitimacy and functions before state monopoly capitalism. Lopes (1999) explains that, during the post-World War I period, the State, fulfilling its functions, began to intervene more systematically in social areas with the intention of readapting and rehabilitating the individuals, which was considered one of the possible peaceful solutions for national reconstruction. It was during this period that occupational therapy became closer, albeit in a subordinate way, to medicine, with the aim of providing the category with greater technical and scientific legitimacy, notably in the field of physical and moral rehabilitation (Lopes, 1999).

In the Brazilian context, the 1988 Constitution was as an important milestone for the work of occupational therapists, in the three pillars of social security: health, social welfare, and social assistance, with emphasis, at that time, on the legal framework of the Unified Health System (SUS). However, this framework of guaranteeing rights was not free from the contradictions of capitalist society, since it occurred in the midst of the full expansion of neoliberalism, which led to the growth of the so-called “third sector” to fulfill this function (Bezerra, 2011). Occupational therapy, obviously, was not spared from this contradiction and, until the present day, an important insertion of this category is observed in private institutions that execute social policies, including in the target context of this study.

It is understood here that, despite occupational therapists being part of the working class, which sells its workforce and is subject to the interests of capital, they also have relative autonomy and can – or should – use a critical perspective when intervening with populations, regardless of the social policy in which they are inserted, making use of their resources to problematize and create concrete paths in the reality where they operate. This should be done with the objective of overcoming the reproduction of actions aimed only at maintaining the workforce, thus being able to respond to people’s daily demands as part of the social support network, based on principles such as promotion of emancipation and autonomy.

The relevance of social support networks in the everyday life of assisted individuals is recognized - a priority space for occupational therapy action, which thus leads to the discussion about intersectoriality as a strategy that must be associated with professional action. However, it is understood that this type of action should not be treated as corporate or exclusive to the professional category, given its intersectoral dimension and the need of many professionals to actualize it.

In view of the previously listed points about networks, intersectorialities, and occupational therapy, this study aimed to investigate the strategy of forming intersectoral networks between the services that comprise social policies in the municipality of Campinas, state of São Paulo, Brazil, from the perspective of occupational therapists working in the public policy services of social assistance, education and health, with a focus on the work of these professionals with the objective of knowing their opinion about their actions in these service networks.

Occupational Therapy in the Service Networks of Campinas

This study was conducted in the municipality of Campinas, state of São Paulo. This city was chosen for its pioneering spirit in proposing intersectoral network government initiatives. Previous studies (Rimoli, 2005; Malfitano, 2008) have reported experiences there. Campinas is located in the interior of the state of São Paulo, has a population of approximately 1,150,753 (Fundação Sistema Estadual de Análise de Dados, 2015) - the third most populated city in that state. Administrative management occurs in five districts located in the territories of each region.

The objectives of this study were contemplated in four sequential phases: a) interviews with district coordinators in the areas of social assistance, education, and health to map the operating networks and learn about their management and view of this institutional device, in a total of 13 interviews; b) application of a questionnaire to occupational therapists, municipal workers - of the 43 occupational therapists working in the municipality, 36 were in office, and 17 (47.2%) collaborated with the research; c) observation of two “networks”, chosen from the mapping conducted in phase a); d) a meeting with the occupational therapists of the network, named “Occupational therapy in network actions”, to discuss and prepare the data from the previous phases¹. Data were collected between 2017 and 2018.

To specifically explore the role of occupational therapy in intersectoral networks, the results found in phases b) and d) are highlighted, and the others are reported in Avelar (2018). Occupational therapists were contacted from a list of their workplaces and received an invitation to respond to the online questionnaire. In some cases, their workplaces were visited and printed questionnaires were handed out so that they could collaborate with the study.

The questionnaire containing multiple-choice and open-ended questions covered the following themes: professional profile; understanding about network - its relevance, impact and objectives; how the operationalization of networks occurs – necessary working conditions, possible difficulties, satisfaction with the results; relationship between networks and occupational therapy. The objective was to learn about the networks where the occupational therapists worked, their profile, and their view of networking and intersectoral work (Avelar, 2018).

The results showed that occupational therapists hired by the Municipality of Campinas work only in services of the Health Department, mostly in PHC units: of the 36 therapists, 21 worked at Health Centers and/or Family Health Care Centers (NASF). In addition, five therapists worked in services related to the second level of assistance, in this case, Worker Rehabilitation Centers (CEREST); four were performing management roles as institutional support in health districts; three worked in Psychosocial Care Centers (CAPS)², in this case, at CAPS-Children and Youth; two worked in a Community Center; one therapist worked at the Home Care Service of a health district.

The workers were aged 30 to 58 years, with predominance of the 32-48 year age range. Time at employment varied between one and 21 years, and 16.7% of the therapists said that they had occupied their position for approximately three years when a group of civil servants was hired through a public competition. All but one worker claimed to have completed some type of graduate course, either latu or stricto sensu.

Regarding the participation of occupational therapists in the networks, it was identified that actions occurred mainly in mental health: the questionnaires and interviews showed that of the 78 networks mapped, 30 have occupational therapists, and 24 have mental health as their theme. In this scope, insertion occurs mainly in networks where the questions of childhood (whether of a more sectorial nature in health or in the interface with education), drugs, or territorial networks, including matrix support, are discussed.

In addition to the mapping, the collaborators were asked to identify, if possible, the services and/or workers that comprise this formation. It is worth noting that, all 15 responses (two workers did not respond to this question) identified the participation of Health Centers in network actions. Among the health services, participation was identified as follows: CAPS-Children and Youth, 14 workers (93.3%); CAPS-Adult and CAPS-Alcohol and Drugs, 12 workers (80%); Emergency Service, two workers (13.3%); Hospital Service, one worker (6.7%). Among the social assistance institutions, 11 therapists (73.3%) identified both the Social Assistance Reference Centers (CRAS) and NGOs linked to this Secretary, and the Specialized Social Assistance Reference Centers (CREAS) were identified by seven therapists (46.7%). Among the educational devices, municipal public schools appeared in nine (60%), early childhood institutions in six (40%) and state public schools in five (33.3%) responses. Culture, Sport and Leisure services were mentioned in three (20%) responses.

Workers who participated in the networks included occupational therapists, psychologists, community health agents, social workers, nurses, nursing technicians, nursing assistants, physicians (pediatricians and psychiatrists, specifically), speech-language pathologists, residents of the Multi-professional Residency Program in Mental Health, NASF professionals (unspecified), teachers, health surveillance professionals (unspecified), nutritionists, local counselors, institutional support professionals, and service coordinators.

Regarding their own participation in some network, 66.7% answered, yes. Among those who do not participate, the main reason was the incompatibility of schedules between their agenda and the time of network meetings linked to their headquarters service.

It was also asked what the objectives of the identified intersectoral networks are. The questionnaire presented the following options: discussing cases, preparing collective actions, debating a specific theme, debating the social policy and its actions, and preparing proposals to be presented to the management. All workers chose the first option, discussing cases, followed by preparing collective actions, with only one point less (93.3%); debating a specific theme received 13 points (86.7%), while debating the social policy and its actions and preparing proposals to be presented to the management came in last, with 60 and 33.3%, respectively. It is worth mentioning that more than one option could be selected.

As for the relevance of acting through the networks, all the collaborators evaluated it as positive, mainly because it enables a “thorough view of the user”, despite the network often not operating in a fully satisfactory way:

I believe that, although the networking format is still not able to function satisfactorily, it has the potential to improve the quality of care provided to the population, reducing the possible fragmentation of cases into sectors. In this way, the users’ complex demands can be met in a shorter time (in regard to bureaucratic issues of public services), as well as with better quality. I emphasize that this view must be understood in light of paradigms that value the complexity of the individuals to the detriment of reductionism into parts and sectors (Questionnaire TO 4, open-ended question).

Concerning the impact of intersectoral networks on users, only positive aspects were raised, as evidenced in the excerpts from the responses presented below:

The involvement of different sectors (transdisciplinary care) brings different perspectives to the case, approaches that increase the chances of reaching and working out the problem, and may even reduce the medicalization and/or institutionalization of people, in addition to involving other actors in the treatments, such as family members, the community, etc. (Questionnaire TO 16).

Intersectoral care favors the success of interventions, as it looks at and assists the user comprehensively, thinking not only about the Health or (Social) Assistance demands, but also about the individual as a complex and unique being (Questionnaire TO 5).

It favors the users’ autonomy, as they participate in choosing the place(s) where they will be assisted; it reduces the users’ dependence on only one device or professional; it increases the inclusion or participation of users in social exchanges (Questionnaire TO 8).

Regarding the recognition of networking, it was questioned whether the workers believed that this was important and what their assessments were of the recognition by the teams in which they worked, as well as by the local, district and municipal management. The answers showed that they all considered intersectoral networks important and that, according to their perception, the further apart from direct user assistance, the smaller the recognition of the importance of networking. Figure 1 shows the responses to this question.

Figure 1
Recognition of networking by the team and the local, district and municipal management. Source: Prepared by the authors based on the completed questionnaires.

Still regarding the understanding of networks, it was asked what the objectives of network action strategies should be. As for the population assisted, the occupational therapists responded: ensure dignity and completeness in health; develop individual actions; prepare collective actions; discuss and share cases, e.g., develop Individual Therapeutic Projects (ITP); discuss more serious cases.

In the relationship between services, the intentions should be facilitate communication and dialogue (exchange knowledge and information); know and recognize the services; reduce institutional barriers, bureaucracy, and referrals (the last sometimes occurs without prior discussion and/or mistakenly); avoid personalism in actions (aiming to solidify the intersectoral practice as a professional posture in all actions in all sectors).

For the work of the occupational therapists themselves, the objectives would be to know the territory where they work in more detail (so that it is even possible to use the resources available there) and to deepen knowledge about specific topics (education). Finally, in regard to public policy, the objective should be its own discussion, in order to develop proposals for improving or adapting the services.

With respect to the operationalization of the networks, the collaborators were asked about their degree of satisfaction in relation to their participation. Only one worker said she was satisfied with it. Three responded that they were happy with the operation. It is worth noting that 11 workers (73.3%) said they were partially satisfied with it. The main reasons included emptying and turnover of professionals, few deliberative measures, little depth in the themes, decisions that do not unfold into concrete actions, inadequate conditions for working in a network, and reduced meeting time to discuss cases. It was emphasized that some services would need to have greater involvement, such as presence, regularity, organization of the information presented, and appreciation of this type of action.

The issue of the priority of this strategy in relation to the institutional routine was quite problematized, especially concerning management:

Because there is still a lack of investment by managers in releasing professionals to participate. There are several reasons: insufficient human resources, inexperience with networking, valuing work with individual care schedules, profile of professionals for this work, among others (Questionnaire TO 16).

Because of the lack of structure for the functioning of each service (especially due to workload, turnover of professionals, and absence of clear guidelines compatible with SUS by the managers) (Questionnaire TO 8).

Excessive meeting time for little resolution. I also verify that the current working conditions do not favor networking, since the services have few employees in the human resources department and high demand, leaving little time to dedicate to networking (Questionnaire TO 4).

The scarcity of resources was also highlighted as a difficulty in operationalizing the deliberations built in a network:

There is a shortage of resources to practically implement the strategies developed from the networks, which precludes the effectiveness of some actions. This lack of resources is also limitedly discussed on the networks (Questionnaire TO 17).

In addition, the workers were asked if they had already stopped participating in any network, and they all responded positively. Among the reasons for their dissatisfaction, they agreed with the aforementioned point and highlighted the following: perception of low resolution or effectiveness; lack of continuity of agreed actions; emptying and high turnover of workers at meetings; care routine, lack of professionals and excess demand in the service of origin, which hinders releases; schedule incompatibility; lack of objectivity in meetings; lack of network organization; choosing of other workers to join the network; maternity leave; in the case of institutional support functions, multiplicity of agendas and prioritization of a given network according to need for support.

Still on operationalization, questions were asked about which factors facilitate and which hinder the networks. When questioning about the facilitators, the objective was that the collaborators responded with factors that actually occur in their daily routine, but it was noticed that, because of the interpretation duplicity of this question, some workers talked about ideal operating conditions, but that do not occur.

Among the facilitators, concrete issues were pointed out, such as adequate physical structure, space in the agenda, and complete teams; organizational issues, such as frequency of people and meetings, participation of different sectors, well-organized and documented meetings, compliance with schedules, and commitment of the network managers to carry out the proposals and discussions that arise; issues related to deliberations and referrals, such as the development of viable actions and expectations to be met. Regarding the workers, the availability for a horizontal dialogue, disposition, education, valorization of collective work, and participation of people dedicated to the network management stood out. With respect to the population, the workers addressed the need to mobilize users and family members. Finally, regarding management, the need for support from local, district and municipal administrators.

The following obstacles that hinder the creation and maintenance of networks were highlighted by the workers: lack of time and space for meetings and lack of transport, in addition to insufficient number and high turnover of professionals, who end up prioritizing another form of care, more “emergency” and, because of the high turnover, end up not being aware of the cases and discussions. Other flaws have also emerged: lack of feedback from discussions, preparation of unfeasible actions, repetition of inadequate flows – it is explained that they are inadequate because they do not respect or are not compatible with the collective constructions; many cases to be discussed in a short time; lack of commitment of some institutions and managers.

The occupational therapists were also asked to list the working conditions necessary to ensure their own participation in the intersectoral networks. Many of these conditions are in line with what was highlighted as facilitators, such as availability, flexibility, and schedule compatibility, as many appointments occur at the same time, precluding participation; service adequate physical structure and transport; support from the team and local management, especially regarding the understanding that “networking is also work”; in addition to the work of other occupational therapists in the region.

Aiming to assess what was previously mentioned, the workers were asked whether they consider they have the conditions they aroused. Most of them (55.6%) answered, partially; 27.8% responded, yes; 16.7% replied, no. As for the role played by occupational therapy in the intersectoral networks, the workers were asked whether they believed that this profession, specifically, can offer contributions to networking: 83.3% of them answered, yes - occupational therapy has a fundamental contribution, whereas 16.7% also answered, yes - but that this contribution is not essential. In addition to the two options previously presented, the collaborators could also choose “no, occupational therapy does not contribute”; however, no one checked this option. Aiming to qualify the previous question, the therapists were asked to freely talk about their understanding of the role played by occupational therapy in networking and what the contributions that can be offered in this type of work by this specific profession are. Professional education was mentioned several times:

Our education alone provides a much broader view of the issues, and this contributes significantly to discussions (Questionnaire TO 14).

Occupational therapists understand human activity as a creative, playful, expressive, evolutionary, productive and self-maintenance process. As our education is extended to the health and social fields, it is possible to assess and propose therapeutic intervention projects that favor the development/improvement of psychic, occupational, social/leisure and everyday life capacities. It proposes improvement in the quality of life, considering personal, family, social and collective relationships. The possibility of transiting in different properties present in human activities as a therapeutic resource enhances the reflections and the possibilities of expanding the ITP (Questionnaire TO 16).

The role played by occupational therapists in the organization of networks becomes important because of their education for comprehensive care, as to consider the specificities of each case, with actions and approaches that enable dialogue with various sectors, such as education, assistance, culture, and leisure (Questionnaire TO 2).

At the same time, other statements showed that factors such as commitment and availability can be more important than the professional category, emphasizing that it is the diversity of perspectives that enriches the network construction.

All professional categories can contribute to the networks, and the diversity of those involved greatly enriches the discussions. Occupational therapy can contribute in different ways, such as rethinking ways to promote the reintegration of users into society and developing accessibility proposals. I believe that, more important than the professional category, is the willingness to accept different ways of existing in society, to rethink behaviors, to be in fact available to work in the interest of the assisted population (although within all the limits imposed by the public service), to seek to understand how other services can contribute to their own service and practice, beyond their limits; and, despite the limits found, to seek ways for the assisted population to have access to their rights together with the different sectors (Questionnaire TO 6).

In phase d) of the fieldwork of this study, a formative, discussion meeting was proposed with the intention of producing material for reflection on the theme of intersectoral networks and the insertion of occupational therapy in this type of action. This meeting was named “Occupational therapy in network actions”. The occupational therapists who responded to the questionnaire and showed interest in the activity, as well as those who did not respond to the questionnaire were invited to participate. Only those who denied the possibility of participating when answering the questionnaire were not contacted. Nine occupational therapists working in PHC/NASF and CAPS participated in the activity, as well as a professional recently promoted to a management position, previously working in a PHC unit. Table 1 identifies the participants’ workplaces.

Table 1
Occupational therapists participating in the discussion meeting according to type of service where they work

Identification	Type of service
TO 1	CAPS III
TO 2	NASF
TO 3	Management
TO 4	CAPS III
TO 5	PHC
TO 6	PHC
TO 7	CAPS-Alcohol and Drugs III
TO 8	CAPS Alcohol and Drugs III
TO 9	CAPS-Alcohol and Drugs III

On the occasion, the following discussion topics were proposed: work of occupational therapists in the Municipality, occupational therapy and networking, brief theoretical presentation on intersectoral networks, presentation of the preliminary results of the first phase of the study, and sharing of experiences in networking.

The objective of this meeting was to bring occupational therapists closer to the debate on intersectoral networks specifically, but also to bring them closer to other colleagues, with the aim of fostering an internal network capable of promoting dialogues about the profession. This is because, until then, nothing had been done in this sense, which we believe to be important to technically and politically strengthen occupational therapy in the Municipality.

In this meeting, we also sought to discuss the data found through the study until that moment to add information and legitimize (or not) what had been analyzed, mainly from the questionnaires.

To warm up the debate, the participants were asked what, in their opinion, would be the greatest difficulties in being an occupational therapist in the services of Campinas. In regard, specifically, to the professional core, they pointed out the lack of knowledge, by society in general, of what an occupational therapist does; the lack of recognition and legitimacy of the resources used; low professional appreciation; the absence of political guidelines for action; the lack of spaces for discussion and education; the small number of professionals in this category in the network services.

The following structural questions were raised: lack of material resources for action; inadequate physical environments, e.g., lack of space, presence of noise; lack of workers in the network; low financial investment, in general, which causes important failures. The participants also pointed out the non-openness to interdisciplinarity, by professionals in general, in addition to the difficulty in composing multi-professional and intersectoral actions with the teams in which they work.

These problems and the possibilities of resolution were discussed, and the following aspects emerged: holding of periodical meetings between occupational therapists for continued education on topics considered important; preparation and incorporation of policy guidelines at the district level; request for the writing of official documents via the category Councils.

In the specific discussion about occupational therapy action in intersectoral networks, the participants were requested to collectively prepared the possible objectives of this action and then list the facilitators that the category has for this action (Figure 2). The prepared objectives indicated that occupational therapists could play the role of “network organizers”, that is, a figure responsible for promoting and organizing actions between actors and services from different sectors. It was also raised that they should participate in the matrix support carried out between the different sectors, in the form of a component of this network. When reflecting on possible facilitators the category has for working in an intersectoral network, it was consensual that professional education enables individuals to be considered completely, which would require the action of other actors involved in this activity. It was also claimed that the work object (or professional core) of occupational therapy is the occupation/everyday life of the assisted individuals.

Figure 2
Production of the meeting participants regarding the objectives, facilitators, and difficulties in occupational therapy networking, in this order, from left to right. (On green – Objectives of work: “Matrixing between sectors to compose the network”, “Network organizer”. On yellow – Work Facilitators in Occupational Therapy: “Cross-sectional view – object of work; occupation”, “Matrix support”, “Education”. On blue: – Difficulties for working: “Lack of material resources”, “Lacks…”.

The participants were asked about the obstacles that would hinder or prevent their action in intersectoral networks: in short, there was talk about shortages - from the general scrapping of services to the lack of material resources, since there is no possibility, in the Municipality, to purchase inputs to be used by the category. The Municipality justifies that it has been managing directly, for a few years, the hiring of occupational therapists for basic health care, which was previously carried out by an outsourced institution, and that since then it has not been possible to organize the acquisition of these materials because of bidding processes.

Regarding the profession, specifically, the participants highlighted the lack of education to work in PHC, at least in Campinas, since internship at this level of care was only recently included in the undergraduate curriculum of the local university.

Occupational Therapy: Transiting and Weaving Networks

After analyzing the field data, the following question is asked: Is occupational therapy located between identity fragility and action flexibility?

During the discussion meeting, occupational therapy was referred to as a profession with an elusive core of action, that is, which often seems to lack a more concrete and objective identity. From the questionnaires, it was possible to highlight the perception of the collaborators about the transiting ability that occupational therapists have to understand the different areas that comprise human life because of the wide range of fields and cores of their activity. Both issues can be considered effects of the historical construction of the profession and of the generalist education provided in undergraduate courses. This dichotomy can be understood in a dialectical relationship: at the same time that it generates ignorance, and perhaps confusion, about the role played by occupational therapists, it allows them to be in different spaces and build actions that demand greater flexibility.

At the beginning of this study, the core of occupational therapy practice was discussed. It can be stated that the action of these workers is centered in the everyday life of individuals (Galheigo, 2020; Bezerra et al., 2022); therefore, when considering the individuals’ lives, the establishment of relationships between them is included: social networks. Involvement with people’s primary network aims to support and strengthen it to ensure the maintenance of life, activities, and the exercise of rights, whereas commitment to connection between services tends to materialize the secondary network as a support as well. According to Malfitano (2016, p. 118):

Regardless of the problems that affect different groups, which require targeted and focused interventions, occupational therapists should dedicate themselves, primarily, to develop actions that enable/facilitate/create forms of inclusion and participation in social life.

Therefore, it is possible to consider the formation of networks between the services of different sectors as one of the work resources of occupational therapists in search of social inclusion and participation. At the same time, the use of networks cannot be considered as specific or exclusive to this category, as it would obviously directly lose its interdisciplinary and intersectoral nature, that is, it is a way of ensuring coherence between the locus of work, everyday life, and its objective of action, starting from its professional core. Moreover, the possibility of intersectoral networks being developed, explored, and widely used by occupational therapists is considered in view of their professional profile and identity, which have special flexibility and availability, although not exclusive, to transit in these circuits.

Malfitano (2016, p. 120) argues that the participation of occupational therapists in the discussion and formulation of political actions is inherent in professional practice:

As occupational therapists are professionals who will work in this society, seeking ways to favor the social inclusion of individuals, their participation in public spaces to face inequality is essential, and the social form of intervention under the conditions of life, in their formal public organization as technicians, will occur through public policies.

The experiences reported by the workers show that they effectively contribute to advancing in the achievement of intersectoral networks in social policies beyond their “common place”, and that they are available in their everyday action to make them effective. According to Amaral & Bosi (2017, p. 432), “[...] there is need to identify the empirical evidence of the practical effects of intersectoral networks and how their conceptual ideality and materiality in the everyday life of services come closer and further apart”.

One of the results of this study (Avelar, 2018) shows that network actions between services are basically supported by frontline workers who, directly involved with the population, see the need to extrapolate from the established limits to respond to the complex problems experienced - limits that are accentuated by the growing lack of resources. In this context, occupational therapists play a leading role in this daily support, seeking more effective means to perform the services they comprise, with availability and dedication to this strategy, combined with their objective of nuclear intervention, centered in the everyday life of the individuals and groups they assist.

A limitation to this study is that it was carried out in a specific local reality in a relatively short time. We reiterate our objective of offering notes that address the assessment and monitoring of intersectoral networks, in addition to disseminating the numerous combinations existing in the studied municipality and, more specifically, with the specific discussion about the participation and contribution of occupational therapists.

Thus, we argue that intersectoral networks are relevant tools for occupational therapy, as they enable connection between its object and the objective of its practice.

• 1
  All collaborators agreed to participate in the four phases of this study and signed an Informed Consent Form. In addition, the study was approved by the Human Research Ethics Committees of the University where the research was carried out and was authorized by the Municipality of Campinas.
• 2
  In this municipality, there are a large number of occupational therapists working in CAPS. However, 11 of these 14 services are managed by the Health Service Dr. Cândido Ferreira and, therefore, they are not directly administered by the Municipality. It should be emphasized that other outsourced institutions have occupational therapists in their workforce, but they were not contacted because these data could not be found in systematically.
• How to cite: Avelar, M. R., & Malfitano, A. P. S. (2022). Occupational therapy and intersectoral networks: concepts and experiences in debate. Cadernos Brasileiros de Terapia Ocupacional, 30, e3236. https://doi.org/10.1590/2526-8910.ctoAO242132361

• Funding Source

  This study was financed in part by the Coordination of Superior Level Staff Improvement - Brazil (CAPES) - Finance Code 001.

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Edited by

Section editor

Profa. Dra. Beatriz Prado Pereira

Publication Dates

• Publication in this collection
  26 Sept 2022
• Date of issue
  2022

History

• Received
  17 Jan 2022
• Reviewed
  26 June 2022
• Reviewed
  29 June 2022
• Accepted
  06 July 2022