Speech disorders from the perspective of community health agents

ABSTRACT

Purpose:

to assess the degree of knowledge of community health workers about speech disorders by means of a survey on the advice they give to patients.

Methods:

a cross-sectional study with Community Health Agents (CHAs) who work in Health Centers (HC) in the Eastern Health District, in the city of Florianópolis, State of Santa Catarina (SC). They answered a questionnaire on sociodemographic features and knowledge about speech disorders. The questionnaire included questions about the advice given to patients in visits for the purpose of health promotion in different life cycles. A descriptive and statistical analysis was performed with the STATA 11.0 software.

Results:

fifty-five CHAs answered the survey; their mean age was 44.56 years. Most of them were women (98.18%) and had finished high school (80%). Among the major health markers of HC, hypertension and diabetes were characterized as chronic non-communicable diseases. The advice given by CHAs on the promotion of maternal and child health showed that they had more knowledge about speech and hearing impaiments in comparison to advice given when promoting the health of children and the elderly.

Conclusion:

the study showed that CHAs have knowledge about speech and hearing impairments, as evidenced by the advice they gave to patients. However, such knowledge can be considered as limited. Considering that CHAs are the main link between the community and the health staff, it is crucial that they gain knowledge about speech and hearing disorders, in order to implement effective procedures for health promotion and disease prevention, thus, providing comprehensive health care.

Keywords:
Community Health Workers; Health Promotion; Speech, Language and Hearing Sciences; Chronic Disease; Public Health Surveillance

RESUMO

Objetivo:

verificar o conhecimento dos agentes comunitários de saúde quanto aos agravos fonoaudiológicos, investigando orientações realizadas.

Métodos:

estudo transversal com Agentes Comunitários de Saúde (ACS) atuantes nos Centros de Saúde (CS) do distrito sanitário Leste do município de Florianópolis, SC. Os ACS responderam a um questionário com caracterização sociodemográfica e conhecimento quanto a agravos fonoaudiológicos, por meio de questionamentos quanto às orientações realizadas em visitas referentes à promoção da saúde nos diferentes ciclos de vida. Foi realizada uma análise estatística descritiva no programa STATA 11.0.

Resultados:

foram entrevistados 55 ACS, com idade média de 44,56 anos, a maioria do sexo feminino (98,18%) e ensino médio (80%). Dentre os principais marcadores de saúde dos CS encontrou-se a Hipertensão arterial e a diabetes caracterizadas como doenças crônicas não transmissíveis. As orientações relacionadas à promoção da saúde materno infantil relatadas pelos ACS envolviam mais conhecimentos quanto aos agravos fonoaudiológicos em comparação com orientações a respeito da promoção da saúde da criança e do idoso.

Conclusão:

o estudo revelou que existe conhecimento por parte dos ACS com relação aos agravos fonoaudiológicos, já que são incorporados nas orientações realizadas pelos mesmos, porém este pode ser entendido como limitado. Considerando-se que o ACS é o principal elo entre a comunidade e a equipe de saúde torna-se essencial incorporar estes conhecimentos ao saber deste profissional como forma de efetivar as ações promoção e prevenção de saúde, configurando a integralidade do cuidado em saúde.

Descritores:
Agente Comunitário de Saúde; Promoção de Saúde; Fonoaudiologia; Doença Crônica; Vigilância em Saúde Publica

Introduction

The expanded concept of health involves "a complete state of well-being, biopsychosocial balance and not merely the absence of disease or illness" [our translation] and was established at the international conference on primary health care in 1978 ¹.

Under this influence, Brazil’s Constitution of 1988 was a milestone in the field of public health in the country because it influenced the consolidation of the Unified Health System (SUS). Thus, a regionalized network of programs and services was defined in order to provide universal and equal access of the population to the promotion, protection and recovery of health, with the fundamental principles of equality, universality and comprehensiveness².

In 1991, PACS (Community Health Agents Program) was created in order to reduce infant mortality³. As a consequence of the positive results of this program, in 1994, the Family Health Program (PSF) - now called the Family Health Strategy (ESF) - was established. This is a health care model, based on a health surveillance paradigm that seeks to articulate the measures of the programs with sectoral and cross-sectoral policies. This model is aimed at improving the population's quality of life by strengthening the link between health care providers and the local community ⁴,⁵ . Thus, a multidisciplinary team is expected, consisting of doctors, nurses, nursing assistants or patient care technicians, community health workers and dentists.

CHAs have a key role in health centers, as they represent the link between the population and the health care staff. They can report the demands and problems faced by users of the health system and report possible solutions to the questions and needs of the population. They reside in the community where they work, hence they are aware of the problems affecting the territory and the local population³.

An act was established to regulate the profession only in 2002; however, it was revoked for adjustments four years later. This means that the construction of the role of CHAs within SUS is characterized by conflicts and uncertainties ⁶,⁷ .

According to the National Primary Care Policy (Ordinance 648/2006), CHAs have the following duties: apply measures that seek to integrate health care providers and the population; work under assignment to a particular number of families; be in regular contact with the families while developing health education activities; fill in and update records; advise families on the use of health services; develop activities for health promotion, prevention of diseases and injuries and health surveillance; through home visits, follow-up all the families under their responsibility and help in the prevention/control of malaria and dengue⁸. In addition to these duties, CHAs must have the conceptual, procedural and attitudinal skills that will enable an effective link between users of SUS and health workers. Thus, they can contribute to health surveillance activities by identifying and recording information so that health plan of a particular territory can meet the real needs of the local population⁹.

Aspects of speech pathology and audiology, if added to the knowledge of CHAs, can contribute to a broader view of the concept of health. Needs under a new point of view can open doors to new forms of intervention; they are an essential link and enable health promotion ¹⁰,¹¹ .

Aspects of speech, language and hearing should be considered as health attributes because their pathological manifestations undermine verbal communication and nonverbal competence and performance, both intra- and interpersonally¹². Communication, as an object of study of Speech Pathology, deserves serious attention of public health policies, as it enables individuals to become agents of transformation of society and reality¹³.

Health promotion is aimed at optimizing quality of life and health. Its priority is to identify and address the social determinants that trigger health-disease processes. This way, it differs from disease prevention, which is focused on detection, control and care provision as regards risks and causes¹⁴.

Given the above, the aim of the present study was to assess the knowledge of CHAs about speech and hearing impairments, in order to implement health surveillance initiatives.

Methods

The research was approved by the Human Research Ethics Committee (CEPSH) of the State University of Santa Catarina (UDESC) - Technical Report no. 1.018.426.

This is a descriptive cross-sectional study with Community Health Agents (CHAs) working in health centers in the Eastern Health District of Florianópolis, SC. The study was conducted between August and September, 2015.

These were the health centers addressed in the present study: Pantanal, Córrego Grande, Itacorubi, Saco Grande, João Paulo, Canto da Lagoa, Barra da Lagoa, Costa da Lagoa and Lagoa da Conceição.

First, the coordinators of the health centers (HC) were contacted and informed about the objectives of this research. Later, the researcher visited the health centers at the start and /or end time of the daily working hours of the CHAs, who were also informed about the research and the request for voluntary participation. Those who agreed to participate signed an Informed Consent Form (ICF). The CHAs did not participate in the survey when they were on vacation or on a sick leave, or when they were not found in the health centers after three attempts of contact for participation in the research.

In order to achieve the proposed objectives, a questionnaire was applied to the CHAs to analyze their knowledge about speech disorders in the areas of voice, orofacial motricity, language, and hearing. It was aimed at investigating if CHAs included these aspects when giving advice on health promotion in different life cycles.

The tool consisted of a survey on characteristics such as identification, age, sex, education, length of work experience in the health care team, if they were tenured, micro-areas of work performance, population under their responsibility, major health markers in their area and closed questions addressing speech-language problems in the routine work of CHAs. In addition, the questionnaire contained some blank lines where they could write an explanation or opinion about their activities.

The CHAs responded to the questionnaire individually, at the health centers, and if they failed to understand any of the questions, the researcher could explain the content of the questions.

For the purposes of analysis, a variable was created with regard to the general knowledge of the CHAs in different life cycles. This variable was created based on reports about the advice given during home visits. An analysis was made of the association between this variable and sociodemographic aspects.

The data were entered into a Microsoft Excel spreadsheet, and a descriptive statistical analysis was performed for sociodemographic features and speech and hearing impairments. The Chi Square Test was run in order to check for possible associations between the knowledge of the CHAs and sociodemographic features, with a significance level of 5%. The analyses were performed with the aid of software STATA 10.0.

Results

The Eastern Health District is composed of nine Health Centers with 67 CHAs, and 55 of them participated in the survey. The HC with the largest population is Itacorubi, totaling 16,394 individuals and only four micro-areas, while the HC with a larger number of micro-areas is Saco Grande, with a population of approximately 12,000 users. This fact is justified by the percentage of use of the population: in Itacorubi, it is 50% of the total population on average, while at the Saco Grande HC, this profile is 100%. Moreover, the number of areas of social concern is only one in Itacorubi, compared with six in Saco Grande (Table 1).

Table 1:
Characterization of the health centers of the Eastern Health District - Florianópolis, SC, Brazil, 2015. (n=55)

• CHA: Community Health Agent

The average age of the CHAs was 44.56 years (SD = 8.52) ranging between 28 and 66 years. As for education, the majority (80%) of the population reported having completed high school and 10.91%, higher education. There was a prevalence of female CHAs (98.18%). The average length of work experience at the HC was 12.12 years (SD = 3.48) and only 14.55% of them claimed to be tenured.

The main health markers reported by CHAs in this district were: diabetes, hypertension, pregnant women, children, the elderly, tuberculosis, bedridden patients, mental illness, HIV, alcoholism and drugs.

Most of the CHAs reported that staff meetings occur once a week (78.18%), and 10.91% reported monthly and fortnightly occurrence.

A large part of the CHAs (65.45%) reported having knowledge of the work performed by speech therapists, but only 10.91% had some training in that area. Nevertheless, all respondents recognized the importance of the role of speech-language therapy in primary health care. When asked about the relationship between non-communicable diseases, such as diabetes and hypertension, and speech and hearing aspects, 54.55% said that there may be a correlation.

The CHAs are concerned about aspects about maternal and child health, as 98.18% of them addressed the importance of exclusive breastfeeding (EBF); 96.36% made some referrals when they realized that a baby had difficulty in coping with EBF. They also advised mothers on breast care. Most referrals (67.27%) were made to the health center.

As for the harm of formula feeding and the importance of breast suction for the development of oral functions, language, and hearing, 83.64% of CHAs claimed that they addressed these issues in their visits. Additionally, 78.18% of them reported that they give advice on the importance of breast suction for nose breathing. A total of 52.73% of the CHAs has never participated in training sessions of the Rede Amamenta Brasil strategy (Figure 1).

Figure 1:
Distribution of responses about promotion of maternal and child health. Florianópolis, SC, Brazil, 2015. (n=55)

All respondents reported paying frequent visits to children; 60% of them do that on a monthly basis. Only 56.36% of the CHAs give advice on speech difficulties; 60% on difficulties in activities that require attention and concentration; 70.91% ask parents about their children’s learning difficulties. Importantly, some CHAs reported that according to the Programa de Saúde na Escola (PSE) program, they began to ask more questions about school and learning issues.

As for the implementation of screening tests, 69.09% reported that they ask parents if their children underwent the Newborn Hearing Screening (NHS) or check the child’s health records. The vast majority (72.73%) said that they do not ask parents about the lingual frenulum evaluation, and some reported sheer lack of knowledge on the subject. More than half (54.55%) of the CHAs has never participated in training offered by the Rede Capital Criança network (Figure 2).

Figure 2:
Distribution of responses about the promotion of child health. Florianópolis, SC, Brazil, 2015. (n=55)

Most home visits to the elderly occur on a monthly basis (44.44%), while 40.74% of visits have a varying frequency, on a case-dependent basis, as some patients require a longer follow-up.

As far as hearing is concerned, 76.36% of the CHAs ask questions about hearing difficulty, 58.18% ask about difficulties in understanding people while 56.36% do not ask about difficulties in hearing the TV set; 81.82%, which is a considerable number, do not ask questions about the audiometry test, when taking into account that the elderly population is the most affected by hearing loss. A total of 65.45% of CHAs said that they ask about the use of hearing aids.

As for aspects of speech, 61.82% of the CHAs reported asking about speech difficulties, but 72.73% of them mentioned nothing about voice weakness. Respectively, 61.82% and 52.73% of them ask questions about difficulty in swallowing and presence of choking. Approximately half of the CHAs (50.91%) reported having already participated in training sessions offered by the Programa Capital Idoso program.

There was an association between the knowledge of CHAs about speech and hearing impairments and longer self-reported work experience at the HC (0.043). There were no associations between such knowledge and sociodemographic features: sex (p=0.700); age (p=0.200); education (p=0.367).

Table 2:
Sociodemographic features of Community Health Agents. Florianópolis, SC, Brazil, 2015. (n=55)

Discussion

A previous study on sociodemographic characteristics, performed to check the quality of life of CHAs, found results similar to those in the present study ¹⁵. Thus, CHAs had these features: predominantly females (84.5%), complete secondary education (79.1%) and mean age of 39.02 years.

The association between the work of CHAs and female housework may be a historically recognized trend within health care¹⁶. Another issue involves the fact that women, by working near home, can control and keep track of the daily life of their children. Females prevail in this profession, and the fact that women used to be seen as caregivers in the Middle Ages may have led a greater number of women to pursue a career in health care¹⁷.

The level of education of these professionals may make a difference in the health care provided to users of health services. The expansion of their role, shifting from the focus on maternal and child health toward the health of families and the community, has demanded new competences in the social and political arena¹⁸. Lack of knowledge deprives CHAs of information they need to properly cope with stressful situations they face at work, especially situations involving social relations ¹⁹.

More recent studies have shown that the demographic profile of CHAs has been changing: they are younger and join the ESF earlier, as they benefit from higher educational levels ¹⁶.

The results of this study show higher figures for the promotion of maternal and child health, especially when compared to health promotion of the elderly, as there are lower percentages for advice on speech and hearing impairments aimed at this population group. In view of the fact that populational aging is a new reality in Brazil, it is worth stressing the importance of prevention and promotion of health of the elderly population. In addition, physiological changes that occur throughout the process of aging have a great impact on individuals’ quality of life ²⁰.

Figure 3:
Distribution of responses about the promotion of health of the elderly. Florianópolis, SC, Brazil, 2015

The work of speech therapists in groups of elderly patients, of paramount importance, is primarily aimed at the promotion of healthy aging, based on maintaining their functional capabilities, otherwise, the elderly might feel ostracized by their limitations. Linguistic-cognitive activities can be performed, for example, focusing on memory, attention, reading and comprehension, as well as workshops on vocal health, hearing health and orofacial motricity²¹.

In contrast, CHAs have already addressed maternal and child health since intrauterine life by means of advice given to pregnant women. Child health is the focus of speech therapists. They can address issues about food habits, encouraging EBF, chewing, speech and hearing (early losses, newborn hearing screening, education and risk factors). In the field of health promotion, speech therapy can address utensils used for food intake, deleterious oral habits, language acquisition and development and reinforcement of the importance of the family environment during all phases of life²². In addition, speech therapists can implement campaigns, for example, vocal hygiene, combating and prevention of deafness, prevention of mouth cancer, and noise reduction.

Considering the association between the knowledge of CHAs about speech and hearing impairments and longer self-reported length of work experience at the HC, it can be inferred that professional experience is broader, and there are more training opportunities and experiences that may have contributed to the acquisition of knowledge about speech disorders for health promotion purposes. The inclusion of CHAs in health care teams is an essential notion of the link underlying community-service, by means of health surveillance¹⁵,²³ -²⁸ .

With respect to health markers, it is worth noting that approximately 40% of the adult Brazilian population presents at least one non-communicable disease. The most important NCDs are hypertension, diabetes, cancer, cerebrovascular diseases and obstructive pulmonary diseases²⁹. A study has shown that the fourth activity developed by CHAs is the control of hypertension, diabetes, tuberculosis and leprosy³⁰.

In view of the aging population, the prevention and control of NCDs, e.g., arterial hypertension and diabetes mellitus, should be priority measures in Primary Health Care in order to avoid complications and promote early diagnosis and active search and monitoring. Although easily diagnosed, these NCDS can pose a challenge to health care teams, because control and monitoring are essential. Other challenges to be faced are the need for change in life habits and lower user adherence to coping programs³¹. CHAs play a key role in these processes on the basis of their knowledge and bond with the population of their territory. It should also be noted that the highest rates of chronic diseases were found in the southern (47.7%) and southeast (39.8%) regions³².

These diseases are still a concern from the point of view of speech therapy, since they can interfere with functions such as swallowing, as in the case of DM, because of xerostomia, sore and sensitive tongue and taste disorder, Also, they are a risk factor for hearing loss. With respect to AH, the risk of cerebrovascular accidents (CVA) is of interest to speech therapists because the main consequence of this condition is a communication disorder called aphasia³³.

CHAs have a privileged role in the dynamics of deployment and consolidation of a new health care model, because with a mediation strategy, they can act as facilitators³⁴. Home visits represent the main work tool of CHAs ³⁵. Their work reinforce bonds and enable health prevention and promotion measures. The knowledge of CHAs represents an advantage for identification of risks and/or vulnerability; it accounts for a health care measure.

In this way, evaluating the actions of CHAs becomes fundamental. Previous studies have shown that the perception of adults and the elderly on the number of monthly visits undertaken by CHAs is insufficient and researchers concluded that most respondents are unhappy because they wish the visits were more frequent^26-36.

A study has shown that almost half of the families registered in the FHS was unaware of the existence of CHAs and had not been visited. On the other hand, 90% of the families visited at home, rated the performance of CHAs as good or very good, mainly as regards knowledge of the health problems of the family and the community, development of a good relationship with the people they follow-up and the health care advice provided. This fact can be justified on the basis of multiple tasks given to CHAs in the HC, a fact that has interfered in their work in the respective territories. In addition, it is worth mentioning issues related to leave of absence which can compromise coverage the territory.

Some authors have analyzed the functions of CHAs within the FHS and identified the need to strengthen their training, so that their performance can be consistent with the guidelines and principles of SUS³⁷. On the other hand, among all professional categories analyzed, CHAs had the highest approval by the respondents (84.7%), thus, corroborating similar studies ³⁷.

What can be seen is that CHAs have a great deal of knowledge; however, this class of workers needs skills that include the knowledge on speech and hearing disorders. To characterize such demand and to develop measures, it is essential that training be offered to CHAs, so that their performance can be effective in different cycles of patients’ lives ²⁶.

One shortcoming of the present study is that the information of the questionnaire is self-reported. Moreover, the loss of 17.9% was due to the difficulty in finding all CHAs in the HCs. It is worth mentioning that 40% of the micro-areas in this district are uncovered on the basis of leaves and dismissals. Replacement of these job positions constitutes a hindrance depending on the form of recruitment and because of discussions about duties and responsibilities of CHAs in the city.

Conclusion

The present study showed that CHAs give advice on issues that involve speech and hearing impairments in different life cycles. However, such advice can be seen as limited. By recognizing the importance of the CHAs in the community, their work could be fully effective if they acquired specific knowledge of speech therapy and audiology, thus, enabling early detection and referrals in all cycles of life.

The longitudinality of health care suggests that for the completeness of measures, health care teams need to be trained to develop initiatives for promotion, prevention and recovery of health, rehabilitation of diseases and injuries, as well as health maintenance in the territory.

Health promotion is a growing field, but it has an enormous potential for strengthening popular participation and social control in health matters. CHAs can help engage local leaders into discussing and coping with health problems and their social determinants in their territory. Moreover, they can optimize the development of comprehensive and effective measures for proper health care management.

Referências

• ¹
  Befi D. A inserção da fonoaudiologia na atenção primária à saúde. In: Befi D (org). Fonoaudiologia na atenção primária à saúde. São Paulo: Lovise; 1997. p. 15-36.
• ²
  Gomes EMGP, Remencius NR. Fonoaudiologia na Unidade Básica de Saúde. In: Largota MGM, César CP (org). A fonoaudiologia nas instituições. São Paulo: Lovise; 1997. p. 183-86.
• ³
  Santos JN, Rodrigues ALV, Silva AFG, Matos EF, Jerônimo MS, Teixeira LC. Percepção de agentes comunitários de saúde sobre os riscos à saúde fonoaudiológica. Rev Soc Bras Fonoaudiol. 2012;17(3):333-9.
• ⁴
  Shimizu HE, Reis LS. As representações sociais dos trabalhadores sobre o Programa Saúde da Família. Ciênc Saúde Colet. 2011;16(8):3461-8.
• ⁵
  Silva JM, Caldeira AP. Avaliação para melhoria da qualidade da estratégia saúde da família e qualificação profissional. Trab Educ e Saúde. 2011;9(1)95-108.
• ⁶
  Gomes KO, Cotta RM, Mitre SM, Batista RS, Cherchiglia ML. O agente comunitário e a consolidação do Sistema Único de Saúde: reflexões contemporâneas. Physis. 2010;20(4):1143-64.
• ⁷
  Barros DF, Barbieri AR, Ivo ML, Silva MG. O contexto da formação dos agentes comunitários de saúde no Brasil. Texto-Contexto Enferm. 2010;19(1):78-84.
• ⁸
  Brasil. Ministério da Saúde. Portaria GM/MS n° 648, de 28 de março de 2006. Brasília, 2006.
• ⁹
  Coll C, Pozo JG, Sarabia B, Valls E. Os conteúdos na reforma: ensino e aprendizagem de conceitos, procedimentos e atitudes. 1a ed. Porto Alegre: Artmed; 2000.
• ¹⁰
  Santos LPGS. A atuação do agente comunitário de saúde em São Bernardo do Campo: possibilidades e limites para a promoção da saúde [dissertação]. São Paulo (SP): Escola de Enfermagem da Universidade de São Paulo; 2005.
• ¹¹
  Minayo MCS. Pesquisa social: teoria, método e criatividade. Petrópolis: Vozes, 2001.
• ¹²
  Andrade CRF. Fases e níveis de prevenção em fonoaudiologia: ações coletivas e individuais. In: Vieira RM (org). Fonoaudiologia e saúde coletiva. 2. ed. Carapicuíba: Pró-Fono; 2000. p. 81-104.
• ¹³
  Souza RPF, Cunha DA, Silva HJ. Fonoaudiologia: a inserção da área de linguagem no Sistema Único de Saúde (SUS). Rev. CEFAC. 2005;7(4):426-32.
• ¹⁴
  Oliveira DL. A 'nova' saúde pública e a promoção da saúde via educação: entre a tradição e a inovação.Rev Latinoam Enferm. 2005;13(3):423-31.
• ¹⁵
  Mascarenhas CHM, Fabio OP, Marcos HF. Fatores associados à qualidade de vida de agentes comunitários de saúde. Ciênc Saúde Coletiva. 2013;18(5):1375-86.
• ¹⁶
  Mota RRA, David HMAL. A crescente escolarização do Agente Comunitário de Saúde: uma Indução do Processo de trabalho?. Trab. Educ. Saúde 2010; 8(2):229-48.
• ¹⁷
  Santana JCB, Vasconcelos AL, Martins CV, Barros JV, Soares JM, Dutra BS. Agente Comunitário de Saúde: percepções na estratégia saúde da Família. Cogitare Enferm. 2009;14(4):645-52.
• ¹⁸
  Tomaz JBC. O agente comunitário de saúde não deve ser um "super-herói". Interface Comun Saúde Educ 2002;6(10):75-94.
• ¹⁹
  Maia LDG, Silva ND, Mendes PHC. Síndrome de Burnout em agentes comunitários de saúde: aspectos de sua formação e prática. Rev Bras Saúde Ocup 2011;36(123):93-102.
• ²⁰
  Martins Filho IE, Pereira AGFF, Araújo JJ, Kato MT, Jorge TM, Peres AS. Saúde bucal e fonoaudiologia no idoso: aspectos preventivos e educativos. In: Bastos JRM, Peres SHCS, Caldana ML (org). Educação em saúde com enfoque em odontologia e fonoaudiologia. São Paulo: Santos, 2007. p.89-97.
• ²¹
  Medeiros EA, Maia RM, Cedro MO, Barbosa MLC, Correia RBF, Tavares PMB et al. A inserção da fonoaudiologia na estratégia saúde da família: vivências em Sobral-CE. SANARE-Revista de Políticas Públicas. 2009;8(2):7-15.
• ²²
  Northern JL, Downs MP. Audição na Infância. Trad. Antônio Francisco Dieb Paulo. 5. ed. São Paulo: Guanabara Koogan, 2005.
• ²³
  Ferraz L, Aertz DRGC. O cotidiano de trabalho do agente comunitário de saúde no PSF em Porto Alegre. Ciênc saúde coletiva. 2005;10(2):347-55.
• ²⁴
  Cardoso AS, Nascimento MC. Comunicação no Programa de Saúde da Família: O agente Comunitário de Saúde como elo integrador entre a equipe e a comunidade. Ciênc Saúde Colet. 2010;15(supl 1):1509-20.
• ²⁵
  Seabra DC, Carvalho ACD, Foster AC. O agente comunitário de Saúde na visão da equipe mínima de saúde. APS. 2008;11(3):226-43.
• ²⁶
  Santos JN. Silveira SMA. Saúde pública - proposta de atuação do fonoaudiólogo na estratégia de saúde da família. In: Cesar AM, Maksud SS (org). Fundamentos e práticas em fonoaudiologia. Rio de Janeiro: Revinter, 2015. p. 212-27.
• ²⁷
  Jardim TA, Lancman S. Aspectos subjetivos do morar e trabalhar na mesma comunidade: a realidade vivenciada pelo agente comunitário de saúde. Interface. 2009;13(28):123-35.
• ²⁸
  Brand CI, Antunes RM, Fontana RT. Satisfações e insatisfações no trabalho do agente comunitário de saúde. Cogitare enferm. 2010;15(1):40-7.
• ²⁹
  Ministério da Saúde. A vigilância, o controle e a prevenção das doenças crônicas não transmissíveis: DCNT no contexto do Sistema Único de Saúde brasileiro. Brasília: 2005.
• ³⁰
  Garcia ACP, Lima RCD, Andrade MAC, Galavote HS, Coelho APS, Vieira ECL et al. Agente Comunitário de Saúde: do perfil às atividades desenvolvidas. 11º Congresso Brasileiro de Saúde Coletiva. 2015 jul 28/ago 1; Goiânia-GO; Goiânia: ABRASCO, 2015.
• ³¹
  Ministério da Saúde. Hipertensão arterial sistêmica - HAS e Diabetes mellitus - DM PROTOCOLO. Brasília: 2001.
• ³²
  Theisen NIS. Agentes Comunitários de Saúde (ACS): condições de trabalho e sofrimento psíquico [dissertação]. Santa Cruz do Sul (RS): Universidade de Santa Cruz do Sul; 2004.
• ³³
  Martines WRV, Chaves EC. Vulnerabilidade e sofrimento no trabalho do agente comunitário de saúde no programa de saúde da família. Rev Esc Enferm USP. 2007;41(3):426-33.
• ³⁴
  Sisson MC, Andrade SR, Giovanella L, Almeida PF, Fausto MCR, Souza CRP. Estratégia de Saúde da Família em Florianópolis: integração, coordenação e posição na rede assistencial. Saúde e Sociedade. 2011;20(4):991-1004.
• ³⁵
  Lima NA, Silva L, Bousso RS. A visita domiciliária realizada pelo agente comunitário de saúde sob a ótica de adultos e idosos. Saude Soc. 2010;19(4):889-97.
• ³⁶
  Brasil. Política Nacional de Atenção Básica. Serie Pacto pela Saúde volume 4. Brasília: Ministério da Saúde, 2006.
• ³⁷
  Gomes KO, Cotta RMM, Cherchiglia ML, Mitre SM, Batista RS. A práxis do agente comunitário de saúde no contexto do programa saúde da família: reflexões estratégicas. Saúde soc. 2009;18(4):744-55.
• ³⁸
  Ronzani TM, Silva CM. O Programa Saúde da Família segundo profissionais de saúde, gestores e usuários. Ciênc Saúde Colet. 2008;13(1):50-62.

• 4
  Research conducted at the Federal University of Santa Catarina

Annex 1

Publication Dates

• Publication in this collection
  Mar 2017

History

• Received
  08 Feb 2016
• Accepted
  04 Nov 2016