Interprofessional health education: learning from an innovative experience of integration between people, curricula and professions ^{1 2 3}

Abstract

This qualitative case study aimed to understand the perception of Community Health Agents and managers about the meaning of the experience of interprofessional education in Primary Health Care services for the training of undergraduate health students at the Federal University of Rio Grande do Sul. We conducted individual semi-structured interviews (n=20) and documentary analysis. We used thematic content analysis to interpret the material. The results showed that teaching activities that integrate people, curricula and professions in the health services have the potential to promote interprofessional learning at undergraduate, to train more collaborative professionals, and to qualify health care.

Keywords
higher education; curriculum; teaching-learning process; curricular integration; qualitative research

Resumo

Este estudo de caso qualitativo teve o objetivo de compreender a percepção de Agentes Comunitários de Saúde e gestores sobre o significado da experiência de educação interprofissional em serviços de Atenção Primária à Saúde para a formação de estudantes da saúde na Universidade Federal do Rio Grande do Sul. Foram realizadas entrevistas individuais semiestruturadas (n=20) e análise documental. O material foi interpretado pela análise temática de conteúdo. Os resultados mostraram que atividades de ensino que integram pessoas, currículos e profissões nos serviços de saúde têm potencial para promover aprendizagens interprofissionais na graduação, formando profissionais mais colaborativos e qualificando a atenção à saúde.

Palavras-chave
educação superior; currículo; processo de ensino-aprendizagem; integração curricular; pesquisa qualitativa

Resumen

Este estudio de caso cualitativo tuvo como objetivo comprender la percepción de los Agentes Comunitarios y gerentes de salud comunitaria sobre el significado de la experiencia de la educación interprofesional en los servicios de Atención Primaria de Salud para la formación de estudiantes de pregrado en salud de la Universidad Federal de Rio Grande do Sul. Se realizaron entrevistas semiestructuradas individuales (n=20) y análisis documental. El material fue interpretado por análisis de contenido temático. Los resultados mostraron que las actividades de enseñanza que integran personas, currículos y profesiones en los servicios de salud tienen el potencial de promover el aprendizaje interprofesional en la graduación, formando más profesionales colaborativos y calificando el cuidado de la salud.

Palabras clave
educación superior; currículo; proceso de enseñanza-aprendizaje; integración curricular; investigación cualitativa

Introduction

This research analyzes the experience of interprofessional education (IPE) in the services of Primary Health Care (PHC) in undergraduate degrees in the area of health. It is an educational proposal based on the integration of education- service- community, which proposes the meeting of students, professors, professionals, and users of Brazil’s National Health System (Sistema Único de Saúde – SUS) aiming to capacitate the attention to the needs of people-families-communities and the improvement of professional education with teamwork relationships (Albuquerque et al., 2008; Toassi et al., 2012; Zarpelon et al., 2018).

In Brazil, this articulation between professional formation and the public health system was established by Law 8080, when SUS was presented as the organizer of human resources training, assuming, thus, a key role to induce changes in the educational processes of health professionals according to users’ interests and needs (Campos et al., 2001).

Since 2001, undergraduate courses in health in Brazil have started orgizing their curricula based on the National Curriculum Guidelines (Diretrizes Curriculares Nacionais - DCN), in line with SUS principles (Brasil, 2001). In 2003, the creation of Secretary of Work Management and Education in Health (Secretaria da Gestão do Trabalho e da Educação na Saúde - SGTES) in the Ministry of Health showed the intention of defining guiding polities to train and develop health workforce to enact the development of SUS (Pierantoni et al., 2008; Dias et al., 2013). Some examples of these change-inducing policies in training are: National Program for the Reorientation of Professional Training in Health (Programa Nacional de Reorientação da Formação em Saúde - Pró-Saúde) (Brasil, 2005, 2007) and the Program for Training Through Work in Health (Programa de Educação para o Trabalho em Saúde - PET-Saúde) (Brasil, 2008, 2015, 2018).

Driven by this context, in 2008, the Federal University of Rio Grande do Sul (Universidade Federal do Rio Grande do Sul - UFRGS, Brazil) established a Health Coordination (Coordenadoria da Saúde - CoorSaúde), a collegiate body connected to the Dean of Undergraduate Studies and composed by the coordination of all undergraduate health courses and the projects in the area in UFRGS. CoorSaúde focuses on the articulation among health degrees, mainly, regarding students’ insertion in health care networks, according to the DCN of the degrees in the area (Universidade Federal do Rio Grande do Sul, 2020). In 2012, as an initiative of CoorSaúde aiming to consolidate the training integration with SUS and the undergraduate degrees, the first class of IPE in PHC services was created. The pedagogical proposal, grounded on the understanding and analysis of the territory and health services, through interdisciplinary/interprofessional experiences in PHC scenarios, stands out at the university, as the panorama of health training is still established by essentially uniprofessional curricula structures (Toassi & Lewgoy, 2016). In 2017, a qualitative study analyzed the perception of students, professors, and university managers on the meaning of this experience and its potential to IPE. The results have shown that the integration among students, professors, and health professionals have broadened the perspective of future health professionals, creating new spaces to reflect and build knowledge, producing different types of learning related to collaborative competences, typical of IPE, and the organization of collaborative-based teamwork. The research highlighted institutional challenges related to the university structure, supported in the departmental logic and curricula organized by subjects in professional nuclei, and the need to develop a faculty to work with IPE activities, pointing out that new research on the evaluation and follow-up of IPE activities are needed (Ely & Toassi, 2018).

Considering the importance to know health professionals’ perception on the meaning of the undergraduates’ experience in service activities, our research question is: What are the perceptions of Community Health Agents and managers on the meaning of IPE experience in health services for the training of undergraduate students, in a public university in the South of Brazil?

To answer this question, this research aimed to understand the perception of Community Health Agents (CHA) and managers on the meaning of IPE experiences in PHC services to train undergraduate students in health.

Methods

This research is part of a larger study entitled ‘Integrated Practices in Health I: the experience of interdisciplinary and multiprofessional training in the Universidade Federal do Rio Grande do Sul’. The study was approved by the Ethics Committees of UFRGS (Report 1.403.420) and the city hall of Porto Alegre (Report 1.527.102). It is a qualitative case study (Yin, 2010), whose research field was the IPE activity at UFRGS. We conducted semi-structured interviews and analyzed documents to produce the research data, as indicated on Table 1

Table 1
Information production and research participants

INFORMATION PRODUCTION	PARTICIPANTS/ ANALYZED DOCUMENTS
Semi-structured interviews	Community Health Agent (n=15)   Managers: Health District Management and Coordinators of Health Units/PHC (n=5)
Document analysis	Education plan of EIP activity (Universidade Federal do Rio Grande do Sul, 2018)

The sample was intentional and aimed to analyze the perception of professionals that agreed with the university on the proposal of an interprofessional educational activity and directly followed the activities developed in the services for at least a year. Thus, we invited to the interviews CHA representatives of each PHC unit that hosts practice experiences, the health professional in charge of coordinating the Units, as well as the health manager of the District where these units are located. Regarding the CHA, the sample size was determined by the criterion of theoretical saturation (Fontanella et al., 2011). The individual interviews followed a semi-structured script, whose guiding questions were based on the interviews of a previous study held with students (Ely & Toassi, 2018) and encompass professionals’ perceptions on IPE activity proposal and the agreement to implement it in their Unit; the process of follow-up/sociality/integration/learning with students and professors; the meaning of the activity to the training of undergraduate students and the health team; the challenges related to the development of the activity; and the consolidation proposals.

The interviews were conducted in 2018, in a pre-scheduled time, in silent spaces that best suited the interviewees, not interfering in their work routine. The interviews lasted around 25 minutes and were recorded in audio and fully transcribed, resulting in 8 hours of recording. The textual material was organized using the software Visual Qualitative Data Analysis (ATLAS.ti). We used thematic content analysis (Bardin, 2011) to interpret the information on a phenomenological theoretical perspective, bringing up the ‘perception’ of research participants as a way to understand how they fell the experienced world (Merleau-Ponty, 2006).

To preserve participants’ anonymity, we coded the Community Health Agents in a sequential order from CHA1 to CHA15 and the managers from M1 to M5.

Results and discussion

15 Community Health Agents and 5 managers (n=20) participated in this research. The characterization of participants is shown in Table 2.

Table 2
Characterization of research participants

CHC VARIABLES (n=15)	n	MANAGERS’ VARIABLE (n=5)	n
SEX		SEX
Woman	14	Woman	4
Man	1	Man	1
AGE (YEARS)		AGE (YEARS)
22 to 37	5	22 to 37	3
36 to 46	3	36 to 46	2
56 to 65	7
EDUCATION LEVEL		EDUCATION LEVEL
Graduated elementary school	2	Graduated higher education	1
Graduated high school	12	Postgraduate in the area	4
Incomplete higher education (in course)	1
TIME WORKING IN THE HEALTH UNIT/PHC (YEARS)		TIME WORKING IN THE HEALTH UNIT/ PHC (YEARS)
2 to 7	7	2 to 4	3
12 to 17	4	7 to 10	2
18 to 22	4

In this context, the focus of the study was the universe of meanings, beliefs, values, and attitudes of research participants regarding the phenomenon studied (Minayo, 2007), i.e., the perception of the experience in a IPE activity articulated with PHC services. We understand phenomenon as “everything human beings live or experience” (Titchen & Hobson, 2015, p. 171). The phenomenological world is the meaning that appears in the intersection of experiences, through the connection of one piece with another; it is inseparable from subjectivity and intersubjectivity (Merleau-Ponty, 2006). From the perception of participation, we sought the experience that, for Merleau-Ponty (2006), calls for a return to things in themselves, to the essence of the world, to perception, and, to Larrosa (2002), it is what touches us, happen to us, and marks us.

From these individual interviews, the themes and main categories of analysis emerged. This article focuses on the categories related to learning, as shown in Table 3.

Table 3
Emerging themes and categories of analysis

EMERGING THEMES	EMERGING CATEGORIES	CONSTITUTIVE DEFINITION
Learning in the IPE activity: the ‘practice’ resignifying the theory	Learning in SUS practical scenarios, from the experience in IPE activity	Presents the perceptions on learning together with the PHC teams and communities, bringing contributions to the training of future health professionals and workers
Sociability and integration in IPE activity	“Learning together to work together’: interaction among people, curricula, and professions	Presents the interactions in the experience of IPE activity

Learning in SUS practices from the experience in IPE activity: the ‘practice’ resignifying the theory

IPE activity started in the first semester of 2012, with the participation of 10 different undergraduate degrees and, in the following years, 15 degrees had the shared initiative in their curricula: Biomedicine, Biological Sciences, Physical Education, Nursing, Pharmacy, Physical Therapy, Speech Therapy, Medicine, Veterinary Medicine, Nutrition, Dentistry, Psychology, Social Service, Public Policies, and Community Health. Each semester, 4 places per degree were offered and established tutoring groups made up of 8 students and 2 professors from different professions. Practice moments take place in PHC services, along with the Family Health Units (Unidades de Saúde da Família) on their respective territories. Besides tutoring moments (80% of the study load), there are also theoretical activities of concentration, gathering all tutoring groups (20% of the study load). The reality experienced is registered and analyzed through individual portfolios. During the activity, the tutoring group, together with PHC work teams, develops a product to offer the Health Unit and/or community. This product results from the integration of students, professors, and professionals of the health team and is established by the materialization of this partnership. The experiences and products are shared among students, professors, health professionals, and representatives of the District Management, in a seminary in the end of each semester (Toassi & Lewgoy, 2016; Universidade Federal do Rio Grande do Sul, 2018). It is mainly the responsibility of CHAs to present the health service and the territory to the tutoring groups, guiding students and professors in the activities. The intention is for students to “see this territory and be able to make proposals” (M5). The IPE activity allows the tutoring group to follow CHAs’ work “in loco, within the territory whenever possible, and in the houses, so that they can see how things work” (CHA3). CHAs perceive their protagonism in this activity and the value of their profession based on their experience with students.

She [student] said that the community agents are pillars of the Unit, that she’d never imagined that a community agent did what we do

(CHA1).

[...] we can show our work in the territory, the potential we have, the difficulties, fragilities of the territory, the team, our work process. And they [students] also tell us that, the changes in the team, the tensions, the good and the bad things

(CHA14).

As professionals of PHC team living and working in the territory, CHAs are strategic partners to reach the intended objectives with this integration activity, as they know the reality and establish themselves as a key link between health professionals and the community, contributing with the bond of these relations (Bornstein & Stotz, 2008; Gomes et al., 2010). The possibility of meeting these people and the ties built with the families potentialize CHAs actions, resulting in the positive implication of these professionals with their working territory (Bezerra & Feitosa, 2018), which reflects in the tutoring group. CHAs observed that students expect to know teamwork in PHC, to understand how this team interacts and relates with users and undergraduate students.

They come here to know the team work, to know everyone, not only the community agents. But to know, to work, and see how this ‘center’ structure works, how we interact, how the theme relates with each other, a team with users and the students themselves

(CHA3).

CHAs and managers recognized the importance of an integration activity in health services, together with the territory, working with multiprofessional teams, acquiring a different knowledge of “theory complemented by practice” (CHA3), which only “the experience based on practice” (M5) provides.

[...] when they are here, they are part of the team with us; if there is a case to discuss [...] they participate with us […] and this gives them a different knowledge. It’s very different from being in a classroom […] In theory it’s one thing, in practice it’s another, the experience is another.

(CA11)

When knowing the territory and the people living there, students reflect on teaching and the production of care in everyday life (Kuabara et al., 2016). This contact with the “practice”, with community, and the opportunity to look “within the territory”, to talk with people and listen to them, allow the transformation of their “view on the territory”.

[...] how do I apply the theory in practice, within a territory, with all its difficulties, a community that comes with all those demands[...] it is the opportunity for student to experience all this in practice [...] they listen to the patients, they look within the territory, which sometimes is not their reality, sometimes they also come from a different life context, they come here are shocked with the periphery, with no sewage system, no electricity, with no treated water, open-air ditches, the work conditions. They can also understand the community […] they enter with a certain perspective and live with another view on the territory

(CHA14).

CHAs and managers reported that, besides contributing to the development of professional competences, like “cultural competence”, the activity of integrative education helps to deconstruct prejudices brought by this group. “It is a life experience” (CHA6).

[...] you develop a series of competences that you wouldn’t have to, if you haven’t experienced things in practice [...] the cultural experience […] it helps to have a certain preparation to face the cultural issues in our everyday life. When you’re in the territory, close to people, you’ll see a series of things from the real world, then you see those things, you stop and think about how you’ll react to those situation, on top of what you’ve learned in theory; so you end up developing this cultural competence, a competence for the work

(M5).

[...] we always end up bringing some theme related to the health of black people. A student here, who will soon graduate, will be a health professional, if he hadn’t experienced this practice, maybe he’d never heard about this theme […] they can also deconstruct a bit the concepts and prejudices they have

(CHA15).

Considering competence as the ability to mobilize knowledge, abilities, and attitudes to act in a certain situation (Perrenoud, 1999), cultural competence involves individuals’ ability to establish an effective communication between people and a work relation that allows overcoming existing cultural differences (Beach et al., 2005). The lack of it might lead to discrimination and stigmatization (Damasceno & Silva, 2018). Therefore, cultural competence is an essential attribute in PHC (Starfield, 2002), standing out in the IPE experience in the services analyzed in the research.

CHAs perceived that the learning process in IPE activity goes through an initial “shock” with the observed reality. During the experience, the “concept of territory and vulnerabilities” is “discussed by professors and professionals from the team”, thus collectively reconstructed from the “perspective and experience” of each group member (CHA14), aiming to develop in students a perception not only of the patient seeking assistance, but of people in their life context, connecting it with their health conditions. These are types of learning that take place in the collective work, experiencing teamwork, and seeking the population’s feedback (Vasconcelos et al., 2016).

[...] after having the general panorama of the territory, everyone will know the micro-area, the social equipment. Talking with the users. There had been users that even participated on the closing activity. Students and teachers participate in the circles of community therapy, know the social equipment we have here, like the community library, learn about the importance of this library in the territory, of this equipment to work with health. All this, the teachers always foment this, it’s very nice. […] Sometimes the dentist sees only inside the mouth. It’s not only a mouth there, there is a whole history behind […] there is a lot behind that mouth, there is a whole context of life, that is sometimes reflected within the office and the professional needs to be prepared to understand that, to be trained to have this perspective

(CA14)

From the understanding of health and sickness as social productions and of the territory as a living space, and not only geographical, it is possible to propose actions, changes, and improve care (Moimaz et al., 2010; Faria et al., 2018).

This concept of living territory is key to deepen discussions, broaden the perspective on the health-sickness process, and potentialize care (Monken et al., 2008; Lima & Yasui, 2014). However, in certain moments of CHAs narratives, it is possible to notice a concept of territory limited to a geographical space– “up to where it is my area, where is someone else’s area. They know everything in an afternoon” (CHA7) –, which highlights the importance of an integration activity to train future health professionals, as well as the permanent education of the team, a mutual benefit we expect from the integration teaching-service-community (Finkler et al., 2011).

An experience that bets on the training qualification of students and professionals “[...] there is an exchange, we give them experience and they give us innovations” (M3). To managers, the presence of students from different degrees in the health services, observing and questioning, instigates professionals to update themselves, to seek unknown information, regarding technical issues and about the territory itself.

[...] the question of having students from different professions, from different degrees, I think is very valid. It instigates professionals to keep updated, or to seek for information they don’t know, they don’t know, about the territory and even the techniques, so, the presence of students is very good

(M4).

Literature has shown that the training of health students in the service practices disturbs, denaturalizes the work, instigates teams to reflect on their actions and seek new knowledge, promotes an exchange of knowledge, and, thus, has the potential to transform practices and improve work processes (Guizardi et al., 2006; Vasconcelos et al., 2016).

Collectively-built learning can broaden critical awareness on the territory and on its population, allowing participants to reformulate and recreate knowledge, i.e., it is an opportunity to critically reflect the practice held, which can improve the next practice (Freire, 1996). In this process of problematizing the experience from the contact with different focuses and perspectives, the openness to dialogue is an essential factor. To Freire (1987) dialogue is indispensable to a transforming awareness. Therefore, it is necessary to build collaboration in the teaching-learning process among participants of the educational activity and promote dialogic interaction as an alternative to allow the active participation of all subjects in sharing and producing meanings and knowledge.

In this analysis, we also highlight the specificity of a IPE in-service activity, with the presence of a professor in the practical scenario (Universidade Federal do Rio Grande do Sul, 2018). We can see that among the CHAs and the professors there is a relation not only of affinity, but also pride of “working together with a professor” (CHA4) and “admiration” for the professors’ professional profiles. “They have the profile of our team” (CHA14).

The professors’ presence in the practice scenario together with the students and the health team, participating and continuously evaluating the proposal, is pointed out by CHAs and managers as the main distinctive feature of this educational activity.

[...] the main distinction is definitely the presence of the professor there with the students, participating and evaluating, [...] having this contact with the team, with the coordinator, as well as with the management to bring up questions they have also been observing, […] I think it’s super important the presence of the professor, to be together, mediating the discussions, to be together in the process really, it’s super positive

(M4).

[...] professors’ viewpoint contributes a lot to the students’ training and also to the professionals. Sometimes, there is information we don’t have, the team creates a culture of researching about everything, to study all, to know what is been discussed, that is not from the common sense”

(CHA14).

Professors act as facilitators of this shared learning, involving students and the team through a sensible approach, open to the existing diversity in the groups (Barr & Low, 2013). This pedagogical strategy of in-person and participative tutoring of professors in a practical scenario is characterized as an educational innovation in health areas that can improve the training of future health workers (Ely & Toassi, 2018).

The innovation allows moments of rupture and/or transition of paradigms, reconfiguring knowledge and power (Santos, 2010). Innovation means to air the ways of building knowledge, change, alternate, broadening perspectives. Innovation changes certainties, creates doubts and concerns, helps to think differently the hegemonic way, unsettling the reproductive mentality, and establishing in its place uneasiness (Leite et al., 2011, p. 25). The work by tutoring establishes, thus, a transformation movement in the current formation models in health degrees.

The ‘learning together to work together’: interactions among people, curricula, and professions

The fragmented model of formation and attention to health, focused on the disease, has been ineffective to deal with social and health needs of this century. We need to reflect on the practices, transform them, building a new care model that values collaborative practice in team and reduces the competition among professionals, overcoming the ‘tribalism of professions’ (D'Amour et al., 2008; Frenk et al., 2010). Interprofessional practice is one of the alternatives discussed on the educational changes of health professionals (Organização Mundial de Saúde, 2010; Reeves et al., 2013). It is a tendency that is consolidating itself in the health area, increasingly demanding that professionals dialogue with different fields and professions (Reis et al., 2020).

IPE is an educational opportunity in which members from two or more professionals interactively learn together, with the explicit aim to improve collaboration and the quality of care of users, families, and communities. When learning together about health work, students will be more prepared to work in teams (Reeves et al., 2016).

The proposal of the researched educational activity goes beyond knowing the territory and health services. It also intends to create interaction among professions through a new perspective, which creates a shift, another logic of knowledge, contributing with the formation of health professionals (Toassi & Lewgoy, 2016) and can be an interprofessional experience during their undergraduate degrees (Ely & Toassi, 2018).

The effective collaboration with better health outcomes demands from professionals the opportunity to “learn about others, with others, among themselves” (Organização Mundial de Saúde, 2010, p. 13).

To CHAs, if the students from different professions “start to talk, share ideas; they can improve their experience and the life of others” (CHA10). It is through this dialogue that one recognizes the importance of each profession to the health team, one of the learning possibilities of IPE activity.

The students talk with each other, they say that one needs the other, they also need to see the patient from the perspective of the other, with the perspective of Pharmacy, the perspective of Veterinary, of Psychology, to share with each other, this is very rich, we can see that

(CHA14).

[...] it is very rich for the students to see the importance that each professional has in health, I think they only really see that more concretely when they’re in the field. And this integration among them, in the group even, becomes very rich, they can know what the nutritionist can contribute here, or how Veterinary Medicine, Dentistry can work in SUS

(M2).

It is an interaction that also benefits the PHC teamwork, “showing a different perspective of each profession” (M2). To be clear about the professional roles is one of the competences for the collaborative practice, to know your own role and that of others, recognize and respect the diversity of roles, communicate using appropriate language, integrate competencies (Canadian Interprofessional Health Collaborative, 2010).

An educational experience with students from different professions, which interact and discuss the service network of SUS together with the territories, becomes a distinction in formation, as it allows broadening the perspective of undergraduate students based on a process of shared learning.

[...] there is no other subject that connects a number of undergraduates from different professions, together, discussing SUS […] that is the difference

(M4)

[...] sometimes the university limits you [...] you are an undergraduate and have little or no interaction with the professionals from other areas, which strongly limits your knowledge, because you can’t broaden your perspective, nor share what you have learned with other areas that can add a lot

(M5).

The perspective of the other allows each one to analyze their way to work. Each person has their own perception, viewpoint, and specific knowledge, as their share their perspectives, they broaden their understanding possibilities, and communication with users of the health services (Merhy & Feuerwerker, 2009).

Through problematization, integrated education activity incorporates in its learning-teaching process the mobilization towards learning, a sensibility to create a favorable attitude to learning, including students, professors and PHC professionals (Toassi & Lewgoy, 2015). From this theoretical and practical integration, in dialogic spaces, and the intersection in the job market and health education emerges something new (Vendruscolo et al., 2016).

This openness to the new establishes an awareness of incompleteness, opening ways to know more and allowing a respectful acceptance of others, of curiosity, of dialogue, convicted that one knows some things and ignore others, together with the certainty of being able to know better what is known and learn what is not, in the confirmed knowledge of one’s own experience (Freire, 1996).

To CHAs, participating in IPE activity is an opportunity to be “constantly learning new things with one another” (CHA3), “a change of experiences” (CHA 6 and 8).

We receive information from the students that we normally don’t know. We also wouldn’t have contact with their professions, with what they’re studying and doing

(CHA2).

[...] with this subject, we have this ‘up’, they bring new things, renew our side. We give what we have, what we do, and they give what new things they have. [...] after we discuss, see what can be improved. [...] we see their side and ours, we learn with each other

(CHA3).

Besides this, it allows a greater interaction within the team, “when they come, we interact much more” (CHA10). These exchanges favor the reflection on the experiences, in a constant learning process, keeping the work alive.

We have grown a lot with the ‘integration’ because we’re in a constant learning process, we are always exchanging, we take our perspective and they bring theirs. “But, who knows?”, to make these questions, I often think that this keeps our work alive

(CHA14).

The “living work” mentioned by the CHAs can be understood as a “work in action”, established in the everyday life of professionals, giving worker freedom to be creative in the care processes and in their relations, associated with light technologies, leading to changes in the production of care, and thinking new ways of acting (Franco & Merhy, 2013).

To the manager, students’ perception allows the team to build a viewpoint “through the lenses” of this group on the same problem.

The observations made by the group, what they’ll notice, what we can perceive through their lenses […] they bring different perspectives on the same problem, sometimes, you are so used to it that you don’t notice this richer construction

(M1).

To work together with students and professors from different courses, in CHAs’ perspective, is “not the same thing as working alone” (CHA 14). “There are some obvious things that we don’t see” (CHA10). These other perspectives, from different professions, with questions and reflection, are the “key ingredient” of the experience.

[...] it’s not the same thing, it’s to have the perspective of Pharmacy, Veterinary, Psychology, all there, we can make this question, these reflections; sometimes we only have the team’s perspective on the territory and we miss this, the key ingredient, the students’ point of view [...] this exchange is to us is gratifying”

(CHA14).

In this meeting of professions, “one learns with the other”, building another knowledge. These learning opportunities include the specific knowledge of each profession and the knowledge of others (Peduzzi et al., 2013). With the work dynamic proposed by the integration activity, workers can have contact with professions that, normally, do not work in Health Units. These are different viewpoints, with a common objective, that can complement each other within the team and allow a broader understanding of health. “I like that different degrees are together because each one has a different perspective and contributions to add” (CHA 11).

The subject, in fact, brings for the Unit a debate among professions and this is very useful […] I have no doubt that the exchange has been productive to both sides, to the professionals and to the students. When you have the professionals talking, one will learn a lot with the other

(M4).

Through the point of view from different areas, we learn a bit from each, this is good [...] there’s always a lot of exchange, participation in several courses. I like this, this perspective, of ‘making health’ from other areas that don’t have as much contact with us, like the social assistants, biologists, vets

(M3).

The moment of discussions, which take place after home visits or after getting acquainted with the territory, is a space of action and reflection. Together, the team, professors, and students share the activities they experienced, exchange impressions among themselves, perceive their differences, and build a common care strategy.

[...] after home visits, we sit together with the professor to talk and discuss the case. To discuss the case is to present the problem we found in that house, with that family, that patient, and try to find a common path to help that family, then each one gives his or her opinion, then we can see the differences among the degrees. It is very nice, very cool. We also see that when they leave to visit the territory, it is the same

(CHA11).

When bringing the situations/problems/cases to be collectively discussed, it is possible to share how each person deals with the situation and re-create new practices together, which can be more effective (Meyer et al., 2013). This interprofessional communication is essential for a practice of collaborative work focused in the care of the patient, the family, and the community (Canadian Interprofessional Health Collaborative, 2010).

Interaction and communication are conceptual elements of work and team atmosphere, which are established as key elements for collaboration (Peduzzi & Agreli, 2018). If collaboration “implies, necessarily, to (re)situate users and their health needs in the center of the process” (Costa, 2017, p. 18), the focus of the practices – in education and health – should be on people and their needs, working with the autonomy of the patient, in a broad perspective of care, considering that the expressions of subjectivities influence relations and care, key attributes to Person-Focused Care (Atenção Centrada na Pessoa- ACP) (Peduzzi et al., 2016). ACP is a central element in the interprofessional collaborative practice and the interprofessional teamwork (D’Amour et al., 2008; Peduzzi et al., 2016; Peduzzi & Agreli, 2018). Health needs have become gradually more complex (Organização Mundial de Saúde, 2010; Barr & Low, 2013), and health teams are “increasingly more convinced that they cannot cope with everything on their own” (M4).

[...] in Primary Care, the situations are increasingly more complex and the health teams are increasingly more convinced that they cannot cope with everything on their own, then we start to look for connections with other professions

(M4).

To work collaboratively together, it is necessary to respect other people’s opinion, recognize, and value the importance of others, to establish a partnership.

[...] you learn to respect others’ opinions, who are health professionals. The continuation of patients’ care also depends on another professional, not only on you, because we can’t promote health alone

(CHA11).

[...] it is a moment in which they also experience with other degrees in the health area. All is interconnected, mainly to us, who work in Family Health, like it or not, the work is always interdisciplinary, multi, and inter, because you are the whole time dealing with patients who have multiple health issues

(M5).

Professional isolation is a significant problem, related to tensions and interprofessional insecurities (Fletcher, Whiting, Boaz & Reeves, 2017). Fragmented care, the inability to learn/work in team and the lack of interaction between professionals are associated with worse results with the patients (Reeves et al., 2016). To CHAs, learning and working together, recognizing the importance and the work of others, can bring future benefits to the patients.

[...] working together does exactly this, you learn more from other professions, you understand better how the other works and you can assemble all this and do the best for your patient in the future

(CHA 11).

Health care practices should, then, reinforce the need to reestablish the users in the centrality of the process, in the perspective of comprehensive care, with the effective collaboration among different professions (Barr & Low, 2013). IPE becomes an alternative to face this complexity, considering its potential to develop collaborative competencies to work in teams (Reeves et al., 2016; Frenk et al., 2010; Organização Mundial de Saúde, 2010).

Students and graduates who have experienced the IPE activity have perceived it as an opportunity to know other professions, talking, listening, and valuing the opinion of others (Ely & Toassi, 2018). This result is also present in the perception of CHAs and managers, who reinforce the understanding that IPE activity allows students to learn to work with colleagues from other professions, respecting their opinions, discovering how each person works, what creates divergences, affinities, and prejudices, and, thus, should be obligatory in the formation of health professions, benefiting the patients.

[...] we have to learn to work with a team, all together, respecting and understanding your workmate’s opinion, even if we often have disagreements.

[...] that is exactly why it should be an obligatory activity, because you learn to be together with your colleagues in health, but that don’t work in the same area, they don’t work the same way you do within the health area, and I think this will benefit your patient

(CHA11).

[...] it would be extremely interesting if everyone could have this experience. Because many people might have an affinity, but have a prejudice

(M1).

However, they associate the “non-obligation” of this educational activity to a certain profile of student, who would be more “interested to know Primary Care, SUS, and that wants to learn”, who are “curious”, willing to be together with people from different degrees and with other ideas (CHA11, 14).

[...] the student ends up getting involved with SUS, with Primary Care by the imposition of the curriculum, and this activity is chosen by the student. It’s another profile. It’s another way of working. [...] you end up meeting other people, from other degrees, who students normally don’t meet. I think that’s quite positive (M1).

Students and graduates who finished the IPE experience also believe the activity should be obligatory in their curricula (Ely & Toassi, 2018). Literature points out the need to make IPE obligatory or else it can be considered as less important and affect students’ commitment (Organização Mundial de Saúde, 2010; Reeves et al., 2016).

The intensity of the experiences marks the team. “There are those students who leave a mark” (CHA1). The professionals try to receive the group in the best way possible, so that they feel “welcomed” (CHA5). The pedagogical proposal of the activity brings lightness and affection to the everyday lives of health teams.

The work process in the integrating activity was always good [...] the interaction with the services was quite light, it left a legacy later, so, it was pleasant to work. Their objective in establishing a multiprofessional contact with SUS, with health services, with the territory was always interesting

(M1).

As it is also a challenging experience for professors, we highlight the importance of a permanent faculty qualification, with institutional support, to guarantee that they will be a IPE facilitator, broadening the opportunities to share knowledge and experiences (Reeves et al., 2016; Costa, 2017).

Aspects related to the heavy workload of the teams, the rotation of the professionals in the teams, the limitations of space in the Health Units and the duration of the activity in the curricula (maximum 4 months) were perceived as barriers to IPE initiatives.

Conclusion

The analysis of the IPE experience during the undergraduate degree in PHC has shown moments of sociability, exchange, discussions, and interaction among different actors in the care process, and the community. CHA and managers reinforce the perception from students and graduates that this educational activity allows learning to work together with different professional nuclei, knowing and respecting how each profession acts, which involves disagreements, affinities, and prejudices. They understand that the activity gives the opportunity for new types of learning, preparing team workers. It stands out as a pedagogical innovation, because it takes place in health services with the presence of a professor in a practice scenario (teaching by tutoring) and allowing shared learning through the integration of students, professors, health professionals, and SUS users. Thus, it should be obligatory in the undergraduate curricula, benefiting patients.

Educational activities that integrate people, curricula, and professionals together with PHC services, as the one researched, have the potential to promote interprofessional learning during undergraduate, training more collaborative professionals, and improving health care. We highlight the importance of institutional support, the formation of a faculty from different professional nuclei, and the participation of service managers/workers to build and consolidate IPE initiatives in services in the curricula of health degrees. We recommend future studies on the perception of health service users.

• 2
  References correction and bibliographic normalization services: Maria Thereza Sampaio Lucínio – [e-mail]
• 3
  English version: Viviane Ramos - [e-mail]

Referências

• Albuquerque, V. S., Gomes, A. P., Rezende, C. H. A., Sampaio, M. X., Dias, O. V., & Lugarinho, R. M. (2008). A Integração Ensino-Serviço no Contexto dos Processos de Mudança na Formação Superior dos Profissionais da Saúde. Revista Brasileira de Educação Médica, 32(3), 356–362. doi: 10.1590/S0100-55022008000300010
  » https://doi.org/10.1590/S0100-55022008000300010
• Bardin, L. (2011). Análise de conteúdo Edições 70.
• Barr, H., & Low, W. (2013). Introducing interprofessional education Center for the advancement of interprofessional education (CAIPE), England.
• Beach, M. C. et al. (2005). Cultural competence: a systematic review of health care provider educational interventions. Med. Care, 43(4), 356-373. doi: 10.1097/01.mlr.0000156861.58905.96
  » https://doi.org/10.1097/01.mlr.0000156861.58905.96
• Bezerra, Y. R. N., & Feitosa, M. Z. S. (2018). A afetividade do agente comunitário de saúde no território: um estudo com os mapas afetivos. Ciência & Saúde Coletiva, 23(3), 813-822. doi: 10.1590/1413-81232018233.00292016
  » https://doi.org/10.1590/1413-81232018233.00292016
• Bornstein, V. J., & Stotz, E. N. (2008). Concepts involved in the training and work processes of community health care agents: a bibliographical review. Ciência & Saúde Coletiva, 13(1), 259-268. doi: 10.1590/1413-81232018233.00292016
  » https://doi.org/10.1590/1413-81232018233.00292016
• Brasil (2001). Ministério da Educação. Conselho Nacional de Educação. Câmara de Educação Superior. Parecer nº 583/2001 Orientação para as diretrizes curriculares dos cursos de graduação. Ministério da Educação.
• Brasil (2005). Ministério da Saúde. Pró-Saúde: Programa Nacional de Reorientação da Formação Profissional em Saúde Ministério da Saúde.
• Brasil (2007). Ministério da Saúde. Ministério da Educação. Pró-Saúde: Programa Nacional de Reorientação da Formação Profissional em Saúde Ministério da Saúde.
• Brasil (2008). Ministério da Saúde. Portaria Interministerial nº 1802, de 26 de agosto de 2008 Institui o Programa de Educação pelo Trabalho para a Saúde – PET-Saúde. Ministério da Saúde.
• Brasil (2015). Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Edital nº 13, de 28 de setembro de 2015. Seleção para o Programa de Educação pelo Trabalho para a Saúde. PET-Saúde/GRADUASUS – 2016/2017. Ministério da Saúde.
• Brasil (2018). Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde (SGTES). Edital nº 10, 23 de julho 2018. Seleção para o programa de educação pelo trabalho para a saúde. PET-Saúde/Interprofissionalidade – 2018/2019. Diário Oficial [da] República Federativa do Brasil, Poder Executivo.
• Campos, F. E., Ferreira, J. R., Feuerwerker, L., Sena, R. R., Campos, J. J. B., Cordeiro, H., & Cordoni Jr., L. (2001). Caminhos para aproximar a formação de profissionais de saúde das necessidades da atenção básica. Revista Brasileira de Educação Médica, 25(2), 53-59.
• Canadian Interprofessional Health Collaborative (2010). A national interprofessional competence framework Vancouver: Canadá.
• Costa, M. V. (2017). A potência da educação interprofissional para o desenvolvimento de competências colaborativas no trabalho em saúde. In Toassi, R. F. C. (Org.), Interprofissionalidade e formação na saúde: Onde estamos? (pp. 14-27). Rede Unida.
• Damasceno, R. F., & Silva, P. L. N. (2018). Competência cultural na atenção primária: algumas considerações. Journal of management & primary health care, 9, e11. doi: https://doi.org/10.14295/jmphc.v9i0.435
  » https://doi.org/10.14295/jmphc.v9i0.435
• D'Amour, D., Goulet, L., Labadie, J. F., Martín-Rodriguez, L. S., & Pineault, R. (2008). A model and typology of collaboration between professionals in health care organizations. BMC Health Service Research, 8, 188. doi: 10.1186/1472-6963-8-188
  » https://doi.org/10.1186/1472-6963-8-188
• Dias, S., Lima, H. D., & Teixeira, M. (2013). A trajetória da política nacional de reorientação da formação profissional em saúde no SUS. Ciência & Saúde Coletiva, 18(6), 1613-1624. doi: 10.1590/S1413-81232013000600013
  » https://doi.org/10.1590/S1413-81232013000600013
• Ely, L. I., & Toassi, R. F. C. (2018). Integração entre currículos na educação de profissionais da saúde: a potência para educação interprofissional na graduação. Interface - Comunic., saúde, educ., 22(2), 1563-1575. doi: 10.1590/1807-57622017.0658
  » https://doi.org/10.1590/1807-57622017.0658
• Faria, L., Quaresma, M. A., Patiño, R. A., Siqueira, R., & Lamego, G. (2018). Integração ensino-serviço-comunidade nos cenários de práticas na formação interdisciplinar em saúde: Uma experiência do Programa de Educação pelo Trabalho para a Saúde (PET-Saúde) no sul da Bahia, Brasil. Interface - Comunic., saúde, educ., 22(67), 1257-1266. doi: 10.1590/1807-57622017.0226
  » https://doi.org/10.1590/1807-57622017.0226
• Finkler, M., Caetano, J. C., & Ramos, F. R. S. R. (2011). Integração “ensino-serviço” no processo de mudança na formação profissional em Odontologia. Interface - Comunic., saúde, educ., 15(39), 1053-1067. doi: 10.1590/S1414-32832011005000023
  » https://doi.org/10.1590/S1414-32832011005000023
• Fletcher, S., Whiting, C., Boaz, A., & Reeves, S. (2017). Exploring factors related to the translation of collaborative research learning experiences into clinical practice: opportunities and tensions. Journal of Interprofessional Care, 31(4), 543-545. doi: 10.1080/13561820.2017.1303464
  » https://doi.org/10.1080/13561820.2017.1303464
• Fontanella, B. J. B., Luchesi, B. M., Saidel, M. G. B., Ricas, J., Turato, E. R., & Melo, D. G. (2011). Amostragem em pesquisas qualitativas: Proposta de procedimentos para constatar saturação teórica. Cadernos de Saúde Pública, 27(2), 389-394. doi: 10.1590/S0102-311X2011000200020
  » https://doi.org/10.1590/S0102-311X2011000200020
• Franco, T. B., & Merhy, E. E. (2013). O reconhecimento de uma produção subjetiva do cuidado. In Franco, T. B., & Merhy, E. E., Trabalho, produção do cuidado e subjetividade em saúde: Textos reunidos (pp. 151-171). Hucitec.
• Freire, P. (1987). Pedagogia do oprimido (11a ed.). Rio de Janeiro: Paz e Terra.
• Freire, P. (1996). Pedagogia da autonomia: Saberes necessários à prática educativa Paz e Terra.
• Frenk, J., Chen, L., Bhutta, Z. A., Cohen, J., Crisp, N., Evans, T., & Zurayk, H. (2010). Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. The Lancet, 376(9756), 1923-1958. doi: 10.1016/S0140-6736(10)61854-5
  » https://doi.org/10.1016/S0140-6736(10)61854-5
• Gomes, K. O., Cotta, R. M. M., Mitre, S. M., Batista, R. B., & Cherchiglia, M. L. (2010). O agente comunitário de saúde e a consolidação do Sistema Único de Saúde: Reflexões contemporâneas. Physis: Revista de Saúde Coletiva, 20(4), 1143-1164. doi: 10.1590/S0103-73312010000400005
  » https://doi.org/10.1590/S0103-73312010000400005
• Guizardi, F. L., Stelet, B. P., Pinheiro, R., & Ceccim, R. B. (2006). A formação de profissionais orientada para a integralidade e as relações político-institucionais na saúde: uma discussão sobre a integração ensino-trabalho. In Pinheiro, R.; Ceccim, R. B. & Matos, R. A. (Orgs.), Ensinar saúde: A integralidade e o SUS nos cursos de graduação na área da saúde (pp. 153-177). IMS/UERJ, Cepesc, Abrasco.
• Kuabara, C. T. M.; Tonhom, S. F. R., & Marin, M. J. S. (2016). Integração ensino-serviço na perspectiva dos profissionais da rede primária de saúde. Revista Fórum Identidades, 22(22), 173-192.
• Larrosa, J. B. (2002). Notas sobre a experiência e o saber de experiência. Revista Brasileira de Educação, 19, 20-28. doi: 10.1590/S1413-24782002000100003
  » https://doi.org/10.1590/S1413-24782002000100003
• Leite, D., Genro, M. E., & Braga, A. M. (2011). Inovações pedagógicas e demandas ao docente na universidade. In D. Leite, M. E. Genro, & A. M. Braga (Orgs.). Inovação e pedagogia universitária (pp. 19-48). Editora da UFRGS.
• Lima, E. M. F. A., & Yasui, S. (2014). Territórios e sentidos: espaço, cultura, subjetividade e cuidado na atenção psicossocial. Saúde Debate, 38(1020), 593-606.
• Merhy, E. E., & Feuerwerker, L. C. M. (2009). Novo olhar sobre as tecnologias de saúde: uma necessidade contemporânea. In Mandarino, A. C. S., & Gomberg, E. (Orgs.). Leituras de novas tecnologias e saúde (pp. 29-56). Editora UFS.
• Merleau-Ponty, M. (2006). Fenomenologia da percepção (3a ed.). Martins Fontes.
• Meyer, D. E., Felix, J., & Vasconcelos, M. F. F. (2013). Por uma educação que se movimente como maré e inunde os cotidianos de serviços de saúde. Interface - Comunic., saúde, educ., 17(47), 859-871. doi: 10.1590/S1414-32832013005000033
  » https://doi.org/10.1590/S1414-32832013005000033
• Minayo, M. C. S. (2007). O desafio do conhecimento: pesquisa qualitativa em saúde (10a ed.). Hucitec.
• Moimaz, S. A. S., Saliba, N. A., Zina, L. G., Saliba, O., & Garbin, C. A. S. (2010). Práticas de ensino-aprendizagem com bases em cenários reais. Interface - Comunic., saúde, educ., 14(32), 69-79. doi: 10.1590/S1414-32832010000100006
  » https://doi.org/10.1590/S1414-32832010000100006
• Monken, M., Peiter, P., Barcellos, C., Rojas, L. I., Navarro, M., Gondim, G. M. M., & Gracie, R. (2008). O território na saúde: Construindo referências para análises em saúde e ambiente. In Miranda, A. C., Barcellos, C., Moreira, J. C., & Monken, M. (Orgs.). Território, Ambiente e Saúde (pp. 23-41). Fiocruz.
• Organização Mundial de Saúde. Marco para ação em educação interprofissional e prática colaborativa WHO, 2010.
• Peduzzi, M., Norman, I. J., Germani, A. C. C. G., Silva, J. A. M., & Souza, G. C. (2013). Educação interprofissional: Formação de profissionais de saúde para o trabalho em equipe com foco nos usuários. Revista da Escola de Enfermagem da USP, 47(4), 977-983. doi: 10.1590/S0080-623420130000400029
  » https://doi.org/10.1590/S0080-623420130000400029
• Peduzzi, M., Oliveira, M. A. C., Silva, J. A. M., Agreli, H. L. F., & Miranda Neto, M. V. (2016). Trabalho em equipe, prática e educação interprofissional. In Martins, M. A., Carrilho, F. J., Alves, V. A., Castilho, E. A., & Cerri, G. G. Clínica médica: Atualização da clínica (pp. 171-179). Manole.
• Peduzzi, M., & Agreli, H. F. (2018). Trabalho em equipe e prática colaborativa na Atenção Primária à Saúde. Interface - Comunic., saúde, educ., 20(59), 905-916. doi: 10.1590/1807-57622017.0827
  » https://doi.org/10.1590/1807-57622017.0827
• Perrenoud, P. (1999). Construir as competências desde a escola Artmed.
• Pierantoni, C. R., Varella, T. C., Santos, M. R., França, T., & Garcia, A. C. (2008). Gestão do trabalho e da educação em saúde: recursos humanos em duas décadas do SUS. Physis: Revista de Saúde Coletiva, 18(4), 685-704. doi: 10.1590/S0103-73312008000400005
  » https://doi.org/10.1590/S0103-73312008000400005
• Reeves, S., Perrier, L., Goldman, J., Freeth, D., & Zwarenstein, M. (2013). Interprofessional education: Effects on professional practice and healthcare outcomes (update) Cochrane database of systematic reviews. Issue 3.
• Reeves, S., Fletcher, S., Barr, H., Birch, I., Boet, S., Davies, N., & Kitto, S. (2016). A BEME systematic review of the effects of interprofessional education: BEME Guide No. 39. Medical Teacher, 38(7), 656-668. doi: 10.3109/0142159X.2016.1173663
  » https://doi.org/10.3109/0142159X.2016.1173663
• Reis, W. B., Gomes, R. J., & Oliveira, R. C. (2020). A interdisciplinaridade no estágio supervisionado de um curso de Educação Física. Pro-Posições, 31, e20180030. doi:10.1590/1980-6248-2018-0030
  » https://doi.org/10.1590/1980-6248-2018-0030
• Santos, B. S. (2010). Pela mão de Alice: O social e o político na pós-modernidade (13. ed). Cortez.
• Starfield, B. (2002). Atenção primária: Equilíbrio entre necessidades de saúde, serviços e tecnologia UNESCO, Ministério da Saúde.
• Titchen, A., & Hobson, D. (2015). Compreensão da fenomenologia mediante perspectivas inversas. In Somekh, B. & Lewin, C. (Orgs.). Teoria e método de pesquisa social (pp.183-191). Vozes.
• Toassi, R. F. C., Davoglio, R. S., & Lemos, V. M. A. (2012). Integração ensino-serviço-comunidade: O estágio na atenção básica da graduação em odontologia. Educação em Revista, 28(4), 223-242. doi: 10.1590/S0102-46982012000400009
  » https://doi.org/10.1590/S0102-46982012000400009
• Toassi, R. F. C., & Lewgoy, A. M. B. (2016). Práticas Integradas em Saúde I: uma experiência inovadora de integração intercurricular e interdisciplinar. Interface - Comunic., saúde, educ., 20(57), 449-461. doi: 10.1590/1807-57622015.0123
  » https://doi.org/10.1590/1807-57622015.0123
• Universidade Federal do Rio Grande do Sul (2018). Faculdade de Odontologia. Comissão de Graduação do Curso de Odontologia. Plano de Ensino Disciplina Práticas Integradas em Saúde I. UFRGS.
• Universidade Federal do Rio Grande do Sul (2020). Pró-Reitoria de Graduação. Coordenadoria de Saúde UFRGS.
• Vasconcelos, A. C. F., Stedefeldt, E., & Frutuoso, M. F. P. (2016). Uma experiência de integração ensino-serviço e a mudança de práticas profissionais: Com a palavra, os profissionais de saúde. Interface - Comunic., saúde, educ., 20(56), 147-158. doi: 10.1590/1807-57622015.0395
  » https://doi.org/10.1590/1807-57622015.0395
• Vendruscolo, C., Ferraz, F., Prado, M. L., Kleba, M. E., & Reibnitz, K. S. (2016). Integração ensino-serviço e sua interface no contexto da reorientação da formação na saúde. Interface - Comunic., saúde, educ., 20(59), 1015-1025. doi: 10.1590/1807-57622015.0768
  » https://doi.org/10.1590/1807-57622015.0768
• Yin, R. (2010). Estudo de caso: Planejamento e métodos (4a. ed.). Bookman.
• Zarpelon, L. F. B., Terencio, M. L., & Batista, N. A. (2018). Integração ensino-serviço no contexto das escolas médicas brasileiras: revisão integrativa. Ciência & Saúde Coletiva, 23(12), 4241-4248. doi: 10.1590/1413-812320182312.32132016
  » https://doi.org/10.1590/1413-812320182312.32132016

1

Responsible Editor: Helena Sampaio: https://orcid.org/0000-0002-1759-4875

Publication Dates

• Publication in this collection
  06 May 2022
• Date of issue
  2022

History

• Received
  01 Mar 2020
• Reviewed
  06 June 2020
• Accepted
  25 Sept 2020