3.1 Phase one: Quantitative
A total of 191 managers answered the email inviting them to participate in the survey. Four managers did not want to participate and 17 answered the form twice which had their answers disregarded due to duplicity. After excluding the duplicates, 170 forms were analyzed, corresponding to 60.9% of the BHU managers of the social and environmental groupings of the highly vulnerable health territories (classified as five, six and seven respectively). Table 2 next presents the distribution of the number and percentage of participation by grouping.
Table 2 Distribution by SGHT and participation in the survey
|
SGHT
|
Number of territories
|
Participants (%)
|
Five
|
131
|
64.12
|
Six
|
101
|
55.44
|
Seven
|
47
|
63.82
|
Participants who stated that they perform intra-sectoral actions correspond to 98.8% and those who perform inter-sectoral actions correspond to 99.4%. The chi-square analysis revealed that there is no relationship between vulnerable SGHT and the existence of intra-sectoral and inter-sectoral actions (Table 3).
About intra-sectoral partners, the analysis demonstrates the relationship of the groupings with the following intra-sectoral partners: Other BHU (p = 0.009) and mental health services (p = 0.007)(Table 4). There is also a significant relationship with some inter-sectoral partners: social assistance (p = 0.007), environment (p = 0.007) and Guardianship Council (p = 0.007)(Table 6).
Table 3 Relationship of the intra-sectoral and inter-sectoral actions and the SGHT of the most vulnerable
|
|
SGHT
|
Yes
|
(%)
|
No
|
(%)
|
Total
|
p
|
Existence of intra-sectoral actions
|
Five
|
83
|
98.8
|
1
|
1.2
|
84
|
0.765
|
Six
|
55
|
98.2
|
1
|
1.8
|
56
|
Seven
|
30
|
100.0
|
0
|
0.0
|
30
|
Total
|
168
|
98.8
|
2
|
1.18
|
170
|
|
|
|
|
|
|
|
|
Existence of inter-sectoral actions
|
Five
|
83
|
98.8
|
1
|
1.2
|
84
|
0.598
|
Six
|
56
|
100.0
|
0
|
0.0
|
56
|
Seven
|
30
|
100.0
|
0
|
0.0
|
30
|
Total
|
169
|
99.4
|
1
|
0.6
|
170
|
Managers fully agreed (69.3%) that intra-sectoral health actions among the basic units take place in the groupings. The managers' statements regarding the existence of intra-sectoral actions for health between the BHU and the Psychosocial Care Centers (CAPS) happening in the groupings was higher: they agreed (15.4%) or agreed (75.0%) with statistical significance: p <0.05.
The managers of socio-environmental grouping six have the greater agreement of intra-sectoral actions with other BHU (23.21% and 46.43%) and grouping five has the greater agreement of intra-sectoral actions with CAPS, (15.48% and 75%). The actions performed with another specialized sector had a greater disagreement in the different groupings.
Table 4 Association of intra-sectoral actions with different partners in the most vulnerable SGHTs
|
|
SGHT
|
Strongly agree (%)
|
Agree (%)
|
Neither agree nor disagree (%)
|
Disagree (%)
|
Strongly disagree (%)
|
Total (%)
|
p
|
BHU with other BHU
|
Five
|
9.5
|
61.9
|
7.14
|
17.9
|
3.6
|
100
|
0.009
|
Six
|
23.2
|
46.4
|
19.6
|
10.7
|
0
|
100
|
Seven
|
0
|
63.3
|
20
|
16.7
|
0
|
100
|
Total
|
12.4
|
57.1
|
13.5
|
15.3
|
1.8
|
100
|
|
|
|
|
|
|
|
|
|
BHU with CAPS
|
Five
|
15.5
|
75
|
3.6
|
3.6
|
2.4
|
100
|
0.007
|
Six
|
33.9
|
58.9
|
3.6
|
3.6
|
0
|
100
|
Seven
|
13.3
|
60
|
20
|
6.7
|
0
|
100
|
Total
|
21.2
|
67.1
|
6.8
|
4.1
|
1.2
|
100
|
|
|
|
|
|
|
|
|
|
BHU with the specialized health sector
|
Five
|
6
|
31
|
6
|
44.1
|
13.1
|
100
|
0.208
|
Six
|
5.4
|
32.1
|
16.1
|
39.3
|
7.1
|
100
|
Seven
|
0
|
23.3
|
20
|
53.3
|
3.3
|
100
|
Total
|
4.7
|
30
|
11.8
|
44.1
|
9.4
|
100
|
Table 5 shows the results of bivariate analyses using the chi-square test. There are statistically significant relationships between intersectoral actions and the following partners: social assistance (p = 0.02), environment (p = 0.04) and the Guardianship Council (p = 0.004). The managers of the SGHT number 5 agreed in 85.7% regarding the existence of the partnership between BHU and social assistance, while the managers of the social and environmental groupings numbers 6 and 7 agreed on 83.9% and 73.3%, respectively. The environment partners and Guardianship Council showed greater agreement (83.9% and 69.6%) with the BHU located in group 6. The managers of the BHU located in group 7 showed the lower agreement of the partnerships in relation to the other groups the Guardian Council which had 62.9%.
Table 5 Association of inter-sectoral actions of different partners and SGHT of the most vulnerable
|
|
SGHT
|
Strongly agree (%)
|
Agree (%)
|
Neither agree nor disagree (%)
|
Disagree (%)
|
Strongly disagree (%)
|
Total (%)
|
p
|
BHU with education
|
Five
|
155
|
71.4
|
6.0
|
7.1
|
0
|
100
|
0.212
|
Six
|
26.8
|
58.9
|
3.6
|
10.7
|
0
|
100
|
Seven
|
13.3
|
83.3
|
3.3
|
0.0
|
0
|
100
|
Total
|
18.8
|
69.4
|
4.7
|
7.1
|
0
|
100
|
|
|
|
|
|
|
|
|
|
BHU with social assistance
|
Five
|
11.9
|
73.8
|
4.8
|
9,5
|
0
|
100
|
0.023
|
Six
|
19.6
|
64.3
|
7.1
|
5,4
|
3,6
|
100
|
Seven
|
0.0
|
73.3
|
20.0
|
6.7
|
0.0
|
100
|
Total
|
12.4
|
70.6
|
8.2
|
7.7
|
1.2
|
100
|
|
|
|
|
|
|
|
|
|
BHU with the environment
|
Five
|
13.1
|
59.5
|
14.3
|
13.1
|
0.0
|
100
|
0.040
|
Six
|
19.6
|
64.3
|
7.1
|
3.6
|
5.4
|
100
|
Seven
|
3.3
|
66.7
|
20.0
|
10.0
|
0.0
|
100
|
Total
|
13.5
|
62.4
|
12.9
|
9.4
|
1.8
|
100
|
|
|
|
|
|
|
|
|
|
BHU with public safety
|
Five
|
2.4
|
23.8
|
25.0
|
44.1
|
4.8
|
100
|
0.660
|
Six
|
1.8
|
19.6
|
28.6
|
37.5
|
12.5
|
100
|
Seven
|
0.0
|
33.3
|
20.0
|
36.7
|
10.0
|
100
|
Total
|
1.8
|
24.1
|
25.3
|
40.6
|
8.2
|
100
|
|
|
|
|
|
|
|
|
|
BHU with the religious sector
|
Five
|
4.8
|
39.3
|
21,.4
|
29.8
|
4.8
|
100
|
0.495
|
Six
|
7.1
|
48.2
|
19.6
|
17.9
|
7.1
|
100
|
Seven
|
0.0
|
60.0
|
16.7
|
20.0
|
3.3
|
100
|
Total
|
4.7
|
45.9
|
20.0
|
24.1
|
5.3
|
100
|
|
|
|
|
|
|
|
|
|
BHU with NGOs
|
Five
|
9.5
|
38.1
|
23.8
|
27.4
|
1.2
|
100
|
0.080
|
Six
|
3.6
|
48.2
|
14.3
|
25.0
|
8.9
|
100
|
Seven
|
3.3
|
63.3
|
16.7
|
13.3
|
3.3
|
100
|
Total
|
6.5
|
45.9
|
19.4
|
24.1
|
4.1
|
100
|
|
|
|
|
|
|
|
|
|
BHU with the Guardianship Council
|
Five
|
3.6
|
63.1
|
16.7
|
15.5
|
1.2
|
100
|
0.004
|
Six
|
12.5
|
57.1
|
12.5
|
14.3
|
3.6
|
100
|
Seven
|
0.0
|
40.0
|
40.0
|
10.0
|
10.0
|
100
|
Total
|
5.9
|
57.1
|
19.4
|
14.1
|
3.5
|
100
|
|
|
|
|
|
|
|
|
|
BHU with the Human Rights Center
|
Five
|
2.4
|
25.0
|
22.6
|
46.4
|
3.6
|
100
|
0.668
|
Six
|
1.8
|
23.2
|
25.0
|
39.3
|
10.7
|
100
|
Seven
|
0.0
|
13.3
|
26.7
|
53.3
|
6.7
|
100
|
Total
|
1.8
|
22.4
|
24.1
|
45.3
|
6.5
|
100
|
3.2 Phase two: Qualitative
The researcher observed fragile housing, few cars on the streets, many people waiting for public transportation, poor sanitation, tangled wiring; and in the BHU, as a general feature, walls with many posters that draw readers' attention to disease prevention or health promotion.
Ten BHU were invited to participate in the focus groups, four of which accepted. In each BHU, a single focus group was carried out, with an average duration of 50 minutes (maximum of 77 minutes and a minimum of 27 minutes). The four groups were conducted with 04 to 09 participants, of which only two are male, and included in all the following professional categories: eight CHA, five nurses, four nursing technicians, one psychologist, one physical therapist, one doctor, two managers, a pharmacist, and two administrative assistants.
The first one focal group with nine participants, the second one focus group with four participants, the third one focus group with five participants and the fourth focus group with seven participants. We identified an advantage in the difference in the information collected in relation to the number of people in each focus group: the larger focus groups presented a diversity of information while the smaller focus groups generated more detailed information. Participants reported the absence of professionals in group two due to extra activities at the BHU.
The diversity of professionals, the average 4.8 years worked at the BHU, the discussions among participants about the partnerships and the participation in inter-sectoral actions, indicates that the groups were representative and relevant to the research. There were no individual drop-outs or refusals to participate in focus groups or people present who did not participate in inter-sectoral actions. In the fourth group, we detected theoretical saturation because the data obtained started to present repetitions(27).
The themes that emerged from the qualitative data presented in table number 6 related to the characterization of the territory and relationship with the partners of intra-sectoral and inter-sectoral practices in health territories included:
Theme 1: Social Inequalities and the Epidemiological Profile
In this theme, two sub-themes were identified: chronic conditions by life cycle phases and social inequality between micro areas within the same territory.
Chronic conditions by life cycle phases
Participants described their territory at the beginning of the focus group. The context of the territories was characterized by different levels of vulnerability considering the life cycle stages or chronic health conditions. They also indicated that chronic diseases coexist with communicable diseases and violence at different stages of the life cycle.
"My micro area is full of problems (smirked laugh) ... My micro area is the main area core, there is a trap house (in Brazil the common name it is "biqueira", which is a common dialect to express a place where illegal drugs are sold), there are many teenagers, which I grew up with them and who are there today, working in drug trafficking. And also, alcoholism cases are very high in my micro area." (Focal group number 1).
"so there is tuberculosis, syphilis, hepatitis and there is a lot of HIV too. Are common diseases in this area ... And there is a lot of condyloma. And there are a lot of outbreaks too, diarrhea for example because here there is a vast extent of lack of ... sanitation" (Focal group number 1).
"... there are many children and pregnant women in my micro area and nothing more different than that, in the population itself in the area (not just in the micro area), there are many pregnant women, this population, in general, are needier (people very poor)..." (Focal group number 4).
Social inequalities between micro areas
Participants point to demographic and social inequalities between micro areas within the same coverage area. They show that the population suffers from different health problems that go beyond the walls of the health sector. While a micro area has no sanitation and children play in the contaminated stream exposed to epidemic phenomena, the elderly, hypertensive and diabetic are affected by violence in another micro area.
" the higher the status [social class], there are different kinds of illnesses ... those on the top have more serious illnesses than people in the lower social classes. Those who belong to the lower classes usually get diarrhea and vomit, or things like these. And those in the upper social classes are afflicted with diabetes, hypertension. They are more severe diseases not restricted to a specific class [social]” (Focal group number 4).
"... up here [in this micro area] there's a lot of violence: theft, things like that ... it's elderly, it's hypertensive, it's diabetic and most of them have medical insurance". (Focal group number 4).
Theme 2: Building expanded health partnerships: individual and collective
From this theme, two sub-themes were built: intra-sectoral and inter-sectoral arrangements established for people and intra-sectoral and inter-sectoral actions for collectivities.
Intra-sectoral and inter-sectoral arrangements for people
A set of complex problems experienced by a single person can lead to the formation of intra-sectoral and inter-sectoral partnerships in highly vulnerable territories. Intra-sectoral partnerships are built according to individual diagnostic and treatment needs while only inter-sectoral partnerships are those built because of socioeconomic vulnerability. While when professionals seek both intra-sectoral and inter-sectoral partnerships, they are mostly for people with chronicity and surrounded by complex socioeconomic situations, as long as the partnerships are not established and the socio-economic problem is managed. It is not possible to advance effective treatment and maintenance of well-being. To guide this work, the professional teams of some territories elaborate on the Singular Therapeutic Project (STP).
The problem case of Magali, described in focus group number 3, clearly demonstrates this situation, as she is a transgender living with HIV and syphilis, worked as a sex worker and had no documents, which demanded the partnership with a specialized service in STDs/AIDS, as well as the social assistance that guided her in the making of documents, which were even necessary for her to receive antiretroviral treatment. In addition, the partnership with education made it possible for her to return to school and with the Specialized Referral Center for Social Assistance (CREAS), which offered a benefit so she could support herself while studying and looking for another profession because she wanted to stop prostituting herself.
Health professionals reported that they use other sectors, just as other sectors seek the BHU to solve installed problems. The most described intra-sectoral partnerships were with the CAPS and the inter-sectoral one was the school and social assistance equipment: Reference Center for Social Assistance (CRAS) and CREAS.
"Meetings, we perform STP [Singular Therapeutic Project] despite being a strategy, as the Belle's complex cases [CHA] right? that we can't handle. We also use intersectoriality. In STP, not only health that comes in, on the contrary, but we also have three STP proposals ... SUVIS [health surveillance supervision] depending on the case, the COVISA [Health Surveillance Coordination], the CAPS [Psychosocial Care Center], and the social care referral center CRAS [Reference Center for Social Assistance] also are triggered in specific cases" (Focal group number 3).
" So a transgender came here ... we identified her demand, drug user, she was also an escort, she had no fixed income and her income was from prostitution, she came to ask for help, she really came here saying that "I need help, I can't take this life anymore" and facing this situation, we went to work to help her. So she has Sexually Transmitted Infection (STI), both of them: HIV and syphilis, and then we went to work to help her ... she had no one official document so we did a super job to regulate that situation. She could not receive medicine in the public SAE [Specialized Care Service] due to a lack of official documents." (Focal group number 3).
Intra-sectoral and inter-sectoral actions for collectivities
The professionals to constitute partnerships for collectives go beyond the established actions, they too innovate in the search for new care practices in the territory, such as for example the Center for Natural Practices (CPN), Adolescent Living Center and Vale Sonhar Non-Governmental Organizations (NGOs), Afromix and Aclaerzinha offering actions to promote physical and mental health for different life cycles. They do not report intra-sectoral actions exclusive to the community but the combination of intra-sectoral and inter-sectoral actions. What sets action arrangements apart is durability: while arrangements are punctual constructions of partnerships, as in partnerships established to treat a person, as described above, actions endure in search of more lasting results in health promotion.
"...so what we could not solve here internally we asked for support from CRAS, went to CREAS, had a lot of abandonment, patient who really needed a legal endorsement and the offer of CPN which is a Center for Natural Practices which gave us a lot of support ... so out of this need: a huge patient waiting for line over two years old that we looked at had a schizophrenia IDC [International Disease Code], ie a patient with a complicated IDC, two years in the queue often just changing the prescription, what other forms of care we could offer to that patient at that time?". (Focal group number 3).
"And so does the Vale Dreaming project. At João Silva School also where the nursing assistant always goes to develop the actions, trained by the nurse and we also have the PSE and that is the health program at school, where I also take a period every month to be going there developing actions with him ... The PSE is something more organized where there is whole planning we sit and talk. Sometimes there is the theme that they want or we change that theme that we would have organized at that time and the CCA [Adolescent Living Center] is the same thing with me, APA, which is an Environmental Promotion Agent, an CHA and nursing assistant always be with me developing these actions" (Focal group number 4).
"...now we have a partnership with Afromix people who are also helping there on the walk they will even cover the court there, do you know?" (Focal group number 4).
Students and older people benefit most from partnerships that are often inter-sectoral. Intra-sectoral and inter-sectoral partnerships are aimed at groups of people in psychotic distress or family members of drug users with the largest partners being CAPS, CRAS and CREAS. In addition, the children and youth groups are covered by the Brazilian Program Health in School (PHS) and receive actions to promote oral health and prevention of immuno-preventable diseases.
"It is also the group that is a partnership with education, which is with oral health that leads to health in education that is the PSE. That enters both the medical part, as the nursing part and also the dental part. In the dental part, there is a new program we go to school to do the dental treatment of children called ART [Atraumatic Restoration]" (Focal group number 2).
"We have a lot of support from them [school] so, whenever they have a problem they come to us, we also delivery some demands to them" (Focal group number 1).
"The schools have already contacted us to do a search to see and such. It is with a kind of alteration at the level of abuse" (Focal group number 1).
"...all CAPS, three CAPS in total, have school participation sometimes, what else do you have? There are CREAS, there is the TJ [Court of Justice] depending on which case you are discussing and depending on the situation..." (Focal group number 2).