ARTÍCULO ORIGINAL / ORIGINAL ARTICLE / ARTIGO ORIGINAL

DOI: 10.17533/udea.iee.v33n2a10

The school health program: teachers' perceptions

El programa de salud escolar: las percepciones de los maestros

Programa de Saúde na Escola: percepções dos professores

Cícero Tavares Leite¹; Maria de Fátima Antero Sousa Machado²; Roberta Peixoto Vieira³; Mirna Neyara Alexandre de Sá Barreto Marinho⁴; Claudete Ferreira de Souza Monteiro⁵

¹RN. Coordinator of the Psycosocial Care Center (CAPS I) in Missão Velha-CE, Brazil. email: ctavaresleite@bol.com.br.

²RN, Ph.D. Professor, Universidade Regional do Cariri, Ceará, Brazil. email: fatimaantero@uol.com.br.

³RN, Specialist. Professor, Universidade Regional do Cariri - Iguatu Decentralized Unit and Faculdade Vale do Salgado, Ceará, Brazil. email: roberta.peixotovieira@gmail.com.

⁴RN, Master. Regional Nursing Council of Ceará and Regional Hemocentro of Crato-CE, Brazil.email: mirna.neyara@bol.com.br.

⁵RN, Ph.D. Professor, Universidade Federal do Piauí. Scholarship Productivity CNPQ. Teresina, Piauí, Brazil.email: claudetefmonteiro@hotmail.com.

Receipt date: February 11, 2015. Approval date: April 15, 2015.

Article linked to research: "Educação em Saúde: Percepção de docentes em relação às ações no Programa Saúde na Escola (PSE)".

Subventions: Programa de Iniciação Científica PIBIC/CNPq da Universidade Regional do Cariri- URCA.

Conflicts of interest: none.

How to cite this article: Leite CT, Machado MFAS, Vieira RP, Marinho MNASB, Monteiro CFS. The school health program: teachers' perceptions.Invest Educ Enferm. 2015; 33(2): 280-287.

DOI: 10.17533/udea.iee.v33n2a10

ABSTRACT

Key words: adolescent; faculty; health education; public health.

RESUMEN

Objetivo. Comprender la percepción que profesores tienen de un programa de salud escolar y su relación con las acciones de educación en salud desarrolladas en la escuela. Metodología. Estudio descriptivo con abordaje cualitativo en el que se hicieron entrevistas a 10 profesores de una escuela pública de la ciudad de Barbalha/Ceará, Brasil. Los datos fueron analizados en categorías temáticas. Resultados. Los profesores percibieron el Programa de Salud en la Escuela como asistencialista, sin integración entre los profesores y los profesionales de la salud y que no era de interés para los adolescentes. Las acciones educativas en la escuela y su relación con este programa fueron percibidas como evaluaciones clínicas que no se integraron a las acciones ya desarrolladas en la escuela. Conclusión. Se encontró una debilidad en la falta de integración de las acciones realizadas por los diferentes actores, por lo que hay necesidad de una mayor relación entre los mismos con el fin de optimizar esfuerzos en la promoción de la salud escolar.

Palabras clave: adolescente; docentes; educación en salud; salud pública.

RESUMO

Objetivo. Compreender a percepção que professores têm de um programa de saúde escolar e sua relação com as ações de educação em saúde desenvolvidas na escola. Metodologia. Estudo descritivo com abordagem qualitativa no que se fizeram entrevistas a 10 professores de uma escola pública da cidade de Barbalha/Ceará, Brasil. Os dados foram analisados em categorias temáticas. Resultados. Os professores perceberam o Programa de Saúde na Escola como assistencialista, sem integração entre os professores e os profissionais da saúde e que não era de interesse para os adolescentes. As ações educativas na escola e sua relação com este programa foram percebidas como avaliações clínicas que não se integraram às ações já desenvolvidas na escola. Conclusão. Encontrou-se uma debilidade na falta de integração das ações realizadas pelos diferentes atores, pelo que há necessidade de uma maior relação entre os mesmos com o fim de otimizar esforços na promoção da saúde escolar.

Palavras chave: adolescente; docentes; educação em saúde; saúde pública.

INTRODUCTION

Adolescence is a period of transition between childhood and adulthood, marked by changes in the body, feelings, and relationships with others. Therefore, young people deserve care that includes monitoring these bio-psychosocial changes, which requires interdisciplinary actions to meet their needs regardless of life situation, through education, health, and efficient public policies. In the Brazilian scenario, a source of concern is the social condition of a significant number of families residing in harsh environments, where education and health are still hindered. Basic sanitation is poor or non-existent, and the access to basic needs such as food is compromised by unemployment.¹ Besides the adverse influences of an unfavorable social environment, many teenagers lack emotional support in the family, which fosters further vulnerability and leads to outcomes such as deaths from external causes, unplanned pregnancy, abortion, sexually transmitted diseases, and involvement in drug trafficking and consumption.² Vulnerability is understood as an individual and social condition of a person, which along with conditioning situations result in illness or undesirable social behavior. This condition should be recognized by the state in its role as provider of the means for the individuals, as holders of rights, to take ownership of the "tools" that allow them to recognize the risk situations that may affect them individually, in their family, and in their surroundings.^3,4

It is therefore important to develop health education actions directed to adolescents, given that this audience represents a significant portion of the population. In this sense, public health policies aimed at teenagers have resulted in an important step in the development of strategies for health promotion. However, due to fragmentation among different sectors, including health and education, these policies have had a strong connotation of welfare or assistentialism.⁵ This weakness can be overcome through the implementation of the federal government's Family Health Strategy (FHS), which though primarily aimed at family care, should also have a more particular focus on adolescent health, by not only making them feel welcome in health facilities, but also by entering the school environment and conducting health-promoting actions.⁶ This opportunity was expanded with the creation of the School Health Program (SHP), established by Presidential Decree No. 6286 of 05 December 2007, whose actions are structured into three components: clinical and psychosocial evaluation; promotion and prevention of health; and training of managers, health and education professionals, and young people. ⁷

The School Health Program has helped to establish a link between professionals within the Family Health Strategy Program and teachers, who must be involved in work with teenagers given that the health education process requires an exchange of experiences and knowledge that must be shared among all the actors mentioned, including the family.⁸ The school is now included as an important locus for the development of educational strategies in health in order to develop adolescents' autonomy, so that they can have greater control of their health and act as a multiplier of actions in the community in which they live.

However, the effectiveness of the SHP will be higher or lower depending upon how the professionals involved perceive it; this perception allows one to organize and interpret the sensory stimuli that result in meaning.⁹ The objective of this research is to understand the teachers' perception of the Family Health Strategy Program and its interface with health education activities already developed at school. We expect to contribute to the strengthening of educational activities on health, raising awareness among professionals of the Family Health Strategy Program and among teachers of the importance of applying health education at school, in order to optimize the sharing of experiences for the main protagonist of the school environment — the adolescent.

METHODOLOGY

This is a descriptive qualitative study, carried out in a public high school of the State Education Network in the city of Barbalha, Ceará, Brazil. The participants were 10 teachers, included according to the criterion of having at least one semester of teaching practice at the school. This criterion was set to ensure the familiarity of the participants with the activities developed by the School Health Program. The instrument for data collection consisted of a semi-structured interview, containing data on the characterization of the participants regarding gender, age, and length of academic training, as well as perception of this Program, the actions developed under the Program, and those already developed at school. After the participants signed the informed consent form for their inclusion as participants in the study, the data collection occurred between February and March 2013. The interviews were recorded and transcribed by the researchers. To organize the data we employed content analysis, which permits inferences about the meanings present between the lines of discourse, seeking to make sense of loose fragments that need to be grouped into a context to convey a message.¹⁰ The material was organized in thematic categories and discussed in the light of the theoretical framework of the study. To preserve the anonymity of the participants, the statements were coded from P1 to P10. The study was approved by the Research Ethics Committee of the Regional University of Cariri, Protocol 98/2011.

RESULTS

Characterization of participants

Participants were five male and five female teachers, aged 25-42 years old. Teachers reported having had an academic training period of three to 16 years. The data characterizing the participants demonstrate that they are young adults, with limited academic background, which can be a driving factor for the development of the actions of the School Health Program.

The teachers' perception of the School Health Program

The most significant perception of teachers about the School Health program concerned partnerships, visibility of the district's schools for the health sector, and integration of public policies aimed at promoting adolescents' health: It is a program conducted through a partnership between the Family Strategy Program and the schools present in the neighborhood it covers, bringing health care to the school (P1); It is a program of integration of health policies added to education, aiming at the health of the student (P4). However, this perception was not unanimous. One of the respondents still perceives the program as a sanitarian model, focused only on diseases and/or disease control: What I know is that the staff of the municipal public health go to schools to prevent diseases in the adolescents (P2).

This form of perception of actions aimed at disease prevention and/or control over them is rooted in how we view and conduct actions in the health-disease process as something curative. Other respondents refer to the manner in which the Family Health Strategy team was inserted at the school, mentioning the absence, on the part of the health professionals, of a survey on the situational diagnosis of the adolescents' needs through asking the teachers about any difficulty or facility they encounter daily while addressing health issues in the classroom: Sometimes students do not want to participate because they do not really know what the program is about, its goals (P9); I think that to educate students one needs to know what they are doing, because the Family Strategy Program professionals arrived here abruptly, and if anyone knew they were coming that would be the director at the time; we, teachers, did not know (P10).

These statements show that an assignment was executed at the school without there having been a prior consultation about the basic issues that could compromise a student's academic performance or pose risks to health. Obviously, professionals must follow what is stipulated for each Program component. However, this does not mean that a meeting cannot be held in the school environment between health professionals and teachers to strengthen relations and discuss the actual situation, in which actions fostering the adolescents' health empowerment will be emphasized. Mismatches are noted in the interface between health and education actions in the school studied, demonstrating a weakness among the organizers of the proposal, leading to a certain complacency on the part of teachers in expecting that the initiative in implementing the actions lies with the Family Health Program, with no need for initiatives or continuity on the part of school.

Educational activities promoting health at school and their interface with the School Health Program

As perceived by respondents, the actions of the SHP underwent a clinical evaluation in accordance with the first main theme of the Program: They came to do dental evaluation and to weigh. There was a psychologist talking to students (P2); They come to measure Blood Pressure, perform eye exams, primary care, and then they can provide appropriate referral when necessary (P4).

A clinical evaluation consists of a survey of the immediate health needs that could compromise the health of adolescents and thus hinder the learning process. The school studied was already developing health projects which were perceived by participants as possibilities for working together with the Program: We have a project here at the school focused on STIs, developed by the biology teacher. It is not inserted into the Program, and yet it is, as there is an activity of the Program that addresses drugs, alcohol, and tobacco and together they complement each other (P6); We had an activity at the school in partnership with the nutritionist and the physical education teacher, where they developed some work focused on healthy eating and physical exercise in parallel with the activities of Program (P8).

The statements show that participants expect to incorporate the actions which are already being taken at the school with those of the SHP, and use the presence of added health professionals to address issues that often go beyond teachers' skills to approach them clearly. One respondent expressed concern about the provision of information and acquisition of new life habits by adolescents, which although fostered in various media, seems to remain ineffective: Another thing that puzzles me is that despite the great access to information in the media, major campaigns for condoms, we have five pregnant students in school at the age of fourteen years old. So we live a paradox, that is, we have a lot of information, but it is not being used properly (P3).

This remark highlights the existence of information about contraceptive methods in different media; however, to the extent this information does not reflect reality, it is the task of the FHS, the school, and the family to adapt it and promote prevention under the learning perspective of the adolescents and of health promotion.

DISCUSSION

Within the context of health promotion, the SHP can be understood as a potential opportunity to meet the needs of the adolescent audience in schools in the fields of health and education. The accomplishment of this program is a differential with respect to the scope of a collective action, favoring the maintenance of a dialogue with the school community and the SHP.⁶ Intersectoriality, understood as significant in the results of this study, creates a possibility of a permanent liaison between health and education in Brazilian municipalities, with the school being the scene of the work process focused on health education, in which FHS teams and teachers can maintain a constant interchange to meet the needs expressed by adolescents in their different forms and in line with the social environment where the school is located. Thus, the role of SHP is to direct its scope of work to the individual and family in the community setting, focus its actions by understanding the evidenced needs, promoting the strengthening of lasting links with its customers, and allocating attention also to the teenage audience within the school setting.¹¹

Assuming that the FSH performs a situational analysis of the community in which it operates and that the continuity of its actions ensures the formation and maintenance of links with the population, a dynamic study can be focused on the needs of its customers, essential for monitoring a teenage audience. To this end, Decree No. 6286 of December 5, 2007 proposes that SHP conduct periodic visits to schools throughout the school year in order to assess the health status of students and articulate disease prevention and health promotion actions in line with the schools' Political Pedagogical Project (PPP).(11) The Ministries of Health and Education established the following three thematic actions to support the implementation of the work of the actors involved, FSH and school (managerial and teaching staff): I- clinical and psychosocial assessment; II- health promotion and disease prevention; and III- training. ⁷

The SHP's actions should be contemplated in accordance with the characteristics of adolescent students, so that some of these are considered priorities by the Ministry of Health: (i) Diagnosis of the general state of all those enrolled in schools regarding: nutrition, obesity, postural, visual and auditory evaluation, anemia, helminths; (ii) Health education: use of an interdisciplinary work addressing various topics such as healthy eating, actions against violence, hygiene, safety, family planning, first aid, among others; (iii) Prevention of risk factors: monitor the vaccination status of school adolescents; advise on accidents, early pregnancy, means of contraception and STIs; strengthen the factors promoting protection and a healthy environment; Interaction with the community to promote social participation: engagement of families in the educational activities of identification and care for health and the environment, and their propagation to community organizations.¹²

Thus, the actions for the development of disease prevention and health promotion for adolescents within the SHP are contracted through an agreement signed by the municipalities in which the municipal health and education agencies commit to offering support to the professionals for continued training of the actors, and technical support for the actions to be developed. However, it was noted that the teachers participating in this study do not yet understand the School Health Program as a policy for the health of adolescents with well-defined objectives and actions.

The results presented in this study also draw attention to some teachers' statements showing a lack of co-ordination between them and health professionals in surveying and assessing needs, as well as the difficulty of approaching health actions with teenagers. They note the lack of co-ordination to enhance activities already underway, and the absence of more precise information about the program being provided to the adolescents, which can contribute to students' disinterest in participating and a gap in what should actually be an intersectorial policy. Contrary to these reports, the literature contains results of a study by FHS professionals in a public school, showing that before carrying out the activities planned for the SHP, the health team held a meeting with a group of teachers and students, which served as a welcome, a presentation of the operation, a familiarization with the target audience, and an opportunity to probe the opinions of the adolescents to develop the actions that would subsequently make up the other two thematic components of the action.¹³

The position of the Ministries of Health and Education is that SHP actions be carried out in line with the educational activities of the school; it is essential that the actors maintain previous contact, and that actions be in accordance with the schools' Pedagogical Political Project implemented throughout the school year. The actions are preset, but it is the purview of the professionals who will perform them to maintain an interdisciplinary approach.

Since actions are shared between health and education professionals, in the context studied each school had developed projects for the prevention of STIs before the municipality joined the SHP. However, the respondents were emphatic in stating that the practice of approaching these diseases with adolescents was limited to prevention of HIV/AIDS and teenage pregnancy, and were restricted to professionals trained in the biological sciences, with no interdisciplinarity in addressing these themes.

It is necessary that other teachers be sensitive in the treatment of sex education for adolescents in their classes, and not just expect that it will be addressed by teachers of biological sciences. Thus, health professionals at schools can contribute by developing health education actions, taking into account what already exists but adapting other methodologies to streamline and facilitate learning. Still, when it comes to adolescents' health actions there exists a misconception that these should be linked only to HIV/AIDS and teenage pregnancy prevention, distancing themselves from a comprehensive health education focused on discussing these issues with adolescents, showing them, for instance, the implications of a pregnancy at that stage, from the physiological to the social aspects.¹⁴ Thus, the concept of disease prevention should be combined with that of health promotion as something continuous, starting from a reflective construction of the subjects, which must be awakened through learning and not by imposition. Through this understanding, the Ministry of Health has released a manual designed for teachers and health team professionals, which aims to help these professionals in addressing gender and sexuality issues and with suggestions for workshops to be run with adolescents.⁷

It is noteworthy here that one of the strategies launched for the development of the SHP actions aims at identifying adolescents with advanced communication skills and preparing them to operate among their peers, in order to advance disease prevention and health promotion. The active participation of this group enhances the effectiveness of health education actions by perceiving the needs highlighted by the subjects of the process themselves. From the perspective of pro-activity, teenager participation as "social entrepreneurs" engages collective interests and entails perspectives that converge for driving behavior changes.^15,16 The integration of health and education, with a view to promoting adolescent health, may be extended to other sectors, covering issues involving the autonomy of individuals and the community, providing opportunities for the participation of these critical actors in decisions involving their life. ¹⁶ Thus, it is beneficial to organize moments that allow the group to align with the program's actions, so that the subjects can express what they think and consequently contribute to the progress of actions with the FHS, to bring together stakeholders in the SHP and strengthen the educational activities on adolescent health, which can be a driving factor for understanding the adolescents themselves.

The FHS teams should perform the role of agents of adolescent health promotion activities in their own territory, actively working in the lifelong learning processes of teachers, staff, parents, and adolescent students. Similarly, education professionals can support these teams in the use and incorporation of pedagogical and educational tools in approaching health education.¹⁷ It is understood that not only teachers and students, but also health professionals must undergo an adaptation process in order for health and education to work in unison. It is believed that the practices for the effectiveness of health education activities aimed at teenage audiences are fundamental to the process that leads to changes in behavior and consequently to health promotion. Therefore, it is expected that there be a closer relationship among the actors involved in SHP actions to meet the needs expressed by adolescents.

Final considerations. The prospect of developing educational activities for adolescents has been a challenge undertaken by the FHS in its scope of work, expanding in Brazilian municipalities with the creation of the SHP, with schools and teachers as partners for the consolidation of actions aimed at minimizing the situations of vulnerability to which teens may be exposed. The study showed advances with regard to the perception of teachers in relation to conducting program actions when reporting health promotion for adolescents as something that should be effected among the actors involved; and setbacks when they considered the program assistentialist, focused only on the biological needs of the school students, and assigning responsibilities for the implementation of actions solely to the FHS. Other shortcomings were a reported lack of integration between teachers and health professionals in initiating action, and the lack of interest of teenagers due to supposedly not knowing the program and its objectives.

One of the limiting factors in conducting the present study was that the SHP had been implemented for just over a year in the municipality in question, which implies an ongoing process of structuring and aligning the health and education aspects, and another was that the research was conducted in only one school. The lack of literature focused on the SHP from the perspective of the actors involved, to allow a comparison between the studied scenario and other realities in Brazilian municipalities, is restrictive. Thus, considering the short time of the program implementation and the accession of the municipalities, the sectors involved may require some time to integrate their activities, insofar as they have historically developed their actions in isolation. The SHP proposal demands synergy to meet the expressed needs in all their various nuances.

We hope to contribute to the enrichment of scientific knowledge, providing other experiences to the actors responsible for developing educational activities for health under this program, and representing how it is structured in the studied scenario. Thus, it is believed that this field presents as "fertile" for the development of other studies

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