A Atuação dos Profissionais da Atenção Primária Acerca das Práticas de Promoção e dos Determinantes Sociais da Saúde Practices of Primary Care Professionals Concerning Health Promotion and Social Determinants

Pesquisa qualitativa, exploratório-descritiva que objetiva desvelar a atuação dos profissionais da Atenção Primáriaà Saúde acerca dos Determinantes Sociais de Saúde das práticas de promoção da saúde. A coleta de dados foirealizada de julho a outubro de 2015, com entrevistas semiestruturadas. Participaram 25 profissionais queatuavam na rede de Atenção Primária em Saúde do Município de Florianópolis, SC. Os dados foram analisados apartir da análise temática de Minayo e discutidos à luz da Promoção da Saúde e dos Determinantes Sociais. Osresultados indicaram que, tanto a academia quanto os gestores estão investindo na formação para a promoçãoda saúde, porém, ainda muito focada nos estilos de vida e pouco articulada com os Determinantes Sociais deSaúde. Os profissionais relataram atuar muito pouco sobre os dados determinantes e alguns não sabem o conceitode Determinação Social da Saúde. Observa-se que há carência de métodos que auxiliem a avaliação e efetividadeda atuação sobre a promoção da saúde, porém, os profissionais já conseguem visualizar mudanças positivas nasaúde da população. Conclui-se que os trabalhadores da Atenção Primária à Saúde têm consciência da necessidadede realizar e manter as práticas de promoção em sua rotina diária, a partir da interdisciplinaridade eintersetorialidade, considerando os Determinantes Sociais de Saúde da população.Palavras-chave: Promoção da Saúde; Determinantes Sociais da Saúde; Atenção Primária à Saúde; Estratégia Saúdeda Família.AbstractExploratory-descriptive qualitative research, which aims to reveal the performance of Primary Health Careprofessionals about the Social Determinants of Health promotion practices. Data collection was carried out fromJuly to October 2015, with semi-structured interviews. Participated 25 professionals who acted on the network ofPrimary Health Care in the city of Florianópolis, SC. Data were analyzed from the thematic analysis of Minayo anddiscussed in the light of the health promotion and social determinants. The results indicated that both theAcademy and managers, are investing in training for the health promotion, however, still very focused on lifestylesand little coordinated with the Social Determinants of Health. The professionals have reported too little acting ondeterminants data and some do not know the Social Determination of Health concept. It is observed that there isa lack of methods to aid the evaluation and effectiveness of action on health promotion, however, professionalscan show positive changes in the population’s health. It is concluded that the Primary Health Care workers areaware of the need to achieve and maintain promotional practices in your daily routine, from the interdisciplinaryand intersectoral approach, considering the Social Determinants of Health of the population.Keywords: Health Promotion; Social Determinants of Health; Primary Health Care; Family Health Strategy


Introduction
Health promotion, as conceptualized in the Ottawa Letter for health promotion (1986), extends the vision of health for a universal welfare, blaming all health sectors for the quality of life of the population, going beyond the health sector and healthy lifestyle. It is necessary that the professionals appreciate the community engagement, promote empowerment, social cohesion, solidarity, and allow the reduction of social inequalities (1) .
In this context, the concept of Social Determinants of Health (SDH) arose in the 70, and was defined as the social conditions in which people live and work, and that point both to the specific features of the social context and the way social conditions reflect the possible impacts on health (2) .
From these ideals, the World Health Organization (WHO) and the National Commission on the Social Determinants of Health (NCSDH) outlined three levels of social determinants that interact and modify the equity in health and well-being of the population, which are: structural factors (social, labor, tax, environmental policies, social norms and values); the social position and the determinants of stratification (social class, gender, race, education, occupation and income); and intermediate determinants (material conditions, behaviors and biological factors; psychosocial factors and health system). It is believed that in order to improve the health outcomes, it is necessary to understand all these factors that lead to poor health and intervene effectively on them (3) .
In Brazil, from who guidance, established the NCSDH under the Ministry of Health (MH). In April 2008, it launched the your final report titled "The social causes of health inequities in Brazil", which was among the main recommendations the creation of a Board of Social Policies in the Civil Cabinet of the Presidency of the Republic to carry out intersectoral coordination at the federal level of public policies that have acknowledged influences on health, and an Executive Office -in the form of the National Secretariat of Health promotion and primary health care, giving due priority to this field (4) .
The SDH are based on a strong epidemiological justification, focused on understanding the impact of inequality on health and social welfare and centered on the role of the policy of reducing inequality, distancing himself from the traditional discourse of health promotion based on the individual (5) .
In this sense, aiming to deploy health care models that favour, at the same time, fairness, completeness, social participation, intersectoral approach and orientation of the health needs of the people, was instituted in Brazil the Family Health Strategy (FHS) to provide accessibility to health and formulate actions directed to the collective, consolidating itself as a main strategy and priority in the reorganization of Primary Health Care (PHC) which to this day is in constant process of improvement according to the needs and profile of each area where it is inserted (5) .
To activeness in PHC on social determinants as a way to promote the health of the population, It is necessary that the professionals implementing biological concepts and take ownership of health concepts which meet the policy guidelines, the anthropological constructs, the social demands and the historical building, and are aware that health is a right public, and is hostage to SDH crosscutting for macro and micro contexts (6) .
Based on what has been exposed, this study had as its guiding question: what is the perception of Primary Health Care professionals about the social determinants linked to the promotion of the population's health?
Thus, we aimed to unveil the performance of Primary Health Care professionals about health promotion practices linked to the Social Determinants of Health.

Method
The present study has a qualitative approach, in the form of a descriptive exploratory research, which intends to make the point explicit problem, aiming at the discovery of intuitions or the improvement of ideas, as well as describe particular aspect of a population or phenomenon (7) .
This research was held in Florianópolis (SC), in 2015, on behalf of a Masters research with the participation of co-authors, and occurred in five Health Units (HU). Among the units of the Sanitary Districts were selected those which had the largest number of Family Health teams and expertise Expanded Family Health Center (EFHC). In order to contemplate the greatest number of professions in PHC, was drawn an EFHC team to join the search.
Data collection took place between July to October 2015, from semi-structured interviews with the professionals from the HU, with questions, guides related to the type of training received to perform the activities; the practices that are developed and your frequency; methodological strategies used; to the facilities, difficulties and relevant results to the PS; and acting on the SDH. The interviews had approximately 1 hour, being held in Florianópolis, by one of the authors.
Were interviewed 25 top-level professionals of the FHS and the EFHC, five doctors of family health, a pediatrician, five nurses, five dentists, a dietician, a pharmacist, a physical therapist, a social worker and five managers. Excluding those who were on vacation and the technical level and community agents do not meet the criterion of having a Bachelor's degree, but no less important in the development of PS. All interviews were carried out in offices of the HU, in private and quiet environment, with date and time.
For data analysis, thematic analysis of Minayo was used (8) , it unfolds in three moments: pre-analysis, material exploration and processing of results obtained with your interpretation. The theoretical framework that guided the analysis of the data was that of PS and SDH (2)(3)(4)(5) . The pre-analysis consisted of faithful transcription taped interviews, readings of the material and organization of data. The transcripts were stored in a file folder of the virtual storage service. These documents include the lines of the subjects interviewed, the notes of the interviewers, interview, time and place.
In this first movement, aimed to establish the first classification of data. The information was organized based on the goals that guided the research, seeking to establish a first approximation with the meanings revealed in the lines of the subject.
After exhaustive reading material transcribed the interviews, captured the central ideas of the subject in question. The central themes were formed based on the primary sense of the questions asked by researchers, for a total of three types: training for performance on health promotion practices, acting on the SDH and evaluation of health promotion practices, seeking to understand the theoretical guidance to the target.
With the definition of the themes, to the third step, processing of the results, in which a code of letters and numbers representing the initials of the unit and the code name chosen by the respondent in each interview, being copied and glued the keynote speech in four worksheets on virtual storage service. Related to interviews with each central theme, confronted the different lines and built the final analysis of the data.

Results and Discussion
The following will be exposed the search result by themes that emerged from the own questions to higher education professionals who work daily with SDH related aspects and health promotion. Three themes emerged: Professional qualification for action in the promotion of health, Acting on the SDH and Health promotion practices evaluation.
Professional qualification for action in the promotion of health In relation to professional qualification, respondents stated that during Under Graduation had some specific discipline of Health Promotion. Even one of them stated that prior to joining the Health Area studied Pedagogy, in which your first contact with the disciplines on health promotion.
The findings of the survey indicate a change in the Undergraduate curriculum, which has emphasized professional training to attend to the real demands of PHC from a broader vision that goes beyond the biomedical model, covering the health promotion actions and considering social determinants of the communities (9) .
After Graduation, professionals have stated they have done a multidisciplinary lato sensu mode Specialization in Family Health and the lato sensu in Public Health, with specific training to perform the practices of health promotion. Among the specializations in the broad sense, the multiprofessional residence in Family Health and residence in Family and Community Medicine were cited by professionals like courses that focus on the promotion of the health of the population. The lato sensu specialization courses, related to PHC, suggests that professionals are qualified to meet the increasingly complex needs of users, as seen in other studies (9)(10) . In Brazil, creating the National Policy of Health Promotion (NPHP) and the National Policy of Permanent Education in Health (NPPEH) enabled the training of human resources in health, through partnerships between the MH and educational and research institutions (10), and contributed to ensure the work environment of knowledge and the need for specific training for health promotion.
The reorientation of the formation constitutes the premise to the strengthening of the health system. The training of future professionals is seen as a challenge to the national health policy in Brazil due to your complexity in promoting a humanistic, critical-social qualification and generalist that lever changes in the process of work, or provide trainings provided by service itself or as the experiences from postgraduate courses in Health Promotion, Public Health or Collective Health, with emphasis on PHC (10) .
In relation to courses and workshops, the professionals claimed to have conducted workshops geared toward health promotion practices, offered by the City Department of Health and carried out trainings and conferences covering the topic of Health Promotion focus on the family health care and sports practices.
Only one respondent stated that he never had any training for acting on health promotion practices.
It is essential to investment in continuing education of professionals, investing in integrated learning to work for the learning and teaching if incorporating the daily lives of organizations, and it is proposed that the training of the employees of the processes health take as a reference the health needs of the people and of the people and have as objective the transformation of professional practices and the organization of work, which should be structured from the questioning process (11) .
It is noted that the professional training of health workers have moved to the practices of promotion, but were not mentioned possible connections between training for health promotion and the social determination. The focus of training for health promotion presents itself still very individualistic and biologicist.
So there is this linkage between health promotion practices and expertise on social determinants, it is necessary to produce management technologies covering the complexity of actions directed to the broad determination of health/disease process and FHS building strategies, from the merger of Permanent Education Policy in the municipalities. Since the poles of the primary care training are contained in instruments of overcoming the barriers that the FHS is to qualify the work toward expanded health (4) .

Acting on the SDH
With regard to SDH, the professionals said that act from intersectoral partnerships with services that directly influence the quality of life of the population as the school, child protective services, the garbage collection of the municipality, nursing homes elderly and non-governmental organizations. These partnerships are aimed at the reduction of people at risk and vulnerability in communities. Social conditions always influenced the health, so you need to schedule actions in all sectors to promote the well-being of society, for the sustainability of the work with the SDH in the framework of the PHC passes obligatorily through solid partnership with other sectors of the community (4)(5) .
Another way to act on the reported social determination of health was to guarantee access to health services. These actions include the home visits to users with difficulty of locomotion, or unable to attend to the unit, the active search of users at risk or vulnerability, attendance to patients individually and considering your personal needs.
Ensuring access requires the removal of physical, financial and social obstacles to the use of health services available, being the period in which the provision of care if it makes more beneficial and necessary. Accessibility becomes sight in addition to the availability of resources in health services and includes features that make it easy and clear the use by potential customers (12) .
In this context, respondents stated that constantly reorganize your work process in order to be able to meet the social demands of community health. Perform territorialization and from the study of the territory draw up the action planning in health, create a map of the region and support networks regularly monitor community health indicators as: chronically ill, pregnant women, children, people with communicable diseases and mental disorders. They cited too, the partnership with the local Health Council as a tool to link with the community and interdisciplinary with the EFHC.
"Studying the territory and make plans based on the needs of the territory, for example the issue of teen pregnancy, looking for work in schools in relation to this issue, as contraception. We seek to identify in the territory the aggravations, these social determinants in order to act before them" [PED].
It is observed that when health teams are willing to perform the analysis of health situation of the population, planning and organization of the service in the PHC, in addition to the epidemiological criteria using a participatory mapping in health, this contributes to the reorganization of the health service. From this, it is possible to ensure access, reception and identification of health problems, facilitating the interdisciplinary and the perception of the living dynamics of economic relations with the production and in the territories and your health interface with the health/disease process (13) .
Strengthening social control was cited as ways of empowering the population to which they seek the necessary paths to work on your own quality of life. The professionals act on social control by encouraging users to train, study, get their social and labor rights and mediating family conflicts.
The performance in the FHS promotes the understanding of reality in the territory and helps people to organize to modify it, developing more political attitudes in communities extending the exercise of autonomy and social control. In keeping with these ideals, public policies in force, proposing social participation as a guideline in the educational activities and mission support for the development of practices that strengthen the creation of those (14) .
However, the pros say they encounter many obstacles in relation to performance on the SDH. Highlight that have great difficulty in an intersectoral acting, some local health councils are unstructured and with a small portion of the population working and, often, are in pursuit of their personal interests. In addition, the lack of community health agents and the excessive demand for individual queries are presented as a challenge in action on the social determinants of community. From the lines of the respondents note that the pros have failed to incorporate a larger view of your entire health covering social issues in the community. This fragility can be as part of the primary care growth paradox and the limited vision of management that serves as the basis for your restructuring. The strategies of strengthening the management and training of the PHC are contained in instruments of overcoming the barriers that the FHS is to qualify the work toward expanded health (3) .
When there are community health agents and the EFHC team acting in unity, respondents stated that the multidisciplinary work with these professionals is a facilitator for the action on the social determinants of health.
Some professionals have questioned during the interview the SDH concept and one said no act on the social determination of health of the population.
Must make it clear that the concept of a primary care attributes expanded, integrating health promotion actions and management of health conditions and disease, which consider the singularities and vulnerability of the subjects, assumes a concern with the SDH. So, there is a need for the expansion of care strategies involving the population and other sectors since social and health issues are deeply intertwined and health promotion has been considered an important response to these challenges, the extent recovering health as socially constructed understood in an institutional and strategic approach which considers the contexts where the social actors are inserted (15) .

Health promotion practices evaluation
With regard to the results of health promotion practices generate in the community, all professionals were emphatic when reporting that there is a systematic way of evaluating these practices. The form of assessment of these results is subjective and individualized, often based only because of the users and the monitoring of vital signs. A systematic review of health promotion practices is useful tool for the enhancement and improvement of primary care in the country and to promote the necessary debate on the change of the current healthcare model. This question points to the fact that the information that teams develop a health promotion practice does not translate the quality of what is being offered or proposed, greatly limiting your efficacy assessment (16) .
However, respondents stated that, when carrying out health promotion practices, act in such a way and can go beyond the biomedical model employed in most sessions of the PHC. What shows that health promotion practices carried out by interdisciplinary actions reflect a positive impact on the health needs of the population, exceeding the simplified view of health promotion and breaking the hegemony of the biomedical model (17) .
In the perception of respondents, health promotion practices carried out result in decreased demand due to illness, increase the number of users in health monitoring and, consequently, these are more care by health and strengthen the links between them. And with this, decreases the number of teenage pregnancy, the incidence of sexually transmitted diseases and the health complications for chronic diseases.
Others noted that after performing the practices of promoting users to reflect on the concept of health. From this, understand your health status and disease, there is a tendency to change unhealthy lifestyles with less exposure to risk factors, and be more empowered to self-care. They believe that this makes users happier, improve self-esteem and quality of life of the population. It is evidenced that the professional that has a larger view of health promotion, worrying about the empowerment of the population, significantly influence your practice, because your performance directs to develop an enhanced vision context socioeconomic and cultural communities in which it operates. In this way, the question of health and your intimate connection to the social and cultural determinants, especially when you think of ethnic minority populations (6) .

Conclusion
With this study it was possible to notice that the PHC workers are aware of the need to achieve and maintain health promotion practices in your daily routine, from the interdisciplinary and intersectoral approach, considering the sdh population.
Regarding to the achievement's education of these practices, it is observed that the courses of the health area are integrating to your curriculum courses geared specifically to this theme, broadening the focus that the academies had biologicist until a short time ago. Note also an effort of the State in promoting additional training to primary care professionals from lato sensu courses free of charge for the performance in the FHS.
Residency programs in Family Health have demonstrated potential to strengthen interdisciplinary and intersectoral on primary health care, being essential for the effectiveness of health promotion practices and incorporation of SDH.
In acting on the SDH understood that, despite being a growing theme and of great importance to primary health care, the professionals still encounter some difficulties to work on the subject, because they are still very focused on individual and present difficulties to intersectoral work.
Note that it is necessary that the pros exceed the activism only to the transformation of the behaviors of individuals, with the focus on guidance related to changes in habits and understand health as a result of factors and cultural, social and economical determinants that relate to the quality of life and which is influenced by SDH.
Health promotion practices should be directed to the community, whereas the individual decisions, shall be determined from the social context that individuals are entered.
For this reason, it is extremely important that primary care professionals understand the territory in that Act and from the needs of this territory to plan their health promotion practices articulated with social determinants.
In the field of health promotion, it is observed that there is a lack of methods to help the professionals to assess the effectiveness of the practices performed, however, from subjective way, these methodologies can show positive changes in health of the population served and an extended look of professionals towards the empowerment of the population for your self-care.
It is considered important to extend this research to other municipalities and other sectors of society, given that population health is influenced by several factors political, economic, social and environmental.