Survival of Betta splendens fish (Regan, 1910) in domestic water containers and its effectiveness in controlling Aedes aegypti larvae (Linnaeus, 1762) in Northeast Brazil.

OBJECTIVE: In Northeast Brazil, large domestic containers used to store water are important breeding sites of Aedes aegypti, the main vector of dengue fever. The objective of this study was to estimate the survival of Betta splendens (Perciformes: Osphronemidae) fish in domestic containers in Fortaleza (Ceará State), as well as its effectiveness in the control of premature A. aegypti stages. METHODS: The use of B. splendens was compared to Bacillus thuringiensis israelensis (Bti) in domestic containers. In a first home visit, B. splendens or Bti were applied to water containers. Two follow-up visits were conducted after 3-4 and 5-6 months to assess the presence of viable fish in the containers and infestation by larvae. Betta splendens fish were still present in 97.6% of containers 45-60 days after application. When the fish was present, the infestation rate was significantly higher (P < 0.001) in the Bti group (IR ratio= 21.60; 95% CI: 6.46-72.28). In deposits where the fish remained, efficacy was 85% better than Bti. The permanence of fish was higher in concrete tanks (48.5%) located outside the house (47.5%) and at ground level (53.3%). We conclude that B. splendens may be suitable for biological control of A. aegypti larvae in large domestic water containers, but that appropriate measures should be taken to assure prolonged survival and the presence of fish in the containers.

Impact of water renewal on the residual effect of larvicides in the control of Aedes aegypti.

This study was carried out to evaluate the residual effect of three larvicides under laboratory conditions for 100 days in Aedes aegypti. The larval mortality rate was measured without water renewal or with daily water renewal (80%). With temephos, there was 100% mortality in both groups until the 70th day. In the Bacillus thuringiensis israelensis (Bti)-WDG test, there was no difference during the first 20 days. With Bti-G, without water renewal, mortality was sustained above 90% for up to 35 days. The second experiment (with water renewal) reduced the mortality to below 90% after the first 20 days. When renewed water was provided, the residual effect was significantly lower for all larvicides.

Survival of larvivorous fish used for biological control of Aedes aegypti larvae in domestic containers with different chlorine concentrations.

The two fish species Betta splendens (Regan) and Poecilia reticulata (Peters) are known predators of Aedes aegypti (L., 1762) larvae. Both species have been used for biological control in northeastern Brazil. However, the feasibility of these fish for the control of Ae. aegypti larvae in domestic containers may be limited by their survival in chlorinated water, as supplied by the public water system. We exposed fish to three different concentrations of chlorine: 1, 1.5, and 2.0 mg/liter. All B. splendens survived at 1.0 mg/liter chlorine concentration; 72.5 and 39.3% of B. splendens survived chlorine concentrations of 1.5 and 2.0 mg/liter, respectively. In contrast, only 4.4% of P. reticulata survived at a chlorine concentration of 1.0 mg/liter. We conclude that B. splendens may be an appropriate species for biological control of Ae. aegypti in domestic water tanks.

[Hansen's Disease in the municipality of Fortaleza, CE, Brazil: epidemiological and operational aspects in children under 15-years-old (1995-2006)]. / Hanseníase no município de Fortaleza, CE, Brasil: aspectos epidemiológicos e operacionais em menores de 15 anos (1995-2006).

This is a sectional study that aims to analyze the occurrence of Hansen's disease cases in 15 year-old minors in the Municipality of Fortaleza and notified in SINAN. The epidemiological indicators in this population show hiperendemicity. In operational terms is observed the maintenance of the service concentration in some reference units, in spite of some progress. Late diagnosis, a high degree of incapacity in the diagnosis and low degree of evaluation of contacts registered reveal the fragility of the actions of control. This study emphasizes the possibility of error diagnostic front to the characteristics of the infection in this population. The occurrence of cases of leprosy in this population represents an epidemiologic indicator of great importance and its analysis extends the discussion on operational problems in the network of health services.

Control of mother-to-child transmission of infectious diseases in Brazil: progress in HIV/AIDS and failure in congenital syphilis.

In Brazil, syphilis and HIV infection are considered serious public health problems. However, in practice, epidemiological surveillance, prevention measures, and prenatal care seem to be more effective in the control of mother-to-child transmission of the HIV than in the control of transmission of the Treponema pallidum. Here we discuss the differences in surveillance, prenatal care, and care of the newborn. Important differences were identified. It is concluded that there is an urgent need to establish prevention of mother-to-child transmission of syphilis as a public health priority, using an integrated approach including women's health, children's health, primary health care, and STD/AIDS programs on all governmental levels. These issues also need to be discussed with all stakeholders involved. Important aspects related to the problem are the training of public health professionals, as well as the participation of the community. The elimination of congenital syphilis does not require expensive drugs, and diagnostic tools, but a long-term sustainable approach.

[Secular plague trend in Ceará State, Brazil]. / Tendência secular da peste no Estado do Ceará, Brasil.

After its introduction into the State of Ceará, Brazil, in 1900, the plague was established in seven ecological complexes: Chapada do Araripe and the Ibiapaba, Baturité, Machado, Matas, Pedra Branca, and Uruburetama mountains. These natural foci were monitored successively from 1935 to 2004 by the National Health Department, National Plague Service, National Department of Rural Endemics, Superintendency of Public Health Campaigns, National Health Foundation, and finally by the National Health Surveillance Secretariat. Data analysis on human cases during these 70 years allowing identifying different plague circulation patterns in the human population, alternating high incidence with silent periods and characterizing a chronological periodicity with unique epidemiological characteristics, besides concluding that plague should still be considered a potential threat, thus justifying the revitalization of surveillance measures by strengthening all levels in the Unified National Health System.

[Efficacy of fish as predators of Aedes aegypti larvae, under laboratory conditions]. / Competência de peixes como predadores de larvas de Aedes aegypti, em condições de laboratório.

OBJECTIVE: To evaluate the efficacy of fish as predators of the Aedes aegypti larvae in laboratory conditions. METHODS: The male and female of five different fish were included in the experiment. The tests to measure their consumption ability lasted five weeks for each species. Each trial involved four test tanks and four control tanks. Two control tanks contained just one fish, and the other two just larvae. Each of the test tanks contained one fish and the larvae. During the first week, 100 larvae were placed in the tank, with an additional 100 added every week, up to a maximum daily amount of 500 larvae. The length and weight of the fish were measured at the beginning and end of every week. RESULTS: A total of 369,000 larvae were used. The Trichogaster trichopteros was the only species in which both sexes ate 100% of the available larvae. The Betta splendens failed to eat only 15 larvae. The male Poecilia reticulate showed a strong capacity for larvae eating, compared with the female of the same species. In terms of weight and size, the Betta splendens proved capable of eating 523 larvae per gram of weight per day. CONCLUSIONS: The female and male Trichogaster trichopteros and Astyanax fasciatus, and the female Betta splendens and Poecilia sphenops proved to be the most effective predators of the Aedes aegypti larvae. And although the male Poecilia sphenops and female Poecilia reticulata were less effective, they were also capable of eradicating the total number of Aedes aegypti larvae that could appear over 24 hours in a breeding site under natural conditions. The male Poecilia reticulata, however, proved incapable of doing so.

State health managers' perceptions of the Public Health Action Organizational Contract in the State of Ceará, Brazil. / Percepções de gestores estaduais da saúde sobre o Contrato Organizativo da Ação Pública da Saúde no Ceará, Brasil.

The Public Health Action Organizational Contract (COAP) / Decree 7.508/2011 aimed to seal health agreements made between federated entities to promote the cooperative governance and management of Health Regions. A qualitative study was carried out adopting a hermeneutic approach to understand state health managers' perceptions of the elaboration and effects of the COAP in the State of Ceará. Open-ended interviewees and documental analysis were conducted. It was observed that the COAP led to the strengthening of regionalization in the government sphere; institutional gains through the implementation of ombudsmen and the National System of Pharmaceutical Care Management; increased information about the state health system's workforce; and health budget transparency. The following problems were (re)visited: institutional weakness in the operation of the network; limited state capacity for regulation of care; and underfunding. Regional governance was restricted to the government sphere, coordinated by the state, and was characterized by a predominantly bureaucratic and hierarchical governance structure. The COAP inaugurated a contractual interfederative model of regionalization, but revealed the institutional weaknesses of the SUS and its lacks of capacity to fulfill its principles as the structural problems of the three-tiered model go unaddressed.

[Aedes aegypti resistance to temefos in counties of Ceará State]. / Resistência do Aedes aegypti ao temefós em Municípios do Estado do Ceará.

The susceptibility of Aedes aegypti to temefos was evaluated by means of samples of eggs and larvae from four large counties in the state of Ceará (Fortaleza, Barbalha, Juazeiro do Norte and Crato). The technique standardized by the World Health Organization for tests with larvicides was used. The CL50 of eight samples from populations of Aedes was determined, as were their respective resistance ratios, compared to the CL50 of the susceptible Rockefeller strain. All populations submitted to the experiment showed resistance to temefos, with resistance ratios varying between 8 and 16. Analysis of these results reinforces prior evidence regarding the dissemination of temefos resistance in different locations in the state, subjected to considerable pressure for control in recent decades. The larvicide may lose its effectiveness if an urgent attempt is not made to reestablish the susceptibility of Aedes aegypti in these areas, profoundly affecting control campaigns currently under way.

Observações sobre as Redes de Atenção à Saúde na perspectiva do jogo (Spiel) hermenêutico / Observations on Health Care Networks from the Spiel perspective

Resumo Este estudo busca refletir sobre o movimento em prol da construção das Redes de Atenção à Saúde à luz dos fundamentos hermenêuticos, notadamente, na noção de jogo (Spiel) e suas repercussões para a Saúde Coletiva. Foi pautado a partir da experiência de pesquisa avaliativa de abordagem qualitativa sobre a Rede de Atenção à Saúde Materna e Infantil desenvolvida no estado do Ceará. A discussão gira em torno de três unidades, a saber: organização e funcionamento dos serviços de saúde em redes; Jogo hermenêutico: fundamentos e relações; e Redes de Atenção à Saúde e o jogo hermenêutico: uma aproximação possível? A partir disso, foi possível compreender que o movimento em prol da constituição das Redes extrapola a dimensão técnica e a disponibilidade dos equipamentos, dispositivos e sujeitos. Por vezes, é capaz de se constituir independentemente do desenho já formatado pelos gestores e profissionais de saúde. A Rede também se constrói a partir dos próprios sujeitos, sejam eles usuários ou não, e é percebida como algo em movimento que se renova em constante repetição. Ela independe da atuação de cada um dos sujeitos que a compõem. A Rede por si só é o próprio sujeito, assim como jogo hermenêutico.

Abstract This study seeks to reflect on the movement towards the construction of Health Care Networks based on hermeneutic foundations, notably on the notion of Spiel and its repercussions for Collective Health. It was based on the experience of evaluative research of qualitative approach on the Maternal and Child Health Care Network developed in the state of Ceará. The discussion lists three units, namely: organization and operation of health services in networks; Hermeneutical game: fundamentals and relationships; and, Health Care Networks and the Spiel: a possible approach? From this, it was possible to understand that the movement towards the constitution of the networks goes beyond the technical dimension and the availability of equipment, devices and subjects. Sometimes it is able to constitute itself independently of the design already formatted by managers and health professionals. The Network is also built from the subjects themselves, whether they are users of health services or not and it is perceived as something in movement and that is renewed in constant repetition. It is independent of the performance of each of the subjects that compose it. The Network itself is the subject itself, as well as the Spiel.

[Residual effect of commercial applications of larvicides temefos and Bacillus thuringiensis israelensis on Aedes aegypti larvae in recipients with water renewal]. / Efeito residual de apresentações comerciais dos larvicidas temefos e Bacillus thuringiensis israelensis sobre larvas de Aedes aegypti em recipientes com renovação de água.

The residual effect of temefos (commercial applications A, B and C) and Bacillus thuringiensis israelensis (D and E) on Aedes aegypti larvae was evaluated, in recipients with water renewal. Forty-four beakers of 1,000ml each (8 for each application and 4 controls) were used. In each beaker, 25 larvae were introduced daily. After 24 hours, the dead larvae were counted, the beakers emptied to 200ml and refilled to original volume, with addition of new larvae. The duration of the maximum residual effect (100% of mortality) was: A-19; B-39; C-40; D-8; E-19 days. The mortality ratio of all applications remained equivalent for 25 days; B, C and E maintained MR equivalent up to 45 days; B and C showed MR 2.40 times greater than E, between 46-95 days; B, compared with A, showed MR 1.90-7.51 times greater between 26-95 days. The conclusion was greater effectiveness of two presentations of temefos, even in an epidemiological situation with long exposure to the product and renewal of water in recipients.

Implantação e implementação do Núcleo de Apoio à Saúde da Família: residência multiprofissional em Saúde da Família como estratégia de efetivação das políticas públicas do SUS / Implantation and implementation of Family Health Support Centers: multiprofessional residence in Family Health as a strategy for the effectiveness of SUS public policies / Implantación e implementación del Núcleo de Apoyo a la Salud de la Familia: residencia multiprofesional en Salud de la Familia como estrategia tan eficaz para políticas públicas de SUS

A Estratégia Saúde da Família (ESF) foi ampliada com os Núcleos de apoio à Saúde da Família (NASF). Devido ao ineditismo dos NASF, sua implantação representa um desafio. Diante disso, objetivou-se relatar a experiência de implantação e implementação do NASF, no município de Arneiroz/CE, a partir da experiência da Residência Multiprofissional em Saúde da Família e Comunidade da Escola de Saúde Pública do Ceará (RMSFC-ESP-CE). Trata-se de relato de experiência oriundo da prática gerencial e assistencial, entre julho/2013 e maio/2016, em Arneiroz/CE. As informações emergentes da prática profissional foram registradas em diário de campo e analisadas na perspectiva hermenêutico dialética com base no referencial teórico e nos dados dos sistemas de informação. A implantação dos NASF exige reformulações no processo de trabalho da ESF capazes de promover a interprofissionalidade e intersetorialidade na perspectiva do apoio matricial. Em Arneiroz/CE, esse desafiador processo aconteceu concomitantemente à implantação da RMSFC-ESP-CE, cujas atividades foram essenciais no suporte técnico-pedagógico aos gestores e profissionais do município, facilitando a incorporação e efetivação do preconizado pelo Ministério da Saúde. Quanto às ações educativas em saúde e aos atendimentos de profissionais de nível superior na ESF, houve um aumento importante depois da implantação do NASF, indicando melhoria no acesso e nos indicadores de saúde. Aponta-se ainda o impacto das Residências Multiprofissional em Saúde enquanto estratégia de Educação Permanente em Saúde e subsídio aos processos de gestão municipal em saúde, especialmente em municípios de pequeno porte, de modo a também subsidiar a implementação das políticas públicas de saúde. (AU)

The Family Health Strategy (ESF) has been expanded with the Family Health Support Centers (NASF). In face of NASF's novelty, its implementation represents a challenge. This study aimed to report NASFs implantation and implementation experience in Arneiroz/CE municipality from Multiprofessional Residency Program in Family and Community Health of the School of Public Health of Ceará (RMSFC-ESP-CE) experience. This is an experience report from management and assistance practice between July/2013 and May/2016 in Arneiroz/CE. The information emerged from professional practice was recorded in a field diary and analyzed in dialectical hermeneutic perspective based on theoretical reference and data of information systems. The NASF's implementation requires reformulations in ESF's work process capable to promote interprofessionality and intersectoriality in matrix support perspective. In Arneiroz/CE, this challenging process happened concurrently with RMSFC-ESP-CE implementation, whose activities were essential in the technical-pedagogical support to managers and professionals of the municipality, facilitating incorporation and effectiveness of the recommended by Health Ministry. Regarding health educational actions and attendances of higher level professionals in ESF, there were a significant increased after NASF implementation, indicating improved access and health indicators. It also pointed out the impact of the Multiprofessional Residency in Health as a strategy of Continuing Education in Health and subsidy to municipal health management processes, especially in small municipalities, in order to also subsidize public health policies implementation. (AU)

The Family Health Strategy (ESF) has been expanded with the Family Health Support Centers (NASF). In face of NASF's novelty, its implementation represents a challenge. This study aimed to report NASFs implantation and implementation experience in Arneiroz/CE municipality from Multiprofessional Residency Program in Family and Community Health of the School of Public Health of Ceará (RMSFC-ESP-CE) experience. This is an experience report from management and assistance practice between July/2013 and May/2016 in Arneiroz/CE. The information emerged from professional practice was recorded in a field diary and analyzed in dialectical hermeneutic perspective based on theoretical reference and data of information systems. The NASF's implementation requires reformulations in ESF's work process capable to promote interprofessionality and intersectoriality in matrix support perspective. In Arneiroz/CE, this challenging process happened concurrently with RMSFC-ESP-CE implementation, whose activities were essential in the technical-pedagogical support to managers and professionals of the municipality, facilitating incorporation and effectiveness of the recommended by Health Ministry. Regarding health educational actions and attendances of higher level professionals in ESF, there were a significant increased after NASF implementation, indicating improved access and health indicators. It also pointed out the impact of the Multiprofessional Residency in Health as a strategy of Continuing Education in Health and subsidy to municipal health management processes, especially in small municipalities, in order to also subsidize public health policies implementation. de trabajo de ESF capaces de promocionar interprofissionalidade y el enfoque intersectorial en perspectiva de soporte de la matriz. En Arneiroz/CE, este proceso desafiante ocurrió al mismo tiempo que ha pasado a la aplicación de la RMSFC-ESP-CE, cuyas actividades eran esenciales en apoyo técnico y pedagógico a los directivos y profesionales municipales, facilitando el desarrollo y realización de la recomendada por el Ministerio de Salud. En cuanto a las acciones de educación en salud y la atención de los profesionales de alto nivel en el ESF, hubo un aumento significativo después de la aplicación de NASF, lo que indica mejoría en los indicadores de acceso y de salud. También destacó el impacto de la Multidisciplinar Residencia en Salud como una estrategia de Educación Continua en Salud y subsidio a los procesos de gestión municipal en materia de salud, especialmente en los municipios pequeños, con el fin de subsidiar la implementación de políticas de salud pública. (AU)

[Perception of family members and health professionals on end of life care within the scope of primary health care]. / Percepção de familiares e profissionais de saúde sobre os cuidados no final da vida no âmbito da atenção primária à saúde.

The objective of this study is to reflect on care for people with terminal illnesses in primary health care. This study is relevant in the current context of demographic and epidemiological transition, in which there is an increase in the aging population and a rise in the prevalence of chronic degenerative diseases. By means of qualitative research with a critical hermeneutic focus, individual interviews were conducted with seven family members, three professionals from the Family Health Strategy and two professionals from the Home Care Program. The analysis established two empirical categories: end of life care from the perception of family members and that of health professionals. The results showed that, despite the humanization discourse, reflected in the prerogative of living the final moments of life with the family, a serious problem in the discontinuity of care is concealed. It was concluded that, despite the efforts, little is achieved in improving the quality of life for those who die from terminal diseases at home in the Unified Health System in municipalities distant from large centers.

O Espaço Socioprofissional da Estratégia Saúde da Família sob a Perspectiva de Psicólogos / The Social-Professional Space of the Family Health Strategy from the Perspective of Psychologists / El Espacio Social de la Estrategia Salud de la Familia bajo la Perspectiva de Psicólogos

Resumo A Estratégia Saúde da Família (ESF) tem se constituído como porta de entrada para os psicólogos no Sistema Único de Saúde do Brasil, oportunizando acesso da população às práticas psicológicas e contribuindo para a expansão do espaço de atuação profissional. O presente trabalho tem como objetivos compreender o espaço socioprofissional da ESF, a partir da ótica de psicólogos inseridos no campo, e analisar os lugares ocupados pelas práticas da Psicologia no referido contexto. Utiliza como referencial teórico o conceito de campo social em Pierre Bourdieu. Consiste em estudo hermenêutico, de abordagem qualitativa, em que foram entrevistados 18 psicólogos com experiência de atuação nos campos da atenção e formação. Os resultados apontam para a caracterização de um processo de construção social das práticas psicológicas no campo, marcado pela territorialização, o ineditismo das práticas e a articulação com outros serviços e saberes técnico-científicos. O campo é descrito como hierarquizado e conflituoso, destacando-se a hegemonia do modelo biomédico e as desigualdades de poder entre as profissões. O lugar das práticas psicológicas na ESF, por um lado, é apontado como subalterno frente à hegemonia médica, por outro, é prestigiado por sua especificidade em lidar com dimensões subjetivas do processo saúde-doença-cuidado....(AU)

Abstract The Family Health Strategy (ESF) has been established as a gateway for psychologists in the Unified Health System in Brazil, providing opportunities for access of the population to psychological practices and contributing to the expansion of professional workspace. This paper aims to understand the socio-professional space of the ESF, from the perspective of psychologists inserted in the field, and to analyze the places occupied by psychology practices in that context. The concept of social field in Pierre Bourdieu was used as a theoretical framework. This is a hermeneutical study of qualitative approach, in which 18 psychologists with experience in the fields of attention and training were interviewed. The results show some featuring elements of the social construction process of psychological practices in the field, marked by the territorialization, the uniqueness of the practices, and the collaboration with other services and technical-scientific knowledges. The field is described as hierarchical and confrontational, especially associated with the hegemony of the biomedical model and the power differentials between the professions. The place of psychological practices in the ESF, on the one hand, is appointed as subaltern to the medical hegemony, and on the other, is recognized by its specificity in dealing with subjective dimensions of the health-disease-care process....(AU)

Resumen La Estrategia de Salud de la Familia (ESF) se ha establecido como una puerta de entrada para los psicólogos en el Sistema Único de Salud en Brasil, proporcionando oportunidades para el acceso de la población a las prácticas psicológicas y contribuindo a la expansión del espacio de trabajo profesional. Este trabajo tiene como objetivos comprender los espacios socioprofesionales de la ESF, desde la perspectiva de los psicólogos insertados en el campo, y analizar los lugares ocupados por las prácticas de psicología en ese contexto. Se utiliza como marco teórico el concepto de campo social en Pierre Bourdieu. Este es un estudio hermenéutico de enfoque cualitativo, en el que fueron entrevistados 18 psicólogos con experiencia en los campos de la atención y la formación. Los resultados muestran elementos del proceso de construcción social de las prácticas psicológicas en el campo, marcadas por la territorialización, la originalidad de las prácticas y la articulación con otros servicios y conocimientos técnico-científicos. El campo es descrito como jerarquizado y lleno de conflictos, destacándose la hegemonía del modelo biomédico y la disparidad de poder entre las profesiones. El lugar de las prácticas psicológicas en la ESF, por un lado, es nombrado como inferior, frente a la hegemonía médica; por el otro, es valorado por su especificidad en el tratamiento de las dimensiones subjetivas del proceso de atención de salud y enfermedad....(AU)

[The strengthening of subjects in health management: advances and challenges in the experience of Fortaleza, state of Ceará]. / Constituição de sujeitos na gestão em saúde: avanços e desafios da experiência de Fortaleza (CE).

This research deals with the potential and limitations of the strengthening of subjects in health management, based on the experience in Fortaleza in the period from 2005 to 2008. The subject is approached from a historical-cultural standpoint, which considers the dialectical interaction between the individual and the collective in deepening human consciousness on the self and the world. Focus groups were conducted with managers linked to Primary Healthcare and secondary data were utilized. An attempt was made to understand the meaning of the narratives constructed using a hermeneutic dialectic approach. Empirical categories were identified and analyzed as well as co-intentionality of change, political and conceptual drives, human management, reduction of hierarchy, fragmentation of work processes and concentration of decision-making power. Reflections arose on three main strategic policies: co-management, humanization, and continuous health education. It was concluded that, despite the persistence of obstacles, in order to improve the quality of healthcare services it is essential to establish a democratic management system through organizational arrangements and participatory methods that enhance integration and commitment of the Unified Health System players (SUS).

Los posibles sentidos del cuidado: el cuidar de sí y el cuidar de otros / Os possíveis sentidos do cuidado: o cuidar-de-si e o cuidar-dos-outros / The possible meanings of care: self-care and care-for-the-other

Objective. To understand and to reflect about care based on the experiences of managers, professionals and users of maternal and child health services. Methods. We developed an evaluative research with a qualitative approach in a Northeastern state of Brazil with extensive experience in the regionalization and implementation process of integrated health networks. Semi-structured interviews were carried out with 68 subjects and direct observation of the maternal and child health services. We adopted the theoretical reference framework of Gadamer's hermeneutics to analyze the narratives. Results. Some units of meaning were present, such as: perception and knowledge about oneself; exercise of autonomy; weaknesses in the provision of resources for the materialization of self-care; and difficulties in accessing health services and care practices. We perceive that care is dynamic, comprises various subjective aspects with respect to the singularities of the subjects and is related to the possibility of generating both individual and collective transformation. Conclusion. Care is built based on a movement among the subjects and between them and the social and health services. Thus, when we intend to take care, we need to consider this instead of focusing care solely on the technical support of health professionals. (AU)

Objetivo. Comprender y reflexionar sobre el cuidado a luz de las experiencias de directivos, profesionales y usuarios de los servicios de salud materna e infantil. Métodos. Se desarrolló una investigación de evaluación con enfoque cualitativo en un estado en el noreste de Brasil, con una amplia experiencia en el proceso de regionalización e implementación de redes. Se realizaron entrevistas semiestructuradas a 68 sujetos y la observación directa de los servicios de salud materna e infantil. Se adoptó el referencial teórico de la hermenéutica de Gadamer para el análisis de las narrativas. Resultados. Estuvieron presentes algunas unidades de significado, como la percepción y conocimiento sobre sí, el ejercicio de la autonomía, las debilidades en la oferta de recursos para la materialización del cuidar de sí mismos y dificultades en el acceso a los servicios de salud y a las prácticas de cuidado. Se percibió que el cuidado es dinámico, se compone de aspectos subjetivos diversos en relación con las singularidades de los sujetos y está asociado a la posibilidad de generar transformación individual y colectiva. Conclusión. El cuidado se construye a partir de un movimiento entre los sujetos y entre éstos y los servicios sociales y de salud. De esta forma, cuando pretendemos cuidar, debemos partir de este horizonte y no centrar únicamente el cuidado en el apoyo técnico de los profesionales de la salud. (AU)

Objetivo. Compreender e refletir sobre o cuidado à luz das experiências de gestores, profissionais e usuárias dos serviços de saúde materna e infantil. Métodos. Desenvolvemos uma pesquisa avaliativa com abordagem qualitativa em um estado do nordeste brasileiro com vasta experiência no processo de regionalização e implantação de redes integradas. Foram realizadas entrevistas semiestruturadas com 68 sujeitos e observação direta dos serviços de saúde materna e infantil. Adotamos o referencial teórico da hermenêutica de Gadamer para análise das narrativas. Resultados. Algumas unidades de significado estiveram presentes, como: percepção e o conhecimento sobre si; exercício da autonomia; fragilidades na oferta de recursos para a materialização do cuidar de si; e, dificuldades quanto ao acesso aos serviços de saúde e às práticas de cuidado. Percebemos que o cuidado é dinâmico, compreende aspectos subjetivos diversos em respeito às singularidades dos sujeitos e está relacionado com a possibilidade de gerar transformação tanto individual como coletiva. Conclusão. O cuidado se constrói a partir de um movimento entre os sujeitos e entre eles e os serviços sociais e de saúde. Desta forma, quando pretendemos cuidar, devemos partir deste horizonte e não centrar o cuidado, unicamente, no apoio técnico dos profissionais de saúde. (AU)

[Identity of the deaf and interventions in health from the perspective of a community of sign language users]. / Identidade surda e intervenções em saúde na perspectiva de uma comunidade usuária de língua de sinais.

The biomedical view sees deafness as a physiological loss of audition and the deaf as individuals with an organic abnormality to be corrected; healthcare interventions support this perception. This study sought to understand deafness from the standpoint of the deaf, in order to identify elements for public policies addressed to them in the context of the ethical dimension of care. The research adopted the qualitative approach (focus groups) and 9 members of a deaf community in Fortaleza (Ceará-Brazil), all fluent in Brazilian Sign Language-LIBRAS, took part. The results show deafness is perceived as a way of being based on day-to-day experiences of visual interaction with nature and society, giving the deaf a different identity in terms of culture (being deaf) and linguistics (LIBRAS). Some public policies for oral training and technological interventions, like cochlear implants, are seen as a setback by the deaf, as it negates their status in the world and involves a loss of identity for the deaf. It is necessary to consider the deaf from a socio-historic, symbolic and cultural standpoint where different discourses co-exist, over and above the physiological dimension.

Percepções de gestores estaduais da saúde sobre o Contrato Organizativo da Ação Pública da Saúde no Ceará, Brasil / State health managers' perceptions of the Public Health Action Organizational Contract in the State of Ceará, Brazil

Resumo O Contrato Organizativo da Ação Pública da Saúde (COAP), instrumento jurídico instituído pelo Decreto 7.508/2011, objetivou selar acordos sanitários entre os entes federados para uma gestão cooperada da Região de Saúde. Realizou-se uma pesquisa qualitativa com referencial hermenêutico para compreender as percepções de gestores estaduais da saúde do Ceará, Brasil, sobre a produção e efeitos do COAP na experiência do estado. Para isso, foram utilizadas entrevistas abertas e análise documental. Observou-se o fortalecimento da regionalização no âmbito do governo, além de ganhos institucionais com a implantação de Ouvidorias e Sistema Nacional de Gestão da Assistência Farmacêutica; informações da força de trabalho e transparência do recurso orçamentário-financeiro por ente federado. (Re)visitaram-se problemas como: baixa institucionalidade do funcionamento em rede e da capacidade do Estado de regulação e o subfinanciamento. A governança regional se fez restrita ao âmbito do governo, coordenada pelo ente estadual e em predomínio do tipo burocrático hierárquico. O COAP inaugurou uma Regionalização Contratual Interfederativa, mas revelando baixa institucionalidade no SUS e impotência para consecução de seus princípios, dado o não enfrentamento de problemas estruturais em cooperação trina.

Abstract The Public Health Action Organizational Contract (COAP) / Decree 7.508/2011 aimed to seal health agreements made between federated entities to promote the cooperative governance and management of Health Regions. A qualitative study was carried out adopting a hermeneutic approach to understand state health managers' perceptions of the elaboration and effects of the COAP in the State of Ceará. Open-ended interviewees and documental analysis were conducted. It was observed that the COAP led to the strengthening of regionalization in the government sphere; institutional gains through the implementation of ombudsmen and the National System of Pharmaceutical Care Management; increased information about the state health system's workforce; and health budget transparency. The following problems were (re)visited: institutional weakness in the operation of the network; limited state capacity for regulation of care; and underfunding. Regional governance was restricted to the government sphere, coordinated by the state, and was characterized by a predominantly bureaucratic and hierarchical governance structure. The COAP inaugurated a contractual interfederative model of regionalization, but revealed the institutional weaknesses of the SUS and its lacks of capacity to fulfill its principles as the structural problems of the three-tiered model go unaddressed.

A Atuação do Psicólogo na Estratégia Saúde da Família: Articulações Teóricas e Práticas do Olhar Gestáltico / The Performance of the Psychologist in the Family Health Strategy: Combining Theory and Gestalt-Oriented Practices / La Actuación del Psicólogo en la Estrategia de Salud de la Familia: Teoría y Prácticas de Visión Gestáltica en Conjunto

Resumo Este trabalho emerge de interrogações da pesquisadora durante desenvolvimento profissional, a partir da experiência em Gestalt-terapia e Residência Multiprofissional em Saúde da Família e Comunidade. Com conhecimento teórico e prático em ambas as áreas, propõe a construção de pontes teórico-conceituais entre elas, mostrando contribuições possíveis da Gestalt-terapia para o trabalho do psicólogo no contexto da Estratégia Saúde da Família (ESF), bem como à sua principal ferramenta de processo de trabalho, a Clínica Ampliada (CA). Trata-se de pesquisa qualitativa, com amostra intencional de psicólogos que trabalham na ESF do Ceará. Realizadas entrevistas individuais, o material empírico foi categorizado em cinco temas: importância das abordagens psicológicas para a atuação do psicólogo na ESF; visões de homem das abordagens humanistas norteadoras da atuação do psicólogo na ESF; valorização pelos psicólogos do modo de vida dos sujeitos e suas demandas; modos de intervenção do psicólogo na ESF; conexões teóricas e práticas. Em síntese, os resultados indicaram: a Gestalt-terapia tem aceitação dos psicólogos que trabalham na ESF; e a principal contribuição da abordagem para esse cenário é a visão de totalidade do ser humano, já que é exigência da ESF e da CA trabalhar com visão integrada de um sujeito singular, compreendido num contexto amplo. Conclui-se que, quando a abordagem psicológica possui visão de homem que se aproxima das diretrizes da ESF e o psicólogo consegue unir ambas as formações na sua prática, uma garantia de atuação qualificada neste contexto é facilitada....(AU)

Abstract This work comes from the researcher’s questions developed in her professional career, from the experience in Gestalt-Therapy (GT) and Multidisciplinary Residency in Family Health and Community. With theoretical and practical knowledge in both areas, proposes the construction of theoretical and conceptual bridges between them, with the objective of showing possible contributions that GT can offer to the work of the psychologist in the context of Family Health Strategy (FHS), as well as to its main work process tool, Extended Clinic (EC). It is qualitative research, with purposive sample of psychologists of the Residence Integrated Health with Emphasis on Health Family and Community, of the Public Health School of Ceará. With the execution of individual interviews, the empirical material was categorized in five themes: importance of the psychological approaches for the performance of the psychologist at FHS; views of man and world of the humanitarian approaches while guiding the performance of the psychologist at FHS; appreciation by psychologists of the way of life of subjects and their demands; intervention methods of the psychologist at FHS; and theoretical and practical connections. In summary, the results indicated that: GT has acceptance and use by the psychologists who work at FHS; and the approach’s main contribution to that scenario is the view of totality of the human being, since it is required of FHS and EC to work with an integrated view of a singular subject, which should be understood in a broad context. In conclusion, when the psychological approach has a view of man closer to the guidelines of FHS, and the psychologist can combine both formations in their practice, an assurance of qualified performance in this context is promoted....(AU)

Resumen Este trabajo es producto de las preguntas desarrolladas por la investigadora en su ejercicio profesional, relacionado tanto con su experiencia con la Terapia Gestalt (GT) como con su Residencia Multidisciplinaria en Salud Familiar y Comunitaria. A partir del conocimiento de la teoría y la práctica en las dos áreas, la investigadora propone la construcción de puentes teóricos-conceptuales entre ellas, con el fin de mostrar las posibles contribuciones que la GT puede ofrecer al trabajo del psicólogo en el contexto de la Estrategia de Salud de la Familia (ESF), así como a la principal herramienta de esa estrategia: la Clínica Ampliada (CA). Se trata de una investigación cualitativa con una muestra por conveniencia de psicólogos provenientes de la Residencia Integrada de Salud con Énfasis en Salud de la Familia, de la Escuela de Salud Pública del Ceará. Con la realización de entrevistas individuales, el material empírico se clasificó en cinco temas: importancia de los enfoques psicológicos para el ejercicio del psicólogo en la ESF; comprensión del hombre y del mundo de los enfoques humanistas en el desempeño del psicólogo en la ESF; valoración por los psicólogos del modo de vida de los sujetos y de sus demandas; métodos de intervención del psicólogo en la ESF; y, conexiones teóricas y prácticas. En resumen, los resultados indicaron que: la GT cuenta con aceptación y uso por parte de los psicólogos que trabajan en la ESF; y, la principal contribución del enfoque para ese escenario es su visión integral del ser humano, ya que es necesario que la ESF y la CA trabajen con una visión integradora de un sujeto singular, entendido en un contexto amplio. Se llega a la conclusión de que cuando el enfoque psicológico tiene una visión del hombre que se acerca de las directrices de la ESF, y cuando el psicólogo puede unir ambas esferas en su práctica, se garantiza un desempeño de calidad en este contexto....(AU)

Regionalização da saúde: (in)visibilidade e (i)materialidade da universalidade e integralidade em saúde no trânsito de institucionalidades / Regionalization in healthcare: (in)visibility and (im)materiality of the universal access and comprehensiveness in health in changing institutionalities

Resumo A regionalização é uma estratégia de organização e integração de serviços em sistemas nacionais de saúde, colocando-se como um caminho a ser trilhado para a integralidade e universalidade. No entanto, constitui-se como princípio ainda invisível na sociedade brasileira, problematizando seus modos de gestão nas regiões de saúde, assim como seus efeitos reais na construção do devir da saúde em direito. Este artigo dedica-se a essa problematização e inscreve-se como uma produção a desnaturalizar processos e a possibilitar o aparecimento de acontecimentos postos em invisibilidade e dizibilidade pela "formação discursiva" da regionalização da saúde. Toma como habitação a regionalização da saúde do Ceará em curso desde meados de 1990. A partir de uma abordagem qualitativa, adota em conexão e análise os discursos em entrevistas com 23 gestores estaduais de saúde e narrativas documentais afins ao tema. Busca a constituição do "feixe de relações", articulando sujeitos e instituições em produção de "saber-poder e verdade-poder", segundo referência foucaultiana, e em diálogo com autores da saúde coletiva. A regionalização do Ceará aponta para uma reforma do setor saúde, delegando a gestão e prestação de serviços à Organização Social e aos consórcios, em contratualização procedimental e produtiva, fortalecendo o "empresariamento" da saúde e afetando a produção da integralidade e universalidade. Conclui-se que o estrato constitucional do Sistema Único de Saúde (SUS) encontra-se em processo de rompimento, forjando um outro "regime de integralidade e de universalidade", que se pode visualizar no fato do SUS estar em trânsito de institucionalidades e na transformação da saúde de direito, em um deslocamento reducionista, para o campo do direito do consumidor.

Abstract Regionalization is a strategy of organization and integration of services in national health systems, in a path to be followed toward comprehensiveness and universal access. However, its principles are still invisible in Brazilian society, and the forms of management in health regions are questioned, as well as its actual effects on the construction of health as a right. This article is dedicated to such questioning and falls as a production aiming to denature processes and enable the emergence of events put into invisibility because of the "discursive formations" of health regionalization. This study comprises the regionalization process of Ceará's health system since the 1990s. This is a qualitative study that examines the reports of 23 state managers of health, as well as the documentary narratives related to this issue. This study aims to build "bundles of relations", articulating the subjects and institutions in the production of "knowledge-power and truth-power", according to Foucault's reference, and in dialogue with public health authors. The regionalization of Ceará points to a reform of the health sector, delegating the management and provision of services to the Social Organization and to the consortium, on procedural and productive contracting, strengthening the "entrepreneurship" of health and thus affecting the production of comprehensiveness and universality. We conclude that the Unified Health System's constitutional stratum is undergoing a breaking process, forging another "regime of comprehensiveness and universality", that can be observed in the fact that the Unified Health System is between institutionalities, and in the change from the right to health care to customer right in a reductionist shift.