Health promotion of Street Clinic workers: convergent care research

Promócion de la salud de los trabajadores del Consultorio en la Calle: investigación convergente asistencial

ABSTRACT

Objective:  To develop a health promotion action for Street Clinic workers.

Method:  Qualitative research which used the Convergent Care Research methodology. The data collection was conducted through participant observation and convergence groups, from May to October 2021, with 39 workers from six teams of the Street Clinic. Data analysis followed the stages of apprehension, synthesis, theorization, and transfer.

Results:  Some integrativepractices such as, stretching, group dynamics, dance, music, massage and cinema were suggested as interventions to be implemented. Given the need, Reichian stretching was developed as an intervention which favored body awareness, promoting the well-being of workers.

Conclusion:  The workers presented a conception of health promotion related to access to services and guarantee of rights. Reichian stretching provided a space for care and reflection on caring and respecting limits, favoring the body awareness and promoting relaxation.

Descriptors: Health promotion; Occupational health; Working conditions

RESUMEN

Objetivo:  Desarrollar acciones para promover la salud de los trabajadores de la Oficina de Calle.

Método:  Investigación cualitativa, que utilizó la metodología de Investigación Convergente Asistencial. La producción de información se llevó a cabo a través de la observación participante y grupos de convergencia, de mayo a octubre de 2021, con 39 trabajadores de seis equipos del consultorio en la calle. El análisis de datos siguió las etapas de aprehensión, síntesis, teorización y transferencia.

Resultados:  Se sucedieron algunas prácticas integrativas como intervenciones a implementar, estiramientos, dinámicas de grupos, danza, música, masaje, cine. Ante la necesidad se desarrolló el estiramiento reichiano como una intervención que favoreció la conciencia corporal, promoviendo el bienestar de los trabajadores.

Conclusión:  Los trabajadores presentaron una concepción de promoción de la salud relacionada con el acceso a servicios y la garantía de derechos. El estiramiento reichiano proporcionó un espacio de cuidado y reflexión sobre el cuidado y el respeto de los límites, favoreciendo la toma de conciencia corporal y promoviendo la relajación.

Descriptores: Promoción de la salud; Salud laboral; Condiciones de trabajo

RESUMO

Objetivo:  Desenvolver ação de promoção à saúde do trabalhador do Consultório na Rua.

Método:  Pesquisa qualitativa que utilizou a metodologia da Pesquisa Convergente Assistencial. Para a coleta de dados, utilizou-se a observação participante e grupos de convergência, de maio a outubro de 2021. Participaram 39 trabalhadores de seis equipes do Consultório na Rua. A análise dos dados seguiu as etapas de apreensão, síntese, teorização e transferência.

Resultados:  Foram sugeridas como intervenções a serem implementadas algumas práticas integrativas, alongamento, dinâmica em grupo, dança, música, massagem, cinema. Visto a necessidade, desenvolveu-se como intervenção o alongamento reichiano, que favoreceu a tomada de consciência corporal, promovendo bem-estar dos trabalhadores.

Conclusão:  Os trabalhadores apresentaram uma concepção de promoção da saúde relacionada ao acesso aos serviços e à garantia de direitos. O alongamento reichiano proporcionou um espaço de cuidado e reflexão sobre o cuidado e respeito dos limites, favorecendo a tomada de consciência corporal e promoveu o relaxamento.

Descritores: Promoção da saúde; Saúde ocupacional; Condições de trabalho

INTRODUCTION

The work of the Street Clinic is characterized by favoring access to healthcare services, ensuring citizenship and providing comprehensive assistance to the homeless population, which raises the need to incorporate new ways of care1. Therefore, there is an urgent need for a practice that adapts to the reality of this scenario, working as an expanded clinic practiced in motion, which deviates from the conventional2. This is because the street presents itself as a work space marked by the unpredictability of users, the lack of physical structure (table, chair, walls, ceiling, etc.) and exposure to adverse weather conditions, requiring adaptation from workers to face these challenges1^,2.

The Street Clinic operates on-site or on an itinerant basis to provide primary care. Therefore, they perform actions such as distribution of water, supplies, health education, harm reduction, seeking to guarantee rights3. Such aspects require the implementation of intersectoral initiatives, which involves overcoming obstacles such as the fragmentation of the health care network, resource restrictions and the complexity inherent to this work process3^,4. Therefore, caring for the group requires not only the technical knowledge of each component of the multiprofessional team, but also human virtues, such as solidarity and a deliberate commitment to understanding the person to be cared for in their completeness4.

The fight for better conditions for work and life has been gradually achieved throughout history. This process is marked by the attempt to overcome the model of Occupational Medicine and Occupational Health by Workers’ Health. The first model understands the worker as the object of health actions and aims to adapt the worker to the job. The second focuses on interventions in the workplace to control environmental risks5.

Workers’ Health emerged as a movement in the most industrialized Western countries in the 1960s and 1970s, in Italy due to the union activity that formed the Italian Workers’ Model (MOI) in health and inspired Brazil. The model has a holistic approach and seeks interventions for the physical, mental and social well-being of workers, so that they begin to take an active stance in controlling working conditions and environments to keep them healthy. It also deals with promoting health at work, whose strategy is to modify people’s behaviors and lifestyles5.

The National Policy on Workers’ Health (Política Nacional de Saúde do Trabalhador e da Trabalhadora- PNSTT) is the result of this struggle, being a normative landmark that recognizes, in health promotion, the search for equity and the encouragement of intersectoral actions and some of its objectives are strengthening social participation; promoting changes in organizational culture; encouraging research and disseminating initiatives aimed at health promotion. Therefore, the PNSTT seeks to develop comprehensive care for workers’ health, aiming to promotion and protection of health, as well as reducing morbidity and mortality resulting from production processes6.

Regarding workers’ health, the PNSTT dialogues with the National Policy for Health Promotion (Política Nacional de Promoção à Saúde - PNPS), as both are aligned with the principles of the Unified Health System (Sistema Único de Saúde- SUS), especially in the understanding of work as one of the determinants and conditions of health. Furthermore, both start from an expanded concept of health and understand it as the result of the modes of organization of production, work and society at a given historical moment. These two theoretical references have as principles and guidelines to be the protagonist of the individual/community and social participation6^,7.

The World Health Organization (WHO) encourages that health promotion be valued in the workplace through actions that encourage healthy eating, physical exercise and the mental health promotion8. The European Union’s strategic framework for dealing with health and safety at work, from 2021 to 2027, encourages healthy lifestyles in work environments, linking the measure to the reduction of absenteeism and non-communicable diseases9.

The consideration that the work environment can affect both individual well-being and interpersonal relationships makes it relevant to analyze the work of the Street Clinic teams from the perspective of health promotion of workers. When work is a source of satisfaction, it contributes to professional identity, personal fulfillment, recognition and autonomy, allowing workers to exercise control over their actions, avoiding workplace oppression2.

Regarding health promotion in the reality of workers at the Street Clinic, it is essential to consider the voice of these workers so that interventions can emerge from their experiences, forming a participatory process. The Convergent Care Research (CCR) allows movement, as it aims at a convergence between research and care with the goal of solving or minimizing a problem and building new knowledge10. Therefore, it is a methodological framework that focus on the role of the participants in solving the problem11.

The interest in the topic arose from the main researcher’s approach and experience in monitoring and participating in the work of the Street clinic teams from 2014 to 2019, through government research programs and local academic leagues, resulting in a research that investigated the occupational risks that the Street Clinic team is exposed and by revealing exposure to risks of all kinds, with greater vulnerability to the emotional health of these workers2.

From then on, there was concern about the need and the importance of promoting the health of workers who make up the Street Clinic team, especially regarding the search for the construction of strategies and development of actions that promote health among the team, configuring the motivation to conduct this study.

In view of the above, this study aims to develop a health promotion action for workers of the Street Clinic in a northeastern capital, based on the theoretical frameworks of the PNSTT and PNPS, in a participatory process provided by the CCR. Therefore, stands out the relevance of developing studies of this nature, considering that the research findings can contribute to shedding light on the reality of the work of the Street Clinic, highlighting the possible invisibility of workers and encouraging the implementation of actions to promote worker’s health in the context of the Unified Health System (SUS).

METHOD

This is a qualitative research that used the CCR methodological framework, conducted in a northeastern Brazilian capital. CCR has its origins in care practice and differs from other methodological approaches, such as action research, for example, since, in action research, the researcher assumes the role of facilitator, without the need for specialization in the area. On the other hand, in CCR the researcher is a health professional who needs to be inserted in the healthcare environment, playing a more proactive role10.

The CCR seeks convergence between research and healthcare practice; thus, the researcher integrates into the healthcare setting and becomes involved to the point of becoming part of the team11. This is done with the aim of addressing or mitigating an identified problem and generating new knowledge for the specific healthcare practice under study10^,11.

The study followed the phases of CCR, namely: conception, instrumentation, investigation, and analysis. In the conception phase, the research question, objective, literature review and theoretical support are defined. In the instrumentation phase, decisions were made about methodological issues such as scenario, definition of participants, data collection technique, etc. The investigation phase consists of obtaining information and recording it with a double intention: building scientific knowledge in the research area and favoring the improvement of the care provided. The analysis phase is divided into four: apprehension, synthesis, theorization and transfer10^-12.

The research setting was established in the public space of the streets and healthcare network services, covering several locations where the Street Clinic teams operate in a northeastern capital. During the research, the capital had six teams classified in modality II13, as recommended by the Ministry of Health. This means that each team is composed of at least six professionals, of which three must have a higher education level, and three high school level. The choice was made because only the capital of this state has Street Clinic teams implemented.

The inclusion criteria were workers in the service for more than six months, considering greater familiarity with the service and the exclusion criteria were workers away from activities due to illness that hindered their participation in the research.

Regarding participant recruitment, contact was made with the coordination of Street Clinic and a presentation about the research was scheduled at a general team meeting, in which the project was presented, and everyone was invited to participate in the study. Those who were interested gave their name and telephone number to the researcher, and a WhatsApp® group was created to facilitate the sharing of information.

Regarding the production of information, participant observation and convergence groups were used, as CCR considers the use of mixed recording techniques to ensure the apprehension of the greatest amount of information10^,11. The participant observation allowed the researcher to immerse themselves in the participants’ healthcare practice scenario, an integral principle of CCR10^-12. This process was facilitated due to the researcher’s previous proximity and familiarity with the Street Clinic teams, as already mentioned. Thus, the researcher was able to work with the teams, experiencing the work routine from May to October 2021, twice a week, with a total of twenty four visits to the field of activity of workers from the Street Clinic teams, totaling 144 hours, with field diary recording each visit. During participant observation, it was possible to schedule the dates for carrying out the convergence groups, which was possible when considering the proactive role that the researcher assumes when conducting the CCR.

The convergence groups aim to acquire information simultaneously with practice10^,11. They were organized as follows: opening of the group meeting; presentation dynamics; presentation of guiding questions, discussion; synthesis; and closure. The technique followed a guide with guiding questions that allowed the for a deepen discussion, namely: “What do you understand by health promotion?”, “What health promotion activities do you develop for the worker’s health?” and “What health promotion interventions can be implemented to promote the health of the Street Clinic workers?”.

The use of this technique allowed a space where workers were heard, reflected on the topic and participated in the collective construction of the possibilities for actions to be developed for their health. Four convergence groups were held with 5-12 participants per meeting, with an average duration of 2 hours, with 60-70 minutes set for discussion, and the remainder for ice-breaking dynamics and tolerance of participants who were late. The meetings had the main researcher as moderator, as well as her advisor, in addition to a nursing academic who underwent prior training on CCR. Upon participants’ authorization, a voice recorder was strategically used to record discussions. Subsequently, this information was presented to workers in a virtual meeting via the “Google Meet” platform, providing an opportunity for data validation.

The analysis of the information followed the CCR analysis phase10. In apprehension, an exhaustive and detailed reading of the content obtained through records in field diaries and convergence groups was carried out, identifying the points that emerged from the information, for coding and categorization. In the synthesis, there was the construction of a coherent text, which provides significant information about the phenomenon studied, based on the categories identified. Theorization consisted of discovering the value contained in the information, in light of theoretical references, namely the PNPS and PNSTT. The choice of this theoretical support is justified by its alignment with the principles and guidelines of the SUS. Finally, the transfer phase concerns the contextualization of these results, reflecting on new practices that impact the quality of care10^-12.

After information analysis, Reichian stretching was implemented as a health promotion intervention for workers at the Street Clinic, as the practice proved to be a viable action for development within the teams. Reichian stretching promotes, in addition to movement and muscular stretching of the body, the integration of mental exercise with the body, by generating awareness and self-perception. Therefore, it provides an interaction between the body and mind, as it is an exercise that focuses on developing both the physical and emotional aspects.

The practices took place in February, and to each worker was offered four Reichian stretching sessions, once a week. The sessions lasted 60-90 minutes and were attended by 8 to 13 participants per session. The moment was conducted by a therapist, with training in physical education and psychology, who created this complementary therapy as a result of her master’s degree.

In the last session, a form was applied to assess the practice, consisting of three open questions: “How did you feel before participating in the Reichianstretching practices?”, “How do you feel now after the Reichian stretching practices?” and “What did these moments of health promotion mean to you?”.

The research was approved by the Research Ethics Committee of the Universidade Federal de Alagoas, under No. 43129020,0,0000,5013 and followed the guidelines of Circular Letter n=Mo. 1/2021-CONEP/SECNS/MS, which guides procedures in research at any stage in a virtual environment. The participants’ consent was given after reading the Informed Consent Form, which was signed in two copies, one by the participant and the other by the research team. The anonymity of the participants was preserved by using the letter “P” (participant), followed by a number, which represents the order of speech in the meetings, and with the “T” (team) also followed by a number according to the order of participation in groups.

RESULTS

The study participants were 39 workers representing the six Street Clinic teams existing in the city studied aligned with the inclusion criteria, out of 46 workers. Four professionals refused to participate in the study, two were on sick leave and one was on leave due to pregnancy. From the 39 participants there are: 6 nurses, 4 social workers, 4 psychologists, 2 dentists, 1 oral health assistant, 1 physical educator, 2 occupational therapists, 11 social workers, 1 nursing assistant, 3 nursing technicians, 1 physician, 1 driver and 2 managers.

After exploration and understanding of the information produced, through the stage of CCR analysis, four categories emerged: “Knowledge and practices to promote the health of Street Clinic workers”, “Workers’ health on alert: reflections on the effects of work on the worker”, “Interventions that can be implemented suggested by workers” and “Action and incentive to promote the health of Street Clinic workers”.

Knowledge and practices to promote the health of Street Clinic workers

The category addresses the knowledge of Street Clinic workers on the topic of health promotion and the strategies they adopt to promote health at work. Thus, the participants demonstrated an understanding of health promotion related to healthdeterminants, access to services, guarantee of social rights, with a holistic and comprehensive view of the human being, distant from the concept of health as the mere absence of disease.

Health promotion is also access to these basic and elementary goods that, from this point of view, are listed in the charter of human rights. (P5, T4)

We think about what thehealth determinants are, what condition this person is in. (P5, T1)

Preventative things, like exercise, sleeping well, risk prevention, nutrition. This, all the time because, often, we take care of one part and don't take care of the other. It's a holistic and free thing. (P1, T5)

They also bring a concept of health promotion related to the uniqueness of this group of workers according to the way they organize themselves at work. A care that is very focused on others, an attentive look at theircolleague.

When we provide comfort to our colleague; when we help a colleague with research; when we help our colleague with adjusting their PPE, requesting cleaning materials to tidy up the room… we communicate about the territory, the field, the users. When we bring comfort to our job. (P1, T6)

It really is the cleaning of the car that makes the environment more pleasant for people who are working, making a coffee, having a coffee together before leaving. (P2, T6)

Workers also recognized as a health promotion practice the way they relate to each other as a team.

So, the team itself, we, have this care, this concern, for each other. (P4, T6)

To this end, they rely on “Taking care of the Caregiver” as an activity promoted by local management with the aim of providing moments of leisure, reflection, and self-care.

This month the management will do "taking care of the caregiver", which besides being a time for a general meeting between the teams, will be a moment of relaxation, for us to lighten up, play. (P5, T6)

They also report their experience with some integrative practices such as acupuncture, auriculotherapy, massage and cupping therapy, the therapeutic effect of music, as well as controlling cell phone use outside of their shift, as well as moments of break and relaxation at work.

P6 brought acupuncture last time[...] it was really cool. (P3, T3)

So, I did auriculotherapy with some people from the team, and massage. [Mentios name of a team member], when he was on the team, did cupping. (PE, T6)

On the journey as we listen to music, you feel a difference, you know? You feel a lightness to everyday life, you feel a lightness to the countryside, when you go out, when you return to the street, it's as if the street became a safe place, you know? A comfortable place to be. (P2, T6)

I had to organize my schedule, so as not to be just on the phone, because otherwise, instead of working thirty hours, I would be working eighty [...] I select the times when I have the phone. When I get home, I leave it there. (P3, T6)

Sometimes, when we are very stressed, it is an exhausting field. Every now and then, we go have ice cream, soup, you know?(P3, T3)

Workers’ health on alert: reflections on the effects of work on the worker

Regarding the context of workers’ health, it was evident that the act of caring itself is exhausting, but the reality of assisting the homeless population has its peculiarities, increasing physical and emotional exhaustion, with consequences on life and health of these professionals. It can be seen in the statements:

I got sick the other day, so I think this stop also has to do with all the suffering we see. I see people getting stabbed, getting shot [...] We freak out sometimes. [...] I sleep because of the medicine, why? Because I've been [working in this service] for ten years. (P8, T4)

So, this hardness of daily life, of what our professional work is, sometimes affects us a lot and we have to be very careful not to enter into a process of mental illness. (P5, T4)

In this context, they reflect that dedication and concern cannot only be focused on others, but also on themselves, in a transcendent relationship that begins within themselves and interferes with the relationships of those around them. Thus, a lack of self-care can trigger the process of illness.

We always stop and ask: How do we take care of others, if we don't take care of ourselves? Many times, we violence ourselves, I don't know if that's the word, but many times we ignore what we are feeling, to be there taking care of the other and it ends up getting worse. (P5, T2)

Interventions that can be implemented suggested by workers

In the convergence groups, workers were able to reflect on health promotion interventions that they can implement for the benefit of their health and the team, including taking advantage of the skills and expertise of each member.

And so, we can take advantage within our own team. There is P9, who is a physical educator, who can do stretching. (P3, T3)

“So, I did auriculotherapy with some people on the team, and massage. P4, when he was on the team, did cupping”.(P2, T6)

From the discussion, they recall interventions already practiced among them and the importance of returning to these activities.

Acupuncture works for me, a little massage, cupping. We need to bring back these moments, very good. (P3, T3)

Moreover, they show an affinity for some integrative practices, as seen in the statements:

What we had in the UFAL care room: Reiki, massage, chiropractic, foot reflexology… This could be also done for us, right? (P3, T5)

Laughter therapy. I've already done an experiment. (P1, T4)

I also think onmeditation, because it works on breathing. (P5, T4)

Furthermore, they also suggest collective interventions such as therapeutic groups, going to the cinema, moments of pause and relaxation.

Group dynamics really come in as therapy because, sometimes, we as professionals need to listen to each other and we don't have that moment. (P1, T5)

So, I have even suggested to the team a trail, a tour, the tour of the nine islands... I already tried to propose. (P1, T5)

I even think a movie session, I don't know. (P1, T4)

Although I don't know how to dance, but I think it's cool, the body movement is good. The body speaks a lot, doesn't it? We express ourselves. (P4, T6)

Finally, they understand the need to create a policy that considers the peculiarities of the work conducted by the Street Clinic.

I think the department needs to take the humanization policy and draw up a plan, make an accurate diagnosis of the different programs, the different areas, on the main bottlenecks and create a human resources policy, which the department does not have. That it needs! And, within this policy, the street clinic itself is included. (P5, T4)

Action and incentive to promote the health of Street Clinic workers

Through the reflections aroused, the discussion in the convergence groups, considering the nature of CCR to bring renewal of care practices and solution/minimization of the identified problem⁽⁶⁾, it was decided with the workers to develop Reichian stretching, considering the feasibility development with the teams. It is believed that Reichian stretching is a stimulus for the team to develop other health promotion practices with the resources they have. Before carrying out this practice, workers reported feeling stuck, tense, accelerated:

Stuck. (P3, T1)

With a lot of pain in the body. (P5, T2)

Tired, stressed. (P10, T6)

I felt heavy, my body felt stuck. (P5, T4)

After practicing Reichian stretching, it was clear that there was relief from tension, relaxation, disposition and body awareness and the need to slow down, as observed in the following statements:

Relaxed, willing, rested. (P7,T3)

More attentive to my body's signals, I mean more perceptive and careful with my body's limits. (P8, T5)

I am becoming more aware of my body and my breathing. (P12, T1)

Thus, Reichian stretching sessions were considered by workers as a moment of care and reflection on the need to stop and look at oneself and take care of oneself, transcending learning to improve relationships with work and with people, as can be observed in the statements:

I feel like I can use the learnings from this practice to improve my relationship with my work and with my partners. (P4, T2)

A rich and necessary moment, as it is a moment to take care of myself, as a person, as a professional, reflecting positively on the work process. (P10, T3)

These moments were very significant, as they gave us lightness and more relaxation, thus contributing to better performance at work. (P12, T5)

It meant self-love, being with myself and with my colleagues. (P6, T1)

DISCUSSION

Health promotion can be understood as the process of empowering people to act to improve their quality of life and health, which includes greater participation and social control. Thus, there is an expanded concept of health that goes beyond the absence of disease and is constituted by the fundamental elements to ensure the exercise of living with access to housing, education, sustainable resources, equity, etc7. It is clear, therefore, that health promotion, besides biological actions, fundamentally covers social aspects14^,15. It was possible to notice that the concept of health promotion brought by the workers is close to the concept of health proposed by the PNPS.

In the excerpt of the statement that addresses health promotion as “a holistic and free thing”, the SUS principles of comprehensiveness, equity and universality can be seen, regarding considering the individual as a whole at all levels of healthcare, regardless of financial conditions and social inequality. This is because it is the responsibility of the Ministry of Health to facilitate mechanisms for co-funding plans, projects and health promotion programs6. Thus, it is understood that health is a social right, and the government must guarantee it by offering essential services and possibilities for people’s development equitably6^,7.

Regarding health care and attention, comprehensiveness in health promotion must consider the specificities and potentialities in the construction of therapeutic, life and health work organization projects, through qualified listening to workers and users, to shift the focus restricted to illness to a welcoming look at their stories and living conditions. According to the PNPS, health actions and services must operate with a view beyond the walls of health units7.

The PNSTT emphasizes the importance of considering the worker according to the reality in which they are inserted. The care offered in the street space is marked by a meeting between those who care and those who are cared for, which involves dealing with a reality surrounded by precariousness of life and vulnerability. This can involve workers’ feelings and have impacts on their personal lives, making it difficult to disengage from work, as memories of what is experienced remain strong in workers’ minds16. This is observed in the statements of research participants when addressing the harshness of their work routines, reporting exposure to situations of violence, which results in mental distress. These aspects, in turn, affect the quality of sleep, leading to the need to use medications.

A research in Canada with service providers working with homeless people also revealed the mental suffering of these workers, including the emergence of burnout, secondary traumatic stress, symptoms of depression and anxiety, as well as compassion fatigue17. Corroborating this finding, another study conducted in four states in Germany, with the participation of two hundred and fifty-three social workers working with refugees and homeless people, showed that this type of service generates work-related stress and demands great emotional effort from the worker18.

The life territory of the homeless population challenges the provision of comprehensive care, as it emphasizes the principles of the SUS3. A study that characterizes the work of the Street Clinic in the same capital as the present study reveals situations of tension that can affect the worker, the difficulty of accessing some services, even causing them to be mistreated due to the prejudice of professionals, who make access difficult due to lack of preparation and discrimination against the homeless population. Furthermore, they suffer from difficulties in providing comprehensive assistance due to lack of resources and adequate structure for assistance, as they form a bond with the user and suffer from restrictions in being able to help4.

In Canada, service providers who work with vulnerable and homeless individuals also face the reality of inadequate care in health services. A study conducted with these service providers revealed a lack of responsibility, besides insufficient knowledge about the approach to harm reduction by certain health professionals who are part of the Canadian healthcare system, especially when it comes to this specific public, resulting in situations of discrimination during service19. These situations can cause stress and emotional distress for workers, leading them to experience a feeling of helplessness.

Therefore, it is important that the work context is permeated with forms of care that value the worker and preserve their dignity and respect. Thus, the participants in this research recognize that they develop some health promotion interventions at work, such as mutual care among team members.

Research conducted with workers from the Street Clinic in the same capital of this study shows that teamwork can also be a way of adapting to the context of working on the street. Always being accompanied in the field and maintaining the bond between the team are light technologies that work as measures to prevent risks at work2. However, this way of working, with unity and companionship, goes beyond risk prevention, it involves respect, acceptance and a feeling of belonging20. In fact, research participants describe health promotion with attitudes of affection towards their colleague, such as maintaining a pleasant work environment, preparing coffee, taking care to clean the car, and worrying about the other.

A study with the Street Clinic in a city in southern Brazil corroborates these findings by showing, through basic lexicography, that the most frequent word in the daily life of this service was “people”, directly relating to teamwork. The way of organization at work that considers the knowledge and skills of each member can be an instrument that enhances health resolution at the Street Clinic. The very nature of the work to develop comprehensive care implies the need for team members to act in an comprehensive and interdisciplinary way4^-20.

Another way to strengthen team bonding and bring lightness to work dynamics is “Taking care of the caregiver”, an initiative mentioned by the participants, which is promoted by management with the intention of holding a general meeting with the teams and having a moment of relaxation. It is worth noting the importance of the practice developed by management for worker health, given that the literature shows worker health actions as not incorporated into the work routine of Primary Care teams. Overall, they are scarce and lack articulation with the PNSTT, facing obstacles to full development such as work overload, inadequate professional training and lack of institutional support21.

A scoping review was supported by the “Institution for Statutory Accident Insurance and Prevention in the Health and Welfare Services” (BGW) in Germany aimed to assess the work of service providers assisting refugees and homeless people. The difficulties involved are related to the bureaucratic system, the high number of cases and frustration with the unsuccessful results of the approaches. Regarding coping strategies, some of them are similar to those presented by the Street Clinic workers in this present study, such as establishing limits and providing support from the team. Furthermore, the study revealed a high prevalence of mental health issues among service providers22.

This corroborates the results brought by the study and underscores the need for and importance of cooperation from the Reference Centers in Workers’ Health (Centros de Referência em Saúde do Trabalhador - CEREST), which are referenced in the PNSTT6. A study that analyzed worker health actions in Primary Care teams in Montes Claros, Minas Gerais, in 132 basic health units, found that teams have difficulty incorporating worker health interventions into their daily work activities, demonstrating the need for professional qualification and pedagogical and institutional support23.

The obstacles to promoting worker health in Primary Care are challenging, however, it was observed that Street Clinic workers seek to overcome them with actions of self-care and team care, such as auriculotherapy, acupuncture and music. When addressing interventions that can be implemented, workers show interest in knowing some Integrative and Complementary Health Practices (PICS), mentioning some that are not yet recognized by the Ministry of Health, such as Reiki, massage, foot baths, laughter therapy and meditation. These practices are related to the definition of health promotion brought by the PNPS, as they stem from the expanded concept of health and have at their core the articulation with other healthy public policies7.

A non-conventional health promotion action proposed by workers draw attention: moments of leisure and entertainment such as rides and going out. It is worth noting that some organizations include in their planning greater attention to weekend leisure activities and holidays, provide partnerships with companies that facilitate worker access to their services, quick coffee breaks and, more recently, have been introducing greater flexibility in managing working time, allowing time for rest and relaxation. Such actions show positive results with improved social interaction in the work environment, therefore, greater performance24^,25.

Another highlight, as an action to promote the health of Street Clinic workers, is the limit on cell phone use outside of work shifts. In this aspect, it is known that the working day has a direct impact on the worker's health, both physical and mental. The “illegal” extraordinary journey needs to be considered, especially with the advancement of technology, in which the worker continues to be connected and working even after the end of their contractual journey, whether through WhatsApp®, Telegram® and other applications or telephone calls25^,26. The use of cell phone outside of work hours gives the feeling of uninterrupted occupation. As a result, the invasion of work into times dedicated to rest has consequences, such as limiting rest and interfering with family life, which manifests itself in the process of worker becoming ill with the emergence of anxiety, stress, depression, burnout syndrome, etc26.

By considering the importance of developing interventions for workers' health, the discussion in the convergence groups allowed reflection on the possibility of resuming previously developed practices and carrying out activities based on the skills of team members. This is positive in CCR, as the aim is to continue health promotion actions even after the end of the research.

The interest mentioned in therapeutic groups may be related to the lack of actions in worker's health, without so many spaces for welcoming, listening and embracing the demands brought by the user-worker. The Clinic translated by speaking and listening enables collective solutions and reframing of experiences and suffering27. The PNSTT proposes the articulation of several actions in worker’s health, but services that assist workers with emotional work-related demands remain scarce6.

The PNPS encourages the construction of public policies according to the factors and conditions of vulnerability, the risks and potentialities that appear in the lives of the population and for production, as well as the dissemination of knowledge and health practices in a shared and participatory way. It also contemplates the expansion of representation and inclusion of subjects in the development of public policies and in relevant decisions that affect the lives of individuals, the community and their contexts7. In worker’s health, shared, decentralized and participatory management operates with the aim of valuing workers, expanding access and comprehensive care6^,7.It is in this context that the workers suggest a public policy based on the Humanization Policy that includes Street Clinic workers.

Research conducted in Berlin and Hamburg, involving social workers who care for homeless and vulnerable people, revealed the importance of developing self-care measures at work, adopting some measures such as time management, establishing personal limits, seeking support in the face of adversity, self-care practices, dedication to leisure, keeping distance from work when necessary, counting on the support of teammates and resorting to management resources and other institutions. Furthermore, they revealed that they were not aware of the availability of specific health promotion activities in the workplace. However, they expressed the desire to implement structural and behavioral health promotion measures18.

Given the need to stimulate and intervene in the promotion of Street Clinic workers' health, considering the participation of the actors in the work process, it was decided together with the workers to develop Reichian stretching, which will possibly bring positive effects, considering their exposure to numerous loads and demands that contribute to energy stagnation, muscle blockage, and consequently muscular armoring. Thus, the exercise allows the integration of mental and physical exercise by promoting awareness and self-perception28^,29.

The sensation reported by workers, before the practices, associated with fatigue, stress and pain is close to the Reichian conception of the formation of muscular armor, which corresponds to a defense mechanism of the body in the face of life’s difficulties and anguish. The body responds with muscle tone to protect itself, remaining in a state of constant muscular tension, which corresponds to the armoring process. The armored organism presents itself from the disconnection between reason and emotion28^,29.

After the practices, it is evident in the statements, that the activity provided not only muscle stretching, but the sensitivity to perceive limits of the body and breathing, going beyond the self-relationship for learning that can be used in other spaces, as noted in the fragment: “in the relationship with my work and with my partners”. They reported that the practices encouraged reflection on the work process and improved performance. A limitation of the intervention is the physical restriction of some participants to practice due to previous comorbidities.

The moment of intervention to the health promotion of the Street Clinic worker with this practice meant a space of care and acceptance. Therefore, moments of health promotion at work should also be a subject in the construction of agendas for the adoption of work life strategies and this means relating the environments and territories of life and work of communities, identifying opportunities for health promotion activities carried out in different locations that excel in dialogue and participation7.

CONCLUSION

It was evident that the reality of assistance and care for the homeless population has its peculiarities, which can increase physical and emotional distress, with direct impacts on the lives and health of the workers, posing the challenge of self-care while taking care for others. Thus, some interventions for promoting the health of Street Clinic workers were raised by the participants and collectively, the decision was made to implement Reichian stretching, which provided a space for practice and reflection on care and respect for boundaries.

The study’s contribution was to shed light to the health of Street Clinic workers, demonstrating the importance of developing worker health promotion actions within the scope of the SUS. It was found that workers have a conception of health promotion related to access to services and guarantee of rights consistent with the expanded concept of health brought by the PNPS.

Acknowledgments:

The present study was conducted with support from the Research Support Foundation of the State of Alagoas (Fundação de Amparo à Pesquisa do Estado de Alagoas - FAPEAL) through the Research Program for the SUS / FAPEAL Notice No. 06/2020, process No. E:60030.0000000204/2021.

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Edited by

• Associate editor:
  Gabriella de Andrade Boska

• Editor-in-chief:
  João Lucas Campos de Oliveira

Publication Dates

• Publication in this collection
  22 Apr 2024
• Date of issue
  2024

History

• Received
  08 May 2023
• Accepted
  04 Dec 2023