POPULAR HEALTH EDUCATION: MEANING OF EXPERIENCE IN TRAINING COMMUNITY HEALTH WORKERS¹

ABSTRACT:

This study brings results from a qualitative research aiming to analyze the meaning of the training experience of Community Health Workers (ACSs, in Portuguese) in the Qualification Program in Popular Education in Health (EdPopSUS), one of the priority strategies of the Operative Plan of the National Policy of Popular Education for the Unified Health System, in Brazil. Data production occurred between 2018-2019 and included documentary analysis and semi-structured interviews with the ACSs and the health and EdPopSUS managers. The textual material produced was interpreted by content analysis, in light of the Popular Education theoretical framework. The results showed that EdPopSUS encouraged the ACSs' reflection, dialogue, and affection, enhancing their creativity and autonomy in an educational space of self-knowledge and interaction with their experienced world. ACSs' personal and professional experiences were valued, improving their communication with the team, the community, and the families, their listening skills, and their ability to conduct collective educational activities. The field trips and the conversation rounds were highlighted as potentialities of this training. Challenges were identified in implementing the principles of Popular Education in Primary Health Care. The experience analyzed strengthened ACSs' role as agents of change and popular educators. In this sense, Popular Education in Health was reinforced as a pedagogical-social practice, strengthening people, movements, teams, care practices, and the health system. The educational processes based on Popular Education are recommended for the permanent education of health teams.

Keywords:
Community Health Workers; Popular Education; Primary Health Care; Unified Health System

RESUMO:

Este estudo traz resultados de uma pesquisa qualitativa cujo objetivo foi analisar o significado da experiência de formação dos Agentes Comunitários de Saúde (ACSs), no Programa de Qualificação em Educação Popular em Saúde (EdPopSUS), uma das estratégias prioritárias do Plano Operativo da Política Nacional de Educação Popular para o Sistema Único de Saúde, no Brasil. A produção das informações aconteceu entre 2018-2019 e incluiu análise documental e entrevistas semiestruturadas com os ACSs e os gestores de saúde e do EdPopSUS. O material textual produzido foi interpretado pela análise de conteúdo, à luz do referencial teórico da Educação Popular. Os resultados evidenciaram que o EdPopSUS incentivou a reflexão, o diálogo e a afetividade dos ACSs, potencializando sua criatividade e autonomia, em um espaço educativo de autoconhecimento e interação com seu mundo experenciado. As vivências pessoais e profissionais dos ACSs foram valorizadas, qualificando sua comunicação com a equipe, a comunidade e as famílias, sua habilidade de escuta e sua condução das atividades educativas coletivas. As saídas de campo e as rodas de conversa foram destacadas como potencialidades dessa formação. Desafios foram identificados na implementação dos princípios da Educação Popular no trabalho da Atenção Primária à Saúde. A experiência aqui analisada fortaleceu o papel do ACS como agente de mudanças e educador popular. Nesse sentido, a Educação Popular em Saúde foi reforçada como prática pedagógica-social, fortalecendo pessoas, movimentos, equipes, práticas de cuidado e o sistema de saúde. Os processos educativos fundamentados na Educação Popular são recomendados na educação permanente das equipes de saúde.

Palavras-chave:
Agentes Comunitários de Saúde; Educação Popular; Atenção Primária à Saúde; Sistema Único de Saúde

RESUMEN:

Este estudio cualitativo analiza el significado de la experiencia de formación de agentes de salud comunitarios (ASCs) en el Programa de Calificación de la Educación Popular en Salud (EdPopSUS), una de las estrategias prioritarias del Plan Operativo de la Política Nacional de Educación Popular para el Sistema Único de Salud, en Brasil. La producción de la información se dio entre 2018-2019 misma que incluyó un análisis de documentos así como entrevistas semiestructuradas con ASCs (n=17), gestores de salud y de EdPopSUS (n=4). El material textual producido fue interpretado mediante un análisis de contenido, a la luz del marco teórico de la Educación Popular. Los resultados mostraron que EdPopSUS alentó la reflexión, diálogo y afectividad, potenciando la creatividad y la autonomía de la ASC, en un espacio educativo de autoconocimiento e interacción con su mundo experimentado. Se valoraron las experiencias personales y profesionales de los ASCs, calificando su comunicación con el equipo-comunidad-familias, la capacidad de escucha y la realización de actividades educativas colectivas. El trabajo de campo y las mesas de conversación fueron destacadas como potencialidades de esta formación. Se identificaron desafíos en la implementación de los principios de la Educación Popular en el trabajo de la Atención Primaria de Salud. La experiencia fortaleció el rol de ASC como agente de cambio en la educación popular lo que reforzó la Educación Popular en Salud como práctica pedagógico-social para fortalecer a las personas-movimientos-equipos-prácticas de cuidado-sistema de salud. En la educación continua de los equipos de salud se recomiendan procesos educativos basados en la Educación Popular.

Palabras clave:
Agentes de Salud de la Comunidad; Educación Popular; Atención Primaria de Salud; Sistema Único de Salud

INTRODUCTION

Challenges regarding inadequate professional training to answer the need for universal access and integrated practice in the health system are present in the debate about the changes in health workers' education (FRENK et al., 2010). This theme has been approached by the journal Educação em Revista, through the publication of studies, reflections, and problematizations conducted by professionals and theoreticians in the education area (STRECK; PITANO; MORETTI, 2017; FRANCA JUNIOR; MAKNAMARA, 2020; CHIANCA-NEVES; LAUER-LEITE; PRIANTE, 2020).

Fragmented, outdated, and static curricula, which weakly develop teamwork competencies, and the gap among teaching, reality, and pedagogical aspects have been insufficient to prepare professionals that can improve the performance of health systems (FRENK et al., 2010; MACHADO; XIMENES NETO, 2018).

Seeking to find other strategies to refocus the educational processes on health, Popular Education is a device to produce shared knowledge (BONETTI; PEDROSA; SIQUEIRA, 2011) by recognizing and facing health problems through the dialogue with popular classes, respect to their culture, and the recognition of their knowledges as valid (VASCONCELOS, 2007). In Brazil, Popular Education, theoretically based on Paulo Freire's problem-based pedagogy (FREIRE, 2003), seeks the decrease of regional inequalities and social inequities as well as the strengthening of constructions in favor of cultural diversities and the possibilities of being in the world (BRASIL, 2013).

The present research was developed to bring the theme of popular education to health workers' training. The assumption that moves this study is the qualification of workers from the Sistema Único de Saúde (SUS - Brazilian Unified Public Health System) through Popular Education (AMARAL; PONTES; SILVA, 2014). The text aims to analyze the meaning of the training experience of Agentes Comunitários de Saúde (ACS - Community Health Workers) at the Programa de Qualificação em Educação Popular em Saúde (EdPopSUS - Qualification Program in Popular Education in Health) (FIOCRUZ, 2017). The Program is one of the priority strategies in the operational plan of Política Nacional de Educação Popular para o Sistema Único de Saúde (PNEPS-SUS - Operative Plan of the National Policy of Popular Education for SUS) (BRASIL, 2013), thus, justifying this study.

METHODOLOGY

This research was established as a journey, a pathway built while walking, with every doubt and fear raised by novelty. Freire (2014) argues that nobody makes a journey in complete terms, mainly without someone's help. Thus, each and every person is important when building this methodological pathway, which seeks to be a dialogue woven by many hands - from the authors to the participants.

It is a qualitative study characterized as a case study (YIN, 2010) that investigated the phenomenon of ACSs training through Popular Education in Health at EdPopSUS. The field research was conducted in the space of Atenção Primária à Saúde (APS - Primary Health Care) in a city in Rio Grande do Sul, Brazil.

EdPopSUS is a program to improve the educational practice of workers and community leaders working at SUS, focused on the training of Agentes Comunitários de Saúde e de Agentes de Combate às Endemias (ACE - Community Health Agents to Combat Endemic Diseases) (FIOCRUZ, 2017). EdPopSUS aims to favor workers' actions to guarantee the population's right to health and strengthen social participation in 13 Brazilian states: Bahia, Ceará, Maranhão, Mato Grosso, Minas Gerais, Pará, Paraíba, Pernambuco, Piauí, Rio de Janeiro, Rio Grande do Sul, São Paulo, and Sergipe. Besides this, it promotes the qualification of the educational practice of workers and community leaders working in territories attended by SUS Basic Care (FIOCRUZ, 2017). The Program is grounded in a democratic and freeing pedagogical proposal, guided by integral learning, establishing a horizontal relationship between teacher and student, valuing local cultures, and incentivizing autonomy and dialogue (BRASIL, 2016).

The political-pedagogical project of the workers’ training course was comprised of individual and collective educational strategies that valued the sharing of knowledges and experiences, so that educands could develop, at the core of their training, the respect towards the autonomy of health system workers and broadening the exclusive focus on the biological aspects of health-disease (FREITAS et al., 2015). Hence, the course has as pillars of this construction: dialogue, love, problematization, shared knowledge building, emancipation, and a commitment to build a participative health education process.

This formation course lasted approximately four months, totaling 160 hours of in-person activities, 136 hours of group activities, and 24 hours of field hours; approximately 17 weekly meetings lasting 8 hours each were intercalated with fieldwork in the territory.

The course structure was organized into six theme axes (Figure 1) divided into in-person and fieldwork moments. These axes were divided into eight-hour periods, weekly, called "encounters," theoretically grounded on the course's didactic material, comprised of a Guide and a book of Support Texts, which organized and provided the content considered fundamental to the course's formation pathway. This structure differs from other curriculum proposals by offering content open to perceptions and the new constructions resulting from learning, with only guiding axes, such as essays, text, and literature reviews. Furthermore, it indicates complementary material, mainly available online, such as videos, interviews, short movies, movies, documentaries, songs, and sites, all considered strategic to support the discussions, helping to deepen the process and ground the reflections that emerged in the learning pathway of EdPopSUS (BORNSTEIN et al., 2016).

Figure 1
- Description of theme axes and workload at EdPopSUS

All course activities were organized to give space to provocations and problematization through a collective path, prioritizing as a method “the implementation of collective works” (BORNSTEIN et al., 2016, p. 15). Therefore, the in-person training process was organized collectively through Conversation Circles to discuss the central axes, Culture Circes (Freirean methodology that proposes integral learning, as these circles are grounded on the democratization of dialogue and the experiences of actors-subjects) as a participative method, which promotes autonomy, Cenopoesia (language produced based on the articulation of languages) to articulate and cocreate, and Workshops, which promote a more horizontal dialogue and knowledge democratization.

There were closing/ending dynamics, theater and dramatization activities, discussion sessions, and the exhibition of documentaries and videos in all in-person activities. Furthermore, a mística² was always organized to jointly build a net of meanings. Besides the in-person encounters, as part of the EdPopSUS training, the course also promoted field trips to know the communities and experiences in different territories, such as a visit to the Landless Movement settlements, Indigenous communities, islands, museums, and local communities.

ACSs studying at EdPopSUS who finished their educational process in 2017 and worked at APS (n=27) were invited to participate in the research, as well as national and state managers of the Program (national and state supporters of EdPopSUS in Rio Grande do Sul), who were part of coordination team (n=2), and health managers in the city studied (n=2). The municipal managers - Municipal Health Secretary and Coordinator of the Family Health Strategy - were selected due to their knowledge and involvement in the program, who could point out the changes in the work process of the teams and every routine of health services from the ACSs' training experience at EdPopSUS.

Data production was conducted from 2018 to 2019, including documental analysis and interviews. The documental analysis included the course's didactic material, students' letter of expectation, and the final letter to contextualize EdPopSUS. The interviews followed the guidelines of COREQ - Consolidated Criteria for Reporting Qualitative Research (TONG; SAINSBURY; CRAIG, 2007). The individual semi-structured interviews followed guiding questions (Figure 2) and were conducted by a researcher during five months in a reserved space at the participants’ workplace on a previously scheduled date and time.

Figure 2
- Interview guiding questions

To determine the sample size in the interviews with the ACSs, the criteria of theoretical saturation was used (FONTANELLA et al., 2011), connected to the research group's analysis of the textual material density. The ACSs who were on vacation or some type of leave during the interview phase were excluded from the research. At the end of data production 17 ACSs and four managers (n=21) were interviewed.

The interviews were recorded and fully transcribed, with an average time of 35 minutes, totaling 12 hours. ACSs received the transcriptions so that they could evaluate them and, if necessary, change and/or add to their reports.

The interpretation of textual material followed the strategy of theme content analysis (BARDIN, 2011), anchored in the theoretical reference of Popular Education.

To keep students’ anonymity, the Agentes Comunitários de Saúde were identified by ACS and managers as Managers, both followed by the number corresponding to the interview/final letter.

The research was approved by the Research Ethics Committee of the University to which it was connected (Report n^o 2.465.370).

RESULTS AND DISCUSSION

Considering the intention that guided this research, seeking to understand the meanings of ACSs’ training at EdPopSUS, the researchers felt the need to start from the socio-historical time of the research protagonists, which culturally originates and establishes it. This "ethnographic moment" (DEMO, 2001) produced by the interviews allowed us to know the context of interviewees' lives to understand their objectives and subjectivities situation better, considering that, in this analysis, time is not an accessory but constitutes each person.

Out of the 21 participants, most were women between 33 and 56 years old who had worked for at least seven years in public service. Regarding education, 10 were undergraduate graduates, six had post-graduation diplomas, and three were undertaking an undergraduate Nursing course (Table 1).

Table 1
- Characterization of research participants

VARIABLES	PARTICIPANTS
SEX
Women	18
Men	3
AGE (YEARS)
33-40	5
41-50	9
51-56	7
EDUCATION
Complete elementary/middle education	1
Complete High School	7
Incomplete Higher Education*	3
Complete Higher Education*	4
Post-Graduation**	6
Complementary training (professional improvement courses)	21
YEARS AT WORK
7-10	11
11-15	5
16-20	3
21-22	2

• Source: Created by authors.
• Note: * Undergraduate degrees in Nursing, Pharmaceutical Sciences, History, Pedagogy, Social Services.
• ** Post-graduate courses in Public Management, Family Health, and Emergency Health.

Among the ACSs, women's predominance is justified for its fundamental role in health care within the community. It follows the social and historical construction of care as intrinsically connected to women in most societies, as shown by other health professions, such as Nursing. The increasing phenomenon of feminilization of the health workforce in Brazil can also be a factor (MATOS; TOASSI; OLIVEIRA, 2013; CONTATORE; MALFITANO; BARROS, 2017; HERNANDES; VIEIRA, 2020).

Women's workforce as ACSs, alongside the multi-professional team, aims to promote the population's health care. The practice of care is attributed to women as a naturalized process, originally emerged in the cultural construction of women in society (SANTOS et al., 2020). Hence, women are identified as having more abilities -the wise women - in caring, related to the triple aspect of being: body - health-disease, as well as in the care of children and/or the elderly (MACHADO, 1986; FEDERICI, 2017). However, this care is often not recognized as a formal work, and when it does, it is commonly perceived as a subaltern activity (SANTOS et al., 2020). According to Hirata (2014), care work is an example of inequality embedded in gender, class, and race, as caregivers are mainly women, poor, black, and vulnerable. Hence, the materialization of women’s unequal inclusion in the work relations in a neoliberal capitalist society can come from the historical naturalization of care, conceived as a biological attribute exclusive to women.

In this study, the participants' qualified training stands out. All ACSs had complementary training in improvement courses, as well as higher education degrees (concluded or underway while working as ACSs). This fact is striking considering that up to 2017 the requirement to work as an ACS was to have completed middle school (BRASIL, 2018). The improvement courses promoted by the Ministry of Health (BRASIL, 2013) and the education policies that increased the access to higher education in the country changed students' profiles in these courses, offering, for instance, night courses in the health area (BRASIL, 2007; BITENCOURT et al., 2023), can justify this finding. The analysis of the information produced by the research on the meaning of the training experience for the ACSs at EdPopSUS made emerge three themes that generated three main categories, as presented in Figure 3.

Figure 3
- Analysis organization into themes, categories, and constitutive description

Learning through experience: perceiving and wanting to seek more

Experiences are daily moments that produce meaning, affect, touch, and transform. It is the moment that passes by and stays, producing stimuli and sensation, which is stored in memory. Experiences require a deeper connection with time, space, and the human body, so that there is meaning and transformation. They are unique to each individual and refer to emotions, thoughts, and impressions individually created (LARROSA, 2002). Daily moments are all the day-to-day interactions with the world. They are quick, do not raise reflection or emotional sharing, and often do not linger in memory (PIRES, 2014).

Bringing this discussion to Popular Education, all the processes experienced will become experiences from the moment they affect and give meaning to those experiencing that moment (BRANDÃO, 2005a, 2006). This experience occurs from encounters with other subjects, oneself, and the world based on dialogue, love, reflection, and emancipation (FREIRE, 2019), producing autonomy in each individual’s knowledge and being (BRASIL, 2013).

Students’ narratives express an educational process marked by “discovery, reflection, and discussion”, raising emotions that were “never felt” before, that “made a difference in the life” (ACS 3 - Final letter) of these workers, having a meaning in their work practices and self-knowledge.

"The course made a difference in my life! [...] it made a difference in how I think, see others, try to understand other people's views and not only show mine. [...] It was an innovation for me. [...] the course brought things from my daily work routine, but that innovated because each one carried their experiences, and we started thinking differently, building individual knowledge, alongside the group." (ACS 3 - Interview).

“I arrived with a very closed perspective, thinking it would be just one more improvement course and I would have nothing new to learn. But I don’t know what was the magic, or the word, or the song, or the expression of each gaze that awakened something new. [...] I learned to know myself, to respect and respect myself, to accept and accept myself with my hits and misses.” (ACS 6 - Final letter).

This opening to the new, the different, or the old in new clothes, mobilizing facts, data, and perceptions of each person involved in the educational process (BRANDÃO, 1986), is essential to establish the experience and its meanings. The expectation of arriving in the course with a “very closed perspective” (ACS 6 - Final letter), considering it one more improvement course, in which there would be nothing new to learn, expresses how this ACS started to build their knowledge during the course, anchored on the fundaments of Popular Education. In this analytical perspective, the ACSs become “subjects of experience," that is, those "open to their own transformation " (LARROSA, 2002, p. 26).

When experiencing the course activities and interacting with their colleagues, the ACS found himself open to the experiences, either through the sensibilization during educational processes - involving music, poetry, mística - or by arriving in the training open to these teaching-learning methodologies. It was an experimental construction to him, as “nobody can learn through the experience of others, unless this experience is, in a way, relived and taken as one’s own” (LARROSA, 2002, p. 27).

The training course allowed to ACSs a constant process of change, denaturalizing the ways of learning, building, and being in the world, because each encounter had its singularities, as did each student, and, in this relation, produced affections and feelings that gave meaning to their unique experiences (BRANDÃO, 2005b).

“You are not the same after each encounter, you transform yourself [...], you won't be indifferent to anything, you will suffer, be hit, have a slap in the face, but you will never again be omissive or submissive [and] if you were like this someday, it is over, this finished the day you start EdPop. [...] this transforming effect of the course, you’ll never forget as a ACS because you’ll be forever changed.” (ACS 5 - Interview).

Popular Education, the conception that grounded the course, demands a specific way of guiding educational actions. This education seeks experience to form and transform wiser people and create fairer social relationships. It is concerned with the political meaning of learning, clearly explaining to the students the objective of each educational act so they know its intention and can be critical and situated in each step (VASCONCELOS; CRUZ, 2013).

In this sense, the course's promotion of an experience based on each ACS's experience grounded the emerging problematization as a “pedagogical moment, as social praxis, as the manifestation of a world reflected by all actors, creating knowledge based on meaningful lived experiences” (DANTAS; LINHARES, 2014, p. 75).

“As soon as I joined, I was a bit scared; everything was new to me there. [...] I was very strict with things. [...] I noticed it could be different. I learned in the course that everyone has their own time! It was difficult for me but, little by little, I changed and got softer. I started having a new perspective [...] I’m a different person after the course, I know how to reflect more, I’m softer, more loving.” (ACS 14 - Interview).

As we can see, the training course was an important experience for the ACSs as subjects of action, related with other subjects and the world they live in (FREIRE, 2003). In the professional aspect, the ACSs highlighted the changes in the “communication with the team, the community, and the family” and when guiding collective educational activities - “group spaces” (ACS 15 - Interview) -, taking to their professional practice the “reference of popular education” (ACS 2 - Interview). Hence, Popular Education intensified the experience by incentivizing reflection, dialogue, and the expression of affection, bringing creativity and autonomy to the students. Due to its reflexive, political, and participative characteristics, Popular Education in Health is a concept and a pedagogical-social practice that strengthens people, movements, teams, and care practices in different populations.

(Re)constructions: the diffusion of the learning experience into the work process

EdPopSUS learning process emerged in the ACSs some fundaments that guide their profession. The ACSs perceived changes in how they understand one of their main professional attributions, which is house calls. Besides entering the houses and filling out forms, the ACSs added to their role the importance of valuing people, their families, and their life stories.

“EdPopSUS made a difference [...]. The question of valuing the person, the family, the life history, the territory, [they] could understand it, but not do it; and, from this course, I saw that people started to really understand our role as Community Health Agents. It is not just about visiting and filling papers; we can understand the reality and help change it. I improved, and the team that did it also improved [...]." (ACS 11 - Interview).

ACSs reinforced that the “know-how” learning shed light to their educational and guiding role as APS workers, which allowed them to learn “to be more professional”, working better in the community.

“[...] I think that my role and how to work with the community is more evident. How to implement projects that really benefit everyone, everything they really need, that make sense to the community. I learned to be more professional [...]. If i don’t know how to do something in my community, I research it in books, in the materials, I learned that at EdPop.” (ACS 3 - Interview).

This perspective corroborates Freire (2006, p. 30) in his idea that exercise consciousness is to be clear about one's role in the world, in which "consciousness, thus, implies overcoming the spontaneous sphere of reality apprehension to reach a critical sphere where reality takes pace as a knowable object and the person assumes an epistemological position."

EdPopSUS training triggered many feelings, knowledge, and perceptions, often silenced amidst the daily bureaucracy and work processes blind to people. This awareness is essential when seeking pedagogic practices that are meaningful to students (FREIRE, 2003).

The course raised the meanings of the relationship between workers, students, and ACSs with their colleagues. The municipal management identified it as a promoter of democratic practices that respect and value the communities' popular knowledge

“We could see changes in the relationships with the other workers through the knowledge, the diffusion, and the dissemination of these knowledges of popular wisdom. [...] respect popular knowledge, I find this one of the striking changes because [based on] respect it is also possible to see the increase in the dissemination of practices in Popular Education in Health.” (Manager 1 - Interview).

Another relevant meaning of the EdPopSus training is ACSs' listening ability. Knowing how to listen is one of the types of knowledge needed for the educational practice (FREIRE, 2003). In this research, "increasing learning" (ACS 17 - Interview) and "learning to listen to others and listen to oneself" (ACS 1 - Interview) privilege dialogues, the basic principle of Popular Education. As one learns to listen to the other, we start talking “with” them and not “for” them.

“[...] the greatest experience of EdPopSUS is always to listen to others, the colleagues, their work, because if you don't listen, you will never know how to help them, the problem of someone else, what you can bring and what you can learn.” (ACS 1 - Interview).

In the ACS's perception, the problem-based methodology in Popular Education stimulated a reflection on being in the world. In the interviewees' words, through the experiences and different sorts of learning, they could “rethink practice" (ACS 2 - Interview), "understand my role in the community again, in the Health Unit, and together with people" (ACS 8 - Interview), and "recognize myself as an agent of change" (ACS 9; ACS 17 - Interview). Such posture reflected in a care model that values the “strengthening of the health system and co-management”, the “recognition of the potentialities of ACSs, communities, and health teams” (Manager 1 - Interview).

The strengthening of ACSs’ role as health promoters was built during the EdPopSUS, from the experiences occurring in the classroom, the field trips, and the communities. The Program allowed them to share several repertoires regarding popular and ancestral health care, mainly with African and Indigenous roots. It was an experience of dialogue and reflection about ethical and aesthetical possibilities to produce care. The course intertwined knowledges, arts, and people willing to broaden and share their cultural repertoire, producing reflections and expressions about health, ways of caring, work processes, and thinking about society. They were learning moments that broadened the gaze over reality, supported by reflection-action-reflection and the development of critical awareness that emerges from the lived problematization.

“What is racial prejudice? Institutional prejudice? I didn’t know, though I’m an Agent and have higher education. [...] listening others was vital, so you can earn to get stronger in your work as an ACS, in your life, in your relationships, in everything. Even your argument improves, your rethink everything and do differently and better what you’ve already been doing.” (ACS 5 - Interview).

The learning process lived raised debates and established a net of meanings, provoking changes and incorporating the knowledge from experience, under the Freirean theory (FREIRE, 2003; BRANDÃO, 2005b; FREIRE, 2006, STRECK; PITANO; MORETTI, 2017). The concept of education unveiled by the Popular Education process is permeated by transformative intentions and methodological components that reach this goal, mainly the sustained collective construction (CRUZ, 2018; CHIANCA-NEVES; LAUER-LEITE, PRIANTE, 2020). The ACSs reported that they were "delighted" with the course, "at ease," welcomed, and their knowledge was valued, which has helped their transformation.

"[...] I was seduced from arrival because the best thing is to feel comfortable talking. We have never felt this way in a course. The ACSs never had a voice [but they] are the base, if you don't take the problem to the Unit, the Unit won't know it." (ACS 1 - Interview).

The narratives from the ACSs and managers about EdPopSUS and their repercussions were loaded with meanings about the “complex web of symbols, senses, and meanings that establish the world” (BRANDÃO, 2005b, p. 86). In this context, the course offered a theoretical framework based on Popular Education that is key to develop new relationships by emphasizing dialogue and valuing the knowledge within popular culture, people, and their voices (VASCONCELOS, 2017), understanding that “respect for popular knowledge, then, necessarily implies respect for cultural context” (FREIRE, 1999, p. 86). Hence, the course is an exercise of actively listening the sharing of knowledges, in which everyone has the power to speak, as well as an opening to the world and others. Participants share a role in producing the knowledge of beings who recognize themselves as unfinished and are open to the world and to others seeking explanations, reflections, and answers (LINHARES, 2007; CHIANCA-NEVES; LAUER-LEITE; PRIANTE, 2020).

“EdPopSUS opens your mind; it explains things that you can't even imagine, things from your daily life and that sometimes we don't work with because we don't know how." (ACS 3 - Interview).

“[...] the workers’ participation shows this success. It is pleasant, agreeable, and appealing to perceive the daily use in the work environment. I see changes in the colleagues who witnessed this experience, mainly regarding dialogue. [...] they give their opinions more, they talk, they claim what they think and want.” (Manager 1 - Interview).

The managers highlighted the development of ACSs’ critical capacity about the routine, as well as the "construction of informed people", "empowered," and emancipated (Manager 2 - Interview). Thus, people’s “respect for the words of others” (Manager 4 - Interview), favoring communication, changed the participants in the course, who will “(re)transform” the whole (Manager 3 - Interview).

Challenges to be overcome and unveiled possibilities

In this educational process, the emerging challenge concerned the return of ACSs to work alongside the APS teams, after they concluded the course, as they faced teams that “didn’t understand” (ACS 1 - Interview) what was experienced and felt during the course, teams that were not “touched” and did not have the “perspective of Popular Education” (ACS 12 - Interview) in their daily practices.

This difficulty of understanding/sensibilization of health teams became, at first, a barrier to implementing Popular Education at APS. Peduzzi et al. (2020) stress the potential of effective teamwork, grounded on intersubjective communicative practice, for the quality of health care and health production. In this context, collaboration among professionals is an attribute of teamwork. When discussing and rethinking their way of working, ACSs present new possibilities for acting in the care process, reflecting collective work, and assuming individual and team responsibilities. This posture can lead to embarrassment, as it brings to light demands that need an answer/action (MENDONÇA; NUNES, 2011).

If the return of ACSs to the work field with different ideas and perceptions bothered the teams, raising “conflicts” (ACS 6; ACS 7; ACS 10; ACS 13 - Interviews), it has also brought a positive rethinking of the work process. The ACSs reported that, with time, the teams noticed the importance of Popular Education to reconsider daily work actions: "things we brought from the course, the activities, and even the reflections and discussions were important to the care given to our population but also to improve our team" (ACS 13 - Final letter).

The transformation that unsettles, creates conflicts, and rearranges knowledge and actions was perceived among the ACSs participating in the educational experience and among the workers who did not as part of learning and problematization.

Managers reinforce the course’s role as a “trigger for a new transformation process at work, in the social field, and participation at SUS” (Manager 3 - Interview), to “rethink daily actions and, this, improve the team work processes” (Manager 1 - Interview).

Even though Popular Education has brought changes on how to rethink action, for the ACS group, the restriction to this group of workers has not contributed to building a new model of more democratic and participative management. A device that could lead to higher democratization would be the institutionalization of PNEPS-SUS as an organizational space to broaden how management is conducted and to create a reference closer to the health-promoting educational acts, strengthening it as a public policy and not as a marginal action. Popular Education in Health cannot be seen as one more activity; it permeates a new posture of being in the world, from workers’ actions to management, reorganizing the service as a whole (VASCONCELOS, 2018).

Finally, the course disseminated the existence of the Política Nacional de Educação Popular for SUS, showing ways to implement it where the ACSs live and work.

“[...] this policy support makes me more at ease to work.” (ACS 1 - Interview).

“EdPopSUS is helping implement the Popular Education policy at the Unit.” (ACS 17 - Interview).

"[...] there is a whole policy that backs it up, so I can say that I’m applying Popular Education in Health at my work.” (ACS 11 - Interview).

“[...] from EdPopSUS, the municipal executive government is backed to legislate and implement popular education actions.” (Manager 1 - Interview).

We reiterate the need to build municipal policies of workers’ permanent education, including a Popular education perspective, so that they are recognized and consolidated nationwide. This construction will demand educational spaces mediated by dialogue and open to a culture of popular participation that welcomes, recognizes, and legitimizes the contribution of popular knowledge alongside the technical-scientific one.

FINAL REMARKS

This research sought to analyze the meaning of ACS’s training experience in a popular education proposal, EdPopSUS. Taking as a theoretical base of reference, the problem-based pedagogy formulated by Paulo Freire in Brazil, the results showed that EdPopSUS incentivizes reflection, dialogue, and affection, potentializing ACSs’ creativity and autonomy, in an educational space of self-knowledge and interaction with their world. The educational-participative process provided by EdPopSUS improved ACSs’ communication with the team, the community, and the families attended by the Program, refining their abilities to listen and lead collective educational experience, bringing Popular Education fundaments to their professional and personal practice.

The experience in the course resignified ACSs’ professional practice, strengthening their role in the team, and allowing them to recognize themselves as health-promoting agents, dialoguing with people and acting against public health inequalities, thus, becoming protagonists of their actions.

These results contribute to increased knowledge of Popular Education in health-workers training, showing that educational processes should involve a professional group and all health team members to create shared learning opportunities. As seen in the research results, if the training is restricted to one group, the team that did not experience the educational process might not be prepared for the changes. Thus, there can be a mismatch between the team and the workers returning to their daily work routine.

Though this research does not give insight into SUS users' perceptions, the participation of those attended by the health services would be important as they can be key agents in identifying and evaluating ACSs' work. Studies that continue this research, including users' perspectives, are recommended.

This research findings confirm that the Programa de Qualificação em Educação Popular em Saúde is a training proposal that potentializes the recognition of Política Nacional de Educação Popular em Saúde, reinforcing Popular Education as a pedagogical-social practice that strengthens people, movements, teams, and universal, integral, and equitable care practices in SUS.

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• 1
  Article published with funding from theConselho Nacional de Desenvolvimento Científico e Tecnológico- CNPq/Brazil for editing, layout and XML conversion services.
• 2
  Mística consists of elements that are used as reference and identification as co-creators of the collective space, meaning the causes for which one fights and as the visualization/aggregation of important elements in this collective construction of knowledge.

Publication Dates

• Publication in this collection
  02 Aug 2024
• Date of issue
  2024

History

• Received
  07 Oct 2023
• Accepted
  27 Apr 2024
• Preprint posted on
  10 July 2022
  10.1590/SciELOPreprints.4830