A pesquisa realizou uma investigação das competências atualizadas nas práticas operadas pelos agentes comunitários de saúde para analisar como estes profissionais podem contribuir para consolidação da reforma psiquiátrica brasileira. O estudo teve como público um grupo de agentes comunitários de saúde (ACS) que atuam em 19 equipes da estratégia de saúde da família no município de Porto Alegre/RS. As ações territorializadas, pautadas por diretrizes de promoção de saúde e humanização da atenção e gestão, impõem-se como necessárias aos avanços do Sistema Único de Saúde e da reforma psiquiátrica. Diante de tal cenário, o objetivo geral da pesquisa foi investigar quais competências as práticas dos ACS atualizam e que podem produzir efeitos de desinstitucionalização da loucura. O levantamento das estratégias de cuidado em saúde mental desenvolvidas pelos agentes, investigação das competências nelas atualizadas, e da presença de efeitos de desinstitucionalização da loucura que possam decorrer da expressão destas competências e a experimentação de uma metodologia pedagógica capaz de potencializá-las, foram objetivos específicos que o estudo também desdobrou. Os aportes teóricos da esquizoanálise e análise institucional compõem o aparato metodológico da investigação desenvolvida em uma perspectiva de pesquisaintervenção e de inspiração cartográfica. Concluímos que a competência dos agentes da qual podem advir as maiores contribuições para o processo de reforma psiquiátrica é a transformação do capital social que possuem vínculos à serem usados na construção de projetos terapêuticos. Diante disso a pesquisa se propôs, a problematizar as relações afetivas entre os agentes de saúde e a população por eles atendida – usando, para isso a filosofia da Baruch Spinoza. Esta análise indicou que no desdobramento do capital social que possuem em vínculos, é mais provável que os bons encontros, e toda a dimensão de alegria que eles envolvem, frutifiquem em vínculos promotores de desinstitucionalização da loucura. Diante disso, argumenta-se a favor da criação de espaços de partilha e troca de experiência, a fim de que a dimensão da afetividade presente no trabalho desses importantes atores do SUS possa ser debatida e de modo a potencializar o exercício da função agente comunitário de saúde. / The research is about an investigation of current skills in the practices operated by community health workers to consider how this workers can contribute to the consolidation of Brazilian psychiatric reform.The study was came up with a group of community health agents (CHA) connected in 19 teams of family1s health strategy in the city of Porto Alegre / RS. Territorialized actions, guided by policies to promote health and humanization of care and management, are riquired to advance the Braziliam’s Health System (SUS) and the psychiatric reform. Seeing this scenario, the objective of this research was to investigate the practices of this works looking for the of skills updated by this practices that are able to promove effects of de-institutionalization of madness. The survey of care strategies developed for comunity healt agentes and the research about skills updated them – analying the presence of effects of de-institutionalization of madness that may result from the expression of these skills; the experimentation with a pedagogical method able to empower the comunity healt agents , were specific objectives study also develop. The theoretical framework of institutional-analysis and schizo-analysis is used to bild the methodological apparatus of this research. It was developed in a research-intervention way and inspirated in cartography.We conclude that the competence of agents which may produce the major contributions to the process of psychiatric reform is the transformation of social capital in bounds able to be used in the construction of therapeutic projects. So we were riquered to think about the relationships between health workers and the population they served to – using to it, the philosophy of Baruch Spinoza. This analysis indicated that the unfolding of the capital they hold in bonds, it is likely that good meetings, and the whole dimension of joy that they involve prosecutors bonds bear fruit in the deinstitutionalization of madness. Therefore, it is argued in favor of the creation of spaces for sharing and exchange of experience, so the dimension of affect present in the work of these important actors in the SUS may be discussed -in order to enhance the exercise of the of community health agents.

Trata-se de uma pesquisa participante cujo objeto de estudo é trabalho em saúde mental do Agente Comunitário de Saúde, um dos principais sujeitos envolvidos na Estratégia Saúde da Família (ESF). Os objetivos da pesquisa são: captar e analisar o processo de trabalho em saúde mental dos ACSs, (finalidades, objeto e instrumentos) de uma Unidade Básica de Saúde a partir de sua própria voz; problematizar e compreender os pressupostos que fundamentam a ação de saúde mental dos ACSs; sistematizar e ampliar, por meio da Oficina de Trabalho, o conhecimento do grupo de ACS sobre o processo de trabalho em saúde mental no território, na perspectiva das diretrizes da Reforma Psiquiátrica brasileira. O conceito de práxis foi eleito para compreender e analisar o trabalho do ACS e sua prática em saúde mental. Cinco categorias emergiram das análises compartilhadas: Quem são as Agentes Comunitárias de Saúde; Formação e reconhecimento; O que consideram potenciais de fortalecimento e desgaste no trabalho; Gênero e Processos de trabalho em Saúde Mental. A escolha da Oficina de Trabalho como estratégia metodológica permitiu a elaboração teórica e prática das potencialidades e limites do cotidiano do trabalho das ACSs, o intercâmbio de ideias, crenças e práticas sobre saúde. As cinco histórias das pessoas acompanhadas pelas ACSs (processos de trabalho em saúde mental) demonstram perda de poder contratual e empobrecimento das redes sociais das pessoas e famílias acompanhadas. As finalidades dos processos de trabalho relacionam-se à recolocação das pessoas ou núcleos familiares (objetos de trabalho) na posição de cidadãos e sujeitos que devem participar da vida social. As concepções e intervenções (instrumentos de trabalho) que permeiam os cuidados estão associadas aos conceitos de desinstitucionalização, autonomia e reabilitação psicossocial (moradia e da troca de identidades). As ACSs reconhecem que as intervenções devem ser desenvolvidas por toda a equipe de forma integrada. A solidariedade aparece como um marcador importante das práticas dessas profissionais podendo ser entendida como um perfil social da profissão. O trabalho em saúde mental não apareceu dissociado das práticas dessas agentes e possui forte relação tanto com uma práxis reiterativa quanto com uma práxis criativa. Ao mesmo tempo em que pautam seu trabalho por normas e diretrizes, o objeto de trabalho em saúde mental (a pessoa no seu contexto de vida) parece invocar uma práxis criativa. Grande parte do sofrimento dessas trabalhadoras aparece associada à falta do reconhecimento profissional, que associam à falta de acesso à formação técnica. Evidencia-se a complexidade do trabalho dessas Agentes, na medida em que lidam com uma realidade dura, produto de uma estrutura social excludente, e que representam o Estado na garantia de direitos para a população atendida. Elas ficam num lugar entre as carências diversas da população e a falta de respostas efetivas para transformar a condição de saúde das famílias que atendem. Mesmo assim foi possível verificar que o trabalho dessas Agentes possui grande potência de transformação das realidades / The study is a participative research whose object of study is the work on Mental Health by the Community Health Worker (ACS), one of the main subjects at the Family Health Strategy (ESF). The aims of this study are: to collect and to analyze the work process on Mental Health by the Community Health Workers (purposes, object and tools) of a Health Center from their own perspective; to render problematic and to comprehend the presuppositions that underlies their actions; to systematize and to extend, through a workshop, their knowledge on the process of work on Mental Health in accordance with the guidelines of the Brazilian Psychiatric Reform. The concept of praxis has been chosen to understand and to analyze the work of the ACS and their practice on Mental Health. Five categories have emerged from shared analysis: Who are the ACS; Professional education and acknowledgment; What they consider to be the invigorating and the wasting potentials of their work; Gender; and the work processes on Mental Health. The choice of a workshop as a methodological strategy allowed the theoretical and practical elaboration of the potentialities and limits of the daily work of the ACS, the exchange of ideas, beliefs and practices on health. The five stories brought by the ACS (processes of work on Mental Health) demonstrate that the patients and family have lost contractual power and their social network. The aims of the work processes are related with the outplacement of the patients and families (objects of work) as citizens and individuals who should participate in social life. The conceptions and interventions (tools of their work) that permeate care are associated with the concepts of deinstitutionalization, autonomy and psychosocial rehabilitation. The ACS recognize that the actions must be developed by the entire team of the Health Center, in an integrated manner. The solidarity shows up as an important practice of these professionals, almost a necessity. The work on Mental Health doesn\'t appear dissociated from the practices of these workers and it presents strong relation with both a repetitive and a creative praxis. While they guide their work through standards and guidelines, the object of mental health work (the person in their life context) seems to invoke a creative praxis. Much of the suffering by these workers appears associated with a lack of professional recognition, which they relate to their lack of access to technical training. This study highlights the complexity of the work of these agents, insofar as they deal with a harsh reality, product of social exclusion, and represent the State at ensuring rights for the population served. They are placed between the various needs of the population and the lack of effective responses on transforming the health condition of the families they serve. Still, it was possible to verify that the work of these agents has a great power on changing realities

A pesquisa realizou uma investigação das competências atualizadas nas práticas operadas pelos agentes comunitários de saúde para analisar como estes profissionais podem contribuir para consolidação da reforma psiquiátrica brasileira. O estudo teve como público um grupo de agentes comunitários de saúde (ACS) que atuam em 19 equipes da estratégia de saúde da família no município de Porto Alegre/RS. As ações territorializadas, pautadas por diretrizes de promoção de saúde e humanização da atenção e gestão, impõem-se como necessárias aos avanços do Sistema Único de Saúde e da reforma psiquiátrica. Diante de tal cenário, o objetivo geral da pesquisa foi investigar quais competências as práticas dos ACS atualizam e que podem produzir efeitos de desinstitucionalização da loucura. O levantamento das estratégias de cuidado em saúde mental desenvolvidas pelos agentes, investigação das competências nelas atualizadas, e da presença de efeitos de desinstitucionalização da loucura que possam decorrer da expressão destas competências e a experimentação de uma metodologia pedagógica capaz de potencializá-las, foram objetivos específicos que o estudo também desdobrou. Os aportes teóricos da esquizoanálise e análise institucional compõem o aparato metodológico da investigação desenvolvida em uma perspectiva de pesquisaintervenção e de inspiração cartográfica. Concluímos que a competência dos agentes da qual podem advir as maiores contribuições para o processo de reforma psiquiátrica é a transformação do capital social que possuem vínculos à serem usados na construção de projetos terapêuticos. Diante disso a pesquisa se propôs, a problematizar as relações afetivas entre os agentes de saúde e a população por eles atendida – usando, para isso a filosofia da Baruch Spinoza. Esta análise indicou que no desdobramento do capital social que possuem em vínculos, é mais provável que os bons encontros, e toda a dimensão de alegria que eles envolvem, frutifiquem em vínculos promotores de desinstitucionalização da loucura. Diante disso, argumenta-se a favor da criação de espaços de partilha e troca de experiência, a fim de que a dimensão da afetividade presente no trabalho desses importantes atores do SUS possa ser debatida e de modo a potencializar o exercício da função agente comunitário de saúde. / The research is about an investigation of current skills in the practices operated by community health workers to consider how this workers can contribute to the consolidation of Brazilian psychiatric reform.The study was came up with a group of community health agents (CHA) connected in 19 teams of family1s health strategy in the city of Porto Alegre / RS. Territorialized actions, guided by policies to promote health and humanization of care and management, are riquired to advance the Braziliam’s Health System (SUS) and the psychiatric reform. Seeing this scenario, the objective of this research was to investigate the practices of this works looking for the of skills updated by this practices that are able to promove effects of de-institutionalization of madness. The survey of care strategies developed for comunity healt agentes and the research about skills updated them – analying the presence of effects of de-institutionalization of madness that may result from the expression of these skills; the experimentation with a pedagogical method able to empower the comunity healt agents , were specific objectives study also develop. The theoretical framework of institutional-analysis and schizo-analysis is used to bild the methodological apparatus of this research. It was developed in a research-intervention way and inspirated in cartography.We conclude that the competence of agents which may produce the major contributions to the process of psychiatric reform is the transformation of social capital in bounds able to be used in the construction of therapeutic projects. So we were riquered to think about the relationships between health workers and the population they served to – using to it, the philosophy of Baruch Spinoza. This analysis indicated that the unfolding of the capital they hold in bonds, it is likely that good meetings, and the whole dimension of joy that they involve prosecutors bonds bear fruit in the deinstitutionalization of madness. Therefore, it is argued in favor of the creation of spaces for sharing and exchange of experience, so the dimension of affect present in the work of these important actors in the SUS may be discussed -in order to enhance the exercise of the of community health agents.

Thesis (MPH.) -- University of Limpopo, 2021 / Background: Chronic illnesses, including non-communicable diseases (NCDs), continue to be a public health concern, globally, and contribute to the high burden of diseases. These health challenges have led to the introduction of community health workers (CHWs) in both developed and developing countries as a way of dealing with these challenges. It is more than five years since ward-based outreach teams (WBOTs) were introduced into the Julesburg area in order to respond to the needs of the community, based on the government’s focus on quadruple burden of diseases. The researcher is aware of the increasing workload, unclear roles and responsibilities, different approaches to CHWs’ work taken, and the ever-changing focus of their work, based on the community needs and diseases that the community faces at a particular time. It is for this reason that the researcher is interested in understanding the CHWs’ experiences and the manner in which they cope with challenges when working in their ever-changing environment, workload, work focus and roles and responsibilities. Methods: A qualitative exploratory, descriptive and contextual study approach was used; data was collected using focus group discussions with CHWs and one-on-one interviews with key informants, using their supervisors to gather more information that could not have been shared by CHWs. Result: The findings from the focus group discussions revealed that the CHWs have a high workload, while receiving stipend and are not permanently employed. CHWs have had experiences that make them feel unimportant and not needed, as well as enduring poor working conditions without sufficient personal protective equipment (PPE). Even though they experience dissatisfaction, they are passionate about continuing with their community-based work for many years, evidenced by those who have up to 22 years of service.

Philosophiae Doctor - PhD / Introduction: National community health worker (CHW) programmes are to an increasing extent being implemented in health systems globally, mirrored in South Africa in the ward-based outreach team (WBOT) strategy. In many countries, including South Africa, a major challenge impacting the performance and sustainability of scaled-up CHW programmes is ensuring adequate support from and supervision by the local health system. Supervisory systems, where they exist, are usually corrective and hierarchical in nature, and implementation remains poor. In the South African context, the absence of any guidance on CHW supportive supervision has led to varied practices across the country. Improved approaches to supportive supervision are considered critical for CHW programme performance. However, there is relatively little understanding of how this can be done sustainably at scale, and effective CHW supervisory models remain elusive. Research to date has mostly positioned supervision as a technical process rather than a set of relationships, with the former testing specific interventions rather than developing holistic approaches attuned to local contexts. This doctoral study was exploratory in nature, seeking to generate an in-depth and contextualised understanding of the supervision phenomenon in one specific district in the North West Province (NWP) in South Africa. Using co-production methodology in an iterative approach, the study culminated in the formulation of a supportive supervision framework with CHWs and other frontline actors. Methods: The study was based on a holistic conceptual framework of supportive supervision, which was viewed as comprising three core functions ‒ accountability, development and support ‒ embedded in a complex and multi-level system of resources, people and relationships. To address the study objectives, the research used a mix of qualitative and quantitative methods. Three studies were conducted in a phased process: study 1 comprised a qualitative description of policy and practices in two districts related to the supervision of WBOTs; study 2 identified the main actors and mapped the supervisory system of WBOTs in the district, using social network analysis (SNA); and study 3 involved a qualitative exploration of workplace and interpersonal trust factors in the district and the supervisory system of WBOTs in the district. These three studies provided inputs for a workshop aimed at developing recommendations for a district-level, WBOT supportive supervisory framework. Four published papers reporting on the research conducted are presented in this thesis. It should be noted that the research was conducted during a turbulent political and administrative period in the NWP, when the WBOT programme changed from being a flagship programme for the country to one in crisis. This shifting context needs to be borne in mind when the findings are viewed and interpreted. Results: The study identified weaknesses in both the design and implementation of the supervisory system of WBOTs, with the absence of clear guidance resulting in WBOTs and PHC facilities performing their roles in an ad hoc manner, defined within local contexts. The study documented evidence of high internal cohesion within WBOTs and (where present) with their immediate outreach team leaders (OTLs). However, the relationships between WBOTs and the rest of the primary health care (PHC) and district health system were characterised by considerable mistrust – both towards other workers and the system as a whole. This occurred against a backdrop of increasing OTL vacancies, and the perceived abandonment of WBOT training and development systems and career opportunities. These findings are not dissimilar to those reported previously on the WBOT programme in South Africa and in programmes in other low-resource settings. Nevertheless, through its in-depth, exploratory and participatory approaches, this study provides additional insights into the phenomenon of supportive supervision. Firstly, in conceptualising supportive supervision as a set of ‘bundled’ practices within complex local health systems, the findings reflected the complexity of everyday realities and lived experiences. Secondly, through the embedded nature of the research and the phased data-collection process, the study was able to observe the impact of wider health system contexts and crises on the coalface functioning of the WBOT programme. Thirdly, the study emphasised how supportive supervision depends on healthy relational dynamics and trust relationships, and, finally, how a co-production approach can translate broad guidance, experience and theoretical understanding into meaningful, local practice owned by all the actors involved. Ultimately, the process of engagement, building relationships and forging consensus proved to be more significant than the supportive supervision framework itself. Conclusion: The lack of explicit, coherent and holistic guidance in developing CHW supportive supervision guidance and the failure to address supervision constraints at a local level undermine the performance and sustainability of CHW programmes. Effective supportive supervisory systems require bottom-up collaborative platforms characterised by active participation, sharing of local tacit knowledge and mutual learning. Supervisory systems also need to be designed in ways that promote relationships and generate trust between CHW programmes, other actors and the health system.

Abstract Fatal coronary heart disease among African Americans is associated with a disproportionate burden of cardiovascular disease (CVD) risk factors. Research has indicated that CVD risk factor knowledge and the prevalence of ideal CVH both persist at suboptimal levels. However, few researchers have investigated the relationship between culturally-tailored community-based heart health sessions, short-term knowledge acquisition of CVD risk factors, and the awareness of the American Heart Association's (AHA's) CVH construct. The purpose of this cross-sectional, secondary analysis study was to examine the interplay between these variables in an urban African American sample. Guided by social cognitive theory, the study analyzed de-identified data (data sets of demographic characteristics and Heart Disease Facts Questionnaire) from participant responses collected at multiple community sites to assist in the planning of future health programs. Multiple community sites were randomized into an intervention (n = 50) or comparison group (n = 57). Pearson's correlation and multiple regression were used to analyze data. Knowledge was higher for intervention group participants (β =.44, p = .001) and tended to be higher for those with more education (β = .20, p = .06) and those with less income (β = -.22, p = .07). Notably, most participants (73%) reported awareness of the AHA construct, CVH. The results support culturally-tailored interventions as a useful strategy for CVD risk reduction. The implication for social change is that initiatives at the community-level may positively impact CVH in minority/ethnic communities and subsequently impact CVD disparities.