Introdução: O excesso de peso destaca-se como importante problema de saúde na atualidade e sua prevenção desde a primeira infância é essencial para a promoção da saúde da população. O uso de material didático e instrucional, como o álbum seriado, contribui para a prática do processo educativo em saúde na rotina dos serviços. Objetivo: Construir e validar um Álbum Seriado sobre prevenção do excesso de peso infantil na atenção básica. Método: Estudo descritivo que foca o desenvolvimento e a validação de um instrumento para intervenção educativa. Integra investigação mais ampla desenvolvida no município de Itupeva, Estado de São Paulo, aprovada por Comitê de Ética em Pesquisa e autorizada pela Diretoria de Saúde do município. Foi desenvolvida em três etapas: 1) Oficinas de escuta com mães e profissionais de saúde da atenção básica; 2) Construção do álbum seriado; 3) Validação do álbum seriado. Com base no referencial teórico da educação crítica, três oficinas com duração de 90 minutos cada, foram realizadas no período de abril a junho de 2015: duas com 10 mães e uma com 14 profissionais da atenção básica. As oficinas foram gravadas, transcritas e submetidas à análise de conteúdo. Os temas extraídos das oficinas, documentos técnicos do Ministério da Saúde e figuras disponíveis no banco de imagens da web foram utilizados na construção do Álbum Seriado. O Álbum Seriado foi validado por oito juízes, profissionais vinculados à Diretoria de Saúde e Educação do município, que avaliaram conteúdo e aparência mediante preenchimento de uma ficha de validação, durante discussão em grupo. Analisou-se a porcentagem de concordância dos juízes. Resultados: A construção do Álbum Seriado teve como base os temas extraídos das oficinas realizadas com mães e profissionais de saúde, porém para uma sequência lógica de apresentação, o material foi organizado de acordo com os temas reconhecimento do excesso de peso/obesidade, consequências para a saúde da criança e estratégias para prevenção e promoção da saúde infantil. O Álbum Seriado foi constituído por 27 folhetos com frente (figura) e verso (ficha-roteiro). Houve 99% de concordância dos juízes quanto ao tema proposto, 96% com relação à clareza/compreensão dos folhetos, 94% quanto à importância de cada uma das figuras para o álbum seriado e 47% quanto à necessidade de ajustes ou exclusão de folhetos. Melhorias na resolução e substituição de algumas figuras foram as principais sugestões para o ajuste do material apresentado para validação. Conclusões: A construção e validação do álbum seriado, com base na educação crítica, envolve os participantes, facilita o uso dessa tecnologia pelos profissionais de saúde no processo educativo na atenção básica e favorece a compreensão e incorporação de passos importantes para a prevenção do excesso de peso infantil, contribuindo para a promoção da saúde da criança. / Introduction: Weight excess stands out as a major health problem today and its prevention since early childhood is essential for the population health. The use of instructional teaching materials such as flip chart in the educational process in health contributes to the effectiveness of this practice in the service routine. Objective: To develop and validate a flip chart on prevention of childhood weight excess in primary care. Methods: Descriptive study that focuses on the development and validation of an instrument for educational intervention. Honest and wide investigation was developed in the city of Itupeva, State of São Paulo, approved by the Research Ethics Committee and authorized by the city\'s Health Board. It was developed in three steps: 1) Listening workshops with mothers and health professionals in primary care; 2) Development of a flip chart; 3) Flip chart validation. Based on the theoretical framework of critical education, where three workshops which lasted 90 minutes each were held from April to June 2015: two with 10 mothers, and one with 14 primary care professionals. The workshops were recorded, transcribed and subjected to content analysis. To develop the flip chart, themes were drawn from workshops, technical documents were used from the Ministry of Health and pictures were taken from the internet. The flip chart was validated by eight judges, who were part of the city professional Board of Health and Education. They evaluated the flip charts content and appearance by filling out a form validation for group discussion. The percentage of the judges agreement was analyzed. Results: The analysis of the listening workshops gave origin to the topics, weight excess acknowledgement\", consequences for the childs health\" and \"strategies for prevention and childrens health promotion. The flip chart consists of 27 sheets: odds pages with figure and even pages with plug-Script. There was 99% of the judges agreement on the proposed theme, 96% regarding clarity and understanding, 94% regarding the importance of each picture, and 47% as for needs of adjustments or exclusion. Resolution improvements and picture replacements were the main suggestions for the material validation. Conclusions: The flip chart construction and validation based on critical education involves the participants, facilitates the use of this technology by health professionals in the educational process in primary care, and promotes understanding and incorporation of important steps to prevent child\'s weight overflow, contributing to the child\'s health promotion.

Objetivo: Avaliar os níveis de hemoglobina de gestantes brasileiras antes e após a fortificação das farinhas de trigo e milho com ferro e investigar as variáveis associadas. Método: Estudo transversal que integra um projeto matricial desenvolvido com dados retrospectivos obtidos de prontuários de 12.119 gestantes atendidas em serviços públicos de pré-natal localizados em 13 municípios das cinco regiões geográficas do Brasil, divididas em dois grupos: Antes-fortificação das farinhas com ferro (gestantes com parto realizado antes de junho de 2004); e Após-fortificação (gestantes com data da última menstruação posterior a junho de 2005). A coleta de dados ocorreu em 2006-2008 e incluiu apenas gestantes de baixo risco, cujos prontuários continham pelo menos a data da primeira consulta de pré-natal e da última menstruação e a dosagem de hemoglobina (Hb). A variável dependente foi o nível de Hb (g/dL) e as independentes foram: grupo de fortificação, região geográfica, características sociais e demográficas, antecedentes obstétricos e características do pré-natal. Realizou-se análise descritiva, univariada e múltipla do nível de Hb para o total das gestantes, por região geográfica e por trimestre de gestação, por meio de modelos de regressão linear. Contruíram-se modelos de regressão polinomial para o ajuste das curvas de Hb por mês de gestação, que foram comparadas com referências nacional e internacional. Curvas de níveis médios e críticos (-2 desvios-padrão) de Hb de gestantes não anêmicas do grupo Após-fortificação também foram comparados às referências. O nível de significância de todos os testes foi de 5%. O estudo foi aprovado por Comitê de Ética em Pesquisa. Resultados: Não houve aumento significativo do nível de Hb para o total da amostra (p=0,325) após a fortificação, exceto em gestantes da região nordeste (p<0,001; =0,214) e em gestantes no segundo trimestre de gestação (p=0,025; =0,093). O nível de Hb foi menor entre aquelas que tinham menor idade, viviam sem companheiro, tinham menor Índice de Massa Corporal-IMC, maior idade gestacional e/ou duas ou mais gestações anteriores. Apesar da curva Após-fortificação apresentar níveis superiores em todos os meses de gestação, a regressão polinomial não mostrou efeito significativo da fortificação de farinhas (p=0,316). As curvas de Hb de ambos os grupos de fortificação mostraram-se acima dos níveis críticos das referências nacional e internacional no primeiro trimestre, com queda a seguir e estabilização no final da gestação. A curva de níveis críticos, construída com dados de gestantes não anêmicas do grupo Após-fortificação, ficou abaixo da curva de níveis críticos da referência nacional e do ponto de corte da OMS, mas semelhante à referência internacional, exceto no final da gestação. Conclusões: A fortificação de farinhas com ferro aumentou significativamente o nível de Hb apenas em gestantes da região nordeste do Brasil e no segundo trimestre de gestação. Idade, situação conjugal, IMC, idade gestacional e número de gestações anteriores mantêm-se como características importantes que devem ser consideradas na avaliação da anemia na gestação. As curvas construídas seguem os padrões das referências nacional e internacional. Propõe-se uma curva de Hb de gestantes não anêmicas para ser utilizada na avaliação da anemia em gestantes brasileiras. / Objective: To evaluate the hemoglobin levels of Brazilian pregnant women before and after fortification of wheat and corn flours with iron and to investigate the associated variables. Methods: This collaborative cross-sectional study was developed with retrospective data obtained from medical records of 12,119 pregnant women who attended public prenatal care services in 13 municipalities of five Brazilians geographical regions. They were divided into two groups: Before-fortification (women who delivered before June/2004), and After-fortification (women with date of last period after June/2005). Data collection occurred between 2006-2008 and included only low risk pregnant women, whose medical records contained at least the date of the first prenatal visit, date of the last menstrual period and measurement of Hemoglobin (Hb). The dependent variable was the Hb level (g/dL) and the independent variables were: group of fortification, geography region, social and demographic characteristics, obstetric history and characteristics of prenatal care. We conducted descriptive analysis, univariate and multiple (linear regression) of the Hb level for the total of pregnant women, by geographic region and trimester of pregnancy. Polynomial regression models were used to fit the curves of Hb by month of pregnancy, which were compared with national and international references. Curve of Hb mean and critical levels (-2 standard deviations) constructed with data of non-anemic pregnant of After-fortification group were also compared to references. The significance level for all tests was 5%. This study was approved by the Research Ethics Committee. Results: There was no significant increase in Hb level for the total sample after the fortification (p=0.325), except pregnant women in the northeast region (p <0.001, =0.214) and pregnant women in the second trimester of pregnancy (p=0.025; =0.093). The Hb levels were lower on those who were younger, lived without partner, had lower body mass index-BMI, had higher gestational age and/or had two or more previous pregnancies. Although the curve of After-fortification group had presented higher levels in all months of pregnancy, the polynomial regression showed no significant effect of fortification of flour (p=0.316). The curves of Hb in both groups of fortification were higher than the national and international references critical levels in the first trimester, followed by a drop and stabilization in late pregnancy. The curve of critical levels constructed with data of non-anemic pregnant women of After-fortification group were below the curve of critical levels of national reference and the WHO cut-off point, but similar to the international reference, except in late pregnancy. Conclusions: Fortification of flour with iron significantly increased the Hb levels of pregnant women only in northeast region of Brazil and in the second trimester of pregnancy. Age, marital status, BMI, gestational age and number of previous pregnancies remain as important characteristics that should be considered in the evaluation of anemia in pregnancy. The constructed curves follow the national and international references. We propose a curve of Hb non-anemic pregnant women to be used in the evaluation of anemia in pregnant Brazilian women.

Submitted by Filipe dos Santos (fsantos@pucsp.br) on 2017-10-31T11:54:08Z No. of bitstreams: 1 Michelle Ribeiro Cordeiro de Souza.pdf: 2530971 bytes, checksum: 7b3c6332d17071b5b0ff3c404cd4f273 (MD5) / Made available in DSpace on 2017-10-31T11:54:08Z (GMT). No. of bitstreams: 1 Michelle Ribeiro Cordeiro de Souza.pdf: 2530971 bytes, checksum: 7b3c6332d17071b5b0ff3c404cd4f273 (MD5) Previous issue date: 2017-09-18 / The formation of health’s profissionals aim for nowadays, to attend to Sistema Único de Saúde. The Supervised Curricular Stage in the process of nurse’s formation is considered a strategy of teaching that approach the student of reality, develops habilities and contract with new experiences helping the existence of the future profissional practic. The study propose chances in curriculares activities on Nursing Course of Faculdade de Ciências Sociais e Agrárias de Itapeva from identification of the learning opportunities this stage in basic care, your contribution on profissional exercise in this área of acting and of competences acquired considering the pedagogical Project, in viewpoint of egresses, Is described explored, of approach quali-quantity, The theory os Social Representations was used like theorical reference and, the Discurse of Coletive Subject, methodological reference in organization and analysis of testimonies. The egresses aprove the stage how much the teaching performance considered fragilities/difficulties: use of small health units, basic nursing procedures, no realization of nurse consultation, monitoring the role of nurse, leadership, management decision-making and technical-scientific development. It is considered essential to extend the experiences during the stage, from the teacher nurse of the planning of the learning opportunities, to contemplate the development of technical skills in the period that precede the stage, to seek innovative learning methods in the proposed activities / A formação dos profissionais de saúde visa, atualmente, atender ao Sistema Único de Saúde. O Estágio Curricular Supervisionado no processo de formação do enfermeiro é considerado uma estratégia de ensino que aproxima o estudante da realidade, desenvolve habilidades e contato com novas experiências, propiciando a vivência da prática profissional futura. O estudo propõe mudanças nas atividades curriculares no Curso de Enfermagem da Faculdade de Ciências Sociais e Agrárias de Itapeva a partir da identificação das oportunidades de aprendizagem desse estágio na atenção básica, sua contribuição no exercício profissional nessa área de atuação e, das competências adquiridas considerando o projeto pedagógico, na ótica dos egressos. É descritivo, exploratório, de abordagem quali - quantitativa. A Teoria das Representações Sociais foi utilizada como referencial teórico e, o Discurso do Sujeito Coletivo e a Análise de Conteúdo, como referencial metodológico na organização e análise dos depoimentos. Os egressos aprovaram o estágio quanto à atuação docente, realização de atividades voltadas à promoção da saúde e os estudos de caso. Consideraram fragilidades/dificuldades: uso de unidades de saúde pequenas, realização dos procedimentos básicos de enfermagem, não realização de consulta de enfermagem, acompanhamento do papel do enfermeiro, liderança, gerenciamento, tomada de decisão e desenvolvimento técnico-científico. Considera-se essencial ampliar as experiências durante o estágio, a partir da interação docente - enfermeiro da unidade no planejamento das oportunidades de aprendizagem, contemplar o desenvolvimento de habilidades técnicas nos períodos que precedem o estágio, buscar métodos inovadores de aprendizagem nas atividades propostas

Esta tese centra-se na problemática da violência contra as mulheres, nas trajetórias em serviços de acolhimento e em práticas sociais e profissionais de cuidado. Baseada em estudos anteriores da autora, parte das afirmações de que serviços e práticas são inadequados, desarticulados, medicalizados e desrespeitam as mulheres vitimadas. Nesse sentido, a partir de experiências de mulheres em situação de violência buscou refletir, compartilhadamente, sua relação com os serviços e suas concepções de cuidado. Trata-se de estudo misto, que descreve e analisa a violência contra mulheres à luz de diferentes enfoques teóricos entre as teorias principalistas do direito à vida em segurança, da saúde e do gênero. O local de realização foi o Centro de Referência e Atendimento à Mulher (CRAM) do município de Porto Alegre. As participantes foram mulheres atendidas no CRAM em decorrência de situações de violência. A geração de dados ocorreu por meio de pesquisa documental em 536 formulários de atendimento, observação sistemática realizada no serviço e entrevistas em profundidade com 14 mulheres. A análise dos dados ocorreu, primeiramente, pela análise quantitativa que sistematizou registros provenientes dos formulários de atendimento do CRAM que corresponderam ao perfil dos atendimentos e das informações sociodemográficas das mulheres atendidas, bem como dos agressores. A segunda etapa correspondeu à análise dos dados qualitativos, provenientes da pesquisa documental, da observação e das entrevistas, com utilização do método da Análise de Conteúdo. Descreveu-se a organização e os processos de trabalho do CRAM, as características dos atendimentos realizados e o perfil das mulheres atendidas e dos agressores. Na análise das trajetórias, constatou-se que na maioria delas estão presentes serviços e/ou profissionais de saúde, principalmente para atendimento relacionados à saúde mental. Identificou-se que as mulheres não são adequadamente acolhidas no setor Saúde. Nos setores Segurança e Justiça, foram observadas negligências institucionais que reproduzem e potencializam a violência. O CRAM foi unanimemente bem avaliado, sendo articulador da rede de atenção. Outros serviços da rede (conselho tutelar, escola, serviços de assistência social, casas abrigos), também se constituem em pontos de apoio importantes para as mulheres, evidenciando a relevância de estabelecer adequada articulação da rede intersetorial. Na linguagem das mulheres, as experiências de sofrimento e busca de acolhimento remetem aos principais elementos para um atendimento eficaz e satisfatório que são: orientação, apoio e proteção. Atribuem às experiências de violência, os sentidos de humilhação, de culpa e de medo, as quais são geradores de intenso sofrimento e têm impactado em sua saúde. As violências impossibilitam o pleno desenvolvimento de uma vida digna. Portanto, entende-se que o enfrentamento dessas situações é necessariamente intersetorial, implicando articulação e fundamentação na garantia dos Direitos Humanos das mulheres. Conclui-se que existe, predominantemente, inadequação das práticas para a construção de projetos de acolhimento e cuidado para as mulheres em situação de violência. Nesse sentido, pensa-se que é preciso assumir nova razão terapêutica, incorporando elementos do cuidado que incluam as tecnologias relacionais e que considerem os direitos humanos, os direitos de cidadania e os aspectos subjetivos nas experiências vividas por essas mulheres. / This dissertation approaches the problem of violence against women upon trajectories in support services and in social and professional care practices. Based on previous studies by the author, it starts from statements that services and practices are inadequate, not articulated, medicalized and that they disrespect victimized women. Thus, a reflection was made from the experiences of women under violence condition by sharing their relation with the services and their care conceptions. This mixed study describes and analyzes the violence against women by considering different theoretical approaches among the Principalism theories regarding the right to safe life, to health and to gender and it was carried out in the Woman Reference and Attendance Center (CRAM) in Porto Alegre. The participants were women attended within the CRAM due to violence situations. The data were collected by means of documentation survey in 536 attendance forms, systematic observation at the service and in-depth interviews with 14 women. At first, the data underwent quantitative analysis that systematized records from CRAM attendance forms which corresponded to the attendance profile and the social and demographic information of the attended women and the offenders as well. The second step corresponded to the analysis of the qualitative data from the documental survey, the observation and the interviews by applying the Content Analysis method. A description detailed CRAM organization and working processes, the characteristics of the performed attendances and the attended women and offenders´ profile. The trajectories analysis showed that in most of them, services and/or health professionals are offered for mental health attendance and that the women are not properly welcome in the Health sector. Regarding Safety and Justice sectors, there has been institutional negligence which reproduces and enhances violence. CRAM service was unanimously well assessed and considered an organizer of the care network. Other network services (guardianship council, school, social support services, shelters) also are important support locations for women that evidence the relevance of establishing adequate articulation of the inter-sectoral network. In the language of women, experiences of distress and search for support address to the main elements of effective and satisfactory service, i.e.: advice, support and protection. They attribute to violence experiences the feelings of humiliation, guilt and fear which generate intense distress and impact on their health. Violence hinder the full development of a dignified life. Therefore, it is understood that the confrontation of these situations is necessarily inter-sectoral, implying articulation and foundation to safeguard the Human Rights to women. The conclusion drawn is that there is predominance of inadequate practices for the construction of support and care projects for women undergoing violence situation. Thus, it is needed to undertake a new therapeutic reason that incorporates care elements which include relation technologies and that consider human rights, citizenship rights and subjective aspects from these women´s experiences. / Esta tese aborda la problemática de la violencia contra las mujeres, en las trayectorias en servicios de acogida y en prácticas sociales y profesionales de cuidado. Considerando estudios anteriores de la autora, parte de afirmaciones de que servicios y prácticas son inadecuados, desarticulados, medicalizados y no respetan las mujeres victimadas. Desde experiencias de mujeres en situación de violencia, se buscó reflexionar compartiendo su relación con los servicios y sus concepciones de cuidado. El estudio mixto describe y analiza la violencia contra mujeres considerando diferentes enfoques teóricos entre las teorías del Principalismo del derecho a la vida en seguridad, de la salud y del género, realizado en el Centro de Referencia y Atendimiento a la Mujer (CRAM) de Porto Alegre. Participaron mujeres atendidas en el CRAM debido a situaciones de violencia. Los datos resultaron de pesquisa documental en 536 formularios de atendimiento, observación sistemática en el servicio, y entrevistas en profundidad con 14 mujeres. Los datos pasaron, primeramente, por análisis cuantitativo que sistematizó registros de los formularios de atendimiento del CRAM que correspondieron al perfil de los atendimientos y de las informaciones sociodemográficas de las mujeres atendidas y de los agresores. La segunda etapa correspondió al análisis de los datos cualitativos, provenientes de la pesquisa documental, de la observación y de las entrevistas, utilizando el método de Análisis de Contenido. Se describió la organización y los procesos de trabajo del CRAM, las características de los atendimientos realizados y el perfil de las mujeres atendidas y de los agresores. El análisis de las trayectorias mostró que en su mayoría están presentes servicios y/o profesionales de salud, principalmente para atendimiento a la salud mental y que las mujeres no son adecuadamente acogidas en el sector Salud. En los sectores Seguridad y Justicia fueron observadas negligencias institucionales que reproducen y potencializan la violencia. El CRAM fue unánimemente bien evaluado, siendo articulador de la red de cuidado. Otros servicios de la red (consejo tutelar, escuela, servicios de asistencia social, hogares de abrigo), también se constituyen en puntos de apoyo importantes para las mujeres, evidenciando la relevancia de establecerse adecuada articulación de la red intersectorial. En el lenguaje de las mujeres, las experiencias de sufrimiento y búsqueda de acogida remeten a los principales elementos para atendimiento eficaz y satisfactorio: orientación, apoyo y protección. Se les atribuyen a las experiencias de violencia, los sentidos de humillación, culpa y miedo, que generan intenso sufrimiento e impacto en su salud. Las violencias imposibilitan el pleno desarrollo de una vida digna. Así, se entiende que el enfrentamiento de esas situaciones es necesariamente intersectorial implicando articulación y fundamentación en la garantía de los Derechos Humanos de las mujeres. Se concluye que existe predominantemente inadecuación de las prácticas para la construcción de proyectos de acogida y cuidado para las mujeres en situación de violencia. Aún, es preciso asumir nueva razón terapéutica, incorporando elementos del cuidado que incluyan las tecnologías relacionales y que consideren los derechos humanos, los derechos de ciudadanía y los aspectos subjetivos en las experiencias vividas por esas mujeres.

A temática deste estudo trata da prática de enfermagem de trabalhadores de nível superior que atuam em serviços da rede de Atenção Básica à Saúde, em especial, na Estratégia de Saúde da Família (ESF). Foi desenvolvido com o objetivo de analisar como os enfermeiros identificam e intervêm nas necessidades de saúde, apresentadas pelos usuários que demandam os serviços de saúde de três Unidades de Saúde da Família, localizadas no município de Marília, São Paulo, além de conhecer as dificuldades e facilidades dos enfermeiros, ao desenvolverem a prática de enfermagem, na perspectiva da produção do cuidado em saúde. Constitui-se em um estudo de natureza descritiva e de abordagem qualitativa. Na coleta de dados, optamos pela observação livre e entrevista semiestruturada. A observação livre se deu durante os atendimentos agendados e eventuais, ocorridos na unidade e também na visita domiciliária. Participaram deste estudo três enfermeiras pertencentes à ESF da zona norte do município citado. Para a análise dos dados obtidos, utilizou-se a Análise de Conteúdo Temático. No decorrer da análise, foi possível apreender uma unidade temática relacionada às identificações e intervenções realizadas pelas enfermeiras, sujeitos desta pesquisa, e duas subunidades: eventos episódicos e problemas anteriores e eventos episódicos e problemas atuais. Os resultados da pesquisa apontaram o predomínio da identificação de necessidades de saúde como sinônimo de queixas, e nas intervenções prevaleceu a fundamentação no conhecimento biológico. Quanto às facilidades apontadas pelas enfermeiras observadas, observaram-se o vínculo e a autonomia em relação a alguns procedimentos, já as dificuldades destacadas foram a falta de recursos humanos, a não adesão dos usuários em relação às atividades coletivas, dentre outras. Dessa forma, concluímos que são necessários investimentos na formação e na qualificação dos enfermeiros para modificarem a prática em saúde, hoje focada na doença, para uma prática fundamentada em um conceito ampliado do processo saúde-doença, para que a satisfação das necessidades, anseios e dúvidas dos usuários passem a se constituir em foco de atenção da prática dos enfermeiros. Consideramos necessário utilizar a Educação Permanente no cenário do trabalho em saúde na atenção básica e assim possibilitar uma escuta qualificada dos trabalhadores, em especial, dos enfermeiros que atuam nos serviços de saúde. / This study deals with the practice of graduated nursing professionals who work in services of Primary Health Care Network, especially in the Family Health Strategy (FHS). It aims to analyze how nurses identify and intervene in health needs presented by the users who demand the health services of three Family Health Units, located in the city of Marilia, state of São Paulo, besides to understand the difficulties and facilities of nurses to develop nursing practice, in view of the production of health care. It consists of a descriptive and qualitative study. For data collection, free observation and semi-structured interview were used. The free observation was during the scheduled and possible attendances occurred in the unit and also at the home visit. Participants were three nurses form the FHS in the north zone of the city. For data analysis, the Thematic Content Analysis was used. During the analysis it was possible to identify a thematic unit related to the identification and interventions performed by nurses, who were subjects of this research, and two subunits: episodic events and previous problems and episodic events and current problems. The results showed predominance of the identification of health needs as a synonym of complaints, and in the interventions, the reasoning in biological knowledge prevailed. Regarding the facilities mentioned by the nurses are the bond and autonomy for some procedures, and the difficulties highlighted were the lack of human resources, non-compliance of users in relation to collective activities, among others. Thus it is concluded that investments are needed in training and qualification of nurses to change their practice in health, nowadays focused on the disease, for a practice based on an expanded concept of health-disease process, so that the satisfaction of needs, desires and doubts of the users becomes the focus of nursing care. It is necessary to use the Continuing Education in the setting of health work in primary care and thus provide a qualified listening of workers, especially nurses, who work in health services.

背景: 公共健康護理在香港的演變可以追溯到二十世紀三十年代，但公共衛生護士的培訓卻自一九五四年才正式開始。由於在此領域工作的護士人數相對比醫院護士少，因而令公共衛生護士的貢獻較不明顯。本研究旨在揭示公共衛生護士於一九五四年至二零一零年期間經歷了文化，社會，經濟和政治的變化後在母嬰健康院的發展。研究目的: 檢視公共健康護理的特點，並對公共健康護理在母嬰健康院的工作和改變進行分析，以確定對公共健康護理在母嬰健康院的發展有重大影響的事件和原因。研究方法: 使用研究歷史的方法，重新審視公共衛生護士的經驗。主要研究數據來源是收集退休公共衛生護士和醫療及護理行政人員的口述歷史。輔助數據來源則包括政府文件，個人筆記，照片和剪報。共有37名受訪者同意接受訪問，其中包括六名行政人員和三十一名退休公共衛生護士，年齡由五十多歲到九十歲。研究員以面對面訪談方法收集口述歷史。並以內容分析法處理所得資料。研究結果: 研究結果描繪公共健康護理有六大特點，包括其分類，護理文化，服務重點，健康教育和健康促進的功能，以及展現出護理的藝術和科學。研究結果表明，文化，社會，經濟，政治因素和社會上的重大事件影響了公共健康護理。其中不明顯和被貶值的公共健康護理服務，醫療優勢和行政影響，公共衛生和公共健康護理的意識形態，作為政府人員和公共健康護士的培訓等專業問題影響了公共衛生護士在香港的地位和護理專業。在這項研究中收集的數據也揭露了香港公共健康護理的發展是密切跟隨公共健康的變化，其發展可分為三個階段:從一九五四年到一九七零年是公共健康護理的演化期一九七零年至一九八零年間是靜態期，而一九九零年至二零一零年則是變化期。研究結論和含義: 公共健康護士需要擴大知識和技能，促進專業自主，推行以實證為基礎的護理並記錄護理成果。歷史研究可以幫助解釋過去和加強理解現狀；而歷史對護理亦提供了重大貢獻。 / Background: The evolution of public health nursing in Hong Kong can be traced back to the 1930s but formal training of public health nurses only commenced in 1954. However, as the number of nurses working in this field was small in comparison with hospital nurses, their practice and contribution is largely unknown. Aim: This study aims to reveal the developments in public health nursing practice in Maternal and Child Health Centres (MCHC) from 1954 to 2010. Objectives of this study include examining the characteristics of public health nursing practice and analysing the changes in public health nursing practice in MCHC, as well as identifying the significant events and factors that influenced its development. Methods: The historical research method was adopted to examine the public health nurses’ experiences. The primary data source was derived from the collected oral histories of retired public health nurses and medical and nursing administrators. The secondary data source was obtained from a review of government documents, personal notes, photographs and newspaper cuttings. In total, thirty-seven informants, including six administrators and thirty-one retired public health nurses were interviewed, ranging in age from late 50s to early 90s. Oral histories were taken from face-to-face interviews with these informants. Content analysis was used to analyse the collected information. Results: The study findings depict six characteristics of public health nursing, including its category, nursing culture, focus of service, health education and health promotion function, and the presentation of art and science in practice. Findings also demonstrate the developments and practice of the public health nursing was influenced by cultural, social, economical and political factors and events. In addition, several important professional issues affect the status and professional identity of public health nurses, among them the invisibility of the service and its devalued status, medical dominance and administrative influence, the ideology of public health and public health nursing in Hong Kong, the impact of working for the government and the preparation of public health nurses. Data collected in this study also disclose how developments in public health nursing in Hong Kong closely followed the changes in public health in which the development can be divided in three phases: the evolution of public health nursing from 1954 to 1970s, the static period from 1970s to 1980s and the period of changes from 1990s to 2010. Implications and Conclusions: Public health nurses are suggested to expand their knowledge and skills to further their autonomy, promote evidence-based practice and document nursing outcomes. The study also demonstrates that historical study can help to interpret the past and enhance understanding of the present. History has much to contribute to nursing. / Detailed summary in vernacular field only. / Foong, Mary. / Thesis (D.Nurs.)--Chinese University of Hong Kong, 2013. / Includes bibliographical references (leaves 293-310). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstracts also in Chinese; appendix H in Chinese. / APPENDICES --- p.xiii / LIST OF TABLES --- p.xiv / LIST OF FIGURES --- p.xv / CHAPTER ONE / INTRODUCTION --- p.1 / Chapter 1.1 --- Aims and objectives of the study --- p.3 / Chapter 1.2 --- Significance of the study --- p.3 / Chapter 1.3 --- Overview of this thesis --- p.4 / CHAPTER TWO / LITERATURE REVIEW --- p.7 / Chapter 2.1 --- Literature search --- p.8 / Chapter 2.2 --- Public health and related terms --- p.9 / Chapter 2.2.1 --- Definition of public health --- p.9 / Chapter 2.2.1.1 --- Characteristics of public health --- p.10 / Chapter 2.2.2 --- Public health in Hong Kong --- p.11 / Chapter 2.2.3 --- Definition of community health --- p.11 / Chapter 2.3 --- Public health nursing and related terms --- p.12 / Chapter 2.3.1 --- Definition and characteristics of public health nursing --- p.12 / Chapter 2.3.2 --- Definition of community health nursing --- p.13 / Chapter 2.3.3 --- Public health nursing versus community health nursing --- p.13 / Chapter 2.3.3.1 --- Differentiation from setting of practice --- p.15 / Chapter 2.3.3.2 --- Differentiation from focus of practice --- p.15 / Chapter 2.3.3.3 --- Differentiation from context --- p.16 / Chapter 2.4 --- Public health nursing and community health nursing in different countries --- p.17 / Chapter 2.4.1 --- Public health nursing and community health nursing in the United States --- p.18 / Chapter 2.4.2 --- Public health nursing and community health nursing in Canada --- p.19 / Chapter 2.4.3 --- Public health nursing and community health nursing in the United Kingdom --- p.19 / Chapter 2.4.4 --- Public health nursing and community health nursing in Asia --- p.20 / Chapter 2.4.5 --- Public health nursing in Hong Kong --- p.23 / Chapter 2.4.6 --- Lesson learned from the differences of public health nursing practice around the world --- p.24 / Chapter 2.5 --- Nursing, history and the history of nursing --- p.25 / Chapter 2.5.1 --- The value of history and nursing history --- p.26 / Chapter 2.5.2 --- The general value of history --- p.26 / Chapter 2.5.3 --- The general value of nursing history --- p.27 / Chapter 2.5.4 --- The value of studying nursing history --- p.27 / Chapter 2.5.5 --- The value of nursing history as suggested by scholars --- p.28 / Chapter 2.5.6 --- The tools to study history --- p.29 / Chapter 2.5.6.1 --- The use of historical research to study history --- p.30 / Chapter 2.5.6.2 --- Standard of historical research --- p.31 / Chapter 2.6 --- Literature review and critique of the previous historical studies --- p.32 / Chapter 2.6.1 --- Summary of the review --- p.45 / Chapter 2.7 --- Conclusion of this chapter --- p.48 / CHAPTER THREE / METHODOLOGY --- p.50 / Chapter 3.1 --- Rationale of selecting a qualitative research method --- p.50 / Chapter 3.2 --- The choice of qualitative method historical research --- p.51 / Chapter 3.3 --- The importance of primary and secondary data sources --- p.52 / Chapter 3.4 --- The relevancy of adopting oral history as the main research strategy and its issues --- p.52 / Chapter 3.4.1 --- An overview of oral history --- p.53 / Chapter 3.4.2 --- Definitions on oral history --- p.53 / Chapter 3.4.3 --- Virtues of oral history --- p.54 / Chapter 3.4.4 --- Issues related to oral history --- p.55 / Chapter 3.4.5 --- Differences between oral history and other qualitative studies --- p.58 / Chapter 3.5 --- Secondary data sources --- p.59 / Chapter 3.6 --- Research procedures --- p.61 / Chapter 3.6.1 --- Ethical consideration and ethical review --- p.61 / Chapter 3.6.2 --- Informed consent --- p.61 / Chapter 3.6.3 --- Sampling method --- p.62 / Chapter 3.6.3.1 --- The use of purposive sampling in qualitative research --- p.63 / Chapter 3.6.3.2 --- The determination of sample size and sample units --- p.63 / Chapter 3.6.3.3 --- Selection of participants --- p.65 / Chapter 3.6.3.3.1 --- Consideration of choosing the retired participants. --- p.66 / Chapter 3.6.3.4 --- Recruitment of participants --- p.66 / Chapter 3.6.3.4.1 --- The sampling process --- p.67 / Chapter 3.6.4 --- Data collection method --- p.67 / Chapter 3.6.4.1 --- Collection of primary data --- p.67 / Chapter 3.6.4.1.1 --- Sequence of interview --- p.68 / Chapter 3.6.4.1.2 --- Setting for interview --- p.68 / Chapter 3.6.4.1.3 --- The process of collecting oral histories --- p.69 / Chapter 3.6.4.1.4 --- Strategies for avoiding personal bias --- p.72 / Chapter 3.6.4.2 --- Collection of secondary data --- p.72 / Chapter 3.6.4.3 --- Data handling and record keeping --- p.73 / Chapter 3.6.4.3.1 --- Handling of primary data --- p.74 / Chapter 3.6.4.3.2 --- Handling of secondary data --- p.74 / Chapter 3.6.5 --- Data analysis --- p.75 / Chapter 3.6.5.1 --- The adoption of content analysis --- p.75 / Chapter 3.6.5.2 --- Process of content analysis --- p.76 / Chapter 3.6.5.2.1 --- Analysis of the primary data --- p.76 / Chapter 3.6.5.2.2 --- Analysis of secondary data --- p.78 / Chapter 3.6.5.2.3 --- Linking the primary and secondary data --- p.79 / Chapter 3.7 --- Rigour of the study --- p.80 / Chapter 3.7.1 --- Quality issues related to qualitative research --- p.80 / Chapter 3.7.2 --- Strategies to enhance the rigour of the study --- p.81 / Chapter 3.7.2.1 --- Strategies applied to ensure credibility --- p.82 / Chapter 3.7.2.2 --- Strategies applied to ensure confirmability --- p.83 / Chapter 3.7.2.3 --- Strategies applied to ensure dependability --- p.84 / Chapter 3.7.2.4 --- Strategies applied to ensure transferability --- p.85 / Chapter 3.8 --- The pilot study --- p.85 / Chapter 3.9 --- Conclusion of this chapter --- p.87 / CHAPTER FOUR / FINDINGS --- p.89 / Chapter 4.1 --- Framework of data handling and presentation --- p.90 / Chapter 4.2 --- Characteristics of the participants --- p.93 / Chapter 4.3 --- The evolution of public health nurses - 1950s --- p.96 / Chapter 4.3.1 --- Data collected from secondary data source --- p.97 / Chapter 4.3.1.1 --- Significant events in the community --- p.97 / Chapter 4.3.1.2 --- The MCHC service --- p.97 / Chapter 4.3.1.3 --- The public health nurses --- p.98 / Chapter 4.3.2 --- Oral histories from the public health nurses --- p.102 / Chapter 4.3.2.1 --- Training of public health nurses --- p.103 / Chapter 4.3.2.1.1 --- Scope of training --- p.103 / Chapter 4.3.2.2 --- Selection of the public health field --- p.105 / Chapter 4.3.2.3 --- Perception of public health nursing duties --- p.106 / Chapter 4.3.2.4 --- Public health nursing practice in IWC --- p.108 / Chapter 4.3.2.5 --- Identifying factors which influenced public health nursing development --- p.112 / Chapter 4.3.2.6 --- Qualities of good public health nurses --- p.114 / Chapter 4.4 --- Challenges from socio-cultural and economical influences 1960 -1969 --- p.114 / Chapter 4.4.1 --- Data collected from secondary data source --- p.114 / Chapter 4.4.1.1 --- Significant events in the community --- p.116 / Chapter 4.4.1.2 --- The MCHC service --- p.117 / Chapter 4.4.1.3 --- The public health nurses --- p.118 / Chapter 4.4.2 --- Oral histories from the public health nurses --- p.119 / Chapter 4.4.2.1 --- Training of public health nurses --- p.119 / Chapter 4.4.2.1.1 --- Scope of training --- p.120 / Chapter 4.4.2.2 --- Selection of the public health field --- p.121 / Chapter 4.4.2.3 --- Perception of public health nursing duties --- p.121 / Chapter 4.4.2.4 --- Public health nursing practice in MCHC --- p.122 / Chapter 4.4.2.5 --- Identifying factors which influenced public health nursing development --- p.125 / Chapter 4.4.2.6 --- Qualities of good public health nurses --- p.129 / Chapter 4.5 --- The increasingly affluent period 1970 -1979 --- p.130 / Chapter 4.5.1 --- Data collected from secondary data source --- p.130 / Chapter 4.5.1.1 --- Significant events in the community --- p.132 / Chapter 4.5.1.2 --- The MCHC service --- p.133 / Chapter 4.5.1.3 --- The public health nurses --- p.134 / Chapter 4.5.2 --- Oral histories from the public health nurses --- p.134 / Chapter 4.5.2.1 --- Training of public health nurses --- p.135 / Chapter 4.5.2.1.1 --- Scope of training --- p.135 / Chapter 4.5.2.2 --- Selection of the public health field --- p.136 / Chapter 4.5.2.3 --- Perception of public health nursing duties --- p.136 / Chapter 4.5.2.4 --- Public health nursing practice in MCHC --- p.139 / Chapter 4.5.2.4.1 --- Health education activities --- p.139 / Chapter 4.5.2.4.2 --- Home visiting --- p.140 / Chapter 4.5.2.4.3 --- Serving clients with different backgrounds --- p.141 / Chapter 4.5.2.5 --- Identifying factors which influenced public health nursing development --- p.145 / Chapter 4.5.2.6 --- Qualities of good public health nurses --- p.145 / Chapter 4.6 --- The impact of the political scenes 1980 1989 --- p.147 / Chapter 4.6.1 --- Data collected from secondary data source --- p.147 / Chapter 4.6.1.1 --- Significant events in the community --- p.147 / Chapter 4.6.1.2 --- The MCHC service --- p.148 / Chapter 4.6.1.3 --- The public health nurses --- p.149 / Chapter 4.6.2 --- Oral histories from the public health nurses --- p.150 / Chapter 4.6.2.1 --- Training of public health nurses --- p.150 / Chapter 4.6.2.1.1 --- Scope of training --- p.151 / Chapter 4.6.2.2 --- Selection of the public health field --- p.152 / Chapter 4.6.2.3 --- Perception of public health nursing duties --- p.153 / Chapter 4.6.2.4 --- Public health nursing practice in MCHC --- p.154 / Chapter 4.6.2.5 --- Identifying factors which influenced public health nursing development --- p.156 / Chapter 4.6.2.5.1 --- Factors not influencing public health nursing --- p.156 / Chapter 4.6.2.5.2 --- Factors influencing public health nursing --- p.157 / Chapter 4.6.2.6 --- Qualities of good public health nurses --- p.161 / Chapter 4.7 --- 1990- 1999 Before and after the new era; the transition of political parties --- p.162 / Chapter 4.7.1 --- Data collected from secondary data source --- p.162 / Chapter 4.7.1.1 --- Significant events in the community --- p.162 / Chapter 4.7.1.2 --- The MCHC Service --- p.164 / Chapter 4.7.1.3 --- The public health nurses --- p.164 / Chapter 4.7.2 --- Oral histories from the public health nurses --- p.166 / Chapter 4.7.2.1 --- Training of public health nurses --- p.166 / Chapter 4.7.2.1.1 --- Scope of training --- p.167 / Chapter 4.7.2.2 --- Selection of the public health field --- p.168 / Chapter 4.7.2.3 --- Perception of public health nursing duties --- p.170 / Chapter 4.7.2.4 --- Public health nursing practice in MCHC --- p.172 / Chapter 4.7.2.4.1 --- Health education activities --- p.172 / Chapter 4.7.2.4.2 --- Home visiting --- p.173 / Chapter 4.7.2.4.3 --- Serving clients with different backgrounds --- p.175 / Chapter 4.7.2.4.4 --- Child developmental screening service --- p.176 / Chapter 4.7.2.4.5 --- Trail of various service delivery approaches --- p.177 / Chapter 4.7.2.5 --- Identifying factors which influenced public health nursing development --- p.178 / Chapter 4.7.2.5.1 --- Factors not influencing public health nursing --- p.178 / Chapter 4.7.2.5.2 --- Factors influencing public health nursing --- p.179 / Chapter 4.7.2.6 --- Qualities of good public health nurses --- p.184 / Chapter 4.8 --- Years of change after 2000 --- p.185 / Chapter 4.8.1 --- Data collected from secondary data source --- p.185 / Chapter 4.8.1.1 --- Significant events in the community --- p.185 / Chapter 4.8.1.2 --- The MCHC service --- p.188 / Chapter 4.8.1.3 --- The public health nurses --- p.190 / Chapter 4.8.2 --- Oral histories from the public health nurses --- p.193 / Chapter 4.8.2.1 --- Training of public health nurses --- p.193 / Chapter 4.8.2.1.1 --- Scope of training --- p.194 / Chapter 4.8.2.2 --- Selection of the public health field --- p.194 / Chapter 4.8.2.3 --- Perception of public health nursing duties --- p.195 / Chapter 4.8.2.4 --- Public health nursing practice in MCHC --- p.196 / Chapter 4.8.2.5 --- Identifying factors which influenced public health nursing development --- p.198 / Chapter 4.8.2.5.1 --- Factors not influencing public health nursing --- p.198 / Chapter 4.8.2.5.2 --- Factors influencing public health nursing --- p.199 / Chapter 4.8.2.6 --- Qualities of good public health nurses --- p.206 / Chapter 4.9 --- Oral histories from the administrators --- p.207 / Chapter 4.9.1 --- Training of public health nurses --- p.207 / Chapter 4.9.1.1 --- Scope of training --- p.209 / Chapter 4.9.1.2 --- Perception of public health nursing duties --- p.211 / Chapter 4.9.1.3 --- Public health nursing practice in MCHC --- p.213 / Chapter 4.9.1.4 --- Identifying factors which influenced public health nursing development --- p.216 / Chapter 4.9.1.5 --- Qualities of good public health nurses --- p.221 / Chapter 4.10 --- Conclusion of this chapter --- p.222 / CHAPTER FIVE / DISCUSSION --- p.225 / Chapter 5.1 --- A sketch of the working life of public health nurses --- p.225 / Chapter 5.2 --- The three research objectives --- p.227 / Chapter 5.2.1 --- Research objective one: The characteristics of public health nursing in Hong Kong --- p.229 / Chapter 5.2.1.1 --- Categories of public health nurses in Hong Kong --- p.229 / Chapter 5.2.1.1.1 --- Public health nurse title as defined by organisation --- p.229 / Chapter 5.2.1.1.2 --- Public health nurse title as defined from training --- p.231 / Chapter 5.2.1.1.3 --- Ranking of public health nurses --- p.232 / Chapter 5.2.1.2 --- Nursing culture --- p.233 / Chapter 5.2.1.3 --- Population-focused service in MCHC --- p.234 / Chapter 5.2.1.4 --- Nursing practice on health education, health promotion and direct care --- p.237 / Chapter 5.2.1.5 --- The invisible service --- p.238 / Chapter 5.2.1.6 --- The presentation of art and science in public health nursing --- p.239 / Chapter 5.2.2 --- Research objectives two: the changes of public health nursing practice during the study period --- p.241 / Chapter 5.2.2.1 --- The delineation of the development of public health nursing practice in MCHC from 1954 to 2010 --- p.241 / Chapter 5.2.2.1.1 --- The first phase of development: 1954 to the 1970s and the evolution of public health nurses --- p.242 / Chapter 5.2.2.1.2 --- The second phase of development: 1970s to 1980s a static period in the public health nursing service --- p.243 / Chapter 5.2.2.1.3 --- The third phase of development: 1990s to 2010s a period of changes --- p.244 / Chapter 5.2.2.2 --- Predominant features in the development --- p.246 / Chapter 5.2.2.2.1 --- Perceived decrease of autonomy --- p.246 / Chapter 5.2.2.2.2 --- Generational differences among nurses influence job satisfaction --- p.247 / Chapter 5.2.2.2.3 --- The cessation of home visits --- p.248 / Chapter 5.2.3 --- Research objective three: significant events and factors influencing public health nursing development --- p.250 / Chapter 5.2.3.1 --- The influence of significant events happened in the community --- p.251 / Chapter 5.2.3.2 --- Devaluation of the service and the invisibility of the practice --- p.254 / Chapter 5.2.3.3 --- Medical dominance, administrative influences and manpower factors --- p.257 / Chapter 5.2.3.4 --- Impact of working for a government organisation --- p.260 / Chapter 5.2.3.5 --- The ideology of public health and public health nurses in Hong Kong --- p.262 / Chapter 5.2.3.6 --- The good practice model initiated by the earlier public health nurses --- p.265 / Chapter 5.2.3.7 --- Training of public health nurses --- p.267 / Chapter 5.3 --- History, historical research and nursing --- p.271 / Chapter 5.4 --- Conclusion of this chapter --- p.276 / CHAPTER SIX / CONCLUSIONS --- p.278 / Chapter 6.1 --- Strengths of the study --- p.278 / Chapter 6.2 --- Limitations of the study --- p.279 / Chapter 6.2.1 --- Shortcomings of historical research --- p.280 / Chapter 6.2.2 --- Threats to internal and external criticism --- p.280 / Chapter 6.3 --- Implications for nursing research, practice and education --- p.282 / Chapter 6.3.1 --- Research --- p.282 / Chapter 6.3.1.1 --- Methodology --- p.282 / Chapter 6.3.1.2 --- Further research questions and new interpretations on history --- p.284 / Chapter 6.3.2 --- Education --- p.287 / Chapter 6.3.2.1 --- Content of nursing curricula related to nursing history --- p.287 / Chapter 6.3.2.2 --- Teaching historical research methodology --- p.288 / Chapter 6.3.2.3 --- Strengthen training on public health nursing --- p.288 / Chapter 6.3.3 --- Practice --- p.289 / Chapter 6.4 --- Conclusion of this chapter --- p.291 / REFERENCES --- p.293

A sistematização da assistência de enfermagem tornou-se um instrumento valioso no trabalho do enfermeiro, por nortear as consultas, produzir registro de suas práticas por meio de processo organizado com linguagem padronizada, pensamento crítico e habilidades lógicas. Na Atenção Básica, para o enfermeiro realizar a SAE, necessita de classificação voltada não apenas para o modelo fisiopatológico, mas que contemple o ser humano de forma integral, respeitando os princípios do SUS de universalidade, equidade, integralidade, resolutividade e de qualidade. A Classificação Internacional de Práticas de Enfermagem em Saúde Coletiva, CIPESC®, atende a essas características, constituindo a opção de classificação para esta elaboração. Assim, o presente estudo teve como objetivo reformular e validar roteiro para primeira consulta de enfermagem à gestante de baixo risco utilizando a CIPESC®. A pesquisa buscou consistência teórica no histórico das classificações das práticas de enfermagem para contribuir no aprimoramento do conhecimento, assim como, na consulta de enfermagem e da saúde da mulher para entendermos a evolução do atendimento à gestante, grupo populacional escolhido como foco do roteiro. Trata-se de Estudo Metodológico realizado em duas fases. A primeira constituiu-se no desenvolvimento de revisão integrativa, analisando as produções científicas sobre Cuidados de Enfermagem, Enfermagem em Saúde Pública, Atenção Primária à Saúde, Saúde da Mulher, Classificação Internacional de Atenção Primária, Gestante e Pré-Natal para fundamentar a reconstrução do roteiro em uso em uma unidade básica de saúde. Foram utilizadas três bases de dados: Lilacs, Pubmed e Cinahl. Obteve-se nove publicações que possibilitaram extrair evidências das informações para aprimorar o roteiro. O resultado da Revisão Integrativa acrescido de analise de documentos oficiais do Ministério da Saúde sobre o tema forneceram os elementos para a formulação do roteiro, que também foi apreciado pelo grupo de trabalho sobre a SAE, constituído de enfermeiras da rede de Atenção Básica, gerando a versão para a próxima fase. Na segunda fase, foi realizada validação por oito experts que, após duas apreciações com incorporação das observações e sugestões, obteve-se como produto final, o roteiro de SAE para primeira consulta da gestante na Atenção Básica. Conclui-se que o roteiro validado oferece subsídios para direcionar os enfermeiros a documentarem a consulta de enfermagem, permitindo além da adequação das exigências do Conselho de Enfermagem espaço para novos estudos relacionados à sua aplicabilidade. O roteiro reformulado e validado, de sistematização de assistência de enfermagem da primeira consulta à gestante na Atenção Básica visa, como finalidade, à sua aplicação prática, para tanto, será apresentado à Secretária Municipal de Saúde do município de Ribeirão Preto para ser incorporado aos protocolos municipais, propondo-se a substituição da Versão inicial atualmente em uso. Palavras-chave: Cuidados de Enfermagem. Enfermagem em Saúde Pública / The Nursing Care Systematization (NCS) has become a valuable tool in the nurses\' work for guiding the consultations and producing a record of their practices through an organized process with standardized language, critical thinking and logical skills. In Primary Care, to perform the NCS, nurses need of the classification not only for the pathophysiological model, but also to contemplate the human being integrally, respecting the SUS principles of universality, equity, integrality, problem solving and quality. The International Classification of the Nursing Practices in Collective Health - CIPESC® meets these characteristics, constituting the option of classification for this development. Thus, this study aimed to reformulate and validate a guide for the first nursing consultation of the low-risk pregnant women using the CIPESC®. The research sought theoretical consistency in the history of the classification of nursing practices to contribute to the improvement of knowledge as well as of the nursing consultation and women\'s health to understand the evolution of care to pregnant women, a population group chosen as the focus of the guide. This is a Methodological Study carried out in two phases. The first was the development of an integrative review, analyzing the scientific productions on Nursing Care, Public Health Nursing, Primary Health Care, Women\'s Health, International Classification of Primary Care, Pregnant Women and Prenatal Care to support the reconstruction of the guide which was being used in a basic health unit. Three databases were used: Lilacs, Pubmed and Cinahl. There were 9 articles that made it possible to extract evidence of the information to improve the guide. The result of the Integrative Review and the analysis of official Ministry of Health documents on the theme provided the elements for the development of the guide, which was also appreciated by the work group on NCS composed by nurses from the Primary Care network, generating the version for the next phase. In the second phase, the validation was performed by 8 experts, and after two evaluations with incorporation of the observations and suggestions, it was obtained as final product, the NCS guide for the first consultation of the pregnant women in Primary Care. It was concluded that the validated guide offers subsidies to help nurses to document the nursing consultation, allowing the adequacy of the requirements of the Nursing Board and the opportunity for further studies related to its applicability. The revised and validated guide of the systematization of first nursing consultation of the pregnant woman in Primary Care aimed at its practical application. For this purpose, it will be presented to the Municipal Health Secretary of the city of Ribeirão Preto to be incorporated into the municipal protocols with the proposal to replace the initial version, which is currently in use

A sistematização da assistência de enfermagem tornou-se um instrumento valioso no trabalho do enfermeiro, por nortear as consultas, produzir registro de suas práticas por meio de processo organizado com linguagem padronizada, pensamento crítico e habilidades lógicas. Na Atenção Básica, para o enfermeiro realizar a SAE, necessita de classificação voltada não apenas para o modelo fisiopatológico, mas que contemple o ser humano de forma integral, respeitando os princípios do SUS de universalidade, equidade, integralidade, resolutividade e de qualidade. A Classificação Internacional de Práticas de Enfermagem em Saúde Coletiva, CIPESC®, atende a essas características, constituindo a opção de classificação para esta elaboração. Assim, o presente estudo teve como objetivo reformular e validar roteiro para primeira consulta de enfermagem à gestante de baixo risco utilizando a CIPESC®. A pesquisa buscou consistência teórica no histórico das classificações das práticas de enfermagem para contribuir no aprimoramento do conhecimento, assim como, na consulta de enfermagem e da saúde da mulher para entendermos a evolução do atendimento à gestante, grupo populacional escolhido como foco do roteiro. Trata-se de Estudo Metodológico realizado em duas fases. A primeira constituiu-se no desenvolvimento de revisão integrativa, analisando as produções científicas sobre Cuidados de Enfermagem, Enfermagem em Saúde Pública, Atenção Primária à Saúde, Saúde da Mulher, Classificação Internacional de Atenção Primária, Gestante e Pré-Natal para fundamentar a reconstrução do roteiro em uso em uma unidade básica de saúde. Foram utilizadas três bases de dados: Lilacs, Pubmed e Cinahl. Obteve-se nove publicações que possibilitaram extrair evidências das informações para aprimorar o roteiro. O resultado da Revisão Integrativa acrescido de analise de documentos oficiais do Ministério da Saúde sobre o tema forneceram os elementos para a formulação do roteiro, que também foi apreciado pelo grupo de trabalho sobre a SAE, constituído de enfermeiras da rede de Atenção Básica, gerando a versão para a próxima fase. Na segunda fase, foi realizada validação por oito experts que, após duas apreciações com incorporação das observações e sugestões, obteve-se como produto final, o roteiro de SAE para primeira consulta da gestante na Atenção Básica. Conclui-se que o roteiro validado oferece subsídios para direcionar os enfermeiros a documentarem a consulta de enfermagem, permitindo além da adequação das exigências do Conselho de Enfermagem espaço para novos estudos relacionados à sua aplicabilidade. O roteiro reformulado e validado, de sistematização de assistência de enfermagem da primeira consulta à gestante na Atenção Básica visa, como finalidade, à sua aplicação prática, para tanto, será apresentado à Secretária Municipal de Saúde do município de Ribeirão Preto para ser incorporado aos protocolos municipais, propondo-se a substituição da Versão inicial atualmente em uso. Palavras-chave: Cuidados de Enfermagem. Enfermagem em Saúde Pública / The Nursing Care Systematization (NCS) has become a valuable tool in the nurses\' work for guiding the consultations and producing a record of their practices through an organized process with standardized language, critical thinking and logical skills. In Primary Care, to perform the NCS, nurses need of the classification not only for the pathophysiological model, but also to contemplate the human being integrally, respecting the SUS principles of universality, equity, integrality, problem solving and quality. The International Classification of the Nursing Practices in Collective Health - CIPESC® meets these characteristics, constituting the option of classification for this development. Thus, this study aimed to reformulate and validate a guide for the first nursing consultation of the low-risk pregnant women using the CIPESC®. The research sought theoretical consistency in the history of the classification of nursing practices to contribute to the improvement of knowledge as well as of the nursing consultation and women\'s health to understand the evolution of care to pregnant women, a population group chosen as the focus of the guide. This is a Methodological Study carried out in two phases. The first was the development of an integrative review, analyzing the scientific productions on Nursing Care, Public Health Nursing, Primary Health Care, Women\'s Health, International Classification of Primary Care, Pregnant Women and Prenatal Care to support the reconstruction of the guide which was being used in a basic health unit. Three databases were used: Lilacs, Pubmed and Cinahl. There were 9 articles that made it possible to extract evidence of the information to improve the guide. The result of the Integrative Review and the analysis of official Ministry of Health documents on the theme provided the elements for the development of the guide, which was also appreciated by the work group on NCS composed by nurses from the Primary Care network, generating the version for the next phase. In the second phase, the validation was performed by 8 experts, and after two evaluations with incorporation of the observations and suggestions, it was obtained as final product, the NCS guide for the first consultation of the pregnant women in Primary Care. It was concluded that the validated guide offers subsidies to help nurses to document the nursing consultation, allowing the adequacy of the requirements of the Nursing Board and the opportunity for further studies related to its applicability. The revised and validated guide of the systematization of first nursing consultation of the pregnant woman in Primary Care aimed at its practical application. For this purpose, it will be presented to the Municipal Health Secretary of the city of Ribeirão Preto to be incorporated into the municipal protocols with the proposal to replace the initial version, which is currently in use

Introdução: O aconselhamento nutricional contribui para a formação de hábitos alimentares saudáveis e promoção do crescimento infantil. No entanto, apesar de investimentos governamentais, diversos estudos mostram problemas para concretização dessa prática, entre os quais se destacam o escasso conhecimento e despreparo dos profissionais de saúde para lidar com aspectos da alimentação das crianças e dificuldades para realizar o acompanhamento do crescimento. Objetivo geral: Implementar uma capacitação em aconselhamento nutricional e avaliar conhecimentos e práticas de profissionais de saúde da atenção básica quanto ao acompanhamento do crescimento e desenvolvimento infantil, o estado nutricional e as práticas de alimentação das crianças, antes e após a capacitação. Objetivos específicos: Avaliar o uso e o preenchimento da Caderneta de Saúde da Criança (CSC), especialmente crescimento e desenvolvimento; Implementar capacitação em aconselhamento nutricional, com avaliação do conhecimento dos profissionais antes e após e sua aplicabilidade na atenção à saúde da criança; Conhecer as dificuldades para realizar aconselhamento nutricional e acompanhamento do crescimento infantil, na perspectiva de profissionais de saúde; Avaliar práticas de alimentação, estado nutricional e acompanhamento do crescimento infantil pelos profissionais de saúde, antes e após a capacitação em aconselhamento nutricional. Método: Estudo de intervenção do tipo antes-depois, quanti-qualitativo, descritivo-analítico, conduzido em três fases no município de Itupeva, São Paulo. Incluiu amostra representativa de crianças <3 anos cadastradas nas unidades básicas de saúde com suas respectivas mães e profissionais de saúde. Na 1ª fase (antes), verificou-se o uso e o preenchimento das CSC; avaliaram-se as práticas alimentares das crianças e as práticas profissionais por meio de entrevistas com as mães, e o estado nutricional foi avaliado por antropometria e dosagem de hemoglobina sanguínea. Na 2ª fase (intervenção) implementou-se uma capacitação em aconselhamento nutricional que envolveu 53 profissionais de saúde vinculados à atenção básica do município. Os conhecimentos e as práticas dos participantes foram avaliados por testes aplicados antes e depois da capacitação e por meio de grupo focal. Na 3ª fase (depois), os mesmos procedimentos da 1ª fase (antes) foram adotados. O projeto foi aprovado por Comitê de Ética em Pesquisa da Escola de Enfermagem da Universidade de São Paulo e todos os participantes assinaram Termo de Consentimento Livre e Esclarecido. Os dados foram digitados no software Epi-Info 3.5.2 em dupla entrada. As variáveis categóricas foram analisadas por meio de frequência absoluta e relativa, teste do Qui-quadrado de Pearson e Exato de Fisher, com uso do software Stata 13.1. O nível de significância foi de 5%. Os dados qualitativos foram transcritos e submetidos à análise de conteúdo. Resultados: Foram descritos em quatro manuscritos que contemplaram os objetivos específicos. Manuscrito 1: Avaliou uso e preenchimento da CSC com dados da 1ª fase (antes). Apenas 53% das mães portavam a CSC no momento da entrevista, proporção similar à de mães que referiram orientação para levar a CSC aos atendimentos de saúde. Anotações na CSC durante os atendimentos foram referidos por 49%. Esquema vacinal estava completo em 97% das CSC, mas apenas 9% e 8% tinham, respectivamente, gráficos de crescimento e desenvolvimento adequadamente preenchidos. Manuscrito 2: Implementou e avaliou a aplicabilidade da capacitação em aconselhamento nutricional e conhecimento dos profissionais antes e após a capacitação. Quatro oficinas com carga horária mínima de 16 horas cada foram desenvolvidas para implementação da capacitação. Participaram 11 enfermeiras, 14 auxiliares/técnicos de enfermagem e 28 agentes comunitários de saúde. Antes da capacitação 55,8% dos profissionais relataram usar muito o aconselhamento nutricional na rotina dos serviços, mas apenas 4% tinham conhecimento satisfatório. Após a capacitação, o conhecimento satisfatório teve incremento de 70%. Foram apontadas potencialidades da capacitação para melhoria dos conhecimentos, mas dificuldades em sua aplicabilidade decorrentes de problemas de infraestrutura dos serviços. Manuscrito 3: Descreveu as dificuldades para realizar aconselhamento nutricional e acompanhamento do crescimento infantil na perspectiva dos profissionais. As principais dificuldades para o aconselhamento nutricional referiram-se às suas crenças e experiências pessoais quanto à alimentação infantil. Para o acompanhamento do crescimento, destacaram-se os problemas de infraestrutura e funcionamento dos serviços de saúde, além da manutenção do modelo médico hegemônico. Manuscrito 4: Avaliou práticas de alimentação, estado nutricional e acompanhamento do crescimento infantil pelos profissionais de saúde antes e após capacitação em aconselhamento nutricional. Depois da capacitação, constatou-se incremento da prática do aleitamento materno e redução do consumo de alimentos ultraprocessados entre as crianças de 15-23 meses (p<0,05). Não houve mudanças no estado nutricional e diminuiu a proporção de gráficos de crescimento adequadamente preenchidos e de mães que receberam orientações sobre a alimentação e crescimento infantil. Considerações finais: Evidenciou-se que capacitações em serviço podem ser medidas simples e facilmente exequíveis para ampliar os conhecimentos dos profissionais e melhorar a assistência à saúde da criança. No entanto, as dificuldades identificadas para sua aplicabilidade podem minimizar todo o investimento realizado e impedir que os efeitos desejados sejam obtidos. Destaca-se a necessidade do efetivo envolvimento dos gestores e investimentos na infraestrutura dos serviços, incorporação do aconselhamento nutricional na educação permanente em saúde, bem como maior ênfase dessa temática nos processos formais de ensino à saúde. Por fim, espera-se que os resultados aqui apresentados possam sensibilizar gestores e profissionais para a revisão de suas práticas e contribuir para a formulação de intervenções efetivas, para que o cuidado com a saúde da criança deixe de ser uma preocupação para se tornar, de fato, uma prática. / Introduction: The nutritional counseling contributes to the development of healthy feeding habits and promotion of childrens growth. Despite the Brazilian government incentives, several studies presented problems to implement this practice. Among them, there are knowledge scarcity and unpreparedness of primary health care professionals to deal with infant feeding aspects and childrens growth monitoring barriers .Objective: To implement primary health care professionals training in nutritional counseling, and to evaluate their knowledge and practices about child growth and development monitoring, the nutritional status and the infant feeding practices before and after training. Specific Objectives: To evaluate the use and the filling of the Children Health Handbook (CHH), especially childrens growth and development charts. To implement the nutritional counseling training, and evaluate its applicability in the primary health care centers routine and professionals knowledge before and after training. To identify barriers to perform nutritional counseling and childrens growth monitoring in the professionals perspective. To evaluate infant feeding practices, nutritional status and childrens growth monitoring by primary health care professionals, before and after training in nutritional counseling. Method: We carried out a before-after intervention study, quanti-qualitative and descriptive-analytic. It was, carried out in three phases in Itupeva city, São Paulo. We used a representative sample of children under three years old enrolled in the primary health care centers (PHCC), your mothers and health care professionals. In the first phase (before), we interviewed mothers to evaluated childrens eating habits, the professionals practices and the use and filling CHH was checked. In this phase, we also evaluated children\'s nutritional status by anthropometry and blood hemoglobin dosage. In the second phase (intervention), we implemented a nutrition counseling training that involved 53 primary care health professionals. The knowledge and practices of the participants were evaluated by tests performed before and after training and through focus group. In the third phase (after), we adopted the same procedures of the first phase. The Research Ethics Committee of the School of Nursing of University of São Paulo approved the project and all participants signed a Consent Form. Data were entered into Epi-Info 3.5.2 software double entry. Using Stata 13.1 software, we analyzed categorical variables through absolute and relative frequencies, Pearson and Fisher\'s exact chi-square test. The significance level was 5%. Qualitative data were transcribed and submitted to content analysis. Results: We wrote four manuscripts that contemplated the specific objectives. Manuscript 1: In this manuscript, we evaluated the use and the filling of the CHH with data from Phase 1 (before). Only 53% of mothers were carrying the CHH in the interview, similar to the proportion of mothers who reported to have received guidance to take CHH to PHCC. Mothers affirmed (49%) that health care professional took notes during the appointments. The vaccination scheme was completed in 97% of the CHH, however only 9% and 8% had respectively, growth and development charts properly completed. Manuscript 2: Reviewed implementation and applicability of training in nutrition counseling and knowledge of professionals before and after training. Four workshops with minimum workload of 16 hours each was developed to implement the training. Study participants were 11 nurses, 14 nursing assistants and 28 community health workers. Before the training 55.8% of the professionals reported \'use a lot\' the nutritional counseling in the services routine, but only 4% had proper knowledge. After the training, this percentage increased 70%. The training had a positive impact in the knowledge improvement, however, according to the health care professionals there are difficulties in its applicability due to the services infrastructure problems,. Manuscript 3: We identified the barriers to implement the nutritional counseling and childrens growth monitoring, from the perspective of professionals. The main barriers for nutritional counseling were professionals personal beliefs and experiences regarding infant eating. The health services infrastructure, functioning and the maintenance of the hegemonic medical model were identified as problems for children growth monitoring. Manuscript 4: This manuscript evaluated the feeding practices, nutritional status and childrens growth monitoring by primary health care professionals before and after training in nutrition counseling. After the training there was an increase in breastfeeding practices and a reduction of ultra-processed food consumption between children 15-23 months old (p<0.05). There were no changes in nutritional status and there was a decreased of the proportion of proper completed filling of the growth charts and of mothers who received guidance on nutrition and childrens growth. Final considerations: It was evident that professional training may be a simple and easily achievable measure to expand the health care professionals knowledge and to improve children health care. However, the desired effects might not be addressed due to the barriers of the practices implementation. Effective involvement of managers and investment in infrastructure of the services is needed, as far as the incorporation of nutritional counseling in permanent health education, and a stronger emphasis in formal health education processes. Finally, there is hope that the presented results might let managers and professionals aware of their practices and to contribute for the effective interventions development to enable proper children\'s health care.

Introduction The clinical community in Western society has long practised medicine as organized by "two dominant principles: 1) the principle of essentialism which states that there is a fixed "natural" border between disease and health, and 2) the principle of specific treatment which states that having revealed a disease, the doctor can, at least in principle, find the one, correct treatment. These principles have served as the legitimization of the traditional, hierarchical organization of health-care" (Jensen, 1987:19). A main feature of medical practices based on these principles has been to address specific kinds of problems impeding or decaying health. This research is centrally concerned with essentialism and the institutional fixation of problems as two important nodal points of Canada's biomedical value and belief system. More specifically, I hope to show in an organized way how these principles shape staff knowledge of client and culture in a community health centre (CHC) in Lethbridge, Alberta. My analysis is based on four guiding points: 1) that in our polyethnic society health care institutions are massively challenged with actual and perceived cultural diversity and cross cultural barriers to which their staff feel increasingly obliged to respond with their services; 2) while the client cultural diversity is "real", institutional responses depend primarily on how that diversity is imagined by staff -often as a threat to a health institution's sociocultural world; 3) that problem-specific, medicalized thinking is central in this community health centre, even though its mandate is health promotion and this problem orientation often combines with medical essentialism to reduce "culturally different" to a set of client labels, some of which are problematic; and 4) while a "lifestyle model" and other models for health promotion are at present widely advocated and are to be found centrally in this institution's (CHC) charter, they have led to little institutional accomodation to cultural diversity. In this thesis my aim is to present an ethnographic portrait of a community health centre, where emphasis is given to the distinctive formal and informal "formative processess" (Good 1994) of social construction of certain perceived common core challenges facing the Canadian biomedical community today - challenges concerning cultural difference and its incorporation into health care perception and practice. I am particularly interested in institutions subscribing to a "health promotion model" of health care, a term I have borrowed from Ewles and Simnett (1992). Ewles and Simnett descrive the meaning of "health promotion" as earlier defined by WHO (World Health Organization): this perspective is derived from a conception of "health" as the extent to which an individual or group is able, on the on hand, to realise aspirations and satisfy needs; and, on the other hand, to change or cope with the environment. Health is, therefore seen as a resource for everyday life, not the objective of living; it is a positive concept emphasising social and personal resources, as well as physical capacities (Ewles & Simnett, 1992:20) Health is therefore concerned with "a state of complete physical, mental and social wellbeing, and not merely the absence of disease and infirmity" (Ewles and Simnett, 1992:6), I am interested in determing how threats to this defintion prevail in a community health centre's ideology of preventive care, and how that ideology encodes dimensions of diversity. I, however, want to go much further than this by exploring everyday staff discourse and practice, to understand how client cultural diversity is formed and informed by what staff do and say. How, in short, do individuals based in a health promotion organization socially construct their clients as objects of institutional concern? We need, as Young (1982) suggest, "to examine the social condition of knowledge production" in an institutionalized health care service provision subculture. There are, I believe, also practical reasons for conducting this research. Over the past ten years the Canadian health care system increasingly has had to focus on two potentially contradictory goals: reducing costs, and lessening persistent inequalities in health status among key groups and categories of persons in the Canadian population. Many now argue that one of the most central dimensions of the latter - of perisistent health inequalities in Canada - is ethnocultural. Few would seriously argue, for example, that Canadian First Nation health statistics are anything but appalling. Moreover, radical changes in immigration patterns over the past three decades have greatly increased urban Canadian cultural diversity. Caring "at home" now assumes international dimensions (McAdoo, 1993; Butrin, 1992; Buchignani, 1991; Indra, 1991, 1987; Galanti, 1991; Dobson, 1991; Waxler-Morrison, 1990; Quereshi, 1989). A growing voiced desire to provide more pluralistic health care and health care promotion has become persistently heard throughout the clinical community in Canada (Krepps and Kunimoto, 1994; Masi, 1993). Even so, for many health professionals cultural difference evidently remians either irrelevant or a threat to the established order of things. Applied research on health care institutions undertaken to investigate how better to meet these challenges nevrtheless remains very incomplete and highly concentrated in two broad areas. One of these is structural factors within the institution that limit cross-cultural access (Herzfeld, 1992; Hanson, 1980). Some of these studies have shown the prevalence of a strictly conservative institutional culture that frequently makes frontline agency workers gate-keeprs, who actively (if unconsciously) maintain client-institution stratification (Ervin, 1993; Demain, 1989; Ng, 1987; Murphy, 1987; Foster-Carter, 1987; de Voe 1981). In addition, extensive research has been conducted on disempowered minority groups. This research has examined the frequency, effectiveness and manner with which ethnic and Native groups make use of medical services. Some institutional research on cross-cultral issues shows that under appropriate conditions health professional like nurses have responded effectively to client needs by establishing culturally sensitive hiring and training policies and by restructuring their health care organizations (Terman, 1993; Henderson, 1992; Davis, 1992; Henkle, 1990; Burner, 1990). Though promising, this research remains radically insufficient for learning purposes. In particular, little work has been done on how such institutions come to "think" (Douglas, 1986) about cultural difference, form mandates in response to pressure to better address culturally different populations and work them into the institution's extant sub-cultral ideas and practice (Habarad, 1987; Leininger, 1978), or on how helping instiutions categorize key populations such as "Indians" or "Vietnamese" as being culturally different, or assign to each a suite of institutionally meaningful cultural attributes (as what becomes the institution's working sense of what is, say, "Vietnamese culture"). This is so despite the existence of a long and fruitful ethnographic institutional research tradition, grounded initially in theories of status and role (Frankel, 1988; Taylor, 1970; Parson, 1951), symbolic ineractionism (Goffman, 1967, 1963, 1961), ethnomethodology (Garfinkle, 1975), and organizational subcultures (Douglas, 1992, 1986, 1982; Abegglen & Stalk, 1985; Ohnuki-Tierney, 1984; Teski, 1981; Blumers, 1969). More recent work on anthropological social exchange theory (Barth, 1981), on institutional and societal discipline (Herzfeld, 1992; Foucault, 1984, 1977), on the institution-client interface (Shield, 1988; Schwartzman, 1987, Ashworth, 1977, 1976, 1975), and on framing the client (Hazan, 1994; Denzin, 1992; Howard, 1991; Goffman, 1974). I also hope that this study makes a contribution to the study of health care and diversity in southern Alberta. Small city ethnic relations in Canada have been almost systematically ignored by researchers, and similar research has not been conducted in this part of Alberta. Local diversity is significant: three very large Indian reserves are nearby, and the city itself has a diverse ethnic, linguistic and ethno-religious population. Also, significant province wide restructuring of health care delivery was and is ongoing, offering both the pitfalls and potentials of quick institutional change. Perhaps some of the findings can contribute to making the future system more responsive to diversity than the present one. / 202 p. ; 29 cm.