Rosineide Santana de Brito^I; Danyelle Leonette Araújo dos Santos^II
INurse. Doctorate in Nursing. Associate Professor of the Federal University of Rio Grande do Norte, Brazil. Leader of the research group Nursing Care in Different life phases. E-mail: rosineide@ufrnet.br.
^IINurse. Master degree by the Post-Graduate Program in Nursing of the Federal University Federal of Rio Grande do Norte, Brazil. Scholar of the Scholarship Program of the Coordination and Improvement of higher-level students. E-mail: danyleonette@gmail.com.

ABSTRACT: This exploratory, descriptive study aimed to identify barriers to the introduction of specific health programs for the male public in primary health care. The participants were 16 doctors and nurses working in primary health facilities in the city of Natal, Brazil. Data were collected in July and August 2011 through semi-structured interview, and treated according to the enunciation analysis proposed by Bardin. The results revealed that the main barriers to inclusion of male-specific health programs are gender conceptions in society and how primary care services are organized. It is important to sensitize health personnel to take a proactive attitude to the needs of men in their respective areas.

Keywords: Public health nursing; primary health care; men’s health; health personnel.

INTRODUCTION

In recent decades, the theme involving the health of men is arousing the interest of scholars because of the high rates of morbidity and mortality attributed to this population. This fact became relevant with the recognition that most diseases/disabling aggravations and deaths that affect the male group could be prevented if the diagnosis and treatment occur early.

Thus, in order to understand the reasons that configure the epidemiological masculine profile as unfavorable has such issues related to the mode of socialization of men, which guided them from an early age to take a proactive stance in the face of situations of risk. This tends to cause health impacts of these individuals, because the maintenance of the ideal of masculinity prevents them from feeling vulnerable and liable to any event capable of causing damage to their health. Furthermore, considering the relationship between the act of caring and the female figure, there is fear in men that can be considered weak if they are looking for a health service in search of assistance^1-3.

From this, it is observed that male socialization does not favor the strengthening of links between men and health services, they do not recognize themselves as people care seekers. However, other factors deserve consideration when it comes to the health of this public, especially at primary care level. Among these are the shortage of specific programs to watch the male group or even difficulty inserting them in already existing actions in basic health units (BHU).

This reality is a reflection of socially established concepts about what it's like to be a man, which interfere with the care practice of health professionals. By sharing the same society that users, workers are also immersed in cultural moorings capable of contributing to a stereotypical vision about the needs of this population segment. Moreover, the fact that most of these workers consist of women, especially in nursing staff tends to interfere with the recognition and acceptance of the demands of men's health, distancing them, even more, of BHU^4-6.

Given these considerations, it is assumed that health workers recognize the existence of barriers able to hinder the insertion of targeted health programs for the care of men. Therefore, it is wondered: what obstacles are recognized by health professionals for the insertion of assistance programs focusing on male in primary health care?

Thus, the present study aimed to identify obstacles to the integration of assistance programs aimed at male public in primary health care.

LITERATURE REVIEW

In order to reduce inequalities in health care to men and women, the Ministry of Health launched in 2009, the National Policy of Integral Attention to Men´s Health (NPIAMH) that has as a priority objective to broaden men's health conditions through the guarantee of access of this group to the actions and health services. To do so, it must be integrated with the National Policy of Primary Health Care and in line with the principles governing the Unique Health System (SUS). Having as one of its principles the humanization, NPIAMH focuses on promoting, recognizing and respecting the ethics and the rights of men, considering their socio-cultural peculiarities, and economic policies. Thus, in order to comply with these principles, the aforementioned Policy conceives as fundamental, among other measures, to expand men public access to health services in different levels of attention; to offer information to the community in general about the promotion of men´s health, but also involve early these individuals in educational activities to prevent losses⁷.

Aiming at the satisfactory development of these actions it is necessary the technical training of working professionals in BHU; the establishment of the monitoring and ongoing evaluation of services and the performance of workers, plus a qualified analysis of indicators, which will make it possible to assess the impact of the measures adopted to improve the health situation of the male group⁷.

Concerning the training and continuing education of professionals on themes related to men´s health, these are of the utmost importance, since to assist this public is essential to go beyond technique, and the professional commitment with change of posture which requires commitment and creativity. Furthermore, we must promote the reception needs of men in general, addressing environmental, psychosocial and cultural factors of the health-disease process and not just focus on the biological aspects in order to answer the demands presented by this clientele. So, to recognize the male needs, health workers will be able to contribute to the elaboration of assistance measures capable of attracting men to health services^3,8.

Therefore, in order to be achieved the goals of the NPIAMH, it is recognized the need for professionals to understand the particularities involved in health-disease process of the male public, aiming at greater efficiency in the actions proposed for this population segment.

METHODOLOGY

Exploratory and descriptive study, qualitative approach, developed in four BHU, located in the West Health district of the municipality of Natal/RN, Brazil. 16 health professionals active in the teams of the family health strategy (FHS) participated in the research in the selected BHU, 10 were nurses and 06 doctors. As inclusion criteria, respondents should be medical professionals or nurses and employees of BHU selected. It should be noted that the number of participants was considered enough when saturation of data, that is, when not obtained new information statements⁹.

Data collection occurred between the months of July and August 2011. For that, initially, the possible participant was contacted in order to verify their willingness to participate in the study. Case showed interest, it was scheduled date and time for the interview, which was held in the staff room. It should be noted that preceded this step was the consent of the Secretary of health of the municipality of Natal/RN; approval of the Research Ethics Committee of the Federal University of Rio Grande do Norte with favorable opinion No. 293/2011 and formal grant of respondents to participate and write the speeches, through the signature of Free and Informed Consent Term.

As data collection instrument a semi-structured interview script consisting of two parts: the first containing demographic questions and professionals, in order to characterize the population; and the second was a guiding question for the specific object of study –  How do you see the new proposal of the Ministry of health in developing programs aimed to assist men in primary health care?

The statements were treated and interpreted using the first stage of enunciation analysis – the thematic analysis. This mode has the relevant characteristic the fact conceive the communication as a process and not as a given, deviating structures and formal elements¹⁰.

So, after transcription and exhaustive reading material, it was teamed the excerpts of the interviews as similarity of the reports of the deponents, considering the relevant ideas. Of this process, were derived from two categories, which formed the central theme entitled Barriers to implementation of assistance programs aimed at the male public. The results were analyzed and discussed on the basis of the National Policy of Integral Attention to Men´s Health and in literary studies about men´s health.

In order to maintain the confidentiality of subjects' identities, the letters E and M were designated to identify the professional nurses and doctors, respectively, followed by a number equivalent to the order of conducting the interviews.

RESULTS AND DISCUSSION

Characterization of the participants

Among study participants, 10 were nurses and six doctors, predominantly female, aged 45 years or more. The largest number of professional nurses was due to the fact that some teams of ESF are incomplete, i.e. without the presence of the medical professional. Furthermore, there was refusal of two doctors in participate in the investigation. Concerning the time of professional performance in primary care services, most worked for more than 10 years in this model of health care and in the BHU.

These data reinforce the idea of feminization of BHU, due to the majority presence of professional women, which can influence the feeling of not belonging to such spaces by men. However, the fact that the participants work for long periods in the same BHU, contributes to the recognition of these professionals by the people assigned, including by those who do not constantly uses the service, as is the case for men.

Barriers to implementation of assistance programs aimed at male public.

This central theme gave rise to two categories of Gender concepts in men´s health and Organization of health services relating to health care which are analyzed below.

Conceptions of gender in attention to men's health

The idea present in male imaginary about men do not need health care because they are unattainable at any event detrimental to his life contributes significantly to this public not seek health services. By such reason, in all the speeches, the deponents have revealed difficulties in admitting the public referred to in the daily lives of BHU, assigning that cultural issues, combined with the biological aspects.

 [...] the man thinks he's stronger, he thinks he's not going to get sick, because who gets sick is the woman. Because she gets pregnant, give birth, has the period, have menstrual cramps [pause] He has nothing! (M2)

They have that idea that are very strong, they don´t need to be on a doctor. The woman is fragile and needs, but [...] the man is strong and do not get sick. (E6)

On the speeches provided, participants mentioned the female figure to establish a relationship of inconsistent health care performed by men and women. Based on it, it was confirmed the belief that women tend to be seen as more fragile and care seekers due to possibility to generate lives. Thus, the physiological female body issues served to support the explanations about the greater presence of women in health services. On the other hand, cultural aspects were identified as an obstacle to seeking assistance by men, being expressed in the speeches by the meaning of existing fortress in these individuals.

The ideal of strength and invulnerability sustained by masculine gender is constructed in its process of socialization in which there is no stimulus for a self-care behavior. In this process the men begin to assume socially attributes required -such as power, strength, autonomy, rationality and repression of emotions-, and tend to distance, to a maximum of typical characteristics of the feminine universe, where it is the act of caring^3,5,11.

To assume a posture based along the lines of male hegemony, men resist in seek assistance for fear of this act be regarded as a feminine practice for people of his social conviviality. This resistance influences not only the way they use health services, but also the degree of commitment in which they find themselves when they decide to search for help⁵. In this way, the male group seeking health services only in situation of disease and not for maintaining his health.

The man is not very close to prevention. [...] When he [...] is unable to work, then seek to the unit. And when we see, generally, is already with the disease advanced. (M3)

Normally, when the man comes, he is with some pathology. They come with the disease, to treat. (E7)

The reports above show the recognition of subjects about the difficulty of the men engage in preventive practices, whether by cultural issues or fear of being harmed in their jobs, if they seek for the health service. In most speeches, the idea of delaying the search for male health burden men´s assistance, given the discovery of the disease occur, generally, in advanced stages, which is not always possible to cure. In this sense, when they sick, men tend to remain hospitalized for long periods in hospitals, unable to work, which generates sensations little experienced by them in their daily life such as passivity and impotence. This, in addition to causing physical and mental suffering to the patient and his family, carries higher costs to the health system and society financial overload⁷.

Another aspect mentioned by participants as a deterrent factor for male group seeking the BHU involves working and the importance attributed by the men to labor activity

It's hard working man, especially one who works in a company. [...] They are afraid that if they say they are going to the doctor, they're going to think as soon as they are sick and unable to perform the service. And here comes the fear of losing that job. (E1)
 
In the view of most respondents, there is fear in men to be considered weak and unable to carry out the work by their employers if seeking health services. Such a feeling arises, in particular, by the possibility of them being replaced or fired from their jobs. Although the last deponent have considered, in his speech, only formal workers, other respondents revealed that the freelancers also seek so scarce the BHU, obtain their incomes according to the amount of hours worked, situation has also evidenced in another study¹².

It is known that in male socialization process, the work gives men respect and social visibility because it enables them to take financial responsibility within the familiar sphere². This becomes even more noticeable when they are inserted into the lower social stratum, in which they need to strengthen the role of provider of their homes⁷. In this way, it is recognized the need for the professionals consider the cultural and social contexts in which individuals are inserted, in order to establish an appropriate assistance¹³.

Thus, it appears that male socialization, tied to conceptions of gender, was regarded as a hindrance for men consider themselves care seekers and seek for assistance. However, other factors also hinder access of this public at BHU, such as the organization of primary care services.

Organization of health services regarding attention to men's health

This subcategory was originated when respondents reflected on the difficulties for implementation of programs geared to the male group. Thus, aspects involving poor conditions of work and reduced contingent of professionals were the most cited.

 [...] the basic attention is scrapped, doesn't have any answers, does not solve problems of the population in general, how are you going to call the man?[pause] have to first structuring units to be able to welcome this man. (M1)

 [...] we are not realizing of women, the number of children who have to meet [...] to meet the man, you have to multiply the number of teams [professionals], if not [pause] you can't! (E6)

The speeches presented revealed a lack of organization in BHU, which hinders the service to the population, regardless of sex and age of the user. Such difficulty, in the view of participants, pervades since the number of working professionals in the services to problems in systems of reference and counter-reference. Thus, the recognition of respondents in organizing the BHU to offer solving assistance is of fundamental importance, especially when there is interest in making men recognize the primary health care as the main gateway of the SUS. The fact the men are known by their behavior based on objectivity and practicality requires health institutions to guarantee the resolution of health problems of these users without requiring frequent visits to services⁵.

It is valid to note that, in most interviews, respondents reported the men as far away from his routine of work, reinforcing the idea of invisibility of these users on the set of policies and assistance programs already established in the daily lives of BHU. The fact that, historically, the health services highlight the maternal and child welfare at the expense of other population groups carries distinct host men and women. This fact may be related to lack of qualification of these workers to cope with the demands of men´s health^5,6,8. This reality was exposed by some deponents, as the following declaration:

In our entire training spoke only in pregnant women, in child [pause] was not spoken in man. Now, after 18 years, you're talking [...] We don't have that culture of giving information to them and this is a management problem, and also professionals. (E4)

In previous testimony, it was noticed the recognition of the need for professional preparation with a focus of assistance to the male public, because, in general, education emphasizes the health conditions of women and children. Associated with this, the presence of cultural patterns tends to make health workers do not identify the men as well as a focus of their care. This entails as a consequence not formulating strategies to attract these individuals to services that make them feel accepted in these spaces. In addition, there was the understanding that responsibility for reduced male demand for services is not only the user but also the managers and health professionals, contrary to findings from another study, in which this charge was reported as exclusively of men⁶.

Recognizing this reality, the NPIAMH proposes technical training of the professionals in order to they inform and guide the general population about the problems that affect the male public, aiming to capture early men and reduce morbidity and mortality indicators of this population⁷.

Still on the organization of services, another aspect discussed was the difficulty of access to doctor's appointments, which are generally obtained by distributing sheets in little convenient schedules and unsafe. Furthermore, the operation of BHU in commercial schedule hamper the male to services, since he cannot or do not want to miss a day of work to search for assistance. This brings up questions of gender that assign men the role of provider⁸.

As for the operation of BHU, some participants pointed out the need to elaborate alternative periods that allow the attendance of men in these services. However, most of the speeches showed a resistance of professionals, especially doctors, in work schedules considered special by them, either for believing that men wouldn't look for assistance; by the reduced number of workers or lack of interest in taking on a function.

About a third time, I think you should hire more professionals [...]it would be great, really, but I wouldn't have conditions. [pause] No way! (M5)

Special schedule does not work. It's proven. Because [...], most of the time, who works in FHP won't, ever, want to work on a schedule of these, out of the ordinary. (M6)

Thus, it appears that respondents have not shown enthusiasm for facing the possibility of working in hours extended, proposing the recruitment of other professionals to work with customers who do not have access to BHU in conventional time. In their conception, enlarge the working shift of BHU does not contribute to attract the male group at BHU. However, refuting this idea, the authors showed in their study the effectiveness of the strategy in assisting the population in turn extended, as it was known the greatest concentration of men searching for assistance⁶. It is important to highlight the fact that those strategies don't focus only the male group, because, whereas, at present, men and women, from all classes are inserted in the labor market, participating in the productive force, an alternative schedule favors the presence of users of both genders in health services^6,7.

From the exposed, it is noted the existence of organizational problems to meet men in primary care services, highlighting especially the difficulty in obtaining medical consultations, lack of preparation of the professionals to assist these users, as well as the resistance of workers to extend their workday to provide assistance to the male public.

CONCLUSION

The results obtained in this study made it possible to respond to the initial questioning. Thus, in the view of the deponents, there are several obstacles that hinder the insertion of programs focusing on men's health in primary care. Among them are included gender issues, which pertain to the social imaginary that men do not need preventive care, reflecting thus on small seeks of them for assistance. Respondents also mentioned that the way BHU are organized does not offer conditions for entering programs focusing on the health of the male group. In this sense, the opening hours of BHU were highlighted, being coincident with the period of the workday of men, lack of professionals and lack of preparation in the host male health demands.

It is noted that the way health services are organized do not promotes the inclusion of strategies and actions which allow paradigmatic changes in the scenario of men´s health. Furthermore, it recognizes the importance of sensitizing the professionals operating in BHU for the issues facing the male group in order for them to adopt a proactive stance against the men attached in their areas of operation to intervene effectively in improving health of these individuals.

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