RESEARCH ARTICLES
Men's Health: approach in nursing education
Danilo Bertasso RibeiroI; Marlene Gomes TerraII; Annie Jeanninne Bisso LacchinniIII;
Silviamar CamponogaraIV; Margrid BeuterV; Cristiane Trivisiol da SilvaVI
ABSTRACT: This study aimed to examine how the issue related to men's health is addressed in the curricula of Undergraduate Nursing Programs in a city of Rio Grande do Sul - RS Brazil. This is a documentary research, qualitative, performed in three Undergraduate Nursing Programs, in a period from September to November 2010. It was used thematic content analysis. From the reading curriculum, five categories emerged: men's health as an anatomical-physiological approach; the male perspective in nursing techniques to adult; men’s health in childhood, adolescence and old age; man in the social and family context; and a new approach to men's health in nursing programs. The results showed a generalized approach to men's health and the inclusion of the National Policy of Comprehensive Care to Men's Health in academic discussions of undergraduate nursing programs.
Keywords: Nursing; curriculum; education; men’s health.
INTRODUCTION
Over the past few years, men's health began to be glimpsed more broadly, both by governments with the adoption of public policies, as through surveys of health. This significant increase in the development of practices for this population is justified by health indicators, which indicate high mortality of men, especially in the younger age groups and in various pathologies1.
Faced with this scenario, since 2009, men's health began to have greater visibility. That year, the National Policy of Comprehensive Care to Men's Health (NPCCMH) was consolidated, created by the Ministry of Health, with the proposition to qualify the health of the male population, on perspective of lines of care that will safeguard the comprehensive care2.
This strategy directed at men is presented as a historical and political framework that leads us to discuss and reflect on the male population, both in health and vocational nursing training aspects. The teaching developed at the university plays a social role of utmost importance; therefore, hereby changes in the social, political, economic and cultural systems of society are determined. As each historical period, the role of education in institutions has been changing, and consequently the university has been encouraged to face up to new challenges and changes3.
Since the establishment of the National Curriculum Guidelines (NCGs) in Undergraduate Nursing Programs4, it has been observed that the courses have sought to argue, more consistently, the principles and guidelines of the Unified Health System (UHS), as well as the policies and strategies implemented by the Brazilian government. Despite this progress, it is verified that, currently, there is an emphasis on debate on National Policies and Programs for Comprehensive Care to Women's Health, Children, Adolescents and Seniors, at the expense of a broader approach, including men’s health. In general, it is realized that the health of the male population is crafted in a generic way in nursing education, not sticking to specific problems related to man. Given the above, it was elected as goal of this research: to analyze how the issue related to men's health is addressed in the curricula of undergraduate Nursing programs in a city in of Rio Grande do Sul (RS) state.
LITERATURE REVIEW
Throughout history, nursing has been rethinking its ways of teaching, doing and researching, making advances and changes in curriculum development of vocational training, as well as in undergraduate and graduate programs. The job market in health care has undergone significant transformations, determined by economic, technological and social policies, which require changes in educational institutions so that graduates meet the new demands5.
The main purpose of NCGs for undergraduate nursing programs is to direct content approaches for nurses to have a generalist, humanist, critical and reflective training. Thus, it is intended that the professional is qualified to nursing practice, based on the scientific and intellectual rigor and follow ethical principles, able to understand and act on the most prevalent problems/situations of health and illness in the national epidemiological profile, with emphasis on its region, identifying the biopsychosocial dimensions of its determinants4.
In this sense, formation becomes a concept that includes education as an institution in a given society, in other words, the formal public and private educational system represented by schools, universities regulated by federal and state regulatory agencies. The learner in this process follows a curriculum that contains disciplines of general and professional nature, in order to prepare him for the exercise of citizenship and the specific practice of a profession6.
The essential content for the Undergraduate Nursing Program is related to health and disease process of the citizen, the family and the community. In addition, the contents need to be integrated into the epidemiological reality and professional skills, providing all shares of nursing care. They include the following thematic areas - biological and social bases of nursing; Fundamentals of Nursing; nursing care; nursing administration and nursing education4.
On the Nursing Care topic, the (theoretical and practical) contents that compose the nursing care in individual and collective level provided to children, adolescents, adults, women and elderly are included4. This is in the problematic of this study, on the investigation of disciplines that address specific content to Men assistance, enabling reflect on how these specific populations are addressed by NCGs for Undergraduate Nursing Programs in the country.
In this sense, the NPCCMH of 2009 becomes a strategy for reflection and dialogue in the academic and professional environment on men’s health, contributing to understand the historical and sociocultural context of these individuals, on the perspective to prevent and promote health, aiming to promote and improve the health of the male population of Brazil. It is understood that this helps, effectively, to reduce morbidity and mortality in this population, through rational confrontation of risk factors and by facilitating access to actions and comprehensive health care services2.
In order to improve the attention to men, and addressing issues related to men’s health and disease in training of health professionals, especially nurses, we believe that this politic strategy will contribute to rethink ways of forming generalists professionals, corroborating with the NCGs principles. In this bias, the proposition of an equitable approach to children, adolescents, women, and elderly in professional training, can result in a comprehensive, equitable and humanistic care for all populations.
METHODOLOGY
This is a documentary qualitative study, approved by the Research with humans Ethics Committee, by Opinion No. 0.193.0.243.000-10, set in three nursing courses from a city in Rio Grande do Sul (RS) state. For this, we developed the Confidentiality Agreement in which researchers are committed to preserving the privacy of Institutions of Higher Education, whose data were collected by analyzing the Pedagogical Project Course (PPC) of Undergraduate Nursing Programs, according Resolution No. 196/96 of the National Health Council7.
The approach with the institutions occurred through direct contact with the coordinators for Nursing Courses, to explain the purpose of the research and request the documents to be analyzed. Institutions provided the curriculum with their contents (PDF files, online and printed) contained in their respective PPCs and will be in this study identified as Institution I, Institution II and Institution III. Mandatory, complementary and elective disciplines from each institution were selected, and the information was organized in a summary table and analyzed in the period from September to November 2010.
For data processing of documents, it was used thematic content analysis8, which consists in the pre-analysis, material exploration, processing and interpretation of the obtained results. After organization of the information obtained in the documents of Nursing Courses, a superficial reading of the material was performed, enabling the elaboration of the corpus of research and material exploration, leading to the construction of the units and categories of records for their analysis, which were interpreted and discussed in the light of relevant literature.
RESULTS AND DISCUSSION
After reading the documents, it was held approximations between the PPCs of the surveyed institutions, which were prepared before the creation of NPCCMH. The categories emerged from the analytical process, corroborated with the interpretation of the authors and literature.
Men’s health as an anatomical and physiological approach
From the analysis it was observed that on the three surveyed institutions, men's health presents great emphasis on anatomical and physiological approach, considering an interconnection between the human body systems, focusing on the balanced functioning of the body (anatomical, cytological, embryological, physiological and genetic features, which interact presenting a healthy or diseased body).
The male reproductive system is explored, particularly with emphasis on the organs and their functions. The cytological and embryological aspects are also emphasized, as well as issues related to hormones production, sex and its reactions in the male body. It was perceived an approach to anomalies, the type of genetic inheritance linked with sexual chromosomes, and even probability of gender and probability of an individual to present or not an abnormal genotype.
Thus, without ignoring the importance of these contents, it appears that the approach on men’s health happens in isolation and de-contextualized. The focus is restricted to cells, organs and their functions, especially with regard to the reproductive system, with no greater inter-relation with specific care practice of nurse performance.
The process of nursing education requires attention to the demands of professional practice from the basic component disciplines, seeking to build, together with the students, the expertise, the knowledge to execute its phases, as well as developing the skills and attitudes in the context of disciplines of the professional component, which enable learning in the theoretical and practical framework9. The meaning of each curricular discipline cannot result from an isolated examination of its content, but from the way the disciplines as a whole are articulated10.
Institutions I, II and III had in their PPCs absence of linkage between base and technical knowledge on the initial disciplines of the course, with nursing practice directed to men’s health-disease process. The gender approach may allow the graduating to early relate members, organs and functions with supporting the health of populations, and may have increased improvement and learning throughout the course. Moreover, emphasizing the functioning of the male body can clarify regarding abnormalities and students may share this learning and develop prevention of men's health.
Male perspective on nursing techniques to adult
Upon further analysis, based on the contents of the disciplines in the adult health area of institutions I, II and III, it was observed that men's health is indirectly addressed. Contents are contained in all subjects of the area, with a generic approach on the health-disease process in the adult, without individualizing men’s health. Further analysis might show an emphasis on some technical procedures that, by their nature, are different for men and for women.
With regard to males, when analyzing the findings, no content about diseases that affect men were visualized. However, there are disciplines that address in details this aspect with regard to women, in the curricula of the three surveyed institutions.
Currently, statistics show an increase of diseases of male genital tract, such as prostate cancer, for example. The techniques related to the identification, treatment and care, as well as prevention methods are not present in the examined curricula. An estimate made by the National Cancer Institute (INCA) for the development of new cases of cancers, says prostate cancer as the most frequent, being surpassed only by the non-melanoma skin cancer2.
In the analyzed curricula, it was noticed also the lack of content related to health promotion and prevention of diseases of man. It was noted that cultural, social, psychological aspects, and especially its consequences, are not related either described in the investigated documents. In this regard it is noteworthy that one must understand that the adult patient is a man, a member of family, consisting of cultural characteristics and inserted into a social organization often based in the absence of self-care. Thus, it became clear that the institutions I, II and III emphasize, in the disciplines of adult health, nursing techniques and members or organs of men to be focused on certain technique, which can result in a fragmented care.
Men’s health in childhood, adolescence and old age
In this category, it was realized through the curricula of the institutions I, II and II, that approach of child, adolescent and elderly man happens in a generalized way. As for the male child, due to anatomical differences, there is requirement for special care, which is covered with nursing students, through theoretical and practical content. On male child it seems to be more emphasis on abnormalities that may occur, for example, retractable testicles and penis phimosis. However, despite abnormalities in boys are more visible, the institutions I, II and III do not have in their curricula the study of major anomalies affecting boys in their disciplines of child health, which can delay the resolution of a problem that could be signaling on the first 12 months of life. Thus, the future nurses must develop skills to act directly in the monitoring of childcare, working mainly in identifying these situations and referral to a pediatrician.
Adolescence is one of the most troubled periods of human development. Countless transformations, questions and discoveries happen in this phase11. The social environment in which the male adolescent is inserted influences him to show masculinity, both in regard to sexual initiation, as in other social aspects. It is at this stage that the adolescent is encouraged to alcohol and other drugs, which often happens in the home environment, in festivities or even in public places12.
Facing the numerous vulnerabilities to which the adolescent is exposed, the approach of content submitted by the institutions I, II and III, with regard to the care of male adolescent are summed up to some developmental changes, hygiene care, sexual debut and condom use. Other issues, such as the main situations of vulnerability and exposure in adolescence and on the statutes and rights of adolescents are not present in the curricula of the institutions studied.
The old man also undergoes several changes in his body and in social life, especially health-related wear, due to not have been careful lifelong, considered healthy in the adult condition. At this stage, the onset of prostate cancer is a major health problem in this population and the sixth most frequent occurrence of new cases of malignancy in the world, being the third most frequent cause of death among men13.
The emphasis on the health of the elderly man is presented in the curricula of the institutions I, II and III with a similar approach, directed to the care of this phase of life, including degenerative-chronic diseases, having no record of a specific approach to elderly man.
Man in familial and social context
The nursing curricula of the institutions I, II and III provide a little depth approach to the family. Focus happens globally with family institution, and not with family members who are part of this core. Also, aspects like family type, functions, role of each member in the family are not approached, and strengths and weaknesses of family care provided by the nurse are not explored.
On socio-cultural perspective, the man is the family responsible for the productive force, both at work and in the family environment. This position proposes that he takes care of his family first, and last, takes care of himself. In some situations, the delay to take care of themselves, contribute to men’s disease. These stereotypical notions of masculinity reduce the possibilities of preventive health care, making men die earlier than women14.
It was also perceived in the curricula of the three institutions, the absence of the relation man versus family versus society. In this sense, it is necessary to understand that man is not isolated but entered in the world in a socioeconomic context that brings in essence a strong cultural background built throughout history, where he puts himself in a strong position, of provider, productive and invulnerable to disease15. Thus, men have difficulty admitting their weaknesses and care needs16. The major causes of men‘s poor adherence to measures of health care are the socio-cultural barriers that favor the beliefs of what means being a male and the gender stereotypes that are ingrained in our culture for centuries17.
Thus, if male approach was inserted in the learning process, issues related to care, prevention and health promotion would be considered important to decrease the incidence of new cases of men’s disease, providing a comprehensive and qualified health care of this population. Thus, the gender perspective offers ample opportunity to enrich the theoretical dilemmas in public health and can be added to other intellectual and political efforts to the understanding of health and its determinants in the fight against inequality and for social justice18.
A new approach to men's health in nursing courses
This new approach to men was present in the curriculum of the institution I, through a complementary, elective course targeted to men's health. Such discipline proposes understanding, in a humanistic, critical and reflective perspective, how the attention to the overall health of men happens, in order to plan intervention actions at different levels of health care of these individuals, identifying the biopsychosocial dimensions and their determinants.
This emphasis, found in the curriculum of the institution I represents the starting point to highlight the importance of a specific discipline to men's health. However, it is observed that it is complementary and elective, in other words, the student is the one who decides whether or not to take the course. So it is a negative option, as in professional practice, it is often not possible to choose whether to care for a man or a woman. Despite advances found in the curriculum of the institution I, in this specific discipline, it was perceived lack of content that addresses male sexual system diseases, as well as other diseases that affect only men.
An interesting aspect is that the three institutions studied approach to women's health in mandatory way. It is worth reflecting on the conditions that enable such gender differences in the curricula of surveyed schools. This leads to wonder: does this happen because women have a specific policy too long; or because women, while generating their children during nine months, have more right to health care? Another aspect that can be associated with it may be related to the fact that nursing has, throughout its history, the predominance of female teachers and nurses.
For a long time, on health area, differences between men and women were naturalized, based on neutral biological theories. Many authors have mentioned that this results in gender conceptions, in which man is considered universal model of the human being, and the woman as other being, especial, deviant18.
Thus to qualify assistance to the male population, it is necessary since the education that future health professionals assist men to recognize their needs, to speak and take care of themselves, to reflect on their behavior, from transgressions to stereotypical masculinity that put them at unnecessary risk. Self care in general, is replaced by a self-destructive attitude, evidenced in the statistics of morbidity and mortality16.
CONCLUSION
This research revealed that men's health presents a general, superficial, fragmented and highly de-contextualized from the socio-cultural environment of men approach. By analyzing the investigated documents, it was observed that there is an emphasis on the anatomical and physiological approach and in a perspective of male gender targeted for nursing techniques to adult. Furthermore, it was found weaknesses in the men’s health approach in childhood, adolescence and old age, as well as on the perspective of man in his social and family context. But there are signs of a new approach to men's health in nursing courses that have as reference the National Policy of Comprehensive Care to Men's Health.
The study of men's health is recent, in academia, and implies considering them in all stages of life, in the social and family context, as well as the right to have health care in an integral and humanized way. Thus, this study indicates that the Undergraduate Nursing Programs need to rework on their curricula and insert specific themes of attention to men's health, addressing socio-cultural issues which interrelate with the prevention of diseases and health problems of male population.
Despite the contribution of this study to approach men's health disciplines in the nursing courses curricula, it had some limitations, including the lack of updated curricula and not the views of pedagogical coordinations and/or teachers of disciplines of their courses in order to compare them with the information found in the surveyed curricula.
From this research, it becomes important to conduct studies to further investigate this reflection on men’s health in nursing education, not only linked to academic learning, but in all spaces that permeate the training of health professionals.
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