Health and services: relationships established with users in the light of social representations about citizenship


Raquel Coutinho VelosoI; Márcia de Assunção FerreiraII

I RN. Doctoral student, Escola de Enfermagem Anna Nery, Universidade Federal do Rio de Janeiro. Rio de Janeiro, Brazil. E-mail:
II Ph.D. in Nursing. Full Professor, Fundamental Nursing Department, Escola de Enfermagem Anna Nery, Universidade Federal do Rio de Janeiro. Rio de Janeiro, Brazil. Leader of the Research Group on Representations and Care Practices in Health and Nursing. Brazilian Scientific and Technological Research Council (CNPq) Researcher 1D. E-mail:



The aim was to identify the relationships users establish with health and health services in the light of their social representations about citizenship. In this qualitative research, Social Representations Theory was applied. Semi-structured interviews were carried out with twenty users of a Policlinic in Niterói, Brazil, from March to April 2006. Thematic content analysis showed that the social representations of health are expressed through activity and physical well-being, and the social representations of citizenship are expressed through behaviors and practices of solidarity, considered in the value (kindness and respect among others) and normative (rights and duties) dimensions. High-quality health services are expressed through dialogue and understanding about information that enables them to make decisions on the best care option. It was concluded that this representation is not articulated with the authoritarian health discourse, granting better conditions for the exercise of citizenship.

Keywords: Human rights; ethics; health; nursing



The right to health, as a fundamental right of human beings, has been established in the Brazilian Constitution but, in practice, it is not guaranteed to all. Thus, despite the determinations in the law that regulates the Unified Health System (SUS), every day, television and the print media give examples of decadence in the quality of public health services offered in the State of Rio de Janeiro and around the country, sometimes demonstrating complete disrespect for life.

In a search of a new and fairer social order prescribed by a democratic society, the entire Brazilian society should make efforts. Nursing should promote critical thinking and conscience toward citizenship within a perspective of social justice for health, in the attempt to overcome inequalities and social exclusions1.

A study about the social representations (SR) of citizenship among users at a public health service indicated that these are based on the ethics of virtues (values), associated with affection; and norms (rules) as, in order to be considered a citizen, one needs to comply with certain value and/or normative requisites2,3.

In this context, the question is raised about what relations can be established between users and health services based on the former’s SR about citizenship. The aim is to identify the relations the users establish with health and health services based on their SR about citizenship.

Discussing users’ representations about citizenship contributes to the construction of knowledge that discloses the dynamics of citizenship in the health area, particularly in nursing, regarding its conception as a social practice in the process of health production and knowledge.



Social Representations Theory (SRT) was applied as the theoretical-methodological framework. SR is a form of knowledge with practices objectives and contributes to the subjects’ construction of a given reality, as it socially elaborated and shared4.

In this research, SRT is applied to the study of citizenship, which serves as a psychosocial object to the extent that it corresponds to the reality of the group under analysis, as it emerges from the subjects’ daily social life, practices and exercises of the rights and duties inherent in the citizens.

SR favors the production of meanings about behavior, preparing the subjects for action, “upon everything because it remodels and reconstitutes elements from the environment in which the behavior is supposed to happen”5:46.

A qualitative research was undertaken at a community polyclinic in Niterói, a city in the State of Rio de Janeiro, and the interviewees, between March and April 2006, were the users of the same clinic. Before the start of data collection, authorization was requested from the polyclinic.

Approval for the research was obtained from the Research Ethics Committee at Escola de Enfermagem Anna Nery andHospitalEscolaSão Francisco de Assis, protocol 082/05. After receiving approval from the director of the health institution and the Committee, the users received the Informed Consent Term (ICT), in compliance with Ministry of Health Resolution196/96. The ICT was read to them before the interview in order to clarify possible doubts regarding their participation in the research.

All interviews were previously scheduled, using the times the users were presented at the clinic for some appointment. The interviews were held before or after the appointments, at the users’ preference.

The interviews were tape-recorded and fully transcribed soon afterwards. Fictitious names were used, which the interviewees chose to identify themselves, preserving their identities.

The following inclusion criteria were adopted: users over 18 years of age, male and female, registered at the polyclinic were the study was carried out; members of the health education group for diabetes mellitus and arterial hypertension patients who were attending the group at the time of data collection; users with preserved verbal communication and socio-cognitive skills; and who accepted to participate in the research, including the signing of the ICT. 

Thirty-five people were registered in the group, 23 of whom were women and 12 men. Twenty of them, i.e. five men and 15 women, participated in the research. The members’ age ranged between 24 and 82 years for the women, with the group between 60 and 70 years as the predominant age range. The men’s ages ranged between 56 and 77 years, with a predominance of people between 70 and 80 years of age. During the meetings, the women were more diligent than the men, which explains that the number of female participants was three times higher than that of male participants. The same relation is present in the subjects’ participation in this research.
A semistructured interview was held, including questions about the group’s sociodemographic profile, to support the analysis of the SR, based on the groups the subjects belonged to.

In view of the research focus – the social representations of citizenship among users at an outpatient health service – the testimonies were organized according to the identified units of meaning, with a view to discovering the groups of meaning in the communication, whose presence or frequency could have some meaning for the research problem. Then, the themes addressed in each unit were identified, the most significant registry units about the themes were separated and the thematic categorization process of the contents started. To understand the SR about citizenship, the contents of the registry unit were exhaustively read in the light of the classification themes, attempting to understand those elements in the subjects’ discourse that granted meaning to the object and how these elements articulated to explain the ways in which users dealt with the practical situations of health care in daily reality.



The thematic content analysis6 led to the organization of three main lines. The first revealed the dimensions of citizenship – value and normative – and their implications for the construction of types of citizens. The second pictured the origin of citizenship, permeated by the citizenship dimensions found. The third, presented in this paper, permitted reflections about the implications of these social representations of citizenship, unveiled by these users, for nursing care delivery at health services.

The links between citizenship, health and health services

The users were asked whether health is related to citizenship and whether care delivery at health services is linked with citizenship. The first question produced answers that were more related to their conceptions about health, and the second made them reflect about the interaction established between users and professionals from a value-affective perspective; and about care delivery at the services from a normative perspective.

Concerning the expression of citizenship in health, eight participants consider health as a state of physical wellbeing, represented by an active body; for five subjects, this active body permits action in solidarity with other people, revealing thoughts related to the value dimension, which considerably marks their representation of citizenship.
In that sense, it is evidenced that health is understood as physical well-being, manifested in the body’s activity, capable of interacting well with its social context; without health and with a sick body, on the other hand, people become inactive, which restricts their possibilities to work, close friendships and help other people:

[...] if your health is not good, you cannot work, you cannot visit a person in hospital, be generous to the other, you cannot be a citizen, if your health is not good, you cannot, you see? (Maria B.).
The relation between health and bodily activity, and between disease and inactivity, marks the SR about health and disease7. As a result of the inactivity deriving from the disease, the subjects’ social participation does not happen, threatening their social identity.

Relating citizenship with health through the idea of physical wellbeing, translated in an active body, makes sense within the general context of the results presented so far. If the subjects in this study represent citizenship within a value-affective dimension, translated into solidary behaviors and practices, it is important for the subjects to take into within a perspective of social participation (in order to feel useful), thus guaranteeing their social identity as citizens. That is one of the routes to explain the relation the users establish between citizenship and health.

The participants were also asked about factors that can influence them towards a better health. Twelve of them answered that a good, correct or appropriate diet is a fundamental factor, and six mentioned medical care as a factor that contributes towards a better health. It is important to remind that these citations were not excluding and were repeated in the interviews.

These answers can be discussed using the same argumentative support as the above, as food is a basic human need that keeps the body functioning, that is, it is the fuel to maintain a body active; and medical care figures in the statements as a mark of the need for solidarity between professionals and users. The following example illustrates the participant’s reference to the physician as a citizen, as this professional takes care of his health (body) and understands him:

[...] because who takes care of it[health] if not a citizen] [...] It has to be a citizen to take care of that patient, to know and understand him better, you see?(Oti)

Mentioning medical care to represent the relation between citizenship and health is no surprise, considering that one lives in a society in which the physician represents a hegemonic figure in the health area. This hegemony prevails because the physician is able to solve the users’ problems, which make them visit the health service as, in most cases, the search for health services happens not for the sake of health promotion and disease prevention, but when the disease has already established and needs diagnosis and treatment.

Concerning prevention, according to the Federal Constitution, art. 198, paragraph II: “holistic care, prioritizing preventive activities”8:137; as a rule, however, this does not happen in the Brazilian reality of public health care. This matter is also evidenced in the contents of the following registry unit:

I think that the government always loses with regard to health because it does not engage in health prevention, it wants to treat the disease, [...] That is a fact because you see that we’ve got a country full of sick people [...] you see it’s full, crowded, there’s a lot of disease[...]. (Marta)

It is highlighted that, less frequently, the following factors appeared to contribute to a better health: having peace at home; a sufficient financial situation to attend to one’s basic needs; living in a clean environment, with dignified housing conditions; having good education to be able to know one’s health; making friends; participating in health education groups at the health services; knowing how to use the SUS; having access to free medicines and receiving clarifications about illnesses at the health services; be solidary; practice physical exercises; and policy makers’ political conducts.

The above mentioned registry unit emerged in a discourse context that contained the idea that politicians are responsible for the course of social public policies in a city, state or country. In that sense, their political conducts will directly influence health-related issues, as health promotion actors are broad, based on which it can be inferred that users possess a health concept that does not oppose it to disease, within a biomedical paradigm, but understand it as a condition/result of several dignified living conditions, in the light of the paradigm of social health production9.

Food, health, education and housing are the social rights established in the Brazilian Constitution published in 1988. These social rights can be considered as social determinants of health – socioeconomic elements that affect a population’s health situation. The following registry unit reveals this content.

[...] our health depends on the demand for education, on a wage [...]. (Zizi)

It is important to highlight that, in view of the inequities present in the population’s health conditions, during the 2004 World Health Assembly, the director-general of the World Health Organization (WHO) Lee Jong-Wook proposed the creation of a commission to work towards improvements in these conditions: the commission on social determinants of health (CSDH-WHO). In that sense, in March 2006, the Brazilian government created the National Commission on Social Determinants of Health (NCSDH) to support and articulate the activities of the public power, research institutions and civil society on social determinants related to the improvement of health and the reduction of health inequities. On August 1st 2008, the final report of the NCSDH was officially handed over to the former President of the Republic, Luiz Inácio Lula da Silva10.

Hence, a dynamic concept of health is needed, as a product of social relations, in order to express quality of life. One may say that quality of life is implicit in the contents of the study participants’ statements as, by relating health with citizenship, they appointed conditions to live better. The term quality of life was explicitly referred to on only one occasion:

Yes, to be able to have a good quality of life so, if the person is not in good health, if the diet is not good, how will that person have a good quality of life? (Marizete)
When considering a good diet, for example, money is needed to purchase foods, as well as to attend to other needs, like housing, among others. In case people do not gain sufficient income for their maintenance, they will be unable to provide the conditions for good health as, considering that the relation between citizenship and health is centered on the body’s physical wellbeing/activity, mainly promoted through food, without quantitative and qualitative wellbeing, bodily activity is compromised, affecting the integrity of that person’s citizenship.

When relating citizenship with health services’ care delivery, the ideas the users transmit also transmitted the marks of the value-affective and normative dimensions. The first was expressed in the importance they attribute to the interaction between users and health professionals (12 users); and the second was manifested in the health services’ care delivery (seven users). Only one participant did not answer this question.

The value-affective perspective was revealed in the interaction between users and health professionals. They considered that, in care delivery, the professionals’ relation/interaction should be permeated by affection and moral virtues, like kindness and respect, respectively, to give an example. This conception is in line with what they consider as citizenship, when focused on a value-affective dimension.

The sphere of transpersonal care, which goes beyond the physical and material world through contact with the person’s emotional and subjective, requires that nursing care be understood in two main categories: the instrumental and the expressive. The first includes the technical, instrumental intervention procedures linked to the clinical, in response to the client’s biological-biomedical demands. The second category joins care in the sphere of interaction and welcoming, corresponding to the relational nature of care, which includes zeal and attention11,12.

The contents of the following registry unit exemplifies expressive care, which the users demand in health care practice:

I think that… relation between health and citizenship? They intend to enhance sick persons a lot, not just with regard to health, but morally. That is a gesture of citizenship, that means providing citizenship to the people who need it, who are sick [...] so he gets here and receives kindness, support, I think that’s it. It is a gesture of citizenship the service offers [...]. (Marta)

At the same time as the users express their desire to be attended well, as this is a right of citizens and a professional duty, it does not happen well, considering that some experiences evidence the opposite to good care:

 It should be good, but it’s lousy, why? Because the people are badly paid, they work against their will, they’re not doing what they like, attend to people badly, as if the people were there asking for aims, but they’re not asking for aims [...]. The people are treated very badly [...].(Zizi)

Unfortunately, it is perceived that health professionals have lost motivation, due to their work conditions, including an inappropriate physical environment, lack of materials and human resources, which are some of the conditions that hamper humanized care13. It should be added that many professionals even have more than one job, which negatively affects appropriate bonding with the clients and with the service itself.
As for the normative perspective, this is revealed exactly when health care delivery is considered as a right for all and a duty of the State:

Everything that belongs to the government, to the State, [...] is connected with citizenship. Do they help the citizens who have little, for example, to go to the health center, where you can get comfort, care, those things? Isn’t it the government who gives these things? It’s the government, the obligation of the government to give [...].(Maria)

In view of the difficulties the public health sector has been facing, however, the right to satisfactory care seems to be reserved for the few, who are people who are part of a social network that holds some prestige in society. One of the interviewees illustrates that concept:

The citizen arrives at the hospital and says: -Great care! They treated me as if I were an outstanding person, gave me care and I was extremely satisfied. (Edson)

To change this scenario, in 2004, the Ministry of Health launched the National Humanization Policy (NHP), in which humanization serves as the guiding axis of care and management practices at all levels of the SUS. This policy underlines the importance of health management and production processes, because the SUS needs to be considered as part of a collective, articulated network construction. Thus, the NHP devices are articulated to guarantee strategies to expand people’s citizenship conditions14.


The crisis in the health sector is responsible for the greater instability Brazil is going through and, in this context, different situations of disrespect for citizens’ rights are witnessed. This cannot be used to justify low-quality care though, revealing professionals’ lack of commitment towards the users, nor as daily natural and normal factors. Often, certain types of procedures and care forms are naturalized as inherent in public service and, therefore, expected by the users. When what happens goes against expectations, it is considered as a novelty and/or a privilege, sporadic and not inherent in the set of civil actions.

In the discussion based on the present research results, it was clear that the users want to be well attended at the health services, and that this quality care reflects the necessary respect for human dignity, as a right instead of a privilege for the few.

The research showed that users are aware that health is a fruit of social production, a right of the citizens, who are active in the construction process of the knowledge that sustains their actions. This indicates the need to overcome passive knowledge transmission models and include users in their care process, in the awakening to their accountability in the prevention, treatment and cure process, as well as in their participation in the social control of health care service delivery to the population.

Thus, health care delivery escapes from the authoritarian health discourse, permitting better conditions for the exercise of citizenship. In this context, nursing appears as a social practice within a perspective of social justice for health.

This research is limited by the fact that it was developed at only one polyclinic and predominantly included elderly participants, concentrated in the female universe. Hence, studies in other fields, with a broader spectrum of groups in distinct age ranges, with equitable parts of men and women, would contribute to enhance discussions on the theme, including the gender concept.

As this is a social representations research, based on human groups in the light of their social belonging, when the subjects’ characteristics change, so do the knowledge production conditions, enhancing the possibilities for reflection on and contribution to the problem studied here.



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Received: 12.10.2012