COTIDIANO DE AGENTES COMUNITÁRIOS DE SAÚDE COM IDOSOS SEGUNDO O REFERENCIAL DE CERTEAU DAILY WORK OF COMMUNITY HEALTH WORKERS INVOLVING THE ELDERLY ACCORDING TO CERTEAU’S FRAMEWORK

We aimed to understand daily practices of community health workers in elderly health care. Qualitative case study, based on Certeau’s theoretical framework of the daily. The participants were eight workers from family health teams in Montes Claros, Minas Gerais, Brazil. Individual interviews were undertaken using a semistructured script. The interviews were held in May 2016, recorded and submitted to content analysis. The workers’ daily practices in elderly health care involve strategies and tactics. The home visits and health education groups stood out in elderly care. In daily practice, the workers revealed difficulties associated with the fact that health system strategies are not put into effect. Based on these findings, nationwide strategies need to be implemented for elderly care to support the workers’ practices, enhancing health care for the users. DESCRIPTORS: Primary health care; Community health workers; Health of the elderly; Aging. Autor Correspondente: Recebido: 01/02/2017 Doane Martins da Silva Finalizado: 06/10/2017 Universidade Federal de Minas Gerais Av. Alfredo Balena, 190 30.130-100 Belo Horizonte, MG, Brasil E-mail: doane.ef@yahoo.com.br http://dx.doi.org/10.5380/ce.v22i4.50436 Artigo original 1Enfermeira. Doutoranda em Enfermagem. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil. 2Discente de Enfermagem. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil. 3Enfermeira. Doutora em Enfermagem. Docente de Enfermagem e do Programa de Pós-Graduação em Enfermagem da Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil. Cogitare Enferm. (22)4: e50436, 2017 Doane Martins da Silva1, Marina Aparecida Chrispim Silva2, Dianna Silva de Oliveira2, Marilia Alves3 COTIDIANO DE AGENTES COMUNITARIOS DE SALUD CON ANCIANOS SEGÚN EL REFERENCIAL DE CERTEAU RESUMEN: La finalidad fue comprender prácticas cotidianas de Agentes Comunitarios de Salude n la atención a la salud del anciano. Estudio de caso de aproximación cualitativa, basado en el referencial teórico de Certeau acerca del cotidiano, cuyos participantes fueron ocho agentes de equipos de salud de la familia del municipio de Montes Claros, Minas Gerais, Brasil. Fue adoptada la entrevista individual mediante un guión semiestructurado. Las entrevistas fueron llevadas a cabo en mayo del 2016, grabadas y sometidas al análisis de contenido. Las prácticas cotidianas de los Agentes en la atención a la salud de ancianos involucran estrategias y tácticas. Las visitas domiciliarias y los grupos de educación en salud se destacaron en el cuidado a los ancianos. En la práctica cotidiana, los agentes revelaron dificultades asociadas a la no efectuación de las estrategias del sistema de salud. Con base en estos hallazgos, se hace necesario implementar las estrategias de alcance nacional para la atención a los ancianos, como apoyo a las prácticas de los agentes, potencializando la atención a la salud de los usuarios. DESCRIPTORES: Atención primaria de salud; Agentes comunitarios de salud; Salud del anciano; Envejecimiento.


INTRODUCTION
The Family Health Strategy (FHS), being the main model for the reorganization of Primary Health Care (PHC) in Brazil, is the preferred entry point for the local health system (1) .The FHS aims to produce new dynamics in PHC, defining the responsibilities between the health services and the population.The basic family health team consists of a physician, nurse, auxiliary nurse and community health workers (CHW) (1) .
In the FHS, health care for the elderly is an important component of the family health teams' care and the professionals' performance is essential due to their potential to intervene in the health needs of this population, which is growing fast in the country, entailing changes in demographic and epidemiological patterns (2) .This growth represents a challenge for public policies and health services (3) .
In Brazil, among the public health policies for the elderly population, the most recent is the National Health Policy for the Elderly (PNSPI) (2) .It proposes PHC / FHS as a gateway for health care to the elderly, defining service organization strategies and setting actions for the professionals to take (2) .
In fact, the FHS is recognized as a scenario for elderly care actions.The professionals' work in an ascribed community and home care permit knowing the reality of the elderly and their family (4) .Among other aspects, the prominent role of CHW in the family health team is acknowledged, as the focus of this study, considering that they establish mediation and bonding between the elderly and the family health team in the primary health care units (PHCU) .
The generic term "Community Health Worker" is used worldwide to refer to a variety of community workers.Despite different denominations, contextual peculiarities, regulatory frameworks, and diverse activities, the link with the community and the health service is an essential feature of PHC in different countries (5) .
Studies (5)(6)(7) have shown the effectiveness of CHWs in improving maternal and child health, increasing access to health care, reducing the disease burden and the costs of tuberculosis and malaria.In Brazil, the work of CHWs is characterized by disease prevention and health promotion activities, through individual or collective actions carried out at home or in the community, developed according to the guidelines of the Unified Health System (SUS) (8) .
In view of the rapid aging of the Brazilian population and the need to plan and manage services for the elderly (3) , it is relevant to study the daily practices of FHS professionals, considering the multiple meanings that strategies can assume in health services, due to the confrontation with daily life, which is dynamic.
Certeau (9) conceptualized the daily as an articulation movement of practices of the "strategies" and "tactics" type."Strategies" correspond to everyday practices derived from formal rules."Tactics" emerge from the difficulties to make strategies feasible.Tactics and strategies interact and coexist in daily life (10) .
Certeau (9) also adds the concepts of "place" and "space" for the understanding of strategies and tactics."Place" is part of the strategic domain and refers to physical structures where the actions of professionals (such as PHCU) occur (11) ."Space" (part of tactical actions) is the practice of the place or the ways in which individuals transform it based on their appropriations (like public squares) (11) .Space is a place practiced (9) .Thus, we depart from the assumption that, in the daily work with elderly, CHW follow what is standardized for a given place (strategies) but, in confrontation with the everyday reality, they establish new ways of doing things through tactics, in different spaces, which expresses the dynamicity of daily life.
The study of CHW's daily practices can provide support to better meet the needs of the elderly in the FHS and put into practice government strategies, increasing the knowledge about different ways of doing (tactics) with the available resources, in different spaces.Thus, the objective of this study was to understand daily practices of Community Health Agents in health care for the elderly.

METHOD
Case study with a qualitative approach, based on Certeau's theoretical framework (9) about everyday life.The case study aims to "grasp the circumstances and conditions of an everyday situation" (12:55) .The qualitative approach makes it possible to "study the meaning of people's lives in the conditions they actually live in" (13:7) .
Studies in several areas of knowledge have adopted this framework (10,(14)(15) .In the context of health, it has been used to study the daily practices of professionals in the Mobile Emergency Care Service (16) ; analyze approaches to routine nursing work (17) ; know the tactics of users and workers in mental health programs (18) .There are no studies that focus on the daily practices of CHW in health care for the elderly though.
The study participants were CHW from the city of Montes Claros, a city in the North of Minas Gerais, Brazil.At the time of data collection, the city had 134 family health teams, distributed across 115 PHCU (19) .Two PHCU (referred to in this study as A and B) were intentionally selected because they had a larger number of users aged 60 years or older, had a larger number of family health teams (4 and 3 teams, respectively) and ease of access to the professionals.
In a first approach, the project was presented to the CHW, inviting them to participate in the research, in compliance with the following inclusion criteria: being a CHW in family health teams from the urban region and having worked at least six months in the function, considering the experiences in daily elderly health care.As exclusion criteria: absence from work because they are on vacation or leave during the period of data collection or refusing to participate in the study.
The data collection was concluded with eight interviewees, considered sufficient to provide for recurrence and complementarity of the information (20) , given the homogeneity of the group, which presented little differentiation and similar characteristics of professional practices.
Data were collected in May 2016, through an individual interview, using a semi-structured script with questions regarding the daily practice of CHW in elderly health care and factors that influence this care in the FHS.To guarantee the anonymity of the participants, the interviews were numbered in the order in which they occurred, attributing the letter "I" for interview.The interviews were recorded, fully listened to, transcribed and submitted to thematic content analysis (21) .
The project received approval from the Research Ethics Committee at Universidade Federal de Minas Gerais, Opinion: 1.486.033/2016.The participants were female and between 28 and 49 years old.In terms of education, two had completed high school, one technical course, two higher education in progress and three had completed higher education.All of them possessed between one and nine years of work experience and work 40 hours per week.
CHWs describe that their daily practices in elderly health care involve strategies and tactics.In the context of the strategies, the participants referred to practices in line with the activities defined a priori by the legislation for the FHS place: i) registration of families, keeping data on the population of the area updated in the information system; (ii) home visits; iii) health education groups.

We start in the morning, we focus more on the issue of registering [...]. (I1) [...] I do the home visits [...] there is an E-SUS system in which we have to digitize the data. It makes groups [...] sometimes there's a target audience. (I3)
The home visit was highlighted as the CHW's main activity in the care for the elderly.During these visits, CHWs provide guidelines related to self-care, disease monitoring and medication use.
[...] sometimes there is an elderly person in the area for whom it is difficult to come to the unit [...] we have to accompany him to his house, if he needs to renew a prescription we ask the doctor to renew it.And instruct the caregiver to pay attention to the medicines [...]

. (I7)
The activities carried out in the FHS with the participation of CHW, doctor and nurse are health education groups for chronic conditions (mainly diabetes and hypertension), the elderly representing the majority of the participants in the groups.

In fact, what we do most are hypertensive and diabetic groups, most of them being elderly [...]. (I5)
Every month we need to have three groups, a requirement of the department [...] I do a hyperdia group [...] the nurse or the doctor gives the lecture, I only participate by organizing [...] we talk about hypertension and diabetes, which is the cause, how to prevent it.(I4) It was described, however, that educational actions are not only transmission of guidelines, but are characterized by the sharing of experiences between users and professionals.

[...] it's actually a conversation between professionals and the population, it's not a lecture, it's a discussion group, it's not the one-talking thing ... we introduce the subject, see the doubts and each person reports his experiences. (I5)
Although the CHW's activities are determined to respond to the demands of older people, they adopt tactics that allow them to deal with daily situations.The professionals have to use tactics essentially to meet the needs of the elderly.These tactics are: i) Leave the formal places (PHCU) and use spaces in the territory that are more accessible to the elderly (such as churches, parks, home of the CHW or the elderly) to carry out health education groups; ii) To adapt the home visits to the needs of the elderly.The CHWs are confronted with elderly people with functional limitations who live alone and are sensitive to this situation, visiting more frequently and being more cautious during the visits;

The elderly require special attention [...] I do their active search each month, I visit up to four times because I'm concerned about him living alone and something happening. (I2)
iii) Adequate health education practices, especially using play activities and using the presence of the doctor, nurse and the provision of procedures (blood pressure measurement and blood glucose) as inviting forms.
We go to the homes, tell them that the group will happen and that the doctor or the nurse will be present [...] that the blood pressure and blood glucose will be measured [

...] in groups we do games and bingos to be able to play and get distract. (I3)
Despite the tactics created by the CHW in daily work in the FHS, difficulties were described in daily practice with elderly people, related to: i) the number of registered users per team; ii) delay in scheduling appointments and specialized examinations.These difficulties are associated with the failure to implement the strategies defined by the Ministry of Health (macro level) for elderly care or to the delay of these strategies in gaining full expression in the FHS.

[...] more medical professionals and nurses to attend because each doctor attends about 3,500 people [...] because the doctor and the nurse, because they have other demands and account for the whole area, cannot go to the visits every month. (I3)
[...] the doctor attends there, a specialized examination is needed, but it takes time to continue the treatment because that exam is not offered, the quota of exams and consultations with specialists is small [.

..] (I5)
The CHW also mentioned: iii) the lack of capacity to act in the area of aging and elderly health.The training is timely, focused on chronic diseases and care in cases of greater vulnerability, such as pregnant women and children, priority targets.

[...] a very quick thing, but there was training ... we took a caregiver course, the social worker offered training on the status of the elderly [...] the nurse talked about falls of the elderly and improvements to adapt the bathroom, carpet use, lighting. (I6)
As far as I remember there was no training.Because there was the Paths of Care, which is for motherhood, but for the elderly I think there was none.(I3)

DISCUSSION
This study explored daily practices of CHW in elderly health care, considering the theoretical framework of Certeau (9) .The results reveal that the PHC practices involve strategies and tactics and difficulties were described in daily practice with the elderly, related to the failure to implement the strategies defined for elderly health care.
The attributions of the CHW are expressed in the strategies of the Ministry of Health, they go through structures of the municipal health departments and the PHC / FHS is the place to carry out the strategic actions previously defined.Thus, the work of the CHW involves the daily practices of the strategies type, based on activities defined a priori, which include: work with ascription of families to micro areas; accompany, through a home visit, families and individuals under their responsibility; develop health promotion activities, disease and health prevention and health surveillance, through home visits and individual and collective educational actions at the homes and in the community (1) .
The home visit stood out as the main practice of the CHW aimed at the elderly.This visit makes it possible to know in loco the reality and the needs of the elderly and their family, the identification and active search for fragile elderly, which allows the planning of actions based on the reality, mediation between elderly-family and health teams of the family (22) .The elderly are often affected by chronic diseases (comorbidities), dependence and functional limitations, usually requiring caregivers (23) , which reinforces the home visit of CHW as an important care tool for the elderly-family binomial.
The CHW reported the practice of health education groups among actions that include the elderly.In the daily routine of family health teams, health education groups (such as hypertension, diabetes, pregnant women, smokers) are frequent and professionals consider that the elderly are included in the hypertension and diabetes groups, as most of the participants in the groups are elderly.Group work with the elderly is a complementary space for individual consultation, information exchange, guidance and health education (24) .
The group work reported by the CHW, guided by the transfer of guidelines on chronic diseases, reproduces and reinforces the biomedical disease-illness model.The focus on chronic diseases may be associated with the fact that the elderly are considered risk groups for these diseases, especially hypertension and diabetes mellitus (25) .
On the other hand, the sharing of experiences in the groups was revealing as a behavior change experience.This study reveals that health education actions can provide access to information and experience exchange, as well as contribute to health promotion and disease prevention (26) .
Tactical practices in the daily work of CHW seem to occur when, in confrontation with the everyday reality, strategies are not feasible or sometimes cannot be carried them out as established a priori.Then, professionals use often silent tactics and take advantage of favorable occasions (9) .
The CHW revealed different tactics in the daily work with the elderly, such as the tactics of appropriation of spaces in the territory in view of the need to deal with the absence of a specific place in the PHCU to carry out group activities.This tactic, therefore, imposes itself in the necessity of daily life (9) .
The CHW take advantage of favorable occasions (the possibilities allowed by the spatial configurations available in the community) and create in these spaces opportunities for the group activities, thus turning them into practiced places (9) , which reveals other possible ways of doing the group education activities, which are not necessarily limited to defined places: they happen, thanks to the tactics of the CHW, in different spaces.
The following are the tactics in the ways of CHWs to tailor the visits to the needs of the elderly.Even amidst the demand to keep up with all the users and families in their coverage area, the CHW provide time to increase the frequency of visits to the elderly, considering that there are elderly people who live alone, which is used to define the priority of visits.
The home visit is one of the main activities recommended by the Ministry of Health for the CHW and should be programmed together with the team, considering the risk and vulnerability criteria, so that families with greater need are visited more often, maintaining the average of one visit / family / month as a reference (1) .
The tactics were also revealed in the ways the CHWs adapt health education practices to the elderly.In order to include the elderly in the groups, they tactically use the presence of the physician, nurse and the provision of procedures, such as blood pressure and blood glucose measurements, and play activities as inviting forms.A study carried out with users attending a group of hypertensive and diabetic individuals in the FHS revealed that play activities were effective to promote learning in a relaxed way and motivated participation in the meetings, being more productive in relation to the understanding of the subjects addressed (27) .
Among the difficulties in daily practice with the elderly, the number of users enrolled by the family health team was described, although the population enrolled was within the limits of the Ministry of Health (1) .Each family health team should be responsible for a maximum of 4,000 people, 3,000 being the recommended average, considering the degree of vulnerability of the families in the territory (1) .This figure was considered high though, and a hampering factor one for regular home visits to the elderly by doctors and nurses.The excess of enrolled users makes prevention and health promotion actions more difficult, mainly for adults and elderly; the overload of users makes it impossible for teams to spend more time on preventive practices (28) .
The need to reduce users to around 2,500 people on average per team was revealed in the Brazilian experience and also in other countries (29) .Other factors, such as the low social conditions of many Brazilians, the country's vast territorial extension and teamwork also point to this reduction (29) .
The delay in the scheduling of exams and the access to consultations with specialists is a concern of the CHA, which reveals limitations of the health system, and not only of the scenario studied.The delay in scheduling appointments, the lack of specialists and difficulties in the regulations of the municipal health system are factors that influence the access to health services (30) .Thus, the cities need to organize the care network with the prerogative of access to specialized exams and consultations.
The lack of training for CHWs in the area of aging and elderly health was another difficulty pointed out.The insufficient qualification of family health team professionals for elderly health care was revealed in another study (28) , which makes it difficult to approach the characteristic issues of this population.
In the PNSPI (2) , the guidelines include the training and continuing education of SUS health professionals in the field of elderly health but, unlike the recommendations, the CHW did not mention this training.Therefore, the guidelines expressed in the PNSPI need to be effectively implemented.
The study was carried out in a city with a reduced number of CHW and, therefore, comes with limitations regarding the generalization of the results.Thus, new research on this subject is suggested, including other professionals from the family health team, their practices and knowledge in elderly health care in the context of FHS.

CONCLUSION
This study revealed that the daily practices of CHW in elderly health care involve strategies and tactics and difficulties were described in daily practice with the elderly.The difficulties were related to the failure to implement the nationwide strategies planned for elderly care.The accomplishment of home visits and health education groups stood out in elderly care.
The confrontation with the reality demanded the use of tactics from the CHW, including the appropriation of spaces within the territory for the accomplishment of group activities.The CHW mentioned the lack of training for elderly care and the insufficient provision of examinations and consultations with specialists for elderly users.
[...] we do not have a place to hold the group [...] we ask families to do the group at their house or I do it at my home [...].(I7) Today I'm doing the Wellness group.We choose a theme per month and discuss it [...] try to organize dynamics, jokes.The place is the church, closer to them [...].(I8)We instruct the elderly with hypertension and diabetes to go to Parque das Mangueiras Square, a nearby square.(I1)