Oral health planning in João Pessoa municipality , Paraíba State : Dental surgeons as protagonists of Basic Care

The aim was to identify the perception of Oral Health Planning (OHP) of basic care (BC) dental surgeons (DSs) in João Pessoa, Paraíba State, Brazil. Seventeen BC DSs from João Pessoa were interviewed. A qualitative analysis was performed using the Discourse of the Collective Subject (DCS) methodology. DCS obtained: Impact “My work is effective when the user’s need remains at the BC”. Social Control “The population participates in the organization of promotional activities, but I think it doesn’t have enough maturity to opine on OHP”. OHP Basis and Organization “The OHP has a diverse organization and is based on user needs”. It can be concluded that the knowledge of the DSs on OHP is varied. There is limited understanding about problem-solving. Social control is considered incipient and weak. It is understood that the organization of the local OHP assumes a diverse character and should be based on user demands.


Introduction
In the healthcare field, planning is the instrument that makes it possible to improve performance, optimize production and increase the efficiency of systems when developing functions of health protection, promotion, recovery and rehabilitation (PINTO, 2008;TANCREDI et al., 1998).Thus, in dental practice, health planning is able to more thoroughly and effectively implement care, with an impact on the public.
In the Brazilian State of Paraíba, oral health planning (OHP) has been regarded as deficient in terms in its impact on the oral health of users (PADILHA et al., 2005).Therefore, it became necessary to alter the oral health work process in order to develop new health strategies and policies to guarantee thoroughness, effectiveness and impact on the oral health of users.
In recent years, the João Pessoa Municipal Department of Health has developed actions to qualify the care offered to the users of the local Public Health System, including: the welcoming policy in health services; attention towards the lines of health care (AZEVEDO et al., 2008); permanent health education training (CAVALCANTI et al., 2008); creation of local health councils, among others.
In that sense, it is worth discovering the perception of Basic Care workers from João Pessoa municipality regarding the strategies to monitor and improve the services offered at that level of care.
From the result, it is expected that healthcare management, workers and the social control of that municipality can more clearly observe the construction of this work process, and thereby improve it in order to provide positive results for the public.
With that, the objective of this study was to identify the perception that basic care dental surgeons (DSs) in the city of João Pessoa have of Oral Health Planning (OHP), specifically with regard to the following aspects: Impact of Basic Care work; Social control; and Organization and Basis of oral health planning.

Material and methods
A qualitative methodology was used, with an inductive approach, featuring a descriptive-comparative procedure and intensive direct observation technique, using interviews (LAKATOS; MARCONI, 2009).
This work was approved by the Research Ethics Committee of the Paraíba State Secretariat of Health, under decision no.0033.349-09.
From the total of 180 dental surgeons (DSs) enrolled in the Basic Healthcare network of the municipality of João Pessoa, 17 were selected through a random draw.To be included, each professional had to agree to take part in the research and sign the free and informed consent form.The sample size (n = 17) indicated repetition in the discourses of participants during the interviews; therefore, the sample size was regarded as sufficient for the objectives of the study.
Data collection was carried out using guided interviews at the Family Health Units where each participating dental surgeon worked.The interviews were recorded in digital audio and transcribed into electronic text using word processing software (Microsoft Office Word 2007).
For data analysis, the "Discourse of the Collective Subject" was applied as a qualitative analysis technique, as proposed by Lefèvre and Lefèvre (2003).According to this technique, Key Expressions (KEs) of each discourse can be identified from individual discourses.Next, individual discourses are distributed into several categories known as Central Ideas (CIs), which sum up the idea of each group of discourses.Lastly, all CIs are combined to build a discourse that represents the speech of a collective subject, that is, Discourse of the Collective Subject (DCS).The methodology used to construct the DCS is shown in Figure 1.

Results and discussion
The CIs and DCSs identified in the study are shown in Table 1, 2, 3 and 4. It was detected that dental surgeons consider the insertion of social control (Table 1) only when discussing the organization of preventive and promotional activities.The report on the enactment of social control reveals the perception that this entity is organized in an incipient manner, with little expression and through sporadic meetings.The professionals believe that it is important to know the needs of the population; however, they deem the public to be unable to opine on OHP.
Table 1.Distribution of Central Ideas (CI) and construction of the Discourse of the Collective Subject (DCS), according to the perception of dental surgeons regarding social control in oral health planning.CI: Social control 1 "The public is not consulted with regard to planning" CI: Social control 2 "The population participates, suggests changes and discusses how Oral Health actions should be" CI: Social control 3 "We must know the needs of users.Nevertheless, the population needs more knowledge and maturity to discuss the planning of actions" CI: Social control 4 "The Oral Health actions built with the public are the preventive measures, which is when I assess the opinion and satisfaction of the community regarding these actions" DCS: Social control "The public participates by suggesting how health promotion activities should be organized; I think they should not opine on OHP, as they are not mature enough to do so.
On certain occasions, we interact with the community through meetings" With regard to the impact of the work in Basic Care (Table 2), effectiveness is defined as the completion of clinical procedures and user satisfaction.The participants in the study evaluated that the work undertaken is not completely effective, but is rather in a process of evolution.Concomitantly, they believe it is only possible to guarantee effectiveness in the Basic Care level, in which they work, without guaranteeing effectiveness at other levels of care.The largest number of CIs was observed with regard to the Organization of OHP (Table 3), which denotes greater variability and amplitude of the understanding of that issue.Among the reported situations, scenarios of constant planning were described, as well as other in which no type of planning was identified.For the Foundation of OHP (Table 4), the interviewed subjects declared that they take in consideration the support of the population and the needs reported by users.Also present is the concern with epidemiological indicators, meeting goals set by health management, following up with risk groups (selected by age group and/or social condition), and decisions based on the autonomy of the team.CI: Foundation of OHP 1 "I regard the needs reported by users and the support of the public as important for oral health planning" CI: Foundation of OHP 2 "For planning, I regard as important the status of epidemiological and production indicators" CI: Foundation of OHP 3 "User age group and social condition are important for planning" CI: Foundation of OHP 4 "Group decisions are the foundations of the planning for good operations" DCS: Foundation of OHP "For OHP, I take in consideration popular support, the needs reported by users, the improvement of health indicators, and group decisions" In order to re-guide and qualify the dental care given at the Public Health Service, the National Policy on Oral Health recommends actions aimed at the thoroughness, effectiveness and good quality of service.To that end, dental surgeons must work under a user-centered model and meet healthcare guidelines, with emphasis on prevention, health promotion and recovery of the population under their responsibility, in addition to basing their actions on evaluation and planning strategies (BRASIL, 2004).In that regard, it was identified that oral health care in the city of João Pessoa must overcome certain challenges in order to improve its model of care.
This study evidenced the conception by dental surgeons that it is necessary to know the needs of the public, but that the community is not sufficiently mature to discuss how health actions should be organized.In that sense, a one-sided perception is built on what the demands of the population are.Evidence was obtained of an understanding by some interview subjects that professionals, given their technical knowledge, should lead the planning and organization of the service for users.These users, for their part, participate in organizing prevention activities, which are understood mostly as group meetings and supervised tooth brushing activities with schoolchildren.
In contrast with this situation, the study by Tavares et al. (2005) evidenced that the social representation of the community, able to speak for its own collectivity, in conjunction with health professionals, must assess the main problems of the population in order to decide on which to intervene, so as to direct health actions and designate care.In that sense, the interaction between the community and professionals should not take place only in the form of educational lectures or informational meetings.There should also be action and intervention on the part of population in managing the process, programming and execution of health actions.
According to the study by Gomes and Pinheiro (2005), the contribution to the democratization of knowledge and the incentive to the effective exercise of social control mean sharing powers and creating accountability.The same authors affirm that the main challenge of Family Health strategy professionals is to overcome, in their daily practice, the monopoly in diagnosing needs and join the "voice of the other", which is more than building a bond of responsibility.Thus, the importance of overcoming the weaknesses of the relationship of these workers with social control is emphasized, so as to produce co-responsible actions with greater impact on the health of the population.
The developing participation of the public in the health planning process can represent a limiting factor for the effectiveness of the scheduled actions.According to Moysés et al. (2004), social participation and inter-sector coordination provided by public authorities increase the likelihood of success, when consistent.Oral health care in the city of João Pessoa shows weaknesses with regard to the social control of health care.The lack of social control in the organization of clinical procedures and autonomy for care groups, for instance, hinders the sustainability of plans and can lead to user dissatisfaction (FERRI et al., 2007;MOYSÉS et al., 2004).
With regard to the effectiveness produced by basic oral health care, according to Azevedo et al. (2008), the perception and knowledge of dental surgeons in the city of João Pessoa, Paraíba State on lines of oral health care is still evolving towards the thoroughness of care.
Nevertheless, the appropriation of that concept is still fragile and the situation impacts on care actions.
The results of this study corroborate the findings of Azevedo et al. (2008) when pointing out the weaknesses of DSs in proposing effective interventions to users, thereby limiting themselves to their own field of action in basic care.Thus, the limited continuity of the line of oral health care suggests low accountability for the effectiveness and thoroughness of care.According to Melo et al. (2004), effectiveness is not perceived as a problem for basic care; however, its inexistence is evidenced by the need to refer patients to higher levels of complexity.It is suggested that the concept of effectiveness in basic oral health care in the city of João Pessoa is limited and inconsistent.
The organization of OHP in the city of João Pessoa was regarded as varied due to the variety of perceptions on health planning.Situations such as the organization of demand ("Work planning is based on a schedule that follows the lines of care" -Subject 3) or execution of inter-sector actions ("Whenever oral health planning goes beyond the office setting, the entire Family Health Team gets involved" -Subject 9) should not be understood as health planning and demonstrate the weakness of professionals in recognizing, proposing and executing the OHP.The study by Tagliaferro et al. (2005) emphasizes that carrying out strategic planning as a management tool in oral health improved the organization, coverage and quality of the dental services in Basic Care.
Thus, the ability to understand and produce an OHP that is attuned to the local reality impacts the organization of the service, as well as the effectiveness and thoroughness of care.It is acknowledged that the understanding of the OHP by Basic Care DSs in the municipality of João Pessoa is complex and fundamental.This may justify the unwillingness of professionals to debate how the actions should occur and be organized.The judgment of lack of maturity by population may evidence the insecurity of professionals in debating and producing the OHP.
To base the construction of the OHP, DSs contradicted themselves by declaring that they take into account "the support of the population and the needs reported by users" (Subject 11).These needs are interpreted to be the themes discussed in educational activities and/or isolated complaints from users during clinical care, or contact with community health agents.Thus, the public's ability to participate and co-manage is reduced to sporadic interventions with low governability.
Even when faced with the difficulties and weaknesses found in producing thoroughness, effectiveness and promotion of basic oral health care in João Pessoa, the study by Soares and Freitas (2007) evidenced that dental surgeons in the Family Health Program in João Pessoa, Paraíba State are professionals who, despite needing more adequate training, take pleasure in being in direct contact with the community, performing teamwork and acting as creative professionals who are able to overcome challenges.Nevertheless, those authors point out that infrastructure and the support from the authorities are obstacles to the full implementation of the principles of the program and to changes in the status of public oral health (SOARES;FREITAS, 2007).
Nonetheless, it is emphasized that the difficulties regarding human resources are reported more frequently than those dealing with aspects of infrastructure of local administration.That situation is corroborated by Chaves and Miranda (2008), who highlight that the frustrations of dental surgeons working in Basic Care are related to: incompatibilities between their motivations and initial expectations for their choice of professions; inadequate training conditions during college; and the saturated private practice marketplace.
Souza and Roncalli (2007) evaluated that cities with no changes in labor relations, effectiveness, thoroughness and programming strategies were unable to satisfactorily advance the assistance model in basic oral health care.With that, the present study suggests that the municipality of João Pessoa needs to overcome the weaknesses of the human resources working in the public healthcare network, so as to increase the quality of its assistance model.

Conclusion
It is concluded that knowledge of OHP by DSs shows a variety of concepts.This is a clear Acta Scientiarum.Health Sciences Maringá, v. 34, n. 2, p. 221-225, July-Dec., 2012 understanding of the impact of their actions on BC, with a limited and imprecise concept of effectiveness.Social control is perceived in a developing and inexpressive manner.It is understood that the organization of the local OHP has a diverse and broad character, based on user demands.For basic oral health care in the municipality of João Pessoa, improvements must be made in qualifying human resources in the public healthcare network, in order to incite changes in practices of the work process.To that end, these changes must be able to improve management, public participation, thoroughness and effectiveness.

Figure 1 .
Figure 1.Steps for the Discourse of the Collective Subject (DCS), according to the methodology proposed by Lefèvre and Lefèvre (2003).

Table 2 .
Distribution of Central Ideas (CI) and construction of the Discourse of the Collective Subject (DCS), according to the perception of dental surgeons regarding the Impact of Basic Care in oral health planning.CI: Impact of Basic Care 1 "Considering what is recommended for Basic Care, my work is effective" CI: Impact of Basic Care 2 "My work has progressed, but has not yet reached total effectiveness" CI: Impact of Basic Care 3 "Whenever the need of the user surpasses the level of Basic Care, I am unable to be effective" DCS: Impact of Basic Care "I consider my work to be effective, because people conclude their treatment and are satisfied.But whenever the need of the user goes beyond the level of Basic Care, I cannot solve it"

Table 3 .
Distribution of Central Ideas (CI) and construction of the Discourse of the Collective Subject (DCS), according to the perception of dental surgeons regarding the Organization of Oral health planning.

Table 4 .
Distribution of Central Ideas (CI) and construction of the Discourse of the Collective Subject (DCS), according to the perception of dental surgeons regarding the Foundation of Oral health planning.