Practical Education in Family Planning : Integrative Review

Creusa Ferreira da Silva1, Cláudia Maria Ramos Medeiros2, Maria de Lourdes de Farias Pontes2, Ericka Silva Holmes3, Suênia Gonçalves de Medeiros Diniz4, Rennaly Kelly de Araújo Ferreira5, Rozileide Martins Simões Candeia4, Tamela Costa6, Maria Fernanda Rocha da Silva7, Maria das Graças Pereira de Asevedo8, Ulanna Maria Bastos Cavalcante3 1 Nurse. Specialist in Emergency and Emergency and UTI. João Pessoa, PB. 2 Nurse. PhD in Nursing from the Federal University of Ceará / UFCE. Professor, Department of Public Health and Psychiatry Nursing / CCS / UFPB. João Pessoa, PB. 3 Nurse. PhD student in the PPGMDS / UFPB Graduate Program in Health Decision and Health Models. João Pessoa, PB. 4 Nurse. Specialist in Family Health and Public Health. João Pessoa, PB. 5 Graduated in Nursing from the Federal University of Paraíba / UFPB. João Pessoa, PB. 6 Nurse, Master's Degree in Nursing at UFPB. João Pessoa, PB. 7 Nurse. Specialist in Emergency and Emergency and UTI. Master's Degree in Intensive Care by SOBRATI. João Pessoa, PB. 8 Nurse. Specialist in Family Health and Work Nursing. Master's Degree in Intensive Care by SOBRATI. João Pessoa, PB.


Introducion
The concept of Family Planning (PF) encompasses a set of actions that goes from contraception itself and is currently considered a rational and healthy way of spacing births, covering areas such as infertility and sexuality.It allows women and men to choose when to have a child, the number of children they want to have and the spacing between the birth of their children [1].This fact was pointed out as an essential component of primary health care, starting in 1978, through the Alma Ata Declaration, in the context of the Health for All Policy.
In the 1960s, with the discovery of the use of the "contraceptive pill", changes in the concept of contraception began and in what concerns the integrality of women's health care, but there were no public programs that offered guidelines [1,2].
The Women's Health Integral Assistance Program (PAISM), launched in 1984, which proposed a comprehensive approach to women's health at all stages of its life cycle, health education and sexuality Approval of the Family Planning Policy, created in 1996, and together constituted a historical landmark that promoted the reorientation of women's health, where, until then, it was exclusively addressed to assist the pregnancy-puerperal cycle, not very efficiently [2].
With regard to the Family Planning Policy, managers and workers have the task of organizing services so that they are accessible and resolvable to the needs of the population, expanding the scope of practices and providing support to the work process, through assistance technologies and Which are capable of guiding the work process of AB teams by subsidizing qualified decision making by health professionals, according to aspects essential to the production of care in AB [3].
Recently, the Ministry of Health launched a publication containing basic care protocols for women's health in Family Planning, which reaffirms the implementation of health actions in reducing morbidity and mortality from preventable and preventa-ble causes, from the adoption of good Professional practices, focusing not only on women, but also on the family and the community; Guaranteeing the legitimacy of their needs, specificities, respecting their diversity and contributing to the construction of the autonomy of women with disabilities, lesbians, bisexuals, transsexuals, blacks, Indians, gypsies, countryside and forest, in street situations and deprived of liberty , In all phases of life [4].
Purposes like these, are part of the Pact for Life, which consists of a set of guidelines aimed at promoting the reduction of Maternal and Neonatal Mortality through better monitoring of assistance to human reproduction from Primary Care [5].Unfortunately, there is still a disparity in the proposed work methodology, since access and offer restrictions to Family Planning services still lack the elementary guarantees of their practice.In this way, it is imperative to seek this improvement through continuous self-evaluation of the work process.
Considering that family planning is a health policy capable of generating great impact on the populations, when well managed by allowing the citizen to choose consciously and in a participatory way, the contraceptive method that best allows to experience their sexuality.The objective of this study is to analyze from the national and international scientific production the family planning educational actions of the last five years, highlighting the factors related to the accomplishment of educational practices and their impacts and the reality of the Family Planning policy in Primary Care.

Method
This research is of the type integrative review and has the purpose of performing the analysis of scientific texts, in a systematic and orderly way, capable of allowing reflections that can be implemented in the medium to which it is proposed; And includes the steps of problem formulation, data collection, analysis and interpretation, and presentation of results [6].
For the search, articles indexed in the databases of the Scientific Electronic Library Online (SciELO), Latin American and Caribbean Literature in Health Sciences (LILACS), and Nursing Database (BDENF) were accessed, seeking to maintain the same Search pattern between them.The option for these bases was taken to cover a large collection of periodicals and their degree of impact.The search was performed in January and February of 2016 using three descriptors: "family planning", "health education" and "contraception".
The criteria for inclusion of the publications were: to relate to the topic of family planning with a focus on contraception, from the perspective of educational practices, to consider publications containing complete texts, peer-reviewed, written with Portuguese language, freely available, published in In the period between 2009 and 2013.Articles in the format of abstracts, those repeated in the databases, articles with a language other than Portuguese, were excluded from the sample because they were an analysis of the literature restricted to the context of a policy National public service.Theses and dissertations were excluded since their results could be published in the form of scientific articles and there is duplicity of the empirical material.
After listing and organizing the information in a database operated from a spreadsheet, the analysis, conducted by two researchers, was started, comparing with the theoretical reference adopted, about educational practices in family planning, and presentation of conclusions and Implications of the review of the literature, pointing out suggestions that corroborate the improvement of health care.

Results
Table 1 briefly summarizes the articles that were part of the sample, after applying the inclusion and exclusion criteria, regarding the title of the article, authors, database, year of publication and place.
Table 2 shows the results regarding educational practices in family planning, including the target audience benefited by the actions developed in the Table 1.Characterization of the articles regarding the title, authors, database, year and place.(N = 27).

Article title Authors Base Year Local
Assistance in contraception and reproductive planning from the perspective of users of three units of the Unified Health System in RJ, BR BDENF 2012 SC various places contemplated by the studies, as well as the area of action of the professionals who developed educational actions.Table 3 makes reference to the facilitating and difficult aspects of educational practices in family planning, contemplated by the studies.For a better understanding of the results, the identified items were related and attributed by competence, being attributed to SUS managers, the points related to the application of public policies.
For the professionals were listed their limitations of execution and factors related to compliance by users of health facilities.

Factors related to the accomplishment of educational practices
Among the 27 articles analyzed, eighteen (67%) reported performing some educational practice on several scenarios, while nine articles (33%) reported the absence of this activity, limiting the Family Planning (PF) application only to delivery of the contraceptive method (MAC), nor did it register as an educational activity (Table 2).
The proposal of the Family Health Strategy aims to break with the passive behavior of health teams and extend health actions to the whole community, by strengthening the capacity of the subjects' choice.In this context, the educational practice is a process that proves to the individuals knowledge and cultural experiences to make them able to act in the social environment and to transform it [10].
The analysis revealed that the Family Health Strategy (ESF) is the main place chosen for the development of educational practices, being cited in twenty articles (74%).In addition, four articles (15%) cited the hospital network, which is characterized by services as the site of definitive contraceptive procedures.Two studies (7%) referred to the school as the place responsible for educational practices, however there is no regular attendance of activities and usually occur through workshops (Table 2).
The Operational Standard for Health Care (NOAS 2001) established the FP as the allocation of basic care and among the minimum responsibilities of municipal management to be implemented in municipalities [7].The results obtained in this study were persuasive the FHS reality.
The Technical Manual of the Ministry of Health [1] advocates the participation of multidisciplinary teams in the activities of the FP.However, some professions stand out with greater involvement in these activities, in which twenty-five articles (93%) identified nursing professionals as the most active category in educational practices, reaffirming the  The doctor is cited in five articles (19%), highlighting the competence of contraceptive prescription and counseling.The other professionals were mentioned in two articles (7%) emphasizing effective participation of psychology and social worker, but no article cited the interdisciplinary work, as recommended by the MS.
Twenty articles (74%) cited the presence of some educational activity in relation to the FP, with some differences when compared to urban and rural areas (Table 2).The recommended approaches for conducting FP activities involve educational activities, counseling, and clinical activities.These should be elaborated in an integrated way, not restricted to issues involving contraception alone, but rather to aspects of women's integral health [1].
In an article, educational activities were carried out through groups in the health units of the urban zone, while in rural areas the guidelines on contraception were restricted to the guidelines during the individual nursing consultation, by spontaneous demand or even only to the distribution of MACs .
Another important factor identified in the articles (63%) [1,15,19] was the fact that the target audience consisted mostly of women, generating in turn a unilateral decision-making process.The difficulty of health care related to the masculine gender [8,3] corroborates directly in the quality of life of these, increasing costs to the public services in the secondary and tertiary levels and avoidable deaths [9].

Reality of Family Planning Policy in Primary Care
Considering the analysis of the study it was possible to observe that although the Family Planning Policy emphasizes the three guiding axes, as a way to fully assist the user in their choice, providing conditions of effectiveness and awareness, the practice of knowledge production in health edu-cation to subsidize Adequate decision-making is still in deficit.
Regarding the Unified Health System, the studies indicated in 13 articles (15%) the difficulty of adhering to the FP, associating it only with the distribution of oral contraceptives and condoms.Therefore, the maintenance of these inputs guarantees the participation of the public with lower socioeconomic conditions that depend almost exclusively on the provision of the method to exercise free choice [1] adapting to their reality.
The lack of physical structure in the Health Units for group meetings was another difficulty pointed out in five studies (19%), while four studies (15%) affirm that appropriate structures make it easier for their development.
The managers have the responsibility to promote training and qualification of the team in the thematic, being well-known the advance that the group of the basic attention will possess [10], having to contemplate the technical, scientific and cultural knowledge directed to the fulfillment of the sexual and reproductive health needs [6,11].
Only four articles (15%) reported having essential resources for practical activities, such as: audiovisual materials, illustrative, while most face the reality of the absence of educational and personal material [12,15,16].
The perception of the nursing professional's accumulation of functions is indicated in eleven percent of the articles; Being justified by the responsibility of management of the team and of assistance activities.The overload generates, in turn, the feeling of demotivation in the exercise of its functions, despite the fact that the quality and efficiency of the care provided is recognized as an important point [8,10,16,17].
It is perceived that, for the PF to have satisfactory results, it is fundamental to establish a communication without judgments in the relationship between professional-user [21], strengthening the links and improving the users' adherence.Howe-ver, some articles revealed that there is difficulty in several fields, including the presence of professionals in the continuity of follow-up [10].The relationship established between the health professional and the people assisted is fundamental, because depending on the quality of the interactions, the potential of trust establishes links and provokes personal transformations that contribute to the production of health.
As for the professionals' unpreparedness in dealing with specific situations, such as adolescents, women in the climacteric phase (33%) [16,17,18,21,22] (Table 3) and women with mental disorders [20,19] emphasize that Program nomenclature makes it difficult for teenagers to join, for example, because they are not thinking about planning a family, but rather are trying to develop their sexuality.Women in the climacteric phase are an important public to be considered because of the risk condition that pregnancy represents for their lives.[17,21].In another aspect, users with mental disorders need recognition of the limitations caused by the disorder itself, and the presence of the family is indispensable in order to receive the information considering each situation [20].
Another challenge faced by FP policy is the attention to women living with HIV/AIDS, since information about unplanned pregnancy, double protection and possible drug interactions with retrovirals is underestimated.Figueiredo [23] adds that pregnancy represents a used resource of social re-signification in the lives of these women and, therefore, the risks and precautions should be clarified.

Impacts of educational practices
In this theme, all the articles that addressed issues related to the impacts caused after the emergence and implantation of the FP and the advent of the PAISM were collected from the sample.Twelve articles (44%) indicated positive points, which can be listed in two areas.Understanding the impacts that reaffirmed the guarantee of rights were presented seven articles (26%) and exalting the quality of life, through the FP, five articles (18%).
Twenty-six percent of the analyzed articles cited that health education in the context of FP expanded the possibilities of choices as well as encouraged collective learning, promoting knowledge and clarifying doubts about correct use, as well as disseminating knowledge about prevention of sexually transmitted diseases, Disclosing the importance of dual protection.[12].
The studies attributed to the educational practices of the FP and its influence on the quality of life of the people reached, to better enable the users to participate actively in the planning of their future and their family, choosing the number of children, spacing the pregnancies, allowing them a better reflection on economic issues.

Conclusion
Therefore, through this research it was possible to identify that the studies indicate the accomplishment of educational practices, while the aspects that focus on the difficulties and facilitators were related to the management of the health service, professional competence and users Thus, although the study has positive results, it still shows many negative points, being insufficient to meet the main objective of the health policy that is the quality of life of women with awareness and educational practices for sexuality.As a relatively recent policy that was implemented, from the basic attention the existence of educational practices predominated in most of the works analyzed (74%), and gaps were identified regarding the efficiency of such actions.
Considering the family planning model contemplated within the national FP policy, implementation has been uneven and challenges need to be addressed with objectivity.In recent years, even in the face of the difficulties pointed out, there is evidence of a search for the achieve-ment of the objectives proposed by the model.Educational practices in family planning as a citizen's right and state duty are tools that need to be better encouraged in all health facilities and services, such as guaranteeing and respecting sexual and reproductive rights.It is suggested that the qualitative evaluation of these services be implemented so that deficiencies are pointed out and alternatives are sought to promote the effectiveness of this right.
The way in which the manager deals with public resources, whether in the physical structure of quality, in the dissemination of programs, in the training of professionals, or in guaranteeing the necessary inputs, favors the professional a viable means in the execution of educational practices in a multiprofessional and interdisciplinary creative way, So that it engages and sensitizes users to exercise their power of choice and social participation in defending their reproductive and sexual rights.

Table 2 .
Variables related to the accomplishment of educational practices in family planning, the target public and professional activity predominant in the publications available in the databases (N = 27).

Table 3 .
Variables related to the facilitating and difficult aspects of educational planning practices prevalent in the publications available in the databases (N = 27).