Possibilities and Limitations in the Implementation of the Policy for Men ' s Health in Primary Care

1 Nurse. Master of Nursing from the Federal University of Paraíba. Member of the Group of Studies and Research on Masculinities and Health of the Men Health Observatory (OSH/UFPB), João Pessoa (PB), Brazil. 2 Nurse. Doctor of Nursing. Leader of the Group of Studies and Research on Masculinities and Health of the Men Health Observatory (OSH/UFPB), João Pessoa (PB), Brazil. 3 Dental Surgeon. Resident in Public Health Dentistry, João Pessoa (PB), Brazil. 4 Nurse. Doctor of Nursing. Member of the Member of the Research Groups: Nucleus of Studies on HIV/AIDS, Health and SexualityNEHAS;"pidemiologicalOperational Studies in Tuberculosis" and "Tuberculosis Study and Qualification Group, João Pessoa (PB), Brazil. 5 Nurse. Doctor of Sciences. Teacher of Nursing Graduation (UFPB), João Pessoa (PB), Brazil. 6 Nurse. Specialist in Family Health and Intensive Care Unit, João Pessoa (PB), Brazil. 7 Nurse. Master of Nursing. Teacher of Nursing Graduation (UFPB), João Pessoa (PB), Brazil.


Introduction
The health needs of different population groups in their various life cycles are daily concerns of the Ministry of Health.However, throug-hout the history the valorization of certain fields of the attention to the detriment to others, like the attention to the health of the masculine population.What makes the delimitation of this research extremely relevant.Thus, in order to solve this lacuna, the National Policy for Integral Attention to Human Health was presented in 2008 in Brazil -PNAISH [1].
The PNAISH is understood as a set of actions of promotion and prevention, assistance and recovery, executed with humanization and quality, in the different levels of attention.This policy is guided by the guidelines: integrality; Organization of public health services in order to welcome and make people feel integrated; Hierarchical implementation of the policy focused on the Family Health Strategy (ESF); Reorganization of health actions and integration of the implementation of said Policy to the other policies, programs, strategies and actions of the Ministry of Health [1].
Although the publication of this policy represents a singular gain in the health care of this population group, the universal and integral right to health was won by society in the 1988 Constitution and reaffirmed with the creation of the Unified Health System -SUS, through the Organic Health Law 8,080/90, with the eighth National Health Conference as the driving force in 1986 [2].The construction of this constitutional right has more recently been based on discussions of the relationship between masculinities and health, categories that have been analyzed based on the gender perspective, focusing on men's difficulties in the search for health care and the ways in which services deal with Specific demands of men.
It is also important to have as a starting point the essence of the proposal of the operative plan for comprehensive health care for men in the biennium 2010/2011, which has in its premises the search for strengthening and qualifying primary care, ensuring health promotion And prevention of preventable diseases.Since the recognition that men enter the health system through specialized care makes us understand the consequences that affect men's health due to lack of care, education and guidance in basic care [3].
Aware of this problem that is already present in the scenarios of the Family Health Units -USF, this study aimed to investigate the possibilities and limits for the implementation of the National Policy for Integrated Management of Human Health in Primary Care in João Pessoa -PB, with the purpose of analyzing the nurses' understanding of the Integrated USF teams of said municipality, regarding the implantation, possibility and operational limits of this policy.

Method
The present study was of the exploratory type, with a qualitative approach.The population of this study was represented by 72 nurses who work in the 18 Integrated USF of the city of João Pessoa-PB, as the research scenario, for a better development and analysis of the sample.For the selection of the sample we used the criteria of accessibility and saturation of data and reports.Thus, the sample resulted in 12 interviewees.
The data were collected from September 2010 to February 2011, through a semi-structured interview.Then, they were analyzed qualitatively, using the technique of Thematic Analysis [4].Presented in a framework and discussed on the basis of contemporary literature on the subject. The

Results
The data are presented in two aspects: socio-demographic profile of the participants and perception about the PNAISH.(For a better understanding of these results obtained) The socio-demographic profile reveals that the nurses who composed the sample are female (100%), with a predominance of 7 subjects (58%) in the age group of 28 to 43 years, another 5 (42%) interviewed are in the Age group of 48-54 years.Regarding the working time in the FHS, 3 interviewees had 1 to 6 years (25%) of work in the strategy, while 9 (nine) had a 7 to 12 year old (75%) work time and in the Basic Health Unit Integrated, between 1 and 3 years.With regard to postgraduate training, it was detected that of the 12 interviewees, 11 (90%) ensure that they hold specialist degrees.
The analysis of the reports regarding the perception of the interviewees about the implementation /implementation of the PNAISH allowed the identification of three categories and five subcategories, as described in Table 1.

Discussion
These data reveal that most of the professionals interviewed have a profile translated by good expe- rience in the ESF, an important fact for the scope of implementation of the PNAISH, since it is expected that the professional relationship and community will already be consolidated, by the time of Coexistence and interaction between caregivers and users.In addition, it can be inferred that they have significant experience in the field of collective health, which may contribute to a better attention to men's health.
The data that translate into the subcategory Deficit in the perception of possibilities of inclusive actions was verified in 9 (nine) of the 12 (twelve) interviewed when reporting the absence of possibility of inclusive actions for male users, such as: ...Specifically for the non male population N6.
No. Specifically not... but so, specifically, we do not have.

N1.
No, at the moment no, men seeking unity come to hypertension care or with complaint of virose, something like that, but, promotion not N10.
Based on this observation, we show that nurses can not perceive the service scenario as possible spaces for actions directed at the health of the man in the primary scope.The same view has the men, because they do not feel welcomed in these spaces, thus representing a huge challenge for the health care of this population group.It should be noted that the inclusion of men in primary health care is a challenge to public policies because men do not recognize the importance of health promotion and disease prevention [5].
Thus, it becomes evident the need for discussions about the deficits in nurses' perception of the existence of actions aimed at the promotion, protection and recovery of health and, consequently, improvement of the quality of life of the male popula-tion in the USF Integrated in the study, so that they perceive the care scenario as a space of possibilities of construction and reconstruction of knowledge.
When analyzing the empirical material regarding the perception of health actions directed at the male clientele, the subcategory specific actions for the man, mentioned only by 02 respondents, according to thematic units: ... making a survey together with the ACS on the PSA issue, it is through this that we are trying to conquer the presence of man in unity... ...come and do a PSA test is so important...

N2.
The aspects mentioned above by the participants are concentrated in an area where the Ministry of Health recognizes as deserving of attention, in view of the high morbidity and mortality associated with it, such as malignant tumors.However, they express a rather limited view when considering the indicators of morbidity and mortality presented by the Ministry of Health [1].
The subcategory actions common to the genres, evidenced from the thematic units: ...we are looking for STDs... E3.
...the cytological woman identifies some problem in her health, his genital and then we guide her to bring the man so that we are guiding..

E4.
It reveals the focus of the interviewees' perception on aspects that involve reproductive health, a common focus in many research involving gender, masculinities and health.Thus, they do not make it evident that the morbidity and mortality that found the pillars of PNAISH involve diseases of the cardiac, digestive, respiratory, urinary systems, as well as violence and mental disorders [1].
Therefore, it is important to emphasize once again the importance of the implementation of the PNAISH, as well as to recognize the real needs of men so as to better plan and organize actions and services within basic care, so as to make them more attractive, Aiming to meet the needs of this group.In this sense, health work, considering that the professionals should be able to assist it individually, as well as qualified for the expanded understanding of health promotion and for the adoption of integrated practices of collective health [6,7].
Regarding the subcategory limits linked to the man to the interviewees' statements, they show the men's resistance to seek care in the health services as a factor that hinders the implementation/implementation of said policy, as noted in the following speeches: ...cultural aspect, the very formation of man... ...hardly come to do some examination... to take care...This distancing is justified by different factors, among them the cultural ones expressed by resistance behaviors in seeking medical care and nonadoption of preventive attitudes regarding health problems.The result is a higher risk of death, greater physical and emotional suffering for the patient and his family, and a higher cost for the Unified Health System (SUS) [8].
Reversing this picture is a great challenge.Because achieving a change of behavior among the male population requires time and continued efforts.The implementation of this policy is being carried out under careful planning in order to achieve its objectives.
Another evidenced aspect is related to the subcategory related to the professionals' limits, where it was possible to identify knowledge deficits about the PNAISH itself, such as the cuts: Lack of information from professionals, lack of clarification... ...very little preparation (of the professionals)...

N6.
Qualification of the personnel (professionals) for the correct attendance to the health of the man...

N11.
There is a need for more care about PNAISH...

N12.
This scenario shows that the professionals' lack of preparation for the development of actions in basic care and their multiple activities with assistance, educational, preventive, domiciliary and intersectoral actions are difficult aspects in the Family Health Strategy, leading professionals to carry out unplanned actions and, sometimes with little justification due to the overload of work [9,7].
Such a situation can be grasped in the subject's speech: ...The workload that the nurse has in particular...

N9.
Faced with the current situation in basic health care, professionals do not know what to do to manage the high demand and the lack of time to dedicate themselves to preventive and health promotion actions related to human health and other health problems existing in our country [10].They feel lost, tired, immersed in unplanned actions, that demand time and cause physical and emotional exhaustion, a picture of an exhausting and inhuman work process.
The current knowledge deficit of the male population related to the promotion of health and the prevention of health problems.As well as the need for effective interlocution between teaching and health services for a greater and better consolidation of the PNAISH [11,12].
Thus, given the data and reports from this study, there are important deficits in the perception of health professionals, especially nurses, regarding this policy, influencing in a singular way its implementation.

Conclusion
The implementation of PNAISH represents a response to society's aspirations in recognizing that male-related health problems are real public health problems.However, the limits expressed in this research require action by users, health professionals and management, so that it becomes a reality in the daily care of primary care.
Given this scenario, it is reaffirmed that transposing the deficits revealed here represents a fundamental principle for the readjustment of these limits.And thus, increase the operational possibilities to implement this policy in the municipality of João Pessoa -PB.
It is hoped that this study will contribute significantly to the good performance of health services that include health care for men, so that the near future may have positive changes in the male morbidity and mortality, and thus increase the expectation and quality of life of this population group.
research project was approved by the Committee of Ethics in Research with Human Beings -CEP of the Federal University of Paraíba under the Opinion nº 615/10.The ethical requirements expressed in Resolution No. 466/12 of the Ministry of Health/National Health Council and in COFEN Resolution No. 311/2007 of the Code of Ethics of Nursing were respected.Thus, all the participants of the research were informed of these aspects and, after signing the Informed Consent Form (EHIC) to participate in the study.
they have some resistance in coming to unity... it's cultural, they claim they work... do not have time... N6.
the PNAISH show the distance of the man from the primary health care and justify the creation of the National Policy of Integral Attention to the Health of the Man by the Ministry of Health.

Table 1 .
Nurses' understanding of the possibilities and operational limits for the implementation/implementation of the PNAISH