DOI 10.29327/226091.55.1-12

RELATOS – ARTIGO INTERNACIONAL

 

 

PluriVox Program in Brazil's Unified Health System: five-step group work to promote patient health behaviors

 

Programa PluriVox no Sistema Único de Saúde do Brasil (SUS): cinco passos na facilitação de grupos para promover nos usuários comportamentos de saúde

 

 

Nedio Seminotti¹; Rogério Meireles Pinto²

Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS

Endereço para correspondência

 

 

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ABSTRACT

This paper describes PluriVox, a user-friendly program aimed to improve group process and dynamics and to promote the health of undeserved population. PluriVox is grounded in psychoeducation, and it can be used in public health efforts to encourage service consumers ("patients") to become more active in realizing their own health-related needs through participation in health promotion groups. We suggest PluriVox as a strategy to help service providers (e.g., physicians, nurses, community health workers) and consumers to work as co-producers of health. PluriVox contains five competencies to help group facilitators: (1) observation protocol; (2) strategies to support group facilitation; and (3) group facilitator training. Training uses participatory methods that take only 15 hours. Herein we provide a description of how PluriVox was developed using group work theories. A preliminary evaluation suggests that PluriVox has potential to improve health professionals' capacity to facilitate health promotion groups in a Unified Health System.

Keywords: PluriVox Program; Group Facilitation; Unified Health System

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RESUMO

Este artigo tem por objetivo apresentar o Programa PluriVox, que é uma estratégia de trabalho em grupos, de fácil aprendizagem e execução. O programa se destina aos grupos psicoeducativos realizados na saúde pública, e como finalidade a promoção, nos usuários, de protagonismo e corresponsabilidade na produção de saúde. O PluriVox é composto por cinco competências para facilitadores de grupos, baseadas em um protocolo de observação, estratégias de apoio para facilitação de grupos e um exemplo do processo de capacitação das competências por meio de metodologia participativa que pode ser executada em 15 horas. Descreve-se o processo de construção do PluriVox e discutem-se as teorias de facilitação de grupos. A avaliação da capacitação possibilita afirmar que os profissionais de saúde capacitados tornam os grupos um método de produção de saúde e que o PluriVox pode atender às necessidades do Sistema Único de Saúde, no que se refere aos grupos.

Palavras-chave: Programa PluriVox; Facilitação de Grupos; Sistema Único de Saúde.

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Introduction

Brazil's Unified Health System (Sistema Único de Saúde [SUS]) requires that public health technicians carry out group activities, commonly achieved by presentations to the health system users ("consumers") in order to promote healthy behaviors regarding various diseases/disorders. Though research provides a strong evidence base for psychoeducational groups in health care settings, presentations are not grounded in the psychoeducation literature. These presentations, referred to as "classes" by consumers occur within the Family Health Strategy ([FHS] Estratégia Saúde da Família), the key program under which Brazil provides preventive care to 60% of Brazil's population of 209 million (Ministério da Saúde, 2019). Topics of interest, such as prevention of hypertension and diabetes are decided based on local epidemiologic data (Seminotti, 2016).

Presentations are often led by, Community Health Agents, "community health workers" (Agentes Comunitários de Saúde [ACSs]) assistant nurses and other technicians, the majority of whom lack training about how to facilitate and coordinate groups. As a result, it has been reported that group participants, i.e., consumers, tend to become spectators in these groups rather than protagonists and co-responsible in the solution of health issues (Campos & Campos, 2006; Merhy & Franco, 2003; Seminotti, 2016). The main reason why consumers remain in this role is the lack of competency to facilitate groups so that all participants have the opportunity to talk about issues and find solutions together. This appears to be directly related to the fact that only Psychologists and Social Workers are trained in their respective professional schools to facilitate groups (Ministério da Saúde, 2002; Seminotti, 2016); a shortcoming prevalent in other health care systems across the globe.

To overcome the lack of expertise in group work, the Family Health Strategy welcomes initiatives, such as the Intergrative Community Therapy (Terapia Comunitária Integrativa) (Barreto, 2010), whose goal is to train healthcare providers in group facilitation. The FHS also publishes recommendations in Primary Care Manuals (Cadernos de Atenção Básica) to promote healthy behaviors when facilitating group sessions (Ministério da Saúde, 2014). Given the high demand for disease prevention groups and the lack of training to facilitate groups among health care providers (physicians, nurses, occupational therapists, and others), PluriVox was created as a user-friendly tool for FHS workers. It comprises five competencies to support group facilitation (Seminotti, 2016).

Next, we will describe how we developed PluriVox through the training we conducted with ESF health care providers and, afterwards, piloted in the First Childhood Better Program (Primeira Infância Melhor [PIM]), reported here, resulting then in the training process that we propose in this paper, which took place at the Rio Grande do Sul State Health Office (Lei n. 14.594, 2014). We also provide preliminary findings of the process evaluation of PluriVox, and we discuss implications for improving psychoeducational groups' facilitation in health care systems worldwide.

 

Patient-Centered Care in Brazil's Family Health Strategy

A key component of the Unified Health System is the integration of primary care and public health via the Family Health Strategy. Established in 1994, the FHS led to the creation of interdisciplinary teams, where a range of providers (primarily nurses, physicians, and community health workers) serve communities across the country (Pinto, da Silva & Soriano, 2012). In 2008, FHS support groups were created, known as Núcleo de Apoio à Saúde da Família ([NASF] Support for Family Health). These groups are comprised of university-level technicians from various health sectors, who support FHS teams to extend this offer of care to SUS users (Ministério da Saúde, 2008; 2011). PluriVox was develop with NASF, technicians from Canoas, a city in the southern region of Brazil, and piloted with PIM.

The Family Health Strategy aims to address patient needs in a patient-centered way so that care can be more effective and efficient. In a patient-centered care system, providers listen to users' needs and solutions for a decision-making process regarding health behaviors, rather than a top-down strategy (Committee on Quality Health Care in America, Institute of Medicine, 2001; Patient-Centered Outcomes Research Institute [PCORI], 2019). This concept is reflected in research and clinical work in Brazil and elsewhere. User-centered care aims to explore users' primary concerns, answer users' questions about preventive care, integrate users' individual needs, find common ground between the users' needs and the provider's solution to the problem, and encourage ongoing interactions between patient and provider (Little et al., 2001; Stewart, 2001). Researchers from various countries (e.g., Canada, Italy, Norway, South Africa, United Kingdom, and United States) suggest that users endorse patient-centered care (Little et al., 2001; Stewart, 2001). Patient-centered care is found to be associated with positive outcomes, such as patient satisfaction, treatment adherence and improved health (Stewart, 1995).

 

PluriVox: Theoretical Considerations

PluriVox embraces the components of patient-centered care as it takes into account user's voices, and thus empowers those users to enhance their experience of being part of a group and being protagonists and co-responsible for their health care development. The group-method covers this need and PluriVox offers the facilitator a step-by-step guide that permits the formation of such a group.

There is consensus in the group literature as to certain ideal characteristics that enhance group dynamics: (1) presence of a facilitator or coordinator; (2) group with a limited number of individuals, minimum of four and maximum of 12; (3) group members should be positioned in a circle, allowing participants to see and listen to each other; (4) specific group purpose and rules, and termination when the goals are achieved (Seminotti, 2016). Various aspects of group facilitation are supported by the leadership, psychoanalytic, cognitive behavioral, and psychodrama theories (Schein, 2009). Most professional group interventions based on these theories privilege facilitator knowledge as above that of group participants.

However, the group work research supports the importance of member-to-member interaction as the basis for effective group change. Moreover, interventions to promote empowerment among organizational employees, using a bottom-up approach, have shown to help participants set goals and developed strategies to reach their goals (Arneson & Ekberg, 2005). Participatory strategies for engaging group members have shown better retention and an enhanced sense of accomplishment among group members (Pinto, Spector, Rahman & Gastolomendo, 2013).

With the rise of manualized group treatments and psychoeducational interventions, the influence members might have for shaping group's goals and processes might be minimized. Psychoeducational groups, more than other forms of group might maximize leader power and minimize participant influence as the facilitator is in a role to deliver specific content, often in a predetermined sequence, for a specified number of sessions. Therefore, group member influence over how the group will be conducted is more minimal and facilitator expertise in delivering curriculum content assumed. Critiquing the delivery of psychoeducational groups in this manner, Gitterman and Knight (2016, p. 105) note group members "lives are rarely neat and sequential and curriculum presentations, however well informed and evidence based, may, in fact, hold little relevance. Furthermore, how group members will interact with one another is not predictable or prescribed." They propose that group workers must balance content and process.

However, even in the psychoeducational context some practices that give group members influence have been recommended. Champe and Rubel (2012) suggest that group workers monitor and facilitate process in a way the encourages members to reach decisions and emotions experienced during group interactions. Caplan and Thomas (2004) propose "client- paced group work" and advocate for an approach that promotes flexibility through use of themes rather than rigid curricula, client-paced ownership of intervention goals and diminishing the power-based hierarchy between client, group worker, and institution.

With the assumptions of the primacy of facilitators knowledge over that of consumers and the power granted by the institution's hierarchical structure (of which the facilitator is a part), facilitators have power to, and in rigid application of psychoeducational curricula often stifle group dynamics. While some authors recommend attention to group process as it emerges in psychoeducational groups, there is relatively little study of how to maximize facilitation that balances group process and content.

Here we choose to invite the concept of phenomenology so as to help us understand and describe the experiences of PluriVox group members from the sociohistorical and political context in the groups operate. In general, the theories discussed above underestimate the capacity of participants to accurately describe the phenomena based on their common knowledge and to suggest appropriate interventions in the group as does the facilitator. Therefore, facilitators have power resulting from their knowledge, their affiliation with an institution, and experience. Thus, a hierarchical structure is immediately established in the facilitator-participant relationship, whereby knowledge and power are restricted (Seminotti, 2017). Next, we discuss how PluriVox was conceived differently.

PluriVox is grounded on phenomenology, an approach that focuses on the study of the meanings attributed to the direct experience of individuals involved in a specific activity, such as group work, and each participant's experience is intentionally directed toward a goal or a result (Farina, 2014). Therefore, PluriVox recommends that group facilitators encourage and allow group participants to understand group dynamics in relation to participants' own experiences within the group, inside the scope of a participatory methodology (Minayo, 2004). From this perspective, phenomenology recommends that group facilitators set aside rigid theoretical assumptions and allow participants to provide their understanding of group dynamics from the meanings they attribute (Capra & Luisi, 2016). The perspective of phenomenology recommends suspending the theoretical assumptions through which one could interpret the phenomena to give way to the participants' understanding.

PluriVox is supported by the strategy proposed by Morin (2008), which encourages group facilitators to (1) accept uncertainties and allow group work to evolve more freely (i.e., without using rigid theoretical precepts to dictate group dynamics), (2) value the multiple voices of group members, and (3) provide opportunities for group members to achieve their objectives.

 

Developing and Piloting PluriVox

Between 2000 and 2013, a psychology postgraduate research group from Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS) in Brazil conducted master's and doctorate degree studies about group processes and dynamics (Cabral & Seminotti, 2011). The key product of this project is a protocol named PluriVox, which has been used to train primary care technicians in Brazil's Family Health Strategy in order for them to become proficient in psychoeducational group facilitation (Freitas, Seminotti & Leite, 2016). PluriVox focuses on the group facilitator's competencies, which need to be used systematically to enable participants (consumers in FHS) to jointly solve their myriad shared biopsychosocial problems (Morin, 2008 & Seminotti, 2016).

Between 2013 and 2017, we advised and trained technicians from Canoas' NASF. Both technicians and community health workers contributed to the development of ten competencies deemed necessary for group facilitation. This ten-competency version of PluriVox was adapted and validated. The key guiding principle in our approach is that when the group facilitator exercises the competencies, members of the group will be more likely to share their goals, thoughts, and feelings, and create an environment that facilitates spontaneous conversations about themselves and health-related themes (Minayo, 2004). This approach is supported by research conducted by Google seeking to understand group work dynamics, and suggests that when coworkers participate in defining goals and rules around their jobs, they acquire a reliable and psychologically secure environment that facilitates spontaneous conversations and collective development (Duhigg, 2016).

With the advances resulting from the NASF training, PluriVox was used in a PIM training program with the objective of training Monitors to facilitate Home Health Aide (HHA) workers (Ministério da Saúde, 2002). PIM is a public health policy associated with the Primary Care System that aims to promote and develop early childhood (e.g., social, economic, etc.) through individual care from pregnancy to 3-year-old children and group care directed to families with children from 3- to 6-years old. PIM includes workers who plan and guide HHAs actions in the cities involving weekly visits to the registered families. PIM workers hold weekly group meetings with the HHAs, in which problems and solutions arising from the visits are reported, and discussions are held for the purpose of collective learning. We trained 25 PIM workers in six learning labs in sessions facilitated over five months, with a total of 15 hours. The goal was to train PIM workers to facilitate HHA groups, to promote listening skills, and to improve group work.

The name PluriVox recognizes multiple voices that constitute the group. From an operational point of view, it offers: (1) a minimum structure to support the facilitator and guide the facilitation steps; (2) an observation tool for other technicians who, when in the same group, play the role of the observer; and (3) support strategies to exercise the competencies (see Appendix A). Using a checklist, the observer checks to see if the facilitator executes the recommended steps. It is important to note that this observation tool can be used as self-observation in cases when another technician-observer is not available. Thus, the facilitator uses the protocol to be prepared to exercise the facilitation competencies and then checks to see if they were implemented (see Seminotti, 2017).

 

Evaluating PluriVox's Feasibility and Acceptability

We used a post-training brief protocol containing quantitative and qualitative questions with 25 trainee PIM workers. When asked about prior knowledge of any group facilitation methodology, only 25% of the respondents agreed positively. Respondents were asked if, after the training, they began to systematically use PluriVox in HHA groups, to which 75% responded positively. When asked how many of the PluriVox competencies they developed, 75% reported that they developed the first competency, 50% developed all competencies, and 50% reported the need for further training. In general, 70% of the respondents agreed that PluriVox training directly benefitted their day-to-day work. Using a qualitative prompt, we asked trainees to summarize their experiences. They reported that (1) PluriVox provided the tools they needed to understand that the responsibility for the group's work is shared between the facilitator and group participants; (2) the group they facilitated became more dynamic, democratic and cooperative; and (3) there was more integration, commitment, and cooperation between the HHAs. Furthermore, the respondents agreed that PluriVox provides a systematized approach that promotes an environment that facilitated dialogue and learning, and thus it helps HHAs feel more welcome to the group.

 

The Current Structure of PluriVox

Based on the results above, we reduced the number of competencies from ten - as in FHS - to five, which consists of 15 hours of training in five stages. Appendix A provides a summary of the minimum structure/resources needed to facilitate PluriVox. We present below a summary of stages we have used to train facilitators. [Note: Due to the COVID-19 pandemic restrictions concerning social distancing, we began to use Zoom, an online teleconferencing platform, to facilitate PluriVox. Using this strategy, the time for each session was reduced to 90 minutes and the entire training to 12 hours. The reduction in time is achieved by the facilitator and the observer exchanging information during the session by using the chat function of the online platform, instead of outside the session.]

Stage 1. Trainees and PluriVox introduction: Introduction and personal expectations; presentation of goals and rules; information on how PluriVox format and implementation; training objectives; guidance to bringing routine group facilitation reports to the next learning lab.

Stage 2. PluriVox training vis-à-vis other techniques: Joint analysis of the groups progress; using role-playing techniques; guidance on facilitation of groups using PluriVox with peer observations, which will include the colleague's record of PluriVox facilitation competencies and report for the next learning lab.

Stage 3. PluriVox group observations: Discussion and analysis of reports; sharing of understanding and learning of PluriVox use; and guidance for another facilitation exercise.

Stage 4. Report on observations of group facilitation using PluriVox: Sharing and learning the facilitation of competencies; guidance for another group facilitation exercise using PluriVox.

Stage 5. Sharing of group facilitation experiences using PluriVox: Analysis and comparison between previously used methods and PluriVox for group facilitation; evaluation of the training process; consolidation of recommended competencies.

 

PluriVox Group Processes and Dynamics

PluriVox is a group method that acknowledges the group facilitator's knowledge and power while stressing that the facilitator needs to welcome a multiplicity of knowledge sets among participants (Seminotti & Alves, 2013). For a traditional group facilitation, the facilitator's knowledge/power is nearly absolute. However, the PluriVox facilitator is encouraged to be in charge of the group facilitation rather than of interpretation of the group content. PluriVox allows participants to build an environment to share their needs and seek solutions to problems that they share - the facilitator is in charge of guiding the group and not its direction. With PluriVox, in addition to the facilitator's competency, a minimum level of intelligence, health, and autonomy of the participants is required. That is, it will not always be possible to facilitate a group without using the dynamics, especially when participants have a high level of dependence on the facilitator. Therefore, the available traditional dynamics can be useful – for example, the facilitator can use traditional methods to start the group and end each session.

In traditional groups, dynamics and previously structured exercises are offered to participants to make them aware of the peculiarities of their relationships, and the facilitator grasps the issues that prevent the group from having a good experience and achieving the proposed goals. For example, when there is competition among group members, one assumes that the participants will realize that and then start to cooperate with one another along with the group dynamics. The assumption is that the facilitator is the only one who understands what happens in the group and knows how to solve it. Distinctly, we believe that group members jointly build goals, generate group process, name them, and seek a solution to potential problems.

Each of PluriVox's competencies is used in distinct moments of the group process, not only in a linear manner. Thus, it is recommended that all competencies be used from the first session to the end of a group's life. During the group process with the same participants over months, for example, something new will occur for various reasons: participants joining and leaving the group, reaffirmation of and/or changes in the group's rules and objectives, and so on.

For capacity building to facilitate groups, it is necessary to meet the expectations of the trainees who, in general, expect that a trainer with knowledge will teach them how to organize groups in a traditional manner. It is the same tendency to establish a hierarchical relationship that happens in psychoeducational groups. To cease this tendency, it is necessary to help group members to collectively set rules and goals, including goals for facilitators and the institution for which they work. Generally, the trainees seek horizontal working relationships with their peers and the facilitator and they cooperate solving problems. This means that the training facilitator needs to ensure: (1) an environment to promote spontaneous and goal-focused conversations; (2) sharing of individual comprehension and learning; (3) evaluation of the progress of the training in each stage, and (4) who is responsible for its effectiveness.

There seems to be an assumption that facilitating groups is a natural process, where no tools are needed. This can be possible but in rare situations. In research conducted with informal groups (independent of the institutional structure) in an educational institution, we found that 72% of the group facilitators who turned out to be competent in leading groups were unaware of group theories. Only their life experiences were used during the facilitation process. Such groups were led by people who were open to discuss topics not commonly debated, such as spirituality in science, racism, and alternative rights (Seminotti, 2016).

Facilitation is a complex task that might produce fear in the facilitator when participants speak out. This is true for most professionals, and it may be true in most health care systems. Therefore, we propose PluriVox, a user-friendly method that requires no more than five competencies and 15 hours of training at the most. Because PluriVox has been well-received by health care providers in the largest Unified Health Care system in world, Sistema Único de Saúde, we believe that it can be used to train professionals elsewhere. We are confident that the five competencies in PluriVox will enhance consumer group's experience and effectiveness.

 

Conclusion

From the evaluation data collected, we conclude that health care professionals can be trained by using PluriVox to promote better group dynamics. However, we also recommend that PluriVox be further tested with diverse groups in order to consolidate its key competencies. PluriVox has implications for public health systems in Brazil and globally. PluriVox suggests that facilitators can develop the facilitation competencies without necessarily mastering theories to facilitate effective groups. It is appropriate to highlight that traditional group theories would only make sense if we conceived them as universal and timeless. However, most of these theories were devised during the last century and in different socio-historical contexts. PluriVox provides an opportunity for group facilitators to question their own power over group members, and to account for local and universal knowledge expressed in the group. Though PluriVox has a minimum structure to be used in future training, it will always be necessary to adjust it to the context and trainees' needs. With such adjustments, PluriVox becomes a powerful tool recommended to enhance the experience of psychoeducational group members in both local and global contexts.

 

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Stewart, M. A. (2001). Effective physician-patient communication and health outcomes: a review. Canadian Medical Association Journal, 152(9), 1423–1433.         [ Links ]

 

 

 

Endereço para correspondência
E-mail:nedio.seminotti@gmail.com

Recebido em: fevereiro de 2021
Aprovado em: setembro de 2022

 

 

¹ Dr. CriaLabTecnopuc – PUCRS - Brasil - Av. Padre Cacique, 1900/802 – CEP 90810240 – Porto Alegre - F. 5551981282902 – nedio.seminotti@gmail.com
² Rogério Meireles Pinto, LCSW, Ph.D. 312 Arbana DriveAnn Arbor, MI, USA 48103 – F. +1 (646) 670-7166