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SMAD. Revista eletrônica saúde mental álcool e drogas

versão On-line ISSN 1806-6976

SMAD, Rev. Eletrônica Saúde Mental Álcool Drog. (Ed. port.) vol.8 no.2 Ribeirão Preto ago. 2012




Nurses and mental health education in primary care: an integrative review


El enfermero y la educación en salud mental en la atención primaria: revisión integrativa



Fernanda Ribeiro SobralI; Claudinei José Gomes CamposII

IIPhD, Professor, Universidade de Campinas, Campinas, SP, Brazil





This is a literature integrative review that has analyzed researches on the participation of nurses in education initiatives regarding mental health in Health Centers.  We researched, in BDENF, LILACS and SciELO databases, articles published between 2001 and 2011. We found eight articles that showed two main themes: health education actions directed to mental health, subdivided into preventive and promoter approach; and difficulties of nurses in conducting educational activities in mental health in primary care. It was concluded that there were few studies on the subject, showing the need for government and nursing educational institutions to include as political and curricular priority educational activities on mental health in Family Health Strategy.

Descriptors: Mental Health; Health Education; Primary Health Care; Nursing.


Revisión integrativa de literatura que analizó pesquisas sobre la participación de los enfermeros en las acciones de educación vueltas a la salud mental en los Centros de Salud. Fueron investigados, en las bases de dados BDENF, LILACS y SciELO, los artículos publicados entre 2001 y 2011. Se encontraron ocho artículos que mostraron dos temas principales: acciones educativas en salud vueltas a la salud mental, subdividida en abordaje preventivo y promotora; y dificultades del enfermero en la realización de acciones educativas en salud mental en la atención primaria. Se concluyó que hubo pocos estudios sobre el tema, mostrando la necesidad de Gobierno e instituciones formadoras de enfermería incluir como prioridad política y curricular las acciones educativas en salud mental en la Estrategia Salud de la Familia.

Descriptores: Salud Mental; Educación en Salud; Atención Primaria de Salud; Enfermería.




The new model of psychiatric care in Brazil has prioritized, mainly, reintegration of patients into society and extra-hospital services expansion(1). The Family Health Strategy (FHS) has agreed with ideas proposed by the Psychiatric Reform(2), but this has increased the family responsibility, which was forced to take an active participation in the care process and social reintegration of mental patients. However, this care responsibility, shared with health groups, did not provide the necessary assistance to the family(3).

The extra-hostpital services are insufficient to meet the demand for psychiatric patients and families, both in quantity and in quality of care; it is difficult to develop prevention activities of factors that facilitate the occurrence of mental disorders(4).

In this context, the Health Centers (HC) are important components of the mental health assistance due to various psychiatric care that are made ​​in these locations(5). The HC are essential in prevention and health promotion, the environments are adequate for developing mental health educational actions(6) because they are close to the community and patient, allowing the group a better knowledge on patient's health situation(5,7).

In order to identify the practices of the FHS mental health nurses it was found a lack of educational actions on mental health (1). Another study has identified the care given by FHS nurses on psychiatric cases and there was no educational action on mental health(6), it is necessary to invest in strategies to promote health assistance in this area.

Despite the low priority given to mental health educational activities in HC, they have high potential to detect risk factors for some types of mental disorders, allowing the nurses to monitor and offer better possibilities for control and intervention(7).

In most countries, mental health services have low priority in public health policies. The investment in the psychiatric area focuses on drug therapy, a long and expensive treatment. Some mental disorders can be prevented with less costly and more effective treatments as therapeutic activities and health education. Such measures can reduce costs in various contexts of care(7).

Health education is the combination of several human behaviors with various learning experiences and educational attitudes that allow voluntary, individual or collective actions, favorable to health(8), to maintain or achieve an ideal level of health, since it is suited to the needs of each person.

Nowadays, health education action is a key strategy in the treatment of mental disorder patients. The educational activity is an important part of the nurse work, whose participation may represent a difference in care an educational mental health an ally of its working process, providing better assistance(9).

This study aimed to analyze the scientific production of Brazilian journals that deal with educational activities for mental health of patients and/or family in the context of HC, with the participation of nurses.



This is a literature integrative review that synthesizes studies, allowing us the simultaneous inclusion of several types of research, the data of theoretical and empirical literature, providing complete understanding and deep knowledge of a particular phenomenon(10). Thus, the main basic steps of the review were:

Identification of the research problem - the question was: "Are there education actions aimed at mental health in the Health Centers with nurse participation?" It is assumed that there is shortage of actions and articles on the theme.

Bibliographic research - we used the following sequence of databases: Nursing Database (BDENF); Latin-American and Caribbean Health Sciences (LILACS) and access to the open electronic library Scientific Electronic Library Online (SciELO). The literature search was performed in January 2012.

We used terms of the Health Sciences Descriptors (DeCS) of the Virtual Health Library (BIREME): health education (HE); Nursing (N); family health (FH); mental health (MH) and primary health care (PHC). We compared the data between the descriptors: HE/N/MH; HE/N/FH; HE/MH;HE/FH. To look for not covered studies, it was performed the comparison MH/PHC. Others possibilities of PHC term were tested with other descriptors cited, but did not reveal significant new texts.

The inclusion criteria were full texts available online or collections of university libraries, in national journals, in Portuguese, English or Spanish, published from January 2001 to December 2011. The papers should be about the theme: health education action aimed at mental health in Health Centers or locations near them. Educational activities in mental health should be directed to both patients, with or without mental disorder and their families. These education actions must be carried out by and/or have the participation of nurses, teachers, from undergraduate or graduate degree in nursing. It was excluded: dissertations, editorials, letters to editor and texts that did not include the theme.

Data organization - forms with information on year of publication, article title, authors, journal, index source; type of study, objectives, results and conclusions; texts synthesis and educational activities as subject matter, target audience, location of activities and professional involved.

Interpretation and data analysis - it was held an exploratory reading of titles and abstracts, obtaining the partial sample from which it was made initial readings, followed by careful reading of the entire articles. The final sample was selected due to the adaptation to the theme.

The corpus of the selected articles was analyze through the following steps: initial reading of texts and data organization (pre-analysis); exploitation of articles, encoding emerging and representative content; categorization based on incidence of the content and characteristics of the studies; treatment of the most significant results, describing and organizing them individually to facilitate critical analysis; inferences were proposed, interpretations and data categorization (11).

Review presentation and publicizing - the most relevant data should be exposed and disseminated to communities with an interest in scientific knowledge on the subject.

Although the criteria used, the review may have some limitations as to the descriptors used and the comparison made between them. Many texts with different themes can be either found, making difficult the pre-selection and allowing us to discover significant portion of articles, or important texts hidden, restricting the final sample.



During the search (Table 1) 99 articles were found. After titles and abstracts reading we excluded 67 (68%) texts. from the 32 (32%) pre-selected articles, after full reading, 24 (24%) were eliminated, because they were inadequate to the theme. Therefore, 91 articles were excluded (92%) and the final sample was composed of eight (8%) publications (Figure 1).

The types of studies were: two (25%) literature searches; two (25%) experience reports; four (50%) qualitative studies (one descriptive, one exploratory, one descriptive-exploratory and one convergent analysis - each one with 12.5%).

The educational activities were directed to: three (37.5%) to mental health patients; two (25%) to the families; two (25%) to the families and to mental health patients and one (12.5%) was directed to diverse audiences, including mental health patients.

The local activities were: three (37.5%) only in HC; three (37.5%) in other areas directed to HC (church parish halls, club hall, community school); two (25%) in HC and other health and/or education services.

As to the principal professionals involved in educational activities there were four (50%) HC nurses; two (25%) were teachers, working with postgraduate students (12.5%) or with an occupational therapist (12.5%). There were teachers and graduate students working together or with one (12.5%) HC nurse or with a communitarian therapist (12.5%).

Two articles (25%) reported using mental health promotion approaches; one (12.5%) of prevention; four (50%) combined promotion and prevention and, in a report, the type of approach was not clear.

The review grouped the articles contents into two themes: 1) Health education activities aimed at mental health, subdivided into preventive and promoter approach; 2) Nurse difficulties to implement educational mental health in the FHS.



Health education actions directed to mental health

Preventive Approach

Prevention is a previous action that invalidates, minimizes or controls the evolution of the disease or its risk factors; it reduces its incidence and prevalence(20-21). Therefore, it can be done before or after the disease(21).

Prevention has three levels: the primary decreases the incidence of the disease and its causative factors; in this case the prevention must be applies in healthy people(20). It includes health actions, which can be a biopsychosocial intervention that promotes well-being and reduces the incidence of the disease; and specific protective action that requires the identification of the causative agent and the vulnerable group that is at risk(20-21). Nursing interventions at the primary level primarily include, mostly, health education and social support assistances(20). A selected study(13) showed that a comprehensive family and a safe school environment are protective factors that promote disease prevention.

The secondary prevention is done in the sick patient, seeking to reduce the incidence of the disease. Its interventions are: diagnosis, assessment, early treatment and immediate(20-21). Among the selected articles, in the preventive approach, the actions were held on installed diseases, and included strategies development to reduce mental/emotional suffering, risks and mental disorder problems and damage in patients already sick.

The third prevention aims to reduce the illness severity or disability caused through rehabilitation(20-21), which enables the serious mental disorder patients to reach them possible highest level of performance, enabling them to live, learn and work in community environments(20).

Prevention is a wide, multidisciplinary action and it is mainly to health professionals the 'technical decisions, direct and educational actions"(21). Thus, prevention and health education are structured by disseminating scientific information and recommendations normalized by the Ministry of Health, with emphasis on lifestyle changes(22).

Promoter Approach

Health promotion is "the process of enabling the community to improve its quality of life and health"(23). It is not restricted to technical and normative applications, to knowledge about diseases and control mechanisms(21). Its actions have several strategies to deal with several health determinants and to exercise more control over them and their living conditions(21,24), in order to make or not conducive health choices.

It promotes health through initiatives that enhance the autonomy, the biopsychosocial well-being, access to health and social services, promoting the empowerment of knowledge and participation in health movements, consolidating intersectoral practices(21, 24).

Several community locations can provide options to run educational activities(22), whose environments are favorable to health promotion(25). It was noticed in some studies(14,17-18) that the place chosen to educational activities was the HC, but in others(13,15-16)there were new places, due to lack of space, the high demand for the activities and the desire to publicize the actions at various locations(19).

Collective places built in HC allow them to perform horizontal and dialogic exchanges, and empowerment environments that free and empower people to make health care decisions(17). It is positive to expand the educational environments: change the traditional therapeutic scenarios and look for areas meaningful to the population(14). Nevertheless, it does not release HC the responsibility of developing educational activities with other community sectors.

On the other hand, studies showed that familiar environment and social life may be risk factors to the school-age child(13), to families living with mental disorder(12,16) and to patient(15,17), hence the importance of valuing the intra family care, promoting mental health, preventing conflicting relationships, improving personal relationships, enabling the well-being and quality of life of patients and family(13).

The therapeutic groups work is one of the main strategies of health education to perform mental health interventions mental health(9, 16). The groups can reduce problems, for public health and society, associated with various mental disorders, addiction to alcohol and other drugs(16). It is important that the groups have space in HC, because they have relevant actions(25), low cost and more access to the population(15).

The nurse should be prepared to work in groups, because this activity is widely used in mental health area(26). The team work is done in some review studies(13-15, 17) it is a possibility for the nurse to provide mental health care to families living with people in psychological suffering. Therapeutic and educational groups offer comprehensive care, including the family, whose participation is essential as is support to itself and as a development assistance and patient care(11, 25).

Health promotion includes educational and therapeutic strategies. The first strategies found in the articles involved: exchange of experiences and reflections; reduction of stigma and exclusion; increase of self-esteem and social and emotional bonds. The educational strategies are characterized by: understanding improvement of health/mental disorder; to enhance the autonomy and citizenship, with active care participation(25).

It is noteworthy that seven studies presented educational interventions for mental health with some promoter approach, in some studies it prevailed as: theater as a pedagogical alternative, effective for nurses because it occurred through the interaction between popular and scientific knowledge for acquisition of health concepts, leisure activities(19); Community therapy was a link-building space and social background, relief and suffering prevention, enabling resiliency(15).

Nurses' difficulties in the implementation of mental health educational activities

Disabilities in nurses' education and training

There are deficiencies in academic training and professional practice of nurses to implement actions to promote health, as well as comprehensive care, because their ideas collide with the biomedical curative model(16). But preventive actions still prevail in practice, but do not go further to a positive health conception that focuses on the human and social resources to achieve improved quality of life(24).

Mental health in primary care training emphasizes the causative agents of mental disorder to detect new cases and interrupt the disease(14), therefore, it is maintained the focus on prevention, while there is lack of training focusing on health promotion(27).

It should be reviewed the nurses' development and training, as many visits focus on medications, individual consultations and other contents prioritized in most nursing curricula. Although professionals ought to be empowered to take the treatment of common mental disorder, they are not always prepared to work in mental health in the FHS(14). There must be educational and health institutions investments to train professionals able to perform in assistance groups(26).

In practice, it can be seen "unpreparedness and lack of motivation of health professionals to perform actions focused on human relations, in bonding production and patient autonomy." An example was reported in a study(14) when there was team displeasure when trying to address the mental health issue in a FHS hypertensive group.

It is recognized, however, the complexity in performing this work due to the social and nurse stigma of mental disorder(16). Moreover, mental suffering contact mobilizes several feelings that overwhelm people. This should be considered in the qualification/training, opening spaces to elaborate the difficulties in patients and families relationship(14).

It is necessary and urgent to awaken nurse's interest regarding educational activity, to use assessment mechanisms to identify problems in mental health education(17), as well as offering expert and matrix support to provide "supervision, establish bonds and resolving references" to the professionals(13).

Using the traditional model of education in educational activities

The health team must be provided with tools according to the service's need for mental health promotion and prevention, using in their educational actions pedagogical proposals(12, 14). The nurse must develop differentiated educational work, with strategies that facilitate individual and collective learning(19) but whose content emphasizes the population needs with effective and efficient actions.

Actions should be horizontal and dialogical, between professionals and patients, integrating technical and popular knowledge(16, 19). An article(19) referred that the theater was an innovative strategy, with playful practices to humanize the educational action, contemplating feelings and strengthen citizenship of mental disorder patients. 

However, the traditional model prevails in educational practice of HC professional, which may indicate the complexity of the comprehensive care model and the difficulties of using new methods(18). A traditional practice that stands out is lecture, which only transmits information, which is commonly normalized by the Health Ministry(18, 27).

Such activities are not aimed at empowering people in health knowledge, or to the exercise of citizenship, they only serve the Health Ministry and FHS interests who have trouble reconciling: the high demand of the service; the population health needs and the guidelines that produce impacts on health community(27). As a matter of fact, the patient usually goes to the HC by the possibility of being sick and not to promote health or to prevent diseases. Therefore, the educational action also tends to be directed to sick people or people with health risks(18).

In the review, we found educational experiences in mental health carried out with innovative systematic methodology(15,17,19), and others with specific, empirical and eventual actions(13,18), contributing to the action discontinuity and nurses detachment, because they have overhead functions that predominate over their health education aimed at mental health and that are not standardized(18).

Insufficiency and deficiency in intra and intersectional support

The deals between the health services are still focused on reference and counter reference actions, with few buildings projects(27) through a group specializing in mental health, such as the matricial. This occurs because the mental health services available to support and restore patients and family are not always enough; therefore, it is necessary disciplinary actions(14).

As to intersectionality, the mental health policy approaches the health promotion policy in relation to increased autonomy and citizenship of individuals and realization of comprehensive care. It is defined as: "Relationship between one or more parts of the health sector with one or more parts of another sector", in order to "achieve more efficient health results"(28), articulating diverse knowledge to formulate and to implement health actions, in which all sectors are responsible for its realization.

Health coordinated actions could motivate nurses to conduct educational activities on mental health in the FHS more resolute(18), but in practice intersectional actions are sporadic and ineffective(27). In the review, there were studies that valued partnerships with public school(13), church(16), municipal club(15), kindergartens, and universities among other places(19).

It is clear that the health sector has difficulty acting alone and difficult to implement effective educational actions, because some partnerships depend on different places(27), especially regarding mental health, where the community services available to patients and families are insufficient to meet their several needs(14). Therefore, it is encouraged alternative health actions with and developed by the community(27), responsabilizing it with the public sector and other non health sectors(24).

Thus, most actions are multisectoral and not intersectoral because they are organized by a single sector to be delegated to another sector. Care planning of mental disorder patients does not present a horizontal discussion about the contributions that each sector can give. This is a serious challenge for intersectoral achievement which is erroneously perceived by professionals as an individual responsibility of each sector, further fragmenting the assistance(28).

Lack of political priority for carry out mental health educational in the FHS

Another difficulty is related to the planning and development of public policies that invest in educational initiatives in mental health and encourage social control(18). Effective participation of the population is fundamental to freedom and citizenship, even to a mental health patient when tries social reintegration(27).

Mental health care should go beyond biologicist logic and promote coexistence, autonomy, freedom and citizenship(17). But a study showed that, among several educational activities in various HC, the "health" guidelines generally were mostly toward installed diseases, as groups for hypertension, diabetes, smoking, and even for the unique group of mental health reported in the research(18).

This is due the biomedical model influence, whose interventions focus on sickness(18). Overcoming this model requires the reorientation of the health system, including the organization, financing services, practices and professionals training(22).

Paying attention to this statement: "Prevention must precede the action of health experts, and in the collective, it must begin at the socio-economic structures and policies level"(20), it is necessary to practice the promotion, reshape health care and change the work process(18, 27), start changing the focus on targeting the disease and planning action for vulnerable groups to certain risk factors(14). Thus, the educational action should also be used to facilitate the reorganization of health services(18).

Another problem to effect the educational actions on mental health in HC is the confusion between prevention and promotion practices(21).  There is, among professionals, an inaccurate concept of health promotion, focused on the absence of disease. Therefore, there is the tendency to associate the diseases prevention activities(27), pointing their risk factors (such as hypertension and diabetes groups) and proposing behavior changes (such as exercise, stopping smoking, alcohol and other drugs)(21), much advocated by Health Ministry programs.

This governmental obligation intimidates the professionals to provide a comprehensive care, making them act as people who follow rules designed to healing and disease prevention, actions that do not meet the needs of the entire population and not to the basic principle of the Unified Health System (SUS): universality. Patients, who do not meet the FHS provision, as mental health patients, are excluded from assistance within their territory(27).

When there are health actions, including education, that includes excluded groups, it is clear that the development and implementation of these practices are not uniform, as they depend on the profile and objectives of the professional who works in the FHS or policy decisions of the local manager(18).

There are also errors in the official information record systems on mental health activities carried out in the HC. This damages the data quantification and knowledge about patients and their families in the territory, preventing assertive intervention plans for mental health and blocking funding for this FHS area. Including, the lack of financial resources blocks the acquisition of material and human resources to offer a better service(14). As a consequence, there is the importance of building partnerships with private and public sectors to support the implementation of educational activities in mental health(19).


Final consideration

Although this review has provided a meaningful participation of HC nurses in educational health activities aimed at mental health, there have been few studies treating on this subject, showing the need for governmental agencies and educational health institutions to include among their policies and curricular priorities the Mental Health issue, with an educational emphasis, for both promotion and prevention.

It is worth noting that it is expected that long-term planning in Mental Health and Health as a whole receive professional, financial and political investment in educational, individual, familiar and community interventions. It also requires the organization and popular participation to mobilize the population on the importance of promoting and preventive quality actions, aimed at the patients with mental disorder, besides the usual demands of society and health professionals for incisive political decisions in the mental health area, especially in primary care.



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Fernanda Ribeiro Sobral
Rua Donato D'Otaviano, 101
Jardim Chapadão
CEP: 13070-136, Campinas, SP, Brasil

Received: Aug. 22nd 2012
Accepted: Feb. 21st 2013