Street office and care practices: emerging conceptions and reflexivities

Objective: To understand the perceptions of users of the "street office" about care practices. Methods: Mixed approach study carried out through semi-structured individual interviews with users of the "street office", with their reports analyzed through the Iramuteq software. Results: The general corpus of the reports consisted of 188 text segments (TS), with 178 TSs (94.68%), with three classes emerging: Class 1 – "Care understood by homeless people", with 85 TS (47.75%); Class 2 – "Satisfaction with access to health actions and services", with 40 TS (22.47%) and Class 3 – "Causes and coping


INTRODUCTION
The Street Office (SO) consists of a service instrument, composed of teams of at least four members and is anchored in the interdisciplinarity of the team of professionals that composes it.These teams are called Street Office Teams (SOT), whose objective is to act as a bridge between individuals who are on the margins of the health system, primarily Homeless People (HP) enabling it to be inserted in the network, in order to provide comprehensive, universal and equitable health care. (1)t is important to highlight that the SO is the priority gateway for HP in Primary Health Care, in addition to being a space for welcoming, listening and mainly strengthening links to the health service network.Thus, the SO allows the insertion of HP into the system in order to contribute to the care process, with a view to strengthening care practices. (2)n a stigmatized way, HP are characterized as individuals who have deviations of character and these stigmas are inserted in the daily lives of health professionals and in society that internalize this prejudice in care practices, influencing the priority and quality of health care. (3)mong the various challenges for the practice of care, the need for a holistic look at the user by health professionals capable of breaking the biomedical Cartesian model and understanding the HP in their entirety stands out. (4)ccording to indicators of the homeless population in Brazil, carried out by the Institute of Applied Economic Research (IPEA), there was an increase of 140% between September 2012 and March 2020 of HP, reaching approximately 222 thousand Brazilians living on the streets, where most of these people live in the large cities of the regions: Southeast, Northeast and South.Due to the economic crisis that the country faces associated with the pandemic scenario, this number is believed to be much higher. (5)hese data contribute to understanding the drama that goes through the lives of the homeless people and their contexts of vulnerability and social exclusion, in addition to seeking to mitigate these issues and generate inclusion actions, being favorable to transform realities and the social and environmental determinants of the health of this population. (6)owever, there are still few studies on SO, most of the findings are related to the way of working of the professionals who make up the SO and little is reflected on care practices, especially by users.
Thus, this study aimed to understand the perceptions of users of the office on the street about care practices, seeking to reflect on their conceptions in people who are on the margins of the health system.

METHODS
This is an exploratory research with a mixed approach, approved by the Ethics Committee of the University of Fortaleza under opinion number 4,460,942 and developed in strategic places of service by SO Street office and care practices: emerging conceptions... English | Rev. enferm.UFPI.2024;13:e4479| DOI: 10.26694/reufpi.v13i1.4479 in the municipality of Fortaleza, Ceará.The choice of the study location was due to the fact that the services were carried out itinerantly in these spaces by the only SO existing in the municipality.
The study was developed with eight users served by SO, in this case, HP, aged 18 years or older.The study population was accessed for convenience, and follow-up was carried out within the service during the period from February to June 2021.
Data collection took place through an individual, semi-structured and recorded interview, lasting approximately 40 minutes.This interview was initiated by investigating the sociodemographic profile of the participants, who had questions related to age, period of stay on the street, color and origin/residence.In sequence, three guiding questions were used: 1.What were the reasons that led you to live on the streets? 2. How long have you been receiving care from the Street Office Team? 3. How is street office care for you?
The speeches were transcribed and inserted in the free software Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (Iramuteq) for later analysis and creation of the thematic nuclei and categorizations.
The analysis of the reports was carried out based on the characterization of the interviewees and the testimonies reported by them, which were transcribed, constituting the textual corpus.Each text had a command line that was ordered respectively, interviewee_01 (I1) to interviewee_08 (I8).Subsequently, the file was saved in UTF-8 format (Unicode Transformation Format 8 bit codeunits), and it was possible to perform the analysis by Iramuteq.
Classical lexicographic analyses were performed to understand the statistical data and quantify evocations and forms.The Descending Hierarchical Classification was obtained to measure the dendrogram data according to the classes generated, considering words with x² > 3.84 (p < 0.05).Subsequently, the Word Cloud was generated, which unifies the words and graphically arranges them according to their frequency and performs the Similitude Analysis, seeking to identify the occurrences between the words and their connections.

RESULTS
This study interviewed eight HP, aged between 27 and 62 years (mean of 44.4 years), four (50%) of whom were over 50 years old.A sample composed of six (75%) males, with four (50%) people who declared themselves black and six (75%) unemployed people.The period of homelessness ranged from 3 to 50 years, with half of these (50%) being over ten years on the streets.
The Descending Hierarchical Classification of the speeches generated a general corpus consisting of eight texts, separated into 188 text segments (TS), with 178 TS (94.68%).5064 occurrences (words, forms or expressions) emerged, 988 distinct words and 516 with a single occurrence.The content analyzed was categorized into three classes: Class 1 -"Care understood by homeless people", with 85 TS (47.75%);Class 2 -"Satisfaction with access to health actions and services", with 40 TS (22.47%) and Class 3 -"Causes and coping with life on the street", with 53 TS (29.78%) (see figure 1).Among the testimonials that make up this class are: I think there is no difference; and I think even people who are from the street are even easier, do you understand?As at that moment the physician said that other people were wanting to be served, then she said that the priority of care is for homeless people.(I6) The service always comes from the office on the street, but we here on the street are in need of other care, because there are ladies, children, everything there and we really need a bath, something like that, more bathroom.Among the constituent reports of this class, the following stand out: Every homeless person is very well served here by the street office team and there at the health center as well.And I feel very good to be served by the team that serves the homeless, the girls from the office of the street office.(I8) [...], the girls at the street office and at the health center have been treating me for about ten years now [...] I have nothing to say, it's very good.Even at the health center, when I arrive with the medical prescription, because here on the street they give me the medical prescription so I can get medication at the health center, at the same time I am seen to.(I2) I have been seen at the health center several times and received very good care; I left there with all the medicines, even though I didn't have the documents.It is scored among the testimonies manifested in this class, as follows: [...] a steady job, but so far nothing and that's how I ended up living on the street, because of my husband; Then we didn't have money to pay rent or eat, so we had no choice but to live on the street.(I5) I ended up on the street because I don't have a job, I never got anything in life, I have a wife, I have children, I have everything, they live at home and everything, but I preferred to go to the street, I can't help at home.(I6) The reasons that led me to have to live on the street was the inheritance fight, they took my mother out of the house and I fought for years and years to be recognized in court as a son, because I was adopted, they did not recognize me and then I disliked myself and disassociated myself from my state, I am from Rio Grande do Sul.(I4) The reasons that led me to live on the streets was my own choice, the attitude I had.I have a house, but I prefer to live here on the street, here in the square with my children, I am known as the father of the square, all homeless people here in the square of Ferreira respect me and call me father, I am a dear person, a leader.(I2) In addition, the analysis of the word cloud obtained through the participants' speeches showed that the most evoked words were: "Street" (f = 95); "People" (f = 63); "To provide service" (f = 35); "Heath post" (f = 34); "Office" (f = 27); "Care" (f = 27); "Live" (f = 25); "Speak" (f = 23); "Stay" (f = 23); "Health" (f= 19); "Well" (f = 19); "Resident" (f = 16); "Service" (f = 15); "Receive" (f = 15) and "Team" (f = 14); (see figure 3).In order to identify the occurrences between the words from the reports and the indications of the connection between them, the similarity analysis was used.It is observed that, as in the word cloud, the term "Street" is at the center of the reports, and from them they are strongly linked with "People", "Care", "Office", "To provide service" and "Post" and from these, several other branches that underlie all textual discourse arise.This word reaffirmed in this analysis represents the place of existence and survival, as well as the space where the office on the street performs its services (see figure 4).

DISCUSSION
The analysis of the reports of the users of the office on the street showed perceptions about care, satisfaction with access to actions and health services, as well as revealed the causes and confrontations present in the daily life on the streets, evoking three empirical classes that were corroborated by the analysis of the word cloud and similarity.
Among the individual needs pointed out in Class 1, users expressed the different forms of care conceptions according to their perceptions, revealing the insufficiency of humanized care based on sensitive listening, displays of affection, medicalization of the body, social recognition in the priority of access and self-care.
Among the forms of care exemplified by one of the interviewees, hear and listening stand out.It is necessary to focus on the understanding of these two words before starting the discussion and then differentiate them and understand them in their uniqueness.The word hear, from the Latin Audire, refers to the perception of sound waves through the auditory system.So, the person who hears is close to the original sound that is transmitted by waves, unlike listening, which crosses the borders of hearing, from the Latin Auscultare, which means listening attentively, listening secretly, obeying.Therefore, the act of listening requires extra care, a concentration on what was said.When bringing to the context of the HP, this form of care (listening) always needs to take into account the place that each subject occupies in society. (7)or Oliveira et al. (8) , actual listening only occurs when the pact of the social group that excludes them is broken.It is understood that the act of listening needs to be free of judgments, since it is possible to treat the suffering of the other, when we immerse ourselves in what is said and in the social dimension of the cause.
Thus, it is possible to assimilate that sensitive listening and dialogue both individually and collectively are indispensable tools in the process of health care, especially when considering the principles, guidelines and policies that guide the care model within the SUS. (9,10)I7) This understanding of care represents the relationship between human rights and the right to health, highlighting the lack of public policies to combat social inequities in health and favor healthy environments that respect the dignity of these people, since the act of not bathing further excludes these people from the economic, social and cultural contexts of cities. (11) In addition, some studies have pointed out the lack of privacy in the environments that offer baths to the homeless people, exposing, especially women, to situations of vulnerability, from situations of embarrassment to possible violence.14)(15)(16) Among other care practices punctuated in the statements, medicalization appeared in the daily life of health services.The care in this category focuses on several practices, from its rational use, as well as the commercialization, a practice that is widely used and punctuated by the nurses of the office team on the street during the interviews.
In contrast, Class 2 shows testimonies related to satisfaction with access and actions of health services, focusing on both the ease of access to SO (Street Office), as well as the fixed health instrument (health post).From these reports, it was possible to perceive that access to health actions and services are not being denied to this population, even without having personal documents.
In this trajectory, Santos et al. (17) pointed out the satisfaction of users with the care provided by the Street Office team, highlighting the lack of continuity and periodicity of care as points protested by the research participants.
Most of the participants are individuals without income and occupation, in a situation of extreme poverty, who enjoyed their right to health when being served and classified the service as positive, justified by the accessibility in the operationalization.
It is noteworthy that health teams face several challenges for the care practices of HP, including the heterogeneity of user profiles and the precariousness of/at work, often limiting medicalization and preventing a more sensitive and qualified listening.However, even in the face of these obstacles, it still provides an opportunity for a service considered satisfactory by users.
Reflexively to these considerations, the question is: Is this satisfaction with care, perceived as positive by users, determined by the health team, the care support instrument or the basic need "met"?English | Rev. enferm.UFPI.2024;13:e4479| DOI: 10.26694/reufpi.v13i1.4479What actions could minimize the shortcomings reported by users in Class 1 and expand the potentialities highlighted in Class 2?
Furthermore, Class 3 addresses the aspects related to the causes and coping with life on the street, emphasizing the reasons that influence these users in this phenomenon and invites the reader to reflect on the structural issues of society, taking into account capitalism as a driving force for people to find themselves in this situation, as well as the exercise of the autonomy of the subjects, which, although not exclusive, instigates to understand the causes and coping with life on the street, highlighting the nuances of the process of living on the street.
The process of living on the street is based on the opposite conception of thinking that people "are from the street", consequently, it is understood as a social process that is characterized by multiple conditions.For this process to be interrupted, preventive actions or even interventions are necessary when the time spent on the street by the subjects is still short, which favors the effectiveness of its reversal. (18)he experience on the streets has its particularities and its pluralities, there are several reasons why this phenomenon occurs and, therefore, the contexts, destinations, ways of living, surviving and inhabiting the streets are multivariate. (18,19)Several are the obstacles that are part of the daily life of the homeless people, whether the weakened bonds, the consumption of alcohol and other drugs, health problems and unemployment, that despite not establishing a unique relationship with the street situation, work plays an important role in society and its absence corresponds to one of the causes that lead to life on the street. (20)owever, it is worth noting that understanding leaving the street, for whatever reason, whether through work or not, as the only form of autonomy of the subjects can lead to a mistaken understanding, which contributes to create impositions that can stigmatize and further exclude these people from the social circuit.
Considering that choosing not to live or live on the streets, being inserted or not in the labor market consists of the exercise of autonomy.Thus, social assistance equipment needs to be articulated so that life projects are created through different contexts and respect for the choice of subjects, without judgments. (21)t is in this unveiling that the causes and confrontations that the HP daily go through are shown.The users who contributed to the discussion of this category only emphasize how subjective it is to inhabit the streets and face the process of living on the street, because as the reports show, the street situation can be the result of the capitalist machine or even a choice.Tiengo (22) , raises a discussion about this phenomenon as a result of capitalism, considering that it produces, since its emergence, misery proportional to the growth of wealth, that is, it is understood that the more it develops, the greater the production of wealth and the production of misery, which culminates in the increase in the number of homeless people.
In this context, it is understood that the casuistic root for a significant number of HP, where many want to be employed and cannot, is not related to inability or lack of effort, in fact, represents the basic consequence of capitalism, where some accumulate excessive wealth, while others too much poverty. (22)n addition, these reflections about the process of people living on the street were corroborated by the analysis of the word cloud and similarity.In the word cloud, the words are randomly positioned in such a way that the most frequent ones appear larger than the others, thus demonstrating their prominence in the research analysis corpus.In this one, the most evoked word was "Street" exposing a semantic sense of vulnerability.
The homeless people represents unequally social and health disparities, which points to the need for actions and services that guarantee the right to health and their social rights as citizens.There are several obstacles that prevent these people from enjoying these rights and having free access to these social instruments, whether it is the barriers that are imposed or the stigmatization and prejudice that is still latent. (20)mong the mishaps that the street offers are variations and climate change, which appears as one of the main problems that affects the health of the homeless people, contributing to the emergence of diseases.These subjects become climate migrants, always trying to escape from these places and their potential risks.In addition to the housing risk that the street offers, there is also a lot of violence and stressful conflicts, which culminates not only in physical but mental illness. (23)ften, the search for attention and health care are neglected and this fact is justified because survival is a primary need, in addition to the lack of resources for treatment and continuous exposure to violence, which leads to the search for medical attention only in emergency cases. (24)nglish | Rev. enferm.UFPI.2024;13:e4479| DOI: 10.26694/reufpi.v13i1.4479 In the analysis of similarity, in addition to the word "street", as a connective center of the words, the expression "to provide service" was representative when connecting with documents, exam, medication, prescription, refer.This link is evidenced when users claim that they can get care even without having personal documents, that medications are prescribed through prescriptions, performed exams, as well as, they can receive care from SO or be referred to other services.
This analysis also highlights the word "people", which represents people living on the streets, with a high rate of occurrence, showing the direct relationship with evoked expressions, such as understanding, embracing, hearing, listening, fear and relating to human aspects, linked to the feelings and desires of these users.Thus, the importance of sensitive listening in health and social care instruments capable of understanding their realities and adapting to them is witnessed, making it possible to offer care based on their realities.
Therefore, important reflections on care practices in this care context emerge from these analyses, evoking the qualification of the health care network, the establishment of bonds of trust and respect between the actors involved in the care process capable of bringing users closer to the service, the expansion of the care network through the integration of other agents, and dialogue with other services.Care practices should enhance health care, due to its binding nature, based on the humanization of care, understanding the human being in his biopsychosocial units and not based only on the biomedical technicist character. (25)mong the limitations of this study is the permanence of the users in the health service that provided the interviews, as well as the consent to participate.These findings reveal the perceptions of users of the office on the street about care practices, emerging weaknesses and potentialities about this care instrument, as well as reflections on the living on the street process that can assist in the operational organization and in the elaboration of new public policies of assistance support to this population that is socially, economically and affectively marginalized.

CONCLUSION
The perceptions of the street office users interviewed in this study about care practices expressed different personal conceptions, evidencing the need for humanized care based on sensitive listening and affective-social reception, although it was considered satisfactory in relation to access and health actions and services.In addition, the phenomenon of living on the street emerges as a reflection of the capitalist system, however, and the autonomy of the subjects in this ethnographic path should be considered.
It was observed that the role of the office on the street is essential to promote access to health actions and services, being an instrument that acts in the prevention of health problems, as well as in the reduction of damages.Furthermore, a joint, articulated and integrated work with all sectors of social support is essential to guarantee the conditions of survival of the population that seeks, resorts to and uses this instrument.In this sense, the need to reformulate basic health care services to qualify the care of homeless people is evident, so that inequities can be mitigated or even overcome.
Thus, the need and importance of investing in the training of professionals who work with this public is revealed, who deal with the ways of life on the streets, peculiarities, particularities of the healthdisease process, as well as forms of approaches, since appropriating these themes makes all the difference and brings humanity to/in care, in addition to contributing to the continuity of care and ways of doing health.

CONTRIBUITIONS
Contributed to the conception or design of the study/research: de Souza JF, Rolim KMC.Contributed to data collection: de Souza JF, Pinto NV, Daniele TMC.Contributed to the analysis and/or interpretation of data: de Souza JF, Pinto NV, Daniele TMC.Contributed to article writing or critical review: de Souza JF, Pinto NV, Frota MA, Rolim KMC.Final approval of the version to be published: de Souza JF, Pinto NV, Daniele TMC, Frota MA, Rolim KMC.