Male primary healthcare: possibilities and limits on night service

Objective: To analyze the contributions from the expansion of the working hours of the Basic Health Units, about the health needs of the male customers. Methods: Exploratory study with a qualitative approach, performed with eight nurses in Basic Health Units woking in the evening service in the city of João Pessoa/PB. Data collection was conducted through semi-structured interviews and speeches subjected to content analysis of Bardin. Results: Four categories emerged: Strategies adopted to extend the service in Basic Health Units; Quantitative evening service of the male population; Fields answering the demands of men's health; Difficulties experienced in night service. Conclusion: The findings show a potentially effective of this strategy the male customers care, especially users workers.


INTRODUCTION
In the especific literature, when it seeks to reflect on the thematic "man and health" some fundamental considerations are in general, men suffer more severe and chronic health conditions than women and also die more than they do, because of the main causes of death 1 .
According to the Mortality Information System (SIM) of the Ministry of Health, in 2007, every three people who died in Brazil being 20 to 59 years old, two were men.If the deaths of Brazilians between 20 and 30 years old are analyzed, this proportion rises to four in every five deaths.According to the system, all deaths that occurred in the country, men are almost 60% of them, and the main causes of death of male population are diseases of the circulatory system, the external causes such as homicides and accidents, and neoplasms, respectively 2 .
However, despite the male rates have a significant impact in the profiles of morbidity and mortality, it is observed that men repress their health needs seeking fewer health services than women, and when they do it, is in hospital care service of medium and high complexity 3 .
The search for health services, when it exists, is tied to a clinical picture of morbidity already chronic with biopsychosocial repercussion for quality of life, as well as significantly burdening the SUS 4 .
In this perspective, the Ministry of Health introduced in 2008 the National Policy of Integral Attention to Men's Health (PNAISH), which aims to promote health actions that collaborate significantly to understanding the male singular reality in their various contexts, allowing the increase in expectation of life and the reduction of the rates of morbidity and mortality in this population 5 .
Thus, several studies have been discussing the issue of men's health, seeking to understand the different motivations that leads men to seek for these services.In this context, the low presence of man in primary health care services, leads to many assumptions and/or justifications, stating that there are socio-cultural and institutional barriers 5 .
The cultural dimension is related to the structure of gender identity, when the man is stimulated to be shown as strong, virile and invulnerable looking for health service, in a preventive perspective, associating him with weakness, fear and insecurity, being close of representations of the feminine universe 1 .
The recognition of gender issues involving the men's access to health services requires inclusive strategies of health services by the adult male population group.
Under the institutional range, there are difficulties related mainly to aspects of general organization of services, such as the opening hours of basic health units (BHU).This is a strong preventing factor, because the vast majority of units works only during business hours, making it impossible for the use of men, particularly workers, due to the incompatibility between the hours of operation of the unit and their work 6 .
In this way, it is observed that men need more significant and specific health care policies to the recognition of their sociocultural conditions 7 .
There are few health units that provide extended care, on the weekends or on a third shift at night.Thus, the male customers who is working in the formal market, with rigid schedules of work, cannot leave from it, because it would undermine their job security.The fear of being penalized at work for absence for medical consultation, even if they win this certificate is one of the reasons that keeps the men of these services 8 .All this causes not searching health services.
In this way, the male population is not being incorporated as a priority in primary health actions, because there are not strategies that address care in men.Such problematic ends up hindering the promotion of preventive measures to men's health, which implies a greater exposure to situations of risk, which tend to cause aggravations and diseases, thereby increasing the rates of morbidity and mortality by preventable and avoidable causes.
It is necessary to check whether the opening hours of the BHU directly influence in search of men for these services, aiming at the formation of data that could be means for the elaboration of strategies that include the different health needs of men, in order to facilitate and expand the access of the male population to health services.
Given the above, the following question arises: Have male users sought basic health units that perform service at night, in order to meet their health needs?
In this sense, the study aims to: assess the strategies adopted by BHU in the expansion of service to men; check the frequency of this population group to service during the night hours; highlight the most frequent demands of men's health met in BHU; and investigate the possibilities and limits of nursing care in attending male during the night.

METHODS
This is an exploratory research with qualitative approach, held at the basic health units, located in the municipality of João Pessoa -PB, who have office hours at night.
The people selected for the study was constituted by the team of nurses who work in the area of research, with a total of ten nurses.The sample occurred by accessibility and to this end, the inclusion of nurses in the sample took place voluntarily and was reaffirmed through the signing of the free and clarified consent form, resulting of eight nurses.
The data were collected during the months of February/March 2013, being effected through individual interview, guided by a semi-structured script, containing data of characterization of the subject, as well as data related to the study problem.Cutting

Male primary health
Cordeiro SVL, Fontes WD, Fonsêca RLS, Barboza TM, Cordeiro CA questions used in the study were: Is there any strategy adopted by the unit to extend the service to male customers?On average, how many men seek this unit daily?What are the demands of the most frequent health by this unit?What are the difficulties experienced in attending this customers during the night?
The data were analyzed qualitatively, using the method of content analysis presented by Bardin 9 , which involves three steps: pre-analysis, analysis and material exploration and data exploitation.
In order to protect the anonymity of the speeches, each participant was identified with the letter N, for nurses, followed by a number corresponding the sequence of the respondent, being N1 the first nurse interviewed, and so on, until the nurse N8.
The development of the study attended national and international standards of ethics in research involving human beings provided for in Resolution 196/96, in order to ensure the rights and duties about the scientific community, the subject of researches and to the State.The research was approved by the Ethics Committee in Research of the Health Sciences Center of UFPB, under Protocol 027/13, with CAAE: 11140412.2.0000.5188.

RESULTS
In the search to understand the possibilities and the limitations experienced by nursing staff of nursing care in primary health care in the context of the night service to male customers, it was decided to present the results of this study from two approaches: characterization of the subjects investigated and aspects related to the specific problems of the study.
Eight nurses composed the sample of the study.This reaffirms the feminization that characterizes even today, the profession of Nursing and, at the same time, the absorption of the female in primary care.These aspects worth mentioning when we refer to human health care, since this has represented a contributing factor to low male demand for BHU.
As for the age, it was found that the age range varied from 24 to 56 years old, with an average age of 32 years old.Thus, this sample considered as a heterogeneous group of people in terms of age, since they were young adults and mature.Therefore, these are professionals who are in productive stage, generally eager to trainings in the area of human health; important fact for the scope of the implementation of the PNAISH, whose planning is widely valued in the plan of action of this policy.
As regards time of activity in the field of Nursing, it was found that the professionals have an average of 11 years of experience.When asked if they received any training on the implementation of the PNAISH, all subjects of the research have denied, reaffirming the need of specific qualification for the men's health care for basic care, since the majority of respondents of the research said not being prepared to meet the specific health needs of this customers.
As for the aspects related to the problem of the study -possibilities and limitations in nursing care in primary health care to male customers at night -the analysis of thematic units from reports of nurses participating in the research, revealed a set of four categories and seven subcategories, which were discussed on the basis of relevant literature and presented below: Strategies adopted to extend the assistance to male customers in BHU Subcategory: Absence of strategies [...]There is no strategy conducted by the unit [...] (N1, N2, N7, N8).

[...] It is more on word-of-mouth [...] we also does lectures before starting the service [...] (N6).
It was observed, through the reports of the research participants that the practices of health education of these professionals are nil or restricted, owing to the shortage of strategies that stimulate men's access to health services, that aspect which contributes significantly to the occurrence of low presence of this population in this scenario.
Being the basic care, locus which is the gateway of the health system, it is necessary to develop actions that encourage the insertion of the male population, seeking access to measures of health promotion and prevention of diseases.
It is appropriate to point out that educational materials printed as leaflets, pamphlets and booklets are valuable instruments in the field of health education, being informative.However, we cannot take it for granted the assumption that these media are satisfactory, since the logic of this education is passive, based only on the transmission of a message, which can be absorbed or not.
On the other hand, the dialogued educational practices, such as the reception and the lectures and educational campaigns, enhance interpersonal exchanges of knowledge, since they provide the community interaction with health services, through dialogic established between both, able to mobilize and motivate them to force a process of change.
It is essential that in addition to the educational aspects, among other actions, the public health services are organized in order to host and make the man feel an integral part of them.

[...] about 12 men on average [...] (N3, N4).
It is worth noting, in this subcategory definition, it was considered in the inexpressive quantitative study amount less or equal to ten men met daily at night, and expressive quantitative, exceeding ten men.
The data reveal that there are a number of expressive men, according to this study, assisted by basic health units.This concentration of men at this time points to a potential effectiveness of this strategy to meet, especially users, workers and contributes to greater male membership in preventive actions.
It should be noted, however, that the care in basic health units, although covering a significant amount of men, not limited only to them, since women work under similar conditions and also make use of this service.

Subcategory: prevention of problems [...] immunization, because the job requires [...] (N5).
Given the above, the main demands of men's health are related to chronic degenerative diseases and immunization.
All these situations showed that the men's demands are included in programs originally already in place in the basic care, facing other population segments, such as Hiperdia, where elderly and women participate more often.
In this context, it is emphasized that although the male population have specific needs, the PNAISH features the inclusive aspect, i.e. as men access the primary care, they must use the services available there and, if their needs require more specialized services, they must be forwarded to reference services.
As regards the workers users, a nurse's reports in relation to the issue of immunizations was highlighted, once it is realized that the workplaces of these men have stimulated the departure of worker health units.
In this way, it is essential a greater involvement of these professionals in actions that may go beyond simple vaccination, seeking to clarify doubts and to encourage the male population to issues of self-care, as well as stimulate a greater involvement of clients in these units.

[...] their resistance to open for a female professional [...] (N3). [...] they're ashamed to expose for us [...] (E2).
In the participants' speeches in the study was highlighted a sense of shame and a posture of resistance to report their problems and fears.Once the establishment of a confident relationship between the health professional and the user is for effective therapeutic communication, there is the pressing need for exploitation of health professionals in order to get through, while assistance and relationship with the male population, cultural barriers and gender stereotypes, rooted in the know popular, which produce intrusive practices in care and access this customers in primary health care services.

[...] lack materials in the unit, sometimes I buy [...] (N6).
Male gender stereotypes rooted for centuries in our patriarchal society is still a challenge for the achievement of the PNAISH.Thus, it is urgent the need for exploitation of nurses to deal with the specifics of this customers.

DISCUSSION
The difficulties of men's access to the service are not just perceptions in what would be his own behavior, but also situations that cause in men the feeling of not belonging to that space, because it is frequented mostly by women and composed by a team of professionals formed mostly by women 3 .
It should be noted that the characterization of services as a femalized space presents a negative denotation that needs to be rethought or can be exploited and potentized to a more welcoming and inclusive posture in integral care man, considering his health needs.It is valid to point out that the solution of this problem is not only to increase the numbers of male health professionals, but in rebuilding the attitudes of these professionals, regardless of gender, in care to men's health demands.

Male primary health
Cordeiro SVL, Fontes WD, Fonsêca RLS, Barboza TM, Cordeiro CA With regard to of professionals training, it is realized that they do not have acquired in their training about the deployment of instrumentalization academic of PNAISH for the care of male customes, since the National Action Plan (2009-2011) of in focus policy prioritizes in its Axis II -Strategies aimed at increasing the demand for men to health services; and Axis 6 -Qualification of health professionals -the need to train professionals in the area to the men's care 5 .
In this context, the continuous training of Nursing professionals in primary care, it is the responsibility of the health institutions, with the aim of promoting the updating of concepts and resources are made available to nurses, to those dealing with social issues and techniques inherent to this new dynamic of work 10 .
It is appropriate to point out that the construction and the recent disclosure of PNAISH directly influence on professional experience in the context of care to men's health, but does not exempt, nor professionals or managers, of social commitment in face of the deficits that characterize the male morbidity and mortality.Thereby, the training of professionals must understand the health within the epidemiological profile, considering each population group uniquely 11 .
Regarding the strategies used by the nurses to extend the demand of men in basic units, it is noted that, besides these are limited, they do not consider the male specificities and singularities.That is, no formal structures are identified for the recognition of social needs and to human health, unlike child segments and programs created for chronic diseases such as the hiperdia 12 .
Thereby, the health services have a deficiency in absorbing the demand presented by men, provided by the organization of services that does not stimulate their access and, because of their own public health campaigns did not return for this population segment 1 .
There is a greater presence of men for service in units that have created new schedules, as well as other services that keep activities running on lunch break.This applies especially to men apparently going out of their jobs, which endorses the discussion about the work as something that restricts the access and use of services by men 12 .
With regard to the demands of male health, some jobs encourage and/or require vaccination, opening space for health professionals guide the employees regarding the activities and invite them to the service.As a result, there has been the constant presence of men seeking the vaccine rooms 12 .
In this sense, the propositions presented in PNAISH claim that the implementation of the policy, with inclusive character, it should take place in an integrated manner with other existing policies in the basic care, full and fair manner 5 .
With regard to difficulties experienced ofr men care by female professionals, it characterizes his justification of how auto-negligence looking for health services 1 .Nursing should help to reverse the male auto-neglicence in health services, considering necessary deepening of this professional about gender issues 13 .
However, it is appropriate to point out that the guilty situation by healthcare professionals cannot be attributed unilaterally to men, given that public policy focused on collective health, and for long time did not attend the health needs of this customers.This resulted in a mismatch between the demands of health of this population group, the services of primary health care and specialized services.
Thereby, primary health care actions should be geared to the real needs of the population so there is recognition of this institutional space as a place of belonging and that their actions are able to promote, with bases dialogical, identification and minimization/efficaciousness of the demands of men's health, since in the contemporary world the construction of a horizontal relationship between professionals and the customers has been a fundamental requirement 14 .
Knowing and understanding the male profile will influence on the behavior of nursing professionals, considering more specific health actions will make it possible and effective.This evolution in attendance will promote changes in the posture of this population commonly considered invisible 15 .

CONCLUSION
The results of this study showed that the increase in the hours of operation at BHU also during night service, points to a potential effectiveness of strategy to create alternate schedules to attend to male customers, especially users with workers.However, it is realized that there are weaknesses that need to be overcome.
Among them, the units of primary health care are considered little capable of absorbing the demand presented by men, because their organization does not stimulate the insertion of this customer, since public health strategies do not give attention this segment.
In addition, among health professionals of the BHU it was observed the deficit of professional instrumentation, in the context of human health, for the assurance of a qualified assistance regarding the care of their health needs.