Professional opinion on the effectiveness of the National Policy of Comprehensive Health Care for Men

Objective: To identify the opinion of health professionals for the realization of the National Policy of Comprehensive Health Care for Men. Methods: Exploratory/descriptive study with a qualitative approach. Sixteen professionals from the Primary Health Care in a city in the interior of Rio Grande do Norte participated through semi-structured interviews. Results: The subjects thought that the policy is relevant to work actions for the man. However, their formative process was on diseases care, fragmented and overly biomedical, discussing the development of health promotion practices. Other difficulty found is the absence of collective action and the lack of training to work with the male population. Conclusion: It is necessary to strengthen the rapprochement between man and health services. Municipal management should provide instruments for strengthening and encouraging full care to the man, contributing to their health/disease process.


INTRODUCTION
In 2008, the Ministry of Health (MOH) released the National Policy for Comprehensive Health Care for Men (PNAISH), seeking to develop actions and services in primary care for men, given the participation of this group in other levels of care for solving their health problems 1 .
Participation of men in primary care began with the reproductive and sexual rights.Sexuality and reproduction are a pattern of social relations based on gender inequality.The PNAISH promotes health actions valuing the natural reality of men respecting the different levels of organizational development of local health systems and types of management, reducing health problems, particularly those related to mortality from preventable and avoidable causes.This health policy includes male population aged 25-59 years old, working on topics as violence, morbidity and mortality, sexual and reproductive health 1 .
One of the indicators for lack of men access to the service is the timeliness in attendance, especially between the time for care demanded and the effectiveness of it.This demand consists on the pursuit of solving the problem that caused the effective search 2 .
The issues of male affordability show the small presence of men in health services justified by work, liked directly to the social imaginary and culturally constructed, devaluing the absence of man motivated by health/disease, besides being an instrument revealing their weaknesses.Employers see the women, in this context, as an individual who needs to take care of themselves and so their absence becomes acceptable 3,4 .
The need to implement a health policy for men is relevant because his figure influenced by society made impossible their access to health services.In this way, we believe that this group unknown health practices and services offered in primary care and in addition, they do not perceive themselves as subjects within the healthcare spaces.
This research comes from concerns within the healthcare spaces on the invisibility of men in action and health practices developed by primary care professionals.In this sense, this study proposes to support discussions to strengthen the participation of men in health care.
From the implementation of PNAISH in 2008 and the need for inclusion of the male population in the health services, the following question arises: what are the opinions of health professionals to PNAISH execution?To answer this question, this study aims to identify the opinion of health professionals for the effectiveness of the National Policy for Comprehensive Health Care for Men.

METHODS
Exploratory/descriptive study with a qualitative approach, developed in two Basic Units of the Family Health (BUFH) that make up the primary care of a city in the interior of Rio Grande do Norte, Brazil.
The study included sixteen health professionals: doctors, nurses, technician nurses, and community health agents.To ensure confidentiality of the participants we used the following terms: DOC, NUR, TEC NUR, CHA.The inclusion criteria of the subjects were to be in the family health strategy and are practicing their activities during the data collection.The exclusion criteria were to be absent from the area during the interview and did not attend the scheduled date for data collection.
Data collection was from November 2011 to January 2012 with the semi-structured interview technique, recorded in MP4 device.Data collections was after clarification of the research objectives and the participation of professionals in the study.The interview began only after signing the consent form.
The transcribed information used the technique of thematic analysis of Minayo (2008), following these steps: Pre-analysis of materials; exploration of the material identifying textual units.Finally, the analysis of treatments and interpretation of these data according to PNAISH and discussed from the literature related to the topic 5 . The

RESULTS AND DISCUSSION
The formulation, implementation and execution of health policies are challenges and situations that require follow up, monitoring and evaluation for possible corrections in the actions, but above all meeting the constant changes and structural process.Health policies are transformation tools involving different areas of the society in pursuit of achieving the corresponding practices of the community 6 .
Therefore, the PNAISH proposed qualifying health care for men in the perspective of lines of care emphasizing comprehensive care.The male population accesses health services for specialized care.It is indispensable to offer qualification strategies and strengthening basic care, not allowing visibility of men only in recovery, but also on health promotion and disease prevention 7,1 .
Men's health: opinion of professionals Araújo MG, Lima GAF, Holanda CSM, Carvalho JBL, Sales LKO A health policy for men is important because it requires educational actions in health.This group has the highest rates of mortality when compared to women.The main causes are cardiovascular diseases, malignant neoplasms, ischemic heart disease, and external causes (accidents, violence and homicides).In this sense, it is a challenge to health services, because most men, take unhealthy behaviors, leading risk factors for the disease 8,9 .
One of the participants' speech highlights the PNAISH tas an important policy pointing out that it is possible to work actions for men from the perspective of health promotion and disease prevention.In addition, he notes the challenges to conquer male access to services and demonstrates knowledge of policies to assert the need to perform actions of ES to alcoholism, drugs and traffic accidents.The professionals understand the anxieties of working PNAISH, and understand the needs to formulate strategies to allow full care for men.
The human being is very important.They need health care too, both in matters of promotion, prevention and rehabilitation.C[5Men just look for attention once they have a health problem.We have to work in the accident, traffic accident, to work drug use, alcoholism that also happens in men and try to bring this population.We have to look for a way to attract them.To start working this policy.(NUR 01).
Therefore, despite the professional does not develop actions for men, understands the needs of working with this people and their singularities, giving encouragement and strengthening of practices to facilitate the performance of actions for the insertion of man in health services.
PNAISH is important for the society and considered an instrument of male participation in the health area, allowing their subjectivities, values and cultural imaginary.Health professionals may consider these implications and support the participation of men through practices and discussions on the approach and the reception of them in health establishments.
Participants' speech reaffirm gender discussions citing that there are health policies for women, and consequently they must exist for men enabling effective actions for them.This discussion is valid, because there is the difficulty of developing primary care activities for the male population.

There are policies for women, and it is interesting a policy for men. Not only on paper but actually happening in practice. (NUR 02).
It is very important as guarantees of women.When talking about health is good for everyone and as there is the exam for women, we need for men, it would be a good option.(CHA 01).
One interviewee compares the performance of tests for men and women showing larger areas of insertion of the female population in services because of having less offering for men.It is noteworthy that women's achievements permitted a comprehensive care in reproductive health and sexual issues and care built culturally favoring the pursuit of public sector investments to their problems of health care.Professionals need to show the examinations for the male population as an initial approach, becoming an instrument of validation for the approach between the service and men.
When there is a comparison between the presence of men and women and the use of these services, women are better than men, both in frequency, as familiarity with the space and the organizational logic 10,11 .
Researches confirmed that the man sees the Health Unit as a purely female environment, although this has contributed to the improvement of living conditions for the population, since the woman is historically responsible for the family when talking about children, home care and family.Thus, the proposal to sensitize men regarding their health needs pervades the speech of the subject, demonstrating that joint actions with the different areas the society, can be a valuable tool for the achievement of health spaces for men [7][8][9]1 .

It is very interesting, it is essential we will have to sensitize these men from their need to seek the basic unit. The basic unit was not only made for women, it is for both genders, and the man has to look for it. (TEC. NUR 01).
In these speeches there is a responsibility imposed on man by "man has to seek", demonstrating the absence of knowledge of the PNAISH proposing actions for health promotion and disease prevention, encouraging activities to engage the man in questions related to their health, proposing to strengthen their participation in health services through a collective construction.
Another subject despite having little knowledge about PNAISH, awake to the importance of the man in the contexts which they operate, including in their own daily lives, citing "without man is worth nothing" proving the uniqueness, the social construction of being a man for the professional.

Without the man is worth nothing, the man is giving a support to all. (CHA 07).
Men's health: opinion of professionals Araújo MG, Lima GAF, Holanda CSM, Carvalho JBL, Sales LKO The professional saying "man gives a support to all" inserts the men on social issues and enables the role of these subjects in gender relations, placing them at the center of discussions and even of collective decisions.Therefore, the male profile is still rooted in several scenarios and contexts, including in the health field.
When asked about the relevance of PNAISH, one of the subjects of the research does not consider this policy a priority for their activities referring health policies for children and elderly people as necessary, given the peculiarities and weaknesses of them before health/disease care.
I consider all policies very important, directed to any segment or any age groups: children, adolescents, elderly.Forman, the high priority should be given to the weakest people, children and elderly.I'm not saying to not take care to adults, but if you take into account that the adult get sick less than the child and the elderly so I think we need a help program to help childhood and old age.(DOC 02).
In men health, it is clear the challenges faced by them in a purely sexist context prioritizing the idea of strength and invulnerability before any circumstances surrounding manhood.In this perspective, the implementation of a policy for this people reaffirms care that people must have with their health.In the promotion perspective, it is not perceived in the speech of the interviewee, because it is guided only look in care forgetting the extrinsic social needs of this field.
Actions developed by FHS professionals prioritize individual consultations, valuing medical care, the consultations are fast and the professionals are more concerned providing a prompt response, taking decisions to known behaviors and focused on pathology therapeutic measures 12,13 .
The formation process of large number of the professionals present in the Unified Health System (SUS) occurred with a focus on diseases care, fragmented and overly biomedical, discussing the development of practices for the recovery of health.The use of a policy for certain groups is not considered, and performing care actions not transcending the BUFH, leading to the predominance of care model of health promotion activities and disease prevention 12 .
These assumptions suggest that most health professionals consider PNAISH as a relevant allowance for working actions for men.This is a challenge with enabling and forming bonds actions, difficulty of building strategies for improving their health.However, professionals do not have enough support to finish their actions and do not know PNAISH in its entirety, they believe in welfare approaches as the health/disease process that group transformers.Therefore, it is necessary to combine other approaches for professionals through training and qualifications, considering the inherent issues of the men and their barriers facing health areas are obstacles to improving their health.
Continuing education is vital for the professional in performing any health activity.Professionals need to be prepared to deal with myths, prejudices and misconceptions built in the imaginary and the social context of patients 9,3 .
After the implementation of PNAISH in 2008, men care became a responsibility of primary care, in particular the FHS.However, the ranking of the organizational process around this policy does not allow professionals, inserted in BUFH, be ready to take action and achieve the objectives proposed by this guideline.This is a result of lack of training and methodological tools to achieve these professionals and prepare them to attend men.
The difficulties mentioned by the professionals are lack of skills and practices to deal with men because of the gap in health services and strategies approaching men.
In the speeches of the participants there are the training and qualification as necessary and one of the solutions to minimize the predominant barriers in service to men as well as allow for approaches helping men integrally and not just the disease.

[...] Professional training would greatly help the approach. (CHA 02). [...] We need to be trained and oriented and have the help of the staff [...]. (CHA 08). [...] It is much more difficult for us to have a contact with them, and we do not have the training to be with them. (CHA 05).
In this way, completeness must be understood as a guiding principle of skills and backgrounds in healthcare, enabling the articulation of knowledge, practices and inter-professional actions from a broad concept of health respecting the subjectivity and the social imaginary of the patient by reception and responsibility, to overcome centered practices in procedures with a focus on disease 14 .
It is very important to have changes in care sctions when achieving a full response mode, because it is necessary to deconstruct the man with the medicalization as single best tool for health needs.For this, the training of professionals is essential, since the fear of accessing health services by man is notorious and enters that space when valuing only medicalization.Thus, professionals must hold coping strategies providing new avenues for service to this subject 10,13,15 .

Men's health: opinion of professionals
Araújo MG, Lima GAF, Holanda CSM, Carvalho JBL, Sales LKO Another obstacle facing the challenge of male access in BUFH is the absence of joint actions of the professionals of the FHS, because using only care practices prevent traders to extrapolate the space of healthcare and develop actions in the community.
Practices and actions developed jointly by professionals are essential to allow greater visibility to the men patient and encourages the practice of self-care and to others.These actions contribute to integration and the presence of man in health areas considered important for the construction of a guided tour in the premises of the SUS and guarantying of rights to health 11 .
In this perspective, discourses reveal the fear of working with men, because 'he feels lonely' in a demand care, that does not allow the construction of a collective practice among professionals.In addition, it shows how the practice of individual care is predominant, preventing that territoriality activities are in second place.

[...] We feel lonely, I feel alone in the area, you know? because the demand here at the health center is great, but then there's no way the nurse and the doctor go with us to the area. (CHA 04).
In other speech, one of the subjects considered his experiences and demonstrates the lack of training to work with men, comparing their approaches with other groups and reflecting the familiarity of working with hypertensive and diabetic women.This reinforces the lack of actions and practices for men as well as the predominance of activities that privilege dominant groups of patients in health care areas.

[...] It is like you said, it's hard. We have a few cases of experience of dealing with men, because if you ask me about hypertension and diabetes and women I'll say yes, but about men I do not, but to me I am available to look for exits and improvements [...]. (CHA 08).
In this speeches, he said "I am available to look for exits and improvements" recognizing the need for training on men's health and the importance of working the PNAISH, but also proposed the construction of devices that allow the strengthening of male insertion in health area, improving their quality of life.The qualification encourages the professional to understand the obstacles to the realization of the male presence in the actions taken by the FHS and assists in building strategies for their participation.
The difficulties of dealing with men, lack of skill and qualification contributes to the diminishment of this group by professionals, with actions to the demands on the health service.A study to examine the patients' views about the services for men in primary care found that they consider unsatisfactory services for men, recommending appointments for male characteristics, among them campaigns, meetings and clarification of different areas of care than the ones for women and children 2 .
These activities are where the professionals have necessary knowledge about the relevance of working actions for men, building a work plan from a planning focused on issues pertinent to the health of the male population, enhancing their health process/disease.
The service becomes organized diminishing access problems of this population, improving the functioning of the offered network services, in addition to providing the solvability of the demands, decreased avoidance of patient's system and strengthening of primary health care as the main gateway to the man to SUS 8,2 .
Other considerations addressed by professional are workshops that enable these individuals to qualify for practice of PNAISH and understanding of the issues pertaining to the health of humans and their peculiarities.The preparation of workshops and access to professional media training courses are offered by MOH as it nears the professional challenges of working with diverse groups, contributing to the formulation of actions in this space and the construction of discussions relating to natural conditions to man.

[...] To attend workshops and training for this job. (CHA 06).
The need for qualification and professional training is evident among the speeches pointing out the barriers, difficulties and shortcomings in the approach to men.It is necessary to develop strategies for man's participation in services and carrying out actions that transcend the areas of healthcare reaching the community.
From this perspective, it is essential to search for opportunities for discussion and strengthening of comprehensive care for men, for the professionals to understand the need for men's health, performing an insertion of the men in health services through training tools and strengthening care for men.
The challenges faced by the FHS professionals regarding the need for accessibility of men are support of management to offer subsidies to minimize the difficulties encountered in performing actions.To minimize the fragility of capacity building and training of health workers in the quality of services we can use the Continuing Education in Men's health: opinion of professionals Araújo MG, Lima GAF, Holanda CSM, Carvalho JBL, Sales LKO Health (CEH), being a training and development of professionals, linking education of these subjects with expansion solvability of services 9,11 .
The CEH identifies training needs and development of workers in the health area, and build strategies and processes that qualify care and health management, allowing the participation of social control, aiming to produce a significant impact on individual health and collective population 10 .
The objective of CEH is to reflect and rethink the processes of change, considering the health needs of the patients/population.It is a work articulating the health care, training, management and social control, encouraging and influencing the transformation of health practices and work organization.It aims to establish a network of teaching and learning in the performance of work in the SUS, with a view to the needs of the population, sensitizing professionals to understand the importance of considering the rights of citizens/patients 14 .
In this way, the professional statements below reported the importance of training courses to better attending men, suggesting that professionals become qualified to work in the assistance of the particularities of that individual.

[...] It should be more seminars by the health department, training course for us to attend this people. (CHA 04).
The interviewee refers the responsibility for municipal management, offering opportunities for training to promote the development of actions and practices to attend men.The professionals do not have the knowledge to work with practices for men, requiring the inclusion of these subjects in CEH courses.
In health services, human resources remains marked by procedures of personnel management, while the answers to the demands of development are punctual, focused on technical-scientific, disjointed and fragmented training, often unrelated to health needs.Thus, the management does not recognize the weaknesses of the professional service to patients, not contributing to the improvement of services, with actions only to the service organization 14 .
In the following speech, the professional know other awareness tools for the improvement of human health care as health education, the use of transmission media, besides the active search required in tracking the farthest individuals in BUFH.
[...] The educational seminars aware men.He is a fragile and interesting, we going to the radio or trying to get this population that tries to move away from health.(DOC 02).
The radio is a valuable community tool for actions reaching specific groups because it allows society to understand the challenges, actions and needs to work with men and giving to all who use this tool a way to raise awareness about relevance of the male population included in the health area.Besides working actions aimed at men, to stimulate men to seek information and assistance in health services, it proposes to wake healthcare professionals on the topic 16,17 .
Another interviewee when asked about the difficulties of access of men and their barriers on the social and cultural conditions in the participation of men, showed the difficulty of access as something common in health services being a reflection of the not organized demand.
[...] The difficulty I see here is an inherent difficulty to all care services in Brazil, usually there is a pent-up demand, there are more people looking for the services everywhere happens, more generally in my case I'll take care of two shifts morning and afternoon daily attendance [..

.]. (DOC 01).
With this, the use of curative actions, on a network of disjointed services without resolving planning mechanisms both the supply and demand of services, focused only on clinical care without prioritizing the construction of the subject search mechanism for promoting health and prevention of disease, not value healthy living conditions and health and proposes to minimize or solve the problems of individuals 11 .
Therefore, the comparison between men other groups should not be seen equally considering the professional to make a routine care of two shifts, only reveals the lack of organization and planning of service oriented to outpatient care, forgetting other paths recovery of health of men.
Professionals have difficulty in attending not only men as to other specific groups.This is due to the service organization, revealing population segments access to public health services and limits problems that these services have to attend their demands call 2,17 .
Among other coping strategies form men, the professionals cited the health campaigns and fairs.They are traditional from FHS.However, these are specific actions to bond formation with BUFH men, but on the other hand are diversified instruments that immediately attracts this group.
The campaign is more incentive, consultations for men encourage more.(CHA 09).
Thus, management needs to identify these opportunities to approach men in health services and try to realize them, since professionals extrapolating the physical space of BUFH Men's health: opinion of professionals Araújo MG, Lima GAF, Holanda CSM, Carvalho JBL, Sales LKO and advancing within the community may cause changes in the approach to men and reveal new ways to health.
Another interviewee states that despite the obstacles found in SUS when seeking solvability of health needs, they are attended.However, the respondent is part of the SUS and his actions are indispensable to solving the problems faced by the health system.
[...] Everything that we go after, we can make it, but talking about health is so complicated because there is so many things that SUS needs [...].(TEC NUR 01).
The difficulties of access of men permeate by professionals and their needs for actions, as they mostly do not develop actions for men that integrate health services.The effectiveness of methodological tools to empower these professionals and the strengthening of mechanisms for integration of professionals in the community to promote awareness and singularities belonging to the predominant social context are essential.
Management can be a partner in the actions enabling access of men in healthcare spaces, supporting care on the integration of actions and the subjects involved, understanding their singularities and health needs.
Therefore, the main limitation of the research was because the study place was a small city, so it becomes necessary new studies contributing to this topic, because the surveys of the man in the healthcare area are very important.

CONCLUSION
Professionals recognize the need to work with men and need encouragement and strengthening of practices to facilitate actions for the inclusion of men in health services.For this, we need health practices and intersectoral discussions involving the approach and the reception of man in health facilities.
Municipal management should provide instruments for strengthening and encouraging comprehensive care for men, contributing to their health/disease process.It is necessary to train and qualify these subjects through the CEH through partnerships with educational institutions, acting in the transformation and changes in health practices and work organization, valuing both professionals and patients.
This research reaffirms the importance of working with the thematic human health, including primary care, because even with the insertion of PNAISH is not visible man's participation in this context.Thus, the initial steps are for men in health area and effective operation enabling the approximation between man and health services are essential.
study followed the proposed legal and ethical considerations by Resolution Nº 196/96 repealed by Resolution Nº 466/12.The Ethics Committee in Research of the University of Rio Grande do Norte (CEP-UERN) approved the study in November 2011 formalized by opinion Nº 052/11 and CAAE 0048.0.428.000-11.