Incentive for practicing counseling on healthy lifestyles in Primary Healthcare

Objective: To analyze the effect educational actions with professionals of Primary Healthcare focused on counseling on healthy ways. Methods: Intervention study with health professionals of a Basic Health Unit of Belo Horizonte MG. Was applied a questionnaire, pre and post-intervention, consisting of socio-demographic data, and counseling practice. The educational activities occurred for four months and consisted of interventions focused on counseling. Results: The participants were 66 professionals who preferably counseled sick individuals (52.1%) during home visits (42.6%) and individual consultation (35.4%) being the main barrier to their achievement, non-adherence of users (52, 2%). After the intervention, there was increasing in realization of regular counseling (p = 0.009) and reduction only for sick users (p = 0.012). Conclusion: Actions enabled the expansion of counseling practice, primarily focused on health promotion and disease prevention, revealing the relevance of including such topics in continuing education activities.


INTRODUCTION
Given the current healthcare scenario, marked by the increase of chronic non-communicable diseases (NCDs), such as cardiovascular diseases, diabetes mellitus and obesity, it becomes paramount to achieving healthy ways of life counseling by health professionals, especially on the regular practice of physical activity and healthy eating, considering their proven benefits 1,2 .
Counseling is a strategy in which the knowledge with a view to changing health behaviors is constructed by the patient in conjunction with the professional, providing the best individual skills for the adoption of healthy ways of life 3 .It assumes the participation of the health professional as an educator that stimulates reflections and changes on behaviors of interest, involving individual or collective guidelines, even intervention strategies 2,4 .
The attendance of users at healthcare services is an important opportunity to carry out the advice, considering the confidence that its professionals attract among users 2 .In primary healthcare services (PHS) such a practice takes character even more relevant when considering that his guiding axis is the strengthening of the ability to choose the subjects in order to influence the health determinants of collectives 5 .However, counseling is still infrequent and often is performed only as a result of an already installed disease 2,6 .
A study in Australia 7 pointed out that most healthcare professionals advised about diet and physical activity only to those individuals who were already overweight at the time of consultation 5 .In the same sense, a study by Toledo (2011) 6 with 417 users of a Basic Health Unit in Belo Horizonte, Brazil revealed the low frequency of counseling (40.8 percent) by professionals and accession (50.9 percent) by users, and receiving advice associated with the presence of diseases such as hypertension and hypercholesterolemia.
It is recognized that several factors may relate to insufficient execution of counseling on healthy ways of life in the PHC.Among them, we highlight the lack of time, financial compensation, for membership of the patients and of theoretical and practical knowledge about issues related to physical activity and nutrition 7,8 .Working, therefore, the subject of counselling practice in permanent education spaces may constitute important strategy to overcome these barriers and strengthen health promotion and prevention of diseases in primary healthcare.
In this sense, this study aimed to analyze the effect of educative actions in health promotion conducted with primary care professionals about their counseling practice focused on healthy ways of life (nutrition and physical activity).

METHOD
This study is an integral part of the project "Promotion of healthy ways of life in adults and seniors living in areas of basic health units of Belo Horizonte -MG, Brazil".The project belongs to one of the research lines of the work education program in health (PET health), developed since 2009 by the Federal University of Minas Gerais in partnership with the Municipal Health Secretariat of Belo Horizonte, Minas Gerais.
It is an intervention study, descriptive quantitative approach carried out with health professionals from five Family Health Teams (FHT) and the Nuclei of Support Family Health (NSHF) acting in a Basic Health Unit (BHU) Eastern Region of Belo Horizonte, planned and carried out from April 2011 to March 2012.
The inclusion criteria of the study consisted of being BHU healthcare professional in question, accept to participate in the study, and not be on vacation or sick leave.Thus, respondents consisted of professionals with training in the healthcare area at all levels, including the community health Agents and Endemics, and excluding only the management.
The baseline of the study lasted three weeks, when it was applied a structured questionnaire and pre-tested, for students and fellow volunteers of PET-health, duly supervised by the preceptors.The instrument consisted of socio-demographic data (age, gender, education, occupation, income, working time in the health system and health insurance) and data relating to the practice of counseling on healthy ways of life (healthy eating and regular practice of physical activity).This questionnaire was also applied after the intervention in order to verify possible differences in the practice of counseling by the professionals.
The activities conducted in the intervention occurred during four consecutive months, in moments and physical spaces conventionally used in UBS and specified by management of the unit, as conference room, kitchen, garage, among others.The use of these spaces aimed to stimulate the participation of professionals in the activities, which were carried out during or after the weekly meetings of the FHS and matricidal work along with the FHSC.
Before starting the procedure, for a month, a step was used to aim at disseminating awareness intervention activities and facilitate the adherence of professionals.This step consisted of different activities, including a workshop named "Workshop of the senses", which explored the touch, smell, taste and hearing of professionals as possibilities for reflection on work and healthcare.Additionally, offered in the BHU activities were stretching and relaxation, and actions for the promotion of healthy eating by culinary workshops with preparing healthy recipes and practices, such as banana peel cake, cereal bars, fruit and natural juices.
After the awareness, the pros were invited, with a week in advance, to participate in the intervention by means of posters and verbal invitations made during meetings of the teams.In order to not harm the work of professionals and ensure the active participation of all activities, actions had maximum duration of 30 minutes and took place during the meetings of every FHS, moment in which all professionals were gathered.

Encouraging the practice of counseling Mendonça RD, Toled MTT, Lopes ACS
In chart 1 are presented the activities carried out in the intervention, including the themes, objectives and educational strategies with a view to contribute to the expansion of the counseling practice.The meetings consist of three stages, first presents the theme, performed following the practice activity and at the end a discussion in which it encouraged reflection on their practice of professional counseling in the context of the subject at that meeting.
The activities developed in step of awareness and intervention paved the way in materials published by the Ministry of health, whose themes covered the promotion of healthy ways of life in a clear and accessible, such as the "Ten steps to a healthy diet" and the "Food Guide for the Brazilian population".Additionally, educational materials were used and ludic, as replicas, pictures and labels of foods prepared by the staff of PET-health.
From the data obtained the descriptive analysis and applied the Kolmogorov-Smirnov test to evaluate the distribution of quantitative variables (normality).For variables with normal distribution, the results were presented in the form of average and standard deviation (SD), and for those with asymmetric distribution using the median, minimum, and maximum values.The categorical data were described by absolute and relative frequencies.
To check the differences related to realization of pre-and post-intervention professionals counseling was employed the McNemar statistical test for the paired analysis of the variables.A significance level of 5% was considered for all tests.Statistical analyses were performed with the aid of the program Package for the Social Sciences, version 17.0 (SPSS Inc., Chicago, IL, 2003).
Regarding ethical issues, the survey was approved by the ethics and research Committees of Belo Horizonte (CAAE 0037.0.410.000-09) and the Federal University of Minas Gerais (ETIC 037.0.410.203-09).All respondents were informed about the research, and those who agreed to participate then signed a consent form, as required by Resolution of the National Health Council.To ensure anonymity, the questionnaire did not register the name to the end of the study.

Objectives Educational strategy
Healthy Snacks • To encourage the promotion of health through healthy eating counseling.Culinary workshop on preparing sandwiches.• Present simple and viable recipes that can be provided to users.

Healthy ways of life at work
• Raise awareness about the importance of quality of life.Scalding feet with aromatic salts and herbs, in a musical setting.
• Discuss the importance of healthy ways of life counseling.
What is health?
• Discuss the expanded concept of health and the factors that influence it.Educational game.• Wake-up call about the importance of thinking about health and the benefits of adopting healthy lifestyles in the community.

Healthy ways of life-healthy nutrition and physical activity practice
• Work issues relating to healthy modes of life: healthy eating and physical activity practice.
Educational game.
Practice of physical activity and healthy eating as promoters of self-care support • Work issues relating to healthy eating and physical activity practice.
Practice of Liang Gong, the conversation circle on healthy eating.
• Stimulate the practice of self-care support by professionals as a strategy for expanding the counseling focused on healthy ways of life.
• Present strategies for working professionals with the healthy lifestyles with users.
Promoting health in everyday life • Discuss different types of sessions focused on health promotion.Theatre technique.
Well-being and hydration • Discuss the importance of hydration for health.Practice of relaxation through the use of a "musical menu" and delivery of bottled water.
• Introduce to ways of working professionals the importance of moisturizing with users.
Encouraging the practice of counseling Mendonça RD, Toled MTT, Lopes ACS

RESULTS
Of the 84 professionals from BHU, 66 (78.6%) were interviewed before the intervention and 48 (57.1 percent) after the intervention.The losses were related to professionals who have not responded to the questionnaire after the intervention, being caused by his absence at BHU during the data collection period, whether by conducting outside activities such as home visits and trainings, or labor holiday.It should be noted that in order to minimize these losses, the professionals were sought on alternate days during the period of data collection by at least three times.Furthermore, all respondents attended at least 57.1% of educative actions, being the average participation in the meetings of 55 professionals.
Of respondents (n = 66), the majority were women (77.3%), with an average age of 38 years (SD ± 10.9 years), 50.0% had high school and most had health insurance (66.7%).The most prevalent occupation was the Community Health Agent (27.3 percent) (Table 1).It should be noted that the demographic characteristics of participants were similar in the moments before and after the intervention.
The execution of counseling about healthy ways of life by users was reported by 85.1% of the professionals at pre-and post-intervention on 89.4% (p = 0.625).The home visits, individual consultations and operating groups were cited as spaces where more counseling was done, at both times (table 2).Additionally, professionals reported to believe that the regular practice of physical activity (95.5%) and healthy eating (98.5%) are able to influence the health, especially improving the quality of life (64.4%)and the profile of diseases (44.7 percent) (data not presented), being the major barriers to achieving the low adhesion of the user and the lack of time.
By analyzing the practice of counseling after the intervention, there were significant changes in the practice of counseling in general, and geared towards healthy Individuals.There was an increase of 29.2% to 50.0%; p = 0.009 and reducing the frequency of realization of advice for users who had some disease (37.5% to 16.7%; p = 0.012).There were no changes as to the spaces and barriers to conducting counselling (Table 2).

DISCUSSION
Interventions conducted by health professionals led to an increase in the percentage of regular advice to users regardless of the presence of diseases, which favors access to counseling.
It shows the positive effect of this finding, when considering the advice on healthy ways of life should be available to all individuals, with the aim of not only the control of diseases, but also prevention and health promotion, in an equitable and universal manner 2 .
However, studies show that the practice of counseling is small among health professionals and occurs mainly to sick individuals 7,9 .Study on United States 9 with primary care physicians showed that less than 50% of workers reported providing specific guidelines on diet, physical activity and weight control, regardless of the presence of diseases between users.The higher frequency of counseling for individuals sick seems to point to health practices, yet in some ways, linked to the biomedical model focused on the treatment of diseases.Situations, which highlights the difficulties of health professionals to counsel with the goal of promoting health.In this context, Silveira et al. 10 in a study on the work process of the FHS, scored that, professionals, as well as the user population still operate according to the logic of traditional focus on therapeutic actions, hindering the completion of the health promotion in the daily services.
Referring to spaces that support if its advice, points out the fact that few professionals cite the reception, waiting room and the operating groups.The host has vital importance in PHC, with Encouraging the practice of counseling Mendonça RD, Toled MTT, Lopes ACS capability to print quality health services.It is configured as a way to operate the work processes in health, in order to serve all who seek health services, listening and responding appropriately to the demands 11 .
The waiting room for being a dynamic territory, where different mobilization occurs people to waiting for care, should and can transform the waiting period for consultations at favorable time for the awakening of the educational processes and exchange of experiences, enabling the interaction of knowledge with a view for the production of integral health care 12 .Already operating groups by promoting and improving the knowledge of those involved (professionals and patients) may reduce symptoms of emotional responses in the face of adverse social pressures often present among individuals requiring changes in lifestyle 13 .Thus, it reinforces the importance of these spaces assigned to the family health Strategy in partnership with the FHSC, being more exploited by professionals, aiming to become a greater breadth of health promotion actions focused on healthy eating and regular physical activity practice, proximal determinants are essential to the health of the subjects.
In addition to the insufficient exploitation of moments and spaces for assistance to carry out health promotion activities, it should be noted that some professionals interviewed, such as community health agents and endemics, dentists and oral health auxiliaries mentioned do not perform counselling on healthy ways of life.A scenario that corroborates the biomedical model of assistance in which the responsibility for care is associated with the figure of the doctor and not the teamwork, as proposed by the family health strategy 14 .
In the current model of health care is of utmost importance to be the co-responsibility of all professionals for job success, avoiding the discontinuity between care actions 11 .Furthermore, Encouraging the practice of counseling Mendonça RD, Toled MTT, Lopes ACS it should be noted that the health education configures itself as a practice planned and assigned to all professionals who make up the PHC 3 .In this sense, the participation of these professionals is essential in establishing and strengthening the link between the residents and the health unit, making the diagnosis of situations of risk, as well as his role as agents of community organizing for the transformation of the health conditions 14 .
The act also advise presupposes preparation and knowledge of professional studies point to difficulties and lack of time, the collaboration of individuals and of practical and theoretical knowledge 7,8 .Wynn et al. 8 found that physicians who reported having greater knowledge about healthy nutrition presented a higher likelihood to undertake counseling on this topic (p < 0.0005).In addition, these professionals were more likely to spend more time discussing nutrition during the consultations of the doctors they considered insufficient knowledge about food and nutrition (p < 0.0005).
In this study, no significant change was observed in relation to the barriers for advice on healthy lifestyles, after the intervention, and the difficulty of user adoption the most important barrier according to professionals.This finding demonstrates that the non-adherence of counselling practice discourages users.The demotivation of the professional can be one of the factors that contributes to that advice is little present in their practice, causing communication difficulties, depleted bond, user dissatisfaction and the low adherance 14 .
However, when the healthcare provider participates in some action, as noted in this study, he responds by extending the practice of counseling which demonstrates the high dependence of permanent education.This is when facing for the understanding of processes that involve behavior change can contribute to empower professionals for better addressing the barriers faced by users to implement healthy lifestyles, which may improve adherence 15 .Updating materials like Booklets by the Primary Care, Ministry of Health, aimed at prevention and control of NCDs, constitute important reinforcement in this sense.
To broaden the practice of counseling in the PHCs and contribute to the rupture of the fragmented and reductionist vision imposed by the biomedical model in health practices it is necessary a process of permanent education to professionals and students in the area, in order to encourage a broader view on the health-disease process.This process must be based on shared construction of knowledge and everyday experience and above all value the professionals as supporters of change.Thus, one can expand the skills and abilities to perform the health care and management of the difficulties experienced daily and thus contributing to the prioritization of actions for health promotion and prevention of injuries 5,15,16 .
An important strategy to enable permanent education in primary health care is the establishment of partnerships between the education and health sectors, as experience lived by PET-Health in this study.These joint actions between universities and service are useful to intervene in reality, allowing you to combine the knowledge produced and accumulated by the two sectors, aiming to articulate health actions 16 .
This study has some methodological limitations that prevented causal inferences and associations of the results with the occupational categories of the participants, in addition to losses in the monitoring.It is noteworthy that the main reason for such losses in the study was the lack of professional at UBS during the period of data collection; however, professionals were sought at least three times in the unit.Moreover, as this study in only one BHU, the results cannot be extrapolated to other health services, but suggest ways to rethink the practice of counseling.It is noteworthy that it is appropriate to investigate the act of advising by professional category in order to study whether there are differences in this practice, but it was not possible in this study due to the small sample size.Nevertheless, it was possible to meet the goal of the study and contribute to the development of health-promoting practices geared to the local reality of the population studied, pointing the importance of further studies on the subject.

CONCLUSION
The study revealed that the educational practices conducted with professionals reflected positively on health promotion actions carried out, by the percentage of increase offer advice to regulate users, especially among those without disease.Thus, new pathways for expanding counseling practice focused on healthy lifestyles in PHCs to include the theme of continuing education in service activities contributing to integral health care.

Table 2 .
Practical advice on healthy ways of life, according to health professionals -Belo Horizonte -MG, 2011-2012 McNemar's Test; HWL-healthy ways of life.