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Concept Note: Programa de Saúde na Escola (PSE)
Date of Request: July 12th, 2015
Name(s): Daniel Wilhite, Amy Nunn, Ines Dourado
Email address(es): daniel_wilhite@brown.edu
Proposed Study Title: An Evaluation of the Challenges of the Implementation of Programa de Saúde na Escola
(PSE) in Camaçari/Bahia
Study Objective:
This study aims to qualitatively analyze the challenges that the municipality of Camaçari is facing in implementing
the Programa Saúde na Escola (PSE) in public schools. It will look at the obstacles that PSE administrators have
faced in trying to establish institutional relationships between the Secretary of Health, Secretary of Education, PSF
units, public schools,and othercommunity entities. It will also examine the perceptions of PSE coordinators,PSF
health care workers, public schooladministrators, teachers,parents,and students,ofthe program since its inception.
Justification:
Programa da Saúde na Escola (PSE), a program established in 2007, according to the Ministry of Education
of Brazil, is designed to “contribute to the integral education of students through health promotion, illness and
disease prevention, and health care, aimed at addressing the vulnerabilities that compromise the full development of
children, adolescents and young people…” through the integration of the public education and health systems (7).
Soon after the inception of this initiative, the Pesquisa Nacional de Saúde do Escolar (PeNSE) was released (5).
This study highlighted the fact that adolescence is a period during which students are particularly at risk of
developing habits that can lead to chronic diseases. The data revealed that as early as middle school (ensino
médio), high percentages ofstudents in both public and private schools in Brazil had reported that they had smoked,
drank, exercised infrequently, ate unhealthy processed foods regularly, started to have sex, experienced physical and
emotional abuse, and brushed teeth infrequently (5). These findings demonstrated the extent to which programs,
like PSE, are important in the effort to educate students about healthy living behaviors and to help students get
access to health care.
While the importance of programs like PSE is clear, the institutionalization of this initiative has been met
with a variety of challenges. One such challenge is the scale of the operation. As articulated in the PSE “Caderno
Gestor,” each Programa da Saúde da Família unit can officially attend to up to 1,000 students at schools in the
surrounding community (1). In large municipalities, like Camaçari, it is often difficult for all schools to receive PSE
coverage. Camaçari, a city with a population of 242,970 in 2010, as of 2015, only has 23 PSF units (2, 8).
Furthermore, a majority of these PSF units are officially serving far fewer students than their 1,000 allotment (2).
Anotherissue that has affected the work of PSE is the lack of continuity within the PSF workforce. On the
ground level, many PSF medical professionals have contracts at particular units for several years, after which they
have the option to leave their posts (4). This is extremely problematic because all of the systems that a medical
professional may have implemented, including that of PSE, can be disrupted. Furthermore, there is no guarantee
that replacement workers will pick up these initiatives or that these new team members will be trained adequately in
the operation of certain programs (4). Additionally, at the administrative level, typically about every four years
municipal governments change. Thus,the managerial sustainability of certain projects is stymied (9).
There is also a significant concern of connectivity within the bureaucratic structure of PSE. A study
conducted on the Programa de Saúde da Família that analyzed the efficacy of this new primary care model identified
that only 15% of PSF health professionals really agreed that the PSF systemis able to effectively refer patients to
specialists (4). Furthermore, in five of the eight cities studied, more than half of families indicated that they were
not able to schedule health examinations with specialists. (9). Therefore, there is a likelihood that PSF professionals
may experience difficulties in linking students to more specialized care.
One of the primary tenants of PSE is “intersetorialidade,” which involves the collaboration of multiple
sectors in the planning, execution, management, and evaluation of programming. PSE is designed to consist of
Grupos Intersetoriais de Trabalho (GTIs) at the federal, state,and municipal levels, that are made up representatives
from the Secretary of Health, Secretary of Education, and local cultural, leisure, sport,transport,urban planning,
civil society,NGO, and othercommunity entities (1). According to a study conducted in 2007 on the construction

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and development of PSF, more than 66% of community subjects affirmed that the PSF health teams should form
relationships with othercivic associations and NGOs in order to resolve community issues (4). Other literature has
pointed to the fact that this PSF model is a complete paradigm shift from the deeply entrenched
“compartmentalized” nature of Brazilian public politics and prevalence of professional divisions within the health
field itself (let alone other sectors)(3, 9). Furthermore, evidence has already suggested that GTI decision-making
has often come to be dominated by the health sector, one reason being that the Ministry of Health is in charge of
funding the program (3).
PSF has also raised ethical concerns about the intrusion of health care into the lives of unwilling citizens.
In regions covered by PSF units,community health agent visits to the homes are technically considered compulsory.
This has raised concerns that the government is overstepping its boundaries and becoming too involved in the
private lives of citizens (6). This concern of private liberty may also translate into the practices of PSE, as medical
teams are entering schools and conducting medical examinations and vaccinations on students without the presence
of parents or legal guardians. While physicians are required to inform parents about their activities and receive
consent to carry them out,this systemmight be creating tensions between parents,schools,and health care workers
(1).
Study Aims
This research seeks to verify the extent to which these previously identified programmatic challenges are relevant to
the experience of PSE in Camaçari, Brazil. The study,through qualitative methods, hopes to capture the state of
PSE at a local municipal level and the primary concerns of all parities involved in its operation.
Study Hypotheses:
1. There are not enough PSF health care worker teams to implement PSE at all public schools in Camaçari.
2. There are issues of programmatic continuity within PSE teams.
3. There are problems of connectivity to specialized care within the PSE system.
4. The Grupos Intersetoriais de Trabalho (GTIs) are underdeveloped and dominated by the health sector.
5. There are ethical concerns of parents about PSE medical care within public schools.
Data Analytic Sample:
Semi-structured interviews will be conducted in July and August of 2015 with PSE coordinators, PSF health care
workers, public schooladministrators, teachers, parents,and students (n=_)in Camaçari-Bahia, Brazil. Participants
were included if they identified as a PSE coordinator, PSF health care worker in a unit officially affiliated with PSE,
or public school(with an official relationship with a local PSF unit) administrator, teacher, parent, or student. In
order to be included participants also had to either live and/or work in Camaçari-Bahia. All interviews were
conducted in Portuguese after informed consent was obtained. Interviews included questions relating to PSE
administration, politics, GTIs, program challenges, professional relationships, community partnerships,and potential
future improvements (see questions below). First-hand observation of PSF medical team schoolvisits, PSF medical
team meetings, and PSE administrative meetings was also conducted.
Main Outcome Measures:
Analysis Plan:
Based on the literature review and interviews, codes will be established.Interview scripts will be read in detail and
categorized based on patterns. As categories become apparent they will be comparatively analyzed against one
anotherin order to decipher relationships and irregularities. All of this information will then be used to extrapolate
and articulate overarching themes.

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Appendix A:
Qualitative Interview Script (PSE Coordinator + PSF Health Care Worker)
 Que é seu papel oficial aqui? Faz o que com PSE?
 Por quanto tempo você tem trabalhado com PSE?
 Em geral, o que você pensa sobre PSE?
 Quais são os desafios principais do programa?
 Acha que há suficiente equipes para o trabalho de PSE?
 Como é a relação entre as escolas (diretores, professores,pais, alunos) e os equipes de saúde? Há alguma
tensão entre os dois? Como é o dinâmico de poder?
 Existe um Grupo Intersetorial de Trabalho em Camaçari? Pode o descrever?
 Como pode a integração entre as escolas,unidades,gestores,e outras entidades comunitárias melhoram?
 Como é o processo de encaminhamento dentro de PSE?
 Em cinco anos ou mais o que você espera que PSE vai ser?
Qualitative Interview Script (Public School Administrator/Teacher)
 Que é seu papel oficial aqui?
 Por quanto tempo você tem trabalhado aqui? Com PSE?
 Em geral, o que você pensa sobre PSE? Na sua escola especificamente?
 Quais são os desafios principais do programa?
 Acha que há suficiente equipes para o trabalho de PSE?
 Acha que essas intervenções atrapalhamatividades normais? O que é envolvida no planejamento de uma
visita?
 Como é a relação entre as escolas (diretores, professores,pais, alunos) e os equipes de saúde? Há alguma
tensão entre os dois? Como é o dinâmico de poder?
 Como pode a integração entre as escolas,unidades,gestores,e outras entidades comunitárias melhoram?
 Como é o processo de encaminhamento dentro de PSE?
 Em cinco anos ou mais o que você espera que PSE vai ser?
Qualitative Interview Script (Public School Parent)
 Tem(êm) um(ns) filho(s) em qual ano e escola?
 Você conhece bem o trabalho de PSE na escolar do seu(s)filho(s)?
 Você acha que esta relação entre as unidades e escolas podem melhorar a saúde do seu(s)filho(s)? O que
você acha sobre o programa em geral?
 Recebe notificações/informações da escola sobre as visitas dos equipes, vacinas, etc? Você sente envolvida
neste iniciativa?
 Seu(s) filho(s) fala(m) sobre as visitas? O que eles dizem ou não dizem sobre isso?
Qualitative Interview Script (Public School Student)
 Quantos anos você tem, em qual ano você é, e qual escola você frequenta?
 Você conhece o trabalho de PSE (ou as visitas dos médicos)?
 Você gosta quando os equipes vêm? Tipicamente o que vocês fazem? As visitas são divertidas?
 Acha que eles podem te ajudar com sua saúde?
 Seu pais sabem sobre estas visitas? Você sabe o que eles pensamsobre PSE?

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Bibliography
1. Caderno Gestor
2. Camaçari. (2010). In Instituto Brasileiro de Geografia e Estatística.
3. Casemiro, J. P., Fonseca,A. B., & Secco, F. V. (2014). Promover saúde na escola: reflexões a partir de uma
revisão sobre saúde escolar na América Latina [Electronic version]. Ciência & Saúde Coletiva,19(3), 829-
840.
4. Escorel, S., Giovanella, L., Magalhães de Mendonça,M. H., & Senna, M. (2007). O Programa de Saúde da
Família e a construção de um novo modelo para a atenção básica no Brasil. Revista Panam Salud
Publica,21(2), 164-175.
5. PeNSE
6. Programa Saúde na Escola (PSE): intersetorialidade como presmissa para desenvolvimento integral. (n.d.).
In Centro de Referências em Educação Integral.
7. Programa Saúde da Escola (2013). In Ministério da Educação.
8. PSE Camaçari Chart
9. Rosa, W., & Labate, R. C. (2007, November). Programa Saúde da Família: A Construção de um Novo
Modelo de Assistência [Electronic version]. Revista Latino-am Enfermagem, 12(6), 1027-1034.