CONCEPÇÕES DE FAMÍLIA NA ESTRATÉGIA SAÚDE DA FAMÍLIA: O OLHAR DO AGENTE COMUNITÁRIO DE SAÚDE

Qualitative study aimed to describe family concepts for Community Health Agents (ACS). We interviewed 20 ACS of Itabirito-MG. A content analysis was conducted and data were organized into 02 categories: Family conceptions in the ACS perspective; Social issues in health care for families. It was found that the meaning of family is a group of people who share the same environment; they want to be good, regardless of consanguinity. Concepções de família na Estratégia Saúde da Família: o olhar do agente comunitário de saúde 427 Cienc Cuid Saude 2016 Jul/Set; 15(3): 421-428 There is a family diversity with new shapes, some disruption. We stressed the importance of the nuclear family as forming unit members. Emphasis was placed on gender issues in family maintenance, with the woman in place of provider and caregiver. In addition to external factors, drug addiction was highlighted regarding the influence in the care and in the health and illness of people. Despite the importance of family support, it was noted the absence of a family approach by ACS, whichever individual. However, it is the professional able to perceive unknown dimensions to the team and is influential in health care. It was concluded that, before new family conformations, there is need for new posture of professional assistance in the teams of the Family Health Strategy, so that the family is allied to comprehensive care.


INTRODUCTION
The definition of the Family Health Strategy (ESF) as supervisor of primary care in Brazil formalized the family as the focus of care of health actions, understanding that the approach of this construct enhances individual, family and individual care as an indivisible whole (1) .
The family-centered care has been discussed as an efficient way to promote the well-being and health of individuals.The family's appreciation for a new care emerged because it is believed that it is the greatest influencer of health status of its members.Therefore, health professionals should offer subsidies to the family in order to encourage participation and collaboration among its members, offering them autonomy to achieve better living conditions, where one is able to assist each other in the health/disease (2) .However, families have been turning up over the years, because the values assigned by society to them have been reconfigured by the members, redesigning the "portrait" recognized as ideal.New structures are being established by factors such as divorces, homosexual marriages and the inclusion of women in the labor market.For instance, single parents, formed by the father or the mother and her children; gay, composed of the couple and their adopted children; or extensive, consisting of consanguineous descendants for at least three generations because often parents work and the children are under the care of relatives (3) .
All these transformations are configured as challenges for health services, bringing a reflection on the concepts of family and making it clear that diversification does not mean disintegration.It is up to professionals to be adapted to such structures and provide subsidies to keep health care holistically among its members, showing them the important role that the family caregiver exercises (4) .
Therefore, health professionals need to review their conceptions of family and should be able to act in the construction process of family environment, in which the individual is not seen only as a biological, but also a being with psychological and social needs that are directly linked to care and health promotion.And he is part of a socio-economic and cultural context that should be considered when it is considered comprehensive care (5) .
Among these professionals there is the Community Health Agent (CHA), responsible for being the link between the health team and the family (6.7) .Among their functions, we highlight the monthly performance of home visits, which allow the integration and participation of that worker in the household routine, providing greater knowledge of the environment and the residents of that place, in order to establish a relationship of trust between them.Thus, the ACS becomes a key to ensure the user's relationship with the health team, which may reflect the success in promoting health.Moreover, it is from these visits it will be possible to identify the main problems in the community (8) .
To recognize the concept that the family health agent is an important way to carry out the family approach in primary health care, this is because the individual conception plays influential role in this approach that ensures or not their effectiveness and success.For the ACS, this understanding sets even more important because through home visits, he becomes part of the daily life of families, sharing the reality experienced by the user within their own home.Therefore, it is important to approach without prejudice or prior judgment, in order to enhance the user's link with the base unit.
In this context, this study aimed to show the family conceptions for community health agents and identify the influence of the meaning of family for their daily work.

METHODOLOGY
This is a qualitative study.The case study should be used when the research questions aim to explain "how" and "why" a social phenomenon works and considers the different views of the actors on the reality studied, allowing a global vision of the event (9.10) .
Data collection was performed in the city of Itabirito, Minas Gerais, in four Primary Care Health Units (UAP), during the month of May 2013.We interviewed five Community Health Agents (ACS) of each UAP, chosen at random totaling twenty research subjects.The respondents were between 22 and 57 years old and at least six months of work with the Family Health Strategy.
Data were collected through individual interviews at each ACS workplace, with semistructured script, which had questions about the meanings and models perceived family, care focused on it, the care relationship between the family and its members, the role that the ACS has on the family environment.
The interviews were recorded electronically and transcribed verbatim.Later, they were subjected to content analysis, thematic modality (11) , carried out in three steps: a) preanalysis: a thorough reading of the material collected through literature review in journals was held, books and electronic materials, which brought the issue proposed research and subsequently were proposed initial questions that could be changed according to the process development; b) exploration of the material: it held the clipping of interviews, highlighting the most important fragments, suggesting the creation of empirical categories; c) treatment of the results and interpretation: the data were organized into categories, interpreted and discussed.
The proposed study was approved by the Ethics Committee (COEP-UFMG), CAAE -03797812.6.0000.5149and authorized by the Health Department of the municipality, the research place.Participants were informed about the legal and ethical aspects of research through the free and informed consent (WIC).

Characterization of the subject
We interviewed 20 community health agents, between 22-57 years-old, 18 female and two male.As for the level of education, three had completed elementary school, 13 completed high school and two incomplete high school education, one has complete higher education and one has teaching degree.Respondents were identified by the letter "E" and a number in order to maintain the confidentiality of research subjects.
From the analysis of the data, two categories emerged: 1) Family conceptions in the perspective of ACS; 2) Social issues in health care of families.

1) Family conceptions in the perspective of ACS
It can be observed the watchful eye of ACS on the family and in the construction of conceptions on it.The definition of "watchful eye" refers to a dedicated and involved posture with the family based on mutual trust and solidarity.
It is in this context that the ACS defines what family is: The characterization of the family as a space where there is mutual support, daily living, affection and complicity among the members prevailed in the reports.This emphasizes that inbreeding is no longer the only factor to scale families.The family relationship is established from identification between people that become lasting, recognizing that there are mutual rights and obligations between them (12) , these individual may be consanguineous or not.
Although there is predominance of the conceptions that exclude consanguinity as a determining factor, there are also those that emphasize the importance of the nuclear family: Who makes up the family's mother, father, the children, but usually the couple is the basis.Father, mother… (E18) It is the father, mother, siblings, those who help each other, who care about the other, to me, it is in this sense.(E2) [...] Then the family has to be one beside the other, following the daily life, as a mother with children [...] All this worries us, husband, mother, father, siblings... Now, a home, separately, as husband, wife and children, there is a conjugal union, so it is a full concern on a daily basis.[.

..] (E13)
There is the concept of the nuclear family, which reinforces the concept of the importance of paternal and maternal figures within a home.It is observed that even if there are consanguineous ties to a family constitutionfather, mother and children -affection and daily contact are not mutually exclusive to be considered a family.
Even for those who bring the representation of the nuclear family as the ideal, it became clear recognition on the family variety, nowadays' brand: There are other types of families.Sometimes they are people who make up the family who are not father and mother, for example, homosexual couple, who call themselves family, sometimes you have no more father or mother, and there are families who are only brothers, but they remain a family.(E2) It changed a lot, because in the past we thought that family was only the father, mother and children.Nowadays there are families of different ways.It is a group of people who enjoy this common space.(E19) [...] We grow in that family environment like father, mother and children, but when we are facing people, we see that is totally different, we find different groups of families.(E17).
This suggests that even with the idealized concept, new family models are found in the agents' daily work.It appears, therefore, that new family conformations detected by them extend the vision of family models that are generally constructed from their experiences as a member.It is important that these professionals recognize different dynamic than their own reference so they can watch all of universal and comprehensive manner, without judgments and preconceptions (4.13) .
Thus, in the daily work we can find the following family structures: They are usually composed of parent-child families; there are some families who have grandparents living together.Such a larger family with three, four, five people, there are few families with few people.[...] (E9) In the families I go, for now, they are so traditional families in my area there aren't these modern families that are emerging [...] In my area, I know, there is only a case of most modern family that is a family of the same sex marriage, which is still rare in my area of coverage.(E7) There is a difference.Each family has its particularity, families are not the same, I think that this enriches us.It is noticed that the nuclear family prevails, but they have also received the extensive families, gay and single parents, present in micro-areas of care.It is emphasized, therefore, the recognition of new families conformation as a consequence of the modern world.Understanding that there were changes in family structure is essential to be able to watch each household differently, according to the needs presented.In addition, experiencing this reality allows the agent to stare these more naturally changes and transfer it to the whole team.
Contacting health professionals with this family diversity was also observed in another study (14) , made with health family professionals, including ACS, where there was a concern of the participants to demonstrate that, regardless of the family configuration, the important thing was to meet in the prevention of risks they were exposed.In addition, the participants were willing to learn and to deal with the various arrangements that they were willing in the day-to-day work.It was possible to show the same result in this study, in which ACS made clear that the assistance is independent of how the family is set up.

2) Social issues in health care for families
The main factors for the emergence of new family rearrangements that permeate modern society, there is addiction, violence, the inclusion of women in the labor market and the lack of family planning.
In my area there is problem of alcoholism, drugs [...] Certainly.A lot {affect the family}.In addition to hinder those who use, it hinders a person's lifetime and those who live perhaps even more, because it is not a choice of them to live this.Oh, it's hard to live with person who is drug user.You do not know how that person will get home.(E12) [...] One problem that is in the family and that I think it is one of the most violent problems is the drugs.I think so, for me, that disrupt some families, it causes struggle.There is a wheelchair man for taking six shots, three, four years ago because of this drug [...] It is noted that drug addiction and violence appear intertwined, it is taken into consideration that the drunk individual or drug user returns home out of mine and disrupts the dynamics of that environment, interfering in family dynamics and can make it weak.
In a survey (15) carried out in an Intensive Care Unit (ICU) with alcohol users, this weakness was reported by family members, who, in addition to emotional distress due to the use of the drug, also revealed a pain correlation to see a loved one exposed to such detention situation.In addition, drug addiction has been discussed as a problem of great impact on public health by bringing serious consequences for society, such as increased mortality and both extra and intra-domiciliary violence (16) .Such situations expose the health worker in a situation that requires caution to the approach.
As the ACS is a professional who participates in the family, their extended view when making a visit can be instrumental in the It is inferred that the care is related to a gender issue because the mother is indicated as a major figure in raising children and also responsible when that education is diverted from the ideal.
Ideal situation would be this family of yesteryear where the mother was at home taking care of the children, and the father working.For me this would be ideal.Not like nowadays, mothers work [...] I think, mother is everything, you have the reference, you tell in childhood that my mother did it; it is very difficult to talk about his father.Because the father is not always present, the father always disrupts a little the family.[...] (E5) [...] Earlier when the parents did not work, in my time, my mother and my father were always with us.I think we were more obedient, I do not know, we had our mother near us, [...] I think that helps a lot to have a dysfunctional family [...] I think it also helps the mother to work out, it's not because it's option, there are times that you need, there are times that the father is not around, the mother has to work and then the children are on the street, I think it is doing a lot of disunity in families.(E7) The fact that the woman is provider or assists the provision at home is seen as a necessary evolution brought by the modern world, however, the patriarchal image of family in which education and the care of children was exclusively a female role, as still identified.With this established representation, the absence of the man in the home is seen as a normal aspect, because it is "naturally provider."When this dynamic is reversed, i.e., the woman becomes the provider, it is something, in a way, intolerable.
The women's financial independence has brought changes in family roles that were previously established (14) .The empowerment of women, while necessary, is seen as detrimental to the family dynamics prevail, even socially, the idea of women as the main reference of the home.This idea may impair routine home visits, this because their absence interferes greatly in approach related to health issues.Thus, it is necessary the extension of the recognition of existing family forms of assistance to families in a more coherent way to the demands presented.
It is just that they are teenagers getting pregnant too early and sometimes forming a family and sometimes they do not continue what we've done, they rent a house and then what happens?They spend two, three, four months far away and then back to mother's house that the boy left, you know?[...] (E4) [...] I see for example, likely, there is another family, a lot of people have been coming to live here, many people, and like, new girls who are 18, 19, I see that they are not married, they say they are married but they just live with their partner and already have a child.So they are not worrying about family ties, to create that link to the marriage work well [...] (E15) Thus, the absence of family planning is indicated as a condition for bringing other factors that lead to a breakdown, such as the return of the children with grandchildren to her parents' house, i.e. grandparents become responsible, financially and socially, for the "new" family made.
In addition, teen pregnancy has been also discussed as a public health problem in Brazil, given the consequences that bring in the lives of young women (17) .The beginning of sexual relations, increasingly early, reinforces the need for a plan of care focused on family planning and forces the family health professionals to rethink this issue, to be extended to health education in this area.It is for the ACS the effective uptake of these adolescents and shows them the preventive and support from the ESF.
It is evident that there is ample discussion when approached the conceptions of family in view of the health agent, which is a gain for the care of family health because diversity is the biggest characteristic of the Brazilian family of the twenty-first century, so this reality must be faced for their practices to be really resolute, it is up to the professional to adapt the family dynamics.

FINAL CONSIDERATIONS
At the end of this study, it is noted that family conceptions are modified over time.These new family constitutions require new attitudes of professionals in the assistance for the staff of FHS, especially for the ACS to act as a link between the family and the team, looking for a care with quality, integrity and with respect.It can be inferred that this can be put as a challenge to be faced by health professionals.
For the participants of this study, although the nuclear family plays a mastermind role for some of them, the inclusion of new family conformations are recognized in their daily lives and it is not a trouble to that assistance is carried out fairly.Understanding that there have been changes in this structure is the first step for the family-centered care to be expanded.And assisting each family in their own dynamics is putting into practice two of the basic principles of SUS: universality and comprehensiveness.
The daily life guided in home intervention experienced by the community agent gives them a greater contact with these changes and expands their concepts making their best practices to every environment where they are inserted.Moreover, it brings awareness that the family can be a greatest ally in the care and the participation of their members influences the health/disease process.
There is a need to review the way in which the family approach is taking place, so to emphasize family needs as a whole and not only from the view of a member in order to promote longitudinally care and put into practice the precepts of families care model of Primary Care.
The family-centered care can be considered a breakthrough to replace the biomedical model established in the country, but it depends on the professionals who are part of the ESF.Thus, it is interesting that everyone renews their concepts and reviews their practices in order to enforce this care model.
It is important that the ACS transmit what they experience every day for their health team because their routine, based on the family environment, allows enlarging the concepts and the exposure of facts that allows the effectiveness of assistance.
Even as a case study, the research may have as a limit to have been developed in a municipality that has been stood out in the consistent construction with the principles of Primary Health Care.Therefore, such studies could be developed in other cities to a better deepening of the phenomenon.In addition, interviews were conducted in the workplace of ACS, which may have influenced the responses of the participants.

CONCEPTOS DE FAMILIA EN LA ESTRATEGIA SALUD DE LA FAMILIA: LA VISIÓN DEL AGENTE COMUNITARIO DE SALUD
RESUMEN Estudio de caso cualitativo, que tuvo el objetivo de describir conceptos de familia para Agentes Comunitarios de Salud (ACS).Fueron entrevistados a 20 ACS del municipio de Itabirito-MG-Brasil. Se realizó el análisis de contenido y los datos fueron organizados en 02 categorías: Conceptos de familia en la perspectiva del ACS; y Cuestiones sociales en la atención a la salud de familias.Fue constatado que el significado de familia es un conjunto de personas que comparten un mismo ambiente, se quieren bien, independientemente de la consanguinidad.Hay una diversidad familiar, con nuevas conformaciones, cierta desestructuración.Se destacó la importancia de la familia nuclear como unidad formadora de sus miembros.Se resaltaron cuestiones de género en el mantenimiento de la familia, con la mujer en el lugar de proveedora y cuidadora.Además de factores externos, la dependencia química recibió destaque en lo que dice respecto a la influencia en el cuidado y en el proceso salud y enfermedad de las personas.A pesar de la importancia del apoyo familiar, se notó la ausencia de un abordaje familiar por el ACS, prevaleciendo el individual.Sin embargo, él es el profesional capaz de percibir dimensiones desconocidas para el equipo e influye en el cuidado en la salud.Se concluye que, ante las nuevas conformaciones familiares, hay la necesidad de una nueva postura de los profesionales en la asistencia de los equipos de la Estrategia Salud de la Familia, para que la familia sea aliada en el cuidado integral.
Cienc Cuid Saude 2016 Jul/Sep; 15(3): 421-428 [...] Family are those people who are united, together in the same space, sharing the same space, the same difficulties and the same problems, solving the same problems [...].(E17) Family to me, in my opinion, is the people who live with you daily and they need or they will help you when you have.(E11) A person you can trust.It's not necessary if you have an aunt, a brother, a cousin, who just want to make you feel bad, to me this is not family, it is not part of a family, family to me is that person you can trust [...].(E1) [...] It is a reality.It is a change of families.There are a lot of single father and mother.[...] They are totally different.In my area so each home is particular, they are not so ... different compositions.(E19) Cienc Cuid Saude 2016 Jul/Sep; 15(3): 421-428 discovery of cases of domestic violence and even chemical dependency.