PERMANENT EDUCATION ON ORGAN/TISSUE DONATION WITH COMMUNITY HEALTH AGENTS EDUCAÇÃO PERMANENTE SOBRE A DOAÇÃO DE ÓRGÃOS/TECIDOS COM AGENTES COMUNITÁRIOS DE SAÚDE EDUCACIÓN PERMANENTE SOBRE DONACIÓN DE ÓRGANOS / TEJIDOS CON AGENTES COMUNITARIOS DE SALUD

Objective: to report the experience with the development of permanent education on the donation of organs / tissues to Community Health Agents (CHA). Method: descriptive study, type of experience report, conducted by six Nursing professionals who developed a theoretical and collective training with CHA from a municipality located in the southern region of Brazil. For the data collection, a structured questionnaire was applied, pre and post-qualification, which contained eight questions on the subject. The results are presented by the frequencies (absolute and relative) of the answers given by the participants in each question of the questionnaire. Results: 126 CHA (64.3% of the total) participated in the training. The frequency of correct answers was greater than 50% in three (37.5%) questions, at the pre-qualification stage, and in six (75%) questions at the post-qualification stage. Conclusion: the pre-qualification evaluation showed that the CHA lacked a solid understanding of organ / tissue donation. However, it was verified that the permanent education made it possible to improve the theoretical-scientific knowledge of the agents in relation to the subject matter, allowing them to be able to disseminate consistent information among the general population. Descriptors: Community Health Workers; Knowledge; Tissue and Organ Procurement; Transplantation; Inservice Training. RESUMO Objetivo: relatar a experiência com o desenvolvimento de educação permanente sobre a doação de órgãos/tecidos para Agentes Comunitários de Saúde (ACS). Método: estudo descritivo, tipo relato de experiência, conduzido por seis profissionais de Enfermagem que desenvolveram um treinamento teórico e coletivo com ACS de um município localizado na região Sul do Brasil. Para a coleta dos dados, aplicou-se um questionário estruturado, pré e pós-capacitação, que continha oito questões sobre a temática abordada. Os resultados são apresentados pelas frequências (absolutas e relativas) das respostas dadas pelos participantes em cada questão do questionário. Resultados: participaram do treinamento 126 ACS (64,3% do total). A frequência de respostas corretas foi superior a 50% em três (37,5%) questões, no momento pré-capacitação, e em seis (75%) questões, no momento pós-capacitação. Conclusão: a avaliação pré-capacitação evidenciou que os ACS careciam de compreensão sólida sobre a doação de órgãos/tecidos. Contudo, verificou-se que a educação permanente possibilitou melhorar o conhecimento teórico-científico dos agentes em relação ao referido assunto oportunizando que esses profissionais sejam capazes de difundir informações consistentes entre a população geral. Descritores: Agentes Comunitários de Saúde; Conhecimento; Obtenção de Tecidos e Órgãos; Transplante; Capacitação em Serviço. RESUMEN Objetivo: relatar la experiencia con el desarrollo de educación permanente sobre la donación de órganos / tejidos para Agentes Comunitarios de Salud (ACS). Método: estudio descriptivo, tipo relato de experiencia, conducido por seis profesionales de Enfermería, que desarrollaron un entrenamiento, teórico y colectivo con ACS de un municipio ubicado en la región Sur de Brasil. Para la recolección de los datos, se aplicó un cuestionario estructurado, pre y poscapacitación, que contenía ocho cuestiones sobre la temática abordada. Los resultados se presentan por las frecuencias (absolutas y relativas) de las respuestas dadas por los participantes en cada pregunta del cuestionario. Resultados: participaron del entrenamiento 126 ACS (64,3% del total). La frecuencia de respuestas correctas fue superior al 50% en tres (37,5%) cuestiones, en el momento precapacitación, y en seis (75%) cuestiones, en el momento poscapacitación. Conclusión: la evaluación precapacitación evidenció que los ACS carecían de comprensión sólida sobre la donación de órganos / tejidos. No obstante, se verificó que la educación permanente posibilitó mejorar el conocimiento teórico-científico de los agentes en relación al referido asunto, propiciando que estos profesionales sean capaces de difundir informaciones consistentes entre la población general. Descriptores: Agentes Comunitarios de Salud; Conocimiento; Obtención de Tejidos y Órganos; Trasplante; Capacitación en Servicio. 1,4,6Specialists, State University of the West of Paraná / UNIOESTE. Cascavel (PR), Brazil. E-mail: vi.faghe@hotmail.com ORCID iD: http://orcid.org/00000002-6467-0279; E-mail: julietanutri@yahoo.com.br; ORCID iD: http://orcid.org/0000-0002-9329-4495; E-mail: regi-pas@hotmail.com ORCID iD: http://orcid.org/0000-0002-7526-2510; 2.3Masters, State University of the West of Paraná / UNIOESTE. Cascavel (PR), Brazil. E-mail: sarapriscilacarvalho@hotmail.com ORCID iD: http://orcid.org/0000-0001-7421-8289; E-mail: rafaliborio@hotmail.com; ORCID iD: http://orcid.org/0000-00018387-6080; 5Graduated, State University of the West of Paraná / UNIOESTE. Cascavel (PR), Brazil. E-mail: marisauer01@hotmail.com ORCID iD: http://orcid.org/0000-0002-4383-8212 CASE REPORT ARTICLE Fagherazzi V, Trecossi SPC, Oliveira RM de et al. Permanent education on organ/tissue donation... English/Portuguese J Nurs UFPE on line., Recife, 12(4):1133-8, Apr., 2018 1134 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i4a231367p1133-1138-2018 Between 2009 and 2016, the number of effective organ / tissue donors in Brazil has evolved from nine to 14.6 per million population, with more than 7,800 transplants performed in Brazil in 2016. Approximately 80% of the procedures are funded by the Unified Health System (UHS), which gives the country the recognition of having the largest public transplant program in the world. In spite of this, there is still a considerable disparity between demand and supply of organs / tissues and there is no doubt that there is a need to improve public policies and actions. It should be noted that the annual increase in the number of effective donors and, consequently, of transplants performed is explained by the growing number of notifications from potential donors and, in particular, by the stagnation in the percentage of family refusals. Even so, this percentage continues to be high, and almost half of the family interviews carried out resulted in a negative outcome to the donation. In this sense, it is understood that implementing educational measures is a strategy to be continually put into practice, since these can contribute to the dilution of beliefs, myths and taboos, besides mitigate the lack of knowledge and information about the donationtransplantation in society and even among health professionals, and which constitute pillars of the reasons for family refusal. When following the provisions, it is worth pointing out that there is a gap in the knowledge about permanent education actions about the donation-transplant process, with primary health care professionals (PHC), and the literature is even scarcer when it comes to studies conducted with teams of Community Health Agents (CHA). CHAs have prestige and, in a way, influence with the general population. Such prerogatives were won by the close bond created in the face of direct and permanent contact with the people of the community. In addition, these professionals have an advantage in promoting qualified health education with clarified and popularly understandable language. Thus, the educative activity reported here was based, in particular, on the understanding that well-trained CHAs may be able to act as multipliers of consistent information about the process of organ / tissue donationtransplantation among the general population. ● To report the experience with the development of permanent education on the donation of organs / tissues to Community Health Agents. A quantitative, descriptive, type of experience report, conducted by six Nursing professionals who developed a theoretical and collective training with ACS from a municipality located in the southern region of Brazil. The project was previously submitted to the Research Ethics Committee (REC) of the State University of Western Paraná (UNIOESTE), which issued a favorable opinion on the development of the training according to its proposed methodological outline (CAAE: 60964516.0.0000.0107).

Between 2009 and 2016, the number of effective organ / tissue donors in Brazil has evolved from nine to 14.6 per million population, with more than 7,800 transplants performed in Brazil in 2016.Approximately 80% of the procedures are funded by the Unified Health System (UHS), which gives the country the recognition of having the largest public transplant program in the world.In spite of this, there is still a considerable disparity between demand and supply of organs / tissues and there is no doubt that there is a need to improve public policies and actions. 1 It should be noted that the annual increase in the number of effective donors and, consequently, of transplants performed is explained by the growing number of notifications from potential donors and, in particular, by the stagnation in the percentage of family refusals.Even so, this percentage continues to be high, and almost half of the family interviews carried out resulted in a negative outcome to the donation. 2[3][4][5][6] When following the provisions, it is worth pointing out that there is a gap in the knowledge about permanent education actions about the donation-transplant process, with primary health care professionals (PHC), and the literature is even scarcer when it comes to studies conducted with teams of Community Health Agents (CHA).
CHAs have prestige and, in a way, influence with the general population.Such prerogatives were won by the close bond created in the face of direct and permanent contact with the people of the community.In addition, these professionals have an advantage in promoting qualified health education with clarified and popularly understandable language. 7Thus, the educative activity reported here was based, in particular, on the understanding that well-trained CHAs may be able to act as multipliers of consistent information about the process of organ / tissue donationtransplantation among the general population.

Related experience
Project development followed the planning steps outlined below.

 First step: Initial planning
An initial meeting was held to define what type of action would be developed, such as the methodological design of the project and the attributions of each member.In this stage, we used administrative tools usually used in situations where decisions are needed, such as brainstorming and the 5W2H technique (What, Why, Where, When, Who, How, How Much).

 Second stage: project design
The scientific writing of the project was done with the structuring of its several integral parts and the elaboration of the documents necessary for the presentation for the ethical appreciation.At that moment, searches were made for previous scientific publications that approached the subject with the CHA recognizing the existing gap in the scientific knowledge.

 Third step: authorization for the execution of the project
At this stage, a meeting was held with the municipal coordination of the CHA Program in which the presentation of the project, its objectives, methodology of execution and other clarifications necessary to the consent for the execution of the project by the municipal health department were made.With the formal and written consent of the person responsible for the CHA, the project was submitted to the REC of UNIOESTE for assessment and opinion on its practical feasibility.

 Fourth stage: elaboration of educational content
The didactic-educational material was built for the exhibition in a slide format with an expository-dialogical presentation of information on: definition of organ donation; brief history of transplantation in Brazil and the world; who can be a donor; which organs / tissues can be donated (in life and post mortem); definition of brain death, main causes and methodology of diagnosis; family responsibility for consent to capture; methodology of selection of the recipient patient and preparation of the waiting list for transplants; statistical data from the Brazilian Transplant Registry; main popular myths about the donation-transplant process.The material was constructed based on the contents published in official documents dealing with the donation-transplantation process published by the Brazilian Association of Organ Transplantation (ABTO) 8 , Brazilian Intensive Medicine Association (AMIB) 9 and the State Transplant Center ( CET) of Paraná. 10

 Fifth stage: final planning
Two final pre-execution meetings were also held to adjust the details of the material to be worked in the permanent education and other subjects necessary for the good practical development of the activity.

 Sixth stage: practical development of the activity
Permanent education occurred in a Brazilian municipality in the South region, which has an estimated population of 319,608 inhabitants by 201711 and has the APS services network composed of 39 units, of which 15 Basic Health Units (BHU) and 24 Family Health Units (FHU).In addition, during the practical development of the project, the general framework of health professionals in the municipality counted on 196 CHA.Considering the total amount of CHA of the municipality, the educational activity itself was developed in the amphitheater of a university institution of the city that had enough space for the execution of the programmed capacities.
The training took place on October 25, 2017, a date that was previously included in the training schedule prepared by the municipal coordination of professionals in which the educational activity on the Basic Attention Information System would occur.Permanent education on donation of organs / tissues, carried out through collective theoretical training (training), lasted approximately 90 minutes.

 Seventh stage: effectiveness assessment
In order to verify the effectiveness of the permanent education developed, an instrument of evaluation of the theoretical knowledge on organ / tissue donation was constructed, consisting of a structured questionnaire and composed of eight questions related to the content addressed during the training.The self-completing assessment instrument was delivered to the CHA in two different moments, namely: 1st) on the same date, time and place of the training, but moments before its practical development; 2nd moment) immediately after the end of the training.Of the eight questions in the evaluation tool, in five there were multiple choice alternatives ("A", "B", "C" and "D") of which only one was correct, while in the other three questions participants check the alternatives presented with "YES" and / or "NO".
For the purpose of analyzing the answers with data systematization, each question was classified as "correct", "partially correct", "incorrect" and "not answered".The data were tabulated in a Microsoft Excel® worksheet, version 2010, analyzed descriptively and the results were presented by the (absolute and relative) frequencies of the answers given by the participants in each question of the questionnaire.
Of the 196 CHA active in the municipality at the time of the project, 126 (64.3%) participated in permanent education on organ / tissue donation.All participants completed the evaluation instrument at the prequalification stage, while at the time of training the instrument was filled by 119 professionals, which corresponds to a loss of only 5.6% (n = 7).From the preliminary analysis of data from the instrument, it was verified that the frequency of correct answers was higher than 50% in three (37.5%)questions ("1", "5" and "8"), at the moment of pretraining (Table 1), and in six (75%) questions ("1", "3", "5", "6", "7" and "8"), at the postqualification stage (Table 2).From the results presented in table 1, it is evident that the CHA participants in the training had low knowledge about organ / tissue donation, and it is possible to suggest the presence of uncertainties and unqualified information.

RESULTS
According to the Ministry of Health (MS), 12 the CHA should add familiarity and rapprochement with popular culture, with adequate and necessary technical knowledge and qualification, to promote integration between the community and other health professionals, as well as develop education and orientation actions, demystifying concepts about various health issues that come from common sense.However, for this to be effective, it is essential that the agents be included in the permanent education programs, aimed at PHC professionals, participating in continuous training.
With a key role in the consolidation of the UHS and its policies, the CHAs should be professionals capable of making profound transformations in the country's public health by providing a proactive stance in the pursuit of the objectives outlined by the National Policy on Popular Health Education in the scope of the UHS (PNEPS-UHS). 7,13-4Thus, it is a mistake not to aggregate the participation of these professionals in the educational actions on the donation-transplant process developed in Brazil.
However, it is inferred that dealing with such a subject is not in the list of themes that CHAs often address with the general population.Because of this, it is understood that it is essential to have the implementation of training and skills to effectively rely on the support of these professionals.In this direction, it is admitted that among the attributions of CIHDOTT members to act effectively in the interface of communication and work between intra-and extra-hospital health teams, including the achievement of permanent education, fostering the acquisition of knowledge about the subject. 15 could be observed in table 2, at the post-training moment, the participants presented a higher frequency of correctly pointed questions and, mainly, a decrease in the frequency of incorrect answers and unanswered questions.This fact suggests that, at the pre-qualification stage, the CHAs also had information based on beliefs, myths and taboos.

DISCUSSION
It should be borne in mind that health professionals, among whom CHAs is inserted, are not "Gods of wisdom."On the contrary, there are many "lay professionals" in various subjects, including the donation-transplant process.In 2016, the family refusal rate for organ / tissue donation in Brazil was 43%. 16[5][6] In view of the above, it is confirmed that the extension project developed showed the importance of the performance of the members of the CIHDOTT in the extra-hospital environment and, above all, the training was carried out with the CHA.These professionals are part of the CHA multiprofessional team that constantly carry out popular education activities 7,13-14 and, once they are wellinstrumented, through lifelong education, they can also sensitize and guide the population by deconstructing incoherent thoughts and promoting dialogue on the theme among the people in their family.
In view of the successful experience in developing the training of the CHA, in less than a month after the activity, the project members were contacted and invited to carry out the same activity with all the multiprofessional team working in a FHU of the city.Nevertheless, it is admitted that the activity presented limitations that are related to the fact that a single training moment was conducted with a relatively short duration and application of an evaluation questionnaire at the instant immediately after the activity.
In this direction, in view of the replication intentions of the project, methodological refinement is suggested in order to achieve even more positive results.Thus, it is recommended that it be sought to develop training at different times and, if possible, with the organization of practical stations, use of instructional videos and other pedagogical approaches that favor the assimilation of content.In addition, it is always important to remember the need to reserve a moment within the total time available to perform the evaluation of the effectiveness of the action, and it is equally important that such evaluation also occurs at different posttraining moments, seeking to ascertain the degree of knowledge delayed by the participants.
The pre-qualification assessment showed that CHA lacked a solid understanding of organ / tissue donation.However, it was verified that the permanent education made it possible to improve the theoreticalscientific knowledge of the agents in relation to the subject matter, allowing them to be able to disseminate consistent information among the general population.Thus, it is encouraged the development of more educational actions on the subject with the CHA of the different Brazilian municipalities, as well as in other countries that have these professionals among the workers of the CHA.

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To report the experience with the development of permanent education on the donation of organs / tissues to Community Health Agents.

Table 1 .
Distribution of the frequency of responses at the pre-qualification time.Cascavel (PR), Brazil, 2017.

Table 2 .
Distribution of the frequency of responses at the post-training moment.Cascavel (PR), Brazil, 2017.