Social Dimension Analysis Script (SDAS): Descriptive Inventory for Problem Based Learning in Health Area ()
1. Introduction
Health is produced and influenced by the social context and, according to this perspective, health problems, as well as their aggravating and protective factors, must also be considered in their biopsychosocial aspects (Garbois, Sodré, & Dalbello-Araujo, 2017) .
Facing this intrinsic complexity of the health-disease process and the care, it is indispensable the formation of health professionals with a critical, reflective, humanist and ethical view, capable of articulating actions of promotion, prevention, care and rehabilitation, including the human being in its totality. These professionals should also be able to communicate in health’s professional-patient relationship, as well as be prepared to act in the management of health services (Garbois et al., 2017; Mamede et al., 2001).
These attributes and abilities are not acquired naturally only by the passage of time and through work experience. These competences also depend on the educational process developed (Mamede et al., 2001) .
To reach this understanding, social responsibility in Medical Education shows that the training process must transcend the knowledge and treatment of diseases, including the context of people’s lives, as well as the social disparities and determinants of health, contributing to care equitable and integral (Thomas, 2014; Greer et al., 2018) .
In pursuit of this professional profile, there is a worldwide transition from traditional methodologies based on knowledge transmission, memorization, compartmentalized disciplines without articulation and teacher-centered teaching, to innovative methodologies, based on an integrated curriculum and student-centered teaching, such as “Problem Based Learning” (PBL) (Campos, Aguiar, & Belisário, 2012) .
PBL emerged in the 1960s in Canada, at Mc Master’s University in its Medical Course. Its philosophical basis is substantiated via action by experimentation and, second Dewey, meaningful learning occurs through reflection from live experience, through problems, situations that provoke imbalance, doubt, and unfamiliarity (Mamede et al., 2001) . For Barrows and Tamblyn, this pedagogical model aims at the development of clinical reasoning and skills for self-training, stimulating the acquisition and integration of new knowledge (Barrows & Tamblyn, 1980) . PBL gained space in the context of social, health and epistemological transformations of the last 25 years of the 20th century (Mamede et al., 2001) .
Thus, the cognitive basis of PBL has as its central focus the construction and apprehension of knowledge by the student, their active participation, their protagonism, and not the mere transmission of knowledge. The learning process in the PBL has characteristics and basic elements for its materialization such as: the problem, the tutorial group, the tutor, the individual study, small groups and the evaluation (Mamede et al., 2001) .
The curriculum at PBL focuses on the use of problems, cases studies to provoke cognitive imbalance. This trigger will be better then more you can cross disciplinary boundaries and present situations and events integrated with a real context. In curriculum using PBL, the curricular elements are organized from compositions such as: organic, morpho-functional, modular, basic-clinical, life cycles, etc. (Mamede et al., 2001) . In this sense, the problem is presented as the guiding thread of teaching-learning process in PBL and the more authentic the case and close to the real world, the more relevant and representative will be for the development of students learning. Because they are complex and situational, the problems will be solved mostly from the interdisciplinary perspective, sometimes being able to do so under the multiprofessional approach and understanding (Mamede et al., 2001; Aquilante, Silva, Avó, Gonçalves, & Souza, 2011; Jonassen & Hung, 2008) .
The construction of problems is presented in form of cases, with the purpose of stimulating the learning in groups, activating the previous knowledge, enabling a contextualized learning, involving several disciplines, motivating the student to search for knowledge and understanding of the situation, leading to a solution that may be convergent or divergent. The construction of problems should stimulate students’ cognitive growth throughout the course (Mamede et al., 2001; Aquilante et al., 2011) .
For each problem available to students, a tutor’s guide can be added, which contains, among other things, the specific objectives to be achieved during the tutorial process. The structure of the problem determines the proposed objectives and may favor meaningful learning (Mamede et al., 2001) .
In accepting reality in its complexity, problems in PBL should locate the individual in their open, non-hermetic relational space and, in health, develop training for care of the same scope (Stewart et al., 2010) . Considering the importance of the problem case and its nature, the following question emerged: How can you prepare meaningful problems that consider the context of people’s lives? In order to answer this question, we analyzed all the problems and tutorial guides of a public medical school in the state of São Paulo, Brazil. Thus, it was necessary to develop a script for rolls’ problem analysis that could serve as a basis for the construction of more complete and pedagogically more efficient problems.
Therefore, the objective of this paper is to present the method used to create an analysis tool, the Social Dimension Analysis Script (SDAS) built throughout dialectical analyze of paper problems used in PBL. The script was elaborated from the literature, illustrating results of current research, to bring the contribution to the processes of construction and analysis of the social dimension in health curricula that use the PBL.
This issue is organized in the following order: first shows how was the construction of the SDAS and after describes each of its nine axes as well as their respective elements. Then, the article discusses the SDAS’s contributions and the study limitations.
2. Method
It is a documentary analysis (Silva, Almeida, & Guindani, 2009) , with a qualitative approach, in which the Content Analysis method was adopted (Bardin, 2012) . As the delineation allowed to explain and clarify the question/problem, Clifford Geertz’s (Geertz, 2017) thick description was used, whose task was to identify the meanings attributed to the social dimension expressed in institutional documents, enabling its description and apprehension of symbolic meanings and acts, of the written as well as the realized (Silva et al., 2009; Geertz, 2017) .
The study scenario was a public college, in São Paulo’s state, in Brazil, where PBL is used in Systematized Educational Unit, which occurs from 1st to 4th year of medical course.
The SDAS was developed by the researchers, based on Brazilian studies and legislation related to local health problems and the current training of physicians in the country. The study of Barros and Lourenço (Barros & Lourenço, 2006) was based on the theoretical references: Health Needs (Cecílio, 2009) , Social Determinants of Health (Garbois et al., 2017) and the National Curriculum Guidelines for medical course (Resolução CNE/CES n˚ 3 de junho de 2014) .
After reading the references, a framework was created with key terms and axes corresponding to social dimension, to which concepts were added on the subject addressed, to develop a detailed description of the materials studied. From the bibliographical survey, in order to better approximate the diversity of problem situations used in a medical course by PBL, and thus better refine the central axes for the construction and analysis of a relevant problem, we have exhaustively read out 69 problems from 1st to 4th medical’s years and their respective tutorial guides.
These problems are paper cases with diverse structures, some report stories of health situations in different complexity level, student conversation, lifestyles description, media news, some with exams other not.
The analysis of investigated literature, problems and guides were made, through Content Analysis, in thematic modality, followed the stages of pre-analysis, in which central ideas were systematized; material exploration, which consisted in codification and transformation of the data into thematic contents; and contents treatment and analysis, which was proposed by inference and interpretations based on theoretical presuppositions of the investigated references (Bardin, 2012) . It resulted in a table containing two columns, the first with the keywords and the second with the sense cores. These themes were dialogued with literature and had their theoretical foundation based on their relevance to person’s quality of life and health needs. Then, there were listed 9 important axes for health care.
3. Results and Discussion
The professionals’ training, contextualized with reality, focused on promotion, prevention, rehabilitation and study of social context led to the creation of SDAS, a descriptive inventory with elements corresponding to social dimension for evaluation and construction of problems in PBL.
Social Dimension Analysis Script (SDAS) consists of nine axes that characterize the profile of characters and contexts of the problems, being presented in Table 10. Each axis presents some elements that can be approached in PBL’s problems and cases in courses for health area. Obviously, other elements can be included and these should be organized over courses’ years and grades, according to their degree of complexity and the desired competence in each moment of training.
Next, we present the description and detail of axes and elements of social dimension that compose the Social Dimension Analysis Script (SDAS), discussing each axis with the current literature. It can be seen that some elements may be specific to Brazilian reality, but can be easily adapted for use in different contexts, since they refer to aspects common to health and human relations. Other elements can still be included depending on the desired competence at each point in training.
3.1. Identification
Refers to recognition and/or localization of demographic and socioeconomic data regarding the peculiarities of individuals, externalizing and preserving their identity. It is assumed that people are subjects of problems, and it is important to qualify their position and social condition (Barros & Lourenço, 2006; Souza & Ciampa, 2017) .
The elements that can be approached in this axis, which refers to the characterization of the subjects, are presented in Table 1.
Space: refers to the territory and its specificities, which represent social, cultural and territorial identity of people. It indicates the space where social, power, cultural, political and economic relations are materialized, as well as the networks of relationships formed by the local morbidity and mortality factors. It corresponds to the conjuncture, structure, network of services, modes of production, represented by diversity, plurality and by social and individual conditions to which individuals are subjected (Política Nacional de Assistência Social, Brasil, 2005; Jaramillo, 2018; Barros & Lourenço, 2006 ).
The elements that can be addressed in this axis, which refers to the characterization of contexts, are presented in Table 2.
Areas of competence: Ability to mobilize cognitive, affective and psychomotor attributes that allow approaching/solving complex situations related to professional practice, learning to observe the problem. Refers to reading and qualified professional responses determined by knowledge, skills, attitudes, articulated to individual and collective needs and management in health area, respecting and valuing the individual in its entirety (Faculdade de Medicina de Marília, 2014; Lima, 2005) .
The elements that can be addressed in this axis, which refers to the characterization of the context, are presented in Table 3.
Health surveillance: A set of interdisciplinary actions, through articulated and intersectoral practices in development of promotion, prevention, care and rehabilitation actions, seeking improvements in living conditions and health protection. Emphasis on health problems, that require continuous attention and monitoring, as well as actions on the territory (Teixeira et al., 2000; Faculdade de Medicina de Marília, 2014) .
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Table 1. Identification axis of Social Dimension Analysis Script (SDAS) and its elements: age, gender, ethnicity, religion, marital status, schooling, profession, naturalness and provenance.
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Table 2. Space axis of Social Dimension Analysis Script (SDAS) and its elements: territory, location, risk areas, social support equipment, intersectoriality, teaching/service integration.
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Table 3. Areas of competence axis of Social Dimension Analysis Script (SDAS) and its elements: individual care, collective care, organization and management of health work.
The elements that can be addressed in this axis, which refers to the characterization of the contexts, are presented in Table 4.
Living conditions: Expresses health needs, individual and collective demands in responses to lifestyles and work influenced by social, economic, cultural, psychological, behavioral, psychosocial, ethnic, political, material circumstances, etc., which establish a relationship with the quality of life, work, health and people’s behavior (Garbois et al., 2017; Cecílio, 2009) .
The elements that can be addressed in this axis, which refers to the characterization of contexts, are presented in Table 5.
Access to health services: The need to have access and be able to consume health technology, capable of improving and prolonging life. These technologies are to acceptance, hospitalization, therapeutic, as well as diagnostic and imaging tests. Access to the set of available technologies will be in accordance with the individual and collective needs expressed in provision of health services (Cecílio, 2009) .
The elements of social dimension addressed in this axis, which refers to the characterization of contexts, are presented in Table 6.
Bonding: Corresponds to the constitution of the link between the user, the team and/or professional in a relationship of reference and trust. An essential device for establishing and strengthening relationships among the actors involved in the health/illness/care process, contributing to the users’ access to health actions and services, in a humanized way. It is influenced by such factors as communication, empathy and professional ethics (Cecílio, 2009) .
The elements of social dimension that can be addressed in this axis, which refers to the characterization of contexts, are presented in Table 7.
Autonomy: Regarding the freedom people need to lead their lives. Health information and education are elements of this construction process. It refers to the ability of the individual and/or social groups to minister and manage life, made possible by decision-making in the exercise of freedom (Cecílio, 2009) .
The elements of social dimension addressed in this axis, which refers to the characterization of contexts, are presented in Table 8.
Diversities and vulnerabilities: Refers to the pluralities and fragilities determined by physical factors; economic; social; life cycles; fragility of bonds of affectivity, belonging and sociability; ethnic, cultural or gender stigmatized identities; handicap resulting from disabilities; use of psychoactive substances; different forms of violence from the family nucleus, groups and individuals. They represent the characteristics and social aspects related to condition of life and personal situation that favor exclusion (Brasil, 2005; Barroco, 2016; Siqueira & Castro, 2017) .
The elements of social dimension addressed in this axis, which refers to the characterization of contexts, are presented in Table 9.
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Table 4. Health surveillance axis of Social Dimension Analysis Script (SDAS) and its elements: promotion action, prevention action, assistance action, rehabilitation action.
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Table 5. Living conditions axis of Social Dimension Analysis Script (SDAS) and its elements: socio-environmental aspects (living conditions and daily habits; income, benefits, retirement; financial aspects; hygiene/care; environment) and psychosocial aspects (religion/spirituality; structure/dynamics and family relationships; psychiatric disorders; mental, psychological and life cycle phases; social support; elements of mental state and conflicts, losses, separations, situations of stress, death, mourning).
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Table 6. Access to health services axis of Social Dimension Analysis Script (SDAS) and its elements: exams, medication, basic network, secondary network, tertiary network, emergency mobile service, specialties consultations, access to information/health education and accessibility.
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Table 7. Bonding axis of Social Dimension Analysis Script (SDAS) and its elements: communication, ethics, empathy/solidarity/alterity, qualified listening and adherence to treatment.
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Table 8. Autonomy axis of Social Dimension Analysis Script (SDAS) and its elements: citizenship and social participation, mobility, dependence X independence and media and social networks.
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Table 9. Diversities and vulnerabilities axis of Social Dimension Analysis Script (SDAS) and its elements: prejudice and discrimination, racism, violence, vulnerable groups and social minorities and cultural diversity.
3.2. Use of Social Dimension Analysis Script (SDAS) in Problem Analysis and Tutoring Guides for a Medical Course
The results related to characterization of the characters evidenced information deficits. Fundamental data such as age, ethnicity, schooling, religion, marital status and profession, which construct the individual’s identity and interfere with health/disease process, were omitted in several situations.
In addition, several elements did not impact reality. The results on the characterization of contexts explained in several situations did not correspond to the real territory, since the areas of risks were poorly explored in their characteristics, recognizing their limits and potentialities. Social equipment and intersectoriality were little activated in attendance the health needs in search for integral care. These information gaps can interfere in representation of social dimension by compromising logical reasoning and the integration of this dimension into the others that comprise integrality of the individual and therefore the integral approach to care practices.
It should be noted that Social Dimension Analysis Script (SDAS) has proved to be a powerful instrument for identifying the necessary elements, qualifying them, organizing the data, indicating the feasibility and potential for use in other studies that intend to characterize and analyze the social dimension in curricula as well as in the process of elaborating problems, as guiding the axes and important elements for training in health area.
The instrument allows the organization of content, performances, activities (depending on the curriculum proposal) in order to visualize at what time of the courses, in which scenarios and/or triggers each theme is being worked out with the students, so, in their training relevant issues are addressed more integrally, in a more comprehensive way, and curriculum management is facilitated.
The complete Social Dimension Analysis Script (SDAS) is shown in Table 10.
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Table 10. Social Dimension Analysis Script (SDAS).
4. Conclusion
This study is the beginning of a reflection to better integrate the social dimension in PBL problems. The originality of this whole material is especially due to the creation of the script, a descriptive inventory of the elements corresponding to this social dimension. An investigation of this nature is configured as an in-depth study of the observed reality. Thus, Social Dimension Analysis Script (SDAS), the descriptive inventory, the fruit of this study, as well as the detailed description of each of its axes and elements can contribute to the evaluation of social dimension present in problems of curricula that use PBL, as well as the construction of new cases and problems, being able to serve as a guiding for elements to be inserted in the Curricular Matrix of Pedagogical Projects for Courses, considering the longitudinality and transversality of performances/ competences/contents.
It stands out a contribution to the identification of different variables and thematic categories for understanding the theme. This contribution makes it possible to understand and expand the insertion of the social dimension in the curricula giving visibility to the theme.
By using the instrument, other institutions can make adaptations according to the specificities of local realities, with diversity in public policies, epidemiological data, health needs, services offered, curricula of courses, habits and cultures. Despite these possible differences, the script presents some universal guidelines, relating to human beings, their social relations, cultural and environmental context. Thus, the same elements are usually important in training of physicians and other health professionals anywhere in the world.
Regarding the limitations, the presented study cannot be considered final. Investigations need be carried about the effectiveness of the SDAS as support for paper case construction, its handle and the results of student learning acquisition evaluation. There are also possibilities for further studies in other learning scenarios and in other institutions with different methodologies.