The Teaching of Integrative and Complementary Practices in the Inter-Unit Modality as Curriculum Innovation

Abstract

Knowing the impact of a hybrid discipline and inter-units of integrative and complementary practices for academics at the University of São Paulo. Cross-sectional quantitative research, with 62 students from USP, São Paulo, Brazil. Data collection between August and December 2021, with questionnaires via Google Form and data analysis using Excel (2016) and Likert Scale. Prevailed students aged between 22 and 25 years (38.5%), from the Obstetrics course (25.6%), with motivation (48.71%) to deepen their knowledge, adequate workload (75.0%), most interesting theme Yoga (75.0%), excellent (40.0%) evaluation strategy, and satisfied with the optional modality (65%) and inter-unit (90.0%) with recommendation of new classes (100.0%). The results showed that it was a positive experience for the students, which strengthens the implementation of the discipline in other courses.

1. Introduction

The Integrative and Complementary Health Practices (PICS) encompass a set of health actions that aim to “encourage natural mechanisms for disease prevention, health promotion and recovery through effective and safe technologies”. These practices emphasize “welcoming listening, the development of the therapeutic bond and the integration of the human being with the environment and society”. Coming from different geographic, cultural, and historical origins, the PICS are based on the model of humanized care and centered on the integrality of the individual [1].

In the Brazilian scenario, from the creation of the Unified Health System (SUS) in the 1980s, the legitimization and institutionalization of PICS approaches were envisioned, while states and municipalities acquired greater autonomy in their policies and actions in health, with decentralization and popular participation. In this sense, the National Policy on Integrative and Complementary Practices (PNPIC) within the scope of the SUS was constituted based on the guidelines and recommendations of several national health conferences and also guided by the recommendations of the World Health Organization (WHO) [2].

In view of this scenario, the PICS were institutionalized in the SUS through the PNPIC, approved by Ordinance GM/MS No. 971 on May 3, 2006 (BRASIL, 2006). The policy supports a set of health practices based on the use of light technologies that encourage the person’s own recovery potential. Given the cost-effectiveness, the PICS are excellent therapeutic approaches for health care in the Unified Health System, which transport other knowledge and practices into the conventional model of care, in addition to already being on the rise and increasing visibility [2].

In this way, specialist authors in the area even reinforce the innovation of the PICS to the conventional model of health, permeating that.

[…] “This advance can be understood as an expression of a movement that identifies itself with new ways of learning and practicing health, since these practices are characterized by interdisciplinarity and unique languages, which in general oppose each other to the highly technological vision of health that prevails in market society, dominated by health plans, whose main objective is to generate profit and fragment patient treatment into specialties that do not handle the totality of human beings in search of a remedy for their ills” (TELESI JÚNIOR, 2016, p. 99) [3].

Parallel to this issue, humanization in health has been envisaged as a quality benchmark for comprehensive care, allowing it to overcome its technical and scientific vision and consider the individuality, dignity and rights of the health-care user.

Health, in addition to recognizing the professional as a person, establishes an individual-individual care relationship [4].

Still, it is possible to mention the importance of disciplinary plurality, which the authors point out as “the path to a broader and more global view of the human being”, in relation to subjectivity in health practices and care. The PICS work precisely in the sense of contributing to disciplinary integration, with its immense variety of resources, since it “descends from an ancient tradition of continued and practically unchanged use of the same technological resources, guided by an interdisciplinary nature”. This allows therefore to note the sustainability and importance of the practices [3].

However, when analyzing the scenario of Integrative and Complementary Practices in undergraduate courses in the health area in Brazil, its presence as a discipline appears to be incipient, revealing a relative lack of knowledge on the part of most professionals. For studies on the subject, according to Tesser, Sousa, and Nascimento (2018), training in PIC in Brazil is insufficient and diffuse, with limitations in supply and quality, proving to be initial and modest, far from the experience of other countries [5].

A study exemplifying this issue estimates that less than 10% of the medical courses offered in the country included PICS content in their curricula, while in the international scenario this number reached up to 80%, indicating that the teaching of PICS has been gradually introduced in courses of graduation in the area of health and, in a smaller number, in those of specialization [6].

The aforementioned perspectives, moreover, are in line with the third goal of the Healthy Development Goals, “to ensure a healthy life and the promotion of well-being for all, at all ages”, by the PICS contemplating the fields of prevention, promotion, maintenance, and recovery of health, aiming at a model of humanized care centered on the integrality of the individual [7].

Similarly, teaching and training in the PICS are also in accordance with the National Curriculum Guidelines (DCNs), which provide changes in the way of teaching and learning, recommending active learning methods and the incorporation of teaching technologies, and at the same time point to the importance of critical and reflective training, committed to the institution of health policies and the needs of the population [8].

Given the above, the incipient training of Integrative and Complementary Health Practices in Brazilian universities, the congruence with the Sustainable Development Goals, and the nuances of the National Curriculum Guidelines reveal the importance of studying practices as an undergraduate discipline. Thus, emerged the present study with the objective of knowing the impact of a hybrid, innovative discipline, offered in the inter-unit mode aimed at integrative and complementary practices for academics of five courses in the area of health at the University of São Paulo.

2. Method

This is a cross-sectional quantitative study, carried out with 62 students enrolled in the undergraduate course called “Comprehensive care throughout the life cycle in the light of Integrative Practices”. The discipline was elaborated, submitted, and approved in a public notice by the University of São Paulo (USP) whose proposal was to build opportunities for modern, hybrid, intra- and inter-institutional training, which would satisfy the recent demands of contemporary society in different areas of knowledge, with a view to comprehensive care, in line with the promotion of well-being for all and at all ages.

The discipline was developed in the second half of 2021 as an optional course, with a workload of 60 hours, in the hybrid format, with 16 meetings of 4 hours each for undergraduates of the Obstetrics, Gerontology, Nursing, Pharmacy, and Medicine courses at USP. It was coordinated by the campus of the São Paulo School of Arts, Sciences and Humanities at USP.

The study population consisted of all 62 enrolled students. Throughout the course, there were some dropouts, and the sample consisted of 46 participants. According to the flowchart shown inFigure 1.

Figure 1.

Represents flow for sample size. Brazil, 2022.

For data collection, which took place between August and December 2021, two questionnaires were prepared and applied via Google Form. The first, carried out before the start of the first class, with the aim of characterizing the students, consisted of 12 questions covering age, profession, year of admission to the university, existence of previous contact with some of the integrative and complementary practices in health (PICS) that justified their interest in enrolling in the course, reason for taking the course, and expectations regarding classes scheduled for the semester.

The second questionnaire, applied on the last day of class, contained 26 questions, through the Google Forms platform. This had the purpose of knowing the impact of the discipline developed for the students. Questions were included regarding workload, topics and content covered, didactic strategy, evaluation methodology, and face-to-face visits and in relation to the hybrid teaching model, in addition to requesting suggestions for possible improvements and new offer of the discipline.

In ethical terms, students were invited to participate in the present study, and data collection took place only upon acceptance and signing of the Free and Informed Commitment Term. The research was submitted and approved by the Ethics and Research Committee of the School of Arts, Sciences and Humanities of the University of São Paulo, under number 5.048.613, complying with all ethical principles required for scientific studies, including voluntary participation, privacy of participants, and confidentiality of information, in accordance with the Resolution of the National Health Council (CNS) n° 466/2012 and n° 510/2016 related to Research with Human Beings.

Dice were analyzed in Microsoft Excel 2016, using absolute numbers and proportions. The independent variables concern the student’s profile (age, course, year of admission, profession, period of study, and fields of study), previous contact with integrative and complementary practices (undergraduate discipline, specialization, health services, and others), and students’ perception of the discipline (workload, content covered, professors in charge, optional modality, remote teaching, inter-unit modality, topic considered the most relevant, and topic offered with better didactics). To analyze the evaluation strategy proposed in the course, a Likert scale was used, developed by the researchers, which ranged from 0 to 10, with 0 considered as poor and 10 as excellent. Finally, Word Clouds (NP) were used, which are graphic resources that simulate the frequency of terms in hypertexts, to identify what it meant for the student to have attended the discipline “Comprehensive care throughout the life cycle in the light of Integrative Practices”.

3. Results

The results presented below refer to data collected from 39 students participating in the first stage of the research and 20 in the second, as represented in the Figure 1.

It is worth mentioning that 122 students expressed interest in the discipline; however, only 60 places could be offered, with authorization for two exchange students, totaling the number to 62 students enrolled. After presenting the evaluation strategy to be adopted, due to difficulty in completing all the tasks, 16 students dropped out, with 46 remaining until the end of the activities. The sample participating in the research consisted of the total number of students present on the first day of class and who answered the first questionnaire and the total also present on the last day of class, who answered the second questionnaire, which made up the representative sample.

The results presented in Table 1 show that most participants were between 22 and 25 years old (38.5%), followed by 18 to 21 years old (33.3%), 30 years old or more (23.1%), and 26 to 29 years old (5 .12%).

Characterization of enrolled students	N = 39
	N	%
Age
18 to 21 years old	13	33.3
22 to 25 years old	15	38.5
26 to 29 years old	2	5.1
30 years or more	9	23.1
Course
Midwifery	10	25.64
Gerontology	6	15.38
Nursing	5	12.82
Pharmacy	5	12.82
Nutrition	3	7.69
Psychology	2	5.12
Others	8	20.51
Year of joining the course
2016	3	7.69
2017	5	12.58
2018	7	17.94
2019	11	28.2
2020	4	10.25
2021	6	15.38
Profession
Student	25	64.1
Other professionals	14	35.9
Period of study
1st or 2nd semester	3	15
3rd or 4th semester	1	5
5th or 6th semester	7	35
7th or 8th semester	7	35
Other semesters	2	10
Fields of study
School of Arts, Science and Humanities	11	55
School of Nursing	3	15
Faculty of Public Health	3	15
Others	3	15

Table 1.

Characterization of enrolled students, according to age, course, year of admission, profession, course period, and study campus. São Paulo-SP, Brazil, 2021. (n = 39 n = 20).

Regarding the proportion of students from the different courses involved, it was observed that most (25.64%) were from the Obstetrics course, followed by Gerontology (15.38%), Nursing and Pharmacy (12.82%), Nutrition (7.69%), and Psychology (5.12%). There was also participation, to a lesser extent, by those enrolled in other USP courses, namely, Pedagogy, Dentistry, and Occupational Therapy and Speech Therapy named as others, represented together (20.51%).

As for the most prevalent year of admission to graduation, it was 2019 (28.20%), followed by 2018 (17.94%) and 2021 (15.38%). Of the participants, 64.10% were only students, and 35.89% already worked as a gerontologist, doula, researcher, floral therapist, teacher, dentist, and self-employed.

It can also be seen in Table 1 that among the students from the different USP campuses involved, the participation (55%) of those from the School of Arts, Sciences and Humanities stood out, followed by the School of Nursing and the Faculty of Public Health and other campuses. From USP (15%), where the majority (70%) of the undergraduates was between the 5th and 8th semester of their course.

The majority (82.1%) of the students had already had previous contact with some of the program’s integrative practices, where 37.7% were in health services, 31.3% with content within other undergraduate disciplines, and 15.38% in specialization, personal life, or study projects, according to the Figure 2.

Figure 2.

Students enrolled in the course, according to previous contact with integrative and complementary health practices. São Paulo, SP, Brazil, 2021.

Regarding the students’ perception of the course’s syllabus and content, most considered the workload and the contents covered adequate (75% and 60%, respectively) and that the professors responsible for the course were excellent (60%) and were satisfied with regard to the discipline being optional (65%) and offered inter-unit (90%), and 80% reported that there were no losses regarding the hybrid modality (Table 2).

Enrolled students’ perception	N = 39
	N	%
Workload
Appropriate	15	75
Good	4	20
Inadequate	1	5
Insufficient	0	0
Content covered
Appropriate	12	60
Good	8	40
Inadequate	0	0
Insufficient	0	0
Responsible teachers
Great	18	90
Good	2	10
Regular	0	0
Bad	0	0
Optional modality
Satisfied	13	65
Indifferent	5	25
Dissatisfied	2	10
Teaching remote
There were losses	16	80
There were no damage	4	20
Inter-unit modality
Satisfied	18	90
Indifferent	2	10
Dissatisfied	0	0

Table 2.

Students’ perception of the workload, content covered, professors in charge, optional modality, remote teaching, and inter-units of the discipline “Integral Care throughout the life cycle in the light of Integrative Practices”. Sao Paulo, SP, Brazil (N = 39).

The topics considered the most interesting in the students’ view were Yoga (75%), followed by Acupuncture (65.0%), Floral Therapy (65.0%), and Auriculotherapy (65.0%). Also, referring to the theme offered with better didactics, Yoga was again the most cited (65.0%), followed by Aromatherapy/essential oils (60.0%), search for scientific evidence (55.0%), Map of evidence of PICs (50.0%), Traditional Chinese Medicine (50.0%), Bioenergetic (50.0%), Reflexology (50.0%), and Shantala (50.0%) (data not shown in table).

Regarding the evaluation strategy proposed in the course, most students scored 9 (40%) and 8 (20%) on the Likert Scale. In addition, the respondents unanimously agreed to recommend the subject for the next classes (100%) (data not shown in the table).

It is noteworthy that among the questions present in the questionnaire, the last one referred to the student’s one-word description of the meaning for him of having the subject studied, with “knowledge” being the most prevalent, followed by “improvement”, “transformation,” and “comprehensiveness” (Figure 3).

Figure 3.

Cloud of words “meaning when attending the Comprehensive Care course throughout the life cycle in the light of Integrative Practices”, São Paulo -SP, Brazil, 2021.

4. Discussion

The school environment has proven to be an opportune place for co-responsibility about the health process recognized as a social space where general information is available, in addition to allowing education for health [9].

Important initiatives corroborate the importance of developing strategies to strengthen integrative and complementary practices in health. The Project for Strengthening the National Policy on Integrative and Complementary Health Practices (PNPIC) advanced in 2022 with the perspective of designing an updated picture of the implementation of PICS in the regions of Brazil and of creating, in partnership with universities and other organizations, possibilities for training of health professionals and technical consultancy to support states and municipalities [10].

According to partial data obtained for the year 2019, PICS were offered in 17,335 services of the Health Care Network and distributed in 4297 municipalities (77%). There was an increase of 16% (2860) in the number of services compared to 2017, where 15,603 (90%) are in primary health care [11].

There are challenges in the health and health-teaching scenarios. The incorporation of integrative practices in the training of future professionals can be an important strategy to awaken, strengthen, and consolidate comprehensive care.

On the one hand, there is a growing demand for new therapeutic practices in health services, especially after 2006, with the publication of the National Policy on Integrative and Complementary Practices (PNPIC) by the Ministry of Health. The patients often seek differentiated care, beyond the conventional, but the professional is not always prepared to offer it, according to the individual needs of the population served [12].

However, the offer of PICs in undergraduate courses, in fact, has been incipient, since the number of health courses that have their teaching in their formal curriculum is reduced, and when offered, they are optional, leading to a fragility of formal education on these practices [13].

The present research showed that the proposal for the discipline integrated more courses, in addition to those of Obstetrics and Gerontology on the campus of the School of Arts, Sciences and Humanities of the University of São Paulo, with content on the different integrative and complementary practices in health, and provided an opportunity common to the different courses at USP, with a focus on promoting a more comprehensive education and with the possibility of qualification beyond the already established technical preparation. In addition, the hybrid modality offered was in line with the National Curriculum Guidelines (DCNs) that encourage changes in the way of teaching and learning, which recommend active learning methods and the incorporation of teaching technologies [8].

In this sense, the data found from the implementation of the curriculum with the insertion of the subject “Integral Care throughout the life cycle in the light of Integrative Practices” made it possible to recognize that there was an impact for enrolled students, since, when comparing the responses from the initial questionnaire applied with those from the second, it was evident that the expectations cast on the discipline were met, with emphasis on access to scientific evidence for the basis of professional practice and health care.

In view of this, the completion of the discipline provided favorable considerations to the participants, when they launched positive perspectives regarding the workload, the themes and contents addressed, teachers involved, didactics, evaluation methodology, and hybrid model offered, in addition to the face-to-face visits that took place during the course semester.

The results of the present study are in line with the findings in the literature, where they show positive points in the perception of PICs as a new field for professional performance14 Otherwise, it is also noted that.

[…] “the insertion of disciplines, focused on PICS, in the curricular matrices of higher education, will provide the professional with lines of work that, sometimes, become unknown, due to the direction of the courses for treatments conservative, in addition to providing them with forms of patient care in a more humane and holistic way” [14].

According to the understanding of the undergraduates about the discipline developed, the proposal was innovative, by promoting interaction and connection between courses in the health area, by configuring inter-units, putting an end to interdisciplinarity. This perspective is discussed by authors who defend disciplinary plurality as a way to reach a broader, holistic, and global perspective of the individual. The result of this process then forms the exchange of knowledge and knowledge sharing [15].

In the same way, offering the discipline in the inter-unit mode, in addition to strengthening multidisciplinarity, could offer knowledge about the PICS made available by the Unified Health System, which are little publicized within the scope of the University of São Paulo, as well as in other public or even private institutions. In view of this, despite being advocated in the policies of the Unified Health System, as well as by the Federal Council of Nursing (COFEN), studies show a shortage of public and private institutions that offer disciplines in undergraduate courses on these practices in the state of São Paulo, location of the USP unit where the discipline involved in this research was developed [16].

For Santos and other collaborators (2022), teaching PICS at undergraduate level means contributing to the implementation of SUS principles, in addition to boosting comprehensive health care17 Thus,

[…] “the presentation of the PICS during graduation occurs as an awareness of the formation of individualized care, which follows bioethical principles and valuing life and which is always looking for new knowledge, but which is not limited to scientific publications, given the incipience of these to assess contexts and individualized care. Within professional experiences, learning about the importance of providing comprehensive care stands out. This offer is essential for the quality of health care, in order to break with the hospital-centered and fragmented model, in addition to re-signifying the concept of health by the users themselves. By observing the multiple field of action, the discipline manages to be useful for all health professionals, regardless of the area they choose to work in” [17].

According to the view of some authors, the multiple field of action, regardless of the area in which the health professional works, the preparation for comprehensive care indicates adherence to a teaching that contains content that supports this care, which is mandatory in training and not as an option.

Therefore, it is known that the discipline “Integral care throughout the life cycle in the light of Integrative Practices” has met with excellence the objectives and goals proposed in its project, positively impacting the training of students, giving visibility to the University of São Paulo, and facing Integrative and Complementary Practices within the scope of the triad: teaching, research, and extension.

A limitation of the study is the fact that not all of the students responded, since only those present on the first and last day participated in the study. Therefore, the findings favor that new courses include the content of integrative practices as a subject in the curriculum so that more students take ownership of recognized and applicable practices for differentiated health care, as well as be able, as professionals, to encourage the provision of PICS as a complementary resource for the health and well-being of the population served.

5. Conclusion

The study showed that the proposal for an innovative discipline, in the interdisciplinary modality, on Integrative and Complementary Practices in Health, offered at the University of São Paulo, was considered positive for students in the health area, with a positive impact on their training. They highlighted as a positive point the workload, topics and contents addressed, teachers involved, didactics of the class taught, and evaluation strategy.

In this way, the importance of expanding content focused on the PICS to other undergraduate health courses and other institutions is verified, especially in the interdisciplinary and mandatory nature, given the limited offer among universities, even 15 years after the institutionalization of the practices in the Unified Health in Brazil.

Acknowledgments

The development of the project and presentation of the results, which provided the presentation of this chapter, were possible with funding from the Program to Stimulate Modernization and Reformulation of Structures.

Curriculum of USP Undergraduate Courses - New Curricula for a New Time.

Notice PRG 01/2020-2021, as well as the participation of all those involved, students, teachers, monitors, and support. Our acknowledgment and thanks.