3.1 Health courses at the Vale São Francisco

In this theme, the year of creation and curricular reform, the total workload, the profile of graduates and objectives were listed, through the Pedagogical Master Plans. Eight health courses were identified, five at a university identified as U1 and three at U2. The only common course at the two universities is Nursing, which will be identified as N1 and N2. The Pedagogical Master Plans were written between 2008 and 2013, with the Medical course document having the oldest reformulation (2008), and the N1 plan, the most recent (2013), as can be seen in Table 1.

The first National Curricular Guidelines for Health courses were launched between 2001 and 2004. However, Medicine and Pharmacy courses updated their Master Plans in 2008 and 2012, respectively, and did not refer to the new National Curricular Guidelines, which are from 2014 and 2017. This fact reinforces, therefore, the need for periodic and permanent evaluation of the Master Plans as a strategy to overcome the identified gaps.

As for the objectives of the courses, the universities describe the ethical and generalist training, with a focus on the holistic view towards the individuals who need their assistance, as described below:

Ensure that undergraduate students in Pharmaceutical Sciences have generalist training, enabling them to work at all levels of health care, with a broad and global vision, respecting the ethical and bioethical, moral, religious and socio-cultural principles of the individual and the community, with the objective of preventing, preserving and promoting individual and collective health. (Pharmacy Pedagogical Master Plan, 2012).

Train professional nurses able to take care of the human being, family, groups and community in situations of health and illness, within the scope of management, administration, supervision and evaluation in the Unified Health System (Nursing Pedagogical Master Plan, N2, 2011).

Training of a health professional able to work in an interdisciplinary team, with an emphasis on integrality in patient care (Physiotherapy Master Plan, 2010).

Train nurses-citizens who use ethics and scientific technical knowledge to work in the various areas of knowledge and provide integral care to the health of the individual, family and community (Nursing Master Plan, N1, 2013).

Train professionals able to critically analyze the social reality in which they live; ensure generalist, humanistic and critical training, qualifying academic-professional intervention, based on scientific rigor, philosophical reflection and ethical conduct (Physical Education Master Plan, 2012).

Formation of an ethical and technically competent professional, without humanistic prejudice, and able to participate effectively in the social transformations of this region (Medical Course Master Plan, 2008).

Train generalist nutritionists, capable of applying the science of Food and Nutrition to improve the health and quality of life of the population in the region and in Brazil (Nutrition Master Plan, 2013).

Train critical, reflective and socially committed professionals, capable of building and contextualizing knowledge and practices, promoting and disseminating knowledge in a systematic way to communities (Psychology Master Plan, 2010).

During the stage of documentary analysis, it was noticed the commitment of universities to describe the importance of training an ethical professional, committed to the integrality of the health of individuals and the community. Thus, it is possible to affirm that the Master Plans of the courses studied are in conformity with the National Curricular Guidelines and, in this sense, reflect the real need of the population for good care. This commitment was also described in a study conducted at a Universidade do Centro-Oeste, in which it was observed that all the analyzed Master Plans met the general premises of the National Curricular Guidelines and the policies that induce health training (^{Moraes & Costa, 2016}).

However, even with the Master Plan built with the concern to meet the National Curricular Guidelines, there is still a major obstacle to be faced: its implementation in practice. The proposed National Curricular Guidelines for the training of health professionals have achieved their goals and are on the path of building a culture of significant change. However, it is important to be aware that it is necessary to overcome this obstacle mentioned above (^{Keller-Franco, Kuntze, & Costa, 2012}), in order to stimulate the most efficient actions and practices in the didactic formulation process of the Master Plans of the courses analyzed.

Another aspect that emerged during the analysis of these documents was the skills and competences that Health courses bring in their Master Plans, which will be described in the next topic.

3.2 Skills and competences necessary for professional training towards an effective service to people with disabilities

Health care for people with disabilities is identified as flawed, both due to ineffective communication (^{Batista, 2012}), and due to architectural inaccessibility (^{Martins et al., 2015}), as well as presumptions and perceptions about the disability, which can even cause threats to that person’s health (^{Shakespeare, Iezzoni, & Groce, 2009}).

One of the possibilities of minimizing these barriers to accessing health services would be educational organizations, which train future professionals, include these thematic contents in their curricula and that health services encourage the training of their professionals in order to acquire communicative skills. In addition, they should adapt the physical structure, so that the needs of these individuals, in the hospital environment, are met in an integral and humanized way (^{Martins et al., 2015}).

As perceived, the minimization of these barriers demands an inclusive and integral training so that the future health professionals can develop the aptitude in the care of all individuals who need their care. However, what is noticeable in the training of professionals, in general, is that there is an empty space, especially with regard to training in the context of health care for people with disabilities (^{Costa, 2015}). There is, then, a dichotomy between what is expected in the face of integral care and the effective training of health professionals. For this reason, it is necessary to understand that competencies and skills are being described by universities and how educational institutions influence the integral and universal care of subjects with disabilities.

Table 2 describes the general skills and competences that health professionals should have, according to the analyzed Master Plans.

In view of the competencies and skills presented, it is clear that decision-making, communication and multi-professional performance were the competencies common to all health professionals.

A pilot study conducted by ^{Castro, Rowe, Andrade and Cyrino (2017)} showed that generalist skills, such as those found in this research, can also be used to train health professionals who meet the health needs of people with disabilities. ^{Kirshner and Curry (2009)} were more specific and proposed six essential skills for disability-related training: (1) Framing disability in the context of human diversity throughout life, within the social and cultural environments; (2) Disability assessment training and the real consequence of health conditions; (3) Training for behavioral care when interacting with people with disabilities; (4) Learning about other health professionals, to form integrated teams; (5) Understanding the legal aspects along with the principles of universal design; and (6) Customer-centered care approach, including their perception of quality of life. Some of these competencies corroborate those found in this research. In this sense, it is expected that professionals have sufficient skills and abilities to serve people with disabilities.

To reinforce this training, with a view to the health of people with disabilities, the disciplines and discussions about their health in the Master Plans were also evaluated, and the results are presented in the next category.

3.3 Disciplines offer and discussions related to the health of persons with disabilities in the master plans of health courses

In view of the process of training health professionals supported by the literature, it is important to analyze how these professionals are being trained for the health care of people with disabilities. From this perception, we sought to identify which courses offered Brazilian Sign Language as an optional or compulsory discipline; whether they mentioned, in their bibliographic references, the National Health Policy for Persons with Disabilities (2008, 2010) in its two versions, in addition to disciplines that described, in the course syllabus, the content related to the care provided to people with disabilities. The results are shown in Table 3 below.

In the case of teaching Brazilian Sign Language in the health courses surveyed, 62.5% of the Master Plans do not have Brazilian Sign Language as an optional discipline, and none of them presents it as a compulsory one. This result is contrary to ^{Decree no. 5.626, of December 22, 2005}, which establishes that, in teacher training courses for the exercise of teaching, at High School and Higher Education, and, in Speech Therapy courses, sign language must be inserted as a compulsory discipline and, in the other Higher and Professional Education courses, it must be optional.

There is divergence when observing the teaching of Brazilian Sign Language and the proposal of the National Curricular Guidelines, in which one of the competences and skills that must be guaranteed in the training of the health professional is communication. All health courses analyzed, except Physical Education, have, in the National Curricular Guidelines, the following text:

Communication: health professionals must be accessible and must maintain the confidentiality of the information entrusted to them, when interacting with other health professionals and the general public. Communication involves verbal, non-verbal communication as well as reading and writing skills; mastering at least one foreign language and communication and information technologies (^{Opinion no. 1.133, 2001}; ^{Opinion no. 3, 2001}; ^{Resolution no. 5, 2001}; ^{Resolution no. 4, 2002}; ^{Resolution no. 5, 2011}; ^{Resolution no. 3, 2014}; ^{Resolution no. 6, 2017}).

This excerpt shows the importance of communication in the training process of these professionals and intensifies the need to attend, not only to the National Curricular Guidelines, but also to the process of integrality and humanization of care, since the communicative process is one of the main challenges for humanization of health (^{Deslandes & Mitre, 2009}). About this, ^{Dias, Coutinho, Gaspar, Moeller and Mamede (2017)}, in a study, explained that the difficulty of establishing the doctor-patient relationship generates frustrations and also infrequency of patients to health care services.

It is noted that public institutions of Higher Education are not offering opportunities for teaching Brazilian Sign Language to their students in health courses. This results in a flawed communication process and consequent damage to the health of deaf people. Therefore, this article reinforces the importance of teaching Brazilian Sign Language as a compulsory discipline and not as optional in the curricula of health professionals, corroborating previous studies (^{Ramos & Almeida, 2017}; ^{Souza & Porrozzi, 2017}).

As for the teaching of the National Health Care Policy for People with Disabilities, it is evident that there is no concern with the discussion of this theme in health courses, since no course from the researched institutions placed it in the references to be worked with future health professionals. This leads to their lack of knowledge about the specific needs of this population group.

Of the Universities surveyed, only two disciplines were found among all health courses, as shown in Table 4.

It is beyond the scope of this research to identify disciplines that diagnose disability or refer to it as a pathology. The objective presented here is the discussion of policies and actions that improve the access of these individuals to health services, that weave discussions, in order to favor the humanization of care, in the social perspective of disability. Of the eight Master Plans analyzed, only 25% brought a specific discipline that discusses the health care of people with disabilities, which are: Psychology and people with disabilities and Physical Education for people with special needs. The others were identified for having content on the health care of people with disabilities within the syllabus to be addressed during the discipline.

When assessing the course load of these disciplines, it is highlighted that the health courses of the studied Universities reserve only 1.1% of their workload, ranging from 30 to 60 hours, for discussion about the health issue of people with disabilities. A study conducted with medical schools in Australia (^{Trollor et al., 2016}) describes that these colleges reserve about 2 hours and 55 minutes of content on intellectual disabilities. The article also emphasizes that only a small number of Universities offer this theme in its compulsory content (^{Trollor et al., 2016}).

This insertion of disciplines/contents has already been discussed since ^{Ordinance no. 1.793, of December 1994}, which recommends the inclusion of content related to the “Ethical-political-educational standardization and integration of the person with special needs” in the group’s courses of Health Science.

One possibility for discussing health care for people with disabilities in health courses would be to involve the context in a transversal way and/or to include disciplines that focus on health care for people with disabilities. However, these possibilities are also not absorbed by the Universities studied, considering that only one nursing course reports that the theme will be transversally worked. However, in the text of the Master Plan, the failure of the referred transversality is already described: “It is admitted the need to deepen these discussions so that more initiatives are adopted in the modules in order to integrate more and more the nuances of the care for persons with disabilities” (Nursing Master Plan, 2013, p. 128).

This type of transversal discussion is what is desired to happen in all courses; however, a more in-depth study is needed to know how the theme is being inserted and discussed, since, in the analysis of the Master Plan, the content was not found either in the curriculum or in its references, which leaves a gap about what is actually being discussed in the aforementioned course. It should be emphasized that, for the best health care for people with disabilities by professionals in the area, it is necessary to go beyond the sporadic insertion of disciplines, as the theme must be discussed and worked on in the daily lives of professionals being trained.

An example of this was the study conducted by ^{Symons, Morley, McGuigan and Akl (2014)} that compared the formation of two groups of medical students: one group, whose course used a longitudinal curriculum for the care of people with disabilities; and another without that specificity. The results show that the longitudinal curriculum led to a significant improvement in several factors related to the comfort and attitude of the students involved in the research, future professionals, towards these people (^{Symons et al., 2014}).

The research done by ^{Sullivan and Mendonca (2017)} compared the contact of students of occupational therapy with the person with disabilities through lectures or in fieldwork. The authors concluded that direct contact (fieldwork) significantly improved students’ attitudes towards people with disabilities (^{Sullivan & Mendonca, 2017}). Thus, specific practices - such as lectures - may not have the desired effect on changing the paradigm and attitudes of health professionals towards people with disabilities. In this sense, attention is paid to the importance of contact with people with disabilities as a trigger for changes in health care for this public. One of these contacts can be experienced in the curricular internship. However, during the analysis of pedagogical projects, none of the universities studied reserves specific hours within the internship proposals, nor does it describe that this service will be included in the internships already established.

In care service, previous contact causes changes in attitudes. The experience of the internship can reveal the lack of familiarity with the reality of the person with disabilities and the encounter with differences (^{Araujo, Santos, Rosa, & Gomes, 2014}). The internship can reduce the negative aspects, in a way that allows the reduction of previous conceptions that give rise to the stigma and the breaking of a unique social vision and make it possible for the student to see the individual’s possibilities and not the misfortunes. It brings, in addition to personal values ​​for human training, incomparable professional resources, with a view of integrality (^{Araujo et al., 2014}).

In this context, the need to rethink the training of health professionals is unquestionable. The need was also highlighted in the first World Report on Disability 2011 (^{World Health Organization [WHO], 2011}), which made it explicit that health professionals need adequate knowledge and skills on the conditions of comorbidities associated with the subject’s disability, as well as how to manage the health care needs of people with disabilities. It focuses on two objectives: meeting the health needs of people with disabilities and understanding that adequate care for these people is a human right. In addition, discriminatory attitudes and implicit misunderstandings are actions that need to be challenged (^{Shakespeare & Kleine, 2013}).

Even so, it is evident that the public universities studied, even with a Master Plan emphasizing the commitment to the formation of a professional committed to the integrality of the health of individuals and the community, do not discuss the health care of people with disabilities and neglect the care to this huge portion of the population. Therefore, it is expected that there will be an update, not only of the Master Plans, with a view to complying with laws and decrees, but that there will be a change of thoughts and attitudes of the academic community, that the discussion will be continuous for the formation of professionals who are, in fact, prepared for health care for the entire population.