Building health care technologies based on health promotion

Abstracts

Este artigo de reflexão discute as bases teórico-metodológicas da Promoção da Saúde e seu potencial na construção de tecnologias de caráter emancipatório, bem como a complexidade de pesquisas de avaliação de ações nesse campo. Para tanto, descreve e analisa um projeto de promoção de desenvolvimento infantil, construído segundo as bases da Promoção da Saúde na vertente crítica e implementado por equipes de saúde da família em regiões prioritárias no município de São Paulo, e pesquisas de avaliação de suas tecnologias e estratégias de implantação. Conclui que o referencial da Promoção da Saúde contribuiu para reorientação das ações dos profissionais para a atenção integral e fortalecimento dos potenciais de saúde das crianças e famílias e que as pesquisas de avaliação de ações no campo da Promoção demandam instrumentos e abordagens múltiplos, que possibilitem abranger a complexidade de processos e resultados das ações.

Promoção da saúde; Saúde pública; Saúde da família; Avaliação de Programas e Projetos de saúde

REPORTS ON EXPERIENCE

Building health care technologies based on health promotion^*

La construción de tecnologías en salud basadas en la promoción de la salud

Anna Maria Chiesa^I; Lislaine Aparecida Fracolli^II; Maria De La Ó Ramallo Veríssimo^III; Elma Lourdes Campos Pavone Zoboli^IV; Lívia Keismanas de Ávila^V; Alfredo Almeida Pina de Oliveira^VI

^INurse. Associate Professor. Public Health Nursing Department at School of Nursing, University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^IINurse. Associate Professor. Public Health Nursing Department at School of Nursing, University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^IIINurse. Ph.D. Professor. Maternal-Infant and Psychiatric Nursing Department at School of Nursing, University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^IVNurse. Ph.D. Professor. Maternal-Infant and Psychiatric Nursing Department at School of Nursing, University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^VNurse. Ph.D. Professor. School of Medical Sciences of the Santa Casa de São Paulo. São Paulo, SP, Brazil. [e-mail]

^VINurse. Master in Nursing. Professor of the University of Campo Limpo Paulista. Campo Limpo Paulista, SP, Brazil. [e-mail]

Correspondence addressed to

ABSTRACT

The article describes a reflection about the implication of the theoretical and methodological bases of Health Promotion to the development of empowerment technologies. It also discusses the complexity of caring out researches to evaluate the actions in this field. We initiated with a description of a protocol on child development focused on the critical bias of Health Promotion principles. The protocol was implemented by family health teams in critical regions of São Paulo city. The researches linked to the protocol evaluated used technologies and the strategies for its implementation. The results pointed that frameworks of Health Promotion contributes to the comprehensive care and strengthening of children and families health. Researches for evaluating the actions in Health Promotion require a variety of approaches, to cover the complexity of the processes and outcomes.

Key words: Health promotion. Public health. Family health. Program evaluation.

RESUMEN

El artículo discute la contribución de las bases teóricas y metodológicas de la promoción de la salud y tecnologías hacia la emancipación del sujeto. También plantea la complejidad de investigaciones para evaluar las acciones en este campo. Se describió y analizó un proyecto para de promoción del desarrollo infantil elaborado con base en los principios de la promoción de la salud en su vertiente crítica. El proyecto se desarrolló en regiones prioritarias de la ciudad de São Paulo a cargo de equipos de salud de la familia. Las investigaciones relativas a este proyecto evaluaron las tecnologías y estrategias de implementación. Se concluyó que la adopción de los principios de la promoción de la salud ha contribuido en la reorientación de las prácticas de los profesionales sanitarios con vistas a la atención integral y el fortalecimiento de salud de los niños y sus familias. Las investigaciones para evaluar las acciones a nivel de la promoción de la salud requieren instrumentales y abordajes variados, a fin de abarcar la complejidad de los procesos involucrados y sus resultados.

Descriptores: Promoción de la salud. Salud pública. Salud de la familia. Evaluación de Programas y Proyectos de Salud.

THEORETICAL-METHODOLOGICAL BASIS OF HEALTH PROMOTION: A SHORT INTRODUCTION

The Health Promotion area has been described as a new and promising paradigm in health, due to the extent of its theoretical-methodological approaches, configuring its complexity and main conceptual basis, for instance: the emphasis on the care integrality and on the prevention of health deterioration; the social commitment to life quality; and the adoption of participatory process participation as planning and evaluation of the programs. On such basis, Health Promotion supports the reorganization of the health work, so that it is constituted as a way of social response organized to tackle the health problems and needs of a certain population.

As an applied theoretical-methodological area, the different conceptions of Health Promotion influence the ways of operating these concepts and implicate the need to continuously review the comprehension of its conceptual body in order to respond to the constantly changing historical and social transformations.

In this context, the understanding of the political processes that influence Health Promotion projects allows to understand the significant differences among the various proposals presented in its scope. The analysis of Health Promotion actions allows to classify them in four different groups⁽¹⁾, as presented in Figure 1.

In the presented model⁽¹⁾, the theoretical basis of Health Promotion circulate around opposite poles that go from the subjectivity to the objectivity and from regulationist theories to social theories that promote the radical transformations. The interfaces between these poles design groups of actions that are considered radical, radical-structuralist, humanist and traditional-functionalist.

Radical actions initiate in the comprehension of the irregular distribution of power in society, which characterizes it as oppressive and alienating. Health problems are originated in the social institutions that, by defining values, affect the human conscious. In this perspective, the way of coping with the social order stands on the community development, on the community empowermentand the encouragement to the self-discovery.

In the Radical-structuralist actions, the theoretical approach is based on the comprehension that the social conflicts are supported by the irregular distribution of income, power and opportunities to the different social groups. The interventions for Health Promotion designed according to this point of view fundamentally comprehend the development of public policies.

Traditional-functionalist actions are based on the comprehension of society from common values, in which humanity may be comprehended from the natural sciences, with incorrect behaviors, lifestyles and habits, and diseases as the origin to health problems. Therefore, Health Promotion interventions are characterized by the modification of individual attitudes and the adoption of healthy lifestyles.

In the group of Humanist actions, society is constituted from the subjectivity of the individuals and their rules are created, supported and modified through the relationships among people. Health problems are configured as changes in the meaning attributed to the person for his identity and action, and the interventions aim at the improvement of the communication and at the meaning of self-knowledge^(2-4).

Recently, the reflections on the concept of health and its articulation to the others areas of life support the construction of another theoretical model for the comprehension of Health Promotion. The model proposed by Labonte⁽⁵⁾, presented in Figure 2, represents a dialectical concept for health and welfare. This model highlights the existence of dimensions and interfaces that express the complexity and dynamism existing in the health-disease process, from the logic of the Health Promotion critical paradigm.

This new model^(5-6) exceeds the biomedical (disease-centered) and behavioral (focused on risk factors and lifestyles) approaches of the health actions, aggregating the positivity of the previous models to the social-environmental and emotional perspectives, intrinsic to the health-disease process. The diagram shows the individual health dimensions, as well as the intersections among them, which represent the range of the individual's power to control and change the determinants of his health. The intersection of all dimensions expresses the possible welfare at a certain historical moment, inside a macro-structural context of society.

According to the previous diagram, the three health dimensions are: the Physics or Vital Energy - related to the vitality level of the biological body to perform daily life activities; the Emotional or Life Project - represents the emotions, aspirations and wishes, which affect the meaning of life projected by the individual; the Social or Community Life - expresses the relationships and interactions of the individual in his environment, through the representations and other social institutions⁽⁵⁾.

The intersection of the health dimensions highlights the areas of Health Promotion action together with individuals and groups: Control over life - implicates the increase of social power of the groups in order to exercise their freedom and socially participate to transform reality; Abilities to do one's wish - comprehends the capability presented by the individual to make decisions resulting in his self-fulfillment and other personal achievements; Social relations - comprehends the individual and/or group potential to build social networks, to have and keep participative and supportive relationships with family, friends, neighbors, community and government representatives.

The work of health professionals in the promotion perspective may be strengthened when considering also other theoretical explanatory concepts of the previously described dimensions and added to the model of Labonte: Resilience, building social spaces in face of adversities, in order to take advantage of good experiences in the context of life and work; Autonomy, comprehending the relation of the physical vitality with the life project, in order to attribute a positive meaning to living; and Community Empowerment, including the future projects of the individuals in the interior of the social relations to generate transformation processes over the determinants of life⁽⁶⁾.

THE DEVELOPMENT OF EXTENSION PROJECTS AND STUDIES ON HEALTH PROMOTION: THE CHALLENGE OF THE PROJECT JANELAS

During the implementation of the Family Health Strategy in the city of São Paulo, the project Nossas Crianças: Janelas de Oportunidades⁽⁷⁾ (Our Children: Windows of Opportunities) was created and implemented, based on the referential of Health Promotion recommended by Labonte. This project constitutes an innovative intervention given the need for new care technologies, in the perspective of the promotion and complementary to the already approved healing practices, and a health technology aimed at triggering a movement of appreciation of the professional subject, instead of a movement to subordinate him to work. It was implemented in prioritary regions in the city, in which children health indicators were more fragile, aimed at serving the children population with a greater demand of care.

In consonance with the theoretical-methodological basis of Health Promotion, the Project Janelas involved a partnership between the City Department of Health, The United Nations Children's Fund (UNICEF), the University of São Paulo (USP), the Federal University of São Paulo (UNIFESP) and institutions with experience in community work with families, such as the Pastoral da Criança, the Japan International Cooperation Agency (JICA) and the NGO Monte Azul.

The Project Janelas aimed to integrate actions in different levels and influence a broad number of factors related to the development of the child, since the daily care and the opportunities she receives in her daily life, aimed at her full development, complementing the traditional approach, centered in the evaluation of development abilities and goals.

In this context, it proposes a systematic structure for monitoring the care offered by the families and other caregivers to children under 6 years old, since the gestational period, which allows professionals to organize their care to the families in order to reinforce favorable aspects and promote the improvement of care, as necessary.

Considering care as one of the determinants on children development, the concepts that subsidized the Project Janelas stand on the following pillars: Health Promotion as the guiding area; the importance of the stimulation in the first years of life; the centrality of the family in the child care; the importance of the child development in the scope of the health monitoring; the commitment of the public sector in the guarantee to properly stimulate the child; the organization of the actions for development continuation from a new approach; the knowledge derived from work experiences with families in need.

These pillars aim at the construction of an enlarged clinic⁽⁸⁾ in the assistance to children, since they comprehend the ethical commitment, and the commitment of responsibility to the families in the production of care to the child, the intersectorial and team performance, and the review of the health actions and technologies, with the support of other sectors and knowledge.

The contents of the project comprehend the areas of nourishment, hygiene, accident prevention, love and safety, playing, rights and participation, approached in different ways in two documents of interdisciplinary authors: a) the form for monitoring the family care, used in the health appointments; b) the textbook named Toda Hora é Hora de Cuidar (Every Time it is Time for Care), a resource for bringing closer community agents and health teams to the care contents, which is available on the internet at http://www.unicef.org/brazil/pt/todahoracartilha.pdf ⁽⁹⁾.

As an essential part of the proposal for applying the technologies of the project Janelas, an educational course was developed for health professionals aimed at promoting the use of the material, structured on the emancipatory education^(10-11). Besides, the handbook Toda Hora é Hora de Cuidar (Every Time it is Time for Care) was also produced, with contents on the subjects and practical suggestions of participative and emancipatory strategies of operationalization with the families. Available on the internet at http://www.unicef.org/brazil/pt/manualtodahora.pdf.

One year after the implementation of the project actions in several family health units, in the public network of the city of São Paulo, technological evaluation studies in health⁽¹²⁾ were carried out, aimed at evaluating the project Janelas. These studies perceived that the instruments of the project Janelas constitute a technology mediated by knowledge, attitude, commitment and responsibility of the professional, as basis for the transforming practices and substitution of the biomedical model in health care. The theoretical referential adopted was the Evaluation in Health in the Promotion Perspective⁽⁵⁾.

The studies highlighted that the main contributions of the project were to evidence: the pertinence of the applicability of the promotion concepts in basic care projects; the qualitative pertinence of the processes for partnership and collective construction of the products textbook, handbook and form^{(7,10-11,13-15)}; the pertinence of the educational and instrumentalizing process of the professionals based on emancipatory methodologies^{(10-11, 14)}; the importance of the technical and social support network of the Project Janelas during the moment of dissemination and identification of the problems in the use of the new material; the appreciation of the contents on Health Promotion and children development by the professionals⁽¹⁴⁾ and by the families⁽¹⁵⁾; as well as the adjustment of the products that constitute the technologies in question^(14-15).

At the initial stage of implementation, at the moment of the studies, it was not possible to verify impacts in the ways of care and consequent benefits to children development. On the other hand, it was evidenced that the project encouraged and supported the leading role of health professionals in the dialogue with families regarding the effective care for better development of the child⁽⁷⁾. This happened due to two main reasons: 1) the material and contents of the Project Janelas were perceived as instruments for the Health Promotion actions and effective approach to the families and, therefore, they were adopted in the practice by the professionals who were concerned about meeting their needs in an integral and broadened way^(13-14); 2) strategies of participative and emancipatory education supported the collective and creative construction of local projects for implementing the Project Janelas, promoting its capability to generate changes and satisfaction with the practices⁽¹³⁾.

It is worth highlighting that the development of the studies brought important contributions to the analysis of the theoretical-methodological referentials in face of the studies on Health Promotion. They confirmed the need for different methodological approaches and different study techniques for approaching the complexity of the interventions in this area, which articulate the acquisition and analysis of subjective and objective data, through quantitative and qualitative strategies, besides the adjustment of the language of the collecting instruments given the diversity of the social actors involved in the process.

Another aspect verified was that the methodologies for studying the effectiveness of Health Promotion still need to articulate the evaluation of processes and results, since the results with the target population of the health actions can only be evidenced in a long term temporal space. Furthermore, the impact of the actions developed does not take place only in the health area, which demands mastering knowledge in other areas to define the place and the way to identify, collect and analyze the data. In this context, there is still the need to improve the research instruments and theoretical charts in order to be entitled to the complexity of the phenomena and provide quality approaches to the Health Promotion actions, increasing the emerging production aimed at the broadened clinic in health services.

FUTURE PERSPECTIVES ON THE STUDY AND PRACTICE OF HEALTH PROMOTION

As an axis for the practices of the Brazilian National Health System, Health Promotion reinforces as essential purposes the production of health and the co-construction of the capability of autonomous action for the individuals involved: workers and users⁽¹⁶⁾. Therefore, there are demands such as the establishment of processes generators of autonomy and appropriation of the complexity of the new object by these individuals. The matters of human relationship, essential to the construction and consolidation of autonomous and emancipatory exchanges are found rather fragile at the National Health System⁽¹⁷⁾. The listening spaces, such as committees and conferences, are dissociated from the daily routine of the professionals. The technicians, based on their knowledge, assume they know what people need, especially the most vulnerable ones.

Health Promotion has been incorrectly executed through orthopedic interventions in the communities, suggesting lifestyle changes. The educative or preventive practices, generally confused with promotion, operate as if technicians have the only existing and valid knowledge. Therefore, both the clinic and the health actions of collective and community character, developed in the health services, are still predominantly prescritive and restricted^(16,18).

The experience of the Project Janelas showed that the incorporation of instruments based on the population autonomy and empowerment construction as well as the use of mild technologies in the health work are capable of reorientating the attention of the professional from the needs to the health potentials present in the users (and their families). It also indicated that Health Promotion requires intersectorial actions that involve not only the individuals, but their families and communities, as well as the importance of guaranteeing didactic-pedagogical resources to facilitate the learning and promote the dialogue between professionals and families. These resources, besides transmitting information, must handle the empowerment of the communities and the place of the individuals in the leading role of their health care^(10-11,16).

Another lesson learned with this project refers to the educational processes of health professionals. It was learned that they must be continuous, based on the respect to others, and they must take the conversation network in order to establish pacts between the team and the family for actions and/or changes to strengthen health or better cope with disease situations. It is important to highlight that professional practices based on these principles increase the probability of bond and compliance to the care in health, since they radicate in a relation of mutual trust and validate the indispensable broadening of the clinic in basic care^(10-11). Provided with the clinic broadening, it will be possible to meet the complex demand to consider an individual (users and professionals) in his singularity, integrality and social-cultural insertion, as protagonists of the care process. The peculiarities of Health Promotion in the scope of the National Health System require the reorientation of the clinical practice and the ethical equation. Both must be unfocused from the hospital-centrism and the high specialization that mark the conformation of the health system, and the education of the professionals must incorporate the richness of the biography of the care protagonists' lives: the people⁽¹⁹⁾.

REFERENCES

• 1. Caplan R. The importance of social theory for health promotion: from description to reflexivity. Health Promotion Inter. 1993;8(2):147-57.
• 2. Domingues J. A percepção de trabalhadores de saúde da família sobre intersetorialidade [dissertação]. São Paulo: Escola de Enfermagem, Universidade de São Paulo; 2006.
• 3. Carvalho SR. Saúde coletiva e promoção da saúde: sujeito e mudança. São Paulo: Hucitec; 2005.
• 4. Ávila LK. A promoção da saúde na organização das ações de enfermagem em saúde da criança no município de São Paulo [tese]. São Paulo: Escola de Enfermagem, Universidade de São Paulo; 2009.
• 5. Labonte R. Health promotion and empowerment: practice frameworks. Toronto: Centre for Health Promotion, University of Toronto; 1996.
• 6. Chiesa AM, Westphal MF. The ingration of quali-quantitative techniques in health promotion: experiences developed in Brazil. In: Book of abstracts of World Conference on Health Promotion and Health Education; 2001; Paris, FR. Paris: UIPES; 2001. p. 20.
• 7. Chiesa AM, Fracolli LA, Veríssimo MLÓR, Solymos GMB. Avaliação da implantação de novos instrumentos para o fortalecimento das ações de promoção do desenvolvimento infantil, na área de atuação do programa saúde da família do município de São Paulo [relatório de pesquisa]. São Paulo: Escola de Enfermagem da USP; 2007.
• 8. Brasil. Ministério da Saúde. Secretaria Executiva. Núcleo Técnico da Política Nacional de Humanização. Humaniza SUS: a clínica ampliada. Brasília; 2004. (Série B - Textos Básicos de Saúde).
• 9. Veríssimo MLÓR, Chiesa AM. A promoção do desenvolvimento infantil: instrumento para o acompanhamento dos cuidados familiares. In: Fujimori E, Ohara CVS, organizadoras. Enfermagem e a saúde da criança na atenção básica. Barueri: Manole; 2009. p. 328-48.
• 10. Oliveira AAP. Análise documental do processo de capacitação dos multiplicadores do projeto "nossas crianças: janelas de oportunidades" no município de São Paulo à luz da promoção da saúde [dissertação]. São Paulo: Escola de Enfermagem, Universidade de São Paulo; 2007.
• 11. Correia KMA. Avaliação da capacitação dos multiplicadores do projeto Nossas crianças: janelas de oportunidades, a partir da percepção dos sujeitos participantes do processo [dissertação]. São Paulo: Escola de Enfermagem, Universidade de São Paulo; 2007.
• 12. Novaes HMD. Avaliação de programas, serviços e tecnologias em saúde. Rev Saúde Pública. 2000;34(5): 547-59.
• 13. Chiesa AM. Autonomia e resiliência: categorias para o fortalecimento da intervenção na atenção básica, na perspectiva da promoção da saúde [tese livre-docência]. São Paulo: Escola de Enfermagem, Universidade de São Paulo; 2005.
• 14. Martins J, Veríssimo MLÓR, Oliveira MA. Avaliação dos instrumentos do projeto "nossas crianças: janelas de oportunidades", segundo agentes comunitários de saúde. Texto Contexto Enferm. 2008;17(1):106-14.
• 15. Grippo MLVS, Fracolli LA. Avaliação de uma cartilha educativa de promoção ao cuidado da criança a partir da percepção da família sobre temas de saúde e cidadania. Rev Esc Enferm USP. 2008;42(3):430-6.
• 16. Campos R, Campos GW. Co-construção de autonomia: o sujeito em questão. In: Campos GW, Minayo MCS, Akerman M, Drumond Júnior M, Carvalho YM, organizadores. Tratado de saúde coletiva. São Paulo: Hucitec; 2006. p. 669-88.
• 17. Lima AC, Morales DA, Zoboli ELCP, Sartório NA. Problemas éticos na atenção básica: a visão de enfermeiros e médicos. Cogitare Enferm. 2009;14(2):294-303. No prelo.
• 18. Cortina A. Ética de la razón cordial: educar en la ciudadanía en el siglo XXI. Oviedo: Ediciones Nobel; 2007.
• 19. Zoboli ELCP. Bioética e atenção básica: para uma clínica ampliada, uma Bioética clínica amplificada. Mundo Saúde. 2009;33(2):195-204.

Correspondência:

Anna Maria Chiesa

Av. Dr. Enéas de Carvalho Aguiar, 419 - Cerqueira César

CEP 05403-000 - São Paulo, SP, Brasil

*

Extraído dos projetos desenvolvidos pelo Grupo de Pesquisa "Modelos Tecno-Assistenciais e a Promoção da Saúde" da Escola de Enfermagem da Universidade de São Paulo.

Publication Dates

• Publication in this collection
  07 Apr 2010
• Date of issue
  Dec 2009

History

• Received
  15 Sept 2009
• Accepted
  03 Nov 2009