Health promotion in professional education : challenges in Health and the need to achieve in other sectors

This article discusses the dynamic and complex nature of health promotion that requires training to facilitate, formulate, and put into practice its theoretical and methodological principles through continuous reflection on the contradictions of the contexts, and the need to face the challenges and expectations of communities in the region it serves. It also considers another challenge facing the health work, which is the mediation/intersectoral action for implementation of the expanded concept of health. Thus, a demand for competency based education, which means a set of attitudes and knowledge that enable the ability to act in a given situation. A discussion on two teaching experiences developed in Brazil that has contributed to the training of health from the perspective of health promotion: the Graduate Program in the strict sense, in Health Promotion at the University of Franca and the Graduate Program broad sense of the ENSP/Fiocruz will be discussed. In both cases, the use of problem-solving methodologies as a tool for capacity building, enabling theory to approach practice and provide critical and reflective training with scientific rigor and thematic relevance.


Introduction
The process of health and illness of a society is the result of the interaction between factors associated with social, economic, cultural, environmental and political, so a complex process that requires intersectoral action.
Health promotion seeks to overcome the biomedical model, using broad fields of action that consider the political aspects, the development of personal and collective skills, community involvement, care for the environment, and reorienting health services.This dynamic and complex nature requires professional training able to build capabilities that facilitate, formulate, and implement theoretical and methodological principles through continuous reflection on the contradictions of the contexts and the need to face the challenges and expectations of the communities in the regions they serve.
Thus, health promotion can be considered as a transformative process, able to improve living conditions and health, and only made feasible by professional critics with the ability to adapt to different contexts.Learning requires training based on political and social action, with the understanding of the importance and essentiality of social determinants.Therefore, demand capacity mediation and intersectoral action development, by workers and institutions involved, around regional plans 1 .
In this article, the challenges at different levels of training in health promotion and the demand for dialogue with other sectors are discussed, using the example of the Specialization in Health Promotion and Social ENSP Development, Fiocruz program and the graduate degree in Health Promotion Program at the University of Franca.In both cases, the use of problem-solving methodologies instrumentalizes capacity building, enabling theory to approach the practice and provide critical and reflective training with scientific rigor and thematic relevance.
Participatory methodologies are shown to be in-line with this process, as they use questioning as a teaching and learning strategy.It provides direction stimulating student to the problem, they stop, look, reflect, and then relate their story, and begin to reframe their findings toward a practice that meets the needs of those who go into the health services 2 .This process should not meet the demands of the labor market only, but foremost serve as a stimulus for the discovery of various forms of actions for health promotion, with consequent improvement in training processes and health care.

The challenges in health and the need to reach other sectors
One of the questions that arise in health work is how to address broader concepts and challenges in regards to implementation.Health promotion confronts these questions using: 5 fields of action, -the development and implementation of healthy public policy, creating supportive environments, strengthening community action, developing personal skills and reorienting health services; and three strategies -advocacy, mediation and training -all priorities for action to be built-up and placed regionally with the participation of individuals and communities in the regions that they serve.
These challenges highlight the need for capacity building for action, focusing on the creation of learning in order to contribute to new decision-making, emphasizing the importance of understanding the cultural and local processes for the development of programs and actions to promote health.This requires understanding of identity, history and memory for sense of belonging and understanding of local processes.
In the Brazilian context, some authors 2,3 agree that the health education should be part of the Single System of Health [Sistema Único de Saúde (SUS)] policy and its government mandate to: conduct the National Curricular Guidelines (DCN); develop a local continuing education for teachers and health professionals; produce relevant knowledge for the Unified Health System (SUS) and the achievement of health care; build health education along with the health system and establish technical cooperation qualify management and secure professionals in SUS.
Proposals and experiences as actions and strategies are under the Department of Education and Health Management (DEGES): Education-SUS; Learning -SUS, the VER-SUS, and the Permanent Education Poles as well as other initiatives such as Facilitators Training courses, Continuing Health Education, Change Enablement (Pro-Health), the Program of Education for Work for health (health PET), multidisciplinary residences, generated and strengthened questioning stances, confronting dominant biological models, using the social sciences to discuss the field as their objective, and subjective conditions of production subjects 3 .
The reorientation of training is a proposed requirement for the consolidation of the health system.However, even in electing the means of training future professionals for health as the focus of analysis, it is recognized that this di-mension is not the only challenge of the national health policy in Brazil and the consolidation or (re) construction of this model presents complexities, and makes clear the need to promote a more humanistic skills, critical-social, and general health professional to enable the change in the work process, either through training, promoted by the service itself, or through courses and post-graduate courses in the Health promotion, Public health, or Public health with an emphasis on primary health 3 .
In Brazil, the National Policy for Health Promotion (PNPS) 4,5 and the National Policy of Permanent Education in Health (PNERS) (2010) contributed to the recognition of the work place as a learning space and the need to specific training for health promotion.The National Health Policy Promotion act was adopted on 30 March 2006, sets out the guidelines and organizational strategies of health promotion activities in the three SUS management levels to ensure comprehensive care.Human resources play key roles in health promotion, and for this reason are cited in its objectives, policies and strategies.Among the objectives is to promote the understanding of the expanded concept of health among health professionals.The guidelines in this document affirm the need to encourage health promotion research (evaluation of efficiency, efficacy, effectiveness, and safety of the provided actions), and to disclose and report on initiatives aimed at health promotion for health professionals, managers and SUSusers.Among the strategies, PNPS considers the development of qualification, in health promotion activities, for health professionals involved in SUS 4 .
Human resources in health refers to the training of technical personnel, necessary for the functioning of the public system of local health, state and national levels to the action activities, regulation, control and supervision, administration, management, and management, research, education and staff training.It includes subtopics for health professionals in career development of human resources in health, distance education, continuing education, health education and training, and human resources policy.
The revised text of PNPS (2014) deepens the essentiality of specific training in health promotion, making this issue a priority, as well as one of its operational axes.It brings a clear understanding that it is to remain in constant dialogue with other policies, with other governmental and non-governmental organizations, including the private sector and civil society.In this regard, it reaffirm the need to the promote education processes, training and specific training in health promotion setting up support training and continuing education in this area to increase the commitment, and both the critical, and reflective capacity of managers, and health workers, as well as encouraging the improvement of individual and collective skills in order to strengthen sustainable human development 5 .
The current models of higher education in health, however, still remains attached to a model of hospital-centered practice, fragmented with a privatization bias, and is shown deficient in meeting the social needs for health care.The predominant profile of graduates of health in undergraduate courses reveals little commitment to the NHS, an understanding of the necessity of teamwork, are poor in humanistic skills, as a result are often unprepared as professionals 6,7 .
Their training depends on the curriculum, pedagogical criteria, political, social and economic standards.For greater humanization in the provision of health services a restructuring of vocational in training in health care is fundamental.
Professionals with highly technical educations, weak commitments to public health policies, and lacking a critical view of society having little humanistic attitudes, and distanced, attitude of health care promote values such as present.They are normally resistant to change and tend to defend the current status quo, further distanced from critical knowledge about the political, social and cultural structuring the theoretical framework of the determinations about social health 7 .
The reorientation of practices means that the best performance of professionals and other individuals involved in the process: students, teachers, managers, and researchers, can provide industry professionals and government agencies an update on health actions that can facilitate the construction, enforcement or recasting of public policies 8 .
Education and health are inseparable categories, and in this context, intellectual production of health education from the perspective of health promotion can be identified as an emancipatory movement of the human being with reference to citizenship and democracy.
Regarding the reorientation of health services in Brazil, the whole process of change since the drafting of the new constitution (1988) and the creation of SUS (1990) indicates that there is a will to undertake a salutary movement for so-cial welfare and improving the health conditions of the population.Reorienting health services meant the adoption of a new logic in the development of the work process, and thus change or shift in health education 9 .This new logic is one of the axes of change for intersectoral work.
Intersectoriality provides multidimensional understandings and broad resources to the problems about health care at all levels 10 , resulting in involvement from various sectors, coordinating different practices and knowledge in order to develop productive and effective actions 11 .
The viability of users' rights in relation to general practice, and the success of these interventions require an integrated action between different sectors to solve the problems of the social problems, noting that these actions do not take place in a disjointed manner, therefore, no organization acting alone can aggregate the resources, knowledge, support networks and confidence to the reorientation of services and practices 11,12 .Given the above, it is understood that intersectionality is the way to work, govern, and build public policies to improve the quality of life and promoting health care 13 .
The intersectoral actions construction process therefore implies the exchange and collective construction of knowledge, languages and practices among the various sectors involved in trying to equate certain health issues, so that it becomes possible to produce innovative solutions for improving quality of life.This process provides each sector with a means to improve their ability to analyze and transform the way they operate from having contact with, or the prospect of, other sectors, paving the way for the efforts of all to be more effective and efficient 4 .
The PNRS in its new version (2014), maintains the importance of intersectoral dialogue proposing that joint efforts should stimulate and encourage other sectors to consider building up their specific policies, factors and conditions of vulnerability, recognize the risks and the potentials of health care that affect people's lives, be responsible, and making health compose the agendas of all public policies in all sectors 5 .For the scope of health promotion actions, which should include others, the intersectoral approach is essential for use in the practice of teaching and learning, questioning, and taking reflection from the work processes, and the reality experienced in its practice.
To meet the new profile of health professionals, required by the labor market, a paradigm shift involving the concepts of health and edu-cation needs to be experienced during training, resulting in an expansion of the possibilities of sharing knowledge and practices.

Curriculum and skills in Health Promotion
In Brazil, the processes resulting from changes in government and constitutional rule in the 80s, had as a later result of political reform triggered in the 90s, influenced paradigm shifts in public health, leading to the development of new technologies and new forms of work organization, requiring the implementation of training models and management of the workforce based on professional skills.These changes affected the training of health professionals, culminating in the construction of the National Curricular Guidelines (DCN) for university courses in the health area that drives changes in health education, based on skills, abilities and attitudes to accordance to SUS.
The National Curricular Guidelines for graduate students in health from 2001, is a further paradigmatic change in the higher education process it is a Flexnerian model, applying biomedical care, and guided by binomial health disease at different levels of care, with promotion, prevention, recovery, and rehabilitation with a view of complete assistance; an individual dimension to a collective dimension; rigid curriculum, composed of increasingly fragmented disciplines, with prioritization of theoretical activities for flexible curricula, modular, directed for the acquisition of a profile and their professional skills, which require modern methods of learning, skills and attitudes, as well as multiple teaching scenarios 14 .
In a curriculum oriented competence, content only has meaning when they emerge from practice, and from there begin to be explored with consistency and functionality when dealing with complex and socially constructed real situations.What matters is not the transmission of accumulated knowledge, but the possibility of action, the ability to resort to what is known to accomplish what you want, for the project 15 .
As recommended by the National Curricular Guidelines general education requires early integration of students into the labor market and for their reflective performance and development of a holistic and critical view of health, with the central axis of health promotion.It is therefore necessary to invest in continuing education and professional training critical to establish in health care a professional acting posture that goes beyond the role of reproduction, maintenance, and lack of commitment to interests and social needs 16 .
This training demands an educational processes focused on the development of skills, which can be defined as "the ability to act effectively in a particular type of situation, based on knowledge, but not limited to them" 17 .Facing a problem requires many cognitive resources synergistically, one among them is knowledge.Therefore, the construction of professional skills requires not only technical expertise, but also those that are incorporated from practice.
The concept of competence is used in various fields of knowledge.In the context of health promotion, other authors define competences as the knowledge, skills, and attitudes needed to program specific actions for health promotion, specifically in dimensions of practices 18 .
Core competencies were developed by the project Developing Competencies and Professional Standards for Health Promotion Capacity Building in Europe (CompHP) in 2009.Its main objective being the establishment of methods for implementation of health promotion standards.They are recognized as a minimum set of core competencies for professional development in health promotion 19 .
In this context, the skills needed to develop health promotion actions include values (equity, social justice, ethics, and autonomy of individuals), skills (conceptual principles of health promotion), and knowledge.These 47 skills are listed in 9 domains.Each domain covers specific knowledge, skills and performance criteria required to demonstrate the acquisition of skills required in that area.The domains contained in CompHP provide a guide for the development of skills and competencies in health promotion, they are: (1) favoring change, (2) health law, (3) partnership, (4) communication, (5) leadership, (6) diagnosis, (7) planning, (8) implementation and ( 9) evaluation and research 19 .
From the analysis of CompHP guidelines, it is concluded that they were minted to think about training and health promotion practice in the European context, but the characteristics of the training model used in Brazil can benefit greatly from the proposals of the CompHP competencies that define a theoretical and practical model for vocational training 20 .
In Latin America, the Inter-University Consortium and Personal Training Centers in Health Education and PS is an important regional action to the theme of Competences in Health Promotion 21 .
A survey from this Consortium, that included the graduate courses at the National School of Public Health Sergio Arouca of Osvaldo Cruz Foundation, Rio de Janeiro, and the University of Franca, São Paulo, analyzed the approaches and characteristics of Latin American academic courses in Health Promotion and Health Education.Their research identified and systematize a number of professional competences to Health Promotion and Health Education, developed from the curricular matrices of undergraduate courses, specialization, master's and doctorate, with emphasis on Health Promotion 22 .
As recent reviews show, conducted in 2012 20 and 2015 23 , the relevance of use of competencies for health promotion is guided by the potential to serve as a point of reference to: establish professional standards to ensure the quality of work; recruit workers; identifying the need for training and organization of professional training programs; guide academic training; prepare accreditation guidelines; guide the development of assessment tools; increase the understanding of knowledge and skills required by health promoters in the planning, implementation and the evaluation of programs 15 .
The main competencies to be developed during professional training in health promotion would be ethical values; knowledge; favoring changes; health advocacy; mediation through partners; communication; leadership; evaluation or needs assessment; planning; implementation and evaluation of research 19 .
To develop these skills, training requires teaching strategies that can help meet the complexity of health promotion and in this sense requires an educational process involving professionals and their technical knowledge in holistic health to discuss the situations of their daily practices in an expanded mode.In addition, a need for transformation in institutions to promote teaching in the act of health promotion so as to consider other possible sectors to discuss issues such as social determinants of health.
An educational process with these characteristics promote spaces for reflection on the challenges of professional practice and provides healthcare workers the possibility of acting as an active subject in the construction process of their knowledge, and a player in the reorientation of their health promotion activities.
It should also combine a problematical dimension and dialogue, enabling understanding and an overcoming of situations and contradictions that are part of the practice and study ob-ject.Learning is continuous and is by experience, permanent education processes and individual actions, are fundamental and necessary to develop advanced skills, maintain knowledge, and required skills for practice and policy changes, strengthening the dialogand theory.Therefore, a value exists in the relationship between work processes and training and should build capacity to articulate knowledge, based on the expanded concept of health; recognizing the context and history of individuals and communities, allowing greater integration between those demanding and hosting in health services aiming emergence of alliances involving training institutions and regulators, users, and social movements 24 .

The training experience at the Graduate Program in Health Promotion at the University of Franca
A pioneer program in Brazil, stricto sensu a graduate program in Health Promotion at the University of Franca, it was established in 1999 by Resolution 06/1999 CON-SUVE (from 09/08/1999) and was recognized by Decree nº2530 of 04/09/2002.The program was accredited in the large multidisciplinary area of CAPES (Coordination the for the Improvement of Higher Education Personnel) and interdisciplinary assessment area.In 2011 the Doctoral degree was created, the first of this level throughout Latin America.By 2015, the course had graduated 310 master's students and 9 doctoral students in Health Promotion.
Its philosophical framework is based on the original letters of International Conferences and the Brazilian Health Promotion Policy, published in 2006, as well as from numerous reflections arising from international conferences organized by the IUHPE (International Union of Promotion and Health Education) 25 .
The goal of the program is to train researchers and teachers to be are able to understand the needs and peculiarities of different population groups and settings, being able to put into practice the knowledge and various technologies committed to the proposed strategies in the Ottawa Charter, namely: building healthy public policy, creating healthy environments, strengthening community action, developing personal skills and reorienting services 26 .
In both levels of training, the graduate program in Health Promotion has a single area of concentration, which is Health Promotion and two lines of research: "Policies and Practices in Health Promotion", "Vulnerability, Technology and Health Promotion".
The program's target audience, which lasts 24 months for the masters level and 36 at the doctoral; is multidisciplinary, including social workers, doctors, dentists, psychologists, physical educators, physical therapists, biologists, nurses, nutritionists, and more recently students from different academic background in the health field that have entered in the program, as business managers and lawyers, with an interest to meet new opportunities by bring their practices, the knowledge acquired in the field of health, notably health Promotion, expanding, and forward action to subjects who are targets of interventions 27 .
Educational institutions must offer the student the conditions to develop the necessary skills to work in these and other areas, favoring knowledge, skills and values 25 .Given the above, the post-graduate program in Health Promotion at the University of France intends, in addition to these objectives, for their the graduates to be are able to deal with the challenges that faces the practice and consolidation of the health system within the premises that are recommended by health Promotion; "Allow the interaction with the population, health services and other educational institutions; and develop national and international research through exchange programs and policies" 27 .
The graduate program in Health Promotion in general, deals with formal studies qualifying human resources for teaching and inclusion in research activities.Developed research projects are derived from theoretical studies, bibliographic, research field or experimentation.Scientific activity is the essential component of education, along with the acquisition and transfer of knowledge and techniques.Science education has had an impact on the activity of professional health, enabling practitioners to keep up to date and exercise its own judgment on the merits of new knowledge and techniques and on the desirability of adopting them or not in each case.
The interdisciplinary feature of the PPG is the formation of masters and doctoral graduates in several areas of health, graduated biological sciences, medical sciences, law, physical education, nursing, physiotherapy, veterinary medicine, psychology and dentistry.
Until 2011 the program was predominantly for female professional nurses and physical therapists, and teachers in private higher education institutions.They worked in research through guidelines for completion of course work and was considered the essential course for professional practice and reported improvement in performance as a teacher and as a researcher 27 .
PPG's challenge in health promotion has been to offer a curriculum that addresses the historical, conceptual and methodological aspects that now integrates and meets diverse disciplinary backgrounds and foster the development of innovative research in social technologies in order to stimulate community participation and empowerment.Applicants go through a selection process before approval to a class.The class is divided into two small groups of 10 to 12 students, who work problem situations and practice reports; the class as a whole meets every time there is a themed class, or when guest speakers visit to share experiences of health promotion.

The training experience in
Its areas of training axes and competency are Health Care, Social Development, Participatory Management of Working Process and Education in order to serve in holistic health care services; identify needs, strengths and opportunities for improvement of living conditions and health; promote social participation and intersectoral coordination; identify problems in the organization of the work process, working on their improvement; permanently learn self qualification, development of autonomy and produce, socialize and articulate knowledge.
The pedagogical approach is the structuring principle of the relationship between work processes and training, based on building curricula oriented competence that creates capacity to articulate and mobilize knowledge, aimed at development of integrated attributes (cognitive, psychomotor and affective) that provide implementation and successful practices in the professional routine.
The dialogic competence approach values the context and practice of professional and social agents, allowing articulation between training institutions, service providers, users, and social organizations.In this sense, the curriculum was developed within the pedagogical perspective of Problem Based Learning (PBL), coupled with the prospect of questioning and the pedagogy of autonomy.The philosophy of Dewey (1859-1952) contributed to the Problem Based Learning, which considers the learning experience, and enabling connections between the things we do and what we enjoy or suffer.The questioning is an approach that seeks to overcome the banking education guided by the transmission of specific content and awaken a critical and liberating education based on students' life experiences 29 .
Working with tutors-teachers to carry out the learning process, which enables significant learning, based on the experiences of the students and the search for solutions to problems related to health promotion and social development.It is the role of the teacher-tutor to ensure that everyone understands the purpose of the group, learning objectives, the results of processing of problem situations and syntheses.
The course of the learning process welcomes students because it is a permanent interaction between the group guided by a respectful listening, effective and active participation (an important factor when evaluating the student), the establishment of an Agreement for Coexistence (respect timetables, use of mobile phone and other devices).
It uses a portfolio, built individually and collectively, as a pedagogical tool that allows the student and the class to systematize learning, the productions and the paths that are formed during the course.The construction of the portfolio does not follow a rigid structure, in contrast, it is flexible and creative, therefore, it allowed singular expressions, without the risk of losing sight of the objectives outlined, and is available throughout route.It also contributes to the development of the ability to evaluate work, establishing close relationship with the trajectory of their personal academic and professional development, as well as create opportunities, documentation, and records on the students' evolution in a systemic and reflexive way.
The evaluation is procedural and wide, that is it follows the entire course development and evaluates many components: teachers, tutors, students, educational resources and the evaluation itself.Students are assessed by their synthesis of relating to problem situations and practice reports; seizure of concepts, and how to use them in settings, or in team work situations, discussions and or dialogues.
The work course conclusion is an intervention project designed to express the development of the student throughout the course.It is developed in their place of origin/work in order to contribute to the implementation of the National Policy Health Promotion (PNPS) and to elaborate strategies of health promotion actions in the three levels of management of the Unified health System (SUS) for ensuring comprehensive care.
Graduates have diverse trajectories that express not only ownership of the method proposed, but also that of the dialogue between theory and practice, as well as key concepts of health promotion and its possibilities and limits for practice.This can be seen in a survey of graduates of the 5 PhD thesis object classes 30 .

Final considerations
The challenge for the implementation of health promotion, is to consider the broader concept of health, and requires discussion process on vocational training within the courses stricto and lato sensu, but also in technical training and graduation.
The training of human resources in health promotion with methodologies based on real problems of regions, provides evidence for decision-making at the local level and increases scientific production, thus contributing to both the improvement of the vocational training processes and health care.
One way to meet the challenges of interdisciplinary training required for the promotion of health, is to constantly evaluate the effectiveness of training and social inclusion of research.Working with graduates allows constant updating of pedagogical practices and an effectiveness of training.In this sense, data from a survey of graduates receiving their degree in Health Promotion showed the ability to self-reported promote intersectoral action, with the skills and expertise to plan actions to solve problems and assist in planning for better conditions for communities 27 .
CPS Studies were presented as facilitators for the development of PS, especially with regard to vocational training and academic contribution but also favored education in health because they saw toconferring certain potential powers, starting from a perspective that values the sociocultural experience of subjects, practical context and the existing policies.However, there are some negative aspects, which suggests caution in CPS employment, to avoid limiting the professional capacity and ignore the diversity of the context in which the practices are embedded 23,31,32 .
Teaching health based on building skills to meet the need to generate references should be to boost social debate on health ideals that can have major challenges to face and act as corresponding responsibilities to key actors, rather than development of a regulatory framework or exhaustive list of activities to meet from a technocratic logic, as proposed by the Pan American Health Organization (PAHO) 33 .
While the skills of research results show that the worker should be able to work in a scientific manner.The curricula establish strategies to build this capacity to be incorporated as acontributor as a health professional in participatory and integrated construction work processes.
Evidence highlights the need for studies to encourage discussion of CPS jobs in the teaching profession, with a view, which emphasized the use of this model in the organization of curricula and professional training programs.
The health education is in process of constant movement, construction, deconstruction, and reconstruction of propositions in order to information for training and finally creating a transformative final form.
Promoting the Specialization Course in Health Promotion and Social Development of ENSP, Fiocruz The Specialization in Health Promotion and Social Development was prepared in the context of the ENSP in Movement Project that aimed commitments by ENSP building permanent education processes allowing alliance between work and training, and especially the recognition that, in training and work processes are made holders citizens of technical and political knowledge; and teaching oriented competence in the perspective of comprehensive care, intersectoral and interdisciplinary way.It was built from a working group composed of health professionals involved in health promotion actions in several states, the 540 hours, consisting of three Learning Units with 180 hours each, named: Health Promotion and Development social in Public Policy Management; Health Promotion and Social Development in the institutions and organizations; Health Promotion and Social Development in the Territories and the Community 28 .