employment and income generation as a Health Promotion Strategy : the case of women submitted to mastectomy in Nova iguaçu , rJ , Brazil

The topic covered in the present article, generating employment and income for women submitted to mastectomy, came from the need to redirect the health practice developed by a breast oncology physical therapy outpatient clinic of a city of the BaixadaFluminense region of the State of Rio de Janeiro, based on Health Promotion. Given the dilemma that most women physically fit for work were not in the labor market because of complications of surgery and changes in post-mastectomy care routine, an intervention project was developed aimed at empowering these women in order to restore their productive capacity and economic independence. Although it has not been completely implemented, expected results are greater autonomy, increased purchasing power, social recognition and strengthening the link between women and other players, thereby creating a support network. The results are in line with National Health Promotion Policy values, such as solidarity, humanization, co-responsibility, justice, and social inclusion.


introduction
The topic covered in the present article is employment and income generation as a Health Promotion strategy for women submitted to mastectomy who will be addressed without the adjective that characterizes their health condition.Regardless of their health status, these women are understood as subjects in their entirety, along with their widely conquered and established rights.The topic is part of an intervention project 1 which led to a Health Promotion action in a breast oncology physical therapy outpatient clinic of a municipality in the Baixada Fluminense region of the State of Rio de Janeiro.
By developing Health Promotion as a political process to build capacity to protect and maintain health and reduce vulnerabilities, intervention projects involve actions in the social and political field, that is, on the social determinants of health, and in capacity building to intervene and make it feasible to carry out interventions according to different social political scenarios.This means promoting social action as an investment in favorable living conditions 2 .
Bearing in mind the theoretical and practical perspective of Health Promotion, understood as a transformation process oriented toward improving health and living conditions, the physical therapy service felt the need to reorient practices to move toward actions based on Health Promotion of users, as a result of the daily dilemmas in the post-mastectomy rehabilitation process.
The reorientation of health services, as one of the fields of Health Promotion action included in the Ottawa Charter 3 , states the importance of social participation, when underscoring that the responsibility for Health Promotion at health services should be shared among individuals, communities, groups, health professionals, health services and governments.Thus, it points out that the work process will lead to changes in attitudes and service organization, focusing on needs of individuals as subjects understood globally, and centered on health investigation and education and training of professionals.
The reorientation of practices focused on Health Promotion requires that institutions and their forms of organization be permeable and have criteria to assess practices within a perspective of enabling greater integration between users and health care workers, and seeking alliances with educational institutions, local businesses and social movements.This shift in the case studied was necessary because there were women physically apt to work, but who were not in the labor market due to sequela from surgery and the changes that the post-mastectomy care routine brought to their lives.
Given the difficulty in entering the labor market and having access to the benefits guaranteed by law, women who underwent mastectomy, already fragile and vulnerable due to the entire path from diagnosis to cure, still had to face the lack of professional prospects arising from physical limitations after surgery, especially when taking into account Brazil´s economic crisis scenario, in which entering the labor market is becoming more difficult in general.
Ayres 4 considers vulnerability generating inter-subjective contexts linked to inter-subjective contexts favorable to the construction of responses to reduce these vulnerabilities as one of the key challenges for Health Promotion and prevention.Abramovay & Castro 5 debate the concept of social vulnerability, trying to move from the reference to risk toward the concept of positive vulnerabilities.Positive vulnerabilities, according to the authors, also cover issues which may boost civilizing changes and positive engagement.It should be clear that the proposal here analyzed may be an important tool to reduce vulnerability of women to the extent that it can provide positive engagement, among other things.
In addition to financial needs, social reintegration of these women with sequela from an often mutilating surgery is vital, so they can restore their autonomy and productive capacity through work.It is very important that these women not be seen as invalid, but be perceived as active subjects in the pursuit of their rights and of their rehabilitation, social relocation and femininity.
By aiming toward autonomy of women submitted to mastectomy and to offer them the possibility of becoming economically independent, the present article, which is based on the intervention project mentioned above, presents empowerment as a Health Promotion tool to build along with these women a sense of belonging and appreciation of their potential, as well as support the struggle that involves conquering their rights, and contribute to equity and opportunities of access that result in better quality of life.
In this respect, the concept of empowerment as a Health promotion tool is essential to restore productive capacity and economic independence of women submitted to mastectomy; and to contribute to strengthening autonomy of women pursuing a better quality of life, in a setting of overcoming the vulnerabilities and negative effects that breast removal brings to them and their family, aspects that will be discussed more in depth elsewhere in the article.
The concept of empowerment is the backbone of Health Promotion and is defined by Perkins and Zimmerman 6 as "a construct that links individual strengths and competencies, natural helping systems, and proactive behaviors to social policy and social change".In an emancipatory conception, the main issue is centered on dialogic and political processes that enable new democratic and distributive practices for existing resources in society, redirecting public policies that simultaneously reduce social environmental vulnerabilities and expand human rights and citizenship of excluded populations.It is the process by which individuals gather resources that allow them voice, visibility, and action and decision power and capacity 7 .
This concept differs from behaviorist Health Promotion focused on decontextualized behaviors that end up blaming victims.The emancipatory perspective of empowerment seeks to encourage women and their social role, considering the social determinants of local health and strengthening social participation in health issues.The problem presented here faces the following issue: how do we think programs and projects that enable the generation of income for women who underwent mastectomy from the Health Promotion perspective and also respect their physical limitations?
To answer this question we used, among other references, the National Health Promotion Policy (PNPS) 8 , which is based on a broader concept of health and a set of individual and collective strategies, characterized by intra and inter-sector coordination and cooperation, and the development of a Health Care Network (HCN), in order to coordinate their actions with other social protection networks, with broad participation and social control.Among the specific objectives of the PNPS, we highlight items II and VII of the seventh article that most relate to the topic presented: Contribute to the adoption of social and health practices centered on equity, participation, and social control in order to reduce unjust and avoidable systematic inequalities, with respect to social class, gender, sexual orientation and gender identity, ethnic-racial, cultural, territorial, intergenerational differences and differences related to individuals with disabilities and special needs 8 .
Promote empowerment and the capacity for decision making and autonomy of individuals and communities through the development of personal skills and competences in promotion and protection of health and life 8 .
Among the cross-sectional topics of the PNPS, production of health and care stands out.It incorporates the topic in logic networks favoring humanized care practices guided by local needs that strengthen community action, participation and social control, and promote dialogue among the various forms of popular, traditional, and scientific knowledge, thus building practices based on comprehensive care that reorient the health care model established on the principles and guidelines of the PNPS 8 .
It is important to connect women submitted to mastectomy to the "Care Network for People with Disabilities", which seeks to qualify health care through the creation, expansion and coordination of health care points for individuals with temporary or permanent, progressive, regressive, or stable disabilities; intermittently or continuously, under SUS 9 .In the municipality studied, the network is incipient, and strengthening it may be an indirect result of the Health Promotion action presented in this article.

Breast cancer, its consequences and the contribution of Health Promotion
Cancer, according to Barbosa 10 , "leads to a huge reality and cost shock, and much physical and psychological suffering", such as: shock upon the news of the diagnosis, fear of death and leaving the children, aggressive and often crippling treatments.In Brazil, cancer is considered a serious public health problem and two aspects contribute to define the problem: Gradual increase in cancer incidence and mortality, in proportion to population growth, population aging and socio-economic development; and the challenge posed to the health system towards ensuring full and balanced access of the population to the diagnosis and treatment of the disease 11 .
Cancer control has been a priority of the Brazilian Government in face of the growth in cases and of the complexity that facing cancer brings to the health system and to the population.The priority translates into the development of policies that support the actions oriented toward facing cancer, and in the implementation of actions and programs developed by SUS managers and executed by health professionals and workers 12 .
According to the World Health Organization (WHO), cancer is unquestionably a public health problem, especially in developing countries, giv-en the world estimate for 2012 was 14 million new cases, over 60% in developing countries 13 .The estimate for the 2016-2017 Biennium in Brazil, points toward roughly 600 thousand new cases of cancer, with 57.960 new cases of breast cancer in 2016 alone.The State of Rio de Janeiro will account for 8.020 cases of the second most frequent cancer among women of the Southeast region 13 .
Breast cancer is a malignant tumor, which is complex due to the different degrees of tumor aggressiveness and to the metastatic potential, mainly after the age of 40, albeit a recent increase in the incidence in younger women 14 .Breast cancer has the highest incidence and mortality in the female population in the world and is the major cause of death due to cancer in developing countries 13 .Treatment is diverse and includes, above all, surgeries such as conservative or radical mastectomies.
For Cavalcanti 15 , "the diagnosis of breast cancer and the possibility of mastectomy lead to many uncertainties, fears and anxieties.Studies state "psychological sequela" as possibly more severe than the deformity left by the mastectomy itself ", leading to consequences to health and the quality of life of women, in addition to social disorders".The most common feelings aroused in women submitted to mastectomy are fear, rejection, guilt and loss [...].Fears include social rejection" 16 .These women need a support network to face this new moment with education on post-mastectomy care, in order to become an active agent in their rehabilitation process 11 .
For Ferreira and Mamede 17 , "mastectomies deconstruct body image abruptly".Rebuilding "life" after a mastectomy is the major challenge of women, victims of breast cancer.After surgery, social links need to be strengthened for better quality of life, because for many women victory against the disease is a new beginning, including all the socioeconomic needs before the disease, which are exacerbated by expenses related to the condition.
A central issue is no matter how functional a woman is, according to WHO 18 , functioning encompasses all body functions and an individu-al´s capacity to perform activities and tasks relevant to daily routine and participation in society.Women addressed in the article have to live with certain aspects of care such as not being exposed to the sun; not pressing the arm on the operated side; avoiding sudden, repeated and continued movements; not carrying heavy objects on the operated side 19 , and depending on the work function, these restrictions may prevent them from working.
Health Promotion Actions at specialized care services for women submitted to mastectomy, among others, may contribute to overcome difficulties, because the promotional viewpoint considers subjects in their entirety, focused on skill building and on valuing skills, and strengthening the importance of working subjects' autonomy in the health building process 20 .Toward that end, it is important to put in effect actions that foster women´s capacity in their environment, aimed at building a feasible scenario to generate work and income, strengthening their autonomy and putting them back as protagonists of the history of their lives.
This view is consistent with some principles of the PNPS, especially social participation, in which interventions take into account the standpoints of different stakeholders in identifying problems and responding to needs, acting as co-responsible in the planning, implementation and evaluation of actions; autonomy, regarding the identification of potentials, and development of capabilities, enabling conscious choices of subjects and communities; empowerment, understood as a process that encourages individuals and collectivities toward controlling decisions and lifestyle choices suited to their socio-economic and cultural conditions; and entirety, when interventions are based on the recognition of the complexity, potential and uniqueness of individuals and collectivities, building interconnected and integral work processes 8 .

Health Promotion, empowerment and work and income generation
Modern Health Promotion has a significant global history, as for example, the Lalonde Report, published in 1974by the Health and Well-Being Ministry of Canada.The report summarized the set of ideas whose core intervention was the recommendation for a set of actions to intervene positively on unhealthy individual behaviors 21 .The Lalonde Report, despite its great importance in breaking the hegemonic biomedical model, was excessively emphatic on behaviorist interventions that considered individuals accountable for the health problems they were not able to manage, thus putting the blame on sick individuals 21 .
Still, at the end of the 1970's, the World Health Organization held the I International Health Conference, in Alma-Ata, that set the goal "Health for All in the Year 2000", reinforcing the primary health care proposal.The Alma-Ata Conference unfolded into the I International Health Promotion Conference, whose core was health and disease in Society, that is, the incorporation of the positive determination of health, a concept that points out society´s commitment to its health ideals and not a matter exclusively dependent on the medical field 22 .
The 1986 Ottawa Charter 3 , the founding document of contemporary Health Promotion defines it as: "the process of building capacity in the community to work on the improvement in quality of life and health, including increased control over the process" 23 .Health Promotion can be understood as a comprehensive political process of social demands, proposing actions oriented toward the development and strengthening of individual and group skills and capabilities, related to the social determinants of health 24 .
One of the philosophical focal points of the promotional approach, according to Carvalho et al. 14 , is the concept of empowerment that in the present article is translated as empoderamento in Portuguese.According to Meis 25 , "empowerment means individuals and groups taking over control of their lives and of the environment, making community organization and sustainability of Health Promotion projects possible in the community".
The emancipatory view of empowerment, previously presented, is our focus by developing with women submitted to mastectomy their role in caring for their health and pursuing their autonomy while socially productive subjects.Empowerment becomes the ideal strategy as an element to enable these women to become active subjects in the conquest of their autonomy and of their repositioning as productive beings, because it refers to development of potentialities, increase in information and perception, with the objective of boosting social participation 26 .
In Brazil, social inequality led part of the economically active population out of the formal work market to retrieve differentiated forms of work organization, production and income generation to lessen unemployment, poverty and exclusion, in the pursuit for social emancipation.Among the new work alternatives are experiences related to Popular Solidary Economy, whose protagonists are the popular classes 27 .The experience is developed with low financial resources and uses the workforce of its members as a production fact or to satisfy basic needs and improve quality of life.
Associative and solidary forms of community work are a privileged approach for social players to participate.These group actions strengthen the feeling of belonging, enhance community links, and reveal themselves as very rich elements to build citizenship, rescue self-esteem and create awareness of the role that each actor plays in the social world 28 .Unlike welfarist proposals regarded as affective and emotional assistance to sustain a relationship of domination that prevents subjects from becoming social players of their reality 29 , the goal is to encourage social emancipation from collective actions to build citizenship.
As The Bambu Method, which encourages social inclusion and strengthening local potentialities to improve quality of life of the population, was developed based on the Project mentioned above.The Bambu method, based on affirmative methodology: Provides growth in self-esteem from micro actions to transform daily reality, generating small changes that produce self-confidence, autonomy and acknowledgement of the need to create daily ties, partnerships and networks, based on the feeling of belonging to the community and valuing the participation of the indivídual 30 .
The Bambu Method was used to enable the construction of a healthy environment, given that, according to Sá 30 ,"a municipality begins a process of being healthy when public authorities, local organizations and citizens commit and begin work processes to improve quality of life, strengthening the social pact".The fundamental concepts of this method are in consonance with the objective of providing opportunity for work and income generation initiatives for women submitted to mastectomy, bearing in mind that a healthy environment can strengthen the link among social players, working as a trigger and support for them to reach their rights.

Development of Work and income Generation action: the case of women submitted to mastectomy in Nova iguaçu
There are roughly one hundred women currently being followed at the breast oncology physical therapy outpatient clinic.Of the total, fifty were selected to take part in the project, given they adjusted to the profile defined, that is, they were submitted to radical or conservative mastectomy, were not on chemotherapy, were being followed by an oncologist at the hospital where they underwent surgery, and did not have monthly income.
The age group was 37 to 70 years, distributed as follows: 3between 30 and 40; 29 between 40 and 50; 14 between 50 and 60 and 4 between 60 and 70.Of the 50 women, 49 lived in the Baixada Fluminense and 1 in the city of Rio de Janeiro.All were literate; 42 had high-school level schooling and none had university education.Data are recent, 2016,andwere extracted from the physical therapy outpatient evaluation forms.
After overcoming all stages of oncology treatment, women seen at the breast oncology physical therapy outpatient clinic were observed to have difficulties, such as gaining access to resources of the National Social Security Institute (INSS), of being readapted to their old job or even getting a new job.After evaluation, they began rehabilitation in order to return to daily life activities more functionally and improve quality of life.During rehabilitation they were asked about the importance of work as an economic and social function and the desire to work in a job adapted to their new condition after mastectomy.
When they wanted to resume work, the proposal to build actions aimed at work and income generation began, as a means to strengthen the link between women and workers, enabling the development of a support network for a new inclusion into the job market.These actions were built collectively with women directly involved, using Bambu Method workshops 31 that are based on boosting empowerment initiatives to increase individual and collective competences of participants.
Workshops were oriented by a social constructionist framework that considers knowledge as being prepared along with individuals, that is, always as a result of group action 32 , and were divided into ten moments: sowing the Bambumobilization and group meeting; beginning the talk -introduction of participants, method and establishment of coexistence rules, presentation of work and income generation proposal, identification of group potentialities; wishing and creating -description of the scenario that the group wants to reach, working together and preparing priority scale, preparing priority maps; planning activities -choose most central objectives of priority maps, define responsibilities and detail of actions, evaluation of workshop, monitoring and supporting actions proposed by the group.Some essential concepts need to be developed at workshops to build along with women the feeling of autonomy and desire to participate so they can become active subjects in the pursuit of their rights and to attain their economic independence, strengthening their struggle for social protagonism 33 .These features approach health action and Health Promotion because they are based on actions that boost empowerment initiatives to increase individual and group skills.
It was important to establish a partnership with city hall, at the breast oncology physical therapy outpatient clinic in order to carry out the health action.However, despite the partnership, it still was not possible to implement the action entirely, due to political and economic limitations, such as changes in the municipal government and, more specifically, in health services management, in addition to lack of material resources and inputs.Although changes in service practices can already be observed, due to training workers in Health Promotion and Social Development, and due to the involvement of women in building actions, work and income generation workshops have not been implemented yet due to the limitations mentioned.
In order to strengthen the initiative, in addition to the partnership with City Hall, other partnerships must be sought with local companies to supply raw material to manufacture the product to be marketed.Training women requires partnerships with teaching institutions oriented to the goods and services business and services that support micro and small companies, for technical and financial support of the project, like in a company incubator.
Regular evaluation, aimed at providing improvements in the actions of the Project such as the workshops will be held based on the Bambu Method that proposes participative evaluation, giving voice to women and to all social actors involved so they can perceive progress made and the power of continuing to execute and improve actions together.This leads to decision making on what was executed, whose function and value are also strengthening autonomy, and thus con-tributing to overcoming adversities and favoring co-responsibility in the construction of the project.
For the full development of the work and income generation action it is necessary to formalize women's interest in participating; applying the Bambu Method questionnaire to evaluate the motivation before and after the process for building action; choose along with women the dates and time of workshops and of the product to be marketed.Moreover, it is essential to commit public authorities and the partners mentioned above for sustainability, strengthening the support network for participating women.

Final comments
Work and income generation action enables a new perspective for working with women submitted to mastectomy, because it aims to provide an economic activity oriented to their needs and limitations, approaching the theoretical and practical foundation of health promotion.According to Facchin et al. 34 , the effectiveness of a Health Promotion project is related to the effect of health actions and practices implemented, that is, changes introduced by an intervention in a real life context.In this sense, work should not harm women's recovery process, but promote positive health actions and enable skill building and changing social determinants of health to benefit their quality of life 33 .
The intention in fully implementing health action is to stimulate the social and economic function of participating women while productive subjects, based on the empowerment and the ability to create links, share feelings, expand awareness on problems faced, and seek solutions.Among results expected, we can mention greater autonomy, increased purchasing power and social recognition of women.
Emphasizing the link between -participating women, workers directly involved, public authorities, local businesses, teaching institutions and entities fostering work and the income generation Project -is also desired as a way to create a network that supports the leading role of these women in rebuilding their lives and having the possibility of rewriting a new post-mastectomy story, with improvement in financial and social status, so as to have an active role in their own history.
These results are in agreement with the founding values of the PNPS, such as solidarity, happiness, ethics, respect to diversity, humanization, co-responsibility, justice, and social inclusion.Social participation as the core contributes to transformation of individual and collective subjects, values personal skills, and strengthens potentialities of women involved in order to overcome vulnerabilities.

collaborators
CSS worked on the development and design of the entire intervention Project process; took part in revision of theory, writing the article and approval of the final version for publishing.GGG guided the development and design of the entire intervention Project; took part in revision of theory, writing the article and approval of the final version for publishing.PMCC guided the development and design of the entire intervention Project; took part in revision of theory, writing the article and approval of the final version for publishing.MFLT took part in revision of theory, writing the article and approval of the final version for publishing.
an example of a positive experience of collective actions involving Health Promotion, in January 2002, the Public Health and Social Development Center (NUSP) of the Federal University of Pernambuco (UFPE) and the Ministry of Health began the Healthy Municipalities Project in Northeastern Brazil as a Health Promotion initiative to promote local development of the municipalities of the State of Pernambuco.The objective of the initiative executed by NUSP was to create affirmative and evaluative mechanisms to improve the individual and collective potential of populations toward social transformation 30 .