Photovoice as a listening mode : subsidies for the promotion of equity

Health Promotion observations of patients from a Rehabilitation Center in rural São Paulo evidenced that these people faced difficulties in dealing with their physical limitations when these prevented them from working. This study aimed to broaden listening methods to facilitate dialogue with people in situations of physical frailty and removal from their work activities, using Photovoice, a participatory research-action method, as a tool and Health Promotion’s theoretical framework. Images captured and reports that accompanied them consisted of the material of this study. Two thematic categories stood out: the expert decision; and physical condition: vanity, power and hope. Labor activity is perceived as a determinant of individuals’ introduction in their environment and defines their role in the family and in the social field. Faced with disability, they feel deprived of their identity, vulnerable and without future prospects of social reintegration, an individual and familiar misfit process, but without social visibility and with negative consequences for global health is observed. Photovoice proved to be effective in apprehending perceptions and stimulating debate, providing essential inputs to promote equity in socially disadvantaged groups.


Introduction
Throughout the history of humanity, labor has been playing an important role in shaping the identity and list of daily activities performed by individuals in their existence 1 .Work can be difficult to define and contextualize, since its meanings are imbued with historical, cultural and social notions.
In a broader sense, Alves and Antunes 2 point out some aspects that are involved in the human act of working: gestures, know-how, body engagement, mobilization of intelligence, ability to reflect, interpret and react to situations, and power to feel, think and invent.In other words, authors say that work is not, in the first instance, the wage relationship or job, but rather labor activity, that is, a way of engaging the personality to address a task delimited by material or social pressures.
Formal or informal work-related activities can be enjoyable or unpleasant; they can be associated or not with economic exchanges (salary) and executed or not within a job 3 .The salary they provide allows for basic needs and provides a sense of security, autonomy and independence.
In Brazil, from the mid-twentieth century onwards, mechanized agriculture and the progressive rural exodus created a new contingency for the cities, receiving the migrant population through wage labor and allowing them to integrate into the new environment.However, the weak process has exposed fractures of the urban environment and vulnerabilities of its population.
In collective health, persistent inequality conditions are called inequities.To address them, the Ministry of Health (MoH) and other spheres of management of the Unified Health System (SUS) recommend the Promotion of Equity through the progressive reduction of these vulnerabilities.It is necessary to understand the social determinants of health of exposed population groups for the organization of health actions and services to ensure resolving access 4 .
Illness or physical frailty that impairs individuals' ability to work can adversely affect their overall health.Although they receive state sickness benefits during their leave, the provision of resources is undermined, exposing them to socially produced inequities, and placing them in a situation of social disadvantage.
The National Institute of Social Security (INSS), an agency linked to the Ministry of Social Security and Welfare was established in 1990 as a public organization providing social security services, which, among other responsibilities, is in charge of standardizing, guiding and leveling-off procedures and payment to beneficiaries of Social Security and Social Welfare with labor disability 5 .
Souza et al. 6 state that illness leading to the professional incapacitation of young adults has a very painful aspect, which is the destruction of life projects, a significant loss of one's personal and professional identity.It is necessary to search for new parameters so that the disabled can recognize themselves, reorganize their previous history and construct a new project for the future, taking charge of this process.
Health Promotion advocacy revives the exercise of citizenship and aims to achieve equity in health and ensure physical, mental and social well-being of the people.Therefore, it is outlined as a tool of social participation aimed at protecting the universal right to health in Brazil 7 .
This paper aimed to increase the use of Photovoice as a Health Promotion tool, in order to expand the dialogue with individuals in situations of physical weakness and removed from their work activities.

Methodological theoretical approach: expanding the listening modes
The theoretical conception underpinning this paper was social psychology in a perspective privileging the understanding of social phenomena, taking into account that meanings and intentionality separate them from the natural phenomena.In this context, a more comprehensive than causal aspect is favored vis-à-vis possible interpretations given to psychosocial phenomena 8 .
Photography is shown as a strategy closely linked to qualitative research 9 .It helps in the descriptive aspect of an event, in the understanding of subjective aspects and can be analyzed inductively.Images captured in photos facilitate the study of aspects of life that cannot be grasped with words alone.
The Photovoice method adopted and adapted for this research was developed by Wang, Burriss and collaborators in the mid-1990s.It is a process that enables individuals to represent and expose their community experiences through a specific photography technique.This method gives voice by providing cameras into the hands of people who will be trained to act as reporters and potential catalysts of political and social change in their own communities [10][11][12] .
Its theoretical body built on three fundamental ideas.The first is based on Paulo Freire's critical education approach (1970 apud 10 ).This approach holds that every human being, no matter how ignorant or submerged in the culture of silence is capable of a critical and dialectical look at the world around him and his own relationships.
Photovoice is classified as a type of participatory research-action in which people produce and discuss photographs that they themselves have taken about their experiences as members of a particular community or group.Through photographs and accompanying reports, it is possible to expand dialogue with the responsible authorities [11][12][13] .
The strength of the visual image shows potential for the empowerment of socially marginalized population groups, allowing a creative process that facilitates the representation of the diversity of their experiences as members of a group or community 14 .
This research was developed and idealized from the experience with a Support Group of the Physical Rehabilitation Center of the Santa Casa de Misericórdia Foundation of the municipality of Franca, a hospital complex linked to the SUS.Established in July 2002, it provides services to the population requiring physical rehabilitation referred by the municipal health network.The treatment provided includes an interdisciplinary view of health care and is performed by a multidisciplinary team: social worker, physiotherapists, speech therapists, physicians (physiatrists), nutritionist, psychologist, nursing technicians and occupational therapist.
The Support Group aimed to accept and work with the emotional aspects of patients in the process of physical rehabilitation, promoting understanding and adaptation to the physical and social limitations resulting from the illness process.The Group was open and received weekly an average of ten (10) users.The sample consisted of five people who agreed to participate in the research approved by the institution's ethics committee (019/2007).All were assigned fictitious syllables to protect their identities.
After signing the Informed Consent Form (ICF), participants had two meetings for technical preparation.With cameras in hand, they were instructed to take pictures, seeking to portray their daily life from the moment they became incapacitated for work, focusing on the changes that occurred in their daily life routines.
Chart 1 shows a brief characterization of the participants including age, marital status, number of children, profession, time and cause of removal from work.

Photographies: pictures and narratives
"To photograph is to align head, eye and heart."(Henri Cartier-Bresson) The group produced 56 photos.Two more group meetings took place between researcher and participants to discuss photos.Accounts that accompanied the display of ideas and meanings assigned to photos were recorded and rewritten in their entirety.A dialogue was established with the researched literature, using the Health Promotion's theoretical framework.
We used the thematic content analysis technique 8 to analyze the material produced.We first sought to read the transcripts of interviews in search of categories, themes, words and expressions that could organize the results in order to interpret them.They were organized in two thematic categories: expert decision; and physical condition: vanity, power and hope.The material was then organized in relation to these prevalent themes and classified within the pre-established categories; finally, we made interpretations, broadening the understanding from the empirical data articulated with the theoretical reference.
The breadth of the Photovoice method has challenged researchers who have used creativity as a research resource during the artisanal work of this qualitative research; without losing sight that pictures had a symbolic potential and an ability to capture emotions that could not be reduced to the words captured in the interviews.

Expert decision
In the municipality were participants live, all of them clicked the INSS.Reports resulting from this setting were accompanied by feelings of sadness and nonconformity, since removal was not a choice but a need due to illness, its sequelae and work limitations.In the statements, the need for another, the medical expert, for example, to endorse the illness, generated distress.
It was difficult for the external observer to assess the status of this theme in the participants' lives, but it was outlined as one of work incapacitating signs and symptoms and the financial and social consequences thereof.-Well, talking about the INSS...This is the line that we face every 2-3 months, depending on the expert.It is a hassle, mentally and psychologically speaking, because they remove you for a short term.You know you are truly unable to work, anyone could see that just by looking at you.[...] (Te.).
Another aspect emphasized was dehumanized care and the certainty that a humanized care would provide a sensitive reception and view from the professional, who could perceive that people who need this place are usually going through critical moments.
-[...] Yesterday, I heard something absurd on the radio: a doctor discharged a patient with terminal cancer.This is what I want to talk about regarding INSS.Things got worse for those who are sick.(Ce.).
-This is a sick situation!All this tension around people, without them knowing if the expert will approve them, and there are many people who are not even supposed to be there.Others, I feel so sorry for them, are being discharged, my God!Some people should die and be borne again to go back to work again.There are so many absurd things![...] (Te.).
Accounts evidence a gap in the understanding of the professional practice of medical experts, which also includes the difficulty of apprehending the criteria used by them for the preparation of the opinion.
The main reason that leads the participants of this study to make use of the social security sickness benefit, which is the benefit granted by the INSS to all insured persons who are temporarily incapacitated to perform their usual work activities 15 .
The social security expert decision appeared as a reason for dissatisfaction and even as an aggravation for already precarious health conditions.Several criticisms and complaints, such as disrespect to the insured for explicitly addressing political interests by denying the relationship of claims to work are aimed at the results of the acts of Social Security experts 16,17 .We observe that this medical decision is subject to variability, depending on the interpretative model adopted by the expert, which shows us the subjective character of this professional exercise.
The expert may also be influenced by his political tendency.Melo and Assunção 17 marks two extremes in these trends; he may be inclined to identify the worker as a victim of work, a sick person, and thus deserving of benefit or the physician will tend to regard the insured as an opportunist, as if sickness were a secondary gain.In contrast, some individuals who persist in working, despite their symptomatology, and are only removed when they evidence a high level of chronicity, recurrence and incapacity.However, none of these positions are adequate for overshadowing and impose their personal values over the attributes of the medical profession 18,19 .

Physical condition: vanity, power and hope
The physical condition for work activities arose, albeit between the lines, in most of the photographs and in several moments of the patients' accounts.We note that the capacity for work promotes achievements, but removal generates tension.
The profession locates the individuals in their environment; it defines their role in the intimate, family and social context.The person is what he or she does and the loss of doing so entails an identity crisis.When the work activity is conceived as synonymous with production, producing and feeling useful are pondered.As societal individuals, the ability to establish exchanges with their peers provides a sense of approval that seems to be part of the participants' need for esteem.
In its multidisciplinary context, Health Promotion covers socioeconomic and psychosocial aspects, as well as the development of new strategies that allow people to improve health and quality of life, actively participating to reduce the risks of illness.We understand that risks go beyond chemical, physical and biological agents, reaching the way the company organizes itself and relates to its workers.All these variables have their importance and the management of each one of them can contribute systematically to an improved environment 20 .
It is interesting to note that statements revealed segmented activities in two areas: heavy and intellectual.The first one restricts the possibilities of introduction into the market since they suffer from irreversible physical weaknesses, since their tool of work would be the body itself, in a deterministic sense of the expression.They would still have a room for intellectual improvement, but resistance is high.The shaken emotional aspect limits their attention and memory capacities and adulthood creates the feeling that one no longer has the time to start over.
The physical condition was portrayed in photo-1 (Te), for example.In the picture, the author appears sweeping the balcony of his house with difficulties, an apparently simple activity that evidences losses.
-It bothers me a lot.Because, as I said, I was always a nimble person, someone who talked and played.I like to work.I have always worked a lot; I have always been working twelve to sixteen hours a day.Therefore, it bothers me that I am away.I am young, I think I still have a lot to do, I have the will, but I do not have the conditions.(Te.).
The negative realm of the work activity is pointed out in the verbalizations referring to the fact that when actions are carried out under inadequate conditions (environment, workload, safety, among others), they cause physical and emotional illness and deprive them of family contact.The low pay for heavy work and the need to maintain basic subsistence issues led individuals to abuse their health to accept overtime on weekends and this seems to have excluded from the participants' lives the possibilities of selfcare 21 .
Photo-2 (Te) shows several medicines set on the table that Te. started to make use due to physical illness.Ma. photographed his trusted psychiatrist, a bond established because of an anxiety disorder arising from her physical condition and its repercussions on overall health. -

No, I have never used any medicine. I have always had good health, willingness, I have always worked with two things, and even when my company made us work twelve hours, I tried to sell something on the side, I always earned some extra cash. I have always been against drugs. Now it is the other way around. I am somewhat groggy today because I went through a drug change. I am somewhat sleepy; I really did not want to get out of bed. [...] (Ma.).
We observe a psychic suffering-work dyad; studies reveal that it is the content of tasks, the quality of relationships with co-workers and the organizational hierarchy that can trigger psychic suffering or be a source of pleasure and balance, depending on the margin of freedom provided in the environment and labor relations 21,22 .
In photo-3, (Ce.3), the participant depicted his wife working in the backyard garage on an outsourced service, illustrating her perception on the changing family provider status.
-I started working early, at the age of eight.There was a candy factory here in Vila Nova, my mother bought candies and we sold them.We had childhood, but a childhood on weekends because we worked on weekdays.Then, suddenly, after more than thirty years of work, my productivity has abruptly interrupted, and that makes anyone annoyed.Then, you depend on other people, and you were contributing before.This bothers me a lot.[...] (Ce.).
These countless factors add up to another observation: to participants, falling ill corroborates with statements by Mendes and Dias 23 when building on the cultural, political and economic significance that society attributes to their bodies.Culturally, in order to be valued by society, a person should be useful, since not working equates to uselessness and ill will, stirring in adults individual feelings of worthlessness, to the point of not feeling worthy to enjoy moments of leisure.
In photo-4 (Di.), the lenses captured a young boy going to work by bicycle early in the morning; his old course when he was employed, valu-ing the physical condition of the body that is capable of producing.
-There are chemical and tannery products.Even before I was removed, I went to get a sack of baking soda that weighed fifty pounds.Today, the difficulty of rubbing my feet is absurd...Then, just imagine reloading the fifty pounds: I am out!Even the doctor told me to forget it.Regarding nimbleness, because everything, even sitting, requires a nimble body.To get up, to sit down, to move.I had to discard the possibility of working as I used to do (Di.). -

I was early up at the firm, because my mother put us early to work. At the age of twelve I already had a formal working relationship; I was already at the firm and I became a formal employee [...] It is another life, another availability. It is very different. You do not get tired. When you come in from work, you do one thing or another. Just lying idle tires you more than working (Di.).
Attributes such as dedication, responsibility, satisfaction and professional recognition are common elements found in self-description of the participants, who kept rhythm and productivity in their jobs, facilitated by the physical and emotional condition that they no longer have.
The difficulty of maintaining the same productivity, coupled with hardships caused by the disease itself ensued changes in their ways of acting and reacting.Significant changes that affected the several aspects of life, combined with anxieties and concerns, mainly due to the delay in improving the clinical condition.
The physical limitation hinders the performance of routine personal and domestic care   activities and leads to require help from other people.These restrictions interfere with autonomous development of leisure activities, of the profession and those required by the treatment, besides raising distrust of coworkers and bosses, and even of relatives, due to the incomprehension about the difficulties caused by the disease 24 .
Next to the arm physically weakened by a traffic accident, the photo evidences pins used to fix Cl. bones; symbolizing change and loss.
-That's it!When I was working, I did not have many things to think about, I did not have much reason to cry or to be sad.There I talked to everyone; I had many friends.After I suffered this accident, it seems as if a lot has changed, even friendships.I was more alone, though I was staying with my kids at home.They have their own lives; they like to play and do other things.There is no way we can spend the whole day together (Cl.).
Work is the arena of suffering and the stage of pleasure.It carries an ambivalent meaning, as we can see in the photographs inserted in this theme.This dubious character of work seems to be synthesized in a sentence by French writer Anatole France in his novel The Amethyst Ring 25 , which says: [...] work is good for man.It distracts him from his own life, keeps him away from the frightening sight of himself; it prevents him from looking at this other that is him and that makes his solitude horrible.It is a holy remedy for ethics and aesthetics.Work has one more excellence: it distracts our vanity, deceives our lack of power and makes us feel hope of a good event.
French psychoanalyst Dejours 26 affirms that the dynamic quality of the articulation of the de-sire to recognize the subject with what he desires and requires work organization (the other's will) should indicate the way of suffering, subjective mobilization and level of commitment both to health and illness, therefore, both pleasure and suffering.
This reveals the ambivalence of this theme, a source of psychic alienation and health and an emancipating tool 27 .However, to be a source of health requires recognition of the one who works, since possibility of giving meaning to the suffering experienced by workers lies in this recognition.In other words, we can say that recognition is an indispensable condition to the process of subjective mobilization of intelligence and personality and plays a crucial role in the possible transformation of suffering into pleasure.This aspect of recognition seems to give meaning to suffering, that is, the individual, through recognition, meets his potentialities and singularities and becomes what Dejours and Abdoucheli 21 call creative suffering.
Photographs and reports expanded the understanding about their physical conditions, and disease was the cross-sectional element.The very relationship with work of these studied subjects was ambivalent.On the one hand, it was remembered as a source of pleasure because it produced the ballast for recognition and identity.On the other, it was a source of suffering, because these people, in addition to addressing daily work pressures and demands, had the disease as their share of engaging in work, a condition that now brings them physical pain and a series of emotional and social consequences that have radically transformed their lives.
-Fifteen years ago, I had a bike to ride and today, thank God I have a house, I have a motorcycle, which I can no longer ride, and I have a car too.That was proof of what it is to be working, to be producing.If I had a plan to refurbish my house, I figured it would take four months in a row working on it late, and I could do it.You had a plan and you could do it (Di.).
-Sometimes, when I have some things to read, because I do not know much, I studied little.However, more often, my wife helps me out [...] I think that staying at home does not pay much either.The good thing is you feeling like coming home.Staying at home makes you sick (Di.).
When approaching work from a generic viewpoint, one risks not perceiving the subtleties of the experiences of the illness process according to the gender and peculiarities of the roles played in the social context.
Boys are oriented to be providers and protectors.From the very start, they are trained to endure without weeping their physical and emotional pains.Thus, a masculine identity image is linked to being strong, capable and protective, violent, determined and courageous.Manly behaviors, which, if on the one hand, strengthen men's ideal of being, on the other, consider and prevent self-preservation.These values instill in men an ambition for ascension and settle in their subjectivity as a manly perspective that does not feed caring or care, thus confusing personal identity and gender identity 28,29 .
The concrete and symbolic organization of social life and power connections in the relationships between sexes are reflexes of the gender that is concerned with the consolidation of a discourse that, when constructing a female and male identity, shackles men and women to their limits.The story of the incapacity for work and its reflections in the participants' daily lives seems, in part, to liberate them from this stigma 30 .
In photo-5 (Ce), among others, the dialogue regarding male roles in the relationship with their emerged, showing paternal and domestic chores assumed from the physical incapacity and resulting changes.
-My current helps me take care of my little ones.It's a way to get closer.If I were in that life, as I have always been, I would never be able to see them all four dressed in their school uniforms and carrying their backpack (Di.).
Torrao Filho 30 observes that some women directly associate symbols of social and professional upward mobility and status ascent, such as prestige and power, to the expression of their male side.Much in the same way, men identify their affective needs by referring to their supposed female side.
The discourse on gender creates an essence of what it is to be a man and a woman, an identity to which women and men are not invited to interfere and preserve diverse prejudices.Thus, the current status of individuals of this study has demanded and facilitated the experience of aspects identified as of the opposite sexes.Women have felt the need to be more active and competitive in search of their rights, thus experiencing aspects culturally associated with masculinity.On the other hand, men have been able to be more affectionate with their offspring, to provide care for their homes, to dialogue more with the family, which are essentially female attributes.We observed in the accounts that emancipation and equitable access are beneficial to them and enable a satisfactory life experience.
-But I, in particular, still intend to return to the labor market.Not the way I am, because I'm incapable at the moment, but not forever.Even if it is not to work as an employee, but to have something of my own, definitely (Ma.).

Final considerations
Objective and numerical data were not sought.This paper aimed to expand listening methods in Health Promotion to facilitate dialogue with the group in a situation of social disadvantage due to the physical weakness and removed from their work activities, in order to identify elements that can support the development of equity-promoting policies.The number of participants was obtained based on their availability, the intended period and not saturation because in this case, stories are unique and relate to the existence of these workers.
This paper may be an invitation to overcome the limits of invisibility imposed by a social alienation that rarely sees individuals incapacitated with nuances of their pains and, thus, ends up sidelining them.The images captured portrayed how these people are excluded not only from the world of work, but also abandoned by public institutions that should protect them.
From images captured by them, the dialogue in the group space flowed deeper.It had the capacity to be a place of sharing experiences and promoting actions of social engagement.It was not restricted to the search for solutions of in- dividual problems, since it privileged proposed collective actions with potential social transformation.The need to seize the liberty of gaining other spaces and ensure the full use of institutional policies was evidenced.
We consider that strategies, such as those promoted by this research, in which the dialogical relationship and subjectivity are valued, generate possibilities for the reflection and construction of new meanings by disadvantaged groups, in this case those that are removed from their work activities, about their rights, their role and participation as agents of social change, a stimulus to the exercise of citizenship.Strengthening citizenship is one of the main objectives of groups supported by the theoretical support of Health Promotion.Although it seems a challenge, especially for the weakest groups, effective actions among the different sectors could increase the possible recovery of individuals incapacitated for work.Thus, the Photovoice methodological option enabled knowledge and assessment of needs that exceeded health diagnosis, by encouraging reflection, sensitization of the participants and consequent planning of action.It is an effective toolkit to apprehend perceptions and stimulate debate, providing essential inputs for building policies that promote socially disadvantaged groups.
The Photovoice method expanded the setting and the possible interventions of participants and researchers.Once recorded, images cannot be silenced with words, and when shared with others with similar experiences, they acquire the power to resuscitate subjectivities alienated by the social system.We hope that studies such as these may inspire Equity Promotion policies for populations with similar characteristics, since we perceive that critical awareness has the potential to mobilize action and to break with the resigning attitude.

Collaborators
MFS Touso, AB Mainegra, CHG Martins and GLA Figueiredo were responsible for designing and outlining the study, writing and critically reviewing the paper and approving the final version to be published.MFS Touso was responsible for extracting data.MFS Touso and AB Mainegra participated in the design of the study, data review and interpretation and approval of the final version to be published.

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[...] So, you get there in an somewhat average condition; when you get in, your already frail psychological condition gets worse, since you know what you're about to expect in there [...] (Ce.).

Figure 2 .
Figure 2. Te. and the several medicines she has to take.Author: Te.

Figure 3 .
Figure 3. Wife of Ce. working in the garage of their own home.

Figure 4 .
Figure 4. Boy heading for work -remembering Di: his old itinerary.Author: Di.

Figure 5 .
Figure 5. Ce. by his computer at his own home, and his youngest son standing by.

Chart 1 .
Participants' profiles by gender, age, marital status, number of children, profession, reason and time of removal from work.