Evaluation matrix for health promotion programs in socially vulnerable territories

Health promotion has a set of strategies for advancing health and reducing inequalities. However, evaluating the effectiveness of health promotion programs has been a challenge. This paper shows the development and application of the Evaluation Matrix, constructed with qualitative-quantitative and multidimensional indicators supported by public policies targeting socially vulnerable territories. This is a cross-sectional study with the implementation of a health promotion program in order to develop an Evaluation Matrix to be applied in two distinct socio-environmentally vulnerable areas. The Evaluation Matrix proved to be easily applicable and enabled the detection of strengths and weaknesses of health promotion programs applied in different territories. The participation of managers, teams, population and multiple sectors of society was decisive for the success of the program. Furthermore, community health workers stood out as essential stakeholders due to their linkages with the population. Contributions include a tool and methodology for evaluating health promotion programs to be applied in different territories and modified according to the territory.


Introduction
In 1946, Sigerist referred to the term "health promotion" in defining essential medical tasks such as health promotion, disease prevention, patient recovery and rehabilitation 1 .
In the 1970s, with the revival of nineteenth-century social medical thinking, the term health promotion was once again used mainly in Canada and in Western European countries, from the discussion about effective high-level curative health care technology, increasing health medicalization and the need to reduce the cost of the current biomedical model 2 .
In the 1980s, the International Conferences of Ottawa (1986), Adelaide (1988) and Sundsvall (1991) initiated the global health promotion movement and brought to the discussion the concepts of health, risk, social vulnerability, territory, intersectoriality, participation and surveillance, as well as the current conceptual and political bases for health promotion 3 .
In Brazil, this discussion was inspired by the progressive model, with a scientific stance and critical analysis of the relationship between health and society.Thus, there was an extensive production of papers aimed at understanding this relationship and the origin of the different epidemiological profiles found in our society, characterized by inequality.Therefore, health promotion began being perceived through its determinants and the understanding of the health-disease process was expanded 3 .
In the last two decades, some Latin American and Caribbean countries have implemented reforms in their health systems that have fostered inclusion, citizen participation and equitable access to health care 4 .Despite these initiatives, huge inequalities in the coverage of health interventions persist in most countries of the region.
In Brazil, the economic advances observed during the military regime have disproportionately benefited the privileged segments of society and the movements for democracy provided a broad discussion on the needs of the population, thus catalyzing the Health Reform 5 .The construction of the Unified Health System (SUS), based on the principles of universalization, equity and integrality was a commitment of the State to comply with its duty to provide health promotion policies.It is in this context that Primary Health Care of SUS, primarily through the Family Health Strategy (FHS), acquired the important role of responsible for providing humanized access, coordinated care, comprehensive ser-vices and equity in its actions 6 .Health promotion programs have been implemented by SUS with the aim of reducing inequalities in different territories 7 , but there is no evidence of an evaluation tool that originates in territorialized social realities 8,9 that considers the participation of societal sectors and stakeholders 7 .
The need to follow-up on the quality of health systems through monitoring and systematic evaluations has been emphasized by the World Health Organization (WHO) 10 , but they generally use disease outcomes such as mortality and morbidity.Previous studies have shown that health promotion has the potential to act effectively in the health-disease process in a way consistent with the reality of each territory 2,3,7 ; but evaluating health promotion programs is a challenge, since health promotion has a differentiated vision based on territoriality and is unrelated to the exclusively biomedical vision of disease.In collaboration with WHO, since 2002, the International Union for Health Promotion and Education (IUHPE) has started to support initiatives to assess and show the effectiveness of health promotion to health system managers 10 .In 2004, the Pan American Health Organization (PAHO) engaged in this debate, which emphasized the importance of establishing health promotion policies and/ or programs built on participatory methodology and agreement of guiding values and principles for the evaluation of health promotion 10 .
At the national level, SUS' performance is evaluated with PROADESS 11 and the quality of Primary Health Care services is evaluated with the PMAQ 12 .However, SUS does not have a tool that evaluates its proposal for the qualification of health promotion actions.
Academia is also addressing this challenge.Restrepo 13 considers that the evaluation of health promotion should be part of planning and developed through social participation and sustainable actions.Pedrosa 7 stresses this characteristic of health promotion evaluation when affirming that it has to be participatory, where stakeholders negotiate, agree and decide collectively in order to achieve the desired changes.According to the author 7 , evaluation thought of in this form acts between the established and the transformative, and is transdisciplinary and multicultural, highlighting the need to be institutionalized in order to be effective, since issues, criteria and evaluation parameters are built from the articulation of the evaluation and its object.
These trends are also found in the quality assessment model, the "Systemic Evaluation Model" proposed by Donabedian 14,15 , which is composed of the analysis of the realms: structure, process and results.For each realm several indicators are selected and used jointly with the intention of enabling stakeholders involved in producing health to appropriate the methods and tools both to make a diagnosis about the organization and operation of services and practices and to build intervention projects for the identified challenges.
The challenge of evaluating health promotion programs is even greater when considering the complex health-disease process in areas of socio-environmental vulnerability, where poverty-related diseases coexist with chronic non-communicable diseases, external causes of injury, inadequate sanitation conditions and difficult access to prophylactic measures, including treatment and educational measures [16][17][18][19][20] .In this context, intestinal parasitic infections (IPI) perpetuate the disease-poverty-disease cycle 18 by impairing cognitive function and school performance and, consequently, employability conditions 6,21 .The impact of IPIs has been largely ignored in Brazil and in other developing countries, neglecting these diseases even more 18,22,23 .
This study builds on the hypothesis that qualitative-quantitative and multidimensional health indicators contribute to the evaluation of the effectiveness of health promotion programs based on public policies, the promotion of perceived health from its determinants and the expanded conception of the health-disease process 3 .
Thus, this study aimed to develop an Evaluation Matrix based on the implementation of a health promotion program, with the theme of confronting intestinal parasites (IPs) in vulnerable territories, using the theoretical bases of health promotion, the quality assessment model 14,15 , health planning 8,13 and evaluation 7 for its construction.

Methodology
This cross-sectional qualitative-quantitative study was carried out through the implementation of a health promotion program in the period of 2013-2015, using participant observation, interviews and census in the 559 households enrolled in the Family Health Strategy (FHS) of the municipality of Laje do Muriaé, RJ, aiming at the construction of the Evaluation Matrix and subsequent testing of its applicability in territories with different realities.Program implementation counted on the partnership of the Municipal Health Secretariat (SMS) and adherence of FHS and Endemic teams of the Municipal Culture and Education Secretariats.Secondary school students from the municipality, members of Scientific Pre-Initiation Program for Young Science Talents, from the Foundation for Research Support of the State of Rio de Janeiro (FAPERJ) also participated in the initiative.

Study areas
The health promotion program was developed in the municipality of Laje do Muriaé, which is located in the northeast of Rio de Janeiro, Brazil (21°12'24''S, 42°7'57''O).It has the second highest Social Vulnerability Index (IVSop = 0.82, 1 being the most vulnerable) 24 , the highest rate of declining population in the State (-0.53% per year) 25 , the second lowest GDP of the State 25 and a large force enrolled in the Bolsa Família (Family Grant) Program (4.208 inhabitants, 60.0%) 25 .
Laje Muriaé has a total area of 250 km 2 and a population of 7,487 inhabitants 25 ; 3,126 (42%) have some occupation, of which only 940 (30%) have a formal employment relationship.The municipality has poor sanitation conditions, piped sewage, but which is exhausted in natura in the River Muriaé that traverses all its urban area.
The Matrix was later applied to the Manguinhos Complex of Favelas located in the northern part of the city of Rio de Janeiro (22°52'47.04"S,43°14'57.18"W),with approximately 40,000 people 26 .The Complex is composed mostly of salaried, underemployed and/or unemployed workers, poor sanitation and water supply conditions and defective public services 27 .Since Manguinhos is not a municipality and does not fit into district boundaries, the Manguinhos Complex of Favelas has limited official population data.However, it is a region with issues related to poverty and increasing violence 28 .Communities also coexist with air, water and soil contamination resulting from polluting industries, namely, the Manguinhos refinery.
Both locations have determinant environmental conditions in the development of health-disease processes.

Stages of the Health Promotion Program
The program carried out in Laje do Muriaé was structured in three stages (Figure 1): 1. Situational diagnosis (pre-test), aiming to identify the frequency and profile of intestinal

Managers and stakeholders
Partnerships?
Planning with the ESF Team (objectives, actions, assignments, schedule, resources, monitoring and evaluation).parasitoses; knowledge, attitudes and practices about IPs and socio-environmental conditions 29 .2. Educational intervention: health education actions with the population based on the identified problem situation, using integrative practices that consider local culture and knowledge and continuing education actions.

Signature of the
3. Epidemiological, socio-environmental and educational re-evaluation (post-test) 29 and the evaluation of the quality of drinking water and peridomiciliar soil 30 ; with distribution of educational material on the proper care of drinking water, water reservoirs and filters.
At all stages, observations made with the population and the FHS team were recorded 28 , aiming to identify qualitative-quantitative indicators in a multidimensional participatory perspective for the construction of an Evaluation Matrix.
All stages were also carried out in partnership with community health workers.Participants were enrolled through Informed Consent Form (ICF) signed by the legal representative of the family.The partnership with the SMS started after program objectives were agreed, when the Deed of Undertaking and Terms of Agreement were signed with the managers and the FHS team, respectively.

Building the Evaluation Matrix
Monitoring of the health promotion program adapted from Moraes Neto et al. 29 allowed for the categorization of the program's stages in the following realms: structure, processes and results 14,15 , and the identification of the need to map the work processes of each realm 14,15 .The analysis of this mapping allowed us to outline the flowchart of the stages of the aforementioned program 31 (Figure 1) and to identify the efficiency and effectiveness 32 of each realm (strengths and weaknesses) 31,32 , thus making the necessary adjustments.These results allowed to evaluate the articulation between structure, processes and results 32 and to identify the two additional realms not proposed by the systemic model of Donabedian 14,15 : 1. Context, since the program started with negotiation and agreement with the FHS team and stakeholders; 2. Continuity, due to the discontinuity of the program and its non-inclusion in the Municipal Health Plan of Laje do Muriaé.
It also allowed for the realization that the program considered nine principles of the PNPS 6 and, therefore, that the construction of research descriptors should be bound to these principles.

Evaluation tool (questionnaire)
The evaluation tool (questionnaire) was prepared through the following: 1. Identification of 23 evaluation descriptors linked to the principles of the policy (Chart 1); 2. Allocation of questions for each descriptor; 3. Establishing the typology of these questions: -Closed with scale: Yes, No, I don't know; -Semi-open that allow for the addition of comments and; -Developed from some important issues in order to obtain better information quality 32 .

Validation of applicability
The validation process of the evaluation tool (questionnaire) used micro and macro analyses based on its applicability.The tool was evaluated through the adapted Delphi Technique, with the collaboration of specialists in education, health promotion and health services using face-to-face meetings 33 (Figure 2).
Submission to the Delphi Technique generated reformulations of the evaluation questionnaire 33 , with each specialist contributing to improve the tool's applicability: 1.The Education specialist carried out an indepth analysis of the tool by broadening its qualitative character; 2. The health promotion specialist shortened the questionnaire, implementing improvements in the statement and reducing the application time to approximately 15 minutes; 3. The health service specialist stimulated the scope of the issues in order to adapt the instrument according to the needs of different territories with varying epidemiological profiles.
The differences in focus of analyses were not stimulated and emerged spontaneously from the evaluators.After obtaining the consensus of experts, the questionnaire that composed the Evaluation Matrix was established.
Then, questions received scores: 1. Closed questions with scale: yes = 2, no = 1, I don't know = 0; 2. Developing questions, one (1) point for each selected option; Intervals and the classification of scores obtained with the application of the Evaluation Matrix (Chart 2) were established following the assignment of scores.

Theoretical and potential alignment of the Evaluation Matrix Intervention
The Evaluation Matrix's potential for intervention and alignment with the theoretical foundations was discussed and evaluated in three workshops, which included the participation of -Health promotion and creativity.
-The evaluation and monitoring of health program and the management of cities.
-National Program for Improving Access and Quality of Primary Health Care (PMAQ).
Workshops 2 and 3: Potential for intervention * Health promotion programs: relevance of evaluation and monitoring for public management.
* Health promotion programs: relevance of evaluation and monitoring for the population.
Workshops 2 and 3 were recorded and suggestions were registered by two rapporteurs and
Can respondents understand and answer the tool?

Is the evaluation guided by theory reflecting its values and principles?
WHAT FOR?

Potential intervention:
• Engagement of the various stakeholders and their moments of participation; • Governability / Continuity; • Relevance; • Political opportunity for intervention.

Does the evaluation allow identifying problem situations within the scope of the respondents' resolution?
WHAT?

PROCESS OF VALIDATION OF HEALTH PROMOTION PROGRAMS EVALUATION TOOLS PROCESS OF CONSTRUCTION OF HEALTH PROMOTION PROGRAMS EVALUATION TOOLS
We used sessions with specialists in Health Services, Health Promotion and Education (Delphi Technique)

Microanalysis Macroanalysis
read at the end of the plenary.They were then incorporated into the Evaluation Matrix (Chart 2) following the participants' approval.The Evaluation Matrix was then applied to the coordinator and to the health workers who participated in the programs carried out in Laje do Muriaé and the Manguinhos Complex of Favelas, the latter by free choice of the FHS team of the Victor Valla Family Clinic, with authorization from the Education and Research Coordination of the Germano Sinval Faria School Health Center, National School of Public Health, Fiocruz, RJ.The results of these applications were submitted to a descriptive analysis (distribution of variables' frequencies).However, although 99.3% of the households received treated water, participant observation revealed that the population had a habit of drinking water from a well or a mine, and therefore, the post-test drinking water and peridomicile soil sample analysis was performed, showing that 84.2% of the water collected in households, water mines and wells were unfit for human consumption due to evidence of fecal coliforms E. coli and/or Salmonella sp.The prevalence of IPs in the soil was 82.7%.
The Evaluation Matrix proved to be easy to apply and facilitated the detection of strengths and weaknesses of health promotion programs carried out in territories with different characteristics: Laje do Muriaé and the Manguinhos Complex of Favelas.
The main strengths and weaknesses identified in the evaluation carried out by the Laje do Muriaé team were: The Evaluation Matrix's application time with the Laje do Muriaé team averaged 15 minutes.The mean score was 102 (78.5%), corresponding to the classification "Very good".
The main strengths and weaknesses identified in the evaluation carried out by the Manguinhos Complex of Favelas team were: The Evaluation Matrix's application time with the Manguinhos Complex of Favelas team averaged 13 minutes.The mean score was 75 (57.7%),corresponding to the classification "Good".

Discussion
The elaboration of the Evaluation Matrix built on the hypotheses that qualitative-quantitative and multidimensional health indicators contribute to the evaluation of the effectiveness of health promotion programs and that these programs are effective in the promotion, prevention and control of poverty-related diseases.It also considered that the construction of health indicators should be based on social reality 8 , participation and negotiation among stakeholders as suggested by Pedrosa 7 and Restrepo 13 .
Pinheiro & Silva-Junior 33 affirmed the need for a collaborative relationship between managers and evaluators for the institutionalization of health promotion programs.The results of the application of the Evaluation Matrix in the two locations also showed the importance of the adherence of health managers and stakeholders to the negotiations, but also the need for their inclusion in the Municipal Health Plan in order to ensure their sustainability and consequent institutionalization.
Pedrosa 7 argues that the lack of institutionalization occurs because municipal managers fail to consider health promotion as a public policy, since they believe that treatment is what matters, understanding health promotion as a chronologically anticipated prevention 35 .Felisberto 36 says that institutionalizing evaluations should be understood as contributing to the quality of Primary Health Care.It helps to trigger a process for building knowledge and better practices, promoting the construction of structured and systematic processes consistent with the principles of SUS, in its various realms of management, care and intervention in the territory.
The proposal of a Health Promotion Evaluation Matrix has been discussed by WHO and authors such as Pedrosa 7 , who, in his proposed health promotion evaluation, identified the construction of three major matrices: health promotion linked to the conception of epidemiological and social risk, health promotion articulated to broad proposals for sustainable development, and a third, intermediate matrix focused on actions of intersectoriality, active participation of the population with a priority for local development 7 .The Evaluation Matrix shown in this paper synthesizes the three strands of the proposed Matrices.
It also is in line with the discussion established by Carvalho et al. 35 based on the challenges associated with the conceptual field of Health Promotion and the requirements of evidence of effectiveness and efficiency faced by managers, evaluators and agents in the development of intersectoral health actions.These authors understand that the need for evidence in public policies can lead to an increased gap between complex health promotion interventions and their conceptions, and that the determination of changes in this area requires collaborative processes that consider the stakeholders involved in the implementation and evaluation of interventions.
Thus, the evaluation cannot be a purely technical procedure, it must have a methodological design which aims for social stakeholders to participate with decision-making power and for the evaluation results to be incorporated into management 37,38 , allowing managers to get acquainted with different problem situations and contribute to the well-being and improvement of the quality of life of the population.with the population, stakeholders, health managers and the FHS team brought to the forefront the need to outline the methodological design of the program in order to consolidate the results and favor the identification of qualitative-quantitative and multidimensional indicators for the Evaluation Matrix 37,39 .We could also observe that the three stages of the program carried out in Laje do Muriaé, in addition to contributing to the epidemiological diagnosis in the six micro areas covered by the local Primary Health Care services, the educational intervention, treatment and follow-up, further strengthened interactions between the population and the FHS team, as well as those with the local managers.In considering the results of the socio-environmental, educational and epidemiological surveys in the shared construction of educational actions, the program linked the specific characteristics of the territory to health education and to the preparation of the teams to engage in health education activities during home visits and throughout the entire process of care 23 .
Besen et al. 40 say that the FHS does not yet include health education as a major focus, since managers are unaware of the health promotion rationale and most have vertical educational practices, in a short-sighted and curativist relationship with the population, still inserted in the biomedical model.
Rootman et al. 41 stressed that there is a need to use multiple strategies to promote health and it would be necessary to be supported by principles of empowerment, integrality, participation, intersectoriality, equity and sustainability, principles found in the 2006 National Health Promotion Policy, which were extended with the introduction of intrasectoriality, territoriality and autonomy principles when reformulated in 2015 6 .This need to have the policy's principles as a strategic basis in the determination of evaluation indicators was identified at the end of the implementation of the program carried out in a participatory manner with all the segments involved in local Primary Health Care and facilitated the establishment of the Evaluation Matrix based on 23 descriptors elaborated from the nine principles of said Policy 6 and linked to the realms of the expanded systemic model of Donabedian 14,15 , aiming to enable the use of multiple strategies required to meet the characteristics of each territory, integrated by different vulnerable groups.
Thus, the Evaluation Matrix was established, corroborating the hypothesis that qualitative-quantitative and multidimensional health indicators contribute to the evaluation of the effectiveness of health promotion programs and that the participatory and integrated evaluation process has the potential to boost the management of quality and to promote the internalization of good public management practices and the continuous improvement of the teams' work processes 8 , aiming at confronting situations of exclusion and inequities, based on the establishment of the determinants of the disease-health process.

Conclusion
The rapid urbanization of cities evidences important situations of exclusion and great inequities.The development of health promotion programs and evaluation of its effectiveness are essential strategies for the promotion of equity and the right to the city.
Thus, contributions of this work include a health promotion program model and an evaluation methodology, namely, the Evaluation Matrix, built from a case study in a municipality with high socio-environmental vulnerability and which has been shown to be applicable in both territories with different characteristics by favoring: -Self-assessment by teams and identification of weaknesses in their work processes; -The identification of individual and collective health problems and the consequent need to act with integrity and equity; The Evaluation Matrix mainly showed the potential to boost quality management and favor the internalization of good public management practices and the continuous improvement of work processes, aiming to cope with situations of exclusion and inequities from the identification of the determinants of the health-disease process.

Figure 1 .
Figure 1.Flowchart Model of the Health Promotion Program developed in the municipality of Laje do Muriaé, Rio de Janeiro, 2013-2015.

Figure 2 .
Figure 2. Process of construction and validation of health promotion programs evaluation tools.
Deed of Undertaking (Municipal Health Secretariat) and Consent Form (ESF Coordination).

Chart 1 .
Principles of the National Health Promotion Policy (2015) and descriptors that meet these principles, 2013-2015.
The second stage of the program (educational intervention) held in Laje do Muriaé, with workshops and round tables