Pub Talk: participation, education and men’s health promotion

Objective: To evaluate the execution process of dialogical actions of a socio-educational group called “Pub Talk”, created by professionals of the Paraisópolis II Basic Health Unit, recognizing challenges related to men’s health. Method: Comprehensive evaluative research, which parameters were conceptual aspects of the Nola Pender’s model. Interviews were conducted with the professionals and the focus group with men participating in the Group, analyzing three components of this model: individual experiences and characteristics; feelings and knowledge about the behavior one wants to achieve; desirable health promotion behavior. Results: The group is a self-care guiding intervention; values scientific and popular knowledge, with protagonism of those involved; covers the prevention of disease and changes of habits; has different perceptions regarding the structural and technical aspects of the meetings. Conclusion: Dialogic actions contributed to the promotion of the health of the participants by favoring the (re)cognition of determinants of their health and living conditions.


INTRODUCTION
Following the reorganization of the Public Health Policy in Brazil, set up by the Unified Health System (UHS), several programs and policies were proposed to ensure the fundamental principles and guidelines. Only in August 2009, the National Policy for Integral Attention to Men's Health (NPIAMH) was introduced to the male public, aiming to qualify the health care of this population in the perspective of lines of care that preserve the integrality of attention. 1 In this Policy, some strategies are mentioned to approaching this public in the places commonly considered as being of concentration of this population, such as soccer fields, quarters and even pubs 1 , the latter being the locus of the present research.
Despite advances in gender and social relations, the man is still considered a financial, sexual and affective provider. 2 As a result, he is still present in the health services in a very timid manner, and in most cases, in the role of companion or in cases of emergency and urgency, or even at a specialized level, when chronicity is already a fact. Of course, there are many reasons for this, among them, the fact that in many health services, maternal and child health care actions predominate, as well as by the lack of preparation of health professionals to attend to this public. [3][4] In the scenario of vulnerabilities related to the health and well-being of men, we can highlight: greater percentage of deaths related to external causes, among groups that comprise the age group of 15 and 29 years; diseases of the circulatory system, followed by tumors, diseases of the digestive apparatus and, finally, diseases of the respiratory system. 1 Faced with these and other vulnerabilities, the male population needs, as well as other groups, specific strategies for the care of their health and promotion of self-care. New mechanisms for the strengthening and qualification of primary health care for men should be sought so that this is, in fact, the gateway of this population, including it in the process of promotion, prevention and recovery. 1,5 Men's difficulty in verbalizing their health needs can be highlighted, evidencing the notion of invulnerability and, at the same time, the little recognition of the importance of NPIAMH for this public. [5][6] Thus, the configuration of NPIAMH needs greater representation not only to the men's health, but also to the man himself. Guilt is still the focus when it comes to health care for this group, and several strategic actions are needed to identify means for them to express themselves. Recognition of such a policy converges to a better understanding of the health-disease process, as well as an understanding of its real needs and the integral promotion of their health. [7][8] In this context, health promotion is an appropriate approach to sensitize the issue, for which several models, such as the Nola Pender's Health Promotion Model, have been developed. Coupled with the most inclusive health education practices and protagonists, Nola Pender is a relevant benchmark. Fundamentally, a nursing model that can be used in multiprofessional contexts to implement and evaluate health promotion actions in three main aspects: 1. Individual characteristics and experiences; 2.
Feelings and knowledge about the behavior to be achieved and; 3. Desirable health promotion behavior 9 . There are no studies in the male population under this framework, although they are present in other publics and contexts. [10][11][12][13] Anchored in the premises of health promotion 14 , professionals from the Family Health Strategy (FHS), from the Basic Health Unit -BHU Paraisópolis II, managed in partnership by the Albert Einstein Hospital, located in the south of the city of São Paulo, developed a project to organize and strengthen basic care, according to principles and guidelines of the UHS: a socio--educational, multiprofessional group, focused on human health, called "Pub Talk". Since 2013, meetings of this group have been held in pubs in the Paraisópolis community, with the presence of 15 local men, on average, and with the participation of a health team consisting of nurses, nursing assistants, community health agents (CHA), as well as professionals from the Family Health Support Center (FHSC), who support the actions of this Group.
Through the use of different socio-educational strategies of a participative and protagonist character, such as the talking map 15 , several themes have been discussed in these meetings in an interdisciplinary way and in accordance with the interest of the group, contributing to qualify the participation of those involved, [15][16] as is also expected of education processes focused on health promotion.
Based on the theoretical-conceptual framework of health promotion, 9 it was in the interest of the executor group to better understand the health promotion behavior developed among the men participating in the "Pub Talk" Group, since in a collective and dialogical educational intervention of this nature, the dynamism in the group limits the clear apprehension of the elements that consolidate the health promotion, although the premise was that its collective application is viable.
Thus, the present research had the objective of evaluating the process of execution of participatory dialogical actions with a male socio-educative group, in the perspective of health promotion.

METHOD
The present study was developed through a qualitative, field-based, exploratory-descriptive approach, 17 based on comprehensive evaluative research, 18 taking as an evaluation parameter the conceptual theorical aspects of the Nola Pender's 9 health promotion model present in the course of development of the socio-educative group, with adult men, denominated "Pub Talk".
The work was carried out in the community of Paraisópolis, considered the second largest slum in São Paulo, located in the southern part of the city, in Vila Andrade, in the neighborhood of Morumbi. In an area of approximately 1 km 2 (0.386 miles²) lives a population of approximately 60 thousand inhabitants in a situation of strong socio-environmental vulnerability 19 . It is a scenario marked by inequality and social exclusion, few leisure options, lack of urban planning and adequate basic sanitation services, among other socio-environmental and health problems.

Men's health promotion
Santos FNP, Baldissera VDA, Toledo RF As for the instruments for data collection, semi-structured interviews and the Focus Group technique (FG) 20 were carried out. Participants in the interviews were seven health professionals from BHU Paraisópolis II who had already participated in at least one meeting of the socio-educational group "Pub Talk": three community health agents; a psychiatrist, a family doctor, a nurse, and a speech therapist. The FG was developed with nine men living in the community of Paraisópolis, comprising the age group between 20 and 59 years, who were already attending the meetings of the Group. Thus, the sample was intentional, considering that those who had experiences with the group were eligible for the study.
The questionnaire used in interviews with health professionals emphasized the following aspects: concepts of health promotion and; planning, development and repercussions of the socio-educational group "Pub Talk" for the promotion of men's health.
For the FG it was also previously elaborated and tested a script of topics that tried to raise the perceptions about: participation in the group; themes of greater interest and appropriateness of the strategies used in the meetings; perceptions of changes in living and health conditions, including self-care; impact of the subjects covered; approach to the BHU and to health professionals. The FG was held in a pub in the community of Paraisópolis on February 24, 2016, which lasted approximately three hours and was attended by nine men, as well as a reporter and an observer (to note non-verbal expressions of the participants), members of the health team. The FG mediator was the principal investigator of this study. The meeting was previously scheduled for this purpose, and all the men who were already attending the Group meetings were invited to participate.
The analysis of the results obtained with the semi-structured interviews and with the focus group was performed by the technique of Triangulation of Methods 21 , favoring different ways of looking at reality. Thus, the results were initially organized and transcribed separately, but analyzed together, searching for convergent and divergent ideas, comparing them with the theoretical--conceptual aspects of health promotion of Nola Pender 9 , in a way that allowed the agglutination of emerging themes apprehended by the researcher, to then evaluate the path of health promotion in the "Pub Talk" group.
In order to meet the ethical aspects required, the participants were asked to fill out a Free and Informed Consent Term and the research project was submitted and approved by the Ethics Committee (Certificate of Presentation for Ethical Appreciation -CPEA) and registered under the number 48,115,715.

RESULTS
The interviews and focus groups allowed the selection of emerging topics, namely: 1) Pub Talk is a self-care guiding intervention; 2) Pub Talk values scientific and popular knowledge through participative techniques with protagonism of those involved; 3) Pub Talk covers prevention of specific diseases and changes of habits in search of well-being; 4) Pub Talk has different perceptions regarding the structural and technical aspects of the meetings. These topics will be presented and discussed.

Pub Talk is a self-care guiding intervention
Regarding the participation of the participating men in this Socio-Educational Group, great satisfaction was reported with the meetings and discussions stimulated. It was noticed that their speeches converged to aspects related to self-care and to the way they understood their health. They valued the importance of this group, since the knowledge shared during the meetings allowed, many times, to recognize determinants of the health--disease process, favoring an approach critical in relation to the conditions of life and health: For me, it's getting to know about a health problem before it happens, I guess.
Among the issues addressed during the meetings, some were discussed and clarified, such as Arterial Hypertension, as one of the focal group participants recalled: I did not know that black people have a tendency to have high blood pressure, so, that marked a lot, I started to take care of myself, that was one of the key points for me.
In addition to discussing specific issues of certain diseases, the participants sought to stimulate, whenever possible and necessary, healthy eating habits and lifestyles, increasing the understanding of their determinants and allowing self-care not to be limited to medication, exchange of prescriptions or undergoing tests. Attempts were made to transform the concept of health and behavior of these men in relation to the biomedical model for a perspective of their participation in the maintenance or recovery of their health.

Pub Talk values scientific and popular knowledge through participative techniques with protagonism of those involved
When questioned about the positive aspects of their participation in the Group, health professionals valued the learning of new strategies, such as the talking map and the integrated panel, the exchange of experiences between different areas and these professionals with the participants in the process of health education. They also considered that this dialogue outside the BHU has contributed to greater interaction and approximation of these to users and, likewise, of users to health services.
In the speech of one of the interviewees, it was clear the recognition of that space as possible for the performing of reflections directed to the education and promotion of the health of men: Even though they were in the pub, they went there to talk about their health, with what they had of doubts and to offer.

Men's health promotion
Santos FNP, Baldissera VDA, Toledo RF Another aspect mentioned by the interviewees was the feeling of recognition of their work when invited to participate in the meetings. There was also the understanding that their specific participation brought more security to the group. Among the negative aspects were: the rotation of participants in the meetings, making it difficult to approach issues of greater complexity and in a continuous way; the discontinuity resulting, especially, from the change of area of action of the teams (reterritorialization) and; the little emphasis given to the topic of health promotion in academic training.
Among the subjects indicated by the interviewees to be addressed in the meetings, it was once again valued that it is an open and dynamic Group, remembering the importance of free demand and dealing with everyday issues, close to the reality experienced by those men, such as alcohol and drugs and STDs. It was also suggested to emphasize the importance of the men who will be parents in the follow-up of the gestation of their children, as well as their involvement and participation in the daily care and of their family:

There is no formula for what we have to do, because health involves a whole human life context.
The reflections, dialogues and shared learning processes promoted by the Group's meetings inside the pub were, according to the participants, always commented with friends and family, also promoting the debate in other environments and conversation circles, increasing their impact in the community. The news of the existence of such work, aimed at the health of men, generated curiosity and attracted more participants.
Among the topics of greatest interest mentioned by the focus group participants were: STDs; smoking; alcoholism; depression; pains in the spine; among others.

Pub Talk covers prevention of specific diseases and changes of habits in search of well-being
All the interviewees agreed that the Socio-Educational Group "Pub Talk" contributes to the promotion of participants' health, since it allows the approach of diverse subjects -from those related to chronic noncommunicable diseases (CNCD), such as Hypertension and Diabetes Mellitus, as also to issues of socio-environmental vulnerability, alcohol and other drugs, sexuality -in an informal space and in accessible language. This was also considered a favorable situation to reduce the resistance of the participating men in relation to health care, whether preventive or curative, bringing them closer to health services and professionals. The Group's meetings therefore provide guidelines for disease prevention.
Regarding possible changes sustained by the participation in the group, there is some resistance in the search for medical care by some of the Group's regulars: For me it started with food, I started taking more care of it, but I avoid looking for a doctor, however it opened the mind more.
For others, the meetings and reflections proposed have contributed to reduce this resistance and bring them closer to the professionals and health services of the community: The information changes, because just as you're talking about here, we have a little problem and go to the health center.

Pub Talk has different perceptions regarding the structural and technical aspects of the meetings
For some professionals, the difficulties of health promotion in the context of group work are: In the non-adherence of users, for example, to the proposed strategies or the existence of inadequate spaces to carry them out.

Inadequacy of the space for the dialogues.
In the adaptation of language and technical knowledge to popular knowledge.
They were discordant to the men, since the environment where the meetings are held was considered propitious: To make them feel free to talk about their problems, ask questions and suggest topics for discussion.
In relation to the educational strategies used in the meetings, the participants emphasized the effort of the health team to carry out a work like this, meeting the demands of the community through techniques that favor the exchange of knowledge. The men participating in the Group made it clear that the strategies used in the meetings made them feel free to participate: I would not talk about it, if it was not here.

So, somebody's here listen little by little, it's very good.
They recognized this space "as theirs", and therefore no change in approach is recommended. They only suggested changing the time for the meetings to be after 5 pm and, if possible, also on weekends, so that more men would participate: The more the merrier, right?

DISCUSSION
The first component of Nola Pender's health promotion scheme refers to individual characteristics and experiences. This component comprises the previous behavior, that is, the behavior that must be changed, as well as the personal factors divided into biological, psychological and socio-cultural factors 9 . In this sense, the findings of this research show that, in a specific way in the themes of group choice, as well as in the participatory strategies adopted within "Pub Talk", these elements were present. Although the individual interventions were not designed as proposed by Pender's model, collective educational intervention was able to incite the group to the understanding of factors involved in the chronic health conditions discussed in the "Pub Talk".
Health education actions focused on the notion of risk end up isolating determinants, disregarding the complexity of social practices. In this case, the chances of illness are related, in isolation, to inadequate behaviors in health, ignorance or irresponsibility. In the health education actions focused on the notion of vulnerability, as discussed in the "Pub Talk", individual, collective and contextual determinants of the health-disease process are considered in an integrated way 22 .
The role of educator of professionals facilitates the autonomy of groups that are socially disadvantaged 23 , as identified in this study, revealing that the first component of the Pender's model may have its apprehension / intervention in dialogical educational groups.
The relevance of the use of participatory techniques and strategies in collective health education and promotion 24-25 also agree with NPIAMH 1 , which recommends the appropriation of strategies that are easily accessible to this population and that establish a direct relationship with the promotion and prevention of the health of participants.
The appreciation of this process of shared learning by the health professionals involved is fundamental to the achievement of the objectives proposed by this Group, that is, a critical and reflective health education in the molds of health promotion, duly contextualized to the local reality 22,[24][25] . And, as Paulo Freire reminds us 26 , [...] I simply cannot know the reality of which they participate except with them, as subjects also of this knowledge that, being for them, a knowledge of the previous knowledge (what happens in the level of their daily experience) becomes a new knowledge 26:35 .
The second component of the Pender's model 9 , feelings and knowledge about the behavior that one wants to achieve, is formed by: perceiving benefits for action and having positive mental representations that reinforce the consequences of adopting a certain behavior; perceive barriers to action, perceive negatively a behavior as difficulties and personal costs; perceive self-efficacy, judge personal capacities to organize and perform actions; have feelings about behavior, which may be positive, negative, agree-able or unpleasant; realize that there are interpersonal influences on behavior; recognize the situational influences, in the sense that the environment can facilitate or prevent certain health behaviors. This component, although not very evident in the implementation process of the "Pub Talk" Group, demonstrates its possibility of deepening, especially by the sense of belonging of men to this group, manifested by the testimonies of "our space".
For this reason, it is argued that, in order to promote health in an effective and sustained way, to dialogue in a group about the benefits of health promotion actions, reinforce the intrapsychic mechanisms for behavior change and the factors that are also external to this path 10 are essential actions to achieve health promotion, evaluated as a potentiality that needs to be better addressed in the "Pub Talk".
It is recognized, therefore, that the multi-professional team acting in an interdisciplinary way in the meetings of the Group, has contributed to the development of bond and, consequently, to the establishment of trust among the participants 16 . The topics covered can be proposed by the health team as well as by the participating men, in a shared and dialogical way, with due respect to the popular knowledge, indicating the fertile ground to move towards a more profound approach to feelings and knowledge of behaviors that is wanted to achieve.
Also, the place for the development of collective health promotion actions, the pub, is perfectly suited for dialogues that facilitate the engagement of the population, as suggested by NPIAMH 1 in the use of these social spaces for the approximation of the male audience.
Finally, the last component of the model under discussion, called desirable health promotion behavior 9 , refers to the commitment to the action plan, in the sense of actions that enable the individual to keep up with the expected health promotion behavior. It is necessary to understand, in this component, that people have low control over behaviors that require immediate changes, while personal preferences exert a high control over behavior change actions.
The findings of this research showed that the biomedical model is still clearly present in some representations, as in the health professionals interviewed, although they recognize the importance of the Group for health promotion, in order to take control over the determinants of their health, also admit that the understanding of the Group's objective is to facilitate and make possible the access of men to the health services of the BHU to carry out preventive examinations or even routine consultations aimed at the monitoring of their integral health, for example.
Despite the existence of NPIAMH, there is still a resistance posture by the male population towards health care 2-4,6 mentioned at various times in the interviews and in the Focus Group. Faced with this resistance, strategies such as the "Pub Talk" expand the possibility of sustaining successful male health promotion practices by adopting desirable behaviors, as recommended by NPIAMH, which are indispensable in contexts of high inequity in health and socio-environmental vulnerability, as portrayed in the community of Paraisópolis.

Men's health promotion
Santos FNP, Baldissera VDA, Toledo RF The impact of a project or an educational action, that is, its power of influence and multiplication over institutions or social actors, is one of the main indicators of changes, as expected in the processes of education and health promotion 27 . This scope was present in the "Pub Talk" by indicating the dissemination of knowledge to its peers in the territory, and is indirectly related to Pender's desirable health promotion behavior.

CONCLUSIONS
The results of this research showed that the Socio-Educational Group "Pub Talk" has contributed to the promotion of the health of the participating men. This conclusion was based on the reflections and discussions proposed and the strategies used in the meetings that, due to their participatory nature, and addressing themes according to local demands and interests, favor the participants' (re)cognition of the main determinants of their living and health conditions. It was also possible to identify and analyze important opinions and knowledge regarding aspects related to health promotion by the multi-professional team that acts in the meetings, as well as their main difficulties to develop socio-educational actions with men participating in this Group.
The data collection instruments used were efficient in achieving the objectives proposed, especially in relation to the FG, since it approached the dynamics of the discussions held at the meetings, leaving the participants comfortable to express their opinions openly. It is also considered that the technique of the Focus Group applied in situations such as those of this research and according to its intentionality, may favor the valorization of popular knowledge in a process of mutual learning aimed at the autonomy of the participants, not reducing them, therefore, to mere objects of research.
Thus, the combined analysis of the results obtained with the interviews and with the Focus Group, supported by the bibliographic review, allowed an extended look at the investigated reality, which, in turn, will contribute to the improvement of the Group's actions.
It was also concluded that the objectives of the Socio--educational Group "Pub Talk" meet the principles of the FHS in seeking to develop actions aimed at promoting, protecting and recovering the health of the participating men in their territorial and socio-environmental dimensions.