The humanization of physical activity in a governmental program : a necessary look

(a) Departamento de Ciências do Movimento Humano, Universidade do Estado de Minas Gerais. Av. São Paulo, no 3.996, Vila Rosário. Ibirité, MG, Brasil. 32400-000. marcos.maciel@uemg.br (b) Departamento de Ciências Administrativas, Faculdade de Ciências Econômicas, Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil. saraiva@face.ufmg.br. (c) Departamento de Psicologia, Universidade de Fortaleza. Fortaleza, CE, Brasil. jclertonmartins@gmail.com. (d) Instituto Federal de Minas Gerais. Santa Luzia, MG, Brasil. paulo.vieira@ifmg.edu.br


Introduction
Over the past 40 years, worldwide demographic, epidemiological and nutritional changes have had a negative impact on morbidity and mortality [1][2][3] .As a result, the World Health Organization (WHO) has promoted discussions and developed strategies to help members countries revert this trend. 4e of the most important of these strategies is incentive to physical activitiy 5,6 .Physical activity programs (PAPs) have been implemented by the Brazilian government under the auspices of the Unified Health Care System (SUS) 10,11 to support primary health care interventions [7][8][9] .Most programs are designed with public health in mind 5,6,8,10 .
The perspective adopted in the present study is in line with Carvalho 12 who believes the SUS needs to consider the relevance of physical activity beyond the quest for efficacy, as reflected in the evolution of 2018; 22(67):1235-45 health indicators.Likewise, Maciel 13 defends the notion that PAPs should take into account the cultural component of physical activity, thereby humanizing it and conferring on it a meaning similar to that proposed by the concept of leisure experiences.The latter is viewed from an autotelic perspective, that is, as having an end in itself: satisfaction, subjetivity and positive valuation of the meanings attributed individually by experience, and capable of contributing to human development [14][15][16] .
Our choice of approach is justified by the fact that the physical activity promoted by Brazilian PAPs is focused on utilitarian aspects, traditionally adopted over the years, which tend to deprive it of meaning.
The incentive to adopt physical activity is very often enveloped in a scientific discourse, presenting human movement as something to be systematized and mechanized.
By acquiring a utilitarian connotation, physical activity has become dehumanized and 'thingified" and is now commonly viewed as a mere health practice, a means to attain specific medical, political and economic ends.In the present study we challenge this outlook by way of a critical analysis of PAP sessions.Initially, we describe the history, structure and routine of a selected government-sponsored PAP center.We then take a close look at the dynamic of PAP sessions observed at the facility.Finally, we analyze our empirical data in light of a theoretical framework contemplating the quest for meaning in physical activity.As epistemological basis we adopted a phenomenological approach.

Methods
This was a descriptive, qualitative field case study 17 Information was gathered at a PAP center in Belo Horizonte (Minas Gerais, Brazil).To be eligible, the center should have existed for at least one year, with instructors engaged in interventions for at least one year.This was considered the minimum period of time required for instructors to promote local community participation, assimilate the program proposal and become familiar with the target public.
With the authorization of the regional program coordinator, we contacted a local PAP center at random.The center met the eligibility criteria and was chosen for the present case study.
Non-participant observations were registered in a notebook during two weeks in January 2016 and interpreted according to a phenomenological approach 17,18 .The study protocol was approved by two institutional ethics committees and filed under entry numbers 1.548.799and 1.808.411,respectively.

Description of the Program "City Of Belo Horizonte Gym"
For the sake of context, in the following we provide a brief description of the physical activity Wednesday-Friday, or Tuesday-Thursday-Saturday) in the morning, afternoon or evening, as the case may be.The classes are structured according to WHO guidelines for physical activity and last one hour (30 min walking + 30 min aerobics and/or anaerobics) per session.
Classes are usually split in two.While half the group walk for 30 min, the other half engage in collective activities, and vice-versa.
As explained by Las Casas et al. 19 , PAP classes are based on the contents proposed by the 1998 National Curricular Parameters of Physical Education, which introduce participants to the body movement culture in order to promote leisure, the expression of feelings, affection and emotions, along with the maintenance and improvement of health.Alternating between the proposed contents throughout the year is recommended 19 .
A PAP center may have up to three shifts (morning, afternoon and evening), depending on demand 19 .Each shift is staffed by two physical education professionals.The center chosen for the study had only two instructors, and each class included 30-40 participants.On the average, PAP centers have around 300 attendees.

Observation of classes
In the first two weeks of January, the classes at the selected center were observed by an investigator with a degree in physical education.In Brazil, this period coincides with the school holidays.Since many participants take the opportunity to spend time with family, attendance declines temporarily.The observed class were therefore not split in two groups.
We chose to observe the classes with the greatest number of participants (at 8-9 am, and 9-10 am) in both weekday schedules (Monday-Wednesday-Friday and Tuesday-Thursday-Saturday).Three observations were made for each class, totaling 12 sessions.
Classes including motivational sessions (similar to low-impact aerobics) and load/strength sessions (similar to targeted exercises) are given over a period of three months (January to March).At the time of observation, activities had already started; thus, the choice of content was not influenced by the presence of the investigators.
The two-week observation period was deemed sufficient for the purpose of the study since, as explained by one of the instructors, only the variables of the physical training would suffer changes, in detriment to the adopted physical exercise routine.In other words, extending the observation period would have added no relevant information.It should be pointed out that our analysis was limited to the contents observed during the field study and cannot be extrapolated to contents given in other periods.In the following, we describe two sessions of the same class (a motivational session and a load/strength session) representative of all the observed sessions.

Description of a motivational session
The first class was observed on 11 January, at 8 am.The instructor greeted the participants respectfully and called the roll.Then the participants were asked to put on name badges containing 2018; 22(67):1235-45 information on physical status and pathologies, if any.The first activity consisted of walking on the pavement encircling the facilities under the supervision of a trainee (a 7th semester physical education student with 2 years' experience on the program).
The participants walked individually or in groups of two or three.No specific pace was determined, but individual walkers appeared to keep a brisker pace than small groups.The slowest-walking participants (or participants who had stopped to talk) were occasionally asked by the instructor to increase the pace.
After the walk, the participants were called into the classroom for a collective activity.Upon entering, the instructor advised the participants, one by one, to drink water and then stand in rows, with enough clearance to move their arms without colliding with their neighbor.At this point, the participants were conversing so enthusiastically the instructor asked for silence.
When the participants had "found their places", the instructor explained the activity, which was new to several of them.The class was split into two groups.At the time of observation, the class included only one man, aged about 50 years.
The instructor stood facing the group while the trainee stood on the side, parallel to the instructor.
When the participants were ready, English-language disco music was played back to start the exercise sequence.The session started with simple and low-intensity warm-up exercises (not actually stretching) which required to open and close the legs sideways in sync with the music.During the activity, the instructor was in constant communication with the participants, demonstrating how to perform the movements and giving verbal instructions about amplitude, direction, rhythm and posture.
The participants were repeatedly addressed as "guys" ("let's move it, guys!" and "way to go, guys!") in order to create a youthful atmosphere, although most were over 50 years old.The trainee performed the same movements, serving as an additional model, and provided individual assistance when necessary.
The exercises became gradually more complex and intensive, demanding greater concentration and motor coordination, especially with the addition of a forward-backward step.Subsequently, another lateral movement was incorporated along with an arm movement, including clapping.Some of the participants found it difficult to follow the sequence, especially those who were doing it for the first time, and did not seem at ease at first, but coordination improved as the steps became better assimilated.
The instructor whistled and cheered, egging on the participants ("you're doing great, guys!") and introduced a rhythmic count ("1, 2, 3 and turn!") repeated by the participants at every change of direction.Some of the participants let out loud cheers.The instructor corrected inadequate movements, addressing the participants by name, thereby showing familiarity with the group.
As the session proceeded, the pace and complexity of the sequence increased.Many participants displayed signs of weariness, based on their bodily expression.Concern with keeping up with the sequence was visibly compromising the precision of the movements.Some of the participants displayed a facial expression of perplexity, as if thinking "I am not sure what I am doing; is it this way or that way?"Eventually, several of the participants said they were exhausted or "burned out", reflecting physical fatigue from performing the new exercise.

2018; 22(67):1235-45
The participants' effort, facial expressions and cheers suggested they were generally enjoying the activity.When asked if they were tired, some said "yes", others said "no".The instructor encouraged them to let out cheers, to "let go" and enjoy the activity, challenging them to "give everything they got".
When the sequence was completed, the instructor asked to slow down, walk in place and take deep breaths to regain calmness.The session ended with stretching exercises.After that, the participants were told to drink water, then return to the center of the room and make a circle, holding hands.This routine was observed in all sessions.
The instructor asked the participants about their weekend and complimented the most assiduous, giving them a glossy foil star for frequent attendance.Then relevant information was conveyed and the participants had the opportunity to share personal information and views, though none wished to speak.
The instructor directed the class to count to three and cry out "have a great day" in unison, followed by applause.He then thanked all for their participation, congratulated them on their performance, and asked them to make and sure and come to the next session.
Overall, the participants seemed satisfied with the session.However, different reactions were observed: some left the premises with a smile, suggesting they had enjoyed the session, while others left with a more introspective demeanor, as if with a feeling of "duty fulfilled".This, however, does not imply they were not satisfied.
Although the observation of a few sessions is insufficient to generalize the perceptions described above, it goes a long way to understand the dynamic adopted by the instructors who have worked on the program for over two years.The dynamic is typical for the area and is very likely reproduced at other PAP centers.

Description of a load/strength session
The second observation was made on 13 January.At the appointed time, the instructor called the participants into the room to start the session.Having called the roll and asked to put on their badges, he recommended special care during the walk because of the presence of puddles of rain water along the path.He also suggesed taking a bottle of water.However, after walking for 15 min the activity was interrupted by rain, making it necessary to continue the session indoors.Back in the room, the participants collected the necessary equipment (free weights or plates, weighted shin pads and mats) and distributed themselves about room, splitting the class into two groups.
The instructor gave details about the exercises, such as the number of series and repetitions.The class included almost 40 participants (only five were male) with an estimated average age of 50 years.
The instructor then played back English-language music with a tempo compatible with the number of heartbeats per minute.
Lying down on their individual mats, the participants started exercising while the instructor moved about the room supervising performance.This part of the session was made more difficult by the absence of the trainee (it was his day off).When the instructor wanted to illustrate how to do an exercise, he used 2018; 22(67):1235-45 one of the participants as an example.Sometimes he encouraged them by using informal language ("you are doing great, guys").
At this point, the participants were performing push-ups and knee-bends at the same time, using weighted shin sleeves.When necessary, the instructor corrected the movements, both collectively and individually (addressing the participants by name), and suggested changes in load.
A second exercise sequence was started but the equipment was insufficient for the whole group so some of the participants had to practice without it.Standing up, the instructor demonstrated the exercise, using free weights, plates and shin sleeves.At first, the movement included only the legs.
Further instructions were given about posture and performance.When necessary, the music was turned down to improve communication with the group, indicating good teaching practice and concern with vocal health.The simplest possible vocabulary was used (e.g., "bend" instead of "flex").Another sequence was then started, involving the arms.Individual and collective instructions were given in the same fashion.
The participants went from one sequence to the next according to individual pace and ability.
Overall, concentration appeared to be good.The instructor changed the music to an English-language track with a faster tempo, then moved about the room supervising, complimenting and encouraging the participants ("don´t hold yourselves back!" or "press on!").
When the scheduled exercises were over, the participants were asked to put away the equipment and badges, then drink water.Finally, everyone stood in a circle, exchanged relevant messages and say goodbye.
As with the motivational session, the participants generally displayed signs of satisfaction with the session.Some left the room smiling, others more introspectively.

Physical activity as health practice or leisure experience?
The physical activity observed in this study was stereotypical and similar to gym classes at private health clubs where movements are adopted according to their ability to improve physiology and promote localized health and fitness.
The movements observed at the PAP center required the use of alternate muscle groups at different levels of intensity, with the main objective of strengthening the "body machinery".This form of activity, regardless of where it is taught (private gyms or government programs) leaves little or no room for creativity.It is based on a scientific view of well-being and on the instructor´s technical knowledge.Thus, participants merely reproduce movements identified as beneficial to the body.
In this context, it is relevant to consider the pervasive discourse of physical activity as a health practice, the causal linearity between physical activity and bodily fitness, and the ideological use of physical activity as a means of social control, promoting the ideal of a "healthy" life style 7,11-13 .The predominance of this perspective reveals an impoverishment of the multiple potential cultural expressions associated with human movement.Most physical education professionals developing contents in this area are influenced by conventional sports or by the rationale of fitness 20 .Unsurprisingly, 2018; 22(67):1235-45 the physical activities observed in this study were designed and performed with an uncritical attitude: mechanical and stereotypical, they conveyed no sense to the participants.
Maciel 13 drew attention to the importance of humanizing physical activity; in other words, viewing it in light of the qualification conferred by the concept of leisure experiences.Leisure is permeated by subjectivities and therefore involves a search for interpretations given by people from different sociocultural contexts 15,16,21 .The sense of leisure experiences emerges heuristically from the relation between the person and the activity.This is because we are conscious of ourselves and of the world in which we are inserted.Thus, leisure may be regarded as a conscious phenomenon of social practice.
In addition to this consciousness, leisure experiences are characterized by intentionality.The latter is a qualification of the act of choosing and attributing meaning to the activity.Intention is the essential bond uniting consciousness and activity.In view of the importance of leisure experiences, Cuenca 22 defines leisure as... [...] a type of human experience perceived by the subject as satisfactory, not compulsory or necessary.Leisure may be said to be a free human experience, satisfactory and with an end in itself; that is, it is voluntary and separated from necessity, viewed as primary experience (p.42).
The psychological benefit of leisure experiences does not flow from the mere act of doing, but primarily through changes in the subject's outlook on life, its values and ethical principles.According to Rhoden 21 , at least in part, it is these values which determine how people employ their resources and their time.Thus, the assimilation of these values necessarily takes place in the educational setting 16 .
The concept and discussion of humanized physical activity implies a view of activity as a psychosocial and subjective phenomenon, rather than a mere health practice characterized primarily by quantitative biomedical parameters.
What we propose is a change in the understanding of physical activity on part of health professionals, especially physical educators, who are often responsible for the development of physical activity interventions in different social contexts (schools, clubs, the workplace, free time), for which it is essential to reflect on historical and sociocultural meanings of human movement.This change may be brought about by expanding discussion on the topic in undergraduate and graduate schools.The proposal may also be applied to other fields of health care.
Our proposal requires the rethinking of PAP objectives, abandoning the hegemonic discourse of organic efficiency and utilitarianism with which they have conventionally been informed, and contemplating a wider spectrum of meanings in physical activity 12,13 .PAP professionals should make an effort to incorporate educational and philosophical aspects, not merely scientific and methodological components, into their understanding of physical activity.The biomedical approach is not devoid of possible biopsychosocial benefits, but awareness of other and more qualitative layers of meaning in movement should be fostered, with a possible spillover into behavior change and holistic health education.

2018; 22(67):1235-45
Adopting our proposal is tantamount to acknowledging subjectivities and cultural peculiarities and going beyond the format currently prescribed for physical activity programs.It involves testing new approaches for a better understanding of physical activity and (re)thinking the humanization process, not just of PAPs but of health care in general.
The humanization process requires a phenomenological approach and dialogue with other perspectives in order to visualize care of the person as a complex whole, rather than a set of measurable organic functions 23 .According to Ayres 23 , this involves rethinking the ethics and morals underlying any discursive formation (e.g., politics, epistemology, professional), with special emphasis on the regulation of social life.
Thus, the purpose of humanizing physical activity is to actively establish processes of intersubjective validation and social legitimation, creating new possibilities of understanding physical activity as significant lived experiences related to health and well-being, within a broadened perspective.
Our reflections seem relevant to recent discussions on the humanization of health care services in the SUS network [23][24][25][26] .According to Deslandes 26 , the concept remains to be clearly defined, but is usually understood as a concern for the quality of care from the technical point of view, coupled with respect for the patient's rights.The same author points out the need to consider individual culture and subjectivities and recognize the health professional providing care as a guiding light for a new praxis in health care production.
Benevides and Passos 25 , believe policies informed by concepts of humanized health care should be reassessed critically to ensure proper changes are made in the models of public health services and management.
This perspective is also applicable to PAP centers.Educational incentives building awareness of the need for greater sensitivity and perception of meaning in physical activity would benefit the participants of such programs in many different ways.
According to Cuenca 15 , the educational process of leisure does not follow a utilitarian perspective of "killing time", releasing from boredom and preventing social vices and maladjustment; it proposes a change not only in behavior, but in attitude, outlook on life and values.In Cuenca's view, leisure experiences can redeem human dignity and give new meaning and direction to existence.
Likewise, Francileudo and Martins 14 point out that contemporary society is afflicted with immediatism and superficiality, a fact clearly reflected in physical activity programs.The authors add that "[...] in today's society leisure may be viewed as a way of helping us 'be' through contemplation, creation and consolidation of ethical values as an unnegotiable asset" 14

(p. 146).
Encouraging the humanization of the services provided by PAP centers is a contribution towards the attainment of this proposal in life.

Final considerations
In general, PAP objectives are informed by a political discourse of idealization of "perfect health".
In other words, they are focused on organic performance according to clinical parameters derived from 2018; 22(67):1235-45 biomedical science.The latter is primarily concerned with the reduction of the prevalence of noncommunicable chronic diseases in view of the high cost to society with which they are associated.This utilitarian perspective tends to "thingify" physical activity, depriving it of the possibility of promoting subjectivities.
In this study, we propose a widening of the current understanding of physical activity, a valuation of the many possible meanings contained in movement, that is, the humanization of physical activity programs.To do so, we believe in borrowing from the concept of leisure experiences.Being autotelic by definition, this concept may contribute to breaking away from the conventional utilitarian perspective.This possibility does not imply a new standardization of physical activity since practitioners may engage in physical activity for many different reasons, but it points to the need for (re)thinking and taking into account the subjectivities and cultural peculiarities inherent in the process.
What is questioned is the hegemonic discourse and mechanization of physical activity flowing from the maladies of contemporary society, such as immediatism, consumerism, acceleration of time, overstimulation of the senses and superficiality.
The adoption of a phenomenological approach in this study naturally imposed certain limitations with regard to the conclusions that can be drawn from our analyses.But phenomenological investigations constitute a useful and relevant complement to the academic discussion on physical activity programs.
Our reflections on the concept of humanization of physical activity are not intended to preclude any of the multiple dimensions expressed by such activity, whether pedagogical-educational, entertainmentrecreational, physiological rest/recovery-related, esthetic-prophylactic, sociocultural, or introspectiveexcitatory.What we insist on is promoting the meaning of physical activity as a psychosocial phenomenon, as a moment of self-discovery and self-surpassing, as a moment of stopping, listening, discovering the other and discovering oneself.

Collaborators
Marcos Gonçalves Maciel contributed actively to the study design, collection of data, discussion of the results, review of the draft and writing of the definitive manuscript.Luiz Alex Silva Saraiva contributed actively to the study design, discussion of the results, review of the draft and writing of the definitive manuscript.José Clerton de Oliveira Martins and Paulo Roberto Vieira Junior contributed actively to the review of the draft and writing of the definitive manuscript.
program.Established in 2006 (Las Casas et al.) 19 , the program covers all nine subprefectures of Belo Horizonte through 63 centers staffed by 170 full-time physical education professionals and attended by 25 thousand beneficiaries.According to a fixed schedule, the participants attend every other day (Monday-2018; 22(67):1235-45