Knowledge and health promotion practice of Family Health Strategy nurses

Rev Bras Enferm. 2020;73(5): e20190362 http://dx.doi.org/10.1590/0034-7167-2019-0362 9 of ABSTRACT Objectives: to analyze the knowledge and health promotion practice carried out by Family Health Strategy nurses. Methods: a descriptive study and qualitative approach. The study was conducted with 18 Family Health Strategy nurses from the city of São Carlos. Data were collected through semi-structured interviews and analyzed through thematic analysis. The study was approved by the Research Ethics Committee. Results: the data revealed that nurses had difficulties to conceptualize health promotion, and it is common to describe the definition of disease prevention. Nurses also reported developing group activities for health promotion; however, individual actions and consultations were still predominant. Final Considerations: it is necessary to develop sustainable strategies for collective health-promoting activities, in addition to strengthening multidisciplinary work and Continuing Education actions. Descriptors: Primary Health Care; Family Health Strategy; Health Promotion; Nurse; Community Health Nursing.


INTRODUCTION
Family Health Program (PSF -Programa Saúde da Família) started in 1994, and has become the main strategy for the reorientation of the care model from Primary Health Care (PHC). In 2006, Brazilian National Primary Care Policy (PNAB -Política Nacional de Atenção Básica) renamed PSF as Family Health Strategy (FHS) (1) .
PHC is the main gateway and communication center for Health Care Networks (RAS -Redes de Atenção à Saúde). PHC can be defined as a set of individual, family and collective health actions that encompass the promotion, prevention, protection, diagnosis, treatment, rehabilitation, harm reduction, palliative care and health surveillance, developed through integrated care practices and qualified management conducted by a multidisciplinary team and directed to the population in a defined territory, over which the teams take on health responsibility (2) .
In this context, FHS has been considered the priority strategy for the expansion and consolidation of PHC, ensuring the user universal, equitable and orderly access to health actions and services. FHS arose from the need to restructure the way Basic Health Units (BHU) are operating, seeking territorial responsibility. It has the focus on assisting the individual, families and community, through the creation of bonds and co-responsibility, besides curative practices (2)(3) .
The implementation of FHS provided advances in health, such as the reduction in the hospitalization rate between 2001 and 2016 of all health conditions analyzed. This implementation pointed to the decline and negative correlation between the rate of hospitalization for PHC-sensitive conditions and FHS coverage in Brazil. It is plausible the relationship of FHS coverage and some factors such as improved monitoring of chronic conditions, diagnosis and population access to medicines (1) .
Among the FHS proposals for the consolidation of PHC, health promotion is understood as a set of strategies and ways to produce health, considering the individual and the collective, besides seeking to meet social health needs and improving the quality of life. Health promotion was advocated in the Ottawa Charter in 1986 by representatives of 35 countries. They assumed that health-promoting actions should result in reducing health inequities and guaranteeing the opportunity for all citizens to make health-friendly choices and to be protagonists in the process of health production and improving the quality of their lives (4) . It is noteworthy that this study used the theoretical framework of health promotion adopted by the Ottawa Charter in 1986.
Health promotion guidelines have been present since the Federal Constitution of 1988 and the Organic Health Law of 1990. However, the Brazilian National Health Promotion Policy (PNPS -Política Nacional de Promoção da Saúde) was instituted in 2006 and was revised in 2014 by the Tripartite Intergovernmental Commission (CIT -Comissão Intergestora Tripartite) and the Brazilian National Health Council (CNS -Conselho Nacional de Saúde). PNPS emphasizes the importance of social health determinants and determinants in the health-disease process and its assumptions are intersectoriality and the creation of co-responsibility networks, aimed at improving the quality of life (5)(6)(7) . PNPS has brought advances in programs and actions to combat the use of tobacco and its derivatives; proper and healthy eating; body practices and physical activities; promotion of sustainable development; coping with the abuse of alcohol and other drugs; promoting safe and sustainable mobility; and promoting the culture of peace and human rights (8) .
However, 25 years after the creation of the first FHS, there is still a predominance of the model focused on the disease and curative care. Health-promoting actions have not yet been consolidated to the point of significantly changing the way health is produced and addressing the determinants of the health-disease process. Therefore, giving PNPS a new meaning and creating strategies to face the challenges according to the epidemiological, demographic and nutritional profile of Brazilians is necessary (8) .
In this setting, nurses stand out as being essential professionals for the development of health-promoting actions, since they have a greater bond with the community ascribed, facilitating the adherence of users to educational actions. Nurses contribute directly to changing people's lifestyles, minimizing risk factors, as well as promoting the user's self-assessment ability and role in their own care.
Thus, nurses should act as one of the main responsible for conducting health-promoting activities, emphasizing their position as educators, which contributes to improving people's quality of life. Considering the relevance of health-promoting activities developed by nurses, it was defined as a problem question of this research: what is the perception of FHS nurses about health promotion?

OBJECTIVES
To analyze the knowledge and health promotion practice carried out by Family Health Strategy (FHS) nurses.

Ethical aspects
This study was conducted after authorization granted by the Municipal Health Secretariat of the city of São Carlos and approved by the Research Ethics Committee of Universidade Federal de São Carlos. All subjects signed the Informed Consent Form, pursuant to CNS Resolution No. 466/2012 (9) .

Design, place of study and period
This is a descriptive study with a qualitative approach. The study was conducted in 18 FHS in the municipality of São Carlos, SP, which has 221,950 inhabitants (Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística), 2010) and FHS coverage in the municipality is 30.6% of the population (67,916 inhabitants). It is noteworthy that the data were collected from August 2017 to December 2017.

Population, and exclusion and inclusion criteria
The study population consisted of 18 FHS nurses from the city of São Carlos, SP, who were included in the study because they had been working in the health unit for more than three months. There are 24 FHS in the municipality, but nurses who were on vacation, leave or who refused to participate in the study were excluded.

Study protocol
Data were collected through semi-structured interviews using an adapted Lasmar tool (10) . The instrument created by Lasmar consisted of three blocks of questions (characterization of the community served; health promotion; perceptions about FHS and professional practice). The block on health promotion was used in this research. One more question has been added. The interviews were recorded, transcribed and, due to ethical issues, were listed from 1 to 18.
The semi-structured interview allowed us to obtain the uniqueness and specificities present in health-promoting actions, which include social relations and subjective aspects (11) .

Data analysis
The data were analyzed through thematic analysis, which began with the exhaustive reading of the interviews, considering the objectives and the theoretical framework, as well as the identification of the central themes and relevant aspects (11) .
The analytical framework used in this study comprised three stages: pre-analysis, which consisted of reading the material and constituting the corpus, that is, the construction of the studied universe; material exploration, a stage characterized by the search for categories; and finally, the classification and aggregation of the data was performed (11) .
Data analysis allowed the identification of two thematic units: nurses' knowledge, ideas and conceptions about health promotion; and practices, actions and perceptions of nurses about health promotion development.

RESULTS
The results on the knowledge and health promotion practices of FHS nurses were subdivided into two thematic units to be explored. The first was called "Nurses' knowledge, ideas and conceptions about health promotion" and the second thematic unit was called "Nurses' practices, actions and perceptions about the development of health promotion". The subthemes were: "Collective and individual health promotion care" and "Challenges and strategies for the development of health-promoting activities".

Nurses' knowledge, ideas and conceptions about health promotion
This thematic unit contains the definitions established by nurses when asked about what they mean by health promotion.
It was observed that the answers related to health promotion immediately referred to the terms "prevent diseases" or "prevent health problems". On the other hand, health promotion for some participants should involve everything from living and working conditions to users' access to health care, highlighting the need to strengthen the population's education about their own health. The link between the family health team and the enrolled population and the user's autonomy in health care were pointed as ways of strengthening and helping in understanding the concept of health promotion. It is understood that for the nurses in this research, health promotion is related to working and living conditions, access to care, health education activities, bond between the team and the population. That is, they present an expanded discourse on the health-disease process, transcending the simplified concept of health, as they integrate socioeconomic aspects and point to the need for the development of health-promoting activities with a view to greater equity.

Nurses' practices, actions and perceptions about the development of health promotion
In this thematic unit, two subthemes are grouped: collective and individual health promotion care; challenges encountered and coping strategies.

Collective and individual health promotion care
During the interviews, practical examples of these actions were questioned, aiming at a better understanding and observation of these practices. The activities performed in operative groups proved to be a very common strategy among the research participants, as a way to develop health-promoting actions.
For the participants of this study, the group strategy is positive and helps in the exchange of information in a horizontal relationship, as well as providing dialogue and rapprochement with the community.
In conjunction with the actions already mentioned, healthpromoting activities are carried out directed specifically at women, such as sexuality conversation circles, family planning, contraceptive methods. In addition, groups have also been reported to return Pap smear results.
Regarding children, the creation of groups is aimed at mothers of children under one year of age, which aims to strengthen guidance on immunization schedule, baby care, breastfeeding and hygiene. Another strategy for child health promotion is to approach day care centers in an attempt to approach children's parents about child health promotion. In connection with the groups of children, there is the PSE, cited by the participants as a collective activity held once a year, targeting adolescents and children. In this activity, dental issues, hygiene, violence prevention, sexual and reproductive education are addressed.
For the research participants, the groups of hypertension and diabetes and pregnant women had the highest adherence of the population.
In addition to group activities, other strategies were also developed to conduct health-promoting actions such as conversations directed to users in the waiting room. Some FHTs have easy and expanded access for users, offering host and nursing and medical consultations when needed. The implementation of expanded access and home visits and active search are important elements for attracting the population, as they expand health intervention actions.
We highlight the diversity of health-promoting activities that are being developed in FHS, and especially because health professionals consider the opinion of the population to perform these actions. Activities such as raffles, bingo games, games, theme parties, and meetings that offer breakfast and gifts are the most appreciated and have the most popular participation according to the interviewees.
On the other hand, participants from two FHS reported not developing any collective activities related to health promotion. In some FHS, activities are punctual and carried out through campaigns such as October Rose for breast cancer prevention and November Blue for prostate cancer prevention.

Challenges encountered and coping strategies
Knowledge about the principles of health promotion need to be interconnected with practice, and for the success of the activities The frequency of collective activities presented in Figure 1 is different in each FHS, ranging from daily, in the case of waiting room, weekly, biweekly and monthly, in addition to activities such as the Health at School Program (PSE -Programa Saúde na Escola) and campaigns that were scored as half-yearly or annual in most cases.
The groups of pregnant women were the most cited, being performed monthly in almost all FHS. Some teams try to develop weekly or biweekly activities in order to increase adherence, as they serve pregnant women in different gestational periods.
Concerning the other groups, the participants stressed the importance of providing guidance on the need for physical activity, especially for people aiming at weight loss, blood pressure control, dyslipidemia, cholesterol and as a therapeutic and social life. The physical activities developed in these FHS refer to walking and stretching. Activities such as zumba and circular dance were also reported.
Participants mentioned that they performed groups of hypertensive people and people with diabetes, as these were activities that were related to the Registration and Monitoring System of Hypertensive and Diabetic (Hiperdia -Sistema de Cadastramento e Acompanhamento de Hipertensos e Diabéticos). Hiperdia aimed at the control and clinical follow-up of people with these diseases, as well as the exchange of experiences, guidance on medications, eating habits and physical activity.
According to the study participants, some group activities that address healthy eating are performed in conjunction with the physical activity group and are sometimes related to Hiperdia, discussing topics such as obesity, cholesterol, diabetes control and blood pressure.
FHS nurses also reported the existence of mental health, relaxation and art therapy groups. The mental health groups were directed to meet the demands of users who use psychotropic drugs, and still have a focused look at the side effects of medication and treatment adherence. Relaxation groups, titled as Lian Gong by some respondents, use as a theoretical framework traditional Chinese medicine, which aims to work with mental health in conjunction with stretching activities.  developed, it is necessary to analyze the territory, conditions and management of adverse situations. For the research participants, the greatest difficulty for the implementation of collective activities is related to the low adherence of the population. Another challenge reported by the participants refers to the socioeconomic context, especially in vulnerable areas, since this condition interferes with the adherence of the population to certain types of treatment, especially non-medication, besides compromising the understanding of health education activities.
The lack of awareness of the population about preventive health is reflected in the ineffective functioning of the health system. The resistance of users to join groups and to participate in health promoting activities contributes to, according to the interviewees, these actions are not performed collectively, even in FHS that has adequate physical structure to meet the groups. The hindering factors found in practice contribute to a distancing from the theory and a greater need to incorporate resilience strategies to the problems faced in the routine. The features of FHS coverage areas appear to be a relevant factor in the implementation of collective activities.
Here at the unit we like the group very much, but we have a population that does not easily join the group. Because it's an adult-young population, a lot of people work, so we have some difficulty. (I14) The participation and commitment of the FHS team in the development of collective actions and health promotion are fundamental, since they contribute to a more comprehensive care and enhance the chances of success in the proposed activities.
I have a team that is very well, very involved. I'm lucky with that I think, you know, the whole team meeting we discuss the cases right, discuss ways of changing care, to be trying to improve access. (I14) The lack of involvement and adherence of the population assigned to the activities developed by FHS impact the physical and emotional strain of the health team, as well as being one of the elements that directly interfere with the demotivation of the team, and minimize the potential of the service. It should be emphasized the high demand for work and the lack of resources, associated with the lack of interest of the enrolled population, which were also present in the participants' speeches, characterized as barriers to the development of health promoting activities, and directly contributes to making FHS a reproduction of the curative model. I think that if the country could realize that prevention is cheaper, it would be much easier right, but unfortunately we still invest a lot of money in outsourced care, right, and forget the primary care. And the basic attention is this, wiping ice, so it is very complicated to work this way. (I3) Health education activities were also listed as a gap in the health system, since they do not clarify for the population about the organization and actions developed in health services. The lack of human, structural, physical or equipment resources was also widely addressed by participants who reported using their own resources or sharing expenses among staff to carry out health-promoting activities. The research participants reported difficulties related to areas that have greater mobility of people, which implies the need for organization and planning of health services activities around this particularity. In addition, the lack of integration into the internet network of health services is emphasized, which contributes to the duplicity of care and lack of information. Regarding the evaluation of health-promoting activities developed in FHS, professionals stated that these activities need to improve to achieve the proposed objectives.
It is noteworthy that even in the face of adversity, nurses seek to maintain an organization and planning of health promoting activities, as well as presenting a critical view on the current situation of health services and contributing to the construction and practice of collective health. Although there are structural and human resources deficits, nurses are developing health-promoting activities coupled with an ideal of improvement and broad thinking about the importance of intersectoriality for the proper functioning of the service. Adaptations to the community and territory, as well as the use of available resources, prove to be important tools and are related to the experience of professionals and team building.

DISCUSSION
In Brazil, PHC prioritizes FHS to make the necessary changes in health care, in order to consolidate the principles established by SUS (Unified Health System -Sistema Único de Saúde) and, thus, provide greater coverage and respond to the health needs of the population (12) .
Therefore, it is essential that FHS be composed of multidisciplinary teams, have structural and organizational resources to face the challenges, and is supported by public policies that ensure the expansion of care coverage and qualified care, and offer alternatives aimed at the implementation and strengthening of health-promoting activities (13) .
Given the results on knowledge, ideas and conceptions of nurses about health promotion, it was possible to observe different views. It was verified the difficulty of professionals in conceptualizing health promotion, as well as the distance of participants with the theme in relating health promotion with diverse and generalist activities, not defining and exemplifying, as occurs in practice.
In addition, the concept of health promotion was associated with disease prevention, presenting a direct relationship between health and absence of disease. In the daily practice of nurses, care should be constituted as an essence, from which one should seek to go beyond the practice of biologicist and fragmented care, aiming at a broader approach of the human being in subjective and social issues (14) .
On the other hand, health promotion, when related to social factors, involves living and working conditions, access to health care, associating comprehensiveness, that is, it considers the importance of social determinants in the health-disease process. Thus, health promotion can be understood as a promising strategy to address the multiple health problems that affect the human population (10) .
To address the problems that affect the health of individuals and the community and to strengthen health-promoting actions, the role of nurses is highlighted. Its actions are directly related to health education, as well as being a protagonist in the execution of health-promoting activities, as well as offering more humanized, comprehensive, and individual-centered care.
So that health promotion is not only related to the prevention of diseases and diseases, presenting a reductionist conception, it is essential to invest in health education actions in a horizontal way, aiming at the sharing of knowledge, as well as the development of knowledge. effective health-promoting activities. In this context, nurses' education should incorporate concepts that encompass interdisciplinarity, intersectoriality, interprofessionality and empowerment and quality of life of users, being considered as references for the support of a practice directed to health promotion (15) .
Thus, the critical-reflexive formation combined with the construction of a theoretical-practical knowledge are essential for the professional education of a nurse-educator, as an agent of social transformation. A study on the perception of undergraduate nursing students at a university in the countryside of São Paulo about health promotion showed that students understand health promotion as a strategy to overcome the biologicist model that aims to break with the technicist view of care, besides considering the social context of the individuals, since it is determinant about the health-disease process (16) .
In this context, it is worth highlighting the role of the user himself in activities to promote his own health, whether seeking information, participating in health-related activities proposed by the health team, or even spreading knowledge in their means of living.
For the development of problem-solving health-promoting activities, it is essential that users express themselves and that nurses seek to value the uniqueness of each individual and thus establish mutual accountability for the care produced. Thus, the practice of comprehensive care must transcend the performance of procedures and techniques, and care should be permeated by the bond with the health team and users' co-responsibility with their health (14) .
The concept of health promotion, therefore, despite presenting difficulties in its theoretical definition, represents a more curative basis of health thinking. It also encompasses broader needs such as improvements in quality of life, investment in health education, strategies for creating a more humane, individual-centered service. Territory knowledge and a more accurate socioeconomic analysis of the space of these health services are facilitating the implementation of health-promoting activities.
Regarding the practices, actions and perceptions of nurses about health promotion in this study, there is a predominance of individual actions and consultations, presenting a distancing from PNPS guidelines. Nursing consultations are essential to the nurse's performance in order to identify the user's needs, as well as strengthen the bond with them. However, health-promoting activities should not be limited to individual care, but should emphasize strategies for carrying out collective health-promoting actions that encompass the social determinants that interfere with the health-disease process (5) .
Corroborating the present study, in an investigation carried out in 11 BHU of Greater Florianópolis, nursing consultation was considered the highlight among the activities performed by nurses. It was understood as a strategy that favors health actions prioritized in women's health programs, child health, care for chronic noncommunicable diseases, reinforcing the biologic model (17) .
According to the results of the above study, nurses reported that the demand for home visits by doctors is higher. However, they are directed to bedridden patients who depend on special care, limiting health promotion to curative procedures and practices (17) . Home visiting is an activity that enables health teams to contact the environment and family relationships, allowing them to go beyond the problems involving the biological, promoting actions directed to the user's real needs (18) .
A similar situation was observed in a study conducted in 7 FHU of southwest Bahia, where the authors highlighted the prominence of nursing consultation among health-promoting activities. In this study, it was found that nurses establish a horizontal relationship with users through welcoming, dialogue and guidance to individuals and family. However, although the service includes family members, the emphasis of care is directed to the biomedical model and to procedures such as blood pressure, capillary blood glucose, dressing and drug dispensing, making it impossible to understand care about the socio-cultural, political and economic aspects inherent to the family (14) .
On the other hand, when considering the context of PHC, one should emphasize the importance of group organization as a way of showing the production of groupality. It is woven by the said and unsaid dialogues in the group and by the sense of belonging of the participants of this space by the recognition of their knowledge and their affective, social and health needs, strengthening the bonds and constitute a new perspective of care production, enabling the active and responsible participation of each member of the group space (19) .
The groups performed in FHS show advances in health care by involving the collective, however, there is a need for expansion in relation to health-related topics, since the most predominant groups are directed to the disease and/or physical condition of users. In considering PNPS, FHS groups should seek to address priority health promotion issues such as coping with the use of tobacco and its derivatives; coping with the abuse of alcohol and other drugs; promoting safe and sustainable mobility; proper and healthy eating; body practices and physical activities; promotion of a culture of peace and human rights; and promotion of sustainable development (5) .
In a comparative study of health promotion practices in PHC, it was found that in Toronto (Canada) health promotion practices are developed individually and collectively as walking groups, hepatitis C counseling, healthy eating, social participation, men's health, women's health, alcohol and drug prevention, parents of children aged zero to six, immigrant health and elderly health. On the other hand, in Florianópolis (Brazil), PHC's health services include groups of pregnant women, smoking, hypertensive and diabetic, healthy eating, elderly and child care (20) .
In the aforementioned study, the authors reported that in Toronto users recognize that health promoting skills consist of autonomy and the relevance of social determinants, while in the city of Florianópolis health promotion is related to health education and popular participation. In addition, the authors found that health-promoting activities in Toronto are directed at the vulnerable population. In Florianópolis, the development of these actions aims to serve the entire population of a coverage area with a certain feature (20) .
In this study, difficulties were found for the implementation of collective activities, highlighting the low adherence of the population, lack of human, structural and physical resources. The success of collective health-promoting actions is also related to the motivation and involvement of the organizing team, as well as the sense of belonging of the group participants and the recognition of their knowledge and their affective, social and health need (19) .
Thus, nurses, when dealing with a broad and challenging social context, should think of strategies that provide greater motivation among health team professionals to deal with adversity. This study also showed that the relational and interaction problems among the FHS team, whether due to vertical relationships, personal problems or management changes, can influence the team's engagement in planning and performing group activities for health promotion.
The deficiencies in the organization of the work process of the FHS team negatively influence the routine and, consequently, the care offered to users. Thus, the awareness of teams and the involvement of professionals are important for the success of health promoting practices, as well as management support in ensuring adequate infrastructure, as well as seeking team continuing training (20) .
Professional training qualifies actions carried out in FHS. In this context, it is emphasized that this study evidenced participants' self-responsibility and self-criticism regarding the gaps related to health-promoting activities, especially the lack of training and commitment of all members of the health team.
FHS should seek partners in both the health and intersectoral sectors to broaden their field. NASF (Family Health Support Center -Núcleo de Apoio à Saúde da Família) contributes human resources, providing professionals for matriculation, care and group composition. Universities are also considered important allies in the implementation of health-promoting activities in FHS, as professors and students perform teaching and extension activities in these services.
Finally, it is understood that a fragmented, poorly articulated and deficient system directly impacts the quality of health service, contributing to FHS not meeting its objectives, not meeting the health and social demands, and thus if one of its principles, which would be the promotion of health and well-being of the population.

Study limitations
The study had as limitation the difficulty in data collection, that is, several interviews were rescheduled numerous times, making it necessary to extend the period of data collection. However, the work overload of nurses is emphasized, since they perform care, educational and managerial functions in FHS, making it difficult to participate in research.

Contributions to nursing, health or public policy
This research contributes to the reflection on the role played by FHS nurses regarding the development of health promoting activities, since it is considered the main responsible for the accomplishment of such actions, besides being seen as an educator par excellence.
This research seeks to awaken the health, management and university professionals to reality, making them understand what surrounds them, inviting to analyze the social context and the implications of both socio-cultural and economic nature that may influence the ways in which actions of health. Health promotion are thought and developed. This would enable self-care capacity and improve the quality of life of the FHS population, as well as helping to think about health in its broader context.

FINAL CONSIDERATIONS
The results of the study revealed that nurses had difficulties in conceptualizing health promotion, being often the definition of disease prevention, as well as having a definition limited to the biologicist and fragmented aspect, disregarding the expanded concept of health.
Despite the high number of collective health-promoting activities, individual consultations are predominant, reinforcing the curative and fragmented model.
Finally, we emphasize the strengthening of interprofessional work and the development of Continuing Education activities for family health teams, in order to ensure the implementation of collective and effective health-promoting actions.
From the results obtained in this study, we suggest the development of research that seeks to understand what users of health services, especially FHS, understand about health promotion.

FUNDING
São Paulo Research Foundation.