Actions for health advocacy and user empowerment by nurses of the Family Health Strategy

Objective: To understand the actions for health advocacy and user empowerment developed by nurses of the Family Health Strategy in Brazil. Method: A qualitative study carried out with nurses working in the Family Health Strategy in a city in the South of Brazil. Participants were selected by non-probabilistic, snowball sampling. Data was collected from a semi-structured interview guide, recorded, transcribed and analyzed through discursive textual analysis. Results: Fifteen (15) nurses participated in the study. Three categories emerged: user participation; health environments; health advocacy actions related to the multiprofessional team. Conclusion: The closer relationship that the Family Health Strategy enables between the multiprofessional team, users and the community promotes health advocacy practices, while user empowerment favors autonomy in health care, encouraging a healthier life and enabling them to intervene in the health decisions of the local community.


INTRODUCTION
Brazilian health is organized by actions that occur under different instances commonly sharing the need for interactions between professionals, users and community; aiming to provide quality care and produce health.Thus, in order to ensure that health actions take place in Primary Care (PC), it is fundamental that social actors engage in genuine encounters which are conquered gradually according to the bond developed and the possibility of exercising autonomy (1) , in addition to the organizational dynamics of material and personnel resources.
In Brazil, PC was developed through specific public policies that resulted in the creation of the Family Health Strategy -FHS (Estratégia Saúde da Família), which has the attribution of focusing care on families and the community as objects of health care.Thus, the multiprofessional team composed of nurses, physicians, and community health agents (among others) must know the communities in their multiple social, sanitary, cultural, economic, functional and organizational aspects, in order to intervene in an active and positive way, empowering the users' autonomy in matters related to health (1)(2) .
In the FHS, the nurses are one of the professionals responsible for consolidating their performance by participating in different actions for the formulation, agreement, monitoring and evaluation of policies that affect health services, the care and the improvement of the quality of life of the communities (3) .Thus, this professional demonstrates important potential for implementation, maintenance and development of health policies that aim to qualify health care, as well as community advocacy when necessary (4)(5) .
Therefore, nurses seek to develop interactions of care, prevention and health promotion, in addition to stimulating the users to defend their rights based on the advocacy in health, thus guaranteeing the effectiveness of the actions of the individuals themselves.This action also encompasses the construction of critical awareness and user participation in decision-making regarding the improvement of quality of life (2) .Health advocacy comprises a broad process that seeks to mobilize actions to defend users' rights and their best interests in order to promote changes in social reality (4)(5)(6) .
The change in users' behavior towards the possibility of exercising their autonomy and their empowerment allows them to move from a category of mere receivers, and become agents that promote changes in the process of appropriation, so that user's empowerment of knowledge means that they can cease being a "passive receiver" of constructed knowledge, and so that they can actively participate in community decisions (2,7) .Health advocacy actions and the empowerment of the user must have their origin from the most intimate reality of those involved; in this context, the FHS and nursing in particular assume the role as promoters of these ideals.In exercising health advocacy, emphasis is placed on the defense of human rights with the creation of conditions that promote exercising autonomy, social equality and justice, as well as equal access to health services by users (8) .
To facilitate these practices through increasing the technical and political power of nurses, the development of trust bonds between users and the multidisciplinary team favors collective work and interactions from the stimulus to strengthen the individual and collective capacity in order to work on the various causes of health-disease, seeking individual autonomy and community actions (9)(10) .In the FHS, the nursing professional has important attributions with actions that aim to stimulate the protagonist role of users in health care as reflective, critical and creative beings, in addition to contributing to self-care (2,10) .
In order to justify this research, it should be noted that no studies were found related to the actions of nurses in health advocacy and user empowerment in the FHS.We also point out that adequately identifying actions for health advocacy and user empowerment in the FHS allows for expanded recognition of its challenges in an attempt to adapt professional conduct and realign public policies.In view of the above, we asked: What are the actions for health advocacy and user empowerment conducted by FHS nurses in Brazil?This study aimed at understanding the actions for health advocacy and user empowerment developed by FHS nurses in Brazil.

METHOD
This was a qualitative, descriptive and exploratory research performed with nurses working at FHS in a municipality in southern Brazil.Inclusion criteria were: being a nurse and working professionally at the FHS for at least 6 months; while exclusion criteria were: being on vacation, away from work or on leave.The data collection period was between January and May 2015.
Fifteen (15) nurses selected by non-probabilistic snowball convenience sampling participated in the study.Thus, after identifying the first participant nurse recognized by the study's authors through the presence of personal characteristics of having routine facts which evidenced their practice of health advocacy towards users, the indication of another nurse with similar characteristics to the first interviewed nurse was requested, meaning nurses that were recognized as advocates of user rights.
This process took place until the participants had no more new nurses to indicate to participate in the research in the FHS environment, and when the information began to repeat itself with it not being possible to verify the presence of new facts.It should be noted that the authors of the study are linked to a Federal University that maintains regular activities in the local FHS, both to undergraduate and family health residency, as well as Master's degree and PhD activities.Several nurses working at the FHS are former students of the various modalities offered by this university, a fact that allowed the researchers to recognize in the selected participants the fundamental characteristics to participate in this research.
Thus, the semi-structured interviews had an average duration of 40 minutes each.It is also worth mentioning that the participants authorized recording the interviews, which in the first stage contained closed questions to obtain participants' characteristics.They subsequently answered open questions with the objective of observing aspects that could present health advocacy actions and user empowerment by FHS nurses.The data analysis process took place from the interview transcripts using discursive textual analysis, understood as a qualitative data analysis methodology which aims to produce new understandings on discourses and phenomena, inserting itself between the extremes of content analysis and discourse analysis (11) .Participants were identified in the study by the letter E, followed by a sequential number (E1 to E15) according to the order of interviews.
Ethical aspects were followed in their entirety in compliance with resolution 466/2012.Participants signed the clear and Informed Consent Form, being fully informed about all the constituent elements of the study and of their possibility to withdraw their participation at any time.This article is part of the macro-project entitled "Patient advocacy and coping in nursing: possibility of exercising power through experiences of moral suffering" (Advocacia do paciente e coping na enfermagem: possibilidade de exercício do poder mediante vivências de sofrimento moral) (CAEE: 17415113.9.0000.5324).

RESULTS
Regarding the participants, it was observed that their ages varied between 35 and 58 years, all were female, 12 had the specialization course as their highest degree, two had Masters' degrees and one had a Doctorate.The time they worked as nurses varied between 10 and 28 years, and the working time in the FHS ranged from 9 months to 16 years.Concerning data analysis of the interviews with the 15 participants, three categories emerged: user participation, health environment and health advocacy actions related to the multiprofessional team.

User participation
In this category, which highlights how much user participation makes it possible to extend the practice of health advocacy through nurses, the following constitutive elements were identified: exchange of knowledge, health education, group formation, home visits (HV) and nursing consultations.It should be noted that although many of these elements are routine situations in FHS, their implementation in a way that strengthens the identity and autonomy of users generates a countermovement of the latter, demanding specific actions for their contexts and requiring nurses to act in ways that amplify and resignify the meaning of health advocacy, meaning that nurses are not only faced with complying with established protocols, but also seeking and stimulating results in the defense of users' interests.
It is also worth noting that health advocacy is especially exercised in times of dialogue with users in assisting the community in decisions about health, aiming to guarantee the quality of care, even if this defense action by nurses may counteract the interests of the health team.
The planned activities in the FHS are fundamental for stimulating user care, in addition to defending the community.By providing a constant exchange of knowledge among those involved, users and nurses are better equipped to observe the local context, enabling users to demand the effectiveness of their rights guaranteed by public policies through nurses who are the main care managers at the FHS.In this sense, communication is perceived as an important tool of nursing professionals, with the aim of directing the multiple actors of the FHS to the best path in relation to the possibilities of individual health care and family/community.Furthermore, communication is a tool that enables users to claim aspects of health promotion with other professionals and the community.In the activities of health education, the themes are worked out from discussing the needs that the users raise; the population here is very participatory, questioning, they have popular knowledge and we have the scientific knowledge, so we have this exchange.In the hypertensive group, they decide the themes to be addressed according to their needs (..

.) so we seek to meet what they see as necessary without losing sight of our role as educators (E5).
We search for the dynamic process of intervention so that they can question, interact so that they can actually participate, and not just gather information, right?Let them participate with suggestions, questions (E6).
Another practice developed in the FHS that enhances developing advocacy actions of the users is health education.According to the participants, it stimulates user empowerment, as well as developing autonomy and knowledge, making them increasingly aware of their local and personal reality.Health education aims to increase the capacity of self-care and better management of individual and collective health in the users and does not distance them from the FHS in meeting their health needs, but rather it creates a bond between them and with each unit with new and more specific requirements, allowing nurses to have the necessary space for developing health advocacy actions: Exchanges of experience become more effective when users empower themselves, because there is no use in just receiving information and not sharing it with other members of the community, if they do not understand the importance of becoming co-responsible for their health and their responsibilities as citizens to fight for their rights (E6).

Health education seeks the dynamic process of intervention so that they can question, interact, work with theater plays, and group activities for them to participate. Not only just receiving information, but participating with suggestions, questions (E14).
The nurses participating in the study also highlighted the realization of groups as an important form of health advocacy that stimulates user autonomy and empowerment; a fact that makes them more active and participative.The groups are held with different people in the FHS and are designed to meet the specific needs and situations of the community, such as the elderly group in order to stimulate the exchange of experiences, discussions on matters related to life in older age, rational use of medications; the group of pregnant women, which focus on topics relevant for the development of pregnancy, delivery and situations related to the baby's life; the group of hypertensive/ diabetics with the aim of stimulating a healthy life, among others.
The accomplishment of the groups is planned according to studying the needs of the community and the suggestions from the users themselves, who in providing the necessary knowledge and recognition of successful experiences among their peers demand nursing actions that exceed the limits established for the functioning of these groups, thereby stimulating health advocacy actions.Thus, in leading the groups nursing professionals not only stimulate users to explain their opinions in relation to the subjects that are discussed, but also to exchange experiences and knowledge, and above all to reinforce values linked to citizenship and the guarantee of rights expressed through the law.Many people participate in this group; it is not just related to chronic, hypertensive or diabetic subjects, but we bring any information intended for health to the meetings, reinforcing the users' suggestions, trying to understand about a certain topic that they want to talk about and act on (E1).
The idea is this: short subjects, in a smaller space, but a place where they can express a question or share information that may be important, not in a tone of speech, but as a conversation, exchanging experiences, favoring collective decision-making (E3).
Another important form of health advocacy conducted by nurses who seek active user participation is the implementation of HV.This practice allows greater knowledge of the community and the concrete reality of users based on perceptions of their housing, customs, daily habits, and possible deficiencies, in addition to strengthening the building of the bond between users, other health professionals and nurses.An important space for the practice of health advocacy has also been found in HV, since by recognizing and clarifying questions about care, guiding users who cannot go to the FHS on better behaviors and evidencing the importance of them by their presence in their homes, users are encouraged to exercise their citizenship, to demand their rights and that the nurse assists them in fulfilling their needs.Because sometimes from behind a table, when you talk to a user, you don't understand what they are going through, and through HV we have the opportunity to experience the daily life of that user, to see their reality.It is no use saying that they need to eat beans, rice, vegetables, and meat every day if they cannot carry out this process (E10).

Sometimes they say things, but it' s not the truth... they (users) show that through the relationship, and you understand their reality based on the HV, on this contact and by establishing a bond (E2).
Closing this category, the nursing consultation also emerged as a way of empowering users in relation to their health in the sense of advocating it, and it represents an important means of interaction between professional nurses and the user/community.The nursing consultation is an option of nursing care to the user, which provides closer interactions and directed to specific situations, with the possibility of greater closeness among those involved, thereby providing an important space for practicing health advocacy.Each of our services ends up generating a consultation.Sometimes the user comes only to check their pressure, but we take advantage of them being here to provide/guidance, to ask about their diet or about hygiene, and their family (E4).
In the nursing consultation we highlight the availability of professional nurses to listen, to get to know the user, to stimulate their participation in health activities to improve local health, and make them feel as though they are the true agent of their care process.

HealtH environments
The health environments category highlights the environmental and local actions carried out by nurses, which go beyond the routine established by the FHS, leading to the possibility of performing health advocacy actions outside the walls of the FHS with an expanded field of actions to other community spaces such as neighborhood associations, schools, kindergartens, social clubs, associations, and home environments, etc.In the first instance, health advocacy actions aim to guarantee closer interactions with the local reality and to allow greater knowledge of the community, along with a guarantee of better care in different scenarios.
Among environmental actions in the community, political advocacy is perceived as an important form of health advocacy by seeking the active participation of the community in implementing public policies and fundamental rights that result in the empowerment of the user in their own community.Such actions seek to exercise the autonomy of the user in the social environments themselves, in the reinforcement of their identities, in broadening the recognition of their potential and in defending the interests and rights of those whose vulnerability and dependence are evidenced.
In fact, tomorrow we will be hosting a health pre-conference here in the unit, we are inviting the population to come and participate, to suggest their ideas, what they want to improve to be included in the plan for the benefit of the community.Because we have this bond with the community, we know the local needs and therefore we can go to the participatory budget and say what is missing (E14).

The community here participates, we have the health management council that always meets on the third Tuesday of the month, an election was made by the community of representatives themselves in an election and this council was created to discuss the functioning, improvements in the community, or any complaints from users to try to rectify and improve care (E9).
Also in relation to environmental issues, another contributing factor for implementing health advocacy actions is community recognition.Identifying a group of individuals within the totality of users with common characteristics and delimited by the experience in the same community space allows nurses to act globally, not only punctually and individually; which, once again, is in line with political advocacy or social advocacy.Knowing the needs and evidencing needs as well as the environmental customs allows the nurse greater closeness with the users, with the potential to broaden their interaction with the collective.

So I call on them on their responsibility because of the relationship I have with them. I already have closeness for this, and they also respect me as a nurse, as a professional (E3).
Figueira AB, Barlem ELD, Tomaschewski-Barlem JG, Dalmolin GL, Amarijo CL, Ferreira AG www.ee.usp.br/reeuspRev Esc Enferm USP • 2018;52e03337 Seeking to establish a good bond with the community and its environments, using these tools as an instrument to improve the user/team relationship.Getting to know people better so we can provide better care, really making use of the user welcoming/ bond strategy lead to a higher demand in the unit (E6).We noticed that the interaction among nurses and community/users facilitates the development of health in the community, in addition to stimulating their citizenship and empowerment.

HealtH advocacy actions related to tHe mUltiprofessional team
The category of health advocacy actions related to the multiprofessional team presents relationships developed between the nurse and the multiprofessional team with an amplification in its potential to generate health advocacy actions, bringing forth the guarantee of adequate care, the exchange of information between the members of the multiprofessional team and the clinical knowledge of the multiprofessional team as constituent elements.The guarantee of adequate care to the user and the community was highlighted regarding the multiprofessional team's actions.The bond that the FHS provides among nurses, health professionals and users allows more objective attention to the needs and desires of each user, creating unique spaces and opportunities for practicing health advocacy: Today I am very happy to know that we did it, we collected blood, I took or the driver took (when he was here) to the laboratory agreed.The laboratory employee himself forwarded the fax and (the hospital was in another city) sent the answer when the child had to go or not.Although the situation is very difficult, we ended up establishing this multiprofessional flow on that need (E13).
Still in relation to multiprofessional actions, another prominent factor in the study was the exchange of knowledge between the multiprofessional team, as in the discussions of user cases, since the exchanges offer a broader view on the potential problems with consequent improvement in the results.The knowledge exchange among the multiprofessional team is a way to better intervene in user health, in addition to demonstrating that professionals can design better therapeutic plans together, especially when they involve the users themselves.The exchange of information broadens knowledge and perspectives, favoring new alternatives that can result in health advocacy actions.

Then we get the problem from that person and discuss with the community agent to see how the involvement of that person is with the family, along with the physician, the nurse technician, because each of the team has a view of the user (E4).
Another important tool that extends the possibilities of health advocacy actions occurring is the clinical knowledge of the multiprofessional team.Adequate identification of situations that require multiprofessional action and health problems that require intervention enhances the individual possibilities of each profession, strengthening the actions that can be potentialized as a team.Being aware of the local needs, the inadequacies, knowing the users and the specific problems guarantee the provision of care being directed to each case, according to the expertise of each professional.
We share these cases and leads to the team, the responsibility is not only for an isolated professional.Sharing is to identify a user problem and bring it to a team meeting, identifying that case and discussing it in a multiprofessional team meeting (E4).

I receive a woman here to do a cytopathological examination, however I see that she is an overweight woman, I have a broad vision, I won't only perform the examination that she came for, I pay attention to comprehensive care, I refer her to another professional, I recommend a nutritionist, I offer her a group of daily physical activities (E15).
Thus, the exchanges in the multiprofessional team provide greater knowledge of the community under the eyes of different professionals and with different approaches, in addition to focusing actions on holistic care which values the individuality of each user and which qualifies defending user interests.

DISCUSSION
The knowledge exchanges among users, nurses and the FHS team stimulate remodeled health practices that aim at a new way of constructing care, with the development of new possibilities for action, especially regarding health advocacy.Through this study it was verified that specific actions routinely developed in the FHS such as nursing consultations, home visits, user welcoming, health education and forming groups (8,10) are important spaces for accomplishing health advocacy actions.
The educational actions in the FHS were highlighted in this research as a way of empowering users, nurses and the community to act as a collective in defense of users' interests.In this sense, the developed advocacy actions are similar to those presented in the literature, with the purpose to: develop and maintain health promotion actions; sensitize and influence public opinion on health issues; demand the development of effective public policies from the responsible sectors; develop guidelines and procedures that positively impact health and reduce health inequities; and to stimulate communities and groups to articulate their needs, claiming resources for actions to promote health (12) .
These actions are similar to the results of a study with nurses who work with health education at the FHS which showed that health education is based on democracy, respect and freedom of those involved, and on awareness regarding individual and collective health improvement (13) .In this approach, awareness refers to critical and reflective thinking of those involved in order to propose transformative actions that lead individuals towards autonomy and emancipation, which may be closer to the political advocacy model (8) .
Actions for health advocacy and user empowerment by nurses of the Family Health Strategy Rev Esc Enferm USP • 2018;52e03337 As another FHS action, forming groups seeks to consolidate the necessary knowledge to individuals with specific demands and thus empower these users, with a view toward autonomy in decision-making, especially in matters regarding the self-defense of their health (2,8) .This way of acting requires the nurse to have specific knowledge according to the groups and group dynamics, thus favoring collective interactions.Studies emphasize that forming groups provides greater knowledge about health care and greater participation of people in the organization of the community itself, with increased control of political actions and social justice, which is then positively reflected in the community's living conditions (14)(15)(16) .
Another action that can consolidate health advocacy actions in the FHS are the HV, configured as an unparalleled opportunity for care in an extra-unit space, in which interactions between users, families and the multiprofessional team take place, with possibilities for multiple interventions aimed at individual and embracing care.This action is also very important to identify the real needs of each user, thus implementing defense actions which are consonant with the most intimate reality of each of them (17)(18) .
Nursing consultations were also highlighted in the statements, evidencing how much they favor closeness with the community in directing care through development of nursing actions in their entirety (19) .A study on nursing consultations in Curitiba's basic network indicated that it enables nurses to identify problem situations and user potentialities, giving these actions greater scientificity and credibility for the multiprofessional team and the user (20) .Among their performance, patient's advocacy itself is highlighted, with the purpose of helping the patient to obtain the necessary health care, defend their rights, ensure the quality of care and serve as a link with the health care environment.It is mainly associated with the recognition by nurses of their role as health advocates, considering their beliefs and actions regarding the care they provide to individuals (5) .
Thus, based on these actions the community can actively participate in discussions related to health, seeking to promote it with an expanded approach that involves intersectoral integration and the broad understanding of health as a social phenomenon that aims to empower individuals and the community (21)(22) .These actions that occur between FHS and users support social advocacy, as they go beyond the concern of professionals with individual defense and the very limits of the health institutions, thus promoting the critical participation of those involved in social change in all scenarios in which they develop their daily actions (5,16) .
In being part of the community itself, and thus participating in local actions in neighborhood associations, schools, social clubs, associations and in the domestic environments, the FHS develops health actions directed to the specific needs of each of these places (23) .When articulated in the territory, FHS workers are able to use the community's own resources and act in a collective to promote beneficial changes in local health (24) , actions that also approach the social advocacy model by sustaining social justice and emphasizing social equity in health care, correcting clinical and social injustices that disrespect the dignity of individuals, their rights and values (16) .
In order to guarantee the best care to the users, effectiveness of actions as well as increasing knowledge of the community, of their needs, and understanding their daily demands are necessary in order to meet these requirements (25) .Multiprofessional teamwork at the FHS is also identified according to participants' statements as an important action to promote health advocacy and user empowerment, being seen as a health intervention instrument with actions and practices that are structured by the team, at the same time as amplifying the object of intervention beyond the individual and curative scope (3) .
Moreover, it was verified that the multiprofessional team exchanges information and plans user care based on their clinical knowledge, in addition to constantly evaluating the efficacy and effectiveness of their actions for the health and defense of the community, and modifying them when necessary (1) .The data of this study are close to the results of another which showed the importance of communication in teamwork and the need to build communication skills and clinical knowledge to consolidate spaces of exchange among professionals, thereby stimulating professional-user and user-service ties, and together deciding the best care direction to be adopted (25) .
Supported by the commitment of nursing professionals with their work at the FHS, this becomes an important link between the user and the community with other health services, in addition to establishing closer contact with those involved and stimulating health advocacy and user empowerment, along with possibilities to positively intervene in the health care of the family itself and community.Thus, nurses, who are imbued with an ethical role in working with the community, may favor the interactions between those involved, in addition to stimulating the construction of user autonomy with a view to improving the health and life quality of the community (5) .

CONCLUSION
This study enabled identifying the importance of nurses within the FHS as an articulator of actions that favor health advocacy and user empowerment, with the possibility of joint interventions based on building bonds due to the proximity that the FHS allows.Regarding the actions developed by nurses towards health advocacy, we have identified an encouragement to empower the community in different moments of interaction, which are considered strategic tools of the FHS, and can generate opportune spaces for practicing advocacy, especially social and political advocacy such as during nursing consultations, HVs, health education activities, groups' meetings, and also at times when the professional acts as a mediator between the multiprofessional team and the users.
Although this study has limitations due to the fact that it was performed in a single FHS of one Brazilian city, the results can contribute to professional nurses to reflect on their actions in defense of users in the FHS services, and they can also indicate changes to be overcome to succeed in defending communities such as by seeking greater participation in health issues.
Thus, we suggest that future studies are conducted in other locations in order to verify the performance of FHS nurses as advocates of users and the community, thus contributing to the qualification of nursing practices, especially considering that this study was conducted in only one city in the south of Brazil, and that comparing its results with those of other cities in the country is not possible.