HEALTH PROMOTION PRACTICES IN PRIMARY CARE: COMPARISON BETWEEN FLORIANÓPOLIS-BRAZIL AND GIRONA-SPAIN

PRÁCTICAS DE PROMOCIÓN DE LA SALUD EN ATENCIÓN PRIMARIA: COMPARACIÓN ENTRE FLORIANÓPOLIS-BRASIL Y GIRONA-ESPANHA

ABSTRACT

Objective:

to understand the health promotion practices developed by nurses in the Primary Care context in Florianópolis and Girona.

Method:

this is a comparative study with a qualitative approach and of the descriptive exploratory type, carried out with eight nurses between June 2021 and April 2022 in health units that developed health promotion practices. The data, collected by means of semi-structured interviews, were analyzed through thematic analysis based on the health promotion framework.

Results:

four categories related to health promotion practices emerged from the data, namely: Training actions for health professionals in health promotion; Health promotion activities in individual consultations; Health education group activities; and Community health promotion actions.

Conclusion:

it is concluded that, in both municipalities, nurses develop individual and collective health promotion practices through groups and community actions, focusing on lifestyle changes. In Florianópolis they are grounded on the National Health Promotion Policy and, in Girona, health promotion actions are based on actions involving specific groups aimed at preventing diseases.

DESCRIPTORS:
Health promotion; Primary health care; Family health strategy; Nursing; Comparative study

RESUMEN

Objetivo:

comprender las prácticas de promoción de la salud desarrolladas por enfermeros en el contexto de Atención Primaria de Florianópolis y Girona.

Método:

estudio comparativo de enfoque cualitativo y del tipo exploratorio-descriptivo, realizado entre junio de 2021 y abril de 2022 con ocho enfermeros en unidades de salud que desarrollaban prácticas de promoción de la salud. Los datos, recolectados por medio de entrevistas semiestructuradas, fueron analizados a través de análisis temático sobre la base del referencial de la promoción de la salud.

Resultados:

cuatro categorías relacionadas con las prácticas de promoción de la salud surgieron de los datos, a saber: Acciones para la formación de profesionales de la salud en promoción de la salud; Actividades de promoción de la salud en consultas individuales; Actividades grupales de educación en salud; y Acciones comunitarias de promoción de la salud.

Conclusión:

se concluye que, en ambos municipios, los enfermeros desarrollan prácticas individuales y colectivas de promoción de la salud por medio de grupos y acciones comunitarias, con énfasis en modificar estilos de vida. En Florianópolis se fundamentan en la Política Nacional de Promoción de la Salud y, en Girona, las acciones de promoción de la salud se basan en actividades relacionadas con grupos específicos dirigidos a prevenir enfermedades.

DESCRIPTORES:
Promoción de la salud; Atención primaria de la salud; Estrategia salud de la familia; Enfermería; Estudio comparativo

RESUMO

Objetivo:

compreender as práticas de promoção da saúde desenvolvidas por enfermeiros no contexto da Atenção Primária de Florianópolis e Girona.

Método:

trata-se de um estudo comparativo, de abordagem qualitativa, do tipo exploratório descritivo, realizado em unidades de saúde que desenvolviam práticas de promoção da saúde, com oito enfermeiros, no período entre junho de 2021 a abril de 2022. Os dados, coletados por entrevistas semiestruturadas, foram analisados por meio de análise temática com base no referencial da promoção da saúde.

Resultados:

emergiram dos dados quatro categorias relacionadas às práticas de promoção da saúde: Ações de formação de profissionais de saúde em promoção da saúde; Atividades de promoção da saúde na consulta individual; Atividades grupais de educação em saúde; Ações comunitárias de promoção da saúde.

Conclusão:

conclui-se que em ambos os municípios os enfermeiros desenvolvem práticas de promoção da saúde individuais e coletivas por meio de grupos e ações comunitárias, com enfoque na mudança de estilos de vida. Em Florianópolis estão fundamentadas na Política Nacional de Promoção da Saúde e, em Girona, as ações de promoção da saúde estão baseadas nas ações envolvendo grupos específicos voltados para a prevenção da doença.

Descritores:
Promoção da saúde; Atenção primária à saúde; Estratégia saúde da família; Enfermagem; Estudo comparativo

INTRODUCTION

Health promotion is the process that seeks to enable people to expand control over their health and improve it1. In this sense, health promotion practices have directed efforts at changing individual behaviors, despite the emphasis given by the Ottawa Charter, and the international conferences that followed it, to the relevance of introducing healthy public policies, creating favorable environments, and applying integral government approaches to reorient health services and strengthening popular participation.

Modern health promotion, in a positive perspective, focuses more on health than on disease. Understanding the salutogenic approach has driven innovations in the theory and design of health promotion interventions that differentiate actions with medical approaches and care systems².

The conception of health promotion can be understood in two streams. The first one reinforces the hegemonic current driven by medical technology and changes in individual lifestyles, as solutions to risk behaviors, such as alcohol or drug consumption, unhealthy eating habits and sedentary lifestyle. The second one emphasizes the intervention in social determinants in order to improve the living conditions and promote equality. It stimulates empowerment and strengthens the principle of participation to produce knowledge, promote people's autonomy and transform reality3.

Health promotion extends the health perspective to complete well-being, making the health sectors responsible for the quality of life of the population, which excludes this responsibility from the health sector, and extends it beyond a healthy lifestyle, from emancipation and popular participation, considering the social determination where each person is inserted4.

The approximation to health promotion, with an approach to social determination, is indispensable for sustainable development. However, to achieve it, it is necessary to incorporate the principles of democracy, social justice, social mobilization and equality. When shared together, the principles of equality, intersectorality and sustainability can reduce health inequalities, which require interventions that cannot be exclusively directed by the health sector2.

In Brazil, the creation in 2006 of the National Health Promotion Policy (Política Nacional de Promoção da Saúde PNPS), whose objective is “to promote quality of life and reduce vulnerability and health risks related to its determinants and conditions”, represents advances in health promotion5. The PNPS was reformulated in 2014, reasserting that solidarity, happiness, ethics, respect for diversity, co-accountability, humanization, social justice and social inclusion are important values for its effective implementation. It highlights the stimulus to intra- and inter-sectoral cooperation and articulation in order to expand action on the health determinants and conditions and encourage democratic, participatory and transparent management6, as well as expansion and qualification of health promotion actions. The 2014 PNPS was revoked by Consolidation Ordinance No. 02 dated September 28^th, 2017, which consolidates the rules on the national health policies of the Unified Health System (Sistema Único de Saúde, SUS), ratifying the Brazilian State's commitment to expanding and qualifying health promotion actions in SUS services and management7.

Established in 1988, the Unified Health System has health as a citizen's right and a duty of the State as a principle. This system seeks to ensure the protection of life for the population, guaranteeing it through two types of functions: public health and assistance to the health-disease process8. It is subdivided into different care levels: hospital, outpatient and primary. Primary Health Care (PHC) chooses family health as a priority strategy for its organization3. It is structured in the logic of new sectoral practices, in which it links clinical work and health promotion, emerging as a possibility for implementing PHC guidelines and principles in Brazilian municipalities.

In Florianópolis, PHC is distributed in four Health Districts: Center, South, North and Continental, comprised by 49 Basic Health Units (BHUs). In 2015, the Municipality was recognized as the capital city with 100% PHC coverage through the Family Health Strategy (FHS). In the FHS, assistance is carried out by a team focused on Family Health, consisting of at least a physician, preferably from the Family and Community Medicine specialty; a nurse, specialized in Family; a nursing assistant and/or technician; and a community health agent7.

The Spanish national health system has universal coverage for all people living in the territory. Its organization is based on care levels: primary care and specialized care8. The primary care area offers the population a series of basic services in a 15-minute isochronous of any residential location. The main assistance devices are primary care teams (multidisciplinary teams comprised by family doctors, pediatricians, nurses, midwives and administrative professionals, as well as social workers and other specialties such as: physiotherapists, psychologists and nutritionists). Given its availability in the community network, this health care level deals with health promotion, as well as with prevention and treatment of diseases9.

The choice to develop this study with the municipality of Girona-Spain is due to the articulation and partnership with the researchers, seeking knowledge internationalization, as both municipalities develop research, extension and training activities in health promotion in their research centers, such as those developed in the Brazilian laboratory. In addition to that, both health systems in PHC are public and have similarities that enable the comparison.

Therefore, the need to provoke reflections on the health promotion practices developed by primary care professionals in Florianópolis - Brazil and Girona - Spain is reiterated. The relevance of comparing the promotion practices developed in these municipalities with different universal care systems in PHC will strengthen health care for the population and contribute to the principle of equality.

In this context, the professionals from the Health Centers of Girona and Florianópolis were asked what they understood by Health Promotion (HP) practices; how they develop, perform and evaluate their work and which the main practicalities and difficulties are. As an objective, it is sought to understand the health promotion practices developed by nurses in the primary health care scenario in Florianópolis and Girona, with different universal health systems.

METHOD

This is a comparative, exploratory and descriptive study with a qualitative approach. This design consists of a series of different interpretive techniques with the objective of describing and decoding the components of a complex system of meanings10. The qualitative research was carried during 2022 out in Florianópolis (Brazil) and Girona (Spain). Subsequently, the data obtained were compared, considering that both countries have public health policies that include health promotion in the primary care field.

The study took place in Florianópolis, a city with 516,524 residents, and in Girona: 101,932 inhabitants. Both have health units from the Primary Health Care network that made it possible to understand and compare the health promotion practices.

The Primary Health Care organizational system in Florianópolis is comprised by 49 health units, subdivided into four districts. Those are responsible for administering the network at the regional level and provide health coverage for the entire population. This municipality has 161 Family Health teams and 12 Family Health Support Centers. In Girona, primary care is organized into four basic health areas.

In Florianópolis, the study took place in five health units. Among the units from the Health Districts, those with the highest number of FHS teams and Family Health Support Center (Núcleo de Apoio à Saúde da Família, NASF) performance were selected. With the intention of covering the largest number of professions working in Primary Health Care in the municipality, a NASF team was drawn to take part in the research.

To select the health units in Florianópolis and Girona, those that, according to their main characteristics, carried out health promotion projects or activities and were comparable in size and structure were considered.

This study consists of two phases. In the first phase, the health units from both territories were characterized, namely: number of health teams, structure and health promotion practices. The diverse information required for this characterization was collected from the municipal health departments of both districts. In the second phase, semi-structured, flexible and dynamic interviews were conducted with health professionals from different basic health units.

Selection of the participants was intentional and the representation of each health district of the municipalities (Florianópolis and Girona) was used as a strategy for their inclusion. The inclusion criteria were as follows: professionals with Nursing training, who worked in the study setting and who developed health promotion activities in their regular care practice. Nurses who did not develop health promotion practices, had worked in PHC for less than six months and did not represent the health district were excluded.

Data collection was carried out in Girona from January to February 2022 and, in Florianópolis, from March to May 2022, through semi-structured interviews with nurses from the health units. Guiding questions related to the following were asked: type of training received to carry out health promotion activities; which practices are developed and how often; which methodological strategies are used; and practicalities, difficulties and results pertinent to health promotion.

The interviews lasted approximately one hour and took place in comfortable and stimulus-free spaces in both municipalities. The interviewees, all nurses, represented the health districts of each town: four from Florianópolis and four from Girona.

For data analysis, Minayo's thematic analysis was used, which unfolds in three moments: pre-analysis, exploration of the material, and treatment of the results obtained with their interpretation. The theoretical framework that guided data analysis was health promotion. Thematic analysis is a method with a descriptive phase in which all the information is organized to describe the data. It was performed by line and holistically; in this way, open codes are generated that are subsequently grouped by similarity criteria and the analysis categories are configured. In a second interpretive phase, the meaning of the answer patterns is theorized; in other words, which meaning is behind the topics and how these signifiers align in the context of the research phenomenon that is intended to be explained. As support for the entire analysis procedure, the Atlas-ti v.8 content analysis program for research was used.

The research was approved by the Research Ethics Committee of the Jordi Gol i Gurina University Institute for Research in Primary Care (IDIAP_Codi CEIm: 21/165-P. In Brazil, approval was from the Florianópolis Municipal Health Department and the Research Ethics Committee, in accordance with Resolution N^o.466/2012 of the National Health Council, involving human beings. In both municipalities, in order to preserve the participants' confidentiality, the names of the health units were not mentioned. The interviewees, duly informed about dissemination of the study, signed the Consent Form.

RESULTS

Demographic characterization of the participants

Eight health professionals took part in the study, all nurses: four from Girona and four from Florianópolis. In Florianópolis, the participants' age group varied from 38 to 44 years old. Their graduation time alternated from one to 20 years. Experience times in PHC from four to 20 years were recorded. In relation to HP training, only 25% of the professionals stated having undergone some type of training during their undergraduate studies. They emphasized the specializations in Family Health and Public Health as important elements for training, with 75% attending a Graduate course (25% lato sensu specialization and 50% stricto sensu MSc and PhD).

The four participants from Girona were aged between 28 and 56 years old. The youngest one had worked in primary care for 4 years and the professional with the most experience in the area, for 26 years. In relation to the training received in health promotion, the interviewed professionals agreed on having attended some program in this area during their university education. However, they explained that this was not enough; therefore, they had continuous training in health promotion to incorporate this activity into the care practice. One of the participants had completed the official MSc degree in Health Promotion at the University of Girona, whereas another two asserted having attended graduate courses related to this field. The fourth participant had continued training in health promotion.

Outcomes related to the health promotion practices

The results related to health promotion activities were classified into 5 categories: a) Training actions for health professionals in health promotion; b) Health promotion activities in individual consultations; c) Health education group activities; d) Community health promotion actions; and e) Home-based health promotion.

The main training of the health professionals in Florianópolis was related to training workshops on health promotion and health education. In Girona, the following health promotion training activities for professionals were described: social prescription; asset mapping; care for street people; and health promotion in specific communities, such as the Roma community. Training and research congresses related to health promotion were also recorded as training spaces for the participants. Chart 1 shows the training activities in health promotion in both territories.

Chart 1 -
Training actions for health professionals in health promotion.

Florianópolis	Girona
Health Promotion workshop	Social prescription
	Health assets
	Care out for street people
Health education workshop	Community health
	Health promotion in the Roma community
	ComSalut conference (Training and Research in Health Promotion)

Regarding health promotion activities in individual consultations, the Florianópolis participants pointed out different activities and interventions in the family planning stages (pre- and post-pregnancy), health promotion activities to minimize the impact of the most prevalent tumors (cervical cancer and breast cancer), suicide and an oral health promotion program.

The health promotion activities in individual consultations in the territory of Girona were similar, with special emphasis on the pre- and post-partum, infant and adolescent phases. The health professionals from Girona also pointed to the program of preventive and health promotion activities as a way to channel different actions, from individual consultations in adulthood (Chart 2).

Chart 2 -
Health promotion activities in individual consultations.

Florianópolis	Girona
Family planning	Program of Preventive and Health Promotion Activities in Adults (Programa de Atividades Preventivas e Promoção da Saúde, PAPPS)
Cervical Cancer Information System
Breast Cancer Information System	Healthy Child program
Suicide prevention	Breastfeeding program
Oral health	Oral health program

The third category was Health education group activities. In Florianópolis, group activities were collected in people with chronic pathologies such as hypertension, diabetes and obesity. There was also support for group activities to quit smoking and increase physical exercise. Finally, group activities for people with mental health problems, relaxation groups and groups promoting a peace culture were inscribed in this territory. Some of these activities were in charge of health professionals, whereas others were directed by a patient specialized in the subject matter in question.

In Girona, the health education group activities were classified in two lines: Specialist Patient Activities and Psychoeducational Group Activities. In the Specialist patient activities, it is the patient with the health problem of interest that conducts the group session. In this methodology, health professionals develop a supporting role. In turn, the psychoeducational groups for disease, tobacco and support for caregivers are led by health professionals from different areas: nurses, physicians, psychologists, physiotherapists or nutritionists. Fibromyalgia and depression psychoeducational groups on were also collected. Finally, the Girona group included health education activities in schools. Chart 3 shows the main health education group activities in both territories.

Chart 3
Health education group activities.

Florianópolis	Girona
Hypertension group	Anticoagulation Specialist Patient
Diabetes group	Diabetes Specialist Patient
Obesity group	Hypertension Specialist Patient
Healthy eating group	Specialist Patient in Chronic Obstructive Pulmonary Disease
Mental health group	Specialized Patient Support Caregiver
Relaxation group	Tobacco Specialist Patient
Physical Activity Group for Adolescents	Fibromyalgia psychoeducational group
Fitness group	Depression and anxiety psychoeducational group
Dance for seniors	Breastfeeding support group
Yoga group	Water aerobics group for pregnant women
Smoking cessation support program	Group of children on the move (prevention of childhood obesity)
Health education in schools to reduce family violence and promote a peace culture	Groups for people with stroke
	Workshop at school: Eating habits
Health education in schools	Workshop at school: Virtual hygiene networks
	Workshop at school: Piercings and tattoos

Regarding the community actions, the participants from Florianópolis reported different community programs, such as garbage recycling and community actions to reduce the number of dogs on the streets. Oral health programs for all ages, neighborhood violence reduction programs, and alcohol, drug and suicide prevention programs were also pointed out. The community actions in the territory of Girona were mainly related to the promotion of physical activity and the prevention of cardiovascular diseases and cancer, through the promotion of healthy habits (diet and tobacco reduction, among others). Activities related to vaccination campaigns and sustainable mobility were also highlighted, as well as participation in different World Days (Chart 4).

Chart 4 -
Community actions.

Florianópolis	Girona
Reduce the number of dogs on the street	Physical activity programs
Garbage recycling	Healthy routes
Workshops to reduce domestic violence	Smoke-free primary care programs
	Health and School program
Suicide prevention programs	Cardio-healthy arrests (advice for cardiovascular diseases)
Alcohol addiction prevention programs	Vaccination campaigns
Drug addiction prevention programs	Sustainable mobility program
Sex education programs	Participation in World Diabetes Day
Oral health program for all	Participation in World Cancer Day
Zero Caries in Schools program	Participation in the physical activity World Day
	Participation in the Happiness Week

Finally, as the last category, health promotion activities in community actions were defined. These health promotion practices are intended to carry out Campaigns in Florianópolis, where the focus is on reducing alcohol and other drugs, sex education, oral health, basic sanitation, and suicide and violence prevention. In Girona, the focus is on vaccination, prevention of chronic non-communicable diseases, safe mobility, school health, physical activity and happiness.

Campaigning with the population on the importance of various topics such as vaccination, cancer, drugs and others, takes place as a preventive intervention capable of reducing morbidity and mortality due to countless diseases. They are prevention actions and, when linked to community and participatory mobilization, they are potent forces for health promotion, which require advances to achieve equality of the population in accessing and reorienting health services.

DISCUSSION

Health promotion represents an important strategy for change in the hegemonic techno-assistance model, based on a new conception of the health-disease process and on the configuration of new knowledge and practices that extend the possibilities of good quality health and life of the population11.

In the health area there is certain concern with professional training in health promotion. Countless initiatives, especially international, have participated in the training of human resources in health, with the production of skills to achieve it. In this context, the performance of some countries such as Canada, Australia and the European continent stands out. In Latin America, on the other hand, advances should urgently include health promotion strategies12.

It is considered that the inclusion of health promotion into health professionals' daily teaching and practices requires changes in their training, requiring new skills to act in their favor. These competencies are focused on the production of knowledge, wisdom and fundamental values for health promotion practices13.

Referring to health promotion activities in individual consultations, studies focused on nurses' role PHC reveal that this type of practice through Nursing consultations is still incipient, as it is not addressed in all its aspects and many professionals only associate it with disease prevention, expressing that the biomedical model is still hegemonic.

The implications for the health workforce need to develop new health promotion skills and skills, as this enables opportunities and challenges. However, its integration can weaken its organizational capacity and visibility, and it risks being absorbed by a traditional Public Health discourse dominated by the medical professions. To address these challenges and seize opportunities, it is essential that the health promotion workforce is transdisciplinary and positioned within the diversified field of Primary Care and Public Health14.

Health education, a powerful tool for health promotion, is applied as a means of transforming practices and behaviors, both individual/collective and environmental, as well as in leveraging people's autonomy and quality of life in the health system. At the Primary Care level, there is the Family Health Strategy (FHS) oriented to practices, especially disease prevention developed by interventions of multiprofessional teams in health centers. It is considered as the main primary care action in this new care model15^-16.

Health education is a possibility aimed at health promotion, protection and prevention of diseases. The educational practice aims at encouraging people to dialog and reflect on their life situation, at co-accountability in relation to care, and at the interaction with their individual and collective environment. Educational actions strengthen health, promote changes in everyday life and favor reflection between popular and scientific knowledge, boosting new knowledge that inspires attitudes and practices, mobilizing the development of health care, social interaction, emancipation, self-esteem and self-confidence, with a rescue of personal, family and social values, thus encouraging healthy behaviors17.

The powers are specific and disjointed, occurring through individual community initiatives in an attempt to implement collaborative and meaningful health promotion networks, in which people are responsible for their self-care and others'. However, in the work process of Primary Care professionals and managers, the productivist logic prevails, in which group activities are oftentimes seen as a possibility to serve more people18.

The improvement in health literacy that can be achieved through community actions and promotion, such as health education, can contribute to a better quality of life for the population. In a study conducted in Tanzania, it was identified that access to good quality health education, both in management and prevention of diseases, is still a challenge for the rural population. It is noted that community health professionals or agents in villages are the main educators and provide health promotion information to these communities, which includes information for groups or individuals19.

Although growing, there are still few studies that problematize home-based care as an important space to organize control tools over the population, the prescription of medical rationality and the exercise of power. By enabling health professionals' access to the home environment of private life, they provide horizontal relationships, highlighting the uniqueness of this encounter, the intersubjectivity of affections between the agents involved20. The appreciation of subjective dimensions “brings out more singularities for the humanization of people and helps embody the social and political problems we experience”.

Considered a work instrument and a powerful tool for health promotion, home-based care provides opportunities for situations involving different aspects of people's health-disease process, requiring training of the professionals for home-based interactions, as there are several barriers between the public and private spaces. The care exercised in home-based care rescues the traditional dichotomy between the public and private, as it is an action carried out by public professionals within a private environment. Furthermore, it is in this care space that qualified listening to people's complaints and problems and their health and disease situation can take place19. In this space, a horizontal relationship can emerge, without imposing power from biomedical knowledge, but valuing the uniqueness of each individual/family20.

As limits, it should be noted that the data refer to the reality of two municipalities; therefore, they cannot be generalized to Brazil or to Spain. In addition, both scenarios present diversity and similarity in their universal health systems, with the consequent need to analyze each one individually.

FINAL CONSIDERATIONS

Based on this study, it was possible to understand the health promotion practices developed by nurses in the Primary Health Care context in two cities with different universal health systems. It was identified that, in both locations, the activities are directed to individual and collective activities developed through groups and community actions. Health care is still preventive and with an emphasis on promoting lifestyle changes. In addition, this is due to the health professionals’ training focused on the hegemonic biomedical model.

In Brazil, there are advances related to public policies aimed at health promotion, such as the National Health Promotion Policy. In Girona, health promotion actions are related to activities involving specific groups, and disease prevention is focused on these groups.

Efforts are urgently required to include health promotion practices linked to inter- and cross-sectoral actions, and it is also important to articulate with the social determination of the health and disease process, endorsing equality as an essential tool for sustainable development. New studies are recommended to be designed, expanding the research to managers, public policy makers and other health professionals at different care levels.

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NOTES

• ORIGIN OF THE ARTICLE

  Extracted from Research Productivity Notice - PQ-2021 - Health promotion and social determination: Challenges and innovation for sustainable development.

• FUNDING INFORMATION

  National Council for Scientific and Technological Development (CNPq).

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved by the Ethics Committee in Research of the Jordi Gol i Gurina University Institute for Research in Primary Care (IDIAP_Codi CEIm: 21/165-P. In Brazil, approval was from the Florianópolis Municipal Health Department and the Research Ethics Committee, under opinion No. 45560721100000121.

Edited by

EDITORS

Associated Editors: Jaime Alonso Caravaca-Morera, Ana Izabel Jatobá de Souza. Editor-in-chief: Elisiane Lorenzini

Publication Dates

• Publication in this collection
  08 Jan 2024
• Date of issue
  2023

History

• Received
  24 Apr 2023
• Accepted
  27 June 2023