“IT IS NOT JUST EXERCISE”: PHYSICAL EDUCATION PROFESSIONALS’ WORK IN HEALTH PROMOTION

Abstract

The study sought to identify and analyse the work of Physical Education professionals with adults and elderly people in health promotion, beyond disease prevention. Based on the theory of salutogenesis, the research project employed the qualitative method of grounded theory proposed by Charmaz (2009) and condensed fieldwork (STENHOUSE, 1978) in four public health promotion programs. Participants included four Physical Education professionals, three health centre coordinators and 34 adults and elderly people. Data were produced through interviews and non-participant observation. Inductive analysis of data identified four practices that are representative of the professionals’ work: seeing people as subjects, caring relationships, development of health resources, and encouraging community protagonism. In conclusion, the ways of working of the Physical Education professionals demonstrated a salutogenic character, suggesting possibilities for overcoming the dominance of the biomedical model.

Keywords:
Public Health; Primary Health Care; Exercise Movement Techniques; Sense of Coherence.

Resumo

O estudo buscou identificar e analisar o trabalho de profissionais de Educação Física com adultos e idosos na promoção da saúde, para além da prevenção de doenças. Baseada na teoria da salutogênese, a pesquisa utilizou o método qualitativo da teoria fundamentada nos dados proposto por Charmaz (2009) e o método de trabalho de campo condensado (STENHOUSE, 1978) em quatro programas públicos de promoção da saúde. Participaram do estudo quatro profissionais de Educação Física, três coordenadoras de centros de saúde e 34 adultos e idosos. Os dados foram produzidos através de entrevistas e observação não participante. A análise indutiva dos dados identificou quatro práticas representativas do trabalho dos profissionais: um olhar para as pessoas, relações de cuidado, desenvolvimento de recursos de saúde e a valorização do protagonismo comunitário. Em conclusão, os modos de trabalho dos profissionais de Educação Física demonstraram um caráter salutogênico, sugerindo possibilidades de superação do modelo biomédico.

Palavras-chave:
Saúde Pública; Atenção Primária à; Saúde; Técnicas de Exercício e de Movimento; Senso de Coerência.

Resumen

El estudio buscó identificar y analizar el trabajo de profesionales de Educación Física con adultos y ancianos en la promoción de la salud, más allá de la prevención de enfermedades. Basada en la teoría de la salutogénesis, la investigación utilizó el método cualitativo de la teoría fundamentada en datos propuesto por Charmaz (2009) y el método de trabajo de campo condensado (STENHOUSE, 1978) en cuatro programas públicos de promoción de la salud. En el estudio participaron cuatro profesionales de Educación Física, tres coordinadoras de centros de salud y 34 adultos y ancianos. Los datos se obtuvieron a través de entrevistas y observación no participante. El análisis inductivo de los datos identificó cuatro prácticas representativas del trabajo de los profesionales: mirada hacia las personas, relaciones de cuidado, desarrollo de recursos de salud y la apreciación del protagonismo comunitario. En conclusión, los métodos de trabajo de los profesionales de la Educación Física demostraron un carácter salutogénico, sugiriendo posibilidades de superación del modelo biomédico.

Palabras clave:
Salud Pública; Atención Primaria de Salud; Técnicas de Ejercicio y Movimientos; Sentido de Coherencia.

1 INTRODUCTION¹

The role of Physical Education professionals (PEP) in public health promotion programs has expanded in the last two decades (OLIVEIRA; WACHS, 2018). Public health policies established bodily practices and physical activity (BPPA)² as priority actions and enabled the insertion of PEP in the Sistema Único de Saúde - SUS (Unified Health System) through strategies such as the Núcleo Ampliado de Saúde da Família e Atenção Básica - NASF-AB (Expanded Nucleus of Family Health and Primary Care) (BRASIL, 2013a) and the Academia da Saúde (Health Gym) Program (BRASIL, 2014).

The emergence of new possibilities for PEP’s role occurred in a context of debates about the need to reconstruct health practices, aiming at expanding knowledge and practice in health with the contribution of Human and Social Sciences, such as the concepts of humanization and care (AYRES, 2004).

However, the expanding role of PEPs in the field of health also posed challenges to the area. Among them, the limitations of initial professional training stood out due to a lack of articulation with health services, and the predominance of a biological approach to the ways of thinking and doing that were centered on controlling risk factors for diseases, protocols and prescriptions (BARBONI; CARVALHO; SOUZA, 2021; OLIVEIRA; GOMES, 2019; NEVES; ASSUMPÇÃO, 2017; SANTIAGO; PEDROSA; FERRAZ, 2016).

In line with Carvalho’s (2016) reflections, it is necessary to overcome the predominant logic of disease cure and prevention (without disregarding the relevance of these actions) and expand Physical Education’s possible ways of working in health promotion including its potential for articulating social, affective, cultural, economic and political factors.

In this context, the purpose of this study was to identify and analyze the practices developed by PEP in working with BPPA for adults and older people in public health promotion programs. The study was guided by two problematizing questions: how has the work in health promotion with BPPA been developed? How has this work contributed to participants’ health? In this inquiry, we adopted salutogenesis as a theoretical lens to support the analysis of health promotion work.

2 THEORETICAL PERSPECTIVE OF SALUTOGENESIS

Salutogenesis was proposed by Aaron Antonovsky (1979; 1996) in order to understand how health is maintained in people’s lives even in adverse conditions. For the author, the dominant model of health, pathogenesis (disease-centered), had limitations for health promotion, raising the need for an alternative model. In the pursuit of another way of thinking about health, Antonovsky (1979) suggested a change in the focus given to the matter, questioning “what are the origins of health?” and “how do people stay healthy?”. Thus, salutogenesis offers an alternative and positive perspective to understand and guide health promotion work in several areas, including Physical Education.

According to the theory, people move through a continuum of health in a dynamic and constant process of becoming. Moving along this continuum is influenced by individual and social factors. At an individual level, people are driven by their “sense of coherence” (a concept referring to an individual disposition and capability to deal with life situations); and, by the context of life or “river of life”, referring to the sociocultural, economic and environmental conditions in which people live (ANTONOVSKY, 1996).

The “river of life”, in its multiple dimensions (historical, economic, sociocultural and environmental), provides a complex of stressors and challenging situations to life cultivation (for example: unemployment, illness, loss of a family member). On the other hand, it also offers “health resources” (MCCUAIG; QUENNERSTEDT, 2018) as salutary factors that favor health development and maintenance.

These resources (originally called “generalized resistance resources”; ANTONOVSKY, 1979) consist of individual and collective characteristics and/or capacities of different types: material (financial condition, access to goods/services); social (supportive networks, community); emotional (identity, self-perception); intellectual (education, access to information); biological (individual characteristics); cultural (religion, art); among others. In their context and living conditions, people access and develop a set of health resources, to a greater or lesser degree. In challenging situations, individuals mobilize the resources they have at their disposal. When mobilized, health resources provide experiences that are characterized by levels of consistency, underload-overload balance (balancing imposed demands) and participation (autonomy in decision-making in life situations). In turn, these consistent, balanced and autonomous experiences shape the sense of coherence of individuals and groups, leading to health production processes. In the study, we consider as examples of these experiences those promoted within the scope of public health promotion programs with the BPPA.

Thus, sense of coherence can be considered as the key concept for salutogenesis theory. The concept refers to people’s capacity and disposition to see life as comprehensible, manageable and meaningful. Sense of coherence indicates a capacity for dealing effectively with adverse situations that affect life, influencing health positively. According to Antonovsky (1979), the sense of coherence involves three components: comprehensibility, manageability and meaningfulness. Comprehensibility indicates that one has a cognitive capacity, information and knowledge to understand one’s world and life, including the challenges, problems and illness. By manageability, Antonovsky (1996) considered one’s capacity to identify and mobilize health resources that are available to deal with a certain situation. And meaningfulness refers to one’s motivation and capacity to get involved with the process of solving and managing life situations. The three components are interrelated and indicate how people comprehend life situations and feel motivated to deal with them, mobilizing the resources that are at their disposal to stay healthy.

The assessment and analysis of individuals’ and groups’ sense of coherence have been the main focus of studies based on the salutogenesis framework (MITTELMARK; BAUER, 2017). Throughout the development of the theory, Antonovsky (1987) created the sense of coherence scale (The Orientation to Life Questionnaire) with 29 items that assesses the three components of comprehensibility, manageability and meaningfulness. The instrument enables measuring the sense of coherence, having been translated and validated in several countries, including Brazil (SCALCO, 2016). However, it should be noted that the potential of salutogenesis theory is not limited to quantifying the sense of coherence, as it has been widely employed in the literature (MITTELMARK; BAUER, 2017). In a broader sense, salutogenesis is also a theoretical orientation to support qualitative studies and practices in health promotion.

3 METHODOLOGICAL DECISIONS

The present study generated qualitative data, and used Grounded Theory (GT) approach. This approach involves a systematic process of successive cycles of production and inductive analysis of empirical data for the development of theoretical explanations about the phenomenon under study (CHARMAZ, 2009). As the first data are generated, the researcher produces an analysis of the material before carrying out a new cycle of data collection. Additional data generation takes into account previous analysis, culminating in a cumulative process of data production and analysis. Therefore, it is a method that guides both data generation as well as the analytical process leading to the construction of theory (CHARMAZ, 2009). The focus of GT is to understand perspectives and experiences of subjects involved in a given context, aiming at the development of a theoretical explanation for the investigated situation (SANTOS et al., 2016).

The method has been increasingly used in the health field, particularly in the areas of Nursing, Social Sciences and Psychology (CRESWELL, 2007; SANTOS et al., 2016). By enabling an understanding and theorizing about the experiences of individuals and groups and their interactions with professionals and services, GT becomes relevant for health studies, especially with regard to the possibilities for contributing to enhancing health practices and work (SANTOS et al., 2016).

The study was carried out following ethical procedures, with approval by the Research Ethics Committee of São Paulo State University Júlio de Mesquita Filho.

3.1 CONTEXT AND STUDY PARTICIPANTS

The study was developed in four public health promotion programs, located in Southern and Southeastern regions of Brazil. The programs delivered BPPA on a regular basis to adults and older people, under the guidance of PEP.

The programs were selected according to theoretical sampling strategy (CHARMAZ, 2009), considering their relevance to the study, a salutogenic perspective and a comprehensive understanding of health (FREITAS; CARVALHO; MENDES, 2013). Therefore, we included programs that demonstrated developing health promotion approaches in a comprehensive perspective, recognizing the multiple dimensions related to health (FREITAS; CARVALHO; MENDES, 2013) and extrapolating the scope of disease prevention and practices strictly guided by biomedical rationality (AYRES, 2004). The programs were identified through exploratory searches in virtual databases of health experiences such as "Community of Practices - Humaniza SUS Network³" and "Observatório Saúde em Movimento (Health in Movement Observatory) - Federal University of Rio Grande do Sul", and from published experience reports in conference proceedings.

Below, we present a description of the four programs included in the study (Chart 1).

Chart 1
Description of public health promotion programs participating in the study.

Program	Type of program	Location	Regular activities	Year of implementation
P1	NASF-AB	Minas Gerais	Yoga, dance and low-impact exercise (1x/week) in groups, events and counselling.	2012
P2	Academia da Saúde (Health gym)	Rio Grande do Sul	Dance, low impact exercise, (2 to 3x/week) in groups, round conversation (1x/week), community actions and events.	2014
P3	Academia da Saúde (Health gym)	Rio Grande do Sul	Recreational activities, group dynamics, low-impact exercise, community actions and events.	2016
P4	Local initiative	Santa Catarina	Adapted sports for older people (volleyball and handball), dance, low-impact exercise, events and games.	2009

Souce: Research data.

Within the context of the four programs, the study participants⁴ involved three groups: a) four PEPs - three women and one man, with an average age of 37 years and an average time of professional experience equal to six years; b) three⁵ health center coordinators (HCC) - with degrees in Nursing and an average age of 40 years; c) 34 users - three men and 31 women, aged between 30 and 80 years.

3.2 DATA PRODUCTION AND ANALYSIS

Data production was conducted through condensed fieldwork (STENHOUSE, 1978). This method unites elements of ethnographic research and case study, characterized by the investigation of different cases during a short and intensive period of fieldwork. Fieldwork was conducted over three days in each program and involved 25 semi-structured interviews with the three groups of participants (PEP - 13; HCC-3; users - 9) and non-participant observation of 34 sessions of regular activities. Interviews with PEPs addressed their objectives and working methods, types of activities developed, resources, strategies for evaluating actions, community profile, program history and perceived results. With the HCCs, interviews sought to understand the impacts of the work developed to the community’s health promotion. Interviews with the users included questions about their experiences with the BPPA and their perceptions about contributions to health. All interviews were audio recorded, transcribed and later validated by the participants.

Data analysis was performed using the constant comparative method (CHARMAZ, 2009). Data were systematically compared in order to identify similarities and differences in relation to the three groups of participants, data sources (interviews and observations) and the four programs. The analytical process involved a sequence of steps: a) organization of the data set and successive readings of the material; b) initial coding; c) axial coding, with additional comparisons between data and initial codes; d) selective coding, with themes refinement. In this last phase, the themes were interpreted through salutogenesis theory (ANTONOVSKY, 1979).

4 RESULTS AND DISCUSSION

Results indicated that PEP developed a set of practices consistent with salutogenesis (ANTONOVSKY, 1979). The practices identified are represented through four themes: a) seeing people as subjects; b) caring relationships; c) development of health resources; d) encouraging community protagonism.

4.1 SEEING PEOPLE AS SUBJECTS

This theme indicates that PEPs’ work with BPPA was guided by a comprehensive and humanized view of health. Their working approach with program participants surpassed a biomedical perspective and adopted a way of seeing people as subjects with life stories permeated by socioeconomic and cultural conditions, family relationships, interests and needs, including illness. It is worth noting that, in this salutogenic view, illnesses lose the centrality they usually have in a pathogenic logic, but it does not mean that they are ignored (ANTONOSKY, 1979).

The holistic perspective as a philosophical foundation for health promotion work was evident in assumptions made by the PEPs, as indicated by Barbara:

A human being is a whole. He is emotion, he is everything he brings with him. He isn’t just a physical body […] From the moment you begin to look at the other in a different, not only illness and body, but a human being with all the story and experiences he/she has […] you don’t see his/her just as a human being who has diabetes, knee injury. But she’s Dona Maria who is a widow or she’s the one who never had a boyfriend, or lives with her sisters and there is all that context. You start to see a whole way of dealing with that person without being just knee, glucose and overweight. (Barbara, PEP-P2)

In Barbara’s view, health promotion work transcends a biological dimension when the practitioner broadens his or her view and seeks to apprehend the subjectivities that constitute people’s ways of living. The PEP adds that: “If you don’t see how the territory is, the people who are inserted there, how they live, what they do, what they need, what their demands are... you end up staying in that little world and not creating anything”. Therefore, having this different way of seeing people and communities is a crucial element in developing new ways of working in health promotion that can be transformative.

Barbara indicates that this way of seeing people, beyond disease:

has a lot to do with humanization issue [...] To understand that it’s not just to prescribe exercise, it’s not just to plan a training or to organize a session. But a PEP that also deals with the emotional side of people. Because from the moment you work this relationship with people, you will not only treat their physical part [...] We see that everyone knows what humanization is, but it does not happen. People know what it is, but it seems to stay in theory. (Barbara, PEP-P2).

Thus, overcoming a reductionist perspective in health promotion requires mobilization of humanizing practices. Although the National Humanization Policy guidelines (BRASIL, 2013b) endorse such practices, they still face resistance to be implemented. An illustrative case is the study by Warmling et al. (2018) which revealed how daily health work with pregnant women remains strongly guided by the biomedical paradigm, imposing barriers for humanizing practices.

In contrast, in the present study, the data indicated work committed to humanization. For example, a practice adopted was the deconstruction of labels that identified groups by names of diseases that members had in common. In forming groups, Susana (PEP-P3) was against grouping by diseases: “No hypertensive, diabetic or depressive. I didn’t want to discriminate against anyone [...] My idea was to try to cover as many people as I could, not separate them by pathology”. Similarly, Sara (HCC-P2) sought to leave this type of identification: “When I arrived, they called it a group of hypertensive and diabetic patients. First, I removed the name. I called it a health group and we started sharing experiences, doing other things”. This change of names already suggests another way of seeing people beyond diseases.

By deconstructing labels that posed weaknesses and reductionism on the subjects’ bodies, the PEP enabled them to reconstruct identities that recognized their potential. For example, in P2, a group of women began to identify themselves as the “Divas of SUS” since they became involved in an emancipatory process mediated by round conversations and dance performances, which contributed to improvements in their self-perception and self-esteem.

In this sense, the study suggests that one of the possibilities for “enriching horizons” (AYRES, 2004) in health promotion work is related to valuing subjectivities and collectivities and creating opportunities for people to rebuild and negotiate their own identities, so that they can recognize and strengthen themselves. To this end, it is essential to have an attentive and sensitive look at people's singularities, in line with the salutogenic perspective.

4.2 CARING RELATIONSHIPS

With a person-centered approach, the PEPs developed practices aimed at building caring relationships. According to Ayres (2004), the concept of care designates a “philosophical understanding and a practical attitude” (p.74) that occurs in the interaction between individuals and in the mediation of knowledge related to the production of health and wellbeing. Caring has a relational nature and involves two main parts: identification of the other’s needs through listening and reflection; and a response to what was identified through actions that are essential to maintain caring relationships (NODDINGS, 2012).

In the study, the PEP’s practices consisted mainly of attitudes and behaviors directed at embracing and creating bonds, such as demonstrating respect and genuine interest in the individuals and groups’ health needs, attentive listening and mobilizing actions in response to the identified demands. For Michele, practices of user embracement are crucial in health promotion work:

Usually, when the population comes, they never say 'I’m depressed' or 'I’m suffering violence and I’m planning to kill myself'. They always come to us with some symptom. Sometimes that symptom is much more a matter of the practitioner doing a good user embracement. That symptom that she has every week, when we analyze, clinically, she has nothing. It’s a person who has some situation behind (Michele, HCC-P3).

According to the National Humanization Policy, user embracement implies “recognizing what the other brings as a legitimate and unique health need” and should permeate the relationship between practitioners, users and health services (BRASIL, 2013b, p.7). In addition to contributing to the identification of situations that are not exposed by people and to the planning of adequate multidisciplinary approaches, user embracement plays an important role in satisfying people’s need to be heard. In this regard, Sara (HCC-P2) explained that: “We try to create this open channel with the community, especially with the elderly, because we know that if we do not listen nobody else will, this is lacking within these families”. Therefore, in working with older people, practices of listening developed by the PEP become particularly relevant.

In fieldwork observation, it was possible to verify how the programs’ participants approached the PEP to talk and tell about a situation. Corroborating these observations, Carlos reported how the groups demonstrate a need to talk:

Once, it took me half an hour to get into the material room. I was in front to the table to take materials, I was already talking to one, when she finished conversation, I took two steps there, then another one came, she finished conversation, I took two more steps, another appeared... So, they were queueing to be assisted, you know? […] They needed someone to unburden themselves (Carlos, PEP-P4).

One of the main needs of program’s participants was relational, that is, they needed to talk, unburden and be heard. Carlos’ response to the participants’ needs was listening: “What I do is let them talk and listen. This I have always done since the beginning. The thing is, they use it here as an escape valve”. From a salutogenic perspective (ANTONOVSKY, 1979), the PEP’s quote suggest that users perceive the program and its representation as resources to deal with problems and needs they have, challenging the idea that meanings attributed to BPPA are only of a biological and physical-motor nature.

In P3, Susana noticed that the practice of listening promoted in the context of BPPA opens possibilities for people to recognize and deal with their emotions: “Sometimes they come here and cry, sometimes they cry in a group”. Faced with participants’ needs to be heard and socialize, the PEP adopted a conversation time strategy in class: “I don’t start the class with exercise […] I always try to get something of conversation. I always ask several things” (Susana, PEP-P3). The interactive moment occurred mainly at the beginning of sessions, and it was stimulated through questions she asked the participants about how they were doing or to follow up on specific situations experienced by them: “I tend to remember a lot of things like this - 'Oh, you had a medical appointment, how was it?'' Because I think it’s very important for them to know that someone cares about them” (Susana, PEP-P3). Thus, caring relationships were built with the demonstration of interest and attention to the users’ daily lives and subjective experiences.

In parallel with the results of the study by Lima et al. (2020), a participant indicated that user embracement promoted by the PEP represents a differential that contributes to motivation and satisfaction with the program:

The PEP always asks if we are well or if we need something in terms of health. I think this user embracement is very cool. Because, of exercise, we do what any regular gym would do, which is this functional part, aerobic exercises. But the user embracement part is what I really like… being able to talk to the PEP, with colleagues, and have access to the health center. That part of you exercising while laughing, talking, being there listening to a colleague, for me I really liked it. And I’d never had contact with this kind of work. So, for me the social aspect is the most motivating (Jeniffer, 30, P3).

Thus, the work developed in the program provides opportunities for building relationships, distinguishing from traditional approaches to physical activity. Similarly, in another participant’s view, the user embracement employed through round conversations in the program represents an important contribution to her life: “On Fridays it is wonderful. There was a time I sat here and started crying. Just by talking with them, I left here and I had even forgotten what I was going through. So this is fundamental” (Diana, 62, P2). Significantly, the round conversation tool seems to have boosted caring relationships in the context of BPPA.

In the salutogenic perspective, experiences of building bonds between people are related to “emotional closeness”, one of the constitutive elements of the sense of coherence (IDAN; ERIKSSON; AL-YAGON, 2017). Experiences of “emotional closeness” contribute to the creation of social support networks and, therefore, to people’s capacity to face challenging situations (IDAN; ERIKSSON; AL-YAGON, 2017).

In general, the PEPs’ practices involved an active pursuit to get to know people (with their stories, experiences and demands), listen attentively and establish bonds. In this sense, an attentive and sensitive attitude contributed to the PEPs identifying and meeting participants’ needs, especially those of a socio-affective nature. In such a way that the establishment of caring relationships and welcoming spaces (BRASIL, 2013b) with BPPA provided encounters between subjects and collectivities, stimulating the development of capacities and experiences that served as health resources.

4.3 DEVELOPMENT OF HEALH RESOURCES

The third practice identified in the PEPs’ work was the development of health resources, that is, a stimulus to the expansion and diversification of experiences, capacities and knowledge that could produce health in participants’ lives. According to salutogenesis theory, people produce health through the mobilization of resources that are available in their life context (ANTONOVSKY, 1979). These resources provide life experiences that help people understand and deal with stressors, face situations of illness and suffering, as well as produce health and wellbeing.

In order to achieve the development of health resources in different dimensions in addition to the physical benefits of BPPA, it is necessary that health work has such intentionality, which was demonstrated by the PEPs’ comments: “[The objective] is health promotion. You promote possibilities for people to observe their lives and pursue health” (Barbara, PEP-P2); “What I always want to achieve is a matter of autonomy [...] because people, when they don’t have access to knowledge, they end up being very dependent on someone else” (Ana, PEP-P1); “First, it is to work on health promotion and disease prevention; second is to work on the physical, mental and social. And third, user embracement, which is also fundamental [...] That’s why it doesn’t focus only on the physical” (Susana, PEP-P3). The quotes indicate the PEPs’ aspirations with BPPA were directed towards different ways of producing health in people’s lives.

In this way, the contributions of BPPA to the users’ lives went beyond the physical and physiological dimension, such as reducing body weight, improving physical fitness and functional capacity, reducing the use of medicines and relieving pain. Significantly, the PEPs’ work boosted health production in participants’ lives through new cognitive, social and emotional resources.

In the cognitive part, the users identified health-related knowledge acquisition, improvements in memory and in the ability to learn in adult and elderly life: “The PEP brings counselling from dietitian, physical therapist... then we learn many things, it makes a complete set” (Sheila, 55, P3); “Memory, sleep, agility, balance, improved a lot” (Joana, 62, P3); “I like to listen to counselling lectures. I like to learn. Because I didn’t have that opportunity to learn. Neither literacy nor school” (Nilza, 80, P1). Therefore, the participants found opportunities to engage in educational processes, especially on health topics.

According to Antonovsky (1979), the cognitive component is related to people’s ability to understand (comprehensibility), which is a fundamental element for perception of the self and the world, including the recognition of singular and collective experiences, as well as the socio-historical conditions that are determinants of health.

In the social domain, health resources perceived by the participants were related to experiences of new friendships, interaction, creation of bonds, solidarity, social support and fun: “It is the regular interaction, day-to-day with people. I was shy, I stayed mostly at home, I didn’t go out. And now, it has changed, communication has improved” (Paulo, 69, P3); “I thought it was going to be very demanding, having to lose weight. Then the PEP said no, it’s to socialize […] We learn to share the good things that we have” (Joana, 62, P3); “This is a family for us” (Lisa, 78, P1); “We have lunch, dinner, then we make more friends” (Sheila, 55, P3); “It’s not just going there to exercise. We talk, we laugh, we play” (Margareth, 46, P3). The quotes suggest that BPPA had the potential to connect people and configured a space for encounters and forming collectivities, corroborating the findings of the study by Jesus, Sventnickas and Vieira (2019) with health service users who attributed importance to regular social interaction, friendship cultivation and exchange of experiences. Carvalho, Guerra and Loch (2020) highlight the relevance of expanding the perspective about BPPA as pleasurable and satisfying activities to the detriment of an imperative force on subjects’ bodies, such as "having to lose weight".

In the emotional dimension, the participants recognized pleasure, affection, mood, self-esteem, vitality, purpose and emotional regulation as health-producing experiences: “I am feeling like a different person. I feel alive again. I want to live. Exercise is living” (Carol, 55, P1); “I went to other gyms, but it didn’t help me that way. It helped in the physical part, right? Here we talk, play, laugh, and it helped me a lot to improve my self-esteem” (Vitória, 52, P2); “It’s the love we build with our colleagues. They give you a hug, a kiss, a smile, it’s that joy” (Diana, 62, P2); “Here is a time of pleasure” (Teresa, 54, P2); “It’s an escape valve that we have” (Emily, 57, P2); “I don’t like to be absent because I feel good. I feel relieved, it makes me more willing, it gives me more courage to continue” (Lisa, 78, P1). In general, the participants’ comments are in line with a view that BPPA contribute to the appreciation of life, human development and a positive self-perception of health (CARVALHO; GUERRA; LOCH, 2020).

As mentioned earlier, the PEP’s ways of working began with an intentionality and involved the diversification of strategies and activities with BPPA. As an example, two participants described that the PEP developed cognitive activities:

MARGARETH: It's not just exercise that the PEP works with us. The work involves mentality, concentration and the friendships that we make here. Activities to exercise our mind, you know?

MÁRCIA: She works on balance and with that we end up working our mind, brain, memory (Margareth, 46, P3; Márcia, 62, P3).

Corroborating the participants’ testimony, fieldwork notes confirmed the use of a variety of recreational activities, such as dynamics and guessing games. In addition to regular activities, PEPs’ work also included commemorative events: “We celebrate all dates. The cool thing is that, just as I make it an event, there are people who take it very seriously and really like it. And there are people who see as just a normal session” (Susana, PEF-P3). Organizing events and celebrations consisted in a complementary action to encourage integration and establishment of bonds.

In short, the expansion of possibilities of working with BPPA with a focus on the cognitive, social and emotional dimensions, without excluding the physical, enabled the development of multiple health resources, enhancing the capacities of adults and older people to produce health and wellbeing.

4.4 ENCOURAGING COMMUNITY PROTAGONISM

The results indicated that the PEPs’ work encouraged users not only to become physically active, but also to establish bonds and a sense of community, favoring engagement in collective actions and the formation of active communities mediated in the context of BPPA.

In P2, the PEP and participants formed the group of “Divas of SUS” to talk about topics that were chosen by them and were generally related to everyday problems, gender issues, interests and experiences. Through the construction of a welcoming and dialogic space, the women were encouraged to express themselves and reflect on the experiences of being a woman in their life context, and to suggest actions for the group, assuming a leading role in their own practices. For Barbara (PEP-P2), the group’s power lies in the fact that: “It is their knowledge that they share, talk, and organize. It's that thing of putting what they experience and sharing with their colleagues, and not just knowledge from someone who has graduated, but from their lives”. So, the round conversations facilitated by the PEP made it possible to value the women’s own knowledge and experiences, contributing to their recognition as autonomous and co-responsible subjects in health production (BRASIL, 2013b).

In the same sense, Susana (PEP-P3) demonstrated valuing co-responsibility in building healthy ways of living: “The gym is not mine, it’s not the city’s, it’s not the neighborhood’s. We are all one. We talk, we understand each other, everyone has the right to express their opinion. I always made that very clear.” As a result of an inclusive environment, some actions emerged as initiatives of the participants themselves, such as the creation of a community library and a solidarity board in which they helped each other. A participant described how the board worked: “If any person needs something, there is a board there. And what we need, write it there. And the person who has that thing at home brings it to that other person” (Jorge, 69, P3). The example of the solidarity board shows the participants’ involvement with the construction of collective actions, strengthening a sense of community.

Another example was reported by Carlos (PEP-P4) about an initiative to create a community garden: “They are planning to build a garden behind the gym and the group will adopt it. A participant started the process, brought seeds and has already planted something here. Thus, they will start taking care of the space here”. Actions like this illustrate how the participants began to take ownership of community spaces and develop a capacity to mobilize resources (ANTONOVSKY, 1979) for health production and collective wellbeing.

Therefore, the PEPs acted as facilitators in the construction of collectivities, which corroborates studies such as by Lima et al. (2020), whose results pointed to a central role of the PEP as a mediator, educator and articulator of a group of older people. The PEPs’ work enabled the creation of opportunities and spaces for community protagonism (BRASIL, 2013b), encouraging users’ active participation in the development of collective health resources and the production of care. These findings support the perspective that BPPAs have the potential to operationalize health promotion principles, such as autonomy and people’s protagonism (CARVALHO; GUERRA; LOCH, 2020).

5 CONCLUSION

This study sought to identify and analyze the practices developed by PEP in working with BPPA for adults and older people in health promotion public programs. The four practices identified, seeing people as subjects, caring relationships, developing health resources and valuing community protagonism, suggest that the PEP’s ways of working surpassed the traditional biomedical model and acquired a salutogenic character.

The PEPs developed new possibilities with BPPA in alignment with a salutogenic perspective, that is, focused on the development of capacities for health production and wellbeing. The experiences constituted with BPPA supported the participants in facing adversities, helping them to perceive life as understandable, manageable and meaningful, and in turn positively influencing their health (ANTONOVSKY, 1979).

The findings of this study reinforce the existence of promising possibilities for PEP’s work in the context of health promotion. The results showed that BPPA can be configured as a privileged space to produce encounters between subjects and collectivities and other health-producing experiences. The development of a health work committed to care, in its philosophical and practical sense (AYRES, 2004), enabled the PEPs to go beyond the promotion of an active lifestyle and disease prevention, and to contribute in a significant way for the humanization and construction of healthy ways of living.

• 1
  The article is a result of doctoral thesis by FERREIRA, Heidi Jancer. Health and physical education professionals' salutogenic and pedagogical practices for working with disadvantaged older adultsx. São Paulo State University (UNESP) – Campus de Rio Claro, 2019.
• 2
  In the study, according to Carvalho (2016), we adopted the terms “bodily practices and physical activities” in a complementary way, aiming to consider multiple meanings attributed by individuals and groups to the forms of human movement in its cultural, playful, social, historical, physical, and biological aspects.
• 3
  Available at: https://www.ufrgs.br/saudeemmovimento/
• 4
  We created fictitious names to ensure participants´ anonymity.
• 5
  P4 coordination was performed by the PEP himself.
• FUNDING
  This work was supported by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Funding Code 001 and Fellowship/Sandwich Doctoral Abroad Program/Grant n. 88881.131900/2016-01; Federal Institute of Education, Science and Technology of South of Minas Gerais (IFSULDEMINAS); Grant n. 2019/05358-7, São Paulo Research Foundation (FAPESP).

RESEARCH ETHICS

This work followed current procedures in line with Resolutions 466/12 and 510/2016 by Brazilian Health National Council and it was approved by Research Ethics Committee, São Paulo State University Júlio de Mesquita Filho. Plataforma Brasil CAAE number: 52527616.1.0000.5465 Report: 3.573.017.

EDITORIAL RESPONSIBILITY

Alex Branco Fraga *, Elisandro Schultz Wittizorecki *, Mauro Myskiw *, Raquel da Silveira *

* Federal University of Rio Grande do Sul, School of Physical Education, Physical Therapy and Dance, Porto Alegre, RS, Brazil.

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Publication Dates

• Publication in this collection
  11 Nov 2022
• Date of issue
  2022

History

• Received
  07 Jan 2022
• Accepted
  13 May 2022