What has been discussed about Popular Health Education in recent years: a narrative review of the literature

This narrative review aims to analyze the literature on Collective Health to recognize what has been discussed in Popular Health Education (PHE) from 2019 to 2022. Fifty-nine articles were selected, critically analyzed, and separated into six summary categories: popular education practices as promoters of a participatory vision of health; popular education and the valorization of local popular culture knowledge and practices; popular health education as a strategy to support social reconstruction in the face of setbacks in public policies; the importance of national articulation in popular education as a response to its devaluation; popular education as a liberating project thinking about the democratic formation and the fight against institutional and structural violence; popular education in the university health training process. We achieved significant results that elucidate the importance of PHE within the Unified Health System and the academic education of health professionals, fostering respect for ancestral knowledge and care horizontality. We also reaffirm the need for national articulation and dialogue with grassroots movements to advance Brazil’s emancipatory and dignifying health agenda.


Introduction
Popular Education (PE) is a theoretical-methodological perspective that guides educational and social practices, articulating a set of ethical, political, and pedagogical foundations that support popular organization initiatives in confronting social inequalities 1 .Therefore, Popular Health Education (PHE) has consolidated into Collective Health as a theoretical-methodological framework guiding movements committed to health practices that emancipate social subjects 2 .
Profound and significant crises have marked the last six years.As stated by Fleury 3 , who analyzes the economic crises, the crises of democratic representation, starting in 2016, with the Temer Government (2016-2018), in the implementation of a public agenda guided by austerity and, thus, the weakening and even the extinction of public policies.In the Bolsonaro Government (2019-2022), the management of the Federal Government deepens its neoliberal perspective.It faces the COVID-19 pandemic with actions and policies characterized by the emptying of the Unified Health System (SUS), escalating necropolitics, and deepening of social inequality 4 .Mbembe 5 argues that necropolitics represents a way of thinking about life, politics, organizations, and their relationships, where violence and the annihilation of other subjects prevail as a social, political, cultural, and economic practice so that whoever holds power determines who dies for the exercise of control in relationships.
Within PHE, we witnessed an institutional abandonment of the National Popular Health Education Policy in the SUS (PNEPS-SUS), represented by the inactivation of its Operational Plan and the extinction of the National for Popular Health Education Committee (CNEPS) at the Ministry of Health 6 .
Recognizing the importance of PHE in strengthening the cultural plurality of popular knowledge and encouraging spaces for discussion in Collective Health, the Extension and Research Program "Comprehensive Practices for Promoting Health and Nutrition in Primary Care (PINAB)", from the University Federal Government of Paraíba, since May 2021, has been building the Observatory of Popular Health Education and Brazilian Reality.This initiative gathers health stakeholders from different Brazilian regions to hold discussions that critically analyze the Brazilian situation and the challenges to PHE 7 practices.The Observatory's meetings and debates triggered the question: "What has been discussed in PHE in the literature of recent years in Collective Health?".Given the above, the present study aims to analyze the bibliography on PHE in Brazil, seeking to identify and systematize the main discussions developed.

Methods
This qualitative narrative review of the literature 8 is understood as an appropriate study to describe and discuss the "state-of-the-art" of a given topic, establishing theoretical and contextual understandings 9 .The bibliography research started in October 2022 in the "CAPES Periodicals Portal" database, using the "Popular Health Education" descriptor.
The inclusion criteria were complete articles published in Portuguese, English, or Spanish from 2019 to October 2022, referring to the PHE experiences and reflections in Brazil.In turn, the exclusion criteria were articles that did not address PHE from a Freirean perspective, abstracts, monographs, and other types of production other than articles published in scientific journals and duplicate articles.
All results found were imported from the "CAPES Periodicals" search database into the Rayyan application (https://www.rayyan.ai/) to organize and archive the studies.Duplicate articles were identified and excluded using the application's native functionality.
The study selection process was divided into two screening stages.Two independent reviewers performed the first screening and blindly analyzed the titles and abstracts of the studies found.Articles that met the inclusion criteria proceeded to the second screening.The second screening occurred through the full reading of these articles by two reviewers, also independently and blindly.Articles from the second screening that met the inclusion criteria were selected to compose the review.Any divergence in the screenings was finally ruled by a third reviewer who had decision-making power over the article's inclusion.
In this process, the selected articles were analyzed from the perspective of content analysis, as referenced by Laurence Bardin 10 .An in-depth reading of these articles was conducted to identify emerging ideas that pointed to alternative responses to this study's objectives.Representative quotes were highlighted for each emerging idea.Then, an analysis of the confluence of meaning between emerging ideas was performed to group them into meaning cores.Finally, different groups were gathered using a thematic approach to summarize ideas to underscore the emerging dimensions from the analysis of the selected scientific productions.(Link SciELO Data: https:// doi.org/10.48331/scielodata.DG4RNR).

Results
The initial search resulted in 113 articles.Fifty-nine articles were selected after applying the criteria (Figure 1).
Chart 1 systematizes the results of the analysis of the articles in the form of the six summary categories constructed, explaining the meaning cores that compose them.
Many articles, such as that from Paro et al. 11 , emphasized the association of PHE practices with a broad conception of health and, consequently, an expanded approach to the health-disease process.In this sense, PHE as a guiding conception of practices that enhance the idea-power of health promotion within the scope of practices and services, as defined by Buss et al. 12 (p.4725) is significantly identified: a promising strategy to address health problems, integrating technical and popular knowledge, and mobilizing institutional and community resources to promote quality of life.
The emphasis that PHE processes have been achieving for educational actions and social work in Collective Health as a whole, in the sense of acceptance and protagonist inclusion of popular knowledge and practices in health action and care initiatives, was also significant in the literature.Publications such as those by Conceição and Conceição 13 and Santos and Santos 14 present reports of practices where this dialogue occurs.
We identified a significant range of contributions in the literature regarding the contributions of PHE practices in the face of the recent setbacks in Brazilian public policies, aggravated by ultra-neoliberal public agendas and the COVID-19 health crisis.Articles such as those by Lima and Pekelman 15 , Paro et al. 16 and by Fernandes et al. 17 reveal initiatives of resistance and systematization, propositions of knowledge and learning accumulated in PHE's power as a response to ex-  Also highlighted were productions with reports of experiences and critical-reflective essays around the need for communication and articulation between PHE practices and projects in the face of the previously mentioned weakening of social actions and public health policies, and given the (still) little appreciation of PHE within the health services, as pointed out by Cruz et al. 18 .
Finally, an relevant set of contributions from the literature indicated the meanings of PHE practices in the training of social stakeholders for struggles to defend democracy, such as those contained in the articles by Brutscher et al. 19 and Brito et al. 20 .

Discussion
Regarding the synthesis category on PE practices as promoters of a participatory vision of health, PE was identified in the literature as a relevant perspective in guiding public health policies in response to fragmented care through actions aimed at autonomy and health from a compre-hensive perspective 21 .Pedrosa 22 (p.306) reinforces this understanding by highlighting PHE as a field in movement, from which "another form of knowledge production and systematization of experiences has been established that point to new designs for health practices from the scope of care to administration and management practices".
Oliveira Junior et al. 23 report the formation of the multidisciplinary group "Movimenta SUS", a PHE initiative focused on comprehensive care through bodily practices and physical activity.In turn, Dantas et al. 24 present art and culture as processes in which people, groups, and popular classes express their representation, recreation, and re-elaboration of reality, inserting them into health practices from the perspective of a liberating social practice.
Lima et al. 25 point out that PHE's dialogicity is fundamental for professionals to integrate the team's work processes actively and organically.Moving in this direction, Cruz et al. 26 (p.11) accentuate this understanding, indicating that PHE mobilizes a "concrete action", before which its stakeholders will broaden their perspectives beyond local and specific practices, realizing "the potential of collective construction and social ac- tion organized in participatory and cooperative fashion between people with different knowledge, including different techniques and professions".
As indicated by the researched literature, PHE is crucial in overcoming Health Education with a vertical approach and technical themes toward education linked to emancipatory care 27 .Pedrosa 22 (p.310) expands this understanding by pointing out, within the participatory management, the contribution of PHE in three dimensions: "a political project to expand spaces for dialogue between SUS management and social movements; a device to mobilize the population for the right to health and equity; and pedagogical strategy establishing critical and propositional subjects with potential for formulating and deliberating political projects".
The researched literature exalts lovingness as the foundation of PHE, which must be valued in educational practice.Lovingness involves care, attitudes, and ethical postures to humanize health work, focusing on dialogue, a receptive presence, and authentic listening.It is, therefore, not a purely romanticized process of professional-user relationship but an ethical stance towards others toward enhancing solidarity and emancipatory action 28 .The bond established on this Freirean basis encourages a collective experience towards autonomy, solidarity, and equity 29 .
The PE framework allows for building an action that includes and values the bond between health professionals and the territory and community, which is associated with promoting people's critical thinking, unveiling silenced perceptions, and valorizing marginalized voices.In this approach, Hélène Laperrière 30 reinforces the idea that conservative science and official reports intentionally exclude "inconvenient" knowledge that arises from community experiences and the practices of local workers.
Broadening the view, we should mention Freire 31 , when he indicates that "commitment, typical of human existence, only exists in engagement with reality, from whose "waters" truly committed men become "wet" and soaked".In the meaning defended by Vasconcelos 32 , this necessarily implies including oneself in reality, observing, studying, reflecting, and acting, which is only possible through regular and systematic interaction with the work context and the construction and mediation of bonds with local leading figures.
Regarding the summary category dedicated to PE in valuing the local popular culture knowledge and practices, we can see that because its foundations lie in dialogue, PE presents approaches that reaffirm a perspective of developing science in a way that respects popular knowledge 33 starting from criticism of the imposition of scientific knowledge on popular knowledge in the construction of social actions and social and educational work within the scope of public policies 13 .Building a bond with the territory and the community is valued once this common and equal space for speech has been established, thus allowing the unveiling of silenced perceptions and valuing marginalized voices 30 .
These perceptions can be seen in the report of the third class in Belém-PA of the Popular Health Education Improvement Course (EDPOPSUS) when they noted how the diversity of places of origin, encouragement of autonomy, and inclusion in a receptive environment consolidated a group of mutual help, companionship, and solidarity 34 .
Dialoguing with this reflection, we should underscore that Acioli et al. 35 (p.650) presented a study in which they found that the surveyed professionals' recognition of popular knowledge was mainly related to the use of medicinal plants in order to include phytotherapy in biomedical knowledge in therapeutic indications.This understanding, when present, needs to be discussed by the professionals in their teams.The PHE emerges as a guiding methodology for educational, social, and partnership relationships that corroborate in this sense, especially in understanding popular knowledge as knowledge that comes from the concrete practice of peoples and communities, whose incorporation into health practices can collaborate to establish appropriate initiatives consistent with the needs and potential of the territory of action and its representatives.
PHE is a perspective that recognizes education's social, historical, and political interrelationships.To this end, its methodology includes respect for the dimension of ancestry and knowledge and practices accumulated by the people as a starting point for the construction of educational work and community health actions.
Lavor Filho and Vale 36 focus on this theme with their experience with African-based religion temple peoples.Realizing that the lecture model was insufficient to meet the demands of the group, a new proposal was developed: Conversation Circles, articulated with the social demands shared by the babalorixás, lalorixás, and African-based religion priests and their disciples.This involvement of community leaders in local cultural practices promotes processes that lead to ideological liberation from systems of educational domination and fragmented health practices.
In systematizing her life of work and activity in grassroots social movements, Palmira Lopes 37 sustains this understanding by highlighting how much she found, in PHE practices, acceptance for her knowledge accumulated through life experiences and learning from her ancestors, feeling respected and welcomed in conducting concrete health actions in her territory.She also draws attention to an aspect sometimes undervalued in part of the PHE movement, as Cruz et al. 26 say, which consists of the ability of grassroots stakeholders to also learn from scientific knowledge and the knowledge accumulated by academia.The previous authors point out that many PHE texts value the inclusion and protagonism of popular knowledge that sometimes erases the powerful and pertinent contributions of academic knowledge.
By directing PHE praxis towards PHC, the literature has reinforced that PHE qualifies the ESF with the necessary methodology to overcome the hegemonic way of developing health actions and enhance emancipatory and comprehensive care 38 .In other words, a shared approach that respects and encourages multiple healing forms, for example, by returning to ancestry 39 .In this sense, Souza et al. 40 recognize the conversation circle as a crucial ally of PHC in promoting women's health from native peoples, valuing their ancestral knowledge, and establishing a professional link with the reality of the community.
These experiences reaffirm PHE's political intent, which sees listening to the socially excluded and encouraging voices full of historicity as the way to strengthen autonomy and social participation.
The summary category that focuses on PHE as a strategy to support social reconstruction in the face of setbacks in public policies includes the consideration that, in recent years, denialism has been revealed as one of the main strategic facets of neoliberalism in its deep struggle against the strengthening of public social policies to promote social and human rights, from the perspective of social emancipation.Brazil's ultra-liberal agenda is based on necropolitics and was implemented by the Federal Government during the 2016-2018 and 2019-2022 administrations 41 .
Authors such as Fleury 3 , Hallal 42 , and Morel 41 have highlighted the impacts, respectively, of ultra-liberalism and its repercussions on social policies and, in particular, on the right to health, the denialism of science and its repercussions on the approach and confrontation with the COVID-19 pandemic in Brazil, and the consequences of fake news for the legitimization of necropolitics and the weakening of health surveillance and prevention actions in the pandemic context, aggravating the exposure of thousands of people to the disease, especially those who already lived in situations of strong social vulnerability 41 .
In this context, PHE practices have had to resist a series of social and political processes that have brought significant difficulties to the continuity of PHE experiences, as they have directly affected the living and working conditions of its participants and mediators.However, it has also been revealed that the PHE has a resilience capacity and a vocation for proposition based on groups, social organizations, and public institutions throughout the country, which have led new practices and initiatives aligned with the PHE for mobilizing emergency aid and keeping spaces for comprehensive care and moments of debate and critical reflection on Brazilian public health 15,17,43 .
Contrary to the violent statements made by several people in positions of power in Brazil in recent years, as revealed in Silva and Silveira's 44 study, which analyzed former president Jair Bolsonaro's media statements on COVID-19 using the theory of social representations, PHE is based on fundamentals such as lovingness, autonomy, criticality, and dialogical sharing of knowledge.Thus, based on the literature, there is a stimulus for professional training in health practices guided by Freirean pedagogy, building bridges with the population assisted, with actions that strengthen the formation of collectivity, based on the dialectical and contradictory relationship of daily life 43 .
This critical moment also revealed the relevance and centrality of the PHE movement, not letting its grassroots practices and experiences be weakened since many of these initiatives emerged precisely from permanent grassroots work.Cananéa and Melo Neto 45 , when reflecting on the institutionalization of popular education in government public policies in the 2003-2016 period, highlight the importance of ensuring that this process does not weaken the continuity and strengthening of grassroots experiences.In a 2014 interview for the Revista Novos Estudos CE-BRAP 46 , reflecting on the origins of the National Policy for Social Participation, Pedro Pontual agrees that, as long as public management can be more thoroughly permeated with the precepts of popular education, the resulting actions should not undermine socially territorialized practices.
PHE is part of preventive proposals, especially when it dialogues with the perspective of Health Surveillance through Popular Health Surveillance, working beyond institutions and promoting popular participation 41 .During the pandemic, PHE strengthened PHC by resuming and revaluing the teams' approach to popular social groups and movements, building new networks to articulate social support.
To this end, we underscore the experience of the community work of popular health workers articulated with Popular Health Surveillance, primarily through the "Solidary Hands Project".In their experiences with popular health workers, they were mainly responsible for providing care in the communities and suburbs, providing education in the prevention of COVID-19, combating denialism, mobilizing food support, and facilitating the vaccination process 17,47 .
The importance of national coordination in PE as a response to its devaluation was an important summary category since some of the literature retrieved considered that PHE is still, to some extent, undervalued in the professional practice of health institutions, which predominantly operate in a hegemonic, individualizing way, based on prompt diagnosis, prescription, and medicalization procedures 48 .
The articles researched in this review point out that PHE movements and practices have recently struggled in ensuring recognition, appreciation, and incorporation into health practices, especially in the day-to-day running of health units.Besides the dominant biomedical history mentioned above, the governmental and public agenda of recent years has brought severe obstacles in this direction, as mentioned above, regarding the ultra-liberal and denialist perspective imposed on the Brazilian public agenda from 2016 to 2022 48 .
Even in the face of such obstacles, the researched productions show the insistence of PHE stakeholders in pointing out, with the help of research and the systematization of their experiences, PHE's potential help in complexifying responses to several health issues, especially health emergencies.
The production of knowledge, experiences, and social and educational technologies based on PHE practices remains vibrant in several territories and contexts, given the fruitful developments of the PHE Thematic Group at the Brazilian Association of Collective Health (ABRASCO), as systematized by Lima and Pekelman 15 .
The knowledge, methodologies, and lessons learned from these experiences contribute, albeit with limitations, to disseminating PHE in health services, primarily via PHC, which is still a challenge in the face of hegemonic banking, authoritarian, and individualizing practices.Also, in this sense, few references seek to configure PHE as a Social Technology (ST) for Health Education 49 .
Paro et al. 16 presented the recent increase in the publication of dossiers in scientific journals and the organization of collections with reports of several experiences, which point to new horizons and possibilities for the fructification of activities to humanize health, promote equity, foster social participation and the critically train health professionals based on the PHE contributions.The Popular Health Education collection organized in 2020 by Paro et al. 50shows another expression of this powerful wealth.
The category dedicated to reflecting on PE as a liberating project, thinking about democratic education, and the fight against institutional and structural violence, was powerful and had innovative aspects compared to previous literature reviews in this field.The review points to experiences and critical-reflective essays that place PHE as a methodology for promoting the autonomy of individuals insofar as people can have their leading roles valued through participatory education.The study emphasizes that it is vital that PHE practices maintain this condition and the clarity of their political intention 19 .
Grassroots work founded from childhood and adolescence with an education based on the PE precepts is powerful in confronting structural and institutional violence.When autonomy is worked on with young people, a sense of belonging to PHE is built up with them.It also helps them to respect the characteristics and beliefs of others by validating the expression of their cultural repertoires.One way of cultivating this sense of belonging is by caring for the school grounds, bringing a sense of collectivity.The use of this methodology with children has been cited positively through Culture Circles by civil society organizations in Florianópolis 51 .
One of the best ways to build this grassroots strategy is through play since playful dialogic interventions with children can be a decisive strategy for generating reflection on the social processes that permeate health and disease.Children's neuropsychomotor development and sociability are also a significant benefit, as this stimulus can outline social struggle issues such as racism, homophobia, and sexism in a way that is accessible to children, based on an understanding of their surrounding reality 20 .
Debates about environmental justice have also emerged from the discussions on PHE since there is active community sovereignty in the search for a space to reaffirm cultural characteristics and popular knowledge through them, breaking with colonial and hegemonic structures 14 .
The articulation of groups, through which knowledge is exchanged, knowledge shared, and participants are empowered, is a process that strengthens PHE.In this sense, the review pointed to "Movimenta SUS", created to promote comprehensive health in communities, using different techniques from those commonly used within healthcare 27 .
A final outstanding summary category was PE in the university Health Education process, where PHE was proven a powerful strategy during academic training 23 .
University extension and research projects are highlighted as fruitful fields for developing PHE methodologies in health education.Historically, these two practices have provided a privileged space for actions and interactions between the academic and social fields.In this sense, they are highly relevant in several social issues and in doing health broadly 18 .The articles identified reveal the powerful meaning of Popular Extension practices in terms of contributing to the promotion of communication and the articulation of different PHE experiences.
Students are challenged to weave humanized and loving practices that speak to the circumstances permeating health care through comprehensive care promoted by the PHE.Thus, we observed PHE productions that guide health training and highlight the relevance of knowing the territory and the conditions of life production as a starting point for teaching actions so that the proposed actions are not devoid of meaning for the assisted population or generate passivity and detachment from the person being cared for 52,53 .

Final considerations
The six summary categories reveal the tangible consequences of the Brazilian Government from 2019 to 2022, pointing to prospects for reviving PHE in the SUS.The perceptions highlight the relevance of PE in promoting a participatory vision of health and in valuing the knowledge and practices of local popular culture, with practices also based on critical-reflective theoretical content.
PHE is also discussed as a strategy to support social reconstruction in the face of setbacks in public policies, emphasizing the importance of national articulation in PE and its role as a liberating project in the fight against institutional and structural violence, generating social stakeholders who resist and defend democratic, critical, emancipatory, and fair education, centered on popular knowledge.The category on popular education in university training highlights the importance of experiences to train professionals committed to SUS principles, recognizing the relevance of considering the various constituent spheres of individuals in society in care, providing singular, receptive, and horizontal care that underscores the value of academic and popular knowledge encounters.
This study aims to systematize and value theoretical and practical constructions to contribute to the debate and implementation of PHE in the SUS.Promoting national coordination and dialogue with grassroots movements is essential to advance a liberating and dignifying health agenda in Brazil.

Collaborations
PNA Brito worked on the planning, methodology, research, data interpretation, and final drafting and formatting of the submitted manuscript.ELP Santana worked on the research, data interpretation, and final drafting and formatting of the submitted manuscript.OA Moraes worked on the research, data interpretation, and drafting.JC Silva worked on the revision and final approval of the version to be submitted.PJSC Cruz worked on the conception, methodology, revision, and final approval of the version to be submitted.

Chart 1 .
Summary categories and component meaning cores.Summary Category Meaning core Popular education practices as promoters of a participatory vision of health Popular Health Education as a promoter of health with a comprehensive conception Horizontal construction of interdisciplinary relationships in PHC Experience in the territory and bonds as facilitators of the process of strengthening social participation Popular education and the valuation of knowledge and practices of local popular culture Shared construction of knowledge and social emancipation Popular Health Education values the revival of ancestry and culture in health practices Popular health education as a strategy to support social reconstruction in the face of setbacks in public policies Denialism and the neoliberal wave in setbacks in public policies Popular Health Education in the Pandemic Context The importance of national articulation in popular education as a response to its devaluation PHE in the SUS, its importance in light of its devaluation The dissemination of theoretical-practical experiences of extension and popular research focused on PHE as a national articulation strategy Popular education as a liberating project thinking about democratic education and the fight against institutional and structural violence Popular Education as a training methodology aimed at democracy and autonomy The formation of social groups as a fighting tool in Popular Health Education Popular education in the university health training process Popular education in the university health training process Source: Authors, 2023.