Health promotion competencies: focus on users of The Beach Without Barriers project

Carrying out university extension actions on beaches represents an innovative opportunity to promote the health of people with disabilities or reduced mobility. This article aims to analyze the understanding of users of the Beach Without Barriers (PSB, Praia sem Barreiras) Project about the Health Promotion practices developed by undergraduate students in the health area. Qualitative, descriptive and exploratory study, based on interviews with ten PSB users in Recife, Pernambuco, Brazil. A thematic analysis of content was carried out anchored on Developing Competencies and Professional Standards for Health Promotion Capacity Building in Europe. Six empirical cate gories emerged: Dedication of students working in the PSB, Technical qualification of students in the PSB, Emotion during contact with the sea, Mental health improvement, User guidance to students as future professionals and Opinions about the PSB. The qualification of students as agents of change in the local reality, effective communication and strategic partnerships were demonstrated. Actions that transcend bodily limitations and assess the participants’ health needs should be valued in undergraduate school.


Introduction
The National Health Promotion Policy (PNPS, Política Nacional de Promoção da Saúde) has social inclusion as one of its founding values and principles and encourages the performance of different health professionals and those from other sectors in the implementation of strategic and diversified actions aiming at the production of health care and social protection networks for people with disabilities (PWD) or reduced mobility [1][2][3] .
Advances in the field of human rights and, particularly, of PWD contributed to a series of achievements related to coping with architectural barriers, urban mobility, interpersonal relationships and access to natural resources available to citizens of a given territory [4][5][6][7] .
According to the last census carried out in 2010, it was estimated that 23.9% of the Brazilian population has at least one type of disability, whether visual, auditory, motor or mental/intellectual.The Northeast region of Brazil concentrated 26.3% of this population, with the states of Paraíba and Rio Grande do Norte showing the highest prevalence of PWD.The state of Pernambuco occupied the third place and had 27.5% of PWD among its population at the time 8 .
Initiatives for PWD arise in different scenarios and contexts aiming at implementing more actions and programs that enable quality of life and well-being activities in contexts that involve activities in nature, citizenship, leisure and tourism 4,9,10 .There are Brazilian beaches with an adequate structure to allow people with physical disabilities or with reduced mobility to swim in the sea 7 .
Since 2013, the Beaches without Barriers (PSB, Praia sem Barreiras) Project has been developed by the Pernambuco Tourism Company (EMPETUR) and supported by the Maurício de Nassau University Center (UNINASSAU) aiming to establish a strategic partnership to carry out university extension activities with students from the Tourism, Nursing, Physical Therapy and Physical Education courses, called monitors, in addition to teachers who coordinate this extension action 11 .
The PSB main objective is to allow assisted sea bathing, strengthen local tourism and establish a leisure area for inclusion and well-being through adapted recreational and sports activities on Recife beaches for people with physical disabilities and/or those with reduced mobility, which are conducted by students (monitors) and teachers (supervisors) of UNINASSAU 11,12 .
Considering this scenario, the perspectives of the participants of an interdisciplinary and intersectoral extension action with emphasis on beaches as innovative environments for the training of undergraduate health students were defined as the object of study.Therefore, this study aimed to analyze the understanding of the PSB users about the health promotion practices developed by undergraduate health students.

Method
This is a qualitative, descriptive and exploratory study, based on a single case study 13 associated to the experiences of the Beaches without Barriers (PSB) Project 11 users and modified based on the version presented and published in the Annals of the 9 th Ibero-American Congress in Qualitative Investigation (CIAIQ) 14 .The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used to refine the structure and credibility of the final version of this qualitative research 15 .
The framework of competencies for Health Promotion recommended in the Developing Competencies and Professional Standards for Health Promotion Capacity Building in Europe (CompHP) 16 supported the comparative analysis of Health Promotion domains associated with professional practices and educational processes 17,18 and discussed by specialists to bring it closer to the public policies and services in the Brazilian context 19 .The research formulation was supported by the constructivist paradigm aiming to access the universe of meanings of the people involved in the contexts, focused on the construction of knowledge 20 .
The group of researchers consisted of two physical therapists, master's degree students and teachers from the Maurício de Nassau University Center (UNINASSAU) and a stricto sensu nurse professor, with a Ph.D. degree in Sciences and a Master's Degree in Nursing, specialist in Health Promotion and Education Practices and Technologies linked to the Master's and Doctoral Program in Nursing at Universidade de Guarulhos (UNG).Two Ph.D. professors were included in the critical review stage of the research to deepen the discussions on the principles of health promotion and public health.
The present research was mostly conducted by the physical therapist, whose role in the initial training process of teachers involved in the PsB grounded the knowledge, ethical principles and practical approaches to care for people with physical disabilities and/or reduced mobility, and who, during the data collection period, had no prior relationship with monitors, supervisors or PSB users 14 .
The study was carried out at the PSB project space, located in an area of 200 square meters on the edge of Boa Viagem Beach, in the city of Recife, state of Pernambuco (PE), Brazil.On alternate days, the main researcher participated in the assembly of the structures required for the operation of this extension action between Thursdays and Sundays, during the opening hours of 8:00 am to 12:00 pm and the transportation, which was carried out on an accessible route from the neighborhood to the edge of Boa Viagem Beach 11 .
The PSB represents a university extension project articulated with the municipal network of Recife (PE), UNINASSAU and private partnerships.In particular, UNINASSAU participation was based on the development of actions with an emphasis on social inclusion coordinated by professors and carried out by Tourism, Physical Therapy, Nursing and Physical Education undergraduate students 11 .Moreover, the mapping of health promotion actions published on the internet about the PSB contributed to the understanding of the scope of this interdisciplinary and intersectoral university partnership in various social media sites 12 .
The collection of empirical material was carried out from December 2018 to April 2019, using a sociodemographic questionnaire for the characterization and a semi-structured interview that contained questions related to the study topic and the central guiding question: How do users of the 'Beach Without Barriers' Project understand Health Promotion actions developed by undergraduate health students who are part of the PSB? 14 A convenience sample was adopted, since all interested users were able to participate in the interviews until group homogeneity was reached, based on the criterion of progressive inclusion 21 .
The study included PSB users on Boa Viagem beach, of both genders, over 18 years old, with reduced mobility or some type of physical disability, wheelchair users or not, who had joined the project for at least three months 14 .There was no pilot project.
The script with thematic blocks of open questions based on the CompHP domains allowed the main researcher to use semi-structured interviews aiming to capture the knowledge, skills and minimum ethical values necessary for the practice of health promotion regarding the performance of Physical Education, Nursing and Physical Therapy students of the PSB project.The interviews were recorded using smartphones and transcribed literally, with an average duration of 15.8 minutes.
The CompHP provides a theoretical and practical framework for professional performance in Health Promotion in different contexts and scenarios, based on 11 domains of competencies for the design of learning objectives and several training processes 16,17 .The knowledge focused on Health Promotion and ethical values were considered as two fundamental domains for the 47 essential competencies divided into nine domains for practices in the promotion field: (1) enable change, (2) advocate for health, (3) mediate through partnership, (4) communication, ( 5) leadership, (6) needs assessment, (7) planning, (8) implementation and ( 9) evaluation and research 16 .
Two physical therapists encoded and analyzed the transcribed literal content of the interviews with the support of a nurse specialized in health promotion practices and with experience in qualitative studies in the area of education and health.After six supervision meetings, the thematic analysis of the corpus consisting of the interviews and field notes was carried out, which allowed retrieving the general aspects of the interactions between the two physical therapists with PSB users, monitors and supervisors 14 .We chose not to use support software for the analysis and management of the qualitative data.
The data from the interviews were organized and thematic content analysis was applied 22 to create empirical categories based on the theoretical framework in an inductive way and the successive approximation between the reports of PSB users and the possible domains of Health Promotion competencies practiced by monitors from the Physical Education, Nursing and Physical Therapy undergraduate courses under the guidance of supervisors from UNINASSAU.
After the transcription, the statements were read repeatedly aiming to understand and capture the respondent's feelings, perceptions and emotions.The interviews were classified with the letter "U" for PSB user followed by a number from 1 to 10.There was no resubmission of the transcribed material to the participants for any corrections or additional contributions.
It is noteworthy that the act of interviewing the users on the beach required special care from researchers to protect participants from sun ex-posure, establish a place to muffle the noise of the waves and wind and to avoid interference from people involved in the adapted, recreational activities, mediated by assistive technologies in PSB 14 .
The research project was approved by the Research Ethics Committee of Maurício de Nassau University Center (UNINASSAU), according to Opinion n. 2.966.774 and the Certificate of Presentation for Ethical Appreciation (CAAE) n. 01265518.3.0000.5193.
The research participants signed the Free and Informed Consent Form (FICF) before the activities at the PSB, were interviewed in a reserved tent on the beach and all transcribed material was anonymized.

Results
Six female and four male users of the PSB participated, eight of which reported having some type of physical disability and two had reduced mobility.Regarding the ethnicity/skin color, seven self-declared as being black or brown.Seven worked and all had finished high school.Half of them had attended this extension action for more than three years.
Six empirical categories were organized, derived from the experiences of PSB users about the Health Promotion practices carried out by participating undergraduate health students, namely: (1) dedication of students working at the PSB, (2) technical qualification of students at the PSB, (3) emotion during contact with the sea, (4) improvements in mental health, (5) users' recommendations to the students as future professionals and (6) opinions about the PSB.

Dedication of students working at the PSB
This category is related to the characterization of students as thoughtful, polite and dedicated.The users describe how PSB students welcome, interact with affection and take care of everyone.
I'm enjoying it, they are very communicative, thoughtful, they treat us very well, with all the attention and affection (U8).
The service provided by the students is firstrate, they welcome us, for me it is a great pleasure to be here at PSB (U9).
I come on Saturdays.But I realize that the students are great at the way they treat us.I think their dedication is the main thing, I have to thank them so much for the project (U3).

Technical qualification of students at PSB
Teaching and learning about the particularities of different types of disabilities, ways to overcome certain limits and user restrictions were highlighted, especially during transfers to the amphibious beach chairs in the assisted sea bathing.
I think training is necessary for students to know the type of disability each one of us has.How they should act for each type, as each person with a disability has their own specificity (U2).
Students need to be more attentive because each disability is different.I realize that they don't always know the difference from one to another.There are people who don't have trunk balance like me, but there are people here that are worse than me.Then they put them on the chair [amphibian]  as if the person had balance, and this is uncomfortable; they should pay more attention to that (U5).

Emotion during contact with the sea
It indicates emotions felt and expressed by PSB users, as they recalled memorable scenes from their lives.Physical disability and/or reduced mobility imply social isolation, loss of certain pleasures and restricted access to different public spaces.Now the scene that had an impact on me, was the first time I came, that one was memorable, how careful they were, when they picked me up on the avenue and brought me here and took me to the water.Being there talking to me, it was sensational for me (U1).

It was exhilarating to go into the sea after years without being able to do it! And through PSB and the help of the students, to have this chance back [...] it's wonderful! Feeling the salt water in my mouth was an indescribable sensation. It moved both me and the students and everyone around me, it was very emotional (U4).
Feeling the sea water again bathing my body, feeling the salty taste of the sea, that feeling of lightness and freshness that only the sea can give us (U9).

Improvements in mental health
There was an emphasis on the feeling of being able to (re)create life projects and ways of taking care of one's health to occupy the mind and protect oneself from negative feelings, such as greater sadness, excessive worries, anxiety and symptoms of depression.
I think that health starts in the mind, when we have a good thinking, a mind that is not thinking nonsense, that will not fall into depression, one's health always improves.[...] I won't say that the program deserves a score of ten, it deserves a score of one thousand, because it promotes health a lot, because first, health starts with the mind and not the body, the mind is everything!(U1).
The coexistence and the stories we tell and listen to, here, make us learn and share them with other people.This is good for our minds because we get entertained too, it makes us feel good (U3).
I think they promote my health by the simple fact that they give me a reason to feel alive and happy.This project made me feel like a person again, gave me strength, mental health.And that in itself contributes to the health of the people who are part of this project (U10).

Users' recommendations to the students as future professionals
PSB users took the opportunity to advise students on the necessary care to look after PWD or people with reduced mobility in their future professional activities, as well as points of improvement regarding the operation of the extension project in new versions together with the community in Recife: By studying [...], researching more and understanding the issue of people with disabilities or limitations and all their aspects (U2).

To ask us, users, what they can do to facilitate our transfer to the sea because people look at us and think we are completely helpless; but first ask me, "What can you do? What is the best way for you? How can I do it? How do you prefer me to do it?" (U6).
They can help by giving us recommendations when they are with us in the sea.Talking about our disease, our limitations and giving tips on how to help with treatment and daily life (U10).

Opinions about PSB
PSB users reinforce the positive exchange opportunities promoted by the monitors (undergraduate health students involved in the program), without disregarding the importance of supervisors (UNINASSAU teachers) and other strategic partners.The gratitude, the exercise of citizenship and the joy of returning to a public place such as the beaches and shores of their own city, with a sense of security and belonging.

I don't have words to describe what I feel when I'm here because I was in bed thinking I couldn't do much more than go from my bedroom to the living room, but I found out that I can do a lot more, in addition to serenely go sea bathing (U1).
I wish this project success, so that people with disabilities and people with mobility difficulties feel like they are embraced and loved citizens, like every pernambucano who lives on the coast (U2).
I can only thank everyone for this project, which gave me a new life stimulus and made me wake up.It made me see that even with the limitation, I can indeed enjoy leisure time and participate in activities that make us feel good (U8).

Discussion
It is important to indicate that this study shows innovative aspects about considering the beach as a scenario of potent practices for the training of future health professionals aiming to provide comprehensive care, without disregarding the needs of social groups with some type of physical disability and/or reduced mobility.
It is important to recognize that such training illustrates opportunities to put into operation the values and principles that are part of the current National Health Promotion Policy 2 and dialogues with the national implementation of the Shanghai Declaration (2017), derived from the 9 th International Conference on Health Promotion, aiming at complying with the 2030 Agenda regarding its aspects of appreciating inclusion and the territory as the focus for the carrying out of strategic actions 23 .
The respondents mentioned the potential and limitations of Health Promotion practices in the PSB.The categories related to the students' training, in particular, call for a broader understanding of accessibility, as discussed in a systematic review on health promotion for people with disabilities, which analyzed 14 studies published between 2000 and 2011 24 .
Studies on teaching carried out on beaches encompass disciplines that seek to develop greater autonomy and leadership in the organization of community-based tourism in Paraty (RJ) grounded on differentiated education 5 , in the study of the environment to build a learning path focused on the coastal elements present in the daily lives of residents of São José de Ribamar (MA) to teach geography 25 and in the training of physical education teachers in a district in Indonesia who utilize the available natural resources to (re)create their classes in outdoor environments and foster innovations in collective ball games or adapt athletic activities 26 .
Despite not listing the beaches among the different natural scenarios, a scope review on the use of activities with direct contact with nature for people with some type of mobility restriction indicates favorable evidence to stimulate different sensory channels, integrating with natural elements and (re)connecting with their place in the world and previous experiences, aiming to achieve mental, physical and social benefits 10 .In this sense, the PSB teachers and students can further explore emotional and mental health aspects as reported by the users.
Specifically about the Praia Sem Barreiras project, two studies anchored on the phenomenological attitude about the existential experiences of PSB users 27,28 revealed the importance of understanding the universe of meanings and resignifications of people with physical disabilities in their daily lives and their reappropriation of spaces that are lawfully theirs as human beings and citizens.This is an important aspect to encourage the ethical-political defense for the exercise of one's citizenship, for universal access and for equity in care during the development of undergraduate health training.
The training of PSB monitors requires a careful view to extrapolate the technique or mechanical use of assistive technology.For example, bathing in the sea assisted by the amphibious beach chair represents a situation with the potential to overcome the students' absence of listening in favor of a dialogue that seeks to understand the human and existential condition beyond the restrictions imposed by the physical disability 27 and create ways to expand the concept of bodies that can break away from limiting ideas and discover potentials in the differences between people 28 .
The scarcity of PSB records mobilized the hemerographic analysis based on the online dissemination of this extension project actions, aiming to identify the image among the overall and specific public of UNINASSAU and which enabled the recognition of Health Promotion practices focused on the well-being, leisure, social inclusion, safety and intersectoral partnerships with the presence of PSB monitors, supervisors and users 12 .
Regarding the CompHP domains, the respondents reinforce the competencies attributed to the domains "enable change", "communication" and "mediate through partnership".The "enable change" domain demonstrated the protagonism and collaborative practices between monitors and their supervisors, aiming to promote possible changes in the direct relationship with PSB users.
The "communication" domain was indicated when students from the three undergraduate courses in Nursing, Physical Therapy and Physical Education excelled in the dialogue and encouraged the participation by using techniques and means of communication that were culturally appropriate for PSB users.However, learning to actively listen to the specific needs of people with disabilities and/or those with reduced mobility requires additional care.
The CompHP framework allowed establishing certain relationships with the experiences of PSB users and can contribute to the design of new versions in a near future after the Coronavirus Disease-19 (COVID-19) pandemic, which include the continuing education of teachers as in a qualitative study with Nursing teachers 29 and student training that aims to incorporate the necessary and relevant skills to promote health in unique situations present in the Brazilian Unified Health System (SUS) and other public policies in the Brazilian context 17,19,30 .
Also regarding the emancipatory premise of health promotion, it is understood that the PSB users' statements reinforce the value of caring for PWD and go beyond the clinical point of view and should be considered as specialists in and for the training of students in the health area 31 .
One limitations of the study is the participation of a single beach linked to the PSB project in the city.The interviews were enlightening, but the absence of data triangulation with the testimonies of undergraduate students (monitors), teachers (supervisors) and the UNINASSAU curriculum represents a point to be further explored on in other studies by the research group or by researchers involved with training committed to the inseparability of teaching, research and university extension in different scenarios such as beaches, shores and reefs.

Final considerations
This study aimed to explore the understanding of users of the Praia Sem Barreiras (PSB) project on the role of undergraduate students from the health area on beaches, understood here as an innovative and differentiated space to defend the rights of people with physical disabilities (PWD) or those with reduced mobility, to develop collaborative actions, aiming at the effective communication of health issues and to articulate intersectoral actions that can contribute to interprofessional training in health.
The experiences reported by PSB users reveal limits in individual and collective actions to promote knowledge and ethical values in Health Promotion and the nine CompHP domains.There was an emphasis on the domains "enable change", "communication" and "mediate through partnership" and potential use of "defense of rights", "leadership" and "implementation".
These findings can help educators, students from different educational levels and the users of similar extension actions in strengthening actions of "assessment of needs", "planning" and "evaluation and research", without disregarding the transversality of ethical values and knowledge on concepts and principles of health promotion throughout undergraduate health courses, as users of the PSB emphasized the positivity of student performance in this action of interdisciplinary and intersectoral university extension.However, respondents indicated gaps in qualified listening to the specifics, the biographies and health needs of people with physical disabilities or reduced mobility.

Collaborations
AA Pina-Oliveira contributed with the study concept and design, methodology, data analysis, conclusions and final version of the manuscript.FGM Cahú and FES Miranda contributed with the study research, data analysis, methodology, conclusions, and final version of the manuscript.MR Apostolico and ACCG Germani contributed with the critical review of the manuscript.