Health Promotion Groups for Improving Autonomy, Living Conditions and Health

This article presents the methodology of Health Promotion Groups, which were conceived as a means of contributing towards developing autonomy, improving living conditions and promoting health. The method is identified as a collective and interdisciplinary health intervention, consisting of a group process. It guides the development of attitudes and behavioral patterns towards continually transforming participants' health levels and living conditions. The Health Promotion Groups are identified within the context of the Sistema Único de Saúde (National Health System) as a means of surpassing the biomedical model. It stimulates the development of actions in which the positive aspects of health are emphasized, while at the same time it can serve to more effectively meet the demands for care for the elderly in health systems.


INTRODUCTION
The present paper aims to contribute towards the construction of discussion and practice for the promotion of health, by presenting the methodology of Health Promotion Groups (HPG).These groups are conceived as instruments serving to promote autonomy and continuous development of better health levels and living conditions.
Conceptual and ethical reflections are developed, with the possibility that they may influence the distinction between: a) preventive group activities that work towards preventing and/or delaying diseases, by means of the biomedical model, which prescribes behavioral patterns and makes individuals fundamentally responsible for the burden of the diseases; and b) promotional activities that transcend the preventive methodologies, insofar as they change the focus from the sick individual towards the eradication or minimization of unnecessary and/or avoidable diseases within the human context. 15llaboration with continuing education for healthcare professionals is also sought, based on wide comprehension of the processes involved in determining the binomial expression "health-disease" and in the contemporaneous phenomenon of the aging of the world's population. 20ss 4 stated that promotional policies constitute a recent and complex field of knowledge.This author encouraged those who are interested in health promotion to improve such methodological and technological approaches, while maintaining them as complementary strategies to the other interventions within public health.
On the basis of the conceptual foundations and health promotion policies debated in the international conferences that took place in Ottawa (1986), Adelaide (1988), Sundsvall (1991), Jakarta (1997) and Mexico  (2000), 3 this chaotic reality forms a challenge.It is recommended that there should be improvement in methods and practices to enable full realization of the health potential of communities and individuals at their different stages of evolution.

What is an HPG?
An HPG is a collective and interdisciplinary health intervention consisting of a group process in which its participants go to the ethical limit of eliminating the unnecessary and avoidable differences between human groups.It is characterized as a group of people connected by time and space constants and func-tional limits, interacting cooperatively to achieve health promotion goals.
The HPG is based upon a broad concept of health and takes into consideration the biopsychosocial dimensions that are related to the health-disease binomial pair and to remaining healthy into old age. 21Within this perspective, health is understood as a positive concept and is experienced as the natural state of affairs, thus breaking down the social representation of disease 11 as a fatal condition.
Consequently, actions can be taken regarding health perspectives, not as reactive responses to the fatality of disease, but as targets to be reached by public health and other social players, by means of methodological tools for intervening in present-day realities. 6Such tools emphasize social and personal resources for eradicating and/or minimizing individuals' diseases and losses of functional abilities, and for preserving and/or developing autonomy.
Building knowledge regarding health in an HPG depends on the following conditions: • cooperative participation by the members: combinations of words, gestures and body postures within the context of actions to accept others as legitimate; and • development of autonomy: a process in which the individuals or human groups broaden their capacity to make choices freely, conscious of their own aims, with the clear understanding that they must not cause any damage or wrong to other individuals or to society. 8 this manner, the social relations in the HPG are guided by dialogue and respect for differences, in which several types of knowledge are integrated, especially studies on attitudes.
In the HPG, the concept of attitude is built on the rationale that forms health promotion: long-lasting organization of beliefs and cognition.These have an affective burden that predisposes to coherent action, with inclinations and cognition that favor the development of autonomy and improvements in living conditions and health.Therefore, learning in the HPG involves components that facilitate the changing of behavioral patterns relating to health promotion, without reducing to a simplistic and paternalistic proposition for changes in individual conduct.
The HPG is organized through mutual internal representations, under the influence of micro and macrodeterminants.Its objectives are built up continuously, with the aims of realizing potential abilities of the subjects and changing behavioral patterns and attitudes towards developing autonomy to face up to the conditions that generate unnecessary and avoidable suffering.
It is understood that the HPG may eventually be applied to the general population and, strategically, to individuals who are exposed to situations of social exclusion, and do not have autonomy.It can be applied, for example, to cases of elderly people who suffer through high prevalence of chronic-degenerative diseases, decreased functional abilities, 22 deep cultural and social transformations, and income losses over recent decades. 12e methodology for the HPG, within the context of the Sistema Único de Saúde (National Health System -SUS), differs from: a) interventions through Therapeutic Groups, as cited by Osório, 19 since these aim primarily towards improving specific diseases in individuals; b) preventive programs based on classical informative education and the hygienist model, which reduces complex sanitary problems to the levels of individual acts of self-care; 5 and c) workshops for the promotion of good citizenship, as proposed by Silva, 23 inasmuch as these are self-defined as distinct from the Therapeutic Groups due to the emphasis on learning through play activities in the meetings.
Another important feature is the political reach they achieve.The HPG enables men and women, through restoring solidarity, to take the process of physically and psychologically overcoming their difficulties from the individual to the group level, and from this to the broader sphere of the social level.
Thus, its actions are based on a new concept of the State and public policies, since they are conceived as initiatives of the State and the organized population that is capable of making decisions autonomously. 13thin the space of the HPG, the users (and also the health professionals) have the opportunity to develop good citizenship and awareness of the right to life under dignified conditions.Access to treatment of diseases is a matter of responsibility and achievement, not only for the individual, but also for the social and political construction.
The HPG, while acting within the field of the community, opens up possibilities for health and human sciences, reaching horizons that go beyond the simple objective of fighting diseases in individuals.A concern for the human individual's own identity must be added to the task of the HPG, through seeking the highest possible degree of physical, mental and social health for individuals and for the society they live in.This is the learning of good citizenship that was highlighted by Morin: 18 "Education must contribute to the individual's self-instruction (learning how to accept the human condition and how to live) and teach how to become a good citizen" (p.65).

The group setting of the HPG
The group setting is conceived as a combination of procedures that organize, create rules for and enable the group process. 26Its definition depends on the objectives for which the group is organized, the target public, the place, the material resources, the theoretical references used by the coordinator, and also the coordinator's style and other factors.
Santos* mentions that it is essential for the professionals who coordinate the groups to clearly define the objectives of the interventions, so that the respective group settings may be organized in a manner that makes it possible to accomplish these projects.
In the case of an HPG, the fundamental purpose is to build up cooperative social relationships so as to have continuous development of autonomy.In this manner, the group settings of the HPG have the function of creating a cooperative space in which the participants have the opportunity to put new meaning on concepts that hinder the process of health promotion; to put value on the available content of the community; to show and deal with emotional expression; to be aware of and reflect upon practices and knowledge regarding health that may favor an increase in individuals' functional abilities.
The definitions of these group settings in the HPG should be established by the teams coordinating the groups and by other members.These definitions must take into account: a) the particular features of the socioeconomic context; b) the emotional expressions emerging in the group processes; and c) the scientific and general knowledge available in the community in which the HPG is set up.
It must also be considered that some operational conditions for the HPG are essential.Such conditions make it possible to obtain an ethical agreement among the participants so that the group can work well and allow the participants' rights and freedoms to be respected.It is suggested that such conditions should be presented by the coordinators in the initial meetings of the groups, so that the limits, potentials and ways of acting within the HPG can be discussed and agreed upon among its members.
It is also recommended that this information should be reinforced whenever a new member enters the HPG.The conditions are the following: promotion of health by means of group cooperation; commitment towards authenticity; confidentiality regarding what the group collectively expresses; respect for scheduled dates and times; active listening to group requirements.Tatagiba & Filártiga 24 correlated action by the coordinator with favoring of the creation of these basic conditions for the group setting to be able to function.
The confidentiality refers to the irrefutable ethical need to protect the content of any manifestation coming from the group dynamics.Therefore, only those who agree with this may participate in the HPG.This rule of respect for confidentiality enables spontaneity.
The utilization of any resources of a theoretical, psychodramatic, systemic, cognitive-behavioral, psychoanalytical or constructivist nature requires a spontaneous environment that enables authenticity of the manifestations.Effective group integration takes place when people feel calm and secure enough to transmit their intimate thoughts within a web of mutual trust, acceptance and, hopefully, development.It is the coordinator's role to maintain this spontaneous environment, interceding in the manner that seems appropriate to his or her theoretical knowledge and personal position.
Telleguent 25 complemented the subject by stating that the wider and freer from distortions this access is, the higher the possibilities will be that the individuals will have to envisage new alternatives for actions that are capable of modifying out-of-date relational structures.
Agreeing with Maturana, 17 it is understood that there are no superfluous members: each and all of the members of the HPG make it operate in the way it does, through their own actions.
Each member's diligence and punctuality has a bearing on the performance of everyone in the group.This way, respect for commitments made to the group must be understood as being a collective responsibility.It is proposed that dates and times should be scheduled well in advance, in conformity with the routines of the health services, working hours of the professional team and, as far as possible, the availability of the other participants.
While intending to support the development of autonomy, it is essential for the coordinator of the HPG to actively undertake observation of the participants so as to hear their genuine demands.In order to overcome displays of preventative and fragmented knowledge that is often authoritarian in nature, it is necessary to plan group dynamics that value the complex needs that emerge in the group process.To achieve this, it is necessary to record what the members express, for subsequent analysis and discussion.The techniques and content proposed for the HPG must be based on the needs raised within the particular situation of each group and the health promotion objectives.
Backing for the target of health promotion through cooperation is obtained through reference to several important authors, among whom the following can be highlighted: • Giordan, 10 who conceptualized health as the linking of interactions at several levels of interdependent complexity, with autonomy and cooperation as the central points; and • Maturana, 16 from the theory of Biology of Social Phenomena, argued for the development of the human species through the formation of a "social system".Internal and external interactions that are established in the social systems modify the structures of their members, just as the structure of the system changes when modifying the ways in which it is integrated, without destroying its organization.

HPG and groups for prevention, control and treatment of diseases
The characterization of the HPG and other group interventions directed towards prevention, control and treatment of diseases is limited to the understanding and differentiation of the promotion and prevention concepts.
Leavell & Clark 14 established an analogy between prevention and knowledge of the natural history of the disease.Prevention programs are based on epidemiological knowledge and aim at developing strategies for controlling infectious and contagious diseases, decreasing the risk of degenerative diseases and minimizing the damage to health.Prevention actions are based on spreading general scientific information and they present weak linkage to the socioeconomic contexts within which they are implemented is weak, or to their symbolic significance.Such knowledge is followed by recommendations for changes in habits and are offered as antidotes to the vulnerabilities presented.
Health promotion identifies and acts on micro and macro-determinants that influence the processes of health/disease. 9Such comprehension implies the transformation of individual and collective processes of decision-making and autonomy development.
Therefore, the objectives of fighting disease and controlling worsening health in the HPG expand to include everyone and, specifically, those in situations of social exclusion.This strategy presupposes the possibility that the technocratic, medicating and disease-curing care system can be reformulated.
At this point, the concept of "Health Promotion" adopted by the World Health Organization (WHO) since 1986 is highlighted as a process for capacitating the community for improving its living conditions and health.Its significance contains a combination of actions: from the State, in its public health policies; from the community, with the reinforcement of community actions; from individuals, through the development of their abilities; and from reorientation of interventions, for intersectoral collective actions.
Other features also differentiate the development of prevention and promotion methodologies.
Preventive strategies are based on modern scientific thinking, which although aiming towards maximum precision and objectivity, actually reduces health and disease to abstract schemes that can be calculated and demonstrated by means of linear causal reasoning.
The perspective of promotion considers an understanding of health as positive, while the individual and collective theoretical and practical approaches are multiple determinants that create human inequality and unnecessary and avoidable diseases and suffering.
Therefore, promotion actions are the product of a complex process that involves the strengthening of individual and collective capacities, acting upon multiple dimensions: on one hand, the overall interventions by the State and, on the other hand, the singularity and autonomy of the subjects. 7e HPG methodology differs from other preventive group interventions in that it overcomes the hygienist tendency that was criticized by Berlinguer, 1,2 who rejected the choice, free of coercion or any irrational pressure, of whether or not to accept advice.
In the HPG, respect for the freedom to be able to choose to change behavioral patterns is the precondition for achieving the objectives of health promotion.In this methodology, the objective translation of singular and subjective experiences is processed and considered within the broader meanings of health and life.The action is within the group process, with discussion of individual experiences of health and illnesses, while relating the social, biological and psychological dimensions to the existential situation of freedom.

Final considerations
The HPG methodology, along with other approaches towards health promotion, was built around the interdisciplinary concepts that particularly be expressed over the last two decades.Therefore, the need for research directed towards promoting and identifying interventions, with their limits and potentials, is imposed on the development and improvement of health technologies.
Despite their guidance for deepening the continuous transformation of health levels and development of better living conditions, in rigorous terms, the HPG does not guarantee precise changes in behavior.It acts on the dimension of human complexity in which attitudes are understood as factors that predispose towards autonomous actions under conditions of freedom.
The work with HPG leads to facing up to great challenges, through connecting dispersed knowledge within the fields of human, biological and other sciences, to popular knowledge.The present work presupposes new interfaces of action within the healthcare model.It requires availability of cooperation for developing interactions among the professionals who make up the working group and between these professionals and other participants.In this manner, a bond may be established, around which the task of health promotion may be built.
In the context of SUS, the HPG may be utilized as an important technical resource that assists in building and improving the services that are associated with a positive concept of health.
Among the contributions towards health promotion, it is highlighted that the HPG may serve for the urgent task of interdisciplinary care, relating to the increasing demand by the elderly for care within the health systems of the twenty-first century.
The practical meaning of the HPG for health promotion, and its contributions and limitations, have been investigated* in six health clinics belonging to the Caregiving Academic Lecturer Program of the municipality of Florianópolis, State of Santa Catarina.
Among the studies being conducted, the research among elderly subjects in an HPG within the Epidoso Project, 22 at the Centro de Estudos do Envelhecimento (Center for Studies on Aging -CEE) of Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM/Unifesp), can be highlighted.In this, the impact of this methodology on the development of autonomy among the elderly is being assessed.
Going beyond the conventional shape of the biomedical model, the HPG methodology corresponds to the perspective of strengthening the subjects' control over the social and ecological environment in which they live.It may also favor progression of health levels towards the utopian limit proposed by Lefévre, 15 with the elimination of unnecessary and avoidable differences among human groups.

Table -
Differences between Health Promotion Groups (HPG) and prevention, disease control and treatment groups, according to category.