HEALTH PROMOTION CONCEPTIONS AND EXPRESSIONS IN THE TRAINING PROCESS OF THE MULTI-PROFESSIONAL RESIDENCY

Vale do Acaraú. Sobral, Ceará, Brasil. ABSTRACT Objective: to analyze the conception and manifestation of health promotion in the training process of the multiprofessional residency in health. Method: a qualitative study anchored in the Theory of Social Representations, carried out from the collection of documentary data and from interviews with 13 professionals from the faculty of five multi-professional residency programs in health in Ceará, from March to July 2017. For data analysis, lexical analysis was performed using the ALCESTE software, with emphasis on the significance and correlation of the terms, through the chi-square test. Results: the training process of the multi-professional residency points to the overcoming of the biomedical model, with health promotion being understood as


INTRODUCTION
Transforming training and health care consists of simultaneous and complementary movements that lead to the conformation of an integrated and socially organized system, which operates in a continuous and proactive manner and is capable of responding effectively and with quality to the health needs of the population. 1 In the Brazilian context, the reorientation of health care is consistent with the adoption of health promotion as a transformative process, capable of contributing to the improvement of health and life conditions and to confronting the dominant biologicist model, adding the social sciences in the problematization and understanding of the subjects' objective and subjective production conditions. 2 In view of its historical construction, with its own characteristics at the time and cultural, economic and political context, health promotion has presented different nuances over the years. Currently, the conception of health promotion is adopted as a theoretical and practical field with a wide action spectrum, translated into actions that seek to identify and face the macro-determinants of the health-disease-care process, as well as providing their transformation in favor of health. 3 This modern conception includes the subjects with and without clinical evidence in its list of care, arguing that they can be strengthened in order to achieve greater health potential, sensations of well-being, and individual and community development. 4 In this sense, the need to promote training processes aimed at health promotion is confirmed, in order to qualify more humanist, critical and generalist professionals, with the potential to change the work processes, expanding the commitment and the development of skills consistent with the human improvement for the Unified Health System. 2 In this light, the Multi-professional Residency in Health initiative assumes training based on permanent education in health that replaces the biological logic by a way of thinking and knowing capable of apprehending the objects in their context and their complexity. It is from this training that the resident, future worker of the Unified Health System, is expected to be a professional committed to the transformation of the health practices, promoting innovations and providing qualified and integrated care and management, in order to consolidate the health system. 5 In this logic, the training process of the Multi-professional Residency in Health meets the changes in the practice, in thinking and acting in health, exceeding the disciplinary limits, generating spaces of service-teaching-community articulation connected with life and social context, allowing for the application of theoretical knowledge, development of skills and attitudes, and construction of values together with the practical experiences. In the Multi-professional Residency in Health, we learn from what is beyond theory and we face the dichotomy between theory and practice, still present in training institutions. 6 Considering the intent of the Multi-professional Residency in Health in training professionals capable of acting on the multi-causality of the health-disease-care processes and of the health determinants, it is fundamental to understand how health promotion has been conceived and expressed in this type of training.
Thus, the objective was to analyze the conception and manifestation of health promotion in the training process of the multi-professional residency in health.

METHOD
This is an exploratory study with a qualitative approach and with a concomitant triangulation strategy, anchored in the Theory of Social Representations in its structural approach. 7 The adoption of this theory as a reference is in line with the study object, since it makes it possible to recognize the meanings attributed by the individuals to their actions, considering the contexts in which they are

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inserted and, in addition to assisting in the apprehension of reality, it enables an expanded view of the investigated data.
The research was carried out from March to July 2017, along with five multi-professional health residency programs, conducted by two public training institutions in the state of Ceará (Institution A and Institution B). The choice of Ceará as the macro scenario for this study is justified by the fact that it concentrates the largest multi-professional residency program in health, with regard to the number of vacancies and professions involved.
Institution A started its activities with the multi-professional residency in 1999, with the proposal of the Multi-professional Residency in Family Health, subsequently adding the Multi-professional Residency in Mental Health. During the period in question, approximately 80 professionals were in training, from the Nursing, Physical Education, Social Service, Psychology, Pharmacy, Physiotherapy, Speech Therapy, Nutrition, Dentistry and Occupational Therapy centers.
Accordingly, Institution B started its integrated health residency program in 2013, with two components: the hospital, with eight emphases concentrated on large hospitals in the capital of Ceará, Fortaleza; and the community, interest of this study, with emphases of Family and Community Health, Collective Health, and Collective Mental Health. Each class of this program offers nearly 327 places, distributed between the two components and in the five health macro-regions of the state of Ceará. Professionals from the same groups highlighted in Institution A are specialized in these programs.
Thus, they made up the totality of programs with a community component aimed at priority action in the network of primary care services and were chosen in view of the understanding that this is a field that allows for the development of health promotion actions. It is worth mentioning that these programs train nearly 250 professionals per class with a focus on primary care, in 22 cities from all the health macro-regions of the state, involving professionals from surrounding states, such as Pernambuco, Paraíba, Piauí and Rio Grande do Norte.
In this context, the population of interest includes professionals engaged in the pedagogical conduction of the residency programs in question, considering that they are responsible both for organizing the pedagogical components of the programs and for structuring the guiding documents, while promoting, through teaching performance, the development of competences and the achievement of the learning objectives established.
By means of an intentional non-probabilistic sample, the program coordinators and tutors who met the eligibility criteria were invited to participate, namely: being a professional linked to the training institution responsible for the multi-professional residency and acting directly in the teaching collegiate, for a minimum of three months, as it is estimated that this period is sufficient to participate in the planning and/or execution of the pedagogical activities, for example, a module/cycle; and not being away from their activities, for any reason, during the study period.
Thus, the study participants were 13 professionals from the teaching faculty of the two institutions offering multi-professional residency programs in community health in Ceará. Of these, two were coordinators, one exercised pedagogical coordination and the other academic, these coordinations being transversal and common to all the programs offered. The other participants were tutors from the Nursing, Social Work, Psychology, Dentistry, Physiotherapy and Physical Education categories. The tutors belonged to the family health (eight tutors) and mental health (three tutors) emphases.
For data collection, it was decided to gather the documentary collection of the multi-professional residency programs, with emphasis on the Pedagogical Project of the Course and curriculum, and interview with the participants. The documentary assessment had as its reference a form organized by the researchers from the domains of competences of the CompHP, addressing the essential aspects characteristic of each domain, the ethical values and the conceptual principles of health promotion.

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The interviews, conducted by a semi-structured script, were made possible by bringing researchers closer to the field, recognizing the participants and inviting them to participate. The interviews were carried out in a private environment, recorded in digital audio with a mean duration of 45 minutes each, guided by questions that dealt with the conception of health promotion adopted in the training process of the multi-professional residency and how it is worked on in the training.
The data obtained from the interviews were fully transcribed in the Microsoft Word 2013 ® program, constituting a corpus processed by the ALCESTE software, version 2015, which performs lexical analysis of the words of a speech, considering the function of the word in the text, enabling its quantification and class delimitation from the occurrence of words and their textual function. Thus, the software gathers groups of words with a similar meaning and extracts the Elementary Context Units (ECUs), segments of some lines originating from the textual division and corresponding to the discursive material referring to the formulation of the classes. It is then up to the researchers to identify the meaning of the classes formed, name them and analyze them according to the distribution and association of the lexicons.
The classes were interpreted from the content perspective, observing the list of words and specific ECUs for each class, based on the graphics and dendrograms generated. The concomitant triangulation strategy took place by the analysis of the reduced forms of full words with greater significance, according to chi-square (χ²) and their semantic contexts; the dendrogram of the Ascending Hierarchical Classification; and the documentary collection of residency programs, to compare, deepen and validate the results.
In order to meet the ethical standards of scientific research, this study was assessed and approved by the Research Ethics Committee. It is duly supported by the use of the Free and Informed Consent Form and, to guarantee the participants' confidentiality, identification was through the abbreviation Part (corresponding to the participant), followed by the number of each interview, according to the order in which they were conducted.

RESULTS
The processing of these professionals' interviews by means of the Alceste software revealed a total of 13 Initial Context Units in the analysis corpus, corresponding to the study participants; and 11,551 words, of which 1,882 are different forms, with a mean frequency of 6 per form. A total of 285 ECUs were structured, of which 203 were listed as valid for analysis, representing a utilization of 72% of the corpus.
In its sectioning process, the analysis material was divided into two blocks that bring together classes formed by UCEs with greater statistical and lexical affinity, thus demonstrating a connection of meanings between the grouped themes. Block 1 ( Figure 1) formed by class 1, with 14% of the ECUs (29 units), and class 2, with 43% of the ECUs (88 units), group the discourses related to the conceptions of health promotion and the way in which they are expressed in the training of the residency, these being the classes of interest in the study.

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The dendrogram illustrates the division of classes, made up of reduced representative shapes and the strength of each shape in the middle of the class, shown by the chi-square (χ²). Thus, adopting content analysis, each class was treated as a category, presented below.
As mentioned in this class and evaluated documents, the training process of the multiprofessional residency points to overcoming the biomedical model still in force in the health practices and, consequently, in the training in the health field. It thus reflects the potential that health promotion has for fragmenting and overcoming this paradigm with strong influences in the health field. […]  In the multi-professional residency, health promotion is then understood as a strategy and as an objective that, when making use of the expanded clinic, seeks to contemplate the health needs of individuals and of the community to which they belong, considering the social determinants in health in the production of health-care. As a strategy, it stands out as a means to improve quality of life and health, to empower the individuals, and to act on the health determinants. As an objective, it translates as a goal to be achieved with each action developed. The following reports illustrate this idea: […] they have that conception that they are going to treat health clinically, while we want that clinic that is beyond the office, the expanded clinic. So then we think about promoting health (Par09).
To be promoting people's health you need to look at the issue of infrastructure, sanitation, education, employment, food, school, transportation, health. So it is very comprehensive (Par04).
However, in order to become effective as a field, a development process is recognized that needs elements that flow into a peripatetic clinic, which takes place in a real context, comprising the multiple dimensions that influence living and living with quality, as social and environmental aspects. Under the perspective of the teaching collegiate of the multi-professional residency programs under study, this class brings together the moments in which health promotion is perceived in this training modality. The approach to health promotion in the residency runs through the various training moments, being present in the theoretical and theoretical-practical moments in order to offer theoretical and reflective basis for the implementation of healthy practices in the practical moments, as can be seen in the speeches and excerpts of the documents, as follows: […] about health promotion, much of what we have been working on has been triggered in the face-to-face modules, during the moments of theoretical-conceptual activity and also through the activities triggered in the circles, in the moments of theoretical-practical activity, that there in the practice scenario together with the preceptors of the service they will make sense (Par13).
[…] This theoretical content is not separated from the practice, it will work, it will lead to activity, it will lead, trigger demands for this resident to build, and that within a training process is worth noting (Par11).
[…] The training process has health promotion as its theoretical-methodological assumption (Institution A documents).
In this sense, according to documentary analysis, each of these moments of the residency training is directed and specified in the pedagogical project of the course, specifically designed and with the particularities of each emphasis or program, and by a curriculum aimed at meeting the proposals thought in this pedagogical project. In the programs under study, the structuring based on a process that aims at the development of competences on the part of the professionals is observed, organized according to the emphasis, to the professional nucleus and to the program.
Health promotion is then materialized in the documents studied as a pedagogical strategy and macro-competence to be developed, which concerns its transversal character, passing through all the emphases, both of the community component, focus of this study, and of the hospital component. The participants' speeches illustrate this thought: […] health promotion ends up being a theme that cuts across training in the residency. Health promotion will be transversal to the residency programs and will be triggered by many professional categories (Par11).
[…] The theory of health promotion happens at all times in a more transversal way of the emphases (Par10).
In order for health promotion to go beyond the theoretical component of training and make the theory-practice relationship possible, some strategies are adopted to make it effective as a professional practice intrinsic to this training modality.

[…] We think a lot about that much broader concept of health promotion, encompassing popular education as a strategy, encompassing the encouragement of participation and social control (Par13). […] It takes on a much larger dimension, much broader, it is not for nothing that we adopt territorialization, participatory planning in the construction of actions (Par08).
Among the strategies listed, the participants scored the territorialization; health planning; teamwork, in a multi and inter-professional manner; popular education; participation and social control.

DISCUSSION
In the field of health promotion and development of training with a focus on improving and consolidating it, tutors and coordinators play a relevant role in the idealization and execution of moments consistent with meaningful learning, based on the experiences of the residents and tutors and on the constant search for solutions to everyday problems related to health promotion, improvements in the conditions and quality of life. These professionals must ensure that all the actors involved understand the purpose of the training, the learning objectives and the desired results in handling situations, problems and their syntheses. 2 The role of tutors and coordinators in articulation with preceptors and residents in the health services resignifies the praxis, transforming the relationships with users and establishing new flows between management and assistance, representing a dialog between the academic realm and the health services, reducing the distance between the space for knowledge production and the space for its application, uniting them, integrating them. 8 Thus, it is important to appropriate the conceptions of health promotion expressed, defended and propagated by these professionals in the multi-professional residency programs, in order to ascertain whether their expressions are in line with what is desired to promote health, according to the Ottawa Charter and to other policies of the area.
It is worth mentioning that the Ottawa Charter proposes five fields of action for health promotion, aiming to overcome the current biomedical model in the health practices, namely: development of public policies, reorientation of the health services, creation of personal skills, reinforcement of community action, and favorable environments. This proposal includes the determination of the social factors in the field of health, guiding the mobilization and reinforcement for intervention in health and production of care. 9 Under this prism, the multi-professional residency programs analyzed point to overcoming the biomedical model, as they generate and strengthen attitudes of questioning and confronting this model, problematizing the field of care and health production, from the insertion of the critical view on 9/15 health and aspects arising from the social sciences, which interfere with it. They also contribute by adopting innovative and current pedagogical practices, organizing training based on a process that is not focused on teaching, but on learning, centered on the student and on the development of the skills necessary to achieve the learning objectives; using active and problematizing methodologies that assist in the development of the critical and creative spirit, in the ability to analyze and solve problems, in the communicative, leadership, innovation and adaptation to change, among others; on the decentralized role of the teacher beyond the classroom, permeating the different learning spaces, among them the fields of practice in the reality of the territory and of the health services; and on the flexibility of the curricula and training moments. 10 In this context, tutors and coordinators present of health promotion conceptions in line with the current policies, recognizing that health promoting professionals must act to help individuals to become able to identify aspirations, recognize needs and modify the environment in the search for the best quality of life and health. In this sense, there is an advance in the representations of these professionals regarding the concept of health promotion, not to be confused with disease prevention in the the participants' speeches.
This misunderstanding in the comprehension of health promotion is still common in the routines of the health professionals and in the population's imaginary, when they consider promotion and prevention as synonyms, the result of epistemological, linguistic and/or cultural issues. 11 However, the conception of health promotion, according to the participants' statements, goes beyond isolated actions with an emphasis on health, when considering that the social determinants are aspects that are directly related to the health and quality of life of the population.
Therefore, the social determinants of housing, leisure, income, education, basic sanitation, food, transportation and access to essential goods and services are considered, articulating in a way that transcends the health sector, thinking beyond healthy lifestyles, involving the well-being of the community. It encompasses political and social actions based on advocacy, empowerment and partnership, aimed at changes in the social and environmental conditions, recognizing the policies of other sectors and the existing technologies aimed at promoting equality and quality of life, reducing the vulnerabilities and risks in health arising from the social, economic, political, cultural and environmental determinants. 12 It is therefore an emancipatory health promotion that seeks to know, discuss and act on the socio-environmental and sanitary problems of the territory, on the verge of transforming the public policies and institutional practices based on legitimate interests and needs of the populations. 13 Convergence is thus recognized between the proposals of the residency and the representations of tutors and coordinators on health promotion and the premises of the promotion initiatives that are characterized, among others, by a holistic conception, by inter-sectoriality, favoring community empowerment and social participation and the search for equality through action on the social determinants of health. 14 Thus, in order for its complexity to be considered, training aimed at health promotion translates as a training process, since it must not be fixed and punctual, being adapted to the contextual reality of the territories and, therefore, adequate to them. It is considered crucial to pay attention to three aspects that must be considered for this training process from the territory: a) the five action fields -elaboration and implementation of healthy public policies, creation of favorable environments, reinforcement of community action, b) the three strategies -advocacy, mediation and training; and c) the priorities for action to be built locoregionally with the participants of the individuals and collectivity in their territories. 2,9 In this way, health promotion is materialized in the residency training in a transversal way to the moments of training, being present in the middle of the living territory and the demands that emerge from it, considering not only the biological aspects of the subjects who live in it, but going further and adding social, psychological, cultural and environmental aspects, as well as the daily lives of the individuals, not being restricted to the physical spaces of the health services.
In the context under study, the training process includes theoretical, theoretical-practical and practical moments. The theoretical moments comprise the modules/cycles, meeting stations between the residents, tutors, tutors and a professional or team of professionals with expertise in a particular knowledge area in order to discuss a specific topic and to promote the development of a teachinglearning process. It also includes the moments for individual study and distance education. They also confirm their relevance for action aimed at health promotion by valuing the construction of capacities that assist in the formulation and implementation of practices that converge with the theoretical and methodological principles of health promotion, which requires adoption and knowledge of theoretical frameworks that support and give meaning to the everyday practice. 2 The theoretical-practical moments, in both institutions, are conducted in the form of circlescore/category, field, teachers, and students circles, among other configurations. They are characterized as spaces for problematizing the work process and that of the territory that take place in the territory itself. It turns to transforming being and doing, aligning theory with practice based on reflections and dialog about what materializes in the daily experiences.
In this way, the theoretical-practical moments result from advances in changing the educational paradigm that reinforces the importance of student-centered education, considering that, in these moments, tutors and preceptors abandon the conservative role of teachers transmitting knowledge and assume the role of facilitators, with advisory, guidance and motivation functions aimed at the acquisition of competences. 10 The circles also show relevance when considering that care production as a training object can be weakened when pedagogical spaces of problematization are not instituted, in which there is reflection and analysis of the students' practices. 15 And, finally, the practical moments consist of those performed in loco, in the territory with the community, the team and the health services. The practical part comprises most of the workload of the residency and, therefore, needs a concrete theoretical basis for carrying out the actions and making them effective.
The residents' insertion in real care production contexts in practical moments contributes to understanding the meaning of the theories applied in the practice, since one must support the other, being connected. 16 To guide these moments that constitute the residency training process, it uses the Pedagogical Course Project and curriculum aimed at the development of competences and with a training path with an emphasis on performance in primary care. Curricula that value a broad approach in the context of primary care enable students to interact directly with the living territory and its community, progressing in attitudinal development in the context of interpersonal relationships and in the estimation of light care technologies, bringing the university closer to the services and the territory itself. 15 In competence-oriented courses, the contents explicit in the curriculum only make sense when they emerge from the practice and are aimed at enriching it, attributing functionality to coping with complex situations and problems common in the social environment, as in the residency training. 2 The teaching of health promotion is therefore based on an approach of integration of the different knowledge areas, constituting an opportunity for deepening, reflecting and integrating the residents' knowledge. 10 In this way, it consolidates itself as a transversal axis of teaching in health that focuses on collective health, overcoming the biomedical model, and values the improvement of 11/15 the living conditions and ways of life, considering the social determinants and the participation of the population in the construction of health and care.
For health promotion to be effective at all times of the training, as a transversal axis, tutors and coordinators point out strategies marked by inter-sectoriality, permanent education, monitoring, evaluation and encouragement of popular participation, in order to enable positive changes in the health of the of population. 17 Detailing each strategy pointed out by the study participants, territorialization refers to the process of recognizing the territory and its peculiarities. It consists of one of the fundamental action principles of the Family Health Strategy, being the basis for the organization of actions aimed at the community with potential partnerships for health promotion. 18 Health planning has the purpose of ensuring an effective response by the Unified Health System to the health demands and needs of the population, being the starting point for the programming of health actions. 19 Teamwork, on the other hand, concerns the formation of internal partnerships in the work environment to meet the changes in the epidemiological profile, aggregating different knowledge in a complementary manner, translating political theory and research into actions that perform well in the health practices. 20 Popular education comprises political education of the working class, in a perspective of both emancipation and the shaping of the status quo, recognizing the territory as a legitimate space for education. 21 Finally, social participation, defended in Ottawa's concept of health promotion, refers to the citizens' initiative to monitor, inspect, evaluate and interfere in state management and in the organization and implementation of the health actions and services. 22 These strategies add up to the complex teaching and learning process from the multi-professional health residency that seeks to involve several technological and pedagogical resources in driving the development of competences. This new teaching-learning context, consistent with transformations and innovations in the field of education, requires a more effective understanding of the search for useful and achievable procedures, as well as the resident-teacher relationship, to provide learning that is consistent with the social reality and, in this specific case, with health promotion. 23 In summary, health promotion is recognized as a strategy to break with and overcome the biomedical paradigm, placing itself transversely to the levels of assistance and seeing the healthdisease-care process in an expanded way, considering the individual and collective singularities and the determinants of health, going through the training process of the multi-professional residency transversally in the theory and practice moments.
The conduction of the study encompassing only the programs with a community component of performance can be pointed out as a limitation, which implies the suggestion of carrying out new studies also involving the hospital component.
Thus, the multi-professional residency in health establishes itself as a training process with powerful contributions to the training of health professionals with competences to work in the field of health promotion, instigating the development of knowledge, skills and attitudes pertinent to this field.

12/15 CONCLUSION
This study consolidated the representations of tutors and preceptors of training processes of a multi-disciplinary residency on health promotion and how it is expressed in this training modality. In the context studied, the conception of health promotion permeates the concepts and premises of the letters of the conferences on health promotion, especially that of Ottawa, as a strategy for training the population to act on their ways of living and having health, including greater participation in this process.
In parallel, it is expressed in all training, theoretical, theoretical-practical and practical moments, and in the ways in which they are structured and organized, being present in the Pedagogical Course Projects and curricula of the residency programs.
It is inferred that there is alignment between the adopted and expressed conception of health promotion in the training process of the professional residency, representing advances in the health and training practices that are consistent with overcoming the biomedical model, consolidating the field of collective health and training of health professionals to act in the face of new ways of producing health and of the health needs in the territories.