Reframing the concept of health promotion by nursing teachersABSTRACT
Objective: To analyze the reframing of the concept of Health Promotion by nursing professors.
Method: Action research, combined with Lev Vygotsky’s historical-cultural approach, developed with professors from the undergraduate Nursing course at a state university, in 2023. Data was produced during an extension course, recording and transcribing the discussions that took place in five meetings on the topic. Thematic analysis led to four themes: The concept of Health Promotion: reframing meanings; Contradictions between HP teaching and nursing practices in the service; Teaching Health Promotion in graduation; Perception of participants regarding their own transformation.
Results: At first, health promotion was understood as synonymous with prevention and specific health actions. During discussions, the redefinition of the concept of health promotion was demonstrated by presenting elements of the concept, such as principles and guidelines, as well as discussions about the presence of behavioral and critical pedagogy models in health promotion.
Conclusion: Reframing implies the need for reviewing, reorganizing, and transforming of teaching based on the appropriation of the concept of health promotion, with the use of innovative teaching methodologies and strategies, allowing progress in the undergraduate Nursing course.
Descriptors:
Health promotion; Health education; Redefinition; Nursing education; Nursing faculty
RESUMO
Objetivo: analisar a ressignificação do conceito de Promoção da Saúde por docentes de Enfermagem.
Método: pesquisa-ação, aliada à abordagem histórico-cultural de Vigotski, desenvolvida com professoras do curso de graduação em Enfermagem, de uma universidade estadual, em 2023. Os dados foram produzidos durante curso de extensão proposto, gravando e transcrevendo as discussões ocorridas em cinco encontros sobre o tema. A análise temática levou a quatro temas: Conceitos de promoção da saúde: ressignificações; Contradições entre o ensino de promoção da saúde e a prática do enfermeiro no serviço; Ensino de promoção da saúde na graduação; Percepção das participantes sobre sua transformação.
Resultados: promoção da saúde como sinônimo de prevenção e ações pontuais de saúde inicialmente emergiram. Durante as discussões, a ressignificação do conceito de promoção da saúde foi demonstrada na apresentação de elementos do conceito, como princípios e diretrizes, bem como nas discussões sobre a presença dos modelos comportamentalistas e da pedagogia crítica na promoção da saúde.
Conclusão: as ressignificações observadas inferem a necessidade de revisão, reorganização e transformação do ensino a partir da apropriação do conceito de promoção da saúde, com o uso de metodologias e estratégias de ensino inovadoras que permitam avançar, nesse contexto, no curso de graduação em Enfermagem.
Descritores:
Promoção da Saúde; Educação em Saúde; Ressignificação; Ensino de Enfermagem; Docentes de Enfermagem
RESUMEN
Objetivo: Analizar la resignificación del concepto de Promoción de la Salud por parte de los docentes de Enfermería.
Método: Investigación-acción, aliada al enfoque histórico-cultural de Lev Vygotsky, desarrollada con profesoras del curso de enfermería de una universidad estatal, en 2023. Los datos se produjeron durante un curso de extensión, cuyas discusiones, ocurridas en cinco encuentros sobre el tema, fueron grabadas y transcritas. El análisis temático condujo a cuatro temas: Conceptos de promoción de la salud: resignificaciones; Contradicciones entre la enseñanza de la promoción de la salud y la práctica del enfermero en el servicio; Enseñanza de la promoción de la salud en el pregrado; Percepción de las participantes sobre su transformación.
Resultados: La promoción de la salud como sinónimo de prevención y acciones puntuales de salud surgió inicialmente. Durante las discusiones, la resignificación del concepto de promoción de la salud se demostró en la presentación de elementos del concepto, como principios y directrices, así como en las discusiones sobre la presencia de modelos conductistas y de la pedagogía crítica en la promoción de la salud.
Conclusión: Las resignificaciones observadas implican la necesidad de revisión, reorganización y transformación de la enseñanza a partir de la apropiación del concepto de promoción de la salud, con el uso de metodologías y estrategias de enseñanza innovadoras, que permitan avanzar, en este contexto, en el curso de enfermería.
Descriptores:
Promoción de la salud; Educación en salud; Resignificación; Enseñanza de enfermería; Docentes de Enfermería
INTRODUCTION
If we understand that the central axis of Health Promotion (HP) is the process of educating people so they can take part and reach the highest possible level of health1, it becomes clear that different contexts, training, and technical and social actors must be involved in its development2. This interdisciplinary, multiprofessional, and multisectoral process can be directed by the sectors of health and education, aiming to understand the wide scope of factors that affect health3, forming a link between public policies, education, and social assistance, in addition to a good environment, support network, and protection of life4.
To educate new health workers trained in HP, well-trained professors are necessary, that can understand the complexity and conceptual scope of HP, as well as the multi-determination of health-disease5,6. Additionally, they must understand the political and social role of the nurse7, the need for intra- and inter-sectoral collaboration to produce and disseminate knowledge, and align their actions with educational processes that lead to critical reflection8, with extensive social participation and control, to produce health and education in accordance with the principles, directives, and laws of the Single Health System (SUS) and the Ministry of Health.
The educational process, as guided by formal or informal education, based on critical educational theory 8, must enable understanding the concept of HP in dialogic, emancipatory, and critical pedagogical processes, encompassing the social needs of individuals9 and valuing professional performance in health promotion networks 5. In this process, people and communities will be able to acquire or build knowledge about their health, to the point of thinking, reflecting, and deciding, autonomously and critically, about habits and attitudes that promote health9-11.
This is also addressed by other studies, such as the matrix of Competences for Health Promotion (CompEPS). Adapted to the Brazilian reality12, it lists the competences necessary to work with health promotion, in order to establish a national standard based on a consensus of the scientific community and attend the needs currently emerging in the field of health 6,12.
Discussions about the establishment of the domains of competences in pedagogical projects of graduation courses represent advancements in the organization of pedagogical practices for a quality training in HP so future professionals can work at SUS, since its presence in the documents of the course and the discourse of professors does not guarantee its full development11.
There are significant gaps in the Brazilian scientific production about the knowledge of university students on the concept of HP in the last five years that addresses understanding the unique reality of knowledge, respecting socio-cultural, political, and educational aspects of professors, which can influence knowledge; this shows the need for further research from this perspective.
This was the topic of interest for this research due to the experiences of the author, a nursing professor and researcher, who found different perspectives on the topic of Health Promotion among professors, and started to seek strategies that could enable reframing the meaning of HP using scientific studies, on the part of the group of professors themselves. Here, reframing is understood as changing meanings through the mediation of others13.
Considering the aspects inherent to health and HP, this research attempted to answer the following guiding questions: How do active nursing professors understand the concept of HP? Can an extension course lead to a theoretical reframing or refining of this concept? How does that happen? Therefore, the objective of this study was to analyze the reframing of the concept of Health Promotion by nursing professors.
METHOD
Qualitative, action research study, developed according to the assumptions of Vygotsky cultural-historical theory13. This study was developed in the nursing course of a state higher education institution in the midwest of the country.
The research action methodology was chosen as it involves researcher and participants in all of its stages, as they, preoccupied with the resolution of a collective issue, contribute to transform reality14. Thus, in line with the cultural-historical theory, we can understand the meanings attributed by people to an experience, considering earlier and later experiences, in constant movement13.
The action research was developed in four stages: a) exploratory; b) planning; c) execution; and d) analysis and synthesis, all of which are inter-related. The information, interaction, and collaboration needed to reach the goal of promoting reflection and reframing practices are themselves the results 15.
The exploratory stage involved identifying the problem-situation (need for nursing professors to gain a deeper understanding of the concept of Health Promotion), analyzing the problem and the main characteristics of the population involved, the institution to be benefited by the action (online course), the relationship between the institutions that are promoting the action, and determining research objectives15. The planning stage involves decision making; following the project determined; getting in touch with potential participants of the research; describing and explaining in detail the proposed action (online course), including the objectives and the method chosen for its development; contracting the participation in all meetings relative to the action; distributing responsibilities; producing data acquired from Google Forms; and discussing the readings for each meeting15. These stages were conducted in the first semester of 2023.
In the second semester of 2023, in the execution stage, the main researcher, an MS, who has worked in this teaching institution as a higher education professor, assumed the role of facilitator. She became involved in the communication, inviting participants through email, and made the participation of professors and mediators possible in all moments of the online course.
Participants were invited by the main researcher through their institutional email, which was provided by the coordination of the courses. All professors of the nursing bachelor's course, active in 2023, were selected. The inclusion criteria considered professors who had more than one year experience in the university, in order to include professors who were more experienced and, therefore, more familiar with the pedagogical project of the course. This is relevant when we consider that the turnover of professors is high, since there are few public processes to select professors for the institution. Were excluded professors who were on medical leave or unavailable to participate in the extension course. Since none of the professors who responded fit that exclusion criteria, none were eliminated.
Of the 38 professors who responded to the invitation, 23 stated that they could participate, 15 agreed with the time frame proposed, 12 participated in the first meeting, and 6 in the other meetings. For this article, we considered the participation of the six professors who were present throughout the course. Most of them were from 33 to 49 years old, all were female women who had worked in higher education from 5 to 18 years.
Data production took place in an extension course, exclusively proposed in the context of this research. The course was carried out online, lasting 30 hours, and was divided into 5 synchronous meetings, conducted weekly via Google Meet. They took place in August and September 2023, and lasted for a mean of 240 minutes each. The course was facilitated by the first author and, since the participants were professors, it was mediated by three PhD professors associated with another Higher Education Institution (HEI), all of whom were researchers in the field of Health Promotion and Education.
In the first meeting, we presented the objectives of the course and its proposed development; all those involved were presented; the Informed Consent was filled in using Google Forms to formalize participation; and two initial questions were answered in writing (How would you define Health Promotion? How would you define Health Education?). Discussions and reflections on the topic of HP were guided by previous readings that originated the initial topics of each meeting, creating a logical path for the study of the concept.
The topic of the first meeting was "Introducing Health Promotion". In it, the concept of HP, according to the Ottawa Charter1, were related to the first written answer of the participants, in an attempt to find theoretical elements that could expand this first discussion on the concept. In the second meeting, the topic discussed was "The historical construction of HP over the last 40 years"3. In the third meeting, the topic was "Theoretical-conceptual aspects"9. It included reflections about the concept of HP brought forth by the authors and promoted discussions about the difference between prevention and HP, types of HP, and other elements that constitute the concept. In the fourth meeting, the topic discussed was "Health promotion and critical education16 including reflections about education in health as an HP strategy, with a focus on critical education and, thus, collaborating with the theoretical-conceptual construction of HP and health education. In the last meeting, participants had a moment to reflect and discuss about the processes and experiences had over the course, once again answering, in writing, the questions presented at the beginning of the course. The data produced in writing at the beginning and end of the course were not considered for this article, as we choose to work with the process of reframing meaning that took place over the course.
All meetings were recorded and transcribed using the Google Chrome extension Tactiq. Corrections to the transcriptions were carried out using the software InqScribe, available on the website inqscribe.com. They were organized using the Microsoft® Word text editor. Transcriptions were not given back to participants. In order to maintain anonymity, professors were identified using the names of nurses famous in Brazil and the world.
The stage of data analysis and synthesis, comprising the discussions that took place during the course, stemmed from the elaboration of a detailed report of the meeting, which was submitted to a thematic analysis17. This allowed the researcher to get more involved with the data produced, in a harmonious, systematized, and flexible analytical process. This thematic analysis17 followed six stages, namely: 1) getting used with the data; 2) generating initial codes and bringing forth significant patterns from the reports, which led to a total of 73 codes; 3) elaborating topics by grouping codes that had important patterns and meanings that could help answer the research question (6 initial themes were found); 4) reviewing the internal homogeneity and external heterogeneity of the themes, that is, the data of each theme must be internally coherent, but they must have specificities (6 sub-themes were found); 5) defining and naming final themes (thematic map with 4 themes); and 6) producing the research report.
The thematic analysis of the data, focused on the process of reframing meaning, allowed the construction of four themes, namely: "The concept of Health Promotion: reframing meanings"; "Contradictions between HP teaching and nursing practices in the service"; "Teaching Health Promotion in graduation"; and "Perception of participants regarding their own transformation".
The thematic analysis is coherent with a historical-cultural perspective13, as it is essentially based on data produced by particdipants, valuing social movements and interactions as essential elements for each one's personal and social formation, as they are consdtantly transforming by going through new experiences.
The international protocol Consolidated Criteria for Reporting Qualitative Research (COREQ)18 was followed. This research was approved by the Research Ethics Committee (REC) of the Universidade do Estado de Mato Grosso, with opinion No. 6.130.781 and CAAE: 70179623.1.0000.5166, being in line with all provisions of Resolution 466/2012.
RESULTS AND DISCUSSION
Concept of Health Promotion: reframing the meaning
The concept of health promotion (HP), as well as the elements it comprises, was analyzed in an ongoing movement involving the statements at the different moments, in an attempt to clarify meanings and feelings attributed to the concept by each participant, in addition to aspects that reframe its meaning, as we can see below:
I think that, in practice [...] we have a bit of trouble to separate promotion from health education [...] it's hard, in general and generically, when we think about promotion and health education, its seems they're all the same, right? But what I understand is that health promotion is when we implement broader measures before some disease or health problem affects the population. (Rachel Haddock, 1st meeting).
At first, it seems an easy question, doesn't it? [...] it seems it's the same, right? But, I mean, for me, when you talk about health promotion, is to improve the quality of life of a population, of a community, it goes way beyond treating disease. (Anna Nery, 1st meeting)
As far as I understand health education is a strategy to promote Health, but it's not the only one nor isolated. (Wanda Horta, 1st meeting)
[...] when you talk about health education, I don't understand that's just you promoting health, but promoting, disseminating information, having people in general participate to prevent and treat disease [...] there is also training in health, which is one of the main goals of health education, right? (Anna Nery, 1st meeting)
Some participants mentioned, at first, trouble finding a difference between concepts such as PH, health education (HE), and prevention, showing a conceptual misalignment 18 that can harm the development of the understanding of students about HP, especially if they are limited to documents and do not reach spaces where debate and practice take place in their formation11. This can lead to the formation of scholars that develop health actions, but do not understand the concepts or references on which health care promotion is based5.
It is worth pointing out that humans are seen as historical beings, the only ones capable of producing culture, and language is the main mediator in this process13. Thus, constructing a space for this broad dialog about HP is an educational process mediated by a dialectical one, in which the participant is constituted by their environment, while projecting themselves dialectically, with their concrete reality, producing meaning which, in essence, is constituted around the relationships that were conducted in the environment of a dialog.
Avoiding the replication of this conceptual conflict found in participants requires interventions that start in the university training of health workers. HP, HE, and preventive practices can be complementary, as they are essential parts of health services. Nevertheless, they can be separated according to their approach, areas of activity, and activities6,9.
The first statements from the participants are strongly associated to the sociocultural and historical context of predominant teaching models and health practices. These are owed to a behavioral branch of teaching9, according to which the population is an active party in the learning process, neglecting historical, social, and cultural aspects of individuals and focusing on diseases and health issues. This can compromise health promotion actions and increase the focus on preventive ones10.
It must be reiterated that humans, in their cultural and biological dimensions, develop dynamically in the same space. They are also the result of a historical process13, which gives meaning to the constant updating of the teaching practices in educational processes.
As discussions about the concept of HP advanced, participants mentioned other important elements, such as its relationship with quality of life, Social Determinants of Health (SDH), and the values, principles, and directives of HP:
[...] the term or concept of promotion, it's very similar to that of quality of life, so when I talk about quality of life, I'm talking about a person who has where to live, how to eat, a person who was educated, who has a family structure, a person who lives in an area with at least the bare minimum basic sanitation, a person who has at least some safety to live [...]. (Glete Alcântara, 2nd meeting)
[...] this health promotion thing, it can't be separated from the determinants and conditions of health. (Wanda Horta, 2nd meeting)
[...] then we get into the social determinants, because then you start thinking about the collective aspect itself. [...] what types of health promotion actions, let's say that I can have, that will meet, let's say, life conditions, right? And then we also discuss the very issue of social participation, and this idea of co-responsibility with the individual, because co-responsibility is very important, but only insofar as they can take on part of the responsibility, right? (Rachel Haddock, 2nd meeting)
In the statements above, we can see that their understanding of the concept of HP became broader as they included other elements expressed in the reorganization of the concepts , which took place in the discussions and social and political proposals that took place in the world, especially over the last 40 years3. Vygotsky 13 mentioned this possibility, since the participants are constituted in the environment and by the environment. Therefore, in this environment promoted by the meetings, the broad dialog among members makes it possible to reach new meanings, when related to issues associated with learning.
Quality of life and HP were related to access to the SDH, also involving co-responsibility and social participation. This understanding is in accordance with essential HP aspects, going beyond intersectoral involvement to develop broad actions that have a direct or indirect relationship with health4,11. In this regard, since the Ottawa charter1, it has been stated that global, regional, and local interests should provide all elements necessary to the wellbeing and health in societies, so individuals and groups can reach the highest possible level in health, bringing together different sectors of society to work for a common goal, overcoming global challenges and helping people take control over their health and lives.
When the SDH is recognized, a process of humanization is reiterated, in which these participants analyze the social interactions established. The mediation, then, is highlighted as the main concept for this theory13, interposing the subject and the object of their knowledge. Thus, acting on the SDH means identifying the differences in life conditions and opportunities, in an attempt to directing resources and efforts to reduce inequality through a dialog between technical and popular knowledge2. The participants show this understanding in their statements, as well as other elements, as shown below:
I also think that the meaning is closer to a discussion about the co-responsibility of the state and the Health Professionals, the individual and their family, and the community they come from. (Ivone Lara, 3rd meeting)
So the focus still revolves around the individual, neglecting the fact that health promotion is not only related to empowering the individual, right? It entails much more, I think [...] that health promotion needs intersectoral actions and need to consider the whole, to consider the social, to consider where this individual is placed, what conditions they have to provide health? (Wanda Horta, 3rd meeting)
In their statements, we can see ideas related to intersectoral relationships, related to the process of articulation of knowledge, potential, and experience from individuals, groups, and sectors, in an attempt to build shared interventions. Thus, it is possible to avoid duplicated actions in a cross-sectional and integrated way, forming commitments and co-responsibilities, exercising the sharing of power, of a main role which is social, political, and supportive, in order to reduce vulnerabilities and risks to one's health, which is an indispensable strategy for the effectiveness of HP3,9.
In mediation13, which is also considered to be a key element in the educational process, intersectoral relations, be it through people who hold the content, is an educational field of knowledge. Thus, when several actors, from different sectors, share their experience, it becomes possible for a person to learn, through mediation, something, without necessarily having to go through the experience directly, as they are mediated by the experiences of other subjects.
An aspect of HP which still must be discussed, and overcome through speech and actions, is the empowerment of individuals, an issue raised by a participant:
So how do I empower this subject, how do I, how can I talk to this subject, group, community, in such a way they'll understand, how to care for their own health. (Wanda Horta, 2nd meeting)
Wanda's statement shows how necessary it is to indicate that empowering is not a function of the health worker, the educational worker, or any other member of society, since professionals can propose conditions for their development, but not act on the autonomy of individuals and society19.
It is worth noting that the learning process, for the historical-cultural theory13, only takes place in interactions with social environments, that is, the meanings and senses must be internalized. Once again, the education of the nursing professional is revisited so we can understand which educational processes were developed, which concepts were acquired, and how external and internal transformations of the learner manifest. In this process of empowerment - the ability to think and act critically1 -, the nursing worker, in the role of educator, can work towards raising critical awareness, since the learning process is made easier by mediation and significant interactions with more experienced people14).
According to the concept of empowerment, the relationship between individual and society is inseparable1. A the study about the contributions of Vygotsky's theory20, emphasized that nursing professionals, teams, and researchers must consider that people are active and interactive people in their learning process and acquisition of knowledge. Merely individual practices are insufficient to appropriate knowledge; it is essential to get involved with others, who are part of the process.
Mechanisms of interaction between professionals and people who participate in the action, with attentive listening, based on the exchange of experience and the formation of bonds, expand the possibility of developing the desired level of empowerment for the HP to be consolidated21. We resort to Vygotsky13 to understand that learning starts with an appropriation, by the subject, of the knowledge around them, in an active process, in the process of interacting with others, be it in person or through formal or informal didactic resources. Thus, a space for learning is formed, and knowledge is cognitively constructed for the self.
The statements of the participants Glete and Rachel, presented below, show conceptual advances regarding the aspects of an environment favorable for one's quality of life and health:
[...] a person who lives in an area with at least the bare minimum basic sanitation, a person who has at least some safety to live, so when we think about health promotion, environment, how we are for our environment, so it cannot produce or anyone careless, right? In our environment, who may increase the risk for disease. (Glete Alcântara, 2nd meeting)
So, when we work with environmental education, people have very little information about environmental problems that, if I'm exposed to them, that exposure can cause me a health issue, because in most cases environmental issues are caused by economic enterprises(...), and sometimes we also have go through this information process, so they understand and notice that their health can also be affected, but to do so, I must promote spaces for dialog, be a really attentive listener, right? (Rachel Haddock, 1st meeting).
The interdependent relations between health and environment were the highlight of the Sundsvall statement, from 1991 4, which highlighted environmental issues for the health agenda. Ever since, an environment that is favorable for health has been discussed, especially in developed countries, where human intervention over the environment is greater.
Another important discussion about the conceptual understanding of HP was the difference between prevention and promotion, in addition to the two branches of the HP concept: the critical and the conservative one9:
[...] when we think of care for the citizens thinking of them, we really want change in behavior, when we talk about prevention we want them to change their behavior, to improve their quality of life, and then, when she said "comes a know-it-all that's it", I think that's when we use a strategy, whatever it is, regarding prevention, and I think it really is very prescriptive. (Ivone Lara, 3rd meeting)
Disease prevention is one of the pillars of health promotion. But it doesn't account alone for the complexity of health promotion. (Glete Alcântara, 3rd meeting)
[...] a hygienist, behavioral concept, I think these concepts have become too strong in the minds of professionals who work or say they work with health promotion. So we ended up working on some issues and thinking we're doing health promotion, that's it, and we have been noticing that it’s clear how much it has caused gaps and so, we had to advance. (Ivone Lara, 3rd meeting)
I think we end up working more from a conservative perspective, in part because it's difficult, I don't know if I'm mistaken, but I mean when you talk about transforming life and health conditions, right, both individual and collective, it's a very macro, very broad issue, that extrapolates my reach as, for example, a nurse from a primary health care unit. Then I think that's why we reproduce these practices which are more in line with a conservative line, because it's difficult to expand and think how do I change people's conditions of life? (Wanda Horta, 3rd meeting)
[...] this issue of considering a theoretical line and a more critical practice, that doesn't have to be just specific to a single moment, it's built gradually, right? Sometimes you start with a small experience that works in a place and then you begin to reproduce it more widely as you manage to start partnerships, right? (Rachel Haddock, 3rd meeting)
Discussions about how to understand prevention, including conceptual differences and practices in this regard, were a highlight of the development of this study. Thus, understanding the difference between disease prevention and health promotion is essential, since prevention can be temporary, but promotion is permanent9, reiterating that the space for dialog, opened through the use of formal and informal educational resources, promotes transformation.
The participants, especially Ivone, stated that they understand that it is not sufficient for professionals to provide a list of generic, protocol-based, pre-made actions, if individuals and communities cannot understand how necessary it is to adapt these to their lifestyles. They also understood that, for an action to be considered HP, it does not need to involve all its aspects, such as a macropolitical and a multifactorial one. Promotion often takes place through smaller, localized actions, which can impact on the life of a community and, from there, affect a larger audience.
The history of disease is dynamic, and the formation and activities related with HP must also be, observing individuals and population from different perspectives, so the interventions carried out are assertive, and have a higher chance of keeping these individuals healthy11. This can be a huge difference when it comes to HP as a social strategy.
In this context, it is worth noting that, for the critical line of HP, there is no group that is dominant and holds the knowledge in the actions and strategies that involve individuals from the community and the multiprofessional and interdisciplinfary teams. The subject changes his environment and changes through their lived experiences13. Therefore, their actions must be discussed and planned together, with the participation of all parties involved, especially the community, which must present their needs, possibilities, and desires, so the actions proposed can be implemented9.
These practices must be presented to the students by the nurse professor. The same is true for other countries, such as a the United States22, where professors are strongly encouraged to give multiple opportunities for undergraduates to develop their competence to assess and intervene in critical HP factors. At the end of the discussions regarding the concept of HP, after having advanced in discussing prevention and the different branches of HP, participants had a new perspective about the concept, indicating that the meaning had been reframed, as the statements below show:
The most interesting aspect of the last meeting, for me, was this clarification of the difference between health promotion and prevention [...] I think that was essential. Because, in practice, we carry out preventive actions and think that these actions, in themselves, are already health promotion. So, in the article, it became really clear for us, from the perspective of everything that was built around promotion, what is the difference between these practices[...] (Glete Alcântara, 4th meeting)
[...] for sure, it expands our view about this understanding that we used to have about this concept [...] regarding what I had written at first, this issue of how many actors are involved in this process to generate such a transformative change, I mean, I put it there, right? And it involves a bunch of strategies from many sectors, policies, right? [...], And regarding health education, I still understand it as one of the strategies of health promotion we can use, and also disease prevention, right? (Ivone Lara, 5th meeting)
[...] and now I added it and all this discussion we had about critical education. Because health education I think it's an essential tool for health promotion activities, but it can only be effective from the moment I consider this critical education branch, because if I continue to carry out health education actions based on the concepts you learn related to transmitting knowledge, I don't think we change attitudes like that. (Wanda Horta, 4th meeting)
The evolution found in these statements show that there were changes in their knowledge, in the process of critical thought, and the potential reframing of meaning. The ideas presented no longer focused on specific aspects of actions around a problem. Their HP concepts were expanded, and they also understood that HE, in addition to being a strategy to transmit knowledge, is also a process in which individuals and society itself must be proactive, and the same is true for the public bodies and the professionals from several sectors, all of whom are responsible for transformative changes in quality of life.
The statement below shows a change in the concept:
[...] these are reflections that make us really think about health promotion as a conceptual and practical strategy to actually change a model, the organization of a healths service. (Anna Nery, 4th meeting)
Anna makes this change explicit in the 4th meeting, showing a leap ahead in her perspective about HP, moving from specific actions to a strategy, a model for the organization of health services. This is quite different from her statements in the first meeting, when she emphasized that promoting health is to disseminate information, with the participation of the population in general, to prevent and treat disease.
Other meanings were reframed, becoming evident in statements already presented, such as:
[...] the term or concept of promotion, it's very similar to that of quality of life [...] I see a huge abyss between theory and practice. (Glete Alcântara, 2th meeting)
[...] In practice, we carry out preventive actions and think that these actions, in themselves, are already health promotion. So, in the article, it became really clear for us, from the perspective of everything that was built around promotion, what is the difference between these practices. (Glete Alcântara, 4th meeting)
Glete highlights the contributions of the course, in regard to confronting the "abyss between theory and practice", a statement from the 2nd meeting that addresses an issue that may immobilize a professional, while in the 4th meeting, she reaches another perspective, in which the concept of HP itself is expanded.
Ivone, in the 3rd meeting, points out: "we worked on some issues, believing that by doing that alone we were doing health promotion, and we've noticed clearly how many gaps that caused, so we had to move forward".
Contradictions between HP teaching and nursing practices in the service
Participants raised the issue of how hard it is to bring a broader concept of HP into practice, so it can be effected in the health service, as the statements below demonstrate:
That's when these curative actions take up a larger and larger part of the daily life of a professional. Because he needs to show him he's efficient and needs to show the community he's efficient, at least in regard to what he can cure. So I feel it, that it's hard to leave this theoretical world and step into practice because how much promotion also depends on our public policies. (Glete Alcântara, 2nd meeting)
[...] which are the mechanisms that can help put this promotion in effect, so we leave the world of theory, because our theoretical world's been established. It's there. So we can live promotion in practice and can really put an end to this fragmentation of care. I think it's not only a fragmentation of care, I think it's a fragmentation of life, I think that from the moment an individual has a life, with a fragmented social side, their life and health conditions are also going to be fragmented. So... we get to think about these policies... everything is so loose, you know? (Glete Alcântara, 2nd meeting)
I think that we lack eloquence, like, public speaking, you know? [...] The nurse does the work of active searching, does an exam, gives the medicine to that child, and six months later the child has the same issue again. (Glete Alcântara, 2nd meeting)
For the operationalization of HP, it is necessary to articulate theoretical and practical, technical and popular knowledge, in addition to mobilizing institutional, human, and community resources, both public and private.
In this regard, participants reflected on the difficulties found in their experiences with theory and practice in health services, with students and nursing teams, especially considering the implementation of the critical branch of HP.
Furthermore, since literature shows that there is a conservative and a critical branch of HP9, this led to important reflections on the part of the participants.
[...] are we, as health workers, and considering here the primary health care setting, are we managing to practice at least the conservative [branch of HP?]? I think the conservative one is the one we do the most. (Ivone Lara, 3rd meeting)
[...] because I need other sectors working together, because I think that, in the context of primary care, if I find a primary care nurse there, I think we can reproduce this conservative branch because we learned it, it's a historically constructed thing, we were taught to work like this and we have trouble moving forward.(Wanda Horta, 3rd meeting)
[...] even we, as professors, as professionals, the students, they also find trouble, a lot of limitations in the conservative branch [of HP] too, regarding the best way to do it, the right way, the possible, let's say, right, imagine talking about a critical branch as well. (Rachel Haddock, 3rd meeting)
Trouble implementing HP, especially in accordance with its critical branch, stem from the persistent misalignment between the concept and the way it is practiced in health services and institutions19.
The debate on theories, worldviews, and the presence of ethical-political projects that guide practices in order to understand and expand perspectives, as advocated by the critical branch of HP, is essential for professors and new health workers. The hegemony of the biomedical model is criticized as it is believed to be necessary, but not sufficient23. Thus, the critical branch of HP is broader. The way in which it is understood and practiced separates the HP that is operated in reality, in the daily life of health services, due to negotiation and agreements with people who are searching for a better quality of life9.
Therefore, universities, which by nature are an essential part of HP strategies19, must invest in educational processes, emphasizing, especially, the cross-sectionality of the topic when it comes to theoretical and practical aspects, teaching-service integration, and debates and dialog regarding the critical and reflective capabilities of health managers and workers2,11).
An investigation on theoretical and practical teaching in this regard would help deal with the questions raised by the participants from the nursing course, in addition to provoking local discussions with municipal secretariats that are partners of the HEIs, social organizations and associations, and regional health offices, so potential action plans can be structured, as well as institutional extension projects, and even Political Pedagogical Projects (PPP).
Teaching Health Promotion in graduation
This is quite the significant topic for our analysis, as it relates to the way in which participants teach HP in university and the reflections that experience provokes. Glete, Rachel, and Ivone presented examples that, they believe, encompass a broader concept of HP.
I also see that the education of our students, the way they are being trained, although we try our best to try to change this biology-centered mindset [...] I see that both students and professors see these actions in ways that are still quite, let's say, impossible to carry out, right? Hard, impossible, doesn't fit in reality, the health care unit won't be able to continue taht action, right? So the student is educated with this perspective, right? (Rachel Haddock, 3rd meeting)
[...] we get an education that is too focused on a cure, hospital-centered. And all the while, primary care is being encouraged, is receiving a good financial push, but to do it we must implement, we must expand this training in health.[...] Therefore, health workers must really be trained, they must implement our knowledge about health promotion. (Glete Alcântara, 4th meeting)
[...] regarding their education, because then if we believe that health promotion is focused on these two branches that were important for our evolution, but they can't solve everything, they leave gaps. I think their education has an important role, because if we reproduce these two branches from an understanding that's only in these two HP branches, we don't push thae concept forward. And if we don't push it forward, we don't go into practice and just reproduce the practices we already understand. (Ivone Lara, 4th meeting)
The statements above highlight the predominance of teaching that revolves around behavioral and biology-centered models. Thus, there is not need to rethink the model in which information is transferred from the specialist to the higher education students, since they are being educated to answer social demands, developing abilities and competences to work in the job market with all its complexity, and the ability to act and defend the current perspective regarding HP7,24. University should, therefore, provide an education informed by the principles and strategies contemplated in the Ottawa Charter:
[...]related to our education, [...] in my case, nurses, we end up reproducing what we learned. We were trained... Who, here... I think everyone... we were trained in a traditional model, so we end up, as professionals, as nurses from health units or hospitals, we end up reproducing educational processes based on our own education, and often we cannot leave it behind and abandon this tradition.(Wanda Horta, 4th meeting)
And then the student finds it difficult when we try to abandon the traditional way and think of a more critical pedagogy. (Wanda Horta, 4th meeting)
[...] this may also be an obstacle for us to work with these issues during graduation. (Ivone Lara, 4th meeting)
Wanda reported that they received, in university, traditional training. This can be another reason for their trouble implementing the critical branch of HP. Glete, similarly, declares she was not familiar with HP discussions during her academic education, as the statement below indicates:
[...] the discussion about health promotion during education. [...] we, during our education, did not have this formative experience involving the construction of a theoretical world of health promotion, not of the theoretical world and even less of the practical world. So I think it was a lack of training. My education in regard to health promotion was really difficult for me [...] Then, I think it's really necessary, in the education of health workers, to implement this knowledge we have about health promotion. (Glete Alcântara, 4th meeting)
The sample presented by Glete has also been observed by the researcher. This research was motivated by the fact that this is a known reality in many higher education institutions, which use a traditional, biomedical, and curative model which has been prominent in the country. As a result, we wanted to promote this discussion as mediators, in order to enable our colleagues, other professors, to acquire theoretical knowledge on the expanded concept of HP.
Another aspect highlighted by Ivone was the lack of cross-sectionality in the teaching of HP in the nursing course.
We don't have an axis of health promotion that crosses our course as a whole, you know, as a branch, it's not cross-sectional in our course. It's like what [Wand Horta] said, so there are a few specific actions in some subjects or some content in some disciplines, and the professor is the one responsible for maybe thinking about that subject, and so on. (Ivone Lara, 4th meeting)
Commitment in the education of the nursing undergraduate, focused on HP, is essential for students to develop a theoretical-practical, critical and reflective construction about the possibilities and challenges for health work, which can establish emancipatory networks for health promotion activities11:
[...] so education in this branch as a transmission of knowledge, as opposed to this education, this more critical and emancipatory pedagogy, which I think is the greatest difference, it's something that stands out [...] for us to work. (Ivone Lara, 4th meeting)
I believe that our course has evolved a lot in this regard, and that's a result not only of the presuppositions associated with the work of preceptors, but also of our movement as professors, as we open our minds to understand how people need to change, even our own behavior, so we can take that to our students.(Olga Verderese, 2nd meeting)
Ivone also mentioned that it is necessary to change into pedagogical models that can better attend the needs of the HP. Regarding improvements to the nursing course in the last few years, Olga mentioned the insertion of preceptors in teaching, increasing teaching-service interaction.
Bringing the student into the health service while still in graduation, enables them to witness the different circumstances of the life conditions of the population being cared for, making the relationship between theory and practice palpable; this can increase the commitment of students with a more humanized and reflective professional practice24.
A study from the United Kingdom 25 suggests that educational content related to social determinants of health, health equality, and people-centered care, should be incorporated into all nursing specialties and adapted into all branches of practice, as to bring closer the approaches associated with lifestyle changes and those associated with person-centered behavioral change.
Ivone highlighted that she does use other strategies in addition to lectures, especially in the school environment, as we can see below:
[...] when we go into practice, at least in our discipline, we always involve the schools [...] with students, and I think it's quite a rich setting for us to work with health promotion and prevention, right? [...] other spaces where we can really work well with these issues. And not just give lectures, as [Wanda Horta] said. Using only strategies such as lectures and conversation circles, right? How much we can explore other forms, too. (Ivone Lara, 5th meeting).
Other strategies, such as home visits, conversation circles, interactive exercises, workshops, experiences in teaching-service programs, and games are presented as ways to develop health education activities26.
Training methods that do not favor criticism and humanistic reflections involving ethics and social context models, necessary to HP, can increase the distance between the formal nature of the Course Pedagogical Project (CPP) documents and the educational process. In actual academic life, there is a predominance of expository classes, with little to no dialogue, and little encouragement to critical-reflective perspectives19.
The distance between proposals and execution, the need to redirect the educational process of nurses and other health workers, which are still strongly affected by the biomedical health care model, and the fact that HP is still addressed as a separate discipline in the curriculum of some universities 5,26, all can make it harder to understand and teach the critical branch of HP, as mentioned by the participants.
When applying HP, it is imperative to get closer to real situations found in work environments and social life during the educational process, and to use methodologies that enable approximation, reflection, and search for social meanings between theory and practice - especially when we consider our collective responsibility to improve the way we live and build health in society9,24,27:
[...] that we may discuss another way or discuss health promotion in education a bit more, then we could show our students, work these other strategies with them, these other possibilities of educating them with the patients, such as this example [Wanda] mentioned of the students she supervises. She said that and I thought, may it could have that influence. (Ivone Lara, 3rd meeting)
The emphasis given by Ivone Lara contributes to the idea that one of the roles of the higher education professor is to contribute for the education of youth and adults, in a humane, ethical, and scientific process, in their social and cultural context, where dialog and participation stand out as pedagogical elements of this educational process for professional activity in research7,19.
Health education for professionals who contribute for the change in indicators in the field, seeking to achieve equal, integral, and resolutive care, is also a worldwide goal of the 2030 Agenda, part of the Sustainable Development Goals (SDGs). In our case, the goal 3C stands out: health and wellbeing for all. This goal proposes to substantially increase the financing of health and recruitment, the development, training, and retention of health personnel4,19.
In this regard, the National Policy for Health Promotion (PNPS) is an important instrument the institution uses to orient HP practices in SUS. It's 5th article includes the directives that anchor the educational work of new health professionals, research development, dissemination of experiences and knowledge tahat emphasize critical and reflective training, the improvement of individual and collective skills, decision making, autonomy, and collective empowering2,9.
Thus, the nursing educational process must favor educational health care practices, that help individuals develop a critical perspective regarding attitudes that cause disease and autonomy when bringing the health process to effect and caring for the individual and the population21.
Perception of participants about their transformation
During the process of studying and discussing the concept of HP, some statements indicating a reframing of concepts and their own process. The statements of Wanda and Glete, below, are examples:
[...] and we talked a lot that health promotion is often associated to educational lectures. So we have the habit of working with lectures a lot, sometimes with conversation circles, and, in most cases, this is basically a transference of knowledge. Which is not the proposal of critical education. To educate is not to transfer knowledge, as Paulo Freire would say.[...] I think, the way we're working with health promotion, if it can be said we are indeed bringing it into our actions, into our health promotion strategies, this element of critical education. I think that in most actions, strategies, our work is still too anchored in traditional, formal education. (Wanda Horta, 4th meeting).
It's just what [Wanda Horta] said. From my perspective, at least, in the sense that health promotion is not to develop actions for an individual, I think that, after these discussions we had, I think it's to develop or take actions together with the individual. The person my action affects is part of it, I don't do it for them, but with them! That's why we talk about critical education, because the person we think of as a learner, I don't if he will, because sometimes we can be the learners. (Glete Alcântara, 4th meeting)
As found in the extracts above, the work of participants, as nursing professors, has timidly moved towards a broader perspective of HP. Nevertheless, the conceptual advance of participants is clear; the statement by Glete, highlighting the main role of the human being, is an example.
In the historical-cultural theory13 of learning, a proximal development zone is established. This is a symbolic and dynamic space, where development takes place with the help of another person who already has that knowledge; this person gradually pushes the other forward, so this knowledge can manifest autonomously in the learner. For this zone to be promoted, there must be interaction based on common objectives, which must also count on a language that is targeted at effective communication.
Participants also highlighted the transformations they felt through the experience of the course, as the statements below make clear:
We also have something new to learn, I think that's what matters, what we must keep in mind. And this process to renew too, right? (Ivone Lara, 5th meeting)
Even for me, it's getting much clearer that health promotion or doing health promotion is not essentially an activity of the health field, of health workers, I think that when it gets entangled, when it gets mixed with education, the responsibility is shared, and health promotion is not only a health activity, is an intersectoral one, involving many fields of knowledge and sometimes even, for those who don't understand this, when you say health promotion they understand that it's just an activity of health workers. (Glete Alcântara, 4th meeting)
And it was so cool, when I talked about it with them [my students] about this topic [...] I was so happy, so proud of myself, that I was addressing this topic in a new way, you know, with more knowledge, more empowered about the topic, I even felt that the discussion flowed more, and they did understand, so it was really cool. (Wanda Horta, 2nd meeting)
In the process of reframing concepts, knowledge, or practices, the active nurse can be a link between the fields of health and education within health promotion programs, community and institutional spaces, in primary, secondary, or higher education environments; they can be an actor that understands and orients actions that involve health-disease-care processes19.
I this context, the challenge of nursing educational processes and other health professios is to advance in establishing intra- and intersectoral articulations, from the perspective of integrating and collaborating for multisectoral, interprofessional, and multiprofessional work, be it educational, cultural, economic, and political, to meet the needs of the population and promote their wellbeing7.
The concept of HP, as defined by theoretical-conceptual works, must be better understood by professors and managers of nursing colleges and universities; it must be more clearly described, in theoretical models that can give support to practice and in CPPs. It must be implanted and implemented, since they are an important strategy for health promotion. Vygotsky13 states that, when plans of development and materials are not clearly adapted to cultural contexts, familiarization becomes more difficult. This reiterates the idea that, if one gets closer to the object they want to learn, especially through elements common in daily life, the learning process happens more effectively.
Many strategies can help reframe the unique meanings that professors and manages attribute to health promotion. This includes permanent education programs about health promotion, tools to manage knowledge and technologies, active methodologies, and interactions of professors with health services, all of which bring theory closer to the sociocultural reality unique to each geographic region.
Limitations of the study include the fact it did not include or analyze the concept of HP descripe in the CPP, the application of the concept in nursing practices, and the educational moments aimed at doing so. Nonetheless, the results of this research can help develop future investigations about the knowledge of higher education professors about the concept of HP, as well as strategies such as extension courses to expand the possibilities of reframing the concept of HP and the importance of working with this concept since the start of the education of health professionals.
FINAL CONSIDERATIONS
Getting closer to the central topic, in a movement of constant mediation and interaction, based on the contributions of historical-cultural approaches, and proposing a prospective form of learning, that is, one that starts prior to the development of the individual, allowed theoretical transformations that were visible in participant statements, indicating new elements and giving new meaning to the concept of health promotion. This included the relationship with health-disease multidetermination, participation, and co-responsibility of people, in addition to associations with intersectorality, interdisciplinarity, and an understanding of the differences between health prevention, promotion, and education. It is worth noting that the space for interaction created by the researchers and participants became a rich environment for the exchange of knowledge. All those involved developed with the help of one another, as they experienced new perspectives about the world and human beings, especially regarding the concept of health promotion.
The highlights of the reframing of the concept, made clear by the discussions, included understanding the difference between health promotion and prevention, and the knowledge about the behavioral and critical branches of health promotion. The statements clearly showed a transition from an initial understanding, where it was hard to separate the concepts of promotion, prevention, and health education into another perspective, the understanding of another meaning of health promotion. This involved comprehending that it involves everything from the micropolitics of daily life to the macropolitics that presuppose an even greater participation of individuals and the community.
Concerns were raised about how education in health promotion, prevention, and health education are understood, since participants found it difficult to separate these topics in order to implement them in their practices at university and health care. Still, it is essential to emphasize that the concepts in the pedagogical projects of the courses of institutions that train health workers must be discussed, redefined, negotiated, and agreed upon, in a process that must involve managers, professors, students, and health workers, for these to be considered health promotion institutions as well. Therefore, it is necessary to review, reorganize, and transform the education and practice of health promotion in nursing graduation.
Acknowledgements:
This work was carried out with the support of the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brazil (the Coordination for the Improvement of Higher Education Personnel - CAPES) - Funding code 001.
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