ORIGINAL RESEARCH

Health promotion from the perspective of primary health care nurses

Leonardo Rodrigues Piovesan^I; Maria Denise Schimith ^II; Bruna Sodré Simon^III; Maria de Lourdes Denardin Budó^IV; Teresinha Heck Weiller^V ; Ana Cristina Passarella Brêtas^VI

^I Nurse. Municipal Department of Health of Sapucaia do Sul. Institutional backer. Sapucaia do Sul, Rio Grande do Sul, Brazil. Email: leonardo.r.piovesan@gmail.com
^II Nurse. Doctor. Adjunct Professor, Department of Nursing of the Federal University of Santa Maria. Rio Grande do Sul, Brazil. Email: ma.denise2011@gmail.com
^III Nurse. Master. Assistant Professor of the Nursing Course at the Federal University of Pampa. Uruguaiana, Rio Grande do Sul, Brazil. E-mail: enf.brusimon@gmail.com
^IV Nurse. Doctor. Associate Professor, Department of Nursing of the Federal University of Santa Maria. Rio Grande do Sul, Brazil. Email: lourdesdenardin@gmail.com
^V Nurse. Doctor. Adjunct Professor, Department of Nursing of the Federal University of Santa Maria. Rio Grande do Sul, Brazil. Email: weiller2@hotmail.com
^VI Nurse. Doctor. Associate porfessor in the Paulista School of Nursing, Federal University of São Paulo. Brazil. Email: acpbretras@unifesp.br

DOI: http://dx.doi.org/10.12957/reuerj.2016.5816

ABSTRACT

Objective: to identify primary health care nurses' understanding of health promotion in the municipality of Santa Maria, Rio Grande do Sul. Method: this was a qualitative study. Data was collected by interviews of ten primary health care nurses, between March and April 2008, and treated according to the operative analysis proposal. The study was approved in CAAE No. 0296.0.243.000-08. Results: the nurses cite social change, economic, educational and environmental change actions as examples of health promotion, coming close to the scope of the concept. There was also found to be a lack of knowledge and biological view of the subject. The professional nurse's role proved crucial in inter-sector relations and achieving health promotion. Conclusion: understanding health promotion is of undeniable importance to taking measures designed to change conditions and advance in establishing Brazil's Unified Health Sys.

Keywords: Health promotion; primary health care; public health nursing; unified health system.

INTRODUCTION

Health promotion had in the Ottawa Charter the disclosure of one of the key documents for its formation, which was the main result of the First International Conference on Health Promotion in 1986. The Charter defines health promotion as "the process of enabling the community to act to improve its quality of life and health, including greater participation in this process"^1:19 . Health promotion is not only in the health sector, but also for achieving an adequate physical, mental and social state.

The National Policy for Health Promotion (NPHP) in Brazil suggests that interventions aimed at health promotion take the problems and the health needs of the population as the object, with focus on their determinants, acting directly on the effects of the illness, but also covering the communities and other sectors. Furthermore, the Charter mentions that health promotion focuses on the living conditions of the population and promotes the expansion of healthy choices by individuals and communities in the places where they live and work².

This study was conducted in primary care (PC) and the choice for this locus is justified because PC is characterized by a set of actions at individual and collective level that should cover, among other aspects, health promotion and protection. It is also the first contact of users with health services, in which the subject must be considered in its uniqueness, complexity, integrality and socio-cultural integration, seeking to promote the user's health³. PC is a scenario of nursing practice, focused

in the development of actions to promote the health of users, individually or collectively.

When considering the importance and relevance of health promotion actions for nursing, the following research question was established: what is the understanding of PC nurses on this subject? The objective was to identify the understanding that PC nurses in the municipality of Santa Maria, Rio Grande do Sul have about health promotion.

LITERATURE REVIEW

Health promotion was legitimated in Brazil through the decree nº 687 of March 30, 2006, which approved the NPHP. However, this issue has been discussed for over 35 years since the International Conference on Primary Health Care held in Alma-Ata in 19784.

Health promotion has as main benchmark the First International Conference on Health Promotion in Ottawa (Canada) held in November 1986. The Ottawa Charter has become a basic and fundamental term of reference to the development of ideas on health promotion worldwide ⁵.

According to the letter, the basic conditions and resources for health are peace, shelter, education, food, income, stable ecosystem, sustainable resources, social justice and equity. It highlights equity as one of the health promotion focuses, because by reducing the differences in the health status of the population and ensuring opportunities and equitable resources to all people, it will be possible to realize the full health potential of the population¹.

The NPHP proposes that actions take health problems and needs, their determinants and constraints, as the object of interventions. Actions should focus on the conditions of life and foster the expansion of healthy choices by individuals and communities in the territory. It is necessary to change the culture that health is only feasible when a structure to meet patients is set up, when the hospital's doors are open, or when doctors are on duty. Preventing people from getting sick requires more complex structures².

However, a number of social and cultural factors and, in the case of Brazil, even the lack of experience of citizenship must be taken into account, as they prevent the adoption of recommended healthy behaviors. Health care is not limited to prescriptions about the living habits⁶.

Prevention of the disease is closely associated with health promotion, provided this is proposed to reorienting health services and follows its principles ⁷. Among them: the participation of subjects in driving their own lives, individually and collectively; the development of actions between different sectors of the community; the combination of complementary methods or approaches, for example, communication, law, education, community development. Furthermore, professionals must act in order to protect the health of the community, not just in assistance services⁸. The general objective of the NPHP includes these principles when it stresses that the promotion of quality of life, reduction of vulnerabilities and risks to health, should be focused on determining and conditioning factors such as ways of living, working conditions, housing, environment, education, leisure, culture and access to goods and services¹.

Health promotion is a theoretical-practical-political field that emerges as a policy that should pass through all the actions and projects in health, present at all levels of complexity of the management and attention of the health system. It should switch the look and listening of health professionals from the disease towards users, potential creators of their own health, with the aim of expanding their autonomy in the health care process⁹.

With the revision of NPHP in 2013/14, the need for coordination with other public policies, social participation and popular movements became evident, due to the inability of the health sector to respond alone to the determinants and conditions that influence health. Progressing towards inter-sectorial action stands also as a challenge, seeking to articulate actions aimed at specific audiences, such as the promotion of health in the work environment, community, seeking to advance projects aimed at improving urban mobility, including disabled people and the elderly¹⁰.

METHODOLOGY

Search field, qualitative, addressing the universe of meanings, motives, values ​​and attitudes¹¹.

The scenario of the research was the municipality of Santa Maria, in the countryside of Rio Grande do Sul. At the time of the survey, the city had 40 nurses working in PC, 24 nurses of basic health units and 16 of family health units.

In order to achieve a result that showed the reality of the theme, all nurses working in PC were given the chance to participate. For this, participants were numbered alphabetically and after a drawing, the order of the interviews was set. Then, the phone contact was proceeded to confirm participation in the study and, later, interviews were scheduled according to the nurses' availability. Data collection occurred in March and April 2008, and 10 nurses were interviewed. Collection was suspended when data saturation was observed.

The data collection instrument used was a semi-structured interview that combines open and closed questions, where the respondent has the possibility to discuss the issue at hand without being attached to the question formulated¹¹. Interviews were recorded in mp3 audio files, transcribed and analyzed.

To analyze the data, operative proposal of analysis was carried out. This consists of three main phases: data ordering, data classification and final analysis. Ordering data refers to transcription and re-reading of the material. The classification of data was characterized by exhaustive and repeated reading of the material collected. Then, the final analysis allowed the construction of core categories¹¹.

Guided by the provisions of the Resolution ^nº 196/9612, this project was registered at the Municipal Health Secretariat and submitted to the Ethics Committee of the Federal University of Santa Maria, obtaining approval under CAAE nº 0296.0.243.000-08. Participants, after accepting to participate, signed an Informed Consent. Anonymity was guaranteed to the respondents by identifying them with the abbreviation N1, N2, N3 and so on, where "N" represents nurse and the corresponding number, refers to the order of the interview. The operational analysis originated the following health-promotion categories: a transforming agent; promotion of health and of citizenship; and health promotion and disease prevention: interconnected actions.

RESULTS AND DISCUSSION

The interviewed nurses are all female, aged between 32 and 49 years and working time between 8 and 20 years. All had some expertise, and two were enrolled in master's programs. The technical responsibility of the health unit was given to seven of them, and one, moreover, was also coordinator of the unit. When they were asked if they participated in any social movement only two said yes, an aspect that will be discussed in this article. All the nurses already had professional experience (at least 8 years); with this, we can infer that all involved participants understand the dynamics of the profession and should not be considered inexperienced in their accounts. As all had some kind of expertise, it appears that there is concern about updating knowledge. Thus, the nurses in this study represent an experienced and skilled group.

Health promotion: a transforming agent

The concept of health promotion arises as a tool for building activities that express a transforming character.

Activities that can promote health through environmental transformation were highlighted:

This group, then, arises as a possibility of income for some families in need, representing an action of social transformation that is thus promoting the health of those involved.

The concept of health promotion is understood in different ways by the interviewed nurses. It is inferred that health practices, which is the translation of the concept into action, have also different formats.

The transforming character is given by the way the activities are carried out and it is interconnected with the concept of education. If nurses, while developing educational practices, sustain an authoritative discourse, little stimulating the process of building autonomy of users, social transformation will not occur, and the purpose of health promotion will not be reached¹³.

Promotion of health and of citizenship

The development of autonomy by the user of health services was also mentioned.

Educational actions can or cannot promote the autonomy of users. Health promotion brings with it the issue of the need for the population to become able to exert control over the determinants of health⁷, because only people with full control of their lives, their habits and their routines will adjust them to make them ever more promoters of health. Furthermore, health promotion acts to provide autonomy to individuals by providing them with information, skills and tools to make them able to choose behaviors, attitudes and interpersonal relationships that produce health¹⁴. Health promotion is the process of empowering the community to work in improving their own quality of life and health, including greater participation in this process¹.

A nurse cites community participation as essential for good health outcomes.

Encouraging the user's autonomy capacity so that this has greater control and information on his own quality of life is, therefore, an investment in health promotion. By assuming its core responsibility, the care, nursing should also be wondering about the impact that its actions are generating in the health of the population for which it is responsible¹⁵.

Inter-sectoriality emerges as a way to support the demands of the unit.

The speech of this nurse shows the support she found to carry out her group.

Inter-sectoriality can also be performed with community educational institutions, enhancing the results obtained from the joint work.

Health promotion actions, because they have the condition of changing the reality of the subjects and the duty of thinking on this subject, taking into account his integrality, they take on the need for intersectionality. Individual and collective health is affected by factors that do not depend only on the performance of health teams. Thus, why would we think that only those are the ones who should ensure integral health?

In this context, it acts as a link between health services, inter-sectorial support and the community, which should also be protagonist in this construction. The inter-sectorial work with educational institutions should not be limited to the use of the school's physical space, for example; there should not be only one service to the partner institution, or an exchange of favors. What makes the work even richer is the exchange of experience and joint work between sectors. It is necessary to mobilize an inter-sectorial cooperation with partners from other areas such as social assistance, education, sports, religious institutions and non-governmental organizations in order to act on the conditions of vulnerability, seeking to overcome it¹⁴.

Health promotion and disease prevention: interconnected actions

When conceptualizing health promotion, it is possible to raise the concern with environment.

In this statement appear the possibilities of promoting health with environmental education or with a walk that becomes a source of awareness and work aimed at the environment.

To meet this quest for health promotion, the Health Academy program stands out as an equipment of primary care with the potential to strengthen and upgrade health promotion activities in communities. The program was created in 2011 aiming at the promotion of body practices and physical activities. It was, however, redefined in 2013, and had its goal expanded for contributing to health promotion and care production and healthy lifestyles among the population, what is in line with the principles and values ​​of NPHP¹⁶.

It is noteworthy that for conceptualizing health promotion, the respondents used an objective view of the concept, that is, they related it to the technical and measurable issues. This fact reveals what happened historically with the concept, due to the consolidation of the biomedical paradigm that continues up to the present days.

The concept of health promotion is presented differently in the literature. On one hand, health promotion means an important displacement of object and focus, namely, from the patient towards the disease, arguing that the disease must be minimized and eliminated from the world so that we will finally have health¹⁷. On the other hand, thinking in promotion as prevention is to consider the explanation of this process in a biologists and behaviorist view, while health promotion is linked to a holistic and environmental view⁷.

The concepts of health promotion and disease prevention were also confused by the research subjects, as shown in the following speech:

Conceptual differences make the understanding even more difficult and may even be a key driver factor for assimilation that appear in the statements. Both health professionals and some authors who are dedicated to carry out publications on the subject, consider health promotion equal to prevention⁷.

In contrast, some nurses indicate differences between promotion and prevention.

The testimonies put away the promotion of factors related to the disease and seek the factors that are crucial to health in its execution, revealing a concept of promoting or expanding health. Corroborating this result, health promotion seeks the determinants of health-disease process to transform them favorably toward health. In turn, prevention of diseases has to do with individuals seeking to be exempted from the same diseases but handling in the focus of the problem⁵.

Health education aimed at promoting health was also cited.

In addition to this preventive aspect, health education can play an aspect that is a promoter of health, according to the themes and approaches used. Health education has a fine line between promotion and prevention. A reflection on whether the aforementioned actions have or not a promoter aspect of health is required. Educational campaigns such asDiabetes Day, Day to combat smoking, Day to combat HIV and others are activities that revolve around a particular disease or etiologic agent, with directions and activities geared to the population involved. Thus they are preventive actions. Even in dates like the World Health Day , the activities are aimed at the prevention of diseases such as checking blood pressure, checking blood glucose, and not specifically at health-promoting actions. This is because public health is defined as responsible for health promotion as their practices are organized around concepts of disease¹⁸.

It was not stated that the activities have this character, but it is emphasized that they run the risk of creating misunderstandings. Thus, health education implies the presence of health professionals in times of meetings with users, balancing with favoring user participation in defining their therapeutic projects¹⁹.

This approach demonstrates a concern by the nurse with regard to the quality of life of this young person, creating life plans, goals for the future and self-esteem, being characterized as an activity that promotes health. Another study also showed that strengthening the emotional and social well-being of individuals can enhance the effectiveness of care ²⁰.

Health promotion initiatives from the perspective of participation and joint construction of the health process fail to match only the technical innovations in offer and provision of services to convert the establishment of spaces for social production of health. In these, individuals and groups, in fact, participate in these processes, giving directions, encouraging or deflating the importance of contents and proposed actions, making their judgments and sending direct or indirect messages about what are their needs and wants²¹.

We stress the need to develop practices aimed at a critical and transformative education, favoring the awakening of a critical consciousness and citizenship, in order to "make society more just, humane and solidary" ^22:60.

CONCLUSIONS

Health promotion seeks to increase the well-being and health of the population based on a comprehensive and environmental view. With this, statements show several insights on the subject. The fact that the promotion of health has emerged from the discourses and practices of some PC nurses in the city of Santa Maria is a rich discovery. The pursuit of social, economic, educational and environmental transformation, which is the most typical attribute of health promotion, allows suggesting that there is a comprehensive understanding of the concept of health promotion.

Health promotion includes the involvement of various sectors of society in order to form a more effective action. In inter-sectoriality, the importance of the professional nurse in the PC is evident because this can make the link between the action itself and the population that needs it, through health promotion. The nurse must take possession of this knowledge and play the role of supporter of health-promoting actions when are not yet present, both with other sectors of society as well as intra-sector.

At the same time, the maintenance of the biologist view of health promotion is noticed. It is shown that nurses who work in the same role, with similar backgrounds, have different understandings about the issue, resulting in unequal practices from the point of view of its scope.

The data collection technique can be considered a limitation of this study. If observation data it were added to the collection, it would be possible to detect other health promotion actions developed by nurses.

We stress that it is necessary not only the theoretical and conceptual development of the theme, but also the development of an ethical stance that may enable the real incorporation of attitudes that promote health in everyday work. Understanding health promotion, considering its broader concept, is essential for the development of actions that seek a real transformation of reality, advancing in the consolidation of the Unified Health System.

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