Articulação entre Práticas Integrativas e Promoção da Saúde: ações coletivas com acupuntura na Estratégia Saúde da Família / Articulation between Integrative Practices and Health Promotion: collective actions with acupuncture in the Family Health Strategy

As Práticas Integrativas e Complementares em Saúde (PICS) são reconhecidas pela Organização Mundial de Saúde e englobam várias terapêuticas corporais e comportamentais, sendo uma delas a acupuntura. Esta pesquisa teve como objetivo analisar uma experiência que articulou ações coletivas de acupuntura com a promoção da saúde em uma Unidade de Saúde da Família. Foi realizado um estudo descritivo e analítico, de natureza qualitativa, que utilizou rodas de conversas e registros em diário de pesquisa como estratégias para produção de dados. Este estudo possibilitou uma ampliação no acolhimento das demandas dos usuários, com estreitamento de vínculo entre a equipe de saúde e a comunidade, contribuindo para a desmedicalização do cuidado. Pôde-se perceber a ampliação da clínica,o aumento do conhecimento sobre as PICS, com incentivo à desmedicalização, autocuidado, participação de práticas coletivas, troca de saberes e inserção de estratégias capazes de colaborar com o processo de reconstrução de modos de viver a vida de pessoas que buscam o serviço de saúde.

Integrative and Complementary Practices in Health (PICS, in Portuguese) are recognizedby the World Health Organization and encompass several bodily and behavioral therapies, one of which is acupuncture. This research aimed to analyze and reflect on an experience that articulated collective actions using acupuncture practices with health promotion in a Family Health Unit. A descriptive and analytical study of qualitative nature was carried out, which used conversation circles and research diary records as strategies for data production. This study enabled an expansion in the understanding ofthe users' needs, with a closer bond between the health team and the community, contributing to the demedicalization of care. It was possible to perceive the expansion of the clinic's offer, the increase in knowledge of PICS, encouraging demedicalization,self-care, participation in collective practices, exchange of knowledge, and insertion of strategies capable of collaborating with the process of reconstructing the life habits of those who seek health care.

Information, control and health promotion in the Brazilian context of the pandemic.

This article discusses how preventive and promotional discourses have been incorporated by the Brazilian population in the context of the coronavirus pandemic. It analyzes materials posted on the internet and social after the first case of COVID 19-related death in Brazil that are related health promotion and COVID-19 aimed at orienting society's response to the pandemic. The analysis considers two key factors: the mismanagement of the pandemic by the Brazilian government and infodemic. There is complex use of scientific information with recommendations that focus on what people should do (intervention) and in transforming individuals' behaviors, based on an ideal model of healthy behaviors. Narratives aimed to delegate to the population and specific groups the task of taking care of themselves have been reinforced, removing from the State the responsibility to offer conditions for the population to address the situation. There is a sophistication of strategies that blame individual practices, personal organization and that are disconnected from the collective, especially for those who live in situation of extreme vulnerability. Concomitantly, there are also discourses based on notions of solidarity and renewed social connections, which are empowering and consistent with the practice of health promotion as it attributes meanings to the subjects and their ways of life. We conclude that greatest advocacy in the field of health promotion at this moment is political and could be directed toward reaffirming health promotion principles, supporting permanent mobilization against setbacks in the public sphere and defending a new, democratic, inclusive and collective vision of society.

Direito humano à alimentação adequada e objetivos do desenvolvimento sustentável: interferências coletivas com crianças em periferias vulnerabilizadas / The human right to adequate food and sustainable development goals: collective interferences with children in vulnerable urban peripheries

Resumo Este artigo teve como objetivo analisar as relações entre o Direito Humano à Alimentação Adequada (DHAA) e os Objetivos do Desenvolvimento Sustentável (ODS) que emergem de ações dialógicas com crianças e adolescentes em periferias urbanas vulnerabilizadas de São Vicente, São Paulo. Utilizando referencial metodológico das pesquisas participativas, a observação e registros de assembleias comunitárias e da parceria entre universidade pública e movimento social apontam para espaços de acolhimento às crianças e adolescentes que viabilizam leituras diagnósticas coletivas sobre a alimentação. Esses processos dialógicos permitem problematizar as dimensões do DHAA a partir da cadeia de produção, comercialização e consumo de alimentos, além da instabilidade a que essas crianças e adolescentes estão submetidos, em uma complexa rede de determinantes que produzem má-nutrição nos territórios onde vivem. Os resultados apontam que estas dimensões dialogam com todos os ODS, na medida em que demandam a sustentabilidade cultural, econômica, social e ambiental da alimentação. A parceria e a integração entre universidade e sociedade fortalece e potencializa os espaços de controle social e formação dos atores para a luta pelo DHAA, e pode também produzir efeitos de transformação nas desigualdades nos territórios e reconhecer a criança como sujeito de direitos com profundo rigor ético na construção de escutas inclusivas e de práticas qualificadas.

Abstract This study aimed to analyze the relation between the Human Right to Adequate Food (HRAF) and Sustainable Development Goals (SDG) resulting from a dialogic experience with children and adolescents in the periphery of São Vicente, São Paulo. Using the methodological framework of participatory research, community assemblies observation, and the partnership between the university and social movements point to a caring place for children/adolescents that enable collective diagnostic readings on food. Dialogical processes enable us to problematize HRAF dimensions based on the chain of food production, trading and consumption, and the instability to which those children/adolescents are subjected in a complex network of determinants that produce hunger and malnutrition in the territories in which they live. Results show that these dimensions dialogue with all the SDGs, as they demand cultural, economic, social, and environmental sustainability of food. The partnership and integration between university and society strengthens and enhances the spaces of social control and training of actors to advocate for the HRAF. It can also change inequalities in the territories and acknowledge children as subjects of rights with deep ethical commitment in the construction of inclusive listening and qualified practices.

Às margens do cuidado: regulações de gênero em uma equipe de saúde / On the margins of care: gender regulations in a health care team

Resumo Embasado em uma perspectiva feminista, este artigo analisa como uma equipe de saúde tece as redes de cuidado e define práticas de saúde a partir do percurso de uma usuária. A metodologia utilizada é da pesquisa-intervenção inspirada na perspectiva cartográfica. Na tentativa de reduzir taxas de mortalidade materno-infantil, a equipe oferece à usuária uma rede que obedece a uma lógica burocrática com regras, normas e regulações. É possível observar como políticas voltadas para a maternidade definem processos de subjetivação responsáveis por formatar as usuárias, desenhando atos performativos enrijecidos. A equipe de saúde acaba por requisitar os corpos das usuárias de diferentes maneiras pelo fato de serem mulheres. Usuárias essas que, na maioria dos casos, são mães e pobres, o que traz singularidades em relação às suas trajetórias e nos modos como são vistas pelas equipes. Laqueadura, pré-natal, cuidados com a casa e (as)os filhas(os), acesso a determinados benefícios, todos juntos constituem elementos que orientam as decisões das equipes e agem como tecnologias de regulação de gênero capazes de legitimar violências institucionais cotidianas. A politização das práticas técnico-científicas se faz urgente a fim de assegurar que questões sobre direitos humanos e sociais possam fazer parte do dia a dia das equipes que estão nos territórios.

Abstract From a feminist perspective, this article analyzes how a healthcare team weaves care networks and defines health practices from the course of a female user. The methodology used is the intervention research inspired by the cartographic perspective. In the attempt to reduce mother-and-child mortality rates, the staff offers female user a network that obeys a bureaucratic logic with rules, norms and regulations. We can notice how policies for maternity define processes of subjectivation responsible for shaping the female users, outlining rigid performative acts. The healthcare team eventually requires the female users' bodies in different ways by the fact that they are women. In most cases those users are mothers and poor, which involves singularities in relation to their trajectories and to the way the teams regard them. Tubal ligation, pre-natal care, care with house and children, access to certain benefits, together are elements that guide the staffs' decisions and act as technologies for gender regulation able to legitimate quotidian institutional violence. The politicization of the technical-scientific practices becomes urgent in order to ensure that issues on human and social rights may be part of the daily routine of teams that work in those territories.

Shared Participatory Research Principles and Methodologies: Perspectives from the USA and Brazil-45 Years after Paulo Freire's "Pedagogy of the Oppressed".

The trajectory of participation in health research by community social actors worldwide has been built on a history of community participation from the Ottawa Charter Health Promotion call for community mobilization, to the emancipatory educational philosophy of Paulo Freire, to social movements and organizing for health and social justice. This paper builds on this history to expand our global knowledge about community participation in research through a dialogue between experiences and contexts in two prominent countries in this approach; the United States and Brazil. We first focus on differences in political and scientific contexts, financing, and academic perspectives and then present how, despite these differences, similarities exist in values and collaborative methodologies aimed at engaging community partners in democratizing science and knowledge construction. We present three case studies, one from the U.S. and two from Brazil, which illustrate similar multi-level processes using participatory research tools and Freirian dialogue to contribute to social mobilization, community empowerment, and the transformation of inequitable societal conditions. Despite different processes of evolution, we observed a convergence of participatory health research strategies and values that can transform science in our commitment to reduce health and social inequities and improve community wellbeing.

Pesquisa participante na estratégia saúde da família em territórios vulneráveis: a formação coletiva no diálogo pesquisador e colaborador / Participant research in the family health strategy in vulnerable territories: collective training in the researcher and collaborator dialog / Investigación participante en la estrategia salud de la familia en territorios vulnerables: la formación colectiva en el diálogo investigador y colaborador

Resumo Neste artigo, objetivamos descrever e problematizar as principais questões de operacionalização do trabalho de campo da pesquisa participante, ressaltando dilemas da relação pesquisador e sujeito-colaborador da pesquisa em contexto de atuação da Estratégia Saúde da Família em território de alta vulnerabilidade social. Criamos o grupo gestor da pesquisa, formado por gestores, profissionais (destacando-se os agentes comunitários de saúde) e pesquisadores, com o objetivo de elaborar estratégias e refletir sobre os resultados da pesquisa. Fizemos observações participantes do cotidiano, diários de campo, anotações sistemáticas e transcrições dos encontros. A metodologia de análise foi a hermenêutica de profundidade, de Thompson. Essa combinação metodológica possibilitou dar ênfase às experiências cotidianas, somando-as ao 'chão', ao que sustenta as vivências, ou seja, a história local, a cultura, a política e a organização do trabalho em saúde, as configurações intersubjetivas e sociais do território e a história de vida das pessoas. Nesse contexto, o grupo gestor deu o tom das ações da pesquisa, ainda que seu processo grupal evidenciasse tensões vividas pela Estratégia Saúde da Família. Os diálogos horizontais conquistados pelo trabalho desse grupo possibilitaram uma transformação e uma construção do conhecimento compartilhada entre atores do campo e pesquisadores, os quais estavam implicados com os dilemas vivenciados.

Abstract In this article, we describe and discuss the main operational issues of participatory research fieldwork, highlighting the dilemmas of the researcher and research subject/collaborator relationship in the context of the Family Health Strategy activities in a territory where there is high social vulnerability. We created the research management group, consisting of managers, professionals (emphasizing the community health agents) and researchers, aiming to develop strategies and reflect on the results of the research. We undertook participant observation of daily life, field daybooks, we took systematic notes, and made transcripts of the meetings. The analysis methodology used was Thompson's in-depth hermeneutics. This methodological combination made it possible to emphasize everyday experiences, adding them to the 'ground,' to what supports the experiences, i.e. the local history, culture, politics, and the organization of the work in health, on intersubjective and social settings of the territory and of people's life history. In this context, the management group set the tone of the research actions, although its group process showed the tensions experienced by the Family Health Strategy. The horizontal dialogs conquered by the work done by this group allowed for a transformation and construction of knowledge shared among the field players and researchers, who were involved with the dilemmas experienced.

Resumen En este artículo, buscamos describir y problematizar las principales cuestiones de operacionalización del trabajo de campo de la investigación participante, resaltando los dilemas de la relación investigador y sujeto/colaborador de la investigación, en un contexto de actuación de la Estrategia Salud de la Familia en territorio de alta vulnerabilidad social. Creamos el grupo gestor de la investigación, formado por gestores, profesionales (destacándose los agentes comunitarios de salud) e investigadores, con el objetivo de preparar las estrategias y reflexionar sobre los resultados de la investigación. Hicimos observaciones participantes del quehacer cotidiano, diarios de campo, anotaciones sistemáticas y transcripciones de los encuentros. La metodología de análisis utilizada fue la hermenéutica de profundidad, de Thompson. Esta combinación metodológica permitió enfatizar las experiencias cotidianas, sumándolas al 'suelo', al que sostiene las vivencias, o sea, la historia local, la cultura, la política y la organización del trabajo en salud, las configuraciones intersubjetivas y sociales de los territorios y la historia de vida de las personas. En ese contexto, el grupo gestor orientó las acciones de investigación, aun cuando su proceso grupal evidenciara tensiones vividas por la Estrategia Salud de la Familia. Los diálogos horizontales conquistados por el trabajo de ese grupo permitieron una transformación y una construcción del conocimiento compartido entre actores del campo e investigadores, los cuales estaban implicados con los dilemas vivenciados.

Sustainability and power in health promotion: community-based participatory research in a reproductive health policy case study in New Mexico.

Health promotion programs are commonly viewed as value-free initiatives which seek to improve health, often through behavior change. An opposing view has begun to emerge that health promotion efforts, especially ones seeking to impact health policy and social determinants of health, are vulnerable to political contexts and may depend on who is in power at the time. This community-based participatory research study attempts to understand these interactions by applying a conceptual model focused on the power context, diverse stakeholder roles within this context, and the relationship of political levers and other change strategies to the sustainability of health promotion interventions aimed at health policy change. We present a case study of a health promotion coalition, New Mexico for Responsible Sex Education (NMRSE), as an example of power dynamics and change processes. Formed in 2005 in response to federal policies mandating abstinence-only education, NMRSE includes community activists, health promotion staff from the New Mexico Department of Health, and policy-maker allies. Applying an adapted Mayer's 'power analysis' instrument, we conducted semi-structured stakeholder interviews and triangulated political-context analyses from the perspective of the stakeholders.We identified multiple understandings of sustainability and health promotion policy change, including: the importance of diverse stakeholders working together in coalition and social networks; their distinct positions of power within their political contexts; the role of science versus advocacy in change processes; the particular challenges for public sector health promotion professionals; and other facilitators versus barriers to action. One problem that emerged consisted of the challenges for state employees to engage in health promotion advocacy due to limitations imposed on their activities by state and federal policies. This investigation's results include a refined conceptual model, a power-analysis instrument, and new understandings of the intersection of power and stakeholder strategies in the sustainability of health promotion and health in all policies.

Reclaiming the social in community movements: perspectives from the USA and Brazil/South America: 25 years after Ottawa.

Since the Ottawa Charter 25 years ago, community participation has been adopted worldwide by nation states and communities as a core health promotion strategy. Rising inequities since that time, however, have been largely unchecked in the Americas and globally, and have presented us with an acutely paradoxical time for community participation and action. On the one hand, transnational globalized markets and accompanying economic and environmental devastation have challenged the effectiveness of community action to create health. On the other hand, hopeful signs of local through national and international activism and of new mechanisms for community engagement continue to surface as meaningful and effective democratic acts. This article presents a dialogue on these issues between colleagues in the United States and Brazil, and considers the broader applicability to Latin America and worldwide. We begin by discussing how community participation and community organizing grew out of our respective histories. We consider the catalytic role of the Ottawa Charter in spurring a reorientation of health promotion and the genesis of healthy city and community initiatives, as well as other current community organizing strategies and the growth of participatory research/CBPR. We unpack the potential for co-optation of both community and social participation and end with recommendations for what we can do to maintain our integrity of belief in democratic social participation to promote improved health and health equity.

Motuca healthy municipality project: building together a better future.

The Brazilian Ministry of Health in collaboration with the Municipality of Motuca and the School of Public Health at the University of São Paulo set up in 2002 the Motuca Healthy Municipality project with the aim of improving the population's health and quality of life. The project used a participatory and holistic approach, which addressed the social determinants and structural inequities, and called for strategies of community empowerment, social participation, intersectoral networking and good governance. All local and public actors from rural and urban areas were consulted and participated in the project to collect information on the living conditions and challenges to better wellbeing. This participatory methodology allowed in turn developing cultural and socially appropriate initiatives to improve local governance and standards of living on a long-term basis. Although there is still the challenge to maintain the momentum and reenergize the efforts, the project serves as a model for further efforts to evaluate the effectiveness of participatory intervention and research methodologies to promote health and well-being in communities.

Theory and practice in the context of health promotion program evaluation.

Evaluation of health promotion (HP) actions is a major challenge, generating inquiries and reflections that can contribute on the effectiveness of the actions themselves. With the aim on fostering exchange on monitoring and evaluation experiences related to the implementation of healthy settings, the 1 st Brazilian Seminar on Health Promotion Effectiveness was launched in 2005. The program included round table and workshops known as Working Groups (WG) in Brazil. The criteria used to constitute the workshops focused settings as spaces of circulation and living as an intrinsic connection to lifestyles and conditions, as well as to social and/or environmental risk factors associated with groups living in these settings day after day. Focusing on evaluation as an activity that generates knowledge, this article highlights and stimulates the discussion about some major issues arising from the theoretical-methodological approach and the discussions developed in the workshops. The debates carried out during the Seminar illustrated the different perceptions and views of the social players involved in implementation and evaluation of H P practices, disclosing a multiplicity of meanings. It became clear that procedures are needed to document a future maturation of concepts and methods, in combination with further in-depth theoretical discussion.

Percepções de gerentes sobre o papel gerencial em unidades básicas de saúde após capacitação na região sul da cidade de São Paulo / Manager's perception on managerial role basic health units after capacity building course in Southern São Paulo city

No processo de consolidação do SUS, na cidade de São Paulo, a descentralização compreendeu a criação de 39 Distritos de Saúde e a capacitação em gerência de unidades básicas de saúde surgiu como uma das propostas de reorganização dos serviços. O I curso de Especialização em Gerência de Unidades Básicas de Saúde do SUS / SMS-SP – GERUS – foi desenvolvido, em 2002, na região sul da cidade, pela Secretaria Municipal da Saúde e pela Faculdade de Saúde Pública / USP. Os objetivos deste estudo foram conhecer as percepções dos gerentes sobre o papel da gerência das unidades básicas de saúde, numa região de mananciais, populosa, com problemas de infra-estrutura e de exclusão social e analisar as contribuições do GERUS no desenvolvimento de capacidades dos gerentes.

A construção do painel de monitoramento das condições de vida e saúde e da situação dos serviços de saúde da Secretaria Municipal de Saúde de São Paulo: para além das normas / The panel construction monitoring living conditions and health status and health services of the Municipal Health Department, in addition to the standards

Apresenta estudo sobre a construção do Painel de Monitoramento que vem contribuir para definição de uma política local mais autônoma, incorporando práticas de democratização da gestão, buscando criar uma cultura política com novas formas de relação entre os diferentes níveis de governo e de cooperação e articulação no desenvolvimento de estratégias coletivas. Este processo busca integrar a produção da informação com seu uso nos diferentes níveis dos serviços de saúde.

Agendas urbanas intersetoriais em quatro cidades de São Paulo / Intersetorial urban agendas based on four cities in São Paulo

Este artigo visa analisar o processo de implementação e avaliação de projetos de melhoria da qualidade de vida, ponto de vista dos gestores municipais brasileiros, que têm buscado alternativas para a prática da gestão local. Optou-se por identificar a percepção de gestores, representantes do poder executivo local, prefeitos, secretários de governo e coordenadores, identificados como atores-chave importantes na implementação de projetos de melhoria de qualidade de vida em quatro municípios do Estado de São Paulo/Brasil. Foram feitas entrevistas individuais e em profundidade, com roteiro semi-estruturado. A análise dos quatro projetos de melhoria de qualidade de vida na cidade mostra que o processo de municipalização e descentralização da gestão, que vem sendo impulsionado no Brasil vem contribuindo para definir uma política local mais autônoma, para criar novas instâncias de decisão, incorporando práticas de controle social e de democratização da gestão. Porém, ainda existem muitas limitações no que se refere à incorporação da avaliação, como elemento retro-alimentador, no planejamento das ações e da prática participativa.