Abstract

Health Promotion consists of individual and group strategies to achieve equity and reduce risks related to the Social Determinants of Health. This study aims to analyze the Capacity for Change and Health Advocacy domains of the CompHP in the reality of a Multidisciplinary Residency Program in Family and Community Health. This qualitative exploratory research was conducted with twenty-one participants. Data were interpreted through Discourse Analysis under the lens of Depth Hermeneutics. In the capacity for change, we identified that promoting healthy lifestyles is insufficient to develop autonomous and emancipated individuals in the search for decent living conditions. Concerning health advocacy, residents guide clients on the importance of popular participation in spaces intended for social control in Primary Health Care.

Key words:
Empowerment; Health Promotion; Continuing Education; Competency-Based Education

Introduction

Health Promotion (HP) consists of individual and group strategies to achieve equity, quality of life, and lower risks and vulnerabilities related to the Social Determinants of Health (SDH). To this end, it articulates actions with the Health Care Network (RAS) and social protection and involves existing policies and technologies. It also considers the subjects’ autonomy and uniqueness in their territories related to their social, economic, political, and cultural context¹1 Brasil. Ministério da Saúde (MS). Política Nacional de Promoção da Saúde: PNPS: Anexo I da Portaria de Consolidação nº 2, de 28 de setembro de 2017, que consolida as normas sobre as políticas nacionais de saúde do SUS. Brasília: Editora do Ministério da Saúde; 2018..

In Brazil, the Ministry of Health started a broad debate in 2005 to guide on the importance of incorporating HP into the daily practice of health services. This process resulted in elaborating the National Health Promotion Policy (PNPS)²2 Bezerra IMP, Sorpreso ICE. Conceitos de saúde e movimentos de promoção da saúde em busca da reorientação de práticas. J Hum Growth Dev 2016; 26(1):11-16.. The institutionalization of this policy legitimized the State’s commitment to promoting and qualifying HP actions, becoming part of the strategic agenda of managers and expanding the public policies’ perspectives¹1 Brasil. Ministério da Saúde (MS). Política Nacional de Promoção da Saúde: PNPS: Anexo I da Portaria de Consolidação nº 2, de 28 de setembro de 2017, que consolida as normas sobre as políticas nacionais de saúde do SUS. Brasília: Editora do Ministério da Saúde; 2018..

However, effectively incorporating the PNPS into the daily practices of the Unified Health System (SUS) also requires reorganizing the training of health professionals. The Family Health Strategy (ESF) has been identified as an essential alternative for implementing and qualifying HP actions. Among its potentialities is the shift of a paradigm from the perspective centered on the individual disease toward a conception of comprehensive care for the family’s health. Thus, it favors care longitudinality without disregarding the impacts of health determinants and conditions on the health-disease binomial³3 Puttini RF, Pereira Junior A, Oliveira LR. Modelos explicativos em Saúde Coletiva: abordagem biopsicossocial e auto-organização. Physis 2010; 20(3):753-767..

The Multidisciplinary Residency in Family and Community Health (RMSFC) stands out in the ESF context by promoting meaningful change and the development of professional competencies. The RMSFC aims to reconfigure practices oriented towards the SUS reality in an interprofessional action and develop competencies and attitudes centered on the health needs of populations⁴4 Silva JC, Contim D, Ohl RIB, Chavaglia SRB, Amaral EM. Percepção dos residentes sobre sua atuação no programa de residência multiprofissional. Acta Paul Enferm 2015; 28(2):132-138.^,55 Zapatka SA, Conelius J, Edwards J, Meyer E, Brienza R. Pioneerina primary care adult nurse practitioner interprofessional fellowship. J Nurse Pract 2014; 10(6):378-386..

The project titled “Developing Competencies and Professional Standards for Health Promotion Capacity Building in Europe” (CompHP)⁶6 Speller V, Parish R, Davison H, Zilnyk A. The CompHP Professional Standards for Health Promotion Handbook. Paris: IUHPE; 2012. was proposed to systematize and guide the incorporation of HP competencies into the reality of services. CompHP comprises nine domains: Health Advocacy, Possibility for Changes and Mediation Through Partnerships, Leadership, Communication, Diagnosis, Planning, Implementation, and Evaluation and Research. It also has a set of values and ethical principles that should underpin the actions and competencies to be developed in HP⁷7 Dempsey C, Barry MM, Battel-Kirk B, Allegrante JP, Arroyo HVA, Hyndman B. The CompHP Core Competences Framework for Health Promotion Handbook. Paris: IUPES; 2011.^,88 Pinheiro DGM, Scabar TG, Maeda ST, Fracolli LA, Pelicioni MCF, Chiesa AM. Competências em promoção da saúde: desafios da formação. Saude Soc 2015; 24(1):180-188..

The authors point out that Health Promotion Competencies (HPC) models bring directly or indirectly the international consensus related to CompHP⁹9 Silva KL, Araújo FL, Santos FBO, Andrade AM, Basilio NC, Sena RR. O que vem se falando por aí em competências no ensino da promoção da saúde na formação do enfermeiro? ABCS Health Sci 2015; 40(3):286-293.. Moreover, studies indicate that Brazilian professional training models can benefit significantly from the CompHP proposal⁸8 Pinheiro DGM, Scabar TG, Maeda ST, Fracolli LA, Pelicioni MCF, Chiesa AM. Competências em promoção da saúde: desafios da formação. Saude Soc 2015; 24(1):180-188.^,1010 Dias S, Gama A. Ensino da Promoção da Saúde em pós-graduação em saúde pública internacional no contexto do processo de Bolonha. Saude Soc 2016; 25(3):771-785.. There is evidence of the importance of reorienting professional training towards HPC, emphasizing the CompHP reference as a guide for training health workers¹¹11 Xavier SPL, Pereira AP, Moreira MRC, Martins AKL, Ferreira HS, Machado MFAS. Competências em promoção à saúde à luz do projeto competencies health promotion (comphp): uma revisão integrativa. Cien Cuid Saude 2019; 18(1):1-8..

We highlight two main competencies proposed by CompHP. The first is the “capacity for change”, which means enabling individuals and the community to build competencies that favor their health, besides using health promotion approaches that support empowerment, leadership, and equity and the construction of capacities for action in health promotion¹²12 Battel-Kirk B, Barry MM. Developing competency - based accreditation for health promotion in Europe. Rev Med 2013; 92(2):87-96.. The second is “health advocacy”, which focuses on claiming better health conditions and quality of life for individuals and communities¹²12 Battel-Kirk B, Barry MM. Developing competency - based accreditation for health promotion in Europe. Rev Med 2013; 92(2):87-96.. Both competencies underlie the political-social axis related to the empowerment of individuals on decisions regarding their health and the search for more equitable public policies¹²12 Battel-Kirk B, Barry MM. Developing competency - based accreditation for health promotion in Europe. Rev Med 2013; 92(2):87-96..

Professionals working in Primary Health Care (PHC) often reveal the HP concept restrictively and with difficulties in societal aspects to understand and actively participate in the health process and modify their surrounding environment. Data indicate that the concepts of empowerment, participation, and social control in HP actions are minimally mentioned by health professionals¹³13 Farias JM, Minghelli LC, Soratto J. Promoção da saúde: discursos e concepções na atenção primária à saúde. Cad Saude Colet 2020; 28(3):381-389..

In this sense, new discussions regarding empowerment and community development in the context of HP involving Continuing Health Education Programs (EPS) are suggested. Furthermore, we recommend exploring professionals’ knowledge and practice regarding their actions’ effectiveness to contribute to the reflection and reconstruction of their practices¹⁴14 Souza AM, Tholl AD, Córdova FP, Heidemann, ITS, Boehs AE, Nitschke RG. Aplicabilidade prática do empowerment nas estratégias de promoção da saúde. Cien Saude Colet 2014; 19(7):2265-2276..

In Ceará, Brazil, the RMSFC, coordinated by the School of Public Health of Ceará (ESP/CE), aims at training/qualifying different professional categories within the PHC as a residency. Work-mediated education prepares workers to operate in the reality of the SUS from a perspective of interprofessionality, intersectoriality, and comprehensiveness¹⁵15 Arruda GM. Colaboração e educação interprofissional na pós-graduação em saúde: estudo de caso da residência multiprofissional em saúde da família [dissertação]. Fortaleza: Universidade Federal do Ceará; 2015..

ESP/CE’s RMSFC Program associates training with professional activity in the health service, oriented under the SUS principles and guidelines and per local and regional needs and conditionalities. As a result, the RMSFC have already reached the potential for change, such as developing team accountability actions regarding care and resolving health problems¹⁶16 Casanova IA, Batista NA, Moreno LRA. Educação Interprofissional e a prática compartilhada em programas de residência multiprofissional em Saúde. Interface (Botucatu) 2018; 22(Supl. 1):1325-1337.^,1717 Carnaúba JP, Ferreira MJM. Competências em promoção da saúde na residência multiprofissional: domínios Diagnóstico; Planejamento; Implementação; e Avaliação e Pesquisa. Interface (Botucatu) 2022; 26(Supl. 1):e210544..

Despite being an essential training and professional qualification center for Public Health in the Northeast, few studies address the development of Health Promotion Competencies (HPC) in professional training within the RMSFC of Ceará. These studies are even scarcer when focused on analyzing the Capacity for Change and Health Advocacy domains¹⁸18 Carvalho PO, Andrade LS, Oliveira WA, Masson L, Silva JL, Silva MA. Competências essenciais de promoção da saúde na formação do enfermeiro: revisão integrativa. Acta Paul Enferm 2021; 34:eAPE02753.. Given the above, the present study aims to analyze the Capacity for Change and Health Advocacy of the CompHP in the reality of an RMSFC.

Methods

This qualitative, exploratory study is based on the theoretical framework of the Core Health Promotion Competencies of the CompHP⁷7 Dempsey C, Barry MM, Battel-Kirk B, Allegrante JP, Arroyo HVA, Hyndman B. The CompHP Core Competences Framework for Health Promotion Handbook. Paris: IUPES; 2011.. It was conducted from June to August 2019 and investigated the RMSFC program offered by ESP/CE.

Residents (R), Preceptors (P), and Tutors (T) participated in the study, totaling twenty-one participants. The professional category of the tutors consisted of a nurse and a physical educator, both Family Health experts. The Preceptors were trained according to the professional category of the residents: psychology, social assistance, nursing, physiotherapy, dentistry, and nutrition. Preceptors and tutors had at least two years of professional experience in residency, while residents were in their second training year.

Two municipalities were selected to conduct this research. Thus, the criterion adopted to choose the assigned settings was having resident professionals in their second training year (R2). Considering these factors, we selected Quixadá and Quixeramobim, both bordering municipalities located in the Central Hinterland of the state of Ceará.

As inclusion criteria for residents, preceptors, and tutors, we opted for professionals who were at least in their second work year regarding the RMSFC of ESP/CE and were in full professional practice when conducting fieldwork. Thus, the universe of research subjects counted on the participation of 21 individuals.

In Quixeramobim, data were collected with seven residents, four center preceptors, and one field preceptor. In Quixadá, data were collected with four residents, two center preceptors, and one field preceptor. Finally, two ESP/CE tutors completed the group of research participants.

Three techniques were adopted in this research to acquire empirical material. Initially, document analysis was conducted to gather evidence for the theoretical-conceptual foundation. In this process, we resorted to the analysis of the Pedagogical Political Project (PPP) and bibliographic materials used as a reference for training residents. Next, five Focus Groups (FG) were held to promote debate and exchange of experiences among study participants¹⁹19 Barbour R. Grupos focais. Porto Alegre: Artmed; 2009.. Finally, after identifying gaps in the corpus of the assembled text, four more semi-structured interviews were held, two with residents, one with a tutor, and another with a preceptor²⁰20 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde.14ª ed. São Pulo: Hucitec; 2014..

Moreover, the approximation with the study object was grounded on the authors’ previous experiences, as both had been residents of the Multidisciplinary Family Health Program. However, during the research, they were no longer included in this formative process, and there were no links with the ESP/CE. We employed the Depth Hermeneutics (DH)²¹21 Thompson JB. Ideologia e cultura moderna: teoria social crítica na era dos meios de comunicação. 9ª ed. Petrópolis: Vozes; 2011. as a theoretical foundation to interpret the qualitative material, which was justified by the possibility of deepening the symbolic universe produced by the language of subjects included in a specific socio-historical context²¹21 Thompson JB. Ideologia e cultura moderna: teoria social crítica na era dos meios de comunicação. 9ª ed. Petrópolis: Vozes; 2011..

According to the DH, the first analysis phase consists of socio-historical analysis, which considers that symbolic formations are built in a typical social and historical context²¹21 Thompson JB. Ideologia e cultura moderna: teoria social crítica na era dos meios de comunicação. 9ª ed. Petrópolis: Vozes; 2011.. To this end, after the transcriptions, we thoroughly read the qualitative material to understand the statements at hand and relate them to social and historical contexts. This process was supported by a theoretical deepening vis-à-vis the documents and materials that underlie the formative process of this RMSFC.

Then, we proceed with the formal or discursive analysis, which addresses the complex symbolic formations that permeate the social fields from which something is enunciated or manifested²¹21 Thompson JB. Ideologia e cultura moderna: teoria social crítica na era dos meios de comunicação. 9ª ed. Petrópolis: Vozes; 2011.. In this sense, Discourse Analysis (DA) was adopted as an interpretation method to seek the meaning and the content of a text²²22 Careganato RCA, Mutti R. Pesquisa qualitativa: análise de discurso versus análise de conteúdo. Texto Contexto Enferm 2006; 15(4):679-684.. In this research, the DA was performed from the social and historical contexts that permeated the participants’ statements, critically and aligned with the CompHP⁷7 Dempsey C, Barry MM, Battel-Kirk B, Allegrante JP, Arroyo HVA, Hyndman B. The CompHP Core Competences Framework for Health Promotion Handbook. Paris: IUPES; 2011. and DH²¹21 Thompson JB. Ideologia e cultura moderna: teoria social crítica na era dos meios de comunicação. 9ª ed. Petrópolis: Vozes; 2011. theoretical-methodological framework. Finally, the study’s stakeholders agreed that the statements arising from the transcripts would be processed collectively.

The interpretation/reinterpretation phase permeates the entire DH process through the synthesis and reconstruction of probable meanings; that is, an explanatory interpretation of symbolic forms. In this sense, when using the DH framework, we interpret something that individuals have previously interpreted and (re) construct a new meaning that may be different from the one initially conferred²¹21 Thompson JB. Ideologia e cultura moderna: teoria social crítica na era dos meios de comunicação. 9ª ed. Petrópolis: Vozes; 2011..

The study was conducted under Resolution No. 510/2016 of the National Health Council linked to the Ministry of Health²³23 Brasil. Ministério da Saúde (MS). Conselho Nacional de Saúde (CNS). Resolução nº 510, de 7 de abril de 2016. Dispõe sobre as normas aplicáveis a pesquisas em Ciências Humanas e Sociais. Diário Oficial da União 2016; 24 maio. and approved by the Research Ethics Committee (CEP) of the Federal University of Ceará, under Opinion No. 3.313.043.

Results and discussion

Capacity for change

In the domain related to the capacity for change in CompHP⁷7 Dempsey C, Barry MM, Battel-Kirk B, Allegrante JP, Arroyo HVA, Hyndman B. The CompHP Core Competences Framework for Health Promotion Handbook. Paris: IUPES; 2011., our study identified the following competencies: carrying out actions that seek empowerment; promoting the development of communities, favoring popular participation and the development of capacities to produce actions in HP, and helping the development of individual competencies that contribute to improving health:

In light of the theoretical-methodological framework of Depth Hermeneutics, we can understand that discourse analysis occurs in an intrinsic relationship between the symbolic universe and concrete reality²¹21 Thompson JB. Ideologia e cultura moderna: teoria social crítica na era dos meios de comunicação. 9ª ed. Petrópolis: Vozes; 2011.. This conceptual basis was essential for us to analyze how dimensions in the field of meanings, such as empowerment and shared responsibility, are mediated and materialized in professional practices. Silva et al.²⁴24 Silva KVLG, Gonçalves GAA, Santos SB, Machado MFAS, Rebouças CBA, Silva VM, Ximenes LB. Formação de adolescentes multiplicadores na perspectiva das competências da promoção da saúde. Rev Bras Enferm 2018; 71(1):98-105. show the capacity for change identified from the participation of stakeholders in the HP actions performed amid the interlocution between meanings and practices, which evidenced a willingness to learn and generate autonomy and empowerment in the decisions of these individuals. In another research, the capacity for change was considered incipient and fragmented. However, the HP actions expanded the participants’ access and empowerment²⁵25 Tusset D, Nogueira JAD, Rocha DG, Rezende R. Análise das competências em Promoção da Saúde a partir do marco legal e dos discursos dos profissionais que implementam o programa saúde na escola no Distrito Federal. Tempus Actas Saude Colet 2015; 9(1):189-204..

Residents see the notion of empowerment as a way to stimulate the clients’ autonomy regarding good decisions for their health. Also, the term “empower” can be understood as a way to sensitize people on decision-making to seek the resolution of concrete problems aligned with the health needs of individuals.

Regarding the capacity for change domain⁷7 Dempsey C, Barry MM, Battel-Kirk B, Allegrante JP, Arroyo HVA, Hyndman B. The CompHP Core Competences Framework for Health Promotion Handbook. Paris: IUPES; 2011., empowerment is associated with promoting equity and developing public policies that collaborate with the population’s health, helping to face the SDHs. In this understanding, HP cannot be based only on the idea that subjects can self-regulate and manage their health. Conditions related to food, healthy environments, and access to information exceed healthy lifestyle habits, requiring public policies and access to services that respond effectively to health needs²⁶26 Furtado MA, Szapiro AM. Política Nacional de Promoção da Saúde: os dilemas da autonomização. Saude Soc 2016; 25(2):277-289..

The autonomy concept is rooted in the freedom culture, in which all human beings can choose and adopt ways of life. However, we should understand that, under the theoretical framework of DH, such choices are limited to the socio-historical context of inequalities designed in the capitalist society’s core²¹21 Thompson JB. Ideologia e cultura moderna: teoria social crítica na era dos meios de comunicação. 9ª ed. Petrópolis: Vozes; 2011.. Thus, it becomes easier to understand that issues related to well-being transcend the health sector and depend on better living conditions. In this sense, HP conceptions are influenced by neoliberalism, in which the power to choose is taken as a justification to legitimize the insufficient state public policies²⁶26 Furtado MA, Szapiro AM. Política Nacional de Promoção da Saúde: os dilemas da autonomização. Saude Soc 2016; 25(2):277-289.. Limiting HP to the concept of educating for acquiring healthy lifestyle habits reduces the superficiality of discussions about public policies that involve the health-disease process²⁶26 Furtado MA, Szapiro AM. Política Nacional de Promoção da Saúde: os dilemas da autonomização. Saude Soc 2016; 25(2):277-289..

Involving the population is fundamental for developing autonomy. In this sense, performing educational activities encourages popular participation and community empowerment:

Residents, preceptors, and tutors realize the importance of involving the population so that educational activities are really apprehended. To this end, they consider that these actions should be developed dynamically, playfully, and based on individual needs.

Health education favors self-care and individual and collective health management. It does not distance clients but links them to units²⁷27 Figueira AB, Barlem ELD, Tomaschewski-Barlem JG, Dalmolin GL, Amarijo CL, Ferreira AG. Actions for health advocacy and user empowerment by nurses of the Family Health Strategy. Rev Esc Enferm USP 2018; 52:e03337..

Pedagogical practices can provide dialogue and debate, leading professionals and clients to build substantial autonomy. In this sense, using games and dynamics enables the involvement and awakening of the participants’ emotions and experiences²⁸28 Almeida ER, Moutinho CB, Leite MTS. Family health nurses' teaching practice in the health education development. Interface (Botucatu) 2016; 20(57):389-401..

Thus, it is necessary to support individuals and communities in which they can be aware of their potential, emphasizing widespread knowledge and self-care. Thus, training people who develop autonomy over their ways of living is possible, which is the direction for HP actions²⁹29 Haeser LM, Buchele F, Brzozowski FS. Considerações sobre a autonomia e a promoção da saúde. Physis 2012; 22(2):605-620.:

The reports show the use of dynamics and other strategies to facilitate the understanding and participation of clients to favor the acquisition and sharing of knowledge. Moreover, HP activities undertaken by residents are more frequent, contributing to the continuity of actions and expanding community participation.

As residents are not the professionals fully responsible for services in the ESF, they have more time to develop educational actions, which differs them from service professionals, who have a greater demand for care and meeting goals. Thus, the health education actions conducted in the residency are systematic, allowing their continuity and, consequently, the clients’ acquisition of knowledge and more robust information.

Health education activities are essential as they help build knowledge and facilitate healthier decision-making by individuals. However, overcoming the superficial conception of individuals who only need to be educated is essential, instigating the development of an emancipatory autonomy, which leads individuals to reflect on their realities and seek better living conditions from more egalitarian public policies²⁹29 Haeser LM, Buchele F, Brzozowski FS. Considerações sobre a autonomia e a promoção da saúde. Physis 2012; 22(2):605-620..

In the residency training process, it is necessary to make residents aware of the need to promote health education activities that can transcend teaching healthy lifestyle habits. Thus, actions are needed to promote reflection and criticality on citizenship and social participation to improve existing services and lead them to develop a critical awareness vis-à-vis their desires and life habits.

Health advocacy

The competencies in the Health Advocacy domain are related to using techniques to claim better health conditions; promoting engagement with influential people of the communities; deepening public opinion regarding health matters; requesting from the sectors responsible for developing public policies’ actions that bring positive impacts; encourage communities to articulate to respond to their needs for HP actions⁷7 Dempsey C, Barry MM, Battel-Kirk B, Allegrante JP, Arroyo HVA, Hyndman B. The CompHP Core Competences Framework for Health Promotion Handbook. Paris: IUPES; 2011.:

The Health Advocacy domain linked to the construction of user citizenship and popular participation was noticed in the discourses. In this sense, residents encourage clients’ participation in the Local Health Councils (CLS) and health conferences as active voices to claim better conditions regarding health services³⁰30 Gandra EC, Silva KL. Advocacia para a promoção da saúde: sentidos e abordagens na formação do enfermeiro. REME 2019; 23:e-1247., and by analyzing the understanding of health advocacy, they unveiled the term as protection of the SUS as a universal system, valuing equity and social justice. Moreover, the authors emphasize popular participation as an essential basis for making clients and professionals jointly responsible for the struggle for their rights.

Thus, from the discursive analysis conducted through the theoretical framework of Depth Hermeneutics, we can understand the relevance of the different social stakeholders in the formulation of discourses that seek to “overcome domination relationships”²¹21 Thompson JB. Ideologia e cultura moderna: teoria social crítica na era dos meios de comunicação. 9ª ed. Petrópolis: Vozes; 2011.(p.76). By encouraging community participation in the CLS, residents fulfill the duty to promote knowledge of the actual role of health councils. Also, through the political axis in the RMSFC, clients are instigated to claim better conditions of care in health services, strengthening their leading role vis-à-vis social control.

The residents’ agendas include actions that strengthen social control and encourage clients’ participation in the activities they must comply. Furthermore, preceptors encourage health advocacy by sensitizing them about the importance of encouraging clients to be present at health conferences as a place of active voice.

Residents are also encouraged to establish groups and waiting rooms with the themes of clients’ rights and needs. Preceptors also recognize that developing activities that guide clients regarding their rights and needs is essential.

Communication is noteworthy as a significant factor in health advocacy. Dialogue between clients and professionals assists the population with decisions about their health, rights, and duties. In this sense, communication is essential to empower the community to demand HP actions from the professionals³¹31 Miwa MJ, Serapioni M, Ventura CAA. A presença invisível dos conselhos locais de saúde. Saude Soc 2017; 26(2):411-423..

The results of this study corroborate with Figueira et al.²⁷27 Figueira AB, Barlem ELD, Tomaschewski-Barlem JG, Dalmolin GL, Amarijo CL, Ferreira AG. Actions for health advocacy and user empowerment by nurses of the Family Health Strategy. Rev Esc Enferm USP 2018; 52:e03337. by considering education practices with citizenship-related themes as strengthening health advocacy in the ESF environment. The authors emphasize that encouraging knowledge exchange between professionals and clients improves the subjects’ understanding of their context and gives a space to claim better health conditions.

Despite all the potentialities identified in the RMSFC formative process for developing health advocacy competencies, some areas for improvement are still noticed. In this sense, some realities require building and strengthening spaces where clients feel comfortable expressing their opinions and acting as enforcers and co-participants in the public debate and state management:

The first statement brings a very restricted health advocacy conception as if the availability of a CLS was the only way to exercise this domain. If there were no CLS in the area where residents operate, it would be essential to raise awareness to reactivate it. Moreover, the lack of a CLS does not invalidate holding activities that promote and strengthen social participation and the empowerment of clients since residents can work on this political axis and the knowledge of clients about exercising their citizenship through the actions in service.

In this treadmill, this account brings to light a significant problem in several locations: the lack and inoperability of the CLS. People manifest a sense of non-belonging to this equipment, in which the community often needs to be more involved in establishing the Councils³²32 Lisboa EA, Sodré F, Araújo MD, Quintanilha BC, Luiz SG. Conselhos locais de saúde: caminhos e (des)caminhos da participação social. Trab Educ Saude 2016; 14(3):679-698..

As for the CLS, we have persisting difficulties regarding community participation in these spaces related to the scarcity of information and often the need for more knowledge of the counselors’ role. In this sense, there is a great need to disseminate the CLS actions, recognize clients’ representatives, and increase the training of counselors to perform their activities³²32 Lisboa EA, Sodré F, Araújo MD, Quintanilha BC, Luiz SG. Conselhos locais de saúde: caminhos e (des)caminhos da participação social. Trab Educ Saude 2016; 14(3):679-698.^,3333 Busana JA, Heiddemann ITSB, Wendhausen ALP. Participação popular em um conselho local de saúde: limites e potencialidades. Texto Contexto Enferm 2015; 24(2):442-449..

Moreover, in some cases, the council meetings are kept from the rest of the population, which leads to a lack of CLS visibility. Furthermore, many clients feel dissatisfied with health services, which contributes to the discredit of public policies. The health counselors themselves feel discredited by the population due to the lack of problem resolutions, which results in the population’s lack of participation in these spaces³¹31 Miwa MJ, Serapioni M, Ventura CAA. A presença invisível dos conselhos locais de saúde. Saude Soc 2017; 26(2):411-423.^,3333 Busana JA, Heiddemann ITSB, Wendhausen ALP. Participação popular em um conselho local de saúde: limites e potencialidades. Texto Contexto Enferm 2015; 24(2):442-449..

Despite these limitations, social participation has been essential for elaborating public health policies³²32 Lisboa EA, Sodré F, Araújo MD, Quintanilha BC, Luiz SG. Conselhos locais de saúde: caminhos e (des)caminhos da participação social. Trab Educ Saude 2016; 14(3):679-698.. Still, to strengthen popular participation in these spaces, it is crucial to democratize information more, discuss, and exchange ideas about the relevance of representativeness in decision-making spaces³⁴34 Ferreti F, Ferraz L, Kleba ME, Boccalon B, Amorim DC, Comerlat T. Participação da Comunidade na gestão e controle social da política de saúde. Tempus Actas Saude Colet 2016; 10(3):51-67..

Also was identified the Association of HP actions focused on health advocacy, very much linked to the professional social worker:

The view of a lack of multidisciplinary work is noticeable in the discourse, implying that the HP actions related to health advocacy are exclusive to the social worker. Manfred et al.³⁵35 Manfred ALD, Valera FM, Padoim GAA, Salamon VGF, Castro TC. Reconhecimento dos espaços de atuação do assistente social. Rev Maieutica 2018; 3(1):105-110. argue that this perception may be related to the work performed by the social worker, precisely in mediating people’s access to social rights guaranteed by law, involving several areas such as access to education, housing, social security, and health.

However, the multidisciplinary team should incorporate the actions related to health advocacy. In this case, as Figueira et al.²⁷27 Figueira AB, Barlem ELD, Tomaschewski-Barlem JG, Dalmolin GL, Amarijo CL, Ferreira AG. Actions for health advocacy and user empowerment by nurses of the Family Health Strategy. Rev Esc Enferm USP 2018; 52:e03337. affirm, a relevant strategy to expand the scope of health advocacy actions consists precisely of the multidisciplinary team’s work. In this context, several professionals provide a diverse understanding of the needs of territories, achieve different perspectives, and care more comprehensively, offering actions to defend individuals’ interests.

Moreover, the health advocacy activities conducted by residents were also considered insufficient and “weak”, showing the need to encourage actions in a multidisciplinary way. Also, the need to awaken in these stakeholders the capacity for activities that emphasize popular participation and social control is evident.

Final considerations

In the capacity for change domain, the activities highlighted were the groups and waiting rooms targeting healthy lifestyle habits through playful and dynamic strategies. However, more than just promoting healthy lifestyle habits is required. It is necessary to develop the autonomy of emancipated individuals, with guarantees and dignified living conditions, achieved from public policies aimed at their real needs.

We should mention that residents are more available to conduct actions in health units since they are in the process of health training through work, which leads us to reflect on the need to expand the teams, with health responsibility for a smaller number of households and work based on interdisciplinarity to guarantee comprehensive care.

For the health advocacy domain, residents advise clients on the importance of popular participation in Health Councils and Health Conferences as an active voice for claiming better living conditions. However, the need for Local Health Councils in the community where residents work was seen as a weakness. Moreover, we should have seen the professionals’ performance in encouraging popular participation regarding their rights, and we should have observed their interest in reactivating the Local Health Council.

Finally, our study contributed to unveiling critical interlocution processes between the complex realities that affect daily professional practices within the RMSFC and the complex concept of HPC. Thus, we highlight the need for further research on the development of competencies in professional training and on how professionals are prepared to work in the health services of the SUS.

References

Publication Dates

History