ABSTRACT

This study aims to use analytical tool, the Critical Event Card (CEC), to potentialize the application of scientific knowledge in health promotion to decision making. A workshop and seven interviews with users of knowledge (management representatives, users, and health professionals) were conducted in order to map these critical events related to health promotion. From the workshop were extracted the events related to health promotion that marked the evolution of the intervention in Nova Aliança; and from the interviews, the pre-established codes on the theory present in the CEC: actants/actors, interests, interactions, technical mediation, actions and consequences, using directed content analysis. Three critical events related to health promotion actions were identified: the arrival of the Community Health Workers Program (Pacs); the first Local Council and the implementation of multidisciplinary and medical residency, which were systematized according to the categories presented. It was observed that the present categories made it possible to understand the intervention and that the CEC is a useful tool that can help decision-makers benefit from the scientific knowledge produced.

KEYWORDS
Family Health Strategy; Health promotion; Health evaluation; Translational medical research

Introduction

The need to apply knowledge in practice is not a recent fact, and accompanies the evolution of humanity. As an example, there are the early hunters who succeeded in agriculture and who passed on practical knowledge, which was passed down from generation to generation¹1 Krieger E. A Hipertensao e a Cardiologia Translacional. Rev. Soc. Cardiol. Estado de São Paulo. 2018; 28(1):20-25.. In recent years, researchers and policy makers have been questioning what can be done to integrate and provide an effective bridge between research and practice²2 Martínez-Silveira MS. "Knowledge translation" na área de saúde. In: X Encontro Nacional de Pesquisa em Ciência da Informação; 2016; Salvador. Salvador: PPGCI/UFBA; 2016. p. 4913-4930.^,33 Barbosa L, Pereira Neto A, Barbosa L, et al. Ludwik Fleck (1896-1961) e a translação do conhecimento: considerações sobre a genealogia de um conceito. Saúde debate [internet]. 2017 [acesso em 2019 abr 5]; 41:317-29. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-11042017000500317&lng=pt&tlng=pt.
http://www.scielo.br/scielo.php?script=s... . For Dias⁴4 Dias S, Gama A, Mendão L, et al. Como potenciar a produção e translação de conhecimento na investigação participativa? A experiência de um projeto na área do VIH. SIDA. 2016; 15:47-52., a challenge of public health research is to use the result of scientific research in more effective health actions and policies that meet the real needs of the population.

Thus, the applicability of knowledge in practice is globally recognized as a relevant factor for the improvement of health care assistance⁴4 Dias S, Gama A, Mendão L, et al. Como potenciar a produção e translação de conhecimento na investigação participativa? A experiência de um projeto na área do VIH. SIDA. 2016; 15:47-52., understanding that Knowledge Translation/Transfer (KT) is interactive and dynamic, including synthesis, dissemination, exchange and application of knowledge for health practice, with flexible boundaries between knowledge creation and action development to produce beneficial results for society⁵5 Canadian Institutes of Health Research. Guide to Knowledge Translation Planning at CIHR: integrated and End-of-Grant Approaches [internet]. Ottawa: Canadian Institutes of Health Research; 2012. [acesso em 2018 out 29]. Disponível em: www.cihr-irsc.gc.ca.
www.cihr-irsc.gc.ca... ^,66 Tetroe J. Knowledge Translation at the Canadian Institutes of Health Research: a Primer. Focus. 2007; 18:1-8., that is, it represents the process of putting knowledge into action⁵5 Canadian Institutes of Health Research. Guide to Knowledge Translation Planning at CIHR: integrated and End-of-Grant Approaches [internet]. Ottawa: Canadian Institutes of Health Research; 2012. [acesso em 2018 out 29]. Disponível em: www.cihr-irsc.gc.ca.
www.cihr-irsc.gc.ca... ^,77 Straus SE, Tetroe J, Graham I. Defining knowledge translation. CMAJ [internet]. 2009 [acesso em 2018 out 11]; 181(3-4):165-168. Disponível em: http://www.ncbi.nlm.nih.gov/pubmed/19620273.
http://www.ncbi.nlm.nih.gov/pubmed/19620... .

Over the last decades, one notices the increase in research on how to reduce the gap between practical-political evidence. In this sense, several authors suggest a strategy to potentiate KT by reducing the gap between the knowledge produced and its translation in the resolution of health problems, in the interface with other sectors and to progress in the science and practice of KT in the health area⁸8 Grimshaw JM, Eccles MP, Lavis JN, et al. Knowledge translation of research findings. Implementation Sci. 2012; 7:50.^,99 Kitson A, Brook A, Harvey G, et al. Using Complexity and Network Concepts to Inform Healthcare Knowledge Translation. Kerman Univ Med Sci [internet]. 2017 [acesso em 2018 out 30]; 7(3):231-243. Disponível em: http://ijhpm.com.
http://ijhpm.com... .

One field in which the interface between research and action is already well established is Health Promotion (HP). It aims to empower people to increase control and improve their health, being a concern and a challenge for the field to delineate the contours and appropriate method for research on HP¹⁰10 Squires JE, Graham ID, Hutchinson AM, et al. Identifying the domains of context important to implementation science: a study protocol. Implement Sci [internet]. 2015 [acesso em 2015 out 8]; 10(1):135. Disponível em: http://www.implementationscience.com/content/10/1/135.
http://www.implementationscience.com/con... . Reflecting on the practical dilemmas for HP, Potvin and McQueen¹¹11 Potvin L, McQueen DV, Hall M. Introduction, Aligning Evaluation Research and Health Promotion Values: practices from the Americas. In: Potvin L, McQueen DV, editores. Health Promotion Evaluation Practices in the Americas: values and research. New York: Springer; 2008. p. 1-9. argued about the need for tools to reflect, value and reproduce HP practices.

In this sense, approaches capable of capturing the dynamics of the actors’ actions involved, as well as the interactions that are established in this process of transformation of knowledge into action, are necessary and timely¹²12 Mantoura P, Potvin L. A realist-constructionist perspective on participatory research in health promotion. Health promot. internation. 2013; 28(1):61-72.. Based on the Actor-Network Theory (ANT), it is proposed that the elements of an intervention make up a Sociotechnical Network¹³13 Figueiro AC, Araújo OSR, Hartz Z, et al. A tool for exploring the dynamics of innovative interventions for public health: the critical event card. Int J Public Health. 2017; 62(2):177-186., which create events that change or reinforce the trajectory of an intervention, becoming markers of its evolution¹⁴14 Potvin L, Clavier C. La théorie de l' acteur-réseau. In: Aubry F, Potvin L, editores. Construire l'espace socio-sanitaire: expériences et pratiques de recherche dans la production locale de la santé. Montréal: Presses de l'Université de Montréal; 2012. p. 75-98.^,1515 Pluye P, Potvin L, Denis JL. Making public health programs last: conceptualizing sustainability. Eval Program Plann [internet]. 2004; 27(2):121-33. [acesso em 2019 nov 15]. Disponível em: http://www.equitesante.org/wp-content/uploads/2015/07/1.-Pluye-Potvin-Denis-2004-EPP.pdf.
http://www.equitesante.org/wp-content/up... . However, health interventions are permeated by controversy, which arises from differences between positions, points of view, social and political projects of many actors, or anything else at stake among those involved¹³13 Figueiro AC, Araújo OSR, Hartz Z, et al. A tool for exploring the dynamics of innovative interventions for public health: the critical event card. Int J Public Health. 2017; 62(2):177-186.^,1616 Pluye P, Potvin L, Denis JL, et al. Program sustainability begins with the first events. Eval Program Plann. 2005; 28(2):123-137.. Controversy can destabilize routines and relationships between actors. We call critical events those that are linked to controversy, generate consequences, and lead to the reconfiguration of an intervention¹⁷17 Latour B. Reassembling the social: an introduction to actor-network theory. Oxônia: Oxford University Press; 2005.^,1818 Oliveira SRA. Sustentabilidade da Estratégia Saúde da Família: o caso de um município baiano. [tese]. Salvador: Universidade Federal da Bahia; 2014. 143 p..

Thus, this study aimed to use the analytical tool, the Critical Event Card (CEC), to enhance the application of scientific knowledge about HP in decision making, with a view to contributing to the improvement of the service users’ quality of life.

Methodological procedures

This is an evaluative research based on ANT. From this theory, critical events were captured, considered the unit of study analysis. The period for the accomplishment of the study was 1992, when HP actions were implemented at the Nova Aliança Unit, located in the municipality of Camaçari, metropolitan region of Salvador, until 2017.

Nova Aliança has a unique configuration because it is a school unit, based on the partnership established between the management of Camaçari and the Family Health State Foundation (Fesf) of the State of Bahia. It consists of four family health teams, composed of: physicians, nurses and dentists, who are first year residents (R1) and second year residents (R2). Included in this group are: preceptor of nursing, medicine and dentistry, who work 40 hours a week directly with residents. The Community Health Workers (CHW), nursing technicians, unit manager, general and administrative services make up the municipality’s staff, which is divided into contracts, commissioned positions and public servants.

For data construction, workshop and interviews were carried out. The workshop took place with the three oldest CHW of Nova Aliança and was based on the question: ‘what events has marked the history of this health unit?’, aiming to identify the HP events that has marked the unit.

The interviews took place with the help of a semi-structured script, in which the questions were related to the HP actions implemented in the unit, with seven knowledge users, being a community leader (representing users), a management professional (primary care coordinator), a resident (physician), two preceptors of the residence (medicine and nursing), a municipal server (nursing technician) and a professional at the time of the Traditional Health Unit (nurse). These were selected according to the explicit involvement with the unit. At the end of the interviews, the events related to the HP that marked the intervention, identified in the workshop, were presented, and the interviewees could add other occurrences when they thought relevant. It is relevant to point out that the relationship of these events with the HP was based on the interviewees’ conception of what this concept would become.

Data obtained after semi-structured interviews were fully read, transcribed and analyzed according to content analysis with a targeted approach, as ANT provided the basis for data capture. Through exhaustive reading of the interviews and the identified events, the various pre-established codes from the theory were extracted from the lines: actants/actors, interests, interactions, technical mediation, actions, registrations, place, time and consequences (chart 1)¹⁹19 Oliveira SRA, Medina MG, Figueiró AC, et al. Strategic factors for the sustainability of a health intervention at municipal level of Brazil Fatores estratégicos para a sustentabilidade de uma intervenção na saúde em nível municipal no Brasil Factores estratégicos para la sostenibilidad de una interv. Cad. Saúde Pública [internet]. 2017 [acesso em 2017 ago 4]; 33(7). Disponível em: http://www.scielo.br/pdf/csp/v33n7/1678-4464-csp-33-07-e00063516.pdf.
http://www.scielo.br/pdf/csp/v33n7/1678-... . This movement facilitated the identification of occurrences that were classified as a critical event, enabling the implementation of the CEC. It could only be considered as a critical event if it fulfilled all categories of the card, if it had caused some change in intervention and was preceded by controversy.

This study was conducted following the ethical precepts defined in the current resolutions and was submitted to the Research Ethics Committee – CEP/Aggeu Magalhães Institute – IAM, and approved with CAAE 73416217.3.0000.5190.

Results

With the applicability of the CEC, three critical events linked to the HP were identified that led to changes in the Nova Aliança health unit, namely: Arrival of the Nova Aliança Community Agents Program (Pacs); Implementation of the 1st Local Health Council; and Implementation of the Multiprofessional Residency Program and Family and Community Medicine.

The use of the tool allowed the understanding of each critical event in relation to the development of HP actions. The ‘actants/actors’ who shaped the network in the intervention were both human actors – management professionals, Pacs’ professionals, Family Health Strategy professionals, users, community leaders, residents – as non-humans: scientific knowledge, medical specialties, reception, dialogue, HP concept, health council, residency program, Fesf, among others.

Two non-human actors identified should be highlighted: the residence program and the concept of HP. The residency program through the teaching-service process becomes a facilitator for performing HP actions, discussing the concept of HP from the problematization of social determinants. Besides the social determinants, the residence discusses with its pedagogical body ways to expand access, improving the context of life in the community.

This concept of HP worked by the residence, therefore, goes far beyond the absence of disease, truly acting on social determinants, which would be the conditions of housing, education, basic sanitation, income, work, food and leisure. It cares about social and environmental problems, valuing and encouraging public policies that aim at social transformation.

It is noticed that the participants shared their actions for changes in the policy, practice and provision of health services, and acted as users of knowledge ensuring its use for decision making.

Understanding the action mode of the interventions allowed us to identify the ‘interests’ of the active, which may be convergent or divergent in relation to some actions, including HP actions, depending on the period studied.

It was seen that, in critical event 1, there were opposing interests between community and CHW: while the former valued traditional health facilities and did not support intervention, CHW had an interest in the program, performing various actions without support from municipal management or participation of other team members acting as an aggregating agent, a node in the network.

It is observed that the conflicting interests can be modified depending on the articulations established in the Sociotechnical Network. It is noticed that, in the critical event 2, an alliance between actors was formed by community, professionals of the basic unit and the Pacs, as a result of the action of non-human actor Local Health Council. This articulation was the result of the empowerment of users and a common interest: social changes from the ‘interaction’ between health, community and other sectors. Such statement strengthens the intersectoriality and the actions of HP.

This empowerment of the community gained consistency with the critical event 3, being the multiprofessional residency program and family and community medicine established in that territory from the ‘interest’ between municipal management and Fesf. However, the established network was dismantled from the disinterest of the unit’s servers, initially hindering the realization of the work process and, consequently, HP actions.

It is noticed that the divergence of interests is closely related to context and time. This process of intervention evolution is characterized by controversies and ‘mediators’ that stabilize the network formed from these interactions. It can be highlighted as crucial mediators some management professionals, being also accompanied by their didactic and technological tools, non-human mediators that facilitated the work process and relationships, leading to the sustainability of intervention and advances of HP actions.

Dialogue was also a ‘mediator’ of relationships, being used from tools such as: welcoming and team meeting. Some specific actors, such as the preceptor physician and the new residents, can also be considered mediators for the continuity of the process. With the CEC, it was possible to identify the main weakness points for subsequent decision making, and dialogue is a crucial factor in the implementation of an intervention.

Through interactions and mediations, therefore, relations were improved and the network of allies stabilized, and the actions of the HP were established. It can be identified from the critical event 1: area mapping and statistical map construction; waiting room with lectures; home visits; registration of areas; Elderly group and lectures in the territory. These actions are present in the CEC, which facilitates the evaluation process of decision makers. Among the actions developed related to the critical event 2 were: monthly meetings in the community, survey of problems in the community and proposals for improvement in many areas.

The actions established in Nova Aliança with the residence were: territorialization, user registration, reception of spontaneous demand, home visit, organization of groups and actions aimed at prevention and health promotion, such as: pregnant group, School Health Program (PSE), collective consultation etc. Regardless of all the difficulties encountered, the positive results of the work done in the community by the residency groups also impacted the training process, broadening the integral view of the user by residents and staff. The developed HP groups brought the participation of the users, being often conducted by them.

In addition to the actions evaluated, it is pertinent to bring that every change leads to ‘consequences’, which tells us how important a particular program was. As a ‘consequence’ for intervention from Critical Event 2, we had: a stronger strengthening of social control, improvements (reform) to Nova Aliança unity from the council’s articulations and a strengthening of the community for social change. The consequence category was also evaluated in the study, being identified with the arrival of Pacs: increased vaccination coverage in children, improvement in the health conditions of the population and greater organization of the Pacs work process.

Finally, the ‘consequences’ described in the CEC generated by critical event 3 were numerous. One of the most important was the change of assistance model after the arrival of the residence, breaking with a model in force for more than 30 years, improvement in the work process, improving the reception to users, improvement in the health levels of that population and greater integration with the community.

Discussions

The study aimed to show the use of an analytical tool for identification and analysis of critical events, and its potential for the application of scientific knowledge in decision making. It was found that the analytical categories based on ANT form a set of powerful elements to understand the complexity of interventions and explain the KT process, being an interactive and flexible approach, as has been advocated by KT studies²⁰20 Figueiró AC, Oliveira SRA, Hartz Z, et al. A tool for exploring the dynamics of innovative interventions for public health: the critical event card. Int J Public Health. 2017; 62(2):177-186.^,2121 Paley J, Eva G. Complexity theory as an approach to explanation in healthcare: a critical discussion. Int J Nurs Stud [internet]. 2010 [acesso em 2018 out 30]; 48:269-279. Disponível em: www.elsevier.com/ijns.
www.elsevier.com/ijns... . KT is conceived as a system of actions that operate with the Sociotechnical Network that produces innovations, creates and reconfigures the connections between actors²²22 Tenbensel T. Complexity in health and health care systems. Soc Sci Med [internet]. 2013 [acesso em 2018 out 30]; 93:181-184. Disponível em: http://dx.doi.org/10.1016/j.socscimed.2013.06.017.
http://dx.doi.org/10.1016/j.socscimed.20... .

Observing the findings regarding the actatns/actors, it is clear that the creation of networks and the construction of ‘effective cooperation’ strengthened the relationships between those involved, creating nodes that allowed the application of knowledge related to HP¹⁴14 Potvin L, Clavier C. La théorie de l' acteur-réseau. In: Aubry F, Potvin L, editores. Construire l'espace socio-sanitaire: expériences et pratiques de recherche dans la production locale de la santé. Montréal: Presses de l'Université de Montréal; 2012. p. 75-98.^,2323 Aubry F, Potvin L. Construire l'espace socio-sanitaire: expériences et pratiques de recherche dans la production locale de la santé. Montreal: Presses de l'Université de Montréal; 2012.. The use of ANT has enabled the recognition of actors who relate in Sociotechnical Network. These actors are not only those traditionally involved in the process of knowledge construction, as users already listed in the literature, but a set of entities that, in general, are not considered.

The non-human actor must be pointed out: the concept of HP. By analyzing it, the relationship that interventions have with the time and space in which it develops is observed. According to Latour²⁴24 Latour B. Como prosseguir a tarefa de delinear associações? Configurações. 2006; 2. 11-27., the fact that this concept is traced, generating traces and marks in the intervention, makes it a non-human in the network, and this study is in accordance with what the theory addresses. The initial focus of HP linked to disease prevention and the evolution of the concept to the focus of social determinants brings us consequences in the implementation of promotion actions and networks built from each approach. Valuing this finding, the knowledge itself, technological resources and the whole set of non-human actors interacting and acting within the intervention facilitates KT.

Knowledge occurs in an active and multidirectional flow of information²⁵25 Jacobson N, Butterhill D, Goering P. Developing a framework for knowledge translation. J. Health Sci Res Policy. 2003; 8:94-9., where interactions and exchanges are established among a wide range of interested parties; understanding such applicability in the intervention, based on the complex interaction between all process actors, with multiple factors determining and interfering with the research-based knowledge found on the path to practice²⁶26 Oliveira SRA. Redes sociotécnicas e translação do conhecimento. Anais do IHMT. 2018; 17: supl. 2. p. 97-104..

Understanding ANT interventions made it possible to initially connect distant universes, negotiating interests in the (re)configuration of their identities and relationships, perceiving KT as a distinct entity. The interactions evidenced in the critical events were the product of alliances that interfere and suffer interference from relationships that are aligned due to common goals²⁷27 Callon M. Some elements of a sociology of translation: domestication of the scallops and the fishermen of St Brieuc Bay. In: Law J, editor. Power, action and belief: a new sociology of knowledge? [internet]. London: Routledge; 1986. p. 196-223. [acesso em 2017 jul 25]. Disponível em: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.614.3046&rep=rep1&type=pd.
http://citeseerx.ist.psu.edu/viewdoc/dow... .

The mediators identified here were able to transform, translate, distort and modify meanings²⁸28 Latour B. A esperança de Pandora. Bauru: Edusc; 2001., enhancing actions within a universe, a network consisting of a heterogeneity of mediators. In the occurrence of actions resulting from critical events, it was indispensable to measure ‘dialogue’, for example, which allowed the creation of bonds that did not exist²⁹29 Bursztyn DC, Delgado PG, Costa D, et al. Conhecimento Compartilhado e Estratégias Colaborativas de Pesquisa na Atenção Psicossocial Research Strategies in Psychosocial. ECOS. 2016; 7(1):68-77..

Thus, it is understood that the CEC analytical tool can contribute to the action or application cycle proposed by Graham, as it allows understanding the interventions, their interactions with the local context, as well as the possible barriers and facilitators in the process of translating this knowledge to clinical practice¹⁸18 Oliveira SRA. Sustentabilidade da Estratégia Saúde da Família: o caso de um município baiano. [tese]. Salvador: Universidade Federal da Bahia; 2014. 143 p.^,3030 Park JS, Moore JE, Sayal R, et al. Evaluation of the "Foundations in Knowledge Translation" training initiative: preparing end users to practice KT. Implement Sci [internet]. 2018 [acesso em 2018 ago 14]; 13(1):63. Disponível em: https://implementationscience.biomedcentral.com/articles/10.1186/s13012-018-0755-4.
https://implementationscience.biomedcent... . The need to use tools that translate the results of investigations into language and formats directed to decision-making should be a precept adopted by knowledge users. It is known that the use of strategies ensures a more relevant research and better use of the results of the investment, as well as facilitate the expansion of the network of allies.

It is also appropriate to clarify that translational research is useful for decision-makers to benefit from the scientific knowledge produced³¹31 Siron S, Dagenais C, Ridde V. What research tells us about knowledge transfer strategies to improve public health in low-income countries: a scoping review. Int J Public Health [internet]. 2015 [acesso em 2018 ago 13]; 60(7):849-863. Disponível em: http://link.springer.com/10.1007/s00038-015-0716-5.
http://link.springer.com/10.1007/s00038-... , evaluating beyond the effectiveness of interventions. It is also understood how factors can enhance the uses of these interventions in real contexts³²32 Nyström ME, Karltun J, Keller C, et al. Collaborative and partnership research for improvement of health and social services: researcher's experiences from 20 projects. Heal Res. policy Syst. [internet]. 2018 [acesso em 2018 ago 14]; 16(1):46. Disponível em: http://www.ncbi.nlm.nih.gov/pubmed/29843735.
http://www.ncbi.nlm.nih.gov/pubmed/29843... . This field also involves collaboration among all knowledge users, including researchers (within and among disciplines), policy makers and managers, health care providers and consumers (that is, patients, family and informal caregivers)⁸8 Grimshaw JM, Eccles MP, Lavis JN, et al. Knowledge translation of research findings. Implementation Sci. 2012; 7:50.^,3333 Peters DH, Tran NT, Adam T. A practical guide implementation research in health ©who [internet]. 2013. [acesso em 2018 ago 13]. Disponível em: www.who.int.
www.who.int... .

Another point that can be emphasized is that the learning potential of organizations can be improved by allowing them to assimilate and apply knowledge³⁴34 Proctor EK, Landsverk J, Baumann AA, et al. The implementation research institute: training mental health implementation researchers in the United States. Implement Sci [internet]. 2013 [acesso em 2018 ago 14]; 8(1):105. Disponível em: http://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-8-105.
http://implementationscience.biomedcentr... . As stated by Proctor et al.³⁴34 Proctor EK, Landsverk J, Baumann AA, et al. The implementation research institute: training mental health implementation researchers in the United States. Implement Sci [internet]. 2013 [acesso em 2018 ago 14]; 8(1):105. Disponível em: http://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-8-105.
http://implementationscience.biomedcentr... , it is necessary, in order to carry out translational research, both a research and theory body that informs effective implementation processes as well as the research workforce capable of conducting rigorous and relevant studies.

Final considerations

It is understood that, by analyzing analytical tools such as CEC, one can find ways to apply knowledge and, consequently, improve the use of research results in practice. Thus, it is emphasized that the science of implementation has a practical relevance. In this sense, the scope of this discussion is to overcome the few researches carried out in Latin America and to call the various actors in the national scenario, regarding translational research, to establish a distinct look at the application of knowledge that can improve health outcomes.

References

Publication Dates

History