Introduction

Health promotion emerged as a key guide to paradigmatic changes related to individual and collective health in the twentieth century. This comprehensive concept gained more impact after the Ottawa Charter for Health Promotion in 1986, when health was recognized in a multidimensional context that included conditioning resources such as peace, habitation, education, food, income, a stable ecosystem, sustainable resources, social justice and equity.¹

In the nineteenth century, Frederich Engels and Rudolf Virchow initiated studies that highlighted the Social Determinants of Health (SDH) as the main tool to enable conditions and resources for good health. The SDH were reaffirmed by Lalonde in 1974 and more recently by Canadian researchers, who defined it as the economic and social conditions that shape the health of people, community and territories.²

This study adopted the definition of Health Promotion as the “process of enabling individuals, families, and communities to improve their quality of life and health, including their participation in the control of this process”.^1:1 Additionally, this study considered the SDH as the main resource to work in health improvement and help families play a greater role in the control of their health. Therefore, the aim of health promotion is to empower people to become the protagonists of their own health.

In Brazil, the creation of the Unified National Health System (Sistema Único de Saúde – SUS) was made possible by the Sanitary Reform and the Brazilian Constitution of 1988. After this landmark, Brazil started to change its concept of health to a comprehensive perception of Health Promotion and established the main guidelines to organize Primary Care in the Healthcare Networks (Redes de Atenção à Saúde – RAS).³

The National Primary Health Care Policy (Política Nacional de Atenção Básica – PNAB) and the National Health Promotion Policy (Política Nacional de Promoção da Saúde – PNAPS) use Family Health (FH) as their major strategy to expand and consolidate their Health Promotion interventions. Those are applied in the context of Primary Health Care (PHC), which is a similar term to Basic Health Care (BHC) used in Brazil and characterized as the front door for health care services offered by SUS.³^-⁴Thus, the integration between PHC and the Brazilian Family Health Strategy (FHS) enables the actions of Health Promotion to reach individuals, families, and communities as well as their territories, population profile, health indicators, and vulnerabilities.³

According to the 2017 PNAB, it is necessary to implement strategies that apply a comprehensive array of PHC services to meet the health needs and demands of any assisted community. This assures the resourcefulness of PHC teams, the coordination and easy access to health care. Therefore, FHS and other PHC teams partner up to share health care activities and to support each other in health services inside territories. However, those actions must consider policies, priority programs, territory and individuals diversity and needs, and social control.³

The aim of Health Promotion is to assist real needs of individuals, families and communities. In order to understand this process we need to know the imaginary of Health Promotion. Such concept is related to the everyday life which holds a lot of images that are full of significance and composes our imaginary through a feedback relationship (image – imaginary).⁵ Additionally, the belief that everyone’s reality is also their imaginary and that this is an essential part of life helps understand that the imaginary world is an expression of culture, behaviors, and values of a particular historical and social context.⁵

This study considered Health Promotion as an integral component of PHC and that the aim of health care teams is the families included in each territory. As a result, the following research question is proposed: what is the imaginary of Health Promotion in the everyday life of families in PHC?

Moreover, the relevance of Health Promotion in the process of FH work still faces challenges encountered in PHC regarding activities used in the preventive health model. Health professionals working in this model deal with barriers for the execution of health promotion activities in their everyday routine. This is due to the development of actions to meet the spontaneous demand of territories with exceeding population. Therefore, this research is justified because FH teams need to advance their activities and exercise health policies. In order to make this happen we need to know the families and their territories as well as how they perceive Health Promotion in their everyday life so we can push forward new proposals.

Accordingly, the objective of this study was to know the imaginary of Health Promotion in the everyday life of families in PHC.

Methods

This is a qualitative, descriptive, and exploratory study based on Michel Maffesoli’s theories of Everyday life and Comprehensive Sociology and performed on a Basic Health Unit in a municipality from South Brazil.

Members regularly enrolled in a municipal program participated in this research. This program exists since 2006 and aims to provide Health Promotion and Quality of Life through body practices guided by Physical Education professionals and educational actions about health and recreation. Besides promoting body practices, this program performs recreational activities such as sightseeing, visits to cultural events in the region, sharing experiences with neighbor members, recreational plays during activities, and artisanal classes taught by other members. Thus, that program was suggested as an integral background for this study as it contemplates the research proposal.

All program members were invited to participate in this research. However, inactive members on sick leave were excluded and a total of 19 participants were added to this study.

At the time of data collection, 25 students were enrolled in the program; two were on medical leave; two were not interested in participating in the study; and two other students were traveling at the time. From the 19 participants in this study, 18 were women and one was a man, all of them with ages between 35 and 81 years. Regarding occupation, 12 people identified as housewives, four as retired, one as a Community Health Agent, one as a housemaid, and one as a carpenter. These occupations allowed the participants to have availability to perform program activities.

It is important to notice that this study considered family as a dynamic care unit that is capable of promoting health to the everyday life of their members at different stages and during changes of their life cycle. Health Promotion is expressed in the internal and external environment of a family and through relationships and familial interactions with their members. It is also an expression of the complex relationships between family members and the society, community, neighborhood, friends, health services, health institutions, public policies, and others⁶ Thus, the group that participates in this program is a family built through friendship and affinity bonds.

The data collection was conducted from August to November 2015 through semi-structured group interviews which used discursive questions during workshops based on the Ninho Project as a data collection strategy.⁷ The workshop strategy facilitated an interactive and recreational experience for the participants and made the semi-structured interview more dynamic. This strategy was already validated by other studies.^7-9 The workshop was composed by four moments: Relaxation and Hosting, Central Activity, Conjunction, and Farewell Relaxation.⁷

During Relaxation and Hosting the researcher used a song to perform stretch exercises and to introduce the participants to each other as a way of hospitality. The Central Activity conducted activities to strengthen group bonds and to make the participants reflect on their own health. Then, it was asked the guiding question: “What is Health Promotion to you?”. At the Conjunction stage, there was a group reflection and discussion to integrate the different perspectives of participants. Finally, during the Farewell Relaxation there was music played and stretch exercises performed and then followed by the conclusion of the discussion.

Three workshops were organized with 5 or 6 participants each. The groups were small to ease dialogue and improve the participation of all participants. Every workshop lasted for an average of one hour and a half.

Data was collected through annotations done after each interview to build a Field Journal in order to aid in the analysis and data interpretation.⁷ The interviews were recorded in digital media and transcribed to Word format by the researcher in charge of this study.

After data registration, the interviews were organized and categorized by the Atlas.TI software version 6.1. Data analysis was based on Schatzman and Strauss and supported by Michel Maffesoli’s theories of Everyday life and Comprehensive Sociology.¹⁰ This analysis sought to connect classes bonds and central ideas as a way to construct categories and subcategories grouped according to the subject of study. After an exhaustive data analysis, this study reached a final discussion and analysis that helped to draw conclusions and considerations according to its objective and with elements to expand and contribute to the studied thematic through four built categories.

In order to assure the anonymity of participants, each member chose a flower’s name to represent them in the reports of this research. Ethical aspects were respected as this research was approved by the Research Ethics Committee under the protocol number 45932915.0.0000.0121 at July 13^th 2015. All study participants signed a Free and Informed Consent Term according to the Resolution number 466/2012 of the Ministry of Health’s National Health Council.¹¹

Results and discussion

During data analysis, four categories emerged: Seeking health in daily life; Prioritize and Promote a better quality of life; Weaknesses of Health Promotion in the daily life of the Unified National Health System (SUS); and Potentialities of Health Promotion in SUS routine.

Seeking Health in Daily life

Health Promotion was described as a search for health in daily life. This search was presented during several speeches from participants and surpassed other categories as something significant to Health Promotion, according to reports:

I think that is a search of different ways to get a better health for us. It is not just going to a Unit, but to search it in our day-to-day life. It is to walk outside, to think about good things, to be in touch with other people because I think all of this is more convenient. People’s union, living with other people because we are nothing alone. (Violet)

Health Promotion is something that needs to be sought and that search goes beyond seeking health services, it happens in daily life. Maffesoli¹² stated that everyday life is where people show their life style, their thoughts, and their ethics based on past experiences and on the tribes which they belong to. This is supported by the aforementioned report that cited that a daily life search for health can be done through a walk, good thinking, and living with other people because those are more convenient. Thus, Health Promotion can be seen as a lifestyle that is expressed in everyday life.

Additionally, the imaginary of modern society is lived in daily life. This anodyne and frivolous routine is not a primary concern of institutions and could be a ground to build and strengthen new ways of thinking and being which are referred as social potency.¹²

This imaginary is also confronted by the comprehensive concept of health which is a ground for Health Promotion. Such notion allows for the recognition of the complex, interdisciplinary, and intersectoral nature of health practices. Therefore, we can reaffirm that health problems cannot be extinguished though medical technology or individual behavior change.¹³

In another moment, when participants were questioned about what is Health Promotion, the definition of health emerged:

Health to me starts by home hygiene. A good bathroom cleaning, an adequate bath, or always putting a lid on food to avoid flies, everything always closed […] it is a composition of a lot of things that we can search for and, sometimes, it is inside our health and we don’t realize it. (Bromeliad)

This testimony brings us back to a concept of health that was expressed by the Hygienist Hypothesis. This perspective is dated from the nineteenth century and posted that changing hygiene habits should be used as rules and recommendations for good health, without accounting for SDH. These determinants are social, economic, cultural, ethnic, psychological, and behavior factors that influence the occurrence of health problems and simplify the disease-health process as an intrinsic biological phenomenon.¹⁴

However, a study¹⁵ about FH patients’ perceptions regarding health conceptions supports this analysis as it demonstrated that health is not only the absence of sickness, but also a condition essential to life maintenance. It stated that health is a result of the interaction between factors, conditions, and habits of life and it is also influenced by the occupation and social and daily interactions, as opposed to the biomedical model of health.

The imaginary of participants in this study presented to us an approximation and distance movement in regards to their definitions of Health Promotion and Health:

[...] promotion is something that I will search to improve my health. I come to the lectures that we have here so I can better understand it. And health I have to seek at my home; at home I have to take my medicine at the right time, and feed myself healthy. And promotion is everything that you go to, like “ah, today there is a lecture there”, this is a promotion; I will go there to learn more, to search understanding. (Bromeliad)

In this testimony, the word promotion, from the Latin word promotio, onis, defined as a promotion, act or effect of promoting, was mentioned as something positive that needs to be sought in order to improve someone’s health. In other words, it is something that comes from the outside, external, and it is connected to education and learning and was exemplified by the lectures at the Basic Health Unit. However, the health that was sought at home was mentioned inside a reductionist model and appointed only as the behavior change that were based on concepts imposed by society and guided by the logic of what someone must be.¹⁶

The search for health improvement through people’s participation in Health Promotion activities is supported by the Ottawa Charter and characterized by the development of personal skills as well as the popular participation. The development of personal skills supports the personal and social dimension that enables people to have more choices and control of their own health and their environment through publications, information, health education, and strengthening of vital abilities.¹

A study about the use of body and meditation practices in Health Promotion at PHC identified the construction of self-health references and the potentiation of changes in the relationships of people and the events in their life. These findings support the importance of Health Promotion in the context of PHC.¹⁷ Thus, family health promotion is also about providing spaces where these families can have a better life and be healthy.

Therefore, this becomes a resource to improve the health of people, families, and communities in different spaces where they are inserted, including the FHS. Through participative strategies that go beyond the traditional education model, they can promote dialogue, reflection, and critic thinking to enable individuals to improve their lives and, therefore, reinforce a liberty thinking that nurtures everyone’s potential.

Prioritize and Promote a better quality of life

It is also mentioned that Health Promotion is associated to quality of life. The act of promoting, boosting, or executing an action represents a positive activity for Health Promotion. And the priority, from the Latin word prioritas, defined as first or to give priority, was also pointed as a way to improve quality of life and is in consonance with the concept of Health Promotion established in the Ottawa Charter.¹

Although, for the participants interviewed, the priority for having a better quality of life seems limited to physical activity, food, and weight control. This brings back the reductionist model and restricts the process to enable people for Health Promotion

Health promotion is to promote or to have a better quality of life. It is its priority. It is a priority to have a better quality of life. It can be done by physical activity or eating. (Azalea)

[...] it is to not over eat after doing physical activity. It is to come home and not eat to control our weight. (Anis)

According to the Ottawa Charter, the process of enabling people is aimed to reach equity in health:

Health promotion actions aims at reducing differences in current health status and ensuring equal opportunities and resources to enable all people to achieve their fullest health potential. This includes a secure foundation in a supportive environment, access to information, life skills and opportunities for making healthy choices.^1:1

In despite of the participants’ views of Health Promotion mainly as healthy eating and physical activity, it is important to state that enabling access to the resources aforementioned is to effectively promote health.

Weaknesses of Health Promotion in the daily life of the Unified National Health System (SUS)

During the interviews, relatives of participants referred to daily life situations to exemplify Health Promotion in their day-do-day to life. After the “Prioritize and Promote a better quality of life” category was emerged, the participants brought up matters to highlight weaknesses faced in the everyday life at SUS which impact the implementation of Health Promotion.

I needed to do an exam through the SUS, but mine is taking six months on the waitlist. A colleague of mine said he’s been waiting for over a year. I mean, if you wait for SUS, you die. (Lavender)

If we rely on SUS, only on SUS, we need to stay calm and wait. (Hibiscus)

The imaginary of health promotion showed us a reality where people who cannot afford private health services worry that if they rely on SUS to perform an exam, they will die before getting examined. On the other hand, to rely on SUS one “needs to” stay calm and “needs to” wait which brings back the “needs to be!” model. This “needs to be” model expresses rules and practices mandated by institutions or the society and does not enable individuals to know their rights and duties as users of the SUS. A study about SUS users that sought the Justice System demonstrated that Brazilians’ apprehension regarding SUS waitlists for services is a public health problem.¹⁸

The imaginary of the weaknesses in Health Promotion in the daily life of SUS showed participants’ impotency feelings through dissatisfaction about the lack of social protests for the improvement of health conditions:

If I fight there, would it matter? (Hibiscus)

[...] we don’t complain at the Basic Health Unit because they can’t be blamed, they are following orders. (Lotus)

Maybe they want to do it, but people who go inside do nothing. (Hibiscus)

There are evidences that the profile of users that sought legal advice to resolve their problems in the SUS is of citizens on the waitlist for a medical procedure who are waiting between 1 and 7 years.¹⁸

Health investiments also emerged in the imaginary of participants when they were questioned about the definition of Health Promotion:

We need to invest more in health. (Lavender)

“Need to” bears the same meaning as “must be”, whereas “to invest” bears the same meaning as to employ (money, time, or effort). The Ministry of Health has invested funds to restructure and reorient PHC in Brazil initially with the creation of the FHS, then with the expansion of professional teams, infrastructure, research, and communication. Additionally, the Ministry has sought to invest in health services that are meant to improve the health of individuals, family, and communities. However, the resources and efforts destined to the SUS are still a governmental impasse in the System. Generally, this is negatively reflected on the daily life of people who seek and believe in SUS’s principles and guidelines which still have not established standards of temporal efficiency for elective procedures. ¹⁸

This “need to” makes us reconsider that the “must be” thinking is not the way for Health Promotion. Then, we start to question if the “should be” thinking is a way that expresses the real needs of people and, therefore, the more effective and productive alternative.

The daily life of SUS or, in other words, the way that people experience the SUS is perceived through services offered in different levels of care. This impact negatively on experiences and it is described in testimonies about neglect in services provided by professionals who stay in the comfort of the office or perform other activities instead of meeting care demands.

It is just like at the UPA [Urgent Care Unit]. If you go there and take a look inside, the doctor is reading, sleeping. My daughter stayed there from morning until noon and then she came home without being examined. They don’t care for us; they think that just because you came in walking you are well. But, sometimes you are dying. (Lotus)

He was at WhatsApp. I caught him once, I was waiting, waiting, then I sneaked in and there he was. (Iris)

WhatsApp presence in the workplace and during working hours catches our attention because it is a reflection of the techno-social power in modern society. According to Maffesoli, post-modernity is characterized by the synergy between the archaic and the technological advances in which internet communication is creating new ways of being, exchanging, and new social bond structures.¹⁰

These testimonies are also a reflection of the Reorientation of Health Services which is proposed by the Ottawa Charter. The Charter supports services to adopt a comprehensive attitude, to perceive and respect cultural peculiarities and individual, family, and community needs to promote a healthier life and open communication channels between health, social, political, economic, and environmental sectors.¹

Potentialities of Health Promotion in SUS routine

On the other hand, the routine of Health Promotion revolves around interactions of a health promotion group and is defined as an experience that contributes to improve the health and daily life of people.

before, I used to wake up in the morning and say that I would give up the program. This was because when I started the program I used to have knee pain. Later, I kept going non-stop. Then all my pains were healed. (Anis)

This testimony mentioned the participant’s before and after joining the health promotion group and showed the physical health improvement after her participation in group activities.

When participants were questioned about “how your experiences here influence your day-to-day life?”, more than half of them mentioned that their experiences in group activities positively impacted their everyday life and also reported changes in their perceptions of Health Promotion:

You have a purpose. It is not to come here and just walk. Everyone here give advice on how you can have a better health. And it is up to you if you want to move forward. I started here. As a fifty-four year old I could not walk from here to the bakery, I would go by motorcycle or by car. Now I walk long distances, thank God. It started here. They gave me advice on how to have a peaceful health. I took that advice home and my sons followed it too. Then, this group and the Gym are everything to me. (Lavender)

The tribe’s force is mentioned in this testimony and the group activities reinforced Health Promotion as the group strengthens and mobilizes families to promote health in their day-to-day lives. According to Michel Mafessoli, the tribe acts as a family, a group of people with established common interests, thought conformity, and lifestyles that can be strengthened by sharing experiences in their daily lives.

Health Promotion is also mentioned as the subject of self-care once the family becomes empowered through the construction of their own resources, such as physical activity:

The father and the mother also had to give a little encouragement. My son-in-law will only buy bread that is 50 meters away from home by car. And his son won’t walk to buy an eraser without saying “Hey dad, let’s drive?”. These days I told them “go walk! Grandma walks everywhere!”. They did nothing, nothing, nothing. They just stay at their “tcheque tcheque tcheque tcheque tcheque”. It is twenty-four hours a day. I get up at three in the morning to go to the bathroom and there they are “tcheque tcheque tcheque tcheque tcheque” [video game]. (Hibiscus)

I am a dancer, but it is also a gym. The doctor said to me that dancing is a gym. (Rosemary)

It is important to highlight that behavior change can be associated to physical activity as this is the main characteristic of the group which they are a part of. Therefore, the main challenge of these Health Promotion activities is to develop actions that go beyond behavior change.

This reality can be a reflection of the people who conduct the activities. Studies that investigated Health Promotion perceptions of FHS professionals observed an incoherence between their spoken perceptions and their practices; the care performed by them was mainly focused in disease prevention and monitoring; and the development of Health Promotion actions is under construction.^16-17

The imaginary of collective force is brought up by participants as a mean of organization and protest and represents people’s union as a possible way to change the health context of their country:

If I call, nobody will come. Everyone wants to, but nobody will complain. Because this would be like a union. Everyone. We won’t fight what can’t be solved. Then it doesn’t matter, we need to be patient, to wait until we’re called. Everyone! [...] they had to complain to the big ones, everyone, but not just one or two. […] we need to unite. (Lotus)

All community. Every neighborhood needs to unite their community. (Hibiscus)

But every four years people unite. We just need to organize it. (Lavender)

We need to unite [...] We want to improve this, that, and that. It is what we want! [Lotus]

The aforementioned testimonies reflect the protests of people that want health improvements. However, the “need to” once again appears as a representation of a “must be” condition that needs to be implemented in order to achieve the collective ideas and desires (everyone, people’s union). This need to unite, to get together, represents the ideal of living in community, a collective potency that does not recognize itself in the contractual artificialism, but rather comforts itself in their natural consent. It is the ethics of aesthetics, in other words, it is a bond forged through a collective feeling. ¹²

It is important to highlight the present economic, political, and environmental crisis that Brazil is facing has a concrete and symbolical impact on health matters. Maffesoli¹² states that there was always a significant relationship between the tragic return and the vital exaltation. Therefore, at the present moment there is a collective ideal that is seen in daily life and in empowered experiences and it also highlights the powerful return of the will to live.

In this context, we need to emphasize that Health Promotion also supports the Reinforcement of Community Action:

[...] through concrete and effective community actions for the development of priorities, decision making, and strategy definition and implementation aimed at the improvement of health conditions. The center of this process is the community empowerment – the possession and the control over their efforts and destiny.^1:3

The reinforcement of community action, in other words, the popular participation is expressed as the Social Control in the principles and guidelines of the SUS which was established and is regulated by the Law number 8.142/90¹⁹ and mandates the inclusion of social actors in the decision making of public policies in Brazil. Thus, the law establishes the creation of Health Councils and Health Conferences at the three spheres of Brazilian Government as well as a collegiate management for health services.

However, the development of community participation in the daily routine of health services that assist individuals, families, and the community in their collective actions is still a challenge for the SUS. This is a process of permanent construction because community participation is a result of recreational and living actions that unveil and value knowledge and experiences inside the potentialities of reality.²⁰

Unfortunately, the integration of care is not really effective in PHC and neither is the promotion of integral quality care.²⁰ Then, in spite of being constitutionally assured, the right to access to health is still a challenge to the health system.

This is how the mention of “One bird alone…” (Iris) is translated, once more, as an expression of potency, of the strength that comes from inside every person and brings up the empowerment of every family and community, all brought up together by the ethics of aesthetics as a being together feeling!

It is evident that Health Promotion goes beyond vertical interventions centered in disease control and prevention and in individual behavior change. Therefore, a critical reflection on lifestyles associated to institutional change is crucial to achieve more effective results on practices of the everyday life of Health Promotion at PHC.¹³

Conclusion

At the end of this study, the imaginary of families perceived Health Promotion as something that needs to be achieved by individuals in daily life through good thinking, living with people, walking, healthy eating, not over eating, home hygiene, searching for advice to improve health, and experiencing daily life in the Brazilian SUS.

Therefore, the results demonstrated that Health Promotion is still referred as a reductionist model because it relies on behavior change, not dealing with health problems beyond the health department and the individual lifestyle, and on not recognizing SDH as strategies to promote change. However, participants described the will to unite and protest their rights as citizens and users of the SUS. This pointed to an imaginary where social potency is brought up by the sense of community, which is intrinsic to human nature, and is manifested by opportunities provided by the ethics of aesthetics.

The limitation of this study was the definition of the research’s participants because there are few groups that work under the light of health promotion. In this context, this study leaves a reflection to health services on how health promotion can be implemented in a way to generate a greater impact in the everyday life conditions and in the SDH.

As contributions to nursing, we can also emphasize Health Promotion as a fundamental part of family nursing care. It is also important that nurses value, strengthen, and perform actions to promote individual, families, and community participation in Health Promotion regardless of their different social and cultural realities. Additionally, nurses must respect the particularities of people and nuclear families to create creative strategies and to promote dialogue during the process of collective construction aimed at giving a worthy life and health conditions to the population.

It is necessary to conduct new investigations to understand the Imaginary of Health Promotion at PHC in other realities and in different activities. Then, we can reinforce actions and assistance to Health Promotion at FHC and provide more autonomy to individuals and families.

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Corresponding author

Name: Juliana Chaves Costa

E-mail: julianachavescosta@gmail.com

Address: 3144 Street,188, ap 603, Centro, Balneário Camboriú, SC.

Zip Code: 88330-296

Author contributions

1 – Juliana Chaves Costa

Conception; research project design; data collection, analysis, and interpretation; writing; critical revision.

2 – Rosane Goncalves Nitschke

Conception; research project design; data analysis and interpretation; critical revision.

3 – Patrícia Fernandes Albeirice da Rocha

Data analysis and interpretation; critical revision.

4 – Betina Barbedo Andrade

Data analysis and interpretation; critical revision.

How to cite this article

Costa JC, Nitschke RG, Rocha PFA, Andrade BB. The Imaginary of Health Promotion in the everyday life of families in Primary Care. Rev. Enferm. UFSM. 2019 [Accessed on: Year Month Day];vol e65: 1-19. DOI:https://doi.org/10.5902/2179769233603