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Abstract

Thank-you for the opportunity to be with you today in this fascinating panel on the state of health promotion in Brazil, Canada and around the world. It is a great pleasure to be here, and to share my thoughts and reflections with you, not as an expert here to tell you how it ‘should’ be, but as a colleague interested in dialogue around points of mutual concern. I feel we have much to learn from what has been happening here in Brazil, and the work of Paolo Freire and many contemporary colleagues who continue this tradition of critical pedagogy for health (like my colleague and friend here at UNIFOR, Dr. Francisco Cavalcante Jr.). So in this spirit of friendship, dialogue and mutual learning, I will be very frank with you about the lessons learned in Canada, including some of our failures and mistakes which I hope you can successfully avoid. Also, I offer my apologies for not being able to speak with you in your own language. I wish to thank my friends Nicolas Ayres and Francisco Cavalcante Jr. for their assistance with translation. In addition to a brief overview of the development of health promotion in Canada, I would like to share some reflections on the social, political and economic context in which the field has evolved, both in Canada and internationally. I will address three (3) key tensions I see in the field at the moment (from a Canadian perspective), and reflect on our successes and our failures. I will close with a few thoughts on future prospects and some of the challenges that I see that lie ahead. I would like to emphasize that any brief history of health promotion in Canada, and any assessment of its strengths, contributions and failures is inherently ‘subjective’ and idiosyncratic. Rather than repeat the work of other analysts and commentators (see for example – cite PHAC/HC docs), I offer my observations based on over a decade of involvement in the field (including involvement in the Critical Social Science and Health group at the University of Toronto), and in my capacity as Director of the Masters of Health Science program in health promotion at the University of Toronto. Doubtless, those with different interests, orientations, and practice backgrounds would come to (slightly or substantially) different conclusions.
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... This study shows that the content included information on effective malaria prevention and information which enhanced community members' ability to practice (self-efficacy); yet there are gaps in the behavioural intention in terms of net use at the community level. Health promotion messages require the identification of best practices, which includes the acknowledgement of contextual differences [23]. Best practices show that interventions' effectiveness is based on the extent to which complex interactions are considered for the health messages. ...
... This means allowances must be made for the uniqueness of settings across time and space [24]. This creates opportunities to situate practice in its social context, optimize interventions for specific contextual contingencies, and target crucial factors influencing behavior [23]. For instance, this study suggests the use of fear appeal and punitive measures as additional strategies that could enhance proper use of the LLINs at the community level. ...
... For instance, this study suggests the use of fear appeal and punitive measures as additional strategies that could enhance proper use of the LLINs at the community level. The bulk of health promotion practice has been oriented to communityy settings and seeks to increase the sophistication with which knowledge about settings is mobilized in the planning, implementation, and evaluation of health promotionn [23]. Investing in the development of culturally appropriate malaria prevention messages is therefore crucial in increasing community awareness on malaria prevention and behavioural intention of LLIN use [25]. ...
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Background The National Malaria Elimination Programme implements the mass LLIN Distribution Campaigns in Ghana. Implementation science promotes the systematic study of social contexts, individual experiences, real-world environments, partnerships, and stakeholder consultations regarding the implementation of evidence-informed interventions. In this paper, we assess the core elements of the mass LLIN distribution campaign in a resource constrained setting to learn best implementation practices. Three core domains were assessed through the application of Galbraith’s taxonomy (i.e., implementation, content, and pedagogy) for evidence-informed intervention implementation. Methods Six districts in two regions (Eastern and Volta) in Ghana participated in this study. Fourteen Focus Group Discussions (FGDs) were conducted across these communities. Eligible participants were purposively sampled considering age, occupation, gender, and care giving for children under 5 years and household head roles. All audio-recorded FGDs were transcribed verbatim, data was assessed and coded through deductive and inductive processes. NVivo software version 13 was used for the coding process. Themes were refined, legitimized, and the most compelling extracts selected to produce the results. Results Sixty-nine (69) caregivers of children under 5 years and sixty (60) household heads participated in the FGDs. All caregivers were females (69), whilst household heads included more males (41). Core elements identified under implementation domain of the LLIN distribution campaign in Ghana include the registration and distribution processes, preceded by engagement with traditional authorities and continuous involvement of community health volunteers during implementation. For pedagogy domain, core elements include delivery of intervention through outreaches, illustrations, demonstrations, and the use of multiple communication channels. Core elements realized within the content domain include information on effective malaria prevention, and provision of information to enhance their self-efficacy. Yet, participants noted gaps (e.g., misuse) in the desired behavioural outcome of LLIN use and a heavy campaign focus on women. Conclusion and recommendations Although the implementation of the mass LLIN distribution campaigns exhibit components of core elements of evidence informed interventions (implementation, content and pedagogy), it has not achieved its desired behavioural change intentions (i.e. continuous LLIN use). Future campaigns may consider use of continuous innovative pedagogical approaches at the community level and lessons learnt from this study to strengthen the implementation process of evidence-based health interventions. There is also the need for standardization of core elements to identify the number of core elements required within each domain to achieve efficacy. Ethical approval Ethical clearance was obtained from the Ghana Health Service Ethics Review Committee (GHS-ERC: 002/06/21) before the commencement of all data collection.
... Nesse sentido, é possível compreender que promoção da saúde se relaciona a ações em saúde de forma participativa (Brasil, 2002). Para tanto, faz-se necessário reconhecer os múltiplos determinantes de saúde, tais como alimentação, moradia, saneamento básico, condições de trabalho, entre outros vetores que ampliam a discussão sobre saúde, não restringindo-a à mera ausência de doenças (Poland, 2007). ...
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The crisis caused by the COVID-19 pandemic highlighted the work of psychology professionals, who were called upon to intensify their activities amid the urgency of actions aimed at the population's mental health. The context led to increased demands on the Unified Health System, historically marked by challenges associated with limited resources, work overload and stress. Given this scenario, this study aimed to reflect on the promotion of care among those who work in public health, especially psychology professionals. To this end, we used qualitative Bibliographic Research, in which we proposed to revisit the literature regarding the mental health of psychologists, Occupational Health and the official documents that guide health actions in situations of health crisis. Thus, the presence of high levels of Stress and risk of illness due to Burnout Syndrome among professionals was observed. Being actions that consider the specificities of this public and their contexts of action, the awareness of self-care strategies, the guarantee of compliance with labor legislation and the expansion of Occupational Health actions, considering that current policies tend to using the biologizing model, disregarding subjective issues that exist in the work dimension of these professionals.
... Além disso, a promoção da saúde é definida como um processo de capacitação de indivíduos e da comunidade para melhorar e aumentar seu controle sobre a saúde, de forma participativa (Brasil, 2002). Com isso, esse texto reconhece os múltiplos determinantes de saúde (não se restringindo a cuidados médicos e paliativos) e avança na discussão sobre saúde que, anteriormente, estava limitada à relação presença/ausência de doença (Poland, 2007). ...
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... A despeito do seu principal sentido, de politização e busca de aproximação entre saberes científicos e técnicos com os saberes populares, mediante a participação ativa dos indivíduos e comunidades em sua vida cotidiana e, consequentemente, no controle sobre os determinantes dos processos saúdedoença, a nova promoção da saúde ainda enfrenta grandes desafios. A aspiração à maior participação de pessoas e grupos nos processos saúde-doença tem sido apreendida sobretudo como responsabilização dos indivíduos pela saúde, privilegiando iniciativas educativas que visam a mudanças nos estilos pessoais de vida, com base nos saberes biomédicos (Polland, 2007). ...
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Resumo O estudo aqui apresentado buscou discutir as contribuições do teatro do oprimido na promoção da saúde, visando a colaborar para a consolidação desse diálogo de maneira que as repercussões no desenvolvimento das experiências práticas sejam potencializadas. Dentre as duas principais vertentes da promoção da saúde, registra-se a incompatibilidade entre os alicerces éticos, estéticos e políticos que fundamentam o teatro do oprimido e os pressupostos teóricos da corrente behaviorista, uma vez que esse teatro se afasta de qualquer tentativa de domesticação dos corpos e de normatização de comportamentos, hábitos e estilos para que sejam atingidos padrões (classificados por alguns como) saudáveis. Já com relação à perspectiva da nova promoção da saúde, de politização e busca de aproximação entre saberes científicos e técnicos com os saberes populares, observaram-se maiores consonâncias entre ela e o teatro do oprimido, a partir do momento em que ambos logram o fortalecimento de práticas cidadãs questionadoras do status quo e de mudanças sociais em prol de uma transformação libertária e crítica.
... The CMHF's operating utopia is a Canadian example of the discontinuity between health behaviourism and existing Canadian rhetoric on the sources and means of addressing health inequalities. CMHF's utopian vision of improving the health of Canadians by empowering individuals to make lifestyle changes takes no note of Canadian governmental statements (Butler-Jones 2008;Epp 1986;Lalonde 1974 (Hancock 2011;Labonte and Ruckert 2015;Poland 2007;Raphael 2008Raphael , 2016a that document how (a) analyses of the sources of health inequalities that take no account of social class, income, and other social locations are not very useful; (b) individualized ''healthy choices'' approaches are ineffective for those most at risk for adverse health outcomes; and (c) neo-liberal inspired restructuring of the welfare state in Canada has markedly altered the distribution of the social determinants of health, thereby threatening men's health and increasing health inequalities. ...
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The Canadian Men’s Health Foundation (CMHF) receives significant funding and media attention for its Don’t Change Much initiative, which claims freely chosen small behavioural changes will improve men’s health across Canada. The enthusiastic support for the CMHF’s individual lifestyle interventions that take no account of the structural drivers of men’s health and health inequalities is considered through an application of Ruth Levitas’ utopian analysis exercise. We consider the utopian visions that permeate the CMHF’s initiative and examine its culture through the lens of discursive institutionalism to identify the hegemonic values that imbue CMHF’s and other Canadian health promotion activities. We then suggest more useful directions for improving men’s health and reducing the health inequalities that pervade the Canadian scene.
... In time, community centrality in HIV research became encapsulated under the rubric of Community-Based Research (CBR) (Allman, Myers, and Cockerill 1997). Although initially largely researcher-led in terms of actual research activity, the emphasis on CBR became a recognisable feature among the practices and processes launched by federal and regional governments in Canada, and one that garnered a degree of international interest (Poland 2007). ...
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Community centrality is a growing requirement of social science. The field's research practices are increasingly expected to conform to prescribed relationships with the people studied. Expectations about community centrality influence scholarly activities. These expectations can pressure social scientists to adhere to models of community involvement that are immediate and that include community-based co-investigators, advisory boards, and liaisons. In this context, disregarding community centrality can be interpreted as failure. This paper considers evolving norms about the centrality of community in social science. It problematises community inclusion and discusses concerns about the impact of community centrality on incremental theory development, academic integrity, freedom of speech, and the value of liberal versus communitarian knowledge. Through the application of a constructivist approach, this paper argues that social science in which community is omitted or on the periphery is not failed science, because not all social science requires a community base to make a genuine and valuable contribution. The utility of community centrality is not necessarily universal across all social science pursuits. The practices of knowing within social science disciplines may be difficult to transfer to a community. These practices of knowing require degrees of specialisation and interest that not all communities may want or have.
... Na maioria das vezes, não se detém o conhecimento de como o paciente encontra-se inserido nesse processo, mesmo conhecendo a importância da percepção dos usuários de serviços de saúde, uma vez que estes são capazes de apontar melhorias e desafios, bem como sugerir caminhos coerentes à superação das atuais necessidades (9,10) . É necessário dar voz aos cardiopatas, pois são pessoas que se encontram com o estado de saúde delicado por tratar-se de doença em órgão vital e, certamente, sua opinião contribuirá para a melhoria da promoção da saúde, que destaca valores como a equidade e a justiça social, definição holística de saúde (bem-estar), incremento da saúde e não apenas a prevenção de doenças, empowerment, participação social, construção de capacitação individual e comunitária, e colaboração intersetorial (11) . ...
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Objetivo: Analisar as percepções de pacientes em pós-operatório de cirurgia cardíaca no que diz respeito à humanização da assistência no período de internação na Unidade de Terapia Intensiva, ao atendimento e ao trabalho dos profissionais de saúde. Método: O estudo apresenta abordagem qualitativa, tendo sido realizado com dez pacientes, de ambos os sexos, internados por mais de 24 horas na terapia intensiva de um hospital público de Fortaleza, Ceará, no período de agosto a outubro de 2006. Uma entrevista semi-estruturada e um diário de campo foram aplicadas seguindo às perguntas norteadoras: Como você percebe o trabalho dos profissionais de saúde na Unidade de Terapia Intensiva? Como você se sentiu durante os dias em que esteve na unidade? A análise de conteúdo foi aplicada aos dados. Resultados: A atenção, paciência, pronta-assistência e competência dos profissionais, associadas aos cuidados e transmissão de informações sobre o processo cirúrgico, contribuem para a humanização da assistência dessa instituição, apesar da presença de aspectos desagradáveis como o tubo orotraqueal, a desorientação temporal, a ventilação-não-invasiva e a freqüência de procedimentos normalmente presentes na fase de recuperação. Conclusão: A pesquisa aponta que, na percepção dos pacientes investigados e, apesar de alguns procedimentos incômodos presentes em um pós-operatório de cirurgia cardíaca, os profissionais da instituição buscam, de forma humanizada e através de pronto atendimento e cuidado, amenizar esse momento delicado e sofrido para os pacientes e seus familiares.
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Resumen Presentamos aquí un modelo teórico para la construcción de respuestas comunitarias a problemas de salud integral adolescente. El mismo condensa el trabajo realizado por nuestro equipo a lo largo de los últimos 15 años, tanto en el ámbito de la investigación como en la asistencia técnica a programas de intervención en Argentina.El modelo está organizado en 3 ejes conceptuales de los cuales se desprenden 10 principios y 6 pasos, los cuales recuperan los debates de la promoción de la salud, la salud colectiva y la pedagogía crítica. Si bien el mismo puede ser utilizado para trabajar distintas problemáticas de salud integral adolescente, se muestra en este artículo aplicado a un tema concreto y de relevancia internacional: el abuso sexual contra niños, niñas y adolescentes. Esta modelización supone una dialéctica que, por un lado, da lugar para que lo singular y contingente de cada experiencia pueda aparecer. No obstante, reconoce que muchos problemas se repiten en distintas comunidades, ya sea cercanas o geográficamente alejadas, y que la experiencia en el abordaje de los mismos puede aportar a construir nueva acción informada en la práctica. Proponemos aquí un trabajo basado en la inclusión de las diferencias, donde se interroguen los mitos, las creencias, los prejuicios y los estereotipos que sostienen las múltiples discriminaciones que pueden sufrir las personas.
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En este artículo presentamos una modelización que tiene como meta la construcción de una respuesta integral y comunitaria frente a problemáticas de salud adolescente. Desde un abordaje integral, que incluye acciones de prevención y promoción, asistencia y protección, y que involucra a diferentes sectores y áreas del Estado y de la comunidad, describimos las bases conceptuales del modelo, los ejes y los principios que recuperamos de los debates de la promoción de la salud, la salud colectiva y de las experiencias de trabajo del equipo de investigación en distintas comunidades a lo largo de los últimos 15 años en Argentina. Posteriormente, damos cuenta de los pasos desarrollados para facilitar la realización de intervenciones y retomamos algunos nudos teóricos, políticos y prácticos que se encuentran en su gestación, en una apuesta por vincular la reflexión crítica con el desarrollo de tecnologías sociales. Este modelo da cuenta de la reflexión sobre cómo llevar adelante acciones de promoción de la salud que busquen transformar las realidades particulares, respetando sus singularidades y recuperando lo que las conecta con otras.
Chapter
Context can be broadly defined as "the circumstances or events that form the environment within which something exists or takes place" (Encarta, 1999). That 'something' can be health behavior, another health determinant, an intervention, or an evaluation. Each of these events unfolds, not in a vacuum, but in a complex social context which necessarily shapes how the phenomena are manifest, as well as how they may be taken up, resisted or modified. In this chapter we unpack the nature and significance of social context for health promotion practice and evaluation. Drawing on critical realism, we develop a framework for understanding key dimensions of social context that impact on three key levels: the target phenomena (what health promotion practice is seeking to change or enhance), the intervention (how it is received and plays out, its impact), and efforts to evaluate health promotion interventions (we propose that evaluation practice is also embedded in social context). That social context matters is widely recognized and nothing particularly new. Context is identified as a fundamental dimension of program evaluation (Suchman, 1967;Weiss, 1972), and person-environment and program- environment interactions can be traced back to the human ecology work of Broffenbrenner (1977, 1979). Applications of these concepts and ecological systems theory, in various guises, are found in the health promotion literature (see Best et al., 2003; Chu and Simpson, 1994; Green and Kreuter, 2005; Green, Richard and Potvin, 1996; Stokols, 1992, 2000). Although context receives attention in many health promotion texts (Bartholomew, Parcel, Kok, & Gottlieb, 2000; Green & Kreuter, 2005), it is not routinely integrated into or adequately accounted for in most program evaluations. The complexities involved in mapping contextual factors in evaluation pose significant evaluation challenges. Some interventionists and evaluators may lack the necessary theoretical breadth and methodological skills to adequately unpack, theoretically and empirically, how context matters. Nor may they feel they have the 'luxury' of time or breadth of mandate to tackle what may be seen as more challenging conceptual and methodological issues associated with doing so. This chapter identifies some of these challenging issues and proposes a critical realist framework for addressing these lacunae. The overwhelming emphasis within the dominant post-positivist paradigm in health promotion evaluation research has been to treat context as a source of potential confounders that need to be either 'factored in' (as variables that apply across cases) or 'factored out' ('controlled for' statistically or through study design such as randomization). Identification of 'best practices' that can be disseminated across space and time with predictable outcomes following the results of promising pilot research, also treats context as something of a nuisance to be addressed only insofar as it threatens to seriously compromise implementation fidelity or program outcomes. Further, following Malpas (2003), we believe that increasingly dominant managerial regimes that privilege efficiency and tight fiscal and legal accountability in health and social service delivery seek to tighten administrative control through the standardization of practice. Standardization accords only grudging acknowledgement to the difference that context makes. The inherent 'messiness', unpredictability, and uniqueness of context is difficult to reconcile with an administrative rationality intent on procedural standardization. In short, epistemological, political, and administrative factors have conspired to either obscure the relative importance of social context to program design, implementation, and evaluation or, at the very least, leave largely unexamined or unexplained the ways in which context matters. From studies of small area variations in healthcare practice (Wennberg & Gittelsohn, 1973), to studies of community-based health promotion interventions (Bracht, 1990; Minkler, 1990, 1997), the evidence that context matters is increasingly difficult to ignore. In some fields, such as tobacco control, there is growing awareness that the failure to sufficiently understand the social context of smoking has compromised the field's success record (Flay & Clayton, 2003; Poland et al., 2006). The social distribution of smoking has changed, and thus the social distance between target populations and interventionists, whose assumptions and world view are reflected in programming (Poland et al., 2006). The popularity of a settings approach in health promotion reflects, in part, an understanding of the importance of aligning program design and intervention activities with the realities of the setting for which they're intended (Chu & Simpson, 1994; Dooris et al., 2007; Mullen et al., 1995; Poland, Green, & Rootman, 2000, Poland, Lehoux, Holmes, & Andrews, 2005; Whitelaw et al., 2001). For example, considerable expertise has emerged in school-based health promotion with respect to the essential features of schools, as well as variability in their expression (e.g., inner city versus rural), that impact on program delivery and outcomes. The identification of aspects of context that impact on practice has also been undertaken with respect to community-based programming, workplace health promotion, and interventions tailored for other settings such as hospitals, Aboriginal communities, and prisons, among others. Context is fundamental to understanding the adequacy of program conceptualization and design: do interventions adequately address the social context within which target phenomena, such as health behaviors, are created, sustained and socially distributed in time and space? Context is also fundamental to program implementation and outcomes: are interventions optimized to take advantage of the unique confluence of opportunities available in each local context and which intervention components produce which results under what conditions? Finally, context shapes the production and utilization of evaluation findings: the influence of key assumptions and stakeholders on the design and implementation of the evaluation, as well as the impact of timing and other factors on research uptake. The organization of this chapter reflects the ways in which social context is implicated at three overlapping levels: (a) the nature of the phenomena that are the object of health promotion intervention (the social context of target phenomena); (b) interventions themselves (the social context of health promotion practice); and (c) knowledge development and utilization (the social context of evaluation research). At this juncture it is worth clarifying what we mean by evaluation. We adopt the definition proposed by Rossi and Freeman (1985, p. 19): "the systematic application of social research procedures in assessing the conceptualization and design, implementation, and utility of social intervention programs". We prefer this over less comprehensive definitions because it explicitly makes room for a critique of the adequacy of program conceptualization and design, whereas many evaluation definitions do not and are restricted to determining the extent to which intended outcomes are achieved. The premise of this chapter is that although context is of inescapable importance in health promotion program evaluation, better conceptual, theoretical, and methodological tools are needed to reposition it at the centre of evaluation efforts. Following a review of each of the three layers of context identified above, we draw on diverse disciplinary perspectives to assemble some of the conceptual, theoretical, and methodological tools necessary for a deeper and more satisfying treatment of context in health promotion program evaluation. In particular, we draw on critical social theory and critical realist perspectives to fashion an understanding of how social relations (at the heart of any social intervention) function in different social contexts, for these are critical to understanding how context matters.
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