Rosilda Mendes

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

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

Agendas urbanas intersetoriais em quatro cidades de São Paulo

Este artigo visa analisar o processo de implementacao e avaliacao de projetos de melhoria da qualidade de vida, do ponto de vista dos gestores municipais brasileiros, que tem buscado alternativas para a pratica da gestao local. Optou-se por identificar a percepcao de gestores, representantes do poder executivo local, prefeitos, secretarios de governo e coordenadores, identificados como atores-chave importantes na implementacao de projetos de melhoria da qualidade de vida em quatro municipios do Estado de Sao Paulo/Brasil. Foram feitas entrevistas individuais e em profundidade, com roteiro semi-estruturado. A analise dos quatro projetos por melhoria de qualidade de vida na cidade mostra que o processo de municipalizacao e descentralizacao da gestao, que vem sendo impulsionado no Brasil, vem contribuindo para definir uma politica local mais autonoma, para criar novas instâncias de decisao, incorporando praticas de controle social e de democratizacao da gestao. Porem, ainda existem muitas limitacoes no que se refere a incorporacao da avaliacao, como elemento retro-alimentador, no planejamento das acoes e da pratica participativa.

A dimensão da ética na pesquisa em saúde com ênfase na abordagem qualitativa

Abstract This article addresses the ethical dimension in health research, relating it more specifically to the qualitative approach, based on contributions of the social sciences and ethnography in particular, as it presupposes building a relationship of trust and res -pect between researchers and researched subjects that is gradually configured. The ethical aspects permeate qualitative research from the choice of the subject matter, the methodological outlines, analy-sis of the results, to the commitment of providing a feedback for the researched subjects regarding the obtained information. The ethical aspects presup-pose the value of an interpersonal relationship in which the different interests, values and worldviews stand as a possibility or not of a joint construction of knowledge. The choice of a subject or object of study is related to a particular life trajectory in which the researcher should ask himself, at all times, how to conciliate the constitution of an ethical attitude in relation to the researched subjects with his own desi -res, dreams, curiosities and expectations. The article aims to discuss such dilemmas experienced by the researcher, highlighting the importance of ethics for his personal, professional and socio-political growth, and emphasizing the desire for knowledge autonomy, solidarity with social groups and with people involved in the research. Based on the report of a research process, the article intends to contri-bute to the understanding of how ethical aspects are inextricably linked to research, and also to the researcher, bringing elements to the conduction of qualitative research especially in public health. Keywords: Qualitative Research; Research Ethics; Social Sciences; Cultural Anthropology; Public Health.

Gestão local de saúde em território de vulnerabilidade: motivações e racionalidades

Os contrastes das cidades trazem questoes a producao da saude e a gestao do cuidado em territorios de vulnerabilidade. Estudou-se a percepcao de gestores e profissionais em relacao ao processo de trabalho em saude, suas motivacoes e racionalidades, em um territorio atendido pela Estrategia Saude da Familia. Os profissionais sentem-se motivados pela filantropia e pela vocacao profissional a partir da percepcao de que a Atencao Basica compreende praticas com menor densidade tecnologica. Acoes emergenciais com enfoque assistencialista reforcam o modelo de cuidado, com predominância de acoes de tratamento diante da naturalizacao dos problemas de saude atrelados a pobreza extrema da regiao.

Experiência, produção de conhecimento e formação em saúde

Este artigo apresenta parte dos resultados de pesquisa sobre a experiencia de formacao interprofissional no eixo Trabalho em Saude na Unifesp - campus Baixada Santista, Santos, SP, Brasil. As estrategias de ensino deste eixo tem como perspectiva expor os estudantes, desde o primeiro ano de graduacao, a experiencias de intervencao de cuidado que possibilitam o exercicio critico das dimensoes envolvidas no trabalho em saude. O objetivo do trabalho foi sistematizar, analisar e estabelecer estrategias de acompanhamento dessa formacao. Foram utilizados diferentes instrumentos de coleta de dados, como grupos focais e entrevistas semiestruturadas, e as analises foram apresentadas e discutidas com os sujeitos envolvidos. Este artigo aborda as questoes relacionadas a tematica da experiencia e producao de conhecimento, e os resultados indicam que a formacao tem contribuido para a construcao de um modo de atuar dos futuros profissionais que considera a complexidade do processo saude-doenca-cuidado.

Práticas democráticas participativas na construção de agendas sociais de desenvolvimento em municípios do sudeste brasileiro

This article present the results of a study which focused on local processes for implementing social agendas Agenda 21 and Healthy Cities in the southeast region of Brazil. It looks at the relations between efforts and their effects on social health determinants, especially those which may be understood by considering the relationship between social actors and the system. Six case studies were carried out to analyze the social experience of implementing their respective agendas. Data was collected through Individual and collective interviews, survey documentation and direct observation of experiences. They were analyzed according to previously defined research topics. Results show that values such as participation, collective construction of policies, sustainability and empowerment become part of the ideology and experience of those directly involved. Furthermore, values also positively impact on actions PARTICIPATORY DEMOCRATIC PRACTICES IN THE CONSTRUCTION OF SOCIAL DEVELOPMENT AGENDAS IN MUNICIPALITIES IN THE SOUTHEAST OF BRAZIL MARCIA FARIA WESTPHAL, JUAN CARLOS ANEIROS FERNANDEZ, PAULO ROBERTO NASCIMENTO, FABIOLA ZIONI, LUCIA MARCIA ANDRÉ, ROSILDA MENDES, GRACE PEIXOTO NORONHA, RAFAEL DA SILVEIRA MOREIRA which have been adopted, promoting health and quality of life of citizens living in theseEste artigo apresenta os resultados e a analise de um estudo que focalizou os processos locais de implantacao das agendas sociais - Cidades Saudaveis e Agenda 21 - em municipios da regiao Sudeste do Brasil, relacionando o esforco realizado e seus efeitos sobre os determinantes sociais de saude, especialmente os que podem ser apreendidos considerando-se a relacao entre atores sociais e sistema. Realizaram-se estudos de caso em seis municipios para analise da experiencia social de implementacao da respectiva agenda. Entrevistas individuais e coletivas, levantamento de documentacao e observacao direta produziram os dados que foram analisados em funcao de temas de pesquisa previamente definidos. Resultados demonstram que valores como participacao, construcao coletiva de politicas, sustentabilidade e empoderamento, passam a integrar o ideario e a experiencia dos atores diretamente envolvidos, alem de interferirem ao ponto de acoes positivas serem adotadas e implementadas, para promover a saude e a qualidade de vida dos cidadaos que vivem nestes locais.

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

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

Promoção da saúde e participação: abordagens e indagações

Este ensaio discute as diferentes abordagens da promocao da saude e da participacao e suas implicacoes no sentido de contribuir para a construcao de novas praticas e compromissos em torno da producao social da saude. Defende a ideia de que praticas de promocao da saude podem ser ativadoras de potencia de acao para construir medidas que resultem em fortalecimento dos sujeitos e das coletividades, na ampliacao da autonomia e no fomento da participacao e das redes. A intencao deste artigo e compartilhar ideias, alem de ser um convite a afastarmo-nos das receitas e das reproducoes, a fim de inventarmos nossos proprios modos de construir a promocao da saude.

Pesquisa-intervenção em promoção da saúde: desafios metodológicos de pesquisar “com”

This article discusses the broadening of the meaning of intervention as a pathway for research in health promotion and raises theoretical-methodological reflections. Its presupposition is that the set of health promotional practices constitute one of the most intriguing and necessary methodological challenges in a field which seeks, in a critical way, to strengthen the autonomy of the subjects, their participation, the institutionalized movement’s value, the processes of subjectivization, and to give meaning to the experiences involved. One important methodological guideline raises the question regarding what type of actions would best address the innumerable challenges of the pedagogical/professional fields and the creation of a collectivity as a catalyst of change. Among recent studies on intervention-research we focused on the theoretical-methodological approach of Institutional Analysis and the writing of research diaries. Finally we consider that methodologies shaped by the principles of inclusion do the following: abandon vertical, self-contained approaches, bring out elements showing the desire to articulate, show the power of action in favor of dialog, highlight that interaction can produce health and that it can activate new forms of constructing health promotion practices.This article discusses the broadening of the meaning of intervention as a pathway for research in health promotion and raises theoretical-methodological reflections. Its presupposition is that the set of health promotional practices constitute one of the most intriguing and necessary methodological challenges in a field which seeks, in a critical way, to strengthen the autonomy of the subjects, their participation, the institutionalized movement’s value, the processes of subjectivization, and to give meaning to the experiences involved. One important methodological guideline raises the question regarding what type of actions would best address the innumerable challenges of the pedagogical/professional fields and the creation of a collectivity as a catalyst of change. Among recent studies on intervention-research we focused on the theoretical-methodological approach of Institutional Analysis and the writing of research diaries. Finally we consider that methodologies shaped by the principles of inclusion do the following: abandon vertical, self-contained approaches, bring out elements showing the desire to articulate, show the power of action in favor of dialog, highlight that interaction can produce health and that it can activate new forms of constructing health promotion practices.

Participação social e a potência do agente comunitário de saúde

O Agente comunitario de saude (ACS) ocupa um lugar de mediacao importante entre comunidade e Estrategia de Saude da Familia (ESF). Todavia, em uma perspectiva critica, consideramos que a atuacao desse profissional, especialmente em territorios de alto grau de vulnerabilidade, evidencia a complexidade e contradicoes que devem ser discutidas em uma perspectiva etico-politica. O objetivo deste artigo foi discutir aspectos da organizacao e convivencia comunitarias que contribuem para a construcao de processos de participacao social do ACS. Estudo de carater qualitativo, realizado em uma unidade de saude da familia no municipio de Cubatao, teve a pesquisa participante como balizadora dos procedimentos empregados, destacando a observacao participante e entrevistas semiestruturadas. Os resultados indicam que o forte sentimento de comunidade e a proximidade com as forcas politicas da comunidade contribuem com o processo de participacao social, ao contrario da predominância do assistencialismo e do medo desencadeado por situacoes de violencia.