INTRODUCTION

In Brazil, Primary Health Care (PHC) is known as Basic Health Care (Atenção Básica em Saúde - ABS). Its organizational strategy is based on integrated actions and on the principles of the Unified Health System (SUS), and it emphasizes teamwork, territorialization and co-responsibility¹. Work in PHC services is considered complex, given the constant changes in paradigms in the management process and in health work². This complexity has attributed different characteristics to primary care, giving rise to challenges regarding the limits of the scope of the strategy as a public policy, an organizer of the care network and a coordinator of care³.

In the context of PHC, the work of the Community Health Worker (CHW) is essential, since these professionals are members of the Family Health Strategy (ESF) team who are in a unique position, as they establish the communication between scientific and popular knowledge⁴⁾⁽⁵. In this sense, the work of the CHW is different from the others, not only because it is a new profession, but, above all, because of its political character⁶.

Dubar⁷⁾ points out that a profession emerges when a defined number of people start practicing a technique/practice based on specialized training or through a culturally acquired craft, and it is characterized by professionals who receive important rewards from a reference group, whose membership is limited to people who have undergone training and who have accepted an ethical code defined by the group⁴.

Thus, the construction of a given profession is not static, unchangeable, and cannot be conceived as finished and consistent, but rather as something with provisional design and fluidity, constructed in a process of identifications that, throughout history, has given structure and life to an identity or identities, which hide negotiations of meanings, games of polysemy and shocks of temporality, in a constant process of transformation⁷.

Identity and difference are the result of a symbolic and discursive process, inherent to social relationships. This means that its discursive and linguistic definitions are subject to vectors of force and power relations⁸. These relationships are inscribed in the body and life of CHWs, sometimes simply defined and imposed by the way health services operate: in limit situations, in a game of hierarchies and in constant disputes.

The work of CHWs, as a social practice, is centered on the development of actions that aim to promote the health of the community under their responsibility. CHWs are different from other health professionals, as they are social agents with a strong bond with the community, and their work object is the practice of care, which legitimizes this profession as exclusive of the SUS.

Health promotion, as it has been understood in the last 30 years, represents a promising strategy to face the multiple health problems that affect human populations and their surroundings, based on a broad conception of the health-disease process and its determinants, proposing the articulation of technical and popular knowledge and mobilizing institutional and community resources, whether public or private, for their confrontation and resolution⁹.

Health promotion is a practical, political and theoretical field built from the struggles of the Health Reform movement. It is a policy that must go through the set of health actions and projects and be present at all levels of complexity of management and care in the health system. The purpose of the health promotion policy is to shift the attention of health professionals from the disease to the subjects and their power to create their own lives, with the objective of building autonomy in health care⁹.

In the Brazilian context, health promotion is presented as a mechanism for strengthening and implementing a transversal, integrated and intersectoral policy, aiming to dialogue within several areas of the health sector, with other sectors of the government, the private sector, non-governmental bodies and society, forming networks of commitment and co-responsibility for the quality of life of the population and valuing the participation of population in the protection and care of life.

Therefore, health promotion takes place in the articulation of the subject/collective, public/private, state/society, clinic/politics, health sector/other sectors, aiming to break the excessive fragmentation in the approach to the health-disease process and to reduce vulnerability, risks and harm in this process¹⁰.

In an effort to guarantee the principles of the SUS and the constant improvement of the services it provides and to improve the quality of life of individuals and communities, it is necessary to overcome the fragmented administrative culture, that is not focused on the interests and needs of the society, avoiding the waste of public resources, reducing overlapping actions and, consequently, increasing the efficiency and effectiveness of existing public policies¹⁰.

Given its importance as one of the governmental strategies to guarantee the effectiveness of health policies through the principles of SUS, a literature review regarding this topic is extremely relevant and can support decision making in the management area and strengthen the need for the profession in the social context of the Brazilian health policy.

It is worth noting that the consolidation of a profession is based on scientific evidence for its permanence in the context of SUS. In this direction, the study aims to identify the knowledge and practices of CHWs in the context of health promotion based on the literature.

METHODOLOGICAL PATH

This is an integrative review of the literature. This research method has the objective of systematizing the results of published research on a specific subject and is used in Evidence-Based Practice, to incorporate evidence into the professional routine¹¹.

In the health area, the integrative review offers, for professionals from different areas of expertise, quick access to the relevant results of studies that support professional conduct or decision making and provide critical knowledge¹².

The integrative review followed a methodological path composed of six distinct stages, namely: 1) identification of the theme and selection of the hypothesis or research question for the elaboration of the integrative review; 2) definition of criteria for inclusion and exclusion of studies/sample or for the literature search; 3) definition of the information to be extracted from the selected studies/categorization of the studies; 4) evaluation of the studies included in the integrative review; 5) interpretation of results; 6) presentation of the review/synthesis of knowledge¹².

The integrative review was guided by the following Research Question (RQ): What knowledge and practices on health promotion are produced in the work process of the CHW?

Studies that met the following eligibility criteria, organized using the SPIDER tool¹³, were included in this review

S - Including in the sample or population of interest Community Health Workers who work exclusively in the SUS, after the implementation of the Community Health Worker Program (PACS).

PI - Evaluating the work process of the CHWs and their health promotion practices. The term work process used here was based on the definition of interdisciplinarity, understood as an instrument and expression of criticism of disciplinary knowledge and as a complex way of understanding and coping with everyday problems, which requires the integration of knowledge and practices of different professions and the interrelation between knowledge and action. In other words, interdisciplinarity is understood as a process of construction of knowledge and action, based on objectives shared by work groups and implied in an ethical and political position that requires dialogue and negotiation to define the skills necessary to solve the problems faced. For the concept of health promotion, we use the one proposed by the World Health Organization (WHO), who defines health promotion as a process with the objective of expanding the possibilities of action of individuals and communities on factors that affect their health and quality of life, increasing participation in the control of this process¹⁰.

D - Using studies of qualitative, quantitative or mixed methods.

E - Presenting studies with discoveries about the experiences of CHWs in the field of health promotion.

R - Including studies that mentioned data collection techniques such as focus groups, interviews, workshops, observation (participant and non-participant), cartographic studies, application of questionnaire and scales.

The following databases were used to search for articles in August, 2019: Latin American & Caribbean Health Sciences Literature (LILACS), Brazilian Nursing Database (BDENF) and Medical Literature Analysis and Retrieval System Online (MEDLINE /PUBMED). To identify keywords and descriptors, we used the Medical Subject Headings (MeSH) in the National Library of Medicine (MeSH) and the Health Sciences Descriptors (DeCS) system to find relevant articles in the health field, using the Descriptors: “Community Health Workers”, “Health promotion” and “Primary Health Care”, associated with the Boolean operator AND.

The PRISMA tool¹² was used to select the articles (Figure 1). It is a series of steps for the identification, selection, eligibility and inclusion of articles. Initially, two independent researchers carried out the database searches to identify potential studies, using the filter (step 1): articles published between 1987 and 2019.

After reading the titles and abstracts (step 2) of the studies found, duplicates, articles that did not answer the RQ, integrative or literature reviews, articles addressing voluntary CHWs and theses/dissertations were excluded. After removing the studies using the exclusion criteria, the selected studies were organized in Excel spreadsheets.

Once the first level of selection was completed, the reviewers held a consensus meeting to evaluate the selection of articles to be analyzed. At the end of this meeting, the full text studies were downloaded, and two libraries and two Excel spreadsheets with identical content were created, for the post-selection full reading.

In the third stage, the reviewers read the full texts. After this selection, another consensus meeting was held to analyze which articles were considered eligible for review.

Figure 1 presents the flowchart for the selection of documents collected in the databases consulted, adapted from the PRISMA tool, and its systematization and organization steps. Data analysis was conducted and the review was presented descriptively, allowing an evaluation of the available literature on the investigated topic, providing support for decision making, and allowing the identification of knowledge gaps for future research.

Figure 1 -  Flowchart of study selection adapted from PRISMA 

To synthetize the results, we used the reading method for data analysis, divided in three stages: 1) syncretic approach: general recognition reading, aiming to find the theme of the study, and selective reading, seeking information about the objective of the study; 2) analytical approach: reflective and critical reading of the selected articles and choice of the main contents related to the theme and 3) synthetic approach: reading of interpretation of the data/results presented in the studies.

The results were analyzed using Minayo's Thematic Analysis¹⁴. The findings were categorized and organized in Tables for the quantitative characterization of the studies, and divided in analytical categories to synthesize the themes that emerged from the studies.

RESULTS

Characterization of the studies included in the analysis

Although our search was from the period starting in 1987, the year of implementation of the PACS in Brazil¹⁵, we found that all the articles evaluated were published in the last 8 years; the oldest was published in 2011 (n=1) and the most recent ones were published in 2018 (n=5).

The analysis of the journals showed 4 national publications and 6 international publications, most of those written in English (n=6), as shown in Table 1.

Regarding the classification of articles, according to Qualis - Capes, most (N = 05) of the publications were classified as B1, followed by 01 classified as A2, 01 as A1 and 03 did not have a qualis classification, showing that the selected intellectual productions presented a good quality, as shown in Table 2.

Considering the objectives of the integrative review and the inclusion and exclusion criteria, 10 articles were analyzed. The other articles were either repeated, were not available in full or did not address health promotion, and when it was cited in their themes and abstracts, the full reading showed that they addressed strategies for prevention, recovery and cure, not focused on health promotion. It was also possible to observe that most studies had a qualitative approach (n=9) based in several methods and techniques such as case study, ethnography, oral history, affective maps, among others. The methods of analysis were thematic analysis, content analysis, speech analysis and others.

Regarding the objectives of the articles, most of them addressed health promotion as an important specific task of the CHA and continuing education/training as a strong indicator in the construction of knowledge. Table 3 describes the objectives and the methodological path of the 10 articles analyzed.

Table 3 -  Synthesis of the studies found and selected, according to authors, objectives and methods/techniques: 

Source: Elaborated by the authors, Fortaleza (CE), 2019.

Table 4 present the synthesis of the main findings of the studies analyzed.

DISCUSSION

Categories for the qualitative analysis of study findings

Health promotion is one of the main attributions of CHWs, as provided in law 13,595 of January 5, 2018 and in the National Policy of Primary Care-PNAB¹⁶⁾⁽¹⁷, which are considered powerful tools to promote healthy behaviors and expand the reach of health systems worldwide¹⁵.

The studies in this review pointed out three health promotion strategies: advocacy, health education and mediation. In the analysis process, we organized three analytical categories, namely:

Health promotion strategies for the improvement of population health

Access to health services and the struggle to guarantee the right to citizenship are indicated by studies^{18)(19)(20)(21)(22)(23} as health promotion strategies, and the participation of the population is important for the consolidation of health promotion practices.

In this sense, as ethical and political subjects recognized by the community, CHWs develop an important advocacy role, aimed at improving the quality of life of the population. The advocacy activities reported ranged from approaching community leaders to provide food for socially vulnerable families, as reported by Seutloali, Naples and Bam²² to activities related to income generation and work²⁴.

In A5²², the CHWs interviewed attribute the successes and positive changes in their practice to their health promotion activities, which include increased circulation of health knowledge in communities, increased access to health care services and early care seeking. For the majority of the CHWs in the studies analyzed^24-25 the health promotion actions are more accepted by the population because they belong to the territory. In this sense, the territory represents a space for the production of health and life and a place where power manifests in its different forms²⁶, where CHWs can take an active role, providing community-based primary health care interventions linked to the health facility.

Enablement and health education practices as enhancers of health promotion knowledge and practices

All the studies analyzed mention that the CHW have a fundamental role in relation to health education as a health promotion practice, especially focused on a healthy lifestyle, such as eating habits and physical exercises^{20)(21)(22)(25}. Maternal and child health and environmental health were reported as the most time-consuming areas of responsibility of CHWs²¹⁾⁽²⁷. We also found, in the study by Javaparast et al²¹, that the health education is included in all health programs.

Historically, one of the educational strategies used by health services is campaigns for the dissemination of health care measures. It is interesting to note that, in the studies analyzed, this practice was incorporated into CHW training as a strategy for improving the quality of the information provided to the community^23)(27)(28.

Authors also emphasize that CHWs are responsible for changing social reality through their significant actions in the field of health and, as the definitions of the term health promotion expand, their commitment to the community also increases²⁹.

However, to perform this activity in a safe manner, the CHW needs training in several themes, as his daily practice in the community requires knowledge, skills and attitudes in different fields of knowledge.

In this perspective, authors emphasize that the training for CHW requires pedagogical processes based on frameworks that enable a meaningful learning and that offer quality to the work they perform, otherwise, there may be losses in the role assumed by the FHS³⁰.

Bond and affection as health promotion strategies

CHWs are referred to as mediators in the territory and have the potential to build bonds with the community, becoming a significant attribute for social relations. Most studies^19)(20)(25 point out to attitudes and dialogues for health care and health promotion in the territory of the Family Health Strategy as enhancers of the bonds between CHWs, the community and health services.

It is also emphasized that the work of CHWs is recognized by users as a space for dialogue, due to the time spent together, the close relationship and the trust for care and health promotion in the territory of the FHS¹⁹. Health promotion is understood as a field of interactions between people living in the community, who give meaning to life, in a mutual relationship, becoming an attribute of social networks present in the territories.

Other studies report that the Home Visit (HV) is a space for health promotion that allows the construction of affective bonds and where the practices of the CHW are guided mainly by empathy and attentive listening¹⁸⁾⁽²⁷, which are the basis of the relationship with older adults, enhancing health promotion for this part of the population.

FINAL CONSIDERATIONS

Based on this study, we believe that there is still a gap in the production of knowledge about health promotion as a daily practice of CHWs and that their work process is strongly marked by disease prevention actions, distribution of commodities/medications (ferrous sulfate, antiparasitic and oral contraceptives), and collection of socio-demographic information and health status of the population. Therefore, the production of care based on health promotion stays in the background.

When we study the dynamics of the knowledge and practices of CHWs regarding the theme of health promotion, we are faced with an infinite number of possibilities. However, the creation of bonds as an inseparable tool in the work of the CHW is very common in the speeches. Furthermore, the mobilization of knowledge on health promotion is strongly associated with the technical training of CHWs, who incorporate disciplinary knowledge from health services to their knowledge of the community, including their own life experience.

Therefore, this study reinforces the importance of the practices and knowledge of CHWs on the development of health promotion actions in their territories, and proposes reflections on the health care model, based on the attributes of Primary Health Care.