Keywords

Introduction

Health promotion as advocated by the National Health Promotion Policy (PNPS) in Brazil considers the autonomy and uniqueness of individuals, collectivities, and territories. Its main objective is “to promote equity and the improvement of conditions and living modalities, expanding the potential for individual and collective health and reducing vulnerabilities and health risks from social, economic, political, cultural and environmental determinants” (Brasil, 2014, p.13).

Starting from this premise, we consider that training processes in health promotion for undergraduates, graduate students, and professionals from different disciplines should also involve participants from social movements and community groups. This involvement thus enhances the collective construction of research and action projects, with tools, skills, and abilities to translate health promotion theory, policy, and research into practice (Battel-Kirk et al., 2009; Pinheiro et al., 2015).

A training process, supported by the principles and guidelines of community-based participatory research (CBPR) and fostering the participation of subjects and the community in all stages of the knowledge construction process, proves to be equally potent as a training methodology in health promotion. We understand communities to be specific groups of people and organizations, including from professional, patient/user, and public manager sectors. This set of stakeholders can be considered an ecologically connected system, in which taking account of contexts and cultural knowledge is considered an important partnership practice (Trickett & Beehler, 2013).

In CBPR, all participants are co-authors of decisions with goals to reduce inequities and improve living and health conditions. The CBPR theoretical and methodological framework has had its effectiveness demonstrated in international studies, for example, at the University of New Mexico, Engage for Equity: A Long-Term Study of Community-Based Participatory Research and Community-Engaged Research Practices and Outcomes (Wallerstein et al., 2020). Beyond Engage for Equity, a major new scoping review identified 100 studies of reviews in English of different types of reviews (systematic, narrative, etc.) of community-engaged/CBPR and other participatory research, with 58% of those demonstrating outcomes (Ortiz et al., 2020). Adding other languages would even more show the growth of the field.

Through the experience developed in Brazil, reported here, the importance of a course on CBPR is highlighted for the development of competencies in health promotion, understood as a combination of knowledge, skills, and attitudes, which allows an individual to perform tasks according to identified demands (Battel-Kirk et al., 2009; Pinheiro et al., 2015). In addition to guaranteeing elements of “diagnosis,” “planning,” and “implementation” in health promotion, participatory research that adopts the process of doing and sharing knowledge with groups and communities creates opportunities for participants to be flexible and permeable actors to produce the necessary changes. These learnings can be transformed into elements of “advocacy,” developing “communication” and “leadership” in the process of following CBPR methodologies so that actions can be implemented and evaluated in a participatory way. Thus, the process of participatory research alone generates empowerment for its participants in the combined act of “teaching-learning-reflecting-acting” and adds value to training in health promotion.

CBPR is designed with the subjects involved, because its members are directly affected by the issues that, according to their understanding and perception, need changes. Here we highlight the contribution of Paulo Freire’s thought, which is based on a political-pedagogical vision that is guided by the methodological principles of action-reflection-action, whose main concepts are dialectical union between theory and practice; education as a political act; and valorization of popular knowledge and dialogue as a condition for knowledge, autonomy, and transformational change (Freire, 1991, 1992, 2011). The action-reflection-action process is proposed as a cyclical model, which starts from self-reflection (generating questions) to listening (from the thematic questions and from the analysis of the experience itself), to dialogue (from the group reflection, from the analysis of a selected case or a concrete reality), to action (as part of planning alternatives and solutions to the problem situation), and to synthesis (which presupposes the collective evaluation of alternatives and arguments). These assumptions can support educators to engage in critical dialogue, using multiple methods and strategies. They can, above all, assist in the development of negotiation skills and other necessary skills for the establishment of dialogue between the various actors in relation (Mendes, 2008). By incorporating these philosophical, evaluative, and political assumptions, research makes it possible to establish effective, affective, cultural, and social communication and, consequently, strongly encourage participation.

Participatory research differs from more conventional research since in opening itself to the participation of people from the choice, deepening, and problematization of issues in relation to the object being investigated, and establishing objectives and analyses of these data, it supposes that participants know “that they already have and that it is brought” into the research, which in Freire’s terms (1991, 1992) would be the generating themes. As Green et al. (1996) have stated, the greatest contribution of this type of research is in the epistemological and political field, since it proposes to question the positivist academic supremacy when recognizing the partnership between researchers and the community.

The elaboration and sharing take place in coexistence relationships that incite, at the same time, the researcher to collect the knowledge derived from actions which contributes directly to the production of knowledge (Thiollent, 1996). For Borda (1986, p. 46,47), it is about “taking off the mask of neutrality and the disguise of objectivity” and asking the following questions: “What kind of knowledge do we want and need? Who is scientific knowledge for and who will benefit from it?”. As an instrument of social transformation, it opposes the adoption of a rigid model of knowledge production that leads to a reductionist and static view of reality (Borda, 1986). Freire (1991) argues that reality is not something static but is built on a dynamic relationship between objectivity and subjectivity.

It is recognized that the phenomenon to be investigated is part of people’s daily lives, which has the primacy of discussing it and presenting it according to their historical and cultural references, attributing meanings to it. CBPR also departs from conventional models because, by providing full participation, it recognizes that the community has its own voice and knowledge and not only behaves toward groups and people but as objects to be observed, studied, and scrutinized by “outside” inward. It demonstrates flexibility and strengthens the role of local actors and their contributions with their knowledge to the processes of partnership and shared power, influencing the change in living and health conditions.

The participation of those involved in all stages of the research – from the definition of objectives to the implementation of actions, per se – does not guarantee that there is, in fact, “spontaneous knowledge directed toward action,” unless the dialectical conditions are guaranteed for reflective dialogue and actions represented by researchers and the community (Westphal et al., 1996). This focus on the health field favors an implementation structure that supports participation and equity, which has already been amply proven through many CBPR projects that report impacts on health equity policies, practices, and results (Cargo & Mercer, 2008; Israel et al., 2010; Wells et al., 2013; O’Mara-Eves et al., 2013; Ortiz et al., 2020; Oetzel et al., 2018). Within CBPR, the form of community-engaged research most committed to equity, shared power, and empowerment is the major driver of this approach (Kleba & Wendausen, 2009; Wallerstein et al., 2019), like much of participatory action research that comes from the global south (Borda, 1986). Thus, development of collaborative actions for health promotion practices, based on the principles of popular education and shared power, promotes respect, overcomes prejudices, and reduces hierarchies of power in the search for equity.

Context of the Experience

In 2019, the research group “Multiple Seeds” (Multiples Sementes) was created, which constitutes a collaborative network between the Center of Participatory Research, College of Population Health, University of New Mexico (USA); the School of Public Health of the University of São Paulo; the Federal University of São Paulo; the Federal University of ABC, University of Brasília; the Federal University of Minas Gerais; the Federal University of Ouro Preto; Federal University of Pernambuco; Community University of Chapecó; Pontifical Catholic University of Rio de Janeiro; Federal University of Paraíba; State University of Maringá; State University of Bahia; Federal University of Goiás; and University Estácio of Sá. This group aims to share tools and reflections on CBPR, foster a collaborative network of educators and multipliers and participatory research centers for local development and democratization of knowledge, and expand the training and research network.

In 2020, the course “Participatory Research and Empowerment” was offered simultaneously in five cities: São Paulo/SP, at USP’s School of Public Health; in Rio de Janeiro/RJ, at the Pontifical Catholic University of Rio de Janeiro (PUC-Rio), in Chapecó/SC, at the Health Secretariat of Chapecó; in Recife/PE, at the Federal University of Pernambuco; and in Goiânia/GO, at the Federal University of Goiás. The experience took place in 2021, and an edition will be held in February 2022 on national-level dialogue with health promotion, Freire-based popular education, and interactive and participatory methodologies in a transversal and structuring way. The participants’ experiences were necessary inputs for the development of skills, attitudes, and positive feelings in the face of interventions anchored in the theoretical assumptions of CBPR.

This course was an outgrowth of an initiative from Nina Wallerstein, with sponsorship by the Health Promotion Unit of the Pan American Health Organization (PAHO), to launch a course with Latin American colleagues in 1999 on Empowerment, Community Participation and Health Promotion, grounded in the philosophy of Paulo Freire. Its current third revision (co-authored by Wallerstein and Parajon, 2021) has been evolving with much collaboration with Brazilian colleagues. The course is now focused on community-based participatory research and empowerment which takes, as its reference, the experience of the “Engage for Equity: Advancing Community Engaged Partnerships” National Institutes of Health study. Engage for Equity (E2) is a 16-year investigation into what makes CBPR and participatory health research (PHR) effective in reducing health inequities (Wallerstein et al., 2020). Engage for Equity has developed CBPR tools and resources to improve participatory methodologies and to evaluate the results of partnerships between universities and communities. Its scope is the creation and implementation of workshops, training tools, and use of resources to strengthen participatory methodologies in diverse contexts to achieve equity in health through interdisciplinary and intersectoral educational practices, committed to critical learning (Parker et al., 2020). In particular, the workshops are based on the CBPR conceptual model, which is being used internationally for strategic planning, evaluation, organizational learning, and quality improvement of partnerships processes, and outcomes (Wallerstein et al., 2021).

This report concerns the experience of the Rio de Janeiro Nucleus, whose authors acted as facilitators under the supervision of Professor Nina Wallerstein of the University of New Mexico, USA. The participants, coming from different areas of activity and professional training, were constituted as an interdisciplinary work group, composed of members with diverse experiences (medical practitioners, social workers, nurses, leaders, dentists, educators, sociologists, psychologists, nutritionists) who were able to share learnings guided by this training process which also successfully produced capacity for a multiplying effect.

The course procedural and training objectives and activities were intended to integrate opportunities for building empowerment into the participatory research process, to analyze local problems and different forms of power relationships, and to collaboratively build skills in participatory processes, so that they could be applied for transforming power relations toward greater equity in health. The course integrated popular education by Paulo Freire as a foundation for facilitating CBPR processes; supported personal and collective reflection on the roles and positions of power and privilege of different social actors; worked with instruments and methods to formulate, identify, measure, and make visible outcome indicators from participatory research processes; and supported reflections on and sharing of experiences inherent to the field of health promotion.

The Methodological Path

The course was offered in the form of face-to-face workshops and addressed the following themes: power, individual and community empowerment, and participatory community-based research, oriented toward training in health promotion.

Workshops can be considered methodological tools that are characterized by dialogue between the subjects with the intention of reflecting on the daily life and work. In this way, the problematizing workshops are in harmony because they are open models of training and research, in which reflection is maintained as a guiding principle in the entire study process (Chiesa & Westphal, 1995). Galletti (2004) clarifies the word “workshop,” saying that it is a broad term, originating from the Latin officina, with different meanings, but encompassing the world of work and has in one of its numerous meanings the place where great transformations take place.

We emphasize that workshops have been widely used in the scope of participatory methodologies and in health promotion in the training processes, pointing to new configurations and uses of the activity. Our intention, when using this strategy to produce data, was to open space to reinvent the encounter between subjects, favoring the processes of creation and production of subjectivities, which could enrich, permanently and dynamically, the exchange of experiences. The workshops allow full integration between theoretical knowledge and practice, as commented by Vieira and Volquind (2002), allowing for reflection in action.

The curricular basis of the course used the CBPR methodological steps created in Engage for Equity, which brings a pedagogy that combines the formal and the experiential and, above all, fosters practical and critical mechanisms for the development of more inclusive training processes in the search for alternative paths to construct health promotion interventions that have a positive impact on improving lives.

Training and Learning Experience

Following the principles of the training process, the “Participatory Research and Empowerment” course was developed in 2020 in 8 modules held in 3 meetings, with 21 participants. Table 21.1 presents the course modules and their objectives.

Table 21.1 Methodological path, course module, and objectives
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Introduction, Expectations, and History of the Projects

In Module 1, after the presentation of the team and workshop participants, a sheet of paper and 5″ X 7″ cards were distributed so participants could write their course expectations, using the following guidelines: my name is, my course expectations are, participatory action research is, and empowerment is. The cards were posted on a mural, having been grouped by themes to make it easier for everyone to see them. The use of this methodological strategy of mobile visualization called Metaplan (Cordioli, 2001) allowed the participants to express themselves freely, since it facilitates the participatory process in a non-hierarchical way.

Another welcoming dynamics called “biography” allowed the participants to present their life and work trajectories. The intention of this activity was for the group to get to know each other, create bonds, and identify possible partnerships based on common work themes. From then on, the following themes of collective interest were identified to generate four working groups that continued together throughout the formative process of the workshop: work and gender; access to primary health care; mental health; and community empowerment.

A collaborative tool from CBPR, called River of Life (Rio da Vida), makes it possible for researchers to document their projects’ context and history, recognizing the route, main milestones, achievements, and barriers. It also allows to review where and how the project started, the status, and what the participants want for the future (Parker et al., 2020; Sanchez-Youngman and Wallerstein, 2018). Participants are encouraged to use symbols that portray the history of the project. This tool used in the workshop provided a reflection on the life journey of the partnership or project, making it possible to create a historical timeline of engagement with communities and partnerships.

As an example, during the training process, the group that chose to work with the theme of gender violence created boats in their River representing women assisted by the project who are victims of violence. They demonstrated the difficulties they experienced with stones in the River, identified as violence, political context, police operation, and other complex daily situations. This graphic representation allowed the group to reflect on the importance of context analysis to guide professional practices around health promotion.

In continuity, a reminder of previous activities was carried out. Participants reported the impact that some dynamics had on them and how they reverberated throughout the formative process, giving rise to a discussion on equity, justice, and power. Also highlighted were the “crossings” of daily life in their different contexts, which do not necessarily reflect who we are nor our potentials and our creativity. In general, we mechanically repeat gestures that make us do our duty. The activities carried out so far have proved to be mobilizing for working with the communities, which should reflect the horizontality of decision-making considering the mutual interests.

Power and Empowerment and Paulo Freire’s Dialogue Methodology

In Modules 2 and 3, the discussion of power and empowerment was mediated by a collective activity that aims at power relations. The objective of this activity is to provide an experience that generates reflections on aspects of our society that dynamically influence unequal relations of power, privilege, collaboration, and capacity to dare to propose new rules, as well as to discuss the impact of these issues on their projects. The interactive activity also allows each participant to recognize in himself and in the other, the conditions that generate inequalities or expand possibilities for reflection on inequities and power, among other related themes. This activity was very potent for the debate about the conditions of power and privilege that are often seen as “natural” and limit our ability to react to unjust rules.

In general, innovative reflection-action tools such as those used in the workshop provide academic and community partners with structured, yet flexible ways of examining their practices and identifying collaborative approaches for greater collective empowerment. Process tools and activities that stimulate our values ​​and commitment to equity and align our work with others who share our vision and ideals contribute to broader project outcomes and reinforce the objectives of the partnership (Parker et al., 2020).

The theoretical questions about power and empowerment have been deepened based on the Freirian framework of “praxis.” Reflecting on hierarchies of power is critical to empowerment, and the tools provided opportunities for continued reflection on power and other issues that support sustained participation in commitment and trust. The topic of power was debated in the workshop projects and was central to the discussions. The memory and history of Paulo Freire and his conceptions were presented in a shared way by participants and facilitators, materializing the essence and theoretical coherence of the workshop.

Community-Based Participatory Research Model

In Module 4, the CBPR conceptual model was presented with four domains: context, partnership processes, intervention and research, and results, which is available on the website https://engageforequity.org. In general, each domain includes constructs or themes that enhance communication between the various actors (communities, universities, professionals, and governments); favor the voices of the community within the research; intervene in real local needs with strong participation of those involved; and combine knowledge and social action for change with an impact on social policies and practices. However, the central dimension of CBPR weakly highlights the specific research and data collection method used but more strongly invests on changing the relationship between researchers and subjects involved, so that people become collaborative partners in the investigative processes (Wallerstein & Duran, 2006; Wallerstein & Duran, 2018).

The format proposed by the model was used by the groups as a reference to develop their intervention projects by articulating participatory research principles and values of health promotion. There was a fine line in relation to what is defined as “research” and “action”/“intervention,” and for many of the course participants, these themes still deserve further theoretical and methodological deepening. An important aspect presented by participants was the adequacy of the activities carried out to promote health promotion actions, both in the context of scientific research and in the areas of assistance, education, development, and health promotion.

The engagement of the people involved permeates their individual history and their contexts. As a pedagogical support for the discussion of “identity and belonging,” a playful activity carried out with a large map of Brazil, using colored tapes, papers, and adhesive tapes, produced affective memories of the places they came from and their life trajectories. Throughout the workshop, the collaborative ambience fostered reciprocity among the members, this aspect being part of the training process in the CBPR methodology, which recognizes the importance of building spaces conducive to reflection and the collective construction of socially relevant projects.

The principles and methodologies of Freirian popular education in Freire were presented in Module 4 as a way of seeing the world. In its pedagogical path, in exercises for coding and decoding “generative themes,” participants create scenes and/or objects that lead to the problematization of a given situation. The identified themes are codified, and their contradictions are pointed out and start to gain meaning as these themes are dialogued and contextualized through a critical and social view of the subject discussed (Freire, 1992). Within the scope of the workshop, participants in small groups brought objects or images that represented people’s reality and presented them to the larger group. As the codifications were elaborated, the participants made their critical analysis, revealing the hidden contradictions.

To exemplify, we can highlight the coding/decoding exercise of the group that worked on access to primary care as a theme. An urban transport card for the city of Rio de Janeiro was presented as a code and triggers the question: does the card guarantee everyone’s access to health? The debate brought as an argument that the transport card is not a guarantee for some people to access to health services, especially for elderly and people with disabilities, nor does it guarantee full circulation in the city.

After a reflective and affective dive that led to individual and collective deepening, the domains of the CBPR conceptual model were resumed, deepening the construction of projects that addressed the themes related to work and gender with women from the favela, reflections on facilitating access to primary health care, mental health from an intersectoral perspective, and ways to involve and strengthen community work.

Partnership Indicators, Participatory Assessment with a Focus on Results, and Empowerment Indicators

In Modules 5–7, participatory assessment, partnership, and empowerment indicators were addressed. In general, it is a challenge to health promotion to define qualitative indicators that can guide and reveal the results obtained from participatory experiences. Evaluative approaches in health promotion policies require innovative and complex strategies, theories, and mechanisms through which actions and programs bring about changes. In each social context, varied methods are required, but, above all, methodologies need to be consistent with the problems involved. Thus, understanding of meanings, perceptions, and cultural aspects is fundamental for successive approximations to the complex reality. To evaluate is to make a judgment of value, and in this direction, the reflections presented in the workshop pointed out that the evaluation process should not be taken as an end but as a precious opportunity; inclusion of diverse actors in reflections about health promotion interventions, programs, or policies for learning and evaluative capacity building can generate information that supports decision-making (Mendes & Sacardo, 2019).

In carrying out this module, the “Definition of Indicators” activity for project evaluation enabled participants to identify the need for the community to actively participate in all stages of the project to be developed, contributing to planning of activities and to identifying results to be achieved. It also made it possible to discuss the political dimension of the actions. Empowerment and autonomy led to the construction of a new narrative in these groups and implied looking at the approach as something constructed, as “fabric sewn” by several hands. This implies for the researcher/researcher/facilitator a change of paradigm and conscience: what is “their objective” or “their looking” no longer makes sense when what is sought is the recognition of choices and reframing by the whole group. In this Module, the participants had difficulties in identifying and building indicators that would make it possible to measure the process and results of health promotion actions. While more time for skill-building was needed, this area of participatory evaluation still constitutes one of the biggest challenges to the evaluation of participatory practices and health promotion projects.

Systematization of the Course and Assessment

Module 8 at the end of the course brought instruments, systematized roadmaps for content evaluation, methodological strategies, facilitation, involvement, and participation. It should be noted that the evaluation was being carried out throughout the training process, but at this moment we sought to recover the most significant learnings of the group. With different expectations, we highlight that the opportunity to acquire new theoretical and practical learning was pointed out, as well as the possibility of reflecting on professional performance and experiencing the CBPR method.

From our point of view, training in health promotion was strengthened based on the methodological construction favored by the development of content and reflections from using the CBPR model and the overall CBPR approach. The experiential aspect acted as a facilitator of the teaching-learning process to the extent that it made everyone part of their own learning process, expanding repertoires and giving reflective vigor to the development of health promotion skills. Thus, the group of participants demonstrated alignment with the purposes of the course and were open to participatory methodologies in all its stages, showing themselves to be involved and committed to all activities.

Considerations About the Applicability of the Experiment

The group’s engagement favored the recognition of the intense and organic connection between research and action and doing with the people, between the knowledge built and the transformation generated in the experienced reality. We highlight important aspects of the methodological formative path of the workshop, starting from reflecting from the personal experiences to generate the central themes that, in this way, embodied the process of collective construction.

We highlight the opportunity to use CBPR approaches in order to acquire new theoretical and practical learning, based on the possibility of reflecting on professional performance. Training in health promotion is enhanced by the methodological construction favored by the development of content and reflections arising from this approach. The proposed experiential aspect acted as a facilitator of the teaching process, in that it made everyone subjects and authors of their own learning, expanding repertoires and giving the necessary reflexive vigor to the development of competencies in health promotion.

The activities allowed the participants to “dive in” in their identities and establish connections, building and strengthening care bonds with each other during the training process. This contributed to the construction of new knowledge, about new approaches and practices.

The 2020 edition of the course materialized a methodological path designed by several hands, configuring new tributaries to our Rivers of Life through the meetings provided throughout the preparation and execution of the course. This path was marked by co-creation, dialogue, dynamism, shared values, knowledge built, and affections exchanged between all involved. As a result of this experience, the network of Multiples Sementes formed a close-knit group of facilitators throughout the year 2020. Given the context of the pandemic of COVID-19 in the year 2021, this group of facilitators chose to deliver the course remotely at the national level simultaneously, in nine groups from nine regions of Brazil. This new approach of an online synchronous format, with 104 participants, allowed for large group presentations, small group projects, and regional dialogues all on zoom. It configured the potential for reapplication of the CBPR and empowerment course and the methodological approaches, considering the different contexts and subjects, but maintaining the guidelines and principles regarding the purposes of action-reflection-transversal action, as an important strategy for health promotion training.

Our results demonstrate and recommend that this active and participatory methodology can be applied in undergraduate or graduate courses as discipline, short-term courses or intersectoral social programs with the goal of developing theoretical and practical skills for the promotion of healthy and equitable communities.

Table 21.2 displays our reflection on the six triggering questions suggested by the editors.

Table 21.2 Authors’ reflections on the six triggering questions suggested by the editors
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