Keywords

1 Introduction

Intersectoriality is highlighted in agendas, policies and models as a central axis for the development of public policies and as a strategy for social transformations. It is also a key health promotion strategy, based on the recognition of opportunities for the social production of health that reside outside the health sector.

Despite the existence of models built around the importance of intersectoriality, conceiving it as tangible and achievable remains a challenge, particularly for health promotion research. Studies provide few details about the processes, contexts and achievements of intersectoriality and highlight the difficulties in identifying its results (Akerman et al., 2014; Chiari et al., 2018; Kranzler et al., 2013; Shankardass et al., 2011; Tess & Aith, 2014). There exist differing and conflicting conceptual and analytical frameworks aimed at explaining what intersectoriality is and how it is incorporated into public policy processes. Sectoral models do not adequately reflect the problems that are the focus of intersectoral action and the social dynamics that affect them (Franceschini, 2019).

Additionally, the complexity of social problems – health inequities, social exclusion, poverty, etc. – requires the development of new strategies. Such social realities mean that the current intersectoral models that focus on institutional or policy processes are not viable. Strengthening networks (social, community, personal, professional, services) has emerged as an alternative to guarantee effective intersectoral public policies and an integrated view of social problems. As such, understanding the interdependence of intersectoriality and networks in our contemporary society opens up new dimensions for health promotion research.

Between 2017 and 2019, research was conducted to understand how intersectoriality had been incorporated into the actions of the Intersectoral Network “Guarulhos, the City that Protects” (GCP Network ) to prevent violence against children and adolescents in the municipality of Guarulhos, São Paulo, Brazil. With this qualitative research, which was based on a health promotion framework and used as a case study approach, the actors who developed it aimed to understand the meanings of intersectoriality and to identify which factors intervened or conditioned the intersectoral processes and the effects of the initiative. The case study was conducted through in-depth interviews with the Network ’s actors, participant observation of Network activities over a period of 2 years and analysis of available materials produced by the Network since its launch in 2010 (documents, communications, reports, etc.) (Franceschini, 2019).

Considering that intersectoriality, by nature, involves actors from various sectors, the research focused on the interfaces between the fields of education, health, social and development assistance and public safety. Decentralization of actions that are under the responsibility of various sectors, participatory management, empowerment and actors’ predisposition to participate in such actions were the objects of this research, and the data produced were the object of reflection by those involved in these practices. The territory – as geographical spaces of life and co-living for children and adolescents – was our empirical base to consider the actions aimed at protecting these populations, conducted by the actors who formed local violence prevention networks. This chapter reflects upon the experience of conducting this research and the lessons that can strengthen health promotion research.

1.1 The “Guarulhos, the City That Protects” Intersectoral Network

The GCP Network was formed in 2010 in the municipality of GuarulhosFootnote 1 as a school health project led by technical personnel from the municipal health and education departments who worked at the local level (schools and primary healthcare centres). It aimed to share information about the types of violence that affected children and adolescents and promote actions to address them (SECEL, 2016). Between 2012 and 2015, districts in four regions of the city were organized as local networks and integrated into the GCP Network .

In 2015, a municipal decree formally established the GCP Network ’s Intersectoral Committee made up of the Health, Education, Development and Social Assistance and Public Safety departments as well as Boards of Education, the Municipal Council for the Rights of Children and Adolescents and Child Protection Services. By 2019, the GCP Network encompassed 195 representatives (from services, institutions, organizations) and formed a city-wide initiative for violence prevention, mobilizing multiple sectors and strengthening their capacities for action, particularly at the territorial level.

1.1.1 Why Did We Study the GCP Network?

An initial assessment was conducted of the local intersectoral initiatives taking place in the state of São Paulo, Brazil, and the GCP Network was selected due to: (1) its express goal of mobilizing various sectors to seek solutions to a common issue; (2) its duration, at the time, of 7 years, which pointed to a capacity to establish sustainable relations, mechanisms, processes and structures that allowed continuity over time and political transitions and (3) its proposal to work across municipal departments and with a territorial basis, which created interesting dimensions to analyze the interfaces between municipal policies and local demands.

2 Defining the Research Object: Why Did We Focus on Intersectoriality?

The complex reality, existential problems and multidimensionality of human and social needs require differential approaches from those who look for solutions for a variety of problems: economic, social, political, educational, health, environmental, etc. These problems are embedded in a globalized world, and their solutions demand a new relation between society and each of these fields. In health promotion, the prevention of social problems and disease requires integration and coordination between practices, policies and the sectors responsible for them. Therefore, research focusing on intersectoriality within a health promotion framework is fundamental.

Intersectoriality is a core health promotion strategy, emphasized as essential to tackle the social determinants of health (Jackson et al., 2006; PAHO/WHO, 2011). It is also an approach to broaden the discussion about how to improve quality of life beyond the health sector and is a requirement in development models.

However, in practice, intersectoriality is often uncoordinated and ambiguous, resulting in technical, political and institutional processes that may be contradictory, ineffective and generate resistance instead of synergies. Researchers point to the limited problematization of its conceptual/analytical framework as an obstacle to conduct studies aimed at understanding the intersectoral process, mechanisms and impacts (Cunnil-Grau, 2005; Santos, 2011).

The literature indicates that data regarding intersectoriality are scarce, superficial, descriptive and are presented from isolated perspectives (Shankardass et al., 2011; Akerman et al., 2014). A review of the literature highlighted the various concepts associated with intersectoriality that can lead to confusion about its scope, reach, mechanisms, processes and expected outcomes (Akerman et al., 2014; Cavalcanti & Nicolau, 2012; Junqueira, 1997; Inojosa, 2001). Health promotion researchers highlight the lack of understanding about effective intersectoral mechanisms as a challenge to consolidating models such as Health in All Policies, promoted by the World Health Organization (Kickbush, 2010; McQueen et al., 2012). The challenges identified include the development of theoretical and analytical frameworks for research and evaluation, the documentation of experiences and the construction of evidence.

This research sought to fill in some of these gaps. The theoretical framework was informed by Manuel Castells’ discussion on the impact of networks and information to catalyze social transformation in a contemporary society and by Anthony Giddens’ social structuration theory, which considers elements such as agent, agency, power, structure and structuration (Castells, 2002; Giddens, 1986). We also considered analytical models for intersectoral action (Solar, 2013; Cunnil-Grau, 2014), how these aligned with the health promotion framework and what the interconnections were between intersectoriality and health-promoting principles such as participation and network development.

2.1 The Need to Work on a Common Understanding of the Object of Study

The research was oriented by the question: How are intersectoral relations and actions being constructed within the experience of the Intersectoral Network Guarulhos, the City that Protects, to address violence against children and adolescents in the municipality of Guarulhos, São Paulo?

The objectives that guided the methodological design included:

  • Analyzing the intersectoral strategies within the GCP Network , considering the perspectives of all sectors involved

  • Identifying factors that affected the consolidation and sustainability of the GCP Network

  • Analyzing conceptions related to intersectoriality and networks among the social actors involved

  • Understanding whether (and how) collective practices were being institutionalized by the sectors/actors

  • Identifying the results and effects of GCP Network activities in relation to intersectoriality

The following definition was proposed as a starting point: “Intersectoriality refers to institutional, technical and political interfaces between governmental and non-governmental sectors, with the goal of overcoming fragmentations and addressing complex social problems beyond the scope of individual public policies. These interfaces potentialize the creation of knowledge and the development of synergetic solutions to social problems. Intersectoriality goes beyond the mere juxtaposition of sectoral actions and aims to promote social development and transformation.”

The approach to the object of study considered the following dimensions:

  • Structures: How was the GCP Network organized, considering the institutional arrangements, sectoral mandates, legal frameworks and resources?

  • Processes: What mechanisms and actions, such as entry points for joint action and planning processes, among others, fostered intersectoriality?

  • Effects and results: What did the GCP Network produce, impact or affect, considering dimensions such as relationships, practices, knowledge, resources, leadership, policies and empowerment?

The research design implemented in this study (presented below in Sect. 15.3) represents the end result of a highly dynamic and interactive process. The definition of the object of study and the conceptual framework and the methodological design of the research evolved greatly over the course of the initial stages, as should be the case in health promotion research tackling complex and interconnected issues in the real world, based on feedback from the participants.

As an example, the initial study design focused on intersectoral models developed in the field of public health and health promotion, which often define the improvement of population health as the end result/objective of intersectoral action. When presented with this design, actors of the GCP Network , particularly those who were not from the health sector, reacted strongly against such models. They expressed discontent about what they understood as a hijacking of the intersectoral efforts by the health sector that dismissed their motivations to engage in such initiatives (for example, improving access to education, improving social safety networks and improving access to housing, among others). One discussion was about what we meant by a broader concept of health, which was not understood by most participants, including those from the health sector itself.

The discussions brought to light the actors’ various conceptualizations about intersectoriality, its purposes, means and strategies. These were often based on different models and conceptions put forward by their training and field of work. For those from the education sector, the goal of intersectoriality was to promote access to quality education for all; actors from the social development sector understood that the goal of intersectoriality was strengthening social protection networks and poverty prevention; public safety representatives understood intersectoriality as a means to improve community security and decrease determinants of crime; those from the health field pointed to intersectoriality as a strategy to promote population health. These visions, interests and intentions created a series of impasses and pointed to the importance of seeking a conceptual alignment among actors about their stakes, interests and responsibilities and a definition of common goals for their collaboration.

As a result of these discussions, the research team went back to the drawing board and conducted a new review of the literature to better understand the models, epistemologies and strategies related to intersectoriality that permeated the work of the other sectors involved in the GCP Network . This pointed to new understandings of the challenges related to intersectoral action (when considering the inconsistencies and conflicts between sectoral and interdisciplinary models) and led to significant changes in the conceptual framework and methodological design of the study, in order to incorporate a multitude of perspectives beyond what is usually the focus of health promotion research. The final study design is the result of this process; it aims to look at intersectoriality as a multi-stakeholder policy and social process. It does not focus on “health” in itself but considers that it is at the intersection of various dimensions, actors and social dynamics that the social production of health takes place.

Taking time and going through this process of reviewing the conceptual and methodological design of the research, which often meant taking steps back, reflecting upon our own biases and adjusting expectations were all crucial in order to gain the trust of research the participants and to establish a fruitful collaboration with them, thus making them our partners rather than objects of study.

2.2 Why Did We Focus on the Actors of the GCP Network ?

Over the course of its existence, the GCP Network has been led by technical personnel from municipal departments and local actors. This became a central point in the definition of the research framework: the network did not emerge from policymakers but from those who were caught up in the challenges of implementing policies while being pressured by local demands. The initiative to launch the Network was based on their dissatisfaction with the mechanisms offered by the municipal administration to address violence against children and adolescents, in-depth knowledge of the problems that afflicted each territory and their frustration with a history of attempted collaborative efforts (formal and informal) that they believed were isolated and ineffective.

The proposal to establish the Network was also based on the recognition of intersectoriality as a fundamental strategy to address their common problems and that of the actors’ roles, responsibilities, competencies and strengths to be part of the solutions. Each actor that is a part of the GCP Network has their own trajectory, goals and interests. In that sense, understanding their motivations, perceptions and experiences became central to understanding the modes of organization, relationships and strategies to overcome challenges and potentials for the development of more effective intersectoral policies.

3 Methodological Design: Approaching the Research Object from Multiple Angles

A qualitative research approach was considered the most appropriate based on the recognition of the subjectivity of human knowledge and experiences. While these are individual and specific, they are also whole, in and of themselves. Knowledge production in social sciences should seek to understand social processes from the perspectives of those immersed in those contexts (DaMatta, 1993). Such understanding depends on the meaning of the world for those who live in it and a “reality” that is made up of multiple, dynamic and simultaneous individual and collective experiences (Victora et al., 2000). Such approach fits in with our research, as intersectoriality is influenced by contextual, social, historical and political factors, and our focus was on understanding this phenomenon through the lenses of those who experienced it and the relationships they developed across social, institutional and political spaces.

The complexity of the research object pointed to the need for multiple methods, namely, social network analysis, content analysis, document analysis and participant observations.

3.1 What Was the Contribution of Each Methodological Component?

  • Social network analysis (SNA): SNA supports the identification of relational and structural links embedded in social processes through visual representations (Higgins & Ribeiro, 2018). It helped understand how the actors of the GCP Network connected among themselves and with the Network structure as a whole and how relationships were formed, considering institutional affiliations and sectors.

  • Qualitative analysis: Analyzing experiences, conceptions and perspectives of the Network participants was a key dimension. This required an in-depth exploration, through semi-structured interviews, of people’s ideas, feelings, interests and interpretations related to intersectoriality and the GCP Network . The contents of the interviews were categorized, interpreted and analyzed using Bardin’s content analysis methodology (Bardin, 2009).

  • Document analysis: Numerous actors and institutions have been involved in the GCP Network . Given that the Network has existed since 2010 and has a high turnover of personnel among the participating institutions, developing a timeline to understand the Network required conducting a thorough assessment of documents, reports, meeting logs, publications and other materials to help reconstruct its history (Cellard, 2012).

  • Participant observation: The observation of phenomena allows for direct contact and a better understanding of the research object (Minayo, 2010; Jaccoud & Mayer, 2012). This requires immersion of the researcher in the group or activities being observed. As such, the researcher becomes an actor in the research and interferes with its object and context. The implication of this is the recognition that qualitative research is not a neutral endeavour and must make explicit the relationship between the researcher, the social reality of being investigated and the research subjects. This methodology helped understand the dynamics of the Network and its interactions, contradictions, dilemmas and strategies. This contributed to identifying the processes, structures and strategies related to knowledge production, practices, challenges, barriers and facilitating factors.

3.2 What Was the Sampling Methodology?

The research sample was constructed through the snowball technique: an interviewee identified his or her main partners in the GCP Network over a period of 2 years prior to the interview and they were invited to participate in the research. The process started with the identification of an initial group of key informants, and, through their connections, other people were identified and invited to participate in the research. This went on until the process reached a saturation point, at which either no new contacts emerged or these no longer offered relevant information (Vinuto, 2014).

A total of 56 persons were interviewed. They mentioned a total of 90 partners. All sectors and regions of the GCP Network were covered by the interviews.

3.3 How Were the GCP Network Actors Involved in the Research Design and Implementation?

Social participation refers to the engagement of state and civil society actors in the development and social control of health promotion actions. It can strengthen community organization and improve resource distribution, access to information and capacity building for those marginalized during decision-making processes, thus creating spaces for social control by citizens (WHO, 1986; Westphal, 2012).

The GCP Network ’s actors were involved in all phases of the research. In 2016, the project was presented to the Coordinating Committee to assess its interest and to gather inputs. This included representatives from all sectors involved, which was particularly interesting since the group’s different perspectives on intersectoriality quickly came into view, sparking reflections about the intentions and motivations that the group had not contemplated until then. The project was also presented to the local networks. Suggestions were incorporated into the project design and helped redirect the research question and methodological framework.

This pattern of interaction accompanied the life cycle of the project. Data collection tools were discussed and field-tested with Network members, the selection of participants included inputs from all sectors and local networks, and document compilation was conducted in conjunction with focal points from municipal departments. Once the results started to come in, they were presented to the group for collective interpretation.

Analyzing the results with the actors was rich and insightful. Their interpretations filled in gaps not previously seen in the research process, redirected the initial analysis and helped shape the research conclusions. These discussions provided insights for the group to rethink through their own actions and led to a reorientation of the strategies related to the GCP Network ’s development. Therefore, the synergies created by the participatory approach benefitted all sides involved, being in and of itself a generator of knowledge and innovation and a support to the reorientation of practices.

However, this process was not seamless or free of conflict. Often, participants did not agree with the opinions of others, or with decisions made by the group, which led to discussions that were not always productive. Some opinions were quite controversial (such as how to treat patients who did not “comply” with the health personnel or how to deal with parents considered “neglectful”). On many occasions, discussions descended into circular arguments about the root cause of the problems in question, with no consensus among the group. These were in part a consequence of the research object, which was influenced by external and interrelated factors embedded in a complex reality, the scope of which was difficult to grasp. Overall, when situations like these arose, members of the GCP Network who acted as mediators were able to circumvent arguments and negotiate acceptable solutions with the group. In relation to the research, it was often necessary to clarify its purpose, limitations and scope and to guide the discussion towards what the research could answer for, which was not to “solve” all of the Network ’s problems.

4 A Picture Starts to Emerge: Results and Aftermath of the Research

This research aimed to study how a complex, conceptual object was given concreteness and put into practice through a real-life experience. The fact that our empirical base was an intersectoral initiative organized in the form of multi-level, interconnected networks, created an extra but interesting challenge. This confluence – the intersectoral and the network – required an analytical and methodological exercise to delineate the research object in order to capture the dynamics of these two phenomena that were intrinsically connected in their daily practices and effects.

The research unveiled a scenario that was filled with nuances, contradictions, strengths and potentialities. During its course, other themes emerged that had to be considered. As such, the research itself was not only an evolving endeavour that required flexibility, openness and sensitivity but also an attention seeker to maintain the focus of a process that was on the move. Examples of these issues included ethical dilemmas faced by professionals; the mental health of professionals; safety concerns as actions to tackle violence can have unpredictable consequences; and relations with the community, among others.

The results were organized in the following structure:

  1. 1.

    Research participants’ profiles (characteristics relevant to the analysis);

  2. 2.

    GCP Network ’s characteristics (modes of organization, goals, mechanisms, institutional arrangements);

  3. 3.

    GCP Network ’s structural characteristics (social network analysis);

  4. 4.

    Supporting structures for intersectoriality (institutional arrangements, territorially based planning, information tools, funding mechanisms, partnerships);

  5. 5.

    Perceptions about intersectoriality and networks.

The research uncovered many of the Network ’s innovative mechanisms to foster an intersectoral process that considered the key health promotion strategies/values as well as the challenges that limited its capacity to advance towards more integrated and sustainable intersectoriality. The analysis of these issues makes up the main body of the research, and, here, we point out the general findings. Limitations included difficulties in mobilizing the interest of policymakers and management, hierarchical and bureaucratic structures that did not support intersectoral actions, little control over decisions and resources, low capacities and competencies for intersectoral work, structural violence that was beyond the Network ’s capacity to tackle and frustration with the lack of long-term solutions.

Having a health promotion framework as the basis for this research was fundamental in order to focus the methodology and analysis on understanding the context and processes and not merely the end results of policies or institutional actions. This research option also helped highlight the benefits and challenges of investing in health promotion strategies, such as having a focus on territories; on integrating a variety of actors and strengthening their capacities and the potential (or barriers) of promoting system changes.

The inclusion of a statistical methodological tool, social network analysis, emerged as an innovation and highlighted how incorporating methodologies can provide new and out-of-the-box insights into data that emerge from health promotion research.

Through SNA, we concluded that the GCP Network was able to mobilize actors from all of the sectors considered essential, namely, education, health, social assistance and public safety. However, the results pointed to an overwhelming representation of actors from public institutions, compared to civil society. As a result, many of the Network ’s actions revolved around implementing institutional programmes and mandates with limited inputs from those who lived and worked in the territories in question. Many factors explained this situation, as will be discussed later.

Social network analyses showed a great distribution of intersectoral partnerships within all the territorial networks. However, they also indicated that the connections among local networks were fragile. This means that while the GCP Network was successful in its efforts to spur local intersectoral partnerships and strengthen local networks, it still struggled to constitute an integrated city-wide network that could more effectively tackle broader structural determinants of violence. From a health promotion perspective, such results point to interesting reflections about the challenges of scaling up innovative local initiatives to spur sustained, broader system changes.

The analysis identified 90 partners (actors or institutions) and 170 active partnerships (joint actions). This points to a success of the Network ’s actions as these partnerships were a direct effect of efforts to promote intersectoral collaboration. An in-depth look at the characteristics and dynamics of these partnerships pointed to their achievements and limitations. Achievements included the establishment of new practices aligned with local needs, development of new strategies for communication and information exchange, design of joint projects and implementation of more appropriate strategies to identify and prioritize local needs. As for limitations, many of these partnerships were short-lived or were focused on solving urgent demands, and there were difficulties in getting managerial buy-in for their development. The results pointed out the potentials that intersectoral partnerships can unlock to redirect efforts and seek joint solutions. However, they also indicated that intersectoriality was perceived and demanded as a strategy to solve specific and/or urgent demands and not necessarily as a strategy to support the development of a common vision to tackle the roots of the problems. For health promotion research, results such as these can point to some of the ingrained, day-to-day factors that affect the feasibility of models that take intersectoriality (and other health promotion strategies) as a central strategy to promote policy and system changes. They lead to a reflection on how to develop models and strategies aimed at tackling such issues at their roots and becoming more fine-tuned, appropriate and applicable in real social and institutional contexts. These results emphasize the importance of fostering intersectoriality not as a utilitarian strategy to achieve sectoral goals but as a logic for the development of public policies with a view to common social goals.

Finally, the research generated insights into the conceptualizations of intersectoriality, networks and their relations. It pointed out how the two phenomena had different dynamics and relevance on each level of the network . While intersectoriality was more emphasized at technical, institutional spheres, with “network formation” being a strategy to achieve it, at the local level, network formation was more valued, with intersectoriality being the secondary outcome. This showed how the two phenomena are different yet intrinsically interconnected, which has important implications in health promotion research. Conceptual frameworks and methodological designs, which look into intersectoral actions that are organized as networks, should seek to delimit clearly and analytically each of these phenomena while also considering their connections and reinforcing attributes.

Initially, our study’s conceptual framework focused on intersectoriality alone. Over the course of the study, it became clear that we had to consider its interconnections, conceptually and methodologically, with networks. One consequence of this development was the incorporation of theoretical frameworks such as that of Manuel Castell’s and an effort to approach these phenomena separately yet analyze them together with our methodological tools. Social network analysis was a key methodology since it helped understand the network as a structure and how intersectoriality fits into it. The qualitative interviews also considered questions regarding each one of these phenomena, which led to the production of data that helped us understand not only participants’ experiences with these concepts separately but also how they interacted.

4.1 The Challenges and Benefits of Multiple Methods in Health Promotion Research

Triangulation of data, a process in which researchers draw conclusions by connecting data from various sources related to the same phenomenon, was key to understanding how intersectoriality was taking place within the GCP Network and to relating that to a health promotion framework.

The process meant that the results obtained with one method were complemented, analyzed, validated or questioned by the results obtained via other sources of data. Afterwards, conclusions were drawn. For example, the data from the SNA indicated that there were limited partnerships with civil society organizations (CSOs) and that most collaborations took place between governmental institutions. This presented a research enigma as data from the interviews pointed to participants placing high value on social participation. How could we make sense of this result using the data we had? We looked into the participation levels of the partners in GCP meetings, which we were able to determine by document analysis. We found that CSO representatives rarely attended meetings, and, when they did, it was short-lived. So, one conclusion could be that they were not interested, but, another question was: were they invited/mobilized to participate? The answer again came from document analysis (invitations, memos, electronic communications, reports) as well as from notations from participant observation (field diary), in which some of the internal discussions over the benefits and challenges of engaging in partnerships with CSOs had been reported. This showed that the group was divided and conflicted about the issue, and efforts to mobilize these organizations were sporadic and depended on individual efforts. By reviewing data from the interviews with members of CSOs, we also found mentions of limitations imposed by the GCP Network ’s legal structure. This led us back to document analysis, where we found that the municipal decree that established the Network specifically defined who could participate in decision-making spaces, that is, who would have a voice in decision-making. This structure emphasized the role of public institutions and placed limits on the participation of CSOs. By being able to connect data from these different sources, we were able to view a fuller picture of the situation and to better analyze the factors that affected intersectoriality for this group. This also allowed us to reflect upon the relationship between health promotion values that are often considered to be reinforcing or complementary but that might not align with real-life experiences – in this case, the value of social participation and of advancing intersectoral efforts.

4.2 How Were the Results Used and Disseminated?

Efforts were made to produce results that might make a contribution beyond academic discussions and translate into new practices, policies and knowledge. This required thinking about the various target groups for the data produced, the strategies and opportunities for sharing results and the types of analysis and recommendations that could be developed by the research. Adopting a participatory methodology was crucial to foster strategic thinking and knowledge translation to attain such goals. Throughout 2019, the results of the research were presented to policymakers, Network actors, public sector managers and civil society at various occasions, through seminars or roundtable discussions in order to allow for an active exchange of ideas and reflections. Messages were tailored to suit the audiences, with attention paid to using language that made the information easy to understand. Recommendations for action were also developed, considering what would be feasible and appropriate for each context. In early 2020, efforts were undertaken to hold workshops to develop a logic model of the GCP Network and to think collectively about how to tackle problems and tap potentials identified by the research. This effort was suspended due to the coronavirus pandemic that paralyzed the GCP Network in early March. Contacts were renewed in late 2020, and so, we expect to resume activities in the near future.

5 How Does This Research Contribute to Advancing and Structuring the Field of Health Promotion Research?

This research sought to address gaps identified by previous health promotion research and contribute to the discussion about how intersectoriality is brought about, how it connects with other health-promoting concepts and what its contributions are to policies and programmes that ultimately affect people and communities. The GCP Network offered an excellent case study. The characteristics of the Network , its history, structure and the strong engagement of the actors all offered a unique scenario to understand the implementation of health-promoting practices. The context was also propitious to the generation of knowledge that can contribute to the development of frameworks more attuned to political and social realities. This, in turn, can strengthen health promotion’s contribution to the academic, political, social and development arenas.

The research provided elements to reflect upon hybrid/mixed approaches that allow the field of health promotion to advance. This included, for example, the recognition of the changing nature of an object of study during the data production process. This approach allowed for a better understanding of the connections between intersectoral efforts and network formation at various levels and dimensions (social, community, policies, services, etc.). The analytical and methodological design had to be adapted in order to accommodate new data and results. Adopting mixed methods made this process easier and more malleable, though more complex. This experience highlights that health promotion research should allow for flexibility and openness to respond to an evolving situation as well as for sensitivity to maintain focus over the course of the research process.

We demonstrated that participatory methods in the planning, collection and analysis of data can favour the restitution/appropriation of research, where it ceases to be “about” something and becomes something “to be with”. This participatory view of a research object helps advance the structuring of health promotion in times of political, institutional, cultural and administrative turbulence. On the other hand, research that aims to work “with” actors requires researchers to be attentive, open to dialogue and willing to listen, negotiate and commit to consider the perspectives of all participants, even when these do not align with their own. This implies being able to look at oneself and the research endeavour and reflect upon one’s own biases (personal, epistemological, methodological), looking for ways to transcend them towards inclusive and horizontal relationships.

This leads to reflecting on the role of researchers in participatory research. As we become embedded and involved in the process, some boundaries turn fuzzy. It is important to maintain clarity about the limitations of the research project and to be mindful of one’s role in the research itself as well as of the relationships developed in the process. Participatory research carries the idea that the separation of subjects and the researcher, advocated by traditional research methods, is not implemented, given that the distance between the two is considered prejudicial to the research and to the generation of knowledge resulting from this approximation.

The recognition of the role of the researcher as a participant that can affect the research and its object has to be emphasized as part of health promotion research. On the one hand, it allows for immersion with, and a deeper understanding of, the study, which will contribute to better analyses and more relevant results and conclusions. On the other hand, it can create conflicts and methodological confusion as it requires constant attention to issues such as research ethics, delimitation of the study object and proper documentation of processes in order to allow for the identification of potential interferences of the researcher in the results.

Another lesson was the challenge of consolidating intersectoriality models based on health promotion values as a new praxis to guide public policies. The GCP Network was able to achieve important results. However, it could not overcome the barriers imposed by the underlying and overreaching structural, institutional and political contexts of the municipality. This points to the limitations of the strategies that rely on long-term structural and societal transformations and to the need to be aware of transitional periods, such as elections and political changes, which can not only bring about new opportunities but also compromise advances and impose new challenges to intersectoral initiatives.

Finally, this research points to interesting reflections about the relation between health promotion values that are often considered to be mutually reinforcing or complementary but that might not align with real-life experiences. For example, theoretically, increased social participation can lead to more effective intersectoral efforts in the long run. However, while values such as social participation, community empowerment and intersectoral action were called for by the Network ’s participants, their translation into practice led to dilemmas and actions that underscored social participation and community empowerment in favour of advancing intersectoral efforts while not creating tension within institutional and sectoral structures. Health promotion researchers must be attentive to understand the trade-offs that affect decision-making processes in real-life situations. Yet, as a field that aims to position itself with relevant political and ethical models for social transformation, it is important to continue to advocate for all health promotion core values and to seek to address the underlying factors that can weaken or shift the focus away from the potential and strengths of an integrated health promotion framework to improve society’s well-being and development.