Keywords

Introduction

At the first World Conference on social determinants of health (SDH), convened by the World Health Organization (WHO) in Rio de Janeiro, Brazil, in 2011, member countries were committed to respond to five key areas that would involve the design, implementation, and evaluation of public policies, including governance, promotion of community participation, alignment of priorities and actors, and monitoring of progress (Balladelli et al. 2012).

Also in 2011, in the region of the Americas, the directive council of the Pan American Health Organization (PAHO) designed solid policy tools to promote specific work plans vis-à-vis the SDH, approved by member states, emboldening the countries to ensure they have the tools they need to bridge the inequality gap, strengthen and expand networks in the region, and monitor and evaluate actions (collection and greater breakdown of data) (Balladelli et al. 2012).

In the execution of actions with a focus on SDH and sustainable development , the processes of health promotion, within the framework of primary health care, are recognized and repositioned as the key strategy of action of governments needing to develop and strengthen technical and intersectoral cooperation in order to design, implement, and, above all, evaluate public policies that seek to create healthy environments, promote social mobilization, and guide health services from an equity perspective, an assessment that allows for the construction of knowledge and reflects the faces of the sociocultural context in which it develops (OMS, OPS 2013; Martínez 2014).

In Mexico, the federal government in recent years has generated and intensified actions that address the SDH in different areas of the country, transforming its social and political agendas and, above all, the role of the state in unveiling an increasing commitment to equity and social justice, actions that are difficult to implement in light of the deep socioeconomic inequalities prevailing in the Latin American region: low- and middle-income countries facing a critical health situation combined with reversed progress of neoliberal globalization (Franco 2011; Frenz and Titelman 2013).

Since 1995, one of these actions has been the Healthy Municipalities strategy , a program with health promotion activities at the municipal level involving the participation of the community. In 2001, this program was strengthened, even changing its name to the Healthy Communities program, a change that was influenced by events in developed countries with the “Healthy Cities” initiative promoted by World Health Organization and in Latin America, in developing countries, through PAHO, the Healthy Municipalities and Communities movement (Gobierno Federal 2014).

The Healthy Communities program was launched to address the public health challenges faced by the most vulnerable populations in Mexico, aiming to generate and strengthen health promotion in and from the country’s municipalities, with the participation of different sectors (public, private, and social), through actions that position the municipality as the most appropriate level to carry out the integral work of health promotion, against the social determinants of health identified at the local level (Ander 2003).

The program’s main objectives are to generate basic sanitation and services, preserve the environment, promote hygiene and cleanliness, encourage healthy behaviors and lifestyles, seek equity, and establish health services to meet the remaining needs of prevention, treatment, and rehabilitation. The importance of community participation in the generation of alliances with existing groups in the community and with the population is emphasized, which will make it possible to work in an organized way to achieve together better health conditions.

However, in the Health Secretariat of Jalisco, Mexico, the Healthy Communities program has been implemented for more than 15 years, but in all this time, there has been no clarity on the mechanisms making it possible to identify the impact of actions since it has only focused on the evaluation of process indicators, noting the actions carried out, but not the effectiveness and sustainability of the process of health promotion at the municipal level with respect to SDH.

Because of the Health Secretariat of Jalisco’s interest in the generation of knowledge derived from the processes of the Healthy Communities program, in 2013 the Department of Research of this same institution participated in efforts to incorporate the scientific method into a project of this program. These efforts involved the project’s design, implementation, monitoring, evaluation, and sustainability. It was an experience that needs to be reflected and shared so that it can be applied to improve and transform our own practices in health promotion with respect to the SDH.

Description of methodological component within Healthy Communities program project: To identify the scope and limitations of the lessons learned as derived from systematization work, this section describes two aspects in general: (1) methodological moments of the Healthy Communities project and (2) methodological aspects for the systematization of the experience.

Methodological Moments of the Healthy Communities Project

Origin: The experience began in May 2013, when the area director of a rural health unit requested that the research department incorporate the scientific method into a project of Healthy Communities to be carried out in a rural locality of Jalisco, Mexico, assuming that, based on this experience, it would be necessary to have evidence of the scope of these intervention projects, which he had been doing for 10 years in other localities. Based on this request, a health educator and a field epidemiologist were formed into a research team, and, together with the area director, they analyzed the proposal of the Healthy Communities project and designed a research protocol.

Considering the subject of study, the objectives of the Healthy Communities intervention project (“Reverse malnutrition, overweight, and obesity, as well as eating disorders, in the population”) and the elements of the rural context, the research team decided to use a critical and dialectical methodology, participatory action research (PAR) , as a systematic circular process and with a focus on primary healthcare, which would allow actions to be taken that would promote health and educate people about health, such as mechanisms to deal with the socio-cultural, economic and geographical factors that generate malnutrition in the locality (Jara 1998).

The idea of carrying out applied research rather than traditional scientific research was considered since the goal was to document the meaning, effectiveness, and sustainability of three actions proposed by the Healthy Communities project to be developed in cooperation with the population: (a) physical activity, (b) training for adequate feeding, and (c) healthy cooking, integrating throughout the entire process ten methodological moments that considered both quantitative and qualitative techniques (Table 13.1)

Table 13.1 Methodological moments of PAR process
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The consolidation and implementation of the ten moments was from January 2014 to December 2016, which did not necessarily follow a rigid linear scheme, but were configured in response to the nature and meaning of the participatory process, which involved actors from different sectors and communities in decision making; this allowed them to guide the process, make a critical assessment of their living conditions, a search for the causes of their problems and the generation of concrete and viable strategies, which were concretized in the work agendas with a continuous reflection on the praxis, making the process more and more emancipatory and transforming of the context.

Methodological Component of Systematization

In December of 2016, at the end of the process of intervention , the group of researchers and health authorities at local, regional, and state levels considered it important to come up with a critical interpretation of the Healthy Community project that would make it possible to learn from the experience of incorporating the scientific method in a health promotion project at the municipal level, objectify the experiences, and analyze them, posing as the objective of the systematization to understand the implications, opportunities, and challenges when incorporating the research into the Healthy Community project, such as actions of health promotion with respect to the SDH, applying the methodological proposal of Oscar Jara. The methodological moments of work are described in Table 13.2 (Santos 2011).

Table 13.2 Methodological moments of the systematization process
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Lessons learned when incorporating the research into a Healthy Communities project: To better understand the lessons learned from this experience, they are presented in three aspects: implications, opportunities, and challenges in incorporating the scientific method into Healthy Communities projects as actions of health promotion against SDH (Tables 13.3, 13.4, and 13.5)

Table 13.3 Opportunities to incorporate the scientific method into Healthy Communities projects as actions to promote health against SDH
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Table 13.4 Implications to consider in the incorporation of the scientific method into the Healthy Communities projects as actions of health promotion against the SDH
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Table 13.5 Challenges with the incorporation of the scientific method into the Healthy Communities projects as actions of health promotion to modify the SDH
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Conclusions

The incorporation of the scientific method into the Healthy Communities strategy, from a critical theoretical perspective, enables the generation of knowledge from the processes of health promotion and not about them, taking into account the different contextual political, social, cultural, and historical elements that happen together with the actions of territorial management against the SDH. Likewise, research can be assumed by the Healthy Communities projects as an opportunity to identify and document the mechanisms that make it possible to describe how the actions of local government in conjunction with the population and the various sectors allow to reduce inequities, in a seedbed of conceptual and theoretical referents that shape and give meaning to the practice of health promotion in the municipal sphere in the country.