Global Health Promotion

Brazil, a Latin American country of continental proportions and contrasts, demographic inequalities, and social inequities, concomitantly faces the challenge of preventing and controlling infectious diseases, injuries, and non-communicable diseases. The loss of strength of the biomedical paradigm, the change in epidemiological profile, and the sociopolitical and cultural challenges of recent decades have fostered the emergence of new formulations about public health thinking and practice. Among them, are the paradigms of Brazilian Collective Health and Health Promotion. The former provides philosophical support for Brazil's Unified Health System (SUS). The aim of this article is to discuss the development of public health within the country's history, and to analyze and compare the theoretical assumptions of Health Promotion and Collective Health. We conclude that health promotion, based on the principles and values disseminated by the international Charters and concerned with social actors and social determinants of the health-disease process, has significant potential to promote the improvement of living and health conditions of the population. This frame of reference guided the formulation of the National Policy of Health Promotion within the Unified Health System, which was institutionalized by a ministerial decree. The importance and application of evaluating the effectiveness of health promotion processes and methodologies in Brazil have been guided by various frames of reference, which we clarify in this article through describing historical processes. (Promotion & Education, 2007, Supplement (1): pp 7-12)

This article summarizes the points of view of professionals from different nationalities, working in diverse organizations and dealing with concepts and activities related to health promotion effectiveness evaluation. This collection of views came from a panel presentation and dialogue held during the First Brazilian Seminar on Effectiveness in Health Promotion. Four professionals working in evaluation and health promotion - two from the United States, one from French Canada and another representing an international professional organization — facilitated by one Brazilian and one Puerto Rican moderator, had an informal dialogue with the audience. Four questions about how these professionals perceive evaluation in health promotion were asked to initiate the dialogue. The panelists deliberated five aspects of health promotion evaluation, asking: “how”, “how much”, “what for”, “with whom” and “why.” Professionals working in developing countries (in this case, Brazil) and those dealing with indigenous communities (in developed countries) tended to put more emphasis on “what for?”, “with whom?” and “why?” regarding initiatives to evaluate effectiveness of health promotion. Questions associated with “how?” and “how much?” were more often mentioned by professionals working for international or governmental agencies. A 90-minute dialogue among panelists with a clearly Brazilian bias, was not sufficient to produce conclusions on the predominant character of international evaluation efforts of effectiveness. Nevertheless, this debate framed the five aspects of evaluation into a value perspective. The questions, “what for?”, “with whom?”, “why?”, “how?” and “how much?” are linked to a political or technical presumptions that could be orchestrated in evaluations of health promotion effectiveness. (Promotion & Education, 2007, Supplement (1): pp13-15)

This article discusses an evaluation framework based on an understanding of the constitutive elements and multi-strategic characteristics of health promotion (HP) programs. Health promotion presents an ongoing challenge for traditional evaluation frameworks (Rootman et al., 2001; Potvin, 2006; Barnes et al., 2003) when it redefines its actions as empowerment, community participation, local development, health literacy and intersectorial activities for the purpose of reducing inequalities for individuals, organizations, and public policies (Kickbush, 1994). This challenge also applies to the discussion on effectiveness of HP practice; what is at stake is the knowledge about how health promotion actions generate changes and outcomes. In short, this article proposes to discuss this redefined HP perspective and identify its usefulness in terms of the debate on effectiveness and evidence of HP in Brazil. (Promotion & Education, 2007, Supplement (1): pp 16-20)

This article focuses on health promotion (HP) outcomes, illustrated through evaluation of case studies and identification of strategies which have contributed to their success and sustainability. Evaluation research and practice in three distinct sceneries are discussed: (i) institutional and governmental agencies; (ii) communities in the “Manguinhos Complex” and Nova Iguaçu Municipality, and (iii) building of potentially healthy municipality networks.

The effectiveness of a social program in a health promotion perspective was based in the “School for Parents” program, undertaken by the First Court of Childhood and Youth of Rio de Janeiro, between 2001 and 2004. The analysis was grounded in the monitoring of 48 parents in charge of children under 18, who were victims of abuse, violence or negligence, and social exclusion, most of all. The study's objectives were: illustrating the evidence of effectiveness of health promotion, discussing the concept of HP effectiveness under macro unfavorable conditions, and identifying strategies that foster sustainability of results. Institutional resources included a multi-professional staff, multidisciplinary approaches, participatory workshops, family case management, partnership with public and private institutions, and volunteer and civil society sponsorship of the families. Evaluation was based on social impact indicators, and psychosocial and contextual determinants. Evaluation methods included program monitoring and quantitative-qualitative methods, through a longitudinal evaluation of 3 years, including one year post program. The evaluation showed highly favorable results concerning “family integration,” “quality of family relations” and “human rights mobilization.” Unsatisfactory results such as “lack of access to formal employment” are likely related to structural factors and the need for new public policies in areas such as education, professional training, housing, and access to formal employment.

The training process of social actors in environmental management and housing, supported by the Public Health Technology Development Project of the Oswaldo Cruz Foundation, was employed as a tool of environmental education and healthy housing. The purpose of this study was to construct an integrated and participatory model of environment management. The methodology included training, research and evaluation of participants, from 21 to 50 years of age, who participated in building Thematic Learning Books and Community Guides about water quality monitoring. Participants'evaluations emphasized the training process, encouraging them to become multiplier agents of environmental education in their communities and to continue learning how to bring together sectors for problems solving.

The Potentially Healthy Districts' Network (RMPS) aimed at increasing knowledge and building capacity to develop actions which originate from each of the local units, based on their characteristics and practices. Developed by the Preventive and Social Department of Campinas State University with PAHO/WHO and the Society Special Research Institute (IPES), RMPS's mission was to cooperate in the construction of healthy public policies in a participatory and articulated way through different municipal representatives. The network offered tools to municipal administrations to develop integrated projects that brought together government, managers, technicians, academy and organizations for the construction of public policies aimed at health promotion and quality of life. The methodology is based in the construction of knowledge and action networks by social actors, stimulating trans-sectorial and inter-district actions. The outcome evaluation is based on case studies, focus groups, oral stories, documents and image analyses. (Promotion & Education, 2007, Supplement (1): pp 21-26)

Evaluation of health promotion (HP) actions is a major challenge, generating inquiries and reflections that can contribute on the effectiveness of the actions themselves. With the aim on fostering exchange on monitoring and evaluation experiences related to the implementation of healthy settings, the 1st Brazilian Seminar on Health Promotion Effectiveness was launched in 2005. The program included round table and workshops known as Working Groups (WG) in Brazil. The criteria used to constitute the workshops focused settings as spaces of circulation and living as an intrinsic connection to lifestyles and conditions, as well as to social and/or environmental risk factors associated with groups living in these settings day after day.

Focusing on evaluation as an activity that generates knowledge, this article highlights and stimulates the discussion about some major issues arising from the theoretical-methodological approach and the discussions developed in the workshops. The debates carried out during the Seminar illustrated the different perceptions and views of the social players involved in implementation and evaluation of HP practices, disclosing a multiplicity of meanings. It became clear that procedures are needed to document a future maturation of concepts and methods, in combination with further in-depth theoretical discussion. (Promotion & Education, 2007, Supplement (1): pp 27-30)