Ciência & Saúde Coletiva ISSN: 1413-8123 [email protected] Associação Brasileira de Pós-Graduação em Saúde Coletiva Brasil

Machado Freire, Maria do Socorro; de Senna Salles, Rosane Paula; Pereira Franco de Sá, Ronice Maria Mapeando iniciativas territoriais saudáveis, suas características e evidências de efetividade Ciência & Saúde Coletiva, vol. 21, núm. 6, junio, 2016, pp. 1757-1766 Associação Brasileira de Pós-Graduação em Saúde Coletiva Rio de Janeiro, Brasil

Available in: http://www.redalyc.org/articulo.oa?id=63046187009

How to cite Complete issue Scientific Information System More information about this article Network of Scientific Journals from Latin America, the Caribbean, Spain and Portugal Journal's homepage in redalyc.org Non-profit academic project, developed under the open access initiative ARTICLE 1757 DOI: 10.1590/1413-81232015216.08172016 ------. Health promotion, Healthy cities, Healthy promotion, Health This paper is part of an excerpt a from 1 1 1 semi-structured interviews and docu held, were mu ‘healthy the name of Under ments analyzed. specific initiatives city community’, or nicipality, part highlightedwere of , in the State ofnetworka existedhas that since whichand 2006 beenhas of politicalmaintained spite in and/or administrative local and State changes at both factors the effectiveness for indicated of level. Key the actions in the 23 municipalities support were: of the university; strong engagement of local lead erships; and participation of social movements words Key Sustainability of programs Networks, of . Its purpose Its map initiatives to was tak of Brazil. en health organizations by of cities, municipali of theirties and communities; become to aware evidencemechanisms of acquire operation; and to of their effectiveness, and the characteristics of collected their by was Information key players. internet, and contact telephone, with government and non-government bodies of these Northeastern this collection lo ofAfter data at distance, states. cal visits each about out more find made to were Duringinitiative. the visit a timeline of the ac tivity working with local partici recorded, was of key information recording sources, After pants. Abstract Abstract eight made in study of the Northeast of the States A mapping of ‘healthy territory’ initiatives, territory’ initiatives, ‘healthy ofA mapping characteristicstheir effectiveness and Núcleo de Saúde Pública Pública Saúde de Núcleo Brasil.socorromfreire@ gmail.com Pernambuco. Av. Prof. Prof. Av. Pernambuco. s/n/HC/Bl. Rêgo Moraes Universitária. Cidade E/4°, PE 50670-901. 1 Social, e Desenvolvimento de Federal Universidade Rosane Paula de Senna Salles Senna de Paula Rosane Sá de Franco Pereira Maria Ronice Maria do Socorro Machado Freire Freire Machado Socorro do Maria 1758 et al.

Freire MSM Freire Introduction effectiveness, rather than exactitude in objective, direct indicators, thus showing the importance The purpose of this paper is to contribute to the of the subject and of the search for evidence that field of Health Promotion in relation to forma- would make it possible to expand and reproduce tion of the concept of what healthy cities are, and the successful experiences, and learn from those draw conclusions on indicators that will charac- that were not successful4-6. terize a healthy city/municipality in Brazil. It re- This view of the subject covers the outlook of lates to the partial analysis of a survey financed by acting on the social determinacy of health, which a Health Ministry tender, executed by investiga- presupposes recognizing equity as a fundamental tors of the Public Health and Social Development principal in the formulation of public policies, Center of the Federal University of Pernambuco in the defense of fair distribution of power and – NUSP/UFPE, in the period 2013–2014. resources of every type to favor accessibility to The survey’s main aim was to identify the ev- goods and services, making it possible to ensure idences of effectiveness of mechanisms of operat- diversity of ethnicity, gender, sexual orientation ing the social agendas of healthy and sustainable and culture7. Cities, Municipalities and Communities in deal- It is also anchored on the possibility of cre- ing with the social determinants of health and ating networks of recovery, and convergences the promotion of sustainable development in the to the advocacy of health promotion and in the Northeast of Brazil. need for articulation of the agendas of the social The World Health Organization defines a movements, events and documents/statements healthy city not only as a city with a high level that have taken place all over the world and of health, measured by indicators of wellness and converge toward recognition of health as a fun- mortality, but a city committed to the produc- damental component for the construction and tion of health of its citizens; a social development evaluation of countries and public policies that project, that has health and its multiple determi- are focused on sustainable human development. nants as a center of attention. This movement This is a context for consideration of the Hel- gives rise to the establishment of urban policies sinki Statement on Health in All Policies, which directed toward improvement of quality of life, puts forward as essential the articulation of inter- with emphasis on inter-sectoriality and social national agendas in Health Promotion, Sustain- participation1. The movement for healthy cities able Development, Healthy Cities/Municipalities, was born with its focus on what is now referred with national agendas. Based on the recognition to as urban health and with an eye for the devel- that health is the biggest target of governments, oped countries, and its name has been adapted and the cornerstone of sustainable development8, to the context of Latin America, where it is now that the challenge of health promotion in Latin known as the Movement for Healthy Municipal- America consists of reconciling economic interests ities2. with the social purposes of wellbeing for all, and In its history, the concept of Healthy Munici- also to work for solidarity and social equity, as in- palities, based on the prerequisites and guidelines dispensable conditions for health and development, of health promotion, has modified, and new in- there arises the recognition that it is essential to tervention strategies are in the process of devel- promote the dialogue between health, economics opment, opening scope for the issues that begin and sustainable development, having socio-envi- to occupy the local agendas such as poverty, vi- ronmental justice as the point of view9. olence, the environment and associative charac- Looking at this from the territorial perspec- teristics, in considering their effects on the health tive is also important, since it is vital for the sus- conditions of the population3. These aspects con- tainability, equity and quality of life that result tribute to programs and initiatives being increas- from actions of health promotion and Healthy ingly complex, including various partnerships, Municipalities. Some studies in this field10-12 have players and contacts. discussed the need to look at the territory that is One of the great challenges in the field of lived in, as the locus for making inter-sectoriality Assessment in Health Promotion and of healthy operational, and give a voice to the people who cities was the difficulty in measuring principles, live there, who have their desires and resolve their values and actions that go outside the health problems there, and also the already existing, and sector. These are complex, open interventions, emerging, social networks, based on the demands and for this reason the main disseminators of and complexities of the territory, the location or the movement agreed to seek overall evidence of the region. 1759 Ciência & Saúde Coletiva, 21(6):1757-1766, 2016

It is known from one recent study13 that in the workshop Weaving of Knowledge – the Con- the Northeast of Brazil there have already been versation with the World. At the invitation of the various Healthy Municipality initiatives since the DSAST (Environmental and Workers’ Health In- 1990s, in the States of Rio Grande do Norte, Ala- spectorate) of the Health Ministry, the technical goas, Paraíba and Ceará. However, after a study team took part in a methodology workshop and in eight of the nine States (Piauí was not visited) a visit to the project Sustainable Territories, pro- of the region, we confirm the highlight position motion of equity and health in traditional commu- of the Pernambuco State Healthy Municipalities nities of the Bocaina Mosaic – Brasília and Rio de Network (Rede Pernambucana de Municípios Janeiro, coordinated by Edmundo Gallo11, with Saudáveis, or RPMS),comprising 24municipal- the purpose of sharing knowledge and deepen- ities throughout all the regions of the State of ing designs for research in healthy and sustain- Pernambuco. able territories and communities. As well as carrying out a mapping of the ini- We made a bibliographical review on the sub- tiatives that exist in the Northeastern region, the ject, with a cataloguing of the projects that were studies sought to identify structuring axes, mech- financed by the National Health Promotion Net- anisms of operationalization and articulation, work of the Health Ministry (a branch of the Sus- critical factors and responsible and/or qualified tainable Development, Violence Prevention and players for taking part in the initiatives in Per- Peace Culture Unit), Health Ministry Projects, a nambuco, in the ambit of the RPMS. The expec- document of the Health Ministry DSAST, theses, tation of this work is to share and disseminate the dissertations and papers. We listed key words that issues that have been learned from the experience emerged from studies on healthy municipalities: of healthy territories, that can stimulate the de- healthy cities, healthy municipalities, healthy bate and reflection on the subject, in the context communities, healthy territories and/or sustain- of management, academia and other interested able territoriality, environment, inter-sectoriality, sectors. social participation, sustainability. These words oriented the search for the initiatives of healthy municipalities in the Northeast of Brazil through Methodology the internet, and after they were identified we contacted them by telephone to get to know their Based on the theoretical suppositions and the initiative better, and to seek to schedule visits methodological strategies and tools developed and contacts with key information sources for in previous studies on health promotion and interviews. We had the assistance of student in- equity in the Northeast of Brazil14,15, the design terns from UFPE selected for carrying out this of the study included a search for concepts, mapping by internet and by telephone contact. comprehensions, descriptions, and evidences of Priority was given to contacts with the State and Healthy Cities/Municipalities/Communities in Municipality Departments – health, education, the Northeast Region. environment, cities, social development, agricul- The method of the survey was in three phases. ture, and Universities and NGOs. Initially, we held orientation/leveling workshops In the second phase, research instruments with a technical team of the survey to train 8 stu- were prepared: interview sheets, timelines, in- dents of the following graduation courses of the formed consent form and a script for an inter- UFPE:4 in Social Sciences, 1 in Social Services, 1 view to be applied with the players identified in in Nursing, 1 in Psychology and 1 in Medicine, the studies. The interview sheet contains general selected to participate in the mapping of the data, personal identification of the interviewee initiatives via internet, telephone contact, and and of the investigator. The informed consent surveying of the projects financed by theSustain - form was read jointly with the interviewee and able Development, Violence Prevention and Peace signature requested. Culture Unit of the Health Ministry’s Health The questions were constructed in the form Promotion Network, among others. The train- of a script to orient the interview so as to facil- ing with the interns, and the sharing of concepts itate apprehension of information on the initia- and methodology of the study with the technical tive, including: name and objective of the initia- team, was an interactive process, in dialogue with tive, time of existence, actors responsible for the the International Course in Promotion of Health, initiative, capacities and actions developed, prin- Development and Healthy Municipalities, and cipal results, existence of training, intersectorial interdisciplinary and intersectorial training in research and actions, values and principles that 1760 et al.

Freire MSM Freire orient the initiative, etc. The timeline was used as Although this is only one network and in a a tool to assist perception of significant changes single state of the Northeast, the mechanisms of in the course of the initiative and help in analysis operationalization in each location are very spe- of controversies16, inspired on the sociology of cific and different. We found a range of attitudes translation17. to management, from ‘local protagonists’ to an The third phase was the field work, which approach that gave little support to the initia- took place in eight states. Using the data of the tives of the healthy and sustainable locality. We telephone mapping a travel plan was made with found some leaders to be committed and active, pre-scheduling of visits to the initiatives and in- and others not so much. The Federal Universi- terviews with the key workers. Using the snowball ty of Pernambuco (UFPE) which has supported technique, we amplified the number of key infor- the RPMS since its creation, seeks to support and mation sources and identification of other local monitor all initiatives. In recent years, as well as initiatives. The interviews were recorded on an accompanying the actions of the RPMS, it has iPad and transcribed for the purpose of analysis. monitored the initiatives relating to prevention of violence, which with the support of the Health Ministry maintains the commitment to training Results and discussion of local managers and leaders in eleven of the 24 municipalities. Chart 1 below summarizes the Mapping of the initiatives existing in the North- initiatives of the healthy municipalities studied east Region was successfully carried out, extract- and their characteristics. ing twenty-three of the twenty-four municipali- One can see the relationship between munic- ties that take part in the RPMS, since the munic- ipality support, committed leadership, support ipality of had only recently joined the from university and/or state government and en- network. These municipalities had been carrying couragement to integration between training, re- out Healthy Municipality activities since their search and policy, and evidence of effectiveness. joining the RPMS, which was instituted in 2006. The mechanisms of operationalization involving Since it is a network with a trend to distributed planning, engagement of the local community, typology18, it is structured on the basis of volun- leadership, integration of training and policy tary work, based on the autonomy of the sub- showed themselves to be the most successful in jects, in continued formations, grounded on the sustainability and strengthening of healthy-terri- principles and values of health promotion19.The tory initiatives. RPMS has operated on various fronts in its quest Excerpts from speeches of the interviewees for improvement of the population’s quality of give an idea of the characteristics of the initia- life and health. tives and the involvement of the actors: After identification of the initiatives in the The meetings of the RPMS always bring us new municipalities of the RPMS, we sought to iden- things, they always have something good to teach. tify the characteristics of their mechanisms of We have a lot of personal growth. operationalization and articulation, critical fac- I have been working in this network since I was tors and actors responsible for and/or capable of a younger girl, right back at the beginning, I had the activity. A large part of those interviewed are to leave to study, I have now come back. I like to promotors of Healthy Municipalities20, acting in take ideas of sustainability, of healthy living, to the accordance with the opportunities and possibili- population. ties that present themselves in their daily working With the Network, one’s head, one’s perception, life, their neighbors, family, leisure and groups in fact changes. You move out of the consensus view of action. The actions range from proposal and and think differently, you evolve and you try to formulation of local public policies to micro-ac- bring the proposal of sustainability to the manage- tions in the territory, in the quest for improve- ment of the municipality – the proposal for healthy ment of quality of life, development of poten- life and improvement of quality of life. tials, individual and collective capacities, on the I feel jealous when other municipalities succeed foundation of the culture that connects and gives in getting the support of their management – we meaning to the local experience of belonging. haven’t got there yet. Sometimes one feels like giv- ing up, but when we see that together we achieve that a lot…..that’s why we’re here. 1761 Ciência & Saúde Coletiva, 21(6):1757-1766, 2016

Chart 1. Summary of the initiatives of healthy municipalities and their characteristics.

Municipality Initiatives Characteristics

Altinho • Artisan products fair • Support from university and from the • Hip Hop Group government of the state • Music and dance group • Continuity of the actions proposed • Local initiatives led by the Education sector

Agrestina • Psychosocial Care Center (CAPS) active • Support from university in the community • Continuity of the actions proposed • Artisans’ group • Intersectoriality in the local management • Dance group • In the Right Measure Project: physical activity in control of diabetes and hypertension

Alagoinha • Healthy food in schools • Support of the local management • Tourist activities • Continuity of the actions proposed • Education and health in festivities • Diversity with focus on the local culture • Health and Reforestation Fair • Territorialized initiatives • Old people’s group • Theater and dance group • Production of artisan products

Águas Belas • Activities in environmental education • Support from the local management and the and combat of the use of drugs with university Quilombo and indigenous communities • Continuity of the actions proposed of the Fulni-ô group • Cultural diversity • Old people’s group • Engagement of social movements • Training and practice operating together

Barra de • Articulation of environmental education • Application of the Bamboo Method Guabiraba and artisan production for promotion of • Support from local management health and healthy municipalities • Continuity of the actions proposed • “Warriors in quest for change” martial • Training, research and practice between arts group community and university • Gender violence prevention women’s • Strong leadership in the area of human rights and support group prevention of violence • Prevention of sexually transmissible • Integration of policies diseases

Bonito • Healthy Environment – art and culture • Application of the Bamboo Method promoting the Healthy Municipality • Support from university • Healthy School: actions in • Continuity of the actions proposed in spite of environmental education and prevention little encouragement from local management of violence in the schools • Training, research and practice between • Artisan and environmental groups community and university • Permanence of qualifications acquired • Policies for youth in dialogue with healthy municipalities

Camocim de • Camociense Center for Support to the • Application of the Bamboo Method São Félix Disabled (CECAPED) • Continuity of the actions proposed • Creation of ‘citizen house’ to welcome • Training, research and practice between victims of violence community and university • Health promotion and prevention of • Strong local leaderships in the area of violence center environment, prevention of violence and gender • Standardization of stalls in front of schools, adaptation of products sold, and stimulus to generation of income it continues 1762 et al.

Freire MSM Freire Chart 1. continuation

Municipality Initiatives Characteristics

Chã Grande • Organic agriculture • Leadership in the area of organic agriculture and • Cultural and sporting activities, artisans’ artisan production group • Participation of social movements • Group of young people to discuss health promotion and sexuality

Cumaru • Old people’s center with health promotion • Support from the state government activities • Community engagement • Bee keeping group with native flora for generation of income

Garanhuns • Environmental education • Support from local management • Bela terapia School of happiness by the • Training and practice Okada health method • Strong leadership in the environmental issues • Sense of belonging to the location • Redemption of ‘city of flowers’ culture

Goiana • Healthy environment and local • Support from the state government development • Empowerment of women • Generation of income for (female) • Leadership in local development shellfish vendors

Jurema • ‘Flag of Peace’ young people’s group • Local teams committed • Work with old people in the country areas • Strengthening of citizenship and local culture • Sense of belonging to the location

Limoeiro • Project: • Support from the local management • Strong integration with the PSE • Intersectoriality in local management • Leadership in environmental issues and healthy diet • Sense of belonging to the location

Maraial • Cuisine based on banana produced locally • Local culture highlighted • Group of embroidery artisans • Local development • Old people’s group

Olinda • Physical activity in the town square • Integration of policies • Old people’s group • Focus on the local culture • Artisans’ group • Local management distanced from the RPMS • Preservation of historic and cultural heritage • Community theater

Palmares • Artisans’ group • Isolate initiatives • Old people’s group • Management distance • Municipality de-structured by climate accident

it continues 1763 Ciência & Saúde Coletiva, 21(6):1757-1766, 2016

Chart 1. continuation

Municipality Initiatives Characteristics

Pesqueira • ‘Recitalho’ Association • Support of the state and local management • Ecological treks and tracks • Continuity of the actions • Artisan sweet products • Strengthening of local groups • Artisan production group • Integration of policies • Gymnastics groups • Environment in my local district • Recycling • Tourist guide routes

Pombos • Organic agriculture • Strong associative culture • Arborization • Intersectoriality in the local management with • ‘Live Culture’ Association focus on the local culture and environment • Old people’s home • Pineapple festival • Artisans’ group • Practice of dance, theater dance, music, capoeira and sport

Salgueiro • Environmental education • Continuing Training and use of the Bamboo • Genders and Citizenship Method in the schools and practices with Youth Farming • Integration of policies with focus on the Health Academy • Extension projects

São Joaquim • Healthy environment in community and • Focus on micro-environment do Monte school • Training, research and practice between • Selective recycling collection community and university • Cooperativism • Leadership in the schools • Generation of income • Use of the Bamboo Method in formation of associations and cooperatives

São Vicente • Solidarity Thread and Income • Support from state management Férrer Association • Local creative economy • Flour House • Focus on generation of income • Cuisine based on banana and grapes • Strengthening of local groups • Old people’s group • Workshops for beneficiaries of theBolsa Família

Sairé • Prevention of use of pesticides • Training, research and practice between • Healthy Sairé Program community and university • Promotion of old people’s health • Formulation of local environmental policy • Selective garbage collection recycling • Strong involvement of local management branch • Integration of policies • Intesectoriality • Committed leaderships • Use of the Bamboo Method

Timbaúba • Artisans’ group • Support from state and local managements • Cultural dance groups • Continuing education • Cooking groups

Source: Authors. 1764 et al.

Freire MSM Freire I love the Healthy Municipality Project, this the initiatives. project (sic) has my very personality. It takes work It is seen that the majority of the initiatives like an army of ants for the work not to die off. have presented continuity of the actions pro- Brazilians don’t give up…..since the beginning posed, in spite of changes in local and state pol- we knew that some municipality would come out icy and administration. The commitment of the well, and it was (municipality x) that did, it lives local managers and the existence of committed and breathes Healthy Municipality. It’s in the life leaderships allied to effective external support, of (municipality x).The conception of cleaning of whether from the university, or the state gov- garbage in (municipality y) has also changed. And ernment, are the most important factors for the this was a consequence of Healthy Municipality. activities to be maintained. Encouragement for The idea from Shiroi in Japan of dealing with gar- training and/or research has the same weight bage is what we are seeing here. and should be associated with the factors men- Figure 1 shows the factors that facilitate and tioned. Constant monitoring by the university impede the effectiveness and the sustainability of supporting local leaders and offering training, workshops, and spaces for reflection and dia- logue, have been reported as fundamental factors for sustainability of the initiatives. The munici- palities where local managers involve themselves directly with the principles and values of the Facilitating Impeding movement for healthy municipalities make more factors factors progress, as for example the municipality of Sairé, where the management is being indicated Committeed local Indifferent local management management by local municipalities as a model and significant +++ - - - changes in the feeling of belonging, and in the population’s commitment are easily measurable Committed Non-visibility of and visible, and the municipality has adopted the leadership programs ‘brand’ of ‘healthy municipality’ as a mark of its +++ - - management. The presence and persistence of committed leaders is necessary in the process of Continuity of the actions Absence of external making the proposals effective. proposed interlocution It has been confirmed that the initiatives that +++ - - maintain training programs are more effective and more sustainable. However, it needs to be External support Absence of leaders noted that one cannot invest in the development and/or monitoring - - of abilities and in training without the responsi- ++ ble institutions, working groups or networks also being strengthened14,21. Further, it is necessary to Engagement of local look at the role of the local leaders and actors that people ++ take part in these training and teaching activities and provide continuity for the actions. The de- Methodology that sires, interests and controversies of these actors facilitates need to be accompanied to make it possible to ++ mobilize around the implementation of activities Public policy of programs and projects, and maintain them. ++

Encouragement of Final Considerations training and/or research ++ This new study reaffirms previous studies14 on the effectiveness of these initiatives. It is found that the involvement of local management, com- Figure 1. Factors that facilitate, and impede, mitted leaders, maintenance of a specific teach- effectiveness and sustainability of the initiatives of the ing experience for the intervention, inter-sec- Pernambuco Healthy Municipalities Network. torial collaboration, existence of a collectively Source: Authors. built social technology (the Bamboo Method), 1765 Ciência & Saúde Coletiva, 21(6):1757-1766, 2016

realization of the importance of reflexive action intervention, the organizational team and struc- through systematic monitoring and evaluations, ture and the environment (financial, political, the support of Brazilian partners/investigators cultural). – these factors, among others, led to these inter- In this mapping of the present activities of ventions seeking effectiveness and permanence the municipalities in the RPMS we have looked and showing greater stability than in other mu- at the specific characteristics depending on the nicipalities of the state. local contexts. Not all of them use the Bamboo Since this is a health promotion experience, Method – which was designed specifically for this and further, a network experience, effective- Network – as was intended, and not all the mu- ness and sustainability were not related to rou- nicipalities encourage the integration of playing/ tine-ization of activities. In these cases, it is pref- learning with local practices, research or policies. erable to carry out complex analyses22 and agree The municipalities that were the pilot entities for what signifies sustainability and also effectiveness the formation of the Network continue to be the for a given initiative. Scheirer and Dearing23 say most involved and the ones that are closest to the that, although routine-ization is important, it is UFPE. The relationship of trust established and not a synonym of sustainability, because sustain- the cognitive support also appear as factors fa- ability is influenced by the characteristics of the voring success in initiatives of this type.

Collaborations

MSMF and RPSS worked on the conception, in- troduction, methodology, research of data, ex- cerpting of the study, analysis and final approval. RMPFS worked on the conception, critical re- view, summary and final approval of the paper.

Acknowledgments

The authors thank the interviewees and the other investigators of this study: Janete Arruda de Araú- jo, Maria José Vieira Lucena, Maria da Conceição Viana, Maria Edione da Silva, Djalma Agripino de Melo Filho, and Tales Iuri Paz e Albuquerque, with double thanks to Leandro Alberto de Castro Silva for the illustrations of the work. 1766 et al.

Freire MSM Freire References

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