Health promotion competencies: challenges of formation

Abstracts

The CompHP was developed in Europe in 2012, with the aim of establishing competencies and a certification system for Health Promotion. This article aims to present a theoretical reflection about the possibilities and limits of using CompHP in health professional training in Brazil. The theoretical bases that support this reflection were sought in the scientific literature and adjusted in the debates that took place in a post-graduation discipline stricto sensu, in 2012. Several papers have discussed and elaborated guidelines for establishing skills in promoting health around the world, however, discussions of professional competencies for health promotion that have been built in Brazil are still confined to particular practices. From the analysis of scientific texts, it is clear that CompHP guidelines were minted to think about training and practice in health promotion in the European context, however, the characteristics of the model of health and vocational training model practiced in Brazil can benefit greatly from the proposed competencies that this document brings.

Health Promotion; Competencies for Health Promotion; Training in Human Resources

O CompHP foi desenvolvido na Europa, em 2012, com o intuito de estabelecer competências e um sistema de certificação para a Promoção da Saúde. Este artigo tem o objetivo de apresentar uma reflexão teórica a respeito das possibilidades e limites da utilização do CompHP na formação de profissionais de saúde no Brasil. As bases teóricas que dão suporte a essa reflexão foram buscadas na literatura científica e ajustadas nos debates que aconteceram no interior de uma disciplina de pósgraduação stricto sensu, em 2012. Diversos trabalhos têm discutido e elaborado diretrizes para o estabelecimento de competências em promoção da saúde em todo o mundo, porém, as discussões sobre competências profissionais para a promoção da saúde que têm sido construídas no Brasil são ainda circunscritas a determinadas práticas profissionais. A partir das análises dos textos científicos, fica evidente que as diretrizes do CompHP foram cunhadas para se pensar a formação e a prática em promoção da saúde no contexto europeu, porém, as características do modelo de formação profissional praticado no Brasil podem se beneficiar muito com a proposta de competências que este documento traz.

Promoção da Saúde; Competências em Promoção da Saúde; Formação de Recursos humanos

Constructing the field of Health Promotion

The range of methodological theoretical approaches in the field of Health Promotion (HP) make it a new and promising paradigm in health care. Its conceptual bases support the re-organization of health care work, making it into a form of organized social response to the population's health problems and needs (Chiesa et al., 2009).

Based on thinkers from the areas of public health and social medicine, health promotion is viewed as a conceptual field, the practices of which seek explanations and responses for articulation between health care and living conditions (Buss, 2000).

Historically, Health Promotion as a model of comprehensive health care and a public health paradigm appeared in the 1970s, based on the results of the Lalonde Report. This report identified that the biomedical, the health care model, still in use, does not include socio-economic, political or cultural aspects in its analysis of the health-disease process, placing greater emphasis on prevention, treatment and recovery and leaving to one side health education and promotion (Pelicioni; Pelicioni, 2007).

The first conceptual and political bases for health promotion with a socio-environmental and inclusive emphasis were developed after international conferences, of which the conferences in Ottawa (Canada) in 1986, Adelaide (Australia) in 1988, Sundsvall (Sweden) in 1991 and Jakarta (Indonesia) in 1997 stand out. In Latin America, the IV International Health Promotion Conference, held in Bogota (Colombia) in 1992, formally introduced the topic in the sub-regional context (Buss, 2000). By introducing the discussion of health promotion into the Latin American context, this conference aimed to reinforce the need to redirect public health activities, orienting them towards combatting situations of vulnerability related to disease (Mendes, 2004).

The Ottawa Charter, from the 1^st International Health Promotion Conference, highlights the rights and responsibilities of individual and community concerning their own health, defining health as "the process of training the community to act to improve their quality of life and health, including greater participation in controlling this process", understanding health not as an objective in itself but rather as an essential resource for daily life (Buss, 2000). This document also lists resources essential for promoting health and identified five action areas: drawing up and implementing public health policies; creating environments favorable to health; reinforcing community action; developing personal abilities and reorienting the health care system and services (Mendes, 2004). These five health promotion action areas involve various sectors of society in constructing health, characterizing health promotion as genuinely inter-sectorial.

The Ottawa charter reaffirms social determinants of health, indicating that, if treating diseases is attributed specifically to the health care sector, Health Promotion is much more complex, requiring diverse inter-sectorial activities in its construction.

Within the five action areas from the Ottawa charter which even today form one of the main references for developing strategies and activities, the "re-orienting health care services" strand stands out, indicating the need for greater efforts in health research, as well as changes in education and teaching for health care professionals (OPAS, 2012).

International conferences following Jakarta, in 1997, have contributed to broadening the field of observation and to constituting the theoretical-methodological framework of the so-called "new Health Promotion" such as the V International Health Promotion Conference which took place in Mexico in 2000, and the VI International Health Promotion Conference in Bangkok in 2005.

The VII Conference, held in 2009 in Nairobi, Kenya, highlighted gaps in the process of implementing and developing Health Promotion action strategies, igniting new debate on the need to increase and improve the competencies of professionals working in promoting health. The document proposes actions strategies for "constructing Health Promotion Competencies" focusing on leadership, ensuring adequate financing to conduct the interventions and improving the competencies of health care professionals and managers (WHO, 2009).

Considering that the Nairobi conference ignited discussions reflecting society's needs Battel-Kirk et al. (2009) point out that the current international scene shows a growth in public health promotion policies. For these authors, this fact leads to the increasing need to develop professional competencies for the effective development of health promotion programs and actions. They also consider that to improve health promotion in the global ambit, it is important to have a trained group of professionals provided with the tools, skills and abilities needed to translate health promotion theory, policy and research into effective action (Battel-Kirk et al., 2009).

In the field of Health Promotion, competency is defined as "a combination of knowledge, ability and attitude that enables the individual to perform tasks according to a standard" (Dempsey; Barry; Battel-Kirk, 2010).

Constructing health promotion competencies – Historical aspects

Health Promotion Competencies (HPCs) were first identified in Australia, by the Australian Center for Health Promotion Research at Curtin University, together with other educational institutions (Shilton et al., 2001).

Since then, several other countries have participated in constructing health promotion competencies, including New Zealand, Scotland and Israel (New Zealand, 2004; Health Scotland, 2004; Melville et al., 2006). However, Australia, Canada and Europe stand out as the countries that contributed most to this discussion (Speller; Smith; Lysoby, 2009; Hyndman, 2009).

In 2004, during the Melbourne World Conference Workforce Development Stream (Shilton, 2008), in Australia, HPCs were highlighted and the importance of the topic was further highlighted with the publication of documents by the International Union for Health Promotion and Education (IUHPE) and the Canadian Health Research Consortium (Hyndman, 2009): there was a need to create a common HPC theoretical framework to guide health promotion activities.

In 2008, the Galway Conference was held (IUHPE, 2007), the aim of which was to spark international debate to construct directives for competencies in health promotion and education. At the end of the Conference, the Galway Consensus was created, presenting the seven domains of competencies in health promotion (Allegrante et al., 2009; Barry et al., 2009).

Although the intention of the conference was to promote exchange between countries, aiming at a common HPC framework, no Latin American representative attended the event, participants being only from European and North American countries. Apart from the Galway Consensus, a document developed by the European IUHPE office also stands out as a HPC framework, the Developing Competencies and Professional Standards for Health Promotion Capacity Building in Europe (CompHP) project (Dempsey; Barry; Battel-Kirk, 2011). This project began to be developed in 2009 and its main aim was to form a consensus establishing methods to implement health promotion standards, aiming at innovation and better practice in European health care

In order to construct the HPC lists of the Com-pHP, the group from the European office based them on the conceptual principals from the Galway Consensus. Research was undertaken, revising the literature from diverse specialists and researchers from the area, as well as using the Delphi technique and focus groups.

It is worth noting that the principles sustaining the CompHP norms and standards: can be used in training health promotion practitioners, either in their basic training or as part of continuous professional development throughout their careers; can be used as criteria for evaluating qualification in health promotion or evaluating experiences that come through practice; can be used both at degree and post-graduation level and, finally, a health promotion practitioner should prove they fulfill all CompHP domains (Dempsey; Barry; Battel-Kirk, 2011).

In the CompHP, the set of competencies needed to develop effective health promotion activities embrace values (equality, social justice, ethics and individual autonomy), skills (HP conceptual principles) and knowledge, listed as 47 competencies and 9 domains. Each domain specifies the knowledge, skills and performance criteria required to demonstrate acquisition of the essential competencies in that domain (Dempsey; Barry; Battel-Kirk, 2010, 2011).

The CompHP domains are: (1) favoring change, (2) Advocacy in health, (3) Partnership, (4) Communication, (5) Leadership, (6) Diagnosis, (7) Planning, (8) Implementation and (9) Evaluation and Research. Together, they provide a guide to developing HP skills and competencies.

Health promotion competencies in the literature

As part of a post-graduation course, a bibliographic search was conducted in the PubMed and Medline databases, using the terms health promotion and competencies, over the last five years (2007-2012), the guiding question of which was: which professional competencies are needed in Health Promotion? A total of 342 texts were found, although after reading and evaluating the abstracts, only three articles became the object of this analysis. The result of this search indicated a small number of publications, limited to training courses.

The literature on health promotion competencies mainly concentrates on presenting the structures and processes used to develop them (Morales; Barry, 2007; Morales et al., 2009; Public Health…, 2007).

Another part of the literature presents the discussion of the contexts that influence the development of competencies, the value of the focus of the competence and the relationship between competencies and professionalization was also found (Health Scotland, 2003; Shilton et al., 2003). However, the utility of competencies in training and practice situations is not discussed in the literature, nor has the applicability of this notion of competence been much explored in the research.

A variety of studies have discussed and drawn up directives to establish health promotion competences all over the world: Europe (Morales et al., 2009), Australia (Howat et al., 1994), New Zealand (McCracken; Rance, 2000), the United States (National Commission…, 1985) and Canada (Public Health…, 1994) stand out in this area.

According to a recent review by Tusset (2012), the relevance of utilizing health promotion competencies is based on their potential as a reference point for: establishing professional standards and creating mechanisms to ensure work quality; recruitment; identifying need for training and to structure preparation and professional training programs; guiding academic training; drawing up directives of accreditation; orienting and drawing up evaluation instruments; increasing understanding of knowledge and abilities required by health promotion practitioners to plan, implement and evaluate work quality.

Permanent actions that propitiate acquiring and developing the skills and capacities of health promotion practitioners is essential to the implementation and the success of health promotion strategies. The complexity for the political, theoretical and practical development of Health Promotion, as well as the need to reorient health care services and to construct the capacity of work teams are internationally recognized and form the bases of international initiatives to define the competencies (Salazar, 2004).

In Latin America, there are few studies focusing on health promotion competencies (Arroyo, 2009, 2010) as, in addition to being new, this topic has been little explored by lecturers or professionals in the area.

The search for professional training in the health promotion area is a growing demand, incipient in Brazil. Renowned higher education institutions in Brazil have organized specialization, Master's and Doctorate courses in health promotion, showing increasing involvement with health promotion training as a theoretical and practical field.

A survey by the Inter-American Consortium of Universities and Health Personnel and HP Training Centers (Arroyo, 2009) - analyzed the curricular matrices of degree, specialization, Master and Doctorate courses, seeking to extract the characteristics of Ibero-American academic courses in health promotion. In Brazil, courses from the Escola Nacional de Saúde Pública Sérgio Arouca da Fundação Oswaldo Cruz and the Universidade de Franca were selected. The result of the research was systemized competencies in HP, approached by the abovementioned courses.

In Brazil, studies dealing with professional training in health promotion are also meager. Health promotion seems to be not so much a specialty as transversal knowledge within post-graduate programs, especially in the health care area (Chiesa et al., 2007; Mello; Moyses, S. T.; Moyses, S. J., 2010; Nascimento; Oliveira, 2010).

In degree courses, teaching health promotion is also incipient, as shown in the findings from the literature, although there are studies that argue for including health promotion training in health care degree courses. One of the difficulties in including health promotion in degree level teaching in Brazil concerns the conceptual inexactness permeating the field of health promotion, and the way this inexactness manifests itself in training and in the care developed by professionals in the day-to-day provision of health care services in Brazil (Chiesa et al., 2007; Silva et al., 2010).

Discussions of professional health promotion competencies have also been constructed in Brazil, albeit limited to specific professional practices (Nascimento; Oliveira, 2010; Silva et al., 2010; Santos; Fracolli, 2010).

It is worth noting that the definitions from the CompHP project have been the target of discussions in Brazil, especially by groups linked to Abrasco (Associação Brasileira de Saúde Coletiva - The Brazilian Association of Collective Health) and The Latin American Office/International Union for Health Promotion and Education (ORLA/IUHPE). The definition of competencies for health promotion teaching and practice is an advance in strengthening and circumscribing the possibilities and limitations of this field of knowledge, especially in Brazil.

For Chiesa et al. (2007), current national health and education policies indicate the need for changes to professional training processes and constructing competencies and their translation into the curriculum is shown to be a consistent and strategic option for training health care professionals oriented towards social needs, bringing the practices of equality and access to health care.

The Curricular Directives for degree courses in health recommended by the Ministry of Education in 2001, point to constructing general and specific professional abilities, albeit without specifying what these competencies directed towards health promotion would be (Brasil, 2001).

Defence of the importance of defining competencies is due to their potency for clarifying expectations concerning professional practice and defining future needs of this practice, as well as providing focus points for curriculum development and to (re) design degree and post-graduate courses. Despite being constructed in a socio-economic and political reality that differs considerably from the context of Brazil, the competencies presented in the "CompHP handbook" (Speller et al., 2012) present definitions of fields of practice, approaches and values that can be applied perfectly to the Brazilian context.

The National Health Promotion Policy (Brasil, 2006), launched in 2006 by the Ministry of Health, recognizes HP as a health production strategy that contributes to constructing actions that enable advances to be made in responding to social health needs. One of the implementation strategies is the development of qualification of HP actions for health professionals in the SUS, but does not explain in what form this qualification will be promoted or these skills developed. Thus, we think the CompHP could add to the National Policy, with references to which domains, competencies and abilities these professionals should develop to be truly effective and complete health promotion practitioners.

Final Considerations

As shown above, the competencies were established in order to provide a useful basis for health promotion training, academic preparation and continuous professional development.

Based on analysis of CompHP guidelines, it can be concluded that they were minted to think about training and practice in health promotion in the European context, but the characteristics of the training model used in Brazil can benefit greatly from the proposed competencies that CompHP brings. Mainly because, when outlining skills for "health promotion practitioners", the CompHP defines a theoretical and practical model for professional training. In addition, it could be said that some of these competencies can be incorporated in the curriculum guidelines of health courses. Thus, we would reach an important issue that affects the training and practice of health promotion in Brazil; the lack of a clear definition of the professional competencies required for health promotion. As this publication is a theoretical reflection by a group of researchers and professors on developing health promotion competencies and the importance of adopting a guiding framework for this purpose, this article has the limitations of not having been based on a large survey. This is a theoretical construct, the result of a literature search; however, it may serve as the beginning of a deepening of this discussion for future research on health promotion competencies.

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Publication Dates

• Publication in this collection
  Jan-Mar 2015

History

• Received
  04 June 2013
• Reviewed
  15 Apr 2014
• Accepted
  19 May 2014