UNIVERSIDADE ESTADUAL PAULISTA “JÚLIO DE MESQUITA FILHO” INSTITUTO DE BIOCIÊNCIAS - RIO CLARO HEALTH AND PHYSICAL EDUCATION PROFESSIONALS´ SALUTOGENIC AND PEDAGOGICAL PRACTICES FOR WORKING WITH DISADVANTAGED OLDER ADULTS HEIDI JANCER FERREIRA Rio Claro Outubro/2019 PROGRAMA DE PÓS-GRADUAÇÃO EM CIÊNCIAS DA MOTRICIDADE INTERUNIDADES HEIDI JANCER FERREIRA HEALTH AND PHYSICAL EDUCATION PROFESSIONALS´ SALUTOGENIC AND PEDAGOGICAL PRACTICES FOR WORKING WITH DISADVANTAGED OLDER ADULTS Supervisor: Prof. Dr. Alexandre Janotta Drigo Co-supervisor: Prof. Dr. David Kirk Thesis submitted to the Institute of Biosciences, São Paulo State University “Júlio de Mesquita Filho” - Rio Claro, Post-Graduate Programme in Movement Sciences, in partial fulfilment of the requirements for Ph.D. degree in Movement Sciences. Major subject: Pedagogy of Human Movement Rio Claro 2019 F383h Ferreira, Heidi Jancer Health and Physical Education professionals´ salutogenic and pedagogical practices for working with disadvantaged older adults / Heidi Jancer Ferreira. -- Rio Claro, 2019 231 f. : tabs. Tese (doutorado) - Universidade Estadual Paulista (Unesp), Instituto de Biociências, Rio Claro Orientador: Alexandre Janotta Drigo Coorientador: David Kirk 1. Educação Física. 2. Promoção da saúde. 3. Idoso. I. Título. Sistema de geração automática de fichas catalográficas da Unesp. Biblioteca do Instituto de Biociências, Rio Claro. Dados fornecidos pelo autor(a). Essa ficha não pode ser modificada. ACKNOWLEDGEMENTS I would like to thank sincerely who supported me during my PhD course. To my supervisor Prof. Dr. Alexandre Janotta Drigo, who offered me an opportunity to study with freedom and autonomy and supported me throughout the process of doing my PhD. Thanks, Alexandre, for teaching me valuable lessons through your example of a Professor who is fully dedicated to the development of Physical Education as a profession and committed to ethical work in the university and society. To my co-supervisor Prof. Dr. David Kirk, who offered me a unique opportunity to widen my perspective and learn about Physical Education at an international level. This world was unknown to me. Thanks, David, for your generosity, patience and support. Thanks for trusting on my work, and for challenging me to move beyond and expand my capacities. To the examiners Prof. Dr. Flávio Soares Alves, Prof. Dr. José Luiz Riani Costa, Prof. Dr. Alex Branco Fraga and Prof. Dr. Felipe Quintão de Almeida, for accepting the invitation to contribute with this study. Thank you all for your availability, interest and commitment. To all participants who collaborated with the research, they were essential to the study. To Thomaz, for his immense love, partnership and support. To my parents Heloisa and Arnaldo, my brothers Hárley, Heber and Heider, my sisters Helen and Huly, for being my basis and inspiration. To Jenna, for her friendship, help and daily presence even at a distance. To my colleagues of the research group on Physical Education profession (GPPEF), for sharing learning and supporting me in many situations. In particular to Juliana, for being so kind and receptive with our research group. To Prof. Dr. Samuel de Souza Neto, for being helpful with my research project. To Norival, for his friendship and help in travelling with me to the university. Finally, I would like to recognise the sponsors that supported this project. This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001. This work was conducted during a visiting scholar period at University of Strathclyde, sponsored by the Capes Foundation within the Ministry of Education, Brazil (Programa de Doutorado Sanduíche no Exterior, grant n. 88881.131900/2016-01). This study was conducted during a study leave sponsored by Federal Institute of Education, Science and Technology of South of Minas Gerais (IFSULDEMINAS). The research project was financed in part by grant n. 2019/05358-7, São Paulo Research Foundation (FAPESP). RESUMO A proporção da população mundial com 60 anos ou mais está aumentando rapidamente. No entanto, vidas mais longas não significam necessariamente vidas mais saudáveis. Assim, faz-se necessário um maior conhecimento sobre como promover saúde. De que forma a Educação Física (EF) pode contribuir e responder a essa situação? Está bem estabelecido na literatura como o exercício previne doenças crônicas. No entanto, falta conhecimento sobre como a EF pode contribuir para a promoção da saúde. Nesse contexto, o presente estudo foi delineado para abordar o tópico de como os profissionais de EF poderiam ajudar idosos a desenvolver sua saúde e vivenciar positivamente o envelhecimento. O objetivo foi investigar as práticas adotadas por profissionais de EF para oferecer práticas corporais para idosos em situações de desvantagem em programas de promoção da saúde e entender os processos de desenvolvimento de saúde que os idosos experimentaram e perceberam como relacionados à sua participação nas práticas corporais. O estudo se fundamentou na salutogênese, uma teoria para a promoção da saúde proposta pelo sociólogo Aaron Antonovsky. Juntamente com essa perspectiva teórica, a investigação se baseou nas noções de práticas corporais e pedagogia. O estudo foi conduzido por meio da abordagem qualitativa e do método da teoria fundamentada nos dados. A amostragem teórica norteou a inclusão de quatro programas de promoção da saúde, localizados nas regiões sudeste e sul do Brasil. Participaram seis profissionais de EF, três coordenadores de centros de saúde e 34 idosos vinculados aos programas. Os dados foram gerados através do trabalho de campo condensado, com a realização de visitas a cada local em um curto período de três dias. As fontes de dados incluíram entrevistas, observação não participante de 34 sessões de práticas corporais e documentos. A análise dos dados foi realizada pelo método da comparação constante, envolvendo codificação inicial e focada. O software qualitativo de análise de dados NVivo 12 da QSR International foi usado para auxiliar o gerenciamento de dados e o trabalho analítico. Os resultados indicaram que os profissionais de EF se envolveram em uma série de práticas consideradas consistentes com as práticas salutogênicas e pedagógicas: visão ampliada de saúde, ética do cuidado, cuidado holístico e abordagem baseada na comunidade. Essas práticas foram relacionadas a dois principais processos de desenvolvimento de saúde vivenciados pelos idosos: o desenvolvimento de recursos de resistência generalizada em múltiplas dimensões (cognitiva, social, emocional, física) e o fortalecimento dos componentes do sentido de coerência (capacidade de compreensão, capacidade de gerenciamento e capacidade de investimento). Em conclusão, as práticas corporais serviram como um recurso que ajudou os idosos a perceberem suas vidas como compreensíveis, gerenciáveis e significativas. Este estudo sugere que a EF poderia ampliar e maximizar sua contribuição para a promoção da saúde de idosos através da criação de comunidades de movimento, facilitando encontros e conectando pessoas por meio do movimento. Intervenções e iniciativas futuras de promoção da saúde poderiam incorporar práticas pedagógicas informadas pela salutogênese como uma possibilidade de ir além de uma visão patogênica da saúde e permitir que os participantes tenham experiências corporais significativas de cuidado holístico, em direção ao cultivo da vida. Palavras-chave : Promoção de saúde. Educação Física. Práticas corporais. Práticas pedagógicas. Modelo salutogênico. Idosos. Envelhecimento saudável. ABSTRACT It is well known that the world population aged 60 or older is rapidly growing. However, longer lives do not mean necessarily healthier lives. Thus, further knowledge about how to promote health has been required. How physical education can contribute and respond to this situation? It is well established in the literature how exercise prevents chronic diseases. Nevertheless, knowledge about the ways physical education might contribute to health promotion is lacking. In this context, the present study was designed to address the topic of how Health-Physical Education (HPE) professionals might help older adults to develop their health and experience ageing positively. The aim was to investigate the practices adopted by HPE professionals to deliver bodily practices for disadvantaged older adults in health- promoting programmes, and to understand what health development processes the older adults experienced and perceived as related to their participation in bodily practices. The study was informed by salutogenesis, a theory for health promotion proposed by the sociologist Aaron Antonovsky. Alongside this theoretical perspective, the investigation drew on the notions of bodily practices and pedagogy. The study was conducted with a qualitative approach and a grounded theory research design. Theoretical sampling guided the inclusion of four health-promoting programmes, located in the southeast and south regions of Brazil. Participants were six HPE professionals, three health centres´ coordinators and 34 older adults enrolled in the programmes. Data was generated through condensed fieldwork by visiting each site in a short period of three days. Multiple data sources included interviews, non- participant observation of 34 bodily practices sessions and documents. Data analysis was conducted through constant comparative method, involving initial and focused coding. The qualitative data analysis software QSR International's NVivo 12 was used to support data management and analytical work. The findings indicated that the HPE professionals engaged in a number of practices that were considered as consistent with salutogenic and pedagogical practices: wide view of health, ethics of care, holistic care, and community-based approach. These practices were connected with two main health development processes experienced by the older adults: the development of generalised resistance resources (GRR) in multiple dimensions (cognitive, social, emotional, physical), and the strengthening of sense of coherence components (comprehensibility, manageability and meaningfulness). In conclusion, bodily practices served as a GRR for older adults, which helped them to see their lives as comprehensible, manageable and meaningful. This study suggests that physical education might widen and maximise its contribution to older people´s health promotion by focusing on the creation of communities of movement, facilitating encounters and connecting people through the medium of movement. Future interventions and initiatives on health promotion might incorporate salutogenic-informed pedagogical practices as a possibility to move beyond a pathogenic view of health, and to enable participants to have meaningful bodily experiences of holistic care, towards life cultivation. Key words: Health promotion. Physical Education. Bodily practices. Pedagogical practices. Salutogenic model. Older adults. Healthy ageing. LIST OF ABBREVIATIONS AND ACRONYMS PE Physical Education HPE Health - Physical Education WHO World Health Organization AHA American Heart Association ACSM American College of Sports Medicine CDC Centers for Disease Control and Prevention SUS Unified Health System PNPS National Health Promotion Policy NASF-AB Family Health Extended Team and Primary Care CAPS Psychosocial Attention Centres SOC Sense of coherence GRR Generalised resistance resource MVPA Moderate to vigorous physical activity GT Grounded theory SDT Self-determination theory CONTENTS Página 1. INTRODUCTION ...................................................................................................................................... 9 1.1 Initial comments and autobiographical reflection ...................................................................................... 9 1.2 The context of the study ............................................................................................................................. 11 1.3 Research questions ..................................................................................................................................... 14 1.4 Purpose of study ......................................................................................................................................... 14 2. THE RELATIONSHIP BETWEEN PHYSICAL EDUCATION AND THE HEALTH SECTOR ......... 15 2.1 Insertion of Health-Physical Education professionals in the Unified Health System, Brazil ................. 15 2.2 Languaging bodily practices and physical activity .................................................................................... 20 2.3 Lessons from Collective Health: a caring dimension ............................................................................... 23 2.4 Lessons from Sport Pedagogy: a pedagogical dimension ......................................................................... 25 3. SALUTOGENESIS AS A THEORY FOR HEALTH PROMOTION ..................................................... 27 3.1 Health promotion ....................................................................................................................................... 27 3.2 Models of health ......................................................................................................................................... 29 3.3 Antonovsky´s salutogenic model ................................................................................................................ 30 3.4 Approximations between salutogenesis and physical education .............................................................. 35 4. METHODS ................................................................................................................................................ 38 4.1 Worldview ................................................................................................................................................... 38 4.2 Researcher reflexivity ................................................................................................................................. 39 4.3 Grounded theory design ............................................................................................................................. 41 4.4 Setting ......................................................................................................................................................... 42 4.5 Participants ................................................................................................................................................. 45 4.6 Condensed fieldwork as data generation ................................................................................................... 48 4.7 Procedures .................................................................................................................................................. 48 4.7.1 Participants recruitment ...................................................................................................................... 49 4.7.2 Online meetings ................................................................................................................................... 49 4.7.3 Visiting sites ......................................................................................................................................... 49 4.7.4 Interviewing ......................................................................................................................................... 50 4.8 Data analysis .............................................................................................................................................. 54 4.8.1 Coding ................................................................................................................................................. 55 4.8.2 Memo-writing ...................................................................................................................................... 55 4.8.3 Theoretical sampling ........................................................................................................................... 56 4.9 Trustworthiness .......................................................................................................................................... 57 4.10 Ethical issues ............................................................................................................................................ 57 5. FINDINGS ................................................................................................................................................. 59 5.1 A wide view of health ................................................................................................................................. 59 5.1.1 Looking at the person .......................................................................................................................... 60 5.1.2 The ubiquity of stressors ...................................................................................................................... 64 5.2 Ethics of care .............................................................................................................................................. 65 5.2.1 Attentiveness ........................................................................................................................................ 68 5.2.2 Respect for limitations caused by age .................................................................................................. 72 5.2.3 Services integration and multi-professional work ............................................................................... 74 5.3 Holistic care ................................................................................................................................................ 83 5.4 Community-based approach ...................................................................................................................... 92 5.4.1 Age-friendly environment .................................................................................................................... 93 5.4.2 Participation ........................................................................................................................................ 98 5.4.3 Empowerment .................................................................................................................................... 101 5.5 Community of movers .............................................................................................................................. 108 5.5.1 Sense of belonging ............................................................................................................................. 110 5.5.2 Positive experiences: ‘we talk, laugh and have fun’ .......................................................................... 112 5.5.3 Friendship .......................................................................................................................................... 116 5.5.4 Attachment: ‘it´s like a family’ .......................................................................................................... 122 5.5.5 Social support .................................................................................................................................... 125 5.6 Building generalised resistance resources .............................................................................................. 128 5.6.1 Physical fitness and functioning capacity .......................................................................................... 128 5.6.2 Knowledge and lifelong learning ....................................................................................................... 135 5.6.3 Emotional skills ................................................................................................................................. 140 5.6.4 Socialisation and communication ...................................................................................................... 148 5.7 Strengthening the sense of coherence ..................................................................................................... 150 6. DISCUSSION .......................................................................................................................................... 160 6.1 The HPE professionals´ practices ........................................................................................................... 161 6.2 Connecting HPE professionals´ practices with older adults´ health development ................................ 170 6.3 Bodily practices as a medium for connecting people .............................................................................. 176 6.4 Community of movement: a way of working with bodily practices for life cultivation .......................... 177 6.5 How is our river? The context matters .................................................................................................... 182 6.6 Final comments ........................................................................................................................................ 183 6.6.1 Limitations of the study ...................................................................................................................... 184 6.6.2 Future directions ............................................................................................................................... 185 7. CONCLUSION ........................................................................................................................................ 186 8. REFERENCES ........................................................................................................................................ 189 9. APPENDIXES ......................................................................................................................................... 206 9.1 Appendix A: interview guides .................................................................................................................. 206 9.2 Appendix B: observation guide ................................................................................................................ 210 9.3 Appendix C: Agreement Term of Participation in Research .................................................................. 211 9.4 Appendix D: approval reports by Ethics Committee on Human Research ............................................ 217 9 1. INTRODUCTION 1.1 Initial comments and autobiographical reflection This study was motivated by my concern with the professional practice of physical education1 (PE) in the health sector. In 2012/2013, I had the opportunity to work as a Health-Physical Education2 (HPE) professional in the health-promoting programme Academia da Saúde (Health gym) and in a bodily practices programme directed at health workers, within the Unified Health System (SUS3). Working in the health sector was new to me and I experienced a feeling of being unable to find enough tools in my backpack knowledge to contribute to complex situations I encountered. I had a negative feeling of not being helpful to the working dynamics of the health centre, and of not finding coherence and compatibility between the way I was trained by the programme´s coordinators to deliver physical activity and what I was seeing in practice during my daily contact and relationship with the older adults. Through practice, I learned that the older adults´ needs and interests were mainly related to social aspects, and that health had other dimensions beyond the physical domain. Then, I perceived that I had other conceptual and practical tools in my backpack (e.g. communication and relational skills, knowledge about multiple forms of movement, organisation of recreational events, among others) that could support me to meet the needs and interests of participants. Similar to my experience, studies have shown a distance between PE practice and the scope of health-promoting programmes (SKOWRONSKI; FRAGA, 2016). There is, moreover, an incompatibility between PE initial professional education and the provision of services in the field of health. This indicates that PE higher education programmes have failed to engage their students in learning processes that are capable of establishing a dialogue with 1 I recognise there are alternative possibilities in English language to name the area of research and practice, e.g. Kinesiology (North America), Sport Sciences (United Kingdom) and Human Movement Studies (Australia), but I stick with Physical Education since it is the most common term in Brazil to refer to the field of School Physical Education and others professional areas, like health care, leisure, fitness and sports. 2 I use the term Health - Physical Education (HPE) professionals to refer to health workers whose speciality is physical education, whether teachers, instructors and others who work specifically with bodily practices and physical activity in public health settings. 3 I opted to stick with the acronyms in Portuguese when they are widely used in Brazil, in order to facilitate the recognition. This applies to SUS (Unified Health System), PNPS (National Health Promotion Policy), NASF-AB (Family Health Extended Team and Primary Care). 10 the complexity of health work (COSTA et al., 2012; FALCI; BELISÁRIO, 2013; GUARDA et al., 2014; OLIVEIRA; ANDRADE, 2016; PASQUIM, 2010; RODRIGUES et al., 2013; STHAL, 2016). Although PE higher education programmes in Brazil demonstrated an intention to prepare students for health work, they did not offer enough health-related modules to provide them with relevant knowledge (FERREIRA; KIRK; DRIGO, 2017). Problems reported by other HPE professionals in the literature confirmed that they did not have access to specific knowledge about public health, health promotion, the health care system, nor to skills development for working within multi-professional teams during their graduation. Other critiques of PE programmes are related to a distance from the reality of health care services, and to a lack of alignment with theoretical foundations of health promotion. There is, in addition, an absence of evaluative methods, and a lack of knowledge about ways of working with health (ANJOS; DUARTE, 2009; BRUGNEROTTO; SIMÕES, 2009; NEVES; ASSUMPÇÃO, 2017; PASQUIM, 2010; SANTIAGO; PEDROSA; FERRAZ, 2016). Regardless of the shortcomings in initial professional education, it is relevant to highlight that some studies have striven to propose alternatives to improve the quality of PE higher education programmes, indicating possibilities for change. For example, some authors have suggested a focus on sociocultural knowledge, the use of critical and pedagogical approaches, and an integration between learning and service (ANDRADE et al., 2014; BAGRICHEVSKY; ESTEVÃO, 2008; SANTIAGO; PEDROSA; FERRAZ, 2016). Seeking alternatives to traditional practice has been the direction that this dissertation sought to follow. Although the motivation for carrying out this study included the identification of problems in initial professional education, the inquiry was not concerned with critiquing this context because previous studies already explored the topic (MARTINEZ et al., 2013; PAULO, 2013; PRADO; CARVALHO, 2016; SANTOS et al., 2011; SILVA, 2016; TOASSI, 2017). On the other hand, knowledge about the relationship between PE and health from the perspective of professional practice is still lacking. There is some practice-based evidence that PE has effectively achieved health goals (ARMOUR; HARRIS, 2013; STONE et al., 1998; TROST, 2006). In the context of this research, Armour and Harris (2013) claimed that there is an urgent need for the development of health pedagogies to support PE practices, due to little knowledge in this area. To summarise, because health knowledge was lacking in my initial professional education (and in the education of many other HPE professionals as confirmed by the literature), I was motivated to investigate and to gain understanding about how PE might help 11 older people to develop their health. This discussion is needed in the PE area in order to improve the quality of services offered to older age communities and, secondarily, to advance professional education as well. 1.2 The context of the study The debate about PE and health have increased recently, although the field of health has strongly influenced PE for a long time, since its systematisation in Brazil. In the nineteenth century, gymnastics was an important component of body education that sought to eliminate immoralities and excesses from the population (SOARES, 2013). Also, it secured a place in society as a normalising and regulating practice, with a disciplinary character, capable of guiding individuals to internalise notions of time, energy expenditure and health as organizing principles of daily life (SOARES, 2013). Brazilian PE borrowed from the European Gymnastic Movement it’s functionalist orientation to hygienist and military ideologies that advocated for race regeneration, individuals´ moralisation, virtues development and health promotion, without any change in population´s life conditions (BAGRICHEVSKY et al., 2006; SOARES, 2013). In line with this historical background, PE incorporated a limited biological conception that exercise is medicine (BAGRICHEVSKY et al., 2006; SALLIS, 2009; TAYLOR, 2014). In addition, epidemiological evidence demonstrated that physical inactivity constitutes a risk factor for major non-communicable diseases (e.g. diabetes, obesity, metabolic syndrome, colon and breast cancer) (LEE et al., 2012; PANG WEN; WU, 2012). The epidemiological research influenced organizations such as the World Health Organization (WHO), American Heart Association (AHA), American College of Sports Medicine (ACSM) and Centers for Disease Control and Prevention (CDC) to recommend regular physical activity as a strategy for disease prevention and health promotion (HASKELL et al., 2007; PATE et al., 1995; WHO, 2010). In turn, these recommendations influenced the development of public policies of physical activity promotion in many countries, including Brazil (BRAZIL, 2006c; KAHLMEIER et al., 2015; OJA; TITZE, 2011; USA, 2008). This association between physical activity and disease prevention has been reinforced by PE research and practice without enough reflection and critical thinking (KIRK, 2006). This becomes clear from messages conveyed by editorials and publications in international scientific journals. Some examples are: “Exercise is medicine and physicians need to prescribe it!” (SALLIS, 2009 - British Journal of Sports Medicine); “Physical inactivity: the 12 biggest public health problem of the 21st century” (BLAIR, 2009 - British Journal of Sports Medicine); “School Physical Education: The Pill Not Taken” (MCKENZIE; LOUNSBERY, 2009 - American Journal of Lifestyle Medicine), “the pandemic of physical inactivity” (ANDERSEN; MOTA; PIETRO, 2016; KOHL et al., 2012 - Series on physical activity, The Lancet); “Exercise Professionals - Could they be the forgotten public health resource in the war against obesity?” (OPRESCU; MCKEAN; BURKETT, 2012 - Journal of Sports Medicine and Doping Studies). Such comprehension is limited as it communicates an idea that individuals are healthy since they are physically active, which is not necessarily true. Due to this socially constructed discourse (KIRK, 2006), it has been widely expected that physical activity has a contribution to make to public health (ARMOUR; HARRIS, 2013; LYON; NEVILLE; ARMOUR, 2017; PÜHSE et al., 2011). In the literature, major studies about PE and health have been concerned with increasing physical activity levels of the population, both in the school context (CASTELLI; CARSON; KULINNA, 2014; DUDLEY; GOODYEAR; BAXTER, 2016; ERWIN et al., 2013; MCKENZIE; LOUNSBERY, 2009, 2013, 2014; MCKENZIE; SALLIS; ROSENGARD, 2016; METZLER et al., 2013a, 2013b; SALLIS et al., 2012; SALLIS; MCKENZIE, 1991), and other settings (BREHM et al., 2005; HENDERSON et al., 2017; MURPHY et al., 2012; PAVEY et al., 2012; SPENCE; LEE, 2003). In prioritising the biological and physical dimensions, PE allowed the body’s fragmentation and disregarded persons with their affects, focusing on and categorising them based on diseases instead of considering them in their wholeness (CARVALHO, 2006a). In this context, Bracht (2013) reminds us that there is still a challenge to transform PE towards a practice of resistance to healthism through knowledge production and alternative bodily activities. Other scholars, mainly supported by Humanities and Social Sciences, have also posed critiques of regulative, medicalising and pathogenic discourses (CARVALHO, 1993; FRAGA, 2006; FRAGA et al., 2007; GOMES; PICH; VAZ, 2006; KIRK, 2006; PALMA; VILAÇA; DE ASSIS, 2014; PALMA, 2001). As an alternative, in school context, researchers have advocated for health pedagogies (ARMOUR; HARRIS, 2013; HAERENS et al., 2011; OLIVEIRA; MARTINS; BRACHT, 2015) and salutogenic approaches (MCCUAIG; QUENNERSTEDT, 2016; MCCUAIG; QUENNERSTEDT; MACDONALD, 2013; QUENNERSTEDT, 2008, 2019). 13 A smaller number of scholars have focused on research in non-school settings with a wide perspective on health, including notions such as quality of life, vitality, happiness, the good life, bodily practices and health resources (ALVES; CARVALHO, 2010; ERICSON et al., 2018; FRAGA; CARVALHO; GOMES, 2013; FRAGA; WACHS, 2007; FREITAS; CARVALHO; MENDES, 2013a, 2013b; GRANT, 2012; JETTE; VERTINSKY, 2011; MANSFIELD; RICH, 2013). Overall, the literature on PE and health has been mainly focused on younger age- groups in the school context. It is less known about how and what forms of movement contribute to health development among people in older stages of life. Considering older age-groups becomes even more relevant given the rapid growth in the ageing population worldwide. By 2025, Brazil will be the sixth country in the world with the highest proportion of the population aged 60 and over (WHO, 2002). In face of this phenomenon of increasing life expectancy, it has been questioned ‘how can the quality of life in old age be improved’ (WHO, 2002, p.5). The World Health Organization (WHO, 2002) have already warned that there is an urgent need, in developing countries in particular, to find ways to help older people to ‘becoming healthier’4 and active in multiple domains (i.e. physically, socially, culturally, economically, spiritually). How can physical education contribute and respond to this situation? In this context, the present study was designed to address the topic of how HPE professionals might help older adults to develop their health and experience ageing positively. The intention was to seek responses in the field of practice, where HPE professionals have mobilised and produced knowledge in action (SKOWRONSKI; FRAGA, 2016; VERENGUER, 2004), with support of the salutogenesis theory5 (ANTONOVSKY, 1979, 1987, 1996) alongside the notions of bodily practices and sport pedagogy. In particular, the study sought to investigate ongoing experiences of public programmes that have operated health promotion principles beyond disease prevention, in order to identify elements that might be taken into consideration for the development of an alternative approach for working with bodily practices throughout life. 4 This expression was borrowed from Quennerstedt (2019), who suggested that health is a process of becoming. 5 Salutogenesis is a theory for health promotion that proposes a shift from focusing on what causes diseases to the origins of health (see chapter 3). The salutogenic model has been considered a promising approach to put forward the ways HPE professionals might contribute to health in young groups (KIRK, 2020; MCCUAIG; QUENNERSTEDT, 2016; MCCUAIG; QUENNERSTEDT; MACDONALD, 2013b; QUENNERSTEDT, 2008b). However, there is little evidence of salutogenesis being used to support older adults in maintaining their health. 14 Grounded in practice-based evidence, this study points to a possible response that physical education might give to the health sector: pedagogical practices informed by salutogenesis, focusing on care, humanization, affects, holism, and on the ‘production of encounters’ through communities of movement. Thus, this doctoral dissertation supports the creation of communities of movement as means of health promotion across the lifespan, that is, a salutogenic and pedagogical way for working with bodily practices for life cultivation. 1.3 Research questions Two questions guided this inquiry, as follows: (1) How do HPE professionals deliver bodily practices for disadvantaged older adults as means of health promotion? (2) How does participation in bodily practices contribute to disadvantaged older adults´ health development? 1.4 Purpose of study According to the research questions, the purpose of the study was twofold: (1) to investigate the practices used by HPE professionals to deliver bodily practices for disadvantaged older adults in health-promoting programmes; (2) to understand what health development processes the older adults experienced and perceived as related to their participation in the health-promoting programmes. 15 2 THE RELATIONSHIP BETWEEN PHYSICAL EDUCATION AND THE HEALTH SECTOR The health sector became a multidisciplinary area, where different professions (e.g. Medicine, Nursing, Physiotherapy, Occupational Therapy, Psychology) apply their knowledge and approaches to intervention. PE was officially included as a health profession with other 13 areas (BRASIL, 1997, 1998). Since then, HPE professionals have had credentials to provide health services for individuals and communities, at the levels of health promotion, protection and recovery. Despite being regulated as a health profession, PE area kept a discrete discussion about health for a decade. It seems that the field of health became noticeable mainly after the formal inclusion of HPE professionals within the Unified Health System (SUS) in 2008 (BRAZIL, 2008), which will be presented in the next section. 2.1 Insertion of Health-Physical Education (HPE) professionals in the Unified Health System, Brazil The SUS was created in 1990 based on the assumption that health is a right for all, and the state must provide the population with conditions for their health development (BRAZIL, 1990). Then, the SUS offers health services for the whole population, without charging the citizens. Indeed, 70% of Brazilians depend on the public health system to get access to health care (CNDL, 2018). The system is organised into three levels: primary health care (basic services of low complexity), secondary (special services of intermediate complexity) and third (hospital´s services of high complexity). As this study focuses on health promotion, it refers to the first level of primary health care, which is carried out in settings like psychosocial centres, social services centres, basic health care units, family health programmes, health gym units, among others. The main strategy for systematising and qualifying primary care service within the SUS is Family Health (BRAZIL, 2006; 2012; 2017). This strategy is organised through professional teams, which are comprised of a physician, nurse, nursing technician, community health agents (workers who live in the local community) and in some cases, dentist and dental technician. Each family health team provides services for 4,000 people, maximum (MINISTRY OF HEALTH, [s.d.]). 16 Based on the argument that sedentariness represents a high economic cost due to associated number of deaths, hospitalizations at the SUS and early retirement provoked by noncommunicable diseases, the Ministry of Health launched the Physical Activity Promotion Programme (BRAZIL, 2001). Accordingly, the Pact for Health (BRAZIL, 2006b) established as an objective to emphasize population´s behaviour change in order to people internalize individual responsibility for an active lifestyle. Then, as planned by the Pact for Health, the National Health Promotion Policy (PNPS) was elaborated and launched in 2006. The PNPS proposed a wide view of health and, it formally included physical activity and bodily practices as a priority action in the scope of public health (BRAZIL, 2006c). A revised version of the PNPS was released in 2014, emphasizing the importance of health sector´s integration with other sectors to work towards equity and better life conditions for all6. The policy´s main goal is to construct a health care model that prioritises actions for improving people´s quality of life (BRAZIL, 2006c; BRAZIL, 2014). The PNPS suggests that local health needs, problems and social determinants are the core of health care in terms of how to organise, plan, deliver and monitor services (BRAZIL, 2006c; BRAZIL, 2014). Thus, there is a clear intention in the document to make an impact on people´s life conditions and to facilitate popular access to a wide range of healthy choices. The PNPS follows the WHO agenda, so it relies on the health promotion framework and on the notion of social determinants of health. With this perspective, health is understood as a result of multiple factors that shape people´s lives, such as food, housing, education, sanitation, income, leisure, culture, transport, environment and work conditions. In 2013, physical activity was also included as a determinant of health in Brazilian legislation (BRAZIL, 2013). The policy criticises the biomedical paradigm as it is disease-centred and focused only on the biological aspects of individuals, not being capable of modifying social conditions and considering life as a whole. The PNPS gives more attention to ways of living in a given historical, social and cultural context (BRAZIL, 2014). It is important to highlight that the document adopts the expression ‘ways of living’ instead of ‘lifestyle’. The PNPS makes clear 6 The PNPS stimulates an articulation across public policies to develop practices that contribute to integral health care (CARVALHO, 2006b). The PNPS´s key strategy is working across sectors, which would enable changes on poor conditions that constrain people´s lives to disadvantaged situations. So, it claims that all other public policies should work cooperatively to address inequalities (BRAZIL, 2014). 17 that how people organise their lives and choose their ways of living does not depend on individual willingness, but they are conditioned by economic, political, social and cultural factors (BRAZIL, 2014). Furthermore, the PNPS acknowledges subjectivity, solidarity, happiness, ethics, diversity, humanisation, co-responsibility, social justice and social inclusion as valuable resources for helping people to recognise their own potential, to find opportunities to overcome barriers and change their conditions towards new ways of living (BRAZIL, 2014). The public policy proposes the delivery of health services in accordance with a set of principles7, namely: equity and social participation, autonomy and empowerment, action across sectors, sustainability, integrality and territoriality. Eight priorities were established by the PNPS to fulfil its goals, as follows: (1) continuous education, (2) nutrition and healthy diet, (3) bodily practices and physical activities, (4) reduction in tobacco use, (5) reduction in alcohol and drugs harmful use, (6) safe mobility, (7) culture of peace and human rights, and, (8) sustainability. The third priority involves actions related to the delivery of bodily practices and physical activity, such as walking, exercise, recreation, sports and leisure activities for the whole community and vulnerable groups. Moreover, it includes other actions like partnerships across sectors to create active environments, counselling about healthy lifestyles, communication of healthy ways of living, and monitoring of activities´ effectiveness for disease control and prevention (BRAZIL, 2006c). Summarising, the PNPS indicated four actions related to bodily practices and physical activity: delivery, counselling, working across sectors, and monitoring. It is important to highlight that from the PNPS official document published in 2006 to the 2014´s version, there was a change in how terms were written: from ‘bodily practices/physical activity’ to ‘bodily practices and physical activity’. The slash seems to be used in 2006 as a way to include both approaches. However, the difference between the terms are not very clear in the document, creating the risk of readers understanding them as similar (see section 2.2). In the revised version, the slash became an ‘and’, which seems to be an 7 The principles can be defined as: (a) equity and social participation - offering equal opportunities for all and considering the voice of different individuals and groups; (b) autonomy and empowerment - stimulating self- perception and capacities´ development towards awareness, decision-making and control over oneself life; (c) action across sectors - articulating collaborative networks; (d) sustainability - considering the importance of promoting actions continuously; (e) integrality - acknowledging the complexity and wholeness of individuals; and, (f) territoriality - referring to local specificities regards social determinants of health (BRAZIL, 2014). 18 attempt to emphasise they are different ways of thinking about movement and health (BRAZIL, 2014). In alignment with the PNPS, the HPE professionals were formally included within the SUS in 2008, through the creation of the Núcleo Ampliado de Saúde da Família e Atenção Básica, NASF-AB (Family Health Extended Team and Primary Care) (BRAZIL, 2008; 2017). The strategy´s purpose was to widen the scope and coverage of primary health care services. The NASF-AB refers to a multi-professional team that has a function to provide support for other programmes and strategies within SUS, such as family health teams, basic health care and Academia da saúde (Health gym). Following the health policy, the NASF-AB established that bodily practices and physical activity were priority actions, delineating a new setting for HPE professionals´ service within the multi-professional team (BRAZIL, 2008). Then, among 13 health workers listed as possible personnel, the HPE professionals were involved8. According to NASF-AB guidelines (BRAZIL, 2010), the HPE professionals should: - develop bodily practices and physical activity with communities; - provide information related to disease prevention and risk factor reduction; - favour social inclusion through regular activities; - provide continuous education about bodily practices and physical activity for other health workers; - intensify the use of public places for social integration; - articulate partnerships with other sectors and public institutions; and - organise events that promote bodily practices and physical activity. The actions must be directed at the whole community, not restricted to ill or vulnerable groups. However, in the field of practice, a study carried out by Santos et al. (2015) with 296 HPE professionals, who were affiliated to NASF-AB programmes, showed that the activities were directed mainly at older women, hypertensive and diabetic patients, and the youth. The authors indicated that there is a need for HPE professionals to engage in 8 The decision of which professional categories constitute the team is made according to city councils´ decision, informed by epidemiological data and local needs (BRAZIL, 2018). Among 5,067 teams distributed over 3,329 cities, the most preferred professions to constitute the multi-professional group are Physiotherapy, Social Service, Psychology, Dietetics and PE (BRAZIL, 2015). Carvalho et al. (2018) found that the HPE professionals had the highest growth rate of 145% from 2008 to 2013 among other areas in SUS. This significant increase demonstrates that there is an expectation that HPE workforce might make an effective contribution to health promotion. 19 continuous professional development and explore other activities in order to improve the quality of services and to reach a wider range of populational groups. Besides the NASF-AB programme, another area for the production and mobilisation of PE knowledge within SUS (SKOWRONSKI; FRAGA, 2016) arose with the community- based strategy Academia da Saúde (Health Gym) (BRAZIL, 2011). Initially, the programme aimed at the promotion of physical activity, leisure and bodily practices among the population, by providing activities free of charge, in public places, with professional supervision (not only HPE professionals9). Later, it was reconceptualised with a wide perspective, broadening its scope to health promotion, production of care and healthy ways of living (BRAZIL, 2013). The new version paid more attention to health promotion principles. The actions of Academia da saúde are directed at individuals and communities through eight themes: bodily practices and physical activity, healthy eating promotion, production of care and healthy ways of living, integrative and complimentary practices, artistic and cultural practices, health education, management and, community mobilisation (BRAZIL, 2013). The Academia da saúde programme assumes that environment and accessibility are important factors to favour community engagement. A relevant aspect is that the strategy addresses inequalities by implementing practices and offering opportunities in socially vulnerable areas (SOUZA ANDRADE et al., 2018). The programme functions as a facility that favour community access to and engagement with bodily practices and physical activity (ibid., 2018). To date, there are 2,459 units operating in Brazil (BRAZIL, 2018). Therefore, NASF-AB and Academia da Saúde are the main programmes that involve formally HPE professionals in Brazilian health sector. There are other settings that include PE service, however in a minor scale, like CAPS (Psychosocial Attention Centres), independent health-promoting programmes sponsored by city halls, hospitals, and more recently, in the context of supplementary health with the initiative of health insurance companies that began to invest on health promotion actions. 9 Besides the HPE professionals, the programme involved other workers, for instance: social worker, occupational therapist, physiotherapist, speech therapist, dietitian, psychologist, sanitarian, social educator, music therapist, arts therapist, artists and dancers (BRAZIL, 2016). 20 2.2 Languaging bodily practices and physical activity Bodily practices and physical activity were adopted by Brazilian health policy as health care actions through the medium of movement. Both terms were used together in the official documents, however they were separated by a slash symbol (/) in the first version (BRAZIL, 2006), and by an ‘and’ in the revised one (BRAZIL, 2014). About the way the terms were associated to each other in the documents, Galvanese, Barros and Oliveira (2017) indicate that it hides the diverging perspectives the terms have. To Damico and Knuth (2014), bodily practices versus physical activity can be considered as an epistemological dispute in the area of PE and health. This study corroborates this idea that bodily practices and physical activity are diverging notions and recognises that they are distinct not only in theoretical basis, but also in political and practical dimensions. In the political dimension, the term bodily practices is not meant to be a new name for what already exists (CARVALHO, 2006b). What it intends is to present a new way of thinking and working with health promotion that involves dialogue with other forms of knowledge, such as those from Humanities and Social Sciences. Bodily practices entail a discourse in favour of the diversity of bodies in movement (ALVES; CARVALHO, 2010), in contrast to the imperative and prescriptive discourses of physical activity as a product for consumption in the market of active life (FRAGA, 2006). Furthermore, the notion of bodily practices questions the assumption that the main contribution of PE to the health sector would be the delivery of physical activity as a regulated practice that seeks to serve as a means to achieve external goals, such as weight loss and disease control. In considering bodily practices, human movement is more than an activity that serves to specific purposes of regulating bodies. In the practical dimension, the adoption of bodily practices has implications in terms of what to do and what not to do (MENDES; CARVALHO, 2015). Engaging with bodily practices implies to not reduce a person into the illness or health condition he/she may have, nor to fragment actions, nor to isolate from the complexity of health services (MENDES; CARVALHO, 2015). Instead, working with bodily practices involves the creation of ways of integrating care, participants´ needs and interests, and knowledge from other areas. Furthermore, the notion invites HPE professionals to offer meaningful bodily experiences, to be responsive to participants´ needs, and to provide them with affective and relational practices (MENDES; 21 CARVALHO, 2015). Hence, bodily practices do not aim to guide people to a particular lifestyle, but to create with them new possibilities of ways of living (SILVA; DAMIANI, 2005). On the other side, physical activity is mainly concerned with fighting against sedentariness, overweight and obesity through the promotion of physically active lifestyles. It has become a medicalised concept (FRAGA et al., 2007), beyond the classic definition that it follows: ‘any bodily movement produced by skeletal muscles that results in energy expenditure’ (CASPERSEN; POWELL; CHRISTENSON, 1985, p. 126). The physical activity approach has its foundations on quantitative and biological knowledge, from disciplines like Anatomy, Physiology and Epidemiology. It is widely accepted that physical activity plays an important role in reducing and controlling risk factors for noncommunicable diseases (DAMICO; KNUTH, 2014). That is the reason why research on physical activity is mostly related to measurements of physical activity levels of the population (DAMICO; KNUTH, 2014). In contrast to physical activity, the notion of bodily practices emerged in Brazilian literature in the late 1990´s related to school PE (LAZZAROTTI FILHO et al., 2010). Its use has increased, and it has been adopted by other areas like Education, Psychology, Anthropology, Arts and Social Sciences. The bodily practices approach has its foundations on Humanities and Social Sciences (LAZZAROTTI FILHO et al., 2010). Bodily practices are conceptualised as the individual or collective expressions of physical culture that convey the meanings people attribute to them (BRAZIL, 2013). They derived from people´s knowledge and experience of play, dance, sports, recreation, martial arts and gymnastics, constructed systematically or not (BRAZIL, 2013, p.28). Bodily practices involve both Eastern and Western traditions to movement, including multiple forms of human expression through the body (CARVALHO, 2006b). The conceptualisation of bodily practices entails a refusal of medicalising and fragmented practices (BAGRICHEVSKY et al., 2013), and an affirmation of the sociocultural aspects of human movement (DAMICO; KNUTH, 2014; LAZZAROTTI FILHO et al., 2010). Bodily practices convey a critique to physical activity, since the latter refers to an approach based on biomedical traditions that tend to focus on illness, symptoms and risk factors as a means to promote health. What can be seen as a limitation is that physical activity, as a biomedical approach, takes account only of the ill-body and not of the whole person with his/her story of life, needs and interests (CARVALHO, 2006b). 22 Moreover, a biomedical approach is likely to reduce the body into an object under control and undermine the caring dimension of health work (MERHY, 2014). In this way, physical activity can serve to specific purposes for governing bodies and inculcating a sense of responsibility and blame into the population (SILVA; DAMIANI, 2005). In this regard, Fraga (2006) revealed how the phenomenon of body governmentality operates mostly at the level of discourse and provision of information for the population. In response to these critiques, bodily practices evolved as an alternative approach that focuses on the person (whether ill or not) and on the ‘production of encounters’ (CARVALHO, 2006b). In these encounters, movement is the language that allows a special dialogue among individuals, communities and health services. Bodily practices are aligned with health promotion principles and they have a potential to contribute to holistic health care (FRAGA; CARVALHO; GOMES, 2013). Furthermore, they are likely to provide participants with meaningful experiences, leading to increased self- care, self-esteem, self-perception, socialisation and fun. Also, they create opportunities for HPE professionals to listen to, observe and stimulate people in the construction of affective, enduring and supportive relationships (CARVALHO, 2006b; SILVA; DAMIANI, 2005). Therefore, this study adopted the notion of bodily practices because it is a potent theoretical tool for operating a comprehensive orientation to health, which considers the wholeness and complexity of human being, and the social determinants of health. The concept of bodily practices has a power to develop other dimensions of health and wellbeing that have been little explored by HPE professionals in service. The notion of bodily practices extrapolates the boundaries of a theoretical concept and reaches the practice. It carries a humanistic basis that is helpful for HPE professionals to position and mobilise their discourses and practices within the health sector. For instance, bodily practices imply the freedom of participants to connect with their culture, needs and interests, and the sensitivity of HPE professionals to identify and boost these connections. Then, bodily practices affect how HPE professionals deliver sessions and care for participants. In working with bodily practices, there is a concern to enable participants to find meaning from movement, in opposition to the imperative to move and spend energy as much as possible. In the theoretical dimension, bodily practices might be capable of mobilising the salutogenic model (see chapter 3) in practice, as they promote human strengths instead of deficits, like connectedness, empowerment, flourishing, resilience, coping, quality of life, among others (ERIKSSON; LINDSTRÖM, 2010). 23 Bodily practices offer possibilities for HPE professionals to engage in other ways of working that allow them to move away from pathogenic models, in a similar way as salutogenesis. Moreover, bodily practices engender relational practices between HPE professionals and participants, participants with themselves, and with others (ALVES; CARVALHO, 2010). Salutogenesis also emphasizes the strength of being relational in the ‘process of becoming’ healthier. Hence, bodily practices demonstrate to have a strong connection with salutogenesis. Such theoretical alignment reinforces the importance of HPE professionals integrating the team of health workers and provide specific services in the health sector. However, it is important to recognise that there are some limitations in using the notion of bodily practices. Some authors say that bodily practices is a concept under construction, because it still lacks stability and consensus within research community (GALVANESE; BARROS; D’OLIVEIRA, 2017; LAZZAROTTI FILHO et al., 2010). The point is that bodily practices do not have the same tradition and recognition as physical activity at the level of research, professional education and service in Brazil (FRAGA; CARVALHO; GOMES, 2013). Nevertheless, the notion of bodily practices is considered in this study as a powerful tool for activating and establishing a dialogue with theoretical concepts from Collective Health, health promotion framework (WHO, 1986) and salutogenesis (ANTONOVSKY, 1979, 1987, 1996). 2.3 Lessons from Collective Health: a caring dimension As Campos et al. (2014) proposed, it is important to identify that there is a set of specific professional knowledge and practices corresponding to a nucleus, or a specialised area. On the other hand, there is a field, a space of intersection that join professions around common practices of health care. Thus, the HPE professionals act in the nucleus of PE and in the field of health. A health worker has an important function of a ‘catalyst’ for health promotion action (WHO,1998), by fostering learning about health10, life skills development11, community empowerment, change in life conditions and population access to policies and health services. 10 Learning about health corresponds to an enhancement of health literacy, which can be explained as people´s ability and motivation to get access to information and improve their capacity to understand and use it in favour of their health development (WHO, 1998). 24 By means of explaining the work of health professionals, Merhy (2014) uses the notion of technology. By technology, the author refers not only to equipment, instruments and materials, but also to the body of professional knowledge, skills, procedures and tools that indicate how practitioners from specific areas produce and organise their services and/or products. Each profession has a technological knowledge, which is complex and defines the whole productive process (MERHY, 2014). Merhy (2014) proposes a classification for health technologies into three types: (1) soft, refers to the production of relational processes as acts of care that are constructed through human interaction; (2) soft-hard, it is the case of highly structured knowledge, for instance clinical practices and epidemiological approaches; and (3) hard, those centralised on the use of equipment, machines and strict rules. The act of producing health services is a ‘lived work’ (MERHY, 2014) as it embraces human action with one´s personal story, creativity, competencies, abilities and knowledge converged on a professional task. To Merhy (2014), the provision of health care services constitutes a ‘lived work’ in action, similar to the work developed in the field of education. ‘Lived work’ is based on ‘soft technologies’, which operates through building practices of attachment, attentiveness, empowerment and others. If it is possible to say that it has a final product, it is an encounter. The encounter refers to what is constructed through the interaction between health professionals and individuals/communities, and between the individuals with themselves. The singularity of health services relies on the essential working process: the ‘act of care’. Care is conceptualised as a humanised act of health assistance concerned with people´s sense of existence (AYRES, 2004). While delivering services, what health workers intentionally produce is care. Thus, the common object of health professions, whatever is the specialisation, is the production of care (MERHY, 2014). Merhy (2014) suggests that a model for working with health might be based on possibilities for producing relationships with individuals/communities that would facilitate attentiveness, autonomy and attachment. It would not ignore the specificity of each professional area and knowledge, instead, it would explore multiple possibilities of caring as a common and major dimension among all professions to maximise their actions. 11 By life skills, the Health Promotion Glossary means ‘abilities for adaptive and positive behaviour, that enable individuals to deal effectively with the demands and challenges of everyday life. (…) Examples of individual life skills include decision making and problem solving, creative thinking and critical thinking, self-awareness and empathy, communication skills and interpersonal relationship skills, coping with emotions and managing stress’ (WHO, 1998, p.15). 25 It is essential to reorient health services towards humanisation, transforming traditional appointments with patients into ‘therapeutic encounters’ (AYRES, 2004). To bring humanisation into practice, it is critical to allow some flexibility in technical procedures with relational and non-technical practices. The encounter privileges a dialogic dimension, paying attention and listening to the other with genuine interest. Listening to refers to an interactional resource, through which people feel comfortable to express their needs, problems and desires. By establishing a relationship with individuals, health workers help people to recover their project of happiness and to make meaning from health services (AYRES, 2004). Furthermore, Ceccim and Merhy (2009) suggest that a micropolitics rooted in encounters and interactions might constitute resistance against a macropolitical governance in health care. The authors add that in micropolitics, the encounters are pedagogical because they allow knowledge production, enabling learning and creativity. The ‘pedagogical encounter’ as Armour (2011) indicates, is similarly used as a conceptual element in the field of education to indicate the interaction between teachers, learners and knowledge. Again, the notions of ‘lived work’, ‘soft technologies’ and ‘production of encounters’ make evident some similarities between the act of teaching and the act of caring. Based on this commonality, this review borrows some elements from Sport Pedagogy as a means to advance the discussion about bodily practices delivery in the health sector, which is presented in the next section. 2.4 Lessons from Sport Pedagogy: a pedagogical dimension The notion of sport pedagogy12 can be useful for improving our thinking about bodily practices and health, since it conveys the wide meaning of cultural performances, beyond athletics, as established by German language (ARMOUR, 2011; HAAG, 1989; TINNING, 2008). In Haag´s (1989) view, sport pedagogy is related to the interaction between curriculum, teaching and learning that occur both in and out of schools. And more importantly 12 Sport pedagogy is a subdiscipline of the major field of Sport Sciences (HAAG, 1989; ARMOUR, 2011). Considering that all subdisciplines are positioned between sport sciences and another related discipline, in the case of sport pedagogy, it is related to sport sciences and education (HAAG, 1989). Armour (2011) has a similar comprehension that sport pedagogy studies the intersection between sport and education, and it integrates all the other subdisciplines in practice. 26 for the purpose of this study, it applies to the whole life of a person, not only to children and youth (HAAG, 1989; ARMOUR, 2011). In this line, Armour (2011) adds that sport pedagogy focuses on learners´ needs in terms of movement, and by consequence, on teachers´ abilities to identify and meet those needs. The author also highlights that sport pedagogy, with its broad scope, can be related to pedagogies for health. In this respect, other scholars reinforced that the notion of pedagogical work is related to movement, bodies, and health (TINNING, 2008), and that instructors should focus on the pedagogical dimension of practices in order to engage more people in forms of movement (CALE; HARRIS, 2011; CARVALHO, 2006b). As far as the concept of pedagogy is concerned, based on Bernstein (2000), it is possible to assume that the processes undertaken in health-promoting programmes constitute a pedagogical practice, as they have an explicit purpose of influencing people´s knowledge and practices regards their health. In ‘The Handbook of Physical Education’ edited by Kirk, Macdonald and O´Sullivan (2006), pedagogy is a central concept and it is defined as a combination of learning, teaching and curriculum that relate to each other in an interdependent way. These aspects interact with each other in the ‘pedagogical encounter’ of a lesson or session (ARMOUR, 2011). What is central to pedagogy is this interaction between the elements as a multidimensional and ‘dynamical system’ (ARMOUR, 2011; HAERENS et al., 2011; KIRK; HAERENS, 2014; KIRK; MACDONALD; O´SULLIVAN, 2006; METZLER, 2011; TINNING, 2008, 2010). As suggested by Kirk and Haerens (2014), it is crucial to give attention to all pedagogical dimensions. In thinking about the context of health sector, it is important to consider: (1) individuals/community´s health needs and conditions; (2) HPE professionals´ knowledge, beliefs, values, behaviour and practices; (3) knowledge and forms of movement developed in health promotion. In summary, it is possible to learn from the literature that pedagogy is a complex concept. By structure, it is multidimensional as it comprises learners/learning, teachers/teaching and knowledge. By nature, it is dynamic, processual, relational and intentional. The relevance of this conceptualization in this study is that it helps us to understand the potential of pedagogical dimension for emphasising relational practices, which can be thought of as a possibility for operationalising the theory of salutogenesis through bodily practices in health-promoting programmes. This connection will become clearer in the next section about salutogenesis. 27 3. SALUTOGENESIS AS A THEORY FOR HEALTH PROMOTION ‘The salutogenic approach does not guarantee problem solution of the complex circularities of people´s lives, but at the very least it leads to a more profound understanding and knowledge, a prerequisite for moving toward the healthy end of the continuum.’ (ANTONOVSKY, 1987, p.5) 3.1 Health promotion Before introducing salutogenesis as a theory for health promotion, I will present the understanding of health and health promotion that guided this study. The complex and multidimensional conceptualisation of health leads us to realise that the notion of health is as broad as the notion of life (CZERESNIA, 2009). With a comprehensive and positive perspective, health can be defined as a result of multiple factors and forms of social organisation, which require state responsibility in conducting a health public policy integrated to other policies of social and economic nature (CAMPOS; BARROS; CASTRO, 2004). In Brazil, health is a right for all citizens (BRAZIL, 1990). The state is committed to provide basic conditions to ensure population´s health development. Brazilian legislation (BRASIL, 2013) establishes that: The levels of health express the national social and economic organisation, having as determinants and conditioning factors, among others, food, shelter, basic sanitation, physical environment, working, income, education, physical activity, mobility, leisure and access to essential goods and services (Art 3rd, Law nº 8080, 1990, revised in 2013). Thus, Brazilian legislation recognises that health has social determinants, which is aligned with the health promotion framework. Health promotion intends to position people at the centre of decision-making processes related to their health (WHO, 1998). Besides participation, other values are essential to health promotion, such as solidarity, equity, citizenship, integrality, collaboration 28 across sectors and, the recognition of social determinants of health13 (BRASIL, 2013; BUSS, 2009). Regarding the term ‘health promotion’, Buss (2009) tells us that it was initially used by Sigerist, in 1946, to establish the four tasks of Medicine: health promotion, disease prevention, recovery and rehabilitation. The meaning has changed over time, mainly after international conferences (BRAZIL, 2002; WHO, 1986) that built conceptual foundations for health promotion and the new public health (NUTBEAM, 2018). Health promotion emerged as an alternative to the medicalisation of health services. Currently, health promotion is conceptualised as a set of strategies to produce health, conducted in co-responsibility amongst government, community, individuals and partners (BRAZIL, 2013; BUSS, 2009). The main goal is to create actions for meeting health-related social needs and fostering people´s health development, beyond striving against diseases (BRAZIL, 2013; CARVALHO, 2006b). Additionally, it has a purpose of articulating technical with popular knowledge, and community with institutional resources to modify living conditions towards better health (BUSS, 2000). In complement to health promotion, disease prevention is also a strategy in primary health care. They are complementary in health services, but theoretically distinct (BUSS, 2009). Health promotion means “the process of enabling people to increase control over the determinants of health and thereby improve their health” (WHO, 1998, p. 1–2). Whereas, disease prevention focuses on detecting risk factors for diseases and establishing mechanisms to control or avoid them (BUSS, 2009). Despite the theoretical distinction, health promotion and disease prevention are commonly mixed-up. The confusion between them comes mainly from interventions aiming at individuals´ lifestyle change to reduce risk factors for certain diseases, which refers to a preventative orientation, but it is often identified as a health promotion´s programme (BUSS, 2009). Actions that are really committed to health promotion have a wide scope and they integrate people with their communities and local environment, not remaining restricted to individual behaviours. Thus, it is possible to note that there are different ways for approaching health, which is examined in more detail in the next section, in light of Antonovsky´s ideas. 13 By social determinants of health, it is understood that living conditions and ways of living determine individuals’ and communities´ health (WHO, 1998). The concept embraces four components that impact on people´s health development: human biology, environment, lifestyle and health services (BUSS, 2009). 29 3.2 Models of health Antonovsky (1979) identified three models of health: (1) clinical model – based on the dichotomization healthy nonpatient versus ill patient and concerned with diagnosis and cure; (2) public health model – it refers to the epidemiological model of studying the associations between diseases and populational groups, concerned with risk factors and prevention; and (3) continuum model – it considers health as a continuum and it is about how people move towards the desirable side. The first and second models are related to a pathogenic orientation to health. Although the epidemiological model makes possible early identification of diseases and prevention, Antonovsky (1979) indicated that it has the same dichotomous classification of people as healthy or ill as the clinical model. The author mentioned three reasons why pathogenesis is not helpful for understanding people´s health issues. First, it focuses only on the disease, which means that who is ill is ignored. Second, it works by what Antonovsky called the ‘magic bullet’: disease - diagnosis - treatment. Third, it operates with binarism and dichotomization of poles, such as ill versus healthy, normal versus pathological and inactive versus active. A pathogenic orientation takes the human being as a perfect organism (homeostasis), which provides a basis for ideas such as normativity and categorisation (ANTONOVSKY, 1996). Then, who is not perfect is not considered normal, and the person is categorised according to the severity of his/her illness or other criteria. Often, subjectivity is supressed and replaced by a disease name14. By contrast, the continuum model is an alternative for each of these aspects. It takes account of who is ill and of what is important to her/him. The continuum model focuses on the entire person rather than disease, and on salutary instead of risk factors (ANTONOVSKY, 1996, p. 18). It endeavours to find out what produces and maintains health. And, instead of binaries, it works with a continuum where a person can be in any point and move towards an ease or ‘dis-ease’ side, according to life situations. The continuum model provides the basis for the salutogenic model, which assumes the principle of heterostasis and the imperfection of human being, which means that it is natural 14 Frequently, in Brazilian health services, actions directed at groups are labelled by the illness that participants suffer from (e.g. group of diabetes, pain, high-blood pressure and so on). 30 and acceptable for all to deal with stressors that adds entropy to our lives, such as illness (ANTONOVSKY, 1987, 1996). It is important to highlight that Antonovsky (1979) criticised the pathogenic perspective, but he did not reject it. He did not dismiss the importance of knowledge about diseases and risk factors avoidance. The point is that there was a need to provide an alternative model of health that would not put too much weight on risks to be prevented, but on resources to be developed. Then, Antonovsky (1979) proposed the salutogenic model, focusing on experiences that could be salutary for people, which is reviewed in the following section. 3.3 Antonovsky´s salutogenic model Antonovsky (1996) warned that working with health promotion without a theoretical foundation may put it at risk of not fulfilling its purpose. Without a theory, health promotion actions may not be effective and sustainable. Thus, Antonovsky (1979, 1996) developed the salutogenic model as a theory for health promotion. Regarding bodily practices delivery, there is little knowledge about theoretical and methodological basis to support HPE professionals for working with health promotion, which partially explains why many Brazilian programmes implement the disease prevention approach. As an alternative to this issue, this study takes salutogenesis as a theory to advance the understanding about bodily practices and health. Antonovsky (1979) proposed a shift on health paradigm based on his studies about women who lived at concentration camps and kept healthy even after their dreadful experiences. Hence, salutogenesis has a strong evidence base (ERIKSSON; LINDSTRÖM, 2010). The author introduced the salutogenic orientation as an alternative to the pathogenic perspective to health. In his view, the main difference between these approaches relies on what questions are posed. Instead of asking ‘what are the causes of certain diseases’, he suggested to ask ‘why people keep healthy’. In addressing different questions, it would be possible to find new answers and contribute to people´s lives. In Antonovsky´s words: If, then, we can begin to understand this mystery – the mystery of survival, the mystery of why some people´s health is such that they go through life for some of the time with relatively little pain and suffering – we might begin to think about applying this understanding to reduce pain and suffering among the rest of us. (ANTONOVSKY, 1979, p.36) 31 Thus, the most important lesson from Antonovsky´s work is that the type of question determines how to gain a better understanding about health. Hence, salutogenesis constitutes a question of what are the reasons that people stay healthy. Antonovsky (1979) used the term ‘salutogenesis’ to refer to the origins (genesis) of health (salus). As an answer, Antonovsky presented the concept of sense of coherence (SOC). Following his first book ‘Health, stress and coping’ (1979), it is possible to track a line of questions that leads us to comprehend the concepts of the salutogenic model (Box 1). The model begins with the idea of health continuum. As mentioned in the previous section, Antonovsky (1979) made a critique to the pathogenic paradigm because it emphasises diseases through a dichotomous idea of disease versus health. The author highlighted that this paradigm is dominant in such a way that he preferred to call health care systems by disease care systems. However, to Antonovsky (1979), nobody is totally ill or totally healthy. To illustrate his point, Antonosvky (1996) used the metaphor of the river and swimmers. Curative medicine tries to rescue swimmers drowning downstream whereas disease prevention works upstream. Health promotion helps people to swim. There is no healthy person standing on the shore. In his words (ANTONOVSKY, 1996, p.14), “we are all, always, in the dangerous river of life. The twin question is: how dangerous is our river? How well can we swim?” In this sense, the author introduced a notion of health as continuum. Health is more about a process than something that an individual has or has not. To make this clear, he used the breakdown concept of ‘dis-ease’. So, in a salutogenic framework there is not an extreme of health and an opposite side of disease. Instead, Antonovsky (1979) suggested that there is an ease/dis-ease continuum. A person can be positioned in this continuum according to her or his life situation. In his words, “(…) all of us, as long as we are alive, we are in part healthy and in part sick, that is, we are somewhere on the breakdown continuum” (ANTONOVSKY, 1979, p.5). Antonovsky (1996) argued that low/high risk factors are not enough to explain how people move towards the ease or dis-ease side of the continuum. He suggested we focus on salutary factors, those that effectively contribute to promote health. 32 Box 1. Summary of questions, concepts and definitions of the salutogenic model of health. Problem of salutogenesis: How do we manage to stay healthy? Sub-question Concept Definition “How can it be explained that a given individual has not broken down?” (p.55) Ease/dis-ease continuum or breakdown A multifaceted state or condition of human organism regards pain, functioning limitation, prognostic implication and action implication (p.64). “What are the factors pushing this person toward this end or toward that end of the continuum?” (p.37) Stressors A demand made by the internal or external environment of an organism that alter its homeostasis and requires an adaptative behaviour (p.72). “What, then, is the response of the organism to a confrontation with stressors?” (p.93) Tension Response to a stressor (p.94). “What determines whether a person in a state of tension will be pushed in one direction or the other on the health ease/dis-ease continuum?” (p.96) Tension management Process which problems are solved, and tensions dissipated. (p.96) “How do we manage tension and prevent it from leading to stress?” (p.98-99) Generalized Resistance resources It refers to characteristics that facilitate dealing with and overcoming stressors (p.105). Answer to the problem of salutogenesis: Sense of coherence “A crucial element in the basic personality structure of an individual and in the ambiance of a subculture, culture, or historical period” (p.124). Source: Compiled from Antonovsky (1979). Antonovsky (1979) proposed the concept of breakdown or the ease/dis-ease continuum. The author defined breakdown as a ‘multidimensional continuum’ that represents the condition of a person. It is comprised of four dimensions: pain, functional limitation, prognostic (degree of severity) and action implication. Antonovsky (1979) suggested that any person has a breakdown profile, which is identified by a score from 1 to 4, on each of the four dimensions. In his model, there are 384 possible profiles and the most desirable profile of a person would have negative terms, such 33 as absence of pain, no functional limitation, no acute or chronic condition and no action to be taken15. In asking how people move toward the ease side of the breakdown continuum, Antonovsky (1979) indicated that the intervening factors are stressors. Stressors represent a demand for a response that is not ready or automatic for a person, which means that they require certain effort to deal with them (ANTONOVSKY, 1979). The author pointed out several sources of psychosocial stressors: “accidents and survivors; others´ experiences; horrors of history, direct and vicarious; intrapsychic conflicts; fear of aggression; immediate world change; phase-specific crises; other normative crises; conflicts in social relations; and goals-means gap” (ANTONOVSKY, 1979, p. 185). Furthermore, he suggested that stressors have been present in all societies, in all times. In the salutogenic model, the organism´s response to a stressor is defined as tension. Tension can be positive or negative. In the author´s view, stress is understood as the negative consequence of failure in coping with tension. And what is determinant to a person being successful or not in this process of tension management constitutes the generalised resistance resources (GRRs). Antonovsky (1979) defined GRRs as any characteristic of a person that is effective in avoiding and/or overcoming stressors. The author indicated major types of GRRs as: 1. Material: money, clothes, food and so on. 2. Cognitive: information and skills to acquire further knowledge. 3. Emotional: ego identity, consisted of a stable sense of the self in relation to context. 4. Coping strategy: rationality, flexibility and far-sightedness, in other words, assessment of stressors, availability of plans and tactics to deal with situations and capacity to anticipate the future effects of present actions. 5. Relational: social support, development of social networks and commitment. 6. Macro-sociocultural: cultural stability, religion, philosophy and art 7. Preventative health orientation: risk-avoidance actions such as balanced diet, regular physical activity and not smoking. 15 Bauer et al. (2019) made a critique about this, as they considered the negative definition of a desirable profile in the continuum as contradictory to a positive view of health. 34 Regarding the last one, preventative health orientation, Antonovsky (1979) considered it as a GRR due to its function of avoiding stressors. But the author pointed out some problems with this approach. In his view, people are affected by discourses that are not supported by empirical knowledge. He warned that “they tend to become true believers, thinking that X is the total, instant solution to the only problem that matters16” (ANTONOVSKY, 1979, p.101). He suggested that disease prevention might lead to undesirable consequences, for instance people´s anxiety due to behaviour surveillance; ‘medicalization of human existence’ and government control. Antonovsky (1979) indicated that the most important GRR in dealing with stressors is the cognitive aspect, which refers to knowledge-intelligence. It consists of knowledge itself and skills for further knowledge acquisition, for example about citizens´ rights. Another crucial resource is how a person is integrated to a social network that represents her/his interests and needs (ANTONOVSKY, 1979). By asking what is common among GRRs, Antonovsky (1996) clarified that they provide life experiences that help people to cope with stressors and find meaning from their world. In exploring the nature of and what binds different kinds of GRRs, Antonovsky (1979) presented the concept of sense of coherence (SOC). SOC is the main concept of the salutogenic model and it provides the answer to the question of how people stay healthy. SOC is defined as: a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that (1) the stimuli deriving from one´s internal and external environments in the course of living are structured, predictable, and explicable; (2) the resources are available to one to meet the demands posed by these stimuli; and (3) these demands are challenges, worthy of investment and engagement. (ANTONOVSKY, 1987, p.19) Thus, SOC has three components: meaningfulness, manageability and comprehensibility (ANTONOVSKY, 1996). They are related to one´s knowledge, motivation and confidence that problems can be understood and solved. This combination is mobilised when one meets a stressor to cope with. Comprehensibility indicates that the person has enough information to understand her problems and world. Meaningfulness refers to what 16 Based on this idea and on Fraga´s study (2006), we can think of how the population has incorporated the discourse of ‘exercise is medicine’, and has begun to believe that exercise is the best solution for the big problem of sedentariness and obesity. 35 motivates her to get involved in the problem-solving process. By manageability, Antonovsky (1996) means the capacity to recognise which resources are available to deal with a problem. In summary, the central idea of Antonovsky´s (1979) model is: when a person is confronted with stressors, her/his strong SOC can mobilise available resources to manage tension and avoid it to be transformed into stress and, in so doing, stay healthy. 3.4 Approximations between salutogenesis and physical education Antonovsky (1979, p.184-85) indicated some key elements in the salutogenic model of health. Three of them are selected here to explore a possible contribution of bodily practices to people´s health: ‘life experiences shape the sense of coherence’, ‘GRRs provide one with sets of meaningful, coherent life experiences’ and ‘successful tension management strengthens the SOC’. Major physical activity programmes are focused only on engaging people to be active, then, they restrict possible outcomes and not necessarily promote health. On the other hand, if such programmes aimed at offering meaningful and relevant experiences through movement (HAERENS et al., 2011; MCCAUGHTRY; ROVEGNO, 2001; QUENNERSTEDT, 2008), the participants would, inevitably, become more active. Beyond that, I would say that bodily practices would contribute to people´s health by providing meaningful experiences that might strengthen their SOC and develop different types of GRRs or ‘health resources’ (MCCUAIG; QUENNERSTEDT, 2016). Movement has a potential to connect bodily experiences with other aspects of human life (MCCAUGHTRY; ROVEGNO, 2001). Quennerstedt (2008) suggested that meaning in movement can be considered itself a resource for people´s health17. Besides meaning in movement, it is very important to provide participants with opportunities to be successful. Kunz (2007) suggested that activities that make possible a feeling of achievement are much more relevant to health promotion than others that focus on energy expenditure, like moderate to vigorous physical activity (MVPA). Furthermore, Kunz (2007) pointed out that physical activity practice concerned with physical aspects does not mean a healthy and longer life. He highlighted that PE can offer many possibilities to develop 17 About this, Quennerstedt (2008) called for further studies to investigate how empowerment, joy of movement, self-understanding and learning in physical activity can become available health resources. 36 salutary factors, which means to promote GRRs. He claimed that there is a need to create real possibilities for PE to strengthen participants´ SOC. Ericson et al. (2017) addressed the question of why older women keep physically active. To do so, the authors explored what health resources were related to physical activity intervention by participants as important for health. The findings showed that physical activity promoted seven health resources: social relations and care, positive energy, self-worth, capability in and about physical activity, the habit of exercising, identity as an exercising person and womanhood related to physical activity. The study of Ericson and collaborators (2017) confirmed that movement can contribute to people´s health by promoting mainly social and affective benefits. The authors highlighted that the social aspect of caring for others and developing a sense of community was expressed as significant to participants. In promoting health resources, the intervention could be considered as an example of social change (ERICSON et al., 2017). In this sense, bodily practices are likely to act as a resource that provide people with opportunities to develop personal and collective characteristics to overcome daily life stressors and maintain or enhance health. In a school context, McCuaig et al. (2013) explored the salutogenic model of health as a strength-based approach within Australian Health and Physical Education Curriculum. The authors drew on a comprehension of health as a dynamic and multidimensional process that constitute a resource for new ways of living rather than a state to be achieved. Through a health literacy´s project with schools, this study showed that students identified joy of movement as a resource for health in PE. According to the authors, this approach was concerned with helping pupils to acquire knowledge and skills to develop resources that were effective for cultivating life. With a salutogenic perspective, bodily practices might contribute to people´s health by producing different types of GRRs (cognitive, emotional, social, physical) that would be on their disposal when they needed to manage tension in life. Thus, the salutogenic model of health provide a basis for exploring how bodily practices help people´s health development in many ways, beyond engagement in an active life. Furthermore, salutogenesis allows HPE professionals to activate a complex of conceptual tools that might be useful to expand the breadth of their practices and help them to find a possibility to escape from pathogenic and prescriptive boundaries in the health sector (VARNIER; ALMEIDA; GOMES, 2016). 37 Therefore, this doctoral dissertation invested on the connection among the notions of bodily practices, sport pedagogy and salutogenesis, in order to advance the analysis of HPE professionals´ practices in working with older adults in health-promoting programmes. 38 4. METHODS This chapter will describe the methodological decisions that were made throughout this investigation. 4.1 Worldview Worldview or paradigm represents a theoretical perspective for inquiry and informs how the investigation is conducted (CRESWELL, 2007). According to Guba (1990, p.17), paradigm is a ‘basic set of beliefs that guides action’. It provides a system of thinking about the nature of the reality to be studied (ontology) that specifies forms of gaining knowledge (epistemology), which the researcher conducts in appropriate ways (methodology) (GUBA, 1990; CRESWELL, 2007; DENZIN; LINCOLN, 2011). In other words, a set of concepts constitute a frame that directs the investigator to proper methods and tools for examining a research problem. This study intended to investigate ways of delivering bodily practices for health and to understand the health development processes that participants related to these experiences. Due to the nature of the research problem, the study adopted a qualitative and constructivist perspective (GUBA, 1990; CRESWELL, 2007; LINCOLN; LYNHAM; GUBA, 2011; GRAY, 2014). By Denzin and Lincoln´s (2011) definition, qualitative research can be stated as: a situated activity that locates the observer in the world. Qualitative research consists of a set of interpretive, material practices that make the world visible. These practices transform the world. (…) qualitative research involves an interpretive, naturalistic approach to the world. This means that qualitative researchers study things in their natural settings, attempting to make sense of or interpret phenomena in terms of the meanings people bring to them (p.3). Qualitative researches involve an interpretive effort to elaborate, organize and connect concepts from empirical data, emphasizing meaning-making processes within a complex phenomenon (DENZIN; LINCOLN, 2011). The process of doing qualitative research includes the use of theoretical lens, collection of multiple sources of data in natural settings, researcher interpretation and reflexivity, inclusion of participants´ voices in reports and the development of a holistic account (CRESWELL, 2007). According to Corbin and Strauss (2015), this approach entails three main components: data, from multiple sources such as interview, observation, documents, videos and audios; 39 procedures, which are used to manage and analyse data, like coding, categorizing, sampling and memo-writing; reports, in different formats to present findings and interpretation. Qualitative strategies can be employed to study in detail a wide range of human experiences, behaviours, emotions, organizational processes and