Introduction

The National University Extension Plan, promoted in the early 2000s, mentions that extension activities are carried out by various areas of knowledge, presenting different strategies. These activities are one of the pillars of the teaching-research-extension triad, favoring that students and teachers acquire skills, competences and critical-reflexive attitude to work with the community (^{Oliveira; Almeida Júnior, 2015}; ^{Alves et al., 2016}).

In the health area, the applied strategies are diversified and aim to stimulate the applicability of knowledge by the student, as well as to constitute a form of communication with society, especially to disseminate themes related to health promotion (^{Oliveira; Almeida Júnior, 2015}; ^{Deus; Krug, 2018}).

In this context, the university extension action is characterized as a dynamic educational process that favors the junction between teaching in the classroom and learning, as proposed in the pedagogical planning of the course, and in the social routine, through experiences of real scenarios (^{Síveres, 2013}; ^{Minetto et al., 2016}).

For the community, the extension action is a time for active participation, discussion and group reflection to acquire knowledge on issues related to the health-disease process and good health practices (^{Minetto et al., 2016}; ^{Silva et al., 2017}).

In this way, the university-community approach, with the interlocution of knowledge, establishes contributions for the deepening of citizenship, strengthening of autonomy and social transformation (^{Cortez; Silva, 2017}; ^{Silva et al., 2017}).

Considering the principles of the Sistema Único de Saúde (SUS), where the care model values ​​the principle of integrality, permeated by humanized practice and health promotion, along with the need for professionals to work with specific skills in this scenario, it is questioned: is the implementation of university extension actions a favorable resource in the teaching-learning process for practical performance within the scope of health promotion?

In view of this, the present article aims to conduct a survey of national publications that address the contributions of university extension action as a strategy for professional training and health promotion.

Methods

For this study, an integrative literature review was carried out and included the analysis of the most relevant national publications on the contributions of university extension action in health promotion in Brazil, enabling reflection and synthesis of knowledge on the subject, as well as proposing its applicability in practice in our context.

The articles were obtained by accessing the Biblioteca Virtual de Saúde (BVS), by consulting the LILACS (Latin American and Caribbean Literature in Health Sciences), MEDILINE (Medical Literature Analysis and Retrieval System Online) and SciELO (Scientific Electronic Library Online) databases. The descriptors that were used: Extension in the community-institution relationship, Health Promotion, Health Education and Professional Training.

It was determined as criteria for inclusion in the study the articles available in full, published in the last five years (2015-2019), in English or Portuguese, that addressed the theme in the following axes: development of University Extension Projects for teaching-learning in health and health promotion actions in the community. The exclusion criteria were articles that were not related to the study’s guiding questions, developed with a focus on other areas of education or that addressed other levels of health care.

The search for descriptors enabled the initial survey of 5,194 articles, of which only 134 met the inclusion criteria. After reading the abstracts and excluding duplicate articles, 48 ​​were selected for reading in full. Of these, only 18 articles were considered for analysis and discussion due to their close relationship to the guiding questions of the study, as shown in Figure 1.

Source: Flowchart outlined by the authors (2019).

Figure 1 Flowchart with Description of Selected, Excluded and Included Articles in the Search for the Study 

Results

During the survey, numerous publications focused on university extension activities were identified. However, priority was given to those that addressed actions aimed at health promotion, coordinated and/or carried out by health professionals or students. In the 18 articles selected for this study the following distribution by year of publication was obtained: 2015 (four), 2016 (three), 2017 (five), 2018 (four) and 2019 (two). The data were organized by year of publication and arranged for their description in the following aspects: title, authorship, objective, method, results and/or conclusions (Chart 1).

The productions are concentrated in five areas, with the largest number of articles aimed at the multidisciplinary and nursing team. Among the methods used by the authors, works with a qualitative approach, documentary studies and review articles stand out. Although the general content is centered on the actions and experiences developed by higher education institutions for health promotion, the focus was on the following categories: academic training, interrelationship between academy and community and the application of educational strategies/methodologies.

Most of the pieces were published in the Northeast and Southeast regions and are aimed at the academy-community sphere, configuring the need to investigate the student’s experience in the local reality and the impact of university extension actions in their education and in the social context. The characterization data of the articles are shown in Table 1.

Discussion

The data obtained allowed to identify three categories that will be described below: University extension as a pedagogical strategy and educational practice with the community, University extension as a dynamic resource for professional training and health promotion and The challenges for implementing extension actions in the health sector.

University Extension as a Pedagogical Strategy and Educational Practice with the Community

It is pointed out that the analysis of the evolution of higher education reveals a dynamic process that is correlated to transformations that occurred in various contexts such as the political, economic and social (^{Vieira et al., 2017}; ^{Sampaio et al., 2018}; ^{Koglin; Koglin, 2019}; ^{Rios; Caputo, 2019}).

Thus, society promotes the approximation of institutions with the social scenario and the development of strategies for the formation of professionals more prepared for the execution of their skills, and the generation and dissemination of knowledge to the community (^{Oliveira; Almeida Júnior, 2015}; ^{Moraes et al., 2016}; ^{Oliveira et al., 2017}; ^{Deslandes; Arantes, 2017}; ^{Barros; Franco, 2018}).

One of these strategies, sanctioned by laws such as the National Education Plan, is university extension. Perceived as an interdisciplinary movement, of an educational-scientific nature and inherent to each course project, it aims to favor the interaction between the teacher-student and community, and provide the universities’ commitment to contribute to social transformation (^{Deslandes; Arantes, 2017}; ^{Barros; Franco, 2018}; ^{Koglin; Koglin, 2019}; ^{Rios; Caputo, 2019}).

It is emphasized that as an educational process, university extension provides the exchange between knowledge and action through the practical application of the knowledge acquired in the classroom environment, articulating the teaching process through action in real settings (^{Costa et al., 2015}; ^{Oliveira; Almeida Júnior, 2015}; ^{Moimaz et al., 2015}; ^{Calil et al., 2016}; ^{Ferreira et al., 2016}; ^{Cortez; Silva, 2017}; ^{Rios; Caputo, 2019}).

It is asserted that the interaction between academy and society, through extension, is widely discussed and used for the training of health professionals. Its implementation is supported and driven by the principles of the current health system in Brazil, the SUS (^{Lima et al., 2016}; ^{Calil et al., 2016}; ^{Vieira et al., 2017}; ^{Koglin; Koglin, 2019}; ^{Rios; Caputo, 2019}).

As a result of the need to train professionals to work in the health field, within the concept proposed by SUS, the National Curriculum Guidelines (DCN) were developed. They have comprehensive concepts and include, among others, professional training focused on work, the diversification of practice scenarios and the teaching-service-management-community integration. The DCN represents a milestone for determining a model for pedagogical-curricular guidance and fostering the creation of numerous programs aimed at training professionals aspiring to consolidating SUS as a model of quality in health care (^{Moimaz et al., 2015}; ^{Carvalho et al., 2017}; ^{Rios; Caputo, 2019}).

In the requirements for the training of health professionals is the development of specific skills that will enable the execution of actions at all levels of care, with the individual or community, with quality and ethics, critical-reflective discernment and social co-responsibility (^{Oliveira; Almeida Júnior, 2015}; ^{Moimaz et al., 2015}; ^{Carvalho et al., 2017}; ^{Barros; Franco, 2018}; ^{Rios; Caputo, 2019}).

The experience of university extension provides students with expertise, directing them towards responsible and safe postures, which contributes to the promotion of communication between the university and the external environment and thus links teaching, research and extension (^{Sampaio et al., 2018}).

In this panorama, the university extension is conceived by the authors as a fundamental and peculiar strategy, with an educational, scientific-cultural and technological character, which favors the development of the skills of health professionals outlined in the pedagogical-curricular project (^{Moimaz et al., 2015}; ^{Calil et al., 2016}; ^{Deslandes; Arantes, 2017}; ^{Rios; Caputo, 2019}). It is perceived that the integration of teacher-student-community in real and everyday contexts, with its particularities and vulnerabilities, provides students with a dynamic that improves know-how, allowing the junction between knowledge theoretically learned and knowledge derived from their own experience (^{Oliveira; Almeida Júnior, 2015}; ^{Volpini et al., 2015}; ^{Ferreira et al., 2016}; ^{Moraes et al., 2016}; ^{Oliveira et al., 2017}; ^{Vieira et al., 2017}).

The development of skills in extension actions expands through experience, problem solving, critical-constructive reflection, autonomy, teamwork and the active participation of individuals in health production processes (^{Lima et al., 2016}; ^{Cortez; Silva, 2017}; ^{Sampaio et al., 2018}; ^{Barros; Franco, 2018}; ^{Rios; Caputo, 2019}).

It is conceived, when analyzing this category, that university extension actions provide the integration between teaching, research and extension, as they promote the association between university and society, in addition to providing assistance services and favoring, above all, development skills and knowledge.

University Extension as a Dynamic Resource for Professional Training and Health Promotion

In actions aimed at health promotion, the extension activity stands out for its integrating characteristic. Knowledge brought to the community is also permeated by local or popular knowledge. The exchange of knowledge expresses a strong component to promote the reformulation of concepts, significant learning about the health-disease process and increased adherence to good health practices (^{Costa et al., 2015}; ^{Calil et al., 2016}; ^{Ferreira et al., 2016}; ^{Lima et al., 2016}; ^{Cortez; Silva, 2017}; ^{Oliveira et al., 2017}; ^{Sampaio et al., 2018}; ^{Souza; Carvalho, 2018}).

It should be noted that during graduation, the triad teaching-research and extension is exercised. The student through the extension action, directed and stimulated by the teacher, has the opportunity to demonstrate and improve their knowledge, develop plans and apply active methodologies for a more assertive approach with the community. Thus, the development of the strategy allows the improvement of skills, abilities and attitudes, in addition to those assimilated in the academy (^{Costa et al., 2015}; ^{Moimaz et al., 2015}; ^{Calil et al., 2016}; ^{Moraes et al., 2016}; ^{Oliveira et al., 2017}; ^{Deslandes; Arantes; 2017}; ^{Rios, Caputo; 2019}).

An aspect considered relevant in the practice of community action is the opportunity to perceive the other, their conceptions and perspectives. In the proposal for ensemble care, the main challenge for the professional is the ability to identify and define the real health and care needs. The perception of the other and qualified listening are fundamental for the planning of effective actions that guarantee quality, humanization in the assistance and acknowledgment of the subjects (^{Moimaz et al., 2015}; ^{Calil et al., 2016}; ^{Lima et al., 2016}; ^{Moraes et al., 2016}; ^{Cortez; Silva, 2017}; ^{Souza; Carvalho, 2018}; ^{Barros; Franco, 2018}; ^{Rios; Caputo, 2019}).

The evaluations carried out, after the extension actions were applied, suggested that academics were encouraged to value the educational and preventive processes, as well as to broaden the perception of teamwork and its importance in the context of health promotion (^{Costa et al., 2015}; ^{Volpini et al., 2015}; ^{Calil et al., 2016}; ^{Ferreira et al., 2016}; ^{Sampaio et al., 2018}).

The experience of collective and interdisciplinary work was considered an expressive activity, as learning to act and produce as a team improves various skills and attitudes considered important for health practice, such as cooperation and knowledge sharing. The interrelation with existing teams in the community is seen as a positive practice for health promotion (^{Moimaz et al., 2015}; ^{Oliveira; Almeida Júnior, 2015}; ^{Cortez; Silva, 2017}; ^{Carvalho et al., 2017}; ^{Sampaio et al., 2018}).

Another aspect considered in the evaluation of the extension action is the perception of the community served. In the developed projects, there was an understanding of the importance of the action as an activity that favors the understanding of the health-disease and self-care process. The individual served in the community is a potential disseminator of the information and knowledge acquired. In this perspective, the extension action contributes to enabling multipliers of health-promoting actions (^{Calil, et al., 2016}; ^{Ferreira et al., 2016}; ^{Barros; Franco, 2018}; ^{Sampaio et al., 2018}; ^{Souza; Carvalho, 2018}).

As a focal point in this discussion, the concept of health education stands out as one of the articulations that aims at the formation of applied educational practices to teach the community to promote health. In this way, the university extension strategy gains relevance due to its social responsibility in generating knowledge in the population, by motivating participation, by encouraging autonomy and empowerment to improve their quality of life.

The Challenges for Implementing Extension Actions in the Health Sector

Although the extension activity is perceived as a positive strategy in many aspects, such as the formation of professional skills and the transformation of practices in search of health behavior, the authors list factors that are challenges for the implementation of actions with society, as shown in Table 2.

It is observed that the factors listed are relevant and refer to the vulnerabilities and challenges linked to the execution of extension actions. Among them, it is necessary to highlight the low valuation of extension activity in the academy scenario and the unfavorable conditions for its practice. It is essential to stimulate projects based on the situational diagnosis of the real needs of the community to be addressed, the incentive for the training and engagement of teachers, the availability of resources for the development of interventions and the expansion of opportunities for health promotion (^{Moimaz et al., 2015}; ^{Oliveira; Almeida Júnior, 2015}; ^{Volpini et al., 2015}; ^{Calil et al., 2016}; ^{Oliveira et al., 2017}; ^{Deslandes; Arantes; 2017}; ^{Carvalho et al., 2017}; ^{Koglin; Koglin, 2019}).

It is emphasized that during the analysis of the publications there was no contradiction between the authors in the categories listed for discussion.

Final considerations

The analysis of the articles made it possible to consider that the partnership between the university and the community can be understood as an alternative for health promotion, through experience and the production of knowledge in the social context and daily life. The extension activity represents a counterpart, within the scope of the current health policy, with the management of the various governmental spheres, aiming to contribute to the expansion of quality health care to the Brazilian population.

The university extension action is a feasible tool that covers the integrality of health care, at different levels of care, and gains greater expression in health promotion through educational practices and the reformulation of knowledge in the combination of technical-scientific and popular knowledge.

It was considered that the experience of university extension provides socio-cultural interaction to the academic community, a factor that seems to contribute to learning and favor the perception of the health-disease process.

It was found that the interaction between the community and the academy strengthens the teaching-practice-research triad, which can boost the development of studies in other areas of academic training, such as the Humanities and Exact Sciences. Considering the university extension action as a training and health promotion strategy, there was a need for greater political and economic incentive to strengthen and implement its proposal in the academy and in the community.

In our teaching practice, it is noted that the interrelationship between university extension and professional training seems to contribute positively to the development of skills for acting in practice scenarios and within the range of health promotion. The teaching-learning process in the community can configure an action that potentiates changes in educational practice in health.

However, this study indicates that, in order to strengthen University Extension as an educational strategy for students and the community, it is necessary to deepen the discussions in the academy, to foster projects aimed at the needs of the population to be served and to value the teachers involved.

One of the limiting factors of the study was the small number of publications on university extension activities with a reflection on their impact on the training of professionals or aimed at health promotion, suggesting the need for greater appreciation of this theme.

Considering the relevance and scope of this theme, as well as realizing the need to expand this discussion and also collaborate to foster new publications, the inclusion of the term University Extension in the data bank of Health Sciences Descriptors (DeCS) is suggested.