INTRODUCTION

This study discussed how the educational methodologies of Paulo Freire and Edgar Morin contributed to graduate education in health promotion (HP).

Focusing on the education of healthcare professionals with competencies and values in HP to improve and strengthen Brazil’s Unified Health System (SUS), this study will consider the methodologies of this education and where it is conducted.

It considered the National Health Promotion Policy (Política Nacional de Promoção da Saúde - PNPS), which was revised in 2014 and which placed HP training as a priority for the country, as stated in objective VIII: to promote education, including professional education and specific training in HP, according to the principles and values expressed in this national policy, for workers, administrators, and citizens (^{Brasil, 2014}).

Education in healthcare for professionals should contribute to a change in health indicators, and greater equity, integrality, and resolvability, it is also a goal of the United Nations Agenda 2030, included in its Sustainable Development Objectives (SDO). Objective three concerns Health and Well-being for all, and its goal three-c calls for countries to substantially increase health financing and the recruitment, development, training, and retention of the health workforce (^{ONU, 2017}).

To plan new courses and allocate resources it is important to analyze graduates from current programs, to determine whether they have the characteristics needed for health promoters, and thus identity whether the institutional objectives of graduate programs are being fulfilled, considering the importance of education and its contribution to society for planning new courses and resource allocation.

This study sought to analyze the profile, competencies in HP and insertion in the job market of graduates from a Graduate Program in Health Promotion whose teaching methodology is based on the ideas of Paulo Freire and Edgar Morin.

EDUCATION IN HEALTH PROMOTION AND THE UNIFIED HEALTH SYSTEM

The concept of HP is based on concepts and practices that date to antiquity, and began to be systematized globally in 1978 at the International Conference on Primary Health Care at Alma Ata, in which HP was defined, considering social determinants, giving a social and political scope to health.

The Alma Ata conference was thus the main inspiration for the First International Conference on Health Promotion, held in Ottawa, in November 1986, which defined HP as a process for training individuals and communities to improve their health and quality of life, and exercise greater control in this process, considering health in a broad sense. Health promotion should contemplate health, solidarity, equity, democracy, citizenship, development, participation and joint action, among others, to improve quality of life and health (^{Heidemann et al., 2006}).

The Ottawa Charter also described the five fundamental strategies for HP: building healthy public policies, creating supportive environments, strengthening community action, developing individual and collective skills, and reorienting healthcare services.

The discussion about the education of professionals who contribute to the five strategies in HP is present in this Ottawa Charter, specifically in the item about the reorientation of health services, by requiring research about health as well as changes in professional education and training of healthcare professionals, so that they can focus on the global needs of the individual as a whole person (^{Ottawa Charter, 1986}).

Social well-being is at the foundation of SUS’ principles of universality, integrality and equity. The system is dedicated to guaranteeing access to all, to meet their needs and decrease inequalities.

The education of professionals based on the principles of SUS requires more than a hospital-centered concept focused on cure, illness and the individual, as is traditional in healthcare courses. In this context, in the 2000s, in Brazil, changes were initiated in the education of healthcare professionals to develop competencies and abilities that are in keeping with the presumptions of HP, with the goal of strengthening SUS. The implementation of the new National Curricular Guidelines (Diretrizes Curriculares Nacionais - DCN) for undergraduate courses in the field of healthcare included the presumptions of HP in a transversal manner, with an incentive to the integration of schools and departments, and community ties, emphasizing interdisciplinarity, intersectionality, and integrality (^{Mello, Moysés and Moysés, 2010}).

In 2005, HP began to take shape as a policy, initially present in the Pact for Health and in the National Policy for Basic Care (Política Nacional de Atenção Básica - PNAB), and in March 2006, based on the new legal guidelines present in the global HP charters, the PNPS was approved, with guidelines and strategies to organize actions on the three levels of administration of SUS to guarantee integral care (^{Silva and Baptista, 2015}).

At a global level, ^{Pinheiro et al. (2015}) emphasize that in 2008 the Galway Conference was held in Ireland, a joint initiative of various countries, but without representatives from Latin America, to construct guidelines for the development of competencies in HP and education, which became known as the Galway Consensus.

The Galway Consensus defined that effective HP practices involve eight domains: catalyzation of change; leadership; assessment (assertiveness in the evaluation of behavior and needs); planning; implementation; evaluation; advocacy and partnerships (^{Barry et al., 2009}).

In 2009, the VII World Conference on HP was held in Nairobi, Kenya, with the theme: “Promoting health and development; closing the implementation gap”, which reflected on the need for advances 20 years after the Ottawa Charter. Five aspects were raised: empowerment of communities (community autonomy); knowledge about health and behavior (individual autonomy); reinforcement of healthcare systems; partnerships and intersectoral actions (strengthening of work in networks); and construction of competencies for HP (^{WHO, 2009}). The focus was on the need to increase and perfect the capabilities of professionals who work in healthcare, initiating the construction of competencies for HP (^{WHO, 2009}).

In the meantime, the Developing Competencies and Professional Standards for Health Promotion Capacity Building in Europe (CompHP) took shape (^{Pinheiro et al., 2015}). Its goal is to identify, implement and establish methods for the practice of HP. For this group, it is already a consensus that HP only takes place with professionals trained with tools, competencies, and skills that allow expressing the theory, policies and research in health promotion in effective actions (^{Dempsey, Battel-Kirk and Barry, 2011}). Competency in the field of health promotion is defined as a combination of knowledge, skills and attitudes, which allow an individual to perform tasks according to a standard (^{Dempsey, Battel-Kirk and Barry, 2011}).

For the CompHP group, developing HP requires the development of values such as: equity, social justice, ethics, and individual autonomy; as well as skills and knowledge, in a total of 47 competencies and 9 domains (^{Dempsey, Battel-Kirk and Barry, 2011}).

The domains described by CompHP, which are presented in Figure 1, are:

Source: ^{Dempsey, Battel-Kirk and Barry (2011}).

Figure 1 - The structure of competencies - Developing Competencies and Professional Standards for Health Promotion Capacity Building in Europe (CompHP). 

The CompHP group remains active, and its productions have served as a reference throughout the world.

In Brazil, in 2014, various actors and sectors were mobilized to review the PNPS, which led to a new version that maintains the importance of intersectionality, encouraging health to be considered in the agendas of all public policies (^{Silva and Baptista, 2015}). In addition to placing HP training as a priority, objective 8 concerns the development of educational processes for specific professional education and training in HP (^{Brasil, 2014}) and Guideline VI addresses support for training and permanent education in HP to expand the commitment and critical and reflexive capacity of healthcare administrators and workers (^{Brasil, 2014}).

HP has become more important in Primary Care (PC) in Brazil, particularly in the Family Health Strategy (FHS), whose objective is to give a new orientation to the assistance-focused model, and emphasize the principles of universality, equity, integrality, and social participation (^{Carvalho, Cohen and Akerman, 2017}).

The IX Conference was held in Shanghai in 2016 and discussed the principles of the Ottawa Charter 30 years after its publication. The conference also promoted the Sustainable Development Objectives - the 2030 Agenda -, which is the most recent update of the global pact for sustainable development, issued in 2015, in New York, with 17 SDO for the millennium, among which the 3C goal, that discusses the demand for the training of health professionals to achieve expanded care.

To attain the results for health established by the SDO, education in health, with values and competencies in HP has been discussed worldwide, as well as a strategy developed to allow this education to be interprofessional and collaborative (^{Batista and Batista, 2016}).

^{Frenk et al. (2015}), from the Commission on Education of Health Professionals for the 21^st Century, also emphasize one of the reforms for education in health for the 21^st century: interprofessional and collaborative education for the development of technical competencies, analytical skills, leadership, and communication skills.

Considering that collaborative interprofessional education involves overcoming a logic based on separate disciplines. It is based on an interdisciplinary integration of contents and knowledge, as presented by ^{Fazenda (2003}) and on developing: the desire to seek alternatives to know more and better; an attitude of reciprocity that encourages exchanges, and dialogues with peers who are similar and those who are different or with oneself; an attitude of humility in light of the limitations of one’s own knowledge; an attitude of perplexity given the opportunity to reveal new knowledge; a challenging attitude when facing the new; and an attitude of responsibility, involvement and commitment to projects and people.

In 2019, the X Global Conference on HP was held in New Zealand, and emphasized a discussion on HP education, in which a working group was created at the International Union for Health Promotion and Education (IUHPE).

To operationalize the principle of reorientation of healthcare services, as stated in the Ottawa Charter, requires qualified professionals, and this qualification has generated international discussions. Brazil has been recognized for the qualification of SUS, and for having professionals with technical excellence and bioethical and social commitments, and for action with quality and resolution (^{Mello, Moysés and Moysés, 2010}).

Expanded, integral care requires professionals dedicated to HP, who have competencies, skills and values that are results of processes that do not end upon completion of undergraduate courses (^{Netto, Silva and Rua, 2016}), which still have a strong emphasis on the biomedical model. Thus, education in HP also takes place in permanent education or graduate courses.

For ^{Siqueira-Batista et al. (2013}), the education of healthcare professionals - who are the main actors in the process of construction of healthcare services - in keeping up with the principles, values, and competencies in HP, allows enacting and strengthening SUS, also contributing to a project for society that expands the limits of the exercise of citizenship, keeping alive the idea that health is a responsibility of the State and a right of all.

CENTERS OF EDUCATION IN HEALTH PROMOTION IN BRAZIL

As previously mentioned, the education of professionals with principles, values, and competencies in HP involves a process, and has occurred in a transversal manner in undergraduate courses since the establishment of the new DCN and has particularly grown in graduate programs.

^{Tavares et al. (2016}) discuss educational experiences in HP in Brazil, emphasizing that the InterAmerican Consortium of Universities and Centers of Personnel Training in Education for Health and Health Promotion conducted a study of competencies in HP found in courses developed in Brazil. ^{Arroyo (2009}) found that graduate programs in health promotion in Brazil focus on HP competencies.

Brazil has five higher education institutions (HEI) that have graduate programs in HP, including: Universidade de Franca (Unifran), Universidade de Santa Cruz do Sul (Unisc), Centro Universitário de Maringá (UniCesumar), Universidade Luterana do Brasil (Ulbra), and Centro Universitário Adventista Engenheiro Coelho (Unasp).

The Graduate Program in Health Promotion at Unifran, located in the municipality of Franca, São Paulo State, is a pioneer in the country on the theme, and was created in 1999 at the master’s level, and in 2011 it was also accredited at the doctoral level as well, and was the first at this level in all of Latin America (^{Tavares et al., 2016}). The graduate program at Unisc, in Santa Cruz do Sul, Rio Grande do Sul, was approved at the master’s level in 2009, and was authorized at the doctoral level in 2018. The Graduate Program in Health Promotion at a master’s level in UniCesumar, in Maringá, Paraná State, was approved by CAPES and began operating in August 2011. The master’s program in health promotion at Unasp, in São Paulo, São Paulo State, was approved by CAPES and began operating in March 2013. The Academic Master’s Program in Health Promotion, Human Development and Society at Ulbra, Canoas, Rio Grande do Sul State, was recommended by CAPES on March 1^st, 2018.

The interlocution between the programs and institutions is expressed in partnerships for the organization of scientific events, academic production and diffusion of knowledge. Although it is spread out at institutions throughout the country, the education of human resources to work in SUS and the consolidation of HP in Brazil is paved by innovative and effective resources and methods in the teaching-learning process.

However, it is possible to note the low frequency of education in HP in the country, highlighting that the centers are concentrated in the South and Southeastern regions, which are more economically and socially privileged. While the North, Northeast, and Midwest regions, which have greater healthcare problems, and which would benefit from the development of HP, have no educational centers in HP.

^{Barreto (2017}) emphasized that the less prosperous regions always have worse living and health conditions, and in terms of differentiated access to the resources available in the healthcare system. These inequalities in health generate unequal opportunities to benefit from the scientific and technological advances in this field. Therefore, it is essential to have educational centers in HP in these regions as well, to allow changes in the health and quality of life indicators.

The references used by the Graduate Program in Health Promotion at Unifran will be presented below, which also served as the foundation for the analysis of the results in this article.

CONCEPTS FROM PAULO FREIRE AND EDGAR MORIN FOR THE EDUCATION OF PROFESSIONALS IN HEALTH PROMOTION

In relation to the educational methodologies in healthcare, we are now in a moment of transition, and much of the content-based, and fragmented pedagogical model is still predominant, which is focused on the disease and individual care, and on an accumulation of technical-scientific information (^{Mello, Moysés and Moysés, 2010}). Meanwhile, there is a contradiction between the profile of the professionals who graduate and those required by healthcare services. Some initiatives are beginning to change how these professionals are educated.

The transformation of healthcare services will only take place with the transformation of education in healthcare. This transformation involves breaking old paradigms and addressing ideological and social issues, which at the same time considers the knowledge of each profession and involves collective values and practices (^{Chiesa et al., 2007}).

Education that is coherent with the principles and values of HP involves overcoming traditional educational methodologies, and goes beyond the transmission of knowledge (^{Loureiro, 2008}).

A graduate program should search for a broader social awareness, and activities focused on students, providing significant learning experiences, and a critical, reflexive, and transformative education that can have repercussions on the modes of conducting healthcare, thus transforming services, professionals and users, and addressing social inequalities.

The education of healthcare professionals must occur, according to ^{Lima and Braga (2016}), with methodologies that propitiate learning to learn, a critical spirit, a capacity for analysis and problem solving, communication skills, leadership, innovation, integration in teams and adaptation to change. The PNPS, in its VI operational line, which concerns education and training considers: incentives to a permanent attitude of learning supported by problematizing, dialogical, liberational, emancipatory, and critical pedagogical processes (^{Brasil, 2014}). It also emphasizes that collaborative and shared practices should be encouraged.

^{Mello, Moysés and Moysés (2010}) also highlight that pedagogical situations for educating about health promotion should include active processes of learning, presenting social realities, provoking students to construct their own citizenship.

Focused on the affirmation that education in health is a process and has occurred at the graduate level, it is clearly aimed at adults, who are often already working in healthcare services. Therefore, education should be based on andragogy, which is the science of orienting adults to learn, considering their needs and interests (^{Bandini and Germani, 2015}).

Andragogy for health education should be understood as a process of construction and struggle in support of life and education as a process that seeks to develop cognitive, affective, psychomotor and sensorial capacities and the social competencies of individuals, so that they can relate positively with the environment, modifying it when necessary (^{Calvinho and Amorim, 2015}). Thus, education includes the autonomy, initiative and motivation to strengthen health, while also strengthening the human being (^{Lima and Braga, 2016}).

In this sense, education in HP, as well as the implementation of new pedagogical and curricular projects for undergraduate and graduate courses based on SUS, require educational methodologies that should promote the autonomy of students, so that they are motivated and intervene as protagonists in the process of their own transformation and that of the population that they assist, which are the aims of the active methodologies of learning. These methodologies allow the development of specific and general competencies, such as learning to learn, critical thinking, the capacity to analyze and resolve problems, communicability, leadership, innovation, integration in a team, and adaptability (^{Lima and Braga, 2016}).

In this work, two educational methodologies were discussed in this perspective, Paulo Freire’s critical pedagogy and Edgar Morin’s Education for the Future.

Despite use of the term pedagogy, Paulo Freire’s work was originally aimed at adults. Critical pedagogy became well known in the 1970s, through a proposal for school activities focused on immediate social realities. Social problems and their determinant factors are analyzed and actions are undertaken with the intention of transforming social and political reality (^{Gadotti, 1991}).

^{Paulo Freire (1996}) proposed the construction of knowledge based on acting upon reality, which he called praxis, a transformative process of action-reflection-action. From this perspective, knowledge is constructed by critical insertion in reality, prioritizing the acquisition of knowledge in loco. For ^{Freire (1996}), educational work based on reality and in reality allows individuals to have a perception of self, and the curiosity to search for reasons for existences.

The more that I recognize how I am, and perceive the reason or reasons for being, why I am like this, the more I am capable of becoming capable of change, of promoting myself, in this case, from a state of naïve curiosity to that of epistemological curiosity. It is not possible to assume that the individual makes himself in a certain form of being and does not have the ability to change. (^{Freire, 1996}, p. 44)

The main purpose of critical pedagogy is to turn individuals into subjects of transformation. To do so, education is developed by strengthening the abilities to think and act, which are basic foundations for the good exercise of citizenship (^{Freire, 1978}, p. 27).

This capacity to act and think constructs praxis, the fundamental element of critical pedagogy, because praxis, the practice of thinking of practice, leads knowledge to transformative action (^{Freire, 1983}). In this process of action-reflection-action, students are led to see themselves as authors of their own stories, valuing cultural and historic aspects of the community in which they are, which is the basis of the Culture Circles.

Praxis is allied to critical thinking and to dialog. Critical thinking is a mediator of knowledge and dialog is understood as a horizontal epistemological relation capable of generating autonomy, responsibility, and commitment to the exercise of speaking and listening (^{Lima and Braga, 2016}).

Praxis, critical thinking and dialog provide individuals with the ability to read the world, to construct history, between the oppressors and oppressed, making it possible not only to adapt, but to promote change (^{Freire, 1967}).

One of the acts of knowledge, for ^{Freire (1983}) is research, to reveal concrete reality, in its forms, relations and causes, overcoming naïveté, and thus gaining transformative potential.

In this way, conducting research, I educate, and I am educating myself with the popular groups. By returning to the field to put in practice the research results, I am not only educating or being educated: I am researching once again. In the sense described here, research and education are identified in a permanent and dynamic movement. (^{Freire, 1983}, p. 36)

Research, as an act of knowledge through the use of research itinerary, is constituted by three moments: thematic investigation, with the discovery of the vocabular universe, and themes from the daily life of the participants; codification and decodification, based on signification, contextualization and expansion of knowledge about the theme to gain consciousness; and critical revealing, which represents the analysis of the knowledge raised, interpreted with elements of subjectivity (^{Heidemann et al. , 2017}).

Using a research itinerary allows discovering the entire diversity and potentialities of any situation, even that of health, expanding the possibilities for interdisciplinary and intersectoral actions (^{Heidemann et al., 2017}).

In all of Paulo Freire’s production, it is possible to observe the breadth of the teaching and learning process and the provocation to teachers, as fundamental links in the process of recognizing themselves as a protagonist of history, thus transforming their exercise of teaching, instigating, recognizing themselves as historic subjects as well (^{Freire, 1967}, ¹⁹⁷⁸, ²⁰⁰⁶).

Thus, ^{Freire (1978}) understands that all individuals have and produce knowledge, and that the teaching learning process should take place in a humanistic relationship, based on ethics, respect, and love.

The recovery of what it is to be human, a planetary citizen, in its different forms - spiritual, social, political - is also a finality of Education of the Future proposed by Edgar Morin.

Morin defends overcoming the dominant paradigm of simplification through integral thinking, breaking with the fragmentation of knowledge, understanding the interaction between the local and the global.

He affirms that a polyocular or polyscopic view is needed, in which, for instance, the physical, biological, spiritual, cultural and historic dimensions of that which is human are no longer incommunicable (^{Morin, 2012}).

Thus, ^{Morin (2012}, p. 46-47) affirms:

A reform of thinking is thus necessary to contextualize, situate, globalize and to attempt to establish a meta point of view that, without causing us to escape from our unique local-temporal-cultural condition, allows us to consider our anthropoplanetary place as a viewing point.

In Morin’s work for the United Nations, entitled, The Seven Complex Lessons for Education for the Future, he affirms that learning should be based on the awareness of the human being as an individual and part of society and of the species.

Education for the future should be careful to not allow the idea of the unity of the human species to erase the idea of its diversity and that its diversity not erase that of unity. There is human unity. There is human diversity. Unity goes beyond the biological features of the human species homo sapiens. Diversity is not only in the psychological, cultural, and social features of the human being. There is also a strictly biological diversity at the heart of human unity; there is a unity that is not only cerebral but also mental, psychological, emotional and intellectual. Moreover, the most diverse cultures and societies have common generative or organizing principles. It is human unity that carries within it the principles of their multiple diversities. To understand what is human means to understand its unity in diversity, its diversity in unity. It is necessary to conceive the unity of the multiple, the multiplicity of the one. (^{Morin, 2000}, p. 55)

To do so it is necessary to overcome educational tradition, ^{Morin (2000}) proposes seven facets of knowledge for the construction of the future of education.

The first concerns the condition for the construction of knowledge, respecting error and illusion as tools of learning, which allows overcoming them. The second facet of knowledge refers to the need that from among the myriad of information that globalization makes available, it is propitious to not decontextualize knowledge, and to unite a wide variety of fields to combat fragmentation. The third facet of knowledge concerns human identity, the individual/society/species, reason/affection/drive, and also brain/mind/culture, to understand that humans are multidimensional beings, who are in a society and that society is in each person. ^{Morin (2000}) proposes in the fourth facet the understanding of what is human, the development of the affective, moral, and intellectual faculties, empathy and identification, without reduction or indifference. In the fifth facet, the author indicates the importance of doubt, incompleteness, the development of abilities, strategies, and flexibility to face the new, the constant challenge of humanity. The sixth facet concerns teaching the comprehension of the planetary condition, considering the processes of all the economic, ideological and social orders for the construction of human solidarity. The seventh facet of knowledge is the ethics of the human genera, the anthropoetic, the humanization of the human, to attain unity in diversity, uniting personal autonomy and social participation for the construction of a common destiny.

The education of healthcare professionals based on the active methodologies of learning, convokes graduates to creation, autonomy, and to the collective (^{Ceccim, 2008}).

The complex and integrated thinking constructed by those seven facets of knowledge allow a systematic conception of reality, raising awareness of the contextualized problems and responses.

The educational processes presented can contribute to a solid education of critical, reflexive professionals who have the competencies needed to act in a wide variety of health services, contributing to the improvement of health of populations and the progress of society.

It is understood that the adoption of these references by the Graduate Program in Health Promotion has been strengthening the education of researchers in the field of HP of this program.

METHODOLOGICAL PATH OF THE RESEARCH

This is a field study of an exploratory nature that sought to analyze the profile of graduates from the Graduate Program in Health Promotion at Unifran from 2012 to 2017. For this purpose, interviews were conducted by telephone, with a method based on the Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey (Sistema de Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico - VIGITEL) system used by the Ministry of Health, with a specific questionnaire, which had an identification portion and 21 questions, 9 of which were closed and 12 open, about the perception of the program and professional insertion and activity.

The research population included 107 people who graduated from the program with a master’s or doctoral degree from January 2012 to December 2017. The graduates were contacted by telephone, from November 2018 to September 2019. The calls were made by cell phone and recorded with the use of the Cube ACR app.

Inclusion criteria were being a graduate of the Graduate Program in Health Promotion at Unifran from 2012 to 2017 and having at least one telephone number to allow contact. Those graduates who did not answer the phone after ten calls made at different days and times, including Saturdays and Sundays, and at night, were excluded, as well as those with incorrectly registered phone numbers.

The interviews were recorded, and the data were analyzed in a quantitative and qualitative form to analyze perceptions about the Graduate Program in Health Promotion and how much and how it influenced the graduates’ insertion in the labor market.

For the quantitative variables, the data were entered into Excel 2016 for Windows spreadsheets for adequate storage of the information and the data was presented in tables, using simple percentages for a descriptive analysis of the data.

For qualitative variables, as ^{Minayo (2004}) described, it is possible to analyze meanings and intentionality, as well as the values and representations of the graduates about the specific issues. To do so, thematic content analysis was conducted, considering the theoretical foundation for understanding the phenomena, using as references central concepts of Paulo Freire, Edgar Morin and HP.

The anonymity of the graduates was maintained, and the excerpts cited are identified by the letter I (for interviewee), following the order in which they responded to the questionnaire: I1, I2, I3, and so on.

THE GRADUATE PROGRAM IN HEALTH PROMOTION AT UNIFRAN AND ITS GRADUATES

The objective of the graduate program at Unifran is to contribute to an intersectoral, interdisciplinary, and integrated view with the national and global needs; to provide support to the strengthening of basic healthcare to overcome the traditional biomedical models and their emphasis on the curative model; to contribute to sustainable strategies of social, environmental, and cultural impact to the contemporary challenges at the local, regional, and national spheres; to prepare graduates who are committed to the principles of ethics, integrality and good research practices; to train graduate students to develop, use, and evaluate new technologies; and to contribute to the education of professionals for the improvement of education (basic, higher, and special education) (^{Universidade de Franca, 2019}).

The Graduate Program in Health Promotion at Unifran develops its programmatic content, seeking to support critical and transformative scientific and professional attitudes, so that graduates will be capable to help strengthen SUS (^{Tavares et al., 2016}).

Combined with these objectives, Unifran is also a member of the Ibero American Network of Universities that Promote Health (Rede Ibero-Americana de Universidades Promotoras de Saúde - RIUPS) since 2008, and of the Brazilian Network of Universities that Promote Health (Rede Brasileira de Universidades Promotoras da Saúde - Rebraups) since it was created in 2018.

For ^{Mello, Moysés and Moysés (2010}), universities involved in HP projects are important to local, regional, and national healthcare, since based on the improvement of institutional and pedagogical projects, they contribute to the improvement of the quality of life of all those involved - students, professors, employees and the surrounding community -, in addition to providing support to a change in focus of research, aiming it at expanded, interdisciplinary actions that search for solutions that impact the quality of life, mitigating social and health inequalities.

The population of this study includes 107 graduates from the Graduate Program in Health Promotion at Unifran who earned master’s or doctoral degrees from 2012 to 2017. Fifty-four graduates answered the call and responded to the questionnaire, making up the study sample, corresponding to a response rate of 50.5%. Two people refused to participate in the study, corresponding to 1.8%. The average duration of the interviews was 8 minutes. The characterization of the participating graduates is described in Table 1.

Of the graduates who participated in the study, 36 (70%) were females. There is a gender component to the social insertion of women in the workforce, and it is understood that healthcare and education are fields of work where there is a predominance of women. As ^{Borges and Detoni (2017}) found in their study about the feminization of healthcare, in the social division of labor, women are steered toward professional activities that are similar to those they perform in daily life, such as caring for the family.

In terms of their initial education, the participants in the study are mostly nurses, 16 (30%), psychologists, 10 (18%), and physical education professionals, 8 (14.5%). Considering that nurses are professionals who must compose the staff at Basic Healthcare Units (Unidades Básicas de Saúde - UBS) of and also of the FHS, the education in HP can help improve the implementation of services of which they are part.

Professional psychologists and physical education teachers, in addition to being part of the staff at health facilities, can also act in other spaces, such as schools, an environment that is also propitious for sustaining HP.

In terms of age, participants were categorized into the intervals used by the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística - IBGE), the country’s census agency. The data revealed that, at the time of earning their graduate degrees, the youngest subject was 24 and the oldest 56, with most between 25 and 29, and an mean age of 32.9. Among the graduates who participated in the study, the mean age at graduation is younger than the national mean of 34.8 years upon earning a master’s degree in a large multidisciplinary field (^{Brasil, 2016}).

It was also possible to examine the motivations for entering the master’s or doctoral programs. Many indicated that a graduate degree is required to be able to continue to teach or to enter an academic career, given that since the enactment of Brazil’s National Educational Guidelines (LDBN/96) (^{Brasil, 1996}), stricto sensu graduate studies are a prerequisite for teaching in higher education. Another factor is the expansion of undergraduate and graduate courses in private HEI, which increases the demand for professors (^{Silva and Bardagi, 2015}).

Most of the graduates were married, but just a few more than those who were single. The largest group claimed to have two children, 48%, while 33% had none, reiterating that the higher the level of education, the lower the level of fecundity, as found in the 2010 census (^{IBGE, 2012}).

PROFESSIONAL PATH OF THE GRADUATES IN HEALTH PROMOTION

The professional insertion and activity of the participating graduates is described in Table 2.

Most of the graduates participating in the study (96%) affirmed that they were working as they studied, and of these, 39% divided their time into two institutions, one public and one private one, and worked as both healthcare providers and as teachers (26%).

At the time of the interviews, almost all (98%) said they were working, of these 48% were teachers in private institutions (37%). In Brazil, the Ministry of Education and Culture (MEC) requires that colleges and universities have a minimum number of professors who have master’s and doctoral degrees on the teaching staff, as a qualification parameter in the HEI evaluation process. Thus, the graduates in the sample are inserted in HEI, as professors, to qualify education.

The fact that the graduates were working while they earned their graduate degrees indicates that they reached the graduate program with experience and knowledge which may have helped improve the quality of the program and the programmatic contents (^{Barreto et al., 2012}).

The data revealed in this study support those found by ^{Velloso (2004}). Most of the students, worked at universities and research institutions, which covered about half of the graduates. Nevertheless, other occupational segments also employed important contingents of the master’s students. Nearly 20% worked in administration and in public services, followed by those who worked in public and private companies. On the other hand, most of the doctors performed academic activities. Nearly 85% of the graduates in the basic field worked in universities and research institutions as university professors.

The rate of employability also stood out in this study. Of those interviewed, 53 (98%) had jobs, which is higher than the national rate found by the Center of Management and Strategic Studies (Centro de Gestão e Estudos Estratégicos - ^{CGEE, 2016}) of the Ministry of Science and Technology, 2016, which found that in a multidisciplinary field, 10 years after earning a degree, the employment rate for masters’ is 72.3 % and for doctors 83.5%.

The data from this study show that the Graduate Program in Health Promotion at Unifran contributes in a positive manner to the insertion of the graduates in the labor market.

RELEVANCE OF HEALTH PROMOTION IN PROFESSIONAL ACTIVITIES

The participants in the study were asked about the relevance and applicability of HP to their current professional work: “I currently work as an assistant nurse in a public hospital. Given that I work directly with the health and disease process, in the curative field, I am able to carry out, in practice, the knowledge acquired in the program” (I1).

The statement by this participant revealed a perception of the dichotomization between prevention and HP.

HP seeks to positively modify living conditions; points to the transformation of the individual process of decision making in search of a better quality of life and better health; it encourages community strengthening with collective decisions aimed at improving the conditions of well-being and health. Meanwhile, prevention is oriented to actions of detection, control, and weakening the risk factors of a certain infirmity (^{Buss, 2003}).

Both concepts are important and complement each other in integral healthcare. The practical application of the knowledge developed during the Graduate Program in Health Promotion was indicated as an important factor for supporting the healthcare policies of those who work in public administration and in educational processes: “In my classes, we even have activities with other professors in Basic Healthcare Units with the students, presenting this vision of health promotion to students is essential” (I12).

The recognition of health proportionally expanded by HP was essential to healthcare and implied an understanding that the knowledge found among professionals and people who seek care compose different health subsystems.

I think that I distinguished myself from my colleagues who study gynecology, in terms of having a multidisciplinary approach that is more integrated with the patient, the patient recognizes this in care, and leaves quite satisfied, [with comments] like: “My, I was never treated this way”, to know about quality of life, in relation to this I think that I added a lot. (I13)

The concept of education as a process that involves action-reflection-action, trains people to learn, revealing the need for concrete action, and overcomes the contradictions (^{Freire, 1996}). Thus, the relationship between education in health and Critical Pedagogy, which is based on a horizontal dialog between professionals and users, can contribute to the construction of the emancipation of the individual for the development of individual and collective health.

^{Freire (1967}) warned that dialog is necessary to have true humanism. I13’s statement: “My, I was never treated this way”, reveals that in the interaction with this professional, there was person-to-person sensibility, which encourages self-growth and self-realization in the interaction.

Often in everyday healthcare services, relations of oppression are established that sustain the paradigm of science (the professional). Processes in which language is dominated by scientific discourse come to be decoded by individuals (who receive care) and produce limiting and challenging situations. They thus increase the condition where care is demanded as well as the right to decent and quality access to healthcare services and guaranteed care by the State (^{Alvim and Ferreira, 2007}): “I did a master’s and was still a teacher, I changed my classes a lot because of the master’s and today, as a coordinator, we study many things, even disciplines because of this perspective that I gained” (I49); “Health promotion permeates my professional practices, whether in caring for my patient and in the relationship with the staff, or in the classroom” (I17).

The statements of the graduates who participated in this study reinforce what was pointed out by ^{Loureiro (2008}), that after education in HP the graduates are expected to having acquired a comprehension of values, theories, and models subjacent to the approaches in HP and its implications in practice in literacy in HP.

PERCEPTIONS ABOUT TEACHING PROCESSES

When questioned about what aspects they considered significant, and what they remember about the program, the graduates reported:

The opening, the issue of opening of the field itself, of work, but also knowing that no one has the absolute truth, while usually we leave undergraduate courses nearly convinced of everything, in the master’s, it leaves you with lots of doubts, given that you learn more, feeling the pain right. And this element of the master’s led me to doubt everything, and always look for an answer. (I5)

This passage indicates the relationship with the fifth facet of knowledge, proposed by ^{Morin (2000}), which indicates the importance of doubt, allowing a constant search for knowledge, which reveals epistemological courage. The notion of the critical attitude proposed by ^{Freire (1996}), the dichotomy of text and context is also seen.

Doubt and critical approaches were aspects that drove the transformation of realities, based on which mobilization for change was revealed.

I think that it added some things… changed, improved some things, like the perspective now as a researcher. I work in the field of technology, my work was in this field, my dissertation was in this field, so I think that it was very interesting in this aspect, it added something for me, in the way of seeing the classes, with the discussions, I think that it improved. (I21)

Note that this graduate reported that the course transformed the common hierarchical classroom into a space for dialog, as advocated by Freire, dialog as a didactic work methodology, to come to constitute oneself as the purpose and the meaning of a consciousness raising education, a basic condition for knowledge.

A dialog that, according to ^{Freire (1967}), is the encounter between people, where reflection and action are oriented toward the world, which must be transformed and made humane. “Love, humility, and faith in humanity are needed, creativity, critical nature and hope” (^{Freire, 1967}, p. 52).

I think [it was] the opening to health promotion, because in my undergraduate studies I did not have a course about health promotion, I did not know what it was and then I entered the program and saw how important and essential it is. It is care before prevention, it’s not about thinking of disease, and the world has to go in that direction. (I44)

In the perspective abstracted from the statements of the graduates, the Graduate Program in Health Promotion at Unifran can be evaluated as successful for having offered integrality, theoretical-practical articulation, the basis for teamwork, and personal and professional growth.

Considering that the Nairobi conference raised discussions that reflect on the needs of society, ^{Battel-Kirk et al. (2009}) indicated that public policies in HP have grown in many countries. These authors affirm that this leads increasingly to a need for effective development of professional competencies to strengthen and implement health promotion.

This study initially planned to investigate whether participants had acquired, by taking the course at Unifran, the competencies of creativity, partnership, planning, empathy, and support for change, and were asked about this, in an objective manner, in the questionnaire. The analysis of the interviews indicated that the statements by the graduates indicated that they had acquired competencies of advocacy and leadership, which were added to the analysis.

This study addressed creativity by considering this to be a competence that catalyzes and gives rise to other competencies. Of the participants in the study, 37 (68.5%) affirm that they consider themselves to be more creative after completing the course at Unifran. The remaining 17 (31.5%) said that they were already creative upon entering the program.

The competence of partnership concerns the process of working collaboratively with various fields of knowledge, sectors, entities, and social actors (^{Dempsey, Battel-Kirk and Barry, 2011}). The participating graduates unanimously recognize having competence in working in partnership after completing the course at Unifran, and that this competence facilitates the development of the actions in HP.

Advocacy is a combination of individual and social actions planned to attain political commitment, and can be expressed in various forms, including the use of the means of mass communication and multimedia, to mobilize a community (^{Dempsey, Battel-Kirk and Barry, 2011}). All of the participants in the study affirm that they had developed this competence in the course at Unifran.

Competence in planning involves being able to develop goals and objectives that can be measured, based on a diagnosis of needs and potentialities, supporting the definition of alternatives and directions, with the participation of actors, partners and the target audience (^{Dempsey, Battel-Kirk and Barry, 2011}). All the participating graduates affirmed that they had this competence after completing the course at Unifran.

Leadership signified contributing to a shared and strategic vision, and is related with abilities to influence, motivate and work in a network, involving mediation and training of the work team (^{Dempsey, Battel-Kirk and Barry, 2011}). Of the sample in this study, 51 (94.5%) of the participants said that they have this competence, the 3 (5.5%) who denied having leadership abilities related this to the receptivity of other people to this competence.

In terms of empathy, ^{Morin (2000}) emphasized it as a means for comprehension, which requires a process of empathy, identification and projection, and demands an opening to sympathy and generosity. The development of comprehension requires a planetary reform of mentalities, and this should be a task of education for the future. All of the participants said they had developed empathy by taking the program.

About the competence of support for change, which is related to reorientation of healthcare services and reduction of inequities through intersectoral and collaborative action for community development and empowerment (^{Dempsey, Battel-Kirk and Barry, 2011}), all of the participants in the study said that they acquired this competence after entering the graduate program at Unifran.

It should be noted that despite being questioned in isolation, all competences are related to one another. For example, the competence in partnership is related to advocacy in healthcare, as partnerships require interlocution and mediation. And for advocacy to be effective it is necessary to create collaborative alliances and use efficient forms of communication. Meanwhile, the competency of collaborative work, is related to leadership (^{Tusset et al., 2015}).

The mobilization of these competencies cited may favor the development of other competencies like empowerment, which is related to autonomy. This competence is highlighted by the ability of individuals and groups to make decisions about issues that concern them, such as: politics, economics, healthcare, culture, and other aspects of a social and individual order (^{Chiesa et al., 2007}).

The questionnaire used did have weak points, given that the competencies acquired were not addressed more objectively and not grasped in their manifestation. It only considered the self-perception of the participants.

The study also examined the graduates’ perceptions of the interdisciplinary format of the Graduate Program in Health Promotion at Unifran, given that ^{Morin (2012}) indicated that education in isolated disciplines limits the ability to contextualize, weakening responsibility and solidarity, by decreasing a perception of the global, and emphasizing the particular. In order to overcome this fragmentation and decontextualization, space should be given to plurality of knowledge in dialog, supported by interdisciplinarity.

When asked whether the Graduate Program in Health Promotion at Unifran was interdisciplinary and interprofessional the graduate participants said: “It was quite valid, in addition to the opportunity to exchange experiences and understand interdisciplinarity, the supervisor from another course had me see new perspectives and directions” (I10); “Ah, the perspective was quite broad, right? It’s important to have a broader view of other professionals and the issue of team work was strong, multiprofessional work, it was very interesting” (I24); “To be with professionals from other fields helped us to expand our perceptions and actions and it also provides a preview to work in a team, in the reality of health facilities, which have multi-professional work” (I16).

The statements of these participating graduates reveal the presence of the concept of the complex human being. For ^{Morin (2012}), the human condition goes beyond biophysical and sociocultural complexity. In the lived context, humans are metamorphized, reconnecting objectivity and subjectivity, the real and the imaginary, that is, uniting different points of view to understand their own human reality, which is produced and reproduced by antagonisms, competition, and complementarity.

The interdisciplinary experience at the Graduate Program in Health Promotion at Unifran, provided spaces for collective reflection that allowed students to go beyond the normatization common to the academic logic. This expansion enriches knowledge, the communication between professionals, decision-making, and administration. This is seen in this statement: “It was good. Because I think that regardless of a person’s education, everything depends on the capacity and didactics of the person. And the person’s education does not always interfere. Also, for the opportunity we had to interact and know other areas of education” (I51).

The interdisciplinary practice is cloaked in great complexity, by demanding from professionals a new form of acting, and involves changes in relations of power between healthcare professionals, to effectively expand the autonomy of users and collectivities (^{Ceccim, 2008}).

The exchange of experiences, the involvement with other professional categories, the learning to work in group, and the search for one’s own knowledge, according to daily needs, also appeared as real acquisitions from the courses.

One limitation of this study was the difficulty of generalizing the findings, given that it focused on graduates from a single graduate program at one institution of higher education. An analysis was conducted of the results of the Graduate Program in Health Promotion at Unifran, which is the most well recognized course in Brazil and Latin America in this field, based on quantitative and qualitative approaches.

Although most of the participating graduates said that they had competencies in health promotion, it is necessary to expand the understanding and manifestation of these competencies.

CONSIDERATIONS

The statements indicate that in general, the Graduate Program in Health Promotion at Unifran provided a positive opportunity for interdisciplinary experience. This acquisition will allow the graduates to practice this paradigm, and to produce transformation in the workplace. It was seen that the logic used by the graduates to positively evaluate the graduate program at Unifran revealed the interdisciplinarity, which provided a broad and contextualized construction of reality, an articulation between theory and practice, and helped develop a capacity for conviviality and respect among the different fields of knowledge needed to provide integral care. The competencies in HP that were perceived to be acquired include creativity, partnership, advocacy, planning, empathy, leadership, and support for change.

By proposing the ideas of Freire and Morin to support the daily process of education in the graduate program, it was possible to construct the critical and reflective perspective essential to attaining a broader conception and action of healthcare. It is widely recognized that the concepts of critical pedagogy and those of Morin are more often used in basic education in Brazil and there are still few experiences with the insertion and discussion of these methodologies in higher education, whether at the graduate or undergraduate level. But those that exist will allow a resignification of professionals and researchers.

It is true that the strategies used at the Graduate Program in Health Promotion will allow the graduates to perceive they are competent to act according to the concepts of HP, and able to support a break from and transformation in the assistance-focused healthcare model and education in healthcare, given that some of these graduates work as teachers and guide their educational process with a perspective of HP.

The development of competencies in HP benefits from the critical reflexive approach adopted by this graduate program and supported by the ideas of Paulo Freire and Edgar Morin, given that these educators discuss action in an innovative manner, focused on the dialog between educators and students, to the degree that they position themselves in a critical manner, reflecting on their condition as subjects, committed to reality, extracting from it the essence of the practice, escaping simple adaptation or accommodation, that is, allowing a transformation of reality.

This study dialogs with the discussions conducted worldwide in efforts to construct new paradigms to respond to issues raised by the crisis in public healthcare, responding to the third goal of the UN’s SDO of Agenda 2030, given that the Graduate Program in Health Promotion at Unifran is a pioneer center in the education of professionals with values and competencies in HP. The results of the study may contribute to the planning of the course that strives for quality and excellence in professional education, better quality of life, and social progress.

The data found reiterate the importance of continuing to invest in an educational process based on competencies in HP, using methodologies that stimulate reflections about professional action in the context of SUS, so that the graduates can contribute with daily, creative, and innovative actions.

This study can contribute both to the planning of courses in HP, and to the implementation of others that will be organized to attain changes in professional education, illuminated by new perspectives on the teaching-learning process.