HEALTH EDUCATI ON: THE FAMI LY HEALTH TEAMS’ PERSPECTI VE AND
CLI ENTS’ PARTI CI PATI ON
1Mar ia de Fát im a Ant er o Sousa Machado2 Neiv a Fr ancenely Cunha Vieir a3
Machado MFAS, Vieira NFC. Healt h educat ion: t he fam ily healt h t eam s’ perspect ive and client s’ part icipat ion. Rev Lat ino- am Enferm agem 2009 m arço- abril; 17( 2) : 174- 9.
This st udy aim ed t o under st and t he concept ion and per for m ance of healt h educat ion dev eloped by t he Fam ily Healt h Team wit h a view t o client s’ part icipat ion. Qualit at ive st udy carried out wit h client s and professionals at t he Fam ily Healt h Pr ogr am ( FHP) in Cr at o, CE, Br azil. Dat a w er e collect ed t hr ough sem i- st r uct ur ed int er v iew s and obser v at ion bet w een May and Sept em ber , 2005. Dat a w er e or ganized accor ding t o cont ent analy sis and lit er at u r e. Fin din gs in dicat e t h at pr of ession als v iew h ealt h edu cat ion as gu idan ce an d t each in g f ocu sed on disease prevent ion and t he part icipat ion of client s is perceived as list ening and at t ent ion. Thus, FHP professionals need t o br oaden t heir under st anding of healt h educat ion and educat iv e st r at egies, w hich should be cult ur ally m eaningful, so t hat client s freely and consciously decide on t heir part icipat ion and behavioral change in healt h.
DESCRI PTORS: healt h pr om ot ion; healt h educat ion; consum er par t icipat ion; fam ily healt h pr ogr am
EDUCACI ÓN EN SALUD: PERSPECTI VA DEL EQUI PO DE SALUD DE LA FAMI LI A Y LA
PARTI CI PACI ÓN DEL USUARI O
Est e est udio t uvo com o obj et ivo com prender la concepción y la act uación en Educación en Salud por part e del Equ ipo de Salu d de la Fam ilia bu scan do la par t icipación del u su ar io. Se t r at a de u n est u dio cu alit at iv o con u su ar ios y pr of esion ales del Pr ogr am a Salu d de la Fam ilia ( PSF) , del Mu n icipio de Cr at o, est ado de Cear á, Br asil. Los dat os f u er on r ecolect ados a t r av és de u n a en t r ev ist a sem iest r u ct u r ada y de obser v ación , en t r e m ay o y sept iem br e de 2 0 0 5 ; f u er on or gan izados m edian t e an álisis de con t en ido con base en la lit er at u r a. Ev idenciam os que el pr oceso educat iv o es per cibido por los pr ofesionales com o or ient ar y enseñar a pr ev enir en f er m edades. La par t icipación de los u su ar ios sign if icó escu ch ar y pr est ar at en ción . Se con clu y e qu e los pr ofesionales del PSF necesit an am pliar la com pr ensión de la educación en salud y de est r at egias educat iv as cult uralm ent e significat ivas para que la part icipación y decisión de cam bios de com port am ient o en salud de los usuar ios sean libr es y conscient es.
DESCRI PTORES: pr om oción de la salu d; edu cación en salu d; par t icipación com u n it ar ia; pr ogr am a de salu d f am iliar
EDUCAÇÃO EM SAÚDE: O OLHAR DA EQUI PE DE SAÚDE DA FAMÍ LI A E A
PARTI CI PAÇÃO DO USUÁRI O
Est e est udo obj et ivou com preender a concepção e a at uação de Educação em Saúde pela Equipe de Saúde da Fam ília, obj et iv ando a par t icipação do usuár io. Est udo qualit at iv o com usuár ios e pr ofissionais do Pr ogr am a Saúde da Fam ília ( PSF) , do m unicípio do Cr at o, Cear á, Br asil. Os dados for am colet ados at r avés da ent r evist a sem iest r ut ur ada e obser v ação, ent r e m aio e set em br o de 2005, e or ganizados m ediant e análise de cont eúdo e à luz da lit er at ur a. Evidenciou- se que a Educação em Saúde é per cebida pelos pr ofissionais com o or ient ar e en sin ar a p r ev en ir d oen ças. A p ar t icip ação d os u su ár ios sig n if icou escu t a e at en ção. Con clu i- se q u e os pr ofissionais do PSF necessit am am pliar a com pr eensão de educação em saúde e de est r at égias educat iv as, cult ur alm ent e significat ivas, par a que a par t icipação e decisão de m udanças de com por t am ent o em saúde dos usuár ios sej am liv r es e conscient es.
DESCRI TORES: prom oção da saúde; educação em saúde; part icipação com unit ária; program a saúde da fam ília
1Paper extracted from Doctoral Dissertation; 2RN, Ph.D. in Nursing, Facult y Universidade Regional do Cariri and Universidade de Fort aleza, Brazil, e- m ail:
fat im aant [email protected] .br; 3RN, PhD., Adj unct Professor, Universidade Federal do Ceará, Brazil, e- m ail: [email protected].
I NTRODUCTI ON
E
ducat ion in healt h and t he part icipat ion of cl i en t s a r e essen t i a l el em en t s f o r p er so n a l a n d structural changes to occur in health prom otion. These statem ents are present in the Ottawa letter from the fir st in t er n at ion al h ealt h con fer en ce in 1 9 8 6 . Th is international m ovem ent was followed by others, which h av e r at if ied t h e d ir ect ion f or g r eat er in t er act ion am on g p r of essi on al s an d cl i en t s, m ai n l y v al u i n g p r e v e n t i v e a ct i o n s a n d h e a l t h ca r e i n a so ci o -sanit arian, inclusive, ecologic and j oint dim ension t o im prove qualit y of life( 1).Education in health, in an enlarged conception of healt h care, requires t he part icipat ion of client s in t h e m o b i l i za t i o n , t r a i n i n g a n d d e v e l o p m e n t o f individual and social abilit ies t o deal wit h t he healt h-disease pr ocess, and also needs t o be ex t ended t o t he im plem ent at ion of healt hy public policies.
Health professionals and clients are the social act or s w ho ar e in cont inued int er act ion. Ther efor e, the therapeutic proj ect should incorporate health care act ions t hat t ranscend t he lim it ed clinical concept ion of curing diseases and value t he cont ext , t he social det erm inant s, t he subj ect ivit y of t he healt h- disease pr ocess and also t he inclusion of client s as act iv e, aut onom ous and part icipat ive individuals. When t he t er m t her apeut ic pr oj ect is used as a r out e t o t he care plan, it is underst ood t hat healt h prom ot ion is t he m ain obj ect iv e of healt h pr ofessionals’ pr act ice at all lev els of car e. This under st anding r equir es a m ult idisciplinar y and com plex v iew of a v ar iet y of actions and shows that professionals should overcom e t he t r adit ional and lim it ed v iew of car e focused on t he disease. Sim ilar ly, pat ient s in t r eat m ent should b e en cou r ag ed t o ad op t t em p or ar y or p er m an en t ch an ges, con sequ en ce of disease an d/ or su ffer in g pr ocesses( 2).
Reaffirm ing health prom otion as the ultim ate goal of t he t her apeut ic pr oj ect im plies t he cult ur al transform ation of health institutions like hospitals and basic health units, into healthy organizations that focus on t he v alor izat ion of people w ho, in t ur n, should part icipat e and decide on care plans at any level of healt h care( 3).
People’s pow er and cont r ol ov er t heir ow n dest iny allow t hem t o produce concret e and effect ive act i o n s i n t h e d eci si o n - m ak i n g p r o cess t o m eet p r i o r i t i e s, a n d t o d e f i n e st r a t e g i e s a n d t h e i r im plem ent at ion t o im prove healt h condit ions, so t hat
in d iv id u als can cop e w it h d iv er se p h ases of t h eir exist ence and illnesses( 4).
However, the power and control of clients can only be exerted through their full participation in Health Educat ion. The Fam ily Healt h Program ( FHP) aim s t o prom ote health and the health team ’s role is to do its best so t hat behavioral changes in healt h occur in a cont inuous pr ocess of lear ning and par t icipat ion of client s, in t he way t hey act for t hem selves, for t he fam ily and t he env ir onm ent , m ak ing it possible t o t ransform people int o act ive and collect ive persons.
I n gen er al, t h e clien t ele’s par t icipat ion in ed u cat iv e act ion s is p assiv e an d en cou n t er s ar e co n d u ct e d t h r o u g h t h e m e r e t r a n sm i ssi o n o f i n f o r m a t i o n f r o m t h o se w h o k n o w ( h e a l t h professionals) t o t hose w ho do not ( client s)( 5). This
attitude in the educative process im pedes people from ident ifying t heir problem s and crit ically reflect ing on t h ei r cau ses so as t o f i n d st r at eg i es, o v er co m e obstacles in the direction of health prom otion through changes in t heir own lives( 6).
These reflect ions led t o t he st udy obj ect ive, w h i ch i s t o u n d e r st a n d t h e co n ce p t i o n a n d developm ent of Health Education by the Fam ily Health Team ( FHT) , aim ing for client s’ part icipat ion.
MATERI AL AND METHOD
This qualit at ive- descript ive st udy was carried out in Basic Healt h Unit s t hat work wit h t he Fam ily Healt h Program in Crat o, CE, Brazil. Current ly, t here are 24 FHTs, 14 in the urban area and 10 in the rural ar ea. The r esear ch par t icipant s w er e fiv e t eam s in the urban area which were hired by the FHP for m ore t han five years, t aking int o account t heir experience w it h client s. For t y - t w o client s and 32 pr ofessionals from t he FHP were included in t he research, t ot aling 73 int erviewed individuals.
t hat his ent ire report was recorded in t he field diary. All interviews, with both clients and professionals, were held at the basic health unit itself, with duration from 30 to 50 m inutes.
The observed educative m eetings were those planned and developed by the team s, with topics and st rat egies t hey had chosen. Sim ilar ly, t alks, gr oups and wait ing room s were observed, w it h an average of t wo t o t hree observat ions per FHT.
The organizat ion of dat a and const ruct ion of cat egories were based on cont ent analysis( 7). These
cat egories form ed t he concept ual m ap of analysis of how Health Education is developed in the Fam ily Health Pr o g r a m . D a t a a n a l y si s w a s b a sed o n r ev i ew ed l i t er a t u r e, a d d r essi n g Hea l t h Pr o m o t i o n , Hea l t h Ed u ca t i o n a n d Fa m i l y He a l t h Pr o g r a m a n d Par t icipat ion.
The pr oj ect w as appr ov ed by t he Resear ch Et hics Com m it t ee at t he Federal Universit y of Ceará a n d co m p l i e d w i t h a l l f o r m a l r e q u i r e m e n t s o f Resolution 196/ 96 by the National Health Council and Min ist r y of Healt h , w h ich r u les r esear ch in v olv in g hum an beings( 8) ( process 86/ 05) .
RESULTS
These st udy dat a are based on t he relat ion of t he Healt h Fam ily Team in t he Healt h Educat ion w or k p r ocess. We op t t o p r esen t w h at t h e t eam u n der st an ds as h ealt h edu cat ion , f ollow ed by t h e par t icipat ion an d m an if est at ion of clien t s on t h eir inclusion in educat ive act ions.
The underst anding of t he FHT on Healt h Educat ion
Th e in t er v iew ed p r of ession als u n d er st an d Healt h Ed u cat ion as t h e t r an sm ission of con t en t , ex ch an ge of in f or m at ion , in st r u ct ion , gu idan ce of underst anding, orient at ion, explanat ion, t eaching and disease prevent ion. According t o observat ions carried out wit h t he FHTs and t he part icipant s’ report , t hese a ct i o n s a r e f o cu sed o n d i sea se p r ev en t i o n ; t h e them es addressed by team s were defined by life cycle or pat hologies, w hile only t w o of t hem w er e about prenat al care and one about oral healt h.
I view healt h educat ion as inst ruct ion you pass t hrough
pr ofessionals ( Physician 1) .
I t hink t hat we are int eract ing, t he professional and
t he client , we exchange inform at ion, t hen he com es and you can
see i f h e i s u n d er st an d i n g t h at , ‘cau se w e p ass a l o t o f
inform at ion, but don’t know if t he person is being educat ed in
relat ion t o healt h ( Nurse 1) .
We have t o pass on what is t he best for people, t o know
how t o t alk, we have t o orient , say everyt hing really well so t hey do
t heir hygiene, and follow t heir t reat m ent (nursing auxiliary 1).
Healt h educat ion is t o m ak e t hem under st and and
pr event diseases ( ACS 1.2) .
I t is a work m ainly direct ed t o needy com m unit ies, it
is a work t hat you have t o do in schools, in t he com m unit y, in t he
fam ily, so t hat t heir healt h is good ( Nurse 4) .
Th e p er cep t i o n o f t h e FHT a b o u t Hea l t h Ed u cat ion is f ocu sed on d isease p r ev en t ion . Th e pr edom in an ce of t h em es in t h e ar ea of biological d et er m in an t s of d isease is ob ser v ed in ed u cat iv e encount er s.
FHT and it s pract ice in ot her scenarios
Th e u se o f r e so u r ce s e x i st e n t i n t h e com m unit y for t he developm ent of educat ive act ions is valued by t he FHT. This at t it ude is in agreem ent w it h int egr al and int er sect or al pr inciples and, t hus, st rengt hens t he Single Healt h Syst em . I t is evident w hen t he t eam r epor t s t he sear ch for par t ner ships wit h schools and daycare unit s in t he com m unit y as well as other institutions in the city for the developm ent of educat ive act ivit ies wit h client s.
We have groups of hypert ensive pat ient s, pregnant
wom en, we also have a school group; we’re always working with the
school and here at the daycare with a group of m others ( Nurse 1) .
We also work at t he school, whenever I ask for a room
and request t he st udent s’ presence t o give a t alk, t hey always
provide one ( ACS 3.1) .
When we plan an act ivit y we call people from t he FNS
( Nat ional Healt h Foundat ion) and t hey give t alks, t each how t o
prepare m ult im ix food ( ACS 5.2) .
Clients’ participation
The fam ily health team reported that the clients’ part icipat ion in Healt h Educat ion act ions is incipient , support ed by m at erial coercion, and t hat t here is no interest, though exchange of ideas and clarification of doubts have been observed. Som e resources used by professionals t o encourage part icipat ion of client s in Health Education actions are harm ful. We have to keep i n m i n d t h at b ar g ai n an d co er ci o n co m p r o m i se par t icipat ion . Th e u se of t h is ex pedien t r ein for ces patronage and dependency. When these tactics are not used, client s no longer par t icipat e. The decision t o participate in an educative process should be conscious, fr ee and spont aneous, an opt ion t o ex per ience t he ed u cat iv e act ion , n ot en cou r ag ed b y an y b ar g ain m echanism .
I still think participation of clients in the health education
process is very poor, also, their participation in the service is very
poor (Physician 1).
They still participate very little, I gathered a group in
wom en’s health, gave talks and very few wom en cam e, com paring
to the num ber we have in the area (Nurse 1).
They pay at t ent ion, t hey t alk, exchange ideas, give
exam ples also, it’s cool (Nursing auxiliary 1)
They list en, ask very few quest ions t o clarify doubt s
because they are shy or afraid (ACS 3.3).
The com m unity, the m aj ority, alm ost has no interest in
this, it’s so little interest that it’s hard to gather people. We schedule
it, get a video to show them som ething, two, three or four attend…
they are not very interested in this, only in those actions they’ll get
som e benefit (ACS 4.3).
I n t he beginning very few would com e, but t hen we
started to think and create strategies, for exam ple, if we have ten
pregnant wom en who don’t want to attend the encounter, we get
som ething to dispose off in a raffle, or get to each of them som ething
for their baby’s outfit, so we started to encourage them this way
and they increased their attendance to encounters (ACS 5.3).
Responses of clients regarding Health Education actions
The participation of clients in actions developed by the FHT in Health Education should be highlighted. As stressed in their reports, these actions represent a place for listening, learning, and though it is still incipient, the process has already exerted a positive im pact.
She was explaining about cleansing, t he hygiene of
children’s teeth; because one-year old children already have to have
their teeth cared for and so forth. I didn’t ask anything because I
wasn’t prepared at the tim e (U-1.3).
We learn wit h t hem and t hen pass t o our group of
children and also pass it t o our wom en because t here are 17
w om en in our group ( U- 1.4) .
I don’t ask anyt hing, I m em orize what t hey say in m y
m ind and use what is t he best ( U- 1.6) .
I l i k e t o p ar t i ci p at e b y l i st en i n g an d , i f I d o n ’ t
underst and, I ask and show m y int erest ( U- 2.6) .
These report s charact erize t he part icipat ion of client s in t he educat ive process developed by t he FHP, whether attending talks or m eetings, learning to p r act ice, r ep r od u cin g in f or m at ion t r an sm it t ed or ask in g.
According t o client s, t he part icipat ion in t he educative process developed in the FHP is focused on nor m at iv e pr act ices.
The difficult ies faced by t he FHT in t he developm ent of Healt h Educat ion
The difficulties m entioned by the professionals are related to m anagem ent. There are barriers related to the organization of work processes because of the gr eat dem and of ser v ices, w hich define pr ior it y of at t endance, and also due t o t he absence of t echnical resources to optim ize com m unication between the FHT and clients, such as didactic m aterial and audiovisual r esou r ces.
Resources are always difficult t o arrange, like t ransport ,
didact ic m at erial, you know, t hese t hings needed t o give t alks
( Phy sician 1) .
We don’t have DVD, don’t have slides, but t he t eam
brings som e chocolat e, som e sandwiches, condom s, is always
t rying t o innovat e, call and m obilize t hese adolescent s so t hey
part icipat e, because adolescent s are very hard t o gat her, if you
don’t do som et hing very at t ract ive, t hey go aw ay ( Nurse 4) .
One difficult y is relat ed t o t he great healt h dem and here
at t he unit , t here’re few t alks so far; I t hink t here should be m ore,
but we don’t have m uch t im e for t hat (Nursing auxiliary 4).
DI SCUSSI ON
Healt h educat ion pract iced in services is st ill f ocu sed on p eop le af f ect ed w it h illn ess or t h ose su scept ible t o h av e t h eir h ealt h con dit ion alt er ed. Thus, pr ofessionals dir ect t heir w or k t o indiv iduals who seek healt h services because of som e pot ent ial pat hology( 9), which is also evidenced in t he st udy.
pr ocesses and guided by t he client s’ dem ands. The n or m at i v e ed u cat i v e p r ocess i s v er t i cal , t h at i s, pr ofessionals define w hat t o addr ess, and how and when t he process will happen( 10).
An o t h e r f i n d i n g e v i d e n ce d i n t h i s st u d y indicates that Health Education actions were restricted to sets, that is, practices were planned by the team s, wit h scheduled dat es and t im es, which were carried out at the sam e unit or at another place in the assigned area. This conduct certainly lim its the range of actions relat ed t o Healt h Educat ion when t hese are ordered and norm alized, without reflection on other spaces or educat ional aspect s. The educat ive process is lim it ed t o edu cat iv e en cou n t er s pr ogr am m ed w it h ou t t h e perspective of continuity, carried out according to the FHP rout ine.
The silent coer cion adopt ed by t he FHT t o st im ulat e t he part icipat ion of client s in t he educat ive process hurts the principles of freedom of choice and decision. Educat ion is a collect iv e and j oint act ion, w hich cannot be im posed, t hat is, one learns w hen ( s) he is at the sam e level, side by side, and educators cannot br ing t heir k now ledge and m et hod r eady t o this world( 11). Thus, Health Education should contribute
t o individual and collect ive awareness regarding t he populat ion’s responsibilit ies and r ight s, encour aging part icipat ion of t he com m unit y( 12). I n t his sense, we
h ig h lig h t t h at ed u cat iv e st r at eg ies ar e ex t r em ely welcom e in the com m unities where the FHT is active; both discovering and valuing their potential, and that of ot her part ners in t he cit y, exchanging experiences and knowledge( 13).
Th e m a n a g e m e n t o f se r v i ce s f o r He a l t h Educat ion act ions was appoint ed as a barrier for t he d e v e l o p m e n t o f t h i s a ct i v i t y. Ho w e v e r, t h e FHT co m p l a i n s r eg a r d i n g l i m i t a t i o n s i m p o sed b y t h e a b se n ce o f a u d i o v i su a l r e so u r ce s a n d d i d a ct i c m aterial. This should not inhibit this practice. We stress that educative processes occur with people, and they are m ore im port ant t han resources. Thus, we argue t h at t h e v alor izat ion of people in t h e pr ocess can ov er com e an y d if f icu lt y f ou n d . Th e local cu lt u r e, con v er sat ion gr ou ps, m obilizat ion an d dialog, an d ot her resources and m eans exist ent in t he assigned area, should be known by professionals, who should not restrict them selves to im porting resources for use in the com m unity. The FHT should get integrated with t he local com m unit y’s com m unicat ion st rat egies.
Th e v a l o r i z a t i o n o f h a r d t e c h n o l o g i c a l resources t o t he det rim ent of cult ure can be a bias
of healt h pr ofessionals. I t is im por t ant t o obser v e t he int egr at ion of hum anist ic and scient ific cult ur e, in w hich professionals need t o value t he individual, t h e con t ex t an d cu lt u r e in t h eir daily liv es( 1 4 ). I n
ed u ca t i o n , w h a t i s m ea n i n g f u l a n d sy m b o l i ca l l y visible t o t hose involved, needs t o be valued( 15). The
t e c h n o l o g i c a l e q u i p m e n t m e n t i o n e d b y t h e p r of ession als m ay n ot b e sy m b olically v isib le t o clien t s. Per h ap s w h at is sy m b olically sen sit iv e t o t hem is t o know t hat , in t he cont ext of t heir lives, t h e r e a r e o t h e r p e o p l e g o i n g t h r o u g h s i m i l a r s i t u a t i o n s . Th u s , i n t h e d i s c u s s i o n a n d con t ex t u alizat ion of t h e f act , t h e gr ou p can gr ow a n d d e v e l o p a l e a r n i n g p r o c e s s i n h e a l t h a n d cit izen sh ip.
Th e r e a r e d i v e r g e n c e s b e t w e e n professionals’ and client s’ report s wit h regard t o t he part icipat ion of client s in t he Healt h Educat ion act ions in t he Program . For exam ple, client s did not report t he ex change of ideas and ex per iences.
Part icipat ion is a procedural act of conquest of t he subj ect in t he collect ive const r uct ion( 16). We
under st and par t icipat ion as a pr ocess t hat im plies achievem ent , com m it m ent , involvem ent and sharing, allow in g in d iv id u als t o f or m a cr it ical con scien ce r e g a r d i n g t h e r e a l i t y t h e y a r e i n se r t e d i n a n d , c o n s e q u e n t l y, b e c o m i n g a u t o n o m o u s a n d em an cip at ed b ein g s, ab le t o m ak e d ecision s t h at affect n ot on ly t h eir life bu t also t h eir fam ily an d com m unit y. This concept ion includes individuals who are cit izens, idealized and expect ed t o put t he proj ect of healt h prom ot ion int o pract ice.
The biologist ic m odel focused on t he disease st ill prevails in t he count ry, whet her incorporat ed in t h e p r of ession als’ p r act ice or in t h e p op u lat ion ’s percept ion. The FHP proposed a different possibilit y for t he organizat ion of basic healt h services, as well a s t h e i r r e l a t i o n s h i p w i t h t h e c o m m u n i t y. Pr ofessionals need t o hav e a sy st em ic and int egr al view of individuals and t heir fam ilies, work wit h t heir r eal n eed s an d av ai l ab i l i t y, w i t h co m p et en t an d hum anized pract ice, and work for healt h prom ot ion, pr ot ect ion and r ecov er y( 17).
CONSI DERATI ONS
g u i d a n ce a n d t e a ch i n g s, e sp e ci a l l y o n d i se a se p r e v e n t i o n . Th e cl i e n t s’ p a r t i ci p a t i o n i n He a l t h Educat ion act ions has been per ceiv ed, t hough it is st ill incipient .
A n ot able fact is t h at t h e FHT w or k s w it h pot ent ial exist ent in t he com m unit y, as well as ot her segm ent s in societ y, t o develop educat ive pract ices. Professionals acknowledge exist ing difficult ies for t he perform ance of t hese pract ices. I n t his perspect ive, we understand that FHT should dialog with clients and seek ot her form s of m obilizing t hem .
We also believe t hat Healt h Educat ion in t he Fam ily Healt h Pr ogram r epr esent s a useful t ool t o ch a n g e t h e cl i e n t s’ b e h a v i o r i n f a v o r o f h e a l t h pr om ot ion. How ev er, t his st udy show s t hat policies for t he im plem ent at ion of healt h prom ot ion are st ill ongoing. Healt h professionals who work in t he scope of t he FHP need t o br oaden t heir under st anding of healt h educat ion and t he use of educat ive st rat egies t hat are cult urally m eaningful, so t hat client s freely an d con sciou sly d ecid e on t h eir p ar t icip at ion an d behavioral change in healt h.
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