Health Promotion of Haitian immigrant families: possibilities and barriers in everyday life in Primary Care*

Objective: to understand the possibilities and barriers in the everyday lives of primary care professionals for health promotion of Haitian immigrant families. Methods: qualitative interpretative research, based on the theoretical foundations of Comprehensive Sociology and Everyday life Sociology. Twenty-seven Primary Health Care professionals who assist Haitian immigrant families participated. Data were collected using an electronic form in Google Forms and submitted to Thematic Analysis. Results: three categories emerged: Public policies and specific actions; Potentialities in health promotion to Haitian families; and Professional everyday life and limitations to health promotion.


Introduction
Immigration is a global event that has always existed and that changes the way of life in different ways, may involve the loss of family ties and cultural connections, in addition to economic and social vulnerabilities. The international immigrant condition may be the reality of about 281 million people (1) , who, by their own will or to flee from political, social, religious conflicts, and natural disasters (2) , leave behind their culture, goods, services, loves, and ties. Thus, this immigration phenomenon expresses a search for safe environments, access to work, freedom, education, health, among other essential needs for healthy living.
The South of Brazil was responsible for receiving an expressive number of Haitian immigrants. Data show that 44.95% of them, with active registration in the country, were concentrated in the South, and the state of Santa Catarina was the destination of choice for 15.5% of them (3) .
The discussions and understandings about the Haitian immigration flow highlight the life stories marked by struggles for survival amidst the inequalities experienced in the country of origin (4) . Immigration in this context represents the search for spaces and opportunities, not always achieved, since they may face old and new vulnerabilities. In this immigration process, they face difficulties of personal and family integration, marked by disrespect for differences. These and many other difficulties distance immigrants from the full exercise of their rights (5) .
The care of immigrants in care spaces, particularly in the context of Primary Health Care (PHC) can be marked by attitudes and behaviors, especially those of professionals, which are favorable or not to the reception and therefore the resolution of the problem that motivated the search for health service (6) . The actions of Health Promotion emerge as essential in the possibility of positive health states (7) , considering the limits faced in the environments, these actions provide the mechanisms for the development of an equitable, democratic "health" that allows the exercise of citizenship (5) . Thus, health promotion actions strengthen the fight for the reduction of inequalities and vulnerabilities, enhancing citizenship and the constitution of rights essential to the care of the immigrant population (6) . Therefore, with the immigration movement, new challenges arise in the everyday life of PHC health professionals, bringing limits and potentials in their everyday lives, in an exercise of recognition and understanding of other cultures and learning to avoid discriminatory practices, among other dimensions involving this phenomenon (3) . It is necessary to understand, in its genuine meaning, that in caring for these people, the knowledge of the collective experience and the satisfaction of existing are manifested concomitantly (4) .
Considering the principles of the Brazilian Unified Health System (SUS) that guide the performance of PHC and even advocates it as the gateway to the health system, the reception of immigrants at this level of care needs to be in the sense of valuing accessibility, the right to information and effective assistance in meeting their needs. Still, it must take into consideration and respect their life trajectories and vulnerabilities experienced on an everyday basis (6) .
Thus, it is essential to understand how PHC professionals perceive health promotion in their everyday lives, with its limits and potentials, for the reduction of vulnerabilities experienced by Haitian African descendant immigrants in their everyday lives. Perceived as a way of life, by the interactions that take place everyday, including in health care spaces, the everyday life values the symbols, signs, beliefs and everything that is produced in the imaginary and that, in a way, direct and favor being and living in a world with opportunities to be healthy, although getting sick can punctuate the course of life of people, families and communities, revealing, therefore, scenes and scenarios of living and living together, with their own rhythm (7) .
Given the presented, the aim of this study is to understand the possibilities and barriers in the everyday lives of primary care professionals for health promotion of Haitian immigrant families.

Methods
This is an interpretative research based on the Comprehensive Sociology and Everyday life (8) . According to this referential, sociality reaffirms the sense of community, and this is plural, aesthetic, imaginary, and aggregating when building the everyday life. There are five theoretical assumptions of Sensibility: 1) Critique of schematic dualism -considers reason and sensibility, lived experiences and interaction with the environment and people; 2) Form -corresponds to the significance of what is proper, internal to the person, thus apprehends the imaginary and understands it together with the social body; 3) Relativistic Sensibility -refers to the truth as being factual and momentary, living is plural and heterogeneous; 4) Stylistic Research -proposes the open and light writing of what is investigated without losing scientific competence; 5) Libertarian Thought -values the construction of subjective and intersubjective knowledge, empathic, with lightness and freedom of gaze (8) .
Interpretive research contributes to the understanding of a phenomenon through its description with associations applied to practice. Thus, through an ordered, coherent, and persuasive narrative, it provides subsidies to encourage care practice (9) . The guidelines of the Consolidated Criteria for Reporting Qualitative Research (COREQ) guided the description of the study results.
The study participants were PHC professionals who developed activities with Haitian immigrant families in four municipalities in the State of Santa Catarina, in southern Brazil: Florianópolis (capital), Blumenau, Pomerode and Gaspar. These cities have a history of colonization by immigrants, especially German, and currently have a significant number of Haitian immigrants.
Data were collected from August to October 2020, through the application of an online question-naire, via Google Forms ® document, due to the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic. To this end, the main researcher initially asked the PHC coordinators of the four municipalities in the study to indicate the Basic Units and Family Health Strategy Teams with the highest number of visits to immigrants. Then, the coordinators of these units were contacted and informed about the objectives of the study and the type of participation desired. After they agreed to participate, we asked them to provide the e-mail addresses of all the health professionals working in the units.
The individual invitation to participate in the study, accompanied by the link to access the Informed Consent Form, was sent to the professionals by e-mail. The invitation explained the study objectives, the criteria to be included as a participant, the type of participation desired, and the researcher's contact details for any further clarifications that might be necessary. Access to the data collection form was available for sixty days.
It is worth mentioning that access to the questions in the online questionnaire was only possible after the signed consent form was returned. This questionnaire was composed of two parts. The first with questions to characterize the participants. The second consisted of seven questions related to the objective of the study, which addressed the perception about the development of actions and practices related to health promotion and Haitian families; perceptions about the limitations and possibilities in the daily lives of professionals to care for these families with a focus on health promotion.
The invitation and all contacts with the health secretariats of the municipalities, coordinators of the health units and the study participants were made by the first author (nurse, university professor, doctoral student in Nursing with experience in qualitative data collection and analysis), who had no previous relationship with the cited individuals.
The eligible subjects for the study were 79 health professionals with any background who worked in the indicated Health Care Units, and who, in their everyday work, attended to Haitian immigrants. It is noteworthy that 46 professionals were not included, since they did not respond to the invitation to participate in the study, even after three biweekly reminders were sent. Three professionals did not accept to participate in the study, and one was not contacted because he was away due to health issues. In turn, two professionals were excluded because they only started to fill out the form, without completing it. Thus, 27 professionals were informants of the study, and their reports were considered sufficient to reflect on the multiple dimensions of the object under study, from the recurrence and complementarity of information (10) .
For data treatment, initially, all the questionnaires answered were printed, and an alphanumeric code was assigned to each one. Then, the material was submitted to content analysis, thematic mode, following the proposed steps: pre-analysis, material exploration, data treatment and inference of results (10) . In the pre-analysis, each questionnaire was individually read, highlighting the aspects considered relevant to the study objective. In the material exploration stage, the answers of all participants to each question were grouped and performed a thorough and exhaustive reading of all the printed content, with coding of the messages from the identification of central ideas, in this case those related to social participation, empowerment of subjects and reception, as they are terms that exemplify the proposal of the National Health Promotion Policy. These, in turn, gave rise to the nuclei of meaning. Finally, after the grouping and classification of the units of meaning according to their similarities and anchored in the research objective, three categories emerged: Public policies and specific actions; Potentialities in health promotion to Haitian families; and Professional everyday life and limitations to health promotion.
In conducting the study, the guidelines of Resolution No. 466/2012 of the National Health Council and the guidelines for research procedures in a virtual environment of the National Research Ethics Committee were respected. The approval for the development of the study was given under Opinion no. 4,195,158/2020 and Certificate of Ethics Appreciation Presentation No. 33590320,0,0000,0121 from the Ethics Committee on Research with Human Beings of the signatory institution. To ensure the anonymity of the participants, the answers to the questionnaires were identified with an alphanumeric code-name indicating the order of inclusion in the study.

Results
Of the 27 professionals under study, 12 were female, being 12 nurses, eight physicians, three nursing technicians, two community health agents, one dentist and one nutritionist. Eight of them worked in Blumenau, six in Pomerode, six in Gaspar and seven in Florianópolis. The time of work in PHC ranged from six months to eight years. Three categories emerged from data analysis: Public policies and specific actions, Potentialities in health promotion to Haitian families and Professional everyday life and limitations to health promotion.

Public policies and specific actions
When discussing the promotion of health in their everyday lives, health professionals pointed out the potential of affirmative action in reducing the vulnerabilities experienced by Haitian immigrants and stressed that the existence of specific public policies and the improvement of existing ones is paramount: For the participants, actions that organize the service and direct the care to the real needs of these families, feedback the health services in a way that makes it possible to trim the edges, move the service and help reduce inequalities: I believe there should be a reference center so that we could refer the users that we are unable to maintain effective communication by language (PAS. 03). We could have informative materials in their language with basic orientations.
We deliver the pregnant woman's booklet, and many of these Haitian

Potentialities in health promotion for Haitian families
The participants of this study realized that some actions performed by the Family Health Strategy teams favor health promotion and help reduce the vulnerabilities experienced by immigrants: Another aspect highlighted by the professionals as a power to contribute to health promotion refers to family ties. In this sense, they realized how much they are and need to be valued in the everyday care and the efforts made to maintain them, especially through solidarity and mutual help: There seems to be a strong bond In the statements presented in this category, PHC professionals demonstrated that they value the health care actions and the SUS guidelines as the main strategies for welcoming and caring for Haitian immigrant families.

Professional everyday life and the limitations for health promotion
When reporting on the everyday life of care to Haitian immigrant families, the language barrier (Baryè Langaj) and the difficulty in verbalizing complaints were highlighted as factors that prevent effective care for Health Promotion: Finally, the professionals referred to the different forms of vulnerability experienced by Haitian immigrant families, which directly or indirectly interfere with the everyday care and promotion of health, characterized as limits and resulting in a timely care without continuity: Vulnerable, they are users who need special care by managers and health professionals due to factors such as language, low education, difficulty of understanding following the care recommendations, the difficulties they go through trying to adapt to a reality very different from what they were used to (PAS. 03). Delay in seeking the health service for fear of losing their jobs. They submit themselves to dangerous, sometimes unhealthy work. They accept lower salaries and, in some situations, without labor rights (PAS. 03).

Discussion
With the new reality experienced in PHC, professionals increasingly need to be convinced of their empowerment and make health promotion happen and thus contribute to the reduction of vulnerabilities (11) . They presented a mediating role in this process of strengthening the inclusion of families, including immigrants, besides identifying their real needs to overcome the challenges faced in the everyday life by these people (11)(12) .
When considering immigrants specifically, it is reported that PHC must be the main reference and gateway to health care. In many moments, these services are spaces for refuge and relief of their pain and suffering resulting from the process of immigration (11)(12)(13) . The care based on actions that promote health must focus on and dialogue with the conditions offered by the public authorities, but demand and present to the political dimensions all the involvement of personal and collective skills, community participation that contribute to the creation of favorable and healthy environments, and then, obtain the restructuring of health services (11) .
These aspects were reiterated by the professionals in this study, when they stressed the importance of a remodeling, with the establishment of "new" guidelines in the services, so that the responsibility for the success or failure of health promotion actions is shared by all: governors, managers, professionals, and community. All these sectors need, jointly and individually, to value and respect cultural aspects, as well as the unique needs of the individuals (14) .
The PHC professionals in this study expressed in their reports that they understand the importance of a care based on the person, and on their cultural and historical characteristics, but they do not always feel prepared and/or supported to do so. The possibility of intersectoral and integrative actions as tools for the development of community actions, performed from robust care networks, characterized by management support and health policies, enhances the awareness of teams and the bond with the community, resulting in the expansion of the field for more creative and welcoming practices (14) . Having access to health services does not mean an effective care (12) , it is necessary to create favorable environments for health, welcoming, and personal and community involvement, which is also proposed in the Health Promotion Policy (15) . In the case of immigrants, evidence points to the importance of considering the influence of aspects related to family functioning on living conditions, to minimize the negative outcomes that can compromise the health of this population, especially mental health (16) . In these cases, the assistance does not happen automatically, but through mutual and continuous help, in which cooperation reinforces the whole of life, the "wanting to live together" (7:45) . Thus, it is necessary to understand that immigrants are also part of this network and, therefore, it is important to seek, through the implementation of individual and collective actions, to promote their insertion in the context of PHC.
The reorganization of strategies and programs that involve Health Promotion may subsidize actions that respond to the current needs (17) . These needs, in the case of immigrants, go far beyond those associated with lack of access, lack of adequate food, decent jobs or language barriers. They involve the genuine understanding and comprehension of PHC, with its potential and limits of action and results. In the case of immigrant families, adjustments can enhance community practice, favoring the implementation of actions that emerge from specific and real needs because in the country of origin they did not have a health system with performance like PHC. This type of action provides the creation of methods and effectiveness of interventions that contribute to the reduction of vulnerabilities and improvement in quality of life (17)(18)(19) .
The health care for immigrants is organized in a more potential way by health professionals, immigrants' associations, and other entities of society, through the reception and the offer of specific information directed to these people. Therefore, every citizen needs to be aware of their rights and duties of the State, to exercise their citizenship and feel like belonging to the State/Nation, to the people who are now theirs. In this sense, the professionals in this study recognize the need to develop skills that allow them to better communicate, understand and know the culture (14) and exchange experiences, from which, everyone can learn. These perceptions corroborate what is described in the National Health Promotion Policy, which recognizes that through the dissemination of information, health education actions, and the intensification of individual skills, personal and social development is enhanced (6) . These practices expand the available options, allowing families to make choices that, besides being more consistent with their culture, are also more appropriate for the current living conditions, while considering what they want and what they understand as good health (20) .
The need for change and reorientation in the training of health professionals pointed out by the participants of this study has already been discussed in recent decades. The conceptual and ideological discussion is pertinent, so that the professional and interprofessional field can change the way of thinking and the culture of doing health in the country. This will become possible through the development of actions that respect cultural differences and characteristics, and that favor the adoption, by all, of healthier lifestyle habits and practices (11) .
It is noticeable that PHC professionals understand their role in improving access to services, reducing diseases and health complications of the population assisted, resulting in the mitigation of vulnerabilities. However, it is irrefutable that, to achieve such results, it is urgent to re-discuss existing policies and practices already incorporated (21)(22)(23) .
It is a reality that many Haitian immigrants do not master the Portuguese language, establishing a cycle of vulnerabilities (19) . Thus, it sets up an everyday life where the linguistic difficulty that delays the search for health services, especially in the context of PHC, stands out. At the time of consultation, for example, communication with professionals is limited, often making it impossible for their complaints and symptoms to be understood (24) .
Health professionals reinforce the maintenance of vulnerabilities, expressed in the difficulty of communication and understanding of cultural, political, and social values. This limits the reception of immigrant families, leading to difficulties in the care from their arrival to health services until the clinical outcome (25) . On one hand, immigrants have difficulties to articulate their health demands, and on the other, professionals face obstacles to establish the diagnosis and, consequently, prescribe treatments and care that are effective (26) . Given this scenario, the conception of healthy spaces is considered unavoidable, in which care permeates not only the access and actions focused on the immigrant's pain, but also on the anguishes experienced by professionals who perceive the limits in their everyday work and in the immigrants' lives.
To obtain the best results, health professionals need and have employed some strategies that favor communication with immigrants, which include the presence of people with a command of the language -whether they belong to the social network of the immigrant or the service itself, the use of mimics, gestures, and application translators. Although these strategies do not always solve the problems related to communication, they contribute to reducing the anguish experienced everyday by professionals and immigrants (27) .
It is emphasized that limitations in communication are an obstacle to understanding and this makes it difficult to approach suffering, even though it is recognized that Haitian immigrants can experience several losses: family life, culture, possessions, social position, and contact with the social group (ethnic and religious), which result in a rupture of reference. The real or symbolic losses may place the person who experiences them in a state of suffering such that the need for psychological help becomes inevitable (25) . It is essential to consider that Haitian immigrants, from their country of origin, experience rights violations, which has repercussions in the search for a better life, and that the reality in Brazilian territory enhances the suffering, since they also experience new pains and losses.
When considering that professionals also undertake in their everyday lives the effort of living their own lives and their limitations of social understanding, it is possible that in certain cases they collaborate to the intensification of barriers of access to health services (27)(28) . Considering this, it is necessary to take actions that instrumentalize not only the professional, but also the management of health services, to recognize the limits and powers of professionals for a better attention and approach to immigrant families (27) .
It is noteworthy that in quantitative terms, immigrants were assisted by the Unified Health System in accordance with the constitutional principle of the right to health in Brazil, although differences have been identified in the demand and use of these services. It is also evident that this situation is more frequent among women and among those who have lived longer in the country, due to their greater knowledge about the health system and better understanding of the Portuguese language (29) . However, there is the possibility of insufficient and sometimes discriminatory actions by some health professionals, including omission in the performance of some actions (30) .
It is believed that these everyday attitudes, rather than being associated with personal characteristics, are related to insufficient training and qualification of professionals who find themselves in a reality for which they were not prepared. Thus, it is necessary to think of ways to offer support to those who deal daily with immigrant users in the health services.
Thus, it is believed that the wishes of immigrants regarding health care will be effectively met when the demands of this population are recognized by municipal and state managers and based on them, seek strategies that can help overcome not only those related to the health sector, since the difficulties faced are the result of living in a reality far from that dreamed (30) . It is noteworthy that recommended actions value the active and effective participation of people and the community -which includes immigrants -in the health process, besides instrumentalizing professionals so that they can better deal with existing inequalities.
Considering this context, it is urgent to rethink the training in the health area. It is essential that new professionals be encouraged to discuss issues related to human mobility and its impacts on health. These discussions can contribute for health professionals to recognize the importance of being trained to care for the immigrant population, offering appropriate services to their needs, enabling equitable access to health, in addition to preventing discrimination (30) , thus ensuring human rights, as well as an affective and, therefore, effective care attuned to Health Promotion.

Study limitations
A possible limitation of this study is related to the fact that the data were collected through an electronic form, which may have inhibited the participation of a larger number of professionals, besides making it impossible to deepen some questions, which would not have occurred if the data had been collected through an interview, especially in person.

Contributions to practice
Understanding how Primary Health Care professionals perceive the potentials and limits of the assistance provided to immigrant individuals, families, and communities enables managers and professionals to reflect not only on changes in the work process, but also on strategies that can be implemented in the everyday care routine, to minimize vulnerabilities, favoring effective assistance, therefore, an effective Health Promotion.

Conclusion
Health professionals realize that their everyday work in Primary Health Care can present itself as a fertile field for promoting the health of immigrant people, families and communities, highlighting the importance of strengthening the Unified Health System. However, they recognize the existence of limits related to language barriers, political conceptions, and social organization. To overcome these limits, it is believed to be necessary to strengthen existing policies and actions, in addition to making changes in the organization of services, which transit through the ways of genuine involvement with individuals, families and immigrant communities, building emotional assistance, therefore, an effective sensitive and health-promoting care.