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CIRCLE OF CULTURE AND PERMANENT EDUCATION FOR TRANSFORMATION OF PROFESSIONAL PRACTICE: AN INTEGRATIVE REVIEW

ABSTRACT
This article aimed to know the scientific evidence that underlies Culture Circle application as a device of Permanent Education in Health for professional practice transformation. This is an integrative literature review carried out in the PubMed, CINAHL, LILACS and Scopus databases, in October 2021, with the descriptors “health professionals”, “professional practice”, “continuing education”, “health promotion” and the uncontrolled term “Culture Circle”. Data were analyzed in a descriptive way. The results identified 217 articles and five were included to compose the final sample. It was identified that the most discussed themes in Culture Circles were health education and health promotion. There was an average of 13 participants, lasting between one and a half to four hours, with the presence of an animator/researcher and carried out in the workplace. It is concluded that applying Culture Circles in Permanent Education in Health is a powerful inducer of change in professional practice. Recommendations are presented for its application in empowering subjects and in strengthening health promotion actions as well as the need for field research to broaden the understanding of the implication of the method and its consequences in professional practice.
Keywords: Permanent Education; Health Personnel; Professional Practice; Health Education; Health Promotion.

INTRODUCTION
Health professionals’ work process requires a constant search for knowledge, in order to base the performance and qualify the actions of comprehensive care provided to health service users, considering the challenges and obstacles faced in people’s and organizations’ daily lives. In-service training requires applying teaching approaches that consider people’s knowledge and previous experiences in daily health practices, providing the construction of scientific knowledge permeated by dialogicity and theoretical-practical reflection1.
In order to subsidize care practice in confrontation and search for resolution of epidemiological demands in the context of the Unified Health System (SUS – Sistema Único de Saúde), the Brazilian National Policy for Permanent Education in Health (PNEPS - Política Nacional de Educação Permanente em Saúde) emerges, which aims to carry out a systematic articulation between learning and work, where teaching and doing become inseparable2.
Incorporating assumptions of problematizing and meaningful learning as devices to instrumentalize a more critical and reflective professional practice is a methodological theoretical foundation in Permanent Education in Health (PEH). PEH present in the work process gives professionals the opportunity to revisit the ways established in health care, new knowledge production and health practice transformation, fostering pillars for ethical and humanistic care3.
The educational device of PEH provokes a more communicative action among work teams, considering professionals’ dialogue and mutual understanding. The emerging consolidation of PEH requires breaking the centralized and vertical logic of knowledge construction, proposed by continuing education, which is marked by a distancing from the real need for the service, with a more instrumental action represented by managers’, supervisors’ or authorities responsible’ inability for improving workers’ professional practice to recognize situations that require listening to those involved4.
Likewise, PEH can be aimed at the public composed of a single professional category or a multidisciplinary public with a focus on interprofessionality, maintaining the understanding of the essentiality of collective production in achieving the complexity and multidimensionality required in health promotion approach. From this perspective, it is necessary that PEH be organized in a way that values each professional category’s specificities, to promote health work as a source of mobilizing knowledge and an action based on the population’s epidemiological profile and the political and sociocultural processes of organizing comprehensive health care2.
Despite the relevance of PEH in the process of building and strengthening the SUS, it should be noted that educational actions applied in PEH in several states and municipalities still leave something to be desired, due to the inadequate way in which they are planned and executed, characterized by the lack of listening to workers and irregular supply to health service professionals. Therefore, it is necessary to reinforce investments in educational projects with learning environments that value workers’ role in the democratization of knowledge construction in a continuous and collaborative way5.
The constructs of dialogicity, problematization and participation of workers in the training course are based on the critical-social, integrative and problematizing pedagogy proposed by educator Paulo Freire6, which highlights the need for reflection on the context conditions in order to extract responses to the problems presented and then point out decisions that enable transforming health practice’s reality6,7.
To generate autonomy and leading role, Freire6 points to the Culture Circle applied to groups of subjects as an emancipatory strategy of co-construction of learning, by encouraging processes of awareness in the intertwined construction of popular and scientific knowledge, recognizing and valuing cultural issues in ways of thinking and acting in health based on dialogue. The methodology involves three stages: investigation, thematization and proposition6–8.
In the first stage, generating themes are defined from participants’ life experience, allowing participating subjects to talk about the contradictions, the concrete and real situations in which they are living. The second stage is configured as the moment of contextualization, when the themes are problematized, questioned, analyzed and subjects begin to have a critical view of the situation and the subject discussed, representing the strengths and challenges for participants. Finally, in the third stage, there is the process of becoming aware of the real situation, the action-reflection-action, to overcome lived reality’s contradictions, generating the context (re)thinking and re-signification and its possibilities for change8,9.
The role of facilitator of a critical and reflective learning process is assigned by Freire as the function of animating debates, breaking with the traditional attitude of teachers and proposing a mobilization and encouragement to the participation of Culture Circle members, expressing their prior knowledge and their concerns, in order to provide a dialogical arena for knowledge exchange9.
The dialogical and problematizing methodology applicability mediated by Culture Circles has emerged as a PEH device, as it is considered an innovative strategy for empowerment and health promotion.10-12 Therefore, this study aims to know the scientific evidence that underlies the application of a Culture Circle as a device of PEH for transforming professional practice.

METHOD
This is an integrative review (IR) of national and international literature. Such a review is designated as the only approach that allows the combination of diverse methodologies with the potential to play a greater role in evidence-based practice.13 The writing Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations were followed14.
For carrying out this IR, the following stages are recommended: (1) research question elaboration (problem identification); (2) primary study literature search; (3) study assessment by inclusion and exclusion criteria; (4) data analysis from primary studies; and (5) presentation of the final work13.
The review question that guided the study was defined using the PICo strategy, an acronym that represents: population (P) - Health professionals, phenomenon of interest; (I) - Culture Circle use; Context (Co) – PEH scope. Thus, the guiding question of this study was: What scientific evidence supports Culture Circle application as a permanent education device for health professionals?15.
Article search was carried out in October 2021, in the electronic databases: Medical Literature Analysis and Retrieval System Online (MEDLINE) via PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO, Latin American Literature and the Caribbean (LILACS) via the Virtual Health Library (VHL) and Scopus (Elsevier).
To develop the search strategy, synonyms and the main controlled descriptors available in the Health Sciences Descriptors (DeCS) and Medical Subject Headings (MESH) were listed: “health professionals”, “professional practice”, “continuing education”, “health promotion”, and the uncontrolled term “Culture of Circle” and its correspondents. Using these descriptors, search keys were constructed, combined with Boolean operators (AND and OR) and adapted for each database. Thus, after pre-tests of key terms, these descriptors were combined in different ways, in the selected electronic databases, in order to ensure a broad search in the literature, as shown in Chart 1.
Chart 1

Original articles published in English, Portuguese and Spanish were included. No specific publication period has been entered. At the end of the survey, duplicate articles in different databases were excluded, followed by reading the title and abstract by two independent examiners who had extensive previous experience in integrative reviews, for subsequent reading of full text. Studies that did not meet the proposed objective were excluded, according to Chart 2. The results were compared and differences resolved by consensus or with the inclusion of a third reviewer, when necessary, in order to favor selection validity.
Chart 2

For collecting data from the articles, the methodological aspects were systematized in a data extraction matrix, containing author/title, year of publication, country, language, journal, database, main objectives, study methodology and level of evidence. The main characteristics in performing Culture Circles were also extracted with regard to: theme addressed; number of participants; average duration and frequency of meetings; typology of the learning environment; materials used; strategies; participation of a facilitator/animator; techniques used; results obtained from Culture Circle application as an PEH device; and contributions to the transformation of participants’ professional practice in the articles studied.
To define level of evidence, the articles were assessed regarding the hierarchical classification of scientific evidence, in line with study design explained by the respective authors, being categorized into: level 1, systematic reviews or meta-analyses with randomization; level 2, at least one randomized controlled trial; level 3, clinical trial without randomization; level 4, cohort or case-control studies; level 5, systematic review of descriptive and qualitative studies; level 6, a single descriptive or qualitative study; and level 7, expert committee opinion or report and/or authority opinion16.
The selection process of articles in the databases was presented in the results through a flowchart, adapted containing four stages (identification, selection, eligibility and inclusion), recommended by PRISMA14.
The results of this integrative review were critically analyzed in a descriptive way, presenting the scientific evidence that supported Culture Circle application as a PEH device for professional practice transformation.
Organization of results was carried out synoptically in a table format containing the coding for each article and discussed based on available literature on the subject.

RESULTS
Database search identified a total of 217 scientific articles (131 in MEDLINE, five in CINAHL, 67 in LILACS and 14 in Scopus), with the description of the search stages, as shown in Figure 1. When considering the study selection criteria, seven articles were excluded because they were duplicates, totaling 210 studies. After reading the titles and abstracts, 191 studies were excluded because they did not answer the research question of this review, leaving 19 articles selected for the next stage. After reading the 19 articles in full, 14 were excluded from the study for not meeting the eligibility criteria, culminating in five publications, which made up the final sample of the review (Figure 1).
Of the five articles17-21, three were published in MEDLINE17,19, 20, one in LILACS21 and one in Scopus18. As for language, two articles were verified in Portuguese17,18 and three in English19-21. Regarding the level of evidence, all articles had their methodological quality classified as level VI, and carried out a qualitative research approach17-21.
Publications were identified between 2010 and 202017-21, highlighting that all publications were in nursing journals17-21. The studies were published in Brazil from different regions of the country: northeast17, midwest18, north19, southeast20 and south21.
In the publications, the main objectives to be achieved by the Culture Circle educational methodology were to (re)think, (re)build or (re)signify professional practice with a reflective, critical, problematizing and dialogical approach aimed at health promotion (Chart 3)17-21.
Chart 3

Chart 4 presents the characterization of PEH’s educational interventions mediated by a Culture Circle with a brief description of the main information regarding the general theme, number of participants, professional category, average duration, number of meetings, periodicity, learning environment, materials used, strategies and techniques applied, and the learning facilitator of the training path.
Regarding Culture Circles’ dialogic proposal, the most discussed theme was “Health Education” in two articles that dealt with this practice in health professionals’ daily actions17,18. One article addressed child health promotion19, another, socio-environmental determinants20, and another, active aging and elder care21.
A minimum of four participants and a maximum of 29 participated in Culture Circles, thus making a general average of 13 involved in the educational process. The studies were carried out with only nurses17,19, only CHW20, or with an interdisciplinary composition, with professionals from the Family Health Strategy (FHS)18 team and the Family Health Support Center (NASF - Núcleo de Apoio à Saúde da Família)21.
Regarding the number of meetings, there were times with just one Culture Circle21 or up to 13 meetings to develop the training itinerary19. The duration of each Culture Circle ranged from one and a half to four hours. It should be noted that two articles did not present this description of average duration of training moments in their publication17,21. The monthly periodicity was the most prevalent in the articles that made up this study18, 20, 21.
Regarding the choice of the learning environment typology, the predominance in all articles of the work environment (Health Unit) was evidenced, being this elected more conducive to implementing the pedagogical approach17-21.
Various materials and techniques were used in the analyzed studies, such as relaxation17, welcoming20, text readings17,18, group discussion21 and availability of low-cost materials for knowledge production individually and collectively17- 21.
All studies applied the three guiding principles of Culture Circles (thematic research, codification and decoding, and critical unveiling)17-21. For each stage, different techniques and teaching strategies were used to encourage professionals’ participation as well as to ensure the achievement of expected results. The study by Monteiro and Vieira stands out17, which reveals, in a pioneering way, systematization for meeting Freire’s 8 stages: discovery of the vocabulary universe; dynamics of awareness; reception; construction of situations for problematization (working on the guiding question(s)); theoretical-scientific foundation (encouraging critical reflection); synthesis of what was experienced; and assessment in each Culture Circle developed17.
It should be noted that in all of the assessed educational intervention studies with Culture Circle application, PEH strategy’s facilitator presented himself as both an animator and a researcher by also taking responsibility for gathering and reliably recording the data produced during training17-21.
As for contributions to professional practice transformation, there was agreement in the legitimization of generating changes in the work context in all articles presented from the application of the critical and reflective pedagogical approach of Culture Circle in PEH actions involved in each scenario presented17-21.
Chart 4

DISCUSSION
The appreciation of the findings was developed following an organization, which begins with a focus on the general characteristics of scientific publications. In continuity, Culture Circles’ specificities are addressed, such as participant profile, themes addressed, teaching methodology and outcomes learned with Culture Circle application in PEH actions.
General characteristics of scientific articles
The results found showed that all the studies in this review took place in Brazil17–21, which is related to Paulo Freire’s nationality, creator of the Culture Circle educational methodology. This demonstrates Brazilian researchers’ growing interest in Freire’s assumptions for PEH training processes that can be performed in the various scenarios of care, management, care10 and in different fields of knowledge8.
Of the five studies reviewed, all were published in nursing journals and covered primary care professionals’ work, with two articles exclusively for nurses. The findings highlight the recognition of FHS as a gateway for users in the Health Care Network (RAS – Rede de Atenção à Saúde) that reorients the health care model, emphasizing the bond between professionals and enrolled families and the organization of the work process aimed at the population’s needs.
In this context, the involvement of nurses who are part of the FHS team emerges, when participating in PEH actions in the application of Freire’s Culture Circle methodology, which strives for valuing popular knowledge and users’ participation in an educational, dialogical arena on the knowledge necessary for health promotion.
Culture Circles are characterized as a democratic space for literacy, literacy, critical awareness training and, above all, human development. They require the predominance of horizontal dialogue and an education contextualized in the work and culture in which students are inserted, thus avoiding oppressive relationships in educational practice9, 22.
When considering that learning is developed from what we are and what we do, Freire’s method uses thematization arising from knowledge brought by students themselves. This practice allows the teaching of an emancipating and, at the same time, singularized education, thus facilitating the incorporation of knowledge produced, as pointed out in the analyzed studies9, 22.
The applicability of Freire’s methodology in PEH actions corroborates the understanding that educational processes occur in different ways and initiatives, assuming various forms in everyday actions that produce knowledge and induce changes, based on the recognition of professionals’ potential in work processes23.

Participant profile in Culture Circles
The development of educational strategies mediated by Culture Circles in the analyzed studies had an average of 13 participants, highlighting the need to control the number of members to ensure knowledge exchange with the active participation of all. The composition of a larger number of members requires an increase in activity duration to allow, democratically, the involvement of members in debates, enhancing the process of awareness and changes in the reality experienced17- 21.
However, to ensure the participation of professionals in the educational process mediated by Culture Circles, a study21 reported the difficulty in composing the group due to management’s inflexibility in guaranteeing the release of health professionals, thus constituting a limitation of this research. Health service organization and management resistance to ensure moments of discussion for health professionals were also evidenced in a study by Dalmolin and Heidmann 11.
There were articles in which participants were characterized by having the same profession, making it possible to deepen discussions of difficulties and expectations experienced in the performance of their duties. The same is observed in studies that point to Culture Circle application to the same professional category as a potential for encouraging the exchange of experiences in a horizontal, critical and participatory way, producing mutual learning20,24,25.
It is also worth considering the need to expand access through PEH on Freire’s methodological proposal to all multidisciplinary team members 17,19,20. The opportunity for other professionals to experience this experience, giving them a voice and dialogic space to reflect on their knowledge and practices, contributes to the expansion of knowledge significantly, enabling a more critical and reflective understanding of their professional practice and the possibilities for improvement19-21,25,26.
In this regard, applying Culture Circles in the PEH process constitutes a tool with several possibilities for interaction and maintenance of interpersonal relationships, providing opportunities for reflections for a work process that aims to overcome multidisciplinarity and expand interprofessionalit18,24.
Another important aspect identified was the lack of clarity of study sample characteristics (gender, age, length of experience, level of education), limiting itself to explaining the professional category of participants in PEH activities17–21. Knowledge about participants’ specificities in research that use the collaborative practice of knowledge production as a strategy for PEH enables greater criticality from the reader about the study developed and the potential of its application in different contexts and audiences.
Knowing the profile, specificities, interests and expectations, which emerge from the group, as well as about their daily work and previous knowledge, is the necessary basis for planning and implementing Culture Circles. Accordingly, one of the studies17 that applied a Culture Circle involving nurses highlighted the initiative to emerge from the group the generating themes, considered of interest in conducting a discussion fostered by problematization, instigating reflections for a praxis based on the consciousness of the lived world.
In general, the analyzed articles configured a collective construction of participants’ identity knowledge, when considering the scenario of care for the population in primary care, and showed, in their results, that the Culture Circle approach enabled transforming professional practice, regardless of participants’ level of education. These transformations were favored by dialogic participation, exercise of criticality in relation to the posed reality and shared production of knowledge17-21, findings corroborated in other studies10,24-26.
FHS workers in the analyzed studies indicated that applying Culture Circles can strengthen educational practices by encouraging users to take a leading role in decision-making about attitudes that can positively impact the population’s quality of life27.

Delimitation of themes addressed in Culture Circles
Applying the Culture Circle methodological approach in the execution of PEH actions contributes to processing daily professional issues considered problematic or challenging and that require to be worked on, from group members’ practical experiences, aiming to measure the complexity and depth of discussions and the co-responsibility of management17,18, 20 with the design of propositional actions aimed at health promotion19-21.
With regard to the theme, health promotion actions constituted a central focus, which in its conceptualization pervades the conception of individual empowerment, which must perceive itself and act as an agent of transformation, from the perspective of individual and collective awareness10,19. The articles demonstrated that reinforcing the appreciation of experiences, feelings, speeches, life stories, values and skills of professionals is essential for a process of emancipation, configured by awakening to the possibilities of contributing to strengthening actions that promote health17-21.
The focus on health promotion permeates the critical and creative exercise of health education, as a strategy to promote bonding between health professionals and families, and for the population’s access to knowledge about health in a contextualized way, developed from horizontal relations and understandable language, which establishes interrelationships with the socioeconomic and cultural dimensions of the public involved.

Culture Circle as a methodological approach in Permanent Education in Health
PEH actions require periodicity, and it is important to define a time compatible with the objectives of in-service training, in order to contribute to updating and improving the care provided to the population20. Developing Culture Circles in a punctual and non-systematic way, as a result of the scarce time allocated for their realization, is pointed out as a limiting factor, as it can compromise the active participation of professionals, in dialogic and reflective moments, necessary to revisit their practices. Other studies were listed that also faced this transitory character in Culture Circle applicability in PEH actions11,26.
The quantitative assessment of the number of meetings set for implementing Culture Circles must be outlined through the essential performance of active listening to the voices, emotions, concerns, thoughts, from reinforcement to the analytical and continuous encouragement of leading role and co-responsibility in the construction of critical and reflective knowledge during educational training, understanding that the longer the contact time between participants, the greater the bond and further discussions11,25.
To execute Culture Circles, the choice of a learning environment close to the work place and that protects a certain privacy reveals itself as a potential to encourage the participation of those involved17-21. In the most intense period of coping with the new coronavirus pandemic, it was pointed out that using the virtual pedagogical environment in the face of social distancing measures made it possible to apply Culture Circles through a technological strategy that enabled, remotely, social interaction, care production and health promotion10,25,28.
Low compliance or underutilization of technological resources was verified in the performance of PEH due to some factors, such as precariousness of physical facilities and computer equipment, lack of interest of workers and/or manager, low quality of broadband or lack of protected time in agenda for workers to have access to courses29.
Along with choosing the most conducive learning environment to ensure a dialogical arena, it is necessary to recognize the presence of an animator/facilitator, who should seek to establish relationships of bond and trust with participants20. It is reinforced in studies that the animator also takes on the role of researcher in Culture Circles. To this end, they must previously invest in knowing participants as well as their prior knowledge to achieve success in fulfilling the dialectical and intertwined moments for the execution of Freire’s pedagogical proposal of problematizing learning17-21.
The animator must present an experience in conducting Culture Circles, since lack of knowledge is a limiting factor for expanding the use of this method, especially with regard to the virtual teaching modality18,28. It is an essential condition for the activity of an animator/facilitator the discernment to have an attitude of active listening, with respect to the differences, mobilizing creativity and sensitivity, as well as encouraging participants’ reflection on the knowledge built during Culture Circles, in addition to safeguarding the ability to be enchanted by the group’s achievements17,18,21,28.
Regarding the materials and strategies used to carry out the educational process, Culture Circles work to approximate the ludic with the scientific to promote a welcoming environment, encouraging the exercise of critical reflection and development of participants’ awareness and autonomy in the collective construction of knowledge10. Using the most varied techniques should be considered in order to meet the objectives to be achieved, including the possibility of dynamics or relaxation techniques, dramatization and games, with low-cost materials that make applicability more accessible and feasible, as they are capable of provoking the group to think about daily practices30.
The understanding on advancing the use of reflective practices in daily work or that integrate teaching-service in PEH initiatives converges with previous discussions31. It stands out that it is essential to safeguard the maintenance of spaces for promoting PEH activities, prior planning, use of active methodologies and team integration as well as guaranteeing protected time and valuing workers and PEH’ logic by managers32.
Outcomes obtained with Culture Circles


The applied teaching methodology enabled the identification of extreme situations arising from the health work process, considering each life cycle’s specificities. It also provided reflection on the concept of health promotion, emerging the understanding of the need to transform practice, with the integration of activities by team members, in order to share the work demands in Basic Health Units and consider users as active subjects in the health and disease process, to provide better health care compliance19,21.
PEH actions mediated by Culture Circles raised the exercise of sociopolitical awareness, essential to empowering health professionals in health education practices, with the development of educational proposals aimed at the demands of population groups in their territories and delimitation of necessary requirements for implementing effective health education actions in the primary care setting17. Understanding the social determinants of health in the context of primary care involved applying Freire’s methodology in the educational process of teams and of teams in relation to users18, given the recognition of community strengthening for health promotion and coping with vulnerabilities and health inequalities20.
It can be reflected from the findings that, by applying the Culture Circle methodology, PEH objectives were achieved in all assessed studies17-21, because, by encouraging leading role and revisiting and discussing the context of professional practice, it enabled achieving participants’ empowerment for decision-making and behavioral changes10,24-25.
The proposition of effective contributions to transforming participants’ professional practice was emphatically revealed in all articles analyzed 17-21, primarily in the last stage of Culture Circle applicability as an PEH device, in which, from the coded and decoded generating themes, critical unveiling is proposed to support the action-reflection-action to change the experienced reality17-21.
As a synthesis resulting from Culture Circle application, it was verified an awareness and provocation of concerns in participants, breaking accommodation attitude regarding issues relevant to daily work in Primary Health Care. It also converged to a critical-reflective deepening, strengthening political awareness and a citizen attitude towards the population, with social responsibility and shared ethics, composing relationships of empathy, with respect for the “other”, with their values and knowledge17,19,20.
It is observed that the engagement of PEH professionals, mediated by Culture Circles, raised the members’ self-esteem and motivation by recognizing the potential for its application with SUS users in individual and collective care10, 26.
From the recognition of health professionals as health educators, their interest in being instrumentalized in Culture Circle development emerges, in a theoretical-practical articulation capable of providing the theoretical foundations as well as the experience in a Culture Circle, as a teaching approach in the PEH process.
From the perspective of educational actions with population groups, Freire’s Culture Circles showed a potential to strengthen knowledge exchange and construction mediated by scientific knowledge and experience sharing. In a study with adolescents on COVID-19 prevention, it was pointed out that the methodology helped to demystify taboos, alleviate doubts and generate possibilities for health and care promotion, in order to move from naive to critical awareness about prevention and care regarding this emerging communicable disease33.
As one of the changes in health professionals’ attitude towards the adoption of new attitudes by users and families, it is proposed to plan actions that can be articulated in an integrated way with other sectors of society and with the community environment, carrying out an extra-wall professional transformation, i.e., beyond the health unit where the Culture Circle training process as a PEH device was carried out18.
With a view to articulating the topics addressed and evolving towards the health peculiarities evidenced by contact with the people in their place of production of life, popular knowledge, cultural traits, lifestyles, eating habits, ways of approaching individuals and family, among many aspects of the work process, Culture Circles allow professionals to learn about the population’s real health needs, in order to reorient the strategic planning of health actions in the territory24,26.
With regard to the work process, a positive proposal arising as a result of Culture Circles applied in one of the analyzed articles was the geographic digitization of one of the products elaborated by participants during the thematic investigation phase, known as a talking map, which integrated local technical and traditional knowledge, thus contributing to better processes of management of health actions in the territory20.
Given the above, there was the reach of PEH ideas, as a tool for problematizing health practice and creating new care strategies29, when showing among the findings that applying Culture Circles provided deepening and re-significations on the themes, which involve the work processes in primary care17-21.

FINAL CONSIDERATIONS
The educational experience in professionals’ PEH mediated by Culture Circles favored a dialogical arena that promoted the articulation of practical and scientific knowledge, grounded in a position of leading role and mobilized by the restlessness of a critical and reflective conscience committed to the possibilities of transforming professional practice.
Culture Circles presents itself as a creative and innovative pedagogical alternative for PEH training actions, breaking with the banking and hegemonic model, through the consolidation of a proposal for an active learning methodology, which make it possible to build new knowledge committed to transforming reality, with an impact on different scenarios and social realities. By awakening health professionals’ critical awareness, it contributes to ensuring a transformative practice as well as strengthening health promotion actions.
Active participation in Culture Circles contributed to health professionals’ critical reflection on their work context and on the possibilities of intervening with health education actions with users and the community, in order to encourage changes in attitudes and the adoption of new attitudes, with more responsibility and autonomy, in the face of the exercise of health care.
It is noteworthy that Culture Circles as a PEH device were developed only in the Brazilian scenario, and were shared in qualitative research, assessed with less scientific evidence. Thus, research is encouraged with Culture Circle application with international articulations and with higher levels of evidence, in order to better understand the impacts of PEH as an educational, dialogical and participatory approach, proposing transformations in professional practices.
The seized evidence culminates in recommendations to apply Culture Circles, in order to ensure the effectiveness in the development of the proposed cyclical stages, namely: that the number of participants does not exceed a quantitative of 25, provided that the animator has expertise in using Culture Circles, in case of initiation or little experience, this number should be closer to 13 participants; and that this actor establishes prior contact with participants as well as being present in all Culture Circles, promoting bond construction.
Furthermore, it can be pointed out that, when considering the objectives proposed for Culture Circles, this may involve participants from a certain professional category, by providing a horizontal relationship and greater security to express their knowledge and concerns, without worrying about hierarchical issues. It also emerges that an interdisciplinary composition of Culture Circle participants instigates the deepening of ties, in order to contribute to improving interpersonal relationships.
Regarding the frequency in carrying out Culture Circles, it is worth considering a systematic application providing continuity in knowledge exchange, based on the development of the proposed stages, to achieve the action-reflection-action process, promoting awareness and autonomy for discernment in decision-making in relation to work processes.
The studies highlighted that applying Culture Circles encourage participation and explore the different forms of expression and production of knowledge, through the use of playful techniques and dynamics, with low-cost materials, which contribute to participants’ awareness and safety to express the intersubjective issues peculiar to the daily work environment.

REFERENCES
1 Ogata MN, Silva JAM, Peduzzi M, Costa MV, Fortuna CM, Feliciano AB. Interfaces between permanent education and interprofessional education in health. Rev Esc Enferm USP 2021;55:e03733.
2 Brasil. Ministério da Saúde. Portaria GM/MS nº 1.996 de 20 de agosto de 2007. Dispõe sobre as diretrizes para a implementação da Política Nacional de Educação Permanente em Saúde e dá outras providências. Brasília (DF); 2007 [cited 2021 sep 25]. Available from: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2007/prt1996_20_08_2007.html.
3 Santos AR, Santos RMM, Franco TB, Matumoto S, Vilela ABA. Permanent education in the family health strategy: potentialities and resignifications. J Nurs UFPE on line 2021;15:e245355.
4 Peduzzi M, Agreli HLF, Silva JAM, Souza HS. Teamwork: revisiting the concept and its developments in inter-professional work. TrabEduc Saúde 2020;18:e0024678.
5 Bispo JP Jr, Moreira DC. Educação permanente e apoio matricial: formação, vivências e práticas dos profissionais dos Núcleos de Apoio à Saúde da Família e das equipes apoiadas. Cad Saúde Pública 2017; 33(9):e00108116.
6 Freire P. Educação como prática de liberdade. 47ª ed. São Paulo: Paz e Terra, 2020.
7 Zucchetti, DT, Severo, JRL. As dimensões tempo e espaço em práticas de educação integral: implicações curriculares a partir do diálogo entre Paulo Freire e Darcy Ribeiro. RevIbe Est Ed2020; 15(2):560-577.
8 Heidemann ITSB, Dalmolin IS, Rumor PCF, Cypriano CC, Costa MFBNAD, Durand MK. Reflections on Paulo Freire’s research itinerary: contributions to health. TextoContextoEnferm2017; 26(4):e0680017.
9 Freire P. Pedagogia do Oprimido. 74ª ed. Rio de Janeiro, São Paulo: Paz e Terra, 2020.
10 Souza JB, Heidmann ITSB, Massaroli A, Geremia DS. Health promotion in coping with COVID-19: a virtual culture circle experience. RevBrasEnferm 2021;74:e20200602.
11 Dalmolin IS, Heidemann ITSB. Integrative and complementary practices in Primary Care: unveiling health promotion. Rev Latino-Am Enfermagem 2020;28:e3277.
12 Souza AA, Heidemann ITSB, Souza JM. Limit-situations in child health care practices: challenges to the empowerment of nurses. RevEscEnferm USP2020;54:e03652.
13 Whittemore R, Knafl K. The integrative review: updated methodology. J AdvNurs 2005;52:546-53.
14 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71.
15 Butler, H, Hall, B, Copnell A. Guide to Writing a Qualitative Systematic Review Protocol to Enhance Evidence-Based Practice in Nursing and Health Care Ashleigh. Worldviews Evid Based Nurs2016; 13(3):241–249.
16 Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing & healthcare. A guide to best practice. China: Wolters Kluwer/Lippincott Williams & Wilkins; 2011.
17 Monteiro EMLM, Vieira NFC.Educação em saúde a partir de círculos de cultura. RevBrasEnferm2010; 63(3):397-403.
18 Fernandes MCP, Backes VMS. Educação em saúde: perspectivas de uma equipe da Estratégia Saúde da Família sob a óptica de Paulo Freire. RevBrasEnferm 2010; 63(4):567-73.
19 Souza AA, Heidemann ITSB, Souza JM. Limit-situations in child health care practices: challenges to the empowerment of nurses. RevEscEnferm USP 2020;54:e03652.
20 Santos FNP, Toledo RF. Culture circles on social and environmental determinants: action research with community health agents of Paraisópolis, SP. Rev Gaúcha Enferm 2020;41:e20190353.
21 Labegalini CMG, Nogueira IS, Hammerschmidt KSA, Jaques AE, Carreira L, Baldissera VDA. Educational and care-related dialogical pathway on active aging with family health strategy professionals. TextoContextoEnferm 2020; 29:e20180235.
22 Silva DLO, Gomes BJJ, Rios PPS. A relação dos Círculos de Cultura de educação popular com a educação do campo. Rev NUPE 2022; 2(2):e202205v2.
23 Campos KFC, Marques RC, Silva KL. Continuing education: speeches by professionals of one Basic Health Unit. Esc. Anna Nery 2018;22(4):e20180172.
24 Netto JJM, Protásio LMBVS, Goyanna NF, Rodrigues ARM, Cavalcante AES, Mendes JDR, et al. Círculo de cultura junto a agentes comunitários de saúde: uma vivência no programa mais médicos. Saúde Redes 2016; 2(3):301-307.
25 Vendruscolo C, Souza JB, ZoccheDA, Geremia DS, Heidmann IT, Korb A, et al. Círculo de Cultura: “Lugar de Fala” das enfermeiras no enfrentamento à COVID-19. Enferm Foco 2021;12(Supl.1):93-8.
26 Menezes FWP, Silva MRFS, Torres RAM, Miranda TP. Popular education and continuingeducation in health: dialogues in the formation of Community Health Agents of a municipality in the interior of Ceará. SaúdeRedes 2018; 4(1):173-182.
27 Pinto AH, Lange C, Santos F, Heidmann ITSB, Lemões MAM, Zillmer JGV. Perspective of Family Health Strategy workers in health promotion for the rural elderly. Rev Enferm UFSM 2022 ;12:e40.
28 Barros MBSC, Silva RGM, Silva ACC, Rocha LP, Menezes MLN, Bushatsky M, et al. Círculo de Cultura virtual como arena promotora do empoderamento juvenil em saúde. Estudos Universitários: revista de cultura.UFPE/Proexc 2021; 38(1):347-374.
29 Oliveira IV, Silva EAP, Pereira PBA, Bonfim D, Zilbovicius C, de Oliveira RN. Educação permanente em saúde sob a ótica de gestores e trabalhadores da atenção primária à saúde. Intern J Educ H. 2022;6:e4412.
30 Rézio LA, Ceccim RB, Silva AKL, Cebalho MTO, Borges FA. Dramatization as a device for Permanent Education in Mental Health: an intervention-research. Interface (Botucatu) 2022;26:e210579.
31 Ferreira L, Barbosa JSA, Esposti CDD, Cruz MM. Permanent Health Education in primary care: an integrative review of literature. Saúde debate 2019; 43(120):223-239.
32 Pinheiro GEW, Azambuja MS, Bonamigo AW. Facilities and difficulties experienced in Permanent Health Education, in the Family Health Strategy. Saúde debate 2018; 42(spe4):187-197.
33 Bubadué RM, Santos CCT, Silveira A, Jantsch LB, Kimura CA. Educational activities about COVID-19 prevention with adolescents:experience report. Rev Enferm UFSM 2022; 12:e27.