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Conteúdo (article):

Participation in Health in the Americas: Bibliometric mapping of production, impact, visibility and collaboration

Participação em Saúde nas Américas: mapeamento bibliométrico da produção, impacto, visibilidade e colaboração

Participación en Salud en las Américas: mapeo bibliométrico de producción, impacto, visibilidad y colaboración

Frederico Viana Machado - Doutor em Psicologia pela Universidade Federal de Minas Gerais. Professor do Programa de Pós-Graduação em Saúde Coletiva da Universidade Federal do Rio Grande do Sul. E-mail: frederico.viana@ufrgs.br .
ORCID: https://orcid.org/0000-0002-8884-1124

Carla Michele Rech - Doutora em Sociologia pela Universidade Federal do Rio Grande do Sul, em estágio pós-doutoral no Programa de Pós-Graduação em Saúde Coletiva da Universidade Federal do Rio Grande do Sul. E-mail: carlatsul@yahoo.com.br.
ORCID: https://orcid.org/0000-0001-6749-885X

Rodrigo Silveira Pinto - Doutor em Ciências Farmacêuticas pela Universidade Federal do Rio Grande do Sul. E-mail: rodrigospinto@gmail.com. ORCID: https://orcid.org/0000-0003-1053-9926

Wagner de Melo Romão - Doutor em Sociologia pela Universidade de São Paulo. Professor do Departamento e do Programa de Pós-Graduação em Ciência Política da Universidade Estadual de Campinas - Unicamp. E-mail: wromao@unicamp.br. ORCID: https://orcid.org/0000-0003-3725-2861

Manuelle Maria Marques Matias - Doutora em Saúde Coletiva pela Universidade do Estado do Rio de Janeiro. Professora do Departamento de Planejamento em Saúde do Instituto de Saúde Coletiva da Universidade Federal Fluminense. E-mail: manumatias29@gmail.com. ORCID: https://orcid.org/0000-0001-6474-8139

Gabriele Carvalho de Freitas - Doutora em Saúde Coletiva pela Universidade do Estado do Rio de Janeiro. E-mail: gabi.cfreitas28@gmail.com. ORCID: https://orcid.org/0000-0002-2610-3003

Henrique Kujawa - Doutor em Ciências Sociais pela Universidade do Rio dos Sinos. Professor Visitante da Università degli Studi di Perugia, Educador Popular do CEAP. E-mail henriquekujawa@gmail.com. ORCID: https://orcid.org/0000-0001-9990-9414

Fernando Antônio Gomes Leles - Mestre em Saúde Coletiva pela Universidade de Brasília. Oficial Especialista em Sistemas de Saúde da Organização Pan-Americana da Saúde, Organização Mundial da Saúde. Setor de Embaixadas Norte lote 19, Asa Norte. 70800-400 Brasília DF Brasil. fernando.leles81@gmail.com. ORCID: https://orcid.org/0000-0002-3891-0443



ABSTRACT: Participation in health has generated a large number of publications around the world. In order to know the specificities of this production in the Americas, a bibliometric analysis of articles in English, Spanish and Portuguese was carried out. Searches were carried out in BVS, PubMed, SCOPUS, WoS and SciELO, consolidating a database with 641 references. With the help of the VOSviewer software, we analyzed citation patterns, co-authorship and the chronological distribution by countries and languages. It was possible to verify growth of the production, the quantitative relevance and the impact of the different countries. The analysis indicated that the USA concentrates the largest number of citations and that Brazil, despite being first in number of publications, is third in number of citations. The same occurs with the Brazilian journals, which, with the largest number of articles, fall behind in the ranking of the most cited. The co-authorship analysis indicated that the University of Toronto, Fiocruz and Harvard University have the most formal collaborations with other organizations. We conclude that there are inequalities regarding impact, visibility and internationalization in this field, indicating obstacles to scientific development and health policies.
KEYWORDS: Public Health; Community Engagement; Social Participation; Bibliometrics

RESUMO: A participação em saúde têm gerado um grande número de publicações em todo o mundo. Para conhecer as especificidades dessa produção nas Américas, foi realizada uma análise bibliométrica de artigos em inglês, espanhol e português. Foram realizadas buscas na BVS, PubMed, SCOPUS, WoS e SciELO, consolidando uma base de dados com 641 referências. Com auxílio do software VOSviewer analisamos padrões de citação, coautoria e a distribuição cronológica por países e idiomas. Foi possível verificar o crescimento da produção, a relevância quantitativa e o impacto dos diferentes países. A análise indicou que os EUA concentram o maior número de citações e o Brasil, apesar de ser o primeiro em número de publicações, é o terceiro em número de citações. O mesmo ocorre com os periódicos brasileiros que, com o maior número de artigos, caem no ranking dos mais citados. Nos dez artigos mais citados descatam-se trabalhos desenvolvidos nos EUA e Canadá. A análise de coautoria indicou que a Universidade de Toronto, a Fiocruz e a Universidade de Harvard são as que mais possuem colaborações formais com outras organizações. Concluímos que existem desigualdades de impacto, visibilidade e internacionalização neste campo, indicando obstáculos para o desenvolvimento científico e das políticas de saúde.
PALAVRAS-CHAVE: Saúde Pública; Engajamento Comunitário; Participação Social; Bibliometria

RESUMEN: La participación en salud ha generado una gran cantidad de publicaciones alrededor del mundo. Para conocer las especificidades de esta producción en las Américas, se realizó un análisis bibliométrico de artículos en inglés, español y portugués. Se realizaron búsquedas en la BVS, Pubmed, SCOPUS, WOS y SciELO, consolidando una base de datos con 641 referencias. Con la ayuda del software VOSviewer, analizamos los patrones de citación, la coautoría y la distribución cronológica por países e idiomas. Se pudo verificar el crecimiento de la producción, la relevancia cuantitativa y el impacto de los diferentes países. El análisis indicó que EE.UU. concentra el mayor número de citas y Brasil, a pesar de ser el primero en número de publicaciones, es el tercero en número de citas. En los diez artículos más citados se descartan trabajos desarrollados en EE.UU. y Canadá. El análisis de coautoría indicó que la Universidad de Toronto, Fiocruz y la Universidad de Harvard tienen las colaboraciones más formales con otras organizaciones. Concluimos que existen desigualdades de impacto, visibilidad e internacionalización en este campo, indicando obstáculos para el desarrollo científico y las políticas de salud.
PALABRAS CLAVE: Salud Pública; Participación de la comunidad; Participación social; bibliometría;

Introduction
Several organization have already pointed to participation of the community as essential to improve Health Care Systems (HCSs)1;2. These practices gained prominence after the Second World War, especially after the Alma Ata Conference held in 1978, although participatory experiences can be identified since the 1920s3. In the 1960s, there were already experiences of community participation in health in several countries, for example, all the federated units of the United States of America (USA) already had laws that provided for participation4. The reform of the Canadian health system4 at the beginning of the 1970s, and of the Brazilian one at the end of the 1980s, included participation as a structural element foreseen in the legislation5;6. After Alma-Ata, each country implemented Primary Health Care (PHC) models with different levels of community participation in the systems, but following a growing importance and interest in management of the health services7. In the Declaration of Astana8, which reasserts and updates the Alma Ata principles to the current reality, participation is one of the signed commitments9. The principles to foster participation in this context are in a specific document10.
Participation of the community is a recurrent topic in research studies and governmental ventures, producing a significant number of publications at the global level. Dozens of papers sought to review the academic production on participation in health, with different approaches and objectives, providing relevant syntheses to understand the topic11. This evidences the diversity of approaches and experiences that meet each country\'s context.
In a bibliometric review, Yuan et al.12 mapped the academic production on community engagement in public health, discussing the evolution and trends in the world literature. However, the authors only considered publications in English, which imposes limits for us to analyze the academic production of the American continent, with a strong presence of Spanish and Portuguese. In addition to that, they ignore the specificities of each continent and, by limiting their survey to the Web of Science index, they privilege studies in the biomedical areas to the detriment of the social sciences13. The HCSs of the American continent respond to the respective social, political and economic contexts that present different directions regarding Community Participation in Health. Consequently, there is diversity of study designs aimed at analyzing the social and health sciences. We can find literature reviews that discuss the understanding of participation as a tool to achieve the results of the health programs14;15 and, in another perspective, they present the vision of participation from the point of view of strengthening democracy and as a right, approaches characteristic of the social sciences16;17.
Seeking to know the specificities of this research field in the Americas and to respond to the gaps in the literature highlighted above, we carried out a study of the academic production on social participation and control in health, through bibliometric and scientometric analyses of articles in English, Spanish and Portuguese written by researchers who have studied the phenomenon in this continent. In this paper we will focus on citation and co-authorship analysis, with the objective of knowing the most relevant authors, journals and institutions, as well as the impact and patterns of collaboration, interaction and hierarchization.
The academic field established around the topic involves journals, institutions and researchers located at the interface between the health sciences and the social sciences, producing complex interaction patterns. These difficulties are especially related to the impact and visibility differences and inequalities that separate research areas, countries, journals, institutions and languages. Consequently, our intention is to spatially and geographically situate the actors, providing an understanding of the research efforts on participation in health in the Americas that can be a reference for future research studies.

Method
As part of the project entitled “Training for Social Control” of the National Health Council, financed by the Pan American Health Organization and carried out by the Center for Popular Education and Counseling, a bibliometric and scientometric analysis study was carried out, comprising scientific articles in English, Spanish and Portuguese that deal with social participation and control in the American continent published until August 12th, 2021. Metric studies about scientific publications allow understanding the content analyzed and its structure, identifying schools of thought and their evolution18. This analysis contributes to understanding the researchers\' production and interaction in a given scientific field, as it considers the institutions to which they are linked, the journals that publish their papers and their countries of origin.
Bibliometrics and Scientometrics assess and measure the characteristics and development of topics and fields of knowledge, through statistical and mathematical methods that identify patterns, structures and relationships presented in a given sample of the literature. In addition to that, they identify the most active researchers and institutions, thus facilitating articulation of collaborative networks. In view of the growing volume of information currently recorded, this method is especially useful because it allows quantifying and organizing large samples of publications18;19. By means of metadata, Bibliometrics quantifies information production, dissemination and use. Scientometric analysis relates these quantitative aspects to social contexts to discuss scientific development in a given knowledge field. Using Bibliometrics to support strategic decisions on policies in Science and Technology is common in several countries, in which it has become an institutionalized practice20;21. We chose to employ the VOSviewer software, which is used to process and visualize bibliometric information and build maps with proximity networks, and which has a large data volume19;21.
The bibliographic searches were conducted in the Portal of Biblioteca Virtual em Saúde (BVS), as well as in Medical Literature Analysis and Retrieval System Online (MEDLINE) via PubMed, SCOPUS, Web of Science (WoS) and Scientific Electronic Library Online (SciELO). Choice of the databases to carry out the searches was both due to relevance and to the possibility of extracting the necessary data to perform the analyses available in VOSviewer. We chose BVS and PubMed because they gather relevant publications in the Natural and Biomedical Sciences, as well as Scopus and WoS, the latter being currently considered the most commonly used database for bibliometric analysis, given its accessibility to bibliographic and citation data from 12,000 most influential journals worldwide22. However, these databases present relatively low coverage regarding the scientific production in the Social and Human Sciences13. In view of this limitation, the SciELO database was included, also with an international scope, including countries in Latin America and the Caribbean, and which houses scientific journals in all knowledge areas, with emphasis on health and on the Social and Human Sciences13. However, it should be noted that a limitation presented by the SciELO, BVS and PubMed databases is that they only have data on authorship, year, title and abstract, not allowing to process all the analyses provided by VOSviewer. As an alternative to perform the analyses in a more comprehensive way, the final database was processed, manually inserting diverse information about the abstracts and keywords, when found, and about the author\'s country, where there was no data on the authors\' institution.
Given the diversity of expressions that define “Social Participation”23;7 and “Social Control”24, the first challenge was to elaborate a search strategy that would approach the literature on the topic in the Natural and Biomedical Sciences and in the Social and Human Sciences. The following search strategy was used in all three languages (Portuguese, English and Spanish): “Controle Social” OR “Participação Social" OR "Participação da Comunidade" OR "Participação Cidadã" OR "Participação Comunitária" OR "Participação Pública" OR "Participação Política" OR "Gestão Participativa" OR "Democracia Participativa" OR "Democracia Deliberativa" OR "Controle Social Formal" AND "Conhecimentos, Atitudes e Prática em Saúde" OR "Saúde" OR "Política de Saúde" OR "Políticas Públicas de Saúde" OR "Políticas Públicas em Saúde" OR "Políticas Sanitárias" OR "Política de Assistência à Saúde" OR "Conselhos de Saúde" OR "Conferências de Saúde", with no date limit.
After excluding duplicates, the screening, eligibility and final selection stages were conducted resorting to spreadsheets, by pairs of independent researchers, using the following eligibility criteria: publications in scientific journals in the form of articles, published by researchers linked to research institutions in American countries or that deal with experiences directly related to social participation and control in health developed in this continent.
Of the 9,487 references found in the searches, 5,640 duplicates were excluded, with 3,847 references remaining for the initial screening. Screening was performed by reading the titles and abstracts. The articles included were those published in English, Spanish or Portuguese, in any year up to the collection date on August 12th, 2021, resulting in a final sample comprised by 641 references. The next step was to assemble and fill in the database containing only the references selected for running in VOSviewer.
Two bibliometric analysis methods were applied: citation and co-authorship. Citation analysis is an important indicator in bibliometric studies, through which it is possible to estimate the influence of certain documents, sources, authors, organizations and countries and measure their relevance, based on the number of citations in a given analysis corpus. Co-authorship analysis is considered a formal measure of collaboration, whose relationship between authors or their institutions is established when they publish a scientific document together. These analyses allow identifying the internationalization of the study agenda, the most influential scientific references and the research sources18;19.
When the software is launched to perform some analysis, the first file generated is a Table which presents the data that will be shown visually. This Table presents the data arrangement by analysis unit (Countries, Institutions, Authors, Documents and Sources where the documents were published), together with the quantitative data (number of publications and citations) and the “linking strength” of that analysis unit. “Linking strength” is understood as the number of associations made by that analysis unit with the others. The connections are made by the number of links or mutual citations, which are represented by edges, where their width reflects the relationship strength between two items. The lower the distance between the items plotted in the bidimensional space, the higher the relationship between them. According to the intensity of these links, clusters are formed, that is, groups of items with common aspects that are represented by the same color.

Results
Chronological trend, language and origin of the authors
The oldest article selected on the topic dates back from 1956 and the publications show an increasing trend, similar to the one verified at the global level12. Community engagement in public health has attracted the interest of researchers around the world, with virtually continuous exponential growth over the last two decades12. This trend is repeated when limiting ourselves to the American countries. Graph 1 shows the chronological distribution of the publications selected in the sample, grouped as follows: strictly Brazilian production, production strictly made in the USA, production by other authors from the Americas, production by authors from other regions (Europe, United Kingdom, Australia, etc.) and co-authored production, which gathers all the articles published in co-authorship by researchers from different countries.

Insert Graph 1. Time distribution of the publication of articles on Social Participation and Control in Health in the Americas

According to the number of publications, the research on social participation and control in health can be divided into three consecutive stages. The initial period, from 1956 to 2002, was relatively stable, with a slight increase and a low number of publications on the topic in the clipping made in this research. From 2005 onwards, there is a gradual increase in publications and, in the last period, from 2008 onwards, we see an increase in the number of publications, reaching a peak of 53 articles in 2020. It should be noted that this growth trend follows the general panorama of the increase in scientific publications during the same period, as can be seen in the Scimago Journal & Country Rank portal (https://www.scimagojr.com), which gathers data from Scopus-indexed journals and performance metrics from 239 countries.
The production strictly made in the USA stands out up to 1990, when production by other authors from the Americas begins to gain strength. In turn, the strictly Brazilian production begins to grow and stand out from 2002 onwards In Brazil, increasing public investments in scientific research in the period from 2005 to 2015 resulted in a significant increase in publications on different topics25, including the rise in production on social participation and control in health, at least in the best evaluated journals, characteristic of the clipping herein used. However, accounting for more than 1/3 of the sample, contrary to the general mean trend, we see that the Brazilian publications had an abrupt increase in 2009, but remained relatively stable until the current period, with a peak in 2012. Considering the exponential growth in the number of Brazilian publications during the period25, proportionally, the topic had its frequency reduced during the last decade in this country.
When analyzing the distribution by language, among the 641 articles included in the databases, there are 350 (54%) in English, 178 (27.77%) in Portuguese, 85 (13.26%) in Spanish, 21 (3.28%) in English and Portuguese, 6 (0.93%) in English and Spanish, and 1 (0.23%) in all three languages.
The articles analyzed include contributions by authors from all five continents of the planet. Considering the profile of the productions according to the authors\' countries, we find the following result: Brazil, in first place, with 257 authors and 582 citations; USA second, with 226 authorships and 2,057 citations; Canada third, with 66 authors and 713 citations; Colombia ranked fourth, with 28 authorships and 178 citations; and, in fifth place, Mexico, with 26 authorships and 43 citations. In the seventh and tenth place, respectively, Chile (21 authorships and 123 citations) and Cuba (10 authorships and 132 citations) offer significant contributions on the topic. The presence of English (6th position, 22 authorships and 404 citations), Spanish (8th position, 14 authorships and 29 citations) and Portuguese (9th position, 11 authorships and 16 citations) authors studying the topic in America also stands out. These results are similar to those found by Ming Yuan et al.12, which argue that USA is the key region for research studies on community engagement in public health, and that developing countries such as Brazil have also contributed to a great extent to this field, whose advances are marked by historically important public health events and evolved from macro-regional strategies for meso-regional and micro-regional actions12.

Analysis of the citations: Relevance of the journals and publications
A total of 299 different journals were included in the sample. Table 1 shows a comparison between the number of publications and citations among the main journals. After each title, we included the number of documents published, followed by the number of citations and the mean of citations per article.

Insert Table 1: Articles and citations by journal about Social Participation and Control in Health in the Americas

Inequality in terms of impact and visibility is observed across the journals when comparing the number of articles published and the mean of citations. When comparing the number of articles published and the most cited ones, using the case of the Brazilian journals, it can be seen that they occupy the first four places in the ranking of journals with the highest number of published documents, although they do not maintain this performance in the ranking of the most cited journals. Revista Brasileira de Enfermagem, fourth in terms of number of publications, disappeared from the ranking of the 20 most cited journals. In the other end, we see The Lancet journal, with only three articles selected totaling 343 citations. This inequality also affects the journals from the other Latin American countries, which do not even appear among the first 20 with most citations. If we take the Scimago Journal & Country Rank, we see that the Latin American journals do not appear among the first 2,000 at the global level.
Tracing the citation analysis by journals, presented in Figure 1, the connections between countries show a strong correlation with the language, as we can see by the proximity and connections between the Brazilian journals and those with titles in Spanish (most present in the blue cluster). In addition to that, in the red cluster it is possible to verify that the Brazilian journals are more interconnected and salient, which indicates the existence of a field with its own and consolidated characteristics on the topic in Brazil. This argument is grounded on the regulation of the graph by the strength of the citation connections, which reduces visibility of the journals that have many citations, such as The Lancet and Social Science & Medicine, for example, but that have weaker connections, as they tend to cite more articles that are not included in the sample. The connection strength between the Brazilian authors indicated in Figure 2 also adds force to this point, as we shall see in the next topic.

Insert Figure 1. Citations among the journals that publish content about Social Participation and Control in Health in the Americas

The ten most cited articles26–35 can be categorized into three types: studies on social participation/community engagement and health (126, 328, 530 and 732); propositional studies of public management models (227, 631 and 833) or on teaching/research in health, focusing on social participation (429 and 1035) and studies that relate political contexts, cultural and structural factors to social participation (934).
Of the first type, we have the most cited article26, the result of research on the strategies to improve maternal and child health, whose conclusions show that, although community mobilization is not a feature of most large-scale primary health care programs, there is diverse evidence that this is an effective method for promoting participation and empowering the communities, in addition to other benefits; the third most cited article28, the result of a public health surveillance survey carried out in Kansas/USA, which concluded that individuals from rural areas presented the highest community involvement but relatively low levels of community ratings, and in densely settled rural areas, they may face increased risks of poor health; the fifth most cited article30 presents case studies from four Latin American countries, whose results show that investment in managerial and political capacity, strong political and managerial commitment and state programs, not only limited governmental actions, have been crucial to sustain success of these policies; and the seventh most cited article32, reporting the results of the research studies on interactions between social determinants, helminthic diseases and health promotion interventions with regard to community participation, intersectoral collaboration, gender and possibilities for scaling up helminthic disease control and eradication programs in the context of integrated and interdisciplinary approaches. The authors of the seventh most cited article conclude that, despite the belief that active community participation and based on control programs can lead to empowerment of the individuals in endemic communities, many of these communities lack institutional systems and structures to encourage people to participate in control strategies and, where they are present, they may not function properly.
Of the second type, we have the second most cited article27, in which the authors offer a framework to promote public involvement in the evaluation of health technologies and policies, both for health policymakers in Canada and abroad, concerned with making health more public; the sixth most cited article31 sought to understand how participation in an online health community provides direct benefits in the use of information and social support and the indirect influence on the user empowerment perceptions, recommending this approach. The eighth most cited article33 highlights the contribution of community engagement to policymaking for mass disasters and health emergencies and recommends how the USA leaders at all levels can improve their ability to rule in a crisis and mitigate losses in the entire community by adopting this approach. The fourth most cited article29 seeks to assist USA academic health centers in learning how to improve engagement with their communities and build an engaged research agenda. In the tenth most cited article35 the authors develop a theoretical framework for understanding public participation in the context of regionalized health governance, based on Canadian experiences.
Of the third type, we have the ninth most cited article34 , which addresses how the cultural and structural influences are discussed in relation to community participation, concluding that situations of financial and economic crisis, economic restructuring and competition and individualization values affect generation and sustainability of participation, being cited and influencing studies that deal with this theme.
The publications from the USA and Canada stand out, with these countries\' contexts as empirical environment. Results from research studies developed in other contexts, such as Brazil, end up not standing out at the top of the sample due to the lack of citations, despite the large number of productions on the topic. It was verified that most of them were published in journals with the highest number of citations (Table 1), with emphasis on the first22 and fifth26, published in The Lancet journal, which occupies the first place26; on the third28 and ninth34, published in the Social Science & Medicine journal, which ranks second, and for the second23 and tenth31, both published in the Health Policy journal, which ranked third28.
Analysis of the citations: Relevance of the institutions and authors
The institutional affiliation of the authors of the manuscripts was analyzed seeking to map the most productive institutions, their citation rates and their connections. The ten institutions with the highest production about the topic were as follows, signaling the number of articles and citations of each in between parenthesis: Oswaldo Cruz Foundation (29 articles - 249 citations), University of California (23 - 414), University of São Paulo (17 - 53), University of Toronto (14 - 121), University of Brasília (10 - 117), Federal University of Bahia (10 - 64), Harvard University (9 - 284), University of North Carolina (9 - 179), McMaster University (8 - 175) and Duke University (7 - 149). The institutions from the USA and Brazil stand out in this list. However, the proportion between published articles and citations confirms the greater impact of the production by USA and Canadian institutions, when compared to Latin American ones. Another interesting data is the fact that they are mostly public institutions, as only the Harvard and Duke universities are private.
As shown in Figure 2, the analysis of citations by authors generated 11 different clusters that demarcate relationships between them, highlighting the thematic proximity, but also the countries and languages of origin. Strong connections are noticed between the Brazilian authors and between the other Latin American authors. The most cited authors from the sample coincide with those than sign the most cited articles, treated in the previous topic, although it is worth noting the most connected authors. We will see that, although the most cited authors are mostly from the USA and Canada, the Brazilian ones stand out when we analyze the most connected authors.

Insert Figure 2. Analysis of citations among authors that publish content about Social Participation and Control in Health in the Americas

The first in the most connected list, José Patrício Bispo Júnior, from the Federal University of Bahia, with four articles, studies the health councils in Brazil and the effectiveness of participation; Pedro da Costa, Fernando de Paiva and Cornelis Van Stralen, linked to the Federal University of Minas Gerais, occupy the next positions, respectively, due to a systematic review on participation in health in Brazil. Then we have Poliana Cardoso Martins, Rosângela Minardi Miter Cotta, Fábio Farias Mendes, Sylvia do Carmo Castro Franceschini, Silvia Eloiza Priore, Glauce Dias, Rodrigo Siqueira-Batista, linked to the Federal University of Viçosa, also studying the experience of health councils.
Next we have Eugenia Delgado-Gallego and Maria Luisa Vazquez, with two articles in the sample and from Universidad del Valle, who study social participation mechanisms in Colombia. Mauro Serapioni, with three articles, linked to the University of Coimbra, but with ties to Brazilian researchers, studies from general topics on participation in health to specific issues about Local Health Councils in Brazil. Jennifer Cook, from the University of North Carolina, with three articles selected, studies community collaboration to improve quality of the services and reduce disparities in health. Helena Eri Shimizu, from the University of Brasília, with two articles selected, studies the advances and obstacles of institutionalized social participation and the mechanisms of social participation in health in Brazil. The analysis of the most connected authors reinforces the perception of a consolidated field with its own characteristics about the topic in Brazil.

Formal collaborations: Co-authorship between authors, organizations and countries
Co-authorship analysis is considered a measure of formal collaboration36, whose relationship between authors or their institutions is established when they publish a scientific document together. This analysis shows the formal collaborations, and the connection is established through co-authorship of the articles selected, with the possibility of grouping them into organizations and countries. It is also possible to verify the type of co-authorship relationship based on the linking strength between the authors or their institutions. The advantage of this analysis is that it allows us to identify the academic collaborations and the social structure of the field, from the observation of the partnerships established between authors, between organizations or between the countries to which the authors are linked.
Considering the linking strength between the authors, the co-authorship analysis found 250 clusters with 3,379 connections between them in the set of authors that comprise the database. This shows the diversity of existing links in this field, largely due to thematic fragmentation and to the different uses and meanings that social participation acquires for these different research fronts. From this universe of authors who work together, it is possible to verify that some of them are more connected, with the following standing out in terms of formal collaboration, according to their connection strength: in 1st place, Mélanie Levasseur; 2nd, Sergio Aguilar-Gaxiola; followed by Yves Couturier, 3rd; in 4th place, Doriane Miller; and 5th, Luiz Odorico Monteiro de Andrade. When analyzing the 40 most relevant authors on the topic, only 4 clusters were formed, in which other authors stand out, as can be seen in Figure 3.

Insert Figure 3. Co-authorship analysis among the 40 most relevant authors that publish content about Social Participation and Control in Health in the Americas.

In these four clusters, it is observed that there is predominance of researchers in the biomedical areas, with a large part of the research studies focused on the development of health intervention strategies through community engagement, especially of social and ethnic minorities, with the objective of reducing inequality and better understand the distribution of morbidities among population groups, especially those that are socially vulnerable. In blue, Cluster 1 gathers researchers whose focus is community-based participatory research and community empowerment in health. In turn, Cluster 2 in red groups researches devoted to research and development of interventions in health aimed at chronic patients. In green, Cluster 3 brings together researchers focused on health interventions aimed at ethnic and social minorities, and Cluster 4, in yellow, gathers researchers devoted to research studies focused on innovative health intervention strategies.
When analyzing the 736 organizations present in the database, 418 organizations were found that published at least one document as co-authors, forming 88 clusters with 994 connections between them. The University of Toronto, Fiocruz and Harvard University are the three organizations that most have formal collaborations with other organizations, according to linking strength, number of documents and citations. The universities of Columbia, California and Sherbrooke follow in the ranking. Among the most connected with other organizations, the University of North Carolina, the University of Montreal, the Johns Hopkins University and the University of São Paulo also stand out. It should be noted that the 288 most relevant organizations form 13 co-authorship clusters, with 916 connections between them, in which other universities in the Americas and also in Africa, Europe, Asia and Oceania appear together with the aforementioned institutions, although with a preponderance of Brazilian and American organizations. Most of the organizations that maintain formal collaborations establish them with others located in the same country.
Finally, we also identified formal collaboration between the countries. We verified that, of the total sample, the 42 most relevant countries made up 3 clusters with 141 connections between them. These results show that, unlike the ranking of organizations that most have formal collaborations with other organizations, where the University of Toronto and Fiocruz occupy the first places, in terms of formal collaboration between countries, the United States is first, followed by Canada and Brazil. It is important to note the variation in terms of co-authorship according to the country. In the Brazilian case, for example, the vast majority of articles are the result of formal collaborations between researchers from organizations in the same country, with greater internal than external articulation between the researchers. Meanwhile, in the case of the United States and Canada, there is both internal and external articulation and greater diversity of collaborations with other countries, showing more internationalization. Analyzing the results, it is possible to assert that, to a large extent, language exerts an influence on the collaborations, as in the case of the collaboration between Brazil and Portugal and the other Latin American countries.

Final Considerations
It was possible to verify not only the increase in the number of publications and of the relative frequency in the American countries but also the quantitative and impact-related relevance of the different countries. In addition to that, the co-authorship analysis indicated the groups of authors that establish formal collaborations among themselves and the internationalization degree of these cooperation works. However, even with the inclusion of indexers that sought to expand reach of the publications in the region and in the Social Sciences, North American countries had more visibility and impact in the sample surveyed. Consequently, new efforts to map and shed light in contexts that were out of the scope of this paper should be encouraged. We consider it relevant that future research studies can review books and the gray literature, including publications from governmental and non-governmental agencies and bodies, which contribute many productions that are equally relevant to understand this field of knowledge production, even if on the margins of the main journals.
When we look at the Americas as a whole in an expanded analysis, the inequalities in terms of visibility and impact of this scientific field give rise to discussions to overcome the obstacles to scientific and technological development and, consequently, of public policies and health care. To identify this inequality, we followed the recommendation proposed by Foratini37 to consider the three lingua francas: English, Portuguese and Spanish. Appreciation of the local and less internationalized languagesin the scientific field is related to the formation of a “critical mass” and to recognizing the cultural achievements of each territory. This research identified several experiences of mechanisms, strategies and theoretical discussions on social participation that bring about important contributions to the topic and which, due to these inequalities, have their potential reduced. Non-inclusion of the French language is one of the limitations of this study, as it may have resulted in the exclusion of articles with metadata only in this language.
As we present throughout the text, the sample selected shows a large discrepancy between the national productions, whether numerical, as in the case of the USA and Brazil, or by relevance in the strength of the connections and citations, such as the USA, Canada and foreign productions on the local contexts. For this reason, we consider important to perform new broad analyses with methodologies that allow delving into the specificities of the diversity of the countries of the Americas and drawing comparisons between them. Accumulation of these comparisons seems to us to be a necessary condition for advancing the debate on the continent, putting into dialogue the local traditions and knowledge with the global advances.

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