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Conteúdo (article):

Integrative mind-body practices: concept proposal for the field of Traditional and Complementary Medicine

Priscilla de Cesaro Antunes
Universidade Federal de Goiás
pri.antunes@ufg.br
https://orcid.org/0000-0003-2739-193X

Alex Branco Fraga
Universidade Federal do Rio Grande do Sul
brancofraga@gmail.com
https://orcid.org/0000-0002-6881-1446

Abstract: The Brazilian National Policy on Integrative and Complementary Practices (PNPIC) was published in 2006. Integrative mind-body practices are part of that policy and they are offered in Brazilian health care services. The concept of Integrative Mind-Body Practices is not consolidated in the literature and its use in government documents is imprecise. The article aimed at proposing a definition for that concept based on the experience of groups of Integrative Mind-Body Practices in Primary Health Care in Florianópolis, Brazil, as well as offering an alternative to the problems of registration and monitoring of the PNPIC. The methodology adopted was Grounded Theory (GT) in its interpretative and constructivist perspective, upon which a formal theory was developed. The data were produced through observations of the activities, conversations with professionals, and interviews with users of groups of Yoga, Lian Gong, Qi Gong, and Circular Dances. The data were coded, validated, and analyzed according to GT steps. The process of devising the concept resulted from the interconnection of the meanings ascribed by participants in contrast to the literature. This analysis enabled us to outline the phenomenon and propose a designation aligned with the PNPIC.
Keywords: Integrative Medicine; Complementary Therapies; Primary Health Care; Grounded Theory.

INTRODUCTION

The field of Traditional and complementary medicine (T&CM), known in Brazil as Integrative and Complementary Practices, involves a varied set of practices, knowledges, and products that differ from conventional medicine.1 In Brazil, a landmark in their institutionalization under the country’s Unified Health System (SUS) was the publication of the National Policy for Integrative and Complementary Practices (PNPIC), which currently includes 29 types of therapeutic practices. 2-4
Even though they became official, studies have pointed out that the scope of what can be defined as Integrative and Complementary Practices (PICs) in public policies is not clear.6-9 In the case of bodily practices, which were the most often provided by the SUS between 20042 and 2017,5 PICs tend to be seen as those with an Eastern background such as yoga, lian gong, tai chi chuan, tui-ná massages, do in, shiatsu, shantala, reiki, etc. Interestingly, hiking, gymnastics, sports, etc., are sometimes also referred to as PICs.
Official guidelines for PIC implementation in Brazil’s health services employ the term ‘bodily practices’ in different ways, and no concept was provided until 2018.10 A corresponding international document1 published by the World Health Organization (WHO) in 2013 includes some of these practices, but without defining them as a group.
The lack of a clear definition about what can be considered PICs under the SUS requires attention because it impacts the field of health knowledges and practices, since they mobilize different intentions, methodologies, and views. In addition, it impacts PIC registration and monitoring as well as funding and management. This also concerns the Ministry of Health’s (MH) attempts to improve registration systems11 and the publication of the PIC Thematic Glossary.12
Considering this scenario, and in order to meet the demands for nationwide definition, we developed a doctoral research project aimed at conceptualizing ‘Integrative Mind-Body Practices.’10 Literature review showed studies pointing to this need and attempting to propose concepts.13,14 However – differently from our doctoral thesis – devising a concept was not their central focus.
This research considers that a concept is always a passing designation in a given field and in each historical period. Therefore, we conducted a logical and epistemological operation defining the phenomena in question not as given things, but as interpreted things construed by systematically contrasting them with reality, within a historically situated theoretical framework.15
We followed the proposition according to which a concept includes three components: 1) the portion of reality to be conceptualized; 2) the set of statements that characterize it; and 3) the name chosen to designate it.16 Therefore, this article describes the development of a concept of ‘integrative mind-body practices,’ and it is organized in order to cover these three dimensions.

METHODOLOGY

The investigation adopted a qualitative approach based on Grounded Theory (GT) in its interpretive and constructivist version.17 The research process under GT does not start from a meta-theory as some a priori theoretical-analytical framework, since conceiving theories based on prospected data is its main contribution to qualitative research studies.
Throughout our research, we employed the principles of constant comparison, sampling, and theoretical sensitivity, as well as processes of microanalysis, coding, and validation of data provided for in that methodology.
The data were produced through observations recorded in a field diary, interviews with users, and conversation circles with facilitators of groups of integrative mind-body practices offered in Primary Health Care under SUS in the city of Florianópolis, Santa Catarina, Brazil – all recorded and transcribed.
The mapping carried out for the research found 20 groups (nine yoga groups, five for lian gong, four for circular dances, and two for qi gong). Most were facilitated by staff from health units or Family Health Support Centers (three Physical Education teachers, two nurses, a doctor, a physiotherapist, and an assistant nurse); five groups led by volunteers and two by Physical Education resident teachers. Middle aged, elderly white women prevailed among users.
After obtaining approval from the Research Ethics Committee of the Federal University of Rio Grande do Sul (report 2107200), we visited each of these groups once, observed the classes, and asked the facilitators if they were familiar with other integrative mind-body practices besides the ones they worked with. Since all 15 people answered yes, we asked them if those practices had anything in common and then analyzed the responses with NVivo software for frequency, resulting in a ‘word cloud’.

Figure 1

Afterwards, we invited all facilitators of the groups visited to participate in a conversation circle – similar to a focus group. Seven of the 15 facilitators attended and accepted to participate in the research; the others were excluded. They were told to form groups according to the practices they worked with. Two pairs were formed for circular dances and lian gong, and a trio for yoga. We asked the question: How would you explain this practice to someone who is not familiar with it? After discussing in the groups, each group presented its explanation to the others in the conversation circle. Then we asked the larger group: What do you think these practices have in common? What gives them a sense of unity? The word cloud was designed to trigger the debate.
Finally, we chose the yoga and lian gong groups and the circular dance group with the largest number of practitioners and we interviewed five users from each – selected according to their seniority in the group. These 15 users were asked the following question: If you were to invite someone who has never participated in an activity like this, how would you explain what happens in class?
We analyzed the data through three coding steps (initial, focused, and theoretical coding). They were systematized into codes and categories, and gradually expanded their potential for abstraction and scope until the research theory emerged, expressed in statements that characterize integrative mind-body practices.
Additionally, Grounded Theory points to the need for data validation as a rigorous strategy for devising the theory, in contrast to the reality under study. This was yet another action to produce results and improve conceptualization, contrasting the statements produced with representations put forward by users and facilitators. That validation process is different from that in which a select group attests the truth about the theory devised.
These analytical actions are detailed in Figure 2:

Figure 2

GT-based research may yield two types of products: 1) a substantive one, when a theory is based on a specific context that only applies to the field investigated; and 2) a formal one, when a theory engenders abstract concepts that can be generally applied to a broader reality.18 This article focuses on presenting a formal theory, clearly stated in the concept devised for ‘integrative mind-body practices.’

RESULTS


1. The portion of reality to be conceptualized.


This research process sought to conceptualize the set of practices, such as lian gong, qi gong, tai chi chuan, lien chi, yoga, circular dances, biodanza, bioenergetics, meditation, etc., offered by the SUS and present in the PNPIC. Therefore, we discuss what is common to them, listing the convergence points that made it possible to systematize statements in order to devise a concept.

2. The statements characterizing the phenomenon.

The process of categorical data systematization resulted in enunciation of a series of characteristics of the phenomenon under study, as shown in Chart 1, corresponding to what was expressed by research participants. The speeches of facilitators and users, added to the researcher’s observations, enabled enunciating 72 statements that characterize bodily practices from the PIC perspective, providing empirical support for conceptualization.

Chart 1

After these statements underwent the first data validation stage, the theory’s core category was established: ‘connection.’ This was the synthesis that brought together the multiple categorical dimensions of the data, as the main attribute of bodily practices from the perspective of PICs, which are characterized by the connection:
- of human beings with themselves, with other people, with the universe and with the present time;
- of health practices with everyday life, taking advantage of the philosophy and values founded by them and spread through practices, for a different living ethics;
- of the physical, mental, emotional, energetic and spiritual dimensions of the body, bodily practices, and health-disease processes;
- of care with health promotion under a comprehensive and complex view that favors expansion of personal and collective resources to address health-disease processes;
- of scientific methods with human experiences to explain and transform them into the proximity of the real, including immaterial dimensions often subjugated by modern instrumental rationality.

In the health field, the notion of connection corresponds to the vitality-energy paradigm, which is the PIC axis of support and contrasts with the normality-pathology paradigm dominant in the biomedical model. Chart 2 provides a synthesis of both, based on comparative studies:19-26

Chart 2

In the case of integrative mind-body practices, this debate takes place around human movement, which distinguishes it from other types of therapy. If these practices adopt the vitality-energy paradigm, human movement cannot be seen as a series of mechanical repetitions of technical gestures, which considers only the body’s organic functionality and whose concerns are focused on the physiological parameters of frequency, intensity, and duration of exercises in search of physical-sanitary regularity.
Exercising negation is the first step in formulating a concept. Therefore, research participants mentioned that integrative mind-body practices are not limited to the biological notion, physical exercise, and performance.

“It’s not just movement, they work with another view of body and health, besides the purely biological or physical one limited to repeating movements ... we have to deconstruct this logic of weightlifting gym classes, of working with a fragmented, piece-by-piece body; that doesn’t make sense to me, we are more than that” (initial visit)

“Everybody can dance (...) so you deconstruct the idea that you have to be a dancer (...) it’s not performance dance, nothing will happen, not even a dance presentation, it’s living the moment together (...) perfectionism is not encouraged, not that we encourage error, but we allow freedom to make mistakes (...) it’s not the predominant technique ... it’s an interaction-based group activity, so that’s the most important thing” (conversation circle)

Such aspects show resistance to reducing the body to the biological indicator, and movement to performance.
From the vitality-energy perspective, as reported by the participants in this study, bodily practices comprise human subjects in their existential complexity and multidimensionality.

“the motto of dance: dance means our life; we may make mistakes but we shouldn’t stop (...) there are more cheerful songs to lift one’s mood, more meditative, with choreographies a little more difficult in order to work our minds ( ...) it works body and mind” (user)

“The physical part is good because it will strengthen your own body, right? Spine, joints (...) and also for the emotional part ... It’s a whole, right? The body is a whole; we are wholes (...) looking inside yourself (...) I think that reflects the whole; you’re doing this for yourself and it reflects in your interaction with others” (user)

“We work with the model of the five koshas, of the five bodies (...) understanding the physical body, our energetic body, the emotional body, the body of belief, right? ... the body in that more rooted thing (...) and the body of pleasure, the body of bliss, in short, it would mean experimenting this feeling of fullness, right? Of connection, of yoga (...) the encounter with oneself and with this feeling, with this connection, with this whole; it’s the healthy state (...) integrating what I feel, what I think, with what is expressed in my body ... so it’s this body-mind-spirit integration” (conversation circle)

“There was a lot of talk about full awareness... actually, awareness of the body, of one’s body’s relationship with others, with the world and the activities that surround us... so it creates empowerment (...) when we are that centered, when we have this notion and intention, then we can make choices, right? And it depends a lot on awareness (...) One thing can’t be dissociated from the other (...) knowing the body (...) controlling emotions (...) reducing pain, which is often also associated with this emotional issue (...) free body expression (...) laterality, coordination, memory (...) contributions of belonging, social integration (...) solidarity” (conversation circle)

Both the body and health-disease processes are conceived in relations between the physical, mental, emotional, spiritual, and energetic dimensions, which are simultaneously activated when we set our bodies in motion. Therefore, the proposed techniques, based on internalization, bodily expression, and the exercise of presence, are means for developing sensitive and reflective work. This work, with body experience as its integrating unit, is the main therapeutic resource for inducing a response towards reestablishing and expanding vitality.
In addition, integrative mind-body practices are related to culture. Participants emphasized philosophical principles and a set of values that support practices and spread through them.

“We work with philosophy (...) with these issues of solidarity, love in action, connection with oneself and nature... this is the philosophical basis of dance... so, even without using these words, we work on these elements with the group (...) there is symbolism, focusing, realizing that we are all in the same position, at the same distance from the center, everyone is important (...) the melodies, the choreography, many of which have a symbolic side to them, it usually explains (...) and the whole relationship is not just there in the circle, they take it to their lives” (conversation circle)

“They involve a philosophy of life, a proposal for internalization, getting to know oneself, because yoga is not just stretching and relaxing (...) you will find it in the Scriptures (...) asanas are a path for meditation, right? For people to reach that full awareness of themselves, their bodies, their minds, their emotions... So we place speeches in the middle of practices, for people to be attentive, to focus their attention on breathing, everything, so it’s not something like just physical exercise, there’s the issue of not being judgmental or competitive” (conversation circle)

“Working on the connection, one to oneself (...) the connection between people, perceiving myself and the other, and myself in the other (...) it works on strength and energy fields, connecting with one’s higher Self (...) dealing with life issues in a better way ... and that also improves health” (first visit)

“I learned to work on this impermanence thing (...) I think it’s hard for all of us to work on impermanence because we want things to stay the same, right? We don’t want any losses” (user)

“I was totally agitated (...) you know what it’s like to do everything on autopilot?! (...) I was doing meditation and then I was noticing every change; how different I was (...) I was going to have my coffee, then I sat down and [pause] how can I say… I felt present! I’m here (...) Do you know that feeling of the best coffee of your life? (...) it looks like it’s not me; it’s like they’ve replaced me” (user)

Therefore, the approach cannot be restricted to ‘exotic’ technical gestures. It must include cosmological components and their cultural roots in the organization of classes. Being able to value the experience’s transcendental component also derives from that, which was expressed in speeches as energy and spirituality, showing another core characteristic of these practices.
Integrative mind-body practices, by mobilizing the dense body and the subtle bodies, are able to produce epiphanies that also impact the ways in which people deal with their health-disease processes. Human movement proposes an involvement of the body that triggers sensitive dimensions – in its invitation to introspection, presence, expression, and bodily awareness – driving the construction of new senses/meanings that can reverberate in subjects’ everyday lives, even contributing to the development of autonomy, empowerment and self-care.
The analyses undertaken so far reflect meanings ascribed by users and facilitators of integrative bodily practice groups who participated in the research. They are summarized in Chart 1. Given the wealth of these findings, the analysis resulted in the following statements about integrative mind-body practices:
1) They are proposals for promoting care and health based on the vitality-energy paradigm.
2) They involve bodily movements that add breathing techniques, relaxation, mental attitude, mobility in rhythmic sequences or permanence postures – all from different cultural traditions.
3) They value introspection and quality of presence.
4) They encourage people to find out their bodies’ limits and potential (in their most visible and subtle dimensions).
5) They promote individual processes, but they also reverberate in the group, as they invite to build a new relationship with oneself, others, and the universe, to question and share life and to redefine health-disease processes.

The first statement situates the concept of integrative mind-body practices in the health field, presenting them as therapeutic proposals relevant to the spheres of care and promotion, with potential to contribute to solve specific problems as well as to expand resources for people and communities to deal with health-disease processes, combining actions of (self) care and social responsibility for health.
Note that their affiliation to the vitality-energy paradigm is related to today’s vitalist view, which overcomes previous animist perspectives as it seeks to integrate human reflexivity as a core element of modernity. Therefore, it is not just a matter of reactivating old mystical practices but also of valuing the mystique of a reflective subject capable of understanding the world of which one is an integral and active part.27 Today, the vitality-energy paradigm is seen as some kind of echo of the vitalist strain that has existed since Ancient Greece28 and which was updated along the course of history.
The second statement presents the most common techniques within the group of integrative mind-body practices – not all of which necessarily need to be present in the same therapeutic practice. The third statement demarcates identity elements, introspection, and presence, which can simultaneously represent intention, method, and the result of experiences.
The last statements present the core purposes of integrative mind-body practices, related to the complexity of self-knowledge/knowledge of one’s own body – considering the dense (physical) dimension and the subtle (energetic, spiritual, emotional, mental) dimensions – as well as the possibilities for changes in subjects’ perceptions and actions by activating the sensitivity and reflexivity caused by integrative mind-body practices based on their gesturality, their rituals and their ethical and cosmological principles. That is why the concept addresses potentials for reframing, questioning, sharing life, building new relationships with oneself, with others and with the universe – the latter being the expression chosen to represent/congregate nature and spirituality regarding the dimension of transcendence.
In general, this concept would include practices associated with other medical rationalities – such as yoga with Ayurveda and tai chi chuan with TCM – whose bases are predominantly Eastern, and those emerging in the West after the 1960s, such as antigimnastics, bioenergetics, circular dances, and biodanza.
Note that the practices that emerged in the West are not necessarily linked to biomedical rationality. There is a set of integrative mind-body practices that originated and now circulate in the West as a counterpoint to that logic, associating with a broader health model, as long as the vitality-energy paradigm underpins it.
To finish the stage of devising the statements, we asked participants to say whether what was written (devising a concept with five statements) was able to represent what they were doing (experiences with integrative mind-body practices).

“It reflects everything we see in here: the results, the interaction, the differences we feel, the desire to come (...) It’ all there” (user)

“They are key words that you can place under a very large umbrella (...) for each one, life has a meaning, but that’s it, we are sharing life... now, what is my life that I share here? So each person will ascribe their meaning to this universe, to what life is... they are total terms and concepts (...) I feel totally represented (...) in terms of text, it covers everything, it reminds me a little of – I’m going to stretch it now – a biblical text; it needs this broader thing and so you understand what fits you best; I think this text of yours is nice because of that, because it has this breadth and each person goes ‘wow, that’s it!’ ... I see myself in it” (user)

“Wow, it makes me want to go out and use it (...) I really liked you using words like vitality, mental attitude, presence, talking about reverberating it on the group, the new relationship with oneself... I found it interesting to use new relationship with oneself rather than self-knowledge, which has been trivialized a lot as a word (...) and questioning life, because it goes beyond that, right? Because it ceases to be a practice restricted to a physical activity and becomes a much more integral and complete attitude” (facilitator)

They were unanimous to sustain that the practices with which they are engaged were represented by that definition. They recognized their intentions and characteristics, valuing the fact that the concept goes beyond the technical component and ascribes a sense of unity to the variety of practices being discussed. Some questioned the choice of words (universe, sharing life, breathing, paradigm, and limits) and were willing to rethink them, but did not come up with suggestions. In the end, most of them said that the wording properly captured the meanings ascribed and defined the concept well.

3) The name chosen to designate it.

The choice of ‘integrative mind-body practices’ is justified by the fact that the compound noun ‘bodily practice’ (prática corporal) is often found both in official documents regulating health services and Brazilian academic productions. However, since it is widely used in other fields besides health, an adjective (integrative) had to be added to demarcate its affiliation to the field of PICs.
In addition to the denomination ‘Traditional and Complementary Medicine’ adopted by the WHO, the terms ‘alternative,’ ‘complementary,’ and ‘integrative’ are also used to distinguish it from the biomedical model.
The alternative model is seen as incompatible (with the biomedical one), and a recommendation is made to replace one with the other.29 In Brazil, the word ‘alternatives’ has been used for a long time but has low acceptance in the institutional context of health. It expresses certain radicality and has been associated with esoteric and scientifically unproven practices.30 Complementary medicine, in turn, means complement, which succeeds elementary, with the possibility of associating models.29 ‘Elementary,’ in this case, are biomedical practices, with the PICs being considered as accessory.
However, the idea of complementing is challenged in everyday life because health actions may be alternatives, that is, not compatible with biomedical prescriptions; or biomedical practices themselves become complementary.30 PICs in Primary Health Care can be an option that precedes typical biomedical resources (medicines), which would be reserved for cases of failure or worsening of the situation.31 Therefore, the nomenclature aims at inscribing the way practices should relate to the biomedical model, but actions in health services sometimes subvert that subordination.
The term ‘integrative medicine’ emerged in the late 1990s to describe a new health model that integrated several therapeutic models, more than simply operating with complementary logic and offering comprehensive care. For many authors, Integrative Medicine means integrating conventional and non-conventional medicine to offer more treatment options to users. For others, it is a paradigm shift that requires changes in health concepts, forms of intervention in the health-disease process and the health care model – something associated with integrality of care, humanized relations, building scientific evidence and changing health education.29
Brazil’s PNPIC chose ‘integrative and complementary practices’ without explaining why. However, as soon as a public policy is published, other social actors enter the scene to interpret, operationalize, and reconfigure its content. The integrative model was seen as a way for certain knowledges and practices to enter the country’s Unified Health System (SUS); it opened room for a dialogue between scientific and popular knowledges; the subjects’ understanding of human multidimensionality, including spirituality; the meaning of integrality.30
Thus, in addition to being the most current concept, the word ‘integrative’ is in line with a paradigmatic shift. It includes the elements that cover the statements above about the concept of bodily practices, as well as the category named connection, which is central to the investigative path that generated the statements from the perspective of the PNPIC. Connection converges both semantically and epistemologically with the notion of integrative. In the former case, because ‘connecting’ can be synonymous with ‘integrating’; in the latter, because it establishes a correlation with the vitality-energy paradigm.
Other terms and definitions circulate in literature that dialogue with what is proposed in this article. One of them13 (p. 107) defines bodily and meditative practices as:

[...] health practices exercised by professionals with different backgrounds and inspired by various health rationales, cultural traditions, and knowledges, which address the uniqueness of being through corporeality as opposed to humans’ ruptures with each other, nature, and themselves. The characteristics common to these practices are: [1] integration between reason, intuition, sensitivity and senses, in order to enable momentary distancing from everyday problems and states of self-observation that may expand understanding of connections between what happens in the body and its relations with others and the world; [2] synergy between therapeutic care and health promotion, which favors caring for people with chronic conditions; [3] commitment to the inclusive complementary logic that guides the PICs and which is expressed in the alignment of these practices with principles, policies and production of care under the SUS.

Another14 one (p. 103) indicates that

integrative mind-body practices would be characterized by integrating various bodily knowledges and techniques that value self-knowledge, sensitization, proprioception, attention, relaxation, slowness, smoothness in order to care for people as well as promote, maintain, and recover health.

The notion of connection is also considered, mainly in the former view, as a frequent enunciative characteristic as indicated by the terms [1] integration; [2] synergy; [3] inclusive logic and alignment – in addition to the uniqueness of being.
Regarding content, both concepts – as well as our proposition – present converging but more detailed definitions than those prevalent in international literature. In the aforementioned WHO document,1 available in seven languages, bodily practices are listed as physical, mental and spiritual therapies associated with ‘mind-body’ in the French (esprit-corps) and English (mind-body) versions and to ‘psychophysical’ in Spanish (psicofísicas) and Italian (psicofisiche).
Interestingly, some coincidences are found in Brazilian and foreign literature when designating these practices, even though the context of their presence in Brazil’s Primary Health Care has few correlates in other countries. In addition to its use as a given term, it is sometimes described only by exemplifying types of practices. In other cases, it is limited to the technical components – mental focus, breath control, and body gesture – and the physical-emotional-mental-spiritual inseparability in human behavior.
With regard to nomenclature, ‘meditative’ in ‘bodily and meditative practices’ may refer to the practice of meditation itself, as a noun rather than a state (of connection) that qualifies the practices when used as an adjective. This denomination is somehow related to ‘body and mental practices’ and ‘mind-body therapies’ present in the official documents previously mentioned.
The term ‘integrative mind-body practices’ was used in a state policy32 and in a Ministry of Health management report,33 and it also appears in the academic field.14 This underscores that it is circulating in the strata where we are studying the phenomenon, in addition to referring to PICs themselves.
The Thematic Glossary of PICs includes ‘bodily practices of TCM’ (práticas corporais da MTC) ‘expressive practices’ (práticas expressivas) and ‘mind-body practices’ (práticas corpo-mente). For the former two, the arguments presented so far indicate compatibility that allows gathering several practices under ‘integrative mind-body practices,’ including those of Chinese tradition and those associated with dances. As for the third one, similar to the WHO document, the hyphen seems to be used to expand the notion of body (inseparable from the mind/psyche), but it is controversial because it conveys duality. In our case, we seek alignment with the PICs through the notion of ‘integrative,’ avoiding fragmentation and hoping for a paradigmatic shift towards a complex view on life.

FINAL CONSIDERATIONS

The purpose of this article was to devise a concept for ‘integrative mind-body practices,’ having developed a formal theory according to the methodological guidelines of Grounded Theory. In sum, based on the three components of a concept, the results of this study indicate the following outcome:

Figure 3

Addressing distinct integrative mind-body practices in health services in Florianópolis, Santa Catarina, this study endeavored to seek convergence points between them. The movement towards devising a concept consisted of finding meanings of unity for the diversity of practices capable of bringing together a series of statements common to the same name, in order to represent a specific portion of reality.
While this investigative choice enabled devising a concept that represents the whole, it left out numerous other analyses derived from each practice’s peculiarities. Another caveat refers to the challenge of trying to communicate aspects of an Eastern characteristic within a Western narrative structure – a challenge that is present throughout the work – simultaneously to the exercise carried out jointly with the research subjects.
During data validation processes, the fact that users and group facilitators unanimously acknowledged that the definition proposed covered their experiences was yet another challenge faced by the study. In addition, not being able to have external experts’ feedback on the concept somehow frustrated expectations and reduced the reach of evaluation. Furthermore, alternation of people in the groups when returning to this stage indicated the provisional nature of mapping exercises and also the difficulty in fixing activities in the routine of health services, with probable impacts on the communities involved and problems/challenges to the actions of registration and monitoring of PICs in Brazil.
Finally, we emphasize that the concept must be understood in relation to the research scenario, with possibilities of being transferred to different contexts, such as: academic field, health services, public policy documents. As much as human experience escapes statements, designation is the price to be paid to recognize things in the world whose existence is defined by language. No set of words can say everything, but what can be said may provide us with a place of existence, always to be reviewed and challenged. Therefore, the concept derived from this study is cast and it is open to new dialogues, with no intention of controlling its reach.


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