Professional practice of occupational therapists in Latin American countries: what characterizes a territorial-community action?

Abstract

This study aimed to identify how the concepts of territory and community are expressed in the practice of occupational therapists in Latin America and which dimensions characterize their territorial-community action in Argentina, Brazil, Chile, and Colombia. The terms territory and community are included in the political, economic and social relations established in the capitalist model of production. In occupational therapy, they have been incorporated as a result of political, social and economic events in different countries as a way to combine critique on social reality with professional practice. This study presents part of the results of a doctoral dissertation. Four social case studies were carried out using participant observation and semi-structured interviews with the social actors of the experiences followed up in the four countries investigated. The results highlighted five strategies that characterize territorial-community action in Latin American occupational therapy: the practice involved in the collectives and social relations, the weaving of formal and informal networks, the building of ties through activities, horizontality and availability in relationships, and the strategies to deal with social vulnerability at the micro- and macro-spheres. In conclusion, the terms territory and community are used in a combined way in professional practice, which presupposes reflection on the individuals’ ways of life and the relationships they establish with their living spaces, with weaving of solidarity networks in the places as one of the purposes of professional action.

Keywords:
Occupational Therapy; Latin America; Concept Formation; Territory; Community; Social Vulnerability

Resumo

O estudo objetivou identificar como os conceitos território e comunidade se expressam na prática do terapeuta ocupacional e quais dimensões caracterizam uma ação territorial e comunitária nos países Argentina, Brasil, Chile e Colômbia. Os termos território e comunidade se inserem nas relações políticas, econômicas e sociais estabelecidas no modelo capitalista de produção. Na terapia ocupacional, foram incorporados em decorrência de eventos políticos, sociais e econômicos nos diferentes países, como uma forma de unir a crítica sobre a realidade social às práticas profissionais. O presente artigo traz parte dos resultados de uma pesquisa doutoral, em que foram realizados quatro estudos de caso social, utilizando observação participante e entrevistas semiestruturadas com atores sociais das experiências acompanhadas, nos quatro países investigados. Os resultados destacaram cinco estratégias que caracterizam ação territorial-comunitária na terapia ocupacional latino-americana: a atuação implicada no coletivo e nas relações sociais; a tessitura de redes formais e informais; a construção de vínculos através do uso das atividades; a horizontalidade e disponibilidade nas relações; e as estratégias para lidar com a vulnerabilidade social nos âmbitos micro e macrossocial. Conclui-se que os termos território e comunidade são utilizados de forma articulada nas práticas profissionais, o que pressupõe a reflexão sobre os modos de vida dos sujeitos e as relações que eles estabelecem com seus espaços de vida, tendo a tessitura de redes de solidariedade nos lugares como uma das finalidades da ação técnica.

Palavras-chave:
Terapia Ocupacional; América Latina; Formação de Conceito; Território; Comunidade; Vulnerabilidade Social

Resumen

El estudio tuvo como objetivo identificar cómo los conceptos territorio y comunidad se expresan en la práctica del terapeuta ocupacional y qué dimensiones caracterizan una acción territorial y comunitaria en los países Argentina, Brasil, Chile y Colombia. Los términos territorio y comunidad se insertan en las relaciones políticas, económicas y sociales que se establecen en el modo de producción capitalista. En terapia ocupacional, se han incorporado como resultado de los acontecimientos políticos, sociales y económicos en diferentes países, como una forma de combinar la crítica sobre la realidad social con las prácticas profesionales. Este artículo aporta parte de los resultados de una investigación de doctorado que realizó cuatro estudios de casos sociales, mediante observación participante y entrevistas semiestructuradas con los actores sociales de las experiencias acompañadas, en los cuatro países investigados. Los resultados destacaron cinco estrategias que caracterizan la acción territorial-comunitaria en la terapia ocupacional latinoamericana: la actuación involucrado en lo colectivo y en las relaciones sociales; el tejido de redes formales e informales; la construcción de vínculos mediante el uso de actividades; horizontalidad y disponibilidad en las relaciones; y estrategias para enfrentar la vulnerabilidad social a nivel micro y macrosocial. Se concluye que los términos territorio y comunidad se utilizan de manera articulada en las prácticas profesionales, lo que presupone una reflexión sobre los modos de vida de los sujetos y las relaciones que establecen con sus espacios de vida, teniendo el tejido de redes de solidaridad en los lugares como uno de los fines de la acción técnica.

Palabras-clave:
Terapia ocupacional; América Latina; Formación de Conceptos; Territorio; Comunidad; Vulnerabilidad social

Introduction

Territory and community are concepts often used in the occupational therapy field in Latin American countries. In addition to representing geographical spaces of intervention, these concepts are used to designate a type of action that differs from those conducted within institutional walls, and which is based on involvement in the context and collective dimensions of that place. However, the definitions of these terms still need further clarification to point out their specificities when performed in occupational therapy. After all, how is territorial-community action characterized in occupational therapy? Which strategies can be identified as predicates of these actions?

In the present study, Latin America is understood as the region of the American continent that includes countries of Latin origin located below the Rio Grande, which separates the United States from Mexico. Latin American countries have similar historical, socioeconomic, political, and cultural characteristics (Araújo, 2006) that have influenced the institutionalization and development of occupational therapy, each related to its local historical specificities (Monzeli, 2021). All these countries have experience economic, political, and cultural consequences resulting from the colonization process and, even today, they are characterized by economic exploitation and enormous social inequalities (Araújo, 2006).

Studies show that occupational therapists in Latin American countries such as Argentina, Brazil, Chile, and Colombia have been developing actions with communities from a territorial and intersectoral perspective. These actions have been associated with local social problems since the 1980s and 90s (Trujillo, 2002; Barros et al., 2007; Oyarzún et al., 2012; Bianchi & Malfitano, 2017; Ortiz & Satizabal, 2019; Vinzón et al., 2020). According to Navarrete et al. (2015), occupational therapy in this region has advanced to the socio-community level through actions initiated in the mental health field, and in Primary Health Care (PHC), which were expanded through the implementation of social policies. This move into territories also extrapolated the space of health action and expanded the possibility of operating in other areas, such as in the social field, education, justice, and policy management. Those authors even indicated that the constitution of this professional practice dimension has generated an effort by professionals to systematize and develop other forms of action, from the definition of their roles to their concern with the professional commitment to current social changes (Navarrete et al., 2015).

Conceptual literature reviews (Bianchi & Malfitano, 2020, 2021) conducted during the first phase of this study showed that occupational therapists from Latin American countries based themselves on conceptualizations of territory and community from other areas of knowledge to prepare and analyze their studies and professional practice. Thus, as a theoretical-methodological framework to understand occupational therapy territorial-community practices, this study is based on concepts theorized by areas of knowledge engaged in the production of reflections and analyses on these concepts that are widely used in the occupational therapy field: critical geography and community psychology.

According to Brazilian geographer Milton Santos (2006), territory should be understood as used territory: a geographical space shaped by historical processes, material and social relations, and the use people make of it in their everyday life. Understanding the concept of used territory requires a reading beyond materiality, it is necessary to capture its movement (Santos & Silveira, 2006). To elucidate and determine the possible uses of territory, Santos prepared some reading keys aimed at highlighting the compositions that produce it and the characteristics that reveal its predicates and socio-spatial inequalities, such as fixtures and flows, verticality and horizontality, luminosity and opacity, rugosity, quickness, and slowness of the people who live in it (Santos & Silveira, 2006). In short, Santos developed a concept of territory that expresses the relationship and impacts of the powers of the social macrostructure on the microstructural dimension of places, considering the solidarity and actions of people in their living spaces.

On the other hand, following the proposition of community psychology, community is defined as a historical social group under constant transformation and evolution, interconnected by a sense of belonging and social identity, with common interests, needs, and organization (Montero, 2004). According to the Venezuelan psychologist Maritza Montero (2004), community way of life presupposes the presence of some processes: participation, a free and collective process that shares interests and goals; consciousness, which allows the overcoming of mistaken ways of understanding, such as alienation and ideologization; acquisition of control and power, as a space that guarantees participation and decision manifestation; politicization, considered as the occupation of public space and the understanding of rights and duties inherent in citizenship; self-management, which supposes the direct influence of communities in their transformation processes; commitment, which instills respect for others in community action; individual growth, since individuals acquire new functions that benefit the collective space by stimulating their own capacities; strengthening, which is the joint development of capacities and resources to achieve the changes aspired by the group; social or community identity, referring to a notion that grants meanings of individual character, such as security, belonging and inclusion, as well as of collective character, such as sharing, commitment and stability (Montero, 2004).

Supported by theoretical frameworks that contribute to informing occupational therapy, this study aimed to identify how the concepts of territory and community are expressed in the practice of occupational therapists in Latin America, and which dimensions characterize their territorial-community action in Argentina, Brazil, Chile, and Colombia.

Methodological Procedures

This study presents part of the results of a doctoral dissertation Terapia Ocupacional, Território e Comunidade: desvelando teorias e práticas a partir de um diálogo latino-americano (Bianchi, 2019) that analyzed four social case studies, each referring to one of the investigated countries, on the professional practice of occupational therapists in territories and with communities.

Social case study is a research method that enables the investigation of collectivities, institutions, and/or collective practices and contributes to the understanding of complex social phenomena where individuals and groups are considered in their condition in society (Becker, 1997). According to Yin (2001), social case studies are chosen when the researcher has little control over the events and the study focuses on contemporary phenomena that occur in some real-life context.

A multiple case study was used following the literal replication strategy, that is, application of the same data collection and analysis procedures to predict similar results (Yin, 2001). It allows experiences to be presented individually and analyzed and generalized under the same theoretical framework, enabling the individual presentation of multiple cases considering the same analysis theory. After this presentation, a joint analysis is conducted aiming at the theoretical generalization of the problem studied (Yin, 2001).

Two other methods were also used to collect the data: participant observation and semi-structured interviews. Aiming to understand the practices of occupational therapists in the different countries investigated, the contexts under analysis were followed up in person by describing the experiences in a field diary.

The first challenge consisted in identifying professionals and territorial-community practices for participant observation. To this end, in the first phase of the doctoral research, a conceptual literature review was conducted, and semi-structured interviews were carried out with the two most recurrent authors in the publications of each country (Bianchi & Malfitano, 2021). During the interviews, these authors were asked to refer to occupational practices and/or therapists that they considered good examples of territorial-community action. Approximately three references were obtained in each participating country, twelve in total, among which those that had been suggested by both interviewees and that contemplated experiences in different areas and contexts were prioritized.

After selecting the place and practice, the same procedure was followed for the four countries: the referred occupational therapists were contacted via email and invited to participate in the study, and the feasibility of participant observation was verified. After the participation in the study was confirmed, the documents needed for institutional authorization, requested in Argentina, Brazil, and Colombia, were provided. All ethical research procedures were followed, and the collaborators involved in data collection signed an Informed Consent Form (ICF). The study was approved by the Research Ethics Committee of the university responsible for it in Brazil (no. 2.182.203 and CAAE no. 66233717.3.0000.5504).

The participant observations occurred between March and September 2018, and included the follow-up of a typical working week, totaling approximately 40 hours in each country. Also, in each place, interviews were conducted with the referred professionals and collaborators indicated by them, such as participants in the actions or co-workers. Two different interview scripts were followed: one for the conversation with the occupational therapists, contemplating questions about the concepts of territory and community and their professional practice; one focused on the other people involved with that practice, addressing histories and characteristics of the territory, information on the service, and their perception about the work of the occupational therapists.

In Argentina, the practice indicated by the two authors was the Cockspur coral tree (Ceibo¹ in Spanish) social enterprise. It started in the 1990s in Buenos Aires and coordinated by three occupational therapists. Five interviews were carried out, with two occupational therapists and three local workers.

In Brazil, the Golden trumpet tree (Ipê Amarelo in Portuguese) community center was selected. It is located in the interior of the state of Sao Paulo. This social facility has a team of two occupational therapists, and one of them is the director. Both occupational therapists, a cleaning service assistant, and a daily user of the canter were interviewed.

In Chile, a practice different from the other subareas of occupational therapy was chosen: a community caregiver program sponsored by the Chilean bellflower (Copihue in Spanish) non-governmental organization (NGO) in Santiago. Two occupational therapists, the NGO director, and an academic who conducts activities in an occupational therapy undergraduate course in partnership with the program were interviewed. In addition, four community caregivers were interviewed collectively.

In Colombia, the participant observation occurred in the community professional internship offered by the Orchid university (Orquídea in Spanish) where the academic responsible for the internship, an occupational therapist from the university, and three senior undergraduate students were followed up. Interviews were conducted with two undergraduate students, the internship occupational therapy lecturer, a co-worker, a physiotherapy lecturer, and a resident of the community who participated in one of the groups promoted by the internship.

For analysis, following the propositions of multiple case studies, the experiences of each country were presented homogeneously, in the form of their descriptions, despite the awareness of the historical and political differences of each country and their distinct development of occupational therapy, both academically and practically. Care was taken not to compare the data between the experiences, but rather to seek similarities in the actions and uses of terms in professional practice. Eventually, the data obtained in the social case studies were analyzed based on the theoretical framework presented, as well as on critical geography and community psychology. Reading keys and characteristics complementary to the concepts of territory and community were used to identify elements of both terms in the professional practices observed. In this sense, the proposal was woven to combine the language of experience with the language of theory, that is, the living and experiencing of practical work with the theoretical framework and conceptual elaboration; after that, the collected data were analyzed and categorized (Caria, 2003).

Finally, as pointed out by Yin (2001), the analysis woven according to the same theoretical framework acts as the guiding thread for the common discussion and conclusion about the different situations presented. In the Results section, four categories are presented, each corresponding to one of the investigated countries; in the Discussion section, based on the intersection of the information found with the themes that emerged in the participant observations, two categories are presented: Intersections of the territory with the community: the strength of place and solidarity in professional practice and Five dimensions of territorial-community action in occupational therapy in Latin American countries.

Results

The results are presented by country, seeking to highlight some of their singularities. A choice was made to read the four realities investigated considering the concepts of territory and community selected for analysis in this study, specifically based on critical geography and community psychology.

Territory and community in occupational therapy action at the Ceibo social enterprise - Argentina

The Ceibo social enterprise is a health and social inclusion service, coordinated by three occupational therapists, offered in a large psychiatric hospital of the public health system in Buenos Aires. Although this social enterprise, which has therapeutic as well as labor purposes, operates in a hospital, it aims to integrate and provide a care service alternative to the psychiatric hospital model. The group, composed of hospital patients and unemployed community members, designs, produces, and sells handcrafted stationery material. The organization of this social enterprise is inspired by the cooperative model, and it proposes horizontal relationships and the active participation of its members in the dynamics of the production unit, such as in input purchase, product manufacturing, price setting, and participation in fairs.

Regarding the work of the occupational therapists, their functions are distributed between coordinating the productive activity and providing therapeutic treatment. In the coordination function, the duties assumed by the professionals include the performance of administrative and economic activities, such as organization and execution of the production process and participation in meetings to market the products. The therapeutic function, on the other hand, refers to mental health care, such as support to the group members, mediation of conflicts and relationships between them, and joint construction of life projects.

Participant observation revealed that the concept of territory is not associated with geographic space. On the contrary, the spatial dimension is an issue that goes beyond the work process, since it occurs inside a hospital, addressing what Santos (2006) calls verticality in spatial reading, that is, even though the hospital does not hold the economic hegemony of the place, it promotes intense circulation and modifies the socio-spatial relations in that territory. The verticality observed is supported by attributes such as the imposition of a specific spatial logic, despite the interests and demands of the place, the surroundings, and the population that lives and circulates there. In this sense, this social enterprise aims to minimize the vertical relationships established by the hospital, providing an open door for participants to go out to market their products and individuals seeking to enter the labor market, as well as for consumers to enter the hospital to buy products.

Another reading of territory was the social circulation of participants in production circuits alternative to the capitalist model, and thus more inclusive to the population with social integration difficulties. Santos (1986) identifies the productive circuits of territories as spaces of production, circulation, and consumption. He analyzes these spaces and classifies them into upper and lower circuits of economic activities: the upper circuit is related to agents and elements that use a high level of technology, capital, and organization, whereas the inferior circuit is formed by agents and elements that use a low level of technology and capital and promote horizontal relationships.

The Ceibo social enterprise integrates and strengthens itself in the productive spaces of the lower circuit, such as events and craft fairs. Participation in the circuit also provides resources for building social circulation, establishing new relationships, and getting hold of different places for the participants. Here is an example: the group was getting ready to participate in an event in a neighboring city. Two members organized themselves to go alone, by public transportation. They would take the products and money, organize the exhibition, and be responsible for the sales; in addition, during the event, they would participate in a conversation circle where they would make a presentation of the Ceibo social enterprise - an unprecedented experience for them. Thus, it was observed that the construction of a place through the lower circuit favors the protagonism of individuals, since it is not constituted as a competitive, hierarchical space with only institutional representation. The identification is also consistent with another aspect addressed by Santos (1986), referring to the composition of organic and horizontal solidarities to the detriment of an organizational solidarity that prevails within firms and production institutions.

According to Santos (1986), it is possible to recognize that the work of occupational therapists does not modify the macrostructure or achieve new work opportunities in the upper circuit of economic activity, but rather it develops alternatives in the lower circuit that modify the everyday lives of the social enterprise participants and create new chances for life.

The concept of community was demonstrated by the notion of community self-management. According to Montero (2004), self-management - characteristic of community practices - is expressed in the autonomy of actions and decision-making associated with the processes of a group, without the need for a verticalized initiative or positioning in relation to negotiations and agreements. Self-management, through collective task management movement, fosters trust, commitment, and security among group members.

The follow-up was illustrated by some self-management scenes. One of them was common in the everyday life of the Ceibo social enterprise: after a period of joint work, a participant and an occupational therapist presented a new notebook cover model to the group. The participants stopped their activities to look at the new proposal. After a brief circulation of the product and a conference among the group members who have greater mastery of the technique, the professional asked their opinion about it and whether they agreed to include it in the sales catalogue. The question was followed by a discussion in which some reservations were pointed out, and a consensus on how to manufacture the product was eventually reached.

In the situation presented, it was possible to identify that the organization and management processes of the social enterprise occur democratically and collectively, through dialogue and the opinion expressed by the participants. The subtlety of the actions was also noticeable, and no hierarchical relationships of organization were observed in the experience; on the contrary, self-management was a natural part of the group's daily coexistence. What was observed was the daily construction of a conduct between and with the group participants that aims to promote control of the productive processes beyond themselves and individual actions, and with that, the strengthening of the collective as a place and a way of acting within the group.

In the Ceibo social enterprise, it was possible to recognize that the term community also reflects a strategy in conducting professional practice, a form of organization, and a guide for the adopted perspective. In other words, the action was not proposed by the community or has a close relationship with the organization of extramural life; however, it is guided by the construction and strengthening of elements that constitute the community way of life, such as self-management, participation, commitment, and belonging to the group.

Territory and community in occupational therapy action at the Ipê Amarelo community center - Brazil

The Ipê Amarelo community center is a facility that provides coexistence and mental health care located in a municipality in the interior of Sao Paulo state. In the current Brazilian scenario, there are no official public policies for the financing and implementation of community centers, and there are few of them. However, Ordinance no. 3088/2011, which officializes the Psychosocial Care Network (RAPS) for the assistance of people with mental health issues, community centers are identified as Primary Health Care (PHC) facilities that can be part of the RAPS in social inclusion actions (Brasil, 2011). Therefore, the Ipê Amarelo community center is part of the RAPS, and works in conjunction with other services such as the Health Centers, Psychosocial Care Centers III (CAPS III), Child Psychosocial Care Centers (CAPS i), and Psychosocial Care Centers for Alcohol and Other Drugs (CAPS ad).

This service offers the following groups and activities: workshops on body expression, experiences with the arts, workshops on care and food production, and groups focused on the development of writings, such as letters and biographies. At the time of the visit, the team consisted of two occupational therapists (one of them was the service manager), a psychologist, a workshop instructor, an administrative assistant, and a cleaning assistant. The flow of people at the Ipê Amarelo community center is high, and the groups are distinct: residents of the neighborhood, users of the CAPS III, people with disabilities, and adolescents sheltered in a facility in the region.

The occupational therapist who manages the community center performs coordination functions, in addition to participating in forums and meetings of the municipal health network, and in economic activities, such as administration of financial resources and maintenance of the service. The occupational therapist who works in direct contact with the patients performs functions aimed at planning, preparing and carrying out workshops, promoting spaces for interaction and living together, organizing tours, trips and events in the service, mediating the interaction between them, and dialoguing with professionals from other services to develop joint activities.

At the Ipê Amarelo community center, the concept of territory is expressed through a combination of the micro- and macro-social spheres, that is, between actions in everyday life and interventions aimed at raising awareness and minimizing power relations that directly impact on the way of life of the assisted individuals. An example of this was the construction and implementation of networks. During the entire period of participant observation, the traffic and circulation of both professionals and patients of other services in the activities offered by the community center were followed up. According to the professionals, the territorial action occurs through the promotion of exchange spaces with the population, universities (reception of interns and residents), and other services.

According to Santos (2006), the technical-scientific-informational stage marks the evolution in the use of networks, and the support of networks is based on the territory, whether in the abstract force that connects the relationships between individuals, or in the purposes of technique, such as the connectivity provided by computers, for instance. Through networks, it is possible to recognize three solidarity levels: the world, the geographic space, and the place. In the current scenario, the world is at our fingertips through connection with the networks, and this produces an idea of totality that occurs not only concretely, but also empirically. The second level refers to the geographic space of a country or a State and the configuration of networks as a form of regulation and/or control. The place is the third level, corresponding to the dimension where the network acquires a socially concrete form, the result of diversity and repetitive happening (Santos, 2006).

Thus, the concept of territory in this experience was expressed by the weaving of networks at the solidarity levels of geographic space and place. At the geographic space level, it was possible to identify that the occupational therapists aim to build intersectoral support and communication networks between different services, composing strategies of the national policy for mental health care. At the place level, the professionals acted in the mediation of relationships in the microsocial scope, weaving closer relationships between the participants to build social and support networks between them.

The concept of community, on the other hand, constitutes a strategy of professional practice to promote collective and participatory actions among patients. The professionals did not deal with the community outside the service nor establish relationships with community leaders to strengthen the territory where the Ipê Amarelo community center was located - characteristics of community action. However, they sought to establish actions to encourage community ties within the community center and somehow attribute a sense of community to the relationships within the service itself.

The occupational therapist who worked in direct contact with patients mentioned, in her interview, the organization of an assembly with the community center regulars as a community-oriented action in her professional scope. Assemblies are democratic groups where the exercise of speech, debate, and consensus are fundamental instruments (Kinoshita, 2009). They seek to favor the social participation of patients in collective decisions, assuming horizontal and co-management relationships.

I was talking about an assembly held when we had a big cut in expenses. We decided to hold an assembly to communicate the community center regulars because we thought we needed to share this with them (...). We conducted this conversation with concern, but we were surprised that many people started to come up with ideas for raising money, such as suggesting that they bring snacks for the group meetings. For me, this showed a very strong sense of community, that people come here because they believe this is a community space, and no one was thinking “oh, then I’m not coming anymore”, it was really a collective thing: “let’s find a solution together”. And I think it’s interesting to strengthen these conversation spaces, because this sense of unity emerges (Occupational therapist who worked in direct contact with patients – Brazil).

The discussion about community also includes community participation. According to Barros et al. (2007, p. 356), community participation is based on principles such as “the importance attributed to the proximity of the concretely experienced everyday life, the involvement of the population in solving their problems, and the achievement of social and political emancipation of this population”. The occupational therapists’ actions aimed to provide a safe space for community participation by mediating the relationships between patients, promoting exchanges and dialogues in a horizontal and democratic manner, and being careful not to inhibit the protagonist role of the participants in the experiences. Nevertheless, the interventions refer only to the first two principles of community participation brought by the authors, with social and political emancipation still a challenge to be addressed.

Territory and community in occupational therapy action at the Copihue community caregiver program - Chile

The Copihue is a feminist NGO started in the 1930s. Remarkable in Chilean history, this NGO was an exponent in the struggle for women's suffrage and the defense of women during the country's dictatorial period. After re-democratization, the Copihue defined that its new stage would have as mission the maintenance and strengthening of the women’s movement and its readjustment to the political process that was just beginning. To this end, the main emphasis was based on working with socially vulnerable women aiming to improve personal development and awareness of rights as a way to foster the exercise of citizenship, strengthen leaderships, and enhance social and economic autonomy (Pastor & Valenzuela, 2017). In this context, the Copihue NGO community caregiver program was initiated. It is an action aimed at articulating a network of home health care for socially vulnerable older people offered by “housewives” who had difficulty entering the labor market. This community caregiver program confers recognition on social care, a task historically performed by women, through paid work (Weber, 2016). In 2016, inspired by the Copihue NGO, the Chilean federal government implemented the Chilean Assistance Program, expanding the training of women, and care for vulnerable older people across the country (Chile, 2016). Thus, the Copihue NGO continued to carry out its actions supported by funding from this federal program. The new funding source enabled it to hire two occupational therapists to compose the community caregiver program team in 2017.

During the period of participant observation, the NGO team was composed only of women, divided into two sub-teams: an administrative team linked to the service coordination that included the director, a lawyer, an administrative assistant, and two coordinators of the Chilean Assistance Program; and a professional team linked to therapeutic work with the community assistants and the older people composed of a nurse, a psychologist, and two occupational therapists.

In the paths taken through the streets of the territory, there was no movement of people, public transportation, or cars. They were mostly quiet, leisurely everyday life places. This is probably due to the fact that the residents who remained in the territory were unemployed or engaged in informal work activities, such as the aforementioned “housewives”.

This identification of the territory was associated with the notion of “slow men” and times, in the words of Milton Santos. Slow times refer to the dynamics of space produced by slow men - those who are oblivious of the fast pace of hegemonic processes (economic, social, and political) and, therefore, do not fit into the formal and accelerated times of commercial activities (Santos, 2006). According to this interpretation, the “slow men” experience the territory more comprehensively because of their own survival condition and, due to this, they can discover resources and opportunities in less predictable places, creating new norms for life.

From this analysis, it is possible to infer that, in that experiment, the slow men were actually slow women². They were the ones who, for various factors (issues of gender, class, and of the territory itself), were faced with processes of labor exclusion and were unable to adapt, even if in a subordinate way, to the labor market, but found a way of acting that involved their own work as housewives and caregivers. Thus, by experiencing the slow times of the space where they live and work, the community assistants play the role of interlocutors between the professional team of the Copihue community caregiver program and the demands, relations and contradictions of the territories. At the same time, the Copihue program team, especially the occupational therapists, work to maintain and strengthen this alternative work for slow women, constituting a work process based on exchange and dialogue between both groups.

In the occupational therapy practice, the professionals have two distinct fronts: monitoring the work and offering training for the community assistants, and assessing and preparing an intervention plan for the older people assisted by the program. The scenes observed are subject to analysis under the concepts of community work and community intervention (Oyarzún et al., 2012).

Community work is defined as collective work, where the community itself constitutes the central subject of action. The promotion of the active participation of its members, the support to their qualities, and the enhancement of their abilities as a group are highlighted, as well as the intention to strengthen individuals and groups so that they can make the transformations necessary for the collective to which they belong. In Chilean occupational therapy, community work was widely practiced before and during the military dictatorship, when the communities were collectively organized and engaged in the processes of reweaving the social fabric (Oyarzún et al., 2012).

Participant observation evidenced initiatives congruent with community work in the practices linked to the community assistants. The education process has included aspects such as the enhancement of dialogue and the participation of community assistants in the exchange of knowledge. The occupational therapist assumed the horizontal role of mediator between relationships and facilitator of the group process. In her interview, she emphasized the importance of exchanges with the community assistants as a way to understand everyday life movements and the expression of culture in the lives of people in the community and in the dynamics of the territory.

Popular knowledge [emerges] in the meetings with the community assistants (...). The shared space is present in the community assistants, the dialogue, and popular knowledge always emerges in these meetings (...) [It is] the popular knowledge of these territories, which also happens from their everyday lives, from their experience (...) I feel distant because I don’t live in these communities, they identify with what they say, they are very spontaneous as assistants and as women, all their knowledge, their emotions, are transmitted (Occupational therapist of the Copihue team – Chile).

The other concept is community intervention. According to Sánchez (1991), community intervention concerns the creation of community resources to solve problems from agents outside the community, that is, the professionals direct their actions towards the territory and conduct their practices in the community, not necessarily with the community, in an initiative to favor the human and social development of the place. In Chilean occupational therapy, community interventions started being developed after the violent dictatorship experienced and the implementation of public policies that, despite having legitimized the creation of territorial-community services, brought implications such as the instrumentalization of practices, implementation of guidelines and models, and specification of the problems to be dealt by professionals (Oyarzún et al., 2012).

In this sense, the other work front of occupational therapists, with the older people assisted by the program, fits into the concept of community intervention. The professionals’ actions correspond to the prerogatives of the program, in which the pre-determined needs of the older people are considered, such as dependency and socioeconomic index, and interventions are constructed based on their individual characteristics, not having as a glimpse, for instance, the realization of groups or collective activities.

From this interpretation, it is also noted that territory is associated with the stage of intervention, that is, with the material, physical and static space where the action occurs. Although the professionals circulated on the streets, there was little dialogue with the social dynamics that occurred in the territory and that impacted on the living conditions of the community assistants and on the health of the older people, or were the actions able to weave dialogues in the macro-social scope to effect the construction of assistance networks.

Finally, what was identified is that professional practice corresponded to the sociopolitical movements experienced by the country. An attempt to safeguard the characteristics of community movements by strengthening and maintaining cohesion among the group of community assistants - the slow women, while a stiffening of technical action is observed as a result of public policies that pose demands on professionals that are closer to control and specialized care than to awareness and active participation.

Territory and community in occupational therapy action at the Orquídea university - Colombia

The occupational therapy undergraduate course at the Orquídea university started in 1986, and was the first in the region. The professional internship in community occupational therapy was introduced in 2007, after a reform in the course curriculum. Upon reaching the eighth semester, the students undergo a rotation trough five practice scenarios: mental health, physical health, education, work, and community fields. In the last semester of the undergraduate course, the students experience a period of deepening the content, when they choose one of the scenarios to prepare a final project. In this way, the community field receives students from the rotating professional practice and from the final period.

The internship in the community field is divided into two scenarios: rural and urban, each with different work fronts. The actions in the rural area include activities in a health center and a public school, which are central facilities in the region responsible for gathering children and adolescents and bringing parents and family closer together in spaces for dialogue about the dynamics and needs of the neighborhood. In the urban area, the interventions occur in two socially vulnerable neighborhoods located on the outskirts of the city. In these neighborhoods, the internship activities consisted in observing the occupational therapist who composed the Community Based Rehabilitation (CBR) team of a PHC service and in forming three groups in a public park together with lecturers from other courses at the university. The groups addressed actions in the fields of mental health, childhood and maternity, and gerontology.

In the rural setting, due to the distance from the urban area, the neighborhood was constituted as the central axis of material production and social and coexistence ties, conforming to a space that is often alien to the influences and modifications of external agents, especially those from the city. The reading of this social organization, based on the understanding of space as shelter, work, and organizer of its own relationships, refers to the concept of place - a component of the territorial dimension.

Place is the space that holds everyday life and the ordinary interactions between people. The construction of a place is woven by social relations in space, and by the historical and cultural dimension that shape relationships and ways of life. Place is configured as the spatial dimension of everyday life, producing identity, and belonging to those who share life in the same space (Santos, 2000). Understanding the concept of place also offers a concrete environment for the community and community relations.

Based on this understanding, the occupational therapists’ actions in rural areas are connected to the place, especially regarding the reconstruction of memories and cultural aspects of the region. Scenes of practice that serve as an illustration of this analysis were part of the participant observation. One of them was the participation in a meeting between the team of occupational therapists and the nurse at the health center to organize the celebration of the International Day of Older Persons. The purpose of the event was to gather older people and students from the local school to exchange experiences, stories, and memories of the neighborhood: how the region was formed, the first families, and what agricultural crops were cultivated in the past, in an intergenerational dialogue. At the meeting, and during the dissemination of the event, the students suggested that the older people brought objects that refreshed their memories, such as old photos, documents, and objects.

In rural neighborhoods, due to the proximity of relationships and the experimentation of slow times, perception of the advancement of technologies, such as television sets and computers, and the distancing of children and youth from the old rural ways of life become more evident. In this sense, this activity of contextualizing stories and memories in intergenerational dialogues is pointed out as a strategy to sustain the identities that render shape, and recognition to the place and the community.

Regarding the urban scenario, it was identified that actions to promote circulation through the neighborhood and the strengthening of ties and support networks were connected to the concepts of territory and community. Some scenes illustrated this identification. One of them, reported by the students, was the realization of social cartography with the group of older people. The activity consisted in building a map of the neighborhood illustrating the important points of the territory, the houses of the group participants, and in which spaces they circulated, addressing at the meeting the affective marks and the uses that the older people made of the territory. In addition, the activity aimed to bring the group participants closer together and strengthen the relationships between them.

Social cartography can be defined as a strategy of political action and critical analysis that aims to follow up and describe relationships, trajectories, compositions, and organizations of spaces, pointing out lines of coexistence, ruptures, and resistances. Thus, unlike the topography and drawing of a traditional map, the strategy is based on the illustration of drawings that demonstrate the dynamics, powers, densities, and places in movement (Prado Filho & Teti, 2013). Social cartography is identified as a powerful resource for the practice of occupational therapists in territories and with communities, since it is a strategy that aims to discuss how the population gets hold of their living and circulation spaces and to analyze the ways of life and the social and collective ties of places.

Discussion

The discussion synthesizes reflections regarding the intersections of the information found and the themes that emerged from the professional practices identified through the semi-structured interviews and participant observations. The concept of place and the search to construct solidarity as objectives of practice and five strategies common to all observed scenarios identified as characteristic of territorial-community action in occupational therapy stand out among the findings.

Intersections of the territory with the community: the strength of place and solidarity in professional practice

Territory and community are concepts often used in a combined and organized way in the field of occupational therapy. In the four experiences observed, it was possible to identify that the elements that characterize the concepts are actually intertwined, and compose a territorial-community action that is found and/or is effective in a relational space-time: place.

Place is the lived space where the great richness is the solidary happening and the proximity to common everyday actions (Santos, 2000). It can also be understood as the portion of space that can be visualized, touched, and gotten hold of by bodies. A neighborhood or a street can be considered as a place because they are the immediate spaces where ordinary relations and identity ties between its inhabitants occur (Carlos, 2007).

The concept of place also rescues and brings to the scene an old conception historically linked to the notions of charity and benevolence, but which endorses the importance of the fabric of relationships woven in the collective sphere: solidarity. Solidarity is seen here not as a moral and fraternal value, but as a specific form of social ties based on the idea of reciprocity between the members of a group, in this case, a community.

According to Freire & Oliveira (2014), solidarity is the antithesis of individualism. The most coherent way to build a fair, democratic, and solidary society is to turn to the idea of community. Resuming a spirit of community, which includes respect and concern for others, is essential for reestablishing strong ties in today's society. Thus, in those authors’ elaboration, solidarity is understood as a cohesive force that facilitates community functioning and social life, as a line that connects people who share the same dreams, including the political dreams of fighting structures of oppression (Freire & Oliveira, 2014).

Nevertheless, the contemporary scenario produces increasingly individualistic and competitive relationships, hindering the construction of solidarity networks that were previously more present in communities (Castel, 1998; Santos, 2000; Freire & Oliveira, 2014). The crisis in the world of work (Castel, 1998), together with the perverse globalization and the construction of superficial and temporary ties mediated by the market and consumption, produce citizens who are alien and, often, not available to exchanges and the reduction of liberties that condition community life.

Changing this scenario will only be possible with the creation of resources that assist in weaving solidarity networks and strengthening places. Thus, it is necessary to plan actions, often mediated by professionals, that intend to provoke the understanding of common problems and the creation of collective strategies for their resolution (Freire & Oliveira, 2014). What can be seen is that, if the work of professionals in the past focused on the demand raised by the community, nowadays, the work has been prior to that, that is, assistance in the reconstitution of communities.

In this sense, it is recognized that the reconstruction of the ethical and political notion of solidarity becomes an important issue for professionals, including occupational therapists, who work in the places, especially in contexts of poverty and social vulnerability, which are the most affected by the vectors of perverse globalization. Freire & Oliveira (2014) pointed out that, in addition to its political value, solidarity corresponds, or should correspond, also to methodological issues of educators and other professionals who intervene in these scenarios.

I always think about solidarity, because we are a team of women, we work with women, all women, and the connection point is solidarity, that is, of mutual understanding and not a hierarchical one; just because I have a degree in occupational therapy, I’m not necessarily in a superior position compared with them because they don’t have a degree. And the same is true of the team, the director says:“I’m nobody’s boss here.”It’s a logic of trust and respect, and I think it helps the team quite a lot to learn, not to control: (...). I believe this has been a new way of relating in teams, not by competition, punishment, or control, but by understanding, trust, and honesty (Occupational therapist – Chile).

Ramirez & Schliebener (2014), in their manifesto against the colonization of knowledge in occupational therapy, indicate that the development of knowledge and actions appropriate to the local context, using the reconstruction of memories, histories and characteristics that make the Latin people unique, such as joy, struggle and solidarity, is imperative to this field in Latin America. In this study, it was identified that territorial-community action is involved in the analysis and rescue of singularities in the Latin American region, especially when proposed around memories, experiences, and sociopolitical conflicts in the everyday life of the territories and their communities.

In summary, this study pointed out that the characteristics of territorial-community action developed by occupational therapists have had the purpose of establishing solidary relationships, which indicates that the field of occupational therapy in Latin America has been concerned with the issue of solidarity, also assuming it as an ethical and political presupposition and as a purpose of professional practice.

Five dimensions of territorial-community action in occupational therapy in Latin American countries

The territorial-community actions conducted by the occupational therapists resorted to compositions considered commonplace regarding professional actions. The professionals did not use pre-established models, assessments, or protocols; on the contrary, the strategies common to territorial-community actions were apparently “simple”, but developed under a complex professional dimension. In this context, constant theoretical and methodological reflection is needed to name and discuss the various strategies used by occupational therapists in their practices, which are often subsumed within the work process.

Furthermore, it is important to emphasize that, although the practices observed are outside the scope of action of Brazilian social occupational therapy, the strategies found are consistent with and similar to the principles of community participation developed by the area, such as the importance and proximity to the everyday lives of individuals, the involvement of the population in solving problems, and collective action (Barros et al., 2007). In addition to these similarities, the studies developed by Brazilian social occupational therapy also point to the inseparability between the terms territory and community in the scope of professional practice and the solidarity and protagonism of individuals as mottoes for professional action (Barros et al., 2007; Lopes & Malfitano, 2016).

Among the strategies visualized in this study, the following five stood out: the practice involved in the collective and social relations, the weaving of formal and informal networks, the building of ties through activities, horizontality and availability in relationships, and the strategies to deal with social vulnerability at the micro- and macro-social spheres.

Practice involved in the collective and social relations. In all the observed scenarios, the occupational therapists organized and coordinated initiatives involved both in actions in the collectives, usually conducted through group strategies, and in the development of activities that brought together and constituted collective relationships with and between the individuals followed up. The group of older women observed in the Colombian experience serves as an example. This group was formed approximately five years ago by academics from the physiotherapy undergraduate course at the Orquídea university, and had as objective the practice of physical activities to promote the active aging of its participants. The actions remained in this format until occupational therapists joined the group. Identifying the fragile ties among the participants, the professionals proposed activities that would facilitate the constitution of a community, for example, the inclusion of dialogues aimed at strengthening their relationships and ties. As a result, the group now has a name, a logo, a t-shirt, and new activities such as city tours, expanding circulation and the possibility of shared experience in that stage of life. It was also observed that the longitudinal and procedural follow-up favored the construction of more solid relationships, with the promotion of group work, sharing of experiences, and search for new possibilities.

Weaving of formal and informal networks. Concerning formal networks, there is action linked to public policies and intersectoral dialogues to strengthen access and care for the individuals assisted. According to Castel (1998), they would be the secondary sociability networks. The experiences of occupational therapists at the Ipê Amarelo community center in Brazil can be used as an example. These professionals included participation in meetings and activities with other facilities from the same region in their action, such as a meeting to support work in Primary Health Care units and the offer of workshops together with professionals from other services. The strategy aimed to expand institutional actions beyond that place to promote greater effectiveness in interventions when carried out together or, at least, in sharing information about the assistance provided.

Informal networks are related to the mediation established by occupational therapists in microsocial relationships, that is, in approaching the assisted individuals to establish support and solidarity networks between them, which can be associated with the propositions of a primary sociability network, according to Castel (1998). As an example, the Argentinian occupational therapist reported that the participants at the Ceibo social enterprise had great difficulty in organizing leisure activities in their free time and that, in principle, the professionals felt “indebted” to this demand. However, during the follow-up, they identified that the construction and combination of relationships and support between the participants for extra-service moments would be more effective than the organization of specific tours, even though they required more strategies and preparation time.

Building of ties through activities. The use of activities and doing together as strategies for bringing people closer and creating ties between them was also a commonly observed strategy. The proposition of interactive dynamics and/or the carrying out of manual or bodily activities were present in all scenarios. The activities, as well as other elements present in the dynamics of territorial-community work, can be understood as components of a ritual in groups and in how they are conducted, because they ensured a safe and regular space for the participation of the group members, promoted the formation of ties between them, and facilitated cohesion and cooperation in the actions carried out. According to Sennett (2013), ritualized moments within a group or a community are elements that converge both to celebrate the difference between and value each member of the group, as well as to reduce comparative acts and promote cooperative relationships.

Horizontality and availability in relationships. Another strategy that stood out in the experiences followed up during participant observation in the four countries was the establishment of horizontal, empathic, and less hierarchical relationships between professionals and assisted people. In order for interventions in territories and with communities to be adequate to the realities and ways of life of that population, technicians should start from the analysis of how individuals understand their reality and their needs, and not from those pre-established by the institution or specific models. As indicated by Paulo Freire (2007, p. 36), being with others means “not denying them the right to speak their word”. Occupational therapy territorial-community action presupposes the recognition of the real needs and knowledge of people/communities and the composition (adding their technical knowledge) of resources to strengthen collectives and places. Thus, it is necessary that professionals be available to build a dialogical, open, horizontal process.

Strategies to deal with social vulnerability at the micro- and macro-social spheres. The last strategy identified was the planning of actions and/or reflections regarding social conditions. The professionals followed up demonstrated that the situations of poverty and social vulnerability experienced by the individuals and groups were not associated with their individual characteristics or responsibilities. The histories and organization of territories represent macrosocial situations that reflect the obstacles posed by capitalism and by the implementation of neoliberal policies in these countries. Thus, activities that valued dialogue and the construction of reflections about the socioeconomic conditions of the countries and how political movements impacted on everyday life were common, for instance, in the sale and circulation of products made by the Ceibo social enterprise. Valuing dialogue and exchange spaces is a resource that assists with the formation of critical individuals who are aware of their social reality (Freire, 2018). Understanding the power relations that occur on everyday life is of great importance for individuals not only to understand the violence to which they are arbitrarily summitted, but also to plan cooperative and solidary actions to transform their realities (Lane, 1996). This aspect was present both in the discursive scope and in the participant observations of the occupational therapists’ practices.

Conclusion

The theoretical-practical elaboration of the terms shows that territory concerns what can be seen: the materiality expressed in buildings, streets, trees, squares, cars, and people circulating, as well as what cannot be seen: the history that permeates the buildings and the lives constructed there, the relationships established between people, and the everyday life that imposes ways of conducting the times and powers that happen beyond face-to-face negotiations and are involved in people’s lives. The occupational therapists of the practices studied develop actions that are interconnected and dialectically connect the micro- and the macro-social axes that synthesize the term territory.

For occupational therapy in Latin American countries, community carries the notion of democracy, collectivity, and production of networks of belonging and identity. Community corresponds to people who inhabit territories and/or participate in organized groups and identify with each other, whether by the place and everyday life they share, by mutual support, or by the understanding of the similar living conditions they experience in the same space. In practice, these are actions that occur in the collective sphere, involve people and their ways of life, and aim to build spaces for participation, dialogue, and autonomy of the collectives.

Although these terms are used separately, it is concluded that professional practice refers to a territorial-community action, that is, to speak of these terms together and dialectically is to point to the proposition of an action that encompasses the individuals’ ways of life, the relationships they establish with their living spaces, and the weaving of solidarity in places as a purpose of professional action. Therefore, it is about the composition of elements of the concepts of territory and community that constitute the possibilities of occupational-therapeutic practice in this sphere.

It is also highlighted the need to overcome the use of territory and community only as an indication of scenarios and physical spaces of action, as this discussion presents and proves other dimensions that constitute specific characteristics for what is defined as territorial-community actions, which differ greatly from “only” modifying the intervention scenario.

Moreover, it is pointed out that occupational therapy territorial-community action is not restricted to a single area of practice. This study followed up a diversity of experiences and demands: a social enterprise linked to mental health, a community caregiver program of an NGO, a cultural community center linked to mental health, and a rehabilitation service via a university project. The principles raised as characteristic of territorial-community action were present in all of them, each applied to the specific needs of its areas. Furthermore, it is also worth emphasizing that Brazilian social occupational therapy has pioneered studies and productions on territorial-community action in its fields of action.

In short, as professionals who have the opportunity to practice in territories and with communities, Latin American occupational therapists can act as mediators in the construction of collectives and solidarity networks that serve to support and sustain common lives. Hence, territorial-community action is not just about promoting displacements of physical spaces for professional intervention, but rather about problematizing and reflecting on who is in that space and how relationships occur in it, apprehend which ways of life are being produced and create mechanisms to support, enhance, or build solidary relationships that strengthen everyday life, and perhaps break down into elements that enable awareness of the social place occupied and the macro-social issues that permeate life.

• 1
  The names of all social services and facilities followed in the study are fictitious. Flowers typical of each country were chosen to represent their identity and preserve the confidentiality of the participants.
• 2
  It is worth noting that, at the time of Milton Santos' writings, it was common to use the term “men” to generalize the human condition. Currently, the use of this term is questioned and problematized because of its insufficiency in contemplating the complexity of the human condition and, in particular, the specificities of the condition of women in society, debated by the feminist movement. Thus, aiming to provoke a discussion on the theme, we chose to point out and highlight the female profile of the Chilean experience.

• Funding Source:

  This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.

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Edited by

Section editor

Profa. Dra. Adriana Miranda Pimentel

Publication Dates

• Publication in this collection
  13 Dec 2021
• Date of issue
  2022

History

• Received
  21 June 2021
• Reviewed
  15 Aug 2021
• Accepted
  15 Sept 2021