Introduction

For those who work in interdisciplinary health teams and create spaces for dialogue and coordination of public policies, the concept of territory is fundamental when it comes to generating information that leads to the decision-making process (1). The territory becomes significant in public health when we observe, for example, inequalities in access to public services, dissimilar standards of living, and, consequently, differences in the way of getting sick, which affect the individual's and the population's perception of well-being (1).

In the area of health, the territory, according to Monken et al. (2), is thought of from two perspectives: "one that sees the territory as a physical, geopolitical space, with a topographical-bureaucratic vision; and another that understands the territory-process as a product of a social dynamic where social subjects placed in the political arena are intended." In other words, the territory is understood as a space with active social subjects that endow it with meanings and identities. Based on the above, it is necessary to put on the table the concept of territoriality with a public health approach, which has evolved and has been endowed with critical meaning regarding the social and community context for the "social determinants of inequalities in the health-disease and death processes" (3). In other words, the territory, from a critical approach to health, is not necessarily a physical space but a socially constructed space that its inhabitants have endowed with certain social, economic, cultural, and environmental relations, and that provides inputs to design and implement public health policies (3,4).

This article aims to discuss two concepts: territory and territoriality, which should be taken into account in the framework of the construction and implementation of public health policies. To achieve this, it starts with a methodology that takes as a reference the perspective of academia, through a literature review on the subject, and the individual and collective perspective of citizens and representatives of the health institutions involved in the framework of the Territorial Health Model called "Salud a mi Barrio, Salud a mi Vereda" (Health in my Neighborhood, Health in my Village), in the hands of the District Health Secretariat (DHS) of Bogotá (Colombia). Subsequently, the results corresponding to these sections are presented, emphasizing the joint analyses and the presentation of the definition of associated concepts. Finally, some discussion points are given, from which the main findings are addressed and perspectives to be taken into account in the framework of the territoriality-public health models debate are raised.

Methodology

Systematic literature review

A systematic search of the literature on the subject was carried out to identify the definitions of territory, territoriality, and rurality in the context of primary and community healthcare models. We included documents that mentioned in their content any of the definitions of interest, that had a publication date after 2000, and that were written in English, Spanish, or Portuguese. No restriction was made by methodological design, type of population, or publication status.

Platforms such as Pubmed, Elsevier, Virtual Health Library, Web of Science, and ProQuest were used for the search. Gray literature was also included, through web search engines, with emphasis on web pages of governmental and non-governmental institutions. Finally, literature submitted by members of the Bogota DHS was included.

A search strategy composed of controlled vocabulary (MeSH, Emtree, and DeCS) and free language was outlined, considering synonyms, abbreviations, acronyms, acronyms, spelling variations, and plurals. The syntax was complemented with controlled term expansion, field identifiers, truncators, proximity operators, and Boolean operators. The strategy was adapted according to the thesaurus of each of the databases used. Additional free and indexing terms were identified using the Vosviewer tool (5). The search was performed on December 23, 2021.

After eliminating duplicate documents, each one separately, two reviewers selected, based on the titles and abstracts of the publications, those references that met the inclusion criteria. To carry out this process, the Rayyan© platform (6) was used. The selected articles were read in full text by a single evaluator, who proceeded to code the text of the articles to extract concepts and definitions using NVivo© 12® (7).

Meetings for the dynamization of groups using the world coffee-type methodology

For the collection of qualitative data, we used the strategy of world coffee-type group interviews, which seeks to "discuss a particular topic in small conversation groups that rotate as the workshop develops" (8). In this way, it allows and deepens different perspectives that contribute to the discussion of the central theme of the debate and enables participants to come up with different solutions and proposals. This methodology is based on generating spontaneous and guided debates and can be carried out with several demographically different and plural people. For this work, two groups were constructed in each of the world coffee-type group interviews: one fully composed of representatives of the institutions, and the other with the presence of people from the community or organizations that work with it. After assigning the participants to their respective groups, due to the flexibility characteristic of this methodological modality, new conversations that arise from combining the discussion groups after a certain time were held (8).

In this case, after a first moment of discussion in the groups determined at the beginning, the groups were combined and given a mixed character to exchange knowledge of what was discussed in the first part of the activity. Under this methodology, participants approach the topic to be addressed through different projective strategies that allow association, construction, completion, or ordering to facilitate the expression of their perceptions, opinions, and analysis of the definitions of the different approaches (8).

The strategy of micro-audiences was used, which is a methodological innovation that employs direct democratic mechanisms to achieve different points of view on one or more topics (8), and seeks to respond to a relevant question. These micro-audiences were previously defined based on the conditions or situations framed in the differential approach (9).

The strategy of micro-audiences was used, which is a methodological innovation. In each of the world coffee-type group interviews, populations of interest for the project were included, namely: people's life course, women and new masculinities, victims of the armed conflict and peasants, LGBTIQ+ population, people with disabilities or caregivers, migrants, the population of different ethnic groups, and other populations with vulnerability (recyclers, paid sex workers and street dwellers). Subsequently, an analysis was made based on the preset categories and those that emerged for each of the interviews.

Finally, a precise definition of the concepts under study was consolidated as a result of a triangulation process carried out by the authors, taking into account the findings of the literature and the analysis of the world coffee-type group interviews.

Ethical aspects

Before the beginning of each of the group interviews, a verbal consent form was read to the participants, which included a documentary record through recordings and the collection of material resulting from the research exercise. Participants were assured of confidentiality, anonymity, voluntariness, and other ethical considerations, as defined in qualitative research methods. The meetings were recorded with the informed consent of the study participants. This research is considered of minimum risk, according to Colombian regulations, per Resolution 8430 of 1993 of the Ministry of Health and Social Protection, which regulates and establishes the scientific, technical, and administrative standards for health research (10).

This study was approved by the Research and Institutional Ethics Committee of the Faculty of Medicine of the Pontificia Universidad Javeriana and the Hospital Universitario San Ignacio, on September 28, 2021, by minute number 34/2021.

Results

Literature review

A total of 6510 references, initially identified by the search strategy, were reviewed. A total of 2099 were eliminated as duplicates. The remaining 4411 were reviewed by title and abstract; in addition, 163 were included for full text reading. Of these 163, 4 were not available in full text, and the information provided by the abstract was insufficient for research purposes. Another 26 were excluded because the full-text review did not identify data relevant to the question posed. After reading the full text, definitions were extracted from 57 documents. The search of gray literature and the documents provided by the DHS identified 36 documents, 26 of which were provided by specialized professionals from the DHS. In total, information was obtained from 93 documents.

Of the 93 documents, 16 references were identified with definitions for the concepts of territory, territoriality, and rurality in integrated healthcare models. Five of the references identified are operational documents or guidelines from entities: The Ministry of Health and Social Protection, Health Secretariats (Bogota and Medellin), the Government of Antioquia, and the Subredada Integrada de Servicios de Salud Sur ESE. The remaining 11 references are described in Table 1.

World coffee-type meetings

In total, within the research, there were eight world coffee-type group interviews in which 97 people participated (93 filled out the characterization survey). Of these participants, 52.6% belonged to the community, while 47.4% belonged to the institutional sector. The institutional participants came from the DHS of Bogota or other governmental entities, as well as representatives of companies that administer benefit plans or institutions that provide health services. On the other hand, most of the community participants were affiliated with non-governmental organizations or foundations, while the rest had no affiliation whatsoever (Table 2).

Results triangulation

Based on the literature on the subject, the territory, seen from the territorial approach, is not exclusively a physical or geographic space, but a socially constructed space that its inhabitants have endowed with certain social, economic, cultural, and environmental relations (3,4). In other words, the territory can be understood as the result of the union between geographic dynamics and how human beings develop their lives in society. In any case, it is a complex relationship that generates tension between the geographic dynamics, since this conditions the type of human relations that develop in the territory; but the human relations that exist in a physical space also generate a transformation of its territory or geographic space and its dynamics (11).

On the other hand, the territorial approach addresses the way public policies are made and considers that information on the territory is an important input for guiding decisions (12). In other words, state interventions aimed at improving the welfare of its citizens should understand the territory as the place where the particularities that guide these interventions are structured (4,13). Thus, based on the territorial approach, a step is taken towards improving public policies focused on specific sectors or populations and making progress in interventions that take into account the social, economic, cultural, environmental, and geographic context in which citizens live (14). Finally, in this approach, citizens are obliged to actively participate in the interventions carried out by the State in their territory (15).

When speaking of the territorial approach in health, it is necessary for any public policy focused on health care to focus on understanding the territory to which the citizens to be intervened belong. Therefore, recognizing the different territorial contexts, interventions must be differential, both in the provision of health goods and services, based on their particularities and determinants (16,17). Such interventions more effectively meet the health needs of citizens while reducing health inequities between territories (rural and urban). Likewise, one of the characteristics of the territorial approach is a contextual reading that leads each territorial entity to strengthen its autonomy and capacity to take care of its own health (15).

As the main findings of the world group coffee-type interviews, the participants representing the institutional framework coincide with this definition of territory. They also stated that in the territory converges, in addition to the land itself, all other human experiences (the habitual, the population, the administrative, and the political).

Seen in this way, there are multiple territories, insofar as the relationships that the inhabitants establish among themselves and with their physical space are unique and unrepeatable; each one has its own conception of the territory it inhabits. Given the existence of multiple territories, the territorial approach is starting to be considered important for the institutional framework, since any public intervention requires serious and informed knowledge of their characteristics, in order to effectively address the population's needs. To achieve this purpose, it is necessary to georeference diverse population groups (with disabilities, migrants, ethnic groups, LGBTIQ+, etc.) within the city and see where they are concentrated in the different territories.

For the members of the institutions participating in the group interviews, territoriality can be understood as a need for public intervention aimed to improve the population's well-being, focusing on the particularities of the territories. To achieve this, an intervention is effective if, in addition to focusing on the community as a whole, it also focuses on the individual inhabiting the territory. The population of a territory, made up of diverse aspects such as sexual orientation, ethnicity, or culture, requires a differential approach (differential focus) to their needs and requirements, which can only be achieved by gathering information in the field. In the words of a member of the institutional framework in the framework of the world coffee-type meetings:

Precisely [it is necessary] to know the territory very well and to make a kind of differential diagnosis in each territory, which must be constant. It cannot remain in a baseline and from there continue the work, but it must be a continuous differential diagnostic work of its territory to be able to know [...] the diversity it has and to be able to build collectively with the people. (Institutional participant in a group interview in world café type)

The members participating in the world coffee-type group interviews belonging to the institutional framework considered it essential to include another component in the concept of territoriality: the provision of health goods and services that used to be provided by the State in hospitals, medical centers, or other scenarios, is now moving to the neighborhood or directly to the citizens' homes (18,19), This type of health intervention, when taken to the territory, necessarily becomes a more participatory action, to the extent that the inhabitants, when visited, become involved by expressing what they require and how they want it to be provided; in addition, it focuses attention on preventive health. In other words, territorial reading becomes vitally important in this scenario.

The community participating in the world café group interviews showed a vision of territory similar to that of the institutions. They understand territory as the conjunction of bodies—with their relationships established by them within it—and physical or geographic space. They also demand the elimination of barriers to health access caused by physical distance and a poor understanding of the needs of citizens in the territories. They consider that health services are not available in the places where they live or that they do not have a different approach that responds to their needs and rights.

According to what has been stated in the specialized literature and by the institutional participants in the research, the public policy required by "the community is one in which its needs are differentially recognized as a community and which is physically close to the homes" (20). Likewise, it is constantly mentioned that it is necessary for the community to participate more in state interventions, to the extent that they are the ones who, through their community organizations and their knowledge of the territory, have the clearest and timeliest information on their health needs (or any other aspect) and the way in which they need them to be met.

Another approach of the community members who participated in the world coffee-type group interviews was that the physical approach of health interventions to the territories, as well as the elimination of distance barriers to care, could generate a comprehensive approach to community care. In this sense, public health policies should not only focus on the prevention or treatment of the disease, but also be broader and articulate with programs for recreation, sports, culture, and care for caregivers. "In short, it is to intervene in the community of a territory, recognizing what makes it particular, from a welfare perspective, and this is not achieved individually, but at a higher level: that of the family and the neighborhood" (20).

Based on the above, the triangulation process carried out considered the different sources collected: literature and documents provided by the DHS, gray literature, and the analysis of the world café group interviews. This process allowed the emergence of the integrating definitions of territory, territoriality, and rurality, included in the research (Table 3).

Territory and territoriality

The territory is the result of a social construction that involves a physical space that is not neutral but is endowed with meaning and in which there are social relations that transform it. In this sense, territoriality is understood as the result of dynamic processes that allow the creation of particular living and working conditions for each population; therefore, the territory remains changing given the social dynamics. Knowledge of territoriality allows for the identification of vulnerabilities and the integration of the institutional framework into the territories.

Rurality

Rurality is understood as non-urban territoriality, the result of dynamic processes that allow the creation of particular living and working conditions for each population. Knowledge of rurality makes it possible to identify vulnerabilities and integrate institutions into the territories.

Discussion

This section aims to address different debates, in a brief and precise manner, on the relationship between territoriality and public health models. What is proposed here is the result of research and analysis by the authors of this article. In this sense, the following topics are addressed insofar as they constitute complex and connected responses: (i) the need to understand the social dynamics that construct territoriality; (ii) the links between territoriality and identity and the social, as well as the ruptures that are present and exist; (iii) the relationship between territoriality and institutionality and their scope; and (iv) the explanation of the concept proposed by this research.

From the literature on the subject, the territory is a space where people live multiple experiences, such as being born, developing, and dying; it is also part of a geographically delimited place inhabited by different groups of people, in which each person creates his or her way of life according to age, gender, ethnicity, among others, and where interaction ties are woven to coexist and survive (13).

It is there that the identity characteristics of social groups that allow their cultural recognition are constructed. This is what is meant by territoriality: that symbolic representation that is evidenced through the human activity as a result of social interaction. For this reason, understanding the social dynamics of geographic spaces is fundamental to identifying and recognizing territoriality and the territories present in them (23). What was found in world coffee-type group meetings shows that territory and territoriality are similar to what was found in the literature, though approached a little more from a more in-depth differential and rights-based approach. In this sense, the qualitative research shows the importance of knowledge of the territory and its social factors as a determinant when implementing public policies.

Territoriality derives from the appropriation of the space one inhabits, which is a characteristic of human behavior. In fact, it can be considered that the concept of ownership responds to the close link that is built between the geographic space and the activities that take place in it, to the point of making them indivisible (24). The activities and interactions that take place in a delimited physical space contribute to defining the identity of the social groups present and their actors. For its part, the territory is recognized based on the identity of the social group that defines it, with varying degrees of cohesion and recognition. Unlike identity, which is constructed by belonging to social groups not related to the territory, identity based on territory also depends on administrative boundaries (neighborhoods or localities), attributes of the physical environment that contribute to delimiting the territory (such as proximity to public transportation, schools, temples, etc.), or physical proximity in geographic space (such as nuclei or settlements that are generated in geographic areas during migration) (25-27). This explains the perception of loss of identity that displacement generates since not only is dominion over the physical space one inhabits lost but also the social group relationships that reinforce identity.

This appropriation of geographic space through the territory has various implications for the individual and his or her environment. First, it implies that different territories can be found in the same geographic area, each responding to different identities with specific social dynamics and cultural codes (25-27). Second, it affects the interaction of the individual with the geographic area and may be affected by the attributes of the physical environment. For example, it has been found that the lack of a sense of belonging to the geographic area one inhabits (whether at home, work, school, etc.) is related to the lack of care for these areas, which increases the perception of insecurity and distrust among people (28,29). Third, this conception of territoriality, as an effect of identity and belonging to a social group, affects people's well-being. This would occur, in part, through self-efficacy and self-esteem, which derive from a sense of belonging and having a social role that contribute to identifying the individual and giving him/her a purpose in life (30). Therefore, the recognition of territories contributes to protecting people's well-being by recognizing their diversity, cultural codes, and the nature of the relationships that are woven between social groups, and between these and the geographic areas that delimit them.

However, due to the close relationship between territory and people's well-being, the implementation of health interventions based on geographic areas implies recognizing the territories present. For example, access to health services at care sites is based on the felt need of individuals and may depend on factors related to them (age, sex, level of education, etc.), but also on contextual factors, such as proximity to care sites or the availability of the required services. When, on the contrary, the aim is to provide care in the places where people live, the offer must take into account the heterogeneity of the social groups found in the territories, to effectively respond to the needs present in these geographic spaces.

These particular needs will vary between geographical areas depending on the territories that compose them and their characteristics. While the demographic composition of the geographical areas provides guidance on their health needs, the presence of other territories would also be important determinants of the population's needs and the most efficient way to respond to them. For example, a demographic space where territories with a migrant population, a population with paid sexual activities, or territories defined by religious beliefs coexist may imply tensions, needs, and interactions that require an assertive approach by the institutions. Ignoring this variability in geographic areas would lead to omitting the provision of relevant solutions for the local population and fostering the population's distrust towards institutions (31).

Understanding the institutional dynamics in the context of primary health care also includes recognizing the relationships and conditions that conflict between health policy and the territory. First of all, the practice of health care at the primary care level is shaped by relationships that seek to reach the citizen, recognizing their needs and the complexities that have to do with the territory. For example, the ability to access quality health services and systems when they live in vulnerable contexts (31). Secondly, the importance of reading context: when the institutional framework arrives in a given territory, it is essential to provide it with territoriality and recognize its needs. In other words, as no primary health care program is fully aware of the social relations of the territory, those who are in charge of its implementation are flexible in their decisions, for example, political actors (councilors, mayors, or legislators), as well as health insurers and provider institutions (32).

The definition proposed by this research team has two components: on the one hand, a definition of territory before addressing territoriality since it is not feasible to separate the territory-territoriality binomial. According to what has been reviewed in the literature, it is not pertinent to address one concept without the other. Based on the above, it is considered that addressing the social, economic, political, and health dynamics in a geographic space is not possible without understanding which of these dynamics persist and constantly change in the territories. On the other hand, territoriality has a component of identification and action linked to institutionality. This is the result of giving weight to the institutional capacities that a health model may have. In this sense, we consider it fundamental to go deeper into this point when planning public policies.

Conclusions

Based on a research exercise around the proposal of the Territorial Health Model: Health in My Neighborhood, Health in My Village, of the DHS of Bogotá, this article focused on discussing the concepts of territory and territoriality that should be taken into account in the framework of the construction and implementation of public health policies.

The territory is usually understood as a socially constructed space, the result of the complex association between geographic dynamics and how human beings develop their lives in society, which is why it is crossed by social, economic, cultural, and environmental relations (3,4). As a result of this research, we include in the definition of territory the non-neutrality of physical spaces and the constant transformations that occur there due to social relations.

Territoriality, as part of identity, is understood as the result of dynamic processes that allow the creation of particular living and working conditions for each population. In this way, the territorial approach should allow the State to approach communities not only from a spatial or geographical dimension but also recognize the multiplicity of territorialities (in terms of identity processes) that coexist in each territory.

Public policies and health systems must recognize this multiplicity, both of territories and their territorialities, not only for the diagnosis of community health problems but also for the design of effective interventions.

Territorially based health models must be aware of the interactions and social tensions that arise in each physical space, to propose interventions and health services according to the specific needs of the various communities and thus produce stable and lasting bonds of trust between the institutions and the population.

Among the aspects that health services should consider is the recognition that people live in multiple territories daily (housing, study, work, etc.), which is why there should be an offer of services in all the spaces inhabited by citizens. In addition, each territory must have an offer of heterogeneous interventions that recognize the particular needs of the households located there, as well as those of the people who, in one way or another, also spend their daily lives there.

The need to understand the territory being intervened in is linked to the reading given to it. In this sense, the institutional framework faces the fundamental challenge of understanding the territory through the lens of territoriality and the multiple territories that coexist in a given geographic space. Likewise, not all the people who live in that territory work in it or inhabit it all the time. In other words, a person may sleep in a certain territory, but work in another; this is a factor to understand the needs of the territory and territoriality. As explained, territoriality is linked to people and their living conditions; therefore, institutions are obliged to give them a critical and honest reading of these geographic spaces.

Based on the proposed definition of territory and territoriality, it is suggested that decision-makers and public policymakers in primary health care orient their programs to strengthen, for example, georeferencing systems with a substantial focus on social determinants of health, to improve the effectiveness of interventions. In general, a health model needs to continue strengthening its strategies and activities under a more participatory territorial approach, considering the perspective of the citizens, their needs, and socio-cultural characteristics.

Funding

As a source of funding, it is necessary to clarify that this research was developed through the Special Cooperation Agreement 3028486 of 2021 between the DHS of Bogotá (Colombia) and the Pontificia Universidad Javeriana.

Conflict of interests

The authors declare that they have no conflicts of interest.

Acknowledgments

We thank the members of the community, representatives of non-governmental organizations and foundations, specialized professionals from DHS and other local and national governmental institutions, as well as representatives of health entities, without whose participation these findings would not have been possible.

We would like to thank the Subsecretaría de Salud Pública; Subsecretaría de Gestión Territorial, Participación Social y Servicios a la Ciudadanía; Subsecretaría de Planeación y Gestión Sectorial, and to the following institutions that decided to participate in this study: Secretaría de Integración Social, Manzana de Cuidado, Instituto Colombiano de Bienestar Familiar, Capital Salud EPS-S, Javesalud IPS, Organización ACDI/VOCA, Corporación Casa de la Mujer Suba, Colectivo Hombres y Masculinidades, Grupo Stonewall, Consejo de Discapacidad de Chapinero, Fundación Saldarriaga Concha, Fundación Mahuanpi, Fundación Red Somos, Fundación Zarakua, Equipo de Justicia y Paz de las Hermanas de la Caridad del Buen Pastor and Entidad Medioambiental de Recicladores.

In addition, special thanks to the DHS Home Care Teams, who were fundamental supporters in the methodological construction, planning, and logistics of the world café-type meetings, and to the DHS, for their willingness to allow the use of their facilities to conduct all the interviews.

References

Author notes

^a Correspondence author: albornoz-m@javeriana.edu.co

Additional information

How to cite: Albornoz Sánchez M, Martínez M, Cepeda-Gil MC, Martínez-Álvarez E, Cadena-Camargo Y, Rodríguez V. Approaches and debates of territoriality in the territorial model of health of Bogotá (Colombia). Univ. Med. 2023;64(1). https://doi.org/10.11144/Javeriana.umed64-1.terr

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