RESEARCH ARTICLES

Environmental interfaces in health: a study of school agers

Arina Fonseca^I; Fátima Helena do Espírito Santo^II; Lina Márcia Miguéis Berardinelli^III; Rose Mary Costa Rosa Andrade Silva^IV

^I Nurse of Aristarcho Pessoa Central Hospital, Master in Nursing. Niterói, Rio de Janeiro, Brazil. E-mail: arinafonseca@hotmail.com
^II Nurse, Ph.D. in Nursing, Adjunct Professor of Medical-Surgical Nursing Department and Aurora de Afonso Costa Nursing School of the Federal University of Fluminense. Niterói, Rio de Janeiro, Brazil. E-mail: fatahelen@hotmail.com
^III Nurse, Ph.D. in Nursing, Adjunct Professor of Medical-Surgical Nursing Department of the Nursing Faculty of the State University of Rio de Janeiro. Brazil. E-mail: l.m.b@uol.com.br
^IV Nurse, Ph.D. in Nursing, Adjunct Professor of Medical-Surgical Nursing Department and Aurora de Afonso Costa Nursing School of the Federal University of Fluminense. Niterói, Rio de Janeiro, Brazil. E-mail: roserosauff@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2015.10086

ABSTRACT

This qualitative, descriptive study used action-research to ascertain children's knowledge of healthy living that can make them co-responsible for their own health. In August and September 2013, during nursing appointments at a Military Medical Clinic in Niteroi/RJ, Brazil, 19 schoolchildren from 7 to 12 years old took part in semi structured interviews. The data were subject to Bardin's content analysis, followed by categorization. The results showed that children have knowledge able to foster a life based on healthy behavior; that, however, requires incentives and professional action to build productive relationship interfaces with the children. It was concluded that nurses can mediate at these interfaces and contribute to children's autonomy in co-responsibility for developing healthy habits.

Keywords: Nursing; children; healthy behaviors; autonomy and co-responsibility.

INTRODUCTION

The World Health Organization (WHO) describes the alarming situation of non-communicable chronic diseases (NCDs) whose incidence increases, both in developed countries as in development, for people of all ages. The main NCDs are cardiovascular, diabetes, some cancers, and respiratory diseases.

The main causes of NCDs are well established: smoking, alcohol intake, sedentary lifestyle, unhealthy diet, and obesidade¹. These are some of the common modifiable risk factors for the main NCDs, i.e. habits or transformable behaviors before they cause damage to the individual's health.

Health promotion actions aimed at reducing morbidity and mortality rates from NCDs are based on the decrease in exposure to modifiable risk factors, and health education is a tool for the practice of health promotion in this ambit.

Between objectives, goals and actions developed by the Strategic Actions Plan for the Confrontation of NCDs from 2011 to 2022², a partnership between Ministries led by the Ministry of Health (MH), the child is targeted as a focus of attention. Although not being a policy focused on health care for the child, it is very important and enables to achieve objectives proposed by the Commitments Agenda for Integral Child Health and reduction of child mortality, which shows the care with children as essential for MH, and emphasizes the integral and multi-professional care^2,3.

Modifiable risk factors integrate the group of individual risk factors, but this does not mean that actions, to decrease the risk exposure, have an individual character. To face the problem, it is necessary to know the environments where this individual is inserted, which concepts are already established in their life and possible ways to collaborate in the formation of healthy behaviors.

Health education in this context should be understood as mobilizing of social participation because the real educational practices have only placed between social subjects, with emancipatory character, participatory, creative and dialogical, contributing to citizen's autonomy⁴.

Given the above, this study aimed to analyze the children's knowledge about healthy living that can make them co-responsible for their health.

THEORETICAL REFERENTIAL

The environment concept proposed in Nola Pender⁵ Health Promotion Model, as the empowerment⁶, structuring concept of health promotion, were used in the analysis. Pender defines environment as the social, cultural and physical context in which life develops, and may be manipulated by the individual to create a positive conjuncture for beneficial health behaviors. Interfaces with family and classmates collaborate determining norms and models, beliefs and attitudes related to the engagement of a particular health behavior⁷.

The empowerment, in Portuguese empoderamento⁶, enables individuals, in particular and collective way, learning that enables them to live all stages of life, dealing with restrictions imposed by the eventual diseases⁶.

Thoughts from authors such as Paulo Freire⁸ and Merleau-Ponty⁹ were also used to analyze and understand learning and child world, from their perspective.

In Freire's pedagogy, freedom is essential to the educational practice, only reaching effectiveness and efficiency with the free and critical participation of individuals⁸. But Merleau-Ponty⁹ states that the body makes the apprehension of a meaning, and when the child gets used to distinguish two colors, for example, it appears that the acquired habit is benefiting the distinction of other colors. Therefore, the child's system changes before the influence of the environment on a form of pre-adaptation to stabilize in the environment and develop the potential, existing reciprocity between stimulus and mean.

METHODOLOGY

This is a qualitative, descriptive, and action type research, performed in the city of Niterói, Rio de Janeiro, in a Military Medical Polyclinic, whose subjects were selected according to the following inclusion criteria: children aged between 7 and 12 years old, demonstrating understanding capacity, regardless of gender, ethnicity, religious belief, with autonomy to answer all questions and express a desire to participate voluntarily.

And exclusion, children of different ages than stipulated, without autonomy to participate and answer questions. The child terminology was used, according to the Law, considering person under 12 incomplete years old and, adolescents between 12 and 18 years old¹⁰. Similarly, this terminology is also considered in the Health Sciences Descriptors (DeCS) ¹¹. Children who agreed to participate in the nursing consultations were authorized by their responsible.

The study was developed according to the recommendations in the current legislation about research involving human beings¹², being approved by the Research Ethics Committee (REC) of the University Hospital Antônio Pedro, at the Federal University of Fluminense, under the Opinion Nº. 411723.

As for the obtained testimonies, it was observed the anonymity of the subjects, which received character descriptions of literature and children's films, followed by their age.

The data were submitted to the analysis content of Bardin¹³ following the steps: pre-analysis, which was systematized the analysis corpus , floating and exhaustive reading, followed by an exploration of material and results treatment, inferences and interpretation.

Then, the relevant contents were identified, i.e., the intervals that marked the testimonials because they are similar or different. After the identification of registration units (RU), the data were grouped by the convergence of content, emerging the following analytical categories: Between the ideal and the real, and the environment interfaces for health.

This article will approach the second category which has four sub-categories to meet the objective in question: Family and school; Health as absence of disease; Change movements; and Playing.

RESULTS AND DISCUSSION

Among the interfaces identified in the statements of children, family and school are remarkable, facts concerning their age that have in these environments the possibility of acquiring knowledge. The produced knowledge lead to the formation of concepts of health and illness, and, when stimulated by other individuals or concepts, lead to the development of critical thinking able to create and recreate actions according to their judgment. Thus, the movement changes happen. Finally, playing, activity inherent to be a child is perceived in context units expressing playing as a way of maintaining being healthy ¹⁴. Playing represents the imagination in action and is the result of human relations, thus originating the relationship interfaces that the child individual possesses.

Family and school

The results show children expressing behaviors mirrored in the parents or other family members, ratifying the familiar importance building good health habits:

My father is trying to teach me foot-volley [...] he taught my sister [...]. My sister already knows, he wants to teach me, without him I can't. (Fiona, 10 years old)

I do not know; my mother said it is good, white meat [...] (Little Bell, 13 years old)

The environment is defined as the social, cultural and physical context where life develops and can be manipulated by the individual to create a positive conjuncture in the beneficial health behaviors. Interpersonal influences such as family, school or work friends, collaborate determining norms and models and beliefs and attitudes related to the engagement of a particular behavior health⁷.

The interfaces influences with people in the environment and not in the family structure should be considered, for example, an employee:

[...] Catia does not well, she fills the food with salt and margarine, now Mom is looking around, and my cholesterol is decreasing. (Little Mermaid, 7 years old)

The mother is, in most families, the primarily responsible for teaching the body care. The father has a similar role, both constituting the first educators transmitting cultural representations, values and beliefs, striking for school because it involves affection⁸. The association of positive emotions to the health behavior increases the likelihood of commitment to action in question^5-7.

And I also stay all day watching TV, playing the videogame, and also my parents don't let me going out of the house to play there. (Wolverine, 9 years old)

The power of parental decision about the children life can be responsible for inappropriate behavior to good health.

Families of obese children are considered an important agent for the prevention or maintenance of obesity condition, playing a significant role in feeding education of the child, influencing in the sense of having or not healthy habits into their routines¹⁵.

My cousin is a little overweight [...] Then, she went to the nutritionist. My grandmother was giving some food for her... then after she started to eat slowly and began to balance. (Minnie Mouse, 10 years old)

Identifying the problem of her colleague, that girl responds to the obesity problem: the balance. Human beings interact with their environment seeking to mold it to satisfy their needs^5-16. So, understanding other people's problem, it can reflect critically shaping their environment positively to their healthy behavior.

Studies describe that physical activity habits can be strongly influenced by the school, assisting in the formation of lifestyle and health behaviors, because children and adolescents spend most of their days inside the school¹⁷.

[...] sometimes there are some sports that help us [...] in school. (Fred Flintstone, 9 years old)

Then, the student is another trigger interface of health behaviors, although, in this case, a feeling of affection and love does not arise in the same way as a family.

In the Pender Model of Health Promotion, previous behavior and acquired beliefs are factors that affect the construction of health behaviors and, consequently, health promotion¹⁸. Here, knowledge's acquired in school are primordial. When asked about what makes good...

Go to school, [...] go to physical education, go to gymnastics, playing on the playground and playing with my toys at the playground in the news day. (Little Mermaid, 7 years)

Individuals, before their bio-psychosocial complexity, tend to interact with the environment, gradually transforming it and be transformed over the time ^5,16,18,19. Thus, children interact strongly with their environment, which, in large part, are the family and the school, suffering changes and modifying them with their curious and innocent affirmative inquiries, but full of truth.

Health as absence of disease

In the early twentieth century, health was understood as the absence of disease and government health promotion actions were focused on the control of diseases. In 1948, the WHO defined health as "a state of complete physical, mental and social well-being and not merely the absence of disease" ^20:65. Considered a utopian concept, it should now be followed by a goal to be achieved.

Currently, several authors understand health more dynamically, as a permanent construction process of each and the comunity^2,4,6.

The student, strongly demonstrates the concept of health as absence of disease, i.e., for them, getting medicine now has health:

[...] I went to the doctor, and then thank God did not give me Benzetacil, right? He gave me some medicine, and then I was taking, taking and got better. So the remedy is good too. (Sweetie, 9 years old)

This conception linked to the disease makes the child connect being healthy and medical actions:

Updated vaccines, see a doctor at least once a month, a week and if you need to take medicine. (Little Flower, 9 years old)

Considering the definition of health by WHO²⁰, no human being is totally healthy. However, the health situation undergoes a series of interactions in complex individual and collective life throughout the life. Not being a stable state, it is constantly influenced by the way of taking care of the body, by the interpersonal relationships, by work, as well as other environments and relationships that interfere with personal dynamics.

For its high degree of subjectivity and historical determination, individuals and societies consider health from experienced moments, values and/or the facing needs²⁰. In the case of the student, this transit between reality and imagination³ contributes to the vision of health as opposed to disease and to the appreciation of the diseases that sometimes they hear:

I've heard of hepatitis, except I do not know what it causes. [...]. Huh. Swine flu [Laughs]. (Shrek, 11 years old)

This study allows understanding the point of view of the student through a crouching attitude, which meets the child closest to the ground, in the world they inhabit²¹, in an almost ingenious way, verifying that many of the submitted statements may be related to the lived or known experiences, the interfaces.

The analogy between healthy habits and the presence of NCDs appeared in a few statements, therefore, for some analysis, it is necessary to appreciate the imaginative context of the student.

[...] if you eat lots of pasta and sweet, you'll end up with too much sugar in the blood [...] when we eat a lot of frying, fat ends up going to the heart [...]. (Minnie Mouse, 10 years old)

The formed neologism demonstrates a fusion between the gluttonous and the obesity state. One can interpret that in the imagination of this child, the act of eating too much, i.e., being gluttonous²², results in obesity:

What is the name of the disease if we get eating junk food? And we get fat [...] I remember, but I forgot. No.[...]. Gluttonous???? It is obesity. You do not get healthy. It is [...] fat. Heart problem. (Bugs Bunny, 9 years old)

WHO studies show that the first step for the transformation is communication and the most updated and accurate information to front-line health professionals and also to the population because with the existing and widespread knowledge it is possible to improve the reaction to unfavorable life styles²³.

Thus, health, in its broadest and complex concept, is constructed as a social product, collectively and individually, with actions at several levels from the individual through the actions of society to government, generated in various interfaces.

Change movements

One of the characteristics observed in the data collection were the actions, indicating changes in lifestyle or health behavior, either because of health problems or medical guidelines and/or family, sometimes stimulated by questions of the researcher.

Lately, I'm eating more vegetables. I didn't eat so much in the past; I didn't like. Now I start eating. [...] Because of my allergy I started to improve the food. (Woodpecker, 12 years old)

Improving my diet. [...] to improve feeding, drink plenty of water. (Minnie Mouse, 10 years old)

The attitudes that usually lead to lifestyle changes are consequences of learning through experienced situations. In this context, the dynamics of empowerment⁶ is flagrant. These actions must be performed in different environments such as schools, homes, workplaces and other collective environments⁶, and health environments.

Some statements about children changing, vulnerable to information that can guide them in healthy ways throughout life, refer to changes in the family that is considered the first and main transmitting agent of behaviors and lifestyles²⁴:

My grandfather smoked, but now he stopped [...] I don't like because I think it's bad for our health. I like tomatoes. Tomato is also good; I eat bananas, grapes, which is also good. I eat the healthiest thing. (Fiona, 10 years old)

Health education actions for children should be a priority in Public Health Policies, since the entry into adolescence is critical on autonomy, affirmation, and independence. If they have the opportunity to develop healthy habits, could be adults with a better quality of life.

Many foods I don't eat. I know I have to learn to eat, but sometimes, I don't like. (Sweetie, 9 years old)

The massification defended by Freire is the inverse of the recognized attitude in these lines. When the individual massifies loses the ability to distinguish what makes good or bad. Even if changes can be retarded and dependent on different levels, it is imperative to recognize the need for change. Thus, the education should be a constant attempt to change attitudes⁸.

Understanding the body as full of subjectivity and shaped by historicity, as the thought of Merleau-Ponty, the consequence of these facts is in the theoretical and practical decisions of life and knowledge of each individual⁹. The empowered student can decide the best for their health, eating or making the unhealthy, but pleasurable in individual moments. In the example, their subjectivity, historicity, and knowledge were used to take such a decision²⁵.

To say no to certain harmful attitude to their health makes the child holds practices, but, as a child, this power passes by adults, giving them the responsibility to guide them in healthy ways.

Playing

The action of playing is defined as a complex behavior and, therefore, has different settings for different authors and may be characterized as a behavior that has an own end, with a free origin, free of obligation, motivated by pleasure²⁶.

Cultural and social issues strongly mark the children games, as well as the social characteristics of each population. Concepts such as ludic area help to explain these playing influence aspects. The ludic area is defined as consisting of three elements where children with their experiences, resources, motivations, pressures and social conditions, interact with the physical space where is inserted, considering the toys that have access, and finally whether relating to the third element that is the timeline (time dedicated playing and family beliefs)¹⁴.

Students also relate playing to the imagination, linked to the dream, the thought and the symbolic and at the same time, as a tool to work the education of children, because during playing they create, recreate and relate to the world^27,28.

It was observed that playing has been identified as a member of various forms of physical activity. Playing was considered a common physical activity for children when asked what types of physical activities they could do.

Physical activity [...] I think to play. Play running? It is to play running, dodge ball, three cuts. (Minnie Mouse, 10 years old)

Swimming, volleyball, basketball, playing fun games, playing, run. (Barbie, 9 years old)

According to some research²⁹, the number of sibling influences the physical activity of child playing, i.e., the more siblings, the more they will play. This fact is related to the regulation of body weight, constituting an obesity preventive factor²⁹. The speech below illustrates what the research describes:

I don't watch television, I stay playing because there is a lot of children, and my home is boring, do not have people to play with. (Minnie Mouse, 10 years old)

Parents and the school, because they are the environments where children practice most games, should be promoters of active playing not only as a preventive measure of obesity but also as a therapeutic way when obesity is already present²⁸. Considering also that playing like games are used as learning tools for various health issues³⁰.

When generating a parallel between physical activity of adult and child, this interviewed corroborated to identify playing as a form of physical activity:

Running, to exercise [...] in the case of children to play, and for adults, going to the gym [...] I think that's all. (Cinderella, 10 years old)

Knowing the child from their world is the proposed by Merleau-Ponty⁹ and recognizes in playing, the way they create and expresses to the things of the world could be the best way to help them mediating the way for building a healthier life.

CONCLUSION

Among the four subcategories analyzed in this article, family and school, health as absence of disease, change of movement and playing , emerged the need to consider the student as a focus for health education, since knowledge demonstrated by them about healthy life and actions that make them co-responsible for their health, were vast. The family and the school as habits generation interfaces should be considered allied in the construction of health behaviors.

Increased access to information should be considered, therefore, allows the child's empowerment and provides a change of thinking about health just as opposed to the disease, as their vulnerability to information from which indicate movement changes in their environments.

It is necessary to make health education a constant search for changing attitudes and behaviors, knowing that often the repetition will be primordial and, at other times, different forms of action should be taken. The government incentives with health programs are important but not the only responsible. The health care professional should understand that their individual actions can affect the health behavior of many individuals, especially when they are children because in their relationships interfaces will add their knowledge to other individuals.

The limitations of this study are due to the occurrence of a single meeting, not being able to reproduce with other children groups, considering the estimated time to develop the study.

It is concluded that the nurse, trained and active professional in different environments, may be the mediator of these interfaces and contribute to the autonomy of the student in the co-responsibility of the development of healthy habits through health education actions.

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