ORIGINAL RESEARCH

Precaution and prevention of accidents in childhood: perspective of adolescent mothers

Jaqueline Silva Santos^I; Marcela Stéfany Bonani^II; Marina Sayuri Yakuwa^III; Raquel Dully Andrade^IV; Débora Falleiros de Mello^V

^I Nurse. Master in Sciences, University of São Paulo. Ribeirão Preto, São Paulo, Brazil. E-mail: jaque_fesp@hotmail.com
^II Graduated in Nursing, University of São Paulo. Ribeirão Preto, São Paulo, Brazil. E-mail: marcela.bonani@usp.br
^III Nurse. Master in Sciences, University of São Paulo. Ribeirão Preto, São Paulo, Brazil. E-mail: marina_yakuwa@hotmail.com
^IV Nurse. Ph.D. Professor of the Nursing Course at the University of Minas Gerais State. Passos, Minas Gerais, Brazil. E-mail: radully@gmail.com
^V Nurse. Associate Professor, Nursing School of Ribeirão Preto, University of São Paulo. Ribeirão Preto, São Paulo, Brazil. E-mail: defmello@eerp.usp.br

ABSTRACT

Objective: to identify childcare focused on preventing accidents in childhood, at age six months to two years, reported by adolescent mothers, from a right-to-health perspective. Methods: this exploratory study applied qualitative, inductive thematic content analysis to semi-structured interviews of 20 adolescent mothers in the municipality of Passos in Minas Gerais, Brazil, in 2014. The study was approved by the Research Ethics Committee (CAAE - 21800413.9.0000.5112). Results: the mothers' reports were organized into two themes: Caring, and recognizing the need for constant monitoring; The family as support for protective care. The results pointed to concerns about childhood accidents and the family's role in preventive action. Conclusion: care to protect children's health was envisaged as the mothers' and families' responsibility, and as occurring through continuous monitoring and adjustment of the home environment.

INTRODUCTION

Unintentional injuries (accidents) in childhood mostly occurring at home are a relevant global health problem¹. These injuries are large avoidable^1,2 pointing to the need for reflections on the range of health threats to children² and the importance of continuous assessment of the home environment for interventions aimed at reducing child vulnerability to injuries³.

In this scenario, adolescence motherhood emerges as an event that can lead to vulnerabilities, generating innumerable transformations in the life of adolescents and their families, imposing challenges and incorporating new habits and social relationships⁴. Thus, the performance of the family, observed as the natural environment for child survival and development,⁵ and health professionals, through contributions to the autonomy and protagonism of the adolescent mother in the care of the child⁶, becoming very important to act in favor of a protective and integral care of the health of the child and the adolescent.

Thus, in this investigation, the focus is on the prevention of child health accidents from the perspective of adolescent mothers, given the magnitude of morbidity and mortality due to external causes in childhood², the importance of safe practices at home⁷, concern about the quality of the environment in the child living and the impact on their development⁸, with the understanding that there is an interface between guaranteeing rights and promoting children's health. It is also important to give opportunities to families and caregivers to better understand their opinions, fears, difficulties and facilities in the care of the child.

Based on these reflections, the following guiding question emerged: do adolescent mothers take care of children seeking the prevention of childhood accidents? Thus, the study sought to identify care for children with a focus on prevention of childhood accidents, between six months and less than two years of age, reported by adolescent mothers to defending the right to health, seeking subsidies for clinical practice Primary health care.

LITERATURE REVIEW

The child is recognized as a subject of rights that needs adequate conditions so he can grow and develop in a healthy way^5,9. Faced with child fragility, it is an ethical precept that all adults undertake to act for the protection and defense of the child´s health in the institutional, family and social contexts⁹.

Child health defense attitudes encompass a multiplicity of factors, starting with an expanded understanding of the health/disease process, highlighting that the health professional take a proactive stance, seeking to establish dialogues and partnerships with caregivers, families, the community, as well as with other sectors that are necessary to guarantee the right to childhood health¹⁰.

Considering that the process of caring for the child is often permeated by uncertainties and difficulties for the adolescent mother, in a context of the defense of children's health, it is necessary to prepare this adolescent to face situations that will be experienced by her, directing her not only on the appropriate way of caring, but also on aspects that should be highlighted in care⁴, such as the promotion of child safety in the home environment¹¹.

It should also be pointed out that child safety can contribute to the effective balance in his process of growth and development¹¹. In this way, health professionals are empowered by the adolescent mother and the family for protective care, raising the position of these subjects in interactions, building accountability plans, sharing knowledge and experiences, so greater attention to the child and the exercise of the right to health occur^9,11.

In this sense, it is important to consider the maternal perspectives on the daily care of the child¹¹ as a strategy to explore aspects regarding the prevention of accidents in the perspective of children's rights.

METHODOLOGY

This is a descriptive study, with a qualitative data thematic analysis, based on care¹² and the defense of the right to health ¹⁰.

The research was carried out in the city of Passos, Minas Gerais, with adolescent mothers assigned by teams that work in family health units (USF). For the selection, the 17 family health teams (SF) of the municipality were arranged in a sequence, in descending order, according to the number of adolescent mothers enrolled in the period from 2012 to 2013.

The following inclusion criteria were adopted: being a mother between 12 and 18 years old, having the child between six months and less than two years old, registered and accompanied by the SF team. Exclusion criteria were: discontinuation of the follow-up of the child´s health in the selected USFs, change in the coverage area of ​​the USF, mother with mental health problems, or not be found after three attempts at home at different times. Thus, 20 adolescent mothers from the first seven USF of the developed sequence participated in the study, who met the inclusion criteria and analyzed the theoretical saturation process¹³, verified in the 20^th interview. These respondents were named E1, E2, E3 ... E20.

The data collection took place in January and February 2014 through semi-structured interviews, recorded, lasting 40 minutes to an hour, conducted by the first author in the house, based on the following guiding question: Tell me how to take care of your child to protect and defend his/her health? The meeting in the homes was organized in the company of a community health agent (ACS), a member of the USF. During the visit, the objectives and procedures of the research were clarified and, after the consent of the legal guardian and assent of the adolescent mother, the interview was performed.

After the interviews had been conducted, they were transcribed and the data organized into individual files. The data were treated based on content analysis of the inductive thematic type,¹⁴ to identify, analyze and report patterns from the collected data, culminating in themes that translate significant parts of the data set.

The research was approved by the Research Ethics Committee of the Foundation for Higher Education Passes (FESP), opinion nº 507.936, CAAE: 21800413.9.0000.5112, using a Free and Informed Consent Term (TCLE) and a Term of Assent (TA) following the guidelines and regulatory norms on research with human beings.

RESULTS AND DISCUSSION

In a general characterization, the age of the study participants ranged from 15 to 18 years old, and the family income varied between 1 minimum wage and 4 minimum wages or more; 10 adolescent mothers were single; 10 were studying; 17 had 1 child; 17 counted on the help of other people for the daily care of the child. About the age of the children, 12 were under one year old.

The statements were organized into two thematic units named: Caring and recognizing the need for constant surveillance; The family as support for protective care.

Caring and recognizing the need for constant surveillance

Adolescent mothers recognize that constant attention is needed in the child for the performance of protective care, considering the child development stage and the risks in the home environment.

In the maternal reports, there are concerns about the safety of the child at home. Mothers point to vulnerable situations and risks of falls, choking, burns, drownings, as well as injuries that can be caused by domestic animals:

He is already trying to get out walking; he goes to whatever side. [...] He is adventurous, but we can take him because if you leave, he can hurt. If you leave him in the stroller alone, he almost falls off the stroller, in the tub, he is already almost dropping too. [...] it is just neglecting that he goes to the floor. (E5)

The hard part is that everything he sees he wants to put in his mouth. You cannot leave him alone for a minute; you have to look. He wakes up quietly and rolls on the bed, lucky that when he gets to the edge of the bed, he screams. [...] I have to pay close attention to him, so he does not fall, do not put things in his mouth. (E18)

The stove is also a danger; we have to keep an eye. (E3)

Oh, there is the pool too, she likes to stay by the pool, but then I keep looking, I stand behind her, I do not leave her alone. (E12)

She does not leave the dogs and the cats quiet. She does not care, she comes and wants to play with them, and I am afraid they will hurt her. She is not afraid. I have to be very watchful. (E20)

Studies also found a variety of risks for accidents with children in the households studied. These risk situations can be prevented through educational actions aimed at preventing childhood accidents^3,15, guiding mothers/caregivers/families about the safe home environment for child development.

Here, it should be emphasized that the importance of the theme of childhood accidents is prioritized in the national health agenda, as well as the need for knowledge to be transformed into action for the promotion of child health and safety¹⁵. The importance of the involvement and partnership of several individuals, such as family members, health professionals, and educators, is also highlighted¹⁶.

Mothers acknowledge that the occurrence of minor carelessness can result in accidents with the child at home:

I went to rinse her father´s clothes and put toys for her in the living room. She put everything aside and went to my room and started to cry. [...] When I saw her, she had her head plastered under the bed. [...] I had to raise the bed to get her out. (E3)

These days he almost fell from the cradle. We [the teenager and her husband] were cleaning the room, and we put him in the crib for him to play. A little while, five minutes we did not look at him, he climbed in the crib and was already half-body like this out, almost falling, I was crazy, man! He was left alone with his legs up, so I said 'Son of the sky!' For a second he fell on the other side. (E5)

Some days ago, I left a knife on the cabinet, when I went to see she had this knife in her hand. The closet is soft, and she reached it. I have to stay running all day after her. (E20)

Children are defined as subjects specifically susceptible to accidents ¹⁷. The absence of adequate supervision mechanisms by the caregivers is among the risk factors for the occurrence of childhood accidents¹⁵. The physical and psychological effects, the impact on the household budget and changes in family plans may be some of the consequences of accidents¹⁵. Given this scenario, the maternal recognition of the child´s dependence on care with continuous supervision ¹¹ is a protective factor for children´s health.

Besides constant supervision, for the defense of children´s health, situations reported by mothers reveal the adoption of some strategies aimed at accident prevention:

We [teenager and her family] had a bookcase; it was big. My son climbed it, he climbed, he went into the drawer he had, and he hid. But, the shelf was not screwed, and it was very heavy, then we were afraid the shelf would fall on top of him. Then, before a tragedy happened, we sold it on the shelf. [...] there was a lot of flowers here at home. But we had to give those flowers because we are afraid of eating them, and it is very dangerous. [...] We thought of him, wanted to protect him, did not want anything bad to happen to him. (E2)

When I put him on the couch, I put a pillow on the edge, so he did not fall, did not hurt. (E13)

The way is to look. Sometimes we take some things that he can hurt, put these things up, so he does not get hurt. When the stove is on, I will not let it go to the kitchen. We always avoid, try to prevent. (E15)

Oh, I think we have to always be around him. One minute we leave him alone is dangerous. [...] Pieces, toys, well, these little things, one avoids leaving close to him, so he does not put in the mouth and choke. (E19)

Recognizing the risks present in the home environment works as subsidies for adolescent mothers to adopt some accident prevention measure. One study reinforces the role and commitment of the nurse in the development of educational actions with parents and caregivers, seeking to contribute to the prevention of childhood accidents¹⁶.

Thus, in general, adolescent mothers were extremely concerned about the prevention of childhood accidents. The preventive measures adopted were linked to individual actions aimed at reducing the risk of accidents at home. However, the impact of these actions may have limited potential if several factors involved in promoting child safety in the home environment are not considered. Thus, health professionals can contribute to the development of targeted educational activities by strengthening maternal skills to identify risks, according to the stage of development in which the child is, and adopt preventive measures in defense of the right to health in the childhood.

The family as support for protective care

Care involves fostering, bonding, and accountability¹². In the context of adolescent motherhood, the presence of a support network that supports the adolescent to take care of the child, respecting their needs and particularities, is fundamental for the guarantee of children's rights.

As it goes through stages of the neuropsychomotor development process, the child is acquiring new skills, such as the ability to walk and explore environments, requiring care and attention of the caregiver. Thus, reconciling the child´s care with other activities, such as household chores, can overwhelm the adolescent mother:

Now it is harder; you have to have the energy to take care of him! He wants to learn how to walk; you have to hold him to walk to everything that is around, you have to look at him because he can hurt. Where you put him, he can fall. I used to put him down on the couch, and he would not turn around, he would sit quietly. Now, if you put him on the couch, if you turn, he is already on the floor. [...] He ends our energies, and he still has half of his energy. (E5)

[...] there are times when she wants to be alone on the lap. And for me, it is difficult because I have things from home to do. [...] When I am alone, and I have to do the service of the house, I always keep watching. The same time, I am in the kitchen doing things I am here in the living room to see how she is doing if she is okay. (E17)

When assuming responsibility for the care of the child, changes occur in the daily routine of the adolescent mother⁴. When they are not supported, adolescent mothers may experience feelings of abandonment ¹⁸. Thus, when the act of mothering is reconciled with domestic tasks, there may be an overload of activities and losses in the daily care of the child.

Although she is present in the environment, the adolescent may be busy with other activities, not performing direct supervision of the child. Thus, the mere presence of a caregiver does not prevent the accident from happening ¹⁹. Therefore, in caring for the child, the adolescent mother needs support, which is provided mainly by the family⁴.

The family emerges as a source of support for the prevention of childhood accidents, assisting the adolescent in the constant vigilance of the child:

Oh, I also think the family can help prevent accidents. [...] Now he is already crawling, and I am scared of some accident with him. (E6)

Oh, I think the family can help by looking, watching [...]. My two girls are already walking; I have to keep an eye on them, so they do not hurt. (E7)

I think the family has to keep an eye on him always, all the time. He climbs up on that table here [points to the table] and plays. He climbs on the bed. You have to keep an eye on the crib because he can fall too. [...] He climbs the shelf here from home, he gets more into the shelf than he climbs, but it is dangerous. He climbs on the grid here from the entrance. So, you have to keep an eye on him, twenty-four hours. (E8)

When he began to crawl, he fell many times. There was a time he fell out of bed. Now that he is walking and climbs on everything, he climbs on the bed, descends from the bed. [...] It is a lot of work, but here, thank God, a lot of people help me to look after him, the people here from home help me to look after him. [...] Oh, we look at him twenty-four hours, there is no way we cannot look at him. And you cannot put all the furniture up, so he does not hurt, so you have to keep an eye on him, take care of him right. (E15)

Social support can be configured as a protection factor against situations of vulnerability¹⁸. The family emerges as a structure that shelters the adolescent mother for protective care. Here, responsibility for promoting and maintaining the safety of the child at home is shared with family members residing in the same house.

The maternal figure also appears as representative for the adolescent in promoting a safe environment, even when not residing in the same address:

These days, I was doing the dishes, then my mother called me, and she asked 'What about the baby?' And I said, 'It is in the room.' My mother always says that I have to be very careful with her. A few days ago, she almost fell out of bed. My mother speaks a lot to me, because in the house that I live there is a staircase, a window, and it is dangerous. She said she would have some protection on the stairs and in the window, so no accidents happen to protect her. I still have not put her on the walker because of the stairs, it is very dangerous, I think something can happen, and I want to protect her, I do not want anything bad to happen to her. (E10)

The maternal grandmother is attentive both to the child´s constant surveillance behaviors and to the accomplishment of adjustments in the home. It is pointed out that maternal grandmother appears as a figure of relevant importance in the context of motherhood in adolescence, giving support in the daily care process of the child⁶.

It should be emphasized that the age range used in this study was for children between six months and less than two years, that is, a period in which parents should refocus attention on their children. In the reports, it is understood that adolescent mothers always emphasize that they and their families have a responsibility for the prevention of accidents, being an obligation to be always attentive to the children. However, they did not mention the possible contributions of health professionals and intersectoral actions to promote child safety at home.

Undoubtedly, in the process of child training and development, responsibility sharing is facilitated when the relationship between health professionals and the family is permeated by involvement, attention, sensitivity, bonding and good communication, impacting on integral assistance and in defense of children´s rights^9.20.

CONCLUSION

This study enabled to identify perspectives of adolescent mothers on daily care with their children, focusing on the prevention of childhood accidents. Child-protective health care has been envisaged as a maternal and family responsibility, and it occurs through constant surveillance and adjustments in the home environment.

The results suggest limited contribution of health professionals to the promotion of child safety in the home environment. There is a need for greater involvement of health and family professionals in the construction of accountability plans to ensure the child the right to grow and develop in a safe place.

Considering that the care and prevention of childhood accidents are complex objects of study, research directed to other aspects related to the promotion of child safety at home can contribute to the practice of child health protection.

REFERENCES

1. Ablewhite J , Peel I , McDaid L , Hawkins A , Goodenough T , Deave T , et al. Parental perceptions of barriers and facilitators to preventing child unintentional injuries within the home: a qualitative study. BMC Public Health . 2015;15:280.

2.Meddings D. Child injury prevention: an overlooked challenge for child survival. Int J Environ Res Public Health. 2013;10(2): 568-70.

3.Lima ICV, Pedrosa NL, Galvão MTG, Aguiar LFP, Paiva SS, Holanda ER. Acidentes domésticos e diagnósticos de enfermagem de crianças nascidas expostas ao hiv. Esc Anna Nery. 2014; 18(2):215-9.

4.Merino MFGL, Zani AV, Teston EF, Marques FRB, Marcon SS. Dificuldades da maternidade e o apoio familiar sob o olhar da mãe adolescente. Ciênc Cuid Saúde. 2013;12(4):670-8.

5.Britto PR, Ulkuer N. Child development in developing countries: child rights and policy implications. Child Dev. 2012;83(1):92-103.

6. Santos AL, Teston EF, Cecílio HPM, Serafim D, Marcon SS. Participação de avós no cuidado aos filhos de mães adolescentes. REME - Rev Min Enferm. 2015;19(1):55-9.

7.Kendrick D, Young B , Mason-Jones AJ , Ilyas N , Achana FA , Cooper NJ , et al. Home safety education and provision of safety equipment for injury prevention (Review). Evid Based Child Health. 2013;8(3):761-939.

8.Walker SP, Wachs TD, Grantham-McGregor S, Black MM, Nelson CA, Huffman SL, et al. Inequality in early childhood: risk and protective factors for early child development. Lancet. 2011; 378(9799):1325-38.

9.Andrade RD, Santos JS, Pina JC, Silva MAI, Mello DF. A puericultura como momento de defesa do direito à saúde da criança. Ciênc Cuid Saúde. 2013;12(4):719-27.

10.Andrade RD, Mello DF, Silva MAI, Ventura CAA. Advocacia em saúde na atenção à criança: revisão da literatura. Rev Bras Enferm. 2011;64(4):738-44.

11.Mello DF, Henrique NCP, Pancieri L, Veríssimo MLOR, Tonete VLP, Malone M. A segurança da criança na perspectiva das necessidades essenciais. Rev Latino-Am Enfermagem. 2014;22(4):604-10.

12.Anéas TV, Ayres JRCM. Significados e sentidos das práticas de saúde: a ontologia fundamental e a reconstrução do cuidado em saúde. Interface – Comunic, Saude, Educ. 2011;15(38):651-62.

13.Fontanella BJB, Luchesi BM, Saidel MGB, Ricas J, Turato ER, Melo DG. Amostragem em pesquisas qualitativas: proposta de procedimentos para constatar saturação teórica. Cad Saúde Pública. 2011;27(2):389-94.

14.Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101.

15. Pant PR , Towner E , Pilkington P , Ellis M , Manandhar D . Community perceptions of unintentional child injuries in Makwanpur district of Nepal: a qualitative study. BMC Public Health. 2014;14:476.

16. Brito MA, Rocha SS. A criança vítima de acidentes domésticos sob o olhar das teorias de enfermagem. Rev Pesqui Cuid Fundam (Online).2015;7(4):3351-65.

17.Pretorius K, Van Niekerk A. Childhood psychosocial development and fatal injuries in Gauteng, South Africa. Child Care Health Dev. 2015;41(1):35-44.

18.Braga IF, Oliveira WA, Spanó AMN, Nunes MR, Silva MAI. Percepções de adolescentes sobre o apoio social na maternidade no contexto da atenção primária. Esc Anna Nery. 2014;18(3):448-55.

19.Tavares EO, Buriola AA, Santos JAT, Ballani TSL, Oliveira MLF. Fatores associados à intoxicação infantil. Esc Anna Nery. 2013;17(1):31-7.

20.Rodrigues BC, D'Artibale EF, Barbieri MC, Bercini LO, Higarashi IH. Intersecções do cuidado à saúde nos centros de educação infantil: percepção das mães. Rev enferm UERJ. 2014;22(1):71-6.