ORIGINAL RESEARCH

Experiences of older people and health care professionals relating to the family health strategy

Eluani Rigon^I; Jéssica Vanessa Corradi Dalazen^II; Grasiele Fatima Busnello^III; Marta Kolhs^IV; Agnes Olschowsky ^V; Silvana Silveira Kempfer^VI

^I Nurse, Graduated in Nursing from the State University of Santa Catarina, Brazil. E-mail: eluani_rigon@hotmail.com
^II Nurse, Graduated in Nursing from the State University of Santa Catarina, Brazil. E-mail: jeh_dallazen@hotmail.com
^III Nurse, Master in Environmental Sciences. Professor, State University of Santa Catarina. Brazil. E-mail: grasi1982@yahoo.com.br
^IV Nurse, Master in Public Policy Management. Professor, State University of Santa Catarina, Brazil. E-mail: martakolhs@yahoo.com.br
^V Nurse, PhD, Professor, Federal University of Rio Grande do Sul, Brazil. E-mail: agnes@enf.ufrgs.br
^VI Nurse, Ph.D. in Nursing, Professor, Federal University of Santa Catarina, Brazil. E-mail: silvana.kempfer@ufsc.br

DOI: http://dx.doi.org/10.12957/reuerj.2016.17030

ABSTRACT

Objective : to ascertain how family health strategy personnel provide care for the elderly. Method: in this qualitative, descriptive study, data were collected by individual semi-structured interviews of 15 older adults and nine health professionals, in three municipalities in western Santa Catarina. Results: three categories emerged from the thematic analysis: thinking about the older adults' satisfaction in the health service; professionals' perceptions of the team's preparation in care for the elderly; and Bonding between the elderly and family health strategy personnel. Conclusion: gaps were observed in health professionals' undergraduate training, a need for denser knowledge for working with the health of older adults, as well as a lack of networking.

INTRODUCTION

The Brazilian Institute of Geography and Statistics has shown a growing increase in the elderly population. In the projection for 2050, the elderly will represent thirty percent of the total population¹.
This growing process of aging is the result of public policy investments and, for the first time in history, there will be more elderly than young people under the age of 15 in the world².
In order to cope with the aging of the population, professionals must develop skills to act in basic care. In this sense, we can see a gap regarding the approach of geriatrics and gerontology in undergraduate training³.

The objective of this study was to verify how family health strategy (FHS) professionals perform care for the elderly.

Aging is not a homogeneous process, and the demands of the elderly vary. Thus, it is necessary to strengthen networking, aiming to provide care for healthy elderly citizens and meeting the needs of those with different degrees of disability. In this context, the FHS was created to reorient health care to the population towards a healthier living³.

The FHS follows the logic of active health intervention, interacting with the community within its territory in a preventive way and not waiting for the community to reach the health service. It is necessary to interact with the community within its territory in a preventive way. This way, the FHS represents a real instrument that reorganizes the demands and needs of the users⁵, intensifying the understanding with the community, thus avoiding behaviors that limit health care.

In this perspective, the FHS is considered a privileged space for comprehensive health care for the elderly, as it has a close proximity to the community and home care, enabling the health team to act in a contextualized way.⁵

METHODOLOGY

Qualitative and descriptive study organized from the operational proposal for qualitative research in three stages: exploratory phase, fieldwork and analysis of the collected material⁶. The study was carried out in three municipalities located in the West side of the state of Santa Catarina.
Elderly and health professionals who are part of three FHS located in the municipalities of Chapecó (183,530 inhabitants), Riqueza (4,838 inhabitants) and Quilombo (10,248 inhabitants) participated in this study. The study was submitted and approved by the Research Ethics Committee of the State University of Santa Catarina, under nº 545,188. Data from a random sample by spontaneous demand were then collected. Five elderly individuals from each FHS and three professionals from each team (a nurse, a doctor and a nursing technician) were selected.

Data were collected through individual semi-structured interviews, which occurred between April and June 2014, in the FHS units of the respective municipalities, in reserved rooms. All participants were informed about the research and signed the informed consent form. The interviews were audio-videotaped and later transcribed. To guarantee anonymity, the subjects of the study were identified in alphanumeric form, by the letters E (elderly) and P (professionals), followed by an ordinal number.

Data were organized and analyzed into thematic categories in the light of the operational proposal of the qualitative analysis.

RESULTS AND DISCUSSION

From the analysis of the statements, three thematic categories emerged as follows.

Perception of professionals regarding the preparation of the team to provide care for the elderly

Professionals have some limitations regarding the preparation to provide care for the elderly, this is demonstrated in the verbatim:

[...] specific preparation, I think that no one FHS team has it [...] we are not prepared to work with the elderly during undergraduate training and nor after, we do not have specific training [...] (P1).

[...] we do not receive training to work with the elderly in specific [...], we do it in the way we know and the conditions allow us to do it (P7).

The aging process of the population brings several changes with regard to health issues. Continuing education is, thus, important for professionals. Some professionals of the health team show interest in keeping up to date and they use other strategies to achieve this aim, as can be seen in the reports:

[...] we have here the manual for filling the elderly's health handbook, many professionals do not even know this manual exists, but it is there [...] (P9).

[...] we have an academic training; during college classes, we see something on the care for different types of patients, elderly, children, but very superficially and different from reality ... (P3).

Team meetings are moments of exchange between professionals, in which everyone can expose their opinions, knowledge, suggestions without judgment. Everyone is there to exchange knowledge⁷

Studies on working conditions and quality of the actions developed by FHS teams demonstrate, in a general way, the fragility in the care given to the elderly, which is due to the lack of knowledge about necessary specific care in old age or the disarticulation in the work process⁸.

Notably, the Hiperdia Program of the Ministry of Health, which works with the hypertensive and diabetic population, is the main care directed to the users of these programs, who are mostly elderly and often present chronic diseases⁸, according to the statement:

[...] diabetic, hypertensive groups are not specific for the elderly, but they are the majority of participants (P1).

In this context, professionals should use their knowledge and creativity to search for new strategies that take advantage from alternative practices, reconciling the culture and habits of the elderly, to identify the best form of treatment and to include integrative and complementary practices that will benefit the user⁹.

Community therapy (CT) emerges as one of the tools of care in the programs of insertion and support to the health of the population and it is a space of reception, for the sharing of sufferings and wisdom of life, and it can be used to provide care for the elderly. The formation of these groups stimulates the individual to interact with other people, and also to unravel the resilient power in each elder and community¹⁰.

Strategies include home visits and health promotion practices, which are considered to be relevant actions that are well accepted by the elderly, family members and caregivers. Home visits promote a closer approximation with reality, representing opportunities to identify the basic needs of each elderly person assisted^11.

To this end, it is necessary for municipal management to promote continuing education for every FHS staff, including filling in the Elderly Health Handbook, since such a Handbook represents one of the important instruments for strengthening basic health care for the elderly¹². However, none of the professionals mentioned that this handbook, considered an instrument for monitoring of health of the elderly, recommended by the Ministry of Health since 2004, was used in their activities.

Other possible actions may be implemented by FHS professionals, either in the unit or in home care, aiming at the permanent education of patients and their families, minimizing possible health problems, as a participant mentioned:

[...] I would like to [act] in the elderly group, to interact with them. We did it once, twice, and it did not work, because there is no time, how are we going to get out of here if it's always full? (P7).

The difficulties encountered by professionals in providing comprehensive care, with an expanded view, are justified by lack of time and few professionals available for care. These factors have serious consequences for the development of health promotion and disease prevention activities, leaving aside the specific strategies for elderly care⁷.

This situation reinforces the importance of FHS to know the reality of the population under its care, identifying health problems and more common risk situations to act with efficiency⁹.

Reflecting on the satisfaction of the elderly in the health service

The satisfaction of the users has occupied an important place in the evaluation of the quality of services, considering that the satisfaction is directly related to therapeutic adherence and to results of the health care, stimulating healthy behaviors¹³.

Regarding satisfaction, the elderly people reveal positive feelings related to care.

The service is very good, they provide assistance very well [...] (E1).

The care for us is fine, we have no complaints, because even if we need the nurses and doctors, they go to the house to assist us [...] (E2).

Satisfaction is a dynamic process that can be influenced by a number of factors such as perception of health status and disease, religion/beliefs, and sociodemographic characteristics¹⁴. Thus, satisfaction with health care can be characterized and evaluated individually in some dimensions such as: access, infrastructure, user-professional interaction and results. The resoluteness of the health service is often a point of disagreement among the elderly users of the health system, as reported by some participants:

[...] some problems occur ... it's fine, but you need to change some doctors that are there for long, and to put new doctors that are more willing to help (E11).

[...] the service I think is regular ... once they made a mistake, they changed my exams, but they solved the problem [...] (E12).

The performance and quality of health services can be evaluated through indicators. Among these, we highlight the evaluation of these services and the attention given by the users that are fundamental, since they capture the expectations and the users' needs¹⁴.

The evaluation of the elderly satisfaction with public health services can contribute to the construction of a new care perspective, to strengthen the social control and the inclusion of these users in the planning processes ¹⁵.

In order to establish a bond of trust, it is necessary for the elderly people to have a sense of confidence in the assistance received, generally linked to the technical and attitudinal competence of professionals, so that they can evaluate the service and, consequently, properly judge the professionals that assist them¹⁶.

Several factors are considered obstacles to the use of services. These include access, cost, location, organization, delay in obtaining service, waiting queues¹⁷.

Another important point is the pre-scheduling of the consultations, which facilitate access, shorten the waiting time, and meet the expectations of some elderly people:

[...] we schedule it, we schedule appointments, we go there at the precise time of service, sometimes even a little earlier to advance (E7).

[...] it's good, because it has a scheduled record and it does not need to wait in a queue (E8).

The scheduling of consultations and examinations is an organizational strategy, used by some FHS, to reduce queues within the units, promoting humanization of care¹⁸.

The use of health services consolidates the functioning of the health system, resulting in the care of individuals who seek the help of professionals who may guide them within this system¹⁹.

It is extremely important to understand how the population identifies and verbalizes their health demands, envisaging the necessary solutions and referrals¹⁸. The importance of access to specialized services, which must be located close to the users and be efficient is evidenced in the statements:

[...] my husband needs to be referred to a specialist, and he was not yet, we cannot make it, I think it's bad that he does not have a doctor here to do more specific tests, we have to go to other cities. (E15).

[...] they lost that only examination that I did, it came with the name of another person; besides delaying, they lose it [...] (E12).

Concomitant to this, some elderly people seek FHS mainly to get medications of continuous use, in most cases for hypertension and diabetes. Some report taking medicines at the health facility, but others buy them at popular drug stores.

[...] I come to get medicine every month, because I have to take it daily and also of my husband's medicine and my brother's, I get here. (E2).

[...] for me, it was good [...] I did not like this system of medicines, they give me the prescription and I have to go to the drug store to buy it (E14).

The elderly population has higher morbidity levels than the general population, with higher consumption of medicines and demand for health services. The distribution of medication is one of the most sought interventions by this age group, since they help increasing the survival rate and improving the quality of life²⁰.

The search for care to solve health problems involves some issues, such as: availability or not of the service, distance, the practices offered to the users, the resources available in each unit, technical training of professionals and accountability for the population problems²¹.

Bond between the elderly and health professionals in the FHS basic unit

Care takes place according to the demand presented and from the knowledge acquired during undergraduate training and during the daily care. It is noticed that the elderly, in some situations, prefer to be assisted by the same professional, creating bonds of trust, as can be observed:

Their care is according to the professional, the relationship with each person - with that one, I do not like him, I do not want to have a consultation with him [...] the elderly arrive at the reception and choose the doctor - I want to consult with that doctor, and so[...] (P9).

[...]The care to the elderly is done according to our experience or affinity [...] I have never learnt of any patients complaining about the assistance (P3).

Establishing bonds is fundamental to the integrality of assistance. In this context, it is relevant that the professionals create this link, because users, often because the lack of confidence in the professional, end up omitting some information that may be aggravating their health. The bond must be established not only with the elderly but with their entire family ²².

Many elderly people seek health care due to lack of affection, seeking emotional support from the professionals.

[...] sometimes elderly people come here to be heard, because at home nobody has patience [...] we talk, we guide within our possibilities, I believe everyone is well assisted, here (P3).

Older people who are vulnerable and fragile should have their autonomy stimulated through actions such as active listening and promotion of self-care²³. Home visits can be seen as health interventions used by the teams, which, based on the establishment of bond, focus on promotion, prevention and rehabilitation, improving the living conditions of the elderly.

We have a schedule; we visit the bedridden elderly and the elderly that have difficulty coming to the health post [...] (P4).

Whenever there is a more debilitated elderly person who is bedridden, the family calls the health center and we make the home visit [...] (P13).

Elderly care is related to actions that involve levels of attention to health and to the family. Concomitant with care, the relationship with the family is of paramount importance for the elderly care, since family members need guidance because they are caregivers. In this sense, the training of nursing professionals is relevant so that they are prepared to meet the demands of the elderly and also to guide the family and other caregivers²⁴.

Nurses have among their attributions the function of health service management, assuming an indispensable role to establish strategies that aim at improving health care for the elderly²².

They are people who have a sense of what they can and they cannot, what they should and what they should not, and how far their commitments go, [...] their capacity (P9).

Ensuring a healthy and quality aging is a challenge for public health; managers and health professionals must be able to meet the demands of this age group, which is increasing each year as a consequence of increased life expectancy. Thus, the comprehensive care and articulated attention with other professionals of the health area is necessary to provide adequate assistance to the elderly that look for the FHS²⁴.

CONCLUSION

Fragilities in the service were identified, which determines the creation of specific strategies for the elderly and skills for professionals. The nurses, integrated with the other professionals of the team, must demonstrate interest in the health care of the elderly. It was evident that professionals have certain limitations regarding the training for such care. It should be noted that user satisfaction has received an important place in the evaluation of the quality of services, contributing to a better planning of their activities.

The number of selected health professionals was a limitation of the study. We recommended that other studies be carried out, including other FHS units, to deepen the analysis of this theme, since working with the elderly require skills that go beyond the technique and integrated team.

REFERENCES

1. Brazilian Institute of Geography and Statistics. Population of Brazil by sex and age - 1980-2050. RJ: IBGE; 2008. [cited on Sep 20, 2016] Available at: http://www.ibge.gov.br/home/estatistica/populacao/projecao_da_populacao/2008/projecao.pdf.

2.Berzins MV, Borges MCB, organizers. Public policies for an aging country.1ª ed.São Paulo: Martinari; 2012.

3.Motta LB, Aguiar AC, Caldas CP. The FHS and the attention to the elderly: experiences in three Brazilian municipalities. Cad Saúde Pública. 2011; 27(4):779-86.

4.Camacho, ACLF, Coelho MJ. Public policies for the health of the elderly: systematic review. Rev Bras Enferm. 2010; 63 (2): 279-84

5.Oliveira JCA, Tavares DMS. Attention to the elderly in the family health strategy: nurses' performance. Rev Esc enferm USP. 2010; 44 (3): 774-81.

6.Minayo MCS. The challenge of knowledge: qualitative research in health. 13th ed. São Paulo: Hucitec; 2013.

7.Coutinho AT, Popim RC, Carregã K, Spiri WC. Integrality of care with the elderly in the FHS: the view of the team. Esc Anna Nery. 2013; 17(4): 628-37.

8.Polaro SHI, Gonçalves LHT, Alvarez AM. Building the gerontological performance by the nurses in the FHS units. Rev Esc enferm USP. 2013; 47 (1): 160-7.

9.Oliveira LPBA, Santos SMA. Reconciling various forms of health treatment: a study with elderly people in primary care. Texto contexto-enferm. 2016; (3):e:3670015.

10.Rocha IA, Braga LAV, Tavares LM, Andrade FB, Ferreira Filha MO, Dias MD et al. Community therapy as a new instrument of mental health care for the elderly. Rev Bras Enferm. 2009; 62 (5): 687-94.

11. Carvalhais M, Sousa L. Quality of home nursing care for dependent elderly people. Saúde soc. 2013; 22 (1): 160-72.

12.Ministry of Health. Department of Health Care. Elderly's Health Handbook. 3th ed. Brasília (DF) Department of Specialized and Thematic Attention;2014.

13.Albuquerque AB, Deveza M. Adherence to family and community physician practice and primary health care. Promef. 2009; 3 (4): 41-72.

14.Macinko J, Lima-Costa MF. Access use and satisfaction with health services in Brazil's family health strategy. Trop Med Int Health. 2012; 17(1):36-42.

15.Brandão ALRBS, Giovanella L, Campos CEA. Assessment of basic care from the perspective of users: adaptation of the EUROPEP instrument to large Brazilian urban centers. Ciênc saúde coletiva. 2013; 18(1):103-14

16.Rodrigues JSM. The care by public health institutions: perception of families of cancer patients. Saúde em Debate. 2013; 37(97):270-80.

17.Marin MJS, Moracvick MYAD, Marchioli M. Access to health services: comparison of the views of professionals and users of basic care. Rev Enferm UERJ. 2014; 22(5):629-36.

18.Silva GL, Rabinovich EP. The barriers to the universality of access experienced by the elderly in family health units. C&D-Revista Eletrônica da Fainor. 2013; 6(1):3-24.

19.Silva KM, Santos SMA. Nursing consultation for the elderly in the FHS: challenges and possibilities. Cienc Cuid Saúde. 2013;13(1): 49-57.

20.Dal Pizzol TS, Pons ES, Hugo FN, Bozzetti MC, Sousa MLR, Hilgert JB. Use of drugs among elderly people living in urban and rural areas of a municipality in Southern Brazil: a population-based study. Cad Saúde Pública. 2012;28(1):104-14.

21.Assis MMA, Jesus WLA. Access to health services: approaches, concepts, policies and analysis model. Ciênc saúde coletiva. 2012; 17(11): 2865-75.

22.Rissardo LK, Carreira L. Organization of the health service and care for the indigenous elderly: synergies and singularities of the professional context. Rev Esc enferm USP. 2014; 48(1):73-81.

23.Goes TM, Polaro SHI,Gonçalves LHT. Cultivation of the well-being of the elderly and nursing care-educational technology. Enferm Foco. 2016; 7 (2): 47-5.

24.Perez CFA, Tourinho FSV, Carvalho Júnior PM. Competences in the nurses' training process for the care of aging: integrative review. Texto contexto-enferm. 2016; 25 (4): e0300015.