RESEARCH ARTICLES

Implications of culture for care by a family health team in a quilombola community

Maria Delma Freitas das Chagas^I; Thaisa Santos da Hora^II; Daniela Bastos Silveira^III; Donizete Vago Daher ^IV; Sonia Acioli^V

^I Nurse graduated at the University Estácio de Sá. Quissamã, Rio de Janeiro. Brazil. E-mail: mdelmafisio@hotmail.com
^II Nurse graduated at the University Estácio de Sá. Macaé, Rio de Janeiro, Brazil. E-mail: thaisabarcelos@hotmail.com
^III Coordinator and Professor of the Nursing School at the University Estácio de Sá campus Macaé.Quissamã, Rio de Janeiro, Brazil. E-mail: danielabsilveira@yahoo.com.br
^IV Associate Professor of the Medical-Surgical Nursing Department at the Federal University Fluminense. Niterói, Rio de Janeiro, Brazil. E-mail: donizete@predialnet.com.br
^V Ph.D. in Public Health. Associate Professor of the Public Health Department at the Nursing School of the University of Rio de Janeiro State, Rio de Janeiro, Brazil. E-mail: soacioli@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2015.17734

ABSTRACT

The object of study was culture and its implications for the family health care team in a quilombola communi­ty. This exploratory, qualitative, descriptive study examined aspects of Afro-descendant culture that influence quilombola community care from the family health care team's viewpoint. The scenario was the Machadinha quilombola community at Quissamã, Rio de Janeiro State, and seven health personnel were the subjects. Data were collected through focus group and non-participant observation in July 2014, and analyzed using Bardin thematic analysis. The population's cultural habits were found still to be strongly present, especially in cooking, dancing, and use of medicinal herbs. Those habits require that health personnel dialogue between technical and traditional knowledge. It was concluded that the family health team needs to consider its practice in view of local culture as a guide for the care process.

Keywords: Family health strategy; nursing; culture; quilombola population.

INTRODUCTION

Culture is understood as a composition of elements that characterize any activities not being from biology, shared by different members of a social group. It involves issues such as values, symbols, practices, traditions and customs. It is a collective product of human life. There are elements from which the subjects construct meanings for concrete actions and social interactions and resist social settings defined.¹

Through culture, the diverse reality of the characteristics of peoples, nations and human groups are expressed, as dance, art, cooking and different ways of living².

The approach of the health worker with the culture of a population enables the care provided and gaining value and meaning, since this professional can understand how people feel and live their health.

As established by the National Primary Care Policy³, the Family Health Strategy (ESF) should guide its work considering the subject in its uniqueness and socio-cultural integration to ensureg comprehensive care. The family health is highlighted as a health service reorganization strategy from the replacement of a health model focusing only on the individual and his fragmented body, to enlarge it considering his family background and his socio-cultural values.

This article comes from a more extensive research that analyzing the implications of culture in nursing care practices. The culture and its implications in nursing care of the family health team in a Quilombola community is the objective of this study. From the context described above, the guiding questions established were: What are the remaining cultural habits of African descent culture of Machadinha Quilombola community? How can the cultural context of the community support promotion and preventive health care from the family health team work?

Based on the guiding questions, aspects of African descent culture in the health care of Quilombola Community of Machadinha (Quissamã-Rio de Janeiro) were analyzed from the perspective of the family health team.

THEORETICAL REFERENCE

The study had the theoretical basis of the National Primary Care Policy (BANP)³, the National Policy on Comprehensive Health of the Black Population (PNSIPN)⁴, Popular Education^5,6, the Theory of Diversity and Madeleine Leninger Universality of Cultural Care⁷ and documents showing the history of Machadinha^8,9.

PNSIPN⁴ reported that according to the 2000 census, Brazil has 54% of people who consider themselves white, 45% black or mulatto and 0.4% indigenous or yellow⁴. These data show the importance of a closer and careful view to the black population, which has its own characteristics and needs that deserve special attention from the health sector and also education.

Data such as poverty and income levels appear significantly worse compared to white people. It can also be mentioned the important health indicators such as adolescents pregnancy, where the black population is almost 2% higher than the white population; as well as increased risk of children under five years die from infectious and parasitic diseases or malnutrition. As for adults, it was found that black people die more than white people⁴.

It is up to ESF to manage the health demands of higher frequency of its territory, considering the risk criteria, the dynamics and the characteristics of a given population or group³. In this sense, reflecting on the unique aspects of a quilombola population it is essential for a singular care, quality and resolving by the family health team.

The Quilombola Community of Machadinha show as the main characteristics the preservation of the traditional dances of slaves (jongo and fado) and rich in culinary roots, remaining habits of the slavery period. Practices like barefoot walking and the use of herbal medicines are very common among the population⁸.

Considering both the dance and the culinary may be linked to health issues, there must be a reflection on the use of cultural resources of the Quilombola population by the family health team, as they can contribute to reviving traditions and also working as motivating for physical activities practices, improving self-esteem. Such resources are critical in the process of building and strengthening the bond between the team and the population as well as the joint construction of the plan of care provided to the group, to enhance scientific knowledge and popular knowledge. In this sense, culture works as a tool for the practice of popular education.

Popular health and education is a social movement of qualified professionals class and researchers committed to link the dialogue between the technical and scientific knowledge and the knowledge gained through the experiences and struggles of the population for health^5,6. Therefore, from this view, the ESF's health care practices in the Quilombola population need to be sustained.

Related to nursing, educational practices constitute an element of the work process in health and reference framework of their work. Thus, the nurse educator in public health plays a fundamental role in the development of these activities in various scenarios of the population¹⁰.

In order to notice their practice considering the cultural issues, nurses can guide their actions supported by the Transcultural Theory of Madeleine Leininger. The theory considers that the perception of the world of individuals in the social and cultural condition affects their health, disease and well-being⁷.

Culture is the values, beliefs, norms and applied ways of life that have been internalized, shared and disseminated by certain groups, generating standard thoughts, decisions and actions⁷. Thus, to explore the cultural context and apply this knowledge as a tool to analyze the actions and decisions, the nurse will be able to provide a differentiated care¹¹.

METHODOLOGY

It is a descriptive-exploratory study with a qualitative approach. The scenario was the Quilombola Community of Machadinha, located in Quissamã in North Fluminense of Rio de Janeiro State. Data collection was conducted through focus group technique and non-participant observation in July 2014. The collective interview was guided by a questionnaire containing seven open questions, pre-tested in a unit with characteristics similar to Machadinha. After the interviews, they were transcribed in full. To identify the participants´ speech, it was decided to use the first letter of their names.

The subjects were seven professionals out of 11 of the ESF team of Machadinha unit. Of this total, at the time of the group construction, there was one employee on holidays, two had the day off and one did not accept to be part in the group. They were the exclusion criteria of the study, while the inclusion criteria was that professionals had at least one year of work in this unit and wanted to participate.

The data processing was carried out from the Bardin content analysis technique. It provides the examination of communications in order to understand the content of messages¹². Initially, the the recordings were listened for the organization of ideas, followed by transcription of the speeches and their interpretation. Then, themes were defined when having relationship with the goals, followed by counting and interpretation of content for the construction of the categories that were examined retrospectively.

About the ethical aspects, the study met the provisions of Resolution 466/12. Participants signed the free and informed consent form and, were aware that they could quit at any stage of the investigation. The study was authorized by the Municipality of Quissamã and approved by a Research and Ethics Committee of healthcare area.

RESULTS AND DISCUSSION

The systematization of the analysis detected 80 important themes discussed by members of the health team, composed from units of records that originated two categories: Culture characteristics of the remaining Machadinha community of its African descent origins; and Strategies used by the family health team to monitor the users.

1^st Category: Culture characteristics of the remaining Machadinha community of its African descent origins

It was observed that the quilombola population still retains many habits and customs of the time of slavery^8,9. In culinary, it was identified a large consumption of tubers, meat and beans, as shown in the described lines:

Presence of a strong supply meat, mealy, roots and tubers. (A)

It was the first time I ate a fish feijoada, captain milk soup that is the bean dumpling with bacon, cabbage. (B)

Through the interviews, it was observed that the team recognizes that the community has its own characteristics and seeks to preserve them^5-7. In that sense, the knowledge to be built on the health of this group must consider its dynamic, and incorporate their knowledge from their experience. Professionals realize that it is a food culture learned by previous generations, passed on by oral tradition, over time^1,2. Thus, it is considering the cultural habits of this population that health workers can understand the meaning of this practice to the group, then build and share knowledge.

The team understands that eating practice as a positive characteristic to maintain the traditions and encourages the formation and maintenance of healthy habits such as breeding and planting home gardens, which facilitates access to essential food and even encourages cultural preservation of the group ⁷. As a point considered to be better worked on the local culinary, the team said that there is exaggeration in the consumption of some foods such as tubers, which raises concerns with increased diseases.

This issue is identified in the reports where professionals mention this concern.

[...] Convincing a diabetic here to decrease these carbohydrates is complicated, it is not easy, but we do not give up. (D)

Therefore, it seems that professionals, while respecting and valuing the eating habits of this population, also conduct educational activities in order to redirect habits and encourage new ones. In this sense, it must be considered the need for the team to reflect on the care when performing very prescriptive actions and perhaps even authoritarian in order to change behavior since it is necessary to consider the subject as protagonists in this process. The analysis shows a path where the team makes an effort to value both scientific and the popular knowledge, seeking complementarity between them^5,6 .

The jongo dance and traditional songs of the slaves are habits expressions of this population. The jongo is a dance that recalls manumission corners that run in sync with the beats of drums⁹. This dance appears as a cultural habit valued by professionals, as evidenced in the later speech.

This jongo dance [...] is a form of very characteristic expression of that place. [...] Another issue that differentiates them is the question of culture, the dance I think it's a very important thing for them, it is the way they have since the last century to communicate via drums [...]. (B)

The rescue of dance in Machadinha contributed to the adolescents be encouraged to insert the jongo. The testimony below is from a unit professional, a descendant of slaves. He highlighted the importance of preserving the traditions and its transmission to future generations⁷, to keep the culture alive, moving through the inclusion of children and adolescents in these practices, teaching them the value of this heritage.

[...] Today we are beginning jongo with grandchildren and great-grandchildren [...]. (M)

Another important point emerging from the statements, is that from the time of insertion of adolescents in jongo dance, there was a significant reduction in the rate of adolescent pregnancy and domestic violence in the community. From the dancing, the team notes that there is a different perspective of life for the girls in the community.

[...] The dance that includes many adolescents [...] early pregnancy has always been a problem in Machadinha [...] the dance saved many girls at that time of early pregnancy and domestic violence [.. .]. (B)

A strong cultural habits of this population is the use of medicinal herbs for therapeutic purposes⁸. Although the team recognize and value this tradition, there seems to be concern of professionals with the lack of scientific knowledge by the group, with regard to the use of these herbs, as found in the following speeches:

The use of these herbs has been part of their culture [...]. (P)

[...] It passes from father to son their function, but they do not know scientifically each one [...]. (D)

It was observed from these statements, that despite the team´s efforts to recognize and preserve the cultural habits of this population in the provision of care, it is still considered relevant legitimize such practices together with the technical knowledge. Thus, the team develops activities that might encourage information exchange^5,6, as identified in the following reports.

[...] We do not want them to stop using the herbs, but associate with the medication that is important [...]. (P)

[...] Together with the pharmacy coordinator [...] we took some herbs that were common in the area, some plants they used and made several teas [...] we try to enhance this knowledge [...] pharmacy herbal they used and we got to explore [...] with them. (B)

[...] We had specific meetings [...] we will talk about the herbs you use, teas you do, what for? How did you discover it? Was this pass by his mother or grandmother? Who does it? How do you do it? And we'll valuing this way [...]. (D)

The dialogue between the different knowledge contributes to more effectively addressing the population´s health problems because they complement each other. In this sense, realizing what the different social groups understand about the health-disease and the available treatment resources, means opening a range of possibilities of care⁶.

2^nd Category: Strategies used by the family health team to monitor the users.

The selected speeches howed that the health team´s strategy open space in community meetings for the community to suggest the topics to be addressed in educational activities¹⁰, that is, the subjects are facing the real interests and needs of the population. This practice present a dialogical and emancipatory educational perspective, welcoming culture and popular knowledge⁵.

[...] We do community meetings, and people bring the topics, and we will be valuing them [...] it is more interesting to talk about standing animals that is [...] more common for them, or about the "white cloth", how to avoid it ... [...] they bring us their doubts [...]. (B)

Other team´s strategy to promote the approach of the ESF employees with community residents to build partnerships and strengthen the bond, was to be inserted in daily life of the other, because the desired change depended on a walk together^5,6.

I started to participate in community football team [...] I played every week with men... [...] Hosting is the most practical way to make the person understand the difficulties it may have in a given matter. (B)

The host is critical [...]. (P)

[...] To criticize and have prejudice are the hardest ways you can change, you have to have empathy for the person, for that problem and try to pass through their experience or technical compared to the experiences of others [. ..] we try to steer, but always respecting their culture [...]. (D)

One factor that limits the work of the team was the high illiteracy and semi-illiteracy rate present in the community⁴. In order to facilitate communication between health workers and the population, the team sought approaches with the vocabulary of the group in order to recognize their culture to facilitate interaction and dialogue^5-7.

[...] So we always try to bring to our discussions some terms that they used, and we were always arguing [...]. (B)

[...] Through the health unit work we will always debating [...]. (M)

According to the cross-cultural theory of care⁷, it is essential that the culture circles established between professionals and clients be strengthen and derived from real and systematic dialogue so that users understand the health codes and are empowered to decision-making.

It was found that, in general, health practices developed by the team sought to expand the cultural interaction channels, where the interests and problems of the population were understood by professionals as part of a process. This understanding has contributed significantly to the possible identification and resolution of health problems, considering the interaction between technical knowledge and popular knowledge in order to build complementarity between this knowledge. This complementarity can contribute to a dialogued, humane, comprehensive and emancipatory care.

CONCLUSION

This research found that the cultural habits of the quilombola population of Machadinha are also strongly present, especially in cooking, dancing and use of medicinal herbs. The illiteracy rate is high and, as a result of these aspects, the health team of the family must value their practice considering the local culture as guiding the care process.

Eating practices and the use of medicinal herbs require the family health professionals having an adjustment to the vocabulary and knowledge transferred from generation to generation. It is necessary to establish a dialogue between popular knowledge brought by this group and the technical knowledge brought by the team.

In this sense, the professionals use as main strategy the community meeting, considered legitimate space for the exchange, including allowing the population to decide on various aspects of the service. Another strategy mentioned was the involvement of professionals in the activities provided by the population to this attitude approaches and facilitates the link. Also, there is appreciation of team meetings as a place of dialogue and joint planning of actions, considering the various aspects involved in the specific cultural issues of the group.

As study limitations there were highlighted the few research on the quilombola population and aspects that involve the relationship of culture with the care provided by the health team. In addition, there were incipient participation of the study subjects during the course of the focus group, because, despite having great experience in the community, it was not urge to give their contribution, even with the emphasis made on the secrecy and confidentiality of the study.

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