ORIGINAL RESEARCH

Quilombo women's perceptions of acute and emergency pediatric care: an approach in the light of Leininger

Samylla Maira Costa Siqueira^I; Viviane Silva de Jesus^II; Lorena Fernanda Nascimento Santos^III; Juliana Pedra de Oliveira Muniz^IV; Elane Nayara Batista dos Santos^V; Climene Laura de Camargo^VI

^I Nurse. MS and PhD Student. Federal University of Bahia. Salvador, Brazil. E-mail: smcsiqueira@hotmail.com
^II Nurse. MS and PhD Student. Federal University of Bahia. Salvador, Brazil. Professor at the Adventist College of Bahia. Cachoeira, Brazil. E-mail: vivi_humaniza@hotmail.com
^III Nurse. MS. Federal University of Bahia. Salvador, Brazil. E-mail: lorenafnasc@yahoo.com.br
^IV Nurse. MS. Federal University of Bahia. Salvador, Brazil. E-mail: julipedra@yahoo.com.br
^V Nurse. Federal University of Bahia. Salvador, Brazil. E-mail: elanensantos@gmail.com
^VI Nurse. Post-doctoral. Full Professor. Federal University of Bahia. Salvador, Brazil. E-mail: climenecamargo@hotmail.com
^VII Work extracted from the dissertation Therapeutic itineraries in pediatric urgencies and emergencies in a quilombola community
^VIII Research funded by the notice 030/2013, process number: 4753/2014 and by the notice 02/2013, process number: 8394/2013

DOI: http://dx.doi.org/10.12957/reuerj.2018.21492

ABSTRACT

Objectives: to examine quilombola mothers' perceptions of acute and emergency pediatric care and to identify difficulties in dealing with these situations. Method: in this qualitative study of 12 mothers in a quilombola community in Salvador-Bahia, data were collected by semi-structured interview from December 2013 to June 2014, and analyzed on Madeleine Leininger's Theory of Transcultural Care. The study was approved by the ethics committee. Results: perceptions of acute and emergency care were associated with the following concepts of Transcultural Theory: cultural difference, diversity and universality of cultural care, cultural context, cultural value, cultural care and world view. Conclusion: the mothers' perceptions comprised cultural factors, as in the associations with the theory proposed by Leininger, and point to the existence of difficulties in addressing these situations, as regards access to health care services both within their own community and on the contine.

Descriptors: African continental ancestry group; child care; community health nursing; emergency identification.

INTRODUCTION

The meaning of urgency/emergency is peculiar to each individual and its elaboration comes from subjective experiences and world view, which refer to the way how people or groups see the world and value it, inserting in it their perspectives.¹

Thus, the perception about these situations have different connotations regardless of the sociocultural context of each individual. Thus, in the occurrence of certain diseases, even if the situation is not clinically characterized as urgent, it is the perception of the subject that will modulate their response, allowing the elaboration of mechanisms and actions for health recovery.²

Considering that in emergency situations the time factor is a predictor in the decision-making and the outcome of the case² – especially in geographically isolated locations, where services of greater complexity are non-existent – this element is important, especially when diseases affect children, since there is a close relationship between child mortality due to preventable causes and access to health services, being necessary to increase the access to the secondary or tertiary sector of Health Care Networks (HCN).³

The quilombos are inserted in this scenario, characterized as spaces secularly inhabited by descendants of slaves;⁴ and because they have been consolidated in remote locations and peripheral regions, ⁵the access of the quilombola individuals to the urgency and emergency unit is impaired by factors such as distance from urban centers and transportation shortages, making the perception of these people differentiated when it comes to urgency/emergency situations.

It is therefore important to understand the individual's perception of these conditions and the difficulties they face when they occur, so that hypotheses are formulated about the motives that influence the search for care in the formal system and its obstacles. These can contribute to the organization of the services that attend this type of aggravation, increasing the access and the qualification of the care,^2-7 the nursing care is included there, according to Leininger,⁶ and they must consider the cultural factors of the individual so that the care provided is appropriate and complete.

In view of the above, this study aimed at analyzing the perception of quilombola mothers about the pediatric urgency and emergency and identifying the difficulties in coping with these situations.

THEORETICAL REFERENCE

This study is supported by the Madeleine Leininger's Transcultural Theory, as it addresses the influence of cultural bases on people's behavior in all contexts of life, including the care performed in health situations, including those of urgency and emergency.⁸

Leininger highlights as one of the premises of his Theory that the individual has meanings and understandings about how they want the care to be performed.¹ In this context, cultural factors should be considered as an essential part of health care, since they allow a more appropriate care provision, so that without their inclusion in the health services, the care provided is partial or incomplete.⁶

In a multiethnic and globalized world such as the one we live in, it is increasingly necessary that care, understood as the essence of nursing, is planned and implemented with the aim of improving the human condition or life, respecting cultural⁹ and symbolic contexts.¹⁰

According to Leininger, concepts, meanings, expressions, patterns, processes and structural forms of care vary transculturally, despite some similarities.⁹ Becoming aware of cultural similarities and differences is currently one of the greatest challenges for health professionals so that the services offered are truly effective.⁶

METHODOLOGY

Qualitative research supported by Madeleine Leininger's Theory of Cross-Cultural Care⁸, carried out in the quilombola community of Praia Grande, Ilha de Maré, Salvador-Bahia.

The eligibility criteria were: to be a citizen of the community, to be 18 years old or over, to be a mother of a child up to 12 years old, and to have no cognitive or verbal disability. 12 mothers who had already provided some urgency/emergency care to their children were selected through an active search conducted from a home visit and at the community family health unit. The interviews were carried out until the theoretical saturation of the data.¹¹

The data collection was carried out from December/2013 to June/2014 through a semi-structured interview script, which contained questions about care and accessibility to services when the child presented an illness characterized as urgency/emergency. The interviews were performed individually, in a place chosen by the participants and, after prior consent, an audio recorder (Sony Icd-px240) was used.

For the treatment of the information, the thematic analysis technique was applied,¹² followed by the steps of pre-analysis, material exploration and data processing, inference and interpretation. Two categories emerged from the analysis of the testimonies: maternal perceptions about child urgencies/emergencies and difficulties in child urgencies/emergencies situations.

The research complied with Resolution No. 466/2012¹³ and was approved by the Ethics Committee under protocol No. 420.096. In order to ensure anonymity, the interviews were coded with the letter E followed by the number referring to the order in which they were performed: E1 to E12.

RESULTS AND DISCUSSION

Profile of the participants

The majority 7 (58.3%) were in the age group of 30-39 years old, were married or were in a stable relationship, with a predominance of one child - 6 (50%); 9 (75%) self-referred as black and one participant identified herself as a brown-skinned. In terms of religion, the evangelical - 5 (41.7%) stood out.

In relation to schooling, half of the informants had only Elementary School, and the majority occupation was the shellfish - 6 (50%), having others highlighted as: housekeeper, cleaner, artisan, child development assistant, and salesperson. Almost all of them, 11 (91.7%), reported benefiting from the "Bolsa Família" Program, having a median family income of R$ 890.00, and a per capita household income of R$ 212.50.

Regarding the sanitary conditions of the households, 12 (100%) of the deponents reported that they inhabit masonry houses, with access to electricity, daily collection of solid waste, water supply through the general network and lack of a sewage network, being the waste destined to a septic tank.

The thematic categories that emerged from the analysis of the participants' testimonials are dealt with below.

Maternal perceptions about child urgencies/emergencies

Urgency is the occurrence of an unforeseen health problem that may or may not present a potential risk to life, whereas the emergency corresponds to conditions which entail imminent risk of death or severe suffering.^14,15

As verified in another study,¹⁶ some participants demonstrated difficulties in conceptualizing these terms. Here are some testimonials:

This difficulty may be related to the fact that these are technical concepts that, in fact, do not have a clear distinction for lay people. Other mothers presented conceptions that closely approximate the real concept, having as possible explanation the appropriation of the scientific technical discourse re-signified by their experiences:¹⁶

In the context of the Transcultural Theory, it is possible to associate the conceptualization and the difficulty of conceptualizing these terms to the cultural differences that exist between the people, being the understanding and acceptance of these differences by nurses essential in promoting proper care.^6,7

Although semantically distinct, these two terms maintain a close association that relates to the value of the variable time in the care provision, since the speed minimizes the situations of risk of death,¹⁷ aspect that was mentioned by the participants:

The previous testimonial shows that, in addition to associating the urgency situation with the possibility of death, the mother acknowledges the delay in offering professional care as an aggravating factor. Perception that, considering the importance of the provision of fast and qualified care in the reduction of the infant morbi-mortality,¹⁸ is characterized as positive, since it is from this understanding that the search for care will be undertaken, and the later it is, the worse the child's prognosis, especially in remote places.

Regarding the perceptions about what are urgency/emergency situations, multiple reports have emerged, some of which were of a biological nature, since the deponents understand as such situations the occurrence of diseases such as asthma, pneumonia, malaise, diarrhea and cutting injuries, as well as symptoms such as intense pain and fever.

The characterization of these problems as urgency/emergency situations is not unique to these mothers, since they have been identified in studies conducted in Brazil,^16,19 Portugal²⁰ and United States²¹ as reasons for searching the pediatric urgency/emergency service. In this respect, the results of this research are related to what Leininger⁹ calls universality of cultural care, that is, the similarities existing between different cultures regarding the meanings of care.

In addition to being highlighted as an urgency/emergency situation, fever has also been widely cited because of the potential for seizures:

Although it is not generally characterized as a problem requiring more complex care, the risk of seizure causes many mothers to consider fever as a situation of urgency, as well as the problems that present this symptom in their prodrome, often triggering exaggerated responses to combat it, resulting from the excessive fear described as fever phobia.²²

Leininger refers to being the meaning of health, disease and care an elaboration related to the cultural context. Thus, in the Western culture, fever is interpreted in a dichotomous way, as a response to a disease and as a disease in itself,²³ being pointed out in the literature²⁴ as one of the most common causes of the demand for pediatric care.

In this context, both in Brazilian studies^16,19 and in foreigners,^20-22 the fever was highlighted as the main reason for seeking care in pediatric emergency units, with the febrile seizure being pointed out²⁵ as the main fear among the parents. This abstraction of fever as an urgency situation is what Leininger¹ called cultural value, which serves to guide the decision-making of the members of a given culture. Thus, it is observed that, regardless of the child's age, fever generates fears of seizures among the mothers, guiding the way of thinking, the decisions and actions.

In the presence of fever or other health problems, in the family environment are mobilized the first measures to contain the problem, these being related to what Leininger¹called cultural care. Besides being the starting point of care, it is also in the family that they are assessed,²⁶ it can be concluded that the depletion of the domestic resources determine when the time comes to enter the formal system, since mothers no longer know what to do, as evidenced by certain authors¹⁶ and in the following report:

In this aspect, the results of this research are close to another study, in which it was revealed that the mothers have a limit of resources to take care of their children, being that the search for services of urgency and emergency begins when they understand that this limit has been reached. ¹⁶ This limit is translated into warning signs that can be related to the persistence of the problem, the recurrence of the complaint or the absence of a positive response to the maternal intervention, as evidenced in the following speech:

The recognition of the limit of the care by the mothers and the need to enter the formal subsystem is strongly associated with the concept of "world view", referred to by Leininger as the way as individuals see the world and the circumstances surrounding their life and assign it a value, being the world view influenced directly by the culture and the one responsible for guiding the desired care.¹

When the participants mention the need to use the formal system, they point out the social and infrastructure problems that interfere with the access to the health services. At this point, it is possible to associate the mothers' perceptions of pediatric urgency and emergency to what Leininger called "cultural diversity of care", that is, the variations and differences that the cultures present with respect to the meanings, standards, values, ways of life, or symbols of care.¹

The choice of the health service to which the child will be conducted depends on factors such as resolution, quality, specificity in pediatrics, ease of access and geographical location.¹⁶ The latter was revealed in this study as one of the main factors that interfere in this choice, since the necessity of displacement to the continent reflects the urgency/emergency nature of the case:

The geographic access is related to the level of distance to be covered, the obstacles to be transposed, the time of transportation and the means of transportation to be used to the health service.²⁷ The need to cross the sea requires time to be consumed and, when the illness occurs at night, the rescue is more difficult, configuring the occurrence of nocturnal injuries as an urgency/emergency situation:

In addition to the precarious functioning during the day, the health unit service closes in the evening, leaving the population unattended at night, when the transportation issue takes on greater proportions, either because of the climatic conditions for the crossing, or due to the time that, because it is not business hours, makes the value of the trip higher, and there is not always the financial resources to do so.

The difficulty of crossing to the continent, along with the occurrence of injuries at night, was considered as potentially problematic by this Quilombola community, in particular, as a result of the geographical, political and social conditions in which they live and which cause inconvenience and suffering.¹⁶

In this sense, it is very important, from the social point of view, knowledge about the perception of urgency/emergency from the perspective of users and the problems they face in relation to the need to enter the health services. Understanding the problems from the point of view of those who experience them is a necessary parameter for making decisions and elaborating answers that can solve the demands presented.

Difficulties in child urgency/emergency situations

In this study, the difficulties of quilombola mothers were mainly related to the absence of 24-hour health services, since in the community there is only one basic health unit (BHU) that, in the occurrence of aggravations, is not effective to provide care, as it is possible to verify in the following statement:

The primary care is characterized as the main gateway and communication center of the Health Care Network from the BHU with the Family Health Strategy (FHS).^28,29 As the entrance gateway of the Unified Health System (SUS – "Sistema Único de Saúde"), these units offer the first care to patients with acute conditions and/or appropriate transportation to a hierarchical health service, since they form the care network of the State Urgency and Emergency Systems.³⁰

In this context, according to the last statement presented, those responsible for the care provision, in addition to disregarding legally established duties,^30,31 impair the SUS principles and the primary care itself - universality, comprehensiveness, accessibility, bonding, accountability and humanization,^31,32 demonstrating misconceptions about the professional behavior regarding the conceptualization and treatment of urgencies.¹⁶

Studies demonstrate the failure of the primary care as a gateway to the health system, with direct repercussions in increasing the demand for services of greater technological density, including for solving simple demands and, therefore, pertinent to the primary care. These problems are related to the scarcity of material and human resources, to the hours of operation, to the delay in attendance, to the lack of resolution, and to the difficulty of receiving spontaneous demand, leading the population to discredit.^{15,16,29,33,34}

In surveys conducted in quilombos, the poor functioning of basic health services was highlighted.^4,5,35 Due to the fact that the primary care does not attend the urgency/emergency situations of these communities, its inhabitants need to move to the continent, having to arrange transportation for the transfer of children, since the health unit does not offer transportation to a hierarchical health service that offers adequate care, as verified in the following speech:

From this perspective, the issue of transportation to the continent has emerged as one of the difficulties to be faced in urgency/emergency situations. It should be said that in some communities isolated by sea or river an "ambu-boat" is available, a boat equipped to provide prehospital care in cases of urgency. Even with this resource, transportation is one of the problems pointed out by the informants, as evidenced in the following testimony:

Such report shows the discredit of the population in the operation of the "ambu-boat", since in addition to the difficulty in calling it, it ends up not reaching the applicant. The mediation between the patient and the
"ambu-boats" service can be done by the BHU located on the island, since the transportation of the patient is one of the tasks of the primary care.³⁰

The issue of the locomotion of the user to the health service was also highlighted in other studies.^36-38 In the context of quilombos, one of these studies pointed as difficulty factors in accessing health services the vehicle availability, ambulance access to quilombos, and difficulty/inability to transport patients,³⁶ corroborating the findings of this research.

CONCLUSION

The objectives set were achieved and the assumptions of the Leininger's Theory were essential to understand the perceptions of the quilombola mothers.

In this direction, there was an association between the following assumptions of the Transcultural Theory and the results presented here: the difficulty of conceptualizing the terms "urgency" and "emergency" by the participants may be associated with cultural differences among people; the universality of the cultural care was unveiled in characterizing fever as a situation of urgency, since in the Western reality this symptom is seen as a problem within what Leininger calls a cultural context, having a cultural value; the concept of cultural care was observed from the mobilization of the first measures of care in the family environment, as well as by the recognition of the limit of the care; this allowed the understanding of the moment to enter the formal care system, and this deals with what the theory characterizes as world view; finally, the concept of cultural diversity of care was identified when there was the need to resort to the formal subsystem, which pointed to social and infrastructure problems that interfere with the access to health services.

In giving voice to these mothers, this study highlighted the problems experienced by them in situations of urgency and emergency, which make it impossible to achieve health care and the principles of comprehensiveness, universality and resolution of the health services, provoking reflections on their effectiveness in quilombola communities.

In addition, it brought to light that the operation of the "ambu-boats" is not effective, since the people do not obtain answer to their calls, distorting its purpose and, consequently, leading to the discredit of the population.

The results expressed here demonstrate that the residents of the quilombola community of Praia Grande do not have comprehensive health care, requiring government action to ensure full access to formal system services and effective responses to their problems, enabling the achievement of the congruent care mentioned by Leininger.

The limitations of this study refer to the distance between the continent and the island, which increased the cost of this work, and the climatic conditions for the sea crossing, which sometimes prevented the access to the community, prolonging the period of data collection. In addition, because it is an unpublished research, there are no publications that contemplate the same object of study and allow a comparison of the results obtained.

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