RESEARCH ARTICLES

Tuberculosis: user embracement and information in home visits

Francisco de Sales Clementino^I; Francisco Arnoldo Nunes de Miranda^II

^I Nurse. PhD in Nursing from the Federal University of Rio Grande do Norte. Specialist in Public Health. Professor at the Federal University of Campina Grande, Center of Biological and Health Sciences, Department of Nursing. Campina Grande, Paraíba, Brazil. E-mail: clementinosales@ig.com.br
^II Nurse. PhD from the University of São Paulo. Professor at the Federal University of Rio Grande do Norte, Department of Nursing, Graduate Nursing Program. Natal, Rio Grande do Norte, Brazil. E-mail: farnoldo@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2015.4289

ABSTRACT

This qualitative, descriptive study examined the activities of family health strategy personnel in home visits to patients with tuberculosis in Campina Grande, Paraiba, in January 2009. Study participants were 34 users diagnosed with pulmonary and extra-pulmonary tuberculosis. Data were collected through semi-structured interviews and analyzed using content analysis. The results indicate three categories: home visits – "health knocks on your door"; feelings – security and gratitude in coping with the situation; and dissemination – a matter of spreading information. It was concluded that Family Health Strategy personnel are distanced from their role as educators, given that the frequency of their educational activities falls short of demand from tuberculosis patients.

Keywords: Tuberculosis; family health program; home visit; primary health care.

INTRODUCTION

Tuberculosis (TB) is a worldwide pandemic that already affects one-third of the world population. According to data from the World Health Organization, a group of 22 countries is responsible for 80% of the burden of TB in the world.

Brazil is the 19th country in the world in number of new cases and the 108th when evaluating the incidence of the disease. In 2010, 70,997 new cases of TB were reported, with an incidence rate of 37.7 cases per 100,000 inhabitants. In addition, it is estimated that 14% of TB patients are also HIV-positive. And although TB is a curable disease, it still causes the death of 8,400 carriers in the country¹.

It is necessary to also highlight issues related to attitudes and beliefs about prejudice, fear of stigma and discrimination from family, friends and neighbors, leading to restriction of interpersonal relationships of kinship and friendship, modifying thus habits and lifestyle².

In Brazil, the decentralization of health actions has been taken as organizational policy, with the implementation of the Federal Constitution, and also the infra-constitutional legislation, namely Law No. 8,080 and 8,142 and the Norma Operacional Básica do Sistema Único de Saúde (Basic Operational Norm of the Unified Health System - NOB- SUS/93), among others³. From this landmark, the tuberculosis control actions started to be under the responsibility of all Brazilian municipalities, given that, especially since the 1980s, tuberculosis has become a serious public health problem_.

In this perspective, international goals were adopted to detect 70% of estimated new cases and to heal 85% of detected cases. On the 6th Millennium Development Goal, it is expected to reduce 50% of the prevalence and mortality from TB by 2015. Thus, the Ministry of Health stands the strengthening of responsiveness to TB as one of the priorities of the Pact for Life².

It is necessary to open spaces for dialogue with the population, generating reflection and questioning that allow the construction of a relationship of co-responsibility, favoring more humane and effective ways in the health work process, both for users and for professionals^1,4.

Thus, considering that the TB patient appears physically, emotionally and socially vulnerable, due to their social context, mostly unfavorable, it is necessary to know the environment in which that individual is inserted so that the health team performs a special approach to each case, thus minimizing the barriers to TB care process⁵.

To control the disease, the World Health Organization (WHO) proposed the Directly Observed Treatment (DOTS) as a strategy to achieve 85% of cure, 70% of case detection and to reduce treatment abandonment to 5%⁶.

Thus, the Programa Nacional de Controle da Tuberculose (National Program for Tuberculosis Control) has the help of the Family Health Strategies and of Community Health Workers (CHW). The decentralization of TB control for the Family Health Strategy (FHS) involves expanding access of patients to health services, and providing greater adherence to treatment through the bond created between the teams and the community⁷.

In this context, the FHS provides for the use of home visits (HV), in order to equip professionals for their inclusion and the knowledge of population's living reality, and for the establishment of ties⁸. It is an activity performed by health professionals in the home in order to provide actions and services for promotion, prevention, maintenance or recovery of health.

However, there are obstacles to its implementation, such as the training of professionals, institutional and social culture and the difficulty of extrapolating the limits of the territory when it is needed a care elsewhere in the health care network⁹. The circumstances that contribute for abandonment of TB treatment often derive from poor monitoring, which can be avoided by a proactive attitude of family health teams in the care of patients with TB and their families¹⁰.

A study conducted in the city of Bayeux, Paraíba, points out flaws and weaknesses in the work process of the FHS during the HV, reporting that such this practice is not followed regularly, since only 40.2% of health units perform it¹¹. Thus, professionals need to be prepared to carry out the HV with competence and efficiency, not becoming overwhelmed by routine and the trivialization of assistance, which could make their performance mechanical and impersonal.

Thus, it is essential that the family health team is willing to provide adequate assistance to the population living in areas with the highest risk of TB, acting thus to improve the quality of life, and understanding the TB patient as a unique being, with peculiarities, without losing sight of their family and social context.

Given these arguments, the following guiding question is pointed out: How is the work of professionals of the Family Health Strategy in face of the TB control? To answer this question we established the following objective: to analyze the performance of FHS professionals in home visit performed to the tuberculosis patients.

Thus, this study may contribute to the organization of propositions involving specific actions for the pursuit of humanization of assistance to tuberculosis patients and their families.

LITERATURE REVIEW

Tuberculosis remains as a neglected disease worldwide and is a public health problem. The TB treatment does not depend solely and specifically on the existence and gratuitousness of drugs and on their pharmacological effectiveness; one has to consider the other elements in the care process, such as improving access to health services, adherence and co-participation of the tuberculosis patient and their family¹².

Thus, it is understood that the front door of a health care system must be accessible to the user, who often resorts to emergency services due to the enormous difficulty of access. This results in physical and emotional suffering for the tuberculosis patient and their family group, since, to ensure accessibility, the local health system should provide the necessary and indispensable adjustments to the implementation of programs.

From this perspective, it is necessary that health professionals transcend the understanding of the strategy, and besides ensuring the intake of medication, it is essential also know the way of life, family dynamics, beliefs, opinions and knowledge about the disease and the treatment itself ^2,13.

It is expected, regarding the Tuberculosis Control Program (TCP) in the coverage area of the Family Health Program, that the Basic Family Health Unit (BFHU) is the customer's gateway and promotes access to the population and provides a basic quality care, including early diagnosis of TB and monitoring of treatment through home visits.

This task meets the specific needs of actions in TB, as diagnosis and effective treatment of patients are the primary basis for disease control ¹⁴.

Thus, knowing the health needs of people with TB will allow the health team redirects its practices, aimed at improving the care provided to the patient and their family ¹⁵.

METHODOLOGY

This is a descriptive study with qualitative approach, and the locus was the city of Campina Grande, Paraíba. The sample was composed of 34 users diagnosed with pulmonary and extrapulmonary tuberculosis, selected by the Sistema Nacional de Agravos de Notificação (National System for Notifiable Diseases - SINAN) database. The choice of the sample extension in the interview was not defined by numbers, but it was related to the repetition of speeches and data saturation.

We selected as inclusion criteria tuberculosis cases with completed treatment, relating to people resident in the area covered by the six health districts and registered with the PCT. While the exclusion criteria were the cases of individuals living outside the municipality, the cases reported as suspect, but discarded and also cases accompanied and treated only in health centers.

From the testimonies of those surveyed tuberculosis patients, the following categories emerged: Home visits: "health knocks on your door"; Feelings: safety and gratitude in facing the situation; Disseminating - a matter of dispersing information.

Data were collected in January 2009 through semi-structured interviews, which were recorded, transcribed and filed, according to Resolution No. 196/1996, approved by the Research Ethics Committee (REC) of the State University of Paraíba (UEPB) under protocol 0519.0.133.000.06¹⁶.

To preserve anonymity, participants were identified with letter R corresponding to respondents, following the numerical order of participation. Interviews were transcribed and analyzed by Alceste 4.5 software and using the Bardin content analysis¹⁷.

RESULTS AND DISCUSSION

Home visits: "health knocks on your door"

Some TB patients demonstrated the need for more support from health professionals, highlighting the home visit as a space for health promotion and for building links between subjects involved in the process.

[...] visiting families at least once a month; talking to see if they combat tuberculosis. (R25)

[...] visiting us, monitoring closely . (R33)

It was verified that the professionals of the FHS do not develop their educational activities as proposed by the Ministry of Health, which interfered with quality of care; it was found that clinical care is still prevalent in the conduct of professionals in BFHU and/or at home. According to technical standards of the Department of Primary Care of the Ministry of Health, it is recommended that there be at least a monthly visit to each household of the Family Health Strategy coverage area, with variations depending on the health status of their residents¹⁸.

Regarding the difficulties of HV, it is important to note that there is no point in only determining that the health team approaches the family as a care unit because there is lack of tools and instructions for professionals working in this health care field. In this context, it is clear, through clinical practice, that in some situations the HV happens mechanically and without understanding of the valuable tool it can be in the health work process and, in particular, in the primary health care services ¹⁰.

Therefore, monitoring of tuberculosis cases by family health professionals should be based on the rescue of humanization of care, through supportive listening, from the identification of the patient's needs. Thus, patients become more receptive to the team that accompanies them and to the proposed therapy. This prevents abandonment of treatment and the occurrence of multidrug resistance and facilitates the breakage of the transmission chain.

From this perspective, the HV emerges as a strategy that integrates the appreciation of the special care and the recognition of tuberculosis patients, increasing the therapeutic possibilities, from the adherence and completion of treatment, which are essential components for effective tuberculosis control and the reduction of multidrug resistance.

Feelings: safety and gratitude in facing the situation

During the home visit, feelings of safety, gratitude and recognition of the assistance offered by the FHS professionals emerged, as verified in the users' speeches:

[...] very well received, the nurse was always at my house. Oh my God, it is a treasure! (R33)

She was always there at home to provide the medication, because a lot of people do not have conditions to reach the health unit. (R34)

According to the interviewees, welcoming, in addition to professional assistance, involves talking to people and assessing what they need. This occurs mainly when they experience moments of conflict, such as: worsening of symptoms, economic and social hardship, which relate to actual income and survival conditions.

Thus, it is necessary that innovative and participatory ways are employed in health education activities by family health teams, especially in the case of TB patients, considering the plural dimension of this disease^10,19.

From this perspective, the FHS must be prepared to meet not only the expectations of patients regarding their disease, as well as other expectations related to their family group and cultural, social and economic factors, establishing links and a process of mutual learning that involves a multiplicity of values, practices, knowledge and perceptions of the world²⁰.

It is understood, therefore, that, from the life experience of patients and professionals involved in the care, it is possible to articulate awareness and action, according to the approach of a liberating education, with subjects participants in health, recognizing that this plan of care is ethically bound in the right of citizens to health.

Disseminating - a matter of dispersing information

After a review of respondents' views on the health care, we can see the interest to become increasingly autonomous and independent in the management of their health-disease process, as the following lines demonstrate:

[...] disseminating more, talking to people about the disease... Doing home visits, knowing how to talk about it with families. (R15)

[...] putting people to give a good training, to locate and visit the families to talk. (R16)

In addition, the reports of respondents show that health education not only occurs in formally instituted spaces, since it can happen at any meetings between those who care and those who are cared for, that is, at home, in social spaces, among others. In this context, tuberculosis patients have the opportunity to broaden their understanding of their problem and reflect on the intervention of the reality in which they live, favoring the promotion of their autonomy.

Regarding the empowerment of TB patients, as a strategy to control the disease, we emphasize the importance of health education as a political act, which is able to promote the dialogue between health professionals and users, the citizen autonomy and the encouragement of an active posture of these subjects in their political and social environments^19,21.

Due to its ancient history, tuberculosis is still a disease wrapped in prejudice, strongly associated with infection; however, this issue needs to be better addressed by health services. This situation demonstrates the need for a joint effort between the tuberculosis patients and their families.

The way the health team is organized to develop their work is crucial to promote adherence of the sick person to treatment, leading to the discharge by heal. So the challenge ahead in the care of TB patient, their family and community is established through health education actions, linking relationships between health professionals and users, which enable sharpening dialogue, exchanging knowledge, mutual learning and the participation of all involved in the disease control¹⁹.

In this context, it is necessary the promotion of an educational practice that includes the active participation of TB patients and families, directed according to their needs, beliefs, representations and stories of life, making them co-producers of this educational process along with health professionals¹³. Thus, new demands can be identified by the patient and families throughout the care process.

CONCLUSION

It is understood that the TB patient's disease process involves issues that go beyond the limits of biology, which are related to multiple factors, not only to the relationship of cause and effect between the bacillus and the infected body.

However, it was observed in the study that FHS professionals still center health care in medical knowledge, and there is almost no space for dialogue and knowledge building. In addition, there is a detachment of FHS health professionals of their role as educators, since the frequency of their educational activities does not match the demand presented by tuberculosis patients.

It is hoped that the work of the teams advance in order to not only incorporate drug supervision but also diagnostic actions, therapeutic monitoring of tuberculosis patients, evaluation of communicating subjects and educational activities in the enrolled community.

Interestingly, the home visit brings a new meaning to the practices of the FHS professionals, because this visit is performed together with the individual/family. This action, in addition to stimulating the sharing of experiences, is part of the health education process and therefore involves the need for health professionals to have a comprehensive knowledge that goes beyond the clinical and pathophysiological aspects and that includes understanding of the meaning of living with tuberculosis, seeking healing.

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