RESEARCH ARTICLES

Preventing accidents in children and teenagers in the family health strategy

Ana Cristina Pereira de Jesus Costa^I; Ester Cíntia Santiago Pereira^II; Ana Larissa Gomes Machado^III; Álissan Karine Lima Martins^IV; Patrícia Neyva da Costa Pinheiro^V; Neiva Francenely Cunha Vieira^VI

^I Nurse, Master's degree in nursing. Professor at the Federal University of Maranhão, Center for Social Science, Health and Technology. Imperatriz, Maranhão, Brazil. Email: anacristina_itz@hotmail.com
^II Nurse, Brazilian Air Force. Sao Paulo, Brazil. Email: ester.cintia@hotmail.com
^III Nurse, PhD in nursing. Professor at the Federal University of Piauí. Picos, Piauí, Brazil. Email: analarissa2001@yahoo.com.br
^IV Nurse, PhD in nursing. Professor at the Regional University of Cariri. Crato, Ceará, Brazil. Email: alissankarine@gmail.com
^V Nurse, PhD in nursing. Professor at the Federal University of Ceará. Fortaleza, Ceará, Brazil. Email: neyva.pinheiro@yahoo.com.br
^VI Nurse, PhD in health education. Professor at the Federal University of Ceará. Fortaleza, Ceará, Brazil. Email: neivafrancenely@hotmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2015.5863

ABSTRACT

This qualitative study aimed to identify nurses' conceptions of health education, and their related actions in the family health strategy, and to highlight those relating to accidents involving children and adolescents at home. Data were collected through semi-structured interviews of 10 family health strategy nurses in Imperatriz, Maranhão State, Brazil, in January 2012, and analyzed using content analysis. The results showed that nurses do not engage in health education directed to preventing accidents in childhood and adolescence, and that it is necessary to address issues of this nature. It was concluded that, as injuries are recurrent in the area assigned to the participants, health education on the subject is necessary in order to reduce accident rates and strengthen users' desire to change health-related behaviors.

Keywords: Nursing; health education; family health; accidents.

INTRODUCTION

About 800,000 children die from accidents each year worldwide, and trauma is the greatest cause of mortality and disability, accounting for more deaths than all diseases combined^1,2.

Similar to other countries, Brazil has a high number of deaths from accident in children aged less than 15 years. Studies show that during a period of eight years (2002 to 2009), accidents with children and adolescents were responsible for 755,826 hospitalizations and 22,373 deaths in Brazil. ³

In the state of Maranhão, according to information from the State Health Department, in 2007 and 2009, 678 cases were reported of care provided to child and adolescent victims of accidents in the state's main emergency rooms, representing 3.9% of the total 17,000 emergency care cases reported. These data indicate that preventing accidents among children and adolescents should be a priority for health care professionals. In addition, it should be noted that the number of accidents with children and adolescents may be underreported, given the lack of mandatory protocols in state health care services to report the causes of accidents and their occurrence by specific age groups^4,5.

There is ample literature pointing out that accidents involving children and adolescents occur predominantly in the home environment, and can therefore be avoided, especially those with greater incidence such as falls, burns, poisoning by drugs and/or chemicals, abuse, animal bites, injury by knives/blades and fire^3,6.

The Convention on the Rights of Health of Children and Adolescents, the Statute of Children and Adolescents (SCA) and Ordinance MS/GM No. 737, which addresses the National Policy for Reduction of Morbidity and Mortality from accidents and violence, hold that basic knowledge of health and accident prevention, and support for application of this knowledge, must be ensured to all sectors of society, especially parents, children and adolescents ^5,7.

It is necessary to educate families so they know the characteristic phases of child and adolescent growth development, adopt healthy behaviors, and promote a healthy domestic environment that reduces accidents⁷. Healthcare professionals must educate and dialogue with the public about preventive practices, with a view to promoting the health of children and adolescents⁸.

The main philosophy of the Family Health Strategy (FHS) of the Brazilian public Unified Health System (SUS, as per its acronym in Portuguese) is to promote community health, especially in vulnerable groups. The impacts of accidents involving children and adolescents on families and society should be considered a significant problem capable of prevention^9-11. Permanent damage or premature death at an early stage in life can lead to limitation and/or total loss of individual, social and spiritual expectations that provide meaning and joy in developing skills for a healthy life¹².

The Ministry of Health recommends preventive measures before the onset of complications, to minimize exposure to factors that trigger accidents. The aim of this study is to identify concepts and actions on accidents in childhood and adolescence in health education carried out by nurses working in the FHS.

LITERATURE REVIEW

Given its rise in incidence, childhood trauma from accidents has become a primary concern of healthcare professionals. For every ten children victims of accidents, one will need care by the SUS, and another 15 will present permanent sequelae⁴.

In Brazil, accidents involving children and adolescents represent a considerable economic impact, mainly due to hospitalization expenses, especially in intensive care units, which represents 8% of expenditures for hospitalizations for all causes. In Brazil, the main accidents involving children are falls, which are the leading cause of hospitalizations, and of which 74% are due to external causes in different age groups^2,7.

In Brazil, it is estimated that by 2020, accidents involving children and adolescents will increase by 22%. Children under three years of age are at greater risk of accident due to curiosity, impulsiveness and lack of maturity to assess hazards, making the need for prevention even more urgent ^10,12.

The need for investment in­ prevention of accidents involving children and adolescents is clear. To this end, an initial first step is to modify the definition of accident as an "unintentional injury", and to disassociate it from unpredictability and randomness. The main forms of action to raise awareness are health education initiatives, involving physical, material and emotional care, and physical changes to home space. Healthcare professionals, especially those working in the FHS, are faced with the challenge of implementing educational measures to prevent accidents¹².

METHODOLOGY

This was a qualitative study carried out in January 2012, in Basic Health Units (BHU) in the city of Imperatriz, in the northern Brazilian state of Maranhão. Imperatriz has 42 FHS teams, distributed into 30 BHUs in six geographical regions. Six BHU units with more than one FHS team participated in the study, representing the reality of each macro-region. The total area encompassed by the BHUs assists 2,700 families.

The 42 nurses working in FHS teams in the municipality were informed about the study, and invited to participate; of these, only 10 nurses agreed to participate. Each participant signed a free and informed consent form.

Data were collected by means of a semi-structured interview, that consisted of 15 questions on personal and professional characteristics of the participants, conceptions and activities for health education with families, training for practicing health education, and educational concepts and activities on child and adolescent accidents implemented with families. Another BHU not included in the present study was used to test the questionnaire. The interviews were scheduled in advance at each participant's workplace, and took place in rooms provided by management of the facility.

To analyze the data, the thematic framework of content analysis¹³ was used, which entailed pre-analysis and exploration of data, followed by organization of data into four categories: health education; information for prevention; training for health education practice; conceptions about accidents and their causes; and, the occurrence of accidents. The nurses' statements were identified by the letter E and interview order number.

The research project was approved by the Research Ethics Committee of the University Hospital of the Federal University of Maranhão, under Opinion No. 320/11. The principles of Resolution No. 466/12 were adhered to.

RESULTS AND DISCUSSION

Characterization of the participants

The study participants were aged between 28-55 years. Eight participants were women, six were married, and six (60%) had children. The mean time for training in nursing was 10 years, and eight participants reported having one of the following specialties: family health, community health or midwifery. Time working in the FHS ranged from 8 months to 12 years. Most of the participants had education in a sub-field of ​​nursing. The categories identified in the statements of the nurses are analyzed below.

Health education: information for prevention

The participants' statements indicate a conception of health education absent of dialogue and exchange of knowledge among subjects, with a focus on preventing diseases through lectures, as portrayed in the following accounts:

Health education concerns directions in lectures to promote health of the population and prevent disease. (E2)

[Health education] is to prevent disease in the population through lectures. (E4)

Health education is the basis of the family health strategy [...] because through it, we can orient families on how to prevent diseases. (E7)

[Health education] is to inform the community on how best to take care of themselves, prevent disease and promote health. (E8)

Health education proposes the development of the individual or community as an agent of change in the health-disease process, through reflective and critical dialogue - elements that were not perceived in the study participants' statements. Conceptions of health education based on the traditional pedagogy of transmission of information predominated among the participants.¹³ Studies also point to the lack of problem-solving educational practices that focus on health promotion and participation of subjects in the FHS^7,8.

Health education should not be a process exclusively geared towards prevention of disease, but also a strategy for exchange of knowledge and experiences between health professionals and users, in order to strengthen individual and collective potential, a factor essential to behavior change. Care must be taken so that health education does not become transmission of knowledge only from educator^14,15.

It is also important that health educators promote strategies to collaborate with users in understanding health and illness processes, and depending on need, should act individually and/or collectively, in a manner that is autonomous, creative, and values the daily lives of users. Dialogue is an important tool in the educational process, yet remains a major challenge for both health professionals and subjects¹⁴.

Although most of the participants had expertise in the area of ​​public health, their educational practices reveal the need for more theoretical and methodological contribution, so that the activities of professionals working in the FHS encourage more participation and discussions on health education with service users.

Training for practicing health education

The team recognized the lack of specific training to provide quality health education to users. Therefore, FHS professionals should be qualified to work in this context, with training on how to plan, implement and evaluate educational activities, based on the realities of communities and demands of users. The statements below demonstrate nurses' lack of training to provide health education:

Since I've been in this unit, there was one training on health education in 2008. (E2)

It's been a long time since we received any training on health education. (E3)

The municipality has continuing education for updates on vaccines, viral hepatitis, leprosy [...]. (E8)

In primary health care, health education is inherent to the FHS work process. However, training opportunities must be included in management of health professionals that take into account knowledge, strategies and technologies in a broad and continuous process, and that consider the experiences, beliefs, values, feelings and perceptions of the community. It is increasingly necessary that managers of healthcare services insert into primary care work, processes for planning, implementation and evaluation of educational activities, based on constant theoretical and practical training⁷. The lack of continuous training of health professionals limits the range of activities in health education, especially when they only consider traditional standardized actions^8,16.

The participants also reported that the health education activities they developed were limited to specific dates in health and monitoring groups in the BHUs, confirming that the professionals related health education to standardized actions and lifestyle prescriptions focusing on health programs, as shown below.

I try to prioritize events for the month: Children's Day, Women's Day, breastfeeding. (E3)

The issue most talked about is hypertension and diabetes [...] on nutrition, exercise; in terms of children, nobody says anything. (E5)

I work with the Hiperdia system [...] I occasionally schedule lectures in schools, depending on what I will work on that month. (E8)

The statements of the FHS professionals were loaded with interventionist determinations and a reductionist perspective of the health-disease process.

Although they recognized the significance of accidents, the participants prioritized issues according to the schedule mandated by Ministry of Health programs on diabetes, hypertension and other diseases. While the importance of these activities for health surveillance should not be disregarded, health professionals should also mobilize to meet the specific educational needs of the area and subjects they assist.

Health education actions need to be seen as strategies aimed at prevention, promotion, cure and rehabilitation. Educational practices should not focus only on prevention; rather, they need to be more comprehensive and integrated, and encourage the personal development of subjects. The proposal for educational practices based on the needs of users is part of the emerging discourse for a model of health education based on dialogue, which, as opposed to the traditional model, is based on the perspective of autonomous subjects who actively participate in health practices. Therefore, review of health education practices under the lens of new standards makes it essential to adopt new visions and rethink the current methodology of this work^15,17 .

Conceptions about accidents and their causes

Knowledge about accidents is important for preventive decision making, and to promote the health of children and adolescents. The participants defined accidents in the following statements:

Accidents are situations that endanger the integrity of a person, and can generally be avoided [...] if there were more prevention by family members, the number of cases would decrease. (E3)

An accident includes everything that can cause damage to the physical and mental integrity of children and adolescents. (E5)

I think that an accident is anything that is not expected to occur, which may cause damage to health [...] A careless mother is also a great factor in causing accidents, in addition to lack of information [...] (E6)

Accidents are predictable events resulting in damage and even death. Accidents can be avoided by adopting careful material, emotional, physical and social measures, with a focus on prevention^3,4. However, any change in behavior occurs by decision of an individual, considering their economic, social and cultural context. Some studies also point out the lack of educational, problem-solving activities, with a focus on health promotion and participation of FHS users^7-10 .

In this perspective, when a negative event occurs in the family, health professionals seek to discover who is responsible and "guilty". Responsibility is often related both to causality and obligations of people. Negligent behavior of families with their children and adolescents contribute to early proximity to risk environments, making them vulnerable to various forms of accidents. They can also be direct responses to the difficulties parents experience in caring for their children, including reflexive responses to the social conditions to which they are subjugated¹⁵.

By attributing responsibility for accidents to parents without delving into the family's social context, such as work overload and maternal role, lack of social support, lack of education, and substance abuse, healthcare professionals merely assign blame without awareness, actions and readiness to intervene appropriately in the realities of users.

The risk of accidents involving children and adolescents are increased by neglect and absence of preventive behavior of households, and lack of responsible adult supervision. In most cases, parents and guardians of youth are unaware of their stages of growth and development, as well as their needs, a context that increases the occurrence of accidents. In this context, educational activities aimed at prevention of accidents are needed, and they must involve all members of the family that live with the child or adolescent, and share the duties of care¹⁰.

The occurrence of accidents

The nurses who participated in the present study recognized the occurrence of accidents in the area they served, as can be observed in the following statements:

Here, a child died because it took various pills of ferrous sulfate [...]. (E3)

We have many cases of burns, pedestrian accidents, motorcycle crashes. (E5)

They come here mainly because of falls: hammock, bed, stairs, bicycle [...], but also for burns. (E6)

Among the predominant causes of accidents reported, falls stand out in the literature, and represent 52.4% of all hospitalizations in Brazil⁵. The literature review performed for the present study found no publications on this topic specifically focused on the southwestern region of Maranhão, which includes the city of Imperatriz, and there is no formal instrument to record the occurrence of these events. Thus, there is a need to deploy a system to record these data, due to the complexity of accidents with children and adolescents, and it is important that those responsible for the preparation and implementation of policies for health and accident prevention make decisions to avoid causes, consequences, suffering and death.

There are conditions in the home that favor the occurrence of accidents, including chemical, physical, biological, structural and cultural factors. Health education work in primary care means promoting knowledge on safety and awareness, so that users adopt safer behaviors at home, and thus reduce the incidence of accidents^2,6.

It is noteworthy that determinant factors of accidents involving children and adolescents are attributed to the particularities of the communities. Therefore, it is necessary that any discussion or proposal for action is based on local conditions, whether from an epidemiological, social or cultural point of view, taking into account the inherent environmental risks and psychomotor developmental stages of both children and adolescents^8,17.

Even though the occurrence of accidents involving children and adolescents is known, health education actions of the BHU do not respond to the need for prevention. It was surprising that the participants did not implement specific activities to this end, as expressed in the following statements:

Education specifically on accidents with children, no, let alone a teenager. I never did anything on this subject at the clinic. (E2)

This is an interesting topic, many children arrive with objects in their nose, children who have fallen, have burns, but I never gave a talk on this. (E3)

I never gave a talk on accidents with children and adolescents. [...] There was a very serious case here, which was reported on TV, due to drowning in a bucket. (E4)

I never talked about this. Health education is not just the responsibility of the nurse [...]. (E6)

The process of developing educational activities for the prevention of accidents must be understood and practiced continuously, especially when the incidence is high. Thus, actions focused on this health problem must emphasize prevention, which is characterized by early action that aims to intercept or paralyze the course of events, preventing any damage from happening by exercising physical, material, emotional and social care¹².

Without disregarding the importance of meeting the programmatic demands of the FHS, action to promote family health means knowledge of the everyday lives of its users and specific attributes of its team members. Studies with families undertaken in various health care scenarios, such as hospitals, showed a significant increase in learning by family members on the subject of accidents, demonstrating satisfactory potential of educational activities in hospitals. The authors of this study therefore recommend training of families on accidents in other healthcare scenarios, including FHS units. The role of nursing must entail a comprehensive view of children, adolescents and their families, related to individual, social and programmatic factors that influence the occurrence and possibility of preventing accidents^10,14.

Studies that emphasize the magnitude of accidents in early childhood and adolescence suggest the need for health education actions with this audience, as well as the family, community and society, in order to raise awareness of risks and the need to adopt safe behaviors in relation to environments subject to accidents. Therefore, health promotion activities must seek the most effective way to reduce high accident indicators in childhood and adolescence ¹⁵.

The Ottawa Charter addresses the concept of health promotion, which means providing conditions for the population served, to make individuals capable of improving their health and exercising control over it. The Charter formalizes the creation of environments favorable to health as one of the five fields of­ health promotion. Such a favorable environment is related to protection of the environment and conservation of natural resources, as well as the environment where work relationships between­ nurses, children, adolescents and their families occur, making it possible to observe biological, social and cultural determinants, seeking comprehensive care at home^16-18.

CONCLUSION

The authors of the present study conclude that educational activities should be undertaken with all of those involved in preventing accidents, including children, teenagers, families and society, in order to warn of risks and adopt safe behaviors in relation to the environments and stages of child and adolescent development.

Healthcare professionals must facilitate the acquisition of health knowledge, and develop educational activities aimed at preventing accidents involving children and adolescents, preferably encompassing all possible scenarios, starting with the home, and including socioeconomic determinants.

Limitations of this study include its small sample size and the inexistence of educational activities on accident prevention undertaken by the participants, despite their recognition of the frequent occurrence of such events. In conclusion, the authors recommend development of educational and preventive programs on risks and damages from accidents in communities, to assist in the development of potential and empowerment of users of the FHS.

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