RESEARCH ARTICLES

Life holders hypertension practices

Fernanda Machado da Silva^I; Maria de Lourdes Denardin Budó^II; Raquel Pötter Garcia^III; Graciela Dutra Sehnem^IV; Maria Denise Schimith^V

^IRN. Master of Nursing at the Federal University of Santa Maria. Assistant Professor of the Nursing Program, at Universidade Federal do Pampa. Member of the Nursing Study Group of Fronteira Oeste, Rio Grande do Sul. Member of the Care, Health and Nursing Study Group of the Federal University of Santa Maria. Uruguaiana, Rio Grande do Sul, Brazil. E-mail: fernandasilva@unipampa.edu.br 
^IIRN. Ph.D. in Nursing from the Federal University of Santa Catarina. Associate Professor of the Nursing Department and the Graduate Program in Nursing of the Federal University of Santa Maria. Vice Leader of the Care, Health and Nursing Study Group. Santa Maria, Rio Grande do Sul, Brazil. E-mail: lourdesdenardin@gmail.com
^IIIRN. Master’s student of the Graduate Program in Nursing of the Federal University of Santa Maria. Member of the Care, Health and Nursing Study Group. Santa Maria, Rio Grande do Sul, Brazil. E-mail: raquelpotter_@hotmail.com
^IVRN. Doctoral student of the Graduate Program in Nursing of the Federal University of Rio Grande do Sul. Assistant Professor of the Nursing Program, at Universidade Federal do Pampa. Member of the Nursing Study Group of Fronteira Oeste, Rio Grande do Sul. Uruguaiana, Rio Grande do Sul, Brasil. E-mail: graci_dutra@yahoo.com.br
^VRN. Graduate of the inter-institution doctoral program in nursing of the Federal University of São Paulo/Federal University of Santa Maria. Assistant Professor at the Federal University of Santa Maria, Rio Grande do Sul, Brazil. E-mail: ma.denise@yahoo.com.br

ABSTRACT

The objective was to understand the influences that determined the choice of lifestyle practices of individuals with hypertension, accompanied by a team of family health. It's qualitative, descriptive research. Were interviewed nine individuals with hypertension, followed up with a team of family health. Was used a semi-structured interviews, observation and document analysis to collect data from the period of february to agust 2009. Emerged mainly the feeding practices, therapies and popular actions that involve emotional factors. Such practices influenced and were influenced by the health-illness care and were grounded in scientific information interpreted by the popular knowledge, built and shared in that specific sociocultural context.

Keywords: Health behavior; hypertension; health education; community health nursing.

INTRODUCTION

Systemic arterial hypertension (SAH) represents an illness of epidemiological importance, both in the national and in the world context, due to its high prevalence and to the fact that it is considered to be the main risk factor for cardiovascular disease¹. In addition, it is asymptomatic throughout most of its course, with a slow clinical evolution and associated with multiple factors. These features make it more difficult to cope with it.

Among the many aspects that affect the course of SAH, modifiable factors stand out because of the high prevalence in the population and the fact that they are the main focus of public health policies1. In fact, these factors are influenced by the life conditions of the population, and expressed in their lifestyle practices and in the relationships people establish with others and with the sociocultural context in which they live. Choosing and living these lifestyle practices is associated with issues that will influence either improvement or worsening of these individuals’ quality of life and health conditions. Therefore, the nature of the disease is verified not only in the clinical case, but also by understanding the life dynamics of these people.

The chronicity of SAH and its impact on the epidemiological profile of the population posed a challenge for the public health system, represented by the assurance of continuous and comprehensive follow-up to its carriers. Among other proposals, the Ministry of Health (MH) indicates combining actions of health promotion and health education, aimed to encourage individuals with SAH to adopt healthy lifestyles².

In order to truly base health actions on comprehensiveness and health promotion, it is necessary to recognize that the health-disease-care process is determined by multiple social, psychological, and behavioral determinants³. From this perspective, it is understood that these individuals choose lifestyle practices based on the association of these determinants and on how they experience and understand the health-disease-care process.

In the light of this and considering the sociocultural reality of the studied community, the present study aimed to understand the influences that determine the choice of lifestyle practices of individuals with hypertension, who were followed up by a family health team.

THEORETICAL FRAMEWORK

Individuals with SAH perceived their disease in a unique and subjective way, due to the variety of feelings and concerns it has in their lives. The chronicity of SAH, that is, its impossibility of cure, constitutes the factor of greater impact on their lives. This feature imposes adaptations in their everyday routine, which often leads to the need for changes in their lifestyle practices⁴.

Lifestyle practices can be defined as representations, meanings and values associated with the group of sociocultural interactions that unite individuals and groups that share the same context and present similar strengths and weaknesses⁵. It means that these practices are considered a construct/action, and are expressed in behaviors aimed at health, disease and care, applied in certain realities, in a certain period of time. 

Hence, the reflection regarding lifestyle practices in the context of chronicity must consider them as individual and collective capabilities that are presented in the routine of every social group, and influenced by multiple elements of the health-disease-care process, such as institutional, scientific, family and sociocultural aspects.

Lifestyle practices are, thus, expressed through habits, guided by the practical knowledge, originating from the daily experience of the social group, for the maintenance of their health, in response to the needs for care and/or coping with health problems⁵. At the same time, the influence from scientific knowledge must be taken into consideration, which is currently disseminated through the media, in the sense that it aims to influence the choices of these groups regarding lifestyle practices that act in the care and maintenance of their health, based on the legitimacy of the scientific knowledge⁴.

METHODOLOGY

This is a qualitative descriptive study. This approach is considered appropriate to the study purpose, as it represents an ideal approach to analyze the reality of the subjects, from their personal perspective, and to understand the several ways through which they interpret their life experiences⁶.

Study participants were nine people living in a community assisted by a family health unit (FHU), in a city in Rio Grande do Sul, Brazil. The inclusion criteria were: individuals with isolated SAH (who did not present cardiopathies or any other associated chronic disease), over 18 years of age and in follow-up with the family health team of the FHU. People considered in follow-up with the team were those who attended the Hypertension and Diabetes Support Group, developed by the FHU team, and also who kept a clinical follow-up at the unit, through medical and/or nursing appointments, as indicated by the protocol of the Ministry of Health, that is, at least once a year². The subjects were included in the study once they signed the Free and Informed Consent Form.

Data were collected using semi-structured interviews, and observation and document analysis6. Fieldwork was developed between February and August of 2009, in three settings of the study location. The first setting was the meetings of the Hypertension and Diabetes Support Group of the FHU, in which the possible study subjects were selected, through observation. The other setting was the FHU, which provided documents for the confirmation of the inclusion criteria of the subjects. Finally, the third scenario was the subjects’ home, where the semi-structured meetings and the observation of the routine of the individuals and their families took place.

Data treatment was performed based on thematic analysis, which is systematized in three stages⁶: pre-analysis, material examination and treatment of the results obtained, and interpretation. In the stages of pre-analysis and material examination, Atlas Ti 5.0 (Qualitative Research and Solutions) was used to assist in coding the interviews. In order to assure the subjects’ anonymity, they were identified by the word S (abbreviation for subject) followed by a number. Each subject’s age was also stated in the respective identification.

The research proposal was approved by the local Research Ethics Committee, as per resolution 196/96 of the National Health Council7 and the Certificate of Submission (CAAE) 0306.0.243.000-08, of January 19, 2009.

RESULTS AND DISCUSSION

The participants pointed out that lifestyle practices aiming at health, disease and care are important actions in family care. Moreover, based on the observation of the home context, it was possible to identify elements of the routine of the subjects, which were important for understanding their lifestyle practices, and went beyond the speeches captured in the interviews. The themes that stood out, mainly, were those regarding eating practices, actions involving emotional factors and folk therapies, with interfaces of common and scientific knowledge.

Eating practices

Eating practices were the most recurring practice reported by the study participants. As observed, these practices were built based on the stories of the subjects, and influenced by common knowledge and what was learned in their family context, since childhood.

I am old, the old eating system was different. [...] it is more intense, more substantial. Because some things are not enough! Nowadays you have to eat fruit, and light food. I eat any type of fruit! But not as food. I eat it as a snack, between meals. [...] I always eat lunch, dinner at the right time... [...] I was raised with a time to eat [...] And I got used to it, my whole life was like this. So our organism [...] gets used to it. (S6, 78 years)

In addition, the eating practices of these subjects as for frequency and times, both in terms of choosing the food and organizing the meals, are guided by the influence of common knowledge, which rules the context experienced by these families.

Eating practices represent a sociocultural phenomenon derived from history, that is, shaped by culture and resulting from the organization of society⁸. Hence, eating choices are established since childhood, when the meanings for eating are also built, as well as the way eating habits are structured and organized.

Thus, eating is not dictated merely by the nutritional value of the food, but also by the satisfaction and pleasure it provides. This understanding justifies the difficulties to establish changes in eating habits, a frequently experienced situation among individuals with SAH.

As observed, common eating practices are associated with those learned from scientific knowledge. Some participants referred this integration of knowledge when reporting their eating choices.

I cannot eat a lot of rice, as the doctor told me. [So] I basically eat vegetables. [...]I eat some salad before I start having lunch. Then you do not exaggerate on other things. [...] I learned this in the meetings [group]. (S9, 68 years).

This strategy was assumed as a way to reorganize meals based on scientific information, aimed to prefer “healthier” food to high-calorie items. The influence of scientific knowledge over common knowledge is, thus, verified, implicating adaptations in eating practices.

In different sociocultural groups, there is both the influence of common knowledge on the nutrition of individuals, and its association with the “nutritional knowledge” of health professionals, publicized in the health services and in the media. Hence, the eating practices of these individuals were based on the reinterpretation of the scientific knowledge, from the perspective of the cultural configurations of the common knowledge⁹.

Another situation experienced by the study subjects is the influence of the family dynamics on eating. Living in a family structure, people guide the organization of their lifestyle practices as per a series of factors, which do not depend only on one family member. Some families make arrangements and structure their eating practices based on the needs of the members.

If I lived alone, I wouldn’t have dinner! [...] Because then I would have to make dinner only for me. But my husband and my son have dinner. [...] I go there, make it, and end up eating too! [...] It is the family habit! (S7, 48 years)

When I make food a little bit saltier, he [husband] complains. Because he looks after me, he is really afraid that something might happen to me, afraid of hypertension. [...] Yes, it is another encouragement for me! (S7, 48 years)

It is understood that the subjects’ practices are significantly influenced by the daily organization of the family dynamics. In order to change the life behavior of individuals with SAH, especially in terms of adjusting their routine, these arrangements must involve the family scope, so that they are performed continuously and with commitment. Since eating practices are social constructs, meals are moments of sociability and encounter with people, in their daily living. They are related with the social institutions to which these people belong, in this case the family institution, based on the historical development⁹, and may be (re)adapted according to the need of the members of these institutions.

The eating act is not limited to the selection of calories and nutrients necessary to keep their body working properly. It also involves eating choices and adaptations for different occasions and for those to which it targets, as well as the evaluation of the effects these food choices will have on their body⁹. Therefore, “health reasons and medical prescriptions preside a group of care practices in the handling and use of food”^9:34.

An adaptation was observed in the eating habits of this family, up to the point in which all members assumed it. This represents a form of family care, since the active participation of family members, in face of these arrangements, serves as support and encouragement for the individual to cope with his/her chronic condition. The family space represents the environment on which people rely for the primary care of diseases. It constitutes, thus, a powerful and efficient network of services that acts reducing the impacts of chronicity on the daily living of these individuals¹⁰. The better the relationship among family members, that is, in a consistent family social network, the easier it will be for them to handle the situation¹¹.

In situations of frailty, the family must be present and provide affection and care, which demands sharing commitments, in this case represented by the adaptations in eating practices, assumed by the family¹². These adaptations made in the common routine are significantly influenced by scientific knowledge, for instance reducing the ingestion of salt, as mentioned by most of the participants.

Actions regarding emotional factors

Another determinant finding for the lifestyle practices of the participants in this study concerns emotional factors. It was possible to perceive, in the experience with the subjects and during the interviews, that people recognize it is important to keep emotional balance, as a way to ensure health, influenced by the scientific knowledge and their life experiences. On the other hand, common knowledge interferes in the determination of the strategies established by the individuals to achieve this balance, based on their life context. The strategies observed in this study involve actions such as nurturing positive thoughts and feelings and performing activities to keep their minds busy.

Because sometimes we carry a heavy burden, which we shouldn’t. But we have to, in order to harvest that good fruit! Because, if you keep the good seed and the good fruit, it gives you prosperity! And if you keep a rotten seed, you don’t evolve, you don’t move forward![...] So I never take the wrong side. I get in the right car! [...] Because we have to see what is right and what is wrong for ourselves! (S8, 65 years).

How are you going to control anxiety? It depends on the person. Sometimes the person is weak! We feel fear! It is a weakness. But if you think something like: God is looking after me, bring it on! [...] Then it goes away! So you cannot go crazy about it! (S9, 68 years).

In the light of the speeches, strategic differences are found with the same purpose, that is, keeping emotional balance as a form of health care. By selecting the feelings and thoughts that must be nurtured, these individuals would be assuming a health care practice. Intrinsic to this discussion, there are values of right and wrong assumed by the individuals, which may be determined socioculturally, influenced by common knowledge. It is possible to perceive that these strategies consist of ways to adjust in face of chronicity¹³.

Relying on the belief that a superior being is watching over their health was another strategy used by some individuals, for coping with emotional unbalance. This is understood as a care practice, since it acts as to recover beneficial thoughts and feelings for their health. In this sense, “this belief may mobilize extremely positive energies and initiatives, with unlimited potential to improve the quality of life of the individual”^14:108.

Therefore, it is possible to state that there is a narrow relationship between faith and mental health, since people adapt more successfully to situations of emotional unbalance and stress. Turning to God is a way to seek balance, in a situation in which disease is present. Believing in the existence of something greater than everything else (including the disease and the treatment) increases the hope to overcome the disease, through divine intervention ¹⁵.

Some individuals highlighted their job, through recreational and intellectual activities, as a way to keep the mind active, aimed to maintain health. The home visits allowed to learn the routine of some participants, and to observe practices involving the intellectual exercise and activities of entertainment, as care strategies.

I read every day! If I have some time, I take the Bible and read it. It is good for both the spirit and the mind! Opening the mind, activating the memory! (S9, 68 years)

I really like games. [...] It helps spend time and entertains me too. Because sometimes you get stuck, just thinking about silly things in life. [...] So, I always try to keep my mind active with something!  (S3, 50 years)

            Reading was pointed as an intellectual activity, aimed to exercise and activate memory, seen as a strategy to preserve mental health. Associating the reading practice to its content, in this case the Bible, becomes a way to strengthen health care, that is, it becomes doubly effective ‘It is good for both the spirit and the mind!’. This evidences the articulation between the maintenance of the health and faith of the individuals, as a care practice for the spirit.

The participants perceived idleness as a threat to mental health, since it creates opportunity for thoughts regarding facts that are not beneficial for their lives. In this sense, keeping the mind busy with recreational activities, such as games, not only promotes distraction and entertainment, but also assures they are distant from harmful feelings and thoughts. In addition, since they provide relaxation, they also act as a therapy for those who execute them⁵, confirming the understanding of occupation as a health care practice.

Folk therapies

The use of traditional folk therapies, either in isolation or with other therapies, was also pointed out by the participants as a factor that influences the choice of their lifestyle practices, in this case regarding health care. The use of medicinal herbs was prevalent among folk care practices.

I take tea, I like it! I drink it because I like it, to warm me up, because I feel cold! When I take it as a medication, sometimes I take boldo tea, after lunch. [...] And I take guabiroba tea for cholesterol, it is also diuretic [...] But I don’t drink it every day. I drink a type of tea one day, and another one on the next. [...] boldo is really good for the liver. Sometimes you eat too much and have indigestion. Then you just mash it [the leaf], and add hot water immediately. It is bitter, but you drink it and it helps digestion (S7, 48 years).

When I am in pain, I use the smoke of the herbs, with all the herbs I have, a lot of things! [...] my husband makes it. And it is very good! [...] And when I feel pain, I take the medication, use the smoke of herbs, and it goes away (S3, 50 years).

Among folk health care practices, the use of medicinal herbs stand out, both in situations of disease and in the maintenance of health. People used to base their knowledge on empirical experiences, which were acquired through life and whose positive or negative results supported the reliability and applicability of these behaviors, in the sociocultural context to which they belonged. The information that supported the folk therapies was, usually, transmitted asystematically, among the family members, associated with sociocultural traditions and habits. These behaviors are supported on the practical knowledge, resulting from the meanings and values produced in the daily experience of coping with care needs.

Folk therapies were pointed out independently and also in association with others, such as the use of medications. This combined use of folk and professional therapies, grounded on the complementarity of knowledge (common and scientific), takes place with the purpose of one strengthening the effect of the other. In this aspect, it is understood that the itinerary of health care practices is taken by the population based on the coping strategies of the groups, oriented by several influences: institutional, family and the sociocultural group¹⁶. Hence, they associate elements of the biomedical scientific knowledge with common knowledge.

It is important to mention the influence of scientific knowledge on folk therapies, in terms of validating the information used to guide such care actions. For instance, there is the use of medicinal herbs, which emerged from common knowledge and practices, being gradually legitimated by scientific knowledge, and validated as a form of therapy. The popular use of herbs, due to the functions and indications of these substances, is often confirmed by health studies¹⁷.

CONCLUSION

The authors’ experience with the study participants and during the interviews evidence that the lifestyle practices adopted by these individuals were both influenced and exerted influence on the health-disease-care process. These practices may be understood as the individuals’ ways of acting, thinking and feeling, in face of the health-disease-care process, established in a certain sociocultural context.

It was possible to observe that the lifestyle practices present in the routine of these individuals were, mostly, based on scientific information interpreted by common knowledge, which is built and shared in that specific sociocultural context. This means the lifestyle practices of these subjects are built by several sources of knowledge, incorporated to their experiences and sensations and, even though they belong to a sociocultural group, they are going to guide the life of each member differently.

The present study reveals important elements that must be taken into consideration by health care teams, mainly in primary care, so that the planning of promoting, preventive and care actions is comprehensive and resolutive. In this sense, it emphasizes the need to analyze the impact of the actions developed by the health care teams regarding the choices of lifestyle practices assumed by the population.

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Received: 28.03.2012
Approved: 13.01.2013