RESEARCH ARTICLES

Hypertensive street market vendors' perceptions of chronic illness

Samara Ribeiro Alves da Silva ^I; Rita da Cruz Amorim^II; Aline Mota de Almeida^III

^I Nurse. Nursing Resident in Intensive Care of the Sócrates Guanaes Institute. Researcher of the Integrated Center for Research and Study on Care/Caring in the State University of Feira de Santana. Bahia, Brazil. E-mail: samaraa_ribeiro@hotmail.com
^II Nurse. Master in Science. Ph.D. student in the Family Program in Contemporary Family, Catholic University of Salvador. Assistant Professor of the Health Department of the State University of Feira de Santana. Bahia, Brazil. E-mail: ritaamorim2003@uol.com.br
^III Nurse. Master in Nursing. Assistant Professor of the Health Department of the State University of Feira de Santana. Bahia. Brazil. Researcher of the Integrated Center for Research and Study on Care/Caring. E-mail: alinedamota@uol.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2015.8494

ABSTRACT

This qualitative study aimed to discover hypertensive street market vendors' perceptions of chronic illness. Ten hypertensive workers at an outdoor market in Feira de Santana, Bahia State, participated. Data were collected between May and August 2012 through semi-structured interviews and subjected to content analysis. The results showed that outdoor market vendors do perceive chronic illness, conceiving hypertension as an insidious, silent disease that kills and considering that busy, stressful living leaves them hypertensive and that living with hypertension requires changes in habits. It was concluded that health professionals can intervene in collective health to address chronic hypertension in outdoor market vendors by investing in health education, so that the latter can adopt healthy habits in line with their culture and their way of life.

Keywords: Chronic illness; arterial hypertension; work conditions; health education.

INTRODUCTION

Systemic hypertension (SH) is a multifactorial clinical condition characterized by elevated blood pressure. It is considered a chronic disease, its treatment requires changes in lifestyle involving weight reduction, physical exercise and a low-sodium diet, and the use of antihypertensive drugs to reduce morbidity and mortality¹.

Stallholders are highlighted among vulnerable occupational groups with hypertension, who develop their professional activities in direct contact with a diversity of people and goods, with a 10-hour work day on average, no holidays or weekly days off, financial instability with variable monthly income, overexposure to the sun and high temperatures. Furthermore, there is unavailability of health care, and often they live in precarious conditions of environmental hygiene. These conditions of life and work can promote diseases to human health².

The free market highly contributes to forming, organizing and consolidating the cities. Its emergence occurred during the Middle Ages, from the need for the exchange of products, as there were surpluses of some goods and shortages of others. From this, there were clusters of people with the same goal - to exchange goods - and these clusters have led to several cities. At that time, the cities did not have permanent markets, so these free markets occurred once or twice a week, allowing the installation of a fixed markets³.

The interest in studying this theme emerged from discussions at the Integrated Center for Studies and Research on Care/Caring (NUPEC), on issues related to care practices, to involve the stallholders, and the lack of studies that addressed this occupational group. Thus, this study intends to reflect on the provision of care appropriate to the real needs of the group studied.

Therefore, this study exploited chronic illnesses of the stallholders as objects. Experiences with them during the execution of the project Daily Care Practices of stallholders in Feira de Santana - BA, led the authors to question: How the stallholders with hypertension realize their chronic disease process? To answer it, this study aimed to understand the perceptions of these stallholders with hypertension on chronic illness.

LITERATURE REVIEW

Hypertension is a chronic degenerative disease of the cardiovascular system that is an important public health problem. It is estimated that its prevalence in the Brazilian adult population is 15-20%, being higher in men and among the elderly population, reaching 65%. Also, the metabolic, functional and/or structural changes of the target organs such as the heart, brain, kidneys and blood vessels, contribute to an increased risk of cardiovascular events. Among sick people, about 30% are unaware they have this medical condition. It is considered that the SH is a high social cost, accounting for about 40% of cases of early retirement and work absenteeism¹.

The control of hypertension is unsatisfactory due to ineffective treatment, or the lack or poor adherence to it. The diagnosis of hypertension and its treatment are considered simple. However, despite the efficacy of existing therapeutic measures, the control of blood pressure is not an easy task, since it usually requires treatment for life⁴.

The care for the person with hypertension requires an interdisciplinary approach, and the nursing consultation has shown the increasing nurse action with the sick people because during the consultation the nurse is providing the data that will assist the person in health care. Authors consider the nursing consultation as "a service mode that allows the monitoring of changes in lifestyle, as necessary to control the disease, and to strengthen the guidelines for self-care using the nursing process"^5:115.

The individual and the social context peculiarities should be considered in care planning since the guidance will result in an adequate control of chronic diseases if the conditions of life and the individual behavior of the sick people are checked.

Working conditions to which the worker is subjected directly impact on his health. This assertion is justified by the broader concept of health because of determinants and conditioning factors, among others, such as food, housing, sanitation, environment, work, income, education, transport, leisure and access to essential goods and services⁶.

A study that aimed to evaluate the quality of life of stallholders workers in Goiânia explored the position and motion adopted by them while working. It pointed out that the stallholders remove the bag of goods, remain standing for long periods, sit on stools, lift and squat several times a day, organize the goods for exhibition, resulting in the leg, spinal and lower back pain. These pains are frequent in the late afternoon, which coincides with the end of the working hours. As regards the feeding, some of them feed homemade pots with food, commercial and fast food; and, moreover, they are dedicated to household chores and rarely practice physical exercises⁷.

It is recommended that health actions for people with high blood pressure should exceed the conventional primary care practices, including educational activities to facilitate the promotion of health by stimulating self-care through group approach⁸.

METHODOLOGY

This study used a qualitative approach, which enabled better investigation of the groups and limited and focused segments, as considered the subjectivity of the life context in which they live, emotions and interpretations of certain phenomena⁹.

The field approach was held, at first, by visiting the street market and presentation of the researchers to the president of the Association of Stallholders of Cidade Nova (AFCN), with the submission of the objectives of the study and the proposal to perform health actions in the market to encourage the promotion of health to the stallholders, and identify hypertensive patients through nursing consultation and measurement of blood pressure (BP). Then, one of the proposed actions was promoted with performing nursing consultation by teachers and students of the Nursing Course at the State University of Feira de Santana, to identify stallholders with hypertension, offering them clarification and guidance on the disease and possible referrals.

During the actions, there were 91 people assisted, 58 stallholders and 33 consumers, shippers and service providers at the market. Also, there were 17 nursing consultations. To this article effect, there were stallholders involved who met the following inclusion criteria: being an adult, act on the open market of Cidade Nova neighborhood in Feira de Santana, and be recognized as a person with hypertension. No exclusion criteria were adopted.

There were ten stallholders participating, nine women and a man, presenting the objectives of the research and agreed to participate by signing the Informed Consent Form. All stages of the study were in compliance with the recommendations of Resolution 196/96 of the National Health Council (CNS). Also, this study was submitted to the Research Ethics Committee (CEP) of the State University of Feira de Santana and was approved under protocol number 48/2012.

Empirical data were obtained through semi-structured interviews, applied between May and August 2012, with an average duration of 40 minutes and the interviews were recorded on audio and transcribed by the authors. The interviews were finished when it was evident saturation of content when the data collection in qualitative research can be closed¹⁰.

The data were subjected to content analysis, which was first organized with the pre-analysis; after, there was an exploration of the material; and, finally, results in treatment, the inference, and interpretation¹¹.

First, a brief reading of all the content collected was held, aiming at a better contact with the material produced. Then, the exploration of this material was proceeded, through repeated readings to divide it into themes and select the lines of respondents that would interest the study. From the analysis, meanings were identified, and they were organized into three categories: HS as a silent and insidious disease that kills; busy and stressful living leaves them hypertensive; and living with hypertension requires changes in habits.

In the end, the results were processed and interpreted to understand the perception of the stallholders on the chronic illness, to articulate their testimonies with the theoretical foundation in search of an understanding of the object of study. To identify the different interviews, the designation E1, E2 ... E10 was used to preserve the anonymity of the stallholder.

RESULTS AND DISCUSSION

The stallholders study participants are between 42 and 71 years old, predominately married and an operating time in free markets ranging from 1 to 40 years, with working hours 5-12 hours a day, every day of the week. Two participants had not completed high school, six had incomplete primary education, and two were illiterate.

Salaries ranged from R$ 400.00 to R$ 1,200.00 and, despite low earnings, only one participant reported having other work to supplement the income. They justified the excessive workload in the open market prevented them from taking other activity.

Nine respondents claimed complications in their health related to hypertension, and drug treatment prevailed among the care accessed. Only one respondent reported no use of pharmacological resources and consumed herbal tea exclusively.

The categories that emerged from the empirical material and showing how the stallholders realize the chronic illness are presented and discussed below.

HS as a silent and insidious disease that kills

When the stallholders were questioned about what is hypertension, they had difficulty answering, perhaps because they have a low educational level or not consider hypertension a disease that requires particular attention of the people affected by it. Some of them have defined hypertension as a silent disease.

Pressure is silent, it does not demonstrate that it is high, we can die now and not knowing why we are dying; it is silent, I am here feeling normal if you measure my blood pressure it is 18 by 12. (E6)

For other participants, hypertension is associated with symptoms presented by the disease, such as a headache, dizziness, dimming of vision, nausea.

Hypertension is a headache, dizziness, sour... I felt that I measure the pressure, and it was high, and I went to the health center. (E2)

The definition of hypertension by its signs and symptoms was observed in the study, in which the respondents associated the presence of malaise, dizziness and blocked vein¹².

From the speeches of the stallholders to characterize hypertension, the relationship of the disease to complications and the risk of imminent death emerged. They considered the control of hypertension as the main factor for the non-appearance of complications.

Pressure has [relationship] also with the problem in the kidney, because you have to leave not too controlled to force the kidney and lower your functioning [...]. (E9)

In a study held with stallholders, it was noted that even knowing the complications of hypertension and being afraid of death, adherence to treatment is difficult, especially by the silent nature of the disease, which causes the ill person does not recognize it as a chronic illness¹³.

The high blood pressure is directly related to the incidence of cardiovascular events such as stroke, myocardial infarction, sudden death, heart failure and peripheral artery disease, as well as with chronic kidney disease¹⁴. It is noteworthy that one of the leading causes of chronic kidney disease is SH¹⁵.

In this study, it was found that, in excessive emotional situations such as stress, anxiety, worry and agitation, the stallholders noticed an increase in blood pressure levels and consequently considered the SH also as an emotional illness.

Boy, it is when I get worried, stressed ... exhausted, because high pressure kills, then I'm always controlling it, taking lemongrass tea. It is a disease that kills. (E8)

A study found that emotional stress is a predisposing factor to the perception of pressure elevation, as reported by 36.7% of the interviewed¹⁶. The sick people label the hypertensive episode as emotional or by a reductionist view of the causes of high blood pressure, or by multifactorial nature of the disease.

Busy and stressful living leaves them hypertensive

The stallholders with hypertension perceived the condition as incurable, and, therefore, recognized the need for drug therapy to control it. However, they said to use medicament when they felt high blood pressure signs and symptoms characteristic.

I know that it has no cure. When I know it is high, I take medicine, when I know it is too high, I run to the doctor, I make my tea at home. (E3)

Drug recovery seems to be involved in the planning of health of the study group, which is closely related to the absence of physical signs and symptoms. Therefore, a reductionist view by the biomedical model, which analyzes the subject mechanistically, in parts, excluding full analysis of the person, and not associating the illness to other factors, such as environmental and social that can influence the healthy state.

In a study on the adherence of the person to hypertensive treatment, it was identified the perception of the disease through the symptoms, and 68% of respondents perceived this clinical condition through the physical discomforts, being necessary an interdisciplinary analysis of the subjects understanding them in their entirety¹².

I realize that ... I am very talkative, but when I shut up I know, my voice is hurried, I do the effort to speak, the neck is groaning, like an old mill, it is high blood pressure, even talking bothers me. (E3)

Além disso, os feirantes hipertensos expuseram suas percepções acerca das alterações emocionais por eles vivenciadas no ambiente de trabalho, que provocavam estresse, preocupações e irritações.

Also, the hypertensive market traders expressed their perceptions about the emotional changes they experience in the workplace, which caused stress, worries and irritations.

When I'm doing my accounts, it comes one, it comes other, and then I get that agony, worried. I understand why this is agony, a hot head, so I [...] I take medicine. (E10)

This information is corroborated by a literature review about the influence of emotional factors on hypertension, in which stress is defined as "a set of reactions of the organism, characterized by an imbalance of homeostasis in response to threats and/or damage arising from environmental stimuli of psychic or physical nature, unusual or hostile"^17:130.

In the study, along with people with high blood pressure, all participants mentioned nervous and stress as reasons triggering the disease resulting from daily concerns¹⁸.

The stallholders of this study also expressed concern about working conditions in their statements, which they are subject, especially regarding the availability of adequate food at the market, where they do meals daily, in addition to times of stress to which they were constantly exposed .

We spend too much time standing here with nothing to eat, only at the bar and thus my blood pressure goes up. It is salty, fat. This hurts me. (E9)

Living with hypertension requires changes in habits

The daily life of the stallholders is permeated by difficulties and challenges that require changes in lifestyle. The study participants expressed new ways of living, particularly by adopting a low-sodium diet, avoiding fats, preservatives.

Ah! It has changed ... what I did, I did not do it anymore. Sometimes, I went out for parties, lost night of sleep, and nowadays I do not lose a night, I do not do a great walk, my walk is always tiny, that all changed, changed the power. (E6)

Changes in food cause feelings of frustration and limitation for the stallholders, who reported that they had to get used to living with everyone around eating delicious food, having to keep controlled and the diet.

[...] Sometimes you are in the mood to eat something, and you do not eat it because eating is with that in mind that it will increase the pressure and will do harm, and then it is best not to eat. I changed the food; it is hard to get used to, you see a so much good thing, not able to eat, everyone eating, it is difficult, I suffered. (E9)

The best way to adherence to treatment of hypertension is to sensitize the multidisciplinary team for frequent health education practice with the sick people, benefiting them socially, offering individualized nutritional counseling, psychological support, so that they become protagonists of treatment ¹⁹.

The inclusion of the family in the context of treatment and monitoring of family and hypertension is of paramount importance, for the treatment of disease causes limitations in lifestyle, not only the for an ill person but also the nuclear family. Also, the family, participating in the monitoring of this treatment, can help the adherence of the ill person in a better way²⁰.

Like the diet, it is important to control blood pressure, the emotional state of the person is also relevant, since when undergoing emotional changes, pressure levels tend to increase constantly.

[...] Today when I am worrying a lot, I change my thinking, I work to control it. I try to avoid, avoid the better when I see I'm shaking, I'll get stressed I go out. (E10)

Studies show that the subjects consider an increase in blood pressure from the everyday exposure to stress, though not proven their role in the genesis of hypertension^2,21. During stress, the sympathetic stimulation occurs, causing increased heart rate and blood pressure. It is speculated that a permanent stress situation could contribute to the development of hypertension^22,23.

In this study, it is clear that, from the neglect of health and the occurrence of complications, care practices were generated, with a change in lifestyle and adoption of healthy attitudes.

I got the problem in the kidney, caused the high pressure. After that, I started to take care of myself, I take the medication at the right times, not carelessness, I took the salt of the food [...]. (E9)

Non-adherence to health care may be related to the lack of the stallholders on the development of hypertension, considering they are ill only after experiencing complications or when the disease does not let them do something²⁴.

The educational actions developed by health professionals together people with chronic diseases provide the sharing of experiences, particularly through self-reflection and the possibility that they could manage their treatments¹⁸.

Some of the stallholders knew the complications of hypertension by family experiences and justified adhering to changes in lifestyle for fear of death.

I changed everything, I think that is why my mother died of a heart attack, and then I'm afraid to have heart attacks, and I changed my diet, I had to take everything [...]. (E5)

In this study, some stallholders reported attending church and go out as the stress of a reduction strategy; none of them practiced physical activity, a practice that would help to ease stressful situations and, consequently, decrease the obesity, high blood pressure, and coronary complications.

A study on risk factors for high blood pressure reported that 81.2% of respondents did not practice physical exercises, and it was concluded that physical inactivity is one of the least controlled factors for people with hypertension²⁵.

The nature of the nurse´s role in the context of public health, puts them as a producer and multiplier of knowledge, allowing their intervention together with people, groups, and communities, promoting well-being, social inclusion and citizenship²⁶, which favoring their acts for workers of different scenarios, like the stallholders².

CONCLUSION

This study aimed to know the perceptions of the stallholders with hypertension on chronic illness. The surveyed participants had low education, living with the intense workload and continued stress in the context of the free market, and with scarce economic resources, involving their chronic illness.

Limitations of this study refer to the shortage of publications and bibliographic references for research on stallholders, showing the need for new studies on the health of this particular group.

Changes in the stallholders' lifestyle habits occur from the observance of symptoms of complications of hypertension. Thus, they adopt new types of food, strategies such as the removal of conflicts face the pressures of work. Adherence to the changes is marked by feelings of anguish, grief, sorrow for having to abandon habits considered pleasant in their lives.

Thus, coping with chronic health requires investment in education, to the understanding of hypertension and its complications, favoring the adoption of healthy lifestyle habits and respect for culture and way of life of the people. It is necessary to reduce the suffering in adherence to treatment and morbidity and mortality due to SH.

The multidisciplinary approach of hypertension for the production of care in the context of free markets can encourage the stallholders to adhere to treatment. Finally, nursing consultation is marked as a tool to contribute to health promotion and prevention of damage to this particular group of workers.

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