Culture Circles Powerful Resource of Dialogue on Health Promotion of Rural Elderly

Abstract

Objectives: Describing culture circles as a powerful device for dialogue on the promotion of rural elderly health by Family Health Strategy workers.

Method: A qualitative study of the participant action type articulated with the methodological framework of Paulo Freire and the concepts of value, counter value, death economy and Cartesian compass of Jaime Breilh.

Results: The following themes were generated: "Being old is being experienced"; "Wearing glasses"; "Use of technology"; "Problem solving of the elderly"; "Adoption of healthy habits"; "Need for socialization/interaction"; " Use of medicines."

Conclusion: The Culture Circles provided space for reflection and collective construction but were also the scene of many contradictions and possibilities among the participants. Through its operational mode, this methodology promoted reflection among participants about how broad health promotion is and requires involvement and intervention in other sectors.

Keywords

Elderly, Primary health care, Health of the rural population, Family health strategy, Care for the elderly.

Introduction

The elderly present a set of specific needs arising from the aging process, both physical and psychological and social. When it comes to elderly people living in the rural context, this specificity in the health care of these people should be considered [1].

To reduce the difficulty faced by rural elderly people in health care, the Family Health Strategy (FHS) seeks to expand users' access to health services, acting as a gateway to the Brazilian health system. The FHS maintains and ratifies the guidelines and principles of the Unified Health System (SUS), as well as impacts favourably on the population enrolled in the territory of coverage, prioritizing the creation of a bond between health teams and the community [2].

The workers of the FHS work in a multidisciplinary way, forming the teams that are constituted by distinct and distinctly valued knowledge. Creating spaces for dialogue to understand the potentiality of differences makes it possible to think and practice health promotion to the non-centred elderly, only, in the perspectives of a single professional, but based on clinical and individual issues related to the field of knowledge of each worker [3].

The culture and values seized by workers can act to expand or restrict the possibilities of perspective in relation to health promotion for elderly people living in rural areas [4].

Ordinance 2436 of 2017 approved the National Primary Care Policy (NPCP) and established the revision of the guidelines for the organization of Primary Care, within the scope of the SUS, highlighting the challenge in overcoming the simplistic understandings existing between health care and promotion [5]. However, while indicating possibilities, the NPCP also brought limitations regarding the financing of Primary Health Care, signalling a change in the care model.

Therefore, workers have another challenge to experience in daily life, which makes increasingly necessary a space for reflection and strengthening of the care practice offered. So, the Circles of Culture, methodological devices belonging to Paulo Freire's Research Itinerary can be a tool capable of inducing reflections about reality and showing the perspective of the FHS worker on health promotion. Collectively, they can unveil and identify possibilities for changes in the work process in primary care and the elderly public.

The participants of the Culture Circles, in this study, the health teams, through the process of action-reflection-action are led to recognize themselves as authors of their stories and, thus, become aware and strengthened to modify their praxis in health promotion. This process of reflection values the cultural and historical sources of these participants [6].

Therefore, starting from the perspective that changes occur in the practical field and require the action of workers to happen, this article aims to describe the Culture Circles as a powerful device for dialogue on the promotion of the health of the rural elderly, by the workers of the Family Health Strategy.

Methodology

This is a qualitative study, of the participant action type, articulated with the methodological framework of Paulo Freire and comprising three distinct phases, dialectically interconnected: thematic research; encoding/decoding; and critical undo [6]. As a theoretical framework, Jaime Breilh's concepts of value, countervalue, death economy and cartesian compass were used. The value is constituted as a good of use, something that provides improvement, while the countervalue is something deteriorated, harmful to the health/disease process [7]. The concept of economy of death is marked by the logic of man at the centre of everything, it apart the human being from nature, creating the owner-commodity relationship. Production is not considered only an economic movement; the author treats it with a broader view, conceiving it as the sum of other processes of use, distribution, transformation and excretion [7]. The concept of cartesian compass addresses the illusion of knowledge based on the positivist paradigm, which believes that the reality of health is a reality of fragments, of parts that relate to each other. Positivism constructs its hypotheses with the empirical data of reality, without connecting them, without producing analyses considering a society based on the accumulation of wealth and systematic social exclusion [8]. The study included 12 workers of a Family Health Strategy (FHS), located in the rural area of a municipality in southern Brazil, listed for convenience. Among the multi professional team workers involved in the research were: nurse, physician, nursing technician, social worker, dentist, community health agents, receptionist and cleaning assistant. The Circles took place in the FHS itself in the team meeting space. To obtain the data, we obtained the help of a research assistant, responsible for recording the images and audios. Five Culture Circles were performed with an average duration of one hour each totalling five hours of recording. The data collection period took place from August to December 2019. The mediator of the Culture Circles was the researcher herself master’s in health sciences.

Participants were identified by the letter "T" followed by the integer according to the order of the speech presented. The study followed all the precepts of Resolution 466 of 2012 [9], being approved under CAAE 15825719.6.0000.5316 and the Free and Informed Consent Form signed in the first contact with the participants.

The first stage of the process of Paulo Freire’s Research Itinerary and thematic research that is characterized by the initial dialogue between the participants and the mediator. At this moment, it is possible to identify the generating themes, which emerge from the participants’ routine vocabulary [6]. To this end, at the first moment, the participants were asked to present themselves briefly bringing the meaning of their names. The choice for this type of dynamics was with the intention of creating the approximation of the participants with the mediator and of making they express themselves bringing subjective characteristics of their personalities. The first trigger used was the request of the participants to write, in cards, a word that represented, for them, what it is to be elderly and to explain the reason for such choice. The second trigger used figures that were selected to represent several aspects of the elderly’s life. Participants could choose as many figures as they wanted, relating them to positive and negative points of aging (Figure1).

Figure 1: Table of the circle of culture 1 thematic research. Source: Pinto, 2019

Coding/Decoding is the second stage of the investigation process, being inseparable from each other. Codification is the moment when the generating themes are dialogued, contextualized, allowing the situation previously figured and apprehended to gain meaning for this group. Decoding is the unveiling of the situation experienced, it is the moment when participants reflect on their actions, question and start to reflect situations they previously did not admire [6]. Attempting to deepen the reflection of the themes generated in the previous stages, the participants were asked to collectively construct a fictitious case of an elderly person from the coverage area of the Basic Family Health Unit (BFHU), aiming at the health promotion plan (Figure 2).

Figure 2: Culture circle table- coding/decoding - Source: Pinto, 2019.

Critical unsealing is the last stage of the Research Itinerary, and, in it, it seeks to become aware of the shared situation. At this moment, the process of action-reflection-action and empowerment of people to understand the reality experienced occurs [6]. To this end, the trigger offered consisted of simulating the speech of the elderly, created in the previous fictitious case, opposing and questioning. The opportunist made the workers’ reflection on the choices made in the health promotion plan offered to the elderly

Results

Next six themes constructed from the Circles of Culture will be presented, they are: "To be old is to be experienced"; "Wearing glasses"; "Use of technology"; "Problem solving of the elderly"; "Need for socialization/interaction" and "Use of medicines". The theme "Being old is being experienced" emerged very naturally in the participants' statements, they showed respect and reverence to the elderly, and words such as maturity, wonderful age, patience, wisdom and privilege were mentioned. The theme is exemplified in the following statements: Experience was the first word that came to me, an old person to me has a lot of life experience. (T1) Same thing, I put experienced too, because you get acquired, with the experiences you get knowledge, want to know old stories, talk to an old person they know. (T2) The group has found that old age is a positive thing, because with it comes wisdom and experience in knowing how to deal with the adversities of life. The theme "Use of glasses" provided the decoding of the device as something necessary; however, for some workers it was synonymous with disability, something that demonstrates the fragility of the senile body. In critical undo, "the glasses" were considered as something that aggregates and assists the elderly in their daily activities. The following statements reflect what the workers mentioned earlier: I don't see the use of glasses as a negative point but as a necessity, no matter if you're old or not, so I think it's positive. (T3) But you, in your old age, if I have to choose between wearing and not wearing it, do you want to wear glasses? I consider it a disability. (T4) The theme "Use of technology" emerged in the figure of the cell phone and generated movement among the participants, because some had the perspective that the cell phone was something negative, that exposed the elderly to malicious people, and that it could generate the isolation of the elderly in relation to other family members, since part of the elderly do not dominate the use of this technology. The statements reflect the situation mentioned: We had spoken on the cell phone as negative because of the prank calls, and because sometimes there are elders who know and do not have access to the cell phone. (T5) The cell phone divides the family, the elderly who have no contact with the cell phone he is in a restricted corner. (T6) The cell phone often ends up taking away people's conversation at home, no one talks, often the elderly feel sideways so, excluded there because they do not talk to him. (T7) However, in the critical unveiling stage, the group was repositioned, and the cell phone was described as a technological tool that provided the emancipation of the elderly, this statement is expressed in the following statements: That day I had chosen the phone as something negative, but now after rethinking, I changed my mind, I do not think the cell phone something negative, I think positive. (T7) When I see an old man messing with the phone I think it's great, managing to evolve with technology. So, I think it's positive. (T3) The theme "Problem solving of the elderly" emerged from the collective construction of the fictitious case of an elderly person living in the BFHU area and scope, presented by one of the group participants and listed as rapporteur: We put old, he is 72 years old, he is male, he is white, widowed, his schooling is fundamental incomplete, he is hypertensive, smoker, has used alcohol in the past and is depressed. He lives with his daughters, participates in the smoke-free group but, he can't quit smoking, he's a retired farmer and continues to grow some plants for leisure. He likes to talk and be well informed. (T7) The unveiling of this theme was that the role of the worker is to guide about the correct, the ideal, but that it is up to the elderly to make the choice. This statement is corroborated by the following statement: Guiding makes sense, I think the role of the professional is to guide the most correct, the ideal. If the patient, it will follow is another story (T8). The group explained that the elderly would not participate in any group, because he did not show a willingness to make commitments with this type of activity. They maintained the orientation of replacing the soda with water, but aware that this would be ideal, but that in the situation in question, it was too radical, because it had replaced alcohol with the soda: We reached a consensus that the elderly will be invited to participate in the mental health group that we do, to make it integrate more with people, to come and talk. And encourage him to replace the soda with water that is healthier because it consumes too much soda. The doctor's going to revaluate the medication. (T7) The workers brought in their statements, the perspective of health promotion linked to the choices considered healthier, as in the following statements: Then suddenly from both listening, both hitting the same key, one day he (user) will start to associate that really water is better, that if he never hears another version he will take soda always. (T8) The option to speak insistently about something that would be beneficial appears as a resource to promote health, and when this is not configured as effective, that is, if the expected behaviour change does not occur, the worker uses the model of harm reduction as an alternative. The following speech translates the above: He disappeared from the group, and had another alternative, criticizing the way the group was developed. And then I proposed another strategy that was harm reduction. Which was to decrease the amount of cigarette used per day? (T9) The theme "Need for socialization/interaction" was addressed focusing on the groups that BFHU offers users. Regarding this theme, the workers pointed out that the elderly (fictitious case) needed to participate in more than one group because he represented, to be very lonely. In this sense, the groups would be an opportunity for the elderly to dialogue and socialize on various subjects of interest. However, in the process of critical unveiling, the group concluded that the elderly in the fictitious case would not participate in the groups, in the way they are executed, and, in addition, the workers involved in the research showed frustration at the difficulty of success in changing the behaviour of elderly people. In my opinion I think he (elderly fictitious case) would not come in the groups. (T3)

I think he (elderly fictitious case) would participate in some group if the activity was only for men. A group of friends just to talk to, but if it's to sit around the table where women do manual labour, I don't think it would attract him no. (T8) I was thinking, all this we can do, but getting that head changed is hard. What can we do? Or that you're already done to help? Because you’re a difficult patient. (T10) The theme "Use of medicines" permeated all culture circles, and the coding/decoding process was extensive, with the constant coming and going between positive and negative points of the therapy. I consider the medication something negative, because it is not legal, the figure there on the poster even the person has a handful of medicine on his hands. But a little all right, as T1 said taking a drug for an elderly person is considered almost nothing. (T6) Because in fact the issue is to take the necessary remedies to maintain quality of life, then using medication is positive. (T9) Aspects related to the choice of the elderly to use medications or not were also addressed, as can be seen in the following statement: If the person self-medicates is not healthy, taking a medication without the doctor's consent is wrong. There's an old woman in my area who takes medication for depression and pain. Then I came to her house, and she said she decided to lower the medication, stopped on her own. The other week he ended up at the UPA with the pressure up there. She just stopped taking her medication. (T7) The critical undo step on the theme "Medication use" occurred after the questioning of a participant about the poster built in the previous circle: I wanted an explanation: what does that item mean a drug all right, but two is already considered something bad? (T8) From this statement, the other participants were positioned and the group when dialoguing chose to define that for them medication is something necessary for the maintenance of health, since with medical supervision.

Discussion

The group of workers has found that being old is being experienced. Those workers who are part of the community and experience the reality of the rural elderly brought their praxis to justify the use of the words 'wisdom' and 'knowledge'. While the others addressed the theme using technical and formal terms, this perspective points to the reflection that the social context from which the worker comes from influences his language, culture and subjectivity in relation to the assisted population. Consequently, these questions act on who the worker is, what he thinks, and what he does and says in the relationship with the user of the health system [10]. It was also observed that in the development of circles in which all speeches are opportunistic, workers can express their opinion and understanding about the aging process. The generating theme "Use of glasses", in its sealing, showed the diversity of opinions existing among workers. Wearing glasses emerged from two perspectives, the first as a counter value brought by those workers who know the reality of the rural elderly and understand the use of glasses as a device that would hinder work in the field, and consequently, bringing consequences to the financial life of the elderly. Even though he is retired, since he is not rarely active cultivating for his own consumption or, still, for the sale of his crop in small fairs, as a financial aggregate. The second perspective, that is, of workers who do not live in the rural area and work most within the physical space of the health unit, described the use of the artefact with a value that would bring beneficial to the elderly in their activities of daily living. It is understood that, in this context, contradictions are essential to foster dialogue and opportunism changes, and the method of data apprehension allowed us to observe and reflect on the potential existing in each participant of the circle. To expand the glasses beyond the simple use for vision correction is to broaden the look and perspective of health promotion to other issues, such as social and economic issues. In this sense, brings that the Latin American people are not conformed to life, to health, but to business, and this was observed in the speeches of the participants when mentioned the use of glasses to maintain work activities [8]. Access to glasses was also mentioned by the participants, and the ability to consume it emerged linked to health. Within a capitalist society, the satisfaction of desires and needs, whether real or created, generates well-being, which is achieved through purchasing power. The ability to satisfy desires classifies people before others, generating social status that influences access to goods and services [11].

In the end, the group decided to consider the glasses a value, which indicates another situation within health teams, that of overlay of discourses of one group of workers over the other, prevailing the opinion of those who are more distant from the reality of the elderly. The situation indicates the possible existence of a power relationship between workers, which [12] called a heteronomy relationship. Relationship that means the condition of an individual or social group being in a situation of oppression, being in the condition of "being for another". Situations of oppression are a concrete reality, and when one is within a multidisciplinary team, composed of workers of various levels of education and who develop distinct roles within the process, the differences become observable and can contribute to this type of situation being established [13]. The theme generator "Use of technology" was configured from the use of the cell phone, even though there were other technologies that the elderly could come to use in their daily lives, such as radio, TV, newspaper, and was expressed by the participants from the perception of change that this device promoted in the rural area, especially for the elderly. It should be considered that when unveiling the relationship of the elderly with technologies, one touches on issues such as historicity, and that different social contexts should be considered, since the contemporary elderly were gradually being presented to the technologies that exist today [14]. Thus, and again indicating differences within the group of workers in the development of the circles, at first a group verbalized fear and pointed out the cell phone as a counter value to the elderly. This allows us to think that this perspective is related to the differentiated access that these workers have to technology. It is known that the different knowledge sat being constructed throughout history and heterogeneously. Some knowledge gained autonomy according to specific and scientific rationalities and became institutionalized according to the construction of hierarchies of recognition and stratification of social prestige [13]. However, by dialoguing and experiencing the process of coding/decoding that culture circles provide, the unblock promoted the change of perspective and the cell phone was described as an object of value and promoter of the evolution and integration of the rural elderly. This situation corroborates the importance of creating spaces for dialogue on various aspects, because by being aware of values and counter values, participants can expand the way of perceiving reality and acting in the promotion of the health of the elderly. The theme generator "Problem solving of the elderly" was one of the themes that most revealed the position that each worker occupies within the FHS. Although the model stimulates horizontal and interdisciplinary relationships, the final decisions on health promotion actions were those of workers who occupy the position of technical workers, that is, those with academic training in the health area. These findings were possible due to the power that the Culture Circles method must promote horizontal and emancipatory dialogue. Some participants, at specific moments, opted for silence and expressed fear in indicating actions based on popular knowledge, such as the use of teas and other alternative care techniques. In this sense, health promotion, in an expanded way, has in popular education an auxiliary resource since popular education problematizes and denaturalizes imposed and biomedical interventions. She considers the common knowledge of people and their experiences in the health and disease process because health promotion takes place amid life production [15]. It was also observed that the workers followed the perspective of health promotion based on clinical and individual questions, corroborating the existing literature on the subject, which brings that this perspective is still present in the operationalization of the health network and in the popular imaginary, as the best way to respond to health problems [16]. Thus, this finding should be relativized considering the overlap of perspectives in the researched group, since the group of workers who work directly with the elderly, in their homes, at various times did not feel at ease and empowered to talk about other possibilities of health promotion. The mediator, when intervening with extra triggers, which the method of this research allows, aimed to deepen the dialogue and realized that this movement generated discomfort in the workers. Expected reality in the process of awareness, in which the subject is impelled to the construction of a political, community consciousness, and a critical look at the reality during the Circles of Culture [17]. Warns about the need to introduce the concepts of public health in daily life and reinforces the importance of using the interpretive framework of integral vision, bringing a science that brings together, connects things that are usually unveiled in a fragmented way, what he calls cartesian compass [8]. Participation in health groups appeared as an alternative to promote the socialization of the elderly, and the study [18] with rural elderly confirmed that participation in health groups contributes to the maintenance of autonomy, assists in memory, concentration, orientation and interpersonal relationships. The generating theme "Use of medicines" was also dialogued to express the different opinions, and as in previous cases, from the incisive questioning of a technical worker, who has the competence to prescribe medications, it was found that the group reconsidered the perspective of the drug as something negative and chose to affirm it as something necessary for the health of the elderly. The therapeutic process includes everything from pharmaceutical products to machinery, which are commodities and, although external to medicine, has its consumption effected only through it [19,20]. This is the reason some workers, due to academic training based on the Cartesian compass, have attributed the use of medicines to something positive. The idea of the Cartesian compass concept believes that the reality of health is a reality of fragments [8]. It should be considered that the prescription of medications is necessary at some times, being relevant to reinforce how much the progress of the pharmaceutical industry influenced the increase in life expectancy. However, it is considered how much the society itself based on capital is a producer of diseases and ends up making the use of medicines as inseparable from people's lives. Thus, only pointing out criticisms directed to workers about their perspectives, disregarding that they are crossed by ideas, by concepts of the capitalist mode of production, either in the way of living, or by the academic training itself is to use the classic way of data can be done, in which only factors are pointed out, but it is not a question of unhooking their relationship with the system in which the participants are inserted.

Conclusion

The article showed data that allowed the showing of the power of culture circles as a methodological device for the dialogue on the promotion of the health of the rural elderly, by the workers of the Family Health Strategy. The Circles of Culture provided space for reflection and collective construction but were also the scene of many contradictions and possibilities, which is expected when one chooses to use dialectics as a theoretical reference. The differences, within the group of BFHU workers, were unveiled demonstrating that the worker's origin, the possibilities and non-possibilities that he is submitted influence his perspectives on health promotion and the space he occupies within the team. The methodology of the Culture Circles, through its operational mode, promoted the reflection to the participants about how broad the PS is and requires involvement and intervention in other sectors. The participants re-flexed and talked about health promotion at the micro level, which confirms the position that the worker occupies within the system, and that makes it difficult to look emancipated to the macro. The worker is immersed within a space, often of possibilities of creation and reflection, but also of oppression and alienation. In view of the findings, we can see the need and the importance of having a permanent education project, instituted within Primary Health Care, and the Circles of Culture are a powerful possibility in the creation of dialogical spaces and promoters of awareness. This perspective, furthermore, may generate not only benefits to workers, but also to the elderly assisted by them, because it was remarkable how much the act of dialogue can provide opportunities and optimize processes within the FHS team.

References

1. Winckler M. et al."Elderly in rural areas: an integrative review." Interdisciplinary Studies on Aging .2016; 21:2.

Google Scholar, Crossref

2. Pinto L F, Giovanella L."From the Program to the Family Health Strategy: expansion of access and reduction of hospitalizations for sensitive conditions in primary care (ICSAB)." Science & Public Health 23 (2018): 1903-1914.

Google Scholar, Crossref

3.  Faria L R de, Aloísio C A. "Care in primary health care: preliminaries of a comparative Brazil/Canada study." Health and Society.2015; 24: 72-85.

Google Scholar

4. Rocha P R da, David H M S L. "Determination or Determinants? A discussion based on the Social Production Theory of Health." Rev. Esc. Enferm. 2015; 49:129-135.

Google Scholar, Crossref

5.  Brazil. National Primary Care Policy. Brasília: Ministry of Health, 2017.

Google Scholar

6. Heidemann ITSB, et al. "Reflections on Paulo Freire's research itinerary: contributions to health." Text & Contexto-Enfermagem 26; 2017.

Crossref

7.  Breilh J. 2nd Brazilian Symposium on Health and Environment – 2nd Sibsa. For a metacritique that transforms the world. XXXX, 2014.

Crossref

8. Breilh J. Center for Studies in Collective Health. Department of Nursing at UFPR and the Observatory of Agrochemicals. Critical Epidemiology Course. The capitalist system is incompatible with health and life. Curitiba: UFPR, 2020.

Crossref

9. Brazil. Law 466 of December. Provides for guidelines and regulatory standards for research involving human beings. Official Federal Gazette, Brasília, DF, December. 2012.
10. Godoy, EV. Santos, VM. A look at the culture. Educ. 2014; 30:3.
11. HEIDEMANN, IT, et al. Reflections on Paulo Freire's research itinerary: contributions to health. Text Context Nursing, Santa Catarina.2017; 26:1-8.
12. REDONDO, GH. Adorando al dinero, capitalismo y humanismo. Un análisis a partir de la obra de F. Hinkelammert.  10.15517/isucr.v20i40.35661.
13.  Freire P. Pedagogy of hope: a re-encounter with the pedagogy of the oppressed. 17 ed. São Paulo: Peace and Earth. 2011.
14. Silva IS Arantes, CIS. Power relations in the family health team: focus on nursing. Rev Bras Enferm. 2017; 70: 580-587.

Crossref

15. Souza JJ, SALES MB. Information and Communication Technologies, smartphones and elderly users: an integrative review in the light of Sociological Theories of aging. Kairós Gerontologia Magazine. 2016; 19:131-154.

Crossref

16. Maciazeki-Gomes RC.et al. The work of the community health agent from the perspective of popular health education: possibilities and challenges. Ciência & Saúde Coletiva.2016; 21:1637-1646.

Crossref

17. Brito GEG, et al. O objeto de trabalho na Estratégia de Saúde da Família. Interface. 2018; 22:77-86.
18. Cabral, et al .The concepts of “consciousness” and “consciousness”. research practice Psychosocial. 2015; 10:412-422.
19.  Lange, C.et al. promoting the autonomy of rural elderly people in active aging. Rev Bras Enferm, 2018; 71:5. 2555-2561.

Crossref

20. Almeida TS. On the role of history in the formation and transformation of medical thought. Ponta de Lance. 2019; 13: 25.