Inter-relations of the social network from the man with cancer in the bioecological perspective: contributions to the nursing

Abstracts

Objetivou-se conhecer as características das inter-relações da rede social do homem com câncer em tratamento quimioterápico. Estudo qualitativo que utilizou como referencial teórico o Modelo Bioecológico de Bronfenbrenner e o método de Inserção Ecológica. Participaram três homens com câncer atendidos em um serviço de quimioterapia, entre abril e setembro de 2010, realizando-se, em média, seis encontros com cada sujeito. Os dados contidos nas entrevistas foram submetidos à análise temática. Constatou-se que, para o fortalecimento das relações e desenvolvimento do homem com câncer, são necessárias características positivas em sua rede social, como: presença, comunicação, compartilhar, confiança, respeito, interesse e proteção, formas de apoio amadurecidas ao longo do tempo que influenciam na vida das pessoas de maneira saudável. Os profissionais de saúde, ao conhecerem a rede e as características de suas inter-relações, poderão intervir conjuntamente com a pessoa no fortalecimento de seus vínculos apoiadores e na mudança significativa de suas relações fragilizadas.

Apoio social; Masculino; Neoplasias; Enfermagem

ORIGINAL ARTICLE

Inter-relations of the social network from the man with cancer in the bioecological perspective: contributions to the nursing

Aline Machado Feijó^I; Eda Schwartz^II; Rosani Manfrin Muniz^III; Bianca Pozza dos Santos^IV; Aline da Costa Viegas^V; Lilian Moura de Lima^VI

^IDoctorate student of the Nursing Post-Graduate Program at the UFPEL. Nurse at the Regional Blood Center of Pelotas (HEMOPEL). Rio Grande do Sul, Brazil. E-mail: [e-mail]

^IIDoctor in Nursing. Professor of the Nursing School and Post-graduate School Program at the UFPEL. Rio Grande do Sul, Brazil. E-mail: [e-mail]

^IIIDoctor in Nursing. Professor of the Nursing School and Post-Graduate School Program at the UFPEL. Rio Grande do Sul, Brazil. E-mail: [e-mail]

^IVMaster´s degree student of the Nursing Post-Graduate Program at the UFPEL. Rio Grande do Sul, Brazil. E-mail: [e-mail]

^VMaster´s degree student of the Nursing Post-Graduate Program at the UFPEL. Rio Grande do Sul, Brazil. E-mail: [e-mail]

^VIMaster of the Nursing Post-Graduate Program at the UFPEL. Professor of the Nursing School at the Anhanguera. Rio Grande do Sul, Brazil. E-mail: [e-mail]

Correspondence

ABSTRACT

It has the objective of knowing the characteristics of the social network inter-relations of the man with cancer, in chemotherapeutic treatment. Qualitative study that used as theoretical referential the Bioecological model by Bronfenbrenner and the Ecological Insertion method. Three men with cancer participated, and they were attended in a chemotherapeutic service between April and September 2010. It was performed an average of six meetings with each subject. The interviews data were submitted to the thematic analysis. It was verified that in order to strengthen the relationships and development of the man with cancer, it is necessary positive characteristics in his social network, like presence, communication, sharing, trust, respect, interest and protection, ways of matured support over time that influence the life of the people in a healthy manner. The health professionals, when knowing the network and inter-relations characteristics, will be able to intervene together with the person in the strengthening of his supporting bonds, and the significant change of his fragilized relations.

Descriptors: Social support. Male. Neoplasms. Nursing.

RESUMEN

Estudio que tiene como objetivo conocer las características de las inter-relaciones de la red social del hombre con cáncer en tratamiento de quimioterapia. Estudio cualitativo que utilizó como referencial teórico el Modelo Bioecológico de Bronfenbrenner y el método de Inserción Ecológica. Formaron parte tres hombres con cáncer bajo el atendimiento de un servicio de quimioterapia, entre abril y septiembre de 2010, realizándose, un promedio de seis citas con cada sujeto. Los datos de las encuestas fueron sometidos al análisis temático. Se constató que, para el fortalecimiento de las relaciones y desarrollo del hombre con cáncer, son necesarias características positivas en su red social, como: presencia, comunicación, compartir, confianza, respeto, interés y protección, formas de apoyo maduradas a lo largo del tiempo que influencian la vida de las personas de modo saludable. Los profesionales de la salud al conocer la red y las características de sus inter-relaciones podrán intervenir conjuntamente con la persona en el fortalecimiento de sus vínculos apoyadores y en el cambio significativo de sus relaciones fragilizadas.

Descriptores: Apoyo social. Masculino. Neoplasias. Enfermería.

INTRODUCTION

The topic social network has been widely discussed in the literature. Its concept is dynamic and allows a diversity of interpretations.^1-4 Thus, over the past decades, new concepts have been developed and/or improved, and in this study, the social network was understood as a social system of sequential interaction and composed of individuals who can support the developing person, even if he is not present.⁵ Development is related to the constancy and change in the biopsychological charasteristics of a person, during his life cycle.⁶

The social network is constructed by interrelations between the developing person and other people/contexts. This reciprocal interaction is called proximal processes. They operate over time and are considered the first producers mechanisms of human development.⁶ It is worth noting that the proximal processes "involving transfer of energy among developing human being, people, objects and symbols in the immediate environment".^7:118 This context (microsystem) is understood as a place where individuals may easily interact face to face, for example, at home, at school, at church and at the health clinic.⁵

People who regularly interact with the subject are part of the social network, like family members, neighbors, friends, health professionals, co-workers and others. This network, through its various components and established linkages, intersects with other networks, influencing and being influenced by them.⁸

Each subject is considered as part of a network that is in constant change, and it occurs according to the socio-cultural context, historical time and development stage of the people who compose it. Usually, this happens in moments of transition, like when somebody becomes ill.^1-2 In the process of illness, the social network becomes more visible and indispensable, because that is when the patient needs more support for his reorganization and adaptation to the new condition and identity. So, if his network does not provide the necessary help he will seek new relationships in order to bear his disease and extend the network.

In the case of a male person, it is difficult for him to accept he is sick and that he needs to look for health services. This may be understood as a reflection of the Western culture, whose tradition values the strong, healthy and virile man⁹ that is able to play the roles of family head, home provider and worker.

Yet, another issue probably related to this fact is, in most cases, that the man is considered invulnerable, becoming indifferent to the practice of taking care of himself and getting exposed to risky situations. This might be linked to the prospect of building social masculinity.^9-11 It is believed these aspects are possible influences on the extent of man's social network, because the thought of considering himself invulnerable, physically and emotionally strong, prevents him from searching for relationships in other contexts than the immediate one.

It is necessary to emphasize that among leading causes of morbidity and mortality affecting the men, it is possible to mention accidents and violence, neoplasias, heart disease and stroke, and also, men get ill and die more than women, and generally earlier.¹²

In this work, it was studied men affected by cancer, which is a disease considered as a public health problem worldwide. In Brazil, according to the National Institute of Cancer (INCA), for the years 2010 and 2011, it was expected 236.240 new cases of cancer in males, and the most insidious types would be skin neoplasm non melanoma (53.000 new cases), prostate (52.000), lung (18.000), stomach (14.000) colon and rectum (13.000).¹³

Proposing to change this reality, in August 2008, the Ministry of Health launched the National Policy of Comprehensive Care to the Men´s Health, regulated by Decree number 1.944 of August 27, 2009. This policy aims to prevent aggravations and promote integral health for men, reducing morbidity and mortality by improving access to the health services, professional awareness and care humanization.¹ Moreover, it points out to take into consideration the uniqueness of each man, various contexts in which they are inserted, political and economic aspects, socio-cultural and historical factors connected to masculinity, which are in constant construction and transformation.¹⁵

It is believed that, for men, experiencing this process is extremely painful and influences their relationships. In this sense, it is important to perform researches in order to understand more deeply the subjective aspects that are part of everyday life for men with chronic illnesses, since the scientific literature about their health is more directed to matters about sexuality, violence and tendency to risk exposure.¹⁵ It is understood that the man with cancer, which is considered as fatal and stigmatized by the society, needs more effectively the social network that helps him to face this situation in a safer way. Thus, it is extremely important to know this social network, i.e. the interrelationships established when he gets ill.

Also, it is essential that health professionals and especially nurses, when identifying this network, seek to strengthen intense and healthy bonds, and offer their patients to plan together ways to improve or modify the fragilized and stressful bonds. Based on this, the objective of this paper is to meet the characteristics in the interrelationships of the social network of men with cancer undergoing chemotherapy.

METHODOLOGY

This is a qualitative study that used as theoretical reference the Bioecological Model of Human Development by Urie Bronfenbrenner, also called PPCT Model, because its main components are Process, Person, Context and Time.⁶ This model was used to anchor the knowledge in the social network of men with cancer, because its process, context and time is loaded with interrelationships.

The subjects of this study were chosen according to the following criteria: equal to or older than 18 years old; being aware and without presenting any communication difficulties, being knowledgeable of cancer diagnosis and treatment; undergoing chemotherapy treatment and living in the urban area of the municipality of Pelotas-RS in order to facilitate his access.

The study was conducted with three men with cancer and treated at the Chemotherapy Service of the School Hospital at the Federal University of Pelotas, Rio Grande do Sul, Brazil, from April to September 2010. The first approach to the subjects was held at the Chemotherapy Service, where they were invited to participate in the study and, subsequently, the meetings were performed at their homes through prior appointments.

Data were collected through semi-structured interviews, field journal record,¹⁶ and ecomap construction.¹⁷ With the patients´ consent, interviews were recorded and fully transcribed after that. In order to make up this article, it was used data contained in the interviews.

It was carried out an average of six meetings with each subject, lasting around two hours and totaling 36 hours. They discussed about problems concerning life before and after their illness, social network and everyday experiences, like for example: treatments, feelings and family routines, among others.

Ecological Engagement was the method chosen for data collection. It aims at determining interactions (processes) between the person and his developing context.¹⁸ This method relies on five essential aspects for determination of proximal processes, namely: (1) researchers and participants interact and engage in a common task; (2) there is a need for many meetings, over a considerable period of time; (3) informal meetings will progress in order to address issues increasingly complexes, reaching a duration of one hour or more; (4)

proximal processes that take place in these meetings are the basis to the whole research development, being fundamental a posture of informality when speaking with them, enabling the dialogue on matters not directly related to the purpose of the study; (5) the topics covered in the interviews are interesting and exciting for researchers and participants, because they explore life stories and the development of the person inserted in the study context.^18-20

Data were analyzed according to the thematic analysis operationalization, and it was identified the core meanings present in the participants' speeches. For that, three steps were developed: pre-analysis, material exploration, interpretation processing and results obtained. In the first step, data were organized to conduct a deeper analysis, and it was made a floating reading of all communications. In the second stage, it was performed the coding of words or significant expressions that organized the speeches content, and after, classification and aggregation of data by choosing the category. In the last step, interpretations looking for meanings and interrelations with the theory were performed.¹⁶

In order to develop this study, it has been respected the Resolution 196/96 of the Health National Council of the Ministry of Health and the ethical principles of the Code of Ethics to the Nursing Professionals 2007, COFEN Resolution number 311/2007. This study is a subproject of the research entitled "Clients with cancer, their families and care systems in chronic conditions", approved by the Committee of Ethics in Research of the Catholic University of Pelotas under opinion number 2008/23. All of the subjects signed a Free and Clarified Term of Consent. To preserve their identities, they were identified by the initial letters corresponding to their status in the study (HC - man with cancer), and followed by their ages.

RESULTS AND DISCUSSION

The results obtained through data analysis were permeated by the concepts of process, person, context and time described in the Bioecological Model of Bronfenbrenner. The concept social network used in this study is grounded in this author, as well as the concept of supportive linkages who are people with whom the developing person has established a positive relationship and has engaged in joint activities. This interrelationship generates mutual trust and well-being by providing support to the developing person.⁵ So, this study made it possible to highlight the category characteristics in the interrelationships of men with cancer in the process of dealing with the disease and treatments (chemotherapy, radiotherapy and hormone therapy), within the context of the social network that is presented below.

Positive features in the interrelationships of the social network of men with cancer

The human development happens through reciprocal interactions (process) progressively more complex, between an active human being who is biopsychologically in evolution and people, objects and symbols in his immediate external environment,⁶ as it happens to the man with cancer.

But, in order to make these proximal processes produce in the man with cancer a developmental effect called competence, which means the acquisition and development of knowledge, skills or capabilities to lead and direct his own behavior,⁶ is necessary positive characteristics in the interrelationships between people/institutions that make up his network and himself.

It is noted, in the PPCT Model, three groups of characteristics that influence the human development: disposition, resources and demand. However, this study found the provisions called generative, which trigger and maintain the proximal processes involving active guidelines,⁶ and they are considered as positive traits.

Thus, positive characteristics that favored the construction of the social network of men with cancer, which were found in the testimonies of the participants, consisted in: supporting bond, concern, interest, sharing, care, protection, safety, help (psychological, financial, in relation to the disease, among others), communication, presence, trust, respect, appreciation, spiritual support and friendship.

The inter-relationship between the man with cancer and people that make up his social network is fundamental to his development. The presence of supporting bonds maintain a good relationship that results in healthy attitudes like help offering (including the financial one) and the unconditional support: [...] our bond. Well, we are going to commemorate 50 years of marriage, is it necessary to say anything else? There is no need to say. Thanks God, we get along really well, ever. Daughters are really daughters [...] (HC74).

[...] with my parents, siblings, wife, children, I always had a good relationship [...] all of them [nephews], we get along very well, they are always by my side, every time they come here they support me, they give me enough strength, they are very good friends, we have a very good relationship [...] then, I ask for his help [brother], to do this and that for me or help me here or there, and sometimes, when I need financial aid he helps me too [...] (HC67).

[...] I have a great relationship with him [former brother-in-law], indeed, he was one of those who participated financially for my recovery [...] (HC58).

This reciprocal interaction between the studied person and other people, objects and symbols, is defined as process.²¹ This mutual interrelation, which is present in the support provided by the social network, is potentiated when being intense and integrated. They are manifestations of material aid, financial and emotional support that are especially demonstrated by relatives. Such support is considered essential to the restoration and maintenance of health and to cope with stressful conditions.^2-3,22-23

It is observed the support occurs more in the immediate context of the developing person, with individuals he has a face to face relationship (microsystem), in this case the family. This support is both emotional and spiritual [...] we have more contact [...] more with the family, the family members give me such support [...] they [brothers] strengthen me spiritually, they give me support, yes, well, they give me full backing [...] (HC67).

In times of change, especially related to health, people need support to recover and the family reorganizes to this role. When this support, both emotional and spiritual, is really perceived, provides welfare and empowerment, i.e. it is a positive influence in his life, which reinforces the importance of the social network for his physical, emotional and mental health.³

Meanwhile, for the person experiencing the process of being ill, emotional, spiritual and even material support are extremely important, and many times the family system can promote that.^2,17,24-25

Help in relation to the disease was something exposed by the participants, for example, the aid to perform examinations and displacement to the treatment site: [...] my niece there, right now she really helped me to do medical exams and other things [...] (HC67).

[...] the help to my comfort also in other sectors, that is, for example, today I need to go to different places and I am having this help [...] for example, my boss, last week took me [for radiotherapy sessions] [...] (HC58).

Study performed with subjects suffering from chronic respiratory problems identified the help in transportation and other health needs, as well as being accompanied to the medical consultation, constituting in the characteristic of support received by the social network. It was emphasized that such support was very meaningful to the respondents, because it allowed living with a chronic illness in a milder form.²

In this sense, people's interest in knowing about the situation of the individual with cancer, how he was feeling and sharing his experiences were characteristics very present in the reports of the subjects, demonstrating that care is something of great value for somebody who received it: [...] they are calling me all the time, some days, the phone here rings like in a call center [...] (HC74).

[...] he calls me every day, it is difficult for him [son] to fail one day [...] they [family] always ask how it was, they are always there, they participate with me [...] my wife is my companion, she is always with me [...] (HC67).

[...] I consider my family more, because she is, she is constantly asking how I am, and she is [sister] here almost every day. And my mother, my father and my brother, they are always asking how I feel [...] in this aspect, in this area for sure I have enough support in relation to my family, and I can say about my co-workers that two of them, actually many of them, however, two of them are always calling me [...] (HC58).

To the men of this study being present is more than the physical body; it is important to realize they have someone to count on when they need something, and family members provide this experience. This happens due to the interest of the network to know about their condition and the will to contribute to the process. Furthermore, to count on the help of people, especially family members, brings comfort and tranquility.²³ These aspects are emphasized in the PPCT Model to favor the developing person.

It is possible to emphasize that living with a chronic illness is challenging, because this condition is related to negative feelings. Therefore, it is necessary that the patient and his social network know the aspects involving the disease and the willingness to contribute for the treatment.²⁶ Support and encouragement, in a situation of illness, make the person find strength and courage to cope with the disease and treatment.²⁷

More than interest, the respondents highlighted concern of their social network and them: [...] everyone is worried about me [...] (HC74). The perception of people's worries that comprise the social network has also been reported in a study on changes in the supporting social network, during family transitions.¹

The participants of the study, when they referred to sharing, the time gained prominence because they believed that bonds become stronger during the interactions (processes): [...] we are in family terms, and we also consider our close friends like family, because after a certain relationship they become part of the family [...] (HC67).

[...] in this case I could include the boss because I know him since a long time ago. The other people, I know them since the last three years and some [...] (HC58).

Time is an important element for human development, it influences interpersonal relationships (processes).⁶ Thereby, a healthy interrelationship depends on friendship, good feelings and they mature over time: [...] for many years they [close friends] always, we always lived in this circle of friendship, love, affection, and all. No matter how, they are always willing to help [...] (HC67).

This perception of friendship by the respondents could also be observed when they reported the presence of people in their disease process, especially in the visits to their homes and help received. At that moment, the psychological help was more noticed [...] they do not stop visiting me, they [bishops] come with them to visit me, people we know since they were pastors of the church [...] (HC74).

[...] sometimes they even help me, psychologically, sometimes he [brother] comes here; he visits me [...] (HC67).

For developing people, friendship is a manifestation of affection that happens when persons from their social network are present, like partners helping and advising them.³ Most of the times, the help they refer to is the psychological one, which is considered essential in order to have well-being during the experienced process.^1,3 Still, it is noted that "supporting a sick person is being together, wanting to meet him, moving in the direction of the other".^4:341

The acceptance also becomes essential in the developing man with cancer and the construction of his social network, because it offers safety to experience difficulties that may arise on daily basis along with the opening for dialogue: [...] I have no doubt about whoever I seek for help he will receive me, they will defend me, this is not because I just want that, it is friendship [...] (HC74).

[...] be willing to listen [...] (HC58).

Sometimes, the fact of suffering from cancer alters the relationships by uniting people and causing the social network to mobilize in order to help the sick person.⁴ Then, living with the disease becomes less suffered because whenever he needs something he will be sure that friendly people will be ready to help,²² and also willing to listen to him.

For the subjects of this study, being safe is much more than having someone to defend them. It is related to know that person will be around to help at all times, including the disease process, in other words, that person will also help to overcome the mishaps of life, sometimes by only advising: [...] who has friends is not afraid of anyone [...] a friend is forever, a friend helps, for example, in my case, I am sick [...] (HC74).

[...] with my brothers I can overcome certain obstacles we go through life, sometimes with an advice [...] with my daughter, too, my daughter sometimes advises me [...] (HC67).

In a situation of need, having friends to count on is a guarantee of support that makes a person feels more relieved and safe. However, this alone is not enough to generate safety, the participation in decisions to be taken, such as counseling and support, also makes a difference due to the effective presence of that person in his life.^2-3

In this sense, it is possible to observe the advantages on health professionals' care, especially nurses, that is conducted in individual and welcoming ways because this makes people feel respected and valued, and even influences the success of the treatment. Feeling they can count on someone who will listen, talk, guide and support, makes the patient more secure emotionally, decreases his physical complaints and provides welfare.²⁸

However, in order to feel safe is necessary to have confidence in the social network, and this also appeared in the reports: [...] we know the people we can trust [...] (HC74). [...] the doctor was wonderful, the doctor, a person who gave me a lot of confidence, he talked to me a lot and such, he explained everything he was going to do, and what he did [...] (HC67).

It is noted the confidence reported by the subjects of the study not only with people who are part of their immediate context such as family and friends, but also in relation to the health professionals. Therefore, it is necessary to mention that a patient might experience his illness with harmony and the purpose to achieve the goals of the therapy employed along with health professionals, including nurses. Because they can also support him through the establishment of trust, dialogue, guidance and pieces of information offering.^2,23,27

This confidence also emerged as protection, because men with cancer know that people of their social network will always be watching and praying to God for them: [...] the same way I ask for their protection, they ask for mine [family ] [...] (HC74). It is believed that constant, active and reliable social network serves to protect the persons; it helps their self-esteem and fosters their physical, mental and emotional health.²⁹ In addition, the support provided by the social network helps to experience crises and stressful situations.¹

However, beyond this mutual feeling of protection, there must be respect on both sides, so that the social network does not become brittle, as it is observed in this phrase: [...] I always respected everybody; they all respect me [...] (HC74). As it is shown, in order to establish proximal processes must be reciprocity on interpersonal relationships.⁶ The study indicates that respect, understanding and appreciation of the possibilities and limits are forms of support and better coexistence among people.²

In the statements of the interviewees, it also became evident the value given to communication, listening and dialogue, because they were fundamental for a healthy relationship. Besides, having someone to talk to was important to strengthen the suffering person, then, relatives and friends are quite important to share the problem. [...] with the family I am talking all day, every day, I am feeling this. I am feeling that and such [...] (HC74).

[...] we [wife] try to discuss and see what could be better for me, and the way I should take, and I asked for help in this case, for one person or the other [...] (HC67).

[...] generally, he is the guy [friend] I talk to more, i.e. since the problem of [deceased wife] to the current one [...] sometimes is one problem [deceased wife], sometimes is the other one and I am always talking to him [...] (HC58).

Talking is a communication process considered as very important help and care, in addition to listening, because it is the right moment to tell everything and get distracted, which brings peace and even happiness.^3-4

Another positive feature that strengthens the bonds that make up the social network is appreciation. This stimulates the person in his journey through life and magnifies the feelings of gratitude, esteem and consideration, as stated by the man HC74: [...] we completed 50 years of marriage, but I did not have any conditions to organize a party, so, what did the bishop do? At the conclusion of a general meeting of the church, here in the region, he prayed for us. The reverends and all the people were there [...] (HC74). These feelings of comfort, satisfaction and gratitude were also observed in another study.³

The speeches allow saying that the inter-relationships to build a solid and strong social network depend on positive characteristics and quality: [...] because sometimes too much help does not mean good help [...] (HC58). Furthermore, the person/institution that are part of this network must be constantly contributing to the welfare of the other, thereby: [...] whatever we need, the guy is there; he does anything to solve the problem [wife´s nephew] [...] (HC58). This way, to be part of the social network of the man with cancer is not: [...] pat on the back and everything is fine, I do not know, it is alright [...] (HC74), but to establish a healthy inter-relationship that will become stronger over time.

In this context, it is important that health professionals, especially nurses, understand the men with cancer "beyond the biological sphere, considering the psychosocial, emotional and spiritual needs of each individual, and even their family and social relationships in order to provide a type of care that glimpse the integrality of the human being".^30:32

FINAL CONSIDERATIONS

Knowing the characteristics in the interrelationships of the social network of men with cancer showed that positive features are needed to the strengthening of their network. This results in the acquisition and development of skills contributing to the evolutionary process of these men. Like this, being together, hearing, dialoguing, the concern with others, sharing, trust, appreciation of the other, welcoming, the offer of help, respect, friendship and protection are mature forms of support over time that affect people's lives, in a healthy way. And that is fundamental to their restructuring in the disease process. It is unquestionable the participation of the family in this process.

In this sense, it is important for health professionals to know and appreciate the positive features of the social network of the person with cancer, so, they could participate with that human being in order to strengthen his supporting ties and the significant change of his vulnerable relations. Among these professionals, it is believed nurses might become supportive bonds, because they are the health professionals who should be closest to the patient. Accordingly, it may be easier for the nurse to capture and communicate the needs of the sick person, become a link between the person/family (microsystem) and other systems.

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¹

Las interrelaciones de la red social del hombre con cáncer bajo la perspectiva bioecológica: contribuciones para la enfermería

Publication Dates

• Publication in this collection
  08 Jan 2013
• Date of issue
  Dec 2012

History

• Received
  21 Mar 2011
• Accepted
  21 May 2012