Fatigue management experiences from women undergoing chemotherapy: self-care strategies a

Objective: In order to understand the experiences of women with breast cancer managing fatigue due to chemotherapy with the use of non-pharmacological strategies. Methods: Explanatory study, qualitative, with theoretical reference of medical anthropology and resources of the ethnographic method for data collection; in which four women took part. Thematic analysis was performed based on interviews and conducted observations. Results: Three strategies of self-care, resulted from the culture were used for physical fatigue management: rest, energy conservation and eat habits. Physical activities, contact with plants and religiosity were constituted as practices to deal with emotional fatigue. We understand that the meaning attributed to the use of non-pharmacological strategies was the possibility of feeling capable, confident and able to continue treatment. Conclusions and implications for practice: These woman’s experiences revealed the following necessities, the use of specific strategies to deal with fatigue, as well as the appreciation and understanding of their singularities and cultural practices present in their contexts. In the nursing care, it is possible to associate these practices with scientific knowledge and thus complement the care in favor of an integral care.


INTRODUCTION
Chemotherapy is found among the forms of treatment for breast cancer and, even at therapeutic doses, adverse reactions are unavoidable. 1Among these, fatigue is an important and prevalent adverse reaction in women with breast cancer. 2or oncology, fatigue is defined as an agonizing, persistent, and subjective sensation characterized by physical, emotional, cognitive, or exhaustion fatigue.It is related to cancer or its therapy; 3 that is, it may be related to chemotherapy, considered a secondary event 4 in this case.It is not proportional to recent activity and interferes with the functional capacity, 3 to the point of increasing the need for rest, changing concentration and leading to restriction in the performance of usual activities.] Researchers have shown interest in identifying ways to attenuate this adverse reaction, with pharmacological and nonpharmacological treatments.Among the pharmacological treatments studied, there are corticoids, psychostimulants, 1 as well as the treatment of other comorbidities or factors associated with fatigue such as pain, anemia, sleep disturbance and nutritional deficit. 3s complementary practices to conventional treatment, the literature describes phytotherapy, as Ashwagandha extract 5 and ginseng, 6 physical exercise, energy conservation, cognitive behavioral therapy, distraction, yoga, massage therapy, sleep hygiene, bright light exposure 7,1,3 and hypnosis.6 The occurrence of chemotherapy secondary fatigue (CSF) in women with breast cancer requires that professionals and researchers seek appropriate strategies for better understanding and management, without ignoring individual and collective experiences in relation to the knowledge and use of sociocultural practices.
This research was developed in order to understand the experiences of women with breast cancer in the management of chemotherapy secondary fatigue with the use of nonpharmacological strategies.

METHOD
This is a clarifying, qualitative study, with theoretical orientation on the medical anthropology and strategies of the ethnographic method for data collect.
Medical anthropology analyzes how people from different social groups explain diseases, their causes, therapeutic resources, and ways for coping. 8It seeks to understand the culture and terms in which the experience was produced, investigates the subjective knowledge constructed through the reality lived by the individual, and explores how the stories related to the experience of the illness make sense to the person. 9] The eligibility criteria were: women diagnosed with stages I and II breast cancer, with intravenous chemotherapy-related fatigue, performing at the maximum the expected third cycle and who had used non-pharmacological strategies to seek relief from the adverse reaction.
Participants were selected for convenience.Recruitment took place in an oncology clinic of a public university hospital in the inland of Minas Gerais, Brazil.Fatigue was identified through applying the Fatigue Assessment Flowchart, 12 and the Piper-Revised Fatigue Scale, 13 during nursing consultation held in an extension project linked to the undergraduate course, under the coordination of the fourth author.After confirming CSF, the confirmation on the use of some non-pharmacological strategy for its management was carried out and, if so, women were invited to take part in the study.
Considering the depth that the qualitative research requires, six women were selected initially.After the first interview, two were excluded.One due to the end of the treatment before the expected time and another because there was no fatigue after the recruitment.Thus, the group of participants was composed by four women, considering data theoretical saturation criterion. 14he investigation obeyed the precepts of Resolution 466/2012 of the National Health Council.The project was approved by the Ethics Committee in Research with Human Beings on April 29, 2015, under written opinion number 1.042.720and registration number CAAE 43007615.5.0000.5152.Anonymity of the participants was guaranteed by using pseudonyms chosen by them, being referred to as: Luíza, Lis, Lívia and Maya.
Data collect took place between June 2015 and July 2016, at the oncology outpatient clinic and at home, according to the participants' choice; always in a private place.For data collect, ethnographic method strategies were used: observation, semistructured interviews recorded in audio and notes in a field diary.
A semi-structured script was developed in order to define the initial content explored in the study, with questions guiding the interviews, such as: Can you tell me how it is for you to use [non-pharmacological strategies] during chemotherapy to deal with fatigue?Do you use any type of drug or treatment for fatigue that is not prescribed by your doctor?What kind of result have you achieved?From these questions, the researcher/interviewer and/or the participants, could diverge or formulate new questions necessary for detailing answers or for proceeding and deepening the reasoning. 10here were twenty interviews, six with Luiza and Lívia and four with Lis and Maya; they had a mean duration of 46 minutes and were transcribed by the principal investigator.The interval between the interviews went from 21 to 28 days, which corresponds to the interval between the chemotherapy cycles.

Fatigue management experiences from women
Cunha NF, Querino RA, Wolkers PCB, Anjos ACY In subsequent interviews, there was always a return with the participants about the topics covered in the previous interview, in order to resume points for clarification and/or deepening.This procedure allowed for the participants to clarify important aspects and validate the researchers' understanding, interpretations and pre-analysis.After reaching data saturation, but before leaving the field, participants were informed about and prepared for the closure of the meetings.
The method used to organize, analyze and describe the data was the thematic and inductive analysis. 15For the analysis, the interviews were transcribed and read repeatedly by the authors, in order to familiarize themselves with the content.Next, codifications and annotations of the initial ideas were made.Following these codes, based on the objective of the study, two major themes and seven sub-themes were outlined.This article is a master dissertation clipping, in which the analyzes of two subtopics are submitted.

RESULTS
The four women inhabited in the city where the oncologic clinic is found.Three are married and Luiza is a widow.All have adult children.Age range went from 43 to 65 years old.Schooling levels are diverse, as are occupations and religions.Table 1 shows their socio-demographic characteristics.
The four women received an anatomopathological diagnosis compatible with invasive ductal carcinoma and were submitted to the quadrantectomy type surgery and underwent chemotherapy with adjuvant intention.After ending chemotherapy, all women were referred to radiotherapy, and hormone therapy was recommended for three of them, except for Luiza.The other data diverged among them and are shown in Table 2.
In general, CSF has been described by women as feelings of discomfort, both physical and emotional.The reports focused on expressions such as fatigue and limitation when referring to physical fatigue; and mood changes, impatience, intolerance, headache and anguish, while sharing information on emotional fatigue.
Through the thematic analysis on the dataset about the women experiences with the management of CSF collected in the interviews and observations, the following sub-themes were identified: "Self-care in the management of physical fatigue" and "Self-care in the management of emotional fatigue".

Self-care in managing physical fatigue
The self-care strategies mentioned by the participants for the management of physical fatigue consisted of: rest, energy conservation and food care.The participants stated that rest, while providing momentary relief, is important to attenuate CSF.Among the three strategies, rest was the one that most stood out in the reports of the participants as an attempt to attenuate CSF: Rest is a key factor.Every time I get tired I try to rest.

Every day, later in the afternoon, I want to lie down. I don't want to sleep, I want to lie down, just to rest. (Maya)
During an interview at her home, the participant Maya says that for relieving the fatigue, she lies down and elevates her lower limbs; she also reports that this practice makes her feel an improvement in the adverse reaction.(Field Diary, April

Self-care in managing emotional fatigue
In addition to strategies to manage CSF in its physical dimension, the women mobilized non-pharmacological strategies to deal with the psychic dimension.Self-care practices for managing emotional fatigue were based on the participants' choices for walking, body movement, religious activities and gardening.
The practice of religious activities was used by the participants as a resource to face the sickness and the reactions to breast cancer therapy, translated as a refuge for relieving CSF, especially in its emotional dimension.Religiousness was a strategy, in the midst of the limitations, to feel more calm and confident.
Limiting! [Fatigue] completely limits us, but it is a limit that we take to read the Bible, to read Torre de Vigia's publications.When I was very fragile, people encouraged me; my brothers in the church prayed for me and visited me, seeking to remain together in the faith, giving a helping hand.It is in him [in God] that we acquire strength to overcome all the steps that we have to undergo in this treatment, which is not easy, but it is not impossible [laughs].(Lívia) Before "chemotherapy" I lie down [on the bed], I put a song, a gospel, I will listen.I stay calm [...] it is a way for you to strengthen yourself, it has added in me the confidence in the treatment and the confidence to go through this process.(Lis) Walking was practiced by Luiza and Maya.The first reported fatigue after the walk, while the second felt better.For both, walking was motivated by the quest for relief from emotional CSF and prevention of depression: Moving the body was one of the resources that Lis and Maya used to deal with CSF in their quest to feel better, as explained in the following sections: When I start going out [of the rest], I begin to get better.Even, sometimes, when my head is bad [headache], I lie in the net; sometimes, I go there, I water the plants a little...I think that this movement gives me some energy.(Lis) [...] even though I'm doing something that will not solve anything, that will not lead to anything, I have to be on the move.Then I'll be fine.(Maya) Gardening and contact with nature resulted in mental rest and in the opportunity to move to an environment outside the limits of their homes, where routines and daily living were held.These were strategies also practiced for managing emotional fatigue.According to the participants,

DISCUSSION
The research's participants show heterogeneous socio-demographic characteristics.Age group, schooling, profession and religious orientations are distinct; such diversity permeates the population served in public healthcare institutions, in the different contexts where they live their experiences.This heterogeneity reflected in the singularities of discourses and in the ways where they have rescued from their culture the construction and utilization of strategies to face the biographical rupture caused by the disease and its treatment, which is understandable when we look at ourselves as ethnographers at the comprehensive presuppositions of the medical anthropology. 16t is through the ethnographic research that the different health behaviors and practices that permeate the therapeutic itinerary are apprehended.Observation leads the researcher to direct contact with what is lived by the participants in his study, in a privileged place -the context where they live -which allows to observe and follow the constant and continuous process of construction and reconstruction of meanings and actions, through the exchange of knowledge among individuals and groups. 17n chemotherapeutic treatment, adverse reactions and undesirable effects are perceived and felt quickly by the patients.The frequency of occurrences, whether due to the characteristics of the drug-related action, to the susceptibility of the organism or even to lack of knowledge about the forms for prevention and management, is high and considerable.
Patients and families mobilize significant strategies of their sociocultural context, and develop actions seeking to face and re-signify the new condition.Thus, explanatory models support this search for unconventional practices, be they complementary, integrative or even alternative, as a response to biographical rupture, imposed by the symptoms of adverse reactions. 16,18atigue, described by the participating women as an important and uncomfortable adverse reaction caused by chemotherapy, was highlighted as a cause for damage in different dimensions of life; in particular, for the physical and emotional dimensions.The subjective description displayed by the participants corroborates the definition of fatigue found in the literature, described by other cancer patients. 3hen living the fatigue experience, the women established self-care strategies in order to relieve the symptoms of the reactions suffered as a result of the treatment, in order to resume the normal conditions essential to life, health and well-being, 19 which can be understood with the comprehensive-interpretive approach of the health-disease-care process, based on the medical anthropology. 20he absence of a specific direction towards the proper fatigue management triggered in the participants a new awareness on the body itself, which became fragile in nature, requiring the mobilization of resources to face the new condition, which is in agreement with the implications of the rupture suffered at different levels. 16In this sense, the participants used three self-care strategies to deal with CSF in its physical dimension: rest, body energy conservation and food care.] In this perspective, we observed that women in this study performed extra-community activities, some with paid work, and others with voluntary religious activities, but always maintaining the roles of wives, mothers and household caretakers.It has been observed that these are still prominent as the main roles of women in the Western Culture, roles which remain strongly highlighted in the verbal reports.Not being able to exercise their roles, implied in physical and especially emotional and psychological harms. 23he desire for a return to normality, that is, to be able to carry out daily activities, was found in the reports when they referred to the fact that they felt they were limited for carrying them out.This social representation on the role of women found in the Brazilian society, as caretakers for their homes and relatives, may also influence the choices for non-pharmacological self-care practices, which are present in different sociocultural contexts. 24mong these strategies used, we observed rest as a referred key strategy and applied spontaneously by the participants in search for relief; even if momentary, given that CSF is not related to work and not being completely solved by the rest. 1,3They maintained it in a positive response to the experiences of CSF, 25 because in some moments they felt better to perform the activities considered to be significant.

Fatigue management experiences from women
Cunha NF, Querino RA, Wolkers PCB, Anjos ACY This choice may have been a priority because of cultural knowledge, shared among the social groups, which involves rest as a possibility for relief of habitual fatigue. 17Another study, when evaluating the prevalence of fatigue in women with breast cancer submitted to chemotherapy, radiotherapy or post-treatment, identified rest and physical exercise as strategies that are more used to obtain relief, followed by distraction, rest, sleep, reading and food. 2 Two other possibilities were described as important strategies to manage CSF in its physical dimension: body energy conservation and food care.Energy conservation consists of managing personal energy in order to prevent its loss.It is based on defining priority activities, performing them at the moment of more disposition and strength, interspersing with rest periods.One may choose to use equipment that is useful for carrying out activities, as well as delegating them to others.It is recommended to avoid long periods of daytime naps for not compromising the repairing night's sleep. 1,3ith regard to energy conservation, the participants indicated the suspension of domestic tasks, resting between activities and retirement at home, in order to avoid or aggravate the fatigue.
Health care through proper nutrition is a frequent and culturally valued practice; influenced by popular and familiar knowledge when the intention is to prevent or treat physical or mental disorders.Examples include teas, foods designated as "healthy", "whole" and "organic", 8 applied as a resource to attenuate CSF, in addition to treating and/or preventing other adverse reactions resulting from chemotherapy.
The consumption of foods and herbs for therapeutic purposes influences the population's cultural behavior. 26In reporting food care as an important strategy to deal with adverse reactions to chemotherapy, women reinforce the influence of the popular knowledge and the family, which leads us to realize that eating involves the elaboration of new sensitivities, knowledge and experiences diffused in the context where people live, coexist, socialize and transit. 27egarding self-care in managing CSF in the emotional dimension, the search for relief to the adverse reaction led to the use of three non-pharmacological strategies: practicing religious activities, walking/moving the body and taking care of plants.
9] An integrative review on the religious/ spiritual coping used by cancer patients on chemotherapy has shown improved well-being and contributed to the adherence to treatment and control of emotional changes. 30uring the therapeutic trajectory, taking care of plants and practicing religious activities consisted in forms of distraction and relaxation that provided general relief for emotional CSF.This finding is corroborated by a pilot study with 22 patients with breast and lung cancer who underwent surgery, chemotherapy or radiotherapy one month after the end of treatment.The authors evaluated the use of the therapies related to contact with the nature, horticulture, meditation, yoga and support group therapy, for twelve weeks and highlighted improvement in quality of life and reduction in the fatigue.As a result, they considered such practices as useful for the emotional and spiritual well-being of the participants. 31 this study, two participants performed walks for fatigue relief.The practice of physical activity directed to improving emotional CSF also suited the need for socialization outside the home routine.The emotional benefits offered by walking and body movement to the women encouraged them to pursue these strategies in an attempt to attenuate the emotional CSF.A qualitative approach developed with women under chemotherapy observed that the reactions to the treatment, especially fatigue, were challenging for accomplishing physical activity, however, the participants found inner motivation to maintain the exercise due to the emotional and physical benefits. 7ecent meta-analysis reiterates these findings when confirming that physical exercise and psychological intervention are effective in reducing fatigue, and are significantly better than pharmacological options.Hence, they are indicated for managing cancer-related fatigue and its treatment. 32It is worth highlighting the cultural symbol for the performance of physical activity in a society where such practice is stimulated and is related to the sensation of well-being and/or to be healthy. 8,25In contrast, this strategy was not a priority in the options of our informants, which leads us to reflect on the need to have the professional skills and knowledge to guide patients about this practice in order to achieve better results.
Regarding the use of self-care strategies for fatigue management, it is worth mentioning a mixed study, which explored the use of non-pharmacological strategies by 362 patients with primary diagnosis of breast, colorectal, Hodgkin's and non-Hodgkin's lymphoma submitted to the chemotherapy .Upon analyzing the qualitative data, four categories emerged, which were based on self-care strategies: "Rest and relaxation", using rest, music and reading; "Remaining active" by practicing activities such as cycling, walking, swimming and golf, which have proved to be beneficial to physical disposition and emotional state; "Psychological wellbeing"; in this category, the participants sought to remain optimistic, used distractions and socialization, practiced yoga and meditation, maintained contact with nature and animals, and a healthy diet; and "support network" involving family, friends, professionals and religion to deal with the fatigue.These data reinforce that the discomforts generated by the fatigue negatively impact the physical and emotional dimensions of oncology patients, and lead to the search for unconventional self-care practices that alleviate CSF. 33lthough the municipality, where the research herein described was developed, offers integrative and complementary practices (ICP) for free through the public health system, such as reiki, acupuncture, homeopathy, circular dance, reflexology and anthroposophy, 34 we noted the absence of these practices among the participants in the research.This finding may be related to several factors, among which we cite: undervaluation of the ICP in the country, where pharmacotherapy prevails, and using biomedical technologies; scarcity of human resources, financial and institutional spaces for developing practices and, in particular, low disclosure for the population. 35In addition to reiterating that, in the majority of cases, complementary practices and non-pharmacological strategies occur through stimulation and indication of the family, social or religious network, permeated and strengthened by the cultural influences. 36atigue management experiences from women Cunha NF, Querino RA, Wolkers PCB, Anjos ACY Given the biographical rupture caused by the cancer illness and the adverse reactions to chemotherapy, especially CSF, the women sought in their cultural repertoire non-pharmacological strategies for managing the fatigue.They discovered that their life experiences as women, mothers, and workers brought a knowledge that was still little explored by the health services, which gave them conditions to achieve relief, even if only momentary, reinforcing self-confidence through self-care, which made possible the continuity of the treatment to resume the normality in their life, this being the meaning that they attributed to their experiences.

FINAL CONSIDERATIONS AND IMPLICATIONS FOR PRACTICE
CSF is an uncomfortable, limiting and common adverse reaction in women with breast cancer.The demands generated by the treatment may cause physical, social and emotional losses that lead to the need for care and reorganization of the activities and routines of patients and close people that make up the social and family network.
The experiences of women with breast cancer undergoing intravenous chemotherapy in managing CSF, in their physical and emotional dimensions, were challenging and led to the search for non-pharmacological strategies that took advantage of the sociocultural and family repertoire, that is, of their beliefs, values, meanings, attitudes apprehended throughout their lives and in the conviviality with the people belonging to their environment.These strategies were expressed through selfcare, in an attempt to alleviate the discomforts generated and enabled the reduction of intensity and consequent attenuation of CSF, although momentary, reinforcing the importance of understanding the singularities of the context and the practices adopted to deal with this reaction adverse.
With regard to the contributions to the practice of individualcentered care, this study demonstrated the importance of valuing the discourses, knowledge, beliefs, values and practices that make sense for this population.The underreporting of CSF evidences the need to listen carefully to these women, with accurate and detailed records of the reports on the occurrence of CSF symptoms.In the practices of nursing care and of all professionals who assist these women, it is always appropriate to associate the understanding of knowledge and of the cultural practices with the scientific knowledge, so that the assistance with integral care may be developed and improved.
In this attempt, the qualitative methodology showed significant contributions, as it allowed to broaden the listening processes of the participants, to understand the meanings attributed to the experience and to their cultural care practices.Studies of this nature stimulate the reflection of professionals and researchers about the insertion of the patient in the caring process, encouraging and promoting actions to facilitate self-care, which compose the daily life of these women, being identified as a central strategy in managing CSF.
As a limitation of the study, it was not possible to address a greater diversity of integrative and complementary practices, although they are made available for free by the municipality.The participants' lack of knowledge about these services was noted.Thus, new studies with participants from different socio-cultural contexts are suggested, in order to increase the knowledge about using other types of non-pharmacological strategies in managing CSF.
[...] The result [is] good!Because I get up pretty well.[laughs].(Luíza) [...] the body itself asks you to lie down, quietly.(Lis)Lis reports on the need to stay in a quiet environment with poor lighting and no noise.(Field Diary,June 27, 2015) (Luíza) It is so good [...] when I am reading [spirit books] I have nothing.I do not feel pain, I'm fine, I'm calm.I must have bought about six books since I started [the treatment], I read all of them thanks to God. (Maya) Saturday I already went to take a "walk" [...] I walk about two kilometers.[I feel] tired!Breathing short, very tired, I lie down there resting.I go out not because I'm okay!But it is in the attempt to move, not to be depressed!Because, it is to join cancer and to be quiet, depression comes for sure!(Luíza)One of the things that is really relaxing me [emphatic in the speech] is walking, making me feel good [...] I am not tired, I am not anxious, I am not stressed, I feel good.I manage to develop the things [domestic activities], till [emphatic in the speech] a certain time also!(Maya) Fatigue management experiences from women Cunha NF, Querino RA, Wolkers PCB, Anjos ACY

Table 1 .
10, 2016) Socio -demographic characteristics regarding the study participants, oncology outpatient clinic of a public university hospital, MG, Brazil, 2017.

Table 2 .
Clinical characteristics on the study participants, MG, Brazil, 2017.Cunha NF, Querino RA, Wolkers PCB, Anjos ACY This renews the state of mind.This moment I stop, rest, lie down a little [...] at least I was feeling calmer.It was not that I was not feeling [fatigue], it is that it became more tolerable, than if I went walking around, if I had been doing the normal activities.(Lívia)Sometimes[fatigue] affects me, I remain so quiet, that the day that this happens, nor the food I make, I don't mess with anything.(Lívia)Ilaid a "little" here [on the coach], I watched the program [on TV], I said: "Oh, I'll see the program, then I'll finish [the household activities]".(Maya)Foodcarerepresented by the consumption of certain food types, teas and juices, although not directly chosen for relieving CSF, was described by women as a way to prevent, attenuate or diminish undesirable effects and adverse reactions during the chemotherapy.There are two days that I don't make it [ginger tea].I think that's why my fatigue is more severe [...] [when I use the tea] I feel myself light, much less tired.The weight in the arms, in the legs diminishes enough, it is only that annoying "little pain".But, I get a lot better, my mood improves.(Maya) *Note: CS: clinical staging; AC-TH: antineoplastic doxorubicin and cyclophosphamide drugs, followed by paclitaxel or docetaxel, associated with the monoclonal antibody trastuzumab; FAC: antineoplastic fluorouracil, doxorubicin and cyclophosphamide; CMF antineoplastic cyclophosphamide, methotrexate and fluorouracil.Fatigue management experiences from women I was drinking passion fruit juice, honey, teas.Everything helped me stay [with the mind] calmer, [the body] more relaxed.(Lívia)