Social support towards the necessity of caring after myocardial infarction Apoio social frente à necessidade de cuidado após infarto do miocárdio

Objective: to know the received or assisted social support by the family towards the necessity of care after acute myocardial infarction. Method: qualitative and exploratory research. Data collection was carried out through observation and interviews with six families, from February to May, 2012. Data were also analyzed based on the thematic analysis. Results: three categories emerged: Immediate social support; Mediate social support; Late social support. Conclusion: social support follows the infarction trajectory, which attains the family members and favors the support according to the needs of care in each lived moments by the patient.


INTRODUCTION
Acute Myocardial Infarction (AMI) is a serious problem that affects the health of individuals and requires that they make significant changes in their life routines (1) .Some families are helpless in the face of the new demands that come with this issue, requiring support to share their anxieties and ease their concerns (2) .Seeking social support at each particular stage of the disease is one way to cope with the illness and its consequences, which provides improved care to the patient (3) .
The concept of social support began being discussed in the 1970s (4) and, currently, the most widely used definition is "any information or helpful material provided by groups or people who know each other, resulting in positive behavioral and emotional responses" (5) .Social support can be classified in multiple ways, however, for the purposes of this article and the data analysis included, it was based on three types: emotional, instrumental and informational support.Emotional support refers to affective support that provides security and understanding while encouraging self-esteem and confidence; informational support involves sharing knowledge and providing individuals with guidance; and instrumental encompasses financial support and assistance with day-to-day activities (6) .
To the extent that there is need for protection and care, people seek one another out, being close and establishing a supportive relationship (7) .These interactions mean that adverse situations are confronted together (4) , such as, for example, when there is a disease that may affect the family as a whole (8) .It is worth noting that support can come from people outside the family, but it mainly comes from inside the family (9) .Thus, it is the job of health professionals to stimulate the strengthening of social support given to the family, aiming to contribute in terms of ensuring care reaches its members with calmness and resolutivity (10) .Nurses particularly need to understand how to provide the families of people who have had AMI with social support, since they can be there together with family group during the illness, whether in hospital, by providing initial guidelines regarding the disease and its progression, or in basic health care, with health education and by monitoring the health-disease process.
In addition, despite there are studies in the nursing area that cover social support, it is worth highlighting that most of these are related to support for the individual patient (1,3,(11)(12) or family caregiver (7,13) .These studies also refer to the hospitalization period (8) , addressing aspects of support for the families in this context, while leaving a gap in relation to the support received following hospitalization, as proposed in this article.
Therefore, this aim of this study was to investigate and understand the social support that is received or provided by the family when faced with care needs following Acute Myocardial Infarction

METHOD
This research was qualitative and exploratory in nature and involved six families of patients who had suffered Acute Myocardial Infarction (AMI).In order to perform the research, the concept that the family goes beyond the bonds of consanguinity, marriage or adoption was adopted (14) .
Firstly, the participants eligible to be included in the survey were identified by means of reading the charts of patients who had AMI, at the Cardiology Outpatient Clinic at a university hospital in southern Brazil, thereby forming an intentional group, i.e. participants who could meet the objectives of the study in a relevant manner were chosen (15) .
In order to be included in this study, one person in the family must have been diagnosed with progressive AMI by atherosclerosis.This diagnosis must have happened at a minimum of six but not more than twenty-four months previously, due to the need to contact the family and talk to them about care while they are still able to recall their perception about this period.In addition, the family members should be pointed out by the person who suffered AMI, at the Cardiology Outpatient Clinic, at the same time as the family was invited to participate.This occurred while patients were waiting to see their doctors or on the day of the interview at the household.Individuals with cognitive speaking or listening limitations were excluded.To ensure that collective interviews could be held with the families, it was necessary for at least two people to be present, with the patient possibly being one of them (14) .
Data collection, which took place in the period from February to May 2012, was performed by observing the cardiology outpatient clinic and the household, in addition to interviewing the family.A field journal was made in order to record the perceptions of the researcher following the observations and interviews.
After the research was clarified, a Term of Free and Informed Consent was signed by those who agreed to participate.The names of the participants were altered by the researcher in order to maintain anonymity and the family was identified as a group, using the letter F, which signified family and the subsequent numbers identified the order in which the data was collected, for example, F1, F2.The research was conducted in accordance with the ethical principles set out in Resolution No. 196/96 (16) ,which was in force at the time, and approved by the Ethics Committee at the University to which this is bound, under Certificado de Apresentação para Apreciação Ética (Certificate of Ethical Analysis Submission) No. 0372.0.243.000-11.
Atlas Ti 6.2 software (Qualitative Data Analysis) was used to help encode the interviews following data collection, which only ended when the research objectives were reached.The data were analyzed by thematic analysis (17) , which was made up by the following steps: pre-analysis, material exploration, processing of results and interpretation.During the first step, the interviews were superficially read with a view to associate the comments with the research objectives.Secondly, the interviews were entered into the Atlas Ti software, with the statement fragments being encoded in sub-themes by similarities.A Microsoft Word document was generated from this encoding using the sub-themes (recording units), these were then grouped into three main themes: experience, care and social support given to the family following acute myocardial infarction.Finally, during the last step of the analysis each of the themes were organized.In this article it was decided that social support be addressed, which contained sub-themes of immediate social support, mediate social support and late social support following AMI.

Families involved in the study
The survey was conducted with six families, all of which had at least two people present at the interview.The families referred to as F1, F2 and F6 had four of their family members present.In the F1 family, the daughter and the daughter-in-law participated, and in families F2 and F6, the daughters participated, along with the person who had the AMI and his/her spouse.In families F3, F4 and F5 the interview involved the couple only.Only in families F4 and F6 was the sick person female.The shortest time since the AMI was found in family F6, which happened 6 months previous to the research.The longest time was in family F3, with there being a 14 months gap from the AMI to the interview.

Immediate social support
The following statements highlight the initial support received from people outside the family, in the time leading up to the hospitalization and the AMI being discovered.

[...] that horrible chest pain, he got here desperate [...] then I saw a gentleman bringing him in. He came in looking for his papers and clothes, he only changed the clothes he had on, the man put him in [the car] and I gave him his wallet with his document inside and he was gone. I said: you go on ahead and I will follow. (F2-Vera)
Then I said to him [a friend]: "I am not well!"I only ate a little so, feeling sick, I went to bed.I lay down, I felt that I could not stand the pain any longer and said: "Bring me more blood pressure medicine".I thought the pain was from the blood pressure and then I said: "Take me to the Emergency Room, I am dying!".Then he dragged me out, put me in the car and drove me to the first general clinic here.From here I went to the ER and then I went there [hospital].(F4-Carmen) In most cases, AMI is unexpected and requires the care and support of people who are close by, even if they are strangers or have little personal contact with the family.According to some reports, the pain caused by a cardiovascular problem seems to be the main reason for seeking help and also for indicating that something is not right.In addition, expressive signals of pain seem to bring feelings of solidarity in other people, moving them and drawing offers of instrumental support during the initial period, mainly in order to assist the family, firstly in the form of getting the patient to the hospital.
Despite this early period being characterized by help from unknown people or friends, it was observed that the family is also responsible for providing immediate support: Even if the family is physically far away, when AMI signals begin, the patients still look for their instrumental or emotional support.Thus, neither distance nor pain seem to be obstacles in the attempt to achieve family care, which gives the patient security that is probably due to the bonds that have previously been constructed.Yet, this search for help within the nuclear family can also occur because of a existing social construction, which puts forward the belief that the family should be responsible for its members and thus provide support where necessary, thereby avoiding the involvement of strangers in their internal problems.

Mediate social support
Soon after the AMI, the help provided by the family during the hospitalization period was identified:

It was not easy, they [children] had to go to the hospital taking things to her. (F1-Daiane)
My two sons and my daughter-in-law helped, I had help from my sister who sometimes gave me food, she sent me over a plate of food, a piece of meat and some bread; she works in a restaurant.(F1-Cleusa) [...] I stayed at home taking care of the house.It is difficult for us to go to the hospital during visiting hours, so we [José and the daughter] took turns to go and I would sit there with her, but it was not easy, we are not used to things like that [...].(F6-José) During the interview, the families highlighted the difficulties faced due to the illness and the hospitalization of one of its members.These questions seem to have an impact in terms of their recognizing the help that they received during this period, remembering what they went through, and also stating who was present.In addition to the need for instrumental (material) support referring to their physical presence, it was observed that these difficulties are permeated by emotions, due to the instability that the illness and the hospital environment cause.Thus, emotional support is a way to mitigate these issues, either by members of the nuclear family or members of the extended family.
However, based on the time spent in the hospital, health professionals were also singled out as sources of support in some instances: At the hospital I was terribly distressed, I did not know how to help him [...], it was painful for me to see him.We knew that we could not do anything, he was full of medical equipment.Then the nurse called me and told me to leave [the cardiology unit] saying: "go outside, calm down, he is going to be okay, then come back in and he will be okay."(FI-Cleusa) I know going there is hard, but the care that the women, the nurses and the doctors give you, look, let me tell you, it is amazing.(F4-Carmen) After I had this problem we had guidance from the doctors, nurses, all of them, so we knew about diet and everything.(F5-Luiz) Health professionals, especially doctors and nurses, have been cited as sources of three types of support: instrumental, by means of their health care actions that treated the sick family member in the hospital environment; emotional, with gestures and words of comfort; and also informational, by offering guidance on the health-disease process.However, it is worth mentioning that the support received from these professionals, in that period, does not seem to continue into the following steps of recovery and returning to normal life, which leaves a gap in care as regards health promotion actions and their continuity.
Thus, following hospitalization, the patient and his/her family return home, which means that support comes mainly in the form of the children: I had to make his food [the patient], do things for him.I asked my son to do this.Then he did it, he bought the chicken to make soup, he bought cookies, he bought all kinds rye bread that he had to eat.My kids helped me for the first few months until I felt better.(F1-Cleusa) Every time I went to college, I used to get ready and went here because mum would get him coffee, then I had to sit him up in bed, wait a bit, then I lay him back down.(F1-Mariana) She [the daughter] helped me in the beginning, she was the one who came and did this stuff [house cleaning] for me.She even made me food, she did everything because the other one [daughter] was notthere.(F6-Angelina) In this study, the children were cited as the main source of social support at all the post AMI stages.However, it is worth mentioning that it is during this period when the patient returns home that this seems more exacerbated, in other words, the children are referenced most regarding the care in the family environment.

Late social support
Following the recovery period, the family seemed more open to receive and seek support from other sources, not only from family members: All the neighbors are good.Sometimes I shout and they all run here to help me.I have plenty of this type of help, I once fell here and the dogs were all over me, crazy, desperate and he [partner] was out back, he did not see it, then they [the neighbors] came running here and picked me up.(F4-Carmen) You know that at the nursery it is like this [...] they are very dear, there is the manager of the nursery, and there are the community mothers who help.I never went without anything I bring everything, both [food] ready food, and dry food and vegetables.(F2-Vera) A long time after the AMI, the families seem to receive support, particularly instrumental, from other individuals, such as neighbors and friends.The children were still mentioned in some interviews, but with less frequency than they were referring to the immediate moments after returning home.
Support received from various sources aims to establish care practices to help resolve problems and support the family's well-being.Nevertheless, support is not always given directly to the ill person, who is the central subject regarding the disease, but also to the other members of the family.
After a while, people who have suffered AMI generally return to a normal way of life, which is when their participation in leisure activities is apparent: At the weekend he goes bowling.It is there that he has his only entertainment, he likes going there.(F2-Vera)

Yes, he feels good doing this because he likes it. (F3-Regina)
For people who have suffered this illness, returning to their normal lives, even if only partially, points to an improved clinical picture and is characterized as something that is relevant to the family, which means the family worry about the person less.Thus, leisure and work activities were highlighted by families as types of support that provide beneficial feelings and promote quality of life.
Despite these circumstances having been reported as support, some families, especially those made up of couples, refer to loneliness some time after the event: My son also came to help, everyone has their things to do, but mostly it is just the two of us.(F3-Regina) [...] it is just the two of us living together, once in a while someone comes along.(F5-Luiz) Social support, which was evident during the AMI and the recovery, seems to decrease following a period of time after the acute episode of the illness.The family returns to their routines, however this shows a certain fragility when the patient is faced with the loneliness that follows when people leave.

DISCUSSION
During an AMI, mainly due to pain, families tend to look for support from people with whom they are close, whether these individuals are family members or not.Pain becomes an external factor to whoever has the AMI and his family, which influences the decision to seek immediate support.Thus, survival becomes dependent on the support of others, who provide transportation and work together so that the pain can be dealt with (11) .When faced with someone in a difficult situation people being to feel the need to help (7) , leading them to be there for the sufferer and prepare supporting alternatives to ease the suffering that comes from such difficulties (13) .Society has an important role in providing suitable conditions that can maintain the well-being of families (8) .This role can be seen in this research, since it can be detected in the effort to help the individual patient and his/her family.
Thus, the initial analysis of the support received by households appears to refer to that given directly to the AMI sufferer, but it observed that this support extends to the entire family.The affirmation is made because the period previous to the AMI being discovered can eased, by the family, through support coming from any source or dimension, since these periods are mostly characterized by great distress and anguish.
In addition to external support, the families also describe a bond between its own members, motivated by the need to provide the care needed at that time.An important point is that the family has a duty to take care of its own as a cultural tradition, a characteristic that has been intergenerationally passed down (18) .Therefore, it is a standard duty of a family member to provide emotional security and support when necessary (8) , because family bonds are usually still there despite any geographical distance (14) .Such support becomes easier when the relationship structure of the family members is solid (13) and able to resolve the problem at hand.
During hospitalization, support by some family members was also relevant, based on the findings of other studies (7,19) , which claim that the family is an important source of emotional support to those who are chronically ill, strengthening the help given as and when care is needed (7) .
The immediate family circle are first called into action and, subsequently, the more distant family members are turned to, if necessary (8) .Thus, in addition to the nuclear family, the extended family becomes essential for coping with the situation, with the exchange of favors and mutual support (10) .
Family members interact and actively participate in the life of the sick person, with this being considered a significant element for relieving the tensions that arise during hospitalization (10) .The unity of the family can be highlighted during this period, which is evidenced by cooperation and tasks being shared (20) .The objective of this organization is to provide care and maintain the well-being of all its group members, because, in as much as there is a relay of care between family members, it is also providing quality of life for others.
Also, due to the hospitalization and their proximity to health care professionals, families reveal the support provided for them.Authors of a study conducted with caregivers for chronically ill family members found health professionals to be members of the network that provides support to families (13) .Such support can be accomplished through actions that enable the multidisciplinary team to interact with families and help ease anxieties regarding the condition (8) .Thus, talking with families and being there for them as a sensitive listener contributes to their well-being (8) and, consequently, to these professionals being recognized in their social support role.
Nonetheless, when the patient returns home and begins his/ her initial recovery, the children make a significant contribution by providing the necessary support.In this sense, social support given by the children is evident by means of intergenerational care, which is characterized by the statement "all in the family give care and are cared for" (18) depending on the specifics required of each member, in each circumstance.This idea develops by virtue of the previously built relationships among family members and associates itself with the need to preserve the family unit.Help is provided in a variety of ways, which may strengthen already close bonds or even resume distant ones (18) .Despite some members of the family being far away, there is complicity in the system during this period, which allows them to be "present" by means of constant communication (19) .
However, the family system limits must be balanced between the permeability and restriction of people from outside the family, because, if it is too permeable, it may result in a loss of identity and prevent its members from reaching their own care potential (14) , which, in some ways, justifies the point of help being searched for among the family members themselves.
On the other hand, a long time after the AMI, the families, despite still being supported by the young members, again look further afield for help, mostly from neighbors and friends.The support given by these people is usually significant to families who live through an illness, which confirms the idea that this disease can bring social relationships closer together (13) .In this way, the material assistance offered by means of solidarity can be present in immediate or extended circles, which is an important aspect in terms of reducing the suffering (8) that the disease causes.Social support is regarded as a way to help in the fight against the disease (21) , especially the chronic form, which establishes several changes from when it emerges.In addition, the satisfaction of whomever receives help will be passed onto the rest of the family.
In this same context, leisure groups were also referred to by some members of the families as a source of support, since recreation points to the possibility of resuming normal life and moving onto a stage in which the disease does not require the same level of supervision.Nevertheless, due to the AMI imposed limitations, in some cases people have to reduce their attendance at some meeting places or stop going altogether, which removes these sources of support.
After AMI there are certain restrictions that arise regarding activities that require physical effort, a point that highlights that the possibility of having a life of intense relationships is limited.However, whenever possible, recreation and social activities with friends were considered relevant so that the patients would feel welcome (12) .Moreover, social support from friends during leisure activities provides considerable relaxation, since it combines a practice of creating well-being with interpersonal contact from different people in the family (22) .
Another issue that was highlighted by the families is that the patients began to feel a certain loneliness after the disease had been stabilized, suggesting that support occurs more intensely during the time when the changes are more acute.Chronic illness can result in social support providers becoming closer or more distant, these are variables that are relative to the situation being experienced (13) .The results of this research highlight this idea because, when the fear of death from AMI reduces, so does the sufferer's families concern, which may have an influence on the reduced frequency of support received, the most prevalent being emotional support.

FINAL CONSIDERATIONS
This study explained the social support that was received or provided by AMI sufferer's families after the event, while distinguishing this support in periods according to the care needs at every step of this experience.Therefore, the affirmation is that social support accompanies the disease's trajectory, meaning the sources of support also vary during this period.
Thus, prior to the AMI being discovered, the support to maintain life, manifested mostly in material actions such as transporting the patient to the hospital, was performed as much by unknown individuals as by his/her own family.On the other hand, during the period immediately after the AMI, namely the time spent in hospital and the subsequent return home, the family receives instrumental and emotional support from both distant and close members of that family, but especially from the children, configuring a remission of the family system in order to gain stability.In addition, during hospitalization the health professionals, particularly the doctors and nurses, are mentioned in the interview statements; these individuals offer three types of support: emotional, informational and instrumental.
Following an AMI episode of lengthier proportions, the family system was seen to become more open, with the possibility of finding social support from neighbors and friends in recreation activities being apparent, since the children begin to withdraw up to the point when the person who suffered the AMI is recovered and the family can resume its normal routine.
Social support was found to be important in order that care be effected in families.Still, regardless of the type of support, even if it is directed to only one individual in the family, it will have a knock-on effect with other members of the group.Thus, it is possible to affirm that the support reaches all family members, because they interact in an integrated and joint way, which includes family members who do not live nearby.
This study is especially relevant to the nursing profession, because only after knowing what kind of support (if any) families receive is it possible to then plan support alternatives and help alleviate the suffering that results from the disease.This research also highlights that the family's own members organize themselves to provide support at the various stages of the illness, which confirms the need for health professionals to work at their side, providing proper support so that the patient can resume a normal routine as soon as possible.On the other hand, this allows new possibilities to be considered to support these families, which enables people outside the family sphere to be involved and avoids its members from becoming overburdened.
Among these possibilities is the option of therapeutic groups being developed, where there is a relationship between health professionals, and the execution of their specific tasks, in order to jointly look for specific support for families facing defined diagnosis in relation to each situation.It is the job of the nurses to identify the difficulties being faced and offer support, while interacting and sometimes referring the family to the most appropriate professional, such as a psychologist for example.This is why it is important to plan specific and comprehensive care, while always respecting the family as a group.Finally, it is suggested that studies be conducted with post-infarction patients, in other health care scenarios, in order to detect whether or not there are differences between the support that these individuals receive.
She spent the night screaming [in pain], it was a Saturday [...] then I called my daughter here, she came with my sonin-law in the car.She said she could stand it no longer, she spent three or four days without eating, only drinking tea.She went to the hospital and I waited at home anxiously, I could see that this was serious and they kept calling me from there, my daughter called me all the time.(F6-José) She [the wife] worked nights and every day I picked her up at eight o'clock in the morning.I woke up with pain, right here on the side [...] then the pain began to get a lot worse, and then I called her at around seven o'clock and said: "I am in a lot of pain, it is terrible, I am going there".I got the car and went [to get help].(F5-Luiz)