UMA COMUNIDADE DE BAIXA RENDA Luiza Akiko

O objetivo desta pesquisa foi descrever as experiências de um grupo de mulheres relativa ao processo decisório sobre o cuidado da enfermidade no domicílio ou em uma instituição de cuidado à saúde. O método da história oral temática foi desenvolvido. As categorias descritivas foram: a) o pobre possui um jeito próprio de cuidar da saúde e da enfermidade; b) o principal suporte para combater a enfermidade está na crença em Deus; c) O cuidado médico é para quando os recursos de cura não são suficientes e a enfermidade é perigosa. Em famílias de baixa renda, a bagagem cultural que está associada à condição socioeconômica permeia o processo decisório relativo ao cuidar da enfermidade em casa ou buscar o cuidado médico institucionalizado. Este conhecimento é essencial para um cuidado significativo na perspectiva de indivíduos e suas famílias.


INTRODUCTION
The families' health-illness values and convictions need to be understood by health professionals in order to consider their perspective in health care practices.This is a principle of the Family Health Program of the Brazilian Government (1) .São Paulo City is a large urban center and attracts families from other states and regions.Internal migration has resulted in a variety of cultural communities in this city.Rio Negro (fictitious name) is one of these communities.During more than a decade of faculty extension activities carried out in that community, it was possible to observe that the health and illness care beliefs, values and practices are shared among family members, their relatives and neighbors.
Among poor families, health care activities are based on a refined socio-cultural guideline and characterized by a high degree of social articulation.
There are solidarity and healing strategies, but these are limited by scarcity of financial resources (2) .Healing rituals based on their own knowledge are performed in order to solve health problems and these practices are very different from the ones performed by the official health care system (3) .
Family health care requires a personalized and contextualized focus on the user's social, ethnic and cultural background (4) .Nurses need to see the person as a unique human being interacting with the family and the community (5) .What a disease symptom means, when and where to leave ill family members in a medical institution are questions answered according to family beliefs and values (6) .
The aim of this research was to describe the experiences of a group of women about the decision making process related to illness care at home or in a health care institution.

Research design
The thematic oral history method was used in this study.The understanding of specific aspects of experience, as well as capturing ideas, values, and beliefs related to the theme, is the essence of this method.Moreover, the method allows people who normally do not have a social voice to express their ideas and feelings (7) .Through the thematic oral history it was possible to understand and describe the experiences of each interviewed women regarding their involvement in carrying out illness care at home or to find an appropriate health care institution.
According to the last demographic census carried out in 2000, Rio Negro was composed of families with a total of about 2,152 persons.Living in the community for at least 10 years, demonstration of empathy, having experience on the topic and willingness to report experiences, are some criteria for the inclusion of a person as research collaborator (8) .These criteria were followed to include the collaborators in this research.each recorded speech, has permitted the narrative´s analysis process (7) .
This process was carried out in an inductive way.During this work it was possible to discover different meanings and expressions related to health and illness care practices in order to permit the construction of descriptive categories.The extraction of quotes from narratives was used as a measure to make the descriptions more real.Finally, each narrative was read once again.It was possible to verify the absence of contradiction between the oral histories and the descriptive categories.This iterative data analysis is considered a significant feature to assure research validity and to make qualitative research a systematic and rigorous process (8) .
Research ethics aspects were in accordance with the Brazilian National Health Council criteria (9) .A research-participation consent form was signed by all collaborators after receiving detailed information about the research and the anonymity guaranteed by utilization of fictitious names.

FINDINGS
The personal characteristics of the women, the vital tones, the descriptive categories and related contents are presented.

Personal characteristics of the women
The women ranged in age from 25 and 70 years (average of 45 years), ten were married, three were divorced and one was a widow.The time they had resided in the community varied from 10 to 30 years (average of 17 years).Regarding employment, nine worked away from home, and among these seven were supporting the family whilst five took care of the household.Twelve women had four years of formal education and two were illiterate.When questioned about religion, seven were Evangelical Christians, six were Catholic and one was a Spiritist.
All women were Brazilian.

The vital tones
Fictitious names, chosen from typical Brazilian flora, were utilized to identify the women.
I make due as I can because when a poor person goes to a physician, she is treated carelessly (Gerânio). Medicine

The descriptive categories -The poor person has an own way to take care related to health and illness
Women learn to deal with the health-illness process based on their own poverty lived experiences.
Poverty is perceived by women as a stigma and is incorporated in their health/illness behaviors, and consequently it permeates their health/illness care decisions and actions.Physical and mental health preservation is considered a main aspect of women´s life.
Nevertheless, the necessary preventive health care practice, like a gynecological cancer exam, isn't usually taken by women.They consider themselves as "lax" in this aspect of life.Priority of care is directed to the other family members, mainly to the child.
According to the women´s own point of view, a child with a disease is a consequence of mothersć arelessness.

The poor person has her own way to confront illness…
When I'm sad or anxious, I take an aspirin, I talk with others and start feeling better...When I feel I'm becoming depressed, I sing, bake a cake and come out of this bad mood... God is one way of caring for health, the head, every problem.
Signs of illness are immediately confronted.
All folk care knowledge is put in practice in order to avoid medical care.
With some wounds, I wrap a red cloth on the place because red helps the body to heat up and defend itself better, I brew tea, sympathetic magic, everything together, so as not to have to go to the hospital.
Knowledge of folk care practices such as herb remedies, sympathetic magic, effects of a variety of teas are shared among the neighbors and relatives.
The easy access for many different herbs, plants and other healing resources, give to them a sense of security.Efforts are made to maintain an easy accessibility to a variety of illness related care resources.The older women are considered references in terms of knowledge related to the herbs, healing effects and other care practices.This scope of knowledge is transmitted from one generation to the next in family and neighborhood context.

God
The belied in God is the womens´ most important support to fight the illness condition.It constitutes the guide for the preservation of life and to direct their own health condition into a good way.
The opposite behavior, or the lack of faith and the belief in God´s power is considered a harm and valued as the cause of the illness and life's malevolent occurrences.Simultaneous measures are taken in order to combat the illness´ signs and symptoms.
When an illness condition is apparent and needs to be faced, women first ask for spiritual power, then the aid of herbs and other healing practices and, lastly, the search for medical care.Medicine, physicians and other health professionals are also seen as having a divine attribute.Spirituality represents to the women an indispensable support for their medical care success.
The strength to face difficulties comes from faith.Lack of faith provokes evil....I first look for help from God, then from the herbs.The doctors and pharmaceutical medicines also help.Cross-cultural communication will only begin to improve when health professionals recognize the meaning of their own individual attitudes.A greater understanding of others can be established only when health professionals increase their own selfawareness (11) .For nurses and other health professionals, creative resources to facilitate and to mobilize socially available resources need to be incorporated in health care planning and implementation (12) .
A great importance in regard to spirituality was observed among women living in Rio Negro.Religion has a major impact on the health care and life style, and studies aimed at developing knowledge about this topic are required, especially in low-income contexts (13) .
In this aspect, nurses and other health care providers should integrate scientific, religious, and cultural knowledge into their clinical practice.It is considered essential for promoting quality of life of families (14) .
This factor and any other influencing popular social and cultural health related actions need to be understood, analyzed and primarily considered in health care projects proposed by professionals and public policy.
Home care nurses and their supervisors need to develop their skills with the aim of offering culturally competent health care.This challenge requires a culturally oriented patient assessment, staff development educational programs and the adoption of an organizational policy to expand culturally diverse client base support for easy use by home care agencies (15) .The family's power to chose become more restricted when a member is sick and the family members are affected as a result of the condition they have to face.The experience of sickness, as well as the condition of vulnerability confronted in this situation, need to be understood by health professionals in a deep and comprehensive way.This knowledge is essential for the proposition of adequate care of families confronting serious situations (16) Research on the health-illness process in specific cultures has important value.Research findings can describe how social and cultural conditions influence behavior in the health sphere.
The research also clarifies the complex relationship regarding socio-economic conditions, geographic localization, attitudes related to health and illness and the reasons that establish these decisions and behaviors.
In low-income settings the social sphere is intrinsically associated with cultural background and these factors need to be considered in health care management.One aim of this research was to offer to those who do not normally have a voice, the opportunity to express their opinions.This is one of the main purposes of oral history research (7) The health of a nation's people is the cornerstone of its economic development.The poor of the world cannot be neglected (17) .The knowledge about the strong and complex factors involved in the health care practices and decisions in low income families can support health professionals´ actions in order to satisfy the real health care needs of the people they serve.
Pap´s smear periodically, for example, because I'm lax.But I do everything for my children, I have to be a good mother.As far as I'm concerned, I'm unimportant.Women maintain a constant state of alert in relation to their own vulnerabilities, mainly in relation to health preservation.The women associate the anxiety condition with their strong poverty reality.Mental health promotion opportunities are few and restricted to the dialogue with friends, godmothers and neighbors, to watch television and to go to church.These resources are considered a way to share daily problems but valued as improper for personal conflict resolutions.They resort to a variety of strategies of self-help improvement.Low socioeconomic conditions and gender oppression affect womens´ mental health because they cannot see how to overcome these problems.Consequently, women must deal with the traumas originated from them.With the aim of obtaining wellbeing, the out-of-control personal, family and social conflicts are confronted in several ways.Women ask for self-medications and to do many other things in order to try to overcome and to promote selfcare.But, the main support is represented by faith because, for women, God represents the safeguard for all confronted problems.
Illness care at home...