"The group facilitates everything": meanings patients with type 2 diabetes mellitus assigned to health education groups1

OBJECTIVE: to interpret the meanings patients with type 2 diabetes mellitus assign to health education groups. METHOD: ethnographic study conducted with Hyperdia groups of a healthcare unit with 26 informants, with type 2 diabetes mellitus, and having participated in the groups for at least three years. Participant observation, social characterization, discussion groups and semi-structured interviews were used to collect data. Data were analyzed through the thematic coding technique. RESULTS: four thematic categories emerged: ease of access to the service and healthcare workers; guidance on diabetes; participation in groups and the experience of diabetes; and sharing knowledge and experiences. The most relevant aspect of this study is the social use the informants in relation to the Hyperdia groups under study. CONCLUSION: the studied groups are agents producing senses and meanings concerning the process of becoming ill and the means of social navigation within the official health system. We expect this study to contribute to the actions of healthcare workers coordinating these groups given the observation of the cultural universe of these individuals seeking professional care in the various public health care services.


Introduction
Diabetes Mellitus (DM) is a metabolic syndrome resulting from the production, secretion or deficient use of insulin characterized by chronic hyperglycemia, frequently accompanied by dyslipidemia, abnormal blood pressure and endothelial dysfunction. It is considered a chronic condition of a multifactor etiology that requires patients to self-manage their lifestyles. The focus of treatment is to control glycemia, metabolic control, absence of acute and chronic complications, changes of lifestyle and psychosocial adaptation (1)(2) .
Preventive measures for DM, and its assessment and treatment, include health education actions administered for individuals and/or groups. In Brazil, with the expansion of the Family Health Strategy and the Reorganization Plan of Hypertension and Diabetes Mellitus Care (3) , these actions have primarily developed in groups that are coordinated by healthcare workers (physicians, nurses and/or community health agents).
In this context, the health education groups directed to diabetic and hypertensive individuals are known as "Hyperdia groups".
Health education activities should promote opportunities for knowledge and experiences concerning the disease to be shared and exchanged so that patients and their families make conscious and informed decisions about the self-management of their chronic condition (4) .
There is evidence that appropriate management improves eating habits, decreases levels of blood glucose and glycated hemoglobin, and also decreases the incidence of complications such as retinopathy and nephropathy (5) .
Given the previous discussion, the question raised in this study is how do individuals affected by DM signify the experience of participating in Hyperdia groups?
In these terms, we note the need for an approach that is sensitive to the contexts in which the different healthcare workers and patients "meet". Therefore, in addition to the most general aspects of everyday life of individuals with DM, we should also pay attention to their representations and experiences in the places where they receive care, as well as the political and economic factors that inform the nature and content of healthcare delivery (6) .
The objective was to interpret meanings type 2 DM patients assigned to health education groups. Studies of this nature enable the understanding of dimensions concerning the experience with a chronic disease, as well as the interactions of the individual and his/her support network with the official healthcare system, contributing to the delivery of nursing care that values and mediates the knowledge and practices of both popular and erudite models of the disease.

Method
Medical anthropology was the theoreticalmethodological framework used in this study; specifically, we linked interpretative anthropology (7) and critical medical anthropology (8) . This strategy was intended to associate the interpretation of symbolic aspects and cultural meanings assigned to a social phenomenon (typical of interpretive anthropology) with a macrosocial perspective from analyses in critical medical anthropology with its focus on the ideological, political, economic, and historical dimensions. Therefore, culture was seen as a material and symbolic system, which, through signs, symbols, codes, cosmologies, values and standards, offered a matrix of meanings within which individuals interpret the world, produce meanings and guide their knowledge, practices and experiences in a given context. Additionally, this matrix of meanings is constantly produced and updated by the action and creativity of social subjects.
The methodological framework used was ethnography because of its explanatory nature.
Ethnography is acknowledged as a theory of practice that comprises social life as a result of interaction between the structure and agency of individuals in their daily practices in a given sociocultural context (9) .
From an operational point of view, ethnography involves a continuous effort to put the researcher in specific meetings and events in order to understand contexts and phenomena significant to a given social group.

Results
The social characterization of the participants was: 75% were women aged 67 years old on average;

Ease access the service and healthcare workers
The informants considered that participating in the Hyperdia groups was a way to ensure easy access to healthcare services. It meant the possibility of In this sense, "know something" means to "see" the parameters used and that the professionals give priority to. Hence, they could "control" parameters, i.e., monitor these parameters so they would not be taken by surprise.

Participation in the groups and experience of diabetes
The impact of participating in the Hyperdia groups was expressed by the patients through a complex system of opposition contained in two categories formed by structural pairs. The first pair: improvement The second pair: concern x tranquility, emerged from the relationships between patients and healthcare workers, especially the doctor-patient relationship. The informants' reports showed concern for those who did not "seek" the service, that is, those who did not access the official health system.  (12)(13) .
Ethnographic data, however, show general aspects concerning the action and creativity of the individuals, the target of this policy, with a view to address this dilemma between the individual and person. Therefore, from this confrontation between the individual's role (universal laws) and the person's role (relationships) emerge coping strategies (trickery, a knack for the system, "do you know whom you're talking to?") through which Brazilians manage to discover and find a way, a manner, a style of social navigation that passes between the lines of these confrontations (13) .
In this sense, facility in accessing services and healthcare workers as reported by the informants reveals the social uses of the Hyperdia groups as the patients used trickery to circumvent difficulties of access imposed by bureaucracy and deficient structure and working conditions. Therefore, the groups, instead of presenting opportunities to learn and encourage treatment adherence, were used by the patients to produce, maintain and use networks of relationships that enabled them to "navigate" within the official health system.
In addition to this distinction between the individual and the person, it is worth noting the basic social mechanism, within everyday Brazilian life with its rituals and models of action, through which a strong and permanent relationship is established among three spaces and dramatic plans as a way to remake the unit of society: home, street and the other world, as shown in and normalize and moralize the subjects' behaviors (12) . * For this study's purposes, only the street and home spaces were addressed. The "other world" space refers to relationships established with the supernatural world.

Home code Street code
• It is averse to change and history, economy, individualism, and progress; • There are no individuals, all are people whose existences are legitimated by the relational links they maintain with other people; • All relate to each other through blood ties, age, sex and relationships of hospitality and friendliness; • It is a space of tranquility, rest, recovery, and hospitality; • There are relationships that define the idea of love, affection, and "human warmth"; • One is a super-citizen in the universe of home.
• It is open to legalism, to the market, linear history and individualistic progress; • It is an impersonal place, individualized, of struggle, and trickery; • It is a space that belongs to the "government" or the "people" and is always fluid and full of movement; • The street is a dangerous place, prone to theft, where people can be confused with indigents and taken for something they are not; • As a public space, it is negative because it has an authoritative, authoritarian, flawed point of view, based on negligence and, in the language of law, which by equaling, subordinates and explores; • In the street universe, one is a sub-citizen. Figure 1 -Characteristics of the social universes: stress and home adapted from DaMatta (12) .
From this analytical perspective, the health system Under these circumstances, the bond and empathy established with the professionals in the impersonal universe of the health service (street code) recovered the relational and personalized dimensions that are inherent to the home's social universe. It was essential, because diabetic patients reported that the empathy of healthcare workers as manifested by an understanding attitude, attentive listening, and holistic approach, produced a feeling of trust and motivated them to become more involved in the management of their disease (14) .
In regard to the guidance and information provided regarding DM, this study's results show the meanings patients assigned to these orientations and the recommendations contained in the biomedical discourse relativizing them. They interpreted the information provided by the healthcare workers and found their own solutions to the particularities of each one's life. These interpretations were notorious for the use of terms such as "measure", "see", and "know". The participants used these terms as corresponding to the technique of the exam in the physician's vernacular. In biomedicine, exams play the role of inverting the "invisibility" of DM (usually asymptomatic) and bringing forth elements the patient could hide. Thus, the exam transforms the individual into a describable object, under the control of permanent knowledge, and enables the exposure of singular traits, his/her particular evolution, and inherent skills or abilities (15) .
In contrast, for the informants, "measure", "see", and "know" enabled the production of coping strategies for the irregular capillary glycemia, food exaggerations, and drug therapy. The anthropological literature specializing in health has shown that what reminds these individuals of DM is the daily monitoring of blood glucose, time of medications, dietary restrictions, the need to perform physical activities, and when necessary, insulin injections (16) . Therefore, the expression "know something" is consistent with daily efforts to keep clinical parameters "under control" and not being "taken by surprise". This study's data corroborate the existence of two conceptions of "control" already reported in the literature: a biomedical conception, which means keeping glycemia and other parameters within normal values; and a popular conception, which refers to practical concerns that mobilize patients to promote adjustments in their prescriptions, trying to balance them amidst nonmedical demands (family, work, religion) that need to be managed in life (17) . These same elements are perceptible in the structural pair "improvement x control".
The structural pair "concern x tranquility" shows the demands of patients for medicalization, considering both productive effects and negative aspects. In the face of "concerns" arising from their everyday lives, the informants count on the effects of "tranquility"  (18)(19) . These aspects in the studied groups need to be known and valued by healthcare workers.

Final Considerations
This study sought to interpret the meanings diabetic patients assign to the Hyperdia groups. The "anthropological lens" enabled the identification of the informants' social uses of the Hyperdia groups, as well as other aspects related to the experience of DM. Therefore, the studied groups showed themselves to produce instances of senses and meanings concerning the process of becoming ill and the means of social navigation used within the official health system. In this process, ethnography contributed by providing the inter-subjective experience that takes place in the field, its craft nature, and situations of otherness that emerged.
The study enabled grasping the means of social navigation constructed by the informants as a way to circumvent the bureaucratic, impersonal, and hierarchical nature typical of healthcare services. The use of Hyperdia groups to facilitate access to primary healthcare revealed the attempts to introduce the logic of interpersonal relationships, interpretations, the production of meanings, of the symbolic, the completeness of being and its needs, in these contexts. At the same time, the Hyperdia groups exposed the weights and scales that enable interference in personal relationships with the universal law imposed by health policy. These abnormalities that are produced are manifested in the "privileges" conferred onto the groups' participants.
Additionally, we presented the meanings assigned to the orientations regarding DM and the information on it that were transmitted during the groups' meetings. Such meanings express the interpretations of the informants concerning medical speech and the naturalized terms such as "control" and "exam". This study's informants view the groups as spaces to share knowledge and experiences. Even though these exchanges were confined to small groups in side conversations when the professionals had not yet arrived (before the meetings started), they influenced the daily coping with the chronic disease.
Finally, the meanings discussed here concerning the Hyperdia groups may serve as a basis for the actions of healthcare workers coordinating these groups based on the observation of the cultural universe of these individuals seeking professional care in the various therapeutic devices available within SUS.