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Therapeutic factors in a group of health promotion for the elderly * * Adapted from the dissertation “O grupo é o nosso remédio: lições de um grupo de promoção da saúde de idosos”, Nursing college of the Universidade Federal de Goiás, 2012.

Abstracts

The aim of this study was to identify therapeutic factors presented in a group of health promotion for the elderly. This is a descriptive, exploratory study with a qualitative approach. Data were collected between December 2010 and April 2011 in focal groups that included participants and their coordinators. Results were submitted to content analysis and thematic approach. Findings showed convergence of answers among participants, who indicated resonance and complementarity in identification of the following therapeutic factors: cohesion, introduction of hope, socialization, information sharing, existential factors, altruism, interpersonal relationships, and universal learning. The identification of these factors indicates the therapeutic potential of focal groups, especially for attending to the needs of elderly people, keeping these patients healthy, and strengthening their feelings of love and life, and being part of a social group.

Aged; Group structure; Health Promotion; Health Services for the Aged; Geriatric nursing


O objetivo do estudo foi identificar fatores terapêuticos presentes em grupo de promoção da saúde de idosos. Estudo descritivo exploratório com abordagem qualitativa, cujos dados foram coletados por meio de grupos focais realizados com participantes do grupo e suas coordenadoras, entre dezembro de 2010 e abril de 2011. Os dados foram submetidos a análise de conteúdo, modalidade temática. Os achados mostraram convergência de respostas entre os participantes da pesquisa, indicando ressonância e complementaridade na identificação dos fatores terapêuticos coesão, instilação de esperança, socialização, compartilhamento de informações, fatores existenciais, altruísmo, aprendizagem interpessoal e universalidade. A identificação desses vários fatores no grupo estudado comprova seu potencial terapêutico, especialmente por atender as necessidades dos idosos, mantê-los saudáveis, fortalecer o sentimento de amor pela vida e pertença a um grupo social.

Idoso; Estrutura de Grupo; Promoção da Saúde; Serviços de Saúde para Idosos; Enfermagem geriátrica


El objetivo del estudio fue identificar los factores terapéuticos identificados en grupo de promoción de la salud para adultos mayores. Estudio exploratorio descriptivo de abordaje cualitativo, cuyos datos fueron recolectados a través de grupos focales realizados con los participantes del grupo y sus coordinadores, entre diciembre del 2010 y abril del 2011. Los datos fueron sometidos al análisis de contenido, con modalidad temática. Los resultados mostraron convergencia de las respuestas entre los participantes de la investigación, lo que indica resonancia y complementariedad en la identificación de factores terapéuticos: cohesión, instilación de la esperanza, socialización, intercambio de informaciones, factores existenciales, altruismo, aprendizaje interpersonal y universalidad. Los resultados apoyan la conclusión que los factores terapéuticos identificados comprueban el potencial terapéutico del grupo estudiado, especialmente por atender a las necesidades de los adultos mayores, mantenerlos saludables, reforzar el sentimiento de amor por la vida y pertenencia a un grupo social.

Anciano; Estructura de grupo; Promoción de la Salud; Servicios de Salud para Ancianos; Enfermería geriátrica


INTRODUCTION

A group, as a tool for health interventions, could be a transformative agent when used as a space to express thoughts and feelings, exchange experiences, provide health education, improve quality of life, and enhance socialization ( 1. Stang I, Mittelmark MB. Intervention to enhance empowerment in breast cancer self-help groups. Nurs Inq. 2010;17(1):47-57.

. Fernandes MTO, Silva LB, Soares SM. Utilização de tecnologias no trabalho com grupos de diabéticos e hipertensos na Saúde da Família. Ciênc Saúde Coletiva. 2011;16 Supl 1:1331-40.
- 3. Combinato DS, Dalla Vecchia M, Lopes EG, Manoel RA, Marino HD, Oliveira ACS, et al. Grupos de Conversa: saúde da pessoa idosa na estratégia saúde da família. Psicol Soc. 2010;22(3):558-68. ) . A group can be defined as a set of people who interact with the aim of widening their perceptions and change their behaviors, thereby favoring the development of autonomy and confronting situations that cause avoidable suffering ( 3. Combinato DS, Dalla Vecchia M, Lopes EG, Manoel RA, Marino HD, Oliveira ACS, et al. Grupos de Conversa: saúde da pessoa idosa na estratégia saúde da família. Psicol Soc. 2010;22(3):558-68. ) . It also enables the study of subjects in the social environment into which they are inserted ( 3. Combinato DS, Dalla Vecchia M, Lopes EG, Manoel RA, Marino HD, Oliveira ACS, et al. Grupos de Conversa: saúde da pessoa idosa na estratégia saúde da família. Psicol Soc. 2010;22(3):558-68. - 4. Schossler AB, Carlos SA. Por uma visualização do processo grupal. Psico [Internet]. 2006 [citado 2011 fev. 25];37(2). Available from: http://revistaseletronicas.pucrs.br/face/ojs/index.php/revistapsico/article/viewFile/1430/1123
http://revistaseletronicas.pucrs.br/face...
) .

In a group setting, different modes of existences are encountered, which produces subjectivity. Therefore, the group process is done by the meanings of situations experienced by subjects from and in the group; this leads to continuous mobilizing of phenomena of changes and concerns with reality ( 4. Schossler AB, Carlos SA. Por uma visualização do processo grupal. Psico [Internet]. 2006 [citado 2011 fev. 25];37(2). Available from: http://revistaseletronicas.pucrs.br/face/ojs/index.php/revistapsico/article/viewFile/1430/1123
http://revistaseletronicas.pucrs.br/face...
) . A group setting can attend to the requirements of the participants, allows the professional facilitator to assume a horizontal position in relation to the other participants, and encourages cooperative knowledge building ( 5. Munari DB, Lucchese R, Medeiros M. Reflexões sobre o uso de atividades grupais na atenção a portadores de doenças crônicas. Ciênc Cuid Saúde. 2009;8 Supl:148-54.

. Santos LF, Oliveira LMAC, Munari DB, Peixoto MKAV, Silva CC, Ferreira ACM, et al. Grupo de suporte como estratégia para assistência de enfermagem à família de recém-nascidos hospitalizados. Rev Eletr Enferm [Internet]. 2012 [citado 2012 dez. 20];14(1):42-9. Available from: http://www.fen.ufg.br/fen_revista/v14/n1/pdf/v14n1a05.pdf
http://www.fen.ufg.br/fen_revista/v14/n1...
- 7. Tavares DMS, Dias FA, Munari DB. Quality of life of the elderly and participation in group educational activities. Acta Paul Enferm. 2012;25(4):601-6. ) .

An efficient group that can changes must be organized and developed according to its members’ needs, which are key elements for revision and reorganization of the group’s objectives. Such changes are possible because of therapeutic factors (TFs) that human groups are able to develop. These mechanisms help group members understand the members’ difficulties and common needs and acquire new and more appropriate behaviors ( 8. Yalom ID, Leszcz M. Group psychotherapy: theory and practice. Porto Alegre: Artes Médicas; 2006. ) .

As described in the literature ( 8. Yalom ID, Leszcz M. Group psychotherapy: theory and practice. Porto Alegre: Artes Médicas; 2006. ) , there are 11 Ts: introduction of hope, universality, cohesion, information sharing, altruism, development of socialization technique, mimicking of behavior, interpersonal learning, existential factors, catharsis, and corrective recapitulation of the primary family group. Although these TFs derive from psychotherapy groups, they can be use used to guide groups of differing purposes.

Identification and analysis of these factors can help health professionals to manage groups, particularly by enabling them to monitor group achievements and limitations. Evidence in the literature indicates that study of TFs helps in guiding coordination in order to achieve more efficient results, with the objective of reaching the group’s highest therapeutic potential ( 9. Santos LF, Oliveira LMC, Munari DB, Peixoto MKV, Barbosa MA. Therapeutic factors in group support from the perspective of the coordinators and group members. Acta Paul Enferm. 2012;25(1):122-7.

10 . Erdman SA. Therapeutic factors in group counseling: implications for audiologic rehabilitation. ASHA Perspect [Internet]. 2009 [cited 2010 Sept 29];16(1): Available from: http://div7perspectives.asha.org/cgi/reprint/16/1/15
http://div7perspectives.asha.org/cgi/rep...

11 . Oliveira LMAC, Medeiros M, Brasil VV, Oliveira PMC, Munari DB. Use of therapeutic factors for the evaluation of results in support groups. Acta Paul Enferm. 2008;21(3):432-8.

12 . Oliveira NF, Munari DB, Bachion MM, Santos WS, Santos QR. Therapeutic factors in a group of people with diabetes. Rev Esc Enferm USP [Internet]. 2009 [cited 2012 Dec 20];43(3):558-65. Available from: http://www.scielo.br/pdf/reeusp/v43n3/en_a09v43n3.pdf
http://www.scielo.br/pdf/reeusp/v43n3/en...
- 1313 . Choi YH, Park KH. Therapeutic factors of cognitive behavioral group treatment for social phobia. J Korean Med Sci. 2006;21(2):333-6. ) .

In Brazil, especially in primary health care (PHC), health promotion groups have been used as strategy in government programs that guide professional behavior ( 5. Munari DB, Lucchese R, Medeiros M. Reflexões sobre o uso de atividades grupais na atenção a portadores de doenças crônicas. Ciênc Cuid Saúde. 2009;8 Supl:148-54. , 1414 . Horta NC, Sena RR, Silva MEO, Tavares TS, Caldeira IM. A prática de grupos como possibilidade de promoção da saúde no Programa Saúde da Família. Rev APS. 2009;12(3):293-301. ) . The main focus of these groups are to develop autonomy ( 2. Fernandes MTO, Silva LB, Soares SM. Utilização de tecnologias no trabalho com grupos de diabéticos e hipertensos na Saúde da Família. Ciênc Saúde Coletiva. 2011;16 Supl 1:1331-40. , 5. Munari DB, Lucchese R, Medeiros M. Reflexões sobre o uso de atividades grupais na atenção a portadores de doenças crônicas. Ciênc Cuid Saúde. 2009;8 Supl:148-54. ) , exchange experiences, provide health education, ( 1515 . Dias VP, Silveira DT, Witt RR. Educação em saúde: protocolo para o trabalho de grupos em Atenção Primária à Saúde. Rev APS. 2009;12(2):221-7. ) and strengthen treatment adherence for chronic diseases ( 2. Fernandes MTO, Silva LB, Soares SM. Utilização de tecnologias no trabalho com grupos de diabéticos e hipertensos na Saúde da Família. Ciênc Saúde Coletiva. 2011;16 Supl 1:1331-40. , 5. Munari DB, Lucchese R, Medeiros M. Reflexões sobre o uso de atividades grupais na atenção a portadores de doenças crônicas. Ciênc Cuid Saúde. 2009;8 Supl:148-54. ) . Elderly people are a target audience for these actions ( 1616 . Brasil. Ministério da Saúde; Secretaria de Atenção à Saúde. Envelhecimento e saúde da pessoa idosa. Brasília; 2010. (Cadernos de Atenção Básica, 19). ) . A literature review of the use of group activities in the aging population shows the potential of this strategy for health promotion for this age group in PHC, mainly in countries such as Brazil and others from Latin America ( 1717 . Victor JF, Vascocelos FF, Araújo AR, Ximenes LB, Araújo TL. Grupo Feliz Idade: cuidado de enfermagem para a promoção da saúde na terceira idade. Rev Esc Enferm USP. 2007;41(4):724-30.

18 . Mazo GZ, Cardoso ASA, Dias RG, Balbé GP, Virtuoso JF. Do diagnóstico à ação: grupo de estudos da terceira idade: alternativa para a promoção do envelhecimento ativo. Rev Bras Ativ Física Saúde. 2009;14(1):65-70.

19 . Velásquez V, López L, López H, Cataño N, Muñoz E. Efecto de un programa educativo para cuidadores de personas ancianas: una perspectiva cultural. Rev Salud Publica (Bogota). 2011;13(3):458-69.
- 2020 . Sapag JC, Lange I, Campos S, Piette JD. Estrategias innovadoras para el cuidado y el autocuidado de personas con enfermedades crónicas en América Latina. Rev Panam Salud Publica. 2010;27(1):1-9. ) .

Considering evidence on group setting theme and its relevance, we identified a group of elderly patients being coordinated by a community health agent (CHA). We chose to study this group because of the positive results it had achieved, mainly with regard to cohesion, adhesion, and member satisfaction. Taking into account the good results, we sought to identify the presence of TFs that could help us understand how a group formed for health promotion could be effective in elderly people.

Study results could help coordinators of groups for elderly patients reinforce aspects considered positive by the participants and minimize the negative ones and improve understanding of what is essential for an efficient and efficacious group.

METHOD

This descriptive, exploratory study with a qualitative approach included a group of elderly people from a Family Health Unit in Goiânia/GO, Brazil. The group had existed for 13 years and was founded in 2000 by CHAs, who are still coordinators of the group. Every week the group has 90-minute meetings, with regular participation of around 30 individuals. Meetings are coordinated by CHAs, and the main focus is health promotion for elderly people through physical, recreational, and socialization activities. The group is remarkable for its high participation rate, high productivity, constant updating of proposed activities, and dynamic and nondirective conduction and participation not influenced by benefits such as medicine and medical consultations.

Twenty-three aging individuals and six CHAs participated in this study. Participants (group member and coordinators) were included only if they had been in the program for more than six months. Exclusion criteria were occasional participation or withdrawal from the group during data collection. We did not include CHAs whose activity was interrupted for any reason during the data collection period.

Invitation to participate in the study took place after researcher field immersion for six months. During a meeting of the group, the study objective, strategies for data collection, and consent form were presented. All participants read and signed the consent form.

Data were collected from December 2010 to April 2011 using the focal group (FG) technique ( 2121 . Gatti BA. Grupo focal na pesquisa em ciências sociais e humanas. Brasília: Líber Livro; 2005. ) . Two researchers conducted FC sessions; one was the mediator and the other the observer, who was also responsible for recording and registering the meeting. Both researchers had basic training in group dynamics and were supervised by experts in group management and coordination.

To achieve the objective and obtain consistent data, we conducted five FGs. Four of them were conducted with elderly patients (eight participants per group were present on average), and one meeting included all coordinators (six persons present). Meetings were scheduled ahead of time and took place in a private room of the health unit that accommodated all participants comfortably.

FGs with elderly patients started with a theme: The elderly group in my life , and the questions that directed the research were: Why did I become a member of the group? How does the group help me? How do members help the group? What maintains the group’s existence? To the CHAs, the theme presented was The group mission , and the following questions directed the research: How does the group help members? How do members help the group? What maintains the group’s existence?

For data analysis, we used the content analysis technique, thematic approach ( 2222 . Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2007. ) . Specifically, we used the procedure known as boxes ( 2222 . Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2007. ) , adopted with predefined categories for the FGs and elements that characterized them, as described in the literature ( 6. Santos LF, Oliveira LMAC, Munari DB, Peixoto MKAV, Silva CC, Ferreira ACM, et al. Grupo de suporte como estratégia para assistência de enfermagem à família de recém-nascidos hospitalizados. Rev Eletr Enferm [Internet]. 2012 [citado 2012 dez. 20];14(1):42-9. Available from: http://www.fen.ufg.br/fen_revista/v14/n1/pdf/v14n1a05.pdf
http://www.fen.ufg.br/fen_revista/v14/n1...
) . To identify characteristics of the FGs, transcriptions of FG records were analyzed in detail; next, we conducted a preanalysis by an exhaustive, comprehensive review of available reading. For this phase of data organization, we used Atlas.Ti 6 software, which is specific for qualitative data analysis. Finally, the results were assessed and interpreted in the context of the theoretical framework of the study.

RESULTS

Based on analysis of the FG record transcription, we identified 8 of 11 TFs presented by Yalom e Leczcz ( 8. Yalom ID, Leszcz M. Group psychotherapy: theory and practice. Porto Alegre: Artes Médicas; 2006. ) . The same TF appeared only once in the discussion of FGs. Chart 1 describes the TFs registered during sessions, identified by numbers: FG1, FG2, and FG4 corresponded to FGs conducted with elderly patients and FG CHA concerns the FG performed with coordinators.

Eight of 11 TFs were identified in at least one FG, catharsis; corrective recapitulation of primary family group and mimicking of behavior ( 8. Yalom ID, Leszcz M. Group psychotherapy: theory and practice. Porto Alegre: Artes Médicas; 2006. ) were not identified in any FG.

Chart 2 shows TFs from the perspective of the study participants presented during the FGs.

DISCUSSION

Chart 1 shows the agreement of TFs perceived by both the elderly participants and the CHAs. All TFs identified in FG CHA were also seen in the elderly FGs. The exception was the TF for universality; this was observed in FG1 but not in FG CHA. The lack of the TFs catharsis, corrective recapitulation of primary family group, and mimicking behavior could be attributed to the approach to the group, which was not done with a psychotherapeutic perspective. Studies that included groups with similar characteristics also found that this result was common ( 8. Yalom ID, Leszcz M. Group psychotherapy: theory and practice. Porto Alegre: Artes Médicas; 2006.

. Santos LF, Oliveira LMC, Munari DB, Peixoto MKV, Barbosa MA. Therapeutic factors in group support from the perspective of the coordinators and group members. Acta Paul Enferm. 2012;25(1):122-7.

10 . Erdman SA. Therapeutic factors in group counseling: implications for audiologic rehabilitation. ASHA Perspect [Internet]. 2009 [cited 2010 Sept 29];16(1): Available from: http://div7perspectives.asha.org/cgi/reprint/16/1/15
http://div7perspectives.asha.org/cgi/rep...

11 . Oliveira LMAC, Medeiros M, Brasil VV, Oliveira PMC, Munari DB. Use of therapeutic factors for the evaluation of results in support groups. Acta Paul Enferm. 2008;21(3):432-8.
- 1212 . Oliveira NF, Munari DB, Bachion MM, Santos WS, Santos QR. Therapeutic factors in a group of people with diabetes. Rev Esc Enferm USP [Internet]. 2009 [cited 2012 Dec 20];43(3):558-65. Available from: http://www.scielo.br/pdf/reeusp/v43n3/en_a09v43n3.pdf
http://www.scielo.br/pdf/reeusp/v43n3/en...
) .

Chart 1
– Therapeutic factors identified in focal groups with elderly patients and group coordinators: Goiânia, GO, 2011.

The agreement between TFs identified in the FGs for the elderly patients and FG CHA revealed accordance and cohesion among the participants and group coordinators; this aspect is sometimes a source of conflict and misunderstanding among users and professionals ( 5. Munari DB, Lucchese R, Medeiros M. Reflexões sobre o uso de atividades grupais na atenção a portadores de doenças crônicas. Ciênc Cuid Saúde. 2009;8 Supl:148-54. , 1919 . Velásquez V, López L, López H, Cataño N, Muñoz E. Efecto de un programa educativo para cuidadores de personas ancianas: una perspectiva cultural. Rev Salud Publica (Bogota). 2011;13(3):458-69. ) .

Analysis of the content in Chart 1 articulation of the findings in Chart 2 verifies that TF cohesion , delimited by significant bonds of affinity and closeness among members, shows the potential of union and friendship among participants and with coordinators. Cohesion was present in all FGs, indicating that mutual trust enables cohesion and reflecting the affectivity, affection, and acceptance in the FGs ( 8. Yalom ID, Leszcz M. Group psychotherapy: theory and practice. Porto Alegre: Artes Médicas; 2006.

. Santos LF, Oliveira LMC, Munari DB, Peixoto MKV, Barbosa MA. Therapeutic factors in group support from the perspective of the coordinators and group members. Acta Paul Enferm. 2012;25(1):122-7.
- 1010 . Erdman SA. Therapeutic factors in group counseling: implications for audiologic rehabilitation. ASHA Perspect [Internet]. 2009 [cited 2010 Sept 29];16(1): Available from: http://div7perspectives.asha.org/cgi/reprint/16/1/15
http://div7perspectives.asha.org/cgi/rep...
) ; it is also evidence that the group is a space where elderly patients felt welcomed and accepted. Other studies also indicated that the presence of trust among members of a group facilitate effective participation ( 9. Santos LF, Oliveira LMC, Munari DB, Peixoto MKV, Barbosa MA. Therapeutic factors in group support from the perspective of the coordinators and group members. Acta Paul Enferm. 2012;25(1):122-7.

10 . Erdman SA. Therapeutic factors in group counseling: implications for audiologic rehabilitation. ASHA Perspect [Internet]. 2009 [cited 2010 Sept 29];16(1): Available from: http://div7perspectives.asha.org/cgi/reprint/16/1/15
http://div7perspectives.asha.org/cgi/rep...

11 . Oliveira LMAC, Medeiros M, Brasil VV, Oliveira PMC, Munari DB. Use of therapeutic factors for the evaluation of results in support groups. Acta Paul Enferm. 2008;21(3):432-8.
- 1212 . Oliveira NF, Munari DB, Bachion MM, Santos WS, Santos QR. Therapeutic factors in a group of people with diabetes. Rev Esc Enferm USP [Internet]. 2009 [cited 2012 Dec 20];43(3):558-65. Available from: http://www.scielo.br/pdf/reeusp/v43n3/en_a09v43n3.pdf
http://www.scielo.br/pdf/reeusp/v43n3/en...
) .

Cohesion is fundamental for the development of group that seeks to achieve positive results because to be accepted in the group requires trust in the other members; the support of others, in turn, helps improve self-esteem and, as a consequence, motivates members to participate, collaborate, and show each other mutual support ( 8. Yalom ID, Leszcz M. Group psychotherapy: theory and practice. Porto Alegre: Artes Médicas; 2006.

. Santos LF, Oliveira LMC, Munari DB, Peixoto MKV, Barbosa MA. Therapeutic factors in group support from the perspective of the coordinators and group members. Acta Paul Enferm. 2012;25(1):122-7.
- 1010 . Erdman SA. Therapeutic factors in group counseling: implications for audiologic rehabilitation. ASHA Perspect [Internet]. 2009 [cited 2010 Sept 29];16(1): Available from: http://div7perspectives.asha.org/cgi/reprint/16/1/15
http://div7perspectives.asha.org/cgi/rep...
) .

This study investigated TF functions in supportive groups. Cohesion was one of the most frequently identified TFs. Through this TF, members of the group felt that they were united and that they all participated in the group as equals who were mutually supported in a welcoming environment characterized by trust and solicitude ( 9. Santos LF, Oliveira LMC, Munari DB, Peixoto MKV, Barbosa MA. Therapeutic factors in group support from the perspective of the coordinators and group members. Acta Paul Enferm. 2012;25(1):122-7. ) . Cohesion enabled sharing of experiences in a more authentic and sincere manner, which strengthened the group ( 8. Yalom ID, Leszcz M. Group psychotherapy: theory and practice. Porto Alegre: Artes Médicas; 2006. , 1010 . Erdman SA. Therapeutic factors in group counseling: implications for audiologic rehabilitation. ASHA Perspect [Internet]. 2009 [cited 2010 Sept 29];16(1): Available from: http://div7perspectives.asha.org/cgi/reprint/16/1/15
http://div7perspectives.asha.org/cgi/rep...
) .

The TF introduction to hope was also identified in all FGs ( Chart 1 ), and the testimonials in Chart 2 show belief in the group as a space for improvement in health and physical, psychological, and social well-being and for emotional balance. Testimonials from members of the group and coordinators showed that positive results are related to strengthened belief in the possibility of improvement of common problems ( 1212 . Oliveira NF, Munari DB, Bachion MM, Santos WS, Santos QR. Therapeutic factors in a group of people with diabetes. Rev Esc Enferm USP [Internet]. 2009 [cited 2012 Dec 20];43(3):558-65. Available from: http://www.scielo.br/pdf/reeusp/v43n3/en_a09v43n3.pdf
http://www.scielo.br/pdf/reeusp/v43n3/en...
) .

Chart 2
– Therapeutic factors that emerged in testimonial of group members and group coordinators: Goiânia, GO, 2011.

The introduction to hope is important to incentive the person to continuing in the support program ( 8. Yalom ID, Leszcz M. Group psychotherapy: theory and practice. Porto Alegre: Artes Médicas; 2006. , 1010 . Erdman SA. Therapeutic factors in group counseling: implications for audiologic rehabilitation. ASHA Perspect [Internet]. 2009 [cited 2010 Sept 29];16(1): Available from: http://div7perspectives.asha.org/cgi/reprint/16/1/15
http://div7perspectives.asha.org/cgi/rep...
) . This TF also remarkably appeared in a study of multifamily group support for the treatment of anorexia and bulimia; that study found the group provided a sense of optimism that enable the perception that other persons in the group had already improved. Such a situation could increase the feeling of hope in others because they begin to believe that achieving good results is possible when people persist in meeting their goals ( 2323 . Souza LV, Santos MA, Moutra FEGA, Campos-Brustelo TN, Saviolli CMG. Fatores terapêuticos em um grupo de apoio multifamiliar no tratamento da anorexia e bulimia. Rev SPAGESP. 2010;11(2):41-50. ) . Other studies ( 9. Santos LF, Oliveira LMC, Munari DB, Peixoto MKV, Barbosa MA. Therapeutic factors in group support from the perspective of the coordinators and group members. Acta Paul Enferm. 2012;25(1):122-7. , 1111 . Oliveira LMAC, Medeiros M, Brasil VV, Oliveira PMC, Munari DB. Use of therapeutic factors for the evaluation of results in support groups. Acta Paul Enferm. 2008;21(3):432-8. - 1212 . Oliveira NF, Munari DB, Bachion MM, Santos WS, Santos QR. Therapeutic factors in a group of people with diabetes. Rev Esc Enferm USP [Internet]. 2009 [cited 2012 Dec 20];43(3):558-65. Available from: http://www.scielo.br/pdf/reeusp/v43n3/en_a09v43n3.pdf
http://www.scielo.br/pdf/reeusp/v43n3/en...
) reinforce the same finding. Research done in a psychotherapy context ( 1313 . Choi YH, Park KH. Therapeutic factors of cognitive behavioral group treatment for social phobia. J Korean Med Sci. 2006;21(2):333-6. ) showed that this TF is not always present in psychotherapy groups because it depends on the participants’ recognition of the significance of group experience.

Another TFs identified in all FGs was the development of socialization techniques , represented by opportunities mentioned by elderly patients and coordinators for making new friendships, keeping active, and engaging in activities. Because this TF was seen in all FGs, it indicates that this group satisfied the common need of elderly people to overcome social isolation, lack of friends, and minimal leisure opportunities ( 1818 . Mazo GZ, Cardoso ASA, Dias RG, Balbé GP, Virtuoso JF. Do diagnóstico à ação: grupo de estudos da terceira idade: alternativa para a promoção do envelhecimento ativo. Rev Bras Ativ Física Saúde. 2009;14(1):65-70.

19 . Velásquez V, López L, López H, Cataño N, Muñoz E. Efecto de un programa educativo para cuidadores de personas ancianas: una perspectiva cultural. Rev Salud Publica (Bogota). 2011;13(3):458-69.
- 2020 . Sapag JC, Lange I, Campos S, Piette JD. Estrategias innovadoras para el cuidado y el autocuidado de personas con enfermedades crónicas en América Latina. Rev Panam Salud Publica. 2010;27(1):1-9. ) . This TF enables the development of more spontaneous and authentic relationships ( 8. Yalom ID, Leszcz M. Group psychotherapy: theory and practice. Porto Alegre: Artes Médicas; 2006. , 1010 . Erdman SA. Therapeutic factors in group counseling: implications for audiologic rehabilitation. ASHA Perspect [Internet]. 2009 [cited 2010 Sept 29];16(1): Available from: http://div7perspectives.asha.org/cgi/reprint/16/1/15
http://div7perspectives.asha.org/cgi/rep...
) and changes in the elderly patients’ lifestyle because it provides an understanding of behavior characteristics or standards that can lead to difficult social interactions. Thus, it enables elderly persons to rethink these characteristics and change their attitudes ( 1010 . Erdman SA. Therapeutic factors in group counseling: implications for audiologic rehabilitation. ASHA Perspect [Internet]. 2009 [cited 2010 Sept 29];16(1): Available from: http://div7perspectives.asha.org/cgi/reprint/16/1/15
http://div7perspectives.asha.org/cgi/rep...
, 1212 . Oliveira NF, Munari DB, Bachion MM, Santos WS, Santos QR. Therapeutic factors in a group of people with diabetes. Rev Esc Enferm USP [Internet]. 2009 [cited 2012 Dec 20];43(3):558-65. Available from: http://www.scielo.br/pdf/reeusp/v43n3/en_a09v43n3.pdf
http://www.scielo.br/pdf/reeusp/v43n3/en...
) .

The TF information sharing appeared in all FGs and is related to any change in knowledge that occurs in a group context ( 8. Yalom ID, Leszcz M. Group psychotherapy: theory and practice. Porto Alegre: Artes Médicas; 2006.

. Santos LF, Oliveira LMC, Munari DB, Peixoto MKV, Barbosa MA. Therapeutic factors in group support from the perspective of the coordinators and group members. Acta Paul Enferm. 2012;25(1):122-7.
- 1010 . Erdman SA. Therapeutic factors in group counseling: implications for audiologic rehabilitation. ASHA Perspect [Internet]. 2009 [cited 2010 Sept 29];16(1): Available from: http://div7perspectives.asha.org/cgi/reprint/16/1/15
http://div7perspectives.asha.org/cgi/rep...
) . Both members and coordinators emphasized the strategic role of the group in elderly participants’ lives, mainly for access to information. When individuals shared their knowledge with others in the group, this sharing improve their self-esteem and the feeling of being important and useful to others.

Information sharing includes didactic instruction, counseling, suggestions, and practice guidance. Other studies have also evaluated this as a tool for effective evaluation of group intervention ( 8. Yalom ID, Leszcz M. Group psychotherapy: theory and practice. Porto Alegre: Artes Médicas; 2006.

. Santos LF, Oliveira LMC, Munari DB, Peixoto MKV, Barbosa MA. Therapeutic factors in group support from the perspective of the coordinators and group members. Acta Paul Enferm. 2012;25(1):122-7.

10 . Erdman SA. Therapeutic factors in group counseling: implications for audiologic rehabilitation. ASHA Perspect [Internet]. 2009 [cited 2010 Sept 29];16(1): Available from: http://div7perspectives.asha.org/cgi/reprint/16/1/15
http://div7perspectives.asha.org/cgi/rep...

11 . Oliveira LMAC, Medeiros M, Brasil VV, Oliveira PMC, Munari DB. Use of therapeutic factors for the evaluation of results in support groups. Acta Paul Enferm. 2008;21(3):432-8.
- 1212 . Oliveira NF, Munari DB, Bachion MM, Santos WS, Santos QR. Therapeutic factors in a group of people with diabetes. Rev Esc Enferm USP [Internet]. 2009 [cited 2012 Dec 20];43(3):558-65. Available from: http://www.scielo.br/pdf/reeusp/v43n3/en_a09v43n3.pdf
http://www.scielo.br/pdf/reeusp/v43n3/en...
) . Information could be offered by coordinators or by others members of the group, and they are related to learning that occurs in a group context ( 8. Yalom ID, Leszcz M. Group psychotherapy: theory and practice. Porto Alegre: Artes Médicas; 2006.

. Santos LF, Oliveira LMC, Munari DB, Peixoto MKV, Barbosa MA. Therapeutic factors in group support from the perspective of the coordinators and group members. Acta Paul Enferm. 2012;25(1):122-7.
- 1010 . Erdman SA. Therapeutic factors in group counseling: implications for audiologic rehabilitation. ASHA Perspect [Internet]. 2009 [cited 2010 Sept 29];16(1): Available from: http://div7perspectives.asha.org/cgi/reprint/16/1/15
http://div7perspectives.asha.org/cgi/rep...
) . In the ACH FG, the coordinators emphasized the carefulness with which they offered information that would be appropriate for the elderly participants’ life experiences and needs. This aspect is often little valorized by health professionals when dealing with groups of elderly people ( 5. Munari DB, Lucchese R, Medeiros M. Reflexões sobre o uso de atividades grupais na atenção a portadores de doenças crônicas. Ciênc Cuid Saúde. 2009;8 Supl:148-54. , 1818 . Mazo GZ, Cardoso ASA, Dias RG, Balbé GP, Virtuoso JF. Do diagnóstico à ação: grupo de estudos da terceira idade: alternativa para a promoção do envelhecimento ativo. Rev Bras Ativ Física Saúde. 2009;14(1):65-70. ) .

Existence factors constitute a TF related to life changes that a group provided for its members; in general, this change is related to feelings that relate to life, friends, family, and existence itself ( 8. Yalom ID, Leszcz M. Group psychotherapy: theory and practice. Porto Alegre: Artes Médicas; 2006. , 1010 . Erdman SA. Therapeutic factors in group counseling: implications for audiologic rehabilitation. ASHA Perspect [Internet]. 2009 [cited 2010 Sept 29];16(1): Available from: http://div7perspectives.asha.org/cgi/reprint/16/1/15
http://div7perspectives.asha.org/cgi/rep...
) . This TF shows that the group process helps the members deal with issues that concern human existence, such as death, freedom, isolation, and feelings of lack of significance ( 8. Yalom ID, Leszcz M. Group psychotherapy: theory and practice. Porto Alegre: Artes Médicas; 2006.

. Santos LF, Oliveira LMC, Munari DB, Peixoto MKV, Barbosa MA. Therapeutic factors in group support from the perspective of the coordinators and group members. Acta Paul Enferm. 2012;25(1):122-7.
- 1010 . Erdman SA. Therapeutic factors in group counseling: implications for audiologic rehabilitation. ASHA Perspect [Internet]. 2009 [cited 2010 Sept 29];16(1): Available from: http://div7perspectives.asha.org/cgi/reprint/16/1/15
http://div7perspectives.asha.org/cgi/rep...
) . Only one elderly FG did not identify this TF, but Chart 2 indicates that for both elderly group members and coordinators this is an important factor because it enables them to review aspects of life that can be improved with interaction. Elderly participants showed acceptance of difficulties and yet sensitivity, love for others, and satisfaction with life. A study carried out with institutionalized elderly patients showed that a supportive group reinforces satisfaction with life among participants ( 2424 . Wang JJ, Lin YH, Hsieh LY. Effects of gerotranscendence support group on gerotranscendence perspective, depression, and life satisfaction of institutionalized elders. Aging Ment Health. 2011;15(5):580-6. ) .

The TF altruism was also absent in one group. Its presence appeared in testimonials as eagerness to help others and satisfaction in being useful for other members of the group ( 8. Yalom ID, Leszcz M. Group psychotherapy: theory and practice. Porto Alegre: Artes Médicas; 2006. , 1010 . Erdman SA. Therapeutic factors in group counseling: implications for audiologic rehabilitation. ASHA Perspect [Internet]. 2009 [cited 2010 Sept 29];16(1): Available from: http://div7perspectives.asha.org/cgi/reprint/16/1/15
http://div7perspectives.asha.org/cgi/rep...
) . Elderly participants showed availability to help others through friendship, attention, active listening, and affection. It is meaningful that one participant provided financial help so that another could attend a trip. This action showed availability to help others, as well as the accompanying personal satisfaction, and shows that this TF is an indicator of good interactions among members. The group context enables a close relationship among members, which stimulate the mutual support ( 8. Yalom ID, Leszcz M. Group psychotherapy: theory and practice. Porto Alegre: Artes Médicas; 2006. , 1010 . Erdman SA. Therapeutic factors in group counseling: implications for audiologic rehabilitation. ASHA Perspect [Internet]. 2009 [cited 2010 Sept 29];16(1): Available from: http://div7perspectives.asha.org/cgi/reprint/16/1/15
http://div7perspectives.asha.org/cgi/rep...
, 1212 . Oliveira NF, Munari DB, Bachion MM, Santos WS, Santos QR. Therapeutic factors in a group of people with diabetes. Rev Esc Enferm USP [Internet]. 2009 [cited 2012 Dec 20];43(3):558-65. Available from: http://www.scielo.br/pdf/reeusp/v43n3/en_a09v43n3.pdf
http://www.scielo.br/pdf/reeusp/v43n3/en...
, 2323 . Souza LV, Santos MA, Moutra FEGA, Campos-Brustelo TN, Saviolli CMG. Fatores terapêuticos em um grupo de apoio multifamiliar no tratamento da anorexia e bulimia. Rev SPAGESP. 2010;11(2):41-50. ) .

Chart 2 shows that from the coordinators’ perspective, altruism is identified by the selflessness and total involvement of CHA in conducting the group. Their responses indicate how such an attitude is valuable for the work developed in the group and for therapeutic potency. Perhaps this is responsible for the high cohesion, adhesion, and satisfaction of participants. Such an indicator should be used by coordinators to guide their planning and development of the group, especially those directed at an elderly population.

Interpersonal learning is represented by changes in the way that members related among themselves and of learning something never experienced before ( 8. Yalom ID, Leszcz M. Group psychotherapy: theory and practice. Porto Alegre: Artes Médicas; 2006. , 1010 . Erdman SA. Therapeutic factors in group counseling: implications for audiologic rehabilitation. ASHA Perspect [Internet]. 2009 [cited 2010 Sept 29];16(1): Available from: http://div7perspectives.asha.org/cgi/reprint/16/1/15
http://div7perspectives.asha.org/cgi/rep...
) . Findings showed that the group is a space for changes, and it was evident through the elderly participants’ and coordinators’ availability to learn by interactions.

Evidence points out that the same behavior occurs both in psychotherapy groups and in that that do not use a psychotherapy perspective. ( 1111 . Oliveira LMAC, Medeiros M, Brasil VV, Oliveira PMC, Munari DB. Use of therapeutic factors for the evaluation of results in support groups. Acta Paul Enferm. 2008;21(3):432-8.

12 . Oliveira NF, Munari DB, Bachion MM, Santos WS, Santos QR. Therapeutic factors in a group of people with diabetes. Rev Esc Enferm USP [Internet]. 2009 [cited 2012 Dec 20];43(3):558-65. Available from: http://www.scielo.br/pdf/reeusp/v43n3/en_a09v43n3.pdf
http://www.scielo.br/pdf/reeusp/v43n3/en...
- 1313 . Choi YH, Park KH. Therapeutic factors of cognitive behavioral group treatment for social phobia. J Korean Med Sci. 2006;21(2):333-6. ) Interpersonal learning was the most evident factor in a study that indicated an action should be first linked to the owner and then related to the other participants. This approach would lead to learning with others or from others ( 2323 . Souza LV, Santos MA, Moutra FEGA, Campos-Brustelo TN, Saviolli CMG. Fatores terapêuticos em um grupo de apoio multifamiliar no tratamento da anorexia e bulimia. Rev SPAGESP. 2010;11(2):41-50. ) .

Universality was identified in one elderly FG. The testimonial showing this TF reveals that group participation enabled the understanding that the person’s problems were not unique and that when he or she looked around, there were persons with similar problems. After that, the person became more resilient with his or her own situation. Universality enables the perception that someone is not unique in dealing with a specific situation, that others are facing similar difficulties and reasons for being unhappy, and that no one is completely different from the others ( 8. Yalom ID, Leszcz M. Group psychotherapy: theory and practice. Porto Alegre: Artes Médicas; 2006.

. Santos LF, Oliveira LMC, Munari DB, Peixoto MKV, Barbosa MA. Therapeutic factors in group support from the perspective of the coordinators and group members. Acta Paul Enferm. 2012;25(1):122-7.
- 1010 . Erdman SA. Therapeutic factors in group counseling: implications for audiologic rehabilitation. ASHA Perspect [Internet]. 2009 [cited 2010 Sept 29];16(1): Available from: http://div7perspectives.asha.org/cgi/reprint/16/1/15
http://div7perspectives.asha.org/cgi/rep...
) .

Because the TF of universality is more common in homogeneous groups ( 8. Yalom ID, Leszcz M. Group psychotherapy: theory and practice. Porto Alegre: Artes Médicas; 2006. ) but was absent in three of the four elderly FGs, we believe that this indicator was neglected during data collection (which used specific questions to identify TFs) because of inappropriate direction. The presence of TFs was identified using only dialogue from the group for interpretation and its relation with each TF characteristic. Another possible reason is the type of approach; TFs can present in different ways according to dimensions such as therapeutic approach and type of disease ( 1313 . Choi YH, Park KH. Therapeutic factors of cognitive behavioral group treatment for social phobia. J Korean Med Sci. 2006;21(2):333-6. ) .

CONCLUSION

From the objective of identifying TFs present in a health promotion group for elderly people, we expected to find evidence on aspects that characterize TFs in this context and that signal how to conduct this type of group efficiently and effectively.

Testimonial analysis in FGs that referred to TFs enabled us to conclude that the studied group is therapeutic because it attended to the needs of elderly participants, kept the participants healthy, strengthened their feelings of love, and enhanced their feelings of being part of a social group. These aspects are important for maintenance of life activity.

The TFs not identified in this study (catharsis, corrective recapitulation of primary family group, and mimicking behavior) are ones more common in psychotherapy groups; however, the fact that they were not identified during the FGs does not mean they do not exist in this group. Their absence in testimonials could represent a limitation of the study methods, which were limited to content expressed from questions presented for discussion in the FGs and did not present direct question that would help individuals identify several TFs.

The strong presence of TFs in testimonials of both the elderly participants and coordinators show that although TFs had been described as therapeutic elements of psychotherapy groups, they also can be identified in other types of groups. In addition, they are important parameters for evaluating and revising the group process; their presence indicates that conduction of the group is in the right direction, whereas its absence indicates the need for change in group management.

These findings, although confined to a specific group, could be generalized to other groups assembled for PHC because they make evident the therapeutic benefits of this care modality. A limitation of this practice is the possibility that the group coordinator may lack the ability to plan and systematically evaluate the group or is unprepared to develop the activities.

Anther relevant aspect of the analysis that confirms the therapeutic potential of the group concerns agreement and convergence of content of the FGs with elderly participants and coordinators. This fact could be related to the real efficacy and therapeutic potency of the group, as well as adequate coordination, which refers to the efficacy of community health agent.

We emphasize that a difference in this group from other health services groups (which often offer benefits and require maintenance of attendance) – is the coordinator’s posture toward the group. When coordinators connect the real needs of the group members, listen to the members, and consider their opinions when planning activities, they show how good practices can be applied for group conduction.

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Publication Dates

  • Publication in this collection
    01 Dec 2013

History

  • Received
    07 Aug 2012
  • Accepted
    25 Aug 2013
Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br