Evaluation of an educational booklet about childcare promotion from the family's perception regarding health and citizenship

Abstracts

Este estudo avalia o instrumento de promoção ao cuidado infantil, a cartilha educativa Toda Hora é Hora de Cuidar, através da análise da percepção dos cuidadores sobre os temas por ela discutidos. Estudo descritivo, utilizando-se das abordagens quantitativa e qualitativa como complementaridade, realizado com 89 cuidadores familiares, usuários do Programa de Saúde da Família, na cidade de São Paulo. Observou-se uma predominância de mães, com ensino fundamental incompleto que relataram compreensão e interesse pelos conteúdos da cartilha. O conceito sobre o cuidado com a criança aparece enquanto ação afetiva e de labor. A Unidade Básica de Saúde se destaca como importante apoio social em detrimento de outras instituições. Conclui-se que existem evidências de efetividade da cartilha como instrumento promotor de habilidades e potenciais da comunidade, família e indivíduos, sendo importante o uso de instrumentos facilitadores do processo de aprendizado com enfoque na promoção da saúde e do empowerment das comunidades.

Promoção da saúde; Educação em saúde; Cuidado da criança; Família

ORIGINAL ARTICLE

Evaluation of an educational booklet about childcare promotion from the family's perception regarding health and citizenship^*

Evaluación de una cartilla educativa de promoción del cuidado del niño a partir de la percepción de la familia respecto a temas de salud y ciudadanía

Monica Lilia Vigna Silva Grippo^I; Lislaine Aparecida Fracolli^II

^IMaster's degree student at the Collective Health Department at School of Nursing, University of São Paulo (EEUSP) São Paulo, SP, Brazil. [e-mail]

^IIAssistant Professor at the Collective Health Department at School of Nursing, University of São Paulo (EEUSP)São Paulo, SP, Brazil. [e-mail]

^{Correspondence addressed to}

ABSTRACT

This study evaluates the instrument of childcare promotion, the educational booklet Toda hora é hora de cuidar (Anytime is time to care), through the analysis of the caregivers' perception regarding the issues discussed in the booklet. This is a descriptive study using the quantitative and qualitative approaches. Interviews were carried out with 89 family caregivers, users of the Family Health Program in the city of São Paulo. It was observed that most mothers had not completed basic education, and reported the booklet contents were understandable and interesting. The concept regarding childcare was related to affective and work activities. Compared to other institutions, the Basic Health Unit stands out as an important social support. In conclusion, evidence shows that the booklet is effective as an instrument to promote skills and potentials of the community, family and individuals. Furthermore, it is important to use instruments that facilitate the learning process focused on health promotion and community empowerment.

Keywords: Health promotion; Health education; Child care; Family.

RESUMEN

En este estudio se evalúa el instrumento de promoción al cuidado infantil, la cartilla educativa Toda hora é hora de cuidar (Toda hora es hora de cuidar), a través del análisis de la percepción de los cuidadores sobre temas discutidos en éste. Se trata de un estudio descriptivo en el que se utilizó abordajes cuantitativos y cualitativos como complementarios, realizado con 89 cuidadores familiares, usuarios del Programa de Salud de la Familia, en la ciudad de Sao Paulo. Se observó predominio de madres, con educación básica incompleta que relataron comprensión e interés por los contenidos de la cartilla. El concepto sobre el cuidado al niño aparece como acción afectiva y de labor. La Unidad Básica de Salud se destaca como importante apoyo social en detrimento de otras instituciones. Se concluye que existen evidencias de efectividad de la cartilla como instrumento promotor de habilidades y potencialidades de la comunidad, familia e individuos, siendo importante el uso de instrumentos facilitadores del proceso de aprendizaje con enfoque en la promoción de la salud y del empowerment de las comunidades.

Descriptores: Promoción de la salud; Educación en salud; Cuidado del niño; Familia.

INTRODUCTION

Soft technologies for Health Promotion

Health education may be defined as a set of practices and knowledge focused on preventing diseases and promoting health ^(1-2). It represents a resource of knowledge socialization produced in the healthcare field, mediated by interdisciplinary teams aiming at improving quality of life and promoting healthy habits and attitudes. Literature emphasizes basic health care as being in a privileged position to develop educational health practices due to the proximity to territory and population ^(3-4).

For the International Union for Health Promotion and Education, IUHPE, Health Promotion is defined as a process that empowers communities. It is based on equality and considers the participation of the population in health promotion actions as essential. The communities recognize and maximize their knowledge so as to generate the required healthconditions ⁽⁵⁾.

Nowadays, one of the greatest challenges for Brazilian collective health and basic care services is the construction of proposals, and also intervention and health education instruments that resort to highly complex technologies, involving knowledge, abilities and techniques to act in the family core. They should be culturally sensitive regarding people's health, especially when they live in situations of poverty and social inequality ⁽⁶⁾.

Historically, educative proposals in the health field have been characterized as transferences of information and knowledge, with little impact on the subjects' reality. The construction of facilitating instruments in this process should guide citizenship, defining the family as a subject likely to intervene. Hence, favoring the encouragement of co-responsibility and the participation of family caregivers in the process of health promotion and maintenance is one of the roles to be performed by the health teams. The application of technologies should exceed the health information status and be guided towards the production of facilitating instruments that will construct new knowledge and provide subsidies for childcare.

The evaluation of child healthcare promotion should take the subject-family complexity into account, recognizing it as a constitution, development and health problem resolution setting.Therefore, it should attempt to have participative methodological perspectives that favor the dialogue between individuals and professionals, with the purpose of empowering the family. The aim would be to support changes in the environment and in the relationships leading to the development of new forms of behavior that are important to obtain better healthcare results.

With the purpose to provide health, it is necessary for society to adopt positive attitudes. Therefore, the literature recommends the concept of empowerment in health. This is related to the real opportunity that people have to participate and grow. It can be defined as a means to acquire more control over decisions that affect life or as changes to promote equality in the social relations of power ⁽⁷⁾.

The Toda Hora é Hora de Cuidar

(anytime is time to care) booklet

The Toda Hora é Hora de Cuidar⁽⁸⁾ booklet is an operational instrument constructed with the purpose of providing information about childcare, intended to be used by families and Community Health Agents (CHAs). It represents one of the results of the project Nossas Crianças: Janelas de Oportunidades (Our Children: Windows of Opportunities), conceived after the partnership with the Family Health Program (FHP) Coordination of São Paulo Municipal Secretariat with the UNICEF fund signed in 2001. This project aims at producing materials that can become suitable technologies when working with families – mainly, in the perspective of strengthening childcare aspects.

Developed based on the health promotion theoretical background, the booklet presents topics related to children's development, including pregnancy and raising children healthly, which can be applied to families in their daily routines. The booklet draws attention to simple actions, which are often underestimated by parents or people who provide care more often and have a significant impact on child development. The booklet also addresses traditional public healthcare questions such as children hygiene and immunization.

This booklet was distributed to families cared by the FHP in the city of São Paulo, with pregnant women and/or 0-6 year-old children and FHP users in the areas chosen to develop the project.

The booklet was conceived as an instrument to facilitate health education, and its administration was planned with a view to promote discussion among health professionals and relatives who take care of children. It brings fundamental concepts to promote childcare. The professionals chosen to promote these discussions were the CHAs. They are more in touch with the families (the caregivers) because of their visits.

The booklet begins its approach by introducing the gestational period and comprises themes related to childcare in all the significant phases of child development, with emphasis on their biological and psychological formation. It deals with the need of protection and care for life maintenance, especially human life. It raises the discussion of responsibility sharing when it comes to care and considers questions related to gender, emotions, male emotivity and the family's right to happiness.

In the sequence, the booklet continues to bring reflection about topics such as feeding, emphasizing the possibility of a balanced nutrition, even when there are financial difficulties, and the importance of establishing habits and routines such as regularity regarding food provision hours. It also describes breast-feeding as a source of protection, affective relationship and care.

It points hygiene as a basic need to maintain health and to exercise healthy habits, noting the valuation of self-care and self-esteem. Yet, it deals with specific attitudes to detect signs and symptoms of the most common diseases in childhood such as fevers, dehydration and pneumonia. In addition, it warns about domestic accidents in relation to the epidemiologic profile of Brazilian children morbimortality.

The booklet ends after focusing on the fundamental rights related to the Statute of Children and Adolescents, pointing out themes such as the right to education, health, leisure, civil register and others.

With a language that is friendly both to professionals and families, and a simple graphic layout (drawings, soft colors for the topics), the booklet calls for reflection about the presented themes. It evokes feelings of solidarity and commitment regarding child and family care. Thus, the caregivers' abilities may be strengthened in relation to the full development of children.

OBJECTIVES

Taking into account the proposal of developing and using a booklet, the objectives of this study were: to contribute to evaluate the effectiveness of the Toda Hora é Hora de Cuidar (anytime is time to care) booklet: to analyze relatives' perception of the themes discussed in the booklet; to identify peoples' acceptance of the booklet; and to characterize family comprehension of the underlying concepts in the booklet.

This study emphasizes on searching traits of effectiveness, understood herein as an initiative that reaches the proposed objectives under uncontrolled conditions⁽⁹⁾, using family caregivers' evaluation about the themes discussed in the booklet. This educational instrument is justified by the need to evaluate this technological resource.

METHOD

This descriptive study, which utilised a quantitative and qualitative analysis of the findings, was performed with 89 family caregivers responsible for 0-59 month-old children. The caregivers were FHP users in the city of São Paulo, from 2005 to 2006.

This research project setting was selected due to the outskirting characterization process of São Paulo. It represents the spatial distribution of the large population, estimated as 10,600,059 inhabitants in 2005, in function of the size of the city (1,509 km²), in addition to high population density, social condition polarities, demographic features, populational growth, income distribution and access to goods and services and life quality. The health units chosen were those with family health modules, located in peripheral regions with a higher population growth, a larger proportion of children and adolescents, which often present worse life conditions, income, and education.

The health care model of the 27 Health Units is in compliance with the FHP guidelines: universal access, search of equality and integrality of actions. In this health pro-motion setting, the proximity of the health team with the population facilitates attachment and the consequent accountability of professionals and the community. Workers' daily actions, such as educational group activities and household visits, help to identify the interviewed families.

In order to collect data, a semi-open interview form was used. There were questions about family constitution, use of the booklet by the family or other means of using it, relatives' acceptance regarding graphic layout and family perception about the underlying concepts of the themes presented. This form was applied in the users' households by previously trained researchers. The instrument registration was written and the dialogues were recorded to complement the required data. The forms consisted of 32 questions, with 11 multiple-choice and 21 open-ended questions.

The quantitative data obtained from the multiple-choice questions were analyzed through the register of the simple frequency of the information obtained. They characterize the social and economic profile of the families. Regarding the booklet, the families' comprehension and approval was analyzed with SPSS (Statistical Package for the Social Sciences), an analytical software. The qualitative analysis (open-ended questions), concerning the characterization of the importance of care, was performed based on the categories obtained from care giving⁽¹⁰⁾ , which considers the work and affective aspects of it.

The necessary ethics procedures to carry out the research were approved by the Ethic Committee of the São Paulo City Hall, number CAAE 0006.0.162.196-05. The participants signed two copies of the consent form, structured in a friendly language, at the moment of data collection.

RESULTS

The initial analyses showed a variation in the number of obtained answers when compared to the overall questions asked to the relatives. This difference occurred due to methodological variations of the different interviewers at the moment when the interviews were performed. These differences are mentioned in the presentation of the findings.

Description of the families in the study

Family Constitution - the families are composed by 4.76 people, in average. Most of them are structured with father, mother and siblings, but also grandparents, uncles/aunts and nephews/nieces. Of 89 families, 59 live Southern region of São Paulo, 16 in the Eastern region, 10 in northern area, and three in the central-western part.

Responsible for childcare - The interviewed relatives are mostly females and mothers of children (97.6%, of the universe of 84 answered interviews). Their ages ranged from 17 to 43 years, with an average age of 29 years. The literacy rate found was 94.2%, and, in average, participants have incomplete basic education (54.7% of the total)

Booklet Evaluation

Regarding access, 70 booklets were distributed by the CHAs while visiting the households and five booklets were given during group activities. Among the units, four of them opted for the content discussion with the caregivers and decided not to hand the booklet back. The average time elapsed from delivery until the moment of the interview was 16 months.

Of the 83 answers obtained, 60 relatives reported that they served as strengthening elements in the relationship with the unit's professionals. The contacts were more common with CHAs (33), followed by nurses (11). The themes discussed were ranked according to Table 1. The topics Protect and Care stand out as the most important in the caregivers' report.

The Sick Child and Accident Prevention topic appears to have less importance among the themes. In the categorized analysis of the caregivers' discourses, it is considerably mentioned in the answers, according to Table 2.

The Children Rights topic is broadly discussed in the caregivers' reports. It was categorized as leisure, education, health, food intake, right to love and be loved, and right to civil register, totalling 185 citations distributed in the answers, as described in Table 3.

The category without specificities was elaborated for the sentences that were explicit or vague, for example: All the rights; the right to everything; All the rights; A bit of everything; All, no exception; Other rights.

It is important to point out from the analysis of the answers about the Other Institutions theme, that the Health Unit is cited more frequently (26 citations out of 71), as a family support resource. Next, Family (18 citations), Neighbors (8), and Church with 7 citations. In addition, the answer that shows that the individuals had never looked for a support network stands out (10 citations).

DISCUSSION

The analysis focuses on a sample of the clientele cared by the CHA in the city of São Paulo, composed primarily by mothers of children living in the peripheral regions of the southern area, and in the other regions to a lesser extent.

Despite the interviewee's good level of literacy (94.2%), the average educational background is incomplete basic education (54.7%). This situation may reflect the gender gap condition, historically determined in Brazil, which characterizes that females spend fewer years in school. They have difficulty in economic and cultural access to other levels such as high school and higher education ⁽¹¹⁾.

Based on the analysis of booklet access and the contents according to the initial Nossas Crianças: Janelas de Oportunidades (Our Children: Windows of Opportunities) project, 78% of the interviewed families had access to the information proposed by the booklet. The CHAs handed and discussed the contents when visiting their households. Hence, the CHA begins to be the element with more contact with the Health Unit after delivering and discussing the educational instrument. Of the 87 answers obtained in the question about booklet conservation, 74% of the relatives alleged not to own a booklet and 67% argue that the booklet served as an opportunity to approach the healthcare team and improve interest in the topics presented in the booklet.

Regarding booklet presentation, the interviewed people (282 citations) classified it as either excellent or good. The interest and the understanding of the booklet themes are mentioned in more than 50% of the answers. With the contents explored during the educational process, there is a positive acceptance of this instrument, serving as a proposal to discuss and favoring empowerment.

Themes such as Protecting and Caring and Child Rights are indicated as the most important by the caregivers. In the qualitative analysis of the discourses, the protecting and caring act appears both as concrete actions and also affective children protection actions. When it comes to describing child rights, it corresponds to those presented and discussed in the booklet, such as the right to civil register and to citizenship.

The theme about the care toward sick children and preventing accidents was the least frequent, numerically and in importance (56% e 80.7%). This result may suggest some previous knowledge from the caregivers as being justified in other answers obtained during the interview. When questioned about the approximation with the professionals, caused by the booklet, they did not come closer because "they know the content by heart; they are experienced; they have always treated their kids well; they have always read magazines; they already knew everything; they solve their doubts with healthcare professionals; they always ask someone in the family".

In another analysis, the same theme is pointed out by the interviewed mothers as one of the most discussed topics with the CHAs. They require further enlightenment on content in the near future (First Aid and Other Health Problems).

Three discourses about care stand out in the answers related to this theme. One refers to interventions in established problems (taking to the doctor when sick, medicating with commercial medication or home-made medication). The other one refers to preventive care actions (taking to the doctor regularly, preventing disease). The last one refers to an affective status (pampering, being concerned).

The focus on care symbolizing affection and human relationship is highlighted in the booklet through the Affection Node history, which was cited as the focus of interest and satisfaction by the relatives.

The Learning, Food Intake and Hygiene topics obtained several responses that showed predominance of required care for children healthy development. The hygiene questions are related to learning and care with food (Hygiene Education; Food Washing, Washing and Preparing Foods) and care understood as affection is pointed out in the answers concerning the three theme topics (Sometimes eating what they like; Not forcing them to eat anything; I do care – food, hygiene and learning; I do not argue and teach tenderly).

The other themes were also referred to as relevant and their discourses expressed concern and family attitudes toward basic care for children healthy development.

CONCLUSIONS

By analyzing the set of caregivers' reports about the importance of care and their daily actions, it may be inferred that the proposal of constructing knowledge and empowerment is likely to be considered by health professionals dealing with children's health.

It is implemented through an instrument that approaches the previously trained professionals regarding health knowledge (in this study, the booklet themes). Furthermore, it is important to establish a relationship between learners and instructors. Essential and basic information that subsidizes the several forms of caring was positively achieved.

The findings suggest that the intervention with the Toda Hora é Hora de Cuidar (anytime is time to care) booklet was effective. It was perceived as an instrument to promote children's health and may be considered as a facilitating element to access the health services. Furthermore, the booklet enables the family-health professional approximation, which triggers involvement and participation of the individuals in reorganizing the services. This is one of the strategies appointed by the Ottawa Charter ⁽¹²⁾.

There is the perspective of simple technology, promoting potential abilities in the community, family and individuals. Effectiveness traits appear in the families' report when they demonstrate interest and understanding about themes such as fundamental rights, violence and the construction of healthy relationships around family and community.

Fundamental human rights, the problematic of poverty and violence and the construction of healthy relationships around families and communities are assumptions and basic guidelines of several documents of international institutions, such as the World Health Organization (WHO) and Pan-American Health Organization (PAOH), which regulate health promotion and education.

Questions of affectivity and protecting care are valued by the interviewed caregivers. This care transposed to the living beings constitutes the theory of care needs and ethical principles towards women and girls, children and the environment, as the only form of maintaining planetary life, as proposed by the Earth Charter, document pending approval at the WHO.

Community integration in the perspective of community action reinforcement and social network construction appears as evidence in the answers that value the importance of the organizations and resources available. The support network appears in relation to other relatives, non-governmental institutions, community projects, religious institutions and solidarity with disadvantaged people. There is the need to strengthen the other resources available and public social policies to promote a healthy life.

Initiatives to construct a facilitating instrument of the learning process aiming at promoting health through the assisted community empowerment such as Nossas Crianças: Janelas de Oportunidades (Our Children: Windows of Opportunities), should be constantly encouraged and incorporated by the Basic Health Care team services. The HFP Units, which are services closer to communities, represent the likelihood of reorientation of the health care model. They should be considered as privileged places for the development of new practices in education for the promotion of health and citizenship.

REFERENCES

Received: 03/27/2007

Approved: 09/18/2007

• 1. Costa M, López E. Educación para la salud. Madrid: Pirámide; 1996.
• 2. Czeresnia D, Freitas CM, organizadores. Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: FIOCRUZ; 2003.
• 3. Vasconcelos EM. Educação popular nos serviços de saúde. São Paulo: Hucitec; 1989.
• 4. Vasconcelos EM. Educação popular e a atenção à saúde da família. São Paulo: Hucitec; 1999.
• 5. Nishtar S. Community health promotion: a step further. Promot Educ. 2007;14(2):61-2,109-10, 124-5.
• 6. Trad LAB, Bastos ACS. O impacto sócio cultural do Programa de Saúde da Família (PSF): uma proposta de avaliação. Cad Saúde Pública. 1998;14(2):429-35.
• 7. Becker D, Edmundo K, Nunes NR, Bonatto D, Souza R. Empowerment e avaliação participativa em um programa de desenvolvimento local e promoção da saúde. Ciênc Saúde Coletiva. 2004;9(3):655-67.
• 8. São Paulo (Cidade). Secretaria Municipal da Saúde. Programa Saúde da Família. Toda hora é hora de cuidar: manual de apoio [texto na Internet]. São Paulo: UNICEF; 2003 [citado 2005 jul. 20]. Disponível em: http://www.unicef.org/brazil/pt/manualtodahora.pdf
• 9. Salazar L, Vélez JA. Hacia la busqueda de efectividad en promocion de la salud en América Latina.Ciênc Saúde Coletiva. 2004;9(3):725-30.
• 10. Boff L. Saber cuidar: ética do humano, compaixão pela terra. Petrópolis: Vozes; 1999.
• 11. Beltrão KI, Alves JED. A reversão do hiato de gênero na educação brasileira no século XX. In: Anais do 14º Encontro Nacional de Estudos Populacionais; 2004 set. 20-24; Caxambu, BR [evento na Internet]. Belo Horizonte: ABEP; 2004 [citado 2005 jul. 20]. Disponível em: http://www.abep.nepo.unicamp.br/site_eventos_abep/PDF/ABEP2004_111.pdf
• 12. Organização Pan-Americana Saúde (OPAS). Carta de Ottawa. Primeria Conferência Internacional sobre Promoção da Saúde; 1986; Ottawa [texto na Internet]. Brasília; 2005. [citado 2005 jul. 20]. Disponível em: http://www.opas.org.br/coletiva/uploadArq/Ottawa.pdf

Correspondence addressed to:

Mônica Lilia Vigna Silva Grippo

Rua Willian Booth, 410 - Jardim Paulicéia

Zip Code 13060-074 - Campinas, SP, Brazil

Publication Dates

• Publication in this collection
  19 Sept 2008
• Date of issue
  Sept 2008

History

• Accepted
  18 Sept 2007
• Received
  27 Mar 2007