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Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.45 no.5 São Paulo Oct. 2011
Approaching the family in the Family Health Strategy: an integrative literature review*
El abordaje a la familia en la estrategia de salud de la familia: una revisión integradora de la literatura
Mariana Cristina Lobato dos Santos Ribeiro SilvaI; Lucía SilvaII; Regina Szylit BoussoIII
M.Sc. in Nursing, University of São Paulo School of Nursing. São
Paulo, SP, Brazil. firstname.lastname@example.org
IIPh.D. student in Nursing, University of São Paulo School of Nursing. Member of the Interdisciplinary Research Group on Losses and Mourning (NIPPEL/USP). Faculty, Undergraduate Nursing Program, Faculdade Marechal Rondon/UNINOVE. São Paulo, SP, Brazil. email@example.com
IIIAssociated Professor, Maternal-Infant and Psychiatric Nursing Department, University of São Paulo School of Nursing. Leader of the Interdisciplinary Research Group on Losses and Mourning (NIPPEL/USP). Member of the Association for Death Education and Counseling (ADEC). São Paulo, SP, Brazil. firstname.lastname@example.org
Today there is consensus regarding the idea that there is mutual influence between the health-disease conditions of family members and family union. Establishing health practice centered on family care is a way to revert the hegemonic disease-centered model, which divides individuals and separate them from their context and socio-cultural values. The Family Health Strategy (FHS) was implemented to reorganize the Brazilian public health system (Sistema Único de Saúde), an each of its teams becomes acquainted with the true situation of the families for which they are responsible. In this sense, an integrative literature was performed to identify the concept of family and the factors associated with the family approach in the FHS. The review identified aspects that contribute to maintaining the fragmented approach in the FHS, as well as aspects that could help overcome towards a model using a family-centered approached.
DESCRIPTORS: Family; Family nursing; Family health; Professional-family relations.
Actualmente, la idea de que las condiciones de salud-enfermedad de los miembros de la familia y la familia como unidad se influencian mutuamente está consolidada. Actuar en salud teniendo como objeto de cuidado a la familia es una forma de reversión del modelo hegemónico enfocado en la enfermedad que fragmenta al individuo y lo separa de su contexto y valores socioculturales. La Estrategia de Salud de la Familia (ESF) se implantó para reorganizar el Sistema Único de Salud; cada equipo es instado a conocer la realidad de las familias por las cuales es responsable. En este sentido, se elaboró una revisión integradora de literatura objetivando identificar el concepto de familia y los factores asociados al abordaje familiar en la ESF. Se identificaron aspectos contributivos para la manutención del abordaje fragmentado en la ESF, así como aspectos que pueden favorecer la superación hacia un modelo de abordaje enfocado en la familia.
DESCRIPTORES: Familia; Enfermería de la familia; Salud de la familia; Relaciones profesional-familia.
The health sector needs to respond to a range of needs, varying from highly complex technological interventions to activities in spaces where people live their daily lives, with a view to enhancing a healthy life.
Thus, a new care model is emerging, focusing on family care and considering the environment, lifestyle and health promotion as its basic foundations(1).
In the family, survival strategies are developed for the present, projects are constructed for the future and the past is assessed(2). Health care practices, beliefs and the values attributed to attitudes and behaviors like food habits, physical exercise, leisure, use of substances like tobacco and alcohol are experienced and learned in the family.
Health care always belonged to the family sphere and home stood out as the locus for health practices(3). During the industrialization period, health care was gradually transferred to the hospital locus(4), excluding families not only from care for their sick members, but also from important family events like birth and death(5).
It was only at the end of the 1970's and the start of the 1980's that health professionals started to develop systematic family care, attempting to create practices that would see to family health(6).
Today, the idea that family members and the family unit's health-disease conditions exert mutual influence has already been consolidated(4). Family health is a concept different from family members' health, in the same way as the family as a system is greater than the sum of its parts. The term "family health", however, is often used with the meaning of health practices directed at each family member individually(4).
Working in health with the family as the care object is a way of reverting the hegemonic, disease-oriented model that fragments individuals and separates them from their context and sociocultural values(7). In the biomedical health care model, family care takes place when a disease emerges in one of its members, and is rarely seen as a group of people who need assessment and intervention(8). Hence, individualized care for family members is privileged, losing its comprehensiveness, so that anxieties, desires, dreams, beliefs, values, relations with other family members and the social context are frequently left aside(7).
In 1994, the Family Health Strategy (FHS) was put in practice as a strategy to reorganize the Unified Health System (SUS) and establish its principles of universalization, equity, comprehensiveness, decentralization, hierarchization and community participation(9). Prioritizing health protection and promotion actions, each health team gets to know the reality of the families they are responsible for through the registering and identifying of their characteristics, gaining sensitivity to the families' needs. Thus, those professionals and the population they monitor create bonds, which facilitate identification and attendance to the community's health problems(9).
In its establishment and expansion process, the FHS has faced several difficulties, many of which are due to the fact that it represents an innovative and counter-hegemonic practice. The assessment and intervention potential of this new practice in family health is rich but, to accomplish it, a context needs to be created in which professionals and families can establish a relation of partnership, trust, regular communication and transparence, as well as cooperation to see to the family's needs(10). The establishment of this context depends on the clarity of the family concept and of theoretical frameworks and instruments that enable professionals to effectively address issues related to the family dynamics.
The family concept should sustain and directly influence aspects related to family approaches in the FHS and, therefore, attempting to explain this concept is important to better understand the practices that take place in this scenario.
In view of this justification, this study aimed to identify the family concept and factors associated with the family approach in the FHS through a review of official Ministry of Health documents and scientific literature published in the last ten years.
With a view to reaching the proposed goals, the following steps of the integrative literature review method were followed: problem identification (the aim of the review was clearly defined), literature search (delimiting key words, data bases and applying the criteria defined to select the papers), assessment and analysis of the obtained data(11-13). In each paper and document, the researchers looked for those aspects that answered the central question: What is the family concept and what factors are associated with the family approach in the FHS?
The search for studies took place between July and September 2008. Initially, a search for official documents was accomplished in the Institutional Database of the Ministry of Health's Virtual Health Library. Among the 79 documents found, three were selected because they addressed the main FHS guidelines, concepts and standardization of its practices.
Then, the scientific literature review was accomplished. The following inclusion criteria were adopted: papers in Portuguese, English and Spanish, published in the last ten years, whose discussion section contained considerations on family care in the FHS, and were indexed in LILACS and MEDLINE.
To accomplish the search, combinations of the following key words were used, which are considered descriptors in DeCS (Health Sciences Descriptors) and MeSH (Medical Subject Headings): Enfermagem Familiar (Family Nursing), PSF (Family Health Program), Saúde da Família (Family Health), Medicina de Família e Comunidade (Family Practice), Relações profissional-família (Professional-Family Relations), Promoção da Saúde (Health Promotion) and Cuidados de Enfermagem (Nursing Care).
In this search, 334 scientific articles were identified in LILACS and 501 in MEDLINE. Abstracts were subject to exploratory reading, after which 25 papers were selected from LILACS and 8 from MEDLINE, which were fully read. After analytic reading of these papers, ten were selected for this study, as they contained aspects that answered the guiding question. Content analysis permitted data organization in thematic categories.
Four thematic categories emerged from content analysis of the publications: 1) the family concept in the guiding documents of the FHS; 2) professional profile and training to work with families, 3) the family approach in the FHS and 4) the FHS' potential to work with families.
It was verified that the family concept is not evidenced in the guiding documents of the FHS. Actions are described that involve the family, focusing on orientation and health surveillance. No actions are specified to see to the family's needs as a system or care unit. The documents underline the need for bonding among the professional team, families and community, with a view to the establishment of more humane relations. The proposed action strategies, however, are directed at specific groups like pregnant women, children under the age of five, hypertensive and diabetic patients.
In the first official document that was analyzed(14), it is affirmed that the family is the object of FHS care and also participates in health care. The family is also a target of health surveillance and care planning, besides the individual care context. It is affirmed that proximity to families makes professionals more humane. Good knowledge of family members and families' social situation is needed to identify care demands. Nevertheless, orientations on how to address these families are not presented.
Based on the analysis of the second document(15), it can be affirmed that the focus on family health demands that professionals have a systematic and comprehensive view of individuals, families and communities. To set up this strategy, the document recommends the establishment of new relations among professionals, families and communities and also presents topics that should be addressed in introductory training for FHS professionals. As for the family, the document recommends identifying and discussing the following aspects: concept, functions, types, role in the community and influence in the health-disease process. These concepts and functions are not presented though, nor is the family's influence in the health-disease process described.
In the third document(9), it is affirmed that the family is the FHS' primary care object and represents the basic core of health care. It is described how many families each team should attend and what aspects should be taken into account during registration: family members, referred morbidities, housing conditions, sanitation and environmental conditions. It is affirmed that one of the teams' tasks is to get to know the reality of the families they are responsible for, emphasizing their social, demographic and epidemiological characteristics. The role of Community Health Agents (CHA) in the identification of individuals and families at risk is reinforced. The document(9) describes families as comprising from newborns to elderly, whose health situations should be accompanied, oriented and monitored.
Hence, although the official documents presented different recommendations, orientations and regulations regarding how to approach the families, no orientations are found about how to conduct professional actions in view of questions raised about the family dynamics.
One can agree with studies affirming that, due to the vague stance on the family concept and approach in the documents that have guided the FHS since its establishment(16-17), the strategy has underlined the individualized and spontaneous-demand centered care model, without taking into account the person's social and family context in health care(18). Although Ministry of Health documents affirmed that the FHS is mainly based on the family theme as an action focus, with a view to reorienting a health model that is guided by collective construction, weaknesses still remain in the implementation of this new model(19).
As for the professionals' profile and training to work with families, some authors(20) affirm that the FHS expects professionals to understand aspects related to family dynamics, functioning, functions, development, social, cultural, demographic and epidemiological characteristics, demanding that they adopt a distinguished attitude, based on respect, ethics and commitment to the families they are responsible for.
Therefore, professionals should privilege actions that enhance the therapeutic relation with health service users(21). These actions should aim for the adoption of conducts that support and strengthen the family(18). To put the FHS proposal in practice, professionals also need to incorporate discussions on the family, as well as to plan health activities based on their experiences in the subjects' life contexts and on family knowledge(19). In addition, professionals should support their practice in the family care process on a clear theoretical framework, and be competent to access and intervene through a cooperative relationship, with aptitude to enter the family's world(8,19).
The ruling biomedical model, however, still exerts strong influence on health professionals' education, limiting their perception of the care object to the individual(19). Hence, a lack of qualified professionals exists in the job market, with the profile to work in this new care model(20). In a study that attempted to get to know nurses' opinion on working with families in the Family Health Strategy (FHS) context, it was found that, although most interviewed professionals participated in the FHS introductory training, only 15% affirmed that, on that occasion, family-related issues were addressed, permitting the conclusion that the lack of contents on the family and emphasis on technical contents regarding the disease, characteristics of the assistential/individual/uniprofessional model, is still predominant at health services, which hampers the practice of FHS principles(20).
Professionals face difficulties to give up the technical intervention method, the directive pedagogy used when the community and the culture that exerts pressure to maintain the health-disease process in this perspective are addressed(17). Hence, the health team's intimacy with the family theme is insufficient, accompanied by a lack of technical knowledge and tradition to develop this new practice.
In that sense, it is fundamental for professionals to seek theoretical support beyond the FHS, in the attempt to overcome the absence of a theoretical-practical framework that sustains and guides inter-relational actions with families, respecting their development cycles and the different moments and characteristics of their life(22).
Working with families demands the rescue of knowledge and practices lost through abusive technology use and the development of teamwork skills(23). The lack of a consensus on family practices can entail great difficulties for care planning and practice.
Analyses and reflections on this work process, however, are fundamental to solve these difficulties, preparing the routes to develop those actions required when the family is the main professional care focus in primary health care(16).
The family approach in the FHS is understood as a consequence of the lack of definition on the family concept and the lack of professional preparation, that is, as a result of the lack of preparation and vagueness about strategies to work with families. Thus, care is often delivered due to the emergence of a disease in one of the family members(8), without any distinction between care for a sick individual who has a family and care for a family that contains a sick individual.
A study accomplished to identify nurses' work process in the FHS in an interior city in São Paulo found that, in their practice, they highlight the individual and curative clinical logic. The researchers observed that, during home visits, the care focus was the sick individual, although professionals affirmed that they visited the family. Thus, the family was seen as someone who contributed to treatment, but not as a social group, one of whose members was influenced by the disease, so that the family dynamics and life changes due to the disease were not considered(24).
Hence, care actions are still curative and individual, despite the search for comprehensive healthcare from a family and community perspective(21). Likewise, a study that aimed to get to know FHS nursing practice in family work in an interior city in Paraná(22) concluded that the focus the nurses intended was the family but that, in practice, activities remained individual, especially directed at persons with a health problem.
Another study, aimed at reflecting on the FHS' potentials and contradictions in the change process of the health care model evidenced that, during home visits, professionals direct their attention at pre-established programs like breastfeeding, hypertension or prevention of some endemic disease. The authors discuss that if, on the one hand, standardization facilitates the program's expansion, on the other, it can simplify and impoverish its range and, thus, the family/community focus is deprived of its characteristics(23).
Finally, despite the lack of preparation and insufficiencies found in practice, the FHS has potential to work with families, showing it as a strategy that permits the encounter between the professional health and family care spheres, entailing different possibilities(19). The theoretical premises of the FHS and the professionals' work context enhance the interaction with families through activities like home visits and orientations(20).
Nurses who participated in a study that investigated FHS nurses' family work practice(22) identified the establishment and maintenance of relations with the family as the base of their work, evidencing a favorable scenario for a critical and reflexive discussion about practice, with a view to overcoming the predominant biomedical model.
It is interesting to observe that, among the ten selected studies, only two(20,22), originating in the same research, presented results from a descriptive-exploratory study about nurses' work with families. The other five studies that specifically investigated this theme were two case studies, a literature review on families' inclusion as the focus of attention in public policies (especially in the FHS) and two theoretical reflection papers that discussed the family's insertion as the focus of attention in the FHS.
It should be highlighted that, although literature on research concerned with focusing on the family approach in the FHS is still incipient, some authors have reported their experience regarding this theme in a very positive way.
In the attempt to describe how a family reacts towards a disease in one of its members, which resources it uses to preserve its stability and what interventions of FHS nurses can be useful and feasible, a study evidenced that, when a reference framework is used that permits apprehending the family as a care unit, the perspective is broadened beyond the individual focus, so that family suffering can be identified and taken care of. Through this approach, interaction with the family is possible and help interventions can be proposed in partnership with that family(25).
A study that aimed to present the experience of assessing families of dependent elderly people from a systemic focus in the FHS context reinforces the need for nurses to seek support in scientific literature and adopt pertinent instruments, so as to contribute to enhance interaction among professionals and families and develop their skills to accomplish the family approach(26).
In that sense, we agree with the definition of some authors mentioned in this review, regarding the relationship the FHS provides between professionals and families, when they affirm that
in this encounter, the care alternatives gain different colors and shapes. Thus, it should be emphasized that everyone lets him/herself get enchanted by the curiosity of knowing the family world and having the opportunity to (re)signify health care practices(19).
Based on the analysis of the reviewed studies, it can be affirmed that there is a lack of studies on FHS professionals' work with families, so as to evidence how this work takes place in these professionals' daily practice. It is believed that the lack of research itself on the theme already discloses the little interest it arouses among professionals and in the academy.
In this study, the analysis on the contents of three Ministry of Health documents also evidenced the lack of definition for the family concept. This finding is reflected in practice with families as, although this approach is a general FHS proposal, the way it should take place is not specified, nor the definition of instruments for family assessment and intervention and professional preparation for this new care practice.
The opportunity the FHS presents of going beyond, towards care practice with a family focus, is unique. Through contact with families, team professionals can perceive demands, anxieties, suffering and potentials that would have been ignored before that. By establishing a context based on theoretical reference frameworks and instruments that enable professionals to effectively address family dynamics issues, the FHS potential overcoming gets closer to reality.
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Received: 10/27/2010 *
Taken from the thesis "Entrevista de 15 minutos: uma ferramenta de abordagem
à família no Programa Saúde da Família", University
of São Paulo School of Nursing, 2010.
* Taken from the thesis "Entrevista de 15 minutos: uma ferramenta de abordagem à família no Programa Saúde da Família", University of São Paulo School of Nursing, 2010.