Friends and neighbors: an active social network for adult and elderly hypertensive individuals

Abstracts

A rede familiar é fundamental na vida dos indivíduos, mas quando ela é ineficiente, os amigos desempenham um papel essencial no apoio físico e mental aos indivíduos. O objetivo foi compreender a atuação da rede representada pelos amigos e vizinhos de adultos e idosos hipertensos. O presente estudo é de abordagem qualitativa e foi realizado com 20 indivíduos de idade entre 50 e 80 anos, em Maringá - PR. Os resultados demonstraram que o tempo de moradia interfere no vínculo do hipertenso com seus vizinhos e apontaram os recursos e locais utilizados para o contato com os amigos. As amizades são importante fonte de apoio, podendo este vínculo ser mais forte que os laços consanguíneos. Ressaltamos a necessidade de os profissionais de saúde valorizarem as redes de amizade, pois isto serve como estratégia para uma assistência mais efetiva, contemplando o sujeito como um todo.

Hipertensão; Apoio social; Amigos; Redes comunitárias; Enfermagem

ORIGINAL ARTICLE

Friends and neighbors: an active social network for adult and elderly hypertensive individuals

Paula Faquinello^I; Sonia Silva Marcon^II

^INurse. Master in Nursing by the Graduate Program at Universidade Estadual de Londrina. Cascavel, PR, Brazil. [e-mail]

^IINurse. Ph.D. in Nursing Philosophy. Professor of the undergraduate and graduate courses at Universidade Estadual de Maringá. Maringá, PR, Brazil. [e-mail]

ABSTRACT

The family network is fundamental in people's lives, but when it is inefficient, friends play an essential role in providing physical and mental support. The objective of this study was to understand how the network represented by the friends and neighbors of hypertensive adult and elderly individual works. This qualitative study was performed with 20 individuals with ages between 50 and 80 years, living in Maringá - Paraná. Results showed that the time of residence affects the attachment between the hypertensive individual and his/her neighbors and pointed at the resources and locations they used to contact friends. Friendships are an important source of support, and this attachment may in fact be stronger than kinship ties. We reinforce the need for health care professionals to value friendship networks, as it serves as a strategy for a more effective health care, with contemplates the subject as a whole.

DESCRIPTORS: Hypertension; Social support; Friends; Community networks; Nursing.

RESUMEN

La red familiar es fundamental en la vida de los individuos, pero cuando es ineficiente, los amigos desempeñan un papel esencial en el apoyo físico y mental al individuo. Se objetivó comprender la actuación de la red representada por amigos y vecinos de adultos y ancianos hipertensos. Estudio cualitativo, realizado con 20 individuos con edad entre 50 y 80 años en Maringá-PR. Los resultados demuestran que el tiempo de residencia interfiere en el vínculo del hipertenso con sus vecinos y notificaron los recursos y lugares utilizados para contacto con los amigos. Las amistades son importante fuente de apoyo, llegando este vínculo a ser más fuerte que el lazo sanguíneo. Resaltamos la necesidad de que los profesionales de salud valoricen las redes de amistad, pues esto sirve como estrategia para una atención más efectiva, contemplando al sujeto como un todo.

DESCRIPTORES: Hipertensión; Apoyo social; Amigos; Redes comunitarias; Enfermería.

INTRODUCTION

All human beings live in society and relate with their kin. Certain factors in the cycle of life can make one prone to diseases. Those factors range from life styles to genetic features. Community factors considered indispensible for one's well being and health include the accessibility to health care and a social support network⁽¹⁾.

The terms social network and social support are used in various studies with different definitions, but with similar characteristics. Social network has been defined as the sum of all relationships that an individual perceives as being meaningful or differentiated from the anonymous mass of society⁽²⁾, and social support refers to a qualitative and functional characteristic of the social network⁽³⁾.

This network of the individual's interpersonal relationships, which is primarily comprised by the family, is increased as the individual includes friends, school and work colleagues, besides the social relationships from sporting and cultural activities, and health care settings⁽⁴⁾.

In the health-disease process, an unbalance in the body system can originate from a natural process of falling ill or from the poor quality of social relationships⁽⁵⁾. Therefore, it is outlined that the social support provided through networks has the purpose of improving people's well-being, as it plays the role of exchanging affection and social companionship⁽⁴⁾, besides promoting the health of the members of that network⁽⁶⁾.

Critical times - for instance in cases of chronic-degenerative and psychosocial diseases - are what determine the significant importance that the care provided by family members, neighbors and friends have as help and support to patients⁽⁶⁾. Nevertheless, in general society, there is a growing fragility of affective and family relationships, in a way that most individuals have no support, especially from a relative or friend, to share the many situations, moments, and desires they have in life⁽⁷⁾.

Furthermore, it should be stressed that the problematic implied from a chronically ill patient not adhering to treatment does not concern exclusively the patient's concept of the disease. Rather, it is a complex and multi factor issue that involves, for instance, the lack of family support, as it is common that not all family members change their daily routine to help a hypertensive patient or to encourage their treatment⁽⁸⁾.

In other cases, it is observed that the family, for certain individuals, is a group that either does not exist or has little influence in their lives. In those situations, friends help to comprise the patient's social network and complement their family, thus often becoming essential in maintaining the patient's health, in physical, mental, psychological and affective-emotional aspects⁽⁴⁾.

Despite the growing interest in studying the influence that social networks have on people's lives, there is a scarcity of studies that address the characteristics of the informal support network of people with hypertension, which justifies the importance of the contribution made by the present study.

The objective of this study is to understand the role of the non-familiar social network, represented by friends and neighbors of adults and older individuals with hypertension.

METHOD

This is a qualitative study. Interviews were performed with twenty individuals, of both genders, between 50 and 80 years old, previously diagnosed with hypertension, living in the city of Maringá - PR, who presented at the Municipal Hospital seeking emergency care due to a hypertension crisis.

Data were collected from March to June 2009, during a visit to the participants' home, which was scheduled in advance. The interviews were performed following a semi-structured script consisting of two parts: one regarding the patient's personal information, and another containing open questions about the social network.

The participants provided written consent and the interviews were scheduled to be performed at their residence. All interviews were recorded using MP4 digital equipment. After each visit and interview, notes were taken on a field diary. The interviews were fully transcribed and then submitted to content analysis⁽⁹⁾. The field diary notes were used as complementary information to help apprehend the participant's reported experiences.

The chosen data analysis technique was thematic content analysis, which consists to find the meaning nuclei comprising a statement⁽¹⁰⁾. The process was initiated by analyzing the raw data from the transcribed interviews, followed by repeated thorough reading of the material, which permitted to extract the register units, so far referred to by a generic title. The chosen register unit was a theme, which was organized and grouped into categories and subcategories, which permitted to organize the data and investigate the common points and diverging elements. The next step was the inference, i.e., the discussion about the data obtained from the existing publications.

The study was developed in compliance with the Brazilian National Health Council Resolution 196/96⁽¹¹⁾, and approved by the Ethics Committee for Research Involving Human Beings at Universidade Estadual de Maringá (Review number 017/2009). Before beginning the interviews, the researcher explained the study to the participants, who signed the Free and Informed Consent Form. In case the participant was illiterate, a family member provided the written consent.

In order to guarantee the participants' anonymity, the digital files were destroyed after the transcription. Also to protect their identity, statements were identified with the letter M if the participant was male and F if female, followed by their age. Each interview was also identified with the letter I followed by the order in which it took place.

RESULTS AND DISCUSSION

Twenty individuals were interviewed; most ⁽¹³⁾ were female. As to their age, five were in their 50's, five in their 60's, six in their 70's, and four in their 80's. Regarding their marital status, ten were married or lived with a partner, eight were widowed, and two were separated. All participants had children.

As to education, six were illiterate, 13 had incomplete primary education, and one had complete secondary education. In terms of occupation, nine were retired, three received alimony, three worked at places such as daycare/school cafeterias, three worked in activities such as babysitting, sowing and recycling, one was a homemaker, and one was unemployed. As to religion, 16 reported being Catholic, and four were Evangelic. According to participants, the time of diagnosis for hypertension ranged between five months and 49 years.

The analysis of the material permitted to identify the thematic unit Intervenient components in the social network of friends and neighbors of hypertensive patients, which was divided into the following subunits: Time of residence at the location; Resources and places to keep in touch with friends; Establishing reciprocity with solid friendships.

According to the participants' statements, it is realized that the social network is represented by the ties with friends and neighbors, and these relationships have been present in the their lives for a long time.

My friends are my neighbors. Just my neighbors really (F76; I18) - [time of residence: 35 years].

[...] I know the whole neighborhood, and many are my friends (M71; I01) - [time of residence: 10 years].

The participants' time of residence ranged between eight months and 43 years. According to their statements, it is observed that this factor interferes on the friendship that the patient establishes with neighbors, and there is a direct relationship between the strength of the bond and the time of residence, as observed in the following report:

Now I haven't been living here for long (eight months), so I really don't have good friends [...]. The neighbors here are very withdrawn and they are not fond of friendships. [...] (F52; I20).

Older patients believe that being in touch with neighbors is important and valuable, because they realize they can count on their neighbors whenever they need any kind of help. In fact, for participants in this age group, neighbors are even more important⁽¹²⁾ and should be considered by the health system as a means to help in the treatment.

It was observed that, in general, the studied hypertensive patients have a harmonious relationship with old neighbors as well, despite living in different neighborhoods. However, not all of them enjoy a close friendship because not all of them value this kind of relationship.

I have lived in many different places, and my experience with neighbors was wonderful (F66; I10).

Well, you know what neighbors are like, some you get along with and other you don't (M71; I06).

I get along with my neighbors just fine [...] as long as they stay at their house and I stay at mine, just like in that popular saying [...] (F70; I02).

A longitudinal study performed in the United States with 4739 individuals found that an important factor that affects the subjects' well-being is having a harmonious relationship with those around them, which is also indispensible for their emotional balance and mental health. Therefore, the individuals' happiness is directly affected by their social network, i.e., it depends directly on the happiness of the people with whom they relate⁽¹³⁾.

Nevertheless, for this happiness to exist, the members of the network must be close physically. Furthermore, happiness (or unhappiness) cannot be considered based on an individual experience or choice, but as a property of a group of people⁽¹³⁾. Therefore, being emotionally close or distant from neighbors depends on the personal characteristics particular to each of the hypertensive patients. In the present study, the time of residence was the only determining factor for the subject's becoming close to their neighbors.

The home visits are an important resource to keep in touch with friends and nurture friendships. In the interviews it was observed that visits were encouraged if friends had a disease or it could serve for simple conversation. In both cases, visits occurred mutually.

Look, I always visit my friends. There's one who is sick [...] an today I feel like visiting him [...] (M71; I06).

I visit my friends every two or three months [...] then we talk and catch up (laughter) [...] and they visit me, too [...] (F66; I12).

On the other hand, some participants prefer to keep relationships more casual, usually because they fear being inconvenient, as they know that people have their own appointments and receiving guests might just disturb them.

Well, some (friends) I see every day [...] and they sometimes come to visit me. I don't visit them because they have their own jobs and I don't want to disturb them, right? (F83; I16).

When genders are compared, it is observed that the women are more active in caring for relatives and friends, which results in their creating informal ties more often and value close relationships more than men do⁽¹⁴⁾.

Phone calls are another common way to keep in touch and hear from friends:

[...] whenever I miss my friends I just call them [...] (F52; I20).

Regardless of the justification of not being able to visit friends and relatives, it is known that telephones have made it easier to keep in touch. This resource is even more useful when the hypertensive patient's friends and relatives live far. Despite the positive aspects of this technology, it should be considered that being physically close is healthy and necessary, and this is made possible only by the visits.

Therefore, the benefit brought by the contact with friendship networks is more than the simple fact of promoting the exchange of experiences with other patients, as they have the chance to ease their minds, talk and spend their time with other people, which helps them to cope better with the demands imposed by the disease and its treatment⁽¹⁵⁾. This is observed in the statement below:

At the (seniors') club we talk, exchange some thoughts, especially when you are with people your age, about the medicine you're on, those things, you know? (F70; I02)

For aged individuals with chronic diseases, friends are very important, as they offer emotional support, which is complementary to the concrete healthcare support usually provided by the family. This often occurs among friends who have a similar health condition, and the friendship serves as a source of information, comfort and empathy that only those enduring the same worries can share⁽¹⁵⁾.

Another important factor revealed in the interviews with the hypertensive patients was their report about different locations and occasions that make it easier for them to be in touch with friends:

Well, we go to church [...] and when my daughter was still in school I participated a lot there too [...] then you meet people and the friendship lasts, you know. For example, I was recently attending hydro aerobics classes, and I made a lot of new friends there (F57; I07).

I meet my friends almost every day outside the health care center [...] and I spend the whole day in front of the health center just talking (M82; I19).

It is observed that hypertensive patients participate in many community activities and visit different locations to meet with friends. This participation helps them maintain their bond with the network, as it permits them to exchange experiences and sometimes to increase the number of members in this informal network.

Friendships are part of the human social network, and are extremely important for their emotional, affective and psychological well-being. Friendship is a word defined as a strong emotional bond that can occur among any member of the social network. Friend, on the other hand, is a term that means someone that will do anything for the other⁽¹⁶⁾. For the interviewed hypertensive patients, friendships are built in the everyday family environment, and they consider their children and spouse as friends:

I have few friends. I consider my friends to be my son and my wife, no one else (M55; I15).

In this example, friendship or friends are terms that the patient understands as being related to a deeper and more welcoming, mutual relationship. Apparently, this is the reason why the patient stated the son and wife are the friends he has.

In some cases, the feeling of affection between two people is not mutual. In the interviews, we observed one case in which past conflicting relationships were the target of complaints and distress for the patient:

We don't really have friends because people are deceiving. I've suffered a lot with friends [...]. I have a lot of acquaintances, but not true friends [...] (F70; I02).

For the adult patients, friendship rules are established according to the particular social context of each group. The characteristics considered important in friendships include trust, loyalty, effort, tolerance, respect, consideration, affection, and support⁽¹⁴⁾; but whenever one friend betrays another, the trust in that person is lost, and it thus becomes difficult to maintain the relationship, which can even lead to a breakage of the bond and make it difficult for them to make new friends.

It was observed that, for the subjects, friendship can also have different levels of intensity, and bonds that are marked only by informal and casual conversations are also included in the relationship network.

I don't have friends to chat with and exchange thoughts [...] we only see each other here at the gate, then we wave and say hello [...] and sometimes we talk about sweets, about crochet [...] (F-73; E04).

Therefore, it is inferred that the hypertensive subjects have different interpretations for the term friend, which can refer to a neighbor, an acquaintance, or someone to talk to about different things. Despite the fact that some networks have few members, it should be stressed that it is not the number of relationships but their quality and character that matters, as they are of primary importance in people's lives, regardless of their life cycle or phase.

The affective relationship and the material support provided by the friendship network are extremely important for the individuals' physical and psychological well-being. In the interviews, it was observed that many hypertensive patients had moved from distant places, which meant they lost complete or most contact with their family. Nonetheless, for subjects who cannot count on support from the family network, or to those whose network is small, the only alternative is to count on other members, such as friends or neighbors. A feeling of solidarity was observed among the individuals in the friendship network, especially in view of difficult situations or when they needed help.

[...] thank God I never had to ask for help [...] But if by any chance we need each other we will do whatever we can, right? They help us, we help them (F57; I07).

[...] So if we need something because of a disease, we all help each other, without the need to ask, nothing. You just go and do it (F66; I12).

Even in the case reported by I07, who never needed the help of friends or neighbors, the subjects understand that the network could be called upon, for example, in the case of a disease. However, for some subjects, there have indeed been some circumstances in the past that required them to turn to that network, as reported in the statements below:

[...] when I broke my foot, my neighbor took me to change the dressings every week [...] (M61; I09).

[...] When I didn't have my car [...] they (friends/neighbors) would always rush me to the health center, to the hospital (F56; I14).

A study performed in Salvador⁽¹⁷⁾ with the purpose to analyze the therapeutic itineraries of the families with a hypertensive patient found that the neighbors' participation was required especially when the family did not know the disease or was insecure about the measures that should be taken when caring for their relative.

Besides this factor, the present study also found that the social network comprised by the patient's friends has an important active role in terms of the transportation of the patient to obtain health care. Also, it is observed that the hypertensive patients' social network is also present and active in providing material and emotional support, including a variety of services.

[...] I have a friend who helped me a lot in building this house; with medication, she has helped me a lot with money. Also with personal help, like talking, supporting [...] (F66; I10).

[...] when my husband was ill, all my friends helped me a lot, in every way [...] they took care of my daughters so I could go to work, they helped me with food, with everything, actually (F52; I20).

In addition to the aforementioned examples, literature reports that neighbors help hypertensive patients with house chores, and by providing important food for their recovery⁽¹⁷⁾. Although there were no references in the interviews, another example reported in literature is the fact that the network encourages patients with chronic diseases to engage in physical activity⁽¹⁵⁾. In some cases, the support from neighbors and friends was essential for the successful treatment of hypertensive patients⁽¹⁷⁾.

By analyzing the everyday routine of the families it is observed that the emotional and material support that hypertensive patients receive is usually from their relatives; however, there are specific situations in life when friends become more participative and appreciated, especially when the family network is small or there is no effective participation. In these cases, individuals seek the support they need in the friend network, which, by responding to that individual's needs, shows it important role in the individual's life.

An interesting fact was observed in the interviews: besides the neighbors, family members are also seen as friends, and, hence, part of the support network.

I have a lot of friends [...] even my daughter's mother in law who lives right in front of us (in the same yard), and we are very close, you know? (F57; I07)

It was also observed that there is an interest by the hypertensive patients to maintain an active friendship network formed by several people they consider to be their friends. Furthermore, it was also found that they nurture old friendships they maintain with former neighbors even after moving to a new neighborhood, and that those friendships are also marked by long-term companionship during their children's childhood and their attending school together.

[...] I have a friend that we raised our children together [...] they are those old time friends that I nurture the friendship (F66; I12).

[...] there are my neighbors from Montreal (a neighborhood in Maringá) who I've known for 24 years [...] (F50; I13).

The long-term friendships with neighbors are marked by attitudes of mutual help, in a way that these individuals have become members of one same life history. There are situations in which a friendship can last for a long time, but moving away can affect these bonds and make it weaker, implying the need for new adjustment and to reorganize the social network.

It is important to emphasize that aged individuals see a particular importance in friendship, because at that age they have much free time, thus making it easier for them to be in touch with friends⁽¹⁴⁾; but their age is also accompanied by physical and financial limitations and a greater emotional susceptibility. Therefore, health care professionals should look out for cases they notice any limitation in the friendship network and seek resources that could be used to meet that affective need, especially in aged patients and those with a chronic disease.

Most of times, the family is the network that takes care of the ill individuals; however, as reported in the interviews, neighbors and friends can also be called on to help in that task.

Another example of this situation is a study performed with family caregivers of individuals with incapacitating diseases. The study found that, after the family, friends and neighbors are referred as the most important members of their relationship network, and that their best friends are those living near the caregivers⁽¹⁸⁾.

In the interviews with hypertensive patients, there were situations in which the friendship with neighbors is so intense that they are considered as part of their family (sister). For interviewee 20, which does not have any family members in Maringá, the fact of having an affective network consisting of friends was primary for her to recover from some personal problems.

I've been through a lot of problems, it was difficult because I don't have any relatives here (in Maringá) [...] I only have my daughters. [...] So, there's a (formal) neighbor of mine that I consider to be more than a sister to me, more than my own sisters (F52; I20).

When there is no family network to provide the necessary support and help in case of diseases or difficulties, the only alternative is to choose people from the circle of friends, neighbors and colleagues for this kind of support.

To tell the truth, a true friendship, I consider to be a man I used to work for [...] (F61; I11).

It was observed in the interviews that true, stable friendship were becoming something more and more rare in the subjects' lives, and that although old friendships did exist, they found it difficult to make or maintain new friends they could consider as truthful and ready to help at all times:

[...] I have two friends that live in Requião (a neighborhood in Maringá). [...] Now, I used to have really true friends, but they passed away, you know (F66; I10).

Besides their friends passing, other factors that could increase the gaps in the social network of aged individuals are diseases and moving to a new address. These changes often disturb their social network connections, and, therefore, the individual needs resources and responses to adjust⁽¹⁹⁾. These changes can occur any time in the cycle of life, from childhood to adolescence to adulthood, with different effects particular of each phase and to each individual.

CONCLUSION

The importance of knowing the individuals' social network lies in the fact that this network is usually called upon at difficult times, e.g., when the individuals have a disease. As to high pressure, we believe that the combination of several segments of the social network can improve the patient's adhesion to treatment based on changes in their life style, and thus improve their quality of life.

With the purpose of accomplishing the objective of the present study, which consisted of understanding the role and participation of the non-familiar social network, represented by the friends and neighbors of adult and aged hypertensive patients, we realized the importance of that network in the subjects' lives.

For hypertensive patients, the term friend can assume several meanings, which range from having a strong mutual bond to a casual and fragile contact. In most cases, the subjects' friendships occurred with neighbors and at different levels of intimacy. One of the factors that affect this affective bond is the little time of residence, which poses a difficulty for establishing a closer relationship. In spite of that, in some cases, even when changing neighborhoods, subjects are able to keep in touch with friends and maintain the affective bond. Making phone calls and visits are important for friends to keep in touch.

As to the support that the friendship network provides to hypertensive patients, we observed that many of them report never having to ask friends or neighbors for help, but they also expressed a feeling of solidarity among the members of the friendship networks whenever they needed or at difficult times. Some subjects had experienced the need to ask their friends/neighbors for help, and that kind of support was represented by providing material and services in addition to emotional support.

The analysis of the interviews performed at the subjects' homes, we perceived the real role for the informal network represented by friends and/or neighbors, which function to improve the subjects' well-being and provide them with the necessary support. This social network consisting of friendships is a form to cope with the adversities of life, and this bond can be just as strong as consanguineous family bonds, in fact, they can be even stronger.

The everyday actions performed at health institutions show that health care professionals are usually not concerned with collecting information about the patients' informal network. This factor implies that it is still unclear to these professionals that there is a need to provide care not only to the family network present in the lives of hypertensive patients, but also to other network representatives, such as religious and philanthropic institutions, or their networks of friends and neighbors, which are the center of the present study.

We certainly agree that some gaps still need to be filled in terms of the primary health care to hypertensive patients, mainly regarding their social network; however, we stress the importance of the present study results as added knowledge for health care professionals, especially for nurses working in primary health care. These professionals should value the social network represented by the friendship bonds of hypertensive patients as a strategy to provide more effective health care that is truly dedicated to improving the quality of life of these patients, in the physical and psychological domains.

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Amigos y vecinos: una red social activa para adultos y ancianos hipertensos

Correspondence addressed to:

Publication Dates

• Publication in this collection
  12 Jan 2012
• Date of issue
  Dec 2011

History

• Received
  22 Mar 2010
• Accepted
  09 Mar 2011