Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.46 no.2 São Paulo Apr. 2012
Map of the family social support network for the promotion of child development*
Mapa de la red social de apoyo a las familias para la promoción del desarrollo infantil
Ana Maria Cosvoski AlexandreI; Liliana Maria LabroniciII; Mariluci Alves MaftumIII; Verônica de Azevedo MazzaIV
IRN. Master student, Nursing Graduate Program, Federal University of Paraná. Fellow of Reestruturação e Expansão das Universidades Federais - Reuni. Curitiba, PR, Brazil. email@example.com
IIRN. Ph.D. in Nursing. Associate Professor, Federal University of Paraná. Curitiba, PR, Brazil. firstname.lastname@example.org
IIIRN. Ph.D. in Nursing. Adjunct Professor, Federal University of Paraná. Curitiba, PR, Brazil. email@example.com
IVRN. Ph.D. in Nursing. Adjunct Professor, Federal University of Paraná. Curitiba, PR, Brazil. firstname.lastname@example.org
This descriptive, qualitative study was performed from September to November 2009, at a Family Health Strategy unit in a city in the metropolitan region of Curitiba-PR. Participants were eight families, represented by mothers, fathers and grandmothers. The study objective was to identify the family social support network for the promotion of child development, from the family's perspective. Data were collected through focal groups and subjected to content analysis. The family social support network was classified as located, consisting of 16 members distributed between the informal and formal network, established by close relationships, with a smaller level of commitment, and occasional. It is considered that the health workers' understanding regarding the role and importance of this network favors the networking proposal between members that contribute to supporting families in the promotion of child development.
Descriptors: Child development; Social support; Family; Child health; Pediatric nursing
Investigación descriptiva, cualitativa, realizada entre septiembre y noviembre 2009, en unida sanitaria con Estrategia Salud de la Familia de municipio de región metropolitana de Curitiba, con ocho familias representadas por madre, padre y abuelos. Se objetivó verificar la red social de apoyo a las familias para la promoción del desarrollo infantil, en la perspectiva familiar. La recolección de datos se realizó mediante técnica de grupo focal, los datos se analizaron según Análisis de Contenido. La red social de apoyo a las familias fue clasificada como localizada, compuesta por 16 miembros distribuidos entre red formal e informal, establecidos por relaciones íntimas, con menor grado de compromiso y ocasionales. Se considera que la comprensión por parte de los profesionales de salud en referencia al papel e importancia de dicha red favorece la propuesta de entrelazado entre miembros, que contribuye al apoyo de las familias en la promoción del desarrollo infantil.
Descriptores: Desarrollo infantil; Apoyo social; Familia; Salud del niño; Enfermería pediátrica
The primary health care to children is of utmost importance to reduce child mortality rates in developing countries, inasmuch as the rates remain high. Thus, it is from age zero to five years that children develop most of their physical, psychological and emotional potentials for life. These characteristics offer the opportunity(1) to recognize the health potentials and the changes particular of this period of life, encouraging families and health care professionals to invest in interventions that promote the health of these subjects.
The quality of health care offered to children in the early childhood affects their performance at school, the development of self-esteem and resilience, and is indispensible for the continuity of learning, to establish the relationships and self-protection required for financial independence, to prepare the individual for life and for family and community living(1).
In this aspect, families have been recognized by the health care services, through their participation in activities for protection and help, as having a role of informal caregivers and assuming a central position in that role(2), thus becoming an important member of the social support network. Therefore, it is important to recognize the health conditions of the families, the life settings, and the care and resources available that contribute with the practice of comprehensive children health care.
It should be stressed that the family alone is unable to answer all the children's health needs, hence the need for community resources, social and governmental organizations to minimize or solve them. Among these needs, special attention should be drawn to the health services that can provide comprehensive health interventions(3). In this sense, the Family Health Strategy (FHS) corroborates for including the family in the co-responsibility of children health care and thus obtain continuum care.
One of the main roles of the FHS is to strengthen primary care by reorganizing health care services, and, consequently, changing the current health care model into a proposal that has family and life setting as the focus of practices(4). The actions of this form or organization should be centered on the locations and families covered by the FHS so that it is possible to create a support network for children's care.
In the social network, the FHS has a relevant role for establishing connections between the different actors that comprise it, e.g. families, neighbors, and community leaders, considering it can encourage the inclusion across the many support initiatives, allying the social support practices to those of health interventions(3).
This study adopted the social network concept proposed in a study(5), that refers to it as (...) a group of individuals with whom we interact regularly, talk, and exchange signals that embody us, make us rea, i.e., consist of a continuity.
It is considered that the health care professionals' understanding of their role and importance of the social network favors the proposal of strategies, associating formal and informal resources that contribute to support the families promote child development. For this to occur, it is first necessary to identify the available social network recognized by the families, considering that prior study results indicate there are many networks working effectively and in collaboration providing support to the population and services(6).
In this sense, the following guiding question is proposed: What social support network do the families recognize as promoting child development?
To identify the family social support network for promoting child development, from the perspective of the relatives of children aged between zero and five years.
Descriptive study, using a qualitative approach, performed at a health unit with the FHS in a city within the metropolitan region of Curitiba-Paraná, from September to November 2009.
The city was chosen considering the connection between the Federal University of Paraná (Universidade Federal do Paraná - UFPR) and the local Health Department, by means of several study projects and integrated activities that aim at improving the health care services.
The choice for the unit with the FHS is justified by the particular activities developed in these settings, by means of direct integrations between the health unit and the families, and also for having a greater number of children of ages zero to five years, living in the covered area.
The families were selected using the territorial division of the health unit, contemplated in three areas, each comprising five micro-areas. A draw was made to select two streets from each micro-area. Next, all the families who had children between the ages of zero and five years were identified, and draw was performed to select one family from each street to participate in the study, which resulted in 10 families per area, i.e. a total of 30 families.
Each family home was visited with the purpose to present the study proposition, invite the family to participate of the focal group session, and obtain their consent, i.e. signing the Free and Informed Consent Form. However, it was only possible to get in touch with 24 families, and only eight families singled the consent form. Thus, one couple, seven mothers, and one grandmother comprised the focal group.
Data were collected by means of a focal group, in which the statements were recorded and later transcribed. The focal group was divided into three moments: in the first, one-by-one the participants identified their social support network, by answering the following request: place your name in the center of the white sheet and then write around you the names of those you consider important as well as the services and people in your community that help you take care of your children.
Performing this activity supported the second moment, characterized by the discussion of the concepts of network, support and social network, based on the knowledge of the group, and theorized by conceptions(5) about the topic.
The Minimal Map of Relationships (MMR) was the chosen instrument, because its applicability is accessible to different cultures, economical situations, education levels, and for considering the individual meanings assigned to the components of the social support network(5). Therefore, in the third moment, the members of the family social support networks were identified. The obtained data were grouped according to the MMR(5) (Figure 1).
The map consists of four quadrants, which represent the different social relationships: family, friends, work and study relationships, and community relationships and religion, subdivided into health systems and social agencies. The quadrants are subdivided into thee concentric circles that indicate the proximity of the relationships. The inner circle represents the close relationships, the intermediate the social or professional relationships, and the outer circle the acquaintances and occasional relationships(5).
Figure 1 was exposed on a poster, and the researcher asked the following questions to the participants: who are the important people in your life? Who are the people you can count on regarding child care? What services or places in the community offer you some type of help in child care? The members stated by the group were included in the MMR by the researcher according to the degree of the relationship established between the members and the families (Figure 2).
Data analysis was performed through the Content Analysis technique(7), because it is an analysis instrument that facilitates the exploratory and enriching attempt of interpretation.
The study was approved by the Research Ethics Committee at Federal University of Paraná (CAAE: 3145.0.000.091-09), and was authorized by the local Municipal Health Department. In order to maintain the anonymity of the subjects, the letter F followed by a progressive number (1 to 8) was used as a reference.
Based on the data analysis about the families social support network, three categories emerged: Members of the family social support network; Map of the informal and formal social support networks; Resources used by the families to promote child development.
Chart 1 presents the characterization of the participants, with a mean age of 31 years, most had an incomplete primary education, a mean of 4.75 members per family, and 2.4 children with several occupations.
Members of the family social support network
The participants indicated the following members as components of the family social support network for promoting child development: day care, health unit, maternal sister, great-grandmother, grandmother, daughters, mothers, pharmacy, Programa do Leite (Milk Program - a governmental program that distributes milk to children in need), Bolsa Família (Family Allowance - a social welfare program of the Brazilian government), friends, neighbors, school, general practitioner and pediatrician, dentist, church, security, television shows (TV), DVD (Digital Versatile Discs), Community Health Agents and the Pastoral da Criança (Pastoral Care of Children, a catholic organization), grouped in the MMR(5) (Figure 2).
The social support network elaborated by the families comprised a total of 16 members. There was a higher concentration of members in the inner circle, as shown in the map (Figure 2), considered a localized network.
Map of the formal and informal social support network
Two types of network formal and informal emerged in the family social support network mapping. The members of the informal social support network were represented by the Family Relationships (mother, daughters, grandmothers, great-grandmothers, sister) and Community Relationships (neighbors); while in the formal, the chosen members were the Work or Study Relationships (day care, school), Social Agencies (health unit, community health agent, physician, Milk Program, Family Allowance) and Community Relationships (Church, pharmacy).
Informal social support network
In this modality, the families stated the mothers, grandmothers, great-grandmothers, daughters and sisters as the members of the family support network.
"I only have my sister, who is the closest person to me" (F8).
"(...) my grandmother always helps. Because I go out for some work, as a maid, then she always looks after them" (F7).
"There are the mothers!(...) the children's great-grandmothers also help" (F5).
"There is my daughter!" (F4).
"(...) my daughter is who looks after hem, helps taking care of them" (F3).
Also in this category, the families reported that their neighbors were components to the network, however, there was no consensus as to the type of relationship that is established in order to indicate whether they comprised the inner, or intermediate circle in the MMR, as expressed in the statements below:
The neighbors (F1)
(...) my husband arrived and she [neighbor] said: look, she went to take [child's name] to the doctor, because she had a fever and she didn't want to wait until late at night. (...) so, in this case the neighbor also helps because, if I hadn't talked to the neighbor, or to anyone, they would come home and besides not being able to get inside the house, they would think what happened? Where did she go? (F8)
(...) for me it is more distant. [neighbors inner, intermediate or outer circle ] (F4)
(...) they can help a lot or a little, in my opinion is it more or less [neighbors intermediate circle] (F2)
It depends. My family lives far away, so for me neighbors are closer, because they live in the same backyard, and it's a lot easier to talk to my neighbors when I have to leave the house (...) [neighbors inner circle] (F5)
Formal social support network
The day care center and school emerged as members of the formal family social support network, and these components were included in the inner circle of the Work and/or Study Relationships Quadrant, indicating a very close relationship, as described below:
(...) the day care (F2)
(...) the school helps a lot (F3)
(...) I don't use it [day care], but some people do (...) people who need the day care center, go there every day (F8)
In this category, in the Community Relationships quadrant and in the Relationship with Health System and Social Agencies subdivision, the families also indicated the health unit, some professionals such as the pediatrician, general practitioner, dentist, as well as community health agents and pharmacy services as members comprising the social support network.
(...) the health center General Practitioner. Because we go to the health center and it is a general practitioner. (F2) I used to be so busy (...) that I was almost missing the date for her ninth month vaccination, if the community health agent hadn't visited, I would have missed it Pharmacy (F8)
(...) first the physician then the pediatrician (F1)
(...) helps [the family with child care], because many times, for example, me, at my time there wasn't such a thing, now that she's just been born and has even seen a dentist already (F3)
When discussing with the families about the type of relationship they established with the Health Unit, it was evidenced there were comparisons between their relationships with the health unit and the day care, and the health unit and the family, as observed in the statements below:
(...) the day care center still comes first [compared to the health unit] (F1)
(...) the health center is the same as the day care, if people need it, they go there everyday, you go to the health center when you need to, but those who use day care, they go everyday (...) I think that when we have a problem, first we turn to the family then the health center, because family is the closest support and then the health center (F8)
(...) from the point of view of being everyday, (...) people who need day care need it every day, so the day care comes first[before the health unit] (F4)
(...) for the point of view of needing it, it comes second [health unit in relation to day care] (F3)
(...) before turning to the family, the health center is the first place (F2)
The participants also mentioned social family support policies, represented by the Milk Program and the Family Allowance, as shown in the following statements:
The milk program is really important (...) we use it a lot, because we get milk on Monday, Wednesday, and Friday, always (F7)
The family allowance, helps a lot. Farther, because it does not reach everyone [outer circle family allowance] (F5)
For those who use the Family Allowance, because it helps raise their children (F8)
The families revealed having different relationships with the Milk Program and the Family Allowance, because these programs were included in the inner and intermediate circles, respectively, in the quadrant of the Relationships with the health system and social agencies (Figure 2).
The Church was also referred as a member of the formal social network, providing spiritual support, and contributing with the family in their children's education.
(...) the church helps having more (...), being more catholic, not to swear, call people names (...) it helps children to not get into fights, and not to call people names (F3)
(...) the church helps a lot in the education (...)(F6)
Resources the families use to promote child development
The families stated television shows and DVDs as resources that help them take care of children. However, while some families report these technological resources as beneficial, others state they are harmful to child development, as mentioned in the following excerpts:
(...) the television (...) has educational programs for children and parents (...) don't you put on a DVD for your children to watch? Don't you watch an educational program that informs you about it, and solves your doubts? (F6)
(...) some shows and cartoons are ok to let them watch (F4)
(...) also the news that airs on tv (F3)
Not all [shows], for example, I won't let my daughter watch all the shows, but some are educational, then we let them watch, or we buy a DVD for them (F3)
(...) it teaches how to educate them better, how to avoid yelling, without violence, be clamer to take care of them [stating a program] (F7)
Even after an intense exposure to ideas, the families did not reach consensus and TV shows and DVDs were indicated as members of the family social support network, and included in the outer circle of the quadrant of Community Relationships (Figure 2) in a situation of occasional relationship.
The composition of the family support network, with 16 members, concentrated in the inner circle, is considered less flexible and effective, because it offers fewer choices of integration and support among the members compared to networks with a broader distribution(5). The burden and work conditions are correlated with the size of the network, indicated by the number of members that compose it(5). Therefore medium networks are characterized by their greater flexibility and effectiveness compared to small or large networks. Minimal networks are less effective in situations that involve tension and long term burden due to the distance the members establish between them aiming to avoid the burden. Large networks, on the other hand, point at the risk of this ineffectiveness founded on the supposition than probably someone is already taking care of the problem(5).
Regarding the roles played by the network members, it is observed that in each connection one or several roles may exist, however, the close family and friendship relationships usually comprise, at the same time, a significant number of roles, many of which, due to their richness, complexity, or idiosyncrasy, transcend the specificities of this list(5). Nevertheless, it is not possible to establish specific roles for each of the stated members.
The process of mapping the family social support network revealed two types of networks formal and informal. Formal social networks are understood as those in which the composition is related to their members' position and roles in the society, including health care professionals, and others; and the informal social network is that in which the members are considered important because of the personal and affective relationships, which includes family, friends, neighbors and others(8).
In the informal social support network, the presence of members from the enlarged family corroborates the literature by affirming that the enlarged family comprises the family support social network for child care, and particularly the grandmothers have a significant participation in promoting child development (...)(9). For the popular groups, the family concept is founded on daily activities and mutual help networks(10), or solidarity networks, which are often effective in the necessary care to their members(11).
The contribution from female members bonded by mother consanguinity evidenced the cultural and hierarchical influences, in terms of child care being assigned to the mother and her sociability network, by means of the trust that she deposits on other women(12).
The indication of neighbors as members of the family social support network has also been evidenced in other studies(2-3), referred to as important members in view of the internal changes that occur in the families, e.g. the birth of children, marriages, deaths, and others.
In these relationships, special emphasis is given to migrations or geographical changes, which are becoming increasingly common in society. In this transition, the individuals' needs increase, and their social support network is broken. The effort to develop new networks, associated to the characteristics of the new place, is what determines the subject's settling in and establishing a new social support network(5), thus affecting the possibilities of help to the families in promoting child development.
In the formal social support network, assigning day care and school to the inner circle of the Work and/or Studies Relationships quadrant express the importance of their support to the families, regardless of their being used or not. Subjects report this importance due to how often this support is used, which confirms the concept of network characterized by the sum of all the relationships that an individual realized as being significant (...)(5). We reinforce the role of these institutions in terms of the experiences that they provide to children to establish trust relationships towards themselves and in the society(13).
We identified the presence of various health care professionals participating in the multiprofessional team, in activities and interventions such as the prevention of diseases and health promotion. The families acknowledgement of these professionals can help establish more reliable professional-user relationships(14), and can generate favorable interactions between the members of the family social support network, so as to contribute to promoting child development.
The discussion regarding the relationship established between the health unit and the family illustrates the different interests regarding the use of these services, founded on the different social relationships, income, education level, formal and informal activities, and others. This discourse reinforces the singular dimension of the meanings assigned to the family social support networks and indicates the main members of the social support network sought by the families to solve health problems.
The reference to governmental programs as members of the family social support network was also evidenced in a similar study, referred to as an intervention that contributes with the families, however, with hesitation regarding the difficult accessibility(9).
The Church, a member that the families refer as being a component of the social support network, was also identifies in a study performed with nurses of the primary health care network, and is identified as a provider of spiritual support(6), which agrees with the present study findings.
According to another study(15), people have sought alternative settings to deal with health-related issues, demonstrating the relevance that families assign to the role of religion as a complement to the structured medical services.
The reference to television shows and DVDs corroborate a study(9) that expressed there is no consensus between families about the use of these resources, showing that they only contribute if the quality of the programs used is assessed.
The relationship of the families with the members of their social support network, including relatives, non-governmental institutions, community projects and religious institutions is pointed out in a study(16) as a potential for the promotion of a healthy life, evidenced through the importance of the available organizations and resources, besides the need to strengthen the importance of more resources and public social policies.
The social network should not be seen as static. In fact, it changes constantly, as it is commanded by automatic mechanisms developed by its composing groups. In this sense, it was observed that, in the discussions, there was disagreement between the group members regarding the inclusion of certain individuals and services in the family social support network, particularly related to the type of relationships that are established.
The familiarity with the theme developed by the participants in the construction of the social support network puts them in a favorable position, leading them towards changes of feasible plans(5), in addition to generating an experience for becoming active agents of their own transformation, seeking alternatives and means to improve the quality of life of the children and their families, besides promoting child development.
The possibility of identifying the family social support network for child development permits health professionals to reach a better understanding of the potential of the network in relation to health, both in the individual and the collective domain. Therefore, it is indispensible to consider it as significant for individuals, because it is through the network that health care professionals are able to identify and discuss about ways to strengthen the actions to encourage child development and also the essential child care.
Health care professionals must establish a closer relationship with users, so that the families can recognize and take advantage of the activities developed in health education in order to improve the children's quality of life.
Furthermore, health care professionals must develop strategies to connect members of the family social support network, aiming to promote development, in addition to encouraging them to become active agents and seek, together, resources and services that improve quality of life.
It is important that studies be performed in other locations in order to confirm and validate the family social support network, through which professionals may propose intervention projects with the purpose to improve children's quality of life.
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* Extracted from the dissertation "A rede social de apoio às famílias para a promoção do desenvolvimento infantil: potencial para a prática de enfermagem", Nursing Graduate Program, Federal University of Paraná, 2010.
* Extracted from the dissertation "A rede social de apoio às famílias para a promoção do desenvolvimento infantil: potencial para a prática de enfermagem", Nursing Graduate Program, Federal University of Paraná, 2010.