Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.46 no.2 São Paulo Apr. 2012
Leisure and mental health in people with hypertension: convergence in health education*
La recreación y la salud mental en personas hipertensas: convergencia en la educación para la salud
Vanessa Denardi Antoniassi BaldisseraI; Sonia Maria Villela BuenoII
IRN. Ph.D. in Sciences by the Program in Psychiatric Nursing, Department of Psychiatric Nursing and Human Sciences, University of São Paulo at Ribeirão Preto College of Nursing. Researcher with Centro Avançado de Educação para a Saúde e Orientação Sexual Preventive Education in Sexuality, STD, AIDS, Drugs and Violence, Enrolled in the CNPq Research Registry. Maringá, PR, Brazil. firstname.lastname@example.org
IIPedagogue. Master in Nursing. Ph.D. in Education. Free-Lecturer, University of São Paulo at Ribeirão Preto College of Nursing. Coordinator of the Teaching, Research and Extension Group at Centro Avançado de Educação para a Saúde e Orientação Sexual reventive Education in Sexuality, STD, AIDS, Drugs and Violence, Enrolled in the CNPq Research Registry. Ribeirão Preto, SP, Brazil. email@example.com
People with hypertension constantly deal with issues related to mental health due to the psychosocial determinants of this illness, and leisure is an important control strategy. The objective of this study was to promote health education to a group of hypertensive patients, through research-action, based on critical-social pedagogy, and taking into consideration the participants' perception of leisure. Educational activities were conducted and, following, an evaluation was performed regarding the subjects' opinion about the impact of leisure on their lives and mental health. The group perceived leisure as a coping strategy for loneliness and also as a late development of independence; it was also regarded as a means of socialization and as a promotion of mental health. These perceptions revealed two themes: aging, leisure, and chronic disease; and knowledge and leisure experiences. Educational actions, such as group dynamics and discussions, were planned considering these themes with the purpose of providing the necessary conditions for socializing and exchanging experiences.
Descriptors: Aged; Hypertension; Leisure activities; Mental health; Health education
En hipertensos, los asuntos relativos a la preservación de la salud mental están siempre presentes, en virtud de los determinantes psicosociales de la enfermedad, para los que la recreación resulta una importante estrategia de control. Se objetivó realizar, mediante investigación-acción, la Educación para la Salud con grupo de hipertensos, basada en pedagogía crítico-social, partiendo de la percepción de los participantes acerca de la recreación, desarrollando actividades educativas y evaluando la opinión de los involucrados respecto del impacto en su vida y salud mental. La recreación fue percibida por el grupo como estrategia de enfrentamiento de la soledad; como construcción tardía de interdependencia; como socialización y como promoción de la salud mental. Estas percepciones permitieron identificar dos temas generadores: Envejecimiento, recreación y enfermedad crónica; Conocimiento y experiencias recreativas, para los que se programaron acciones educativas, dinámicas y grupos de discusión, ofreciendo condiciones que permitan la socialización y el intercambio de experiencias.
Descriptores: Anciano; Hipertensión; Actividades recreativas, Salud mental; Educación em salud
Systemic arterial hypertension (SAH) is a chronic illness whose magnitude is a concern due to its prevalence and relation to morbimortality in relation to cardiovascular disease (1). It is estimated that this illness affects approximately 30% of the adult population, particularly older adults, and its involvement in deaths by myocardial ischemia and stroke is confirmed(1).
The origin of SAH has already been related to obesity, the influence of gender, ingestion of sodium, low consumption of potassium, excessive consumption of alcohol, black race, sedentarism, family history, low education and use of medications such as oral contraceptives(1- 2).
As a consequence, questions emerge regarding the maintenance of mental health due to psychosocial determinants of this illness as described in the literature, particularly stress(1,3), which has been identified as one of the causes of increases in pressure values and is held partially responsible for the genesis of SAH(4), since it causes an increase in cardiovascular reactivity(1,5).
It is also important to highlight the restrictions imposed by the treatment of SAH as triggers for unpleasant perceptions(6) that may generate stress. On the other hand, the quality of life lost due to stress negatively influences the desire to adhere to treatment(4), as it interferes in the desire to improve one's life. It is known, however, that in the thematic delimitation of SAH and stress, there is still much to investigate.
Leisure, however, has been pointed out as being a stress reliever, a way of decreasing the harmful effects of unpleasant events, especially due to its socializing characteristic(7). It is a psychosocial need influenced by subjectivity, dependent on the social and cultural objectivity. It is important to point out that it involves pleasure and, therefore, it is considered to be one of the fundamental factors necessary for a sense of well-being(8) and contributing to health, especially to mental health.
The term leisure is defined as a number of occupations to which the individual may indulge of his own free will - either to rest, to amuse himself, to add to his knowledge or improve his skills, or to increase his voluntary participation after discharging his professional, family and social duties(9). Its study emerged in response to the political-social demands of work, mainly in the capitalist society, at a period in time in which the worker's state of health began to be recognized, appreciated and discussed.
It is important to understand that leisure has three basic functions: rest, entertainment and development of the personality(9). Corroborating this, it has been stated that current times have caused substantial changes in values, also guiding new constructive experiences in leisure(10).
It is important to point out the relationship between leisure and mental health, because socializing activities performed as a means of entertainment and social support are enhancing to health(7). Therefore, leisure and mental health can be thought of as being mutually supportive.
Leisure must become an important component of the care interventions for patients with SAH, particularly educational interventions, since it may contribute to the maintenance of mental health through the prevention and control of stress caused both by the illness itself and by the lifestyle restrictions of treatment, as well as adverse life conditions. In this context, this study is justified by the use of an educational approach that goes beyond treating the ill body, aimed at avoiding the reductionism in which the pedagogical strategies in health are normally conducted, and, more than this, treating the body, mind and context of the individuals involved.
In light of the above, this study had the objective of performing, through a research-action, interventions aimed at the health education of a group of individuals with SAH, based on the critical-social pedagogy and the perceptions of the participants towards leisure, developing educational activities and evaluating the opinions of the individuals involved regarding its impact on life and mental health.
The present study consists of a research-action based on the concept, applicability, purpose and stages of referential methodology(11) We have also found methodological support applicable to health education(12), dividing this study into two stages: the first, where data were collected regarding socio-demographic characteristics and the thematic universe, listing the themes; and the second, constituted by the educational interventions. These stages are supported by the referential methodology(11), denominated the exploratory stage and result disclosure.
Therefore, the study was conducted using the following techniques: 1) focal group; 2) Freire's research group; and 3) semi-structured interview.
The target population of this study included all the SAH patients participating in a group that has weekly meetings at a health unit (n=6), located in the northwest region of the state of Paraná, in Brazil.
The participants took part in the study after it was certified by the Committee of Ethics in Research involving Human Beings (Document 1005/2009) and were authorized by the service's direction and through the signature of the Term of Authorization of Data Use. Participants signed the Term of Free and Clarified Consent, complying with the principles of human experimentation, defined by the resolution 196/96 of the National Health Council (NHC). Names of flowers were used as fictitious names for the participants in order to preserve their anonymity and confidentiality, according to their choice: Rose, Red Rose, Yellow Rose, Daisy, Sunflower and Azalea.
The procedures were matched to the methodological referential and the study techniques. The subjects met in the second semester of 2009 and the data collected were separated into three distinct but related phases:
The first phase corresponded to the first two meetings in which the leisure theme was discussed using the focal group technique. The discussions were recorded using a Foston MP4, transcribed and, later, sorted using the technique of content analysis into thematic analysis type, according to the stages: 1) pre-analysis floating reading, constitution of the corpus (exhaustiveness, representativeness, homogeneity, pertinence), formulation and reformulation of hypotheses (recording units, context units, methods of categorizing); 2) exploration of the material (categories); and 3) treatment and interpretation of the results. Throughout the group discussion, a repetitive pattern of poor participative behavior was perceived. As a result of this, the focal group technique was adapted using a dialogue panel, in which participants were divided into pairs, by affinity, and received a card on which they were supposed to write positive and negative things and/or problems perceived regarding leisure. These cards were attached to a board and discussed, one by one. This moment was important because, besides achieving results, it encouraged the participation of the subjects and exposed their ideas and reflections. As for the study, ideas, images and perceptions were then consolidated.
During the second phase, the interviews took place. Data collected at the first moment were then validated and explored through individual interviews, allowing the authors to learn the perceptions regarding leisure through a more accurate comprehension of the symbolic universes. The definition of the categories, now definitive, happened in confrontation with the categories previously collected by focal group, allowing triangulation of the data. Interviews were performed in October 2009 in the houses of the participants, who were previously contacted to choose the date and time of their preference. Interviews were recorded on an MP4 device manufactured by Foston, with an average duration of 12 minutes and 15 seconds. The interviews were then transcribed and later submitted to the technique of content analysis(13), of the thematic analysis type, following the previously described stages: 1) pre-analysis floating reading, constitution of the corpus (exhaustiveness, representativeness, homogeneity, pertinence), and formulation and reformulation of hypotheses (recording units, context units, ways of categorizing); 2) exploration of the material (categories); and 3) treatment and interpretation of the results.
This moment also allowed the definition of the themes based on the perceptions of the individuals, creating the focus for the elaboration of the educational intervention and its respective pedagogical strategies, which occurred during the following moment. The themes and the referential for the discussion and elaboration of educational interventions were based on the autonomy pedagogy, prioritizing dialogue as part of the educational interventions and centered on the group's previous knowledge, achieving education as a way of emancipation and intervention in the world (14).
In the third phase, the authors planned and executed the educational intervention, based on the themes uncovered in the previous phase. Four new meetings took place for the purpose of educational development, in addition to the other meetings that took place during the data collection, in which actions of this nature were performed. Therefore, the health education development led to an educational intervention, through activities discussed in the previous phases and chosen by the group a priori, as well as dynamic group activities for discussion regarding leisure. The participants' opinions regarding each meeting were discussed with the group and recorded with a Foston MP4 for formative evaluation. The meetings were later transcribed in a journal, with each being approximately 1h on average. The educational interventions occurred in November, 2009. The last meeting included a discussion with the focal group regarding the impact of the research-action on their lives and possible changes in perceptions and/or attitudes towards leisure, which allowed the authors to perform a somative evaluation on the perceptions of the participants and the researcher.
RESULTS AND DISCUSSION
The studied group presented homogenous characteristics, as all of the participants were women aged 60 years and over (mean 69.6 years); were retired; were widowed or divorced; had a monthly income up to and including two minimum wages; and had three to nine children but lived alone and did not have any dependents. The majority (5) had an incomplete elementary education and participated in the group for two to seven years.
As this study constitutes a research-action, the authors divided the results into two different stages: the investigation stage and the action stage.
Stage 1: Investigation
This stage refers to the investigation regarding the perceptions of the participants towards leisure, corresponding to the first and second phases described in the method section of this study.
Leisure was perceived by the group: 1) as a coping strategy for loneliness; 2) as a late development of independence; 3) as a means of socialization and, consequently; 4) as a promoter of mental health. These perceptions were uncovered by the authors during the interviews, through the focal group and during the educational interventions described as follows by a didactic division, rather than methodological, since the research-action aims at a simultaneous investigation and action(11).
The authors verified that the main leisure activity of the studied group was playing bingo. In this context, it was perceived that leisure is a behavior style that can be represented by any activity, as long as it is freely executed. Therefore, the separation between leisure and pleasure is not clear, and both are interconnected. As a consequence, leisure is claimed to be a right, as substitution for domestic, conjugal and family obligations, due to the social advances that have reestablished rules for life in society. Notwithstanding, it is stated that, despite the fact that society shouts for support of work and family obligations, there is a social movement embracing the concept of leisure(9).
In fact, in addition to rethinking and rebuilding concepts of roles and obligations, older women who live alone participating in this study also experience an idleness of time that must be filled. Thus, for most of them, leisure constitutes the most extensive and significant group of activities in this age, even when disease or misery has built obstacles(9).
This reality was supported in the studied group. In the focal group, participants verbalized that:
We cannot wait for the day to come, because it feels very lonely at home. Being here, at bingo, is really friendly. One gets the telephone number of the other, we make friends here. Whenever one of us does not come someone already knows the reason, and if no one does, we call her to find out what happened. That's it.
It is really good. A sort of support, because we understand each other. When the time to go is coming it seems like the soles of my feet start to itch. It is really good; we do not have words for it.... God, it was one of the best things that happened to me. I cannot wait for the day to come. It is a therapy, a good thing, you know. It is good for our mind.
Regarding their life experience living with the disease (SAH) and its relationship to leisure, the participants pointed out in the dialogue panel, that the illness interferes with their lives. They mentioned that SAH often prevents them from participating in leisure activities such as attending a dance, due to the increase in blood pressure caused by the excitement of the event and the intensity of the physical activity. In addition, the frequency with which they attend parties had to be reduced due to the nutritional restrictions demanded by the disease which isolates them even further. Finally, leisure activities, especially bingo events, help them forget temporarily, amongst other things, that they are ill.
It is also important to highlight that they mentioned that leisure activities have been experienced in an expressive way only at this stage of their lives and that they helped them become more independent, by allowing them to live beyond the walls of their homes, increasing their social networks and allowing them to realize there are pleasures in life that transcend domestic chores. Similar findings were described in the literature(10,15), pointing to the benefits of leisure through social experience for the emotional and cognitive development of its participants. Moreover, leisure allows new interactions and modifies daily living, promoting the physical, mental and social aspects and achieving favorable results for life(15) .
The authors support the concept of salutogenesis, the relationship of coping with adverse conditions of life and disease within the sociological aspect. The salutogenesis theory is aimed at understanding how people are able to organize their lives despite facing situations perceived as adverse. Therefore, this study understands and supports the leisure practice as a movement of social choice.
Thus, it is understood that there is no resiliency unless there is the perception of risk (16). In terms of risk, it is possible to state that, for the studied group, the socialization provided by leisure was a strategy of resistance to situations perceived as a risk, especially loneliness and the risk of becoming mentally ill(15,17). It is important to highlight that the authors considered that leisure was experienced due to the capability they showed in searching for strategies for coping and to the sense of coherence they found in these activities; this capability and sense of coherence found in social support highlight the theory of salutogenesis.
This study defined, therefore, the existence of a perception process rooted in the objectivity of the reality: leisure activities fill perceived gaps and promote mental well-being(15,17). This reality, being shared, became an accepted and experienced truth.
In the interviews, the participants commented that:
I like bingo because it entertains our mind. And time passes by. It is all in the company of women. It is good. We play bingo, everyone brings a reward gift, buys their part and sometimes we lose, we win, and life goes on (Rose).
It entertains our mind. You know, I think we cannot be alone. Because we go crazy if we stay alone (Sunflower).
Bingo is good, there is nothing better. If there was an event every night, I would go (Daisy).
Ah, it is good! Because we are playing, it is only bad when I lose. It is a very good thing for older people (Red Rose).
Ah, it is good for our minds (Azalea).
It is good to be entertained. I like bingo!(Yellow Rose).
It becomes important to point out that, due to being a widow and most of them without a partner, living this experience (widowhood) was an important divisor in their attitudes, because widowhood causes a huge impact on people's lives, as they face two extremely painful events simultaneously: the separation from the partner and the confrontation with death and finitude(18). For this reason, the authors defend that widowhood, and the subsequent loneliness, may have been decisive factors in encouraging them to participate in the socializing leisure, especially because in light of the partner's death there is the perception of urgency to live intensely(19).
There were also statements regarding this aspect:
I was married for 54 years, I lost my husband 1 year and 8 months ago, but I am here, living my life[..] (Azalea).
Sometimes we think things can change. First I had a husband, my children were close, and now I am alone. My husband died, my children went their own way... my daughter has been in Japan for 10 years, I even have a granddaughter who got married there. So I had everyone around and, suddenly, everything changes and you find yourself alone, thinking about how life used to be and how it is now. It changed a lot. We get used to it, because life changes, but you have to keep going (Rose).
It is inferred, therefore, that the participation in socializing leisure activities was positive for the resignification of values, feelings and attitudes(10), since they made these women project and experience new possibilities.
Stage 2: Action
This stage refers to the educational intervention and its evaluation, corresponding to phase 3, described in the method section of this study. It is worth highlighting that, as it involves an educational intervention, the formative evaluation took place during the entire educational process, and the somative evaluation at the end of the intervention. Regarding the formative evaluation, each activity performed was scored according to involvement, willingness, development, motivation and participation of the individuals involved, as will be shown at the end of the presentation of each activity. The somative evaluation, however, was limited to the end of the educational process, outlined in the perspectives of the individuals involved. This evaluation will be presented at the end of this stage of the study.
The perceptions regarding leisure led to the identification of two themes: 1) aging, leisure, and chronic disease; and 2) knowledge and leisure experiences. Based on these, the educational activities described as follows were listed, including the pedagogical support of group dynamics and techniques(20).
In order to better illustrate this stage, the authors decided to demonstrate the path of the pedagogical planning based on the defined themes, pedagogical strategies and educational interventions with hypertensive individuals through a summarized project of educational intervention (Chart 1).
The authors highlight, however, that the findings of these activities were already described in stage 1 of the investigation, reinforcing that in research-action there is no dissociation between doing and researching, and that both may occur simultaneously, similarly to this study.
Educational Activity 1 (focal group as a space for discussion, exchange of knowledge and approach to the theme of leisure), in addition to achieving the educational objective presented, worked effectively as a study technique, since it allowed participants to discuss this theme, creating a channel of dialogue among the group and favoring respect towards the ideas, concept, values and meanings attributed. The participants were organized in a circle and the discussion was conducted as a debate. The mediator conducted the questions: What is leisure to you? What does it represent in your life? What do you like doing? At first, participation had to be actively driven by the mediator. However, all participants spoke and expressed their personal experiences and perceptions, especially once they felt protected by the group. The authors evaluated that the discussion flowed satisfactorily. It was noted that at the end of the first meeting, one of the participants, surprisingly the most reserved one, verbalized: We want you to be here with us. It is good, isn't it? You bring something good (...). When asked whether the meeting was valuable, they answered that it was good, it made us think. Thus, as formative evaluation, the authors considered that the activity allowed reflection(21), the exchange of experiences and pleasure in the collective social life(10,19).
Educational Activity 2 (dialogue panel regarding aging, leisure and chronic disease), in addition to achieving the educational objectives proposed, also broadened the discussion regarding these themes, consolidating the investigation. The group was divided into pairs and received cards on which they were to write the best and the worst aspects of leisure. After that, each pair attached their card on the board and the group discussed, for approximately 30 minutes, their agreements/disagreements, opinions and experiences. The discussion was recorded and later transcribed. The evaluation made through the careful observation of the entire process was significantly important in allowing the authors to understand that cognitive ability was compromised and there was resistance towards writing activities because they had difficulties expressing and exposing themselves. These observations were verified through the following verbalizations: I'm ashamed of writing because our handwriting is too ugly or I do not know how to write correctly, you can write for us, your handwriting is more beautiful. The authors encouraged autonomous activity, but respected those who refused to write and wrote for them. Nevertheless, at the end of the activity it was observed that some of them discreetly began to write on pieces of paper on the table, as if they were trying to overcome their reticence and experiment with their skills. Regarding the formative evaluation, the authors inferred that this moment was significantly important to consolidate the thematic discussion, also working as a guide to remodel the language in order to help the authors to be understood by the group. This contributed, extraordinarily, to the planning of the individual interviews that would take place in the second phase of this study, as explained in the method section. It also allowed for a more open environment within the group. When they were asked about what topics they would like to approach in the next meeting, they said we can talk about anything, because we are only among women, there is no problem talking about silly things, if that is the case. At that moment, it was confirmed that the dialogue had been established, in a remarkable way(13). When their opinion was asked regarding this meeting, they verbalized it had made them think(21-22); in addition to allowing them to practice their writing, one of them subtly complimented the group for the quality of the discussion.
Educational Activity 3 (dynamics I agree, I disagree and I still do not know) allowed the authors to perceive values, attitudes and behaviors regarding coping with the adverse conditions of life and hypertension, as well as the practice and difficulties in leisure, in addition to achieving the educational objective established. Paper cards were used with the sentences I agree, I disagree and I still do not know written on them. Three spaces were then defined, separated by an imaginary line. In each space there was a corresponding note on the wall: I agree, I disagree and I still do not know. Sentences were read one at a time and the participants had to choose in which space to place themselves, according to their opinion. After everyone had placed themselves according to their opinion, they discussed the reason behind their opinions. The sentences presented were: 1- The senior stage is the best stage of life; 2- High blood pressure does not interfere in my life at all; 3- I do not like bingo; 4- I do not like coming to the meetings on Thursdays; 5- I really like meeting new people; 6- I do not like dancing and going out; 7- I cannot eat many things I want to because of my disease; 8- I really like watching television; 9- I know many people who have the same disease and they help me to cope with it; 10- I am not afraid of getting sick; 11- I do not like going to church; 12- I love retirement; 13- I love shopping; 14-During the day, I spend many hours with nothing to do; and 15- I would like to have more moments of leisure during the week.
As formative evaluation, it was perceived that the group dynamics stimulated reflection, communication, expression of ideas, respect for the opinions of the others(21) and relaxation. The participation was significant and intense. Some of the sentences previously mentioned were improvised by the participants, which is an indication of their willingness to participate in the activity cheerfully and in a relaxed manner.
Educational Activity 4 (bingo) took place at all meetings, because it was a practice already enjoyed by the group for several years and it was the activity chosen to be executed during this research-action. The group was joined by some other people in addition to the participants of the study, but they were not segregated. The authors tried to execute the activities in an open way with whoever wanted to participate. The participants brought with them their bingo cards and prizes, which they called gifts. The participation of the authors was limited to helping them, supporting them and conducting the game without, however, interfering in the rules they already used in playing the game. The formative evaluation of this activity confirmed the perception regarding the social organization of the participants, the joy they took in the meetings, their desire to be together and, especially, the participation in a recreational activity that gave a new meaning to their lives and prevented the emergence of negative feelings(17) impacting their mental health.
It is worth highlighting that the formative evaluations of the mentioned activities were significantly important in regards to the educational activities, since the evaluative process played a relevant role in the contextualized comprehension of what was taught and how it was learned; it also provided security and the constant possibility of planning, aimed at the adaptation of the content program.
The somative evaluation, however, was determined by the individualized perceptions of the participants and the researcher. Therefore, in the perception of the participants, they reported that the social experience was very good; in the first questions they wanted to hide from the recorder, and it was very difficult to open themselves up, but the naturalness and trust they felt allowed a greater participation. Regarding the changes in perception, leisure began to be understood as a right and a need, although they had never thought of it in this way. They stated they felt more secure as they realized many other women shared the same experiences and perceptions, and they also realized that there are other realities and perceptions that may be shared, indicating the possibility of opening themselves up to the dialogue and to the cognitive-emotional development(20-22).
They reported they got to know themselves better and that the meetings became more enjoyable due to the innovative activities that were performed. They also stated, as mentioned, their great motivation for attending the meetings as favorable to the mental health, to entertain, to forget stress, to talk, to live with other people, defining the impact on their mental health and the quality of life(7,17).
In the researcher's perception, it was considered that the investigative and educational process enabled by the research-action was, undoubtedly, marked by challenges regarding: 1) the acceptance of the group by the researcher and vice-versa, because there were different universes that had to be placed and considered in the dialogue; 2) the complexity of the theme and the preparation of the educational actions permeated by the dialogue, which required greater flexibility and, in contrast, less previous control of the actions; and 3) the evaluative character, because as a process it was not routinely practiced.
Evaluating is always surrounded by uncertainties when it has classification purposes. Since this was not the purpose of this evaluation, it allowed for a new experience, rich in details. The experience of the authors confirmed the reasoning that dialogue, applied in the strategies of education and health, is a way of valuing popular knowledge, enabling the participants to be transformed by their reality and themselves, making them co-responsible. At the same time it increases their capability for creation and allows an educational action guided in the care of people (22). Moreover, it was considered that the educational strategy, when supported by the emancipation of the individuals involved, allows the necessary integrality of health care regarded as a principle of the Single Health System(21), by valuing questions of life and health that go beyond the body.
Therefore, it is understood that the greatest value of this study would not be manifested in the radical and informed change in behaviors, because education is not immediate and prompt. The greatest value was manifested in the educational practice that created the opportunity for pedagogical moments which stimulated autonomy, respect towards knowledge and integrality of care. Value was also apparent in the small changes of attitudes: the desire to be together, staying together, exchanging ideas and protecting each other, in the most delicate meaning of this word. Undoubtedly, the sense of community provided by the meetings contributed to the promotion of mental health.
The authors inferred that leisure was felt and experienced by these women as a coping strategy for loneliness, allowing for socialization and a sense of satisfaction towards life and, consequently, promoting mental health. It was also viewed as a strategy for treatment of systemic arterial hypertension (HAS). The themes listed allowed the programming of educational interventions in which dialogue was encouraged, using educational strategies such as group dynamics and discussions, favoring conditions that allowed the socialization and exchange of experiences. The appreciation of knowledge previously existing among the group, the educational planning shared and carefully defined, the bonds established and the consequent reinforcement of the human capabilities for the creativity and resolution of problems were immeasurable results, but perceptible in the educational practice and coherent with Freire's pedagogy.
The limitation of the study is in the number of participants, which did not allow generalizations in the perceptions of leisure for the target population. However, there was the opportunity to program educational interventions in an individualized and contextualized way, focused on the existing demand, regardless of the number of participants.
The authors arduously wish that many other studies may come to question what is regarded as an absolute truth in the oppressive educational actions aimed at health, which separates mental health from organic health. Therefore, based on a population characterized as patients with a chronic disease, it was possible to understand the impact of educational interventions that transcend the physically ill body, aimed at human integrality, including mental health.
1. Sociedade Brasileira de Hipertensão Arterial; Sociedade Brasileira de Cardiologia; Sociedade Brasileira de Nefrologia. VI Diretrizes Brasileiras de Hipertensão Arterial. Arq Bras Cardiol. 2010;95(1 Supl 1):1-51. [ Links ]
2. Irigoyen MC, Lacchini S, De Angelis K, Cichelini LC. Fisiopatologia da hipertensão: o que avançamos? Rev Soc Cardiol Estado São Paulo. 2003;13(1):20-45. [ Links ]
3. Sparrenberger F, Moreira LB, Canepele MCGL. Associação entre estresse e hipertensão. Hipertensão. 2004;7(3):96-99. [ Links ]
4. Lipp MEN. Controle do estresse e hipertensão arterial sistêmica. Rev Bras Hipertens. 2007; 14(2):89-93. [ Links ]
5. Guyton AC, Hall JE. Tratado de fisiologia médica. São Paulo: Elsevier; 2006. [ Links ]
6. Bonomo E, Caiaffa WT, César CC, Lopes ACS, Lima-Costa MF. Consumo alimentar da população adulta segundo perfil sócio-econômico e demográfico: Projeto Bambuí. Cad Saúde Pública. 2003;19(5):1461-71. [ Links ]
7. Ponde MP, Caroso C. Lazer como fator de proteção da saúde mental. Rev Ciênc Med. (Campinas). 2003;12(2):163-72. [ Links ]
8. Jannuzzi FF, Cintra FA. Atividades de lazer em idosos durante a hospitalização. Rev Esc Enferm USP. 2006;40(2):179-87. [ Links ]
9. Dumazedier J. A revolução cultural do tempo livre. São Paulo: Studio Nobel/SESC; 1999. [ Links ]
10. Gáspari JC, Schwartz GM. O idoso e a ressignificação emocional do lazer. Psicol Teoria Pesq. 2005;21(1):69-76. [ Links ]
11. Thiollent M. Metodologia da pesquisa-ação. São Paulo: Cortez; 2007. [ Links ]
12. Bueno SMV. Marco conceitual e referencial teórico da educação para a saúde: orientação à prevenção de DST/AIDS e drogas no Brasil para crianças, adolescentes e adultos jovens. Brasília; 1997/8. [ Links ]
13. Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2002. [ Links ]
14. Freire P. Pedagogia da autonomia: saberes necessários à prática educativa. São Paulo: Paz e Terra; 1996. [ Links ]
15. Sousa MNA, Bezerra ALD, Alexandre JNM, Almeida JLS, Motta VLB. Lazer e qualidade de vida na terceira idade: percepção dos idosos de um Centro de Convivência Campinense. Qualit@s Rev Eletr [Internet]. 2010 [citado 2011 maio 25];9(1):1-14. Disponível em: http://revista.uepb.edu.br/index.php/qualitas/article/viewFile/318/407 [ Links ]
16. Paludo SS, Koller SH. Resiliência na rua: um estudo de caso. Psicol Teoria Pesq. 2005; 21(2):187-95. [ Links ]
17. Davim RMB, Dantas SMM, Lima VM, Lima JFV. O lazer diário como fator de qualidade de vida: o que pensa um grupo da terceira idade. Ciênc Cuidado Saúde. 2003;2(1):19-24. [ Links ]
18. Baldin CB, Fortes VLF. Viuvez feminina: a fala de um grupo de idosas. Rev Bras Ciênc Env Human. 2008;5(1):43-54. [ Links ]
19. Neri ALI. O legado de Paul B. Baltes à psicologia do desenvolvimento e do envelhecimento. Temas Psicol. 2006;14 (1):17-34. [ Links ]
20. Antunes C. Manual de técnicas de dinâmicas de grupo de sensibilização de ludopedagogia. Petrópolis: Vozes; 2002. [ Links ]
21. Machado MFAS, Monteiro EMLM, Queiroz DT, Vieira NFC, Barroso MGT. Integralidade, formação de saúde, educação em saúde e as propostas do SUS: uma revisão conceitual. Ciênc Saúde Coletiva. 2007;12(2):335-42. [ Links ]
22. Pires CGS, Mussi FC. Reflecting about assumptions for care in the healthcare education for hypertensive people. Rev Esc Enferm USP [Internet]. 2009 [cited 2011 May 25];43(1):229-36. Available from: http://www.scielo.br/pdf/reeusp/v43n1/en_30.pdf [ Links ]
* Extracted from the thesis " Pesquisa-ação em lazer, sexualidade e educação para a saúde com pessoas que vivenciam a hipertensão arterial" University of São Paulo at Ribeirão Preto College of Nursing, 2009.