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Acta Paulista de Enfermagem

Print version ISSN 0103-2100

Acta paul. enferm. vol.24 no.4 São Paulo  2011 



Social representations of arterial hypertension and its care: a collective subject discourse*


Representaciones sociales sobre hipertensión arterial y el cuidado: el discurso del sujeto colectivo



Geovana Brandão Santana AlmeidaI; Elisabete Pimenta Araújo PazII; Girlene Alves da SilvaIII

IPhD in Nursing. Professor of the Nursing Faculty of the Universidade Federal de Juiz de Fora - UFJF - Juiz de Fora (MG), Brazil
IIPhD in Nursing. Professor of the Escola de Enfermagem Anna Nery - EEAN – Rio de Janeiro (RJ), Brazil
IIIPhD in Nursing. Professor of the Nursing Faculty of the Universidade Federal de Juiz de Fora - UFJF - Juiz de Fora (MG), Brazil





OBJECTIVE: To analyze the social representations of the health team about arterial hypertension and the manner that develops specific care with hypertensive patients.
METHODS: We used semi-structured interviews with 21 health professionals who worked in the Basic Health Units. The technique of collective subject discourse was used for organization and interpretation of the data, using the theory of social representation.
RESULTS: The representations of health professionals showed a gap between the actions recommended by the control program and those taking place in health facilities.
CONCLUSIONS: Professionals recognized hypertension as a serious disease, with great consequences, but the structural difficulties for part of the services, together with the user's motivation to participate in activities to promote health, did not favor health care focused on the needs of those suffering with hypertension. These results indicate the need for interdisciplinary actions in care practice that impact positively on the delivery and quality of care.

Keywords: Hypertension; Health professional: Primary Health care Unit; Health promotion; Delivery health care.


OBJETIVO: Analizar las representaciones sociales del equipo de salud sobre la hipertensión arterial y la manera cómo desarrollan los cuidados específicos a los hipertensos.
MÉTODOS: Se utilizó la entrevista semiestructurada con 21 profesionales de salud que actuaban en Unidades Básicas de Salud, la técnica del discurso del sujeto colectivo para la organización de los datos e interpretación por la teoría de las representaciones sociales.
RESULTADOS: Las representaciones de los profesionales revelaron un distanciamiento entre las acciones preconizadas por el programa de control y las que se realizan en las unidades de salud.
CONCLUSIONES: Los profesionales reconocen a la hipertensión como una enfermedad grave, con grandes consecuencias, sin embargo las dificultades estructurales por parte de los servicos, aliadas a la desmotivación del usuario para participar en acciones de promoción en salud, no favorecen a un cuidado en salud volcado a las necesidades de los portadores de hipertensión. Tales resultados indican la necesidad de acciones interdisciplinaris en la práctica asistencial que impacten positivamente en el ofrecimiento y calidad de los cuidados.

Descriptores: Hipertensión; Profesional de salud; Unidad Básica de Salud; Promoción de la salud; Prestación de atención de salud.




Systemic hypertension is a chronic disease, which is detected almost always late, due to its asymptomatic presentation. Because it is currently considered one of the most important risk factors for cardiovascular, cerebrovascular and kidney diseases, it is one of the most serious public health problems. Brazil has approximately 17 million hypertensive patients, representing 35% of the population with more than 40 years of age, and the disease is responsible for at least 40% of deaths caused by cerebral vascular accidents, 25% of deaths due to coronary artery disease, and in association with diabetes mellitus, it accounts for 50% of the cases of end stage renal disease(1).

In Minas Gerais, Hiperdia / DATASUS recorded up to July 2008, 789,211 patients with hypertension, 24,483 of which are hypertensive patients living in Juiz de Fora. According to the Information System of Primary Care, only 17,639 hypertensive patients are being monitored by basic health services in the city, despite efforts to increase such services reach(2).

Hypertensive care has been challenging healthcare professionals with regard to achieving control of blood pressure levels. In general, users are demotivated when faced with the actions proposed by the services, such as educational and physical activities. When users participate in the activities, numbers are considered small when compared to the number of people registered in the health centres(3). A similar situation was found by a study with a group of mothers who attended Basic Health Units (BHU) in Rio de Janeiro, and it stated that "the population's access to the units does not occur in an uniform way, and the location where healthcare services are provided is chosen based on what and how healthcare services are provided"(4).

In Juiz de Fora this is also observed in the routine of basic municipal services, especially when users of different programs, including hypertension program users, present difficulties adhering to health treatments. Therefore, thinking about hypertensive patients' care requires a link among users, professionals and service in order to meet health needs with autonomy and responsibility.

The question of co-responsibility and co-construction of autonomy when providing care should be discussed as an essential and relevant factor in health(5). This means that, when seeking for the co-construction of autonomy for both users and professionals, it is important to consider the clinic and public health organizational scale, and consequently, the management models and care scales. In this sense, the essential goals of healthcare work would be promoting health and co-building the ability of independent care and reflection among the subjects involved in these processes - workers and users. The study aims to establish a space for dialogue and action for nursing professionals, and to redirect the practice, so as to value the user as the protagonist of care.



Based on the observation of the healthcare practice dynamics for hypertensive patients in primary care services, we have decided to develop a research to analyse the healthcare staff's social representations about hypertension and how to develop specific care to hypertensive patients.



Twenty one professionals working for the basic health units (BHU) and providing care to hypertensive patients in Juiz de Fora - MG participated in the research, namely: four social workers, four nurses, six nursing assistants, six physicians and one dentist. The inclusion criteria for professionals to participate in the study were: providing care to hypertensive users for more than a year in one of the city's BHU and agree to voluntarily participate in the study.

Professionals who did not agree to participate in the research, and did not provide care to hypertensive patients for over one year were excluded. A semi-structured interview was performed from October to December 2007, after participants signed the Informed Consent Term, with the following questions: What does high blood pressure mean to you? Tell me about care initiatives that you develop in the program with hypertensive patients, and which means are made available by the service for your use with hypertensive patients.

The research project was approved by the Research Ethics Committee of the Escola de Enfermagem Anna Nery, Universidade Federal do Rio de Janeiro, according to the Legal Opinion No. 062/07.

Interviews were recorded on tape, and transcribed, and data were organized with the software Qualiquantisofter. In the end of the research, a synthesis speech was built and called Collective Subject Speech (CSS)(6). Such method processes statements and testimonials, in order to express the group's thinking.

Building the CSS, some instruments are used, such as: key expressions, which are continuous or partial segments of the testimonials, that are meant to summarize the contents of an answer to a question of the research, revealing the essence of the statement, and referring to the core idea. Core Idea (CI): describes the meaning presented by the key expressions (KE) in a more concise and accurate way. Collective Subject Speech (CSS): it gathers key phrases that have the same core idea or the same grounds in a single homogeneous synthesis-speech. It is understood as a way to directly express social representations of a given collective subject. Any additional information about the subjects, such as gestures and behaviours during the interview were recorded in a diary. The speeches recorded were numbered and identified according to the order of the interviews. Further on, the Social Representations Theory was used for the data interpretation(7).



When analysing the speeches of healthcare professionals, hypertension was represented as a disease that could potentially be controlled through resources that are available to users at basic health services. However, hypertensive patients seem to be fairly resistant to care. Two themes will be presented regarding care representations elaborated by the professionals in this study. The first theme is related to the hypertension representation, and the second refers to the care representation.

Hypertension representation, elaborated by professionals

Within the theme hypertension representation, professionals elaborated their concepts with the following core ideas: Hypertension can be controlled, but people are resistant to treatments due to the alterations in their lifestyle; Hypertension is a disease that limits life.

The first core idea observed in Q1 of the CSS was elaborated by 57.1% of the professionals:

"It is a manageable disease in terms of drugs, eating habits, and lifestyle. It is a disease that has to be tracked on everyone (...), but people have to manage it, keep the balance, a good nutrition, exercise and take medication more regularly. I see it as a disease; I do not see it as a serious illness. I think it must be monitored, people have to be careful with food, change their lifestyles, try to go for walks. I see it as a disease people can live with, when they seek for treatment. The sociocultural situation itself is also very important. Far beyond a simple disease, a simple diagnosis, I think it can be considered a public health issue. The number of hypertensive individuals has greatly increased and (...) there are even younger people who discover they are hypertensive. People do not look after their health. There is a large group of hypertensive patients who need monitoring and treatment, but they do not care and we have to convince them. Users got used to the fact that everyone has hypertension, and it became a commonplace, so, the serious consequences are growing fast, and everything we try to do as professional educational work is difficult!".

For the professionals in this study, hypertension is a disease that can be controlled by various mechanisms offered by the basic health services, such as medicines, appointments, and groups. Professionals' role is to know patients affected by the disease who seek for assistance in the units, to enable the bond between health units and users, and to identify possible hypertensive patients in the community. However, it is fairly difficult to enable group care due to the users' resistance participating in activities that are offered by the service, which can be a demotivating factor for professionals.

The second core idea elaborated by professionals represents hypertension as a disease that limits life. Q2 of the CSS demonstrates such representation:

"The disease meaning is that it will limit the individual, and from the moment it is settled, it can harm a person's life, to the point of leaving them in bed, with sequelae. It is a disease that brings serious consequences if not controlled, and disables individuals for work and life. I think anyone who has it, will have to live with it for the rest of their lives, there is no cure. It stops many people from working, which represents an impact in terms of social security, families, communities, and the market place".

For these professionals, hypertension represents the end of a "normal" life, given the limitations it imposes on individuals. As a health problem, it is also a challenge to professionals, for they need to promote awareness among users with regard to risk factors, prevention and aggravation control, which is a consequences of the disease.

Professionals' representations on hypertensive patients' care.

The representation of hypertensive patients' care presented the following core ideas: drug therapy, along with guidance on hypertension care; hypertensive patients' care based on the importance of a lifestyle change, and on responsibilities sharing.

The core idea regarding drug therapy and hypertension care actions was elaborated by 76.2% of the professionals, and is observed in Q4 of the CSS:

"Here, we supply them with medicines, assess patients, check if they are overweight, if they have an appropriate diet, perform a cardiac evaluation, and forward them to the cardiologist, and further on, we monitor care by measuring weight gain, checking on medication, controlling weight, and providing the necessary guidance. (...) We are aware of what hypertension is, so we try to control and minimize the high blood pressure, bring it down with medication as much as we can, but often it does not work. (...) We make them a little scared, because the lack of treatment can really lead to serious consequences, and we find a lot of difficulties on the way. Patients prefer the system where they go to the doctor and he prescribes a drug. If lines are not too long, then maybe they will wait and get the medicine. But when they go home, they won't take the medicine regularly. If there is a barbecue, for example, with drinks and such, they think they shouldn't take it, and they don't...".

In this CSS, it is clear that drug therapy is seen as an action that needs more focus/emphasis at the health service, in order to better control the disease. Professionals also say that is necessary to work with other treatment modalities to control hypertension, including lifestyle changes, revealing an extended health focus, which is a great possibility to better manage the hypertension problem.

The interviewed professionals believe that health services are seeking strategies to improve the health of hypertensive patients. However, if they can raise awareness and control the disease through drug therapy, this is considered a great achievement.

The core idea of "Hypertensive patients' care based on the importance of lifestyle changes and co-responsibility," was elaborated by 23.8% of professionals, and is illustrated by Q5 of the CSS:

"we have difficulties grouping them, and with some diseases, it is not possible, because they are stigmatized diseases. But with hypertension it is always good to work with, because you can develop a lot of educational activities. I haven't developed educational activities towards hypertension, because we generally work with hypertension and diabetes together, since they are diseases that constantly appear together, but I believe in education when it comes to hypertension too, because it has to do with lifestyle change, which is a difficult thing... You won't achieve it in the first talk, in the first appointment. There are other professionals, who are better qualified to do so, better than the physician. I worked with a social worker with a nurse, a physical educator, so, control was much better. We do not have a specific job: a group of hypertensive patients. They are invited to participate in our work, (...) let's say, being one step ahead of the complication, doing prevention work (...), we work a lot on the co-responsibility, because it's not worth it if only the health professional takes the responsibility, but the family does not care about it. Patients have to take responsibility, so we can work a lot with what we call a treatment plan together. You do not impose a plan, you talk to the patient (...), in an attempt to improve treatment adherence, or at least delay hypertension. The hypertensive patient (...) does not come to us specifically because of this pathology, but because of several other issues (...), and we try to create space within the service to be able to encourage prevention, such as gymnastics and walking, which are constantly encouraged...".

In Q5 of the CSS, some aspects indicate that professionals represent hypertension control as something that implies lifestyle changes and care co-responsibility, as it requires that responsibilities are taken by professionals and by hypertensive patients. Professionals also have encouraged hypertensive patients to take part in the actions promoted by the units, not only for hypertensive individuals, but especially to people who care about health in general. The disease prevention approach is the target of meetings and discussions about high blood pressure.



Hypertension is represented by professionals as an important disease, but with possibilities for control and prevention of aggravations, as long as users follow professional guidelines. It was also possible to identify among the professionals the representation that hypertension cannot be seen as a disease only healthcare services deal with, but rather as a disease that needs to have shared care between patients and the healthcare service. However, it is relevant for them to understand that the concept of health is generated through experiences, beliefs, values and feelings, which directly influence the way people cope with the disease treatment(8). The professionals' speech considers all aspects, but leaves the decision to be mad by users whether they want to promote the necessary changes in their lives, bringing a positive impact and reducing blood pressure levels.

Capitalist societies increasingly demand men that produce, characterizing individuals as producers, therefore, they are required to be healthy, and the disease has an actual power to break this process. Such concept assumes that individuals are perfectly rational, and want to prevent health risks, for this is an essential objective for everyday life. Thus, the processes that involve health and illness are experienced and conceived by individuals, based on their social relationships, realizing that through health and illness, one can be inserted into or excluded from society(9).

Another aspect found in the CSS regards consequences imposed by work licenses, as well as early retirement due to problems generated by hypertension. Such factor, besides costly to the Treasury, also presents difficulties for hypertensive patients' social and family lives. The Ministry of Health states that about 40% of the people who retire early through the National Social Security Institute, are affected by the lack of control and aggravations resulting from hypertension(10). Being away from work and other daily activities, makes them feel weak and limited in life, and this may trigger mental and organic alterations, which are reflected by the lack of blood pressure control.

The drug therapy issue is a great challenge to the health system, because people do not adhere to treatments the way they should. The medication is used inappropriately by a large proportion of hypertensive patients, complicating the treatment prescribed. Users do not commit to healthcare initiatives, and this behaviour is seen by professionals as a demotivating factor for healthcare actions that are performed at the basic units. If users do not take responsibility for the appropriate use of the prescribed drugs, other actions become even more difficult, given the necessary lifestyle changes hypertensive patients have to go through.

In Q4 of the CSS, it is possible to perceive that health professionals are worn out with regard to the development of care services. Even though professionals express concerns regarding the group, they reveal that hypertensive patients seem careless about the disease they have. The fact that there might be other comorbidities is also seen as a major impediment to the use of antihypertensive medication, and patients end up not using them correctly. Moreover, prescribing and adjusting the medication that controls the disease does not always happen easily.

Medication is an effective way to treat and control hypertension. However, it is necessary that professional actions are not reduced to prescribing and administering drugs as if this was sufficient for disease control(8). Other aspects such as attention to the diet and physical exercising are relevant if combined with drug therapy, and present positive results controlling hypertension. Such broad view of the hypertension treatment, even with all its difficulties, should be implemented in healthcare services centres, and guide healthcare actions towards hypertensive patients.

For professionals in this study, hypertension is represented as a disease unlike others, which brings difficulties to be addressed by healthcare service. The large number of patients enables professionals to work with specific groups and promote educational activities to raise awareness regarding care. However, this type of work is not observed in healthcare units. Hypertensive patients are treated according to the available vacancies, which makes it difficult to create specific care groups, promoting interaction between service and user.

When discussing strategies to cope with the disease, professionals try to somehow solve its problems, and create a "shield" of coldness and detachment to bear the fact they know "what to do," but do not "have the ability to do it"(11). Such results also reflect the routine of basic healthcare service centres in the city, especially when professionals talk about the structural difficulties they find to develop actions that raise users' awareness with regard to hypertension care.

While professionals try to encourage hypertensive patients to participate in activities offered by health units, they also invite users who care about health in general, and discussing the disease prevention is the main goal of such meetings. They also try to work on issues related to the hypertension treatment/control in order to reach as many people as they can and not just a specific group.

The speech built based on the professionals' statements reveals a concern regarding the development of what they believe is important for users to do to improve their quality of life. Actions promoted in the basic healthcare units, such as gymnastics, for example, although in a lower proportion to what they believe is necessary to strengthen the link between users and the requirements of disease control, are highly valued by the interaction generated between hypertensive patients and the teams.

Professionals believe they can raise users' awareness, so as to change their lifestyle, often considered inadequate, however it is necessary to create spaces of trust for the joint construction of the changes users are expected to incorporate. Thus, the responsibility for care should be shared between professionals and users, and actions taken after the meetings will be set differently from the general logic of the service, which is structured through care protocols, and will be built in a unique way, tailored to the group needs and performed according to each individual's decision(9).

The actions of a healthcare professionals' team are not only developed by different technical knowledge or methods that result from various professional backgrounds, but especially by the values that guide them, produced in the work environment, that can be shared by workers(12-13).Such thinking comes from the context of hypertensive patients care, which should not be restricted to actions from manuals and protocols, for situations that arise in the daily routine are specific to the experiences of individual users and professionals.

Another aspect represented by professionals is in Q5 of the CSS and regards their attempt to integrate with families. Such theme has been discussed in many scientific areas, considering the importance it has for the disease treatment consolidation. The family has an important role stimulating healthcare. The understanding of how important families are for the activities they develop, show that professionals are going towards providing better care to hypertensive patients, as observed in healthcare service centres(14).



Hypertension presents a social history, through which significant developments that comprehend, among other things, individuals' lifestyle can be noticed, despite the difficulties to control it, both at home and in the healthcare service centres. For the professionals in the present study, hypertension is a severe disease that limits the life of patients, interferes with their social relationships and presents great difficulties to the BHU daily care routine.

For workers who experience the care practice, hypertension care is here represented as a difficult action to be developed in the healthcare service units, given the lack of basic resources to control the disease, and specific medications for more serious cases that are still helped at basic healthcare centres, an insufficient number of healthcare professionals to meet the demand, and personal difficulties that users have adhering to the prescribed treatment.

For professionals, although healthcare service units have the main resource for hypertension control - the medication - they have not been sufficient to modify care provided in relation to the requirements of different degrees of the disease. By listing the supply of drugs currently available in the city as a positive aspect for hypertension control, professionals highlighted there are no antihypertensive drugs for every stage of the disease at the BHU, which makes it difficult to control it in basic healthcare units.

Thus, it is not enough for healthcare units to have the necessary medicines to control hypertension, it is necessary to know how to use them, understand their meaning, so that actions do not go towards the indiscriminate use of hypotensive substances. Nor will it be enough to hire professionals to work in the units, without preparing them for the development of actions that are broader than just medication.

It is necessary that health professionals think about the limits of care provided to hypertensive patients, beyond technical and physiological mechanisms, always working from the perspective of disease control and treatment, and considering the complexity of the process because there is no simple solution to such a large problem. The present study discusses the reality and brings contributions to care, but does not mean to establish any generalizations regarding other realities, for careful thinking and specific knowledge are required for each situation.

Healthcare must have an intentional character, and be the link between users and healthcare service units, addressing and solving problems. The hypertension representation as a disabling disease cannot reduce its seriousness or accommodate professionals in relation to providing quality care to people, considering that each individual is unique and specific in the way they live and see the world. Thus, it is important that any proposal on how to care for hypertensive patients considers individuals as unique, identifying their weaknesses and desires, but at the same time enhancing their potential before starting the process of building activities to the group members, so that they can choose the healthcare proposal elaborated for them.



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Corresponding Author:
Geovana Brandão Santana Almeida
R. José Lourenço Kelmer, s/n - São Pedro - Juiz de Fora - MG - Brazil CEP. 36036-900



Received article 02/10/2009 and accepted 27/01/2011



*Article extracted from a PhD Thesis presented to the Escola de Enfermagem Anna Nery - EEAN – Rio de Janeiro (RJ), Brazil.(in July 2009).

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