The routine of families with nursing infants

Abstracts

Através deste estudo descritivo, de abordagem qualitativa, investigou-se as rotinas de famílias com filhos lactentes de 6 meses a 2 anos, cujas mães enfrentam o mercado de trabalho e se utilizam de Unidade Básica de Saúde em um município do Sul do Brasil. Como referencial teórico, utilizou-se a abordagem das rotinas familiares. Foram entrevistadas 25 mães, através de formulário semi-estruturado. A análise dos dados qualitativos seguiu as fases de organização, codificação, categorização e interpretação dos dados. Identificou-se que as rotinas familiares de cuidado variam com a periodicidade, horário e tipo de ocupação da mãe. Foram identificadas diferentes alternativas de cuidado da criança e, apesar de grande parte das entrevistadas se considerarem casadas, quase não houve menção aos maridos na rotina. A investigação, baseada nas rotinas da família, possibilita identificar os papéis familiares, as relações sociais e a organização de cuidados na saúde.

cuidado do lactente; saúde da família; família

Por medio de este estudio descriptivo, con enfoque cualitativo se investigó las rutinas de familias con niños lactantes entre 06 meses a 02 años de edad, cuyas madres trabajaban y tenían como referencia un Servicio Básico de Salud de un municipio del sur del Brasil. Como fundamento teórico fueron utilizadas las rutinas familiares. Siendo entrevistadas 25 madres, por medio de un formulario semi estructurado. El análisis de los datos cualitativos fue realizado por medio de las fases de organización, codificación, categorización e interpretaciòn. Identificándose que los cuidados en las rutinas familiares varían con la periodicidad, el horario y el tipo de ocupación de la madre. Se identificaron diversas alternativas de cuidado brindado al niño y, a pesar de la gran mayoría de las entrevistadas ser casadas, no fue mencionado el esposo como coadyuvante en las rutinas. Esta investigación permitió identificar los roles familiares, las relaciones sociales y la organización de los cuidados a la salud.

cuidado del lactente; salud de la familia; familia

ORIGINAL ARTICLE

The routine of families with nursing infants¹

Astrid Eggert Boehs^I; Márcia Grisotti^II; Marly Denise Wuerges de Aquino^III

^IAssociate Professor, e-mail: [e-mail]

^IIAdjunct Professor

^IIINurse, Secretary of Health of the Florianopolis Municipal Government, Brazil, Master student. Santa Catarina Federal University, Brazil

ABSTRACT

This descriptive study investigates the routine of families with nursing infants ages between six months and two years old, involving working mothers users of a Basic Health Unit in a city in the South of Brazil. The theoretical discussion is based on the families' routine approach. A total of 25 mothers were interviewed through a semi-structured questionnaire. The qualitative data analysis followed the phases of organization, codification, categorization and interpretation. The findings suggest that childcare routines vary according to the periodicity, schedule and occupation of the mother. Different alternatives to childcare were identified, and although most of the women interviewed reported to be married, they almost did not mention the husband's participation in the routine. The investigation based on family routines allows the identification of family roles, the social relations and the health care organization.

Descriptors: infant care; family health, family

INTRODUCTION

In the last few decades, knowledge construction in family health has emphasized the conception that the family represents a basic health unit ⁽¹⁾. In this conception, the family home is considered as a health producer because its internal resources, such as time, material and financial conditions, in combination with external resources, such as formal health services, aim to protect, maintain and restore the family ⁽²⁾.

In the 1980's, some researchers⁽³⁾, departing from the premise that social support constituted a mediator between a stressful life and susceptibility to diseases, appointed the imprecise nature and difficult measurement of this conception. Acknowledging that human beings have an elementary need for stability, predictability and continuity, they decided to focus on studies about domestic routines and rituals as a more objective way of assessing families' social support ans its relation with diseases. After a literature review and two cross-sectional studies involving families from different social classess and ethnic origins in the United States, these researchers⁽³⁾ attempted to understand the relation between the routines and the disease, defending the thesis that family routines are observable and repetitive behaviors that involve different group members and occur at a predictable regularity. Family routines can protect the health and well-being of their members, providing for stability and continuity during stressful period, promoting solidarity and cohesion.

More recently, one author⁽⁴⁾ attracts attention to the need for nursing to look at family health, recovering the concepts of routines and rituals previously mentioned⁽³⁾ and emphasizes the importance of this reference framework for care and research. In later studies ^(5-6), attempts were made to define the differences between routines and rituals: routines are repetitive and standardized activities, closely linked with daily and regular activities, while rituals are acts or actions conducted by a group of people, using one or more symbols in a repetitive, formal and precise way, described in terms of celebration, religious traditions and symbolic events.

In Brazil, a more specific study⁽⁷⁾ about rituals involving families of newborn infants concluded that the care given since birth as passage rites are important aspects in the nursing context. Another research⁽⁸⁾, aimed at understanding how families construct the family environment, elaborated a category called governing daily life. In this category, the families describe daily life routines within the focus related to the roles and tasks of their different members. However, these studies differ from the initially appointed approach ^(3-6), despite showing the importance of routines and rituals in nursing research.

Nowadays, in the Brazilian reality, efforts have been made to consolidate the Family Health Strategy (FHS). In this sense, understanding families' dynamics is essential to look after their health needs ⁽⁹⁾. Moreover, routine activities of daily living, such as eating, sleeping and preparing meals, constitute fundamental items for the functional assessment of the family ⁽¹⁰⁾.

Thus, this study aims to describe the routines of families with infants between six months and two years old, whose mother goes out to work.

METHOD

This descriptive study used a qualitative approach and was carried out in Florianópolis, Santa Catarina, Brazil, among families who lived in the area attended by a Basic Health Unit (BHU). The family routine approach was used as a theoretical reference framework ^(3-6).

The BHU is located in a neighborhood that includes different areas, marked by the conflicting relationship between communities considered native and new. The new immigrants come from other regions in Greater Florianópolis, from the interior of the State of Santa Catarina and from other Brazilian states⁽¹¹⁾. The Unit attends a population of approximately 18,000 inhabitants. It is operationally subdivided in four sub-areas, where four family health teams are active. The BHU offers space for the Multiprofessional Residency in Health and for curricular training activities for students from health courses.

In this study, a form was used to identify the mothers who would be interviewed. If the mother attended to the criteria, her permission was asked for the interview, which was then scheduled to be held at her home or, provided the mother was available, at the BHU. A semistructured form was used, which consisted of four parts: a) identification data; b) getting to know the family, which included the interviewed mother's perception of whom she considered as her family, a genogram, an ecomap^(10,12) and data about the main caregiver while the mother goes out to work; c) getting to know the mother's daily, weekly and monthly routines involving the family and the infant; d) care for the infant's health. The interviewees were recorded if allowed and, when this was not possible, records were made immediately after the end of the interview, attempting to maintain the interviewees' statements in full.

Three subject selection criteria were used. First, the family should include a child between six months and two years old. This age range was chosen in view of exclusive breastfeeding recommendations until the sixth month, which often changes and delays the mother's entry or return to the job market. The second criteria was the child's growth and development follow-up at the BHU, in accordance with the care protocol for children between 0 and 6 years old from the Florianópolis Health Secretary. The third criterion was that the mother should work regularly, at least three days per week.

A simple classification was used to analyze identification data of the interviewed mothers' characteristics ⁽¹³⁾. In the analysis of the genogram, family composition and structure were considered and, in the ecomap, the broader relationship networks the family members established^(10,12). As to qualitative data, the following steps of content analysis were followed: data organization, coding, categorization, inferences and interpretation ⁽¹⁴⁾. Data categorization corresponded to items previously established on the form: the interviewee's family, daily, weekly and monthly routines and care for the infant's health. Data were interpreted in the light of the family routine reference framework ^(3-6).

This research was approved by the Institutional Review Board at Santa Catarina Federal University, in accordance with Resolution 196/96 with respect to secrecy, anonymity, free and informed consent and the participants' freedom to stop participating in the study at any time.

RESULTS

Characteristics of the interviewees

Most (68%) of the 25 interviewed mothers' education level is restricted to basic education, 44% of whom unfinished and 24% finished. The remainder is taking or has already finished secondary education.

As to the type of occupation, 72% of the interviewees perform domestic functions. Fifty-six percent of this group works in families' homes, while 16% are cleaners in commercial establishments. The remainder (24%) mentions work as kindergarten aid, bakery aid, health agent, telephone operator, trainee and typist. More than half (52%) have a formal job registry.

It should be highlighted that 60% of the 25 interviewed mothers live in their own house and 36% in a rented house, while only one mother is living in a borrowed house. The neighborhood is characterized by great mobility, as 52% of the interviewees have only lived at their current address between one and six months. As to civil status, 72% of the interviewees consider themselves married^*.

All of the interviewees indicate using their salary to pay for primary needs: food, paying bills, rent and clothing. The main reason that made them go out to work was the "financial necessity".

The interviewees' families

When analyzing answers to the question about "whom they consider as part of the family" and when analyzing the genogram, it was found that the interviewees consider people who live with them as family. Some of them are traditionally composed by father, mother and children or mother and children, while others include mother, children, nephew and grandparents. When asked about who else they consider as part of the family, they mentioned other relatives who live in the same or in distant cities. In this case, the criterion they considered was kinship. They also mentioned relationships based on affection as important requisites to consider who is part of the family, including neighbors, babysitter and boyfriend.

In the analysis of the ecomap, the network of social relationships was identified. The work environment stands out as the most constant relationship of adults who are part of the family core. In some cases, the church and the neighborhood's health unit also appear. For the women, the mother and sisters generally appear as very close relationships and, in some cases, their children's caregivers were mentioned. For men, on the other hand, in the interviewees' perception, close relationships are more frequent with friends from work and/or soccer.

The child's caregiver

When the mother goes out to work, she needs to find alternatives to take care of the child. Two modes appeared in the data: the kindergarten, which can be public or private, and the private caregiver, which can be paid or not.

Only two mothers use the public kindergarten, which belongs to the municipal network and is free of charge as, according to the interviewees, there is great difficulty to find a place and, when they manage, there is the inconvenience that the service is only offered half-time. The interviewed mothers care in a public kindergarten as the ideal solution although few of them have the opportunity to achieve it, due to the reasons mentioned above.

There are two private kindergarten modes: formal and domestic. The formal mode, which is a private, for-profit institution, is officially regulated. The testimonies indicate the high monthly cost as a limiting factor for this mode. Domestic kindergartens are not regulated by official municipal entities. The service is delivered in a house where various children are joined.

In the private caregiver mode, the mother selects one person to take care exclusively of the child, whether at the caregiver's house or at the child's own house. In this mode, the cost of care is paid for through a formal payment. Some cases do not involve payment in money, but retribution of favors. In other situations, either other small children, from the age range of eight, or grandmothers take care of the child.

The choice of the private caregiver attends to some criteria. Some mothers choose girls younger than 15 to take care of the baby, while others consider the caregiver's experience important and, thus, look for neighbors who already have grandchildren.

Daily and weekly routines

When analyzing the answers about the daily routines of the interviewees and their families, two categories emerged: the sequence and the type of routine activities.

The sequence of routines is strongly related with the mother's type of occupation, education level, age, civil status and work hours. Three groups were identified: the first consists of ten interviewees who work full-time, five days per week; the second includes ten interviewees who work half-time, between four and five days per week; and a third group with five interviewees who randomly work a couple of days per week, depending on whether cleaning jobs come up.

Of the ten interviewees who work full-time (first group), only two are younger than 20, two are between 21 and 25 years, one 28 years and the remainder more than 30 years. With respect to civil status, 80% consider themselves married and 20% separated. This group contains women with more children and lower education levels: 70% did not pass the fifth year of basic education. Moreover, 80% work as maids, that is, workers who remain at the same house several days per week, either half or full-time. Only two of them have performed this function for less than a year, while the remainder has worked in the same place longer. Ninety percent have a formal job contract.

These women's routine can be translated by the following statement.

(...) I wake up early, at 6 a.m., I change the baby's diaper, I get her ready to leave, feed her and prepare breakfast for everyone. I leave, drop the baby off at the kindergarten and go to work. As the bus takes a long time, I only get there at 9 a.m. At noon, my older son (14 years), who studies in the morning, picks up the baby at the kindergarten (...). He takes care of her in the afternoon. He already knows what to do and I trust him. I get back in the late afternoon and prepare dinner, give her a bath and prepare food for the next day.

In the group who considered themselves married (80%), none of the mothers mentioned the husband in this routine.

In the group of five interviewees who "clean occasionally", considered in this study as casual cleaners (work in different homes during the week, without a formal contract, but registered), one is 29 years old and the remainder over 30; they have between one and three children; only one of them finished secondary education, while the rest did not get past the sixth year of basic education; as to civil status, one mentions being divorced while the others consider they are married.

These women have an unstable routine, as they work according to the cleaning opportunities that emerge. When they know that they are going to work the next day, they prepare their families' meals and clothing the day before and provide for a private caregiver. This person also has an unstable bond, as (s)he is requested occasionally. This instability generates constant changes in caregiver and also makes it difficult for the infant to create bonding. Only one of the interviewees mentioned her husband's help in housework and care for the child.

The group of ten women working half-time contains the youngest interviewees, that is, six mothers younger than 25, two between 26 and 30 years and two others over 30. As to civil status, six consider themselves married, three separated and one single. This group has a higher education level: only two did not finish basic education; three finished it and the remaining five are taking or have already finished secondary. Hence, this group contains the largest number of jobs outside the domestic sphere (50%), in which 80% has a formal job contract.

In the analysis of the social network, using the ecomap, it is observed that this group of women receives most help from family members, in most cases the child's grandmother. Thus, they can conciliate their domestic activities with formal work, with the possibility to take care of the infant one part of the day. Also, in this group, the husband is more present in reports on daily routines.

In the category of routine activities, activities appeared related to food, body hygiene, cleaning the house and taking care of clothing. These needs are attended to at more or less strict times, according to the groups mentioned above and the support from the social network the interviewed mother has at her disposal.

Weekend routine was not very different among the three groups: in one group, the mothers "do not go out because they do not have time" and use the opportunity to clean the house. In another group, the mothers mention "going out" to family members' home or other public places like the "park and the mall". Another option to go out at weekends is church.

Monthly routines could not be analyzed further, as the interviewees, perhaps because they do not conceive their life in the long term, alleged that they could not respond.

Infant health care

With respect to decision making in care for the infant's sleep, food and hygiene needs, various subjects were mentioned (some indicated various subjects at the same time): mother (16), grandmother (10), husband (4), sister (2), daughter (2), babysitter (2) and sister-in-law (1). The mother's and grandmother's predominance in this role is visible and, again, little mention was made of the husband in the interviewees' reports.

As to daily orientation, the interviewees indicated: grandmother (10), mother (8), physician (6), BHU team (4), mother-in-law (1), sister (1), aunt (1), husband (1) and sister-in-law (1). When reconsidering the mother's and the grandmother's role, on the one hand, and the physician's and the BHU team's on the other, the relation between health professionals' and family caregivers' practices is marked by complementariness. Moreover, again, the husband's almost total lack of participation in this process stands out.

In case of disease, the interviewees answered that it depended on the "severity". The categories "mild diseases" and "severe diseases" they mentioned implied different types of therapeutic courses. If the disease was considered mild, the mothers took care at home with medication or home-made teas, or took the child to the neighborhood BHU. If considered severe, they turned to the emergency sector of the hospital. The categories mild diseases and severe diseases were exemplified as follows.

Mild: flue, looking downcast. Severe: tuberculosis, pneumonia, diseases requiring hospitalization. [...] In case of mild diseases I take him to the station; in other cases (high fever for example) I take him straight to the hospital.

As to confidence in infant care advice, the interviewees indicated some subjects: the BHU physician (14), grandmother (9), mother (3), a family member (1), oldest son (1). Others indicated: nobody (1) and do not know (2).

DISCUSSION

The results of this study appoint a relation between the sequence and type of routine activities developed and the factors: education level, type of occupation and support from the social network.

The interviewees perceive low education level as a limiting factor in their insertion process in the job market and in the choice of the type of occupation, and also justifies their expectations about the future, as they hope for the possibility to continues studying, have a better job and being able to let the children study.

Social network is a system composed of people, functions and situations that offer emotional and instrumental support to people in their different needs ^(15-16). Moreover, it constitutes a mediator in stressing situations, favoring attendance to the human being's elementary need for predictability, continuity and stability ^(3-6) and allowing for the mother's insertion in the job market. In this study, this network is represented by people who, within (grandparents, aunts, sisters and adolescents and pre-adolescents) as well as outside the family (neighbors, friends and others), and either remunerated or not, perform the function of caregivers. The daily dynamics of this network influences the working mother's type of employment contract, periodicity and work hours.

It is observed that this network is fragile, as the mothers directly depend on a caregiver for the child, and is predominantly female, as the partners are hardly mentioned in the daily routine. This finding differs from another study⁽¹⁵⁾, carried out in a population with characteristics similar to this study, in which the mother considered the husband's/partner's support as more important than the others. On the other hand, this network plays a crucial role in the mothers' job maintenance (as she cannot count on her partner's help) and allows them to contribute with basic material goods, which guarantee continuity, predictability and stability by attending to housing, food and clothing needs.

In decisions about daily care for infants, as well as in disease situations, the female network constitutes a bridge to find resources outside the family circle, where the physician was the most indicated professional.

This network contains weaknesses, mainly for those interviewees with little qualification and without support from the extended family, such as occasional cleaners for example, who need to pay a caregiver from the low amount they receive. Thus, they hire other women, for an extremely low amount, using merely the following competence parameters: the person needs to be calm, has some experience (in the case of the elderly, because they have grandchildren and, in the case of young people, because they take care of their siblings).

These interviewees' unstable routine demands constant changes in caregiver, which should be considered negative as these infants need bonding and care delivered by responsible and trained persons. It is considered that health services still lack more systemized data about who actually takes care of the children in neighborhoods with poor populations when the mother needs to work and when kindergartens are insufficient. Therefore, a primary task in promoting the health of children in basic care would be to identify the caregivers' situation while the mothers leave their homes to work.

What the aspect of caregivers is concerned, a phenomenon occurs which seems to be rooted in the Brazilian culture, in which women are responsible for taking care of the children. It is perceived as "natural" that, when the mothers go out to work, the other women, appointed in this study, whether younger or older, and also following their "natural" aptitudes, perform these functions, whether paid or not and qualified or not. It should be highlighted that, often, the naturalization of socially constructed abilities can intervene in the direction of public policies ⁽¹⁷⁾. The results show this phenomenon, as the female network, although fragile and overloaded, permits the mother's insertion in the job market, transfiguring that, apparently, kindergartens are sufficient, children are being cared for and public authorities are complying with their functions.

Finally, this kind of research based on families' routines is considered relevant for nursing as well as for other health professionals, as it permits understanding the daily family life of mothers of infants who go out to work. Based on these aspects, it is relatively easy to identify the family roles, how the different members relate inside and outside the family, how they get organized to attend to basic needs, in health promotion and disease situations, mainly childhood diseases, as well as health professionals' possibilities to strengthen or help the family group.

ACKNOWLEDGEMENTS

We are grateful to nurse Daniela Mafioletti Floriano for her help in planning the research, as well as in data collection and registry.

Recebido em: 6.3.2006

Aprovado em: 14.2.2007

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1

Financial support from Funpesquisa/Santa Catarina Federal University. General support from the Nucleus of Research and Extension in Popular Education, Nursing and Health NEPEPS

*

Women living in non officialized relationships were considered as married, in accordance with the interviewees' perception

Publication Dates

• Publication in this collection
  17 Dec 2007
• Date of issue
  Oct 2007

History

• Received
  06 Mar 2006
• Accepted
  14 Feb 2007