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Revista Latino-Americana de Enfermagem

On-line version ISSN 1518-8345

Rev. Latino-Am. Enfermagem vol.17 no.3 Ribeirão Preto May/June 2009 



The use of social network methodological framework in nursing care to breastfeeding women



Maria Helena do Nascimento SouzaI; Ivis Emília de Oliveira SouzaII; Florence Romijn TocantinsIII

IPh.D. in Nursing, Adjunct Professor, Escola de Enfermagem Anna Nery, Universidade Federal do Rio de Janeiro, Brazil, e-mail:
IIPh.D. in Nursing, Full Professor, Escola de Enfermagem Anna Nery, Universidade Federal do Rio de Janeiro, Brazil, e-mail:
IIIPh.D. in Nursing, Full Professor, Escola de Enfermagem Alfredo Pinto, Universidade Federal do Estado do Rio de Janeiro, Brazil, e-mail:




This study aimed to discuss the contribution of the social network methodological framework in nursing care delivered to women who breastfeed their children up to six months of age. This qualitative study aimed to elaborate the social network map of 20 women through tape-recorded interview. Social network analysis evidenced a "strong" bond between these women and members from their primary network, especially friends, neighbors, mothers or with the child's father, who were reported as the people most involved in the breastfeeding period. The contribution of this framework to nursing practice is discussed, especially in care and research processes. We believe that nurses' appropriation of this framework can be an important support for efficacious actions, as well as to favor a broader perspective on the social context people experience.

Descriptors: social support; qualitative research; nursing research; nursing




The social network approach emerged in human sciences, especially in sociology and anthropology, and has been increasingly explored in the health area. The trend to include issues related to social network in research instruments addressing populations' health conditions is based on the understanding that individual or collective health is the result of complex relations between biological, psychological and social factors(1-2).

Social network is understood as a "set of interpersonal relations that determine a person's characteristics, such as: habits, customs, beliefs and values", and this network might provide emotional or material help, services and information(3-4). The expression social network also indicates a set of situations that evidence affective, friendship, work, economic and social relationships. People are therefore inserted in a relationship network in which they are considered social subjects who interact with the world that surrounds and influences them and is also influenced by them. These relationships might be important at certain moments, and irrelevant or absent at others(5-6).

In this perspective, the study of social networks permits the understanding of how social networks influence actions taken by individuals in view of their specific needs.

According to some authors, social networks positively affect people's health, protecting them from diseases, whereas relatively poor social relations represent a risk to health(7).

In the health area, more specifically in nursing, qualitative methodology guided by theoretical frameworks from human and social sciences has been increasingly used, which indicates that interventions focused on the biomedical model have been insufficient to understand the populations' real needs(8).

In this perspective, concepts of social network and support have been presented as resources applicable to nursing practice with a view to improving the quality of life of families receiving care. However, literature shows that a consensus on these two concepts has not been achieved in the nursing area and that, most times the concept used to understand interpersonal dimensions is social support(9). This lack of agreement on these concepts, as well as scarce research on the methodological framework of social network of breastfeeding women, justify this study.

We opt to address nursing care delivered to breastfeeding women to discuss the use of the social network framework, based on the relevance of having a broader perspective, and need to be attentive to the factors involved in breastfeeding because its experiences are permeated by both biological and sociocultural dimensions(10).

The value of mother's milk is unquestionable from a nutritional and emotional point of view, considering that it is anti-infectious, immunological, economic and anti-contraceptive, among others. It is a consensus that it should be children's exclusive source of nutrients during their first six months of life, although early weaning rates are still high(11).

High rates of early weaning reveal that, in practice, breastfeeding is not instinctive or automatic, but an action based on women's subjectivity and experience, which are influenced by their social context. In this context, breastfeeding women can play diverse roles like: family head, single mother, have a paid work, be an adolescent, live in places with poor sanitary conditions, among others, which reveal the need and importance of support from a relationship network(6).

Based on the above, this study aimed to discuss the contribution of the social network methodological framework to nursing care, through its application to women who breastfeed their children up to the age of six months.

Social networks: nature and characteristics

Social networks can be primary or secondary. In primary networks, the bonds established are characterized by relations of parenthood, friendship or neighborhood, and are based on reciprocity and trust.

Secondary networks can be formal and/or informal, from the third sector, market or mixed. They differ by the kind of exchange: reciprocity, entitlement, money or a combination of these.

Formal secondary networks are composed of official social and structured institutions (health, education institutions and others), and are characterized by service delivery according to people's demands and by exchange based on entitlement.

The composition of informal secondary networks starts from the primary network, based on common needs or difficulties experienced by members of the same network. In this network, bonds are based on solidarity and services are exchanged, not money.

Third sector secondary networks or third sector organizations are associations or organizations composed of people from the civil society who deliver services but do not aim for profits; are characterized by exchanges based on entitlement and solidarity. On the other hand, market secondary networks are related to profitable economic activities and their existence is closed linked to money and profits, like commercial establishments and private health clinics. In this case, exchange is based on entitlement and money(3-4).

An individual's relationship network can be analyzed through the elaboration of a map of his(er) social network and is based on qualitative research that permits understanding the dimension, the way social connections are established, as well as meanings of actions and human relations.

In order to analyze a social network, it is necessary to know, among other factors, how it is presented, that is, its structure. In this perspective, some indicators permit understanding how these connections are established in people's relational context that composed the network. They are: range - related to the quantity of people and permit affirming whether a given network is small, medium or large; density - refers to the quantity of people who know each other; intensity - refers to the type of exchange, whether exchanged things are material, affective or informative; closeness/distance - permits reflecting on the affective distance and reveals levels of intimacy; frequency - indicates the regularity at which bonds are established; duration - indicates the time of acquaintance between people in the network; physical proximity - refers to the place of residence of members composing the network(3-4).



This qualitative descriptive analysis was carried out with 20 women living in a needy community, in Rio de Janeiro, RJ, Brazil, who were experiencing the breastfeeding process with a child younger than six months of age.

After identification, these women were invited to participate in the study, received explanation about objectives and read the free and informed consent term. The interviews, previously scheduled, were tape-recorded and held between January and February 2005 at a central place in the community.

To elaborate the social network map, we initially asked participants to list people they knew and who were present in their lives during the breastfeeding period. These people could be relatives, friends, neighbors, acquaintances, co-workers or members of institutions.

According to the study objective, these names can be chosen from a list of people with whom the person is regularly in touch, from the description of the person's daily routine or yet, in response to a precise question. Before people start listing the names, they have to be clarified about the interest in studying their social network. Establishing a relationship of trust with the person to be studied is also essential because it ensures that the identification and exploration of networks are more truthful(3-4).

During the interviewees' report, we asked them to help the researcher to draw a representation of people or families close to or distant from their family context, work ties and institutions they attended to get benefits, indicating the position these occupied in relation to them. On that occasion, two charts were presented, one with geometric figures representing the members of their network (Figure 1) and another with a graphic representation of the layout corresponding to the type of bonds established (Figure 2). With these two charts, women easily identified the types of bonds they had with the members of their social network.





The study followed the guidelines recommended by Resolution 196/96 of the National Health Council(12) and was approved by the Research Ethics Committee at Anna Nery School of Nursing. To preserve participants' anonymity, fictitious names were used to identify them in the social networks maps.



The knowledge process on the social context of the studied women reveals that they actively participated in the elaboration of their social network map. It was evident in view of their interest in adding to or subtracting people from their network, so as to have the most comprehensive representation possible of their context. Another relevant aspect was the fact that these women observed their relationship network and started to reflect on their lives, despite all adversity that surrounded them.

The social network maps obtained during interviews permitted an overview of the relational context of the women participating in the study. As an example, the map representing the social network of the interviewee Bia is presented (Figure 3):



Bia's map evidences a medium-sized primary network, with low density, that is, it is composed of 13 members who establish few relationships among them. The map reveals Bia has a strong bond with her mother, spouse, daughter, nephew, siblings, uncles and aunts, with her employer I and with her neighbor A. However, her relatives (mother, siblings, uncle and aunt) live in Maranhão, very far way. Because Bia was on maternity leave during that period, she was not frequently in touch with her employer. She also identified two other neighbors, three friends who live in the community and four friends who live in another neighborhood. However, she referred to these relationships as circumstantial - she related with friends and neighbors because she needed to pass by them to get to her house and the involvement with friends was because she had lived in another community. This way, Bia revealed that these relationships did not influence her breastfeeding practice and the type of bonds maintained with these people was normal.

Bia's family depends on her and her spouse's job to survive, which constitute her market network.

Another aspect that should be taken into account is that she did not include names of people working at the Maternity or the Municipal Health Center (MHC), which compose the secondary network, indicating there are no ties with professionals from these institutions and that their relationship is superficial.

Bia reported that, during the period of five months after delivery, while she was exclusively breastfeeding her daughter, the person she was mostly involved with and whom she could count on was her neighbor. This neighbor was mentioned several times as the one who actually provided her with support, as her mother lived in Maranhão.

Analysis of the 20 studied women's maps revealed that their social networks were composed of the following members: mother, spouse, father of their other children, siblings, parents, cousins, grandparents, uncles and aunts, sister-in-law, mother-in-law, the child's godmother, nephew, neighbors, friends, acquaintances, employer, health professionals at the Maternity and Municipal Health Center, daycare employees, schools, church and Social Work Center. The majority of women, however, reported that members of their social network who were most involved in the breastfeeding phase were the mother, one friend or neighbor (Table 1).




The fact that the majority of studied women reported they could count on the involvement of the mother, a friend or neighbor, evidences the predominance of the female figure by their side, i.e. the female figure was more familiar. Thus, the family environment is the first place of reference for women having to face the breastfeeding process post delivery. During this phase, due to the closeness to family members, women can exchange knowledge and share experiences, habits and conducts(13).

Regarding the presence of members of the secondary network in the breastfeeding process, especially health professionals, we verified that these members were not reported as the most involved during the process. Discourse analysis revealed that the secondary network does not provide support to breastfeeding women during this process because they seek help among members of their primary network, composed of family, friends and neighbors.

In this perspective, we highlight the importance of nursing care in the puerperal period as a way to broaden the contact of these women with their secondary social network, diminishing the social isolation that is characteristic of this phase. Acknowledging the social network grants these women-mothers the feeling of being loved, valued, of belonging to a group, which helps them to escape from a condition of isolation and anonymity(2).

It is worth mentioning that, even though women reported that their social networks were composed of family, friends, acquaintances, neighbors, health professionals and others, these members were not always involved in women's lives during the breastfeeding process, so that they would be able to establish a relationship of trust and seek the necessary support and help. Thus, some women mentioned they had not counted on the majority of the members of their social networks during breastfeeding and claimed they felt alone and did not perceive close relationships with the professionals who attended them in health services.

We observed that, many times, when women are attended at a health service, their subjectivity is not addressed and they end up establishing an anonymous relation with the professional delivering care. Thus, it is increasingly necessary to establish interpersonal relations between nurses and women so as to permit experience exchange and see to their real needs(14-15). Therefore, nurses should favor women's verbalization of their desires, expectations and difficulties during the breastfeeding experience that is oftentimes a new one, so as to enable interventions according to the singularity and daily life of each client. Taking this issue into account, the Ministry of Health recommends health professionals to promote, protect and support breastfeeding, through a multidisciplinary approach, considering the singularity of women in their context, treating them with respect and attention. "Giving them a voice, allowing them to calmly express their doubts, fears and previous knowledge on breastfeeding allows the emergence of this woman/mother/nourisher, what she thinks, what kind of help she needs and what she decides to do to breastfeed"(11).



The social network methodological framework permitted verifying that the elaboration phase of the map of these women's social networks meant something to them. Because they were seen in their singularity, they felt free to talk about their life and their relationships, allowing them to appear as subjects and protagonists of their history in a context in which breastfeeding involves more factors than giving their children their own milk.

Therefore, we verified that understanding the relationships established between breastfeeding women and members of their social network implies opening a broader reality that transcends biological aspects involved in the breastfeeding process and which are not restricted to classical orientations on advantages and techniques of breastfeeding. This understanding allows nurses to perceive breastfeeding as a social practice with elements defined by culture(10) and to consider women as the protagonists of the breastfeeding process in a certain context and intentionality, helping them to acknowledge the presence of other people who, in their daily life, can help them during the entire breastfeeding period.

Therefore, professionals need to be realistic and take into account the constrains involved in the breastfeeding practice, that is, professionals need to face these women detached from their ideas or preconceptions on breastfeeding, willing to understand the context these women live in, established relationships, their expectations regarding these relationships, difficulties or problems they face or expectations they have regarding the health service. In this attitude of openness and observation, women allow professionals to know them and professionals, in turn, have the opportunity to grasp the phenomena these women experience and intervene according to the reality showed, based on what women reveal, on what they are and are not, on what they need to learn, to do or follow.

This study evidenced that the primary network needs to exist for the secondary network, that is, the breastfeeding woman needs to be acknowledged by health professionals as a person with a name, experiences, problems, motivations, intentions, who is a "being", a "being with others". Oftentimes, health professionals do not have resources to concretely help women in work, family or domestic situations and others. But in a professional welcoming relationship where concerns are shared, mothers can be helped to find solutions or support to conciliate breastfeeding in their context.

One of the strategies for care to breastfeeding women is the establishment of breastfeeding support groups. These groups can strengthen social networks and help women during the entire breastfeeding period. Living among other "close" and "equal" people, women have the chance to acquire knowledge and understand conducts based on the experiences of other women.

Household visits in the first weeks after delivery are also an opportunity for health professionals to know social networks, help women to identify one member who can help them cope with everyday situations and provide support to the breastfeeding family.

In this perspective, this study supports the formulation and implementation of public policies, as well as interdisciplinary work of health professionals who, based on an overview of women's relational context, can consider and strengthen bonds established in the primary network when planning their actions and convene family members and friends to consultations.

Thus, we observe that the use of the social network framework points to improved qualitative research as well as to the innovation of health intervention processes. The appropriation of this framework by researchers in the health area, including those from the nursing area, supports an understanding about the efficacy of their actions in professional practice and favors a more comprehensive perspective of the social context people experience.



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Recebido em: 27.3.2008
Aprovado em: 3.3.2009

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