Beliefs and cultural values of the undernourished child's family

Creencias y valores culturales de la familia del niño desnutrido

Crenças e valores culturais da família da criança desnutrida

ORIGINAL ARTICLE

Beliefs and cultural values of the undernourished child's family^*

Crenças e valores culturais da família da criança desnutrida

Creencias y valores culturales de la familia del niño desnutrido

Mirna Albuquerque Frota^I; Rosalba Maria Viana de Sousa^II; Maria Grasiela Teixeira Barroso^III

^IPhD, Professor of the Universidade de Fortaleza - UNIFOR - Fortaleza (CE), Brazil

^IINursing of the Prefeitura Municipal de Fortaleza - PMF - Fortaleza (CE), Brazil

^IIIFree-Lecturer Professor Emeritus of the Universidade Federal do Ceará – UFC - Fortaleza (CE), Brazil

^{Corresponding Author}

ABSTRACT

OBJECTIVE: To identify and analyze the meanings of the mothers' participation in looking after their undernourished child.

METHODS: An ethnographic approach was adopted, focusing on group dynamics within the family.

RESULTS: Family influence in undernourished child care and the prevention of current and future practices related to the factors impede quality care.

CONCLUSION: The cultural meanings that guide mothers, in terms of care, support, education and culture, are sustained by the social structure and have direct effects on the quality of people's life, as individuals and as social groups.

Keywords: Child nutrition disorders; Health promotion; Culture; Child health; Family

RESUMO

OBJETIVO: Identificar e analisar o significado da participação das mães no cuidado da criança desnutrida.

MÉTODOS: Foi utilizada uma abordagem etnográfica, focalizando na dinâmica de grupo dentro da família.

RESULTADOS: Foi evidenciado que a família influencia no cuidado à criança desnutrida e a prevenção das atuais e futuras práticas relacionadas aos fatores culturais impedem a qualidade do cuidado.

CONCLUSÃO: O significado que conduz a mãe, em relação ao cuidado e suporte, educação e cultura são sustentados por uma estrutura social e tem efeitos diretos na qualidade de vida das pessoas, como indivíduos e também como grupo social.

Descritores: Transtornos da desnutrição infantil; Promoção da saúde; Cultura; Saúde da criança; Família

RESUMEN

OBJETIVO: Identificar y analizar el significado de la participación de las madres en el cuidado del niño desnutrido.

MÉTODOS: Fue utilizado el abordaje etnográfico, focalizando en la dinámica de grupo dentro de la familia.

RESULTADOS: Fue evidenciado que la familia influye en el cuidado al niño desnutrido y la prevención de las actuales y futuras prácticas relacionadas a los factores culturales que impiden la calidad del cuidado.

CONCLUSIÓN: El significado que conduce la madre, en relación al cuidado y soporte, educación y cultura son sustentados por una estructura social y tiene efectos directos en la calidad de vida de las personas, como individuos y también como grupo social.

Descriptores: Trastornos de desnutrición infantil; Promoción de la salud; Cultura; Salud del niño; Familia

INTRODUCTION

Developing countries continue to struggle with the complexity and diversity of health problems. Technological changes exerted a strong influence on health care. These changes lead to a constant search for quality; a tendency imported from large industries, and that starts to take over the health industry as well. Even though there is a significant investment in hospital technology, there are undernourished children in different regions and even in families with the same financial power, showing, thus, a serious problem of health policies⁽¹⁾.

The situation in the North-East of Brazil, for example Fortaleza – in the State of Ceará, demonstrates the growth of the rural exodus, which has crowded the slum population, increasing the crime, prostitution, and violence rates. In this sense, people who live in slum areas endure a daily battle for survival. As a result, malnutrition has become a children's disease. The greatest impact is to children under five years of age, because of their physical vulnerability in addition to the socioeconomic factors.

A Continuous Education Program (CEP), was organized by the Instituto de Prevenção à Desnutrição e a Excepcionalidade – IPREDE (The Institute for the Prevention of Exceptionality and Malnutrition), in which workshops were given by a multiprofessional team. The workshops were organized for the benefit of the mothers of undernourished children, although any other family member - fathers, grandparents, uncles, aunts - and even neighbors were invited, since they often accompanied the children. The professionals were particularly disappointed because, apparently, to be successful in achieving their health education aim, meant offering ways for possible transformations in people/communities.

In addition, family and clients have complicated characteristics that present a challenge for health professionals. The experience of living together with undernourished children in Brazil must be considered first from the family perspective to then be thought within its "second world" context, in addition to an understanding of both medical and social/cultural models of health and disease. The family world is complex; it has its own living process, which may not have similarities with others families.

However, the family has the liberty to expose feelings and doubts, and shares faiths, values, and knowledge. This implies that the family has an integral strength the most important influence in child health care. Assessment and intervention with the family group is often more effective and successful if based on clear therapeutic goals. First, it is necessary for the health professionals to engage in the family with the proposal to help the behavior change. The change does not necessarily occur equally in all family members⁽²⁾.

It is understood that the problem of malnutrition tends to be solved in conventional health care, as it is for the family, considering that hunger is associated with symptoms and clinical manifestations. Although it is sometimes important to see this relationship, it is equally important not to separate the contribution of poverty to "health-disease" by focusing only on the clinical treatment. Many professionals involved in the malnutrition treatment recognize that the socioeconomic and cultural aspects of hunger are as important as the clinical manifestations. More and more, we have been moving away from the clients' basic needs, because the biomedical model has prevailed in the country's health systems. As for the health system's response to expectations and needs, there were some striking characteristics, varying between health needs defined by the dominant biomedical model as compared to the people themselves^(3-5).

An analysis of education through life evokes the ideas of Paulo Freire, for whom education is part of the everyday life. Education should be seen as an instrument of transformation, which can help people if they discover and develop its potential for individual and collective growth. Conceived in this way, education implies an effort from each person to become subjects of their own learning. This learning is not isolated, since it takes place in a relationship with other people who have common objectives⁽⁶⁾.

Even though malnutrition is sometimes understood as an individual problem, this study calls attention to the fact that malnutrition contributes to an increase in disease as well as to physical and mental disorder. Consequently, the population has a shorter life expectancy and lower work production potential. This means that malnutrition is a collective problem. Therefore, lack of basic education is considered an underlying problem in the described situation, since it is directly related to the quality of life of this population and to health care.

However, it is important to notice that when developing health education activities, it is necessary to consider "freedom education", where the family participates, discussing its thoughts and world vision, implicit or explicitly. Professionals should make the purpose an educational one, and the focus of action should be to share and explore the family's faiths and values, which seek services regarding information about health, as well as to discuss practical implications. The educational system needs to focus on people, regarding their relationships with the world, to become effective rather than counter-productive. Overall, the situation of banking education is indicative of one in which the culture of silence is enforced: relationships are forged between those who would like to name the world according to their education perceptions and those who are denied their own right to name the world at all^(7-8).

In this context, communication is important when developing actions that involve health promotion. According to the literature, the communication theory and health promotion refers to the relationship with innovation-diffusion theory, interest that an innovation that concerns new forms of behavior related to health practices requires communication and that diffusion is the process by which an innovation is communicated⁽⁹⁾.

Therefore, the present study is important due to its focus on understanding the reality of the child's family context. It is relevant to have an integrated approach that includes the family, involving child care during the first three years of life, with guidance about malnutrition, infectious prophylaxes, and transmissible diseases, because everything that happens in the first years will directly affect the child's general state.

The aims of the study were to identify and analyze the meanings of the mothers' participation in the care for their undernourished child.

METHODS

Ethnography was adopted as one of the best choices to approach the cultural context of the clients and their meanings, feelings, cultural practices, beliefs, taboos, which are related to health and illness and their attitudes to cope with risk situations. First, it is necessary to become immersed in the lives of the subjects. Then, after achieving a deep understanding through rigorous effort, produce a contextualized reproduction and interpretation of the stories they tell^(10-11).

The study was carried out at the The Institute for the Prevention of Exceptionality and Malnutrition (IPREDE). It is a non-for-profit civil organization, based on a philanthropic rather than political character. The policies that permeate the work of the institution are concerned with analyzing hunger and malnutrition not simply as a world problem concerning overpopulation or unequal distribution of income. We believe there is a more complex conjunction of problems dependent on more difficult solutions, in which economic, social and political influences have to be investigated. The study participants were mothers who accompanied their undernourished children to the outpatient and inpatient department of the IPREDE. The main research instrument used was the Culture Circle technique⁽¹²⁾ of Paulo Freire. The technique helped to understand the world of the undernourished children's families and showed the ways by which those families cared for their children, their cultures, faiths, and lifestyles.

Data collection was done using the Model of Participation, Observation and Reflection, in which the researcher remains an active observer, listener, participant, and reflector of what transpires⁽¹³⁾. It was possible to identify what occurs naturally in the environment and in interactions with mothers of undernourished children. After gradually learning about the informants' world, becoming participants in their lifestyles. Observing the mothers, listening to stories during the Culture Circle, using periods of silence, being patient, keeping focused on what is being told or what is happening is critical to obtain accurate, meaningful, sequential and authentic data. It was important to document actives about care and health needs in the data collection.

The analysis of the data was supported by the ethnographic method, and data collection was accomplished following the Leininger's Phases of Ethnonursing Analysis for Qualitative Data, which are: First Phase – The researcher collects, describes, records, and begins to analyze data related to the purpose, domain of inquiry, or questions under study. The Second Phase – Data are coded and classified as related to the domain of inquiry and sometimes the questions under study. Recurrent components are studied for their meanings. The Third Phase – Data are scrutinized to discover saturation ideas and examined to show patterning with respect to meanings-in-context and along with further credibility and confirmation of findings. Fourth Phase – This is the highest phase of data analysis. It requires synthesis of thoughts and interpretation of the findings⁽¹³⁾.

The study was approved by the Research Ethics Committee of the University of Fortaleza – UNIFOR. Participants were given verbal and written information about the project. The mothers of undernourished children provided written consent.

RESULTS

A variety of subjects (breast feeding, parasite, malnutrition, etc.) were discussed in the first and second Culture Circle by observing and participating with the mother who accompanied the hospitalized child. Questionnaires and predetermined ideas were not used, but, through the interaction, it was possible to learn about life, as well as the perceptions and perspectives of each informer.

In the development of the Culture Circle, we placed ourselves as facilitators or coordinators and stimulated the dialogue. We tried to reduce the differences between researcher and researched in order to discover the mothers' common vocabulary. We observed and identified their thoughts through the words they used, and identified the cultural values. Using these talks, it was possible to generate key words and phrases common to these mothers.

The general keywords were: parasite, breast-feeding, diarrhea, fever, work, abortion, husband, family, prayer, and discharge from the institution. Each word meant many concerns, fears and hopes of the mothers; for instance, living with pain, always dreaming about the child's recovery, and living with starvation. Thus, each word offers countless characteristic difficulties of a suffering people.

In the third and fourth Circle of Culture, therefore, it was possible, through the participation and observation, to select the words that emerged through the mothers' daily speech. They seemed to represent the symbolic language relevant to the most significant situations of the collective life, which was part of the mothers' reality, and their beliefs about how to plan the next baby. I drank tea made from marijuana, cytotec is very expensive. I don't like condoms, pills make me sick and I don't know how to raise another son alone.

Another link was observed in the mother's talk. My mother said that a child that is breastfeeding has diarrhea. In our society, it is intriguing to consider the accusation patterns in families' experiences. Frequently, when a disease causes interpersonal conflict inside a family, their members often accuse something or someone else from outside the family for their health problems.

There is divergent interpretation between health professionals and mothers about the importance of breastfeeding, which seems to disagree with the cultural elements presented in this study. My child is breastfeeding and we are very close.

Another relevant point relates to the beliefs in care for their undernourished child is the association with the parasite problem. Thus, it was observed that the mothers related clinical symptoms such as diarrhea and parasite with malnutrition. He got thin after the parasite crisis.

In the fifth Culture Circle, there was a strong feeling from most group members that their husband did not collaborate in the relationship, being aggressive, not contributing to childcare, and drinking excessive amounts of alcohol.

I didn't come yesterday to stay with my son, because my husband was arrested because of alcohol, so I went to bail him out.

All interviewees highlight the aspects of the lack money to buy medicines, food, and most of the times they cannot work because it is necessary to take care of their children. I don't have money to buy medicine for my son. Therefore, they emphasized, they end up living with their mothers due to the difficulties they face to live with their husbands.

When he knew that I was pregnant he didn't want to be with me, he does not give anything for the boy, he does not want to see his son, if it was not for my family the boy would be worse. Her father wanted me to get an abortion, I told him: don't worry; I'll raise my daughter alone.

In this path, the right to health in its collective and social dimension is the basis of equality: health should be guaranteed for everybody. The field of public health is, fundamentally, a main concern of family health, while social right has to be guaranteed by the State as an essential service. Education should prepare people to have a critical view of the alternatives proposed by the government and give them the opportunity to choose their own way.

In the two last Culture Circles, following reflection on key and general words and starting from the code, the cultural theme emerged, which was: Beliefs and cultural values from the undernourished child family.

The mothers' concern can make them not follow the advice given about taking care of the child and could result in the child's return to the institution. It is worth to point out that a wide variety of beliefs hold together a care attitude. The presence of faiths and traditional beliefs in the mothers' language characterizes the people's culture suffering daily difficulties. The son has urine problems, because it is always full of ants in the cradle. My daughter got undernourished after my neighbor visited us. Before coming to Iprede I took her to a woman to pray and I gave her all kinds of tea. I don't like hospitals, I am worried about my other children, I wish I could go back home.

It was clear that some mothers wanted their children to leave the Institution so that they could return to their homes. Mothers also perceived their hospitalization experience with the child and the symptoms noticed at home, besides conversations with other parents, as resources that facilitate making decisions about the undernourished child's care. Alternative health practices frequently offer hope when the limits of more conservative exhaustive medical treatment. Mothers use home remedies and they do not tell health professionals about it.

DISCUSSION

All interviewees mention the importance of the mothers' participation in care for the undernourished child. However, it is necessary to reflect on what constitutes "care", particularly when mothers listen to healthcare advice on children care, but do exactly what they believe to be the best for the child, which often does not agree with the advice they received.

Care is a powerful and significant means to explain the health and well-being of people in their culture. In fact, health care professionals are realizing the power of using explicit care to heal and improve health⁽¹⁴⁾.

In a complementary way, the illness experience depends on the beliefs that have embraced experience priorities as well as the beliefs that involve illness experiences. The family members beliefs are often reconstructed after the experience of an illness⁽²⁾.

In general, the family consequences due to illness have this in common: each family must make sense of their own experience. Cultural and ethnic differences, social class and economic constraints, and many other factors will manifest as a part of a family's construction of reality. Understanding the influence of the illness on the family's needs, when the family becomes the focus, it is seen that the illness influences relationships as profoundly as it is for the subject⁽¹⁵⁾. Most of the time, the person is not aware of how culture develops. However, popular culture develops in the day-to-day life, through one's small gestures and lifestyles.

Literature highlights that the informants hope that generic care-cure models will be recognized as the first and last ways to prevent illnesses, treat human conditions, and heal those with illnesses. The prevention of current and future practices related to cultural imposition, cultural conflicts, cultural pain, and other cultural factors impede quality care⁽¹³⁾.

Among the several themes, which appeared from the mothers' cultural reality, the selected theme was that concerning the beliefs, faiths, and myths in the care of undernourished children, which had a direct relationship with the study object. Based on the statements of the participants, it was noticed that the care delivered to the undernourished child varied according to family lifestyle in the context of its own culture. Each family, as revealed by the mother, shows its own way of taking care of children, determined by its resources, and facing difficulties, such as acquiring food, which are day-to-day uncertainties for these people^(16-18).

The presence of faiths and family beliefs, which form a link between the mother and the child's care, are characteristic of the Brazilian culture. The mother, in the constant fight against the child's disease, seeks prayer as much as the health-care system. It was also observed that such people in pain seek Catholic folk healers or rezadeiras (prayers) to cure them from health problems, in this case, the malnutrition⁽¹⁹⁾.

We found that effective health can produce changes in knowledge and in the way of thinking. Furthermore, it can affect cultural values and facilitate the acquisition of abilities, therefore causing change in the families' behavior and lifestyle.

CONCLUSION

Through the results of this study, it is reaffirmed that the meanings of mothers' participation in care for their undernourished child is related to the cultural values and beliefs, and characterized by the family influence. It was also possible to identify other associated factors, such as education and socioeconomic structure.

The study points out the importance of educational actions for the health services, focusing on risk situations, mainly with undernourished children. One crucial need for the health care is to understand the family's real day-to-day situation.

Each family from the research has its own beliefs and cultural values about health, as well as explanations on the origin and cure of the diseases. It is necessary for professionals to learn about the infinite complexity of family life. But, at the same time, these families need information and understanding if these are to be transformed into new behaviors and new habits. For this to happen, it is necessary that health professionals use a holistic approach to care, because without it, development will not occur.

In summary, the participation of all health professionals can contribute to the reduction of malnutrition and its consequences through preventive programs involving the attendance to the undernourished children families. Indeed, the cross-cultural factors may in fact be the critical indicators for health promotion and maintenance.

ACKNOWLEDMENTS

The present study had the financial support of the Fundação Cearense de Apoio ao Desenvolvimento Científico e Tecnológico – FUNCAP- MS, and of Patrícia Bathory – USA, who reviewed the English version of this article.

Received article 04/04/2007 and accepted 18/09/2007

* Study caried out at the The Institute for the Prevention of Exceptionality and Malnutrition (IPREDE).

• ¹
  Brasil. Ministério da Saúde. Saúde no Brasil: contribuições para a agenda de prioridades de pesquisa. 2a ed. Brasília: Ministério da Saúde; 2006.
• 2. Wright LM, Leahey M. Nurses and families: a guide to family assessment and intervention. 3rd ed. Philadelphia: FA Davis Company; 2000.
• 3. Bunton R, Macdonald G. Health promotion: disciplines and diversity. London: Routledge Press; 1992.
• 4. Azevedo LO, Queiroz RSB, Rezende CEM. The World Health Survey: a report on the field experience in Brazil. Cad Saúde Pública = Rep Public Health. 2005; 21 Suppl 1: S25-32.
• 5. Ferreira HS. Desnutrição: magnitude, significado social e possibilidade de prevenção. Maceió: EDUFAL; 2000.
• 6. Freire P. Educação e mudança. 23a ed. Rio de Janeiro: Paz e Terra; 1999.
• 7. Freire P. Pedagogy of the oppressed. New York: Continuum; 2002.
• 8. Tones K. Health education as empowerment. In: Sidell M, Jones L, Katz J, Peberdy A, editors. Debates and Dilemmas in Promoting Health: A Reader. London: Open University/Macmillan; 1997. p.33-42.
• 9. Macdonald JJ. Primary Health Care: medicine in its place. London: Earthscan Publications; 1994.
• 10. Vieira NFC, Vieira LJES, Frota MA. Reflections on the ethnographic approach in three research studies. Rev Latinoam Enferm. 2003; 11(5):658-63.
• 11. Vidich AJ, Lyman SM. Qualitative methods: their history in sociology and anthropology. In: Denzin NK, Lincoln YS, editors. Handbook of qualitative research. Thousand Oaks: Sage; 1994. p.23-59.
• 12. Brandão CR. O que é o método Paulo Freire. 9th ed. São Paulo: Brasiliense; 1985.
• 13. Leininger M. Overview of the theory of culture care with the ethnonursing research method. J Transcult Nurs. 1997; 8(2):32-52.
• 14. Leininger M. Special research report: dominant culture care (EMIC) meanings and practice findings from Leininger's theory. J Transcult Nurs. 1998; 9(2):45-8.
• 15. Kleinman A. The illness narratives: suffering, healing, and the human condition. New York: Basic Books; 1988.
• 16. Frota MA, Barroso MGT. Desnutrição infantil na família: causa obscura. Sobral: UVA; 2003.
• 17. Frota MA, Barroso MGT. Repercussão da desnutrição infantil na família. Rev Latinoam Enferm. 2005; 13(6):996-1000.
• 18. Frota MA, Barroso MGT. Cuidado cultural à criança desnutrida filha de adolescentes. In: Barroso MGT, Vieira NFC, Varela ZMV, organizadores. Saúde da família II: espaço de incertezas e possibilidades. Fortaleza: Sociedade Brasileira de Enfermeiros Escritores; 2005. p.57-71.
• 19. Nations MK, Nuto S de A. "Tooth worms", poverty tattoos and dental care conflicts in Northeast Brazil. Soc Sci Med. 2002; 54(2):229-44.

Publication Dates

• Publication in this collection
  24 Apr 2008
• Date of issue
  Mar 2008

History

• Accepted
  18 Sept 2007
• Received
  04 Apr 2007