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Stress and cardiovascular risk: multi-professional intervention in health education

ABSTRACT

Objective:

to identify cardiovascular risk in educators (administrators and teachers) from the South region of Brazil, evaluated before and after intervention with stress management activities and health education.

Method:

longitudinal study of the before and after type. The sample consisted of 49 participants. Variables studied were socio-demographic, morbidity antecedents and lifestyle habits. Measured risk factors for cardiovascular disease were arterial blood pressure, body mass index, ratio of waist to hip size, lipid profile and capillary blood glucose. Stress levels were evaluated using the Lipp Stress Symptoms Inventory (LSSI). The study ran for four months, with weekly meetings of a multidisciplinary team.

Results:

after intervention, the study observed a statistically significant reduction of the investigated variables, except for blood glucose levels in the administrators group.

Conclusion:

stress management activities are potential tools in the identification and control of the risk factors studied, particularly in those involving multi- and trans-disciplinary focus.

Key words:
Psychological Stress; Cardiovascular Diseases; Health Education; Nursing; Psychology

RESUMO

Objetivo:

identificar o risco cardiovascular e o estresse em educadores (gestores e professores) do sul do Brasil, avaliados antes e depois de intervenção com atividades de gerenciamento do estresse e educação em saúde.

Método:

estudo longitudinal do tipo antes e depois. A amostra foi constituída por 49 participantes. Foram obtidas variáveis sociodemográficas, antecedentes de morbidade e hábitos da vida diária. Os dados de risco para doença cardiovascular foram pressão arterial, índice de massa corporal, relação cintura-quadril, perfil lipídico e glicemia capilar. O estresse foi avaliado pelo Inventário de Sintomas de Stress para Adultos de Lipp (ISSL). O gerenciamento ocorreu durante quatro meses, em encontros semanais com equipe multidisciplinar.

Resultados:

após as intervenções, observou-se redução estatisticamente significativa das variáveis investigadas, salvo glicemia no grupo gestores.

Conclusão:

atividades de gerenciamento são potenciais ferramentas na identificação e controle dos fatores de risco estudados, em especial aquelas de foco multi e transdisciplinar.

Descritores:
Estresse Psicológico; Doenças Cardiovasculares; Educação em Saúde; Enfermagem; Psicologia

RESUMEN

Objetivo:

identificar riesgo cardiovascular y estrés en educadores (gestores y profesores) del sur de Brasil, evaluados antes y después de intervención con actividades de manejo del estrés y educación en salud.

Métod:

estudio longitudinal, tipo antes y después. Muestra constituida por 49 participantes. Fueron obtenidas variables sociodemográficas, antecedentes de morbilidad y hábitos de vida diarios. Los datos de riesgo de enfermedad cardiovascular fueron: presión arterial, índice de masa corporal, relación cintura-caderas, perfil lipídico y glucemia en sangre. El estrés fue evaluado por Inventario de Síntomas de Stress para Adultos de Lipp (ISSL). La acción se continuó cuatro meses, en encuentros semanales con equipo multidisciplinario.

Resultados:

luego de las intervenciones, se observó reducción estadísticamente significativa de las variables investidas, exceptuando glucemia en grupo de gestores.

Conclusión:

las actividades de manejo son potenciales herramientas de identificación y control de los factores de riesgo estudiados; en particular, aquellas de foco multi y transdisciplinario.

Palabras clave:
Estrés Psicológico; Enfermedades Cardiovasculares; Educación en Salud; Enfermería; Psicología

INTRODUCTION

In recent decades, with increased awareness of chronic non-communicable diseases (NCD), preventive health care has become imperative to reduce vulnerability in cases of illness, as well as reducing the possibility that illness will lead to incapacity, chronic suffering and premature death. Among the most common NCDs are cardiovascular disease (CVD), diabetes, hypertension, cancer and respiratory diseases(11 Carvalho MD, Morais Neto OL, Silva Junior JB. Presentation of the strategic action plan for coping with chronic diseases in Brazil from 2011 to 2022. Epidemiol Serv Saúde [Internet]. 2011[cited 2015 Apr 27];20(4):425-38. Available from: http://scielo.iec.pa.gov.br/pdf/ess/v20n4/v20n4a02.pdf
http://scielo.iec.pa.gov.br/pdf/ess/v20n...
).

In the case of CVD, many of the risk factors are modifiable variables with significant morbid-mortality rates in the general population. This study, conducted in southern Brazil, identified behavioral risk factors for CVD such as: tobacco use, lack of leisure time physical activity, habitual consumption of meat with exposed fat, and daily consumption of processed meat, red meat and whole milk. The study indicated the possibility of CVD prevention linked to behavioral changes, which represents a challenge to be overcome(22 Muniz LC, Schneider BC, Silva ICM, Matijasevich A, Santos IS. Accumulated behavioral risk factors for cardiovascular diseases in Southern Brazil. Rev Saúde Pública [Internet]. 2012[cited 2015 Apr 27];46(3):534-42. Available from: http://www.scielo.br/pdf/rsp/v46n3/en_3690.pdf
http://www.scielo.br/pdf/rsp/v46n3/en_36...
). It is believed that, beyond the mentioned risk factors, stress is potentially harmful to health.

The concern with stress stems from the fact that it affects 90% of the world population, and is strongly linked to diseases of the circulatory system(33 Stults-Kolehmainen MA. The interplay between stress and physical activity in the prevention and treatment of cardiovascular disease. Frontiersand Physiology [Internet]. 2013[cited 2015 Apr 27];4(346):1-4. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3841719/pdf/fphys-04-00346.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles...
), which are among the greatest causes of death in Brazil(44 Mansur AP, Favarato D. Mortality due to cardiovascular diseases in Brazil and in the metropolitan region of São Paulo: a 2011 update. Arq Bras Cardiol [Internet]. 2012[cited 2015 Apr 27];99(2):755-61. Available from: http://dx.doi.org/10.1590/S0066-782X2012005000061
http://dx.doi.org/10.1590/S0066-782X2012...
). As we study the nature of a stressor event, we may define it as any circumstance that threatens, or is perceived as threatening, to someone's well-being. Such threats may be related to immediate or long term physical security, self-esteem, reputation and other behaviors and actions that the person values(55 Barcaui A, Limongi-França AC. Estresse, enfrentamento e qualidade de vida: um estudo sobre gerentes brasileiros. RAC [Internet]. 2014[cited 2015 Apr 27];18(5):670-94. Available from: http://www.redalyc.org/articulo.oa?id=84031708006
http://www.redalyc.org/articulo.oa?id=84...
,66 Silveira KA, Enumo SRF, de Paula KMP, Batista EP. [Teachers stress and struggle to cope with pressure: a literature analysis]. Educ Rev [Internet]. 2014[cited 2015 Apr 27];30(4):15-36. Available from: http://www.scielo.br/pdf/edur/v30n4/02.pdf Portuguese.
http://www.scielo.br/pdf/edur/v30n4/02.p...
).

The association between psychosocial factors and cardiovascular diseases is not new, and stems from the observation of harm caused by stress, not only in cardiac patients, but also in healthy subjects. This relationship is corroborated by evidence found in animal studies, which show that chronic psychosocial stress can be an aggravating factor in arteriosclerosis, as well as in endothelial dysfunction and even in apoptosis, which probably stems from excessive, reiterated and prolonged activation of the nervous system(77 Sardinha A, Nardi AE, Zin WA. [Are panic attacks really harmless? The cardiovascular impact of panic disorder]. Rev Bras Psiquiatr [Internet]. 2009[cited 2015 Apr 27];31(1). Available from: http://www.scielo.br/pdf/rbp/v31n1/a14v31n1.pdf Portuguese.
http://www.scielo.br/pdf/rbp/v31n1/a14v3...
).

Furthermore, this constant stimulation causes similar activation of the hypothalamus-pituitary-adrenal (HPA) group, provoking a series of neuroendocrine alterations in the organism, such as increased heart rate and elevated blood pressure, among others. Psychological effects are also set into motion, such as anxiety, attention deficit and memory deficit. Thus, more and more, studies indicate that stress is an important risk factor to be considered, treated and prevented, especially due to its implications for the development and aggravation of cardiovascular diseases(77 Sardinha A, Nardi AE, Zin WA. [Are panic attacks really harmless? The cardiovascular impact of panic disorder]. Rev Bras Psiquiatr [Internet]. 2009[cited 2015 Apr 27];31(1). Available from: http://www.scielo.br/pdf/rbp/v31n1/a14v31n1.pdf Portuguese.
http://www.scielo.br/pdf/rbp/v31n1/a14v3...
,88 Albert CM, Chae CU, Rexrode KM, Manson JE, Kawachi I. Phobic anxiety and risk of coronary heart disease and sudden cardiac death among women. Circulation [Internet]. 2005[cited 2015 Apr 27];111(4):480-7. Available from: http://circ.ahajournals.org/content/111/4/480.full.pdf+html
http://circ.ahajournals.org/content/111/...
).

Bodily response to stress can be modeled into three stages: alarm, defense or resistance, exhaustion, and burnout(99 Selye H. A syndrome produced by diverse nocuous agents. Nature [Internet]. 1936[cited 2015 Apr 27];138(32). Available from: http://neuro.psychiatryonline.org/doi/full/10.1176/jnp.10.2.230a
http://neuro.psychiatryonline.org/doi/fu...
). There is also a four-stage model, in which Lipp and Rocha added the phase of near-exhaustion(1010 Lipp, MEN. Inventário de sintomas do stress para adultos. São Paulo: Casa do Psicólogo; 2000.). According to this model, the stages of response to stress are: (i) alert phase, considered positive, in which the individual is more attentive, productive and motivated. This phase is also characterized by orientation and identification of danger; (ii) resistance phase, characterized by the resistance of the individual to stress stimulants, which demands large amounts of energy and adaptive effort. That is why in this phase there is increased vulnerability to risk factors; (iii) near-exhaustion phase, in which the individual oscillates between emotional equilibrium and disequilibrium, with manifestation of psychological symptoms (such as anxiety) and predisposition to the development of physical diseases, such as gastritis, hypertension and diabetes mellitus, among others; (iv) exhaustion phase, characterized by depletion of resistance mechanisms. This is the pathology phase, in which there is triggering of or susceptibility to diseases, due to the weakened state of the immune system in affected individuals.

Thus, as an individual experiences the successive phases of stress, there is a corresponding intensity and severity of physical and psychological symptoms; at the same time, there is a greater probability of disease, especially cardiovascular maladies, strongly linked to stress and certain lifestyle habits. Based on the foregoing analysis, we see that work conditions can be determining factors for increased risk of stress-related symptoms. The conditions that present elevated risk for cardiovascular diseases include those that require heightened psychological and physical exertion, reduced personal autonomy and decreased professional satisfaction(1111 Nascimento MC, Andrade A, Silva OMP, Nascimento JF. Estresse laboral e gênero enquanto fatores associados ao risco de doenças cardiovasculares. Salusvita [Internet]. 2008[cited 2015 Apr 27];27(3):383-97. Available from: http://www.usc.br/biblioteca/salusvita/salusvita_v27_n3_2008_art_06.pdf
http://www.usc.br/biblioteca/salusvita/s...
). In other words, work-related stress may cause increased risk of CVD. Therefore, it is likely that educators have a potential for developing stress-related symptoms and CVD, in light of typical work overload and continuous contact with people who require their assistance.

In this context, we believe that health education initiatives are beneficial in the identification of cardiovascular and stress risk variables; and that nurses are key agents as health educators, working together with a transdisciplinary team.

OBJECTIVE

To investigate stress and cardiovascular risk indicators in educators, along with options for stress management and health education.

METHOD

Ethical considerations

This study was approved by the Ethics and Research Committee of the Faculdades Integradas de Taquara (FACCAT). In accordance with resolution 466/2012, all participants were duly informed regarding the study procedures, and indicated their voluntary participation by signing of free and informed consent forms.

Design, site and duration of the study

This is a longitudinal study of the before and after type, conducted in the city of Vale do Paranhana, Rio Grande do Sul, Brazil, from March to December, 2012.

Population and sample

The population was composed of all educators in the municipal public school system, and we invited all of them to participate in the study. Participants were selected according to the following inclusion criteria: they were considered teachers in the municipal public school system in the aforementioned city, and they agreed to participate in the study. The sample was determined by those who voluntary agreed to sign the free and informed consent form. Initially, the sample had 100 participants, of which 60 were teachers and 40 were administrators; 20 administrators and 29 teachers actually participated in all phases of the study - a total of 49 people.

Research protocol

Sociodemographic data were obtained through a questionnaire that investigated gender, age, marital status, schooling, wages, hypertension and diabetes mellitus, medications, physical activities, smoking and alcohol consumption.

Regarding risk data for cardiovascular disease, these were determined by measurement of arterial blood pressure (BP), body mass index (BMI), ratio of waist to hips (WHR), a lipid profile and capillary blood glucose test. Measurement of BP and respective classification of results followed guidelines set by the Brazilian Society of Cardiology(1212 Brandão, AA. (Coord). Conceituação, Epidemiologia e prevenção primária. In: VI Diretrizes Brasileiras de Hipertensão. Arq Bras Cardiol [Internet]. 2010[cited 2014 Nov 27];95(1Sup1):I-III. Available from: http://www.scielo.br/pdf/abc/v95n1s1/v95n1s1.pdf
http://www.scielo.br/pdf/abc/v95n1s1/v95...
). The BMI was estimated according to indicators set by the Brazilian Ministry of Health(1313 Brasil. Ministério da Saúde. SISVAN - Norma técnica da Vigilância Alimentar e Nutricional. Brasília: Ministério da Saúde, 2004.). The WHR data were classified according to recommendations of the World Health Organization(1414 World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. Geneva: World Health Organization Technical Reports Series [Internet]. 2000[cited 2014 Nov 27];894:1-253. Available from: http://www.who.int/iris/handle/10665/42330
http://www.who.int/iris/handle/10665/423...
).

Levels of triglycerides, cholesterol and glucose were measured with a finger-stick test, using the Accutrend Plus (Roche®) and requiring a 12-hour fast before collection. Normal ranges were considered to be the following: serum triglycerides ≤ 150 mg/dl, total serum cholesterol ≤ 200 mg/dl, serum glucose ≤ 99 mg/dl(1515 Sposito AC, Caramelli B, Fonseca FAH, Bertolami MC (Coord). Sociedade Brasileira de Cardiologia. IV Diretriz brasileira sobre dislipidemias e prevenção da aterosclerose. Arq Bras Cardiol [Internet]. 2007[cited 2015 Apr 27];88(supl1):1-18. Available from: http://www.scielo.br/pdf/abc/v88s1/01.pdf
http://www.scielo.br/pdf/abc/v88s1/01.pd...
).

Stress levels were evaluated according to the Lipp Stress Symptoms Inventory (LSSI), which classifies the phases of alarm, resistance, near exhaustion and exhaustion, according to symptom incidence during a period of 24 hours, one week and one month. For any given subject, the inventory shows if stress is present, which phase of stress is experienced and whether the prevalent symptoms are physical or psychological(1010 Lipp, MEN. Inventário de sintomas do stress para adultos. São Paulo: Casa do Psicólogo; 2000.).

Stress management and health education were administered during a four-month period, with weekly meetings, alternating between teachers and administrators. In each meeting, the subjects participated in activities that helped them learn to control symptoms of stress and prevent cardiovascular disease. The classes were taught by professors and students of Nutrition, Psychology, Chiropractic, and Physical Education. Health education actions included workshops for relaxation, muscle stretching, dietary education, physical exercise and self-monitoring for cardiovascular risk factors.

After completing four consecutive months of stress management and health education, the aforementioned variables were tested again.

Results and statistical analysis

Statistical analysis was performed using the program Statistical Package for the Social Sciences (SPSS), version 14.0. The data were analyzed by the Wilcoxon Test for sample analysis, Student t-test, and also by descriptive frequency analysis. The degree of certainty was 95% (p<0.05).

RESULTS

The 49 educators who participated in the study had an average age of 34.9 years, were predominantly white (93.8%), women (95.9%) and married (40%). Twenty-nine participants (59%) had finished undergraduate degrees and 36% (18) had graduate degrees or were in graduate study. The average monthly wage of the educators varied between two and three minimum salaries.

Regarding chronic NCD, 14 participants (28.6%) said they suffered from hypertension and three participants (6.1%) said they were diabetics. Fourteen participants said that they used regular medication to control these pathologies.

Regarding lifestyle habits, 18.4% (9) said they were tobacco users, and 30.6% (15) said they drank alcoholic beverages at least once weekly. Thirty participants (61.2%) said they exercised at least once a week; of those, 42.8% (21) said they exercised three or more times a week.

This study also evaluated the stress levels of the participants. Using the Lipp four-phase model, we found that a large proportion of administrators (63.6%) and teachers (50%) were in the resistance phase, and many were in the near exhaustion phase (31.82%). At the end of the study program, there was a statistically significant reduction of stress levels (p=0.02). The percentage of participants in the resistance phase was reduced: administrators to 33.3% and teachers to 27.27%, as recorded in Table 1.

Table 1
Frequency and prevalence of symptoms, stress phases and characteristics of stress symptoms in administrators and teachers, before and after stress management activities

The following tables present the variables relative to stress in administrators and teachers, separately, before and after the management activities, for better visualization of the impact of the activities on the results.

The LSSI showed that stress management significantly reduced the symptoms of stress in participants (administrators: Z -1.897; p = 0.05; teachers: Z -4.436; p = 0.0000) and positively impacted the stress phase of each subject (administrators: Z -2.3119; p = 0.02; teachers: Z -2.456; p = 0.02), using the Wilcoxon test.

In relation to the variables studied as risk factors for cardiovascular disease, there was a statistically significant reduction after stress management interventions in both groups, except for the blood glucose variable in administrators, using the Student t-test for paired samples, as outlined in Table 2.

Table 2
Average ± standard error of risk factors for cardiovascular disease in administrators and teachers, before and after stress management
Table 3 shows the averages and standard error for stress variables related to variables for cardiovascular risk.

Table 3
Average ± standard error of risk factors for cardiovascular disease in administrators and teachers, with and without stress, before and after stress management

In the data collected after stress management, there was no statistically significant difference in relation to the variables of cardiovascular risk (Table 3) in the groups of educators with and without stress. Therefore, upon completion of stress management, the averages of the indicators for cardiovascular disease of the group with stress exhibit no apparent difference from the group without stress.

DISCUSSION

The presence of stress and other cardiovascular risk variables was significant in the studied groups. The participants were in the middle of their productive years (average age of 34.9 years), which could possibly be linked to excessive workload, stress symptoms and lifestyle habits related to cardiovascular risk factors.

When asked about lifestyle habits, some participants in this study said that they used tobacco (18.4%) and consumed alcoholic beverages at least once a week (30.6%). Those that practiced physical exercise three or more times per week were 42.8% of the group. In a separate study conducted in the city of Pelotas (Rio Grande do Sul, Brazil), 21.3% of the participants said they used tobacco. In the same study, however, the proportion of those who practiced little or no physical activity was 75.6%(22 Muniz LC, Schneider BC, Silva ICM, Matijasevich A, Santos IS. Accumulated behavioral risk factors for cardiovascular diseases in Southern Brazil. Rev Saúde Pública [Internet]. 2012[cited 2015 Apr 27];46(3):534-42. Available from: http://www.scielo.br/pdf/rsp/v46n3/en_3690.pdf
http://www.scielo.br/pdf/rsp/v46n3/en_36...
), which is different from the physical activity data of this study. The element of physical activity was an important discovery in this study. While physical activity was reported by a large portion of the participants, it was also observed that such isolated activities was not able to guarantee, by itself, protection against injury, since many people in the group presented stress symptoms and risk factors for CVD at the outset of the study.

Concerning habits and daily activities, they are connected to bodily manifestations, whether physical or psychological. Thus, an overload of activities and workplace pressure may be triggers of stress, just as stress and sedentariness may be related to cardiovascular diseases. It should be emphasized that, in the group of administrators and teachers studied, there is not only concern for the shared strenuous work routine, but also for professional training, which is demonstrated by the number of participants in graduate programs or who have completed graduate study (18.36%).

It is important to note that stress may not only be linked to lifestyle, but also to the work environment. This study identified that 67% of the participants presented stress symptoms before the application of management activities. It has been demonstrated that work conditions which induce stress, such as those that include intense psychological and work demands, reduction of personal autonomy and satisfaction in the workplace, correlate with higher risk factors for cardiovascular diseases(1111 Nascimento MC, Andrade A, Silva OMP, Nascimento JF. Estresse laboral e gênero enquanto fatores associados ao risco de doenças cardiovasculares. Salusvita [Internet]. 2008[cited 2015 Apr 27];27(3):383-97. Available from: http://www.usc.br/biblioteca/salusvita/salusvita_v27_n3_2008_art_06.pdf
http://www.usc.br/biblioteca/salusvita/s...
). Indeed, the educators who participated in this study presented elevated stress levels, with predominantly psychological symptoms, which may be associated with the work environment.

The high prevalence of stress levels in educators may indicate the presence of a significant and accentuated degree of tension, which favors the occurrence of injury due to disequilibrium of the immune system. A large part of the participants was in the resistance phase before management activities and health education (63.6% of administrators and 50% of teachers). It is important to note that, in this phase, the organism seeks to return to a state of equilibrium, using a large amount of energy in this task. This may cause a general sensation of fatigue with no apparent cause, along with memory lapse, among other consequences. The more effort an individual makes to readapt and reestablish interior equilibrium, the greater the weakening of the organism(1616 Goulart Jr E, Lipp MEN. [Stress in teachers from government public schools of fundamental education]. Psicol Estud [Internet]. 2008[cited 2015 Apr 27];13(4):847-57. Available from: http://www.scielo.br/pdf/pe/v13n4/v13n4a23.pdf Portuguese.
http://www.scielo.br/pdf/pe/v13n4/v13n4a...
).

Although most participants were initially in the resistance phase, 31.82% of the teachers were in the near-exhaustion phase, and 36.2% in the exhaustion phase. After stress management, however, there was a reduction in the percentage of individuals in the resistance phase (teachers 22.73%, administrators 30.27%) and the near-exhaustion phase (teachers 23.51%). At the same time, there was an increase in the number of participants in the alarm phase (teachers 36.2%, administrators 57.7%), which corresponds to the first phase of stress. We observed that, after performing the proposed activities, the participants presented a reduction in stress symptoms and were better able to deal with daily situations of stress. This was demonstrated by the change in stress phase they were experiencing.

After four months of stress management, conducted through workshops and meetings with various health care professionals, there was a significant reduction in the number of participants with stress symptoms (from 67% to 28.6%), showing the positive impact of the work of the multi-professional team. We believe that activities that strengthen and stimulate the individual toward proactivity and personal ownership of health care are able to augment the ability to deal with adverse situations. This was the tenor of a study conducted in Rio de Janeiro with a patient suffering from Post-Traumatic Stress Disorder (PTSD) and Major Depressive Disorder. The study concluded that after four months of psychotherapy, the patient showed a reduction of the sympathetic balance, negative affectivity and symptoms of post-traumatic stress, depression, anxiety and dissociation, in addition to an increase in resilience scores, social support and positive affectivity, as well as normalization of physiological alterations of the autonomous nervous system and the neuroendocrine system linked to PTSD(1717 Lages AC, Nórte CE, Pedrozo AL, Gonçalves RM, Marques-Portella C, Souza GGL et al. [Neurobiological and psychometric markers of the efficacy of cognitive behavioral therapy in post-traumatic stress disorder with dissociative symptoms: a case report]. Rev Psiquiatr R Gd Sul [Internet]. 2011[cited 2015 Apr 27];33(1):55-62. Available from: http://www.scielo.br/pdf/rprs/v33n1/v33n1a11.pdf Portuguese.
http://www.scielo.br/pdf/rprs/v33n1/v33n...
).

These conclusions were corroborated by another study conducted in a hospital in Rio de Janeiro, which investigated the impact of a three-month program of music therapy on stress levels of health care professionals. Observers noted a statistically significant reduction (60%, p<0.001) in stress levels of the subjects of the study(1818 Gunnar GCT, Borba- Pinheiro CJ, Figueiredo NMA, Dantas EHM. [Impact of a music therapy program on the stress level of health professionals]. Rev Bras Enferm [Internet]. 2013[cited 2014 Nov 27];66(3):385-90. Available from: http://www.scielo.br/pdf/reben/v66n3/a13v66n3.pdf Portuguese.
http://www.scielo.br/pdf/reben/v66n3/a13...
). The stress management activities of this study included relaxation exercises, self-awareness training for identification of stress-provoking situations, diet evaluation, physical exercise and lifestyle education for dealing with stress and disease. All of these activities may have contributed to the adoption of strategies for health improvement, although they may not have been the only factors that influenced the study's conclusions. The participants may have discovered motivation and a favorable environment for ownership and adoption of positive health behaviors, so that group initiatives became drivers of change, strengthened by the fact that these activities happened in the workplace, where people spend a large part of their lives.

It deserves mention that an adequate response of a person's stress defense system is a crucial prerequisite to a feeling of well-being and positive social interaction. By contrast, if the person's resistance to stress is inadequate, or if she is subjected to simultaneous stressors, a stress reaction process will evolve to the phase of exhaustion(1616 Goulart Jr E, Lipp MEN. [Stress in teachers from government public schools of fundamental education]. Psicol Estud [Internet]. 2008[cited 2015 Apr 27];13(4):847-57. Available from: http://www.scielo.br/pdf/pe/v13n4/v13n4a23.pdf Portuguese.
http://www.scielo.br/pdf/pe/v13n4/v13n4a...
); an inappropriate response to stress will cause a series of endocrine, metabolic, autoimmune and psychiatric alterations(1919 Timmermans W, Xiong H, Hoogenraad CC, Krugers HJ.Stress and excitatory synapses: from health to disease. Neuroscience [Internet]. 2013[cited 2015 Apr 27];17(248):626-36. Available from: http://www.sciencedirect.com/science/article/pii/S0306452213004715
http://www.sciencedirect.com/science/art...
), culminating in the triggering or worsening of cardiovascular diseases.

In both the administrators and teachers groups, there was a significant improvement of the variables linked to cardiovascular risk after stress management and health education activities were applied (p<0.05), except in the glucose variable for the administrators group (p=0.58).

The average systolic blood pressure in administrators and teachers was reduced from 119.2 to 99.7 mmHg and from 137.7 to 112.2 mmHg, respectively, at the end of the study. In the case of diastolic pressure, there was a reduction from 82.5 to 71 mmHg in administrators and from 92.03 to 75.92 mmHg in teachers. A study conducted in the city of São Paulo achieved a reduction in systolic blood pressure from 139.7 to 134.8 mmHg after nutritional intervention of 20 weeks with hypertensive patients (2020 Alvarez TS, Zanella, MT. [Impact of two nutritional education programs on cardiovascular risk in overweight hypertensive patients]. Rev Nutr [Internet]. 2009[cited 2014 Nov 27];22(1):71-9. Available from: http://www.scielo.br/pdf/rn/v22n1/07.pdf Portuguese.
http://www.scielo.br/pdf/rn/v22n1/07.pdf...
). A similar randomized study conducted in Madrid (Spain) investigated the effectiveness of an integrative Yoga program alongside clinical treatment of hypertension. After three months with two sessions weekly, the intervention group had a statistically significant reduction in systolic and diastolic blood pressure, measured before and after the sessions, in comparison with the control group. The same study showed reduction of symptoms for anxiety and stress(2121 Roche LT, Hesse BM. Application of an integrative yoga therapy programme in cases of essential arterial hypertension in public healthcare. Complement Ther Clin Pract. [Internet]. 2014[cited 2015 Apr 27];20(4):285-90. Available from: http://www.ctcpjournal.com/article/S1744-3881%2814%2900069-3/pdf
http://www.ctcpjournal.com/article/S1744...
). In light of such data, we can infer that health education actions and management of stressful situations favor reduced blood pressure. Although the period of the cited studies was relatively brief, the results showed that it was possible to impact pressure markers as well as stress symptoms, as the present study also indicates.

The participants of this study, in relation to lipid profiles, achieved results that kept them within the safety range for prevention of cardiovascular diseases. Total cholesterol readings were reduced from 170±17.33 to 142.27±14.01 mg/dl for administrators, and from 199.69±6.82 to 176.07±7.64 mg/dl for teachers, which indicates that as the participants reduced their risk factors for cardiovascular events, they also achieved universally accepted levels for prevention of such events, according to Framingham's risk score(1515 Sposito AC, Caramelli B, Fonseca FAH, Bertolami MC (Coord). Sociedade Brasileira de Cardiologia. IV Diretriz brasileira sobre dislipidemias e prevenção da aterosclerose. Arq Bras Cardiol [Internet]. 2007[cited 2015 Apr 27];88(supl1):1-18. Available from: http://www.scielo.br/pdf/abc/v88s1/01.pdf
http://www.scielo.br/pdf/abc/v88s1/01.pd...
). The same score indicates absolute zero risk when one considers total isolated cholesterol < 160 mg/dl, an index achieved by the group of administrators. When triglycerides are considered, although the group of administrators were already in an acceptable range for cardiovascular risk at the onset of the study (≤150 mg/dl), there was a significant improvement in the two groups studied, which achieved readings of 96.5±6.53 mg/dl (administrators) and 129±10.62 mg/dl (teachers) post-management, which is consistent with the recommendations of the Brazilian Cardiology Society for control of dyslipidemias and prevention of arteriosclerosis(1515 Sposito AC, Caramelli B, Fonseca FAH, Bertolami MC (Coord). Sociedade Brasileira de Cardiologia. IV Diretriz brasileira sobre dislipidemias e prevenção da aterosclerose. Arq Bras Cardiol [Internet]. 2007[cited 2015 Apr 27];88(supl1):1-18. Available from: http://www.scielo.br/pdf/abc/v88s1/01.pdf
http://www.scielo.br/pdf/abc/v88s1/01.pd...
).

Among the preferred methods for control of lipid profiles are physical exercise and dietary education, which were the approaches used in the present study. The results corroborated those of studies that involved research of lipid profiles, physical exercise(2222 Guedes DP, Gonçalves LAV. [Impact of the habitual physical activity on lipid profile in adults]. Arq Bras Endocrinol Metab [Internet]. 2007[cited 2015 Apr 27];51(1):72-8. Available from: http://www.scielo.br/pdf/abem/v51n1/08.pdf Portuguese.
http://www.scielo.br/pdf/abem/v51n1/08.p...
,2323 Silva DAS, Petroski EL, Pelegrini A. Effects of aerobic exercise on the body composition and lipid profile of overweight adolescents. Rev Bras Ciênc Esporte [Internet]. 2014[cited 2014 Nov 17];36(2):295-309. Available from: http://www.scielo.br/pdf/rbce/v36n2/0101-3289-rbce-36-02-00295.pdf
http://www.scielo.br/pdf/rbce/v36n2/0101...
) and nutritional intervention(2424 Damião R, Sartorelli DS, Hirai A, Bevilacqua MR, Salvo VLMA, Ferreira SRG et al. [Impact of a lifestyle intervention program on metabolic, anthropometrical and dietary profile of Japanese-Brazilians with and without metabolic syndrome]. Arq Bras Endocrinol Metab [Internet]. 2011[cited 2014 Nov 17];(2):134-45. Available from: http://www.scielo.br/pdf/abem/v55n2/a06v55n2.pdf Portuguese.
http://www.scielo.br/pdf/abem/v55n2/a06v...
). Therefore, we believe that multi-professional interventions bring benefits in different areas, but they should be maintained so the observed results may be preserved.

The body mass index of participants also showed a statistically significant reduction, such that both groups, on the average, moved from the obese category to the overweight category. Obesity is known as one of the major risk factors for predisposition to hypertension and, consequently, other cardiovascular diseases. Linked to the BMI, the other anthropometric variable that should be highlighted is the waist-hip ratio (WHR). WHR is related to the deposit of adipose tissue in the abdomen, especially in internal visceral deposits, intrinsically related to risk for Diabetes Mellitus, hyperlipidemia, arterial hypertension and arteriosclerosis(2525 Serafim TS, Jesus ES, Pierin AMG. Influence of knowledge on healthy lifestyle in the control of hypertensive. Acta Paul Enferm [Internet]. 2010[cited 2014 Nov 17];23(5):658-64. Available from: http://www.scielo.br/pdf/ape/v23n5/en_12.pdf
http://www.scielo.br/pdf/ape/v23n5/en_12...
). Our study showed a significant reduction of WHR values: the average WHR of administrators post-management was 0.78±0.01 cm, while that of teachers was 0.83±0.01 cm. Thus, the group of administrators achieved values consistent with the recommended numbers for the WHR variable, which is 0.82 cm(1414 World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. Geneva: World Health Organization Technical Reports Series [Internet]. 2000[cited 2014 Nov 27];894:1-253. Available from: http://www.who.int/iris/handle/10665/42330
http://www.who.int/iris/handle/10665/423...
).

It is worth noting that, although the study showed significant reduction in anthropometric variables, the final general average BMI of the participants was localized in the overweight category. A study conducted in the city of São Paulo highlighted BMI and abdominal circumference consistent with the average increase of these values among other populations around the world(2525 Serafim TS, Jesus ES, Pierin AMG. Influence of knowledge on healthy lifestyle in the control of hypertensive. Acta Paul Enferm [Internet]. 2010[cited 2014 Nov 17];23(5):658-64. Available from: http://www.scielo.br/pdf/ape/v23n5/en_12.pdf
http://www.scielo.br/pdf/ape/v23n5/en_12...
). The authors observed that, in developing countries, obesity is related to unhealthy lifestyles, which include sedentariness and a diet heavy in processed foods. In this context, health education initiatives are potential tools for the identification and management of modifiable risk factors by multi-professional teams, with the goal of giving patients greater autonomy in the identification of health threats and the ability to cope with them.

During the final phase of data collection, in addition to providing the measurements that resulted in the statistical findings, participants told of the positive impact of the study: they adopted a healthier lifestyle using simple techniques, such as walking to work and exchanging snacks of processed food for fruit. These actions influenced weight loss and an improvement in interpersonal relationships in the workplace.

Among the limitations of the study, we should mention the attrition of some participants, resulting in a reduction of the sample size. Also, the four month time frame for the study is considered relatively short. In addition, beyond the formal semi-weekly meetings of the two groups, there was no systematic follow-up of participants to insure that they were actually implementing the suggested stress management and health betterment activities.

Based on this study, we may infer that trans-disciplinary activity is an important strategy for health improvement, prevention and care of existing problems. The proposed activities represent low cost and high effectiveness, and are able to be strategically adopted in educational settings, with the goal of contributing to the improvement of the overall health of educators.

CONCLUSION

Stress and poor lifestyle choices represented risk factors for cardiovascular disease among the educators who participated in the study. Nevertheless, health education activities and stress management both contributed to revert this process. The cardiovascular system actively participates in adaptations to stress, so actions that reduce stress levels through educational initiatives and that are directed at potential risk factors become important tools for prevention and treatment. It should be noted that stress management also caused an improvement in those individuals who did not change their stress phase, for a reduction of the intraphase measurements of the LSSI was observed, although it is not possible to present such results in absolute numbers in the published tables.

Although it is not possible to affirm that stress management activities and health education were solely responsible for the positive results found among the participants in this study, it is plausible that they had a positive influence on the patients' ownership of and commitment to their individual health. In this situation, the nurse as an educator has a key role, since nurses contribute directly in health evaluation, information and orientation for the adoption of proactive initiatives in relation to individual and collective health.

Similarly, a focus on multi- and trans-disciplinary approaches maximizes health initiatives, because a collaborative posture reinforces the goals of prevention, control and treatment of health problems. Thus, nurses can substantially contribute to the widening of multi-disciplinary investigation, since research helps build evidential incentives for health care focused on the patient and his/hers needs.

For the field of health research, and specifically for nursing, this study shows that it is possible to act with autonomy and leadership in the performance of health education initiatives, thus contributing to the improvement of human health conditions and, consequently, to the work they perform for society.

It is advisable that other studies of this type be conducted, with larger samples and longer duration, and prolonged follow-up of participants.

FUNDING

Faculdades Integradas de Taquara - FACCAT, Research Support Foundation of Rio Grande do Sul (FAPERGS).

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Publication Dates

  • Publication in this collection
    Mar-Apr 2016

History

  • Received
    05 Jan 2015
  • Accepted
    09 Nov 2015
Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
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