Social representations of integrative community therapy by the elderly

ABSTRACT

Objective

To elicit the social representations of the elderly regarding integrative community therapy (ICT).

Method

This is an exploratory study conducted with 273 elderly people in a municipality of northeastern Brazil, in 2014. It is based on the theory of social representations and the free-association test for the inductor term “integrative community therapy”. The data were processed using EVOC software and examined with the structural approach of social representations, followed by a similarity analysis and confrontation with literature.

Results

The organisation and meaning of the representations of ICT chiefly occurred through the core element: Group.

Conclusion

The analysis revealed that the ICT is a support network for the elderly, where they feel they belong to a group and feel empowered through participation in the sessions.

Therapeutics; Aged; Mental health

RESUMO

Objetivo

Conhecer as representações sociais dos idosos concernentes à terapia comunitária integrativa (TCI).

Método

Estudo exploratório, realizado com 273 idosos de um município no nordeste do Brasil, em 2014, tendo por base a teoria das representações sociais e a aplicação do teste de associação livre de palavras por meio do termo indutor “terapia comunitária integrativa”. Os dados foram processados pelo software EVOC e examinados pela abordagem estrutural das representações sociais, realizando-se uma análise de similitude, bem como o confronto com a literatura.

Resultados

A organização e o significado das representações de terapia comunitária integrativa ocorreram, principalmente, através do elemento central: Grupo.

Conclusão

A análise permitiu inferir que a TCI constitui uma rede de apoio para idosos, na qual se verificam um sentimento de pertencimento a um grupo e o empoderamento dos participantes através de sua participação nas rodas.

Terapêutica; Idoso; Saúde mental

RESUMEN

Objetivo

Conocer las representaciones sociales de los ancianos acerca de la Terapia Comunitaria Integradora (TCI).

Método

Estudio exploratorio, con 273 ancianos de una ciudad en el nordeste de Brasil, en 2014, basado en la teoría de las representaciones sociales y la aplicación de la prueba de asociación libre de palabras, por medio del término inductor “terapia comunitaria integradora”. Los datos fueron procesados por el software EVOC y examinados por el enfoque estructural de las representaciones sociales, poniendo de relieve un análisis similar, así como la confrontación con la literatura.

Resultados

La organización y el significado de las representaciones de la TCI se producen a través, sobre todo del elemento central: Grupo.

Conclusión

El análisis permite inferir la función TCI como una red de apoyo para la tercera edad, reflejada en el sentimiento de pertenencia a un grupo. Por último, refleja el empoderamiento de los ancianos mediante la participación en las ruedas de TCI.

Terapéutica; Anciano; Salud mental

INTRODUCTION

The strategic location of primary care, the preferred gateway to the unified health system (SUS), makes is a common meeting ground between health workers and patients in mental distress. Despite being anchored in a well-structured policy, this level of care is still fragile in terms of offering interventions for users in emotional stress.

Therefore, it is necessary to incorporate or improve the mental health competencies in the daily practice of healthcare professionals, and ensure these interventions consider the subjectivity, singularity, and worldview of users in the process of comprehensive care(¹). An example of these group interventions is integrative community therapy (ICT), which consists of creating a space where participants sit side by side in a circle to share life experiences, their suffering and pain, and express their feelings(²).

In primary care, ICT was officially incorporated in 2008, with the national policy of integrative and complementary practices (“PNPIC”). Later, in 2013, ICT was recommended by the national mental health policy as a psychosocial intervention to expand care in this area, since those who needed it were singled out as belonging to socially vulnerable groups.

Studies on the applicability and repercussions of ICT on the elderly revealed its effectiveness as a care strategy for this group. It was observed that the elderly are the most frequent users of the ICT group sessions, followed by people with mental disorders and users of psychoactive substances that participate in the sessions of the psychosocial care centre. The findings also revealed that the ICT helps the elderly cope with everyday challenges, boosts their self-esteem, and provides them with a community solidarity network(³-⁵).

Given the higher frequency of the elderly in the ICT sessions(²)and the need to ensure that SUS managers and public policy makers raise the awareness of this intervention among the elderly, we chose to work with this population in this study. After all, this knowledge can support decisions to include ICT in new spaces and reformulate ICT in existing spaces through lower-cost technologies for large populations with excellent levels of solvability.

That said, it should be noted that this study focuses on the social representations of the elderly regarding integrative community therapy. Consequently, the relevance of this study is its contribution to update health workers and the academic community on the subject of community mental health. It is also important to note that ICT is a key issue in national studies. However, most studies(²-⁵)base the investigation on other theoretical inputs, and the application of the theory of social representations is still unprecedented. This research is originally from a dissertation titled, “Estrutura das Representações Sociais construídas por idosos e profissionais de saúde sobre a Terapia Comunitária Integrativa”.

METHOD

This is an exploratory study based on the theory of social representations (TSR). The criterion of this theory involves an object, which is investigated, and a subject, which represents the investigated object(⁶). In the case of this study, the subject is the elderly and the object is integrative community therapy.

The study population was elderly people of both sexes, living in the neighbourhoods Grotão and the Comunidade Maria de Nazaré in the southern area of the municipality of João Pessoa, Paraíba, Brazil. The sample consisted of 263 elderly people. The inclusion criteria were individuals aged 60 years or older and residents of the census sector for more than 6 months. The exclusion criterion was elderly people who did not regularly frequent the ICT sessions.

The sampling process was probabilistic conglomerate through two-stage selection. The census sector was the primary sample unit, with probability proportional to the size of the sector, identified according to the 2000 Census (600 sectors in João Pessoa). The street corresponded to the unit drawn in a second stage. This procedure maintained the self-weighting of the final sample of people ≥ 60 years residing in the urban area of the respective municipality. We decided on a sample of 263 elderly people, which guaranteed a maximum error of 6.3%, with 95% probability. To reach the value of n = 240, 20 census sectors were drawn from the 617 existing sectors. This resulted in identical sampling fractions for all the individuals.

Data were collected from August to December 2011, with application of the free word association test (FWAT) – used to obtain the guiding information of the structure of social representations (SR) – and of the questionnaire with data on the sociodemographic profile. The subjects were asked to say five words or expressions that immediately occurred to them in relation to the inductor term, “integrative community therapy”. The most important word they mentioned was highlighted in the instrument with an asterisk (*). There was no bias of understanding for the FWAT with regard to the inductor term.

The sociodemographic variables were analysed using statistical descriptions (relative frequency, average, and median) with the Statistical Package for Social Sciences – SPSS 16.1. The collected empirical data were categorised and organised in a database to form the corpus, which was analysed using the Ensemble de Programmes Permettant L’analyse des Evocations – EVOC. This programme calculates and notifies the simple frequencies (f) of occurrence of each word, and the weighted average in relation to the order of evocation (AOE), and the average of the order of the weighted averages of the set of evoked terms (AOE). The adopted cut-off point was a frequency over 14.

The structural data analysis took into account the order of evocation and the frequency of evocation, thus enabling the identification of the content of the representation structure. Next, the co-occurrence of the observed categories was assessed using analysis of similarity. Finally, the results were discussed according to other studies on the subject to detect cognitive aspects of the SR of the subjects.

This investigation was approved by the research ethics committee of the Hospital Universitário Lauro Wanderley/UFPB, Protocol CEP/HULW #261/09. It should be noted that the subject participated voluntarily in the study. All the subjects completed and signed an informed consent statement, in compliance with Resolution 466/2012 of the Ministry of Health, the National Health Council, and the National Commission of Ethics in Research, and with the guidelines and standards governing research involving human beings(⁷).

RESULTS AND DISCUSSION

The 263 seniors were aged between 60 and 100 years, with an average of 70.08 years. Most of the subjects were women (73.07%), married (52.9%), and Catholic (72.1%). The household income was 1 to 3 minimum wages (40.4%), and the education level was low (up to 5 years of school, 27.9%).

The lexicographical analysis of the corpus resulted in 1,315 evocation, with 400 different words, revealing the polysemy of the inductor term. The average frequencies (i.e. 39) and the average order of evocations (i.e. 3) were calculated, crossed, and analysed to build the four-box table, as shown in Chart 1 below.

Chart 1
– View of the Central Core. Social Representations of Therapy Integrative community constructed by elderly people: average frequency and order of evocations. João Pessoa – PB, 2011

	AOE < 3			AOE ≥ 3
	1 st Quadrant (Core)			2 nd Quadrant (1 st Periphery)
Fm ≥ 39	Group	123	2.382	Friendship	102	3.147
	Help	81	2.556
	Communication	76	2.789
	Joy	52	2.904
	Activities	51	2.922
	Meeting	43	2.093
	Problem	40	2.800
	3 rd Quadrant (Contrast)			4 th Quadrant (2 nd Periphery)
Fm < 39	Good	38	2.158	Exchange	36	3.194
	Unknown	24	1.292	Art	27	3.074
	Treatment	22	2.864	Venting	24	3.042
	Fun	19	2.842	Distraction	23	3.304
	Coexistence	14	2.643	Knowledge	21	3,286
				Trip	21	3.667
				Health	19	3.263
				Love	18	3.611
				Experience	18	3.278
				Professionals	16	3.375

• Source: Research of the Ministry of Health, 2011.
• Legend: AOE (Average Order of Evocation); AFE (Average Frequency of Evocation).

The structural approach of the SR was used to describe the results. The terms that simultaneously observed the criteria of evocation with greater frequency and the first places apparently carried greater importance in the cognitive schema of the subjects and configured the hypothesis of the core of the social representation(⁸).

Considering the salience as a characteristic of the core elements in the comparison of frequencies of evocation and importance, it was found that the difference was greater than 80% for the elements Group and Problem, representing an extension of the meaning of the core. The prototypical structure suggests that, through ICT, the elderly had the feeling of belonging to a Group and of building Friendship bonds, an element of the first periphery, next to the core.

This result indicates the relevance of conducting studies on preventive mental health in which all the cultural and social elements of the community focus on group work, social consciousness, and gradual, transforming therapy grounded in the competencies and formation of a support network(⁹-¹⁰). Moreover, it should emphasised that the subjects represented the ICT as Help. Considering the methodology of this intervention, in the questioning stage, the people shared their experiences and coping strategies. When the sessions were closed, there was a communion of sentiments and the solidification of a support network.

One of the theoretical pillars of this technology of care – systemic thinking – states that problems can be understood and resolved when they are perceived as integrating parts of a complex network, with branches that connect people to the whole(¹¹). This network gains momentum through Communication, which is also one of the theoretical pillars of ICT – the Pragmatics of Human Communication of Watzlawick -, that is, the conception that all behaviour and every symptom have their communication value. That means that consciousness of oneself is the result of a relationship of communication with the other(¹²).

This result rekindles the notion that, in every culture, between the use of given codes and thoughts of order, there is the naked experience of order and its ways of being or propitiating relations(¹³). Indeed, such findings have confirmed the important role of social representations for the institution of consensual realities, in the sense of guiding communications and conducts in the face of the new.

This representation allows us to reach an understanding that we are all responsible for finding solutions to the Problems, and that we all contributed to their occurrence. In the ICT session, the participants aired their concerns. Within the circle, looking to the community revealed that the problems and crises they face have biological, social, and mental consequences.

Moreover, these facts tend to promote the search for alternative ways of dealing with the grievances of the population, and the session becomes a space to promote this co-responsibility of the group in the search for solutions and ways to overcome problems, thus restoring their Joy of life and self-esteem, and their capacity to make decisions and share emotions(⁹).

When the subjects were asked about this care technology, it was found that they still represent it as one of the Activities of preventive healthcare. The use of such resources encourages them to participate in the sessions and supports the strengthening of values, knowledge, and individual and community skills(¹³).

In this work, the hypothesis of centrality was verified with the analysis of similarity of relations established by the existing elements and the co-occurrences in these categories, which facilitates identification of the existing processes of categorisation and schematisation(¹⁴). Figure 1 shows the tree of similarity.

Figure 1
– Tree of similarity of the SR of the elderly. João Pessoa, PB, 2011

As seen in Figure 1, with regard to representations of integrative community therapy, the maximum tree similarity of the corpus evoked by the elderly revealed two stars: the star of the Group element and the star of the Friendship element. The first star establishes a relationship with Exchange, Unknown, Treatment, Coexistence, and Problem. It is worth noting that 21 individuals also showed a relationship between Group and Professionals, that is, a more meaningful similarity index in the group.

The element Friendship was connected with Joy, Fun, Trip, Venting, Art, Meeting, Experience, Knowledge, and Coexistence. It also showed a greater relationship with Trip, indicating a greater similarity between the two, considering that 24 individuals established a relationship between the elements Friendship and Trip. The results show that these two elements, Friendship and Group, had a higher power of connectedness, a core feature of the SR. Despite appearing in the first periphery, the element of Friendship showed a strong relationship with the key elements and even similar behaviour, confirming their symbolic power. Thus, on the basis of compliance with the criterion for centrality or connectedness, there are nine key elements of representation.

In addition to these elements, we also determined three circles: one from the connection of Group, Professionals, Communication, and Treatment; another connecting Group, Treatment, Communication, and Unknown; and finally, one circle relating Group, Knowledge, Friendship, and Coexistence. In this respect, the greatest similarity index (17) was established between Group and Knowledge. All the circles share the element Group, confirming its symbolic power.

Our analysis also suggests the centrality that is characteristic of the element Group, revealing that the ICT is a support network for the elderly, reflected in the feeling of belonging to a group. For these subjects, the group awakens knowledge of self and of others through coexistence, which facilitates the establishment of friendly relations. With communication, the unknown is revealing together, and the subjects get help from the professionals, in this case, the community therapists.

The ability to help should not be delegated only to the therapist in the ICT session since, in this space, the therapist is merely a facilitator. The group must co-participate in this process, where all the people involved – the therapists and the participants – help and are helped.

In this sense, the participation of the elderly in coexistence groups is positive. Integrative community therapy reaffirms the relevance of these spaces as a pathway to empowerment and citizenship in the everyday lives of the participants, and promotes individual and collective mechanisms of interventions for the elderly(³, ⁵, ¹⁵).

Finally, the results stress the relevance of collective care practices, such as ICT, which has already gained ground in national, state, and municipal policies. These policies include ICT in the national policy on drugs, in the national policy of primary care, and above all, in the family health strategy and the national policy of integrative and complementary practices(¹⁶).

In mental health, there is concordance between the ICT proposal and the agenda of the psychiatric reform movement in Brazil. This reform sustains that people in emotional distress must rely on community health resources for their rehabilitation and social inclusion, in particular with regard to the elderly, their autonomy, and social transformation(³).

Expansion of the ICT is considered a care tool for other age groups, and can lead to the same good results as those observed for the elderly subjects. An example of the use of ICT as a collective care practice is shown in an investigation with university nursing students of the Universidade Federal de Mato Grosso. This investigation identified the contributions of ICT in the promotion of student health since it provided a space for them to express their feelings and, consequently, encouraged the creation of solidarity networks for these students(¹⁶).

CONCLUSION

Based on the discussions presented above, it can be inferred that the study reached its goal. The results of the social representations of the elderly reveal a shared knowledge in society about ICT that can be applied to the everyday lives of the population. A study with this profile can effectively indicate the elements that should be changed or strengthened.

In this case, healthcare workers and managers should focus on promoting mental health activities in the population group of this study. We propose the qualification of community therapists who can provide the elderly and the population in general with ICT sessions since, according to a retrospective survey, there were no therapists in the neighbourhoods at the time of data collection. Thus, learning more about the SR of the ICT can strengthen this care tool. It seems reasonable to assume that the sets of elements suggest a “popular theory” of ICT, from the idealisation of academic knowledge to the ramification of an artistic knowledge.

This study brings forward an important discussion based on the Theory of Social Representations, a rarely used theoretical framework in research on ICT. The structural approach highlights a cohesive and well-structured representation between the peripheral and core elements of the SR of the subjects. Moreover, it guarantees the necessary stability and flexibility for the fluidity of the representation.

It should be emphasised, however, that the focus on elderly people alone is a limitation of this investigation, and the type of representation may have been different with people of all age groups. This gap can be explored in future studies with subjects of other age groups, such as adults or children.

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Publication Dates

• Publication in this collection
  2017

History

• Received
  14 Aug 2015
• Accepted
  21 Mar 2017