FAMILY SUPPORT IN THE CONTROL OF HYPERTENSION

A hipertensão arterial está relacionada ao surgimento de doenças cardiovasculares. Para que o paciente consiga o controle da doença é imprescindível o apoio da família. O estudo teve como objetivo analisar se a família do hipertenso contribui positivamente para o controle de sua pressão arterial. Foi realizado na cidade de Teresina com pessoas cadastradas, no ano 2005, no programa de hipertensão de um centro integrado de saúde. Os dados foram coletados através de entrevista individualizada, utilizando-se a técnica do incidente crítico. Após a análise de conteúdo, identificou-se que o elemento conseqüência obteve 146 referências, sendo 58 positivas e 88 negativas, definindo-se quatro categorias: aspecto familiar, aspecto financeiro, aspecto de saúde e aspecto emocional. De acordo com os relatos, pôde-se inferir dificuldades no relacionamento familiar, preocupação do hipertenso em relação a seus descendentes e pouco envolvimento da família no plano de cuidado do doente.


INTRODUCTION
The prevalence of high blood pressure is estimated at about 15 to 20% in the young adult population (20 years or older) and can reach 50% of the elderly.It is related to 80% of encephalic vascular accident cases and 60% of ischemic heart disease, and kills approximately 3.9 million of people per year worldwide.In Brazil, it was responsible for 255,585 deaths in 2000 (1)(2) .
The incidence of hypertension is associated to several factors like age, gender, genetic factors, eating habits, obesity, smoking, alcohol, physical activity, education, race, occupation in the tertiary sector, migration, low economic level and diseases like nephropathies, endocrinopathies, coarctation of the aorta and certain medications (3)   .
The treatment for hypertension aims to reduce cardiovascular morbidity and mortality.Nevertheless, this treatment involves education on the disease, its inter-relations and complications and, most of the times, implies changing life habits and using antihypertension medication, which work to reduce the arterial pressure and to diminish the occurrence of fatal and non-fatal cardiovascular events (4)   .One of the main reasons patients fail to control their hypertension is the lack of adherence to the treatment, which involves regular use of medication, aspects related to the health system, socio-economic factors and those related to the treatment, the patient and the drug itself.For the efficient control of the disease, due to its great complexity, individuals need to be valued and have their beliefs, ideas, thoughts and feelings regarding the pathology (5) respected.
The social network that involves the hypertensive patient has the function of encouraging personal attitudes positively associated to health monitoring, like the sharing of information, helping in moments of crisis and care with health in general, including care with diet, physical exercises, sleep and adherence to the medication regime.Family members are capable to transmit tranquility, strength and courage to patients, which make them feel safe and supported in the disease experience (6) .
In routine care to hypertensive groups, frequent alterations of pressure levels are observed.This reality is a cause of concern to nurses because of the disease's high morbidity and mortality, which encourage them to search for solutions towards the patients' wellbeing.In view of the relevance of this topic, this study aimed to analyze, through the critical incident technique, taking into account the consequence element, whether the families of patients positively contribute to the control of their blood pressure according to the patients' own point of view.

METHOD
This is a descriptive study, in which data collection was carried out through interviews, using the critical incident technique.This technique allows one to obtain reports of situations and/or experiences of individuals who have, by their own criteria, classified them as positive or negative, according to the proposed objectives for the pre-determined function.Based on the reports and procedures necessary for data analysis, critical behaviors are identified and critical demands for a determined activity were determined (7)(8) .
The critical incidence technique is frequently used for the collection of information on past experiences and relevant events in human behavior.
However, it is limited to the individual's memory, that is, the longer the interval between the observed activity and its report, the lesser the quantity and the lower the quality of the described incident (9) .clarified regarding the study objectives and clearly informed that their participation would be spontaneous and free of any onus in case they quit the study.In case of agreement, the free and informed consent term was signed, formalizing their participation.

RESULTS AND DISCUSSION
According to the reports, 146 consequences were obtained, 58 of which were classified as positive and 88 as negative.In this study, only the element consequence was presented and analyzed.According to the analysis of reports, four categories of consequences were elaborated, and these were grouped in positive and negative subcategories (Table 1).The category family aspect presented a higher The family represents, for the majority of people, an important source of support and security, and permits exchanges of love, affection, respect and values (10)(11) .The family organization and its interactions directly influence the success of the hypertension treatment, which can be perceived in the following report: My daughter was dating a guy I didn't like.The day she told me she had broken up with him was a blessing, my home got calmer, no fights, even my pressure got under control (participant 3).
Concern with family members is a constant source of stress and anxiety for hypertensive patients and can lead them to neglect their self-care, not control their disease and consequently aggravate their health condition, as observed in the following example: When my son decided to go to São Paulo, I got very worried because it's violent there and he drinks.When he was getting ready to leave, my blood pressure got so high that I got a stroke (participant 4).
Difficulties in adhering and lack of interest in the treatment increase when there is no involvement of the family in the patient's daily care and the relationship between members is conflictive (11)(12) .
However, when family members assume the caregiver role, a satisfactory response is perceived in the disease control, as exemplified in the report below: I had no money to buy medication and decided not to take any medication.Then my daughter told me: mom, take at least the ones you have, it should help, it's better than nothing.
Then she took them and gave them to me.It was a great joy realizing that someone likes me.(participant 4).
The death of family members can generate feelings of loss and suffering in chronic patients, aggravating their lack of care with their health even more (13) .Hypertensive patients already need support from their social networks in normal circumstances and, at tense and sad moments, caused by the loss of a relative, understanding and helping them to overcome fears and isolation is necessary.The following report is an example of a situation in which the mother needs her family's support nto maintain care for her health.The category Financial aspect obtained two subcategories: Financial improvements in the family, whose positive references are related to the feeling of relief when debts are paid; Financial difficulties, with negative reports regarding lack of financial control.
The financial difficulty the country faces directly affects families and causes uncertainty, insecurity and fear.When the situation involves a hypertensive patient, it can cause severe problems related to the acquisition of medication, exams, adherence to healthy habits and even emotional disorder, leading to uncontrolled blood pressure (13)(14) .
The discourse that follows exemplifies a circumstance in which financial difficulty alters the patient's health state: I had to get some money to buy things for my father and I didn't have anything, I had to take the money my daughter was saving to pay her bills and everything got out of control.I got upset and sad, my blood pressure got altered right away (participant 17).
Employment or unemployment in the family interferes in the relations and feelings experienced by its members, consequently interfering in the family relationship as evidenced in the report below: We were in a bad shape with a lot of debts and my daughter got a job and then after two days I got my pension the social security wasn't releasing.Ah!It was so good!We paid the bills and because of this my pressure got fine.(participant 8).
The category Health aspect presented three subcategories: Control of blood pressure; Health treatment, whose positive references are related to the importance of medication use and the negative ones to the need for hospitalization; Alterations in health condition with positive reports on the improvement of health problems, while the negative ones are related to sickness, passing out and weight loss.
Blood pressure control significantly reduces the risk of cardiovascular complications, especially encephalic vascular accidents.However, one of the greatest challenges in fighting blood pressure refers to treatment adherence.
Reports that entailed the consequence of controlled blood pressure were permeated by circumstances in which the patient was satisfied, as showed below: A good thing was the day my son got his children's custody.The children's mother did not take good care of them.
When my son won their custody in court I got calm and my pressure got under control for many months (participant 11).
Reports regarding treatment and alteration of health condition presented a higher number of negative references.The disease or physical disability generate limitations and anguish in the individual, who needs support and care from family, who also goes through moments of stress and needs to adapt (11) .
Daily problems are capable of causing alterations in the patient's health state, like difficulties in the marital relationship, reported in the following: There are three subcategories in the category its direct effect on health and, consequently, on quality of life (15) .
The following discourse shows a patient who reports her joy when she found out that she would not need to go through mastectomy despite her breast cancer.The nursing consultation is an opportunity for patients to express their feelings and doubts and, therefore, diminish taboos regarding the disease and its treatment.The nursing professional attends hypertensive patients, aiming to value their anguish and difficulties in following the treatment, so that (s)he can elaborate interventions with a view to the resolution of identified problems, whether individually or collectively.

CONCLUSION
The adoption of effective actions to contain the progression of hypertension is necessary to reduce the high levels of morbidity and mortality due to In spite the fact that family involvement is essential for the control of patients' blood pressure, and lack of family support can destabilize the whole treatment plan, it is still a challenge.Thus, this study intends to provide support to health professionals, especially nurses, to reflect on the families' interaction with the care necessary to control patients' hypertension, towards the establishment of strategies with family members, so that these patients' adherence to treatment can be improved.
Participants were 21 people diagnosed with hypertension, enrolled in the hypertension program of an Integrated Health Center in Teresina, PI -Brazil in 2005, residents in the capital's urban area, aged 18 years or older.Data were collected through individualized interviews with a script, carried out in a quiet place, to obtain critical incidents.Patients were asked to recall facts related to the care necessary to control their blood pressure, involving family members or important people in their life, who either helped or harmed the adequate control of their disease.After reading the reports, the element consequence was identified and categorization and sub-categorization were performed, based on similarities found in the reports.The definition of critical incidents as positive and negative took into account each interviewee's judgment.After approval was obtained from the Ethical Research Committee at the Federal University of Piauí, Brazil, the interviews were held.Participants were Family support in the control… Costa RS, Nogueira LT.
number of references and was composed of four subcategories: Harmony in the family, with references related to moments of tranquility and peace; Concern with children/grandchildren, in which positive reports referred to children's separation and negative ones showed moments of suffering experienced by mothers and grandmothers; Relationship with family members/friends, whose positive references showed the patients' satisfaction for having close family members and the negative ones reflected disagreement and discord with family members and friends; Family members' death with reports of children's and parents' death.
Emotional aspect: wellbeing, with reports referring to moments of joy, tranquility and self-esteem; emotional alteration, reporting crying, anger and agitation; neurovegetative disorder referring to typical alterations of this disorder like tachycardia, palpitation and motor alteration.Studies show the influence of the sociopsychological context on the hypertensive patient's adherence to treatmentn and, consequently, on disease control.Authors report the dependence of the disease in relation to emotional and physical factors and argue that the individual is a mind-body unit, whose emotions are physical phenomena, and that physiological alterations possess an emotional component.It shows that emotional alteration is an aspect currently valued in clinical practice because of cardiovascular diseases.Adherence to treatment constitutes an essential tool in this struggle.H o w e v e r, i t d e p e n d s o n p a t i e n t s , h e a l t h professionals, family and community to provide the support necessary for an effective participation in the search for adherence.Through the application of the critical incident technique, taking into consideration its flexible character, several aspects related to the hypertensive patient's daily routine could be perceived, which contributed for the analysis of the involvement of family members in the treatment.The subcategories "Harmony in the family", "financial improvements in the family", "control of hypertension" and "wellbeing" got only positive references, evidencing the influence of the family dynamics on the control of the disease in the patient's perception of the care necessary for the hypertension treatment."Concern with children/grandchildren", "Relationship with family/friends", "Alteration of health condition" and "Emotional Alteration" were subcategories that presented the highest number of negative references.Although with positive considerations, they evidenced conflictive and unpleasant circumstances in the routine of these patients and little involvement of family members in relation to the disease control.

Table 1 -
Numerical distribution of categories and subcategories of the element Consequence, with One day I found out that my son was in prison, in Pará.He left prison and came back home.Three months after he was back, he tried to rob the family's own business.After that, he decided to leave and that day was the last time I saw him alive.
found out I had cancer and knew that the worse would be to lose my breasts.I wouldn't bear getting handicapped.