Self-care related to the performance of occupational roles in patients under antineoplastic chemotherapy treatment*

Objective: to analyze and correlate occupational roles, symptoms and self-care capacity in oncologic patients seen at the chemotherapy service of a university hospital. Method: cross-sectional study, in which the instruments were applied sociodemographic and clinical questionnaire, M.D Andersons Symptom Inventory - core, Appraisal of Self Care Agency Scale-Revised and Occupational Paper Identification List to oncologic patients seen in the chemotherapy service of a university hospital. Data analysis included absolute and relative frequency tables and multiple linear regression, adopting a significance level of =0.05. Results: the sample showed capacity for self-care operationalized with an average of X=57.8. In the correlation between the degree of importance of the occupational papers and the scores of the evaluation instrument for self-care was found statistical significance in the papers of volunteer (r=0.26; p=0.02) and friend (r=0.33; p= <0.001). The linear regression showed that the greater the interference of symptoms in life activities (=0.20; p=0.05) and greater the importance of the role of friend (p=0.001; p=0.43), the higher the rates of self-care. Conclusion: the operationalization of self-care can be directly related to the degree of importance attributed to the performance of social roles.


Introduction
The antineoplastic chemotherapy treatment can be long and disabling, as well as involving environmental and social aspects, which aggravate and alter the functional capacity and various activities of life (1)(2) .
Adverse events related to cancer treatment are very frequent and 86% of patients report experiencing, at least, one side effect (3) . Even with technological advances, the treatment has caused adverse events such as myelodepression, alopecia, nausea, vomiting, diarrhea, dyspnea, pain, loss of appetite, cognitive changes, cachexia, depression and fatigue, interfering with adherence or making the patient give up the chemotherapy treatment (4)(5) .
It becomes relevant to guide the oncologic patient about his/her health condition and treatment, promoting his autonomy and self-care, in search of the prevention of disabilities resulting from his chronic condition. The Orem's Theory of Self-Care bases the interventions on self-care, not only among the nursing team but, also, serves as a theoretical subsidy for the occupational therapists. This concept presents itself as a complex, innate ability, performed throughout life, with a focus on recognizing and performing personal needs (6)(7) . By providing self-confidence in performing self-care in cancer patients during chemotherapy, a positive impact on side effects, such as fatigue, can be achieved (8) .
The adverse events of cancer and chemotherapy imply changes in the performance of daily activities which, in turn, impact the performance of occupational roles. One of the main theoretical references of occupational therapy, the Human Occupation Model (HOM), describes occupational actions, such as the identity and expectation of the person in relation to his/her attributions in society. Occupational roles include being a student, worker, caregiver, performing leisure, domestic and family activities, participating in groups of friends, religious or other (9) .
Studies covering self-care and the performance of occupational roles in chemotherapy patients contribute to evidence-based practice, since national and international research aimed at analyzing the consequences of chemotherapy treatment on the capacity of self-care and the performance of occupational roles is scarce.
Furthermore, the public health policies available for the person with cancer emphasize the need to expand care, instituting multidisciplinary practices, in order to reduce the losses resulting from the disease and treatment, often responsible for costly treatments and burdens to the health system and society (9)(10)(11) .
Given the above, this article aims to analyze and correlate the occupational roles, symptoms and self-care capacity in oncologic patients seen at the chemotherapy service of a university hospital.

Method
This is a quantitative study, with cross-sectional design, conducted at the chemotherapy center of a university hospital, located in a medium-sized city   As for the structure, part I of MDASI is composed of 13 questions that investigate the presence and intensity of symptoms in the patient's life, being zero "without symptoms" and 10 "a symptom as strong as you can imagine". Part II addresses, in five questions, how much the symptoms described in part I affect life, which varies from zero to "symptom did not interfere in the life of the patient" to ten "interfered completely". For not having a general score, the result is the average of the sum of the scores of the two parts of the instrument.   The Occupational Paper Identification List instrument was used to evaluate the performance of the participants' life roles and the importance attributed to them, having been translated and validated into Brazilian Portuguese (11) . This instrument has been used in researches from the calculation of the frequency of the different occupational roles in the past, present and future times, as well as the degree of importance.
The participant points out among the ten roles listed (student, worker, volunteer, caregiver, domestic service, friend, family member, religious, hobby/amateur and participant in organizations) about their performance in the past, present and future, giving the degree of importance for each of the roles, considering the score 1 for none, 2 for some and 3 for much importance. The total score goes from 15 to 75 points and the closer to 75, the more operationalized the capacity of self-care is (7) .

Results
A total of 79 patients participated in the study, 50.6% of whom were women, 54.4% were elderly, the age range was 23 to 86 years, with a standard deviation (SD) of 13.5 and a mean age of 56.9 years. Regarding schooling, 45.6% had up to 4 years of study and 8.9% of these were illiterate.
Regarding occupation, 58.2% were retired. The prevailing cancer was that of the digestive system (35.4%), followed by breast, uterus and prostate cancers (20.3%).
Fatigue and lack of appetite were reported by 64.6%, followed by nausea with 58.2%. The highest averages obtained were for symptoms of concern (3.82) and fatigue The frequency analysis of the total SCCAS scores showed capacity for operational self-care with an average of =57.8 and SD=5.2 and the closer to 75, the greater the capacity for self-care (Table 1). The result of the answers "I fully agree" was 70.9% on the items of the instrument that related to seeking to develop the best ways to care for oneself and on the ability to obtain information, when identified health threats.
To In the correlation between the degree of importance of occupational roles and the scores of the evaluation instrument for self-care, statistical significance was found in the roles of volunteer (r=0.26; p= 0.02) and friend (r=0.33; p= <0.001). These results showed that the more important the performance of these roles for the participant, the greater is his self-care (Table 2).

Discussion
Studies with the adult and elderly population served in the Brazilian Unified Health System (UHS) and that perform antineoplastic chemotherapy treatment present sociodemographic data consistent with those of this research (13)(14) . In the oncologic practice, sociodemographic variables, such as gender, age, income, schooling, cohabitation and occupation, must be considered, due to its influence in the early detection of cancer and the consequent search for the health service, facilitating the institution of the best treatment and even the survival to cancer. In turn, early detection is permeated by population health education, which should be focused on self-care practices, even before the diagnosis of an illness (15)(16) .
Among the oncologic adult and elderly patients attended at UHS, researches point out that, when seeking health care, the disease is in a more advanced stage, if compared to the stage of those seeking health care in developed countries. For the health system and society, this factor may generate burdens due to increased disabilities and loss of functionality, leading to early retirement and decreased health-related quality of life (HRQL) and hindering chances of survival (1,17) .
By accepting these issues, it is the duty of health professionals to provide guidance and education on self-care practices during chemotherapy treatment in order to prevent the adverse effects of antineoplastic chemotherapy and to increase the chances of survival and higher HRQL (18) .
Self-care practices can be classified as passive, when the professional performs the care without the help of the patient; collaborative, when the professional and the patient perform together health care actions and active, related to the practices and actions performed by the person without the help of a health care professional (19) .
However, the person's involvement with cancer in self-care practices may vary according to their socioeconomic situation, the treatment performed, the socio-family support and their life perspectives. The health professional should encourage the significant adoption of habits and behaviors that favor the active practice of self-care throughout the life of the sick person and his/ her family, engaging him/her in these actions beyond the treatment period (19) .
In order for healthy habits and behaviors to occur in people with cancer, it is important that these patients psychologically face the new lifestyle, adjusting to the new health condition and the challenges experienced as a result of the chronic disease, in addition to psychological adaptation, in order to become resilient to the stressful variables that impact on behavior and interaction with the environment (20) .
In this study, the concepts of psychological adjustment and adaptation can be linked to the good operationalization of self-care among the participants, as they reported looking for the best ways to care for themselves and the ability to obtain information when they feel health threats.  (20) .
In addition, the literature brings how much social and family support is indispensable when it comes to favorable responses to treatment and life perspectives of the person with cancer. Such psychological support, offered by the social and family support network, helps in the management of feelings and emotions, which may limit or engage the person in face of the diagnosis and treatment (20)(21) .
In helping to have a positive perspective to face the changes caused by cancer, studies report that the role of friend has different characteristics than that of family members, because he is less involved in the daily stress caused by the disease and its treatment. This makes him more able and emotionally prepared to offer support and support to patients undergoing treatment, engaging them in a more active posture through the necessary adaptations (20,22) .
Although several demographic variables were analyzed as predictors of the operationalization of selfcare, no sociodemographic variable was statistically significant in this study. Nevertheless, the sex of the individual, socioeconomic condition and schooling are commonly found in the literature, as influencing self-care ability and should be considered in clinical practice (21,23) .
It is valid for health professionals to know the conditions and variables that may protect and/or influence the adaptation of the chronic patient to his new health condition (20) . It is also stated that, even after a diagnosis such as cancer, it is possible that many patients manage to resign their lives, adopting habits and behaviors in order to restructure themselves and live a more active and healthy www.eerp.usp.br/rlae 6 Rev. Latino-Am. Enfermagem 2021;29:e3421.
life, by committing themselves, even more, to their occupations and their family and social relationships (24) .

Conclusion
The results showed that there are symptoms that