Actions of nurses toward obesity in primary health care units

Actuación de enfermeros orientada a la obesidad en la Unidad Básica de Salud

ABSTRACT

Objectives:

To understand the actions of nurses toward obesity in primary health care units.

Methods:

A phenomenological study was carried out with 12 nurses of a city in the state of Minas Gerais. The interviews were organized into categories and analyzed according to the social phenomenology of Alfred Schütz and literature associated with the theme.

Results:

The following categories emerged, expressing the actions of nurses toward obesity prevention and control: “Guidance on healthy lifestyle habits”, “Barriers to the actions of nurses”, and “Focusing specifically on obesity”.

Final considerations:

Considering that guidance on healthy lifestyle habits was mostly carried out during individual and collective activities directed to the general population, regardless of their weight conditions, nurses must reorganize their professional practice in primary health care units by implementing specific actions for users with obesity or at risk of developing it.

Descriptors:
Obesity; Health Centers; Nursing, Practical; Primary Health Care; Qualitative Research

RESUMEN

Objetivos:

Comprender la actuación de enfermeros orientada a la obesidad en la Unidad Básica de Salud.

Métodos:

Estudio fenomenológico, entrevistando a 12 enfermeros de un municipio de Minas Gerais. Los testimonios fueron organizados en categorías y analizados según fenomenología social de Alfred Schütz y literatura relacionada con la temática.

Resultados:

Surgieron categorías que expresan la actuación de los enfermeros respecto de la prevención y control de la obesidad: “Orientaciones sobre hábitos de vida saludables”, “Obstáculos para la actuación del enfermero” y “Especializarse específicamente en obesidad”. Consideraciones Finales: Considerando que las orientaciones sobre hábitos de vida saludables fueron realizadas fundamentalmente durante las actividades individuales y colectivas abiertas al público en general, independientemente de la condición ponderal, señálase la necesidad de que el enfermero reorganice sus prácticas profesionales en la Unidad Básica de Salud, con el objeto de implementar acciones específicas para los pacientes con obesidad y/o con riesgo de desarrollarla.

Descriptores:
Obesidad; Centros de Salud; Enfermería Práctica; Atención Primaria de Salud; Investigación Cualitativa

RESUMO

Objetivos:

Compreender a atuação de enfermeiros voltada para a obesidade na Unidade Básica de Saúde.

Métodos:

Pesquisa fenomenológica que entrevistou 12 enfermeiros de um município de Minas Gerais. Os depoimentos foram organizados em categorias e analisados segundo a fenomenologia social de Alfred Schütz e literatura relacionada à temática.

Resultados:

Emergiram categorias que expressam a atuação dos enfermeiros em relação à prevenção e ao controle da obesidade: “Orientações sobre hábitos saudáveis de vida”, “Barreiras à atuação do enfermeiro” e “Voltar-se especificamente para a obesidade”. Considerações Finais: Considerando que as orientações sobre hábitos de vida saudáveis eram realizadas predominantemente durante as atividades individuais e coletivas voltadas para o público em geral, independentemente da condição ponderal, sinaliza-se a necessidade de o enfermeiro reorganizar suas práticas profissionais na Unidade Básica de Saúde, de modo a implementar ações específicas para os usuários com obesidade e/ou com risco para desenvolvê-la.

Descritores:
Obesidade; Centros de Saúde; Enfermagem Prática; Atenção Primária à Saúde; Pesquisa Qualitativa

INTRODUCTION

Nowadays, chronic non-communicable diseases exert an important impact on populations’ morbidity and mortality, which are influenced by demographic and epidemiological changes, increase in life expectancy, and practice of unhealthy habits. Obesity is a serious public health problem, considered, at the same time, a risk factor and a chronic disease⁽¹⁾. The World Health Organization (WHO) estimated that, in 2016, the rate of overweight people reached more than 1.9 billion adults, of which 650 million would be obese, corresponding to 13% of the world’s adult population. Regarding children under the age of 5 years, the estimate was 41 million⁽¹⁾.

Data from Vigitel Brazil 2016 (Protective and risk factors for chronic diseases by telephone survey) showed that in Brazil, 53.8% of the adult population was overweight. This increase was higher among men than among women, in the age group between 35 and 64 years. Obesity reached 18.9% of the population, which in 2010 was 15%⁽²⁾.

Obesity is a complex health condition that is difficult to be faced due to its multifactorial etiology composed of genetic, environmental, and sociocultural factors. The genetic factor may exert a significant role in energy imbalance. Environmental factors are currently characterized by the increase in intake of low cost, processed, and high-energy concentration food. In addition to cultural and social habits that influence on inappropriate dietary intake, as well as physical inactivity, these factors cause overweight⁽³⁾. Therefore, interventions in the obesity prevention and control area imply an approach combining biological, socioeconomic, and cultural dimensions experienced by individuals in their daily living.

In Brazil, primary health care (PHC) units are responsible for the undertaking of governmental programs at the primary health care level, especially those focused on health promotion and health complication prevention. These health care services have the potential to enable obesity prevention and control actions, especially promoting coordination with other social and health equipment, leading to activities that make sense for the population, thus facilitating adherence to the actions proposed⁽⁴⁾.

In PHC units, nurses are involved in actions carried out in health promotion, complication prevention, and recovery contexts; in direct contact with individuals and their families, being able to understand the context necessary to overcome local health problems⁽⁵⁾, including obesity prevention and control.

Understanding social, economic, cultural, and health contexts of families living in the area of coverage of the PHC unit, added to nurses’ professional and interactional skills, makes this professional an important element for strengthening actions associated with obesity confrontation. Studies showed that nurses’ actions in primary care services can assist individuals in controlling/losing weight, as well as improving their dietary habits and physical activity, impacting on the daily living of the entire family^(6-7).

In this respect, the following questions guided the present study: What are the actions carried out by nurses in their daily practice in primary health care units toward obesity? What are these professionals’ expectations regarding their actions?

OBJECTIVES

To understand the actions of nurses toward obesity in primary health care units.

METHODS

Ethical aspects

The present study met the ethical aspects of resolution 466/2012 of the Brazilian National Health Council⁽⁸⁾, and was approved by the human research ethics committee of the School of Nursing of the University of São Paulo.

Theoretical-methodological framework

The present study was based on concepts of the social phenomenology of Alfred Schütz⁽⁹⁾. Man’s action among his fellows in the social world has the biographical situation as a basis – human being’s position in the social context –, as well as its pool of knowledge acquired throughout life. The act corresponds to the action already undertaken (reasons why) and personal projects experienced in the intersubjectivity of social relationships are called “reasons for”. The present study presents the set of “reasons why” and “reasons for” of the actions of nurses toward obesity in primary health care units.

Study design

This was a qualitative study with a phenomenological approach. This study respected the steps recommended by the consolidated criteria for reporting qualitative research (COREQ)⁽¹⁰⁾.

Study setting

The present study was carried out in primary health care units of a city in the state of Minas Gerais. This city has 63 health care units distributed into seven administrative regions and 12 health regions.

Data source

Twelve permanent nurses who worked in PHC units for at least three years participated in the study, assuming that this length of experience could be a facilitating factor to carry out obesity prevention and control activities. Temporary nurses, those who had management positions, and on sick or maternity leave were excluded.

Data collection

Access to the participants was provided after authorization from the city’s Department of Programs and Actions of the Primary Health Care Secretariat. The department provided the list of telephone numbers of the PHC units that could be included in the study. Nurses were contacted and those who met the inclusion criteria were invited to participate in the study, with scheduling of interviews’ date, time, and place. The main researcher was in contact with the nurses since their graduation, which facilitated the approach.

Data were collected from December 2017 to February 2018 using the phenomenological interview as an instrument. In this type of interview, researchers ask and participants answer, describing the social action studied⁽¹¹⁾. A semi-structured guideline was used with the following questions: What have you done regarding obesity prevention and control for primary health care users? What are your expectations regarding your actions with users against obesity? In addition to these questions, personal, socioeconomic, and professional information was added to the data collection guideline. All interviews were included in the study, with no sample losses.

Before beginning the interviews, the main researcher explained the study objectives, ethical aspects involved, and the need for signing an informed consent form. Participants’ permission was asked for the use of an audio recorder, in order to enable interviews’ full record and subsequent analysis. Each interview lasted for approximately 40 minutes.

Most interviews were carried out in private rooms of the PHC facilities during work time, so participants could be comfortable and safe to express their experiences. One of the interviews was carried out in the residence of a participant, in an appropriate place for its conduction.

The audio recorded was stored in a place to which only the main researcher had access. The interviews were concluded when their content was considered sufficient for deepening, comprehensiveness, and diversity of the subject studied⁽¹²⁾. In order to ensure anonymity, the interviews were identified by the abbreviation of the word nurse (N) followed by an Arabic number corresponding to the order of the interviews, namely N1 to N12.

Data organization and analysis

The organization and analysis of the results were grounded on concepts described in studies based on social phenomenology by means of the following stages: interview, reports’ careful reading and rereading, distancing from theory to value the meanings explained by the participants; interviews’ comprehensive analysis and organization into categories that express the experience of nurses toward obesity prevention and control in primary health care units; results’ interpretation based on phenomenology and theoretical framework associated with the theme studied⁽¹¹⁾.

RESULTS

Nurses' age ranged between 32 and 57 years, most were women, length of time since graduation was 10 to 29 years (11 had a graduate degree in Family Health and three had specific training on obesity). The length of time working in primary health care units ranged between four and 15 years.

Guidance on healthy lifestyle habits (reasons why)

In nursing appointments, nurses provided guidance on healthy eating to mothers of newborn babies, infants up to 2 years of age, and pregnant women:

In child care, I work with infants from 0 to 2 years of age. In the case of bottle-fed infants who are already overweight, I cut out flour and recommend mothers to give them only milk… I carry out dietary evaluation and guide mothers. (N7)

Actually, regardless of being obese or not, I guide pregnant women on the best possible natural diet and water intake. (N3)

When admitting people with chronic conditions, nurses, in addition to guidance on healthy eating, encouraged the undertaking of physical activities:

Upon admission, I assist hypertensive and diabetic people and provide guidance on nutrition, need for physical activity, and weight control. (N1)

Mostly in adults, overweight and obesity already come with some chronic condition... I try to encourage them to undertake physical activities provided by the service. (N5)

For the group of pregnant women and people with chronic conditions, such as systemic arterial hypertension and diabetes mellitus, nurses encouraged healthy eating and carried out an anthropometric evaluation:

In the group of hypertensive and diabetic people, I always weight them and carry out body mass index calculation and abdominal circumference measurement…I encourage healthy eating, salt reduction, and appropriate use of medication. (N4)

Both in the group of pregnant women and hypertensive and diabetic people, I carry out an anthropometric evaluation and body mass index classification. From then on, I start working on the weight issue. (N6)

The walking-oriented group is an activity carried out by PHC units under the responsibility of physical education professionals, with nurses are collaborators:

There is a walking group for adults on Mondays and Wednesdays. A physical education teacher conducts this activity. Actually, she works together with the nursing team and physicians to improve laboratory indexes of the walking-group participants. (N5)

A physical education professional comes three times a week… I do not act directly in these walking activities. However, because the participants come to the PHC unit, I measure their blood pressure and weight. (N11)

Cases of severe obesity in children, pregnant women, and adults are referred to an endocrinologist and a nutritionist in the secondary health care level:

In cases of comorbidities associated with obesity, I refer them to the endocrinologist. Even to consider bariatric surgery if applicable. (N6)

Sometimes, I have to refer pregnant women to the high-risk sector. There, they have a follow-up with nutritionists and endocrinologists. I also refer child obesity cases to the specialized care of the health care network. (N9)

Barriers to the actions of nurses (reasons why)

Nurses reported difficulties, such as resistance to changing users’ lifestyle habits and lack of adherence to educational groups provided by PHC units:

I think that difficulties come from individuals’ own resistance to changing habits. [...] Resistance to adhere to diets, healthy eating… (N4)

What I still was not able to accomplish here in the PHC unit, is the issue of educational groups due to the lack of adherence, because users do not consider it important. (N12)

The imbalance between the reduced number of healthcare professionals working in PHC units and the great demand for this service, in addition to the lack of other categories in the team, were considered limiting factors for the actions of nurses toward obesity:

Lately, I am involved in several demands such as vaccination against yellow fever, actions on dengue, evaluation of the primary health care department portal [PMAQ, as per its acronym in Portuguese], and visits from the Ministry of Health. I was not able to plan anything else. (N5)

I am the only nurse in the PHC unit where I work. I am the supervisor of the unit and I have to undertake several other activities. Sometimes, an individual with obesity comes to the unit and I do not even know about it because I am undertaking another activity. (N 8)

Poor primary health care facilities, as well as the lack of appropriate equipment and educational material, hinder the undertaking of obesity prevention and control activities:

I do not have anything, only a scale. There is nothing visual I can show to obese users who come to appointments. (N3)

The PHC unit’s team does not receive support from the management with supplies and training to deal with demands. In the group appointments, if I need educational material, I have to create it myself... There is a lack of basic material, even scales. (N6)

Because the participants are not nutritionists, they consider themselves limited to act with users regarding obesity:

Sometimes, I deal with the eating issue, but I feel limited in terms of specific knowledge, such as how to prepare a diet for a diabetic person… An expert is required. (N3)

I do not have the appropriate training to guide people with obesity. I tell people not to eat pasta, rice…but it is very vague to prescribe them a diet. (N10)

Focusing specifically on obesity (reasons for)

Learning about the dietary and weight profile of the population by means of instruments from the Brazilian Food and Nutrition Surveillance System to establish obesity prevention and control strategies is an expectation of nurses:

One of the goals is to feed the dietary markers to carry out a clearer population diagnosis of who has a normal weight and who is overweight and obese, and then, discuss and propose strategies with the team...This is one of my expectations. (N6)

The Secretariat of Health agreed with PHC units regarding the need for drawing the dietary and weight profile of pregnant women and children under the age of two years...I fill in the dietary marker form in every nursing appointment. The filling in is my expectation to learn about the population’s profile regarding weight. (N11)

Another expectation is to carry out specific groups for weight control in PHC units:

I want to create a weight control group for children and adults because appointments are currently individual... I wish to carry out a specific group for weight loss because it works... (N2)

It is our duty to do something because we are a PHC unit. I want to have a weight control group as other units…However, this is something I still did not accomplish. (N5)

Nurses expect to improve interaction between PHC units and community services that provide physical activities for the population, in addition to undertaking health promotion actions for children and adolescents in schools:

I wish to improve interaction with community services. I want to refer users to physical activity projects in the community…I talk a lot with the local health council about the issue of narrowing the relationship between community and PHC units. (N9)

I wish to undertake activities in schools to provide students with information…If we are able to sensitize them early on, they will grow up knowing what they must and must not eat. (N7)

Receiving training to act in obesity control is also an expectation of nurses:

I hope to be better trained to act with people who present obesity, because despite having some knowledge, certain clinical skills, even those to deal with group work, it is difficult to deal with obese people. (N6)

The Municipal Health Secretariat provided the PHC unit with a manual on Brazilian population health that discusses obesity, but we always need training. (N10)

DISCUSSION

The results showed that the characteristics of the actions of the group of nurses toward obesity in PHC units gather past and present experiences (reasons why) imbricated in the practice of guidance to mothers of children, pregnant women, and adults with chronic conditions on healthy lifestyle habits and, collectively, in oriented-walking groups, and operative groups functioning in healthcare units. In this practice, nurses perceive barriers that hinder obesity prevention and control actions regarding resistance to the change of lifestyle habits, in addition to limitations imposed by the services and healthcare teams. They also gather these nurses’ expectations regarding their actions (reasons for): learning the population’s dietary and weight profile; undertaking specific groups for weight control; improving the integration of PHC units with other social equipment; acting with children and adolescents out of the unit’s space; and receiving training to act in obesity prevention and control.

Regarding the follow-up of infants up to the age of two years, the nurses in the present study emphasized guiding mothers on healthy eating and encouraging breastfeeding. Corroborating these results, one study carried out in southern Brazil showed that encouragement to breastfeeding is one of the nurses’ actions that aims at preventing and fighting childhood obesity⁽⁵⁾. In Australia, one study on guidance content regarding obesity provided during routine nursing appointments to children from zero to five years of age showed that most nurses advised parents on the different aspects of child nutrition⁽¹³⁾.

Dietary guidance is also carried out in groups of pregnant women, which is a strategical time for encouraging the adoption of healthy habits. One study carried out in the state of Rio Grande do Sul, Brazil, reported the experience of nursing students in a university extension project with groups of pregnant women and showed that this health education strategy could maximize care in PHC units⁽¹⁴⁾.

In addition to guidance on healthy eating, nurses reported undertaking anthropometric and body mass index evaluations in pregnant women and people with chronic conditions. This result is corroborated by another Brazilian study carried out in São Paulo, Brazil with professionals of PHC units, showing significant actions of nursing teams regarding the measurement of users’ anthropometric measures. It was highlighted that the underestimation or negligence of the population’s anthropometric data may generate care deprivation to people with a need for weight follow-up⁽¹⁵⁾.

Nurses are considered leaders in healthcare teams in the undertaking of interventions focused on the management of chronic diseases in the primary care context⁽¹⁶⁾. One study carried out in Finland identified that guidance on lifestyle changes carried out by nurses during three years resulted in a reduction of at least 5% of the initial weight in 18% of the overweight people and with comorbidities, which they were able to maintain for three years. In addition, the majority succeed in stabilizing their weight after interventions⁽¹⁷⁾.

Nurses in the present study encourage users’ participation in oriented-walking groups. One study carried out in the state of Bahia, Brazil, analyzed the results of a 12-week oriented-walking and nutritional program directed to women with obesity, and, after an intervention carried out by professors and students of physical education and nutrition courses, observed reduction in the mean value of all fat indicators analyzed and a statistical difference significantly smaller of the subscapular skinfold⁽¹⁸⁾.

It is worth mentioning that the participants in the present study were not responsible for the oriented-walking groups; however, they assisted in associated activities. Nurses’ participation in physical activities was discussed in one study carried out in the state of Santa Catarina, Brazil, with 10 professionals who worked in educational groups in PHC units. These professionals took advantage of the presence of users in oriented-walking activities to promote health education, aimed at improving quality of life, exchanging experiences, and developing a relationship with the community⁽¹⁹⁾.

When undertaking guidance aiming at the promotion of healthy lifestyle habits, nurses establish a face-to-face social relationship with users. This type of relationship happens when people involved are aware of each other and share the same time and space. Therefore, there is an interaction where one is within the reach of the other’s direct experience, maintaining an interchange between them in a communicative environment⁽⁹⁾. In this respect, the effectiveness of nurses’ interventions toward obesity in PHC units is directly associated with the quality of the interactions established between professionals and users, in which intersubjectivity is relevant for the success of these interventions.

Some clinical conditions of overweight people indicate the need for referral to specialized care, such as patients with suspected secondary obesity and indication for bariatric surgery. According to Brazilian obesity guidelines, responsibility for care coordination in the healthcare network lies with the primary health care level, acting in patient referral and counter-referral to specialized services⁽²⁰⁾. However, referral of people with obesity to the secondary health level does not exempt professionals of PHC units from the responsibility in acting toward changes in lifestyle aiming at weight loss, which, even if modest, produce clinically significant benefits for these people.

Nurses mentioned the resistance of users to behavior changes, which compromises the adoption of healthy lifestyle habits and control of chronic health problems. This result was corroborated by one study carried out in Portugal with nurses, physicians, and nutritionists who worked in primary care. These professionals pointed out negative beliefs and attitudes regarding overweight people, who were described as discouraged and passive in the face of treatments, associating weight loss with professionals’ responsibility and not with a personal chance of unhealthy lifestyle habits⁽²¹⁾.

Difficulty in adherence of people to educational groups proposed by the PHC units was also emphasized in one study carried out with adults in São Paulo, Brazil, concluding that lack of self-confidence and time were among the main reasons of users with obesity for abandoning weight loss treatment⁽²²⁾.

Services’ limitations regarding human, material, and structural resources, which hinder the undertaking of nurses’ actions toward users with obesity, are corroborated in one study carried out in northeastern Brazil. This showed that actions aiming at dietary and nutritional safety were carried out by professionals of a PHC unit in a fragmented and discontinued way, due to factors such as professionals’ excess of demand, lack of supplies provided by the management, users’ unfavorable life conditions, as well as limited professional training on the theme⁽²³⁾.

In addition to the reduced number of professionals in the team and lack of material resources, the routine of nurses is full of demands requested by the management, in detriment of activities consistent with the needs of the population of the local area. Corroborating this finding, one study carried out with healthcare teams of 20 PHC units of the state of Paraíba, Brazil, showed that lack of time, overwork, and high demand were among the main difficulties to undertake actions in the dietary and nutrition area⁽²⁴⁾.

The complexity and multifactorial nature of obesity hinder its confrontation, demanding multidisciplinary work. The healthcare team, when developing interdisciplinary actions, may affect these patients’ quality of life improvement and reduction of diseases. One study that reported the experience of a healthcare team in dietary and nutritional education activities in a PHC unit in the state of Alagoas, Brazil, observed weight loss, blood pressure reduction, change in family eating habits (reduction in salt, sugar, and processed foods consumption, and increase in salad and fruit consumption), greater care in food preparation, and greater commitment to taking walks⁽²⁵⁾.

The limited knowledge in the theme of obesity for not being nutritionists was another difficulty mentioned by nurses. One study carried out in England also showed that nurses had insufficient knowledge of obesity care, representing a barrier to their practice in primary healthcare services regarding prevention and control of this condition⁽²⁶⁾.

Reflection on daily practice regarding obesity in PHC units led nurses to project new actions aiming at the prevention and control of this chronic condition. According to Alfred Schütz’s social phenomenology, human action is endowed with intent and associated with a project where human beings find meaning⁽⁹⁾.

Learning the dietary intake and weight profile of the population of the area covered by the PHC unit was an action project of nurses toward obesity care. Professionals recognize that the dietary and health condition of users under their responsibility must be the starting point for the undertaking of obesity prevention and control activities. In this respect, nurses must be able to carry out the situational diagnosis of the population in coordination with the healthcare team, identifying the dietary profile and risk conditions of the local people, which include overweight and obesity⁽²⁷⁾.

The implementation of specific groups for weight control was also nurses’ intention toward their practice in obesity care. One study carried out in a PHC unit of northern Paraná, Brazil, showed benefits from group activities for obesity control. Significant changes in lifestyle habits were observed, such as an increase in the physical activity level and intake of fibers, reduction in salt, processed food, and sugar intake, and frequency of red meat intake, in addition to significant reduction in weight, waist circumference, and body mass index⁽²⁸⁾.

In order to maximize users’ adherence to activities carried out in PHC units, nurses reported a desire to broaden the partnership between this service and other local social equipment, especially schools. The results of a systematic literature review highlight the relevance in promoting obesity prevention and control actions, involving cross-sectoral strategies in health, education, and culture contexts. This interaction is considered necessary due to the multifactorial aspect of this chronic condition, which requires continuous broad and integrated practices that favor users’ adherence to healthcare services⁽²⁹⁾.

Nurses’ intervention with schools may influence the improvement of dietary choices, resulting in healthy lifestyle habits. One study carried out in the state of Piauí, Brazil, evaluated an educational intervention of nurses based on the promotion of healthy dietary habits with 35 preschool children between 5 and 7 years of age. After the intervention, 76.8% were able to classify foods considered healthy and 75.5% were able to classify unhealthy foods⁽³⁰⁾.

The need for receiving training to act in obesity prevention and control was reported by the nurses in this study. Corroborating this result, one study carried out in Australia showed that 85% of the healthcare professionals working in PHC services reported interest in being trained to act better in childhood obesity prevention in the community where they worked⁽³¹⁾. Participation in training events and continuing education programs provides healthcare professionals with access and knowledge on obesity prevention and control policies in the PHC context. Consequently, they are able to provide appropriate guidance on healthy eating, physical activity practice, undertaking of anthropometric measurements, and other demands associated with obesity.

Study limitations

Because this was a qualitative study, the results may translate characteristics that are specific of the studied group. Their reality may differ from others, hindering the generalization of the results. Therefore, other exploratory possibilities must be implemented.

Contributions to the nursing, healthcare, and public policy areas

Nurses must reorganize their professional practice in order to carry out specific actions for users with obesity or risk of developing it, since, in the present study, most of the guidance on healthy lifestyle habits was carried out during individual and collective activities toward the diverse populations of the PHC units, regardless of their weight condition.

Despite the existence of policies directed to the care of people with obesity, systematizing planned actions for this population is of utmost importance, with the aim at directing guidance on healthy eating, practice of physical activities, anthropometric evaluation, and coordination with community services, as well as definition of competencies of each service of the healthcare network, thus maximizing the referral and counter-referral system. It is worth mentioning the need for discussing the applicability of these policies, considering the life context of the population cared, to maximize obesity prevention and control actions carried out in PHC units. The inclusion of the population’s participation in these actions, by means of local and municipal health councils, and dietary and nutritional safety councils may strengthen professional performance in PHC.

FINAL CONSIDERATIONS

The social phenomenology of Alfred Schütz enabled to observe that the actions of the studied group of nurses toward obesity in PHC units gather guidance on healthy lifestyle habits individually, and oriented-walking, as well as operative groups for the diverse population previously cared, regardless of their weight condition. It also includes the perception of difficulties for their performance associated with users’ resistance to behavior changes, in addition to limitations imposed by the service and healthcare team. Their projects include the desire to learn the dietary and weight profile of the population, undertake specific groups for weight control, improve coordination of PHC units with other social equipment, act with children and adolescents out of the unit’s space, and receive training to act in obesity prevention and control.

These characteristics associated with the actions of nurses toward obesity contribute to the reflection on how people are receiving care in this service of the primary health network, and indications to the management of healthcare services toward the need to reorganize professional practices in PHC units, in order to ensure specific actions for users with obesity or risk of developing it.

These results are expected to contribute to the nursing practice toward obesity prevention and control in PHC units and promote discussions on this theme in the context of training and continuing education. In addition, further studies associated with the theme may add other aspects to the present study, thus adding value to this area of the knowledge.

ACKNOWLEDGMENT

To the Brazilian Coordination for the Improvement of Higher Education Personnel (CAPES, as per its acronym in Portuguese) for awarding a master’s program scholarship to the author Vanessa Augusta Souza Braga.

REFERENCES

• ¹
  World Health Organization. WHO. Obesity and overweight: Key facts [Internet]. 2017 [cited 2018 May 26]. Available from: http://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
  » http://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
• ²
  Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde. Vigitel Brasil 2016: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2016 [Internet]. 2017 [cited 2018 May 26]. Available from: http://portalarquivos2.saude.gov.br/images/pdf/2018/marco/02/vigitel-brasil-2016.pdf
  » http://portalarquivos2.saude.gov.br/images/pdf/2018/marco/02/vigitel-brasil-2016.pdf
• ^3.
  Dobbs R, Sawers C, Thompson F, Manyika J, Woetzel J, Child P et al. Overcoming obesity: an initial economic analysis executive summary. McKinsey Global Institute [Internet] 2014 [cited 2018 May 26]. Available from: https://www.mckinsey.com/~/media/McKinsey/Business%20Functions/Economic%20Studies%20TEMP/Our%20Insights/How%20the%20world%20could%20better%20fight%20obesity/MGI_Overcoming_obesity_Full_report.ashx
  » https://www.mckinsey.com/~/media/McKinsey/Business%20Functions/Economic%20Studies%20TEMP/Our%20Insights/How%20the%20world%20could%20better%20fight%20obesity/MGI_Overcoming_obesity_Full_report.ashx
• ⁴
  Costa JP, Jorge MSB, Vasconcelos SMGF, Paula ML, Bezerra IC. Resolubilidade do cuidado na atenção primária: articulação multiprofissional e rede de serviços. Saúde debate [Internet]. 2014 [cited 2018 May 26];38(103):733-743. Available from: http://www.scielo.br/pdf/sdeb/v38n103/0103-1104-sdeb-38-103-0733.pdf
  » http://www.scielo.br/pdf/sdeb/v38n103/0103-1104-sdeb-38-103-0733.pdf
• ⁵
  Santos FDR, Vitola CB, Arrieira ICO, Chagas MCS, Gomes GC, Pereira FW. Ações de enfermeiros e professores na prevenção e combate à obesidade infantil. Rev Rene [Internet]. 2014 [cited 2018 May 26]; 15(3):463-70. Available from: http://www.periodicos.ufc.br/rene/article/download/3205/2464
  » http://www.periodicos.ufc.br/rene/article/download/3205/2464
• ⁶
  Sargent GM, Forrest LE, Parker RM. Nurse delivered lifestyle interventions in primary health care to treat chronic disease risk factors associated with obesity: a systematic review. Obes Rev [Internet]. 2012 [cited 2018 May 26];13(12):1148-71. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3533768/pdf/obr0013-1148.pdf
  » https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3533768/pdf/obr0013-1148.pdf
• ⁷
  Dillen SME, Noordman J, Dulmen S, Hiddink GJ. Examining the content of weight, nutrition and physical activity advices provided by dutch practice nurses in primary care: analysis of videotaped consultations. Eur J Clin Nutr [Internet]. 2014 [cited 2018 May 26];68(1):50-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24169459
• ⁸
  Brasil. Ministério da Saúde. Resolução 466 de 12 de dezembro de 2012: Aprova diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos [Internet]. 2012 [cited 2018 May 26]. Available from: http://conselho.saude.gov.br/resolucoes/2012/reso466.pdf
  » http://conselho.saude.gov.br/resolucoes/2012/reso466.pdf
• ⁹
  Schütz A. Sobre fenomenologia e relações sociais. 1st ed. Org. Wagner HTR. Petrópolis: Vozes; 2012.
• ¹⁰
  Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care [Internet]. 2007 [cited 2019 Jan 09];19(6):349-57. Available from: https://academic.oup.com/intqhc/article/19/6/349/1791966
  » https://academic.oup.com/intqhc/article/19/6/349/1791966
• ¹¹
  Jesus MCP, Capalbo C, Merighi MAB, et al. The social phenomenology of Alfred Schütz and its contribution for nursing. Rev Esc Enferm USP [Internet]. 2013 [cited 2018 May 26];47(3):736-41. Available from: http://www.scielo.br/pdf/reeusp/v47n3/0080-6234-reeusp-47-3-00736.pdf
  » http://www.scielo.br/pdf/reeusp/v47n3/0080-6234-reeusp-47-3-00736.pdf
• ¹²
  Minayo MCS. Amostragem e saturação em pesquisa qualitativa: consensos e controvérsias. RPQ [Internet]. 2017 [cited 2018 May 26]; 5(7): 1-12. Available from: https://edisciplinas.usp.br/pluginfile.php/4111455/mod_resource/content/1/Minayosaturacao.pdf
  » https://edisciplinas.usp.br/pluginfile.php/4111455/mod_resource/content/1/Minayosaturacao.pdf
• ¹³
  Laws R, Campbell KJ, van der Pligt P, Ball K, Lynch J, Russell G, et al. Obesity prevention in early life: an opportunity to better support the role of maternal and child health nurses in Australia. BMC Nurs [Internet]. 2015 [cited 2018 May 26];14:26. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4429503/pdf/12912_2015_Article_77.pdf
  » https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4429503/pdf/12912_2015_Article_77.pdf
• ¹⁴
  Nunes GP, Negreira AS, Costa MG, Sena FG, Amorin CB, Kerber NPC. Grupo de gestantes como ferramenta de instrumentalização e potencialização do cuidado. Cidadania em Ação [Internet]. 2017 [cited 2018 May 26];1(1):1-16. Available from: http://www.revistas.udesc.br/index.php/cidadaniaemacao/article/download/10932/pdf
  » http://www.revistas.udesc.br/index.php/cidadaniaemacao/article/download/10932/pdf
• ¹⁵
  Ferreira MCS, Negri F, Galesi LF, Detregiachi CRP, Oliveira MRM. Monitoramento nutricional em unidades de Atenção Primária à Saúde. RASBRAN [Internet]. 2017 [cited 2018 May 26]; 8(1):7-45. Available from: https://www.rasbran.com.br/rasbran/article/download/227/156
  » https://www.rasbran.com.br/rasbran/article/download/227/156
• ¹⁶
  Stephen C, McInnes S, Halcomb E. The feasibility and acceptability of nurse-led chronic disease management interventions in primary care: an integrative review. J Adv Nurs [Internet]. 2018 [cited 2018 May 26] Feb;74(2):279-288. Available from: https://onlinelibrary.wiley.com/doi/pdf/10.1111/jan.13450
  » https://onlinelibrary.wiley.com/doi/pdf/10.1111/jan.13450
• ¹⁷
  Korhonen PE, Järvenpää S, Kautiainen H. Primary care-based, targeted screening programme to promote sustained weight management. Scand J Prim Health Care [Internet]. 2014 [cited 2018 May 26];32(1):30-6. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4137900/pdf/pri-32-30.pdf
  » https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4137900/pdf/pri-32-30.pdf
• ¹⁸
  Oliveira CS, Brito BJQ, Quadros TMB, Gordia AP, Coelho FT. Avaliação de um projeto de extensão universitária de prática de caminhada e orientação nutricional para mulheres obesas. REMEFE [Internet]. 2015 [cited 2018 May 2018];14(1):163-176. Available from: http://editorarevistas.mackenzie.br/index.php/remef/article/download/6161/5994
  » http://editorarevistas.mackenzie.br/index.php/remef/article/download/6161/5994
• ¹⁹
  Maceno PR, Heidmann ITSB. Unveiling the actions of nurses in primary health care groups. Texto Contexto Enferm [Internet]. 2016 [cited 2018 May 26; 25(4):e2140015. Available from: http://www.scielo.br/pdf/tce/v25n4/0104-0707-tce-25-04-2140015.pdf
  » http://www.scielo.br/pdf/tce/v25n4/0104-0707-tce-25-04-2140015.pdf
• ²⁰
  Associação Brasileira para o Estudo da Obesidade e da Síndrome Metabólica. Diretrizes brasileiras de obesidade [Internet]. 2016 [cited 2018 May 26]. Available from: http://www.abeso.org.br/uploads/downloads/92/57fccc403e5da.pdf
  » http://www.abeso.org.br/uploads/downloads/92/57fccc403e5da.pdf
• ²¹
  Teixeira F, Pais-Ribeiro JL, Maia A. Uns desistem, outros insistem: semelhanças e diferenças no discurso de profissionais de saúde face à obesidade. Rev. Port. Sau. Pub. [Internet]. 2015 [cited 2018 May 26];33(2):137-47. Available from: http://www.scielo.mec.pt/pdf/rpsp/v33n2/v33n2a03.pdf
  » http://www.scielo.mec.pt/pdf/rpsp/v33n2/v33n2a03.pdf
• ²²
  Soares AH, Oliveira C, Rocha TR, Cordoba GMC, Nobre JAS. Porque obesos abandonam o planejamento nutricional em uma clínica-escola de nutrição? RBONE [Internet]. 2017 [cited 2018 May 26];11(65):368-375. Available from: http://www.rbone.com.br/index.php/rbone/article/download/551/454
  » http://www.rbone.com.br/index.php/rbone/article/download/551/454
• ²³
  Vasconcelos ANCP, Magalhães R. Práticas educativas em Segurança Alimentar e Nutricional: reflexões a partir da experiência da Estratégia Saúde da Família em João Pessoa, PB, Brasil. Interface (Botucatu) [Internet]. 2016 [cited 2018 May 26]; 20(56):99-110. Available from: http://www.scielo.br/pdf/icse/v20n56/1807-5762-icse-1807-576220150156.pdf
  » http://www.scielo.br/pdf/icse/v20n56/1807-5762-icse-1807-576220150156.pdf
• ²⁴
  Pedraza DF, Menezes TN, Costa GMC. Food and nutrition actions in the family health strategy: structure and work process. Rev Enferm UERJ [Internet]. 2016 [cited 2018 May 26];24(4):e15848. Available from: http://www.e-publicacoes.uerj.br/index.php/enfermagemuerj/article/download/15848/19432
  » http://www.e-publicacoes.uerj.br/index.php/enfermagemuerj/article/download/15848/19432
• ²⁵
  Almeida AAS, Silva SC, Araújo WTC, Vasconcelos SML, Mélo MTS. Alimentação saudável na perspectiva multiprofissional: A experiência do Projeto "Saúde no Prato" desenvolvido na Atenção Básica. REBES [Internet]. 2017 [cited 2018 May 26];7(4):109-116. Available from: http://www.gvaa.com.br/revista/index.php/REBES/article/download/5180/4899
  » http://www.gvaa.com.br/revista/index.php/REBES/article/download/5180/4899
• ²⁶
  Blackburn M, Stathi A, Keogh E, Eccleston C. Raising the topic of weight in general practice: perspectives of GPs and primary care nurses. BMJ Open [Internet]. 2015 [cited 2018 May 26];5(8):e008546. Available from: http://bmjopen.bmj.com/content/bmjopen/5/8/e008546.full.pdf
  » http://bmjopen.bmj.com/content/bmjopen/5/8/e008546.full.pdf
• ²⁷
  Brasil. Ministério da Saúde. Departamento de Atenção Básica. Orientações para avaliação de marcadores de consumo alimentar na Atenção Básica [Internet]. 2015 [cited 2018 May 26]. Available from:http://bvsms.saude.gov.br/bvs/publicacoes/marcadores_consumo_alimentar_atencao_basica.pdf
  » from:http://bvsms.saude.gov.br/bvs/publicacoes/marcadores_consumo_alimentar_atencao_basica.pdf
• ²⁸
  Vannuchi RO, Carreira CM, Pegoraro LGO, Gvozd R. Impacto da intervenção multiprofissional em grupo no perfil nutricional e hábitos de vida de mulheres com sobrepeso e obesidade. Espaço para a Saúde [Internet]. 2016 [cited 2018 May 26];17(2);189-198. Available from: http://www.uel.br/revistas/uel/index.php/espacoparasaude/article/download/27052/pdf19
  » http://www.uel.br/revistas/uel/index.php/espacoparasaude/article/download/27052/pdf19
• ²⁹
  Rech DC, Borfe L, Emmanouilidis A, Garcia EL, Krug SBF. As políticas públicas e o enfrentamento da obesidade no Brasil: uma revisão reflexiva. Rev de Epidemiologia e Controle de Infecção [Internet]. 2016 [cited 2018 May 26];1(1). Available from: https://online.unisc.br/seer/index.php/epidemiologia/article/viewFile/7974/5165
  » https://online.unisc.br/seer/index.php/epidemiologia/article/viewFile/7974/5165
• ³⁰
  Nascimento APS, Avelino DM, Maximo MMG, Moura WC. Role of the nurse at nutrition education of children in an core of child education. Rev Enferm UFPI [Internet]. 2016 [cited 2018 May 26];5(1):40-45. Available from: http://www.ojs.ufpi.br/index.php/reufpi/article/download/4572/pdf
  » http://www.ojs.ufpi.br/index.php/reufpi/article/download/4572/pdf
• ³¹
  Robinson A, Denney-Wilson E, Laws R, Harris M. Child obesity prevention in primary health care: investigating practice nurse roles, attitudes and current practices. J Pae-diatr Child Health [Internet]. 2013 [cited 2018 May 26];49(4):294-9. Available from: https://onlinelibrary.wiley.com/doi/epdf/10.1111/jpc.12164
  » https://onlinelibrary.wiley.com/doi/epdf/10.1111/jpc.12164

Edited by

EDITOR IN CHIEF: Antonio José de Almeida Filho

ASSOCIATE EDITOR: Elucir Gir

Publication Dates

• Publication in this collection
  09 Mar 2020
• Date of issue
  2020

History

• Received
  07 June 2018
• Accepted
  17 Feb 2019