Leads for potentializing groups in Primary Health Care

ABSTRACT

Objective:

to analyze the aspects that potentialize groups in Primary Health Care according to their coordinators and participants.

Method:

This is a descriptive study with a qualitative approach, conducted with a health promotion group affiliated with a Family Health Unit. The data were collected by means of focus groups with participants and community workers who were submitted to thematic content analysis.

Results:

the analysis gave rise to three thematic categories: The group is our medicine; Healthy living and learning; and Priceless leadership.

Conclusion:

the leads identified during the study were as follows: group organization involves investment in motivation and leadership by the coordinators; production of grouping and cohesion is a result of participants and coordinators meeting together, interspersed with dialog, things said and left unsaid that the subjects expressed in the group dynamic; the sense of belonging guarantees their placement in the group based on the recognition of their knowledge and affective, social and health needs.

Descriptors:
Group Processes; Group Structure; Health Promotion; Primary Health Care; Nursing in Community Health

RESUMO

Objetivo:

Analisar os aspectos que potencializam grupos na Atenção Primária à Saúde segundo seus coordenadores e participantes.

Método:

Estudo descritivo de abordagem qualitativa, realizado com um grupo de promoção da saúde vinculado a uma Unidade de Saúde da Família. Os dados foram coletados por meio de grupos focais com participantes e agentes comunitários, submetidos à análise temática de conteúdo.

Resultados:

três categorias temáticas emergiram da análise: O grupo é o nosso remédio; Vida saudável e aprendizado; e Liderança que vale ouro.

Conclusão:

as pistas identificadas destacam: organização do grupo que envolve investimentos de motivação e liderança por parte de quem coordena; a produção da grupalidade e coesão é resultado do encontro entre participantes e coordenadores, tecida pelos diálogos, ditos e não ditos que se expressam no movimento grupal; o sentimento de pertença garante a permanência no grupo pelo reconhecimento de seus saberes e necessidades afetivas, sociais e de saúde.

Descritores:
Processos Grupais; Estrutura de Grupo; Promoção da Saúde; Atenção Primária à Saúde; Enfermagem em Saúde Comunitária

RESUMEN

Objetivo:

evaluar los aspectos que potencian a grupos de Atención Primaria de Salud según sus coordinadores y participantes.

Método:

Estudio descriptivo cualitativo, empleado en un grupo de promoción a la salud de una Unidad de Salud de la Familia. Se recolectaron los datos a través de grupos focales con participantes y agentes comunitarios, para después someterlos a un análisis temático de contenido.

Resultados:

del análisis han surgido tres categorías: El grupo es nuestra medicina; Vida sana y aprendizajes; y Liderazgo que es oro.

Conclusión:

las pistas identificadas destacaron: organización del grupo que cuenta con motivación y liderazgo por quien lo coordina; la producción grupal y la cohesión son resultado del encuentro entre participantes y coordinadores, construidas por conversaciones, dichos y no dichos que se expresan en el movimiento del grupo; la sensación de pertenencia le garantiza la permanencia en el grupo debido al reconocimiento de sus saberes y necesidades afectivas, sociales y de salud.

Descriptores:
Procesos Grupales; Estructura Grupal; Promoción a la Salud; Atención Primaria de Salud; Enfermería en Salud Comunitaria

INTRODUCTION

Group practices in the everyday activities of Primary Health Care (PHC), as a tool to promote health, are included in the list to reorientate the services proposed by the Brazilian Ministry of Health (MS). These practices are part of the procedures funded by the Brazilian Unified Health System (SUS)⁽¹⁾, because they are considered tools capable of extending user understanding regarding their problems and, consequently, of promoting changes in life habits that pose a risk to health^(2-4).

Group activities in PHC can enable the health situation of the users to be monitored, which is a tool that can streamline the professionals' work because it decreases the demand for consultations⁽³⁾. Streamlining financial resources and the work of professionals is important to make PHC services accessible to all countries in the world; however, the main purpose of using the group strategy, at this level of care, is based on the possibility of developing characteristics such as cooperation, partnerships, communication, critical and reflective adaptation to reality, among others aspects regarding the sustainable development of communities^(5-8).

The group concept, developed over the history of humanity, refers to the efforts made to understand collective life and how it can be made more efficient. This concept generally refers to the idea of gathering people with the objective of a common goal, a task that is in the interest of all concerned, whom have a psychological relationship with each other, which thereby forms a new identity, a product built on the interaction of its parts that goes beyond the simple sum of these parts^(9-10).

When conducted properly, the groups work to create a collective knowledge, a reflection regarding the reality experienced by the group members^(5,8,11), which constitutes a potentializing health promotion tool.

With the aim of being meaningful in the lives of its participants, the individuals within the group must compare their realities with each other, as well as to stimulate reflection and expand the ability of the members to resolve their own problems^(4,12). This process allows the individuals to organize and give meaning to their own experiences, feelings, perceptions, emotions and thoughts, as well as construct their own internal models^(3,13-14). The technique also makes it possible to socialize, provide support in times of transition, treatment or crises and help adaptation towards healthier behavior^(11,15).

In the context of PHC, groups are frequently used in educational activities, however, studies^(16-18) show that these are more focused on disease or health problems presented by users of the services and not on using the group's potential as an agent of change or to promote the autonomy of the subjects involved. The literature review showed that the limitations include, for example, a lack of proper planning, both regarding the needs of the users and the logistics required for good group practices^(12,17). Another prominent limiting factor is the obligation imposed on the chosen professionals to assume responsibility of coordinating the groups without the ability or desire to do so⁽¹⁹⁾. These aspects can affect the result of this intervention, the therapeutic potential of which can be diminished due to a lack of ability, satisfaction and professional competence.

Another shortcoming indicated in literature refers to the subjects' participation in the group, which is mainly motivated by symbolic activities^(17,20) related to treatment continuation, such as receiving medicine, exchanging drug prescriptions and scheduling examinations and consultations.

There are also studies^(14,21) that point to limitations regarding the performance and efficiency of group activities, namely those that depend on the intervention models focused on the vertical and authoritative transmission of professional knowledge, without considering popular knowledge or the perspective of the subject regarding his/her life.

Thus, despite the evidence showing the efficiency of using group activities in the PHC, the aforementioned shortcomings indicate that there are still a great deal of limitations in terms of the performance of these groups and that this technology has not reached its full potential.

It is therefore essential that we investigate the aspects that can improve the performance of these groups, which can guide the creation of new activities, as well as revitalize these practices in PHC.

The evidence and shortcomings regarding the use of group activities in PHC was the motivation behind this study, the objective of which was to analyze the aspects that leverage groups in primary health care according to its coordinators and participants.

METHOD

Ethical aspects

This research was conducted in accordance with the Brazilian standards for research with human beings, approved by the Research Ethics Committee of the Clinical Hospital of the Federal University of Goiás (HC-UFG).

Study type

Descriptive study with a qualitative approach, performed with a health promotion group attached to a Brazilian Family Health Unit in a capital city from the Central-West region of Brazil.

Study scenario

The group referred to in this study has existed for 15 years and was founded in 2000 by Brazilian Community Health Agents, hereafter referred to as CHAs, who have been its coordinators ever since. The group meets every week for a 90-minute duration meeting, which involves an average of 30 regular group participants, coordinated by six CHAs. The focus of the activities is promoting health through education, physical activities, recreation and socialization. The group has resulted in high levels of member cohesion, adhesion and satisfaction, low rates of avoidance; there is significant productivity and permanent renewal of the proposed activities therein. It is also worth highlighting the dynamic non-prescriptive dynamic in the group context and as well as the unrelated participation of some other benefits. All the aforementioned attributes in this group make it possible to identify factors that give it potential, thereby providing clues for creating groups in primary health care while still reflecting on those classified by health workers as "unsuccessful".

Data source

The group involved the participation of 23 individuals and six CHAs. The group inclusion criteria were as follows: having participated in the group for a period longer than six months, applicable both for the members and the coordinators. Individuals who only occasionally attended or were absent from the group during data collection were excluded; and, in regards to the CHAs, those who were absent for any reason during the data collection. The number of participants involved the survey was defined considering the theoretical saturation of data criteria⁽²²⁾.

The participants were invited to be part of the research after the researcher had been immersed in the field for six months. The objectives of the research were subsequently presented in a group meeting, as were the data collection strategy and informed consent form, which was read and signed by all those willing to participate in the research.

Data collection and organization

The data were collected between December 2010 and April 2011, using the Focal Group (FG) technique⁽²³⁾. The FGs were performed by two researchers, one being a mediator and the other an observer, who were responsible for recording and registering the data. Both researchers had basic training in group dynamics and were supervised by a specialist in group management and coordination. Reaching the objectives and data consistency involved conducting five focus groups, four being with members of the group, with an average of six participants per meeting, and one with the six CHAs. The meetings were scheduled beforehand and conducted in a room at the health unit, with the participants given a high level of privacy and comfort. The FGs with the group members started with the theme "The group in my life" and the following main issues: Why do we come to this group? How can this group help us? How can we help the group? What keeps people in this group? What keeps the group going? In regards to the CHAs, the presented theme was "The purpose of the group", the main issues being as following: How does the group help its members? How do the members help the group? What keeps the group going?

Data analysis

For the data analysis, the thematic modal the content analysis technique was used⁽²⁴⁾. The analytic procedure by detailed trail was carried out from the transcript of the recordings of the GFs, followed the pre-analysis, with exploitation of the material by exhaustive reading and understanding, in order to identify the characteristic elements of the potentializing factors for proper development factors of the group. We used qualitative data analysis software for this stage of the data organization. We finally proceeded to processing and interpreting the obtained results, discussing them in light of the study's theoretical framework. In the text, the data were identified using the FG abbreviation, followed by a number indicating which focus group the data had been extracted from.

RESULTS

The data analysis pointed to the groups' potentializing aspects that can be considered leads regarding understanding the Factors that Potentialize the Groups from PHC.

These were organized based on three thematic categories: The group is our medicine; Healthy living and learning; and Priceless leadership. The category "The group is our medicine" was subdivided into three subcategories: love, friendship and family; Unity is strength; and Life lessons. Figure 1 illustrates the emergent categories and sub-categories:

Figure 1
Potentializing factors presented in categories and subcategories, Goiânia, Goiás, Brazil, 2012

The table below contains the data that make up these categories; the statements will be labeled by FG I (focus groups with the members) and FG CHA (focus group with the coordinators).

Box 1
Chart showing the categories, senses and meanings with statements made by group members and coordinators, Goiânia, Goiás, Brazil, 2012

Category	Sense/meanings/leads	Statements
The group is our medicine
Love, friendship and family	Companionship, partnership, love, friendship and affection are highlighted features for taking part in the group, which develop strong ties, similar those of a close family, that provide safety, support, and appreciation.	[...] and love, we feel when others love us and we love other people in return, I myself am a very loving person [crying], if someone misses a meeting I am like: why was he/she not here, why did this person not come? (FG I) [...]this here is the friendship with the group, which is one hand holding another, if I fall and she is my friend, she will pick me up. (FG I) I think there is also their integrity, they are united, relate well with each other, with much friendship, so much love between them and us, so it is a team. (FG CHA) [...] it is a lot of love, dedication, it is a great deal of love, it is very important to me. (FG CHA) Because I consider the people there as part of my family, a family that gives strength to each other, with a smile, a hug, friendship, so I feel very comfortable. (FG I) [...] we are a brotherhood, we are not angry at anyone, we are good friends, it is the same kind of thing between a father and son, a mother and daughter. (FG I) I think it is like a family, with much respect, a lot of friendship, so much love is extreme dedication, come rain or shine. (FG CHA)
Unity is strength	Cohesion is highlighted as a great potentializer of the group operation, which is evidenced by the solidarity, empathy and union. These aspects ensure biopsychosocial equilibrium, socialization and enhanced ability to confront difficulties.	The important aspect of this group is the union, this is why they always keep us together, with nobody leaving, each day it just keeps getting bigger, each person inviting another. (FG I) Everyone tries to help each other, no one behaves badly towards anyone. So, if we cannot help, the group will not make things worse. (FG I) Our union is good, we are united, those who want to laugh, laugh, those who want to tell jokes do so, me personally, I like everyone. (FG I) We help to cheer people up, to give them strength, like when she herself wanted to go away and did not have the money, and I did, so I gave her the money, I paid for her trip, even bought her a swimsuit, so we are happy to be able to help a person participate in the group. (FG I) They help each other, if there is any activity that someone is not involved in, they help, they teach. If we do an exercise and make a mistake doing so, the others fix it. (FG CHA)
Life lessons	Group participation means that people have the opportunity to talk to others, along with their eccentricities and different ways of coping. Stories about life and overcoming difficulties are examples that enable learning, coexistence, respect and consequent personal growth.	The group taught us to live, to love, it taught me to be more patient with my life, with my job, I am not feeling the pressure as much as I used to, which was a big problem for me in the past. (FG I) “The thing is, I thought I was the world’s biggest sufferer, nobody could suffer more than I did. There I learned by looking down that there was another deeper level, that I could hold out my hand, then I accepted it.”(GF I) I also find very important when the health agents teach us about being more united with others, our families, friends, and colleagues. You therefore learn to get along with people outside and inside our homes, with those inside.(FG I) [...] there is a change that occurs in the mental aspect. We saw that they arrived in a bad mood, they sometimes did not like physical comfort, they did not like us to touch them, they did not like us to play, and today, they get here and embrace us.(GF ACS) Today, I see the group as something in my life that changed the way I am, the way I think, I see it really as recognition of what they once were, of what they did. (GF ACS)
Healthy living and learning
	The strength of coexistence, from the stories of overcoming difficulty and the awareness that we are not alone, strengthens the desire to improve the physical condition throughphysical activities, controlling medication and promoting health. Practicing physical activity is also mixed with fun and recreational activitiesand tours, which generates learning and provides mental and spiritual health.	The group involves a lot of good things, we know that the group brings a lot of happiness, and that happiness is inside, and it is this inner happiness that beams to the outside, it also strengthens our physical being, problems such as illness, if you have any, end up getting better, becoming solved. (FG I) I went to the group and thought it was great, my blood pressure subsequently improved and remained stable. So, the important point of this group for my life is that it is good for my health. Because I have been feeling a lot better since I began going to this group. (FG I) It is very important there. There we take our blood pressure, do physical activity, so it helps a lot, because when one reaches a certain age one cannot be idle, because otherwise we give up, at the group we do activities that helps a great deal. (FG I) The important aspect of the group is that we are always meeting, sharing information about everything that is going on, it is about knowing if everything is fine with the group, if you are taking your medication properly, this is how it is, and this kind of thing encourages us, and we miss the group, because when you do not have someone reminding you, you forget things. (FG I)
Priceless leadership
	The leadership provided by the group coordinators is highlighted as being responsible for the success and cohesion of the group. The professionalism, love, dedication and belief in the potential of the group characterize the coordination that acts with satisfaction and no obligation.	The agents are best aspect of the group, because they treat us very well, they talk to us, give us advice, they help us during the physical activity. (FG I) I like the health agents, they are really kind and nice people, which is why I am still with them. (FG I) They really helped as only they would. The health care agents, those girls, are a blessing. You may be down in the dumps and they come up to you and really lift your spirit, there is no sadness in them, they really cheer us up.(FG I) Firstly, we have to like what we do, we the health agents. If they did not participate in the group, the group would not exist, which would be true if we had to coordinate the group, so I think that we have to really like what we do and do it well, because just as happens in the group, we do go above and beyond, we play with them, there is no mechanical thing that we do when we get there, we only do some stretching and we are ready, we make up games because we believe that it is important for us to do so. (FG CHA) [...] the integration, the participation is important, but I see that no matter how integrated the group is, the leadership is important, a good leadership, a leadership that is creative. (FG CHA)

DISCUSSION

The category "The group is our medicine" was built based on the most expressive of all the content data, the core being the idea that the group represents a "remedy" for its participants. This category has a connotation of physical, spiritual and social care, because it enables improvement in the physical condition, which is pursued in a warm atmosphere in the company of people who have experienced similar life conditions, who are supportive individuals, companions, which strengthens the ties of friendship and identification among its members. The shared life in the group encourages a feeling of belonging and the formation of a united family, which often supports its members and provides them with the attention, affection and appreciation that many do not find in their own families.

Building links, exchanging experiences confronting differences, overcoming conflicts produce learning and, in turn, a therapeutic effect, despite this not being the group's objective⁽²⁵⁾.

In order to better understand the ideas expressed in the data from the above category, we split them into three subcategories. The first, "real love, friendship and family", emphasizes the identification among the group members as a defining characteristic of the group, who become companions, aware of each other, with a strong friendship being generated among them^(3,26). Such an aspect makes this affection possible, with the group acting in the same way as a family. There was also a feeling of belonging observed within the group members, which highlights the attachment of these individuals to this entity's participates^(7,14).

Group membership is characterized by the first visits, whereas belonging is the feeling that comes from the spirit of being part of something. These are the two vectors that are used to evaluate the group process from the Pichon Rivière perspective⁽¹⁰⁾. Based on the presented results, one lead for the groups in the CHAs is the production and evaluation of the sensation of belonging felt by the participants.

The depth of the closeness and affective bonds between the group members and the same with the coordinators is characterized by several statements including the use of the word "love", with the reciprocal of the affectivity between the coordinators and members being clear. This closeness leads to a trusting relationship and a mutually supportive network of interaction and security^(3,5), which encourages allegiance, commitment and co-responsibility in the group⁽⁴⁾.

Bonding is a bipersonal and tripersonal structure that is produced during the processes of transfer and counter-transference among the participants of the group process⁽²⁷⁾. These are produced in the matches and mismatches among participants and between these and the coordinating team of the groups.

The second subcategory refers to "unity is strength", which is characterized by a strong cohesion that the members who to their fellow members and coordinators, along with the sense of belonging which the group provides⁽¹⁴⁾.

The members stand out as obvious factors in group, as a supportive and empathic union. The union between the members shows how each one is important for the group and that this does not measure the efforts to help each one of its members: this can be in terms of financial help, support or a friendly word.

The group is so cohesive that the members help each other, they support each other and are united with each other as they are with their own coordinators, which leads to another remarkable characteristic of the group which is the effective participation in the proposed activities^(8,13,28).

Coexistence in groups and, in particular, the existence of cohesion in the group space is important for biopsychosocial equilibrium, thereby reducing personal and environmental conflicts and facilitating the socialization^(3,7,11,15).

The third subcategory refers to "Life lessons" and allows the understanding that the group provides, within the coexistence, to express cultures, knowledge, life stories, and experiences of suffering and overcoming difficulties. This coexistence fortifies tolerance, the acceptance of difference among the group. This enables the group members to become closer to these singularities and allows its participants to experience personal growth while observing examples experienced by their colleagues.

The learning about coexistence is exemplified in the statements made by the group members who learned to love more, to respect differences, as it is in the statements given by the coordinators, who learned to see the members with a different point of view, with respect and the possibility of learning from life.

Despite the group coexistence enabling different people to meet, these people are understood to be able to find group members who have been through similar life situations, encouraging learning and psychosocial reconstructions, thereby enabling them to make significant changes in their lives^(3,8,11,20).

The category "healthy living and learning" is summarized in terms of the group providing healthier living conditions, the objective being to encourage physical activities, stretching and offer guidelines to promote health. This encourages physical betterment, maintenance of health, self-esteem, self-image, lessens depression and improves the participants' physical condition in order to perform day-to-day activities^(2,14,26,28).

Using creative methodologies encourages group participation and health promotion^(13,29). It was clear in the analyzed group that this process goes beyond encouraging the practice of physical activities, with weekly recreational activities being performed.

During these activities, the members recall childhood games, they sing, play, play ball games, walk, among other things, which stimulates their potential, lifts their self-esteem, allows them to find their joie de vivre, to enjoy being human, in addition to feeling active^(5,11).

By reliving their childhoods, through fun and games, it is still possible to alter the mental state of conflicts, resulting in a refreshing of their internal mutual-representation, which are the images and perspectives that build on each other and that tend to crystallize⁽²⁵⁾.

The group activity focused towards promoting health enabled the participants to achieve better living conditions while encouraging medication control and providing health promotion guidelines. This process generates learning which in turn contributes to maintaining physical and mental health, self-care, autonomy and empowerment for the individuals; in addition to decreasing vulnerability, facilitating adhesion to treatment and minimizing complications from diseases^(3-5,8).

The category "leadership gold" highlights the ideas concerning the importance of the coordinators' role in the life of the group; the coordinators' recognition of the group members and the gratitude that the participants have for the care, attention and professionalism that these coordinators give them. The coordinating body is recognized for its effective leadership, which believes in the group's potential. The coordinators' activities thereby becomes much more than an obligation, because they perform them with love and satisfaction.

The group coordination body, according to Pichoniana⁽¹⁰⁾, is a role that involves possessing the fundamental dimensions, as it is a figure in which participants entrust their anxieties and difficulties. With the objective of developing group process, there are fundamental attitudes regarding parenting, thinking together and supporting autonomy construction. A good coordinator must gradually become unneeded by the group, since the lesser involvement of this individual stimulates independence, autonomy and leadership among its members. When this process is being consolidated, the coordinator is ready to prepare his/her exit.

The coordinator in this group is highlighted based on the good relationship that he/she develops with the members, this horizontal and closely-tied relationship creates a context that can stimulate the potential of the group members^(5,8).

The good performance of the CHAs in the group's coordination is a credit to these dedicated professionals who try to do the best for the group that they coordinate, because they recognize the limitations that exist in the context of day-to-day basic care. It is worth highlighting that these individuals are not trained to conduct group activities, but as human beings, they notably use their intuition in a gregarious sense.

Despite the fact that knowledge regarding how to coordinate a group can improve efficiency and stimulate the potential of the group⁽⁵⁾, this study clearly showed that knowledge alone does not guarantee good performance by a coordinator. This research⁽²⁸⁾ showed that, despite not having any specific training for coordinating groups, the coordinators managed to mobilize the full potential of the group. The potential of these professionals is possibly intensified due to the closeness that they have with the group members, which derives from their ability to identify the needs of the population and develop activities out of desire to do so and not out of obligation.

One study with health workers, performed using an operating group⁽³⁰⁾, is based on a perspective in which the four interchangeable elements are important for the mental health of workers: trust, cooperation, subjectivism and recognition. Groups held by the community agents may be mobilized with these four attributes.

Limitations of the study

We consider the limitations of this study to be that it was only conduced from the perspective of the group members and the coordinating CHAs, in addition to the fact that only one data collection technique was used, namely the focus group method. Using the perspective of family members and health professionals that coexist with the group's participants would also bring new elements that could improve the group method as a therapeutic resource in the context of health care. Observations regarding the development of the groups and their recording in a research journal could enrich data analysis with triangulation.

Contributions to the field of nursing and health

This study contributes to the area of nursing and health as it highlights the aspects that are considered group potentializers in the PHC context, from the user perspective. These findings offer leads for health professionals who work as coordinators of groups in order to improve how existing groups operate. They also enable a panoramic view of the factors considered relevant for proposing new groups, or even evaluating and reflecting on the results from the groups in which they participate.

FINAL CONSIDERATIONS

The results reached during the research pointed to the following leads regarding the betterment of the groups in the CHA context: group organization in a way to show the motivation and leadership of the coordinators; production of grouping and cohesion as a result of successive meetings between participants and coordinators, interspersed with dialog, things said and left unsaid that the subjects expressed in the group dynamic; the sense of belonging indicates that the participants remain in the group based on the recognition of their knowledge and affective, social and health needs.

Such aspects are new a perspective when investigating the provision of care using the group technique as a resource in such care, in particular in terms of reinforcing the idea that the subjective aspects strengthen individual bonds and are powerful elements maintain participant involvement in this activity, thereby demonstrating that groups focused on disease are not always attractive and may not be efficient for this reason. The possibility of active and responsible participation, besides the exercise of giving and receiving help from the members themselves or the coordinators, means that the participants seem to cherish above all the group space and its potential for human empowerment.

Studies that investigated factors that potentialize high-performance groups are still required. The researcher becoming immersed in the group's day to day activities can shed light on aspects that were not identified during this research, and is therefore an important gap that deserves attention. These may point to new leads that can represent a possibility to improve this technology in the PHC context, and therefore can help other groups become more efficient.

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Publication Dates

• Publication in this collection
  Sep-Oct 2016

History

• Received
  27 Dec 2015
• Accepted
  28 July 2016