Rede social de apoio ao desenvolvimento infantil segundo a equipe de saúde da família

Objective: To identify the social support networks for families for the promotion of child development from the perspective of the Family Health Strategy team. Methods: Qualitative, descriptive research. The subjects were twelve health professionals, three from each of the professional categories working in the health centers studied (nurse, doctor, auxiliary nurse, and community health worker). The data was collected through semi-structured interviews, and analyzed through thematic categorical analysis. Results: The results evidenced three empirical categories: Elements of the social support network; Functions of support for the families; Difficulties and gaps in the social support network for the families. Conclusion: It is considered that the social networks have an important role in the linking of the families, strengthening their potential for healthy child development. It is recommended that health professionals should articulate actions capable of influencing these elements, soas to promote appropriate child development. 1 Universidade Federal do Paraná. Curitiba PR, Brazil. 2 Universidade Federal do Paraná. Curitiba PR, Brazil. 3 Universidade Federal do Paraná. Curitiba PR, Brazil. 4 Universidade Federal do Paraná. Curitiba PR, Brazil. 5 Universidade Federal do Paraná. Curitiba PR, Brazil. RESEARCH Rede social de apoio ao desenvolvimento infantil segundo a equipe de saúde da família Esc Anna Nery (print)2013 Sep-Dec; 17 (4):721 729 Ana Paula Dezoti1, Ana Maria Cosvoski Alexandre2, Vanessa Aparecida Bida Tallmann3, Mariluci Alves Maftum4, Verônica de Azevedo Mazza5 Red social de apoyo al desenvolvimiento infantil según el equipo de salud de la familia Family; Nursing; Child Development; Social Support.


INTRODUCTION
With the institution of the Unified Health System (SUS), under which health is a social right of the citizen, popular participation in social control and in the construction of a new model of healthcare has become important.In this concept, in order to increase the system's power to resolve issues, there is a focus on primary healthcare practices and on the interaction between the different subjects involved, so as to respond to the new health demands, which require a new work process and multiprofessional, interdisciplinary and intersectorial practice.In this regard, these practices are grounded in the principles of universality, equality and comprehensiveness, transcending the curative dimension of the biomedical model.It is, therefore, necessary to think of health in terms which extend beyond the focus on a cure, with a view to the promotion, protection and recuperation of health, with de-centralization and social participation 1 .
The promotion of health, as a way of thinking and operating articulated to the other policies and technologies developed in the Brazilian health system, contributes to the construction of actions which make it possible to respond to the social needs in health.This is a strategy for transversal articulation in which one confers visibility on the factors which place the population's health at risk and on the differences between needs, territories and cultures found in Brazil, aiming for the creation of mechanisms which reduce the situations of vulnerability 1 .
It is in this context that one has, as the gateway for health needs, Primary Health Care (PHC).This is characterized as a set of health actions, undertaken through the exercising of managerial, sanitation-related, democratic and participative practices, in the form of teamwork, directed at the populations of delimited territories, for which it takes sanitary responsibility, taking into account the dynamicity existing in the territory in which these populations live.The PHC considers the subject in her uniqueness, complexity, comprehensiveness and socio-cultural integration, seeking the promotion of her health, the prevention and treatment of illnesses, and the reduction of harm or suffering which may compromise her chances of living healthily 2 .
In this way, PHC has, as one of its tools, the Family Health Strategy (FHS), which focusses on the family and the territory, correlating them with the health-illness process as the focus of its practices 3 .Understanding and extending this view on the family in all its aspects and complexities, beliefs and potentials is important in healthcare for the child, as it is in this environment that she develops, in all her multidimensionality.
In recent years the family has been recognised as an institution which performs a relevant role in individuals' social life, as it is in the family environment that most of the care is promoted, with positive actions which influence the subjects' health 4 , the family taking on the main role in the context of child development 3 .
In the light of this, the family has become considered a system in which the individuals interact for the health care of its members.It is permeated by a set of values, beliefs and knowledges which, together, promote health protection and the prevention of illness and, in situations of illness, are responsible for the care of its members 4 .Studies have presented a protective effect of families' social networks for the health and well-being of their children.The social cohesion within a neighborhood can promote social processes in the family environment which contribute to the improving of the health of the children and adolescents 5 .In this circumstance, it is necessary to strengthen the power of public policies which reach the micro-spaces and to rely on the different sectors of society for the strengthening of the families, such that in this way they may promote healthy child development 2 .
Thus, the social support networks can contribute to the families in this care, helping them in actions which may present difficulties to be done, providing different types of support -financial, material, of social company, cognitive guidance and advice, and legal, among others.The social network is understood as the sum of all the relationships which the individual perceives as significant or differentiated from the anonymous mass of society.These relationships define who is a member of a family and who is not.Within each cultural and socio-economic niche, there is a normative profile of the individuals' social networks, with their predictable life cycle, in harmony with the life cycle of other members and vicissitudes of the members of the nuclear family and its context 6 .
In the light of this, strengthening the care existent in the families' and community's social relationships can contribute to a better quality of life for their members, reduce the strain in relation to health, and reduce infant mortality 7 .For this to occur, it is necessary for the health professional to consider the families and their social support networks, so as to extend her routine care actions and practices directed at the families and children, aiming for child development which is healthy and compatible with the social and economic contexts in which these families are found.
This being so, nursing, by acting taking into account the social network, must be attent to all the factors which encompass not only the child, but also the carer/family.It points to the need for the health professionals to act as a real support for the families, going beyond guiding the undertaking of care, as with qualified listening, also investing in the interpersonal relationships, so as to effectively qualify the assistance 8 .In this aspect, there still remain gaps between the elements of the network which the family recognizes as relevant and those which nursing Dezoti AP, Alexandre AMC, Tallmann VAB, Maftum MA, Mazza VA Social support network for child development has used as support for them.The families make use of the spaces of solidarity and emotion of the subjectivity of this network's relationships, and the nurses are based in the institutional dimension of these.
In the light of the above, this study's objective is to identify the social support network for the families, for the promotion of child development in the perspective of the Family Health Strategy team.

METHODOLOGY
This descriptive research with a qualitative approach was under taken in three FHS centers, in a municipality of the metropolitan region of Curitiba, in the period April -November 2010.The decision to use FHS centers was made due to the integrated actions which they under take with the families.The three Health Centers (HC) chosen cover the municipality's geographical diversity, one being located in each Health District.They were selected because of the higher number of children in the age range 'zero to five years' in the areas they cover.
As this is a qualitative study, the decision was made to use intentional sampling, by convenience, in order to select the subjects with a higher probability of offering information relevant to the issue.This research's subjects were 12 health professionals; one representative of each professional category -nurse, doctor, auxiliary nurse and community health worker (CHW) -from each of the three HC included in the study.The inclusion criteria were to be working in one of the health centers selected and to be a doctor, nurse, auxiliary nurse or CHW.The exclusion criteria corresponded to those professionals who were on medical or maternity leave, or on leave.
The data was collected through semi-structured interviews, and was recorded and later transcribed.The thematic axes which guided the interview were the types of support offered by the community to the families in the care for the child; the families' difficulties in the care for the child; and the activities which the health service offers the families which contribute to child development.
The data was analyzed according to categorical thematic analysis and organized in three stages: pre-analysis, or organization of the material; exploration of the material through grouping by category; and the inference from and interpretation of the data.The categorization was carried out through classification, differentiation and re-grouping of the constitutive elements, elaborating classes which bring together groups of common elements, which provide representations of the raw data 9 .For organizing and interpreting the data, as a theoretical support, the Minimum Map of Relationships (MMR) proposed by Sluzki 6  Dezoti AP, Alexandre AMC, Tallmann VAB, Maftum MA, Mazza VA Social support network for child development with the first circle representing relationships with the greatest degree of commitment, the intermediate circle, relationships with a lesser degree of commitment, and the outer circle, the occasional relationships.

RESULTS
The networks of social support for the families were recognized by the health professionals and indicated as sources of help in the promotion of child development.
Based on the results obtained, the data was ordered into three empirical categories: Elements of the social support network; Functions of support for the families; and Difficulties and gaps in the social support network for the families.

Elements of the social support network
The elements of the social network of family support are in constant relational evolution.This process of evolution includes family members, friends and acquaintances, work and study connections and the relationships resulting from participation in formal and informal organizations, which may be religious, recreational, political or health-related 6 .
These elements of the network include all those people with whom the family relates and which distinguish it and, reciprocally, it is distinguished from the multitude, thus being identified by it without falling into anonymity.The members of the nuclear family are the essential elements of this network during the first years of life, expanding substantially when the child establishes relationships with other members of the community 6 .
According to health professionals, the elements belonging to the Social Network of Family Support which help the families in caring for the children are mothers, fathers, grandparents, uncles and aunts, and siblings, as shown in the discourses below: In this group, the gender issue stands out, emphasized by the figure of the mother, held as a fundamental and principal element in the role of caregiver, followed by the maternal and paternal grandparents, as in the accounts below: The elements belonging to the social network of friendship support, indicated by the health professionals as support for the families, are the friends and close family friends, characterized by voluntary non-consanguinary relationships, as shown in the accounts below: The elements belonging to the community social network of support and faith, recognized by the health professionals, are: the health sectors, represented by the Health Centers (HC); the neighbors; the governmental social inclusion programs, the Bolsa Família 1 and the Programa do Leite 2 ; and the religious institution, represented by the Church and by the Pastoral da Criança 3 .
The Health Center is recognized for the work carried out by the health professionals working there, including community health workers, nurses, doctors and auxiliary nurses, among others, as shown in the accounts below: The governmental programs -Bolsa Família and the Programa do Leite are recognized as integral parts of the network of support for families, as made clear in the accounts below: The religious institution is mentioned as an element of support for families in caring for their children, linked to the actions undertaken by the Pastoral da Criança.Another element mentioned by the health professionals as helping the families in the care of the children are the neighbors, as in the account below.In the social support network of Work/study, the health professionals recognize the crèche as a relevant element of support for the families in the care of the children:

Functions of support for the families
The types of support offered to the families by the elements of the social support network, recognized by the health professionals, were classified in accordance with Sluski's proposal 6 which terms them "Functions of support", distributed in Social Company, Cognitive Guidance and Advice, and Assistance with Materials and Work.Social Company refers to undertaking joint activities, or simply being together; Cognitive Guidance and Advice related to the interactions aimed at sharing social and personal information, clarifying expectations and providing role models; and Assistance with Materials and Work refer to specific collaboration based on specialist knowledge or physical help 6 .
The function of Social Company is offered by the elements of the family social network, principally the women, as in the accounts below: The HC performs this function, recognized by the actions carried out by the FHS professionals, such as the monitoring in the governmental programs, including nutritional assistance and childrearing, which stand out, mentioned in all the discourses as important resources of this network of indirect assistance to the families and in the promotion of child development.

[...] who does the monitoring is the nurse, the doctor, the dentist and the auxiliary nurses in a general way, and the CHWs in the home visits [...] (NUR. 1) [...] here, we have the childrearing program, we monitor the younger children, both in the nursing and the doctor's appointments, we do this monitoring [...] (DOC.3) [...] there's childrearing, which is very important [...] (DOC. 1) [...] the childrearing, which we monitor, in all its aspects [...](AUX. 2)
In addition to this attendance, the HC also weighs the children monthly for the Programa do Leite and the Bolsa Família program, so as to monitor their growth and development, also considered a function of the Cognitive Guidance and Advice.

Social support network for child development
The Pastoral da Criança is also indicated in the function of Cognitive Guidance and advice, through the offering of help and guidance in regard to the feeding and care of the children, in addition to the weighing to monitor their growth and physical development.The function of Assistance with Materials and Work support was considered to be offered by the governmental programs of the Bolsa Família program and the Programa do Leite, which offer the family monthly financial assistance and the provision of a liter of milk a day for children aged between six months and three years old, thus aiming to guarantee a minimum nutrition.This action is also undertaken by the Pastoral da Criança, through the provision of the multimixture, a food which complements the children's daily nutrition.

Gaps and difficulties in the social support network for the families
According to the health professionals, areas for leisure and recreation are important for the families in the promotion of child development, however, all mention in the same way the absence of this type of support for the children who live in this region.

[...] our region ends up not offering any other type of activity, there isn't a suitable play area, there isn't any activity [...] (NUR. 2)
In thinking about networks and the comprehensiveness of the care, the subjects mentioned the need to improve intersectorial articulation between the different elements of the network, so as to promote support which is consistent with the families' context and needs.

[...] I had commented on the difficulty which we had in working with the other department [other sector...] (NUR. 1)
[...] it has to be like this, not just inside or outside the unit, I think one has to be added to the other [...] (AUX.2) Nevertheless, they mentioned as one of the difficulties that the number of professionals available is not sufficient, and considered that having more would contribute effectively in this interaction and in the support for the families.The lack of spaces in crèches is mentioned by all the health professionals

DISCUSSION
The recognition on the part of the health professionals of the various family elements which assist in the care for the child show a broad view of the social support network, through which the health professional can extend her guidance and the care she provides, increasing the chance of promotion of child development with the contribution of the family's entire social support network.
For the health professionals, the family social support network is made up of various elements, such as the nuclear family, mothers, fathers, grandparents, uncles and aunts, brothers and sisters, and also by those who are part of the wider network, with whom the child establishes Dezoti AP, Alexandre AMC, Tallmann VAB, Maftum MA, Mazza VA Social support network for child development relationships during her development.The understanding of these elements in the social support network, which influences the care for the child, is important because it can establish actions which promote child development.Knowledge of the elements which make up the social support network causes the health professionals to respect the individual characteristics of each child, who is involved in a diversified socio-historical-cultural context.
One study indicates that, in the nurses' opinion, the support network seeks to see the person as a whole, offering her support and help according to her needs, providing means for coping with the situations present 10 .
The participants in the research stated that the female figure is the central element of the support network for the families, being able to contribute positively to the promotion of child development.This panorama was also mentioned in another study which stated that the women continue to value their role of provider of the care, or "head of the house", in regard to the emotion and domestic care, while the figure of the father remains associated with the role of "head of the family", responsible for the family income 11,12 .
The care provided by the grandmothers involves various aspects, such as being a female figure which keeps her linked to the maternal role, the search for her care being owed to the trust which she has in this element of the network.Another function which the grandmothers perform is that of material support, as they care for the child and charge nothing for doing so, this action resulting in the family saving money 7,13 .
The health professionals involved in this study recognized that the social support network is also made up of friends and neighbors, who perform the role of Social Company.This function can provide the children with opportunities, differentiated by their influence in the children's day-to-day.For that to occur, the health professionals must recognize this cultural, social and community-relations space, using its positive potential for increasing acts for promotion of the health of the child and family.
The support offered to the family by friends is considered important, as it is part of the human being's social network, and the affective relationship and instrumental support originating from this network help the families in the care of their children.These relationships can contribute to the individuals' physical and psychological well-being 13 , although the family's health needs require a network of resources which go beyond those found in the intrafamily network 7 .A study of families with children with chronic illnesses presents a positive influence of the social support network, in the parents' quality of life, in particular in the function of emotional support 14 .
In this regard, one of the public policies which try to articulate the necessary resources is the Family Health Strategy (FHS), which has centered its actions on the family, and -as the years have gone by -has taken various forms which go beyond the nuclear family, broadening its networks of relationships, thus aiming to comply with the public policies for the promotion of the support necessary to care for health beyond cure and rehabilitation 15 .The promotion of actions directed at the family is one of the issues of the FHS which is being discussed in academic circles, due to the difficulties which permeate this work, such as the lack of a professional qualification 16 .
In this study, the health professionals indicate the FHS and the actions carried out under its auspices as one of the support networks for families.The following were cited as functions of this network: childrearing consultations, weight for monitoring in the Programa do Leite and Bolsa Família program, and guidance which, if articulated strategically, support the families in the promotion of child development.These elements are mentioned as important resources for this network in indirect assistance to the families, and refer to the function of Cognitive Guidance and Advice, offering help and guidance in relation to the feeding of, and care for, the children.
This data suppor ts a separate study, which states that the governmental programs indicated by the health professionals as elements of suppor t for the families, when used, can be strengthening for the families' autonomy in the care for their members, in par ticular in the care of the children 7 .In terms of promotion of health and prevention of ill-health, the parents should be encouraged to maintain and invest in their social suppor t networks 14 .
In another study, the participation of the health sector was also mentioned as important as, in monitoring the child's growth and development, the health professionals have the conditions to start a diagnosis of the situation in the community, which allows it to guide work in health promotion and the prevention of ill-health 17 .This research's results diverge from other studies, which bring in the Church in the condition of spiritual, moral and emotional support for the populations, as an institution with credibility for families from less-favored classes 10 .
In this study, the support of the religious institutions refers to the activities of the Pastoral da Criança, considered as an action which can contribute to child development, given that the health professionals can use it as a space for carrying out their activities directed at the prevention of ill-health, and the promotion of health, in children and families.
In this research, the health professionals expressed the understanding that child development requires the participation of other sectors of society, and that for this, causes greater integration between the different elements which make up the families' social support for the promotion of the child's health.Among the factors involved in this Dezoti AP, Alexandre AMC, Tallmann VAB, Maftum MA, Mazza VA Social support network for child development process, emphasis can be placed on leisure activities, which can make the children more sociable and promote their development.However, the health professionals in this study refer to there being gaps and difficulties in the social network of support for the families, such as the lack of areas for leisure and recreation, communication difficulties between the different elements of the network, and an insufficient number of health professionals.These gaps compromise the performance of actions/activities for the promotion of the development expected in childhood.
Studies indicate health professionals' recognition of leisure as an important part of child development, as playing and socializing promote healthy development.The lack of public spaces with grassy areas, parks, squares and specific places for practising sports ends in contradicting one of the rights of every child -that of playing.Among these spaces' advantages, one finds socializing, coexisting with others and the resolution of problems, among others, which make the right to these spaces favor the promotion of healthy child development 7 .
If the health professional recognizes the functions of the network, he can act significantly for child development.These health professionals need to move beyond their conception of the health-illness process, using elements which permeate the family network in their care practices for the promotion of health, going beyond what is prescribed, optimizing the family benchmark in their professional practice.
In summary, in this research, the recognition of the families' support network was centered on the service itself and on the institutional programs implemented by public policies.This perception is considered limited; it misses the dimension of the social relationships contained in the community space, the space of life.The results of a study on social capital and children's health suggest that the presence of social interaction between neighbors particularly benefits children's health, and therefore requires more attention 5 .

FINAL CONSIDERATIONS
The recognition of the elements belonging to the network of social support for families for child development, in the perspective of the health professionals, makes it possible to recognize this network's potential for caring for children, supports the professional intervention project and allows one to recognize the limits and potentials for the promotion of child development, in addition to causing in the nurses a reflection on the actions which are carried out in the dimension of the care for the promotion of child development.
It stands out that, in addition to the child care practices, the social networks have an important role in linking families in a process of development of skills which assist and strengthen their potential for healthy child development in all its dimensions.The recognition of the various elements which make up the social network of support for families favors the health professionals' work, as they can use, articulate or strengthen the different elements, favoring the promotion of child development.
In the light of this, it is suggested that health professionals should articulate actions capable of influencing these elements of the network so that they promote adequate child development.
This study selected support elements present in the community, which give support to the families in the care for the children, and are recognized by the FHS teams.These elements, however, cannot be generalized, as they present the understandings of a specific social group.
Moreover, it is necessary to promote investigations with a view to extending knowledge in relation to the events which make up the care, and in relation to the family relationships, based in the subjects' experiences.In spite of its limitations and losses, the study sought to record the relevancy of this issue for nursing, because this is a profession which has, in its essence, care in exploring issues which underlie the process of caring for a family member and the relationships involved.
It is proposed to encourage further production in regard to this issue, to deepen discussions on it which may confirm the carrying-out of actions for child development.

[
...] real care, that's the family network, it's the father, the mother, the grandparents, there are lots of grandparents who help care for their grandchildren[...] (NUR. 1) The child stays [...] with the relatives, usually the grandparents.[...] (NUR.2) [...] we see the children with their mothers a lot, sometimes the grandparents help to care so the mothers can work [...] (CHW.3)Some elements of the Community Social Network and of the Work/study Network also help the families in the direct care for the children, such as the neighbors and the crèche, performing the function of Social Company, as exemplified in the accounts below: [...] even the neighbors help [...] (AUX.3) [...] there's the crèche, which receives the child when the mother is working[...] (DOC.2) [...] there are crèches here, which care for the children whose mothers go to work [...] (NUR.3) In relation to the function of Cognitive Guidance and Advice, elements were considered which offer support in relation to the indirect care for the child and guidance/information related to the care.

[
...] the people from the Pastoral da Criança weigh the children, and have a chat with the mothers, and give guidance in relation to the weight [...] (CHW. 1) [...] a better structure here in the center, more staff who could attend the programs like childrearing better [...] (CHW. 1) [...] the center's structure maybe, we don't have enough staff, more professionals in the team [...] (AUX.3) 18 the parents, the grandmother, and in last place the godmother [...] (AUX. 1) [...] the family, there's this whole network, in this case it'll rely on the parents, the child's grandparents, friends [...] (NUR. 1) Dezoti AP, Alexandre AMC, Tallmann VAB, Maftum MA, Mazza VA the Programa do Leite works, I think this program is very valid, for these families which are really poor [...] (DOC.3) 4 Campos RMC, Ribeiro CA, Silva da CV, Saparolli ECL.Consulta de enfermagem em puericultura: a vivência do enfermeiro na Estratégia de Saúde da Família.Rev.Esc.Enferm.USP.2011Jun;45(3):566-74.1BolsaFamília:governmentprogramwherebypoorBrazilianfamilies receive money, conditional on their children attending school and being vaccinated.Translator's note.2ProgramadoLeite: the 'Milk program', a government program whereby children from poor families, aged 6 months to three years, receive one liter of milk a day, free of charge.Translator's note.3PastoraldaCriança:ecumenical health program run under the auspices of the National Conference of Bishops of Brazil.Its focus is on the healthy development of children up to the age of six within their community.It has been expanded outside Brazil to 19 other countries.Translator's note.4Multimistura:'Multi-mixture' -a bran mixture composed of wheat/rice/ corn brans, seeds (pumpkin, watermelon, sesame), ground up egg-shells and ground-up leaves from cassava or sweet potato.Info: Wikipedia.The Brazilian Federal Council of Nutritionists recommends against its use for a variety of reasons.Translator's note.