Knowledge and practices in care focused on individuals with wounds

Objective: Describe the knowledge and practices of clients in wound care. Methods: A qualitative descriptive study of the ethnographic nature was performed from January to May 2014, including 20 clients with some type of wound in an outpatient clinic for wound care of a Primary Health Unit in the city of Niteroi, Southeastern Brazil. Data were collected through participant observation and semi-structured interviews and subsequently subjected to content analysis. Results: The category defined as "knowledge and practices of customers" emphasized the history and development of wounds, the dependence on care provided by health care professionals and the use of allopathic and popular practices originated from information obtained with family members and individuals who share their lives with clients. Conclusion: To identify knowledge and practices of clients in wound care allows the development of cultural care and promotes the preparation of a health care plan which is coherent with their culture, enabling them to be more participatory in the process of care and caring for themselves.


INTRODUCTION
The majority of studies and research that deal with the question of wound care reveal their concern about objectivity, following a curative approach aimed at treating wounds.This approach has little emphasis on the educational question geared towards individuals with wounds and their knowledge and experiences in the treatment and prevention of such wounds.Thus, health care practices that enable one to overcome the biological-visible dimension are required, transcending knowledge about the physical and mental aspects of wounds. 1,2n the other hand, studies indicate that the population has the habit of using popular resources such as teas, plants, fruit skin and fruits, bark and religion/faith before seeking health services.The aspects and practices of folk wisdom can be important allies when seeking more efficient health care.][5][6] Individuals who live with wounds can have certain physical and emotional problems throughout life.The physical problems are due to a possible impairment for certain routine activities, while the emotional problems are associated with a possible psychological effect on one's life, influencing one's way of being and living in the world. 7s a result, health professionals should understand the several dimensions comprising the process of living and being healthy -biological, social, cultural and subjective -as questions inherent in health and disease need to be thought about from socio-cultural contexts, seeking to integrate knowledge and practices of clients with wounds into the scientific knowledge that guides the practices of health professionals. 8he experience that individuals from each society have with the health-disease process is rooted in values, beliefs, practices, representations, imagery, meanings, and individual and group experiences, confirming the socio-cultural nature of phenomena comprising it, apart from the psycho-biological aspects involved with it where culture implies a system of signs subject to interpretation. 9n nursing, in Leininger's perspective, the health-disease process is influenced by culture and, in the development of adequate actions, the differences between the professional culture and personal culture of those involved with care should be taken into consideration.Analyzing the cultural context of clients enables the identification of approximations between popular care and professional care, based on a specific reality, including more quality so that knowledge can be shared. 10onsidering the reality and culture, the importance of adequate cultural care stands out, including the meeting between the popular health system and that of health professionals.The popular health system encompasses knowledge and practices developed by the family, neighbors and community and it has a very relevant meaning, as it is understood and transmitted from generation to generation.In contrast, the health professional system is developed by professionals who provide organized care or healing services.By interacting with clients, nursing must use health care actions so as to preserve, negotiate or re-standardize them, constantly seeking adequate cultural care.Such organized and balanced actions are aimed at the well-being and autonomy of both clients and professionals, preventing cultural imposition. 10ased on this situation, care for clients with wounds is not focused on such wounds, but rather the clients whose experience includes their own knowledge and practices, which need to be identified for health care planning and implementation.Thus, in their professional practice with clients with wounds, nurses must enable an approximation between scientific knowledge and folk wisdom, respecting the diversity of human culture.
However, health care is traditionally characterized by the biomedical model, whose focus is on the disease and cure based on biological parameters and the vertical relationship between physician and patient, for which psychosocial and cultural determinants are of little interest for the diagnosis and therapy. 11hus, seeking to understand the knowledge and practices of clients in wound care brings us closer to Paulo Freire's liberating dialogical perspective.In his conception, everyone has knowledge and this knowledge comes from human beings' reflection about the concrete context, i.e. the experiences they have in the reality in which they are included, in addition to fulfilling the role of analyzing and reflecting about such reality, aiming to acquire a critical perspective of it. 12n this way, the dialogical relationship between the one who cares and the one cared for is essential for knowledge, practices and experiences to be shared and, as a result, in the case of the present study, for clients with wounds to bring meaning to the instructions received, based on their cultural context and personal trajectories.
From this scenario where health professionals continue to provide fragmented, technical and prescriptive instructions, without taking into consideration the multi-dimensionality of care in terms of the social, cultural and historical aspects of clients, the present study is relevant because it enables greater understanding of beliefs, knowledge and practices of these clients in wound care, aiming to offer culturally adequate care that meets their needs.
The present study aimed to describe the knowledge and practices of clients in wound care.

METHODS
A qualitative descriptive study with an ethnographic nature was performed in an outpatient clinic for wound care of a Primary Health Unit in the city of Niterói, Rio de Janeiro, Southeastern Brazil.
Participants were selected through theoretical saturation, 13 including a sample of 20 clients with a certain type of wound, who were being treated in this outpatient clinic.The inclusion criteria were as follows: clients of both sexes and aged 18 years and more.Moreover, the exclusion criteria were the following: clients with psychological and/or mental alterations that could affect participation in this study.
Data collection was conducted between January and May 2014, when we went to the research field to make a simple observation.Next, guidelines developed by the authors were used to make a participant observation.Such observations were performed three times a week, totaling 12 weekly hours and aiming to identify the way clients arrived at the primary health unit, their speech, the difficulties encountered, the functioning of the wound care room and its infrastructure.
Data obtained from the simple and participant observations 14 were recorded in a field diary.The records consisted in the written description of all manifestations that observers perceived of the research field and clients.These records were dated, signaling the individuals involved, the location, the situation observed, the conditions that could interfere with the fact, the influence of routine, the institutional norms, and the impressions from the observer.
The interviews were performed outside the wound care room, on the waiting benches immediately after the service, aiming to identify the knowledge and practices of clients in wound care.Semi-structured guidelines were used with the following questions: What do you usually use to care for wounds?Do you use any other means to treat wounds which are not based on drugs?Which ones?Where did you learn this other type of treatment?How do you apply it?What results do you expect to achieve?And what results have you already achieved?
Permission was requested from participants to use a recorder during interviews, aiming to fully record their reports, which were identified by fictitious names.Aiming to characterize clients, the following data were collected: age, sex, marital status, level of education, religion, comorbidities and type of wound.
The functioning of content analysis 15 was regulated by the following stages: pre-analysis, material exploration, treatment of results and interpretation.These stages began with the repeated and attentive reading of transcriptions from the interviews.According to the study objectives, relevant extracts were defined for the subsequent preparation of thematic categories.
The interpretation of the material was performed based on the association between the results and scientific evidence on this theme.Additionally, concepts developed by Leininger 10 (theoretical and methodological framework) through culture and care and by Freire 12 (theoretical framework) through dialogue, culture, awareness and liberation, in terms of the cultural context of practices and knowledge about health care.
After the analysis of content, the following six themes were identified: challenges in health care, wound, care, professional power, popular practices, and the environment of care and associated diseases.Subsequently, the emerging common themes were grouped into categories and the following category stood out in the present study: knowledge and practices of clients with wounds, when the description of development of their wounds, the care provided through the association between allopathic and popular practices, and the knowledge about alternative therapies in wound care.
The present study was performed in accordance with Resolution 466/12 of the Brazilian Health Ministry's National Health Council, after being submitted to the Institution's Research Ethics Committee under CAE number 26647614.3.0000.5243and approved under official opinion 559.436.

Knowledge and practices of clients with wounds
This category emphasized the description of wound development, care through the association of allopathic and popular practices and knowledge about alternative care practices.
Regarding the progress of and search for treatment in the outpatient clinic for wound care, clients described the development of their wounds, although it was possible to identify the fact that seeking health services or medical care occurred when such wounds became worse, as shown in the following reports: For a long time my leg had been feeling hot and throbbing with pain, I could feel it burn and itch.I couldn't say exactly how it felt (...) It was all of this mixed up.Then, it got itchy (...) and I scratched it so much that I had a small lesion.It was very small at first, but then I saw it got worse and so I went to see a doctor.(Raimundo) It's been some time since I forced my leg, you know?Well, I used to work outdoors and as time went by I noticed some veins that looked very different and I got worried (...)Then, after some time, I felt something in my bone here, it was a bit high at the ankle and it was very itchy.I thought it was a small fly, so I kept scratching it until one vein burst while I was in the shower.Anyways, it's all that stuff!In the same Knowledge and practices in wound care Chibante CLP, Santo FHE, Santos TD, Porto IS, Daher DV, Brito WAP week, I hit my leg on a corner in the shower and the wound opened.I didn't look for help as I was afraid (...) I didn't go see a doctor.Then, it started to spread!I continued to force my leg, you know?Then, when there was no other way, i had to see a doctor.(Sebastiana) Lack of time, the responsibility of caring for their home and children, going to work, and the distance between their home and the health unit were the factors reported by clients as the reasons for the delay to seek outpatient care.Others stated that it took them some time to seek help because they thought the wound would improve after a while.
Regarding wound care, clients reported the frequency of visits to the outpatient clinic, how they changed the wound dressing and what they used in their wounds, emphasizing the hygiene when caring for a healing wound: I take care of it here and at home (...).At home, I do it every day because I have to shower, you know?So I take advantage to do this.(José) Sometimes, when I come to pick up the material like today, as I haven't taken a shower, there's no point doing the wound dressing here (...).I prefer to pick up the material and, when I get home, I take a shower and put the dressing.(Raimundo)

I use serum and collagenase, but I don't change the dressing every day. The correct way would be every day, because this secretion can't stay there overnight. (Antonio)
The association between the habit of body hygiene and the possibility of improvement in wounds was identified in the speech of some clients, which can also be related to the sensation of well-being when they feel relieved from the presence of secretion or even odor caused by the wound.
However, some clients reported that they had the dressing of their wounds changed in the outpatient clinic, showing their dependence on care provided by health professionals, as described below:

I don't do anything at home. When it opens, I come here, but I don't do it at home. I only wait until I get here. I do it here and wait until it heals. (Sebastião) I only do it in the clinic. I only do it when it gets wet, but this rarely happens. I don't do it at home because I don't think it's hygienic. Here I have all care, you know? (João)
Regarding the knowledge of other forms of wound healing, apart from the drug-based one, clients revealed that they knew alternative ways of care that they had learned from other individuals, such as their mother, aunts and grandmothers.However, they were suspicious of such use as they are not acknowledged as scientific, as described below: My grandma said that cashew skin and bark is good for healing wounds, but I've never used it.It may work, but it's not medicine, right?(Raimundo) I've never used tea, plants, things like this, because I'm afraid!But my aunt told me about some kind of bamboo, like grass, which has water inside and this is good for healing.(Sebastiana) "Aroeira" bark.My mom tells me that I should make some tea and put it on the wound, but I've never used it.I don't believe it helps to heal wounds.I wouldn't use it, not even as a test.I think it'll get better if I take antibiotics or apply some ointment.(Joana) Although knowledge about popular practices is passed on from generation to generation, clients reported fear of using an unknown substance in their wound, especially when such knowledge does not come from a professional.
Based on their experiences, clients bring knowledge about wound healing and eating habits associated with the control of other diseases, such as arterial hypertension and diabetes mellitus, which can interfere with care.However, some clients reported having used alternative practices in health and wound care, such as cashew fruit, saião (a type of tropical, succulent flowering plant), aroeira (a flowering plant from the cashew family), and onion, although they stopped using these plants after they started going to the outpatient clinic and followed the instructions of the unit's health professionals:

I've already used cashew skin, but after I came to the clinic, the doctor said I should only use collagenase and silver sulfate. (Antonio) "Saião" is good because it removes the infection. I've already used it in my wound, it removes the infection well, but I haven't used it since the doctor said I shouldn't. (Sebastião)
I know that "pata de vaca" and eggplant water can lower blood pressure...You make a tea and drink it.(Antonio) Eating onions with the food is good to heal wounds.Cucumber, yam...The more green you eat, the faster the wound will heal.(Josélia) "Aroeira" is good to put on the wound, you make some tea with this plant and then put it on the wound.(Pedro) Another practice identified in client reports was the question of religion/faith, understood as a type of support that helps to heal wounds and recover one's health:

I don't believe in these things. I think only God's power can heal. (Josélia)
If we have faith, we believe the wound will heal... (Sebastiana)

Knowledge and practices in wound care
Chibante CLP, Santo FHE, Santos TD, Porto IS, Daher DV, Brito WAP

I only believe in Jesus' commandments. I have faith that this wound will heal. So this is all that matters. (Cosme)
We have faith that the wound will heal... (Sebastiana) I'm also in the church... I've been asking God, I pray, so it's getting better.I only go to church to pray...I pray in the morning and at night.When I go to sleep, I ask God for this.(Hélio)

DISCUSSION
Although the present study was performed in a primary health unit and the majority of participants were males, contrasting data from the literature, this result is justified by the fact that men seek the wound care clinic when their wound becomes worse, while other studies show that such care is not a regular male practice. 6,16egarding associated diseases, arterial hypertension and diabetes mellitus were reported by clients.The presence of comorbidities is considered to be an intrinsic factor in the development of skin lesions, especially chronic diseases, such as diabetes mellitus and cardiovascular diseases. 17he results of the present study indicated that health services were sought when the wound became worse.Some studies show that delaying the search for health services is associated with clients' knowledge about their disease, the distance between their home and the health unit, transport expenses, the impossibility of being absent at work or cancelling appointments, the satisfaction with the service provided and the search for alternative care. 18,19lients' speech revealed an association between the habit of body hygiene and a possible improvement in wounds.Habits are the result of ritualized social practices and their purpose is to integrate individuals into the group, thus representing ways of being and acting to maintain life.Therefore, life habits tend to be structured around the notions of well-being or ill-being based on their threat to existence.As they occur repeatedly, they are emphasized and spread in the group, becoming the "foundation of thinking habits that transform into beliefs". 20n the other hand, some of the reports revealed clients' dependence on wound care provided by health professionals.It is important that they are active in such care, having their autonomy and independence preserved and promoted to maintain their own health.This can be achieved through instructions that enable decision-making regarding what and how to do to contribute to the process of wound recovery and healing in their routine, rather than being conditioned to the presence of health professionals and visits to the health institution for wound dressing, which is merely a part of this process.
The bond between professionals and individuals requiring health care is intertwined with affections and subjectivities that reject the places occupied in the area of health services, the totalitarian knowledge and interventionist practices.Apart from being institutional and physical, the area of health care is affective and it produces singularities, where caring does not always mean acting, performing actions or executing procedures.At certain moments, individuals who require care only need to have a unique autonomy in this affective area. 21t is through dialogue that individuals achieve communication.Dialogue is regulated through a mutual horizontal interaction, in contrast with the depository education, when the oppressor deposits knowledge in others in a vertical, unidirectional way through a monologic discourse.The dialogical practice enables knowledge and practices to be shared through words among those involved.At this moment, the knowledge that others have is taken into consideration, valuing their culture, beliefs, and social, political and economic context. 22n this sense, it should be taken into consideration that this problem, which includes users' lack of information about the therapies applied to them and about the required discussion on their agreement on or interest in being cared for is not restricted to the universe of integrative practices.This is because it is a recurring situation in the sphere of health services that deserves to be considered when one expects to provide humanized and integrated care, regardless of the therapeutic option of professionals and users. 23owever, in health services, clients tend to take on a passive role which is little or not participatory at all.Although their participation in the treatment is encouraged, it tends to be exclusively guided by the transmission of prescriptive information which neither includes nor promotes their health care autonomy.Knowledge and practices resulting from cultural inheritance and experiences of clients and their families are not investigated. 24n Leininger's cultural care theory, accommodation/negotiation represents ways to negotiate, adapt or adjust clients' health care patterns.This negotiation implies the establishment of a dialogue, which enables nurses to understand the way clients care for their wounds and clients to understand the type of care proposed by nurses. 10hile the present study was performed, health professionals' care was focused on the clients' wounds and there was no dialogue between them.Their concern revolved around the wound dressing procedure rather than the individuals undergoing this.There was no initiative to talk to clients to know how they were caring for their wound, what they were using to treat it at home and if they had any questions about wound healing.
When approaching knowledge and practices of clients in an educational perspective, their culture is considered through the sharing of knowledge and practices of health care between these clients and professionals.This takes into account the differences between the cultures of those involved with care: the professional one, originated from the technical-scientific knowledge, and the personal one, associated with clients' folk wisdom.
To achieve this, Paulo Freire stated that the critical-reflexive approach was relevant, as it discusses the educational action in an innovative way, centered on dialogue.It is not sufficient to access clients' knowledge and practices of health care for wounds and to identify their cultural aspects, one must reinterpret them in the process of dialogue in the light of scientific knowledge.This new knowledge would allow these clients to develop their autonomy and responsibility for their own care. 22nowledge and practices in wound care Chibante CLP, Santo FHE, Santos TD, Porto IS, Daher DV, Brito WAP Thus, it is essential to establish an interaction with each client, aiming to identify their trajectory from the onset of the wound to their experiences and practices when treating it.As a result, the need to combine knowledge and practices of care for these clients stands out, while acknowledging their beliefs, values and culture, which are understood and shared in the social group to which they belong, aiming to minimize the gap between scientific knowledge and folk wisdom. 3egarding the knowledge about any type of wound care apart from the drug-based one, clients brought knowledge originated from the life they shared with individuals such as their grandmothers, mothers and aunts.The transfer of knowledge about the use of alternative ways to treat wounds usually occurs in the social and family context, which was identified in another study on folk wisdom and practices of health care with the use of medicinal plants.Additionally, folk wisdom about the use of plants is a resource transmitted from generation to generation, used for therapeutic purposes by the population. 4,6owever, popular culture has still been pushed into the background, compared to scientific knowledge.A study on the representations and purpose of the use of phytotherapy in primary health care emphasized that practices rooted in folk wisdom, which are already known in the scientific field, should be integrated, although in a way that is connected to the health care system as a whole. 25n this sense, aiming to fill health professionals' gaps of knowledge about the use of complementary therapeutic resources and to promote incentives founded on knowledge and actions in health education for the population, there are actions and efforts geared towards the maintenance of efficient practices, although not systematized, through guided actions such as the Política Nacional de Práticas Integrativas e Complementares (PNPIC -National Policy on Integrative and Complementary Practices) in the Sistema Único de Saúde (SUS -Unified Health System).26 This is a policy that proposes the inclusion of other therapies in the field of public health services, such as phytotherapy, medicinal plants, acupuncture and homeopathy.One of its main objectives is to incorporate and implement these practices in the perspective of disease prevention and health promotion and recovery, with an emphasis on primary care, geared towards continuing, humanized and comprehensive health care.26 Another theme identified in clients' speech was that of health professionals exclusively giving instructions on the use of the product prescribed for wound healing.Perhaps, for this reason, some individuals reported not using alternative ways of wound care or questioning about the possibility of such use in certain cases.In an international study, 60% of patients resorted to integrative practices without informing their physician about this, which occurred due to the fear of physicians advising against such practices.27 However, the interviews revealed knowledge about both wound healing, through the use of teas, plants and barks, and eating habits associated with the treatment of other diseases, such as arterial hypertension and diabetes mellitus, which need to be recognized due to the possibility of interfering in wound care.
In view of the folk wisdom about the use of alternative practices in wound care, some were found to have therapeutic indications similar to those found in the literature, such as cashew skin, saião an aroeira.][30] According to a study on the origin of knowledge and practices in the therapeutic use of medicinal plants performed in Rio Grande do Sul, the link between folk wisdom and scientific knowledge enables individuals in a community to be closer to both health services and health professionals, whose perspective of comprehensive health care presupposes respect for differences and the socio-cultural context of those cared for. 4edicinal plants require adequate management and preparation so that their use can bring benefits to patients, otherwise the effects can aggravate problems.To achieve this, the Brazilian Ministry of Health issued Decree MS/GM number 533 from 2012, which establishes the group of drugs and materials of the Relação Nacional de Medicamentos Essenciais (RENAME -National Essential Drug List).Among such drugs, aroeira is mentioned and it has a healing, anti-inflammatory and antiseptic effect. 31nother practice in wound care described by clients was faith, because, according to them, to have a religion, to pray and to think positively bring spiritual and emotional comfort, in addition to wound healing.Religious practice was also found in a study on knowledge and practices of clients with wounds performed in the city of Cruzeiro do Sul, Northern Brazil. 3pirituality is intrinsic to human beings and it is associated with faith in God or, simply, in something in which they believe and which can help them, promoting comfort and giving them strength.Moreover, regarding the human quest for meaning in life, through one's relationship with oneself, others and the divine.][34] In the health service practice, it is understood that scientific knowledge needs to be connected to folk wisdom so as to identify the origin of the meanings through which individuals find sense in the way they care.It is important that clients participate in their care, being aware so they can choose the best for themselves, which determines their autonomy and independence in the implementation of such care.To achieve this, a dialogical relationship needs to be established, when knowledge and experiences can be exchanged, so that this knowledge can be shared through an approach which is culturally coherent with clients in health services.

Knowledge and practices in wound care
Chibante CLP, Santo FHE, Santos TD, Porto IS, Daher DV, Brito WAP

CONCLUSION
The present study enabled the description of knowledge and practices of clients in wound care, when they reported their knowledge about alternative practices, such as the use of cashew bark, aroeira and saião as teas to put on their wounds.Nonetheless, some reports revealed lack of trust in what has not been confirmed through scientific knowledge, ranging from eating habits associated with diseases to religious practices in their search for spiritual and emotional comfort for wound healing.Additionally, the fragmented view of individuals with a focus on the wounds to the detriment of a comprehensive view of individuals with wounds emphasizes their dependence on what is informed and recommended by professionals.
Thus, it is relevant to plan shared care, where culture, knowledge, practices, values and beliefs of clients can be taken into consideration in educational actions and the health care process.In this sense, to identify the knowledge and practices of clients with wounds for the development of cultural care enables the development of a health care plan which is adequate for their culture, allowing them to be more participative in the process of care and caring for themselves.
Considering the client as the main participant in the care process poses the challenge of tapping the potential of knowledge originated from their experiences in a given socio-cultural context, as this underlies their knowledge and practices in wound care and, consequently, the foundation for the nursing practice provided to these clients.
Considering the importance of the present study, there are still gaps that need to be dealt with and explored, given the need to combine scientific knowledge and folk wisdom, seeking coherence in health care.This becomes a challenge when health professionals believe they are the ones who have knowledge and practice, neglecting the culture and reality of clients.
This study indicates the possibility of other studies that can enable identification of the paths included in the trajectory of clients with wounds, who seek health services with their own questions and demands regarding health.Thus, health professionals must know and establish interventions that go beyond disease treatment, including effective actions that enable one to achieve well-being and autonomy through the implementation of care that integrates knowledge and practice between caregivers and those who receive such care in the context of health institutions.