ZIKA VIRUS EPIDEMIC : THE INFLUENCE OF RELIGION / SPIRITUALITY IN PREGNANT AND PUERPERAL WOMEN EPIDEMIA VIRUS

Objective: to know the conception of health professionals, religious leaders, and pregnant and puerperal women about the influence of religion/spirituality in the face of the Zika virus epidemic. Method: qualitative study based on Dialectical Historical Materialism (DHM). The empirical material was collected through interviews with 19 participants. The main themes emerging from the transcription of the speech fragments were grouped into blocks of meaning and gave rise to the empirical categories analyzed by the Discourse Analysis Technique. Results: the professionals emphasized allopathic care. The pregnant and puerperal women presented behaviors vulnerable to the Zika virus epidemic and the spiritual performance of the religious leader was limited to religious dogmas. Conclusion: the conception of health professionals is technicist and does not recognize the influence of religion/spirituality in the context of the Zika virus epidemic. Pregnant and puerperal women emphasize the influence of religion/spirituality on their lives, reinforced by the testimonies of religious leaders, which leads to the conclusion that religion/spirituality may offer means to help to cope with pathological conditions, as in the case of the Zika virus epidemic, and can complement the technicist performance of health professionals. Descriptors: Zika Virus; Microcephaly; Spirituality; Religion; Health Personnel. RESUMEN Objetivo: conocer la concepción de profesionales de la salud, líderes religiosos, gestantes y puerperas acerca de la influencia de la religión/espiritualidad frente a la epidemia virus Zika. Método: estudio cualitativo, fundamentado en el Materialismo Histórico Dialético (MHD). La recolección de material empírico fue hecha por medio de entrevistas realizadas con 19 participantes que, a partir de la transcripción de los fragmentos de los discursos, fue hecha la deprección de los temas principales, agrupados en blocos de significación que originaron las categorías empíricas, analizadas por la Técnica de Análisis de Discurso. Resultados: los profesionales enfatizaron el atendimiento alopático, gestantes y puerperas presentan comportamientos vulnerables a la epidemia virus zika y la actuación espiritual del líder religioso está limitada a los dogmas de la religión. Conclusión: la concepción de los profesionales de la salud es tecnicista y no recoocen la influencia de la religión/espiritualidad en el contexto de la epidemia virus Zika. Gestantes y puerperas enfatizan la influencia de la religión/espiritualidad en sus vidas, reforzada por las declaraciones de los líderes religiosos, lo que lleva a la conclusión que la religión/espiritualidad han demostrado ofrecer medios que ayuden al enfrentamiento de la condición patológica, como en la epidemia virus Zika, y puede complementar la actuación tecnicista presentada por los profesionales de la salud. Descriptores: Virus Zika; Espiritualidad; Religión; Personal de Salud. Doutora, Curso de Enfermagem, Universidade Federal de Campina Grande/UFCG Campus Cuité. Cuité (PB), Brasil. E-mail: luciana.dantas.farias@gmail.com ORCID iD: http://orcid.org/0000-0003-2081-2869; Enfermeira, Curso de Enfermagem, Universidade Federal de Campina Grande/UFCG Campus Cuité. Cuité (PB), Brasil. E-mail: manumorena015@hotmail.com ORCID iD: http://orcid.org/0000-0002-6999-8839; Especialista em Saúde da Família, Secretária de Saúde do Município de Picuí. Picuí (PB), Brasil. E-mail: nainamla@ig.com.br ORCID iD: http://orcid.org/0000-0002-6736-3936; Doutora, Universidade Federal de Campina Grande/UFCG Campus Cuité. Cuité (PB), Brasil. E-mail: aninhacdr@hotmail.com ORCID iD: http://orcid.org/0000-0001-5782-3102; Mestre, Curso de Enfermagem, Universidade Federal de Campina Grande/UFCG Campus Cuité. Cuité (PB), Brasil. E-mail: carolina_pcs@hotmail.com ORCID iD: http://orcid.org/0000-0002-4457-6568; Mestre, Curso de Enfermagem, Universidade Federal de Pernambuco/UFPE Campus Vitória de Santo Antão. Vitória de Santo Antão (PE), Brasil. E-mail: benegelania@yahoo.com.br ORCID iD: http://orcid.org/0000-00024333-5439 ARTIGO ORIGINAL Andrade LDF de, Santos EM dos, Almeida JML et al. Epidemia zika vírus: influência da religião... Português/Inglês Rev enferm UFPE on line., Recife, 12(2):329-36, fev., 2018 330 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i2a23245p329-336-2018 A forma como as pessoas constroem a narrativa de suas vidas inclui estratégias para enfrentar os desafios cotidianos, como o adoecimento do próprio corpo ou de um familiar, conduzindo à reflexão do que realmente o ser humano deve priorizar e, neste sentido, existem ressignificações do senso comum que conduzem ao sagrado. Para que algo se torne sagrado é preciso ser retirado do senso comum e concebido como realidade separada, a qual requer autoridade e expertise para manejar e os novos sagrados imanentizados – vida, saúde e corpo – presentes no atual contexto sociocultural sofrem influência ideológica da religião/espiritualidade. Entende-se religião como um sistema de crenças e práticas relativo a seres sobrehumanos dentro de universos históricos e culturais específicos, enquanto a espiritualidade transcende o humano com valorização do sobrenatural, incluindo a busca do autoconhecimento para elevar-se em outro nível através da fé e devoção. Em 2015, a epidemia Zika vírus foi associada a um elevado registro de casos de microcefalia congênita em bebês cujas mães apresentaram em comum sintomas sugestivos de infecção por Zika durante a gestação, levando progressivamente à necessidade de capacitação para profissionais de saúde e avaliações criteriosas das gestantes durante o pré-natal, preocupando autoridades sanitárias, gestores dos serviços de saúde, profissionais da área, pesquisadores e comunidade, visto que ainda não existe um tratamento específico às complicações que esse vírus pode causar. Dentre as complicações causadas pela infecção Zika vírus, destacam-se a microcefalia e o baixo peso ao nascer dos bebês. Essa epidemia tem deixado as mulheres que pretendem engravidar em estado de alerta, uma vez que a doença pode acometer em qualquer período da gestação, influenciando também na decisão de ter ou não filhos, pois todo casal tem a expectativa de que seu filho seja saudável e em condições de crescer nos padrões de normalidade a fim de tornar-se independente. Esta pesquisa surgiu de uma inquietação no tocante à influência da religião e espiritualidade perante a epidemia Zika vírus após participação em uma palestra sobre o tema no GEPISE (Grupo de Estudos e Pesquisas Interdisciplinares em Saúde e Enfermagem) e que motivou o aprofundamento no tema. Justifica-se a sua realização em face da constatação de que a influência da religião/espiritualidade pode ser benéfica às gestantes e puérperas, principalmente no contexto da epidemia Zika vírus, sobre o estado emocional da mulher, homem e demais membros familiares. A religião/espiritualidade apresenta aspectos ideológicos que, convergentes com os preceitos do Ministério da Saúde, têm demonstrado oferecer meios que auxiliam o enfrentamento da condição patológica, quaisquer que sejam elas. ● Conhecer a concepção de profissionais da saúde, líderes religiosos, gestantes e puérperas acerca da influência da religião/espiritualidade perante a epidemia Zika vírus. Estudo qualitativo, fundamentado no Materialismo Histórico e Dialético (MHD), visando buscar explicações coerentes e racionais para os fenômenos da natureza, da sociedade e do pensamento a fim de compreender o objeto ou fenômeno a partir de aspectos que girem em torno de sua totalidade, estudando o problema exposto, desde seu início, detalhando-o o máximo possível, para depois chegar aos resultados finais, considerando que o sujeito poderá passar por mudanças de ideia no decorrer do tempo. O município de Picuí, Curimataú paraibano, Brasil, foi escolhido para realização da pesquisa pela proximidade com Campina Grande, referência do SUS para tratamento, por apresentar gestantes com sintomatologia sugestiva para Zika vírus e desenvolver projetos de pesquisa em parceria com a UFCG – Universidade Federal de Campina Grande, campus Cuité, Paraíba, Brasil. Picuí apresenta alguns estabelecimentos assistenciais de saúde, como o Hospital Regional Felipe Tiago Gomes, o Centro de Atenção Psicossocial (CAPS) e quatorze Estratégias Saúde da Família (ESF), sendo nove na zona rural, quatro na zona urbana e uma no distrito de Santa Luzia. Foi considerado como cenário da pesquisa quatro ESFs da zona urbana, a igreja católica, protestante e espírita adscritas ao território com atividades de campo realizadas nos meses de agosto e setembro de 2016, após aprovação do Comitê de Ética em Pesquisa, cujo projeto foi aprovado pelo CAAE: 56867916.7.0000.5575. INTRODUÇÃO

The way people build the narrative of their lives includes strategies for coping with everyday challenges, such as the illness of one's own body or of a family member, leading to a reflection on what the human being really must prioritize.In this sense, there are common sense resignifications that lead to the sacred.For something to become sacred, it must be removed from common sense and conceived as a separate reality.This, in turn, requires authority and expertise to manage, and the new immanentized sacred conceptslife, health, and body -present in the current sociocultural context undergo an ideological influence of religion/spirituality. 1 Religion is understood as a system of beliefs and practices concerning super-human beings within specific historical and cultural universes 2 , while spirituality transcends the human being with an appreciation of the supernatural, including the pursuit of selfknowledge to feel elevated to another level through faith and devotion. 3 2015, the Zika virus epidemic was associated with a high number of cases of congenital microcephaly in infants whose mothers had had symptoms suggestive of Zica infection during pregnancy, progressively leading to the need for training health professionals and conducting a careful evaluation of pregnant women during prenatal care. 4The epidemic caused concern among health authorities, health service managers, health professionals, researchers and the community in general, for no specific treatment exist so far for the complications that this virus can cause. 5ong the complications caused by the Zika virus infection are microcephaly and low birth weight of infants.This epidemic has left women who intend to become pregnant on alert because the disease can affect any stage of the gestation.It also influences the decision on whether or not to have children, since every couple expects their children to be healthy and enjoy the conditions to grow in normal patterns in order to become an independent person. 5is research arose from the concern with the influence of religion and spirituality before the Zika virus epidemic after participating in a lecture on the subject in the GSIRHN (Group of Studies and Interdisciplinary Research in Health and Nursing) that motivated the deepening in the subject.
The study is justified by the fact that the influence of religion/spirituality can be beneficial for pregnant and puerperal women, especially in the context of the Zika virus epidemic, on the emotional state of women, men and other family members.Religion/spirituality presents ideological aspects that, in agreement with the precepts of the Ministry of Health, have shown to offer means to aid the coping with pathological conditions, whatever they may be. 6To know the conception of health professionals, religious leaders, pregnant women and puerperal women about the influence of religion/spirituality in the face of the Zika virus epidemic.This is a qualitative study based on Historical and Dialectical Materialism (HDM) that aimed at seeking coherent and rational explanations for the phenomena of nature, society and thought in order to understand an object or phenomenon based on aspects that revolve around its totality, studying the problem from the beginning, detailing it as much as possible, and then arriving at the final results, considering that subjects may change their mind over time. 7e municipality of Picuí, Curimataú from Paraíba, Brazil, was chosen for realization of the research due to its proximity to Campina Grande, a SUS reference for treatment of Zica, and also due to the presence of pregnant women with suggestive symptomatology of Zika virus infection, and the development of research projects in partnership with the UFCG -Federal University of Campina Grande, Cuité campus, Paraiba, Brazil.
Picuí presents some health care facilities such as the Felipe Tiago Gomes Regional Hospital, the Psychosocial Care Center (PCC) and fourteen Family Health Strategy (FHS) units, nine of which are in the rural zone, four in the urban zone and one in the district of Santa Luzia.Religious leaders (priests, pastors and spiritual guides) over 18 years of age who had lived and served in Picuí for at least six months, and who had assisted at least one pregnant or puerperal woman in the community with suspected or diagnosed Zika virus infection were invited to participate in the study, as well as health professionals over the age of 18 and who have worked in the FHS for over one year were invited.For the selection of pregnant and puerperal women, women over 18 years of age, who lived in Picuí for more than one year, accompanied by the FHS program during the prenatal period, and who regularly attended activities offered by their religion were interviewed.
In order to avoid revealing the identity of the participants, the speech fragments received alpha numeric codes (HP1 to HP11), (P1 to P3), (PU1), (R1 to R4), where "HP" means health professional, "P" pregnant woman, "PU" puerperal women and "R" religious leader, followed by a number that indicates the sequence in which they were interviewed.Thus, "HP1" represents the first health professional interviewed.
Collection of empirical material involved recorded interviews conducted with the aid of a previously prepared semi-structured script.Interviews were scheduled according to the availability and convenience of each interviewee, and they occurred in the environment of FHS units, churches or domiciles.The recorded interviews were conducted individually and transcribed for later analysis by the Fiorin's speech analysis technique. 9e transcribed speech fragments of the participants were the bass for identification of the main themes, which were grouped into blocks of meaning that gave rise to the empirical category, raw data extracted from the speeches, in which it was possible to encode the speech fragments of the religious leaders, health professionals, pregnant women and puerperal women into units of representation of what they described regarding their experiences with the epidemic Zika virus epidemic and religion/spirituality. 9 present herein the description of the discourse analysis 9 of the empirical universe of nineteen (19) participants systematized into three empirical categories: 1. Difficulties faced by health professionals in cases of Zika virus infection; 2. Family and spiritual support in the face of the Zika virus epidemic; 3. Convergences and divergences involving science and religion.

EMPIRICAL CATEGORY I: Difficulties faced by health professionals in cases of Zika virus infection
With the outbreak of Zika virus epidemic in the Brazilian territory, the care directed to pregnant and puerperal women has been reinforced, especially during prenatal care.Symptoms such as low fever, non-purulent conjunctivitis, headache, arthralgia, with inflammation in the joints in some cases, fatigue or myalgia, asthenia, maculopapular rash and, less frequently, retro-orbital pain, anorexia, vomiting, diarrhea and abdominal pain may indicate Zika virus infection.The symptoms disappear within 7 days.However, the Zika virus may cause severe complications such as Guillain-Barre syndrome, neurological complications (encephalitis, meningesencephalitis, paresthesia, facial paralysis and myelitis), ITP (idiopathic thrombocytopenic purpura), and ophthalmic and cardiac damage. 10ter clinical evaluation and signs and symptoms, pregnant women are referred for tests such as serological tests for Dengue and Chikungunya, whose laboratory diagnosis is based on the search for viral RNA, considering the viraemic period of about four to seven days after the onset of symptoms. 11e association of cases of microcephaly with Zika virus infection in pregnant women has been recently presented through fetal virological and pathological images and analysis, and confirmed by Brazilian studies 12- 4 through the identification and sequencing of the virus in the amniotic fluid of two pregnant women who had an infection during pregnancy and fetuses with microcephaly.Although microcephaly is linked to many environmental and genetic exposures, use of drugs during gestation, in addition to infections such as rubella, toxoplasmosis and cytomegalovirus, among others, the association with Zika virus infection has followed the increase in microcephaly and other cases of neurological malformations in Brazil since 2015. 11ong the main challenges faced by health professionals in the context of the Zika virus epidemic are the coping with a poorly studied pathology, still lacking specific treatment, with the only possibility of palliative treatment based on analgesics and anti-inflammatories so as to ease the RESULTS AND DISCUSSION discomfort with the symptoms, and prospects for long-term scientific responses.These challenges can be highlighted in the lines: Another limiting factor involves the therapeutic follow-up before a diagnosis of microcephaly during the prenatal period, because these pregnant women will have to go to the ISEA (Elpídio de Almeida Health Institute), the SUS reference maternity unit located in the city of Campina Grande, Paraíba, and 144 km far from the municipality of Picuí.The women's displacement depends on the availability of transportation offered by the city hall and generates physical wear during the trip, increased financial expenses with food, and no prospect of improvement of the clinical situation.
Although care through health education actions on prevention against dengue, chikungunya and Zika virus has been emphasized, some pregnant women delude themselves not to acknowledge the vulnerability of the context, as highlighted in the following speech: [...] So, it's complicated to talk about this, because it may even shock, that is, so much has been said about microcephaly in the media, we from basic care, including doctors, all of use, and also the CHAs, we talk about the risks of contracting the virus and the child having problems and sometimes I think I don't see much interest from the part of some pregnant women, some really care and seek all the necessary care, but others find it a fantasy, that what the media explains, it's not really like that.As a nurse, I worry [...].(HP8) Nursing has stood out as a profession that has a close proximity with patients and is, therefore, responsible for a holistic view that contemplates in the process of caring the biological, mental, emotional and spiritual dimensions of the human being.From this point of view, the professionals' concern, from health promotion to rehabilitation, demonstrates sensitivity and convergence with aspects of humanization in provision of health care aiming at paradigmatic behavioral changes. 15e speech gives evidence of initiatives of health education actions in order to implement preventative activities to be propagated at the national level, since primary care plays an important role in the prevention, attention and control of diseases.This is especially true in the combat of the Zika virus epidemic because primary health care units are closer to the community in which they operate, 16 although a complete coverage of the target population is not possible because some pregnant women do not express concern about the epidemic context.
Although religion/spirituality have the potential to exert an ideological influence on believers, eloquence on the influence of religion/spirituality in prenatal consultations or puerperal care was never mentioned by health professionals -nurses, nursing technicians and community health agents.There is no negative criticism toward the role of religious leaders or their ideological practices, and initiatives of a partnership involving churches in the territory and the FHS units were omitted.
Health professionals may find it difficult to understand the articulation between spirituality and health actions, as well as to incorporate the spiritual dimension into their professional activities.One of the reasons for this problem may be the professional training, in which the topic of spirituality is only superficially and subjectively approached.Moreover, not knowing how to differentiate spirituality from religiosity interferes with the way in which spiritual care is rendered to the individual. 17though spirituality is embraced in the discourses of the health care area from the perspective of biopsychosocial and spiritual care, this human need is still neglected or even unknown in the professional practice. 17he sociocultural influence that values beauty, power, and financial achievements associated to an eminently technicist higher education hampers the practice of spiritual care by health professionals.Labor practices aimed at reducing the human being in their simplistic values may exert a more humanized and holistic performance with emphasis on bonding and empathy without necessarily addressing the client's spirituality/religiosity in the assistance provided, although this aspect is considered a potentiating factor for therapeutics . 17

EMPIRICAL CATEGORY II: Family and spiritual support in the face of the Zika virus epidemic
Spiritual and family support is presented as of utmost importance in cases of illness, taking into account that the diagnosis of microcephaly may lead to a nebulous consequence in the psychological and spiritual spheres.The reports of the three pregnant women and one puerperal woman with a child diagnosed with microcephaly converged on the importance of such support, especially in the Zika virus epidemic context.

[...] It is in the family, at the health unit, right? I would pray, thank and ask God also, to help me. That my baby may come with health [...]. (P2)
[...] Jesus, we must accept this as God's will, because killing, no, I won't kill, right?And also ask God for strength to care for him because it is not easy and the support of the family too, it's very difficult.Jesus Christ, may God forbid it!That I may not go through the situation of a sick baby, but it is too difficult, because it is the same as caring for a sick child because the care he will need is even greater, is not?[...].(P3)

[...] I went to ten prenatal consultations, all consultations. [...]. So they (medical and nursing professional) measured, right, the belly and listened to the baby, everything, but the ultrasound never showed anything. So, what I did[...] was the one of two months and the morphological one. But I could not see anything, no, only after my son was born. None of the ultrasounds showed anything, because I only did the morphological ultrasound, and then the last one I did not do it, I was going to do it, but then, my son was born, then I did not do it anymore. And I saw my baby with microcephaly[...] (cry)[...] only Jesus now!!! [...]. (P1)
It is in the motherhood that the care lines emerge: responsibility, experience and giving of oneself for the child.But, as noted, it is necessary for the family to take the key role of supporting these mothers.In the case of an expected and planned pregnancy, it may be received with much happiness, surprise and joy; and if not planned, a baby may cause discomfort, fear, anguish and worry and, in some cases, regret.When negative feelings are associated with the lack of support from the partner or the family, the woman may feel insecure and lonely and she may tend to resort to spirituality in its religious representations.Thus, the presence of religious leaders or spiritual guides may be interesting.The speeches show a strong dependence on religious/spiritual precepts in the women's lives. 18cording to the interviewees, biomedical assistance seems to be necessary during the care process, although it does not converge with religious institutions during the process of illness, showing a form of assistance eminently based on allopathic therapy, without the emphasis on the health-disease process.Moreover, health professionals, in general, act in a curative way. 19en though nursing represents a profession conducive to spiritual comfort, it was defined in speeches as a specific action focused on biomedical and scientific aspects with few demonstrations of transdisciplinarity and attempts to overcome the spiritual limitations expressed by the pregnant and puerperal women.

EMPIRICAL CATEGORY III: Convergences and divergences involving science and religion
In modern society, there are physical or emotional discomforts, with the own illness or the illness of the relatives, with epidemics and endemics, and the support of religion/spirituality is considered important by believers.The search for religion is put even above the search for health professionals according to the fragments below: However, health professionals do not interact with religious leaders and vice versa.Such interaction could be interesting because of the possibility of participation of these leaders in the context of the Family Health Strategy.According to the words of religious leaders, the assistance of health professionals converges with allopathic therapy, while religion follows in parallel with its precepts, dogmas and spirituality.It is important to emphasize that some religious leaders expressed a desire to carry out social actions with the FHS, but without a plan that converges with health professionals.
We observed that some religions work with renowned pastors as groups of faithful persons dedicated to caring for people, such as pastoral health care groups, which acts in the prevention of diseases and care for persons in the process of illness by taking the religious ideology to the sick people through home visits and hospital visits that happen without the participation or guidance of health professionals, even in a context where leaders and professionals are physically in the same environment.
Recognizing oneself as an opinion-maker consciously reflects on the sort of leadership that these religious people take on in the community in which they work.Leadership is understood as a type of personal power, because through leadership a person influences others in function of existing relationships, being necessary for all types of human organization, including in ecclesiastical organization. 20e transcribed speeches of these leaders show that in their role of community leaders, they have guided their believers in a manner consistent with the precepts of the Ministry of Health to combat and prevent the Zika virus.They show concern towards the Zika virus epidemic and the increased microcephaly in the municipality.However, without any joint proposal between religion and health services, their influence is limited to cults, spiritual sessions and other religious activities.
The religious/spiritual experience is recognized as a further tool to cope with the day-to-day difficulties imposed by daily limitations caused by aspects of different natures such as financial, emotional, political, cultural, and biopsychosocial. 2 For religious leaders, it is up to the pregnant women, puerperal women and their relatives to search for religion/spirituality with emphasis on availability for counseling, ratifying the parallel action with health professionals.
To know the conception of health professionals, religious leaders, pregnant women and puerperal women about the influence of religion/spirituality in the face of the Zika virus epidemic led to relevant and contradictory aspects.
The conception of health professionals is a technicist one, and does not recognize the influence of religion/spirituality in the Zika virus epidemic.Pregnant and puerperal women emphasize the influence of religion/spirituality on their lives, reinforced by the testimonies of religious leaders, demonstrating that religion/spirituality offers a means of help to cope with pathological conditions such as Zika virus epidemic, and can complement the technicist performance developed by health professionals.
Health professionals and religious leaders describe their work activities as parallel, despite the context where there is the possibility of convergence, since there are pastoral health care groups and similar initiatives of the church in hospitals, prisons and domiciles (home visits), where professionals are also present.This points out to the dichotomy between religion and science.
Although the study was carried out in a small municipality in Paraíba, it may contribute scientifically to the reflection on the active participation of the main spiritual representatives of the community such as priests, pastors, spiritists, Jehovah's Witnesses, and folk healers in the area covered by FHS units.This would favor the therapeutic process of the community and the understanding that there is a possibility of common sense in dealing with controversial religious dogmas that go against the main public policies such as the prohibition of the use of contraceptive methods, prohibition of blood transfusions, interruption of allopathic treatment "because God healed".For this reason, transdisciplinarity and cultural diversity can be achieved in the context of Primary Care for greater benefits in the context of the Zika virus epidemic.

CONCLUSION REFERENCES
So it's like, because doing this prenatal care there at ISEA, if there are likely consequences, there's nothing to be done[...] It's very complicated for us in basic care, we get[...] what will I do with