Table 5 Psychosocial approach to chronic disease care practices

Knowledge of the socio-epidemiological profile of the area

(PHY 10) “(…) is a population with a low economical level. Sometimes they have a difficult educational understanding, they do not understand the issue of medication. (…) our territory is a peripheral area so all this definitely influences care.”

(NUR 1) “these patients have low educational level, are older, patients that we notice. They live in broken families or alone, patients who have associated psychological problems basically make healthcare very difficult.”

Intervention actions on social risks and vulnerabilities in the territory

(NUR 13) “If we had time, we could do a much better job, there is this woman who participates in all our activities, and her blood pressure is never controlled, (…) then we began to follow her up individually. Then I discovered that it is because her son is involved in drug trafficking. Every time there is a police raid, her pressure goes up and no medication can control it. She needs another device to help her, now, imagine doing this with six hundred (hypertensive patients). Today, after follow-up, her pressure is 120/80.”

(NUR 3) “(…) most of them (hypertensive and diabetic patients) are older, many live alone or live with a partner who is also older and one helps to care for the,(…), so I have to give more attention to these patients (…), follow them up closely.”

Promotion of autonomy and self-care development in HBP and DM patients

(NUR 2) “We try to make him (patient) understand well, at least the process of non-medicated and medicated treatment, we try to talk, show, we even draw if needed, (…) so we try in every way to stimulate self-care.”

(PHY 10) “I always consider the issue of care, changes in habits, always the issue of food, weight loss, taking the right drug, doing physical activity, self-care, stress, so, they can change things, right?”

Presence and role of social support network

(NUR 3) “(…) here in the neighborhood there is the community room that is always available, and in this sense the community here also helps a lot, they are always ready to organize (…), make things happen.”

(NUR 20) “(…) you don’t have much family participation because most family members work, and elderly patients spend the whole day alone. So, it is difficult, and when the family is present at the time of care or visit, they even listen to the guidelines, but they are not active in participating in this care process.”