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Art therapy and education between peers connecting the group: an experience report

Rev Bras Enferm. 2020;73(5): e20180958 http://dx.doi.org/10.1590/0034-7167-2018-0958 5 of ABSTRACT Objective: to report the “Talent Workshop: Art Therapy Connects the Group”. Method: this is an experience report of a workshop developed in November 2018, in 3 meetings, at the Family Clinic setting Rio de Janeiro. Twenty-eight users participated, including diabetics and health professionals. In the first meeting, dynamics was used for presentation. At the second meeting, the circular process and peer education were used to address issues related to diabetes, in addition to exposing talent to workshop participants. At the third meeting, there was exposure of talents to every health unit. Results: the workshop provided comprehensive, individual and collective health promotion of users, allowing knowledgemultiplicationin their living environment. Final Considerations: the workshop was relevant for health education, changing the understanding of the subject’s autonomy about his role in self-care. Descriptors: Diabetes Mellitus, Type 2; Health Education; Complementary Therapies; Health Promotion; Health Personnel.


INTRODUCTION
Type 2 diabetes mellitus (T2DM) is considered one of the major global epidemics of the 21 st century and a public health problem in both developed and developing countries. The number of individuals with T2DM allows us to assess the magnitude of the problem. There were 240 million in 2005 and its evolution in the world is expected to reach 366 million in 2030, an expected growth of 114%. The current setting of DM in the Brazilian population reflects the need to institute preventive measures at all levels. It is based on scientific evidence, aiming to equip the health professional in clinical practice, as well as the governmental agencies to establish public policies (1) .
In this sense, health education has undeniable importance for the promotion of individuals' lives, contributing to the prevention of complications. It is used as a vehicle for transforming individual practices and behaviors, and in developing the autonomy and quality of life of people with T2DM (2) . For this, we used as a strategy the "Talent Workshop: Art Therapy Connects the Group", mediated by peer education. This workshop had its anchorage in Integrative and Complementary Practices in Health (PICS -PráticasIntegrativas e ComplementaresemSaúde), which has art therapy at its core.
Workshops are relevant tools to enable the relationship between health professionals and the subject or community to occur in a non-vertical manner. They facilitate the individual and collective expression of the needs, expectations and life circumstances that influence health, being made possible by a space for valuing dialogue, thus allowing the construction of collective consciousness and the meeting of reflection with action (3) . There are studies that developed workshops as strategies for health education and presented as results the transformation of the inserted subject (3)(4) .
Regarding Peer Education (PE), which is part of current health education practices, it has grown in popularity due to its widespread use in health promotion. It is defined as the exchange of knowledge among people who have the same profile and share the same experiences, which greatly facilitates the exchange of knowledge and practices (5) .
In Brazil, the debate on Integrative and Complementary Practices (PIC -PráticasIntegrativas e Complementares) began to emerge in the late 70's, following the Alma-Ata declaration and mainly validated in the mid-1980s with the 8 th Brazilian National Health Conference. In view of this, the Federal Government, in order to ensure comprehensive health care, instituted a permanent public policy that considered not only the natural mechanisms for disease prevention and health recovery, but also the expanded approach to the health-disease process and global promotion of human care (6) .
One of the integrative practices cited in PNPIC is art therapy, which is defined as: Artistic, visual expressive practice, which acts as a therapeutic element in the analysis of the conscious and unconscious and seeks to interconnect the internal and external universes of the individual, through their symbolism, favoring physical and mental health (7) . This study is justified by the importance of disseminating health education actions developed by PE being guided by PNPIC. Possible actions are indicated in care and learning process of health service users, improving knowledge and practices, and pointing to the need for further research on the subject. It is hoped that this practice can be replicated in new actions, contexts and settings.

OBJECTIVE
To report the "Talent Workshop: Art Therapy Connects the Group" and the various possibilities of health education strategies for people living with T2DM. PE is used as a mediator in this process, being guided by the PNPIC (2015), developed in a playful way through art therapy.

METHOD
This is an experience report regarding the "Talent Workshop: Art Therapy Connects the Group"implementation. It is organized collectively by health professionals, CHA (Community Health Agents) and service users who live with T2DM, as well as their family members, in November 2018, in the health setting called Family Clinic -RJ. Its primary purpose was to broaden the bond between these users and health professionals, creating a space for exchanging effective experiences that would make them give a new meaning to their living with the disease.
In this setting, there was already a group for T2DM called"Sweetness Group", that has been working with the PE proposal since 2015. The decision to adopt this strategy was made by the participants to live with T2DM and present stabilization of their condition, thus sharing their life with other diabetic subjects who did not have adequate glycemic control. Including one of the CHA of the team lives with T2DM. Through actions we observed greater adherence of other users its neighbors and they reported improvement in their health.
The "Sweetness Group" consists of health professionals, CHA, service users who lived with T2DM and their families. These users had great potential to be facilitators in their environment, presented by showing interest in sharing their learning with people with similar diagnosis and that there were limitations to treatment adherence. These facilitating peers were also elected for their improvement in glycemic results, as observed in the Electronic Medical Record (EMR).
In order to expand the integration between peers living with T2DM, the Talent Workshop was implemented. Art therapy was considered a therapeutic process, where the participants of the "Sweetness Group" continue to be great facilitators in this health promotion process.
The workshop's previous meetings were attended by members with the purpose of detecting common artistic practices among users that would be worked on during the workshop, such as poetry recitation, fabric embroidery, fabric painting, toy production made of scraps, musical performance, non-sugar recipes/ menus, other forms of crafts and circular dancing.
The workshop brought together 28 people who belonged to the "Sweetness Group", 22 users, 6 health professionals and 02 CHA. The professionals who led both the group and the of Art therapy and education between peers connecting the group: an experience report Marins MR, Daher DV, Pinto AA, Cardoso RSS, Sá SPC. talent workshop were: 01 doctor, 01 nurse, 01 nutritionist, 01 physiotherapist.
The "Talent Workshop: Art Therapy Connects the Group" took place in three meetings of at least 120 min each. It was conceived and carried out as a strategy for the closing of activities of the "Sweetness Group" activities at the end of the year, and also a moment for welcoming new participants. The idea of the Talent Workshop was a collective decision of professionals and users.
The results were presented descriptively. As this was an experience report, it was not necessary to submit the study to the Human Research Ethics Committee. However, it should be noted that the ethical precepts contained in the Brazilian National Health Board(CNS -Conselho Nacional de Saúde) Resolution 466/2012, which deals with ethics in scientific research, were followed, both for data analysis and for the socialization of results.

First Meeting
The first meeting began with the realization of a dynamic where everyone seated in a circle introduced themselves, informing their name, what is their favorite food and their talent. Thus, the next participant, when introducing himself, should repeat the speech of all who had already presented themselves, sequentially, working the intermingling, icebreaker and memory of each of the meeting's components.
All foods referred to were fatty/frying foods, which prompted health professionals to come up with healthy and adapted food recipes. Thus, that same day, the topic of healthy eating was discussed.
Subsequently, to demonstrate the amount of sugars in the diet, the nutritionist brought sugar bags, representing the amount of sugar in soft drinks, box juices, mate, chocolate powder, and water. The use of the methodology caused great amazement to users, who did not know that some foods were harmful to their health. After this activity, the difference between light, diet and zero foods was explained.
Subsequently, it was decided on the theme and the facilitating user for the next meeting, by the participating collective in a democratic way. For the next workshop meeting, it was also proposed that users bring healthy recipes or snacks, as well as demonstrate/expose their talents.

Second Meeting
The second meeting was held in the Health UnitAuditorium,and we created areas for each one to expose their work, following the themes: crafts, music, texts/poems and food.
The beginning of this meeting took place with the participants in a circle, using the Circular Process, which is a process performed in a circle, with the purpose of promoting support and integration or mediating conflicts. There is a need for a mediator who presents objects to be a speech stick, so that only those with the stick have the right to speak. After choosing the stick are presented selected materials and a question that guides the process. Afterwards, the participants answer the question (8) .
Thus, the Circular Process was presented to the participants, and the nurse was the mediator of this process. Three objects were presented for speech stick selection. The objects were: glucometer, toy carrot, heart keychain, and the participants opted for the speech stick toy carrot. The Circular Process began with the exhibition of the video "Ame-se e sejaamor. Se permitaerrar" (freely translated as Love yourself and be love. Allow yourself to make mistakes) by Braulio Bessa. At the end of the exhibition, the question was asked "Have I flown as you would like?". Thus, the speech stick was passed in order to the participants, in order to answer the proposed question.
After the activity, the facilitator user chosen in the first meeting brought the discussion about the role of family in T2DM care proposed by the group in the first meeting, through PE methodology.

Third Meeting
The third meeting took place with the exhibition of all talents in the Health Unit courtyard, being open to the general public, including many brought their relatives. At this time, a cookbook prepared with the food that was brought to the participants by the second meeting was also distributed.
To close the meetings, participants presented their talents, sharing with others the importance that art has in their life, and a healthy snack was made, with food that all participants brought.

RESULTS
The workshop initially resulted in "ice breaking" and bonding between the professional and participating users. The dynamic form of art therapy and other educational resources created participants' expectations for upcoming meetings both regarding recipes/ menus and the presentation of their talents to other participants.
The first meeting raised everyone's interest in the "Sweetness Group"activities and, consequently, in their health care. Thus, we observed that during the meetings, the participants presented their difficulties about living with diabetes and the need for support from friends and family in this process.
At the second meeting, the exposition of talents and the discussion about the role of the family in the care of T2DM resulted in an exchange between all participants and self-confidence to share their knowledge, experiences and skills.
The Circular Process met its proposal to promote support and integration of participants, and most were thrilled with the video "Love yourself and be love. Allow yourself to make mistakes", sharing experiences and situations felt during the experience with T2DM. The wording of the phrase "Have I flown as I would like?" The moments lived in these meetings boosted the desire of each one to present their talent in the Health Unit courtyard, contributing to the self-esteem of users who presented their talents. In this way, a relationship of friendship and complicity was created among the participants, since most were already known from the neighborhood, and from the Talent Workshop they began to indicate other health promotion activities for each other. Another relationship we saw closer was the familiar. In addition, users with longer coexistence demonstrated great ease of exchange. They are fundamental and could share with their peers with less time living with the disease and family, their care practices, the challenges and the many possibilities to have a healthy life. Some Talent Workshop participants, after exposing their talents, reported beginning to appropriate the art after discovering their diagnosis of T2DM. They occupied their time better and thus failed to access foods that are restricted in their diet. Thus, it was evidenced that handicrafts of Art therapy and education between peers connecting the group: an experience report Marins MR, Daher DV, Pinto AA, Cardoso RSS, Sá SPC.
brought great satisfaction to users and that art, besides a self-control mechanism, can promote health. The end result of the "Talent Workshop: Art Therapy Connects the Group" was to provide comprehensive, individual and collective health promotion to users. It allowed the multiplication of knowledge in their living environment and the interaction between participants with health professionals. Individual become a participant and responsible for changing the habits of their community.

DISCUSSION
As seen in the results of the "Talent Workshop: Art Therapy Connects the Group" through rich experience exchanges, users with longer treatment and self-care were critical and were able to share with their peers less time living with the disease and relatives. This behavior contributes to support adherence to self-care, as PE is a favorable method for self-management, including diabetic users (9) .
The use of art therapy was an innovative experience and was well accepted in the workshop, stimulating self-knowledge through the use of resources such as poetry, embroidery, painting on fabric, construction of toys from scraps, music, construction of food recipes without addition and sugar, crafts and circular dance. The management of this activity facilitates knowledge and, at the same time, promotes greater expression of the participants' talents, valuing natural resources not passed on by professionals. This method increases users' confidence in self-care, self-esteem and self-management.
The activity was based on art therapy, which "in addition to healthy generates creativity, repressed by negative experiences, leading to overcoming shyness, low self-esteem, collaborating in various situations in the education and health processes, to help overcome pain and sufferings (10) . " This appeal was well accepted by the population, with no rejection, since everyone had some talent to present.
All the methods used in the workshop achieved the expected and favored the results, being positive for the group and consequently having greater adherence to the existence of a diabetes group in the health unit.

Study limitations
The limitation of this study is related to the non-generalization of its results to other settings of Primary Health Care, as these results represented the report of a specific setting and participants.

Contributions to nursing
It is hoped that this report can contribute by encouraging other professionals and Health Units to promote similar activities, reflecting on new educational practices, increasing autonomy and thus reducing the risk of such frequent readmissions among users living with T2DM.

FINAL CONSIDERATIONS
The "Talent Workshop: Art Therapy Connects the Group" proposal was successful in its approach. The possibility of experienceexchangein PE and using art therapy among participants increased adherence and generated greater interest of diabetic users in the participation of groups of the unit,and, later, greater adherence to outpatient consultations and physical activities, which take place through the "ProgramaAcademia Carioca" (the ProgramaAcademia Carioca is a model of community and intersectoral activity with emphasis on the promotion of regular physical activity, accessible to users of the Rio de Janeiro municipal health network). It also provided self-care and self-management when the invitation was made to neighbors, family and friends, serving as supporters in the management of T2DM.
Finally, the workshop generated the creation of a product, which was a cookbook, which will be used in the unit and in health promotion actions and distributed to diabetic and family users, with recipes from professionals and workshop participants.
It is concluded that the workshop was an important tool for improving the lives of diabetic users and that its creation was successful given the pre-existing bond between them, since most of them were neighbors and registered in the family health team that runs the "Sweetness Group". They are responsible for their health monitoring.
It is believed that the frequency of the meetings and the responsibility of the professionals involved were also decisive in joining the talent workshop and, consequently, in consolidating the frequency with the Health Unit activities.
Thus, the artistic approach is a valuable resource for health professionals when used for health promotion.
It is hoped that this report can contribute by encouraging other professionals and Health Units to promote similar activities with diabetic users, thus reducing the risk of such frequent readmissions among these users.