Analysis of integrative and complementary therapies applied by health teams in Primary Care

Introduction: Integrative and complementary therapies are being increasingly sought after in the field of health by the general population almost all over the world and, in Brazil, it is no different. Therefore, this research aimed to identify the integrative and complementary therapies used by health teams in Primary Care, after the publication of the National Policy on Integrative and Complementary Practices, and to verify the role of Nursing in the use of therapies. Materials and Methods: Exploratory-descriptive research, with a qualitative character. This is a bibliographical review with scientific articles published from 2008 to 2018, by consulting the Lilacs, Scielo and Capes databases. It was found 11 articles related to the topic. Results and Discussion: It was possible to perceive the constant search for comprehensive care by health professionals to identify and meet the real needs of users who seek the service, using integrative and complementary therapies. Conclusion: This research identified the need to strengthen the work process in health teams so that it has attended to seek a re-evaluation to keep the actions taken under discussion so that its essence is not lost, including the necessary steps to take advantage of therapies in its entirety.


Introduction
With the emergence of new technologies in the health area, such as monitoring devices, tests and medicines, we notice the constant search for techniques that approach the cure and disregard the disease as part of the human being. With this, the humanization in the care of the individual, tries to rescue him as a being who needs the union of mind, body, and environment in balance (Rodrigues et al., 2009;Stroschein, de Aguiar Cicolella, & Serra, 2018). Nursing cannot be oblivious to technological advances in health and should be much more concerned than just saving lives. Because it has frequent interaction with a diverse population, it is necessary to understand that each person has their own experiences and beliefs (Figueiredo & Tonimi, 2011).
In this context, integrative and complementary therapies have been increasingly sought after by the population, but their application in primary care has been devalued by professionals, as well as little used by nurses in health care. It is noteworthy that the application of these therapies was perform by professionals who, in most cases, are not in the health area (Stroschein, de Aguiar Cicolella, & Serra, 2018). For this reason, the Ministry of Health (MS) created on May 3, 2006, the National Policy on Integrative and Complementary Practices (NPICP) in the Unified Health System (UHS). Its role is to work with the promotion, maintenance, health recovery and disease prevention based on humanized health care and focused on the individual's integrality to contribute to the strengthening of UHS principles (da Costa Andres et al., 2020;Brasil & Ministério da Saúde, 2006).
In the Health Area, the traditional Biomedical model provides care to human beings in a fragmented way. The individual's body has been seeing as a complex machine, with parts that interrelate and when they present some defect, one can intervene to fix it physically or chemically. This model works in a mechanistic, technical, and specialized way, in which the focus is on the individual's illness, recovery and rehabilitation. With these new approaches applied to health care, regarding the issue of the individual's illness and the ways to intervene in it, one can think about the importance of humanization of care and the expanded clinic. It aims to give autonomy to users, maintaining a relationship between subjects, always keeping them influenced by the social history and the psychic characteristics of the subject involved (Melo et al., 2013).
It is worth highlighting the importance of thinking about health care that offers a holistic view of the individual in a situation of the health-disease process. It considers all their contexts, such as the social, cultural, emotional, among others, and not the disease, as in the model traditional biomedical. For these practices, the body consists of an indivisible system, integrating the physical, psychological, and social system, as well as other issues that are related to the individual's context must be considered (Salles & Silva, 2011). However, Integrative and Complementary Practices (ICPs) do not devalue the Traditional Biomedical Model, by avoiding and alleviating people's pain and suffering, but as a way that the professional approaches to expand the forms of treatment and promotion of health, when considering the user's lifestyle, social relationships, and emotions. From this, there are possibilities for the professional to see the individual, filling the gap left by the traditional model (Ceolin et al., 2009;Freitag, 2020).
It is important to note that the NPICP provides guidelines for the structuring and the strengthening of ICP in the UHS as well as the development of ICP qualification strategies for HUS professionals in accordance with the principles and guidelines established for continuing education, dissemination, and information on basic PIC knowledge for health professionals, managers, and users. This must consider participatory methodologies and popular and traditional knowledge as well as strengthening social participation, ensuring access to other strategic inputs, among other possibilities (Brasil & Ministério da Saúde, 2006).
With the implementation of the NPICP, several professionals, especially nurses, contributed to the health landscape that has been changing through research that gives another meaning, with the various integrative and complementary practices, applying them in comprehensive care to the user (Salles & Silva, 2011). The use of these practices is challenging because it breaks with the traditional model and presents other perspectives for health care that go beyond illness. In addition, other approaches and ways of thinking are required that require the willingness to build paradigms that broaden perceptions, perceiving and acting both at the micro and macro levels of the interaction between human beings and the universe in which they inhabit.
The health team in Primary Care potentially has the tools to apply integrative and complementary therapies, as they work directly in the communities, knowing closely the reality and living conditions of UHS users, adapting, and directing this care (Stroschein, de Aguiar Cicolella, & Serra, 2018). With this, the question arises about what would be the main integrative and complementary therapies that have been use by health teams after the publication of the NPICP. This study is justified because it believes that there is little knowledge and study of nursing in the use of integrative and complementary therapies in Primary Care.
The fact is that many Nursing students do not encounter these possibilities of care, which are integrative and complementary therapies, as well as there are no competitions for hiring professionals specialized in this area (Stroschein, de Aguiar Cicolella, & Serra, 2018). The NPICP in UHS provides legal support for the use of therapies, but there is little interest on the part of health professionals in knowing them, as well as in using them. It has noticed that many faculties do not have disciplines in their curriculum that deal with integrative and complementary therapies, thus, the dissemination to health professionals in the use of these therapies in health care becomes fragile.
Demand in demand for these therapies is increasing. Thus, this research intended to contribute to the expansion of knowledge of health professionals working in Primary Care, about the use of these therapies, enabling new discussions on these practices, which can increase the interest of professionals in using them in health care. Based on these premises, the general objective of this study was to promote a reflection on the integrative and complementary therapies used by health teams in Primary Care after the publication of the PNPIC and by the role of nursing, more specifically.

Methodology
This is a literature review, exploratory-descriptive research with a qualitative character. The bibliographic review was developed from documents already prepared and published, such as books, articles, theses, scientific monographs, allowing the theoretical construction of new knowledge related to the topic that one wants to know (Gil, 2008). This method studies the history of beliefs, perceptions and opinions produced and interpreted by humans regarding the constructions of themselves, how they feel and think. It also allows for the discovery of little-known social processes, providing the construction of new approaches and new concepts related to groups (Minayo, Hartz, & Buss, 2000;Minayo, 2010). Research, Society andDevelopment, v. 10, n. 15, e222101522842, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i15.22842 The purpose of exploratory research is to develop, clarify and modify concepts and ideas. The objective of this type of research is to provide the greatest insight that one can have of a fact that is normally little explored. Descriptive research, on the other hand, seeks to describe the characteristics of a population, phenomenon or establish relationships between variables.
Included in these surveys are those that seek to identify opinions, attitudes and beliefs of a given population (Gil, 2006).
The search carried out in the BDENF, CAPES, SCIELO, LILACS and Google Scholar databases, with articles published since the PNPIC publication, that is, in the last ten years. Inclusion criteria were included scientific articles, written in Portuguese and available in full online. The exclusion criteria observed paid articles, articles whose access links present a problem in any publication, such as theses, dissertations, books, course conclusion works, protocols and primary care notebooks and newspapers.
The descriptors used were complementary therapies, Primary Care and Nursing. Then, the titles were select, and the abstracts have read to choose the articles that address the research question. During data collection for careful reading, 55 articles found, by crossing the descriptors, five of them from LILACS, six from SciELO and none from Capes. Ethical aspects were respected as all authors of the works used in the research were referenced, following the norms of the Brazilian Association of Technical Norms (ABNT).

Results
The healthcare paradigm has undergone major changes over the years. Before, we had a hospital-centric model, where the focus was only on the disease, with a mechanistic and reductionist practice. Thus, the individual was dividing into parts that were study separately, with only the transmission of knowledge seeking to prevent and cure diseases. This paradigm began to make room for a new health care model, as it no longer met the needs of individuals or the scientific community. In this context, a new look at care began to emerge, where the individual became the focus of health care, in a unique way, enabling them to act and produce their own health, that is, having their autonomy and building together with the professional, their health care (Ramos et al., 2013).
In Brazil, several nomenclatures were emerging for unconventional practices. At the beginning of its appearance, the term used was alternative medicine, but over the years, the word medicine was replaced by therapy or practice, the same happening with alternative which was replaced by complementary or integrative. The use of the term integrative seems to be more appropriate to these practices, as its rediscovery came to expand the therapeutic resources used by conventional medicine. It is important to note that it is not just a change of term, but a change in the concept of health, as the complementation and integration of therapeutic models broadens the vision of care for the individual who has seen as an indivisible being who needs a comprehensive care.
It is noteworthy that the search for integrative and complementary therapies by users has stimulated by factors such as stress, anxiety, economic situation, aesthetics, diseases, and their symptoms. People seek quality of life and treatments that meet their needs both in the physical, social, and psychological spheres, as well as in other areas (Rosa & Soares, 2010).
Practices within integrative and complementary therapies include Reiki, acupuncture, massage, music therapy, aromatherapy, herbal medicine, Therapeutic Touch, among others. However, each one works the individual differently, but all seek to emphasize prevention and health promotion, using the most natural treatment possible (Salles & Silva, 2011).
It is natural condition that what comes from nature as leaves, roots and plants that have used as a form of natural treatment, as opposed to what is produced in the laboratory synthetically, which uses artificial chemicals and products. The elements of nature are seen as healthy, that is, not harmful to health and that they act according to the rhythm of nature, if they are applied correctly (Monteiro & Iriart, 2007). The Ministry of Health, seeking to meet the needs of using practices that were already been developed in the health care network, with the NPICP, incorporated the following therapies in primary care: Research, Society and Development, v. 10, n. 15, e222101522842, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i15.22842 Traditional Chinese Medicine -acupuncture, homeopathy, medicinal plants and phytotherapy, anthroposophical medicine and thermalism-crenotherapy (Brasil & Ministério da Saúde, 2006).
Traditional Chinese Medicine consists of an Integral Medical System that uses languages that deal with the laws of nature, valuing the harmonious interrelationship between the parts that seeks integrity. It has based on the Yin-Yang Theory, which deals with the division of the World into two forces, interpreting phenomena in complementary opposites with the aim of balancing these two means. On the other hand, thermalism and crenotherapy use mineral waters in different ways, with therapeutic purpose, complementing the other treatments. Anthroposophical medicine also presents itself as a complementary medical-therapeutic approach that seeks comprehensive care. This model was organizing in a transdisciplinary way and, in addition, uses homeopathic, herbal and some specific anthroposophical medicines. (Brasil & Ministério da Saúde, 2006).
The main objective of integrative and complementary therapies is to re-establish or expand the health of the individual in a situation of illness. It is important to know about the practices used, both for their differentiation and for their correct use (Rosa & Soares, 2010

Concept Efeccts
Reiki It is the activation of the natural direction and application of Universal Vital Energy, promoting complete energy balance. This method of healing has performed by laying on of Hands.
Aligns the energy in the body-emotion-mind-spirit dynamic, acting on energy blocks. It stimulates the body to balance itself through the immune system, improves the will power to change habits, signs of relief and symptoms of some diseases.

Massage
It is the manual manipulation of the body's soft tissues, through friction, percussion, kneading, rolling and pressure at specific points.
They act on the nervous, muscular, respiratory system and on blood and lymphatic circulation. Produces relaxation, relief from pain, reduces edema, among others.

Phytotherapy
It is any plant that, when applied in a therapeutic form, can cause a pharmacological effect. It is a practice arising from the know popular.

Homeopathy
Homeopathy, a complex medical system with a holistic character. It uses natural substances from the kingdom mineral, vegetable, and animal.
Substances capable of causing effects in an organism can also cure similar effects to these in a sick organism. Acupuncture A set of procedures with insertion of metallic filiform needles that allow the precise stimulation of defined anatomical sites.
They act in pain control, against insomnia, nausea control, emotional stress, energy deficiency, hypertension, anxiety, and obesity, among others. Auriculotherapy Auriculotherapy has been used to normalize body dysfunctions through stimulation of ear points, promoting energy balance. Some methods used as ear treatment are ear massage, seed pressure and ear bleeding, among others.
They act on various symptoms of pain, endocrine diseases, against insomnia, nausea control, emotional stress, energy deficiency, hypertension, anxiety, and obesity, among others.
Floral therapy It is the use of flower essences, prepared from the solar infusion of wildflowers in containers with water. It has a Vibrational nature incorporated from drops specific energy patterns of flowers.
They act as catalysts in negative spiritual, emotional, and mental states, in addition to helping to develop intuitive skills, aligning our emotional, mental, and spiritual bodies.

Chromotherapy
It is healing through colors. Every color influence body. The purpose of this technique is to strengthen and purify every color in a person's aura. Colors are applied through colored lights, light boxes, glass etc.
The use of colors restores balance. Each color is responsible for an action, for example, yellow reduces inflammation and pain.

Iridology
It is the study of the iris, in which we can identify physical, emotional, and mental aspects of the individual. In addition to discoloration, the iris can reveal pathological disorders through of abnormal lines and points.
It identifies developing disorders early so it can intervene before they develop into the disease.
Research, Society and Development, v. 10, n. 15, e222101522842, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i15.22842 6 Primary Care is understood as the always open gateway into the Health System, decentralizing the service, making it as close as possible to the individual, families, and communities, promoting their participation in the health-disease process, as well as involving sharing their knowledge between user and professional (Santos & Miranda, 2007). In Brazil, Primary Care based on the principle of universality, equity, accessibility, integrality, continuity of care, bounding, humanization and social participation. Its performance has characterized by a set of actions for health promotion and protection, disease prevention, diagnosis, treatment, and rehabilitation, developing comprehensive care are their impact in the health-disease process and people's autonomy (Brasil & Ministério da Saúde, 2012). The search found 11 articles related to the topic that met the selected criteria, which correspond to publications in the last ten years, in Portuguese. The Table 2 presents these selected articles to answer the questions of this research.  During the data collection phase of the research, numerous articles related to integrative and complementary therapies applied in the hospital environment was find. However, as the focus of the research is the application of therapies in Primary Care, and it was decided to exclude articles that addressed this topic. After obtaining the results, it sought to answer the guiding questions of this research by reading the articles. For this work, it was identified that many integrative and complementary therapies come from popular knowledge. It is believed that this may be determining factor for some being more sought then anothers. The most used therapies or at least the most reported in the articles that were part of this research are acupuncture, homeopathy, phytotherapy (herbal medicine) and color therapy. It is noteworthy that herbal medicine appears in five of the articles selected for this research.

Discussion
Regarding the choice of a therapeutic treatment, it was possible to verify that it was influence by cultural knowledge, past experiences, and problems with modern allopathic medicines. It includes family traditions that pass from generation to generation and may undergo some modifications according to experiences of each. (Rosa & Soares, 2010). As they have seen, each of these therapies has its particularities, which allows us to understand why they has used separately or together. All have in common to provide the user's well-being, promoting their emotional, spiritual, physical, psychological, social, and environmental balance, acting in an integral way. In addition, these therapies seek to develop the user's self-knowledge, strengthening the active person in the health care process.
Integrative and complementary therapies seek to reestablish the individual in an integral way, treating him in his entirety. The healing process in therapies consists of a greater involvement of the user with their own treatment, where they must make time to take care of themselves, promoting their results that are often not immediate, but are part of this healing process (Salles & Silva, 2011). It believes that the cure through therapies consists of a process of self-knowledge in which the individuals must perceive themselves and seek to get involved with the treatment that was propose, expressing events that often do not seem to be the cause of their problem, but they are of extreme importance for restoring the balance in that body.
Several factors encourage the search for integrative and complementary practices, such as the knowledge that Traditional Medicine is deficient in some aspect, the high cost of medicines, less harm potential, increased life expectancy, among others (Otani & Barros, 2011). Because these treatments are more natural, if used correctly, they end up not having harmful side effects like most allopathic medications. As the population seeks a better quality of life, interest in integrative and complementary therapies has increased, and the cost is not high. However, it is noteworthy that the term complementary, from integrative and complementary therapies, comes to complete the treatment that was designate by the health professional.
Integrative and complementary therapies seek to make the user feel the subject of the action being proposed, thus strengthening the professional's bond with the user, seeking simple therapeutic means with the possibility of strengthening their autonomy, providing greater control over their body and treatment (Melo et al., 2013). It should be noted that therapies bring the health professional only as a facilitator in the health care process, with the responsibility to discuss with the user ways of caring, so that he/she finds devices to understand their health process-disease. However, it is up to the user to try to understand that the professional provides ways that approach to establish the balance of their body. However, the results will depend on their commitment to the proposed treatment, that is, it is necessary to follow the guidelines given by the health professional and understand that therapies work together with self-care to have the expected result.
Integrative and complementary therapies, in their treatment process, seek to restore the user's self-esteem and selfconfidence, rescue their identity, expand the perception of their problems and possibilities for solutions, strengthen family and social ties, so that the users see in themselves the potential to overcome their difficulties in life (Cordeiro et al., 2011;de Oliveira et al., 2020). It is believed that for the treatment to have a better result, it is necessary for the user to see its potential, but for that, it is necessary for him to meet what is causing the problem so that he can understand the ways to solve it. As well as it is necessary for professionals who work with integrative and complementary practices to create therapeutic devices to help everyone in coping with problems, based on singularity.
Bonding is a relationship of respect created between people, through solidarity, listening, care, help and love. The health professional and user bond favor the user's participation in care, increasing the effectiveness of health actions ( Ilha et al., 2014). It is believed that there is a possibility that this link may be confused by the user, and that this professional may be seen as the only person who provides them with welcoming listening, thus being able to develop a dependency on the team, making it difficult for the patient to be discharged to treatment.
Welcoming listening extends the listening time of professionals and enhances the users' speech space, where they express their feelings of insecurity, stress, loss, abandonment, material, and emotional needs, thus generating a strong bond between professional and user (Sá et al., 2012). It is believed that welcoming listening enables the strengthening of the professional and user bond. From the moment, when health care begins, based on the individual's need, and not with an exclusive focus on the disease, there are possibilities for the professional to approach integrality.
Continuing Health Education allows the exchange of knowledge among the team, through the problematization methodology. There is an appreciation of the knowledge of each professional in training in the work process, providing the formulation of new actions in health care and expanding the transformation of practices. This educational process provides that there is a dialogue between professionals through which the exchange of knowledge and knowledge takes place, focusing on the construction of their actions in health care in a humanized way. This seeks to establish bonds with the community, strengthening the reception in the service and providing the participation of all health professionals in this construction (Weigelt et al., 2015).
During the research, it was notice that many professionals do not have the formal knowledge for the applicability of the therapies. For this reason, training in integrative and complementary practices is very important, as theoretical, and practical foundations are necessary for the use of complementary methods safely, effectively and with quality (Salles & Silva, 2011). It is noteworthy that the scarcity of studies on the use of these Practices in Health Services reinforces the need for research addressing this issue (Santo et al., 2012). It was also notice that to have an integral work with the user, it is necessary to see the individual in all its dimensions. Therefore, there is a need to have an interdisciplinary team where health professionals from different areas work with the objective that is the treatment of the user.
Integrative and complementary therapies work with an interdisciplinary health team, with several health professionals specialized in different fields, within the same scenario, exchanging knowledge by promoting a unitary action in the face of an exposed problem that covers the human being, thus replacing the conception fragmented, expanding the work process of the health team (de Oliveira et al., 2011). A team that has professionals from different areas increases the probability of meeting demands incorporates several important knowledge and practices so that an integral and resolute approach can be took (Santo et al., 2012).
It is possible to note that the participation and involvement of more than one area in the health field is necessary to be able to provide comprehensive care to the user. With this, it finds the need for efficient communication, as the Nurse, despite being at the front of the community, does not work alone, but with an interdisciplinary team. This team can ensure the identification of problems that present themselves collectively and/or individually, planning care that is appropriate and effective in that situation (Santos & Bernardes, 2010).

Conclusion
For integrative and complementary therapies to be use in their entirety of action, the need for professionals that were train in some of these practices was realized to understand what is intrinsic in the health care process proposed by integrative and complementary. This research reveals the need to strengthen the work process carried out with the teams, so that the work carried out by them can continued. Along with the potential, we identified some difficulties reported in the articles, such as the avoidance of treatment when the user shows improvement, the user's dependence on the use and the resistance to carry out the care process in its entirety.
It is noteworthy that the therapies do not act alone, as they need the active subject who also has responsibilities for their treatment and needs to be committed to their health care process, that is, for therapies to have the expected result, it is necessary to have user participation. In Health Care Services, the uniqueness of each therapy was identified and that these were choose from the weaknesses presented, focusing on the user and not the disease. These therapies have used by Primary Care Professionals in a unique way or are associated with each other.
This research provided knowledge of the reality of services that use integrative and complementary therapies in their daily work, including the steps necessary to take advantage of the therapies in their entirety. However, there is a need to carry out more work in the use of these practices in the hospital environment and in Primary Care, so that it is possible to eliminate prejudices that still exist in these work environments. Therefore, it is necessary to encourage health professionals to employ these activities in their daily lives, adding content about therapies during their training, as well as carrying out research activities on the verified benefits that should be disseminate in new academic studies on that topic.
For future research, it is necessary to think about how these integrative and complementary practices can help and change the lives of users who have a chronic disease.