Introduction

The World Health Organization (WHO) defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. While most would agree with this definition, it is also true that the social dimension of this model has also gained other, deeper meanings, and it has gained prominence in the analysis of health issues. Health in our current society is intrinsically linked to the socio-politic-cultural-economic reality that surrounds it. Therefore, health can be understood as the ability that people have to develop in the world, in a specific reality and in a particular historical moment.ⁱ

Additionally, each country's Healthcare System is understood as a part of politics, for it bears a responsibility to answer to social inequality, an obligation that is assumed as a professional and ethical commitment to people's health and the progress of society.ⁱⁱ

In the social setting that this research is contextualized in, the political dimension acquires especial relevance, and hence an understanding of the process for independence of Catalonia is key. Popularly known as the Procés, it has reached the present day as a sequence of events that have developed since 2012 with the goal of achieving self-determination of Catalonia and independence from Spain. One of the key moments that frames this study occurred on the 1^st of October of 2017 (known from then on as the 1-O), when a referendum for self-determination was held. It had been declared outside of state law by the regional government, the Generalitat de Catalunya, and took place in a climate of maximum social tension. The events led to the State intervening in the institutions of self-government of Catalonia and taking subsequent legal measures against its organizers, proceedings that have generated an intense social response.^iii-5

The political situation that unfolded in Catalonia in the months from October to December of 2017 befits a thorough analysis in relation to the repercussion it has had on public health. Previous to these events, Barcelona lived the traumatic experience of a terrorist attack. As primary health nurses whose domain contains Las Ramblas where the incident occurred, we have seen many of our patients suffer the shock of enduring such traumatic events. It seemed that the city in general, and the Raval district in particular, were recovering, thanks to quick social action, when further moments of tension and threat arose during the referendum of the 1^st of October 2017. During patients' visits to the nursing offices in the Raval Healthcare Center, references were made to the events and people explained how they were affecting them.

One of the reasons that prompted us to conduct this research was to identify the political process as a social determinant that was affecting people's health. Medicalizing symptoms such as insomnia, high blood pressure, severe headaches, dizziness, fears, and anxiety, which had appeared as an adaptive response to the ongoing political situation was, from our point of view, a way of providing an individual solution to a collective problem. This is a commonplace response in the face of many other health problems that are neither a disease (a biological condition) nor an illness (the subjective perspective that a patient has of a disease).⁶

Knowing how people face this crisis and other situations at a macro level (economic crises, social vulnerability, etc.) also justified our interest in carrying out the study.⁷ Giving patients a voice so that the nurse can integrate the most qualitative aspects of their environment into their care becomes fundamental when it comes to incorporating sociocultural factors into nursing practices. Knowing the context in which the health-disease process takes place, as well as the patient's own perception of their own experience is fundamental to offer comprehensive and quality healthcare.⁸,⁹

Therefore, this study aims to analyze the perception of people in relation to the repercussion of the political crisis experienced during the process of independence in Catalonia on their health and their coping mechanisms.

Methodology

This is a phenomenological qualitative study, in which the data collection was carried out by means of a semi-structured interview that relied on a prepared script, shown in Table 1. Interviews were conducted during the months of February to March 2018. After presenting the study to the participants and obtaining their consent, the meeting was arranged in the units of the Healthcare Center, a place that favored both confidentiality and spontaneity, and it also guaranteed a clear audio recording. The interview lasted approximately one hour. It was carried out individually, as it favored the emergence of different issues and allowed to delve into the aspects which proved relevant to the aims of the study. The interviews were later transcribed word for word.

The scope of the study was limited to the Dr. Lluís Sayé Raval Nord Healthcare Center. The population we deal with belong to low socioeconomic groups and has one of the lowest health rates in Barcelona, according to data from the Statistical Institute of Catalonia. Five patients participated in the study, who were chosen exclusively on the grounds that they had spontaneously verbalized feelings of unwellness related to the political context during their visits in October to December 2017.

The exploratory nature of the study allowed for categories of analysis to arise which are fundamental in order to understand the problem at hand, although the reduced sample of subjects did not grant the saturation of the data. A wider sample would likely increase the diversity of informants' discourses, taking into account the polarities that the events have created in the population. However, we considered that a larger sample would not substantially alter the analysis scheme of the study.

Both the collection of data, as well as its interpretation and analysis, were carried out by triangulation. All the researchers in the study interpreted the data. The different topics that arose in the first analysis were analyzed in pairs. The nature and meaning of the issues were contrasted with some of the participants to ensure their credibility. The transferability of the interview was addressed through the use of direct quotations in the presentation of the results.

The audio interviews were transcribed word for word. Each interview was read several times by the researcher who conducted it, in order to identify the main issues. Classification and codification followed. No previously designed system was used, as it became a mostly inductive process carried out by the researchers. Finally, the objective of the study was met by describing the discomfort and coping mechanisms that patients had showed during the political crisis in Catalonia as a consequence of the process for independence of 2017. The software Weft-QDA was used for the analysis of qualitative data.

All participants were briefed about the study viva voce and in writing. To meet the privacy and confidentiality criteria, an informed consent was requested from the patients as was their approval for the recording of the interviews. Confidentiality was kept at all times in the handling of the data.

Results

Five patients were interviewed, three women and two men with an average of 75,4 years of age (the oldest was 85 and the youngest 62) whose profiles are described in Table 2.

In terms of the participants' perception of the impact of the political crisis on their health, the following issues have been identified: emotional discomfort, physical discomfort, causes of the discomfort, coping mechanisms and identity.

One of the participants used Spanish during the interview, the rest spoke Catalan. Below, we have included excerpts from the interviews translated into Spanish (in the annex to the digital edition we provide the literal transcription of the most representative excerpts of the interviews).

Emotional discomfort. All informants except one expressed some kind of emotional discomfort during the months of October to December 2017. They expressed subjective sensations in the form of unspecific symptoms that according to them were affecting their quality of life in different spheres: physically, socially and emotionally. They felt threatened by external stressors and identified that the beginning of their discomfort had coincided with the events around 1-O and the ensuing political events. They related these feelings of discomfort to different aspects of themselves and their interpretation of the world, their culture, and their social and family network. Below are some of the excerpts from interviews which display negative emotions:

Anxiety: "I suffer from a lot of anxiety" (E2); "I can't do much and I'm very worried" (E4).

Anger: "It makes your blood boil!" (E2); "I watch the news every day and I see so many lies" (E5).

Fear: "I wasn't scared. And I wasn't, I was terrified" (E3).

Sadness: "only thinking about it makes me want to cry" (E4); "I'm sad rather than scared" (E3); "if you can feel anything at all, you're bound to feel sorry about what's going on" (E5).

Physical discomfort. All participants are diagnosed with one or more chronic illnesses that are continuously monitored at the Healthcare Center. The period of October to December 2017 saw an increase in spontaneous consultations for acute physical symptoms, which in all cases were explicitly related to the sociopolitical environment and the impact it was having on the patients' lives. The physical problems that interviewees expressed during the consultations, which they later noted during the interviews, were the following:

Insomnia: "It affects my sleep" (E2).

High blood pressure: "Sometimes, at the chemist, they'll ask me, 'would you like to check your blood pressure?' and I say, 'No, no.' I say no because I'm sure it's going to be high" (E5).

Severe headaches: "I felt like sometimes my head hurts from talking so much about the same thing, in the end I feel like my head is going to explode" (E1).

Panic attacks: "(...) and one day I had a panic attack" (E3).

Causes of discomfort. In the speech of the interviewees, the causes of their discomfort emerge. They identify the events that took place after the 1-O referendum and the 1-O referendum itself as the main trigger of their discomfort. Two of the participants describe their personal experience on the day of the referendum when they went to vote, by expressing the uncertainty caused by the process; the mistrust generated by the Catalan and Spanish institutions, the decisions that were taken and they do not share; and the aggressiveness that security forces of the state used against the people.

In older people, feelings come to the surface that remind them of the Franco era, a period when both in Catalonia and in the rest of Spain democratic freedom was lost, political parties were persecuted and banned and Catalan's status as an official language was abolished. In their discourse, they also express the frustration and impotence that some manifest by not being able to do anything due to their physical limitations. A general feeling of indignation and incomprehension of what happened during the 1-O is detected.

Aggressiveness: "(...) the state's reaction was so brutal and so ruthless against the people" (E2).

Uncertainty: "this is definitely not over yet! (E4); "You can't see the way we will go it's a huge problem" (E2).

Frustration and mistrust: "and they applied bloody article 155 of the Constitution, and I won't forgive them for that, for the pain they've caused Catalonia" (E5); "If I was 40 or 45 I'd be on the streets with everyone else, but it's impossible for me, it's impossible and I'd never felt as bad as I feel now" (E4); "Yes, of course they're not criminals, they're political prisoners and they won't let them out" (E5); "Treason and sedition, are only applied during time of war, but in times of peace?" (E5); "They can do whatever they want and that's what they're doing, exactly what they're doing, you've fought and you've done, you've been to demonstrations and in the end they do what they want. They've got their jobs... and you think 'they're all the same, they do what they want,' and why do you have to worry about them if they don't worry about us" (E1).

Coping mechanisms. The participants expressed different efforts, both cognitive and behavioral, to manage stress and respond to different internal and external demands, as well as the conflicts that arose between the two. The main differences in the types of coping were perceived according to their personality, their immediate context and their own personal situation. Four types of coping mechanisms were found during the analysis of the interviews:

1) Implication in the process, be it by taking part in demonstrations or by trying to keep up with new developments at all times: "I've actively taken part in all the mobilizations that there's been to support the process for independence and in protest for the political prisoners" (E2); "I follow the news well, I watch it on TV and read the papers; sometimes I'll buy two or three newspapers" (E5); "I go to bed very late because I'm watching the news, (...) we banged our pots and pans for the cassolada because I couldn't do much more, at least we went out and did something!" (E4).

2) Socialization or desire for social support by engaging in mobilizations in order to feel part of a group: "I've been to a lot of places where we didn't go before, and now I do" (E5).

3) Avoidance: "No, I don't watch TV (...), I steer clear of the subject, (...). That's why I'm one of those who've stepped aside" (E1).

4) Resignation: "No, I think we've just got to accept it. Well, but you feel sorry, you feel sorry and more so with your own family. You can't talk about a lot of things, but you know how it is, we're different and that's all right, but we've always respected each other" (E3). "I just don't know anymore; may God's will be done!" (E4).

Identity. As they talk, the participants reference their origins and that of their families, the places where they have lived, their education, the use they have made of their languages, both Catalan and Spanish. They also discuss different historical and political moments that have shaped their system of values and symbols which they use to decode and confront life. They express the synthesis of their values and behaviors that the different media to which they belong transmit, values which they integrate according to their individual characteristics and their own life trajectory. Identity contributes to a person's psychic balance: on the one hand, it helps to hold a positive view of oneself and to create sense and meaning; on the other hand, it allows one to adapt to the environment and to the changes that take place in it.

In their interviews, they try to give an answer to what is happening in the present moment, taking past events as reference. In their discourse there are examples of how identity is defined in relation to others, either by similarities or differences. One of the participants expresses his feeling of identity by justifying himself in his life trajectory from birth. They talk about relationships with their families and friends, as well as the supposed values that each one attributes to the current political conflict.

Elements of identity such as beliefs and values were observed in this category. During their stories, elements related to historical heritage, family history and language also emerged.

Historical heritage, values and beliefs: "The Spanish oligarchy doesn't negotiate. We saw it with Cuba, with the Philippines, in Morocco they didn't want to negotiate with those Berbers either, we've seen it over and over" (E2); "This phobia towards Catalonia is nothing new, it's always been there! My father, God rest his soul, suffered it terribly" (E4); "It's a pity what they're doing in Catalonia, because Catalonia has always been a welcoming place" (E5).

Family history: "I was born in Murcia, I was, I was born in Murcia, I came here when I was one (...). My sympathies lie here in Catalunya. I don't deny my roots, I don't, but I feel Catalan all over, I don't know how to say it. And what's been done here, it's not that big a deal" (E5); "I've had family come here to work who've left singing the praises of this place and now they're back at the village, they respect Barcelona, and they respect it" (E4).

Discussion

The results show that the profile of the participants is that of a fragile population group, with multiple pathologies; in other words, regular patients of the CAP. This favors the sharing of concerns that have been collected in the study and that the results show. The people interviewed start to feel emotional discomfort and feelings of unwellness that are associated with the political process which was experienced in Catalonia during the months of October to December 2017. The team that treated the victims of police violence of the Barcelona City Council wrote a report that collects similar results. The qualitative analysis of the report based on 65 cases identifies that feelings of anger, impotence, fear and sadness are present in the people who have used the support services for victims. These feelings result in a generalized distrust towards public institutions that the participants of our study also manifest. The symptoms that we collect as physical discomfort probably respond to cases of anxiety and stress, as the report also points out.¹⁰ Regarding the causes of the feelings of unwellness, the informants make reference above all to the uncertainty and mistrust in political institutions, both Catalan and Spanish. According to Lazarus and Folkman, there are no universally effective or ineffective management strategies, since it depends on the situation, the person or the type of threat.¹¹,¹² Within this framework we observe two types of coping mechanisms: on the one hand, avoidance and resignation behaviors which are more focused on emotion and aimed at reducing the degree of discomfort; on the other, those aimed at taking a more active role, such as socialization and involvement, seeking to feel part of a group.

Likewise, theoreticians like B. Neuman indicate that from primary prevention, professionals can have an impact on the reduction of stressors in people or on reinforcing the individual when facing the stressor.¹³,¹⁴ Nurses often work with people whose values and priorities might be different from theirs. Collière points out that caring for a person implies recognizing their cultural values, beliefs and convictions. The person recognizes the influence of their environment on them and evolves in the search for a quality of life that they will define according to their potential and priorities. Thus, health is a value and an experience that is lived according to the individual's perspective.¹⁵-¹⁸

The social and political factors that people live with determine changes in morbimortality patterns.¹⁹ Nowadays nurses develop their profession within the paradigm of transformation, in which it is essential to take into account the person within a new orientation of social openness in continuous relationship with a changing environment. Theorists such as Watson, Newman, Rogers and Parse are associated with this paradigm.²⁰ Nursing is therefore an intersubjective experience replete with feelings, emotions and uncertainties.²¹-²³

Conclusions

The participants perceive that their health has been affected by the political crisis that they experienced during the process of independence in Catalonia, which has motivated the activation of coping strategies to compensate for their feelings of unwellness. The social determinants of health become relevant and the political context is identified as the main stressor which affects different spheres of the patients' lives and their biopsychosocial health. The participants express different types of coping strategies according to their identity, values, beliefs, personality and their circumstances as an adaptive response to changes in the environment.

This study aims to contribute to the realization of a professional practice that exceeds the biomedical model of care. Sociocultural changes and related health problems require that health systems and other institutions adjust and that they facilitate this approach to professionals as well, which should ultimately lead to a transformation in the culture of this field. The social dimension and its perception are vital to the understanding of certain health situations in the current context. Integrating qualitative variables of the environment into nursing, as well as the perspective of individual experience, is key in order to gather a comprehensive vision of the person and all the dimensions of their health; it is an essential step to offer an effective and high-quality holistic care.