Profile and Social Assessment of Liver Transplant Candidates: A Retrospective Approach

Introduction: The complexity of liver transplantation requires a highly qualified team, in which the social worker plays a crucial role in analyzing and intervening in the social situation of candidates. Objectives: To investigate the social profile of liver transplant candidates and relate it to the interventions and reflections made during the social assessment at the Hospital de Base Liver Transplant Unit. Methods: Based on the records of the Social Work, the information of the candidates evaluated between January 2019 and December 2020 was analyzed. This quantitative-qualitative, retrospective, descriptive and documentary study, with participant observation, was conducted from a dialectical perspective. Results: During the data collection period, 174 evaluations were obtained. Social profile: Average age 55.8 years, predominantly male (N=116; 66.7%), with a partner (N=129; 74.1%), living in municipalities in the state of São Paulo (N=124; 71.3%), incomplete primary education (N=68; 39.1%), low level of education (N=65; 37.4%), inactive in the job market (N=151; 86.8%), accessing social security benefits (N=120; 69%), positive acceptance of the transplant (N=158; 90.8%), nuclear family (N=120; 69%), offer of care and family adherence (N=172; 98.9%), partial access to medication (N=122; 70.1%), ease of access to the transplant center (N=157; 90.2%), per person family income of 1\2 to 2 minimum wages (N=107; 61.5%) and satisfactory/conserved housing standard and state of repair (N=157; 90.3%). Conclusion: The social profile of greater social vulnerability required more interventions in most of the 25 variables assessed, providing important elements for identifying and meeting the social needs of each individual.


INTRODUCTION
Brazil is among the countries with the highest absolute number of liver transplants, specifically occupying fourth position, having performed a total of 2,044 procedures in 2021, behind India (2,847), China (5,822) and the United States (9,236).However, despite its leading position, the country is still far from meeting the total demand for transplants.In 2022, 2,118 liver transplants were carried out, while the estimated need was 5,254.In other words, only 40.2% of the demand was met. 1 Meeting this demand involves a central variable: organ donation.Despite the direct impact of the Covid-19 pandemic on donations, 1,2 rates have been increasing positively since the first half of 2023.For this increase to continue, attention needs to be paid to several important factors, such as the rate of medical contraindications for donation, an increase in family refusal of this process and adequate records of potential donors. 2 These figures from the Brazilian Organ Transplant Association (ABTO) 1,2 allow us to reiterate how complex and multifactorial this type of procedure is.
Still on the subject of the complexity of transplants, these procedures involve various health professionals.These agents assess and intervene in the risk factors that can impact on the success and adherence of candidates to treatment.With this in mind, as far as the Liver Transplant Unit team is concerned, the social worker has the role of identifying, analyzing and intervening in the social conditions that condition the candidate's life in relation to continued access to treatment.This professional directs actions that include the application of social assessments and interventions which, 3,4 in this context, relate to the issues of this research.
The social assessment consists of gathering information about the candidate's social profile.It includes sociodemographic variables, acceptability for transplantation, family dynamics, accessibility to the transplant center and socioeconomic conditions.This information is essential for formulating a social opinion, conducting and recording counseling sessions, talking to the transplant team and providing information tools to support the candidate. 4ogether with the profile survey, the particular needs that condition the candidate are identified, a process that makes it possible to articulate social interventions.In addition, what has been learned by the candidate and his or her affective-family network is also measured, which is essential for joint actions between the Social Work and these agents.The intervention with families is guided by strengthening bonds and encouraging protagonism in the production of health, 5 a process which involves the coresponsibility of the applicant and family for the treatment. 3his study demonstrates its relevance by providing sociodemographic, social security and occupational data, as well as helping to gain an in-depth understanding of the social profile of transplant candidates, which is a fundamental process for future research and mapping.This research can also support health professionals, as it can serve as a basis for developing reflections and strategies to meet the social needs of the population waiting for a transplant.
The objective of this research was to demonstrate the interface between the results of the social assessment of liver transplant aspirants and the analyses, positions and interventions of the Social Work regarding facilitating access to treatment.To this end, it was necessary to survey the social profile (sociodemographic, social security, occupational and attitudinal in relation to treatment) of aspirants assessed by the Social Work at the Liver Transplant Unit of the Hospital de Base de São José do Rio Preto, from January 2019 to December 2020.

METHOD
This study, which is quantitative-qualitative, 6 descriptive, 7 documental8 and associated with participant observation, 9 analyzed the results using a dialectical approach. 10In its retrospective approach, no human beings were directly involved since the data were obtained from the social assessment instruments in the files of the Social Work of the Liver Transplant Unit of the Hospital de Base de São José do Rio Preto.
The social evaluations that were analyzed in this study were carried out between January 2019 and December 2020, a total of 24 months. 4The selection of evaluations included all the candidates evaluated by the Social Work in this time frame, in other words, 100% of the candidates who started treatment at the Unit in the period reported.
Regarding the classifications used in the social assessment tool: 4 the individual level of education was determined based on the level of schooling; the occupational level according to the quality of insertion in the job market; the family model based on the individuals or group of families that lived with the aspirant.Also within this scope, the family typology of adherence was determined because of resolution or evasive responses from family members regarding the candidate's transplant.Family education level was determined by the education level of the family in question. 4icrosoft Excel and Google Spreadsheets were used to record the information on the social profile and the care provided, as well as to calculate and process the results.The quantitative results were presented in tables and subjected to descriptive statistical analysis.On the other hand, the qualitative results, which include information about the care provided and which respect the ethical principles of National Health Council Resolution 466/2012, were categorized in a dialectical manner to facilitate their description and analysis.

DISCUSSION
2][13][14][15][16][17][18][19] This incidence may be related to the fact that men are more affected by liver disease than women. 20This may be due to men seeking medical care late, which is possibly linked to gender determinations that put pressure on men to assume the position of family provider as a priority, which may lead them to neglect seeking health services. 21,22lso within this scope, the social worker works with multidisciplinary strategies aimed at dealing with the anguish and suffering 23 of the candidate.With an educational focus, as well as reinforcing the idea of transplantation as a right, the social worker also works to reflect on changing preconceived notions about treatment and self-care.These educational actions seek to deconstruct conceptions of the search for treatment and health services as supposedly synonymous with fragility or deviation from gender roles, such as the social imposition of the male figure as the family's absolute provider. 21,22s for the findings of candidates with a partner (N=129; 74.1%), they are in line with other studies (most > 60%). 12,14,15,19n addition to contributing to dialogue and communication between family and team, the presence of a partner is a positive and strategic factor both in terms of conveying information and in terms of family care and monitoring, which are fundamental dimensions of the treatment. 12In this context, the transplant social worker carries out a humanized process 5 of listening, dialogue and planning with families and candidates 23 so that family care does not become an overload for the partner.
The predominance of individuals from municipalities in the state of São Paulo (N=24; 71.3%) is similar to the findings of previous studies carried out in this Unit. 12,19This geographical emphasis is justified by the principles of regionalization and hierarchical distribution in the SUS, a structure that tends to absorb demands closer to the transplant centers due to the logistical factor.However, people from other states had access to the Unit (N=31, 17.8%) due to the principles of universality and comprehensiveness advocated in the Organic Health Law (LOA). 24In contrast, it is important to note that access to health care is still far from being exercised by the entire population, as shown below.
In association with the positions of the Social Work, this information makes it possible not only to identify the most suitable means of transportation but also to ascertain the degree of knowledge that the applicants and their families have about access to the rights of locomotion. 12With this, in addition to education about rights, the necessary transportation can also be articulated via Treatment Outside the Home (TFD, in Portuguese) and/or via assistance, both aimed at exercising the right to health. 24egarding schooling, the findings on aspirants with incomplete primary education (N=68; 39.1%) show proximity not only to other studies 12,16,19 but also in relation to surveys by the Brazilian Institute of Geography and Statistics (IBGE).According to the Institute, incomplete primary education in 2019 reached 32.2%, characterized as the highest educational rate in the aforementioned survey. 26The interface between education and health is fundamental, both in the context of the health conditioning factors and determinants emphasized by the LOA, 24 and in the field of conveying and assimilating strategic information that circumscribes the actions and guidelines of the transplant teams.
Individual education, in relation to the prominence of the low level (N=65; 37.4%), shows conformity with other studies 12,16,19 and with the data already mentioned the levels of education captured in Brazil by the National Household Sample Survey (PNAD).Considering that access to education influences the exercise of citizenship and social development, 26 the social worker is attentive to the individual's level of education, as this can indicate a greater or lesser need for educational actions or advice to convey rights. 5till within this scope, the level of individual education allows for a pedagogically personalized service, enabling the process of listening 18 and dialogue that is efficient, didactic and in line with the social conditions of each applicant and/or family member and Tabela 1. Continuation.
directed towards access to rights in a conscious and empowered manner.For example, in social security guidance, in legal terms, the progress of processes and even the use of digital platforms, such as "My INSS", 27 are subjected to a process of intelligibility based on the profile of the people served.The same is true of the TFD, as counter-referral reports, subsistence allowances, 25 the administration of appointments compatible with the family's reality, and other procedures are "decoded", applicants and their families access their rights and become active and aware 5 of the processes that condition them.
The quantitative prevalence of subjects in an inactive occupational condition (N=151; 86.8%), which is also similar in other studies, 12,[15][16][17][18][19] can be contextualized by the problem of the huge transplant queues of people suffering from serious and/or chronic illnesses. 2As a result of these illnesses, many people are affected by complications that lead to their absence from the job market.However, the candidate is also affected by national unemployment, which reached 8.7% in the third quarter of 2022, affecting a total of 9.5 million Brazilians. 28ecause of its impact on income, inactivity in the labor market directly affects the livelihood of many families. 12This situation is even worse when a family member has to restrict their professional activities to act as a caregiver and/or companion.Considering the various occupational structures and configurations, the social worker operates according to the specificities of the context involving the candidate and their family, with initiatives aimed at corroborating safe access to treatment. 5s for the predominance of regular occupational status (characterized by income and job stability) (N=77; 44.3%), this demonstrates a favorable character regarding transplant treatment, suggesting greater possibilities of access to social security benefits.However, despite being covered by social security, 27 it is clear that many candidates face obstacles such as a lack of information, excessive bureaucracy, and delays in analysis deadlines, among others, to gain access to these benefits.
The prominence of the Catholic religion (N=109; 62.64%) is in line with the Datafolha Institute survey, in which the largest portion of the Brazilian population was identified as Catholic (50%±2%). 29This variable, as a phenomenon that articulates religiosities and spiritualities, can play a relevant role in the social context of treatment.Religiosity can have a beneficial effect on an individual's mental and physical health, helping them to accept and adopt healthy habits, 30 which is important at all stages of transplant treatment.
In this sense, attention must also be paid to ethical and religious factors, as they may require the transplant to be replanned.For example, the procedure with Jehovah's Witnesses (who do not adhere to blood transfusion) requires hematological preparation of the individual and, intraoperatively, technologies to reduce blood loss, which allows access to treatment without violating these ethical issues. 31Therefore, through qualified listening, dialog,18 and respect for the religious plurality of individuals, including those who choose not to start or continue with transplant treatment, the social work professional can understand the religious conceptions of the candidate and their family, articulating a positive interface between treatment and spirituality. 30he prominence of candidates with access to social security benefits (N=120; 69%) is in line with previous research. 12,19n general, these benefits represent a crucial source of income for the subsistence of individuals and their families, especially in the context of the (already) mentioned transplant queues, 1 a scenario in which it is notable that many people are unable to work due to chronic illnesses.Now, the role of the social worker is fundamental in providing strategic access to benefits and other appropriate rights, as well as the transplant treatment itself. 5Also in this area, in the case of beneficiaries permanently incapacitated for work, when appropriate, the social worker advises the candidate and their family to request an increase of 25% in the value of the benefit, a feasible process if there is evidence that the beneficiary needs assistance from another person. 27he quantitative emphasis on fixed residence (N=146; 83.9%) at origin cannot be understood as synonymous with comfort for the candidates because as seen in other studies, 12,19 a considerable proportion of aspirants live in municipalities or states outside the municipality of the transplant center.
In this context, when there is a medical indication to stay around the transplant unit, it is not always possible for candidates and their families to bear the costs of a temporary stay.Faced with this demand, the social worker carries out a process of listening, dialog 23 and guidance to make it possible to articulate and then refer them to support homes that are in line with the particularities and preferences of the family-candidate group. 12,19he predominance of communication via mobile phone (N=164; 94.3%) is in line with data from the IBGE, which indicates that in 2021 alone, 155.2 million Brazilians over the age of 10 had a mobile phone for personal use, or 84.4% of the population. 32In the context of the transplant service, the Social Work, candidates, their families and other team members establish communication networks that optimize time, facilitate the sending of documents, deliveries and information tools, and help register demands.As a result, the mobile phone is an allied tool in planning actions to prevent impacts, promote health, share experiences and strengthen bonds. 33he high percentage of acceptability for liver transplantation (N=158; 90.8%) shows that it is close to other studies in which acceptance rates are higher than 85%.This factor may be linked to the extensive guidance and information provided by the Serrano LCA, Pereira VA, Barbeiro RM, Duca WJ, Silva RCMA, Arroyo Júnior PC, Lemes JD, Fortunato AC, Virches A, Miyazaki ET, Sciarra AMP, Silva RF transplant team, 12,16,19 which helps to improve the understanding of aspirants and their families so that they can make autonomous and informed decisions about adherence to treatment. 12t is also important to note that providing health information is not only the responsibility of the team, but also a fundamental right of the public health user. 24When individuals and their family networks are properly informed, trained and empowered, their actions become even more positive in the context of treatment.
As for nuclear families (N=120; 69%), the findings are in line with other studies. 12,19,34Finding out the type of family can facilitate the social worker's guidance, planning and interventions, as it shows how these groups are organized.By understanding the family structure, interventions and dialogues become more humanized and concrete, especially when it comes to the complex processes involved in transplantation, such as physical recovery, adaptation and experience with the new organ.In this sense, the social support of family and emotional networks is not only an ally but also fundamental. 12,34he predominance of family caregivers (N=166; 95.4%), consistent with other studies showing a presence of more than 90%, once again reinforces the crucial role of families in the context of care. 12,19The fact that family caregivers are a potential decisive agent for a favorable social opinion is due to their contributions as disseminators of information about the treatment 12 and emotional support for the candidate due to the pre-existing emotional bond.
It is important to emphasize that in addition to articulating possible caregivers from the family network, the Social Work also provides guidance and conveys the rights of the caregiver 5 as a subject of law. 24However, it is also essential that the social worker directs their qualified listening 23 to monitor how sustainable the act of caring and accompanying the candidate is, since family caregivers are potentially subject to intense and sometimes uninterrupted work, as well as stress and overload.
The predominance of a resolute family response (N=172; 98.9%) is also similar to the data mentioned previously (> 90%). 12,19his high level of adherence can be explained by the fact that families understand that transplantation represents a possibility of treatment for a family member suffering from a serious and/or chronic illness, even if there are various risks. 35,36To minimize insecurities and emphasize autonomous decision-making, the Social Work and the entire team provide guidance and information during treatment, 5,24 which also contributes to family and user adherence.
The prominence of the intermediate level of family education (N=89; 51.2%), observed in this Unit (<55%), 12 can be attributed to the predominant family configurations (nuclear and extended), in which the members have varying levels of education, a factor that can balance out the results for the middle.The higher the level of education, the easier it tends to be for the family to assimilate guidance. 12In this context, the social worker pays attention to each consultation and dialogue, as well as listening to the family's needs, 18 with a focus on providing personalized, didactic guidance that conveys the democratization and universalization of health. 24s for the percentile of applicants with partial access to medicines (N=122; 70.11%) through the public network, similar to that found in another study (> 70%),12 this can be attributed to a problem emphasized by the National Health Council, the structural insufficiency or lack of medicines. 37This issue goes beyond an administrative problem, as it represents a violation of the fundamental right to comprehensive therapeutic care, including pharmaceutical care, as recognized in the Health LOA. 24n this context, the social worker dialogues with applicants, families and the medical team, reinforcing the importance of prescribing medicines on the National List of Essential Medicines.This is done to facilitate access and to avoid lawsuits 38 as well as delays in the legal release of the medication, which can have an impact on the individual's health.In this scenario, due to the lack of structural compliance with the right to health (in terms of comprehensive therapeutic care), 24 donations of medicines by solidarity networks of other individuals undergoing treatment often end up representing one of the few agile ways to remedy this situation.
Easy geographical access (N=157; 90.2%) to the transplant center, consistent with previous studies showing an access rate of over 85%, 12,19 is in line with the coverage offered by the SUS, especially regarding the TFD. 24,25 he Social Work provides advice and guidance to candidates and their families to ensure compliance with the legal requirements for access to the TFD and other benefits, especially to avoid losing these benefits.This process helps to reduce the burden of legal bureaucracy and stress during treatment.
The prominent per-person family income of ½ to 2 minimum wages (N=107; 61.5%), which is in line with a previous survey that also shows a percentage higher than 60%, 12 is also in line with the average per-person household income of Brazilians in 2020 (R$1,349.00).Meanwhile, per-person incomes above 2 minimum wages (N=47; 27%) and up to ½ minimum wages (N=20; 11.5%), which are also similar to those found in a previous study, 12 may reflect national income inequality by region, gender, and color, among others, as addressed by the IBGE through the Continuous PNAD. 39he emphasis in spending on medicines (N=83; 47.7%), which was also observed in a previous survey, 12 indicates that half of the applicants do not have full access to public healthcare, often leading them to use their own resources to buy medicines.In exceptional cases, the social worker investigates the availability of donations at the outpatient pharmacy.However, the social worker's actions are aimed at conveying access to comprehensive treatment as a fundamental right, 5,24 in other words, charity does not replace the right and should not be understood in this way.
Regarding the occupational level of the family provider, the predominance of the bad indicator (N=63; 43.7%) may vary according to the current configuration of the socioeconomic field.Previous studies have shown the respective variation in percentages: 24.7%, 67.5%, and 12.3%. 12,19This negative indicator may be linked to the inactivity factor, which may be linked to the fact that the provider is sometimes the candidate undergoing treatment and is thus impacted by chronic/serious illness and unemployment.
Still within this scope, high levels of unemployment, coupled with a highly demanding job market, 3,28 can considerably affect access to an active job position.With this in mind, the social worker articulates actions aimed at accessing and/or maintaining possible benefits, as well as reintegrating or securing ties in the labor market.These factors can contribute to a positive scenario in the field of autonomy and financial management for the family as a whole, helping not only to facilitate access but also to maintain treatment. 12he majority of people with satisfactory housing standards, in other words, properties in a good state of repair (N=157; 90.3%) is similar to previous findings (> 85%). 12,19This reality is possibly justified by the influence of housing programs, in which there are dynamics of land regularization, housing improvement and even a reduction in interest rates for real estate loans. 40Housing is a determining factor for health, 24 as well as being one of the spaces most frequented by families and aspirants.In this sense, wellmaintained housing is essential for the care of individuals, especially those on immunosuppression, as it considerably reduces the risk of contamination by bacteria and fungi. 19egarding the result of the social worker's assessment, the prominence of the favorable opinion (N=108; 62.1%), similar to previous studies (>60%), 12,19 characterizes the synthesis of the social study carried out in the assessment process.Even if the social opinion is defined as favorable for the transplant to go ahead, the social worker continues to work together with the families and candidates/transplant recipients. 19These continuous actions seek constant access since the reality investigated changes according to the dynamics of support networks, family relationships and social policies.

CONCLUSION
The analysis of the social profile of liver transplant candidates, based on twenty-four (24) social assessment variables, reveals a population with lower social vulnerability in ten (10) categories: marital status, religion, links with SUS, nationality, means of communication, acceptance of the transplant, family model, caregiver, family adherence and access conditions.
On the other hand, greater social vulnerability was observed in fourteen (14) categories: gender, origin, level of individual and family education, inactivity, occupational level in the labor market, social assistance or social security ties, partial access to medication, per person family income and extra expenses.This profile provides important elements for identifying and reflecting on the social needs/demands of each assisted individual.
The various social opinions, although favorable to the transplant, demonstrated demands on the Social Work.The other opinions (limited favorable) suggested the need for more attention, monitoring and care but did not constitute a contraindication to the transplant.In addition to the effectiveness of the professional actions of the Social Work being manifested in the evaluation process, this also occurs to the extent that the analysis is followed by personalized interventions and guidance.In general, these dynamics serve as a basis for decision-making by applicants and their families with a view to exercising their rights.
Thus, professional actions take place through a process of humanizing care and the dynamics of respect and consideration for pluralities and differences.By accessing health rights in accordance with the particularities that shape demand, it is possible to reduce financial impacts, which corroborates with family security and facilitates access to transplantation, in accordance with the fundamental principles of the SUS.
Considering the above, further research is recommended to identify the effectiveness of the work of social workers in accessing liver transplants, as well as make it possible to increase and improve their professional tools.
Serrano LCA, Pereira VA, Barbeiro RM, Duca WJ, Silva RCMA, Arroyo Júnior PC, Lemes JD, Fortunato AC, Virches A, Miyazaki ET, Sciarra AMP, Silva RFThe research project that precedes this article was approved by the Research Ethics Committee of the São José do Rio Preto Medical School (Opinion: 3.950.444;CAAE: 29383720.3.0000.5415).To develop the scientific discussions and reflections, a documentary and bibliographic survey was carried out in the Pubmed, Web of Science, Google Scholar and SciELO databases.

Table 1 .
Social assessments of liver transplant candidates from 2019 and 2020.
Tabela 1. Continuation.Continue... Source: Own elaboration.a: Municipalities in the state of São Paulo except for the municipality of the transplant center.b: Municipalities in Brazil except for those located in the state of the transplant center.c: Municipality where the transplant center is located.d: Spiritist; Seicho-no-ie.e: Retirement due to length of service; Temporary incapacity benefit; Permanent incapacity benefit; Death pension; Unemployment insurance.f: Continuous benefit; Emergency aid.g: Covenants, housing, exams and consultations.