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Paulista de Enfermagem, Universidade Federal de São Paulo
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Acta Paul Enferm. volume 27, issue(6), November/December 2014
ISSN: 1982-0194 (electronic version)
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Erika de Sá Vieira Abuchaim, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Manuela Frederico-Ferreira, Escola Superior de Enfermagem de Coimbra, Coimbra, Portugal
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Sonía Ramalho, Instituto Politécnico de Leiria, Escola Superior de Saúde de Leiria, Leiria, Portugal
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Editorial Board
National
Alacoque Lorenzini Erdmann, Universidade Federal de Santa Catarina-UFSC, Florianópolis-SC, Brazil
Ana Cristina Freitas de Vilhena Abrão, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Cibele Andrucioli de Matos Pimenta, Escola de Enfermagem da Universidade de São Paulo-EE/USP, São Paulo-SP, Brazil
Circéa Amália Ribeiro, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Conceição Vieira da Silva-Ohara, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Elucir Gir, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Emília Campos de Carvalho, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Isabel Amélia Costa Mendes, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Isabel Cristina Kowal Olm Cunha, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
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Margareth Ângelo, Universidade de São Paulo-USP, São Paulo-SP, Brazil
Margarita Antônia Villar Luís, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Maria Antonieta Rubio Tyrrel, Escola de Enfermagem Anna Nery- EEAN/UFRJ, Rio de Janeiro-RJ, Brazil
Maria Gaby Rivero Gutiérrez, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
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Maria Helena Palucci Marziale, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
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Mariana Fernandes de Souza, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Mavilde da Luz Gonçalves Pedreira, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
I
Paulina Kurcgant, Universidade de São Paulo-USP, São Paulo-SP, Brazil
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International
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Helen M. Castillo, College of Health and Human Development, California State University, Northbridge, California, USA
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Joanne McCloskey Dotcherman, The University of Iowa, Iowa, USA
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Maria Müller Staub, Institute of Nursing, ZHAW University, Winterthur, Switzerland
Martha Curley, Children Hospital Boston, Boston, New York, USA
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Shigemi Kamitsuru, Shigemi Kamitsuru, Kangolabo, Tokyo, Japan
Sue Ann P. Moorhead, The University of Iowa, Iowa, USA
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III
Editorial
G
lobalization of economy and rapid technological change occurring
in the world are transforming society. The Brazilian society has big
challenges. One of them is reviewing/changing the service model,
which is centered on acute diseases, to a model based on the interaction
between different sectors for integration of health services. Therefore, the
challenge is political and financial and the goal is to ensure the right to
health for all Brazilians.
The Internet of Things (IoT) emerged as a new technological revolution,
which will change computing and communication and will shape a new
society.
The IoT will make people and objects closer to each other from any
devices, including home appliances, hospital equipment, medical records,
sensors, mobile phones, and chips, which will be identified, linked to the
internet for information exchange and common-interest decisions. This
new mode of communication will generate a large amount of data (Big
Data), which will be stored and available to people and will bring new business opportunities.
In the health area, we will have applications allowing real-time monitoring of patients’ health status and hospital equipment with chips that send
signals from patients to the medical staff. Moreover, we will have efficient
and fast access to the internal network (for both professionals in hospitals
and teams in field service) in the use of monitoring applications to obtain
real-time information, including at critical points in the city where attention is needed.
The IoT has begun and will change our lives. Nothing will be as it was
before. In the coming years, we will see things crucial to change the society
in the XXI century. The world will reach a new stage of communication,
global interaction, and expansion of human knowledge through all the virtual things/devices. Incorporating new healthcare technologies, with priority to solve unexpected difficulties with patients and caring for the elderly,
will become the top priorities and challenges of this century.
Profa Dra Mônica Mancini, Cobit, ITIL, ISO 27002, PMP
Professor of the Graduate Program in Technology, Universidade
Presbiteriana Mackenzie
DOI: http://dx.doi.org/10.1590/1982-0194201400081
IV
Contents
Original Articles
Experiences of illness among individuals with sickle
cell anemia and self-care strategies
Experiências do adoecimento de pessoas com anemia falciforme e estratégias de autocuidado
Rosa Candida Cordeiro, Silvia Lucia Ferreira, Ane Caroline da Cruz Santos���������������������������������������������������������������������������� 499
Access of patients with myocardial infarction to cardiology reference hospitals
Acesso de usuários com infarto do miocárdio a hospitais referência em cardiologia
Andreia Santos Mendes, Virgínia Ramos dos Santos Souza Reis, Tânia Maria de Oliva Menezes,
Carlos Antonio de Souza Teles Santos, Fernanda Carneiro Mussi�������������������������������������������������������������������������������������������� 505
Parasitological profile of residents of a maroon community
Perfil parasitológico de moradores de uma comunidade quilombola
Débora Luiza de Oliveira Rangel, Cesar de Oliveira, Cynthia Maria Kyaw, Antônio Marmoro Caldeira Júnior,
Pedro Sadi Monteiro��������������������������������������������������������������������������������������������������������������������������������������������������������������� 513
Nursing staff knowledge in relation to complications
of diabetes mellitus in emergency services
Conhecimento da equipe de enfermagem nas complicações do diabetes mellitus em emergência
Daiani Moraes Oliveira, Soraia Dornelles Schoeller, Karina Silveira de Almeida Hammerschmidt,
Mara Ambrosina de Oliveira Vargas, Juliana Balbinot Reis Girondi����������������������������������������������������������������������������������������� 520
The healthcare network to the amputee
Rede de atenção à saúde à pessoa amputada
Mara Ambrosina de Oliveira, VargasSílvia Ferrazzo, Soraia Dornelles Schoeller, Laila Crespo Drago,
Flávia Regina Souza Ramos����������������������������������������������������������������������������������������������������������������������������������������������������� 526
Factors related to absenteeism due to sickness in nursing workers
Fatores relacionados ao absenteísmo por doença entre trabalhadores de Enfermagem
Eliete Boaventura Bargas, Maria Inês Monteiro����������������������������������������������������������������������������������������������������������������������� 533
Occupational risks and illness among mental health workers
Riscos ocupacionais e adoecimento de trabalhadores em saúde mental
Márcia Astrês Fernandes, Maria Helena Palucci Marziale��������������������������������������������������������������������������������������������������������� 539
The access and the difficulty in resoluteness of
the child care in primary health care
O acesso e a dificuldade na resolutividade do cuidado da criança na atenção primária à saúde
Anna Luisa Finkler, Cláudia Silveira Viera, Mauren Teresa Grubisich Mendes Tacla,
Beatriz Rosana Gonçalves de Oliveira Toso������������������������������������������������������������������������������������������������������������������������������ 548
Qualidade de vida em mulheres com neoplasias de mama em quimioterapia
Quality of life in women with breast cancer undergoing chemotherapy
Sâmya Aguiar Lôbo, Ana Fátima Carvalho Fernandes, Paulo César de Almeida, Carolina Maria de Lima Carvalho,
Namie Okino Sawada�������������������������������������������������������������������������������������������������������������������������������������������������������������� 554
Factors associated with indicators of health needs of adult men
Fatores associados aos indicadores de necessidades em saúde de homens adultos
Guilherme Oliveira de Arruda, Aurea Christina de Paula Corrêa, Sonia Silva Marcon������������������������������������������������������������� 560
V
Nursing care to patients in brain death and potential organ donors
Cuidados de enfermagem ao paciente em morte encefálica e potencial doador de órgãos
Layana de Paula Cavalcante, Islane Costa Ramos, Michell Ângelo Marques Araújo, Maria Dalva dos Santos Alves,
Violante Augusta Batista Braga����������������������������������������������������������������������������������������������������������������������������������������������� 567
Sexual dysfunction and associated factors reported in the postpartum period
Disfunção sexual e fatores associados relatados no período pós-parto
Juliana Bento de Lima Holanda, Erika de Sá Vieira Abuchaim, Kelly Pereira Coca, Ana Cristina Freitas de Vilhena Abrão���� 573
Meaning of aromatherapy massage in mental health
Significado da massagem com aromaterapia em saúde mental
Thiago da Silva Domingos, Eliana Mara Braga����������������������������������������������������������������������������������������������������������������������� 579
Clinical conditions and health care demand behavior of chronic renal patients
Condições clínicas e comportamento de procura de cuidados de saúde pelo paciente renal crônico
Thalita Souza Torchi, Sílvia Teresa Carvalho de Araújo, Alessandra Guimarães Monteiro Moreira,
Giselle Barcellos Oliveira Koeppe, Bruna Tavares Uchoa dos Santos��������������������������������������������������������������������������������������� 585
Prevalence of risk behaviors in young university students
Prevalência de comportamentos de risco em adulto jovem e universitário
Yone de Oliveira Faria, Lenora Gandolfi, Leides Barroso Azevedo Moura������������������������������������������������������������������������������� 591
VI
Original Article
Experiences of illness among individuals with
sickle cell anemia and self-care strategies
Experiências do adoecimento de pessoas com anemia
falciforme e estratégias de autocuidado
Rosa Candida Cordeiro1
Silvia Lucia Ferreira1
Ane Caroline da Cruz Santos1
Keywords
Self care; Anemia, sickle cell;
Qualitative research; Sick role; Quality
of life
Descritores
Autocuidado; Anemia falciforme;
Pesquisa qualitativa; Papel do doente;
Qualidade de vida
Submitted
August 18, 2014
Accepted
August 26, 2014
Corresponding author
Ane Caroline da Cruz Santos
Auristides street, 2, Salvador, BA, Brazil.
Zip Code: 40210-340
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400082
Abstract
Objective: To determine the experience of sick individuals with sickle cell anemia and their self-care strategies.
Methods: This was a qualitative study of 17 individuals with sickle cell anemia. Data collection and analysis
occurred simultaneously by open codification and categorization, according to steps in the theory based on
data. This procedure led to the development of categories related to the experience of individuals who have
sickle cell anemia and their self-care.
Results: Experiences of patients who became chronically ill enabled the construction of strategies to better
determine the disease, changes in daily life, and the manner in which it affects how patients observe and
experience time. Also identified were specific skills for self-care that were developed from lessons learned
and mistakes made.
Conclusion: We found that individuals with sickle cell anemia had several favorable approaches for adapting
to having become sick during adulthood.
Resumo
Objetivo: Conhecer as experiências do adoecimento de pessoas com anemia falciforme e suas estratégias
para o autocuidado.
Métodos: Pesquisa qualitativa realizada com 17 pessoas com anemia falciforme. A coleta e a análise dos
dados ocorreram simultaneamente, realizando-se a codificação aberta e sua categorização, segundo os
passos da Teoria Fundamentada nos Dados. Tal procedimento deu origem a categorias relativas à experiência
do adoecimento de pessoas com anemia falciforme e autocuidado.
Resultados: As experiências com o adoecimento crônico possibilitaram a construção de estratégias para
conhecer melhor a doença, determinaram mudanças na vida cotidiana, e afetaram o modo como cada pessoa
observa e vivencia o tempo e como as habilidades específicas para o autocuidado foram desenvolvidas a partir
dos aprendizados e deslizes cometidos.
Conclusão: Constatou-se que as pessoas com anemia falciforme apresentaram vários elementos favoráveis
em busca de adaptação ao adoecimento na fase adulta.
Escola de Enfermagem, Universidade Federal da Bahia, Bahia, BA, Brazil.
Conflicts of interest: none reported.
1
Acta Paul Enferm. 2014; 27(6):499-504.
499
Experiences of illness among individuals with sickle cell anemia and self-care strategies
Introduction
The World Health Organization (WHO) recognizes sickle cell anemia as a priority for public health,
especially because of problems with access to health
services in several regions of the world. In Brazil,
this disease is predominantly found among black
people, pardos, and Afro-descendants. In general,
3,500 children/year are born with sickle cell anemia, and 1 child in a 1000 births has the disease.
The Bahia state, northeast Brazil, has the highest
incidence of sickle cell anemia: 1 case for every 650
newborns and 1 individual with sickle cell trait for
every 17 births.(1)
Sickle cell anemia has been treated as a single
medical specialization for long time, mainly in hematology, and has not been a part of other health
services. Care for sickle cell anemia patients must
become a focus of primary care services.
Publication of a self-care manual for individuals
with sickle cell anemia revealed the need to share
with all health professionals self-care practices, such
as meetings among individuals (i.e., a collective
construction). These practices can be changed from
a disease-centered model to one that prioritizes the
daily practices of individuals and families who seek
health care.
To understand individuals with sickle cell anemia, experience is important to organize nursing
care and obtain broader access to care for this population group. This study aimed to understand the
experience of sick individuals with sickle cell anemia and self-care strategies.
Methods
This descriptive study with qualitative analysis used
a theory based on data as the methodological reference point. This approach enabled us to develop a
theory from the data obtained to perform concomitant and comparative analysis of the data.(2)
This study was developed in three municipalities of Bahia state. We included 17 patients aged
18 to 49 years old who were diagnosed with sickle
cell anemia.
500
Acta Paul Enferm. 2014; 27(6):499-504.
Participation selection was intentional and theoretical. After a search for participants conducted
with community health agents, we invited individuals to participate; these initial participants then
referred others to participate. We attempted to obtained a varied sample in relation to age, time of
diagnosis, formal education and sex.
Data were collected by “deep interviews”.(3) In
the first meeting, we requested participants to reveal their experience with sickle cell anemia. Interviews were transcribed and simultaneously analyzed. This process yielded data that we used to develop a script for further interviews. The findings
from the interviews were analyzed and codified
according to inductive development of qualitative
research, but without losing the characteristics of
an open interview.
Interviews occurred at participants’ houses. Participants’ testimonials were digitally recorded and
later transcribed in full. As mentioned earlier, data
collection and analysis occurred simultaneously
through open codification and categorization based
on steps of theory grounded in data.(2) During open
codification, data were analyzed line by line, examined, and compared for similarities and differences.
Through this process, the phenomena were questioned and explored, which enabled discoveries.
Codified data were grouped by similarities. Each
category was considered saturated when it was not
possible to add any more new data. This procedure
led to the creation of categories for the experiences of
sick individuals with sickle cell anemia and self-care.
To maintain rigor in the study, we used the following strategies: all interviews, after transcription,
were made available to all participants in order to
verify that interviews were represented in a manner
consistent with how the data were being analyzed,
and we used consolidated criteria for reporting
qualitative research (COREQ) as the supporting
tool. This tool for qualitative research methods is
composed of 32 items that should be verified by
the research team for the research project and data
analysis.(4)
Development of this study followed national
and international ethical standards for research on
human subjects.
Cordeiro RC, Ferreira SL, Santos AC
Results
According to the referral adopted, the resources
that the patients created to manage the process of
becoming sick, as well as self-care strategies, were
represented by four categories, as shown in figure 1.
The category “building an explanation for the
disease” concerns the efforts of patients to better
understand sickle cell anemia. This is an important process that involves day-to-day organization,
taking care of themselves, and facing the reality of
their situation. In collecting the experiences of the
participants, we identified the rupture caused by the
disease and the need to reclaim balance in order to
proceed forward.
The category “observing time and physical
signs” shows that being sick results in changes to
daily life and affects the way in which each person
observes and experiences time.
The category “falling and learning to provide
self-care” identifies that steps followed to keep the
disease stabilized, such as self-care, are meaningful.
In this sense, self-care means a zealous approach to
health behavior and the need to be alert to physical
signs and symptoms.
Finally, the category “taking care of faith and
spirituality” shows that in critical moments, strategies are employed to ensure that the experience of
becoming sick as incorporated into the daily routine
will be valid. The study participants seek strength
Action strategies/interaction
Defining the trajectory for living with sickle cell anemia
1. Building an explanation for the disease
Attempting to better understand the disease
Explaining the hereditary nature of the disease
Finding the disease in the blood
Giving a casual explanation for the disease
Providing a racial explanation for the disease
Explaining the disease better
Trying to control
emotions
2. Observing time and physical signs
Measuring time by counting the number of crises
Needing to isolate the body
Observing alert signs of the body
Seeking to strengthen
the body
3. Making mistakes and learning to provide self-care
Care interpreted as zealous approach to health
Building standards for self-care
Trying to maintain an adequate diet
Attending regular medical visits
Developing specific skills for self-care
Learning to provide self-care on the basis of experience
4. Taking care of faith and spirituality
Seeking strength to understand suffering
Having faith and hope
Believing in a healing miracle
Figure 1. Flow diagram about living with sickle cell anemia
Acta Paul Enferm. 2014; 27(6):499-504.
501
Experiences of illness among individuals with sickle cell anemia and self-care strategies
in facing suffering to help them overcome difficult
moments.
Discussion
The study is limited because qualitative research
does not enable generalization of results. However,
our findings can contribute to the knowledge of demands placed on individuals with sickle cell anemia
for self-care.
The category “building an explanation for the
disease” shows that sickle cell anemia has complex
meanings beyond a simply biological dimension. Its
social meanings incorporate values and structure of
elements related to health professionals,(5) who are
always reinterpreting the biomedical model and
looking for common-sense knowledge.
When individuals acquire information, they begin to construct an explicative frame that includes
biological, behavioral and racial factors and that
shows the idea of integrative plurality to explain
the presence of the disease. This frame of meaning
is built into the interactions with several environments and the individuals who make up their social
relationships; these interactions are also changed by
these relations and the course of the disease.(1)
Explanations are plentiful and differentiated
according to whether they are created as important referral points in the interface of the individual with society. This is equally important in helping to understand several aspects of life, to realign
the present, and plan actions for the future. In the
studied group, we identified their effort to present
a biomedical, legitimated and hegemonic discourse
related with health and disease, which necessarily
does not implicate, in complete understand of this
knowledge.
To pursue an explanation about the disease
helps to answer more safely, be more open, and be
available to face challenges. Efforts to strengthen
patients’ comprehension and learning during daily life can help them build their knowledge of and
ability to manage self-care.
We observed that the type of disease determined
the patients’ way of life and how they interpret time,
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Acta Paul Enferm. 2014; 27(6):499-504.
defined mainly by crises. To be sick, therefore, is not
a constant, but there is a determined period that depends on remission phases and exacerbation of the
disease.(6) In this sense, years and months are considered good or poor, based on crises that appear.
In this interaction with time, we also observed a
relationship with climate because crises occur more
often in cold periods. The winter is seen as threatening the patients’ lives because symptoms and crises become more latent. Individuals with sickle cell
anemia, in general during these periods or at night,
need to isolate their body as a self-care strategy to
protect and avoid the precipitation of crisis.
Following this observation of time, we identified alert signs of how the body responds to being
sick (the circumstances that cause and can bring
challenges related to indisposition and fatigue).
Weakness and indisposition to conduct daily activities are among these signs.
The chronicity of a disease is characterized by
uncertainty regarding the future. Although individuals have periods of stability, they need to be
alert and take self-care measures, such as adopting
changes in their eating habits. Some patients experience tiredness, weakness, and pain every day, and
others have moments in which these signs are present and times of “normality”.
Signs of an impending crisis vary from person
to person, but they are all aspects and changes perceived in the body. Dehydration signs indicate that
the body needs water.(1) Some reports indicate that
crises can begin spontaneously, with little warning.
Thus, the patient wages a daily battle to maintain
daily life activities with continuous care, and sometimes there is a need to intervene so that the body
remains strong.
We found that men reported using vitamins
and seeking ways to strengthen the body and avoid
fatigue; women tried to control their emotions
because those also trigger crisis (generally with regard to physical aspects and stressful situations at
home).(1) It is possible to identify how difficult it is
for men to say that they are sick by their immediate
correction of the term “more or less sick” because
they do not feel totally incapable of conducting
daily activities.(7)
Cordeiro RC, Ferreira SL, Santos AC
Because patients cannot control when crises will
appear, they are aware of the need for daily control
to avoid future complications. In this sense, they
live with a disease that can be controlled by self-care
and cannot neglect themselves.
Building norms for self-care consists of a series of
norms that are instituted. The evolution of chronic
condition is marked by a routine of time, food that
can be ingested or not ingested, medicines that can
be taken, exams to be conducted periodically, and
control of hemoglobin. There are rules to take care
of the body, protect from the sun and cold, and eat
a healthy diet. Sometimes slippage occurs because
of a hurried life or the difficulty young people have
in taking care of themselves.(5)
To visit the doctor consistently is also important
for care, such as the performance of exams. Regular
follow-up with specialists is necessary. The aggregated knowledge gathered by observing the recurrence of fundamental experiences helps construct
the meaning of care and create rules for facing daily
life with a chronic disease. Elements of care must
provide support and help patients pursue their daily life activities. The meaning of care is developed
by incorporating knowledge of different origins and
orders that are molded by physical experience.
Self-care strategies that are developed with experience are based on daily practice and allow patients
to keep their lives as close to normal as possible.
Strategies for facing chronic illness often transcend
mere bodily care—it is also necessary to attend to
faith and spirituality.
To accept the restrictions, health implications,
and life changes that accompany sickle cell anemia
is difficult, and to do so when supported only by
fundamental materials is not be enough. Religiosity/spirituality is a predictive factor for well-being
and social support. Seeking support from religious
practice is one of the ways patients face health problems. In our study, religiosity and spirituality appeared as elements of care directed to health and
the experience of illness. Going to church, praying
or listening to religious music seem to be strategies that help the individual to feel healthier and,
sometimes, improve pain, in addition of providing
a space of refuge and social support.(8,9)
To believe that life is guided by a superior
force can help patients find meaning in life with a
chronic disease. According to this view, physicians
cannot always provide healing; healing is present
in hope and depends on the divine will. To believe in healing is also a form of obtaining relief,
perhaps even interpreted as a miracle and not associated with associated with medical knowledge
and becoming possible, because it is transferred
for divine field: faith in God (8,9) Going forward
depends on, above all, integrating all the patients’
feelings with expectations and support that will be
organized on a pathway to overcome the suffering
caused by sickness.
Conclusion
Experience of sick individuals with sickle cell anemia and self-care strategies indicated favorable
elements in seeking for adaptation to the sick in
adult phase.
Collaborations
Cordeiro RC; Ferreira SL and Santos ACC contributed to the conception of the Project, analysis
and interpretation of data, drafting the manuscript,
critical review relevant for intellectual content and
approval of finals version to be published.
References
1. Gomes LM, Vieira MM, Reis TC, Barbosa TL, Caldeira A. Knowledge of
family health program practitioners in Brazil about sickle cell disease: a
descriptive, cross-sectional study. BMC Family Practice. 2011; 12:89.
2. Hunter A, Murphy K, Grealish A, Casey D, Keady J. Navigating the
grounded theory terrain. Part 2. Nurse Res. 2011; 19(1):6-11.
3. Boyce C, Neale P. Conducting In-depth interviews: A guide for designing
and conductin in-depth interviews for evaluation input. Pathfinder Int
[Internet]. 2006 [cited 2014 Jun 18]. Available from: http://www.
pathfind.org/site/DocServer/m_e_tool_series_indepth_interviews.pdf.
4. Tong A, Sainsbury P, Craig, J. Consolidated criteria for reporting
qualitative research (COREQ): a 32-item checklist for interviews and
focus groups. Int J Qual Health Care. 2007;19(6):349-57.
5. Hirschberg M. Living with chronic illness: an investigation of its impact
on social participation. Reinnvention [Internet] 2012; 5(1). [cited 2014
Aug 21]. Available from: http://www.warwick.ac.uk/reinventionjournal/
issues/volume5issue1/hirschberg.
Acta Paul Enferm. 2014; 27(6):499-504.
503
Experiences of illness among individuals with sickle cell anemia and self-care strategies
504
6. Fonseca LM, Galera SA. [Expressions used by family members to share
experiences of living with mental illness]. Acta Paul Enferm. 2012;
25(1):61-7. Portuguese.
8. Adegbola M. Spirituality, self-efficacy and quality of life among
adults with sickle cell disease. South Online J Nurs Res. 2011;
11(1):pii: 5.
7. Fontes WD, Barboza TM, Leite MC, Fonseca RL, Santos LC, Nery TL.
Atenção à saúde do homem: interlocução entre ensino e serviço. Acta
Paul Enferm. 2011; 24(3):430-3.
9. Lekisha YE, Christopher LE. Psychosocial treatments in pain
management of sickle cell disease. J Nat Med Assoc. 2010; 102(11):
1084-94.
Acta Paul Enferm. 2014; 27(6):499-504.
Original Article
Access of patients with myocardial infarction
to cardiology reference hospitals
Acesso de usuários com infarto do miocárdio a
hospitais referência em cardiologia
Andreia Santos Mendes1
Virgínia Ramos dos Santos Souza Reis2
Tânia Maria de Oliva Menezes1
Carlos Antonio de Souza Teles Santos3
Fernanda Carneiro Mussi1
Keywords
Public health nursing; Education,
nursing; Myocardial infarction; Health
services; Access to health services;
Health services needs and demand
Descritores
Enfermagem em saúde pública;
Educação em enfermagem; Infarto do
miocárdio; Serviços de saúde; Acesso
aos serviços de saúde; Necessidades e
demandas dos serviços de saúde
Submitted
August 18, 2014
Accepted
August 26, 2014
Corresponding author
Fernanda Carneiro Mussi
Doutor Augusto Viana Filho Avenue,
unnumbered, Salvador, BA, Brasil.
Zip Code: 40110-060
[email protected]
Abstract
Objectives: Characterize the access of patients with myocardial infarction to cardiology reference hospitals
Methods: Cross-sectional study conducted in two cardiology reference hospitals. A sample of 100 patients,
with a diagnosis of myocardial infarction, was interviewed employing a specific instrument. Mean, standard
deviation and percentage values were used in the analysis.
Results: Male subjects; black skin; married; low socioeconomic status and mean age of 56.4 years
predominated. The onset of symptoms at home, use of inadequate means of transportation, emergency
service as the first place sought for assistance; and admission to cardiology reference hospitals up to the
third medical assistance prevailed. Of the 67 patients with myocardial infarction with ST segment elevation,
12% received reperfusion therapies. The lack of resources was the main reason for the pilgrimage within the
healthcare system.
Conclusion: Use of inappropriate means of transportation, low proportion of myocardial reperfusion, and lack
of structure of the healthcare network to deliver care related to the infarct was observed.
Resumo
Objetivo: Caracterizar o acesso de usuários com infarto do miocárdio a hospitais referência em cardiologia.
Métodos: Estudo transversal, realizado em dois hospitais referência em cardiologia. A amostra de 100
usuários, com diagnóstico de infarto, foi entrevistada empregando-se instrumento específico. Na análise
utilizou-se médias, desvio padrão e percentuais.
Resultados: Predominaram homens, raça negra; casados; baixo nível socioeconômico, idade média de 56,4
anos. Prevaleceu início dos sintomas no domicílio, uso de meios de deslocamento inadequados, procura de
serviço de emergência como primeiro local de atendimento, admissão nos hospitais referência em cardiologia
até o terceiro atendimento. Dos 67 usuários com infarto com supradesnível do segmento ST, 12% receberam
terapias de reperfusão miocárdica. A insuficiência de recursos foi a principal razão para a peregrinação na
rede de saúde.
Conclusão: Constatou-se uso de meios de transporte inapropriados, baixa proporção de reperfusão miocárdica
e falta de estrutura da rede para atendimento ao infarto.
Escola de Enfermagem, Universidade Federal da Bahia, Salvador, BA, Brazil.
Escola Bahiana de Medicina e Saúde Pública, Salvador, BA, Brazil.
3
Universidade Estadual de Feira de Santana, Feira de Santana, BA, Brazil.
Conflicts of interest: there are no conflicts of interest to declare.
1
DOI
http://dx.doi.org/10.1590/19820194201400083
2
Acta Paul Enferm. 2014; 27(6):505-12.
505
Access of patients with myocardial infarction to cardiology reference hospitals
Introduction
Cardiovascular diseases are still the main cause of
death and disability in Brazil and worldwide. Each
year, 17.3 million deaths occur because of these diseases, and it is estimated that 40% of deaths will
be related to them in 2020.(1) In Brazil, in 2010,
326,345 deaths occurred from cardiovascular diseases and, of this total, 79,662 were due to myocardial infarction.(2)
Myocardial infarction represents more than
80% of the cases of ischemic heart disease, being
considered the most lethal(3) and significant cardiovascular disease. One of the factors contributing to
the decline in mortality from myocardial infarction
is the prompt medical care, since most deaths occur
in the first hour after the onset of symptoms.(4,5)
The success of the treatment is associated with
early initiation of chemical or mechanical coronary
reperfusion therapies.(5) These therapies modify the
progression of the disease, however, their effectiveness is time-dependent,(5) that is, the earlier the initialization the greater the therapeutic benefit.
Although the Brazilian health system is regarded as universal, it may not be able to guarantee
patients with infarction access to appropriate care.
The difficulty of access to health services of higher
level of complexity has been identified as one of the
factors favoring the fragmentation of health care.(6)
The deficiencies in the provision and organization
of the services delivered by the Unified Health System (SUS, as per its acronym in Portuguese) expose
individuals to a difficult journey in pursuit of health
care. During this pursuit, patients with infarction
go through numerous health services, resulting in
delay to obtain an effective treatment,(7) increased
risk of morbidity and mortality and increased treatment costs for individuals and society.
Thus, it is necessary to learn how the access to
public healthcare services is presented to patients
with myocardial infarction, in order to support
measures that optimize a specialized treatment. Access to these services can be configured differently,
due to the specificities of healthcare networks in
different countries or regions, and little is known
about it in the national literature.
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Acta Paul Enferm. 2014; 27(6):505-12.
Given the aforementioned, the objective of
this study was to characterize the access of patients with myocardial infarction to cardiology
reference hospitals.
Methods
Cross-sectional study, conducted in two cardiology
reference hospitals, in the city of Salvador, state of
Bahia, northeastern Brazil. One institution is philanthropic and admits people for treatment through
private health insurance agencies and through the
Unified Health System; the other institution is public and admits people through the Public Regulation System of the state of Bahia.
The estimated prevalence for myocardial infarction of 99/100000 adults in Salvador, Bahia, was
used as parameter to calculate the sample size (n)
of 100 individuals.(8) The following parameters were
also considered in the calculation of the sample:
n=
NP (1 – P)
(N – 1) D + P (1 – P)
in which, D=
B2 and B= 1 – a P
Za/2
N - total number of the population assumed
during the period of data collection = 1000; P - proportion within the population studied = 0.099; n sample size; a - significance level; (1 – a) 100 - confidence level; B - maximum estimated error desired;
Za/2 = 1,96; 1 – a = 0,95, B = 0,04 or 4%.
Inclusion criteria were having a diagnosis of
myocardial infarction with or without ST segment
elevation, being hospitalized for at least 24 hours
and the maximum of 20 days, being oriented in
space and time and without medical restrictions for
the interview.
The data collection instrument consisted of
three parts with structured questions. Part I, Sociodemographic Characterization, examined data
on the place of hospitalization, age, gender, self-declared ethnicity, schooling, marital status, employment status, household income, household members, number of dependents, place of residence and
possession of a health insurance plan. Part II, Clin-
Mendes AS, Reis VR, Menezes TM, Santos CA, Mussi FC
ical Characterization, was aimed to obtain information regarding the type of infarction, execution of
myocardial reperfusion and clinical manifestations
of the infarction. Part III, Characterization of Access to Health Services, collected data regarding the
location, date and time of symptom onset, means of
transportation used, type and the number of health
services accessed before being admitted to a cardiology reference hospital, the conducts of health professionals in the first place of assistance and knowledge of the participants on the health service that
should be sought.
Data were collected by means of interviews conducted in inpatient units, the coronary care unit and
the semi-intensive care unit. After the identification
of individuals in the logbook and medical records,
those who met the inclusion criteria and who were
not scheduled for exams and/or procedures for an
hour were selected. All data were obtained through
the interview, except for the medical diagnosis that
was verified in the medical record and confirmed
with the physician assistant, as well as the date and
time of hospital admission and the registration of
myocardial reperfusion.
The data obtained were processed using the statistical software Stata, version 11.0. In the analysis, mean, standard deviation and percentage values
were used. Data were presented in tables.
The development of this study complied with
national and international ethical guidelines for research involving human subjects.
Results
Sociodemographic and clinical characteristics of the participants
Of the 100 individuals who suffered infarction,
71 were men, with a mean age of 58.7 years (SD
11.1) and 29 were women, with a mean age of 59.0
years (SD 12.1). Most were aged <60 years (56%).
Predominant origin was Salvador and the Metropolitan Region (73%), black skin (71%), married/
stable union (75%), low schooling (56% had completed elementary school and 13% were illiterate),
monthly family income of up to three minimum
wages (63%), up to 3 family members living on
this income (58%), active employment status
(67% were economically active, that is, employed,
self-employed or retired with activity). Most lived
with someone, a greater proportion with a partner
(69%) and child/stepchild (65%).
Most individuals showed infarction with
ST segment elevation (67.0%). Of these, 88%
had no medical records of myocardial reperfusion. The predominant symptom was pain in the
chest (81%), followed by sweating (66%) and
respiratory distress (47%). The description of
chest tightness (45%) predominated, followed
by burning (36%), lasting more than 15 minutes
(96%) and characterized as intensive (83%). Of
the 89% of individuals who informed the frequency of pain, 74.2% characterized it as constant/uninterrupted.
Characterization of the access of participants to the first health service
The majority (76%) of the participants was at home
when infarction symptoms started, followed by
those at thoroughfares (18%) (Table 1).
The use of one’s own automobile/that belonging
to acquaintances or a taxi (70%) to get to the health
service prevailed. Only 11% of the participants
used the ambulance service and, of these, 3% used
regular ambulance and 8% used the Mobile Emergency Medical Service (SAMU, as per its acronym
in Portuguese). (Table 1).
Regarding the type of health service sought for
the first medical assistance, 89% sought an urgency
and emergency service. Although most sought for
the adequate service, 77% did not know which service was indicated for the treatment of myocardial
infarction (Table 1).
At the time of occurrence of the cardiovascular
event, 76% were in Salvador and in the Metropolitan Region. In the case of these individuals, the authors tried to identify the existence of an emergency
service in the health district of their residence/stay,
and it was not possible to obtain such information
for three men. Thus, 84.9% of the 73 participants
were in neighborhoods of Salvador that offered
healthcare coverage. Knowing that 73 participants
Acta Paul Enferm. 2014; 27(6):505-12.
507
Access of patients with myocardial infarction to cardiology reference hospitals
Table 1. Characterization of the access of participants to the first health service sought after the onset of myocardial infarction
symptoms
Characteristics related to the access of the participants
n(%)
Place of symptom onset (n=99)*
Home
76(76.8)
Thoroughfare
18(18.2)
Work
5(5.1)
Means of transportation (n=99)*
Mobile emergency medical unit / Regular ambulance
11(11.1)
Automobile / Cab / Motorcycle
72(72.7)
Bus/Walking
16(16.2)
Type of health service sought as the first place of assistance
Service with urgency and emergency assistance **
89(89.0)
Service without urgency and emergency assistance***
11(11.0)
Mentioned knowing where to seek for health care
Yes
23(23.0)
No
77(77.0)
Existence of emergency unit in the neighborhood of residence / stay in Salvador (n=73)****
Yes
62(84.9)
No
11(15.1)
Sought the health services from the neighborhood of residence / stay in Salvador (n=50)*****
Yes
39(78.0)
No
11(22.0)
Conduct of health professionals in the first place for care
Expected conducts
82(82.0)
Unexpected conducts
18(18.0)
*One woman was in a health service performing exams when infarction symptoms started. **Open access hospital/Cardiology reference hospital/Emergency unit/Mobile emergency medical unit/***Outpatient Service/Primary
Healthcare Unit. ****For users who were in Salvador and in the Metropolitan Region at the time of symptom onset; *****For users who were in Salvador, in the Metropolitan Region and at home at the time of symptom onset
had an emergency unit in their health district, the
authors identified those who were at home when
the symptoms started. Of the 50 participants who
were at home, 78.0% sought healthcare facilities
belonging to the district (Table 1).
Regarding the conducts of health professionals
in the first health service sought, for 82% of the
participants the conducts were the ones expected (assisted and admitted or assisted, admitted
and transferred). It is noteworthy that 18% were
victims of unexpected conducts such as denial of
service (6%), medical assistance and orientation to
find another service (6%), medical assistance and
subsequent discharge (4%), medical assistance and
orientation to follow up with a cardiologist (2%),
(Table 1).
Characterization of the access of participants to cardiology reference hospitals
after searching for the first health service
In the public health network of Salvador, Bahia,
and in the Metropolitan Region, the access of patients to cardiology reference hospitals does not
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Acta Paul Enferm. 2014; 27(6):505-12.
happen directly, but through the central regulation. Thereby, participants must have passed by
at least one health service prior to admission in
these hospitals.
On average, participants passed by 1.6 (SD
0.9) services before admission to cardiology reference hospitals, which occurred for most of
them in the second (60.6%) and in the third assistance (29.3%).
Table 2 shows the various types of health services visited by the participants until admission to
the cardiology reference hospitals. With the exception of one participant who was admitted in the first
visit, all others had to resort to another assistance
before admission in the study sites. Most sought
emergency services for first medical assistance, but
11 went to outpatient services or primary healthcare units.
Table 3 shows the conduct of health professionals for the 99 participants who were assisted at
least once before admission to cardiology reference
hospitals. In 80.1% of the 156 assistances received
the conduct was “assistance, admission and subse-
Mendes AS, Reis VR, Menezes TM, Santos CA, Mussi FC
Table 2. Types of health services sought according to the order of assistance received before admission to the cardiology reference
hospitals
Número de serviços de saúde procurados
Type of health service
First
Second
Third
Fourth
Fifth
Sixth
Seventh
n=100)
n=99
n=39
n=10
n=5
n=2
n=1
Hospital
41
22
9
4
2
1
-
Emergency Unit
39
12
1
1
-
-
-
Mobile Emergency Service
8
1
-
-
-
-
-
Outpatient Service
7
4
-
-
-
-
Primary Healthcare Unit
4
-
-
-
-
-
-
Admission to cardiology reference hospitals*
1
60
29
5
3
1
1
100
99
39
10
5
2
1
Total
*Number of the participants admitted to cardiology reference hospitals according to the number of health services visited
Table 3. Conducts of health professionals distributed by type of health service sought
Conducts of health professionals
Medical assistance, admission and subsequent transfer
Hospital
Emergency Unit
SAMU*
Primary
Healthcare Unit
Outpatient
Service
Cardiology Reference
Hospitals
Total
n(%)
n(%)
n(%)
n(%)
n(%)
n(%)
n(%)
61(78.2)
51(96.2)
9(100.0)
2(50.0)
2(18.2)
-
125(80.1)
Medical assistance and orientation to look for another service
5(6.4)
-
-
1(25.0)
7(63.6)
-
13(8.3)
Denial of assistance
7(9.0)
1(1.9)
-
1(25.0)
1(9.1)
1(100.0)
11(7.1)
Medical assistance and subsequent discharge
4(5.1)
1(1.9)
-
-
-
-
5(3.2)
Medical assistance and orientation to look for a cardiologist
1(1.3)
-
-
-
1(9.1)
-
2(1.3)
78(100.0)
53(100.0)
9(100.0)
4(100.0)
11(100.0)
1(100.0)
156(100.0)
Total
* Mobile Emergency Medical Service – SAMU, as per its acronym in Portuguese
quent transfer”, especially in hospitals and emergency units. However, 19.9% of conducts were
unexpected, both in minor and more complex
services. Such conducts were described by participants as medical assistance and orientation to look
for another service; denial of assistance; medical
assistance and subsequent discharge or orientation
to look for a cardiologist.
The 99 participants who underwent more than
one service reported 156 reasons for going to another health service, such as insufficient resources (141
- 90.4%), followed by denial of care (7 - 4.5%), discharge after care (5 - 3.2%) and orientation to look
for another service (3 - 1.9%). Of the 141 times that
the lack of resources was mentioned, most of the
times, the participants were unable to inform the
type of resource unavailable (107 - 75.9%). When
informed by the participants, the reasons that predominated were: impossibility to perform catheterization and percutaneous transluminal angioplasty
(23 - 16.3%), impossibility to deliver emergency
care (2.8%) and to conduct electrocardiograms (2
- 1.4%). Also, service overcrowding (3 - 2.1%) and
absence of a physician/cardiologist (2 - 1.4%) were
highlighted as reasons.
Discussion
The limits of the results of this study are related
to the cross-sectional method that does not allow
the establishment of cause and effect relations. The
study contributed to greater understanding of the
access of patients with myocardial infarction to
public health services, in the sample studied. Its results are relevant to guide the actions of health managers and professionals, as they evidence the gaps in
the care of patients with infarction in the healthcare
network.
Male subjects were predominant, as it was also
observed in other national studies,(1,9) as well as age
the group under 60 years, noting that women developed infarction at an early age, when considering the presence of early coronary artery disease in
women aged ≤ 65 years and in men ≤ 55 years.(10)
The predominant marital status was married/with a
partner, in agreement with other studies.(9,11)
Participants had similar socioeconomic characteristics, expressed by the dependence on the
Unified Health System, low level of schooling and
low family income. Also, one third was professionally inactive, due to unemployment or retirement.
Acta Paul Enferm. 2014; 27(6):505-12.
509
Access of patients with myocardial infarction to cardiology reference hospitals
These findings evidence deficient socioeconomic
conditions, which are associated with an increased
risk of death from cardiovascular disease.(12)
Most participants declared themselves as having
black skin, a determining aspect to a high risk for
cardiovascular events.(13)
Most participants presented a typical clinical
profile of myocardial infarction due to the nature
and characteristics of the chest pain,(5) and they were
at home when the symptoms started. In the space
of the house, surrounding people, such as family
members and friends, have a fundamental role in
optimizing the access of the individual to a health
service, be it for the recognition of the severity of
the situation or when alerted by the victims. To this
end, the community in general needs to be trained,
especially, to recognize cardiovascular events and to
alert the emergency medical service.
Most participants used inappropriate transportation to go to the health service. A low percentage called the Mobile Emergency Medical Service,
although this is the means recommended since it
is equipped with human and material resources for
the first medical assistance.(14) Other national studies(9,15) have also found that this service is poorly
used, demonstrating that this situation still persists.
Its low use may reflect the lack of knowledge or appreciation of its importance by the participants or
indicate negative experiences regarding their performance in the city under study. Regarding this aspect, studies revealed problems in the time-response
of this service in Brazilian cities.(16,17)
For the first medical assistance, most participants went to an urgency and emergency service.
However, most reported not knowing where to seek
treatment at the time of a cardiovascular event. The
discomfort caused by the infarction symptoms and
the potential severity associated with them may have
contributed to the pursuit of this type of service.
Participants who had an emergency unit in the
health district of their place of residence / stay and
were at home when the symptoms started sought
a service in their district, which is expected in the
infarction service network in Salvador, Bahia, when
the service offers emergency care. It is important that
users be educated about the appropriate service that
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Acta Paul Enferm. 2014; 27(6):505-12.
can assist with their clinical condition and about its
location, aiming the early treatment. Therefore, dissemination of information to the community about
emergency services near the region of residence and
place of work is necessary. Such information may
be provided by nurses in various scenarios of action,
as in primary care during monitoring programs as
the HIPERDIA, considering that diabetes and hypertension are cardiovascular risk factors, and in the
health education activities performed in the home
and community settings. This information should
also be offered to people with cardiovascular disease
or with a potential risk for cardiovascular events,
hospitalized or in outpatient services, as well as to
their families.
Although there was a greater proportion of individuals who reported experiencing expected professional conducts in the first place of care, a portion
was victim of misconduct, which was expressed in
the form of lack of structure of the institutions and
difficulty of clinical management of health professionals when caring for patients with infarct.
Most participants suffered infarction with
ST-segment elevation similar to the proportion recorded by Ferreira et al. (2009). Among those with
this type of infarction, only 12% were reperfused.
Although some may not have met the criteria for
myocardial reperfusion, these findings indicate
exposure to a higher risk of death and complications and reiterate the need for optimization and
qualification when caring for patients with infarct.
There are reports of low prevalence of myocardial
reperfusion in Brazilian cities in the literature.(1,19)
In Salvador, Bahia, despite the creation of a network
of care for infarction patients, Solla et al. (2013)(20)
found that of 287 patients with myocardial infarction with ST-segment elevation, only 90 underwent
myocardial reperfusion therapies.
Therefore, despite advances in the knowledge
of the treatment of the disease, it is still necessary
to qualify and prepare health professionals to diagnose and treat it,(19) and to improve public health
services for the early implementation of therapeutic reperfusion.
The participants, on average, went through 1.6
health services before being admitted to a cardiol-
Mendes AS, Reis VR, Menezes TM, Santos CA, Mussi FC
ogy reference hospital, which happened mostly in
the second assistance received. It was expected that
the admission did not occur in the first assistance
because these hospitals only admit referred people.
However, needing to receive assistance two or more
times, before the admission to the hospital, was not
expected. The research findings showed that the
number of times people received assistance before
hospitalization was associated with significant delays
in having access to specialized care. Having to go to
various health services and the unexpected conducts
faced in these services, exposed the participants to
higher morbidity and mortality risks and showed a
deficiency in the municipal health network.(21)
The lack of structure of health services in the
city was evident by the insufficient resources in the
first institutions sought. This lack of structure has
been observed from December 2003 to June 2004,
showing that the conditions for early treatment for
acute coronary syndromes appear to have had no
significant changes.(21)
Individuals with infarction need to rely on a network of health services that is prepared to assist them.
(22)
Therein lies the importance of public policies that
aim to organize the healthcare network with equipment, materials and skilled human resources. However, it is worth noting that the success of care depends
not exclusively on the establishment of infarction care
networks, but also on the commitment and scientific
and technical quality of health professionals and on
the awareness of the patients and the surrounding people to seek an emergency service early.
rely on the third service due mainly to the lack of
resources in the first services sought.
Conclusion
4. Mussi FC, Ferreira SL, Menezes AA. [Experiences of women in face
of pain from acute myocardial infarction]. Rev Esc Enferm USP. 2006;
40(2):170-8. Portuguese.
Use of inadequate means of transportation; emergency health services as first place for assistance;
and medical assistance, admission and subsequent
transfer as the most frequent conduct were predominant characteristics for individuals with infarction.
Few individuals with myocardial infarction with
ST-segment elevation underwent myocardial reperfusion. Admission to cardiology reference hospitals
occurred mainly in the second service accessed, as it
was expected; however, a significant portion had to
Acknowledgments
The present study is part of the matrix project entitled “Retardo pré-hospitalar face ao infarto do
miocárdio: diferenças de gênero” funded by the Research Foundation of the State of Bahia (FAPESB,
as per its acronym in Portuguese) - Process No. APP
121/2009 and coordinated by Prof. Fernanda Carneiro Mussi.
Collaborations
Mendes AS; Reis VRSS and Mussi FC participated
in the project conception and development of the
phases of the study, drafting of the article, adaptation to the journal’s guidelines and final approval
of the version to be published. Menezes TMO collaborated with the data analysis and final approval
of the version to be published. Santos CAST contributed with the project conception and with the
analysis and interpretation of data.
References
1. Soares JS, Souza NR, Nogueira FJ, Cunha CC, Ribeiro GS, Peixoto RS,
et al. [Treatment of a cohort of patients with acute myocardial infarction
and ST-segment elevation]. Arq Bras Cardiol. 2009; 92(6):464-71.
2. Brasil. Ministério da Saúde. Datasus. Indicadores de Saúde. [Internet].
[citado 2013 Fev 10]. Disponível em: http://tabnet.datasus.gov.br/cgi/
deftohtm.exe?sim/cnv/obt10uf.def.
3. Acosta González M, Hernandez Valdés E, Nadal Tur B, Castellano
Almeida, Herrera Giró ML. Evaluación de lasacciones de enfermería en
el tiempo puerta aguja en pacientes com tratamiento trombolítico. Rev
Cubana Enferm. 2011; 27(1):79-87.
5. Sociedade Brasileira de Cardiologia. IV Diretriz sobre o Tratamento do
Infarto Agudo do Miocárdio com Supradesnível do Segmento ST. Arq
Bras Cardiol. 2009; 93(6 Supl 2): e179 - e264.
6. Silva SF. [The organization of regional and integrated healthcare
delivery systems: challenges facing Brazil’s Unified Health System].
Ciênc & Saúde Coletiva. 2011; 16(6):2753-62. Portuguese.
7. Mussi FC, Mendes AS, Queiroz TL de, Costa AL, Pereira A, Caramelli
B. [Pre-hospital delay in acute myocardial infarction: judgement
of symptoms and resistance to pain]. Rev Assoc Med Bras. 2014;
60(1):63-9. Portuguese.
8. Lessa I. Epidemiologia das doenças cerebrovasculares no Brasil. Rev
Soc Cardiol. Estado de São Paulo. 1999; 9(4):509-18.
Acta Paul Enferm. 2014; 27(6):505-12.
511
Access of patients with myocardial infarction to cardiology reference hospitals
9. Sampaio ES, Mendes AS, Guimarães AC, Mussi FC. Percepção de
clientes com infarto do miocárdio sobre os sintomas e a decisão de
procurar atendimento. Cienc Cuid Saúde. 2012; 11(4):687-96.
10.Sociedade Brasileira de Cardiologia; Sociedade Brasileira de
Hipertensão; Sociedade Brasileira de Nefrologia. VI Diretrizes
Brasileiras de Hipertensão. Arq Bras Cardiol. 2010; 95 (1 Supl 1):1-5.
11. Bastos AS, Beccaria LM, Contrin LM. [Time of arrival of patients with
acute myocardial infarction to the emergency department]. Rev Bras
Cir Cardiovasc. 2012; 27(3):411-8. Portuguese.
18. Ferreira GM, Correia LC. Reis H, Filho CB, Freitas F, Ferreira GM, et al. Maior
letalidade e morbidade por infarto agudo do miocárdio em Hospital Público,
em Feira de Santana - Bahia. Arq Bras Cardiol. 2009; 93(2):97-104.
19. Coelho LM, Resende ES. [Profile of patients with myocardial infarction
in a university hospital]. Rev Med Minas Gerais. 2010; 20(3):323-8.
Portuguese.
12.Girotto E, Andrade SM, Cabrera MA, Ridão EG. [Prevalence of risk
factors for cardiovascular diseases among people with hypertension
enrolled in a family health unit]. Acta Scientiarum Health Sciences.
2009; 31(1):7-82. Portuguese.
20. Solla DJ, Paiva Filho I de M, Delisie JE, Braga AA, Moura JB, Moraes
Xd Jr, et al. [Integrated regional networks for ST-segment-elevation
myocardial infarction care in developing countries: the experience of
Salvador, Bahia, Brazil]. Circ Cardiovasc Qual Outcomes. 2013; 6(1):
9-17. Portuguese.
13. Lessa I, Araújo MJ, Magalhães L, Filho NA, Aquino E, Costa MC. [Clustering
of modifiable cardiovascular risk factors in adults living in Salvador (BA),
Brazil].. Rev Panam Salud Publica. 2004; 16(2):131-7. Portuguese.
21.Mussi FC, Passos LCS, Menezes AA de, Caramelli B. Entraves no
acesso à atenção médica: vivências de pessoas com infarto agudo do
miocárdio. Rev Assoc Med Bras. 2007; 53(2):184-9.
14.Perkins-Porras L, Whitehead DL, Strike PC, Steptoe A. Pre-hospital
delay in patients with acute coronary syndrome: Factors associated
with patient decision time and home-to-hospital delay. Eur J Cardiovasc
Nurs. 2009; 8(1):26-33.
22. Kushner FG, Hand M, Smith SC Jr, King SB 3rd, Anderson JL, Antman EM,
Bailey SR, Bates ER, Blankenship JC, Casey DE Jr, Green LA, Hochman JS,
Jacobs AK, Krumholz HM, Morrison DA, Ornato JP, Pearle DL, Peterson
ED, Sloan MA, Whitlow PL, Williams DO. 2009 focused updates: ACC/AHA
guidelines for the management of patients with ST-elevation myocardial
infarction (updating the 2004 guideline and 2007 focused update)
and ACC/AHA/SCAI guidelines on percutaneous coronary intervention
(updating the 2005 guideline and 2007 focused update) a report of the
American College of Cardiology Foundation/American Heart Association
Task Force on Practice Guidelines. J Am Coll Cardiol. 2009 ;54(23):220541.Review. Erratum in: J Am Coll Cardiol. 2009 Dec 15;54(25):2464. J Am
Coll Cardiol. 2010 Feb 9;55(6):612. Dosage error in article text.
15.Figueiredo AE, Siebel AL, Luce DC, Schneider I. Determinação do
tempo de apresentação a emergência de pacientes com infarto agudo
do miocárdio. Rev Enferm UFSM. 2013; 3(1): 93-101.
16.Morais DA, Carvalho DV, Timerman S, Gonzalez MM. [Out-ofhospital cardiac arrest: cases assisted by the mobile emergency
service of Belo Horizonte]. Rev Bras Clin Med. 2009; 7(4):211-8.
Portuguese.
512
17.Silva NC, Nogueira LT. [Evaluation of operational indicators in a mobile
emergency care service]. Cogitare Enferm. 2012; 17(3):471-7. Portuguese.
Acta Paul Enferm. 2014; 27(6):505-12.
Original Article
Parasitological profile of residents
of a maroon community
Perfil parasitológico de moradores de uma comunidade quilombola
Débora Luiza de Oliveira Rangel1
Cesar de Oliveira2
Cynthia Maria Kyaw1
Antônio Marmoro Caldeira Júnior3
Pedro Sadi Monteiro1
Keywords
Parasitic diseases; Health promotion;
Public health nursing; Community
health nursing; Advanced practice
nursing
Descritores
Doenças parasitárias; Promoção da
saúde; Enfermagem em saúde pública;
Enfermagem em saúde comunitária;
Prática avançada de enfermagem
Submitted
February 18, 2014
Accepted
August 20, 2014
Corresponding author
Débora Luíza de Oliveira Rangel
Campus Universitário Darcy Ribeiro,
Brasília, DF, Brazil.
Zip Code: 70910-900
[email protected]
Abstract
Objective: Analyzing data on prevalence and species of intestinal parasites among residents of a maroon community.
Methods: A non-probabilistic sample survey for accessibility or convenience was used. The sample consisted of 153
individuals who answered an epidemiological investigation form and underwent parasitological examination of feces
by sedimentation technique of Hoffman-Pons-Janer and analysis of water, according to the multiple tube technique
to estimate medium density of microorganisms. The selection of the sample collection sites took into consideration
the environmental and sanitary criteria.
Results: The proportion of infested individuals was 16.8% and the statistically significant variables were the
municipality of residence (p = 0.048) and hygiene habits of hand washing (p≤0.001). Variables such as piped water,
presence of thermotolerant coliforms in the water (p = 0.038) and treatment of drinking water (p≤0.001) were
statistically associated with the variable of diarrheal episode in the last month (p = 0.008).
Conclusion: The results indicated infestations by different species of parasites related to diarrheal episodes
associated with poor hygiene conditions, especially the lack of drinking water treatment.
Resumo
Objetivo: Analisar dados sobre prevalência e espécies de parasitos intestinais entre moradores de uma comunidade
quilombola.
Métodos: Foi utilizado levantamento amostral não probabilístico por acessibilidade ou conveniência. A amostra
constituiu-se de 153 indivíduos que responderam uma ficha de investigação epidemiológica e que realizaram
exames parasitológicos de fezes. por meio da técnica de sedimentação de Hoffman-Pons-Janer e da análise da
água, segundo a técnica de tubos múltiplos, para estimativa da densidade média dos microrganismos. A seleção dos
locais de coleta das amostras levou em consideração critérios ambientais e sanitários.
Resultados: A proporção de infestados foi de 16,8% e as variáveis estatisticamente significativas foram município
de moradia (p=0,048) e hábito de higiene de lavagem das mãos (p≤0,001). As variáveis água encanada, presença
de coliformes termotolerantes na água (p=0,038) e tratamento da água de beber (p≤0,001) associaram-se
estatisticamente à variável episódio diarreico no último mês (p=0,008).
Conclusão: Os resultados indicaram infestações por diferentes espécies de parasitos relacionados a episódios
diarreicos associados às condições de higiene precárias, destacando-se a falta de tratamento da água para
consumo humano.
Universidade de Brasília, Brasília, DF, Brazil.
University College London, London, United Kingdom.
3
Faculdade Sena Aires, Valparaíso de Goiás, GO, Brazil.
Conflicts of interest: no conflicts of interest to declare.
1
DOI
http://dx.doi.org/10.1590/19820194201400084
2
Acta Paul Enferm. 2014; 27(6):513-9.
513
Parasitological profile of residents of a maroon community
Introduction
This study is based on the concept of health in its
social determinants interface. The health of populations is defined as a result of the forms of social
organization and production, which can generate
large inequalities in living standards. This complex
network of factors is interrelated and affects the
health-disease process in the individual specificity
and scope of the collective way of life.(1)
Intestinal parasitosis is a public health problem and considered a disease closely related to socio-sanitary conditions.(2,3 ) In data from the Brazilian Federal Government, the Kalunga territory is
described as possessor of the lowest human development index in the state of Goiás, with notable
problems related to housing, low educational level,
frailty and even the total absence of basic sanitation
and/or distribution of drinking water.(4)
The scenario of social vulnerability justifies studies in the area of health and its social determinants,
as well as the fact that in Brazil there are insufficient
references on the topic of incidence of parasitism in
the population, despite its relevance in the epidemiology and public health.(5) Therefore, the question
of parasitic infestations demands attention when it
comes to specific minority groups.
This study aimed to analyze data on the prevalence of intestinal parasites among Kalunga residents, describing the species of greater prevalence
and medical-social interest.
Methods
The study was carried out in the state of Goiás, in the
municipalities of Cavalcante, Teresina de Goiás and
Monte Alegre, in the west-central region of Brazil.
Historically and numerically, Kalunga is considered
the most important remaining maroon community
of the region, with about 5,000 inhabitants. (6)
The cross-sectional design, with non-probabilistic sample survey was chosen in the composition
of the sample. Socioeconomic information and
other data regarding the source of drinking water,
sanitation and hygiene habits were collected. Stool
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Acta Paul Enferm. 2014; 27(6):513-9.
examination was performed by the sedimentation
technique of Hoffman-Pons-Janer and analysis of
water, according to multiple tube technique to estimate the average density of microorganisms. The
selection of the sample collection sites took into
consideration environmental and health criteria.
Statistical analyzes were performed with the
IBM Statistical Package for the Social Sciences application version 21, in partnership with the University College London. The chi-square test at a significance level of 5.0% and a confidence interval of
95% were adopted.
The development of the study met national and
international standards of ethics in research involving human beings.
Results
The investigation form was answered by 67 families
and 153 individuals (Table 1). It was observed that
only two (1.3%) residents had permanent formal
employment, while the remaining 151 (98.7%)
survived with informal activities. The illiteracy rate
was 51.0% (n = 78) and the monthly family income
lower than minimum wage (n = 91, 59.5%) prevailed. In homes, the adobe was the most common
material used for construction (n = 79, 51.6%),
and burnt cement (n = 89, 58.2%) or dirt (n = 64;
41.8%) were used for indoor flooring. The earthen floor comprised 100 per cent of peridomestic
space. The diet was based on subsistence cultivation of local (n = 91, 59.5%) crops. All residents
were using water from rivers in the region, whether
through capture by hoses (n = 87, 56.9%), wells
(n = 38, 24.4%) or river water search with gallons
(n = 28, 18.3%). Almost half of the residents (n =
76, 49.7%) did not carry out any treatment in the
drinking water. Some level of thermotolerant coliforms was detected in 42.5% (n = 65) samples.
Only 64.7% (n = 99) of the residents had a
bathroom inside the house. The use of septic tank
occurred in 21.6% of cases (n = 33), the remaining
residents were using black sump (n = 89, 58.2%) or
open sewage discharge (n = 31, 20.3 %). As for the
household waste disposal, 95.4% of Kalunga com-
Rangel DL, Oliveira C, Kyaw CM, Caldeira Júnior AM, Monteiro PS
munity (n = 146) accumulated it on the ground for
burning later. The presence of domestic animals was
found in all residences. The occurrence of diarrhea
in the previous two months was reported by 88.2%
of respondents (n = 135) and 64.7% in the last
month (n = 99).
Table 1. Sanitary socioeconomic characteristics observed in
Kalunga community
Variables
Formal employment
Yes
n(%)
No
n(%)
eliminations. There was a statistically significant association with the last two variables, with p = 0.031
and p = 0.001, respectively.
Table 2. Distribution of infestation according to municipality,
gender, age group and educational level
Infestation
Variables
Yes
n(%)
No
n(%)
Municipality
Cavalcante
2(13.3)
13(86.7)
Teresina de Goiás
13(26.0)
37(74.0)
Monte Alegre de Goiás
9(10.2)
79(89.8)
Male
10(15.6)
54(84.4)
Female
14(15.7)
75(84.3)
2(1.3)
151(98.7)
Education level (literacy)
75(49.0)
78(51.0)
Monthly income (lower than minimum wage)
91(59.5)
62(40.5)
Type of material used for construction of the house (adobe)
79(51.6)
74(48.4)
Type of indoor flooring (burnt cement)
89(58.2)
64(41.8)
Peridomicile (earthen floor)
153(100.0)
-
<18
13(16.3)
67(83.8)
Provenience of the water (river)
153(100.0)
-
18-50
7(13.7)
44(86.3)
87(56.9)
66(43.1)
>51
4(18.2)
18(81.8)
Literate
13(17.3)
62(82.9)
Iliterate
11(14.1)
67(85.9)
Yes
14(14.1)
85(85.9)
No
10(18.5)
44(81.5)
Piped water inside the house
Treatment with drinking water
76(49.7)
77(50.3)
Water with presence of thermotolerant coliforms
65(42.5)
88(57.5)
Presence of bathroom in peridomicile
Gender
Age group (years)
Educational level
99(64.7)
54(35.3)
Presence of septic tank at home
33(21.6)
120(78.4)
Destination of household waste (burned)
143(95.4)
10(4.6)
Presence of any animal
153(100.0)
-
Grown food predominating in last meal
91(59.5)
62(40.5)
Yes
9(10.2)
79(89.8)
Case of diarrhea in the previous two months in the residence
135(88.2)
18(11.8)
No
15(23.1)
50(76.9)
Case of diarrhea in less than a month in the residence
99(64.7)
54(35.3)
Yes
2(3.5)
55(96.5)
No
22(22.9)
74(77.1)
The prevalence of intestinal parasites was 16.8%.
Table 2 shows the distribution of the sample according to the presence of infestation. The municipality of Cavalcante had 13.3% of positive results
for intestinal parasites, all Endolimax nana. Teresina
de Goiás had 26.0%, of which 42.9% of Entamoeba coli, 28.6% of Iodomoeba butshilii, 14.3% of E.
nana, 7.1% of Entamoeba hystolitica and 7.1% of
hookworms. Monte Alegre lot had 10.2% of positive results, of which 40.0% of E. coli, 20.0% of
E. nana, 20.0% of E. hystolitica , 10.0% of I. butshilii and 10.o% of hookworms. The variables gender, age and education showed a similar distribution, not constituting determinant for infestation.
Among infested people, 14.1% reported diarrhea in
the last month; 10.2% used water with the presence of thermotolerant coliforms; and 91.7% did
not wash their hands regularly after physiological
Diarrheal episode in the last month
Thermotolerantes coliforms in water
Do you always wash your hands after using the toilet?
Table 3 shows the results of the percentage distribution of the sample by occurrence of diarrhea in
the last month.
It was evident that among the infected individuals (n = 24), 58.3% reported diarrhea episodes in
the previous month. However, only 14.1% of the
residents without infestation reported such reference.
The education variable inferred that there were
no significant differences between literate and illiterate regarding the occurrence of diarrheal episode
in the previous month. In the association between
the occurrence of diarrhea in the last month and
parasite species responsible for the infestation, the
values were: 33.3% (n = 1) with E. nana, 60% (n =
6) with I. butshilii, 100.0 % (n = 3) with E. coli, and
50.0% (n = 3) with E. histolytica; 100.0% (n = 2) of
Acta Paul Enferm. 2014; 27(6):513-9.
515
Parasitological profile of residents of a maroon community
Table 3. Distribution of cases of diarrhea in the last month
according to sanitary conditions of households and infestations
by parasites
Variables
Diarrheal episode in the last month
Yes n(%)
No n(%)
Yes
14(58.3)
10(41.5)
No
85(65.9)
44(34.1)
Iliterate
52(66.7)
26(33.3)
Literate
47(62.7)
28(37.3)
Infestation
Education level
Type of parasite
Cysts of Endolimax nana
1(33.3)
2(66.7)
Cysts of Iodomoeba butshilii
6(60.0)
4(40.0)
Cysts of Entamoeba coli
3(100.0)
-
Cysts of Entamoeba histolytica
3(50.0)
3(50.0)
Eggs of ancilostomideo
2(100.0)
-
-
1(100.0)
Yes
64(73.6)
23(26.4)
No
35(53.0)
31(47.0)
Yes
66(66.7)
33(33.3)
No
33(61.1)
21(38.9)
Yes
63(71.6)
25(28.4)
No
36(55.4)
29(44.6)
Yes
36(46.8)
41(53.2)
No
63(82,.)
13(17.1)
Yes
41(71.9)
16(28.1)
No
58(60.4)
38(39.6)
Entamoeba hystolitica + eggs of hookworms
Tap water inside the house
Presence of bathroom inside the house
Water with presence of Thermotolerants Coliforms
Treatment of drinking water
Do you always wash your hands after using the toilet?
those infested by E. hystolitica and hookworm also
reported diarrhea in the previous month.
Piped water showed a statistical significance in
association with diarrheal episode in the last month
(p = 0.008). Both in homes with indoor bathroom
and in others, there was a high percentage of affirmative responses for the occurrence of diarrheal
episodes: 66.7% (n = 66) and 61.1% (n = 33), respectively. There was a statistically significant association (p = 0.038) between the variables diarrheal
episodes and presence of thermotolerant coliforms
in the water, while 71.6% (n = 63) of households
supplied by water with thermotolerant coliforms
reported diarrheal episodes in the previous month.
Treatment with drinking water expressed strong association (p≤0.001) with the occurrence of diarrhea
in the last month. The group that did not treat the
drinking water had 82.9% (n = 63) of cases of diarrheal episode in the previous 30 days. Washing
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Acta Paul Enferm. 2014; 27(6):513-9.
hands after using toilets or equivalent was not statistically significant regarding the diarrheal episode
variable; however, the non-occurrence of diarrheal
episodes was lower in percentage among Kalunga
residents who reported regularly washing the hands
(n = 16, 28.1%) compared with those who reported
no such regularity (n = 38, 39.6%).
Discussion
The limit of the results of this study refers to the
cross-sectional design, in which the possible associations between variables are known only during
analysis of data, thus not allowing a temporal
knowledge of when a certain fact would have occurred, or even how a certain evolution would have
happened.
It is relevant to know the parasitological profile
of such a singular community, because it can contribute to the planning and programming of local
and regional actions that address the real needs of
the Kalunga community, taking into account cultural considerations, the tradition, the customs and
values​​. The results of this study may have practical
applicability in the field of public health, which is a
vast practice area of nurses.
The exposure of the Kalunga community to
predictors of occurrence of intestinal parasite infestations was observed. This is because the risk
factors for intestinal parasites are the poor sanitary, educational, social and economic conditions;
lack of water treatment for human consumption;
the high rate of agglomeration of people; inappropriate soil use, as well as its contamination and of
the food.(7)
These results suggest that intestinal parasites diseases can arise as a disorder capable of illustrating
the interface between health and social conditions,
demonstrating by means of the high proportion of
infestation, the risk of exposure of residents and diarrhea cases,(8) and taking into account that water
comes from rivers, through hoses, wells or active
uptake in gallons. In most homes, it does not receive treatment before consumption. This is heightened in serious problem, since untreated water can
Rangel DL, Oliveira C, Kyaw CM, Caldeira Júnior AM, Monteiro PS
be a source of transmission of diseases, including
intestinal diseases.(9)
Most of this group had no permanent formal
employment, surviving through activities at the
margins of existing labor standards in the country.
Many families were below the poverty line or even
indigence.(10) Educational level was low because
among the literate, 45.1% had only incomplete
primary education; illiterates accounted for 51.0%.
This reality revealed discrepancy relative to other regions because according to the Brazilian Institute
of Geography and Statistics (IBGE – Instituto Brasileiro de Geografia e Estatística), the illiteracy rate is
twice the national average of 8.6% among residents
of rural areas.(11)
In the studied villages, there was no demarcation of streets and there was certain isolation between houses. These followed the traditional style
used by black ancestors who built their houses with
local materials.(12) Such physical, simple and rustic
structure (adobe walls, burnt cement floor or earthen floor) associated with the sanitary standards of
the population reflects the precarious socioeconomic conditions.(13)
The sanitary infrastructure is one of the main
health demands of the community. Not all residents had a bathroom; 64.7% reported having
bathroom just around the homes; and 34.3%
used rivers or the soil for physiological eliminations. In houses with presence of excreta disposal
system, 78.7% open sewage discharge and black
sumps were predominant. The community had
no regular waste collection and in 95.4% of cases this accumulation occurred on the ground to
burn later. In every home, there were domestic
animals, both within domestic space as around
the houses. This situation of absence of toilet in
most homes, accumulation of solid waste and
disposal of human waste and household animals,
favors not only the proliferation of vectors and
microorganisms that cause endemic diseases and
parasites, but also contamination of surface water sources.(13)
The presence of thermotolerant coliforms in waters that supplied 42.5% of homes reinforces the
hypothesis that the effluent waste produced can
reach the sources of drinking water when they percolate the soil.(9)
Intestinal parasites are an important indicator of
the hygiene and sanitation conditions of the entire
population.(14) This corroborates the findings in the
Kalunga community described so far, supporting
the statistical significance (p = 0.031) found between the variables presence of thermotolerant coliforms and infestation by enteropathogens.
The parasites identified in the study have mechanisms of fecal-oral transmission, with prevalence
of the non-pathogenic over the pathogenic.(13) This
indicates contamination with fecal waste, which is
plausible of understanding when considering the
poor sanitary conditions of the Kalunga community.(6) The finding reinforces the need of investment
in preventive actions to promote health, especially
in education and health, in infrastructure and basic
sanitation.(15-17)
The close relationship between hygiene habits
and enteroparasite infestation(18) supports the statistical significance (p = 0.001) found between handwashing and infestation variables. Our hands serve
as a vehicle of fecal-oral contamination, therefore,
the lack or failure of principles of hygiene such as
handwashing is a predisposing factor to infestation
by intestinal parasites.(5,19)
Diarrhea has approximately 88% of its occurrence attributed to water supply, inadequate sewage
and hygiene.(20) This fact justifies the high rates of
diarrheal episodes in previous months to conducting the study: 64.7% in first month and 88.2%
in the second. Although these conditions are not
directly responsible for the occurrence of diarrhea,
they favor the proximity of its determinants.(1)
Furthermore, the diarrheal event is related to the
action of the parasite, with clinical manifestations
proportional to the harbored parasite load.(5)
The presence of infestation showed a similar
pattern across the variables of municipality, gender,
age and education. The proximity of the data can
be related to the fact that Kalunga habitants live in
towns / villages with no exact boundaries and similar living conditions.(21) The statistical significance
(p = 0.048) of the municipality variable confirmed
the proposed.
Acta Paul Enferm. 2014; 27(6):513-9.
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Parasitological profile of residents of a maroon community
The occurrence of diarrhea had statistical significance in the association with presence of thermotolerant coliforms and piped water. The unavailability of piped water is a determinant factor
of diarrheal disorder because easy access to water
contributes to personal, domestic and food hygiene,
without which it is impossible to break the cycle
of intestinal parasites transmission.(22) In addition,
water quality is a potentiating factor of interruption
of the chain.(18)
As previously described by other authors, the
study also showed that in the Kalunga community
sanitation conditions were deficient, public services
of water treatment non-existing, and living conditions were inadequate in terms of infrastructure and
Quality of Life.(6,23,24) This scenario is aggravated by
the disposal of human and solid waste in peridomestic areas close to rivers; by the consumption of
untreated water; and the contamination of water by
thermotolerant coliforms. All these are associated
with the prevalence of insufficient hygiene habits,
high percentage of parasites and poor sanitation.(25)
Such environmental fragility negatively impacts
on the social determinants of health and keeps the
Kalunga community prone to intestinal parasites. (9)
Conclusion
The Kalunga community showed infestation by different parasites associated with diarrheal episodes.
Cases of diarrhea were associated with precarious
hygiene conditions, especially the lack of drinking
water treatment.
Acknowledgements
Thanks to the support provided by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes) under process BEX 3914 / 13-5 and
the Programa Institucional de Bolsas de Doutorado
Sanduíche no Exterior.
Collaborations
Rangel DLO contributed to project design, execution of the research, drafting the article and relevant
critical revision of the intellectual content. Oliveira
518
Acta Paul Enferm. 2014; 27(6):513-9.
C; Kyaw CM and Caldeira Júnior AM contributed
to the execution of the research. Monteiro PS contributed to the final approval of the version to be
published.
References
1. Sant’anna CF, Cezar-Vaz MR, Cardoso LS, Erdmann AL, Soares JF. [Social
determinants of health: community features and nurse work in family
health care]. Rev Gaucha Enferm. 2010; 31(1):92-9. Portuguese.
2. Frei F, Juncansen C, Ribeiro-Paes JT. [Epidemiological survey of
intestinal parasite infections: analytical bias due to prophylactic
treatment]. Cad Saúde Pública. 2008; 24(12):219-25. Portuguese.
3. Menezes RA O, Gomes MS, Brabosa FH, Brito GC, Proietti Junior AA,
Couto AA. [Intestinal Parasites in residente population in humid área
in Macapá, Amapá, Brazil]. Rev Biol Ciênc da Terra. 2013; 13(2):10-8.
Portuguese.
4. Magalhães NA, Koyanagi R. [Photo essay: Kalunga´s territory in Vão das
Almas community in the satate of Goiás]. Rev RDP. 2013; 1(1):198201. Portuguese.
5. Andrade EC, Leite IG, Rodrigues IO, Cesca MG. [Intestinal parasites: a
review of its social aspects, epidemiological, clinical and therapeutic].
Rev APS. 2010; 13(2):231-40. Portuguese.
6. Fioravant MC, Sereno JR, Neiva AC, Abud LJ, Lobo JR, Francescantônio
DD, et al. [Reintroduction of cattle Curraleiro maroon community in
the Kaluga Cavalcante, Goiás, Brazil. Partial results]. In: IX Simpósio
Nacional do Cerrado, II Simpósio Internacional de Savanas Tropicais;
2008 Oct 12-17; Brasília, DF: PariaMundi; 2008.
7. Borges WF, Marciano FM, Oliveira HB. [Intestinal parasites: high
prevalence of Giardia lamblia. in patients treated by the Public Health
Service in Southeast Region of Goiás, Brazil]. Rev Parasitol Trop. 2011;
40(2):149-57. Portuguese.
8. Nyarango RM, Aloo PA, Kabirun EW, Nyanchongi BO. [The risk of
pathogenic intestinal parasite infections in Kisii Municipality, Kenya].
BMC Public Health. 2008; 237(8):1-6.
9. Cordeiro MR, Rodrigues AM, Souza PR, Ferreira MI. [Assessment of
the contamination with domestic wastewater in supply wells over
sandbank area]. Bol Observatório Ambiental Alberto Ribeiro Lamego.
2011; 5(1):89-102. Portuguese.
10. Tibúrcio BA, Valente AL. [Is the fair trade an alternative for impoverished
segments of the population? Case study in Kaluga Territory (GO)]. Rev
Econ Sociol Rural. 2007; 45(2):497-519. Portuguese.
11.Instituto Brasileiro de Geografia e Estatística (IBGE). Coordenação de
População e Indicadores Sociais. Síntese de indicadores sociais: uma
análise das condições de vida da população brasileira: 2012. Rio de
Janeiro: IBGE; 2012.
12.Araujo RE, Foschiera AA. [Contradictions between the reality
socioeconomic community quilombola Mimoso do Kalunga warranty
and legal rights education and territory]. Revista Pegada. 2012;
13(2):203-27. Portuguese.
13.Amorim MM, Tomazini L, Silva RA, Gestinari RS, Figueiredo TB.
[Evaluation of housing conditions and health community Quilombola
Boqueirão, Bahia, Brazil]. Biosc J. 2013; 29(4):1049-57. Portuguese.
14. FD, Cocco J, Bento RRL, Ribeiro F. [Evaluation of intestinal parasitosis
Rangel DL, Oliveira C, Kyaw CM, Caldeira Júnior AM, Monteiro PS
in school-children in the municipality of Coração de Jesus, State of
Minas Gerais, Brazil]. RBAC. 2011; 43(4):277-83. Portuguese.
15. Ngui R, Ishak S, Chuen CS, Mahmud R, Lim YA. [Prevalence and risk
factors of intestinal parasitism in rural and remote west Malaysia].
PLoS Negl Trop Dis. 2011; 5(3):1-7.
16.Gonçalves AL, Belizário TL, Pimentel JB, Penatti MP, Pedroso RS.
[Prevalence of intestinal parasites in preschool children in the region
of Uberlândia, State of Minas Gerais, Brazil]. Rev Soc Bras Med Trop.
2011; 44(2):191-3.
20.Reymão AE, Saber BA. [Access to clean water and insufficient
income two dimensions of the problem of poverty in the Northeast
Brazil from the perspective of the Millennium Development Goals].
Revista Iberoamericana de Econom Ecol. 2009; 12(1):1-15.
Portuguese.
21.Souza CL. [The community Kalunga]. Ateliê Geográfico. 2010;
4(1):196-210. Portuguese.
22. Freitas DA, Cabaleto A, Hernande C, Antunes S. [Health and quilombolas
communities]. Rev CEFAC. 2011; 13(5):937-43. Portuguese.
17.Oramas JL, Rodrígues AP, Villavilla CM, Pérez JS. [Parasitismo
Intestinal em uma cohorte de escolares em 2 municipios de Ciudad de
La Habana]. Rev Cubana Med Trop. 2008; 60(3):114-28. Spanish.
23.Neiva AC, Sereno JR, Fiorivanti MC. [Geographical indication in
conservation and value aggregation to curraleiro cattle of the Kalunga
community]. Arch Zootecnia. 2011; 231(60):357-60. Portuguese.
18.Santos AS, Merlini LS. [Prevalence of enteroparasitosis in the
population of Maria Helena, Paraná State]. Ciênc Saúde Coletiva.
2010; 15(3):899-905. Portuguese.
24. De Lima LN. [The constitution of an identity territory for a warranty of
land rights: The historical and cultural site Kalunga]. Soc. & Nat. 2013;
25(3):502-12. Portuguese.
19.Londoño AL, Mejía S, Gómez-Marín JE. [Prevalence and risk factors
associated with intestinal parasitismo in preschool children from the urban
area of Calarcá, Colombia]. Rev Salud Pública. 2009; 11(1):72-81. Spanish.
25. Dagei H, Kurt Ö, Demirel M, Östan I, Azizi NR, Mandiracioglu A et al.
The prevalence of intestinal parasites in the province of Izmir, Turkey.
Parasitol Res. 2008; 103(1):839-45.
Acta Paul Enferm. 2014; 27(6):513-9.
519
Original Article
Nursing staff knowledge in relation
to complications of diabetes
mellitus in emergency services
Conhecimento da equipe de enfermagem nas
complicações do diabetes mellitus em emergência
Daiani Moraes Oliveira1
Soraia Dornelles Schoeller1
Karina Silveira de Almeida Hammerschmidt1
Mara Ambrosina de Oliveira Vargas1
Juliana Balbinot Reis Girondi1
Keywords
Emergency nursing; Diabetes mellitus;
Diabetes complications; Nursing care
Descritores
Enfermagem em emergência; Diabetes
mellitus; Complicações do diabetes
mellitus; Cuidados de enfermagem
Submitted
July 28, 2014
Accepted
August 20, 2014
Corresponding author
Karina Silveira de Almeida
Hammerchmidt
Campus Universitário Reitor João David
Ferreira Lima, Florianópolis, SC, Brazil.
Zip Code: 88040-900
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400085
520
Acta Paul Enferm. 2014; 27(6):520-5.
Abstract
Objective: To investigate nursing staff knowledge in relation to acute complications of diabetes mellitus (DM)
in emergency services.
Methods: A qualitative study conducted with 18 nursing staff members working in an adult emergency
hospital service. Inclusion criteria were: 1) having worked for at least six months in the emergency service; 2)
having no plans of being absent from the service. Semi-structured interviews were recorded and conducted
individually. The thematic analysis was used for organizing and analyzing data.
Results: Four themes emerged: 1) recognizing the signs and symptoms associated to severity in diabetes;
2) determining the urgency of care for people with diabetes; 3) the sequence of nursing care for acute
complications of diabetes; and 4) recognizing risks and complications during nursing care.
Conclusion: The nursing staff working in the studied adult emergency service displayed knowledge in relation
to how to care for acute DM complications, however, there were limitations regarding routine care practices.
Resumo
Objetivo: Investigar o conhecimento da equipe de enfermagem sobre assistência nas complicações agudas
do diabetes mellitus em serviço de emergência.
Métodos: Pesquisa qualitativa realizada com 18 profissionais da equipe de enfermagem de um serviço
hospitalar de emergência para adultos. Critérios de inclusão: atuação no serviço de emergência há pelo
menos seis meses; sem previsão de afastamento do serviço. As entrevistas gravadas foram realizadas
individualmente, utilizando roteiro semi-estruturado. Para organização e análise dos dados, seguiram-se a
Análise Temática.
Resultados: Emergiram quatro temas: reconhecimento dos sinais e sintomas associados à gravidade no
diabetes; determinação da urgência nos atendimentos das pessoas com diabetes; sequência dos cuidados
de enfermagem nas complicações agudas do diabetes; reconhecimento dos riscos e complicações durante
o atendimento de enfermagem.
Conclusão: Os profissionais de enfermagem que atuam numa emergência adulto possuem conhecimento
acerca do atendimento às complicações agudas do diabetes, porém há limitações referentes à prática
rotineira dos cuidados.
Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.
Conflicts of interest: there are no conflicts of interest to declare.
1
Oliveira DM, Schoeller SD, Hammerschmidt KS, Vargas MA, Girondi JB
Introduction
Diabetes mellitus (DM) refers to a group of metabolic diseases characterized by high levels of blood
glucose (hyperglycemia) due to defects in insulin secretion and/or action. In 2002, there were 173 million people diagnosed with diabetes throughout the
world, and this number is estimated to reach 300
million by 2030.(1) This disease ranks among the
most serious health problems due to its high rates
of morbidity, disabilities, and premature death, as
well as the public cost involved with its treatment
and related complications.(2)
There are two main acute situations related to
diabetes in the professional practice of adult emergency nursing: severe hypoglycemia and diabetic ketoacidosis. Professionals must immediately identify
both conditions, as they can provoke altered level of
consciousness leading to airway impairment, coma
and even death.(1)
Considering the Brazilian context, in which hospital emergency services can be the entryway into
the Brazilian Unified Health System (SUS, as per
its acronym in Portuguese), it is essential that nursing staff master the management of such emergency
situations. Diabetes-related emergency care must be
organized in order to ensure patient embracement,
and quality and decisive care, thus reducing acute
DM morbimortality rates.(3,4)
Thus, the objective of this study was to investigate the nursing staff knowledge of care for acute
DM complications in emergency services.
Methods
This was a qualitative study conducted with nursing
professionals working in an adult emergency service
in a teaching hospital in Santa Catarina, southern
Brazil. The risk classification system adopted by
the SUS was used to define the priority of patients’
treatment: red (emergency), orange (very urgent),
yellow (urgent), green (not very urgent), blue (not
urgent) and white (procedures).
Eighteen professionals participated in the
study, five of which were nurses and 13, nursing
technicians. Sample size was guided by the principle of data saturation and staff members from
all work shifts were included: morning, afternoon and night. Inclusion criteria were: 1) having
worked for at least six months in the hospital’s
emergency service; 2) having no plans of being
absent from the service for more than a month
during data collection.
Semi-structured interviews were recorded and
conducted individually between May and July
2013. In order to ensure participants’ anonymity,
nurses were identified with a capital “N” and nursing technicians with “NT”, and they were assigned
a number according to the order in which they were
interviewed.
The assumptions of the thematic analysis were
observed for data organization and analysis: First,
the speeches were organized, once the interviews
had been fully transcribed and an exhaustive reading of the empirical material was conducted. Afterwards, speech excerpts were organized by selecting
relevant ideas that formed units of meaning, which
were then coded and organized into sub-themes related to the broader themes.
The development of this study complied with
ethical guidelines for research involving human
subjects.
Results
As characteristic signs of diabetes-related alterations, nurses and nursing technicians mentioned
sweating, altered levels of consciousness, pallor, ketotic breath, thirst, labored breathing, tachypnea,
general discomfort, nausea, apathy, polyuria, weakness, faintness, dizziness, abdominal pain, deterioration of general condition, altered visual perception and edemas.
Some nurses reported how the risk classification
applied to patients in emergency care: “[...] if there
is hyperglycemia, the patient is classified as yellow”; “
[...] if the patient condition is more severe, he/she is
classified as orange”; “If the blood glucose test is altered,
patients are classified with a higher color, or if there
other alterations, they are orange or red, depending on
Acta Paul Enferm. 2014; 27(6):520-5.
521
Nursing staff knowledge in relation to complications of diabetes mellitus in emergency services
the severity”; “If blood glucose is above 300mg/dl, I
immediately classify patients as orange and pass them
on to the doctor”.
All nurses emphasized the importance of referring emergency patients directly to medical care:
“[...] if they wait outside the emergency room, their
condition may worsen, so it’s best to take them directly
to a resuscitation or medication room [...],” “[...] if
blood glucose is below 60mg/dl, I place them straight
inside [...],” “[...] hypoglycemia or ketoacidosis characterizes priority patients and I generally accompany
them all the way inside, I call the doctor and request
immediate care. I place the patient inside the emergency service, inside the examining room or in the resuscitation room. But I don’t leave them waiting outside the
emergency service, they stay inside, practically in front
of the doctor so that procedures can begin.”
Within the sub-theme priority of care, extreme
glycemic levels were mentioned as priority (hypoglycemia and hyperglycemia): “[...] when blood
glucose test indicates very altered results, either very
high or very low, that is a priority” “Both diabetic ketoacidosis and hypoglycemia are priorities, emergency
situations.”
Altered levels of consciousness were also mentioned as priority: “[...] when the patient arrives
unconscious and the family member reports that they
have a history of diabetes,” “[...] fainting,” “[...]
drowsiness.”
Blood glucose testing was mentioned as a priority nursing care action and establishing venous
access as the first nursing action in diabetic ketoacidosis and severe hypoglycemia situations. Other
first and priority nursing actions reported by participants included identifying the situation, verifying
respiratory pattern, assessing signs and symptoms,
monitoring vital signs, conducting arterial blood
gas analysis and providing supplementary oxygen.
Regarding general actions recommended for
acute DM complications, all participants highlighted compliance with medical prescription; institutional routine in cases of hypoglycemia; patient stabilization and assisting medical procedures when a
situation becomes worse. They also mentioned primary patient assessment according to the ABCDE
approach (airways, breathing, circulation, disabili-
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Acta Paul Enferm. 2014; 27(6):520-5.
ty, exposure), and monitoring hydroelectrolytic and
acid-base balance.
Nursing care records in diabetic ketoacidosis
and severe hypoglycemia situations were carried out
on complementary nursing observation forms, vital
sign forms (with slots for time of measurement and
values of blood glucose tests and the presence or
absence of respective correction insulin). All nurses mentioned keeping nursing assessment records,
emphasizing that the nursing care methodology is
only applied to patients in the resting unit.
Five nursing technicians reported not keeping
any type of care record: “[...] maybe the nurses write
it down.” One nurse reported sometimes keeping
records only on the patient’s emergency form: “If
the patient does not have a chart yet, I end up keeping
records right there on the emergency care form.”
Regarding diabetes-related complications, professionals mentioned rebound glycemic instability
due to glucose or insulin treatment, which can lead
to hypoglycemia or hyperglycemia, according to the
situation: “[...] it all happens very fast, the patient’s
blood glucose changes and can cause damage if it decreases or increases too quickly.”
Professionals also mentioned diabetic coma as
an important complication that can occur during
patient care: “[...] the patient can fall into a diabetic
coma and have an arrest [...],” “If patients wait too
long to receive care, they risk progressing to a hyperosmolar coma and presenting complications and needing
more invasive care.” Cardiac arrest and even death
were mentioned: “With diabetic ketoacidosis, there is
a risk of initiating insulin too prematurely and not
monitoring hydroelectrolytic parameters, the patient
can lose too much potassium and have an arrest.”
Other reported complications were patient falls,
risk of seizures and multiple complications.
Discussion
This study presented limitations related to the
routine practice of the care procedures mentioned by participants, such as the absence of
record keeping by some nursing technicians and
the poor use of the institution’s hypoglycemia
Oliveira DM, Schoeller SD, Hammerschmidt KS, Vargas MA, Girondi JB
protocol. Another limitation is one inherent to
qualitative research, as it limits the degree to
which results can be generalized.
Four themes emerged: 1) recognizing the signs
and symptoms associated to severity in diabetes; 2)
determining the urgency of care for persons with
diabetes, 2) the sequence of nursing care for acute
complications of diabetes and 4) recognizing risks
and complications during nursing care.
Within the first theme, participants reported
17 diabetes-related signs and symptoms that indicate severity, with emphasis on sweating and
pallor, frequently identified during initial assessments of hyperglycemic cases. According to the
literature, altered levels of consciousness can occur
both in hypoglycemia and in diabetic ketoacidosis.
(1,5-11)
Five nurses mentioned altered mental status
as important, and of these, three emphasized it as
a sign of severity.
Some of the signs and symptoms of hypoglycemia described in the literature were not mentioned, such as: tremors, anxiety, hunger, parasthesia, dysarthria, gait disorders and headaches.
Similarly, participants did not report some severe symptoms of diabetic ketoacidosis, such as
flushing, vomiting, dehydration and arterial hypotension, which can progress to hypovolemic
shock.(1,7,10,12,13)
Ketotic breath and Kussmaul breathing, which
are commonly cited in the literature as characteristic
signs and indicators of severity in diabetic ketoacidosis, were mentioned by six interviewees. Ketotic
breath is not always present or noticeable. However, altered breathing patterns are visible and manifested initially as tachypnea, followed by Kussmaul
breathing, which can progress to shallow breathing
in more severe cases.(1,2,7,12)
Within the second theme, determining the
urgency of care for persons with diabetes, situations such as extreme blood sugar levels prevailed
as requiring priority care. Severe hypoglycemia can
provoke arrhythmia and increased myocardial demand for oxygen, favoring angina conditions, in
which irreversible neurological damage can occur.
Thus, it is essential that it be identified as early as
possible.(8,12,14-16)
Considering the third theme, sequence of nursing care for acute complications of diabetes, professionals identified hypoglycemia as having higher priority over hyperglycemia. Regarding priority
actions in cases of diabetes-related complications,
nurses mentioned venipuncture and nursing technicians mentioned periodic verification and monitoring of blood glucose levels. According to protocol
guidelines, measuring blood glucose levels systematically following a rigorous verification schedule
is part of the duty of nursing professionals, as well
as recording blood glucose levels and administered
doses on an institutional form.(15,17) When treating
diabetic ketoacidosis with intravenous insulin infusion, blood glucose must be verified on an hourly
basis. After blood pH is normalized, verifications
can occur every four hours.(2,11,14-16)
Establishing venous access for large-caliber
catheters is required due to the need for vigorous hydration, continuous insulin infusion, and
hydroelectrolytic and acid-base imbalance correction, in accordance with each case. One nurse
reported only performing punctures on patients
in the presence of a physician. The Brazilian Federal Nursing Council establishes that if there is a
clinical protocol validated by the institution for
cases of hypoglycemia, nursing staff can establish
venous access in severe cases and carry out the initial treatment until the physician returns for reassessment and to continue medical management.
However, this protocol is underused, probably
because there is a physician present in the sector
24 hours a day.(11,18)
Still regarding sequence of care, participants
mentioned the issue of nursing care records. Five
nursing technicians stated not keeping any record
of the care provided in cases of severe hypoglycemia
and diabetic ketoacidosis. It is the responsibility and
duty of nursing professionals to record professional
actions in the patient’s chart and in other appropriate documents, electronic or non-electronic. Nursing records document the work done by the team
and are indicators of quality care; whereas their incorrect completion and lack of periodicity are factors that hamper assessment, certification and the
creation of indicators, and also hinders the action of
Acta Paul Enferm. 2014; 27(6):520-5.
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Nursing staff knowledge in relation to complications of diabetes mellitus in emergency services
inquiries and investigations that can provide professionals and institutions with legal support.(17)
All nurses mentioned keeping care records on
complementary observation and nursing assessment forms. They also emphasized the difference
between routine care in the Internal Emergency
Service and in Resting. Nursing care is only systematized in the Resting sector, where all patients
have gone through admissions, which includes
nursing assessment and prescriptions. According
to legislation, these actions are mandatory in all
environments, whether public or private, in which
professional nursing care takes place.(19) It is a tool
that allows nurses to apply their technical and
scientific knowledge and document patient care;
actions which characterize nursing professional practice and help define the role of nurses in a
multiprofessional health team.(19)
Regarding the fourth theme, risks and complications that can occur while caring for cases of
hypoglycemia and diabetic ketoacidosis, most professionals mentioned rebound glycemic instability
due to insulin or glucose treatment, with oscillations to lower or higher extremes of blood glycemic
levels, according to the situation. Glycemic variation is an important factor in the rise of mortality
by inducing cellular oxidative stress.(14) Iatrogenic
hypoglycemia affects up to 90% of individuals
treated with insulin.(9)
The most common complications to diabetic
ketoacidosis are hypoglycemia as a result of inappropriate insulin use, hypocalcemia due to inadequate doses of insulin and/or sodium bicarbonate
and hyperglycemia secondary to the interruption
of insulin infusion without the correct compensation with subcutaneous insulin, hypoxemia, and
acute pulmonary edema and hyperchloremia due
to excessive fluid infusion. Cerebral edema is a rare
complication among adults, but can progress to a
seizure and even a coma and cardiopulmonary arrest, complications mentioned by a great portion
of those interviewed. Severe hypocalcemia offers
the risk of complications such as cardiac arrhythmia with cardiopulmonary arrest or respiratory
muscle weakness, which can potentially progress
to acute respiratory failure.(12,17,20,21) Risk of falls is
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Acta Paul Enferm. 2014; 27(6):520-5.
also present, especially if there is mental confusion
and agitation.
Investigating nursing staff knowledge with respect to treating diabetic patients who seek out
emergency services, allows us to identify the gaps
and strengths of nursing care. Considering that
emergency services are frequently an entryway
to the health system, careful assessment and efficient care can avoid complications and even death
among diabetics.
Further studies in this line of research need
to be carried out to identify and prepare for possible training needs for nursing professionals who
work in adult emergency services. It is important
to mention that, despite this study being local, it
presents important themes that must be highlighted globally: nursing staff knowledge of diabetes;
protocols for treating diabetic patients in emergency services; urgent and emergency care actions
that can be conducted by nursing professionals;
professional training on the topic of urgencies and
emergencies when caring for diabetic patients, and
preventing complications when caring for such patients in emergency services.
Conclusion
The nursing professionals working in the studied
adult emergency service displayed knowledge regarding the clinical presentation of acute DM complications. Severe hypoglycemia was more frequently mentioned than diabetic ketoacidosis. They were
able to recognize signs and symptoms associated
with the severity of diabetes; determining urgency
of care for individuals with diabetes; sequence of
nursing care and acute complications of diabetes,
and recognizing risks and complications during
nursing care.
Collaborations
Oliveira DM contributed with the project conception, data analysis and interpretation, drafting of
the article and content review. Schoeller SD and
Hammerschmidt KSA collaborated with the project conception, data analysis and interpretation,
Oliveira DM, Schoeller SD, Hammerschmidt KS, Vargas MA, Girondi JB
drafting of the article, critical review of its relevant
intellectual content and final approval of the version for publication. Vargas MAO and Girondi JBR
contributed with the critical review of its relevant
intellectual content and the final approval of the
version for publication.
References
1. AC Farmacêutica. II Diretrizes da Sociedade Brasileira de Diabetes
2012 - 2013. São Paulo: AC Farmacêutica; 2013.
2. Sousa JN, Nóbrega DR, Araki AT. Perfil e percepção de diabéticos sobre
a relação entre diabetes e doença periodontal. Rev Odontol UNESP.
2014; 43(4):265-72.
3. Brasil. Ministério da Saúde. Portaria 2048, de 5 nov 2002. Regulamento
Técnico dos Sistemas Estaduais de Urgência e Emergência [Internet].
Brasília (DF): Ministério da Saúde; 2002. [citado 2014 Ago 9].
Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2002/
prt2048_05_11_2002.html.
4. Brasil. Ministério da Saúde. Portaria n. 1600, de 7 jul 2011. Reformula
a Política Nacional de Atenção às Urgências e institui a Rede de
Atenção às Urgências no SUS [Internet]. Brasília (DF): Ministério da
Saúde; 2011. [citado 2014 Ago 9]. Disponível em: http://bvsms.saude.
gov.br/bvs/saudelegis/gm/2011/prt1600_07_07_2011.html.
5. Goyal A, Mehta SR, Díaz R, Gerstein HC, Afzal R, Xavier D, et al.
[Differential clinical outcomes associated with hypoglycemia and
hyperglycemia in acute myocardial infarction]. Circulation. 2009;
120(24):2429-37.
6. Modenesi RF, Mesquita ET, Pena FM, Souza NR, Soares JS, Faria CA.
[Hiperglicemia de estresse na síndrome coronariana aguda: controle e
importância prognostica]. Rev Bras Cardiol. 2010; 23(3):178-84.
7. Federle CA, Almeida RR, Monteiro RA, Barbosa ME. Atuação do
enfermeiro na cetoacidose diabética. Voos Revista Polidisciplinar
Eletrônica da Faculdade de Guairacá. 2011; 3(2):54-67.
8. Castro L, Morcillo AM, Guerra-Júnior G. Cetoacidose diabética em
crianças: perfil de tratamento em hospital universitário. Rev Assoc
Med Bras. 2008; 54(6):548-53.
9. Nery M. Hipoglicemia como fator complicador no tratamento do diabetes
mellitus tipo 1. Arq Bras Endocrinol Metab. 2008; 52(2):288-98.
10.Santos JC. Protocolo Clínico e de regulação para abordagem do
diabetes mellitus descompensado no adulto/idoso [Internet]. 2012.
[citado 2014 Jul 12]. Disponível em: http://www.saudedireta.com.br/
docsupload/1333459552diabetes_adulto_e_idoso.pdf.
11.Mcnaughton CD, Auto WH, Slovis C. Diabetes in the Emergency
Department: Acute Care of Diabetes Patients. Clin Diabetes. 2011;
29(2): 51-9.
12.Bianca B, Melaine R, Maria CP, Lenita Z, Adolpho M, José EP.
Cetoacidose diabética em adultos: atualização de uma complicação
antiga]. Arq Bras Endocrinol Metab. 2007; 51(9):1434-47.
13.Grossi SA. O manejo da cetoacidose em pacientes com Diabetes
Mellitus: subsídios para a prática clínica de enfermagem. Rev Esc
Enferm USP. 2006; 40(4):582-6.
14.Sociedade Brasileira de Diabetes. Controle da hiperglicemia intrahospitalar em pacientes críticos e não críticos [Internet]. São Paulo:
AC Farmacêutica, 2011. [citado 2014 Jul 12]. Disponível em: http://
www.nutritotal.com.br/diretrizes/files/228--posicionamento_sbd_
hiperglicemia.pdf.
15.Cardoso GP, Silva J, Cyro T, Cardoso RB. Estados hiper e
hipoglicêmicos agudos: conduta atual. J Bras Med. 2013;
101(02):41-5.
16.Balthazar AP, Rigon FA. Avaliação dos diferentes esquemas de
insulinoterapia prescritos aos pacientes hiperglicêmicos do Hospital
Governador Celso Ramos, Florianópolis, SC, Brasil. ACM Arq Catarin.
2013; 42(1):34-9.
17.Boas LC, Lima ML, Pace AE. Adherence to treatment for diabetes
mellitus: validation of instruments for oral antidiabetics and insulin. Rev
Latinoam Enferm. 2014; 22(1):11-8.
18. Conselho Federal de Enfermagem. Decreto n. 94.406, de 8 jun 1987.
Regulamenta a Lei 7.498, de 25 jun 1986 [Internet]. Brasília (DF);
1987. [citado 2014 Jul 12]. Disponível em: http://novo.portalcofen.
gov.br/decreto-n-9440687_4173.html.
19.Pimpão FD, Lunardi WD, Vaghetti HH, Lunardi VL. Percepção
da equipe de enfermagem sobre seus registros: buscando a
sistematização da assistência de enfermagem. Rev Enferm UERJ.
2010; 18(3):405-10.
20. Terwee CB, Bot SD, Boer MR, Windt DA, Knol DL, DekkerJ, et al. Quality
criteria were proposed for measurement properties of health status
questionnaires. J Clin Epidemiol. 207; 60(1):34-42.
21.Conselho Federal de Enfermagem. Resolução n. 358, de 15
out 2009 [Internet]. Brasília (DF); 2009. [citado 2014 Jul
12]. Disponível em: http://novo.portalcofen.gov.br/resoluocofen-3582009_4384.html.
Acta Paul Enferm. 2014; 27(6):520-5.
525
Original Article
The healthcare network to the amputee
Rede de atenção à saúde à pessoa amputada
Mara Ambrosina de Oliveira Vargas1
Sílvia Ferrazzo1
Soraia Dornelles Schoeller1
Laila Crespo Drago1
Flávia Regina Souza Ramos1
Keywords
Health care (Public Health); Nursing
in public health; Ethics; Amputation;
Information services
Descritores
Atenção à saúde; Enfermagem em
saúde pública; Ética; Amputação;
Serviços de informação
Submitted
July 29, 2014
Accepted
August 11, 2014
Corresponding author
Sílvia Ferrazzo
Campus Universitário Reitor João David
Ferreira Lima, Florianópolis, SC, Brazil.
Zip Code: 88040-900
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400086
526
Acta Paul Enferm. 2014; 27(6):526-32.
Abstract
Objective: Analyzing the network of care for the amputee from the perspective of healthcare professionals
inserted in high complexity services.
Methods: A qualitative research with data collection through semi-structured interviews with professionals
from different areas involved in care of the amputee.
Results: It was observed that a part of the interviewed professionals knows and acts in a perspective of referral
to rehabilitation, while others are unaware of the flow of referrals, as well as of the care network that supports
these users.
Conclusion: The data showed the multidisciplinary and inter-institutional work occurring in some areas as the
great fortress in the context of rehabilitation. The main weaknesses found were the lack of knowledge of high
complexity professionals about the networks of health care, and the way rehabilitation is seen, not inserted in
a context of care unless there is the possibility or occurrence of amputation.
Resumo
Objetivo: Analisar a rede de atenção à pessoa amputada na perspectiva dos profissionais de saúde inseridos
nos serviços de alta complexidade.
Métodos: Pesquisa qualitativa com coleta de dados mediante entrevista semi-estruturada com profissionais
de diferentes áreas de atuação envolvidos no cuidado à pessoa amputada.
Resultados: Observou-se que uma parte dos profissionais entrevistados conhece e atua em uma perspectiva
de encaminhamento para reabilitação, enquanto outros desconhecem o fluxo de encaminhamento bem como
a rede de atenção que ampara estes usuários.
Conclusão: Os dados evidenciaram como grande fortaleza no contexto da reabilitação o trabalho
multiprofissional e inter-instituicional ocorrido em alguns espaços. Como principal fragilidade aponta a falta
de conhecimento dos profissionais sobre a alta complexidade das redes de atenção à saúde, assim como
a maneira como a reabilitação é vista, não sendo inserida em um contexto de cuidado desde que exista a
possibilidade ou ocorrência da amputação.
Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.
Conflicts of interest: no conflicts of interest to declare.
1
Vargas MA, Ferrazzo S, Schoeller SD, Drago LC, Ramos FR
Introduction
Chronic non-transmissible diseases, especially those
affecting the cardiovascular system and those associated with external causes such as traffic accidents
and work accidents are responsible for a growing
number of people with physical sequelae. These
consequences result in physical disability and require services and actions aimed at the rehabilitation and social re-integration with guaranteed quality and access.(1,2)
Among the people affected by the aforementioned diseases, a significant number progresses to
amputation. Amputation may result from inadequate prevention of underlying diseases, therapeutic action in the treatment of advanced diseases or
an acute event.(3,4) It is considered a reconstructive
surgery in which a limb or a body part is partially or
completely separated from the organism.(5)
Therefore, there is the need for assistance in the
sense of rehabilitation of amputated people, regardless of the origin causes, assuring them the right to
comprehensive health care for health maintenance.
Among the organizational models of health actions and services are the Health Care Networks,
with different levels of care integrated to guarantee
the excellence of care to users of the system. It aims
to enhance the performance of the health system in
terms of access, equity, health and clinical effectiveness and economic efficiency.(5) Health Care Networks seek to maintain horizontal relationships between health care services and the Primary Health
Care. Meanwhile, the users of the health system
pass through these networks to care for their health,
depending on the effectiveness of the agreement
between them to have their needs met.(5) In this
sense, studies(6,7) indicate the difficulties faced by
people with disabilities as they seek to implement
their rehabilitation, confronted with professional
disinterest, distrust of the existing public policies,
the unprepared educational system and difficulties
of access.
Therefore, this study is justified since the amputation has a great social impact and involves services
and professionals of all levels of health care. Concomitant to this, care and treatment in health to
amputees requires that health professionals develop
specific skills on the issue of amputations.(8.9) Skills
for interventions in the care process of amputation
and rehabilitation should be contextualized and
developed with guidance of public policies and its
availability of physical infrastructure, management
of people, processes and services of a network of
care coordinated and based on the principles of the
Brazilian SUS – Sistema Único de Saúde (Unified
Health System).
Given the above, the objective of this study was
to analyze the network of care for the amputee from
the perspective of health professionals who work
with people who underwent amputation.
Methods
This is a qualitative study carried out at the level of
high complexity care. It included public hospitals
of the municipalities that make up the great Florianópolis, southern Brazil, with specialized services
in traumatology and orthopedics, physiatry, general
surgery, vascular surgery and Rehabilitation Center.
The study participants were health professionals involved in caring for people with amputation
during hospitalization and rehabilitation. Professionals who refused to participate in the study
and those away on vacations or sick leave during
the period of data collection were excluded. The
speeches of participants were coded to carry out
the analysis.
Semi structured interviews were carried out
with 19 professionals from the following fields of
knowledge: doctors, nurses, social workers, nutritionists, psychologists and physiotherapists. The
interviews took place in the workplace of each
professional from December 2012 to March 2013,
then were audio recorded and later transcribed
and imported into Atlas Ti software, to assist in
the process of categorizing the data. Data analysis
was by analysis of content. It is inserted in a set
of techniques for analyzing the communication
processes in order to learn the content delivered
and is organized in three phases: (1) pre-analysis,
in which the material is organized by reading and
Acta Paul Enferm. 2014; 27(6):526-32.
527
The healthcare network to the amputee
systematization of initial ideas; (2) exploration of
the material, aimed at defining categories, categorization and classification of data; (3) treatment
of the results, inference and interpretation, which
corresponds to the moment of critical and reflective analysis of the results found, confronting
them with the objectives outlined at the beginning
of the research.
The development of the study met national and
international standards of ethics in research involving human beings.
Results
In order to present the results obtained in the research, it was chosen to develop a scheme in the
form of a flowchart, representing how the network
of care for the amputee is mentioned by the interviewed professionals.
In figure 1 the roles of Primary Health Care
and the Family Health Strategy are emphasized,
which, at times, do not participate of the process
of care network in the care of people with amputation. Some professionals expressed that referral to
rehabilitation occurs in a direct flow of high complexity, demonstrated here by the link established
between the hospitals that perform the amputation
surgery and the outpatient visit after the procedure,
and the reference service in rehabilitation. Figure 2
represents there commendation of the Ministry of
Health, in which the primary care is the coordinator element of the reference and counter-reference
for various health services. Thus, it is found that the
results presented in figure 1 are not consistent with
the recommendations of the Ministry of Health.
Reference
hospital
Trauma surgery
Reference
hospital cardiac/
vascular surgery
Outpatient
clinic hospital
Reference
hospital
vascular surgery
Outpatient
clinic hospital
Blue - Reference
Red - Counter-reference
Outpatient
clinic hospital
PHC/FHS
municipality
Outpatient clinic
trauma/endocrine/vascular/
physiotherapy
General
Hospital
Outpatient
clinic hospital
Reference center
state rehabilitation
Figure 1. Flowchart of the network from the perspective of professionals in high complexity; PHC - Primary Health Care; FHS - Family
Health Strategy
528
Acta Paul Enferm. 2014; 27(6):526-32.
Vargas MA, Ferrazzo S, Schoeller SD, Drago LC, Ramos FR
HIGH
COMPLEXITY
Primary
Health
Care
MEDIUM
COMPLEXITY
PRIMARY CARE
Source: http://www.conass.org.br/pdf/Redes_de_Atencao.pdf
Figure 2. Network model proposed by the Ministry of Health in Brazil
From the speeches of the study participants
emerged two topics to be discussed, namely: Fortresses of the care network and Weaknesses of the
care network.
In the category entitled ‘Fortresses of the care
network’, it is noteworthy the allusion to the word
fortress, where the positive points of the care network are discussed. In this direction, it appears that
the Brazilian health system, from its principles of
universality, fairness and integrity in health care,
recognizes and seeks to ensure the necessary conditions for rehabilitation to amputated people.
The partnerships between various professions,
or jobs done jointly in the same institution and
focused on referrals for rehabilitation emerged as
the fortresses of the care network to the amputee.
It is worth noting the effort of professionals to referring amputated people to other rehabilitation
services, even to distant counties, interacting with
primary care.
In the category called ‘Weaknesses of the care
network to the person with amputation’, the word
weakness is understood as barriers established
throughout the rehabilitation process of people with
amputation, whether by failure of the public system
or unawareness of the process flow by the professionals involved in it. One obstacle mentioned by
the professionals working with amputated people is
about which professionals should be responsible for
referrals of such patients to the reference in rehabilitation. However, no consensus was found among
participants.
Discussion
The limitation of the present study was the difficulty in finding at least one professional from each area
to carry out the interview. The results represent the
previously fixed view from the level of care of the
hospital. On the other hand, the existence of health
care networks demands the understanding of a continuous process in which various levels interact with
each other to establish the right of access to health
services, one focus of this article.
In face of the study results, a significant fortress
found was the fact that Health Care Networks are
consolidated as a public health policy. Therefore,
they have shared responsibility at all levels of management, and greater financial incentive.(10)
Acta Paul Enferm. 2014; 27(6):526-32.
529
The healthcare network to the amputee
A positive point indicated by the speeches of
professionals regards the understanding of the
flow of the care network services. Many clearly
understand the need to begin the process of acceptance with amputated people in order to rehabilitate them for social interaction and work
activities. They also demonstrate knowledge of
the network of assistance offered to people who
depend on these services. In this sense, studies
discuss(11,12) the importance of highly specialized
training professionals, who are focused on educating the people with amputation throughout
their rehabilitation process that is aimed at rehabilitating in an adequate time and optimizing
the treatment costs. By the logic of the authors,
professionals trained on how and when to rehabilitate help the service that pays the treatment
for preparing a limb for prosthetic placement.
It is noteworthy that in the context of acquired
disability it should be taken into account the singularities of each person, the variables as degree
of capability and functionality, in the sense to offering support to people, respecting their choices,
compensations and potentialities.(13-15)
Another emphasis in the speeches of professionals concerns the work of the multidisciplinary
team. Internally in institutions, social service works
with psychology, nursing, medicine and physiotherapy. Externally, the social service acts in contact with primary care, showing a significant work
in this care network.
The commitment demonstrated by professionals in the preparation of post-amputation
referrals as soon as the diagnosis is established is
noteworthy. Some showed specific knowledge on
the financial support to rehabilitation provided by
the public system, with distinction on the areas of
physiotherapy and social work. Furthermore, they
demonstrated understanding the bureaucracy that
permeates the referral of people with amputation
to rehabilitation services.
Finally, there is the fact that the public system
for rehabilitation of people with disabilities offers
the Assistive Technology, which is the whole arsenal
of resources and services that contribute to provide
or enhance functional abilities of people with dis-
530
Acta Paul Enferm. 2014; 27(6):526-32.
abilities by promoting independent living and social inclusion.(16)
With regard to weaknesses in the care network
for people with amputation, many of the professionals interviewed in this study demonstrated not
knowing the referrals to rehabilitation, passing the
activities of referrals and patient orientation to social workers and physiotherapy professionals, which
highlights the fragmentation of care. In this way,
each professional of the health team covers part of
the service. While nursing and medicine are occupied with the care of the operative wound and
associated comorbidities, physiotherapy acts in
the orientation of exercises to prepare the stump
for possible prosthetics, and social service interacts
with patients, their families and the care network to
ensure continuity of treatment.
The fragmentation between the practice of professionals intra and inter institutionally is due to
the universal crisis of health care systems, which
were designed and developed with the idea of continuity of a practice aimed at solving acute events,
but disregarding the contemporary epidemic of
chronic conditions. Hence, there is the demand of
a health situation in the twenty-first century which
is treated by a health care system established in the
twentieth century, when acute conditions were predominant.(16)
In this study, the majority of amputations occurring in local services are a result of chronic diseases. Thus, the healthcare team must know the care
network to these people. In this perspective, it is
observed that the international literature of different countries shows good evidence that networks
of health care can improve clinical quality, including sanitary outcomes, user’s satisfaction and cost
reduction of health care systems.(14)
A highlight for the speeches of professionals is
the lack of referrals to the primary care network,
which should be the service that most assists users,
because with the proximity of primary care units
and with the service of the family health strategy,
the real needs and difficulties of people with amputation would be better addressed. And yet, part
of the complications originating from chronic diseases that progress to amputation can be avoided
Vargas MA, Ferrazzo S, Schoeller SD, Drago LC, Ramos FR
with early diagnosis and establishment of an effective treatment and follow-up in primary care. The
PHC (APS – Atenção Primária à Saúde) in theory,
is the central axis of the health care network (RAS
– Rede de Atenção à Saúde) for being the first level
of care, with emphasis on its role of solving the
most common health problems and from which it
conducts and coordinates care across all points of
attention.(17)
When inferring such importance to primary
health care, it is necessary to criticize the norms
that organize basic, medium and high complexity
health services. In this sense, by considering primary health care as less complex than the secondary
and tertiary levels, there is a distortion of the concept of complexity, regarding the trivialization of
primary health care.(16) Furthermore, a person with
amputation or with potential risk to evolve into an
amputation, demands a complex process of health
care, which will permeate all levels of complexity.
Following this logic, one can consider the existence
of a paradox, as the figure 2 indicates that primary
care is the foundation of the pyramid of the health
system, which should be focused on injury prevention, reducing the suffering of users and the operating costs of the health system in the secondary and
tertiary levels. And yet, in a network system that
covers all levels of care, primary care is the central
point of coordination between the existing services
and assistance to the population.
When questioned about the existence of a care
protocol for amputated people, the medical professionals and nursing are assaid there is nothing
systematic to follow. The reason is that, in most
cases, amputation is performed by complications
of vascular diseases, a fact that particularizes the
care even further. The existence of protocol is
mentioned by social service professionals in the
sense of referrals to a rehabilitation service. Another information emphasized by respondents is
the difficulty of vascular medical professionals in
referring patients to the rehabilitation reference
after carrying out the procedure. But this information is refuted by the professionals heard at the
rehab center, claiming that they accept referrals
from any doctor and that the major difficulty is
the appropriate referral of the amputated person
to the reference center.
Another relevant aspect in this study shows
how professionals understand the rehabilitation.
Many attribute it to a specific service, with qualified professionals that are able to reestablish the social condition of the person with amputation, with
procedures, such as the fitting of prosthetics. But it
is clear that actions should permeate rehabilitation
care, from the conduction of treatment to chronic diseases until the restoration of mental, physical
and social conditions of people with amputation.(18)
Conclusion
The main objective of the study, understanding the
care network to the amputee, was achieved. On one
hand, the effort of professionals in providing health
care to this part of the population was evident. On
the other hand, the obstacles that make it difficult
to provide services focused on rehabilitation, where
patients can have their rights granted by law and
avoid much inconvenience and long waiting periods. The major existing fortress in the context of
rehabilitation is a consolidated legislation, and established through the Networks of Health Care, in
addition to multidisciplinary and inter institutional
work present in some spaces. The main weakness
found were the lack of knowledge of high complexity professionals about the networks of health care,
and the way rehabilitation is seen, not inserted in
a context of care unless there is the possibility or
occurrence of amputation.
Acknowledgements
Study carried out with the financial support of the
Conselho Nacional de Desenvolvimento Científico e
Tecnológico - CNPq, Edital Universal 14/2011.
Collaborations
Vargas MAO and Ramos FRS contributed to project design, development of analysis and data interpretation. Ferrazzo S; Drago LC and Schoeller SD
collaborated with the construction of the critical and
relevant revision of intellectual content. The authors
Acta Paul Enferm. 2014; 27(6):526-32.
531
The healthcare network to the amputee
Vargas MAO and Schoeller SD cooperated with the
final approval of the version to be published.
References
1. Secretaria de Estado de Santa Catarina. Plano Operativo para a
Organização da Rede de Assistência à Pessoa com Deficiência Física
em Santa Catarina. Nov, 2008. Disponível em: http://www.saude.
sc.gov.br/geral/planos/Plano_reabilitacao_deficiencia_fisica/Plano_
de_Reabilitacao_Fisica.pdf.
8. Pasquina, PF. Twenty years forward. J Rehab Res Develop. 2013;
50(10):17-20.
9. Hordacre B, Birks V, Quinn S, Barr C, Patritti BL, Crotty M. Physiotherapy
rehabilitation for individuals with lower limb amputation: a 15-year
clinical series. Physiother Res Int. 2013 ;18(2):70-80.
10. Resnik L, Meucci M, Lieberman-Klinger S, Fantini C, Kelty DL, Disla R, et
al. Advanced Upper Limb Prosthetic Devices: Implications for Upper Limb
Prosthetic Rehabilitation. Arch Phys Med Rehab. 2012; 93(4):710-7.
11. Huang CJ, Wang YW, Huang TH, Lin CF, Lib CY, Chen HM, et al. Applications
of machine learning techniques to a sensor-network-based prosthesis
training system. Applied Soft Comput. 2011;11 (3):3229-37.
2. Barmparas G, Inaba K, Teixeira PGR, Dubose JJ, Criscuoli M, Talving
P, Plurad D, Green D, Demetriades D. Epidemiology of Post-Traumatic
Limb Amputation: A National Trauma Databank Analysis. Am Surg.
2010; 76 (11):1214-22.
12. Brasil. Ministério da Saúde. Saúde sem Limite - Manual de Ambiência
dos Centros Especializados em Reabilitação (CER) e das Oficinas
Ortopédicas. Brasília (DF): Ministério da Saúde; 2013.
3. Lazzarini PA, O’Rourke SR, Russell AW, Clark D, Kuys SS. What are
the key conditions associated with lower limb amputations in a major
Australian teaching hospital? J Foot Ankle Res. 2012;5:12.
14. Liu F, Williams RM, Liu HE, Chien NH. The lived experience of persons
with lower extremity amputation. J Clin Nurs. 2010 ;19(15-16):2152-61.
4. Santana P, Costa C, Loureiro A, Raposo J, Boavida JM. Geografias
da diabetes mellitus em Portugal: como as condições do contexto
influenciam o risco de morrer. Acta Med Port. 2014;27(3):309-17.
5. Luccia N. Amputação e reconstrução nas doenças vasculares e no pé
diabético. São Paulo: Revinter; 2005.
6. Resende MC, Cunha CP, Silva AP, Sousa SJ. Rede de relações e
satisfação com a vida em pessoas com amputação de membros.
Ciências & Cognição. 2007; 10:164-77.
7. Silva SF. Organização de redes regionalizadas e integradas de
atenção à saúde: desafios do Sistema Único de Saúde (Brasil).
532
Ciênc & Saúde Coletiva. 2011; 16(6):2753-62.
Acta Paul Enferm. 2014; 27(6):526-32.
13. Bersch R. Introdução à tecnologia assistida. Porto Alegre: CEDI; 2008.
15.Archer KR, Castillo RC, MacKenzie EJ, Bosse MJ; LEAP. Perceived
need and unmet need for vocational, mental health, and other support
services after severe lower-extremity trauma. Arch Phys Med Rehabil.
2010; 91(5):774-80.
16.Mendes EV. As redes de atenção à saúde. 2a ed. Brasília (DF):
Organização Pan-Americana da Saúde; 2011.
17.Mendes EV. As redes de atenção à saúde. Ciênc Saúde Coletiva.
2010;15( 5):2297-305.
18. Maguire MT, Boult J. Building a foundation of strength. Addressing the
incidence of limb loss. Rehab Manag. 2010; 23(6):20-3.
Original Article
Factors related to absenteeism due
to sickness in nursing workers
Fatores relacionados ao absenteísmo por doença
entre trabalhadores de Enfermagem
Eliete Boaventura Bargas1
Maria Inês Monteiro1
Keywords
Nursing staff; Occupational health
nursing; Nursing administration
research; Working conditions;
Absenteeism
Descritores
Recursos humanos de enfermagem;
Enfermagem do trabalho; Pesquisa
em administração de enfermagem;
Condições de trabalho; Absenteísmo
Submitted
July 28, 2014
Accepted
August 11, 2014
Abstract
Objective: To evaluate the association of absenteeism due to sickness with sociodemographic characteristics
and relate it to the work of nursing professionals.
Method: Descriptive exploratory study that analyzed medical certificates of up to 15 days off work presented
by 994 nurses at a university hospital. The data source was the frequency system of the institution.
Results: Most workers were female, married and technical nurses. The average age was 41.9 years and a
third worked in adult inpatient services. Of the 994 professionals, 645 had at least one sick day.
Conclusion: Absenteeism due to illness is complex and multifactorial. The factors associated with it were: age
group, education, function, shift, time in the institution and workplace.
Resumo
Objetivo: Avaliar a associação do absenteísmo por doença com o perfil sociodemográfico e relacioná-lo ao
trabalho dos profissionais de Enfermagem.
Métodos: Estudo descritivo exploratório, que analisou atestados médicos de até 15 dias de afastamento do
trabalho apresentados por 994 profissionais de enfermagem de um hospital universitário. A fonte de dados foi
o sistema de frequência da instituição.
Resultados: A maioria dos trabalhadores era do sexo feminino, casada e técnica de Enfermagem. A idade
média foi de 41,9 anos e um terço atuava no serviço de internação de adultos. Dos 994 profissionais, 645
apresentaram pelo menos um dia de atestado médico.
Conclusão: O absenteísmo por doença teve fatores complexos e multifatoriais. Os fatores associados a ele
foram: grupo etário, escolaridade, função, turno de trabalho, tempo na instituição e local de trabalho.
Corresponding author
Eliete Boaventura Bargas
Vital Brasil street, 251, Campinas, SP,
Brazil. Zip Code: 13083-888
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400087
Universidade Estadual de Campinas, Campinas, SP, Brazil.
Conflicts of interest: there are no conflicts of interest to declare.
1
Acta Paul Enferm. 2014; 27(6):533-8.
533
Factors related to absenteeism due to sickness in nursing workers
534
Introduction
Methods
The absence at work is, at present, an important
problem in different countries and entails high
costs for the institutions.(1)
Absenteeism due to illness is the period of lack
of labor attributable to an inability of the individual(2) and can be categorized into voluntary (for
private reasons), legal (supported by law, as is the
case of maternity leave, disgust and vacation), compulsory (impediment due to disciplinary action)
and by disease. Absences due to work accidents
are recorded differently.(3) The work environment
of nursing professionals is unhealthy, both in material and psychological aspects and, being subject
to poor work conditions, the maintenance of their
health is impaired.(3)
Different studies have shown that absenteeism
varies according to sex, age, occupation, level of responsibility and work, among others.(4-7) However,
studies point to the need for comparative information between hospital departments and correlate
absenteeism due to illness to the environment, the
nature of work and individual characteristics.(6,7)
A systematic literature review covering the period from 1986 to 2006 found that individual factors
(previous record of missed work) and work related
factors (job satisfaction, organizational commitment and job involvement) reduced absenteeism,
with emphasis on the absence of a theory that supports the discussion of absenteeism.(8)
A longitudinal Canadian study identified six
factors that interfered with the reduction in absenteeism: inflexible work schedule, understaffing,
stress at home and at work, poor work conditions,
low wages, communication with superiors and colleagues and lack of incentives not to abuse of sick
leaves and health problems.(9)
Recognizing the problems resulting from absenteeism due to illness as important in labor dynamics, since this interferes with work conditions
and undermines the nursing care environment, this
study was proposed to evaluate the association of
absenteeism due to illness with sociodemographic
characteristics and relate it to the work of nursing
professionals.
Descriptive exploratory study with a quantitative
approach, developed in a public university hospital
of high complexity, with approximately 400 beds,
in the state of São Paulo, in southeastern Brazil. The
database of the Human Resources department with
information on age, sex, marital status, education,
function, workplace, shifts, employment relationship and working time was used – these details make
up the frequency system used by the institution.
The total sample consisted of 994 nursing
professionals approved by public tender, working
in the Department of Nursing. The group that
showed absenteeism due to illness was composed
of 645 nursing professionals. Absenteeism was
analyzed considering the absences from work due
to illness lasting ≤ 15 days, supported by medical
certificates for the period from January 1 to December 31, 2011.
The variables were divided into two categories:
related to sociodemographic (gender, age, marital
status and education) and job characteristics (function, capacity, employment relationship and time in
the institution).
The data were entered into a Microsoft Excel spreadsheet and analyzed using the Statistical
Analysis System 9.2 and R-Project version 2.15.0.
Descriptive analyses were performed to check the
consistency of data and comparisons were made
involving the sociodemographic and work related
variables in the total sample and in the group with
absenteeism (Mann-Whitney and Kruskal-Wallis
tests). The chi-square test was used to study between categorical variables. For all analyses, the significance level was < 5%.
The study met national and international
standards of ethics in research involving human
subjects.
Acta Paul Enferm. 2014; 27(6):533-8.
Results
The majority of the sample was female, married,
with a mean age of 41.9 ± 10.1 years, ranging
between 20 and 69 years. Regarding their edu-
Bargas EB, Monteiro MI
cation, most professionals had completed high
school (593 professionals), followed by higher
education (372 professionals) and elementary
school (29 professionals). As for their job, 6%
were nursing assistants, 67% technical nurses
and 27% were baccalaureate nurses. Just over a
third of the employees were in Adult Inpatient
Unit; 17% were in Operating Rooms and Material Centrals; 13% in Intensive Care Units; 9% in
clinics; 9% in Pediatric Nursing, 8% in Support
and Diagnosis Unit; 7% in the Emergency Unit
and 2% worked directly in the Department of
Nursing. In relation to the time on the job, the
average was 11.4 ± 8.7 years.
Education and absenteeism due to illness were
statistically significant in both the group with
absenteeism and the entire group (p = 0.02 and
0.0007). The age group was statistically significant in the overall study group (p = 0.001), but
not significant among those who had at least one
absence (p = 0.14). There was no statistical relationship between sex and absenteeism (p = 0.56)
(Table 1).
Job and absenteeism were statistically significant in the entire study sample and those with
medical certificates (p = 0.02 and 0.0000). As for
the workplace, the analyses were statistically significant in the study sample (p = 0.02) and not
statistically significant among those who had at
least one absence (p = 0.9). Also, work time was
statistically significant in the overall study sample
(p = 0.0000) and not statistically significant for
professionals who had at least one absence (p =
0.10) (Table 2).
Table 1. Days absent, up to 15 days, of the nursing staff according to sociodemographic variables
Only employees who presented certificates
Variables
Study sample
Total days per absence
n
Average
SD
Median
p-value
n
Average
SD
Median
p-value
0.39
850
7.6
10.6
8.5
0.56
144
7.1
9.5
8
120
4.4
8.2
0
Gender
Female
6,476
550
11.8
11.2
8
Male
1,018
95
10.7
10.0
8
20-29
533
58
9.2
9.8
7
30-39
2,190
201
10.9
10.0
7
305
7.2
9.6
3
40-49
2,421
200
12.1
12.3
7.5
305
7.9
11.5
3
50-59
2,089
163
12.8
10.9
10
228
9.2
10.9
5
60-69
261
23
11.3
10.5
11
36
7.2
10.0
2.5
Married
3,676
310
11.9
10.6
8
470
7.8
10.3
3
Divorced/Widowed
1,050
83
12.6
10.4
10
118
8.9
10.5
4.5
Single
2,768
252
11.0
11.6
7
406
6.8
10.6
2
Elementary
405
25
16.2
10.8
15
29
14.0
11.5
13
High School
4,798
397
12.1
11.0
8
593
8.1
10.7
3
College
2,291
223
10.3
10.8
7
372
6.2
9.7
2
Age group (Years)
0.14
0.0001
Marital status
0.43
0.12
Education
0.02
0.00007
SD - Standard deviation
Acta Paul Enferm. 2014; 27(6):533-8.
535
Factors related to absenteeism due to sickness in nursing workers
Table 2. Days absent, up to 15 days, of the nursing staff according to work related variables
Variables
Total days absent
Only employees who presented certificates
Study sample
n
Average
SD
Median
p-value
n
Average
SD
Median
p-value
0.02
0.0000
Job
Nurse
1,728
162
10.7
11.0
7
273
6.3
10.0
2
Technical nurse
4,980
435
11.4
10.5
8
664
7.5
10.1
3
Nursing assistant
786
48
16.4
13.8
14
57
13.8
14.0
11
Workplace
Nursing Department
Surgery/Materials Center
Support and Diagnosis
80
6
13.3
13.1
10
20
4.0
9.2
0
1,548
124
12.5
11.8
7.5
0.90
165
9.4
11.6
5
647
49
13.2
13.0
10
82
7.9
12.0
2
0.0002
Service
Outpatient Unit
837
70
12.0
10.6
10.5
92
9.1
10.5
5
2,654
229
11.6
11.0
8
345
7.7
10.5
2
Pediatric Nursing Unit
542
52
10.4
8.0
9
90
6.0
78.0
2
Emergency Unit
424
40
10.6
11.9
5.5
72
5.9
10.3
1.5
Intensive Care Unit
762
75
10.2
9.8
7
128
5.9
9.0
2
Morning
1,764
152
11.6
10.3
8
251
7.0
9.8
2
Evening
1,050
102
10.3
11.7
6
180
5.8
10.1
1.5
Night
3,299
279
11.8
10.9
9
402
8.2
10.6
4
Administrative
1,381
112
12.3
11.5
9.5
161
8.6
11.1
4
6,735
585
11.5
11.02
8
915
7.4
10.4
3
759
60
12.6
10.81
11
79
9.6
10.9
5
Adult Inpatient Unit
Shifts
0.56
0.04
Relationship
CLT
CLT retired
0.45
0.07
Time in the institution (Years)
0-4
1,466
151
9.7
9,9
7
288
5.1
8.6
1
5-9
1,893
163
11.6
10,6
7
0.1
211
9.0
1.05
5
10-14
1,317
100
13.2
11,4
10
160
8.2
11.0
3
15-19
402
37
10.9
8,1
10
55
7.3
8.4
4
20-24
1,507
134
11.2
10,6
7
197
7.6
10.2
4
25-29
909
60
15.1
15,0
10
83
10.9
14.4
5
0.0000
CLL - Consolidation of Labor Laws
Discussion
One limitation of this study is that, being retrospective, it was not possible to identify whether the cause of absenteeism was because of work
or motivation related illness. Another aspect is
that the data from the institution’s information
system did not include the International Classification of Disease (ICD) for worker absenteeism for 2011.
In this study, the average number of absent days
was observed to be lower in the 20-29 age group
and higher in the 50-59 age group.
Research conducted in Canada found that older
female workers, nursing assistants and those with
lower wage per hour are more likely to exhibit absenteeism.(10)
In the present study, nursing assistants had
higher average of absences compared to nursing
technicians, and these, more than baccalaureate
536
Acta Paul Enferm. 2014; 27(6):533-8.
nurses, but the relationship with age was nonlinear.
A similar finding was reported in a study conducted in the state of Rio de Janeiro, in which the
authors report that nurses tended to take a leadership role in the team, which requires greater diligence; had lower risk of contamination and disease
and also took on administrative tasks.(11) The higher prevalence of unplanned absences in the high
school level of education category was also observed
in another study.(12)
There was a relationship between absenteeism
and work shift (p = 0,04) in the present study.
Research conducted in Spain corroborates these
findings.(13) Absenteeism of the nursing staff was
analyzed by implementing a shift rotation system in 2011, with an increased workday (8h to
20h, 20h to 8h, 10h to 22h, 22h to 10h and
from 15h to 8h) and, consequently, an increase
in rest days. There was a reduction of 40.8% in
Bargas EB, Monteiro MI
overall absenteeism, but there was an increase in
absenteeism due to illness, probably due to the
longer shifts.(13)
As for the workplace, similar results were found
and the largest registered absence from work due to
illness was at the Material Center, in which 91.6%
of the workers had at least one absence, followed by
the Surgical Center.(7)
Although not the subject of this study, it is important to highlight some research in other countries, which related absenteeism and the ratio of
nursing professionals to patients, with no similar
data in national surveys.
A study conducted at a university hospital in
France found that patient satisfaction was related
to absenteeism due to illness of the nursing staff.(14)
Research conducted in the UK found that hospitals with greater numbers of patients per nurses had
26% higher mortality rates than observed in those
with a lower patient to nurse ratio.(15) In a study
conducted in Brazil, a high patient to nurse ratio
was associated with increased incidents of patients
falling from beds, central venous catheter infections, absenteeism, staff turnover and low patient
satisfaction.(16) In Germany, it was identified that
low nurse-patient ratio was associated with higher
risks for the patient and also other stress indicators,
such as absenteeism.(17) A study in the Netherlands
reported as predictors of absenteeism, health complaints and consultations with the general practitioner.(18)
The findings of this study support the consideration of absenteeism with complex and multifactorial determinants that need to be analyzed from the
perspective of the working process, the institutional culture, the health and welfare of workers. It is
important that the coordination of nursing services
involves the workers in carrying out the planning
and decision-making, so that there is commitment
from the staff and workers feel that they are a fundamental part of the work process.
This study contributed to the advancement of
knowledge in nursing regarding the characteristics
absenteeism due to illness, signaling the importance
of investing in actions aimed at promoting health
and quality of life at work.
Conclusion
Absenteeism due to illness has complex and multifactorial features, so that it is essential to approach
these to improve the quality of nursing care, satisfaction with work and reducing institutional costs.
Factors associated with absenteeism due to illness
were: age, education, job, shift, time in the institution and workplace conditions.
Acknowledgments
Statistician Henrique Ceretta, the General Directorate of Human Resources (GDHR), GDHR’s IT
and Nursing departments, HC/Unicamp for their
contribution to the development of this study.
Collaborations
Bargas EB contributed with the project design,
analysis and interpretation of data and drafting the
article. Monteiro MI contributed with the project
design, analysis and interpretation of data, critical
review of the content and approval of the version to
be published.
References
1. Roelen CA, Bültmann U, Groothoff J, Rhenen WV, Magerøy N, Moen BE,
et al. Physical and mental fatigue as predictors of sickness absence
among Norwegian nurses. Res Nurs Health. 2013; 36(5):453-65.
2. Organización Internacional del Trabajo (OIT). Enciclopedia de salud,
seguridad e higiene en el trabajo. Madrid (Espanã): Centro de
Publicaciones del Ministerio de Trabajo y Seguridad Social; 1991. p.
5-11.
3. Elias MA, Navarro VL. [The relation between work, health and
living conditions: negativity and positivity in nursing work at a
teaching hospital]. Rev Latino-Am Enferm. 2006; 14(4):517-25.
Portuguese.
4. Laisné F, Lecomte C, Corbière M. Biopsychosocial determinants
of work outcomes of workers with occupationalinjuries receiving
compensation: a prospective study. Work. 2013; 44(2):117-32.
5. Chibnall JT, Tait RC. Long-term adjustment to work-related low back
pain: associations with socio-demographics, claim processes, and post
settlement adjustment. Pain Med. 2009; 10(8):1378-88.
6. Silva DM, Marziale MH. [Conditions of work versus absenteeism/illness
in the nursing job]. Ciência, Cuidado e Saúde. 2006; 5:Supl:166-72.
Portuguese.
7. Belita A, Mbindyo P, English M. Absenteeism amongst health workers –
developing a typology to support empiric work in low-income countries
and characterizing reported associations. Hum Resour Health. 2013;
11(1):34.
Acta Paul Enferm. 2014; 27(6):533-8.
537
Factors related to absenteeism due to sickness in nursing workers
8. Davey MM, Cummings G, Newburn-Cook CV, Lo EA. Predictors of
nurse absenteeism in hospitals: a systematic review. J Nurs Manag.
2009; 17(3):312-30.
9. Gaudine A, Saks AM, Dawe D, Beaton M. Effects of absenteeism
feedback and goal-setting interventions on nurses’ fairness
perceptions, discomfort feelings and absenteeism. J Nurs Manag.
2013; 21(3):591-602.
10.Gorman E, Yu S, Alamgir H. When healthcare workers get sick:
exploring sickness absenteeism in British Columbia, Canada. Work.
2010; 11:117-23.
11.Ferreira RC, Griep RH, Fonseca MJ, Rotenberg L. [A multifactorial
approach to sickness absenteeism among nursing staff]. Rev Saúde
Pública. 2012; 46(2):259-68. Portuguese.
538
absenteeism]. Gac Sanit. 2012; 26(5):480-2. Spanish.
14.Duclay E, Hardouin JB, Sébille V, Anthoine E, Moret L. Exploring the
impact of staff absenteeism on patient satisfaction using routine
databases in a university hospital. J Nurs Manag. 2014.
15.Rafferty AM, Clarke SP, Coles J, Ball J, James P, McKee M, et al.
Outcomes of variation in hospital nurse staffing in England hospitals:
cross-sectional analysis of survey data and discharge records. Int J
Nurs Stud. 2007; 44(2):175-82.
16.de Magalhães AM, Dall’Agnol CM, Marck PB. Nursing workload
and patient safety – a mixed method study with an ecological
restorative approach. Rev Latinoam Enferm. 2013; 21(Spec
No):146-54.
12.Fakih FT, Tanaka LH, Carmagnani MI. [Nursing staff absences in the
emergency room of a university hospital]. Acta Paul Enferm. 2012;
25(3):378-85. Portuguese.
17.Isfort M. [Influence of personnel staffing on patient care and nursing
in German intensive care units. Descriptive study on aspects of patient
safety and stress indicators of nursing]. Med Klin Intensivmed Notfmed.
2013; 108(1):71-7. Germain.
13.Blanca Gutiérrez JJ, del Rosal González A, González Ábalos Mde L,
Aceituno Herrera A, Martín Afán de Rivera JC, Arjona González A.
[Effect of the introduction of “on demand” nursing shifts on hours of
18.Schalk R. The influence of organizational commitment and health on
sickness absenteeism: a longitudinal study. J Nurs Manag. 2011;
19(5):596-600.
Acta Paul Enferm. 2014; 27(6):533-8.
Original Article
Occupational risks and illness
among mental health workers
Riscos ocupacionais e adoecimento de trabalhadores em saúde mental
Márcia Astrês Fernandes1
Maria Helena Palucci Marziale2
Keywords
Occupational risks; Health personnel;
Mental health; Occupational health;
Occupational diseases
Descritores
Riscos ocupacionais; Pessoal de saúde;
Saúde mental; Saúde do trabalhador;
Doenças profissionais
Submitted
August 18th, 2014
Accepted
August 26th, 2014
Corresponding author
Márcia Astrês Fernandes
Campus Universitário Ministro Petrônio
Portela, Teresina, PI, Brazil.
Zip Code: 64049-550
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400088
Abstract
Objective: To analyze the association between illness and occupational risks among mental health workers.
Methods: An epidemiological cross-sectional study was conducted with 163 professionals who were members
of a multidisciplinary mental health team at a psychiatric hospital, split into two groups: those who had and
those who had not taken medical leaves of absence. Data were collected using a questionnaire examining the
studied variables and by accessing records of medical leaves of absence.
Results: The identified occupational risks were primarily exposure to bacteria and virus (87.12%), tobacco
smoke (82.82%), noise (81.60%), adopting inadequate body posture due to ergonomic inadequacies (72.39%)
and stress (71.17%). Approximately 64.42% of workers became ill during the period of the study and 270
diagnoses were recorded.
Conclusion: More than half of the mental health workers presented health problems, however, only a small
portion of their diagnoses was included on the list of occupational diseases. There were statistically significant
associations among the variables illness, chemical risk and psychosocial risk.
Resumo
Objetivo: Analisar a associação entre o adoecimento de trabalhadores em saúde mental e os riscos
ocupacionais.
Métodos: Estudo epidemiológico, transversal, realizado com 163 profissionais da equipe multidisciplinar de
saúde mental atuante em um hospital psiquiátrico, divididos em dois grupos: com e sem licença saúde. O
instrumento de pesquisa foi um questionário com as variáveis de estudo e os registros de licenças saúde.
Resultados: Os riscos ocupacionais identificados foram principalmente; exposição a bactérias e vírus (87,12%),
tabaco (82,82%), ruídos (81,60%), indução a adoção de postura corporal inadequada devido a inadequações
ergonômicas (72,39%) e ao estresse (71,17%). Cerca de 64,42% dos trabalhadores adoeceram no período
de estudo sendo registrados 270 diagnósticos.
Conclusão: Mais da metade dos trabalhadores de saúde apresentam problemas de saúde, no entanto,
pequena parte dos diagnósticos registrados consta da lista de doença ocupacional. Houve associação
estatisticamente significativa entre a variável adoecimento e risco químico e risco psicossocial.
Universidade Federal do Piauí, Teresina, PI, Brazil.
Escola de Enfermagem, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.
Conflicts of interest: There are no conflicts of interest to declare.
1
2
Acta Paul Enferm. 2014; 27(6):539-47.
539
Occupational risks and illness among mental health workers
Introduction
The International Labour Organization (ILO)(1) estimates that 2.34 million people die every year due
to work-related accidents and diseases, of which
2.02 million (86.3%) are caused by occupational diseases and 321 thousand are due to work accidents. Every day, there are 6,300 work-related
deaths, 5,500 of which are caused by professional
diseases. Such figures are unacceptable and indicate
the need for more intense actions in the quest for
decent work (i.e. work which delivers fair income
and is exercised in conditions of freedom, equity
and security, as well as ensuring a dignified life).
The risks ensuing from technological, social and
organizational changes (consequences of globalization) severely affect the health of workers, despite
the fact that some traditional risks have been reduced due to greater security, improved regulations
and better technical resources employed. Parallel to
this, emerging risks have given rise to new types of
occupational diseases, such as those caused by deficient ergonomic conditions, exposure to electromagnetic radiation and psychosocial situations.(1)
In the specific case of workers in mental health
services, due to the accumulated experience of one
of the authors of this study as a worker and a manager in psychiatric institutions, we believe that more
attention should be given to the work situations
experienced by such professionals. In addition to
the common occupational risks to which workers
in health institutions in general are exposed, these
mental health professionals perform their activities
with individuals affected by mental illness in a setting imbued with high emotional tension due to the
unpredictability of their patients’ behaviors.(2)
Brazil’s National Worker’s Health Policy recognizes health promotion as a means for pursuing
equity and stimulating intersectorial actions. Furthermore, it is also a form of strengthening social
participation, promoting changes in organizational culture, incentivizing research and disseminating initiatives directed at the health promotion of health workers, managers and users of the
Unified Health System (SUS, as per its acronym
in Portuguese).
540
Acta Paul Enferm. 2014; 27(6):539-47.
The issue of occupational diseases among mental health workers due to exposure to occupational
risks as well as the consideration of national and
international worker’s health guidelines motivated the development of the present study to answer
the following question: Do mental health workers
recognize the occupational risks to which they are
exposed and which can make them ill? The objective of this study was to examine the association between illness and occupational risks among mental
health workers.
Methods
This was a retrospective and epidemiological
cross-sectional study using a quantitative approach,
which was conducted at a psychiatric hospital in
the city of Teresina, Piauí, Brazil. The target population was a multidisciplinary health team consisting of 185 workers from 12 different professional
categories, of which 163 (88.1%) participated in
the study and met the selection criteria of working
in the institution in the period between 2010 and
2012. Workers who were on vacation or leaves of
absence during the period of data collection, which
took place between October 2012 and March 2013,
were excluded.
Data were collected using a survey with
closed-ended questions regarding the workers’
sociodemographic, occupational and health information (this instrument was assessed and approved by five researchers with regard to its objectivity and adequacy for the study). Data were also
collected by consulting the hospital’s records for
medical leaves of absence, whose diagnoses were
described as per the International Statistical Classification of Diseases and Related Health Problems
(ICD 10).
To verify the association between workers’ health
problems and occupational risks, research subjects
were assigned to one of two groups. The first group
comprised workers who had taken medical leaves
of absence (GA), whereas the second consisted of
those who had not taken leaves of absence (GB).
The occupational risks identified by the subjects
Fernandes MA, Marziale MH
were then analyzed, and the two groups were finally
compared to each other.
Based on data from GA, the authors determined
whether medical diagnoses for leaves of absence
were included in the Brazilian Ministry of Health’s
List of Work-Related Diseases.(3) In the sequence,
the possible relationship between health problems
presented by workers and their reported occupational risks was analyzed.
Data were recorded in Microsoft Excel spreadsheets and transferred to the Statistical Package
for the Social Sciences (SPSS) program, version
19.0, for descriptive statistical analysis. Fisher’s
test was used to analyze how the health problems
presented by workers were related to their occupational risks.
The development of this study complied with
national and international ethical guidelines for research involving human subjects.
Results
Most subjects were female, between the ages of 40
and 59 years (127-77.92%), married (82-50.31%),
brown-skinned (self-reported) (103-63.19%), had
less than a college education (67-41.10%), resided
with a partner or spouse (89-54.60 %) and had one
child (125-76.69%), worked 30 hours a week (8049.08%) or 40 hours a week (43-26.38%). Most
did not smoke (153-93.87%) or drink alcohol
(130-79.75%). A great number reported frequently
practicing leisure activities (65-39.88%), although
42(25.77%) subjects did not report carrying out
any leisure activity. Table 1 presents the results
of occupational risks reported by mental health
workers as per work sector.
Among the occupational risks in the Inpatient
Unit, the most common were: physical (noise 5761.96%); biological (bacteria 86-87.76% - and viruses 69-70.41%); chemical (tobacco smoke 87-92.
55%); ergonomic (inadequate posture 52-62.65%);
and psychosocial risks (stress 64-78.05% - and
physical assault 40 - 43.48%).
In the Urgent and Emergency Care Sector, the
most commonly reported risks were: physical (noise
12-60.0%); biological (bacteria 14-70.0% - and
viruses 10-50.0%); chemical (tobacco smoke 18 85.71%); ergonomic (inadequate posture 9-50.0%
- and monotony and repetitiveness 6 - 33.33%);
and psychosocial risks (stress 14 - 70.0%, physical
assault 11 - 55.0 %).
The most commonly reported risks in the Day
Hospital were: physical (noise 9 - 90.0%); biological (bacteria 8 - 80.0% - and viruses 6 - 60.0 %);
chemical (tobacco smoke 9 - 81.82%); ergonomic
(inadequate posture 7 - 77.78%); and psychosocial risks (stress 6 - 66.67% - and physical assault
5 - 50.0 %).
In the Outpatient Unit, the main risks identified were: physical (noise 15 - 83.33%); biological
(viruses 21 - 100 % – and bacteria 20 - 95.24 %);
chemical (tobacco smoke 9-52.94%); ergonomic
(inadequate posture 11 - 68.75 %); and psychosocial risks (stress 11 - 84.62%).
In our search to answer the question on what
makes psychiatric hospital workers ill, the medical
leave of absence records of all 163 participants were
analyzed. Of this sample, 105(64.42%) workers
took a total of 297 leaves of absence and 58 did not
have any records of a leave of absence during the
period investigated in this study.
The highest prevalence of medical leaves of absence took place in 2012 (105 - 35.35%), followed
by 2011 (98 - 33.00%) and 2010 (94 - 31.65%).
In 2010, 48 workers were absent due to
medical leaves of absence, of which 14(29.17%)
received diagnoses included on the List of
Work-Related Diseases and 34(70.83%) workers
took leaves of absence due to health problems
that were not included on this list. In 2011, 48
workers were absent due to medical leaves of absence, of which 12(25.0%) were due to diagnoses included on the List of Work-Related Diseases and 36(75.0%) were workers whose diagnoses
were not listed. In 2012, 54 workers took a medical leave of absence, of which 17(31.48%) were
diagnosed with diseases included on the List of
Work-Related Diseases and 37(68.52%) had diagnoses that were not listed.
The results of this documentary research show
that the 297 medical leaves of absence recorded
Acta Paul Enferm. 2014; 27(6):539-47.
541
Occupational risks and illness among mental health workers
Table 1. Occupational risks to which mental health workers are exposed in psychiatric hospitals by work sector (n= 163)
Work sector
Inpatient
Unit
Urgent and
Emergency
Care
Day
Hospital
Outpatient
Unit
Food and
Nutrition
Services
Laboratory
n(%)
n(%)
n(%)
n(%)
n(%)
n(%)
Noise
57(61.96)
12(60)
9(90)
15(83.33)
3(75)
3(100)
Temperature
29(31.52)
4(20)
4(40)
1(5.56)
4(100)
-
Humidity
13(14.13)
-
-
2(11.11)
-
-
Vibrations
10(10.87)
-
2(20)
5(27.78)
-
-
6(6.52)
1(5)
-
-
-
-
-
-
-
1(5.56)
-
-
Bacteria
86(87.76)
14(70)
8(80)
20(95.24)
2(100)
4(100)
Víruses
69(70.41)
10(50)
6(60)
21(100)
1(50)
4(100)
Bacilli
67(68.37)
11(55)
6(60)
10(47.62)
1(50)
3(75)
Parasites
61(62.24)
9(45)
5(50 )
9(42.86)
2(100)
4(100)
Protozoa
43(43.8)
7(35)
2(20 )
11(52.38)
1(50)
4(100)
Animals
8(8.16)
-
2(20)
1(4.76)
2(100)
-
Plants
3(3.06)
-
1(10)
-
-
-
Others
2(2.04)
1(5 )
-
-
-
-
Risks
Physical
Abnormal pressure
Radiation
Biological
Chemical
Tobacco smoke
87(92.55)
18(85.71)
9(81.82)
9(52.94)
1(33.33)
1(33.33)
Dust
32(34.04)
5(23.81)
5(45.45)
6(35.29)
1(33.33)
2(66.67)
Chemical products
25(26.6)
4(19.05)
2(18.18)
3(17.65)
2(66.67)
1(33.33)
Vapors
8(8.51)
1(4.76)
1(9.09)
3(17.65)
3(100)
-
Gases
5(5.32)
-
2(18.18)
2(11.76)
2(66.67)
1(33.33)
Others
4(4.26)
-
-
2(11.76)
-
2(66.67)
Smog
-
-
-
-
-
-
Fog
-
-
-
1(5.88)
-
-
Inadequate posture
52(62.65)
9(50)
7(77.78)
11(68.75)
1(100)
3(75 )
Monotony and repetitiveness
33(39.76)
6(33.33)
3(33.33)
6(37.5)
-
2(50)
Physical strain
30(36.14)
3(16.67)
2(22.22)
4(25)
-
1(25)
Carrying weight
20(24.1)
1(5.56)
1(11.11)
-
-
1(25)
Strict productivity control
5(6.02)
1(5.56)
-
-
-
-
Others
1(1.2)
1(5.56)
-
1(6.25)
-
-
Ergonômicos
Psychosocial
542
Stressful situation
64(78.05)
14(70)
6(66.67)
11 (84.62)
3(100)
2(66.67)
Physical assault
40(43.48)
11(55)
5(50)
3(16.67)
1(25)
1(33.33)
Working night shifts
24(29.27)
8(40)
-
1(7.69)
-
-
Relationship with boss, coworkers and patients
24(29.27)
9(45)
2(22.22)
1(7.69)
-
-
Heightened environmental stress
23(28.05)
4(20)
3(33.33)
3(23.08)
-
-
Long working hours
12(14.63)
1(5 )
1(11.11)
-
-
1(33.33)
Intense work routine
1(1.22)
2(10 )
-
1(7.69)
-
2(66.67)
Others
1(1.22)
-
-
1(7.69)
-
1(33.33)
Acta Paul Enferm. 2014; 27(6):539-47.
Fernandes MA, Marziale MH
Factors influencing health status
Injury, poisoning, and other external causes
Symptoms, signs and abnormal findings not elsewhere classified
Pregnancy, birth and puerperium
Diseases of the genitourinary system
Diseases of the musculoskeletal system and connective tissue
Diseases of the skin and subcutaneous tissue
Diseases of the digestive system
Diseases of the respiratory system
Diseases of the circulatory system
Diseases of the eye and ear
Diseases of the nervous system
Mental and behavioral disorders
Endocrine, nutritional and metabolic diseases
Diseases of the blood and hematopoietic system
Neoplasms
Infectious and parasitic diseases
No ICD classification
20.40%
9.40%
2.60%
3.70%
3.70%
9.40%
0.60%
4.50%
4.30%
9.90%
4.30%
0.60%
4.30%
0.30%
2.80%
3.10%
7.00%
9.10%
Figure 1. Diagnoses of the disease or health problem, grouped according to the ICD 10, as recorded for medical leaves of absence of
the psychiatric hospital workers (n= 297)
in the three-year period of 2010-2012 involved
64.41% of the workers and resulted in a total of
4671 days of absences.
Figure 1 illustrates the distribution of medical
diagnoses recorded for the 297 leaves of absence,
grouped according to the ICD-10.
The group that was most commonly recorded for medical leaves of absence was that of factors influencing health status (60.58 - 20.40%),
followed by diseases of the circulatory system
(29.40 – 9.90%); diseases of the musculoskeletal
system and connective tissue (27.91 - 9.40%);
injury, poisoning and other external causes
(27.90 - 9.40%) and infectious and parasitic diseases (20.79 - 7.00%).
Of the 270 medical diagnoses recorded for
leaves of absence, 62(23.33%) were included on the List of Work-Related Diseases and
208(77.03%) were not. Table 2 presents the results regarding workers’ illnesses and their relation with the occupational risks reported by the
psychiatric hospital workers.
Fisher’s test resulted in a statistically significant
association between the variables medical leave of
absence and chemical risks over the years of 2010
and 2011, p=0.03352 and p=0.008281, respectively. In 2010, a statistically significant association was found between the variables medical leave
of absence and psychosocial risks, p=0.03161. In
2012, no associations among the studied variables
were found.
Discussion
The limitations of our results include the study’s retrospective design, which does not allow the establishment of cause-and-effect relationships.
The results, however, identified new scientific
knowledge that support the planning of health promotion actions, preventing factors that negatively
affect health in the work place, especially in hospital institutions in the northeastern region of Brazil,
where this theme is still underexplored.
The sociodemographic data illustrate the characteristics of the studied population. In this respect,
it is important to highlight that 77.92% of subjects
were between the ages of 40 and 59 years, which diActa Paul Enferm. 2014; 27(6):539-47.
543
Occupational risks and illness among mental health workers
Table 2. Mental health workers’ leaves of absence from 2010 to 2012, by presence or absence on the List of Work-Related Diseases,
types of occupational risks and year of occurrence(n2010=61; n2011=56; n2012=65)
Year of leave of absence
Risks
2010
On the list
Not on the list
2011
Total
On the list
Not on the list
2012
Total
On the list
Not on the list
Total
n(%)
n(%)
n(%)
n(%)
n(%)
n(%)
n(%)
n(%)
n(%)
Yes
14(23.0)
33(54.1)
47(77.0)
12(21.4)
35(62.5)
47(83.9)
17(26.2)
34(52.3)
51(78.5)
No
-
1(1.6)
1(1.6)
-
1(1.8)
1(1.8)
-
3(4.6)
3(4.6)
Yes
13(21.3)
30(49.2)
43(70.5)
11(19.6)
28(50.0)
39(69.6)
14(21.5)
30(46.2)
44(67.7)
No
1(1.6)
4(6.6)
5(8.2)
1(1.8)
8(14.3)
9(16.1)
3(4.6)
7(10.8)
10(15.4)
Yes
13(21.3)
30(49.2)
43(70.5)
11(19.6)
33(58.9)
44(78.6)
15(23.1)
31(47.7)
46(70.8)
No
1(1.6)
4(6.6)
5(8.2)
1(1.8)
3(5.4)
4(7.1)
2(3.1)
6(9.2)
8(12.3)
Yes
14(23.0)
25(41.0)
39(63.9)
8(14.3)
32(57.1)
40(71.4)
14(21.5)
28(43.1)
42(64.6)
No
-
9(14.7)
9(14.7)
4(7.1)
4(7.1)
8(14.3)
3(4.6)
9(13.8)
12(18.5)
Yes
10(16.4)
29(47.5)
39(63.9)
9(16.1)
27(48.2)
36(64.3)
15(23.1)
28(43.1)
43(66.2)
No
4(6.6)
5(8.2)
9(14.7)
3(5.4)
9(16.1)
12(21.4)
2(3.1)
9(13.8)
11(16.9)
Yes
9(14.8)
28(45.9)
37(60.7)
8(14.3)
29(51.8)
37(66.1)
13(20.0)
27(41.5)
40(61.5)
No
5(8.2)
6(9.8)
11(18.0)
4(7.1)
7(12.5)
11(19.6)
4(6.2)
10(15.4)
14(21.5)
Occupational
Physical
Biological
Chemical
Ergonomic
Psychosocial
verge from other studies, such as a study conducted
in 22 mental health services in the state of Goiás,
Brazil, which found that 66,4% of healthcare professionals were no older than 39 years old.(4)
Regarding occupational characteristics, one
positive finding was that 49.08% of the psychiatric hospital health professionals worked 30
hours per week, as reducing work hours has been
a demand of Brazilian health professionals. On
a national level, nursing professionals are waiting for the Senate Bill 2.295/2000 to be voted
on, better known as PL 30 Horas (30 hours bill),
which would establish a maximum weekly workload of 30 hours for nurses, nursing technicians
and nursing aides.(5)
Considering the variables that influence health
status, we found that 39.88% of workers carried
out leisure activities routinely and 25.77% did not.
This finding is worrisome, for leisure is considered
a psychosocial necessity. It is a form of mitigating
the harmful effects of unpleasant events, especially
because of its socializing aspects, one of the fundamental factors to well-being and that contributes to
health, especially mental health.(6)
Most of the workers at the psychiatric hospital did not report abusive drinking. However,
544
Acta Paul Enferm. 2014; 27(6):539-47.
the study demonstrated that alcohol abuse was
commonly mentioned by workers who reported
using drinking as a way to relax and relieve the
tension experienced at work, marked by pressure
from superiors, risks, high level of attention and/
or responsibility.(7)
The analysis of the identified occupational risks
according to work place indicate that subjects from
different work places reported being exposed to
similar risk agents. Among these, the most common physical risk in all units was noise; among
biological risks, bacteria; chemical risks, tobacco
smoke; ergonomic risks, inadequate body posture;
and stress and physical assault (violence) among
psychosocial risks.
In a study conducted with nursing technicians and aides in a psychiatric hospital, researchers found that these professionals were exposed
to objects such as knives and pieces of wood that
could be used by patients in physical assaults.
(8)
However, in general, physical assaults are expressed with kicking, punching, slapping and
strangulation attempts.
In some psychiatric units, the rates of violence
against workers surpasses the figure of 100 cases per
100 workers a year.(9) A study conducted with fo-
Fernandes MA, Marziale MH
rensic psychiatric nurses in England and Wales examined the impact of violence at work on workers’
mental health and found that individuals who had
experienced a high level of stress adopted palliative
behaviors such as alcohol use.(10)
In the case of hospital workers, biological
risks are mainly represented by infections caused
by bacteria, viruses, chlamydiae, fungi and parasites such as protozoa, helminthes and arthropods.(11) In psychiatric institutions, workers are
frequently exposed to risks while administering
injectable drugs or manipulating sharp instruments. In addition, special mention goes to the
risks of infection due to parasites and contact
with human bodily secretions, since by caring
for patients with mental illness who are also infested with lice and/or scabies health workers
consequently expose themselves to the risk of
infestation.(12)
Other biological agents identified by all twelve
categories of workers in the psychiatric hospital
were parasites and protozoa. The presence of felines,
rodents and plants as potential risk agents to worker
and patient health were also mentioned.
The use of tobacco by patients was mentioned
as an important chemical risk factor, in addition to
manipulating chemical substances such as medications, sterilization and cleaning solutions.
The most commonly mentioned physical agent
was noise 67.67% coming from patients with mental illness, as altered speech is common in most
psychopathologies, especially logorrhea, echolalia,
increased flow, coprolalia and tachylalia.
Considering ergonomic risks, inadequate
body posture, monotonous/repetitive tasks and
physical effort exerted when performing routine
activities were all factors mentioned by most
workers. Their work activities were considered
both repetitive and unpredictable: repetitive due
to their routine nature and unpredictable due to
unexpected behavioral changes of some psychiatric patients.
Stressful situations were the only psychosocial
risk factor identified by workers across all professional categories. In this sense, work-related stress
is cause for concern due to its consequences for
workers’ health. Cases of psychological harassment,
intimidation, moral and sexual harassment and
other forms of violence are increasingly present in
work environments. In an attempt to deal with such
stress, professionals may resort to unhealthy behaviors, such as alcohol and drug abuse. Researchers
have identified a relationship between stress and
diseases of the musculoskeletal, cardiac and digestive systems. The economic crisis and recession have
also led to an increase in work-related stress, anxiety,
depression and other mental disorders, even causing
some people to go to the extreme of committing
suicide.(1)
A study states that health institutions present
a complex context, as their work environments
are permeated with a diversity of tense inter-relations, in which several different subjects participate,
among them managers, workers and users, with differing, heterogeneous and conflicting needs. These
situations lead to satisfaction and/or dissatisfaction,
due to the conflict resulting from the fact that the
institution’s interests are not always in consonance
with those of its workers.(13)
Dissatisfaction with and lack of enthusiasm for
one’s work generate unease, which coupled with
tiredness and fatigue constitute important factors
that lead to psychological distress among psychiatric hospital workers. Work satisfaction is an important protective factor regarding work-related mental
illness. Thus, when a situation is unfavorable, mental disorders may occur.(8)
A study conducted with mental health workers
in a psychosocial care center in Fortaleza, Ceará,
Brazil, found that direct contact with users led to
work satisfaction, whereas work conditions and low
wages were reasons for dissatisfaction. Dissatisfaction with work had several effects on these individuals’ organizational life, as well as on their physical
and mental health.(14)
Regarding health problems obtained in this documentary research, 297 records of medical leaves of
absence between 2010-2012 were found, which involved 64.41% of the psychiatric hospital’s health
professionals and resulted in 4,671 days of absences
(working days lost). These results are worrisome, for
more than half of the workers were ill during this
Acta Paul Enferm. 2014; 27(6):539-47.
545
Occupational risks and illness among mental health workers
three-year period, resulting in losses for workers,
institution and patients.
In 2008, the number of cases of social security benefits that were conceded in Brazil due to
work disability lasting longer than two weeks,
and which were the consequence of work-related
mental and behavioral disorders, surpassed 12
thousand.(15)
Of the 270 medical diagnoses recorded for
leaves of absence during the analyzed three-year period, 62 (23.33%) were on the List of Work-Related Diseases published by the Brazilian Ministry of
Health and 208 (77.03%) were not.
Although our analyses found statistically significant associations between psychiatric hospital workers’ health and chemical or psychosocial
risks, it is important to state that establishing
causal relationships between work and disease is
complex. This is especially true when considering psychological and emotional illness, such as
depression.
Collaborations
Fernandes MA and Marziale MHP declare that
they contributed to the project conception, data
analysis and interpretation, drafting of the article,
critical review of its important intellectual content
and approval of the final version to be published.
Conclusion
5. Portal da Enfermagem. PL 30 Horas. [citado 2014 Fev 20]. Disponível
em: http://www.portaldaenfermagem.com.br/30-horas.asp.
Psychiatric hospital health workers across all professional categories recognized and identified occupational risks to which they are exposed, as well as
the possibility of becoming ill. More than half of
mental health workers presented health problems;
however, only a small portion of diagnoses were included on the list of occupational diseases. There
were statistically significant associations between
the variables disease and chemical risks and disease
and psychosocial risks.
Acknowledgements
This study was funded by the Coordination for
the Improvement of Higher Education Personnel (CAPES) in partnership with the Inter-institutional Doctoral Project incorporating the
Fundamental Nursing Graduate Program of the
University of São Paulo at Ribeirão Preto School
of Nursing (EERP/USP) with the Federal University of Paraíba (UFPB) and the Federal University of Piauí (UFPI).
546
Acta Paul Enferm. 2014; 27(6):539-47.
References
1. Organização Internacional do Trabalho. A prevenção das doenças
profissionais [Internet]. 2013. 20 p. [citado 2014 Fev 5]. Disponível
em:
http://www.ilo.org/public/portugue/region/eurpro/lisbon/pdf/
safeday2013_relatorio.pdf.
2. Tavares JP, Beck CL, Magnago TS, Zanini RV, Lautert L. [Minor
psychiatric disorders among nurses university faculties]. Rev Latinoam
Enferm. 2012; 20(1):175-82. Portuguese.
3. Brasil. Ministério da Saúde . Secretaria de Atenção à Saúde.
Departamento de Ações Programáticas e Estratégicas. Lista de
doenças relacionadas ao trabalho: Portaria n.º 1.339/GM, de 18 de
novembro de 1999. 2a ed. Brasília (DF): Editora MS; 2008. 70 p.
[acesso 2013 out. 12]. Disponível em: http://bvsms.saude.gov.br/bvs/
publicacoes/doencas_relacionadas_trabalho_2ed_p1.pdf.
4. Silva NS, Espiridião E, Silva KK, Souza AC, Cavalcante AC. [Professional
profile of university level workers in mental health services]. Rev
Enferm UERJ. 2013; 21(2):185-91. Portuguese.
6. Baldissera VD, Bueno SM. [Leisure and mental health in people with
hypertension: convergence in health education]. Rev Esc Enferm USP.
2012; 46(2):380-7. Portuguese.
7. Mendes DP, Moraes GF, Mendes JC. [Analysis of risk management
at nursing work in the psychiatric assistance]. Trabalho & Educação.
2011; 20(1):73-84. Portuguese.
8. Merchant JA, Lundell JA. Workplace Violence Intervention Research
Workshop, April 5-7, 2000. Washington (DC). Background, rationale,
and summary. Am J Prev Med. 2001; 20(2):135-40.
9. Coffey M, Coleman M. The relationship between support and stress
in forensic community mental health nursing. J Adv Nurs. 2001;
34(3):397-407.
10.Marziale MH, Santos HE, Cenzi CM, Rocha FL, Trovó ME.
Consequências da exposição ocupacional a material biológico
entre trabalhadores de um hospital universitário. Esc Anna Nery.
Rev Enferm. 2014; 18(1):11-6.
11.Marziale MH, Rocha FL, Robazzi ML, Cenzi CM, Santos HEC, Trovó
ME. Organizational influence on the occurrence of work accidents
involving exposure to biological material. Rev Latinoam Enferm. 2013;
21(Spe):199-206.
12.Marziale MH, Galon T, Cassiolato FL, Girão FB. [Implementation of
Regulatory Standard 32 and the control of occupational accidents].
Acta Paul Enferm. 2012; 25(6):859-66. Portuguese.
13.Ribeiro AE, Christinne RM, Espíndula BM. [Identification of the
institutional risks in nursing professionals]. Rev Eletrôn Enferm
(Centro de Estudos de Enfermagem e Nutrição). 2010; 1(1):1-16.
Portuguese.
Fernandes MA, Marziale MH
14. Campos AS, Pierantoni CR. Violência no trabalho em saúde: um tema
para a cooperação internacional em recursos humanos para a saúde.
RECIIS – Rev Eletron Comum Inf Inov Saúde. 2010; 4(1):86-92.
15.Guimaraes JM, Jorge MS, Assis MM. [(Dis)satisfaction with mental
healthcare work: a study in Psychosocial Care Centers]. Ciênc Saúde
Coletiva. 2011; 16(4):2145-54. Portuguese.
Acta Paul Enferm. 2014; 27(6):539-47.
547
Original Article
The access and the difficulty in resoluteness
of the child care in primary health care
O acesso e a dificuldade na resolutividade do cuidado
da criança na atenção primária à saúde
Anna Luisa Finkler1
Cláudia Silveira Viera2
Mauren Teresa Grubisich Mendes Tacla3
Beatriz Rosana Gonçalves de Oliveira Toso2
Keywords
Primary health care; Child care; Health
services accessibility; Nursing care;
Pediatric nursing
Descritores
Atenção primária à saúde; Cuidado da
criança; Acesso aos serviços de saúde;
Cuidados de enfermagem; Enfermagem
pediátrica
Submitted
July 25, 2014
Accepted
August 11, 2014
Abstract
Objective: To learn how access is conducted in two primary care units, traditional and family health strategy,
and assess whether there was resoluteness of assistance to child health.
Methods: This is a qualitative study, we used hermeneutic for understanding the data. The research instrument
was non-participant observation technique; the data were analyzed using thematic analysis method.
Results: There are four sub-categories: children, their family members and the first contact in primary care;
the service organization and its influence on access; the therapeutic itinerary of the family and child in search
of health care; scheduled access to health care.
Conclusion: Access to health services showed weaknesses regarding the child health care and the proposed
care service could build stable relationships and humanized care to child demand in primary health care.
Resumo
Objetivo: Apreender o acesso em duas unidades de atenção primária, tradicional e saúde da família e avaliar
se houve resolutividade da assistência a saúde da criança.
Métodos: Trata-se de pesquisa qualitativa, utilizou-se a hermenêutica para compreensão dos dados.O
instrumento de pesquisa a técnica de observação não participante, os dados foram analisados pelo método
da análise temática.
Resultados: Estão apresentados em quatro sub-categorias: a criança, seus familiares e o primeiro contato na
atenção primária; organização do serviço e sua influência no acesso; o itinerário terapêutico da família e sua
criança em busca de cuidado em saúde; o acesso à atenção programada em saúde.
Conclusão: O acesso aos serviços de saúde apresentou fragilidades quanto ao cuidado à saúde da criança
e que a proposta do acolhimento pode construir relações estáveis e cuidado humanizado à demanda infantil
na atenção primária à saúde.
Corresponding author
Anna Luisa Finkler
Carmelita Nodari street, 132, Toledo,
PR, Brazil. Zip Code: 85905-562
[email protected]
Prefeitura Municipal de Toledo, Toledo, PR, Brazil.
Universidade Estadual do Oeste do Paraná, Foz do Iguaçu, PR, Brazil.
3
Universidade Estadual de Londrina, Londrina, PR, Brazil.
Conflict of interest: there are no conflicts of interest to be declared.
1
DOI
http://dx.doi.org/10.1590/19820194201400089
548
Acta Paul Enferm. 2014; 27(6):548-53.
2
Finkler AL,Viera CS, Tacla MT, Toso BR
Introduction
The care provided to children in Primary Health
Care aims to promote health through priority actions of surveillance and monitoring of growth and
child development. It is necessary to establish conditions for the provision of this care, strengthening
the team through the provision of resources and
subsidies to health teams, autonomy and accountability to users, so that the health work reach its
purpose, which is solving the health needs of the
child and family.(1)
One of the requirements necessary to effective
care is individuals’ access to health services. Access
of first contact is one of the essential attributes of
primary health care and denotes the accessibility and use of these services in case of problems in
which people seek health care.(2)
It can be said that an accessible service that is
easy to approach, available to people in which there
is no geographical, managerial, financial, cultural
or communication barriers, enabling individuals to
receive care, and that is resolute, ie, the problem is
solved there or in another level of care, in the first
contact with the health service.(3)
In this perspective, the study aimed to learn
the access in two units of primary health care, one
traditional and another with family health strategy, with different work processes and assess whether
there was resoluteness in the health care of children
in this context, the two models used in Brazil.
Methods
This is a descriptive qualitative study whose theoretical and methodological framework for data interpretation was the hermeneutic.(4-6)
Data collection was conducted in two primary
care services that have primary care models distinct
from one another. The study subjects were all professionals working in these two units.
For data collection, we used the technique of
non-participant observation, with previously established script and for the observation record’s a field
diary was used. The period of data collection was
two months and ended due to saturation of information observed, providing the researcher enough
information to respond the research question.
The information collected from the field diary from the observation were ordered, organized,
categorized, contextualized and interpreted by the
method of thematic analysis.(7)
In pre-analysis, we established the first contact
with the material, identifying the units of meaning,
then explored through units of representative parts
of the texts of the field diary and finally the data
were grouped and interpreted allowing the construction of a category that explained access to services in the health units investigated.
The development of the study met national and
international standards of ethics in research involving human subjects.
Results
We chose to present the data in box format in which
we can observe the systematic category: “The influence of the work process in access and resoluteness
of the primary health care of children” with their
sub-categories and the related reports of observation in each unit of analysis, according to chart 1.
Discussion
We understand the results as inserted in the observed reality, which is a limitation of qualitative
method. Therefore, these results should not be generalized. Thus, we analyzed the information collected and systematized earlier around the difficulty of
access to childcare in primary health care.
We highlight that the performance in primary
health care is a fertile field of nursing work, looking
at the data can reflect on their way to take care of
children in the context of primary care and change
their practice to expand access and improve the resoluteness for children and their families, this is the
practical application of the study.
Regarding access to health services, we found
that the reception is the first place for seeking inActa Paul Enferm. 2014; 27(6):548-53.
549
The access and the difficulty in resoluteness of the child care in primary health care
Chart 1. Systematic category
The first contact in primary health care
Users come to the counter requesting information, the receptionists guide them or refer to the respective sectors that are ordered: dressings,
vaccines, inhalation.
The information given on reception are given in a timely manner, the user of this service depends on the orientation of the receptionist: “Where
is the vaccination room? [asks the user] turn around and wait in the lobby [the receptionist responds]”, “would you like to speak with the nurse?
She is not here today; she is on sick leave, replies the receptionist and the woman go home.
The service organization and its influence on access Before eight o’clock in the morning, Community Health Agents (CHA) is the one who work in the reception: meet the patients, take the charts,
schedule specialties consultations, answer the telephone and give information requested by users.
Patients need to stand in line all day to get a form, arrive around four or five o’clock in the morning. The security guard of the unit tells how many
forms will be available that day.
In the morning, about 30 individuals wait for the health unit open forming two lines, one for each physician in the area covered by the FHS. After
opening the unit, the receptionists deliver the forms according to the order in the line, if there are no left over form the user goes home, or if he/
she is very ill and wants to wait, an assessment is performed.
[...] when there is no form or the pediatrician is on vacation, they contact another Health Unit to try a vacancy for the child.
People who fail to get a form that day and want to wait to undergo an assessment, can wait. In this assessment, the pre-consultation (measures
of vital signs) is made, if the person is not well, they speak [technicians and/or nursing assistants] to the patient go to the Emergency Unit (UPA).
Access to scheduled primary health care
The childcare Nurse agenda of Team 31, in the morning provides consultations to children in general and one afternoon for newborns at high risk.
This organization aims to meet the return of discharged children from NICU and they could not schedule childcare.
Every Thursdays afternoons are addressed to care for pregnant women and children 0-3 years through the open agenda, in which the team of
dentistry teaches mothers preventive measures of oral health. For the rest of the age group, the agenda is open from time to time and patients
come to leave their name on the waiting list.
formation for users, which seeks care. In this place,
patients are oriented according to their needs, questions or complaints.
The reception of both units, regardless of the
care model adopted, whether traditional or family health strategy acted as a barrier and filtered
users. The indication would be to care for them
and change this moment, establishing a bond, in
qualified listening, good care practices in order to
ensure a humane, effective care, legitimizing this
level of care as a preferential entrance to network
of health care.(8)
These characteristics denote a care in child
health, involving mothers and the family integrally. It assumes the adoption of an expanded concept
of health, in which they are engaged in biological, psychosocial, cultural and subjective needs. In
order to be effective, it is essential the interdisciplinary action of interdisciplinary teams of health,
with longitudinal coordinates actions of multiple
professionals.(9)
One way of interdisciplinary approach is to invest in the care, which can be developed through
two dimensions: attitudinal, toward humane care,
with qualified hearing of health problems, involving
a positive response to the demands and the creation
of bonds between the health team and the enrolled
population. The other is organized to establish
flows, references and count references, territorialization, overcoming the constraints or negative responses such as lack of forms and the establishment
of an adequate initial assessment process.(10)
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Acta Paul Enferm. 2014; 27(6):548-53.
In other words, the reception is no longer a
place of power, capable of deciding about the user
access or not.
This tool can be implemented through the establishment of dialogue and can provide solutions
to present difficulties, forming a mixture of technical knowledge with popular knowledge. In this
perspective, knowledge sharing can occur since the
health worker present sensitivity to listen, understand the health needs and thus integrate them with
technical knowledge, providing the user a better
care at the clinic.(11)
We observed the existence of problems in the
organization of work, in which many workers left
their specific functions to do their work at different
sectors of their competence, supplying a shortage of
workers. Moreover, the excess of work and site conditions become hindering factors for the worker to
develop their work in caring and humane manner
with a view to solve the health problems of children.
Study with receptionist workers of a basic health
unit described the work as fragmented, in which the
focus of his/her work were addressed based on procedures offered, the health needs facing a biological
view of the health-disease process, hard and softhard technologies. The purpose of this study proved
to work as charity or undetermined, unknown to
the worker.(12)
Another study that evaluated access to family health strategy in the view of users, obtained
similar result, where users reported delay in consultations, helping to reduce the credibility of the
Finkler AL,Viera CS, Tacla MT, Toso BR
family health strategy, and thus hindering access,
reinforcing disbelief in the health service provided
by the public sector.(13)
This finding is also similar with the study cited,
among other similar results, the (de) humanization
of care, demonstrated by the presence of people at
dawn waiting for being cared.(14)
Thus, instead of adopting the practice of risk
classification, with the choice of an appropriate
methodology for this, one of the units adopts the
conduct called assessment. This practice should not
be taken as care, since this is a device with the principle of managing new ways of doing care in any
space and time to work with the use of conversation
technology providing sensitive listening, ensuring
universal access and giving a positive response with
agility to services and users.(15)
This perspective could be present in a more
expressive and consolidated family health strategy
teams studied, however, the observed results showed
no differences in the organization of services in the
access of family health strategy at the traditional
basic health unit. On the contrary, showed to offer better access and resolution of cases, compared
to the family health strategy unit, who through
“forms” and “assessments”, turned out to distance
from principles that characterize as the preferred
strategy for promoting health of the population.
Family Health is a strategy to actions to promote health through the empowerment of individuals and families for their care, since to be responsible for the health of the territory’s population, teams should extend the curative/preventive
practice, seeking to promote quality of life, which
corresponds to one of the main foundations of the
changing healthcare model.(16)
However, adopting only the family health
strategy as practice without actually changing
the model of care makes service users deviate, because the population is unaware and “lost”, they
do not know which service trust to clarify their
health needs.
One of the actions of the family health strategy is scheduled care, which describes itself as the
clinical encounter initiated by the health professional who focuses on aspects of care that are not
considered an acute condition or an exacerbation
of chronic condition. This encounter becomes the
basis of a care plan drawn up, reviewed and agreed
upon the health team and the users.(10)
In the observations, it was possible to detect
that type of childcare for nurses in both units, the
puerperal consultation associated with the first visit
of a newborn with the team of physicians and the
team of dentistry’s from the family health strategy
with oral health prevention for pregnant women
and children up to three years.
Regarding access to these services, it was observed that changes in the form of scheduling occurred with childcare group of newborn at high
risk coming from the neonatal intensive care unit,
where learned by the nurse, the difficulty of scheduling and caring for this priority, which lacks meticulous care.
These findings complement the study of the
care of preterm and low birth weight, discharged
from neonatal intensive care unit, where families
described their journey in health services in search
of continued health care for their child after hospital discharge. Mothers are expressed that this itinerary is marked by barriers to access, fragile bond
and institutional vulnerability of health services,
generating insecurity, dissatisfaction and non-effectiveness in child monitoring.(17)
It was possible to observe that most of the care
provided to children is through medical consultations, where access to care in child health is prioritized in acute situations of disease, ie, the focus of
that care ends up being the disease, complaints and
intervention for their healing, which indicates a
physician-centered healthcare, which overestimates
the biological aspects of individuals and soft-hard
and hard technologies instruments use for care,(1)
which ultimately do not reach the health needs of
the child integrality.
Regarding health needs, study conducted based
on perception of users, found that these needs are
linked to production and social reproduction and
accessibility to health actions and the related bond
needs for autonomy and self-care, concluding that
the relationship confidence allows strengthening the
potential for addressing the health-disease process.(18)
Acta Paul Enferm. 2014; 27(6):548-53.
551
The access and the difficulty in resoluteness of the child care in primary health care
Health care can become effective if care technologies be inverted, seeking to insert therapeutic projects in actions that transfer knowledge
to the user, raise their self-esteem, making them
able to incorporate experience in their unique
therapeutic process, making it also subject of
his/her health, having the opportunity to work
with soft health technologies in a more relational
process than instrumental, which means designing therapeutic projects focused on users’ needs
and having him/her as the protagonist of their
health process.(19)
In this study there were no differences in programmatic care executed in the model of the family
health strategy in contrast to the traditional health
unit, both kept such care through weekly schedule.
The largest portion of childcare was accomplished
through spontaneous demand care, caused by the
demand for care, cases of acute conditions of diseases and ailments, all resolvable within the primary
health care.
critical revision of intellectual content and Toso
BRGO participated in the project design, analysis,
interpretation of data, drafting the paper and critical revision of the important intellectual content.
References
1. Iriart C, Franco T, Merhy EE. The creation of the health consumer:
challenges on health sector regulation after managed care era. Global
Health. 2011; 7(2):2-17.
2. Malouin RA, Starfield B, Sepulveda MD. Evaluating the tools used to
assess the medical home. Manag Care. 2009; 18(6):44-48.
3. Oliveira BR, Viera CS, Collet N, Lima RA. [Access first contact in
primary health attention for children]. Rev Rene. 2012; 13(2):332-42.
Portuguese.
4. Regan P. Hans-Georg. Gadamer’s philosophical hermeneutics: concepts of
reading, understanding and interpretation. META: reseach in hermeneutics,
phenomenology, and practical philosophy. 2012; 4(2):286-303.
5. Carvalho BG, Peduzzi M, Mandú EN, Ayres JR. Work and Intersubjectivity: a theoretical reflection on its dialectics in the field of health
and nursing. Rev Latinoam Enferm. 2012; 20(1):19-26.
6. Ayres JR. [Hermeneutics and humanization of the health practices].
Ciênc Saúde Coletiva. 2005; 10(3): 549-60. Portuguese.
7. Minayo MC. Qualitative analysis: theory, steps and reliability. Ciênc
Saúde Coletiva. 2012; 17(3):621-6. Portuguese.
Conclusion
Access to first contact demonstrated weaknesses
concerning child in primary health care, it was evidenced the existence of organizational barriers, preventing or hindering access to care through imposed
bureaucratically devices. Furthermore, it was noticed a fragmented and uncoordinated care in both
primary care services, demonstrating that such services need to structuring and development of health
care effectiveness for the child and his/her family.
Aknowledgements
To the Conselho Nacional de Ciência e Tecnologia
(CNPq) for funding, process 474743/2011-0.
Collaborations
Finkler AL contributed to the project design, analysis, data interpretation and writing of the paper.
Viera CS collaborated with the project design, analysis, interpretation of data, drafting the paper and
critical revision of the important intellectual content. Tacla MTGM cooperated with writing and
552
Acta Paul Enferm. 2014; 27(6):548-53.
8. Ministério da Saúde (BR). Secretaria de Atenção à Saúde.
Departamento de Atenção Básica. Acolhimento à demanda
espontânea: queixas mais comuns na Atenção Básica. Brasília:
Ministério da Saúde; 2013. 290p. (Cadernos de Atenção Básica
28).
9. Giovanella L, Mendonça MH, Almeida PF, Escorel S, Senna MC,
Fausto MC, et al. Saúde da família: limites e possibilidades para uma
abordagem integral de atenção primária à saúde no Brasil. Ciênc
Saúde Coletiva. 2009; 14(3):783-94.
10. Mendes EV. O cuidado das condições crônicas na atenção primária à
saúde: o imperativo da consolidação da estratégia da saúde da família.
Brasília: Organização Pan-Americana da Saúde; 2012.
11. Coelho MO, Jorge MS, Araújo ME. [Access through sheltering in basic
health attention]. Rev Baiana Saúde Pública. 2009; 33(3):440-52.
Portuguese.
12. Sá ET, Pereira MJ, Fortuna CM, Matumoto S, Mishima SM. [The work
process in the reception of a Primary Care Unit: worker’s view]. Rev
Gaúch Enferm. 2009; 30(3):461-67. Portuguese.
13. Schwartz TD, Ferreira JT, Maciel EL, Lima RC. [Family Health Strategy:
evaluating the access to SUS from the perception of the users of the
health unit Resistência, in the region of São Pedro, Vitória, Espírito
Santo State]. Ciênc Saúde Coletiva. 2010; 15(4):2145-54.Portuguese.
14.Oliveira BR, Collet N, Mello DF, Lima RA. [The therapeutic journey
of families of children with respiratory diseases in the public health
service]. Rev Latinoam Enferm. 2012; 20(3):453-61. Portuguese.
15.Ayres JR. Care and reconstruction in healthcare practices. Interface
(Botucatu). 2004; 8(14):73-92. Portuguese.
16.Freitas ML, Mandú EN. [The promotion health regarding the Family’s
Finkler AL,Viera CS, Tacla MT, Toso BR
Health strategy: analysis of health policies in Brazil]. Acta Paul Enferm.
2010; 23(2):200-5. Portuguese.
17. Viera CS, Mello DF. [The health follow up of premature and low birth
weight children discharged from the neonatal intensive care unit]. Texto
& Contexto Enferm. 2009-2010; 18(1):74-82. Portuguese.
18. Moraes PA, Bertolozzi MR, Hino P. [Perceptions of primary health care
needs according to users of a health center]. Rev Esc Enferm USP.
2011; 45(1):19-25. Portuguese.
19. Franco TB, Merhy EE. [Cartographies of Work and health care]. Tempus
Actas Saúde Coletiva. 2012; 6(2):151-63. Portuguese.
Acta Paul Enferm. 2014; 27(6):548-53.
553
Original Article
Quality of life in women with breast
cancer undergoing chemotherapy
Qualidade de vida em mulheres com neoplasias de mama em quimioterapia
Sâmya Aguiar Lôbo1
Ana Fátima Carvalho Fernandes1
Paulo César de Almeida2
Carolina Maria de Lima Carvalho3
Namie Okino Sawada4
Keywords
Breast neoplasms/drug therapy; Quality
of life; Oncology nursing; Woman health
Descritores
Neoplasias da mama/quimioterapia;
Qualidade de vida; Enfermagem
oncológica; Saúde da mulher
Submitted
May 15, 2014
Accepted
August 20, 2014
Abstract
Objective: This study aimed to assess the health-related quality of life of women with breast cancer undergoing
chemotherapy.
Methods: A cross-sectional study carried out in a specialized institution, comprising 145 women. Two
standardized questionnaires for health-related quality translated and validated for the Portuguese language
were used. The scores manual of the EORTC was used to calculate the domain scores of the questionnaires.
Results: According to the first questionnaire, the emotional function was the most affected. The treatment
causes financial difficulties for most patients (mean = 41.83). The symptoms with the highest scores were
Insomnia (37.93), Fatigue (36.01) and Loss of Appetite (33.56). According to the Quality of Life Questionnaire
− Breast Cancer 23, the mean score for Side effects was 50.07, meaning that many women experience side
effects of chemotherapy, and impaired sexual satisfaction.
Conclusion: Women with breast cancer showed changes in the following domains: financial, emotional, sexual
satisfaction and future prospects. The most frequently mentioned symptoms were fatigue, insomnia and loss
of appetite.
Resumo
Corresponding author
Ana Fátima Carvalho Fernandes
Alexandre Baraúna street, 1115,
Fortaleza, CE, Brazil.
Zip Code: 60430-160
[email protected]
Objetivo: Conhecer a qualidade de vida relacionada à saúde de mulheres com câncer de mama em tratamento
quimioterápico.
Métodos: Estudo transversal realizado em instituição especializada, não qual foram incluídas 145 mulheres. Foram
utilizados dois questionários padronizados de qualidade relacionada à saúde, traduzidos e validados para a lingua
portuguêsa. Utilizou-se o Manual dos Escores da EORTC para calcular os escores dos domínios dos questionários.
Resultados: Segundo o primeiro questionário, a função mais afetada foi a emocional. O tratamento provoca dificuldade
financeira na maioria das pacientes (média = 41,83). Os sintomas com os maiores escores foram Insônia (37,93),
Fadiga (36,01) e Perda de apetite (33,56). Segundo o instrumento Quality of Life Questionnaire − Breast Cancer 23,
o escore Efeitos Colaterais teve média de 50,07, significando que muitas mulheres apresentam efeitos colaterais da
quimioterapia e satisfação sexual prejudicada.
Conclusão: Mulheres com câncer de mama apresentaram alterações nos domínios emocional, financeiro, de
satisfação sexual e nas perspectivas futuras. Os sintomas mais mencionados foram fadiga, insônia e perda de apetite.
Universidade Federal do Ceará, Fortaleza, CE, Brazil.
Universidade Estadual do Ceará, Fortaleza, CE, Brazil.
3
Universidade da Integração Internacional da Lusofonia Afro-Brasileira, Fortaleza, CE, Brazil.
4
Universidade de São Paulo, Ribeirão Preto, SP, Brazil.
Conflicts of interest: no conflicts of interest to declare.
1
2
DOI
http://dx.doi.org/10.1590/19820194201400090
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Acta Paul Enferm. 2014; 27(6):554-9.
Lôbo AS, Fernandes AF, Almeida PC, Carvalho CM, Sawada NO
Introduction
Breast cancer is a major public health problem
because of its high incidence and mortality. This
neoplasm is probably the most feared by women,
especially by the negative stigma brought by its diagnosis(1) and due to its psychological effects, which
affect the perception of sexuality and their own personal image.
This disorder has good options of treatment that
enable patients to extend their lives. The choice depends on the stage of the disease, the tumor type and
the general health of the patient. Among the procedures, chemotherapy is defined as the treatment using chemotherapeutic drugs to destroy the cells that
comprise the tumor. Such drugs are mixed with the
blood and carried to all parts of the body, thereby
destroying the sick cells that form the tumor, preventing them from spreading throughout the body.(2)
There was a significant improvement in life expectancy of women with that disease because of the
possibility of early diagnosis and the evolution of
treatment methods. Thus, more researchers have
been concerned about investigating the needs of
survivors of breast cancer, aiming at a more global
attention to the female group.(3)
Recent models of definitions and concepts of
Quality of Life related to health are being applied
to cancer patients. Validated instruments are used
to measure and explore effects and symptoms of the
disease, as well as to evaluate the Quality of Life
after treatment. Currently, several specific instruments to measure the impact of disease on Quality
of Life are called ‘instruments of Quality of Life related to health’.(4,5)
The aim of this study was to evaluate the
health-related quality of life of women with breast
cancer undergoing chemotherapy.
Methods
This is a cross-sectional study carried out in institutions specialized in the treatment of various types of
neoplasms, in the city of Fortaleza, state of Ceará,
northeastern region of Brazil.
The study included a convenience sample of
145 women with breast cancer, who were undergoing chemotherapy in the period between April and
July 2012, with the following inclusion criteria: age
greater or equal to 18 years, diagnosed with breast
cancer at any stage of disease, being on chemotherapy from the second cycle, following the mentioned
months of the cycle, and being present every day of
the week.
The following instruments were used: sociodemographic and clinical form; European Organization for Research and Treatment of Cancer
30-Item Quality of Life Questionnaire (EORTC
QLQ-C30), version 3.0, in Portuguese; and Quality of Life Questionnaire Breast Cancer − 23 (QLQBR23). The EORTC QLQ-C30 and the QLQBR23 are questionnaires of Quality of Life related
to health, translated and validated in Portuguese;
the use of both questionnaires is authorized by the
European Organization for Research and Treatment
of Cancer (EORTC).(6)
The Statistical Package for the Social Sciences
(SPSS), version 20.0 was used for data analysis. The
scores manual of the EORTC was used to calculate the domain scores of the questionnaires. All
mean scores were transformed linearly into a scale
from zero to one hundred points, as described in
the manual, where zero represents the worst health
status and one hundred the best state of health except for the symptom scale, in which the higher score represents more symptoms and the worst
quality of life. Thus, a high score in the functional
scale meant a healthy functional level, while a high
score in the symptom scale represented a high level
of symptoms and side effects.
Demographic data were evaluated by descriptive analysis of the variables selected for the
characterization of sample. A descriptive statistical analysis of sociodemographic, clinical and
therapeutic data of the EORTC QLQ-C30 and
the QLQ-BR23 was done through calculation of
mean, standard deviation and Pearson’s correlation
coefficient.
The development of the study met national and
international standards of ethics in research involving human beings.
Acta Paul Enferm. 2014; 27(6):554-9.
555
Quality of life in women with breast cancer undergoing chemotherapy
Results
The sample consisted of 145 women who were
in neoadjuvant and adjuvant chemotherapy for
breast cancer.
Table 1 refers to the sociodemographic characteristics of the studied women.
Table 1. Sociodemographic data of patients
Variables
n(%)
Mean ± SD
8(5.5)
52±11
Age range, years
Up to 35
36-45
37(25.5)
46-55
42(29.0)
56-65
46(31.7)
66-82
12(8.3)
Table 2. Clinical characteristics
Clinical characteristics
n(%)
Mean ± SD
Combined treatment (n=145)
Marital status
Without partner
63(43.4)
No
63(43.4)
With partner
82(56.6)
Yes
82(56.6)
Chemotherapy regimens (n=145)
Income, minimum wage*
Up to 1
83(57.2)
1-2
25(17.2)
3-4
17(11.7)
5-40
20(13.8)
2.14±3.63
Capital
54(37.2)
Interior
89(62.8)
38(26.2)
5-8
50(34.5)
9-11
43(29.7)
12 ┤more
14(9.7)
2.23±0.98
Source: Regional Center of Chemotherapy and Santa Casa de Misericórdia, Fortaleza (CE), 2012.
*The minimum wage at the time of research was R$ 622.00; SD - Standard Deviation
The average age in the studied group was 52±11
years, ranging between 29 and 82 years. In relation
to marital status, 82 women (56.6%) had a partner,
i.e., were married or living in a stable union. Regarding the monthly income, 81 women (55.9%)
received at least a minimum wage; 25 (17.2%)
patients received between one and two minimum
wages and were in treatment by the Unified Health
System; 20 (13.8%) patients had monthly income
above five minimum wages and in treatment with
the health insurance plan.
Regarding the origin of patients, 86 (59.3%) of
them were from the interior of the state; 54 women
Acta Paul Enferm. 2014; 27(6):554-9.
54(37.2)
AC (adriblastina + cyclophosphamide)
18(12.4)
Others
73(50.3)
<6
99(68.3)
>6
46(31.7)
5.61±6.97
Source: Regional Center of Chemotherapy and Santa Casa de Misericórdia, Fortaleza (CE), 2012.
SD - Standard Deviation
Years of education
1-4
TAC (docetaxel+doxorubicin+cyclophosphamide)
Time of treatment (n=142), months
Origin
556
were from the capital (37.2%) and three from other
different states (3.5%).
With respect to the years of study, 38 women (26.2%) had 1-4 years of study and 50 women (34.5%) had 5-8 years of study, equivalent to
uncompleted and complete primary education. In
addition, 43 (29.7%) women at least started high
school and studied 9-11 years. Only 14 women
(9.7%) started or finished college.
Table 2 shows the clinical data, such as combined therapy, chemotherapy regimens and treatment time, its absolute values, percentage, mean
and the standard deviation of each variable.
Regarding clinical data, 63 patients (43.4%)
had not undergone any other treatment, therefore,
the event consisted in a neoadjuvant chemotherapy.
Eighty-two (56.6%) other women had undergone
other treatments prior to chemotherapy (surgery or
radiotherapy).
The most frequently used schemes were TAC
(docetaxel + doxorubicin + cyclophosphamide) in
54 women (37.2%) and AC (adriblastina + cyclophosphamide) in 18 women (12.4%). The predominant treatment time in the studied sample was <6
months in 99 women.
Table 3 shows the descriptive data (mean
and standard deviation) relating to the results
obtained in the EORTC QLQ-C30 and QLQBR23 scales.
It is noteworthy that the score of the Global
Quality of Life (76.14) is nearer to one hundred,
which is considered reasonable or satisfactory by
women.
Lôbo AS, Fernandes AF, Almeida PC, Carvalho CM, Sawada NO
Table 3. Mean and standard deviation of the items of functions
and symptoms of the questionnaires: European Organization
for Research and Treatment of Cancer 30-Item Quality of Life
Questionnaire (EORTC QLQ-C30) and Quality of Life Questionnaire
Breast Cancer - 23 (QLQ-BR23)
Items
Mean ± SD
Functions*
Physical (n=145)
70.39±25.04
Role performance (n=145)
64.13±34.43
Cognitive (n=145)
73.33±27.94
Emotional (n=145)
61.32±29.01
Social (n=145)
76.89±28.06
Body image (n=145)
73.79±31.91
Sexual (n=145)
72.41±34.54
Sexual satisfaction (n=66)
50.50±34.21
Future perspectives (n=145)
46.20±42.34
Symptoms****
Fatigue (n=145)
36.01±27.38
Pain (n=145)
28.39±32.87
Nausea and vomiting (n=145)
28.62±29.89
Dyspnea (n=145)
10.34±23.41
Insomnia (n=145)
37.93±43.32
Loss of appetite (n=145)
33.56±38.98
Constipation (n=145)
29.88±37.21
Diarrhea (n=145)
20.68±32.41
Financial difficulty (n=145)
41.83±40.59
Side effects (n=144)
50.07±21.22
Symptoms related to the arm (n=145)
22.06±23.27
Symptoms related to the breast (n=145)
22.47±17.76
Hair loss (n=130)
37.43±44.12
Overall quality of health (n=145)
76.14±23.54
Source: Public Institutions Fortaleza (CE), Brazil, 2012.
*The closer to one hundred, the better the Global Quality of Life; **The closer to one hundred, the worse
the Global Quality of Life; SD - Standard Deviation
With regard to the functions according to the
EORTC QLQ-C30 scale, scores were high in the
following items: Physical Function (70.39), Role
performance (64.13), Cognitive Function (73.33)
and Social Function (76.89), indicating a level between regular and satisfactory. Most patients showed
no confinement in bed, did not need help with
bathing, dressing, eating, were not prevented from
doing leisure activities, presented no difficulty with
concentrating and / or remembering information,
and also the physical condition and the treatment
did not interfere in family life and social activities.
The lowest score was the Emotional Function (average 61.32), indicating feelings of slight tension,
anger, depression or worry.
In the symptom scale, the highest scores were
Insomnia (37.93), Fatigue (36.01) and Loss of Appetite (33.56). Thus, part of the women had some
(albeit little) difficulty with sleeping, fatigue, appetite loss.
The result of this research showed the mean value of the low score for symptoms of Pain (28.39),
Nausea and Vomiting (28.62), Dyspnea (10.34),
Diarrhea (20.68) and Constipation (29.88). This
may mean that these symptoms had little interference in daily activities.
In this sample, the physical condition and the
treatment caused some financial difficulties (average 41.83).
Regarding the subscales of the QLQ-BR23 instrument, the result shows 50.07 as the score for
Side effects, meaning that many women experience side effects of chemotherapy. The most affected scores were Hair Loss (37.43), Arm Symptoms
(22.06) and Breast Symptoms (22.47). The high
score on Body Image (73.79) means that there was
good acceptance of this feature. The high score for
Sexual Function (72.41), on its turn, revealed that
the practice of sexual intercourse continues for most
patients, however, the Sexual Satisfaction (average
50.50) was unsatisfactory or impaired. In relation
to the concern about future, the mean was 46.20.
Discussion
The limitations of the results of this study are related to the cross-sectional design that does not allow
establishing relations of cause and effect.
The patients with breast cancer receiving chemotherapy showed considerable changes in the
Global Quality of Life and its various dimensions.
The women in this study considered their state of
health and the quality of life as satisfactory, which
was evidenced by the score of the Global Quality of
Life (76.14).
Acta Paul Enferm. 2014; 27(6):554-9.
557
Quality of life in women with breast cancer undergoing chemotherapy
The EORTC QLQ-C30 scores were high
for Physical Function (70.39) Role performance
(64.13), Cognitive Function (73.33) and Social
Function (76.89), indicating a level between satisfactory and regular of these functions. In contrast,
women who received chemotherapy showed a significant decrease in physical, social and cognitive
function between the beginning and end of treatment (six complete cycles of chemotherapy). The
results may provide support for planning the nursing care for women undergoing chemotherapy.(7-10)
The score of the Emotional Function (mean
61.32) was considered the lowest among the functions of the first scale. It was observed that psychological distress in patients with breast cancer is related to depression, anxiety and low emotional function, and also to decreased quality of life, especially
in the emotional function and mental health.(11)
It was identified that the magnitude of change
in psychological anguish has a significant impact
on the physical and functional state, but not in the
social condition of Quality of Life. The anguish is
more closely related to symptoms, treatment factors or loss of skills than to family or social relationships.(12-15)
The most affected symptoms on the scale
of symptoms were Insomnia (37.93), Fatigue
(36.01) and Loss of Appetite (33.56). It is common to have increased fatigue and loss of appetite
in women with breast cancer at this stage.(8) With
respect to items of the QLQ-BR23 instrument,
the result showed a mean score of 50.07 for Side
Effects, in other words, many women had side effects of chemotherapy.
Among the physical effects of chemotherapy,
Fatigue was the most prevalent symptom reported
and source of high stress for patients. This symptom was accompanied by complaints of lack of
energy, exhaustion, loss of interest in previously
pleasurable activities, weakness, dyspnea, pain,
changes in taste, rash, sluggishness, irritability and
loss of concentration.(16,17)
The physical condition and the treatment caused
some financial difficulty (mean 41.83) in most patients. During treatment, the patient experiences
physical and financial losses, and adverse symp-
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Acta Paul Enferm. 2014; 27(6):554-9.
toms such as depression and decreased self-esteem,
requiring constant adjustments to the sociological,
social, family, physical and emotional changes. In
addition, limitations may occur in activities of daily
life and biopsychosocial changes that may also interfere with quality of life, such as job loss.(18-20)
The score of Sexual Satisfaction has a mean of
50.50, showing there was relative dissatisfaction in
the quality of the relationship. In young patients,
the interruption or dissatisfaction with sex life was
related to a poor quality of life, to chemotherapy, total mastectomy and difficulties with partner,
with respect to sexual relations. Researches suggests that problems with sexual functioning are
common in women with breast cancer undergoing
chemotherapy.(11,21,22)
Studies on the quality of life related to health
encompass both clinical morbidity caused directly
by the disease state, as the influences of disease and
treatments on daily activities and satisfaction with
life. Intervention strategies can be formulated by
evaluating aspects of quality of life related to health,
in order to minimize the effects of the disease of
progressive character, and improve aspects of quality of life.(20)
Conclusion
Women with breast cancer showed changes in the
following domains: financial, emotional, sexual satisfaction and future prospects. The most frequently
mentioned symptoms were fatigue, insomnia, and
loss of appetite.
Acknowledgements
Thanks to the Fundação Cearense de Apoio ao Desenvolvimento Científico e Tecnológico - FUNCAP for
granting the master’s scholarship.
Collaborations
Lôbo AS and Fernandes AFC contributed to the
project design, analysis and interpretation of data,
drafting the article and final approval of the version
to be published. Brilhante AF contributed to the
data collection. Almeida PC collaborated with the
Lôbo AS, Fernandes AF, Almeida PC, Carvalho CM, Sawada NO
analysis and interpretation of data and final approval of the version to be published. Carvalho CML
and Sawada NO collaborated in writing the article
and final approval of the version to be published.
References
1. Verde SM, São Pedro BM, Mourão Netto MD, Teixeira NR. [Acquired
food aversion and quality of life in women with breast cancer]. Rev Nutr.
2009; 22(6):795-807. Portuguese.
2. Instituto Nacional de Câncer. Estimativas 2014 de incidência de
mortalidade câncer no Brasil [Internet]. INCA; 2014 [citado 2014 Mai
14]. Disponível em: http://www.inca.gov.br/estimativa/2014.
3. Cangussu RO, Soares TBC, Barra AA, Nicolato R. [Depressive
symptoms in breast cancer: Beck Depression Inventory - Short Form].
J Bras Psiquiatr. 2010; 59(2): 106-10. Portuguese.
4. Delgado-Sanz MC, García-Mendizábal MJ, Pollán M, Foriaz MJ, LópezAbente G, Aragonés N, Gómez BP. Heath-related quality of life in
Spanish breast cancer patients: a systematic review. Health Qual Life
Outcomes. 2011; 9: 3.
5. Baena-Cañada JM, Estalella-Mendoza S, González-Guerrero M,
Expósito-Álvarez I, Rosado-Varela P, Benítez-Rodríguez E. [Influence
of clinical and biographical factors on the quality of life of women
with breast cancer receiving adjuvant chemotherapy]. Rev Calid Asist.
2011;26(5):299-305. Spanish.
6. European Organization for Research and Treatment of Cancer
Data Center. European Organization for Research and Treatment of
Cancer Quality of Life Questionnaire - EORTC (QLQ- C30) Scoring
Manual [Internet]. Brussels, Belgium; 2001[cited 2014 Mai 10].
Available from: http://www.eortc.be/qol/files/SCManualQLQ-C30.
pdf.
7. Ashing-Giwa KT, Tejero JS, Kim J, Padilha GV, Hellemann G.
Examining predictive models of HRQOL in a population-based,
multiethnic sample of women with breast carcinoma. Qual Life
Res. 2007; 16(3):413-28.
8. Browall M, Ahlberg K, Karlsson P, Danielson E, Persson LO, GastonJohasson F. Health-related quality of life during adjuvant treatment
for breast cancer among postmenopausal women. Eur J Oncol Nurs.
2008; 12(3):180-9.
9. Nicolussi AC, Sawada NO. [Quality of life of breast cancer patients in
adjuvant therapy]. Rev Gaúcha Enferm. 2011; 32(4): 759-66. Portuguese.
10.Silva CB, Albuquerque V, Leite J. [Quality of life in patients carrying
breast neoplasms submitted to chemotherapy]. Rev Bras Cancerol.
2010; 56(2): 227-36. Portuguese.
11.Bardwell WA, Natarajan L, Dimsdale JE, Rock CL, Mortimer JE,
Hollenbach K, et al. Objective cancer-related variables are not
associated with depressive symptoms in women treated for earlystage breast cancer. J Clin Oncol. 2006; 24(16): 2420-7.
12.Caplette-Gingras A, Savard J. Depression in women with metastatic
breast cancer: A review of the literature. Palliat Support Care. 2008;
6(4): 377-87.
13.Wong WS, Fielding R. Change in quality of life in Chinese women
with breast cancer: changes in psychological distress as a predictor.
Support Care Cancer. 2007; 15(11):1223-30.
14. Zandonai AP, Cardozo FMC, Nieto ING, Sawada NO. [Quality of life in
cancer patients: integrative review of Latin American literature]. Rev
Eletron Enferm. 2010; 12(3):554-61. Portuguese.
15. Membrive JM, Granero-Molina JMa, Salmerón JS, Fernández-Sola C,
López CM, Carreño TP. Qualidade de vida em mulheres climatéricas
que trabalham no sistema sanitário e educativo. Rev Latinoam Enferm.
2011; 19(6): 1314-21.
16. Conceição LL, Lopes RL. [The daily life of mastectomized women: from
diagnosis to chemotherapy]. Rev Enferm UERJ. 2008; 16(1):26-31.
Portuguese.
17.Lotti RCB, Barra AA, Dias RC, Makluf ASD. [Breast cancer treatment
and its impact in quality of life]. Rev Bras Cancerol. 2008; 54(4):36771. Portuguese.
18.Arabiat DH, Al Jabery MA. Health related quality of life in paediatric
chronic health conditions: A comparative study among children and
adolescents in Jordan. Health. 2013; 5(11B):19-24.
19.Beckjord E, Campas BE. Sexual quality of life in women with newly
diagnosed breast cancer. J Psychosoc Oncol. 2007; 25(2): 9-36.
20. Broeckel JA, Thors CL, Jacobsen PB, Small M, Cox CE. Sexual
functioning in long-term breast cancer survivors treated with
adjuvant chemotherapy. Breast Cancer Res Treat. 2002;75(3):
241-8.
21.Fernandes AF Cruz A, Moreira C, Santos MC, Silva T. Social support
provided to women undergoing breast cancer treatment: a study
review. Adv Breast Cancer Res. 2014; 3:47-53.
22. Spagnola S, Zabora j, Brintzenhofeszoc K, Hooker C, Cohen G, Baker F.
The satisfaction with life domains scale for breast cancer (SLDS-BC).
Breast J. 2003; 9(6):463-71.
Acta Paul Enferm. 2014; 27(6):554-9.
559
Original Article
Factors associated with indicators
of health needs of adult men
Fatores associados aos indicadores de necessidades
em saúde de homens adultos
Guilherme Oliveira de Arruda1
Aurea Christina de Paula Corrêa2
Sonia Silva Marcon1
Keywords
Nursing in public health; Nursing in
primary care; Men’s health; Needs and
demands of health services; Adults
Descritores
Enfermagem em saúde pública;
Enfermagem em atenção primária;
Saúde do homem; Necessidades e
demandas de serviços de saúde; Adulto
Submitted
May 15, 2014
Accepted
August 4, 2014
Abstract
Objective: To identify associated factors as indicators of health needs of adult men.
Methods: Cross-sectional study, type of population-based household survey, conducted with 421 men aged
between 20 and 59 years selected at random and systematic way. The research instrument was structured in
a form based on the variables of study. For the analysis, we used multiple logistic regression models.
Results: Unemployed men, aged between 30 and 39 years and with lower levels of education reported a
greater proportion of self-perceived health as fair/poor, being economic class, an important variable, adjusted
for the multiple model. Retired men or on sick leave, aged between 40 and 49 years old and white, had higher
frequency of morbidity.
Conclusion: The age group and occupational status were associated with self-perceived health and morbidity,
the latter being also associated with skin color.
Resumo
Objetivo: Identificar fatores associados aos indicadores das necessidades em saúde de homens adultos.
Métodos: Estudo transversal, tipo inquérito domiciliar de base populacional, realizado junto a 421 homens
com idade entre 20 e 59 anos selecionados de forma aleatória e sistemática. O instrumento de pesquisa
foi um formulário estruturado com base nas variáveis de estudo. Para a análise utilizaram-se Modelos de
Regressão Logística Múltipla.
Resultados: Homens desempregados, com idade entre 30 e 39 anos e com menores níveis de escolaridade
referiram, em maior proporção, a autopercepção de saúde regular/ruim, sendo a classe econômica, uma
variável importante, pois ajustou o modelo múltiplo. Homens aposentados ou em licença médica, com idade
entre 40 e 49 anos e de cor branca, apresentaram maior freqüência de morbidade.
Conclusão: A faixa etária e o status ocupacional estiveram associados à autopercepção da saúde e à
morbidade referida, sendo esta última também associada à cor da pele.
Corresponding author
Guilherme Oliveira de Arruda
Colombo Avenue, 5.790, Maringá, PR,
Brazil. Zip Code: 87020-900
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400091
560
Acta Paul Enferm. 2014; 27(6):560-6.
Universidade Estadual de Maringá, Maringá, Paraná, Brazil.
Universidade Federal de Mato Grosso, Cuiabá, Mato Grosso, Brazil.
Conflict of interest: there are no conflicts of interest to be declared.
1
2
Arruda GO, Corrêa AC, Marcon SS
Introduction
Health needs can be analyzed from different perspectives. firstly, in an abstract nature, referring
to the social and historical dimensions of each
individual with regard to health needs; and secondly, other concrete and operative, dedicated to
health care, in which the needs of the population
drive policies and programs.(1) Consistent with
this second conception, it is worth highlighting the Andersen Behavioral Model of health
needs, from two basic health indicators: the state
of health of the individual (presence/absence
of morbidity) and the perception of their own
health as nearest determining demand for care
and use of services.(2)
This model, besides being the pioneer, has been
the most used, aiming mainly to the understanding
of the use of health services due to the needs approach.(3) However, a systematic review of research
conducted between 1998 and 2011 reveals that
there are still few studies that focused on indicators
of health needs.(4) Thus, it is proposed here, the use
of a piece of the above model, focusing the analysis
of indicators among adult men.
Thus, it is important to distinguish between
male and female needs, different possibilities coexist
because of illness and health perceptions.(1) Despite
the unfavorable morbi-mortality profile to health
condition, men still largely report less often than
women having morbidity and poor health, even given the need for care, which compromise the health
care of this population.(5) We identified, however,
a gap in knowledge, considering that studies have
not investigated factors associated with indicators
of health needs in the male population.
Although men recognize that they have health
needs, they hesitate to seek care due to their own
behavior or profile of services and health professionals.(6) Furthermore, in a study conducted
with health professionals, the authors reported
that teams struggle to identify men health needs
and to plan their actions. They also emphasize
that the use of epidemiological data does not appear among the strategies addressed to identify
the needs of this population.(6)
Based on these assumptions, the objective of
this epidemiological study was to identify associated
factors to indicators of health needs in adult men.
Methods
This is a cross-sectional study, population-based
and a household survey type, conducted with
421 men aged between 20 and 59 years, living in
the city of Maringá, located in southern Brazil.
For the sample size calculation, we used the base
population count of men aged between 20 and
59 years, in 2010, which was 103 819 individuals,(7) and the following parameters and estimates:
50% for the prevalence of the response variables
among adult men, the associated estimation error of 5% and a 95% confidence interval to detect associations between the independent variables and the outcome. 10% (38 individuals) of
the the calculated minimum sample (383 individuals) was added, considering the possibility
of errors in the completion of the data collection
instruments.
For the selection of subjects, we used the technique of systematic random sampling, from the division of Maringá in 20 weighting areas that takes
into account the socio-occupational similarities
of individuals residing in the territory and which
is adopted by Metropolis Observatory - Core Region Metropolitan of Maringa. With the number
of men aged 20 to 59 years in the Weighting Areas,
we conducted the proportional calculation, which
we obtained the subsample to be collected in each
weighting area. So, the streets visited were randomized, in which we respected the default interval for
the selection of individuals: the fourth house on the
right side of the street. The interviews took place at
the homes of men, mostly during weekday mornings and afternoons between the months of January
and July 2013.
For data collection, we used a structured instrument. The variables of interest were: self-perceived health and morbidity. The independent
variables were socioeconomic and demographic: age, race, marital status, children, religion,
Acta Paul Enferm. 2014; 27(6):560-6.
561
Factors associated with indicators of health needs of adult men
education (in levels), work, family income (in
minimum wages), occupational status, health
insurance and economic classes categorized by
the Economic Classification Criterion of Brazil
developed by Brazilian Association of Research
Companies.(8)
The data were compiled in Microsoft Excel
2010 software, with subsequent analysis in IBM
SPSS 20 software. For data analysis, we performed univariate analysis using chi-square test
and multivariate analysis using multiple logistic
regression models not conditioned. We used the
method Forwards, whereby the variables with
p-value <0.20 in the univariate analysis were
tested in logistic analysis as increasing order of
p-value in order to identify variables that remain
associated with or could adjust the model. The
measure of association used was the odds ratio
(OR) with 95% confidence interval and significance level set at p-value <0.05 for the tests.
The development of the study met national and
international standards of ethics in research involving human subjects.
Resultados
A total of 421 individuals participated in the
study, they had a mean age of 40.9 years, they were
mainly white men (58%), with a partner (67.9%),
with children (71.3%), adherents to religions (89,
8%), had completed high school (36.8%), included in the labor market (80.3%), with incomes between 2.1 and 4 times the minimum wage (34%),
employers/independents (40.9% ), with no health
insurance (52.7%) and belonging to economy
class B (53%). We found a prevalence of 23%
and 42.8% for fair/poor self-perceived health and
morbidity, respectively.
In univariate analysis of fair/poor self-perceived health, we found an association (or p
values <0.20) with the following variables, in
order of significance: age (p <0.001), education
(p <0.001), occupational status (p <0.001), economic class (p <0.001), work (p = 0.002), family
income (p = 0.005), ethnicity (p = 0.054), health
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Acta Paul Enferm. 2014; 27(6):560-6.
insurance (p = 0.065) and religion (p = 0.118).
However, only the variables age, occupational
status and education remained in the multivariate model because men, aged between 30 and
39 years (p=0.012, OR=2.94) and unemployed
(p=0.025, OR=3.17) reported more often fair/
poor self-perceived health, whereas those with
high school education had significantly lower
odds ratio than those with lower levels of education for this outcome (Table 1).
Table 1. Socioeconomic and demographic variables with selfperceived health
Socioeconomic and demographic
variables
Self-perception of health (fair/poor)
n(%)
OR (95%IC)
p-value*
Age group
20 to 29
10(11.0)
1
-
30 to 39
27(28.4)
2.94(1.26; 6.86)
0.012
40 to 49
20(16.9)
1.26(0.52; 3.09)
0.606
50 to 59
40(34.2)
2.29(0.95; 5.53)
0.064
Occupational status
Independent/employer
39(22.7)
1
-
Employee
26(16.6)
0.76(0.43; 1.36)
0.370
Retired/on sick leave
21(44.7)
1.95(0.9; 4.15)
0.084
Unemployed
9(45.0)
3.17(1.15; 8.72)
0.025
Student/Intern
2(8.0)
0.51(0.10; 2.57)
0.419
Education
Until 4ª série
22(44.0)
1
-
Elementary School
31(31.0)
0.66(0.31; 1.39)
0.279
High School
23(14.8)
0.38(0.16; 0.87)
0.023
College
21(18.6)
0.63(0.24; 1.65)
0.346
Economic Class
Class A
4(12.9)
1
-
Class B
37(16.6)
1.52(0.46; 5.05)
0.494
Class C/D
55(33.1)
2.60(0.71; 9.49)
0.149
*Multiple Logistic Regression, with model adjusted by the variable “economic class”
Regarding the reported morbidity, we identified
in the univariate analysis, the following variables
were associated (or with p<0.20): age (p<0.001), occupational status (p<0.001), education (p=0.004),
work (p=0.004), economic class (p=0.016), children
(0.034) and ethnicity (0.053). The multiple model
showed that only the variables “age” and “occupational status” remained associated, and the variable
“ethnicity” turned to be associated significantly.
Thus, men in the age groups 40-49 years (p=0.007,
OR=2.45) and 50-59 years (p<0.001, OR=4.40),
retired or on sick leave (p=0.006 OR=3.01) and
Arruda GO, Corrêa AC, Marcon SS
white (p=0.016, OR=1.69) reported morbidity
more frequently than other men (Table 2).
Table 2. Socioeconomic and demographic variables with
reported morbidity
Socioeconomic and demographic
variables
Morbidity
n(%)
OR (95%IC)
p-value*
Age group
20 to 29
24(26.4)
1
-
30 to 39
26(27.4)
1.13(0.57; 2.25)
0.726
40 to 49
53(44.9)
2.45(1.28; 4.68)
0.007
50 to 59
77(65.8)
4.40(2.22; 8.71)
<0.001
Occupational Status
Independent/employee
72(41.9)
1
-
Employer
55(35.0)
0.88(0.55; 1.41)
0.592
Retired/on sick leave
36(76.6)
3.01(1.36; 6.65)
0.006
Uneployed
10(50.0)
1.62(0.60; 4.34)
0.333
Student/Intern
7(28.0)
1.04(0.37; 2.87)
0.937
1.69(1.10; 2.87)
0.016
Ethnicity
White
114(46.7)
Not white
66(37.3)
*Multiple Logistic Regression
Discussion
Among the limitations of this study, we emphasize the fact that the data collection was conducted
during periods of the day, which represent great
difficulty to find men in their homes, which may
have afforded greater proportion of independent
employed men, unemployed men, retirees and
men on sick leave. Still refers to the limitation the
cross-sectional design, which does not allow the establishment of causal relationships or predisposes
to reverse interpretations of causality. However, it
is emphasized that this study identified important
associations of socioeconomic and demographic factors with indicators of health needs among
adult men, which direct perspectives of work actions for nurses.
In this sense, the results of this study present
substantial epidemiological information for the
organization of services in the health care of men,
because they point to factors to be considered in
the approach to male health needs. Furthermore, it
emphasizes the importance of nursing professionals
to consider the male self-perception and the presence of morbidity, as well as associated factors, concerning, however, the singularities of gender in the
perception of these indicators by men.
The prevalence of fair/poor self-perceived
health found (23%) is similar to the study conducted with adults in southern Brazil (22.3%),
which compared with the adolescents and the
elderly,(9) but diverged from the prevalence in
northern Brazil.(10) Most of the studies also address the elderly population and generally have
prevalence higher than 30%.(9,10) It is noteworthy the gap relating to the investigation of factors associated with the same indicator of health
needs, especially in the adult population, and
even more among men.
It should be noted that self-perceived health
is an easily collected variable, and exposure to
diseases (diagnosed or not by a health professional). The impact that these generate in the physical, mental and social well-being of individuals,
being important in the analysis of individual
and population health by health professionals.
(11)
Understanding the health subjectively creates
relationships with other factors involving the individual’s life (such as access to information), in
addition to the physical condition, which reinforces its importance as an indicator of health
needs.
The association of this variable with advancing age has been observed in the literature,
mainly due to the increase in chronic diseases
and complications, most prevalent among the
elderly. However, the present study identified a
significantly higher proportion of fair/poor perception of their health for men aged between
30 and 39 years. It is inferred that this finding
shows the importance of further investigation
on the health of the adult male and on aspects
that influence it, in this phase of life, and more
specifically that lead men to refer to a negative
perception of health.
The occupational status proved important in
regard to fair/poor self-perception and this finding is consistent with other studies, in that inactive individuals in relation to the work, especially the unemployed, also are more likely to live
in unfavorable health conditions and seek health
services.(12) The occupational status may be a determinant of health inequalities, especially when
Acta Paul Enferm. 2014; 27(6):560-6.
563
Factors associated with indicators of health needs of adult men
considering the possibilities of social protection
(with/without work bond/social security contributions).(13)
Regarding the economic class, it does not
show association, we observed in other studies that this variable is important in regard to
self-perceived health.(9,10) The literature reveals
that education and socioeconomic status converge in the formation of certain social and
cultural contexts, implying health beliefs, perceptions and motivation to act, determining behaviors and lifestyles.(13) Therefore, it is worth
mentioning the need for health professionals to
know these characteristics of men in order to
contextualize their actions, because the appropriate professional support can also be determinant of self-perceived health.(14)
Regarding the reported morbidity, the identified prevalence is in the interval range by a national study, which is 33.9% to 62.0% among
individuals aged 25 to 64 years. In studies considering Morbidity as only hypertension and diabetes mellitus were noted prevalence similar to
30% adults.(15,16) The male population has important deficiencies of self-care, which increases
the rates of morbidity and mortality and requires
the commitment of health professionals in the
inclusion of men in programs and services, particularly in primary care.(17)
In a study conducted in a small city inland of
Paraná State was evident that men report less their
health problems than women, which is linked to
the way men perceive and conceive health.(18) Thus,
besides considering the possible underestimation
of data on morbidity among men, health professionals should know the peculiarities and individualities as the recognition of morbidity, according to
gender, in order to provide access, especially men,
to health actions.
Among adult men, we found that those with
more than 40 years when compared to younger patients reported more often having diseases.
This finding is according to other studies that
found increasing trend of diseases with advancing age, mainly due to biological issues, time of
exposure to risk factors and aging.(19) It is note-
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Acta Paul Enferm. 2014; 27(6):560-6.
worthy that, although the reference to morbidity
was higher among older men, the same was not
true in relation to self-perceived health, which
suggests the existence of other variables that imply about the way men perceive their health as
they age.
Thus, we emphasize the importance of occupational status with regard to the association
with morbidity. In men on sick leave, this association can be established in two ways: first, in
that the work conditions, the non-recognition of
their role and the dissatisfaction with this favor
the development of disease; and, second, that the
existing morbidity or worsening, undertakes the
work and determines the distance.(18) Both situations deserve attention from policies and health
services, so that health professionals can identify occupational hazards and act on them, contributing to the maintenance of adequate health
conditions for men to develop their activities, especially as they attribute important sociocultural
value to the work.(20)
With respect to ethnicity, lack of studies investigating health inequalities, specifically from the reported skin color as being associated to morbidity is
observed. However, the finding of this study - that
is, the highest proportion of individuals reporting
morbidity was white - differs from other studies that
have shown significant associations between black
skin and causes of morbidity and mortality, mainly external causes.(21,22) Although there is influence
of self-perceived health over reports of presence of
morbidity, we cannot justify the association of skin
color with morbidity from this variable, because the
association between this perception and the skin
color was not identified in present study and in another study conducted in southern Brazil.(9)
In general, this study contribute to the organization of health services by identifying
those factors associated with indicators of health
needs. Similarly, a study investigated adults in
the use of medical and hospital services in Canada and the United States showed that indicators
of health needs (self-perceived health and morbidity) are factors directly related to the demand
for health care.(13)
Arruda GO, Corrêa AC, Marcon SS
It is noteworthy that self-perceived health, may
still be related to adherence to preventive, promotion or treatment practices, while the morbidity as
assessed need, can determine the type of practice to
be implemented in monitoring health adult men.
However, these aspects are still indicators that, as a
rule, are not taken as targets of health services in everyday practice toward men. In this sense, the identification of factors associated with these indicators,
as findings of this study may contribute to the direction of attention to adult male and contextualize
the actions taken by health teams, aligning them to
the characteristics that influence the socialization of
men’s needs.
Acknowledgements
To Coordination of Improvement of Higher Education Personnel and Araucaria Foundation of Support of Scientific and Technological Development
of Paraná (Masters’ student scholarship, GO).
Collaborations
Arruda GO; Corrêa ACP and Marcon SS contributed in the design and development of research, analysis and interpretation of data, drafting the article, critical revision of the important
intellectual content and final approval of the
version to be published.
Conclusion
The age and occupational status were found to be associated factors, both with regard to fair/poor self-perceived health and morbidity among adult men, and
the education level and ethnicity were associated with
self-perceived health and presence of morbidity, respectively. Although not statistically significant, the
economic class was an important factor in setting the
proposed model for self-perceived health
2. Pavão AL, Coeli CM, Lopes CS, Faerstein E, Werneck GL, Chor D. [Social
determinants of the use of health services among a public university
workers]. Rev Saúde Pública. 2012; 46(1):98-103. Portuguese.
3. Pavão AL, Coeli CM. Modelos teóricos do uso de serviços de saúde:
conceitos e revisão. Cad Saúde Coletiva. 2008; 16(3):471-82.
4. Babitsch B, Gohl D, Lengerke TV. Re-revisiting Andersen’s Behavior
Model of Health Services Use: a systematic review of studies from
1998-2011. GMS Psyc-Soc-Med. 2012; 9(11):1-15.
5. Brasil. Ministério da Saúde. Política Nacional de Atenção Integral à
Saúde do Homem [Internet]. 2009. 46 p. [citado 2013 Set 6]. Disponível
em: http://dtr2001.saude.gov.br/sas/PORTARIAS/ Port2008/PT-09CONS.pdf.
6. Schraiber LB, Figueiredo WS, Gomes R, Couto MT, Pinheiro TF, Machin
R. [Health needs and masculinities: primary health care services for
men]. Cad Saúde Pública. 2010; 26(5):961-70. Portuguese.
7. DATASUS. Departamento de Informática do SUS-DATASUS. Informações
de saúde – Demográficas e socioeconômicas. 2013. [citado 2013
Mai 5]. Disponível em: http://www2.datasus.gov.br/DATASUS/index.
php?area=0206.
8. Associação Brasileira de Empresas de Pesquisa (ABEP). Critério de
Classificação Econômica Brasil-CCEB. 2010 [Internet] [citado em
2012 Jun 6]. Disponível em: http://www.abep.org.
9. Reichert FF, Loch MR, Capilheira MF. [Self-reported health status in
adolescents, adults and the elderly]. Cienc Saúde Coletiva. 2012;
17(12):3353-62. Portuguese.
10. Agostinho MR, Oliveira MC, Pinto ME, Balardin GU, Harzheim E. [Selfperceived health of adults users of Primary Health Care Services in
Porto Alegre, RS, Brazil]. Rev Bras Med Fam Comum. 2010; 5(17):915. Portuguese.
11.Venskutonyte L, Brismar K, Öhrvik J, Rydén L, Kjellström B. Selfrated health predicts outcome in patients with type 2 diabetes and
myocardial infarction: a DIGAMI 2 quality of life sub-study. Diab Vasc
Dis Res. 2013; 10(4)361-67.
12.Fernandes LCL, Bertoldi AD, Barros AJ. [Health service use in a
population covered by the Estratégia de Saúde da Família (Family Health
Strategy)]. Rev Saúde Pública. 2009; 43(4):595-603. Portuguese.
13. Giatti L, Barreto SM. [Labor market status and the use of healthcare services
in Brazil]. Cienc Saúde Coletiva. 2011; 16(9):3817-27. Portuguese.
14. Blackwell DL, Martinez ME, Gentleman JF, Sanmartin C, Berthelot JM.
Socioeconomic status and utilization of health care services in Canada
and the United States: findings from a binational health survey. Med
Care. 2009; 47(11):1136-46.
15.Lenardt MH, Michel T, Wachholz PA. [Self-rated health and life
satisfaction by institutionalized elderly women]. Ciênc Cuid Saúde.
2010; 9(2):246-54. Portuguese.
16.Capilheira MF, Santos IS. [Individual factors associated with medical
consultation by adults]. Rev Saude Publica. 2006; 40(3):436-43.
Portuguese.
17.Boing AF, Matos IB, Arruda MP, Oliveira MC, Njaine K. [Prevalence of
medical visits and associated factors: a population-based study in
Southern Brazil]. Rev Assoc Med Bras. 2010; 56(1):41-6. Portuguese.
References
18. Merino MF, Marcon SS. [Conceptions of health and therapeutic itinerary
adopted by adults from a small city]. Rev Bras Enferm. 2007; 60(6):
651-8. Portuguese.
1. Schraiber LB. [Healthcare needs, public policies and gender: the
perspective of professional practices]. Cienc Saúde Coletiva. 2012;
17(10):2635-44. Portuguese.
19.Pereira JC, Barreto SM, Passos VM. [Cardiovascular risk profile and
health self-evaluation in Brazil: a population-based study]. Rev Panam
Salud Publica. 2009; 25(6):491-8. Portuguese.
Acta Paul Enferm. 2014; 27(6):560-6.
565
Factors associated with indicators of health needs of adult men
20.Ferreira DKS, Bomfim C, Augusto LGS. [Working conditions and
referred morbidity in military police officers, Recife-PE, Brazil]. Saúde
Soc. 2012; 21(4):989-1000. Portuguese.
21. Figueiredo WS. Masculinidades e cuidado: diversidade e necessidades
de saúde dos homens na atenção primária [tese]. São Paulo: Faculdade
566
Acta Paul Enferm. 2014; 27(6):560-6.
de Medicina da Universidade de São Paulo; 2008.
22.Araújo EM, Costa MC, Hogan VK, Mota EL, Araújo TM, Oliveira
NF. [Race/skin color differentials in potential years of life lost due
to external causes]. Rev Saúde Pública. 2009; 43(3):405-12.
Portuguese.
Original Article
Nursing care to patients in brain death
and potential organ donors
Cuidados de enfermagem ao paciente em morte
encefálica e potencial doador de órgãos
Layana de Paula Cavalcante1
Islane Costa Ramos1
Michell Ângelo Marques Araújo1
Maria Dalva dos Santos Alves1
Violante Augusta Batista Braga1
Keywords
Nursing care; Brain death; Tissue
donors; Intensive care units
Descritores
Cuidados de enfermagem; Morte
encefálica; Doadores de tecidos;
Unidades de terapia intensiva
Submitted
August 20, 2014
Accepted
August 26, 2014
Abstract
Objective: Analyzing the opinion of nurses about nursing care to patients with brain death and potential organ
donors.
Methods: A descriptive, exploratory study, of qualitative approach, carried out in a general hospital. The
produced material was analyzed, from where emerged the category called Dimensions of care, with two
subcategories, namely: technical dimension and bioethical dimension.
Results: The dimensions of the nursing care to potential donors of organs and tissues give indications of
a practice focused on maintaining hemodynamic, also with the presence of the conflict between assisting
patients with brain death or others with possibilities of survival.
Conclusion: The nursing care to potential organ donors is a complex process and requires better skills and
emotional maturity, which are not always present.
Resumo
Objetivo: Analisar a opinião dos enfermeiros sobre os cuidados de enfermagem ao paciente em morte
encefálica e potencial doador de órgãos.
Métodos: Pesquisa descritiva, exploratória, de abordagem qualitativa, desenvolvida em um hospital geral. O
material produzido foi analisado, onde emergiu a categoria Dimensões do cuidado, com duas subcategorias:
dimensão técnica e dimensão bioética.
Resultados: As dimensões do cuidado dos Enfermeiros ao potencial doador de órgãos e tecidos dão indicativos
de uma prática voltada para a manutenção hemodinâmica, estando presente, também, o conflito entre assistir
ao paciente em morte encefálica ou a outros com possibilidades de sobrevida.
Conclusão: O cuidado de enfermagem ao potencial doador de órgãos configura-se como um processo
complexo e que requer melhor qualificação e maturidade emocional, nem sempre presente.
Corresponding author
Layana de Paula Cavalcante
Universidade Avenue, 2853, Fortaleza,
CE, Brazil. Zip Code: 60020-181
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400092
Universidade Federal do Ceará, Fortaleza, CE, Brazil.
Conflicts of interest: no conflicts of interest to declare.
1
Acta Paul Enferm. 2014; 27(6):567-72.
567
Nursing care to patients in brain death and potential organ donors
Introduction
The care for patients with brain death is characterized as a complex activity, implemented by multidisciplinary teams working in intensive care units.
In such activity, the role of nurses stands out, since
they are responsible for providing direct care for
the potential organ donors and their families. Their
work is of fundamental importance in the management of the pathophysiological repercussions characteristic of brain death, in the hemodynamic monitoring and in the provision of individualized care.
The success of transplantation is closely related to
the ideal maintenance of the potential donor.
The role of nurses in the embracement of patients’ families is of crucial importance in this moment, since they offer support and sufficient and
appropriate information for families in order that
they can collaborate with the process of donation
and transplant, if this is their will.(1)
The regulation of brain death diagnosis by the
Federal Council of Medicine (CFM - Conselho
Federal de Medicina) occurred in 1991, and it was
defined as the irreversible condition of all respiratory and circulatory functions or cessation of all brain
functions, including the brain stem.(2)
The maintenance of the potential donor of organs and tissues should be carried out as soon as the
suspected brain death occurs. The awareness of the
irreversibility of the condition of death should alert
professionals about the chance of using the organs
for transplantation. However, the actions of these
professionals are essential for maintaining the body
waiting in appropriate hemodynamic conditions,
while the family decides about the donation of usable organs.(3)
The family is usually fragile and needs care and
attention from the health care team, as they are facing a moment of pain with the diagnosis of brain
death and the loss of a loved one. In most of the
times, the death occurs tragically and unexpectedly. At this moment, the doubts of family members
should be eliminated at all stages of the process, and
it is essential that the professionals are adequately
prepared to operate in this process. Thus, it is possible to establish a link between the team and the
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Acta Paul Enferm. 2014; 27(6):567-72.
family, which may influence, positively or not, at
the time of decision about the organ donation.(4,5)
Given this context, it is important to identify
elements in the work process of nurses with the
patients who are potential organ and tissue donors
and their families that may interfere in the donation/transplantation process.
The nurses of intensive care units have different
conceptions of values, as well as social, religious,
philosophical and cultural beliefs that may impact
on their everyday actions, in the relations with the
family of patients with brain death and in the whole
process of donation and transplantation. Hence, the
objective of this study is to analyze the opinion of
nurses about the nursing care to patients with brain
death and potential organ donors.
Methods
This is a descriptive, exploratory study of qualitative approach, carried out in an intensive care unit
of a general hospital in the city of Fortaleza, state
of Ceará, northeast region of Brazil, in the period
between August and December 2013. The research
subjects were 30 nurses who had been working in
the institution for at least six months. This is because after this period, allegedly, the professional is
adapted to the environment and the experience of
assisting the patients who are potential organ and
tissue donors.
Data were generated by two sources. One were
the interviews using a structured questionnaire,
containing a part of the characterization of the research subjects, with information on gender, age,
length of service and training in the field of transplantation. The other was composed of five guiding questions: How do you conceive the donation
of organs and tissues? How is your daily life in the
care of patients who are potential donors of organs
and tissues? How do you perceive your professional
practice with patients who are potential organs and
tissues donors? Do you consider there are differences in the care provided to patients with brain death
and other hospitalized patients? If yes, what are
these differences? What are the implications of your
Cavalcante LP, Ramos IC, Araújo MA, Alves MD, Braga VA
practice to patients with brain death for completing
the donation-transplantation process?
The interviews were recorded and transcribed to
carry out the content analysis.
In the construction of results, excerpts from
speeches were used to illustrate the findings that
were classified into two subcategories – Technical
dimension of nursing care to the potential organ
donor; Bioethical dimension of nursing care to the
potential organ donor. These subcategories originated a single category called Dimensions of nursing care to the potential donor patient.(6)
The development of the study met national and
international standards of ethics in research involving human beings.
Results
The studied group was composed of 30 nurses with
the following characteristics: 28 female and two
male individuals; aged between 20 and 60 years; 17
had training time lower than five years; 12 were specialists in intensive care; and only three had training
in transplantation.
Category: Dimensions of nursing care to
the potential donor patient
This category grouped aspects related with care to
patients with brain death and potential organ donors, and their families. Two subcategories emerged
from this: Technical dimension of nursing care to
the potential organ donor; and Bioethical dimension of nurs care to the potential organ donor.
The technical dimension of care comprises the
professional skills, the fulfillment of protocols and
specific technologies for this care, focused on care
aimed at maintaining, monitoring and making viable the organs for transplant. The bioethics dimension consists in care in the context of interpersonal
relationships with patients and their families.
Subcategory 1: Technical dimension of
nursing care to the potential organ donor
Nurses reported that care to potential organ donor
patients is permeated by many complementary and
interdependent activities, configuring a complex,
multidimensional and multidisciplinary process.
Based on the reports of the study subjects, this
subcategory seeks to demonstrate the need for a
differentiated care to patients with brain death and
potential organ donors, with all the technological
support and scientific knowledge, aiming to make
the donation organs viable.
It is a potential organ. Some people may benefit
from these organs. So I try to keep the blood pressure,
keep the patient in temperature, heat this patient, if
the pressure starts to get lower and go down, I ask the
doctor to start vasoactive drugs, to make more fluids.
I will hydrate, protect the corneas, keep the
pressure hemodynamically stable, do everything
possible to maintain a stable condition and enable
the donation.
The nurse also reported being responsible for
other tasks regarded as indirect care, in the process
of monitoring the potential organ donor patient, as
it appears in the speech:
[...] Making the act itself faster. From providing the declaration and informing the team, trying
that the second assessment is made as soon as possible, until assisting the doctor who’s doing the initial
evaluation, in order that it occurs satisfactorily.
The nurse has an important place in the team
of organ transplant, and should be trained to start
the donation process, which includes, among
other procedures, the identification and notification of the donor to the hospital coordination
donation team, the monitoring and maintenance
of these patients, as well as the embracement and
care for their families.
Subcategory 2: Bioethical dimension of
nursing care to the potential organ donor
This subcategory combines aspects of posture and
action that nurses deem as necessary with the families, and for maintaining the body of patients in
brain death. At this point, the personal and ethical
values interfere in the professional practice with not
always positive effects, and repercussions on the donation/transplantation process.
The difficulties of dealing with patients in brain
death and potential donors of organs and tissues reActa Paul Enferm. 2014; 27(6):567-72.
569
Nursing care to patients in brain death and potential organ donors
sult on the neglect of care and professional distance
from patients.
In general, a change in the behavior of professionals is noticeable in relation to the provision of
care from the moment when the diagnosis of brain
death is defined.
When dealing with patients in brain death
and potential donors, the nurses mentioned the
importance of maintaining the care, considering
that the lifeless body still represents a person and
as such, deserves care and respect, as expressed in
the speeches:
First, I think the issue of respect must be very well
preserved. Despite being a person in brain death, it is
still a living person there, a body that still has a beating
heart.
[...] The assistance has to be maintained with dignity and respect.
In this subcategory, the ethical issues, of rights
and duties of professionals stand out, in relation to
organ donors and their families, as in the discourse
excerpt below:
We start by giving a differentiated attention to the
family, not as with a living patient, when we give hope
to the family that the patient will be fine and get better. And we try to talk to the family, for the family
understand and accept the mourning and also for preparing to the donation.
The nurse recognizes that organ donation is an
act of solidarity of the family who experiences the
pain of loss, and that despite the suffering, is able
to detach from the body (material) of the loved one
and opt for the donation.
The empathic behavior of nurses with the family can be an important support to these people,
although it emotionally drains the professionals,
reflecting in their professional practice, leading
them to withdraw from those moments as a form
of protection.
In the speeches of nurses, it was possible to
identify that they feel responsible, directly and
indirectly, by the care of patients in brain death,
considering the aspects of technical and bioethical dimensions of care to patients who are
potential donors of organs and tissues and their
families.
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Acta Paul Enferm. 2014; 27(6):567-72.
Discussion
The speeches refer the technical and bioethical
dimensions that constitute the nursing care to
patients who are potential donors of organs and
tissues and their families. The concern of these
professionals is noticeable in relation to technical
procedures for the hemodynamic maintenance of
patients in brain death, and for acceleration of
the process.
The assistance of nurses to patients with brain
death aims to preserve the condition of the potential donor. The transplantation of organs and tissues
is a safe and effective alternative treatment of various diseases that determines improvements in the
quality and perspective of life. Given the growing
shortage of organs, it is essential to optimize the use
of organs obtained from donors with brain death,
which are the main source of organs for transplants
currently.(7)
The demands for care of the patient with brain
death is differentiated from others in its specificities, because the aim of the care is different and
no longer a curative treatment. The assistance of
nurses will be focused on the stabilization of multiple deleterious effects that brain death has on the
body in a short period of time, causing hemodynamic instability, which requires extreme agility in
bureaucratic processes.
Some nurses state not to prioritize patients
who are potential donors of organs and tissues
due to considering that other hospitalized patients
with life prognosis are more important. The fact
that patients in brain death are in an irreversible
situation leads professionals to distance themselves
from them.
The nurses recognize that the withdrawal from
care to patients with brain death is caused by not
accepting the condition of patients, associated with
the ‘lack of professional, personal and emotional
maturity’. It stands out that (not) caring for patients is not due to negligence, but by ignorance
and psychological and emotional unpreparedness in
dealing with the situation. However, it is emphasized that this kind of attitude directly reflects on
the process of organ donation.
Cavalcante LP, Ramos IC, Araújo MA, Alves MD, Braga VA
Some studies have found similar results with regard to nursing care for these patients. The person
with brain death is the one receiving less attention
and care by the nursing staff.(1-3)
This distance from patients with brain death
is reflected in the care provided, because the
nurses return to their service with care focused
on the technical performance, and concern with
control of equipment and technologies present in
the intensive care unit. This change in conception can impair the assistance to potential donors
and their families, having as consequences the familiar negative and loss of organs that could be
donated.(3)
Bioethics is considered a transprofessional,
transdisciplinary and transcultural space in health
and in life, because it reflects the moral status of
our complex societies, emphasizing the quality of
life based on tolerance and solidarity. It leads to a
reflection about the conflicts that emerge from human evolution and the scientific revolution, but
also concerns the existing problems, the emerging
problems and the persistent problems.(8,9)
However, it is worth emphasizing that the focus of bioethics is the quality of human practices
on the phenomena of life.(9) In the care for patients
with brain death and potential donors of organs
and tissues, the nurses find themselves in a dilemma when caring for a dead person that at the same
time, makes life possible.
The process of donating organs is permeated by
issues involving human morality. The care of patients with brain death stands out, since they are
considered clinically dead, but have the characteristics of a living person. Thus, the professional relationship with the donor leads to a reflection on the
meaning of the human being.(10)
When thinking about death and dying, professionals give the meaning of finitude associated with
the transience of the material being, which is related
to feelings of loss, sadness, grief and longing. Death
means transition, transformation and rebirth, relating this perspective to religious beliefs, and finally,
gives contradictory meanings.(1,8,9,11)
The organ donors are seen as a means and not
an end in themselves. The professional gives them
importance because they congregate organs and tissues that will be viable to be used by others, hence,
they are a source of hope to someone who is waiting
for a transplant. However, the donor in brain death
is clinically dead, but maintains the characteristics
of an alive person.(9)
Conceptually, the donors are not ‘people’ for
their condition of death, however, at no times the
nurses refer to them as dead or corpse. The nurses
care for ‘people’ with physiological functions preserved alive, and the family gives the status of alive
for a dead person, making it difficult to understand
the potential donor as a corpse.(7)
In the opinion of nurses, being with the family
of the donor is a complex experience, but they recognize the delicacy and respect needed in this moment of great pain for the family. The nurses suffer
due to understanding that even in this situation
they need to perform their professional role.(4,5,10)
More than informing the status of potential donor patients, or about the process of organ donation, it is essential that nurses, for being closer to
family, are available and open to perceive the needs
of the relatives. Not only informing them about the
real condition of the patient with brain death, but
also helping them to understand reality as it is presented.(10,11)
The nurses who position themselves away from
the contact with family members act this way in an
attempt of self-preservation, to avoid exposing their
human vulnerability due to the inability of organizing the feelings of sadness and helplessness in that
moment.(11)
In situations that cause discomfort, the health
professionals fractionate and isolate themselves.
Dealing with distressing situations hinders the care
for others, which may explain the difficulty of the
staff in dealing with patients in brain death, since
the universe of these patients is surrounded by situations of suffering and helplessness.(1,8,9,11)
It is important to emphasize that the care
provided to patients with brain death requires
not only technical skills from nurses, but also
skills of multiple aspects (physical, biological,
psychological, social, spiritual, economic, political, sociological and historical) closely interActa Paul Enferm. 2014; 27(6):567-72.
571
Nursing care to patients in brain death and potential organ donors
twined. The fact that professionals cannot deal
with some of these aspects may lead them to not
care properly, keeping away of patients and their
families, or even neglecting the patients in this
condition.(8,9,11)
Providing nursing care to the families of potential donors who are part of the organ donation process is of utmost importance. Joining patient care
with the care for the family is a positive aspect in the
direction of reaching the consent in the donation of
organs of brain-dead patients.(1,4,5,10)
Conclusion
The nurses seek to address the technical and bioethical dimensions of care to patients who are
potential donors of organs and their families,
while recognizing the complexity of the process
and the need for better qualification and emotional maturity.
Collaborations
Cavalcante LP; Ramos IC; Araújo MAM; Alves
MDS and Braga VAB declare that contributed to
the project design, analysis and interpretation of
data, drafting the article, critical revision of the important intellectual content and final approval of
the version to be published.
572
Acta Paul Enferm. 2014; 27(6):567-72.
References
1. Santos MJ, Massarollo MC, Moraes EL. [Family interview in the process
of donating organs and tissues for transplantation]. Acta Paul Enferm.
2012; 25(5): 788-94. Portuguese.
2. Moraes EL, Silva LB, Moraes TC, Paixão NC, Izumi NM, Guarino AJ.
[The profile of potential organ and tissue donors]. Rev Latinoam
Enferm. 2009; 17(5):716-20. Portuguese.
3. Guido LA, Linch GF, Andolhe R, Conegatto CC, Tonini CC. [Stressors
in the nursing care delivered to potential organ donors]. Rev Latinoam
Enferm. 2009; 17(6):1023-9. Portuguese.
4. Dalbem GC, Caregnato RC. [Organ and tissue donation for transplant:
family refusal]. Texto & Contexto Enferm. 2010; 19(4):728-35.
Portuguese.
5. Pessoa JL, Schirmer J, Roza BA. [Evaluation of the causes for
family refusal to donate organs and tissue]. Acta Paul Enferm.
2013;26(4):323-30. Portuguese.
6. Fontanella BJ, Campos CJ, Turato ER. [Data collection in clinicalqualitative research: use of non-directed interviews with openended questions by health profissionals]. Rev Latinoam Enferm.
2006;14(5):812-20. Portuguese.
7. Rech TH, Rodrigues Filho EM. [Care of the potential organ donor]. Rev
Bras Ter Intensiva. 2012;19(2):197-204. Portuguese.
8. Lunardi VL, Barlem EL, Bulhosa MS, Santos SS, Lunardi Filho WD, da Silveira
RS, BaoI AC, DalmolinI Gde L. [Moral distress and the ethical dimension in
nursing work]. Rev Bras Enferm. 2009;62(4):599-603. Portuguese.
9. Mascarenhas NB, Rosa DO. [Bioethics and nursing formal education:
a necessary interface]. Texto & Contexto Enferm. 2010;19(2):366-71.
Portuguese.
10.Cinque VM, Bianchi ER. [Stressor experienced by family members in
the process of organ and tissue donation for transplant]. Rev Esc
Enferm USP. 2010;44(4):996-1002. Portuguese.
11.Lima AA. [Donation of organs for transplant: ethical conflicts in the
perception of professionals]. Mundo da Saúde. 2012;36(1):27-33.
Portuguese.
Original Article
Sexual dysfunction and associated factors
reported in the postpartum period
Disfunção sexual e fatores associados relatados no período pós-parto
Juliana Bento de Lima Holanda1
Erika de Sá Vieira Abuchaim2
Kelly Pereira Coca2
Ana Cristina Freitas de Vilhena Abrão2
Keywords
Sexual behavior; Obstetrical nursing;
Nursing research; Physiological sexual
dysfunction; Postpartum period;
Questionnaires
Descritores
Comportamento sexual; Enfermagem
obstétrica; Pesquisa em enfermagem;
Disfunção sexual fisiológica; Período
pós-parto; Questionários
Submitted
August 19, 2014
Accepted
August 26, 2014
Corresponding author
Ana Cristina Freitas de Vilhena Abrão
Napoleão de Barros street, 754, São
Paulo, SP, Brazil. Zip Code: 04024-002
[email protected]
Abstract
Objective: To estimate the prevalence and factors associated with sexual dysfunction in the postpartum period.
Methods: Cross-sectional study of 200 postpartum women in their resumption to sexual activity. Data were
collected in a private place, through interviews and recorded in forms, containing information regarding sexual
life of postpartum women.
Results: Among the women studied, it was found that 33.5%, 76.0% and 43.5% had sexual dysfunction
before pregnancy, during and after delivery, respectively. The types of dysfunction most frequently identified
were dyspareunia, vaginismus, dysfunction of desire, orgasmic and arousal. The significantly associated
factors were Catholic or protestant religions, vaginal delivery with suture, dyspareunia during pregnancy,
vaginismus before pregnancy and working hours over 8 hours/daily.
Conclusion: The prevalence of sexual dysfunction was high and associated factors were religion, working
hours, previous history of dysfunction and type of delivery.
Resumo
Objetivo: Estimar a prevalência e os fatores associados à disfunção sexual no período pós-parto.
Métodos: Estudo transversal com 200 puérperas que retomaram a vida sexual ativa. Os dados foram coletados,
em local privado, por meio de entrevista e registrados em formulário contendo informações pertinentes a vida
sexual das puerperas.
Resultados: Dentre as mulheres pesquisadas verificou-se que 33,5%, 76,0% e 43,5% apresentavam
disfunções sexuais antes da gravidez, durante e após o parto, respectivamente. Os tipos de disfunção
identificados com maior frequência foram a dispareunia, seguida do vaginismo, disfunção do desejo,
orgásmica e excitação. Os fatores significativamente associados foram as religiões católica ou evangélica, o
parto vaginal com sutura, a dispareunia durante a gravidez, o vaginismo antes da gravidez e uma jornada de
trabalho além de 8 horas/diárias.
Conclusão: A prevalência das disfunções sexuais foi alta e os fatores associados foram: religião, jornada de
trabalho, história prévia de disfunção e tipo de parto.
Universidade Federal de Alagoas, Maceió, AL, Brazil.
Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
Conflict of interest: Abuchaim ESV is Associate Editor of the Acta Paulista de Enfermagem and did not
participate in the peer review process of the manuscript.
1
DOI
http://dx.doi.org/10.1590/19820194201400093
2
Acta Paul Enferm. 2014; 27(6):573-8.
573
Sexual dysfunction and associated factors reported in the postpartum period
Introduction
Sexual dysfunction prevalence varies between 2073% in women. It is a behavior resulting from a
combination of biological, psychological, social
and cultural factors, which makes a total or partial
blockage of the sexual response of subjects related
to desire, arousal and orgasm.(1,2) In this sense, it is
a public health problem and thus deserve the attention of health professionals.
Although the difficulties in sexual activity
could affect various stages of an individual’s life,
the pregnancy-puerperal cycle, especially the postpartum period, deserves a closer analysis, as it promotes significant changes in women’s, partner’s
and family lives.(3)
The need to adapt to the demands of the newborn and the parental role may adversely affect the
intimacy of the couple, as well as changes in body
image and the desexualized figure of woman, cultivated by society. These features, plus the fear of pain
in the intercourse and/or becoming pregnant again
may cause distress difficulties and limitations in the
sexual female sexuality.(1,4)
The difficulties in returning to sexual activity,
which usually occurs around the 6th week postpartum and encouragement of partner, are common in most of women. Early diagnosis of female
sexual dysfunction, in this period, has been little
discussed in the scientific literature, despite the direct impact on quality of life and woman’s health.
Early identification is critical for the detection of
emotional and relational conflicts, in addition to
medical referrals.(3,5-7)
The dyspareunia appears in most studies as major sexual dysfunctions in the postpartum, compromising the desire, sexual satisfaction and frequency of sex. Presumably related to normal delivery,
the presence of episiotomy and/or lacerations and
breastfeeding, dyspareunia is not the only sexual
dysfunction that affects women in this period of
their lives, deserving an expansion of the studies on
this theme.(4,7,8)
Research shows that the integrality of care in
women is neglected, since most of the orientations of healthcare team about sexuality postpar-
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Acta Paul Enferm. 2014; 27(6):573-8.
tum are limited to recommend the resumption
period of sexual activity, without addressing the
aspects of the quality and the strategies to deal
with the changes resulting from pregnancy-puerperal cycle.(1,9,10)
Knowing the epidemiology of sexual dysfunctions may contribute to the address actions in the
care process. The aim of this study was to estimate
the prevalence and factors associated with sexual
dysfunction in the postpartum period.
Methods
Observational study with cross-sectional design
conducted in an outpatient pediatric clinic in the
State of Alagoas, northeastern Brazil. The population consisted of women with partners during the
data collection period, which had already returned
to sexual intercourse and were between the third
and sixth month postpartum. It was considered
as exclusion criteria: pregnant women and/or any
pathology that could not reccomend sexual intercourse for women. The sample size calculation
considered: the proportion of 50% in the population, absolute precision of 7% and a significance
level of 5%; the final sample was set at 200 postpartum women.
Data collection was performed by one of
the researchers, through interviews with eligible
women, in a private location, preserving the individuality.
The data collected were recorded on a specific
form developed specifically for the study; and the
variables studied were related to data regarding
identification, obstetric history and sex life, including sexual dysfunction, before and during pregnancy and after delivery.
The storage of the data was performed on the
electronic spreadsheet (Microsoft Excel® 2003), in
which each row corresponded to a form of data collection. Two entries were performed independently
and blindly. Disagreements were resolved through
form consultation.
Regarding statistical analysis, qualitative variables, absolute (n) and relative (%) frequencies
Holanda JB, Abuchaim ES, Coca KP, Abrão AC
were used. For quantitative variables, we used
measures of central-tendency: mean, median and
standard deviation (minimum and maximum) to
present variability. In the comparisons of the categories of the qualitative variables the chi-square or
Fisher’s exact test were used when necessary. Comparing mean between two groups of interest, the
Student t test was used. All tests had a significance
level of 5%.
A logistic regression analysis was used to determine which characteristics influenced together sexual dysfunction. For this analysis, the initial model, the variables that had a significance
level of <0.10 in the univariate comparisons
between patients with and without sexual dysfunction were included. In this analysis, using
the stepwise forward method, variables analyzed
together that did not present statistical significance were not included in the final model.
Thus, from the variables initially included in the
model, only entered the final model, those with
statistical significance (p <0.05); the others were
not part of the model. For all tests, we considered a significance level of 5%.
The development of the study met national and
international standards of ethics in research involving human beings.
Results
A total of 200 postpartum women with the following sociodemographic characteristics were
included: mean age of 24 years, with an average
of 7.8 years of education and family income of
one or more minimum wages. Among the postpartum women, 184 (92%) lived with their partners, 172 (86%) worked only at home, averaging 8.5 hours of work per day, and 101 (50.5%)
were Catholic. On average, 4.6 people lived in
the house.
As for obstetric data, we found that 44.5%
women were primiparous. The majority 55.5% had
undergone vaginal delivery and from these, 33.5%
were in their 3rd month postpartum, 21.5% were in
the 4th month, 20% at 5th month and 20% at their
6th month postpartum. The resumption to sexual
activities occurred, usually between 6 and 7 weeks
postpartum and, in most cases 70%, initiated by
the partner.
The prevalence of sexual dysfunction identified
before pregnancy was 33.5%, increasing to 76.0%
during pregnancy, declining to 43.5% in the postpartum period.
Data on table 1 show the distribution of types
of sexual dysfunction presented in postpartum
women.
Table 1. Types of sexual dysfunction identified in the
postpartum period
Types of sexual dysfunction*
n(%)
Dysfunction of desire
25(12.5)
Dysfunction in the arousal stage
16(8.0)
Dyspareunia
57(28.5)
Orgasmic dysfunction
21(10.5)
Vaginismus
32(16.0)
*Some women had more than one disorder; n=87
Data on table 2 show the logistic regression
analysis as the aggregate interference of the variables
for the presence of sexual dysfunction in the postpartum period.
Table 2. Interference of the variables for the presence of sexual
dysfunction in the postpartum period (n=200)
Variables
Coeficient
p-value
Odds ratio
Confidence Interval
Religion
None
0.027
Catholic
1.03
0.010
2.81
(1.28-6.16)
Protestant
0.99
0.036
2.69
(1.06-6.82)
0.004
3.04
(1.41-6.54)
0.575
1.25
(0.57-2.73)
2.57
(1.34-4.92)
8.53
(2.60-28.00)
1.12
(1.02-1.24)
Delivery
Cesarean
0.014
Vaginal with suture
1.11
Vaginal without suture
0.22
Dyspareunia
During pregnancy
0.004
0.94
Vaginismus
Before pregnancy
0.000
2.14
Workload
Above 8 hours/day
0.024
0.11
CI – Confidence Interval
Acta Paul Enferm. 2014; 27(6):573-8.
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Sexual dysfunction and associated factors reported in the postpartum period
Discussion
As an observational study with cross-sectional design, we could not establish cause and effect relation, thus limiting the results of the research.
Recognizing sexual dysfunctions as a public
health problem, which affects most women during
pregnancy-puerperal cycle, especially during pregnancy. In the postpartum period, although showing
improvement, a significant level of dysfunction is
maintained which shows its importance for health
professionals. Caring for women integrally means
being concerned with their sexual health, requiring
nurses to search for theoretical and practical approaches on the strategies that enable confrontation
of this reality.(1,3,4,11)
Similar results were identified in a study of women in the first 3 months of postpartum, in which it
was identified that 83% of them experienced sexual problems, decreasing to 64% at 6 months - although not reaching pre-pregnancy levels of 38%.
(12)
In this sense, the fact is that health professionals need to be aware of issues related to sexuality of
women/couples.
The satisfactory exercise of sexuality, including
sexual activity during pregnancy and postpartum is
a concern not only of women, but present among
couples, reinforcing the need for care in the difficulties by specialists, main professionals in the promotion of sexual health through clarification about the
normal fluctuations that occur during pregnancy
and after childbirth, with respect to the function
and sexual interest.(4,6,13)
In this sense, although sexual dysfunctions
are well known, they are not diagnosed, because
of inhibition of the woman who does not have a
complaint, or the physician, who is uncomfortable
to investigate. The diagnosis is relevant, since this
problem interferes with quality of life, besides being associated with health issues in general. Studies
show that although many couples present sexual
difficulties, especially after the first birth, few are
those who, in fact, seek professional help.(1,3,4,14)
Regarding types of sexual dysfunctions identified in this study, we recognized more frequently, dyspareunia, vaginismus, dysfunction of desire
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Acta Paul Enferm. 2014; 27(6):573-8.
and orgasmic, and finally, dysfunction of arousal
stage. The factors associated with these dysfunctions were women belonging to the Catholic or
Protestant religion; working over 8 hours/daily;
vaginal delivery with suture; the presence of dyspareunia during pregnancy; and the presence of
vaginismus before pregnancy.
The fact that Catholic and Protestant women
present nearly three times higher risk for sexual
dysfunction than those without religion invites us
to reflect about maintenance of the century ideal
worshiped woman/mother immaculate and submissive as one that is fully dedicated to her child
and should not or can experience the pleasures arising from sexual activity.(13,15)
Trying to combine maternal functions with
other conducted in society, for example, working, some women end up putting their needs as
a last plan, running out of time, disposition and
physical and/or emotional conditions for satisfactory performance of their sexuality.(13,15) The results
confirm this fact by highlighting working hours
over 8 hours/daily, boosted by 12% with each additional hour work daily journey, which contributes to the presence of female sexual dysfunction.
The results also highlighted as a factor associated with the development of dysfunction in the
postpartum period, type of delivery, i.e. vaginal
with suture represented a threefold higher risk
for sexual dysfunction when compared to the cesarean birth. Study conducted in 2010, comparing women with intact perineum after delivery,
those undergoing episiotomy or who suffered
lacerations to second degree perineal, reveals
that these complaints had lower levels of libido,
orgasm, satisfaction and pain during sexual intercourse.(11)
However, as mentioned, the literature is inconclusive on the indication of cesarean delivery as a
practical protection to female sexual function and
promote early recovery of sexual activity during this
period; instead, the studies diverge about the published results.(4,5,12)
The ignorance of one’s own body, as well as the
physical and emotional changes, characteristics of
pregnancy, may increase the development of sex-
Holanda JB, Abuchaim ES, Coca KP, Abrão AC
ual dysfunction in some women and/or couples.
(9,13)
The high prevalence of sexual dysfunction in
pregnancy and childbirth cycle, particularly dyspareunia, found in this study and reinforced by the
literature, seems to be justified by these conditions,
and other factors such as perineal trauma, fatigue,
physical discomfort, fear of infection, pain in the
breasts, impaired of self-image and body image, and
depression.(1,3,4,11)
Understanding the association of primiparity
factor with female sexual dysfunction seems to be in
both religion and familiarity of these women, with
regard to their corporeality, their rights and their
duties in functions within society. Education based
on traditional precepts, veiled in a sexist male society, especially with regard to education and women’s sexual health, also seems to be present in this
association.(13)
Most postpartum dyspareunia are related to local aspects of the genitalia, such as suturing, vaginal
dryness, inflammation or infection. Studies confirm
these findings claiming that perineal trauma, with or
without suture, episiotomy and/or forceps are factors
associated with insufficient lubrication and/or persistent dyspareunia in the postpartum.(1,4,7,16)
Vaginismus corresponded to the second leading
cause of sexual dysfunction. When present before
pregnancy, it represented a greater risk of 8.5 times
for sexual dysfunction in the postpartum. Among
postpartum women investigated, the causes referred
to this dysfunction were the same as dyspareunia,
strengthening the hypothesis previously mentioned,
the little knowledge of them in their own bodies and
their manifestations confusing pain and difficulty or
unconscious inability to intercourse.(7,15)
Deficiency or absence of sexual fantasies and desire for sexual activity, defined as desire dysfunction,
represented the third highest prevalence of sexual
dysfunction in this population, which may be related to change in self-image and maternity.(7,15,16)
Studies have shown that half of women experience
changes in their libido in the first trimester with a
significant deterioration in the last trimester, reaching 90% prevalence.(1,3,4,6)
In this study, the most frequent causes reported
by the women were decreased desire to stress, fa-
tigue and the presence of pain during intercourse. A
similar result was found in another study, in which
tiredness and fatigue, in addition to dyspareunia,
depression and breastfeeding, contributed to the reduction of sexual desire.(1,3,4,15)
The orgasmic dysfunction was present in 10.5%
of women interviewed. Much higher frequency, in
the same period was identified in another study,
with 41% in the first six weeks, decreasing to 27%
at the3rd month and 15% at the 6th month after
delivery.(6)
Research conducted during pregnancy and after birth was conducted in English and nulliparous
women. In the 3rd trimester of pregnancy, 67% reported lack of orgasm during sexual intercourse. In
the postpartum period, these percentages were lower, ranging from 61%, 40% and 39% in the period
between the 6th, 12th and 24th week, respectively.
The orgasmic function was reported by most women at 12 weeks postpartum, similar to the period
before pregnancy.(17)
Regarding the change in the arousal stage, the
impairment was smaller in a number of women
(8%). Pain was one of the most cited causes for the
development of the deficit or lack of lubrication
during intercourse, probably explained by the feeling of not being able to be all in the intercourse,
being divided between the roles of woman, mother
and wife.(15,16)
Studies are in agreement with the above hypothesis to unveil the reduction in rates of this disorder, as postpartum time increases, that is, as woman
adapts to motherhood and the demands of the new
situation. Among these index, one can cite the lack
of lubrication present in 51% of women in the first
6 weeks postpartum, decreasing to 29% and 13% at
3 and 6 months postpartum, respectively.(4,17)
The fact that Catholic and protestant women
present a nearly three times higher risk for sexual dysfunction than those without religion invites
us to reflect on the maintenance of castrating and
repressive functions of religion, perpetuating the
century worshiped of the ideal of woman/mother
immaculate and submissive, as one that is fully dedicated to her child, which should not feel and freely
enjoy sexual and erotic pleasures.(15)
Acta Paul Enferm. 2014; 27(6):573-8.
577
Sexual dysfunction and associated factors reported in the postpartum period
Trying to combine the maternal role to other
roles they play in society, for example, work, make
some women end up putting their needs last plan,
running out of time, disposition and physical and/
or emotional conditions for satisfactory exercise of
their sexuality.(15)
The results confirm this fact by highlighting the
working hours over 8 hours/daily as a factor associated with the presence of female sexual dysfunction,
which was aggravated in 12% every 1 hour added to
the daily working time.
Although frequent, sexual dysfunction, especially postpartum, may be missed if health professionals are not aware and do not investigate the
types and factors associated with their presence.
It is important that there is integrality of care in
assisting women, whatever stage of life in which
they are.
The problems and difficulties may be minimized
with appropriate orientation and encouragement to
women to the presence of their partners in times
of service, which will strengthen investigation and
a better understanding of female sexual dimension.
Conclusion
The prevalence of sexual dysfunction was high and
associated factors were religion, working hours,
previous history of sexual dysfunction and type of
delivery.
Collaborations
Holanda JBL; Abuchaim ESV; Coca KP and
Abrão ACFV declare that contributed to the
project design, analysis and interpretation of
data; manuscript drafting, critical revision of intellectual content and final approval of the version to be published.
578
Acta Paul Enferm. 2014; 27(6):573-8.
References
1. Vettorazzi J, Marques F, Hentschel H, Ramos JGL, Martins-Costa SH,
Badalotti M. [Sexuality and the postpartum period: a literature review].
Rev HCPA. 2012; 32(4):473-9. Portuguese.
2. Prado DS, Mota VP, Lima TI. [Prevalence of sexual dysfunction in two
women groups of different socioeconomic status]. Rev Bras Ginecol
Obstet. 2010; 32(3):139-43. Portuguese.
3. Acele EO, Karaçam Z. Sexual problems in women during the first postpartum
year and related conditions. J Clin Nurs. 2012; 21(7-8):929-37.
4. Leeman LM, Rogers RG. Sex after childbirth: postpartum sexual
function. Obstet Gynecol. 2012; 119(3):647-55.
5. Klein K, Worda C, Leipold H, Gruber C, Husslein P, Wenzl R. Does the
mode of delivery influence sexual function after childbirth? J Womens
Health (Larchmt). 2009; 18(8):1227-31.
6. Abdool Z, Thakar R, Sultan AH. Postpartum female sexual function. Eur
J Obstet Gynecol Reprod Biol. 2009; 145(2):133-7.
7. Rogers RG, Borders N, Leeman LM, Albers LL. Does spontaneous
genital tract trauma impact postpartum sexual function? J Midwifery
Womens Health. 2009; 54(2):98-103.
8. Kennedy CM, Turcea AM, Bradley CS. Prevalence of vulvar and vaginal
symptoms during pregnancy and the puerperium. Int J of Gynecol
Obstet. 2009; 105(1):236-9.
9. Pancholy AB, Goldenhar L, FellnerAN, Crisp C, Kleeman S, Pauls
R. Resident education and training in female sexuality: results os a
national survey. J Sex Med. 2011; 8(2):361-6.
10. Shindel AW, Ando KA, Nelson CJ, Breyer BN, Lue TF, Smith JF. Medical
student sexuality: how sexual experience and sexuality training impact
U.S. and Canadian medical students comfort in dealing with patient’s
sexuality in clinical pratice. Acad Med. 2010; 85(8):1321-30
11.Ribeiro MC, Nakamura MU, Abdo CHN, Torloni MR, Scanavino MT, et
al. [Pregnancy and Gestational Diabetes: a prejudicial combination to
female sexual function?] Rev Bras Ginecol Obstet. 2011; 33(5):21924. Portuguese.
12. Belentani LM, Marcon SS, Pelloso SM. [Sexuality patterns of mothers with
high-risk infants]. Acta Paul Enferm. 2011; 24(1):107-13. Portuguese.
13. Salim NR, Gualda DM. Sexuality in the puerperium: the experience of a
group of women. Rev Esc Enferm USP. 2010; 44(4):888-95.
14.Pauls RN, Occhino JA, Dryfhout VL. Effects of pregnancy on female
sexual function and body image: a prospective study. J Sex Med. 2008;
5:1915-22.
15. Abuchaim ES, Silva IA. Vivenciando a amamentação e a sexualidade na
maternidade: “Dividindo-se entre ser mãe e mulher”. Ciência Cuidado
e Saúde. 2006; 5(2):220-8.
16.Ejegård H, Ryding EL, Sjögren B. Sexuality after delivery with episiotomy: a
long-term follow-up. Gynecol Obstet Invest. 2008; 66(2):1-7.
17.Connolly A, Thorp J, Pahel L. Effects of pregnancy and childbirth on
postpartum sexual function: a longitudinal prospective study. Int
Urogynecol J Pelvic Floor Dysfunct. 2005; 16(1):263-7.
Original Article
Meaning of aromatherapy
massage in mental health
Significado da massagem com aromaterapia em saúde mental
Thiago da Silva Domingos1
Eliana Mara Braga2
Keywords
Nursing research; Nursing care;
Nursing, practical; Mental health;
Aromatherapy
Descritores
Pesquisa em Enfermagem; Cuidados
de Enfermagem; Enfermagem
prática; Saúde mental; Aromaterapia;
Massagem
Submitted
July 26, 2014
Accepted
August 11, 2014
Corresponding author
Thiago da Silva Domingos
Monte Carmelo street, 800, Marília, SP,
Brazil. Zip Code: 17519-030
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400094
Abstract
Objective: To understand the meaning of the aromatherapy massage intervention in mental health for the
patient during psychiatric hospitalization.
Methods: A qualitative study including 22 participants with a diagnosis of personality disorder hospitalized
in a psychiatric unit of a general hospital. We used semi-structured interviews with a guiding question for
participants, for whom the aromatherapy massage intervention was performed. The content of the interviews
was assessed according to content analysis.
Results: Among the study subjects, there was a predominance of females and the majority presented a
diagnosis of Emotionally Unstable Personality Disorder. Two categories that emerged were identified from
qualitative data: “Identifying the benefits of aromatherapy” and “Enabling self-knowledge.”
Conclusion: The meaning of the aromatherapy massage intervention was represented by improvements
in nursing care and treatment during psychiatric hospitalization, while assisting in the reduction of anxiety
symptoms and coping with mental illness.
Resumo
Objetivo: Compreender o significado da intervenção de massagem com aromaterapia em saúde mental para
o usuário durante a internação psiquiátrica.
Métodos: Pesquisa qualitativa que incluiu 22 participantes com diagnóstico de Transtornos de Personalidade
internados em unidade psiquiátrica de um hospital geral. Foram realizadas entrevistas semiestruturadas,
com uma questão norteadora aos participantes, os quais se submeteram a intervenções de massagem com
aromaterapia. O conteúdo das entrevistas foi avaliado segundo a Análise de Conteúdo.
Resultados: Entre os sujeitos de pesquisa, houve predominância do sexo feminino e do diagnóstico de
Transtornos de Personalidade Emocionalmente Instável. Dos dados qualitativos, emergiram duas categorias:
“identificando os benefícios da aromaterapia” e “possibilitando o autoconhecimento”.
Conclusão: O significado da intervenção de massagem com aromaterapia foi representado por melhorias
no cuidado de enfermagem e no tratamento durante a internação psiquiátrica, ao auxiliar na diminuição dos
sintomas ansiosos e no enfrentamento do transtorno mental.
Hospital das Clínicas, Faculdade de Medicina de Marília, Marília, SP, Brazil.
Universidade Estadual Paulista “Júlio de Mesquita Filho”, Botucatu, SP, Brazil.
Conflicts of interest: none to declare.
1
2
Acta Paul Enferm. 2014; 27(6):579-84.
579
Meaning of aromatherapy massage in mental health
Introduction
The utilization of complementary and alternative practices in hospitals has gradually
increased around the globe and throughout
the country.(1-3) Among numerous techniques
that integrate those practices, aromatherapy is
based on the prescription of essential oils from
aromatic plants, along with the therapeutic
plan, administered using the dermal or olfactory pathway, in order to promote and assist
the treatment of health problems from various
medical specialties.(4)
Aromatherapy is considered to be a growing
area, with advances in medical specialties such
as psychiatry and oncology. It has been shown
to constitute a safe and potentially therapeutic
resource to decrease symptoms, such as psychomotor agitation and aggression in patients with
signs of dementia.(5) A randomized controlled trial with 67 patients with dementia did not show
a statistically significant difference associated
to the use or nonuse of aromatherapy massage,
however, improvements related to the aggression
status were shown.(6) In another similar study, no
significant results were found comparing the use
of the essential oil, Melissa officinalis, donepezil
or placebo.(7) The use of this practice for cancer
patients showed an improvement in depressive
and anxious symptoms.(8) The use of a self-governing aromatic inhaler reduced symptoms such
as nausea and anxiety, enhancing relaxation of
cancer patients.(9) In a group of women in the
postpartum period at risk for developing postpartum depression, a significant decrease in levels of anxiety and depression was demonstrated,
by using essential oils of Lavandula angustifolia
and Rose otto at a concentration of 2%.(10)
In this context, to provide aromatherapy as
a working tool for use with the patient during
psychiatric hospitalization helps with the identification of new ways to qualify the care provided by nurses in the area of psychiatry and
mental health, in addition to strengthening
the implementation and application of complementary and alternative health practices in
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Acta Paul Enferm. 2014; 27(6):579-84.
the country, and to advance the development
of knowledge that supports safe and effective
practices. Given the above, the objective of
this study was to understand the meaning of
the aromatherapy massage intervention for the
user with personality disorders during psychiatric hospitalization.
Methods
This was field research, using a descriptive, exploratory, and qualitative approach that included
the meanings that users attached to aromatherapy
during psychiatric hospitalization. A semi-structured interview was used as an instrument for
data collection, with the guiding question: “How
did you feel about your participation in the aromatherapy massage during hospitalization?”. The
interviews were recorded and subsequently fully
transcribed.
The results were analyzed according to content
analysis, with the intention of understanding the
obtained data and its immediate meanings. This
means that overcoming uncertainty, and the possibility of an enriched in-depth reading of the investigated phenomenon were proposed. In this analytical procedure, the following steps were taken: (1)
pre-analysis, (2) coding, (3) categorization and (4)
inference.(11)
Participating in the study were 22 patients in
a psychiatric care unit in a general hospital in the
state of São Paulo (SP), in treatment between May
and October of 2013, with the medical diagnosis of
Personality Disorders and Adult Behavior, according to the International Classification of Diseases
(ICD 10), 18 years old or older.(12) The selection of
this population occurred by considering the prevalence rate in the unit, the impact that this condition
caused on the health team, and the perception of
the need to diversify nursing care that was offered
in this unit.
We considered as exclusion criteria: hypersensitivity to essential oils, pregnancy or signs suggestive of pregnancy, continued use of antiarrhythmic
medications, and cognitive impairment.
Domingos TS, Braga EM
The intervention consisted of eight meetings
that took place during the psychiatric hospitalization. In the first meeting, the initial contact
between the researcher and the research subject
was made. This meeting occurred no later than
one day after admission to the unit, when the
research was presented, and the signing of the
consent form was explained. The aromatic solution was also applied in the patients’ antecubital
fossa, and signs of irritation or allergy were observed during the following 24 hours (sensitivity
test). From the second to the seventh meeting,
sessions previously scheduled with users on alternate days occurred with aromatherapy massage
and measurement of cardiac and respiratory frequencies. In the eighth meeting, which occurred
a day after the last session of aromatic massage, a
semi-structured interview with the study subject
was performed.
The aromatherapy intervention was characterized by the application of essential oils in six sessions of massage on the muscles of the trapezius and
the posterior thorax, lasting 20 minutes, three times
a week, on alternate days for two weeks for a total
of six sessions conducted in the patient’s room with
him/her in the sitting position.
As for the application of the massage, the
technique selected was the effleurage, or stroking,
which is the application of light and continuous
movements on the surface, performed with the
entire palmar surface by applying movements in
several directions. This is an established method
in the aromatherapy literature since its inception,
which promotes increased skin absorption of the
essential oils and does not stimulate acupuncture
points.(4)
The essential oils chosen were lavender (Lavandula angustifolia) and geranium (Pelargonium graveolens), since they present, chemically,
a high concentration of ester of 40 to 55%
and 15%, respectively. Thus, these oils have a
soothing and calming action, being both indicated for anxiogenic situations. We used a
0.5% concentration of each essential oil that
was diluted in a neutral gel application during
massage.(4,13)
The development of this study met national
and international standards of ethics in research
involving human beings.
Results
Among the 22 subjects who participated in the
survey, 18 were female (81.81%). The mean age
of the sample was 34.6 years, with a minimum
age of 18 years and a maximum age of 60 years.
All patients resided in the same city in which the
hospital was located, and had previously used
anxiolytic drugs. In relation to psychiatric diagnoses, Emotionally Unstable Personality Disorder predominated in 18 of the study subjects
(81.81%); two presented Histrionic Personality
Disorder (9.01%), one had Antisocial Personality Disorder (4.54%) and one had Dependent
Personality Disorder (4.54%).
The categories of data were prepared using the
subject as the unit of record, which, in turn, was
portrayed in context units, allowing the anchoring of their meanings. After the development of
the qualitative analysis corpus, two categories
arose: (i) identifying the benefits of aromatherapy
and (ii) enabling self- knowledge.
Category 1 - Identifying the benefits of
aromatherapy
In this category, the data that converged to identify the benefits of aromatherapy were presented
among the diversity of themes identified by the
research subjects.
• Subcategory 1.1 - Favoring psychological
and physical well-being
The subjects assigned to aromatherapy the
function of promoting psychological and physical well- being during the hospitalization period,
assisting them in adapting to the environment
and reducing some characteristic symptoms of
anxiety, such as fixed ideas related to personal
problems, anxiety and the state of permanent
alert. Collaborating with this experience, the
aroma generated by the volatilization of the essential oils was actively perceived by subjects
Acta Paul Enferm. 2014; 27(6):579-84.
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Meaning of aromatherapy massage in mental health
who assigned to it a factor of reassurance and
safety.
In relation to physical symptoms, such as decreased psychomotor agitation, tremors of the
extremities, palpitations and physical fatigue,
which often feature a sudden onset and expose
patients to experiences previously suffered and
decontextualized during hospitalization. The reduction in symptoms during hospitalization offered a better development of integration, openness and a greater willingness of the patients
to participate in activities that were offered to
them.
• Subcategory 1.2 - Improving sleep pattern
Research subjects reported irregularities in
sleep patterns prior to hospitalization, including experiencing this in their homes, where they
used to take medications for insomnia. Of the
22 study subjects, 20 reported improvement in
sleep pattern (91%), with sleep becoming invigorating or by decreasing the difficulty of initiating sleep. This result was attributed to the application of aromatherapy, given the almost immediate improvement of the sleep pattern, as was
noted by the research subjects on the evening
after the intervention.
• Subcategory 1.3-Emphasizing the therapist-patient commitment
The intervention was explained in detail and
scheduled with research subjects. This aspect
confirmed the therapist-patient commitment,
and was found to be positive, according to the
discourses of research subjects. Furthermore,
they reported the expectation generated by the
scheduling of the sessions and the security they
felt from the explanations that were offered on
the intervention (essential oils used and the body
part that would be massaged).
• Subcategory 1.4- Comparing drug therapy
and aromatherapy
The research subjects compared, surprisingly,
the agility they realized from the effects attributed to aromatherapy with the allopathic treatment they used, even before admission. They
also exposed the importance of the availability of
aromatherapy after discharge as an alternative to
582
Acta Paul Enferm. 2014; 27(6):579-84.
the use of inadvertent drugs if anxiety symptoms
appeared suddenly.
Category 2 - Enabling self knowledge
The aromatherapy sessions favored the reflection of the research subjects about themselves
and the events that led to psychiatric hospitalization. Whereas the psychological functioning of these patients caused pain in their
intrapersonal and interpersonal relationships,
activities that promote self knowledge favor
their ability to address the recognition and
control of symptoms, such as impulsivity and
self- centeredness. Two subcategories composed this phenomenon.
• Subcategory 2.1 - Promoting a time for
self-reflection
The statements elucidate that the aromatherapy sessions served to provide a moment
during psychiatric hospitalization in which
the subjects could reflect on their actions and
behaviors. The subjects illustrated that their
daily routines limited these moments to reflect about who they are, about their feelings,
their behaviors and their relationships. This
reflection led to their awareness of how behaviors, emotional incontinence and impulsivity
exposed their interpersonal relationships, creating suffering for themselves and those with
whom they lived.
• Subcategory 2.2 - Assisting in controlling
symptoms
The research subjects were able to identify
some symptoms related to personality disorders
and observed their decrease: less impulsivity and
irritability were the most cited. The reflection
promoted by aromatherapy, as explained in the
previous subcategory, allowed the research subjects to conceive of their symptoms as traits of
their personality, taking responsibility for them.
The mobilization of the family and the need for
attention during visiting hours were symptoms
addressed by research subjects and, according to
the subjects, were controlled from the moment
they became aware of their psychodynamic
functioning.
Domingos TS, Braga EM
Discussion
One must consider that the use of aromatherapy in
healthcare and its configuration as a nursing care
modality are emerging themes in the scientific literature, reflecting the lack of research that address
these issues. Thus, we limit the discussion of the
results of this research to specific theoretical frameworks of aromatherapy and complementary and alternative health practices. Another limitation of this
research was the relationship between therapist and
patient as a phenomenon that may have influenced
the results, constituting a placebo effect, which is
inherent in complementary practices. The results
of this research, however, assist in addressing this
limitation to be represented in a sub-analysis. Concomitant drug treatment performed during hospitalization represents a bias, as the relief of symptoms
may have occurred due to the use of anxiolytics. It is
noteworthy that all participants were already using
this type of medication and still reported episodes
of anxiety before and during hospitalization.
Regarding the study population, the prevalence
of women and the diagnosis of Emotionally Unstable Personality Disorder are still questionable factors in the epidemiology of mental disorders. There
is no consensus evidence that females have higher
prevalence of this subtype of diagnosis. The young
age of the population met epidemiological data that
considers a negative relationship between the diagnosis of personality disorder and age.(14)
The benefits of aromatherapy were evident
from the moment subjects experienced a decrease
in anxiety, physical and psychological symptoms,
and improved sleep patterns. These results have
been suggested previously in studies of clinical design without, however, directly focusing on the users’ perception of such improvements.(13,15,16) These
results are attributed to the use of essential oils of
lavender and geranium and their respective chemical constitutions, although incomplete knowledge
remains about their mechanisms of action. The
lavender essential oil is beneficial and indicated
for the treatment of irritability, heightened anxiety
and insomnia, whereas geranium, in addition to
these indications, is associated with hormone ac-
tion and is related to the promotion of vitality and
willingness.(4,14,17)
Complementary and alternative health practices
offer the potential for technical care diversification in
the Brazilian National Health System (known as SUS),
as important tools in promoting autonomy over treatment and increasing the user’s share of responsibility
about his or her health. Moreover, it is an alternative
care practice to the use of a medical drug, discouraging the phenomenon of social medicalization.
(18-20)
These aspects are evident in the perception of the
research subjects, when one observes that the improvements promoted by aromatherapy were experienced
immediately, and when one compares them with the
medications that had been taken previously.
The commitment established by the therapist
during the intervention, represented by the establishment of dates and the fulfillment of the aromatherapy sessions, highlights the importance of positive recovery of the therapist figure, through the bond and
commitment with the user. These factors are inherent
to complementary and alternative health practices and
represent some of the reasons why users seek out and
use complementary treatments.(13,19,21) Still, the therapist-patient relationship is a procedure of great importance to patients with personality disorders, since the
therapeutic contract is an indispensable care tool.(22,23) It
is observed that psychiatric admissions in general hospitals is a place that fosters the establishment of this
bond, because of the low turnover of professionals, thus
offering follow-up throughout the patients’ hospitalization and the performance of the nurse as a therapist
for patient care in techniques of complementary and
alternative health practices. It is noteworthy that in the
current mental health policy, psychiatric admissions
to general hospitals is a substitutive alternative to crisis management, when other psychosocial care services
such as mental health services and primary health care
(PHC), were not sufficient for the user’s care.(24)
The intervention provided an opportunity to
promote self-awareness, a result that makes it an
enriching tool for nursing actions for patients with
mental disorders in the psychiatric unit environment in general hospitals, which must focus on providing the users with the ability to recognize themselves in their actions.(22) The recognition of oneself
Acta Paul Enferm. 2014; 27(6):579-84.
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Meaning of aromatherapy massage in mental health
in the psychodynamics of personality disorders was
a result pointed out by the subjects, who observed
that they were responsible for their symptoms, in
particular, for impulsivity. This concept of autonomy and recognition of oneself are affinities based
on the knowledge both in alternative and complementary health practices and in the therapeutic interpersonal relationship.(25,26)
Conclusion
Intervention with aromatherapy in psychiatric
hospitalization in general hospitals has brought
about improvements in many spheres, such as
the decrease of anxiety symptoms and the possibility of coping with the mental disorder, and
they were accessed through the perception that
the user assigned to nursing care and treatment.
Collaborations
Domingos TS and Braga EM state that they contributed to study design, result analysis and article
writing. Domingos TS performed the intervention
and data collection.
References
1. Salomonsen LJ, Skovgaard L, La Cour S, Nyborg L, Launso L, Fonnebo
V. Use of complementary and alternative medicine at Norwegian Danish
hospitals. BMC Complement Altern Med. 2011; 11:4.
2. Fujiwara K, Imanishi J, Watanabe S, Ozasa K, Sakurada K. Changes in
Attitudes of Japanese Doctors toward Complementary and Alternative
Medicine - Comparison of Surveys in 1999 and 2005 in Kyoto. Evid
Based Complement Alternat Med. 2011; 2011:608921.
8. Boehm K, Büssing A, Ostermann T. Aromatherapy as an adjuvant
treatment in cancer care – a descriptive systematic review. Afr J
Complement Altern Med. 2012; 9(4):503-8.
9. Stringer J, Donald G. Aromasticks in cancer care: an innovation not be
sniffed at. Complement Ther Clin Pract. 2011; 17(2):116-21.
10. Conrad P, Adams C. The effects of clinical aromatherapy for anxiety and
depression in the risk postpartum woman – a pilot study. Complement
Ther Clin Pract. 2012; 18 (3):164-8.
11.Graneheim UH, Lundman B. Qualitative content analysis in
nursing research: concepts, procedures and measures to achieve
trustworthiness. Nurse Educ Today. 2004; 24:105-12.
12.Organização Panamericana de Saúde (OPS). [International Statistical
Classification of Diseases and Related Health Problems] 10ª ed.
[Internet]. 2006 [cited 2014 Jul 20]. Available from: http://www.
datasus.gov.br/cid10/V2008/cid10.htm. Portuguese.
13.Gnatta JR, Dornellas EV, Silva MJ. [The use of aromatherapy in
alleviating axiety]. Acta Paul Enferm. 2011; 24(2):257-63. Portuguese.
14. McGilloway A, Hall RE, Lee T, Bui KS. A systematic review of personality
disorder, race and ethnicity: prevalence, aetiology and treatment. BMC
Psychiatry. 2010;10:33.
15. Goes TC, Antunes FD, Alves PB, Teixeira-Silva D. Effects of sweet orange
aroma on experimental anxiety in humans. J Altern Complement Med.
2012; 18(8):798-804.
16. Kouvalind PH, Ghadiri MK, Gorji A. Lavender and the nervous system.
Evid Based Complement Alternat Med. 2013; 2013:681304.
17. Lyra CS, Nakai LS, Marques AP. [Effectiveness of aromatherapy in reducing
stress and anxiety levels in undergraduate health science students: a
preliminary study]. Fisioter Pesqui. 2010; 17(1):13-7. Portuguese.
18.Ischkanian PC, Pelicioni MC. [Challenges of complementary and
alternative medicine in the SUS aiming to health promotion]. Rev Bras
Crescimento Desenvolv Hum. 2012;22(2):233-8. Portuguese.
19. Gaudenzi P, Ortega F. [The statute of medicalization and the interpretations
of Ivan Illich and Michel Foucault as conceptual tools for studying
demedicalization]. Interface (Botucatu). 2012; 16(40):21-34. Portuguese.
20.Manzini T, Martinez EZ, Carvalho AC. [Knowledge, beliefs and practices
toward alternative and complementary therapies among speech-language
pathologists]. Rev Bras Epidemiol. 2008; 11(2):304-14. Portuguese.
21. Souza EF, Luz MT. [The socio-cultural bases of alternative therapeutic
practices]. Hist Ciênc Saúde- Manguinhos. 2009; 16(2):393-405.
Portuguese.
3. Melo SC, Santana RG, Santos DC, Alvim NA. [Complementary health
practices and challenges of tis applicability in hospital: nurses’ point of
view]. Rev Bras Enferm. 2013;66(6):840-6. Portuguese.
22.Paris J. Effectiveness of different psychotherapies approaches in the
treatment of borderline personality disorder. Curr Psychiatric Rep.
2010; 12(1):56-60.
4. Price S, Price L. Aromatherapy for health professionals. 4th ed. London:
Elsevier; 2012.
23.Zanarini MC. Psychotherapy of borderline personality disorder. Acta
Psychiatr Scand. 2009; 120(5): 373-7.
5. Fung JK, Tsang HW, Chung RC. A systematic review of the use of
aromatherapy in treatment of behavioral problems in dementia. Geriatr
Gerontol Int. 2012; 12(3):372-82.
24.Lucena MA, Bezerra AF. [Reflections on the management of
deinstitutionalization process]. Ciênc Saúde Coletiva. 2012; 17(9):
2247-56. Portuguese.
6. Fu CY, Moyle W, Cooke M. A randomised controlled trial of the
use of aromatherapy and hand massage to reduce disruptive
behaviour in people with dementia. BMC Complement Altern Med.
2013; 13:165.
25.Calgaro A, Souza EN. [Nurse perception about the assistencial
practice in mental health public services]. Rev Gaucha Enferm. 2009;
30(3):476-83. Portuguese.
7. Burns A, Perry E, Holmes C, Francis P, Morris J, Howes MJR, et al. A
double-blind placebo-controlled randomized trial of Melissa officinalis
584
oil and donepezil for the treatment of agitation in Alzheimer’s Disease.
Dement Geriatr Cogn Disord. 2011; 31(2):158-64.
Acta Paul Enferm. 2014; 27(6):579-84.
26. Peternelj-Taylor CA, Yongue O. Exploring boundaries in the nurse-client
relationship: Professional roles and responsibilities. Perspect Psychiatr
Care. 2003; 39(2):55-66.
Original Article
Clinical conditions and health care demand
behavior of chronic renal patients
Condições clínicas e comportamento de procura de
cuidados de saúde pelo paciente renal crônico
Thalita Souza Torchi1
Sílvia Teresa Carvalho de Araújo1
Alessandra Guimarães Monteiro Moreira1
Giselle Barcellos Oliveira Koeppe1
Bruna Tavares Uchoa dos Santos1
Keywords
Nursing care; Public health nursing;
Chronic renal failure; Patient
acceptance of health care; Qualitative
research
Descritores
Cuidados de enfermagem; Enfermagem
em saúde pública; Insuficiência renal
crônica; Aceitação pelo paciente de
cuidados de saúde; Pesquisa qualitativa
Submitted
August 19, 2014
Accepted
August 26, 2014
Corresponding author
Thalita Souza Torchi
Afonso Cavalcanti street, 275, Rio de
Janeiro, RJ, Brazil.
Zip Code: 20211-110
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400095
Abstract
Objective: To identify the clinical conditions and health care demand behavior of chronic kidney patients in the
therapeutic itinerary for hemodialysis.
Methods: Qualitative, descriptive and exploratory study based on an interview with ten patients at a renal
replacement therapy clinic under hemodialysis treatment and analysis resulting from the use of the Collective
Subject Discourse technique, by means of the software qualiquantisofty.
Results: The clinical conditions on the therapeutic itinerary evidenced symptoms of unease and the baseline
disease profile identified included hypertensive nephrosclerosis, diabetic nephrosclerosis, undetermined cause
and diabetic nephrosclerosis associated with arterial hypertension. The behaviors that negatively affected the
health control were the delay to receive care in the health network, the non-acceptance of the disease and
the treatment.
Conclusion: Few patients received early monitoring without any sign of symptoms. Nevertheless, the majority
were hospitalized suddenly.
Resumo
Objetivo: Identificar as condições clínicas e comportamento de procura de cuidados de saúde pelo paciente
renal crônico no itinerário terapêutico para a hemodiálise.
Métodos: Estudo qualitativo, descritivo e exploratório a partir de entrevista com dez pacientes de uma clínica
de terapia renal substitutiva em tratamento hemodialítico e análise resultante da utilização da técnica do
Discurso do Sujeito Coletivo por meio do software qualiquantisofty.
Resultados: As condições clínicas no itinerário terapêutico evidenciaram sintomas de mal-estar e o perfil
das doenças de base identificadas foram nefroesclerose hipertensiva, nefroesclerose diabética, causa
indeterminada e nefroesclerose diabética associada com hipertensão arterial. Os comportamentos que
prejudicaram o controle de saúde foram à demora no atendimento na rede de saúde, a não aceitação da
doença e do tratamento.
Conclusão: Poucos tiveram acompanhamento precoce, sem manifestação de sintomas. Todavia, a maioria
deles tiveram internação hospitalar de maneira repentina.
Escola de Enfermagem Anna Nery, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.
Conflicts of interest: no conflicts of interest to declare.
1
Acta Paul Enferm. 2014; 27(6):585-90.
585
Clinical conditions and health care demand behavior of chronic renal patients
Introduction
The global prevalence of chronic renal disease is estimated at around 8-16% and represents a growing public health problem around the world. In the
United States, the incidence and prevalence have
doubled in the last 10 years.(1)
The number of people diagnosed with the disease who have reached the advanced stages and
need to start emergency treatment is increasing
and in unfavorable conditions for patients and
health professionals, as it significantly compromises the quality of the inclusion in and adaptation to
the treatment.
This situation arouses the following reflection:
- What factors are present in the patient’s therapeutic itinerary that interfere in the diagnosis and
treatment?
Therapeutic itinerary is considered as the route
the individuals follow in search of health or therapeutic care. The evolution of chronic renal disease
is silent and the course is frequently asymptomatic
until the advanced stage is reached. As a result, the
patient only seeks medical care when one or more
complications of the disease and/or comorbidities
are already present,(2) which puts up a greater challenge for professional care.
The therapeutic approach is essential for inter/
cross-disciplinary actions and also fundamental for
communicative practice oriented towards mutual
understanding.(3) And, when the conduct is early
and appropriate to patients with diabetes mellitus, arterial hypertension or chronic renal disease,
and articulated among the complexity levels of the
health network, this permits retarding the start of
dialysis therapy.(4)
Chronic renal disease has gained alarming proportions.(4) Brazil has important prevalence and incidence levels of patients under renal replacement
therapy, and hypertensive, diabetic and obese patients are considered risk groups for the development of chronic renal disease.(5,6)
Although the National Primary Health Care
Policy considers that all health professionals are
responsible for guaranteeing holistic care delivery,
highlighting the prevention of problems, a gap re-
586
Acta Paul Enferm. 2014; 27(6):585-90.
mains between the primary and secondary care levels, as obstacles remain for user access which can
compromise the comprehensiveness of care.(5)
At the medium complexity level, specialized
diagnostic and therapeutic care is expected, guaranteed based on the referral and counter-referral
process of arterial hypertension, diabetes mellitus
and kidney disease patients. At the high complexity
level, the access to and quality of the dialysis process
needs to be guaranteed with a view to achieving a
positive impact on survival, morbidity and quality
of life.(6)
It is considered important to know the factors
present on the therapeutic itineraries of patients demanding health care, which influence the form of
coping with the disease diagnosis as well as with the
prescribed treatment. Knowing the itinerary allows
to us apprehend the interference of the scenario and
of the team’s approach and posture in client care.
Thus, the objectives of this research were to
identify the clinical conditions and behaviors of
kidney patients on their therapeutic itinerary to
take part in hemodialysis and to discuss how these
data can support nursing interventions.
Methods
Qualitative research developed between January
and March 2013 at a private renal replacement
therapy clinic accredited by the Unified Health System in the City of Rio de Janeiro, in the Brazilian
Southeast.
The research participants were ten patients with
chronic kidney disease, corresponding to 70% of
the adults from the daytime hemodialysis service,
over 18 years of age, male and female, in the first
year of hemodialysis treatment, in order to allow
them to remind their therapeutic trajectory. Adults
without clinical conditions to participate at the moment of the interview were excluded.
Information on the participants’ personal and
clinical characteristics was obtained from their patient histories. Next, during the hemodialysis session, an individual interview was held, using semistructured questions, with a mean length of one
Torchi TS, Araújo ST, Moreira AG, Koeppe GB, Santos BT
hour, addressing the therapeutic trajectory, including aspects of professional care at different health
institutions until that moment.
In the data analysis and discussion, the Collective Subject Discourse technique was used, by
means of the software qualiquantisofty. Based on
the methodological figures Key Expressions, Core
Ideas and CSD, the essence and meaning of each
testimonial could be revealed in one sole collective
synthesis discourse.(7)
The reading and rereading of the testimonials
and the use of the program devices for data analysis
permitted unveiling the meanings the participants
attributed, arranged as CSD, as a first approach of
the clinical conditions and individual behaviors on
the therapeutic itinerary until their inclusion in the
hemodialysis.
The study development complied with the Brazilian and international ethical standards for research involving human beings.
Results
The sample consisted of three (30%) male and seven (70%) female patients, with a mean age of 51
years. The baseline diseases identified in the histories indicated 50% hypertensive nephrosclerosis,
20% diabetic nephrosclerosis, 10% undetermined
cause and 20% diabetic nephrosclerosis associated
with arterial hypertension.
In the testimonials of the recorded interview, it
was evidenced that they discovered the kidney disease when they felt bad, starting their care trajectory through the primary care service 30%, hospital
30%, private consultations through the health insurance 20%, adding up 80% of individuals who
suddenly started the hemodialysis in an intra-hospital context. The other 20% did not manifest any
symptoms, despite periodical monitoring of the
baseline diseases at the primary care service, followed by conservative treatment and the start of
hospital dialysis. Nevertheless, the kidney problem
was detected in a late phase.
As regards the behaviors for care in the health
network, two core ideas prevailed as harmful fac-
tors for health control. In this respect, 50% were
related to the delay in health care, as indicated in
the following key expressions: [...] to schedule the
first appointment at the primary care service I had
to arrive at four a.m. to catch a queue that went already around the block! I had to sleep in the queue
to get a number! [...] That’s a massacre for who’s ill!
[...] But that’s what we see every day [...]. I kept on
waiting all day, I was only attended at night [...].
Another idea 60% of the participants indicated
was related to the non-acceptance of the disease and
treatment, as evidenced in the key expressions: [...]
the main complication was that I did not want to
go there to do it! Not have the courage [...], difficulty to accept it [...]. It is horrible to sleep thinking
that you have to wake up the next day [...] to go for
dialysis, [...] to leave in order to try and survive, [...]
go to a machine and depend on it to live, that’s very
difficult [...].
Discussion
The results cannot be generalized to the experience of the chronic kidney clients undergoing hemodialysis. Although the method promotes the
combination and synthesis of the testimonials in
a collective discourse, each of them presents the
individual wealth of each participant’s clinical and
behavioral conditions on the therapeutic trajectory. These, in turn, constitute singular experiences
that contain peculiar and individual characteristics, although they can come up as core ideas in a
collective discourse.
The understanding of the patients’ life dynamics
contributes to the reflection on nursing care, as it
implies considering behaviors related to the coping
and adaptation difficulties, besides existing frailties
in the professional approach, indicating that the intervention needs to be more precise. And that the
act of welcoming, which is so important for these
individuals, lies within reach.
To prevent the kidney disease, all patients in the
risk group, even if asymptomatic, need an annual
assessment. Simple and cheap tests, such as blood,
serum creatinine and urine tests to detect protein,
Acta Paul Enferm. 2014; 27(6):585-90.
587
Clinical conditions and health care demand behavior of chronic renal patients
as these are kidney function markers that can be
controlled at the primary care level.(2)
The care flow demonstrated that the disease
was discovered late, so that the patient needed
emergency care. More detailed professional care
during the diagnosis avoids coming and going to
the health sector and the galloping progression of
the disease.(8) The late diagnosis and late visit to
the nephrologist indicates that 25.8% of the primary care physicians do not forward patients with
characteristic cases of advanced reduction of the
kidney function rate to the specialized nephrology
service. This signals the risk this situation causes
with regard to the morbidity and mortality and
the costs related to the complications deriving
from inappropriate conducts.(4-6)
Due to the absence of symptoms in the initial
stages of the disease, the health professionals always
need to maintain suspicious, mainly in patients
with risk factors. This early diagnostic difficulty
hampers the opportunity to implement prevention
measures, partially due to the lack of knowledge
about the definition and classification of the disease
stages and the non-use of simple tests for its diagnosis and functional assessment.(9,10)
Studies indicate that, when patients are attended in the pre-dialysis phase and by an interdisciplinary team, compared to patients who
only received traditional medical care, their survival increased by eight months after they started
dialysis.(11)
And the care this team delivers grants the patients satisfactory clinical results when in therapy
and reduces the frequency of emergency dialysis,
the occurrence of hospitalizations and the mortality
rate.(12,13) For that purpose, the health service team,
within its own care logic, in order to attend to the
patients’ needs to a certain extent and in a certain
way, should stimulate their autonomy in view of
their new health condition.(14)
The diagnosis was evidenced as a difficult phase
of coping with the disease and the constraints the
treatment imposes. Nevertheless, the support, respect and attention the health professionals granted
to these patients were highlighted as a professional
competence and a factor that makes things easier.
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Acta Paul Enferm. 2014; 27(6):585-90.
The professionals should know and identify them
based on the behaviors, so as to help them cope
with their current condition and relieve their tensions and fears. In addition, it permits a more focused intervention that can impede/prevent future
complications.(15)
Despite the thoughtful care and, sometimes,
lack of welcoming in hospital care, overcrowded
emergencies, which are constant in Rio de Janeiro and cause a low level of problem-solving
ability of primary care and a precarious hospital
network, leading to uncertainties and/or fears
with regard to the accomplishment of the treatment.(16,17)
The characteristics of the emergency service, as
the patient’s main entry door to the services, make
it difficult to maintain individual privacy in view of
the many patients attended and procedures. Sharing actions can be an additional stressor for the patient, already aggravated by the diagnosis and the
unstable clinical condition. This influences and
hampers patients’ coping with the chronic kidney
disease and their adaptation to the renal replacement therapy.(18)
Effective communication is the first step towards good welcoming and, in a way, when well
used, it can mitigate the infrastructure problems
they describe. This approach has been documented
as a key point in care, with great potential to damage or benefit the patient. Approximately 63% of
the sentinel events are directly linked to communication errors.(19)
The second limitation, of the personal type, was
the difficulty to accept the disease and the treatment. The factors that influence the compliance
with treatment are trust in the team, support networks, acceptance of the disease; while the hindering factors are non-acceptance of the disease/treatment and insecurity.(20)
Denial can be related to insecurity and all other factors identified as limiting. At the start of the
treatment, the prevalence of anguishing and depressive symptoms is significant, hampering the adaptation. Therefore, more extensive and active psychological care needs to be considered still during the
pre-dialysis phase.(17)
Torchi TS, Araújo ST, Moreira AG, Koeppe GB, Santos BT
This limitation can be closely related with the
short time between the diagnosis and the start of
the treatment. When the start of the dialysis is not
an unexpected event, 85% have time to get to grips
with the disease, imagine what it would be like to
live with dialysis and prepare well to start the treatment, through monitoring in nephrology consults
for six months before the dialysis.(21)
On the other hand, a downward trend was observed in the negative feeling over time, indicating
that the patients felt less concerned and less inclined
to cry at the end of the first year after starting the
treatment.(21)
As the treatment negatively affects the patients’
social and family relations and physical-psychological condition; and the stress, anguish and depression many of them go through stem from the lack of
information about the disease, their treatment and
life expectancy, there is an urgent need for changes
in the elaboration of approach strategies.
The health team working in dialysis therapies
and mainly in conservative treatment needs to get
structured to cope with the problems that emerge
among the clients in their respective activity areas,
in order to start changing this reality.(13)
The nurses are responsible for monitoring and
helping the patients in the process of coping with
the disease, surveillance and monitoring of therapeutic targets and strengthening of the health care
systems.(22)
In addition, they need to heed all aspects surrounding these patients with a view to respecting the limits of each individual, as their knowhow needs to be integrated, in which the care is
based on a committed, responsible and sincere
relationship of trust between professionals and
users.(23)
As the third limiting factor on the trajectory, the
delay to get care demonstrated that the organization
of this system is permitting a larger demand than
supply at the nephrology service. This hampers the
access to the treatment and contributes to the late
start; affects the choice of the therapy that best attends to them; and results in a lag in the orientations received, insecurity and non-acceptance of the
disease and the health condition.
A better access to health care has been associated
with a better treatment and control of hypertension
and diabetes, a potential mechanism through which
the incidence of chronic kidney disease could be
avoided.(24)
This therapeutic retrospective of successes and
errors, fear, facilities and difficulties permitted attributing a new meaning to postures and conducts
in coping with the disease and treatment and the
steps and mismatches common to patients in the
health network. These support professional actions
that make the therapy more effective.
Conclusion
Most participants started their care trajectory
through the public health network. The clinical
conditions during the therapeutic itinerary evidenced symptoms of feeling ill and the advanced
clinical profile of the baseline diseases.
The behaviors negatively affected the health
control because of the delay to get care in the
health network, the non-acceptance of the disease
and the treatment. Few participants were periodically monitored for the baseline diseases at a primary care service and did not manifest symptoms.
Nevertheless, most of them were hospitalized in
emergency situations.
Acknowledgements
To Anny Nery School of Nursing for the institutional support to accomplish the study. To the Brazilian Scientific and Technological Research Committee for the Research Productivity Grant, Level 2,
to the Rio de Janeiro Research Foundation and to
the Coordination for the Improvement of Higher
Education Personnel for the Master’s grants.
Collaborations
Torchi TS contributed to the project conception,
execution of the research and writing of the paper. Araújo STC contributed to the project conception, writing of the paper and relevant critical
review of intellectual content. Moreira AGM,
Koeppe GBO and Santos BTU cooperated with
Acta Paul Enferm. 2014; 27(6):585-90.
589
Clinical conditions and health care demand behavior of chronic renal patients
the writing of the article and final approval of the
version for publication.
References
1. Jha V, Garcia-Garcia G, Iseki K, Li Z, Naicker S, Plattner B, et al.
CW.Chronic kidney disease: global dimension and perspectives.
Lancet. 2013; 382(9888):260-72.
2. Bastos MG, Kirsztajn GM. [Chronic kidney disease: importance of early
diagnosis, immediate referral and structured interdisciplinary approach
to improve outcomes in patients not yet on dialysis]. J Bras Nefrol.
2011; 33(1):93-108. Portuguese.
12.Goldstein M, Yassa T, Dacouris N, McFarlane P. Multidisciplinary
predialysis care and morbidity and mortality of patients on dialysis. Am
J Kidney Dis. 2004; 44(4):706-14.
13.Cho EJ, Park HC, Yoon HB, Ju KD, Kim H, Oh YK, et al. Effect of
multidisciplinary pre-dialysis education in advanced chronic kidney
disease: propensity score matched cohort analysis. Nephrology
(Carlton). 2012; 17(5):472-9.
14.Nygardh A. Malm D. Wikby K. Ahlström G. The experience of
empowerment in the patient–staff encounter: the patient’s perspective.
J Clin Nurs. 2012; 21(5/6): 897-904.
15.Koeppe GB, Araújo ST. [Communication as a tesearch theme in
Nephrology: basis for nursing care]. Acta Paul Enferm. 2009;
22(Spe 1):558-63. Portuguese.
3. Viegas SM, Penna CM. [The construction of integrality in the daily work
of health family team]. Esc Anna Nery Rev Enferm. 2013; 17(1):13341. Portuguese.
16.O’Dwyer, Gisele O, Oliveira SP, Seta MH. [Evaluation of emergency
services of the hospitals from the QualiSUS program]. Ciênc Saúde
Coletiva. 2009; 14(5):1881- 90. Portuguese.
4. Pena PF, Silva Junior AG, Oliveira PT, Moreira GA, Libório AB. [Care for
patients with Chronic Kidney Disease at the primary healthcare level:
considerations about comprehensiveness and establishing a matrix].
Ciênc Saúde Coletiva 2012; 17(11): 3135-44. Portuguese.
17.Walters BA, Hays RD, Spritzer KL, Fridman M, Carter WB.
Health-related quality of life, depressive symptoms, anemia,and
malnutrition at hemodialysis initiation. Am J Kidney Dis. 2002;
40(6):1185- 94.
5. The National Collaborating Centre for Chronic Conditions (UK). Chronic
Kidney Disease: National Clinical Guideline for Early Identification and
Management in Adults in Primary and Secondary Care. London: Royal
College of Physicians (UK); 2008 Sep.
18. Harwood L. Wilson B. Sontrop J. Clark AM. Influência de estressores da
doença renal crônica na escolha da modalidade de diálise. J Adv Nurs.
2012; 68(11):2454-65.
6. Cueto-Manzano AM, Córtés-Sanabria L, Martines-Ramirez HR. Management
of chronic kideney disease: primary health-care setting, self-care and
multidisciplinar approach. Clin Nefhrol. 2010; 74 Suppl 1:S99-S104.
7. Lefevre F, Lefevre AM, Marques MCC. [Discourse of the collective
subject, complexity and self-organization]. Ciênc Saúde Coletiva.
2009; 14(4):1193-204. Portuguese.
8. Peixoto ER, Reis IA, Machado EL, Andrade EL, Acurcio FA, Cherchiglia
ML. [Planned dialysis and regular use of primary care by diabetic
patients in the city of Belo Horizonte, Minas Gerais State, Brazil]. Cad
Saúde Pública. 2013; 29(6):1241-50. Portuguese.
9. Bastos MG, Kirsztajn GM. [Chronic kidney disease: importance of early
diagnosis, immediate referral and structured interdisciplinary approach
to improve outcomes in patients not yet on dialysis]. J Bras Nefrol.
2011; 33(1):93-108. Portuguese.
10.Bastos MG, Bregman R, Kirsztajn GM. [Chronic kidney diseases:
common and harmful, but also preventable and treatable]. Rev Assoc
Med Bras. 2010; 56(2):248-53. Portuguese.
11. Santos FR, Filgueiras MS, Chaoubah A, Bastos MG, Paula RB. [Quality
of life and improvement of laboratory parameters as an outcome of an
interdisciplinary approach to the care of patients with chronic kidney
590
disease]. Rev Psiquiatr Clín. 2008; 35(3):87-95. Portuguese.
Acta Paul Enferm. 2014; 27(6):585-90.
19.Garrick R, Kliger A, Stefanchik B. Patient and facility safety in
hemodialysis: opportunities and strategies to develop a culture of
safety. Clin J Am Soc Nephrol. 2012; 7(4):680-8.
20. Maldaner CR, Beuter M, Brondani CM, Budó ML, Pauletto MR. [Factors
that influence treatment adherence in chronic disease patients
undergoing hemodialysis: [review]]. Rev Gaúcha Enferm. 2008;
29(4):647-53. Portuguese.
21. Ruiz AF, Basabe BN, Saracho RR. El afrontamiento como predictor de
la calidad de vida en diálisis: un estudio longitudinal y multicéntrico.
Nefrología (Madr.). 2013; 33(3):342-54.
22. Malta, DC, Dimech CP, Moura LS, Jarbas B. [Brazilian Strategic Action
Plan to Combat Chronic Non-communicable Diseases and the global
targets set to confront these diseases by 2025: a review]. Epidemiol
Serv Saúde. 2013; 22(1):171-8. Portuguese.
23. Leonello VM, Oliveira MA. [Integrality of healthcare as an educational
competency of the nurse]. Rev Bras Enferm. 2010; 63(3):366-70.
Portuguese.
24.Evans K, Coresh J, Bash LD, Gary-Webb T, Köttgen A, Carson K,
Boulware LE. Race differences in access to health care and disparities
in incident chronic kidney disease in the US. Nephrol Dial Transplant.
2011; 26(3): 899-908.
Original Article
Prevalence of risk behaviors in
young university students
Prevalência de comportamentos de risco em adulto jovem e universitário
Yone de Oliveira Faria1
Lenora Gandolfi1
Leides Barroso Azevedo Moura1
Keywords
Prevalence; Risk-taking; Universities;
Young adult; Ethics
Descritores
Prevalência; Assunção de risco;
Universidades; Adulto Jovem; Ética
Submitted
September 2, 2014
Accepted
September 15, 2014
Abstract
Objective: To assess the prevalence of risk behaviors in young university students.
Methods: Cross-sectional study carried out with 210 university students aged between 18 and 24. The applied
research instrument was a validated questionnaire called National College Health Risk Behavior Survey. Data
were analyzed using descriptive statistics, bivariate analysis and logistic regression.
Results: Among the studied individuals, 40% ingested alcohol, 25% were overweight, 19% used motorcycles
as a means of transportation, and 6% reported suicide attempts. Alcohol consumption, overweight and
practicing sports were associated with men. Suicide attempts and healthier eating habits were associated
with women.
Conclusion: Participants adopted behaviors that risked their health status, being such attitude more frequently
observed among men. Alcohol consumption was the most prevalent risk behavior in this population.
Resumo
Objetivo: Conhecer a prevalência de comportamentos de risco em adulto jovem e universitário.
Métodos: Estudo transversal com 210 universitários com idades entre 18 a 24 anos. O instrumento de
pesquisa foi um questionário validado National College Health Risk Behavior Survey. Para análise dos dados,
utilizaram-se estatística descritiva, análise bivariada e coeficientes de regressão logística.
Resultados: Dentre os estudantes, 40% consumiram álcool, 25% apresentaram excesso de peso, 19%
utilizaram motocicletas para transporte e 6% relataram tentativa de suicídio. Consumo de álcool, excesso de
peso e prática de atividades esportivas associaram-se aos homens. Tentativa de suicídio e hábitos alimentares
mais saudáveis associaram-se às mulheres.
Conclusão: Os participantes adotaram comportamentos que colocaram a saúde em risco, sendo essa atitude
mais frequentes nos homens. O consumo de álcool foi o comportamento de risco mais prevalente nessa
população.
Corresponding author
Yone de Oliveira Faria
Campus Universitário Darcy Ribeiro,
unnumbered, Brasília, DF, Brazil.
Zip Code: 70910-900
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400096
Universidade de Brasília, Brasília, DF, Brazil.
Conflicts of interest: there are no conflict of interest to declare.
1
Acta Paul Enferm. 2014; 27(6):591-5.
591
Prevalence of risk behaviors in young university students
Introduction
Health-risk behaviors adopted by university students have been assessed worldwide. Recent studies
aimed at comprehending, controlling and monitoring such behaviors point out their high prevalence
reflected on sedentary habits, eating disorders, traffic accidents, consumption of tobacco, alcohol and
other drugs, and violence against oneself and others.
(1-5)
Wang et al. observed a high percentage of university students who presented unhealthy lifestyles.
The researchers stood up to defend the need for taking social and territorial contexts into account in the
preparation of plans toward minimizing the morbidity-mortality loads caused by non-transmissible
chronic diseases, as well as the need for improving
the quality of life of this population by means of regional development programs of healthcare education that may mitigate social-spatial inequalities.(6)
In Brazil, violence has become a public healthcare challenge as a result of the high morbidity-mortality rates originated in the adoption of risk behaviors, such as consumption of alcoholic beverages
and illicit drugs, as well as the broad availability of
fire guns and the lack of adequate infrastructure of
the traffic system.(7)
It is possible that young students entering the
university adopt health-risk behaviors in detriment
of the commitments related to the dynamics of the
academic life, in such a way that their lifestyles are
modified.(8) The entrance of the student in the university overlaps periods in which values, beliefs, autonomy and the establishment of limits by parents
are questioned. In Portugal, a research involving
university students showed that the educational level was not a protection factor in choosing healthy
conducts among young Portuguese university students. Veteran students, who have been experiencing the academic life for a longer period, display
significant proportions of risk factors for non-transmissible chronic disease, in comparison with students who have recently entered college.(9)
The number of Brazilian students enrolled
in higher education institutions has been steadily
growing, and the expansion of the university population represents an opportunity to identify health-
592
Acta Paul Enferm. 2014; 27(6):591-5.
risk behaviors. Additionally, very few studies related
to health-based behaviors among young university
students in the Midwest region of Brazil, and especially in the Federal District and its surroundings,
have been produced. In face of the aforementioned
introduction, the objective of the present study was
to identify the prevalence of health-risk behaviors in
young university students.
Methods
This cross-sectional study was carried out with 210
young university male and female students, with
ages ranging from 18 through 24, in a higher education institution located in Brasília, in the central
region of Brazil.
The data collection instrument is part of the
National College Health Risk Behavior Survey,
elaborated by the Centers for Disease Control
and Prevention (CDC), and which has the aim to
monitor health-risk behaviors among American
adolescents and youngsters. The questionnaire
includes: sociodemographic data (sex, self-declared skin color, age group, period taken in
the university, and body mass index); issues addressing risk behaviors concerning young people
as college students (driving behaviors; violence
against oneself and third parties; consumption
of substances such as tobacco, alcohol, inhalants,
marijuana; weight control, eating habits, and
practice of physical activities).
Data were processed with the aid of the Statistical Package for the Social Sciences (SPSS,
version 22), and analyzed using descriptive statistics, Pearson’s Chi-Square test and logistic regression tests.
The development of this study complied with
national and international ethical guidelines for research involving human subjects.
Results
The study was composed of 210 young adults who
responded the questionnaire, corresponding to 71%
Faria YO, Gandolfi L, Moura LB
of the university students enrolled in the institution
during the period of the research.
The mean age of the participants was 21.35
years old (standard deviation of 1.7555), being
the youngest 18 and the oldest 24 years old.
There was a predominance of female participants, 128 (61%) students. There was also a predominance of respondents who self-declared being white. The group with the largest amount of
respondents was the one comprised of first-year
students (first and second semesters), totaling
83 (40.3%) students. The number of students
in the initial periods who responded to the questionnaire was predominantly higher than in all
other periods.
Table 1 presents health-risk behaviors among
students by sex and self-declared skin color/ethnic group.
Although other significant statistical correlations were not detected, men displayed a higher
percentage (29; 19.1%) regarding driving a motorcycle and not making use of a helmet (7; 3.3%).
Behaviors related to self-aggression or aggression
of third parties presented low results, even though
they showed slightly higher patterns among women
who had attempted suicide (12; 9.4%), thus gen-
erating a significant statistical correlation (p-value
=0.018) (Table 1).
Alcohol consumption was very high among
students (82; 40.0%), with a marked percentage
among men (42; 51.9%), and presenting a significant difference (p-value = 0.006) (Table 1).
Black and indigenous categories showed the
highest occurrence of risk behaviors: passengers
who did not use the seat belt (1.210), who drove a
motorcycle (1.083), suicide attempts (0.0118) (Table 1), and provoked vomit/use of laxatives (1.832),
ingestions of diet pills (1.078), and overweight
(1.114) (Table 2).
Even though higher overweight results were
found among men (32; 60.3%), there was also a
higher participation of men in sports activities in
the seven previous days (56; 68.2%), which generated a statistical correlation (p-value =0.001)
(Table 2).
High results regarding healthier eating habits
were found among women, although there were reports on diets toward losing or maintaining weight
(58; 45.3%). Nevertheless, regarding eating fruits
or drinking fruit juice (in the previous day, between
one and three times), a significant difference was
observed between sexes (p-value =0.007) (Table 2).
Table 1. Health risk behaviors among students by sex and self-declared skin color/ethnic group
Risk behavior
Total
n(%)
Gênero
Male
n(%)
Self-declared skin color/ethnic group
Female
n(%)
p-value
Odds ratio*
White
n(%)
Black
n(%)
Indigenous
n(%)
p-value
Odds ratio**
Traffic
Passenger did not make use of seat belt
Driver did not make use of seat belt
Use of motorcycle
Use of motorcycle without the protection of a
helmet
9(4.3)
4(4.9)
5(3.9)
0.740
1.251
5(4.1)
3(4.8)
1(5.3)
1.000
1.210
4(2)
2(2.4)
1(1.6)
0.644
1.575
3(2.4)
1(1.6)
-(0.0)
1.000
0.498
29(19.1)
16(27.6)
13(13.8)
0.055
2.374
16(19.0)
8(16.3)
5(33.3)
0.342
1.083
7(3.3)
4(4.9)
3(2.3)
0.089
2.137
5(4.0)
2(3.2)
- (0.0)
0.876
0.595
Self-aggression or aggression against others
Bearing of weapons
9(4.3)
2(2.4)
7(5.5)
0.487
0.429
7(5.7)
- (0.0)
2(10.5)
0.094
0.414
Involvement in fights
4(1.9)
- (0.0)
4(3.2)
0.155
-
3(2.4)
1(1.6)
-(0.0)
1.000
0.500
Suicide attempts
1(6.2)
1(1.2)
12(9.4)
0.018
0.118
7(5.7)
5(7.9)
1(5.3)
0.906
1.308
5(2.5)
3(3.8)
2(1.6)
0.383
2.368
2(1.6)
2(3.3)
1(6.2)
0.447
2.466
Consumption of substances
Habitual consumption of cigarettes
Consumption of marijuana
Risky consumption of alcohol
Consumption of inhalants
4(2.0)
1(1.2)
3(2.4)
1.000
0.515
3(2.4)
1(1.6)
-(0.0)
1.000
0.513
82(40.0)
42(51.9)
42(32.3)
0.006
2.262
49(40.8)
24(38.1)
8(44.4)
0.859
0.946
8(7.8)
8(10.1)
8(6.3)
0.423
1.678
11(8.9)
1(1.6)
4(22.2)
0.014
0.688
* Reference category: male; ** Reference category: black/indigenous
Acta Paul Enferm. 2014; 27(6):591-5.
593
Prevalence of risk behaviors in young university students
Table 2. Health behaviors by sex and self-declared skin color
Total
n (%)
Health behaviors
Gender
Male
n (%)
Self-declared skin-color/ethnic group
Female
n (%)
p-value
Odds ratio*
White
n (%)
Black
n (%)
Indígenous
n (%)
p-value
Odds ratio**
0.001
1.689
84(61.7)
40(29.4)
12(8.8)
0.339
1.114
27(54)
16(32)
7(14)
0.219
1.022
0.523
1.004
Body mass index
<25
136(64.7)
45(33)
91(66.9)
≥25
53(28)
32(60.3)
21(39.6)
Self-perception of body weight
Way below weight
11(5.3)
1(1.25)
10(7.8)
7(5.6)
2(3.1)
1(5.2)
Slightly below weight
14(6.7)
9(11.2)
5(3.9)
0.18
0.650
10(8)
2(3.1)
1(5.2)
11(57.8)
Right weight
120(57.9)
40(50)
80(62.9)
73(58.8)
41(65)
Slightly above weight
54(26.0)
26(32.5)
28(22.8)
31(25)
16(25.3)
4(21)
8(3.8)
4 (5)
4(3.1)
3 (2.4)
2(3.1)
2(10.5)
Way above weight
Attempts to cause the body to
Lose weight
87(42.4)
33(42.3)
54(42.5)
55(44.3)
30(47.6)
12(63)
Gain weight
43(20.9)
21(26.9)
22(17.3)
0.313
1.35
28(22.5)
11(17.4)
2(10.5)
Maintain the same weight
44(21.4)
13(16.6)
31(24.4)
23(18.5)
13(20.6)
2(10.5)
Not attempting anything
31(151)
11(14.1)
20(15.7)
18(14.5)
9(14.2)
3(15.7)
83.(39.9)
25(31.2)
58(45.3)
0.44
0.795
42(33.8)
28(44.4)
8.(42.1)
0.166
1.179
16(7.7)
2(2.5)
14(10.9)
0.031
0.206
7(5.6)
4(6.5)
4(21.1)
0.020
1.832
Weight control
Diet to lose or maintain weight
Provoked vomit or use of laxatives
Diet pill
18(8.6)
7(8.6)
11(8.6)
1.000
1.006
10(8.1)
5(8.1)
2(10.5)
0.934
1.078
Physical exercises to lose or maintain weight
82(39.4)
36(43.9)
46(36.5)
0.313
1.305
47(37.9)
24(38)
9(4.3)
0.267
1.039
103(49)
56(68.2)
47(36.7)
0.001
1.996
57(45.9)
38(60.3)
10(52.6)
0.300
1.303
100(47.6)
44(53.6)
56(43.7)
0.161
1.214
64(51.6)
28(44.4)
12(63.1)
0.386
0.945
168(80)
58(70.7)
110(85.9)
0.007
0.480
95(76.6)
53(84.1)
16(84.2)
0.388
1.475
147(70)
52(63.4)
95(74.2)
0.096
0.705
82(66.6)
49(77.7)
15(78.9)
0.504
1.543
134(63.8)
46(56)
88(68.7)
0.063
0.712
78.(62.9)
39(61.9)
15(78.9)
0.504
1.086
Sports activities
Participated in sports activities in the previous 7 days
Walked or used a bike for at least 30-60 minutes in the
previous 7 days
Eating habits
Ate fruits or drank fruit juice (yesterday, yes, between
1-3 times)
Ate green salad (yesterday)
Ate boiled vegetables (yesterday)
* Reference category: male; ** Reference category: black/indigenous.
Discussion
This study was limited by the fact that 1) it was carried out in a single institution, although it was the
only educational institution in that location; and 2)
its cross-sectional design did not allow for the establishment of cause and effect correlations.
The findings showed that the risk behaviors
adopted by university students were: alcohol consumption, use of motorcycles as a means of transportation, suicide attempts, overweight, and unhealthy eating habits.
The study also showed that the consumption of
alcohol was more frequent among male students.
Previous studies show that the pressure exerted by
academic demands, the need for being part of a
group, the accessible price of alcoholic beverage,
and the lack of prohibition of alcohol consumption
in the college environment were some of the causes
related to the alcohol consumption patterns among
university students.(10,11)
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Acta Paul Enferm. 2014; 27(6):591-5.
Violent and aggressive behaviors against oneself
or third parties related to the bearing of guns, involvement in fights and suicide attempts were predominant among women. Another research indicated higher frequencies of these behaviors in men,
except for the suicide attempts.(1)
In agreement with other studies, reports
on suicide attempts reached higher frequencies
among female students.(12,13) A study also mentions some factors related to the suicide risk,
such as generalized anxiety disorder (bipolar disorder and depressive episodes), traffic accidents,
fights with physical aggression, low confidence
level regarding communication with parents, alcohol and tobacco consumption, sexual assault,
and depression symptoms.(14)
Behaviors related to traffic safety displayed significant results, and gave proof to the overall approval of the use of the seat belt and helmet by drivers. This study showed a higher frequency of male
students as motorcycle drivers.
Faria YO, Gandolfi L, Moura LB
Among men, the study pointed out higher occurrences of sports practices; among women, on
the other hand, healthier eating habits were found.
Such findings agree with other studies in which female participants were found more likely to have
healthier eating habits and lower interest for physical activities.(5,15) A research with Spanish college
students showed that women were less active and
had a more sedentary lifestyle than men and therefore the realization of specific intervention actions
for women was recommended.(3) Data pointing out
that college students who live with their families
had better nutritional habits have also been found,
and that those enrolled in the first year of college
tend to present improved health behaviors when
compared with students in subsequent periods.(15)
As for the overweight, this study observed a
higher percentage of cases in comparison with the
findings among American university students. The
causes for the overweight and obesity were the eating disorders and lack of physical activity during the
academic life.(16)
The findings suggest that new health behavior
patterns regarding the sex, skin color/ethnic group
of university students have become a reality to be
dealt with by the university.
Optimistic young university students tend to
adopt health-risk behaviors and therefore an articulation between the positive psychology and the preventive education of health-risk behaviors should
be inserted into the undergraduate curriculum of
higher education institutions.
Conclusion
The participants adopted health-risk behaviors, being such attitude more frequent among male students. Alcohol consumption was the most prevalent
risk behavior in this population.
Collaborations
Faria YO; Gandolfi L and Moura LBA contributed to
the project conception, analysis and data interpretation, relevant critical review of its intellectual content
and final approval of the version to be published.
References
1. Eaton DK, Kann L, Kinchen S, Shanklin S, Flint KH, Hawkins J, et
al. Centers for Disease Control and Prevention. Youth Risk Behavior
Estados Unidos 2011. MMWR Surveill Summ. 2012; 61(4):1-162.
2. El Ansari W, Stock C, John J, Deeny P, Phillips C, Snelgrove S, et al.
Health promoting behaviours and lifestyle characteristics of students
at seven universities in the UK. Cent Eur J Public Health. 2011;
19(4):197-204.
3. Varela-Mato V, Cancela JM, Ayan C, Martín V, Molina A. Lifestyle and
health among Spanish university students: differences by gender and
academic discipline. Int J Environ Res Public Health. 2012; 9(8):272841. Erratum in: Int J Environ Res Public Health. 2013; 10(8):3590.
4. Martínez S MA, Leiva O AM, Sotomayor C C, Victoriano R T, Von
Chrismar P AM, Pineda B S. [Cardiovascular risk factors among
university students]. Rev Méd Chile. 2012; 140(4):426-35.
Spanish.
5. Tirodimos I, Georgouvia, Sawala TN, Karanika E, Noukari D. Healthy
lifestyle habits among Greek university students: differences by sex
and faculty of study. East Mediterr Health J. 2009; 15(3):722-8.
6. Wang D, Xing XH, Wu XB. Healthy lifestyles of university students in
China and influential factors. Scient World J. 2013; 2013:412950.
7. Reichenheim ME, Souza ER, Moraes CL, Jorge MH, Silva MF, Minayo
MC. Violence and injuries in Brazil: effects, progress made and
challenges ahead. Lancet. 2011; 377(9781):1962-75.
8. Rozmus CL, Evans R, Wysochansky M, Mixon D. An analysis of health
promotion and risk behaviors of freshaman college students in a rural
Southern setting. J Pediatr Nurs. 2005; 20(1):25-33.
9. Brandão MP, Pimentel FL, Cardoso MF. [Impact of academic
exposure on health status of university students]. Rev Saude Pública.
2011;45(1):49-54. Portuguese.
10. Wechsler H, Nelson TF. What we have learned from the Harvard School
Of Public Health College Alcohol Study: focusing attention on college
student alcohol consumption and the environmental conditions that
promote it. J Stud Alcohol Drugs. 2008; 69(4):481-90.
11.Lambert Passos SR, Alvarenga Americano do Brasil PE, Borges dos
Santos MA, Costa de Aquino MT. Prevalence of psychoactive drug use
among medical students in Rio de Janeiro. Soc Psychiatry Psychiatr
Epidemiol. 2006; 41(12):989-96.
12.Muñoz M J, Pinto M V, Callat C H, Napa D N, Perales C A. [Suicidal
ideation and family cohesion in pre-college students between 15 to
24 years old, Lima 2005]. Rev Perú Med Exp Salud Publica. 2006;
23(4):239-46. Spanish.
13.Villalobos-Galvis FH. [Suicidal behaivor in high school and college
students in San Juan de Pasto, Colombia]. Salud Ment. 2009; 32(2);
165-71. Spanish.
14.Pérez-Amezcua B, Rivera-Rivera L, Atienzo E, Castro F, Levya-López
A, Chávez-Ayala R. [Prevalence and factors associated with suicidal
ideation and intent adolescents in higher average education of the
Mexican Republic]. Salud Pública de México. 2010; 52(4):324-33.
Spanish.
15.Wei CN, Harada K, Ueda K, Fukumoto K, Minamoto K, Ueda A.
Assessment of health-promoting lifestyle profile in Japanese university
students. Environ Health Prev Med. 2012; 17(3):222-7.
16. Desai MN, Miller WC, Staples B, Bravender T. Risk factors associated
with overweight and obesity in college students. J Am Coll Health.
2008; 57(1):109-15.
Acta Paul Enferm. 2014; 27(6):591-5.
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