Official Organization for Scientific Dissemination of the ... · Facebook: Twitter:...

I

Official Organization for Scientific Dissemination of the Escola Paulista de Enfermagem, Universidade Federal de São PauloActa Paulista de Enfermagem/ Escola Paulista de Enfermagem/ Universidade Federal de São PauloAddress: Napoleão de Barros street, 754, Vila Clementino, São Paulo, SP, Brazil. Zip Code: 04024-002Acta Paul Enferm. volume 30, issue(1), January/February 2017ISSN: 1982-0194 (electronic version)Frequency: BimonthlyPhone: +55 11 5576.4430 Extensions 2589/2590E-mail: [email protected] Page: http://www.unifesp.br/acta/Facebook: https://www.facebook.com/actapaulistadeenfermagemTwitter: @ActaPaulEnfermTumblr: actapaulenferm.tumblr.com

Editorial Council

Editor-in-ChiefJanine SchirmerActa Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil

Technical EditorEdna Terezinha RotherActa Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil

Associate EditorsAriane Ferreira Machado Avelar, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil.Alexandre Pazetto Balsanelli, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil.Ana Lúcia de Moraes Horta, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil.Bartira de Aguiar Roza, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil.Dayana Souza Fram, Universidade Federal de São Paulo, Escola Paulista de Enfermagem, São Paulo, SP, BrazilEdvane Birelo Lopes De Domenico, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil.Eliana Campos Leite Saparolli, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil.Erika de Sá Vieira Abuchaim, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil.João Fernando Marcolan, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil.Manuela Frederico-Ferreira, Escola Superior de Enfermagem de Coimbra, Coimbra, PortugalMaria Magda Ferreira Balieiro, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil.Rosely Erlach Goldman, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil.Tracy Heather Herdman, University of Wisconsin, CEO & Executive Director NANDA International, Green Bay-Wisconsin, USA

Editorial BoardDonna K. Hathaway, The University of Tennessee Health Science Center College of Nursing; Memphis, Tennessee, USADorothy A. Jones, Boston College, Chestnut Hill, MA, USAEster Christine Gallegos-Cabriales, Universidad Autónomo de Nuevo León, Monterrey, MexicoGeraldyne Lyte, University of Manchester, Manchester, United Kingdom, USA Helen M. Castillo, College of Health and Human Development, California State University, Northbridge, California, USAJane Brokel, The University of Iowa, Iowa, USAJoanne McCloskey Dotcherman, The University of Iowa, Iowa, USAKay Avant, University of Texas, Austin, Texas, USALuz Angelica Muñoz Gonzales, Universidad Nacional Andrés Bello, Santiago, ChileMargaret Lunney, Staten Island University, Staten Island, New York, USAMaría Consuelo Castrillón Agudelo, Universidad de Antioquia, Medellín, ColombiaMaria Müller Staub, Institute of Nursing, ZHAW University, Winterthur, SwitzerlandMartha Curley, Children Hospital Boston, Boston, New York, USAPatricia Marck, University of Alberta Faculty of Nursing, Edmonton Alberta, CanadaShigemi Kamitsuru, Shigemi Kamitsuru, Kangolabo, Tokyo, JapanSue Ann P. Moorhead, The University of Iowa, Iowa, USA

Editorial Office Bruno Henrique Sena FerreiraMaria Aparecida Nascimento

Graphic DesignAdriano Aguina

II

Information Services

App Acta Paulista de Enfermagem

Support

Member of the Brazilian Association of Scientifi c EditorsAll content of the journal, except where identifi ed, is licensed under a Creative Commons attribution-type CC-BY.With a view tward sustainability and accessibility, Acta Paulista de Enfermagem is published exclusively in the digital format.

Completion

III

EditorialLeadership in nursing: Challenges and possibilities

The labor market has required from nurses a leader behavior, which can impact care outcomes. This stateman has allowed us to advance in the knowledge of this subject and discover its challenges and

possibilities in the context of the 21st century. Some of them are cited in the following paragraphs. However, there are other subjects can be consid-ered, which constitute subject to discussion and analysis to integrate this construct.

Understanding that leadership is a skill not a position is essential. From this perspective, it is possible to propose strategies to maximize its continu-ous development in both educational and occupational institutions. How-ever, for this process to be effective, it is necessary that managers adopt a model(1) that is compatible with this practice.

Studies on Authentic Leadership(2) and Transformational Leadership(3) offer choices. They have measurement instruments, that can optimize the mapping of leadership styles of nurses and adopt individual development plans, with goals to be achieved, to provide the development of this com-petence. Leaving the utopian aspect and building an intervention proposal is necessary to form human resources that can meet the so emerging health demands. This is a strategic decision, which is associated with the man-agement model,(4) with the view of making actions effective. If there is no congruence between them, failure may occur and the desired results may not be achieved.

It is necessary to stimulate researchers in Leadership in Nursing to pro-pose, test, and validate models that can fit to different world realities, and construct research methodological designs that can provide managers with ev-idence of the best option to implement in their services. This advancement is necessary to both instrumentalize management and make research applicable.

In undergraduate and graduate education, a clear model in leadership will also guide professors in what they can expect from student development in training future leaders.

Some challenges and possibilities are posed. However, there are others that have not been included in this editorial. Certainly, they are present in the uneasiness of many nurses, service managers, directors and professors. Translating these wishes into investigations will allow evidence and propose new strategies to form new leaders, so necessary nowadays.

References

1. Giltinane CL. Leadership styles and theories. Nursing Standard, 2013; 27(41): 35-9.

2. Walumbwa OF, Wang P, Wang H, Schaubroeck J, Avolio BJ. Psychological processes linking authentic leadership to follower behaviors. Leadership Quarterly. 2010; 21: 901-14.

IV

3. Herman S, Gish M, Rosenblum R. Effects of nursing position on transformational leadership practices. J Nurs Adm. 2015; 45(2):113-9.

4. Bernardes A, Cummings G, Évora YDM, Gabriel CS. Contextualização das dificuldades resultantes da implementação do Modelo de Gestão Participativa em um hospital público. Rev Lat Am Enfermagem. 2012; 20(6): 1142-51.

Prof. Dr. Alexandre Pazetto BalsanelliAdjunct Professor, Department of Administration of

Health and Nursing Services,Escola Paulista de Enfermagem, Universidade Federal de São Paulo;

Associate editor of Acta Paulista de Enfermagem;orcid.org/0000-0003-3757-1061

DOI: http://dx.doi.org/10.1590/1982-0194201700001

V

Contents

Original ArticlesPrimary care nurses’ role in the control of breast cancerAtuação do enfermeiro da Atenção Primária no controle do câncer de mamaMichele de Souza Teixeira, Rosely Erlach Goldman, Valterli Conceição Sanches Gonçalves, Maria Gaby Rivero de Gutiérrez, Elisabeth Níglio de Figueiredo ................................................................................................. 1

Vulnerability of the elderly to sexually transmitted infectionsVulnerabilidade de idosos a infecções sexualmente transmissíveisJuliane Andrade, Jairo Aparecido Ayres, Rúbia Aguiar Alencar, Marli Teresinha Cassamassimo Duarte, Cristina Maria Garcia de Lima Parada ......................................................................................................................................... 8

Preoperative period of potentially contaminated surgeries: risk factors for surgical site infectionPré-operatório de cirurgias potencialmente contaminadas: fatores de risco para infecção do sítio cirúrgicoTatiana Martins, Lúcia Nazareth Amante, Janeisa Franck Virtuoso, Juliana Balbinot Reis Girondi, Eliane Regina Pereira do Nascimento, Keyla Cristine do Nascimento ........................................................................................ 16

Visual acuity in the management of diabetes mellitus: preparation of the insulin doseAcuidade visual no manejo do diabetes mellitus: preparo da dose de insulinaGerdane Celene Nunes Carvalho, Roberto Wagner Júnior Freire de Freitas, Márcio Flávio Moura de Araújo, Maria Lúcia Zanetti, Marta Maria Coelho Damasceno .............................................................................................................. 25

Nursing workload related to the body mass index of critical patientsCarga de trabalho de enfermagem relacionada ao índice de massa corporal de pacientes críticosLuana Loppi Goulart, Fernanda Souza Angotti Carrara, Suely Sueko Viski Zanei, Iveth Yamaguchi Whitaker .......................... 31

Depressive symptoms in pregnancy and associated factors: longitudinal studySintomas depressivos na gestação e fatores associados: estudo longitudinalMarlise de Oliveira Pimentel Lima, Maria Alice Tsunechiro, Isabel Cristina Bonadio, Marcella Murata..................................... 39

Therapeutic itinerary of elderly cancer survivorsItinerário terapêutico de idosos sobreviventes ao câncerAngela Brustolin, Fátima Ferretti ............................................................................................................................................... 47

Assessment of somatic and affective-cognitive symptoms of people living with HIV/AIDSAvaliação dos sintomas depressivos somáticos e afetivo-cognitivos de pessoas vivendo com HIV/AIDSRenata Karina Reis, Carolina de Castro Castrighini, Elizabete Santos Melo, Giselle Juliana de Jesus, Artur Acelino Francisco Luz Queiroz, Elucir Gir ....................................................................................................................... 60

Prevalência de hepatite B e fatores associados em internos de sistema prisionalPrevalence of hepatitis B and associated factors in prisonersAndréia Alves de Sena Silva, Telma Maria Evangelista de Araújo, Sheila Araújo Teles, Rosilane de Lima Brito Magalhães, Elaine Leite Rangel Andrade ..................................................................................................................................................... 66

VI

Children with kidney diseases: association between nursing diagnoses and their diagnostic indicatorsCrianças com doenças renais: associação entre diagnósticos de enfermagem e seus componentesRichardson Augusto Rosendo da Silva, Moiziara Xavier Bezerra, Vinicius Lino de Souza Neto, Deborah Dinorah Sa Mororo, Itaìsa Cardoso Fernandes de Andrade ........................................................................................ 73

Meanings of breastfeeding interruption due to infection by human T cell lymphotrophic virus type 1 (HTLV-1)Sentidos da interrupção da amamentação devido infeção pelo vírus linfotrópico de células T humanas do tipo 1( HTLV-1)Karina Franco Zihlmann, Maria Cristina Mazzaia, Augusta Thereza de Alvarenga .................................................................... 80

First aid in schools: construction and validation of an educational booklet for teachersPrimeiros socorros na escola: construção e validação de cartilha educativa para professoresNelson Miguel Galindo Neto, Joselany Áfio Caetano, Lívia Moreira Barros, Telma Marques da Silva, Eliane Maria Ribeiro de Vasconcelos ........................................................................................................................................ 87

Alcohol effect on HIV-positive individuals: treatment and quality of lifeEfeito do álcool em pessoas com HIV: tratamento e qualidade de vidaVanessa da Frota Santos, Marli Teresinha Gimeniz Galvão, Gilmara Holanda da Cunha, Ivana Cristina Vieira de Lima, Elucir Gir ................................................................................................................................ 94

Postoperative complications in elective and non-elective neurosurgeryComplicações pós-operatórias em neurocirurgia eletiva e não eletivaEllen Maria Pires Siqueira, Solange Diccini ............................................................................................................................ 101

Factors related with breastfeeding self-efficacy immediate after birth in puerperal adolescentsFatores relacionados à autoeficácia na amamentação no pós-parto imediato entre puérperas adolescentesCarolina Maria de Sá Guimarães, Raquel Germano Conde, Flávia Azevedo Gomes-Sponholz, Mônica Oliveira Batista Oriá, Juliana Cristina dos Santos Monteiro ....................................................................................... 109

1Acta Paul Enferm. 2017; 30(1):1-7.

Original Article

Primary care nurses’ role in the control of breast cancer

Atuação do enfermeiro da Atenção Primária no controle do câncer de mamaMichele de Souza Teixeira1

Rosely Erlach Goldman1

Valterli Conceição Sanches Gonçalves1

Maria Gaby Rivero de Gutiérrez1

Elisabeth Níglio de Figueiredo1

Corresponding authorMichele de Souza TeixeiraNapoleão de Barros street, 754,04024-002, São Paulo, SP, [email protected]


1Universidade Federal de São Paulo, Escola Paulista de Enfermagem, São Paulo, SP, Brazil.Conflict of interests: Goldman RE is an associate editor of Acta Paulista de Enfermagem, but he did not participate in reviewing this paper.

AbstractObjective: To analyze actions performed by primary care nurses for opportunistic breast cancer screening based on the parameter proposed by the Brazilian Ministry of Health.Methods: This descriptive, cross-sectional study included 70 nurses. We used a validated questionnaire elaborated according to actions determined by the Brazilian program for control of breast cancer.Results: 97.1% of nurses referred patients for clinical breast exam, 88.6% indicated mammography annually and 75.7% guided patients to perform the first mammography exam starting at age 40 years, and 52.9% promoted educational meetings. However, guidance on age range and time interval for mammography and clinical breast exam, as well as an active search for women who did not show up, was not in agreement with parameters established by the Brazilian Ministry of Health.Conclusion: Nurses have conducted actions for the control of breast cancer, but some nonconformities exist between executed actions and actions proposed by the Brazilian Ministry of Health for cancer screening.

ResumoObjetivo: Analisar as ações realizadas por enfermeiros da Atenção Primária em Saúde para rastreamento oportunístico do câncer de mama, tendo como parâmetro a proposta do Ministério da Saúde. Métodos: Estudo descritivo, transversal, realizado com 70 enfermeiros, com auxílio de questionário validado, elaborado segundo as ações determinadas pelo programa de controle de câncer de mama do Brasil.Resultados: 97,1% dos enfermeiros realizavam exame clínico das mamas, 88,6% indicaram a mamografia anualmente e 75,7% orientaram o primeiro exame a partir dos 40 anos e 52,9% promoviam reuniões educativas. Entretanto, a orientação sobre faixa etária e intervalo de tempo para mamografia e exame clínico das mamas, bem como busca ativa de mulheres faltosas não apresentavam conformidade com o preconizado.Conclusão: Os enfermeiros têm realizado ações para o controle do câncer de mama, mas existem algumas não conformidades entre as ações executadas e as propostas do Ministério da Saúde para o rastreamento desta neoplasia.

KeywordsPrimary care nursing; Breast

neoplasms; Mass screening; Oncology nursing; Questionnaires

DescritoresEnfermagem de atenção primária;

Neoplasias da mama; Programas de rastreamento; Enfermagem oncológica;

Questionários

Submitted July 6, 2016

Accepted March 8, 2017

2 Acta Paul Enferm. 2017; 30(1):1-7.


Introduction

Early breast cancer detection is crucial for the control of this disease, especially because of the high rates of morbidity, mortality and late di-agnosis seen in Brazil. Early detection consists of early diagnosis and opportunistic or orga-nized screening performed with mammography (MMG), clinical exam (CEM) and breast self-ex-am (BSE). Among these methods, MMG con-tributes to the initial detection of breast cancer and is considered the gold standard for screening of the target population.(1-7)

Strategies to control the disease in Brazil have been implemented since the latter part of the last century, and they are characterized by isolated actions. In 2004, these actions become system-atized in programs whose goal is to reduce breast cancer mortality and morbidity. In that year, a consensus document was published regarding the control of breast cancer. It defined criteria for early screening and diagnosis, such as annu-al CEM after age 40 years, MMG every 2 years for those aged 50 to 69 years, and annual CEM and MMG for women age 35 years or older with higher risk for the disease.(3)

In 2015, the Brazilian Ministry of Health approved new National Guidelines for Breast Cancer Early Detection. These guidelines estab-lished actions based on better scientific evidence in order to be more effective and less harmful to population health. In the guidelines, MMG was maintained as a screening method for the priority age groups (50 to 69 years) every 2 years. This exam has proven efficacy in the re-duction of mortality for breast cancer. In other age groups and with other screening frequencies, the balance between risks and benefits of MMG screening is unfavorable.(8)

However, even with these instituted screen-ing actions, high rates of mortality due to the disease are still seen. One reason is unequal ac-cess to early diagnosis and treatment in Brazil. Therefore, it is fundamental to establish coher-ence among actions to be performed by profes-sionals for early breast cancer detection and pro-

posals for programs established for this disease. In addition, the Brazilian Public Health System (SUS, acronym in Portuguese) must be able to provide screening measures that guarantee fol-low-up of all detected cases in order to reduce mortality and large regional inequalities.(1,4,7-10)

The main location considered for devel-opment of these actions is primary health care (PHC). The PHC’s main care-based model is the Family Health Strategy (FHS), which con-stitutes the main entry point for assistance by the SUS and integrates and resolves most health issues of the population.(7,8,11)

Nurses’ role in early breast cancer detection in the PHC is crucial to stimulate patients’ ad-herence, including actions for health promotion and even treatment and rehabilitation. In addi-tion, all opportunities for interactions should be taken during care provided at Basic Health Units (BHU), which might enhance the nurse’s role as an agent of change whose actions are close to users.(7,11,12)

The main nursing contributions to the control of breast cancer are conducting nursing consulta-tion, recommend CEM screening based on age group and clinical features, examining the patient for signs and symptoms related to cancer, request-ing and evaluating exams based on local proto-cols, referring patients to and following up pa-tient after services for diagnosis and/or treatment, and performing and participating in activities of education.(7)

However, recent studies have drawn atten-tion to the need to train these professionals about breast cancer control because of the insuf-ficient knowledge about risk factors and screen-ing methods and the lack of permanent educa-tion. These aspects could compromise the pro-fessional performance and efficiency of actions proposed by the Brazilian Ministry of Health for control of the disease.(13-15)

The proposal to establish the PHC as the structural axis of the National Program of the Control of Breast Cancer is recent, and few published studies have ad-dressed the development of actions in this area, partic-ularly in terms of the nurse’s role in this level of care.


Teixeira MS, Goldman RE, Gonçalves VC, Gutiérrez MG, Figueiredo EN

This study analyzed primary health care nurses’ actions in opportunistic screening of breast cancer, with the actions proposed by the Brazilian Ministry of Health considered as the parameter.

Methods

This cross-sectional cohort study was carried out from November to December 2013 and included 90 nurses who worked at 20 BHUs located in the city of Diadema (SP). This municipality has the greatest population density in Brazil, and it fea-tures 100% coverage by the FHS program. Manag-ers of two BHUs did not allow access for the study; therefore, we interviewed 70 nurses who worked at 18 BHUs.

We included in the study nurses who worked in the service network of the PHC at Diadema for 1 or more years. This was length of time was considered necessary to acquire decision making competence in more complex situations.(16) We excluded nurses who were on work leave for any reason.

Before data collection, the researchers provided BHU managers with a copy of the project and the data collection instrument. After manager approv-al, nurses were invited to participate in the study. After confirmation, their interviews were sched-uled for a time that did not affect the dynamic of their work hours.

Collection was carried out at the BHU in a pri-vate room. Interviews were guided by structured and validated questionnaire; the 55 questions were related to the respondents’ sociodemographic characteristics and the PHC’s professional actions determined by the National Program of the Con-trol of Breast Cancer. To analyze execution of rec-ommended actions for early detection of the dis-ease, we considered variables related to workflow, protocol execution, and offerings of professional training.(3,7,17)

Data analysis of qualitative variables was descriptive, with frequency tables (ordinal or nominal); 95% confidence intervals (96% CIs)

were included for proportions, calculated by a bootstrap resampling method that obtained its sample through sampling with reposition of the original sample 1,000 times. Posteriorly, the hy-potheses were evaluated by bivariate analysis in contingency tables with the use of the Fisher ex-act test. All tests considered a bidirectional α of 0.05 with 95% CI and were carried out using the IBM SPSS 20 software (Statistical Package for the Social Sciences) and Excel 2010® (Microsoft Office).

The study protocol followed national and inter-national ethical and legal principles for research on human participants (Research Ethics Committee Certificate Number: 17461613.2.0000.5505).

Results

Professional characteristics of 70 nurses who participated in the study are shown in table 1.

Chart 1 includes data concerning actions pre-conized by the Ministry of Health for the control of breast cancer and those developed by nurses at BHU of the study.

In relation to the main problems found by nurses for development of CEM actions, 32 nurs-es (45.7%) reported difficulties performing this action; among these, 17 (53.1%) highlighted lack of time and 10 (31.1%) mentioned lack of appro-priate location. Regarding MMG, 39 (55.7%) of interviewees admitted to present difficulties, 23 (59%) had difficulties scheduling the examina-tion, and nine (23.15%) referred to the lack of an MMG system.

Table 2 presents the association between vari-ables for training in the Brazilian Ministry of Health guidelines on actions regarding breast cancer early detection, nursing consultation and promotion of educational meetings about the subject.

According to data presented, 31 nurses were trained on Brazilian Ministry of Health guidelines and 20 (64.6%) were developing educational ac-tions, and this difference was statistically signifi-cant (p=0.042) in relation to those who did not have any training.

4 Acta Paul Enferm. 2017; 30(1):1-7.


Twenty-seven nurses performed fewer than 10 consultations a day and 8 (29.2%) developed an ed-ucational activity. However, of 42 who conducted more than 10 consultations, 28 (66.7%) developed this action; this difference was statistically signifi-cant (p=0.003).

Discussion

One limitation of our study is data collection by using self-report of nurses, which can generate

Table 1. Professional and training characteristics of nursesVariable Category n (%) 95% CI*

Time working at the Basic Health Unit Less than 5 years 45(64.3) 22.6 - 44.3

5 to 10 years 23(32.8) 52.8 - 75

More than 10 years 02(2.9) 7.9

Higher degree Bachelor's 05(7.2) 1.5 - 13.9

Specialist 64(91.4) 83.8 - 97.3

Master's 01(1.4) 0.0 - 4.6

Specialty Family Health Program 34(48.6†) 36.0 - 59.7

Public Health 14(20†) 10.9 - 30.4

Obstetrics 03(4.3†) 0.0 - 9.5

Others 27(38.6†) 27.1 - 50.0

Training on actions defined by the Brazilian Ministry of Health No 37(52.8) 40.3 - 65.2

Yes 31(44.3) 31.9 - 56.5

Not recorded 02(2.9) 0.0 - 7.8

Last training 1 year to 1.5 years 04(12.9) 2.9 - 25.9

1.5 years to 2 years 03(9.7) 0.0 - 21.2

> 2 years 24(77.4) 60.0 - 91.2

Availability of publication “Caderno de Atenção Básica 13” No 15(21.4) 12.2 - 31.4

Yes 40(57.2) 45.2 - 68.8

Do not Know 15(21.4) 11.8 - 32.4

Availability of consensus document No 25(35.7) 23.7 - 46.2

Yes 20(28.6) 18.4 - 39.7

Do not Know 25(35.7) 25.0 - 48.6

*Confidence Interval (CI); †Each relative frequency was calculated from the total number of the sample (70 subjects). Totals do not add up to 100% because each individual could cite more than one category of response. 95% Confidence Interval.

Table 2. Association between trainings on guidelines of the Brazilian Ministry of Health, nursing consultation and educational meetings conducted by the nurse

Variables

Promotion of educational meetingTotal

p-valueNo Yes

n(%) n(%) n

MS* training

No 22(59.5) 15(40.5) 37 0.042

Yes 11(35.6) 20(64.5) 31

Total 33(48.5) 35(51.5) 68

Nursing consultation**

Less than 10 19(70.4) 8(29.6) 27 0.003

More than 10 14(33.3) 28(66.7) 42

Total 33(47.8) 36(52.2) 69

*Fischer exact test; Obs. Missing date=2; **Fischer exact test; Obs. Missing date=1

Chart 1. Comparison between actions defined by the Ministry of Health and developed by Primary Health Care nursesActions defined by the Brazilian Ministry of Health for nurses % of nurses who have completed the actions

Risky investigation 100% declared to perform the action

Annual follow-up in case of high-risk women for the disease 11.9% guided the annual screening

Annual breast cancer clinical examination 97,1% confirmed performing the clinical examination

Annual clinical breast cancer examination for women aged 40 years or older and for those aged 35 years with higher risk

35% indicated annual examination, 10% oriented breast clinical examination from 20 to 35 years of age for population at risk

In case of altered clinical examination, the woman should be referred to complementary diagnostic investigation

77.9% were referred to medical evaluation in case of abnormal exam

Requesting mammography 82.9% of nurses requested mammography

Mammography is recommended for women aged 50 to 69 years every 2 years 4.3% recommended exam for women aged 50 years or older

Guidance regarding self-exam 94.3% provided guidance on how to perform the self-exam

Self-palpation in any age group and without established interval 43.9% recommended self-exam for any age group; 19.3% provided counseling for self-examination without a defined period

Holding educational meetings, including on breast cancer 52.9% conducted educational meetings

Nurse consultation 100% participated in nurse consultation



information or memory bias. In an attempt to reduce this bias, we sought to complement infor-mation by consulting the medical records of us-ers. However, the fact that 40% of records lacked relevant notes showed that this data source was inadequate; therefore, it was disregarded. As a re-sult, we considered that, despite the limitation, self-report constitutes a useful source of infor-mation in research in which direct observation is viable.

In relation to the characteristics of investigated population, studies carried out in other municipali-ties involving FHS also identified a high number of nurses with specialization in the public health area. These data reflect the eagerness of these profession-als for continuing education and valorization of the working area.(12,18)

However, studies reinforce the insufficient num-ber of professionals who engaged in periodic train-ing, pointing out the need for permanent education for PHC professionals; actions must be included in planning these services, with emphasis on the topic of early detection of breast cancer.(12,13,15)

Most nurses (97.1%) affirmed recommend-ing CEM with annual indication (50%) in a spe-cific age group (41.4%) and, if breast changes were observed, 77.9% of nurses said that their main management approach was to request med-ical assessment. These results are in agreement with those of other studies and suggest that professionals addressed recommendations of the Brazilian Ministry of Health on conducting CEM to identify mammary changes and, in the identified case, referring the patient to complete the diagnostic investigation.(7,12)

Regarding actions that involved MMG, 88.6% of interviewees emphasized the annual request for this exam and 75.7% recommended the first exam at age 40 years. However, there is controversy in the literature in terms of age of re-ferral for first MMG screening as part of routine health care. Law no. 11,664/08 and the Ameri-can Cancer Society determine recommend per-forming the exam in all women starting at age 40 years. On the other hand, the Brazilian Ministry of Health and the United States Preventive Ser-

vices Task Force recommend initial mammogra-phy at age 50 years. In agreement with this last recommendation, a recent study that analyzed cost-effectiveness on the initial age for screening in Brazil favored the age group 50 to 69 years, and this finding corroborates data obtained in other systematic reviews.(7,19,20)

In relation to MMG, the municipality of Di-adema has a protocol that authorizes nurses to request this examination. However, this has been criticized because it is contrary to the new pub-lic health paradigm, in which a multidisciplinary approach takes the central role, attributing to nurses an importance in the team because they are trained to develop health promotion actions and prevent diseases. This reinforces the auton-omy of nurses to perform this action and has found support in Brazilian legislation. However, many municipalities still have not established a protocol that guarantees this right and publica-tions are not found mentioning nurses’ requests for MMG.(7,12)

During interviews, the nurses in this study stated that in their municipality, the active search of women with suspicion of malignancy involves MMG carried out in a program titled “Quarteirão da Saúde,” which is the referral service for special-ized care and diagnostic exams. In the case exams with abnormal results, follow-up is carried out in the same service. However, if the patient does not return to check the result of the exam, the nurses from BHU should be notified so that they can con-tact the patient.

Nurses reported lack of control regarding wom-en who were referred for MMG and did not show up for the exam; lack of monitoring can be ex-plained by the shortage of time during their daily activities. Nonmonitoring of these patients can lead to late diagnosis of the disease.

Based on established flow, we could observe that organized work in the network is still used as a strat-egy to enable the monitoring of women who are absent at any step of care; this system has been pro-posed by the Brazilian Ministry of Health, but this flow is not always successful and does not include all women.(7)

6 Acta Paul Enferm. 2017; 30(1):1-7.


Nurse who were interviewed reported no con-sensus related to guidance on BSE. The current literature also points to divergences in this regard. The United States Preventive Services Task Force does not recommend BSE as a screening method for breast cancer. However, the American Cancer Society and the Ministry of Health clarify that it although BSE does not constitute an adequate tech-nique for early diagnosis, it has been considered a support method because it allows women to know their own breasts; with this knowledge, therefore, she can provide information to help collaborate in the diagnosis.(7,8,19,20)

In terms of general actions developed by nurses, an important finding was that only 52.9% of them conduct educational meetings on breast cancer. This conflicts with guidance from the Brazilian Ministry of Health, which defines as a competency in these professionals the pro-motion of information to patients on actions of control of this disease. In addition, according to data reported in other studies on PHC, especial-ly related to work developed by nurses, health education is fundamental to facilitate the acqui-sition of knowledge by the users based on early cancer detection.(7,12,22)

Other investigated actions included the nurs-ing consultation, which was confirmed by nurs-es interviewed. This information shows that pro-fessionals completed one attribution of the FHS program proposed by the Brazilian Ministry of Health. A number of studies have clarified the rele-vance of this action, particularly because it enables the nurse to discuss with patients the functioning of their own body and the importance of acquiring a healthy lifestyle in order to find better solutions for established health problems.(23)

To better understand difficulties mentioned by interviewees, we assessed associations among ed-ucational activities, training and number of nurse consultations daily (Table 2). Results indicate that the number of educational activities is greater than the number of nurses who received training on rec-ommended actions for breast cancer compared with those who did not receive this training. We also observed that the number of educational activities

is not low when the nurse conducts more than 10 consultations daily.

Therefore, these results indicate that the num-ber of consultation is not a limiting factors for educational activity. However, the lack of training interferes in the development of this action. There-fore, these data confirm reports from other studies on the importance of permanent education for ba-sic care nurses. Training is considered a supporting factor for professional development of activities and competence.(12-15)

In this context, it is possible for a nurse in PHC to perform, via teamwork, individual and collective actions to control breast cancer that are facilitated by use of permanent education, evaluation, and planning, among other actions of local management. However, conditions for such collective actions should be provided and articulated.

Conclusion

Nurses at the FHS program performed actions pro-posed by the Ministry of Health for opportunistic breast cancer screening. However, some activities are not developed according to recommendations of the Brazilian Ministry of Health, such as age range and time interval to perform the clinical exam and MMG, active search for women who did not show up for MMG, and educational meetings about breast cancer. It is important to highlight that the justification for nurses to perform these activities mainly originated from lack of training, high care demand, and lack of time. Actions for opportunis-tic breast cancer screening should be implemented as proposed by the Brazilian Ministry of Health. Investments in professionals’ qualification are fun-damental and can be achieved by restructuring the working process of family health teams. These changes are expected to facilitate and stimulate edu-cational actions and improve access to consultations and exams for women, thereby helping to reduce rates of late diagnosis of breast cancer. This study should serve as a model for future studies in other municipalities.



AcknowledgementsWe thank National Council for Scientific and Technological Development (CNPQ) for funding the project “Action in the control of breast cancer: identification of practices in basic care”; this study is part of this project.

CollaborationsTeixeira MS, Goldman RE, Gonçalves VCS, Guti-érrez MGR and Figueiredo EM declare participat-ing in the conception of the study, data analysis and interpretation, drafting the manuscript, critical re-view of the content and approval of final version to be published.

References

1. Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA). Estimativa 2016: incidência de câncer no Brasil [Internet]. Rio de Janeiro: INCA; 2016 [citado 2016 Out 3]. Disponível em: http://www.inca.gov.br/bvscontrolecancer/publicacoes/edicao/Estimativa_2016.pdf.

2. World Health Organization (WHO). Global action plan for the prevention and control of noncommunicable diseases 2013-2020 [Internet]. Geneve: WHO; 2013 [cited 2016 Oct 3]. Available from: http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf?ua=1.

3. Instituto Nacional de Câncer José de Alencar Gomes da Silva (INCA). Controle do câncer de mama. Documento de consenso. Rio de Janeiro: INCA; 2004.

4. Silva RC, Hortale VA. Rastreamento do câncer de mama no brasil: quem, como e por quê? Rev Bras Cancerol. 2012; 58(1):67-71.

5. Dey S. Preventing breast cancer in LMICs via screening and/or early detection: The real and the surreal. World J Clin Oncol. 2014; 10; 5(3):509-19.

6. Shah R, Rosso K, Nathanson SD. Pathogenesis, prevention, diagnosis and treatment of breast cancer. World J Clin Oncol. 2014; 5(3):283-98.

7. Brasil. Ministério da Saúde. Controle dos cânceres do colo do útero e da mama. Brasília (DF): Ministério da Saúde; 2006. [Cadernos de Atenção Básica, n. 13. Série A. Normas e Manuais Técnicos].

8. Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA). Diretrizes para a detecção precoce do câncer de mama no Brasil [Internet]. Rio de Janeiro: INCA; 2015 [citado 2016 Out 3]. Disponível em: http://www1.inca.gov.br/inca/Arquivos/livro_deteccao_precoce_final.pdf.

9. Girianelli VR, Gamarra CJ, Silva GA. [Disparities in cervical and breast câncer mortality in Brazil]. Rev Saúde Pública. 2014; 48(3):459-67. Portuguese.

10. Silva GA. Breast cancer in Brazil: strategies for prevention and control. Cad Saúde Pública. 2012; 28(1):4-6.

11. Brasil. Ministério da Saúde. Portaria GM no. 648, de 28 de março de 2006. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da atenção básica para o Programa Saúde da Família (PSF) e o Programa Agentes Comunitários de Saúde (PACS) [Internet]. Brasília (DF): Ministério da Saúde; 2006 [citado 2016 Out 3]. Disponível em: http://dab.saude.gov.br/docs/legislacao/portaria_648_28_03_2006.pdf.

12. Jácome EM, Silva RM, Gonçalves ML, Collares PM, Barbosa IL. Detecção do Câncer de Mama: Conhecimento, Atitude e Prática dos Médicos e Enfermeiros da Estratégia Saúde da Família de Mossoró, RN, Brasil. Rev Bras Cancerol. 2011; 57(2):189-98.

13. Cavalcante SA, Silva FB, Marques CA, Figueiredo EN, Gutiérrez MG. Ações do Enfermeiro no rastreamento e Diagnóstico do Câncer de Mama no Brasil. Rev Bras de Cancerol. 2013; 59(3):459-66.

14. Fotedar V, Seam RK, Gupta MK, Gupta M, Vats S, Verma S. Knowledge of Risk Factors & Early Detection Methods and Practices towards Breast Cancer among Nurses in Indira Gandhi Medical College, Shimla, Himachal Pradesh, India. Asian Pacific J Cancer Prev. 2013; 14(1)117-20.

15. Yousuf SA, Al Amoudi SM, Nicolas W, Banjar HE, Salem SM. Do Saudi Nurses in Primary Health Care Centres have Breast Cancer Knowledge to Promote Breast Cancer Awareness? Asian Pacific J Cancer Prev. 2012; 13(9):4459-64.

16. Benner P. From novice to expert. Am J Nurs. 1982; 82(3):402-7.

17. Marques CA, Figueiredo EM, Gutiérrez MG. Validação de instrumento para identificar ações de rastreamento e detecção de neoplasia de mama. Acta Paul Enferm. 2015; 28(2):183-9.

18. Bartieri T, Marcon SS. Identificando as facilidades no trabalho do Enfermeiro para o desenvolvimento da longitudinalidade do cuidado. Rev Enferm UERJ. 2011; 19(2):212-7.

19. Siu AL; U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2016; 164(4):279-96. Erratum in: Breast Cancer Recommendation Statement From the U.S. Preventive Services Task Force. Ann Intern Med. 2016; 164(6):448.

20. American Cancer Society. Breast cancer. Causes, risks, and prevention topics [Internet]. 2015 [cited 2016 Oct 3]. Available from: http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-risk-factors.

22. Souza MG. Percepções de Enfermeiro sobre seu trabalho na Estratégia de Saúde da Família. Texto Contexto Enferm. 2013; 22(3):772-9.

23. Souza PA, Batista RC, Lisboa SF, Costa VB, Moreira LR. Percepção dos usuários da atenção básica acerca da consulta de enfermagem. Rev Min Enferm. 2013; 17(1):11-7.

8 Acta Paul Enferm. 2017; 30(1):8-15.

Original Article

Vulnerability of the elderly to sexually transmitted infectionsVulnerabilidade de idosos a infecções sexualmente transmissíveisJuliane Andrade1

Jairo Aparecido Ayres1

Rúbia Aguiar Alencar1

Marli Teresinha Cassamassimo Duarte1

Cristina Maria Garcia de Lima Parada1

Corresponding authorJuliane AndradeSantana Avenue, 323,18600-020, Botucatu, SP, Brazil. [email protected]


1Universidade Estadual Paulista “Julio de Mesquita Filho”, São Paulo, BrazilConflicts of interest: the authors declare no conflict of interest.

AbstractObjective: To identify the prevalence and factors associated with sexually transmitted infections (STIs) among the elderly.Methods: Cross-sectional study was conducted in a municipality of São Paulo from 2011 to 2012. A structured questionnaire was administered to 382 elderly people, and their blood samples were collected to test for syphilis, hepatitis B, and HIV/AIDS. Data were analyzed using the logistic regression model, with discussion based on the benchmark of vulnerability.Results: The prevalence of STIs was 3.4%, with 2.6%, 0.5%, and 0.3% prevalence of syphilis, hepatitis B, and HIV infection, respectively. Sex and a history of STIs were independently associated with this outcome: women had 12 times more likely to contract STIs than men, and the elderly with a history of these infections were 5 times more likely to contract an STI than those without a history of these infections.Conclusion: The results indicated individual and programmatic vulnerabilities of the elderly to STIs. It is essential to suggest strategies that encourage women to negotiate safe sex practices as well as educating healthcare professionals on this subject.

ResumoObjetivo: Identificar a prevalência e fatores associados às Infecções Sexualmente Transmissíveis (IST) em idosos.Métodos: Estudo transversal, realizado em município do interior paulista, entre 2011-2012. Aplicou-se questionário estruturado a 382 idosos, coletou-se exame para sífilis, hepatite B e HIV/Aids. Análise de dados foi realizada por modelo de regressão logística, com discussão a partir do referencial da vulnerabilidade.Resultados: A prevalência de IST foi 3,4%, sendo 2,6%, 0,5% e 0,3% de sífilis, hepatite B e infecção pelo HIV, respectivamente. Associaram-se de forma independente a este desfecho sexo e história de IST: mulheres tiveram 12 vezes mais chance que homens e, em idosos com história destas infecções, houve cinco vezes mais chance de IST, quando comparados àqueles sem história.Conclusão: Os resultados apontam para vulnerabilidade individual e programática dos idosos às IST. Sugerem-se estratégias que favoreçam às mulheres negociarem a prática de sexo seguro e a educação permanente dos profissionais na temática.

KeywordsSexually transmitted diseases; Vulnerability; Aged; Health of the elderly

DescritoresDoenças sexualmente transmissíveis; Vulnerabilidade; Idoso; Saúde do idoso



9Acta Paul Enferm. 2017; 30(1):8-15.

Andrade J, Ayres JA, Alencar RA, Duarte MT, Parada CM

Introduction

The rapid aging of the population may be the most important and dynamic aspect of modern demo-graphics, which consequently has a substantial in-fluence on public health. Globally, there has been a modest increase (approximately 2% from 8% to 10%) in the proportion of people aged ≥60 in the last six decades. However, future predictions are somewhat different as in 40 years 22% of the global population is expected to be ≥60 years old, resulting in the rise in elderly population from 800 million to 2 billion people.(1)

The situation in Brazil is similar: between 1980 and 2000, the Brazilian population aged ≥60 years increased by 7.3 million to >14.5 million people in 2000. It is believed that by 2025, the country will have the sixth largest population of the elderly worldwide.(2)

Faced with this global demographic transition, the World Health Organization, in its Global Re-port on Aging and Health, stated that recent evi-dence on the aging process indicates that many per-ceptions and common assumptions regarding the elderly are based on outdated stereotypes.(3) In the context of sexuality, researchers have demonstrated that the elderly continue to be sexually active, even after 80 years of age.(4)

A study conducted in northeastern Brazil also demonstrated that in this country, many elderly people maintain an active sex life with desires and pleasures and often continue to have sex in an un-safe manner.(5) This may be because the elderly do not perceive themselves as vulnerable to sexually transmitted infections (STIs) and HIV/AIDS,(6) a perception that can be contested by global data on the distribution of these diseases by age group.

A literature review on the epidemiology of STIs, with a particular focus on the elderly, has demon-strated increased rates of these infections in the population aged ≥50 in North America, Australia, China, Korea, and sub-Saharan Africa.(7) In Brazil, there are no national data on the prevalence of STIs in the general population and among the elderly in particular because many of these diseases do not involve compulsory notification. For HIV, a signif-

icant increase in the rates among men and women aged ≥60 years over the last decade has been report-ed,(8,9) indicating that the elderly are vulnerable to this disease.

The concept of vulnerability focuses on under-standing how individuals and groups of individuals expose themselves to a health risk, based on total-ities created by summaries that are pragmatically constructed on three analytical dimensions: indi-vidual, social, and programmatic.(10)

Individual vulnerability is related to the amount and quality of information that the individual has regarding certain problem and the possibilities of addressing it. Several factors are considered: person-al factors, including the level of knowledge, educa-tion, and access to information; subjective factors, including values and beliefs; and affective, behav-ioral, and biological factors that increase the expo-sure and susceptibility to risk. Social vulnerability is formed from access to data, healthcare, education, culture, and employment, as well as the practice of change when new information is received; these conditions are associated with access to material resources and social equipment. Programmatic vul-nerability is characterized by the identification and analysis of the scenario of government programs, including policies, programs, services, and activities for health protection and promotion.(10)

Although the vulnerability of the elderly to STIs is clear, few studies have addressed the factors associated with this problem, especially in Brazil. Therefore, in this study, we aimed to identify the prevalence and factors associated with STIs among the elderly.

Methods

This was a cross-sectional analytical study that fo-cused on the occurrence of STIs among the elderly. We chose to study three major infections (syphilis, hepatitis B, and HIV/AIDS) and to adopt the the-oretical framework of vulnerability to discuss the data obtained.(10)

The study was conducted the city of Botucatu, a medium-sized municipality in the interior of the

10 Acta Paul Enferm. 2017; 30(1):8-15.

Vulnerability of the elderly to sexually transmitted infections

state of São Paulo. In 2015, it had an estimated population of 139,483 inhabitants, and according to the last census in 2010, there were approximately 17,312 elderly residents.(11)

The study population comprised elderly peo-ple aged ≥60 who were registered with the munic-ipality’s 17 basic health units (UBSs). The calcula-tion of the sample size was based on the number of elderly people enrolled in the municipal health information system in 2011 in each health unit, with a 50% prevalence of STIs, a 5% margin of er-ror, and 95% confidence interval. We determined that the minimal sample size would be 377 elder-ly people. Next, we identified the proportion of elderly per UBS and maintained this proportion when creating the sample.

The elderly participants were included in the study by inviting them when they were in the waiting room of the health units, according to the inclusion criteria: residing in the municipal-ity and having had sexual intercourse at some point during life. Exclusion criteria were seniors diagnosed with diseases that impair the cognitive state, such as dementia or other neurological dis-turbances, which could impair the quality of the data obtained. The final intentional sample size was 382 elderly participants.

The data obtained covered the period from September 2011 to April 2012 and were collect-ed through individual interviews conducted in a private location by the author, a nurse, and three trained nursing students. The instrument used for data collection was developed specifically for this study and was based on a national survey(12) and a questionnaire proposed by the Brazilian Ministry of Health.(13) It was previously tested in the elderly people who were not included in the sample; a few changes were made to the final instrument before it was used.

Peripheral blood samples were collected for HIV, HBsAg, and Venereal Disease Research Labo-ratory testing, and cases were confirmed using qual-itative polymerase chain reaction ribonucleic acid reaction for HIV and using treponemal testing and automated chemiluminescent microparticle immu-noassay for syphilis.

The outcome variable was STI (yes, no). Ex-posure variables included characteristics related to the sociodemographics and sexual behavior of the elderly participants: sex (male, female); age in years (60-74, ≥75); color (white, nonwhite); years of school completed (≥4, ≤3); receiving an income (yes, no); income of at least two times the min-imum wage equivalents at the time of data col-lection, R$ 622.00 (yes, no); regular partner (yes, no); current sexual relations (yes, no); history of STI (yes, no); prior serum testing for STIs (yes, no); and use of condoms in all sexual relations (yes, no). Note that we investigated the use of the barrier method (condoms) in all sexual relations, whether vaginal or anal.

Statistical analysis included univariate analysis (first step) using the chi-square or Fisher’s exact test as appropriate, with the calculation of the re-spective odds ratios (ORs). This was followed by multivariable logistic regression analysis conduct-ed using the Wald test (second step) in which vari-ables from the univariate analyses with p < 0.20 were inserted into the model. In the third step, multiple logistic regression analysis was performed with the variables from the second step with p < 0.20; p < 0.05 was considered statistically signifi-cant. This strategy for modeling and selecting the adjustment factors was intended to avoid over-ad-justment as the result in question had a low fre-quency. The analyses were performed using SPSS software, version 20.0.

With regard to the ethical aspects, all elder-ly people included in the study received pre-test counseling, when they were informed of the con-fidential nature of the testing; the immunological window period; the difference between HIV, AIDS, and other STIs; the possible results of the tests; and how to prevent STIs. In the post-test meeting, if the results were negative, the professional discussed with the participant the risk, the immunological window, and preventive practices; if the results were positive, the participant was offered emotional sup-port, answers to questions, and strong preventive practices, and the partner was identified for testing.(14) In addition, participants with syphilis were treat-ed in their health unit, and those with confirmed

11Acta Paul Enferm. 2017; 30(1):8-15.


HIV or HBsAg were referred to the municipality’s specialized service.

The study was approved in advance by the Fac-uldade de Medicina de Botucatu (UNESP) Uni-versity Research Ethics Committee and registered under process 3949-2011. All participants signed a document indicating their free and informed con-sent before data were collected.

Results

The prevalence of STIs was 3.4%; among the 13 patients with infections, 10 patients had syphilis (2.6%), two had hepatitis B (0.5%), and one had HIV infection (0.3%) (data not shown in table).

Among the 382 participants, most were wom-en (61.8%), were aged between 60 and 74 years (70.4%), were white (69.4%), had ≥4 years of ed-ucation (52.1%), and were living with a partner (61.0%). Income was received by 84.8% of the par-ticipants, and 74.3% lived on an income less than two times minimum wage equivalents of family in-come. In terms of sexual activity, 62.2% reported having a regular partner, 55.0% were sexually active, and only 5.2% used condoms in all sexual relations. The vast majority of the participants (82.2%) did not report a history of STIs, and 20.4% had never undergone serological testing for these diseases.

Table 1 presents the results of univariate analy-ses of the characteristics of the elderly participants and the occurrence of STIs.

The following factors were considered to be po-tentially associated with STIs: sex, income, regular partner, current sexual relations, and history of STI (Table 1). Tables 2 and 3 present the results of mul-tivariate logistic regression analysis.

The variables sex, income, regular partner, cur-rent sexual relations, and a history of STIs with p < 0.20 from the univariate regression model were added in the multivariate logistic regression model (Table 2). Only history of STIs was associated with the risk of STIs among the elderly (p = 0.039, OR = 4.78, 95% CI = 1.08-21.11).

Only the variables sex and a history of STIs with p < 0.20 were retained in the multivariate analysis

(Table 3). In this case, both results were significant: elderly people with a history of STIs were five times more likely to present with an STI (p = 0.027, OR = 5.08 and CI 95% = 1.20-21.38), and older wom-en were 12 times more likely to contract an STI than older men regardless of a history of STIs (p = 0.022, OR = 12.27 and CI 95% = 1.44-104.08).

Table 1. Univariate analysis of the factors associated with the occurrence of sexually transmitted infections in the elderly

Variable

Sexually transmitted infection

p-value OR (95% CI)Yesn(%)

Non(%)

Sex

Female 12(5.1) 224(94.9) 0.015* 7.77(1.04-161.64)

Male 1(0.7) 145(99.3)

Age (years)

≥75 2(1.8) 111(98.2) 0.253* 0.42(0.06-2.06)

60-74 11(4.1) 258(95.9)

Color

White Non 8(3.0) 257(97.0) 0.533* 0.70(0.20-2.51)

White 5(4.3) 112(95.7)

Education (years)

≥4 6(3.0) 197(97.0) 0.607* 0.75(0.22-2.53)

0 to 3 7(3.9) 172(96.1)

Partner

Yes 6(2.6) 227(97.4) 0.264* 0.54(0.16-1.82)

No 7(4.7) 142(95.3)

Receives income

Yes 11(3.4) 313(96.6) 0.604** 0.97(0.19-6.50)

No 2(3.5) 55(96.5)

Income > 2x the minimum wage

Yes 0(0.0) 59(100.0) 0.094** --------

No 13(4.3) 290(95.7)

Regular partner

Yes 6(2.4) 247(97.6) 0.119* 0.42(0.12-1.44)

No 7(5.4) 122(94.6)

Current sexual relations

No 11(5.2) 199(94.8) 0.057** 4.70(0.97-31.13)

Yes 2(1.2) 170(98.8)

History of STIs

No 10(3.0) 327(97.0) 0.188** 0.43(0.10-2.05)

Yes 3(6.7) 42(93.3)

Condom use

Yes 0(0.0) 18(100.0) 0.528** ----------

No 13(3.6) 351(96.4)

Previous serology

Yes 4(5.3) 71(94.7) 0.303** 1.86(0.55-6.23)

No 9(2.9) 298(97.1)

*Chi-square test; **Fisher’s exact test

12 Acta Paul Enferm. 2017; 30(1):8-15.


Discussion

The obtained prevalence of STIs, especially that of syphilis, was considered high. Few articles on the prevalence of STIs among the elderly have been published; the present literature cannot be com-pared with the data from this study as they are based on populations over 50 years of age. However, na-tional population data demonstrated an upward trend the last decade in the HIV detection rate in men and women aged ≥60 years.(15,16) In São Paulo, an increase in the syphilis detection rate from 17.0 per 100,000 in 2010 to 45.4 per 100,000 in 2013 has been observed in this age group.(17)

This study identified two factors that were inde-pendently associated with STIs among the elderly: a history of STIs and female sex.

Having an STI in other stages of life indicates that risk behaviors were adopted previously. Rein-fection or developing a new infection after 60 years of age consequently shows individual vulnerability. One Brazilian study that aimed to estimate the vul-nerability of the elderly to AIDS(18) and other stud-ies on STIs in general populations also found that a history of STIs was a factor associated with new infections or re-infections.(19,20)

Women receive care from health services more frequently than men, a fact associated with social and historical issues related to maternal and child healthcare, which tends to continue throughout life, and gender issues as the female body is often

associated with the locus of care.(21) Therefore, be-cause women have more diagnostic opportunities than men, we expected fewer cases of STIs among the women in this study. In contrast, the situation we found indicates both social and programmatic vulnerabilities experienced by women through the loss of opportunities to identify cases and imple-ment effective treatment in the health services.

One study on factors associated with sexual risk behaviors among the elderly has indicated the benefits of appropriate interventions for this group, which are aimed at reducing behaviors that make them vulnerable; however, the fact that the elderly and healthcare professionals are reluctant to address these issues is considered as a complicating factor. The authors argue that healthcare professionals tend to consider the elderly asexual and, consequently, unable to acquire STIs, making prevention unnec-essary. On the other hand, this approach makes it difficult for the elderly to perceive themselves as vulnerable. Thus, we can conclude that healthcare professionals need to be trained to record the sexual history of the elderly during their routine visits to health services as this can increase self-perception of risk and the need to adopt safe behaviors.(22)

In southern Brazil, a qualitative study on sexu-ality demonstrated that the elderly use the media to inform themselves about issues related to sexuality and STIs. No participant reported communicating with healthcare professionals about their sexuality during consultations. The authors conclude that there are barriers on the part of healthcare profes-sionals, who may consider sex to be exclusive to young people.(23)

The loss of opportunities to develop interven-tions for elderly women is especially relevant, con-sidering that at this stage of life, women experience physiological changes, such as the thinning and dryness of the vaginal wall, which increase the like-lihood of contracting STIs.(24)

The results of this study in which women were 12 times more likely to contract an STI differ from those of the previously cited study by Fos-ter et al.(22) on sexual behavior among the elderly, which included people aged ≥50 years. These au-thors found that female sex was a protective factor

Table 2. Logistic regression model to estimate the risk of sexually transmitted infections (STIs) among the elderlyVariable p-value* OR 95% CI

Sex 0.095 6.76 0.71-63.54

Income of up to two times the minimum wage equivalents 0.997 -----* -----**

Regular partner 0.904 0.92 0.25-3.29

Current sexual relations 0.267 0.37 0.06-2.10

History of STIs 0.039 4.78 1.08-21.11

*Multivariate logistic regression using the Wald test; **Impossible to estimate

Table 3. Logistic regression model to estimate the risk of sexually transmitted infections (STIs) among the elderlyVariable p-value* OR 95% CI

Sex 0.022 12.27 1.44–104.08

History of STIs 0.027 5.08 1.20–21.38

*Multivariate logistic regression using the Wald test

13Acta Paul Enferm. 2017; 30(1):8-15.


against developing sexual risk behaviors.Potential explanatory factors include the fact that our study was conducted in a medium-sized municipality in the interior region of the state of São Paulo, Bra-zil, where beliefs and taboos surrounding sexuality in the elderly women may be more intense than those observed in the United States. In addition, the American study included slightly younger pop-ulation, which may have favored addressing female sexuality in this group.(22)

In Brazil, policies focused on active aging have been established to promote health, result-ing in benefits for the population aged ≥60 years. With the achievements obtained by this group in recent decades, extending the sex life takes on greater importance. The increase in quality of life, incentives to socialization, resumption of re-lations as people get older, and greater relevance accorded to collective activities and dance, for example, can lead to meetings among the elder-ly. These meetings associated with technological health advances, including hormone treatments and the use of drugs to enhance male sexual per-formance at more advanced ages, have enabled the rediscovery of new experiences and have con-tributed to the increase in sexual activity among the elderly.(25) However, interventions to caution about the negative consequences of unsafe sexual practices are essential to ensure that this pop-ulation is less vulnerable to HIV infection and other STIs.

All elderly participants in our study with STIs stated they did not use condoms, a situation that has been identified as an important aspect of in-dividual vulnerability. A systematic review with the meta-analysis of condom use by the elderly confirmed condom use to be a protective factor or behavior against HIV infection as its decreases the vulnerability of individual.(26) Explanations for low rates of condoms use that have been reported in the literature may also be useful to explain the situation in our study: the elderly have difficulty perceiving themselves as vulnerable to STIs; marriage is con-sidered as a protective factor, with the notion that having a regular partner does not necessitate con-dom use;(27) the experience of menopause and the

perception that because women are no longer fer-tile, they are not at risk of contracting STIs.(23)

We emphasize that in this study, we collected blood samples from individuals of both sexes who were seeking care at health services. It is also notable that these individuals with positive serum results for HIV, syphilis, or hepatitis B were not diagnosed during routine health checkups. Consequently, they were unaware of their infection status, indicat-ing programmatic vulnerability characterized by the unreliability of resources offered to the individual in the area of prevention, diagnosis, and treatment,(10) which are the most important when considering control measures.(28)

It is notable that the municipality where the study was conducted offers the following services that should permit the diagnosis and treatment of STIs among the elderly: the municipal STD/AIDS program, which conducts the state campaign (“Fique Sabendo”) and blood testing offered at the UBS; a testing and counseling center for STI/AIDS, and an outpatient service specializing in infectious diseases. The fact that despite these resources, the participants were only diagnosed in a study indi-cates the failure of the healthcare network for the elderly and, again, programmatic vulnerability as there is no intervention specifically designed for the elderly population and primary care professionals are not sensitive to the vulnerability of the elderly to STIs. Corroborating these findings, another study performed in the same municipality demonstrat-ed that serum HIV testing among elderly patients only occurred in secondary and tertiary care, clearly showing that primary care professionals do not con-sider the elderly to be vulnerable to STIs/AIDS.(6)

The results obtained are relevant for nurses as well as for the multidisciplinary team as they receive elderly people in UBSs and participate in planning and implementing activities aimed at the elderly health.

Lastly, we suggest caution in generalizing the data presented herein because this was not a pop-ulation-based study but a convenience sample, al-though we were careful to collect data from all mu-nicipal UBSs and to include participants in propor-tion to the populations served by them.

14 Acta Paul Enferm. 2017; 30(1):8-15.


Conclusion

The prevalence of STIs was high (3.4%) in the study population and was independently associated with female sex and a history of STIs, indicating individ-ual and programmatic vulnerabilities. To change this scenario, we suggest conducting educational activities for women, so that they feel they are in a position to negotiate safe sex practices. We also suggest establish-ing strategies for early diagnosis and implementing immediate treatment, thereby interrupting the chain of transmission; this can be made possible if healthcare professionals implement a protocol of recording broad health history of the elderly that includes asking about sexual history and offering blood tests for the elderly with a history of STIs and for the patients in vulnerable situations. This requires continuous education on this topic among healthcare professionals, so that they can contribute to the successful implementation of policies to promote and prevent STIs/AIDS, with an emphasis on the elderly population.

CollaborationsAndrade J, Ayres JA, Alencar RA, Duarte MTC, and Parada CMGL declare that they participated in the conception of the study, the critical review related to intellectual content, and the approval of the final version for publication.

References

1. Beard JR, Biggs S, Bloom DE, Fried LP, Hogan P, Kalache A, et al. Global population ageing: peril or promise. Geneva: World Economic Forum; 2011.

2. World Health Organization. Envelhecimento ativo: uma política de saúde. Tradução Suzana Gontijo. Brasília (DF): Organização Pan-Americana da Saúde; 2005.

3. Organização Mundial de Saúde. Resumo: Relatório mundial de envelhecimento e saúde. Genebra: OMS; 2015.

4. Schick V, Herbenick D, Reece M, Sanders AS, Dodge B, Middlestadt SE, et al. Sexual behaviors, condon use, and sexual health of Americans over 50: implications for sexual health promotion for older adults. J Sex Med. 2010; 7 Suppl 5:315-29.

5. Sales JC, Teixeira GB, Sousa HO, Rebelo CR. A percepção do idoso de um centro de convivência de Teresina - PI sobre a aids. Rev Min Enferm. 2013; 17(3):620-7.

6. Alencar RA, Ciosak SI. O diagnóstico tardio e as vulnerabilidades dos idosos vivendo com HIV/aids. Rev Esc Enferm USP. 2014; 49(2):229-35.

7. Minichiello V, Rahman S, Hawkes G, Pitts M. STI epidemiology in the global older population: emerging challenges. Perspect Public Health. 2012; 132(4):178-81.

8. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde, Departamento de DST, Aids e Hepatites Virais. Boletim Epidemiológico de HIV/aids. Brasília (DF): Ministério da Saúde; 2014. 84 p.

9. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde, Departamento de DST, Aids e Hepatites Virais. Boletim Epidemiológico de HIV/AIDS. Brasília (DF): Ministério da Saúde; 2015. 100 p.

10. Ayres JR, Paiva V, Júnior IF. Conceitos e práticas de prevenção: da história natural da doença ao quadro da vulnerabilidade e direitos humanos. In: Paiva V, Ayres JR, Buchalla CM. Vulnerabilidade e direitos humanos. Curitiba: Editora Juruá; 2012. 71-94p.

11. Brasil. Ministério do Planejamento. Orçamento e Gestão. Sinopse do censo demográfico. Região de São Paulo e Rio de Janeiro [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2010 [citado 2016 Maio 20]. Disponível em: http://www.cidades.ibge.gov.br/xtras/perfil.php?lang=&codmun=350750&search=sao-paulo|botucatu.

12. Oliv M, Santana RG, Mathias TA. Behavior, knowledge and perception of risks about sexually transmitted diseases in a group of people over 50 years old. Rev Lat Am Enfermagem. 2008; 16(4):679-85.

13. Brasil. Ministério da Saúde. Manual de capacitação para profissionais de saúde utilizando testes rápidos. Formulário de atendimento do SI-CTA [Internet]. 2005 [citado 2016 Maio 20]. Disponível em: http://www.aids.gov.br/sites/default/files/anexos/page/2012/50770/manual_do_mult ip l icador_de_trd_14_07_2011_pdf_23160.pdf.

14. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde, Departamento de DST, Aids e Hepatites Virais. Diretrizes para organização e funcionamento dos CTA do Brasil. Brasília (DF): Ministério da Saúde; 2010.

15. Brasil. Ministério da Saúde. Boletim Epidemiológico de HIV/aids. Brasília: Secretaria de Vigilância em Saúde, Departamento de DST, Aids e Hepatites Virais. Brasília (DF): Ministério da Saúde; 2014. 84p.

16. Brasil. Ministério da Saúde. Boletim Epidemiológico de HIV/aids. Brasília: Secretaria de Vigilância em Saúde, Departamento de DST, Aids e Hepatites Virais. Brasília (DF): Ministério da Saúde; 2015. 100p.

17. Centro de Referência e Treinamento em DST/AIDS. Boletim Epidemiológico de DST/AIDS. São Paulo. Secretaria do Estado de São Paulo: Coordenadoria de Controle de Doenças; 2014. 147 p.

18. Andrade MD, Pontes ER, Paniago AM, Cunha RV. Vulnerability to AIDS among the elderly in an urban center in central Brazil. Clinics. 2012; 67(1):19-25.

19. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines. Atlanta: CDC; 2015.

20. World Health Organization. Sexually transmitted infections (STIs) [Internet]. Geneva: WHO; 2015. [cited 2016 Jan 28]. Available from: http://www.who.int/mediacentre/factsheets/fs110/en.

21. Machin R, Couto MT, Silva GS, Schraiber LB, Gomes R, Figueiredo WS, et al. Concepções de gênero, masculinidade e cuidados em saúde: estudo com profissionais de saúde da atenção primária. Ciênc Saúde Coletiva. 2011; 16(11):4503-12.

22. Foster V, Clark PC, Holstad MM, Burgess E. Factors associated with risky sexual behaviors in older adults. J Assoc Nurs AIDS Care. 2012; 23(6):487-99.

15Acta Paul Enferm. 2017; 30(1):8-15.


23. Laroque MF, Affeldt AB, Cardoso DH, Souza GL, Santana MG, Lange C. Sexualidade do idoso: comportamento para a prevenção de DST/AIDS. Rev Gaúcha Enferm. 2011; 32(4):774-80.

24. Maschio MB, Balbino AP, De Souza PF, Kalinke LP. Sexualidade na terceira idade: medidas de prevenção para doenças sexualmente transmissíveis e AIDS. Rev Gaúcha Enferm. 2011; 32(3):583-9.

25. São Paulo. Secretaria de Estado da Saúde. Centro de Referência e Treinamento em DST/Aids. Coordenadoria de Controle de Doenças. Área Técnica de Saúde da Pessoa Idosa. Grupo Técnico de Ações Gráficas. Documento de diretrizes para prevenção das DST/aids em idosos. Bepa. 2011; 8(92):15-23.

26. Paz MA, Alencar JM, Souza CL, Nogueira JA, Rodrigues JA. The influence of the usage of the male condon by seniors in the vulnerability to HIV: a systematic review with meta-analysis. J Bras Doenças Sex Transm. 2013; 25(3):150-6.

27. Moreira TM, Parreira BD, Diniz MA, Silva SR. Conhecimento das mulheres idosas sobre doenças sexualmente transmissíveis, conhecimento, uso e acesso aos métodos preventivos. Rev Eletron Enferm [Internet]. 2012; 14(4):803-10 [citado 2016 Maio]. Disponível em: http://www.fen.ufg.br/revista/v14/n4/v14n4a08.htm.

28. Markle W, Conti T, Kad M. Sexually transmitted diseases. Prim Care. 2013; 40(3):557-87.

16 Acta Paul Enferm. 2017; 30(1):16-24.

Original Article

Preoperative period of potentially contaminated surgeries: risk factors for surgical site infectionPré-operatório de cirurgias potencialmente contaminadas: fatores de risco para infecção do sítio cirúrgicoTatiana Martins1

Lúcia Nazareth Amante1

Janeisa Franck Virtuoso1

Juliana Balbinot Reis Girondi1

Eliane Regina Pereira do Nascimento1

Keyla Cristine do Nascimento1

Corresponding authorTatiana MartinsAgronômica street, 69, 88110-505, São José, SC, [email protected]


1Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.Conflicts of interest: no conflicts of interest to declare.

AbstractObjective: To associate risk factors of the preoperative period of potentially contaminated surgeries performed in a teaching hospital in the southern region of Brazil with the occurrence of surgical site infection in the postoperative period in the hospital and at home.Methods: A quantitative descriptive cross-sectional study conducted from February to June 2015 with 90 participants by means of individual data collection and observation, from the preoperative period, immediate postoperative period and up to seven days after discharge. The Statistical Package for Social Sciences was used for data analysis. Categorical variables were analyzed descriptively by simple frequency and percentages, and numerical variables by position and dispersion measurements.Results: The surgical site infection in the postoperative period in the hospital occurred in 10% of participants, and in the postoperative period at home in 46.7%. Risk factors: gender, age, underlying diseases, medications, alcoholism and smoking habits were significant for the development of these infections.Conclusion: Checking the health history and performing follow-up of surgical patients during the preoperative period and surgical recovery to reduce surgical site infection are recommended.

ResumoObjetivo: Associar fatores de risco do período pré-operatório, de cirurgias potencialmente contaminadas, realizadas em hospital escola da região Sul do Brasil, com a ocorrência da infecção do sítio cirúrgico no período pós-operatório hospitalar e em domicílio.Métodos: Estudo transversal descritivo quantitativo realizado de fevereiro a junho de 2015 com 90 participantes mediante a coleta de dados realizada sob a forma de entrevista individual e observação, desde o período pré-operatório, pós-operatório imediato e mediato até sete dias após alta hospitalar. Para análise de dados utilizou-se o Statistical Package for Social Sciences, sendo as variáveis categóricas analisadas descritivamente através da frequência simples e porcentagens e as numéricas pelas medidas de posição e dispersão.Resultados: A infecção do sítio cirúrgico no período pós-operatório hospitalar ocorreu em (10%) e no pós-operatório domiciliar em 46,7%. Fatores de risco: sexo, idade, doenças de base, medicações, etilismo e tabagismo foram significativos para o desenvolvimento destas infecções.Conclusão: Recomenda-se a realização de histórico de enfermagem e acompanhamento dos pacientes cirúrgicos, durante o período pré-operatório e recuperação operatória, para reduzir a infecção do sítio cirúrgico.

KeywordsPatient safety; Perioperative nursing; Surgical nursing; Surgical wound infection; Cross infection

DescritoresSegurança do paciente; Enfermagem perioperatória; Enfermagem cirúrgica; Infecção da ferida operatória; Infecção hospitalar


Accepted January 30, 2017

17Acta Paul Enferm. 2017; 30(1):16-24.

Martins T, Amante LN, Virtuoso JF, Girondi JB, Nascimento ER, Nascimento KC

Introduction

The perioperative period encompasses the preopera-tive, intraoperative and postoperative stages and im-plies the interdependent performance of the nursing and surgical teams.(1) The preoperative period is the time interval between the recognition of the need for surgery and the patient’s arrival at the surgical center. At this moment, nurses identify and evalu-ate patients’ conditions, obtaining information that can diminish their fears and insecurities, and thus promote quality care for the next surgical periods.(2)

Not only in the preoperative period, but also throughout the postoperative period in the hospi-tal and at home, the nursing team should perform specific care for each type of surgical procedure, with infection control, and seeking tools to reduce prevalent rates of infection and predisposing risk factors.(3,4)

The confirmation of risk factors, creation and use of intervention protocols, and management of the nursing team to use care technologies and pro-vide safe care are relevant aspects to provide periop-erative nursing care that is active in the control and prevention of complications and hospital infec-tions.(5) Surgical safety is based on saving lives and preventing disabilities through actions to prevent surgical site infection; safe anesthesia; safe surgical teams and indicators of surgical care.(6)

Surgical Site Infection (SSI) results from poor surgical manipulation involving subcutaneous tis-sue, deep soft tissues (fascia and muscle), organ and cavities with incision. They are characterized as those occurring up to the 30th postoperative day or up to a year for surgeries with prosthesis implants. They rank third among all infections in health ser-vices and occur in 11% of surgeries performed in Brazil, since this rate varies according to the type of surgical procedure and the patient’s own immunity. It is one of the main infections related to Brazilian health care and the most important cause of post-operative complication in surgical patients.(4,7)

Potentially contaminated surgeries are those performed in tissues colonized by small microbial flora or in colonized tissues absent from infectious and inflammatory processes and with discrete intra-

operative technical failures. There is penetration in the digestive, respiratory or urinary tract without significant contamination. Examples of potentially contaminated surgeries are elective surgery in the small intestine, biliary surgery without stasis or biliary obstruction, gastric and duodenal surgery, clean traumatic wounds, cholecystectomy, vagoto-my with drainage, prolonged cardiac surgeries with extracorporeal circulation.(2)

In a teaching hospital in southern Brazil, 2259 surgical procedures were performed in 2013, of which 1248 (55.25%) were potentially contam-inated and 40 (1.77%) were infected surgeries. Of the 1248 patients who underwent potential-ly contaminated surgical procedures, 82 (6.57%) acquired Hospital Infection (HI) and 35 (2.80%) developed SSI. These numbers, when added, show a HI incidence within the range recommended by the Centers for Disease Control and Prevention and the Ministry of Health (3 and 11%; and up to 10%, respectively).(8)

The search for scientific knowledge to support the practice of perioperative nursing care is import-ant to perform interventions focused on meeting surgical patients’ needs, based on the scientific lit-erature, and with interaction between care practice and the theory.(9)

In relation to protection against situations that endanger the essential aspects of life and physical and mental integrity, the right to health with safe-ty is a central mechanism in the development and implementation of health care actions with quality and safety.(10)

The relevance of this issue is to provide subsidies for infection control, reduction of hospital costs, and improvement of surgical care. The provision of nursing care to surgical patients, especially in the preoperative period, together with the identification of risk factors are indispensable to prevent SSI, thus promoting patient safety. In addition, the impor-tance of the issue of surgeries was given based on the considerable number of the type and classification of this surgery performed at the teaching hospital. According to the number of surgical procedures, it was possible to detect the presence of SSI in poten-tially contaminated surgeries as a complication at

18 Acta Paul Enferm. 2017; 30(1):16-24.

Preoperative period of potentially contaminated surgeries: risk factors for surgical site infection

the teaching hospital, requiring effective prevention measures and early therapy to reduce the number of cases.(11) From this perspective, the question is: Which risk factors of the preoperative period of potentially contaminated surgeries performed in a teaching hospital in southern Brazil are associated with the occurrence of surgical site infection in the postoperative period in the hospital and at home? The aim of this study was to associate preoperative risk factors of potentially contaminated surgeries performed in a teaching hospital in southern Brazil with the occurrence of surgical site infection in the postoperative period in the hospital and at home.

Methods

Descriptive cross-sectional study of quantitative ap-proach conducted in two surgical units of a teach-ing hospital in the south of Brazil from February 12 to June 30, 2015.

The convenience sample was calculated based on the number of patients submitted to potentially contaminated surgeries performed in 2013, which was 1248 in total according to data collected at the collection site. The sample was calculated using the Web Statistics Teaching-Learning System (SEstat-Net - Sistema de Ensino-Aprendizagem de Estatísti-ca na Web),(1) with p value of 50% and confidence level of 95%, resulting in a sample of 90 patients.(12,13) Inclusion criteria were age of 18 years or old-er; auto-alo-chrono-oriented, admitted during the data collection period in the preoperative period of potentially contaminated elective surgeries, and that provided contact information for the period after hospital discharge. The excluded patients were those with previously infected surgeries, who were included in the sample and submitted to a new hospitalization during the data collection period to perform another surgical procedure, or those with any type of systemic infection confirmed prior to surgery.

The instrument used to collect data during the preoperative period was an individual interview through a structured script, and information from the medical records. The script contained data re-

lated to the following variables: age (young adult aged up to 24 years, adults aged 25-59 years, and elderly aged 60 years or more); gender; degree of dependency (semi-dependent and independent); living alone or not; diabetes mellitus as underlying disease; smoking habits; diagnosis of current disease such as cholelithiasis; use of the following medi-cations: antihypertensive, anxiolytic, antidiabetic, anticoagulant, anticoagulant and gastric protector; use of a peripheral venous catheter and admission to the Intensive Care Unit (ICU) after a surgical procedure.

An interview script and observation were used to collect data in the immediate postoperative pe-riod and up to seven days after surgery, and the presence or absence of SSI were verified as categor-ical variables. For this end, the following were eval-uated: characteristics of the surgical site dressings in dry and clean; presence or absence of pain, hy-peremia, heat, edema and dehiscence. In addition, the characteristics for SSI classification such as pain, flushing, heat, edema, fever, dehiscence and puru-lent exudate were investigated to confirm SSI in postoperative periods in the hospital and at home.

Participants were followed up from the preop-erative period until their hospital discharge. Seven days after discharge, they were contacted by tele-phone with the objective of monitoring changes in the cicatricial evolution of the surgical site (favor-able or not). Therefore, participants answered some questions of an individual interview script related to the healing process of the surgical incision and the clinical condition evolution, besides monitoring and/or confirming changes in the cicatricial evolu-tion of the surgical site (favorable or not).

Data were stored and analyzed in the Statistical Package for Social Sciences (SPSS), version 22.0. Categorical variables were analyzed descriptively by means of simple frequency and percentages, and numerical variables by position and dispersion mea-surements. In the inferential analysis of modifiable risk factors and presence/absence of SSI, was ap-plied the Chi-square test (χ2). The bivariate associa-tion was analyzed through binary logistic regression to verify the association between SSI (in the postop-erative period in the hospital and at home) and its

19Acta Paul Enferm. 2017; 30(1):16-24.


preoperative risk factors. For the regression model were inserted only variables with p ≤ 0.200 in com-parison with the presence of SSI. The significance level was set at 5% (p = 0.05), where the based lim-it proves if the deviation originates from chance or not. To confirm the influence of risk factors on the occurrence of SSI, the EXP (B) - OR interval was 1.

The study was approved by the Committee of Ethics and Research with Human Beings (CEPSH - Comitê de Ética e Pesquisa com Seres Humanos) of the Institution and approved under protocol num-ber 925.511/14, and by the Certificate of Presenta-tion for Ethical Appreciation (CAAE - Certificado de Apresentação para Apreciação Ética) under num-ber 39866414.1.0000.0115.

Results

Regarding sociodemographic characteristics of the 90 patients, four (4%) were young adults; 62 (69%) were adults, and 24 (27%) were elderly. The majori-ty were women, 68 participants or 76% of the sam-ple. Of the total number of participants, 82 (91%) had children, 24 (27%) had completed elementary school and 27 (30%) had completed secondary ed-ucation, which were the most common. In relation to underlying diseases, 48 (54%) had systemic ar-terial hypertension (SAH); 23 (25%) had diabetes mellitus (DM) and 19 (21%) had morbid obesi-ty, 33 (37%) were alcoholics and 32 (36%) were smokers. Regarding the diagnoses of diseases for surgical intervention, 23 (26%) had acute chole-cystitis; 21 (24%) had cholelithiasis, and 17 (19%) were diagnosed with obesity. In relation to degree of dependency, 81 (90%) patients were independent and nine (10%) were semi-dependent, requiring as-sistance with the sprinkler, support in walking and feeding, and care when leaving and returning to bed. The mean length of hospital stay in the post-operative period in the hospital was 13.71 days for seven (8.3%) patients who developed hospital SSI.

The SSI in the postoperative period in the hos-pital occurred in nine (10%) participants. The as-sociation of SSI with preoperative risk factors was interpreted by bivariate analysis (Table 1) with em-

phasis on the degree of dependency (χ2 = 6.049; p = 0.014) and admission to ICU after surgery (χ2 = 6.429; p = 0.011).

Differently from the postoperative period in the hospital, there was prevalence of SSI at home in 42 participants (46.7%) of the 90 interviewed. Through bivariate analysis, the association of SSI in

Table 1. Bivariate analysis between preoperative risk factors and presence/absence of SSI in the postoperative period in the hospital

Risk factors

Without SSI in the hospital

SSI in the hospital

Total

χ2 p-valuen = 81 (90)

n(%)n = 9 (10)

n(%)

n = 90 (100)n(%)

Gender

Male 18(22.2) 4(44.4) 22(24.4) 2.166 0.141

Female 63(77.8) 5(55.6) 68(75.6)

Underlying disease

Diabetes Mellitus

Yes 19(23.5) 4(44.4) 23(25.6) 1.875 0.171

No 62(76.5) 5(55.6) 67(74.4)

Smoker

Yes 27(33.3) 5(55.6) 32(35.6) 1.746 0.186

No 54(66.7) 4(44.4) 58(64.4)

Diagnosis of current disease

Cholelithiasis

Yes 21(25.9) 0(0) 21(23.3) 3.043 0.081

No 60(74.1) 9(100) 69(76.7)

Medications

Anxiolytic

Yes 17(21) 0(0) 17(100) 2.329 0.127

No 64(79) 9(100) 73(81.1)

Antihypertensive

Yes 49(60.5) 8(88.9 57(63.3) 2.812 0.094

No 32(39.5) 1(11.1) 33(36.7)

Antidiabetic

Yes 19(23.5) 4(44.4) 23(25.6) 1.875 0.171

No 62(76.5) 5(55.6) 67(74.4)

Anticoagulant

Yes 11(13,6) 3(33.3) 14(15.6) 2.406 0.121

No 70(86,4) 6(66.7) 76(84.4)

Invasive device

Peripheral venous catheter

Yes 40(49.4) 2(22.2) 42(46.7) 2.401 0.121

No 41(50.6) 7(77.8) 48(53.3)

Degree of dependency

Semi-dependent

6(7.4) 3(33.3)¥ 9(10) 6.049 0.014*

Independent 75(92.6)¥ 6(66.7) 81(90)

ICU admission

Yes 15(18.5) 5(55.6)¥ 20(22.2) 6.429 0.011*

No 66(81.5)¥ 4(44.4) 70(77.8)

n - %; ICU - Intensive Care Unit; χ2 - Chi-square; p - significance level; ¥ = Residual adjustment ≥ 2.0; *p ≤ 0.05

20 Acta Paul Enferm. 2017; 30(1):16-24.


Table 2 demonstrates that 33 (78.6%) par-ticipants with SSI in the postoperative period are adults, 20 (47.6%) live alone, 35 (83.3%) did not present cholelithiasis, 30 (71.4%) used gastric protection medication, and 38 (90.5%) did not use anticoagulants.

In the binary logistic regression, the crude anal-ysis shows that chances of patients presenting SSI in the postoperative period in the hospital according to preoperative risk factors are higher in semi-depen-dent patients (OR = 6.25 , 95% CI = 1.24 - 31.46) and admitted to the ICU (OR = 5.50, 95% CI = 1.32 - 22.98). The use of a peripheral venous cathe-ter (OR = 0.29, 95% CI = 0.06 - 1.50) was observed as a protective factor, that is, those who used this device had 29% less chance of developing SSI com-pared to patients who did not use it (Table 3).

In the adjusted analysis, no risk factors of the preoperative period influenced the onset of SSI.

the postoperative period at home and preoperative risk factors (Table 2) emphasized the category of living alone or not (χ2 = 13.448; p < 0.001) with significant difference.

Table 2. Bivariate analysis of modifiable preoperative risk factors and presence/absence of SSI in the postoperative period at home

Risk factors

Without SSI at home

SSI at home

Total

χ2 p-valuen = 48(53.3)

n(%)

n = 42(46.7)

n(%)

n = 90(100)n(%)

Age 5.382 0.068

Young adult 4(8.3) 0(0.0) 4(4.4)

Adult 29(60.4) 33(78.6) 62(68.9)

Elderly 15(31.3) 9(21.4) 24(26.7)

Living alone 13.448 < 0.001*

Yes 6(12.5) 20(47.6)¥ 26(28.9)

No 42(87.5) 22(52.4) 64(71.1)


1.957 0.162

Cholelithiasis

Yes 14(29.2) 7(16.7) 21(23.3)

No 34(70.8) 35(83.3) 69(76.7)

Medications 1.676 0.195

Gastric protection

Yes 28(58.3) 30(71.4) 58(64.4)

No 20(41.7) 12(28.6) 32(35.6)

Anticoagulant 2.181 0.140

Yes 10(20.8) 4(9.5) 14(5.6)

No 38(79.2) 38(90.5) 76(84.4)

n-%;χ2-Chi-square; p-significance level; ¥ - Residual adjustment ≥ 2.0; *p≤ 0.05

Table 3. Binary logistic regression analysis of preoperative risk factors in the presence of SSI in the postoperative period in the hospital

Risk factorsGross analysis Adjusted analysis

OR CI 95 OR CI 95

Gender

Male 2.80 0.68 - 11.53 4.95 0.65 - 37.58

Female 1.00 1.00

Underlying disease

Diabetes Mellitus

Yes 2.61 0.64 - 10.71 0.41 0.04 - 3.87

No 1.00 1.00

Smoker

Yes 2.50 0.62 - 10.07 3.84 0.56 - 26.27

No 1.00 1.00


Cholelithiasis

Yes 0.00 0.00 - 0.00 0.00 0.00 - 0.00

No 1.00 1.00

Medications

Anxiolytic

Yes 0.00 0.00 - 0.00 0.00 0.00 - 0.00

No 1.00 1.00

Antihypertensive

Yes 5.23 0.62 - 43.79 3.62 0.29 - 45.95

No 1.00 1.00

Antidiabetic

Yes 2.61 0.63 - 10.71 0.41 0.04 - 3.87

No 1.00 1.00

Anticoagulant

Yes 3.18 0.70 - 14.62 2.40 0.28 - 20.54

No 1.00 1.00

Invasive device

Peripheral venous catheter

Yes 0.29 0.06 - 1.50 0.08 0.007 - 0.98

No 1.00 1.00

Degree of dependency

Semi-dependent 6.25 1.24 - 31.46 7.40 0.63 - 87.00

Independent 1.00 1.00

ICU admission

Yes 5.50 1.32 - 22.98 1.44 0.22 - 9.27

No 1.00 1.00

OR - Odds Ratio; CI 95% - 95% Confidence Interval; Adjusted Analysis - All variables were introduced in the independent adjusted p-value model. The variables with p ≤ 0.200 remained in the adjusted model

However, patients who used a peripheral venous catheter as an invasive device had a protective factor (OR = 0.08; 95% CI = 0.007-0.98), that is, 8% less chance of developing SSI over those who did not use this invasive device (Table 3).

The binary logistic regression of the post-operative period at home, in the crude analysis, showed that by preoperative risk factors, the chances of developing SSI were higher for pa-tients living alone (OR = 6.36, 95% CI = 2 , 23 - 18,15), i.e., 6.3 times more opportunities of developing SSI than those who do not live

21Acta Paul Enferm. 2017; 30(1):16-24.


alone. In the adjusted analysis by preoperative risk factors, the chances of patients developing SSI in the postoperative period at home were also predominant in those living alone (OR = 8.32, 95% CI = 2.45 - 28.21). The risk factor of those diagnosed with cholelithiasis (OR = 0.30, 95% CI = 0.09 - 1.06) was evidenced as a protec-tive factor. In this case, patients diagnosed with cholelithiasis are 30% less likely to develop SSI in the postoperative period at home (Table 4).

tient Safety itself are the development of values that aim at communication improvement, information transparency, empowerment and patient participa-tion in health services.(12)

However, there are risk factors such as condi-tions or variables associated with the possibility of negative outcomes for the health and well-being that lead to the development of nosocomial infec-tions, in contrast to the commitment assumed by the WHO and the World Alliance for Patient Safe-ty. Among the factors related to patients, the most prevalent were: clinical conditions; advanced age; gender; housing situation; obesity; malnutrition; immunosuppression; smoking habit; alcoholism; medications and degree of dependency; prolonged preoperative period of hospitalization; and associat-ed diseases.(13,14)

In the present study, five (55.6%) of the partici-pants who presented SSI in the hospital setting were female. Thus, it was not possible to establish a re-lationship between gender and a higher probability of developing SSI, as in a study in which there was moderate prevalence of SSI in women undergoing cardiac surgeries.(15)

Regarding the prevalence of the female gender in the studied population, researchers revealed that men do not have the habit of seeking health services because of cultural, institutional and medical barri-ers. For them, the disease is not recognized as intrin-sic to their condition. On the other hand, they are usually affected by severe and chronic health condi-tions, and health programs with preventive actions are mostly still focused on the female population.(15)

DM, smoking, the use of antidiabetics and ad-mission to ICU in the immediate postoperative period are considered risk factors.(15,16,18) However, in this study, the difference was not significant to confirm that patients with these risk factors suffered more SSI than those who did not have them.

Although DM was not associated with the oc-currence of SSI in the hospital, this comorbidity contributes to the development of this type of hos-pital infection because it interferes in the phago-cytosis of white blood cells, increasing the suscep-tibility to infections, and therefore increasing the risk of SSI. According to recommendations for SSI

Table 4. Binary logistic regression analysis of preoperative risk factors in the presence of SSI with the risk factors of the postoperative period at home

Risk factorsGross analysis Adjusted analysis

OR CI 95 OR CI 95

Age

Young adult 0.00 0.00

Adult 1.90 0.00 - 0.00 3.64 0.00 - 0.00

Elderly 1.0 0.72 - 5.00 1.00 0.98 - 13.54

Living alone

Yes 6.36 2.23 - 18.15 8.32 2.45 - 28.21

No 1.0 1.00


Cholelithiasis

Yes 0.48 0.17 - 1.35 0.30 0.09 - 1.06

No 1.0 1.00

Medications

Gastric protection

Yes 1.78 0.74 - 4.31 2.28 0.80 - 6.45

No 1.0 1.00

Anticoagulant

Yes 0.40 0.11 - 1.39 0.60 0.13 - 2.82

No 1.0 1.00

OR - Odds Ratio; CI 95% - 95% Confidence Interval; Adjusted Analysis - All variables were introduced in the independent adjusted p-value model. The variables with p ≤ 0.200 remained in the adjusted model

The findings indicate that modifiable and non-modifiable variables related to the preoper-ative period for the development of SSI in the postoperative period in the hospital were: female gender, without DM as comorbidity, smoker, an-tihypertensive use, no use of peripheral venous catheter as invasive device, admission to ICU, and in relation to degree of dependency, being independent.

Discussion

Among the commitments of the World Health Or-ganization (WHO) and the World Alliance for Pa-

22 Acta Paul Enferm. 2017; 30(1):16-24.


prevention, it is essential to control serum levels of blood glucose in diabetic patients during the preop-erative period to avoid perioperative hyperglycemia.(19) To this end, measures of control and prevention are fundamental and related to the postoperative treatment. Health care programs are necessary to address the characteristic aspects of individuals af-fected by this underlying disease not only during hospitalization, since many postoperative compli-cations result from decompensation associated with this comorbidity.(20-22)

Regarding smoking habits, of the nine (10%) participants in the study who developed SSI in the hospital, five (55.6%) were smokers. Smoking has a vasoconstricting action that leads to a deficit in oxy-genation of tissues because of the gas exchange diffi-culty in the lungs, affecting the cicatricial process of the skin after surgical interventions, and resulting in SSI risk.(17,23)

Regarding the diagnosis of the disease for surgi-cal intervention, the presence of cholelithiasis was not considered a significant factor for SSI in the hospital setting, although it is a risk factor for SSI development because bacteria present in bile at the time of surgery are the main source of postoperative surgical infection.(24)

In the present study, eight (88.9%) participants using antihypertensive medication developed SSI, confirming the association of this drug with SSI, like findings of other studies.(24,25) This fact is jus-tified because SAH is an important element for the patient’s prognosis given the systemic conse-quence, resulting in renal and cardiovascular defi-cit, decreased peripheral arterial perfusion, besides interfering in the humoral and cellular immunity, collaborating for the appearance of SSI in the post-operative period in the hospital.

The peripheral venous catheter is installed when rapid and immediate action of medication is required. The intravenous infusion therapy is a set of knowledge and techniques for the administra-tion of solutions and medications in the circulatory system. In this study, of the 42 (46.7%) partici-pants who used this invasive device in the preop-erative period, two (22.2%) developed SSI in the postoperative period in the hospital. There was no

evidence that the presence of a peripheral venous catheter was a risk for SSI in the postoperative peri-od in the hospital, although this is known as a risk factor for hospital infection because of the required procedures with maintenance, salinization, chang-es and discard.(26) In view of the study results, using a peripheral venous catheter was considered a pro-tective factor in the development of SSI compared to those who did not use this device, considering this is a route of choice for prophylactic antibiot-ic therapy. Studies indicate that using prophylactic antibiotics in the preoperative period decreases the incidence of SSI.(24,27)

Dependency on nursing care predisposes to SSI in the hospital setting.(27) However, in this study, SSI occurred in six (66.7%) independent partici-pants, a fact corroborated by some studies.(21,23-25,28)

In the present study, five (55.6%) participants who needed ICU admission in the immediate postoperative period developed SSI. The fact of surgical patients admitted to ICU postoperatively developing SSI is justified by surgical stress due to the nature of the surgical procedure and clinical conditions.(29)

At times, there are short periods of manifes-tation depending on the SSI etiology, usually be-tween the fourth and the sixth postoperative day, requiring constant and effective surveillance during the hospitalization period. In other situations, the period is longer and according to the Center for Disease Control and Prevention (CDC) definition, SSI can occur within 30 or even 90 days of the procedure. Although the CDC recommends the expansion of monitoring after hospital discharge in surgical patients, because of specific factors in-herent to the surgical procedure and its condition, surveillance of these patients occurs only during the hospitalization period. Rates of SSI occurrence after hospital discharge range from 12 to 84%. In these cases, the lack of follow-up after hospital discharge generates underreported rates and, con-sequently, underestimation of the true incidence, impact and relevance of SSI.(30)

Regarding the postoperative period in the hos-pital, the surgery and monitoring of surgical pa-tients had considerable advances, reflecting in the

23Acta Paul Enferm. 2017; 30(1):16-24.


reduction of morbidity and mortality of these indi-viduals. However, many hospitals monitor surgical patients only during hospitalization, but the possi-bility of infection after hospital discharge cannot be discarded.(31)

In this study, there was SSI in the postoperative period at home given the aspects and characteristics of this infection reported by patients and/or family members at the time of the telephone interview. In a different study, 12% to 84% of SSI were diag-nosed in the post-discharge period, while in anoth-er study 25% of SSI were identified in the hospital setting and 75% at home.(6,31)

The association of preoperative risk factors with the occurrence of SSI in the postoperative period at home did not present relative risk for all the categories evaluated, except for the age factor (adults aged 24 to 59 years or older) and medi-cation use (gastric protector). In other studies, adulthood is also the most susceptible period to the development of SSI at home.(6,31) Regarding the association of gastric protection medication and the occurrence of SSI, there was no evidence in the literature studied. The condition of living alone was proven as a risk factor of greater chance for development of SSI in the postoperative period at home.

The association of living alone and the oc-currence of SSI at home was confirmed because people who live alone are 6.3 times more likely to develop SSI at home during this postoperative period than those who live with other people. The criterion of living alone may have been a risk factor, since people without a family mem-ber or caregiver in their home context are vul-nerable to postoperative care, thus increasing the probability of SSI.

Thus, the main contribution is the confirma-tion that SSI occurs at home and in people liv-ing alone, which can be seen as safety indicators that require continuity of care of high and me-dium complexity, and in primary care provided by nurses.

Some limitations of the study include reduced data collection period, study conducted only in a teaching health institution, and participants’ fol-

low-up in the postoperative period at home only by telephone contact.

Conclusion

The investigated risk factors indicate some aspects that should be evaluated in the perioperative con-text of potentially contaminated surgeries that require evaluation and the need to implement prevention and control measures. Accordingly, it is essential that professionals acquire knowl-edge about the inherent and extrinsic factors to patients that collaborate for infections. There are gaps related to the orientation to patients regard-ing home care, in the surgical site and health con-ditions, besides the surveillance and control since the preoperative period. Most factors involved in the pathogenesis of SSI are controllable with use of appropriate interventions, considered critical components of any patient safety program. Thus, it was possible to meet the objective of this study in view of the identification of risk factors for the occurrence of SSI in potentially contaminated surgeries, by the association and relationship of the established variables.

CollaborationsMartins T, Amante LN, Virtuoso JF, Girondi JBR, Nascimento ERP and Nascimento KC declare they have contributed to the project design, data analy-sis and interpretation, article writing, critical review of the intellectual content and final approval of the version to be published.

References

1. Brandão DE, Galvão CM. O estresse da equipe de enfermagem que atua no período perioperatório: revisão integrativa. Rev Rene. 2013; 14(4):836-44.

2. Marques PF, Bastos AQ, Souza RA, Souza FM. Reflections on nursing care in the pre-and postoperative period: an integrative literature review. Ciênc Cuid Saúde. 2013; 12(2):382-90.

3. Sasaki VD, Romanzini AE, Jesus AP, Carvalho E, Gomes JJ, Damiano VB. Vigilância de infecção do sítio cirúrgico no pós-alta hospitalar de cirurgia cardíaca reconstrutora. Texto Contexto Enferm. 2011; 20(2):328-32.

24 Acta Paul Enferm. 2017; 30(1):16-24.


4. Campos JA, Costa AC, Dessotte CA, Silveira RC. Produção científica da enfermagem de centro cirúrgico de 2003 a 2013. Rev SOBECC. 2015; 20(2):81-95.

5. Duarte MR, Chrizostimo, MM, Christovam BP, Ferreira SC, Souza DF, Rodrigues DP. Nursing practice on puerperal infection control: integrative review. J Nurs UFPE. 2014; 8(2):433-41.

6. Agência Nacional de Vigilância Sanitária. Cirurgias seguras salvam vidas. Brasília (DF): Agência Nacional de Vigilância Sanitária; 2009.

7. Batista TF, Rodrigues MC. Vigilância de infecção do sítio cirúrgico pós-alta hospitalar em hospital de ensino do Distrito Federal, Brasil: estudo descritivo retrospectivo no período 2005-2010. Epidemiol Serv Saude. 2012; 21(2):253-64.

8. Masukawa II, Vieira GB, Klein TR. Serviços de Controle de Infecção Hospitalar (SCIH/HU). Bol Epidemiol. 2014. 89p.

9. Ramos IC, Oliveira MA, Braga VA. Assistência de enfermagem no pós-operatório de transplante hepático: identificando diagnósticos de enfermagem. Ciênc Cuid Saúde. 2011; 10(1):116-26.

10. Faria PL. Perspectivas do direito da saúde em segurança do doente com base na experiência norteamericana. Rev Port Saúde Pública. 2010;(10):81-8.

11. Pina E, Ferreira E, Uva MS. Infecções associadas aos cuidados de saúde. In: Paulo SW, organizador. Segurança do paciente: conhecendo os riscos nas organizações de saúde. Rio de Janeiro: FIOCRUZ; 2014. 452p.

12. Nassar SM, Wronscki VR, Ohira M. et al. SEstatNet - Sistema Especialista para o Ensino de Estatística na Web [Internet]. [citado 2017 Jan 21]. Disponível em: http://sestatnet.ufsc.br.

13. Agência Nacional de Vigilância Sanitária. Segurança do paciente e qualidade em serviços de saúde. Brasília (DF): Agência Nacional de Vigilância Sanitária; 2011.

14. Ercole FF, Franco LM, Macieira TG, Wenceslau LC, de Resende HI, Chianca TC. Risk of surgical site infection in patients undergoing orthopedic surgery. Rer Lat Am Enfermagem. 2011; 19(6):1362-8.

15. Oliveira RS, Braga GF, Souza ML, Almeida EC, Oliveira JG, Azevedo NM. Homem gênero masculino: a busca dos serviços de saúde uma análise reflexiva da enfermagem. Rev Uniabeu. 2014; 7(17):107-24.

16. Lilienfield DE, Vlahov D, Tenney JH, McLaughlin JS. Obesity and diabetes as risk factors for postoperative wound infections after cardiac surgery. Am J Infect. Control. 1998; 16(1):3-6.

17. Rodrigues AE. Assistência de Enfermagem no pré e pós-Operatório Mediato ao utente em risco de desenvolver uma infecção do local cirúrgico.[Internet]. Portal do conhecimento. Jul; 2015. [citado 2017 Jan 29] Disponível em: http://hdl.handle.net/10961/4678.

18. Ferreira LG, Rosa ML, Meyuska MA, Santos SB, Aparecida PP. Tricotomia pré-operatória: aspectos relacionados à segurança do paciente. Enferm Global. 2014; (34):264-75.

19. Belusse GC, Ribeiro JC, Campos FR, Poveda VB, Galvão CM. Fatores de risco de infecção da ferida operatória em neurocirurgia. Acta Paul Enferm. 2015; 28(1):66-73.

20. Ahmed D, Cheema FH, Ahmed YI, Schaefle KJ, Azam SI, Sami SA, et al. Incidence and predictors of infection in patients undergoing primary isolated coronary artery bypass grafting: a report from a tertiary care hospital in a developing country. J Cardiovasc Surg (Torino). 2011; 52(1):99-104.

21. Magedanz EH, Bodanese LC, João Carlos Vieira da Costa Guaragna JC, Albuquerque LC et al. Risk score elaboration for mediastinitis after coronary artery bypass grafting. Rev Bras Cir Cardiovasc. 2010; 25(2):154-9.

22. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection. Am J Infect Control. 1999; 27(2):97-132; quiz 133-4; discussion 96.

23. Aguiar AP, Prado PR, Opitz SM, Vasconcelos SP, Faro AR. Fatores associados à infecção de sítio cirúrgico em um hospital na Amazônia ocidental brasileira. Rev SOBECC. 2012; 17(3):60-70.

24. Melo EM, Leão CS, Andreto LM, Mello MJ. Infecção cirúrgica em colecistectomia videolaparoscópica usando ácido peracético como esterilizante dos instrumentais. Rev Col Bras Cir. 2013; 40(3):208-14.

25. Silva QC, Barbosa MH. Fatores de risco para infecção do sítio cirúrgico em cirurgia cardíaca. Acta Paul Enferm. 2012; 25(2):89-95.

26. Moncaio AC, Figueiredo RM. Conhecimentos e práticas no uso do cateter periférico intermitente pela equipe de enfermagem. Rev Eletr Enferm. 2009; 11(3):620-27.

27. Lenza, M, Ferraz SB, Viola DC, Garcia Filho RJ, l. Epidemiologia da artroplastia total de quadril e de joelho: estudo transversal. einstein (São Paulo). 2013; 11(2):197-202.

28. Oliveira AC, Bettcher l. aspectos epidemiológicos da ocorrência do enterococcus resistente a vancomicina. Rev Esc Enferm USP. 2010; 44(3):725-31.

29. Guimarães RC, Rabelo ER, Moraes MA, Azzolin K. Everity of postoperative cardiac surgery Patients: na Evolution Analysis According to TISS-28. Rev Lat Am Enfermagem. 2010; 18(1):61-6.

30. Centers for Disease Control and Prevention (CDC). Procedure-associated Module SSI. Atlanta: CDC; 2016. 29p.

31. Oliveira AC, Ciosak SI. Infecção do sítio cirúrgico em hospital universitário: vigilância pós-alta e fatores de risco. Rev Esc Enferm USP. 2007; 41(2): 58-63.

25Acta Paul Enferm. 2017; 30(1):25-30.

Original Article

Visual acuity in the management of diabetes mellitus: preparation of the insulin dose

Acuidade visual no manejo do diabetes mellitus: preparo da dose de insulinaGerdane Celene Nunes Carvalho1

Roberto Wagner Júnior Freire de Freitas2

Márcio Flávio Moura de Araújo3

Maria Lúcia Zanetti4

Marta Maria Coelho Damasceno5

Corresponding authorMarta Maria Coelho DamascenoAlexandre Baraúna street, 949,60430-160, Fortaleza, CE, [email protected]


1Universidade Estadual do Piauí, Picos, PI, Brazil.2Fundação Oswaldo Cruz, Fortaleza, CE, Brazil.3Universidade da Integração Internacional da Lusofonia Afro-Brasileira, Acarape, CE, Brazil.4Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.5Faculdade de Farmácia Odontologia e Enfermagem, Universidade Federal do Ceará, Fortaleza, CE, Brazil.Conflicts of interest: no conflicts of interest to declare. *Article extracted from the Master’s thesis “Assessment of near visual acuity of people who prepare insulin doses”, presented and approved in the Graduate Nursing Program, Universidade Federal do Ceará, Fortaleza, CE, Brazil.

AbstractObjective: To assess the near visual acuity of people who prepare insulin doses.Methods: Cross-sectional study developed at 20 Primary Health Care services between April 2013 and January 2015. The convenience sample consisted of 65 diabetes mellitus patients and 35 caregivers responsible for preparing the insulin dose. A form was used with sociodemographic and clinical variables and the Jaeger eye chart.Results: The near visual acuity in the preparation of insulin doses was 40% lower in the patients and 20% in the caregivers. A statistically significant association was found between reduced near visual acuity and economic class (p=0.032) and age range (p=0.024) for patients, and reduced near visual acuity and age (p=0.024) for caregivers.Conclusion: The near visual acuity was compromised and specific protocols need to be constructed for use in Primary Health Care.

ResumoObjetivo: Avaliar a acuidade visual para perto das pessoas que preparam doses de insulina.Método: Estudo transversal, realizado em 20 Unidades Básicas de Saúde, no período de abril de 2013 a janeiro de 2015. A amostra por conveniência foi constituída por 65 pacientes com diabetes mellitus e 35 cuidadores responsáveis pelo preparo da dose de insulina. Utilizou-se um formulário contendo variáveis sociodemográficas e clínicas, e o cartão de Jaeger.Resultados: A acuidade visual para perto no preparo de doses de insulina estava diminuída em 40% nos pacientes e 20% nos cuidadores. Houve associação estatisticamente significante entre acuidade visual para perto diminuída e classe econômica (p=0,032) e faixa etária (p=0,024) para pacientes, e acuidade visual para perto diminuída e idade (p=0,024) para os cuidadores.Conclusão: A acuidade visual para perto esteve comprometida e há necessidade de construção de protocolos específicos que possam ser utilizados na Atenção Primária.

KeywordsVisual acuity; Diabetes mellitus; Insulin; Diabetes complications; Primary health

care

DescritoresAcuidade visual; Diabetes mellitus;

Insulina; Complicações do diabetes; Atenção primária à saúde

Submitted September 22, 2016


26 Acta Paul Enferm. 2017; 30(1):25-30.


Introduction

Diabetes mellitus patients’ compliance with the medication treatment has represented a problem in clinical practice and a challenge for health pro-fessionals.(1) In daily life, depending on the type of diabetes, the medication treatment can be oral or subcutaneous.

One of the factors that negatively affect the compliance is the error of patients or responsible caregivers when preparing the insulin dose. In that context, errors related to the medication, dose, time, administration route, action time and expiry are frequent.

What the use of insulin is concerned, additional errors are related to the dose preparation technique, administration and storage, ranging from the verifi-cation of the ideal temperature to apply the doses, the homogenization of the insulin without shaking it, the needle angle, waiting five seconds to withdraw the needle after applying the dose, among others.(2)

Particularly concerning the insulin preparation, among other errors, a mismatch is noticed between the prescribed and prepared doses, compromising the achievement of the desired glucose control.(3,4)

The lack of knowledge on the disease and of skills required to prepare insulin doses and the de-ficient near visual acuity can lead to the application of insufficient or excessive doses.

In clinical practice, the assessment of near visu-al acuity hardly ever precedes the teaching-learning process the nurse, patient or caregiver should par-ticipate in. The lack of this essential element com-promises the nurse’s clinical judgment and, conse-quently, decision making on the best conduct to respond to this therapeutic need.

In accordance with the safe preparation and ap-plication practices of insulin doses, this drug was included on the list of the five drugs that most provoke damage to adult and child patients, due to usage errors. In addition, being a narrow ther-apeutic index drug, excessive or insufficient doses can cause hyperglycemia or hypoglycemia, respec-tively.(5) These considerations highlight the impor-tance of assessing the near visual acuity before the start of the teaching-learning process, with a view to

guiding the actions involving insulin treatment and minimizing the risks of applying an incorrect dose.

In the literature, the various errors committed in the preparation of insulin doses are appointed but, as far as the probable causes are concerned, the decrease in near visual acuity is hardly mentioned.(3,6,7) Also regarding the theme, there is a lack of studies on the assessment of near visual acuity in Primary Health Care, evidencing knowledge gaps. Particularly the people who prepare the daily insu-lin dose need normal visual acuity to guarantee the accuracy of the prescribed dose. Based on the above, the objective in this study was to assess the near vi-sual acuity in the preparation of insulin doses.

Methods

Cross-sectional study developed at 20 Primary Health Care services reoriented and operated by the Family Health Strategy in the urban region of Picos (PI), in the State of Piauí, between April 2013 and January 2015.

The population consisted of diabetes mellitus patients. The inclusion criteria were: being regis-tered at the referred services; under monitoring in the Registration and Monitoring System of Hyper-tensive and Diabetic Patients (HIPERDIA); being ≥20 years; using insulin as continuing drug treat-ment; and preparing insulin doses.

The cut-off point in terms of age is justified when considering that the main cause of reduced visual acuity are refraction errors.(8) Patients using insulin pens and infusion pumps; patients whose dose was prepared and applied by a health profes-sional at the services; and patients who were not at home during the data collection period were ex-cluded from the sample.

The convenience sample consisted of 100 dia-betes mellitus patients. When considering the final inclusion criterion, however, we verified that, for 35 patients, a caregiver prepared the dose. Thus, the study sample consisted of 65 patients and 35 care-givers. For the purpose of the study, the sociode-mographic were selected (age, sex, education, pro-fessional activity, socioeconomic classification and

27Acta Paul Enferm. 2017; 30(1):25-30.

Carvalho GC, Freitas RW, Araújo MF, Zanetti ML, Damasceno MM

marital situation) and clinical variables (length of disease and glycated hemoglobin - A1c); variables related to the insulin therapy (type of syringe used, reuse of syringe and type of insulin used); and to the visual acuity (ophthalmological monitoring and level on the Jaeger card) were chosen for the diabe-tes mellitus patients who prepared the insulin doses; and socioeconomic (age and sex) and visual acuity (ophthalmological monitoring and level on the Jae-ger card) variables for the caregivers responsible for preparing the insulin doses.

The data were collected at home after the signing of the Free and Informed Consent Form. Initially, the form was applied to collect the sociodemographic and clinical variables of the diabetes mellitus patients and sociodemographic variables of the caregivers who prepared the insulin doses; next, a venous blood sample was collected for the A1c dosage. Previously hired specialized laboratory technicians collected the blood samples, complying with the sample preserva-tion and patient safety standards.

To assess the near visual acuity of the 65 diabe-tes mellitus patients and 35 caregivers, the Jaeger eye chart was used. It consists of optotypes: numbers 1 to 9 in increasing order of size, and the letter E in increasing order of size and in different directions (upwards, downwards, right, left). Each number (1 to 9) and letter (E) size corresponds to the letter J, scored as follows: J1, J2, J3, J4, J5 and J6, ac-cording to the increasing order of the optotypes and the equivalent distance of 0.37m, 0.50m, 0.67m, 0.75m, 1.00m and 1.25m, respectively.(9)

The card was placed at eye height at a distance of 35cm. First, the right eye was investigated, fol-lowed by the left and both eyes simultaneously. De-pending on the education level, the numbers 1 to 9 were appointed for reading, or the letter E in order to reproduce the position with the fingers.

As far as the interpretation of the results is concerned, for each letter J, there is an equiva-lent distance, using 20/40 (0.50m) as a parame-ter, which corresponds to J2. Thus, people clas-sified as level J1 or J2 were assessed with normal near visual acuity, while people with levels J3 to J6 or who could not see were considered as re-duced near visual acuity.

The data were exported to the statistical soft-ware Statistical Package for Social Science, ver-sion 20.0 for treatment to produce the results. For the inferential analyses of comparison of means, the Kruskal-Wallis test was used, and the qualitative variables were measured by means of the likelihood ratio, in order to associate the visual acuity with the age range and economic class. For all statistical tests, a first-rank error of 5% was adopted (p<0.05).

Approval for the study was obtained from the Ethics Committee for Research involving Human Beings at Universidade Estadual do Piauí, under opinion 901.145.

Results

What the preparation of the insulin dose is con-cerned, 35% indicated that it was prepared by a caregiver, 80% of the caregivers being women, with a mean age of 45 years and finished second-ary education (31.4%). To prepare the insulin doses, the diabetes mellitus patients and caregiv-ers used U-100 syringes with the needles attached and 72% reuse the syringe. Eighty percent used NPH insulin, 3% regular insulin and 15% both types of insulin.

Ophthalmological monitoring was found in 72.3% and 57.1% of the diabetes mellitus pa-tients and caregivers, respectively. The test using the Jaeger card evidenced reduced near visual acuity in 40% of the patients and 20% of the caregivers (Table 1).

Table 1. Visual acuity of patients (n=65) and caregivers (n=35) responsible for preparing the insulin doses

Visual acuityPatients Caregivers

n(%) n(%)

Both eyes J1 10(15.4) 17(48.6)

J2 29(44.6) 11(31.4)

J3 11(16.9) 5(14.2)

J4 6(9.2) 1(2.9)

J5 2(3.1) -

J6 3(4.6) -

Could not see 4(6.2) 1(2.9)

Total 65(100.0) 35(100.0)

28 Acta Paul Enferm. 2017; 30(1):25-30.


As regards the patients, a statistically significant association was found between reduced near visual acuity and economic class (p=0.032) and age range (p=0.024) (Table 2). Hence, the higher the percent-age of reduced near visual acuity, the lower the eco-nomic class and the higher the age.

With regard to the caregivers, a statistically sig-nificant association was found between reduced near visual acuity and age (p=0.024) (Table 3), showing a higher percentage of reduced visual acui-ty in older caregivers.

Discussion

The lack of literature limited the discussion of the study results. Therefore, further research on the theme is recommended to arouse the nurses’ need to question the near visual acuity of people who prepare insulin doses.

This study of diabetes mellitus patients assessed the near visual acuity in the preparation of insulin doses, considering that an appropriate sight for this

distance is one of the conditions needed to guarantee the accuracy of the dose that needs to be prepared. Nevertheless, the results have shown that, in 35% of the patients, caregivers prepared the dose, being mostly relatives. In daily care, it is common for a caregiver to prepare and apply the insulin doses.(10) This dependence, which is frequently observed in clinical practices, means a lack of competence for self-care, represented by factors like reduced visu-al acuity, commitment of motor function, lack of compliance with medication treatment and partic-ularities of the insulin syringe.(1,10-12)

The percentage of patients and caregivers who prepared insulin doses and revealed reduced near visual acuity in this study was similar to the find-ings in a study involving a population of elderly di-abetes mellitus patients.(7,13) A study has shown that patients on insulin aspire a dose different from the prescription due to difficulties to see the quantity of the drug in the syringe.(3,13)

The types of syringes and needles in the mar-ket to prepare insulin doses are made of plastic. Although indicated for single use, the reuse is recommended in clinical practice.(14) The total capacity ranges between U-30, U-50 and U-100, and the needles can be fixed or not, besides pre-senting marks along the body of the syringe. According to the capacity of the syringe, each mark represents one unit (syringes of U-30 and U-50) and two units (U-100).(15) Part of these particularities, in combination with the reduced near visual acuity, can favor errors related to the preparation of the insulin dose, mainly in case of uneven doses in U-100 syringes. In addition, for

Table 2. Association of near visual acuity with economic class and age of patients who prepare insulin doses (n= 65)

Variables

Both eyes

p-value*J1 J2 J3 J4+

n(%) n(%) n(%) n(%)

Economic class A - 2(33.3) 2(33.3) 2(33.3)

0.032B 3(18.8) 10(62.5) 2(12.5) 1(6.3)

C 7(23.3) 8(26.7) 7(23.3) 8(26.7)

D or E - 9(69.2) - 4(30.8)

Age 22 - 32 3(100.0) - - -

0.024

33 - 43 4(44.4) 2(22.2) 1(11.1) 2(22.2)

44 - 54 1(7.1) 8(57.1) 1(7.1) 4(28.6)

55 - 65 2(9.5) 11(52.4) 4(19.0) 4(19.0)

66 - 76 - 7(43.8) 4(25.0) 5(31.2)

>77 - 1(50.0) 1(50.0) -

*p-value related to likelihood ratio

Table 3. Association between visual acuity and age range of caregivers who prepare insulin doses (n= 35)

Sociodemographic characteristics

Jaeger - both eyes

p-value*J1 J2 J3 J4+

n(%) n(%) n(%) n(%)

Age 21 - 31 5(62.5) 2(25.0) 1(12.5) -

0.024

32 - 42 7(77.8) 2(22.2) - -

43 - 53 4(50.0) 3(37.5) 1(12.5) -

54 - 64 1(14.3) 3(42.9) 3(42.9) -

>65 - 1(33.3) - 2(66.7)

*p-value related to likelihood ratio

29Acta Paul Enferm. 2017; 30(1):25-30.

Carvalho GC, Freitas RW, Araújo MF, Zanetti ML, Damasceno MM

people who prepare regular and NPH insulin in the same syringe, the possibility of these errors increases. The reuse of syringes also facilitates the disappearance of the marks printed on the body of the syringe and favors differences be-tween the prescribed and the aspired doses.

Appropriate technologies exist nowadays to help people with reduced near visual acuity, such as magnifiers which, when placed on the body of the syringe, serve as magnifying lenses, making it easier to see the marks.(3)

The visual acuity tests are examples of tools that should be part of problem prevention actions, per-mitting the early identification of visual problems. In this study, the Jaeger test was used, which the nurse can apply, who should read it to support the diagnosis.(15) Any abnormalities identified define the Family Health team’s priorities to forward the per-son to the ophthalmologist.

Particularly concerning the eye health of people who prepared insulin doses, the Primary Health Care professionals should also monitor compliance with ophthalmological monitoring in accordance with established protocols.(16) In this study, considerable amounts of patients are caregivers were registered who were being moni-tored by an ophthalmologist, in accordance with the relevant literature.(17) On the other hand, the patients forwarded do not always attend the ophthalmological appointments, representing yet another case of lack of treatment compliance and self-neglect.(16)

The reduced near visual acuity of people who wore glasses underlines the importance of ophthal-mological monitoring, as the prescription of cor-rective lenses reduced the prevalence of decreased visual acuity.(8)

The statistically significant association found between reduced near visual acuity, age and eco-nomic class for patients is supported by other stud-ies. The speed of the visual problems is directly re-lated with the age, and the easy access to ophthal-mological services depends on the socioeconomic conditions.(16,18,19)

As the entry door to Primary Health Care, the Family Health Strategy is a health care model based

on longitudinality and care integrality, favoring the autonomy of individuals, families and groups to practice care and self-care in accordance with the potentials and limitations of each.(20,21) The identifi-cation of people who prepare insulin doses despite their reduced near visual acuity reveals the extent of a problem that can contribute to increase the preva-lence of diabetes mellitus complications, comorbidi-ties, mortality rates and costs for the Unified Health System.

The Jaeger eye chart is a tool that can be used in Primary Health Care to assess the near visual acuity, due to its easy use and low cost. The nurses working in the Family Health Strategy are also responsible for channeling efforts to offer dose magnifiers to people diagnosed with deficient near visual acuity, as well as to monitor the attendance to ophthalmo-logical appointments.

Conclusion

The near visual acuity was reduced in a consid-erable number of patients with diabetes melli-tus and in the caregivers who prepared insulin doses. A statistically significant association was found between reduced near visual acuity and economic class and age range for the patients, and reduced near visual acuity and age for the caregivers. These results are relevant for nursing practice, as they show the need to construct spe-cific protocols to assess near visual acuity that can be used in Primary Health Care. Thus, nurs-es can start the teaching-learning process on the preparation of insulin doses based on clinical judgment for decision making, with a view to empowering the patient or caregiver.

CollaborationsFreitas RWJF, Araújo MFM and Zanetti ML declare that they contributed to the writing of the article, relevant critical review of the intellectual content and final approval of the version for publication. Carvalho GCN and Damasceno MMC collaborat-ed with the conception of the study, analysis, inter-pretation of the data, writing of the article, relevant

30 Acta Paul Enferm. 2017; 30(1):25-30.


critical review of the intellectual content and final approval of the version for publication.

References

1. Boas LC, Foss MC, Freitas MC, Pace AE. [Relationship among social support, treatment adherence and metabolic control of diabetes mellitus patients]. Rev Lat Am Enfermagem 2012; 20(1): 52-8. Portuguese.

2. Stacciarini TS, Pace AE, Haas VJ. [Insulin self-administration technique with disposable syringe among patients with diabetes mellitus followed by the family health strategy]. Rev Lat Am Enfermagem. 2009; 17(4):474-80. Portuguese.

3. Stacciarini TS, Caetano TS, Pace AE. [Prescribed insulin dose versus prepared insulin dose]. Acta Paul Enferm. 2011; 24(6):789-93. Portuguese.

4. Milligan FJ, Krentz AJ. Sinclair AJ. Diabetes medication patient safety incident reports to the National Reporting and Learning Service: the care home setting. Diabet Med. 2011; 28(12):1537-40.

5. Sociedade Brasileira de Diabetes (SBD). Diretrizes da Sociedade Brasileira de Diabetes. São Paulo: A.C Farmacêutica; 2016.

6. Peyrot M, Barnett AH, Meneghini LF, Schumm-Draeger PM. Insulin adherence behaviours and barriers in the multinational Global Attitudes of Patients and Physicians in Insulin Therapy study. Diabet Med. 2012; 29(5):682-9.

7. Marques MB, Silva MJ, Coutinho JF, Lopes MV. [Assessment of self-care competence of elderly people with diabetes]. Rev Esc Enf USP. 2013; 47(2);415-20. Portuguese.

8. Kyari F, Tafida A, Sivasubramaniam S, Murthy GV, Peto T, Gilbert CE. Prevalence and risk factors for diabetes and diabetic retinopathy: results from the Nigeria national blindness and visual impairment survey. BMC Public Health. 2014; 14: 1299.

9. Jarvis C. Exame físico e avaliação de saúde para a enfermagem. 6ª ed. Rio de Janeiro: Elsevier; 2012.

10. Batista JM, Becker TA, Zanetti ML, Teixeira CR. [Group teaching of the insulin application process]. Rev Eletr Enf. 2013; 15(1):71-9. Portuguese.

11. Daien V, Peres K, Villain M, Colvez A, Carriere I, Delcourt C. Visual acuity thresholds associated with activity limitations in the elderly. The Pathologies Oculaires Liées à l’Age study. Acta Ophathalmologica. 2014; 92 Suppl 7:500-6.

12. Wisnesky UD, Azevedo SL, Barga AL, Carvalho CA, Cunha MA. [Insulin therapy: the reuse of disposable syringes by diabetic patients]. Perspectivas Médicas. 2014; 25(2):5-12, 2. Portuguese.

13. Jannuzzi FF, Cintra FA, Rodrigues RC, São-João TM, Gallani MC. [Medication adherence and quality of life among the elderly with diabetic retinopathy]. Rev Lat Am Enfermagem. 2014; 22(6):902-10. Portuguese.

14. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Estratégias para o cuidado da pessoa com doença crônica: diabetes mellitus. Brasília (DF): Ministério da Saúde; 2013. Caderno de Atenção Básica; 36.

15. Conselho Regional de Enfermagem de São Paulo (COREN-SP). Parecer Coren-SP 026/2014 - CT. Competência dos profissionais de Enfermagem para realização de testes de acuidade visual e exames oftalmológicos. São Paulo: COREN/SP; 2014.

16. Sheppler CR, Lambert WE, Gardiner SK, Becker TM, Mansberger SL. Predicting Adherence to Diabetic Eye Examinations. Ophthalmogy. 2014; 121(6):1212-9.

17. Borrelli M, Rehder JR, Squarcino IM, Gonçalves AM, Piaia FA, Fernandes PK. [Evaluation of the quality of vision in daily reading habits in relation to text configuration]. Rev Bras Oftalmol. 2010; 69(2):1-7. Portuguese.

18. Fung MM, Yap MK, Cheng KK. Correctable visual impairment among people with diabetes in Hong Kong Fung, Yap and Cheng Visual impairment in Hong Kong diabetic patients. Clin Exp Optom. 2010; 93(6):453-7.

19. Robinson B, Feng Y, Woods CA, Fonn D, Gold D, Gordon K. Prevalence of visual impairment and uncorrected refractive error - report from a Canadian urban population-impairment based study. Ophthalmic Epidemiol. 2013; 20(3):123-30.

20. Damasceno MM, Zanetti ML, Carvalho EC, Teixeira CR, Araújo MF, Alencar AM. [Therapeutic communication between health workers and patients concerning diabetes mellitus care]. Rev Lat Am Enfermagem. 2012; 20(4):1-8. Portuguese.

21. Bozorgmehr K, Szecsenyi J, Ose D, Besier W, Mayer M, Krisam J, et al. Practice network-based care management for patients with type 2 diabetes and multiple comorbidities (GEDIMAplus): study protocol for a randomized controlled trial. BioMed Central. 2014; 15: 243.

31Acta Paul Enferm. 2017; 30(1):31-8.

Original Article

Nursing workload related to the body mass index of critical patients

Carga de trabalho de enfermagem relacionada ao índice de massa corporal de pacientes críticos

Luana Loppi Goulart1

Fernanda Souza Angotti Carrara2

Suely Sueko Viski Zanei1

Iveth Yamaguchi Whitaker1

Corresponding authorIveth Yamaguchi WhitakerNapoleão de Barros street, 754, 04024-002, São Paulo, SP, [email protected]


1Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil.2Associação Paulista para o Desenvolvimento da Medicina, São Paulo, SP, Brazil.Conflicts of interest: there are no conflicts of interest to declare.

AbstractObjective: To measure and compare the nursing workload and the frequency of the items scored in the Nursing Activities Score (NAS) considering the different groups of BMI of patients hospitalized in Intensive Care Units (ICU).Methods: Longitudinal study conducted in the ICU of a university hospital in São Paulo in which the BMI of patients was calculated by dividing the weight by the square of the height and the nursing workload was measured through the NAS.Results: Analysis of 529 patients showed that the NAS did not differ between the groups according to the BMI. Obese patients demanded more time for hygiene procedures and more people to support the mobilization/positioning process. Underweight patients received treatment for improving lung function with a higher frequency.Conclusion: The results showed no difference in the nursing workload when the BMI of the patient was considered.

ResumoObjetivo: Mensurar e comparar a carga de trabalho de enfermagem e a frequência dos itens pontuados no Nursing Activities Score (NAS), considerando os diferentes grupos de IMC de pacientes internados em Unidade de Terapia Intensiva (UTI).Métodos: Estudo longitudinal realizado na UTI de hospital universitário em São Paulo, na qual o IMC do paciente foi calculado dividindo-se o peso pelo quadrado da altura e a carga de trabalho de enfermagem foi mensurada pelo NAS.Resultados: A análise de 529 pacientes mostrou que o NAS não diferiu entre os grupos conforme o IMC. Os pacientes obesos demandaram mais tempo para o procedimento de higienização e maior número de pessoas para mobilização/posicionamento. Pacientes de baixo peso receberam mais frequentemente tratamento para melhora da função pulmonar.Conclusão: Os resultados não apontaram diferença na carga de trabalho de enfermagem quando se considerou o IMC do paciente.

KeywordsIntensive care units; Workload; Body

mass index; Obesity; Nursing care

DescritoresUnidades de terapia intensiva; Carga

de trabalho; Índice de massa corporal; Obesidade; Cuidados de enfermagem

Submitted September 22, 2016


32 Acta Paul Enferm. 2017; 30(1):31-8.


Introduction

It is necessary to consider the various aspects relat-ed to the available therapeutic resources, compe-tency, and dimensioning of the multidisciplinary team in order to meet the needs of patients hos-pitalized in the Intensive Care Unit (ICU) with safety and quality.

In the nursing team the inappropriate propor-tion of nurses/technicians per patient may result in a high rate of absenteeism due to work overload and health impairment, possibly affecting hospital costs.(1) Dimensioning the nursing team according to the needs of patients is not an easy task, and the use of an instrument to measure the workload may support nurses in this process. Studies on nursing workload and demand of care in ICU have point-ed out the Nursing Activities Score (NAS) as a re-liable tool.(2-4)

The NAS was developed in order to define the nursing activities that best describe the workload of nurses in an ICU. It consists of seven major categories: basic activities; ventilatory; cardiovas-cular; renal; neurological; and metabolic supports, as well as specific interventions, totaling 23 items. The application of the NAS aims to measure the time required to perform the nursing activities during patient care within a 24-hour period, to-taling a maximum score of 176.8%, representing the time spent by the nursing team in patient care per shift.(2)

The NAS was translated and validated in Brazil-ian Portuguese(3) and since then a number of Brazil-ian publications have emerged regarding its perfor-mance, considering the clinical and demographic profiles, the severity of illness and organ dysfunc-tion scores, mortality, and length of stay of patients hospitalized in the ICU(5-8) The results of the inte-grative review that analyzed the application of the NAS in the ICU, considering the organization of health care, evidenced its dissemination through-out the world. It also pointed out the variables with which the NAS was confronted in analyzing the nursing workload in intensive care environments. The studies selected for this review included, with a higher frequency, the variables related to the char-

acteristics of patients (age and gender), the clinical conditions (severity of illness, organ dysfunction, risk of mortality, and risk of pressure injury), con-ditions of the unit (including type of ICU, propor-tion of nurses/technicians per patient, and occupa-tion rate), and the outcome (mortality and length of stay). In addition, the importance of exploring the use of the NAS with a view to the analysis of the care process, costs management, and care quality(9) was emphasized.

The nursing team has pointed to patient obe-sity among the factors related to the increased workload. Obese patients may be hospitalized in the ICU due to their comorbidities or other health problems. Regardless of the factors related to the impairment of the clinical condition of obese pa-tients in the ICU, complaints by the nursing team pointed out that this type of patient demands more time and a higher number of professionals for mobilization, whether during bathing or mo-bilization/positioning.

Thus, considering that the nursing team points out the high demand for care of an obese patient and the scarcity of studies assessing the relationship between Body Mass Index (BMI) and the nursing workload in the ICU, this study intends to analyze to what extent the BMI of the patient may result in nursing team work demand. Therefore, this study aims to measure and compare the nursing work-load and the frequency of the items scored in the NAS considering the different groups of BMI of ICU patients.

The results are expected to support nurses in the dimensioning of nursing staff according to the demand for care of patients when consider-ing their BMI in the daily routine of the clinical practice.

Methods

Descriptive, longitudinal study with a quantitative approach to analyze the relationship between nurs-ing workload and BMI.

This study is supplementary to the research: “Obesity in intensive care unit patients: character-

33Acta Paul Enferm. 2017; 30(1):31-8.

Goulart LL, Carrara FS, Zanei SS, Whitaker IY

ization and analysis of morbidity,” conducted in the Intensive Care Center (ICC) of the Universi-ty Hospital at the Federal University of São Paulo (HU/UNIFESP). The ICC consists of two general ICUs and one neurological ICU, totaling 35 beds for adult patients. The present study was approved by the Research Ethics Committee of UNIFESP (CEP-CAAE: 37296914.4.0000.5505) in compli-ance with national and international ethics stan-dards for research involving human beings.

The sample consisted of 529 patients includ-ed in the previously mentioned primary study on obesity in the ICU within the period between May and November 2012. These patients were selected according to the following inclusion criteria: length of stay >24 hours; both genders; and age equal or superior to 18 years, as it was an ICC for adults. Minimum length of stay of 24 hours in the ICU was adopted due to the need to collect data on the scores of organ dysfunction and nursing workload measured applying the Sequential Organ Failure Assessment (SOFA)(10) and the Nursing Activities Score (NAS), respectively. Pregnant patients, pa-tients with ascites, patients diagnosed with brain death at admission, and patients who were ICU readmission were not included in the study. The criterion of excluding patients readmitted to the ICU was considered in order to avoid selection bias. Measurements of anthropometric data, severity of illness, and organ dysfunction are not conducted in patients with brain death admitted to the ICU. The specific goal is maintenance until the retrieval of organs; therefore, they were not included in the sample of this study.

The nursing workload was measured applying the NAS; the scores were calculated per patient and per day of hospitalization, resulting in a final score of the length of stay of the patient in the ICU. In this study the analysis of the workload was conducted consider-ing the frequency with which each item of the NAS was scored. The first 24 hours and the discharge of the patient from the ICU were considered, as in these two different moments the demand of care required by the patient is different, possibly allowing the ob-servation of the impact of the BMI, particularly in the execution of nursing interventions.

The BMI of each patient calculated in the prima-ry study was considered for analysis. The classifica-tion of individuals according to body weight is based on the BMI, one of the measures widely used to esti-mate the body fat percentage for anthropometric-nu-tritional assessment of the population. It is obtained through calculation of the weight in kilograms (kg) divided by the square of the height in meters (m2). The patients’ weight was collected in their medical records, preferably the weight measured at the mo-ment of their admission at the hospital. Preoperative weight was considered for surgical patients without these data. For the others, the study considered the weight recorded in the ICU during the first 24 hours of hospitalization through the use of the Jack 150 de-vice, a lift system with a digital dynamometer, model IWB 500, with a capacity of 150 kg. The height was obtained from the patient’s medical record, routinely measured at the moment of admission of the patient to the ICU and performed through the use of an an-thropometric rule.

The BMI was classified for analysis according to the tables provided by the World Health Organi-zation (WHO).(11) Therefore, patients presenting a BMI <18.5 kg/m2 were considered as underweight, while patients presenting a BMI between 18.5 and 29.9 kg/m2 were considered normal and pre-obese, and BMI ≥30 kg/m2 were considered obese.

The variables age, gender, origin, admission cat-egory, length of ICU stay, ICU discharge, the index-es Simplified Acute Physiology Score 3 (SAPS 3),(12) calculated with data from the first hour of hospi-talization of the patient in the ICU, and SOFA(10) admission and discharge were obtained for charac-terization of the sample.

Data for analysis were entered in an electron-ic spreadsheet using Microsoft Office Excel. Mean, standard deviation, median, minimum, and maxi-mum values were calculated for the continuous vari-ables (age, length of ICU stay, SAPS 3, SOFA ad-mission and discharge, and NAS). Relative frequency was calculated for the categorical variables (gender, origin, type of patient, ICU outcome, and BMI).

Variance analysis (ANOVA) was used to compare the groups of BMI with the continuous variables. Chi-squared test or Likelihood Ratio test were used for

34 Acta Paul Enferm. 2017; 30(1):31-8.


comparison with the categorical variables. The ANO-VA for repeated measures with segmented factors was used for comparison of the groups of BMI considering the NAS scores and the length of stay. A level of signif-icance of 5% (p<0.05) was adopted in all of the tests.

Results

The sample consisted of 529 patients: 50.7% were male, with a mean age of 59.5 years (SD=18.3), from the Operating Room (64.1%) and the Emergency

Department (24%). The mean length of ICU stay was 7.3 days (SD=9.2). Most patients presented with a surgical diagnosis 48.6% for elective and 15.9% for emergency surgery, the other 35.5% were medi-cal. The mortality rate in the sample was 12.5%. The mean value of the SAPS 3 was 44.2 (SD=15.4), the SOFA admission was 3.5 (SD=3.1), and the SOFA discharge was 2.2 (SD=3.8). The mean value for the workload measured by the NAS was 64.5% (SD=8.2).

Table 1 presents data of the groups according to the BMI; underweight patients representing 6.4%, normal weight and pre-obese 73.7%, and obese

Table 1. Demographic, hospitalization, and clinical variables according to the groups of Body Mass Index (underweight, normal weight/pre-obese, obese)

Variables

Body Mass Index

Total p-value

Underweight(<18.5)

Normal/pre-obese(≥18.5 and <30)

Obese(≥30)

Age

Mean (SD*) 57.2(22.3) 60.2(18.3) 57.8(16.9) 59.5(18.3) 0.366†

Median 57.5 61 59 60

Minimum-Maximum 21-96 19-98 22-91 19-98

Gender - n(%)

Female 18(52.9) 181(46.4) 62(59.0) 261(49.3) 0.065‡

Male 16(47.1) 209(53.6) 43(41.0) 268(50.7)

Discharge - n(%)

Discharged alive 26(76.5) 342(87.7) 95(90.5) 463(87.5) 0.098‡

Death 8(23.5) 48(12.3) 10(9.5) 66(12.5)

Length of ICU stay

Mean (SD*) 7.0(7.7) 7.5(9.5) 6.8(8.2) 7.3(9.2) 0.736 †

Median 5 4 4 4

Minimum-Maximum 1-39 1-114 1-47 1-114

Admission category - n(%)

Elective surgery 15(44.1) 190(48.7) 52(49.5) 257(48.6) 0.882‡

Emergency surgery 7(20.6) 63(16.2) 14(13.3) 84(15.9)

Medical 12(35.3) 137(35.1) 39(37.2) 188(35.5)

SAPS 3§

Mean (SD*) 48.4(16.5) 44.2(15.0) 42.5(16.5) 44.2(15.4) 0.147†

Median 50 43 40 43

Minimum-Maximum 19-90 16-93 16-84 16-93

SOFA|| admission

Mean (SD*) 3.7(3.1) 3.5(3.1) 3.5(3.4) 3.5(3.1) 0.912†

Median 3 3 2 3

Minimum-Maximum 0-11 0-18 0-13 0-18

SOFA|| discharge

Mean (SD*) 2.5(3.9) 2.3(3.8) 2.0(3.7) 2.2(3.8) 0.709 †

Median 1 1 1 1

Minimum-Maximum 0-15 0-20 0-19 0-20

NAS

Mean (SD*) 64.4(8.4) 64.2(7.9) 65.3(9.1) 64.5(8.2) 0.467 †

Median 65.3 63.4 64.0 63.6

Minimum-Maximum 47.7-77.5 45.4-93.9 47.0-103.2 45.4-103.2

*SD - Standard deviation; †Analysis of Variance (ANOVA); ‡Chi-squared test; §Simplified Acute Physiology Score 3; ||Sequential Organ Failure Assessment

35Acta Paul Enferm. 2017; 30(1):31-8.


19.9%. Considering the previously mentioned de-mographic, clinical, hospitalization, and workload variables no statistical differences were observed be-tween the three groups of BMI.

The data in table 2 show that the mean NAS values in the three groups of BMI in two different moments, whether in the admission or in the dis-charge of patients in ICU, were not statistically dif-ferent. Based on this finding the NAS scores during admission were used to verify which items of this scale were selected to define the nursing workload according to the BMI of the patient considering the variety of nursing interventions performed at this moment.

Table 2. Values of the Nursing Activities Score at admission and discharge of patients according to the Body Mass Index (underweight, normal weight/pre-obese, obese)

Variables

Body Mass Index

Total p- value‡Underweight(<18.5)

Normal/pre-obese

(≥18.5 and <30)

Obese(≥30)

NAS* admission 0.802

Mean (SD†) 79.7(5.6) 78.9(6.4) 79.1(7.6) 78.0(6.6)

Median 77.8 77.8 77.1 77.8

Minimum-Maximum 65.8-89.6 65.8-100.5 67.2-111.9 65.8-111.9

NAS* discharge 0.954

Mean (SD†) 68.7(8.7) 68.9(8.0) 68.9(8.2) 68.9(8.8)

Median 68.3 67.2 68.2 67.9

Minimum-Maximum 58.2-88.3 46.1-103.3 58.2-97.0 46.1-103.3

*NAS - Nursing Activities Score; †SP - Standard deviation; ‡ ANOVA - Analysis of variance

The items scored with higher frequency by the NAS in the first day of hospitalization, with per-centages between 95-100%, were: 1b - Presence at bedside and continuous observation or active for two hours or more during a shift, 2 - Laboratory investigations 3 - Medication, 4a - Performing hy-giene procedures, 7a - Support and care for patients and their families, 8b - Performing management and administrative tasks requiring full dedication for about two hours, 17 - Quantitative urine out-put measurement.

Table 3 shows the items scored in the NAS according to the BMI of patients in the first day in the ICU. The items that indicated statistical differences among the groups of patients accord-ing to the BMI were: 4b - Performing hygiene procedures for more than two hours in a shift (p=0.037), 6c - Performing procedure(s) with

Table 3. Comparison of the frequency of the items scored in the Nursing Activities Score in the first day of hospitalization with the groups of Body Mass Index (low weight, normal weight/pre-obese, obese)

Variables

Body Mass Index

p-valueUnderweight

(<18.5)

Normal/pre-obese

(≥18.5 and <30)

Obese(≥30)

n(%) n(%) n(%)

1-Monitoring and controls

1a - 3(0.8) - 0.399*

1b 34(100.0) 382(97.9) 104(99.0) 0.396*

1c - 5(1.3) 1 (1.0) 0.644*

2-Laboratory investigations

Yes 34(100.0) 390(100.0) 105(100.0) -

No - - -

3-Medication Yes 34(100.0) 390(100.0) 105(100.0) -

No - - -

4-Hygiene procedures

4a 34(100.0) 387(99.2) 101(96.2) 0.071*

4b - 2(0.5) 4(3.8) 0.037*

4c - 1(0.3) - 0.737*

5-Care of drain Yes 29(85.3) 328(84.1) 91(86.7) 0.807†

No 5(14.7) 62(15.9) 14(13.3)

6-Mobilization and positioning

6a 4(11.8) 65(16.6) 15(14.3) 0.666*

6b 30(88.2) 322(82.6) 84(80.0) 0.542*

6c - (-) 3(0.8) 6(5.7) 0.007*

7-Support and care for patients and their families

7a 34(100.0) 390(100.0) 105(100.0) -

7b - - -

8-Management and administrative tasks

8a - - - -

8b 34(100.0) 390(100.0) 105(100.0)

8c - - -

9-Respiratory support

Yes 29(85.3) 337(86.4) 88(83.8) 0.791†

No 5(14.7) 53(13.6) 17(16.2)

10- Care of artificial airway

Yes 12(35.3) 138(35.4) 31(29.5) 0.527†

No 22(64.7) 252(64.6) 74(70.5)

11-Treatment for improving lung function

Yes 17(50.0) 170(43.6) 33(31.4) 0.047†

No 17(50.0) 220(56.4) 72(68.6)

12-Vasoactive medication

Yes 16(47.1) 140(35.9) 43(41.0) 0.319†

No 18(52.9) 250(64.1) 62(59.0)

13-Intravenous replacement of large fluid losses

Yes 4(11.8) 43(11.0) 9(8.6) 0.748†

No 30(88.2) 347(89.0) 96(91.4)

14- Left atrium monitoring

Yes 1(2.9) 10(2.6) 2(1.9) 0.907*

No 33(97.1) 380(97.4) 103(98.1)

15-Cardiopulmonary resuscitation

Yes - 1(0.3) 1 (1.0) 0.584*

No 34 (100.0) 389 (99.7) 104 (99.0)

16-Hemofiltration techniques

Yes - 1(0.3) - 0.737*

No 34(100.0) 389(99.7) 105(100.0)

17-Quantitative urine output measurement

Yes 34(100.0) 390(100.0) 105(100.0) -

No - - -

18-Measurement of intracranial pressure

Yes 2(5.9) 23(5.9) 5(4.8) 0.904†

No 32(94.1) 367(94.1) 100(95.2)

19-Complicated metabolic acidosis/alkalosis treatment

Yes 1(2.9) 6(1.5) 4(3.8) 0.374†

No 33(97.1) 384(98.5) 101(96.2)

20-Intravenous hyperalimentation

Yes 1 (2.9) - (-) - (-) 0.063*

No 33(97.1) 390(100.0) 105(100.0)

21-Enteral feeding Yes 5(14.7) 60(15.4) 12(11.4) 0.594†

No 29(85.3) 330(84.6) 93(88.6)

22-Specific interventions in the unit

Yes 7(20.6) 51(13.1) 14(13.3) 0.470†

No 27(79.4) 339(86.9) 91(86.7)

23-Specific interventions outside the unit

Yes 8(23.5) 89(22.8) 25(23.8) 0.975†

No 26(76.5) 301(77.2) 80(76.2)

*Likelihood ratio; †Chi-Square

36 Acta Paul Enferm. 2017; 30(1):31-8.


sults were observed in Italian ICUs.(17) However, differences in the NAS mean values were observed in studies conducted in Norway, where a higher mean value was obtained (96.2%),(18) and Belgium, with a lower mean value than those observed in the Brazilian studies (54.7%).(19)

The NAS is an instrument that enables the anal-ysis of the nursing workload in ICUs considering the variety of factors related to patient care. The dissemination of studies about the workload mea-sured with the use of the NAS in different critical adult populations was observed, and their results were compared to the results found in this study.(9) However the scarcity of studies analyzing the im-pact of the body mass of the patient in the nursing workload hindered the comparison and analysis of the results observed in this study.

In a study that compared the nursing work-load generated in Brazilian ICUs during admission and discharge of 600 patients in public and private hospitals, the mean NAS of admission was higher (61.9%) than the value for discharge (52.8%),(13) similarly to the results observed in the sample of this study. Analysis of nursing workload in the ad-mission and discharge of patients was also conduct-ed in a Spanish ICU. Patients were divided into three groups: those with acute coronary syndrome; those with acute respiratory failure; and those with sepsis. The sample consisted of 563 patients, and significant differences were observed in the work-load in the first day of hospitalization in relation to discharge in the three groups; the highest workload in both admission and discharge was observed for patients classified as having acute respiratory failure and sepsis.(20)

The cardiac surgery postoperative ICU also presented significant reductions in the mean NAS in the 72 hours after admission (58.1%) in com-parison with the mean NAS in the first 24 hours (82.4%).(21)

In order to compare the nursing workload re-quired per each adult, elderly, and very elderly pa-tient, the NAS was applied to 600 patients hospi-talized in the general adult ICUs of two public and two private hospitals in the city of São Paulo. The NAS scores for admission and discharge of patients

three or more nurses in any frequency (p=0.007), and 11 - Treatment for improving lung function (p=0.047).

In items 4b and 6c the percentage of patients in the obese group was higher in relation to the other groups (3.8% and 5.7%, respectively). In item 11 the percentage of patients in the underweight group was higher (50.0%).

Discussion

The nursing workload in the different groups of BMI was not statistically different in the studied sample. That is, the NAS values observed in the group of underweight patients, normal weight/pre-obese, and obese patients were similar in both gen-eral mean and admission or discharge mean.

The characteristics of the studied sample in re-lation to the variables gender, age, length of stay, origin, and mortality rate were found to be similar to those observed in other studies that applied the NAS in different ICUs for adults. In these, more than half the patients were also males(4-6,13) with a mean age between 53 and 64 years,(4,5,7,13) length of ICU stay between 5 and 9 days, mainly referred from the operating room and emergency depart-ment (elective surgeries representing the most fre-quent ones).(7,13,14) Although the mortality rate was between the values presented in the several studies, from 3%(7) to 26%(8,15,16) in the analysis of variation of the percentages of mortality, it is important to take into account that, in addition to the admission category, other variables also interfere in the out-come, including the clinical condition or severity of illness.

The predominance of normal and pre-obese pa-tients followed by obese and underweight patients was observed in relation to the BMI in the studied sample. Regarding the demographic, clinical, hospi-talization, and workload variables, the three groups of patients presented no statistical difference.

The workload measured by the NAS was sim-ilar to the value observed in Brazilian adult ICUs, whose variation in the mean value of the scores has been between 62.2% and 70.4%.(5,7,8,14) Similar re-

37Acta Paul Enferm. 2017; 30(1):31-8.


that these patients demand a higher number of these professionals. One explanation for this fact is that several obese patients in this study were hospi-talized for elective surgeries, particularly bariatric surgeries. Therefore, it is possible to infer that in the first 24 hours of hospitalization in the ICU the patients, possibly with better clinical conditions, collaborated with the nursing team in relation to their mobilization in the bed. This study points out the fact that the insufficient number of profes-sionals to perform the care involving the mobility of obese patients with total dependence may con-tribute to a higher risk of occurrence of adverse events as well as to generate physical overload in the professionals due to physical efforts exceeding the recommended levels.

The results obtained in this study do not infer that the BMI of patients hospitalized in the ICU have contributed to increase the nursing workload. This finding may be related to the reduced number of underweight patients and the predominance of normal and pre-obese patients associated with the fact that this is a unicentric study, an aspect con-sidered as a limitation of the study. In relation to future research on the effect of the BMI on the nursing workload in the ICU, in addition to con-sidering different clinical conditions and levels of severity it is important to analyze the observed and indicated number of professionals per patient in the ICU. It is also important to observe the need to expand the data collection through a multicentric study in order to increase the study of underweight and obese patients.

The objective measurement of the nursing workload in the ICU for allocation of professionals considering the complexity and demand of care to critical patients has been a useful tool for nurses in their daily clinical practice, as it enables them to provide more safety and quality of care.

Conclusion

The results of this study allow the conclusion that the nursing workload in the ICU, according to the NAS, presented no differences between groups with

differed among the three groups between 64.4% and 59.0% at admission and between 55.8% and 50.4% at discharge. The elderly group obtained the high-est mean NAS value in both measurements. A sta-tistically significant difference was observed between the NAS scores for discharge in the adult and elderly groups, indicating that advanced aged patients pos-sibly presented a higher demand for care and that, after leaving the ICU, this condition would result in a higher nursing workload in the receiving unit.(15)

In the present study a detailed analysis of the NAS items that scored with higher frequency on the first day of hospitalization, namely 1b, 2, 3, 4a, 7a, and 17, corroborates the results of other stud-ies evaluating the frequency of the items at admis-sion(13,15,16) as well as in the studies that analyzed these items throughout the length of stay of the patient in the ICU.(5,14) These findings result from the fact that the nursing interventions, such as the presence at bedside and continuous observation or active for two hours or more in a shift, laborato-ry investigations, medication, performing hygiene procedures, support and care for patients and their families, performing management and administra-tive tasks requiring full dedication for about two hours, and quantitative urine output measurement, are part of the daily routine activities in an ICU.

Focusing on the BMI of the patients, the items scored with higher frequency in the NAS and that presented statistically significant difference were 4b - Performing hygiene procedures for more than two hours in a shift, 6c - Performing procedure(s) with three or more nurses at any frequency, and 11 - Treat-ment for improving lung function. Item 11 was the most frequent in underweight patients, indicating that the pulmonary function of these patients was worse at admission in relation to the other groups. It is important to observe that this group of patients presented higher levels of severity and worse organ dysfunction both at admission and at discharge, as well as a higher percentage of mortality.

Although obese patients present a higher fre-quency of the item 6c, as these patients require a higher number of people for mobilization, the frequency at which this item was scored was insuf-ficient to increase the nursing workload and affirm

38 Acta Paul Enferm. 2017; 30(1):31-8.


different BMIs. However, obese patients demanded more time for hygiene procedures and more peo-ple to assist in the mobilization/positioning process. Underweight patients received treatment to improve their pulmonary function with a higher frequency.

CollaborationsGoulart LL, Carrara FSA, Zanei SSV, and Whitaker IY declare that they have contributed to the design of the study, analysis and interpretation of the data, writing of the article, relevant critical review of intellectual con-tent, and final approval of the version to be published.

References

1. Carneiro TM, Fagundes NC. Absenteísmo entre trabalhadoras de enfermagem em unidade de terapia intensiva de hospital universitário. Rev Enferm UERJ. 2012; 20(1):84-9.

2. Miranda DR, Nap R, Rijk A, Schaufeli W, Iapichino G. Nursing Activities Score. Crit Care Med. 2003; 31(2):374-82.

3. Queijo AF, Padilha KG. Nursing Activities Score (NAS): cross-cultural adaptation and validation to portuguese language. Rev Esc Enferm USP. 2009; 43(Spe):1001-8.

4. Valls-Matarín J, Salamero-Amorós M, Roldán-Gil C. Analysis of the workload and the use of the nursing resources in an intensive care unit. Enferm Intensiva. 2015; 26(2):72-81.

5. Panunto MR, Guirardello EB. Nursing workload in an intensive care unit of a teaching hospital. Acta Paul Enferm. 2012; 25(1):96-101.

6. Goulart LL, Aoki RN, Vegian CFL, Guirardello EB. Carga de trabalho de enfermagem em uma unidade de terapia intensiva de trauma. Rev Eletr Enf. 2014; 16(2):346-51.

7. Coelho FU, Queijo AF, Andolhe R, Gonçalves LA, Padilha KG. Carga de trabalho de enfermagem em unidade de terapia intensiva de cardiologia e fatores clínicos associados. Texto Contexto Enferm. 2011; 20(4):735-41.

8. Camuci MB, Martins JT, Cardeli AA, Robazzi ML. Nursing Activities Score: nursing workload in a burns Intensive Care Unit. Rev Lat Am Enfermagem. 2014; 22(2):325-31.

9. Lachance J, Douville F, Dallaire C, Padilha KG, Gallani MC. The use of the Nursing Activities Score in clinical settings: an integrative review. Rev Esc Enferm USP. 2015; 49(Esp):147-156.

10. Vincent JL, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, Reinhart CK, Suter PM, Thijs LG. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996; 22(7):707-10.

11. World Health Organization [Internet]. Body Mass Index (BMI) classification. [cited 2013 Jan 29]. Available from: http://apps.who.int/bmi/index.jsp?introPage=intro_3.html.

12. Moreno RP, Metnitz PG, Almeida E, Jordan B, Bauer P, Campos RA, Iapichino G, Edbrooke D, Capuzzo M, Le Gall JR; SAPS 3 Investigators. SAPS 3-From evaluation of the patient to evaluation of the intensive care unit. Part 2: Development of a prognostic model for hospital mortality at ICU admission. Intensive Care Med. 2005; 31(10):1345-55. Erratum in: Intensive Care Med. 2006; 32(5):796.

13. Nogueira LS, Koike KM, Sardinha DS, Padilha KG, Sousa RM. Carga de trabalho de enfermagem em unidades de terapia intensiva públicas e privadas. Rev Bras Ter Intensiva. 2013; 25(3):225-32.

14. Leite IR, Silva GR, Padilha KG. Nursing Activities Score e demanda de trabalho de enfermagem em terapia intensiva. Acta Paul Enferm. 2012; 25(6):837-43.

15. Sousa RM, Padilha KG, Nogueira LS, Miyadahira AM, Oliveira VC. Nursing workload among adults, elderly and very elderly patients in the Intensive Care Unit. Rev Esc Enferm USP. 2009; 43(Esp 2):1284-9.

16. Nogueira LS, Padilha KG, Silva DV, Lança EF, Oliveira EM, Sousa RM. Pattern of nursing interventions performed on trauma victims according to the Nursing Activities Score. Rev Esc Enferm USP. 2015; 49(Esp):29-35.

17. Lucchini A, De Felippis C, Elli S, Schifano L, Rolla F, Pegoraro F, Fumagalli R. Nursing Activities Score (NAS): 5 years of experience in the intensive care units of an Italian University hospital. Intensive Crit Care Nurs. 2014; 30(3):152-8.

18. Stafseth SK, Solms D, Bredal IS. The characterisation of workloads and nursing staff allocation in intensive care units: a descriptive study using the Nursing Activities Score for the first time in Norway. Intensive Crit Care Nurs. 2011; 27(5):290-4.

19. Debergh DP, Myny D, Herzeele IV, Maele GV, Miranda DR, Colardyn F. Measuring the nursing workload per shift in the ICU. Intensive Care Med. 2012; 38(9):1438-44.

20. Monge FJ, Pérez AJ, Herranz CQ, Rodríguez GR, González IC, Gómez SG, et al. Carga de trabajo en tres grupos de pacientes de UCI Española según el Nursing Activities Score. Rev Esc Enferm USP. 2013;47(2):335-40.

21. Oliveira LB, Rodrigues AR, Püschel VA, Silva FA, Conceição SL, Béda LB, Fidelis B, Santana-Santos E, Secoli SR. Assessment of workload in the postoperative period of cardiac surgery according to the Nursing Activities Score. Rev Esc Enferm USP. 2015; 49(Esp):80-6.

39Acta Paul Enferm. 2017; 30(1):39-46.

Original Article

Depressive symptoms in pregnancy and associated factors: longitudinal study

Sintomas depressivos na gestação e fatores associados: estudo longitudinalMarlise de Oliveira Pimentel Lima1

Maria Alice Tsunechiro2

Isabel Cristina Bonadio2

Marcella Murata3

Corresponding authorMarlise de Oliveira Pimentel LimaArlindo Béttio street, 1000,03828-000, Ermelino Matarazzo,São Paulo, SP, [email protected]

DOI: http://dx.doi.org/10.1590/1982-0194201700007 1Escola de Artes, Ciência e Humanidades, Universidade de São Paulo, São Paulo, SP, Brazil.

2Escola de Enfermagem, Universidade de São Paulo, São Paulo, SP, Brazil.3Hospital do Rim e Hipertensão, Fundação Oswaldo Ramos, São Paulo, SP, Brazil.Conflict of interest: no conflicts of interest to declare.

AbstractObjective: To identify the frequency of depressive symptoms during pregnancy and verify their association with sociodemographic, obstetric and health variables.Methods: A longitudinal study conducted with 272 pregnant women in 12 health units in the city of São Paulo. Data were obtained using a form for the independent variables, and the Edinburgh Postpartum Depression Scale applied at the 20th, 28th and 36th gestational weeks. A model of generalized estimating equations was used to evaluate the associated factors and odds ratio.Results: The frequency of depressive symptoms was 27.2%, 21.7% and 25.4%. Higher educational level, planned pregnancy and continuity of gestation were protective factors. Suffering or having suffered psychological violence was an independent risk factor of the gestational period.Conclusion: The frequency of depressive symptoms during pregnancy was high. The associated factors were higher educational level, planned pregnancy, continuity of pregnancy, and suffering or having suffered psychological violence.

ResumoObjetivo: Identificar a frequência de sintomas depressivos no decorrer da gestação e verificar sua associação com variáveis sociodemográficas, obstétricas e de saúde.Métodos: Estudo longitudinal realizado com 272 gestantes de 12 unidades de saúde do Município de São Paulo. Os dados foram obtidos por meio de um formulário para as variáveis independentes e da Escala de depressão pós-parto de Edimburgo aplicada nas 20ª, 28ª e 36ª semanas gestacionais. Utilizou-se modelo de equações de estimação generalizadas para avaliar os fatores associados e chances de risco.Resultados: A frequência de sintomas depressivos foi de 27,2%, 21,7% e 25,4%. Maior escolaridade, gestação planejada e continuidade da gestação foram fatores de proteção. Sofrer ou ter sofrido violência psicológica foi fator de risco independente do período gestacional.Conclusão: A frequência de sintomas depressivos na gestação foi elevada. Os fatores associados foram maior escolaridade, gestação planejada, continuidade da gestação e sofrer ou ter sofrido violência psicológica.

KeywordsDepression; Pregnancy; Prenatal care;

Pregnancy complications; Obstetric nursing

DescritoresDepressão; Gravidez; Cuidado pré-

natal; Complicações na gravidez; Enfermagem obstétrica

Submitted October 3, 2016

Accepted February 10, 2017

40 Acta Paul Enferm. 2017; 30(1):39-46.


Introduction

The pregnancy-puerperal cycle is a phase in wom-en’s lives that requires special evaluation because it includes innumerable physical, hormonal, psychic and social insertion modifications that can reflect directly on mental health.

Over the years, the interest in evaluating preg-nant women’s mental health in a systematized way has deserved little attention, probably for the belief that pregnancy is a period of well-being, and also for the greater attention given by professionals to psychotic disorders that can occur after birth be-cause they require hospitalization.(1)

During pregnancy, 10% to 15% of all women experience mild to moderate anxiety and depression symptoms. In general, they are similar to symptoms in depression at any other time in women’s lives, such as lack of appetite and energy and feelings of guilt. In addition to the own woman’s suffering, these manifestations may interfere with the proper process of fetal development, increase the risk of ad-verse events in pregnancy for mother and fetus such as preeclampsia, and be associated with unfavorable obstetric outcomes such as preterm birth and low birth weight. Depression may persist in the post-partum period and compromise parental behavior, the relationship with the partner and family, the process of mother-child bonding, and the child’s cognitive, motor and psychosocial development.(2-5)

Studies on depression and its effects in the pre-natal period are recent, dating back two decades, with an increase thereafter.

In pregnancy, the prevalence of depression ap-pears to vary depending on the country’s degree of development. Studies show prevalence rates are lower, around 10% and 15% in developed coun-tries such as the United States, England, Canada, and Sweden. In developing countries such as Brazil, Bangladesh, Pakistan and South Africa, the average rate is around 25%.(6-8)

In Malawi, a less developed country, rates at pregnancy were 10.7% for major depression and 21.1% for minor depression. In Turkey, the prevalence in the first trimester of gestation was 16.8%.(9,10)

The prevalence also varies according to gesta-tional age or trimester, on average 7.4% in the first trimester until 12.0% in the last trimester.(7)

Depressive symptoms such as altered sleep pat-terns, sadness with no apparent reason, decreased performance and feelings of guilt, among others, are common in gestation, ranging from 11.9% to 33.8%, and indicate a risk for depression.(7,11,12)

Thus, pregnant women should be evaluated to ensure specialized referral of suspected cases of de-pression for diagnosis and treatment.

In this sense, we highlight the recent position of American national health services recommending the screening of depressive symptoms in pregnancy and postpartum periods.(13)

Even though this is a relevant public health problem, given its frequency, few recent studies have been found on depressive symptoms in ges-tation in emerging countries.(8) Therefore, there is need for new studies that analyze women’s mental health throughout the gestational period.

The objectives of this study were to identify the frequency of depressive symptoms during preg-nancy and verify their association with sociodemo-graphic, obstetric and health variables.

Methods

A longitudinal study was conducted in three steps (20th, 28th and 36th gestation weeks, with variation of ± 2 weeks) in 12 prenatal care services that assist pregnant women through the Brazilian Unified Health System (SUS), located in the southern area of the city of São Paulo, Brazil. This is a subproject of a broader research called ‘Quality of life of women with depressive symp-toms during the gestational period’.

The study included pregnant women at usual risk, who received prenatal care in the aforemen-tioned services. Inclusion criteria were minimum age of 18 years, gestational age ≤22 weeks, and ability to read and understand the data collection forms. Exclusion criteria were diagnosis of twin pregnancy or clinical or obstetric comorbidity during pregnancy, and pharmacological treatment for mental disorders.

41Acta Paul Enferm. 2017; 30(1):39-46.

Lima MO, Tsunechiro MA, Bonadio IC, Murata M

It should be mentioned that the start of the first stage of collection at the 20th gestational week, ensured the inclusion of pregnant women without prior clinical, obstetrical and mental pathology, with normal results of clinical exams, and negative results for serological tests (all checked in medical records and/or the pregnant woman’s card).

For the selection of participants, the National System of Registration of Pregnant Women (SIS-Pré-Natal) was used to find out eligible pregnant women. Women who met the inclusion criteria and attended the prenatal care visit at the determined gestational age for the first step of collection were invited to participate after clarification on the ob-jectives and procedures of the study.

The minimum sample size for this study was calculated based on the formula: n=z2.p.q/e2, considering n=minimum sample size; z=coeffi-cient of confidence, adopting the value of 1.96 for an alpha of 0.05; p=prevalence of the studied phenomenon; q=additional measure of preva-lence (1-p); e= maximum error in absolute val-ue. Based on the national study that indicates a prevalence of 20.7% of depressive symptomatol-ogy during the gestational period, was adopted a value of 0.22, which equates to a higher relation between p and q and a desired precision of 5%.(12) Thus, was obtained n=264.

Considering 40% of loss to follow-up, 443 pregnant women were included in the initial step. There was a loss of 171 pregnant women; 99 in the second step, and 72 in the third. The main reasons were disengagement from service due to change of address and referral to high-risk prenatal care due to clinic-obstetric complications such as pre-ec-lampsia, gestational diabetes, twin pregnancy, and preterm delivery. During the study, there was no exclusion of pregnant women by pharmacological treatment for mental disorders. The final sample consisted of 272 pregnant women (61.4%) who completed the study steps.

The study variables of the final sample and the dropped out group were compared, with no differ-ences between groups, except for psychological vi-olence (p = 0.013), which was present in a higher proportion in the final sample.

The study participants were recruited from July 2008 to September 2009. The follow-up of preg-nant women lasted until January 2010.

Two forms were used for data collection. A form to gather sociodemographic, obstetrical and health data was used in the first step. The Edinburgh Post-natal Depression Scale-EPDS (translated and vali-dated version for Brazilian Portuguese) was used in the three steps.(14) The EPDS is a simple response in-strument designed to be applied by a non-specialized mental health professional. It can be used at any stage of pregnancy and up to 12 months after birth.(12,15) It is a self-administered instrument composed of ten statements and covering the following symptoms: depressed or dysphoric mood, sleep disorder, lack of pleasure, idea of death and suicide, decreased perfor-mance, and guilt. Each statement has four options of answers scored from 0 to 3 according to the absence, presence and intensity of symptoms. The final score ranges from 0 to 30, by simple sum of the points of each item, showing that the higher the score, the higher the presence of depressive symptoms.

As the intention of this study was to evaluate the presence of depressive symptoms throughout gesta-tion, was chosen a longitudinal approach, starting from an early gestational age (20th gestational week), with an interval of eight weeks between steps, and considering the evolution of gestational changes oc-curring in the maternal organism.

The collection forms were applied by nurses, re-searchers of the present study, before or after the prenatal care visit, in a private room, after reading, clarifying and signing the Informed Consent Form. In the period corresponding to the gestational ages determined for follow-up, the collection took place at the health service or at home, depending on the pregnant woman’s preference.

The dependent variable of the study was the presence of depressive symptoms and the cut-off point adopted was the score ≥13, as suggested in a study conducted in Brazil (specificity of 88.4% and sensitivity of 59.5%).(12)

In each step of collection, the referral to a philan-thropic service with mental health professionals for evaluation and treatment, if necessary, was offered to pregnant women with depressive symptoms.

42 Acta Paul Enferm. 2017; 30(1):39-46.


The independent variables were: age (com-pleted years), years of study, self-defined ethnic-ity (white, black/mixed race, Asian), marital sta-tus (with and without partner), religion (catholic, evangelical, other, no religion), paid work (yes/no), family income in minimum wage of 2009 (≤R$465.00; R$466.00├ R$931.00; R$932.00├ R$1,397.00; ≥R$1,398.00), number of pregnan-cies including the present one (one, two, three or more), number of births (none, one, two, three or more), number of alive children (none, one, two, three or more), number of children living with the pregnant woman (none, one, two, three or more), number of cited gestational complaints such as nausea, vomiting, burning sensation, low back pain (none, one, two, three or more), suffering or having suffered physical violence such as slaps or pushes, or psychological violence such as threats of abandonment, shouting, before or during preg-nancy (no, yes), and who was the aggressor (part-ner, family, others), pregnancy planning (no, yes), pregnancy acceptance (no, yes, in process of ac-ceptance), use of tobacco (no, yes), use of alcohol (no, yes), use of other drugs (no, yes), previous or current mental problem (no, yes), and mental problem in the family (no, yes).

The Cronbach’s alpha coefficient was used to check the EPDS reliability. To compare the results of the EPDS throughout the three steps was used the Friedman test.

The model of generalized estimating equations (GEE) for binomial distribution was used to eval-uate all possible predictors for depressive symp-toms and chances of risk, encompassing the three steps of the study. In the multiple model were in-cluded all variables in which the associative tests (chi-square and Student’s t) had p-value <0.20. The selection of variables was performed using the backwards stepwise method. The level of signifi-cance was set at 5%. The analyzes were done with the Statistical Program for Social Science (SPSS)®, version 17.0.

The project was approved by the Research Eth-ics Committee of the Municipal Health Secretariat of the City of São Paulo (CAAE: 0060.0.162.000-08 number 154/08 - CEP/SMS).

Results

The 272 pregnant women in the study had the following characteristics: age (n = 271) 25.3 (5.4) years; white (n = 269) 52.1%; educational level (n = 270) 9.5 (2.5) years of study; with part-ner (n = 268) 91%; catholic (n = 263) 60.5%; family income (n = 269) of 50.6% of up to R$ 931.00; first pregnancy in 37.5%; one or more births 65.9%, one or more alive children 66.7%; one or more cited gestational complaints 90.1%; smokers 19.8%; alcohol users 28.7%; illicit drug users (n = 271) 4.8%; suffering physical (n = 271) and psychological violence before or during pregnancy were, respectively, 11.8% and 29.8%, with partner and relatives as the main aggressor (87.1% and 78.6%); unplanned pregnancy (n = 270) was 71.9%, and had accepted it (n = 271) 90.8%.

The frequency of depressive symptoms in the three steps and the Cronbach’s alpha coefficient are presented in table 1.

Depressive symptoms occurred throughout the gestational period in 7% of pregnant women, at some step in 38.5%, and no occurred for 54.5%, showing little variation between steps according to the Friedman test during pregnancy (p = 0.23 ), and between scores ≥13 (p=0.12).

The frequency of pregnant women who scored one to three points in each statement throughout the steps is shown in table 2.

Feeling anxious or worried for no good rea-son (Statement 4) was the most frequent item among pregnant women in the sample, main-taining percentages above 80% during pregnan-cy. Blaming oneself unnecessarily when things went wrong (Statement 3) was also frequent, but it decreased during pregnancy, while not being able to face up to problems (Statement 6) in-creased throughout the evolution of pregnancy. These three statements refer to symptoms of de-crease of performance and guilt. Statement 10, the though of injuring oneself was present in the smallest proportion.

The associative analysis of depressive symptoms with independent variables was significant with

43Acta Paul Enferm. 2017; 30(1):39-46.


education (p <0.001), number of pregnancies (p <0.001), number of births (p <0.001), number of children (p <0.001), number of children living with the pregnant woman (p=0.006), number of com-plaints during pregnancy (p = 0.039), pregnancy planning (p <0.001), smoking (p <0.001), phys-ical violence (p = 0.007), psychological violence (p =0.001), and mental problems reported by the pregnant woman (p = 0.024).

The evaluation of possible predictors for the presence of depressive symptoms during pregnan-cy (GEE model) showed there were differences be-tween the steps, as presented in the data of table 3.

The chance of presenting depressive symptoms decreased by 21.6% and 21.5%, respectively, in the second and third steps. Planned pregnancy decreased the chance of presenting depressive symptoms during pregnancy (first step - 75.4%; second step - 91.4%; third stage - 56.1%). Having higher educational lev-el decreased the chance in 14.3% per year of study, regardless of gestational age. Therefore, higher educa-tional level, planned pregnancy and the evolution of pregnancy were protective factors.

Suffering or having suffered psychological violence has increased twice the chance of presenting depressive symptoms throughout pregnancy, hence is a risk factor.

Discussion

When interpreting the results of this study, the lim-itation imposed by the sample of pregnant women attended in the public health system must be taken into account because it prevents the generalization of results to the universe of pregnant women.

The results show the need for attention focused on mental health since the beginning of pregnancy. They also offered subsidies to formulate strategies of specialized care to women with use of the EPDS as a tool for screening of depressive symptoms in prenatal care.

Table 1. Depressive symptoms in pregnant women according to results of the Edinburgh Postnatal Depression Scale in the three steps

STEPS(gestational weeks)

EPDS score

Cronbach’s alpha≤12 ≥13Minimum Maximum Mean (SD)

n(%) n(%)

20th 198(72.8) 74(27.2) 0 27 9.1(5.9) 0.83

28th 213(78.3) 59(21.7) 0 29 8.6(5.7) 0.84

36th 203(74.6) 69(25.4) 0 24 8.6(5.6) 0.84

Table 2. Pregnant women who scored one to three points in each statement of the Edinburgh Postnatal Depression Scale in the three steps

EPDS statement1st Step 2nd Step 3rd Step

n(%) n(%) n(%)

1. I have laughed and been able to look on the bright side of life. 99(36.3) 91(33.5) 99(36.4)

2. I have looked forward to the future. 134(49.2) 123(45.2) 131(48.1)

3. I have blamed myself unjustifiably when things have gone wrong. 210(77.2) 203(74.7) 184(67.7)

4. I have become anxious or worried for no good reason. 228(83.8) 233(85.6) 217(80.1)

5. I have felt frightened or panicky for no good reason. 123(45.2) 119(43.8) 127(46.6)

6. I have not been able to face up to problems. 197(72.4) 218(80.1) 226(83.1)

7. I have felt so bad that I have had difficulty in sleeping. 96(35.3) 98(36.0) 114(42.2)

8. I have felt sad or unwell. 141(51.8) 143(52.6) 141(52.2)

9. I have felt so sad that I have cried. 138(50.8) 130(47.8) 134(49.6)

10. I have thought about injuring myself. 61(22.4) 43(15.7) 39(14.5)

Table 3. Odds ratio (OR), confidence interval and level of significance for depressive symptoms in pregnant women

Variables OR CI 95% p-value

Gestational age 0.007

20th week 1

28th week 0.784 0.565 - 1.088

36th week 0.785 0.539 - 1.143

Educational level (years) 0.857 0.780 – 0.941 0.001

Planned pregnancy < 0.001

No 1

Yes 0.246 0.108 – 0.559

Psychological violence 0.003

No 1

Yes 2.184 1.355 - 3.521

44 Acta Paul Enferm. 2017; 30(1):39-46.


In this study, there was an expressive pro-portion of women with depressive symptoms during pregnancy, especially those with early gestational age. Studies using the EPDS and the same cutoff point (≥13) showed frequency vari-ation. In Brazil, 20.7% with a mean gestational age of 27.7 weeks.(12) In Ethiopia 24.9%, with predominance of women in the last trimester. (8) In Tanzania the result was higher, with 33.8% of depressive symptoms during pregnancy.(7)

The relatively high frequency observed at the beginning of pregnancy in this study may be a re-sult of changes occurring in women’s bodies, and the acceptance of their pregnancy condition. It can also be related to the support and acceptance re-ceived from their partners and family members. In the last trimester, around the 36th week, the fre-quency also increased. At this time, characterized as antepartum period, it is not uncommon to ob-serve more preoccupations because of the proximi-ty of labor and birth.

Using the cutoff point ≥12, lower frequencies were found in some European studies. In Holland, the frequency was 6.0% at the 12th and 36th weeks of pregnancy, and in Norway it was 8.0% at the 28th week of pregnancy.(5,16)

In Brazil, a longitudinal study with cut-off point ≥11 presented higher frequencies, with 33.3% in the second gestational trimester and 27.9% in the third.(17)

These variations may result from different ways of using the EPDS for gestational age and cut-off points. Thus, the analysis of the results obtained in studies should consider these methodological aspects.

In addition to economic differences between countries, there are cultural, ethnic and life his-tory differences among women who participated in these various studies, which interferes in preva-lence results.(5,18)

Depressive symptoms are undervalued by wom-en because they assume these are part of the preg-nancy process hence, accepted as something normal and adjustable over time, and by a presumed neg-ative social valuation that still persists on mental health care.(19)

In this study, the most frequent type of de-pressive symptom was decreased performance and guilt, as suggested by statements 3, 4 and 6 of the scale used. It was observed that factorial analysis studies with the EPDS showed an anxi-ety factor (subscale 3A) related to statements 3, 4 and 5. However, in the EPDS there is no dis-tinction if the anxiety score of these three items is a characteristic of depression in the perinatal period or a distinct morbidity.(20,21)

Although these symptoms are relatively com-mon in pregnancy, professionals involved in this process should be alert to women’s behavioral man-ifestations that demonstrate exacerbated emotional reactions, and act in order to alleviate negative feel-ings, if possible, turning them into positive feelings. The presence of these symptoms at high levels can lead to unfavorable maternal and perinatal out-comes.(2-5)

The least frequent was the thought about in-juring oneself. However, its presence at all stages shows the importance of a specific screening tool to identify pregnant women at risk. In a study conducted in Tanzania, only two (0.5%) women reported suicidal ideation, which is lower than in the present study. In Brazil, the prevalence of suicidal ideation found in pregnant women was 6.3%.(7,22)

Higher educational level, planned pregnancy and the course of gestation were protective factors in this study. On the other hand, suffering or hav-ing suffered psychological violence was a risk factor for the presence of depressive symptoms through-out pregnancy.

A systematic review has indicated the fol-lowing as major risk factors for the presence of depressive symptoms: prior history of depres-sion or mental illness, unplanned or unaccepted pregnancy, absence of partner or social support, high perceived stress level and having suffered adverse events in life, history of abuse or domes-tic violence, past or present history of gestational complications, and fetal loss. Besides these fac-tors, financial difficulties, low educational level, unemployment and dependence on psychoactive substances were also mentioned.(7,23)

45Acta Paul Enferm. 2017; 30(1):39-46.


Planned pregnancy was a protective factor, vary-ing as the gestation progressed. In this context, fail-ure to plan pregnancy was a risk factor for perinatal depression according to a systematic review with meta-analysis.(24)

Psychological violence was a risk factor for the presence of depressive symptoms through-out gestation, considering the main perpetrators were partners and family members. In longitudi-nal studies conducted in Brazil and Turkey and in a review study, one of the factors associated with gestational depression was exposure to domestic violence.(17,25,26)

Currently, violence against women is a highly valued social problem that has received recogni-tion from governmental agencies. According to the Low Risk Prenatal Care Handbook, a mistreated pregnant woman develops a condition of constant emotional stress associated with low self-esteem, isolation and suicide, excessive or abusive use of cigarettes, alcohol and drugs. It also states that the pregnancy-puerperal cycle does not give protection to women and points prenatal care as a privileged time to identify women who suffer violence, and is often the only opportunity to stop this situation.(27)

The early identification of depressive symptoms during pregnancy is important because it provides subsidies for risk assessment and necessity of refer-rals, providing timely interventions and more favor-able maternal and child outcomes.

Pregnant women’s spontaneous search for help may be difficult because of some factors such as in-ability to verbalize their need for specialized care, and it is compromised by the presence of depressive symptoms. There is also the fact of not feeling con-fident to expose their complaints to professionals, since it is not uncommon to hear that these symp-toms are common in pregnancy. A study conduct-ed in an ultra-orthodox Israeli community showed that most pregnant women only seek help after ex-acerbation of symptoms.(11)

Professionals also faces barriers to detect preg-nant women with depressive symptoms because of the lack of knowledge of systematized forms in mental health, and lack of preparation for the man-agement and assistance of these women in primary

care. The limitation of focus to physiological aspects of the development of pregnancy and the postpar-tum period prevents an integral care during antena-tal and postpartum periods.(28,29)

Thus, health professionals should understand the state of higher psychic vulnerability of preg-nant women, without trivializing their complaints and, when necessary, request referring support from mental health professionals to pregnant women in mental suffering.(29)

Conclusion

The frequency of depressive symptoms in the first, second and third steps was 27.2%, 21.7% and 25.4%. The associated protective factors were higher educational level, planned pregnancy and continuity of pregnancy. Suffering or having suffered psycholog-ical violence was a risk factor throughout pregnancy.

AcknowledgementsThanks to the Conselho Nacional do Desenvolvi-mento Científico e Tecnologico – CNPq (pro-cess number 479.016/2007-0 for Maria Alice Tsunechiro).

CollaborationsLima MOP, Tsunechiro MA, Bonadio IC and Murata M declare they contributed to the project design, analysis and interpretation of data, article writing, critical review of the intellectual content and final approval of the version to be published.

References

1. Almeida MS, Nunes MA, Camey S, Pinheiro AP, Schmidt MA. [Mental disorders in a sample of pregnant women receiving primary health care in Southern Brazil]. Cad. Saúde Pública 2012; 28(2):385-93. Portuguese.

2. Jarde A, Morais M, Kingston D, Giallo R, MacQueen GM, Giglia L et al. Neonatal Outcomes in Women With Untreated Antenatal Depression Compared With Women Without Depression: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2016; 73(8):826-37.

3. McDonald S, Kehler H, Bayrampou H, Frase_Lee N, Tough S. Risk and protective factors in early development: results from the all our babies (AOB) pregnancy cohort. Res Dev Disabil. 2016; 58:20-30.

46 Acta Paul Enferm. 2017; 30(1):39-46.


4. Lewis AJ, Austin M. Prenatal maternal mental health and fetal growth restriction: a systematic review. J Dev Orig Health Dis. 2016; 7(4):416-28.

5. Shakeel N, Eberhard-Gran M, Sletner L, Slinning K, Martinsen EW, Holme I et al. A prospective cohort study of depression in pregnancy, prevalence and risk factors in a multi-ethnic population. BMC Pregnancy Childbirth 2015; 15:5.

6. Fisher J, Cabral de Mello M, Patel V, Rahman A, Tran T, Holton S, et al. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Bull World Health Organ. 2012; 90(2):139G-149G.

7. Rwakarema M, Premji S, Nyanza EC, Riziki P, Palacios-Derflingher L. Antenatal depression is associated with pregnancy-related anxiety, partner relations, and wealth in women in Northern Tanzania: a cross-sectional study. BMC Women’s Health. 2015; 15:68.

8. Biratu A, Haile D. Prevalence of antenatal depression and associated factors among pregnant women in Addis Ababa, Ethiopia: a cross-sectional study. Reprod Health. 2015; 12:99.

9. Stewart RC, Umar E, Tomenson B, Creed F. A cross-sectional study of antenatal depression and associated factors in Malawi. Arch Womens Ment Health. 2014; 17(2):145-54.

10. Aslan AP, Aydin N, Yazici E, Aksoy AN, Kirkan TS, Daloglu GA. Prevalence of depressive disorders and related factors in women in the first trimester of their pregnancies in Erzurum, Turkey. Int J Soc Psychiatry. 2014; 60(8):809-17.

11. Glasser S, Hadad L, Bina R, Boyko V, Magnezi R. Rate, risk factors and assessment of a counselling intervention for antenatal depression by public health nurses in an Israeli ultra-orthodox community. J.Adv. Nurs. 2016; 72(7)1602-15.

12. Silva R, Jansen K, Souza L, Quevedo L, Barbosa L, Moraes I, Horta B, Pinheiro R. Sociodemographic risk factors of perinatal depression: a cohort study in the public health care system. Rev Bras Psiquiatr. 2012; 4(2):143-8.

13. O’Connor E, Rossom RC, Henninger M, Groom HC, Burda BU. Primary care screening for and treatment of depression in pregnant and postpartum women Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2016; 315(4):388-406.

14. Santos MF, Martins FC, Pasquali L. [Postpartum Depression Self-Assessment Scale: A Study in Brazil]. Rev Psiquiatr Clin (São Paulo). 1999; 26(2):90-5. Portuguese.

15. Cox J, Holden J, Henshaw C. Perinatal Mental Health. The Edinburg Postnatal Depression Scale (EPDS) Manual. 2nd ed. London: RCPsych Publications. 2014. p.17-26.

16. Meijer JL, Bockting CL, Stolk RP, Kotov R, Ormel J, Burger H. Associations of life events during pregnancy with longitudinal change in symptoms of antenatal anxiety and depression. Midwifery. 2014; 30(5):526-31.

17. Castro e Couto T, Cardoso MN, Brancaglion MY, Faria GC, Garcia FD, Nicolato R et al. Antenatal depression: Prevalence and risk factor patterns across the gestational period. J Affec Disord. 2016; 192:70-75.

18. Robinson AM, Benzeies KM, Caims SL, Fung, Tough SC. Who is distressed? A comparison of psychosocial stress in pregnancy across seven ethnicities. BMC Pregnancy Childbirth 2016; 16(1):215.

19. Carrascón A, García S, Cena B, Fornés M, Fuentelsaz C. Detección de la depresión durante el embarazo y el posparto. Matronas Prof. 2006; 7(4): 5-11.

20. Matthey S, Fisher J, Rowe H. Using the Edinburgh Postnatal Depression Scale to screen for anxiety disorders: conceptual and methodological considerations. J Affec Disord. 2013; 146(2):224-30.

21. Fallon V, Halford JC, Bennett KM, Harrold JA. The Postpartum Specific Anxiety Scale: development and preliminary validation. Arch Womens Ment Health. 2016; 19(6):1079-90.

22. Huang H, Faisal-Cury A, Chan YF, Tabb K, Katon W, Menezes PR. Suicidal ideation during pregnancy: prevalence and associated factors among low-income women in São Paulo, Brazil. Arch Womens Ment Health 2012; 15(2):135-8.

23. Biaggi A, Conroy S, Pawlby S, Pariante CM. Identifying the women at risk of antenatal anxiety and depression: A systematic review. J Affec Disord. 2016; 191:62-77.

24. Abajobir AA, Maravilla J, Alati R, Najman JM. A systematic review and meta-analysis of the association between unintended pregnancy and perinatal depression. J Affec Disord. 2016; 192:56-63.

25. Kirkan TS, Aydin N, Yazici E, Aslan PA, Acemoglu H, Daloglu AG. The depression in women in pregnancy and postpartum period: A follow-up study. Int J Soc Psychiatry. 2015; 6(4):343-9.

26. Howard LM, Oram S, Galley H, Trevillion K, Feder G, 2013. Domestic violence and perinatal mental disorders: a systematic review and meta-analysis. PLoS Med. 2013; 10(5):e1001452.

27. Brasil. Ministério da Saúde. Departamento de Atenção Básica. Cuidado pré-natal de baixo risco. Series A. Normas Técnicas e Manuais - Cadernos de atenção básica, nº 32. Brasília: Publicado pelo Ministério da Sáude. 2012. Portuguese.

28. Meira BM, Pereira PA, Silveira MF, Gualda DM, Santos Jr HP. Challenges for primary healthcare professionals in caring for women with postpartum depression. Texto Contexto Enferm. 2015; 24(3):706-12.

29. Freed RD, Chan PT, Boger KD, Tompson MC. Enhancing maternal depression recognition in health care settings: a review of strategies to improve detection, reduce barriers and reach mothers in need. Fam Syst Health. 2012; 30(1):1-18.

47Acta Paul Enferm. 2017; 30(1):47-59.

Original Article

Therapeutic itinerary of elderly cancer survivorsItinerário terapêutico de idosos sobreviventes ao câncer

Angela Brustolin1

Fatima Ferretti2

Corresponding authorAngela BrustolinSete de Setembro street, 1621,99700-000, Erechim, RS, [email protected]


1Universidade Regional Integrada do Alto Uruguai e das Missões, Erechim, RS, Brazil.2Universidade Comunitária da Região de Chapecó, Chapecó, SC, Brazil.Conflicts of interest: there are no conflicts of interest to declare.

AbstractObjective: To identify the therapeutic itinerary of elderly cancer survivors since detection of signs and symptoms until the end of treatment.Methods: Qualitative research with four elderly cancer survivors (two prostate cancer and two breast cancer patients), two men and two women aged between 73 and 81 years. Data collection was carried out through interviews developed in five visits to the collaborator’s households and with duration of 15 hours on average. Thematic content analysis was used.Results: The journey experienced by the elderly starts with the discovery of signs and symptoms; the course towards the diagnosis in the Health System; the confirmation of cancer; surgery and chemotherapy and the inclusion of complementary and alternative practices in the itinerary.Conclusion: The health care for cancer survivors demands intense articulation of the health system. In that sense, knowing the itinerary becomes a mechanism to qualify this assistance.

ResumoObjetivo: Identificar o itinerário terapêutico de idosos sobreviventes ao câncer, desde a detecção dos sinais e sintomas até o final do tratamento.Métodos: Pesquisa qualitativa com 4 idosos sobreviventes ao câncer (dois de próstata e dois de mama), dois homens e duas mulheres, com idades entre 73 e 81 anos. A coleta de dados foi realizada por meio da entrevista, com 5 visitas no domicílio e duração média de 15 horas. Foi realizada análise de conteúdo temática.Resultados: O percurso percorrido pelos idosos vai desde a descoberta dos sinais e sintomas; a caminhada para o diagnóstico no Sistema de Saúde; a confirmação do câncer; a cirurgia e quimioterapia e a inclusão das práticas alternativas e complementares no itinerário.Conclusão: A atenção em saúde para pacientes sobreviventes ao câncer demanda intensa articulação do sistema de saúde, nesse sentido, conhecer o itinerário torna-se um mecanismo para qualificar essa assistência.

KeywordsNeoplasms; Aged; Life change events;

Health systems

DescritoresNeoplasias; Idoso; Acontecimentos que

mudam a vida; Sistemas de saúde



48 Acta Paul Enferm. 2017; 30(1):47-59.

Therapeutic itinerary of elderly cancer survivors

Introduction

In Brazil, research on health systems and on de-cisions that individuals make when they fall ill are still incipient. Currently, oncological studies have focused on biomedical processes related to the diagnosis and treatments and on the knowl-edge about adaptive reactions to diagnosis and treatments, with lower investment in post-treat-ment or survival phases. The paths traveled in the search for solutions to health problems are generally little known. This theme is not a pri-ority in health, and it is rarely present in the concerns of researchers, managers and policy makers.(1)

Therapeutic itinerary refers to the journey patients experience in the search for treatment in which individuals or social groups choose, evaluate and adhere (or not) to certain forms of assistance.(2) Elderly people will define their path from an array of possibilities marked by distinct, individual or collective, and sometimes even contradictory projects.(3) Knowing these paths requires reconciling aspects of health care to the elderly, as well as identifying the cultural universe of these subjects experiencing a phase marked by complexity, diversity and transforma-tion in which decision-making and choices are necessary.(4) To the extent health requirements of the elderly are intensified, it is essential that professionals who provide their care develop an attentive look towards the journey that the el-derly need to pass in the pursuit of solving their problems within therapeutic itineraries.

In this context, the study aims to identify the therapeutic itinerary of elderly cancer patients from detection of signs and symptoms until the end of treatment. We believe that knowing the itinerary of elderly cancer survivors will allow a better understanding of health and illness pro-cesses and the building of relationships in time and space. This information may deepen the de-bate on the development of lines of care with more integral and humanized approaches that may strengthen individuals and guarantee the right to health.

Methods

This is a qualitative research focused on the method of thematic oral history. Oral history is defined as a social practice generator of changes, as it modifies the focus of the experience itself and reveals new issues and can overcome emotional barriers such as those found in the experiences of the elderly during and after cancer treatment.(5)

The research took place in a city in the west of Santa Catarina. Four elderly were the collaborators of the study: two prostate cancer survivors aged be-tween 76 and 81 years, and two breast cancer survi-vors, one aged 73 and the other, 74 years. Collabo-rators were selected by the following criteria: resid-ing in the city of the study; aged over 60 years; hav-ing evidence of cancer through biopsy diagnosed as breast cancer or prostate cancer; having knowledge of the diagnosis and treatment performed; having survived more than five years after completion of oncological chemotherapy, radiotherapy and/or surgery, without signs and symptoms of cancer re-currence. All were initially identified in medical re-cords in the reference oncology outpatient clinic of the studied city and, subsequently, telephone calls were made to start the field work.

In-depth interviews were used as data collection instrument. This included guiding questions about the diagnosis of cancer; the first day of treatment; all stages of treatments performed and experiences that participants had throughout this journey; ac-cess difficulties to and the possibility of being under any kind of monitoring. Five meetings with each collaborator were held. The first meeting aimed at the initial approach; the second, third and fourth meetings consisted in the interviews; and the fifth meeting was held for validation of interviews. A to-tal of 15 hours on average were necessary to com-plete each interview. Data collection was conducted from November 2014 to January 2015.

We chose thematic content analysis as method for analysis of information. This was carried out in three stages: pre-analysis, material exploration and treatment of results and interpretation. The anal-ysis unfolds in three phases: pre-analysis - phase of organization and systematization of ideas by resum-

49Acta Paul Enferm. 2017; 30(1):47-59.

Brustolin A, Ferretti F

ing the initial assumptions and objectives of the re-search and developing indicators to guide the final interpretation; material exploration - raw material data are encoded into units of records to reach the core understanding of the text and a pre-catego-rization is proceeded; processing and interpretation of results - phase when analytical categories based on the surveyed information are developed, when the researcher proposes his inferences and conducts the his interpretation according to the theoretical framework and the proposed objectives, or identi-fy new theoretical dimensions suggested by reading the material.(6) Collaborators self-identified them-selves by adjectives related to coping mechanisms, as follows: Strength (76 years), Faith (81 years), Family (73 years) and Determination (74 years).

The research project was approved by the Eth-ics Committee of the Chapeco Region Community University (Unochapeco) under Opinion nº 909 718, of December 9, 2014.

Results

The figure 1 represents the journey experienced by the elderly in the search for diagnosis and treat-ment; initially, how they discovered the signs and symptoms, the search for diagnosis with consul-tations and examinations, the confirmation of the diagnosis, the surgery, chemotherapy, radiotherapy and hormone therapy, the impact of this treatment on their lives and their experiences with comple-mentary and integrative practices in this process.

After analysis of the empirical material, summa-rized in figure 1, five themes emerged:

1- Start of therapeutic itinerary: discovery of signs and symptoms;

2- The journey in the search for diagnosis in the Health System: moves in the therapeutic itinerary;

3- Confirmation of the diagnosis of cancer: ex-periences in this stage of the therapeutic itinerary;

4- And now? Surgery, chemotherapy, radiother-apy and hormone therapy: complex stage of the therapeutic itinerary;

5- Alternative and complementary practices: part of the therapeutic itinerary.

Discussion

1- Start of therapeutic itinerary: discovery of signs and symptomsThe search for a therapy begins with the realiza-tion that something is not right, usually translat-ed into physical manifestations that generate dis-comfort. At this stage, the individual and their families begin to reflect on what might be causing this symptom and seek ways to obtain the “di-agnosis”, starting the search for care and treat-ment. From that decision, choices are generally those that make sense for each person, they are anchored on previous experience, always pro-visional and under constant evaluation. At this point, there is no single path. Each subject makes choices within the possibilities they see. Paths are multiple and different.

The signs and symptoms were perceived by three of the four collaborators (Strength, Faith and Family). Among the signs and symptoms of breast cancer, the most common is the nodule (lump) in the breast, with or without pain at the site, as was the case of Family:

In October 2003, while taking a bath, I did breast self-examination, I felt a small lump in the right breast, it was very tiny, the size of the tip of a finger. So I thought it could be something more serious [...] although I was worried, I waited about 15 days, I kept it to myself, I did not tell anyone. (Family, 73 years).

The recognition of a body sign or symptom de-pends on the perception of individuals and on their previous knowledge. Before the fear of the disease and perhaps the lack of pain, Family did not take the detection seriously, she procrastinated searching for medical care - a frequent behavior among peo-ple, regardless of social class.(7)

As for prostate cancer at an early stage, this has silent evolution: some patients do not manifest any specific symptom; others just find it difficult to uri-nate or need to urinate more often during the day or night,(8) as it is the case of the collaborators:

In 2005, when I was 72 years old, I already lived in Chapecó, then I began to feel severe pain and diffi-

50 Acta Paul Enferm. 2017; 30(1):47-59.


culty to urinate; I would wake up four, five, six times at night, the urine would “stuck”, I felt all those same symptoms the first time, I was very worried [...] (Faith, 81 years).

The study collaborators are elderly, and age is a recognized risk factor for prostate cancer - in fact, the only risk factor well established for de-velopment of this cancer. The incidence of pros-tate cancer is linked to the aging process. This has become the most common type of cancer among elderly men; approximately 62% of diag-nosed cases worldwide occur in men aged 60 or older. With increasing life expectancy through-out the world, it is expected that the number of new cases of prostate cancer increase by nearly 60% by the year 2015.(8)

When the collaborators identified or felt some-thing different, they took different paths to search for diagnosis. Along the way, the relationship estab-lished with health professionals can facilitate or not

the acceptance, adhesion, adaptation and decision making regarding treatment.

In the case of collaborators of this study, we identified that Family, Faith and Strength sought aid in the Public Health System, while Determi-nation choose annual monitoring in the private system. Identification of signs and symptoms and the initiative to seek care are part of the therapeutic itinerary, and this consisted in the way how each collaborator sought assistance and care.

2- The journey in the search for diagnosis in the Health System: moves in the thera-peutic itineraryCollaborators followed different paths in the run-up to diagnosis, marked by laboratory and imag-ing tests required in soon after the onset of signs and symptoms. The searching paths, production and management of health care undertaken by in-dividuals and families follow an own logic and are

Figure 1. Path taken by the study collaborators while seeking care in the health system

Waiting

Waiting

Feminine network, health clinic, emergency, general hospital. Urologist, breast cancer specialist, gynecologist, general practitioner, nurse. Waiting.

Rectal examination, general blood tests and imaging tests, mammography, PSA. Waiting.

Anxiety, fear, pain. Waiting.

Consultations Examinations in the Basic Network

Biopsy

Diagnosis

Surgery

ChemotherapyRadiotherapy

Hormone therapy

Signs and symptoms

SURVIVAL

Complementary treatments

Anxiety, fear, initial impact,

preparatory exams.

Quadrantectomy, waiting, preparatory exams, fear,

anxiety, post-surgical care, self-image.

Toxicities.Fear.

Monitoring in the health system. Profession-al support and follow-up.

Building friendship ties. Side effects.

Sexual dysfunction, depression,

professional support and follow-up

Breast lump, pain, loss of strength, paresthesia,

difficulty urinating, worry, fear and anxiety.

51Acta Paul Enferm. 2017; 30(1):47-59.


woven in multiple health care networks, in order to ensure support during the experience of falling ill.(9) Reconstitution of the therapeutic itineraries of elderly cancer survivors presented in this research brings forth a reflection about the functioning of the health care network. The experiences of older people in the search for meeting their needs showed how services are organized to serve this population.

Faith, for example, sought help to solve his health problem in the Basic Health Unit (BHU) in his neighborhood:

[...] I went to the health center here in my neigh-borhood, where I used to go, but the doctor did not even look at me, he did not give me much attention, he asked blood tests and an ultrasound and told me to bring them to the specialist of the health secretariat, who was urologist. (Faith, 81 years).

What calls attention in the report is the lack of a welcoming and empathetic attitude of health profes-sionals towards the user. In this context, we agreed that the welcoming hosting is not an isolated prac-tice, but a set of actions that translate into attitudes that professionals adopt while interacting with their patients in health services.(10) In this perspective, the reception becomes a point of intersection between different subjects and care practices in primary care. It is clear that dialogue was not meaningful during the meeting between the collaborator Faith and the health professional. The need for dialogical hosting in health work is essential for providing an effective comprehensive care.

In the case of Strength, it is important to note that the hospital represented the public service sought by him and his family, according to his need of care:

[...] I felt a damping and loss of strength in the legs, was when I was in the bathroom shaving, then I could not move, I came from the bathroom crawling, and stayed on the couch waiting for my son. When he arrived, he took me to the hospital. [...] The next day I went to the health center in my neighborhood and there they referred me to see the urologist [...] (Strength, 76 years).

After entering the hospital emergency room, Strength was sent to a BHU. Many people return to BHU for lack of resoluteness and due to failures

in the guidelines, to adopt a treatment, or even to carry out a proper assessment. (11)

Collaborator Determination followed a dif-ferent path: ass she had a health insurance plan, she appointed a consultation directly with the gynecologist:

I did not try the primary care network, I did not look for SUS. At the time, as an employee of the state, I had health insurance plan, and I thought this was the fastest way because I was aware of many stories, many facts that there is a delay in setting up appointments and receiving care by the SUS [...]. On the mammo-gram, there was a lump in my right breast. In the first appointment with the breast cancer specialist, he actu-ally said that there was something different, and even though I had no symptoms, we would have to investi-gate that; then he scheduled a biopsy. (Determination, 74 years).

The collaborator demonstrated a lack of confi-dence in the public health system. There are indi-viduals who openly state they prefer using private medicine or health insurance plans because they believe their problems are solved more quickly and effectively in this system. They express a negative evaluation of the provision of care in the public sector.

For diagnosis of cancer, a biopsy is performed. During and after this examination, the collabora-tors reported different experiences and sensations. Strength felt pain and discomfort at the time of biopsy:

What I did not think was a good experience was this biopsy; at first it did not hurt at all, but then at the end, I felt a lot of pain. They took 12 pieces of my prostate, I could not take it anymore, I suffered, my vision blurred because of the pain. This stressed me a bit; no one likes to feel pain. I felt fear of pain, sadness for having to go through that, besides the concern, be-cause it could be something complicated; if things were all right, of course I would not have be doing all those exams, all that mess. (Strength, 76 years).

The pain during the procedure is associated to two reasons: the input of a transrectal transducer and the needle penetration in the prostate capsule. Because of this necessary but painful procedure, it is important to make use of analgesia or anesthe-

52 Acta Paul Enferm. 2017; 30(1):47-59.


sia to reduce the discomfort and thereby increase the number of samples taken and the success of the procedure.(12)

For Family and Determination, this moment was marked by the search for definition of the dis-ease and diagnosis:

As soon as I entered the room, she promptly asked me “Are you afraid of needles?” I said: “I do not think so.” I felt a little prick, it hurt [...]. This medical expert examined, touched and felt the lump that was there, at that very moment she asked the ultra-sound, took another piece to remake the exam, she herself sent it for biopsy (Family, 73 years).

I did this procedure [biopsy]; eight days after consultation, in a radiology clinic, I went with my sister to the biopsy, I felt pain, mixed with concern, fear, insecurity, uncertainty, sore [...] (Determina-tion, 74 years).

The biopsy is the apex of the path taken towards the definition of the diagnosis in the therapeutic itinerary.(13) Patients showed signs of anxiety, an-guish and helplessness. The period of diagnosis can be quite traumatic, especially if it is prolonged or ends with the confirmation of the disease.

In general, a flow is observed in the study collaborators that starts in the BHU, from the suspicion of cancer, and follows with referral to specialized services of medium complexity in the municipality patients live for diagnostic investi-gation, and then to Reference High Complexi-ty Oncology Centers (CACON) to confirm the diagnosis, staging and treatment. In practice, we see that formally provided references do not always correspond to the actual network de-signed for users with cancer in their search for care. Other flows and new references appear as a way of overcoming the difficulties of access, as it was the case of Faith, who sought private care to solve his health problem:

I did the tests and after about twenty days, when I took them there [health secretariat], they told me that the urologist who would see me was on vacation [...] I would have to wait and I waited, I waited for almost one year, it was then that things got complicated, be-cause the pain and the symptoms got worse too. It was like this: I would go there every three months to see if

he had returned from vacation, and nothing, I went there and he was never there, he was a long time on vacation! I knew there was something wrong. During this waiting period I never mentioned to anyone about what was happening to me, I kept that just for myself; I would simply go by myself to the doctor. I would not tell anyone because I was ashamed, I did not want to bother, to bother anyone, but I was more for shame. I was in a very difficult moment, waiting, holding up all those symptoms [...]. It was then that I, I was very angry and I did it on my own, I went to the doctor’s office, the urologist who operated on me the first time and that was the best thing I did, got tired of waiting! (Faith, 81 years).

The difficulties to access medium complexity services, that is, specialized consultations and ex-aminations represent one of the great challenges of the SUS.(14) The resoluteness of primary care is associated with issues related to the physical struc-ture of the services, processes and management of work and professional training, which, in turn, have repercussions on the demand for specialized services.(15) Hence the importance of knowledge and interpretation of the therapeutic itinerary; this help professionals and managers to become aware that the ways pre-established in service net-works have not always been effective and they do not always work. The collaborators’ search for the diagnosis shows that these needed to exercise the ability to elaborate coping mechanisms to over-come health disparities, not only in the sense of detecting them, but to overcome them in a context of large heterogeneities and inequalities within the health system.

3- Confirmation of the diagnosis of can-cer: experiences in this stage of the ther-apeutic itineraryOf four collaborators, three were informed of the diagnosis of cancer. One of them, Faith, did not re-ceived the information of his diagnosis: even being aware that he was undergoing treatments for cancer, he was not informed by health professionals neither by his family about his health condition. The im-pact of the diagnosis and the experiences in this phase will be explored below.

53Acta Paul Enferm. 2017; 30(1):47-59.


The collaborator Strength had mixed feelings when he received the diagnosis:

I got a bit scared, it was a shock because nobody wants to have this disease, but thought I had to go on, face this obstacle just as I have faced all in my life. Of course, deep down we feel fear, it was an unknown thing for me, but I never lose my balance for the prob-lems of life, I was always the type that to goes forward without looking back. (Strength, 76 years).

Upon receiving the diagnosis of cancer, a disease that brings so much suffering and worries, it cre-ates a deconstructive situation, not only for those who are for it affected, but for everyone around you, once you see surprised for a moment of great stress, which generates behavioral changes and puts the subject in front of a new stage of life, the unex-pected beginning. We can assume that the diagno-sis of cancer triggers various reflections and feelings, which, influenced by previous experiences and in-dividual differences, result in unique behaviors of adaptation to face the stress and anxiety caused by this moment.(16) (Determination, 74 years).

The moment of diagnosis was very difficult, I thought it was something that would never happen to me, it was a mixture of fear, doubts about what would happen, on how would be the future, all came to my mind, and at the same time I wanted to show confi-dence for my family [...] so I tried to show that it was nothing, but inside, I had many fears, many fears! At the time I felt that fear of cancer, I am human [...]. The word cancer scared a little my children and the other family members; it was very scary because I was always the strength in the family.

When you receive a diagnosis of breast cancer, women face the prospect of an uncertain future, in which the fear of death and mutilation prevails. We experience a time of contradictory and intense feelings, in which fear, anger, uncertainty and even acceptance become part of the everyday life. Anoth-er important aspect to be discussed is how the diag-nosis of cancer is released to the patients and their families by medical professionals:

The day of consultation had arrived, I was curi-ous, I wanted to know the result, my chest was very tight. My older daughter, who always accompanied me in everything, she was with me; getting there, the

urologist gave us the news that it was cancer, I would have to take some injections and undergo radiotherapy. (Strength, 76 years).

[...] So I said: “Doctor, do not tell me it’s cancer!” And then she said: “Yes, it is cancer, but I do not know the type, I have to tell you, I cannot hide this from you.” [...] My husband was out there waiting for me, I left the office frightened, giddy, could not feel the floor, got in the car, and he was worried, he asked me what had happened, I said: “Do you know what I have? It is cancer!” At that moment, we felt a mixture of fear, sadness, it seemed a nightmare. (Family, 73 years).

[...] So I said: “Doctor, do not tell me it’s cancer!” And then she said: “Yes, it is cancer, but I do not know the type, I have to tell you, I cannot hide this from you.” [...] My husband was out there waiting for me, I left the office frightened, giddy, could not feel the floor, got in the car, and he was worried, he asked me what had happened, I said: “Do you know what I have? It is cancer!” At that moment, we felt a mixture of fear, sadness, it seemed a nightmare. (Family, 73 years).

Delivering bad news as the case of a diagnosis of cancer is an extremely complex issue and requires preparation and sensitivity.(17) So, planning how the disclosure will occur can make it easier for health professionals to provide the flow of information, as well as how to best do it. Revealing the diagnosis in fast manner and in a place that restricts the possibil-ity of dialogue is far from being the most appropri-ate way to disclosing such information, as pointed the reports of the study collaborators.

The non-disclosure of the diagnosis produces discomfort and distress, as in the case of Faith (81 years):

Nobody told me anything, neither the doctor nor the family, I suspected something, because I thought “they are not doing all of this for no reason”. The urolo-gist did not tell me it was cancer, neither the radiother-apy doctor. They never told me anything. But I knew it because it was written there. It was a place of treat-ment for cancer... And then, I would see and talk to all the other patients undergoing treatment, radiotherapy, there were ninety or a hundred people there for treat-ment, and then everyone would speak of their problem [...]. I was anxious, I knew my diagnosis, I had doubts, but I did not ask anyone about it, I was always quiet, I

54 Acta Paul Enferm. 2017; 30(1):47-59.


was raised that way. This doctor [the oncologist] said it was nothing, but I knew and he surely also knew that I had cancer, he knew it, he should have known, right ?!

Often, even because of family pressure, a dilem-ma of telling the truth or not for the elderly patients takes place. This aims to spare them from suffering. In fact, the main issue is actually the most appropri-ate way of communicating the diagnosis, because, when there is no communication, patients do not have their right of autonomy assured. This refers to the right patients have to decide whether or not to perform a treatment indicated by the health profes-sionals, except in cases where their cognitive func-tion is impaired.

Elderly cancer patients cannot be mischaracter-ized, deprived of the information on their diagno-sis, on the proposed treatment and the care needed at this stage of life. It is understood that open dia-logue can strengthen the link between patients and professionals, besides dignifying the human being by recognizing their autonomy and power of deci-sion-making about their own lives.(18)

Confirmation of the diagnosis of cancer can trig-ger suffering that tends to affect people’s universe of relationships. It can lead them to become closer or to move away from those around them, as well as to face in different ways the coming treatment steps.(19) Even in times of sorrow, distress, and great stress generated by the waiting period and by the confir-mation of the diagnosis - or even if the case of Faith who was prevented from learning the diagnosis as formalized news - none of the collaborators was un-deterred or gave up face the next steps; all adhered to the forms of treatment proposed and, from that, they chose to give continuity to their itinerary.

4- And now? Surgery, chemotherapy, ra-diotherapy and hormone therapy: com-plex stage of the therapeutic itinerary.At this stage, collaborators enter high complexity contexts and perform treatments in High Com-plexity Oncology Center (CACON) in the munici-pality where the study was conducted. With regard to cancer care, the high cost of treatment must be considered. It is known that most cancers in Bra-zil are diagnosed in advanced stages, which leads to

greater concentration of interest in providing high complexity services and resulting in low patient sur-vival.(14) Among the various ways to treat cancer are surgery, chemotherapy and radiotherapy. The way elderly survivors experience these therapeutic mo-ments will mark their life story.(20)

Among the four collaborators of the study, the elderly who had prostate cancer were not submit-ted to surgery. As for the two women, after diag-nosed with breast cancer, they underwent quadran-tectomy. It is noteworthy that Strength performed transurethral resection of the prostate (TURP) with negative biopsy for cancer in the period before the diagnosis of cancer.

Oncologic surgery is a cause of much anxiety, uncertainties and fears,(16) as expressed in the fol-lowing account:

Surgery was an important moment for me because I thought I could “die on the table”. I couldn’t wait to do the surgery; from that stage on, I got better, it seems that they had taken that “thing” out of me. (Family, 73 years).

Women who undergo mastectomy face a whirl-wind of feelings such as fear, apprehension and con-cern, especially in the moments prior to surgery; all promptly mention the lack of information and awareness about the disease.(21) Another important topic to be discussed in this step of the itinerary is the waiting time for the surgery in the SUS (Fami-ly) and in the private network, by the health insur-ance plan (Determination):

Five months after discovering cancer, I had the sur-gery. (Family, 73 years).

[...] between the discovery and the surgery, it prob-ably took thirty days. (Determination, 74 years).

Specifically in the case of breast cancer, among other recommendations, INCA indicates that treat-ment should begin as soon as possible and not later than three months after the confirmation of the di-agnosis. To carry out the complementary chemo-therapy or hormone therapy, the maximum period should be 60 days, and for radiotherapy, 120 days. Delay in the commencement of treatment increases the risk of local recurrence of the disease and de-creases survival rates.(22) Delaying the start of treat-ment brings complications such as increased tumor

55Acta Paul Enferm. 2017; 30(1):47-59.


volume and decreased life expectancy. For the col-laborator Determination, who began the treatment process in the supplementary health system, the deadline set by public policy was fulfilled. In the case of the collaborator Family, SUS user, this did not happen.

Among the collaborators of the study, Family and Determination received chemotherapy: the first underwent treatment in the CACON reference of her city; and the second in a supplementary che-motherapy service provided by her health plan. On the experience of undergoing chemotherapy, both highlight the care provided by health professionals during the course:

My first consultation with the oncologist happened a month after surgery [...] I felt well with him, he ex-plained me everything [...] (Determination, 73 years).

In April 2004, I had my first consultation with the oncologist. The doctor said that treatment was nec-essary to survive and in order to stand chemotherapy, I would have to be very strong; the doctor was very kind to me. (Family, 74 years).

Proper communication in chemotherapy units provides comfort, soothes the mind state, relieves symptoms, and reduces anxiety of the unknown.(23) Conversely, the noise coming from poor communi-cation causes fear, anxiety and other negative feel-ings. It is essential that health professionals under-stand and interpret the attitudes of people through the experience of illness, because this information offer a direction for decision making with regard to the care guidelines.(20)

The diagnostic process is the most difficult and distressing period for the elderly. However, after re-ferred to hospitals for treatment of cancer, factors such as anxiety, pain and ignorance of the disease are problems that are far from properly addressed. The time between the first medical care, comings and goings to professionals and the arrival at the re-ferral hospital for oncological care lasts months and generates various feelings of uncertainty, as denoted in the speech below:

Around 10 to 15 days after the first visit, I went to the first chemotherapy session, I was anxious just as the days before this moment, that, in fact, was filled with curiousity: “What would happen? What was

that? How is it applied? How is it that I would take it? What reaction would I have? How long would it take?” I was full of questions, doubts and fears. (De-termination, 74 years).

The waiting time is a factor that concerns can-cer patients, reverberates psychically, accelerates the disease process and reduces the chances of cure.(24) All collaborators of the study underwent radiother-apeutic treatment and reported preparation, expec-tation and anxiety for starting such treatment, as recorded in the following report:

[...] before radiotherapy, I got a tattoo, I actually have three, which are some dots that I still have, one on each side of the hip and down from the waist, that was for them to know exactly where they should apply treat-ment and after a month of preparation I made my first application of radiotherapy [...] (Strength, 76 years).

It is understood here that the experience of on-cological radiotherapy represents to these patients the need to undergo a form therapy with drug-poi-son characteristics. This causes fear, but it is neces-sary if the goal is to get cured or even survive cancer.(25) Generally, after passing this stage, patients have the impression that they are strengthened and won one more barrier and this, in turn, facilitates adher-ence to treatment.

After I finished the last application of radiotherapy, I had the impression that I had woken up to life; I re-member I got home and began to see things differently, I asked my family, “Why haven’t you painted this house anymore?!” It was like I had waked up! I returned to be Family! (Family, 73 years).

For Determination, moments experienced in radiotherapy led to occasions of support and of building new relationships:

Very interesting that when I finished the treat-ment of radiotherapy, I always had the impression that I needed to go for radiotherapy, needed to go at that time, needed to be with those people. I remember I had difficulties to leave those friendships I made during treatment. I think I felt this need because being with people in the same situation used to make me feel safe, they had the same problems, the same fears. I identified myself with them, for eight to ten days I wanted to go there, I still missed going there, something was missing. (Determination, 74 years).

56 Acta Paul Enferm. 2017; 30(1):47-59.


Study that aimed to understand the meaning of oncological radiotherapy to ten patients of both sexes noted that the symbolism of radiotherapy is built little by little, as informants perform the treat-ment sessions. This process contributes to the un-derstanding of all aspects comprising the process of falling ill, and those embodied in the experience of undergoing treatment, giving direction to the re-covery of the individual and social body.(25)

The individual perception or the one of a group on the disease defines the search for care. In order to understand the health of individuals and the way they face the disease, it is necessary to analyze their practices from the context in which they take form. From the perspective of authors, the demand for care is conditioned to attitudes, values and ideologies, as well as to the profile of the disease, the economic access and the availability of technology.(4)

In this study, even if the radiotherapy had as-sumed the form of an aggressive moment, collabo-rators remained active and adhered to the therapy. The decision to stick to treatment came from the construction of such networks and the search for therapeutic care to address their health problems. Hence the importance of social support networks to deal with daily problems, especially regarding the search for health care and the individual’s ability to mobilize such resources.

All collaborators of the study underwent treat-ment hormone therapy. The collaborators Strength, Faith and Family kept under follow-up in CACON, where they continued this treatment considered highly complex. Apparently, collaborators have no difficulty in acquiring the medicine:

In the middle of the radiotherapy treatment I was directed to the treatment with injections in the stom-ach [anti-hormone therapy]. The radiotherapy doctor referred me to chemotherapy, he gave me a referral order and I went there; and then after two weeks they called for me to see the oncologist. I made eight applications, one per month, always the same, that little prick in the stomach, but it did not hurt much. (Strength, 76 years).

When I reached the middle of the radiotherapy treatment, the doctor referred me to take the shots in

the stomach; I waited around ten days for them to call me for this treatment. (Faith, 81 years).

After the anti-hormone Tamoxifen, the collabo-rator Determination returned to the public health system to receive another anti-hormonal, Arimidex (Anastrozole):

After five years, when I finished Tamoxifen, I start-ed taking Arimidex, which I used for five years, but this one at the time would cost around R$ 400.00 each box. It was when the health plan oncologist explained me that I could receive this medication by SUS. He referred me to the Health Secretariat with a high cost drug request, and soon after, the reply came informing that I should go to the hospital’s oncology clinic. This process took about two or three months, and after this time I started to go to this clinic to receive Arimidex, thus, the first boxes I bought and then it was fine, I would get them monthly, always respecting the date they determined. (Determination, 76).

The situation experienced by this collaborator was also reported in another study, whose subjects had difficulty accessing medicines in the supple-mentary care network, with the need to seek the SUS to give continuity to their treatment. Accord-ing to the authors, this seems to be one of the main limitations of private health plans regarding the treatment of breast cancer.(26)

A study on therapeutic itineraries observed that patients move between the public and private systems to access health care and many difficulties are present in the coverage of health plans, with eventual need to seek the SUS for medication.(1) In the view of these authors, several arrangements are established in the everyday life of users when they seek, through their own choices or strat-egies, to overcome the gaps in the access and in comprehensive care. This condition has been also observed in this study, when the collaborator De-termination had to move between the public and private health systems.

More comprehensive assessments of care mod-els established for users in the current Brazilian daily care routine are needed to qualify the health care.(20) The investigation of the therapeutic itin-erary of the elderly with cancer showed the dif-ficulties experienced by patients in the search for

57Acta Paul Enferm. 2017; 30(1):47-59.


care, starting from the discovery of the disease and extending to the end of the treatment carried out in health services. Often these difficulties are exacerbated with the limitations imposed by age and disease, producing pain to the user and to the family nucleus. In this perspective, they could pur-sue different strategies and ways to overcome such phase, among them, the complementary and inte-grative health practices that emerge in the thera-peutic itinerary.

5- Alternative and complementary prac-tices: part of the therapeutic itineraryComplementary and alternative practices (CAPs) are a group of diverse medical and health care sys-tems that are not considered part of the conventional medicine such as homeopathy, Reiki, chiropractic, acupuncture and meditation.(27) These therapeutic approaches point to a view of health understood as broad welfare, which involves a complex interaction of physical, social, mental, emotional and spiritu-al factors. In this perspective, the human body is understood as an energy field from which different methods can act.(28)

The collaborators of this study sought the appli-cation of medicinal mud, Reiki and medicinal teas and supplements in their health treatment during the therapeutic itinerary.

At that time I used to drink lots of tea... and I had faith that things would improve and solve. (Strength, 76 years).

At the end of radiotherapy I was tired, I wanted to be alone, I would come pretty stressed, angry, they had to leave me alone and quiet, so I always took tea to improve digestion; to tell the truth, I had tea all the time, chamomile, lemon balm, fruits; my daughter and my husband would prepare it to me, it helped me and calmed me down. (Family, 73 years).

[...] I did lots of Reiki, Reiki relaxed me a lot [...] (Determination, 74 years).

In order to ensure comprehensiveness in health care, the Ministry of Health created in 2006 the National Policy on Integrative and Complementa-ry Practices (PNPIC) in SUS. This aimed to sup-port, incorporate and implement experiences in the

public network, such as acupuncture, homeopathy, herbal medicine, and others.(29)

In addition to the therapies prescribed by health professionals, it is common for patients to seek oth-er care strategies when facing a disease. This search is intended to complement the health care needs and is focused on cultural beliefs directly influenced by individual and family choices.(30) The collaborators emphasized welfare and decreased stress during and after the use of complementary practices, a factor to be taken into account when establishing a health care planning for this population.

Conclusion

During the therapeutic itinerary, the elderly of this study transited between the private and the public health sectors, with more frequent use of the latter, especially of medium and high complexity services. Their reports showed that primary care is not struc-tured to provide care at the stage of survival, which brings forth the need to discuss the organization of health care to patients with cancer before and after cancer treatment, with a view guarantee compre-hensive health care in this phase, minimizing hu-man suffering. The health care for cancer patients demands intense articulation of the health system and work of a wide range of services and profes-sionals for the production of comprehensive care. The need for the comprehensive work of the ar-ticulated health team towards the patient’s families becomes evident.

Elderly cancer survivors faced difficulties in accessing health services when they sought diag-nosis and treatment in the public sector. The long waiting times for examinations and consultations are one example. In this scenario, the need to re-think health care for this population seems to be necessary. Investments not only in technological resources and infrastructure but also in human re-sources and in the organization of work processes are needed, as well as a support network to back up the actions of health teams, not only in the therapeutic course, but after that period, in the survival phase.

58 Acta Paul Enferm. 2017; 30(1):47-59.


AcknowledgementsTo the Support Fund for Maintenance and Devel-opment of Higher Education - FUMDES of the State Secretariat for Education/SC, for granting scholarships at the master’s level that supported the development of this research.

CollaborationsBrustolin A and Ferretti F state that contributed to the conception, analysis and interpretation of data, article writing, relevant critical review of the intel-lectual content and final approval of the version to be published.

References

1. Conill EM, Pires D, Sisson MC, Oliveira MC, Boing AF, Fertonani HP. [The public-private mix and health service utilization: a study of the therapeutic itineraries of Brazilian supplementary care beneficiaries]. Ciênc Saúde Coletiva. 2008; 13(5):1501-10. Portuguese.

2. Alves PC, Souza IM. Escolha e avaliação de tratamento para problemas de saúde: considerações sobre o itinerário terapêutico. In: Rabelo MC, Alves PC, Souza IM. organizadores. Experiência de doença e narrativa. Rio de Janeiro: Editora Fiocruz; 1999. p. 125-38.

3. Mângia EF, Muramoto MT. [Therapeutic itinerary and the construction of caring therapeutic projects]. Rev Ter Ocup. 2008; 19(3):176-82. Portuguese.

4. Gerhardt TE. [Therapeutical itineraries in poverty situations: diversity and plurality]. Cad Saúde Pública. 2006; 22(11):2449-63. Portuguese.

5. Thompson P. A voz do passado: História Oral. Rio de Janeiro: Paz e Terra; 1992.

6. Minayo MCS. Desafio do Conhecimento: pesquisa qualitativa em saúde. 13a ed. São Paulo: Hucitec; 2013.

7. Anjos AC, Zago MM. [The cancer chemotherapy experience in a patient’s view]. Rev Lat Am Enfermagem. 2006; 14(1):33-40. Portuguese.

8. Brasil. Ministério da saúde. Instituto nacional do câncer [internet]. Incidência do Câncer no Brasil: estimativas 2014-2015 [citado 2016 Jul 13]. Rio de Janeiro, 2013. Disponível em: http://www.inca.gov.br/estimativa/2012/index.asp?ID=5.

9. Belatto R. Itinerários terapêuticos de famílias e redes para o cuidado na condição crônica: alguns pressupostos. In: Pinheiro R, Martins PH. Avaliação em saúde na perspectiva do usuário: abordagem multicêntrica. Rio de Janeiro: CEPESC; IMS/UERJ; ABRASCO; 2009. p.187-94.

10. Guerrero GP, Zago MMF, Sawada NO, Pinto MH. [Relationship between spirituality and cancer: patient’s perspective]. Rev Bras Enferm. 2011; 64(1):53-59. Portuguese.

11. Cholze AS, Silva YF. [Potential risks for health on routes of healing and care]. Cogitare Enferm. 2005; 10(2):9-16. Portuguese.

12. Barbosa RA, Silva CD, Torniziello MY, Cerri LM, Carmona MJ, Malbouisson, LM. [A comparative study among three techniques of general anesthesia for ultrasound-guided transrectal prostate biopsy]. Rev Bras Anestesiol. 2010; 60(5):457-465. Portuguese.

13. Salci MA, Marcon SS. [After cancer: a new way of living]. Rev Rene. 2011; 12(2):374-83. Portuguese.

14. Peroni FM. [Making networks : therapeutics itineraries of patients with cancer in te macro-region of Campinas] [tese]. São Paulo: Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas; 2013. Portuguese.

15. Spedo SM, Pinto NRS, Tanaka OY. [The difficult access to secondary health care services: São Paulo city case study, Brazil]. Physis. 2010; 20(3):953-72. Portuguese.

16. Costa P, Leite RC. [Coping strategies of oncology patients submitted to mutilating surgeries]. Rev Bras Cancerol. 2009; 55(4):355-64. Portuguese.

17. Silva VC, Zago MM. [The cancer diagnosis disclosure for the patient and healthcare professionals]. Rev Bras Enferm. 2005; 58(4):476-80. Portuguese.

18. Visentin A, Labronici L, Lenardt MH. [Autonomy of elder patients suffering from cancer: the right to know about their diagnoses]. Acta Paul Enferm. 2007; 20(4):509-13. Portuguese.

19. Menezes NN, Schulz VL, Peres RS. [Breast cancer diagnosis’ psychological impact: a study since patients’ reports in a support group]. Estud Psicol. 2012; 17(2):233-40. Portuguese.

20. Visentin A, Lenardt MH. [Therapeutic itinerary: oral history of elderly patients with cancer]. Acta Paul Enferm. 2010; 23(4):486-492. Portuguese.

21. Alves PC, Barbosa IC, Caetano JA, Fernandes AF. [Nursing care during the preoperative stage and rehabilitation of mastectomy: narrative review of literature]. Rev Bras Enferm. 2011; 64(4):732-7. Portuguese.

22. Brasil. Ministério da Saúde. Instituto Nacional do Câncer. ABC do câncer: abordagens básicas para o controle do câncer. Rio de Janeiro: INCA; 2011. p. 128.

23. Rennó CS, Campos CJ. [Interpersonal communication research: valorization of the oncological patient in a high complexity oncology unit]. Rev Min Enferm. 2014; 18(1):106-15. Portuguese.

24. Aquino R, Vilela MB. [Communication with patients cancer: Concern related wait time for access and therapeutic itinerary care oncologic]. Distúrb Comum. 2014; 26(2):420-2. Portuguese.

25. Muniz RM, Zago MM. [The oncologic radiotherapy experience for patients: a poison-drug]. Rev Lat Am Enfermagem. 2008; 16(6):998-1004. Portuguese.

26. Sisson MC, Oliveira MC, Conill EM, Pires D, Boing AF, Fertonani HP. [Users’ satisfaction with the use of public and private health services within therapeutic Itineraries in southern Brazil]. Interface (Botucatu). 2011; 15(36):123-36. Portuguese.

27. Cruz CT, Barros NF, Hoehne EL. [Evidences of complementary and alternative therapies in conventional breast neoplasm treatment]. Rev Bras Cancerol. 2009; 55(3):237-46. Portuguese.

28. Andrade JT, Costa LF. [Complementary medicine in the sus: integrative practices in the perspective of medical anthropology]. Saúde Soc. 2010; 19(3):497-508. Portuguese.

59Acta Paul Enferm. 2017; 30(1):47-59.


29. Brasil. Ministério da saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Práticas Integrativas e Complementares no SUS (PNPIC-SUS). Brasília (DF): Ministério da Saúde; 2006. p. 92.

30. Rosa LM, Radünz V. [Therapeutic itinerary in breast cancer: a contribution to the nursing care]. Rev Enferm. 2013; 21(1):84-89. Portuguese.

60 Acta Paul Enferm. 2017; 30(1):60-5.

Original Article

Assessment of somatic and affective-cognitive symptoms of people living with HIV/AIDSAvaliação dos sintomas depressivos somáticos e afetivo-cognitivos de pessoas vivendo com HIV/AIDSRenata Karina Reis1

Carolina de Castro Castrighini1

Elizabete Santos Melo1

Giselle Juliana de Jesus1

Artur Acelino Francisco Luz Queiroz1

Elucir Gir1

Corresponding authorRenata Karina ReisBandeirantes Avenue, 3900,14040-902, Campus Universitário, Monte Alegre, Ribeirão Preto, SP, [email protected]


1Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.Conflicts of interest: none to declare.

AbstractObjective: To analyze the somatic and affective-cognitive symptoms of depression according to the sex of people living with HIV/AIDS.Methods: Analytic study developed at specialized care services in Ribeirão Preto-SP, including a sample of 331 participants. To collect the data, a sociodemographic characterization tool and Beck’s Depression Inventory (BDI) were used.Results: Among the interviewees, 50.4% were male, 52.1% of whom in the age range between 20 and 35 years. Higher education (p=0.001) and lower income (<0.001) were found for the women and more comorbidities (p=0.004) for the men. It was identified that the women presented higher mean depression scores in the somatic (p<0.001) as well as in the affective/cognitive domains (p<0.001).Conclusion: These study results appoint that the women present higher depressive symptom scores than the man, in the somatic as well as in the affective/cognitive domains of the BDI subscales.

ResumoObjetivo: Analisar os sintomas somáticos e afetivo-cognitivos de depressão segundo o sexo de pessoas que vivem com HIV/AIDS.Métodos: Estudo analítico realizado em serviços de atendimento especializado em Ribeirão Preto-SP, com amostra de 331 participantes. Para coleta de dados foram utilizados instrumento de caracterização sociodemográfica e o Inventário de Depressão de Beck (BDI).Resultados: Dos entrevistados, 50,4% eram do sexo masculino e destes, 52,1% estavam na faixa etária de 20 a 35 anos. As mulheres apresentaram maior escolaridade (p=0,001) e menor renda (<0,001), e os homens apresentaram mais comorbidades (p=0,004). Identificou-se que as mulheres apresentaram maiores médias de escores de depressão, tanto no domínio somático (p<0,001) quanto no afetivo/cognitivo (p<0,001).Conclusão: Os resultados deste estudo apontam que as mulheres apresentam maiores escores de sintomatologia depressiva do que os homens, tanto no domínio somático quanto no afetivo/cognitivo das subescalas do IDB.

KeywordsHIV; Depression; Sex

DescritoresHIV; Depressão; Sexo



61Acta Paul Enferm. 2017; 30(1):60-5.

Reis RK, Castrighini CC, Melo ES, Jesus GJ, Queiroz AA, Gir E

Introduction

The introduction of Combined Antiretroviral Ther-apy (cART) and the universal access to these drugs represent a landmark of changes in the treatment and progression of HIV infection. The cART has resulted in more effective infection control, restor-ing the immunity and reducing the mortality,(1) be-ing currently considered a chronic condition.

In that perspective, it is highlighted that Peo-ple Living with HIV/AIDS (PLHA) still face many challenges, ranging from the intense clinical mon-itoring to drug treatment compliance,(2) lack of so-cial support(3) and stigma, which can have implica-tions for their mental health.

Particularly among the mental disorders, de-pression is the most common psychiatric complica-tions associated with HIV.(4) In PLHA, it is known for being negatively associated with worse compli-ance with antiretroviral treatment,(5) therapeutic outcomes and risk behaviors,(6) besides its consid-erable impact in the treatment and social relation-ships(7) and in the more rapid progression to Aids and death.(1) Hence, the importance of measuring and understanding the influence of depression in this population is highlighted.

In recently published studies, high depression levels have been reported among PLHA around the world.(8,9) In a study developed in the interior of the State of São Paulo, Brazil, it was identified that 63 (27.6%) individuals presented symptoms of depres-sion, being 13 (5.7%) with mild, 29 (12.7%) with moderate and 21 (9.2%) severe, as measured by the Beck Depression Inventory (BDI-I).(10)

In addition, in other studies, it has been report-ed that the prevalence of depression among PLHA is two to three times higher when compared to the general population.(11,12) Nevertheless, the popula-tion living with HIV/Aids consists of several groups with socioeconomic differences and peculiar behav-ioral characteristics.(8) Therefore, these differences need to be understood.

These studies(11,12) appointed variations between men and women with major depressive disorder in terms of perceived depressive symptoms, as mea-sured by the Beck Depression Inventory.

In Brazil, various studies have been found that assessed depression in PLHA,(13-15) but none of them assessed the somatic and affective-cognitive symp-toms among men and women living with HIV/AIDS. The pertinence of assessed sex-related partic-ularities is highlighted with a view to understanding the differences and supporting qualified care. Thus, the objective in this study is to analyze the somatic and affective-cognitive symptoms of depression and to compare the differences according to sex among PLHA.

Methods

An analytic and cross-sectional study was developed at Specialized Care Services (SCS) in a city in the State of São Paulo, Brazil.

The study participants were people living with HIV/AIDS who complied with the following in-clusion criteria: having been diagnosed with HIV/AIDS for more than six months, being under clin-ical and outpatient monitoring at the selected ser-vices, male and female and age 18 years or older. Individuals in situations of confinement, such as convicts, and institutionalized individuals, such as people living in support homes, were excluded.

The data were collected through individual in-terviews, using a tool to collect sociodemographic data and the Beck Depression Inventory in the ver-sion adapted to Portuguese.(16)

The BDI-I is a 21-item inventory that describes behavioral, affective, cognitive and somatic man-ifestations of depression. Each item comes with four alternatives progressively ranging from zero to three, in which the highest scores indicate increased severity of the symptoms. The highest total scores suggest more severe depression symptoms.(17)

According to a review(18) to categorize the af-fective-cognitive domains, items 1 to 10 and 12 to 14 (sadness, pessimism, feeling of failure, lack of satisfaction, feeling of guilt, feeling of punishment, self-depreciation, self-accusations, social retraction, indecision, suicidal ideas, bouts of crying, distorted body image) to calculate the subscale of cognitive-af-fective symptoms of the BDI-I (range from 0 to 39).

62 Acta Paul Enferm. 2017; 30(1):60-5.

Assessment of somatic and affective-cognitive symptoms of people living with HIV/AIDS

Similarly, to categorize the somatic domain, items 11 and 15 to 21 should also be added up (irritability, inhibition for work, sleep disor-der, fatigue, appetite loss, weight loss, somatic concern and decreased libido) to calculate the somatic symptom subscale of the BDI-I (range from 0 to 24).(19) Higher scores on the subscales mean higher somatic and cognitive-affective disorders.(20)

To analyze the data, the software IBM SPSS ver-sion 17.0 for Windows was used. Descriptive analy-sis was applied to characterize the sample, Student’s t-test for independent samples compared the mean domain scores of the somatic and affective/cogni-tive symptom subscales and the Mann-Whitney test was used to calculate the mean item scores. Signifi-cance was set at 0.05.

Approval for the study was obtained from the Research Ethics Committee at the University of São Paulo at Ribeirão Preto College of Nurs-ing, protocol nº 0699/2006. The participants re-ceived information on the study objectives and data secrecy and anonymity were guaranteed. Data collection stated after they had given their agreement by means of the Free and Informed Consent Form.

Results

The study participants were 331 people living with HIV/Aids, being 167 (50.4%) male and 164 (49.5%) female. Ages ranged between 20 and 71 years, with an average age of 40 years.

As far as the participants’ profile is concerned, 64.0% had more than eight years of education and 88.2% received between 1 and 3 minimum wag-es. In addition, most women (72.6%) had a high-er education level (p=0.001) but a lower income (<0.001) than men, with a statistically significant difference.

Concerning the clinical characteristics, the men (61.1%) presented more comorbidities than the women (45.1%) (p=0.004), although without a statistically significant difference in CD4 cell counts (Table 1).

In table 2, the mean scores in the somatic and affective/cognitive domains of the BDI are com-pared between men and women living with HIV/Aids. It was identified that the women presented higher means with a statistically significant differ-ence, in the somatic (p<0.001) as well as in the af-fective/cognitive domain (p<0.001).

Table 1. Sociodemographic and clinical profile of people living with HIV/Aids according to sex (n=331)

Variables

Male(n=167)

Female(n=164)

Total331 p-value

n(%) n(%) n(%)

Age range 0.459†

20-35 87(52.1) 95(57.9) 182(55.0)

35-59 76(45.5) 67(40.9) 143(43.2)

> 60 04(2.4) 02(1.2) 06(1.8)

Education (years of study) 0.001*

≤ 8 74(44.3) 45(27.4) 119(36.0)

> 8 93(55.7) 119(72.6) 212(64.0)

Income (minimum wages) <0.001†

≤ 3 133(79.6) 159(97.0) 292(88.2)

> 3 34(20.4) 05(3.0) 39(11.8)

Presence of comorbidities 0.004*

Yes 102(61.1) 74(45.1) 176(53.2)

No 65(38.9) 90(54.9) 155(46.8)

CD4 counts (cells/mm3) 0.909

> 500 69(41.3) 64(39.0) 133(40.2)

499-200 66(39.5) 68(41.5) 134(40.5)

< 200 32(19.2) 32(19.5) 64(19.3)

*Chi-squared test; †Fisher’s exact test

In table 3, it was verified that women present higher scores with a statistically significant differ-ence in 14 BDI items when compared to men.

Table 2. Comparison of mean domain scores in Beck Depression Inventory according to sex (n=331)

BDI*Woman(n=164)

Man(n=167)

Woman/Man(n=331)

p-value

Somatic BDI

(SD)a 5.9(5.1) 4.1(3.9) 5.06 (4.6) <0.001**

Mean 4.0 3.0

Affective/cognitive BDI

(SD)a 8.7 (9.4) 5.4 (6.5) 7.07 (8.2) <0.001**

Mean 5.0 3.0

a (SD): mean (standard deviation); *Beck Depression Inventory; **Student’s t

63Acta Paul Enferm. 2017; 30(1):60-5.


Discussion

As a limitation in this study, we can highlight the cross-sectional study design, which does not permit highlighting the causal relations among the research variables, nor appointing wheth-er the individuals already presented depressive symptoms before the diagnosis of the HIV/Aids infection. In addition, being a self-assessed mea-sure, the use of the BDI can be related with a response bias.

The sociodemographic and economic charac-teristics of the people living with HIV/Aids ev-idenced in this study support other background studies developed in Brazil(15,20) and around the world.(10,19,21)

In the United States, depression is very com-mon and, according to one study,(11) the overall prevalence rate was estimated at 6.6%, while rang-ing between 5 and 10% in PLHA. Similarly, in a Brazilian study, a higher prevalence rate of depres-sive symptoms was found in PLHA, equivalent to 27.6%, measured by the BDI.(10)

Some authors present a high prevalence of de-pression in PLHA, exerting a significant impact in the development of diseases and being registered as one of the main causes of suicide and psychiatric appointments.(6)

Despite the high depression rates identified in this population, however, knowledge gaps about depression remain among PLHA in low and mid-dle-income countries.(4) And the difference in the depressive symptoms of men and women living with HIV in Brazil according to the BDI domains is not understood yet, which made it difficult to compare these results with other studies developed in the country.

When comparing the occurrence of depres-sive symptoms among the sexes, a higher pro-portion was found for women than for men, ac-cording to other background studies in the same population.(12,13)

In the same perspective, there are studies that suggest that female vulnerability to depression is also associated with socioeconomic disadvantag-es(4) and lack of social support.(7) In addition, other authors argue that women are more prone to ex-periencing negative social determinants, assuming a disproportional load in care delivery, and mostly correspond to a low and middle-income popula-tion, besides the accumulation of housework and child raising activities.(13,22)

These study result appoint that women present higher means in the two domains, with the high-est mean score for the affective/cognitive symptoms subscale. This result is similar to a study that as-sessed somatic and cognitive-affective depression symptoms in cardiac patients.(19)

The affective-cognitive symptoms present subjective elements that can be characterized by pessimism, feeling of guilt and punishment. Therefore, some behavioral practices need to be adopted to minimize this situation, such as cog-nitive-behavioral treatment to reduce the per-son’s suffering.(23)

Irritability, reduced libido and disposition for work were the most prevalent and significant so-matic symptoms for women. This decrease in sexual desire in women can be explained by a coping strat-

Table 3. Distribution of mean items scores in the domains of the Beck Depression Inventory according to sex (n=331)

VariablesWomen (n=164) Men (n=167)

p-valueb

(SD)a (SD)a

Affective/cognitive BDI

Sadness 0.75(1.0) 0.47(0.8) 0.003

Pessimism 0.71(1.1) 0.34(0.9) 0.001

Feelings of failure 0.45(0.9) 0.25(0.8) 0.001

Lack of satisfaction 0.81(1.0) 0.41(0.9) 0.001

Feeling of guilt 0.71(0.8) 0.53(0.8) 0.001

Feeling of punishment 0.91(1.0) 0.95(1.1) 0.983

Self-depreciation 0.48(0.7) 0.27(0.6) 0.005

Self-accusations 0.65(1.1) 0.56(1.0) 0.706

Suicidal ideas 0.36(0.5) 0.14(0.4) 0.001

Bouts of crying 0.80(1.1) 0.47(0.9) 0.001

Indecision 0.63(1.1) 0.35(0.9) 0.008

Distorted body image 0.73(0.9) 0.44(0.8) 0.014

Social retraction 0.71(0.9) 0.29(0.7) 0.001

Somatic BDI 0,97(1.1) 0.29(1.1) 0.001

Irritability

Inhibition for work 0.60(1.1) 0.38(1.1) 0.018

Sleep disorder 0.80(1.3) 0.61(1.2) 0.286

Fatigue 0.74(1.0) 0.53(1.0) 0.053

Appetite loss 0.48(0.9) 0.35(0.75) 0.172

Weight loss 0.38(0.8) 0.43(0.8) 0.571

Somatic disorder 0,74(1.1) 0.68(1.1) 0.681

Decreased libido 1.24(1.3) 0.41(0.9) 0.001

a(SD): mean (standard deviation) *Beck Depression Inventory bMann-Whitney Test

64 Acta Paul Enferm. 2017; 30(1):60-5.

Assessment of somatic and affective-cognitive symptoms of people living with HIV/AIDS

egy of PLHA who, in the attempt to protect their serum status and the health of third parties, avoid sexual relationships or even affective relationships, which can aggravate the effect of depressive symp-toms even further.(4)

The lack of disposition for work, as well as oth-er symptoms (fatigue and social isolation) were appointed as important predictors for the develop-ment of depression and associated with the use of antiretroviral drugs.(24)

People living with HIV generally present a form of coping through isolation (elusion, self-blame, confrontation, distancing) instead of ac-tive coping (problem solving, search for social support, acceptance of responsibility, positive reappraisal).(24)

We agree with other researchers that the sep-arate use of the BDI subscales entails implica-tions for clinical practice,(19) as it permits iden-tifying the type and severity of the depression symptoms, which can contribute to the health team’s interventions. Depression is a complex disease with multiple symptoms that affect the health and quality of life of the patients in a very particular way.

In the Brazilian context, a great power disequi-librium remains between the roles men and women play in society, which continues to deny women’s access to their sexuality and at the same time blames her for prevention and health care.

Women with depressive symptoms whose family and friends deny them social support in view of the HIV/Aids diagnosis turn to health professionals in search of support and under-standing.(18,25) The results also indicate that PLHA are victims of depressive symptoms and that health professionals should take this into account in the clinical management of their pa-tients. An in-depth understanding of this rela-tion contributes to a better care practice for peo-ple living with HIV/Aids.

These symptoms can be mixed up with ad-verse effects of the cART, being undervalued by professionals or even by the patients. In our re-sults, these changes can be grouped under So-matic Symptoms of the BDI, demonstrating how

the use of validated tools can be applied in the daily work of health professionals and guidelines for their clinical practice.

In that sense, it is fundamental for physicians, nurses and other health professionals to understand and identify the depressive symptoms and their se-verity, as these are manifested differently between men and women.

In addition, the relevance of this study for nursing care for the sake of support is appointed, allowing these professionals to identify depres-sive signs and symptoms early and to make in-terventions to reduce the symptoms and prevent the complications, thus guaranteeing qualified comprehensive care.

Identifying the symptoms of depression in the population living with HIV/Aids is an important step to develop therapeutic interventions and psy-chosocial support for this population, aiming not only for appropriate treatment, but also for the pre-vention of depressive episodes, in view of the high prevalence of depression and the different manifes-tation of its symptoms in the population living with HIV/Aids.

Conclusion

These study results appoint that the women pres-ent higher depressive symptom scores than the men, in the somatic as well as in the affective/cognitive domain of the BDI subscales. Under-standing these differences is fundamental to pro-pose effective interventions. Assessing the mani-festation of depressive symptoms among people living with HIV/Aids should be part of the mon-itoring for this population, as manifestations dif-fer between men and women. The identification and appropriate screening for psychiatric comor-bidities, particularly for depressive symptoms, is fundamental in health care for PLHA, who can benefit from the treatment with improved com-pliance and quality of life. Screening for depres-sive symptoms is recommended at the start of the treatment and monitoring is due in the course of health care monitoring.

65Acta Paul Enferm. 2017; 30(1):60-5.


CollaborationsReis RK, Castrighini CC, Melo ES, Jesus GJ, Que-iroz AAFL and Gir E declare that they contributed to the conception of the project, analysis and inter-pretation of the data, writing of the article, relevant critical review of the intellectual content and final approval of the version for publication.

References

1. Tancredi MV, Waldman EA. Survival of AIDS patients in Sao Paulo-Brazil in the pre-and post-HAART eras: a cohort study. BMC Infect Dis. 2014; 14(1):1-8.

2. Wagner GJ, Ghosh-Dastidar B, Garnett J, Kityo C, Mugyenyi P. Impact of HIV antiretroviral therapy on depression and mental health among clients with HIV in Uganda. Psychosom Med. 2012; 74(9):883-90.

3. Macapagal KR, Ringer JM, Woller SE, Lysaker PH. Personal narratives, coping, and quality of life in persons living with HIV. JANAC. 2012; 23(4):361-8.

4. Uthman OA, Magidson JF, Safren SA, Nachega JB. Depression and adherence to antiretroviral therapy in low-, middle-and high-income countries: A systematic review and meta-analysis. Curr HIV/AIDS Rep. 2014; 11(3):291-307.

5. Kamat R, Morgan E, Marcotte TD, Badiee J, Maich I, Cherner M, et al. Implications of apathy and depression for everyday functioning in HIV/AIDS in Brazil. J Affect Disord. 2013; 150(3):1069-75.

6. Sin NL, Dimatteo MR. Depression treatment enhances adherence to antiretroviral therapy: a meta-analysis. Ann Behav Med. 2014; 47(3):259-69.

7. Shrestha S, Poudel KC, Poudel-Tandukar K, Kobayashi J, Pandey BD, Yasuoka J, et al. Perceived family support and depression among people living with HIV/AIDS in the Kathmandu Valley, Nepal. J Int Assoc Provid AIDS Care. 2014; 13(3):214-22.

8. Feuillet P, Lert F, Tron L, Aubriere C, Spire B, Dray-Spira R; Agence Nationale de Recherche sur le Sida et les Hépatites Virales (ANRS)-VIH: Enquête sur les personnes atteintes (Vespa2) Study Group. Prevalence of and factors associated with depression among people living with HIV in France. HIV Med. 2016; Sept 14. doi: 10.1111/hiv.12438.

9. Sherr L, Clucas C, Harding R, Sibley E, Catalan J. et al. HIV and depression-a systematic review of interventions. Psychol Health Med. 2011; 16(5):493-527.

10. Reis RK, Haas VJ, Santos CB, Teles SA, Galvão MTG, Gir E. Symptoms of depression and quality of life of people living with HIV/AIDS. Rev Lat Am Enfermagem. 2011; 19(4):874-81.

11. Do AN, Rosenberg ES, Sullivan PS, Beer L, Strine TW, Schulden JD, et al. Excess burden of depression among HIV-infected persons receiving medical care in the united states: data from the medical monitoring project and the behavioral risk factor surveillance system. PloS One. 2014; 9(3):1-10.

12. Delisle VC, Beck AT, Dobson KS, Dozois DJ, Thombs BD. Revisiting gender differences in somatic symptoms of depression: much ado about nothing? PLoS One. 2012; 7(2):e32490.

13. Junqueira P, Bellucci S, Rossini S, Reimão R. Women living with HIV/AIDS: sleep impairment, anxiety and depression symptoms. Arq Neuropsiquiatr. 2008; 66(4):817-20.

14. Silveira MP, Guttier MC, Pinheiro CA, Pereira TV, Cruzeiro AL, Moreira LB. Depressive symptoms in HIV-infected patients treated with highly active antiretroviral therapy. Rev Bras Psiquiatr. 2012; 34(2):162-7.

15. Tufano CS, Amaral RA, Cardoso LR, Malbergier A. The influence of depressive symptoms and substance use on adherence to antiretroviral therapy. A cross-sectional prevalence study. Sao Paulo Med J. 2015; 133(3):179-86.

16. Gorenstein C, Andrade L. Inventário de Depressão de Beck: propriedades psicométricas da versão em português. Rev Psiquiatr Clin. 1998; 25(5):245-50.

17. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961; 4:561-71.

18. Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clin Psychol Rev. 1988; 8(1):77-100.

19. Dessotte CA, Silva FS, Furuya RK, Ciol MA, Hoffman JM, Dantas RA. Somatic and cognitive-affective depressive symptoms among patients with heart disease: differences by sex and age. Rev Lat Am Enfermagem. 2015; 23(2):208-15.

20. Troncoso FT, Conterno LD. Prevalence of neurocognitive disorders and depression in a Brazilian HIV population. Rev Soc Bras Med Trop. 2015; 48(4):390-8.

21. L’akoa RM, Noubiap JJ, Fang Y, Ntone FE, Kuaban, C. Prevalence and correlates of depressive symptoms in HIV-positive patients: a cross-sectional study among newly diagnosed patients in Yaoundé, Cameroon. BMC Psychiatry. 2013 Sep 22; 13:228.

22. Nyirenda M, Chatterji S, Rochat T, Mutevedzi P, Newell ML. Prevalence and correlates of depression among HIV-infected and-affected older people in rural South Africa. J Affect Disord. 2013; 151(1):31-8.

23. Flores AC. Terapia cognitivo-comportamental e tratamento psicológico de pacientes com HIV/AIDS. Rev Bras Ter Cogn. 2012; 8(1): 55-60.

24. Talukdar A, Ghosal MK, Sanyal D, Talukdar PS, Guha P, Guha SK, Basu S. Determinants of quality of life in HIV-infected patients receiving highly active antiretroviral treatment at a medical college ART center in Kolkata, India. JIAPAC. 2013; 12(4):284-90.

25. Tonnera LC, Meirelles BH. Potencialidades e fragilidades da rede de cuidado da pessoa com HIV/Aids. Rev Bras Enferm. 2015; 68(3):438-44.

66 Acta Paul Enferm. 2017; 30(1):66-72.

Original Article

Prevalence of hepatitis B and associated factors in prisonersPrevalência de hepatite B e fatores associados em internos de sistema prisionalAndréia Alves de Sena Silva1

Telma Maria Evangelista de Araújo1

Sheila Araújo Teles2

Rosilane de Lima Brito Magalhães1

Elaine Leite Rangel Andrade1

Corresponding authorAndréia Alves de Sena SilvaCampus Universitário Ministro Petrônio Portella, 64049-550, Teresina, PI, [email protected]


1Universidade Federal do Piauí, Teresina, PI, Brazil.2Faculdade de Enfermagem, Universidade Federal de Goiás, Goiânia, GO, Brazil.Conflicts of interest: there are no conflicts of interest to declare. *Originated from the master thesis entitled: Prevalência de Hepatite b e fatores de risco associados em internos no sistema prisional do estado do Piauí, presented at the Nursing Graduate Program, of Universidade Federal do Piauí.

AbstractObjective: To estimate the prevalence of HBsAg marker in prisoners of the Brazilian prison system, correlating it to associated factors.Methods: An epidemiological, cross-sectional study was conducted in prison units with closed or semi-open regime (n=12), totaling 2,131 participant prisoners. Data were collected in an interview, followed by rapid testing for Hepatitis B (HBsAg). Simple, bivariate and multivariate descriptive analyses were carried out, with the use of logistic regression with the p value settled at 0.05.Results: The prevalence of positive HBsAg was 0.5%, with a statistically significant association with the variables “does not like to wear condoms” (ORa=3.63) and “does not know how to prevent sexually transmissible diseases” (ORa=5.02).Conclusion: The estimated prevalence was equal to or lower than that found in the general population of the country and the results proved that there are factors statistically associated with the prevalence of HBsAg positivity in the studied population.

ResumoObjetivo: Estimar a prevalência do marcador HBsAg em internos de sistema prisional brasileiro, correlacionando-a a fatores associados.Métodos: Pesquisa epidemiológica, transversal, realizada nas unidades prisionais com regime fechado ou semiaberto (n=12), totalizando 2.131 internos participantes. A coleta de dados ocorreu por meio da realização de entrevista, seguida de testagem rápida para Hepatite B (HBsAg). Foram realizadas análises descritivas simples, bivariadas e multivariadas, utilizando-se a Regressão Logística com o valor de p fixado em 0,05.Resultados: A prevalência de HBsAg positivo foi de 0,5%, com associação estatisticamente significativa com as variáveis “não gostar de utilizar preservativo” (ORa=3,63) e “não saber como prevenir infecções sexualmente transmissíveis” (ORa=5,02).Conclusão: A prevalência estimada esteve igual ou menor que a encontrada na população geral do país e comprovou-se que existem fatores estatisticamente associados à prevalência de positividade do HBsAg na população estudada.

KeywordsHepatite B; Prisons; Risk factors; Public health nursing

DescritoresHepatite B; Prisões; Fatores de risco; Enfermagem em saúde pública



67Acta Paul Enferm. 2017; 30(1):66-72.

Silva AA, Araújo TM, Teles SA, Magalhães RL, Andrade EL

Introduction

The population that is deprived of freedom (PDF) has showed higher vulnerability to sexually trans-missible infections (STIs), because of the existing conditions in the prison units, which enhance the possibilities of transmission of infectious diseases, such as hepatitis B. Poor infra-structure, prison cell overcrowding, low socioeconomic level, and risky sexual practices potentiate infection possibilities.(1-3)

The topic of health in prisons has been constant-ly addressed by the scientific community that sees it as question of public health to be faced, emphasiz-ing the need for implementing specific strategies for this population.(4)

Health care appears as an element that con-tributes to the return to life in society, with health care to the population deprived of freedom be-ing legally provided and guaranteed, with actions related to prevention, early diagnosis, and timely treatment to the STI included in the minimum list of procedures.(5,6)

Studying the occurrence of hepatitis B and its associated factors in prisons is relevant to public health, since the risk behaviors of inmates can con-tribute to maintain the chain of infection transmis-sion. Thus, the objective of this study was to esti-mate the prevalence of HBsAg marker, correlating it to associated factors in inmates of the prison system of a Brazilian northeast state.

Methods

This cross-sectional epidemiological survey was car-ried out in 12 criminal units of the state of Piauí, distributed in nine cities, with concentration in the capital of the state. Inmates in closed and semi-open regimes (n=2,839) were selected to compose the study population, in a universe of 2,955 in-mates. Those who were not in conditions to answer the study questions of interest (n=73); and inmates who, in the period of data collection, were in units with riots/rebellions (n= 464) were excluded. In ad-dition, 171 people refused to participate, resulting in 2,131 participants.

Data were collected after signature of a free and informed consent form by the studied pop-ulation, from January to July 2014, by the re-searchers and a team of professionals specifically trained in testing and counseling on STI/Aids/viral Hepatitis.

The collection took place in two stages, in the pavilions of the prison units, in order to guarantee privacy during the interview, with the supervision of the safety team of each institution. Initially, an interview was conducted using a pre-tested form, adapted from other studies.(7,8) The next stage, for testing, was performed by means of rapid tests with the lateral immunocromatography meth-od for detention of HBsAg (VIKIA HBsAg test, BioMérieux Brazil S/A). Collection tests and ma-terials were supplied by the State Health Depart-ment of Piauí.

The rapid test for Hepatitis B is a screening test; therefore, positive cases were referred by the Depart-ment of Justice to the state or municipal reference ser-vices, for the performance of confirmatory serological tests, and the necessary follow-up. Reports were pro-vided regarding the examination, in two copies (one for the researcher and another one that was attached to the prisoner’s report), with the final interpretation of the results of the samples: “Reactive sample for hepatitis B or non-reactive sample for hepatitis B”.

The dependent variable was positive result in the rapid test for HBsAg. The independent vari-ables were: sociodemographic (age, gender, city of origin, marital status, skin color, level of educa-tion, personal income); pattern of use of alcohol and other drugs (type and frequency); parenteral exposure (sharing of needlestick and sharp ma-terials, having tattoos, having piercings); sexual behaviors (sexual practice, number of partners, criterion for selection of sexual partner, use of condoms, reason for not wearing a condom, use of alcoholic beverages, and drugs before sexual in-tercourse); information on hepatitis B (about the infection and the vaccine), existence of some STI throughout life, information on how to prevent STIs; and immunization status.

For the analysis of the immunization status, the schedule was considered complete for those who

68 Acta Paul Enferm. 2017; 30(1):66-72.

Prevalence of hepatitis B and associated factors in prisoners

received the three doses of the hepatitis B vaccine. This information was collected verbally, because of the unavailability of vaccine cards in the prisons in-vestigated.

Data were typed and analyzed with the use of the software Statistical Package for the Social Sciences (SPSS), version 20.0. In the inferential statistics, bivariate and multivariate hypotheses tests were applied. Simple logistic regression was used as the bivariate test of association among the qualitative variables, referred here as unad-justed odds, with the objective to select the pos-sible factors that could explain the prevalence of hepatitis B. As selection criterion for the refer-ence categories, clinical importance was adopt-ed. The variables, which in the bivariate analysis presented p value < 0.05, were submitted to the multivariate model of logistic regression, called here adjusted odds.(9)

For all other analyses, significance at 0.05 was kept for rejection of the null hypothesis. The ab-sence of multicollinearity between the variables se-lected through bivariate analysis was examined by means of the variance inflation factor (VIF), and the cutoff value adopted for the existence of multi-collinearity was VIF≥ 4.(9)

To conduct the research, authorization from the Department of Justice of the State of Piauí, and appreciation of the Research Ethics Committee of the Federal University of Piauí were requested, being approved under Report 345.469 and CAAE 17610613.4.0000.5214.

Results

Of the participants, 92.8% were male, with pre-dominant residence in the interior of the state (52.4%), 48.6% were aged 23 to 32 years old, with mean age of 30.9 years, maximum and minimum 17 and 81 years. Regarding self-reported skin col-or, 61.6% were brown, and 58.8% declared being single, separated or widowed. The mean length of education was 6.3 years, with the education level of most participants being compatible with incom-plete primary education (63.0%). A significant

part of the participants did not have any income (37.2%) or received a minimum wage (32.4%).

Regarding their immunization status, 58.0% of the prisoners reported having received a dose of the vaccine, and 42.0% did not receive or could not answer. Only 17.7% reported to have received the complete schedule (Table 1).

Table 1. Immunization status of inmates of the prison system (n=2131)Variables n (%) CI 95%

Has already been vaccinated

Yes 1236(58.0) 55.9-60.1

No/does not know 895(42.0) 39.9-44.1

Doses received

1 dose 618(50.0) 47.2-52.7

2 doses 399(32.3) 29.7-34.9

3 doses 219(17.7) 15.7-19.9

Of all prisoners, 11 (0.5%) were reactive in the test for hepatitis B specific antigens (Table 2).

HBsAg positivity in the population occurred in its totality in male patients, with no significant pre-dominance for skin color and marital status. Mean age was 33.36 years, with 6.36 years of study. No sociodemographic variable was statistically associat-ed with HBsAg positivity, neither those regarding use of alcohol and other drugs. Absolute frequen-cies were 81.8% for the use of alcohol, and 72.7% for the use of other drugs, such as crack, cocaine and marijuana.

The variables related to parenteral exposure did not present a statistically significant association, but it is worth emphasizing that, among reactive cases, 54.5% reported sharing needlestick and sharps in prison, and having tattoos.

Regarding sexual practice, the nonuse of con-doms was highlighted; only 27.2% of the positive cases reported making regular use of condoms

Table 2. Prevalence of HBsAg in inmates of the prison system (n=2131)Variables n (%) CI95% Standard error

Positive 11(0.5) 0.2-0.8 0.2

Negative 2120(99.5) 99.2-99.8 0.2

69Acta Paul Enferm. 2017; 30(1):66-72.


during intercourse. Among the reasons for not wearing condoms, the variable “does not like to wear a condom in sexual intercourses” presented a strong association in the bivariate analysis, with OR= 3.52 (CI95% 1.02-12.09), and p value =0.04. More than half of the prisoners who were reactive to HB-sAg (63.3%) reported using alcoholic beverages and other drugs before sexual intercourses. Regarding the type of sexual intercourse practised, it is worth considering that in a bivariate analysis vaginal inter-course was a marginally protective factor for hepa-titis B in the prisoners studied (OR=0.14 - CI95% 0.01-1.19; p=0.07).

Of the variables related to the information on hepatitis B, only 18.1% of the cases had informa-tion on the infection, with only one of the cases having knowledge about the vaccine. Among the questions on the prevention of STIs, the variable “does not know how to prevent STIs” was statistically associated with the presence of HBsAg in bivariate analysis (OR=4.90 CI95% 1.48-16.13; p= <0.01). Regarding the existence of STIs, 90.9% reported that they had never had any sexual infection in life, with 81.8% reporting fear to contract a STI.

In the model of multiple logistic regression, the variables that presented significant association in the bivariate analyses kept the strongest relation (Table 3).

Discussion

The study had some limitations because the an-swers were self-reported. The immunization status survey considered only the prisoners reports, since they did not have the vaccine card in hands, and the prison units did not have immunization infor-mation on the medical records, which may have underestimated or overestimated the data. In addi-tion, the organization diversity of the institutions

Table 3. Multiple logistic regression of the factors related to the prevalence of HBsAg positivity (n=11)

Variables Odds

(Adjusted)p-value CI95%

Does not like to wear a condom in sexual intercourse 3.63 0.04 1.05-12.48

Does not know how to prevent STIs 5.02 <0.01 1.52-16.59

Statistical significance was set at p ≤ 0.05

visited, the safety logistics of the criminal system, and the prison environment itself were factors that brought difficulties to the development of the re-search, since during counseling and application of the questionnaire the presence of the prison agent was constant, and may have influenced the an-swers, especially those regarding the use of drugs and sexual behaviors.

The results show the need for public health ac-tions, including the coordination of the governmen-tal spheres, and between the management of health and justice areas, to elaborate strategies considering the prisoners’ health needs. The research brought, as a contribution for the strengthening of the Na-tional Health Plan in the Prison System (PNSSP, as per its acronym in Portuguese), the expansion of the offer of rapid tests, allowing the early diagnosis of the infection to the prison population. It suggests the use of STI testing at admission, and as a routine in the criminal units, as well as continuous activi-ties of health education for prisoners and training of health professionals that work in these environ-ments, reinforcing surveillance through the active search and notification of problems.

The reports of prisoners from the prison system studied showed that they have poor immunization coverage, and prevalence of HBsAg positivity con-sistent with the trend of the region. These findings are related to their demographic, social and behav-ioral characteristics.(3,10-15)

The low frequency of history of vaccination against hepatitis B was below the expected, consid-ering that the implementation of a vaccination pro-gram is a goal of the PNSSP, and an international recommendation.(1,6,16) Low vaccination coverage in prisons and, therefore, the high number of in-dividuals susceptible to infection, are common and confirm the need to ensure access to health services, education programs, and implementation of vacci-nation programs to prevent HBV infection in pris-ons.(17,18) It should be noted that there was a certain devaluation of vaccination records by some health services, nowadays minimized by the computer-ization and systematization of the registration of doses in the health units. Users who do not follow the dates of doses, or that do not keep their cards

70 Acta Paul Enferm. 2017; 30(1):66-72.


are also common. These practices result in lack of knowledge of the immunization status of the pop-ulation and, therefore, in possible administration of unnecessary doses.(19) In this perspective, many prisoners could have received the three doses of the vaccine before going to prison, since this a predom-inantly young population.

The prevalence of HBsAg in the study pop-ulation was a little higher than that found in the general urban population of the Northeast region of Brazil (0.42%, CI 95% 0.16-0.67), a fact that can be explained by the high frequency of risky be-haviors presented.(3) The finding was similar to that found in other Brazilian prison complexes, as that of Goiânia (0.7%, CI95% 0.0-4.3)(20) and Mato Grosso do Sul (0.5%, CI95% 0.08-1.9).(21) The serological investigation in the prison of the city of Ribeirão Preto, Southeastern region of Brazil, presented a higher rate (2.4%) because, unlike the findings of this study, behaviors such as the use of injectable drugs and sharing of syringes were shown and strongly associated.(22) In comparison with oth-er countries, the rate was also low, such as in Iran (3.3%) and Spain (2.6% CI95% 0.2-4.9).(23,24)

Studies show that the condition of being im-prisoned by itself increases the risk for infection of hepatitis B, and in particular when associated with the structural quality of the confinement, and with the marginal social position predominantly occu-pied by the PDF, that in turn triggers a process of poor life conditions correlated to crime and abu-sive use of drugs, favoring the occurrence of several health problems.(4,21,23) The high social, program-matical and individual vulnerability suffered by this population can exacerbate the situation. Ruptured affective bonds, emotional instability, little motiva-tion, low self-esteem, and generally the exclusion experienced by prisoners are noteworthy.(25)

The low frequency of condom use found, as well as the reasons for not wearing it are noteworthy: not liking it, not having it available at the moment, trusting the partner, believing in the divine pro-tection, having sexual intercourse only with clean people, having allergy to the condom material, in-sufficient time for putting it, and lower sensitivity during the sexual act. International surveys have

shown that a small portion of the world imprisoned population has consistent access to measures for prevention of STIs, highlighting the low frequency of condom use in the prison environment, which, among other factors, has the existence of imposed sexual relations as determinant.(26,27)

Condom use is an important measure for the prevention of new cases of hepatitis B, because its efficacy is proven as a physical barrier in the transmission of particles with size similar to that of small STI-causing viruses. In addition, if used correctly, it reduces the risks of slides or ruptures. In this perspective, its use is indispensable in this population, being the main measure of prevention for STIs.(23,28)

It is recommended that condoms and lubri-cants be of easy, discrete and of free access in the prisons, being available in accordance with the physical spaces and prisoners movement.(1,2) It is noteworthy that the simple delivery of the meth-od does not ensure good results. The institution of educative health programs in prisons should induce the change of prisoners’ behaviors and attitudes. In this case, the guidelines regarding the adequate use should precede the action.

The information on hepatitis B revealed to be insufficient. The possibility for a person who did not know how to prevent STIs of having hepatitis B was about five times higher when compared with those who knew. This result confirms the impor-tance of implementing educative programs in the prison environment addressing measures for the prevention of these infections in the units of the criminal system. Low knowledge concerning STIs has been observed in some studies.(29,30)

The fact that most of the prisoners participating in this study stated that they do not have informa-tion on hepatitis B can be explained by the few years of referred studies. However, the low level of educa-tion did not present any association with the prev-alence of HBsAb antigen positivity, contradicting some studies.(21,29) Having few years of education leads to lower comprehension and apprehension of information in general, which probably makes it difficult to assimilate the strategies of prevention regarding the ways of transmission of this infection.

71Acta Paul Enferm. 2017; 30(1):66-72.


Conclusion

The prevalence found was equal to or lower than that found in the general population of the country (0.5%), but within that expected for this popula-tion. It was proved that there are factors statistically associated with the prevalence of HBsAg positivi-ty in the population studied, which are: not liking to wear a condom in sexual intercourse, and not knowing how to prevent STIs.

CollaborationsSilva AAS and Araújo TME declare that they contrib-uted in the stages of study conception, data analysis and interpretation, article writing, relevant critical re-view of its intellectual content, and final approval of the version to be published. Teles SA collaborated in the data analysis, writing and critical review. Magalhães RLB and Andrade ELR collaborated with the article writing, critical review of its intellectual content, and final approval of the version to be published.

References

1. World Health Organization. [Internet]. Prisons and Health. WHO Regional Office for Europe, Copenhagen; 2014 [cited 2015 Jan 10]. Available from: http://www.euro.who.int/en/home.

2. World Health Organization. [Internet] Hepatitis B (fact sheet no. 204), 2012 [cited 2015 Jan 10]. Available from: http://www.who.int/mediacentre/factsheets/fs204/en.

3. Brasil. Ministério da Saúde. [Internet]. Secretaria de Vigilância em Saúde. Departamento de AIDS, DST e Hepatites Virais. Boletim Epidemiológico: hepatites virais. Ano III, nº 01. Brasília (DF): Ministério da Saúde; 2012.

4. Gois SM, Santos Junior HP, Silveira MF, Gaudêncio MM. Para além das grades e punições: uma revisão sistemática sobre a saúde penitenciária. Ciênc Saúde Coletiva. 2012; 17(5):1235-46.

5. Departamento de Ações Programáticas Estratégicas. Secretaria de Atenção à Saúde. Legislação em saúde no sistema penitenciário. Brasília (DF): Ministério da Saúde; 2010.

6. Brasil. Portaria Interministerial nº 1, de 2 de janeiro de 2014. Institui a Política Nacional de Atenção Integral à Saúde das Pessoas Privadas de Liberdade no Sistema Prisional (PNAISP) no âmbito do SUS. Diário Oficial da União. Brasília (DF): Ministério da Saúde; 2014.

7. Sá LC, Araújo TME, Griep RH, Campelo V, Monteiro CFS. Seroprevalence of Hepatitis C and factors associated with this in crack users. Rev Lat Am Enfermagem. 2013; 21(6):1195-202.

8. Carvalho SM. Prevalência da infecção pelo vírus da hepatite B em usuários de crack no Piauí. [dissertação]. Teresina: Universidade Federal do Piauí; 2013.

9. Hosmer DW, Lemeshow S. Applied logistic regression. 2nd ed. New York: Wiley; 2000.

10. Walsh E, Forsyth K, Senior J, O’Hara K, Shaw J. Undertaking action research in prison: Developing the older prisoner health and social care assessment and plan. Act Research. 2014; 12(2):136-50.

11. Brasil. Ministério da Justiça. Departamento Penitenciário Nacional. Sistema integrado de informações penitenciárias [Internet], 2013. [citado 2016 Out 12]. Disponível em: http://portal.mj.gov.br.

12. Murray J, Cerqueira DR, Kahn T. Crime and violence in Brazil: systematic review of time trends, prevalence rates and risk factors. Aggress Violent Behav. 2013; 18(5):471-83.

13. Peres MF, Feliciano JA, Vicentin D, Ruotti C, Batista MN, Cerda M, et al. Evolução dos homicídios e indicadores de segurança pública no Município de São Paulo entre 1996 a 2008: um estudo ecológico de séries temporais. Ciênc Saúde Coletiv. 2012; 17(12):3249-57.

14. Kumar SD, Kumar SA, Pattankar JV, Reddy SB, Dhar M. Health Status of the Prisoners in a Central Jail of South India. Indian J Psychol Med. 2013; 35(4):373-7.

15. Albuquerque AC, Silva DM, Rabelo DC, Lucena WA, Lima PC, Coelho MR, et al. Soroprevalência e fatores associados ao Vírus da Imunodeficiência Humana (HIV) e sífilis em presidiários do Estado de Pernambuco, Brasil. Ciência Saúde Colet. 2014; 19(7):2125-32.

16. Solomontos-Kountouri O, Panayiota H. Brief report: Past, present, emergent and future identities of young inmates. J Adolescence. 2016; 47:119-24.

17. Gidding HF, Mahajan D, Reekie J, Lloyd AR, Dwyer DE, Butler T. Hepatitis B immunity in Australia: a comparison of national and prisoner population serosurveys. Epidemiol Infect. 2015; 143(13):2813-21.

18. Rumble C, Pevalin DJ, O’Moore É. Routine testing for blood-borne viruses in prisons: a systematic review. Eur J Public Health. 2015; 25(6):1078-88.

19. Santos GR, Silva SS, Guimarães EA, Cavalcante RB, Oliveira VC. Avaliação do monitoramento rápido de coberturas vacinais na Região Ampliada de Saúde Oeste de Minas Gerais, 2012. Epidemiol Serv Saúde. 2016; 25(1): 55-64.

20. Barros LA, Pessoni GC, Teles SA, Souza SM, Matos MA, Martins RM. Epidemiology of the viral hepatitis B and C in female prisoners of Metropolitan Regional Prison Complex in the State of Goiás, Central Brazil. Rev Soc Bras Med Trop. 2013; 46(1):24-9.

21. Stief AC, Martins RM, Andrade SM, Pompilio MA, Fernandes SM, Murat P, et al. Seroprevalence of hepatitis B virus infection and associated factors among prison inmates in state of Mato Grosso do Sul, Brazil. Rev Soc Bras Med Trop. 2010; 43(5):512-5.

22. Coelho HC, Oliveira SA, Miguel JC, Oliveira ML, Figueiredo JF, Perdoná GC, et al. Soroprevalência da infecção pelo vírus da hepatite B em uma prisão brasileira. Rev Bras Epidemiol. 2009; 12(2):124-31.

23. Dana D, Zary N, Peyman A, Behrooz A. Risk prison and hepatitis B virus infection among inmates with history of drug injection in Isfahan, Iran.Scientific World Journal. 2013; 2013:735761.

24. Hoya OS, Marco A, García-Guerrero J, Rivera A. Hepatitis C and B prevalence in Spanish prisons. Eur J Clin Microbiol Infect Dis. 2011; 30(7): 857-62.

25. Onofre EMC, Juliao EF. A educação na prisão como política pública: entre desafios e tarefas. Educ Real. 2013; 38(1):51-69.

26. Kamarulzaman A, Reid SE, Schwitters A, Wiessing L, El-Bassel N, Dolan K, Moazen B, Wirtz AL, Verster A, Altice FL. Prevention of transmission of HIV, hepatitis B virus, hepatitis C virus, and tuberculosis in prisoners. Lancet. 2016; 388(10049):1115-26.

72 Acta Paul Enferm. 2017; 30(1):66-72.


27. Rich JD, Beckwith CG, Macmadu A, Marshall BDL, Brinkley-Rubinstein L, Amon JJ, Milloy M, King MR, Sanchez J, Atwoli L, Altice FL. Clinical care of incarcerated people with HIV, viral hepatitis, or tuberculosis. Lancet. 2016; 388(100049):1103-4.

28. Sosman J, Macgowan R, Margolis A, Gaydos CA, Eldridge G, Moss S, et al. Sexually Transmitted Infections and Hepatitis in Men With a History of Incarceration. Sex Transm Dis. 2011; 38(7):634-9.

29. Feng MC, Feng JY, Chen YH, Chang PY, Lu PL. Prevalence and knowledge of sexual transmitted infections, drug abuse, and AIDS among male inmates in a Taiwan prison. Kaohsiung J Med Sci. 2012; 28(12):660-6.

30. Ravlija J, Vasilj I, Marijanović I, Vasilj M. Risk behaviour of prison inmates in relation to HIV/STI. Psychiatr Danub. 2014; 26 (Suppl 2):395-401.

73Acta Paul Enferm. 2017; 30(1):73-9.

Original Article

Children with kidney diseases: association between nursing diagnoses

and their diagnostic indicatorsCrianças com doenças renais: associação entre

diagnósticos de enfermagem e seus componentesRichardson Augusto Rosendo da Silva1

Moiziara Xavier Bezerra1

Vinicius Lino de Souza Neto2

Deborah Dinorah Sa Mororo1

Itaìsa Cardoso Fernandes de Andrade1

Corresponding authorRichardson Augusto Rosendo da SilvaSenador Salgado Filho Avenue, 3000,59078-970, Natal, RN, [email protected]


1Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil.2Universidade Federal de Campina Grande, Campina Grande, PB, Brazil.Conflicts of interest: there are no conflicts of interest regarding the publication of this paper.

AbstractObjective: To identify the nursing diagnoses in children with kidney diseases, and to analyze the association between these diagnoses, their defining characteristics, related or risk factors.Methods: A cross-sectional, quantitative study, conducted with 68 hospitalized children in a university hospital in northeastern Brazil. An interview guide and physical examination was used to collect data. The selection of diagnoses was procedural, and the data were analyzed using descriptive and inferential statistics.Results: Thirteen diagnoses were identified. The most frequent diagnoses presented statistically significant association with their diagnostic indicators and were found in the domains of health promotion, elimination/exchange, nutrition, safety/protection and activity/rest.Conclusion: The most prevalent nursing diagnoses were: excess fluid volume, risk for infection, impaired urinary elimination, fatigue, and ineffective protection. In general, the defining characteristics and the related/risk factors of the diagnosis showed significant association.

ResumoObjetivo: Identificar os diagnósticos de enfermagem em crianças com doenças renais e analisar a associação entre esses diagnósticos, suas características definidoras e os fatores relacionados ou de risco.Métodos: Estudo transversal, quantitativo, realizado com 68 crianças internadas em um Hospital Universitário no Nordeste do Brasil. Para a coleta de dados foi utilizado um roteiro de entrevista e exame físico. A elaboração dos diagnósticos foi processual e os dados foram analisados por meio da estatística descritiva e inferencial.Resultados: Identificaram-se 13 diagnósticos. Os mais frequentes tiveram relação estatisticamente significativa com seus componentes e estavam inseridos nos domínios promoção da saúde, eliminação/troca, nutrição, segurança/proteção e atividade/repouso.Conclusão: Os diagnósticos de enfermagem mais prevalentes foram volume de líquidos excessivo, risco de infecção, eliminação urinária prejudicada, fadiga e proteção ineficaz. Em geral, as características definidoras e os fatores dos diagnósticos apresentaram associação significante.

KeywordsNursing process; Nursing diagnosis;

Pediatric nursing; Kidney disease; Child; Interview

DescritoresProcessos de enfermagem;

Diagnósticos de enfermagem; Enfermagem pediátrica; Nefropatia;

Criança; Entrevista



74 Acta Paul Enferm. 2017; 30(1):73-9.

Children with kidney diseases: association between nursing diagnoses and their diagnostic indicators

Introduction

Kidney diseases, such as primary or secondary glomeruli, congenital abnormalities, urinary infection, and tubular diseases are among the most common in children.(1) If not identified and treated early, they can lead to severe com-plications due to recurrent clinical changes, requiring dietary changes, dialysis therapy, in-vasive procedures, constant use of medications, frequent hospitalizations, and separation from family life.(2,3)

In spite of this, the care of children with kidney diseases requires professionals with skills and com-petences in the identification of the priority needs for the planning of care, optimizing of behaviors, and attainment of goals that promote the reestab-lishment of health, decreasing patient encounters with the health service, and promoting their quality of life.(4)

Nursing care for children with kidney diseases can be based on the nursing process (NP) and on the use of standardized languages, as a way to meet the real needs of this clientele. The NP include the nursing diagnosis stage, which constitutes an im-portant focus of professional practice, as potential risks will be identified through its use, and nursing care will be adjusted.(3,4)

The identification of nursing diagnoses in-volves clinical reasoning about the individual’s health status, the use of data obtained by the interview and physical examination. A careful analysis of the client’s health situation supports the identification of the patient needs which re-quire specific interventions.(5,6) Therefore, a good clinical judgment about the manifestations pre-sented is essential, as well as the correct identifi-cation of the diagnostic indicators of the nursing diagnoses.

Studies on the association between nursing diagnoses and their defining characteristics, re-lated and risk factors in specific populations are fundamental for the nurse’s clinical practice. These studies allow us to test the hypothesis that a relationship between the statements and their diagnostic indicators exist, besides making pos-

sible the determination of their predictive capac-ity, increasing the reliability of the process of di-agnostic inference; these facts justify the present study.

From this context, the question is: what are the nursing diagnoses present in children with kidney disease? Is there an association between the diag-noses, their defining characteristics, related and risk factors? Thus, the purpose of this study was to iden-tify nursing diagnoses in children with kidney dis-eases and to analyze the association between these diagnoses, their defining characteristics, and related or risk factors.

Methods

This was a quantitative, crossover study, con-ducted with 68 hospitalized children in a pediat-ric health care unit (Unidade de Atenção a Saúde da Criança - UASC) of a university hospital, and located in the northeastern region of Brazil. The population size was based on the arithme-tic mean of hospitalizations of children with a medical diagnosis of kidney disease in the unit, during the last five years (2010 to 2014), total-ing 220 patients.

For the sample calculation the formula for finite populations was used, considering the confidence coefficient, the sample error, complementary per-centage (100-P) and the prevalence. The parameters considered were the confidence level of 95% (Z∞ = 1.96), the sample error of 5%, and a population of 220 patients.

In the absence of a study estimating the prev-alence of association of nursing diagnoses and their diagnostic indicators for children with kid-ney diseases, a conservative value of 50% was considered. At the end, a sample of 68 children was obtained.(7)

The convenience sample selection occurred consecutively, with the following criteria adopt-ed: children up to ten years of age, with medical diagnosis of kidney disease, who were hospital-ized during the data collection period. The ex-clusion criteria were: children who, in addition

75Acta Paul Enferm. 2017; 30(1):73-9.

Silva RA, Bezerra MX, Souza Neto VL, Mororo DD, Andrade IC

to kidney diseases, presented other diseases, such as neoplasias, infectious diseases, neurological diseases and mental disorders.

All those responsible for the children who par-ticipated in the study signed the Terms of Free and Informed Consent Form.

The data collection occurred between June and December of 2015, in the identified unit, by means of physical examination and interview guide. These instruments included socio-demographic and clin-ical data, as well as defining characteristics (signs and symptoms), risk/related factors subdivided into the 12 domains (Health promotion, Nutri-tion, Elimination and Exchange, Activity/Rest, Perception/cognition, Self-perception, Roles rela-tionships, Sexuality, Coping/Stress tolerance, Safe-ty/protection and comfort) present in taxonomy II of nursing diagnoses from NANDA International (NANDA -I).(8)

The instruments were evaluated by 38 expert nurs-es. The search for experts occurred through a review of the curriculum vitae in the Lattes platform of the National Council for Scientific and Technological De-velopment (Conselho Nacional de Desenvolvimento Científico e Tecnologico - CNPq). The inclusion cri-teria were: professional nurse, graduate level education (specialization, master’s or doctorate), related to nursing diagnosis with patients with chronic kidney failure, or having academic specialization in the area; and, as ex-clusion criterion, solely having undergraduate research with an end-of-course written paper on the subject.

The contact with the specialists occurred via e-mail, by means of an invitation letter and the Terms of Free and Informed Consent form. Their task was to validate the instruments re-garding appearance, content, clarity and appli-cability. They were also requested to provide any suggestions and modifications they considered pertinent. The items that achieved an index of concordance ≥0.80 were considered validated among the specialists.(9)

After the adjustments made to the instru-ment, a pre-test was applied with 10% of the study sample, to verify if the instruments met the research objectives. Since no need for in-

strument changes was necessary, the pretest par-ticipants’ responses were included in the study sample.

The diagnosis identification was procedural, conducted simultaneously with the data collec-tion, seeking to identify the defining character-istics and related/risk factors according to NAN-DA-I, version 2015-2017. The Risner’s clinical judgment stages were followed for structuring of nursing diagnoses.(10)

In the process of diagnosis inference, the clinical information was individually evaluat-ed by two authors of this article, one being a master’s-prepared nurse and the other holding a doctoral degree, in order to achieve greater reli-ability of the results. The diagnoses that showed agreement between them were accepted. Those in which there was disagreement among the eval-uators were referred to three nursing professors, who worked in the referred service, and who were specialists in nephrology, until a consensus was achieved.

Then, a database was developed using Mic-rosoft Excel 2009 software, and all the variables obtained in the research instruments were en-tered, such as the respective nursing diagnoses, defining characteristics, and the identified relat-ed and risk factors.

Subsequently, the data were compiled and pro-cessed using the IBM Statistical Package for the Social Sciences (SPSS), version 20.0 for Windows. Central tendency measurements and the Shap-iro-Wilk test were performed for the nursing diag-noses, to verify the normality of distribution at a significance level of 5%. The Pearson’s Chi-square test and Fisher’s exact test were used to verify the association of nursing diagnoses with the defining characteristics and related factors, considering a sig-nificance level of 5%.

The development of the study met the stan-dards of ethics in research involving human be-ings, and received registration of the Certificate of Presentation for Ethical Appreciation (Certificado de Apresentação para Apreciação Ética - CAAE) 42666815.0.0000.5292.

76 Acta Paul Enferm. 2017; 30(1):73-9.


Results

Among the 68 patients, the age range was 2 - 10 years, with a mean age of 7 years (SD:2.81), male (51.40%), resident of the state (67.80%), present-ing as main complaints: fever (80.20%), edema (55.10%), pain when urinating (60.30%), urine with abnormal coloration (75.10%), lack of appe-tite (50.35%), weight gain (70.20%), and fatigue (50.15%). The kidney diseases identified were: nephrotic syndrome (35.25%), hydronephrosis (15.50%), and acute diffuse glomerulonephritis (AGN) (49.25%).

The Shapiro-Wilk test presented a value of 0.041, evidencing an asymmetric (abnormal) distri-bution. Thus, 13 nursing diagnoses were identified, and the most prevalent were: excess fluid volume, risk of infection, impaired urinary elimination, ineffective protection and fatigue. Table 1 shows the 13 diagno-ses identified, with their respective frequencies and percentages.

Regarding the defining characteristics, table 2 presents their respective prevalence, as well as their associations with nursing diagnoses, identified in children with kidney diseases.

Table 3 shows the associations between nursing diagnoses and their related risk factors in children with kidney diseases.

Table 1. Distribution of nursing diagnoses identified in children with kidney diseases (n=68)

Nursing diagnoses n(%)

Excess fluid volume 62(91.17)

Risk for infection 60(88.23)

Impaired urinary elimination 55(80.88)

Ineffective protection 40(58.82)

Fatigue 35(51.47)

Hyperthermia 25(36.76)

Acute pain 20(29.41)

Risk for disproportionate growth. 16(23.52)

Risk for delayed child development 16(23.52)

Disturbed sleep pattern 14(20.58)

Constipation 10(14.70)

Imbalanced nutrition: less than body requirements 10(14.70)

Diarrhea 08(11.76)

Table 2. Distribution of the association between nursing diagnoses and defining characteristics, identified in children with kidney diseases (n=68)

Nursing diagnoses

Defining characteristics

Present(%) Absent(%) p-value

Excess fluid volume

Weight gain over short period of time

60(96.77) 2(03.23) 0.001*

Edema 60(96.77) 2(03.23) 0.001 †

Alteration in blood pressure

25(40.32) 37(59.68) 0.001†

Anasarca 6(09.68) 56(90.32) 0.004†

Impaired urinary elimination

Dysuria 53(96.36) 2(03.64) 0.002†

Urinary retention 50(90.90) 5(09.10) 0.001†

Hesitancy 50(90.90) 5(09.10) 0.002†

Urinary urgency 2(03.64) 53(96.36) 0.004†

Ineffective protection

Deficient immunity 36(90.00) 4(10.00) 0.001†

Fatigue 32(80.00) 8(20.00) 0.002†

Weakness 32(80.00) 8(20.00) 0.001†

Fatigue Tiredness 32(91.43) 3(08.57) 0.001†

Insufficient energy 26(74.28) 9(25.72) 0.002†

Hyperthermia Skin warm to touch 25(100.0) 0(00.00) 0.301†

Irritability 18(72.00) 7(28.00) 0.079†

Acute pain Expressive behavior 19(95.00) 1(05.00) 0.082†

Facial expression of pain

19(95.00) 1(05.00) 0.232†

Proxy report of pain behavior/ activity changes

14(70.00) 6(30.00) 0.087†

Disturbed sleep pattern

Alteration in sleep pattern

10(71.43) 4(28.57) 0.079†

Difficulty initiating sleep

8(57.14) 6(42.86) 0.240†

Constipation Abdominal pain 8(40.00) 2(60.00) 0.318†

Imbalanced nutrition: less than body requirements

Insufficient interest in food

9(90.00) 1(10.00) 0.160†

Pale mucous membranes

9(90.00) 1(10.00) 0.071†

Diarrhea 8(80.00) 2(20.00) 0.096†

Food intake less than recommended daily allowance

8(80.00) 2(20.00) 0.452†

Abdominal pain 8(80.00) 2(20.00) 0.182†

Diarrhea Loose liquid stools > 3 in 24 hours

8(100) 0(00.00) 0.160†

Abdominal pain 8(100) 0(00.00) 0.452†

* Fisher exact test; † Pearson chi-square test; p < 0,05

77Acta Paul Enferm. 2017; 30(1):73-9.


Discussion

The nursing diagnosis of excess fluid volume was associated with weight gain over a short period of time, edema, and change in blood pressure, ana-sarca, change in respiratory pattern, anxiety, and was related to the regulatory mechanisms involved. In patients with kidney impairment, the cause for this fluid imbalance arises from a decrease in the glomerular filtration rate, which may be due to de-struction of the glomerular capsule by the immune system, recurrent infections and loss of protein.(11)

Kidney diseases can modify glomerular filtration, reducing the capacity of water excretion. In addition, the production of urine can be impaired, resulting in accumulation of fluids in the body, contributing to increased weight in a short period of time.(12)

Most of the children studied had elevated urea and creatinine, as well as cystatin C, a protein mark-er against renal preservation, showing that the com-pensatory mechanisms were imbalanced. In view

of such changes, planned care on the part of the nurse is important, in order to control the hydro-electrolytic balance, hypervolemia, weight, and to ensure monitoring of the vital signs and nutrition to achieve fluid balance and preservation of renal function.(13)

The nursing diagnosis, impaired urinary elimi-nation, was associated with dysuria, urinary reten-tion, hesitancy, urinary urgency, urinary tract in-fection, and multiple causation etiologies. Kidney disease directly affects the diuresis process, result-ing in the accumulation of nitrogenous and liquid excreta, which overload the vascular system, devel-oping vascular congestion, dysuria, retention and hesitancy.(14)

In addition, some children underwent bladder catheterization, with the main objective of achiev-ing better fluid control and attenuating the signs and symptoms of urinary discomfort.(15) Thus, it is fundamental that the nurse, performing actions such as guiding the mothers about the importance

Table 3. Distribution of the association between nursing diagnoses, related and risk factors identified in children with kidney diseases (n=68)Nursing diagnoses Related / risk factors Present(%) Absent(%) p-value

Excess fluid volume Compromised regulatory mechanism 60(96.77) 2(03.23) 0.001*

Risk for infection Invasive procedure 45(75.00) 15(25.00) 0.001†

Immunosuppression 36(60.00) 24(40.00) 0.001†

Decrease in hemoglobin 23(38.33) 37(61.67) 0.001†

Alteration in skin integrity 17(28.33) 43(71.67) 0.003†

Chronic Illness 17(28.33) 43(71.67) 0.004†

Impaired urinary elimination Multiple causality 48(87.27) 7(12.73) 0.001†

Urinary tract infection 8(14.54) 47(85.46) 0.002†

Ineffective protection Abnormal blood profile 23(57.50) 17(42.50) 0.001†

Immune disorder 36 (90.00) 4(10.00) 0.001†

Fatigue Physiological condition 32(91.43) 3(08.57) 0.001†

Environmental barrier 8(22.85) 27(77.15) 0.003†

Hyperthermia Illness 25(100) 0(00.00) 0.099†

Acute pain Biological injury agent 14(70.00) 6(30.00) 0.247†

Risk for disproportionate growth Chronic illness 16(100) 0(00.00) 0.507†

Economically disadvantaged 10(62.50) 6(37.50) 0.085†

Infection 8(50.00) 8(50.00) 0.096†

Risk for delayed development Chronic illness 16(100) 0(00.00) 0.507†

Treatment regimen 16(100) 0(00.00) 0.085†

Inadequate nutrition 10(62.50) 6(37.50) 0.146†

Disturbed sleep pattern Environmental barrier 8(57.14) 6(42.86) 0.829†

Constipation Pharmaceutical agent 8(40.00) 2(60.0) 0.365†

Recent environmental change 8(40.00) 2(60.0) 0.118†

Imbalanced nutrition: less than body requirements Insufficient dietary intake 8(80.00) 2(20.00) 0.160†

Diarrhea Infection 8(100) 0(00.00) 0.790†

Treatment regimen 8(100) 0(00.00) 0.143†

* Fisher exact test; † Pearson chi-square test; p < 0,05

78 Acta Paul Enferm. 2017; 30(1):73-9.


of performing correct and frequent intimate hy-giene, explain the reason for the use of the device, its permanence and the risk of infection.(16)

Risk for infection was also one of the diagno-ses identified in children with kidney diseases, related to invasive procedures, increased environ-mental exposure to pathogens, chronic disease, malnutrition and pharmaceutical agents (immu-nosuppressants).

A high level of leukocytes was found in the chil-dren, with an average of 12,000/mm3, hyperther-mia and, in some cases, the dialysis access presented phlogistic signs, characterizing an infectious focus at the insertion site of the catheter.

It is important to emphasize that the hospital-ization process itself places children in a state of vulnerability, exposing them to a diversified micro-biota, affecting the immune system. In addition to the hospital setting, invasive procedures increase the risk of opportunistic infections.(17) Thus, for this diagnosis, the goal is to maintain an adequate immune status (natural and acquired resistance). Infection prevention and control require technical and behavioral measures, affecting quality of health and a consequent reduction in effort, sequelae, complications and costs.(15)

The nursing diagnosis, fatigue, demonstrated an association with the defining characteristics of tired-ness, and a report of constant insufficient energy; related factors included disease states and impaired physical condition. The mean hemoglobin level was 9.4 g/dl in the studied patients, below the 11.5 to 14.8 g/dl level, which is justified by the pathophys-iology of renal diseases. Thus, oxygen diffusion be-comes impaired, leading the cells to produce large amounts of lactic acid, causing the saturation of the muscle fiber and consequent fatigue.(18)

The decrease in hemoglobin in patients with re-nal disease is related to the lack of erythropoietin pro-duction. In addition to this deficiency, the majority of children showed folate levels and a cyanocobalamin index below the standard, which also participates in the process of red blood cell formation.(19)

Fatigue directly affects the activities of daily liv-ing (ADL), reducing the functionality of patients.(17-19) Thus, one of the goals of the plan of care is

to maintain activity tolerance, characterized by re-sponses to body movements that consume energy, which are involved in everyday activities. In this sense, nursing interventions include the promotion of light exercise, guidance on maintaining a rhythm for activities, sleep hygiene, and supplementation with foods rich in folate (folic acid) and cyanoco-balamin (vitamin B12) that contribute for matura-tion of red blood cells.(20)

On the other hand, the diagnosis of ineffective protection has been associated with the defining char-acteristics of deficient immunity, fatigue and weak-ness, and with the related factors of abnormal blood profile and immunological disorders. As already mentioned, the presentation of fatigue and weakness in these patients stems from a decrease in hemoglo-bin, which contributes to anemia and the symptoms of dyspnea and weakness in the individual.

In addition, immunity in individuals with kid-ney disease is compromised due to uremia, inflam-mation, decreased erythropoietin production, and malnutrition.(21) Patients with chronic kidney fail-ure have low immunity as a direct result of loss of kidney function. Thus, the mechanisms involved in the inadequate immune response are related to the improper elimination of suppressive diagnostic in-dicators, as well as the impaired metabolism in the damaged kidney parenchyma.(21-23)

In this sense, the nurse should establish the im-provement of the immunological status as a goal, and implement interventions such as risk identifi-cation, protection against infection, evaluation of laboratory tests, observing for signs and symptoms of infection, and guiding the nutritional supple-mentation of foods high in vitamin A, C, E, folate, zinc and selenium.(20)

Conclusion

Thirteen nursing diagnoses were identified in chil-dren with kidney diseases. The most frequent were: excess fluid volume, risk for infection, impaired uri-nary elimination, fatigue and ineffective protection. The study enabled the verification of a statistically significant association between these nursing di-

79Acta Paul Enferm. 2017; 30(1):73-9.


agnoses and their respective diagnostic indicators, which were identified in these patients. The limita-tions of this study consist of the fact that clinical evaluation is a subjective process, and the diagnosis is subject to uncertainties. On the other hand, the study has strengths, which must be highlighted. The identification of NDs and their respective diagnos-tic indicators is essential, in practice, to establish the specific nursing interventions aimed at the specific needs of children with kidney diseases. In addition, the association of nursing diagnoses and their diag-nostic indicators, in children with kidney disease, can contribute to the development and visibility of the nursing knowledge as a science, and to high-light aspects that demand the skill, education and abilities of the professionals who work in the area of pediatric nephrology nursing so that, together with the multiprofessional team, they may collaborate significantly in the care process.

CollaborationsSilva RAR and Bezerra MX contributed to the study design, analysis, data interpretation, article writing, relevant critical review of the intellectual content, and final approval of the version to be published. Andrade ICF, Mororo DDS and Souza Neto VL contributed to the analysis, data interpretation, article writing, rel-evant critical review of the intellectual content, and final approval of the version to be published.

References

1. Harambat J, van Stralen KJ, Kim JJ, Tizard EJ. Epidemiology of chronic kidney disease in children. Pediatr Nephrol. 2012; 27(3):363-73.

2. Oliveira BR, Viera CS, Furtado MC, Mello DF, Lima RA. Perfil de morbidade de crianças hospitalizadas em um hospital público: implicações para a enfermagem. Rev Bras Enferm. 2012; 65(4):586-93.

3. Lopes M, Koch VH, Varni JW. Tradução e adaptação cultural do Peds QLTM ESDR para a língua portuguesa. J Bras Nefrol. 2011; 33(4):448-56.

4. Santos WN. Sistematização da assistência de enfermagem: o contexto histórico, o processo e obstáculos da implantação. J Manag Prim Health Care. 2014; 5(2):153-8.

5. Duran EC, Toledo VP. Análise da produção do conhecimento em processo de enfermagem: estudo exploratório-descritivo. Rev Gaúcha Enferm. 2011; 32(2):234-40.

6. Tastan S, Linch GC, Keenan GM, Stifter J, McKinney D, Fahey L, et al. Evidence for the existing American Nursing Association - recognized standardized nursing terminologies: a systematic review. Int J Nurs Stud. 2014; 51(8):1160-70.

7. Miot HA. Tamanho da amostra em estudos clínicos e experimentais. J Vasc Bras. 2011; 10(4):275-8.

8. Herdman TH, Kamitsuru S. Nanda International. Nursing Diagnoses: definitions and classification 2015-2017. Oxford: Wiley Blackwell; 2015.

9. Lopes MV, Silva VM, Araujo TL. Validation of nursing diagnosis: challenges and alternatives. Rev Bras Enferm. 2013; 66(5): 649-55.

10. Faria JO, Silva GA. Diagnósticos de enfermagem do domínio segurança e proteção em pacientes com HIV/Aids. Rev Eletr Enf.2014; 16(1):93-9.

11. Dallé J, Lucena AF. Diagnósticos de enfermagem identificados em pacientes hospitalizados durante sessões de hemodiálise. Acta Paul Enferm.2012; 25(4):504-10.

12. Olivera VV. Desórdenes del metabolismo óseo-mineral asociados con enfermedad renal crónica. Diagnostico. 2011; 50(1):34-42.

13. Branco CS, Pontes YA. Diagnósticos de enfermagem em crianças portadoras de insuficiência renal crônica em tratamento hemodiálico. Rev Enfer Contempor. 2013; 2(1):103-11.

14. Ferreira SAL, Echer IC, Lucena AF. Nursing diagnoses among kidney transplant recipients: evidence from clinical practice. Int J Nurs Knowl. 2014; 25(1):49-58.

15. Bastos MG, Kirsztajn GM. Doença renal crônica: importância do diagnóstico precoce, encaminhamento imediato e abordagem interdisciplinar estruturada para melhora do desfecho em pacientes ainda não submetidos à diálise. J Bras Nefrol. 2011; 33(1):93-108.

16. Teixeira CG, Duarte MC, Prado CM, Albuquerque EC, Andrade LB. Impact of chronic kidney disease on quality of life, lung function, and functional capacity. J Pediatr (Rio J). 2014; 90(6):580-6.

17. Coca SG, Singanamala S, Parikh CR. Chronic kidney disease after acute kidney injury: a systematic review and meta-analysis. Kidney Int. 2012; 81(5):442-8.

18. Karkar A. Modalities of hemodialysis: quality improvement. Saudi J Kidney Dis Transpl. 2012; 23(6):1145-61.

19. Maciel AT, Park M, Macedo E. Urinary electrolyte monitoring in critically ill patients: a preliminary observational study. Rev Bras Ter Intensiva. 2012; 24(3):236-45.

20. Santos CM, Kirchmaie FM , Silveira WJ , Sena CA. Perceptions of nurses and clients about nursing care in kidney transplantation. Acta Paul Enferm. 2015; 28(4):337-43.

21. Vandecasteele SJ, Ombelet S, Blumental S, Peetermans WE. The ABC of pneumococcal infections and vaccination in patients with chronic kidney disease. Clin Kidney J. 2015; 8(3):318-24.

22. Vecchio LD, Longhi S, Locatelli F. Safety concerns about intravenous iron therapy in patients with chronic kidney disease. Clin Kidney J. 2016; 9(2):260-7.

23. Topaloglu R, Orhan D, Bilginer Y, Karabulut E, Ozaltin F, Duzova A. et al. Clinicopathological and immunohistological features in childhood IgA nephropathy: a single-centre experience. Clin Kidney J. 2013; 6(2):169-175.

80 Acta Paul Enferm. 2017; 30(1):80-6.

Original Article

Meanings of breastfeeding interruption due to infection by human T cell lymphotrophic virus type 1 (HTLV-1)Sentidos da interrupção da amamentação devido infeção pelo vírus linfotrópico de células T humanas do tipo 1( HTLV-1)Karina Franco Zihlmann1

Maria Cristina Mazzaia2

Augusta Thereza de Alvarenga3

Corresponding authorKarina Franco ZihlmannRua Silva Jardim, 136,11015-020, Santos, SP, [email protected]

DOI: http://dx.doi.org/10.1590/1982-0194201700012 1Departamento de Gestão e Cuidado em Saúde, Universidade Federal de São Paulo, Santos, SP, Brazil.

2Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil.3Faculdade de Saúde Pública, Universidade de São Paulo, São Paulo, SP, Brazil. Conflicts of interest: no conflicts of interest to declare.

AbstractObjective: Understand the meanings of breastfeeding inhibition to prevent vertical transmission among women living with HTLV-1 (WLHTLV).Methods: A qualitative research with participant observation and in-depth interviews was undertaken, using a pretested thematic script, analyzed by means of Bardin’s thematic content analysis. The participants were 13 people - 11 women and two men - over 18 years of age, diagnosed with HTLV-1 and without co-infections. The study was undertaken at a private room in a specialized center in São Paulo between June/2006 and April/2008, where the researcher worked, so that she was familiar with and had access to the users. The subjects were selected by convenience, during the participant observation. The subjects’ reports were recorded, transcribed and analyzed in search of senses and meanings to elaborate the categories. Excerpts were presented, identified by fictitious names.Results: Breastfeeding inhibition is a complex decision that is even more difficult in a context in which the health team does not know this infection.Conclusion: The lack of knowledge on HTLV-1 in the hospital context is a risk for the vertical transmission of this virus and entails significant emotional consequences. The health team needs information and education for comprehensive care and welcoming of WLHTLV’s specific needs.

ResumoObjetivo: Compreender os sentidos da inibição da amamentação como prevenção da transmissão vertical entre mulheres vivendo com HTLV-1 (MVHTLV).Métodos: Trata-se de pesquisa qualitativa com observação participante e entrevistas em profundidade, por meio de roteiro temático, pela análise de conteúdo temática de Bardin, pré-testado e realizados com 13 pessoas - 11 mulheres e dois homens - maiores de 18 anos, diagnosticados com HTLV-1 e sem co-infecções, entre Junho/2006 a Abril/2008, em sala reservada de centro especializado em São Paulo, onde atuava a pesquisadora, psicóloga, com familiaridade e acesso aos usuários. A seleção dos sujeitos ocorreu por conveniência durante a observação participante. Os relatos dos sujeitos foram gravados, transcritos e analisados na busca dos sentidos e significados para elaboração das categorias e, foram apresentados trechos destes, identificados por nomes fictícios.Resultados: A inibição da amamentação é uma decisão complexa dificultada em um contexto de desconhecimento dessa infecção pela equipe de saúde.Conclusão: O desconhecimento do HTLV-1 no contexto hospitalar se torna um risco para a transmissão vertical desse vírus, além de consequências emocionais significativas. Indica-se a necessidade de informação e formação da equipe de saúde para um cuidado integral e o acolhimento das necessidades específicas de MVHTLV.

KeywordsHTLV-1; Vertical transmission; Public health; Sexually transmitted diseases; Breastfeeding

DescritoresHTLV-1; Transmissão vertical; Saúde pública; Doenças sexualmente transmissíveis; Amamentação

Submitted November 24, 2016


81Acta Paul Enferm. 2017; 30(1):80-6.

Zihlmann KF, Mazzaia MC, Alvarenga AT

Introduction

HTLV-1 causes an infection that is unknown to most health professionals and is neglected in public health,(1-4) as its true epidemiological dimension is only estimated, considering that, between 10 and 20 million people have been infected around the world.(5) It is relevant that most people are asymp-tomatic (about 95% of the cases), do not know their serological status and can infect their partner or children.(3-7)

Zihlmann et al.(3) appoint the invisibility of HTLV in Brazil and around the world, raising a discussion about the influence of the hegemon-ic healthcare model that considers the low risk of illness as a justification for neglecting this endem-ic condition. Thus, the lack of knowledge about HTLV-1 entails implications for care practice, pre-vents the identification of infected patients and per-petuates the infection in society.

The infection by HTLV-1 is mixed up with the infection by HIV, but each entails different illnesses and demands distinct treatments, as the infection by HTLV-1 does not respond to antiretroviral drugs. The reasons why few people evolve to diseases associ-ated with HTLV-1 are yet unknown, the most com-mon of which are adult T-cell leukemia/lymphoma (LTTA) and HTLV-1-associated myelopathy/tropi-cal spastic paraparesis (HAM/TSP).(7)

The infections by HIV and HTLV-1 have iden-tical transmission forms,(7) but epidemiological data appoint that the main transmission form of HTLV-1 is through breastfeeding. Therefore, the main form to prevent the vertical transmission of HTLV-1 is the interruption of breastfeeding.(8,9)

In Brazil, few epidemiological studies exist on the endemic condition of HTLV-1. The great het-erogeneity of prevalence rates in the serological screening of blood bank donors in large Brazilian urban areas is known, the highest prevalence be-ing found in the cities of São Luiz do Maranhão (10/1,000 donors), Salvador (9.4/1,000 donors), followed by Belém (9.1/1,000 donors).(6)

Until recently, Japan presented high vertical transmission rates of HTLV-1 but, through pub-lic policy actions that established prenatal serum

screening among pregnant women and the inter-ruption of breastfeeding for seropositive patients, the vertical transmission rate dropped from 20% to approximately 3%.(10)

In Brazil, few studies exist on the prevalence of HTLV-1 among pregnant women. In a study de-veloped in Salvador, a rate of 0.88 % of the preg-nant women from the low socioeconomic level was indicated.(11) Between 2002 and 2006, a study was developed in Campo Grande, revealing a preva-lence rate of 0.13% of HTLV 1/2 among pregnant women.(12)

The duration of the breastfeeding interferes in the vertical transmission risk. If breastfeeding can-not be avoided for socioeconomic reasons, however, a maximum of six months is recommended.(13,14)

The most accepted recommendation - including in Brazil - is the interruption of breastfeeding to pre-vent the vertical transmission.(7)

One of the few disclosure actions on HTLV-1 in Brazil took place in 2003: the Recommendation Guide on the Management of HTLV.(7) Preventive actions to cope with HIV/Aids,(15) such as prena-tal testing or access to formula milk, do not attend to specific demands of people living with HTLV (PLHTLV), and are rarely extended to women liv-ing with HTLV (WLHTLV).

Concerning HTLV-1, the identification of in-fected persons in the family network is a crucial problem and, in these cases, secondary actions to prevent the risk of vertical transmission of the virus need to be considered (especially during breastfeed-ing). These issues are challenges the public policies should face with caution, as reported in Zihlmann.(16) Therefore, to cope with the vertical transmission prevention of this virus (through the interruption of breastfeeding), we need to reflect on the place of breastfeeding in our society and the possible effects of interrupting breastfeeding for the stakeholders.

As from the 19th century, breastfeeding started to be considered as a shared social good, or as an attribute that characterizes motherhood and wom-en’s identity, within an essential conception of im-portance in the health area. Nowadays, the relation breastfeeding/weaning can take the form of a clash between health and illness, representing a task that

82 Acta Paul Enferm. 2017; 30(1):80-6.

Meanings of breastfeeding interruption due to infection by human T cell lymphotrophic virus type 1 (HTLV-1)

needs to be undertaken with pleasure and abne-gation, as the health professional’s success. In that context, the health actions are intended to inform the women about the advantages of breastfeeding, making them responsible for the future outcomes, in a top-down and authoritative care model. That logic intends to modulate women’s behavior in fa-vor of breastfeeding, blaming them for weaning as a form of health problem for their children.

Nursing professionals are currently the main boosters of this process, exercising power established in the health spheres and contributing to dissemi-nate knowledge that has been validated as scientific. Overall, however, these orientations are limited to physiological aspects and ignore the women’s social and psychological universe. In the past decade, the traditional biological reductionism has been pro-gressively replaced by a new focus on the woman as a subject, beyond the idealization surrounding breastfeeding in the social imaginary.(17)

In view of the lack of studies that investigate the emotional aspects and meanings of the inhibition of breastfeeding in WLHTLV, we can draw paral-lels with the reports of women living with HIV/Aids who also inhibited breastfeeding. In addi-tion, it should be kept in mind that experiencing a pregnancy in this context is a complex emotional experience loaded with biased feelings. Therefore, healthcare needs to be based on the humanization perspective, beyond a mere prophylactic practice.(18)

Some studies appoint that, for women liv-ing with HIV/Aids, being pregnant is equivalent to “being healthy”. When the infant is born, the impossibility to breastfeed turns into a first “symp-tom” of HIV in the eyes of society.(19) For Moreno et al.,(20) the inhibition to breastfeed among wom-en living with HIV/Aids is considered something punishing and painful (especially the bandaging of the breasts). In that sense, the women revealed that they did not consider themselves complete and val-ued as mothers and that, although this action served to protect their infant’s health, they felt guilty and afraid of being socially judged.

For the pregnant women living with HIV/Aids, the mother’s milk gains a new meaning and breast-feeding turns into a threatening act for their child’s

integrity.(21) Therefore, in the context of HIV/Aids infection, the inhibition of breastfeeding requires a symbolic redefinition that makes it difficult to exercise the maternal role and articulates a loss ex-perienced in a melancholic and blameful manner, which the woman elaborates little by little, based on strategies intended to avoid anguish.(22)

What would the WLHTLV’s experience be like concerning the orientation not to breastfeed?

Therefore, the objective in this article is to un-derstand the meanings of inhibiting breastfeeding as a way to prevent the vertical transmission among women living with HTLV-1 and, in addition, to present related situations on experiences of actually interrupting breastfeeding.

Methods

The study is part of a research entitled “From the invisibility to the visibility of the subject living with the HTLV-1 infection/disease and the place of the reproductive decisions in the webs of knowledge and care”.(16) In this qualitative study,(23) participant observation and in-depth interviews, by means of a pretested thematic script,(24) using Bardin’s thematic content analysis,(25) were applied to 13 people - 11 women and two men - over 18 years of age, diag-nosed with HTLV-1 and without co-infections, be-tween June/2006 and April/2008, at a private room in a specialized center in São Paulo, where the re-searcher, a psychologist, worked, so that she was fa-miliar with and had access to the users. The subjects were selected by convenience during the participant observation.(24) The subjects’ reports were recorded, transcribed and analyzed in search of senses and meanings for the elaboration of the categories. Ex-cerpts were presented, identified by means of ficti-tious names.

Two thematic analysis categories were construct-ed:(25) The diagnosis of HTLV and the emotional implications of the need to inhibit breastfeeding and situations experienced at the maternity hospital in the postpartum period: the drama of inhibiting breastfeeding as the first symptom of an infection unknown to the health team.

83Acta Paul Enferm. 2017; 30(1):80-6.


Approval for the study was obtained from COEP/FSP under 297/06 and COEP/Instituto de Infectologia Emílio Ribas 34/06. After receiving orientations, the interviewees signed an Informed Consent Form, in compliance with resolution 466/12.

Results and Discussion

The diagnosis of HTLV and the emotional implications of the need to inhibit breast-feedingNot breastfeeding was like a bomb. We get that expec-tation, right? I think I won’t have that contact with the child, right? Because you’re the only one who can breastfeed. That news that I won’t be allowed to breast-feed really touched me and my husband. He thought it would negatively affect the baby. But I think she (daughter) won’t miss something she never had! (Ma-ria, 27 years, married, asymptomatic).

It was sad not to be allowed to breastfeed but, on the other hand, I felt relieved to know that was part of the care for my daughter not to have the HTLV (Ana, 27 years, married, symptomatic).

In these women’s statements, we can observe an emotional discourse, loaded with expectations on motherhood and breastfeeding. These overwhelm-ing statements indicate that the act of breastfeeding would provide an irreplaceable and special bond, besides being an act they consider intrinsic in the maternal role. That means that WLHTLV anchor their female and maternal identity in the breast-feeding process, in accordance with an idealized and socially shared discourse.

They also reveal a clash between emotion and reason. If, on the one hand, idealizations continue to exist on the act of breastfeeding, on the other, the experts’ information on the vertical transmis-sion risk serve as a reference framework for decision making that is intended to guarantee the infant’s health. In that sense, the inhibition of breastfeeding is a decision that grants them the feeling that they regain control over the situation.(14) We can recog-nize that these women try to accomplish a ratio-nalization process that may, or may not, facilitate

an elaboration process. The statements illustrate that this is not a response to a simple orientation by the health team, but also a position that requires involvement from the women, as well as support from their family network.

Situations experienced in the postpartum period at the maternity hospital: the dra-ma of inhibiting breastfeeding as the first symptom of an infection unknown to the health teamDifferent difficulties were reported in relation to the postpartum situation. The health team’s attitude is highlighted which, when discovering what the HTLV-1 infection is, welcoming the woman and family’s singular needs. In Maria’s report, the ap-propriate welcoming at the maternity hospital and the preparation of the health team are observed.(16) Her statement illustrates the relief for having been allocated to a separate room as, for her and her husband, besides having to cope with the need to inhibit the breastfeeding, the most difficult was to cope with the questioning look of other people and give explanations. She felt relieved for not having to watch other women breastfeed.

I stayed at a separate room. Nobody came in ask-ing. It would be very hard to see other women breast-feed. But there was one nurse* who came in and asked “Why don’t you like to breastfeed?”. And I had to explain what HTLV was. Ah, not being allowed to breastfeed was hard, right? (gets emotional) And when she (the daughter) cried, my breast filled. Then my breasts were bandaged so as not to have contact with her. But who really suffered was her father. But it was difficult that everyone was asking “oh dear, she’s so big, does she drink a lot?” Everyone asking, my neigh-bors. Not in my house, because I told them (about the HTLV) (Maria, 27 years, married, asymptomatic).

In the hospital context, different actors partici-pate, who may or may not serve as facilitators of the inhibition process of breastfeeding. A first actor is the health team and, although the majority showed to be prepared to cope with the situation, one team member was surprised at the situation and inquired about the reasons not to breastfeed. The profession-al mentioned not only demonstrates a critical pos-

84 Acta Paul Enferm. 2017; 30(1):80-6.


ture towards the inhibition process of breastfeeding, but also illustrates a total lack of knowledge on the patient’s specific medical situation. It is highlighted that, although the interviewees refer to nursing pro-fessionals, it was not clarified whether the nursing professional mentioned was the nurse or another member of the nursing team (see footnote).

Maria’s discourse also reveals the role of the oth-er patients’ looks, as Maria mentioned difficulty to see (another woman breastfeeding) and to be seen (inhibiting the breastfeeding), putting the inhibit-ing of breastfeeding in the position of core signifier in the expression of her condition as a WLHTLV.

As for the companions and relatives, the experi-ences are similar to those reported by women living with HIV/Aids,(19) that is, what is observed in the anticipation of the situation through information for key figures in the family, preparing them for moments of commotion and suffering. Concerning the visitors - another actor in the hospital scenar-io - a list of apologies is constructed to justify the breastfeeding inhibition. This conduct is intended to avoid evidencing the infection by HTLV-1, in view of the fear of prejudice and stigmatization. In that context, the importance is observed of preg-nant women’s taking an active stance towards the generalized ignorance about HTLV-1. The situa-tions reported reveal that the hospital setting can be a risky environment, that is, women in this con-dition experience invisibility for the health area, as reported by Zihlmann.(16)

Other participants reported on situations in which the health teams ignored the HTLV-1 and took an inappropriate stance. Maria Rita’s report is dramatic and revealed the health team’s pressures for her to breastfeed, even after having explained

that she was seropositive to HTLV-1. This inter-viewee told that she had been diagnosed (in the eighth month of pregnancy) with HTLV-1 and that the infectious disease specialist at the specialized re-ferral center had instructed her not to breastfeed, providing a formal statement for that diagnosis. In her report, Maria Rita revealed that the conversa-tion with the health team of the maternity hospital was tense and that she was confronted with disbelief in her information:

The nurse* brought her (the child) to breastfeed, then I said “I won’t breastfeed!” The nurse* said “why won’t you breastfeed? You’ve got milk”. I said “I’ve got milk, but I can’t breastfeed, I was instructed by the infectious disease specialist”. The obstetrician said “Yes you can breastfeed!”. The nurse* said “you can breastfeed, I’ve talked to the physician and there’s no problem”. I said “No! I see a specialist and he ad-vised me not to breastfeed, because when I got here, at this hospital, nobody knew about the topic HTLV, why would I trust you now?” (Maria Rita, 27 years, asymptomatic).

It should be reminded that Maria Rita had her daughter in 2007, in the city of São Pau-lo, which is considered the region with the best access to health in the country.(26) This report does not only illustrate a situation of the team’s lack of preparation to deliver care to WLHTLV, but also reveals the risk this unpreparedness can entail. This means that there exists a risk when the hospital ignores these subjects’ specific needs and does not acknowledge them as subjects with rights. It should be highlighted that the final consequence is the perpetuation of this infection in our midst.(3,7)

Maria Rita also reported that her rights were in-fringed as, even without any infectious-contagious condition, the patient would still have the right to decide whether she wants to breastfeed or not. The following expert discusses these aspects:

I explained it to the nurse*, but she nevertheless in-sisted. She put the baby here at my breast. I said I won’t breastfeed! She said “I’ll teach you how to breastfeed”. Then I took the baby off my breast. Do you think I didn’t want to breastfeed? Why did this have to be like that? (Maria Rita, 27 years, asymptomatic).

*Foot note: In the interviewees’ statements, the term “nurse” is fre-quently observed to designate an interlocutor during the hospitaliza-tion. It is not clear or impossible to distinguish, however, based on the statements, whether that person is truly a nursing professional or the particularity of her function. For the sake of analysis, we consider that the interviewee’s discourse indicated that, from her perspective, that person was a nursing professional, independently of other attributes. Even if the interlocutor does not come from the nursing area, she was identified as such by the interviewee and held responsible for this care during the hospitalization. This identification may indicate that the in-terviewee revealed her viewpoint on the importance and central role of this professional’s engagement in the context appointed in this study. Therefore, for the sake of this article, the use of the term “nurse” will follow the considerations proposed.

85Acta Paul Enferm. 2017; 30(1):80-6.


This patient’s posture was firm, as she felt safe as a result of the information and support received at the specialized center. The continuation of her re-port shows that she had to ask the infectious disease specialist’s help as the health team did not consider anything she said was valid.

I said “is there milk here for my daughter? If not, someone should bring it”. Then they said “you can’t bring other milk! It’s the first breast milk she needs”. I had to call the infectious disease specialist on my mo-bile phone. Dr. J. managed to calm me down and then I passed my phone to the hospital pediatrician, who was waiting at my side. Afterwards, the pediatrician said “it’s best not to breastfeed” (Maria Rita, 27 years, asymptomatic).

Finally, this case revealed that the patient bond-ed with the team at the specialized center, and was not merely “informed/advised”. We can infer that this bond strengthened her to cope with an incon-ceivable situation, all the more when we consider the sensitiveness of her circumstances.(16)

As a study limitation, we observed that the in-terviewees’ discourse frequently contains the term “nurse” to designate an interlocutor during the hospitalization. It is not clear or impossible to dis-tinguish, however, based on the discourse, whether that person is truly a nursing professional or even the particularity of her function. Therefore, this identification may indicate the central role of this professional’s engagement in the context appointed in this study.

Conclusion

The interruption of breastfeeding as a way to pre-vent the vertical transmission of infectious-con-tagious diseases is a complex decision. Among WLHTLV, however, this experience comes with additional particularities and anguish, especially due to the aggravating factor of the general igno-rance on this infection. The reports presented re-veal a gap in health professionals’ education, that is, our study unveiled the need for public policies that enhance the visibility of HTLV. Preparing the pregnant or parturient woman in advance is con-

sidered fundamental in order to help her to play a protagonist role, especially in a context of neglect of her specific needs. Therefore, diagnosing the in-fection by HTLV-1 in prenatal care is fundamental to guarantee the appropriate conduct of the vertical transmission prevention process. This research can contribute to dissemination on the subject, besides allowing reflection on the need for the construction of integral health care, which, after all, can allow the welcoming of PVHTLV’s complex needs.

AcknowledgementsTo the Brazilian Scientific and Technological Devel-opment Council - CNPq, Universal call 14/2012 - process 471624/2012-8 (Funding).

CollaborationsZihlmann KF, Alvarenga AT and Mazzaia MC contributed to the conception of the project, analysis and interpretation of the data, writing of the article, relevant critical review of the intel-lectual content and final approval of the version for publication.

References

1. Casseb J. Is Human T Cell Lymphotropic Type 1 (HTLV-1) - Associated Myelopathy/Tropical Spastic Paraparesis (HAM/TSP) Syndrome a Neglected Disease? PLoS Negl Trop Dis. 2009; 3:e487.

2. Guiltinan AM, Murphy EL, Horton JA, Nass CC, McEntire RL, et al. Psychological distress in blood donors notified of HTLV- I/II infection. Transfusion. 1998; 38(11-12):1056-62.

3. Zihlmann KF, Alvarenga AT, Casseb J. Living invisible: HTLV-1-infected persons and the lack of care in public health. PLoS Negl Trop Dis. 2012; 6(6):e1705.

4. Carneiro-Proietti AB, Catalan-Soares B, Proietti FA; GIPH (Interdisciplinary HTLV-1/II Research Group). Human T Cell Lymphotropic viruses (HTLV I/II) in South America: should it be a Public Health concern? J Biomed Sci. 2002; 9(6 Pt 2):587-95.

5. Gessain A, Cassar O. Epidemiological aspects and world distribution of HTLV-1 Infection. Front Microbiol. 2012; 3:388.

6. Catalan-Soares B, Carneiro-Proietti AB, Proietti FA. Interdisciplinary HTLV Research Group. Heterogeneous geographic distribution of human T-cell lymphotropic viruses I and II (HTLV-I/II): serological screening prevalence rates in blood donors from large urban areas in Brazil. Cad Saúde Pública. 2005; 21(3):926-31.

7. Brasil. Ministério da Saúde. Grupo de Trabalho em HTLV. Cartilha contendo informações básicas sobre HTLV para distribuição na rede Pública de Saúde. Brasília (DF): Ministério da Saúde; 2003.

86 Acta Paul Enferm. 2017; 30(1):80-6.


8. Carneiro-Proietti AB, Amaranto-Damasio MS, Leal-Horiguchi CF, Bastos RH, Seabra-Freitas G, Borowiak DR, et al. Mother-to-Child transmission of human T-cell lymphotropic viruses-1/2: what we know, and what are the gaps in understanding and preventing this route of infection. J Pediatric Infect Dis Soc. 2014; 3 Suppl 1:S24-29.

9. Ando Y, Matsumoto Y, Nakano S, Saito K, Kakimoto K, Tanigawa T, Ekuni Y, Kawa M, Toyama T. Long-term follow up study of vertical HTLV-I infection in children breast-fed by seropositive mothers. J Infect. 2003; 46(3):177-9.

10. Kashiwagi K, Furusyo N, Nakashima H, Kubo N, Kinukawa N, Kashiwagi S, et al. A decrease in mother-to-child transmission of human T lymphotropic virus type I (HTLV-I) in Okinawa, Japan. Am J Trop Med Hyg. 2004; 70(2):158-63.

11. dos Santos JI, Lopes MA, Deliège-Vasconcelos E, Couto-Fernandez JC, Patel BN, Barreto ML, et al. Seroprevalence of HIV, HTLV-I/II and other perinatally-transmitted pathogens in Salvador, Bahia. Rev Inst Med Trop Sao Paulo. 1995; 37(4):343-8.

12. Dal Fabbro MM, Ferrairo J, Cunha RV, Bóia MN, Portela P, Botelho CA, Freitas GM, Soares J, Ferri J, Lupion J. Infecção pelo HTLV 1/2: atuação no pré-natal como estratégia de controle da doença no Estado de Mato Grosso do Sul. Rev Soc Bras Med Trop. 2008; 41(2):148-51.

13. Mylonas, I, Bruning A, Kainer F, Friese K HTLV infection and its implication in gynecology and obstetrics. Arch Gynecol Obstet. 2010; 282(5):493-501.

14. Van Tienen C, Jakobsen M, Van de Loelf MS. Stopping breastfeeding to prevent vertical transmission of HTLV-1 in resource-poor settings: beneficial or harmful? Arch Gynecol Obstet. 2012; 286(1):255-6.

15. Brasil. Ministério da Saúde. Portaria nº 822, de 26 de junho de 2003. Exclui da Tabela de Procedimentos Especiais do SIH/SUS os Testes Rápidos para Triagem de Sífilis e/ou HIV (Por Teste) e dá outras providências. Diário Oficial da União: 2003; 26 jun.

16. Zihlmann, KF. Da invisibilidade à visibilidade do sujeito vivendo com a infecção/doença do vírus linfotrópico de células T humanas do tipo 1 (HTLV-1) e o lugar das decisões reprodutivas. [tese]. São Paulo: Faculdade de Saúde Pública. Universidade de São Paulo. 2009.

17. Almeida, JA; Novak, FR. Amamentação: um híbrido natureza-cultura. Jornal de Pediatria. 2004; 80: S119-S125.

18. Carneiro AJ, Coelho EA. Aconselhamento na testagem anti-HIV no ciclo gravídico-puerperal: o olhar da integralidade. Ciênc Saúde Coletiva. 2010; 15 Supl. 1:1216-26.

19. Knauth DR. Subjetividade feminina e soropositividade. In: Barbosa RM, Parker R, organizadores. Sexualidades brasileiras: direitos, identidades e poder. 34a ed. Rio de Janeiro: IMS/UERJ; 1999. p.121-36.

20. Moreno CC, Rea MF, Filipe EV. Mães HIV positivo e a não-amamentação. Rev Bras Saúde Mater. Infant (Recife). 2006; 6(2):199-208.

21. Gonçalves TR, Piccinini CA. Aspectos psicológicos da gestação e da maternidade no contexto da infecção pelo HIV/Aids. Psicol USP. 2007; 18(3):113-42.

22. Cartaxo CM, Nascimento CA, Diniz CM, Brasil DR, Silva IF. Gestantes portadoras de HIV/AIDS: aspectos psicológicos sobre a prevenção da transmissão vertical. Estud Psicol (Natal). 2013; 18(3):419-27.

23. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Quality Health Care. 2007; 19(6):349-57.

24. Turato ER. Tratado de metodologia da pesquisa clínico-qualitativa: Construção teórico-epistemológica, discussão comparada e aplicação nas áreas da saúde e humanas. Petrópolis (RJ): Vozes; 2003.

25. Bardin L. Análise de conteúdo. Lisboa: Edições 70; 1977.

26. Travassos C, Oliveira EX, Viacava F. Desigualdades geográficas e sociais no acesso aos serviços de saúde no Brasil: 1998 e 2003. Ciênc. Saúde Coletiva. 2006; 11(4): 975-86.

87Acta Paul Enferm. 2017; 30(1):87-93.

Original Article

First aid in schools: construction and validation of an educational booklet for teachers

Primeiros socorros na escola: construção e validação de cartilha educativa para professores

Nelson Miguel Galindo Neto1

Joselany Áfio Caetano1

Lívia Moreira Barros1

Telma Marques da Silva2

Eliane Maria Ribeiro de Vasconcelos2

Corresponding authorNelson Miguel Galindo NetoAv. Prof. Moraes Rego, 1235,50670-901, Recife, PE, [email protected]


1Universidade Federal do Ceará, Fortaleza, CE, Brazil.2Universidade Federal de Pernambuco, Recife, PE, Brazil.Conflicts of interest: there are no conflicts of interest to declare.

AbstractObjective: To develop and validate an educational booklet for preschool and elementary I education teachers on first aid procedures in schools.Methods: Methodological study based on the construction of an educational material with subsequent validation by 22 experts and assessment by 22 teachers. Content validation was established based on the Content Validity Index higher than 0.8. Binomial test considering p equal or higher than 0.8 was used for the proportion of agreement among the experts.Results: The educational booklet containing 44 pages addresses first aid procedures that should be performed for 15 health-related problems. All the items were considered relevant and the Level Content Validity Index presented mean value of 0.96. The booklet was approved by the teachers with an agreement index of 1.0.Conclusion: The booklet was developed and validated and may be used by nursing in health care education with teachers regarding first aid procedures in schools.

ResumoObjetivo: Construir e validar uma cartilha educativa para professores da educação infantil e ensino fundamental I sobre primeiros socorros na escola.Métodos: Estudo metodológico realizado a partir da construção do material educativo, com posterior validação por 22 juízes e avaliação de 22 professores. A validação de conteúdo foi estabelecida a partir do Level Content Validity Index maior que 0,8. Para proporção de concordância entre os juízes foi o utilizado o teste binomial e considerado p igual ou maior que 0,8.Resultados: A cartilha aborda os primeiros socorros que devem ser realizados em 15 agravos e possui 44 páginas. Todos os itens foram avaliados como pertinentes e o Level Content Validity Index possuiu média de 0,96. A cartilha foi aprovada pelos professores com índice de concordância 1,0.Conclusão: A cartilha foi construída e validada e pode ser utilizada pela enfermagem na educação em saúde com professores sobre primeiros socorros na escola.

KeywordsHealth education; First aid; Schools;

Validation studies; Nursing

DescritoresEducação em saúde; Primeiros socorros; Escolas; Estudos de

validação; Enfermagem

Submitted December 7, 2016


88 Acta Paul Enferm. 2017; 30(1):87-93.


Introduction

First aid procedures are defined as the initial actions aimed at helping people in suffer or at risk of death and that may be performed by any individual, not only by health professionals.(1) School is a major place where situations of urgency and emergen-cy occurs. It consists in an environment in which injuries may affect students, and the teacher has a significant chance to be present and act during a sit-uation. However, their education-oriented training lead teachers to lack self-confidence and qualifica-tion to perform first aid procedures.(2)

A study conducted in India assessing the knowl-edge of teachers about first aid procedures in schools showed that 13% of the teachers had low level of knowledge and 87% presented moderate level of knowledge, evidencing a scenario that reveals the lack of a proper qualification of teachers to provide first aid care.(3) Similar results were observed in a study conducted in Africa that identified the lack of knowledge and qualification of elementary educa-tion teachers in relation to the appropriate first aid procedures.(4)

Education in health is an effective strategy for coping with the deficit of knowledge by teachers on the theme. A study conducted in China investi-gating the knowledge of teachers six months, nine months, and four years after conducting a training on pediatric first aid procedures concluded that, de-spite their decreased knowledge, overtime the ed-ucational intervention improved the apprehension of knowledge on a short-term and long-term basis.(5) In view of the effectiveness of training programs on first aid procedures for teachers this study high-lights the importance of conducting further stud-ies contributing to the education in health for such professionals.

Nursing occupies a strategic position for edu-cation in health regarding first aid procedures in school as it is part of urgency and emergency ser-vices and due to its presence in schools. Nursing is present in the School Health Program, dealing with the promotion of health of students in proj-ects such as SAMU in Schools and Samuzinho, in which professionals from the Mobile Emer-

gency Care Services (SAMU) conduct educa-tional interventions in schools. Therefore, stud-ies on educational technologies related to first aid procedures are relevant for nursing as they may contribute to the educational interventions conducted by this professional category in the school environment.

The effectiveness of educational interventions in health is affected by a number of variables, including the availability of materials that may be used as a didactic resource. Considering that teaching the first aid procedures should occur with the use of educational technologies devel-oped from scientific evidence, this study points out the relevance of developing high-quality ed-ucational material with appropriate content to facilitate the understanding of information by the target audience.(6) Such materials are useful resources that may be used to contribute to the training and qualification of teachers. In this sense, the objective of the present study was to develop and validate an educational booklet for preschool and elementary I education teachers on first aid procedures in schools.

Methods

The present methodological study was based on the development of an educational booklet with subsequent validation by experts and assessment by the target audience. The content of the book-let was obtained from the recommendations of the Prehospital Trauma Life Support, studies with the characterization of pediatric emergency care, the National Policy on Emergency Care, the manual of accidents by venomous animals of the Ministry of Health, and the guidelines of the American Heart Association.(7-9)

Previous knowledge and opinions of teach-ers regarding the themes that should be includ-ed in the booklet were investigated through the implementation of a focus group with teachers from the municipal education network of Bom Jesus-PI in order to base the educational material on the needs of its target audience. This survey

89Acta Paul Enferm. 2017; 30(1):87-93.

Galindo Neto NM, Caetano JA, Barros LM, Silva TM, Vasconcelos EM

pointed out the influence of popular myths in the implementation of first aid procedures, and the teachers suggested that the booklet should contain information about the appropriate pro-cedure for episodes of convulsive crisis, heat injuries, decreased level of consciousness, air-way obstruction, exogenous intoxication, and drowning.

Considering that pediatric first aid proce-dures differ according to the age of the child and aiming at developing a didactic educational material without confusing information, the in-formation of the booklet was specified for the actions to be adopted in first aid for children be-tween four and ten years old as this age group encompasses seven years of the childhood and presents the same pattern of first aid procedures, without details and specifications existing for some first aid actions for older or younger chil-dren. Therefore, the educational material was developed for preschool and elementary I edu-cation teachers as it is in this school period that the age of students is compatible with the first aid procedures addressed in the booklet.

The layout and text structure of the booklet were based on recommendations in relation to the writing and formatting of the text of edu-cational technologies.(10) The theoretical frame-work of the instructional events of Gagné, which covers the components of the instruction that need to be present so that the apprehension of knowledge may occur from the cognitive pro-cesses that are responsible for learning, was used in the construction of the material.(11) The illus-trations were created by a designer, and subse-quently colored and adjusted with the use of the Corel Draw X7 software.

The next step consisted in the material vali-dation. The sample calculation to determine the number of experts was obtained through the for-mula n=Za2.P(1-P)/e2. The stipulated values were Za (level of confidence) = 95%, P (proportion of concordance between the experts) = 85%, and (ac-cepted difference from the expected) = 15%,(12) resulting in 22 experts. Working in the educa-tional, care, and research areas involving first aid

was considered for the selection of participants.(13) The search for such professionals was conducted among professors of the specialization course in urgencies and emergencies of a public university of the state of Pernambuco and included names of other professionals with the desired profile sug-gested by these professors. They were contacted via email in November 2014.

The instrument was developed with 21 items (Table 1) in which the experts should record the assessment of the educational material by means of one of the five options available to be marked, ranging from totally disagree to totally agree. The items of the instrument covered the con-tent, text, images, layout, motivation, and cul-ture, and there was a request for a written record of suggestions in a space available in the instru-ment.

After face and content validation, and conclu-sion of the adjustments suggested by the experts, the amended educational material was assessed by teacher. The number of professors invited for this assessment was established by the same for-mula that determined the sample of experts, thus 22 teachers assessed the booklet. The names of the teachers of the Education Department of the city of Bom Jesus-PI were drawn through sim-ple random sampling. The selected teachers were approached in person in the schools where they worked, and their assessment occurred with the use of an instrument adapted from the Suitabili-ty Assessment of Materials,(14) with 19 questions (about the understanding of the text and the im-ages) and a space to record their opinion and/or suggestion in relation to the booklet.

Data were analyzed in the Microsoft Excel software, and the Content Validity Index was calculated in three ways: I-CVI (Item-Level Con-tent Validity Index) - related to the proportion of agreement among the experts in relation to each item; S-CVI/AVE (Scale-level Content Va-lidity Index, Average Calculation Method) - it is the proportion of items that each expert agreed, related to each expert; and S-CVI (Scale-level Content Validity Index), which is the mean val-ue of the S-CVI-AVE. In addition, the binomial

90 Acta Paul Enferm. 2017; 30(1):87-93.


test was performed to compare whether the pro-portion of experts that agreed with the validity of the booklet was statistically equal or higher than 0.80 (value previously defined to validate an item).(15) A level of significance of 5% was adopted for this test.

The recommendations of Resolution 466/12 were followed and this study was approved by the Research Ethics Committee of the Federal Univer-sity of Pernambuco (protocol 930.697).

Results

The professionals that participated in the vali-dation of the booklet had a nursing degree, and three of them were firefighters, in addition to be-ing nurses. Ten worked as professors, and twelve worked as licensed practical nurses. Regarding their degrees, 18 had concluded a specialization course in urgency and emergency, 8 had a mas-ter’s degree in nursing, and 5 had a PhD degree.

Sixteen participants had teaching experience in the area, 21 had completed courses on first aid procedures, and 20 had been instructors and/or professors in this type of courses.

Of the 21 items of the instrument, ten present-ed the options agree or totally agree marked by all the experts, seven had agreement of 95%, three pre-sented 90% of agreement, and in one item there was 86% of agreement and the I-CVI was 0.96 (Table 1).

For 17 of the 22 experts, the S-CVI/AVE was 1 by their agreement with all the items of the booklet and for two experts it was 0.95. After the calcula-tion of the mean value of the S-CVI/AVE, a S-CVI of 0.96 was obtained.

Four teachers that assessed the booklet had an undergraduate degree, seventeen had completed a specialization course, and one had a Master’s degree. Nine teachers had more than six years of teaching experience.

The agreement index of the assessment by the teachers was 1.0. All of them pointed out that the text and content of the booklet were easy to under-

Table 1. Agreement of the experts in relation to the items of the bookletItem n(%)* I-CVI** p***

1. Content

1.1 The content meets a possible situation for teachers. 22 100 1 1

1.2. Heads/subheads are divided consistently. 21 95.5 0.95 0.972

1.3 Highlighted parts deserve in fact to be highlighted. 21 95.5 0.95 0.972

1.4 The content meets the needs of the target audience. 21 95.5 0.95 0.972

1.5 There is logic in the sequence of the text. 20 90.9 0.90 0.863

1.6 The content is relevant to be informed to teachers. 22 100 1 1

1.7 The content is correct in the scientific perspective. 19 86.4 0.86 0.661

2. Language

2.1 The writing is compatible with the target audience. 20 0.90

2.2 The phrases are attractive and not boring. 22 100 1 1

2.3. There is clarity and objectivity in the text. 22 100 1 1

3. Illustrations

3.1 The illustrations are consistent with the content. 21 95.5 0.95 0.972

3.2 The illustrations are easy to understand. 21 95.5 0.95 0.972

3.3 Legends help the reader to understand the images. 22 100 1 1

3.4 The number of images is sufficient to cover the content. 20 0.90

4. Layout

4.1 The font size and type favor the reading process. 21 95.5 0.95 0.972

4.2 The colors used in the text facilitate the reading. 21 95.5 0.95 0.972

4.3 The arrangement of the items on the pages is organized. 22 100 1 1

4.4 The number of pages and the size of the material are consistent. 22 100 1 1

5. Motivation

5.1 The reader is encouraged by the content to keep reading. 22 100 1 1

5.2 The booklet is enlightening. 22 100 1 1

6. Culture

6.1 The booklet meets the several profiles of teachers. 22 100 1 1

Mean 0.96

*Percentage of agreement; **Item-Level Content Validity Index; ***Binomial test

91Acta Paul Enferm. 2017; 30(1):87-93.


stand and that there were an appropriate number of illustrations to help in the understanding of the information. The booklet was considered enlighten-ing by all the participants.

The booklet consisted of 44 pages, including cover, back cover, technical sheet, coversheet, sum-mary, and introduction page. Prior to the specific first aid-related topics there were two chapters ad-dressing important issues regarding the professional performance in severe cases: the safety of the place and the proper manner to call for support. Then, the booklet presented the first aid procedures for 15 urgency and emergency situations (bleeding, blows, bone integrity problems, convulsive crisis, heat in-juries, amputations, burns, traumatic eye injuries, dental avulsion, exogenous intoxication, accidents involving venomous animals, lowered level of con-sciousness, cardiorespiratory arrest, airway obstruc-tion, and drowning). Finally, the booklet presented bibliographical references and a space for notes.

The text was written in a popular language, avoiding the use of technical terms. Some im-

portant phrases were emphasized by being insert-ed in a yellow table with an exclamation mark on the left margin. Phrases related to actions indi-cated for the relief of a particular injury were presented in green tables with a green “v” sign; contraindicated actions were inserted in red ta-bles signed with a red “x”. Figure 1 shows some pages of the booklet.

Discussion

The exclusivity of the educational material for pre-school and elementary I education teachers repre-sent a limitation of this study. Another limitation consists in the lack of studies on the construction and validation of other technologies for teach-ing first aid procedures in schools or for laymen, which made it impossible to compare and discuss the results.

The construction and validation of the educa-tional booklet on first aid procedures in the school environment converges in the School Health Pro-gram, which aims at the promotion of health of stu-dents and points out the qualification of teachers as a resource to strengthen its actions.(16) Also, it cor-roborates the National Policy for Reduction of Mor-bidity and Mortality by Accidents and Violence, as it contributes to the dissemination of information for teachers in relation to the appropriate actions to be adopted in cases of urgency and emergency.(17)

The relevance of the content of the booklet and its applicability to situations that may be faced by teachers obtained agreement by all the experts. Another study that validated a booklet on healthy eating for pregnant women also ob-served agreement among the experts on the appli-cability of the educational material.(18) It is import-ant that studies involving educational technologies investigate whether these technologies apply to the context in which they will be used, as although its content is valid and easy to understand, it is neces-sary that the technology is applicable so that its use is practicable.

The practicability of the use of education-al booklets permeates the understanding of the

Figure 1. Some pages of the educational booklet on first aid in schools

92 Acta Paul Enferm. 2017; 30(1):87-93.


reader on the content presented in the material. Results of a study conducted in Sweden show that 29% of the educational material provided in 27 hospitals to patients undergoing colorectal can-cer surgery were difficult to understand, and the authors point out that the investigation of the opinion of the target audience may contribute to obtaining educational materials that are more ap-propriate to the language of the reader.(19) Regard-ing the understanding of the educational booklet, a study conducted in the eastern region of Afri-ca assessing the impact of education in health in schools on the reduction of cases of schistosomi-asis points out that 75% of the readers did not understand the information contained in an edu-cational booklet.(20)

These findings diverge from studies conducted in Brazil: in relation to the language of the booklet, in the present study the phrases were considered at-tractive, clear, and objective by all teachers. Similar results are observed in other studies that validated educational materials, and their target audience also assessed the language as clear and compatible with a good understanding.(21,22) In view of such findings, this study highlights the relevance of the assessment of educational materials by their target audience as parts that are not compatible with the effectiveness of the communication may be identified and fixed.

The assessment performed by the teachers re-garding the understanding of the images is sim-ilar to this study in relation to the construction and validation of an educational booklet on ve-nous ulcer-related care procedures, in which the target audience was also questioned, pointing out that the images of the material were appropriate.(23) These findings corroborate the practicability of the illustrations in booklets and their contribu-tion to make the information clear and attractive to readers. Therefore, well-illustrated educational booklets are presented as relevant resources to be used in the most diverse healthcare areas and spe-cialization programs.

No unanimity was observed among the ex-perts in relation to the compatibility of the text with the target audience. The two experts that disagreed in relation to this item suggested chang-

es, which were then implemented. In fact, such changes may have contributed so that all the teachers that assessed the booklet at a later mo-ment considered it appropriate. It is important to mention that as more than 80% of the experts had agreed with the item, there was no obligato-riness in accepting/implementing the suggestions, but the subsequent unanimous approval by the teachers suggests that it is important to analyze suggestions that are reasonable and conducting changes in the educational material, even if the item to which the suggestions were indicated was approved by the established proportion of agree-ment among the other experts.

Most experts agreed that the content of the booklet was scientifically correct (I-CVI of 0.86). The I-CVI was higher than 0.8 and the S-CVI was 0.96, therefore the educational material was validat-ed in relation to its face and content.

Conclusion

Previous knowledge and opinion of representa-tives of the target audience were considered in the construction of the booklet on first aid proce-dures. Face and content validation was obtained, and the material was assessed by the teachers as well-illustrated, easy to understand, and enlight-ening, consisting in a pedagogical tool to be used by nursing in education in health in schools and in the training of education professionals. The ad-opted stages and criteria and the theoretical frame-work used in the construction of the booklet were compatible with the attainment of a practicable educational material to be used and approved by the target audience. This fact may contribute to the methodological decision of professionals in-volved in health education to build educational technologies in a range of fields. The final version of the booklet was made available for electron-ic access at the Open University of the Brazilian National Health System of the Federal University of Pernambuco (UNA-SUS UFPE) for Latu Sen-su Graduate students in Family Health. Despite the practicability of the use of the book evidenced

93Acta Paul Enferm. 2017; 30(1):87-93.


by its validation of content and assessment by the target audience, it is necessary that further stud-ies be conducted in order to investigate the effec-tiveness of the material as a didactic resource, as well as the apprehension of knowledge of teachers based on its use.

CollaborationsGalindo Neto NM, Caetano JA, Barros LM, Silva TM and Vasconcelos EMR participated in the con-ception of the project, data analysis and interpreta-tion, writing of the article, relevant critical review of its intellectual content, and final approval of the version to be published.

References

1. Singletary EM, Charlton NP, Epstein JL, Ferguson JD, Jensen JL, MacPherson AI, et al. First Aid: 2015 American Heart Association and American Red Cross Guidelines Update for First Aid. Circulation. 2015; 132(Suppl 2)18:574-89.

2. Oliveira IS, Souza IP, Marques SM, Cruz AF. Knowledge of edutors on prevention of accidents in childhood. J Nurs UFPE on line [internet]. 2014 [cited 2014 Jan 03]; 8(2): 279-85. Available from: http://www.revista.ufpe.br/revistaenfermagem/index.php/revista/article/view/3390/pdf_4530.

3. Joseph N, Narayanan T, Zakaria S, Nair AV, Belayutham L, Subramanian AM, et al. Awareness, attitudes and practices of first aid among school teachers in Mangalore, south India. J Prim Health Care. 2015; 7(4):274-81.

4. Ngayimbesha A, Hatungimana O. Evaluation of first aid knowledge among elementary school teacher in Burundi. Int J Sport Scienc Fit. 2015; 5(2):304.

5. Li F, Sheng X, Zhang J, Jiang F, Shen X. Effects of pediatric first aid training on preschool teachers: a longitudinal cohort study in China. BMC Pediatr. 2014; 14(209):1-8.

6. Ryan L, Logsdon MC, McGill S, Stikes R, Senior B, Helinger B, et al. Evaluation of printed health education materials for use by low-education families. J Nurs Scholarsh. 2014; 46(4):218-28.

7. Atkins DL, Berger S, Duff JP, Gonzales JC, Hunt EA, Joyner BL, et al. Part 11: Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(Suppl 2)18:519-25.

8. Singletary EM, Zideman DA, De Buck EDJ, Chang WT, Jensen JL, Swain JM, et al. Part 9: First Aid: 2015 International Consensus on First Aid Science With Treatment Recommendations. Circulation. 2015; 132(Suppl 1)16:269-311.

9. Ciampo LA, Ferraz IS, Tazima MF, Bachette LG, Ishikawa K, Paixão R. [Clinical and epidemiological characteristcs of injuried children in a department of emergency care]. Pediatria (São Paulo). 2011; 33(1):29-34. Portuguese.

10. Hoffmann T, Warrall L. Designing effective written health education materials: considerations for health professionals. Disabil Rehabil. 2004; 26(9):1166-73.

11. Khadjooi K, Rostami K, Ishaq S. How to use Gagne’s model of instructional design in teaching psychomotor skills. Gastroenterol Hepatol Bed Bench. 2011; 4(3):116-9.

12. Lopes MVO, Silva VM, Araujo TL. Methods for establishing the Accuracy of Clinical Indicators in Predicting Nurseing Diagnoses. Int J Nurs Knowl. 2012; 23(3):134-9.

13. Melo RP, Moreira RP, Fontenele FC, Aguiar ASC, Joventino ES, Carvalho EC. Criteria for selection of experts for validation studies of nursing phenomena. Rev Rene. 2011; 12(2):424-31.

14. Doak CC, Doak LG, Root JH. Teaching Patients with Low Literacy Skills. 2nd ed. Philadelphia: JB Lippincott; 1996.

15. Polit D, Beck CT. The Content Validity Index: are you sure you know what’s being reported? Critique and recommendations. Res Nurs Health. 2006; 29(5):489-97.

16. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Saúde na escola. Brasília (DF): Ministério da Saúde; 2009.

17. Brasil. Portaria GM/MS nº. 737 de 18 de maio de 2001. Política nacional de redução da morbimortalidade por acidentes e violências. Diário Oficial da União, Brasília, n.96, seção 1e, 2001.

18. Oliveira SC, Lopes MVO, Fernandes AFC. Development and validation of an educational booklet for healthy eating during pregnancy. Rev. Lat Am Enfermagem. 2014; 22(4):611-20.

19. Smith F, Carlsson E, Kokkinakis D, Forsberg M, Kodeda K, Sawatzky R, et al. Readability, suitability and comprehensibility in patient education materials for Swedish patients with colorectal cancer undergoing elective surgery: A mixed method design. Patient Educ Couns. 2014; 94(2): 202-9.

20. Stothard JR , Khamis AN, Khamis IS, Neo CHE, Wei I, D. Rollinson. Health education and the control of urogenital schistosomiasis: assessing the impact of the juma na kichocho comic-strip medical booklet in Zanzibar. J Biosoc Sci. 2016; 48(Suppl 1): S40-55.

21. Reberte LM, Hoga LAK, Gomes ALZ. Process of construction of an educational booklet for health promotion of pregnant women. Rev Lat Am Enfermagem. 2012; 20(1):101-8.

22. Coriolano-Marinus MWL, Pavan MI, Lima LS, Bettencourt ARC. Validation of educational material for hospital discharge of patients with prolonged domiciliary oxygen prescription. Esc Anna Nery. 2014; 18(2):284-9.

23. Benevides JL, Coutinho JFV, Pascoal LC, Joventino ES, Martins Mc, Gubert FA, et al. Development and validation of educational technology for venous ulcer care. Rev Esc Enferm USP. 2016; 50(2):306-312.

94 Acta Paul Enferm. 2017; 30(1):94-100.

Original Article

Alcohol effect on HIV-positive individuals: treatment and quality of lifeEfeito do álcool em pessoas com HIV: tratamento e qualidade de vidaVanessa da Frota Santos1

Marli Teresinha Gimeniz Galvão1

Gilmara Holanda da Cunha1

Ivana Cristina Vieira de Lima1

Elucir Gir2

Corresponding authorVanessa da Frota SantosAlexandre Baraúna 1115,60430-160, Fortaleza, Ceará, [email protected]


1Universidade Federal do Ceará, Departamento de Enfermagem, Fortaleza, Ceará, Brazil.2Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil.Conflicts of interest: there are no conflicts of interest to declare.

AbstractObjective: To evaluate the influence of alcohol on adherence to antiretroviral therapy, and quality of life, of HIV-infected individuals.Methods: A cross-sectional study investigated 114 people with HIV using the Alcohol Use Disorder Identification Test (AUDIT), a Questionnaire to Assess the Compliance to Antiretroviral Treatment (CEAT-VIH), and the World Health Organization Quality of Life Instrument - HIV Bref (WHOQOL-HIV Bref).Results: Adequate adherence to therapy (63.2%) and low alcohol consumption (89.4%) were observed. There was a significant association between the harmful use of alcohol and the past history of use of this substance (p=0.03). The Physical (p=0.01) and Social Relations (p=0.01) domains of quality of life were affected by at-risk alcohol consumption.Conclusion: Low alcohol use did not have negative repercussions on adherence to antiretroviral therapy; however, the harmful use of alcohol altered domains of quality of life.

ResumoObjetivo: Avaliar a influência do álcool na adesão à terapia antirretroviral e qualidade de vida de pessoas com HIV.Métodos: Estudo transversal investigou 114 pessoas com HIV utilizando o Teste de Identificação de Problemas Relacionados ao Uso do Álcool (AUDIT), Questionário Para Avaliação da Adesão ao Tratamento Antirretroviral (CEAT-VIH) e Instrumento World Health Organization Qualityof Life Instrument - HIV Bref (WHOQOL-HIV Bref).Resultados: Observou-se adesão adequada à terapia (63,2%) e consumo de baixo risco de álcool (89,4%). Houve associação significativa entre o uso nocivo do álcool e o histórico prévio de uso dessa substância (p=0,03). Os domínios Físico (p=0,01) e de Relações Sociais (p=0,01) da qualidade de vida foram afetados pelo consumo de risco do álcool.Conclusão: O baixo uso do álcool não trouxe repercussões negativas sobre a adesão à terapia antirretroviral, porém, o uso nocivo do álcool alterou domínios da qualidade de vida.

KeywordsHIV; Alcoholism/therapy; Alcoholism/complications; Quality of life; Antiretroviral therapy, highly active

DescritoresHIV; Alcoolismo/terapia; Alcoolismo/complicações; Qualidade de vida; Terapia antirretroviral de alta atividade

Submitted December 7, 2016


95Acta Paul Enferm. 2017; 30(1):94-100.

Santos VF, Galvão MT,Cunha GH, Lima ICV, Gir E

Introduction

Advances in the health area, and the implemen-tation of preventive measures and control of HIV infection have reduced the detection of new cas-es of AIDS; in contrast, people living with HIV/AIDS (PLWHA) have increased their use of sub-stances that lead to dependence(1) and this influ-ences this population’s social, economic, and psy-chological life.(2)

The use of alcohol by PLWHA is related to a worse prognosis, with increased morbidity and mortality,(3) high-risk sexual behaviors, acceler-ated disease progression, low adherence to an-tiretroviral therapy (ART), CD4+ T lymphocyte decline, and increased viral load, as well as the spread of HIV infection, because alcoholics are more likely to have unprotected sex, favoring vi-rus transmission.(3,4)

Many PLWHA use alcohol because it acts on their mental state, providing relief of stress from the stigma and prejudice.(5) It is also noted that abusive use of this substance, and of other drugs, negatively influences Quality of Life (QoL).(6) QoL can be described as a subjective expression, cover-ing several areas, including social, environmental, and spiritual relations, varying from individual to individual, and this depends on health status, be-cause it is a result of the interaction of different areas of human life.(4,7)

Therefore, considering the increase in alco-hol consumption among PLWHA,(3-5) and conse-quently its possible repercussions on ART adher-ence and quality of life, this study was designed to evaluate the effect of alcohol on adherence to an-tiretroviral therapy and quality of life of HIV-in-fected individuals.

Methods

This is a cross-sectional study with a quantita-tive approach developed at an infectious clinic of a university health service in the city of For-taleza, state of Ceará, Brazil, developed from

May to November 2015 with people living with HIV.

In order to meet the objectives of the study, a sample was dimensioned, a 95% confidence interval adopted, with a presumed prevalence of 0.50, for the population of 160. The tolerable error was (0.05), with a sample of 114 patients being calculated.

Inclusion criteria were individuals with HIV, of both genders, aged 18 years or older, and on ART for at least six months. Exclusion criteria involved: mental illness; pregnancy; imprisonment in peni-tentiaries; and shelter residents.

Data were collected in a private environment, through an interview, with an average duration of 60 minutes, using the Sociodemographic and Clinical Form, Alcohol Use Disorder Identification Test (AUDIT), Cuestionario para La Evaluación de La Adhesión al Tratamiento Antiretroviral (CEAT-VIH), and the World Health Organization Quality of Life Instrument-HIV Bref.

The Sociodemographic and Clinical Form in-cludes the following variables: gender; age; color; schooling; marital status; sexual orientation; rela-tionship with partner religion; occupational sit-uation; monthly family income; ART; CD4+ T lymphocyte count; viral load; and history of use of alcohol and other illicit drugs.

The Alcohol Use Disorder Identification Test (AUDIT) was developed by the World Health Organization and validated in Brazil.(8) It identi-fies at-risk drinkers and investigates the pattern of alcohol consumption in the last 12 months, through 10 items, which cover three theoretical domains: alcohol consumption; dependence on alcohol consumption; adverse consequences of alcohol consumption. There is a possibility of an answer for each question, so that the scores range from zero (0) to 40 points.(9) The score ≥8 was used as the cutoff point to define the risky or harmful use of alcohol, that is, low risk (<8), and at-risk use (≥8).(3)

The questionnaire for evaluating adherence to antiretroviral treatment (CEAT-VIH), vali-dated in Brazil,(10) has 20 items, among which

96 Acta Paul Enferm. 2017; 30(1):94-100.

Alcohol effect on HIV-positive individuals: treatment and quality of life

17 have Likert-type responses, scored from one to five, and three items present dichotomous re-sponses (yes/no), with a minimum value of 17 and a maximum of 89. Adherence degrees were classified into two groups: adequate adherence, with a gross score of ≥75, and inadequate adher-ence, with a score ≤74.

The Quality of Life Instrument-the World Health Organization Quality of Life Instru-ment-HIV Bref (WHOQOL-HIV Bref ), vali-dated in Brazil, has 31 questions and is divided into six areas: (I) Physical; (II) Psychological; (III) Level of independence; (IV) Social rela-tions; (V) Environment; and (VI) Spirituality/religion/beliefs, in addition to the general aspect of QoL, and general perception of health.(11,12) Scores between 4 and 9.9 represent lower per-ception of Quality of Life; from 10 to 14.9, in-termediate perception; and from 15 to 20, high-er perception.(13,14)

Descriptive statistics (simple frequency, cen-tral tendency measures) and dispersion measures (standard deviation, minimum, and maximum) were used for analysis of the sociodemograph-ic and clinical characteristics and description of AUDIT, QoL, and CEAT-VIH scores. All cor-relations performed used Spearman’s correlation coefficient. The scales were evaluated for the in-ter-item correlation (Cronbach’s alpha) whose variation is 0 to 1; the closer to 1, the greater the internal consistency.

An analysis of the association between the AUDIT scale and sociodemographic and clinical variables was performed through Fisher’s meth-od, and odds ratio with the Odds Ratio method. Mann-Whitney test was used to compare two AU-DIT and WHOQOL-HIV Bref averages. Spear-man’s correlation was used to correlate the AUDIT classification with adherence according to CEAT-VIH. In all cases, the level of significance was set at 0.05 (5%).

The study was approved by the Research Eth-ics Committee of the University Hospital of the Federal University of Ceará under protocol no. 1.003.964.

Results

Of the 114 HIV-infected people, there was a higher frequency of males (54.4%), aged between 30 and 50 years (81.5%), heterosexuals (74.5%), with up to 12 years of schooling (86, 8%), brown-colored (53.5%), Catholic (62.2%), living with a partner (45.6%), employed (52.6%), with a family income between one and two minimum wages per month (43.8%), with the minimum wage in force at the time of the study of R$788.00. Regarding clinical data, the highest proportion had a CD4+ T lym-phocyte count above 300 cells/mm³ (79.0%), and a viral load lower than 50 copies/ml (81.5%).

Regarding alcohol use, 44.8% reported a histo-ry of consumption, and 19.3% of illicit drugs. Re-garding the classification of alcohol use, 102 (89.4%) PLWHA were low risk users (mean ± standard devi-ation: 1.6±2.0, median: 1, minimum: 0, maximum: 7). However, 12 (10.5%) patients showed at-risk use of alcohol (mean ± standard deviation: 12.5±5.7, median: 10.5, minimum: 8, maximum: 27). The in-ter-item correlation (Cronbach’s alpha) of the AU-DIT questionnaire showed 0.844, demonstrating a high consistency index. Information on alcohol use and its relation to the socio-demographic character-istics of the population is described in table 1.

Regarding adherence to ART, 42 subjects (36.8%) presented inadequate adherence. Regarding the correlation between the classification of alcohol use and adherence, 66 (64.7%) people with low-risk alcohol use showed adequate adherence (mean ± standard deviation: 1.8±2.0), while 36 (35.3%) showed inadequate adherence (mean ± standard deviation: 1.2±2.0). Of the 12 (10.5%) individuals who presented at-risk alcohol consumption, 6 (50%) showed adequate adherence (mean ± standard devi-ation: 14.0±7.4), and 6 (50%) inadequate adhesion (mean ± standard deviation: 11.0±3.5). There was no statistically significant correlation between the AUDIT classification and adherence according to CEAT-VIH (Spearman’s correlation: 0.095; P=0.32).

The domains of WHOQOL-HIV Bref are showed in table 2. The association between the domains of this instrument and AUDIT is shown in table 3.

97Acta Paul Enferm. 2017; 30(1):94-100.


Discussion

Due to the advent of ART and AIDS chronicity, PLWHA tend to be involved in risky behaviors, such as the use of substances that cause dependence and that may negatively influence their health status.(15)

Regarding past history of alcohol use, almost half of the participants reported previous contact with this substance. Alcohol has a negative influ-ence on health status and adherence to treatment, and increases the risk of virus transmission and un-protected sex.(16) In another study conducted with patients on ART, the frequency of alcohol consump-tion, and of at-risk drinkers, was 33.0%, therefore higher than the present sample.(15) In another study, the percentage of patients consuming alcohol was 5.2%, a value closer to that of this sample.(16)

The history of alcohol use had a significant re-lation with its current harmful use, demonstrating the importance of investing in expanded alcohol prevention strategies involving the political and so-cial spheres. These actions should include family, school, and health services participation, in order to avoid the early onset of alcohol use in childhood and adolescence, based on awareness of the negative impact of this substance on social, financial, and health aspects.(17)

Past history of illicit drug use was unrelated to the risky consumption of alcohol, diverging from another study.(18) In Brazil, alcohol consumption is

Table 1. Association between the scores of the Alcohol Use Disorder Identification Test (AUDIT) and the sociodemographic and clinical characteristics of 114 HIV-infected individuals

Sociodemographic and clinical variables

AUDIT Classificationp-value*

Odds Ratio(CI 95%)†Low risk

n(%)Use of Risk

n(%)Gender

Male 54(52.9) 8(66.7) 0.37 1.7(0.5-6.2)

Female 48(47.1) 4(33.3)

Age (years)

≤50 90(88.2) 12(100) 0.40 3.4(0.1-62.0)

>50 12(11.8) 0(0.0)

Sexual orientation

Heterosexual 74(72.5) 11(91.7) 0.18 4.1(0.5-33.7)

Homo/bisexual 28(27.5) 1(8.3)

Number of years of study

≤8 26(25.5) 5(41.7) 0.24 2.0(0.6-7.1)

>8 76(74.5) 7(58.3)

Skin color

Brown 56(54.9) 7(68.6) 0.82 1.5(0.3-3.8)

Non-brown 46(45.1) 5(31.4)

Family income(minimum salaries)‡

≤2 62(60.8) 7(58.3) 0.21 0.46(1.3-1.5)

>2 40(39.2) 5(41.7)

Religion

Yes 95(93.1) 11(91.7) 0.85 0.81(0.09-7.2)

No 7(6.9) 1(8.3)

Functional situation

With income 70(68.6) 11(91.7) 0.12 5.0(0.62-40.6)

With no income 32(31.4) 1(8.3)

Past history of alcohol use

Yes 42(41.2) 9(75.0) 0.03 4.2(1.1-16.7)

No 60(58.8) 3(25.0)

Illicit drugs use history

Yes 17(16.7) 5(41.7) 0.04 3.5(1.0-12.6)

No 85(83.3) 7(58.3)

Viral load (copies/ml)

<10.000 99(97.1) 12(100) 0.93 0.8(0.04-18.0)

≥10.000 3(2.9) 0(0.0)

CD4+ T cells (cells/mm³)

≤200 10(9.8) 3(25.0) 0.13 3.0(0.7-13.2)

>200 92(90.2) 9(75.0)

Antiretroviral therapy time(months)

<12 12(11.8) 1(8.3) 0.72 0.6(0.08-5.76)

≥12 90(88.2) 11(91.7)

*Fisher’s Test; †CI 95%-Confidence Interval of 95%; ‡At the time of the study, the minimum salary in force was R$ 788.00, equivalent to US$251.77

Table 2. Distribution of scores regarding the domains of the instrument for quality of life evaluation of HIV-infected individuals (WHOQOL-HIV Bref)Domains ofWHOQOL-HIV Bref*

Mean±Standarddeviation

MedianMinimum

ValueMaximum

ValueCronbach’s

alpha

Physical 16.00±3.57 17.00 5.00 20.00 0.702

Psychological 15.83±2.64 16.80 7.20 20.00 0.598

Level of Independence

15.00±2.55 15.00 7.00 20.00 0.500

Social Relations 16.00±3.13 16.00 6.00 20.00 0.718

Environment 15.00±2.68 15.00 7.00 20.00 0.770

Spirituality/Religion/Beliefs

16.00±3.92 16.50 5.00 20.00 0.669

*WHOQOL-HIV Bref-World Health Organization Quality of Life Instrument-HIV Bref

Table 3. Scores of the domains of the quality of life assessment tool HIV-infected individuals (WHOQOL-HIV Bref), according to the classification of risk of the Alcohol Use Disorder Identification Test (AUDIT) in HIV-infected individuals

Domains do WHOQOL-HIV Bref AUDIT nMean ±

standard deviationp-value*

I -Physical Low risk 102 16.3±3.3 0.01

At-risk use 12 13.1±4.3

II -Psychological Low risk 102 15.9±2.4 0.15

At-risk use 12 14.4±3.8

III -Level of independence Low risk 102 15.1±2.5 0.14

At-risk use 12 14.1±2.0

IV -Social relations Low risk 102 16.1±2.8 0.01

At-risk use 12 13.0±3.9

V -Environment Low risk 102 15.0±2.6 0.71

At-risk use 12 13.0±2.9

VI -Spirituality/religion/beliefs Low risk 102 15.9±3.7 0.11

At-risk use 12 13.8±4.9

*Mann-Whitney Test

98 Acta Paul Enferm. 2017; 30(1):94-100.


legally accepted and culturally encouraged, while the consumption of other drugs is illegal.(17) This may justify the lower proportion of interviewees who mentioned a previous history of drug use and, consequently, the absence of an association between prior drug use and harmful use of alcohol.

As for markers of disease progression, individu-als using alcoholic beverages had a lower CD4+ T lymphocyte count and higher viral load.(18) Patients with a CD4 + T lymphocyte count below 200 cells/mm3 had higher chances of being a lower alcohol user, while individuals with an undetectable viral load are more likely to use alcohol.(1)

Regarding adherence to pharmacological treat-ment, it was observed that most patients had ade-quate adherence to ART, diverging from the previ-ous research.(19-21) This result may be related to the fact that only 12 individuals in this study were clas-sified as in harmful use of alcohol, probably due to the small number of people.

In addition, this evidence points to the need for the multidisciplinary team to perform an ac-tive search for individuals who do not attend rou-tine visits, in order to identify and intervene in cases where absence from the service is related to the harmful use of alcohol. As has been warned, the reception of the health team should be free of prejudice or value judgment, with emphasis on actions that minimize or reduce the adverse consequences of alcohol use, not necessarily re-quiring abstinence.(22)

Patients on ART, and those who consume al-cohol, are significantly more likely to stop or for-get to take a dose of antiretroviral therapy.(19,20) In addition, some patients stop taking the medicines to drink alcoholic beverages on weekends;(23) conse-quently, they do not reach complete viral suppres-sion and are more susceptible to viral resistance.(24) In general, alcohol use is a strong predictor of drug adherence failures, and worsens the clinical out-come of PLWHA.(2,16,25)

The consumption of alcohol and other sub-stances that cause dependence in PLWHA can trigger competition and interactions with antiret-rovirals, and change their binding protein, because ethanol competes with the drugs in the isoenzyme

linkages of the metabolization process. Thus, these consumers may be at increased risk of toxicity and ineffective therapy due to inadequate concentra-tions of the drug in plasma.(26)

The present study identified a statistical associa-tion between risky alcohol use and the Physical and Social Relations domains of the WHOQOL-HIV Bref instrument, similar to another study.(18) The Physical domain evaluates the pain, discomfort, energy, fatigue, sleep, and rest of PLWHA, while the Social Relations domain evaluates the person-al relationships, social support, sexual activity, and social inclusion of these individuals.(14) This finding reaffirms the already known negative impacts of the harmful use of alcohol on the physical, social, and cognitive domains.(27)

When social networks of support and family in-volvement are present, there is a reduction in the stigma and prejudice imposed by the disease, and the consequent improvement of PLWHA quality of life.(28) In addition, employment, the presence of a partner, better socioeconomic conditions, and the time of use of ART are related to the best scores in the different dimensions of the QoL assessment instrument.(29)

Interference in the Physical and Social Relations domains can compromise the continuity of HIV treatment,(15,23) because it alters individuals’ ability to take care of themselves, and hinders the provi-sion of social support by family, friends, and health professionals.(28) This results in difficulties in attend-ing follow-up visits and routine exam performance, and in the taking of antiretrovirals. These risk situ-ations may make PLWHA using alcohol harmfully more susceptible to opportunistic infections and death.(2,16,25)

In general, alcohol use has been shown to be a strong predictor of drug adherence failures, and worsens the clinical outcome of PLWHA when compared to patients who do not consume alco-holic beverages.(2,17,27) The higher the alcohol con-sumption, the higher the rate of nonadherence to ART.(16,20)

Regarding the correlation of alcohol use, quality of life, and adherence to ART, a study showed that patients who were not alcohol users

99Acta Paul Enferm. 2017; 30(1):94-100.


References

1. Soboka M, Tesfaye M, Feyissa GT, Hanlon C. Alcohol use disorders and associated factors among people living with HIV who are attending services in south west Ethiopia. BMC Res Notes. 2014; 7(828).

2. Molina PE, Bagby GJ, Nelson S. Biomedical consequences of alcohol use disorders in the HIV-infected host invited review. Curr HIV Res. 2014; 12(4):265-75.

3. Schwitters A, Sabatier J, Seth P, Glenshaw M, Remmert D, Pathak S, et al.HIV and alcohol knowledge, self-perceived risk for HIV, and risky sexual behavior among young HIV-negative men identified as harmful or hazardous drinkers in Katutura, Namibia. BMC Public Health. 2015; 15(1):e1182.

4. Marshall BD, Operario D, Bryant KJ, Cozinheiro RL, Edelman EJ, Gaither JR,et al. Drinking trajectories among HIV-infected men who have sex with men: a cohort study of United States veterans. Drug Alcohol Depend. 2015; 148: 69-76.

5. Kekwaletswe CT, Morojele NK. Alcohol use, antiretroviral therapy adherence, and preferences regarding an alcohol-focused adherence intervention in patients with human immunodeficiency virus. Patient Prefer Adherence. 2014; 8:401-13.

6. Cunha GH, Fiuza ML, Gir E, Aquino OS, Pinheiro AK, Galvao MT. Quality of life of men with AIDS and the model of social determinants of health. Rev Lat Am Enfermagem. 2015; 23(2):183-91.

7. Mutabazi-Mwesigire D, Katamba A, Martin F, Seeley J, Wu AW. Factors that affect quality of life among people living with HIV attending an urban clinic in Uganda: a cohort study. PLoS One. 2015; 10(6):e0126810.

8. Lima CT, Freire AC, Silva AP, Teixeira RM, Farrell M, Prince M. Concurrent and construct validity of the AUDIT in an urban Brazilian sample. Alcohol Alcohol. 2005; 40(6):584-9.

9. Moretti-Pires RO, Corradi-Webster CM. [Adaptation and validation of the alcohol use disorder identification test (AUDIT) for the riverside population of the interior of the Amazon]. Brasil. Cad Saúde Pública. 2011; 27(3):497-509. Portuguese.

10. Remor E, Milner-Moskovics J, Preussler G. [Brazilian adaptation of the “Assessment of Adherence to Antiretroviral Therapy Questionnaire]. Rev Saúde Pública. 2007; 41(5):685-94. Portuguese.

11. Zimpel RR, Fleck MP. Quality of life in HIV-positive Brazilians: application and validation of the WHOQOL-HIV, Brazilian version. AIDS Care. 2007; 19(7):923-30.

12. Pedroso B, Gutierrez GL, Duarte E, Pilatti LA, Picinin CT. Quality of life assessment of HIV/AIDS carriers: an overview of the WHOQOL HIV and WHOQOL-HIV-BREF instruments. Rev Fac Ed Fis UNICAMP. 2012; 10(1):50-69. Portuguese.

13. Ferreira BE, Oliveira IM, Paniago AM. [Quality of life of HIV/AIDS carriers and their relationship with CD4 + lymphocytes, viral load and time of diagnosis]. Rev Bras Epidemiol. 2012; 15(1):75-84. Portuguese.

14. Passos SM, Souza LD. An evaluation of quality of life and its determinants among people living with HIV/AIDS from Southern Brazil. Cad Saúde Pública. 2015; 31(4):800-14.

15. Rego SR, Oliveira CF, Rego DS, Santos RF, Silva VB. [Study of self-report of adherence and problematic use of alcohol in a population of individuals with AIDS using HAART]. J Bras Psiquiatr. 2011; 60(1):46-9. Portuguese.

and who are on ART were 1.69 times more likely to have a better quality of life when compared to those who used this substance. Thus, alcohol use had a significant negative association with overall quality of life.(7)

The use of alcohol negatively influences the markers of disease progression, causing a worsening of the clinical picture, leading to seroconversion to AIDS, and consequent increase in mortality.(18) In addition, PLWHA using alcohol are more prone to the use of a higher number of medications, a factor that decreases quality of life.(13)

Although the instruments applied showed good internal consistency, a limitation of the study consisted of the inclusion of active individuals in health monitoring, and the reduced number of participants. For future studies, the active search for individuals with low adherence is recommend-ed to identify those whose commitment to adher-ence is related to the harmful use of alcohol. It is also necessary to implement intervention studies and actions in the health services directed to the prevention of alcohol use and reduction of damage from this substance.

Conclusion

In this study, most PLWHA presented low-risk con-sumption of alcohol, adequate adherence to ART, and good quality of life. Low alcohol use did not have negative repercussions on adherence to an-tiretroviral therapy or quality of life. However, the harmful use of alcohol has altered the domains of quality of life that are essential for the continuity of treatment, indicating the importance of social sup-port among PLWHA with a risk of consumption of this substance.

CollaborationsSantos VF, Galvão MTG, and Cunha GH contrib-uted to the project design, research performance, scientific research writing, and approval of the fi-nal version to be published. Lima ICV and Gir E collaborated with the conduction of the research and article writing.

100 Acta Paul Enferm. 2017; 30(1):94-100.


16. Wandera B, Tumwesigye NM, Nankabirwa JI, Kambugu AD, Parkes-Ratanshi R, Mafigiri DK, et al. Alcohol consumption among HIV-infected persons in a large urban HIV clinic in Kampala Uganda: a constellation of harmful behaviors. PLoS One. 2015; 10(5):e0126236.

17. Zalaf MR, Fonseca RM. [Problematic use of alcohol and other drugs in student housing: meet to face]. Rev Esc Enferm USP. 2009; 43(1):132-8. Portuguese.

18. Tran BX, Nguyen LT, Do CD, Nguyen QL, Maher RM. Associations between alcohol use disorders and adherence to antiretroviral treatment and quality of life amongst people living with HIV/AIDS. BMC Public Health. 2014; 14:27.

19. Kader R, Govender R, Seedat S, Koch JR, Parry C. Understanding the impact of hazardous and harmful use of alcohol and/or other drugs on arv adherence and disease progression. PLoS One. 2015; 10(5):e0125088.

20. Yaya I, Landoh DE, Saka B, Wasswa P, Aboubakari A-s, N’Dri MK, et al. Predictors of adherence to antiretroviral therapy among people living with HIV and AIDS at the regional hospital of Sokodé, Togo. BMC Public Health. 2014; 14: 1308.

21. Galvão MT, Soares LL, Pedrosa SC, Fiuza ML, Lemos LA. [Quality of life and adherence to antiretroviral medication in people with HIV]. Acta Paul Enferm. 2015; 28(1):48-53. Portuguese.

22. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de DST, Aids e Hepatites Virais. Cuidado integral às pessoas que vivem com HIV pela Atenção Básica Manual para a equipe multiprofissional. Brasília (DF): Ministério da Saúde; 2015.40p.

23. Silva JA, Dourado I, Brito AM, Silva CA. [Factors associated with non adherence to antiretrovirals in adults with AIDS in the first six months of therapy in Salvador, Bahia, Brazil]. Cad Saúde Pública. 2015; 31(6):1188-98. Portuguese.

24. Chibanda D, Benjamin L, Weiss HA, Abas M. Mental, Neurological, and Substance Use Disorders in People Living With HIV/AIDS in Low- and Middle-Income Countries. J Acquir Immune Defic Syndr. 2014; 67(1):54-67.

25. Williams EC, Bradley KA, Balderson BH, McClure JB, Grothaus L, Mccoy K, et al. Alcohol and associated characteristics among older persons living with hiv on antiretroviral therapy. Subst Abus. 2014; 35(3):245-53.

26. Kumar S, Rao P, Earla R, Kumar A. Drug-drug interactions between anti-retroviral therapies and drugs of abuse in HIV systems. Expert Opin Drug Metab Toxicol. 2015; 11(3):343-55.

27. Oliveira AL, Gonçalves FM, Cabral RW, Borges LS, Cruz CA, Cabral HW. [The impacts on the attentional capacity in workers who use drugs]. Rev Bras Med Trab. 2016; 14(2):84-8. Portuguese.

28. Srisorrachatr S, Zaw SL, Chamroonsawasdi K. Quality of life among women living with HIV/AIDS in Yangon, Myanmar. J Med Assoc Thai. 2013; 96 Suppl 5:S138-45.

29. Tran BX, Ohinmaa A, Mills S, Duong AT, Nguyen LT, Jacobs P, et al. Multilevel predictors of concurrent opioid use during methadone maintenance treatment among drug users with HIV/AIDS. PLoS One. 2012; 7(12):e51569.

101Acta Paul Enferm. 2017; 30(1):101-8.

Original Article

Postoperative complications in elective and non-elective neurosurgery

Complicações pós-operatórias em neurocirurgia eletiva e não eletivaEllen Maria Pires Siqueira1

Solange Diccini1

Corresponding authorEllen Maria Pires SiqueiraNapoleão de Barros street, 754, 04024-002 , São Paulo, SP, [email protected]


1Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil.Conflicts to interest: none to declare.

AbstractObjective: To evaluate the incidence of postoperative complications and mortality among patients submitted to elective or non-elective neurosurgery.Methods: Prospective cohort study in adult patients, followed from preoperative period until hospital discharge or death.Results: One hundred and twenty seven patients were included in elective surgery group and 75 patients in non-elective surgery group. The elective group had more vomiting (p=0.010) and pain (p<0.001) and the non-elective group presented more intracranial hypertension (p=0.001), anisocoria (p=0.002), cerebral vasospasm (p=0.043), light-unresponsive pupil (p=0.006) and reoperation (p=0.046). The mortality rate was 5.5% in the elective surgery group and 26.7% in the non-elective surgery group (p<0.001).Conclusion: Elective procedures in neurosurgery are related to higher frequencies of systemic complications while non-elective surgeries had significantly higher rates of neurological complications and mortality.

ResumoObjetivo: Avaliar a incidência de complicações pós-operatorias e mortalidade entre pacientes submetidos a neurocirurcia eletiva e não eletiva.Metodos: Estudo de coorte prospectivo com pacientes adultos, acompanhados desde o período pré-operatório até a alta hospitalar ou óbito.Resultados: Foram incluídos 127 pacientes no grupo cirúrgico eletivo e 75 pacientes no grupo cirúrgico não eletivo. O grupo eletivo teve mais vômitos (p=0,010) e dor (p<0,001) e o grupo não eletivo apresentou mais hipertensão intracraniana (p=0,001), anisocoria (p=0,002), vasoespasmo cerebral (p=0,043), pupilas não fotorreagentes (p=0,006) e reoperação (p=0,046). A taxa de mortalidade foi de 5,5% no grupo de cirurgia eletiva e 26,7% no grupo de cirurgia não eletiva (p<0,001).Conclusão: Os procedimentos eletivos em neurocirurgia estão relacionados a maior frequência de complicações sistêmicas, enquanto as cirurgias não eletivas tiveram taxas significativamente mais altas de complicações neurológicas e mortalidade.

KeywordsNeurosurgical procedures;

Postoperative complications; Perioperative nursing

DescritoresProcedimentos neurocirúrgicos;

Postoperative complications; Perioperative nursing

Submitted January 18, 2017


102 Acta Paul Enferm. 2017; 30(1):101-8.


Introduction

Neurosurgical patients are at high risk of neuro-logical and systemic complications even in elective procedures. Inherent complexities of this popula-tion, extended hospital stays, urgent and emergen-cy procedures and secondary complications end-up increasing the basal risk.(1)

The most commonly observed neurological complications in the postoperative period of elective skull surgeries include decreased level of conscious-ness,(1) cerebral vasospasms,(2) refractory seizures,(1,3) reoperation,(4-6) hemiparesis and intraparenchymal hematoma.(7,8) In non-elective surgeries, intracranial hypertension,(9) motor deficits,(10) recurrent subdural hematoma,(10,11) intraparenchymal hemorrhage,(12) vasospasms,(13) and seizures(10,14) are also reported.

Systemic complications in the postoperative pe-riod of elective neurosurgeries include nausea and vomiting,(15) hypotension, respiratory distress,(1) and surgical site infection.(16) For non-elective sur-geries, pain(17) and nosocomial infections are also observed.(5)

The overall mortality rate has been reported to be only 1%(1,18) after elective neurosurgery, as com-pared to 29% after emergency neurosurgery,(19) with postoperative complications increasing the risk of death in both groups.(5,18) The early recognition and management of the complications are crucial for the outcome of these patients.

The purposes of this study were to report and compare post-operative complications rates after elective and non-elective neurosurgeries.

Methods

This prospective study was conducted in a universi-ty hospital in São Paulo, Brazil. All patients submit-ted to elective or non-elective procedures and above 18 years old were included. Exclusion criteria were pregnancy, presence of infections or abnormal coag-ulation at admission, previous thrombolytic treat-ment, transference to another hospital during the postoperative period and absence of pre-operative computed tomography (CT) scan.

Preoperative data were obtained from medi-cal charts. Patients were followed on a daily basis from the surgical procedure to hospital discharge or death. Variables included in the analysis were: age, gender, past medical history, diagnosis, type of care unit, Glasgow Coma Scale (GCS), pre-op-erative length of stay and type of surgery (elective or non-elective, the latter including urgency and emergency procedures).

The postoperative period data was divided into immediate (first 24 hours) and late postop-erative (> 24 hours). The following variables were analyzed: GCS or Ramsay sedation scale, type of care unit (neurosurgical intensive care unit or neu-rosurgical ward), and length of the postoperative stay, total hospitalization time, neurological and systemic complications, and outcomes (discharge or death).

Sample size calculation was based on number of surgeries per month that fulfilled the inclusion criteria. The number of surgeries was observed for three months and considering a 95% confidence in-terval, a sample of 171 patients was calculated in a period of 10 months.

All analysis were performed using the SPSS19™ (SPSS Institute Inc., Chicago, IL, USA). The descriptive analysis was carried out by means of absolute and relative frequencies. The calculation of the relative risk (RR) was per-formed using Poisson regression with covariance matrix and logit logistic function. The confi-dence interval (CI) of the RR was estimated by Poisson distribution. The hypothesis test used was based on the Wald test, Student’s t-test, and Fisher’s exact test. Kaplan-Meier survival analy-ses were used to estimate the mean and median survival rates. The hypothesis test for equality of means according to factors was done via the non-parametric log-rank test (or Mantel-Cox). All tests took into consideration a two-tailed α of 0.05 and a 95% CI.

The development of the study met the stan-dards of ethics in research involving human beings (CEP 0707/10 - Research Ethics Committee of the Universidade Federal de São Paulo/ Hospital São Paulo).

103Acta Paul Enferm. 2017; 30(1):101-8.

Siqueira EM, Diccini S

Results

A total of 229 patients were screened, out of which 27 were excluded (15 due to transference to another hospital in the postoperative period, five patients were under chronic anticoagulation, four had an preoperative infection, three refused to participate in the study), resulting in a total of 202 patients included in the study and divided in 2 groups: elective group (n=127) and non-elective group (n=75).

The median age of the patients in the elective group was 50 years (range, 19-80 years) and in the non-elective group was 53 years (range, 18-91 years) (p=0.35) and 46.7% were men in the elective group while 64.0% in the non-elective group (p=0.01). A predominance of patients with diagnostic of brain tumors was observed in the elective group (51.9 vs 2.7%, p = 0.001) while traumatic brain injury was the most fre-quent diagnosis in the non-elective group (0.8 and 38.7%, p <0.001). The frequency of intra-cranial aneurysms was similar between groups (22.8 and 21.3%, p = 0.92).

The preoperative median of GCS was 15 (range, 11-15) in patients of elective group and 14 (range, 3-15) in patients of non-elective group (p<0.001). The median preoperative period was 5 days (range, 1-62 days) in elective surgeries and 2 days (range, 1-12 days) in the non-elective group (p<0.001).

Patients who underwent elective surgery had a history of seizures more frequently (10.2%, p=0.006) whereas patients who underwent non-elective surgery had more often a history of alcoholism (p=0.024) and were free of previous co-morbitities (p<0.001).

Most patients from the elective surgery group underwent craniotomy (78.7%), where-as in the non-elective surgery group, craniecto-my (45.3%) and burr hole trepanation (37.3%) were the most frequently performed procedures (p<0.001). The average anesthesia and sur-gery time (12.2 ± 4.6 hours vs 7.6 ± 4.6 hours, p<0.001) was longer among patients from the elective surgery.

Immediate postoperative periodAfter the procedure, 114 (89.8%) patients from the elective group and 60 (80%) patients from the non-elective group were admitted to the intensive care unit (ICU) (p=0.052). Using the Ramsay se-dation scale, patients from the non-elective group were more sedated in the immediate postoperative period (median of 6, p<0.001).

Neurological and systemic complications rate per patient were similar between groups (45.5% vs 52.9%, p=0.402, elective vs non-elective; 98.3% vs 98.5%, p>0.99, elective vs non-elective, respec-tively). Types and rates of specific complications are shown in table 1.

Table 1. Neurological and systemic complications during the immediate postoperative period

CharacteristicsElective(n=127)

Non-elective(n=75) p-value RR (CI95%)

n (%) n (%)

Neurological

Intracranial hypertension

1(0.8) 8(10.7) 0.013† 0.07(0.01-0.57)

Intraparenchymal hemorrhage

3(2.4) 2(2.7) 0.893† 0.88(0.15-5.18)

Pneumocephalus 16(12.6) 3(4.0) 0.061† 3.15(0.94-10.45)

Periorbital hematoma

18(14.2) 11(14.7) 0.923* 0.97(0.48-1.93)

Anisocoria 5(4.7) 14(18.7) 0.002* 0.21(0.08-0.56)

Cardiovascular

Arterial hypotension

16(12.6) 15(20.0) 0.160* 0.630(0.33-1.19)

Arterial hypertension

44(34.6) 26(34.7) 0.998* 0.99(0.67-1.47)

Vasoactive drugs 24(18.9) 30(40.0) 0.001* 0.47(0.30-0.74)

Sinus bradycardia 18(14.2) 12(16.0) 0.724* 0.88(0.45-1.73)

Sinus tachycardia 45(35.4) 29(38.7) 0.643* 0.91(0.63-1.32)

Gastrointestinal

Vomiting 23(18.1) 1(1.3) 0.010† 13.58(1.87-98.5)

Metabolic

Potassium disorders

4(3.1) 9(12.0) 0.022† 0.26(0.08-0.82)

Hyperglycemia 86(67.7) 43(57.3) 0.155* 1.18(0.93-1.48)

Intensive insulin therapy

3(2.4) 2(2.7) 0.890† 0.88(0.15-5.18)

Hyperthermia 26(20.5) 26(34.7) 0.026* 0.59(0.37-0.93)

Hypothermia 19(15.0) 18(24.0) 0.109* 0.62(0.35-1.11)

Headache 33(26.0) 5(6.7) 0.003* 3.89(1.59-9.55)

*Chi-square test; †Fisher’s exact test; RR - Relative risk; CI - Confidence interval

Late postoperative periodThe GCS and Ramsay sedation scale were similar in both groups during the postoperative period (p>0.99). Neurological and systemic complica-tions rate per patient were also similar between

104 Acta Paul Enferm. 2017; 30(1):101-8.


groups (71,7 vs 79.7%, elective vs non-elec-tive, p=0.24; 99.2 vs 98.6%, p>0.99, elective vs non-eletive, respectively). Major complications like intracranial hypertension, light-unrespon-sive pupil, and hemodynamic instability among others occurred more often in the non-elective

group. Types and rates of specific late complica-tions are shown in table 2.

The median stay in the ICU during the post-operative period in elective group was three days (range, 1-63 days) and 11 days (range, 1-54 days) for non-elective group (p<0.001). The total median

Table 2. Neurological and systemic complications during the postoperative period

CharacteristicsElective (n=127)

Non-elective (n=75) p-value

RR(CI95%)

n (%) n (%)

Neurological

Intracranial hypertension 14(11.0) 37(49.6) 0.001* 0.22(0.13-0.38)

Intraparenchymal hemorrhage 7(5.5) 5(6.7) 0.735† 0.83(0.27-2.51)

Intraventricular hemorrhage 2(1.6) 5(6.7) 0.080† 0.23(0.04-1.18)

Vasoespasm 2(1.6) 6(8.0) 0.043† 0.19(0.04-0.41)

Focal seizures 4(3.4) 1(1.3) 0.438† 2.36(0.26-20.4)

Generalized seizures 3(3.4) 2(2.7) 0.893† 0.88(0.15-5.18)

Hydrocephalus 1(0.8) 2(2.7) 0.316† 0.30(0.27-3.20)

CSF leak 5(3.9) 4(5.3) 0.643* 0.73(0.20-2.66)

Periorbital edema 40(31.4) 24(32.5) 0.941* 0.98(0.64-1.49)

Periorbital hematoma 31(24.4) 19(25.3) 0.883* 0.96(0.58-1.54)

Light-unresponsive pupil 6(4.7) 13(17.3) 0.006* 0.27(0.08-0.68)

Aphasia 5(3.9) 3(4.0) 0.482† 0.98(0.24-4.00)

Reoperation 10(7.9) 13(17.3) 0.046* 0.45(0.21-0.98)

Cardiovascular

Arterial hypotension 26(20.5) 35(46.7) 0.001* 0.43(0.28-0.66)

Arterial hypertension 94(74.0) 63(84.0) 0.082* 0.88(0.76-1.01)

Vasoactive drug 31(24.4) 46(61.3) <0.001* 0.40(0.28-0.57)

Arrhythmia 2(1.6) 5(6.7) 0.080† 0.23(0.04-1.18)

Sinus bradycardia 33(26.0) 36(69.3) 0.001* 0.54(0.37-0.79)

Sinus tachycardia 75(59.1) 55(73.3) 0.033* 0.81(0.66-0.98)

Cardiac arrest 6(4.7) 20(26.7) 0.001* 0.18(0.07-0.42)

Venous thromboembolism 1(0.8) 1(1.3) 0.708† 0.59(0.04-9.30)

Pulmonary embolism 1(0.8) 2(2.7) 0.316† 0.30(0.03-3.20)

Gastrointestinal

Nausea 25(19.7) 10(13.3) 0.258* 1.48(0.75-2.90)

Vomiting 35(27.6) 25(33.3) 0.382* 0.83(0.54-1.27)

Gastroesophageal reflux 4(3.1) 14(18.7) 0.001† 0.17(0.06-0.49)

Renal

Acute kidney injury 2(1.6) 8(10.7) 0.014† 0.15(0.03-0.68)

Urinary retention 13(10.2) 13(17.3) 0.148* 0.59(0.29-1.21)

Metabolic

Potassium disorders 29(22.8) 38(50.7) 0.001* 0.45(0.31-0.67)

Calcium disorders 33(26.0) 33(44.0) 0.008* 0.59(0.40-0.87)

Sodium disorders 42(33.1) 44(58.7) 0.001* 0.56(0.41-0.77)

Hypoglycemia 17(13.3) 26(34.7) 0.001* 0.39(0.23-0.66)

Hyperglycemia 86(67.7) 55(73.3) 0.390* 0.92(0.77-1.11)

Infectious

Hypothermia 64(50.4) 42(56.0) 0.435* 0.90(0.69-1.17)

Hyperthermia 65(51.2) 54(72.0) 0.002* 0.71(0.57-0.89)

Bloodstream infection 7(5.5) 6(8.0) 0.488* 0.69(0.24-1.97)

SSI 3(2.4) 4(5.3) 0.277† 0.44(0.10-1.93)

Meningitis 2(1.6) 5(6.7) 0.080† 0.24(0.05-1.19)

Pulmonary infection 10(7.9) 23(30.7) <0.001* 0.26(0.13-0.51)

Urinary tract infection 6(4.7) 8(10.7) 0.117* 0.44(0.16-1.23)

Headache 83(65.4) 21(28.0) <0.001* 1.98(1.42-2.76)

*Chi-square test; †Fisher’s exact test; RR - Relative risk; CI - Confidence interval; CSF - Cerebrospinal fluid; SSI - Surgical site infection

105Acta Paul Enferm. 2017; 30(1):101-8.


postoperative periods were fi ve days for elective sur-gery patients (range, 1-63 days) and 11 days (range, 1-88) for non-elective surgery patients (p<0.001). Th e hospitalization period was 12 days (range, 5-76 days) for the elective surgery and 15 days for non-elective surgery patients (range, 3-91 days) (p=0.090).

Seven patients (5.5%) from the elective surgery group and 20 patients (26.7%) from the emergency surgery group died during the postoperative peri-od (p<0.001). Brain death was diagnosed in three patients from the elective surgery group and in eight patients from the non-elective surgery group (p=0.030; RR, 0.21). Kaplan Meyer survival curves from both groups are shown in fi gure 1.

the probability of death had increased to 35% for non-elective surgery patients and 20% for elective surgery patients.

Discussion

Th e limitation of this study is related to the pre-op-erative evaluation, where only prior neurological complications were found and monitored during the postoperative period and the systemic compli-cations were not, it were only noted on the patho-logical history.

In recent study that assessed postoperative complications in patients who underwent surgi-cal treatment for epilepsy and resection of brain metastases, no intracranial hypertension was observed during the postoperative period.(4) By contrast, among 270 patients who underwent decompressive craniectomy in a previous study, 91 (33.7%) went on to develop a herniation in the postoperative period.(14) Here, the intracranial hypertension’s incidence was found to be greater among patients who underwent non-elective as compared to elective surgery patients. Th e lack of studies that compare these two surgical possibil-ities makes the comparison more diffi cult. How-ever, it has been well-established that in patients having undergone decompressive craniectomy, persistent intracranial hypertension is often ob-served after the surgical procedure.(9,12) In this study, pupillary changes were examined in the postoperative period in patients who underwent emergency skull surgery. Based on the literature, pupillary changes that occur in the pre-operative period are associated with a worse prognosis.(9,20)

According to previous studies, vasospasms are reportedly observed during the postopera-tive period in 53.8% of patients having under-gone resection of acoustic neuroma,(2) whereas in patients having undergone surgery for ruptured aneurysms, vasospasms have been reported in 22.3% of all cases.(13) Conversely, in our study, only 1.6% of patients who underwent elective surgery suff ered vasospasms. However, it is worth noting that detailed examinations were only per-

Figure 1. Kaplan-Meier survival curve*Log Rank (Mantel-Cox)

Th e patients from the non-elective surgery group were hospitalized for a signifi cantly shorter period before death compared to patients from the elective surgery group (p=0.003). Until day 5 after surgery, the probability of death among the patients from the non-elective group was approximately 10%, whereas it was 0% for the elective surgery group. Until day 10 of the postoperative period, the probability of death remained zero for the elective surgery patients, and reached 20% for the non-elec-tive surgery group. After 25 days of hospitalization,

p=0.003*

Elective

1.0

0.8

0.6

0.4

0.2

0.00.005.0010.0015.0020.0025.0030.0035.0040.0045.0050.0055.0060.0065.0070.0075.0080.0085.0090.0095.00100.00105.00

Non-elective

TIME (DAYS)

CUM

ULAT

IVE

SURV

IVAL

(%)

106 Acta Paul Enferm. 2017; 30(1):101-8.


formed for symptomatic patients, and the actual incidence rate may hence be higher. Similarly, in patients having undergone non-elective surgery in our study, the vasospasm incidence was higher (8.0%) in the postoperative period, but still sub-stantially lower than the results presented in the literature.

Reoperation for hematoma formation or re-currence, cerebral edema, and hydrocephalus are more common in patients who have undergone emergency skull surgery compared to elective surgery patients, because of a greater neurolog-ical instability in these patients. In a previous study, patients who underwent elective surgery for resection of brain metastases were examined in order to assess the need for a new surgical pro-cedure, and it was found that 13.9% needed re-operation,(4) which is a substantially higher rate than what was observed in this study. Among patients who underwent emergency surgery for spontaneous cerebellar hematomas, 15.8% re-portedly needed a new surgical procedure, similar to our results.(21)

In this study, the incidence of headache was high-er than other study that observed postoperative com-plications after craniotomy for brain tumor surgery.(17) Headache has moreover been identified in 60% of patients undergoing surgery for acute-on-chronic subdural hematomas in a previous study.(22) In our study, 28% of patients who underwent emergency surgery experienced headache, but it is worth men-tioning that although the median rate in the Ramsay sedation scale was similar in the two groups, emer-gency surgery patients remained in deep sedation longer in the postoperative period, thus reducing the reports and signs of pain during this period.

Patients who undergo elective skull surgery re-portedly experience nausea and vomiting in 33% of cases, which is similar to the results of our study, 18.1% of patients from the elective surgery group.(15) Interestingly, it has been demonstrated that fe-male sex and the absence of steroids intra-operative-ly are associated with an increased risk of nausea and vomiting.(15)

In patients who underwent emergency skull sur-gery there were more cases of hypotension, arrhyth-

mia, and cardiac arrest, and greater use of vasoactive drugs in comparison with elective surgery patients. One study that followed patients who underwent electives and emergencies neurosurgeries identified only 0.6% of cardiac arrest.(6)

In the postoperative period, patients from the emergency surgery group experienced more cases of acute kidney injury (AKI). In studies with patients who underwent emergency skull surgery for TBI and SDH drainage, AKI was diagnosed in only 1.3 to 2.5% of patients.(9,22) Patients from the emergen-cy surgery group moreover had a greater incidence of hypotension with the need for vasoactive drugs, which may be related to the AKI.(23)

Patients in the emergency surgery group also had a higher incidence of hypoglycemia and use of intensive insulin protocols than patients in the elective surgery group. This result may be associat-ed with the higher mortality rate in the emergency surgery group. A study that followed patients after resection of brain tumor found 1.5% of patients with manifestations of poor glycemic control, hy-poglycemic coma in most cases.(24)

Cases of hyperthermia in the postoperative peri-od may indicate an infectious state, or even a change caused by a failure in the central control of tem-perature. Studies that included patients who under-went skull surgeries identified pneumonia during the postoperative period in 0.5%-4.1% of patients.(5,7-9) In our study, the incidence of pneumonia in the postoperative period was higher among emer-gency surgery patients. One study found 3.0% of unplanned reitubation and 7.6% of failure to wean from ventilator for more than 48 hours in the post-operative period of neurosurgery but the incidence of pneumonia was 3.6%.(6)

Few studies to date have assessed the mortali-ty of patients resulting from elective or emergency skull surgeries. In this study, the mortality rate was higher in the non-elective surgery group compared to in the elective surgery group (26.7% vs. 5.5%, respectively). The mortality rates observed in pre-vious studies with emergency surgery patients vary from 1.4% to 35.0%.(10,19,22,25) Some studies with emergency surgery patients analyzed factors associ-ated with the risk of death: low scores in the GCS

107Acta Paul Enferm. 2017; 30(1):101-8.


and anisocoria were identified as important factors associated with a worse prognosis.(6,9,20) Accordingly, in this study, patients who underwent emergency surgery had lower scores in the GCS compared to the elective surgery patients.

Conclusion

No differences between the two groups of patients regarding the number of neurological and systemic complications were observed in this study. Patients who underwent elective surgery suffered more vom-iting and headache events in the immediate postop-erative period, and headache in the postoperative pe-riod. Conversely, patients who underwent non-elec-tive surgery experienced more anisocoria events in the immediate postoperative period, and in the postop-erative period, besides higher rates of IH, vasospasm, light-unresponsive pupil, need for reoperation, use of vasoactive drugs, hypotension, tachycardia and sinus bradycardia, cardiac arrest, gastric reflux, electrolyte alterations, hypoglycemia, hyperthermia, and pneu-monia. The mortality rate was higher among patients who underwent emergency surgery.

CollaborationsSiqueira EMP e Diccini S declare that they contrib-uted to the conception of the project, analysis and interpretation of the data, writing of the article, rel-evant critical review of intellectual content and final approval of version for publication.

References

1. Bui JQ, Mendis RL, VanGelder JM, Sheridan MM, Wright KM, Jaeger M. Is postoperative intensive care unit admission a prerequisite for elective craniotomy? J Neurosurg. 2011; 115(6):1236-41.

2. Qi J, Jia W, Zhang L, Zhang J, Wu Z. Risk Factors for Postoperative Cerebral Vasospasm After Surgical Resection of Acoustic Neuroma. World Neurosurg. 2015; 84(6):1686-90.

3. Englot DJ, Young WL, Han SJ, McCullock CE, Chang EF, Lawton MT. Seizure predictors and control after microsurgical resection of supratentorial arteriovenous malformations in 440 patients. Neurosurgery. 2012; 71(3):572-80; discussion 580.

4. Stark AM, Stöhring C, Hedderich J, Held-Feindt J, Mehdorn HM. Surgical treatment for brain metastases: Prognostic factors and survival in 309 patients with regard to patient age. J Clin Neurosc. 2011; 18(1):34-38.

5. Lepänluoma M, Takala R, Kotkansalo A, Rahi M, Ikonen TS. Surgical safety checklist is associated with improved operating room safety culture, reduced wound complications, and unplanned readmissions in a pilot study in neurosurgery. Scand J Surg. 2013; 103(1):66-72.

6. Rolston JD, Han SJ, Lau CY, Berger MS, Parsa AT. Frequency and predictors of complications in neurological surgery: national trends from 2006 to 2011. J Neurosurg. 2014;120( 3):736-45.

7. Reponen E, Tuominen H, Hernesniemi J, Korja M. Patient-reported outcomes in elective cranial neurosurgery. World Neurosurg. 2015; 84(6):1845-51.

8. Zeng L, Wang L, Ye F, Chen J, Lei T, Chen J. Clinical characteristics of patients with asymptomatic intracranial meningiomas and results of their surgical management. Neurosurg Rev. 2015; 38:481-8.

9. Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D’Urso P, et al. Decompressive craniectomy in diffuse traumatic brain injury. New Engl J Med. 2011; 364(16):1493-502.

10. Aboukaïs R, Marinho P, Baroncini M, Bourgeois P, Leclerc X, Vinchon M, et al. Ruptured cerebral arteriovenous malformations: Outcomes analysisafter microsurgery. Clin Neurol Neurosurg. 2015; 138:137-42.

11. Park J, Cho JH, Goh DH, Kang DH, Shin IH, Hamm IS. Postoperative subdural hygroma and chronic subdural hematoma after unruptured aneurysm surgery: age, sex, and aneurysm location as independent risk factors. J Neurosurg. 2016; 124(2):310-7.

12. Kurland DB, Khaladj-Ghom A, Stokum JA, Carusillo B, Karimy JK, Gerzanich V, et al. Complications associated with decompressive craniectomy: a systematic review. Neurocrit Care. 2015; 23(2):292-304.

13. Inoue T, Shimizu H, Fujimura M, Sato K, Endo H, Niizuma K, et al. Risk factors for meningitis after craniotomy in patients with subarachnoid hemorrhage due to anterior circulation aneurysms rupture. Clin Neurol Neurosurg. 2015; 139:302-6.

14. Honeybul S, Ho KM. Decompressive craniectomy for severe traumatic brain injury: the relationship between surgical complications and the prediction of an unfavourable outcome. Injury. 2014; 45(9):1332-9.

15. Latz B, Mordhorst C, Kerz T, Schmidt A, Schneider A, Wisser G, et al. Postoperative nausea and vomiting in patients after craniotomy: incidence and risk factors. J Neurosurg. 2011; 114(2):491-6.

16. Walcott BP, Neal JB, Sheth SA, Kahle KT, Eskandar EN, Coumans JV, et al. The incidence of complications in elective cranial neurosurgery associated with dural closure material. J Neurosurg. 2014; 120(1):278-84.

17. Lonjaret L, Guyonnet M, Berard E, Vironneau M, Peres F, Sacrista S, et al. Postoperative complications after craniotomy for brain tumour surgery. Anaesth Crit Care Pain Med. 2016 Oct 4. pii: S2352-5568(16)30164-3.

18. Ibañez FAL, Hem S, Ajler P, Vecchi E, Ciraolo C, Baccanelli M, et al. A new classification of complications in neurosurgery. World Neurosurg. 2011; 75(5-6):709-15.

19. Fatigba HO, Savi de Tove MK, Tchaou BA, Mensah E, Allode AS, Padonou J. Surgical management of head trauma: problems, results, and perspectives at the departmental teaching hospital of Borgou, Benin. World Neurosurg. 2013; 80(3-4):246-50.

20. Tagliaferri F, Zani G, Iaccarino C, Ferro S, Ridolfi L, Basaglia N, et al. Decompressive craniectomies, facts and fiction: a retrospective analysis of 526 cases. Acta Neurochirurg (Wien). 2012; 154(5):919-26.

21. Tsitsopoulos PP, Tobieson L, Enblad P, Marklund N. Prognostic factors and long-term outcome following surgical treatment of 76 patients with spontaneous cerebellar haematoma. Acta Neurochirurg (Wien). 2012; 154(7):1189-95.

108 Acta Paul Enferm. 2017; 30(1):101-8.


22. Javadi A, Amirjamshidi A, Aran S, Hosseini SH. A randomized controlled trial comparing the outcome of burr-hole irrigation with and without drainage in the treatment of chronic subdural hematoma: a preliminary report. World Neurosurg. 2011; 75(56):731-6.

23. Badin J, Boulain T, Ehrmann S, Skarzynski M, Bretagnol A, Buret J, et al. Relation between mean arterial pressure and renal function in the early phase of shock: a prospective, explorative cohort study. Critical Care. 2011; 15(3):R135.

24. Zacharia BE, Deibert C, Gupta G, Hershman D, Neugut AI, Bruce JN, Spencer BA. Incidence, cost, and mortality associated with hospital-acquired conditions after resection of cranial neoplasms. Neurosurgery. 2014; 74(6):638-47.

25. Rush B, Rousseau J, Sekhon MS, Griesdale DE. Craniotomy versus craniectomy for acute traumatic subdural hematoma in the United States: A national retrospective cohort analysis. World Neurosurg. 2016; 88:25-31.

109Acta Paul Enferm. 2017; 30(1):109-15.

Original Article

Factors related with breastfeeding self-efficacy immediate after birth in puerperal adolescents

Fatores relacionados à autoeficácia na amamentação no pós-parto imediato entre puérperas adolescentes

Carolina Maria de Sá Guimarães1

Raquel Germano Conde1

Flávia Azevedo Gomes-Sponholz1

Mônica Oliveira Batista Oriá2

Juliana Cristina dos Santos Monteiro1

Corresponding authorCarolina Maria de Sá GuimarãesAvenida dos Bandeirantes, 3900, 14040-902, Campus Universitário, Ribeirão Preto, SP, [email protected]


1Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil.2Universidade Federal do Ceará, Fortaleza, CE, Brazil.

Conflicts of interest: none to report. *This article is based on the master degree’s thesis: Breastfeeding Self-efficacy in the immediate postpartum period between adolescents and adults mothers at a maternity hospital in Ribeirao Preto, Brazil. 2015. The thesis was presented to Nursing School of Ribeirão Preto Graduate Program at Universidade de São Paulo.

AbstractObjective: To determine the association between breastfeeding self-efficacy and sociodemographic and obstetric factors of adolescents.Methods: This observational, cross-sectional and descriptive study was carried out at a public maternity in the municipality of Ribeirão Preto, São Paulo, Brazil. Data were collected from January to July 2014 using the Brazilian version of Breastfeeding Self-Efficacy Scale that evaluated the breastfeeding self-efficacy.Results: Higher levels of self-efficacy were associated with the following variables: to be supported by mother or mother-in-law after delivery (p=0.0083), breastfeeding in the first hour of life (p=0.0244) and exclusively breastfeeding upon data collection (p=0.0148).Conclusion: The support of mother and mother-in-law received by puerperal women, to breastfeed within the first our and exclusively breastfeed during the admission period in the nursing ward influenced levels of breastfeeding self-efficacy among adolescent puerperal.

ResumoObjetivo: Verificar a associação entre a autoeficácia na amamentação e os fatores sociodemográficos e obstétricos das adolescentes.Métodos: Estudo observacional, transversal e descritivo, desenvolvido no alojamento conjunto de uma maternidade pública no município de Ribeirão Preto, São Paulo. Os dados foram coletados no período de janeiro a julho de 2014, utilizando a versão brasileira da Breastfeeding Self-Efficacy Scale (BSES) que avaliou a autoeficácia na amamentação.Resultados: Os níveis de autoeficácia mais elevados estavam associados às variáveis: ter apoio da mãe ou da sogra no pós-parto (p=0,0083), amamentar na primeira hora de vida (p=0,0244) e estar em aleitamento materno exclusivo no momento da coleta de dados (p=0,0148).Conclusão: O apoio da mãe ou da sogra recebido pela puérpera, a amamentação na primeira hora de vida e a prática do aleitamento materno exclusivo durante o período de admissão no alojamento conjunto, influenciaram os níveis de autoeficácia na amamentação entre as puérperas adolescentes.influenciaram os níveis de autoeficácia na amamentação entre as puérperas adolescentes.

KeywordsBreast feeding; Self efficacy; Trust;

Adolescent; Maternal and child health

DescritoresAleitamento materno; Autoeficácia;

Confiança; Adolescente; Saúde materno-infantil

Submitted February 9, 2017


110 Acta Paul Enferm. 2017; 30(1):109-15.


Introduction

The World Health Organization (WHO) consid-ers adequate feeding in childhood as the most ef-ficient intervention to promote childhood health, and WHO recommends that children should be exclusively breastfed until the six month of life and complimentary up to 2 years of age or over. This recommendation is also followed by the Brazilian Ministry of Health.(1,2) Advantages of maternal breastfeeding are largely described in the literature and its benefits is extended to child’s and woman health, as well as promotion of economic advantag-es for the family and society as a whole.(3)

Maternal breastfeeding indexes presented an sig-nificant improvement in the last decades in Brazil, contributing to reduce childhood mortality in the country.(4,5) However, the prevalence of exclusive breastfeeding remains below of what is recommend by the WHO.(1,2)

Early weaning is a complex phenomenon that is influenced by biological, psychological, social and cultural factors, and it characterized by introduc-tion of other type of food in the diet of the child who is exclusively breastfed before the six month of age.(6)

Maternal age appears as one of the factors that can influence duration of breastfeeding. For adoles-cents, the association of age with personal factors increases the risk of early weaning compared with adult women.(7) In addition, cultural habits and social norms, as well as difficulties in the first day after delivery and support received from family, es-pecially from their mothers, influence the behavior of adolescents concerning breastfeeding.(7,8)

Other factor that influences both beginning and maintenance of breastfeeding is maternal con-fidence in the ability of breastfeeding, which is constructed and maintained by personal support and situations experienced by the woman.(9-11) Maternal confidence is also called breastfeeding self-efficacy, which is a changeable and easy to ac-cess variable by health professionals. The analysis of this variable also enable to identify women at higher risk for early diagnosis, as well as to perform individualized interventions when necessary.(12,13)

Maternal self-efficacy in the ability of breastfeeding is explained by the theory of breastfeeding self-ef-ficacy developed by Dennis(14) and from the self-ef-ficacy construct that integrates the social-cognitive theory of Bandura.(14,15)

According to self-efficacy construct, individu-als need to be convinced that they could perform successfully a specific task or behavior, and they should believe that he/she could achieve an ex-pected health result. Individuals should believe that such behavior would help to achieve the ex-pected result, as well as to feel capable to perform it.(15) Therefore, the breastfeeding self-efficacy is related to woman’s perception about her ability to breastfeed her baby, and in the belief that she has knowledge and enough skills for successfully breastfeeding.(14)

To evaluate the level of breastfeeding self-effica-cy, Dennis and Faux(16) developed and validated the Breastfeeding Self-efficacy Scale (BSES).The BSES is Likert-type scale with content created from prob-lems related to practice and duration of breastfeed-ing presented in the literature, and it was adapted in a number of countries, including Brazil. This in-strument is valid and trustable, and it can be used to support health professional to identify women with higher risk of early weaning.(11,17,18)

Studies performed with BSES proved that wom-en with higher level of breastfeeding self-efficacy for longer time compared with those that present lower level of confidence, and some factors such as support received and hospital practices, might in-fluence women’ behavior in breastfeeding.(12,18) This study verified breastfeeding self-efficacy among pu-erperal adolescents and the existence of association between breastfeding self-efficacy and sociodemo-graphice and obstetric factors. This study soughts to contribute for profesional pratice in the moth-er-child binomial, as well as to implement actions to benefit maternal breastfeeding.

Methods

This was an observational, cross-sectional and de-scriptive study, developed in a nurse ward from a

111Acta Paul Enferm. 2017; 30(1):109-15.

Guimarães CM, Conde RG, Gomes-Sponholz FA, Oriá MO, Monteiro JC

public maternity in the municipality of Ribeirão Preto, São Paulo, Brazil. The sample of the study was calculated based on information of the annual report of nurse ward in which the study was done and based on previous study involving maternal confidence for breastfeeding among Brazilian wom-en. Considering a tolerable sample error of 5%, level of confidence was 95%, and previous loss was 10%. The sample was composed by 94 puerperal adolescent.

Puerperal women were randomly selected con-sidering the following inclusion criteria: no more than 18 years of age, good physical conditions for breastfeeding, children with term gestational age (>37 weeks), at least 24 hours after delivery and newborn in the maternity. Exclusion crite-ria were: presence of any disease, intercurrences after the delivery that could avoid breastfeeding, newborn with any disease and/or requiring spe-cial care, child with hearing, visual or cognitive impairment.

Adolescents were invited to participate, and they received previous information about the study. After understand the study and its ethical aspects, those who agreed to participate signed the consent form. The signature in the consent form of the legal guardian was also requested for under-age puerperal women.

Data were collected from January to July 2014 using two instruments. The first instrument on identification data and sociodemographic and ob-stetrics characteristics of participants. The second instrument entailed the BSES – the Brazilian ver-sion, used to evaluate participants breastfeeding self-efficacy.

BSES is Likert type scale including 33 ques-tion a divided into two domains: technical and intrapersonal intelligence. Each question has five possibilities of answer with scores ranging from 1 to 5, i.e., 1 - I totally disagree, 2 - I disagree, 3 - sometimes I agree, 4 - I agree, 5 - I totally agree. Therefore, total score of scale ranged from 33 to 165 points.(17) Breastfeeding self-efficacy to identi-fy through the scale is distributed according to ob-tained score from calculation of each question: low self-efficacy (33 to 118 points), medium self-effi-

cacy (119 to 137 points), high self-efficacy (138 to 165 points).(19) This instrument was already tested in several phases of the puerperal-pregnancy cycle, and results presented support its use in any stage of the perinatal period.(20) Because it is self-appli-cable, this instrument was answered directly by the puerperal women, without interference of the re-searcher. Therefore, puerperal women answered if and on how intensity they agreed or disagreed to each issue.

Data were double-typed in electronic spread-sheets in Microsoft Excel. Double-typing enabled validation of typed data in order to eliminate any possible errors and guarantee confidence in data compilation. For data analysis, we used the Analy-sis System SAS® 9.0 statistical software and R ver-sion 3.0.

To characterize the sample, data analysis was crucial for descriptive statistics. The association be-tween qualitative variables was verified using the Fisher Exact test. The level of significance was 5% (α = 0.05).

This study was approved by Ethics and Re-search Committee of Nursing School of Ri-beirão Preto at University of São Paulo, protocol nº21346013.80000.5393.

Results

We included 94 puerperal adolescent. Partici-pants’ mean age were 16.53 years (SD=1.44), and 50% declared to be “parda”, 58.51% had com-pleted primary education, 46.81% had a partners but they were not married, and 52.13% lived on their own house. Most of participants (87.23%) reported to be unemployed, and mean month family income was 2.23 Brazilian minimal wag-es. Participants obstetrics characteristics were: most of them were adolescents (93.2%) primipa-ra and 65.96% did not planned the gestation. Of them 60.49% underwent standard prenatal care in the first trimester of gestation, and most of them (85.06%) attended six or more consulta-tions. A total of 86.17% had normal full delivery, 57.4% breastfeed within the first hour of life and

112 Acta Paul Enferm. 2017; 30(1):109-15.


92.55% were exclusively breastfeeding their baby when data were collected. All adolescents report-ed they were helped by someone to take care of the baby.

In terms of breastfeeding self-efficacy, 54.26% of puerperal adolescent presented high self-efficacy, according to data presented in table 1.

The analysis of the association used the depen-dent variable “breastfeeding self-efficacy” and inde-pendent variables concerning sociodemographic, obstetrics and breastfeeding characteristics. Results showed a significant association between the vari-able “support with care of the baby” and “breast-feeding self-efficacy”, i.e., adolescents who reported to receive help of their mothers and/or mothers-in-law had higher level of breastfeeding self-efficacy (p=0.0083). The table 2 presents results of associa-tion between breastfeeding self-efficacy and consid-ered variables.

We also observed a significant association for variables “maternal breastfeeding within the first hour of life” and “type of maternal breastfeeding at time of collection”. Adolescents who breastfeed in the first hour of life had higher level of breastfeed-ing self-efficacy (p=0,0244), as well as those who were exclusively breastfeeding at the time of data collection (p=0.0148), and this result was statisti-cally significant, according to table 3.

According to results, no previous obstetric vari-ables (number of gestations, delivery, abortion, and lived child) were statistically significant associated with breastfeeding self-efficacy, as well as current obstetric variables (planned gestation, gestational age in the beginning of pre-natal care and number of pre-natal consultations attended), intercurrences in gestation, at delivery and after delivery, and type of delivery.

Table 1. Distribution of puerperal adolescents in terms of breastfeeding self-efficacy classification

Self-efficacy classificationAdolescents (n=94)

n(%)

Low 11(11.70)

Moderate 32(34.04)

High 51(54.26)

Table 2. Analysis of breastfeeding self-efficacy, associated with sociodemographic, obstetrics and breastfeeding characteristics among adolescents

Variables

Self-efficacy

p-value*Lown(%)

Moderaten(%)

Highn(%)

Skin color reported

White 02(2.13) 09(9.57) 15(15.96) 0.4529

Black/Parda 07(7.45) 22(23.40) 34(36.17)

Asian 02(2.13) 01(1.06) 02(2.13)

Formal education

Incomplete primary education

04(4.26) 07(7.45) 10(10.64) 0.1900

Complete primary education

03(3.19) 21(22.34) 31(32.98)

Complete high school 04(4.26) 04(4.26) 10(10.64)

Left school because of the pregnancy

Yes 06(6.38) 14(14.89) 16(17.02) 0.2743

No 05(5.32) 18(19.15) 35(37.23)

Religion

More than one religion 07(7.45) 23(24.47) 33(35.11) 0.7753

Believe in God, but do not have religion

04(4.26) 09(9.57) 18(19.15)

No religion 00(0.00) 00(0.00) 00(0.00)

Occupation

Employed 00(0.00) 06(6.38) 06(6.38) 0.3357

Unemployed 11(11.70) 26(27.66) 45(47.87)

Marital Status

Single/divorced 03(3.19) 13(13.83) 21(22.34) 0.7215

Married/not married but lives with a partner

08(8.51) 19(20.21) 30(31.91)

Type of house

Own house 03(3.19) 15(15.96) 31(32.98) 0.1772

Rented 06(6.38) 13(13.83) 17(18.09)

Bored 02(2.13) 04(4.26) 02(2.13)

Other 00(0.00) 00(0.00) 01(1.06)

Month family income in Brazilian minimal age (R$ 724,00) (n=65)

No more than 2 04(6.15) 10(15.38) 22(33.85) 0.4278

2,1 to 4 02(3.08) 11(16.92) 10(15.38)

More than 4 01(1.54) 01(1.54) 04(6.15)

Help to take care of the baby

Mother/mother-in-law 07(7.45) 14(14.89) 35(37.23) 0.0083

Husband/partner/boyfriend

04(4.26) 10(10.64) 04(4.26)

Other family member/friend

00(0.00) 08(8.51) 12(12.77)

*Fisher exact test; CI - 95% Confidence Interval

113Acta Paul Enferm. 2017; 30(1):109-15.


Table 3. Analysis of breastfeeding self-efficacy associated with variables “breastfeeding within the first hour of life of the newborn” and “type of maternal breastfeeding at the time of collection”

VariablesSelf-efficacy

p-value*Lown(%)

Moderaten(%)

Highn(%)

Breastfeeding in the first hour of life of the newborn (n=93)

Yes 09(9.68) 13(13.98) 32(34.41) 0.0244

No 02(2.15) 19(20.43) 18(19.35)

Type of maternal breastfeeding at the time of collection

Exclusively breastfeeding 11(11.70) 27(28.72) 49(52.13) 0.0148

Predominance of breastfeeding 00(0.00) 00(0.00) 02(2.13)

Mixed breastfeeding 00(0.00) 05(5.32) 00(0.00)

*Fisher exact test; CI - 95% Confidence Interval

Discussion

The result of the study with puerperal adolescent showed that most of participants (54.26%) had high level of breastfeeding self-efficacy. A study car-ried out in Canada using the reduced version of the BSES showed that between puerperal adolescent that begun the breastfeeding, 57% of them had high self-efficacy in pre-natal care.(21) We did not found studies analyzing levels of self-efficacy imme-diate after delivery among adolescents.

Adolescents who reported to be assisted to take care of their baby by their mother or mother-in-law had higher level of self-efficacy, therefore, this result corroborates with other studies that described family support after delivery as an important factor to be-gin and maintain breastfeeding.(22) The support after delivery is one of the environmental and emotion-al factors that influence the decision of the women for breastfeeding and it improves their self-esteem, confidence and promotes a healthy behaviors.(23) Mother of adolescent are the major influencers in their breastfeeding experience, in terms of decide to breastfeed or not, and its maintenance.(24) When mothers of adolescent are presented, they are im-portant to supply adolescent need of emotional and information support regardless of social class.(22)

Results also present a significant association be-tween self-efficacy in breastfeeding and the variables “Breastfeeding within the first hour of life of the newborn” and “Type of maternal breastfeeding at the time of collection”. No studies were found in the literature that analyzed this association in puer-peral adolescent. However, we understand that skin-to-skin contact and early beginning of breastfeeding

bring a variety of benefits to mother and baby, and they are related with higher maternal satisfaction and increase of confidence of women and their ability to breastfeeding and delivery care of their baby.(25) In addition, the physical feeling experienced by women just after the delivery can increase or decrease the confidence, situations in which women experience higher anxiety, stress and pain, reduced the level of oxytocin and reflect the of maternal milk ejection, leading to perception of insufficient milk and, con-sequently, reduce of levels of self-efficacy.(26,27)

Results showed increase of self-efficacy among adolescents when they reported to be helped by others to take care of the baby compared with “breastfeeding within the first hour of life of the newborn” and “type of maternal breastfeeding at the time of collection”. It also showed that these data can be important to support the continuity of breastfeeding, considering that scientific literature reports that adolescent mothers have higher risk of not begin breastfeeding, higher risk of early wean-ing, especially during the hospitalization, lower chance of exclusively breastfed at hospital discharge and higher risk of discontinuing breastfeeding after hospital discharge.(28)

Conclusion

We highlight that specific practices given to pu-erperal women, such as receiving support from mother or mother-in-law, breastfeeding within the first hour of baby’s life and practice of exclu-sive breastfeeding during the period of admission to nurse ward influence the increase breastfeeding

114 Acta Paul Enferm. 2017; 30(1):109-15.


3 Toma TS, Rea MF. Benefícios da amamentação para a saúde da mulher e da criança: um ensaio sobre as evidências. Cad Saúde Pública. 2008; 24(Suppl 2): s235-46.

4. Venancio SI, Escuder MM, Saldiva SR, Giugliani ER. Breastfeeding practice in the Brazilian capital cities and the Federal District: current status and advances. J Pediatr (RJ). 2010; 86(4): 317-24.

5. Victora CG, Aquino EM, Leal MC, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet. 2011; 377(9780): 1863-76.

6. Monteiro JC, Nakano AM, Gomes FA. O aleitamento materno enquanto uma prática construída: reflexões acerca da evolução histórica da amamentação e desmame precoce no Brasil: revisão. Invest Educ Enferm. 2011; 29(2): 315-21.

7. Cruz MC, Almeida JA, Engstrom EM. Práticas alimentares no primeiro ano de vida de filhos de adolescentes. Rev Nutr. 2010; 23(2): 201-10.

8. Nesbitt SA, Campbell KA, Jack S M, Robinson H, Piehl K, Bogdan JC. Canadian adolescent mothers’ perceptions of influences on breastfeeding decisions: a qualitative descriptive study. BMC Pregnancy and Childbirth. 2012; 12:149.

9. Kools EJ, Thijs C, De Vries H. The behavioral determinants of breast-feeding in The Netherlands: predictors for the initiation of breast-feeding. Health Educ Behav. 2005; 32(6): 809-24.

10. Kronborg H, Vaeth M. The influence of psychosocial factors on the duration of breastfeeding. Scand J Public Health. 2004; 32(3):210-6.

11. Dennis CL, Heaman M, Mossman M. Psychometric Testing of the Breastfeeding Self-Efficacy Scale-Short Form Among Adolescents. J Adolesc Health. 2011; 49(3): 265-71.

12. Blyth R, Creedy DK, Dennis CL, Moyle W, Pratt J, De Vries SM. Effect of maternal confidence on breastfeeding duration: an application of breastfeeding self-efficacy theory. Birth. 2002; 29(4): 278-84.

13. Oriá MO, Ximenes LB, Almeida PC, Glick DF, Dennis CL. Psychometric assessment of the Brazilian version of the Breastfeeding Self-Efficacy Scale. Public Health Nurs. 2009; 26(6):574-83.

14. Dennis CL. Theoretical underpinnings of breastfeeding confidence: a self-efficacy framework. J Hum Lact. 1999; 15(3):195-201.

15. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977; 84(2): 191-215.

16. Dennis CL, Faux S. Development and psychometric testing of the Breastfeeding Self-Efficacy Scale. Res Nurs Health. 1999; 22(5):399-409.

17. Oriá MO, Ximenes LB. Tradução e adaptação cultural da Breastfeeding Self-Efficacy Scale para o português. Acta Paul Enferm. 2010; 23(2):230-8.

18. Dennis CL. Identifying predictors of breastfeeding self-efficacy in the immediate postpartum period. Res Nurs Health. 2006;29(4):256-68.

19. Blyth R, Creedy DK, Dennis CL, Moyle W, Pratt J, De Vries SM, et al. Breastfeeding duration in an australian population: the influence of modifiable antenatal factors. J Hum Lact. 2004;20(8): 30-8.

20. Lewallen LP. A review of instruments used to predict early breastfeeding attrition. J Perin Educ. 2006; 15(1):26-41.

21. Mossman M, Heaman M, Dennis CL, Morris M. The influence of adolescent mothers’ breastfeeding confidence and attitudes on breastfeeding initiation and duration. J Hum Lact. 2008; 24:268-77.

self-efficacy among puerperal adolescent. The ma-ternity in which this study was carried out is part of Brazilian program “The Friend of the Children Hospital”, which is a factor considered a limitation of our study because institutions in this program makes strong efforts to promote breastfeeding, and this fact may reflect responses given by participants. Although the “The Friend of the Children Hospi-tal” program constitutes a strategy that improves the maternal self-efficacy, we did not find studies associating actions or indicators of “Friend of Chil-dren” institutions and breastfeeding self-efficacy.

Few studies so far have analyzed breastfeeding self-efficacy immediate after birth. Considering that BSES can be developed in a manner that ad-olescents would be followed-up retrospectively and prospectively, with aim to improve knowledge and follow-up mother and child binomial in relation for breastfeeding practice. This study provides support for professional practice in terms of establish plan-ning for maternal breastfeeding, and self-efficacy in breastfeeding is an important variable to be iden-tified and worked along with adolescent at higher risk for early weaning.

AcknowledgementsWe thank National Council for Scientific and Technological Development (CNPQ) and Coor-dination for the Improvement of Higher Educa-tion Personnel (CAPES).

CollaborationsGuimarães CMS, Conde RG, Gomes-Sponholz FA, Oriá MOB and Monteiro JCS declare to participate in conception of the study, data analysis and interpre-tation, drafting the manuscript, critical review of the content and approval of final version to be published.

References

1. World Health Organization. Infant and young child feeding. Model chapter for textbooks for medical students and allied health professionals. Geneva: WHO; 2009. 111 p.

2. Brasil. Ministério da Saúde. II Pesquisa de prevalência de aleitamento materno nas capitais brasileiras e Distrito Federal. Brasília (DF): Ministério da Saúde; 2009a. 108p.

115Acta Paul Enferm. 2017; 30(1):109-15.


22. Barona-Vilar C, Escribár-Agüír V, Ferrero-Gandía R. A qualitative approach to social support and breast-feeding decisions. Midwifery. 2009; 25(2):187-94.

23. Ku C-M, Chow SK. Factors influencing the practice of exclusive breastfeeding among Hong Kong Chinese women: a questionnaire survey. J Clin Nurs. 2010; 9(17-18): 2434-45.

24. Fairchild CB. Overcoming barriers to improve breastfeeding self-efficacy in older adolescent mothers [tese]. Minneapolis: Walden Universtiy; 2013. 195p.

25. Aghdas K, Talat K, Sepideh B. Effect of immediate and continuous mother–infant skin-to-skin contact on breastfeeding self-efficacy of primiparous women: a randomised control trial. Women Birth. 2014; 27(1): 37-40.

26. Monteiro JC. Análise da percepção da nutriz sobre o leite produzido e a satisfação da criança durante aleitamento materno exclusivo [tese]. Ribeirão Preto: Universidade de São Paulo; 2008. 120p.

27. Oriá MO. Tradução, adptação e validação da Breastfeeding Self-Efficacy Scale: aplicação em gestantes [tese]. Fortaleza: Universidade Federal do Ceará; 2008. 188p.

28. Kingston D, Heaman M, Fell D, Chalmers B, Maternity Experiences Study Group of the Canadian Perinatal Surveillance System, Public Health Agency of Canada. Comparison of adolescent, young adult, and adult women’s maternity experiences and practices. Pediatrics. 2012; 129(5):e1228-37.

116

ErratumIn the article published in Acta Paul Enferm. 2016; 29(4):439-45, Car-valho RB, Nobre RS, Guimarães MR, Teixeira SE, Silva AR; “Risk factors associated with the development of metabolic syndrome in children and adolescents”, should to publish the following errata:

Substitute, in Methods section, the paragraph: “O perímetro da cintura foi obtida usando uma medida de fita inelástica co-locado sobre a pele, com o objecto em posição vertical, no ponto médio entre a ultima costela e a borda superior da crista ilíaca, no final do movimento de expiração, e classificado como proposto ao público.(14)”

For: “The waist circumference was obtained using an inelastic tape measure placed on the skin, with the subject in an upright position, in the midpoint between the last rib and the upper edge of the iliac crest at the end of the expiratory movement, and classified as proposed to the public.(14)”


Official Organization for Scientific Dissemination of the ... · Facebook: Twitter:...

Documents

Transcript of Official Organization for Scientific Dissemination of the ... · Facebook: Twitter:...