v24n5a13

ORIGINAL RESEARCH

 

Treatment as a reason to prevent relapse of alcoholism

 

Janaina Rocha SoaresI; Marilurde DonatoII; Maria Yvone Chaves MauroIII; Liane Gack Ghelman IV ; Sheila Nascimento Pereira de FariasV

I Nurse. Master. Doctorate Degree Student. Federal University of Rio de Janeiro. Brazil. E-mail: janainarsoares@gmail.com
II Nurse. Doctor. Assistant Professor. Federal University of Rio de Janeiro. Brazil. E-mail: marilurdedonato@superest.ufrj.br
III Nurse. Doctor. Visiting Professor. Federal University of Rio de Janeiro. Brazil. E-mail: mycmauro@uol.com.br
IV Nurse. Doctor. Assistant Professor. Federal University of Rio de Janeiro. Brazil. E-mail: lgghelman@gmail.com
V Nurse. Doctor. Assistant Professor. Federal University of Rio de Janeiro. Brazil. E-mail: sheilaguadagnini@yahoo.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2016.16207

 

 


ABSTRACT

Objective: to analyze treatment as a reason to prevent relapse of alcoholism. Method: this qualitative descriptive study involved 31 participants aged 18 to 65 years at the Rio de Janeiro Municipal Department of Health and Civil Defense (SMDC-RJ), between July and September 2009, through a focus group. Data was analyzed by content analysis. The project was approved by the Research Ethics Committee on March 2, 2009 (Certificate of Presentation for Ethical Assessment CAAE - 0019.0.314.000 - 09, protocol 25/09). Results: five categories emerged that portray treatment to prevent relapse: treatment preventing relapse; difficulty with abstinence; religion as support complementing relapse prevention treatment; multidisciplinary intervention in the family; and multidisciplinary intervention in the social environment. Conclusion: the prevention of relapse can be motivated by treatment, and is complex and personal.

Keywords : Alcoholism; recurrence; public health; family.


 

 

INTRODUCTION:

Alcoholism is a serious public health problem, which has increased progressively, bringing negative consequences for the individual and all those who surround this individual¹.

Each year, approximately 3,300,000 deaths occur in the world because of the harmful consumption of alcohol, representing 5.9% of total deaths. Since individuals age 15 years-old and above drink, on average, 6.2 liters of pure alcohol per year, i.e. 13.5 grams of pure alcohol per day is consumed 2.

In Brazil, according to the World Health Organization (WHO), in their report in the year 2014, the consumption of alcohol was 15.1 liters, making the country to stand out with rates higher than 140 other countries 2.

In addition, in 2012, 5.1% of the global amount of diseases were attributable to alcohol consumption, which corresponds to 139 million years of life adjusted due to disability3.

These premises point out that alcohol consumption is considered a social problem depending on the quantity and frequency of use, as this may cause serious damage to health, as well as compromising family and social relationships and working conditions4.

However, the severity of the problem can vary from individual to individual, which can be a key factor to be considered when designing the treatment. And, in this context, the prevention of relapse arises, which is a behavioral maintenance program for use in the treatment of problems caused by addiction, based on total abstention from substance used by the individual, or the maintenance of regulatory programs about the behavior of the individual, which consisted in abstinence or moderation in the use of alcohol5.

Alcoholism can also be responsible for important economic and social losses for individuals and society. It is estimated that the country loses 7.3% of Gross Domestic Product (GDP) because of alcohol-related problems, or around R$372 billion in 20142.

And before the issue of relapse prevention it is proposed to have strategies and interventions to prevent initial lapses and teach the needed skills for when a person undergoes a relapse situation 6.

Despite the magnitude of the problem, this theme is little explored in literature, especially when it comes to treatment as a factor of protection for prevention of relapse7.8.

Thus, the present study had as objective: to analyze the treatment as a reason for alcoholism relapse prevention.

 

THEORETICAL FRAMEWORK

Alcoholism is a silent disease, but the patient and their family members do not to recognize it as such, denying its presence, its troubles and causing consequences to bring suffering both for the family and for the alcoholic 8.

The recovery is complex due to biological, psychological and social factors. However, the greatest limitation of the recovery process is to remain abstinent for a long period, preventing relapse episodes9 .

Relapse is considered a set of symptoms of the disorder, which manifests itself by the return of drug use in the same proportion as the preceding the abstinence period10.

In this context, the treatment of prevention of relapse is based on avoiding relapse to start the identification and understanding of high-risk situations and of the determinants of relapse, developing skills that help the alcoholic to deal with these situations11.

The Brazilian Government, in 2004, instituted within the Unified Health System (SUS) the Ordinance No. 2,197/GM, from October 14, 2004, current National Policy of the Ministry of Health for Integral Attention to Users of Alcohol and Other Drugs12. In addition, another action taken by the Brazilian Government was the National Policy on Alcohol, through Decree No. 6,117, from May 22, 2007, which provides for measures to reduce the abuse of alcohol and its association with violence and crime 13.

Other Public health policies of Brazil, such as the Emergency Plan of Expansion of Access to Treatment and Prevention of Alcohol and Other Drugs 14, the Network of Psychosocial Care for people with pain or mental disorder and needs arising from the use of crack cocaine, alcohol and other drugs15 and the National Agenda on Health Research Priorities16, reinforce the need to promote effective actions that promote the treatment of the problematic due to alcoholism.

 

METHODOLOGY

This is a descriptive study with a qualitative approach, carried out from July to September 2009, in the Coordination of Human Resources/Management of Applied Psychology of the City Department of health and Civil Defense of Rio de Janeiro (SMSDC-RJ), which develops the Rainbow Project.

The subjects of the study totaled thirty-one (31) persons, municipal civil servants who sought or were referred to the Management of Applied Psychology for specialized care for problems related to the abuse of alcohol. The alcoholics who were part of the study were men and women aged between 18 and 65 years-old, workers and not workers, with higher, middle or elementary education level, who voluntarily agreed to participate in the study.

Inclusion criteria were to be abstinent for at least a month and be over 18 years-old. Exclusion criteria were diagnoses of psychotic disorders and mental retardation.

As data collection technique, we opted for the realization of the focal group, which, from the group interaction, promotes a wide questioning about a theme or specific focus17. And to develop it, the authors counted with the participation of two managers for each scenario practice. The sessions were recorded with the participants' consent, by signing the informed consent (TFCC).

After data collection, the material for the focus groups were transcribed and read. We used the technique of content analysis, thematic category, observing the production of speech, making inferences about the messages systematized and guiding the context of production18.

Therefore, the organization of the corpus, consisting of transcribed testimony in its entirety and floating and exhaustive reading testimonials, making himself a general synthesis and cutouts. Therefore, we analyzed the central ideas from the aggregation of the most relevant speeches, which were: treatment, abstinence, religion, family and social environment.

The paucity of new subjects corresponded to the theoretical saturation, whereas the attributes of analysis and interpretation19.

Finally, the description of each of the categories, namely: the treatment to prevent relapse, difficulty on abstinence, religion as support as complementary support to treatment in preventing relapse; multidisciplinary intervention by the family; multidisciplinary intervention in social environment.

The words of the participants have been identified with the letter "E", followed by Arabic number, according to the following order (1 to 31).

The study was carried out in line with the guidelines established by resolution 466/12 the Ministry of Health20 and approved by the Research Ethics Committee (CEP) of SMSDC-RJ, being approved on March 2nd, 2009 - with certificate of introduction to Ethics Assessment (CAAE): 0019.0.314.000-09 under Protocol # 25/09.

 

RESULTS AND DISCUSSION

The analysis of the statements, identified five thematic categories: 1) treatment to prevent relapse; 2) difficulty on abstinence; 3) religion as complementary support to treatment in preventing relapse; 4) multidisciplinary intervention by the family; 5) multidisciplinary intervention in social environment.

Treatment to prevent relapse

The alcoholic when he becomes aware that the treatment is necessary, looks for alternative solutions based on how close he/she is to the institution or the health professional. In this way, the individual begins treatment following him, trying to keep your conduct abstinent, aware that the phase in which it is perhaps not permanent, because the relapse and return to the initial stages may happen. Here are a few lines about the treatment as prevention of relapse:

For me the reason was the treatment. (E2)

One who is in treatment has a huge awareness to his/her favor to avoid relapse. (E4)

For me, I was only able to prevent because of the treatment I've been doing. (E10)

The treatment is the best prevention of relapse. (E16)

Treatment helps in preventing [relapse]. (E18)

Through treatment and follow-up, I have been able to overcome. (E19)

The motivation for treatment is the first stage in the process of behavior change21. Since there are different levels of motivation, from the pre-observation, representing little motivation for change, observation and maintenance, which translates motivation quite a lot12.

The treatment is a way to get the awareness of dependency, change the behavior, improve control over himself, confront or mitigate the damages arising from the use of drugs and assist in users' perception about the determinants that precede the relapse22. It is a privileged moment to motivate the patient to prevent relapse into alcoholism.

Difficulty on abstinence

During the professional practice, it was found that the treatment is one of the most important alternatives to prevent relapse, because the specialized care you receive from every health care professional can help you stay abstinent. However, not always the alcoholic can abstain from drinking, as desired.

I am in treatment, because when I'm not drinking that gag reflex, dizziness, feeling faint, everything comes, then I must drink at least a little bit... But I can 't stand this bad feeling. (E7)

The difficulty reported is because withdrawal symptoms are persistent, causing the alcoholic to try to minimize them, as they can be light or more severe, perhaps leading to to death. It is valid to remember that the withdrawal symptoms begin 6 hours after stopping the use of alcohol, when the first signs and symptoms: tremors, anxiety, nausea, insomnia, nausea and irritability23. And the withdrawal of alcohol without planning or systematization can endanger the health of patients 24.

Thus, few seek treatment because the drink is no longer a source of pleasure as before, but only a means to alleviate the symptoms of withdrawal21.

This is an important time to keep warm, empathetic and unprejudiced attitude, conducive to motivate the patient to comply with the treatment 25.

Religion as complementary support to treatment in preventing relapse

The participants of this study understand religion acts positively, constituting an important resource for their treatment. Whereas, the fact of attending a religious environment or be in contact with the Sacred Scripture can bring positive feelings by providing welfare.

What saved me was the religion . (E1)

Attending Church. (E15)

I could only keep me abstinent when I started studying the Bible. (E22)

The statements indicate that religion positively influences on health, and on prevention and recovery for the problem of alcohol consumption. Thus, the internalization of religious values and beliefs may contribute to the self-control of destructive behaviors26, allowing the confrontation and strengthening of the subject in their relationship with alcohol.

The alcohol dependent tries to replace periods of increased beverage consumption for activities related to religious practice, which aim to help them to divert the focus from the act of drinking and from alcohol 27, helping them to cope with their problems28.

Religion is considered a protective factor, because it not only helps in the treatment process, but it is also a means to search for comfort, strength and meaning to life, as well as providing welfare, which used to be achieved using psychoactive drugs29. It is an additional resource for treatment, promoter of change of habit and routine by promoting social support27.

Multidisciplinary intervention by the family

During focus groups, there were identified the possibilities for intervention by the multidisciplinary team to assist in the prevention of relapse. Here are some testimonials:

The team could explain to my family that alcoholism is a disease. (E11)

My family also needs to come here to hear these things that you teach us, talk to my wife, trying to make her understand that it is a disease. (E16)

Show them that I 'm sick. (E19)

My family has come here to listen to you, so they can better understand what I 'm going through. (E21)

My family needs to know I 'm sick, and that I do I need them to help me. (E23)

The acceptance of the disease alcoholism in the family is important in the process of recovering alcoholic, which should be explained to their members by health professionals, to a greater understanding about the importance of family support in preventing relapse. It is also important to learn what is the best way to deal with the alcoholic to build a healthy family relationship. Since the family is identified not only as a risk factor for relapse, but also as protection factor30.

Everyday conflicts in social environment and family conviviality, represent situations that, in the absence of skills for coping, represent reason for relapse31.

However, the family falls ill with their member, who is dependent on chemicals, so there's no way to think about this without considering the social and family context in which it is inserted and, thus, providing intervention programs for families29.

The good family support link, affection and stimuli for social reintegration collaborate for a better life quality30. The participation and support of the family during treatment can contribute significantly to the success of the treatment and, consequently, restructuring of the lifestyle and changes in user behavior32.

The alcoholics also showed much concern related to children, according to the testimonials, respectively:

If they called them here would be very good for them to understand me and I wouldn 't want to fall. (E2)

They could do a follow-up work with my son, so that he can understand what I go through. (E5)

It would be nice to my son to attend here also to have greater understanding of my illness, because it would help me not to relapse. (E17)

I wanted my children to listen too what I hear here because they would stop saying things to me that make me want to relapse. (E20)

Family is fundamental in rehab and alcoholic and adhesion must be considered a fundamental axis in the recovery of the same33, be encouraging or participating actively in the treatment. However, the lack of information, understanding and wear related to consequences of the frequent use of alcohol by the dependent represents low tolerance, culminating in the difficulty of acceptance of chemical dependency as sickness30.

It is a connecting link between the family and the alcoholic, and the professional is to meet not only the needs of the patient, but also of the family, which is still ignored, being mere support in the treatment 23.

Multidisciplinary intervention in social environment

The importance of addressing issues related to alcoholism, not only in the outpatient care, but also in other environments affected by the problem:

They could do in the workplace what they do here, because I was weak because my co-workers make fun of me. (E6)

What could be done, are these lectures [group gatherings] what you guys have here in other places like schools to talk about alcoholism because I was weak, for my son has arrived home saying that colleagues laughed at him because he has an alcoholic father. (E13)

The prevention of relapse of alcoholism is a very complex subject because to prevent it, we need to reach all environments and layers of society with the goal to minimize the prejudice and stigma that surrounds it, based on the information on the disease called alcoholism.

It is known that alcohol, perhaps because it is the psychoactive substance consumed with greater frequency, bring consequently the occurrence of various complications, including social33.

In this way, the social support is important to complement positively in treating alcoholic34. Seeking, through actions of health, to develop ways to sensitize society to the understanding and treatment of alcoholic35.

The statements of the participants made it clear that the prevention of relapse not depends only on the activities of the multidisciplinary team towards the alcoholic and their family, but it depends also on the enlightenment on the subject in the different social environments to clarify the population.

 

FINAL CONSIDERATIONS

This research presents limitations when considering the perception of alcoholics to only one treatment device.

However, due to the analysis and discussion of the content of the testimonials, it was possible to infer that the treatment as a reason for the prevention of relapse is something complex and personal, which involves life situations.

One could observe, in their speeches, that this is a subject of much complexity because, to prevent relapse we need to reach all environments and layers of society with the goal to minimize the prejudice and stigma that surrounds it, based on the information on the disease alcoholism.

The statements of the participants made it clear that the prevention of relapse does not depend only on the activities of the multidisciplinary team together to the alcoholic and their family, but also of enlightenment on the subject to clarify that there may be a more responsible behavior of people regarding the disease, as described in the National Alcohol Policy13 and on the national Agenda of Health Research Priorities 16.

It was noted that the difficulty in dealing with the symptoms of withdrawal is no easy task, requiring the team planning and careful consideration in order not to endanger the health of the alcoholic.

Some statements pointed to the religion to think about a change of attitude and discover well-being. This could be observed when the testimonials showed that attending Church and studying the Bible meant positive attitudes to not relapse.

Family is of the essence in the treatment and prevention of relapse of the alcoholic. Therefore, their participation is essential to actively encourage the treatment.

For both, it was observed the alcoholic's effort towards the pursuit of understanding and acceptance on the part of the people who surround him, highlighting the desire of the relapse doesn't happen and avoiding their disbelief in front of friends and family members, being as significant factor in your search for treatment.

Based on the above considerations, it is evident that there is a long road to be traveled by those who deal with issues linked to alcoholism, in particular the prevention of relapse, whereas they need to be trained and updated about the subject to spare attention to the alcoholic, having goals encouraging achievement of the recommended treatment.

 

REFERENCES

1.Mangueira SO, Guimarães FJ, Mangueira, JO, Fernandes AFC, Lopes MVO. Health promotion and public policies on alcohol in Brazil: integrative review of literature. Psicologia & Sociedade, 2015; 27 (1): 157-68.

2. Organização Mundial de Saúde. Global status report on alcohol and health – 2014. Genebra (Sui): OMS; 2014.

3. Organização Mundial de Saúde. World health statistics. Genebra (SUI): OMS; 2012.

4. Organização Mundial de Saúde. Global status report on alcohol and health. Genebra (Sui): OMS; 2011.

5.Marlatt A, Gordon J. Determinants of Relapse: Implications for the maintenance of behavior change In Davidson PO, Davidson DM, organizers. Behavioral medicine: Changing health lifestyles. New York (EUA): Brunner / Mazel; 1980.

6.Marlatt GA, Gordon JR. Relapse prevention. New York (EUA): Guilford; 1985.

7.Soares JR, Farias SNP, Donato M, Mauro MYC, Araujo EFS, Ghelman LC. The importance of the family in the process of preventing relapse. Journal for Nurses UERJ. 2014; 22 (3): 341-6.

8.Guimarães ABP, Hochgraf PB, Brasiliano S, Ingberman YK. Family aspects of teen girls addicted to alcohol and drugs. Psychological Journal Clin. 2009; 36 (2): 69-74.

9.Ferreira ACZ, Capistrano FC, Maftum MA, Kalinke LP, Kirchhof ALC. Characterization of admissions of drug addicts in a rehabilitation unit. Cogitare Nurses. [Virtual Health Library] 2012 [quoted in December 13, 2016]. 17 (3): 444-51. Available in: http://dx.doi.org/10.5380/ce.v17i3.29284

10.Silva AP, Perrelli JGA, Guimarães FJ, Mangueira SO, Cruz SL, Frazão IS. Identification of nursing diagnosis ineffective health self-control in alcoholics: a descriptive study. Elect. Journal for Nurses [Virtual Health Library] 2013 [quoted in December 13, 2016]. 15 (4): 932-39. Available at: http://dx.doi.org/10.5216/ree.v15i4.19841 .

11. Marlatt GA, Witkiewitz k. problems with alcohol and drugs. In: Marlatt GA, Donovan DM, organizers. Relapse prevention: maintenance strategies in the treatment of addicts. Porto Alegre (RS): Artmed; 2009. p.15-50.

12. Ministry of Health (Brazil). Ordinance 2197 of Oct. 4, 2004. Redefines and expands the comprehensive care for users of alcohol and other drugs, in the context of the unified health system - SUS, and other matters. [quoted in Dec 15, 2016]. Available at: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2004/prt2197_14_10_2004.html

13. Federal Government (Br). Decree No. May 22, 2007. Approves the national policy on alcohol, provides for measures to reduce the abuse of alcohol and your association with violence and crime, and other matters. [quoted in Dec 10, 2016]. Available in: www.planalto.gov.br

14. Ministry of Health (Brazil). Ordinance No. 1190 from June 4, 2009. Establishes the emergency plan of expansion of access to treatment and prevention in alcohol and other drugs in the Unified health system (SUS) (HDPE 2009-2010) and defines its general guidelines, actions and goals. [quoted in Dec 15, 2016]. Available in: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2009/prt1190_04_06_2009.html

15. Ministry of Health (Brazil). Ordinance No. 3,088 of December 23, 2011. Sets up the network of psychosocial care for people with pain or mental disorder with recurring need to use crack cocaine, alcohol and other drugs, in the context of the unified health system (SUS). [quoted in Dec 15, 2016]. Available at: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt3088_23_12_2011_rep.html

16.Ministry of health (Br). Secretariat of science, technology and strategic inputs. National agenda for health research priorities. Brasília (DF): Department of Science and technology: 2008.

17.Backes DS, Colomé JS, Erdmann RH, Lunardi VL. Focal group technique of data collection and analysis in qualitative research. O mundo do saber, São Paulo: 2011; 35 (4): 438-442.

18. Bardin, L. Análise de conteúdo. Translation by Luis Antero Reto e Augusto Pinheiro. São Paulo: Editions 70/ Livraria Martins Fontes; 1979.

19.Fontanella BJB, Luchesi BM, Saidel MGB, Ricas J, Turato ER, Melo DG. Sampling in qualitative research: proposed procedures to establish theoretical saturation. Reg. Public Health [Scielo-Scientific Electronic Library Online] 2011 [quoted in December 15, 2016]. 27 (2): 388-94. Available in: http://www.scielo.br/pdf/csp/v27n2/20.pdf .

20. National Health Council (Br). Resolution number 466, from December 12, 2012.Guidelines and Regulatory Norms of Research Involving Human Beings. Brasília, 2012 [quoted in Dec 15, 2016]. Available in: http://www.conselho.saude.gov.br/web_comissoes/conep/index.html .

21.Sousa PF, Ribeiro LCM, Melo JRF, Maciel SC, Oliveira MX. Drug addicts in treatment: a study on the motivation for change. Psycological themes. 2013; 21 (1): 1-8.

22.Ferreira, ACZ, Czarnobay J, Borba LO, Capistrano FC, Kalinke LP, Maftum MA. Intra and interpersonal determinants of relapse of drug addicts. Electronic Journal for Nurses [Virtual Health Library] 2016 [quoted in December 13, 2016]. 18: e1144. Available in: https://revistas.ufg.br/fen/article/view/34292

23. Quaglia MAC, Bachetti LS, RS, Tostes JGA, Days, Heck AVP. Hollow mask illusion during the mild alcohol withdrawal syndrome. Ciências & Cognição 2014; 19 (3): 315-324

24.Ponce TD, Prates JG, Vargas D, Oliveira MAF, Claro HG, Gnatta LR. Nursing teams training for assistance to alcohol withdrawal syndrome: integrative review. Electronic Journal on Mental Health, Drug and Alcohol [Virtual Health Library] 2016 [quoted in December 18, 2016]. 12 (1): 58-64. Available in: http://pepsic.bvsalud.org/pdf/smad/v12n1/pt_08.pdf

25. Laranjeira R, Nicastri S, Jerônimo C, Marques AC. Consensus on the alcohol withdrawal syndrome (AWS) and treatment. Brazilian Journal of Psychiatry [Scielo-Scientific Electronic Library Online] 2000 [quoted in Dec 16, 2016]. 22 (2): 62-71. Available at: http://www.scielo.br/pdf/rbp/v22n2/a06v22n2.pdf

26.Wills TA, Pokhrel P, Morehouse E, Fenster B. Behavioral and emotional regulation and adolescent substance use problems: a test of moderation effects in a dual-process model. Psychol. Addict Behav. 2011; 25 (2): 279-92.

27.Zerbetto SR, Gonçalves MAS, Santile N, Galera SAF, Acorinte AC, Giovannetti G. Religiosity and spirituality: mechanisms of positive influence on life and treatment of the alcoholic. Esc. Anna Nery [Scielo-Scientific Electronic Library Online] 2017 [quoted in February 1, 2017]. 21 (1): 1-9. Available in: http://www.scielo.br/pdf/ean/v21n1/1414-8145-ean-21-01-e20170005.pdf

28.Murakami R, Campos CJG. Religion and mental health: challenge of integrating religious with the care to the patient. Brazilian Journal for nurses 2012; 65 (2): 361-67.

29.Al-Omari H, Hamed R, Tariah HA. The role of religion in the recovery from alcohol and substance abuse among Jordanian adults. J. Relig. Health. 2014; 1 (1): 1-10.

30.Silva ML, Guimarães CF, Salles DB. Risk and protection factors to relapse in the perception of users of psychoactive substances. Rev. Rene. 2014; 15 (6): 1007-15

31.Czarnobay J, Ferreira ACZ, Capistrano FC, Borba LO, Kalinke LP, Maftum MA. Intra and interpersonal determinants perceived by the family as a cause of relapse of chemical dependent. Brazilian Journal for Nurses 2015; 19 (2): 93-99

32.Xavier M, Rodrigues P, Silva M. The perception of family in the support and treatment of addicts. Find. Psychol. Journal 2014; 17 (26): 99-110.

33.Soares JR, Farias SNP, Donato M, Mauro MYC, Araujo EFS, Ghelman LC. The focal group as a strategy for alcoholism relapse prevention Journal for nurses UERJ. 2014; 22 (4): 494-9.

34.Teixeira EP, Hoepers NJ, Correa AM, Dagostin VS, Soratto MT. The confrontation of family in front of alcoholism. Health Journal 2015; 11 (3): 213-226.

35.Oliveira GC, Nasi C, Lacchini AJB, Camatta MW, Maltz C, Schneider JF. Psychosocial rehabilitation: process of reconstruction of the subjectivity of the drug user. Journal for nurses UERJ [Scielo-Scientific Electronic Library Online] 2015 [quoted in December 2, 2016]. 23 (6): 811-6. Available at: http://www.e-publicacoes.uerj.br/index.php/enfermagemuerj/article/view/11742/16185