id 5702

ORIGINAL RESEARCH

 

Tuberculosis among the elderly: health care system gateway and late diagnosis

 

Séfora Luana Evangelista de AndradeI; Débora César de Souza RodriguesII; Anne Jaquelyne Roque BarrêtoIII; Annelissa Andrade Virgínio de OliveiraIV; Ana Rita Bizerra do Nascimento SantosV; Lenilde Duarte de SáVI

I Nurse. Ph.D. student of the Graduate Program in Nursing at the Federal University of Paraíba. João Pessoa, Paraíba, Brazil. E-mail: seforaejoab@hotmail.com
II Nurse at the Family Health Strategy. Municipal Health Secretary. João Pessoa, Paraíba, Brazil. E-mail: deboracesarufpb@gmail.com
III Nurse. Professor at the Federal University of Campina Grande. João Pessoa, Paraíba, Brazil. E-mail: annejaque@gmail.com
IV Nurse. Ph.D. student of the Graduate Program in Collective Health of the University of Brasília. João Pessoa, Paraíba, Brazil. E-mail: annelissa_ufpb@hotmail.com
V Nurse. Master degree in Nursing by the Graduate Program in Nursing of the Federal University of Paraíba. João Pessoa, Paraíba, Brazil. E-mail: anaritabizerra@hotmail.com
VI Nurse. Ph.D. in Nursing. Associate Professor of the Department of Nursing at the Federal University of Paraíba. João Pessoa, Paraíba, Brazil. E-mail: lenilde_sa@yahoo.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2016.5702

 

 


ABSTRACT

Objective: to examine the factors related to late diagnosis of tuberculosis (TB) among the elderly in a town in the metropolitan region of João Pessoa, Paraiba, Brazil, and evaluate them in relation to the system gateway. Method: in this qualitative study with the participation of seven elderly individuals, data were collected by semi-structured interview and analyzed by thematic content analysis. The study was approved by the research ethics committee (Protocol No. 0589/2008). Results: primary health care (PHC) did not figure as the main gateway for the elderly for diagnosis of tuberculosis in the city studied, revealing that PHC organization suffers from weaknesses relating to health actions, access and bonding, which interfere with the utilization of PHC as a gateway. Conclusion: a new work process logic is required in which health practices prioritize technologies that potentiate reception and bonding, for earlier confirmation of diagnosis and start of TB treatment.

Keywords: Primary health care; family health strategy; health of the elderly; tuberculosis.


 

 

INTRODUCTION

Tuberculosis (TB) remains a problem of global importance. Even after more than a century of the Mycobacterium tuberculosis bacillus identification and about 50 years after the discovery of a specific and effective medicine treatment, TB continues to increase in an absolute number of cases, characterized as a neglected calamity1.

In Brazil, the TB control is a priority in the government health policies, and its implementation is carried out by the of the Family Health Strategy teams (ESF) which, under the concept of primary health care (APS) the responsibility is for the care of the patient with TB². Therefore, it is noteworthy that the ESF is configured as an APS model in Brazil3 .

In this sense, it should be noted that in Brazil, to differentiate the selective design of existing APS in other countries, the name of Primary Health Care (ABS) started to be used3 - defined as health actions at the individual and collective level, located on the first level of attention focused on health promotion, disease prevention, diagnosis, treatment, rehabilitation and health maintenance4. Therefore, in this study, ABS and APS were adopted as synonyms and acronyms.

The ABS have the following dimensions: access, door entry, link, service list, coordination, family focus, community orientation and training. This study is based on the door entry dimension, which involves access and the use of the ABS service in every new problem or a new episode of a problem for which people seek health care, always like the first sought care, except in emergency cases5.

Thus, the ESF, incorporating the main control measures for TB, should act as the patient´s door entry to the various health care levels. However, the decentralization of TB control actions to the door entry of municipal health systems has been hampered by favoring then abandoning the treatment of TB6 and delay diagnosis.

Following the global trend of population aging, there is the incidence of TB in the higher age groups in Brazil even slowly7,8. Thus, the elderly population growth together with the resurgence of TB gives greater concern to scholars and the health authorities, justifying detailed studies and incisive action against the disease in this age group9.

Considering TB in the elderly is an emerging and complex health problem, given the peculiarities of the disease and the presence of other features that favor its severity7 and, despite the efforts made in the care of that patient, the delay to diagnosis remains a stumbling block, aggravating and enhancing the spread of the disease. It is necessary to study the elements related to this event to identify their weaknesses and strengths to optimize the production of care to the patient within the ABS.

Therefore, this study aimed to analyze the factors related to delayed diagnosis of TB in the elderly in one of the municipalities in the metropolitan region of João Pessoa/Paraíba, Brazil, evaluating them under the door entry dimension.

 

LITERATURE REVIEW

The increased incidence of TB in the higher age groups is not a reality only in Brazil, because, according to different studies, this epidemiological problem is being recorded and experienced by other countries in the world, which indicate that although the number of TB cases have decreased, there is an increased incidence of cases in the elderly compared to the general population10-13.

Following the highest incidence of TB in the elderly, there is also an increase in mortality rates from the disease in this age group, associated scenario mainly due to increase in the elderly population; the specific conditions of age; the socioeconomic components and health policies9.

The clinical presentation of TB in the elderly is variable14, moving away from the classic symptoms and features, especially not characteristic symptoms, such as anorexia, weakness, weight loss and mental changes14,15. This often means a delay in diagnosis by the difficulty of recognizing the clinical picture, which is often confused with aging changes for health professionals and family members, or not properly reported by the patient7,14,16,17.

There is still no consensus about the time that sets the delay in the diagnosis of TB. Studies show that, in this delay, the time ranged from 30-162 days, and the health system 2-18 days. The delay in diagnosis related to TB patient reflects the delay in seeking medical service after the onset of symptoms of the disease, and, in the health service, the time interval between the first visit at any health unit until the date of diagnosis18,19.

Access to the diagnosis of TB should be provided at first contact with the patient, and this happens in the system is the door entry. The National Primary Care Policy (PNAB) in Brazil provides that the ABS is responsible for providing services in primary care, acting as a door entry to the health system4.

Thus, the ABS contemplating the main actions for the control of TB should work as a patient entrance door with TB for the various health care levels, enabling a comprehensive service and more resolute, especially to old people.

 

METHODOLOGY

This is a qualitative research, conducted by the content analysis technique, thematic mode21. It was developed in one of the municipalities in the metropolitan region of João Pessoa/PB, considered a priority for TB control by the Ministry of Health (MOH).

Participants were seven elderly people who underwent the treatment of TB. The inclusion criteria were: to be over 60, have completed TB treatment in health units in the city setting and reside in it. Elderly people who fit the study profile were identified by the Notifiable Diseases Information System (Sinan) and are identified by the letter C of customers, and arranged in the sequence they were interviewed, that is C1 to C7.

The empirical material was obtained by the technique of a semi-structured interview. Information was collected from December 2010 to February 2011 in the residence of the participants and recorded individually, with the audio handset.

For the treatment of information, the content analysis technique (AC) was used, a thematic mode proposed by Bardin22. The steps used for processing the data were pre-analysis in which the initial reading of the testimony was conducted, constituted by the analysis of the corpus, followed by an exhaustive reading of the material; analysis where the registration units were selected (phrases), forming a cut of the reports and subsequent organization. Then, the themes were built emerging the following categories: Health Care Network Use Flow for elderly people with TB and Weaknesses in the professional bond/service - patient.

Considering the ethical aspects and by Resolution Nº 196/96 CNS, the research project was submitted to the Ethics Committee on Research of the Health Sciences Center of the Federal University of Paraíba - CCS/UFPB being approved on December 17, 2008, under Protocol Nº 0589.

 

RESULTS AND DISCUSSION

Health Care Network Use Flow for elderly people with TB

Through the ESF, THE PNAB consolidates the ABS as the preferred door entry to the Unified Health System (SUS) and the starting point for the structuring of local health systems being responsible for servicing the first level of health care4. In theory, the ESF is configured as the health service gateway, helping to maintain healthy habits and better quality of life for human beings, seeking health promotion and disease prevention for all23.

However, the elderly in their reports showed that the first health services sought for diagnosis and treatment of their disease were the specialist hospital, the private hospital, and other health services. It is noteworthy that only one mentioned searching ESF for initial care, and in this case, it was the search for a referral to a more specialized level:

I went straight to Clementino [referral hospital] because he wanted me to hospitalize. (C2)

I went to the hospital because he was very sick. I was hospitalized, even in the ICU (C4)

My daughter took me to Clementino hospital [...]. (C5)

I went first to Santa Izabel [hospital], then, they sent me to Laureano [hospital] and from there to Clementino [...]. (C6)

I searched the health center staff, because everywhere else I was going, they would ask me for the paper of the health center. They only assist you [in another service] if you take the paper. (C3)

Thus, the ESF was not the door entry to elderly people with TB in the city studied. In this sense, this study confirms the results of other research showing that the ABS services are not the first sought by TB patients and not the first to be effective for diagnostic confirmation24,25. This reveals the incipient performance of these services in the diagnosis and control of TB that in this case is extensive to the elderly24.

The results showed a parallel performance of services, in which the ESF does not work as a mandatory filter for specialized care, accessed directly by the patient, suggesting weaknesses in the health services network organization of the municipality studied. This may contribute to the delay in diagnosis, being a threat to the control and early diagnosis of TB, and contribute to the worsening of the patient´s health status, once the disease at an advanced stage and the extension the transmission period of the disease are discovered.

A study in a Brazilian Northeast capital evaluating the access to diagnosis and treatment of tuberculosis in the ESF showed that although most patients seek health facilities for diagnosis of the disease, such services were not prepared and not organized to meet the needs of patients, not effectively ensuring early diagnosis26.

For the gradual horizontalization of the health care organization27, the ESF must observe the principle of comprehensiveness, articulated to a set of health actions on the individual and the environment to control this disease, the protection of vulnerable groups or exposed the risks and access to health services28 that is, in a conformation in health care networks. The care networks are the organization of health services oriented non-hierarchical relationships of common goals sharing among various actors with the exchange of resources among themselves29.

Thus, this understanding enables the formation of a horizontal network of health care centers in different technological densities and their support systems, without order and degree of importance between them29. Thus, the ESF has been adopted as the care model change of perspective in the ABS with the constitution of this strategy as the preference gateway26.

The organization of the health services network flow use with the ESF as the first contact of the patient with the service is also expected in the elderly care, as established by the policy. It defines the health care of this age group to be the ABS gateway, concerning the network of specialized services of medium and high complexity30. In this context, proposed as the point of the first contact with the patient, the ABS should identify the real submitted care needs to maximize the effectiveness of primary and specialized care services. Thus, it diminishes the occurrence of unnecessary and excessive specialized interventions that generate high costs for the health care system, and thereby strengthen the principle of equity5.

However, the reports of the elderly reveal a contradiction with what is recommended. Thus, it emphasizes the transfer of responsibilities of the family health units (USF) to the highest technological content services:

To find out if I had TB, first I looked for a polyclinic; then they sent me to Clementino; then from Clementino, they sent me to treat in the unit, because it is close. (C1)

There [in the hospital] the doctor told me that I could treat me at home [...]. Just get the medication in the health center. (C3)

I was in the hospital [...] when they discovered that I had TB, then, they sent me to the PSF, to follow up. (C4)

It is observed that despite the ESF has the potential to organize and develop the prevention, control, diagnosis and treatment of TB31 , it is not being sought by the elderly affected by the disease for their diagnosis and treatment, occurring the reverse referral, that is, the specialized service for the next USF of residence, reflecting disruption of the flow of the elderly people with TB in the network of health services.

When seeking the specialized service, the elderly with TB recognizes the referral hospital as the appropriate place for the diagnosis and treatment of infectious diseases such as TB, using local historically defined and socially recognized place as effective to do it. Thus, it must also be pointed out the influence of prejudice that still accompanies the disease in this search process by the health service, since there is no denying that the stigma surrounding the compete disease to undermine the process of decentralization of TB control actions for the services of ABS32 .

Weaknesses in the professional bond/service - patient

From the reports, it is evident that older people believe in resolute proposal by technologies used in other levels of care, which can interfere with their relationship of trust/distrust as to obtain successful results in the services offered by USF and its role as gateway to the health system:

Because I wanted to be hospitalized, and the unit did not admit. (C2)

[...] The Health Center gave me the referral to the hospital, and there, I already started taking the drugs. (C3)

I did not go to the health center because he thought there did not solve because I thought that this problem was only an expert to solve. Because I wanted a specialized treatment. (C6)

The way patients are welcomed, and the link established between them and the health service reinforce feelings of reliability. This facilitates the demand for services closer to solving their needs. However, the pursuit of other health levels by the elderly of this study reveals that there was no training services link between professionals and the community in which they live. That is, this reality contradicts the existence of a regular supply of care by health staff and their consistent use over time, in an environment of the mutual and humane relationship between health staff, individuals, and family33.

The link is considered a dimension of ABS and presupposes the existence of a regular source of care and use over time34. Existing weaknesses in its construction, between the healthcare team and the TB patient, can lead to decreased quality and effectiveness of control actions of the disease within the ABS33. One of the actions identified in a study to bring more health professionals of tuberculosis patients was the home visit. This visit is a health promotion space and building links that strengthen the care35.

Another event that draws attention to the reports of the participants is that even aware of the existence of USF, next to their home, these elderly people have chosen to look for another health service in search of the diagnosis of TB, passing, most of the time, by problems of transportation to the more distant services:

It has, yes [USF] [...]. (C5)

I knew there was PSF here [...]. (C6)

Difficulties in transportation were much, mainly financial. My daughter spent a lot on transportation whenever I needed to go to the hospital. (C4)

The greatest difficulty we have is the lack of money to do things. (C5)

I had difficulty also to go to the hospital, I had transportation difficulties, because here everything is far away, and I had no money to pay a taxi. (C6)

The decentralization of TB control actions to the ABS services was based on the way these services are organized: by territories. The geographical proximity of the individual with the health service facilitates access to diagnosis and adherence to treatment of the disease. However, only the geographical proximity does not determine the patients´ choice for health services, which is influenced by the relationship between patients and professionals, motivating them to seek certain health service, even more distant25.

Although the expansion of the basic network have contributed to improving geographical accessibility36, it is observed that having health units close to the patients´ home, it did not improve to seek for this service to identify it as a gateway to the network of health services. By choosing the demand for reference services or hospitals, the elderly found geographical barriers related to distance and transportation costs. It is known that the most affected group by geographical barriers, with difficult access to the network at the time of greatest need, is that one formed by older people with limited socioeconomicconditions37,38. In this sense, it is evident the need for strengthening of host actions and the link between the professionals of the health services of ABS and patients, to enhance the ABS as the gateway and to minimize the impact of barriers identified.

 

CONCLUSION

This study enabled to verify that the ABS is not configured as a major door entry of respiratory symptomatic elderly of TB for diagnosis in the city studied, revealing that the organization of ABS has weaknesses relating to health actions, access and link, that interfere with the pursuit of ABS as a gateway. This fact contributes to the delay in diagnosis, being a threat to the control and early diagnosis of TB and contributing to the worsening of the health status of patients and extension of transmission of the disease.

Thus, a new logic of the work process is required for the execution of the ABS as the main gateway to the local health system, based on changes in local health policy to universalize health care as recommended by SUS. In this sense, it is essential that health practices prioritize technologies that enhance host and link, to abbreviate the confirmation of the diagnosis and early treatment of TB and other diseases.

As a study limitation, the difficulty of the location and access to research participants is highlighted, since the collection of the reports was the residence of the elderly and the first contact depended on the availability of community health worker unit in which the elderly completed the TB treatment. Also, the study has a limit of not contemplate elderly residing in all health districts of the county health scenario. Moreover, despite not allow generalizations, the results raise discussions about the fragility of ABS as an entrance door of the elderly with TB to health care services.

 

REFERENCES

1.Ruffino-netto A. Tuberculose: a calamidade negligenciada. Rev Soc Bras Med. 2002; 35(1):51-58.

2.Ministério da Saúde (Br). Secretaria de Políticas de Saúde. Departamento de Atenção Básica. Manual de recomendações para o controle da tuberculose no Brasil. Brasília(DF): Editora MS; 2011.

3.Giovanella L, Mendonça MHM, Almeida PF, Escorel S, Senna MCM, Fausto MCR et al. Saúde da família: limites e possibilidades para uma abordagem integral de atenção primária à saúde no Brasil. Ciência saúde coletiva. 2009; 14(3):783-94.

4.Ministério da Saúde (Br). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção. Brasília(DF): Editora MS; 2002.

5.Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília(DF): Ministério da Saúde /Unesco; 2002.

6.Souza KMJ, Sá LD, Palha PF, Nogueira JA, Villa TCS, Figueiredo DA. Abandono do tratamento de tuberculose e relações de vínculo com a equipe de saúde da família. Rev esc. enferm, USP. 2010; 44(4):904-10.

7.Vendramini SHF, Villa TCS, Cardozo Gonzales RI, Monroe AA. Tuberculose no idoso: análise do conceito. Rev Latino-Am Enfermagem. 2003; 11(1):96-103.

8.Oliveira AAV, Sá LD, Nogueira JA, Andrade SLE, Palha PF, Villa TCS. Diagnóstico da tuberculose em pessoas idosas: barreiras de acesso relacionadas aos serviços de saúde. Rev esc. Enferm USP. 2013; 47(1):145-51.

9.Tavares LM, Oliveira ABM, Braga LAV, Andrade FB, Ferreira Filha MO. Incidência de casos de tuberculose em idosos no município de Cabedelo, Paraíba, Brasil. Fiep Bulletin [Internet] 2010 [cited 2016 Aug 12]; 80(Special). Available from: http://www.fiepbulletin.net/index.php/fiepbulletin/search/titles?searchPage=69

10.Shin JY, Jung SY, Lee JE, Park JW, Yoo SJ, Park HS, et al. Characteristics of pulmonary Webb-Yates M. Tuberculosis in the elderly: a different disease? tuberculosis in elderly people. Tuberc Respir Dis. 2010; 69(3):163-70.

11.Pešut DP, Gledović ZB, Grgurević AD, Nagorni-Obradović LM, Adzić TN. Tuberculosis incidence in elderly in Serbia: key trends in socioeconomic transition. Croat Med J. 2008; 49:807-12.

12.Trigueiro, JS, Tomaz MLRP, Souza RFRC, Pinheiro PGOD, Souza SAF,Sá L et al. Análise da produção acerca da tuberculose em idosos na literatura lusa e inglesa. Rev Enferm UFPE on line., 2016; 10(5):1847-56.

13. Lopez-Pelayo I, García-Martos P, Saldarreaga A, Montes de Oca M, Moreno I, González-Moya, E. Características de la tuberculosis em pacientes mayores de 65 años en el área sanitaria de Cádiz (España). Rev. Méd. Chile. 2004; 132(3):325-30.

14.Sood R. The problem of geriatric tuberculosis. Journal of Indian Academy of Clinical Medicine. 2004; 5(2):156-62.

15.Lee JH, Han DH, Song JW, Chung HS. Diagnostic and therapeutic problems of pulmonary tuberculosis in elderly patients. J Korean Med Sci . 2005; 20(5):784-89.

16. Schaaf HS, Collins A, Bekker A, Davies PDO. Tuberculosis at extremes of age. Respirology. 2010; 15(5):747-63.

17.Hino P, Costa-Júnior ML, Sassaki CM, Oliveira MF, Villa TCS, Santos CB. Time series of tuberculosis mortality in Brazil (1980-2001). Rev Latino-Am Enfermagem. 2007; 15(5):936-41.

18.Mfinanga SG, Mutayoba BK, Kahwa A, Kimaro G, Mtandu R, Ngadaya E, et al. The magnitude and factors associated with delays in management of smear positive tuberculosis in Dar es Salaam, Tanzânia. BMC Health Serv Res. 2008; 8:158.

19.Basnet R, Hinderaker SG, Enarson D, Malla P, Mørkve O. Delay in the diagnosis of tuberculosis in Nepal. BMC Public Health. 2009; 14(9):236

20.Oliveira MF, Arcêncio RA, Ruffino-Netto A, Scatena LM, Palha PF, Villa TCS. A porta de entrada para o diagnóstico da tuberculose no sistema de saúde de Ribeirão Preto (SP). Rev esc. enferm USP. 2011; 45(4):898-904.

21.Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 8.ª ed. São Paulo: Hucitec; 2004.

22. Bardin L. Análise de conteúdo. Lisboa (Pt): Editora 70; 2009.

23.Pacheco RO, Santos SSC. Avaliação global de idosos em unidades de PSF. Textos Envelhecimento. 2004; 7(2).

24. Sá LD, Scatena LM, Rodrigues RAP, Nogueira JA, Silva AO, Villa TCS. Gateway to the diagnosis of tuberculosis among elders in Brazilian municipalities. Rev Bras Enferm. 2015; 68(3): 408-14.

25.Mizuhira VF, Gazeta CE, Vendramini SHF, Ponce MAZ, Wysocki AD, Villa TCS. Procura da atenção básica para o diagnóstico da tuberculose. Arquivos de Ciências da Saúde. 2015, 22(2):94-98.

26.Santos TMMG, Nogueira LT, Santos LNM, Costa CM. O acesso ao diagnóstico e ao tratamento de tuberculose em uma capital do Nordeste Brasileiro. Rev enferm. UERJ. 2012; 20(3):300-5.

27.Teixeira MGLC, Paim JS. Os programas especiais e o novo modelo assistencial. Cad Saúde Pública. [Scielo-Scientific Electronic Library Online] 1990 [cited 2016 Aug 12]. 6(3):264-77. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X1990000300004

28.Paim JS. Modelos de atenção à saúde no Brasil. In: Giovanella L, organizadora. Políticas e sistema de saúde no Brasil. Rio de Janeiro: Fiocruz. 2008. p. 547-73.

29.Vilaça EM. As redes de atenção à saúde. Brasília(DF): Organização Pan-Americana da Saúde; 2011.

30. Ministério da Saúde (Br). Secretaria de Assistência à Saúde. Departamento de Atenção Básica. Envelhecimento e saúde da pessoa idosa. Brasília (DF): Editora MS, 2006.

31. Sa LD, Gomes ALC, Nogueira JA, Villa TCS, Souza KMJ Palha PF. Intersetorialidade e vínculo no controle da tuberculose na Saúde da Família. Rev Latino-Am Enfermagem [Scielo-Scientific Electronic Library Online] 2011[cited 2016 Aug 12]; 19(2): [09 telas]. Available from: http://www.scielo.br/pdf/rlae/v19n2/pt_22.pdf

32.Pinheiro PGOD, Sá LD, Palha PF, Souza FBA, Nogueira JA, Villa TCS. Busca ativa de sintomáticos respiratórios e o diagnóstico tardio da tuberculose. Rev Rene. 2012; 13(3):572-81.

33.Gomes ALC, Sá LD. As concepções de vínculo e a relação com o controle da tuberculose. Rev. esc enferm USP. 2009; 43(2):365-72.

34. Almeida C, Macinko J. Validação de uma metodologia de avaliação rápida das características organizacionais e do desemprego dos serviços de atenção básica do sistema único de saúde (SUS) em nível local. Brasília(DF) : OPAS/OMS; 2006.

35 Clementino FS, Miranda FAN. Tuberculose: acolhimento e informação na perspectiva da visita domiciliar. Rev enferm. UERJ. 2015; 23(3):350-4.

36 Souza ECF, Vilar RLA, Rocha NSPD, Uchoa AC, Rocha PM. Acesso e acolhimento na atenção básica: uma análise da percepção dos usuários e profissionais de saúde. Cad Saúde Pública. 2008; 24 (Sup 1):S100-S110.

37.Drachler ML, Côrtes SMV, Castro JD, Leite JCC. Proposta de metodologia para selecionar indicadores de desigualdades em saúde visando definir prioridades de políticas públicas no Brasil. Cienc. Saúde Coletiva. 2003; 8(2):461-70.

38.Louvison MCP, Lebrão ML, Duarte YAO, Santos JLF, Malik AM, Almeida ES. Desigualdades no uso e acesso aos serviços de saúde entre idosos do município de São Paulo. Rev Saúde Pública. 2008; 42(4):733-40.



Direitos autorais 2016 Séfora Luana Evangelista Andrade, Débora César de Souza Rodrigues, Anne Jaquelyne Roque Barreto, Annelissa Andrade Virgínio de Oliveira, Ana Rita Bizerra do Nascimento Santos, Lenilde Duarte de Sá

Licença Creative Commons
Esta obra está licenciada sob uma licença Creative Commons Atribuição - Não comercial - Sem derivações 4.0 Internacional.