Repercussions of the program for education through work for health (pet-health) in the training of students from the health area

Abstracts

OBJECTIVE:

The study aimed to investigate the repercussions of the Program for Education through Work for Health (PET-Health) in the training of students in the health area.

METHODS:

This study is exploratory-descriptive, with a qualitative approach. Twenty students participating in the PET-Health scheme participated in the study. The data collection technique was the semi-structured interview and thematic content analysis was used for analysis of the data.

RESULTS:

The data indicated that the PET-Health is a program which facilitates the search for comprehensiveness and allows the articulation of theory and practice between the students, the health service and the community, which is essential for re-orienting health training.

CONCLUSION:

It is concluded that the challenge centers on the critical-reflective training of the professionals in the area of health, indicating new behaviors and attitudes.

Nursing; Community-Institution relations; Professional Education in Public Health

OBJETIVO:

O estudo teve como objetivo conhecer as repercussões do Programa de Educação pelo Trabalho para a Saúde/PET-Saúde na formação de estudantes da área da saúde.

METODOS:

Configura-se como exploratório-descritivo, com abordagem qualitativa.Fizeram parte do estudo, vinte estudantes participantes do PET-Saúde. A técnica de coleta de dados foi a entrevista semi-estruturada e o método de análise dos dados empregado, a análise de conteúdo temática.

RESULTADOS:

Os dados sinalizam que o PET-Saúde configura-se como um programa facilitador para a busca da integralidade e que proporciona articulação teórica-prática entre estudantes, serviço de saúde e comunidade, o que é imprescindível para a reorientação da formação em saúde.

CONCLUSÃO:

Conclui-se que o desafio centra-se na formação crítico-reflexiva de profissionais da área da saúde, apontando para novos comportamentos e atitudes.

Enfermagem; Relações Comunidade-Instituição; Educação Profissional em Saúde Pública

OBJETIVO:

El estudio tuvo como objetivo comprender las repercusiones del Programa de Educación por el Trabajo para la Salud / PET-Salud, en la formación de estudiantes en el campo de la salud.

MÉTODOS:

Estudio exploratorio, descriptivo, con abordaje cualitativo. Participaron veinte estudiantes del PET Salud. La técnica de recolección de datos fue la entrevista semiestructurada y el método de análisis de los datos empleado, el análisis de contenido temática.

RESULTADOS:

Los datos muestran que el PET Salud se configura como un programa facilitador para la búsqueda de la integralidad y que proporciona articulación teórico-práctica entre estudiantes, servicio de salud y comunidad, lo que es imprescindible para la reorientación de la formación en salud.

CONCLUSIÓN:

Se concluye que el reto se centra en la formación crítico-reflexiva de profesionales del área de la salud, apuntando para nuevos comportamientos y actitudes.

Enfermería; Relaciones Comunidad-Institución; Educación en Salud Pública Profesional

INTRODUCTION

Since the Unified Health System was implanted in the 1980's, a critical line of thinking has been gaining strength in health, incorporating discussions on social determination in the health-illness process. With this, a new paradigm in health care has appeared, whose principles and guidelines break with the clinical Flexnerian paradigm and indicate the need to imprint a new way of producing and distributing health actions and services, that is, of configuring and defining this new model of health care¹. Associated with this idea, one can perceive the need for change in the models of care and in the training of the health professionals to act in harmony with the model of health proposed.

Since 2001, the National Curricular Guidelines for Graduate Courses (DCN) have been established, with the aim of providing Higher Education Institutions (HEI) with guidance for implanting political-pedagogical projects. It should be noted that the DCN are not ready formulas, but emphasize that the training institutes must seek innovative ways of teaching, with the mission of producing critical professionals, capable of grasping the context and of working in a team, taking into account the social context for comprehensive and quality care in a regionalized and hierarchized system².

Due to the need to renew the teaching-learning process, the Judicial Decision 198/GM/MS was created in 2004, instituting the National Policy for Continuous Education in Health as a strategy for the SUS, for the training and development of workers for the health sectors³.

In continuity with the process of transformations in the area of training in health, in 2005 a policy articulated with health education was established, which called for technical cooperation between the Ministries of Education and Health for the training and development of staff⁴. It was in this perspective that the National Program for the Re-orientation of Professional Training in Health (PRÓ-SAÚDE) was set up, which has the integration of teaching and work as its central axis, with the consequent integration of the students in the real practice setting - the SUS network - with an emphasis on primary care from the beginning of their training⁵.

It was in this context that the Program for Education through Work for Health (PET-Health) was set up in 2008, with the objective of facilitating the process of integrating teaching, work and community, investing in the training of health professionals in the workplace, as well as in the initiation of work and experiences directed at undergraduate students in the health area, in line with the SUS's needs⁶.

Institutions of higher education - both public and non-profit-making private ones - and municipal and state health departments from all over Brazil participated in this program, selected by bid-solicitations published by the Ministry of Health. The program is effected through setting up work teams composed of student tutors, preceptors from the primary care network, and volunteer students. It is thought that the investments in the program, up to February 2010, reached 63,027 PET-Health grants.

These changes were necessary to favor the training of health professionals in the perspective of comprehensiveness, which is a challenging proposal, as it strengthens the break with the traditional model of training and requires the re-organizing of the services and the work processes⁷.

The big challenge lies in changing the training of the professionals from the network of services and teaching institutions, keeping in view training for continuous education in health, the implementation of monitoring activities for specialized services for professionals with technical or university training. These guidelines emphasize working comprehensively in the area of primary health care, with emphasis on family health and the use of active teaching-learning methodologies⁸.

Thus, this study gives rise to some questions: what relationships do the students identify between training and work in the community? What changes are occurring in this scenario, and effectively bring together the teaching, the work and the community? What is the impact of this program in the training of the student in the health area?

Considering these questions and the need for dynamic, ongoing problematization of the program in question, this study aimed to investigate the repercussions of the Program for Education through Work for Health/PET-Health in the training of students in the area of health.

METHODOLOGY

This is an exploratory-descriptive study, structured in a qualitative research approach. The study was undertaken in the PET-Health Group developed in two Higher Education Institutes, one private and one public, in the city of Santa Maria, RS. The group is made up of four teams, each one made up of 1 tutor, 6 preceptors, twelve sponsored students and eighteen volunteer students, totalling 148 participants. The study was carried out between July and November 2010.

Regarding the study subjects, all the students participating in the PET-Health, on different courses in the health area, were invited to participate in the research, including the Psychology course, due to the group's training being interdisciplinary. No pre-stipulated order was followed in inviting them, but their availability to be part of the study group, and the interest they showed in the research, was taken into account. The first twenty students who accepted to participate in the study were selected to do so.

As a result, among the students, two are from the Biomedicine course, one from the Nursing course, four from the Pharmacy course, two from the Physiotherapy course, one from the Speech Therapy course, two from the Medicine course, one from the Nutrition course, three from the Dentistry course, one from the Psychology course, two from the Social Services course, and one from the Occupational Therapy course.

The technique chosen for data collection was the semi-structured interview, which had as its guiding questions: What did the PET-Health represent in your academic training? What contributions did the program bring to the relationships between the teaching, the health services and the community? How would you evaluate the functioning with professionals and students from other courses in the area of health?

The participants were asked for their permission for the interviews to be recorded on MP4s, so as to ensure data being captured in full and to guarantee the essence of the discourses. So as to maintain the participants' anonymity, the denomination 'P' followed by numbering from 1 to 20 was adopted.

This type of analysis, a mode of content analysis, can be separated into three stages: pre-analysis, when the researcher undertakes an exhaustive reading of the material, letting herself be pervaded by the content; exploration of the material, a stage in which the researcher seeks to find categories which are significant expressions and words, as a function of which the content shall be organized; and treatment and interpretation of the results obtained, a stage in which the researcher proposes inferences and makes interpretations⁹. These stages were followed in this sequence after the interviews' transcription in a text editor and organization of the material.

The decision was made to use fragments of the participants' discourses to illustrate the study's categories. This study was submitted to the Research Ethics Committee of the Centro Universitário Franciscano - CEP/UNIFRA for analysis and approval, and was registered under number 207.2010.2, on the 21^st of July 2010. In addition to this, the participants were handed Terms of Free and Informed Consent containing information on the study, a guarantee of anonymity and authorization of dissemination of the data collected, as called for in Resolution 196/96 of the Brazilian National Research Council (CNPq).

ANALYSIS AND DISCUSSION OF THE DATA

Of the research subjects, 17 were female and 3 male, being in the age range between 18 and 46 years old. After analysis of the data, the same was organized into three categories: Reflecting on the PET-Health program, Experiencing the program's impact on the academic training and the work in the community, and Learning to act in an interdisciplinary health team.

Reflecting on the PET-Health Program

The Program for Education through Work for Health - PET-Health - is mentioned by some students as a program which genuinely allows the re-orientation of health training, in that it articulates, through the integration of teaching and work, the training institutions and the health services. The discourses below denote this understanding of the students':

The PET-Health is a way for the academic to experience, in practice, what is learnt in theory. The academic must have the profile to be part of this program, have will-power, and be interested in learning and contributing to future projects, and must always be studying about issues relevant to the Program and also for his life and training. (P11)

The PET consists of a Federal Government program in partnership with the universities, made up of a multiprofessional team, which makes it an excellent learning space. This is the first time I have participated in a project. The teaching-research-work triad is what I consider to be the difference, it was through the PET that I discovered my passion for research, and its importance. (P18)

This understanding on the part of the students supports the conception of the program proposed by the Ministries of Education and Health, which has as its perspective the initiation of the work and experiences for the students from the undergraduate courses in the area of health, in line with the SUS's needs. It seeks, therefore, the integration of the student into the health field, with the aim of identifying the services' needs and using it as a source for the production of knowledge and research for the teaching institutions, with the integration of teaching-work-community as the theme⁶.

In this way, this program shows the need for investment in a contextualized and concrete training process, grounded in the population's social, economic and cultural dimensions, integrating popular knowledge, scientific knowledge and theory with practice. This entails stimulating interdisciplinary and multiprofessional functioning among these future health professionals, respecting the principles of social control and of the SUS and acting with responsibility with the population in a specific territory¹⁰.

In addition to this, in taking into account that the students participating in the program in question will be working directly and indirectly with the human being, a complex, singular and unique being, it is essential that they be familiar with the context of which they shall be part or with which they shall work, appropriating the knowledge of the public health policies and developing competences for effective care at all levels of care¹¹.

In the same way, for the participants in the study, the PET-Health represents an opportunity to be integrated into the community, when they understand that bringing students closer to the health work brings mutual benefits for the different actors, as expressed in the discourses below:

It was my first experience in the community. The PET broadens the view of the health-illness process, as well as increasing each student's pro-activity and teaching her to work in a team, with its negative and positive points. (P1)

[...] the PET means bringing together study and work, and means feedback, which benefits the community and learning feedback for the academic. It's a program which gives the student an excellent opportunity to be integrated in the community, so that he can have his first contact with it.(P2)

In this regard, the students' experience in the community is an opportunity to transfer the knowledge acquired in their training to practice, allowing a broadening of the students' vision of the health-illness process¹².

The outreach actions in the community can result in a feeling of use and be an opportunity for personal and professional learning. The students' and lecturers' work in the community is, therefore, of the utmost importance as, in addition to being of great academic relevance, it makes it possible to reflect on the indissociability of the teaching-research-outreach and the experience of interdisciplinary work. The discourses of the students presented below back up these arguments:

It's a growth space, which occurs through exchanges between students, professionals and service users in different areas, as the contact with the reality makes us capable of visualizing our future and deciding which is our greatest area of interest [...]. As well as being a way of making the other health professionals, who have already graduated, also work in a multidisciplinary way.(P8)

It means an opportunity for contact and interaction with colleagues from other health centers, working together for ideas which can favor our reality in Collective Health. It allows the sponsored student to become familiar with the routine of the professionals in the area she works in in Primary Care, gaining vast practical knowledge. (P20)

The students' reflections support the findings of another study carried out with participants in tutorial programs in the health area, who mentioned that the experience engendered values, beliefs and attitudes which show the need for the defense of the SUS, as well as encourage the student's human potential, the course's theoretical-practical content, and the student's participation in organized social movements. It is believed that experiences of this kind contribute to the technical, scientific and political training of undergraduates in the area of health, from the interdisciplinary and intersectorial perspective¹³.

By this, one can understand that the role of the training institutions transcends the transference of knowledge, making it necessary to invest in programs which allow the integration of teaching, work, community, research and outreach with the aim of facilitating the training of the new professional profile required in the health area, that is, a professional integrated into society to perform her functions in the complex field of health.

Experiencing the program's impact on the academic training and the work in the community

The study's participants showed in their discourses that the program in question has a social relationship with impact between the training institution and the community, constituting an instrument of change and transformation in the training in health, as well as seeking quality of life for the population.

Regarding the impact on academic training, the students indicated that participation in the PET-Health promotes articulation with the SUS and, as a consequence, the knowledge of team-work and the service users' health needs, as related in the discourses below:

Observing the program's potential and shortcomings, I think it facilitates understanding the community's health, and humanizes the academic training. I think the impact is positive, because our objective is to improve the service so that the community may have greater quality. Through the PET, the community benefits with the transformative actions, supporting the work teams in the community and contributing to change of some contexts. This impact is also created through our research, denouncing the health situation in our city, indicating changes and helping them to become reality. (P20)

I managed to learn to find the place of the health professional in the SUS and I learnt to be sensitive to other people's problems. It was very good and productive, because I learnt to see people with a more human eye. (P1)

In the PET, I could have real knowledge in health, of the reality in the Primary Health Care Centers (UBS), from the physical part through to organization of the work, knowledge in the areas of the other courses involved, and learning in my area through practice, research and supervision. (P18)

For transformation of the organization of the services and the training processes, it is necessary for there to be articulated work between the health system and the training institutions, given that the comprehensiveness of care involves the understanding of the widening of the services offered, knowledge of the context, the team work, the intersectorial action and the humanization. In this way, the student widens and enriches her vision of the local socio-political context, interacting with society and developing social thought about her future professional practice¹⁴.

The students also mentioned that the experience in the context of the PET-Health promotes the strengthening of broadened knowledge in relation to primary care and collective health, in that it makes possible the students' integration into actions carried out with the community. In the students' view, the program transcends the barriers of the traditional health training, in which the future professionals, generally speaking, are not prepared to work in the field of promoting health. This occurs due to a biologistic, curative, medical-centered focus, still predominant in many training institutions, which is not articulated with the health practices and policies. These arguments support the perceptions below:

[...] it brings you an experience which is different from what we have at college, where the vision is much more clinical than of collective health, even though collective health is one of the areas where speech therapy works.(P14)

For me, participating in this project means knowing the SUS, improving quality and the need for the work provided to the community through the experiences. The program brings us a big return, as we have the opportunity to be in a practical field within the system and that is the only way that we learn to do. (P7)

[...] it allows greater contact with the System and with the work in Primary Care, in addition to stimulating multiprofessional work and team work. In the academic curriculum at college, there are few moments for discussing the SUS and Primary Care actions, the majority still occur in the hospital area. (P12)

In this perspective, a health professional's training is not limited to learning technical competences and skills, but also includes the management of intersubjective situations. The training requires the stimulation of critical reflection in the lecturers, the professionals from the service networks, and the students integrated in the various learning settings. It is therefore considered important to reflect critically on the situations experienced, to know how to question, create and collect knowledge and experiences, as well as to know the reality⁸.

On reflecting on this program's impact on their training process, some students evidenced some difficulties due to the fact of their professional category not being represented in the health service, or further, by the ignorance of the team itself regarding the competences used in the center where these professions work, as emphasized in the statements:

The Nutrition course is somewhat impaired due to this professional's non-existence in the UBS, but we're trying to recognize the place of functioning, the professionals, so that we can contribute to the academic knowledge and incorporate the professionals' and population's experiences. (P13)

As the areas of Speech Therapy are still not well-known, we have a little difficulty in thinking up actions which favor the community, as the PSF people (Family Health Program) didn't know how to identify the demands. (P14)

The course didn't incorporate this proposal, principally because Occupational Therapy isn't found in the SUS network. (P19)

For the students' insertion into the various professional categories to be effective, one must re-think how the health professionals' training and work processes are structured, organized and operated, and practical pedagogies and learning settings must be incorporated as strategies of change for the different experiences, which influence the choice of new content¹⁵. For this, it is necessary to invest in the interdisciplinary approach, capable of embracing and valuing the specificities of each professional category in health.

In relation to the community impact, the students show in their discourses that the program in question made possible the strengthening of the education and the health care in the community, which facilitates the exchange of knowledge and makes them feel more prepared to face the challenges of the reality when they are professionals:

[...] and for the community, to contribute to the improvement of the health of the people who seek care. The impact is to bring health education to people. For it to improve, it is necessary to implant more public and collective health courses. (P2)

The impact on the community was the guidance for some aspects which are important for quality of life, helping the community to know more about health and their rights. (P14)

In this way, for the students, educational action is understood as a fundamental axis for professional training in health. From this viewpoint, the experiences of outreach in the community constitute spaces for constructing knowledge, getting closer to reality, developing sensitivity and experiencing new ways of caring. University outreach, seen as an educational, cultural and scientific process, articulates the teaching and the research, viabilizing meetings and dialogs between students, lecturers and society, based on a movement of exchange and construction between the knowledges, making possible conceptual innovations and new ways of thinking, knowing and doing¹⁶.

The students also mentioned that the impact on the community of the program in question will take place over the long term, through the integration of professionals with a different attitude, closer to the real context and therefore more qualified to function in health in line with the community's needs:

Nowadays, it is becoming increasingly necessary to learn to work in multidisciplinary groups with a view to training future professionals who know how to interact and cooperate with each other, doctors with nurses, pharmacists, psychologists, so that we can treat the patient in a complete way, rather than just his illness. The course is in alignment with this proposal, it's a slow process, as the majority of students in medicine despise Community Medicine and prefer medical specialities.(P10)

Theoretically, the impact on the community will occur in the future through the training of professionals who know how to work based on the population's needs, and who are capable of articulating strategies as a team which mobilize the service users for effective participation in the concretization of the SUS and of the Health care policies. (P17)

In this way, the students perceive the importance of being inserted in these spaces for practice and discussion during the undergraduate course, with a view to being professionals with a differentiated profile on the job market.

For this new perspective to become real, motivated educators are fundamental, to articulate theory and practice, encouraging the students to experience new contexts of learning, without removing from them the investigation and the questioning through teaching and research activities, the interdisciplinarity, and the participative methodologies^{12 - 17}.

In this regard, the PET-Health offers an opportunity for the students to have training in which they can reflect and act in favor of humanized care and a greater impact on the community, becoming active and critical subjects in their learning process, and thus contributing to the transformation of the context of the training and of the health care.

Learning to act in an interdisciplinary health team

The students who participated in the study also undertook an assessment of the functioning of the teams in which they were inserted, that is, the PET-Health work teams. For the participants, the group has good interaction, as the members have common objectives, such as the undertaking of health care studies and actions in the services involved in the program.

Programs like the PET-Health provide important learning settings in which the multiprofessional team works on the study questions with the participants from the community involved in the projects16. Within the ambit of the outreach actions, it is essential that it should be made possible to have significant experiences, which give the student conditions to reflect on the questions of the day and, based on them and on the knowledge produced, to experience training which is committed to the community's context.

The statements below evidence this assessment from the student regarding the positive interaction to be found between the components of the program:

I think the interaction is one of harmony and mutual help, because everybody is in the process of learning and sharing knowledge and experiences which lead to mutual growth. (P12)

I believe that everybody is interested and disposed to work mutually to try to reduce society's difficulties in general. (P15)

The majority of the tutors, preceptors and monitors are engaged in the program and concerned with its future success. (P16)

The health professionals do not experience, during their training, strategies which articulate their activities and knowledges with those of the other professionals in the team; generally, the learning in which it becomes necessary to share knowledges and spaces with the other professionals following graduation is mentioned as one of the difficult times. The learning often creates extremely conflict-ridden situations in which the individual needs end up prevailing, to the detriment of more qualified care¹⁷.

On the other hand, although the majority of the participants demonstrated in their discourses that the PET-Health team interacts harmoniously and in mutual help, they show that there are flaws in the individual functioning of some members of the team. In the students' view, the preceptors, who are the health care network professionals involved in the program, need to be more dedicated to the knowledge of the projects and to putting into action the actions proposed by the PET-Health:

The tutors are fairly interested, they're dedicated in relation to the PET activities, although they are being very theoretical and not very practical. Some preceptors are very un-interested in the PET. And the monitors are showing interest and concern with the execution of the project and the majority have difficulty in creating a project. (P10)

I see plenty of willingness on the part of the tutors. The majority of the monitors show plenty of interest in the work, but I can't say the same of the preceptors, given that some of them don't know what they do on the Program and don't have much interest in departing from their routine to do something extra for health. (P20)

Analyzing the students' discourses, it stands out that it is fundamental, therefore, that these preceptors should be active elements in the entire process of implementation of the program, from the conception of the proposals through to their carrying-out and continuous evaluation, through team work. The work in the interdisciplinary team makes it possible for one to complement the work of another, both being transformed and prepared for the intervention in the context in which they are integrated¹⁸.

It is necessary to identify in the work teams of programs which bring teaching and work together those elements which indicate a new logic in the acting and in the production of care, given that studies have evidenced the distancing which exists between the teaching proposed by the training institutions and the population's health needs, in addition to the low involvement of some members of these teams.

In this same sense, the participants also indicate interdisciplinary functioning as one of the difficulties faced by the work teams in which, often, the members of particular professional categories act in isolation from the members representing the other courses:

[...] people have difficulty in working in a multiprofessional team because we know it's not easy, as each person has his or her own values and way of thinking, which makes the work difficult. (P19)

The main difficulty is the multidisciplinarity, some courses are still resistant to accommodating others. (P13)

In this regard, the interdisciplinary work in health entails the constant and intense interaction of a set of social actors; principally, a reciprocal relationship of communication and articulation between the members, so as to ensure comprehensive care for the community's health needs¹⁸. For many members of the PET-Health teams, often, it is not easy to "do things together", each one trying to do their part. In addition, the students assess that in some cases the teams suffer from competitiveness, conflicts and hostility between members.

Therefore the great value of the diversity of knowledge and skills among the team members is recognized, it being possible to articulate the actions carried out by the different professional categories to benefit interaction between them, to have ethical commitment, respect for one another and for the community, making the construction of a common project possible^{7 - 15}. In this way, the programs for re-orienting the training must take into account the diversity of the students' characteristics and needs, support and help for the student being essential in applying the knowledge acquired or to be constructed, revealing a relationship of mutual help and cooperation^{7 - 10}. One should note the relevance of the experiences acquired in professional practice for the academic's training for allowing the exchange of experiences which contribute to the learning and make the student stronger for facing the complexity of professional life. For this, the articulation of theory and practice, based on the interaction between student and lecturer, health workers and service users - that is, between the various actors who interact in the setting of the teaching-learning process - is very important.

FINAL CONSIDERATIONS

Through the discussion of the results provided by the study, it was possible to observe that the Program for Education through Work for Health is a facilitative means for seeking the integration of theory and practice among the students, health service and community, which is essential for the re-orientation of training in health.

The Program makes it possible for the students to experience what the professionals experience in their reality, causing critical and reflective thinking, so as to develop critical, active, creative and transformative attitudes.

Because the program has not been running for long, the results anticipated have not yet been achieved, either regarding impact in the places where it is in action, or in professional re-orientation, although positive results are already being obtained, as shown by this study's results.

The results indicate that there are certain limitations such as the difficulty in implanting an interdisciplinary work, not only in the theoretical field, but also in the reality of the health services and in the construction of research projects; this indicates that further, there is the need for greater knowledge of health policies and the guiding principles of the SUS and the PET-Heath project itself on the part of all the members of the work teams.

It is understood that integrating teaching and work still constitutes a big challenge for professionals who often content in their work routines which are grounded in the traditional training paradigms.

In relation to the students, one can perceive that in many cases they are not accustomed to face the routine and the difficulties found in the primary care services, which makes them discover that promoting health encompasses a broad field of knowledges, attitudes and practices.

For the advances and consolidation of the program, it is necessary to widen the areas in which it functions, reaching other communities which are not part of the program, as well as increasing the number of academics, courses which participate, professionals from the service, and city managers, in search of better results.

One should also seek to increase relationships with the PET-Health Programs in other cities, carrying out multicentric projects and strengthening improvement actions for the service and the community. Another advance which is necessary for greater recognition and visibility of the Program is the dissemination of research and successful actions undertaken by the Program in events, journals and the community.

These, therefore, are the efforts which must be made such that the Program may continue to make possible the inter-relation of different knowledges, producing knowledges in articulation with the socio-political, economic and cultural context, obtaining better results and training professionals able to meet the SUS's needs.

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Publication Dates

• Publication in this collection
  Jul-Sep 2013

History

• Received
  10 Aug 2012
• Reviewed
  21 Mar 2013
• Accepted
  02 May 2013