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Ciência & Saúde Coletiva

Print version ISSN 1413-8123On-line version ISSN 1678-4561

Ciênc. saúde coletiva vol.20 no.6 Rio de Janeiro June 2015

https://doi.org/10.1590/1413-81232015206.02102015 

Article

Is it possible to overcome suicidal ideation and suicide attempts? A study of the elderly

Ana Elisa Bastos Figueiredo 1  

Raimunda Magalhães da Silva 2  

Luiza Jane Eyre Souza Vieira 2  

Raimunda Matilde do Nascimento Mangas 1  

Girliani Silva de Sousa 3  

Jarlideire Soares Freitas 4  

Marta Conte 5  

Everton Botelho Sougey 3  

1Centro Latino-Americano de Estudos sobre Violência e Saúde Jorge Carelli, Escola Nacional de Saúde Pública, Fiocruz. Av. Brasil 4036/700, Manguinhos. 21040-361 Rio de Janeiro RJ Brasil. aebfigueiredo@yahoo.com.br

2Programa de Pós-Graduação em Saúde Coletiva, Universidade de Fortaleza (Unifor)

3Programa de Pós-Graduação em Neuropsiquiatria e Ciências do Comportamento, Universidade Federal de Pernambuco

4Centro de Ciências da Saúde, Unifor

5Secretaria de Estado da Saúde do Rio Grande do Sul


ABSTRACT

This study presents a qualitative analysis of how older people who had attempted suicide began to overcome the desire and the urge to take their own life. This article is based on a survey of 87 Brazilian men and women aged 60 and over, living in different regions of Brazil, who have demonstrated suicidal behaviour; twenty of whom gave important information about their coping strategies. The analysis in this article only refers to the aforementioned twenty participants. All the participants were heard through semi-structured interviews, which included questions about the process of overcoming suicidal ideation and suicide attempts. The central focus of the analysis - overcoming suicidal ideation and suicide attempts - was based on the following concepts: coping strategies, autonomy, and emotional balance. Irrespective of the gender of the respondents, five centers of meaning emerged from the discourses of the elderly, which highlighted the effectiveness of the following factors: religiosity and religious practices; social and family support; the support of health services; contact with pets; and the recovery of the autonomy to manage their own lives. This study can help to support the primary and secondary prevention of suicidal behavior in older people.

Key words: Suicide attempt; Suicidal ideation; Elderly; Overcome

RESUMO

Este estudo apresenta uma análise qualitativa sobre como idosos que tentaram suicídio passaram a superar o desejo e o impulso de tirar a própria vida. Faz parte de uma pesquisa com 87 homens e mulheres brasileiros de 60 anos ou mais, residentes em várias regiões do país e com comportamento suicida, dos quais 20 deram pistas importantes sobre suas estratégias de enfrentamento (coping). A análise aqui realizada se refere apenas a esses últimos. Todos foram ouvidos por meio de entrevistas semiestruturadas, que incluíam em seu escopo perguntas sobre o processo de superação das ideações e tentativas. O foco central da análise – superação – se apoiou nos seguintes conceitos: estratégias de enfrentamento (coping), autonomia e equilíbrio emocional. E da fala dos idosos emergiram cinco núcleos de sentido que ressaltam a efetividade dos seguintes elementos, independentemente do sexo dos entrevistados: religiosidade e práticas religiosas; apoio social e familiar; suporte dos serviços de saúde; contato com animais de estimação; e retomada da autonomia para gerir a própria vida. Este estudo pode subsidiar a prevenção primária e secundária dos comportamentos suicidas em pessoas idosas.

Palavras-Chave: Tentativa de suicídio; Ideação suicida; Idoso; Superação

Introduction

This study seeks to answer the following questions: what were the strategies developed by elderly people to overcome suicidal behavior, both those admitted to long-stay institutions and those attended by the health services? How are they able to re-assess the suffering and the feeling of hopelessness that led to their desire or attempt to kill themselves?

The idea of overcoming is understood in this article as an intentional act of an individual that mobilizes internal defense resources and ways of coping with everyday threats, thereby representing a subjective and contextual self-readjustment1.

Aging is a single, unique and special experience for each individual. The aging process is continuous and promotes a progressive decline in physiological functions that reduces the organic and functional capacity of the elderly2.

In addition, other changes happen at this stage of life, such as the loss of autonomy, dependency on others concerning the activities of daily living, changes in family dynamics and income, retirement and the loss of important people, all of which can cause feelings of sadness and loss3,4.

These changes can be positive or negative depending on the interpretation that each elderly person assigns to events in their life, which are influenced by psychological, emotional, social and cultural factors, the outcome of which can be, for most elderly people, suicidal ideation or attempted suicide.

In research conducted on the suicide of elderly people in Brazil5, the accounts of family members reveal struggles against badly adapted schemes6 such as: discipline, lack of love, control, guilt and the deprivation of desire, which prevent the elderly from performing enjoyable activities and which contribute to undermining their lives7. However, within this universe of loss and restrictions some elderly people are able to overcome vulnerability to suicide and choose to live and reframe their existence. The idea of overcoming is understood as a deliberation containing multidimensional characteristics: it is perceived by people who experience striking situations, such as a possible act of self-recognition and finding solutions to the problems6 of everyday life that are reflected in subjectivity.

Thus, adaptive and coping resources are mobilized, configuring what is referred to in the literature as ‘resilience’, a term derived from physics that relates to the ability of materials to withstand certain impacts. This term has been adopted by the fields of human and social sciences to refer to the ability of individuals to endure adversity, to overcome difficulties and to rebuild their lives, often in a richer and more complex manner6,8.

Recognized as a challenge to contemporaneity, and permeating many areas of knowledge, suicidal ideation, suicide attempts and suicide itself are all closely linked9. Suicidal ideation refers to thoughts, utterances and attitudes that show the interest of an individual in ending their own life; this can be in the form of a desire for suicide or plans to commit suicide, not necessarily the implementation of the act itself. Suicide attempts are characterized as deliberate self-destructive acts that fail to achieve their goal10.

The American Society of Suicidology reported that in 2012 there was one death for every twenty-five suicide attempts in the USA. Among the elderly, this proportion reached the ratio of one death for every four attempts11. It is still difficult to specify the occurrence of suicidal ideation due to the complexity and controversy surrounding this phenomenon12. The literature on the subject has estimated that 60% of those who have committed suicide had some previous manifestation of suicidal ideation12,13.

In a study conducted in Campinas (SP), Brazil by a subgroup of the Estudo Multicêntrico de Intervenção no Comportamento Suicida (SUPRE-MISS - Multisite Study on Intervention in Suicidal Behavior), of the World Health Organization, involving eight countries and attended by 10,641 people aged 14 – 60 or over (13.8% aged over 60), 16% reported having had suicidal thoughts during their lives. Of these, 12% had attempted suicide a year later12,13.

The elderly are more vulnerable to self-destructive attitudes and it is essential to identify protective factors that can allow them to overcome the feelings of suffering and hopelessness that can lead to self-inflicted death. In this study, it is the elderly themselves who indicate possible paths to avoid this eventuality. It is hoped that this study will provide support for the health sector in terms of preventive actions, particularly in the organization of primary care and mental health, as these areas of care offer possibilities to encourage the independence of older people and to promote adaptive modes with a positive perspective.

Methodological approach

This study emphasizes the need to provide spaces in which to hear the voices of the elderly, in order to understand the contextualization of the underlying meanings attributed to their experiences that are related to suicidal ideation and suicide attempts, thereby allowing them to narrate their life stories and to link the past, present and the future. By paying attention to the elderly and listening sensitively to their stories, this study seeks to provide a form of objectification that consider opinions, values and beliefs, as well as forms of human thinking, feeling, relating and acting in relation to the experiences and the significance of experiences, which make human beings historical beings14,15.

Eighty-seven (87) elderly people participated in the survey matrix, “Study of suicide attempts in the elderly from the perspective of public health”, which was performed by the Centro Latino-Americano de Estudos sobre Violência e Saúde Jorge Careli (CLAVES - Jorge Careli Latin American Center for Studies on Violence and Health), ENSP, Fiocruz, RJ, Brazil. This article analyzes the cases of twenty of those elderly people who had a history of suicidal ideation or suicide attempts after the age of 60 in nine municipalities (Teresina, Fortaleza, Recife, Rio de Janeiro, Campos dos Goytacazes, Manaus, Dourados, Candelária and Santa Cruz do Sul) which have high suicide mortality rates in this age group.

Considering that the desire for death is a subjective process involving positive and negative factors and experiences, it is not possible to state that these twenty elderly people definitely overcame this desire; however, at the time the interviews were conducted, they showed a positive attitude to life, despite the many problems that they faced.

The case studies were selected with the help of health service professionals at long-stay institutions for the elderly, and the Fire Department. Although it was not the intention of this article to analyze differences in coping skills in relation to suicidal ideation and suicide attempts among institutionalized elderly people and the elderly living with their families, it is worth noting that some of the elderly people were receptive to the institutional environment, as will be subsequently described. Differently to what we expected, in these cases the institutional experience was a protective factor in relation to suicidal ideation and suicide attempts.

The elderly people who were unable to relate their stories coherently because of memory impairment, confusion, delusions or hallucinations, as well as those who refused to participate in the interviews, were respected for their decisions in accordance with the ethical principles of research involving human beings.

The instrument used for data collection was semi-structured interviews, with a qualitative approach, from a script with issues that had been previously established by researchers. These questions included how those who were interviewed had survived suicide attempts and how they managed to overcome the desire for death. The empirical categories analyzed in this article emerged when the data was analyzed. The interviews took place in the homes of the elderly in the long-stay institutions and accommodation provided by the health services, in order to provide the necessary comfort and privacy. These interviews were carried out from November 2013 to July 2014 and the elderly people who agreed to participate signed informed consent forms.

Folkman's analysis of coping16 was used for the theoretical foundation and the organization and analysis of the reports. Coping is defined as a group of subjective, cognitive and behavioral efforts directed towards the management of internal or external requirements or demands, which are assessed as posing a threat to the quality of personal life, and which are mediated by cognitive responses17,18.

Coping strategies are classified into two types: the first is based on emotions and aims to change the emotional state of the individual, seeking to reduce the unpleasant sensations arising from the stresses of life; the second focuses on problems and aims to direct internal and external actions to modify existing difficulties, and to improve the relationships between people and their social and cultural environment.

All twenty interviews were analyzed in depth. A perspective was adopted which articulated the reports provided by the elderly, incorporating the peculiarities of their socio-cultural environments, the comprehensive and interpretive inferences of the researchers, and a discussion of the findings in relation to the literature on the subject. This comprised the central outcome of the study - overcoming – which was organized into the following conceptual categories: coping strategies, autonomy, and emotional balance. Out of these conceptual categories, the following centers of meaning were established in accordance with the reports of the respondents: religiosity and religious practices; social and family support; support from the health services; contact with pets; and the resumption of the autonomy to manage their own lives.

The research project on which this article is based was approved by the Research Ethics Committee of the Oswaldo Cruz Foundation (CEP/ ENSP).

Results and Discussion

Coping strategies

The common thread of the analysis of the interviews was the strategies used by the elderly to cope with the stress factors that culminated in a sense of hopelessness, and its intrinsic relationship with the wish to die. The narratives revealed clues that made it possible to understand how humans can handle internal and external forces to overcome suicidal behavior.

Several authors have concluded that coping strategies are an important variable in dealing with depression in the elderly, which is often associated with suicidal behavior19, because people in a depressed state lose their capacity to cope with stress factors, in comparison with those who do not have such a symptomatology 20.

1. Religiosity and religious practices

The elderly often commit suicide due to feelings of intolerable pain, self-devaluation, isolation, hopelessness associated with frustration, the loss of affection, the inability to perform daily tasks, and unsatisfactory family and social support. These factors are almost always combined21.

In his study of suicide, Durkheim22 notes that reflective practice on the meaning of life only develops when there is a real need, i.e. when ideas and feelings are disorganized to the point that they produce a void in human existence. This void may represent either a withdrawal, or a change that makes the human being stronger and more resistant.

Concerning these strategies, the literature23,24 points to positive associations between the religious dimension and the ability to cope with crisis situations. In other words, religiosity offers protection, comfort and answers in the face of the adversities of life, as well as creating opportunities to share and interact with others, for example in shared communal events, rituals and prayers. Religious attitudes re-orientate identity markers, allowing the individual to live in a zone of comfort and familiarity, from the subjective point of view1.

In the present study, the support of religion (Catholic, evangelical or spiritualist) was mentioned as being fundamental to the ability to overcome suicidal thoughts. The institutions of ‘churches, ritual spaces and temples’ appeared in the testimonies of the elderly as places to renovate and reframe their lives, not only for the doctrinal principles that are preached there, but also, and mainly, because they become environments where new relationships, companionships and occupations can be found that which offer a way to ‘fill time’ and take people out of the places that bring them suffering. From the perspective of the respondents, belonging to a religious group means feeling useful, to be alive, to have the opportunity to speak and to be heard, to share anxieties with others, to practise physical activities, and to exercise a sense of belonging and purpose in life.

One of those who were interviewed, a man aged 60 from Rio de Janeiro commented: In the Spiritist Center I participated in the reading workshops, I started attending and then I woke up. I learned a lot of things late on. But I learned. I can say that I learned. The group to which he belonged carry out activities that go beyond religious practices and they are combined with reflective activities, which are crucial for dealing with stressful situations, such as functional and affective losses (physical, mental, family and financial) that are known to be factors associated with the risk of suicide25.

Another interviewee, a 74 year-old man from Rio de Janeiro, said that he frequently contemplated suicide until the moment he joined the Catholic Church. He stated that his relationship with God gave him support and protection and that it a restraining effect on him in relation to suicidal thoughts: It was not me who gave me life. It was him who gave it to me (referring to God). So it is he who has the right to take my life. So I have to wait until the time that he decides.

A relationship with God was often referred to in the interviews with the interviewees, regardless of their association with religious beliefs or practices. Many stated that they believed in a “divine being” that they should obey and respect, and who had protected them in times of deep despair. However, although some were not affiliated to any religion, they possessed a spirituality that gave them comfort. This was the case of a 71 year-old woman from Recife: I believe that God is in our hearts and that's the most important thing in my life, he knows our hearts.

It is worth clarifying that we sought to understand religious attitudes and faith in God as presented in the narratives of the interviewees. Therefore, one of the limitations of this study relates to discussions about religious interventions in the health care of elderly people at risk of suicide, which would need to be further assessed by health professionals. However, it is important to make it clear that “every time the intolerability of the experience of living with intense and continuous suffering becomes empty of meaning, it requires a reconstruction, which can result in success or failure; however, it is always a mode of re-appropriation, albeit subversive, in relation to scientific discourse”1.

A key point expressed in the narratives of the elderly was the ambivalent coexistence of the desire to die and the will to live. It is within this context that faith influences the control of emotions and behaviors, functioning as a factor of comfort and protection. Studies have shown that individuals who maintain a belief, and practice any type of religion, have lower levels of suicidal ideation and behavior in relation to those who do not24,26.

2. Social and family support

Another important aspect in terms of facing and overcoming suicidal ideation and suicide attempts that was observed in the statements of the elderly was social and family support. Family support is the protection provided by family members who show understanding, empathy and the encouragement of positive experiences for older people. Social support refers to the attitudes and actions of emotional, instrumental and material support offered by institutions and social and health workers, or by members of the community, in order to keep elderly people independent and active. From this point of view, “people who have healthy social networks are more resistant (…) but it is the quality of relationships that seems to be most important, not simply the quantity”27.

In relation to emotionally positive interpersonal exchanges, social and family support gives the elderly a sense of a rehabilitating psychosocial experience, and it was clear from their interviews that this support was fundamental in overcoming suicidal ideation and suicide attempts. This was evident from an interview with a 71 year-old woman from Recife: My children won't let me be alone; to this day, I am never alone. This elderly woman lost two family members in the period of one year, which led to her to want to die. This was soon noticed by her children, who made changes in the family dynamics and this allowed the woman to restructure herself emotionally. As Durkheim22 observed, the more intense the emotional ties with family members, the more that people will be linked to life. The strength of this bond is mainly related to the appreciation of affective relationships and not simply material support. Studies have stressed that one of the means to prevent the suicide of the elderly is to restrict their access to the means to end their life28,29. In the case of the aforementioned elderly woman, the presence of her children was crucial in preventing her from planning a new suicide attempt.

Some of the elderly mentioned their concern about their family and the fear that their absence would leave their children and grandchildren in a difficult situation; they cited this as a factor that stopped them from killing themselves. These sentiments were clear in an interview with a 63 yearold woman from Teresina: Thinking about these three children [her grandchildren] helped me. Her husband [her daughter's husband] died, so she really needs me. She works and I take care of the house. I'm taking care of my three grandchildren.

Social support can range from making the elderly feel welcome, to institutional care. Friendships are significant elements in situations where suicide may be attempted, as well as specific care provisions that have been developed by the World Health Organization. Barnes30 studied informal, formal, family and extra-family social networks and mentions the importance of extra-family social ties in everyday life. Although many elderly people feel excluded and misunderstood by their families, it is possible for them to receive the support from their friends that they need to continue their lives and achieve their goals. Therefore, the cultivation of these relationships is seen as an important protective factor against suicidal ideation, suicide attempts and suicide itself28,31. This was reflected in an interview with a 68 year-old man from Campos de Goytacazes, for whom the presence of friends proved to be fundamental. He felt that he was loved and supported by people who no longer formed part of his daily life, but who appreciated him and this supported the care that he received from his family: I had many friends where I worked. They all liked me. When I had that bad depression they visited me, they came from work to see me.

The importance of friendship and companionship were also highlighted by elderly people living in Instituições de Longa Permanência para Idosos (ILPI - long-stay institutions for the elderly), where they were able to create new affective ties that gave them real emotional support, particularly when family members were absent.

Listening to other people minimizes the need to only listen to themselves and awakens in the elderly an understanding of their own value and usefulness, thereby allowing them to reconstruct a positive self-image. A 60 year-old man who was living in an ILPI in Rio de Janeiro made the following comment: I feel the need to be here [ILPI], with people talking, listening. They are always telling their stories! Because then I'm thinking of someone else's problems and not mine.

The literature still has little information with regard to the existence of higher or lower risks of suicide among elderly people living in ILPIs, compared to those who live with their families. It is important to note that residents in such institutions have several stories relating to their affective losses. Sometimes their children leave them to the care of others, thereby removing them from important affections in the last phase of their lives. However, many elderly people are given a renewed meaning to their existence when they are able to give new impetus to their relations, creating links with other residents and often turning them into friends.

3. The support of health services

The treatment offered by health services was also quoted by the elderly interviewees as an important factor. The National Mental Health Policy32 stresses that Centros de Atenção Psicossocial (CAPS – Psychosocial Care Centers) are the appropriate spaces to conduct comprehensive care for people with intense psychic suffering and the desire to die. The importance of these centers was underlined in an interview with a 63 year-old woman from Candelária: One thing that helped me was this doctor; the important thing was that he gave me medicine. If it wasn't for the CAPS I wouldn't be here now. Or in an interview with a 67 year-old man, also from Candelária who referred to the medical treatment he received: I began to have hopes of getting better again, I was no longer believing that this [health condition] was going to change, and then, when I began to improve, I forced myself to look after myself and take my medicine on time.

The cure of diseases, or treatments that can improve their quality of life, stand out as important factors for the elderly in recovering their desire to live and to overcome suicidal ideation. Improvements in their health contribute to the elderly being able to think about new life projects, which is critical to keep them active and with good self-esteem: The truth is that the return of my vision was a great thing. And they operated on the other eye, I start writing my book in early February (Man, 71, from Fortaleza).

In relation to health care and social assistance it is important to note that “an effective program must meet the needs of every elderly person and cover the various components of their life, such as health, education, social interactions and living conditions, providing relevant services that reduce their risk of suffering violence or of harming themselves”33.

4. Contact with pets

An important finding of this study relates to contact with pets. Living with animals was one of the alternatives that were considered as a relevant interaction, especially when the elderly lived with them as if they were family members. The emotional attachment of an elderly person who has suicidal behavior with any pets facilitates their ability to overcome the desire to kill themselves: What distracts me are these dogs. Sometimes I think about leaving, but I think about these dogs. Who will give food to them? They will starve (Man, 66, from Manaus).

In the face of family estrangement and loneliness, which are characteristics of the condition of the elderly, attachment to pets represents a resumption of their functional capacity – taking care of something and not just being cared for, as the elderly man mentioned in the extract above – the feeling of being useful and loved. Besides providing a sense of belonging and affection, animals help to fill time. As Costa34 states: “A pet can provide a more harmonious, attractive and dynamic life. [It can] give value to the skills, competencies, knowledge and culture of the elderly, increasing their self-esteem and self-confidence, giving importance to the interests, motivations and benefits that pets can offer, as well as basic animal care: feeding, hygiene, immunization and diseases that are communicable to humans.” Suthers-McCabe35 considers that the relationship between individuals and animals is perhaps more intense and profound in old age than at any other time of life. According to Costa et al.36 the interaction between humans and animals is of a beneficial and dynamic character in that it includes not only the company provided by animals, but also the exchange of emotional, psychological and physical experiences between people.

5. Recovery of autonomy

The autonomy to make decisions about everyday life, about their property and about their own lives, was indicated by the elderly as giving meaning to their lives, which are often constrained by orders and decisions taken by their families. These restrictions are part of the circumstances that have acted for some as a trigger to the desire to die37,38. A 71 year-old woman from Recife, who is quoted below, felt too intimidated to perform household activities because of a family member with whom she lived and who considered her to be incapable: I can say that I've changed. I moved house and now my life has meaning. Now I have space to do my things, take care of my house, make my food the way I like it. This resumption of control of her life brings with it a sense of pleasure and the possibility of projection into the future.

The issue of financial autonomy was touched upon in an interview with a 63 year-old woman from Teresina: I learned to embroider and when I see people buying it I think that if I had died and had not learned I would not be earning money today. The resumption of pleasurable activities was reported by a 73 year-old man from Rio de Janeiro, who was producing a newspaper in the long-stay institution where he lives. This activity revived the writer and poet in him and made him feel useful: When I got here, we founded a newspaper - The Shelter. Through this paper we began to help the elderly.

Filling time with activities that mobilize subjective and social resources, or pleasant thoughts, is part of the reconquest of autonomy and the ability to make decisions, which allow the elderly to shift the focus of attention from the discomfort and discontent represented by their problems towards new life projects and expanding their subjective time and their social resources1.

Final considerations

At the end of this study our conclusions are as follows:

  1. Suicidal ideation and suicide attempts among the elderly are important issues that require further study. It is estimated that suicidal behavior (ideation, thoughts and attempts) are up to four times higher than the numbers of suicides registered in Brazil, which represents a serious public health problem. However, the most severe cases come to the attention of the health services and are notified.

  2. The health services, which are intended, among others, to serve the elderly population with suicidal behavior, need greater investment in terms of public power. The majority of the population over 60 is healthy and active, but in this study we are referring to a group that is experiencing intense suffering, i.e. the elderly who have suicidal ideation or who attempt suicide. In relation to comprehensive care for the elderly, it is necessary to improve that care by integrating sectors such as health (residential care, therapeutic care, primary care, CAPS, access to medicine, etc.), housing, security, continuing education, among others, so that policies are more integrated in order to provide comprehensive care for the elderly39.

  3. Religiosity and religious practices were effective defense mechanisms in relation to suicidal ideation and suicide attempts in some of the cases that were studied because they provided the elderly with feelings of security and belonging to communities that carry out interactive activities.

  4. Social and family support is key in overcoming suicidal ideation and suicide attempts in older people because the strengthening of affective ties help to rebalance their vital energies.

  5. The recovery of the autonomy to perform daily activities, administer their assets and perform creative activities were cited by some of the elderly (who did not have incapacitating dependencies but who were hindered by family members and institutional rules) as being effective in increasing their ability to cope with the difficulties of life and to prevent suicidal behavior.

  6. When the inability to want to live is present, coping strategies - which typically complement each other - should be encouraged by caregivers and professionals in the fields of social welfare and health in order to provide primary and secondary prevention.

  7. Although the elderly people who were interviewed did not specifically mention primary care as a health initiative that would provide a solution for their pain and suffering, we believe that actions aimed at health promotion are of importance because they have an impact on the quality of life.

As Buss40 points out, “It is vital to integrate the programmatic agendas of the Family Health Strategy and other bodies of the Ministry of Health that develop health promotion programs in order to streamline efforts and to give cohesion to the expansion of comprehensive primary care work that has been done until now.” Or, as Minayo and Cavalcante4 observe, “it is necessary to invest in training professionals who are able to understand and diagnose what drives a person to try to kill themselves and who can help them overcome hopelessness.”

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Received: March 05, 2015; Revised: March 25, 2015; Accepted: March 27, 2015

Collaborations

AEB Figueiredo, RM Silva, LJES Vieira, RMN Mangas, GS Sousa, JS Freitas and M Conte participated in designing the theme of the article, data collection, analysis of the interviews and drafting of the text. EB Sergey participated in drafting the text.

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