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Escola Anna Nery

Print version ISSN 1414-8145

Esc. Anna Nery vol.18 no.4 Rio de Janeiro Oct./Dec. 2014

http://dx.doi.org/10.5935/1414-8145.20140086 

RESEARCH

The man in primary healthcare: perceptions of nurses about the implications of gender in health

Grayce Alencar Albuquerque1 

Mônica Fonseca Leite1 

Jameson Moreira Belém1 

Jeane Fonsêca Cavalcanti Nunes1 

Marcelo Alves de Oliveira1 

Fernando Adami2 

1Faculty of Juazeiro do Norte. Juazeiro do Norte - CE, Brazil.

2Faculty of Medicine of ABC. Santo André - SP, Brazil.


ABSTRACT

Objective:

To understand the perceptions of nurses about the implications of gender on man health and in the provision of services to this public.

Methods:

Qualitative research conducted with 10 nurses inserted on Primary Care in the municipality of Juazeiro do Norte - CE, through the adoption of semi-structured interviews. The obtained speeches were categorized and analyzed through literature.

Results:

According to the nurses perception, there is little demand of male health services, due to the socialization of gender and deficit in the organization of services, with low professional qualification, since highlight they had not received training.

Conclusion:

There are fragilities in the performance of health services before the male public. Thus, the management support becomes essential, in the structuring of services and professional training for the introduction of a differentiated care, in the gender perspective.

Key words: Men's Health; Nursing; Primary Health Care; Gender and Health

RESUMO

Objetivo:

Compreender a percepção de enfermeiros sobre as implicações das questões de gênero na saúde do homem e na oferta de serviços a este público.

Métodos:

Pesquisa qualitativa, realizada com 10 enfermeiros inseridos na Atenção Básica do município de Juazeiro do Norte - CE, através da adoção de entrevistas semiestruturadas. Os discursos obtidos foram categorizados e analisados por meio da literatura pertinente.

Resultados:

Segundo percepção dos enfermeiros, existe pouca demanda do segmento masculino aos serviços de saúde, em decorrência da socialização do gênero e do déficit na organização dos serviços, com baixa qualificação profissional, já que ressaltam não terem recebido capacitações.

Conclusão:

Existem fragilidades na atuação dos serviços de saúde perante o público masculino. Assim, torna-se imprescindível o apoio da gestão na estruturação dos serviços e na capacitação dos profissionais para a introdução de um cuidado diferenciado, na perspectiva de gênero.

Palavras-Chave: Saúde do Homem; Enfermagem; Atenção Primária à Saúde; Gênero e Saúde

RESUMEN

Objetivo:

Comprender las percepciones de las enfermeras sobre las implicaciones de género en la salud humana y la prestación de servicios a este público.

Métodos:

Investigación cualitativa realizada con 10 enfermeros de la Atención Primaria en el municipio de Juazeiro do Norte - CE, a través de la adopción de entrevistas semiestructuradas. Los discursos fueron clasificados y analizados a través de la literatura.

Resultados:

Según la percepción de las enfermeras, hay poca demanda masculina de servicios médicos, debido a la socialización de género y el déficit en la organización de los servicios, con el segmento de baja calificación, ya que resaltan que no habían recibido capacitación.

Conclusión:

Existen debilidades en el desempeño de los servicios de salud delante de la audiencia masculina. Es esencial el apoyo de la gestión en la estructuración de los servicios y la formación profesional para la introducción de un cuidado diferenciado, en la perspectiva de género.

Palabras-clave: Salud del Hombre; Enfermería; Atención Primaria de Salud; Género y salud

INTRODUCTION

In recent decades several studies have been outlined, around the relationship of men and health, approaching gender issues to understand how they influence male behavior and how the social construction of different masculinities, affects the health of adolescents, adults and elderly men.

In the international and national literature, when it seeks to reflect about the theme "man and health" it is necessary to consider that in general, men are more affected by severe and chronic health conditions than women. Moreover, the construction of masculinity and commitment of human health are directly related, since they must be seen from the relational perspective of gender1.

Health indicators have clearly shown that male mortality is higher in almost all ages and almost all of the causes, being the most important neoplasms and external causes2.

The men, therefore, have a greater predisposition and vulnerability to acquiring diseases than women, due to greater exposure to cultural and behavioral risk factors permeated by gender stereotypes, that devalue prevention practices and health care, raising in men's, the vulnerability to injuries as a result of not looking for the services.

In this context, the professional nurse as a member of the multidisciplinary health care team and the Family Health Strategy (FHS), considered the gateway to the health system, present a prominent role, acting through the adoption of health care, preventive, and health promotion practices. In this sense, it is for this professional to develop with the male public, a healthcare and attractive preventive approach, based on the completeness and humanization of care.

Thus, from these considerations and with the relevance of the theme in question, by the growing discourse about human health, this study aimed to understand the perceptions of nurses about the implications of gender on man health and the provision of services to this public.

It is pointed out as relevant to problematize man health assistance from the perspective of gender, since health care practices, directed to these public, must take into account the insertion of the male population in a sociocultural and historical context that is specific to them.

Thus, it is expected that the results of the research can subsidize the debate for the re-suitability of services and actions of nurses in the FHS, in front of inherent demands to Men's Health, so that may contribute to the reflection about the care of this professional to the male clientele, as well as, provide the direction of strategies for successful implementation and effectiveness of the National Policy of Integral Attention to Men's Health (PNAISH) for health services

MATERIALS AND METHODS

This is a descriptive study with qualitative approach, conducted with 10 nurses from the FHS, of both sexes, with a predominance of females (n = 08), aged between 24 and 39 years (average of 31 years) and time approximately 07 years of experience in the FHS located in Juazeiro do Norte - CE.

The insertion of the nurses in the study was linked to the fixation of these in FHS that were in regular operation and located in the urban area. From a total of 66 FHS, only 56 met these criteria. Thus, for the selection of FHS able to integrate the research field, of a total of 56 units, the adoption of the technique of simple random sampling was opted, which defined the FHS, by classification order, that would be visited in order to invite nurses to participate in the research.

Thus, after selecting each health unit through sampling technique, proceeded to the contact of the researchers and nurses inserted in the same, in the period August-September 2013. It was adopted as criteria for inclusion of nurses in the study, the existence of regularized registration at the Regional Nursing Council (RENCO) and a minimum of one year performance in Primary Care.

During the contact, the nurses were informed about the purpose of the research, methodology and relevance of the study and invited to collaborate with its development by signing the Informed Consent Form (ICF). It is emphasized that only after effective data collection, it was proceeded to the contact between researchers and nurses from other selected FHS, until identify the saturation point of the subjects' speech, in line with the guidelines for conducting qualitative research, which occurred during the inclusion of the 10th participant.

Data collection took place by means of a semistructured interview, previously validated after applying a pre-test. The interviews were recorded with permission of the participants. After, were transcribed and organized according to qualitative content analysis of Bardin, operationalized in three steps, namely: pre-analysis (first stage); exploration of the material (second stage); and treatment of the results and interpretation (third stage)3.

The research was submitted to the Ethics Committee in Research of the Faculty of Juazeiro do Norte (FJN) and was approved under Opinion No. 453 273. The study ensured the anonymity of the participants and the information were used only for scientific purposes, attending to the ethical principles established in Resolution 466/12 of the National Health Council (NHC), which regulates the researches involving human beings (BRAZIL, 2012).

RESULTS AND DISCUSSION

Aiming a better understanding of the obtained empirical data, an interpretive synthesis was structured, corroborated with the literature, which revealed four categories, presented and discussed below.

Meanings attributed to male being

It is understood that gender is a term used to indicate the features socially constructed that constitute the definition of male an female being in different cultures and2 denotes power relations between sexes4.

The construction and socialization of the concept about "man being" follow from a multiplicity of social and cultural conventions permeated by gender stereotypes, reinforcing the hegemonic ideology of masculinity. This fact can be evidenced in the discourse of the subjects in the research, which characterized the man being as invulnerable, provider, reproductive and leader.

In the historical context is the representative of the family, is the figure of greatest respect, that represents the support of the family, that represents the idea of family values (Nur. 07).

It is a complex, sexist, competitive individual, it is considered invulnerable, that can everything, unreachable (Nur. 01).

Is who acts with reason, that is not swayed by feelings, have initiative and more freedom to impose their sexual desires (Nur. 06).

Thus, the man is recognized as a strong, confident, active, fearless, determined, realizer, independent, objective, pragmatic, rational, emotionally balanced, professionally competent, financially successful and sexually impositive5.

These definitions reflect a social and historical construction of the "man being" and the presence of strong gender stereotypes, still rooted in a culture that assigns values, behaviors, roles and different spaces to be occupied by men and women in society. Such behaviors would be constructed from the naturalization of differences between men and women, and established by various social segments, being seized during the learning process and reproduced as natural truths within personal and social relationships6.

In these relationships, therefore, it is possible to recognize that the way as how these truths are pervaded and reproduced, favor greater male vulnerability to several factors that predispose to morbidity, because the process of socialization leads men to assimilate and adopt behaviors based on the belief of invulnerability, and towards constant affirmation of a strong and virile masculine identity.

In the same perspective, the extended perception of health professionals about the relationship between gender and man health, favors the knowledge of more complex dimensions of the male population, facilitating the recognition of their personal and social barriers relating to the care and valorization of health, thus reflecting in an integral care, as identified by the following speech:

(...) he often comes with a complaint that behind has several other related factors, sometimes, if you just holds on the pathology that he has and not see him as an integral body, slightly hampers. Therefore, is good to know the insertion of this subject in society, knowing that despite the hard way, being rebel, needs care also as a woman, that sometimes comes already crying, right? You hear what he says and what is happening around, will offer clues to a more accurate diagnosis. The question is not treating the disease, is to identify the cause and eliminate it and with the man this is very subjective and sometimes goes unnoticed (Nur. 01).

In this sense, it is realized the need and importance of promoting a holistic service to man, to consider the heterogeneity and construction of different meanings of their being, that explores the life context of the individual, not just treating the patient as a sick body, but to identify the root causes that led him to seek assistance.

In the NPIAMH proposal, the integrality of care proposes that the understanding of health disorders across the male population, consider the complexity of lifestyles and social status of the individual, in order to promote systemic interventions covering and including social determinations about health and disease, in addition to the adoption of medical and biological measures7.

Given the above, one realizes that it is necessary to know the gender issues and how they socially shape the representations of masculinity, because each individual has a theoretical and conceptual perspective about these issues, based on their own reality and within the reality that they act. Understanding how this discourse is reproduced and articulated by professionals within the health services, constitutes the first step to dealing with problems arising from the differences constructed between men and women across the services.

Gender issues and man health: Implications on care and in the search for assistance

Discussing the panorama of morbidity and mortality in Brazil, health indicators have clearly shown that male mortality is higher in almost all ages and for almost all causes2. Nevertheless, men seek health services only in situations of manifest disease, valorizing the healing practices and failing to recognize the importance and necessity of prevention actions or health promotion8.

Although currently is perceived a progressive and significant change in the attitudes of men towards demands for health services, there is still some resistance to the demand of services, especially in the popular lower layers, where cultural traits are striking and access to health information, limited.

Therefore, this category presents and discusses how nurses perceive the differences between men and women with regard to the needs and health care. The speeches have questions regarding physiological, cultural and moral aspects that fix as differences between men and women in how they understand their health.

A woman goes through a cycle, which makes her worry more, pregnancy, family planning, child care, the postpartum period. There are phases, events in the life of the woman that she has by necessity of what she's going through, need to care for her normal physiological part, it's okay (Nur. 01).

Many are careless, does not value, does not go to the doctor, only when are feeling something, this prevention with them is complicated, not all, but largely because of their own machismo (...) It is a fact, is machismo, 'I am a man, I can everything, I'm just going to the last'. Is this, and sometimes it is also educational issue (Nur. 05).

The man was not polite to expose and talk about him to a woman or to another man. This makes him feel intimidated, that his pose of strong male and bully is threatened, right? He fears to have their weak points discovered, having his personality "reduced" to the personality of the woman who is sensitive, is careful, concerned about her health and body. And many are embarrassed or afraid to discover disease (Nur. 06).

I see that most of the time they do not want to go because they have fear of the diagnosis or procedure that will be done, to stay in hospital, taking injectable medication and only seeks when they can not postpone it (Nur. 04).

The little presence of the men in FHS is remarkable, since they only seek it in situations of manifest disease. The social imaginary of ideal masculinity, inhibits the practice of preventive care, this being delayed or rejected.

Another factor observed in the speech is that the absence of men in health services is related to fear of diseases discovery and instituted therapeutic procedures. Such situation can have connotations related to the consequences of the disease about the body and the confrontation with masculinity, associating the illness with fragility, because the disease is considered a sign of fragility that men do not understand inherent to their own socio-psychical and biological condition7.

Thus, the assertion of masculinity passes constantly by the need to assume characteristics and patterns behaviors that make them to be recognized as men, such as not manifestation of fears, typical of a female representation.

In the female socialization, physiological conditions enabled the presentation and manipulation of the woman's body, were seen as more natural than man, causing the passive condition of the patient could be perceived as something that confronts the idea of male, i.e., there may be a perception that the male is feminized to be treated as passive9.

Thus, the construction of masculinities, by establishing themselves in opposition to the feminine universe, oppose to behavior based on health care. Therefore, it is admitted that the demand for assistance is not preventive, aimed at self-care.

He only seeks assistance when in fact that pain, that event of illness is affecting his productivity at work or in his daily actions, but the man has no appreciation for the care and the woman have (Nur. 07).

For other services only comes when they are required, until to work, when the company requires updating vaccination records, admission exams and certificates (Nur. 04).

Such speeches refer to the construction of masculine identity associated with the work process, entering the man in society as provider and head of family, being these striking characteristics attributed to the man, who from childhood is encouraged to be independent, to belong to public life.

Therefore, the absence of man in health services is also justified in the male discourse, by the incompatibility between work schedules and units operation10. Moreover, there are still bureaucratic aspects, coping queues, poor reception and attendance delays, which further hinder the search for assistance.

In contrast, this same space that difficult, can also facilitate and somehow influence men to seek health care, because it is observed that when looking for a Basic Health Unit (BHU) often do it to meet the requirements of conditions of employment, such as updated vaccination card, exams performance and request medical reports.

Is also verify, the search for health services by the male population beyond labor needs. It is possible to certify that the aging process approaches the male public to health services. Thus, the demand for primary care occurs exclusively after the illness or facing chronic diseases, that require rigorous monitoring by professionals.

To age, although it is a natural process, must be accompanied, because confronts the individual with a number of chronic and degenerative diseases. Studies show that mortality rates are higher among men, although the prevalent diseases in the elderly are more frequently reported by older women11.

The male public only look for on the issue of groups like in the HIPERDIA, right, if there are young in this group is because the disease already exists, attendance is higher only in relation to this program (Nur. 04).

Arterial Hypertension (HBP) and Diabetes Mellitus (DM) represent the mais Chronic Conditions and Noncommunicable Diseases (CCNCD) which risk factors and complications constitutes the largest disease worldwide burden12. Allusion to the program for monitoring hypertension and diabetes (HYPERDIA) present in the speeches, refers to the adherence of the elderly male segment, specifically to consultations and group of health education directed to hypertensive and diabetic patients, more receptive to interventions.

Through speeches, also inferred a concern on the part of elderly men in giving sequence to therapy of control for the diseases that present, because being sick they perceived the need to recover or maintain their ability to perform usual activities.

It is observed, therefore, the presence of cultural values that lead man to an incipient concern with health, away him from the primary care, both by stereotypes about preventive care, as for prioritized labor activity at the expense of health. However, this reality is modified when limitations caused from physiological aging, impel the elderly to be present in the health service to deal with vulnerabilities that provide their illness. Thus, the inherent fragility to senescence overrides the belief in male invulnerability in vigor.

Organization and responses of health services to the demands of the male population: barriers to care

It must be admitted that the absence of males in the Basic Health Units (BHU) is not only by the lack of attention given to health, but reflects issues related to routine services that often, does not include care strategies to contemplate the different health needs of men, understood in a sociocultural context and from the relational gender perspective13.

Some analyzed speeches refer to the attempt of some health units in developing attractive strategies to the male public, such as the establishment of special schedules and activities that promote the integration of man with Primary Care. However, unanimously, the interviewees mentioned the current lack of actions geared specifically to the health care of the man.

A proposal for differentiated service was launched, already following a proposal from the man's health policy right, so when he comes does not have so many women and not take as much, but it did not work (Nur. 03).

It is possible to list yet, that little structuring of health services, in terms of human and material resources, in a qualitative and quantitative perspective, as well as adequate physical space to receive and attend the male clientele, reinforces the low demand by men for primary care services14. The statement below, points to a failure in service orientation from the managers.

There is no policy use if there is no support of the municipal administration, of the secretary of health, making care simple matter to provide numbers to the system, and there is no return to the patient for lack of continuity, poor attention due to the lack of resources, incentives that support the policy proposal in question (Nur. 02).

The implantation and execution of actions directed to man health, collides into deficits and failures of the system. Therefore, precarious infrastructure, bureaucratization of services, insufficient human and financial resources, lack of continuity of health actions and appropriate timely response, end up generating discrediting of service, not contributing to the adherence and to the increased of the demand by male public.

Thus, seeking to fill these gaps and include the man in a health policy geared to meet their specific features, was created in Brazil in 2009, the National Policy for Integral Attention to the Man Health (NPIAMH), proposing to qualify health care to male population in order to promote, prevent and assist men and understand their particularities.

However, an important finding identified in the reports, relates to the lack of knowledge about the political health of man. Among the ten respondents, only two said they had received training of man health in the form of courses lasting 40 and 120 hours, respectively.

No, I never studied about, I only read because of the disclosure. In general I feel prepared to meet the male public, but to attend them specifically, I do not have that security, we do not get a training during faculty nor training (Nur. 04).

I know because I read, I know a little, but I'm not sure about preparation. If he comes with a genital complaint I will not know how to be impartial and be empathetic at the same time with no confusion, so my fear is that, do you understand? (...) because if he comes, for example, he show the penis saying it has urethral discharge, I feel more embarrassed in the examination than when he shows his penis, I'd be tied, is uncomfortable (Nur. 09).

No. I know there are, but I do not know about the policy and also I do not see myself able to meet the man in a specific way, not that in other respects I'm not and that health care should be different for men and women, but following this gender issue, even I am a man and knowing the difficulties, I have difficulty structuring my assistance in this direction (Nur. 05).

The speeches relate that exist a knowledge about the NPIAMH, however superficial, acquired by own initiative. Considering that the policy was developed and has being implemented over five years, there was no real concern for management in disseminating and promoting training of professionals to work with this new perspective.

Yet, neither is discussed in academia the human health in a gender perspective, since epidemiological transitions, the health profile of the man and existing barriers in the effectiveness of care for this population. In this sense, it is considered the importance of the construction of a sensible approach to male problematic since graduation, through technical and scientific content approach, which promote an integral care that meets complexities related to gender14.

It is noticed, however, an insufficient preparation of men professional to assist the male segment, showing a deficit in professional qualification with reflection in precarious process of reception, approach and effectiveness of care. Meanwhile, there is a lack of preparation on the part of women professional to deal with situations that require physical examination in man. It is inferred questioning how to cohere the empathetic care and the physical examination, without confusing the intention of touch.

Limitations of assistance directed to man health to proposed changes in the nursing perspective

The increase of the access of the male population to health services is one of the main challenges to be achieved. Studies reveal that the dimension of access involves the interaction between user and their health needs and the provision of procedures by the services, which can result in processes that imprint a greater or lesser degree of facility in obtaining health care15.

The professional nurse as a member of the multidisciplinary team, working within the FHS has the responsibility to act with the male public and therefore, has an important role in developing an attractive approach, based on completeness and humanization of care, valuing being care, their experiences, and adopting coherent care measures with their needs.

The consolidation and effectuation of NPIAMH represent an indispensable condition for changing the current epidemiological profile and paradigm of man health. Considering the aforementioned findings regarding the knowledge of nurses about the policy in question, it is noted the need to expand and facilitate continuing education in the context of man health, through courses, training and coaching.

It is noteworthy, in this sense, the need for professional qualification to deal with the male segment and the occurrence of a qualitative transformation in the health services, which will occur through the collective professional awareness, encouraging the learning, of political will and deconstructions of gender, considered barriers to men's health15.

Nursing is very sensitive to these issues, is a more individual change, have another stance that let the man more relaxed, to acquire updated knowledge, constantly improving to be aware of the needs of their health and how to deal with them (Nur. 07).

Thus, educational activities directed to health professionals become an instrument for effective NPIAMH, enhancing the care of nurses and directing the actions of this professional for the promotion, maintenance and restoration of human health16.

Generally, nurses has support for health education in the FHS, the ability to guide, we have to work a lot with that and involve the whole team, train health workers to capture this population and teach, educate, advise about preventive care and promotion (Nur. 01).

In this respect, one should enhance the actions and health education campaigns in order to promote awareness and alert of the population, not only male, but the general population, to the importance of adopting healthy lifestyles and need to seek health services for imposition of preventive attitudes, especially offered for primary care.

In their statements, the nurses also suggest the need for teamwork (FHS professionals and management) and commitment to this with users, because the effectiveness of the actions of health services also goes through the action of several other professionals, so that meet the needs of users in full.

It is a matter of team partnership, NASF, doctor, health agents, many factors influence because it is not only the nurses who work, is a team, must be a team work. When something falls, not only the nurse has responsibility for the program, it is also the municipal transfer, guidance, health education, professional training in the area, to understands what is happening and where these data are going, the purpose and the answer for the team and population (...) have to see how nurses are inserted to the program (Men's Health), must to define strategies for each team member and primarily to the municipal manager, so that they have an effectiveness of actions within the FHS, or everything will continue broken as now (Nur. 01).

Therefore, it is observed the need and importance of offering a service that addresses the health needs of man in its entirety, through the performance of a multi-professional team, qualified to attend the specifics of the male public health, and management support for the provision of structured and qualified services to meet the health needs of this clientele.

In this context, it is important to establish partnerships with other sectors and institutions where the male population is inserted, with the aim of promoting a greater incentive to health care and a greater demand for primary care services.

Many already have that incentive, right, as well as some companies that have occupational physician, then favors, is a gateway to both companies that provide doctor and nurse at work, but also the health team inset in the community (Nur. 01).

Thus, it points to the workplace of the male population as a potential ally for the prevention of diseases, from the moment in which companies (place where insert the men in their productive activities) adopt an active participation in this relationship, stimulating from the employee, the care of their health, such as the need to keep current vaccine card and provision of organizational space for educational activities17.

Furthermore, it is important to think about and discuss ways to insert health professionals in environments where male population is routinely concentrated, as in the workplace or occasionally in fairs and events, especially when exist the need for distribution of information pamphlets, lectures, workshops, group guidelines, risk assessment for Hypertension and Diabetes Mellitus, cardiovascular problems, sexually transmitted diseases, among others. With these attitudes, greater awareness was being allowed about the need to prevent diseases and increasingly approximate the man to the health service.

FINAL CONSIDERATIONS

Through this study, we could show that even reductionist vision of nurses about the meanings of man being, can commit to this full public assistance, because it does not understand the particularities involved in the process of socialization of man, difficult the recognition of their personal and social barriers related to care, and reflected a superficial assistance, which does not approach to the male universe nor satisfies their demands.

It appears therefore, being necessary to develop strategies with the male population, allowing the deconstruction of gender stereotypes that spread the misconception of invulnerability in man. This vision must be modified so that it can promote the quality of life of the male segment. It is essential to enable to man, a place where he feels welcomed to talk about their fragilities and needs, having resolved their demands in order to improve their approach and presence in primary care services.

Thus, as potential strategies to provide the insertion of man in health services, it points to the need for continued education and training of health professionals to serve the National Policy for Integral Attention to Men's Health to consolidate the construction of knowledge about the relationship gender and health. The debates on these topics must begin at graduation, since there is a little preparation of professionals in assisting the male public. And urges as indispensable, the re-suitability of health services by managers in the economic, political and institutional context.

Although this study presents some limitations, such as the research universe (10 FHS nurses), it is necessary to raise questions for the re-suitability of the actions of health professionals in Primary Care across the male population, especially in regard to the implications of gender issues in human health.

Therefore, it is concluded that the performance of the healthcare team, especially the nurse, it is essential to transform this scenario, when designing an empathic care that promotes attractive and humane care, appreciating not only the somatic aspects but who is guided by the vision of man as a holistic and integral being. In this sense, the implementation of NPIAMH is crucial to give visibility to the health needs of man, inserting him in the context of Primary Health care, through the development of programs that address, in a specific way, their demands and coping the issues related to male identity with regard to gender issues.

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Received: March 04, 2014; Accepted: April 29, 2014

Corresponding author: Grayce Alencar Albuquerque. E-mail: geycy@oi.com.br

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