Cervical cancer prevention among quilombola women in the light of Leininger’s theory

Abstract

OBJECTIVE

Our purpose was to discuss practices of cervical cancer prevention among Quilombola Women.

METHOD

This study used, in 2014, a qualitative research approach aiming twenty women from a quilombola community (people who live in quilombos, descendants of Afro-Brazilian slaves), which is located in Bahia. A semi-structured interview was developed by researchers in order to collect data. The Ethno-nursing Research method was used to analyze the data.

RESULTS

The use of cultural care through medicinal plants, and the nursing professional care (Pap Smear exam procedure) were stated by Quilombola women as serving as prevention practices against cervical cancer. However, most women stated that they did not use any prevention practices.

CONCLUSION

Social, cultural and health access issues are practices that are linked to the cervical cancer prevention among Quilombola Women. Therefore, it is indispensable to create an appropriate care plan for Quilombola women’s reality.

Keywords:
Diseases prevention; Uterine cervical neoplasms; African continental ancestry group; Culture; Nursing.

Resumo

OBJETIVO

Discutir as práticas de prevenção do câncer do colo do útero de mulheres quilombolas.

MÉTODO

Estudo qualitativo, realizado em 2014 com vinte mulheres de uma comunidade quilombola, localizada na Bahia. Os dados foram coletados por meio de entrevista semiestruturada e analisados através da etnoenfermagem.

RESULTADOS

As quilombolas apontaram como práticas preventivas para o câncer do colo uterino o cuidado cultural, através do uso de plantas medicinais, e o cuidado profissional, caracterizado pela realização do Papanicolau. Contudo, uma maioria de mulheres não realizavam prevenção.

CONCLUSÃO

Questões de ordem social, cultural e de acesso relacionam-se com as práticas preventivas para o câncer do colo uterino de quilombolas. Assim, torna-se imprescindível um planejamento de cuidados congruentes com a realidade dessas mulheres.

Palavras-chave:
Prevenção de doenças; Neoplasias do colo do útero; Grupo com ancestrais do continente africano; Cultura; Enfermagem

Resumen

OBJETIVO

Discutir las prácticas de prevención del cáncer de cuello de útero de mujeres quilombolas.

MÉTODO

Estudio cualitativo, realizado en 2014 con veinte mujeres de una comunidad quilombola, localizada en Bahía. Los datos fueron recolectados por medio de entrevista semiestructurada y analizados a través de la etnoenfermería.

RESULTADOS

Las quilombolas apuntaron como prácticas preventivas para el cáncer de cuello uterino el cuidado cultural a través del uso de plantas medicinales y el cuidado profesional, caracterizado por la realización del Papanicolau. Sin embargo, la mayoría de las mujeres no realizaron prevención.

CONCLUSIÓN

Cuestiones de orden social, cultural y de acceso se relaciona con las prácticas preventivas para el cáncer de cuello uterino de quilombolas. Así que se torna imprescindible un planeamiento de cuidados congruentes con la realidad de esas mujeres.

Palabras clave:
Prevención de enfermedades; Neoplasias de cuello de útero; Grupo de ascendência continental africana; Cultura; Enfermería

INTRODUCTION

Cervical cancer is one of the most common among women, accounting for approximately 500,000 new cases and 230,000 deaths per year worldwide, which leads to great social and financial loss, since these women occupy hospital beds and are away from the labor market and family life¹.

The treatment of this neoplasm is more effective when there is an early detection, which is mainly due to the cytopathological examination (Pap smear), which is simple, effective and has a low cost for the health system¹.

However, this cancer is still considered a public health problem in developing countries, such as Brazil, due to high rates of prevalence and mortality, especially in women of lower socioeconomic status².

Regarding the prevention of cervical cancer, women living in the popular neighborhoods of Salvador-BA mentioned in one study the performance of routine examinations and controls, others refer specifically to the Pap smear, and others also associate its prevention with meanings granted to the female body, such as lack of hygiene³.

In the case of quilombola women, few studies are focused on preventive care and, for cervical cancer, they are even scarcer, specifically when it comes to the relationship between cultural values and preventive care. The findings of the study, which sought to analyze the factors associated with failure to perform a Pap smear among quilombola residents in Vitória da Conquista, Bahia, demonstrate that it is necessary to reflect on the factors that influence the non-performance of the preventive exam, and it is important to think in actions to prevent cervical cancer⁴.

The lack of adequate information about the importance of prevention, or even the difficulty of women incorporating these preventive practices into their daily concerns, may reflect the delay in the demand for these services⁵.

Health professionals have a fundamental role in the prevention of this cancer, either in the primary prevention, through the planning and supervision of the programs; or secondary prevention, by conducting the preventive examination, which contributes to the early diagnosis⁶.

Facilitating women's access to information, preventive examination, as well as knowledge of their benefits and coping with the results, not allowing fear and anxiety to impair the care to their own bodies are fundamental actions, since prevention is the best weapon for the reduction of morbidity and mortality due to cervical cancer⁶.

This study is justified by the need to understand that any preventive action should consider the values and practices of the care used in specific cultures; and it is necessary that the nurse knows the women of the community in which he/she is working in the prevention of cervical cancer, in order to establish a relationship of trust and to facilitate the care provided⁷.

In this sense, it is questioned: what are the prevention practices for cervical cancer used by quilombola women? The objective of this research was to discuss the prevention practices of cervical cancer by quilombola women.

Challenges for prevention, information, education and health promotion are experienced in the cultural differences of care, since it can lead to prejudice, especially when there is no knowledge about the culture of care of the recipients, which need the construction of a dialogue and culturally competent healthcare. Thus, it is believed that knowing and understanding the culture of populations, as well as their relationship with health behaviors and care practices, is fundamental for the assistance of health professionals⁸.

METHOD

The method used was the ethno-nursing, proposed by Madeleine Leininger's Theory of the Transcultural Care. It is an open and qualitative method of research, in search of ideas, perspectives and knowledge about care and culture of certain populations that includes four phases: collection, description and documentation of the raw material; identification and categorization of components; standard and contextual analysis; main themes, research results, theoretical formulations and recommendations⁹.

The research was carried out in the quilombola community of Araçá Cariacá, located in the rural zone of Bom Jesus da Lapa, Bahia, which is located in the central-western region of the State, in the micro-region of the Middle São Francisco. The community is comprised of 98 families and 173 women over 18 years old.

The fieldwork was carried out between July and September 2014, during which we obtained information about the community through visits, contact with local leaders and Community Health Agents (CHAs), observation of the physical conditions of the place, and interviews with 20 women living in the area. The inclusion criteria in the study were: women from the quilombola community, aged eighteen or over, representing the key informants, and CHAs who represented the general informants. Those excluded from the study were the ones who failed to finish the interview due to emotional and/or cognitive reasons.

For the data collection, we have used the recorded semi-structured interview, which happened in a private place, individually. This moment made possible greater interaction with the women, the creation of a bond of trust and depth of what we wanted to investigate. It was guided by the following questions: In your opinion, what can women do to prevent cervical cancer? What are the preventive care for cervical cancer related to your cultural habits? And you, what have you been doing to prevent yourself from this cancer? In addition, a socio-economic-cultural form has been used, with the following aspects to be questioned: technology, religion and philosophy; fellowship and social; lifestyles; political and legal; economic; education; characteristics of reproductive health and behavioral factors. The analysis of the testimonies was based on ethno-nursing data analysis.

In order to approach the field and the selection of the interviewees, we had the collaboration of a CHA and a community health agent who also served as general informants. Their participation in the research was of fundamental importance in establishing trust with the women during the home visits, as well as providing complementary information to the study.

The project was approved by the Association of Small Rural Producers of Araçá and by the Research Ethics Committee of the Universidade Federal da Bahia, through the Opinion No. 684,165, on June 11, 2014. It is a cut of the dissertation entitled "Preventive care for cervical cancer: a study with quilombola women", which was supported by the Coordination for the Improvement of Higher Education Personnel (CAPES), through a master's degree scholarship.

RESULTS E DISCUSSION

The results and discussion refer to the socioeconomic, demographic and cultural context of the study, and preventive care for cervical cancer. From this category emerged the following subcategories: Cultural care; Professional Care and Prevention: Me? I do not do much!

Socioeconomic, demographic and cultural context of the study

The ethno-nursing proposed by Leininger presents the Sunrise Model with the purpose of helping the nurse to identify the influences of the human conditions that need to be considered in order to provide the holistic care to the people. The essential components of this theory are described in this model, which illustrates human beings as inseparable from their cultural background and social structure, world view, history, and environment context⁹. In the Sunrise Model, dimensions are identified that when properly analyzed, provide a congruent care; among these dimensions is the cultural and social structure that we present for the present study.

The study was developed in a rural area of Araçá Cariacá, where are located the lands inhabited by the quilombola people, self-referenced as descendants of the slave Roque. He was a symbol of struggle and resistance to the community, for even though he was sold by the farmer to São Paulo, he remained on the farm, gained the trust of the owner, becoming in charge and then added to the farm; currently, he is the main reference for the construction of the quilombola identity of this people¹⁰.

The community has piped water from an artesian well; electric light; there is no basic sanitation; in homes, there are appliances; and the main means of transportation are motorcycle and car that make 'the line', and which are mainly used for the transport of people to the city in search of health services, for shopping and receiving benefits, such as “Bolsa Família”. Women refer liking the home where they live in and feel good about them. The age range of the women in the study varied between 22 and 69 years old; they are all black, with little schooling and low income, mostly married. They have, on average, three children; the majority of their deliveries were normal and performed in a hospital. Commonly, they do not consume alcoholic beverages and tobacco; they have only one sexual partner, they do not use condoms and deny Sexually Transmitted Infections (STIs).

Black people, especially women, receive the lowest wages¹¹. This fact, associated to the low level of schooling among quilombolas, depicts important factors of vulnerability to access to prevention⁴. Thus, "gender, race/color and social class intersect and generate disadvantages on the health of black women, which must be taken into account in the analysis of the health-disease process of this population group."^(11:291).

The quilombola women stated that they did not use the condom because they already used oral contraceptives, which means that they did not consider condoms as a preventive method for STIs. Thus, their responsibility, as married women, was to control the size of the family through the use of the pill, which makes them more vulnerable to STIs¹².

Although health itself is not a subject commonly discussed in the community under study, during the interviews, women were interested in learning about aspects related to sexual and reproductive health. The daily care to the family, as well as the responsibility for the domestic duties, mean that many women do not care for themselves, seeking healthcare only in cases of extreme need^1,5. In the case of the quilombola women, this situation is aggravated by the difficulties of access to health services, commonly reported⁴.

The community is organized politically through the Quilombola Association, whose president motivated the participation of other women in monthly meetings. This fact may represent only the need that these women have to organize themselves to solve, in a collective way, everyday problems.

Preventive Care for Cervical Cancer

Cultural care

Ethno-nursing defines as cultural care what is related to knowledge and practices of local, traditional and popular care, transmitted and learned to assist and support those who need health in order to improve their well-being⁹.

The use of condoms, self-care, and the non-use of medication (oral contraceptives) were reported by women when asked what to do to prevent the cervical cancer:

Use condom. (E 16)

I think it's taking care of themselves even more (referring to the girls in the community).(E 04)

I think I could not take these pills (oral contraceptives), but today it is difficult because women do not want to have that many children, and there is no other way, what they have is to operate, to take these medicines. (E 06)

The prolonged use of oral contraceptives is presented in the literature a factor related to the etiology of cervical cancer¹³. Another study highlights that hormonal contraception poses a risk for cervical cancer, and the low adherence to condoms increases the incidence of sexually transmitted diseases, such as HPV, the virus responsible for more than 90% of cervical-uterine cancer¹².

Some women (three) said they did not know anything about cervical cancer prevention:

I don’t know anything. (E 17)

I also don’t know what to do not to have it. (E 12)

I also don’t have any idea. (E 07)

The literature reveals a lack of women's knowledge about cervical cancer prevention, fear of disease, preventive examination and its outcome, as well as shame in seeking care⁵.

In the cultural care, the use of medicinal plants is commonly used for the prevention and treatment of diseases, in this study, a general informant (CHA) added that the consumption of medicinal plants is rather used in the community, however for treatment of certain diseases and not for the prevention of cervical cancer:

It is one of the diseases that has been killing women, I think it can be avoided through the examination, I think it is very important [...] Specifically for the prevention of cervical cancer, I do not have this information (use of medicinal plants by women), but for other diseases people use it a lot, to prevent I don’t think so. (CHA 2)

However, some quilombola women refer as a traditional practice preserved by older women to treat inflammation and "warmth in the uterus" and to prevent cervical cancer from using the bark of the following plants: barbatimão, pomegranate, jatobá and quixaba, as indicated in following reports:

I sometimes take those weed remedies, those barks that they say it's good. I usually take ‘Baba de timão’, ‘jatobá’, ‘quixaba’, those things that people say that is good I always take. These things are good for inflammation, infection, I always try to prevent myself from it, I feel good. (E 19)

I see comments from women, especially older women, that they take a bark medicine, which is good for warmth, inflammation in the womb, I see those comments, but... The bark of the pomegranate, bark of ‘barbatimão’ also, which is very good also for inflammation. (E 08)

A study carried out in the community of Casinhas, in Jeremoabo, state of Bahia, which aimed to inventory the medicinal plants used, demonstrated that the bark of “Jatobá” is used in the form of syrup, inhalation and tea for influenza, and "things of the air"; the fruit of the pomegranate is ingested or used in the form of tea for inflammation of the throat; the bark and leaves of “barbatimão” are used macerated or in the form of tea and bath for inflammations and injuries¹⁴.

Studies carried out in a literature review have confirmed the medicinal properties of the leaves and barks of Striphnodendronadstringens (“barbatimão”) as an important antimicrobial agent, anticancer and even antiophidic serum¹⁵.

Through some speeches, it was possible to observe doubts about the efficiency of the cultural care, although none deny this care:

I see people talking about taking a bark medicine, a 'lot of nonsense' that people do, they usually take it, I do not know if it helps. (E 03)

There are (women) doing it right, they start doing the preventive. But there are others who say that roots are good, I do not know, it used to work, but now for me with health contact I think it's a little bit out of the same treatment. But what can I do if they like to do this? They like to take bark to prevent it, saying they are preventing cervical cancer. The correct are the exams, the preventive, the Pap smear, have the HPV vaccines as well. (CHA 1)

In view of the above, it is possible to bring another concept studied and defined by the Leininger theory, regarding the universality of care, since it was identified in this study values, ways of life or symbols of caring that are manifested in other cultures.

Several studies have been developed in the face of the consequences of the encounter of groups of different cultures, such as the difficulty of communication, education and health, adaptive processes and acculturation, which refers to the experiences of the person in contact with another culture¹⁶.

Professional care

The professional care refers to the care learned, taught and transmitted by health professionals. For the ethno-nursing, it is the one that is formally learned through educational institutions and must be culturally congruent care. They are actions that are tailored to the values of people of a specific culture in order to provide meaningful and beneficial healthcare services⁹.

Seven women interviewed reported that they have already taken the preventive exam to prevent cervical cancer:

I do the preventive every year, from year to year and it has never showed anything. (E 20)

Every year I do the Paps (Pap smear) (E 15)

I do it year after year, I'm doing thanks to God, it's going to be a year since I did it, and thank God, it was everything OK, everything normal. (E 13)

I always go to the doctor, I do the preventive. I think it's been two years. (E 03)

According to INCA, the Pap smear should be offered to women in the age group of 25 to 64 years old, who have already had sexual activity; and that this is a target population, since a higher occurrence of high-grade lesions that could be treated before progressing to cancer was identified. The recommended routine is to perform the cytopathological exam every three years, after two normal examinations performed in the interval of one year, in order to reduce the possibility of false negative¹⁷.

The search for the doctor, the accomplishment of examinations and/or of the Pap smear were actions commonly cited:

Do the preventive and take care of yourself. Take the exams and always follow up with the gynecologist. (E 20)

I think it is going to the doctor often, doing all kinds of tests, doing preventive, doing ultrasound every now and then is the right thing. (E 19)

You have to always consult your doctor, do the Pap smear from year to year to see what it is like, if she has it, if she has it, she needs to begin the treatment to be able to cure it. (E 15)

The best thing to do is to seek a doctor, the gynecologist, to see how it is, the care you have to have. (E 02)

It is to do the same exam. You have to do the exam to see how it is, if it is well, and take care, the woman has to take care of herself, in order not to reach the disease. (E 01)

In a study that sought to understand the meanings of the preventive practices of cervical cancer among women from the popular neighborhoods of Bahia, the high appreciation of the Pap smear was also noticed in the interviewees' speeches³.

One of the women reported using both cultural and professional care:

The exams I've done, these exams I've done six times or more, the preventive. And sometimes I take the medicine at home, the home remedies, I take that “baba de timão”, they say it's very good for us to be taking. I take that "picão"; they say it is very good for many problems. I take these medicines, I do not know if it's good (laughs). (E 14)

In a study of women diagnosed with cervical cancer, they only perceived their vulnerability when they found the disease. From there, they followed the treatment and used other alternatives contained in the popular beliefs that could help in the recovery, thus the therapeutic process of them shows a mixture between professional and popular knowledge, in which the latter exercises an aid to medical treatment⁵. The approach of cultural valorization, specifically of minority groups, is a resource for the revaluation of cultural identities¹⁶.

The nursing care proposed by ethno-nursing is in intersection with generic (popular) care and professional care⁹. The nurse is the one who has the most contact with who is cared for, who assumes the role of educator and facilitator of client interconnection and other health professionals.

Prevention: Me? I do not do much!

Thirteen of the twenty women interviewed said they had never done the preventive exam and, when asked about what they have done to prevent themselves from CC, some women said they did nothing, sometimes justifying carelessness, sometimes ignorance of the disease, absence of symptoms or sexual partner, which is evidenced in the speeches:

Me? I do not do much! I hardly do the exam. (E 09)

Nothing (laughs), I almost do not understand much, never heard of it, even heard, but not so well to explain. (E 16)

I never did anything because I was single, then I left to work in the house of others, I raised a daughter, I did not have much husband. (E 12)

I (laughs) did not do anything, it will be eighteen years since my husband died and thank God I was never left with no other man. (E 04)

I've never done anything, but I know it's a very dangerous disease, I'm so sloppy in that area, I do not take care of myself. But because until now I felt nothing to be afraid of and to take care of myself. But I was already guided, my health agent always tells me that ‘you have to go for the exam’, if you prevent it, because it can happen to every woman, you have to take care of yourself, but I've never been to the doctor before. (E 01)

In a study conducted in the city of Rio Grande do Sul with women during the meetings held to promote sex education and to know their sexual health profile, it was verified that they recognize the importance of prevention for the maintenance of a healthy life, however, some said that when they sought assistance was due to the appearance of symptoms².

In another study carried out in a city in the south of the country, 50% of the women interviewed only go to the doctor's office when they present health problems, together with those who did not know how to inform and those who did not consult, a percentage of 70% of women who do not consider important preventive attitudes¹⁸.

The issue of "neglect" of prevention also appeared in a study of women diagnosed with cervical cancer, who reported that they did not do the preventive exam before presenting the disease because of shame and neglect⁵. These authors point out that the various reasons mentioned by women for not seeking health services reinforce their lack of knowledge about the risk of acquiring a disease such as cervical cancer, the consequences of the disease and the importance of prevention.

Women users of a Basic Unit in the capital of Bahia report superficial care by health professionals, who give more time to white women when compared to black women. Some statements also point out that the fact that they are black and poor leads to unequal and disqualified care in health services, thus, they recognize that, in some way, the assistance provided results in differential care and, sometimes, in restriction of access¹¹.

Racial inequalities determine access to health services and limit the care provided by identifying that "factors associated with gender and race inequalities determine social disparities, hierarchizing access to health services through different individual characteristics."¹⁹.

The lack of search for prevention by the quilombola women, lack of will or difficulty in access is also evidenced by general informants when questioned as to what women in the community have done to avoid cervical cancer:

Very little, even the exams are difficult to do, they do not have any will, others have the will, they go to the unit and cannot do it, schedule and do some preventive. It's very complicated here, the oldest ones even use roots, the younger ones do not give a damn, they just leave it. (CHA 1)

Women have a resistance in doing the preventive, but a good part of the women have already looked for us, they have done it, whenever they have the opportunity they do the preventive. And... sometimes people get a bit like this (pause). Because once people did it and did not get the result, then they thought they were exposed to do the test, to collect the sample and finally did not have the result, they build that resistance. Sometimes material is missing, the distance is also detrimental. (CHA 2)

In addition to the deficiencies in hospital attendance and referrals, the issue of access was also a barrier identified in the quilombo of Buriti do Meio-MG regarding the use of health services, since the community is 30 km away from the municipality's headquarters²⁰.

Women living in low-income neighborhoods in Salvador-Bahia also reported that they did not do the exam because of difficulties in accessing health services³. In another study, women reported that they attended health services but were not attended; and in some cases they went seeking the result of the exam that was not found⁵.

The difficulty of reaching the health services is something that should be highlighted, in the specific case of the study community, these services are distant about twenty kilometers, so the search for care is often neglected. The CHA that participated in the study stated that the first dose of the vaccine for the HPV prevention was carried out integrally in the girls of the community, since the health professionals from the municipality went there to carry out the vaccination; however, in the second dose this did not happen, because fathers and mothers should take their daughters to the city to receive the vaccine and even if she warned, many did not go.

FINAL CONSIDERATIONS

According to the results, it is concluded that social, cultural and access issues are related to the preventive practices for cervical cancer used by quilombola women.

The cultural care, also called by Leininger as generic care, has in many cases been mentioned by women when questioned as to preventive care related to cultural habits. Taking care of themselves, not using oral contraceptives, the use of condoms and medicinal plants were used by the quilombola women to prevent cervical cancer. Other women in the study, however, said they knew nothing about the prevention of this neoplasm.

Perhaps by the process of acculturation they tried to answer what health professionals want to hear, for they consider their own knowledge as inferior. And these habits were always related to the elderly.

The idea of prevention is linked to professional care and preventive examination. Performing medical consultations, exams and the Pap smear were preventive actions for cervical cancer also cited by women. However, thirteen of the twenty women interviewed never performed the preventive examination; many said they did not know much about the exam, others due to lack of symptoms and others due to "sloppiness".

The study was relevant because it sought to know the preventive care for cervical cancer by women, especially those socially vulnerable, such as the quilombola women. This fact is of great importance for the planning of actions that are congruent with the reality of these women and, thus, to enable effective and efficient care.

However, the study is limited by the number of women interviewed and, specifically, in a quilombola community. It is therefore recommended that further studies be conducted with a larger number of women, from other communities, with different contexts, in order to obtain more comprehensive results.

In addition, the shortage of studies developed with quilombola women, specifically with regard to health and disease prevention, while presenting itself as a limitation for the discussion of the data collected, is a driving force for the development of new research. Knowing communities with such a rich cultural background and still so far from the eyes of health professionals is essential to think of an assistance that is effective to these people.

Nursing actions based on lifestyle are the practical result of the Sunrise Model, proposed by theory and it is believed that the accommodation and/or negotiation of cultural care would be an appropriate action to the community of this study; through professional help people negotiate with professional care providers for a beneficial health outcome.

For the Transcultural Care Theory, it is important for nursing to understand the cultural care, especially in a society with a very diverse cultural representation such as the Brazilian one. From this perspective, we believe that the knowledge of cultural values, presented in studies such as this, contributes to an assistance based on the principles of integrality and equity.

REFERÊNCIAS

• ¹
  Rodrigues BC, Carneiro ACMO, Silva TL, Solá ACN, Manzi NM, Schechtman NP, et al. Educação em saúde para a prevenção do câncer cérvico-uterino. Rev Bras Educ Med. 2012 jan/mar[citado 2016 set 10];36(1, Supl. 1):149-54. Disponível em: Disponível em: http://www.scielo.br/pdf/rbem/v36n1s1/v36n1s1a20.pdf
  » http://www.scielo.br/pdf/rbem/v36n1s1/v36n1s1a20.pdf
• ²
  Casarin MR, Piccoli JCE. Educação em saúde para prevenção do câncer de colo do útero em mulheres do município de Santo Ângelo/RS. Ciênc Saúde Coletiva. 2011 set[citado 2016 set 10] 16(9):3925-32. Disponível em: Disponível em: http://www.scielo.br/pdf/csc/v16n9/a29v16n9.pdf
  » http://www.scielo.br/pdf/csc/v16n9/a29v16n9.pdf
• ³
  Rico AM, Iriart JAB. "Tem mulher, tem preventivo": sentidos das práticas preventivas do câncer do colo do útero entre mulheres de Salvador, Bahia, Brasil. Cad Saúde Pública. 2013 set[citado 2016 set 10];29(9):1763-73. Disponível em: Disponível em: http://www.scielo.br/pdf/csp/v29n9/a16v29n9.pdf
  » http://www.scielo.br/pdf/csp/v29n9/a16v29n9.pdf
• ⁴
  Oliveira MV, Guimarães MDC, França EB. Fatores associados a não realização de Papanicolau em mulheres quilombolas. Ciênc Saúde Coletiva . 2014 nov[citado 2016 set 10];19(11):4535-44. Disponível em: Disponível em: http://www.scielo.br/pdf/csc/v19n11/1413-8123-csc-19-11-4535.pdf
  » http://www.scielo.br/pdf/csc/v19n11/1413-8123-csc-19-11-4535.pdf
• ⁵
  Pimentel AV, Panobianco MS, Almeida AM, Oliveira ISB. Percepção da vulnerabilidade entre mulheres com diagnóstico avançado do câncer do colo do útero. Texto Contexto Enferm. 2011 jun[citado 2016 set 10];20(2):255-62. Disponível em: Disponível em: http://www.scielo.br/pdf/tce/v20n2/a06v20n2.pdf
  » http://www.scielo.br/pdf/tce/v20n2/a06v20n2.pdf
• ⁶
  Silva MRB, Silva LGP. O conhecimento, atitudes e prática na prevenção do câncer uterino de uma unidade da zona oeste Rio de Janeiro. R Pesq Cuid Fundam. 2012 jul/set[citado 2016 set 10];4(3):2483-92. Disponível em: Disponível em: http://www.arca.fiocruz.br/bitstream/icict/9169/2/O%20conhecimento%2c%20atitudes%20e%20pr%C3%A1tica%20na%20preven%C3%A7%C3%A3o%20do%20c%C3%A2ncer%20uterino%20de%20uma...pdf
  » http://www.arca.fiocruz.br/bitstream/icict/9169/2/O%20conhecimento%2c%20atitudes%20e%20pr%C3%A1tica%20na%20preven%C3%A7%C3%A3o%20do%20c%C3%A2ncer%20uterino%20de%20uma...pdf
• ⁷
  Cestari MEW, Zago MMF. A atuação da enfermagem na prevenção do câncer na mulher: questões culturais e de gênero. Cienc Cuid Saude. 2012 [citado 2016 set10];11(supl.):176-82. Disponível em: Disponível em: http://periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/viewFile/17073/pdf
  » http://periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/viewFile/17073/pdf
• ⁸
  Ramos MNP. Comunicação em saúde e interculturalidade: perspectivas teóricas, metodológicas e práticas. RECIIS: R Eletr Com Inf Inov Saúde. 2012 dez[citado 2016 set 10];6(4). Disponível em: Disponível em: http://www.reciis.icict.fiocruz.br/index.php/reciis/article/view/742/1385
  » http://www.reciis.icict.fiocruz.br/index.php/reciis/article/view/742/1385
• ⁹
  Leininger MM, McFarland MR. Culture care diversity and universality: a worldwide nursing theory. 2nd. ed. New York: Jones and Bartlett Publishers, Inc.; 2006.
• ¹⁰
  Macedo DJS. Os conflitos e a luta da comunidade negra rural Araçá Cariacá BA: a posse da terra e o reconhecimento do território como quilombola. In: Anais do XI Congresso Luso Afro Brasileiro: Diversidades e (Des)igualdades; 2011 ago 7-10; Salvador, Brasil. Salvador: Centro de Estudos Afro-Orientais (CEAO) da Universidade Federal da Bahia; 2011 [citado 2016 set 10]. Disponível em: Disponível em: http://www.xiconlab.eventos.dype.com.br/resources/anais/3/1306201496_ARQUIVO_OsconflitosealutadacomunidadenegraruralAracaCariaca-BAapossedaterraeoreconhecimentodoterritoriocomoquilombola.pdf
  » http://www.xiconlab.eventos.dype.com.br/resources/anais/3/1306201496_ARQUIVO_OsconflitosealutadacomunidadenegraruralAracaCariaca-BAapossedaterraeoreconhecimentodoterritoriocomoquilombola.pdf
• ¹¹
  Domingues PML, Nascimento ER, Oliveira JF, Barral FE, Rodrigues QP, Santos CCC, et al. Discriminação racial no cuidado em saúde reprodutiva na percepção de mulheres. Texto Contexto Enferm . 2013 abr/jun[citado 2016 set 10];22(2):285-92. Disponível em: Disponível em: http://www.scielo.br/pdf/tce/v22n2/v22n2a03.pdf
  » http://www.scielo.br/pdf/tce/v22n2/v22n2a03.pdf
• ¹²
  Neri EAR, Moura MSS, Penha JC, Reis TGO, Aquino PS, Pinheiro AKB. Conhecimento, atitude e prática sobre o exame Papanicolaou de prostitutas. Texto Contexto Enferm . 2013 set[citado 2016 set 10];22(3):731-8. Disponível em: Disponível em: http://www.scielo.br/pdf/tce/v22n3/v22n3a20.pdf
  » http://www.scielo.br/pdf/tce/v22n3/v22n3a20.pdf
• ¹³
  Leite MF, De Vitta FCF, Carnaz L, De Conti MHS, Marta SN, Gatti MAN, et al. Conhecimentos e prática das mulheres sobre câncer de colo do útero de uma unidade básica de saúde. J Human Growth Develop. 2014[citado 2016 set 10];24(2):208-13. Disponível em: Disponível em: http://pepsic.bvsalud.org/pdf/rbcdh/v24n2/pt_14.pdf
  » http://pepsic.bvsalud.org/pdf/rbcdh/v24n2/pt_14.pdf
• ¹⁴
  Gomes TB, Bandeira FPSF. Uso e diversidade de plantas medicinais em uma comunidade quilombola no Raso da Catarina, Bahia. Acta Bot Bras. 2012 dez[citado 2016 set 10];26(4):796-809. Disponível em: Disponível em: http://www.scielo.br/pdf/abb/v26n4/09.pdf
  » http://www.scielo.br/pdf/abb/v26n4/09.pdf
• ¹⁵
  Ferreira EC, Silva JLL, Souza RF. As propriedades medicinais e bioquímicas da planta Stryphnodendron adstringens “barbatimão”. Persp Online: Bio & Saúde. 2013[citado 2016 set 10];11(3):14-32. Disponível em: Disponível em: http://www.seer.perspectivasonline.com.br/index.php/biologicas_e_saude/article/view/9/7
  » http://www.seer.perspectivasonline.com.br/index.php/biologicas_e_saude/article/view/9/7
• ¹⁶
  Ramos N. Interculturalidade(s) e mobilidade(s) no espaço europeu: viver e comunicar entre culturas. In: Pina H, Martins F, Ferreira C, editoras. The Overarching issues of the European space. Porto: Ed. Faculdade Letras Universidade do Porto; 2013[citado 2016 set 10]. p. 343-60. Disponível em: Disponível em: http://ler.letras.up.pt/uploads/ficheiros/12349.pdf
  » http://ler.letras.up.pt/uploads/ficheiros/12349.pdf
• ¹⁷
  Instituto Nacional de Câncer (BR). Programa Nacional de Controle do Câncer do Colo do Útero. Rio de Janeiro (RJ): INCA; 2012.
• ¹⁸
  Soares MC, Meincke SMK, Mishima SM, Simino GPR. Câncer de colo uterino: caracterização das mulheres em um município do sul do Brasil. Esc Anna Nery. 2010 mar[citado 2016 set 10];14(1):90-6. Disponível em: Disponível em: http://www.scielo.br/pdf/ean/v14n1/v14n1a14.pdf
  » http://www.scielo.br/pdf/ean/v14n1/v14n1a14.pdf
• ¹⁹
  Goes EF, Nascimento ER. Mulheres negras e brancas e os níveis de acesso aos serviços preventivos de saúde: uma análise sobre as desigualdades. Saúde Debate. 2013 dez[citado 2016 set 10]; 37(99):571-9. Disponível em: Disponível em: http://www.scielo.br/pdf/sdeb/v37n99/a04v37n99.pdf
  » http://www.scielo.br/pdf/sdeb/v37n99/a04v37n99.pdf
• ²⁰
  Freitas DA, Silveira JCS, Ferreira LA, Zucchi P, Marques AS. Mulheres quilombolas: profissionais na estratégia de saúde da família. Rev Espaço Saúde. 2011 jun[citado 2016 set 10];12(2):56-62. Disponível em: Disponível em: http://www.uel.br/revistas/uel/index.php/espacoparasaude/article/view/9221/pdf
  » http://www.uel.br/revistas/uel/index.php/espacoparasaude/article/view/9221/pdf

Publication Dates

• Publication in this collection
  28 May 2018
• Date of issue
  2018

History

• Received
  09 Dec 2016
• Accepted
  05 Sept 2017