Quality of Life of caregivers of equine therapy practitioners in the Federal District

Jéssica Maíssa Gonçalves de Souza Giovana De Marchi Castelli Leonardo Petrus da Silva Paz Andréa Gomes Moraes Marianne Lucena da Silva About the authors

RESUMO

O cuidador oferece atendimento individualizado, e a qualidade de sua atuação influencia na Qualidade de Vida (QV) da pessoa com deficiência. A sobrecarga de trabalho ou a falta de orientação quanto à melhor forma de sua atuação pode influenciar negativamente em sua saúde. Este artigo teve como objetivo avaliar a QV dos cuidadores dos praticantes de centros de equoterapia do Distrito Federal. Foi realizado um estudo de corte transversal em oito centros de equoterapia do Distrito Federal vinculados a Ande-Brasil, utilizando como instrumento de avaliação o questionário WHOQOL-bref para avaliar a QV dos cuidadores dos praticantes de equoterapia. Foram estudados 389 cuidadores, dos quais 71,72% correspondem ao gênero feminino e 28, 27% correspondem ao gênero masculino. Na análise dos resultados dos questionários, o domínio Relações Sociais obteve maior satisfação com escore de 66,13; o domínio Psicológico obteve escore de 64,52; o domínio Ambiente obteve escore de 60,8; e o domínio Físico apresentou o menor escore, obtendo 56,46. A média dos escores obtidos foi de 61,89. Os resultados demonstraram que a tarefa de cuidador pode provocar alterações físicas e mentais de forma negativa, e isso pode influenciar na qualidade de atendimento e no bem-estar do praticante.

PALAVRAS-CHAVE
Terapia assistida por cavalos; Cuidadores; Qualidade de Vida

ABSTRACT

The caregiver offers individualized care, and the quality of his/her performance influences the Quality of Life (QoL) of disabled individuals. Overworking or lack of guidance can affect the caregiver’s health either positively or negatively. This article aimed at evaluating the QoL of caregivers of equine therapy practitioners in the Federal District. A cross-sectional study was carried out in eight equine therapy centers of the Federal District, linked to Ande-Brasil, using the WHOQOL-bref questionnaire, to evaluate the QoL of caregivers of equine therapy practitioners. A total of 389 caregivers were studied, 71.72% of which were females and 28.27% were males. The analysis of answers to the questionnaires showed that the Social Relations domain obtained the highest satisfaction score (66.13); the Psychological domain scored 64.52; the Environment domain scored 60.8; and the Physical domain presented the lowest score, 56.46. Scores average was 61.89. The results showed that the work the caregiver performs may cause negative physical and mental changes, and these changes can influence the quality of care and her/his own well-being.

KEYWORDS
Equine-assisted therapy; Caregivers; Quality of Life

Introduction

Equine therapy is proving effective in treating a number of dysfunctions. In this therapeutic modality, the horse is used as a tool, in an interdisciplinary approach, associated with a multi-sensorial environment, providing sensory-motor stimuli11 Silkwood-Sherer DJ, Killian CB, Long TM, Martin KS. Hippotherapy-An Intervention to Habilitate Balance Deficits in Children With Movement Disorders: A Clinical Trial. Phys Ther [internet]. 2012 [acesso em 2018 jul 2]; 92(5):707-17 Disponível em: https://academic.oup.com/ptj/article-lookup/doi/10.2522/ptj.20110081.
https://academic.oup.com/ptj/article-loo...
. On this basis, equine therapy is able to proportionate improvements in postural control and coordination, weight distribution and transfer22 Rodrigues IF, Nielson MBP, Marinho AR. Avaliação da fisioterapia sobre o equilíbrio e a qualidade de vida em pacientes com esclerose múltipla. Rev Neurociencias. 2008; 16(4):269-74, equilibrium, improvements in proprioception, spatial and temporal parameters and march33 Beinotti F, Correia N, Christofoletti G, et al. Use of hippotherapy in gait training for hemiparetic post-stroke. Arq Neuropsiquiatr [internet]. 2010 [acesso em 2018 jul 2]; 68(6):908-13 Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-282X2010000600015&lng=en&nrm=iso&tlng=en.
http://www.scielo.br/scielo.php?script=s...
, promoting better Quality of Life (QoL) and leading to the individual’s bio-psycho-social development44 Hsieh YL, Yang CC, Sun SH, et al. Effects of hippotherapy on body functions, activities and participation in children with cerebral palsy based on ICF-CY assessments. Disabil Rehabil. 2017; 39(17):1703-13.

Despite these benefits, better QoL does not exclusively depend on the rehabilitation process: it is effective when the context of disabled person is inserted in and, even more importantly, the daily care he/she is submitted to. In this context, the Unified Health System (Sistema Único de Saúde – SUS) has been informing health professionals the importance of including both the family and the caregivers in their evaluations, in order to provide the more adequate therapeutic routes, as well as to promote the well-being of disabled individuals55 Vieira FS. Avanços e desafios do planejamento no Sistema Único de Saúde. Ciênc. Saude Colet. 2009; 14(supl.):1565-77..

The caregiver activity is included in Brazilian Occupations Classification, where this professional is defined as responsible for helping the person under care in his/her daily activities and for watching over his/her well-being, directly influencing conditions such as the patients’ level of physical activity and precocious institutionalization66 Oliveira DC, D'Elboux MJ. Estudos nacionais sobre cuidadores familiares de idosos: revisão integrativa. Rev Bras Enferm [internet]. 2012 [acesso em 2018 jul 2]; 65(5):829-38 Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&amp%5Cnpid=S0034-71672012000500017.
http://www.scielo.br/scielo.php?script=s...
. The physical and psychological burden experienced by the caregivers may lead them to neglect their own health and to jeopardize their own quality of life, with negative impacts on their own well-being77 Ozturk Y, Riccadonna S, Venuti P. Parenting dimensions in mothers and fathers of children with Autism Spectrum Disorders. Res Autism Spectr Disord. 2014; 8(10):1295-306

8 Miura RT. Paralisia cerebral grave : o impacto na qualidade de vida de mães cuidadoras. Mudanças - Psicol da Saúde [internet]. 2012 [acesso em 2018 jul 2]; 20(1-2):7-12. Disponível em: https://www.metodista.br/revistas/revistasmetodista/index.php/MUD/article/view/3146/3126.
https://www.metodista.br/revistas/revist...
-99 Pimenta RA. Avaliação da qualidade de vida e sobrecarga de cuidadores de pessoas com deficiência intelectual. Rev Bras Ciências da Saúde [internet]. 2010 [acesso em 2018 jul 2]; 14(3):69-76 Disponível em: http://periodicos.ufpb.br/ojs2/index.php/rbcs/article/viewFile/9687/5406.
http://periodicos.ufpb.br/ojs2/index.php...
.

Relevant as they are, the QoL of caregivers, who may be either a member of the family or a hired professional, is one of the main concerns in home care of chronic patients1010 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde Básica. Caderno de Atenção Domiciliar [internet]. Brasília, DF: Ministério da Saúde; 2013 [acesso em 2018 jul 2]. 2 v. Disponível em: http://189.28.128.100/dab/docs/portaldab/publicacoes/cad_vol2.pdf.
http://189.28.128.100/dab/docs/portaldab...
. The main purposes of health promotion programs for care-dependent patients are caregivers’ QoL and functional skills, factors that may exert negative influence when the their physical and mental well-being are inadequate, leading to a complex multidirectional interaction between structures and physiological functions, abilities and performance of activities, besides social participation1111 Ory MG, Hoffman RR, Yee JL, et al. Prevalence and Impact of Caregiving: A Detailed Comparison Between Dementia and Nondementia Caregivers. Gerontologist. 1999; 39(2):177-85,1212 Cox CR, Eaton S, Ekas NV, et al. Death concerns and psychological well-being in mothers of children with autism spectrum disorder. Res Dev Disabil. 2015; 45-46:229-38..

The purpose of this study was, thus, to evaluate the QoL of caregivers in charge of practitioners of equine therapy in the Federal District.

Material and methods

From September to November 2015, a transversal study with convenience sample was carried out, using a questionnaire submitted to caregivers of practitioners in eight Equine Therapy centers in the Federal District, linked to the National Equine Therapy Association (Ande-Brasil): Centro Básico de Equoterapia General Carracho; Vila Equestre Equilíbrio; Centro de Equoterapia do Regimento de Polícia Montada do Distrito Federal; Instituto Cavalo Solidário-Sede; Instituto Cavalo Solidário – Unidade Regimento de Cavalaria de Guarda; Centro de Equoterapia Cavaleiros de São Jorge; Asbrate – Espaço Equestre Sociedade Hípica de Brasília.

The research was carried out using verbal approach during Equine Therapy practices. The caregiver was the person primarily responsible for the care offered to the practitioner, irrespective of family relationship. The study was approved by the Research Ethics Committee of Universidade Paulista (Unip) (CAAE: 48306915.2.0000.5512), and all those who were evaluated have previously formalized their participation by signing the Free and Informed Consent.

The shortened version of the World Health Organization Quality of Life (WHOQOL-bref), developed by the World Health Organization, and validated in Brazil by Fleck et al.1313 Fleck MPA, Lousada S, Xavier M, et al. Aplicação da versão em português do instrumento de avaliação de qualidade de vida da Organização Mundial da Saúde (WHOQOL-100). Rev Saude Publica [internet]. 1999 [acesso em 2018 jul 2]; 33(2):198-205 Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-89101999000200012&lng=pt&nrm=iso&tlng=pt.
http://www.scielo.br/scielo.php?script=s...
was used for the evaluation. The questionnaire includes four domains: physical, psychological, social relations and environment, with 26 subjective evaluation questions, two of which are general questions about QoL, and each of the remaining 24 represents one of the 24 four facets.

Data analysis was performed using the software Statistical Package for the Social Sciences – SPSS 21, according to the model of means and scores proposed by Fleck et al.1313 Fleck MPA, Lousada S, Xavier M, et al. Aplicação da versão em português do instrumento de avaliação de qualidade de vida da Organização Mundial da Saúde (WHOQOL-100). Rev Saude Publica [internet]. 1999 [acesso em 2018 jul 2]; 33(2):198-205 Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-89101999000200012&lng=pt&nrm=iso&tlng=pt.
http://www.scielo.br/scielo.php?script=s...

Results

The 389 caregivers sample included 279 women (71.72%) and 110 men (28.27%).

In the analysis of questionnaire results, Social Relations and Psychological domains obtained the highest scores (respectively 66.13 and 64.52), while the Physical domain presented the lowest score, as shown in figure 1.

Figure 1
Representation of the score per domain

The analysis of each domain involves specific questions. In the Physical domain (domain I), individuals evidenced their satisfaction with their locomotion abilities (89.09), were not very satisfied with their performance at work (66.58), not very satisfied with their daily energy and not very satisfied as to sleep and rest (59.77). The majority of the interviewees reported constant need of medicines, pain and discomfort, which led to dissatisfaction and strong dissatisfaction scores (respectively 29.56 e 22.43), as shown in figure 2-A.

Figure 2
Representation of the scores per domain A – Physical; B – Psychological; C – Social relations; D – Physical environment and access to services

As to the psychological aspects (domain II), the individuals reported self-satisfaction (84.25), reasonably satisfied with their physical appearance (73.97), as well as with their beliefs and religion (69.34), and their learning, memory and concentration skills (64.20). They presented themselves as reasonably satisfied with their feelings and positive thoughts (61.95), but periodically referred negative feelings (33.42), which led to dissatisfaction score, as shown in figure 2-B.

As to social relations (domain III), they were reasonably satisfied with their bonds with friends, colleagues, relatives and acquaintances (67.99), with their sexual life and with the support received from friends (64.07) (figure 2-C).

Domain IV involves aspects related to the physical environment and access to services. When questioned about their environment, as to climate, noise, pollution, and the attractiveness and conditions of the place where they live, opinions were reasonably satisfactory (respectively 73.20 and 63.69). Access to information (65.04), to health services (51.61) and to transportation (68.89) were also considered reasonably satisfactory; and security (65.17) and financial resources available for their needs (50.32) were considered not very satisfactory.

They were dissatisfied with the limited opportunities for leisure (48.46) (figure 2-D).

In questions 1 and 2, where the individual evaluates his/her own quality of life, a median satisfaction score was obtained (71.45).

Discussion

The study has shown a prevalence of female caregivers, which corroborates the results of previous studies1414 Gonçalves LHT, Costa MAM, Martins MM, et al. The family dynamics of elder elderly in the context of Porto, Portugal. Rev Lat Am Enfermagem [internet]. 2011 [acesso em 2018 jul 2]; 19(3):458-66 Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692011000300003&lng=en&tlng=en.
http://www.scielo.br/scielo.php?script=s...
,1515 Guedea MTD, Damacena FA, Carbajal MMM, et al. Social support needs of mexican elders family caregivers. Psicol e Soc [internet]. 2009 [acesso em 2018 jul 2]; 21(2):242-9 Disponível em: http://www.openpsychodynamic.com/?page_id=32.
http://www.openpsychodynamic.com/?page_i...
and demonstrates the social relevance of women as care providers, and the importance of an increase in male participation in the caregiving role1616 Amendola F, Oliveira MAC, Alvarenga MRM. Qualidade de vida dos cuidadores de pacientes dependentes no programa de saúde da família. Texto Context - Enferm [internet]. 2008 [acesso em 2018 jul 2]; 17(2):266-72 Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072008000200007&lng=pt&tlng=pt.
http://www.scielo.br/scielo.php?script=s...
.

Based on the WHOQOL-bref, the analysis of QoL is classified as median, as demonstrated in other studies1717 Stackfleth R, Diniz MA, Fhon JRS, et al. Sobrecarga de trabalho em cuidadores de idosos fragilizados que vivem no domicílio. ACTA Paul Enferm. 2012; 25(5).,1818 Pimenta GMF, Costa MAS, Goncalves LHT, et al. Profile of the caregiver of dependent elderly family members in a home environment in the city of Porto, Portugal. Rev da Esc Enferm da USP [internet]. 2009 [acesso em 2018 jul 2]; 43(3):609-14 Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=cin20&AN=2010436773&lang=es&site=ehost-live.
http://search.ebscohost.com/login.aspx?d...
. The decline in physical well-being, mainly resulting from drug dependence, presence of pain or discomfort, and difficulties and/or lack of sleep and rest are the main factors influencing QoL deficit.

Eker & Tuzun1919 Eker L, Tüzün EH. An evaluation of quality of life of mothers of children with cerebral palsy. Disabil Rehabil [internet]. 2004 [acesso em 2018 jul 2]; 26(23):1354-9 Disponível em: http://informahealthcare.com/doi/abs/10.1080/09638280400000187.
http://informahealthcare.com/doi/abs/10....
evaluated the QoL of mothers of children with brain paralysis, and reported the impact of daily caregiving tasks with their children on the mothers’ physical well-being. The study showed that helping or performing daily life activities (DLA) and the physically disabled children’s locomotion exerts high physical pressure on the caregiver’s functional capabilities1919 Eker L, Tüzün EH. An evaluation of quality of life of mothers of children with cerebral palsy. Disabil Rehabil [internet]. 2004 [acesso em 2018 jul 2]; 26(23):1354-9 Disponível em: http://informahealthcare.com/doi/abs/10.1080/09638280400000187.
http://informahealthcare.com/doi/abs/10....
. In the same vein, Trigueiro et al.2020 Trigueiro LCL, Lucena NMG, Aragão POR, et al. Perfil sociodemográfico e índice de qualidade de vida de cuidadores de pessoas com deficiência física. Fisioter e Pesqui [internet]. 2011 [acesso em 2018 jul 2]; 18(3):223-7 Disponível em: http://www.scielo.br/pdf/fp/v18n3/04.pdf.
http://www.scielo.br/pdf/fp/v18n3/04.pdf...
reported that constant emotional tension and physical effort generate physical pain for the caregiver, which, summed to other responsibilities, such as domestic tasks, attention to other members of the family, yet added to professional work, are factors that lead to health deterioration.

Low income is also an important factor affecting QoL, and this study did obtain low scores in aspects that evaluate financial resources. Nakatan et al.2121 Kyosen Nakatan AY, Soares Souto CC, Paulette LM, et al. Perfil dos cuidadores informais de idosos com déficit de autocuidado atendidos pelo programa de saúde da família. Rev Eletrônica Enfem [internet]. 2003 [acesso em 2018 jul 10]; 5(1):15-20 Disponível em: http://www.revistas.ufg.br/index.php/fen/article/view/773/862.
http://www.revistas.ufg.br/index.php/fen...
and Gonçalves et al.1414 Gonçalves LHT, Costa MAM, Martins MM, et al. The family dynamics of elder elderly in the context of Porto, Portugal. Rev Lat Am Enfermagem [internet]. 2011 [acesso em 2018 jul 2]; 19(3):458-66 Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692011000300003&lng=en&tlng=en.
http://www.scielo.br/scielo.php?script=s...
reported that one of the consequences of caregiving responsibilities, particularly when person under care presents high levels of functional dependence, is the large amount of time the caregiver spends and that, under such circumstances, many caregivers come to present professional limitations, which usually lead them to abandon the professional life.

They also report that, as a consequence, the caregiver tends to neglect his/her self-care, including health, which affects the physical domain and aspects related to the environment and to access to services, justifying the ‘not very satisfactory’ result in the present study.

Delalibera et al.2222 Delalibera M, Presa J, Barbosa A, et al. Sobrecarga no cuidar e suas repercussões nos cuidadores de pacientes em fim de vida: revisão sistemática da literatura. Cien Saude Colet [internet]. 2015 [acesso em 2018 jul 10]; 20(9):2731-47 Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232015000902731&lng=pt&tlng=pt.
http://www.scielo.br/scielo.php?script=s...
observed impacts on caregivers’ routines, since the individual under care tends to be involved in several rehabilitation activities, which requires more time dedicated to him/her, thus reducing the time the caregiver could use for his/her own care and leisure, at the cost of damage to his/her social life and psychological consequences. According to Tekinarslan2323 Tekinarslan IC. A Comparison Study of Depression and Quality of Life in Turkish Mothers of Children with down Syndrome, Cerebral Palsy, and Autism Spectrum Disorder. Psychol Rep [internet]. 2013 [acesso em 2018 jul 2]; 112(1):266-87 Disponível em: http://journals.sagepub.com/doi/10.2466/21.02.15.PR0.112.1.266-287.
http://journals.sagepub.com/doi/10.2466/...
, caregivers who attend patients with special needs are more vulnerable to depression, due to the large amount of time and effort required. The author also reports that with patients with socialization difficulties, such as Autistic Disorders, the caregivers participation in outside activities is even more troublesome, since his/her attention is completely drawn to the child, and some professionals find it difficult to understand the child’s behavior2323 Tekinarslan IC. A Comparison Study of Depression and Quality of Life in Turkish Mothers of Children with down Syndrome, Cerebral Palsy, and Autism Spectrum Disorder. Psychol Rep [internet]. 2013 [acesso em 2018 jul 2]; 112(1):266-87 Disponível em: http://journals.sagepub.com/doi/10.2466/21.02.15.PR0.112.1.266-287.
http://journals.sagepub.com/doi/10.2466/...
. Therefore, the resulting overload and the sparing opportunities for leisure due to the time spent in care, financial problems, dissatisfaction with the environment and the constant perception of tiredness can lead to negative feelings and to impacts on social relations, which correspond to the psychological and social domains that registered low scores in this study.

As to self-evaluation, it can be noticed that individuals focused in this study evaluate their own QoL as median. According to Kluthcovsky et al.2424 Kluthcovsky ACGC, Takayanagui AMM, Santos CB. Avaliação da qualidade de vida geral de agentes comunitários de saúde: a contribuição relativa das variáveis sociodemográficas e dos domínios da qualidade de vida. Rev Psiquiatr do Rio Gd do Sul [internet]. 2007 [acesso em 2018 jul 2]; 29(2):176-83 Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0101-81082007000200009&lng=en&nrm=iso&tlng=pt.
http://www.scielo.br/scielo.php?script=s...
, this analysis results from the combination of the most relevant aspects of their lives, which leads to a global evaluation that may change over the lifetime. The authors also remark the importance of this evaluation as a tool to appreciate the individual’s opinion. In this study, similar scores were obtained in the overall evaluation of both the questionnaire and the self-evaluation.

This study did not detail characteristics and correlations between caregivers’ and practitioners’ profiles. Future research should proceed to deeper characterization of the sample and investigate to what extent the practitioner’s functional dependence on the caregiver impacts his/her performance. Another important aspect was the fact that many caregivers had low educational level, requiring the researcher to help him/her when filling out the questionnaire, which may have influenced the responses.

Conclusions

The results evidenced that the task of caregivers of practitioners of equine therapy can lead to negative physical and mental changes, which can affect the quality of the care provided to the person under care and his/her well-being. Adequate assistance must thus be provided to these individuals.

The research included all the equine therapy centers in the Federal District, and a significant parcel of the caregivers was interviewed. Nonetheless, further studies in other equine therapy centers are necessary to confirm these findings.

  • Financial support: non-existent

References

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    Rodrigues IF, Nielson MBP, Marinho AR. Avaliação da fisioterapia sobre o equilíbrio e a qualidade de vida em pacientes com esclerose múltipla. Rev Neurociencias. 2008; 16(4):269-74
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    Beinotti F, Correia N, Christofoletti G, et al. Use of hippotherapy in gait training for hemiparetic post-stroke. Arq Neuropsiquiatr [internet]. 2010 [acesso em 2018 jul 2]; 68(6):908-13 Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-282X2010000600015&lng=en&nrm=iso&tlng=en
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    Hsieh YL, Yang CC, Sun SH, et al. Effects of hippotherapy on body functions, activities and participation in children with cerebral palsy based on ICF-CY assessments. Disabil Rehabil. 2017; 39(17):1703-13
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    Vieira FS. Avanços e desafios do planejamento no Sistema Único de Saúde. Ciênc. Saude Colet. 2009; 14(supl.):1565-77.
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    Oliveira DC, D'Elboux MJ. Estudos nacionais sobre cuidadores familiares de idosos: revisão integrativa. Rev Bras Enferm [internet]. 2012 [acesso em 2018 jul 2]; 65(5):829-38 Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&amp%5Cnpid=S0034-71672012000500017
    » http://www.scielo.br/scielo.php?script=sci_arttext&amp%5Cnpid=S0034-71672012000500017
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    Ozturk Y, Riccadonna S, Venuti P. Parenting dimensions in mothers and fathers of children with Autism Spectrum Disorders. Res Autism Spectr Disord. 2014; 8(10):1295-306
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    Miura RT. Paralisia cerebral grave : o impacto na qualidade de vida de mães cuidadoras. Mudanças - Psicol da Saúde [internet]. 2012 [acesso em 2018 jul 2]; 20(1-2):7-12. Disponível em: https://www.metodista.br/revistas/revistasmetodista/index.php/MUD/article/view/3146/3126
    » https://www.metodista.br/revistas/revistasmetodista/index.php/MUD/article/view/3146/3126
  • 9
    Pimenta RA. Avaliação da qualidade de vida e sobrecarga de cuidadores de pessoas com deficiência intelectual. Rev Bras Ciências da Saúde [internet]. 2010 [acesso em 2018 jul 2]; 14(3):69-76 Disponível em: http://periodicos.ufpb.br/ojs2/index.php/rbcs/article/viewFile/9687/5406
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    » http://189.28.128.100/dab/docs/portaldab/publicacoes/cad_vol2.pdf
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    Ory MG, Hoffman RR, Yee JL, et al. Prevalence and Impact of Caregiving: A Detailed Comparison Between Dementia and Nondementia Caregivers. Gerontologist. 1999; 39(2):177-85
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    Cox CR, Eaton S, Ekas NV, et al. Death concerns and psychological well-being in mothers of children with autism spectrum disorder. Res Dev Disabil. 2015; 45-46:229-38.
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    Fleck MPA, Lousada S, Xavier M, et al. Aplicação da versão em português do instrumento de avaliação de qualidade de vida da Organização Mundial da Saúde (WHOQOL-100). Rev Saude Publica [internet]. 1999 [acesso em 2018 jul 2]; 33(2):198-205 Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-89101999000200012&lng=pt&nrm=iso&tlng=pt
    » http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-89101999000200012&lng=pt&nrm=iso&tlng=pt
  • 14
    Gonçalves LHT, Costa MAM, Martins MM, et al. The family dynamics of elder elderly in the context of Porto, Portugal. Rev Lat Am Enfermagem [internet]. 2011 [acesso em 2018 jul 2]; 19(3):458-66 Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692011000300003&lng=en&tlng=en
    » http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692011000300003&lng=en&tlng=en
  • 15
    Guedea MTD, Damacena FA, Carbajal MMM, et al. Social support needs of mexican elders family caregivers. Psicol e Soc [internet]. 2009 [acesso em 2018 jul 2]; 21(2):242-9 Disponível em: http://www.openpsychodynamic.com/?page_id=32
    » http://www.openpsychodynamic.com/?page_id=32
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Publication Dates

  • Publication in this collection
    Jul-Sep 2018

History

  • Received
    26 Oct 2017
  • Accepted
    04 July 2018
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