ORIGINAL ARTICLES

Prevention of cervical cancer in pregnant women: a phenomenological study

Rita de Cássia Rocha Moreira¹, Regina Lúcia Mendonça Lopes¹, Normélia Maria Freire Diniz²

¹Feira de Santana State University
²Bahia Federal University

ABSTRACT
Problem: pap smear tests during pregnancy are part of pre-natal care routines. However, many pregnant women are not well informed regarding the importance of the exam.
Aim: to understand the perception of cervical cancer from the point-of-view of pregnant women.
Method: this is a Heideggerean phenomenological study, based on the methodological steps of phenomenological reduction, construction, and destruction. The development of this study followed the ethical standards described in Resolution 196/96.
Results: the results show that pregnant women who experience the prevention of cervical cancer try to ignore the word ‘cancer,’ when referring to the possibility of being sick, as seen when they speak and the way they discuss the relationship between themselves and the health professionals.
Conclusion: we need to deal with the challenge to recognize the fragility of the biomedical model to take care of the health of women, aiming to achieve more comprehensive care.
Descriptors: Prevention; Neoplasms; Pregnant Women; Nursing; Philosophy.

INTRODUCTION

Pregnancy represents an experience filled with feelings of pleasure, satisfaction, fear, anxiety and others. Sometimes, in emotionally confusing moments, these feelings can interfere in the intrapsychic and relational world of people. There is a narrow relationship between physiologic aspects, as well in pathologic, emotional, social, and marital aspects⁽¹⁾. Within this perspective, these elements compose the existence-project, which holds a certain ontological content as yet unexplored, which belongs to the essence and specificity of beings.

The pre-invasive wounds that characterize the development of cervical cancer are associated with infection by the Human Papilloma Virus (HPV). Between 1970 and 1980, the first evidence associating HPV to this pathology were observed and, by the end of the 1990s, there was a viral presence in almost 100% of HPV cases⁽²⁾.

The Brazilian National Cancer Institute (INCA, in Portuguese) generated an estimate for the years 2012-2013, noting the occurrence of 518,510 new cases of cancer in Brazil. Among these cases, INCA estimated new cervical cancer cases could make up 17,540 cases in 2012-2013, or 17 cases in every 100,000 women⁽³⁾.

During pregnancy, the estimate of the incidence of cervical cancer is 1:1,000, which represents around 5% of the population of pregnant women. There is a prevalence of this pathology in 5.7% of women, as was also found in the literature (around 5%), despite the fact that in Brazil there are few journals that deal with the topic, and they do not provide updated statistics⁽⁴⁾.

A third of cervical carcinoma cases occur during the reproductive period and around 3% of the diagnoses occur during pregnancy. Pregnant women present a higher chance of being diagnosed with initial wounds, as pregnancy is an excellent opportunity to track this sort of neoplastic event, and the performance of pap smear exams to look for cervical cancer are part of the pre-natal care routine⁽⁵⁾.

Nursing professionals who receive the pregnant mothers must pay attention to, besides physical factors, a diversity of other factors such as existential, economic, and familiar spectrums, as they all can influence the adherence of the pregnant woman to consultations and examinations during the pregnancy period⁽⁶⁾.

To assist a woman who has or has had cervical cancer during pregnancy represents a singular moment to the nurse. Among the situations experienced by one of the authors, we highlight the situation of a patient seeking information who was sensitized, fragile, and crying, and this instance demonstrates the necessity for developing a more welcoming and comprehensive pre-natal care consultation.

Sometimes women do not undergo the recommended exams because of fear or anguish regarding the possible diagnosis⁽⁷⁾. Therefore, an innovative side towards the prevention of cervical cancer in pregnant women can be created based on phenomenological positions, as these stances are an invitation to reflect upon models and questions considered solved, permitting us to rethink actions in healthcare⁽⁸⁾.

Heidegger’s phenomenological studies emerge as an important philosophical contribution and are seen as an open door to the possibility to reflect and improve the quality of nursing care. When using an existential approach to the questions in health and illness, we are opening new possibilities to a comprehensive and humanized care^(9,10).

This may be the step to be taken to propose an existential understanding to women’s health, based on Heidegger’s philosophical perspective. Such a step will allow us to see that there is more than technicality and scientific knowledge, although they are also important in healthcare. The formal knowledge must sum up to the construction of new standards that will be welcome to those searching for an improvement in healthcare⁽¹¹⁾.

Within this perspective, this study aims to understand the sense of the prevention of cervical cancer from the perspective of the pregnant woman. In the prevention of the pathology, there is a possibility of unveiling existential situations.

METHOD

Heidegger’s method is built upon three components: reduction, construction, and destruction. It aims to find a hermeneutic interpretation of the facts. It starts with a vague and average comprehension of the facts, which is brought up by the subjects in the study, and then from this understanding, the explicit question regarding the sense of being emerges, as well as the development of the concept contained in the understanding^(12,13).

This research was performed in a municipality in the countryside of the Brazilian state of Bahia, from February 27 to April 25, 2012, and included the participation of 10 pregnant women, all over 18 years old, who had both signed the Free and Clear Consent Agreement (FCCA) and had had pap smears. They were registered in the pre-natal ward and assisted by nurses. To preserve anonymity, they had their names changed to flowers. The data collection technique used was the phenomenological interview and, as an instrument, a previously tested guide.
The sample number was determined at the moment the reports showed themselves to be enough to answer the questions of this research.

Some approaching questions were applied, such as “What do you understand as prevention of cervical cancer?” and the guiding question of this research, “‘For you, how important are the preventive exams during pregnancy?”
The comprehensive analysis based on the hermeneutics of facticity started with an attentive reading of each interview. The phenomenological sight needs to be driven towards an entity in a way this entity is highlighted and works on a possible theme. Then, the ontological-existential investigation is driven toward the entity, trying to find the reason of being.

Thus, based on the phenomenological reduction, a fundamental component of the method guides the being to the entity and then back to the being; from this point, it is possibly the redirection, projected to build the unveiling. All projection of the being is done in a reductive regression process from the entity. Hence, the moment of awareness of the ontological difference permits the entity to understand the truth, in both the ontological/phenomenological characteristics (reduction or redirection from the entity to the being) and the ontic characteristics (reduction or redirection from the being to the entity).

To understand and apply the phenomenological reduction, a spreadsheet was created to consolidate the testimonies, from which some ontic elements were extracted, such as: fear; anxiety; silence; disinformation; lack of understanding and; insecurity and distrust in the marital relationship. Ontological elements included: to be-with; solicitude; fear; concealment; ambiguity; pre-occupation and; inauthentic care.

In phenomenological construction, the understanding is processed upon the idea of being, constructed upon the welcoming; what was investigated was how the pregnant women reported this moment and how they projected themselves in regard to prevention. In the phenomenological destruction, the ontic/ontological truth was found based on what was observed regarding being and entity from Heidegger’s existential structures.

This research was approved by the Ethics in Research Committee of Feira de Santana State University (UEFS, in Portuguese), under protocol number 125/2011 (CAAE registry 0130.0.059.000-11), on November 29, 2011.

RESULTS

The participants of this study were pregnant women aged between 20 to 38-years-old. In regard to their marital status, two were single, one was divorced, three were married and four were in ‘enduring relationships’. The age of the women at their first sexual encounter ranged from 12 to 23-years-old and the number of partners in life oscillated between two to six. In regard to safe sex, all mentioned the use of condoms during sexual intercourse.

The ways of being that support the lived experience of pregnant women during the phenomenon of the prevention of cervical cancer were unveiled. With this unveiling, the units of sense emerged, which are: (i) The veiling of the word cancer: fear of illness and death?; (ii) Inauthenticity of the relationship between the professional and the client: the impact of the prevention of cervical cancer in pregnant women; (iii) Expressions of solicitude and to be-with in the relationship between pregnant woman/fetus: implicit aspects in the prevention of cervical cancer; (iv) Chatter: what happens with pregnant women during the prevention of cervical cancer.

Veiling the word cancer: fear of illness and death?
The pregnant women did not verbalize either the word cancer during their reports about the prevention of cervical cancer or the importance of the pap smear exams during pregnancy, which possibly demonstrates the veiling and the fear this word can offer to their existence.

Concerning the forms of prevention and the fear of the illness:

I think that…, well… Having sex wearing a condom must avoid it… I don’t know, … A good hygiene too? I don’t know much, doctor. I think that’s all! (Sunflower)

[ ... ] I already had the experience, you know? Not a cancer, you know? God forbids me, but… I already had some wounds, I needed cauterization, and I was also afraid, thinking it could have been something worse. (Orchid)

Concerning the importance of performing pap smear exams during pregnancy:

[ ... ] Because of pregnancy, right? It is good for the people to protect themselves, doing all exams during pregnancy [ ... ] To check if there is something wrong or not [ ... ]. (Violet)

Oh! I don’t know how to say that [ ... ] the preventive exams during pregnancy can spot many diseases that can even affect the baby. (Rose)

The pregnant women show the mode of concealment, as seen in the language expressions used, where the word cancer was not pronounced, substituted by expressions such as:

[ ... ] to see if there was something there or not [ ... ] [ ... ] many types of diseases [ ... ] [ ... ] so nothing serious happen [ ... ] [ ... ] a good hygiene (Violet; Rose)

In the following reports, it is possible to see that the pregnant women fearfully experience the prevention of cervical cancer:

[ ... ] It is good to do the exams, as a follow up… so nothing serious happen, or it doesn’t get worse than it already is… [ ... ] affecting the state of health, to have some risk, risk of death, something like this... (Wild Daisy)

[ ... ] Cancer: the main one, which is the cervical cancer, right? [ ... ] Because, because it is what we are most fearful about, right? Because we know there is no cure for it [ ... ]. (Lily)

Inauthenticity of the relationship between the professional and the client: the impact of the prevention of cervical cancer in pregnant women
The condition of inauthenticity observed in this study points to the process of the lack of understanding and information that the pregnant woman has regarding the importance of undergoing pap smear exams. Despite the fact that this client is supported by health professionals, it is known that the service provided in basic care is focused in the prevention of illnesses and the promotion of health, yet as evident in the reports from the pregnant women Sunflower and Rose, besides the fact they underwent the exams, these women were not able to express their importance:

In fact, we know it is necessary to do the preventive exams, at least once a year, but we don’t know exactly why we do the preventive exam. [ ... ] Another thing we also don’t know for sure is cervical cancer [ ... ]. (Sunflower)

Oh! I don’t know how to explain that well [ ... ] The preventive exam during pregnancy prevents many types of diseases that can even affect the baby. (Rose)

Lily mentions that:

[ ... ] There is a lack of information; we know there is cervical cancer, but we don’t know how to protect ourselves. Many times I think that the information is scarce, especially for the pregnant women. We come to do the pre-natal consultation, but we are not informed. They ask us to perform the preventive exams, but there is no explanation why we need to do that.

In the abovementioned report, it was unveiled that the co-presence (the meeting between the pregnant woman and the health professional) occurred on the mode of inauthenticity, representing the fragility of the professional compromise to be-with the pregnant woman, thus demonstrating that the professionals did not feel touched by the other (patient).

The pregnant women in this study made clear the deficiency and the indifference in their experiences with the health professionals when dealing with the prevention of cervical cancer. This is seen in Lily’s comment:

[ ... ] They ask us to do the preventive exam, and then they don’t explain why should we do the preventive exam [ ... ].

Expressions of solicitude and to be-with in the relationship between pregnant woman/fetus: implicit aspects in the prevention of cervical cancer
In the sense unit that unveils the expressions of solicitude to be-with in the relationship between the pregnant woman/fetus, there is a need to consider the process of unawareness and disinformation that are present in the following reports:

[ ... ] To not transmit it to the baby! To avoid the contamination of the baby, right? With the presence of a bacteria or any other problem that may affect the baby, to be seen on the result, right? (Lily)

I think that, so the baby is born healthy, and the mother to have a healthy pregnancy. (Jasmine)

It was evident that the pregnant mother does not know that cancer is not a contagious disease and, therefore, there is no way to transmit it to the fetus, unless extreme conditions affect the labor process, but even then there is no contamination based on the perspective held by the pregnant women.

The solicitude, which overlaps the basic characteristics every person needs to have in order to be considerate to the others and the patience needed when dealing with the others, is observed in the following report:

[ ... ] I know many people that have many problems during pregnancy, transmitted to the child and then… I don’t want that to my child! [ ... ] (Violet)

In the reports by Sunflower, a way of solicitude was also found:

I think that… Avoids transmitting anything to the baby? (Sunflower)

This report led to the conclusion of the ways of opening and disposition of the pregnant woman to watch over her own pregnancy status. The disposition is the condition of a possibility of a ‘drive towards’. This pregnant mother is then in an opening relationship between a Dasein and the other, hence the solicitude becomes undeniably important to build the ontological-existential constitution of love. That is how the women demonstrated love for their children.

Chatter: what happens with the other during the prevention of cervical cancer
The pregnant women reported the experiences lived by other people:
[ ... ] HPV, there are many diseases, I know a person who got HPV and developed a condyloma. (Angelica)

I know people that have been eight years since their last preventive exam. Then when decide to go, they are surprised that they are… and then, sometimes there is no more time to do the treatment. (Orchid)

(Silence) It’s life, right? First of all, it’s life, because we cannot play with that [ ... ]. (Orchid)

Thus, in this study, in some moments, the horizons of significance in the prevention of cervical cancer in pregnant women were projected in the ways of their chatter.

DISCUSSION

Within the perspective of Heidegger’s hermeneutics circularity, understanding is always an anticipative process developed during the interpretation; the understanding gives us the references to the things and the world. To interpret is to elaborate understanding from the anticipative hermeneutic structures. The interpretation will articulate and elaborate a reason, giving the discussion a meaning. This reason necessarily represents a perspective. Therefore, in regard to the hermeneutics, we must include interpretation any time we present some understanding of the facts observed⁽¹²⁾.

The understanding and the interpretation are intimately connected, constantly switching places in a hermeneutic circle. Heidegger connected the questions regarding the meaning of historical texts with the questions regarding the meaning of life; in a conference in 1923, he moved to a hermeneutics of facticity, which was seen as an interpretation of the human being—Dasein—and of daily life⁽¹⁴⁾.

Ontological difference is present in the reports and it demonstrates the spaces of identity during the prevention, characterized especially by fear⁽¹⁵⁾. Fear is a non-permanent mode of disposal, a natural way of being for a woman who is going to undergo a pap smear exam and feels frightened and fearful of the possible results because, based on the wealth of information that the patient has access to, the piece of knowledge with the higher impact is that cancer leads to death.

In Heidegger’s meditation, language is not only an existential characteristic, but it is the primary existence in which all the ways of being-in-the-world are crisscrossed, making it possible to understand the situation of man in the world. To exam the truth about the prevention of cervical cancer from the perspective of pregnant women is to analyze how the Dasein is open to what is seen⁽¹⁵⁾.

The fear and the unveiling of the word cancer, which seemed filled with some important meaning to the pregnant women, is always taken as a previous condition⁽¹²⁾. Related to cancer, there is a precedent understanding that it is a serious pathology, which can even lead to death. The explanation of being-to-death is caught in the chatter of the impersonal and it is in daily life that they affirm the certitude of death. But the delimitation of the existential structure of the being to the end also works to elaborate a way of being of the Dasein in which it can become the whole⁽¹²⁾. Therefore, even with the possibility of connection between cervical cancer and death, the pregnant woman has shown an existential plan to perform pap smear exams with confidence.

The pregnant woman already understands the prevention from the meanings that mass media, the health professionals, and other people provide to her. In some situations there is a flux of information that may compromise the human capacity to judge⁽¹¹⁾.

The fear of cancer, especially the cervical type, could clearly be witnessed in the pregnant women. There is always a primitive phenomenon in the human being that is the preoccupation with one’s own health, even in an ambiguous form and, in the reports, this concern was surrounded by feelings of ignorance, insecurity, and disinformation, which may lead to the phenomenon of fear⁽¹¹⁾.

Therefore, in regards to this ambiguous configuration containing these feelings, what is generated is a general understanding in which everything can be understood, however superficially; in an ambiguous environment we do not have the contact with the basis, the origin of the object we are dealing with, nor we are able to fully appropriate the object⁽¹⁶⁾.

To understand the way of disposal of being-in-the-world and the relationship established with healthcare, it is urgent to recognize that we are released-in-the-world. And to be released means to find yourself with a possibility of authentically or inauthentically living your life, without considering the moral conditions, but based on the ways of being-in-the-world⁽¹⁵⁾.

Consequently, it is important to reflect upon the gap between the capacity to perform and the responsible want-to-do, so that we can proceed with another step towards the understanding of more authentic relationships in the world of health⁽¹¹⁾.

From the reports taken, it was seen that the state of inauthenticity reaches also the meeting between the pregnant woman/the health professional during the healthcare services, as in the condition of being pregnant and when being cared for, the patients see themselves without any possibility of understanding the importance of undergoing the pap smear exams, even mentioning that there is a request for the exam without explaining the necessity and importance for this exam to be performed.

The being-in-the-world is determined by the ‘with,’ as the world is always shared with others. The Dasein world is shared. The be-in is be-with the others, which is the characteristic of the co-presence⁽¹²⁾.

Therefore, the adoption of innovative proposals in the health assisting routines is urgent in terms of aiming to strengthen a nurse’s work and welcoming processes for the women looking for support in preventing cervical cancer.

Within this comprehensive perspective, it is possible to offer some support to healthcare services through mobilization and education that promote the reflection and changes of professional attitude in order to offer a more inviting welcome to the women, permitting them to explain the importance of healthcare, especially the prevention of cervical cancer. Thus, it is the thinking and doing, as existential and equiprimordial possibilities, that mutually overlap⁽¹⁷⁾.

In addition, there is a need to incorporate in the discussion other factors that involve prevention, such as the subjectivity of the female body and the psychoaffective aspects and the relationships that these women established with their ways of being and existing⁽¹⁸⁾.

Solicitude is guided by consideration and patience. The solicited care is seen at the level of what are we taking care-with and together with our own understanding of this process. Thus, the other is immediately seen unveiled during the caring solicitude⁽¹⁷⁾.

In the reports, it was possible to observe the way of being-with of the pregnant woman toward the fetus in regard to the prevention of cervical cancer. In this relationship, pap smear exams are no longer seen as cancer tracking procedures, but an element that may protect the fetus⁽¹⁾.

The women have shown that they do not have the habit of taking care of their own health to help themselves, as a practice of self-care, but as caring for the other, the baby. The being-with of the pregnant women was surrounded by the way of being, existentially determined by the preoccupation that the other cannot be substituted but, on the other hand, other possibilities to jump over the other arise, by way of consideration and patience, because the being-with of the pregnant/fetus, in this study, represented the being-for-the-others, and was seen by the projection of women’s being to themselves ‘in another one’⁽¹²⁾.

To be considerate and patient with the others are not moral principles, but ways of living with the others based on experiences and expectancies⁽¹⁷⁾. The reports unveil the relationship that is established with what is experienced in the contacts with other people, waking up in the pregnant woman the zeal to the child that is yet in her womb.

Hence, in this study it was seen that the being-with is the constituent of all of us. In that sense, here we observe that healthcare is aimed at the woman that takes care of her own child in her womb, pointing out that it is not possible to perform any caring without the presence of the other; the mother is being cared for by the health professionals and she takes care of the fetus also based on this professional care.

The being-with is always done in a shared world. In this world, the nursing professionals must be motivated since their first moments during their undergraduate studies to learn how to promote caring based on the abilities focused on human relationships⁽¹⁹⁾.

The chatter should not be taken pejoratively. This is a positive phenomenon that is built from the way of being, of understanding, and also from the daily interpretation of the Dasein. Everybody first pays attention to how the other behaves and to what the other is going to say. Therefore, in existence, the chatter is always insinuating something⁽¹¹⁾.

In regards to the impersonality, the Dasein mixes with the other Daseins, being absorbed by them. The reports show the ‘way of impersonality’ through the chatter, either by the demonstrations of curiosity and also by the ambiguity in the discourse. In this perspective the relationships with the others in an ordinary world are guided by the collective interpretations and then doing and saying what others say⁽¹⁰⁾.

Dasein is always there in an ambiguous way, from the public opening to live in the community, in which the most intense chatter and the most acute curiosity control daily life⁽¹²⁾. There is an ontological way for the Dasein to unveil itself. A fundamental way of being in the everydayness is called decadence. In this aspect, the chatter, the curiosity, and the ambiguity are characterized by the way the Dasein performs daily its ‘pre,’ the opening of being-in-the-world.

The word decadence does not express any negative connotation; it only pretends to be that, in a first moment and most of the time, the Dasein is close and in the world of occupations.
Ambiguity is not related only to the inclination and the way of dealing with what is available, but it is also already consolidated in the understanding how a can-be exists in the ‘mode of projection’ and the preliminary donation of possibilities. It is already present in the familiarity, while it is a familiarity already used in the world⁽¹²⁾.

The reports are related to the situations associated to the chatter, which supervene cervical cancer. There is always a connection between the reports of HPV and cancer, between the non-performance or the delay in performing pap smears, with the situations of diseases that can be linked to cervical cancer.

During some moments, the pregnant woman is silent for several seconds to get connected with the impersonal mode of ‘we.’ This format of expression refers to the way of living with the others in daily life. This ‘we’ has its own characteristics and is the dominant public in the way of living with the others⁽¹⁷⁾.

There are no value connotations to the ‘we’ with regard to the way of living, but we call attention to the fact that it is a living diluted in popularization, absorbed in the collectivity, transforming into a piece, a manageable object⁽¹⁷⁾.

In the chatter, what is said is that, besides trying to find the objectivity of the discourse, it has no contact with the ontological origin of the entity of reference, or in other words, the basis of what is being dealt with is unknown, and then being led to repeat what was already said and repeating the discourse. What is communicated stays in the area of average understanding. Such comprehension is supported by the fact that in the world we are always placed in, our existence has a structure of being-in-the-world, and this world is seen as a shared one⁽¹⁶⁾.

The world is seen on itself and it is not the sum of all living beings and things, neither is a physical space on which all the things are placed together. The world is, before all, a horizon of meanings on which the existence is always being projected⁽¹²⁾.

Therefore, it is from this horizon that the existent finds the meanings of the self and the being of things that come along⁽¹²⁾. From the moment the world reveals the meaning of the things it is understood as language. Hence, language is the opening because it demonstrates the moment of projection of the Dasein in the world⁽¹³⁾.

CONCLUSION

It is understood that the women did not demonstrate an awareness of the ‘pre’ in prevention, as anticipation in the diagnosis of pathology. And, because of a lack of understanding, disinformation, or non-adherence to pap smear examinations—because they are invasive and impersonal—this transfers the exams’ purpose from the women to the child they were gestating. The pregnant women led to the transpiring of a veiling regarding the recognition of the importance of undergoing the exams, because the exams are covered with the existential disposition of fear.

The pregnant mother is seen as fearful of the possibility of falling ill and the dying associated with cancer. She does not create a direct relationship between pap smear exams and the prevention of cervical cancer, which demonstrates a distance between the client and the health professionals, as the units of sense pointed to an unveiling of a relationship based on inauthentic care, which is characterized by people that live their encounters based on prejudging, values, and pre-established ideas.

When understanding that the discourses pointed to the visibility of a relationship between the health professional/pregnant woman that were, most of the time, based on inauthenticity, some questions arose: how can we contribute to the changes of attitude in academia and in health services? Which strategies of confrontation can be used to mobilize and awaken nursing professionals to a more comprehensive approach in the matters of health? How much is forgotten in the matters of authentic relationships in healthcare? What needs to be done to improve the inauthentic ways of being in the relationships?

The gap that the way of inauthenticity leaves in ordinary daily lives found in the locations of healthcare services can support the chatter about the occurrence of cervical cancer, and it can also awaken in the pregnant woman the way of being in ambiguity, because she is exposed to the influence of many sources of information, permitting collective interpretations and, then, she repeats what is done or said based on what others have said.

It is from the opening to an authentic care that a possibility arises to a more comprehensive sight towards the women and the actual public health policies that involve the prevention of cervical cancer.

It is necessary to move towards the dynamics found in the fabric of existential meeting with the pregnant women, in a way to interpret their discourses when performing pap smear exams, once the discourse is an articulation of the understanding, and it can assist them to understand the exams as something necessary to maintain their health, and not only as a factor to protect and care for the fetus, as unveiled in this research.

In attempting to recognize progress in public policies in the area of women’s health, it is also necessary to confront the challenge to recognize the fragility of the biomedical model in this area of healthcare service. We defend that the model of pre-natal care must be based on a comprehensive mode of solicitude, centered in the existential dimension of women that search for health services. This is the acting in health linked to the time and historicity of Dasein, which deals with the human action linked to the horizon of existentiality and the open mode of being-in-the-world, permitting the welcoming, the linkage, and the responsibility in healthcare. The challenge is launched!

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Received: 07/08/2012
Revised: 18/07/2013
Approved: 22/08/2013