Dilemmas and challenges for HIV prevention in representations of young Catholics

Pablo Luiz Santos Couto1, Mirian Santos Paiva2, Jeane Freitas de Oliveira2, Antônio Marcos Tosoli Gomes3, Larissa Silva de Abreu Rodrigues4, Marizete Argolo Teixeira5
1 Guanambi Higher Education Center
2 Federal University of Bahia
3 University of the State of Rio de Janeiro
4 State University of Bahia
5 State University of Southwest of Bahia

ABSTRACT

Aim: analyze the process of formation of social representations built by young Catholics on HIV prevention. Method: This is a qualitative and quantitative study, carried out on Facebook and based on Social Representation Theory. The in-depth interview was used as a data collection technique, which was processed in Alceste software, allowing the analysis of lexical content. Results: The representations of young people about HIV prevention, shaped in the systems of cognition, point out that the object is signified as a phenomenon intrinsic to the sphere of sexuality, influenced by both the Catholic religion and progressive knowledge. Discussion: Influences on the formation of representations of young people about HIV prevention reveal dilemmas, pointing to the formation of a strange element due to the duality of structured social thinking. Conclusion: The influence of Catholic doctrine implies confronted dilemmas about safe sexual practice and interferes with HIV prevention: this is the greatest challenge.

Descriptors: Religion and Sex; Sexuality; Human Immunodeficiency Virus; Health.

INTRODUCTION

The Catholic Church, as the predominant religion with the greatest number of adherents in Brazil, has been a source of knowledge and representations regarding sexual practice and the preventive forms of human immunodeficiency virus (HIV) infection.

With this, most of the discourse of the ecclesiastical institution is presented reaffirming traditional positions on sex and sexuality, which contrasts with the reified discourse of institutions and bodies that govern health as well as academics. Prevention is the most effective means of combating AIDS and the Church can be a suitable place for the cultural training of young people in terms of HIV prevention and its representations**.**

Around these discussions, there is a relation between the challenges of prevention with the spread of HIV/AIDS and, at the center, the young people who are perceived as vulnerable. The increased incidence of HIV/AIDS in the groups represented by teenagers and young people should be highlighted(1). The future course of the global HIV/AIDS epidemic is related to the vulnerabilities of young people and the contextual factors that can influence healthy behaviors, such as safe sex practices(2).

Therefore, this study was necessary to help understand how young Catholics deal with the dilemmas that involve sexual freedom, the adoption of HIV/AIDS prevention practices and the way they represent such phenomena in relation to religious principles.

The purpose of this study was to analyze the process of formation of social representations built by young Catholics on HIV prevention. In this perspective, this work deals with the contents that emerge from the psychosocial constructions of Catholic youths belonging to the Catholic Charismatic Renewal (CCR)(3).

METHOD

It is a qualitative-quantitative study, presented in the Theory of Social Representations (TSR) in its procedural approach. The TSR, in the procedural perspective, which allows the comprehension in terms of how social representations are constructed, leads to an understanding of the mental constructions related to the reality common to a group of people, encompassing a set of concepts, propositions and explanations of daily interpersonal experiences that work as a theory of common sense(4-6). The theory makes it possible to understand the meanings, symbols and ideologies of the unconscious that conform the human cognitive system and that is shared, diffused and propagated by people who have characteristics that approach them, forming the groups of social belonging.

The research was done on the internet, specifically on Facebook, which was constituted as a research scenario, with subjects who were online in the network, after invitations and the fulfillment of the established criteria. The following inclusion criteria were adopted: being a young adult of both sexes, being a catholic, being between 18 and 24 years of age, being a church goer in the parish (minimum of twice a week), integrating church groups linked to CCR, having participated in the World Youth Day (WYD) and being a member of the WYD group on Facebook. The mentioned group presents murals restricted to the people that integrate it, so that the information, images and status are shared and visible only by the members.

After invitation, 84 participants were willing to contribute with the research, thus being in conformity with a non-probabilistic random sample. The research was carried out in three stages; in the first two (application of the sociodemographic questionnaire and a script for the test of free association of words, whose results were not used in this study) all those who met the pre-established criteria participated; Participants were invited to proceed with their participation in the survey, but only 19 accepted it. This portion of the sample responded to an in-depth interview in February 2015, guided by a script with three open questions that sought to deepen the meanings that young people possessed about the relationship between the Catholic religion and the exercise of sexuality, prevention of HIV.

The excluded were: young people who did not confirm their participation after sending and reading the Term of Free and Informed Consent; those who attended church regularly (two or more times a week), but who did not participate in any church group; or who gave up before the end of data collection.

The speeches from the interviews were organized in a single corpus. To that end, one of the researchers copied the participants' answers to the online spaces for conversation and dialogue, known as the 'chat box', and pasted it onto the sheets for writing documents in Microsoft Word software. The corpus was then processed in Alceste software version 4.5. Alceste enables the understanding of the meanings of objects of social representation (such as sexuality and HIV/Aids), attributed by individuals belonging to a particular social group, through the reports and graphs emitted and the statistical analysis of lexical content, from the representations constructed in the systems of cognition. Two graphs, the dendrogram of classes that made possible the analysis from the descending hierarchical classification (DHC) and the map of the factorial plan that aided in the factorial correspondence analysis (FCA) were used for this study as software results.

The research was approved by the Research Ethics Committee of the Federal University of Bahia, on November 19, 2014, with protocol number 878.042/2014, CAAE: 33858514.0.0000.5531. The Free and Informed Consent Form was sent online through the tools provided by the social network, and after reading the participants confirmed their participation with the digital signature.

RESULTS

For a better understanding of the social representations, it is necessary to present the characteristics of the belonging group that contributed to the study. Of the 19 interviewees, 11 were men and eight women; six from the state of Bahia, four from Minas Gerais, three from São Paulo, two from Rio de Janeiro, two from Pernambuco, one from Pará, and one from Sergipe.

As to the degree of study, eight said they had completed high school, eight others said they had incomplete higher education and three had completed higher education. Nine, seven and three of the interviewees described themselves as white, brown and black, respectively. Ten go to church two or three times a week; while the rest say they go four or five times a week.

Regarding sexual orientation, the majority (n=14) declared to be heterosexual, three affirmed to be homosexual and two considered bisexual. Of the group, 11 reported practicing safe sex with condom use. Among the eight who did not use a condom, three were virgins and five had unprotected sex.

Data from the interviews and processed in the Alceste software from the standard statistical analysis, originated a corpus of 19 initial context units (ICU), totaling 10,115 occurrences, 1,855 distinct words and a mean of five occurrences per word, with equal frequency or higher than the average and with khi²≥3,84. After reducing the vocabulary to its lexical roots, 268 reduced and analyzable radicals were found, of which 217 were Elementary Context Units (ECU). The DHC retained 95% of the total corpus ECUs, which were organized into four classes, as can be seen in figure 1.

It can be seen in the Dendrogram that the initial corpus suffered a single division, giving rise to two sub-bodies: the left one, agglutinating classes 1 and 3, and the right one with classes 2 and 4.

Class 1 - "Sex with condoms alone" - showed 32 ECU, with 42 analyzable words meaning 16% of the corpus. Class 3, categorized as "Benefits of safe sex: condom or fidelity?", involved 57 ECUs, containing 46 analyzable words with a total of 28%. Class 2 - "Sexuality: pleasure x Christian values" - presented 45 ECUs, with 42 words, corresponding to 22% of the corpus. Class 4, called "Meanings of chastity", contained 70 ECUs and 48 words, corresponding to 34% of ECU.

To complement the results obtained with the DHC analysis, Alceste also performed the FCA, visualized in figure 2. The FCA was structured by reading the lexical content and the attribute variables with higher factor loads, whose organization shows the degree of proximity between the contents of classes.

Figure 2. Chart of the factorial map of correspondence issued by Alceste software. Salvador-BA, 2015

Source: Authors, 2015.

The content of the interviews was divided into four zones, non-randomly and corresponding to the specific designs for each of the four classes, which contribute to the zero (central zone) of both factors (abscissa and ordinate), even though the distribution occurs discretely in opposite ways in both axes (axis 1 and axis 2) or factors (F1 and F2). The two factors, together, account for 75% of the total variance of the UCE.

The horizontal line of the abscissa (axis 1 or F1) reveals the largest factor loads identified by Alceste, accounting for 40% of the total variance of the ECU. In this axis, on the negative (left) side, are the words grouped in classes 2 and 4 that emerged from the speeches of the participants. In the factorial space, the two classes have overlap in F1-, sharing the attribute variables and the word sexuality. Class 4 still cooperated individually on the axis, with the words: faith, speech (in the sense of dialoguing), abstinence, live, follow (follow/practice doctrines), desire, dating and profess.

The words with higher factorial loads agglutinated in classes 1 and 3, also overlapping, and in opposition to the negative factor are in axis 1 positive (right). Women with full tertiary education from within their states collaborated with class 1 by issuing the words: use, prevention, method and day (current days). Class 3 had the contribution of young people with incomplete higher education with the following words: mean, condom, protect, partner, disease, discourse, time and fidelity.

In the vertical axis, where F2 is visualized, the four classes are also highlighted, which together explain 30% of the total variance of the ECUs. Classes 1 and 2 are superimposed on factor F2+. Class 1 is formed by the following semantic-lexical fields: duty, topic, group and opinion. In class 2, the participants represented the terms value, doctrine, discussed (discussion), body, pleasure, moment and understandings.

In F2 classes 3 and 4, which are juxtaposed, were categorized and contributed to this sector. Class 3 highlights time and fidelity objectifications. Class 4, which was influenced by class 2 variables (observed with the F1- overlap), was formed by the lexical content: faith, respect, women, abstinence, live, speech (in the sense of dialoguing), follow (follow/practice doctrines), dating and profess.

It should be noted that some participants had their own ICUs, which also contributed to the respective classes: class 1 (interviewed 05, 11, 14 and 19); class 2 (interviewee 07); class 3 (interviewed 18); class 4 (interviewed 08). Participants highlighted in the factorial table (figure 2) also collaborated, albeit discreetly, with more than one class, according to the overlays visualized on the chart: interviewee 14 (class 1 and 2); interviewees 05 and 19 (classes 1 and 3); interviewees 11 and 18 (classes 3 and 4); interviewees 05 and 18 (classes 1, 3 and 4); interviewed 19 (classes 1, 2 and 3); and interviewed 11 (all classes).

The following four classes are described, in order from left to right, as shown in figure 1, which shows the words with the highest khi² and the variable-attributes that contributed significantly: sex (woman or man), origin (capital/metropolitan region or countryside), race (white or black) and schooling (complete secondary education, incomplete higher education or complete higher education).

Class 1, "Sex with condoms", was composed of words and radicals in the interval between khi²=29 (stay) and khi²=07 (problem). The variables-attributes that had significance for this class were women, coming from the countryside of their respective states, with complete higher education. Following, there are excerpts from the participants' speeches, revealed by the software, which characterizes this class:

Even knowing your partner, condoms are the best way to avoid getting an unwanted pregnancy and not catching a sexually transmitted disease such as AIDS (Interviewed 1; March 2015).

Safe sex is certainly sex with a condom (Interviewed 19; March 2015).

Class 3, "Benefits of safe sex: condom or fidelity?", Was formed by words and radicals in the interval between khi²=36 (condom) and khi²=06 (want). The variable-attribute that contributed the most was schooling - incomplete higher education, for both sexes. Next, a cut of the elementary context that characterizes the denomination of this class:

(...) I do not think the use of condoms should be so much criticized since, in a way, it's a matter of maintaining life. If you think about sexually transmitted diseases, I'm super in favor of using it (Interviewed 05; March 2015).

(...) people should be aware of their actions (...) safe sex is the intimacy that you have with your partner. (...) When there is mutual fidelity it is difficult to contract diseases (Interviewed 13, March 2015).

Class 2, "Sexuality: pleasure x Christian values", presented words and radicals in the range khi²=23 (pleasure) and khi²=07 (media). This class was characterized by black men residing in capitals/metropolitan regions with full tertiary education. The following dialogues enable a better understanding:

In my view sexuality implies the involvement of two people, regardless of sexual choice. It brings with it extreme pleasure in sex (...) sexuality is free, independent of sexual orientation (Interview 14; March 2015).

(...) sexuality is seen as something sacred, a gift of God, for two purposes: union and procreation. I stand with the same thought: this should be done with someone also separated for you (Interviewee 07; March 2015).

Class 4, defined as "Meanings of chastity", shows the lexical content referring to the traditional concept of chastity followed by some young people and the new way that others found of experiencing sexuality without chastity. This part of the corpus had its characterization established by words and radicals in the range khi²=20 (desire) and khi²=06 (world). Regarding the descriptive variables, the class did not present variables with degree of association that contributed specifically. However, when the factorial map of the correspondence plane is visualized (figure 2), the interference of class 2 variables (black men residing in capitals/metropolitan regions and with complete higher education) is clear for the characterization of class 4, once they intersect. Below, excerpts from ECU to contextualize the class:

(...) I understand abstinence for something you've tried, but decided to stop. So, if you've never had sex before then I think it's going to be chastity (...) (Interviewed 2; March 2015).

(...) for me the proposal of chastity is a way to deepen love and to preserve the dignity of the person, (...) sexuality being something sacred that must happen in a sacred moment (Interviewee 07; March 2015).

(...) There is a blockage created by the Church. We are called to live chastity and leave sexuality for after marriage (Interviewee 15; March 2015).

From the foregoing, it can be inferred that, although they have peculiar characteristics that give them dissent and contradictions in the formation of representations about HIV/AIDS prevention, they have more similarities in the semantic and lexical content, which contributes to the formation of a consensual group.

DISCUSSION

It can be seen that the online interviews conducted with the young Catholics for this study allowed us to understand the process of formation of representations built on HIV prevention, once the differentiations and similarities were understood through their speeches. Since all representation goes from an object (prevention) to a social group(5), it can be observed that in these network relationships there are groups of belongings that share ideas, beliefs and similar aspects of lives(6-7), which allowed the social representation of the representation studied. In this way, social networks are defined as the representation of a set of autonomous participants that unite ideas and values around shared interests(7).

It should be noted that the variable origin did not characterize significant intragroup differences on the representations of the studied youngsters. This evidence corroborates the role of social networks in rapidly propagating information, forming membership groups and promoting a "cybernetic culture".

Schooling, especially in the division of complete and incomplete higher education, characterized classes 1 and 3 respectively, which were discreetly opposed in the correspondence factorial plan, but did not determine the social thinking of those who participated in the study, since the classes had a significant semantic approximation, reinforcing the idea, which still needs to be deepened, of the role of social networks, such as Facebook, in the construction and diffusion of representations.

Words that contributed to the dubious discourse presented by the young people were highlighted, regarding the representation of HIV prevention: before marriage with condom use, anchored in the use of condoms when doing casual sex (expressed by the word stay (ficar), typical of young people's language in Portuguese), whose main goal is to prevent HIV/AIDS or unwanted pregnancy, especially present in the discourses of the most progressive wing of the Church; and after the marriage, with the binomial fidelity and trust with the only partner chosen by God, with the intention of having children.

These words reinforce the discourses in which the social representations of the young Catholics reveal symbolic opposition between the discourse of the tradition of the Church, usually denominated conservative, and that which includes the technologies available at the present time as mechanisms of personal protection in the sexual exercise.

As a process of reinforcement of the traditional sphere, greatly increased by the movements of charismatic renewal, it can be observed that the representation of sexuality associated with HIV prevention for this group presents itself with a certain degree of idealization from the propositions of the faith that was embraced. For this reason, they need strength not to fall into temptation and sin, since sin has many consequences, for example taking them from the sphere of action of divine grace or diminishing them in the face of the pattern they have(1). Therefore, it is possible to understand some relationships that representations of HIV prevention have with those built in relation to sexuality: ambiguity between what one should be, as idealization of faith, and what is accomplished in the daily life.

With this discourse permeated by psychosocial constructs composed of negative elements about sexuality, many young people initiate sexual practices without accurate information or have "hidden" sex from the Church because they cannot maintain the experience of chastity and experience fidelity in their relationships. The representational construction of fidelity as a means of HIV prevention enhances vulnerability, especially of women, since having a fixed relationship with a single partner represents, in the social imaginary and tradition of the Church, security and protection against sexually transmitted infections, especially HIV/AIDS(8-9).

The representation of the vulnerability of young Catholics can be invisible as a strategy in the face of Catholic doctrines and is based on male/patriarchal hegemony, which ends up reinforcing social constructs such as virginity, marriage, trust and fidelity in relationships(10).

Invisibility for issues related to vulnerability may also be associated with social constructs and hegemonic representations about AIDS. Corroborates these findings a study carried out with charismatic religious leaders, in which the representations of Aids relate to elements circulating in society in the 1980's of last century, as if there had not been an ethical, scientific, human and moral evolution in the Western civilization from the emergence of HIV(11).

At the same time, in the set of results, one can observe a duality in the discourse of the young Catholics as to the meanings they have about sex: in the first group are those who opt for free will (freedom) and defend that people are free to exercise the sexual practice and the adoption of prevention mechanisms with the purpose of obtaining pleasure and desire; in the second group are the young people who consider that sex serves to unite the couple (man and woman), which must be realized with the person they love, respecting values and faith, which generates a cognitive dissonance between the doctrinal requirements and the practical demands of the age.

It is worth noting that the social representation of HIV prevention shows the influence of the tradition of the Catholic Church in the process of formation of these representations, in tension with the presence of representational contents linked to scientific knowledge and the recommendations of the official health authorities in the country, which is concretized in the adoption, side by side, of the condom and of chastity/fidelity as methods of prevention.

In this way, the religious group to which one belongs, with which a relationship of social identity is constructed, constitutes, in practice, a cultural network that, among other things, monitors, investigates and advises people about right and wrong, materializing in the control of the bodies and imposing limits to autonomy. The doctrines of the Catholic religion, at least over the centuries, discipline the sexuality of the faithful through the submission of bodies(12).

The results showed that although the object of study is the social representation of HIV prevention for young Catholics, the representational meanings of sexuality were also present as a dilemma, since they are intrinsic. The consideration of chastity as a method of prevention shows this in a striking manner or even the construction of scientific discourse as a counterpoint to that traditional of the Church, with its own legitimacy in contemporary times(10).

The Catholic Church supports the hierarchical father-mother-child conception, naturalized as the original place of the subject's formation. This heteronormative construction considers a single conception of family, based on the relationship between man and woman, whose objective is to maintain social order and contribute to the formation of the adult person(13-14).

However, it stands out that, at the same time that hegemonic representations on sex and sexuality are maintained, new ones emerge and escape the traditional one that is officially disseminated by the Catholic Church. These ideas contradict traditional doctrines and gain strength with progressive thinking, which proposes that young people can be good Catholics but disagree with the position of the Church(11,15).

This dissonance between the young people's new visions with traditional Catholic ideals shows a strange element in the whole of social representation itself. It is a new rethinking of sexuality that implies diverse practices of HIV/AIDS prevention.

This polarity of ideals about HIV prevention and even sexuality and its free exercise (with safe sexual practice or not) has constituted the social thought of belonging and conforming to the representations of the group, pointing to a complex duplicity of ideologies that the Church has been facing: the traditional and conservative side, with the idea of sex restricted to marriage and the prohibition of artificial preventive methods; and, on the other hand, the progressive ideal about preventive and sexual practices redirected to the autonomy of bodies(16).

Dominant, traditional and hegemonic social representations, such as those derived from Catholic doctrine, reflect ideologies that are functional and/or self-replicating, allowing the status quo to run its course without challenge. However, representations stemming from progressive thinking, whose practices are counter-ideologically and morally unacceptable by the conservative group, tend to break several taboos(17).

This is the case of the social representations evidenced among the youngsters of this study, since the strange element of the representations stems from a process of accommodation of a new form of social thought whose possible and future modifications of the social representations about HIV prevention for young Catholics encompass this strange element, previously pointed out, which has certainly been absorbed from society and the media by the Church through the faithful who begin to incorporate new practices a little more distinct from the traditional ones.

CONCLUSION

The elaboration of social representations by young Catholics in their mental construction systems on HIV prevention has revealed that this object is intrinsic to the sphere of sexuality and to the free exercise of sexual practice whose behaviors are influenced by traditional Catholic doctrines and dogmas , although it is recognized that progressive thinking and the use of technologies (such as adherence to condoms in safe sex) converge towards the formation of these representations, which is a dilemma among young people and a challenge for the Church. However, one should recognize the impossibility of generalizing the results of this research to the daily life experienced by other young Catholics, even if the methodology applied on Facebook can reach a larger population, which constitutes one of the limitations of this study.

Thus, in reflecting the social representations of young Catholics, health professionals can plan care, based on the group's knowledge of the object investigated, and propose dialogues with the Church to elucidate doubts and promote advances in discussions on sexuality, safe sex and the prevention of sexually transmitted infections such as AIDS.

REFERENCES

  1. Bernier A, Lefèvre M, Henry E, Verde L, Costa ME, Benmoussa A, et al. HIV seropositivity and sexuality: cessation of sexual relations among men and women living with HIV in five countries. AIDS care. 2016. 28(S1):26-31.

  2. UNAIDS/WHO. AIDS: epidemicup date: December 2012. [www.unaids.org]{.underline}< acessado em 20/10/2013 >.

  3. Benelli SJ, Silva SIM. Subjetividade na Renovação Carismática Católica: Mecanismos de Funcionamento e de sua Produção. Psicol. Ciênc. Prof. 2016; 36(3):610-24.

  4. Dantas MS, Abrão FMS, Freitas CMSM, Oliveira DC. Social representations of HIV/AIDS among healthcare professionals in benchmark services. Rev Gaúcha Enferm. 2014. 35(4):94-100.

  5. Moscovici S. Representações sociais: investigações em psicologia social. Petrópolis: Vozes, 2003.

  6. Jodelet D. Representações sociais: um domínio em expansão. In: JODELET, D. (Org.). As representações sociais. Rio de Janeiro: EdUERJ, 2001.

  7. Mendoza RIL. Representaciones de Facebook: nomenclaturas de vida ante la ley, la amistad y la muerte. Cultura y representaciones sociales*.** 2014.* 8(16):137-174.

  8. Santos EI, Oliveira JGAD. Social representations of nurses about professional autonomy and the use of technologies in the care of patients with wounds. Invest. Educ. Enferm. 2016; 34(2):387-95.

  9. Trigueiro DRSG, Almeida SA, Monroe AA, Costa GPO, Bezerra VP, Nogueira JA. AIDS and jail: social representations of women in freedom deprivation situations. Rev Esc Enferm USP. 2016. 50(4):554-561.

  10. Couto PLS, Paiva MS, Gomes AMT, Lucky ETB, RLSA, Rabbit EA. Meanings about HIV / AIDS and sexuality prevention for young Catholics. Rev. Gaúcha Enferm. [Internet]. 2017 [cited 2018 June 17]; 38 (4): e2016-0080.

  11. Couto PLS, Paiva MS, Oliveira JF, Gomes AMT, Teixeira MA, Sorte ETB. Sexuality and HIV prevention: consensus and dissent of Catholic youths. Invest. Educ. Enferm. 2018; 36(2):e06.

  12. Mackworth-Young CRS, Bond V, Wringe A, Konayuma K, Clay S, Chiiya C et al. "My mother told me that I should not": a qualitative study exploring the restrictions placed on adolescent girls living with HIV in Zambia. Journal of the International AIDS Society 2017, 20:e25035.

  13. Silberman P, Buedo PE, Burgos LM. Barreras en la atención de salud sexual en Argentina: percepción de las mujeres que tienen sexo con mujeres. Rev salud publica. 2016. 18(1):1-12.

  14. Suto CSS, Paiva MS, Oliveira JF, Rodrigues AS, Oliveira DS, Porcino CA. Care for the Acquired Immune Deficiency Syndrome in the contemporary world: understanding the professionals' perspective. Rev Rene. 2017; 18 (6): 779-86.

  15. Leite KLC. O que fez da AIDS a peste atemorizante do século XX? Uma análise das implicações simbólicas. RBSE: Revista Brasileira de Sociologia da Emoção. 2015. 14(41): 159-169.

  16. Palhoni ARG, Amaral MA, Penna CMM. Representations of violence against women and its relationship to their quality of life. Online braz j nurs [internet]. 2014 Mar [cited year mouth Day]; 13 (1): 15-24. Available from: http://www.objnursing.uff. br/index. php/nursing/article/view/4286.

  17. Gibbs A, Campbell C, Akintola O, Colvin C. Social contexts and building social capital for collective action: three cases studies of volunteers in the context of hiv and AIDS in South Africa. J. Community Appl. Soc. Psychol. 2015; 25: 110--122.

All authors participated in the phases of this publication in one or more of the following steps, in according to the recommendations of the International Committee of Medical Journal Editors (ICMJE, 2013): (a) substantial involvement in the planning or preparation of the manuscript or in the collection, analysis or interpretation of data; (b) preparation of the manuscript or conducting critical revision of intellectual content; (c) approval of the version submitted of this manuscript. All authors declare for the appropriate purposes that the responsibilities related to all aspects of the manuscript submitted to OBJN are yours. They ensure that issues related to the accuracy or integrity of any part of the article were properly investigated and resolved. Therefore, they exempt the OBJN of any participation whatsoever in any imbroglios concerning the content under consideration. All authors declare that they have no conflict of interest of financial or personal nature concerning this manuscript which may influence the writing and/or interpretation of the findings. This statement has been digitally signed by all authors as recommended by the ICMJE, whose model is available in http://www.objnursing.uff.br/normas/DUDE_eng_13-06-2013.pdf

Received: 12/14/2016

Revised: 01/06/2019

Approved: 01/06/2019