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Texto & Contexto Enfermagem
ISSN: 0104-0707
texto&contexto@nfr.ufsc.br
Universidade Federal de Santa Catarina
Brasil
Tiburcio Rodrigues do Nascimento, Larissa; de Souza, Jacqueline; Gaino, Loraine Vivian
RELATIONSHIP BETWEEN DRUG DEPENDENCE AND ALCOHOL USERS RECEIVING
TREATMENT IN A COMMUNITY HEALTH CENTER SPECIALIZING IN ALCOHOL
TREATMENT
Texto & Contexto Enfermagem, vol. 24, núm. 3, julio-septiembre, 2015, pp. 834-841
Universidade Federal de Santa Catarina
Santa Catarina, Brasil
Available in: http://www.redalyc.org/articulo.oa?id=71442216027
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- 834 - Original Article
Text Context Nursing, 2015 Jul-Sep; 24(3): 834-41.
RELATIONSHIP BETWEEN DRUG DEPENDENCE AND ALCOHOL
USERS RECEIVING TREATMENT IN A COMMUNITY HEALTH CENTER
SPECIALIZING IN ALCOHOL TREATMENT
Larissa Tiburcio Rodrigues do Nascimento1, Jacqueline de Souza2, Loraine Vivian Gaino3
1 Undergraduate student, Escola de Enfermagem de Ribeirão Preto at Universidade de São Paulo (EERP/USP). Ribeirão Preto, São
Paulo, Brasil. E-mail: larissa.tiburcio.nascimento@usp.br
2 Ph.D. in Nursing. Professor, EERP/USP. Ribeirão Preto, São Paulo, Brasil. E-mail: jacsouza2003@usp.br
3 Doctoral student, Programa de Enfermagem Psiquiátrica e Ciências Humanas, EERP/USP. Ribeirão Preto, São Paulo, Brasil. E-mail:
lorainegaino@usp.br
ABSTRACT: The aims of this study were: to identify the therapeutic activities of a psychosocial care center specically for family
members, and to consider whether the care offered provided benets to the relationship between the family and alcohol users. This
was a qualitative research study, and included 15 families of alcohol users from Minas Gerais. The data collection occurred during
January and March of 2012. Thematic analysis was used. The analysis identied three themes: 1) relationship: before and after the
initiation of treatment in the service; 2) assistance for the family; 3) treatment suggestions. The results showed that the care in the
service contributed to improving the family relationship, but families provided some suggestions to improve this care. We concluded
that the service was an important provider of social support for improving the family relationship.
DESCRIPTORS: Family relations. Mental health services. Alcoholism.
RELACIONAMENTO ENTRE FAMILIAR E USUÁRIO DE ÁLCOOL
EM TRATAMENTO EM UM CENTRO DE ATENÇÃO PSICOSSOCIAL
ESPECIALIZADO
RESUMO: Os objetivos deste estudo foram: identicar as atividades terapêuticas de um Centro de Atenção Psicossocial, especicamente
para os familiares, e analisar se os cuidados oferecidos proporcionam benefícios para a relação entre o familiar e o usuário de álcool.
Trata-se de uma pesquisa qualitativa. Foram entrevistados 15 familiares de usuários de álcool de um município de Minas Gerais. A
coleta de dados foi realizada entre janeiro e março de 2012. Utilizou-se a análise temática. A análise permitiu identicar três categorias:
1) Relacionamento: antes e depois do início do tratamento no serviço; 2) Assistência ao familiar; e 3) Sugestões ao tratamento. Os
resultados evidenciaram que a assistência proporcionada contribuiu na geração de benefícios para a relação familiar. Conclui-se que
o serviço consiste numa importante fonte de suporte, proporcionando melhorias às relações familiares.
DESCRITORES: Relações familiares. Serviços de saúde mental. Alcoolismo
RELACIÓN ENTRE EL FAMILIAR Y EL USUARIO DE ALCOHOL EN
TRATAMIENTO EN UN CENTRO DE ATENCIÓN PSICOSOCIAL DE
ALCOHOL Y DROGAS
RESUMEN: Los objetivos de este estudio fueron identicar las actividades terapéuticas de un centro de atención psicosocial
especícamente para los miembros de la familia y considerar si la atención que se ofrece proporciona benecios a la relación entre los
usuarios de la familia y el usuario de alcohol. Se trata de una investigación cualitativa. Se entrevistaron 15 familiares de usuarios de
alcohol de Minas Gerais. La recolección de datos se llevó a cabo entre enero y marzo de 2012. Se utilizó el análisis temático. El análisis
identicó tres temas: 1) Relación: antes y después del inicio del tratamiento en el servicio; 2) Asistencia para la familia y; 3) sugerencias
de tratamiento. Los resultados muestran que la asistencia prestada por el servicio ha contribuido beneciosamente a la relación de la
familia, sin embargo, hubo varias sugerencias realizadas por los familiares con el n de mejorar la asistencia. Se concluye, por lo tanto,
que el servicio funcionaba como una fuente importante de apoyo favoreciendo la relación de familia.
DESCRIPTORES: Relaciones familiares. Servicios de salud mental. Alcoholismo.
834
http://dx.doi.org/10.1590/0104-07072015003610013
Text Context Nursing, 2015 Jul-Sep; 24(3): 834-41.
Relationship between drug dependence and alcohol users receiving... - 835 -
INTRODUCTION
Alcoholism, as well as the abuse of other
drugs, have been described as an important fac-
tor related to the increase of morbidity, mortality,
interpersonal harm and family dysfunction.1-7 The
relationship among alcoholism and the family is
discussed mainly from two perspectives: a) ge-
netics, behavior, and relational aspects in family
context, as a risk factor for substance abuse;1-3,5-6,8-14
b) the impact of alcoholism on family relation-
ships.2,5,7
The rst perspective asserts that families
with decient patterns of communication and
those which do not promote support to their mem-
bers, or those with home, work and income insecu-
rity, as well as situations of negligence, domestic
violence and a family member as a substance user,
in general provide an environment that is more
susceptible to substance related disorders.1,6,8-13
Various studies1,6,8-13 have prioritized the rst
perspective, meaning that there is a family inu-
ence on the development of drug dependence.
The researchers that follow this approach have
produced evidence and recommendations to im-
prove the family context as a important strategy
to prevent substance-related disorders.
The second perspective is that alcoholism
has a negative impact on the family. These au-
thors2,5,7,15-16 believe that the consumption of this
substance creates worries, negative emotions,
tension, conicts and breakups, in addition to
nancial and legal problems, risk for clinical and
psychopathological disease, behavior problems,
traumatic experiences, loss of condence, decit
of communication, and a trend toward social
isolation.2,5,7,15
Due to some psychological symptoms such
as irritability, aggressiveness, bad comprehension
and changes in one’s worldview, the alcoholic
tends to present progressive difculties related to
interpersonal relationships.17
The inconsistency and affective instability
of family relationships with their addict member
weakens the family structure and promotes the
emotional detachment of members,15 because, in
general their answer to this situation is to develop
protective strategies, such as limiting contact with
the addicted person or having contact only when
necessary.18
Some studies about alcoholism16,19-21 have
characterized the family as an impaired unit,
fragmented, deteriorated by frequent conicts and
existential crises; however most often the family
members are not well aware of the extension of this
psychic suffering. Thus, in the second perspective,
the authors recommend the consideration of the
family and the drug user as a unit, as a whole,
and they add that the success of the treatment for
a substance related-disorder is directly related to
inclusion of the family in a recovery process aimed
at abstinence.
Given these considerations, including the
family as part of treatment is a presupposition of
Brazilian legislation and guidelines for assistance
of substance-related disorder people.22 Family
activities are included in the Community Health
Centers specializing in the treatment of substance-
related disorders in Brazil (CAPSad), as a primary
strategy in the routine treatment of patients.22-23
These guidelines recommend that profes-
sionals from this service do a progressive thera-
peutic planning for each patient following an inter-
disciplinary review, including various activities as
individuals (medication, psychotherapy, advices
and others) as well as through therapeutic groups
and workshops, home visits, and psychosocial
family assistance.22
Considering that the alcoholism can promote
negative changes in interpersonal relationships
between the individual and society, and that as-
sistance offered by CAPSad should include this
assistance, it is understood that the improvement
of relationships in the family context can be an
important outcome indicator of the mental health
assistance promoted by CAPSad. Thus, the guid-
ing question is proposed: how does the assistance
offered by this service inuence the relationship
between family members and alcoholics under
treatment?
Thereby, this study aims to identify the
therapeutic activities from CAPSad, specically in
regard to the family; and to analyze whether this
assistance provided a benet for the relationship
between the family and the alcohol addict.
METHOD
This was a qualitative, descriptive, cross-
sectional study performed in a CAPSad in Minas
Gerasi, Brazil. In the beginning, one of the re-
searchers participated in four family meetings
promoted by this service. In the last meeting, she
presented the proposal of this research to these
families, and they were formally invited to par-
ticipate in this study.
Text Context Nursing, 2015 Jul-Sep; 24(3): 834-41.
Nascimento LTR, Souza J, Gaino LV- 836 -
The inclusion criteria for selection of partici-
pants were: having a family member in treatment
in this CAPSad with an alcoholism diagnosis, par-
ticipating in at least one monthly family meeting
promoted by this service, and being greater than
18 years old. The 15 family members invited met
these inclusion criteria, and agreed to participate
in this study.
During the period of January until March of
2012, domiciliary visits were performed along with
semi-structured interviews for data collection.
An interview guide was used with content about
socio-demographic data, the family relationship
during the process of the addiction, and assistance
offered to the family by CAPSad. The interviews
lasted about one hour, and were recorded and
transcribed. To preserve the anonymity of the
participants, the transcriptions were coded with
the letter F, that signied “family”, and with a
number related to each participant and the degree
of relationship, for example: “F1-father”.
For data analysis, the theoretical perspective
on the impact of alcoholism in family relationships
was adopted, based on bibliographical references
about alcoholism: which aspects of these relation-
ships are affected, what are the behavior changes
of the members, what are the changes and psycho-
logical repercussions on family by relating to the
alcoholic person.2,5,7,15,19-21
The rst step of the analysis was to describe
the prole of participants, and the second was the
thematic analysis that is a genre of content analysis.
The transcripts of interviews were successively read
in order to cluster common elements, ideas or ex-
pressions from the interviews. In this interpretative
phase, a kind of chronologic sequence in the data
was identied, then a grouping of information oc-
curred, highlighting how the relationship was of the
family before and after the psychosocial treatment.
From this group of information, the interventions
were identied from CAPSad, described by fam-
ily along with their suggestions about them. Thus,
three thematic categories were created: 1) Relation-
ship: before and after beginning treatment at the
CAPSad 2) Family assistance, and 3) Treatment
suggestions offered by CAPSad. The next phase
was theory building; the researchers crossed the
information of the present study with the outcomes
of previous studies developed using the same theo-
retical perspective adopted in this one.24
The Ethics Committee of the Escola de Enfer-
magem de Ribeirão Preto, Universidade de São Paulo
(CEP-EERP/USP 011/2012), approved this study.
The ethical principles were attended to, and the
Terms of Free and Informed Consent swas used.
RESULTS
Regarding the sociodemographic character-
istics of the family members, the majority were
female (10 participants, 66%) with a mean of 50
years old (minimum 21 and maximum 80 years
old), as shown in Table 1. According to interviews,
11 of the family members in treatment had already
received assistance from other services before, and
they met CAPSad through health professionals,
colleagues or relatives.
Table 1 – Socio-demographic data from those interviewed. Minas Gerais, 2012
Participant and
parenthood
Time of treatment of
addict Age Gender* Monthly family income
(minimum wage) Marital status
F1-Father† 15 days 66 M 3 - 5 Married
F2-Father‡ 1 month 55 M 1 - 2 Single
F3-Wife‡ 1 month and 15 days 34 F 1 - 2 Married
F4-Wife† 2 months 49 F 1 - 2 Married
F5-Girlfriend§ 2 months 39 F 3 - 5 Single
F6-Mother† 4 months 80 F 1 - 2 Married
F7-Son || 4 months 21 M 3 - 5 Single
F8-Girlfriend|| 4 months 35 F 3 - 5 Single
F9-Brother§ 8 months 68 M 1 - 2 Married
F10-Husband§ 8 months 49 M 3 - 5 Married
F11-Mother† 1 year 64 F 3 - 5 Widowed
F12-Wife† 1 year 40 F 1 - 2 Married
F13-Sister‡ 1 year 52 F 1 - 2 Stable union
F14-Mother¶ 2 years 62 F 1 - 2 Married
F15-Sister† 2 years 39 F 3 - 5 Married
*M=Male, F=Female; †Participant with incomplete elementary school; ‡Participant completed elementary school; §Participant com-
pleted high school; ||Participant with incomplete high school; ¶Participant illiterate.
Text Context Nursing, 2015 Jul-Sep; 24(3): 834-41.
Relationship between drug dependence and alcohol users receiving... - 837 -
The data analysis allowed the identication
of three thematic categories: 1) Relationship: before
and after beginning treatment at the CAPSad; 2)
Family assistance; and, 3) Treatment suggestion
offered by CAPSad, according to Figure 1.
Figure 1 – Thematic categories related to family and user relationships
Relationships: before and after beginning
treatment at the CAPSad
The majority of family members expressed
that their relationship was unstable and con-
icted before the alcoholic began treatment at the
CAPSad; they mentioned emotional distress, strife
and strained relationships.
Just a couple of those individuals inter-
viewed described the existence of respectful re-
lationships, even before treatment. Nevertheless,
all those interviewed mentioned an improvement
in relationships with the user after he/she began
treatment at the CAPSad, and some afrmed that
the user now had a quieter behavior.
God! It was a terrible life, I don’t like to remember,
terrible even [...] There was a lot of strife between us and
his family [...].After his treatment began he changed a
lot, he had other thoughts (F4-wife).
I was blackmailing her, I didn’t visit her and she
called me saying that I was the only one she had, because
no one called her, and I told her that if that situation
continued, she wouldn’t actually be able to count on me
either, because I’d stop worrying about her (F13-sister).
After his treatment began he was more quiet, you
know? We are living much better; everything is calmer,
now we have more conversation to solve the things [...]
even his behavior at home, his mood changed, he is more
fun and willing [...] (F12-wife).
Assistance to family
With regard to the family assistance offered
by CAPSad, the participants mentioned profes-
sional support, opportunities to express them-
selves, and being listened to during the meetings
that occurred in this service with professionals and
family members. Some participants referred to dif-
culties participating in these meetings because of
schedule conicts, it meaning, the days and hours
of the meetings were the same as for their jobs.
The support offered to users by CAPSad
also was mentioned as a kind of indirect family
assistance, because of the benets related to the
relationship between them.
Here I have all the structure that I need, the trust
that I need to know that treatment is really good for him.
I think this service is one of the best things, the freedom
that we have to come and express what is happening,
and trust in the work of these professionals (F12-wife).
All that they do for him [user] they are doing for
us, too. When the CAPSad takes care of him, it is taking
care of the family (F9-brother).
They offer support, have meetings [...], but for
me, it is difcult to go there because of my job (F7-son).
Treatment suggestions
There were many suggestions to improve
the assistance offered by CAPSad, for example:
Text Context Nursing, 2015 Jul-Sep; 24(3): 834-41.
Nascimento LTR, Souza J, Gaino LV- 838 -
availability of transportation; possibilities for par-
ticipating in joint meetings with professionals and
the user; and, inviting recovering alcoholics to share
their history with users. Many family members
gave other suggestions, although they expressed
satisfaction with all assistance offered by CAPSad.
If there was some transportation, like a bus, it
could be easier. It could be interesting also for him and
me to talk with some professional together (F4-wife).
In addition, to invite people that had this experi-
ence before, that re recovering and aren’t currently
drinking, to give advice to users. Then, people that had
treatment at CAPSad, could go back there to help those
that are in treatment (F7-son).
If it was possible for them to stay there, it could
be easier than them coming back home [...] then I think
that if it was possible to accommodate all of them there
for about six months, it could be easier for these people
to recover (F1-father).
[...] I think that it could be good for her to study,
because she does not have a lot of knowledge, she writes,
but cannot read [...]. Then I think that if she could learn
to read, she could participate more in the life activities of
her son [...], I would also like to have something to help
her stop smoking, because she smokes a lot (F13-sister).
[...] Could be better if he could keeping attending
the CAPSad at least twice per week, because I heard
that he is well and that soon he will be discharged, but
I think that he should keeping attending at least twice
per week (F14-mother).
DISCUSSION
According to the results, the participants
have a lower educational level and monthly in-
come below two minimum wages, corroborating
the current literature that highlights these condi-
tions as risk factors for the impact of alcoholism.25-30
With regard to the prevalence of the female gender
among the family members that accompany the
alcoholism treatment of their loved one, the results
also are similar to previous research.16,31
Related to time of treatment, according to
Table 1, this was between 15 days and two years;
of the 15 participants, ten were in treatment for
less than one year. Studies show that only 25% of
people that use alcohol excessively ask for some
kind of help. This low demand is related to stigma
and therapies that are different than what is need-
ed by the patient. Another challenge is that only
a low percentage of patients adhere to treatment,
culminating in an abandonment index of about
20%. Thus, it is recommended to use strategies
to improve the family relationships as a focus for
maintaining and completing treatment.19-21
Related to the rst category, the participants
pointed out that daily life with the alcoholic family
member was characterized by instability, strife and
worries that resulted in physical and emotional
distress, beyond shameful situations, constraints
and humiliation for the family as well as for the
alcoholic, corroborating previous results.5,7,15,18,21
According to some participants, the feeling
of impotence when confronting addiction of a
family member is common, however information
about alcoholism and the treatment process can
help with more effective management of conicts,
and strengthen interpersonal relationships beyond
the avoidance of withdrawal from social life.7
A study developed with relatives of alcoholic
individuals shows that receiving information and
advice about how to help the alcoholic family
member are the main needs related to treatment.
The lack of knowledge about medication side ef-
fects is an important difculty that creates feelings
of stress, isolation, depression, low self-esteem
and anger among family members.21 In addition,
the patterns of communication in these contexts
are not clear, with pejorative expressions and dif-
culty establishing limits; therefore, advice for
improving the relationship and decision-making
is important.15
One specic piece of data found in this re-
search that is discordant of descriptions in the cur-
rent literature is that some families mentioned not
having any problems in their relationships with
the alcoholic family member before treatment,
despite the fact that the alcohol use was already
happening. The difculty pointed out by these
participants was seeing the condition of addiction
that was causing suffering in their family member.
The results of this study show that, after
beginning treatment, CAPSad was congured
as space promoting the self-knowledge of users,
generating an important impact on family rela-
tionships. The participants mentioned that, after
beginning treatment, the users showed changes
in their thinking, new life plans, friendships,
strengthening of social and affective links with
family, better mood, dialogue, more skill in listen-
ing, and diminishment of responding to impulses.
It was also cited that CAPSad provided leisure and
occupied times of idleness. Thus, it is considered
that this service provides a potent mechanism that
helps to amplify and recongure the social support
network of the alcoholic.31-33
Text Context Nursing, 2015 Jul-Sep; 24(3): 834-41.
Relationship between drug dependence and alcohol users receiving... - 839 -
With regard to category two, researchers
who recommended interventions for the family
during the treatment of alcoholics have afrmed
that it is important to offer many options for as-
sistance, such as: approaches to resolve family
conicts, and treatment related to drug addiction
for other family members.1,19 In addition, other
recommendations include: being available to give
informational support, psychoeducational activi-
ties, social support groups, strategies to improve
quality of life of these families, encourage open
discussions about the alcoholic family member’s
behavior, provide opportunities to express feelings
and share personal experiences.7,15,21
In the present study, some of these interven-
tions were pointed out. Additionally, to value
the treatment of the user, the participants dem-
onstrated appreciation of the care that CAPSad
provided to them, and cited many benets gener-
ated in the relationship between the user and the
family members.
The participants explained the indirect ben-
ets from the treatment; meaning that the recovery
of the alcoholic individual impacts the relation-
ships with the family. They also mentioned that
the CAPSad’s team welcomed the needs of the
family, providing enlightenment, guidance and
assistance when it was needed. These interven-
tions contributed their tearning about how to deal
with situations that, in the past, could lead the user
to psychiatric hospitalization, and this result was
corroborated by other studies.19-21,34
The participants mentioned the freedom to
express themselves, discuss and be heard - giving
a positive evaluation about the treatment model
proposed as a substitute to the psychiatric centered
model. It motivated families to take a participatory
stance in CAPSad and in the treatment of their
loved one, contributing to the improvement of the
operation of this service and the adjustment to the
family context.
The restriction on the schedule of family
meetings provided by the service was a negative
aspect cited in this study about the care provided
to the family. These meetings occur only on Fri-
days during mornings and afternoons. Consider-
ing that many family members work during these
times, the CAPSad should offer some assistance
during the evening hours whenever possible and
necessary, following the recommendations about
the operation of CAPSad from Ministry of Health
guideline;35 this could provide more opportunities
for families to participate in treatment.
The participants perceived positive changes
in the relationships with the user after beginning
treatment at CAPSad; however, according to results
from the third category, many suggestions were
made about operation of this service. For example,
enabling transportation, because the geographic
access to these service is not easy from downtown.
This result corroborates with a previous study
with families of alcoholics in the United States,
that demonstrated transportation difculties were
a main factor related to users leaving treatment.21
Another suggestion from participants was
for CAPSad to provide joint interventions with the
family, professionals and users. This result also was
shown in a previous study in the United Kingdom
that recommended this kind of intervention as an im-
portant strategy for the maintenance of treatment.7,36
The suggestion that recovering alcoholics
share their experience with users in treatment
is consistent with the Alcoholics Anonymous
proposal, and it is possible to put it in practice at
CAPSad; this provides possibilities for members
to help each other, share their experiences of suf-
fering and history of recovery, which are strategies
compatible with the proposal of this service.
The statements of some family members sug-
gesting that CAPSad provide hospitalization for a
long period demonstrated a lack of understanding
about the philosophy of this service, maybe due
to their being with their user only a few times for
treatment, or due the proposal of this service not
being well claried. This highlights the importance
of providing clarication about the activities, phi-
losophy and operation of the community-based
service at the beginning of treatment, explaining
the difference between what is offered in an inpa-
tient and an outpatient services that, according to
the Psychiatric Reform Law, have as a principle
an “open doors” operation , avoiding isolation of
the user from his social life.21,37
To attend the suggestions about offering
more activities, such as workshops or more formal
education, treatment for smoking cessation, and
groups for maintaining abstinence after patient
discharge, it is necessary for CAPSad to involve
multiple sectors in this operation, including other
healthcare, educational and social protection pro-
viders from the territory.35
CONCLUSION
It follows that CAPSad generates many ben-
ets to relationships between the family and the
Text Context Nursing, 2015 Jul-Sep; 24(3): 834-41.
Nascimento LTR, Souza J, Gaino LV- 840 -
user. The relationships prior to beginning treat-
ment were highlighted by instability, becoming
in a step by step fashion, respectful relationships
based on user self-knowledge and self-control.
The participants mentioned the family meet-
ing as an informational support source and an
opportunity for being heard. In addition, they
highlighted indirect benets for the family from
treatment provided to their loved one, as well as di-
rect benets from assistance provided by CAPSad,
specically for the family. It is understood that the
activities mentioned by participants are minimal, if
we compare them with the recommendations from
the scientic literature and current public policy.
Thus, the results from this study have op-
erational implications related to reinforcement of
the need of amplify the therapeutic activities from
community-based mental health services targeted
to families, enhancing the assistance for collabo-
rating with families to enable them to feel more
supported and to better understand the problem
faced by the user. Certainly these can contribute
to the maintenance of a participatory stance by
the family on the treatment of its loved one, also
contributing to adherence of his own treatment.
The relevance of the families’ suggestions
and recommendations from the data analyzed
are important highlights. It requires the need of
multi-sectorial actions related to health, education
and social protection, self-help groups similar to
Alcoholics Anonymous, alternative schedules and
explanation to family members about the philoso-
phy and operation of the service. These actions
could contribute to more effective assistance for
the user and his family, resulting in an even more
prosperous relationship for them both.
In addition, it is important to think about
the competence of nursing professionals, enabling
strategies to integrate the different knowledge
elds to improve group interventions, facilitation
of informational support, as well as administra-
tive exibility of the work operation in health
services. Putting these competences into practice
in a multi-professional team could surely amplify
the effectiveness of these services.
This study is limited to the family members’
perception about treatment and relationships, so a
larger study that could also consider the users’ and
professionals’ perceptions could certainly enable
effective cross-information, and a more extensive
analysis of the real benets related to assistance
provided by CAPSad on the relationship of the
family members with the user receiving treatment.
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Correspondence: Jacqueline de Souza
3900, Bandeirantes Ave - Campus Universitário
14040-902 - Monte Alegre Ribeirão Preto, Brasil
E-mail: jacsouza2003@usp.br
Received: December 10, 2013
Approved: July 11, 2014
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