Sociodemographic Characteristics Related to Resistance to Breast Cancer Screening

Objective: To describe the sociodemographic characteristics of women related to resistance to breast cancer. Methods: Cross-sectional study, with a quantitative approach, whose research took place in the Basic Family Health Units of the municipality of Mossoró. The study included 362 women aged between 40 and 69 years. One used a validated questionnaire with questions divided into five blocks. The data were entered in a spreadsheet, transferred to the SPSS software, and subsequently coded to perform the analysis. The Research Ethics Committee of the State University of Rio Grande do Norte, in Opinion No. 356958, approved the project. Results: Black women were two times more likely to be resistant when compared to white women (OR = 2.01, 95% CI = 1.12 3.69; p = 0.018). Women who have studied up to primary school 122 (58.1%) were two times more likely to be resistant when compared to those 14 (6.7%) who studied up to higher education (OR = 2.69; 95% CI = 1.31 5.48; p = 0.012). Women who had first-degree relatives with breast cancer 153 (72.9%) were three times more likely to be resistant. Conclusions: The findings show the need for investments in educational practices with a view to public awareness and professionals’ training to disseminate information regarding tests used in practice directed to women’s health.


Introduction
Currently, breast cancer (BC) is the most often diagnosed malignancy in women worldwide. There is a significant increase in the number of new cases of the disease in both developed as developing countries and, considering only demographic changes, one expects an increase of 55% in the incidence and 58% in the mortality in developing countries by 2020 [1].
The coping strategies of BC follow methods of primary and secondary prevention.
The role of primary prevention is to modify or eliminate risk factors and the secondary is part of the early diagnosis and treatment of cancer [2].
It is noteworthy that there is no flawless method regarding primary prevention for BC. However, in secondary prevention, there are three strategies for early detection: the breast self-examination (BSE), the clinical breast exam (CBE) and mammography (MMG). The MMG, for its impact on mortality, is the chosen screening method in population programs [3].

Review of Literature
BC early tracking concerns the active search for new cases in a presumably asymptomatic population, looking for individuals who have a potential risk of developing certain cancer, even before signs and symptoms become evident, subjecting them to screening tests to detect cancer (or cancer predecessors lesions) and fully providing a follow-up, organizing referrals for diagnostic confirmation and treatment [4] [5].
Thus, screening programs aims to influence mortality rates, from early diagnosis, and, thus, cause less physical, mental and social damage arising from more aggressive therapies [6]. Therefore, screening programs provide improved prognosis through early detection and treatment providing less mutilating and aggressive effects for women.
In order to make the Breast Cancer Screening (BCS) possible, the care network needs to organize around the Family Health Strategy (FHS), a model based on primary health care. The municipality must also have, in its environment, capacity to perform the necessary MMG examinations [7].
However, apart from the need to organize the care network, it is necessary to reflect other aspects that relate to resistance of women to BCS, as well as lifestyle and sociodemographic characteristics. The resistance of someone or a group is the expression of the internal relationship system that the person or group has with the world and, in turn, interferes with the form of participation in those spaces [8]. While a situation of compromise, resistance tends to provide us with the necessary elements to understand how the subject or the group builds the perception of themselves and their reality, as well as interacts on issues/aspects that are the focus of that resistance.
By understanding the importance of grasping the aspects that hamper the daily flow of action, particularly in the adherence of the users in the practices of services, one decided to develop this study, with the objective of describing the sociodemographic characteristics of women related to resistance to tracking breast cancer.

Methods
Cross-sectional study, with a quantitative approach, whose empirical research took place in the Family Basic Health Units (BFHU) in the city of Natal, in the period from June to November 2014.
In order to compose the locus of such research and for better definition of the sample, one observed that, in health area, Mossoro is divided into six zones and 43 UBS, which, in turn, are distributed among urban and rural areas and their neighborhoods.
Among the existing BFHU in the city, there was a random selection of four units, one in each zone, namely: Dr. Chico Costa, Vereador Durval Costa, Marcos Raimundo da Costa and Dr. Cid. Salem Duarte. They are located, respectively, in the following districts of the city: Santo Antônio, Liberdade II, Belo Horizonte, Abolição IV.
For the delimitation of the sample, the following inclusion criteria were: being a woman aged between 40 and 69 years, as recommended by the Ministry of Health (MOH), residing in one of the areas covered by the defined BFHU and being registered at the Family Health Strategy (FHS) in one of the neighborhoods of the chosen units.
As for the exclusion criteria, they were: women who had performed CBE and MMG in the past year, because the MOH recommends that the average time may not exceed the maximum period of two years; women who were unable to answer the information covered in the questionnaire and who used psychotropic and/or hallucinogenic drugs.
In the end, the sample consisted of 362 women.
The used research tool was a structured questionnaire from a doctoral thesis entitled "Early detection of breast cancer: knowledge and practices of women and FHS professionals in Dourados/MS." It is noteworthy that this study used the adapted version of the instrument, with the insertion of block 5 [9].
With the aforementioned addition, there was division of the instrument into five blocks of questions: 1) sociodemographic profile; 2) information about the knowledge and practices related to the BC; 3) information regarding the knowledge and practices related to methods for early detection of BC; 4) information on the use of health services related to BC; 5) characteristics of the woman resistant to BCS.
Among the different issues of the instrument, the questions that best characterized the women as resistant to the BCS were listed, based on the objectives of this research and on the Document that defines the Brazilian strategy for the control of BC [10]. In that document, the MMG and the BCE are the methods recommended for BC screening in routine of comprehensive care to women's health [11]. This study characterized women as resistant to BCS if responses to the block 5 were all negative.
The data were entered in a spreadsheet, and then transferred to the SPSS software (version 22.0, SPSS, Inc., Chicago, IL, USA) subsequently coded to perform the analysis. Several groups were compared, obtaining odds ratio (OR), confidence interval (CI) of 95% and p-value, through the significance determined using Chi-square test (χ2) and Fisher's exact test. This last test was used when verifying values with expected frequency lower than five. The Research Ethics Committee (CEP) of the State University of Rio Grande do Norte, in Opinion No. 356,958, approved the project.

Results
By the cuts that were possible for the theme analysis: women resistance to the BCS, a first comparison was performed (Table 1) regarding sociodemographic characteristics and resistance to BCE among women of this investigation.
Thus, Table 1 results from the univariate analysis, which deal with already-mentioned issues, showing that, among the sample of 362 women, 210 (58.0%) were resistant to tracking the BC at the expense of 152 women (42.0%) who showed no resistance to the BCS. It is noteworthy that we will emphasize the data that showed greater resistance to BCS.
Study pointed out that the Santo Antônio neighborhood is the largest of Mossoró, with high incidence of cancer patients in relation to the distribution of patients affected by cancer in the neighborhoods, in addition to having a population with low level of education, low and middle income, so those factors relate to women's resistance [12].
The skin color of 83 women (39.5%) was white and 82 (39.0%), black. Regarding education, 122 (58.1%) reported studying up to elementary school and only 14 (6.7%) had higher education. In terms of the kinship degree, 72 (34.3%) reported having relatives with breast cancer and 107 (51.0%) said they had no relative (Table 1). Table 2 shows the results of the multivariate logistic regression analysis on the resistance of women related to BCS as the response variable. This table addressed only the results of statistically significant associations related to resistance to the BCS, namely: skin color, education and kinship degree.
Regarding skin color, black womenwere two times more likely to be resistant when compared to white women (OR = 2.01, 95% CI = 1.12 − 3.69; p = 0.018). Statistics show that in the city of Mossoró-RN, where the study was conducted and in private households, 38,081 families have black skin color or belong to the black race, whereas there are 27,702 white families [13] Such characterization demands a different look in the construction of public policies for the region in view of the need to reflect and list the specificities of the groups and, thus, propose action strategies that meet their demands.

Discussion
The fact that black women are more resilient may relate to several factors. Black women experience different types of race and gender discrimination, which, when intersect, harm their integration into society as someone who has rights, especially in relation to health inequalities imposed by racism and sexism differentiate women access to health services, as well as in the disease process [14].   [15].
Thus, the study shows evidence to explain that resistance in black women, possibly due to genetic differences, disparities in obtaining medical care, receiving inferior treatment or low adherence to prevention methods [15].
Therefore, since people cannot change genetics, black women should pay more attention to the prevention of breast cancer, which includes, besides the preventive exams, maintaining a healthy weight, exercise regularly, limit consumption of tobacco and alcohol, avoid trans-fat and even processed foods, too much salt and sugar in the diet.
Another study also reflects that black women do not receive the same standard of care than white women and, possibly, when taking into account the color indicator, there might be more worrying data related to social inequalities in access to various services, including health [16].
With regard to class and gender indicators, studies also hardly incorporate in their proposals to the specific health of black women. The studies that use the concept of gender to study health and disease are still recent. Those that already exist usually show the social conditions, lifestyle, and how knowledge about health interferes in the health/ disease [17].
Women who have studied up to primary school 122 (58.1%) were two times more likely to be resistant when compared to those 14 (6.7%) who studied up to the higher education (OR = 2.69; 95% CI = 1.31 -5.48; p = 0.012). As for women who have studied up to high school 74 (35.2%) were two times more likely to be resistant when compared to those 14 (6.7%) who studied up to the higher education (OR = 2.87, 95% CI = 1.35 -6.08; p = 0.012) ( Table 2).
Individuals with higher levels of education tend to be healthier than individuals with lower levels of education. Researches have shown significant correlations between education and mortality, heart disease, cancer, diabetes, lost workdays, smoking, alcohol consumption and self-reported health problems [18].
Therefore, the highest level of education is a determining factor in the search for better living conditions and, consequently, better quality of life. In this respect, it is possible to infer the existence of a relationship between low family income, low education and BC, for those two factors hinder access to information about prevention and treatment, reducing the demand for health services [19].
Education also correlates with the use of preventive care services; individuals with higher levels of education perform more preventive practices, such as flu shots, mammograms, Pap tests and colonoscopies [19].
Thus, knowledge and insight to decision-making, as a rule, relate to the level of education acquired by the individual. If women receive information about prevention methods for the BCS, they will certainly have knowledge and insight to determine their attitudes and practices in the prevention of the disease. Therefore, one observed that the higher education improves the chance of a woman to undergo CBE and MMG [20].
A study developed by Schneider and D'Orsi (2010) points out that illiterate women have risk of mortality from BC is 7.4 times higher than in women with higher education. As for those with incomplete primary education, the risk is 3.76 times greater. Women with higher income and education, who have more knowledge, adhere more often to preventive practices. That research corroborates this fact, because the resistance is directly proportional to the few years of formal study, which suggests that the poor knowledge about cancer contributes in a unique way in the search for preventive practices for cancer and perhaps other diseases [21].
Another dimension that made women more resistant to practice the BCS was the presence of relatives of first degree with BC. There were 153 (72.9%) women who were three times more likely to be resistant when compared to those 107 (51.0%) women who had no relatives of first degree with cancer (OR = 3.30; 95% CI = 1.89 -5.75; p = <0.0001) ( Table 2).
Those findings are worrisome because the most resistant women were precisely those who had first-degree relative with BC. However, those women identified as more resistant, should receive more education and take extra care regarding the adherence to screening practices, because the risk of a woman developing BC is higher among those who had the disease in first-degree relatives (mother, sister or daughter) [22].
Study shows the rarity of cases of certain cancers exclusively by hereditary, family and ethnic factors. In the case of breast cancer, family history, especially in first-degree relatives younger than 50 years, is an important risk factor (4). It points out that the risk of disease almost doubles; and having two first-degree relatives increases the risk by about three times [23].
In this reading, it is essential that health professionals, as well as the production of policies in the area, reflect those limitations and adopt action strategies to make family members, especially women, aware of the risks and perform preventive practices. Those actions would possibly make women less resistant to BC screening practices. Therefore, the information research during medical and nursing consultations is extremely valuable because the bond built between professionals and users is a great tool for knowledge of the population's real needs and questions.

Conclusions
The sociodemographic profile showed that black women, with educational attainment up to elementary school and family with BC were considered resistant to tracking, reinforcing the impact of social determinants on the health of the female population. Thus, the found data highlight the need for investment in educational practices focused on the population awareness and training of professionals, because the bond built between them characterizes as a tool to disseminate information regarding tests used in practices aimed at woman's health.
Therefore, although being a disturbing and challenging process, it is necessary that the health teams from BFHU ensure adherence of women to preventive care. It is noteworthy that the educational activity with client-professional mutual respect is an important strategy to understand the importance of preventive screening and for women to feel motivated to accomplish it, overcoming any difficulties, such as those identified in the study.

Introduction
A leaning towards psychological stress is the result of cognitive distortions and a physiological hyper reactivity before psychosocial demands that may be created due to hyper sensibility of the limbic system, which produces excessive catecholamines, testosterone and cortisol. Some individuals seem to have the tendency to stress, which can be the result of outside forces, and its effects are mediated by the ability to face stress, something learned mainly during childhood [1].
The early and cumulative (chronical) exposure to stress factors may result in neuroendocrine alterations and subjective behavioral changes. These stress factors tend to be involved in long-term process and hinder the development of the brain systems that are responsible for learning, motivation, work stress reductions and adaptive behavior [2].
Individuals that experienced some form of childhood stress may present, in adulthood, consequences that manifest into mental disorders such as: humor, anxiety, personality disorders and the problematic use of alcohol and other substances [3].
ELS experiences lived in childhood may be Physical Abuse, Sexual Abuse, Emotional Abuse, Physical Neglect and Emotional Neglect, according to Bernstein et al. (2003) [4].
Physical Abuse is when aggressions are committed by someone older with the risk of lesions, which are erroneously used to educate children by parent or guardians, resulting in body wounds that may lead to death.
Sexual Abuse is any contact or sexual behavior between a child and someone older, seeking to sexually stimulate the child or adolescent and/or using them to obtain sexual stimulation for someone or a third party.
Emotional Abuse is verbal aggressions that affect a child's wellbeing or moral integrity, or any conduct that humiliates, embarrasses or threatens the child. It also occurs when an adult constantly depreciates a child, blocking their efforts in self-acceptance and causing emotional grief.
Physical Neglect is when a parent or a responsible party fails in providing food, adequate clothing or other basic necessities such as: shelter, security and health supervision.
Emotional Neglect is when a guardian fails in providing basic emotional and psychological needs such as love support and motivation, also, when a child emotional necessity is not given, such as affection, cognitive and psychological support [4].
Stress during the early stages of life is a precursor of alcohol abuse and/or other drugs and dependence of such in adulthood. The risk/resilience relation to dependence on psychoactive drugs may be, in part, due to the interaction between genetic variations and environment stress factors, such as experiences with early types of abuse (sexual abuse during childhood, physical and emotional abuse, physical or emotional neglect) [5].
Psychoactive substance dependence may onset in individuals due to the influence of biological, psychological and social factors. Biological factor are associated with each individual's organism, the psychological are associated with personality, fears, anxiety and insecurity in facing everyday life situations. Social factors are associated with family, culture or, in other words, with the context in which the subject finds himself inserted in. The individual that receives attention, care and limits in an adequate manner are more equipped to grow into well-adjusted adults. Those who face negligence have a tendency to inappropriate behaviors and emotional hardship to solve conflicts [6].
There are many tools that can be used to investigate traumatic events in childhood, We decide to standardize our sample with this tool because the CTQ is a very commonly used tool, and can be considered the gold standard tool for research in the clinical and forensic fields of ELS [8].
The Integrative Review (IR) is a data collection method which contributes to the phase of the search for Evidence-Based Practice to construct a comprehensive literature analysis contributing to discussions on methods and results of research and experiments, and aims to deepen the understanding of certain phenomenon, based studies and previous evidence [9]. The Evidence-Based Practice comes from the Evidence-Based Medicine (EBM) had origin in the work of the British epidemiologist Archie Cochrane in 1972. It is an approach which defined a problem and carried out the search and evaluation of available evidence sore the subject, after the evidence is implemented in practice, and the results evaluated. This approach incorporates the evidence from research, along with the expertise of professional and customer preferences, enabling improved quality of care [11] [12].

Purpose and Research Question
The purpose of this integrative review was to Identify, Analyze and Synthetize scientific evidence that support the hypothesis that Early Life Stress (ELS), measured by the CTQ, may in fact result in the use and abuse of psychoactive substances in adolescence and adulthood.
We chose PICOT methodology to formulate the research question PICOT represents the acronym: P = Patient or Population; I = Intervention or Indicator; C = Comparison or Control; O = Outcomes; and T = Time [10].
In this review, the PICOT strategy was used in the following manner: After removing articles that appeared more than once, due to different databases, the number of references left for this study was 359. The titles and abstracts were evaluated according to relevance, and 157 studies were selected for a complete reading. After this integral reading, texts that didn't answer the research question were eliminated, resulting in eight articles left for this review. A flow diagram of study selection process was developed to illustrate the articles selection process ( Figure 1).

Analysis and Synthesis
The articles that were selected to compose this integrative review are described at Objective: To examine the associations between the types of child maltreatment and its inception, climbing and severity of substance use in cocaine-dependent adults. Study Design: Quantitative cross-sectional study with observation, not experimentation, with no control group. Samples by convenience. Software used for statistical analysis and significance level not informed the data analysis plan. Held simple regression analysis. Tests: Chi-square, T-test and Wilcoxon Rank-Sum. Population: Sample with 87 participants, men (n = 55) and women (n = 32) in treatment for cocaine addiction. STROBE: Does not contemplate: 5) Setting: Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data collection; 6) Participants: Cross-sectional study-Give the eligibility criteria, and the sources and methods of selection of participants; 9) Bias: Describe any efforts to address potential sources of bias; 14) Descriptive data: (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and potential confounders; 19) Limitations: Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction and magnitude of any potential bias. Main Results and Conclusions: In men, emotional abuse was associated with a younger age for the first use of alcohol and a bigger severity of substance abuse. In women, the sexual abuse, emotional abuse and mistreatment in general were associated with the first use of alcohol, emotional abuse, neglect and mistreatment were associated with a bigger severity of substance abuse. The results suggest that early intervention for childhood victims especially girls, may delay or prevent the early onset of alcohol use and reduce the risk of a more severe course of addiction [17]. Main Results and Conclusions: Childhood trauma were directly and indirectly related to psychological stress and substance abuse. The childhood trauma self-reported was significantly related to higher substance abuse and psychological disorders, through low levels of education and avoidant coping strategies.
The results indicate importance of educational strategies to support and interventions to teach coping skills to prevent substance abuse and long-term psychological distress in children exposed to trauma. STROBE: Does not contemplate items: 7) Variables: Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if applicable; 9) Bias: Describe any efforts to address potential sources of bias; 17) Other analyses: Report other analyses done-eg analyses of subgroups and interactions, and sensitivity analyses; 22) Funding: Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on which the present article is based [20].

ELS and the Use of Alcohol
The psychoactive drug more often used by those participating in these selected studies for this review was alcohol. Individuals tend to start with alcohol and nicotine (legal substances) before starting with illegal substances. According with the IV National

Survey regarding Psychotropic Drugs among Students of Public and Private Middle
School and High School in the 27 Brazilian Capitals in 2010, alcohol and tobacco are the prevalent drugs used in life, in all capitals, followed by inhalant drugs [15].
Cigarettes and alcoholic beverages, mainly beer and wine, were indicated as having been used much earlier in life than illicit drugs. On average, marijuana tends to come 2, 5 years after the use of cigarettes or alcoholic beverages, and cocaine and crack were used a little after a year from marijuana [16].
The age of the first use of alcohol is considered as a predictor for the age of cocaine first use in both genders. It may have indirect correlation to mistreatment during childhood and the leaning towards using cocaine, which is predicted using the first use of alcohol. Childhood mistreatment may contribute directly to the age of first use of alcohol. The use of alcohol and nicotine opens the door to other drugs [17].
In the study by Shin et al. (2010) [18], which classified adolescent substance users in latent classes, the use of alcohol and cannabis was present in all classes of substance users, and all the classes which made use of cannabis, also reported having used alcohol as well. All classes that used heavy drugs reported also having used alcohol and cannabis.

ELS and the Use of Psychoactive Substances during Adolescence
Mistreatment and cumulative stressful events before puberty and especially in the first years of life is linked to the early drinking abuse in adolescence and alcohol and other drugs dependence at the beginning of adulthood [5].
In Scomparini et al. (2013), a study performed with children and adolescents with an average of 12.47 years, the Substance Use Disorder was positively associated with the exposure to multiple traumas and with each new trauma, the likelihood of the disorder increased by 34% [22].
Shin et al. (2010), defend that adolescents involved in public service in the city (regardless of sex), when older, are more likely to use multiple substances when compared to younger adolescents (ages between 13 -15 years). The bigger risk factor is the influence of use by pairs and the protection factor is the parental control [18].
In the study by White et al. (2013), adolescents that made use of multiple substances were directly associated with psychological stress and use by pairs. Older adolescents tended to have higher access and availability throughout life to a myriad of drugs when compared to younger adolescents [23].
While mistreatment during childhood may contribute directly to the age of first alcohol use, other factors in the early use of alcohol in the adolescent's life (for example, the use of substances by pairs) may contribute to a faster progression of cocaine use [17].

ELS and the Female Sex
Authors who have performed research with both gender, indicate that childhood traumas and later use of psychoactive substances are more present in female [17] [18] [21].
The ELS may affect directly upon the vulnerability of women regarding the use of alcohol, especially in association with stress factors beyond their control. Extremely stressful life events were associated with the consumption of alcohol only among women and these effects were negative on men, when exposed to mistreatment during childhood [24].

ELS and Coping Strategies
A study with incarcerated women showed a negative association between Sexual Abuse and other traumas regarding the treatment for psychoactive substances abuse. This abusive substance use may have been used as a coping mechanism (non-assertive coping), or these women failed to notice the connection between the substance abuse and the trauma lived [19].
Childhood trauma were significantly associated with low levels of education and use of non-assertive coping mechanisms (avoidance). The reason for this low level of education may be due to Neglect and Emotional Abuse of children that have not received the proper parental support to attend school regularly and thus learned to use avoidance tactics, such as skipping class and using alcohol and other drugs to deal with the impact of the abuse and/or neglect [20].
For Eames, et al. (2014), the association between ELS and the later use of alcohol may be due to traumas, which conditioned the way the child learned to deal with stress and can predict the gravity of alcohol dependence. This effect was stronger on men that have lived with stress continuously throughout their adult lives. Due to stress factors during rehabilitation, individuals in treatment who experienced high levels of childhood trauma are more likely to relapse [27].
Mistreatment during childhood may potentialize the genetic vulnerability to alcohol use as a stress coping mechanism, and the impact of these effects may be measured by the interaction between gene and environment. Risk factors such as childhood mistreatment likely increase the change these individuals have of developing non-assertive coping mechanisms [5] [24].

Nursing Contribution on ELS
Considering the nursing mental health care developed during the vital cycle, nurses represent professionals that are remaining most time with patients. These professionals provide assistance to children and adolescents, and have the better opportunities to observe and identify the signs and symptoms of abuse and neglect in childhood, which means ELS. Nursing professionals should act preventively about ELS in nursing care plan. In this way, nurses have to provide to their clients possibilities to develop assertive coping strategies and even actuate legal support for removal of stress factors when it would be necessary.
Among adults who suffered ELS and developed problematic use of psychoactive substances, the ELS should be identified, and stress reduction interventions must be guar-anteed, considering a cumulative history of adversities throughout life.

Study Limitations
The studies included in this review corroborate the research question, showing that the use and abuse of psychoactive substances in adolescence and adulthood is an outcome of the childhood trauma, though each one should be carefully assessed.
All studies included in our sample are cross-sectional studies, so there may be casual interference, and it is known that other factors may also influence drug use (genetics, family, social factors etc.) (Hyman et al. 2006; Maltreatments experienced in childhood are self-reported, so there may be memory leaks or omission of facts. The samples of studies was gathered by convenience (they were already users of alcohol and/or other psychoactive substances, or were considered a population at risk/vulnerable) [17] [28].
In our sample, only one study was conducted in Brazil by Tucci et al. (2010) with a control group (psychoactive substances non-dependent group without psychiatric diagnosis), confirming the hypothesis that childhood trauma was prevalent in the group that made use of psychoactive substances [21].
The studies used different types of data collection for evaluating the use of psychoactive substances and to measure other psychiatric disorders, but all the authors selected for this review used only the CTQ as a tool to assess ELS.
The research associated with Childhood Trauma is an interdisciplinary field, since the children's wellbeing is a concern not only for health care courses, but to the education, social services, legal fields, as well as for the public in general. Despite being a multi/interdisciplinary field, there was not found studies performed by nurses to answer the research question, even if the search was performed in multidisciplinary databases [29].

Conclusions and Implications
Through this integrative literature review, scientific evidence supporting ELS as one of the factors of alcohol abuse and/or other psychoactive substances in adolescence and adulthood were identified in all articles included in this study. Studies show that the occurrence of mistreatment in combination with environmental and genetic factors influence the onset of substance use, the emergence and maintenance of addiction and also the relapse processes.
As a drug, alcohol was the most frequent substance in this research. In addition to alcohol and other illicit drugs, traumatic childhood experiences may also be associated with prolonged use of BZD in patients undergoing treatment for opioid use and this may be an important starting point for the prevention of substances abuse [25].
ELS may turn adolescents living in populations at risk more vulnerable to alcohol and other psychoactive substances. The improvement of substance use prevention and the creation of treatment services for adolescents, victims of Child Sexual Abuse is imperative. It is important that appropriate public policies be developed for the prevention of child abuse, especially to reduce the risk of subsequent mental disabilities [18] [22].
In studies using samples with both genders, there is the confirmation that the abuse of psychoactive substances after ELS, was more frequent in women. The early interventions for abused children, especially females, can help delay or prevent the early onset of alcohol use and reduce the risk of a more severe dependence [17].
Min et al. (2007) suggests the importance of understanding trauma in women seeking treatment for psychological disorders and substance abuse, so that interventions may be created to promote assertive coping skills, to reduce or prevent the problems associated with childhood trauma [20].
Incarcerated women who suffered ELS have shown low levels of demand for treatment for the abuse of psychoactive substances. One should consider and seek to understand the barriers faced by this population, so that better interventions can be provided to encourage them to seek help [19].
It was also possible to identify the use of psychoactive substances as a non-assertive coping strategy for traumas experienced in childhood, and in addition to the use of psychoactive substances, ELS is strongly linked with the development of psychological stress disorders. It is important to include traumas in childhood in the diagnostic process of people making treatment for substance abuse, so these coping strategies can be worked, reducing the number of relapses [21]. Eames et al. (2014), suggests a strong need to work on these coping skills, stress management background and pharmacological treatment at the beginning of the recovery process for substances users [27].
The author used CTQ only as a tool to measure ELS and confirmed it as being highly useful to identify childhood traumas.
This study reinforces the need to investigate the ELS occurrence in people that abuse of psychoactive substances, as strategy to improve treatment, making it more effective for these specific patients. Assertive coping skills must be developed, as well as stress management. It is important to note that early interventions with mistreated children (especially females) helps to slow down or even prevent substance abuse later on and a more serious evolution of psychoactive substances dependence.

Abstract
Patients requiring Subacute and Complex Care services continue to challenge hospitals attempting to reduce inpatient stays and improve efficiency. In recent years, numbers of high severity of illness patients in hospitals have increased, adding to this challenge. Nurse care managers have a major responsibility for supporting the care of these patients. This study described the development of services for Subacute and Complex Care patients in the hospitals of Syracuse, New York. These hospitals used their own resources to develop programs including high cost medications, intravenous therapy, extensive wound care, and bariatric care in settings where they had not been available. In the absence of third party funding of another level of care, the hospitals provided program development funds for limited time periods in order to initiate these services. The Syracuse hospitals were able to phase out support for these programs after they were operational in the nursing homes for an extended period of time. The study data indicated that implementation of these programs limited the rate of increase of adult medicine stays and reduced adult surgery stays. The severity of illness for both major services increased in the Syracuse hospitals during this time. This process required acute and long term care providers who were interested in making the process work for the benefit of the patient populations involved, as well as for the needs of their own organizations.

Keywords
Hospital Lengths of Stay, Hospitalization, Long Term Care

Introduction
Transitions from acute to lower levels of care have always been a challenge. In hospitals and health care systems, the role of the nurse care manager has taken on greater importance in moving patients between levels of care. This is a major responsibility to patients and to provider organizations.
Providers such as acute hospitals need efficiency in the delivery of care because extended stays detract from the quality of care and result in large additional expenditures for increased labor, room and board, pharmaceutical, and other costs. Reimbursement for inpatient hospital care from payors is based on discharges and does not include separate additional payments for many of these expenses [4]. The implementation of bundling programs by Medicare has stimulated health care providers to improve care by reducing hospital stays and expediting discharges home.
These programs began with orthopedic procedures, but are expanding to medical diagnoses [8]. In most facilities, every episode is being scrutinized to assure that all care is provided in the appropriate setting in a timely, efficient manner. Patients remaining in a hospital longer than necessary risk infections such as pneumonia, loss of mobility, skin breakdown, and other complications. Payors are assessing financial penalties when these adverse outcomes occur in an effort to stimulate providers to improve quality [9] [10] [11] [12].
Transitions from acute care require that lower intensity services are available in the community where the patient may need them. For example, patients requiring several weeks of intravenous antibiotic therapy may not require acute care but may require a skilled nursing facility employing a staff who are qualified to administer and monitor the antibiotic.

Population
This study describes the efforts of the hospitals in the metropolitan area of Syracuse, New York, to support transitions from acute care. These hospitals comprise the acute care system of the area. At the time of initiation, these less intense services were not available in nursing homes resulting in disruption of patient flow, backups in emer-gency departments, and staff frustrations.  • Combinations of Medications such as antibiotics and Lovenox.

Method
• Extensive Wound Care including vacuum assisted equipment and intravenous medications.
• Behavioral Issues Requiring One on One Care.
The Subacute and Complex Care Programs were implemented through agreements including the Syracuse hospitals, participating nursing homes, and the Hospital Executive Council. Those agreements included the following components. 1) Certification by an Access Coordinator at each hospital that the need for the program was the barrier to the discharge of each patient.
2) A community wide pool of funding.
3) Distribution of Program Development Funds for specific types of care by the Hospital Executive Council.
It was intended that Program Development Funds should support the development of these services in nursing homes, rather than being an indefinite source of funding.
For this reason, the funding was phased out as nursing homes implemented most of the services.
The study was carried out using patient specific data from each of the hospitals by the Hospital Executive Council. These data were obtained through Business Associate Agreements with each of the hospitals. The Council functions as a mechanism for the development of multihospital studies in the Syracuse metropolitan area.
The study data included quantitative information concerning utilization of the Sub-

Results
Data concerning the initial component of the study, including utilization of the Sub-acute Programs in the Syracuse area, are summarized in Table 1. Related information also includes descriptions of the implementation and operation of the programs.
The initial Subacute Program developed by the Syracuse hospitals and area nursing homes focused on the implementation of intravenous therapy for single medications. The program was implemented in 2004 when no long term care facilities in the Syracuse area were providing this service.
The study data indicated that use of the Intravenous Medications Program declined  The Extensive Wound Care Program, focusing on the use of vacuum assisted closure device equipment in nursing homes, was implemented. The study data indicated the utilization of the Program ranged between 18 patients in 2006 and 19 patients in 2014. The original need for the program was based on high costs of the service associated with a single vendor as the provider. After 2012, the entry of additional vendors into the market reduced prices and the need for hospital support. It was eliminated in 2016.
The Subacute Bariatric Program was implemented in 2007 in order to stimulate the development of programs in nursing homes for patients with high Body Mass Indices discharged from hospitals. Program Development Funds were provided to 3 area nursing homes to support the acquisition of lifts, bariatric beds, wheelchairs, and other equipment for these patients, as well as for additional staff and training.
The study data indicated that, because of the limited scope of the program and the small number of nursing homes participating, utilization ranged from 10 patients in 2008 to 17 patients in 2010. By 2015, the participating nursing homes had implemented their own programs for care of bariatric patients and use of the Program was declining. It was eliminated in 2016.
The Patient Transportation Program, for stretcher and wheelchair transports, was implemented in 2007 to support the ability of area nursing homes to admit hospital patients who required transportation to offsite services. Most of these patients required dialysis that could be obtained at a number of area facilities. Most of the program population consisted of Medicare patients, for whom transportation was not a covered service. Medicaid patients were not included because Medicaid reimbursed the services directly to approved transport vendors.
The study data indicated that utilization of the Patient Transportation Program ranged from 13 to 27 patients between 2008 and 2016. Between January and June 2016, 24 patients used the program. Utilization of the Program has continued to justify its operation.
The study data also indicated that the Program Development Funds associated with each of the Subacute Programs ranged between $108,000 and $229,000 during their lifetimes. This amounted to approximately $20,000 -$40,000 per year for each program.
Data concerning the second component of the study, including utilization of the Complex Care Programs in the Syracuse area, are summarized in Table 2. Related information also includes descriptions of the implementation and operation of the programs.
The Complex Care Programs were developed by the Syracuse hospitals in 2015 as means of supporting long term acute care services that were beyond the scope of the Subacute Programs. They involved combinations of medications for patients in need of extended long term care services.
The Multiple Intravenous Medications Program was developed for hospital patients who required more than a single intravenous medication. In addition to the costs of the additional drugs, this need required nursing homes to increase staff beyond levels re-  The study data also demonstrated that mean lengths of stay for adult surgery de-

Discussion
Patients who require subacute and complex care services have been a challenge for hospitals attempting to reduce inpatient stays and improve efficiency. These patients need the continuing services that they received in acute care but in residential settings. These services are frequently not available in rehabilitation or skilled nursing facilities. In recent years, increases in numbers of high severity of illness patients in hospitals have added to this challenge.
Nursing care managers have a major responsibility in supporting the care of these patients. This includes the development of programs and assuring that the needs of individual patients are met. Increasing numbers of elderly patients do not have family or friends to assist as care providers. Care for them must be arranged in rehabilitation or skilled nursing facilities.
In the United States, some states have implemented long term acute care programs which add another level of care to serve the needs of these patients. The Medicaid expenses related to these services have limited the use of these programs. In many communities, which do not have access to these programs, acute hospitals have had to develop their own programs with nursing homes and other providers.
This study described the efforts of hospitals in Syracuse, New York, a small metropolitan area, to develop services for subacute and complex care patients using their own resources in cooperation with local nursing homes. The clinical content of these services, including high cost medications, intravenous therapy, extensive wound care, and bariatric care made their delivery in settings where they had not been available a considerable challenge. In the absence of third party reimbursement for another level of care, the hospitals provided Program Development Funds for limited time periods in order to initiate these services.
The study data suggested that most of these efforts in Syracuse were successful in implementing these programs in nursing homes. Hospital resources helped support the development of intravenous therapy, the use of high cost medications, extensive wound care, and bariatric services in nursing homes where none existed previously.
Of equal or greater importance was the manner in which the Syracuse hospitals were able to phase out support for these services after they were operational for extended periods of time. This process suggested that the participating nursing homes had a genuine interest in the provision of these forms of care and in the development of their own resources to support them.
Although it was difficult to separate the impact of these initiatives from other efforts, the study data indicated that their implementation in Syracuse long term care facilities contributed to a lower rate of increase in adult medicine lengths of stay and a reduction in adult surgery lengths of stay in the Syracuse hospitals between 2008 and 2016. During this period, the severity of illness of patients in both major services increased in the combined hospitals.
The planning and development of the Subacute and Complex Care Programs in Syracuse was not an overly complicated process. It did, however, require both acute and long term care providers who were interested in making the process work for the benefit of the patient populations involved, as well as for the needs of their own organizations. The work of the Hospital Executive Council was also useful in carrying out the planning process and in maintaining consistency in distribution of program development funds according to the standards set.
As they face the future, nursing care managers need to prepare for continuing changes in how and where medical services are provided, as well as how those services are reimbursed. They need to look at alternative settings and professional preparation needed to offer long term acute services for the population that requires them. Results: Toilets designed for physically disabled people were accessible as the location and signs (59.9%), identified with symbols for males and females (57.3%); however, the doorway width was smaller than needed to accommodate a wheelchair (77.7%). Inside the bathroom, only the forward approach was possible (59.9%). Grab bars positioned on the side and rear walls were inadequate or nonexistent (67.6%); toilet seats (91.1%) and toilet paper dispensers (96.2%) were mostly in inaccessible heights; flush controls in appropriate height (59.2%) and activated by light pressure (58%). Sinks without pedestal (51%), but higher than recommended (80.3%) and without single handle faucets (95.6%). It was verified that the toilets of basic health units located in urban areas had better accessibility conditions compared to those in rural areas. Conclusion: Results showed that the analyzed units presented physical inaccessibility in some toilet facilities, making it difficult or even

Introduction
Accessibility concerns the physical conditions or the communication elements that enable safe and autonomous participation of people in public and private areas, in the use of urban equipment and street furniture, providing greater social inclusion and better quality of life [1] Ensuring the access of disabled people is an act that respects their freedom of movement, allowing them to use essential public services. It is worth highlighting the difference between access and accessibility. Even though access complements accessibility, these are two distinct concepts, in which accessibility enables people to come to the environment, while access provides the appropriate use of services to achieve better results [2].
There are many challenges in evaluating the accessibility of specific groups, such as people with mobility issues in a particular urban space. Methods that are usually based on technical standards and legislation can be adapted to seek a broader approach to identify and understand accessibility, as well as the perception of the space and environment where these groups live [3].
Despite the extensive Brazilian law to guarantee the accessibility right to health care of disabled persons, most are not respected. Legislation focuses on basic precepts to promote accessibility to spaces and urban equipment, emphasizing the importance of architectural planning of facilities to ensure the universal right to access and quick and safe mobilization [4].
Nevertheless, the association between the dimensions of accessibility, both in terms of health services organization and geographical aspects, mediated by users' empowerment, has not been achieved, as well as analyzing the reasons why these problems remain [5].
Health care accessibility of disabled people comprises a set of strategies and equipment incorporated and linked to the physical space. It should include practices and care that point to independence and social inclusion processes from the first interventions to the optimization of spaces available in health services [6].
Additionally, it refers to the characteristics of resources that facilitate or limit its use by potential clients, corresponding to the aspects of services with special significance when analyzed according to the impact they have on people's ability to use them. Therefore, accessibility is an important supply factor in explaining the variations of how the population uses health services, representing a crucial dimension in studies about equity in health systems [7].
Among the various locations offered to the population in primary health care services, access to toilet facilities should promote the independence of disabled persons, assuring their intimacy and privacy. Going to the bathroom can become an extremely difficult task, even impossible sometimes, when the right measures for the physically impaired or people with reduced mobility are not implemented [6].
Developing projects that strengthen the accessibility and designing manuals and routines for primary health care, to encourage the humanization through welcome practices, along with intersectoral actions, favor the expansion of comprehensive care [8].
By recognizing the legitimate rights of accessibility and social integration of disabled people, it is intended to contribute to mapping architectural barriers to their accessibility to toilet facilities of basic health services. Thus, this study seeks to contribute to the care and teaching in the field of nursing and areas of health sciences, human sciences, and engineering [9].
Given the importance of primary health care as the health system gateway, this work aims to analyze the physical accessibility to toilet facilities in urban and rural primary health care units.

Methods
It was a quantitative research of descriptive approach consisting of measurement proce-  Table 1 shows that toilet facilities were accessible as the location and signs, with statistically significant differences (p < 0.001 and 0.010, respectively). Regarding the separation of bathrooms by gender, it was found that 57.3% were divided into male and female.

Results
Of all toilet facilities, 77.7% have inaccessible doorways (p < 0.001), despite presenting space to perform the 1.20 m forward approach (p = 0.006). Nonetheless, in absolute majority, there were no obstacle-free space for maneuvering the wheelchair in 90˚, 180˚ and 360˚, thus being considered inaccessible (p < 0.001).
Regarding the presence of horizontal bars on the side and rear walls, 67.6% were allocated inappropriately or non-existent, constituting the inaccessibility of this item with significant results (p = 0.019).
Toilet seats and toilet paper dispensers were evaluated mostly as inaccessible to the physically disabled (p < 0.001), considering they did not contain accessibility aspects, like appropriate height. Flush controls, however, were considered accessible as the height and activation by light pressure (p = 0.002 and 0.006, respectively).
Sinks presented accessibility aspects, such as the absence of pedestals (51%), but the height and faucet type were inadequate (p = 0.000).

Discussion
Primary health care is the first occasion of user assistance in the health system, thus the assistance model should meet the specific needs of various population groups, including disabled people. Nevertheless, in Brazil, a difficult access of this public to primary care is verified, aggravated by the development of fragile, inconsistent, and discontinuous health actions, demonstrating that it does not meet their real needs [6]. The right to accessibility preserves the individual autonomy. In this sense, it is essential to evaluate the movements of disabled persons in health services, considering their independence, ease, and security in using the space, existing equipment, and furniture.
Among the various sectors that compose the physical structure of health units, toilet facilities are one of the main areas that need adaptation to provide privacy, maintenance of bodily functions, and proper personal hygiene to users with reduced mobility.
In this study, inaccessibility was observed in most toilet facilities in health units, which causes disabled users to experience difficulties in using this space, in addition to dependence, stressful moments, embarrassment, discomfort, and losses in performing self-care. The location and signs of toilets met the standards of NBR 9050, since 79.6% were in easily accessible locations and 59.9% had indicative toilet signs.
These points are worth highlighting because a study evaluating the infrastructure of health units in the state of Paraíba, Brazil, identified an opposite reality, observing that the bathrooms were not arranged in accessible locations, away from the main circula-tion and with inappropriate signage, representing one of the items with the most critical accessibility conditions [11]. It is worth mentioning that the units with accessibility in these items were located predominantly in urban areas, indicating greater infrastructure of urban units compared to those in rural areas, since toilet facilities require a greater space to allow the various rotational movements.
The lack or inadequate placement of grab bars also hinders the use of bathrooms.
Aimed at offering support, balance, and safety during the use of toilet accessories, they require length and mounting height in compliance with the technical standard [10]. A total of 67.6% of toilets had inaccessible bars on the side and rear walls, as they were installed in improper height.
These elements were also observed as inaccessible in a study that analyzed accessibility issues in primary health care services in the State of Pernambuco, Brazil, which verified that 97% of the units did not have accessible toilets, highlighting the absence of grab bars in bathrooms [13].
Regarding toilet seats, they were inaccessible because they did not have a 46 cm height above the finish floor (91.1%). Additionally, toilet paper dispensers (96.2%) were non-standard; they should be at a height between 50 and 60 cm above the finish floor and 15 cm from the front end [10].
Sinks were also evaluated. Among those with physical accessibility items, it is hig-hlighted that 51% had sink without pedestal, thus allowing the wheelchair approach.
Nonetheless, when measuring its height, 80.3% were inaccessible, as well as the faucets, which should be of single handle type.
Evaluation of physical accessibility of bathrooms in 27 schools of Chapecó, Santa Catarina, Brazil, identified that only 13 had toilet facilities adapted for disabled people.
Different from the present study, 76.92% of analyzed bathrooms had suspended washbasins from 78 cm to 80 cm above the finish floor [14].
This type of evaluation is also common in other environments, such as long-term care facilities for the elderly. A study conducted in Portugal in this kind of institution detected that the position of sanitary equipment also constituted a limiting agent, hindering the proper use by persons with reduced mobility, besides the restricted access to the toilet, resulting in physical constraints. As for the sinks, they are lower than required by legislation and do not have single handle faucets [15].
The lack of accessible toilets for disabled people is evident. When asked, users themselves reported being unaware of fully accessible toilets for disabled persons in health services, because even if they exist, they are inappropriate for use [16].
People with physical disabilities have several mobility limitations, ranging from the inability to turn on a faucet to depend on a wheelchair for locomotion. This diversification implies an underreporting of this public, since many reject the international symbol of accessibility, represented by a wheelchair. The concept accepted by most of this population consists of people with limited mobility, not disabled persons, and they reject being identified as wheelchair users. In this context, they do not exercise their rights [17].
Toilets designed for physically disabled people were accessible as the location and signs, identified with symbol for male and female, but with doorway narrower than required to accommodate a wheelchair. Inside the bathroom, only the forward approach was available.
Grab bars on the side and rear walls were inadequately positioned or non-existent; toilet seats and toilet paper dispensers were mostly in inaccessible heights; flush controls in proper height and activated through light pressure. Sinks without pedestal, but higher than recommended and without single handle faucets. It was found that the toilet facilities in basic health units located in urban areas had better access conditions than those in rural areas.
With this purpose, it is imperative to investigate health services access barriers to support health planning. Information about the access of people with disabilities or mobility restriction in the Brazilian health system are incipient, especially in the socioeconomically disadvantaged regions. Thus, there are few indicators that assist in monitoring and evaluating the performance of the health system, essential tools for planning actions [18].

Conclusions
Regarding the health sector, the access of disabled persons is still incipient, since archi-tectural barriers are easily observed in health care services, constituting obstacles to health care. Awareness and commitment of leaders, managers, and professionals need to be established to create favorable spaces to universal health care.
It is worth highlighting that a report describing the problems identified in the toilet facilities of health units was made and delivered to the leaders of the municipalities.
Nevertheless, since this is a cross-sectional study, a new assessment did not take place.
Thus, it is suggested to conduct a longitudinal research to verify the occurrence of any changes after this study.
Although limited in assessing only the toilet facilities of health units in a specific region, this study showed that physical accessibility should be considered in any location, since eliminating these barriers provides significant value to this population in using health services, enabling equality and equity for disabled people. Inclusive awareness and sensitivity to the reality of this group are essential to meet their basic and specific human needs.
the past 5 years, and the percentage of older adults staying at long-term care facilities has increased to 57% over the same period [1]. Older adults staying at nursing homes have diverse health problems, including physical and psychosocial problems. Among them, functional decline, depression, and low levels of social interaction are common, and serious problems must be controlled [2] [3].
Depression is one of the most common psychosocial problems among older adults staying at long-term care facilities [4] [5] and 40 -48 percent of residents at long-term care facilities show depression, compared to the 33 percent of older adults living in their own home [6]. Depression at long-term care facilities is related to change of living environment, personal interaction and social support system, and isolation from family [7]. Because of depression, residents also show reduced interaction with other residents at the facilities. Although depression is serious and common in long-term care facilities, depression is under-assessed and under-managed by health professionals [8].
Personal relationships are generally defined as relationships among more than two persons and the psychological relationship among members of a group [9].

Participants
The study was a quasi-experimental one-group pretest/posttest design. Participants were 30 elderly individuals staying at a nursing home in D-city, South Korea. Convenience sampling was used. Inclusion criteria were as follows: 65 or older, no physical impairment, ability to communicate, understood the purpose of study, and willing to participate in the study. The minimum size of a group was 27 based on the G *Power 3.1. Program analysis [23] with moderate effect size of 0.50, power of 0.80, and alpha value of 0.50. Therefore, the number of participants in this study satisfied the minimum samples size.

Instruments
• Grasping power Grasping power was measured using a dynamometer (Lavisen's KS-301). For the measurement, subjects stand upright, straighten their arms to the side, and drop them until they are 15˚ from the body. A subject grasps the dynamometer with one hand while the second finger is at 90˚. When the PI says "start," the subject grasps the dynamometer as hard as possible. S/he repeats the process one more time with the other hand and the better record is kept. The dynamometer results are measured in kilograms, recorded to one decimal point.

• Depression
Depression was measured using the Korean version of the Geriatric Depression Scale-Short Form (GDS-SF) [24]. The GDS-SF Korea version includes 15 items, and each item is answered with yes (1) or no (0), for a total possible range of 0 to 15.
Higher scores reflect greater depression, and scores over 5 reflect depression. The reliability of the GDS-SF is 0.88 [24].

• Personal relationships
To measure personal relationships, the modified Relationship Change Scale (RCS) was used [25]. The original RCS consists of 25 items, and it was modified in Park's (1998) study [26]. The modified RCS includes only 7 items, and each item is answered from 1 (never happened) to 4 (always happens). Higher scores reflect better personal relationships, and the reliability of the RCS is 0.77 [26].

Band Therapy Using Music
Band therapy using music was primarily developed by the PI and the authors based on the results of a literature review [27] [28] [29] [30], and the first draft of band therapy was modified by the nursing faculty. The band therapy method is presented in Table 1, and the contents of band therapy consist of an introduction (5 minutes), development (30 minutes), and closing (5 minutes). The introduction includes introduction greetings and warm-up exercises with background music. The development stage includes singing with dance and playing instruments, and the closing stage includes closing speech and stretching with background music. Band therapy was provided by the PI and four research assistants in the activity room of a long-term care facility for 40 minutes at a time, and a total of four sessions (Thursday, once a week).
The music for band therapy changed every week, including "say hi like this," "spring of hometown," "goodbye song," and so on. During the therapy, rhythm instruments, such as a drum, tambourine, triangle, and castanets were used to promote easy use. The PI demonstrated how to use the band and the music instruments. The other authors helped participants with the therapy during each session.

Data Collection
This study was approved by the Institutional Review Board at K University and the data collection was performed from November to December 2015 after receiving IRB approval. The PI and co-authors visited S-nursing home and first presented the purpose of the study to the director. After the presentation, the director allowed the authors to present the contents of the study to residents of the nursing home. When the presentation was completed and subjects expressed desire to participate, formal written consent was obtained from the subject or his/her legal representatives. After formal consent was obtained, data collection began. The PI explained that the subjects could withdraw from the study at any time. The PI emphasized that the data would be kept in a locked cabinet.
A pretest was conducted right before the first session of the exercise program. The pretest included subject characteristics, grasping power, depression, and personal relationships. After the final session of the program, the posttest, including grasping power, depression, and personal relationships, was conducted. When it was hard for participants to answer the questionnaires, their medical records were used.

Data Analysis
Data analysis was performed using SPSS version 18.0. Descriptive statistics were used to describe participant characteristics, and paired t-tests were used to compare differences in grasping power, depression, and personal relationships between the pretest and posttest.

Differences in Grasping Power, Depression, and Personal Relationships
Differences in grasping power, depression, and personal relationships are presented in Table 4. The mean level of grasping power in the pretest was 18.13 ± 9.91 kg and decreased to 15.40 ± 6.45 kg in the posttest. The difference in grasping power level between pretest and posttest was not significant (t = 1.50, p = 0.144). The mean level of depression in the pretest was 7.45 ± 3.46 and decreased to 6.27 ± 3.42 in the posttest.
This difference was not significant (t = 1.70, p = 0.099). The mean personal relationships score in the pre-test was 19.97 ± 3.27, and this increased to 20.79 ± 3.98 in the posttest. This difference was also not significant (t = −0.95, p = 0.348).

Discussion
The current study investigated the use of band therapy for residents at a long-term care facility and measured its effect on grasping power, depression, and personal relationships. Results showed that grasping power, depression, and personal relationships improved at posttest compared to pretest, but the differences were not statistically significant. Even though the differences were not significant, the current study is meaningful because nursing-home-dwelling elderly have not been studied enough in Korea. exercises with elastic bands, aerobics, gross motor activity, action/reaction speed, and floor exercises. In addition, band exercise was provided in 20 sessions over 4 weeks for active older adults in the community, and the intensity of the exercise was modulated according to the expert's perception of each training session. Based on the comparisons, band therapy to improve grasping power needs to include gross motor exercises focused on functional exercises, as well as more planned exercise programs for nursing home elderly. In Kim et al.'s (2013) study [32], the Qi-gong exercise and elastic band exercise group improved grip strength in healthy elderly women in the community compared to the no exercise group. Band exercise was provided 3 times/week and included 10 sessions. However, it is difficult for health professionals to provide interventions such as band exercise more than once a week in nursing homes. Thus, band exercise needs to be more intense to improve grip strength among nursing-home-dwelling elderly.
In the current study, depression (7.44) at pre-intervention improved to 6.48 at postintervention, but it was not statistically significant. In Kim et al.'s (2013) study [32], depression at pre-intervention (8.06) improved to 4.93 at post-intervention in the band exercise group, and the difference between the two groups was significant. The lack of a significant difference in depression level in the present study might have resulted from insufficient program duration. Further, nursing home elderly may be at greater risk of depression because of factors such as pain, lack of social contact, and length of stay [33]. Further studies of band therapy should include exercises to improve social contact among nursing-home-dwelling elderly.
During the intervention period, band therapy was provided with music. For the first time, the same music was provided four times in a row, and this may have bored the participants. For future studies, depending on participants' music preferences, a diverse variety of music needs to be provided with the band therapy from the outset. In addition, even participants with poor cognitive function can follow the beat of percussion instruments for the exercise, and so future studies are highly encouraged to use percussion instruments, and it is further encouraged for band therapy to indicate the start and direction of each motion in the exercise.
During the intervention, some participants were very excited to perform the band therapy with music, and they exercised with the band in their own way. On the other hand, other participants sometimes complained that it was difficult to follow the entire process of band therapy. Accordingly, further studies should implement individualized band therapy to meet the cognitive and functional levels of individual participants. Participants also did not prefer fast-paced music for band therapy, instead preferring music with a tolerable speed and familiar lyrics for them to sing and follow along easily.
Thus, the contents of band therapy need to be simple and repeated for participants to follow the instructor's demonstration. Also, the current study was performed with only one group so the study needs to be provided with a control group for the further studies.
The current study was performed at one nursing home, and so generalizability is li-mited. In this study, band therapy was provided in an experimental group without a control group. For future studies, a control group needs to be provided for the comparison of outcomes between the two groups. In terms of nursing home conditions, band therapy was performed only once a week for a total of four sessions. For effective results, it should be provided more than four times to investigate longer-term effects of the intervention.

Conclusion
Band therapy improved grip power, depression, and personal relationships, but the effects were not statistically significant. For nursing-home-dwelling elderly individuals, it is possible that band therapy needs to be intense with exercises to improve cognitive and functional status over long periods.