Recognizing the risks in the work of Street Medical Consultations: a participative process

ABSTRACT

Objective

To describe the work environment and recognize the occupational hazards to which Street Medical Consultation teams are exposed, as well as the applicable preventive measures according to the perception of the professionals who are part of the team.

Method

A qualitative, exploratory and descriptive study carried out with professionals representing the six Street Medical Consultation teams existing in a Northeast Brazilian state. The information was collected from the focus group technique, and the data were analyzed by the thematic analysis technique.

Results

Fourteen (14) professionals participated. The work environment was described as stressful, with difficulties and vulnerabilities, but also enabling personal growth. Occupational risks caused by physical, biological, chemical, accident and psychosocial factors were recognized. Implemented preventive measures were predominantly light technologies. New personal protective equipment was suggested to be included/used.

Conclusion

The group reflection on the environment and work process enabled recognizing its risks, difficulties and challenges, demonstrating the need to implement measures to address the identified factors.

Occupational Health; Occupational Risks; Working Environment; Primary Care Nursing; Delivery of Health Care; Homeless Persons

RESUMO

Objetivo

Descrever o ambiente de trabalho e reconhecer os riscos ocupacionais a que a equipe do Consultório na Rua está exposta, bem como as medidas preventivas aplicáveis segundo a percepção dos profissionais integrantes da equipe.

Método

Pesquisa qualitativa, exploratória, descritiva, realizada com profissionais representantes das seis equipes de Consultório na Rua existentes em um estado do Nordeste brasileiro. As informações foram coletadas a partir da técnica de grupo focal, e os dados foram analisados à luz da análise temática.

Resultados

Participaram 14 profissionais. O ambiente de trabalho foi descrito como de tensões, dificuldades e vulnerabilidades, mas também de crescimento pessoal. Foram reconhecidos riscos ocupacionais ocasionados por fatores físicos, biológicos, químicos, de acidentes e psicossociais. As medidas de prevenção utilizadas foram predominantemente tecnologias leves. Sugeriu-se a inclusão de novos equipamentos de proteção individual.

Conclusão

A reflexão grupal sobre o ambiente e processo de trabalho permitiu o reconhecimento de seus riscos, dificuldades e desafios, demonstrando a necessidade de implementação de medidas de enfrentamento dos fatores identificados.

Saúde do Trabalhador; Riscos Ocupacionais; Ambiente de Trabalho; Enfermagem de Atenção Primária; Assistência à Saúde; Pessoas em Situação de Rua

RESUMEN

Objetivo

Describir el ambiente laboral y reconocer los riesgos ocupacionales a que está expuesto el equipo del Consultorio en la Calle, así como las medidas preventivas aplicables según la percepción de los profesionales integrantes del equipo.

Método

Investigación cualitativa, exploratoria, descriptiva, realizada con profesionales representantes de los seis equipos del Consultorio en la Calle existentes en un Estado del Nordeste brasileño. Las informaciones fueron recogidas mediante la técnica de grupo focal, y los datos fueron analizado a la luz del análisis temático.

Resultados

Participaron 14 profesionales. El ambiente de trabajo fue descrito como de tensiones, dificultades y vulnerabilidades, pero también de crecimiento personal. Fueron reconocidos los riesgos ocupacionales ocasionados por factores físicos, biológicos, químicos, de accidentes y psicosociales. Las medidas de prevención utilizadas fueron predominantemente tecnologías ligeras. Se sugirió la inclusión de nuevos equipos de protección individual.

Conclusión

La reflexión en grupo acerca del ambiente y el proceso laboral permitió el reconocimiento de sus riesgos, dificultades y retos, demostrando la necesidad de implementación de medidas de enfrentamiento de los factores identificados.

Salud Laboral; Riesgos Laborales; Ambiente de Trabajo; Enfermería de Atención Primaria; Prestación de Atención de Salud; Personas sin Hogar

INTRODUCTION

The scenario where work activities occur and their work processes are permeated with risks to workers’ health. The risk situations can be caused according to the nature of the work functions and by external factors which contribute to the occurrence of physical, psychological or patrimonial damage¹ - ² .

Regarding the work actions performed by the Street Medical Consultation team workers, the work environment has an unconventional space compared to the conventional places where healthcare takes place. Working in the street scenario presents specific difficulties of this space which can put the integrity of the workers at risk, as the teams visit several locations around the city, some dangerous, and face weather conditions of sun, rain, wind, heat, dust and stench from the streets³ .

It is important to consider that this healthcare work environment is recent. The Street Consultation strategy was incorporated by the Ministry of Health into some plans such as the Emergency Plan to Expand Access to Treatment and Prevention for Alcohol and Drugs ( Plano Emergencial de Ampliação de Acesso ao Tratamento e Prevenção em Álcool e Drogas – PEAD ) in 2009, and the Integrated Plan to Combat Crack and other drugs ( Plano Integrado de Enfrentamento ao Crack e outras drogas – PIEC ) in 2010. This strategy was instituted in 2011 by the National Primary Care Policy ( Política Nacional de Atenção Básica – PNAB ) to facilitate access to health services and guarantee the comprehensive health of the population living in the street, considering the vulnerability conditions they are exposed to⁴ .

Thus, these teams are responsible for the primary healthcare of these people, performing medical actions on site or in an itinerant way through conducting an active search of users of alcohol and drugs in order to provide the necessary assistance to them. The professionals use light technologies in their interventions such as reception, listening and dialogue, which contributes to forming a bond with the users. But they also face challenges in this process, such as difficulty in articulating with the Healthcare Network, inadequate transportation and insufficient human resources⁵ - ⁶ .

Health workers are generally exposed to various risks, particularly in the environment and work processes¹ . Regulation No. 09 (NR-9) of the Ministry of Labor and Employment ( Ministério de Trabalho e Emprego – MTE ) classifies environmental risks into three types: chemical, physical and biological. In addition to these, it also presents accident and ergonomic risks in Annex IV⁷ . There are also psychosocial factors which interfere with the work process such as stress, dissatisfaction with working conditions and impotence⁸ .

When dealing with workplace risk, the focus is often on its identification and elimination, however without considering the vision of the workers who are involved in daily practices when adopting the preventive measures, which contributes to ineffectiveness. In order to adequately cope with occupational hazards, it is necessary to understand them at their levels of complexity and in the context of the generation-exposure-effects cycle⁹ .

Faced with this reality, this study aimed to describe the work environment and to recognize the occupational hazards to which the Street Medical Consultation team is exposed to in their work environment, as well as the applicable preventive measures according to the professionals’ perception.

METHOD

STUDY DESIGN

This is a qualitative exploratory-descriptive study carried out in a capital city in Northeast Brazil.

POPULATION

The participants were 14 professionals representing the six existing Street Medical Consultation teams of a Northeast Brazilian state, including representatives of nursing, social work, occupational therapy and social agents. The meetings took place in a room provided at a Psychosocial Care Center for users of alcohol and other drugs ( Centro de Atenção Psicossocial para usuários de álcool e outras drogas – CAPS ad ), considering accessibility to the participants and familiarity with the place as a referral service for its users.

SELECTION CRITERIA

The inclusion criterion was to work at least 1 year in the service, and exclusion criterion was non-availability to participate in the focus group meetings.

DATA COLLECTION

The production of information took place from February to April 2018. The Focus Group (FG) technique was used because it is a data production technique in qualitative research that is consistent in studies which seek to discuss reality and plan interventions. This method enables both information gathering and reflection on the topic, as well as reinforcing the participant’s role in their health production and in knowledge construction¹⁰ .

Thus, the focus group meetings followed a road map composed of guiding questions which enabled the discussion to be deepened¹⁰ . It is worth mentioning that the road map had three main objectives and each session corresponded to one of these objectives. In addition, strategies were used to facilitate the group’s conduct such as nominal groups, where the moderator asks a question and each respond individually in writing in order to document personal opinion without interference from the group, as well as to prepare the participants for the discussion¹¹ and a search in journals for figures related to the theme and context.

Three focus group meetings were held with a duration of 120 minutes each, with 70 to 90 minutes of discussion with the presence of the participants and a moderator (the researcher of the study), as well as two nursing students as observers. The meetings were organized as follows: opening of the group meeting, presentation of guiding questions, discussion, synthesis and closure.

DATA ANALYSIS AND PROCESSING

Organizing the information began by transcribing the speeches of the participants in full and their subsequent validation in two meetings with the group by presenting the printed transcripts and also on an image projector. The study followed the three stages of thematic analysis, which consists of pre-analysis, material exploration and processing the results/inferences/interpretation¹² . The National Policy on Worker Health ( Política Nacional de Saúde do Trabalhador e da Trabalhadora – PNSTT ) and Regulatory Standards #6, 9, 15, and 32 were used as theoretical support.

After exhaustive and comprehensive reading of the produced information and exploration of the material with the core meanings being identified, three categories emerged: “Re-signification of work: experiences of pleasure and suffering”, “Occupational risks from the perception of workers” and “Prevention: measures in practice, their dilemmas and what needs to be implemented”.

ETHICAL ASPECTS

The ethical principles were respected in accordance with Resolution 466, of December 2012, and the work was approved by the Ethics and Research Committee of the Universidade Federal de Alagoas under opinion No. 2.482.548, on February 2, 2018. The workers signed the clear and Informed Consent Form, which ensured their confidentiality and use of the information for only scientific purposes. The anonymity of the participants was assured by the use of the letter “P”, qualified as participant, followed by the speech order number for each participant from the discussion in the first focus group meeting. The encounters were identified as E1, E2 and E3 respectively.

RESULTS

RESIGNIFYING THE WORK: EXPERIENCES OF PLEASURE AND SUFFERING

The professionals described their work environment as a scenario permeated by stress, difficulties and vulnerabilities, but at the same time rich in learning and pleasure which provoke changes in the way of being and living of the professional.

One of the stresses experienced by the professionals is the difficulty of integration and reception in the Basic Health Unit (BHU) of reference, demonstrated by the lack of cleanliness and physical structure of the room destined to the Street Medical Consultation team, by a lack of materials, as well as by the lack of understanding from professionals about the purpose of this service.

They (BHU professionals) do not want to accept a new thing that is coming because the Street Medical Consultation team did not exist before, so it is relatively new (P3; E1).

The work environment starts there. It is with this more rejection energy than to add, integrate, welcome (P3; E1).

Even the cleanliness itself is precarious when it is our room. It’s a separate thing, it’s not part, it’s Apart (P6; E1).

We’re verbally assaulted, sometimes they leave us [team workers accompanying people on the street] waiting there to be the last of the last to be attended (P2; E1).

They think that we are doing palliative care, they think that we are covering up some holes in the government (P7; E1).

Our room has no light. A team member brings a light every day, a flashlight, and something else they have improvised (P10; E1).

We are beggars (...) we have to be asking for alms for our users (P9; E1).

By the following statements, it is possible to perceive experiences of paradoxical feelings in the reality of these workers such as the perception of personal growth and of doing something meaningful, even though there are worries and stresses.

It is something that at the same time makes us grow, but at the same time makes us restless to see social injustice (P1; E1).

For me it’s tense because something that was (to be) fast is not fast, understand? (...) But, it is extremely gratifying (P14; E1).

Still, some team members also face the precariousness of work in service delivery, and it is possible to note the feeling of insecurity and lack of motivation of the team.

This is the insecurity of these workers who have a precarious work bond. All of a sudden they have dedicated themselves, taken all this risk, bonded with users, given their blood, to suddenly be thrown out as a result of a political statement (P9; E2).

The scenario is still seen as an environment of direct encounter with human vulnerability.

I find people in full social vulnerability in my work environment, meet people who use drugs, people who use their body as a means of survival, people who are dealers (P2; E1).

However, in the midst of all this, the professionals create their own coping strategies and manage to re-signify work, being transformed into their way of being and living.

The professional that I am today, who I am today, I say it was the Street Medical Consultation team that made me the person I am today (P5; E1).

Of all the works since 1994 that I have been in the secretariat, this is what has given me the most pleasure... It was in the Street Medical Consultation team that I experienced several changes (P6; E1).

It is an environment in which we learn a lot as a human being and as a professional (P10; E1).

OCCUPATIONAL HAZARDS FROM THE WORKERS’ PERCEPTIONS

Workers perceive factors and situations to which they are exposed in their work scenario and can cause damage to their health. These are physical, chemical, biological, psychosocial and even factors which can lead to illness, even if it is difficult to perceive this process.

We have the risk of catching some infectious disease that we don’t know that a user has (P7; E2).

The sun is one of the risks that sometimes even harms the work (P11; E2).

We go out and have to keep our eyes open to check if there is glass, if there is a nail (...) because we will be working on the street, then the trash that is out there, we don’t know what danger it could pose (P12; E2).

We are always exposed to crack and cigarette smoke, glue, dust from the environment (P10; E2).

The emotional risk, the emotional interference, I think it’s much more harmful because it’s something that seems to have a domino effect (P13; E1).

Suddenly you get lost in the process of taking care of another person and you get sick from it, and we don’t realize it (P1; E2).

(...) Her bandaging takes too long (...) and I take about 40 minutes. Then all this time I’m in a position I shouldn’t be, my posture, leads to issues of low back pain, neck pain (P10; E2).

PREVENTION: MEASURES TAKEN IN PRACTICE, THEIR DILEMMAS AND WHAT NEEDS TO BE IMPLEMENTED

The measures adopted during the workers’ practice (previously mentioned) go beyond the use of Personal Protective Equipment (PPE), there is a predominance of using light technologies such as bonding, respect of individual and collective limits, observation of the context before the approach and investment in periodic meetings in order to promote a moment of distraction. The professionals also recognize their uniform as a preventive measure, since it enables to distinguish the team (including for the police) at the moment they are doing some health work approaches.

(...) Because, in this way, the uniform is what protects us from the police (P4; E1).

Bonding is a big prevention factor for us. Prevention and protection is the bond (P7; E3).

Respecting this limit of the other and respecting our individual and collective limit, I think this is a fundamental PPE (P1; E3).

If there is the heavy use of something, people are fighting between them, we avoid doing an approach at that moment so that we can’t be the victim of a conflict situation that happens between them (P12; E3).

The “Caring for the caregiver” (...), which is when we meet, joins all the teams and we end up having a different day, usually with recreational activities, so that we can then become distracted a little from our hard reality, which is the Street Medical Consultation (P10; E3).

The workers mention that in some cases they choose not to protect themselves in order not to embarrass or break their bond with the user, facing the dilemma between protecting themselves and maintaining the bond.

At times you even give up protecting yourself in a few moments which is necessary because at that moment you can’t demonstrate to them that they you are sick (P2; E3).

And how am I going to say no to this hand that is reaching out to me? (P11; E2).

Regarding the measures that need to be implemented, workers suggest some new products which could prevent work-related risks.

A hooded raincoat! The rain is coming (...) the rain is coming and we will suffer (P2; E3).

Cap, sunscreen, boots, especially people who walk in community, understand? Because the mud is really visible there (P8; E3).

Repellent, sunglasses (P1; E3).

Workers also realize that educational action is also a prevention and protection measure for workers.

How can we prevent violence? Then our leader put on the workshops (P8; E3).

DISCUSSION

The worker’s health can be positively or negatively affected¹ depending on the reality experienced in the work environment, so much that the PNSTT considers work as a determinant and conditioner of the health-disease process and therefore has one of its purposes to ensure the identification of health activities and their consequences¹³ .

One of the workplaces of the Street Medical Consultation teams ( equipes do Consultório na Rua – eCR) is the BHU, which must therefore be linked to a unit in its territory of operation, legally being part of the service. And this is of great value, since the maintenance of a place for the eCRs in these establishments contributes to include homeless people. In addition, ensuring an enclosure within the public services enables greater resolution of demands, as well as reaffirms the citizenship of homeless people, who have the right to enter any health services⁶ . However, even with the obligation of the Street Medical Consultation team to be linked to a BHU, the workers mention experiencing difficulty of integration and reception in this environment.

The recent linking of the Street Medical Consultation team with Primary Care may justify the difficulty of including the eCR in the BHU, as mentioned by one of the participants. In addition, it is important to consider that this link with the unit represents greater demand of homeless people accessing the service, which implies welcoming them, and can generate discomfort and estrangement for not being familiar with this clientele and the unpreparedness of the professionals³ .

Despite this healthcare provision, Regulation Standard 32 (NR-32) ensures a clean and dignified work environment, and it is the duty of the health services to maintain the environment in clean and preserved conditions¹⁴ . Thus, regardless of the estrangement and tensions with the arrival of a new service, the appropriate conditions of comfort and hygiene must be offered.

Maintaining an environment in dignified conditions is key to healthy work. In addition, providing adequate resources, materials and conditions contributes to performing quality work and promotes the well-being of the user and the professional.

Studies show that those who provide healthcare at the primary care level face organizational, structural and relational difficulties. Thus, these barriers create an emotional, physical and cognitive load for these workers¹⁵ - ¹⁷ . Their work corroborates the reality mentioned by the workers of the present study who are vulnerable to such burdens. One of the reasons is that the existing legislation on the physical space of the BHU does not include a room for the Street Medical Consultation team, certainly because of its recent linkage to Primary Care. Therefore, elaboration of standardized policy which guarantees an adequate space for the eCR is essential.

Dealing with the homeless population situation is to face a submerged reality in the context of social inequality, precariousness of life and social invisibility. It is possible to observe that the scenario involves meeting people marginalized from society, which also has limitations in the practice of public policies¹⁸ . Thus, working with this population implies bonding, affective involvement and accountability by the user, which can also constitute an opportunity for emotional enrichment.

However, some barriers may jeopardize this care, such as what was cited by a participant on the precariousness of work, which can be understood as an employment relationship characterized by uncertain conditions, where the risks are mainly assumed by the worker and not by the State. In this sense, precarious workers are in a situation of vulnerability due to lack of security and stability at work¹⁹ - ²⁰ . This type of labor relationship is extremely worrying in relation to a differentiated work, such as that exercised by the eCR , in which bonding is essential for user assistance.

Although workers face burdens and difficulties (as noted in the statements), they can use strategies to re-signify suffering. Psychodynamics understands that suffering is present at work, since the subject inevitably faces frustrating situations. The experience of failure puts the identity of the worker at risk, causing the subject to try to solve the problem, subverting suffering to pleasure²¹ . This situation was observed when eCR workers mentioned being able to withdraw life lessons, learning and personal transformations from their work.

Regarding the occupational risks perceived by the workers, it was possible to notice the presence of all risk types classified in NR-9⁷ . Physical risk was highlighted by sun exposure in an unprepared manner, which according to Regulatory Standard 15 (NR-15) is configured as an unhealthy activity, since these workers do not receive sunscreen, and exposure to solar radiation can affect their health and still compromise the development of their work. Operations considered unhealthy by this standard guarantee to the worker additional pay in their remuneration; nevertheless, the important thing is not this type of gratification, but to make the environment and its workers healthy²² .

Regarding the perception of biological risk presence, although NR-32 is a parameter which guides the construction of the Environmental Risk Prevention Plan ( Plano de Prevenção de Riscos Ambientais – PPRA ) observed in NR-9 to identify biological risk in health work environments⁷ , ¹⁴ , the fragility with which the implementation of this regulation occurs in the context of the Street Medical Consultation can be observed, as the worker remains exposed to adverse conditions without adequate protection.

The same occurs regarding chemical risk, exposure to crack smoke, environmental dust and the smell of glue. Even though these are characteristic risks of works which aim at approaching the subjects through creating bonds and contributions to their lives marked by vulnerability⁶ , the permanence of a modus operandi which maintains a distance from the PNSTT principles and regulatory standards is noticed.

This also applies to the issue of ergonomic hazards, since the streets do not offer furniture or work spaces which respect ergonomics, where workers only have sidewalks and boxes/cardboard as supports for performing their activities. Thus, they permanently adopt inappropriate postures when approaching users to perform the necessary procedures during their work shifts. But, how can the street environment be adapted to reduce the ergonomic risk and its effects on the health of these workers?

Regarding the psychological load demanded, a closer look at these workers is essential, since in addition to the occupational risks described above, they are surrounded by an unpredictable environment and emotional stresses which can increase the risk of mental problems and psychosomatic complaints⁸ . In addition, these professionals deal with an inhumane reality which demands an attitude from them, but they are limited to modifying it due to obstacles such as the lack of working conditions, a network of non-systematized care and the lack of preparation of some professionals¹⁶ , ²³ .

These factors may contribute to the workers’ illness process. Thus, it is important to understand why and how the work is related to the illness process so that these workers are listened to and can report their experiences at work, how they can respond to demands and whether they are offered (or not) the necessary conditions so that they can carry out what is demanded from them¹⁵ - ¹⁶ .

In this perspective, when relating the adopted prevention measures by the teams in carrying out their activities with the NR-32 provisions, it is noticed that the Street Medical Consultation team uses predominantly light technologies, which are not addressed in such standard¹⁴ . In order to adapt to the work context, the team adopts intuitive mechanisms such as the bonding as a protection measure, since its construction enables security and predictability, and involves knowledge and recognition⁵ .

As it is not always possible to establish positive bonds, it is necessary to constantly re-evaluate the actions performed by the team. It is recognized that actions at such moments are restricted, and therefore personal limits must be preserved⁵ . Such recognition of boundaries is subjectively posed by the workers as being fundamental protective equipment.

Observing the context before addressing users is also relevant, since the presence of police in the location can change the behavior of this clientele by the stress caused by the police approach. There may also be conflict between the street population itself, so this insightful look at the environment is fundamental²⁴ . Although the uniform (blue vest) is not PPE, it constitutes a protection element in the Street Medical Consultation team’s work in that it enables identifying the team and its distinction in some situations.

Although the team has these light technologies to help protect them, it also experiences a dilemma between preventing themselves and maintaining the bond, because the user can understand protection as a form of aversion, compromising the relationship that has been built. Given the constant exposure to hostile situations and discrimination in the health services suffered by the street population, the success of the Street Medical Consultation team’s strategy⁶ should be valued. However, there are coping measures and new prevention technologies for eCR workers, which enable protection and do not cause embarrassment to either the user or the worker.

Regarding the prevention of workers’ mental health, actions focused on caring for the caregiver through play activities, and the possibility of the team experiencing leisure spaces, both inside and outside work, are extremely important in improving the organizational climate and the interaction between the team⁵ , ¹⁵ . These actions are fundamental, since taking care of the other involves warm and humane care which is more effective when the person performing this care has their physical, emotional and psychological needs also taken care of²⁵ .

With regard to the measures which need to be implemented from the perspective of the team, new PPE such as a raincoat and repellent were suggested. Regulatory Standard No. 6 (NR-6) allows the request of new products which are not yet listed in this legislation, so that they are considered as PPE after evaluation and approval by a Tripartite Commission, as constituted by the national body competent in health and safety of work²⁶ .

The group educational process was also pointed out as a prevention measure to be elaborated to confront violence. Health education, which can be developed by the workshop method as exposed by the participants, enables construction of a collective consciousness and reflection with action, which is based on the pedagogical model of Paulo Freire who argues that dialogue is the way which man gains meaning and provides empowerment to the individual and the community²⁷ .

Finally, the implementation of the group reflection on the environment and the work process and the measures to face occupational hazards is considered positive, since it enables a broad and critical view on the part of the worker and consequently knowledge construction about the reality and its challenges, instigating elaborating/adopting feasible measures.

A limitation of this research was the lack of observation of the team’s practice during the activities in the period of its development and the scarcity of literature about the study object. It is understood that these results can contribute to deepening the theme, so that prevention, control and elimination measures of occupational risks in this scenario are elaborated.

CONCLUSION

The results of the study demonstrated that the work environment on the street is described as dynamic, constantly in contact with human vulnerability and shaped by difficulties, challenges, and tensions, but nonetheless workers are able to re-signify their practice and have their identities influenced by this job. From the perspective of the workers, the work environment is permeated by physical, biological, chemical, ergonomic and accident agents. However, the psychosocial risk was the most emphasized, deserving attention in order to think of prevention and protection strategies in the area of mental health.

The prevention measures which are already adopted by the majority of the team are not contemplated, mainly by NR-32, which specifically deals with health and safety at work in health services. There was a predominance of implementing light technologies. For prevention, workers experience a dilemma between protecting themselves and giving up this protection to maintain the bond with the user and not constrain them; a situation which deserves reflection on strategies and even new technologies which enable preventing injuries to workers but also maintain the bond with the users.

It was also noted that the precautionary principles of PNSTT are weak and how important it is to implement an Environmental Risk Prevention Program in this work environment. The study enabled learning and problematizing the occupational hazards to which six Street Medical Consultation teams are exposed to in a capital city in the Northeast of Brazil, contributing to understand the environment and the work process, the occupational risks of this space and the adopted prevention measures in practice in order to encourage reflection on those which can be elaborated from the perception of those who are in this scenario daily and know it well.

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Publication Dates

• Publication in this collection
  19 Aug 2019
• Date of issue
  2019

History

• Received
  19 June 2018
• Accepted
  21 Nov 2018