Matrix support actions in Primary Health Care: a phenomenological study

Abstract

Objective:

To understand the meaning of mental health matrix support actions in Primary Health Care from the perspective of matrix supporters and nurses.

Methods:

A qualitative study, with a phenomenological sociology approach, developed in a Primary Health Care unit of a city in Southern Brazil. Interviews were carried out with five matrix supporters and 22 nurse assistants, who worked in the territory from July to August 2017. Comprehensive interpretation followed the steps of careful reading of speeches, identification of concrete categories, phenomenological verification of social action and establishment of the typical action, according to Alfred Schütz's theoretical and methodological framework.

Results:

It was revealed that matrix supporters experience the phenomenon of matrix support actions in Primary Care through instruction and participation in care represented in the following concrete categories: (1) To instruct the health professionals of the units; and (2) To participate in mental health care in the territory. Experiences of nurses are demonstrated in the concrete categories: (3) Meeting the user's mental health demands; and (4) Matrix support structure improvement.

Conclusion:

There was a mismatch between intentions and expectations, clearly exposing the conflict between what is intended and expected. Given this, it was recognized that there is no reciprocity of perspectives, evidencing the need for self-analysis of matrix supporters and nurses. (Re)thinking public policies and management of the matrix support strategy regarding instituted practices is necessary, so that actions in mental health can bring health production, citizenship and existence.

Keywords
Psychiatric nursing; Primary health care; Mental health; Mental health assistance

Resumo

Objetivo:

Compreender o significado das ações do apoio matricial em saúde mental na Atenção Primária à Saúde, na perspectiva de apoiadores matriciais e enfermeiros.

Métodos:

Estudo qualitativo, com abordagem da sociologia fenomenológica, desenvolvido na Atenção Primária à Saúde de um município na Região Sul brasileira. Foram realizadas entrevistas com cinco apoiadores matriciais e 22 enfermeiros assistenciais, que atuavam no território, no período de julho a agosto de 2017. A interpretação compreensiva seguiu as etapas de leitura atenta das falas, identificação de categorias concretas, verificação fenomenológica da ação social e estabelecimento do típico da ação, conforme referencial teórico-metodológico de Alfred Schütz.

Resultados:

Foi desvelado que os apoiadores matriciais vivenciam o fenômeno das ações do apoio matricial na Atenção Primária, por meio da instrução e participação nos processos de cuidar, representadas nas seguintes categorias concretas: (1) Instruir os profissionais de saúde das unidades; e (2) Participar do cuidado em saúde mental no território. Quanto aos enfermeiros, as suas vivências estão demonstradas nas categorias concretas: (3) Atendimento às demandas em saúde mental do usuário; e (4) Melhora da estrutura do apoio matricial.

Conclusão:

Constatou-se um descompasso entre intenções e expectativas, expondo, nitidamente, conflito entre o que é intentado e esperado. Diante disso, reconheceu-se que não há reciprocidade de perspectivas, evidenciando a necessidade de autoanálise dos apoiadores matriciais e enfermeiros e um (re)pensar a nível de políticas públicas e gestão da estratégia do apoio matricial quanto às práticas instituídas, para que as ações em saúde mental possam representar produção de saúde, cidadania e existência.

Descritores
Enfermagem psiquiátrica; Atenção primária à saúde; Saúde mental; Assistência à saúde mental

Resumen

Objetivo:

Comprender el significado de las acciones de apoyo matricial en salud mental en la Atención Primaria de Salud, bajo la perspectiva de apoyadores matriciales y enfermeros.

Métodos:

Estudio cualitativo, con un enfoque de la sociología fenomenológica, realizada en la Atención Primaria de Salud de un municipio en la región Sur de Brasil. Se realizaron entrevistas con 5 apoyadores matriciales y 22 enfermeros asistenciales que trabajaban en el territorio, en el período de julio a agosto de 2017. La interpretación comprensiva incluyó las etapas de lectura atenta de los relatos, identificación de categorías concretas, verificación fenomenológica de la acción social y establecimiento de las características de acción, según el marco de referencia teórico-metodológico de Alfred Schütz.

Resultados:

Se descubrió que los apoyadores matriciales experimentan el fenómeno de las acciones del apoyo matricial en la Atención Primaria a través de la instrucción y participación en los procesos de cuidar, representadas las siguientes categorías concretas: (1) instruir a los profesionales de la salud de las unidades, y (2) participar en el cuidado de la salud mental en el territorio. Con relación a los enfermeros, sus vivencias están demostradas en las categorías concretas: (3) atención a las demandas de salud mental del usuario, y (4) mejora de la estructura del apoyo matricial.

Conclusión:

Se constató una divergencia entre intenciones y expectativas, lo que expone claramente un conflicto entre lo que se intenta y lo que se espera. Ante este hecho, se reconoce que no hay reciprocidad de perspectivas, lo que deja en evidencia la necesidad de un autoanálisis por parte de los apoyadores matriciales y enfermeros y un (re)pensar respecto a las políticas públicas y gestión de la estrategia de apoyo matricial con relación a las prácticas instituidas, para que las acciones en salud mental puedan representar producción de salud, ciudadanía y existencia.

Descriptores
Enfermería psiquiátrica; Atención primaria de salud; Salud mental; Atención a la salud mental

Introduction

Historically, Brazil was marked by mental health actions directed at people suffering from psychic suffering and their families, based on the hospital-centered paradigm, that is, focused on care in the asylum institution. Validation of the asylum model was based on the alienism manifested in the French Revolution. Hospitalization would offer to demented or dispossessed-of-reason people a space of cure, and asylum would allow the maniac to exercise his freedom.⁽¹⁾

In the 1970s, change began in this model, called Psychiatric Reform. In Brazil, this Reform was founded not only in the conjuncture critique of the Brazilian subsystem of mental health, but also, and mainly, in the structural criticism to knowledge and the classic psychiatric institutions, in the midst of all the political-social movement that characterizes this same redemocratization.⁽²⁾

Conceptual and practical change, regarding mental health care for people, breaks with the exclusionary proposal to be experienced by individuals and families, which reflects in the possibility of planning life projects, mobilizing peers and enjoying the daily life. In the community, Psychiatric Reform pointed to the overcoming of the hospital-centered model in psychic suffering care, aspiring to a care that does not alienate the person from his social space. For this matter, Primary Health Care is a privileged space for intervention, being an important strategy to draw actions focused on the territorial axis.^(3,4)

In the aggregation between Primary Care and mental health, in Brazil, matrix support was instituted as an organizational arrangement that enables the specialized technical support to the teams assigned to mental health actions in the Primary Network. Matrix support, formulated and conceived theoretically in 1999, has collaborated with the structuring of an integrative care, in which mental health actions are produced from the valorization of the social scope in the community.⁽³⁾

As a possibility to look at health care and nursing in an attentive and extended way, the theoretical-methodological framework of Alfred Schütz's phenomenological sociology has been used in research. According to this framework, social realities are constructed in meanings and identified by their immersion in social interaction, language, actions and the world being inseparable in this type of approach.⁽⁵⁾

Phenomenological sociology deals with action, as a process anchored in motivational functions, having as one of its purposes the understanding of intersubjective processes, starting from the description of these by the individual who experiences them.⁽⁶⁾ However, description must be natural, exploring what the individual speaks, avoiding forging hypotheses and expressing only what is presented by the person.

In the perspective of understanding the subjective action of individuals explicit in their intentions and expectations, Schütz relies on the concepts of “reasons for” and “reasons why”. “Reasons for” refer to something that one wants to accomplish, goals that one seeks to achieve, having a future-oriented temporal structure and forming a subjective category of action. On the other hand, “reasons why” are evident in the completed events, which explain certain aspects of project accomplishment, having a temporal direction turned to the past.⁽⁷⁾

Social action is how Schütz defines human relations in the social world,⁽⁶⁾ in which actions in mental health are directed to a social subject. Therefore, they must go through the care that is offered to a subject who is going through psychic suffering, entering the vital context in which the user is the protagonist of their existence. In the sphere of health and nursing, there is a possibility of reflecting and evaluating the social relations constituted among all individuals involved in mental health therapy,⁽⁸⁾ for which the Schützian framework can contribute to the understanding of human action in a social dimension, linking action in health care to the social relations existing in the caring process.

Thus, using phenomenological sociology implies approaching the aspect that identifies in this theme a propitious space to discuss mental health care as a production of meaning and social action. In care, according to Schütz, there is the possibility of “going to things” through detachment of judgement, in order to penetrate the truth of the other's existence. The purpose is not to institute truths, but to understand what was lived by unveiling human social action.⁽⁷⁾

This article aimed to understand the meaning of matrix support actions in mental health in Primary Health Care, considering intentions of matrix supporters and expectations of nurses from the perspective of Schütz' phenomenological sociology.

Methods

This research is a qualitative study of a phenomenological nature that used Schütz' framework, using phenomenological interview for information gathering and phenomenological sociology as an analysis method. Primary Health Care was the study setting, specifically in health units located in a municipality in the state of Rio Grande do Sul, Brazil. This type of methodological approach presents a deeper space of relationships and phenomena that cannot be reduced to a changeable device, that is, it investigates aspects that acomprise the values and experiences that make up human relationships.⁽⁹⁾

Study participants were five matrix supporters and 22 nurses working in Primary Care. Voice was given to matrix supporters, because their actions are the foundation for mental health care in the study setting. Participation of nurses in the study is intertwined with their relevance in the first mental health care involved in the process of receiving users in Primary Care, privileging this important category, given the scarcity of studies with a focus on nurses. All participants were intentionally selected, meeting the following inclusion criteria: being part of the city's staff; being a matrix sponsor or nurse of a health care unit of a certain region of the municipality; not being on leave and/or taking leave during data collection period; and having been working in the service for 6 months or more.

Data collection was carried out through phenomenological interviews with the aforementioned research participants, having as matrix supporters, workers of several professional categories: (2) psychiatrists, (1) occupational therapist, (1) speech therapist and (1) nutritionist. In the study setting, matrix support is carried out by the Family Health Support Center (NASF - Núcleo de Apoio à Saúde da Família), which structures the actions in mental health in the territory with the joint participation of all the supporters in interventions with the health units of the territory.

Due to the phenomenological nature of the investigation, the number on interviewed participants was not initially consolidated, thus interviews were ended when convergence of data in participants' speech was identified. Interviews were carried out from July 18 to August 18, 2017, in varying days during the day shift at the participants' work places.

In seeking the understanding of the phenomenon from the being that experiences it, the technique of phenomenological interviewing was used, in which there is no right or wrong to be declared, valuing the speech of the being, and the conditions understood and developed by him.^(10,11) In this perspective, two guiding questions were used for the interest group of matrix supporters, and one question for nurses. For matrix supporters, the questions were: “What mental health actions have you been carrying out with Primary Care?” and “What do you intend with these actions?” ; for nurses, the question was: “What do you expect from the actions of matrix support in mental health at Primary Care?”.

Information analysis was built based on the rigor of the Schützian phenomenological method, following the concepts of phenomenological reduction, intentionality and typification of the action. To unveil the phenomenon essence, the following steps emerged:⁽⁸⁾ careful reading of speeches to capture the experienced situation and the subjects' “reasons for”; identification of concrete categories that comprise subject acts; phenomenological verification of social action. Based on the typical characteristics of the speech, the meaning of subjects' actions was established, aiming to describe the typical action of matrix supporters and nurses.

From the convergences of the units of meaning that emerged from the reports, information was analyzed in the light of Schütz's framework and, later on, the results of the experiences of supporters and nurses were organized into concrete categories. In comprehensive interpretation of social action, it becomes fundamental to make a more rigorous exploration of problematic situations in relation to social typification, in which the collection of knowledge and its different dimensions are placed in the creative formulation of projects situated in acting. In all the elements and distinctions, Schütz' proposes, in his descriptions of the world of life, the importance of the mundane analysis, including the role of objectivations of imaginary worlds in the construction of lived experiences.⁽¹²⁾

Statements were identified by letters “S”, for matrix support, and “N”, for nurses, with sequential numbers from one to 22, preserving the participants' anonymity. To produce descriptions of mundane life, participants were heard without critical judgment and were interacted with from a comprehensive approach.

In this research, the requirements established by Resolution 466/2012 of the Brazilian National Health Board (Conselho Nacional de Saúde) were met. This study was approved in Research Ethics Committees with Human Subjects under CAAE (Certificado de Apresentação para Apreciação Ética - Certificate of Presentation for Ethical Consideration) 63099916.2.0000.5347, opinion 2,014,999 and CAAE 63099916.2.3001.5338, opinion 2,059,857.

Results

Categorization was configured as the representation of the lived experience, from speeches of each social actor, anchored in a reflexive process in the light of phenomenological sociology. With the Schützian framework, it became feasible to identify the “reasons for”, considering the motivation of the being-in-the-world, with the construction of two categories that replicated the intentions of matrix supporters: (1) Instructing health professionals of the units and (2) Participating in mental health care in the territory. Also, two categories of the investigated phenomenon that the nurses have experienced are: (3) Meeting the demands from patient mental health and (4) Matrix support structure improvement.

Concrete category 1. Instructing health professionals of the units

In this category, elements are presented regarding the training and learning of the health professionals of the units, based on the reports of matrix supporters regarding their intentions towards matrix support mental health actions in the territory. In reports of matrix supporters, there are explanations in which they indicate the effectiveness of the professional qualification and discussion of the work carried out in the territory:

“Unit training, […] to be able to discuss this work that is done within the unit, some training spaces ”. (S3)

“[…] permanent education with the team […] to really trade and bring more subsidies”. (S4)

“Performing this training, […] with discussion, […] some group”. (S5)

“A learning of professionals, they changed their vision and were more able handle these kinds of cases”. (S1)

Thus, when supporters conduct training and meetings, they seek to instruct the health professionals of the units, strengthening the mental health care in the territory by means of a theoretical-practical contribution to facilitate the management of users in psychic suffering in the setting of primary network.

Concrete category 2. Participating in mental health care in the territory

The intention of these supporters is not limited to the instruction of the professionals of the health units, because their reports reveal that they also intend to participate in care, thus emerging the category: Participating in mental health care in the territory. In this category, it is presented how matrix supporters experience participation in mental health care in the territory, where the presence of these supporters in these spaces, through dialogue and joint evaluations, has resulted in improvements in the care of people with demands in mental health, through actions shared with other health professionals:

“More home visits and more joint evaluations”. (S1)

“Joint assessments […] with all senior and technical professionals”. (S2)

“[…] participation in matrix with the team, or only with me, depending on the day that we go and how many professionals there are at that time”. (S3)

“[…] to make a joint assessment, a home visit that could be included”. (S5)

Based on the reports, the intention of matrix supporters to participate in health units of mental health care is observed, since they highlight the implementation of shared practices through dialogue and joint interventions, working with health unit teams. Faced with these two concrete categories of matrix support, the construction of the typical action has raised the importance of identifying intentions, so that the idealizations and purposes rooted in the daily life of these supporters can be elucidated.

Concrete category 3. Meeting the demands on user mental health

In the other facet of the phenomenon, we have the expectation of nurses regarding the mental health ca re of the user, based on aspects such as referrals and improvement of the user, as well as case solution. Moving closer to the reports of each nurse, it is noted that the speeches are marked by the desire that users be followed up in a specialized service, that there is improvement in individual processes, as well as resolution in the conduct of mental health demands in the territory:

“That there were a care core (service), and that patients could be referred to a care core (service) that were resolutive”. (N20)

“[…] the patient needs psychotherapy, its absence is a problem of the network. However, we have to have something that can make the referral”. (N2)

“That he recovers and can supply his needs, whether it is school or attention”. (N1)

“[…] he is well, better in his day-to-day life, that he can stand alone and without the need for the (health care) unit”. (N7)

“[…] What I always hoped for was more resolutiveness”. (N3)

“In cases where I have no resolution in the unit, I could be debating with them and trying to see a possibility of support”. (N16)

“[…] to solve the patient's problem, that he does not stand in a waiting line for case discussion for several months without being able to have the return that he needs”. (N10)

Facing this set of statements, the emphasis given by nurses to specialized care is observed, in cases where the chances of success of Primary Care therapy are reduced. However, in proposing the joint construction of actions in the community, the matrix support seeks to minimize the excessive system of referrals to the specialized service, with a view to care in the territory, keeping the individual in his social environment. Thus, the exposure of these expectations can guide discussions about user follow-up in the territory, according to their health needs.

Concrete category 4. Matrix support structure improvement

In this category, it is revealed the need for new conformations for a better structured care, planned and implemented in the territory. To that end, nurses characterize the matrix team as a numerically insufficient group to offer actions in mental health in the basic network:

“Anyway, multiplying, […] I think the number of team professionals. “ […] That it really multiplied the team so that it could better serve the units. (N4)

“The number of professionals that we need for this is lacking.” (N9).

“[…] it would be a positive experience to have more professionals to do matrix work”. (N15)

“[…] a well-structured service to meet both individual and collective (needs). […] A more complete care is lacking in relation to our patients in mental health”. (N12)

“That's why I do not believe in matrix support, compared to what we have and what we had. […] There is no way to talk and solve it, it is very scarce”. (N8)

“[…] I think there had to be a team, greater HR”. (N18)

“[…] To increase the number of professionals to do this matrix support”. (N22)

Reports have verified the view of nurses problematizing the resources for effective mental health care in Primary Care. And in the two categories presented, there are expectations that do not illustrate decontextualized opportunities, but rather, relevant perspectives for the problematization of practices aiming to consolidate care that is shared and interpreted by all, with the power to transform individualities and social contexts.

Discussion

Matrix support, an organizational arrangement that enables specialized technical support to the teams, has collaborated with the structuring of an integrative care in Primary Health Care in our country, in which mental health actions are based on the valuation of the social conjuncture in the territory.⁽³⁾ In this direction, the results present the potential to emphasize matrix support actions in mental health in the primary health network setting. Intention of matrix supporters and nurses' expectations do not illustrate decontextualized opportunities, but relevant perspectives for the consolidation of care that is shared and interpreted by all, with the power to transform individualities and social contexts.

In the first category, matrix supporters exemplify the “system of relevance” constructed by Schütz, when they attempt moments of training and learning to the health professionals of the units, through the handling of cases of mental health and the plan of care in mental health, taking into account the shared work with “do-it-yourself”, guided by the user's peculiar demand. Education is not the only reproduction of the theoretical-practical domain, consisting in the strengthening of spaces that prioritize the exchange of knowledge and values. It is a reading of the world beyond diseases, which acknowledges the conditions and contexts of life that people are subjected to.⁽¹³⁾

Another representative element of this intention of the supporters, expressed in the results, is the learning of health professionals, which has the potential to foster the analysis of reality and to reconstruct it, through a change of theoretical-practical vision and, mainly, identification with the planned actions. Studies have pointed out that the learning of health professionals can contribute to health care in the territory, where the professional process is set up as an interactional structure, in which each professional controls his own work, but there are interpersonal connections with the others, where intersubjectivity shows a world that is common to all of us.⁽¹⁴⁾

In this logic, it becomes important to consolidate the concept of instruction of professionals aiming to overcome the traditional view of catechizing the other, so the premise of information sharing counterposes it to develop care which is, for now, frail and fragmented.

Subsequently, findings indicate how matrix supporters experience participation in mental health care in the territory, in which the structure of this intention is based on immediate interests, such as participating in and assisting the care in the units. From the point of view of supporters, mental health care in the territory is considered elementary, with matrix support participation, because it becomes necessary to create an environment that allows spaces of exchange between supporters and professionals of the units, as well as the establishment of joint actions. In this direction, matrixing traces a line of thought that shifts the focus to joint action, from disease to the subject, instituting a care based on mental health.⁽¹⁵⁾

On the other hand, in pointing out the different forms of operationalization and the difficulties encountered in the process, matrix supporters point out that their intention when participating in the units runs through the assistance projections to meet the demands of the user, since it goes into the conformation of the work process in this setting. In order to do so, studies indicate that overcoming barriers requires the sensitization and active participation of managers, professionals and users, which allows collective and contextual health production.^(16,17)

Aside from responding to the objective of this study, it was possible to look at nurses, who have a relevant role in mental health care in Primary Care, since they receive, on a daily basis, people in psychological distress who demand actions in mental health from primary care services. Thus, evidencing the expectations of nurses can contribute to strengthen matrix support actions in mental health in the territory, whereas these actions, when considering nursing work relevant to its implementation, can make this worker an exponent for the consolidation of mental health in the community.

With regard to nurses ‘expectations regarding the actions of matrix support in mental health in Primary Care, “reasons for” were identified in light of the Schützian framework, bringing to light the convergence of this network of nurses’ motivations to seek care in mental health for the patient, and improvement of the matrix support structure. This study corroborates these findings, indicating that the way in which the being interprets their behaviors and the behaviors of others, according to their histories and relevance, can contribute to the subjects' finding themselves within the world, revealing the social phenomenon.⁽¹⁸⁾

The third category reveals that the expectation of mental health care for the patient inhabits the “face-to-face relationship” proposed by Schütz,⁽¹⁹⁾ with regard to aspects such as referrals and improvement of the individual, going into each nurse's speech. It is noted, in the experiences reported by the professionals, the difficulty encountered in the daily life of health units in referring users for continuity of therapy in other health services and, at the same time, other nurses express the desire that this user be followed up by specialized care.

However, there are studies that oppose these findings when they affirm that the matrix team also aims to minimize the excessive system of referrals to the specialty service, with a view to care in the territory, keeping the individual in their social environment.⁽¹⁷⁾ From this perspective, it is necessary to potentialize this purpose of the matrix team by strengthening mental health care in the territory through its incitement in general therapeutics of people and in health production at the social environment.

From the speeches, the emphasis given by nurses to the quality of life for the user with mental health demands is also observed. In this sense, studies corroborate the findings by emphasizing that the meeting between health professionals and users directs health care towards solutions arising from the real evocations of subjectivity, in which the care produced in the singularity of each being allows one to understand what is experienced in the subjective environment, in order to promote quality of life and to retrieve the right to health of these users.^(20,21)

Finally, the fourth category indicates that nurses expect to improve matrix support structure, in view of reports regarding matrix team arrangement improvement. Studies indicate that the work between supporters and teams of the health units requires constant dialogue, which can generate new constructs, aiming at the integration of knowledge, skills and behaviors in health care.⁽²²⁾ However, nurses affirm that there is a quantitative lack of support professionals, which harms the offered support, generating spaces with scarcity of discussions and institutional reference to handle the daily demands.

Matrix support represents expansion of care beyond the substitutive network, especially Primary Health Care, which reinvigorates the idea that Psychiatric Reform cannot advance if Primary Care is not incorporated into care.⁽⁴⁾ Therefore, it is necessary to broaden the awareness of teams, managers and community regarding the importance of implementing strategies that strengthen the ideals of the Psychiatric Reform and the Brazilian Unified Health System (SUS - Sistema Único de Saúde), which are affected by dismantling actions that interfere with the therapeutic results that lead to proposals for the return of the asylum model to the country's Public Policies. In view of this, the strengthening of Primary Health Care becomes essential as a mechanism to contain setbacks in the process of consolidation of the Brazilian Psychiatric Reform, as well as containing the dismantling of SUS.

Despite the tensions and challenges presented, matrix support is a potent strategy for working in mental health in the basic network, and it has contributed to bring mental health, health unit teams and users closer. Among the main tensions, the integration and awareness of these teams for mental health work can be found, and investing in people portrays the movement to overcome the isolation arising from a health model focused on disease.⁽²³⁾

It is noteworthy that in this research, with the unveiling of the senses expressed by the lived experiences of matrix support workers and nurses, comprehensive analysis was carried out. The phenomenological method, as the axis of health practices, contributes to actions that are based on the comprehensive way of living experiences of supporters and nurses, provoking the problematization of lived experiences for the production of health, citizenship and existence.

In addition, it should be noted that there are limitations, since the study brought the problematization of a reality, when investigating only conceptions of a certain team of supporters and nurses of a certain region of the municipality, not covering the totality of the matrix in the municipality under study. Even so, the actions of matrix support in Primary Care are considered a relevant topic for new research in the area of mental health, in which there is also a need to problematize conceptions of other professionals, users and family members in the care process.

Conclusion

The findings of this study indicate that support team members intend to instruct unit health workers when they wish to promote training and learning. The intention to participate in mental health care in the territory was also evidenced, on the occasions in which they wish to assist care provision in the units. In the other facet of the phenomenon, there are the expectations of nurses. They are exposed when nurses report that they expect to meet the demands of the user with individual improvement and referrals. In addition, there is an expectation regarding matrix support structure improvement, when nurses wish for the improvement of matrix array arrangement. Hearing the experiences uncovered the mismatch between intentions of matrix supporters and nurses' expectations. This mismatch is linked to the conflict between what is intended and expected, making it evident that there is no reciprocity of perspectives, in which the intention of action is motivated by the context as translated by expectation.

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Publication Dates

• Publication in this collection
  02 Dec 2019
• Date of issue
  Nov-Dec 2019

History

• Received
  07 Mar 2019
• Accepted
  11 June 2019