STRESS IN THE ELDERLY IN THE CONTEXT OF THE COVID-19 PANDEMIC AND ITS ASSOCIATED FACTORS

ABSTRACT

Objective:

To identify stress in the elderly living in the city of Lima and its association with demographic factors, infodemics, the presence of physical and psychological symptoms, and the use of illicit substances in the context of the Covid-19 pandemic.

Method:

Quantitative, transversal, and analytical study through the web-based survey with 384 elderly from the city of Lima - Peru between April and August 2021. The instruments of demographic profile, Perceived Stress Scale, and self-reported symptoms were used for the study. The Multiple logistic regression was used, considering the significance level of 5%.

Results:

62% were women, and the age ranged between 60 and 95 years with a mean of 70.5. The stress average was 26.8 points. Stress was associated with fear of relatives dying and concern for the elderly.

Conclusions:

it is important for health professionals trained to identify changes in mood in the elderly and to create individualized care plans.

DESCRIPTORS:
Aged; Covid-19; Stress disorder traumatic; Pandemics; Infodemic.

RESUMO:

Objetivo:

identificar o estresse nos idosos que vivem na cidade de Lima e sua associação com fatores demográficos, infodemias, a presença de sintomas físicos e psicológicos e o uso de substâncias ilícitas no contexto da pandemia de COVID-19.

Método:

estudo quantitativo, transversal e analítico através da pesquisa baseada na web com 384 idosos da cidade de Lima - Peru, entre abril e agosto de 2021. Os instrumentos de perfil demográfico, Escala de Estresse Percebido e sintomas autorrelatados foram utilizados para o estudo. A regressão logística múltipla foi utilizada, considerando o nível de significância de 5%.

Resultados:

62% eram mulheres, e a idade variou entre 60 e 95 anos, com uma média de 70,5 anos. A média de estresse foi de 26,8 pontos. O estresse estava associado ao medo da morte de parentes e à preocupação com os idosos. Conclusões: é importante para profissionais de saúde treinados para identificar mudanças de humor nos idosos e criar planos de cuidados individualizados.

DESCRITORES:
Idoso; COVID-19; Transtornos de Estresse Traumático; Pandemias; Infodemia.

RESUMEN

Objetivo:

identificar el estrés en ancianos residentes en la ciudad de Lima y su asociación con factores demográficos, infodemias, presencia de síntomas físicos y psicológicos y consumo de sustancias ilícitas en el contexto de la pandemia COVID-19.

Método:

estudio cuantitativo, transversal y analítico mediante encuesta vía web a 384 adultos mayores de la ciudad de Lima - Peru, entre abril y agosto del 2021. Para el estudio se utilizaron los instrumentos de perfil demográfico, Escala de Estrés Percibido y síntomas auto reportados. Se utilizó regresión logística múltiple, considerando el nivel de significación del 5%.

Resultados:

el 62% eran mujeres, y la edad oscilaba entre 60 y 95 años, con una media de 70,5 años. La puntuación media de estrés fue de 26,8 puntos. El estrés se asoció con el miedo a la muerte de familiares y la preocupación por los ancianos.

Conclusiones:

es importante que los profesionales sanitarios formados identifiquen los cambios de humor en los ancianos y creen planes de atención individualizados.

DESCRIPTORES:
Anciano; COVID-19; Trastornos de Estrés Traumático; Pandemias; Infodemia.

HIGHLIGHTS

1. Stress in the elderly during COVID-19, was associated with fear of death of relatives.

2. Healthcare professionals need to be prepared to identify mood changes in the elderly to create individualized care plans.

3. Information from the Internet and radio was not a cause of stress in the elderly.

HIGHLIGHTS

1. Stress in the elderly during COVID-19, was associated with fear of death of relatives.

2. Healthcare professionals need to be prepared to identify mood changes in the elderly to create individualized care plans.

3. Information from the Internet and radio was not a cause of stress in the elderly.

INTRODUCTION

In December 2019, SARSCoV2, a new coronavirus that causes an infectious disease called Covid-19 and in severe cases causes respiratory failure, pneumonia, kidney failure, and other conditions, which could lead to death, was discovered in Wuhan ¹-².

The World Health Organization (WHO) declared Covid-19 a pandemic in March 2020, causing, as of June 16, 2022, a total of 6.316,054 deaths and 237,770,528 infections worldwide ³. In Peru, 213,343 deceased persons have been registered, of which 148,235 are over 60 years; males had a higher incidence, with a fatality rate of 5.98%, and 3,551,540 cases of infection ⁴.

This overwhelming increase in cases was due to the high transmissibility of the virus, and the number of deaths has generated the idea of a containment public health strategy that includes social isolation, forcing families to modify activities and routines at home ⁵-⁶.

The elderly were and are the most vulnerable to Covid-19; the most frequent causes that put them at high risk are the indices of frailty and vulnerability to adverse events, disability and degree of dependency, and susceptible health conditions that hinder their recovery and increase mortality ⁷.

Likewise, this pandemic stage has affected mental health, causing fear, anxiety, and stress, altering the emotional stability of the elderly, and adding to misinformation by the different media, causing isolation, loss of independence, loneliness, and anguish ⁷. Information overload and unsubstantiated comments can make people feel insecure, which, in turn, can cause fear and stress, increasing the possibility of worsening mental health conditions ⁸. In addition, negative psychological effects due to the information received about the pandemic generated symptoms of post-traumatic stress, confusion, intense mental anger ⁹ disorder, anxiety ¹⁰, stress, and fear ¹¹.

Strengthening and caring for the mental health of the population is essential; with the beginning and development of the pandemic, the difficulties that people, especially the elderly, in using and understanding the information received by different media can cause physical and emotional disturbances. In this context, the following research question was formulated: What is the stress level of the elderly and its associated factors due to the Covid-19 pandemic in the city of Lima?

The objective of this study was to identify stress in the elderly living in the city of Lima and its association with demographic factors, infodemics, the presence of physical and psychological symptoms, and the use of illicit substances in the context of the Covid-19 pandemic.

METHOD

A quantitative, cross-sectional, and analytical study was carried out in the city of Lima, Peru, between April to August 2021 through a web-based survey. This study is part of the project “Infodemic of Covid-19 and its repercussions on the mental health of the elderly”. Lima is the capital of Peru and is located on the country’s central coast. Currently, it has a population of over nine million, representing 30% of the total population, ranking fifth in Latin America and the Caribbean and one of the 30 most populous cities in the world ¹².

The study participants were the elderly living in the city of Lima. To calculate the sample size, the proportions formula for finite populations was used to calculate the sample size with a final sample of 384. To be part of the study, the following inclusion criteria had to be met: being 60 years old or older, of both sexes, and having a cell phone or computer with Internet. The exclusion criteria were not answering the questionnaire in its entirety.

The collection of information was carried out through the publication of the web-based survey; a link was made available on social networks and applications such as Facebook, Instagram, and/or WhatsApp. The snowball technique was used to reach the number of elderly participants.

For the collection of information, the following instruments were used:

Sociodemographic profile: in order to identify information such as sex (male and female), age (in years), marital status (with and without a partner), education (no studies, elementary, secondary, university, and postgraduate), number of children, type of housing (own, rented, family, and other), place of residence (urban and rural), use of health services (public, private, both, and neither) and income changes during the pandemic (no, increased or decreased).

Perceived Stress Scale: elaborated to measure the degree to which people evaluate the situations of daily life that can be considered stressful and demanding. The 14 items that make up the scale assess the degree to which people perceive life as unpredictable, uncontrollable, or overloaded. The questions are general and relatively free of specific content any particular population can understand ¹³.

Exposure to information about the pandemic (Infodemic): identifying the time in hours the elderly were exposed to information about Covid-19 with the use of the Internet, TV, and radio.

Self-reported symptoms: List of related symptoms linked to the physical and psychological changes that the older adult could present during the pandemic. Each symptom had a Likert-type response (no, rarely, sometimes, and often). In addition, they were asked about the consumption of illegal substances, alcohol, and psychotropic drugs.

The data was analyzed using the program Statistical Package for the Social Sciences (SPSS) v. 25.0. Descriptive statistics were used to describe the sociodemographic characteristics of the sample. Stress scores were presented as means and standard deviations.

To identify the differences in the stress mean scores for each sociodemographic variable, the non-parametric Mann-Whitney U tests were used for variables with two groups and the Kruskal-Wallis H for variables with multiple groups. Likewise, the Pearson and Spearman correlation was used to detect the correlations between the variables.

To identify the association between the dependent variable, stress, with demographic variables, symptoms (physical and psychological), and the use of substances categorized as yes, and no, the multiple logistic regression was used, considering the significance level of 5% and a Confidence Interval (CI) of 95%.

The Ethics Committee approved the digital informed consent of the study with the n° 2021-CE-EPG-000003 of the Universidad Peruana Unión. The acceptance or not to participate in the study was automatically registered in the database generated by the web-based survey.

RESULTS

The sample comprised 416 elderly; 258 (62%) were women. The age of the participants ranged from 60 and 95 years, with a mean of 70.5 (SD=8.2). The average number of children per person was 3.3. Regarding marital status, 225 (54.1%) had a partner, and 157 (37.7%) had am university level of education (Table 1).

Table 1
Demographic characteristics of the elderly according to stress during the COVID-19 pandemic. Lima, Peru, 2021

Variable	Category	n	%	Stress M (SD)	KW(p)
Gender	Male	158	38.0	26.20 (10.4)	0.62 (p=0.42)
	Female	258	62.0	27.21 (9.87)
Age	60 - 69	238	57.2	27.96 (9.62)	6.30 (p=0.04)
	70 - 79	126	30.3	25.55 (10.19)
	80 and over	52	12.5	24.73 (11.14)
Number of Children	0	43	10.3	27.12 (9.85)	1.56 (p=0.66)
	1 - 5	313	75.2	26.78 (9.90)
	6 - 9	53	12.7	27.19 (11.02)
	10 - 12	7	1.7	24.57 (14.40)
Marital Status	No partner	191	45.9	25.38 (10.22)	5.84(p=0.01)
	With partner	225	54.1	28.05 (9.83)
Level of Studies	No studies	17	4.1	20.71 (11.77)	24.87 (p<0.001)
	Elementary	66	15.9	24.98 (10.71)
	Secondary	129	31.0	24.71 (10.91)
	University	157	37.7	28.89 (8.34)
	Postgraduate	47	11.3	30.53 (9.01)
Housing	Own house	297	71.4	27.08 (10.30)	3.41 (p=0.33)
	Rent house	49	11.8	27.67 (7.35)
	Family house	63	15.1	24.91 (11.00)
	Other	7	1.7	27.19 (8.85)
Health services	Public	118	28.4	26.02 (10.29)	2.30 (p=0.51)
	Private	121	29.1	27.33 (9.33)
	Both	149	35.8	27.46 (9.65)
	Neither	28	6.7	24.68 (14.06)
Income during the pandemic	No	173	41.6	26.44 (10.02)	4.16 (p=0.12)
	Increased	22	5.3	23.91 (12.48)
	Decreased	221	53.1	27.42 (9.86)

Fonte: Os autores (2021).

The average stress in the elderly was 26.8 (SD=10.1). Regarding the frequency of exposure, the average stress score was compared for the various media, being related to exposure to the use of the Internet (KW=10.73, p<0.01) and TV (KW=7.68, p<0.01). (Table 2)

Table 2
Association of stress in the elderly according to the frequency of exposure to news about COVID-19. Lima, Peru, 2021

Variable	Categories	n	%	Stress M (SD)	KW(p)
Internet	Unexposed	145	34.9	24.47 (10.7)	10.72 (0.001)
	Exposed	271	65.1	28.09 (9.5)
TV	Unexposed	43	10.3	22.86 (10.3)	7.68 (0.006)
	Exposed	373	89.7	27.28 (9.98)
Radio	Unexposed	190	45.7	27.92 (8.5)	2.55 (0.11)
	Exposed	226	54.3	25.91 (11.2)

Fonte: Os autores (2021).

The association between physical symptoms, use of alcohol, illegal substances, and psychotropic drugs with the stress level was evaluated. When applying the Kruskal-Wallis test, it was found that the significant symptoms were lack of energy, difficulty breathing, headache, muscle pains, sleeping problems, nutritional problems, palpitations, and fatigue. In addition, stress was related to using illegal substances (Table 3).

Table 3
Relationship between stress with physical symptoms and substance consumption in the elderly during the COVID-19 pandemic. Lima, Peru, 2021

Variables	Category	n	%	Stress M (SD)	KW(p)
Cold sweats or chills	No	274	65.9	26.10 (10.3)	0.00 (0.93)
	Yes	142	34.1	28.23 (9.5)
Low sex drive	No	293	70.4	26.38 (10.05)	0.00 (0.97)
	Yes	123	29.6	27.90 (10.15)
Digestive problems	No	227	54.6	25.48 (10.9)	1.99 (0.15)
	Yes	189	45.4	28.45 (8.6)
Dry mouth	No	252	60.6	26.17 (10.3)	0.46 (0.49)
	Yes	164	39.4	27.84 (9.7)
Lack of energy	No	233	56.0	24.01 (11.9)	10.11 (0.001)
	Yes	183	44.0	29.04 (7.7)
Chest tightness	No	239	57.6	25.60 (10.9)	0.76 (0.38)
	Yes	177	42.5	28.48 (8.7)
Difficulty breathing	No	272	65.4	25.45 (10.5)	5.30 (0.02)
	Yes	144	34.6	29.43 (8.7)
Trembling	No	290	69.7	26.26 (10.2)	0.00 (1.00)
	Yes	126	30.3	28.14 (9.8)
Headache	No	237	57.0	24.70 (11.1)	6.38 (0.01)
	Yes	179	43.0	28.43 (9.0)
Muscle pains	No	217	52.2	24.00 (11.6)	16.45 (<0.001)
	Yes	199	47.8	29.42 (7.6)
Sleeping problems	No	226	54.3	23.93 (11.2)	17.39 (<0.001)
	Yes	190	45.7	29.27 (8.4)
Nutritional problems	No	232	55.8	25.38 (10.8)	2.72 (0.10)
	Yes	184	44.2	28.65 (8.9)
Palpitations	No	264	63.5	25.05 (10.5)	13.24 (0.00)
	Yes	152	36.5	29.91 (8.6)
Fatigue	No	236	56.7	23.91 (11.5)	12.86 (<0.001)
	Yes	180	43.3	29.06 (8.2)
Alcohol or Tobacco	No	359	86.3	26.8 (10.1)	1.30 (0.25)
	Yes	57	13.7	27.09 (10.1)
Illegal Substance	No	370	88.9	26.90 (9.8)	3.58 (0.04)
	Yes	46	11.1	26.24 (12.1)
Psychotropic drugs	No	310	74.5	26.08 (10.4)	1.63 (0.20)
	Yes	106	25.5	29.01 (8.7)

Fonte: Os autores (2021).

When analyzing the association between psychological symptoms and stress level, applying the Kruskal-Wallis test, it was found that the most significant symptoms were lack of hope, irritation, fear of getting sick, nervousness, fear of dying, worry, anxiety, sadness, fear, discouragement, fear that their loved ones will die (p<0.05) (Table 4).

Table 4
Relationship between stress and psychological symptoms in the elderly during the COVID-19 pandemic. Lima, Peru, 2021

Psychological symptoms	Category	n	%	Stress M (SD)	KW(p)
Lack of hope or pessimism	No	253	60.8	23.47 (12.5)	16.96 (<0.001)
	Yes	163	39.2	28.99 (7.8)
Irritation	No	216	51.9	24.89 (10.99)	8.00 (0.00)
	Yes	200	48.1	28.92 (8.6)
Unwillingness	No	210	50.5	25.20 (11.2)	2.24 (0.13)
	Yes	206	49.5	28.49 (8.6)
Fear of getting sick	No	351	84.4	21.17 (12.6)	14.56 (<0.001)
	Yes	65	15.6	27.87 (9.2)
Nervousness	No	292	70.2	23.15 (11.9)	11.69 (0.00)
	Yes	124	29.8	28.39 (8.8)
Panic	No	214	51.4	25.76 (10.9)	1.18 (0.27)
	Yes	202	48.6	27.96 (9.1)
Fear of dying	No	268	64.4	24.62 (11.6)	4.40 (0.03)
	Yes	148	35.6	28.04 (8.9)
Lack of interest	No	211	50.7	25.30 (11.5)	2.22 (0.13)
	Yes	205	49.3	28.31 (8.2)
Worry	No	320	76.9	20.73 (12.4)	30.16 (<0.001)
	Yes	96	23.1	28.66 (8.5)
Will to die	No	317	76.2	26.61 (10.1)	1.26 (0.26)
	Yes	99	23.8	27.53 (10.2)
Anxiety	No	253	60.8	24.26 (11.7)	8.12 (0.00)
	Yes	163	39.2	28.48 (8.6)
Sadness	No	322	77.4	21.71 (12.3)	19.25 (<0.001)
	Yes	94	22.6	28.32 (8.8)
Fear but I do not know of what	No	249	59.9	24.02 (11.6)	10.49 (0.00)
	Yes	167	40.1	28.71 (8.4)
Discouragement	No	245	58.9	23.83 (11.9)	12.89 (0.00)
	Yes	171	41.1	28.92 (8.0)
Anger	No	221	53.1	25.34 (10.8)	3.72 (0.05)
	Yes	195	46.9	28.51 (8.9)
Fear that their loved ones will die	No	317	76.2	17.09 (11.8)	94.44 (<0.010)
	Yes	99	23.8	29.87 (7.16)
Willingness to be alone	No	257	61.8	25.65 (10.6)	3.50 (0.06)
	Yes	159	38.2	28.74 (8.8)

Fonte: Os autores (2021).

The multiple linear regression analysis identified that stress was triggered by the fear of relatives dying and the concern of the elderly. On the other hand, not using the Internet and radio did not cause stress in the participants (Table 5).

Table 5
Association between stress and demographic variables, infodemic, physical and psychological symptoms, and substance consumption in the elderly. Lima, Peru, 2021

Variables	B	CI 95%	p-value
Internet exposure (no)	0.27	0.09 - 0.46	0.00
Radio exposure (no)	-0.44	-0.71 - -0.17	0.001
Fear of relatives dying (no)	11.33	9.17 - 13.48	<0.001
Worry (not)	2.65	1.48 - 4.82	0.01

Fonte: Os autores (2021).

DISCUSSION

The start of the Covid-19 pandemic brought many health problems to the elderly population. In the study, a predominance of the female sex was identified, those between 60 and 69 years old and who have a partner and with a high level of education. In addition, that stress was associated with the fear of relatives dying and concern about the pandemic. However, not accessing the Internet and radio did not cause stress.

Among the psychological symptoms identified in the elderly were fear of family members dying and concern about getting sick. Covid-19 has affected different stages of life and caused many individual and collective psychiatric problems such as panic, anxiety, depression, post-traumatic stress disorders, suspicion, infodemic, cacophony, xenophobia, and racism, among others, causing a global crisis of mental health in people, as well as a great psychosocial experiment in pandemic situations ¹⁴.

Stress pictures are prolonged psychophysiological reactions of the individual to external and internal events, which depend on the subject’s cognitive assessment, producing activation of symptoms such as psychosomatic and behavioral responses ¹⁵. Stress leads to impatience, irritability, lack of consideration for other people, and constant physical discomfort such as stomachache, back pain, headache, hair loss, dizziness, and constipation, among other symptoms ¹⁵.

Psychological reactions and mental health problems to epidemics and pandemics suggest that various psychological and psychosocial factors of vulnerability may play a role in coronaphobia, including individual difference variables such as intolerance of uncertainty, perceived vulnerability to illness, and the propensity for anxiety (worry) ¹⁶.

The infodemic of Covid-19 affected the elderly, a group especially vulnerable to contagion by the virus and more likely to suffer problems, both physical and psychological ¹⁷; the impact has been so significant on an emotional level that they can easily reach chronicity ¹⁸, coupled with misinformation by the different media, causing isolation, loss of independence, loneliness, and anguish ¹⁹.

In this study, it was identified that stress in the elderly during the pandemic was generated by fear that their relatives would die and concern about the disease. These results relate to a study on the immunological mechanisms, fear of illness, the uncertainty of the future, stigma, traumatic memories of serious illness, and social isolation experienced by people during Covid-19 that can trigger mental health problems ²⁰.

However, it was found that not using the Internet does not generate stress in the elderly when the information benefits their health. However, the daily disclosure in the media of the increase in infections and deaths in the pandemic, plus the alarm generated in the early stages due to the need to flatten the curve, contributed to the increase in the perception of the severity of the disease, which has influenced the rise in misinformation about it, generating fear and anxiety ²¹.

Indeed, during the bombardment of information, the population began to feel overwhelmed and believe in everything they read or heard, causing an emotional imbalance that led to the paranoia of feeling the symptoms of the coronavirus without having been in contact with someone sick and even without leaving the house or being exposed to positive contacts ²².

To examine the cumulative effects and potential moderators of exposure to Covid-19 news and information on concomitant emotions, appraisals, and behaviors. Broad exposure to the media caused negative effects on adverse psychological reactions, presenting a moderate and positive association with concern about the disease and preventive measures. Furthermore, associations between public media exposure and adverse psychological reactions were moderated by experience with Covid-19 ²³.

On the other hand, so that the population obtains greater knowledge about Covid-19, electronic services have been implemented that allow digital literacy in health aimed at different vulnerable populations. Electronic services are aimed at increasing knowledge about diseases and using social networks and the media to cope with changes in routines and practices, reduce fear and anxiety, increase knowledge and digital skills and increase the acceptance of the technology in specific groups ²⁴.

A descriptive ecological study that explores the percentage of the population with an inability to recognize fake news, the percentage of trust in the content of social networks, and the percentage of their use as the only source of news in Argentina, Brazil, Chile, Colombia, Mexico, and Peru until November 29, 2020, calculated the internet penetration rate in each country, the Facebook penetration rate and the mortality rate from Covid-19, finding that Chile and Argentina were the countries with the highest internet penetration rates (92.4% and 92.0%, respectively) and is also among those that use social networks the most as the only means of obtaining news (32.0% and 28.0% respectively); Brazil and Colombia showed an intermediate behavior in both indicators Mexico presented that it has the highest use of social networks, while Peru and Colombia presented the highest values on the index of inability to recognize false news ²⁵.

Within a few weeks of the appearance of Covid-19 in China, misleading rumors and conspiracy theories about its origin circulated around the world, along with scaremongering, racism, and the massive purchase of masks and protective equipment; all closely linked to the new “Infomedia” ecosystems of the 21st century marked by social networks. The virus spread very quickly, and misinformation about the outbreak, consequently, panic and fear among the inhabitants worldwide ²⁶.

Also, not using the radio caused less stress in the elderly. A study carried out in the United States identified that the consumption of news increased by 32% over the period before the health crisis, and traditional media, especially TV, are the ones that obtain the highest percentages, both in the consumption of news as in the positive assessment of credibility by the public ²⁶.

Another study in Brazil indicates that TV 862 (44.80%) and social networks 651 (33.84%) were reported as frequent sources of exposure to news or information about Covid-19. The participants indicated that TV (46.47%), social networks (30.81%), and radio (14.48%) affected them psychologically and/or physically. Receiving false news about Covid-19 on TV (19.8%) and on social networks (21.5%) resulted mainly in stress and fear. The information disseminated contributes to awareness but also affects the elderly physically and/or psychologically, mainly generating fear and stress ¹¹.

Studies suggest high prevalence rates for mental disorders, including depression, anxiety, mood disorders, suicidal behavior and self-harm, schizophrenia, substance consumption, neurodevelopmental, dementia, and other mental health problems ²⁷. One would expect deleterious emotional effects motivated by fear, stigma, and forced isolation ²⁸.

Among the limitations, it is indicated that the study population is homogeneous and that it is impossible to infer these results for the elderly population of Lima. It is important to highlight that this research contributes to identifying possible stress problems in older adults by health professionals; for this, constant training is necessary for their detection.

CONCLUSION

Stress was associated with the female sex, aged between 60 and 69 years, who have a partner. In addition, the pandemic generated feelings such as the fear that their relatives would die and concern about the disease. On the other hand, not using the Internet and radio was a protective factor against stress.

This study collaborates in identifying stress by health professionals in geriatrics and gerontology to create strategies and welcome this population that will need support from professionals in this area and the inter-and multi-disciplinary agency team.

It is necessary to create public policies that direct efforts toward the care of the elderly at the different levels of care. With the pandemic, the fragility of the different health organizations, the policies themselves, and the lack of preparation of health professionals to face this context have been seen. In this sense, government bodies need to review the different health policies in light of the new reality.

REFERÊNCIAS

• ¹
  Machado RB. Uso de dispositivos intrauterinos (DIU) em nulíparas. São Paulo: Federação Brasileira das Associações de Ginecologia e Obstetrícia (FEBRASGO); 2017. (Série Orientações e Recomendações FEBRASGO, no. 1- Comissão Nacional Especializada em Anticoncepção).
• ²
  Hauck B, Costescu D. Barriers and misperceptions limiting widespread use of intrauterine contraception among Canadian women. J Obstet Gynaecol Can. [Internet]. 2015 [cited on 2021 June. 10]; 37(7). Available in: https://pubmed.ncbi.nlm.nih.gov/26366817/
  » https://pubmed.ncbi.nlm.nih.gov/26366817/
• ³
  Gonzaga VAS, Borges ALV, Santos OA dos, Santa Rosa PLF, Gonçalves RFS. Organizational barriers to the availability and insertion of intrauterine devices in Primary Health Care Services. Rev Esc Enferm USP. [Internet]. 2017 [cited on 2021 June 10]; 51. Available in: https://www.scielo.br/j/reeusp/a/6sW3wZNcTJ53586zcsrmv5q/?format=pdf⟨=en
  » https://www.scielo.br/j/reeusp/a/6sW3wZNcTJ53586zcsrmv5q/?format=pdf⟨=en
• ⁴
  Harper CC, Comfort AB, Blum M, Rocca CH, McCulloch CE, Rao L, et al. Implementation science: scaling a training intervention to include IUDs and implants in contraceptive services in primary care. Prev Med. [Internet]. 2020 [cited on 2021 June 10]; 141. Available in: https://www.sciencedirect.com/science/article/abs/pii/S0091743520303145
  » https://www.sciencedirect.com/science/article/abs/pii/S0091743520303145
• ⁵
  Fleming K, Cheng Y, Botfield J, Sousa M, Bateson D. Inclusion of intrauterine device insertion to registered nurses’ scope of clinical practice. Collegian. [Internet]. 2019 [cited on 2021 June 10]; 26(1). Available in: https://www.collegianjournal.com/article/S1322-7696(17)30179-8/fulltext
  » https://www.collegianjournal.com/article/S1322-7696(17)30179-8/fulltext
• ⁶
  Trigueiro TH, Ferrari JC, Souza SRRK, Wall ML, Barbosa R. Follow-up of copper intrauterine device insertion by nurses: a prospective longitudinal study. Rev Bras Enferm. [Internet]. 2020 [cited on 2021 June 10]; 73(Supl 4). Available in: https://www.scielo.br/j/reben/a/Tp4sWQSYGdvPbTJgTCSL4zn/?lang=en
  » https://www.scielo.br/j/reben/a/Tp4sWQSYGdvPbTJgTCSL4zn/?lang=en
• ⁷
  Organização Mundial de Saúde. ODS - Alcançar a igualdade de gênero e empoderar todas as mulheres e meninas [Internet]. 2022 [cited on 2022 Aug. 01]. Available in: https://brasil.un.org/pt-br/sdgs
  » https://brasil.un.org/pt-br/sdgs
• ⁸
  Paiva CCN de, Caetano R. Avaliação de implantação das ações de saúde sexual e reprodutiva na Atenção Primária: revisão de escopo. Esc Anna Nery. [Internet]. 2020 [cited on 2022 June 10]; 24(1). Available in: https://www.scielo.br/j/ean/a/ktpRXV4tHmFjDJzphC4XFnz/?format=pdf⟨=en
  » https://www.scielo.br/j/ean/a/ktpRXV4tHmFjDJzphC4XFnz/?format=pdf⟨=en
• ⁹
  Jubilut LL, Lopes RO, Garcez GS, Fernandes AP, Silva JCJ. Direitos humanos e vulnerabilidade e a agenda 2030. [Internet]. 2020 [cited on 2022 Aug. 01]. Available in: https://repositorio.usp.br/directbitstream/5335e65e-052d-4245-ae92-fe306ae2f372/3014945%20Livro%20e-book%20Direitos%20Humanos%20e%20Vulnerabilidade%20e%20a%20Agenda%202030.pdf
  » https://repositorio.usp.br/directbitstream/5335e65e-052d-4245-ae92-fe306ae2f372/3014945%20Livro%20e-book%20Direitos%20Humanos%20e%20Vulnerabilidade%20e%20a%20Agenda%202030.pdf
• ¹⁰
  Ministério da Saúde (BR). Lei n. 9263, de 12 de janeiro de 1996. Lei do Planejamento familiar. [Internet]. 1996 [cited on 2022 Aug. 01]. Available in: http://www.planalto.gov.br/ccivil_03/leis/l9263.htm
  » http://www.planalto.gov.br/ccivil_03/leis/l9263.htm
• ¹¹
  Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Saúde sexual e saúde reprodutiva [Internet]. 2013 [cited on 2022 Aug. 01]. Available in: https://bvsms.saude.gov.br/bvs/publicacoes/saude_sexual_saude_reprodutiva.pdf
  » https://bvsms.saude.gov.br/bvs/publicacoes/saude_sexual_saude_reprodutiva.pdf
• ¹²
  Moura LNB de, Gomes KRO. Planejamento familiar: uso dos serviços de saúde por jovens com experiência de gravidez. Cien Saude Colet [Internet]. 2014 [cited on 2021 June 10]; 19(03). Available in: https://www.scielo.br/j/csc/a/zzXK6X3tyzv6xwBbZbsDLrD/?format=pdf⟨=pt
  » https://www.scielo.br/j/csc/a/zzXK6X3tyzv6xwBbZbsDLrD/?format=pdf⟨=pt
• ¹³
  Assis MMA, Jesus WLA de. Acesso aos serviços de saúde: abordagens, conceitos, políticas e modelo de análise. Ciênc saúde coletiva [Internet]. 2012 [cited on 2021 June 10];17(11)). Available in: https://doi.org/10.1590/S1413-81232012001100002
  » https://doi.org/10.1590/S1413-81232012001100002
• ¹⁴
  Trindade RE da, Siqueira BB, Paula TFD, Felisbino-Mendes MS. Uso de contracepção e desigualdades do planejamento reprodutivo das mulheres brasileiras. Cien. Saude Colet. 2021 [cited on 2021 June 10]; 26(suppl 2). Available in: https://www.scielo.br/j/csc/a/wYMBdngQjR9dRs48jbwjCVL/abstract/?lang=pt
  » https://www.scielo.br/j/csc/a/wYMBdngQjR9dRs48jbwjCVL/abstract/?lang=pt
• ¹⁵
  Gonçalves TR, Leite HM, Bairros FS de, Olinto MTA, Barcellos NT, Costa JSD da. Social inequalities in the use of contraceptives in adult women from Southern Brazil. Rev Saúde Públ [Internet]. 2019 [cited on 2021 June 10]; 53(28). Available in: https://www.scielo.br/j/rsp/a/CYT57svKjbvz9S4Hxhw9YwD/?format=pdf⟨=en
  » https://www.scielo.br/j/rsp/a/CYT57svKjbvz9S4Hxhw9YwD/?format=pdf⟨=en
• ¹⁶
  Borges ALV, Araújo KS, Santos AO dos, Gonçalves RFS, Fujimori E, Divino E do A. Knowledge about the intrauterine device and interest in using it among women users of primary care services. Rev Latino-Am Enfermagem. [Internet]. 2020 [cited on 2021 June 10]; 28(e3232). Available in: https://www.scielo.br/j/rlae/a/MBdtsctXQTtVZhMX6rmyQzB/?format=pdf⟨=en
  » https://www.scielo.br/j/rlae/a/MBdtsctXQTtVZhMX6rmyQzB/?format=pdf⟨=en
• ¹⁷
  Ali M, Folz R, Farron M. Expanding choice and access in contraception: an assessment of intrauterine contraception policies in low and middle-income countries. BMC Public Health [Internet]. 2019 [cited on 2021 June 10]; 19(1707). Available in: https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/s12889-019-8080-7.pdf
  » https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/s12889-019-8080-7.pdf
• ¹⁸
  Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde: 2019 - ciclos de vida - Brasil. [Internet]. IBGE, Coordenação de Trabalho e Rendimento [cited on 2022 Aug. 01]. Available in: https://biblioteca.ibge.gov.br/index.php/biblioteca-catalogo?view=detalhes&id=2101846
  » https://biblioteca.ibge.gov.br/index.php/biblioteca-catalogo?view=detalhes&id=2101846
• ¹⁹
  Armstrong MA, Raine-Bennett T, Reed SD, Gatz J, Getahun D, Schoendorf J, et al Association of the Timing of Postpartum Intrauterine Device Insertion and Breastfeeding With Risks of Intrauterine Device Expulsion. JAMA Netw Open. [Internet]. 2022 [cited on 2021 June 10]; 5(2). Available in: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8886522/
  » https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8886522/
• ²⁰
  Jatlaoui TC, Riley HEM, Curtis KM. The safety of intrauterine devices among young women: a systematic review. Contraception. [Internet]. 2017 [cited on 2021 June 10]; 95(1). Available in: https://pubmed.ncbi.nlm.nih.gov/27771475/
  » https://pubmed.ncbi.nlm.nih.gov/27771475/
• ²¹
  Woldeyohannes D, Arega A, Mwanri L. Reasons for low utilization of intrauterine device utilisation amongst short term contraceptive users in Hossana town, Southern Ethiopia: a qualitative study. BMC Womens Health. [Internet]. 2022 [cited on 2021 June 10]; 22. Available in: https://bmcwomenshealth.biomedcentral.com/track/pdf/10.1186/s12905-022-01611-6.pdf
  » https://bmcwomenshealth.biomedcentral.com/track/pdf/10.1186/s12905-022-01611-6.pdf
• ²²
  Birgoda GT, Gebrehiwot H, Hebo SH, Hagos B, Assefa G, Sidamo NB, et al Determinants of intrauterine contraceptive device utilization at primary health care facilities in Mekelle City, northern Ethiopia. Contracept. Reprod Med. [Internet]. 2021 [cited on 2021 June 10]; 6(20). Available in: https://contraceptionmedicine.biomedcentral.com/track/pdf/10.1186/s40834-021-00164-7.pdf
  » https://contraceptionmedicine.biomedcentral.com/track/pdf/10.1186/s40834-021-00164-7.pdf
• ²³
  Heisel E, Kolenic GE, Moniz MM, Kobernik EK, Minadeo L, Kamdar NS, et al. Intrauterine device insertion before and after mandated health care coverage: the importance of baseline costs. Obstet. Gynecol. [Internet]. 2018 [cited on 10 jun 2021]; 131(5). Available in: http://doi.org/10.1097/AOG.0000000000002567
  » http://doi.org/10.1097/AOG.0000000000002567
• ²⁴
  Godinho A, Florentino D M, Violante FF, Dias H, Coutinho E. O enfermeiro promotor da saúde sexual e reprodutiva na adolescência: o caso do planeamento familiar. Rev. UIIPS. [Internet]. 2020 [cited on 2021 June 10]; 8(1). Available in: https://doi.org/10.25746/ruiips.v8.i1.19906
  » https://doi.org/10.25746/ruiips.v8.i1.19906
• ²⁵
  Flores GT, Landerdahl MC, Cortes LF. Ações de enfermeiras em planejamento reprodutivo na atenção primária à saúde. Rev Enferm UFSM. [Internet] 2017 [cited on 2021 June 10]; 7(4). Available in: https://periodicos.ufsm.br/reufsm/article/view/25777/pdf
  » https://periodicos.ufsm.br/reufsm/article/view/25777/pdf
• ²⁶
  Morete ÁS, López JRG. Métodos anticonceptivos en las mujeres inmigrantes y el papel de la enfermera: una revisión bibliográfica. Enferm Global. [Internet]. 2015 [cited on 2021 June 10]; 14(1). Available in: https://scielo.isciii.es/pdf/eg/v14n37/en_revision5.pdf
  » https://scielo.isciii.es/pdf/eg/v14n37/en_revision5.pdf
• ²⁷
  Somefun O, Constant D, Endler M. Immediate IUD insertion after second trimester abortion: implications for service delivery. BMC Health Serv Res. [Internet]. 2021 [cited on 2021 July 10]; 21. Available in: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-07306-2
  » https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-07306-2
• ²⁸
  Bhadra B, Burman SK, Purandare CN, Divakar H, Sequeira T, Bhardwaj A. The impact of using nurses to perform postpartum intrauterine device insertions in Kalyani Hospital, India. Int J Gynecol Obstet. [Internet]. 2018 [cited on 10 jun 2021]; 143 (Suppl. 1). Available in: https://pubmed.ncbi.nlm.nih.gov/30225877/
  » https://pubmed.ncbi.nlm.nih.gov/30225877/
• ²⁹
  Ouedraogo L, Habonimana D, Nkurunziza T, Chilanga A, Hayfa E, Fatim T, et al Towards achieving the family planning targets in the African region: a rapid review of task sharing policies. Reprod Health. [Internet]. 2021 [cited on 2021 June 10]; 18(22). Available in: https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-020-01038-y
  » https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-020-01038-y
• ³⁰
  Bækgaard RS, Damhaugh GE, Mrema D, Rasch V, Khan K, Linde DS. Training of healthcare providers and use of long-acting reversible contraception in lowand middle-income countries: A systematic review. Acta Obstet. Gynecol. Scand. [Internet]. 2021 [cited on 2021 June 10]; 100(4). Available in: https://pubmed.ncbi.nlm.nih.gov/33594675/
  » https://pubmed.ncbi.nlm.nih.gov/33594675/

Edited by

Associate editor: Dra. Luciana Kalinke

Publication Dates

• Publication in this collection
  16 June 2023
• Date of issue
  2023

History

• Received
  06 Sept 2022
• Accepted
  21 Feb 2023