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Revista da Escola de Enfermagem da USP

Print version ISSN 0080-6234

Rev. esc. enferm. USP vol.47 no.4 São Paulo Aug. 2013

http://dx.doi.org/10.1590/S0080-623420130000400017 

Original Article

The structure and flow of the health care network as an instrument of change in psychosocial assistance services *

Milena Hohmann Antonacci1 

Luciane Prado Kantorski2 

Janaína Quinzen Willrich3 

Carmen Terezinha Leal Argiles4 

Valéria Cristina Chistello Coimbra5 

Valquíria de Lourdes Machado Bielemann6 

1Nurse. MA. Doctoral candidate at the Nursing School of Ribeirão Preto, University of São Paulo. Pelotas, RS, Brazil. miantonacci@hotmail.com

2Nurse. PhD in Nursing, Nursing School of Ribeirão Preto, University of São Paulo. Associate professor, School of Nursing, Federal University of Pelotas. Pelotas, RS, Brazil. kantorski@uol.com.br

3Nurse. MSc. Assistant professor, School of Nursing, Federal University of Pelotas. Pelotas, RS, Brazil. janainaqwill@yahoo.com.br

4Psychologist. Master’s candidate at the Graduate Nursing Program of Federal University of Pelotas. Pelotas, RS, Brazil. carmen_argiles@yahoo.com.br

5Nurse. PhD in Nursing, Nursing School of Ribeirão Preto, University of São Paulo. Adjunct professor, School of Nursing, Federal University of Pelotas. Pelotas, RS, Brazil. valeriacoimbra@hotmail.com

6Nurse. MA in Nursing, Graduate Nursing Program of Federal University of Santa Catarina. valvmb@gmail.com

ABSTRACT

Changes in mental health care demand changes in the structure and function of health care networks. The aim of the present study was to understand how workers assess the structure of their network and how they use it as a tool for psychosocial rehabilitation. The present qualitative study is part of a larger research project, Rehabilitating networks – assessing experiences of innovation in network development for psychosocial care . Interviews were conducted with six workers at the Therapeutic Home Service (THS) of Alegrete, and four field observation notebooks were analyzed. The results revealed the transversal nature of the investigated network, the relationships between its various components, the strategies used to make non-institutionalized care effective, the responsibilities of the network users, and the relationships between the residents and the workers in the service and at home. In conclusion, the Alegrete network facilitates exchanges between the participants, which indicates that future work should focus on the subjects of reflection and transformation.

Key words: Health evaluation; Mental Health Services; Health Care Reform; Mental health

INTRODUCTION

In recent years, mental health care has undergone a significant transformation with regard to the knowledge and actions required to overcome the institution-based model of assistance. This transformation occurred in conjunction with changes in policies and legislation, as well as changes in the organization of mental health care service networks intended to facilitate changes in the mechanics of assistance and to address the complexity of mental illness ( 1 ) .

Now that some of the premises of the novel mental health care paradigm have been implemented, it is time to stop and assess the work that has already been performed and formulate alternative paths for areas that are still weak despite many years of efforts to implement new modalities of mental health care. To meet this aim, we began by investigating concrete examples of innovative, network-based models (a) .

According to the new policy, mental hospitals must be gradually closed and replaced. Well-structured networks that include assistive devices for providing necessary and humane care to individuals with mental health problems must be constructed to replace them.

A network might be understood as

connections among several units, which make mutual exchanges through definite links, and thus strengthen one another (…) the nodes of a network represent the units, and its threads the channels that connect the units and enable the flow of exchange ( 2 ) .

The structure of a network is a determinant of the modes of interaction between its components and thus influences the entire health care system ( 3 ) at the municipal level.

In the specific case of mental health care networks, the component known as Therapeutic Home Services (THS) ( 4 ) still seems quite far from reaching its full potential. THS is a housing alternative for individuals who have been confined to institutions for many years; it enables patients to engage in activities outside of the hospital setting and supports the process of social reinsertion ( 5 ) .

Therefore, including THS as a component of the mental health care network requires deconstructing the prevailing models of living, health care, and clinical care. This inclusion takes the unpredictability inherent in the encounter between mental illness and the urban setting into consideration in the individual process of social reinsertion. The combination of THS with the possibilities afforded by an innovative network may create opportunities for transforming the practice of mental health care ( a ) .

Therefore, it is important to understand how health care workers assess the structure of their network and how they use it a tool in psychosocial rehabilitation.

METHOD

The present study employed data collected within the context of a larger research project, Rehabilitating networks – assessing experiences of innovation in network development for psychosocial care (REDESUL) , funded by a partnership between the Ministry of Science and Technology and the National Council of Scientific and Technological Development (Public Call MCT-CNPq/CT-Saúde/MSSCTIE-Decit/33/2008). The study was approved by the Ethics Committee of the Dentistry School of Federal University of Pelotas, ruling No. 073/2009. All of the volunteers signed an informed consent form.

To broaden the scope of the study, both quantitative and qualitative methods were used. In the quantitative stage, an epidemiological approach was used to conduct a descriptive study to characterize the development and structure of mental health care networks. Next, a cross-sectional approach was applied to assess the autonomy of network users in five counties of Rio Grande do Sul (Alegrete, Bagé, Caxias do Sul, Porto Alegre, and Viamão).

Based on the quantitative assessment, we identified the networks that exhibited the greatest potential for innovation by comparing the psychosocial attention networks to the criteria established by the Health Ministry. Two counties (Caxias do Sul and Alegrete) were selected for the qualitative stage of the study.

The qualitative assessment was a fourth-generation (i.e., responsive constructivist) evaluation ( 6 ) based on the Everyday Network Analysis Method (Metodologia de Análise de Redes do Cotidiano – MARES) ( 7 ) . To have the broadest possible access to the volunteers’ actual experiences, a case study model was selected.

Based on the characteristics of THS, we investigated features related to the structure of the municipal assistance network, communication, interactions, and flow between the various services in each case, as well as the users’ social and sociability networks. The data were collected in May 2010 through participant observation and interviews with the THS residents and the mental health care workers and managers.

The present article is specifically devoted to analyzing the features related to the structure and function of the assistance network in Alegrete, RS, one of the case studies included in the REDESUL project, because it was identified during the qualitative assessment by the groups of interest (i.e., workers at the local THS). The strategies used for data collection were semi-structured interviews with six workers and 700 hours of field observation.

RESULTS

Transversal nature of the network at Alegrete

The transversal structure of the municipal health care network broadens the scope of discussion because it involves many individuals (i.e., workers, managers, and users), thus ensuring the collective construction of the processes of management and assistance. The participants’ approval of network management was apparent in all of the interviews. The workers feel that their demands are taken into consideration not only by the managers but also by the professionals assigned to other services within the network.

1.1 Our Monday meetings are very good because we talk about problems, difficult points, and easy points. (…) and we get the support of the system coordinator and then also of the secretary (Interviewee 2).

1.2 The staff holds meetings quite often. (…) It is extremely important to give the employees support because then they give the users support, in turn, by ensuring a good level of assistance all across the network (Interviewee 6).

The relationship between the network’s fixed components and its flow

The organization of the flow (movement, circulation of people) through the fixed network components is a direct outcome of the structure and processes involved in constructing an innovative network.

2.1 Each service depends on the others; I wouldn’t be able to do anything here without the support given by CAPS II, CAPS AD, and CAPS I because one doesn’t work alone; I believe this makes things easier – I mean the dialogue, the communication among us (Interviewee 2).

According to the interviewed workers, whenever hospitalization is needed, the bureaucratic process flows quite easily as the required contact is made directly between the services involved. The continuity of care is thus ensured. When no beds are available in the psychiatric ward, the patients might be admitted to wait in the emergency unit.

2.2 It works like this: one has to call the Holy House of Mercy and ask whether there´s a bed available before calling the patient’s doctor (…) in very serious cases, the patient might stay at the ER for 24 hours, that is, might wait for a hospital bed at the ER (Interviewee 1).

Nevertheless, some interviews indicate that this type of operation is still limited to the services included in the mental health care network. In the workers’ view, the relationship with primary care is still limited, which was confirmed in the field observations.

2.3 Primary care has virtually no connection with the residents; many of them don’t even know where the Health Basic Unit (HBU) is. There are two health care centers in the neighborhood, and one of them is included in the Family Health Strategy (FHS) (Observer 2).

The flow might also be limited by the fact that some workers do not even know what network they belong to, thus reducing the chances for inter-service collaboration.

2.4 I’ve been working in mental health care and here at the Home for seven months. I know nothing about how other services work. I truly don’t know; I can’t say anything about the other services (Interviewee 3).

Connections to make non-institutionalized care effective

The workers believe it is important for the residents to go out in public to facilitate the social reintegration of individuals with mental problems. In this regard, they stress the importance of maintaining a connection with specific spaces in addition to the importance of the services.

3.1 In the beginning (…), there was a community orchard for the people at the Home. I think it should be started again (…). There are workshops for them (…); they participate in the CAPS. However, I think that the workshops should be carried out in places like parks to improve their connections with society at large (Interviewee 6).

Network responsibility facing the users

According to the interviewees, Alegrete’s policy is to avoid referring local users to other counties for hospitalization because the structure of the network enables the treatment of users within the county borders. However, the network’s ability to function is impaired because patients from other counties are hospitalized in Alegrete, which makes the number of mental health care beds insufficient.

4.1 We try not to send the patients to other counties because there are psychiatric beds in the general hospital; we try to treat them here. Whenever they need it, our Home residents are treated at the hospital, get their medication, stay there if they must be hospitalized, or come back to the Home, where they are given their medication (Interviewee 2).

4.2 The demand is very high (…) because people from other places and small towns come to Alegrete for treatment (Interviewee 4).

With regard to the need to enlarge the municipal health care network, one of the interviewed workers made some interesting remarks that elicited relevant reflections from the other participants when the study results were presented to the group for validation.

4.3 I believe that the crux of matter is not whether or not to enlarge the network services, the number of beds, and so forth. It seems to me that the focus should be on the work with society. (…) It’s pointless to build more [therapeutic] homes to fill them up with people: the larger the number of available beds, the greater the number of people who should be admitted will be, and the greater the number of therapeutic homes, the greater the number of people living in them will be. The focus should be on the work with society at large to learn how to live with these people. Ill people will never lack (Interviewee 3).

Network flow inhibitors

Although the structure of the health care network was satisfactory, the THS workers indicated critical areas that have a direct influence on the assistance given to the residents. The number of workers at THS was mentioned as one of these critical areas.

5.1 There’s a shortage of employees. I believe that quantity is an important factor in service quality, to provide better care for the users (…) We strive to provide proper care, but it’s difficult (…) there’s a clear imbalance (Interviewee 6).

5.2 I was talking to Worker 1, and he said that the number of employees was reduced from 14 to seven, and for that reason, they have to work weekends and holidays (…) It’s clear that the employees care for the service and the users (…) and that the relationship goes well beyond the work setting (Observer 1).

The hiring pattern was also identified as an inhibiting factor. The public exams are established for generic areas (e.g., health) but do not include the specific job description; thus, the selected individuals are assigned to a wide variety of services.

5.3 You go, sit and pass the exam, and they send you, say, here, and you don’t like it (…) or you shut up and stay because you need the job, and you have to let the pressure out somehow. It will happen, it has already happened here several times (…) which isn’t right, to be angry at them, to lose one’s patience, then things become truly complicated (Interviewee 2).

On that topic, it was suggested that one possible strategy to solve that problem is to train the workers for the specific areas to which they are assigned. Some of the employees currently working at THS have had no training. In addition, trained THS workers might also provide therapeutic accompaniment.

5.4 I have no training whatsoever. I’m an assistant; I’ve never attended any course or had any training whatsoever to work here. All I know I learned in everyday practice (Interviewee 3).

5.5 I asked for therapeutic accompaniment from the system coordinator, and she requested it from the health secretary. However, it was very difficult to create a profile that matches the job description (Interviewee 2).

The relationships between the residents and the workers in the home/service space

The workers must have a very clear idea of the subtle line that demarcates the service space from the home so that the latter does not become a space devoted to the regulation of the residents’ lives but instead remains a congenial place where conflict is solved through agreement and consensus.

6.1 This job requires a lot from us: you have to have a lot of patience and affection, you have to pay close attention, be very understanding, and quick to solve the everyday problems (…) You have to have some strategies, must know what to do and what your limits are. As a rule, we solve everything by talking things out; it has worked pretty well until now (Interviewee 2).

The workers consider THS to be a novel alternative for people who have lost their family connections, especially as a result of long stays in psychiatric hospitals. Freedom must consistently characterize the relationships established within the therapeutic space because for the residents at THS, freedom might enable them to start over.

6.2 These people here didn’t have any place to go; they had been thrown in hospitals. Now they’re here, they have a home, a family, someone who cares for them (Interviewee 2).

6.3 They go out whenever they want, they aren’t prisoners. They have to be free, not like before when they were committed to institutions, they would go and stay in Porto Alegre for four or five years before coming back here. That is not so anymore (Interviewee 4).

DISCUSSION

The transversal nature of the network at Alegrete

The interviews with the THS workers at Alegrete show that the network is understood as a network of people rather than services, where exchanges are based on the connections built through dialogues between individuals, including both managers and workers, and there is a feeling of belonging to a complete and efficacious network.

The relationship between the services and municipal management is transversal in nature ( 8 ) , which guarantees opportunities for differentiation and health innovation by creating spaces for multi-vector discussion, such as meetings within the system. These spaces allow the managers to learn about the everyday problems in the services and thus help to solve some of them.

The transversal nature of the service is helpful because it enables intensive communication between the various levels and multiple perspectives. It offers the widest possible access to procedural actions and to multiplicity to overcome the impasses associated with pure vertical organization or pure horizontal organization. Conversely, a transversal system is effective because it enables maximum communication between the various levels, and more specifically, between the various perspectives ( 8 ) . As a result, the managers become aware of daily work issues, reflecting the quality of the assistance received by the network users.

In this regard, the relationships between the workers in various services form a network. This network comprises dialogue-based relationships characterized by mutual support; that characteristic is considered to be a mediating factor in the network.

The relationship between the network’s fixed components and its flow

The workers stressed the importance of the support given by other network services to THS for assisting its residents because the staff does not include any university-trained health care professionals. This situation was foreseen in the policy for THS; it is supposed to be a dwelling place rather than a healthcare facility.

According to Ministry ruling No. 106/2000 and a complementary document ( 5 ) , THS must have links to referral services, such as CAPS or mental health outpatient clinics, and to FHS teams, which offer specific mental health care support. Therefore, the THS residents might use CAPS on the weekdays and emergency rooms for emergencies and weekends.

Whenever hospitalization is needed, the THS workers call the Holy House of Mercy and talk directly with the doctor in charge to investigate the availability of beds and to request an assessment. When beds are not available, the emergency room has four beds assigned for the THS residents in Alegrete, where they can wait for an opening in the psychiatric ward.

Therefore, the service network also operates as a support network. Health care professionals are able to establish connections and collaborate with the various network components. The result is a process in which the responsibility for the users’ health is shared, a so-called hot network ( 9 ) (i.e., a network that performs actions within its working space that serve as catalysts of change in psychosocial assistance).

Nevertheless, some areas are still critical because they inhibit the operation of the network. One area is communication with primary care, which was described as difficult by the interviewees and which the field observation further corroborated. To comply with the latest health policies, the Health Ministry ( 5 ) emphasizes the need for appropriate connections between mental health and primary care.

Consequently, active advocacy is needed for policies related to the formulation, expansion, and assessment of guidelines for the interactions between primary and mental health care, following the territory-based network model of assistance. Transverse interactions with other specific policies aiming to develop links and receptivity ( 10 - 11 ) are also needed. Accepting such a compromise is a way to assume responsibility for promoting health, pursuing efficacy in practice, and promoting equity, integrity, and citizenship in the broadest sense ( 5 ) .

In addition, the interviews show that the network we investigated is still considered a facility that focuses primarily on mental health care; no other territory-based facility was listed as a therapeutic resource for the THS residents. This finding seems to highlight the complexity of the processes of socio-historical change, which gives them a culturally possible, albeit often slow rhythm ( 12 ) .

The reconstructed mental health care network must include novel approaches to practice and institutions that are overtly committed to freedom and social inclusion for individuals with mental problems. Some authors have argued that changes should be oriented toward integrated intra- and inter-institutional care, not only involving health-related institutions but also investing in the management of territory-based resources, resulting in the collective construction of health care ( 12 - 13 ) .

Another factor that limits the flow within the network was disclosed by the two employees who reported not knowing the other services in the network. Restricting user access to known services and focusing on the already identified health problems might narrow the scope of the assistance available to the users by hindering their access to territory-based intersectoral services. Making investments in constructing a model of assistance that focuses on the satisfaction of health needs requires more complex tools than the ones that merely aim to reduce the patients’ symptoms. These tools are supported by the knowledge supplied from several different areas when interdisciplinary and intersectoral practices are established to focus on the integrality of care and consider the singular characteristics of each individual patient and his or her social reintegration ( 14 ) .

Connections to make non-institutionalized care effective

According to the interviewees, some intersectoral interactions should be enhanced to bring the THS residents closer to society (e.g., re-plant the community orchard that was tended by the THS residents and the local population).

The interviewed workers believe that it is extremely important for the THS residents to go out into the service area and interact with the local population, walk on the streets, visit the parks, and thus fulfill the prescriptions of psychiatric reform for the social reintegration of individuals with mental problems. THS seems to challenge its residents and caretakers to deconstruct the traditional and prevalent living, caring, and clinical models by taking into consideration the full scope of possibilities that the encounter between mental illness and the urban space might exhibit.

Assisting individuals with mental problems outside mental health care services might represent a significant step forward in the conceptual shift on mental illness, whereby it is no longer reduced to a mental disease requiring specialized medical treatment but is understood as suffering-existence ( 15 ) , which might be addressed by an interdisciplinary staff in any type of space, including community-based spaces.

Network responsibility for users

Alegrete’s network seems to assume the responsibility for the demand for services because it adopted a formal policy not to transfer patients to other counties for hospitalization. The network’s structure allows the users to be treated within the municipal borders. Psychiatric reform facilitates access to decentralized services increasingly closer to the community to prevent the de-territorialization of individuals with mental health problems ( 16 ) .

The issues related to the availability of hospital beds were thoroughly discussed as an issue of negotiation. Most workers believe that more beds should be made available at the municipal hospital because in their view, the demand for mental health care exhibited a remarkable increase in recent years, and thus, the extra beds available at the emergency department do not suffice. Part of the increase is explained by the number of patients referred from neighboring counties that lack a mental health care network capable of meeting the needs of their local population. These patients place a strain on the bed availability and other health care services in Alegrete.

Changes in mental health care policy demand a minimal network of services capable of mobilizing the capacity needed to effectively implement the transformation. Nevertheless, it is believed that c ontextual diversities do not allow for that process to unfold in a linear and homogeneous manner, but its implementation is conditioned by political, economic, and cultural factors, among others ( 17 ) .

One of the interviewed workers made interesting remarks about the psychosocial assistance provided in the county. According to the worker, the proposal to close the mental hospitals and give the individuals with mental problems the opportunity to live in towns cannot be restricted to the establishment of non-hospital-based services but also must include different spaces that allow a reconceptualization of the relationship between mental illness and society.

In this regard, the actors involved in territorial-based alternative psychosocial assistance services must bear in mind that the changes arising from the novel paradigm in mental health care might not be understood as mere changes in the assistance devices but as a thorough transformation of the relationships between people and institutions as well as the approaches to the theory and practice of mental health care ( 18 ) . The relationship between society at large and individuals with mental problems, who have been marginalized in spite of their inherent nature as social beings, might represent the greatest and most complex transformation in the psychosocial approach. As the abovementioned interviewee stated ill people will never lack . However, the way they are observed might indeed change.

Network flow inhibitors

According to the interviewees, the number of employees correlates directly with the quality of care provided to the home residents. Currently, the THS staff includes seven employees to assist twelve regular residents and seven residents with special and more intensive needs.

According to the Health Ministry ( 5 ) , professional assistance must focus on establishing THS as dwelling places and inserting their residents into existing social networks. This goal explains the interviewees’ concern with the quality of assistance they provide.

Some strategies were developed by the employees to compensate for the staff shortage. For instance, they agreed to work every day of the week, including weekends and holidays, so that THS residents would not be left unassisted during the staff shortage. This decision indicates that the staff members are flexible, able to adjust, and able to organize themselves to meet the service demands efficiently. According to some authors, these traits reveal innovation in the management processes at various levels of the organization and in the management of human resources ( 19 ) .

Despite the commitment to the service exhibited by the interviewed staff, some issues represent significant obstacles to the quality of the assistance provided. One obstacle is associated with the hiring practices, which are based on exams that are not specific to mental health. Thus, employees are hired who have no commitment to psychiatric reform.

With regard to that issue, one interviewee suggested new approaches to hiring that explore the employees’ commitment to the users and high-quality assistance. A clear job description, as well as a clear understanding of the boundaries between the dwelling and service sides of THS, is extremely important to avoid reproducing institution-based practices and to exclude them within the space. In addition, the interviewed workers observed that once the employees are hired and included in the municipal health care network, they are not given any training. This hiring practice does not contribute to the development of new models of care. Training is closely related to improvements in the quality of health care. Training also promotes medium- and long-term changes and provides an avenue to inform, organize, and prepare professionals for higher-quality health interventions and to update staff members about the actual needs of the service ( 20 ) .

Therefore, training might represent an important means for filling services with skilled workers who are properly prepared to understand the suffering-existence ( 15 ) of others and who are able to understand the needs of individuals experiencing an important stage in the reconstruction of connections lost after many years of social exclusion.

In addition, the interviews revealed the lack of workers trained for therapeutic accompaniment (TA). According to the interviewed workers, although TA is needed in Alegrete’s THS, these professionals are not hired because there are no candidates with the required professional profile.

TA plays an important role in the reorientation of mental health care services because it uses public and urban spaces as action sites. Thus, it goes far beyond the narrow limits of health care institutions. By providing wall-free assistance , TA favors the inclusion of users’ in the everyday world and invests in strategies for social bonding ( 21 ) .

The relationships between the residents and the workers within the home/service space

According to the interviewees, THS poses a challenge for them because it demands breaking with the notion of the service as a therapeutic space. THS is far more than a mere treatment facility; it must be viewed as the residents’ true dwelling place. The relationships between the workers and the residents are intense and develop according to the pace of everyday life: there are times to draw back and times to move forward. A substantial amount of flexibility is needed to create new spaces for a therapeutic, non-institution-based model of care.

This novel space (home) is much more than a simple dwelling place for the residents because it represents freedom and care, a place where one can start over and gain his/her life back. THS favors the reconstruction of the social and affective links of those whose lives were confined to the world of institutions ( 22 ) . THS provides a model for deconstructing the stigma associated with mental illness because it assumes that mad people can live in cities as regular citizens and aims to replace mental hospitals with the freedom to walk in the street.

CONCLUSION

Evaluation-focused studies, especially in the field of mental health care, seem to make a significant contribution to developing novel models of care based on the paradigm of psychosocial assistance. Evaluation, however, might not be merely meant to simplify processes and to indicate what is right and what is wrong; it also serves as a useful tool for identifying opportunities for change.

Assessing the composition of innovative networks allowed us to understand the relevance of a structure of services organized to facilitate interaction between the network nodes. Communication between the various nodes, with their particular social, cultural, physical, and functional characteristics, might produce the arrangements and rearrangements needed to meet the social and health care needs of the users.

The network at Alegrete, by escaping the fixed network structure and establishing spaces that favor flow between the various individuals (i.e., workers, managers, and users), shows that it is possible to turn the work process into an object of permanent reflection and transformation, thus promoting freedom and health.

Based on the perspectives of the workers in a service that is considered a strategic part of the network in Alegrete (i.e., THS), it was possible to identify the agreements, obstacles, and relationships between the residents and the workers at the service/home space to determine the premises of rehabilitation. Rehabilitation depends on reclaiming spaces, stimulating the skills required to establish agreements, and resuming social and affective relationships. In summary, rehabilitation requires the continuation of an individual’s life outside the institutional walls and the recovery of his or her own place to live, work, experience material and spiritual exchanges, and build a life.

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*Extracted from the study “Redes que reabilitam – Avaliando experiências inovadoras de composição de Redes em Atenção Psicossocial”, Federal University of Pelotas, 2008.

(a)Identified in the quantitative stage as exhibiting the greatest potential for innovation. The innovative characteristics were assessed by comparing the adequation of the psychosocial assistance networks to the criteria established by the Health Ministry.

Received: February 22, 2012; Accepted: December 09, 2012

Correspondence addressed to : Milena Hohmann Antonacci. Rua Gomes Carneiro, n. 1 – Campus Porto/UFPel. CEP 96010-610 – Pelotas, RS, Brazil

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