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Revista Brasileira de Educação Médica

Print version ISSN 0100-5502On-line version ISSN 1981-5271

Rev. bras. educ. med. vol.41 no.2 Rio de Janeiro Apr./June 2017

https://doi.org/10.1590/1981-52712015v41n2rb20160072 

ARTIGO ORIGINAL

Ethical Conflicts Experienced by Medical Students

Conflitos Éticos Vivenciados por Estudantes de Medicina

Márcia Mendes MenezesI 

Luciana Colares Maia

Caroline Urias RochaI 

Cristina Andrade SampaioI 

Simone de Melo CostaI 

IUniversidade Estadual de Montes Claros, Montes Claros, MG, Brasil.


ABSTRACT

The current study aimed to identify and analyze the prevalence of ethical conflicts experienced by medical students. This study is a cross-sectional and analytical research that was conducted in a public school in the state of Minas Gerais, Brazil. The instrument used for the data collection was a self-administered questionnaire. The data collected were presented in absolute and percentage values. For the analytical statistical treatment of the data, the level of significance was considered p <0.05. The outcome variables were: Experiences of ethical conflicts in interpersonal relations within the medical course and Ethical conduct in health care. The identification of the prevalence of ethical conflicts in the undergraduate program adopted the perspective of different interpersonal relations (academic-teaching, academic-academic, academic-employee, academic-patient, teacher-teacher, teacher-patient, teacher-employee and employee-patient). (Importance of identifying themselves to the health services user and requesting consent to perform the physical examination, assistance without the supervision of the teacher, issuance of health documents without the signature of the professional responsible and use of social networks to share data Of patient). It was verified the association of the outcome variables with sex, year of graduation and course evaluation. A total of 281 undergraduate students enrolled in all undergraduate courses in Medicine of both sexes, with a predominance of female (52.7%). The students reported having experienced conflicting situations in interpersonal relations with teachers (59.6%), provided assistance without proper supervision of a teacher (62.6%), reported having issued health documents without the accompaniment of teachers (18, 5%). The highest frequency was observed among those enrolled in the most advanced years of the undergraduate program (p <0.05). The use of social networks for the purpose of sharing patient data (25.1%) was prevalent in the most advanced years of medical graduation and among those who evaluated the course as regular (p <0.05). It is concluded that undergraduate medical students experienced ethical conflicts during their medical training, with a prevalence of conflicts in the advanced years of the course. From this perspective, it is necessary to provide a space for discussion and collective reflection on the ethical problems experienced by students, during their graduation in Medicine, in order to build a professional ethical practice.

Key words: Medical Ethics; Bioethics; Medical Education; Medical Students

RESUMO

O atual estudo teve como objetivo identificar e analisar a prevalência de conflitos éticos vivenciados por estudantes de Medicina. Este estudo trata-se de pesquisa com delineamento transversal e analítico e que foi conduzida em uma escola pública do estado de Minas Gerais, Brasil. O instrumento utilizado para a coleta de dados foi um questionário autoaplicado. Os dados coletados foram apresentados em valores absolutos e percentuais. Para o tratamento estatístico analítico dos dados considerou-se o nível de significância p<0,05. As variáveis desfecho foram: Vivência de conflitos éticos em relações interpessoais no âmbito do curso médico e Condutas éticas na assistência em saúde. A identificação da prevalência dos conflitos éticos na graduação adotou a perspectiva das diferentes relações interpessoais (acadêmico-docente, acadêmico-acadêmico, acadêmico-funcionário, acadêmico-paciente, docente-docente, docente-paciente, docente-funcionário e funcionário-paciente) e condutas na assistência médica (importância de identificar-se ao usuário dos serviços de saúde e dele solicitar consentimento para realizar o exame físico, assistência sem supervisão do docente, emissão de documentos de saúde sem assinatura do profissional responsável e uso de redes sociais para compartilhar dados de paciente). Foi verificada associação das variáveis desfecho com sexo, ano da graduação e avaliação do curso. Participaram da pesquisa 281 acadêmicos matriculados em todos os anos da graduação em Medicina, de ambos os sexos, sendo predominante o sexo feminino (52,7%). Os estudantes relataram ter vivenciado situações conflituosas nas relações interpessoais com os professores (59,6%), prestaram assistência sem a devida supervisão de um professor (62,6%), afirmaram ter emitido documentos de saúde sem o acompanhamento de professores (18,5%), sendo a maior frequência observada entre aqueles matriculados nos anos mais avançados da graduação (p<0,05). O uso das redes sociais com a finalidade de compartilhar os dados de pacientes (25,1%) foi prevalente nos anos mais avançados da graduação em medicina e entre os que avaliaram o curso como regular (p<0,05). Conclui-se que os estudantes de graduação em Medicina vivenciaram conflitos éticos durante a sua formação médica, com prevalência de vivência dos conflitos nos anos mais avançados do referido curso. Nessa perspectiva, faz-se necessário propiciar um espaço de discussão e de reflexão coletiva acerca dos problemas éticos vivenciados pelos estudantes, ao longo da graduação em Medicina, a fim de se construir um agir profissional eticamente correto.

Palavras-Chave: Ética Médica; Bioética; Educação Médica; Estudantes de Medicina

INTRODUCTION

The Federal Medicine Council, by the Medical Ethics Code, in the chapter that deals with the Fundamental Rights, establishes that it is up to the professional to ensure and work for the excellent ethical performance of medicine, for the prestige and the good concept of the profession. Such aspect suggests the need to value the content of ethics in the graduation1.

With the technological development in health, the medicines discovery and the use of modern apparatus, other values have emerged in the field of interpersonal relations, scientific knowledge have surfaced and new conflicts have become questionable2. The ethical training of future medical professionals is one of the responsibilities of the graduation, which should enable students to develop their capacity to deal with problems in the field of morals, inherent to the professional practice3.

One of the international normative instruments, the Declaration on Bioethics and Human Rights, adopted by the United Nations Educational, Scientific and Cultural Organization (Unesco), proclaimed ethical principles raised by medicine, to guide States in the construction of laws and policies. And it highlighted education, training and information on bioethics as a means of ensuring a better understanding of the ethical implications coming from the advances in science and technology, particularly among young people. States should promote education and bioethical training, at all levels, and encourage the information and dissemination of knowledge related to bioethics4.

The Declaration is in conformity with the “Education Report, a treasure to be discovered”, prepared by the International Commission on Education for the 21st century for Unesco. The Report is based on four pillars of knowledge: learning to know, learning to do, learning to live together and learning to be. The Commission has considered learning to be the essential path that integrates the other pillars of knowledge. Educational policies serve as a permanent process for enriching knowledge of the know-how, but they should serve, primarily, as a privileged way for the construction of the individual person and the relations between individuals and groups5.

In the pillar of knowledge learning to be, education should contribute to the development of sensitivity and personal responsibility. Every human being should be prepared to elaborate autonomous and critical thoughts and formulate their own value judgments, to decide how to act in the different circumstances of life. In education, one’s should provide the intellectual strengths and references for young people to understand the world and to behave in it as responsible and fair actors. The school should revalue the oral culture and the knowledge derived from personal experiences and not privilege the access to knowledge to the detriment of other forms of learning, since education must be conceived as a whole5.

The National Curricular Guidelines of the graduation course in Medicine, in Brazil, highlighted the need for the ethical and humanistic training of the graduates in Medicine, who should be able to act with social responsibility and commitment to defend citizenship, human dignity and the integral health of the human being6. Little is known about the ethical conflicts experienced in the medical course by undergraduates. In this sense, the objective of this study was to identify and analyze the prevalence of ethical conflicts experienced by Medicine students.

MATERIAL AND METHOD

This is a quantitative, cross-sectional and analytical census study, whose population analyzed was composed of students enrolled in an undergraduate course of Medicine, in the State of Minas Gerais. From a potential of 338 students, 57 did not return the data collection instrument, which was a semi-structured and self-applied questionnaire, prepared by the authors themselves based on the bibliographical research about the topic: ethics in medical education. The questionnaire was composed of questions about the student’s profile (period of enrollment, gender and age), perceptions of the subject regarding the course (course evaluation) and ethics in medical education (ethics teaching, Medical and Medicine’s Student Ethical Code and ethical conflicts experienced in the graduation).

The identification of the prevalence of ethical conflicts in the undergraduate program adopted the perspective of different interpersonal relations (academic-teacher, academic-academic, academic-employee, academic-patient, teacher-teacher, teacher-patient, teacher-employee and employee-patient) and conduct in medical care (the importance of identifying themselves to the health services user and requesting consent to perform the physical examination, assistance without the supervision of the teacher, issuance of health documents without the signature of the professional responsible and use of social networks to share data of patient).

The application of the questionnaire was carried out after the academic activities, such as tutorials and lectures, after the evaluation of reliability by the test-retest conducted with the participation of 12 students, two of them of each year of the course, with the same proportion for women and men in the interval between the test and the retest. The concordance of the categorical variables was estimated by the Kappa statistic, from substantial (0,60 to 0,80) to almost perfect (0,80 to 1,00)7, demonstrating the improbable difficulty of the academics to interpret the questions of the collection instrument of data.

The statistical treatment of the data was conducted in the IBM-SPSS 22.0 Program, with descriptive analysis in percentage values and bivariate analysis by the Pearson chi-square test or its alternative Fisher to associate the ethical conflicts in the graduation with the variables gender, year of graduation and medical course evaluation. The level of significance was set at p<0,05.

The results of the research were discussed based on the bibliographical research about the theme, focusing on the reflexive approach about the ethical conflicts experienced in the graduation in the Medical course by the students.

The study was conducted according to the Resolution 466/12 of the National Health Council of the Ministry of Health8. The project was approved by the Research Ethics Committee involving human beings, under Opinion nº 845.561/2014. Each participant received and signed an Informed Consent Form, guaranteeing to students the anonymity and confidentiality of the information provided, used exclusively for scientific purposes.

RESULTS

The study had the participation of 281 students, representing 83,1% of the students enrolled in all the years of medical graduation, most of them referring to undergraduate students in the first three years of the course (55,9%) and people of the female gender (52,7%). The non-participation rate in this study was 16,9% of the students, with similar proportions between the genders.

The course was rated as very good for 30,8% and good for 54,5%. Regarding the teaching of ethical content in medical education, it was considered very good for 13,9% and good for 40,2%. The knowledge of most of the content of the Medical Ethics Code of the Federal Medical Council (CFM) was highlighted for 46,7% of the respondents. The elaboration of the specific Student Code of Ethics for the institution of its graduation was considered important by most the students, 82,2% (Table 1).

TABLE 1 Profile of the student of Medicine and considerations about graduation and medical ethics 

Variables n %
Gender
Female 148 52,7
Male 133 47,3
Year of enrollment in the graduation
1 to 3 157 55,9
4 to 6 124 44,1
Total 281 100,0
Course evaluation*
Very good 86 30,8
Good 152 54,5
Regular 41 14,7
Bad 0 0,0
Very bad 0 0,0
Evaluation of ethics teaching in the graduation
Very good 39 13,9
Good 113 40,2
Regular 99 35,2
Bad 23 8,2
Very bad 7 2,5
Total 281 100,0
Do you know the contents of the Medical Ethical Code?*
Completely 18 6,6
Large part 128 46,7
More or less 97 35,4
Little 27 9,9
Very little or nothing 4 1,5
Total 274 100,0
Do you consider it important to elaborate a Medical Student Ethical Code?*
Yes 226 82,2
No 49 17,8
Total 275 100,0

* Losses of respondents to questions, adjusted percentage values

Ethical conflicts in interpersonal relationships were identified, with the highest prevalence in the relation between academic and teacher (59,6%) followed by the relation between teacher and patient (46,5%) and between academic and academic (39,3%) (Table 2).

TABLE 2 Ethical conflicts mentioned in different interpersonal relationships in the graduation in Medicine (n = 275) 

Ethical conflicts Yes No
Interpersonal relationship * n % n %
Academic-teacher 164 59,6 111 40,4
Academic-academic 108 39,3 167 60,7
Academic-patient 51 18,5 224 81,5
Academic-employee 36 13,1 239 86,9
Teacher-patient 128 46,5 147 53,5
Teacher-employee 11 4,0 264 96,0
Teacher-teacher 4 1,5 271 98,5
Patient-employee 11 4,0 264 96,0

*Sum of percentage values above 100,0% by identifying ethical conflicts in more than one interpersonal relationship.

The prevalence of ethical conflict in the academic and teaching interpersonal relationship was higher among students of the advanced years of the medical course (71,9%) in comparison with those who attend the first years of the graduation (p<0,001). The students that evaluated the course as regular presented a higher prevalence of ethical conflicts in the academic and patient relationship (41,5%) than those with evaluation very good/good (14,2%), with statistical significance. In the conflicting relationship between the academic and the teacher, women and students in the most advanced years were those with the highest prevalence of conflicts experienced in this interpersonal relationship (p<0,05) (Table 3).

TABLE 3 Experience of ethical conflicts in interpersonal relationships within the medical course according to gender, year of graduation and course evaluation 

Variables Academic-teacher p
Yes No
n % n %
Gender 0,601
Female 88 61,1 56 38,9 <0,001
Male 76 58,0 55 42,0 0,206
Graduation year
1 to 3 77 50,0 77 50,0
4 to 6 87 71,9 34 28,1
Course evaluation*
Very good/good 134 57,8 98 42,2
Regular 28 68,3 13 31,7
Variables Academic-academic p
Yes No
n % n %
Gender
Female 52 36,1 92 63,9
Male 56 42,7 75 57,3
Graduation year 0,260
1 to 3 60 39,0 94 61,0 0,905
4 to 6 48 39,7 73 60,3 0,173
Course evaluation*
Very good/good 87 37,5 145 62,5
Regular 20 48,8 21 51,2
Variables Academic-patient p
Yes No
n % n %
Gender
Female 29 20,1 115 79,5
Male 22 16,8 109 83,2
Graduation year 0,476
1 to 3 24 15,6 130 84,4 0,154
4 to 6 27 22,3 94 77,7 <0,001
Course evaluation*
Very good/good 33 14,2 199 85,8
Regular 17 41,5 24 58,5
Variables Teacher-patient p
Yes No
n % n %
Gender
Female 76 52,8 68 47,2
Male 52 39,7 79 60,3
Graduation year 0,030
1 to 3 50 32,5 104 67,5 <0,001
4 to 6 78 64,5 43 35,5 0,513
Course evaluation*
Very good/good 109 47,0 123 53,0
Regular 17 41,5 24 58,5

*Losses of respondents to the questions, adjusted percentage values.

The need to identify themselves to the users of health services during clinical care was considered very important to 88,7% of the students, and 74,6% always request consent for the physical examination to the patient or caretaker. The provision of assistance to a user without the supervision of the professional responsible was highlighted by 62,6% of the students, and the issuance of some health document, such as prescriptions, requirements and/or certificates, at the time of the assistance, without the accompaniment and the signature of the teacher was reported by 18,5% of the undergraduates. The use of social networks to send photos of clinical situations or to discuss information of patients with colleagues, teachers or friends was confirmed by 25,1% of university students (Table 4).

TABLE 4 Distribution of medical students according to ethical conduct in health care 

Variables* n %
Degree of importance of being identified to the user in the clinical consultation/examination
Very important 244 88,7
Important 25 9,1
More or less 3 1,1
Little importance 3 1,1
No importance 0 0,0
Total 275 100,0
Do you always request the consent of the user/responsible for the physical examination?
Yes 203 74,6
No 69 25,4
Total 272 100,0
Have you ever assisted a user without the supervision of the teacher?
Yes 169 62,6
No 101 37,4
Total 270 100,0
Have you issued health documents without accompaniment or signature of the responsible professional?
Yes 51 18,5
No 224 81,5
Total 275 100,0
Use of the social networks to share patient data
Yes 69 25,1
No 206 74,9
Total 275 100,0

* Losses of respondents to the questions, adjusted percentage values.

Identifying themselves to the health services user was considered very important/important in a higher percentage (98,7%) among the students who better classified the medical course (p<0,05). The patient’s consent to the physical examination was more prevalent among the academics of the first year of graduation (85,4%), with a significant difference. Differently from the previous result, the assistance and the issuance of health documents without professional supervision were higher among those who were in the advanced years of the graduation (p<0,05). Sharing information about patients in social networks was not associated with gender, although men used this technology more (27,7%) than women (22,8%), p=0,346. Being enrolled in the last three years of graduation and classifying the medical course as regular have remained associated with the use of social networks in health care (Table 5).

TABLE 5 Conduct in health care according to gender, year of graduation and evaluation of the medical course by the students of Medicine 

Variables Identify yourself to the health user p
Very important/important More or less/little important
n % n %
Gender
Female 143 98,6 2 1,4
Male 126 96,9 4 3,1
Graduation year 0,426
1 to 3 151 98,7 2 1,3 0,411
4 to 6 118 96,7 4 3,3 0,046
Course evaluation
Very good/good 229 98,7 3 1,3
Regular 38 92,7 3 7,3
Variables Consent of the user to the physical examination p
Yes No
n % n %
Gender
Female 102 71,3 41 28,7
Male 101 78,3 28 21,7
Graduation year 0,187
1 to 3 129 85,4 22 14,6 <0,001
4 to 6 74 61,2 47 38,8 0,473
Course evaluation
Very good/good 174 76,0 55 24,0
Regular 29 70,7 12 29,3
Variables Unsupervised assistance p
Yes No
n % n %
Gender
Female 88 60,7 57 39,3
Male 81 64,8 44 35,2
Graduation year 0,486
1 to 3 82 55,0 67 45,0 0,004
4 to 6 87 71,9 34 28,1 0,118
Course evaluation
Very good/good 139 60,4 91 39,6
Regular 28 73,7 10 26,3
Variables Documents issuing without supervision p
Yes No
n % n %
Gender
Female 24 16,6 121 83,4
Male 27 20,8 103 79,2
Graduation year 0,369
1 to 3 10 6,5 143 93,5 <0,001
4 to 6 41 33,6 81 66,4 0,777
Course evaluation
Very good/good 41 17,7 191 82,3
Regular 8 19,5 33 80,5
Variables Did you share patient data on social networks/internet? p
Yes
n % n %
Gender
Female 33 22,8 112 77,2
Male 36 27,7 94 72,3
Graduation year 0,346
1 to 3 24 15,7 129 84,3 <0,001
4 to 6 45 36,9 77 63,1 0,023
Course evaluation
Very good/good 52 22,4 180 77,6
Regular 16 39,0 25 61,0

DISCUSSION

In this study was observed the predominance of the female gender among medical students, a fact coherent with a study that presented the phenomenon of feminization of health, even in the medical course9.

Although the content of ethics is mainly worked on in two modules, in the first and fourth year, the evaluation of the ethics content teaching approach was very good and good, in the eyes of most of the students. The study of the professional ethics and bioethics should constitute one of the priorities in medical education, combined with technical knowledge, since the future professional will take care of the health of people10,11.

As for the knowledge of the content of the Medical Ethics Code of the Federal Medicine Council (CFM), the majority knows it well/completely. An important result, since this document governs the conduct of the medical professionals, and academics need this knowledge, because in the future they will be subject to the supervision of the class Council12.

The students considered important the elaboration of the Ethics Code of the Medical Student (Ceem), specific for the institution of its graduation. The importance of such a Code goes beyond the incentive to prevent the illegal exercise of the profession. It affects, also, the humanization of the future doctor, who by means of this instrument will absorb the principles and guidelines directed to the exercise of the citizen of medicine13.

The existence of ethical conflicts in the interpersonal relations was highlighted by the undergraduates, with a higher prevalence in the teaching-academic relationship among those enrolled in the last years of the course. In the teacher and patient relationship, ethical conflicts were more experienced by women and among those in the more advanced stage of graduation. This result can be explained, in part, by the greater sensitivity of women in the perception of ethically conflictive situations and by the longer time lived in graduation.

Conflicts in the academic and patient relationship were more prevalent among those who evaluated the course as regular. In the student and student relationship, the conflicts experienced by more than a third of the students were not associated with gender, year of graduation and evaluation of the medical course.

Human dignity, human rights and fundamental freedoms must be respected4. The pillars of the knowledge learning to live together and learning to live with others represent one of the greatest challenges of education. Teaching non-violence in educational institutions is an idea of fighting against prejudices that generate conflicts. People tend to overvalue their qualities and those of their group and feed prejudices towards others, exacerbating historical rivalries. To minimize violence, education should use complementary pathways, the progressive discovery of the other, which would be the first level, and, throughout the life, at the second level, stimulate participation in common projects among different subjects to prevent or solve latent conflicts5. It is a matter for the medical school provide for the students the development of the ability to deal with problems in the field of morality, with which they will face during professional practice3.

Academics considered it important to identify the users of the health services during clinical assistance and to obtain consent to perform the physical examination in health care. Attitudes that are ethically correct and that should be stimulated by the teachers during the graduation in Medicine, because in this study it was observed a higher frequency of this attitude in the students of the initial periods.

The student must learn that the human being deserves and needs to be respected and not only considered as a mere object of study. Unfortunately, there is a certain banalization of the disrespect for the individual in many professional practice environments, because of the “objectification” of the human being3. Consent is an ethical principle that must be respected, and any intervention in the medical field, whether of a preventive, diagnostic or therapeutic nature, can only be performed with the prior free and informed consent of the subject4.

The provision of assistance without the supervision of the teacher was highlighted by much of the students, with a higher prevalence for those enrolled in the final periods of the course. It should be considered that, with the aid of teacher supervision, students acquire greater self-confidence and become more empowered to establish authentic relationships with patients and assume greater responsibility for their care14.

The issuance of health documents, such as prescriptions, requirements and/or certificates without the accompaniment and signature of the responsible teacher/professional is something that occurs within the scope of the medical education, with a higher prevalence for those enrolled in the final years of the course.

It is necessary to question this training role in which the supervisor should guide the student in both technical and ethical aspects15 and be committed to follow and supervise the attitudes of the students. Among the characteristics of a good teacher is the respect for ethical principles within the medical profession.

In this perspective, studies have highlighted important characteristics to positively classify the teacher. Among them, ethics was signaled along with other technical, didactic and scientific characteristics16-19.

In the current study, the use of social networks to share photos of clinical situations or to discuss patient information was confirmed, being the highest prevalence among students of the last graduation years and among those who considered the course as regular. It is an ethically conflictual situation experienced by the students, since it is considered right of the patient to have their privacy preserved, and duty of the doctor to guide his or her assistants and students to ensure that professional confidentiality is maintained1. The private life of the individuals and the confidentiality of their information must be respected. Information for purposes other than those for which they were collected or consented should not be used or disseminated, and, even so, should be in accordance with international law relative to human rights4.

Also in the Medical Ethics Code, in the chapter IX and article 75, the physician is prohibited from referring to identifiable clinical cases, displaying patients or their portraits in professional advertisements or disseminating medical matters in general media, even with authorization of the patient1. In this perspective, it is necessary for teachers to be attentive to these attitudes of the students, future medical professionals, and to orient them regarding the use of social networks in an adequate way in the practice of medicine. The breach of professional secrecy is considered an ethical infraction, with penalties foreseen by the Federal Council of Medicine. Exposing facts and images of patients in social networks may involve impairments to the professional career and constraints or losses to the patient.

As limitations, this study has a cross-sectional delineation and therefore the associations between the variables cannot be interpreted as a cause-effect relationship. Possible information and memory biases should be considered, since data were collected through a self-applied questionnaire, and students may not have registered all the ethical conflicts experienced in graduation.

The current study allowed us to reflect on the ethical conflicts experienced by the students in the scope of the graduation. Among them, it is highlighted the sharing of patient data in social networks, which characterizes the privacy and anonymity disclosure inherent in the medical act. Most of the conflicts related to health care were associated with the later years of graduation. Thus, strategies should be adopted in the institution to provide a space for discussion and collective reflection about problems throughout the undergraduate course, in search of resolution or, at least, minimization of the conflictual situations experienced by the medical students and better construction of professional action ethically correct. Daily dialogue should be part of building ethical human beings and graduating citizens.

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Support

Research Support Foundation of the State of Minas Gerais (Fapemig). Process nº CHE-APQ. 00707-15 and research grant Process CHE- BIP 00058-16.

Received: October 03, 2016; Accepted: October 21, 2016

MAILING ADDRESS Simone de Melo Costa. Universidade Estadual de Montes Claros. Avenida Dr. Rui Braga, s/no–prédio 6 – sala 109 Campus Universitário Prof. Darcy Ribeiro–Montes Claros. CEP 39401-089 – MG. E-mail: marciam.menezes@yahoo.com.br; luciana_colares@yahoo.com.br; carolurocha@hotmail.com; cristina.sampaio@unimontes.br; smelocosta@gmail.com

CONTRIBUTION OF AUTHORS

Márcia Mendes Menezes and Simone de Melo Costa participated in all stages of the study: planning, execution, writing and final revision of the manuscript. Caroline Urias Rocha participated in the execution. Cristina Andrade Sampaio and Luciana Colares Maia contributed in the execution and final revision of the manuscript.

CONFLICT OF INTERESTS

There is no conflict of interests.

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