Access to health care levels and quality of life for women with fibromyalgia during the COVID-19 pandemic: cross-sectional study

ABSTRACT

BACKGROUND AND OBJECTIVES:

Fibromyalgia is a clinical condition that presents generalized and chronic musculoskeletal pain. With the COVID-19 pandemic, factors such as social distancing and a reduction in the search for and supply of care for chronic diseases may have contributed to worsening the quality of life (QoL) of people with fibromyalgia. The aim of this study was to investigate the relationship between access to health care and the QoL of women with fibromyalgia during the COVID-19 pandemic.

METHODS:

This was a descriptive cross-sectional observational study of 30 women diagnosed with fibromyalgia, with a mean age of 56.3±10.4 years, who took part in group therapy promoted by the Fibro Dance (Dança Fibro) extension project at the Trairi Health Science Faculty of the Federal University of Rio Grande do Norte (Faculdade de Ciência da Saúde do Trairi da Universidade Federal do Rio Grande do Norte - FACISA/ UFRN). QoL was evaluated using the Short Form 36 Health Survey (SF-36) and access to health care was investigated using a questionnaire developed by the researchers, which also included sociodemographic questions and questions about health conditions. Descriptive and inferential statistics were used to analyze the data. The Shapiro-Wilk normality test was used to check the distribution of the data, and the t-test was used to compare the means of the variables with normally distributed data, while the Mann-Whitney non-parametric test was used for the variables without normal distribution. A 5% significance level was adopted for the inferential analysis.

RESULTS:

66.7% of the participants received care in primary care, while 36.7% and 26.7% received care in specialized care and hospitals, respectively. As for QoL, the domains that showed the greatest impairment, with the lowest mean score, were limitation of physical aspects (9.2; 95%CI: 1.6; 16.7), limitation of emotional aspects (11.1; 95%CI: 0.6; 21.6), pain (29.9; 95%CI: 23.9;35.8), general state of health (35.8; 95%CI: 32.2; 39.4) and vitality (38.7; 95%CI: 31.9; 45.4). In the inferential analysis, there was no statistically significant difference in QoL between the group of women who received primary care or hospital care compared to the group who did not receive care at these levels (p > 0.05). On the other hand, there were statistically significant differences when the comparison was analyzed in specialized care. In the functional capacity domain (p = 0.005), the average score for the group that received specialized care was higher than the score for the group that did not, 38.2 and 24.2, respectively. For the social aspects domain (p = 0.045), the average score was 54.5 for those who received care and 37.5 for the group who did not receive care at the level of care in question.

CONCLUSION:

This study concluded that access to specialized care during the COVID-19 pandemic contributed to women with fibromyalgia showing better results in QoL domains such as functional capacity and social aspects.

Keywords:
Chronic disease; Health care; Lifestyle

RESUMO

JUSTIFICATIVA E OBJETIVOS:

A fibromialgia é uma condição clínica que apresenta dor musculoesquelética generalizada e crônica. Com a pandemia da COVID-19, fatores como distanciamento social e redução na busca e oferta por cuidados para as doenças crônicas podem ter contribuído para piorar a qualidade de vida (QV) das pessoas com fibromialgia. O objetivo deste estudo foi investigar a relação entre o acesso aos níveis de atenção à saúde e a QV de mulheres com fibromialgia durante a pandemia da COVID-19.

MÉTODOS:

Trata-se de um estudo observacional transversal descritivo com 30 mulheres diagnosticadas com fibromialgia, apresentando média de idade de 56,3±10,4 anos, que participaram da terapia em grupo promovida pelo projeto de extensão Dança Fibro, da Faculdade de Ciência da Saúde do Trairi da Universidade Federal do Rio Grande do Norte (FACISA/UFRN). A QV foi avaliada usando o Short Form 36 Health Survey (SF-36) e o acesso aos níveis de atenção à saúde foi investigado por meio de um questionário desenvolvido pelos pesquisadores, que também contemplou questões sociodemográficas e sobre condições de saúde. Para a análise de dados, foram usadas a estatística descritiva e a inferencial, sendo aplicado o teste de normalidade de Shapiro-Wilk para verificação da distribuição dos dados, e o teste t para comparar as médias das variáveis que apresentaram os dados normalmente distribuídos, enquanto que para as variáveis que não apresentaram distribuição normal, foi utilizado o teste não paramétrico de Mann-Whitney. Na análise inferencial, foi adotado um nível de significância de 5%.

RESULTADOS:

Foi observado que 66,7% das participantes receberam cuidados na atenção básica, enquanto que 36,7% e 26,7% foram assistidas na atenção especializada e hospitalar, respectivamente. No que diz respeito à QV, os domínios que apresentaram maior comprometimento, com menor escore médio, foram limitação dos aspectos físicos (9,2; IC95%: 1,6; 16,7), limitação dos aspectos emocionais (11,1; IC95%: 0,6; 21,6), dor (29,9; IC95%: 23,9;35,8), estado geral de saúde (35,8; IC95%: 32,2; 39,4) e vitalidade (38,7; IC95%: 31,9; 45,4). Na análise inferencial, não foi observada diferença estatisticamente significativa na QV entre o grupo de mulheres que foram assistidas na atenção básica ou na atenção hospitalar em comparação com o grupo que não recebeu assistência nestes níveis de atenção (p > 0,05). Em contrapartida, constatou-se diferenças estatisticamente significativas quando a comparação foi analisada no âmbito da atenção especializada. No domínio capacidade funcional (p = 0,005), o escore médio para o grupo que recebeu cuidados na atenção especializada foi superior ao escore do grupo que não recebeu, 38,2 e 24,2, respectivamente. Para o domínio aspectos sociais (p = 0,045), o escore médio foi de 54,5 para aquelas que foram assistidas e de 37,5 para o grupo que não recebeu assistência no nível de atenção em questão.

CONCLUSÃO:

Este estudo concluiu que o acesso à atenção especializada durante a pandemia da COVID-19 contribuiu para que as mulheres com fibromialgia apresentassem melhores resultados nos domínios da QV, tais como capacidade funcional e aspectos sociais.

Descritores:
Assistência à saúde; Doença crônica; Estilo de vida

HIGHLIGHTS

The women with fibromyalgia who were assessed in this study had functional limitations in performing activities of daily living, regular to poor sleep, moderate feelings of tiredness and high levels of stress.A difference in the quality of life domains related to functional capacity and social aspects was observed among the group of women with fibromyalgia who received specialized care, compared to the group who did not have access to this level of care, during the COVID-19 pandemic.

The results point to the importance of individuals with chronic pain being able to access all levels of health care in order to receive adequate assistance compatible with their needs, including guidance on self-management in health.

INTRODUCTION

Fibromyalgia is a clinical condition that presents generalized and chronic musculoskeletal pain, associated with symptoms such as fatigue, anxiety, depression and sleep disorders, as well as hyperalgesia and allodynia. Usually, this rheumatic disease causes significant psychosocial and economic changes, compromising the quality of life (QoL) and general state of health in these individuals¹.

Self-management in health has been considered a relevant factor for individuals with chronic pain, given that it is related to a multidimensional perspective. This gives rise to the importance of psychosocial and behavioral self-care, as well as pain management².

In this context, primary care services are a privileged level of care to develop actions that address health self-management, providing support in the prevention of health problems and motivation for the empowerment of their users in the management of fibromyalgia. Such actions can minimize the costs of specialized care and excessive use of drugs, making the system more efficient, while at the same time favoring the provision of comprehensive care compatible with the needs of people with fibromyalgia³. On the other hand, the responsibility for care and problem-solving inherent in primary care, with the necessary referrals to other health services, are important for welcoming individuals with chronic illnesses, promoting a more empathetic and effective approach⁴.

With the COVID-19 pandemic, factors such social distancing and a possible reduction in the search for and supply of care for people with chronic conditions may have contributed to worsening the QoL of individuals diagnosed with fibromyalgia. In addition, other negative effects have become more evident, especially changes in daily routine and a reduction in regular physical activity⁵. During the pandemic period, physical, psychological and/or social factors increased the severity of the symptoms already reported by individuals with fibromyalgia, having a negative impact on QoL⁶.

The QoL of people with fibromyalgia can be impacted by factors that modulate symptoms, such as changes in the level of physical activity and stress, which have been experienced during the pandemic period of the coronavirus disease, by the restriction of social contact and leisure activities, by financial and health concerns⁷. In this context, a study that assessed the effects of the COVID-19 pandemic on the physical and psychological well-being of people with fibromyalgia found adverse mental and physical outcomes, pointing out that factors related to the interruption of therapeutic approaches may have an important influence. The authors identified high levels of pain, anxiety, depression and sleep disturbances, which significantly influenced the quality of life of people with fibromyalgia⁸.

Considering that this scenario may have led to greater difficulties in accessing health services, the aim of this study was to investigate the relationship between access to health care and QoL of women with fibromyalgia during the COVID-19 pandemic.

METHODS

A cross-sectional descriptive and observational study was carried out with a sample of women with clinical diagnosis of fibromyalgia. Participants were recruited by convenience, through digital means of communication (via WhatsApp call, as well as by invitation with an illustrative image), from August to September 2022. Data collection took place remotely via video call. During this period, a total of 30 women were recruited and all met the criteria for participation in this study, which followed the recommendations of the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist.

The participants were informed verbally and in writing about the objectives and procedures of this research, after the researcher sent them a digital Free and Informed Consent Term (FICT), in which they could confirm or refuse to take part in the research, in accordance with Resolution 466/12 of the Brazilian National Health Council (Conselho Nacional de Saúde). The individuals who took part in this research accessed FICT through a Google Forms® form, presented on the first page, before having direct access to the questions in the research instrument. They agreed to take part in this research by filling in a field such as: “( ) I accept; ( ) I don’t accept”. This study was approved by the Institutional Research Ethics Committee of the Federal University of Rio Grande do Norte Trairi Health Science Faculty (Faculdade de Ciência da Saúde do Trairi da Universidade Federal do Rio Grande do Norte – FACISA/UFRN), under Opinion Number 5.383.410.

In addition to the clinical diagnosis of fibromyalgia, the inclusion criteria included: (a) chronic and persistent pain for more than three months; (b) and having undergone therapy at the FACISA/UFRN Fibro Dance (Dança Fibro) extension project for at least one month (eight sessions), as a way of adapting to the sessions. Exclusion criteria included (a) not having a mobile device or access to the internet, to enable contact at the time of data collection.

The extension project took place twice a week at the FACISA Physiotherapy School Clinic, lasting approximately one hour, and was led by volunteer and scholarship students who had dance skills. The project was considered an excellent aerobic, non-pharmacological and low-cost exercise. In this context, in addition to the group interaction, the dance therapy was designed according to the participants’ functional capacities and limitations, offering benefits such as pain reduction and improvement in the psychosocial factors that encompass fibromyalgia. However, the project was unable to return to its activities after the pandemic.

Data sources/measurement

Access to levels of health care was investigated using a questionnaire developed by the researchers specifically for this study, containing items on access to health care services, which asked whether or not the participants received health care during the pandemic and the level of health care at which the care was offered. This instrument also included sociodemographic questions to characterize the participants, such as age, participation in a stable union, schooling and occupation; as well as items on health conditions: presence of comorbidities, body mass index (BMI), lifestyle habits, aspects of well-being and functional limitations, such as in activities of daily living (ADLs), locomotion and/or work.

The Short Form 36 Health Survey (SF-36) was used to assess QoL. This is a 36-item instrument that assesses eight QoL domains. These domains are measured on a scale of 0-100, to be highlighted: functional capacity, limitations due to physical aspects, pain, general state of health, vitality, social aspects, emotional aspects, and mental health. A higher score represents better QoL.

Study size

The sample was defined by convenience and was non-probabilistic, totaling 30 women with fibromyalgia aged over 39. Before the Covid-19 pandemic, all the participants took part in group therapy promoted by the FACISA/UFRN Fibro Dance extension project, in the municipality of Santa Cruz, RN; this project had its activities interrupted after the start of the pandemic period.

Due to social restrictions and the reduction in the supply of some health services, not all of the participants in this study were able to receive all levels of care during the pandemic, not even primary care, whose policy is based on longitudinal care. Thus, the scores of the QoL domains were compared between two different groups: the group of participants who had access to health care and the group of those who did not. This comparison was made for each level of health care: basic, specialized and clinical.

It should be noted that the participants may have received more than one level of health care, but the comparison of QoL was made between the two groups, with and without care, separately for each level of care.

Statistical analysis

Data was first tabulated in an electronic spreadsheet and then transferred to the Statistical Package for the Social Sciences (SPSS)®, version 20.0. Descriptive statistics were used for data analysis, using absolute and relative frequencies for categorical variables, as well as measures of center and variation for continuous quantitative variables. An inferential analysis was carried out, using hypothesis tests to verify the normality of the data and compare QoL measures in relation to access to the different levels of healthcare. The Shapiro-Wilk normality test was used to check the data distribution and the t-test was used to compare the means of the variables with normally distributed data. The Mann-Whitney non-parametric test was used for variables that did not have a normal distribution. A 5% significance level was adopted for the inferential analysis.

RESULTS

The mean age of the participants was 56.3±10.4 years. Most of the participants were overweight, with an average BMI of 28.2±4.6. As for lifestyle habits and health conditions, 56.6% of the women reported eating well, while 46.7% said they slept regularly. As a result, 70% of the participants reported feeling tired to a moderate degree, and 46.7% reported high level of stress. Regarding functional limitations, the majority (63.3%) reported difficulty in performing ADL (Table 1).

Table 1
Sociodemographic characteristics and health conditions of the participants

	n	%
Age (56.3±10.4) (years)*
39 to 49	10	33.3
50 to 59	10	33.3
60 years or more	10	33.3
Stable union
Yes	20	66.7
No	10	33.3
Education
None	1	3.3
Primary	12	40.0
High School	10	33.3
College	7	23.3
Sleep
Poor	13	43.3
Regular	14	46.7
Good	3	10.0
Fatigue
Low	1	3.3
Regular	21	70.0
High	8	26.7
Comorbidities
Diabetes	25	83.3
Osteoporosis/osteopenia	21	70.0
Osteoarthritis	19	63.3
Systemic arterial hypertension	13	43.3
Herniated disc	7	23.3
Other	4	13.3
Currently practicing physical activity
Yes	15	50.0
No	15	50.0
Occupation/Daily activities
Manual labor	28	93.3
Non-manual work	2	6.7
BMI (28.2 ± 4.6)*
Overweight	13	43.3
Grade I obesity	8	26.7
Average	6	20.0
Grade II obesity	3	10.0
Food
Poor	3	10.0
Regular	10	33.3
Good	17	56.7
Stress
Low	4	13.3
Regular	12	40.0
High	14	46.7
Functional limitations
ADL	19	63.3
Labor	6	20.0
Locomotion	4	13.3
Other	1	3.3
Total	30	100

• ^*
  Mean ± standard deviation; BMI= body mass index; ADL = activities of daily living.

Regarding the QoL domains, some criteria had a lower average score and, consequently, greater impairment. These were: “limitation of physical aspects” (9.2; 95% CI: 1.6; 16.7) and “limitation of emotional aspects” (11.1; 95% CI: 0.6; 21.6), followed by “pain” (29.9; 95% CI: 23.9; 35.8), “general state of health” (35.8; 95% CI: 32.2; 39.4) and “vitality” (38.7; 95% CI: 31.9; 45.4). The probability corresponding to the Shapiro-Wilk normality test (p-value) was also presented, by which it was verified that only the data from the “limitation of physical aspects” and “limitation of emotional aspects” domains were not normally distributed (p < 0.05). Table 2 shows the means for each QoL domain, with the respective 95% confidence intervals.

Table 2
SF-36 domain scores

SF-36 domain	Mean	CI 95%	Shapiro-Wilk test
Functional capacity	29.3	24.2; 34.5	0.510
Limitation of physical aspects	9.2	1.6; 16.7	0.000*
Pain	29.9	23.9; 35.8	0.062
General state of health	35.8	32.2; 39.4	0.184
Vitality	38.7	31.9; 45.4	0.269
Social aspects	43.7	35.3; 52.2	0.199
Limitation of emotional aspects	11.1	0.6; 21.6	0.000*
Mental health	46.7	40.2; 53.1	0.070

• CI = Confdence interval; *Variable does not show normal distribution (p<0.05).

The results of the comparison of the means of each QoL domain between the participants who had or had not had access to the different levels of health care are shown in table 3. There was no statistically significant difference between the mean QoL domains scores between the participants who had access to primary care and those who did not (p > 0.05). At the same time, the same lack of difference was also observed when comparing the group of women who had access to hospital care and the group who did not (p > 0.05).

Table 3
Scores in SF-36 domains in relation to access to levels of health care

Scores	Primary care		p-value
	No n=10	Yes n=20
Functional capacity	29.5	29.2	0.964
Limitation of physical aspects	12.5	7.5	0.650
Pain	25.5	32.0	0.298
General state of health	36.3	35.6	0.855
Vitality	40.0	38.0	0.780
Social aspects	50.0	40.6	0.187
Limitation of emotional aspects	10.0	11.7	0.713
Mental health	46.8	46.6	0.977

Specialized care	No n=19	Yes n=11	p-value
Functional capacity	24.2	38.2	0.005*
Limitation of physical aspects	4.0	18.2	0.307
Pain	27.8	33.4	0.359
General state of health	33.3	40.3	0.052
Vitality	34.2	46.4	0.075
Social aspects	37.5	54.5	0.045*
Limitation of emotional aspects	5.3	21.2	0.185
Mental health	43.2	52.7	0.146

Hospital care	No n=22	Yes n=8	p-value
Functional capacity	28.6	31.2	0.655
Limitation of physical aspects	7.9	12.5	0.872
Pain	28.3	34.1	0.389
General state of health	36.1	34.5	0.655
Vitality	39.5	36.2	0.666
Social aspects	42.6	46.9	0.655
Limitation of emotional aspects	13.6	4.1	0.765
Mental health	46.2	48.0	0.803

• ^*
  p<0.05 (T-test for independent samples).

On the other hand, when comparing the mean scores for access to specialized care, a statistically significant difference was found in the “functional capacity” domain (p = 0.005), in which the mean score for the group that received specialized care was higher than the score for the group that did not, 38.2 and 24.2, respectively. Similarly, a statistically significant difference was also found in the “social aspects” domain (p=0.045), with a mean score of 54.5 for the women who had access to specialized care and 37.5 for those who did not. For the other QoL domains, there were no significant differences between the mean scores (p>0.05).

It’s worth noting that these women didn’t receive care either because it was difficult to access, since primary care provides longitudinal care, or because they didn’t need to use hospital services, for example.

DISCUSSION

This study aimed to evaluate the access to different levels of health care and the QoL of individuals with fibromyalgia during the COVID-19 pandemic. The results obtained in this study reinforced fibromyalgia as a clinical condition that encompasses multidimensional aspects and, for this reason, the search for effective, safe, and enjoyable care has become constant. Symptoms such as drowsiness, stress and limitations in daily activities contribute to a decline in functionality and a reduction in QoL⁹. In this context, the results found in this study indicate that the participants predominantly reported regular to poor sleep. It should be noted that sleep has developmental, neural plasticity, energy preservation, memory and learning functions, making the relationship between pain and sleep a frequent one¹⁰.

A significant number of women had high levels of stress. It is known that among the various events that aggravate the symptoms of fibromyalgia is daily stress, which can be associated with the occurrence of depressive symptoms¹¹. Another study found similar results, pointing out that individuals living with pain, fatigue and depressive symptoms are more sensitive to environmental barriers and that these physical and psychological problems lead to restrictions on participative activities and social relationships¹².

The results of this study show that almost all of the participants used drugs to manage their symptoms. Research has indicated that various neurotransmitter dysfunctions have been identified in individuals with fibromyalgia, linking the action of sensory inhibition pathways descending from brain to the spinal cord¹³. This justifies the use of drugs as a therapy in the treatment of fibromyalgia, and the association with non-pharmacological therapies is recommended¹⁴. From this perspective, the most widely explored treatment modalities include aerobic and resistance exercises, hydrotherapy and neuromodulation¹⁵.

With regard to the presence of comorbidities, most of the participants were diagnosed with osteoarthritis, in line with the prevalence in the general population, since osteoarthritis is the most common form of joint disease in the world¹⁶. The literature points to fibromyalgia as a condition that can have a major influence on increasing cardiovascular risk¹⁷. This understanding is in line with the data obtained in this study, which found that most of the participants were hypertensive. In addition, half of the participants were not doing any physical activity at the time of data collection, which may contribute to an unfavorable prognosis in terms of cardiovascular risk.

A study that aimed to measure the repercussions of social isolation on individuals with chronic pain during the COVID-19 pandemic found that self-care (e.g. meditation, exercise, yoga and tai chi) was not significantly impacted. This finding suggested that despite the turbulence experienced with the implication of COVID-19, the way of dealing with chronic pain may have been sustained or intensified¹⁹. From another perspective, it is important to consider that since the beginning of the pandemic some individuals have stopped practicing or reduced the practice of self-management of their health conditions, being more vulnerable to the development or worsening of pain¹⁹.

The panorama of health conditions for women with fibromyalgia in the period after the social isolation measures is possibly concatenated with the findings regarding the decline in the domains of QoL. When the average SF-36 scores were analyzed, the greatest impairment in the “limitation of physical aspects” and “limitation of emotional aspects” domains stood out. A study carried out with participants in Fibro Dance group after 12 weeks of intervention compared the QoL domains scores using SF-36, finding a statistically significant difference only for the “functional capacity” domain²⁰. After the intervention, the domains with greatest impairment were “limitation of physical aspects” (38.16), “pain” (41.47), “vitality” (48.42) and “limitation of emotional aspects” (49.6). Similarly, in a study on fibromyalgia patients from a municipality in Rio Grande do Sul State hinterland, it was shown that 60% and 90% of participants had low or very low scores for the “limitation of physical aspects” and “limitation of emotional aspects” domains, respectively, corroborating the results obtained in this study²¹.

When analyzing the scores for each QoL domain on the SF-36 questionnaire compared to access, this study found that there was no difference between the means of participants who had or had not accessed primary care, a similar result also found when comparing hospital care. However, the potential of primary care to promote educational interventions to enable self-management of chronic health conditions was recognized, as well as helping to change habits that harm QoL. From this perspective, it is important to point out that the services and actions offered in primary care were reduced during the pandemic, jeopardizing care for its users through education and health promotion.

In this view, an experience report on the work of physiotherapy in primary care in a Unidade Básica de Saúde (Basic Health Care Unit - UBS) in the Ceará State countryside during the COVID-19 pandemic, based on face-to-face and remote activities, highlighted that the exchange of health information, the presentation of doubts and the request for printed materials in waiting rooms by service users facilitated health education. The authors of this study stated that the majority of individuals reported an improvement in feelings of anguish and a reduction in pain after the suggested guidance, while the few who did not feel supported by the virtual modality showed difficulties in carrying out self-management at home²².

In relation to specialized care, the “functional capacity” and “social aspects” domains showed a statistically significant difference in relation to the other domains related to QoL. Thus, it was noted that the assistance offered by specialized care may have favored self-management of health, contributing to less impairment in these domains. In Brazil, specialized care includes actions, practices and services that incorporate specialist professionals and a greater technological density, which can guarantee higher quality of service. In the Brazilian Public Health System (Sistema Único de Saúde - SUS) specialized care can be offered in different ways, with different organization and scope, such as hospital outpatient clinics, reference centers, services and private associated clinics²³.

In this context, it is understood that the levels of health care are interdependent. However, comprehensive care for SUS users with chronic conditions has been facing challenges, both in primary care and in specialized care, which are characterized by the need to increase supply, with an increase in the number of services and professionals and the establishment of care flows that favor access to health. Given this, among the groups most affected by barriers to accessing health services are those with chronic conditions²⁴.

The results presented emphasize the importance of individuals with chronic pain being able to access all levels of health care in order to receive adequate assistance compatible with their needs. Health care for these individuals should include guidance on the regular practice of physical exercise to maintain activity, including during the period when social restriction measures are necessary, as well as in the post-pandemic period, seeking information from health professionals with a scientific basis, so that these individuals are enlightened about how to carry out their activities, as well as to avoid the harmful effects of a sedentary lifestyle.

As for limitations, it should be noted that the study did not follow the participants’ therapeutic itinerary through the levels of health care, with a sample defined by convenience. It is therefore suggested that further studies be carried out with a longitudinal methodological approach, covering a larger number of participants.

CONCLUSION

The study concluded that access to specialized care during the COVID-19 pandemic may have contributed to women with fibromyalgia having better QoL, especially in the “functional capacity” and “social aspects” domains.

Thus, the importance of providing comprehensive care for women with fibromyalgia was highlighted, based on assistance at different points in the health care network, so that they can receive specialized treatment and interventions that enable them to self-manage their health conditions, according to their needs.

• - Sponsoring sources: none

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Edited by

Responsible associate editor: Levi Higino Sales Júnior

https://orcid.org/0009-0008-0895-8041

Publication Dates

• Publication in this collection
  11 Dec 2023
• Date of issue
  Oct-Dec 2023

History

• Received
  29 May 2023
• Accepted
  05 Oct 2023