Aging and social isolation: an integrative review

Abstract

Objective:

To analyze the concepts available in the literature about the social isolation of older people.

Method:

This was an integrative literature review with basis on the theoretical perspective of ageism. The data were collected from March to May 2019, in LILACS, MEDLINE, EBSCO and Web of Science databases. The crossing of keywords “Older adult” and “Elderly” were used, with the controlled descriptors “Aged,” “Social Isolation,” and “Loneliness” registered in the Medical Subject Headings (MeSH), using the Boolean operator AND. The final sample consisted of 18 articles.

Results:

The social isolation of older person is related to absence or inadequacy of family, friends and general social networks; isolation does not necessarily mean loneliness; operationalization of the social isolation concept needs standardization for a better measurement; risk factors was already identified with possible consequences; interventions are available, but there is insufficient information whether they are based on evidence; the relationship between isolation and loneliness is described and protective factors are presented, but with a low level of evidence.

Conclusion:

Instruments to operationalize the concept of social isolation need to be created, as the studies present heterogeneity of concepts and theoretical bases.

Keywords
Aging; Aged; Ageism; Social isolation; Loneliness; Social behavior

Resumo

Objetivo:

Analisar os conceitos disponíveis na literatura sobre o isolamento social de pessoas idosas.

Métodos:

Métodos: Revisão de literatura do tipo integrativa baseada na perspectiva teórica do ageísmo. Os dados foram coletados nos meses de março a maio de 2019, nas bases LILACS, MEDLINE, EBSCO e Web of Science. Utilizou-se o cruzamento das palavras-chave “Older adult” e “Elderly”, com os descritores controlados “Aged”, “Social Isolation” e “Loneliness”, registrados no Medical Subject Headings (MeSH), com o uso do operador booleano AND. A amostra final foi composta por 18 artigos.

Resultados:

O isolamento social da pessoa idosa relaciona-se com a ausência ou inadequação da família, amigos e redes sociais gerais; isolamento não significa necessariamente solidão; a operacionalização do conceito de isolamento social necessita de padronização para uma melhor mensuração; há fatores de risco já identificados e possíveis consequências; há intervenções, mas insuficiente informação se elas se baseiam em evidências; descreve-se a relação entre isolamento e solidão e apresentam-se fatores protetivos, porém com baixo nível de evidência.

Conclusão:

Conclui-se que há necessidade de criação de instrumentos para operacionalizar o conceito de isolamento social, uma vez que os estudos apresentam uma heterogeneidade de conceitos e embasamentos teóricos.

Descritores
Envelhecimento; Idoso; Ageísmo; Isolamento social; Solidão; Comportamnto social

Resumen

Objetivo:

Analizar los conceptos disponibles en la literatura sobre el aislamiento social de personas mayores.

Métodos:

Métodos: Revisión integradora de literatura basada en la perspectiva teórica del edadismo. Los datos fueron recopilados entre los meses de marzo y mayo de 2019, en las bases LILACS, MEDLINE, EBSCO y Web of Science. Se utilizó el cruce de las palaras clave “Older adult” y “Elderly”, con los descriptores controlados “Aged”, “Social Isolation” y “Loneliness”, registrados en el Medical Subject Headings (MeSH), con el operador booleano AND. La muestra final estuvo compuesta por 18 artículos.

Resultados:

El aislamiento social de la persona mayor se relaciona con la ausencia o falta de capacidad de la familia, amigos y redes sociales generales. Aislamiento no significa soledad necesariamente. La funcionalidad del concepto de aislamiento social necesita estandarización para obtener una mejor medición. Existen factores de riesgo ya identificados y sus posibles consecuencias. Hay intervenciones, pero sin suficiente información si se basan en evidencias. Se describe la relación entre aislamiento y soledad y se presentan factores protectores, pero con bajo nivel de evidencia.

Conclusión:

Se concluye que hay una necesidad de crear instrumentos para operacionalizar el concepto de aislamiento social, dado que los estudios presentan una heterogeneidad de conceptos y fundamentos teóricos.

Descriptores
Envejecimiento; Anciano; Ageísmo; Aislamiento social; Soledad; Conducta social

Introduction

The process of population aging is a reality in Brazil. For the first time, most people can expect to live up to age 60 or older.⁽¹⁾ However, living longer does not equal living better. The cities and work dynamics, new housing and family arrangements, the growing cult of individualism and changes in traditional society values have an unequal and contradictory influence in people’s quality of life.^(2,3)

Social isolation is one of the factors that has emerged as a potential public health problem.⁽⁴⁾ It can be defined as a state in which individuals experience less and less social involvement than they would like with other people, which interferes with their quality of life. It is related to the objective separation from other individuals, causing absence or few social interactions in daily life.⁽⁵⁾ Although this phenomenon can be experienced at any stage of life, it is more prevalent among older adults, with an estimate prevalence of around 10% to 43%, depending on the historical course and living conditions.⁽⁶⁾ The experience of isolation may occur along with the subjective feeling of loneliness or even generate it as a consequence.⁽⁷⁾ This reality has proven to be a multifaceted problem. A study states that it is associated with increased all-cause mortality.⁽⁸⁾

The territories in Brazil are characterized by significant variability in the living conditions of older adults, including social, economic, demographic, cultural and environmental characteristics. The impact on social interaction can be quite different and, consequently, the longevity and quality of life of older adults. Understanding this problem contributes to extending the development of policies toward spaces for sociability and interaction between the older adults, families and caregivers and, in addition, redefine the education of health professionals to deliver care.

The magnitude of population aging is increasing and it is influenced by different factors, related to unequal and contradictory forms of living in old age and having social interaction as a marker for quality of life. This study aimed to analyze the concepts available in the literature on the social isolation of older people.

Methods

This was an integrative literature review, consisting of six steps.⁽⁹⁾ First, the research question adopted was: What concepts and perspectives are available in the literature on the social isolation of older adults? In the second step, the inclusion criteria established were: (i) to present factors that contribute to the social isolation of older adults; (ii) to discuss aspects related to health risk factors; (iii) to describe perspectives on the social isolation of older adults; iv) articles published in English, Spanish or Portuguese. The exclusion criteria were: (i) literature reviews; (ii) texts, letters, theses, dissertations and articles not indexed in scientific journals; (iii) not presenting the concept neither the definitions of social isolation; (iv) addressing loneliness only.

The article search was conducted in Web of Science, EBSCO, LILACS, and MEDLINE databases, the latter two by consulting the Latin American and Caribbean Center on Health Sciences Information. The search in EBSCO included the CINAHL database, and the findings were presented as the total amount of EBSCO, from March to May 2019. The search was performed by cross-referencing the keywords “Older adult” and “Elderly,” with the controlled descriptors “Aged”, “Social Isolation” and “Loneliness”, found in Medical Subject Headings (MeSH), using MESH + all fields, using the Boolean operator AND. Although the term “elderly” is considered a stereotype according to the theoretical perspective that underlies ageism, this term had to be used because DeCS and MeSH still contain several articles that use this descriptor when addressing aging. There was no limit regarding the year of publication. The study followed the recommendations of Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA).

A total of 216 selection data were identified, 82 from the Web of Science, 48 from EBSCO, 2 from Lilacs and 84 from Medline. The first step of the literature selection process included reading the paper titles and abstracts. One hundred forty-eight articles were excluded because they did not meet the object of the guiding question and the inclusion criteria. A total of 23 articles was found in duplicate and were removed.

From the total, 45 articles were selected and a comprehensive reading was performed. After applying the exclusion criteria, a total of 18 articles were obtained as a final sample (Figure 1)

Figure 1
Databases and selected search strategy

During the steps, any disagreements in the selection of articles were decided by two evaluators, knowledgeable on the subject, who validated the selection of articles in the final sample.

A new reading was then performed of all the articles in the sample, based on a pre-structured form, which included: authors, year, location, study design, concept of social isolation, scales used and main results referring to social isolation. After the systematization, a qualitative analysis was performed⁽¹⁰⁾ with reading of the findings and extraction of the fragments, as presented in the results and final considerations. The Iramutec 0.7 alpha 2 software was used to support the analysis. Finally, the ethical aspects, authorship of ideas, concepts and definitions present in the articles were considered.

Results

From the total, 18 articles were selected; written in English (28% from USA, 28% from England and the remaining 5.5% each: India, Netherlands, Italy, Japan, Malaysia, Netherlands and Taiwan). The year of publication ranged from 2009 to 2019. The year with the highest number of publications was 2013, with 22%. Individual and social issues that were identified as factors associated with the risk of social isolation in the studies are described as:

1. Factors related to the individual’s physical and mental health: people with physical dependence or functional impairment, deafness or hearing loss, neurological diseases and limited long-term illness;^(11–21)

2. Sociodemographic factors and factors based on social inequities: being a woman, single or widowed, experiencing loss of persons or close relatives, unemployed or economically dependent, with low education, low health skills, low decision-making power, low family income, no children, smaller family arrangements, with little or no religious ties, living in rural areas and geographical issues, low mobility and access to transportation, without access to a social security system, living in residential care places or long-term institutions, and being hospitalized;^{(15,17,18,20,21–27)}

3. Contextual and structural factors: e.g. economic and social policies that generate and maintain socio-economic inequalities, restricting the opportunity for participation in social activities.⁽¹⁸⁾

All articles presented a conceptual definition for social isolation, as shown in chart 1.

Chart 1
Summary of conceptual definitions on social isolation and major findings according to year, country of publication and study design

Year and Country	Study design	Social isolation concept	Main findings
(2018) Taiwan (11)	A prospective study based on the longitudinal study “Social Environment and Aging Biomarkers in Taiwan”	Objective aspect of social relationships, network size, diversity and frequency of contact.	Social isolation is associated with worse quality of sleep in older adults and indicates that this effect is not related to the subjective feeling of loneliness.
(2009) USA (12)	A study on the psychometric properties of scales of Social Disconnection and Isolation Social, based on data from research National Social Life, Health and Aging Project (NSHAP)	Social disconnection (physical separation from others) and perceived social isolation (feelings of loneliness and lack of social support). Individuals with no social connection tend to feel isolated.	Individuals with a small social network or rarely participate in social activities do not necessarily feel lonely. The person may be surrounded by friends and family, but realizes the lack of social support and feels excluded. Inconclusive on whether social isolation increases with age.
(2013) USA (13)	A cross-sectional study performed in Institutions for the elderly in Alabama	Objective experience of absence of contact with other persons, especially people who provide the necessary social support. Social isolation is the lack of a meaningful social interaction.	The frequency of Internet use affects loneliness, but not the perceptions of isolation, indicating a higher frequency associated with lower levels of loneliness, but not with lower levels of social isolation.
(2012) USA (14)	A study of indicators of social isolation based on data from a longitudinal research “Health and Retirement Study” developed by University of Michigan.	Objective lack of relationships and social interaction.	Isolation and loneliness are not highly correlated, which implies that two constructs are distinct. The impacts on physical and mental health can have different repercussions. Distinguishing them is necessary to intervene
(2017) USA (15)	A cross-sectional study conducted with older adults living in government-subsidized residences	Social isolation is associated with lack of social resources (friends, family and trustful relationships), which results in worse outcomes in terms of physical and mental health.	The average score for older residents of housing affordable to lower economic people revealed that almost half of residents were socially isolated or had “high risk”.
(2012) Italy (16)	Longitudinal study with older people hospitalized, using the “Global survey on geriatrics.”	Defined as absence or reduction of more closed social networks and/or informal social support.	For hospitalized individuals, the quality of life was an independent predictor of isolation; woman had a 2-fold higher risk of hospitalization; the isolation meant greater chance of re-hospitalizing.
(2013) Malaysia (17)	A study based on data from the national research “Patterns of Social Relationships and Psychological well being social relationships among elderly adults of Malaysia”.	Defined social isolation objectively as absence of contact or interaction with others individuals, and subjectively as feeling of loneliness or lack of genuine company or communication with other people.	Number of children, brothers, aggregate size, and health self-evaluation, local of residence, property, sex and ethnicity were closely related to social isolation.
(2018) India (18)	A study based on data from the Research “Building Knowledge on population ageing in India” (BKPAI).	Social isolation occurs when, in the previous12 months, the older adult does not attend a public meeting; meeting of a group/club/organization; religious program, nor received visit from a friend or family.	Absence of social security benefits, Alzheimer’s and having a dependency for activities of daily living. increase the risk to isolation. Being an active Christian or having three to five children diminishes the risk. Association with cancer was not significant.
(2015) The Netherlands (19)	A study with qualitative approach by means of in-depth interviews.	The definition of social isolation begins with the context of state policies of social well-being assumed by western European countries, which emphasizes the importance of independence and self-confidence of citizens and presents a theoretical background typology of interventions that extend the older people’s self-confidence considered socially isolated.	The social isolation was perceived from two classifications: after a recent life event - situational - and the individuals who are long isolated - structural. Motivations for change and support are more required in the structural case
(2019) Canada (20)	A cross-sectional study based on the Canadian Longitudinal Study on Aging (CLSA) and the Census 2016, with inferential statistics of multilevel logistic regression.	Contact and bonds that individuals have on social networks, from the closest to the least close, based on the “ Social Relationship Train Model “.	Age, sex, education, income, commitment functional, chronic diseases were related to social isolation and loneliness. Being aged 65 and older with a. low income can increase the relationship with isolation.
(2016) Canada (21)	A quantitative, population study, involving people 45 years or older from the “Canadian Community Health Survey - Healthy Aging (CCHS-HA)”.	Social isolation mixed variable that measures loneliness and sense of community involvement using two scales. The participant is considered socially isolated if he/she feels lonely and has a weak sense of community affiliation.	The isolation increases with hearing disability in women, not in men. Age, education, coexistence, regularity physical motor, job, incontinence, fear of falling and functional limitations increased the chances.
(2012) Japan (22)	A quasi-Experimental study to test a social isolation coping program for Japanese older adults with an intervention group and a control group, pre-test before intervention, random sampling, and data collection in the first and sixth month after intervention	Qualitative e quantitative imperfections in social interactions associated with poor relationships. It’s correlated with the concept of emotional, instrumental and social support	Programs designed to prevent social isolation are effective when using the resources available in the community; they are made considering the individual needs and target people who may share similar experiences.
(2019) England (23)	A quantitative study based on data from the English Longitudinal Study of Ageing (ELSA) with English people aged 50 or older, from the sixth phase of data collection (2012-2013).	Social isolation defined as no regular monthly contact with family and friends, as well as lack of involvement in activities of social organizations.	Isolation is related to the decrease in physical activity objective and the largest sedentary time. That can contribute to increase the risk of health problems and welfare associated with isolation.
(2011) England (24)	A quantitative study based on data from the English Longitudinal Study of Ageing (ELSA)	Absence of regular contact with family and friends and lack of organizational social involvement.	Social isolation and loneliness can affect health, independently. Isolation can increase the blood pressure and inflammatory processes associated with cardiovascular disease development.
(2013) England (25)	A quantitative study based on data from English Longitudinal Study of Ageing (ELSA)	Absence of regular contact with family and friends and lack of organizational social involvement.	Isolation was associated with reductions in verbal fluency, immediate memory and delay in memory during a four-year period. Isolation and loneliness were closely related with worse cognitive function.
(2015) England (26)	A quantitative study based on data from the English Longitudinal Study of Ageing (ELSA), with inferential analysis along four years.	Absence of regular contact with family and friends and lack of organizational social involvement.	The isolation and loneliness were associated, by means of different forms, to changes on the course of cognitive and affective (evaluative) (hedonic) well-being over time.
(2018) England (27)	A quantitative study based on data from the English Longitudinal Study of Ageing (ELSA), second data collection step (2004-2005), with inferential analysis over six years.	Social isolation defined according with the marital situation, cohabitation, and contact with children, relatives, friends and participation in social organizations.	Low level of health literacy and isolation were independently associated with increased mortality risk from different causes. Separately, low literacy represented higher chance of die in 22% and isolation, 28%.
(2013) Holland (28)	A quantitative study based on data from a web platform of Longitudinal Internet Studies for the Social Sciences (LISS Panel), with a representative sample of the Dutch population.	Defined as social loneliness due to the absence of a more extensive contact group and disengagement. Subjective measures involve social connection, feeling of isolation or disconnection.	Volunteer work, cultural activities, vacation, sports, reading, hobbies and shopping are predictors of success for social connection of old people. Watching TV, listening to the radio and using the computer were not associated with social connection.

Similitude analysis enables decoding the associations between the words in the text corpus, helping to infer the text composition and the relevant themes. Figure 2 presents an analysis of similitude and describes the words “social”, “organization” and “lack”, which facilitated the identification of the representative field of definitions attributed to social isolation. The results indicated three fields: (i) lack of contacts and social support; (ii) family absence; and (iii) lack of regular involvement/organization in the friends networks. Loneliness was weakly linked to the concepts attributed to social isolation.

Figure 2
Similitude analysis

To measure social isolation, three articles used the Lubben Social Network Scale (LSNS), one article used the UCLA Loneliness Scale associated with subjective questions, and all the other studies created their own indexes or instruments, representing a total of 78% of the studies. The attributes linked to the development of these instruments resulted mainly from: evaluation of marital status; number of children; family relationship; religious activity; participation in groups (social, voluntary); frequency of contacts; housing arrangements and geographical analysis.

Evaluation of factors associated to: risk of isolation; possible consequences; interventions to isolated older adults; relationship between isolation and loneliness; and possible protective factors are among the main themes presented in the results.

Discussion

The article analysis identified a more general concept of social isolation of older adults, linked in an objective way to the shortage of human relations and regular contacts with people, whether they are family, friends or community members. In these cases, the individual, in his daily life, interacts with fewer people than he/she would like to, his/her social network is reduced and has insufficient social support - emotional, informative and instrumental. It relates to the history of life and the context of social organization. In this perspective, isolation does not refer to those who have voluntarily disconnected themselves, but to possible barriers that hinder or prevent social connection.

The concept of isolation, for them, is linked to the lack of objective social interaction and it is related to a subjective perception of emotional isolation. These concepts approximate the absence or scarcity of social interaction to the feeling or perception of loneliness.

Although this conceptual approach between isolation and loneliness, studies^{(12,14,24–26)} sustain that the constructs are different and not necessarily correlated. Loneliness does not depend on the amount of social interactions, once it is a highly subjective experience. On the other hand, isolation is directly related to the objective decrease of social networks.⁽²⁹⁾ Considering these differences, the authors indicate a need to differentiate these problems among older people. A more specific and targeted intervention is needed, as the health consequences may be different.^(24–26)

However, all the definitions analyzed show that, in social isolation, the number of interpersonal relationships is significantly reduced or even absent. The forms of measuring social isolation still lack operational standardization and this might be one of the reasons why different conceptual approaches on isolation and few studies with validated measures beyond the scales of loneliness were found. Most articles do not present the operationalization of the concept in a way that favors the measurement of the phenomenon; only one article⁽¹⁹⁾ discusses the importance of using cultural issues for conceptual construction and intervention programs to reduce social isolation of older adults.

A study published⁽³⁰⁾ in Brazil, based on the Brazilian Longitudinal Study of Aging (ELSI-Brazil), shows that aspects of social participation and neighborhood perceptions are influenced by urban characteristics. Urban situations such as difficulty in crossing streets and accessibility to public transportation were identified as barriers to social participation. These aspects express the heterogeneity of situations faced by older people, the access to the right to the cities and the differences between countries.

Among the consequences of social isolation in the life of the older person there are: higher risk for health problems, reduced well-being and increased mortality.^(23–25,27) Other findings can also be considered, such as: cognitive health impairment and mental health impairment; ^(25–26) increased risks for depression and anxiety;⁽²⁶⁾ reduced daily physical activity and longer sedentary time;⁽²⁶⁾ worse quality of sleep;⁽¹¹⁾ increased chance of developing cardiovascular disease ⁽²⁴⁾ and unsatisfactory living sensation.⁽²¹⁾

The consequences may be even more dramatic, according to a study in Japan, which has the largest number of older people in the contemporary world. It is estimated that they will represent 40.5% of the population in 2055. The so-called solitary death has been identified as one of the consequences of social isolation.^(1,31)

This solitary death happens when an individual dies alone at home and goes unnoticed by others. The body of the deceased can be left unattended for days, months or even years. It is considered a tragic consequence and represents, symbolically and concretely, the social isolation that part of humanity is experiencing.⁽³¹⁾

The literature studied reveals that social isolation is potentially avoidable and that interventions capable of preventing it or acting in its overcoming have multiple dimensions. Programs aimed at preventing social isolation are most effective when they utilize existing resources in the community; they are tailor-made according to the needs of the individual and target people who can share similar experiences.⁽²²⁾ In this regard, the articles indicate that individual singularities need to be well defined for the intervention to be performed.

A study conducted in Alabama⁽¹³⁾, e.g., identified that the frequency of Internet use has the potential to affect individuals who suffer from loneliness but did not modify perceptions of isolation. An Indian study evidenced that watching TV, listening to the radio and using the computer were also not associated with social connection.⁽²⁸⁾ Face to face contact seems to be the method to positively intervene in isolation.

In the research conducted in the Netherlands⁽¹⁹⁾ it was shown that older people with a low level of interaction for a long time, need greater motivation and support than those living in recent, situational isolation. Considering this, interventions should consider from poorly resolved relationships to the reconstruction of ties and bonds, with interventions using social activities and supporting groups, investing in an active sociability.

The studies also showed protective factors against the lack of social relations: voluntary work, cultural activities, holidays, sports, reading, hobbies, shopping, be an active Christian and have children, work and/or retirement were considered successful predictors for the social connection of older people.^(18,28)

These countries, as well as Brazil, should seek alternative solutions for older adults, employed or retired people to maintain a structured welfare system, provision and allocation of adequate health and community resources They include access to opportunities for social interaction and community connectivity and configuration of creative and interactive cities that plan spaces for intergenerational coexistence that enables new forms of human interaction, in order to positively affect the isolation experienced by older adults.

The analysis between social isolation and the ageism construct emerges as an analytical possibility for further investigation.⁽³²⁾ Ageism allows us to understand that the social narrative embedded in popular statements and in broader societal spheres consolidates a vision of aging from a negative perspective, on a daily basis. Prejudices and stereotypes disseminated within society interfere with the full experience of aging and have the potential to disturb the effective formulation of policies that face the challenges of aging in contemporaneity, among them, the social isolation. The very theory of social disengagement as part of the life cycle of the older person, as proposed by Cumming and Henr,⁽³³⁾ presents a conceptual theoretical background of aging that approaches ageism and requires further theoretical revision and analysis.

A Korean study⁽³⁴⁾ introduces a new dimension to studies on social isolation when it suggests that the concept should also be thought of from the perspective of ethnic loneliness and diaspora, in which individuals are isolated due to an experience of migration, political persecution or even abandonment. It is the experience of isolation due to injustice or subjugation, associated with an impossibility of being heard. This perspective corroborates the possibility of a relationship between ageism, social isolation and social inequity, opening up possibilities for new studies.

Scales to identify social isolation need to be standardized to enable measuring and comparing phenomena between countries. Although Lubben’s validated scale exists, most of the studies have developed their own indicators for measurement that allow the inclusion of circumstantial and cultural issues of each region. The heterogeneity among older people and between countries and their populations suggests caution in the analysis of social isolation identified in the studies.

The limited number of databases consulted and the lack of inclusion of grey literature prevented the identification of studies from Latin American and Caribbean countries, which have greater geographic, cultural and social proximity to Brazil.

Conclusion

The conclusion is that research on social isolation of older adults presents gaps when describing the instruments adopted, the operationalization of the epistemological bases and the theoretical perspectives of the concept adopted. The studies showed a heterogeneity of methods in the attempt to address the multidimensionality of social isolation of older people, its implications, consequences and protective factors. This research allowed to understand that social isolation is multifaceted and that isolated older adults do not have homogeneous characteristics. This combination of distinct characteristics, with different means of detecting and intervening in the problem, shows the need to intensify and specify strategies to minimize this societal problem and expand the construction of evidence-based programs, with monitoring and evaluation of their effectiveness for heterogeneous groups. Loneliness and isolation were identified as two distinct constructs that are not necessarily correlated in their implications. Isolation, regardless of other factors, is able to negatively influence health, satisfaction and well-being outcomes in a unique way. The scales for identifying social isolation need to be standardized to allow measuring and comparing of phenomena between countries. Although Lubben’s validated scale is available, most of the studies created their own indicators for measurement to include situational and cultural issues of each region. The cultural diversity of countries and their populations suggests caution in the analysis of the social isolation identified in the studies. The expansion of the role and social function of the older person needs to be reframed, and society needs to overcome the separation of these people in the dynamics of the cities, including them organically. The allocation of resources in health, the battle against ageism, the welfare system, and the development of creative solutions in the cities can collaborate to this confrontation.

Acknowledgements

To the Federal District Research Support Foundation - Fundação de Apoio à Pesquisa do Distrito Federal (FAPDF) for funding the research project coordinated by Leides Barroso Azevedo Moura.

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Publication Dates

• Publication in this collection
  15 Mar 2021
• Date of issue
  2021

History

• Received
  12 Sept 2019
• Accepted
  01 June 2020