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Original Article • Cad. Bras. Ter. Ocup. 32 • 2024 • https://doi.org/10.1590/2526-8910.ctoAO395738402 linkcopy

Open-access Occupational therapists’ work process during the Covid-19 pandemic through telecare and telemonitoring

AuthorshipSCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction  The emergence of the COVID-19 pandemic has intensified challenges related to health care. Ministry of Health Ordinance No. 467, of March 2, 2020, provides, on an exceptional and temporary basis, for telemedicine actions, with the aim of regulating and operationalizing measures to deal with the public health emergency.

Objective  To find out how occupational therapists in Alagoas, Brazil, worked during the COVID-19 pandemic.

Method  This is a cross-sectional, descriptive study carried out with occupational therapists from the state of Alagoas (Brazil) who carried out telecare and telemonitoring during the COVID-19 pandemic. The sample was based on convenience. Participants were invited to take part in this study through contact via messaging groups, emails and active search. Data collection took place through an online questionnaire that sought to understand the work process of occupational therapists.

Results  The study included 35 occupational therapists who carried out telecare/telemonitoring to the public of all ages, the consultations took place once a week, lasting between ten and thirty minutes and the maintenance of the bond, family engagement and closeness to the patient's context were positive points, while the difficulty was access to quality internet.

Conclusion  This type of care has been considered in the post-pandemic period, standing out as a complementary strategy to face-to-face follow-ups. Further studies on the subject and investigations with patients/users are needed to understand other questions that this research was unable to answer.

Keywords:
COVID-19; Telemedicine; Occupational Therapy

Resumo

Introdução  O surgimento da pandemia de COVID-19 intensificou desafios relacionados à atenção em saúde. A portaria do Ministério da Saúde n. 467, de 2 de março de 2020, dispõe, em caráter excepcional e temporário, sobre as ações de telemedicina, com o objetivo de regulamentar e operacionalizar as medidas de enfrentamento da emergência de saúde pública.

Objetivo  Conhecer como se deu o processo de trabalho dos terapeutas ocupacionais de Alagoas, Brasil, durante a pandemia de COVID-19.

Método  Trata-se de um estudo transversal, descritivo, realizado com terapeutas ocupacionais do estado de Alagoas (Brasil) que realizaram teleatendimento e telemonitoramento, durante a pandemia de COVID-19. A amostra foi por conveniência, os participantes da pesquisa foram convidados a participar deste estudo a partir de contato realizado em grupos de mensagens, e-mails e busca ativa. A coleta de dados aconteceu por meio de um questionário on-line que buscou compreender o processo de trabalho dos terapeutas ocupacionais.

Resultados  O estudo contou com 35 terapeutas ocupacionais que realizaram teleatendimento/telemonitoramento ao público de todas as idades, por meio de atendimentos semanais, com duração de dez a trinta minutos. A manutenção do vínculo, o engajamento familiar e a aproximação com o contexto do paciente foram pontos positivos, enquanto a dificuldade foi o acesso à internet de qualidade.

Conclusão  Este tipo de atendimento tem sido considerado no período pós-pandemia, destacando-se como uma estratégia complementar aos acompanhamentos presenciais. São necessários novos estudos sobre a temática e investigações com os pacientes/usuários, para compreender outros questionamentos que esta pesquisa não conseguiu responder.

Palavras-chave:
COVID-19; Telemedicina; Terapia Ocupacional

Introduction

Since the onset of the coronavirus outbreak (SARS-CoV-2), which causes COVID-19, there has been great concern regarding a disease that spread rapidly across various regions of the world, being highly contagious and having different impacts (Freitas et al., 2020). According to Conejo et al. (2020), pandemics are characterized by large-scale infectious outbreaks that increase morbidity and mortality across a wide geographical area, causing serious economic, social, and political consequences. The history of humanity is marked by significant epidemics and pandemics that have decimated various populations.

Cases of a new strain of influenza were soon reported worldwide, due to the reach of television and the internet. According to the Pan American Health Organization (2020a, 2020b), region of the Americas the emergence of several severe pneumonia cases in Hubei province, China, prompted an alert from the World Health Organization (WHO) (Organização Mundial da Saúde (OMS), on December 31, 2019. A new type of coronavirus, previously not found in humans, was identified (2019-nCoV). The exponential increase in cases and deaths, initially in Chinese territory and later expanding to other countries, led the WHO to declare on January 30, 2020, that the outbreak of the new virus constituted a Public Health Emergency of International Concern (PHEIC), which corresponds to the highest alert level under the International Health Regulations.

Aquino et al. (2020) state that many countries immediately began implementing a series of interventions to reduce the transmission of the virus and curb the rapid progression of the pandemic. Such measures included isolating cases, promoting hand hygiene, adopting respiratory etiquette, and using homemade face masks, along with progressive social distancing measures, such as closing schools and universities, banning events and gatherings, restricting travel and public transport, and raising public awareness to stay at home, up to the complete prohibition of movement in the streets except for purchasing food and medication or seeking healthcare assistance.

According to Reichenberger et al. (2020), people with disabilities faced specific vulnerabilities, especially in the context of the health, social, and political crisis Brazil was experiencing, and encountered greater challenges due to the COVID-19 containment measures. Saldanha et al. (2021) note that the COVID-19 pandemic intensified challenges related to healthcare and social protection for people with disabilities.

Ministério da Saúde (The Ministry of Health) (Brasil, 2020a) issued Ordinance MS/G No. 467 on March 2, 2020, which establishes, in an exceptional and temporary manner, the actions of Telemedicine, aiming to regulate and operationalize the measures to address the public health emergency of international importance outlined in Article 3 of Law No. 13,979, dated February 6, 2020, resulting from the COVID-19 pandemic.

According to Caetano et al. (2020), Telehealth allows for the continued care of patients with pre-existing diseases and comorbidities who, although not infected, cannot attend in-person medical consultations due to social distancing guidelines. Santos et al. (2014) states that Telehealth has the potential to facilitate access to healthcare services, improve quality, and contribute to professional training. However, until the pandemic occurred, its potential had not been fully understood, and its incorporation had been slow.

Therefore, some professional health councils published ordinances to ensure health care, even with the social distancing protocol. The Federal Council of Physiotherapy and Occupational Therapy (COFFITO), in compliance with the recommendations of the World Health Organization (WHO), and aiming to provide Physiotherapy and Occupational Therapy services to the population and, at the same time, ensure professional well-being, authorized, through Resolution No. 516, published in the Official Gazette of the Union, on March 20, 2020, Teleservices1 , Teleconsulting2 and Telemonitoring3 .

Given the experience experienced during the period of social isolation, caused by the COVID-19 pandemic, new ways of offering occupational therapeutic care were developed, therefore, the objective of this study was to understand the work process adopted by occupational therapists in Alagoas, who provided teleservice and/or telemonitoring during the COVID-19 pandemic.

Methods

This is a cross-sectional, descriptive study with a quantitative analysis involving occupational therapists from the state of Alagoas who provided telehealth services and telemonitoring during the COVID-19 pandemic. This work was approved by the Research Ethics Committee (CEP), under CAAE 60577222.1.0000.5011.

The sample was non-probabilistic and census-based, where the authors aimed to invite all occupational therapists who conducted telehealth services and telemonitoring in the state of Alagoas. Eligible participants were occupational therapists active in the state who used this model of care during the pandemic. Participants were invited to collaborate in this study through contact made in messaging groups, emails, and active outreach, based on a list of registered professionals provided by the regional council.

The researchers developed an investigative instrument to identify issues related to the work process, such as service duration, session frequency, communication methods used, therapeutic resources, and the format of guidance and intervention provided.

A questionnaire prepared by the researchers was used (which had its content validated by three judges4 ), with the aim of identifying how the work of occupational therapists was conducted through telehealth services and telemonitoring in the state of Alagoas. The judges participating in the validation of the instrument were invited because they had experienced these practices during the COVID-19 pandemic. Three judges were selected and contacted by phone. All accepted and confirmed their availability to participate in the validation process of the instrument.

This process occurred in three stages. The first stage involved sending an invitation letter to the judges, inviting each one to analyze the questions. The analyses were related to the clarity of the language used in the questions posed to participants, the relevance of the research question to the object of study, the feasibility of implementing the question, the inclusion, removal, or modification of the question, as well as any other considerations the judges could provide regarding the instrument.

The second stage consisted of creating a spreadsheet to consolidate the analyses conducted by the judges. All analyses were incorporated into the instrument. The final instrument contained twenty-six questions. In the third stage, the finalized instrument was resent to the judges for further analysis, with validation or the need for additional adjustments. All judges responded via email, validating the instrument and making it suitable for use in the research. The final version of the questionnaire included 26 questions, divided into two parts. The first part addressed questions related to the participants, including their workplace, average salary, and type of audience served; the second part included questions related to telehealth services and/or telemonitoring.

The information was stored in a computerized database and analyzed descriptively using BioEstat software version 5.3.

Results

Data collection took place between September 2022 and January 2023 and included a total of 41 voluntary participants. However, only 35 met the inclusion criteria. Therefore, the six participants who responded to the questionnaire but had not conducted services in the studied modality were excluded from the database.

The majority of the participants were graduates of the State University of Health Sciences of Alagoas (UNCISAL) (n=33, 80.5%). Regarding the municipality of practice, 25 (61%) of the occupational therapists indicated they worked in Maceió or in the capital and other municipalities in the interior of Alagoas; 8 (19.5%) worked in other municipalities in the state, and 8 (19.5%) did not respond.

Regarding the nature of employment ties, public services and the third sector linked to the Unified Health System (SUS) were the most prevalent, with 20 (57.14%) responses, 9 (25.71%) conducted services through the private sector, and 6 (17.1%) were linked to both public and private services, as described in Table 1.

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Table 1
Characterization of research participants.

The second part of the questionnaire addressed the work process of the research participants in the investigated model. When participants were asked how long they had been working in this format, 11 (31.42%) reported using telehealth services and/or telemonitoring for a period of 1 to 6 months. The mobile phone was the most commonly used technological resource for this type of service, with 26 (74.3%) of the responses.

When asked whether the technological resources used in remote care were made available by the work establishment, 23 (65.7%) stated that they used their own resources and 12 (34.3%) received the necessary resource for the service from the service to which they were located. service. When asked whether they believe teleservice/telemonitoring will continue to be part of their work routine, the majority of survey participants 19 (54.3%) say yes. These data are described in Table 2.

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Table 2
Characterization of the work process.

Regarding the teleservice or telemonitoring format, 21 (60%) responded that they carried out teleservice and 12 (34.3%) carried out telemonitoring. Regarding how the assistance took place, 25 (71.4%) stated that it was synchronous and 9 (25.7%) used the asynchronous format. Regarding the frequency of care, 28 (80%) had weekly contact with the patient, however, other frequencies were mentioned and are described in Table 3. Regarding the experience with this type of care, 26 (74.3%) stated that it was a positive experience, while 7 (20%) did not consider it a good experience.

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Table 3
Characterization of the sessions.

Regarding the occupational therapist's perception regarding the evolution of the patient covered by telecare/telemonitoring, 21 (60%) stated that they had noticed progress in their patients, and 7 (20%) reported not having noticed progress. Information about the characterization of the sessions is described in Table 3.

When asked about the difficulty the professional had in carrying out teleservice/telemonitoring, 29 (82.9%) responded that they had difficulty and 6 (17.1%) said they had no difficulty at all. When asked about the duration of contact, 22 (62.8%) held sessions lasting 10 to 30 minutes.

Research volunteers were able to list up to three positive points and three negative points observed in the work process in the format investigated. Among the positive points, the continuity of the therapeutic bond, expansion of access, family participation and engagement, convenience and the fact of having the possibility of better understanding the context in which the patient is inserted were mentioned, with the frequency described in Figure 1. Worth It should be noted that one participant reported that he did not observe any positive points.

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Figure 1
Positive points observed. Source: Elaborated by the authors.

The difficulty in accessing quality internet, as well as the inability to use digital equipment were the most cited, considering families and patients, when considering the negative points. Furthermore, non-adherence to treatment, lack of physical contact, difficulty in the availability of therapeutic resources to assist the therapist's work, were the most cited, as shown in Figure 2.

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Figure 2
Negative points observed. Source: Elaborated by the authors.

Discussion

The objective of this research was to understand the work process adopted by occupational therapists in Alagoas who provided telehealth and/or telemonitoring during the COVID-19 pandemic, considering the necessary changes to adapt to this unique moment. According to Ferrari et al. (2022), the COVID-19 pandemic required social distancing to confront it, posing threats to occupations.

As Hermes et al. (2022) state, the pandemic caused by the coronavirus (SARS-CoV-2) demanded flexibility in service delivery, leading to greater adherence of health professionals to the telehealth system, for example. The interventions of occupational therapists were supported by positions from the COFFITO and by Resolution No. 516, of an emergency nature, from the Federal Council of Physiotherapy and Occupational Therapy (Brasil, 2020b), which previously did not recommend non-face-to-face care. De Carlo et al. (2020) highlight telehealth as one of the possibilities for providing occupational therapy services during the pandemic, provided it is contextualized.

The majority of the research participants (n=34, 97.2%) are graduates of the State University of Health Sciences of Alagoas (UNCISAL). Founded in 1968, it was then called the School of Medical Sciences of Alagoas (ECMAL) and is the only university offering the Occupational Therapy course in the state of Alagoas, which justifies the high number of participants from this institution. When asked about their place of work, 25 (61%) practice in the municipality of Maceió, where the university is located, being the capital of the state and offering more job opportunities. A study by Bezerra et al. (2009) showed that most employers of occupational therapists in Maceió are in the public sector (60%, including both municipal and state levels), followed by the third sector (33%) and the private sector (12%).

The majority of research participants (n=33, 94.3%) reported having completed a postgraduate degree. Continued education is necessary for the professional training of occupational therapists to meet market demands, and postgraduate studies have been one of the resources sought by these professionals. Cury (2004) states that postgraduate education has been an essential support for the training of highly qualified human resources and the production of knowledge necessary for the scientific and technological development of the country.

The area most frequently cited by occupational therapy professionals participating in the research as the target of interventions was pediatrics (14, 40%) and 10 (28.6%) across all life cycles, including childhood. Folha & Della Barba (2020) affirm that attention to childhood is one of the most structured and developed areas in occupational therapy.

Almeida and Neves (2020) report an increase in diagnoses of Autism Spectrum Disorder (ASD), according to research conducted, particularly in Europe and the United States. Thus, the occupational therapist who is part of the multidisciplinary team for this population has observed job market opportunities in this area. According to Gomes & Oliver (2010), occupational therapy plays an important role with this population and seeks to contribute to their development, autonomy, and participation in social life. Therefore, the authors of this study hypothesize that these statements may justify the greater concentration of professionals working with the pediatric population.

The availability of job positions for professionals in the state of Alagoas was predominantly in the public service and the third sector, with the most cited in this study (n=20, 57.14%). However, the private sector has shown growth for the category. As Lancman & Ghirardi (2002) state, changes in the labor market have an impact on work-employment relationships, and this insertion tends to take various forms, including outsourcing services and offering freelance work. In this context, traditional notions of employment, stability, retirement, or a linear and progressive professional career, as well as labor rights and worker health protection, are giving way to new relationships in the labor market.

Bezerra et al. (2009) conducted a study between 2007 and 2008 and observed that, although the public sector remained the largest employer, the so-called third sector occupied a significant space in the labor market for the category at that time. Costa (2012) mentions that, among specialized actions, the participation of the private sector is the most significant, reaching 90.9% of establishments providing Therapeutic and Diagnostic Support Services (SADT). Thus, this expansion of the private sector allows occupational therapy professionals to access employment in this type of assistance.

With the onset of the pandemic in 2020, society had to reorganize in response to the new scenario, especially health service providers. Castillo-Allendes et al. (2021) assert that telehealth emerged as a new opportunity to fill gaps in certain services, becoming a major alternative for conducting therapeutic sessions for individuals who were undergoing treatment or sought it during the pandemic, providing a means for them to continue receiving care.

According to Heinzen & Possolli (2022) from the perspective of traditional service approaches, one might think that telehealth or even telerehabilitation may not be effective. However, given the current reality caused by the pandemic, these methods have become indispensable for the continuity of services that were previously provided in person.

With the announcement of the pandemic on March 11, 2020, the World Health Organization (WHO) authorized, through Resolution No. 516, published in the Official Gazette on March 20, 2020, the services of Teleconsultation, Teleconsulting, and Telemonitoring. Thus, when the research participants were asked how long they had been using this model of care, eleven participants (31.2%) reported using it for about a year and six months.

With the need to reorganize services and maintain assistance to patients, professionals had to quickly and effectively adopt the distance care model, using mobile phones as a bridge for communication with their patients. According to the National Telecommunications Agency (ANATEL), there are 268,266,822 active lines in mobile telephony in Brazil. This data is from September 2023, indicating that mobile phones are one of the most accessible forms of communication among the Brazilian population.

In the study by Giovanella et al. (2022), titled “Challenges of Primary Care in Facing the COVID-19 Pandemic in SUS,” the author stated that, in her research, 72% of professionals used their own cell phones to contact users during the COVID-19 pandemic, with a higher frequency in the North and Northeast regions, highlighting their responsibility for user care. Souza-Junior (2014) states that the use of mobile phones also allows for information exchange via text messages, with some having access to various resources through internet connectivity. This information supports the findings of this study, where the most used technological resource by occupational therapists was their personal cell phones.

According to the results of this study, the professionals investigated have more than one work connection, being self-employed and holding a formal employment relationship under the Consolidation of Labor Laws (CLT) or being public servants with another work connection. In a study conducted between 2007 and 2008 by Bezerra et al. (2009) in Alagoas, the authors found a different reality regarding labor conditions, where 53% of the sample had statutory ties, followed by service provision at 23%.

There is a culture of job accumulation among healthcare workers, and this practice anticipated a current characteristic of contemporary work organization, which is “flexibility”. Bernardo et al. (2013) describe this notion as encompassing a set of characteristics, among which the need for workers to perform a wider variety of tasks stands out; the deregulation of working hours, with a bank of hours. Bernardo et al. (2013) assert that, due to the severe crisis faced by capitalism starting in the 1970s, which led to the reorganization of workers aiming to restore job accumulation levels, there was consequently an intensification of existing work processes and the creation of new forms of labor relations.

Regarding the characterization of telehealth sessions, the occupational therapists who participated in this study stated that the least used distance care model was the asynchronous format (n=9, 25.7%). Valverde et al. (2022) observed that, in asynchronous care, the main barrier identified was the engagement of some family members in the study and the use of the materials provided for training and subsequent application with children. Although the guides and audio materials were adapted to an appropriate language to facilitate understanding, and interns made themselves available for discussions about the materials, these moments occurred less frequently than expected by the therapists.

According to Heinzen & Possolli (2022), from the perspective of traditional service approaches, one might think that telehealth is inefficient; however, in the context of the pandemic, this method became indispensable for the continuity of services that were previously conducted in person. Medeiros (2023) tates that there are multiple applications of telemedicine, such as interactions between patients and health professionals, and interactions among health professionals and management activities, for example. Despite the diversity of telehealth actions, all contribute, in an interconnected way, to the needs of health systems, even if in different ways. In this research, 21 (60%) of the respondents used this method during the COVID-19 pandemic to maintain contact with their patients.

Regarding the documentation of sessions, only one (2.8%) participant reported not documenting the telehealth sessions. It is important to highlight the existence of Resolution 415, sanctioned in May 2012 by the Federal Council of Physiotherapy and Occupational Therapy (COFFITO), which specifically addresses the obligation of clinical records for occupational therapists and stipulates the obligation of documentation in patient records by the occupational therapist, as well as their storage and disposal.

Rodrigues (2021) states that therapy sessions conducted by phone were significantly shorter than those held in person, corroborating the findings of this research, where the average duration was between 10 and 30 minutes, according to 22 (62.8%) of the participants. The frequency of sessions was also reduced, occurring weekly, as indicated by the majority of responses (n=28, 80%). Souza-Junior (2014) emphasizes that professionals responsible for interventions must have the necessary knowledge and skills to conduct telehealth sessions, as well as demonstrate receptiveness and value respect and ethical conduct.

According to Magalhães et al. (2021), as a measure to maintain care and reduce the impacts caused by social restrictions, telehealth through online platforms served to ensure the maintenance of physical and mental well-being through guidance on health care, hygiene, and the performance of activities, involving the family in the therapeutic context.

Thus, homes were transformed into spaces that enabled remote meetings with professionals to ensure health promotion. Consequently, 26 (74.3%) of the occupational therapists who responded to this survey stated that their experience with telehealth was positive, highlighting points such as the maintenance of the bond with family and patients and expanded access, as found in the research conducted with occupational therapists in Alagoas.

While the absence of physical contact was seen as a negative aspect of this care format, it supports the reflections of Noal (2020) In an interview, the author of the book “The Human of the World: Diary of a Borderless Psychologist” discusses the challenges of care during COVID-19, noting that one of the challenges is directly related to our culture, considering the value placed on proximity and touch, as opposed to the need for social isolation imposed by the pandemic. She emphasizes the human capacity to reinvent oneself in extreme situations and the creativity that can be employed in this atypical context.

Considering the experience with this new work format, Morais & Azoni (2023) assert that professionals’ satisfaction with the work model was reported even before the COVID-19 pandemic, as most professionals from different categories agree that care through telehealth is effective. Medeiros (2023) notes that scientific evidence shows that telemedicine interventions are effective and facilitate access to and delivery of services, improving efficacy and promoting accountability in health care. This justifies the findings regarding whether there has been progress in patients with this mode of care.

The results found can prompt reflection on the remote care model, which was already being used by some health professionals in different situations. As Haddad (2012) states, the Brazilian Ministry of Health identified various existing experiences in the country involving telemedicine and telehealth starting in 2006. By uniting these experiences, a pilot telehealth project was developed and implemented to promote service qualification for Family Health Teams, increasing the resolvability of health care provided to the population and strengthening the primary care-based model as the entry point and organizer of the health system.

Over the years, and with increased access to the internet, remote care gained more visibility, and with the onset of the COVID-19 pandemic, other professionals utilized telehealth/telemonitoring as a means to ensure care for their patients. Oliveira et al. (2015) assert that the popularization of the internet has further accelerated advancements in Information and Communication Technologies (ICT), expanding the reach of telemedicine to include web-based applications, such as email, teleconsultations, and teleconferences, as well as multimedia approaches (digital images and video), increasing the availability and use of these technologies in developing countries and underserved areas of industrialized nations.

Studying new models of care and patient access is necessary to plan and execute higher quality and productivity in care. The results show that occupational therapy professionals encountered difficulties in this planning and that, despite noting positive aspects and observing good progress in their patients, they still require more tangible guidance on executing these services.

Conclusion

This study identified that the occupational therapists who conducted telehealth/telemonitoring in Alagoas are post-graduate professionals with more than five years of graduation; they provided assistance to individuals of all ages and are primarily employed in the public sector. The services lasted for about a year and six months, and personal cell phones were the main technological resource used.

The professionals conducted telehealth sessions once a week, with a duration of ten to thirty minutes. The occupational therapists faced challenges in starting this practice but noted progress in treatment and considered the experience positive. Additionally, they highlighted that maintaining the bond, family engagement, and closeness to the patient's context were positive aspects, while the difficulty of accessing quality internet was the main negative factor.

This type of care has been considered in the post-pandemic period, emerging as a complementary strategy to in-person follow-ups. The importance of studies in this area is emphasized, as it is a practice that already existed but has become more popular in recent years and is being used by health professionals, particularly occupational therapists.

There is a need for further studies on this topic and its use by occupational therapists, as well as investigations with patients/users to understand other questions that this research could not answer.

During the course of this study, some barriers were encountered, such as the difficulty of adherence from research subjects and the limited availability of literature on the topic.

  • 1
    It is care with remote interaction (suffix “tele”) using technology, in which the health professional and the user are in different locations.
  • 2
    It is registered and carried out between workers, professionals and managers in the healthcare area, using two-way telecommunication instruments.
  • 3
    It is the remote monitoring of users’ health and/or illness parameters through ICT. Monitoring may include the collection of clinical data, transmission, processing and a management by a healthcare professional using an electronic system (Simões, 2020).
  • 4
    Two masters and a doctor with expertise in the area.
  • How to cite: Silva, S. D. S., Amorim, N. C. R. S., Assis, V. L. B., Reis Neto, J. A., & Reis, M. C. S. (2024). Occupational therapists’ work process during the Covid-19 pandemic through telecare and telemonitoring. Cadernos Brasileiros de Terapia Ocupacional, 32, e3840. https://doi.org/10.1590/2526-8910.ctoAO395738402

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Edited by

  • Section editor
    Profa. Dra. Patrícia Leme de Oliveira Borba

Publication Dates

  • Publication in this collection
    17 Jan 2025
  • Date of issue
    2024

History

  • Received
    27 Apr 2024
  • Reviewed
    06 May 2024
  • Accepted
    22 Aug 2024
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