Worker’s health in the context of family health strategy: integrative literature review

ABSTRACT

Objective

To identify the production of knowledge about Worker’s Health in the Family Health Strategy (FHS) based on the national scientific literature.

Method

Integrative literature review. The search was carried out in October 2019 and updated in April 2020, in the following databases: Latin American and Caribbean Health Sciences Literature (LILACS) and Scientific Electronic Library Online (SciELO), through the Virtual Health Library (VHL) portal.

Results

754 publications were found in which the final sample of 19 articles was obtained. The analysis culminated in the construction of three categories: Actions aimed at Continuing Education; Environmental conditions and work overload and; Illness and mental and emotional overload of workers.

Conclusion and implications for practice

The insertion of the line of health care for workers in the FHS is still fragile, both with regard to actions aimed at FHS workers and for other workers in the territory. The scarcity of studies points to the need to expand professional and managerial initiatives that are able to meet the needs of professionals in the territory, as well as those who work in the units.

Keywords:
Occupational Health; Primary Health Care; Family Health Strategy; Education, Continuing; Work Environment

RESUMO

Objetivo

Identificar a produção de conhecimento sobre a Saúde do Trabalhador na Estratégia de Saúde da Família (ESF), com base na literatura científica nacional.

Método

Revisão integrativa de literatura. A busca foi realizada em outubro de 2019 e atualizada em abril de 2020, nas seguintes bases de dados: Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) e Scientific Electronic Library Online (SciELO), por meio do portal da Biblioteca Virtual em Saúde (BVS).

Resultados

Foram encontradas 754 publicações, nas quais se obteve a amostra final de 19 artigos. A análise culminou na construção de três categorias: Ações voltadas para a Educação Permanente em Saúde; Condições ambientais e a sobrecarga de trabalho; e Adoecimento e sobrecarga mental e emocional de trabalhadores.

Conclusão e implicações para a prática

A inserção da linha de cuidado da saúde do trabalhador na ESF ainda é frágil, tanto no que diz respeito às ações voltadas para o trabalhador da ESF como aos demais trabalhadores do território. A escassez de estudos aponta para a necessidade de ampliação de iniciativas profissionais e gestoras que consigam atender às necessidades de profissionais do território, bem como aqueles que trabalham nas unidades.

Palavras-chave:
Saúde do trabalhador; Atenção Primária à Saúde; Estratégia Saúde da Família; Educação em Saúde; Ambiente de Trabalho

RESUMEN

Objetivo

Identificar la producción de conocimiento sobre Salud del Trabajador en la Estrategia de Salud de la Familia (ESF), con base en la literatura científica nacional.

Método

Revisión integrativa de literatura. La búsqueda se realizó en octubre de 2019 y se finalizó en abril de 2020, en las siguientes bases de datos: Literatura Latinoamericana y del Caribe en Ciencias de la Salud (LILACS) y Scientific Electronic Library Online (SciELO), a través del portal de la Biblioteca Virtual en Salud (BVS).

Resultados

Fueron encontradas 754 publicaciones en las cuales se obtuvo la muestra final de 19 artículos. El análisis culminó en la construcción de tres categorías: Acciones dirigidas a la Educación Permanente en Salud; Condiciones ambientales y sobrecarga de trabajo y; Enfermedad y sobrecarga mental y emocional de los trabajadores.

Conclusión e implicaciones para la práctica

La inserción de la línea de atención de salud para los trabajadores en la ESF sigue frágil, tanto con respecto a las acciones dirigidas a los trabajadores de la ESF como a otros trabajadores en el territorio. La escasez de estudios apunta la necesidad de ampliar las iniciativas profesionales y gerenciales que puedan satisfacer las necesidades de los profesionales en el territorio, así como de aquellos que trabajan en las unidades.

Palabras clave:
Salud Ocupacional; Atención Primaria de Salud; Estrategia de Salud de la Familia; Educación Continua; Ambiente de Trabajo

INTRODUCTION

Worker’s Health is a field of Collective Health, with inheritances of Occupational Health, whose main objective is to establish relationships between the health-disease processes and the work routine, based on the assumption that work is one of the organizing axes of social life and determinant of people’s living and health conditions.^1,2

Interventions in Occupational Health must seek to transform productive processes, making them health promoters and not of sickness and death, and guarantee comprehensive health care for workers, considering their insertion in the productive processes.³

One of the spaces for the development of worker’s health interventions is Primary Care (PC), currently guided by the Family Health Strategy (FHS), in which multi-professional teams assume the health responsibility for a given territory, integrating surveillance actions, promoting health, disease prevention, diagnostics, curative treatments, rehabilitation, palliative care, and even harm reduction at individual and collective levels.⁴

It is a fertile ground suitable for carrying out health actions for workers, such as: mapping the productive activities of the territory; the identification of the workers’ social support network; the survey of basic records on occupation during family registration; the identification of health risk situations related to the occupation of the registered user; among others.⁵ Such activities are encouraged by the Ministry of Health, which also highlights the importance of offering actions to promote and protect workers’ health, focusing on the prevention, diagnosis and treatment of work-related injuries.⁵

It is assumed that the performance of all these activities could increase the health of workers. However, such activities are still incipient, and are often restricted to reports of accidents at work.⁶ Thus, the question arises as to how issues and problems inherent to the relationship between work and health in PC have been addressed.

This article aims to identify the production of knowledge about Occupational Health in the FHS, based on the national scientific literature. The justification for this investigation is based on the observation that, despite being a line of care, the health of the worker is a little explored theme in family health, especially with regard to workers performing in the territory of health responsibility.

METHOD

An integrative literature review (ILR) is presented, which addresses health actions aimed at assisted and active workers in the FHS. This is a technique for mapping the literature in a given research area, which allows the researcher to have a comprehensive view of what is published in a given domain.⁷

The PICo – Population, Intervention, Context and Outcome strategy⁸ was used to support this research. In the present study, the Population (P) included male and female workers part of and/or assisted by the FHS; Intervention (I) sought to understand the production of knowledge on occupational health; the Context (Co) was the territory; and the Outcome included the results and conclusions of the articles referring to the actions of the FHS focused on Worker’s Health. Thus, as the first step of ILR,⁷ the guiding question of the research was constructed: what are the actions aimed at the health of the worker attended/active in the FHS? For this, searches were carried out in national scientific databases. The research period included publications from 2012, until December 2019, since 2012 was the year of publication of the Law that provides for the National Policy on Occupational Health, as well as the National Policy for Primary Care.

In the second stage of ILR,⁷ the following inclusion criteria were established: 1. publications in article format; 2. publications in Portuguese, as it is a Brazilian health policy research; 3. publications with full text, available online. 4. texts between 2012 and 2019. As exclusion criteria, the following were outlined: 1. publications that did not answer the guiding question; 2. duplicate publications; 3. publications such as literature reviews on the same theme.

In the third stage of ILR,⁷ the information to be collected was defined, aiming to facilitate the categorization of studies, and, for this, an instrument with the following variables was used: title, year, country of origin, database, objective and prevalent themes.

The search was carried out in October 2019 and updated in April 2020, in the following databases: Latin American and Caribbean Health Sciences Literature (LILACS) and Scientific Electronic Library Online (SciELO), through the portal Virtual Health Library (VHL); the main collection of Web of Science, through the Capes Journal Portal. These bases were chosen due to their academic-scientific relevance.

For the search, Health Sciences Descriptors (“DeCS”) were initially used in the format of a Boolean phrase, citing: “worker’s health” AND “Family Health Strategy”. It is emphasized that such terms were listed after an exhaustive analysis of synonyms and combinations that expressed the search content, understanding that important terms for such construction have already been indirectly incorporated into this search, such as, for example, the concept of territory, which is indirectly associated with the term “family health strategy”. The search was complemented in April 2020, with the incorporation of new terms of analysis, in which the Boolean phrases were used, citing: “worker’s health surveillance” AND “worker’s health” AND “Family Health Strategy”; “Work Environment” AND “worker’s health” AND “Family Health Strategy”, and “work” AND “worker’s health” AND “Family Health Strategy”.

The flowchart with the representation of eligibility and inclusion of articles in the selection of studies is shown in Figure 1.

Figure 1
Flowchart with representation of eligibility and inclusion of articles in the selection of studies, 2020.

In the fifth stage,⁷ the studies were analyzed in a descriptive and interpretative manner, taking into account the ethical aspects, and respecting the authorship of the ideas, concepts and definitions pointed out by the authors. The selection of relevant studies was carried out based on the incorporation of inclusion and exclusion criteria, in the first search result, followed by the reading of titles and abstracts and, subsequently, of the publication as a whole. It should be noted that the evaluation process was carried out by three researchers, and only the publications relevant to at least two evaluators were included in the analysis corpus.

The sixth stage of ILR⁷ is to present this review in a synoptic table format, in order to summarize the most relevant findings. The variables selected to compose the table were the same as those used in step three of the ILR, to mention: title, year, country of origin, database, objective and prevalent themes.

RESULTS

754 publications were found. In the first exclusion stage, only manuscripts that met the inclusion criteria were considered, whose sample consisted of 266 articles. In the second stage, duplicate articles, literature review and not relevant to the theme articles were discarded, and at that moment, the sample of 46 articles was reached. After analyzing the results among peers, a sample of 19 articles was obtained, as described in Chart 1.

Chart 1
Articles selected for the study – Brazil, 2020.

Title, year, country and database	Population / Sample and study location	Objective	Prevailing themes
Work and mental health of professionals in the Family Health Strategy in a municipality in the State of Bahia, Brazil (2012, Brazil, SciELO)9	152 professionals (nurses, doctors and dental surgeons) – Feira de Santana (BA)	To describe sociodemographic and work characteristics and the prevalence of Minor Psychological Disorders (MPD) and of positives for the CAGE Questionnaire (alcohol abuse) among doctors, nurses and dental surgeons of the FHS in Feira de Santana, Bahia	Conditions / Work overloadMental health
Evaluation of Burnout Syndrome in professionals of the Family Health Strategy in the capital of Paraíba (2012, Brazil, SciELO) 1010	337 professionals (nurses, doctors, dental surgeons, nursing assistants, dental assistants and community health agents) – João Pessoa (PB)	To identify the possible affecting by Burnout Syndrome among professionals of the Family Health Team (FHSt) in João Pessoa, Paraíba	Health Prevention in Mental Health
Family Health Strategy professionals in the face of medical and social demands: difficulties and coping strategies (2012, Brazil, SciELO)11	68 professionals (nurses, doctors, nursing assistants and community health agents) – São Paulo (SP)	To investigate the difficulties and ways of coping mentioned by professionals of FHS teams, in face of the medical-social demands presented by users in their daily work	Conditions / Work Overload
			Education, Continuing
Psychosocial risks in family health teams: workload, pace and work schedule (2012, Brazil, SciELO)12	24 professionals (nurses, doctors, nursing assistants and community health agents) – No indication of Municipality (SP)	To analyze the psychosocial risks related to the workload, pace and work schedule of family health teams	Conditions / Work Overload
			Mental Health
The psychological distress of community health agents and their relations with work (2012, Brazil, SciELO)13	24 professionals (community health agents) – Rondonópolis (MT)	To analyze aspects that, when present in the conditions and work relationships of Community Agents of Health (CHA), can be related to the triggering of psychological suffering	Conditions / Work Overload
			Mental health
			Education, Continuing
The work process in the Family Health Strategy and its repercussions on the health-disease process (2012, Brazil, SciELO)14	243 professionals (nurses, doctors, nursing assistants and community health agents) – Brasília (DF)	To analyze the perception of workers in the Family Health Strategy of the Federal District about their work process and its repercussions on the health-disease process	Conditions / Work overload
			Interpersonal relationship
Psychological suffering in workers of the Family Health Strategy (2013, Brazil, VHL)15	79 health professionals (psychologists, nurses, social workers, physiotherapists, teachers, among others) – João Pessoa (PB)	To Investigate psychological suffering in health workers who participated in the Training Course of Multipliers in Workshops – Caring for the Caregiver	Conditions / Work Overload
			Mental health
			Education, Continuing
Worker’s health in the Family Health Strategy: perceptions of the nursing team (2013, Brazil, SciELO)16	6 nurses – Porto Alegre (RS)	To analyze the perception of the nursing team about the health of the worker of Family Health Strategy in southern Brazil	Conditions / Workload
			Mental Health
			Health Prevention
The process of mental illness of the worker of the Family Health Strategy (2013, Brazil, SciELO)17	36 professionals (unidentified categories) – João Pessoa (PB)	To know the process of mental illness of FHS workers and the triggering factors	Conditions / Overload Working
			Mental health In-service
			Education
University extension and practice of community health agents: welcoming and citizen learning (2014, Brazil, SciELO)18	Community Health Agents – Santos (SP)	To present the systematization of an intervention experience through a university extension project, bringing elements that enhance the actions of community health agents, of the Family Health Strategy (FHS) in Baixada Santista	Education, Continuing
The Community Health Agent Qualification and Development Program, from the perspective of the various subjects involved in primary health care (2015, Brazil, SciELO)19	15 participants (community health agents, managers, teachers and users) – A capital of the Southeast region	To identify, analyze and understand the implications of the Qualification and Development Program, concluded in 2009 by the School of Public Health of the State of Minas Gerais, in the personal and work life of the CHA and in the health care process, in the view of the various subjects involved in Primary Health Care (PHC)	Continuing Education
Training of doctors and nurses of the Family Health Strategy in the aspect of worker health (2016, Brazil, LILACS)20	6 professionals (nurses and doctors) – Goiânia (GO)	To assess the recognition of doctors and nurses of the Family Health Strategy of Aparecida Goiânia on occupational diseases	Education Continuing in Health
The worker in the family health program in the interior of the state of Amazonas: a qualitative study (2016, Brazil, LILACS)21	75 professionals (nurses, doctors, dental surgeons, nursing technicians, laboratory technicians, planning technicians, receptionists, dental assistants and community health agents) – Coari, Manacapuru, Parintins and São Gabriel da Cachoeira (AM)	Analysis of the work-subjectivity relationship in the Family Health Strategy in the interior of the state of Amazonas, from the perspective of psychodynamics of work	Mental health
			Interpersonal relationship
Sociodemographic, occupational profile and assessment of mental health conditions of workers of the Family Health Strategy in a municipality in Rio Grande do Sul, RS (2016, Brazil, LILACS)22	83 professionals (nurses, doctors, nursing technicians / assistants and community health agents) – without indication of Municipality (RS)	To describe the sociodemographic and occupational factors and to assess the prevalence of common mental disorders in workers of the Family Health Strategy (FHS) in Santa Cruz do Sul, RS	Conditions / Work Overload
			Mental health
Perceived stress in professionals of the Family Health Strategy (2017, Brazil, LILACS)23	450 professionals (nurses, doctors, nursing assistants and community health agents) – São Paulo (SP)	To assess the perceived stress (PS) of professionals in the Family Health Strategy (FHS) and the association with team characteristics. An association between PS and self-reported morbidity was also investigated	Mental Health
Evaluation of indicators and experiences of pleasure/suffering in family health teams using the Psychodynamics of Work framework (2017, Brazil, LILACS)24	68 participants (nurses, nursing technicians, doctors, dentists, psychologists, oral health technicians, social worker) – Porto Alegre (RS)	To evaluate indicators and experiences of pleasure and suffering among workers working in Family Health teams based on theoretical-methodological framework of the Psychodynamics of Work	Conditions / Work Overload
			Mental health
Burnout Syndrome in Family Health Strategy Doctors of Montes Claros, MG, and Associated Factors (2018, Brazil, LILACS)25	89 doctors – Montes Claros (MG)	To investigate the prevalence of Burnout Syndrome in doctors of the Family Health Strategy in Montes Claros, MG, and its association with stress at work, effort-reward imbalance and quality of life	Conditions / Work Overload
			Mental health
Analysis of the Work Capacity of Community Health Agents in João Pessoa-PB (2019, Brazil, LILACS)26	279 Community Health Agents – João Pessoa (PB)	To analyze the Work Capacity (WC) of Community Health Agents (CHA) of a Health District in João Pessoa-PB	Conditions / Work Overload
Evaluation of work in Primary Health Care in the city of Rio de Janeiro: an approach to worker health (2017, Brazil, LILACS)27	62 professionals (nurses, doctors, nursing technicians and community health agents) – Rio de Janeiro (RJ)	To analyze the evaluation of work in Primary Health Care in the city of Rio de Janeiro, with a focus on worker health	Conditions / Work Overload

• Source: The authors.

The articles were organized and analyzed using the thematic elements evidenced in their results and discussions, using interpretive reading for this purpose. The analysis culminated in the creation of three categories, to mention: Actions aimed at Permanent Education in Health; Environmental conditions and work overload and; Illness and mental and emotional overload of workers.

It is worth noting that, in the search, no initiative, strategy or action aimed at workers in the territory was identified and, thus, the results analyzed were only about professionals working in the FHS.

In addition, it is stated that all professional categories working in the minimum family health team were considered as participants in at least one study of the analysis corpus.

DISCUSSION

Actions aimed at permanent education in health

In this category, eight articles were included,^{11,13,15,17-21} which corresponds to 42% of the number of articles analyzed. In this context, it was observed that Permanent Health Education (PHE) can be a protective factor for workers, and one of the areas of greatest need to implement practices in PHE is mental health.^{11,13,17,19,20} Here, therefore, a relationship is established between PHE actions and the health of FHS workers, including health promotion, prevention and mental health care.

From spaces designed for structured and organized conversation, so that topics raised by the team itself can be discussed, it is possible for professionals to interact and get to know each other better, improving team performance and enabling mutual growth. This moment is also conducive to the identification of possible gaps between managers and workers, expanding their participation in decision-making, establishing co-responsibility in the results and improving the established indicators.^11,17,21

In order to establish educational processes based on PHE, in the context of the FHS, the interests of those involved must be respected, as well as the particularities of the work territory. The use of dynamic methodologies can better involve workers and facilitate learning, since the history and practice of those involved will be the starting point for changes and shared constructions, thus favoring the protagonism of the worker, being a defense mechanism in the establishment of illness processes.^{13,15,17,19,21}

Illness and mental and emotional overload of workers

Environmental conditions and work overload

In this category, nine articles were included,^{9,11-17,24,26} which corresponds to 47% of the number of articles analyzed. The work environment has a very close relationship with the professional’s motivation and also with the possibility of falling ill. In this sense, studies show that the intense workload, the inappropriate environment, as well as the lack of training can lead to the illness of professionals, both from a physical and mental point of view.^{9,11-13,15,16,24}

The workday was mentioned in all the studies analyzed as intensifying the workers’ stress. Nevertheless, it is taken into account that many of them continued to work in other jobs or in homes, ahead of the chores of the home and the education of their children.^{9,11,12,14-17}

Low wages contribute to financial insecurity, especially for the Community Health Agent, which creates the need to supplement family income with the help of other tasks.^9,11,17

The emotional involvement of professionals with work and the families served by the FHS was also mentioned as a factor of emotional distress, due to the limitations of the actions carried out and, above all, to the absence of interdisciplinary and intersectoral responses that assist the necessary referrals. This situation generates a great feeling of frustration and impotence because of the low resolution, which can lead to processes of exhaustion and illness.^11,14

The organization of the work process was mentioned among the factors of emotional stress for workers. Multitasking, due to the lack of human resources and work protocols, lack of training in specific areas – domestic and family violence, mental health, use of illicit drugs – translate into overload and low quality in the services provided, and still generate conflicts between the teams,^12-17,24 aggravating absenteeism.²⁴

The lack of inputs also contributes to the physical and emotional stress of the teams, generating insecurity during the workday and delay in completing tasks. Some professionals reported the feeling of incapacity in situations where they needed to perform a task and were prevented by the lack of material.^14-16,26

Another factor present in the studies was the demanding of goals and results by the management, without considering the variables described above.^14-17,24

Illness and mental and emotional overload of workers

In this category, 14 articles were included,^{9,10,12,13,15-17,21-27} which corresponds to 74% of the number of articles analyzed.

The FHS is seen as the structuring basis of Primary Care and an instrument for the reorganization of the UHS;⁴ however, there are operational failures that generate distances between the “theoretical UHS”, as formulated, and the “real UHS”, as found in the quotidian of Basic Health Units (BHU). These may be related to long working hours and rhythms, the almost non-existence of rest breaks throughout the day, the intense responsibility for the tasks performed, technical, personal and material limitations, the high demand for care and, in particular, low income. Such factors, when added to organizational pressures and experienced daily, generate emotional overload, which can even interfere in the relationship between professionals and users.^9,10,27

In this context, workers with long daily hours, especially when they have more than one job, inflexible hours and precarious working conditions, are vulnerable to psychosocial risks, being more likely to present a risk of psychological distress.^{9,12,13,15-17,21,24}

It appears that the institutional requirements – of the community and personal –, associated with the actions involved in the act of working, lead to consequences such as loss of the profession’s specifics, distortion of its attributions and states of alienation, expressed by the little reflection and discussion about the own practice. This process, in turn, catalyzes psychological suffering.^{13,16,17,21,24,26}

The mental health of the worker is directly influenced by the conditions of the place where the work is performed, and, among the various mental health problems that affect health workers, it is possible to mention depression, anxiety and Burnout Syndrome as the most frequent. Such grievances were associated with high psychological and professional demand, high wear and effort, excessive commitment to work and imbalance in the effort-reward ratio and poor working conditions.^15-17,23,25

It is necessary for UHS managers to recognize that the mental health of FHS professionals has a direct impact on the quality of services provided, and on their relationship with work and the community.^10,16,17,27

The prevention of mental suffering requires an integrated action, articulated between the assistance and surveillance sectors; and the assistance to workers in situations of suffering must be carried out by a multidisciplinary team, with an interdisciplinary approach, trained to deal with psychological suffering. In this sense, measures to protect and promote workers’ health must be outlined based on spaces for listening, reflections and support.^17,22

In-service Health Education (PHE) is the theoretical and methodological answer to the need for professional qualification, being considered one of the main pillars of support of the Unified Health System.²⁸ The PHE policy discusses the need for educational actions to be implemented and maintained in health services in the form of qualifying and training projects – based on the needs of the service –, taking into account the professional training of those involved, as well as the particularities of the region.²⁹

The practice of FHS workers is often influenced by the high demand for work and technical processes, pointing to an urgent need for constant qualification. In this sense, PHE is the most viable educational perspective, as it favors a space for the exchange of experience among workers, facilitating learning through acquired experiences and allowing integration between teams through interdisciplinary knowledge exchanges. Therefore, the practice of PHE is observed as a protective factor for workers’ health, as it allows the modification of practices based on their own professional experience.³⁰

Nevertheless, it is emphasized that, in the FHS, actions in workers’ health are beyond the educational perspective. Environmental factors, especially risks and work overload in the FHS, produce situations that directly impact workers’ health, affecting the work process and generating the need for immediate interventions, which are not always carried out.³¹

Allied to environmental conditions, devaluation is also present and influences the organization of the labor process.³² Analyzed in the light of the field of Occupational Health as social production, it can be said that environmental, organizational conditions and interpersonal relationships are elements that make reproduction of the health workforce difficult.^33,34

The sum of these vertices culminates in possible illness processes and, despite the high frequency of illnesses related to mental and emotional issues, coupled with the existence of a worker health protection policy,⁵ actions carried out for psychic emotional well-being are still scarce .

Mental illnesses are some of the main reasons for absences of the FHS worker and are mainly related to situations of dissatisfaction, such as inadequate physical structure, difficulties in the availability of inputs and materials, work evaluation processes and bureaucratization.³⁵

CONCLUSIONS

The analysis of the publications indicates that the insertion of the line of health care for workers in the FHS is still fragile, both with regard to actions aimed at FHS workers, as well as other workers in the territory. The scarcity of studies on this theme points to the need to expand professional and managerial initiatives, aiming to meet the needs of professionals in the territory, as well as those who work in the units, in order to develop health promotion actions and identify and intervene in processes illness.

At the present moment, when important changes are taking place within the scope of the National Primary Health Care Policy, in addition to the conjuncture of political and economic crisis and changes in the State’s capacity to guarantee social security for the working class, it is important to develop new studies. The aim is to know the working conditions and processes in the health sector, as a way to defend the Unified Health System and the right to quality public policies, for workers and the population.

Nevertheless, the lack of scientific and academic records that address the needs of workers performing in the FHS is highlighted. In this sense, there is a need for new participatory and resolute research, as well as the creation of public policies that guarantee the well-being of the worker.

In addition, new investigations must be carried out in this area, also contemplating assistance to workers in the territory who were not the focus of attention in the studies analyzed. A reorientation of the management of the FHS is necessary so that it can contemplate its original objective of health responsibility over the territory.

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Edited by

ASSOCIATED EDITOR: Gerson Marinho

Publication Dates

• Publication in this collection
  03 July 2020
• Date of issue
  2020

History

• Received
  18 Feb 2020
• Accepted
  29 Apr 2020