Prevalence of cardiometabolic risk factors in Brazilian military firefighters of both sexesAbstract
Introduction The high cardiovascular burden of the firefighting profession and the increased prevalence of risk factors for cardiometabolic diseases (RFCD) in the general population requires special attention in this workforce.
Objective To investigate the prevalence of RFCD in Brazilian military firefighters of both sexes.
Methods In 2023, a cross-sectional study was conducted among 247 firefighters, 27.5% women (36.3 ± 7.2 years) and 72.5% men (41.6 ± 9.1 years), through online, translated, and validated questionnaires. Cardiovascular risk stratification was carried out according to American College of Sports Medicine-ACSM guidelines.
Results The most prevalent modifiable RFCD were arterial hypertension (38.5%), hyperglycemia (30.8%), and hypercholesterolemia (20.2%). 75 participants (30.4%) reported not knowing their lipid profile and 58.7% were unable to report whether their blood glucose was within or outside the normal range. Most participants (52.6%) presented high cardiovascular risk, with the proportion being higher among women (73.5%). Only 15.4% of the sample were physically inactive.
Conclusion The military firefighters evaluated showed a worryingly high proportion of RFCD, as well as high cardiovascular risk. Our findings support the need for health education and screening, prevention, and treatment strategies for RFCD in these professionals, especially given the intrinsic high cardiovascular risk associated with this profession.
Firefighters; Cardiovascular Diseases; Cardiometabolic Risk Factors; Occupational Health
Resumo
Introdução A alta sobrecarga cardiovascular da profissão de bombeiro e a elevada prevalência dos fatores de risco para doenças cardiometabólicas (FRDCM) na população em geral orientam atenção especial nesta força de trabalho.
Objetivo Descrever a prevalência de FRDCM em bombeiros militares brasileiros de ambos os sexos.
Métodos Estudo descritivo, com amostra não probabilística, cuja coleta de dados foi realizada em 2023, por meio do uso de formulário on-line, que continha instrumentos traduzidos e validados. A estratificação de risco cardiovascular foi realizada segundo diretrizes do Colégio Americano de Medicina do Esporte – ACSM.
Resultados Participaram 247 bombeiros, sendo 72,5% do sexo masculino. Os FRDCM modificáveis mais prevalentes foram: hipertensão arterial (38,5%), hiperglicemia (30,8%) e hipercolesterolemia (20,2%); 30,4% dos participantes relataram desconhecer seu perfil lipídico e 58,7% não souberam reportar se a glicemia estava dentro ou fora da faixa de normalidade. A maioria dos participantes (52,6%) apresentou alto risco cardiovascular, sendo a prevalência maior no sexo feminino (73,5%). Apenas 15,4% eram fisicamente inativos.
Conclusão Os bombeiros militares avaliados apresentaram prevalência preocupantemente elevada de FRDCM, assim como de alto risco cardiovascular. Os achados suportam a necessidade de estratégias de educação em saúde e de rastreio, prevenção e tratamento de FRDCM nesses profissionais, especialmente frente ao elevado risco cardiovascular associado a esta ocupação.
Bombeiros; Doenças Cardiovasculares; Fatores de Risco Cardiometabólico; Saúde do Trabalhador
Introduction
The duties of the military firefighter profession are associated with high health risks because they include intense physical and emotional demands, which result in high cardiovascular overload1,2. Evidence shows that during the performance of their duties, professional firefighters can suffer additional increases in heart rate and blood pressure, which are accompanied by changes in blood flow, vascular shear stress, a decrease in plasma volume, an increase in blood viscosity, a procoagulant state, and even low-level myocardial damage and ischemia1,3,4.
In parallel with the characteristics of the profession, which entail a high cardiovascular burden1,4, it is important to consider the global context, in which the most recent estimates from the World Health Organization (WHO), with data from 2019, indicate that, as in 2010, cardiovascular diseases (CVD), especially ischemic heart disease, are still the leading cause of death in the world5. Other WHO estimates suggest that by 2030 the number of deaths will be 23.6 million6. In Brazil, 30% of deaths are due to CVD7. Among firefighters, the situation seems quite similar, despite the great physical and emotional demands inherent in the job1,8.
A large-scale study among North American firefighters showed that the prevalence of cardiometabolic risk factors among firefighters was similar to that of the general population9, although the prevalence rates were high, and the profession of firefighter is known to have a higher cardiovascular risk4. A study carried out in Rio de Janeiro, Brazil, showed that the main causes of death among male military firefighters between 2006 and 2015 were CVD, accounting for 29.7% of deaths10.
The main risk factors for cardiometabolic diseases (CMD) can be divided into non-modifiable ones, such as age, sex, and family history; and modifiable ones, such as obesity, systemic arterial hypertension (SAH), dyslipidemia, sedentary lifestyle, smoking, and diabetes mellitus11.
The findings regarding age are particularly worrying when analyzing the risks of CMD among firefighters, given that the prevalence of hypertension has been shown to be very high among these workers12,13, as well as the fact that there seems to be a trend towards longer career spans, given the changes in pension schemes in different countries14.
The high cardiovascular burden that comes with being a firefighter and the increased prevalence of CVD risk factors in the general population call for greater attention and care for this population. The international scenario points to a high prevalence of CVD risk factors among firefighters in different countries. A study evaluating more than four thousand North American firefighters identified a high prevalence of obesity, which in turn was associated with a high prevalence of hypertension, dyslipidemia, and hyperglycemia9. A similar condition of high proportions of conditions that increase cardiovascular risk has also been reported among Korean firefighters15. A recent systematic review including firefighters from different regions of the world confirmed this worrying scenario16.
The aim of this study was therefore to investigate the prevalence of risk factors for CVD in Brazilian military firefighters of both sexes. It is estimated that more detailed knowledge of the cardiometabolic risk scenario among these professionals could be of great value in guiding disease prevention and health promotion actions.
Methods
Study design and context
This is a cross-sectional study carried out between May and June 2023 with Brazilian military firefighters.
Participants
The sample was non-probabilistic, made up of volunteers. The only inclusion criterion was to be working in a Brazilian military firefighting institution, without any medical restrictions for work activities.
The general invitation presenting the survey was published in the partner institution’s internal bulletin, as well as sent by e-mail to all active-duty military personnel, thus boosting dissemination to around 5,000 military firefighters of both sexes.
Data collection
Data was collected using a questionnaire on Google Forms. The Informed Consent Form (ICF) was displayed on the initial screen of the electronic form received with the invitation to participate. After signing their agreement, the participants proceeded to fill in the questionnaire.
Due to the low turnout resulting from the initial publication of the survey in the institution’s internal bulletin, two extensions were made to the initially planned deadline, and the e-mail strategy was included, which resulted in a significant increase in the number of participants.
There was no electronic lock a priori to prevent duplicate answers, inconsistencies or filling in by robots. However, no repeated data was identified, and any inconsistencies were rectified during the preliminary exploratory analysis of the data. Given the diversity of answers and fields on the form, as well as the fact that filling it in was voluntary, we believe that the possibility of robots filling it in, even if possible, is negligible.
All the information collected was self-reported by the participants.
Variables
Socio-demographic data and data on general aspects of health and work were collected. The work regime was classified into three possibilities: 1) 24hx72h scale, used in the standby teams in the barracks and meaning 24h shifts interspersed with 72h of rest; 2) 12hx24h and 12hx72h, for the pre-hospital emergency teams, with 12h work shifts for 24h of rest followed by other 24h shifts and a subsequent 72h off; and 3) expedient, characterized as a daily routine of 8h working on working days.
A cardiovascular risk stratification questionnaire adapted from the American College of Sports Medicine (ACSM) guidelines was used. This questionnaire is divided into three main parts: one which asks about the presence of cardiometabolic risk factors, another about the presence of signs or symptoms suggestive of CMD, and a third part about knowledge of previous diagnoses of CMD, such as diabetes and coronary heart disease. Risk factors include age, family history, smoking, hypertension, hypercholesterolemia, fasting glucose, obesity, and a sedentary lifestyle17.
Those classified as low risk were younger individuals (men < 45 years old; women < 55 years old) who were asymptomatic and had at most one risk factor present. Those at moderate risk were older (men ≥ 45 years of age; women ≥ 55 years of age) and with two or more risk factors. High risk included all those with any signs or symptoms of CMD or with a previous medical diagnosis of these conditions17.
For the anthropometric assessment, body weight and height were collected, and the body mass index (BMI) was calculated. Nutritional status was classified according to WHO criteria: less than 18.5 kg/m2, underweight; from 18.5 to 24.9 kg/m2, eutrophic; from 25.0 to 29.9 kg/m2, overweight; from 30.0 to 34.9 kg/m2, grade I obesity; from 35.0 to 39.9 kg/m2, grade II obesity; equal to or greater than 40 kg/m2, grade III obesity18.
The level of physical activity (PA) was assessed using the International Physical Activity Questionnaire (IPAQ) validated for Portuguese19, categorizing the participants as active (those who met the minimum PA recommendations for health according to the WHO / ≥ 150 min/week of moderate to vigorous intensity PA; and inactive (those who did not meet the recommended minimum weekly amount)20.
Biases
Considering the nature of the variables being analyzed and the hierarchical system in which the volunteers are inserted, selection bias might occur. To minimize the possibility that subgroups with a higher or lower cardiometabolic risk might have different motivations for participating or refusing, during the research announcement/invitation, emphasis was placed on explaining that everyone’s participation was necessary and welcome, regardless of characteristics such as function, rank, age, sex/gender, among others. It was also made clear that this was independent research, conducted by members of the university with prior evaluation by the Ethics Committee and without any employment links or repercussions. The use of a self-reported information to assess the study variables possibly introduced bias, such as overestimation of the level of PA. To mitigate the occurrence of this type of bias, validated questionnaires appropriate for the study population were used.
Data analysis
Microsoft Excel® 2016 software version 16.0 was used to organize the database. Descriptive statistics were used, expressing the data as mean values and standard deviation, and absolute and relative frequencies were calculated for categorical variables.
Ethical considerations
The project was approved by the Human Research Ethics Committee of the Faculty of Health Sciences of the University of Brasília (CAAE: 80792017.8.0000.0030) on June 16, 2018. Prior authorization from the military corporation in which the study was carried out was obtained. All participants consented to the ICF.
Results
The sample consisted of 247 military firefighters, 27.5% (n= 68) female and 72.5% (n= 179) male. The average age was 36.3 (standard deviation: 7.2 years) among female participants and 41.6 (standard deviation: 9.1) males. Most participants of both sexes were married (71.3%), almost all of whom (92.3%) had at least completed higher education (college degree, specialization, or master’s degree), 71.3% worked in the expedient regime and 43.7% had a BMI within the normal range. Around half of them, 46.6% (n = 115), earned between five and ten minimum wages and 42.1% (n = 104) were the only ones contributing to the family income. More than half of the sample consumed alcohol to some degree, 64.8% (n= 160) (Table 1).
The most prevalent risk factors were hypertension (38.5%), age 45 or over in men (33.6%), and hyperglycemia (30.8%) (Table 2). However, 30.4% reported not knowing whether they had hypercholesterolemia and more than half, 58.7%, were unable to report whether their blood glucose levels were within or outside the normal range. It is therefore highly likely that these two cardiometabolic risk factors were underestimated. More than half of the military firefighters had a high cardiovascular risk (52.6%), according to the ACSM classification (Table 3).
The prevalence of signs and symptoms suggestive of CMD or pulmonary disease among military firefighters was higher in females, except for claudication, which was more prevalent in males (Table 4). The prevalence of previously diagnosed metabolic disease was also higher in females (Table 5).
Discussion
This study found a high prevalence of cardiometabolic risk factors, as well as a worrying proportion of firefighters classified as being at high cardiovascular risk, especially females. The findings corroborate those of previous studies, in the sense that firefighters have high proportions of cardiometabolic risk factors, often like those of the general population, although they perform very different activities and are known to have a higher cardiovascular risk12.
In this scenario, the high proportions of firefighters in the overweight range (overweight + obesity) and reporting systemic arterial hypertension stand out, which again confirms previous findings12,21. In these cases, the proportion of overweight male firefighters is almost twice as high as that of females, as is the proportion of hypertension. A new finding worth highlighting is that, despite the lower prevalence of cardiometabolic risk factors in females and the lower average age, the proportion of those with high cardiovascular risk was higher than in males, which can be explained by the greater presence of reports of signs and symptoms suggestive of CMD, as well as a previous diagnosis of diseases associated with higher cardiovascular risk. It is also important to mention that, despite the fact that most of the sample was not working exclusive shifts for those directly involved in rescue or emergency activities, which is a distinguishing feature of the sample in this study, the findings are very worrying in view of the high physical and emotional demands characteristic of the profession2,4, in which everyone can be called upon at any time.
The findings of this study have important practical implications, whether for the workers involved in this profession, for the health services of military fire departments in Brazil, or for society, in the sense that they contribute to understanding the cardiometabolic risk scenario in a large category of workers with high social importance. Better knowledge of the distribution of cardiometabolic risk factors in this category can contribute to the implementation of training strategies aimed at self-care, the possible improvement of routine occupational assessments, which can incorporate strategies for even earlier identification of more prevalent risk factors, firefighters belonging to groups with a higher risk of greater illness, as well as an understanding of the differences found between the sexes.
About the high prevalence of cardiometabolic risk factors, especially obesity and hypertension, the findings of this study are consistent with what has been found in firefighters in other countries. A study of 417 firefighters in France found that the most common cardiovascular risk factors were overweight and obesity (62.1%) and hypertension (27.8%)22. American firefighters followed from 2015 to 2018 showed a 48% prevalence of overweight and 36% of obesity. In addition, among male and female firefighters with obesity, 81% and 58% had high blood pressure levels, respectively. Being in a higher BMI category was significantly associated, regardless of age, with a higher prevalence of all the CVD risk factors examined in male firefighters, including high blood pressure, high cholesterol, high triglycerides, and high blood glucose. Among normal-weight female firefighters, 25% had high blood pressure and 0% had high blood glucose, while obese firefighters had a prevalence of 57% and 11%, respectively9.
In Quebec, Canada, a study of female firefighters, also using online questionnaires and with a similar average age (38.2, standard deviation 9.9 years) and risk stratification approach to the present study, showed that around 11% were at moderate risk and 65% at high risk of CVD, according to the ACSM23. It should be noted that these results were very similar to those reported here.
In this study, the proportion of signs and symptoms suggestive of CMD among female firefighters was higher than among male. Self-reported chest pain, according to the Cardiovascular Statistics - Brazil 2021, can be related to cardiovascular problems and obstruction of the heart’s arteries and was more prevalent in women than in men in all the studies described7. In women, the most significant traditional risk factors for CVD include systemic arterial hypertension, dyslipidemia, diabetes mellitus, smoking, obesity, and a sedentary lifestyle24. The prevalence of these risk factors has been increasing, even in younger women and, when associated gender-specific risk factors, they contribute to an increase in morbidity and mortality24.
The high prevalence of risk factors in military firefighters is worrying, given that firefighters can exert maximum effort under stressful conditions. In this context, the high prevalence rates observed here, in both sexes, would already be worrying in the general population. Among firefighters, the concern is even greater, since the higher cardiovascular risk in these professionals may be related to their work activities1.
According to Vigitel 2023, the frequency of being overweight in Brazil in 2022 was 61.4%, and this was higher among males (63.4%) than females (59.6%). Obese adults accounted for 24.3% of the population interviewed, which was similar for females (24.8%) and males (23.8%). For the total population and for women, the frequency of obesity was lower among those with more schooling. In the Federal District, 60.3% of adults were overweight, 62.4% males and 58.6% of females; while 21.9% were obese, 16.9% males and 26.2% females25. In this study, the prevalence of overweight and obesity was lower than in the general population and, as in the population as a whole, there was a higher prevalence in males than in females. Compared to data stratified by sex and age group25, the findings presented here indicate a lower prevalence of obesity in this group of military firefighters, especially in females (7.4% vs. 27.4%). In males, the difference also favored firefighters, but to a lesser extent (16.2% vs. 26.5%). A lower prevalence of overweight among firefighters compared to the general population is desirable and expected, given the physical demands of the profession8. However, considering the demands of the job and the known harm to health cardiovascular associated with obesity26, prevalences of 7.4% and 16.2% among female and male firefighters, respectively, with such a low average age, cannot be underestimated.
In the United States, a survey of firefighters found that 49% of male participants were overweight and 37% were obese. Among female firefighters, 39% were overweight and 27% were obese9. In Espírito Santo, Brazil, a high prevalence of overweight (48.7%) and obesity (11%) was reported among male firefighters26. A study previously carried out in the Federal District reported that 54.3% of male firefighters were overweight and 14.7% were obese21. In the current study, the prevalence rates were lower than those found in fire departments in other studies, and only slightly higher than those reported among firefighters in the Federal District (14.7% vs. 16.2%).
Obesity is an independent risk factor for CVD. An accumulation of excess adiposity leads to various pro-inflammatory effects on the vascular system, including dysregulation of adipocyte tissue and decreased sensitivity to insulin. These conditions can cause endothelial dysfunction, which is further linked to atherosclerosis, hypertension and hyperlipidemia27. Obesity has also been associated with a twofold increased risk of left ventricular hypertrophy in firefighters28.
SAH is a chronic non-communicable disease characterized by persistent elevation of blood pressure (BP), i.e. systolic BP (SBP) greater than or equal to 140 mmHg and/or diastolic BP (DBP) greater than or equal to 90 mmHg29.
A study carried out in Pará, Brazil, found that only 23.5% of the military firefighters surveyed had systemic BP within the normal range30. An American study, which used lower diagnostic values for SAH: SBP > 130 mmHg and DBP > 80 mmHg, reported that in the 20-29 age group, 45% of male firefighters were hypertensive and 11% of females had SAH. These figures increased to 77% and 79%, respectively, in the 50 to 59 age group, showing that at older ages, the prevalence of SAH in women is similar to that in men12.
Because it is often an asymptomatic and silent disease, hypertension tends to progress with structural and/or functional changes in target organs such as the brain, heart, kidneys, and vessels and has an independent, linear, and continuous association with CVD, chronic disease, and premature death. Increased BP contributes directly or indirectly to 50% of CVD deaths29. In this study, hypertension was the most prevalent risk factor for CVD in both men and women.
Another risk factor for CVD that has increased in prevalence in recent years is dyslipidemia31. When total cholesterol is greater than or equal to 200 mg/dL, it is considered high. High cholesterol was found in 22.98% of military firefighters in the state of Espírito Santo26. In the United States, there was an increase in cholesterol values from 9% to 14% in a five-year follow-up of a group of firefighters32. In the current study, cholesterol was high in 20.2% of the sample, which is highly worrying in this population, given the association between high total cholesterol values and the risk of CVD33,34.
The 2019 Brazilian National Health Survey (PNS) revealed that 7.5% of people had never had a blood test to measure cholesterol and triglycerides, of which 4.4% were female and 11.0% male31. In this study, 30.4% of the participants were unaware of their cholesterol levels. This finding is worrying given the recognized role of cholesterol in the formation of atheromatous plaques, which increases the risk of CVD33, especially in a profession with a high cardiometabolic risk. There’s no way of thinking about prevention when you don’t know the problem exists.
High cholesterol is a risk factor for the formation of atherosclerotic plaque, which begins with aggression against the vascular endothelium and, as this becomes more fragile, contributes to plaque instability, rupture, and ultimately thrombosis, which leads to the occurrence of an acute cardiovascular event34. In this way, identifying asymptomatic individuals who are more predisposed is crucial for effective prevention, with the correct definition of individual therapeutic goals, which is absolutely necessary for members of a profession with a high cardiometabolic risk.
Among all the risk factors for the development of atherosclerotic disease, diabetes mellitus is one of the most damaging 33,34. The frequency of diabetes in Brazil in 2023 was 10.2%. As with hypertension and dyslipidemia, women had a higher proportion of reported diabetes diagnoses than men (11.1% vs. 9.1%)25. A study in Canada with female firefighters reported a prevalence of 3%23. In the present study, more than half of the participants were unable to say whether their blood glucose levels were within or outside the normal range, a fact which may hinder screening for health risk factors and early diagnosis of diabetes, preventing more effective disease prevention measures, as in the case of lack of knowledge of dyslipidemia.
In Brazil, 9.3% of adults smoke, and the prevalence is higher in males (11.7%) than in females (7.2%)25. Smoking was a cardiovascular risk factor with a low prevalence in this study.
This survey found a low prevalence of inactive participants (15.4%). When categorizing by sex, 13.2% of female and 16.2% of male firefighters were classified as inactive according to the IPAQ (< 600 MET/week). The low prevalence found may be related to the very nature of the profession. This professional activity is classified in the Compendium of Physical Activities as a profession with vigorous intensity work activities ranging from 6.8 to 9.0 MET35. In a Brazilian study evaluating the intensity of PA performed by military firefighters while fighting forest fires, it was observed that firefighters performed more than 110 minutes of vigorous intensity (>76% and < 94% of the maximum heart rate predicted for their age) and more than 30 minutes of very vigorous intensity (>= 94% of the maximum heart rate)36.
A cross-sectional censitary study among military personnel from a fire department battalion in the state of Minas Gerais, Brazil, which investigated levels PA using the IPAQ short version, revealed a higher prevalence of physical inactivity than that observed in this study. Of the 202 participants in the study, 70.3% were physically active and 29.7% insufficiently active37. Even though the numbers observed were higher than in this study, the prevalence of inactivity was still lower than that observed in the Brazilian population31. It is known that a sedentary lifestyle is directly related to risk factors for CVD12. Despite the low prevalence of physical inactivity, more than half of the military firefighters had a high cardiovascular risk (52.6%), making the occupational risk of the profession more evident. However, this does not diminish the importance of practicing PA, as it seems to be inversely associated with occupational stress and serves as an important mitigating factor of occupational stress in firefighters38. A study, in Greece, with 430 firefighters aged between 21 and 60 investigated the association between PA and occupational stress. Using logistic regression models with multivariable adjustment, it was found that firefighters who exercised had a 50% lower risk of occupational stress and, using a categorical model, it was shown that each hour per week of increased PA by firefighters was associated with a 16% lower risk of occupational stress after adjusting for age, education, smoking, and BMI38. This evidence demonstrates the indirect effect of PA on factors directly related to cardiovascular health, such as occupational stress among firefighters.
It is important to recognize the limitations of this work. Firstly, the non-probabilistic nature of the sample, which could lead to selection bias. The low proportion of respondents also limits the external validity of the findings. The relatively short time taken to publicize the survey is one of the possible explanations for the low response rate. Self-reported answers may constitute response bias and have affected the validity of the results, in addition to the impossibility of debating the answers39. BMI has limited capacity to distinguish between fat mass and fat-free mass, which can lead to incorrect classification of obesity using this index. However, BMI is accepted worldwide for estimating the prevalence of obesity and has even been validated for use among firefighters, without overestimation occurring, both in Brazil and abroad40. Another important limitation of our study concerns the high percentage of respondents who reported not knowing their lipid profile and blood glucose values (30.4% and 58.7%, respectively). There may have been an underestimation of the estimated prevalence of both risk factors and the proportion of those with a moderate level of cardiovascular risk.
Conclusion
The most prevalent risk factors among the firefighters taking part in the study were hypertension, age 45 or over in males, and hyperglycemia. Most of the participants were unable to report whether their cholesterol and blood glucose levels were within or outside the normal range, and these risk factors may have been underestimated. More than half were at high risk of CVD, and the proportion of signs and symptoms suggestive of CVD in women was higher than in men.
Military firefighters, together with health professionals, should consider a comprehensive program that addresses screening, prevention, counseling, education, and treatment of prevalent cardiometabolic risk factors, since this class of workers is routinely exposed to greater cardiovascular risk. These efforts should be instituted early in the firefighter’s career, as aging is associated with worsening cardiometabolic health, and many firefighters remain operationally active throughout their careers.
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Information about academic work:
The authors inform that the work was based on the master’s thesis by Alessandro Fernandes de Oliveira, entitled “Risco cardiometabólico de bombeiros militares de ambos os sexos e sua associação com o estilo de vida, saúde e trabalho (Cardiometabolic risk of military firefighters of both sexes and its association with lifestyle, health, and work)”, presented in 2023 to the Postgraduate Program in Physical Education at the University of Brasília.
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Data availability:
The data set that supports the results of this study is not publicly available. The data collected comes from a research project previously approved by the Ethics Committee for Research with Human Beings, in which there was no provision, at the time, for the data to be made publicly available.
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Presentation at a scientific event:
The authors declare that this study has not been presented at a scientific event.
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Funding:
The authors declare that the study is part of a project that received funding from the Federal District Research Support Foundation (FAPDF) - Call for Spontaneous Proposals 3-2016, project 00193.001467/2016
Edited by
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Editor-in-Chief:
Ada Ávila Assunção
Data availability
The data set that supports the results of this study is not publicly available. The data collected comes from a research project previously approved by the Ethics Committee for Research with Human Beings, in which there was no provision, at the time, for the data to be made publicly available.
Publication Dates
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Publication in this collection
13 June 2025 -
Date of issue
2025
History
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Received
03 Nov 2023 -
Reviewed
14 Apr 2024 -
Accepted
24 June 2024
