Effects of pay for performance on motivation and professional engagement in primary health care

Abstract

Pay-for-performance has been used as a strategy to encourage improved health outcomes. This qualitative study analyzed the effects of this strategy on the motivation and engagement of the professionals involved. Focus groups, analyzed using content analysis, revealed mixed effects: while some reported recognition, professional appreciation, and enthusiasm for achieving goals, others pointed to perceptions of unfairness, embarrassment, and inappropriate behaviors. It is therefore highlighted that the success of performance-based pay programs depends on careful planning, transparency, effective communication, and active participation of professionals, to transform financial incentives into genuine engagement and improved services.

Keywords
Primary health care; Pay for performance; Motivation; Work engagement

Resumo

O pagamento por desempenho tem sido utilizado como estratégia para incentivar a melhoria de resultados em saúde. Este estudo, de abordagem qualitativa, analisou os efeitos dessa estratégia na motivação e no engajamento de profissionais envolvidos. Grupos focais, verificados por meio de análise de conteúdo, revelaram efeitos mistos: enquanto alguns relataram reconhecimento, valorização profissional e entusiasmo em atingir metas, outros apontaram percepções de injustiça, constrangimento e comportamentos inadequados. Destaca-se, portanto, que o êxito dos programas de pagamento por desempenho depende de planejamento criterioso, transparência, comunicação efetiva e participação ativa dos profissionais, a fim de transformar incentivos financeiros em engajamento genuíno e aprimoramento dos serviços.

Palavras-chave
Atenção primária à saúde; Pagamento por desempenho; Motivação; Engajamento no trabalho

Resumen

La remuneración por desempeño se ha utilizado como estrategia para fomentar mejores resultados en salud. Este estudio cualitativo analizó los efectos de esta estrategia en la motivación y el compromiso de los profesionales involucrados. Los grupos focales, analizados mediante análisis de contenido, revelaron efectos mixtos: mientras que algunos participantes reportaron reconocimiento, aprecio profesional y entusiasmo por el logro de objetivos, otros señalaron percepciones de injusticia, vergüenza y comportamientos inapropiados. Por lo tanto, se destaca que el éxito de los programas de remuneración por desempeño depende de una planificación cuidadosa, transparencia, comunicación efectiva y la participación activa de los profesionales, con el fin de transformar los incentivos financieros en un compromiso genuino y mejores servicios.

Palabras clave
Atención primaria de salud; Pagar por el rendimiento; Motivación; Compromiso laboral

Introduction

Pay for performance (P4P) has been a strategy used in the health sector to improve the performance of service providers by encouraging behavior change for the desired output¹. It encourages healthcare professionals and institutions to improve performance to increase the quality of care or reduce costs².

Recent evidence shows that pay for performance (P4P) in health can generate short-term improvements, especially in specific goals, as well as positive impacts on the quality of care and on indicators of chronic disease³. Potential risks include generating undesirable effects and unintentional behaviors, such as distortions; fraud in reports, dependence on financial incentives, neglect of important, unrewarded tasks, selection of patients to achieve goals more quickly, demoralization, bureaucracy, reduced intrinsic motivation, and other uncertainties^3,4.

Although widely used across countries, the P4P strategy still lacks further evidence on its effects³. Despite isolated P4P initiatives in Brazil and discussions on this topic since the mid-eighties, at the end of the 2000s, government initiatives focusing on managerial strategies were still incipient⁵. However, in the interior of Piauí, the municipality of Piripiri adopted P4P strategies even before the Ministry of Health programs launched its most recent programs, making it fertile ground for this investigation.

In 2008, the municipality instituted an oral health incentive aimed at improving coverage of essential oral health services that concentrated on three indicators (individual basic dental procedures, first programmatic dental appointment, and supervised brushing). The implementation of this program coincided with the achievement of the best oral health indicators in the state of Piauí, which was nominated for the Smiling Brazil National Prize in 2008 and 2010^6,7. In the following year, the initial incentive was expanded and replaced by the Incentive Program for Family Health Performance Improvement in the Family Health Strategy (PIMESF), covering all primary health care (PHC) teams, designed to face some challenges of the Municipal Health Secretariat (SMS): lack of performance evaluation, weak integration of teams, lack of self-monitoring, and disparity in health outcomes. With voluntary participation, the program offered a financial incentive tied to the team’s performance in six indicators of the Pact for Health, resulting in overall improvement^6,7.

At the national level, P4P gained strength with the Primary Care Access and Quality Improvement Program (Programa de Melhoria do Acesso e da Qualidade da Atenção Básica, PMAQ-AB), launched in 2011, which financially rewarded family health teams through an evaluation system that merged structure, work process, health outcomes, and permanent education, through the monitoring of pre-established indicators and voluntary participation of health teams^5,8.

The PMAQ-AB was established to improve access and quality of services in Primary Health Care, emerging amid growing pressure from managers for greater funding in the face of reduced federal transfers and the political need to link resources to results. Despite having consolidated itself as an important additional source of funds for PHC, the program had weaknesses in its incentive designs, which lacked greater clarity and better structuring to induce improvement sustainably⁹.

In 2019, the Previne Brasil Program replaced the PMAQ-AB to overcome organizational challenges and ensure greater funding for PHC. The program sought to restructure the primary care financing model, increase access to services, expand effective coverage, and improve the quality of care, focusing on health indicators and the accountability of managers and professionals¹⁰.

Considering this path, it is important to recognize that P4P programs are not restricted to technical monitoring instruments; they also configure social systems that mobilize different reactions among health professionals, even in similar contexts, producing varied effects within the organization¹¹. Thus, the analysis must go beyond formal indicators and contemplate the processes, perceptions, and behaviors that support or tension the results¹².

This study sought to analyze the effects of pay for performance instituted by the PMESF, PMAQ-AB, and Previne Brasil programs on the motivation and engagement of PHC professionals, contributing to the debate on the consequences and impacts of this strategy on public health.

Methodology

This is a qualitative and descriptive study, with an analytical scenario located in Piripiri, Piauí, Brazil, a municipality that has a population of approximately 65,000 inhabitants¹³ and a mostly public health care network¹⁴, with total coverage of PHC¹⁵.

Data were collected through interviews with PHC professionals in focus groups. A focus group (FG) is a type of qualitative interview in which participants exchange ideas, points of view, and experiences on topics of common interest¹⁶.

In April 2024, three focus groups were held. Each group had seven to eight participants, totaling 22 professionals. Group composition was defined by draft. Group A was formed by higher education professionals; group B, by higher education and secondary education professionals; and group C, exclusively by secondary education professionals. Each participant was part of only one group, ensuring diversity of professional categories and the representativeness of different perspectives on the research object.

The participants of the groups were healthcare providers who had been actively working in the care or management of PHC since 2010 and who agreed to participate in the study, signing the Informed Consent Form (ICF). Professionals admitted after the end of the first P4P program implemented in the municipality (PIMESF) and those who were on vacation, leave, leave of absence or in management positions without direct association with PHC during the data collection period were excluded.

The focus groups took place in the SMS, with an average duration of one hour and a half, and were attended by two researchers: a mediator and an observer. The mediator conducted the interview based on a semi-structured script guided by the research questions. The speeches were recorded in audio and video and later transcribed separately, and participants were identified by numbers.

After transcribing the audios, the material was submitted to content analysis according to Bardin’s proposal¹⁷, developed in three stages. In the pre-analytical phase, we proceeded to the floating reading of the transcripts, in order to ensure familiarity with the corpus. In the material exploration stage, the transcripts were imported into the MAXQDA software, used for coding, organization and data crossing.

Speech excerpts were coded, and, from these codes, emerging categories were built, aligned with previously defined thematic categories, namely: satisfaction and well-being, performance and productivity, participation and cooperation, and unintended side effects. With MAXQDA, the hierarchical systematization of the codes and the performance of comparative analyses between categories was possible, through visualization tools and co-occurrence matrices, which favored the identification of patterns and interrelationships in the empirical material. Finally, in the treatment and interpretation stage, the consolidated categories were subjected to a process of refinement and critical analysis by two researchers, allowing the identification of thematic nuclei and the in-depth interpretation of the results.

Pay for performance was adopted as a context unit using the transcribed content related to the three programs implemented in the municipality: PIMESF, PMAQ-AB, and Previne Brasil. The transcripts were analyzed cumulatively from the groups and were not stratified, since the central purpose was to explore and have a comprehensive understanding of the speeches and perceptions related to the effects of P4P programs in the municipality.

The study was approved by the Research Ethics Committee with opinion No. 6,626,728.

Results and discussion

The testimonies of the professionals showed that pay for performance (P4P) has multiple and contradictory impacts on motivation and engagement at work. Four main categories emerged from the analysis: satisfaction and well-being, performance and productivity, participation and cooperation, and unintended side effects.

In the satisfaction and well-being category, P4P influenced the way workers perceive their work and their professional fulfillment, arousing feelings of appreciation, but also of inequity and discomfort in the face of the evaluative logic.

In the national programs, municipal management had autonomy over resource use, allocating part to the maintenance of Basic Health Units (UBS) and another portion as a bonus to health professionals. The division of resources between management and teams was identified as a source of dissatisfaction, as part of the amount was allocated discretionarily by management and not fully attributed to bonuses. As one participant pointed out:

In all programs, the teams never receive 100% of the resources; the municipality always receives something, so sometimes we think it is unfair. (B2)

This perception of unfairness can affect motivation and engagement, undermining the effectiveness of the program. On the other hand, transparent demonstration of how resources are applied, especially when destined to the improvement of UBS, can mitigate this impact.

It should be noted that the motivation of workers can be influenced by aspects other than financial incentives, such as recognition for the work done and opportunities for professional development. The complementary benefits are psychosocial, such as pride and motivation, which go beyond measured scores and are not accounted for in the performance evaluation process¹⁶. Furthermore, the effects of bonuses or penalties (financial) are intertwined with those of reputation, confidence, and peer pressure (non-financial), making it difficult to separate them¹⁸.

I realized that I needed to do it, or I wasn’t going to support this indicator, so you decrease the classification of your team, and you don’t want to get involved, you know? (A7)

We were proud of the score, it wasn’t not about the financial aspect, it had to do with the score, our dedication was recognized. (B6)

These statements demonstrate that the feeling of personal fulfillment and professional appreciation, the non-financial aspects, were important motivators. In addition, they reveal that the perception that their performance can negatively affect the team leads to additional effort, showing that both positive recognition and social pressure acted as stimuli. Thus, non-financial incentives, such as recognizing outstanding professionals, establishing them as teaching references, and publicizing their work, contribute to valuing them¹⁹.

On the other hand, people are social beings and can experience different feelings in the face of the same action. While some were happy and proud of the strategy, others showed discontented when evaluated. Reactions, whether of satisfaction or discomfort, can also trigger behaviors with unintended consequences¹⁶. The speeches of professionals illustrate this trend:

It was in front of the other teams, so, there is embarrassment, shame, you know? (C2)

There’s that spreadsheet that they have, which is also embarrassing to us. Some teams say: oh, my God, I worked so hard and we’re on that range well below. (C5)

This discomfort was reinforced by reports that associated the evaluation format with feelings of inadequacy, shame, incompetence, and guilt, leading, in some cases, to psychological distress²⁰. To minimize the negative impacts on professionals’ satisfaction and well-being, especially regarding the disclosure of team rankings, the performance evaluation system must be implemented through extensive dialogue, respecting the particularities of individuals and the organization¹⁶.

P4P alone does not support motivation at work. It is essential to plan different types of incentives based on workers’ attitudes and personalities. This will help foster positive competition by limiting peer and organizational pressure¹². By fostering a constant communication environment and considering local differences, the organization can help ensure that everyone feels valued and understood, which contributes to healthcare providers’ motivation, stress reduction, and a more collaborative work environment.

Regarding performance and productivity, P4P had an impact on the work processes of professionals and, consequently, influenced the overall performance and quality of service to the population.

I persisted in the practice of collecting the cytopathological exam for the indicator. In the past I used to say: ‘oh, you don’t want to do with me, it’s ok, life goes on.’ And some time ago, I started setting up my stall every Friday to see the patients. (A7)

With the indicator, I worry about whether someone came to see me for another reason. If they had their BP checked, so we have this closer look. (A3)

The contribution to improving professional practice stands out, both in the aspects directly encouraged and in the organization of work routines. The demand for the achievement of indicators led professionals to become more attentive and careful in relation to the monitored activities. The expansion of access to services, such as the greater offer of cytological examination, blood pressure measurement, disease screening, was also reported. This closer look, combined with the expansion of coverage, reinforces the quality of individual and collective service.

The professionals report that their commitment increases when they believe they will be fairly rewarded and highlight the importance of recognition and demand to increase motivation and performance, avoiding the natural tendency to relax in the absence of supervision and monitoring.

It was worth working a little more, staying after hours, not worrying when it was time to go home because we knew that at the end of the month we would be well rewarded. (B2)

It is good to know that our work is being valued, that we have our duties, because whether you like it or not, we as human beings, if we are not asked to do what has to be done, we relax. (C1)

Thus, the reports show that both recognition and external demands were important reinforcements of extrinsic motivation. The influence of strategy on workers’ extrinsic motivation results in greater productivity and better quality of care and records^20,21. By achieving goals and overcoming challenges, professionals tend to feel greater job satisfaction, which in turn improves their performance and creates a virtuous circle of improvement¹².

However, it is necessary to reflect on the design of the P4P and the evaluation process to prevent competition and excessive control from generating alienation and subordination. Professionals focused on improving productivity and achieving results can move away from creative, innovative and/or even reflective aspects of the work process. Conversely, the withdrawal of the incentive tends to reduce commitment and may even lead to an intentional decrease in performance^20,22.

The PMAQ incentive made us try harder, searching for more procedures, because we knew we had that financial recognition. Today, Previne encourages us to do nothing, because you work hard, there’s a lot of demands and little recognition. (B6)

It should be noted that P4P can reduce the motivation necessary to achieve results due to overlapping payments (salaries and incentives) for the same activities, changing the professionals’ perception about their earnings, which may lead to a drop in their performance, including the retreat of their daily activities²².

We were really motivated to achieve that goal. This was very satisfactory. I think that over time, we lost this motivation to achieve the goal. (C1)

Initially, professionals may feel significant enthusiasm when achieving goals, which is motivating and rewarding. However, over time, this motivation tends to decrease, especially if goals become repetitive or incentives lose their attractiveness. This change in attitude suggests the need to review the goal system to maintain engagement. This may include introducing new challenges, diversifying incentives, or fostering an environment that values not only goal achievement but also innovation and creativity at work.

In the participation and cooperation category, there were changes in the engagement of professionals with P4P programs, including their active participation and collaboration with the team. Financial incentives and competition are extrinsic factors that can influence the intrinsic motivation of healthcare providers. The bonus acted as a primary stimulus, alongside recognition and professional respect²³.

The team was much closer because of this, as everybody was seeking to comply together with their obligation. (B3)

PIMESF brought this team perspective into the basic unit. [...] The impression we had was that of a bunch of professionals: a dentist with an assistant. The nurse with the agents and the nursing technician. And the doctor alone in the office. Then, the idea of the unit having to have a good average so that everyone receives some money motivated everybody, because no matter how small the amount was, everyone wanted to receive it. (A7)

The statements indicate that P4P promoted the union of the health team around a common goal: to achieve the goals to receive the incentive. Although the objective was aimed at the financial bonus, stimulating teamwork is an important side effect in the context of the Brazilian PHC model. In this sense, managers were able to exploit this strategy to foster a more collaborative work environment, with more comprehensive health care, higher quality, and better results²⁴.

Self-monitoring carried out by the team expanded the vision of professionals beyond their individual production, encouraging the habit of monitoring collective performance. The quality of PHC can be evaluated by the consensus of team professionals, who analyze the work process in its context. This self-assessment helps in the performance of the team, in the decision-making process, and in the organization of care practices, strengthening the Family Health Strategy (FHS)²⁵.

The three of them, since PIMESF, have led us to such a sensitive improvement from the point of view of interpersonal relationships, when looking at global performance. They make us work better as a team. (A7)

This report shows that team evaluation strengthened collective responsibility and favored more integrated interpersonal relationships. Improvements in effective participation and interprofessionality are highlighted, corroborating the theory that the more positive the work climate, the greater the collaboration between team members tends to be²⁴. In addition, PHC essentially depends on teamwork and, therefore, on a collective group responsible for both decision-making and planning necessary to organize health services appropriate to the population²⁶.

It should be considered, however, that the municipal management expanded its perspective of control over the teams, directing them to achieve specific indicators. This top-down model, marked by the low participation of professionals in the definition of the evaluation design and the reward system, tends to limit creativity and autonomy, in addition to obstructing the transversal dimensions provided for in some programs, such as the PMAQ-AB, which incorporated initiatives of permanent education and institutional support.

The context significantly influences the participation of professionals in the teams, as well as the working conditions affect the teams’ ability to engage. In addition, the administrative organization of the health sector and negotiations on financial transfers emerge as important local factors. The expansion of the dialogue and the inclusion of professionals in the prior negotiations over incentives and evaluation criteria can minimize conflicts and demotivation during the program’s execution²⁷.

Despite its potential to improve, P4P also revealed paradoxical effects: monitoring mechanisms designed to support quality were perceived as forms of policing, surveillance, and/or control. This dynamic, especially when it occurs between peers, can generate tension and conflict, establishing an environment of distrust and discomfort that compromises collaboration and weakens team morale²³.

The dynamics of implementing performance programs are influenced by contextual and structural factors, such as social and political conditions. Within the scope of the PMAQ-AB and Previne Brasil programs, local management assumed a two-fold condition: it acted as a funder, which maintained control and discretion over the use of program resources, determining volume and periodicity, and encouraging professionals; and as an encouraged actor, since part of the resources transferred by the Ministry of Health was destined to its governance, especially focused on service organization. This overlapping led to an asymmetry of roles, generating conflict of interest and denoting fragility to the programs.

Although pay-for-performance programs have the potential to induce improvements, they also have risks of unintended side effects, such as the induction of inappropriate or unnecessary care practices, often directed more towards meeting indicators than the real needs of the population. In addition, the excessive emphasis on financial incentives can undermine professionals’ motivation to achieve immediate goals, favoring strategies of artificial result adaptation, manipulations, and even fraud, phenomena already documented in national and international experiences^22,23,27.

Unintended side effects resulted from conscious behaviors to obtain expected results. These behaviors include tactics such as gaming, cheating, cherry picking¹⁶ and focusing²². Gaming practice was reported when professionals performed preventive examinations without clinical indication, solely to comply with the program metric, as illustrated by the statement:

If I couldn’t achieve the metric, I would do perform preventive measures, just to achieve the goal. I’m tired of just doing it to achieve the goal. (C5)

Data makeup (cheating) situations also emerged, in which inputs were presented in different units to simulate suitable conditions during external evaluations:

The unit that did not have, for example, a focus, it would suddenly appear, and when the inspectors left, the focus would vanish too [...]. There would be inspection, the benefits would appear, but after they left, the benefits were gone. (C2)

Another effect identified was focusing, characterized by the exclusive targeting of encouraged activities, to the detriment of other aspects of care:

There is an overvaluation of what generates revenue, leading to the neglect of other things, and a search only for achieving that goal. If I reach the goal, I’m satisfied. (A7)

Finally, there was the bias of the intentional selection of patients (cherry picking), a practice in which more appropriate users were chosen to compose the evaluation, as evidenced by the reports:

To know whether the user was well served, I remember that we would say: my people choose who is the best in the area. (B4)

Such strategies illustrate how the pressure for measurable results can induce behaviors that distort care and compromise the comprehensiveness of attention. In the case of PMAQ-AB, the municipal management was also involved in these actions, since better certifications of the teams meant a greater volume of resources for the municipality. This scenario favored a connivance between managers and professionals, as pointed out below:

As the colleague recalls, if it happened, we could not blame only management, we were part of it, we agreed with it. (C2)

The practice of presenting a masked reality during the PMAQ-AB, known as “Pmakeup”²², was also identified in other contexts. Santiago et al.²⁸, based on reports from health professionals, and Tajra et al.²⁹, based on testimonies from supervisors and interviewers of the external evaluation, revealed that both managers and workers tried to mask reality during the external evaluation. Similarly, Siqueira et al.³⁰ observed that, as the evaluation date approached, the teams would come together to correct flaws, both in continuing education and in the infrastructure, to avoid negative evaluations and hide the real situation.

These practices tend to occur in contexts of low organizational capacity and in underfunded health systems, where pressure to achieve performance goals can generate unexpected results or encourage the adoption of alternative logics in the implementation of programs³¹. The rigor and reliability of information are crucial to the success of P4P programs, since decisions based on inaccurate information can compromise both management and results. Factors such as lack of technical knowledge, poor resource management, lack of knowledge of appropriate tools and, in some cases, bad faith, directly affect the effectiveness of these programs and cause unwanted side effects. On the other hand, evidence suggests that programs that promote active participation of professionals and coherence between incentives and values of care tend to generate greater engagement and more sustainable results^32,33.

In summary, this analysis highlights different dimensions of participants’ motivation and engagement related to P4P, with positive effects such as recognition, cooperation, and the expansion of practices, but also negative impacts, such as perceptions of injustice, psychological distress, and distorted strategies aimed at achieving goals, as summarized in Frame 1.

Frame 1
Effects of P4P programs on the motivation and engagement of healthcare providers.

Category	Positive Effects	Negative Effects / Risks
Satisfaction and Well-Being	Professional recognition, sense of pride and belonging, appreciation of work, satisfaction with results achieved.	Perception of injustice in the division of resources, public exposure generating embarrassment, stress and psychological distress.
Performance and Productivity	Greater attention to indicators, organization of routines, increase in productivity and quality of records, expansion of access to services (e.g., cytology).	Loss of motivation over time, overlapping payments reducing engagement, risk of alienation and loss of creativity, intentional retraction of activities in the face of the withdrawal of the incentive.
Participation and Cooperation	Greater unity and collaboration between professionals, strengthening of teamwork, internal self-monitoring, collective view of production.	Participation restricted to the achievement of goals, top-down management control, perception of vigilance, limitation of creativity and innovation.
Unintended side effects	Mobilization of efforts in the short term, one-off improvement in specific indicators.	Gaming (repetition of procedures only to meet goals); cheating (use of shared inputs or artificial records); focusing (prioritization of encouraged activities); cherry picking (selection of more convenient users); Pmakeup (artificial adjustment of data and scenarios).

From this perspective, P4P is not limited to a technical arrangement, aimed at achieving pre-established standards, but it is a dynamic and paradoxical social process, capable of redefining practices and relationships in the daily life of PHC, while conditioning different forms of professional engagement.

Final considerations

Pay for performance, by linking financial incentives to results, offers a promising path to improving health services. However, this strategy carries substantial challenges. If, on the one hand, it can guarantee external motivation to the participants, on the other hand, it can generate negative effects, increasing inequalities, causing distortions in the provision of care and prioritization of quantity at the expense of quality, aspects that can also undermine the confidence and motivation of the participants.

In this study, we observed intentional and unintentional effects of different P4P programs on the motivation of healthcare providers, directly influencing the effectiveness of initiatives and, consequently, their results. The positive aspects included recognition for the work done, professional appreciation, enthusiasm for achieving goals, active participation, and greater team collaboration. On the other hand, perceptions of injustice, embarrassment, shame, stress and even inappropriate behaviors to achieve goals emerged, which demonstrate the potential for negative interference of the strategy in the teams’ work process.

To mitigate the negative effects on employee motivation and engagement, it is critical for managers and policymakers to be mindful not only of the program’s expected outcomes, both positive and negative, but also of the participants’ levels of motivation, participation, and engagement over time. It is also crucial to ensure transparency, diversify incentives and promote effective communication between managers and workers, instituting a culture of evaluation oriented towards learning, continuous improvement and the strengthening of good practices, to the detriment of excessive control or punishment. The inclusion of professionals in the decision-making process, adequate supervision, and careful planning of the evaluation criteria are essential strategies to balance the intended gains and the possible side effects of these programs.

It should be noted that this study has limitations due to its qualitative nature and the local context explored, which restricts the scope of generalization of the findings. In addition, the analysis focused exclusively on the professionals’ perception, not incorporating the users’ view or directly measuring the effects of P4P on the quality of care. Therefore, paths are opened for future research that explore different P4P actors, scenarios, and designs in PHC and use methodologies capable of capturing, from a long-term perspective, impacts on equity, quality of care and effectiveness of practices.

• Sousa LMC, Carvalho MF. Effects of pay for performance on motivation and professional engagement in primary health care. Interface (Botucatu). 2025; 29: e250771 https://doi.org/10.1590/interface.250771

Data Availability

The contents underlying the research text are included in the manuscript.

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Edited by

• Editor
  Rosana Teresa Onocko-Campos https://orcid.org/0000-0003-0469-5447

• Associated editor
  Thereza Christina Bahia Coelho https://orcid.org/0000-0003-4787-4103

Publication Dates

• Publication in this collection
  19 Jan 2026
• Date of issue
  2025

History

• Received
  28 Jan 2025
• Accepted
  03 Nov 2025