Acute and chronic musculoskeletal pain among older adults in a rural area in Southern Brazil: who suffers most?

Dor musculoesquelética aguda e crônica em idosos em uma área rural no sul do Brasil: quem sofre mais?

Abstract

Introduction:  Musculoskeletal pain is frequent in the elderly, but it is little known in rural residents.

Objective:  To estimate the prevalence, intensity and associated factors of acute and chronic pain in the neck, upper back, lower back and knee of the older adults.

Method:  Cross-sectional study carried out on a cohort of older adults in the rural area of the municipality of Rio Grande (RS), Brazil. To investigate the outcomes, a structured questionnaire and an anatomical model were used. Descriptive and bivariate analyses were performed and crude and adjusted multinomial regression was used to verify associated factors, following a hierarchical model.

Results:  The prevalence of acute and chronic pain in each region was, respectively, 11.9 and 12.5% in the neck; 14.3 and 14.1% upper back; 14.1 and 15.4% lower back; 15.8 and 23.0% in the knees. Being female and having arthritis/arthrosis were associated with acute pain. Being female, having worked with pesticides and fishing, having hypertension, arthritis/arthrosis and self-assessing health as regular and bad/very bad were associated with chronic pain.

Conclusions:  We found a high prevalence of acute and chronic pain. Identification of those at greater risk of having worse symptoms together with pain duration can help providing more appropriate care.

Keywords:
musculoskeletal pain; chronic pain; acute pain; older adults.

Resumo

Introdução:  A dor musculoesquelética é frequente em idosos, mas pouco conhecida em residentes rurais.

Objetivo:  Estimar a prevalência, intensidade e fatores associados de dores agudas e crônicas na cervical, parte superior das costas, região lombar e joelhos em idosos.

Método:  Estudo transversal realizado em uma coorte de idosos da zona rural do município de Rio Grande (RS), Brasil. Para investigar os desfechos, foi utilizado um questionário estruturado e um modelo anatômico. Foram realizadas análises descritivas e bivariadas e foi utilizada regressão multinomial bruta e ajustada para verificar os fatores associados, seguindo um modelo hierárquico.

Resultados:  A prevalência de dor aguda e crônica em cada região foi, respectivamente, 11,9 e 12,5% cervical; 14,3 e 14,1% torácica; 14,1 e 15,4% lombar; 15,8 e 23,0% joelhos. Ser do sexo feminino e ter artrite/artrose estiveram associados à dor aguda. Ser do sexo feminino, ter trabalhado com agrotóxicos e pesca, ter hipertensão arterial, artrite/artrose e autoavaliar a saúde como regular e ruim/péssima estiveram associados à dor crônica.

Conclusões:  encontramos alta prevalência de dor aguda e crônica. A identificação daqueles com maior risco de apresentar sintomas piores, juntamente com a duração da dor, pode ajudar a fornecer cuidados mais adequados.

Palavras-chave:
dor musculoesquelética; dor crônica; dor aguda; idoso fragilizado.

INTRODUCTION

Pain is defined by the International Association for the Study of Pain (IASP) as an unpleasant sensory and emotional experience described in terms of actual or potential tissue damage¹. Its duration determines how it is typified, i.e. acute pain starts suddenly and remains for no more than days or weeks, while chronic pain lasts for more than three months¹.

Primary pain affects muscles, bones, joints or tendons and is characterized by emotional stress or functional disability and is not attributed to a specific morbidity². Secondary pain is associated with other causes, such as inflammatory processes, infections, local musculoskeletal changes, as well as causes of neural origin².

Musculoskeletal pain is frequent among older adults, but its prevalence in residents of rural areas is less known. Characteristics such as heavy workloads, inadequate postures for a prolonged period of time, less access to information and health services can predispose those living in rural areas to a high burden of musculoskeletal pain in old age³-⁵. In addition, non-communicable chronic diseases, low education and behavioral factors such as smoking may favor the worsening of pain symptoms in this population³,⁴. It is unclear how common musculoskeletal pain sites (low back, neck, upper and knees) are, as well as their duration (acute or chronic) among older adults in rural areas. It should be noted that the impact of pain, especially chronic pain among older adults, may constitute a health burden to patients and their economically active family members³.

The objective of this study was to estimate the prevalence, intensity and associated factors with acute and chronic symptoms in the lower back, neck, upper back and knee regions in older adults in the rural area of a municipality in southern Brazil.

METHODS

This is a cross-sectional study nested in the “Epi Rural Study: a cohort of older adults in the rural area of Rio Grande (RS)”. Rio Grande is a coastal city in the far south of the state of Rio Grande do Sul, Brazil. The rural area of the municipality is characterized by family farming, commodities, logging and fishing.

The baseline of the cohort study was conducted in 2017 and included 1,029 older adults (≥60 years) who were identified based on systematic random sampling of the permanently inhabited households in the rural area of the municipality⁶ (Figure 1).

Figure 1
Flowchart of participant selection.

The first follow-up of the individuals who took part in the baseline study took place between September 2018 and March 2019. The questionnaires were administered in household interviews and evaluated demographic, behavioral, anthropometric and health characteristics. All the interviewers received training and met the standardization criteria for taking anthropometric measurements in accordance with Habitch et al.⁷.

To investigate the outcomes, chronic and acute pain in the neck, upper back, lower back and knee regions, an instrument was used that assessed the presence of symptoms by asking the following question: “Since <MONTH> of the last year and now, have you felt pain in any of these regions of your body?” At the same time the respondent was shown an anatomical model adapted from Kuorinka et al.⁸, with the anatomical regions of interest painted yellow (neck), blue (upper back), red (lower back) and purple (knees)⁸. If the respondent replied that they had felt pain in at least one of these regions, the next question was asked: “Since <MONTH> of the last year and now, have you had this pain in the yellow/blue/red/purple region for 12 continuous weeks (3 months) or more?”. If the answer was negative, the pain was classified as acute and, if positive, as chronic pain. Then, the respondents were asked about the intensity of the symptoms in each of the anatomical regions using the Visual Analog Pain Scale which ranges from 0 to 10, where 0 is no pain and 10 is the worst possible pain.

The independent variables investigated were sex (male/female), age (61-69/70-79/80 or over), smoker (no, never/yes/former smoker), working with pesticides (no, never/yes, still works/yes, used to work), working as fishermen (no, never/yes, still works/yes, used to work), hypertension (no/yes), diabetes (no/yes), rheumatism/arthritis/arthrosis (no/yes) and depression (no/yes), continuous medication use (no/yes) and self-rated health (very poor/poor/ /regular/good/very good).

The information was collected through a pre-coded questionnaire with closed questions using the RedCap^® (Research Electronic Data Capture) application on tablets. Every day after the interviews had finished, the answered questionnaires were exported from the tablets to the server of the Federal University of Rio Grande and submitted to analysis of data consistency. At the end of data collection and cleaning, the database was exported to the software Stata version 14.0.

The univariate analysis was performed using absolute and relative frequency to describe the sample according to each independent variable. Bivariate analysis was used to calculate the prevalence of outcomes according to the independent variables using Fisher’s exact test. The multivariate analysis was performed according to a hierarchical model to adjust for confounding factors. The hierarchical levels used were: 1^st level (sex, age), 2^nd level (tobacco smoking, working as a fisherman, working with pesticides), 3^rd level (self-reported diagnosis of hypertension, diabetes mellitus, rheumatism and depression) and 4^th level (self-rated health and use of medication). Variables with a p<0.20 were maintained in the adjusted model to control confounding factors. Multinomial logistic regression was used to calculate the crude and adjusted odds ratio (OR) and its corresponding 95% confidence intervals (95%CI) and p-values. The variables with a statistical significance level of less than 5.0% were considered to be associated.

Pain intensity (acute or chronic) was defined by adding together the pain scores for each of the anatomical regions investigated. The lowest possible score was zero (0) and the highest was forty (40). Following this, the median and respective interquartile ranges of the symptoms according to the type of pain variable were presented in boxplots, stratified according to sex and diagnosis of arthritis/arthrosis.

This project was submitted to and approved by the Federal University of Rio Grande Health Research Ethics Committee, as per Opinion No. 51/2017, and its procedures were in accordance with Resolution No. 466/12. All participants agreed to the free and informed consent document. The participants were informed that they could withdraw from the interview at any time and were advised that their data would be treated confidentially.

RESULTS

Follow-up was provided to 862 older adults, i.e. the follow-up rate was 83.8%. Of those who took part in follow-up, 54.1% were male, 44.3% were between 61 and 69 years old, 12.7% were smokers and 7.1% worked with pesticides. A total of 59.0% reported having hypertension, 15.0% diabetes mellitus, 38.1% rheumatism/arthritis/arthrosis and 19.8% depression. Continuous medication use was reported by 78.9% and poor/very poor self-rated health by 7.2%. The prevalence of acute and chronic pain in each region was, respectively, 11.9 and 12.5% in the neck; 14.3 and 14.1% in the upper back; 14.1 and 15.4% in the lower back; 15.8 and 23.0% in the knees (Table 1).

Table 1
Characteristics of the older adults rural population in the municipality of Rio Grande (RS), Brazil, 2018 (n=862).

Variable	n	%
Sex
Male	466	54.1
Female	396	45.9
Age group
61-69	382	44.3
70-79	311	36.1
80 or over	169	19.6
Smoker
No, never	451	52.3
Yes	109	12.7
Former smoker	302	35.0
Works/worked with pesticides
No, never	531	61.6
Yes, still works	61	7.1
Yes, used to work	270	31.3
Works/worked as a fisherman/woman
No, never	622	72.1
Yes, still works	35	4.1
Yes, used to work	205	23.8
Hypertension
Yes	507	59.0
Diabetes mellitus
Yes	129	15.0
Rheumatism, arthritis or arthrosis
Yes	328	38.1
Depression
Yes	170	19.8
Continuous medication use
Yes	678	78.9
Self-rated health
Very good/good	502	58.4
Regular	295	34.4
Poor/very poor	62	7.2
Pain in all four regions
None	260	30.8
Acute pain	273	32.3
Chronic pain	312	36.9
Neck pain
None	643	75.6
Acute pain	101	11.9
Chronic pain	106	12.5
Upper back pain
None	608	71.6
Acute pain	121	14.3
Chronic pain	120	14.1
Lower back pain
None	598	70.5
Acute pain	120	14,1
Chronic pain	131	15.4
Knee pain
None	520	61.2
Acute pain	134	15.8
Chronic pain	196	23.0

According to the bivariate analysis, women had greater prevalence of chronic symptoms in three regions (neck, upper back and knees). Respondents with hypertension reported more chronic symptoms in the neck (13.8%) and knees (27.3%); those with diabetes reported more chronic symptoms in the upper back (24.2%) and knees (25.8%); those with rheumatism/arthritis/arthrosis reported more chronic symptoms in all regions.

Those who needed to use medication continuously had more chronic pain in the neck, upper back and knee regions. Those who rated their health as poor/very poor reported much more chronic pain when compared to those who considered their health to be very good/good (Table 2).

Table 2
Prevalence of acute and chronic pain in the older adults rural population in the municipality of Rio Grande (RS), Brazil, 2018 (n=862).

	Neck			Upper back			Lower back			Knees
	Acute (%)	Chronic (%)	p-value	Acute (%)	Chronic (%)	p-value	Acute (%)	Chronic (%)	p-value	Acute (%)	Chronic (%)	p-value
Sex
Male	10.6	7.2	<0.001	13.9	10.2	0.001	13.7	12.8	0.050	13.5	17.4	<0.001
Female	13.4	18.8		14.7	18.8		14.7	18.6		18.5	29.8
Age
61-69	14.3	12.9	0.299	14.5	15.0	0.525	14.3	16.9	0.263	16.8	21.3	0.782
70-79	11.0	12.3		14.3	15.3		15.2	16.1		14.9	25.2
80 or over	8.1	11.8		13.7	9.9		11.9	10.6		14.9	23.0
Smoker
No, never	11.9	13.7	0.668	14.2	15.1	0.868	14.7	16.5	0.267	16.0	25.5	0.286
Yes	12.0	8.3		12.0	13.9		17.6	17.6		12.0	19.4
Former smoker	11.7	12.1		15.2	12.8		12.1	13.1		16.7	20.7
Works/worked with pesticides
No, never	12.5	12.3	0.828	14.4	14.8	0.820	13.4	14.0	0.120	16.9	24.3	0.119
Yes, still works	8.2	9.8		11.5	9.8		19.7	9.8		13.3	11.7
Yes, used to work	11.6	13.5		14.6	13.8		14.3	19.6		14.2	23.1
Works/worked as a fisherman/woman
No, never	11.4	12.1	0.506	14.0	14.0	0.506	14,4	15.3	0.426	16.5	23.0	0.766
Yes, still works	14.3	5.7		20.0	5.7		22.9	8.6		11.4	17.1
Yes, used to work	12.9	14.9		14.0	16.0		11.9	16.9		14.4	24.3
Hypertension
No	9.2	10.4	0.023	14.7	12.7	0.645	15.1	12.8	0.212	14.5	17.1	<0.001
Yes	13.8	14.0		14.0	15.0		13.6	17.1		16.7	27.3
Diabetes mellitus
No	11.5	11.8	0.260	15.3	12.2	0.001	14.4	14.6	0.255	14.4	22.5	0.014
Yes	14.1	15.6		8.6	24.2		12.5	20.3		23.4	25.8
Rheumatism, arthritis or arthrosis
No	9.3	6.9	<0.001	13.0	8.4	<0.001	12.0	11.6	<0.001	13.0	13.6	<0.001
Yes	16.1	21.6		16.3	23.4		17.6	21.6		20.3	38.5
Depression
No	11.2	9.7	<0.001	14.6	11.1	<0.001	13.9	13.6	0.010	14.5	21.7	0.005
Yes	14.8	23.1		12.4	26.0		15.5	22.6		20.7	29.0
Continuous medication use
No	8.4	6.7	0.005	12.4	9.0	0.036	15.3	10.2	0.083	12.4	10.7	<0.001
Yes	12.4	14.1		14.8	15.6		13.9	16.9		16.7	26.5
Self-rated health
Very good/good	10.5	7.9	<0.001	14.6	9.1	<0.001	13.7	10.7	<0.001	16.1	15.7	<0.001
Regular	14.8	17.6		14.8	20.0		15.2	20.1		14.8	30.7
Poor/very poor	9.8	24.6		9.8	27.9		11.5	32.8		18.0	44.3

In the adjusted analysis, women were at greater odds of reporting acute pain (odds ratio - OR 1.53; 95%CI 1.08-2.17) and chronic pain (OR 2.03; 95%CI 1.45-2.85), as were respondents who reported diagnosis of arthritis/arthrosis (OR 2.55; 95%CI 1.68-3.85) and (OR 4.14; 95%CI 2.77-6.20) for acute and chronic pain, respectively. The odds of reporting chronic pain was greater than 2.0 for individuals who had previously worked with pesticides, while those with poor/very poor self-rated health had an odds of 3.29 (95%CI 1.54-7.02) in reporting chronic pain (Table 3).

Table 3
Multinomial logistic regression model for factors associated with acute and chronic pain in the older adults rural population in the municipality of Rio Grande (RS), Brazil, 2018 (n=862).

	Crude*					Adjusted†
	Acute		Chronic			Acute		Chronic
	OR	95%CI	OR	95%CI	p-value	OR	95%CI	OR	95%CI	p-value
Sex
Male	1	-	1	-	<0.001	1	-	1	-	<0.001
Female	1.51	1.07-2.14	1.97	1.41-2.76		1.53	1.08-2.17	2.03	1.45-2.85
Age
61-69	1	-	1	-	0.08	1	-	1	-	0.051
70-79	0.86	0.58-1.26	1.27	0.88-1.85		0.87	0.59-1.28	1.31	0.90-1.90
80 or over	0.65	0.41-1.03	0.82	0.52-1.28		0.63	0.40-1.00	0.78	0.50-1.23
Smoker
No, never	1	-	1	-	0.94	1	-	1	-	0.362
Yes	0.84	0.49-1.41	0.85	0.51-1.41		0.94	0.54-1.64	1.20	0.69-2.08
Former smoker	1.02	0.70-1.48	1.04	0.73-1.50		1.22	0.81-1.85	1.52	1.00-2.30
Works/worked with pesticides
No, never	1	-	1	-	0.01	1	-	1	-	<0.001
Yes, still works	0.71	0.38-1.32	0.43	0.21-0.85		0.94	0.49-1.81	0.72	0.35-1.50
Yes, used to work	1.14	0.78-1.68	1.46	1.02-2.11		1.52	0.99-2.31	2.26	1.50-3.41
Works/worked as a fisherman/woman
No, never	1	-	1	-	0.30	1	-	1	-	0.10
Yes, still works	1.62	0.72-3.65	0.79	0.31-1.99		2.00	0.87-4.63	1.22	0.47-3.17
Yes, used to work	1.18	0.78-1.77	1.29	0.87-1.92		1.31	0.85-2.01	1.61	1.06-2.44
Hypertension
No	1	-	1	-	<0.001	1	-	1	-	0.025
Yes	1.35	0.96-1.90	1.92	1.37-2.69		1.26	0.88-1.80	1.65	1.15-2.38
Diabetes mellitus
No	1	-	1	-	0.24	1	-	1	-	0.804
Yes	1.30	0.79-2.13	1.50	0.93-2.40		1.19	0.70-2.01	1.15	0.68-1.93
Rheumatism, arthritis or arthrosis
No	1	-	1	-	<0.001	1	-	1	-	<0.001
Yes	2.79	1.88-4.15	5.20	3.54-7.63		2.55	1.68-3.85	4.14	2.77-6.20
Depression
No	1	-	1	-	0.001	1	-	1	-	0.199
Yes	1.55	0.97-2.47	2.22	1.43-3.43		1.26	0.77-2.06	1.54	0.96-2.48
Continuous medication use
No	1	-	1	-	<0.001	1	-	1	-	0.375
Yes	1.51	1.02-2.24	2.58	1.70-3.93		1.27	0.80-2.03	1.41	0.85-2.35
Self-rated health
Good/Very good	1	-	1	-	<0.001	1	-	1	-	<0.001
Regular	1.32	0.90-1.95	3.20	2.21-4.64		1.07	0.71-1.62	2.28	1.52-3.41
Poor/very poor	1.33	0.59-3.01	4.66	2.29-9.49		1.03	0.44-2.41	3.29	1.54-7,02

• OR: odds ratio; CI: confidence interval.
• ^*
  Crude OR was calculated using univariate multinomial logistic analysis;
• ^†
  Adjusted OR was calculated using multivariate and weighted multinomial logistic analysis. The estimates took three levels into account: 1^st level: sex, age; 2^nd level: tobacco smoking, working as a fisherman/woman, working with pesticides; 3^rd level: self-reported diagnosis of hypertension, diabetes mellitus, rheumatism and depression; 4^th level: self-rated health, use of medication. p<0.20 were kept in the model.

As can be seen in Figure 2, intensity of symptoms is significantly greater in individuals with chronic pain, both for men and for women (p<0.001). Women with acute and chronic pain feel more pain than men with the same symptoms (p<0.001).

Figure 2
Intensity of acute and chronic pain by sex in the older adults of the rural population of Rio Grande (RS), 2018 (n=862).

Men and women who do not have arthritis/arthrosis, but do have some amount of chronic pain, feel more pain than those who only have acute pain (p<0.001). Men and women who have arthritis/arthrosis feel more pain when symptoms are chronic (p=0.02 and p<0.001).

DISCUSSION

This study examined the prevalence of acute and chronic symptoms in the neck, upper back, lower back and knee regions among older adults living in the rural area of a South Brazilian municipality, in addition to investigating factors associated with acute and chronic symptoms. Acute and chronic pain prevalence was high and knee pain was most prevalent. Being female, having worked with pesticides and fishing, having hypertension, rheumatism/arthritis/arthrosis and poor/very poor self-rated health were the characteristics associated with the presence of acute and/or chronic pain.

There is a scarcity of studies in the literature assessing differences in prevalence of acute and chronic pain. The study conducted by Skillgate et al. in 2012⁹, in Sweden, assessed chronic and acute pain prevalence in the neck region. The majority of studies assessed¹⁰-¹⁷ chronic symptoms and had prevalence rates varying between 30.7% in the United States, 33.9% in Japan and 42% in Sweden¹³,¹⁶,¹⁷. A cross-sectional population-based Brazilian study¹⁰ of older adults living in the urban area of Goiânia, state of Goiás, which considered chronic pain to be that with symptoms lasting for more than six months, reported prevalence of 52.8%, located most frequently in the lower limbs (34.5%) and the lower back region (29.5%).

With regard to pain prevalence in specific anatomical regions, knee pain is frequent among the older adults in rural Tamil Nadu (64.5%)³, Netherlands (30.0%)¹⁸, Australia (40.0%)¹⁹ and Japan (39.1%)¹⁷. The Australian study assessed older adult males aged 70 or over, and chronic pain was defined as that which was felt most days for at least one month in the last year. The Japanese study assessed the presence of pain which had lasted for at least six months.

The prevalence of chronic lower back pain among the rural older adults in Rio Grande was lower than that reported by European studies where prevalence varied between 23.0 and 60.0%⁹,¹⁸,²⁰.

Although the literature contains studies with methodological differences in relation to the symptom characterization and profile of the populations assessed, the prevalence rates of acute and chronic symptoms found among the older adults of the rural area of Rio Grande can be considered high. Cartilage impairment, reduced ligament elasticity, reduced bone and muscle mass, as well as fat-infiltrated tissues²¹ can contribute to the appearance of pain, bringing negative consequences for the health and functionality of the older adults. Rural populations are generally most exposed to heavy labor over their lives, which can accelerate the wasting process and the appearance of symptoms as aging progresses. In places distant from the urban center of a municipality, the presence of joint pains can make it difficult to do tasks and compromise the mobility of this population.

According to several studies, women have a higher risk of having chronic and acute symptoms¹⁶,²². Anatomical and functional characteristics, such as lower height, less muscle and bone mass, more adipose tissue, more fragile joints²³, as well as hormone changes, predispose women to greater risk of musculoskeletal symptoms⁵. Moreover, women tend to report their symptoms more frequently than men do.

Various studies examine lifetime exposure to pesticides and association with a variety of diseases, especially cancer and central nervous system diseases²⁴. Few studies analyze the association between pesticides and musculoskeletal symptoms. However, some authors highlight the association between headache and abdominal pain, which are frequent symptoms in cases of acute pesticide poisoning²⁵. An occupational study conducted in Brazil²⁶ with tobacco growers aged 18 years old or over identified that reporting some form of lifetime pesticide poisoning was strongly associated with chronic lower back pain. However, the physiology of this association is not clear.

Hypertension has been investigated by some authors as a predictor of back and knee pain, and this association may be related to other comorbidities²⁷,²⁸. People with knee and/or hip osteoarthritis and comorbidities tend to report more pain and functional deterioration than those without comorbidities²⁸.

Self-rated health is an important indicator of an individual’s perception of their own health and is an important predictor of mortality²⁹. Some authors report¹⁰ a significant association between self-perception of health and chronic pain among women, but not among men, while others report an association regardless of the presence of chronic diseases, sex or age³⁰. Pain results in physical limitations. Hence, this affects self-rated health, and thus characterizes reverse causality.

According to the literature, symptom intensity is greater among women and individuals who report having arthritis/arthrosis³¹,³². A relevant aspect in the context of the municipality of Rio Grande is the influence of the climate. The subtropical climate with sudden changes in temperature as well as high humidity and cloudiness contribute to the worsening of musculoskeletal symptoms, particularly chronic pain³².

Although this study is subject to recall bias, this limitation is restricted to acute pain.

CONCLUSION

The results of this study showed that approximately one third had acute pain and one in four had chronic pain in some region of the spine, with the knees being the most prevalent. The main factor that was strongly associated with both acute and chronic pain was rheumatism/arthritis/arthrosis. The groups most at risk for chronic pain were: women, those who have worked with pesticides and fishing, having hypertension, and those who self-rated their health as bad/very bad.

The detailed description of the frequency and factors associated with acute and chronic musculoskeletal pain among older adults in a rural area provides an original contribution about a condition responsible for great suffering and limitation in performing activities of daily living. Furthermore, the findings can be useful for health services that provide care to the older adults in rural locations. Identification of those at greater risk of having worse symptoms together with pain duration can help providing more appropriate care.

ACKNOWLEDGMENTS

Elizabet Saes-Silva, Vanise dos Santos Ferreira Viero, received scholarships from CAPES (Coordination for Improvement of Higher Education Personnel).

• How to cite:
  Meucci RD, Saes-Silva E, Viero VSF, Paludo CS, Costa JB, Santos FDR. Acute and chronic musculoskeletal pain among older adults in a rural area in Southern Brazil: who suffers most?. Cad Saude Colet. 2024;32(2):e32020372. https://doi.org/10.1590/1414-462X202432020372
• Funding:
  FAPERGS (Fundação de Amparo à Pesquisa do Rio Grande do Sul), through notice number 17/2551-0000845-6; Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, (CAPES) N/A, Brazil.

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Publication Dates

• Publication in this collection
  29 Nov 2024
• Date of issue
  2024

History

• Received
  17 July 2021
• Accepted
  10 Dec 2021