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Feng X, Sarma H, Seubsman SA, Sleigh A, Kelly M. Impact of age and gender differences in the prevalence and patterns of multimorbidity in the Thai Cohort Study. Int Health 2024; 16:454-462. [PMID: 38520373 PMCID: PMC11218883 DOI: 10.1093/inthealth/ihae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 09/30/2023] [Accepted: 03/19/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND The study aims to identify the common patterns of multimorbidity and their distribution by age and gender. METHOD This cross-sectional study collected self-reported data from 42 785 Thai Cohort Study members through mailed questionnaires. Employing prevalence-based analysis, it identified common multimorbidity (coexistence of two or more chronic conditions) patterns, analysing the three most common patterns stratified by age and sex. P for trend (p-trend) was used to test the linear trend for associations between age and prevalence of these chronic conditions in the multimorbidity patterns. RESULTS Chronic conditions with the highest prevalence were related to metabolic syndromes: obesity (28.5%), hyperlipidaemia (13.2%) and hypertension (7.2%). A positive linear age-multimorbidity association was observed (p-trend = 0.0111). The 60+ participants averaged 1.20 diseases, with 33.7% multimorbidity prevalence. Hyperlipidaemia + obesity was most prevalent in the under-40 multimorbid group (38.7%). Men exhibited a higher prevalence of multimorbidity and associated patterns involving hypertension, hyperlipidaemia and obesity than women. CONCLUSION Metabolic syndrome components were the prominent factors driving multimorbidity. Significant age and gender differences were also revealed in multimorbidity prevalence. People aged 60+ faced high risk of multimorbidity, while younger individuals tended towards the multimorbidity pattern of obesity and hyperlipidaemia. Men were more susceptible to multimorbidity patterns associated with metabolic syndromes. Future studies for metabolic-related multimorbidity should consider these differences, addressing age and gender issues.
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Affiliation(s)
- Xiyu Feng
- Department of Applied Epidemiology, National Centre of Epidemiology and Population Health, the Australian National University, Canberra 2601, Australia
| | - Haribondhu Sarma
- Department of Applied Epidemiology, National Centre of Epidemiology and Population Health, the Australian National University, Canberra 2601, Australia
| | - Sam-ang Seubsman
- School of Human Ecology, Sukhothai Thammathirat Open University, Nonthaburi, 11120, Thailand
| | - Adrian Sleigh
- Department of Applied Epidemiology, National Centre of Epidemiology and Population Health, the Australian National University, Canberra 2601, Australia
| | - Matthew Kelly
- Department of Applied Epidemiology, National Centre of Epidemiology and Population Health, the Australian National University, Canberra 2601, Australia
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Liu X, Zhang J, Zhang S, Peng S, Pei M, Dai C, Wang T, Zhang P. Quality of life and associated factors among community-dwelling adults with multimorbidity in Shanghai, China: A cross-sectional study. Nurs Open 2023. [PMID: 37243492 DOI: 10.1002/nop2.1770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/23/2023] [Accepted: 04/16/2023] [Indexed: 05/28/2023] Open
Abstract
AIM To compare the quality of life of patients with and without multimorbidity and investigate potential factors related to the quality of life in patients with multimorbidity. DESIGN A descriptive cross-sectional study. METHODS This study included 1778 residents with chronic diseases, including single disease (1255 people, average age: 60.78 ± 9.42) and multimorbidity (523 people, average age: 64.03 ± 8.91) groups, who were recruited from urban residents of Shanghai through a multistage, stratified, probability proportional to size sampling method. The quality of life was measured using the World Health Organization Quality of Life Questionnaire. The socio-demographic data and psychological states were measured using a self-made structured questionnaire, Self-rating Anxiety Scale, and Self-rating Depression Scale. Differences in demographic characteristics were estimated using Pearson's chi-squared test, and independent t-test or one-way ANOVA followed by S-N-K test was used to compare the mean quality of life. Multiple linear regression analysis was conducted to identify risk factors for multimorbidity. RESULTS There were differences in age, education, income, and BMI between single-disease and multimorbidity groups, but no differences in gender, marriage, and occupation. Multimorbidity had lower quality of life, reflected in all four domains. Multiple linear regression analyses showed that low level of education, low income, number of diseases, depression, and anxiety were negatively related to quality of life in all domains.
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Affiliation(s)
- Xingyue Liu
- Graduate School, Shanghai University of Medicine & Health Sciences, Shanghai, China
- Graduate School, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Juhua Zhang
- Department of integrated traditional Chinese and Western Medicine, Shanghai University of Medicine and Health Sciences Affiliated Zhoupu Hospital, Shanghai, China
| | - Shixiang Zhang
- School of Nursing & Health Management, Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Shuzhi Peng
- Graduate School, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Mengyun Pei
- Graduate School, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Chunying Dai
- Department of medicine, Kashgar Vocational and Technical College, Kashgar, China
| | - Tingting Wang
- School of Nursing & Health Management, Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Peng Zhang
- School of Management, Hainan Medical University, Haikou, China
- School of Clinical Medicine, Shanghai University of Medicine & Health Sciences, Shanghai, China
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Prescription of potentially inappropriate medicines and comparison with lists of essential medicines for treatment of chronic disorders in older patients. Arch Gerontol Geriatr 2023; 109:104939. [PMID: 36746015 DOI: 10.1016/j.archger.2023.104939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/17/2023] [Accepted: 01/18/2023] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To examine the current situation of potentially inappropriate medicines (PIM) for treatment of chronicity in older patients and whether the inappropriate medicines were included in the 22nd World Health Organization (WHO) Model List of Essential Medicines (EMLs), China National Model list of Essential Medicines (China EMLs), or supplementary list of essential medicines in Guizhou Province 2018 (Guizhou EMLs) through real world data, so as to promote the development of lists of essential medicines suitable for older patients and provide a reference for the revision of lists of essential medicines to reduce adverse effects, drug-induced diseases and even possible death due to use of inappropriate medicines existing in lists of essential medicines. METHODS A retrospectively study was conducted. Dispensing records of patients aged ≥ 65 admitted to convenience clinic of a tertiary hospital from January 1, 2021 to December 31, 2021 were extracted through electronic information system. Then, we merged dispensing records of the same patient on the same date as one record and patients with at least one chronic disease were included. The American Geriatrics Society(AGS)/Beers Criteria 2019 (Beers 2019) was used to evaluate the PIM status. Thereafter, the inappropriate medicines were compared with WHO EMLs, China EMLs, and Guizhou EMLs to find out percentages of drugs of PIMs existing in above lists of essential medicines in all drugs of PIMs. The above evaluation was conducted using Excel software (version 2019). RESULTS A total of 5314 dispensing reports were included in this study. 5.95% (316/5314), 7.88% (419/5314) of PIMs met Table 2 (medicines that are potentially inappropriate in most older adults), Table 4 (medicines that should be used with caution) of Beers 2019, respectively. Among PIM drugs which met Table 2 of Beers 2019, 47.37%, 78.95%, and 78.95% were respectively included in WHO EMLs, China EMLs, and Guizhou EMLs, and that was 47.06%, 76.47%, and 82.35% for Table 4 of Beers 2019. CONCLUSIONS PIM in older patients is common in clinical practice. Patients with diabetes, hypertension, arthritis, depression and/or anxiety and Parkinson' diseases were more frequently prescribed drugs of PIM according to Beers 2019. Take older patients into consideration and formulate List of essential medicines special for older patients may be a key way to reduce PIM.
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Giang NH, Vinh NT, Phuong HT, Thang NT, Oanh TTM. Household financial burden associated with healthcare for older people in Viet Nam: a cross-sectional survey. Health Res Policy Syst 2022; 20:112. [PMID: 36443746 PMCID: PMC9706832 DOI: 10.1186/s12961-022-00913-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 09/16/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Population ageing and the associated increase in the healthcare needs of older people are putting pressure on the healthcare system in Viet Nam. The country prioritizes healthcare for older people and has developed financial protection policies to mitigate financial hardship due to out-of-pocket health expenditures (OOPHEs) borne by their households. This study examines the level and determinants of the financial burden of OOPHE among households with people aged ≥ 60 years in Viet Nam. METHODS A cross-sectional household survey was conducted among a sample of 1536 older people living in 1477 households in three provinces representing the North, Central and South regions of Viet Nam during 2019-2020. The financial outcomes were catastrophic health expenditure (CHE), using WHO's definition, and financial distress due to OOPHE. Multivariate binary logistic regression analysis was employed to determine the factors associated with these outcomes. RESULTS OOPHE for older household members accounted for 86.3% of total household health expenditure. Of households with older people, 8.6% (127) faced CHE, and 12.2% (181) experienced financial distress due to OOPHE. Households were at a higher risk of incurring financial burdens related to health expenditures if they had fewer household members; included only older people; were in rural or remote, mountainous areas; and had older members with noncommunicable diseases. There was no significant association between health insurance coverage and financial burden. However, when older people sought tertiary care or private care, the possibility of a household facing CHE increased. Regardless of the type and level of care, health service utilization by older people results in a higher likelihood of a household encountering financial distress. CONCLUSIONS This study reveals that OOPHE for older people can impose substantial financial burdens on households, leading them to face CHE and financial distress. This study provides evidence to justify reforming financial protection policies and introducing policy interventions targeted at better protecting older people and their households from the financial consequences of OOPHE. There is also the need to strengthen the grassroots health facilities to provide primary care closer to home at lower costs, particularly for the management of noncommunicable diseases.
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Affiliation(s)
- Nguyen Hoang Giang
- grid.492361.b0000 0004 0642 7152Health Strategy and Policy Institute, Lane 196, Ho Tung Mau Street, Mai Dich Ward, Cau Giay District, Hanoi, Viet Nam
| | - Nguyen The Vinh
- grid.492361.b0000 0004 0642 7152Health Strategy and Policy Institute, Lane 196, Ho Tung Mau Street, Mai Dich Ward, Cau Giay District, Hanoi, Viet Nam
| | - Hoang Thi Phuong
- grid.492361.b0000 0004 0642 7152Health Strategy and Policy Institute, Lane 196, Ho Tung Mau Street, Mai Dich Ward, Cau Giay District, Hanoi, Viet Nam
| | - Nguyen Thi Thang
- grid.492361.b0000 0004 0642 7152Health Strategy and Policy Institute, Lane 196, Ho Tung Mau Street, Mai Dich Ward, Cau Giay District, Hanoi, Viet Nam
| | - Tran Thi Mai Oanh
- grid.492361.b0000 0004 0642 7152Health Strategy and Policy Institute, Lane 196, Ho Tung Mau Street, Mai Dich Ward, Cau Giay District, Hanoi, Viet Nam
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Ferreira JRS, Zandonade E, de Paula Alves Bezerra OM, Salaroli LB. Insulin resistance by the triglyceride-glucose index in a rural Brazilian population. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:848-855. [PMID: 35929905 PMCID: PMC10118758 DOI: 10.20945/2359-3997000000509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
Objective The aim of this study was to estimate the prevalence of insulin resistance (IR) in a rural population in Brazil, to verify its association with sociodemographic, labor, lifestyle, and health factors. Subjects and methods This is a cross-sectional study with 790 farmers in the state of Espírito Santo/Brazil. Triglyceride-glucose (TyG) was calculated and a cut-off point of Ln 4.52 was used. A hierarchical logistic regression for the association of insulin resistance with sociodemographic, labor, lifestyle and health variables of farmers living in Espírito Santo was performed. Results The prevalence of insulin resistance was 33.7% (n = 266), and the association with insulin resistance was found in the age group 31 to 40 years of age (OR = 1.85; 95% CI 1.19-2.87); in smokers or former smokers (OR = 1.63; 95% CI 1.08-2.48) and overweight (OR = 3.06; 95% CI 2.22-4.23). Conclusion The prevalence of insulin resistance was high in a rural population of Brazil, and was mainly associated with age, smoking and obesity. The use of TyG as an instrument for assessing the health of individuals living in areas where access to health services is difficult, such as rural areas, can represent an important advance in terms of health promotion, protection and recovery. In addition, by identifying the risk factors associated with IR, as well as their consequences, a more adequate scheme for the prevention and treatment of these comorbidities can be defined.
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Affiliation(s)
| | - Eliana Zandonade
- Programa de Pós-graduação em Saúde Pública, Universidade Federal do Espírito Santo (UFES), Vitória, ES, Brasil
| | | | - Luciane Bresciani Salaroli
- Programa de Pós-graduação em Saúde Pública, Universidade Federal do Espírito Santo (UFES), Vitória, ES, Brasil
- Programa de Pós-graduação em Nutrição e Saúde, Universidade Federal do Espírito Santo (UFES), Vitória, ES, Brasil
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Fleitas Alfonzo L, King T, You E, Contreras-Suarez D, Zulkelfi S, Singh A. Theoretical explanations for socioeconomic inequalities in multimorbidity: a scoping review. BMJ Open 2022; 12:e055264. [PMID: 35197348 PMCID: PMC8882654 DOI: 10.1136/bmjopen-2021-055264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 01/27/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To document socioepidemiological theories used to explain the relationship between socioeconomic disadvantage and multimorbidity. DESIGN Scoping review. METHODS A search strategy was developed and then applied to multiple electronic databases including Medline, Embase, PsychInfo, Web of Science, Scielo, Applied Social Sciences, ERIC, Humanities Index and Sociological Abstracts. After the selection of studies, data were extracted using a data charting plan. The last search was performed on the 28 September 2021. Extracted data included: study design, country, population subgroups, measures of socioeconomic inequality, assessment of multimorbidity and conclusion on the association between socioeconomic variables and multimorbidity. Included studies were further assessed on their use of theory, type of theories used and context of application. Finally, we conducted a meta-narrative synthesis to summarise the results. RESULTS A total of 64 studies were included in the review. Of these, 33 papers included theories as explanations for the association between socioeconomic position and multimorbidity. Within this group, 16 explicitly stated those theories and five tested at least one theory. Behavioural theories (health behaviours) were the most frequently used, followed by materialist (access to health resources) and psychosocial (stress pathways) theories. Most studies used theories as post hoc explanations for their findings or for study rationale. Supportive evidence was found for the role of material, behavioural and life course theories in explaining the relationship between social inequalities and multimorbidity. CONCLUSION Given the widely reported social inequalities in multimorbidity and its increasing public health burden, there is a critical gap in evidence on pathways from socioeconomic disadvantage to multimorbidity. Generating evidence of these pathways will guide the development of intervention and public policies to prevent multimorbidity among people living in social disadvantage. Material, behavioural and life course pathways can be targeted to reduce the negative effect of low socioeconomic position on multimorbidity.
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Affiliation(s)
- Ludmila Fleitas Alfonzo
- Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Tania King
- Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Emily You
- Academic Unit for Psychiatry of Old Age, Department of Psychiatry, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia
| | - Diana Contreras-Suarez
- Melbourne Institute: Applied Economic and Social Research, University of Melbourne, Melbourne, Victoria, Australia
| | - Syafiqah Zulkelfi
- Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ankur Singh
- Centre of Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
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Feng X, Kelly M, Sarma H. The association between educational level and multimorbidity among adults in Southeast Asia: A systematic review. PLoS One 2021; 16:e0261584. [PMID: 34929020 PMCID: PMC8687566 DOI: 10.1371/journal.pone.0261584] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/03/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND In Southeast Asia, the prevalence of multimorbidity is gradually increasing. This paper aimed to investigate the association between educational level and multimorbidity among over 15-years old adults in Southeast Asia. METHODS We conducted a systematic review of published observational studies. Studies were selected according to eligibility criteria of addressing definition and prevalence of multimorbidity and associations between level of education and multimorbidity in Southeast Asia. The Newcastle-Ottawa Scale (NOS) was used to measure the quality and risk of bias. The methodology has been published in PROSPERO with registered number ID: CRD42021259311. RESULTS Eighteen studies were included in the data synthesis. The results are presented using narrative synthesis due to the heterogeneity of differences in exposures, outcomes, and methodology. The prevalence of multimorbidity ranged from 1.7% to 72.6% among over 18 years-old adults and from 1.5% to 51.5% among older people (≥ 60 years). There were three association patterns linking between multimorbidity and education in these studies: (1) higher education reducing odds of multimorbidity, (2) higher education increasing odds of multimorbidity and (3) education having no association with multimorbidity. The association between educational attainment and multimorbidity also varies widely across countries. In Singapore, three cross-sectional studies showed that education had no association with multimorbidity among adults. However, in Indonesia, four cross-sectional studies found higher educated persons to have higher odds of multimorbidity among over 40-years-old persons. CONCLUSIONS Published studies have shown inconsistent associations between education and multimorbidity because of different national contexts and the lack of relevant research in the region concerned. Enhancing objective data collection such as physical examinations would be necessary for studies of the connection between multimorbidity and education. It can be hypothesised that more empirical research would reveal that a sound educational system can help people prevent multimorbidity.
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Affiliation(s)
- Xiyu Feng
- Department of Global Health, Research School of Population Health, The Australian National University, Canberra, Australia
| | - Matthew Kelly
- Department of Global Health, Research School of Population Health, The Australian National University, Canberra, Australia
| | - Haribondhu Sarma
- Department of Global Health, Research School of Population Health, The Australian National University, Canberra, Australia
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Dhungana RR, Karki KB, Bista B, Pandey AR, Dhimal M, Maskey MK. Prevalence, pattern and determinants of chronic disease multimorbidity in Nepal: secondary analysis of a national survey. BMJ Open 2021; 11:e047665. [PMID: 34315794 PMCID: PMC8317126 DOI: 10.1136/bmjopen-2020-047665] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 07/13/2021] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES To assess the prevalence, pattern and determinants of non-communicable diseases (NCDs) multimorbidity in Nepal. DESIGN Secondary analysis of the data from the NCD survey 2018, which was conducted between 2016 and 2018. SETTING The data belong to the nationally representative survey, that selected the study samples from throughout Nepal using multistage cluster sampling. PARTICIPANTS 8931 participants aged 20 years and older were included in the study. PRIMARY OUTCOMES NCD multimorbidity (occurrence of two or more chronic conditions including hypertension, diabetes, chronic obstructive pulmonary disease, chronic kidney disease, coronary artery disease and cancer). Descriptive statistics, prevalence ratio and odds ratio were computed to assess pattern and determinants of multimorbidity. RESULTS Mean (SD) age was 46.7 years (14.9 years). The majority of the participants were women (57.8%), without formal education (53.4%) and from urban areas (51.5%). Multimorbidity was present in 13.96% (95% CI: 12.9% to 15.1%). Hypertension and diabetes coexisted in 5.7%. Age, alcohol consumption, body mass index, non-high-density lipoprotein (non-HDL) level and rural-urban setting were significantly associated with multimorbidity. CONCLUSION Multimorbidity was prevalent in particular groups or geographical areas in Nepal suggesting a need for coordinated and integrated NCD care approach for the management of multiplicative co-comorbid conditions.
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Petarli GB, Cattafesta M, Sant’Anna MM, Bezerra OMDPA, Zandonade E, Salaroli LB. Multimorbidity and complex multimorbidity in Brazilian rural workers. PLoS One 2019; 14:e0225416. [PMID: 31743369 PMCID: PMC6863555 DOI: 10.1371/journal.pone.0225416] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 11/03/2019] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To estimate the prevalence of multimorbidity and complex multimorbidity in rural workers and their association with sociodemographic characteristics, occupational contact with pesticides, lifestyle and clinical condition. METHODS This is a cross-sectional epidemiological study with 806 farmers from the main agricultural municipality of the state of Espírito Santo/Brazil, conducted from December 2016 to April 2017. Multimorbidity was defined as the presence of two or more chronic diseases in the same individual, while complex multimorbidity was classified as the occurrence of three or more chronic conditions affecting three or more body systems. Socio-demographic data, occupational contact with pesticides, lifestyle data and clinical condition data were collected through a structured questionnaire. Binary logistic regression was conducted to identify risk factors for multimorbidity. RESULTS The prevalence of multimorbidity among farmers was 41.5% (n = 328), and complex multimorbidity was 16.7% (n = 132). More than 77% of farmers had at least one chronic illness. Hypertension, dyslipidemia and depression were the most prevalent morbidities. Being 40 years or older (OR 3.33, 95% CI 2.06-5.39), previous medical diagnosis of pesticide poisoning (OR 1.89, 95% CI 1.03-3.44), high waist circumference (OR 2.82, CI 95% 1.98-4.02) and worse health self-assessment (OR 2.10, 95% CI 1.52-2.91) significantly increased the chances of multimorbidity. The same associations were found for the diagnosis of complex multimorbidity. CONCLUSION We identified a high prevalence of multimorbidity and complex multimorbidity among the evaluated farmers. These results were associated with increased age, abdominal fat, pesticide poisoning, and poor or fair health self-assessment. Public policies are necessary to prevent, control and treat this condition in this population.
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Affiliation(s)
- Glenda Blaser Petarli
- Postgraduate Program in Collective Health, Health Sciences Center, Federal University of Espírito Santo, Vitória, Espírito Santo, Brazil
| | - Monica Cattafesta
- Postgraduate Program in Collective Health, Health Sciences Center, Federal University of Espírito Santo, Vitória, Espírito Santo, Brazil
| | | | - Olívia Maria de Paula Alves Bezerra
- Department of Family Medicine, Mental and Collective Health, Medical school, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | - Eliana Zandonade
- Postgraduate Program in Collective Health, Health Sciences Center, Federal University of Espírito Santo, Vitória, Espírito Santo, Brazil
| | - Luciane Bresciani Salaroli
- Postgraduate program in Nutrition and Health, and Graduate Program in Collective Health, Center for Health Sciences, Federal University of Espírito Santo, Vitória, Espírito Santo, Brazil
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