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Chen JH, Wen M. Experiences of Forgone Care During the COVID-19 Pandemic and Older Adults' Mental Health: Variations by Race and Ethnicity. J Racial Ethn Health Disparities 2025:10.1007/s40615-025-02304-0. [PMID: 39934497 DOI: 10.1007/s40615-025-02304-0] [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: 08/03/2024] [Revised: 12/17/2024] [Accepted: 01/30/2025] [Indexed: 02/13/2025]
Abstract
The COVID-19 pandemic led to substantial forgone care. However, relatively few studies have investigated the mental health consequences of forgone care experiences on older adults and how these associations vary by race and ethnicity during this period. This study analyzed US older adults aged 55 or older from the Health, Ethnicity, and Pandemic Survey (N = 883; average age = 65), a nationally representative survey conducted in late 2020. Weighted OLS regression was used to examine the association between measures of forgone care and mental health outcomes. Results showed that experiences of forgone care were prevalent and similar across racial and ethnic groups, with some variations across types of missed care. Furthermore, forgone care and missing various types of care during the COVID-19 pandemic were associated with higher psychological distress and poorer sleep quality, with some variations by race and ethnicity. Black older adults who had forgone care and missed more types of care showed even poorer sleep than their White counterparts. Additionally, missing chronic care, mental care, and preventative care, but not other types of care, was associated with greater psychological distress and poorer sleep for all racial and ethnic groups. However, Black older adults who missed chronic care had even poorer sleep than Whites. Findings emphasize the need to support all older adults' healthcare access of various types during the pandemic and the importance of focusing on specific racial and ethnic groups such as Black older adults who were more affected by forgone care.
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Affiliation(s)
- Jen-Hao Chen
- Department of Sociology and Department of Psychology, National Chengchi University, Taipei, Taiwan.
| | - Ming Wen
- Department of Sociology and Research Hub of Population Studies, University of Hong Kong, Hong Kong, China
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Alshehri K, Wen M, Michaud T, Chen B, Li H, Qu J, Chen L, Li J, Zhang D, Li Y, Chen Z, Han X, Shi L, Su D. Experience of Racial Discrimination was Associated with Psychological Distress and Worsening Sex Life Among Adult Americans During COVID-19. JOURNAL OF SEX RESEARCH 2025; 62:199-207. [PMID: 37307401 PMCID: PMC11819546 DOI: 10.1080/00224499.2023.2221673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The recent escalation of racism in the U.S. during the COVID-19 pandemic points to the importance of examining the association between experienced racism and sexual health. Based on data from a nationally representative survey conducted in the U.S. in October 2020 (n = 1,915), Chi-square tests and multivariable logistic regressions were estimated to examine the association between experience of racism and changes in sex life during the pandemic. We further performed a causal mediation analysis using the bootstrap technique to assess the mediating role of psychological distress in the observed association between the experience of racism and changes in sex life. Among the respondents, the proportions reporting better, worse, or no change in sex life were, respectively, 15%, 21%, and 64%. Experiencing racial discrimination during COVID-19 was significantly associated with worsening sex life (adjusted odd ratio [AOR] = 1.53; 95% confidence interval [CI] = 1.04, 2.25). Respondents with experienced racism were also more likely to report psychological distress (AOR = 1.68; 95% CI = 1.09, 2.59). About one-third (32.66%) of the observed association between experienced racism and worsening sex life was mediated through psychological distress. Addressing racism and its association with psychological distress has the potential to improve sexual health and reduce related racial and ethnic disparities.
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Affiliation(s)
- Khalid Alshehri
- Department of Health Services Research and Administration, College of Public Health, University of Nebraska Medical Center
- Center for Reducing Health Disparities, College of Public Health, University of Nebraska Medical Center
| | - Ming Wen
- Department of Sociology, University of Utah
| | - Tzeyu Michaud
- Center for Reducing Health Disparities, College of Public Health, University of Nebraska Medical Center
- Department of Health Promotion, College of Public Health, University of Nebraska Medical Center
| | - Baojiang Chen
- Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center at Houston
| | - Hongmei Li
- Department of Media, Journalism and Film, Miami University
| | - Joshua Qu
- Center for Reducing Health Disparities, College of Public Health, University of Nebraska Medical Center
| | - Liwei Chen
- Department of Environmental Health Sciences, Fielding School of Public Health, University of California Los Angeles
| | - Jian Li
- Department of Environmental Health Sciences, Fielding School of Public Health, University of California Los Angeles
| | - Donglan Zhang
- Division of Health Services Research, Department of Foundations of Medicine, New York University Long Island School of Medicine
| | - Yan Li
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai
| | - Zhuo Chen
- Department of Health Policy and Management, College of Public Health, University of Georgia
| | - Xuesong Han
- Surveillance and Health Services Research Program, American Cancer Society
| | - Lu Shi
- Department of Public Health Sciences, Clemson University
| | - Dejun Su
- Center for Reducing Health Disparities, College of Public Health, University of Nebraska Medical Center
- Department of Health Promotion, College of Public Health, University of Nebraska Medical Center
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Leitner SM. Working from home and mental well-being at different stages of the COVID-19 pandemic. PLoS One 2024; 19:e0312299. [PMID: 39535982 PMCID: PMC11560032 DOI: 10.1371/journal.pone.0312299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 10/03/2024] [Indexed: 11/16/2024] Open
Abstract
This paper analyses the relationship between working from home (WFH) and mental well-being at different stages during the first two critical years of the COVID-19 pandemic, when governments repeatedly imposed lockdowns and enacted WFH mandates to contain the spread of the virus. Using data from a representative survey conducted at four different time periods in 2020 (first lockdown, subsequent gradual reopening), 2021 (further lockdown) and 2022 (restrictions widely lifted) in the 27 EU member states, it examines the changing role of several mediators over time: work-family conflict, family-work conflict, stability, resilience, isolation, the importance of different support networks, workload, physical risk of contracting COVID-19 at work and housing conditions. For the first lockdown, it also differentiates by previous WFH experience, in terms of WFH novices and experienced WFH workers. It likewise differentiates by gender, in order to take the potential gendered nature of COVID-19 measures into account. The results point to several important mediators: for those who work from home, less family-work conflict and isolation, but greater stability, resilience, network support from family and friends, and superior housing conditions were associated with better mental well-being. The relevance of mediators was specific to certain stages of the pandemic. Stability was the most important mediator during the first lockdown. Work-family conflict and family-work conflict were only relevant during the first lockdown, while resilience and isolation mattered especially towards the end of the pandemic. Unlike established WFH workers, WFH novices had an advantage during the first lockdown, benefiting from lower family-work conflict and more helpful networks of family and friends. Our results differ by gender: for females who undertook WFH, important mediators were work-family conflict and family-work conflict. Both were related to adjustments they had to make in work and non-work hours in response to the enforced closure of schools and childcare facilities. For males who undertook WFH, support from networks of family and friends was an important mediator during the first lockdown.
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Affiliation(s)
- Sandra M. Leitner
- The Vienna Institute for International Economic Studies, Vienna, Austria
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Lippert JF, Lewis T, Bruce D, Trifunović N, Singh M, Prachand N. Work-related factors of mental health among Chicago residents two years into the COVID-19 pandemic. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2024; 21:365-377. [PMID: 38560920 DOI: 10.1080/15459624.2024.2323108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
The COVID-19 pandemic led to widespread consequences for economic, social, and general wellbeing with rates of anxiety and depression increasing across the population and disproportionately for some workers. This study explored which factors were the most salient contributors to mental health through a cross-sectional 68-item questionnaire that addressed topics related to the pandemic. Data were collected through an address-based sampling frame over the two months from April 2022 to June 2022. A total of 2,049 completed surveys were collected throughout Chicago's 77 Community Areas. Descriptive statistics including frequency and percentages were generated to describe workplace characteristics, work-related stress, and sample demographics and their relationship to psychological distress. Independent participant and workplace factors associated with the outcomes were identified using multivariable logistic regression. The weighted prevalence of persons experiencing some form of psychological distress from mild to serious was 32%. After adjusting for potential confounding factors, certain marginalized communities experienced psychological distress more than others including females, adults over the age of 25 years of age, and people with higher income levels. Those who had been laid off, lost pay, or had reduced hours had increased odds of psychological distress (aOR = 1.71, CI95% 1.14-2.56; p = 0.009) as did people that reported that their work-related stress was somewhat or much worse as compared to before the COVID-19 pandemic (aOR = 2.22, CI95% 1.02-4.82; p = 0.04, aOR = 11.0, CI95% 4.65-26.1; p < 0.001, respectively). These results warrant further investigation and consideration in developing workplace and mental health interventions.
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Affiliation(s)
- Julia F Lippert
- Department of Health Sciences, DePaul University, Chicago, Illinois
| | - Taylor Lewis
- RTI International, Washington, District of Columbia
| | - Douglas Bruce
- Department of Health Sciences, DePaul University, Chicago, Illinois
| | - Nena Trifunović
- Department of Health Sciences, DePaul University, Chicago, Illinois
| | - Meha Singh
- Office of Epidemiology, Chicago Department of Public Health, Chicago, Illinois
| | - Nik Prachand
- Office of Epidemiology, Chicago Department of Public Health, Chicago, Illinois
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Giusti L, Mammarella S, Del Vecchio S, Salza A, Casacchia M, Roncone R. Deepening Depression in Women Balancing Work-Life Responsibilities and Caregiving during the COVID-19 Pandemic: Findings from Gender-Specific Face-to-Face Street Interviews Conducted in Italy. Behav Sci (Basel) 2023; 13:892. [PMID: 37998639 PMCID: PMC10668961 DOI: 10.3390/bs13110892] [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: 09/25/2023] [Revised: 10/24/2023] [Accepted: 10/24/2023] [Indexed: 11/25/2023] Open
Abstract
PURPOSE This study investigated the impact of the COVID-19 pandemic on mental health, quality of life, and family functioning in a sample of the general female population, exploring difficulties encountered in managing family and work responsibilities and burden of care when taking care of a loved one. This study was, moreover, aimed at investigating factors capable of influencing severe depressive symptomatology in the context of socio-demographics, traumatic events, individual vulnerability, and family functioning. METHOD The sampling method used in this research was non-probability sampling. The survey took place during a Hospital Open Weekend (8-10 October 2021) organized by the National Gender Observatory on Women's Health "Fondazione Onda" on the occasion of the World Mental Health Day. RESULTS A total of 211 women were interviewed (mean age = 35.6, 53% living alone, more than 15% with financial difficulties, 47% exposed to the 2009 L'Aquila earthquake). More than 50% of the sample reported a higher complexity in managing their lives during the COVID-19 pandemic compared to their previous routine, with no statistically significant differences between working women and non-workers, although the latter obtained higher scores for depressive symptomatology and poorer quality of life. Compared to non-caregivers, female caregivers (22.3%) in charge of the care of loved ones affected by physical (10.9%) or psychiatric disabilities (11.4%) complained of a poorer quality of life, especially in general health perception (p = 0.002), physical function (p = 0.011), role limitations related to physical problems (p = 0.017), bodily pain (p = 0.015), mental health (p = 0.004), and social functioning (p = 0.007). Women caring for people affected by mental disorders seemed to experience a more significant worsening in vitality (p = 0.003) and social functioning (p = 0.005). Approximately 20% of the total sample reported severe depressive symptomatology. Previous access to mental health services (O.R. 10.923; p = 0.000), a low level of education (O.R. 5.410; p = 0.021), and difficulties in management of everyday lives during the COVID-19 pandemic (O.R. 3.598; p = 0.045) were found to be the main variables predictive of severe depressive psychopathology. Old age, good problem-solving skills, and ability to pursue personal goals were identified as protective factors. CONCLUSIONS The COVID-19 pandemic underlined the need for support amongst emotionally vulnerable women with pre-existing mental health conditions, partly reflecting the cumulative effects of traumas.
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Affiliation(s)
- Laura Giusti
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (L.G.); (S.M.); (S.D.V.); (A.S.); (M.C.)
| | - Silvia Mammarella
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (L.G.); (S.M.); (S.D.V.); (A.S.); (M.C.)
| | - Sasha Del Vecchio
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (L.G.); (S.M.); (S.D.V.); (A.S.); (M.C.)
| | - Anna Salza
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (L.G.); (S.M.); (S.D.V.); (A.S.); (M.C.)
| | - Massimo Casacchia
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (L.G.); (S.M.); (S.D.V.); (A.S.); (M.C.)
| | - Rita Roncone
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (L.G.); (S.M.); (S.D.V.); (A.S.); (M.C.)
- University Unit for Rehabilitation Treatment, Early Interventions in Mental Health, S. Salvatore Hospital, 67100 L’Aquila, Italy
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Ishimoto Y, Sotodate T, Namba Y, Uenishi T, Iwasaki K, Tomita H. Benefits of Working from Home During the COVID-19 Pandemic for Undiagnosed Workers with Attention-Deficit/Hyperactivity Disorder Symptoms. Neuropsychiatr Dis Treat 2023; 19:1607-1621. [PMID: 37484117 PMCID: PMC10356549 DOI: 10.2147/ndt.s414862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/05/2023] [Indexed: 07/25/2023] Open
Abstract
Purpose Our previous study suggested that working conditions might impact work productivity amid the COVID-19 pandemic. This study aimed to investigate the association between working from home (WFH) and depressive symptoms, work productivity, and quality of life (QOL), in undiagnosed workers with attention-deficit/hyperactivity disorder (ADHD) symptoms during the COVID-19 pandemic. Methods During the pandemic, the survey was conducted among eligible workers with (N = 904) and without (N = 900) ADHD symptoms based on the Adult ADHD Self-Report Scale [ASRS]. Each group was further stratified by working conditions (full working on-site [FWOS], hybrid, full WFH [FWFH]). Two-way ANOVA was performed to investigate the impact of WFH on depressive symptoms (Patient Health Questionnaire [PHQ-9] score), work productivity (Work Productivity and Activity Impairment scale [WPAI] scores), and QOL (EuroQol 5-Dimensions 5-Levels [EQ-5D-5L] score). The Tukey-Kramer test was used to assess differences between the stratified subgroups. Poisson and multiple regression analyses were also performed to assess the factors associated with these outcomes. Results Other than PHQ-9 score between FWOS and hybrid work in workers with ADHD symptoms (p < 0.05), no significant differences were observed in outcomes among the working condition subgroups in both workers with and without ADHD symptoms. In workers with ADHD symptoms, hybrid work and FWFH were significantly associated with a lower PHQ-9 score (hybrid, p < 0.001; FWFH, p < 0.05) but neither were significantly associated with WPAI score nor EQ-5D-5L. Annual income and discretionary work were significantly associated with a lower PHQ-9 score and a higher EQ-5D-5L score in workers with ADHD symptoms. Job type (manufacture/construction) was significantly associated with a lower presenteeism score. Conclusion WFH (hybrid and FWFH) may be associated with lower depressive symptoms compared with FWOS in undiagnosed workers with ADHD symptoms. The findings may be useful when considering suitable working environments for workers especially with ADHD symptoms.
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Affiliation(s)
| | - Takuma Sotodate
- Japan Medical Office, Takeda Pharmaceutical Company Limited, Tokyo, Japan
| | - Yuki Namba
- Medical Affairs Department, Shionogi & Co., Ltd., Tokyo, Japan
| | | | | | - Hiroaki Tomita
- Department of Psychiatry, Tohoku University Graduate School of Medicine, Sendai, Japan
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Matthews TA, Guardiano M, Omidakhsh N, Cushing L, Robbins W, Hong O, Li J. Associations of COVID-19 Related Work Stressors with Psychological Distress: Racial and Ethnic Disparities in Californian Workers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:144. [PMID: 36612463 PMCID: PMC9819092 DOI: 10.3390/ijerph20010144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 06/17/2023]
Abstract
The COVID-19 pandemic continues to exert immense societal impacts, with recent data showing inequitable distribution of consequences among racial and ethnic groups. The objective of this study was to assess associations between COVID-related work stressors and psychological distress, with special emphasis on differences by race and ethnicity. Data were from the population-based California Health Interview Survey (CHIS) 2020. Associations of individual and cumulative work stressors, including job loss, reduced work hours, and working from home, with psychological distress in 12,113 workers were examined via multivariable linear regression, and stratified analyses were conducted for racial and ethnic subgroups. After adjustment for covariates, compared to workers with no work stressors, those who experienced either one or two/more work stressors had higher psychological distress (βs and 95% CIs were 0.80 [0.51, 1.09] and 1.98 [1.41, 2.56], respectively). Notably, experiencing cumulative (two/more) work stressors had much stronger effects on psychological distress among participants who were Black (β and 95% CI were 3.51 [1.09, 5.93]) or racial minorities (β and 95% CI were 3.57 [1.10, 6.05]). Occupational consequences of the COVID-19 pandemic were associated with increased psychological distress in Californian workers and inequitably distributed, with racial and ethnic minorities suffering the greatest burden.
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Affiliation(s)
- Timothy A. Matthews
- Department of Environmental Health Sciences, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Megan Guardiano
- School of Nursing, University of California Los Angeles, Los Angeles, CA 90095, USA
| | | | - Lara Cushing
- Department of Environmental Health Sciences, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Wendie Robbins
- Department of Environmental Health Sciences, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA 90095, USA
- School of Nursing, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - OiSaeng Hong
- Occupational and Environmental Health Nursing Graduate Program, School of Nursing, University of California San Francisco, San Francisco, CA 94143, USA
| | - Jian Li
- Department of Environmental Health Sciences, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA 90095, USA
- School of Nursing, University of California Los Angeles, Los Angeles, CA 90095, USA
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Griep RH, Almeida MDCC, Barreto SM, Brunoni AR, Duncan BB, Giatti L, Mill JG, Molina MDCB, Moreno AB, Patrão AL, Schmidt MI, da Fonseca MDJM. Working from home, work-time control and mental health: Results from the Brazilian longitudinal study of adult health (ELSA-Brasil). Front Psychol 2022; 13:993317. [PMID: 36262442 PMCID: PMC9574257 DOI: 10.3389/fpsyg.2022.993317] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 08/29/2022] [Indexed: 11/22/2022] Open
Abstract
This cross-sectional study investigated the association between work-time control (WTC), independently and in combination with hours worked (HW), and four mental health outcomes among 2,318 participants of the Longitudinal Study of Adult Health (ELSA-Brasil) who worked from home during the COVID-19 pandemic. WTC was assessed by the WTC Scale, and mental health outcomes included depression, anxiety, stress (measured by the Depression, Anxiety and Stress Scale, DASS-21), and self-rated mental health. Logistic regression models were used to determine odds ratios (ORs) and 95% confidence intervals (CIs). Among women, long HW were associated with stress (OR = 1.56; 95% CI = 1.11–2.20) and poor self-rated mental health (OR = 1.64; 95% CI = 1.13–2.38), whereas they were protective against anxiety among men (OR = 0.59; 95% CI = 0.37–0.93). In both sexes, weak WTC was associated with all mental health outcomes. Among women, the long HW/weak WTC combination was associated with all mental health outcomes, and short HW/weak WTC was associated with anxiety and stress. Among men, long HW/strong WTC was protective against depression and stress, while short HW/strong WTC and short HW/weak WTC was associated with all mental health outcomes. In both sexes, weak WTC, independently and in combination with HW, was associated with all mental health outcomes. WTC can improve working conditions, protect against mental distress, and fosterwork-life balance for those who work from home.
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Affiliation(s)
- Rosane Harter Griep
- Laboratory of Health and Environmental Education, Instituto Oswaldo Cruz, Rio de Janeiro, Brazil
- *Correspondence: Rosane Harter Griep, ; orcid.org/0000-0002-6250-2036
| | | | - Sandhi Maria Barreto
- School of Medicine and Hospital das Clínicas/EBSERH, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - André R. Brunoni
- School of Medicine, Universidade de São Paulo, São Paulo, Brazil
| | - Bruce B. Duncan
- Postgraduate Programme in Epidemiology and Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Luana Giatti
- School of Medicine and Hospital das Clínicas/EBSERH, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - José Geraldo Mill
- Department of Physiological Sciences, Universidade Federal do Espírito Santo, Vitória, Brazil
| | - Maria del Carmen B. Molina
- Postgraduate Programme in Health and Nutrition, Universidade Federal do Ouro Preto, Ouro Preto, Brazil
- Postgraduate Programme in Collective Health, Universidade Federal do Espírito Santo, Vitória, Brazil
| | - Arlinda B. Moreno
- Department of Epidemiology and Quantitative Methods in Health, Escola Nacional de Saúde Pública Sérgio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Ana Luisa Patrão
- Center for Psychology, Faculty of Psychology and Education Science of the University of Porto, Porto, Portugal
- Institute of Collective Health, Federal University of Bahia, Salvador, Brazil
| | - Maria Inês Schmidt
- Postgraduate Programme in Epidemiology and Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Maria de Jesus Mendes da Fonseca
- Department of Epidemiology and Quantitative Methods in Health, Escola Nacional de Saúde Pública Sérgio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
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