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Domingues RMSM, Dias MAB, do Carmo Leal M. Women's preference for a vaginal birth in Brazilian private hospitals: effects of a quality improvement project. Reprod Health 2024; 20:188. [PMID: 38549093 PMCID: PMC10976663 DOI: 10.1186/s12978-024-01771-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 03/11/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND In 2015, a quality improvement project called "Adequate Childbirth Project" (PPA) was implemented in Brazilian private hospitals in order to reduce cesarean sections without clinical indication. The PPA is structured in four components, one of which is directed at women and families. The objective of this study is to evaluate the effects of PPA on women's preference for vaginal birth (VB) at the end of pregnancy. METHODS Evaluative research conducted in 12 private hospitals participating in the PPA. Interviews were carried out in the immediate postpartum period and medical record data were collected at hospital discharge. The implementation of PPA activities and women's preference for type of birth at the beginning and end of pregnancy were compared in women assisted in the PPA model of care and in the standard of care model, using a chi-square statistical test. To estimate the effect of PPA on women's preference for VB at the end of pregnancy, multiple logistic regression was performed with selection of variables using a causal diagram. RESULTS Four thousand seven hundred ninety-eight women were interviewed. The implementation of the planned activities of PPA was less than 50%, but were significantly more frequent among women assisted in the PPA model of care. Women in this group also showed a greater preference for VB at the beginning and end of pregnancy. The PPA showed an association with greater preference for VB at the end of pregnancy in primiparous (OR 2.54 95% CI 1.99-3.24) and multiparous women (OR 1.44 95% CI 0.97-2.12), although in multiparous this association was not significant. The main factor associated with the preference for VB at the end of pregnancy was the preference for this type of birth at the beginning of pregnancy, both in primiparous (OR 18.67 95% CI 14.22-24.50) and in multiparous women (OR 53.11 95% CI 37.31-75.60). CONCLUSIONS The PPA had a positive effect on women's preference for VB at the end of pregnancy. It is plausible that more intense effects are observed with the expansion of the implementation of the planned activities. Special attention should be given to information on the benefits of VB in early pregnancy.
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Affiliation(s)
- Rosa Maria Soares Madeira Domingues
- Instituto Nacional de Infectologia Evandro Chagas/Fundação Oswaldo Cruz, Laboratório de Pesquisa Clínica em DST/Aids, Av. Brasil, 4365, Manguinhos, Rio de Janeiro, CEP 21040-360, Brazil.
| | - Marcos Augusto Bastos Dias
- Instituto Nacional da Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira/Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Maria do Carmo Leal
- Escola Nacional de Saúde Pública Sérgio Arouca/ Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
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Souza FC, Domingues RMSM, Torres JA, Gomes ML, Leal MDC. Evaluation of labor and childbirth care by nurse-midwives in Brazilian private hospitals: results of a quality improvement project. Reprod Health 2023; 20:17. [PMID: 36658552 PMCID: PMC9850504 DOI: 10.1186/s12978-022-01537-0] [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] [Accepted: 11/25/2022] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND In 2015, a quality improvement project-the "Adequate Childbirth Project" (Projeto Parto Adequado, or PPA)-was implemented in Brazilian private hospitals with the goal of reducing unnecessary cesarean sections. One of the strategies adopted by the PPA was the implementation of labor and childbirth care by nurse-midwives. The objective of this study is to evaluate the results of the PPA in the implementation and adequacy of labor and childbirth care by nurse-midwives in Brazilian private hospitals. METHODS Cross-sectional, hospital-based study, carried out in 2017, in 12 hospitals participating in the PPA. We assessed the proportion of women assisted by nurse-midwives during labor and childbirth care and the adequacy of 13 care practices following parameters of the World Health Organization. Women assisted in the PPA model of care and in the standard of care model were compared using the chi-square statistical test. RESULTS 4798 women were interviewed. Women in the PPA model of care had a higher proportion of labor (53% × 24.2%, p value < 0.001) and vaginal birth (32.7% × 11.3%, p value < 0.001), but no significant differences were observed in the proportion of women assisted by nurse-midwives during labor (54.8% × 50.1%, p value = 0.191) and vaginal birth (2.2% × 0.7%, p value = 0.142). The implementation of recommended practices was adequate, except the use of epidural analgesia for pain relief, which was intermediate. There was a greater use of recommended practices including "oral fluid and food", "maternal mobility and position", "monitoring of labor", "use of non-pharmacological methods for pain relief" and "epidural analgesia for pain relief" in women assisted by nurse-midwives in relation to those assisted only by doctors. Many non-recommended practices were frequently used during labor by nurse-midwives and doctors. CONCLUSIONS There was an increase in the proportion of women with labor and vaginal birth in the PPA model of care and an appropriate use of recommended practices in women assisted by nurse-midwives. However, there was no difference in the proportion of women assisted by nurse-midwives in the two models of care. The expansion of nursing participation and the reduction of overused practices remain challenges.
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Affiliation(s)
- Fabrine C Souza
- Programa de pós-graduação em epidemiologia em saúde pública, Escola Nacional de Saúde Pública Sérgio Arouca, Fundação Oswaldo Cruz, Rua Leopoldo Bulhões, 1480 - Manguinhos, Rio de Janeiro, RJ, 21041-210, Brazil.
| | - Rosa Maria Soares Madeira Domingues
- Laboratório de Pesquisa Clínica em DST/Aids, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | - Maysa Luduvice Gomes
- Faculdade de Enfermagem, Departamento de Enfermagem Materno-Infantil, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Maria do Carmo Leal
- Escola Nacional de Saúde Pública Sérgio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
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Nicolotti CA, Lacerda JTD. Avaliação da organização e práticas de assistência ao parto e nascimento em três hospitais de Santa Catarina, Brasil. CAD SAUDE PUBLICA 2022; 38:e00052922. [DOI: 10.1590/0102-311xpt052922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 09/01/2022] [Indexed: 11/29/2022] Open
Abstract
O objetivo foi avaliar a assistência hospitalar ao parto e ao nascimento, analisando aspectos de gestão e assistência desde a admissão das mulheres para o parto até o pós-parto. Foi realizada uma pesquisa avaliativa dos aspectos de gestão e práticas de assistência ao parto e nascimento, desenvolvida no período de novembro de 2019 a fevereiro de 2020, em três hospitais de Santa Catarina, Brasil, com melhor desempenho em uma avaliação nacional de boas práticas de assistência ao parto e ao nascimento. A coleta de dados envolveu análise documental, observação e entrevistas com profissionais da gestão, assistência e puérperas. Foram analisados 30 indicadores, que compuseram uma matriz de análise e julgamento, agrupados nas dimensões Político-Organizacional e Tático-Operacional. O julgamento orientou-se pela comparação entre a pontuação observada e a pontuação máxima esperada em cada um dos componentes da matriz avaliativa. A assistência ao parto e ao nascimento foi parcialmente satisfatória nos hospitais 2 e 3 e insatisfatória no hospital 1. A dimensão Político-Organizacional foi classificada como insatisfatória e a Tático-Operacional parcialmente satisfatória nos três hospitais. Nenhum hospital obteve avaliação satisfatória em mais de 40% dos indicadores. Os hospitais analisados ainda não conseguiram consolidar as mudanças no modelo assistencial na perspectiva do cuidado humanizado, orientado por evidências científicas e direitos.
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Vidal ÁT, Barreto JOM, Rattner D. Barriers to implementing childbirth recommendations in Brazil: the women's perspective. Rev Panam Salud Publica 2021; 45:e17. [PMID: 33643400 PMCID: PMC7898362 DOI: 10.26633/rpsp.2021.17] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 09/24/2020] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To identify barriers to the implementation of National Childbirth Guidelines in Brazil from the women's perspective. METHODS A descriptive exploratory study was performed using a qualitative approach and an interpretive perspective. The hermeneutic unit of analysis was established based on the contribution of users to a public online consultation about the National Childbirth Guidelines in Brazil, performed in 2016 by the National Committee for Health Technology Incorporation into the Unified Health System (CONITEC). Content analysis techniques were used to examine the answers provided to the following specific question: "Considering your local reality, what would hinder the implementation of this protocol or guideline?" RESULTS Of 396 contributions recorded by CONITEC, 55 were included in the content analysis. The mean age of women was 31 years, with most self-declared as white (69%) and living in the Southeast of Brazil (56.3%). Coding revealed seven barrier categories, which were grouped into three families - barriers related to 1) professional training and culture (which highlighted the centrality of physicians, not women, in childbirth), 2) social culture (general population not well informed), and 3) political and management issues (little interest on the part of managers, lower physician compensation for vaginal childbirth vs. cesarian section, and poor hospital infrastructure). CONCLUSIONS Aspects of professional training and culture, social culture, and political as well as management issues are critical points to be considered in future interventions aiming at overcoming or weakening the barriers to implementing childbirth recommendations in Brazil.
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Affiliation(s)
- Ávila Teixeira Vidal
- Universidade de Brasília (UnB), Faculdade de Ciências da Saúde, Departamento de Saúde ColetivaBrasília (DF)BrazilUniversidade de Brasília (UnB), Faculdade de Ciências da Saúde, Departamento de Saúde Coletiva, Brasília (DF), Brazil.
| | - Jorge Otávio Maia Barreto
- Fundação Oswaldo Cruz (Fiocruz)Brasília (DF)BrazilFundação Oswaldo Cruz (Fiocruz), Brasília (DF), Brazil.
| | - Daphne Rattner
- Universidade de Brasília (UnB), Faculdade de Ciências da Saúde, Departamento de Saúde ColetivaBrasília (DF)BrazilUniversidade de Brasília (UnB), Faculdade de Ciências da Saúde, Departamento de Saúde Coletiva, Brasília (DF), Brazil.
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Barreto JOM, Bortoli MC, Luquine CD, Oliveira CF, Toma TS, Ribeiro AAV, Tesser TR, Rattner D, Vidal A, Mendes Y, Carvalho V, Neri MA, Chapman E. Implementation of national childbirth guidelines in Brazil: barriers and strategies. Rev Panam Salud Publica 2020; 44:e170. [PMID: 33417646 PMCID: PMC7778467 DOI: 10.26633/rpsp.2020.170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/03/2020] [Indexed: 02/07/2023] Open
Abstract
The present report describes the process and results obtained with a knowledge translation project developed in three stages to identify barriers to the Implementation of the National Guidelines for Normal Childbirth in Brazil, as well strategies for effective implementation. The Improving Programme Implementation through Embedded Research (iPIER) model and the Supporting Policy Relevant Reviews and Trials (SUPPORT) tools provided the methodological framework for the project. In the first stage, the quality of the Guidelines was evaluated and the barriers preventing implementation of the recommendations were identified through review of the global evidence and analysis of contributions obtained in a public consultation process. In the second stage, an evidence synthesis was used as the basis for a deliberative dialogue aimed at prioritizing the barriers identified. Finally, a second evidence synthesis was presented in a new deliberative dialogue to discuss six options to address the prioritized barriers: 1) promote the use of multifaceted interventions; 2) promote educational interventions for the adoption of guidelines; 3) perform audits and provide feedback to adjust professional practice; 4) use reminders to mediate the interaction between workers and service users; 5) enable patient-mediated interventions; and 6) engage opinion leaders to promote use of the Guidelines. The processes and results associated with each stage were documented and formulated to inform a review and update of the Guidelines and the development of an implementation plan for the recommendations. Effective implementation of the Guidelines is important for improving the care provided during labor and childbirth in Brazil.
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Affiliation(s)
- Jorge Otávio Maia Barreto
- Fundação Oswaldo Cruz (Fiocruz)Brasília, DFBrazilFundação Oswaldo Cruz (Fiocruz), Brasília, DF, Brazil.
| | - Maritsa C. Bortoli
- Secretaria de Estado da Saúde de São Paulo, Instituto de SaúdeSão Paulo (SP)BrazilSecretaria de Estado da Saúde de São Paulo, Instituto de Saúde, São Paulo (SP), Brazil.
| | - Cézar D. Luquine
- Secretaria de Estado da Saúde de São Paulo, Instituto de SaúdeSão Paulo (SP)BrazilSecretaria de Estado da Saúde de São Paulo, Instituto de Saúde, São Paulo (SP), Brazil.
| | - Cintia F. Oliveira
- Secretaria de Estado da Saúde de São Paulo, Instituto de SaúdeSão Paulo (SP)BrazilSecretaria de Estado da Saúde de São Paulo, Instituto de Saúde, São Paulo (SP), Brazil.
| | - Tereza S. Toma
- Secretaria de Estado da Saúde de São Paulo, Instituto de SaúdeSão Paulo (SP)BrazilSecretaria de Estado da Saúde de São Paulo, Instituto de Saúde, São Paulo (SP), Brazil.
| | - Aline A. V. Ribeiro
- Secretaria de Estado da Saúde de São Paulo, Instituto de SaúdeSão Paulo (SP)BrazilSecretaria de Estado da Saúde de São Paulo, Instituto de Saúde, São Paulo (SP), Brazil.
| | - Taís R. Tesser
- Secretaria de Estado da Saúde de São Paulo, Instituto de SaúdeSão Paulo (SP)BrazilSecretaria de Estado da Saúde de São Paulo, Instituto de Saúde, São Paulo (SP), Brazil.
| | - Daphne Rattner
- Universidade de Brasília (UnB), Faculdade de Saúde, Departamento de Saúde ColetivaBrasília (DF)BrazilUniversidade de Brasília (UnB), Faculdade de Saúde, Departamento de Saúde Coletiva, Brasília (DF), Brazil.
| | - Avila Vidal
- Universidade de Brasília (UnB), Faculdade de Saúde, Departamento de Saúde ColetivaBrasília (DF)BrazilUniversidade de Brasília (UnB), Faculdade de Saúde, Departamento de Saúde Coletiva, Brasília (DF), Brazil.
| | - Yluska Mendes
- Universidade de Brasília (UnB), Faculdade de Saúde, Departamento de Saúde ColetivaBrasília (DF)BrazilUniversidade de Brasília (UnB), Faculdade de Saúde, Departamento de Saúde Coletiva, Brasília (DF), Brazil.
| | - Viviane Carvalho
- Universidade de Brasília (UnB), Faculdade de Saúde, Departamento de Saúde ColetivaBrasília (DF)BrazilUniversidade de Brasília (UnB), Faculdade de Saúde, Departamento de Saúde Coletiva, Brasília (DF), Brazil.
| | - Mônica Almeida Neri
- Universidade Federal da Bahia (UFBa), Instituto de Saúde ColetivaSalvador (BA)BrazilUniversidade Federal da Bahia (UFBa), Instituto de Saúde Coletiva, Salvador (BA), Brazil.
| | - Evelina Chapman
- Fundação Oswaldo Cruz (Fiocruz)Brasília, DFBrazilFundação Oswaldo Cruz (Fiocruz), Brasília, DF, Brazil.
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Vidal ÁT, Barreto JOM, Rattner D. [Barriers to implementing childbirth recommendations in Brazil: the women's perspectiveObstáculos para la aplicación de las recomendaciones de asistencia al parto normal en Brasil: perspectiva de las mujeres]. Rev Panam Salud Publica 2020; 44:e164. [PMID: 33337448 PMCID: PMC7737643 DOI: 10.26633/rpsp.2020.164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 09/24/2020] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To identify barriers to the implementation of National Childbirth Guidelines in Brazil from the women's perspective. METHOD A descriptive exploratory study was performed using a qualitative approach and an interpretive perspective. The hermeneutic unit of analysis was established based on the contribution of users to a public online consultation about the National Childbirth Guidelines in Brazil, performed in 2016 by the National Committee for Health Technology Incorporation into the Unified Health System (CONITEC). Content analysis techniques were used to examine the answers provided to the following specific question: "Considering your local reality, what would hinder the implementation of this protocol or guideline?" RESULTS Of 396 contributions recorded by CONITEC, 55 were included in the content analysis. The mean age of women was 31 years, with most self-declared as white (69%) and living in the Southeast of Brazil (56.3%). Coding revealed seven barrier categories, which were grouped into three families - barriers related to 1) professional training and culture (which highlighted the centrality of physicians, not women, in childbirth), 2) social culture (general population not well informed), and 3) political and management issues (little interest on the part of managers, lower physician compensation for vaginal childbirth vs. Caesarian section, and poor hospital infrastructure). CONCLUSIONS Aspects of professional training and culture, social culture, and political as well as management issues are critical points to be considered in future interventions aiming at overcoming or weakening the barriers to implementing childbirth recommendations in Brazil.
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Affiliation(s)
- Ávila Teixeira Vidal
- Universidade de Brasília (UnB)Faculdade de Ciências da SaúdeDepartamento de Saúde ColetivaBrasília (DF)BrasilUniversidade de Brasília (UnB), Faculdade de Ciências da Saúde, Departamento de Saúde Coletiva, Brasília (DF), Brasil.
| | - Jorge Otávio Maia Barreto
- Fundação Oswaldo Cruz (Fiocruz)Brasília (DF)BrasilFundação Oswaldo Cruz (Fiocruz), Brasília (DF), Brasil.
| | - Daphne Rattner
- Universidade de Brasília (UnB)Faculdade de Ciências da SaúdeDepartamento de Saúde ColetivaBrasília (DF)BrasilUniversidade de Brasília (UnB), Faculdade de Ciências da Saúde, Departamento de Saúde Coletiva, Brasília (DF), Brasil.
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Barreto JOM, Bortoli MC, Luquine Jr CD, Oliveira CF, Toma TS, Ribeiro AAV, Tesser TR, Rattner D, Vidal A, Mendes Y, Carvalho V, Neri MA, Chapman E. [Implementation of the National Childbirth Guidelines in Brazil: barriers and trategiesObstáculos y estrategias para la aplicación de las Directrices Nacionales para el Parto Normal en el Brasil]. Rev Panam Salud Publica 2020; 44:e120. [PMID: 33346245 PMCID: PMC7745726 DOI: 10.26633/rpsp.2020.120] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 12/03/2020] [Indexed: 01/05/2023] Open
Abstract
The present report describes the process and results obtained with a knowledge translation project developed in three stages to identify barriers to the National Childbirth Guidelines in Brazil as well strategies for effective implementation. The Improving Programme Implementation through Embedded Research (iPIER) model and the Supporting Policy Relevant Reviews and Trials (SUPPORT) tools provided the methodological framework for the project. In the first stage, the quality of the Guidelines was evaluated and the barriers preventing implementation of the recommendations were identified through review of the global evidence and analysis of contributions obtained in a public consultation process. In the second stage, an evidence synthesis was used as basis for a deliberative dialogue aimed at prioritizing the barriers identified. Finally, a second evidence synthesis was presented in a new deliberative dialogue to discuss six options to address the prioritized barriers: 1) promote the use of multifaceted interventions; 2) promote educational interventions for the adoption of guidelines; 3) perform audits and provide feedback to adjust professional practice; 4) use reminders to mediate the interaction between workers and service users; 5) enable patient-mediated interventions; and 6) engage opinion leaders to promote the use of guidelines. The processes and results associated with each stage were documented and formulated to inform a review and update of the Guidelines and the development of an implementation plan for the recommendations. An effective implementation of the Guidelines is relevant to improve the care provided during labor and childbirth in Brazil.
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Affiliation(s)
- Jorge Otávio Maia Barreto
- Fundação Oswaldo Cruz (Fiocruz), BrasíliaDFBrasilFundação Oswaldo Cruz (Fiocruz), Brasília, DF, Brasil.
| | - Maritsa C. Bortoli
- Secretaria de Estado da Saúde de São Paulo, Instituto de SaúdeSão Paulo (SP)BrasilSecretaria de Estado da Saúde de São Paulo, Instituto de Saúde, São Paulo (SP), Brasil.
| | - Cézar D. Luquine Jr
- Secretaria de Estado da Saúde de São Paulo, Instituto de SaúdeSão Paulo (SP)BrasilSecretaria de Estado da Saúde de São Paulo, Instituto de Saúde, São Paulo (SP), Brasil.
| | - Cintia F. Oliveira
- Secretaria de Estado da Saúde de São Paulo, Instituto de SaúdeSão Paulo (SP)BrasilSecretaria de Estado da Saúde de São Paulo, Instituto de Saúde, São Paulo (SP), Brasil.
| | - Tereza S. Toma
- Secretaria de Estado da Saúde de São Paulo, Instituto de SaúdeSão Paulo (SP)BrasilSecretaria de Estado da Saúde de São Paulo, Instituto de Saúde, São Paulo (SP), Brasil.
| | - Aline A. V. Ribeiro
- Secretaria de Estado da Saúde de São Paulo, Instituto de SaúdeSão Paulo (SP)BrasilSecretaria de Estado da Saúde de São Paulo, Instituto de Saúde, São Paulo (SP), Brasil.
| | - Taís R. Tesser
- Secretaria de Estado da Saúde de São Paulo, Instituto de SaúdeSão Paulo (SP)BrasilSecretaria de Estado da Saúde de São Paulo, Instituto de Saúde, São Paulo (SP), Brasil.
| | - Daphne Rattner
- Universidade de Brasília (UnB), Faculdade de Saúde, Departamento de Saúde ColetivaBrasília (DF)BrasilUniversidade de Brasília (UnB), Faculdade de Saúde, Departamento de Saúde Coletiva, Brasília (DF), Brasil.
| | - Avila Vidal
- Universidade de Brasília (UnB), Faculdade de Saúde, Departamento de Saúde ColetivaBrasília (DF)BrasilUniversidade de Brasília (UnB), Faculdade de Saúde, Departamento de Saúde Coletiva, Brasília (DF), Brasil.
| | - Yluska Mendes
- Universidade de Brasília (UnB), Faculdade de Saúde, Departamento de Saúde ColetivaBrasília (DF)BrasilUniversidade de Brasília (UnB), Faculdade de Saúde, Departamento de Saúde Coletiva, Brasília (DF), Brasil.
| | - Viviane Carvalho
- Universidade de Brasília (UnB), Faculdade de Saúde, Departamento de Saúde ColetivaBrasília (DF)BrasilUniversidade de Brasília (UnB), Faculdade de Saúde, Departamento de Saúde Coletiva, Brasília (DF), Brasil.
| | - Mônica Almeida Neri
- Universidade Federal da Bahia (UFBa), Instituto de Saúde ColetivaSalvador (BA)BrasilUniversidade Federal da Bahia (UFBa), Instituto de Saúde Coletiva, Salvador (BA), Brasil.
| | - Evelina Chapman
- Fundação Oswaldo Cruz (Fiocruz), BrasíliaDFBrasilFundação Oswaldo Cruz (Fiocruz), Brasília, DF, Brasil.
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