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Mohiuddin SG, Ward ME, Hollingworth W, Watson JC, Whiting PF, Thom HHZ. Cost-Effectiveness of Routine Monitoring of Long-Term Conditions in Primary Care: Informing Decision Modelling with a Systematic Review in Hypertension, Type 2 Diabetes and Chronic Kidney Disease. PHARMACOECONOMICS - OPEN 2024; 8:359-371. [PMID: 38393659 PMCID: PMC11058158 DOI: 10.1007/s41669-024-00473-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/24/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Long-term conditions (LTCs) are major public health problems with a considerable health-related and economic burden. Modelling is key in assessing costs and benefits of different disease management strategies, including routine monitoring, in the conditions of hypertension, type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) in primary care. OBJECTIVE This review aimed to identify published model-based cost-effectiveness studies of routine laboratory testing strategies in these LTCs to inform a model evaluating the cost effectiveness of testing strategies in the UK. METHODS We searched the Medline and Embase databases from inception to July 2023; the National Institute for Health and Care Institute (NICE) website was also searched. Studies were included if they were model-based economic evaluations, evaluated testing strategies, assessed regular testing, and considered adults aged >16 years. Studies identified were summarised by testing strategies, model type, structure, inputs, assessment of uncertainty, and conclusions drawn. RESULTS Five studies were included in the review, i.e. Markov (n = 3) and microsimulation (n = 2) models. Models were applied within T2DM (n = 2), hypertension (n = 1), T2DM/hypertension (n = 1) and CKD (n = 1). Comorbidity between all three LTCs was modelled to varying extents. All studies used a lifetime horizon, except for a 10-year horizon T2DM model, and all used quality-adjusted life-years as the effectiveness outcome, except a TD2M model that used glycaemic control. No studies explicitly provided a rationale for their selected modelling approach. UK models were available for diabetes and CKD, but these compared only a limited set of routine monitoring tests and frequencies. CONCLUSIONS There were few studies comparing routine testing strategies in the UK, indicating a need to develop a novel model in all three LTCs. Justification for the modelling technique of the identified studies was lacking. Markov and microsimulation models, with and without comorbidities, were used; however, the findings of this review can provide data sources and inform modelling approaches for evaluating the cost effectiveness of testing strategies in all three LTCs.
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Affiliation(s)
- Syed G Mohiuddin
- Centre for Guidelines, National Institute for Health and Care Excellence, London, UK
| | - Mary E Ward
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - William Hollingworth
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jessica C Watson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Penny F Whiting
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Howard H Z Thom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Shettigar L, Sivaraman S, Rao R, Arun SA, Chopra A, Kamath SU, Rana R. Correlational analysis between salivary and blood glucose levels in individuals with and without diabetes mellitus: a cross-sectional study. Acta Odontol Scand 2024; 83:101-111. [PMID: 37823574 PMCID: PMC11302642 DOI: 10.1080/00016357.2023.2267678] [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: 07/06/2023] [Revised: 09/18/2023] [Accepted: 09/30/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVE To estimate the association of patient-related demographic, socioeconomic status, physical activity, stress, and dietary factors influencing the relationship between salivary and blood glucose levels in individuals with and without diabetes mellitus (DM). METHOD This cross-sectional study was conducted on 166 participants with and without DM. Saliva and blood were collected to estimate the glucose levels. Age, gender, occupation, socioeconomic and education level, BMI, hip to waist circumference, stress, dietary pattern, lifestyle, physical activity, family history of diabetes, and type of diabetes were recorded. The association of saliva to predict blood glucose levels was analysed using Spearman Rank Correlation and how these patient-related factors influence the correlation was estimated for future machine learning models. The difference in medians for various groups was calculated using the Mann-Whitney U Test or Kruskal Wallis Test. RESULTS Blood glucose level is not significantly correlated to salivary glucose level. However, a statistically significant difference in the median blood glucose levels for diabetic participants (median = 137) compared to healthy controls (p-value < .05) was noted. The correlation between blood and salivary glucose was more positive for higher levels of glucose (Spearman 0.4). Age, alcohol consumption, monthly wages, intake of vegetables, and socioeconomic status affect blood glucose levels. CONCLUSION A correlation between saliva and blood glucose levels in healthy individuals was weak. Saliva should only be used as a monitoring tool rather than a diagnostic tool and is more reliable for patients with poorly controlled diabetes mellitus.
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Affiliation(s)
- Laasya Shettigar
- Department of Periodontology, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Sanchita Sivaraman
- UBC School of Population and Public Health, British Columbia, Vancouver, Canada
| | - Rohini Rao
- Department of Data Science and Computer Applications, Manipal Institute of Technology (MIT), Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Sanjana Akhila Arun
- Department of Data Science and Computer Applications, Manipal Institute of Technology (MIT), Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Aditi Chopra
- Department of Periodontology, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, India.
| | - Shobha U Kamath
- Department of Biochemistry, Kasturba Medical College and Hospital, Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Raju Rana
- Department of Biochemistry, Kasturba Medical College and Hospital, Manipal, Manipal Academy of Higher Education, Manipal, India
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Kone N, Cassim N, Maposa I, George JA. Diabetic control and compliance using glycated haemoglobin (HbA1C) testing guidelines in public healthcare facilities of Gauteng province, South Africa. PLoS One 2023; 18:e0278789. [PMID: 37585388 PMCID: PMC10431606 DOI: 10.1371/journal.pone.0278789] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 08/02/2023] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVE This study aimed at evaluating diabetic control and compliance with testing guidelines, across healthcare facilities of Gauteng Province, South Africa, as well as factors associated with time to achieve control. South Africa's estimated total unmet need for care for patients with type 2 diabetes mellitus is 80%. RESEARCH DESIGN, METHODS AND FINDINGS The data of 511 781 patients were longitudinally evaluated. Results were reported by year, age category, race, sex, facility and test types. HbA1C of ≤7% was reported as normal, >7 - ≤9% as poor control and >9% as very poor control. The chi-squared test was used to assess the association between a first-ever HbA1C status and variables listed above. The Kaplan-Meier analysis was used to assess probability of attaining control among those who started with out-of-control HbA1C. The extended Cox regression model assessed the association between time to attaining HbA1C control from date of treatment initiation and several covariates. We reported hazard ratios, 95% confidence intervals and p-values. Data is reported for 511 781 patients with 705 597 laboratory results. Poorly controlled patients constituted 51.5%, with 29.6% classified as very poor control. Most poorly controlled patients had only one test over the entire study period. Amongst those who started with poor control status and had at least two follow-up measurements, the likelihood of achieving good control was higher in males (adjusted Hazard Ratio (aHR) = 1.16; 95% CI:1.12-1.20; p<0.001) and in those attending care at hospitals (aHR = 1.99; 95% CI:1.92-2.06; p<0.001). CONCLUSION This study highlights poor adherence to guidelines for diabetes monitoring.
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Affiliation(s)
- Ngalulawa Kone
- Department of Chemical Pathology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Service (NHLS), Johannesburg, South Africa
| | - Naseem Cassim
- National Health Laboratory Service (NHLS), Johannesburg, South Africa
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Innocent Maposa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Jaya Anna George
- Department of Chemical Pathology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Service (NHLS), Johannesburg, South Africa
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DuGray K, Duff E. Type 2 Diabetes in Indigenous Youth Living in Remote Communities. J Nurse Pract 2023. [DOI: 10.1016/j.nurpra.2022.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
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Nunes Oliveira C, Galvão Oliveira M, Wildes Amorim W, Nicolaevna Kochergin C, Mistro S, de Medeiros DS, Oliveira Silva K, Moraes Bezerra V, Honorato Dos Santos de Carvalho VC, Bispo Júnior JP, Louzado JA, Lopes Cortes M, Arruda Soares D. Physicians' and nurses' perspective on chronic disease care practices in Primary Health Care in Brazil: a qualitative study. BMC Health Serv Res 2022; 22:673. [PMID: 35590417 PMCID: PMC9121587 DOI: 10.1186/s12913-022-08078-z] [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] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 05/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Primary health care-oriented systems provide better healthcare, especially for chronic diseases. This study analyzed the perspectives of physicians and nurses performing care for patients with chronic diseases in Primary Health Care in a Brazilian city. METHODS A qualitative study was conducted in Vitória da Conquista, Bahia, Brazil, using semi-structured interviews with five physicians and 18 nurses. The interview included questions from an analytical matrix based on three dimensions of healthcare practices: organizational, technical care, and biopsychosocial, following a deductive approach. The interviews were fully transcribed and analyzed using a thematic categorical approach. RESULTS The results indicated that the provision of chronic care occurs in a comprehensive way. Potentialities were identified in the diversification of access, offer of care actions and technologies, integration of teamwork, and bringing together social networks to foster autonomy and self-care. Weaknesses were mostly related to the high number of people in the teams, follow-up of several cases, high turnover of support teams, low integration of Primary Health Care with other levels, difficulties in intersectoral articulation and family participation in care. CONCLUSION The multidimensional assessment of health care practices aimed at individuals with chronic noncommunicable diseases was useful to portray the strengths and weaknesses of the services. It also ratifies the need to consider the importance of and investment in primary health care by offering the necessary technical, political, logistical and financial support to the units, to ensure the sustainability of the actions by nurses, doctors and entire team.
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Affiliation(s)
- Carolinny Nunes Oliveira
- Master's Program in Collective Health, Multidisciplinary Health Institute, Federal University of Bahia, Vitória da Conquista, Bahia, Brazil
| | - Marcio Galvão Oliveira
- Epidemiology and Collective Health Nucleus, Multidisciplinary Health Institute, Federal University of Bahia, Hormindo Barros Street, 58 - Candeias, Vitória da Conquista, Bahia, 45029-094, Brazil
| | - Welma Wildes Amorim
- Departament of Natural Science, State University of Southwest of Bahia, Vitória da Conquista, Bahia, Brazil
| | - Clavdia Nicolaevna Kochergin
- Epidemiology and Collective Health Nucleus, Multidisciplinary Health Institute, Federal University of Bahia, Hormindo Barros Street, 58 - Candeias, Vitória da Conquista, Bahia, 45029-094, Brazil
| | - Sóstenes Mistro
- Epidemiology and Collective Health Nucleus, Multidisciplinary Health Institute, Federal University of Bahia, Hormindo Barros Street, 58 - Candeias, Vitória da Conquista, Bahia, 45029-094, Brazil
| | - Danielle Souto de Medeiros
- Epidemiology and Collective Health Nucleus, Multidisciplinary Health Institute, Federal University of Bahia, Hormindo Barros Street, 58 - Candeias, Vitória da Conquista, Bahia, 45029-094, Brazil
| | - Kelle Oliveira Silva
- Epidemiology and Collective Health Nucleus, Multidisciplinary Health Institute, Federal University of Bahia, Hormindo Barros Street, 58 - Candeias, Vitória da Conquista, Bahia, 45029-094, Brazil
| | - Vanessa Moraes Bezerra
- Epidemiology and Collective Health Nucleus, Multidisciplinary Health Institute, Federal University of Bahia, Hormindo Barros Street, 58 - Candeias, Vitória da Conquista, Bahia, 45029-094, Brazil
| | - Vivian Carla Honorato Dos Santos de Carvalho
- Epidemiology and Collective Health Nucleus, Multidisciplinary Health Institute, Federal University of Bahia, Hormindo Barros Street, 58 - Candeias, Vitória da Conquista, Bahia, 45029-094, Brazil
| | - José Patrício Bispo Júnior
- Epidemiology and Collective Health Nucleus, Multidisciplinary Health Institute, Federal University of Bahia, Hormindo Barros Street, 58 - Candeias, Vitória da Conquista, Bahia, 45029-094, Brazil
| | - José Andrade Louzado
- Epidemiology and Collective Health Nucleus, Multidisciplinary Health Institute, Federal University of Bahia, Hormindo Barros Street, 58 - Candeias, Vitória da Conquista, Bahia, 45029-094, Brazil
| | - Matheus Lopes Cortes
- Epidemiology and Collective Health Nucleus, Multidisciplinary Health Institute, Federal University of Bahia, Hormindo Barros Street, 58 - Candeias, Vitória da Conquista, Bahia, 45029-094, Brazil
| | - Daniela Arruda Soares
- Epidemiology and Collective Health Nucleus, Multidisciplinary Health Institute, Federal University of Bahia, Hormindo Barros Street, 58 - Candeias, Vitória da Conquista, Bahia, 45029-094, Brazil.
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Rhyu J, Lambrechts S, Han MA, Freeby MJ. Utilizing point-of-care A1c to impact outcomes - can we make it happen in primary care? Curr Opin Endocrinol Diabetes Obes 2022; 29:29-33. [PMID: 34889878 DOI: 10.1097/med.0000000000000700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Hemoglobin A1c testing provides a marker of glycemic control and is the standard for diabetes risk assessment. According to the Centers for Disease Control (CDC), only 67.3-71.4% of diabetic patients between 2011 and 2016 had at least two A1c levels tested per year. Moreover, 27.8% had uncontrolled diabetes with an A1c of ≥8.0%, increasing the risk of microvascular complications. Lack of monitoring presents a significant barrier, and improving ease of testing could improve glycemic control. RECENT FINDINGS Point-of-care (POC) A1c testing, obtained via capillary blood with results provided in 5-6 min, is available and used frequently in endocrine clinics. However, POC A1c testing is not standard in primary care, where 90% of type 2 diabetes patients are treated. Barriers include access and costs of POC A1c machines and standardization of testing in the primary care setting. Review of literature, however, suggests that POC A1c testing in primary care may lead to A1c reduction whereas being potentially cost-effective and strengths the patient-physician relationship. SUMMARY POC A1c testing in primary care, if widely available and integrated into workflow, has the potential to positively impact diabetes care. Real-time feedback may change patient and physician behaviors, allowing earlier therapeutic intensification.
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Affiliation(s)
- Jane Rhyu
- David Geffen UCLA School of Medicine, University of California Los Angeles (UCLA), Los Angeles, California, USA
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Camargo MS, Passos LCS, Mistro S, Soares DA, Kochergin CN, de Carvalho VCHDS, Macedo JCL, Cortes TBA, de Souza AA, Rumel D, Oliveira MG. Improving Access to the Glycated Hemoglobin Test in Rural Communities With Point-of-Care Devices: An Application Study. Front Med (Lausanne) 2021; 8:734306. [PMID: 34881257 PMCID: PMC8645789 DOI: 10.3389/fmed.2021.734306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 10/29/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Living in a rural or remote area is frequently associated with impaired access to health services, which directly affects the possibility of early diagnosis and appropriate monitoring of diseases, mainly non-communicable ones, because of their asymptomatic onset and evolution. Point-of-care devices have emerged as useful technologies for improving access to several laboratory tests closely patients' beds or homes, which makes it possible to eliminate the distance barrier. Objective: To evaluate the application of point-of-care technology for glycated hemoglobin (HbA1c) estimation in the assessment of glycemic control and identification of new diagnoses of diabetes in primary care among rural communities in a Brazilian municipality. Materials and Methods: We included individuals aged 18 years or older among rural communities in a Brazilian municipality. From September 2019 to February 2020, participants were assessed for anthropometrics, blood pressure, and capillary glycemia during routine primary care team activities at health fairs and in patient groups. Participants previously diagnosed with diabetes but without recent HbA1c test results or those without a previous diagnosis but with random capillary glycemia higher than 140 mg/dL were considered positive and were tested for HbA1c by using a point-of-care device. Results: At the end of the study, 913 individuals were accessed. Of these, 600 (65.7%) had no previous diagnosis of diabetes, 58/600 (9.7%) refused capillary glycemia screening and 542/600 (90.7%) were tested. Among tested individuals, 73/542 (13.5%) cases without a previous diagnosis of diabetes, were positive for capillary glycemia. Among positives, 31/73 (42.5%) had HbA1c levels that were considered indicative of prediabetes and 16/73 (21.9%) were newly diagnosed with diabetes. Among the participants, 313/913 (34.3%) were previously diagnosed with diabetes. Recent HbA1c results were unavailable for 210/313 (67.1%). These individuals were tested using point-of-care devices. Among them, 143/210 (68.1%) had HbA1c levels higher than target levels (>7% and >8% for adults and elderly individuals, respectively. Conclusion: The application of point-of-care devices for HbA1c level measurement improved the access to this test for people living in rural or remote areas. Thus, it was possible to include this technology in the routine activities of primary health care teams, which increased the rates of new diagnoses and identification of patients with uncontrolled glycemia.
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Affiliation(s)
| | | | - Sostenes Mistro
- Program of Post-graduation in Collective Health, Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista, Brazil
| | - Daniela Arruda Soares
- Program of Post-graduation in Collective Health, Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista, Brazil
| | | | | | - Jéssica Caline Lemos Macedo
- Program of Post-graduation in Collective Health, Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista, Brazil
| | - Taciana Borges Andrade Cortes
- Program of Post-graduation in Collective Health, Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista, Brazil
| | - Amós Alves de Souza
- Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista, Brazil
| | - Davi Rumel
- Department of Community Health, School of Medicine, Municipal University of São Caetano do sul, São Caetano Do Sul, Brazil
| | - Marcio Galvão Oliveira
- Program of Post-graduation in Collective Health, Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista, Brazil
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Lemos Macedo JC, de Carvalho VCHDS, Cortes TBA, Soares DA, Mistro S, Kochergin CN, Rumel D, Oliveira MG. Community-Based Interventions to Improve the Control of Non-Communicable Diseases in Underserved Rural Areas in Brazil: A Before-and-After Study. Front Pharmacol 2021; 12:644599. [PMID: 33935739 PMCID: PMC8080168 DOI: 10.3389/fphar.2021.644599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/10/2021] [Indexed: 12/26/2022] Open
Abstract
Background: Hypertension and diabetes mellitus are the second and third highest leading causes of disability-adjusted life-years (DALY), respectively, in Brazil. The clinical outcomes of chronic diseases are influenced by various factors. Therefore, there is a need for multifaceted interventions to achieve a decrease in the rate of DALY, with a better control of these diseases. Objective: To verify whether sustainable long-term interventions, such as health worker training and provision of health education to the patients, contribute to health improvements in patients with hypertension and diabetes from rural communities. Methods: Over a 6 month period, educational and medical interventions were provided to optimize the treatment of hypertension and diabetes. Furthermore, blood pressure and glycated hemoglobin (HbA1c) measurements were taken at baseline and after the interventions. Results: The monitored hypertensive patients (n = 276) had a reduction of 13.4 mmHg (p = 0.021) and 5.8 mmHg (p < 0.001) in mean systolic and diastolic blood pressure, respectively. Diabetic patients who were followed-up (n = 71) achieved a 0.55% (p = 0.185) reduction in HbA1c level. The desired blood pressure level (<140/90 mmHg) was achieved in 38.8% of patients with hypertension, whereas the desired level of HbA1c (<7.0% for adults and <8.0% for the elderly) was achieved in 16.9% of patients with diabetes; in addition, 38.0% had a reduction of HbA1c of at least 1%. Conclusion: The results showed that the interventions improved the blood pressure and HbA1c levels in patients with hypertension and diabetes from rural communities in a municipality in Northeast Brazil.
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Affiliation(s)
- Jéssica Caline Lemos Macedo
- Master's Program in Collective Health, Multidisciplinary Health Institute, Federal University of Bahia, Vitória da Conquista, Brazil
| | | | - Taciana Borges Andrade Cortes
- Master's Program in Collective Health, Multidisciplinary Health Institute, Federal University of Bahia, Vitória da Conquista, Brazil
| | - Daniela Arruda Soares
- Master's Program in Collective Health, Multidisciplinary Health Institute, Federal University of Bahia, Vitória da Conquista, Brazil
| | - Sóstenes Mistro
- Master's Program in Collective Health, Multidisciplinary Health Institute, Federal University of Bahia, Vitória da Conquista, Brazil
| | | | - Davi Rumel
- Department of Community Health, School of Medicine of the Municipal University of São Caetano Do Sul, São Caetano Do Sul, Brazil
| | - Marcio Galvão Oliveira
- Master's Program in Collective Health, Multidisciplinary Health Institute, Federal University of Bahia, Vitória da Conquista, Brazil
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