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Dumith SC, Martins OPL, Moreira MKV, Paulitsch RG, Simões MO, Marmitt LP, Silva PEA, Silva MP. Is the increment of diabetes mellitus in Brazil associated with the consumption of artificially sweetened beverages? A time trend analysis with 757,386 adults from 2006 to 2020. Public Health 2023; 221:66-72. [PMID: 37421755 DOI: 10.1016/j.puhe.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/19/2023] [Accepted: 06/06/2023] [Indexed: 07/10/2023]
Abstract
OBJECTIVE To describe trends in the prevalence of diabetes mellitus (DM) in Brazil and to analyze its association with the consumption of artificially sweetened beverages among individuals aged 18 years or older. STUDY DESIGN This was a repeated cross-sectional study. METHODS Annual data from VIGITEL surveys (2006-2020) were used, which included adults from all Brazilian state capitals. The outcome was the prevalence of DM (type 1 and type 2). The main exposure variable was consuming beverages like soft drinks and artificial juices, either in its 'diet, light, or zero' form. Covariates included sex, age, sociodemographic characteristics, smoking, alcohol consumption, physical activity, fruit consumption, and obesity. The temporal trend in the indicators and the etiological fraction (population attributable risk [PAR]) were calculated. Analyses were performed using Poisson regression. The association between DM and consumption of beverages was tested, excluding the year 2020 due to the pandemic; restricting the analysis to the final three years (2018-2020). RESULTS Overall, 757,386 subjects were included. The prevalence of DM increased from 5.5% to 8.2%, with an annual growth of 0.17 percentage points (95% CI 0.11-0.24). Among those who consumed diet/light/zero beverages, the annual percentage change of DM was four times greater. The PAR corresponding to the consumption of diet/light/zero beverages on the occurrence of DM was 17%. CONCLUSIONS An increasing prevalence of DM was observed, while diet/light/zero beverages consumption remains stable. A substantial reduction in the annual percentage change of DM could be observed if people stopped consuming diet/light soda/juice.
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Affiliation(s)
- S C Dumith
- Postgraduate Program in Health Sciences, Universidade Federal de Rio Grande. Rio Grande, RS, CEP: 96203-900, Brazil; Grupo de Pesquisa em Atividade Física e Saúde Pública, Universidade Federal do Rio Grande, Rio Grande, RS, CEP: 96203-900, Brazil
| | - O P L Martins
- Postgraduate Program in Health Sciences, Universidade Federal de Rio Grande. Rio Grande, RS, CEP: 96203-900, Brazil; Grupo de Pesquisa em Atividade Física e Saúde Pública, Universidade Federal do Rio Grande, Rio Grande, RS, CEP: 96203-900, Brazil
| | - M K V Moreira
- Grupo de Pesquisa em Atividade Física e Saúde Pública, Universidade Federal do Rio Grande, Rio Grande, RS, CEP: 96203-900, Brazil; Postgraduate Program in Epidemiology, Universidade Federal de Pelotas, Pelotas, RS, CEP: 96020-220, Brazil
| | - R G Paulitsch
- Grupo de Pesquisa em Atividade Física e Saúde Pública, Universidade Federal do Rio Grande, Rio Grande, RS, CEP: 96203-900, Brazil; Empresa Brasileira de Serviços Hospitalares, Universidade Federal do Rio Grande, Rio Grande, RS, CEP: 96203-900, Brazil
| | - M O Simões
- Grupo de Pesquisa em Atividade Física e Saúde Pública, Universidade Federal do Rio Grande, Rio Grande, RS, CEP: 96203-900, Brazil; Universidade Vale do Rio Doce, Governador Valadares, MG, CEP: 35020-220, Brazil
| | - L P Marmitt
- Grupo de Pesquisa em Atividade Física e Saúde Pública, Universidade Federal do Rio Grande, Rio Grande, RS, CEP: 96203-900, Brazil; Postgraduate Program in Biosciences and Health, Universidade do Oeste de Santa Catarina, Joaçaba, SC, CEP: 89600-000, Brazil.
| | - P E A Silva
- Postgraduate Program in Health Sciences, Universidade Federal de Rio Grande. Rio Grande, RS, CEP: 96203-900, Brazil
| | - M P Silva
- Postgraduate Program in Health Sciences, Universidade Federal de Rio Grande. Rio Grande, RS, CEP: 96203-900, Brazil; Grupo de Pesquisa em Atividade Física e Saúde Pública, Universidade Federal do Rio Grande, Rio Grande, RS, CEP: 96203-900, Brazil
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Cesar JA, Marmitt LP, Mendoza-Sassi RA. Episiotomy in Southern Brazil: prevalence, trend, and associated factors. Rev Saude Publica 2022; 56:26. [PMID: 35476104 PMCID: PMC9004702 DOI: 10.11606/s1518-8787.2022056003908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/24/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To identify and analyze the prevalence, trend, and factors associated with episiotomy in Rio Grande, in the state of Rio Grande do Sul, Southern Brazil. METHODS A single, standardized questionnaire was applied to all pregnant women, residents in the municipality of Rio Grande, who had children in local hospitals between January 1 and December 12 of the years 2007, 2010, 2013, 2016 e 2019. Demographic and socioeconomic characteristics were investigated, as well as the assistance received during pregnancy and delivery. Chi-square test was used to compare proportions and Poisson regression with robust variance adjustment was used for multivariable analysis. Prevalence ratio (PR) was used as effect measure. RESULTS Among the 12,645 births that occurred in the five years, 5,714 (45.2%) were vaginal delivery. Of these mothers, 2,930 (51.3%; 95%CI: 50.0%–52.6%) underwent episiotomy. Over this period, the episiotomy rate decreased from 70.9% (68.4–73.5) in 2007 to 19.4% (17.1–21.7) in 2019. Adjusted analysis showed a high PR of episiotomy occurrence among women who were young (PR = 2.23; 95%CI: 1.89–2.63), had higher education (PR = 1.21; 95%Cl: 1.03–1.42), had a higher family income (PR = 1.25; 95%CI: 1.10–1.41), were primiparous (PR = 3.41; 95%CI: 2.95–3.95), had prenatal care in the private sector (PR = 1.25; 95%CI: 1.07–1.46), had oxytocin-induced labor (PR = 1.18; 95%CI:1.09–1.27), underwent forceps (PR = 1.32; 95%CI: 1.16–1.50), and whose newborn weighed 4,000 g or more (PR = 1.43; 95%CI: 1.14–1.80). CONCLUSION Although the prevalence of episiotomy fell sharply within the studied period, its occurrence is more likely among women at lower risk of birth complications.
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Affiliation(s)
- Juraci A Cesar
- Universidade Federal do Rio Grande. Faculdade de Medicina. Programa de Pós-graduação em Saúde Pública. Rio Grande, RS, Brasil
| | - Luana P Marmitt
- Universidade do Oeste de Santa Catarina. Programa de Pós-Graduação em Biociências e Saúde. Flor da Serra, SC, Brasil
| | - Raúl A Mendoza-Sassi
- Universidade Federal do Rio Grande. Faculdade de Medicina. Programa de Pós-graduação em Saúde Pública. Rio Grande, RS, Brasil
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Marmitt LP, Cordeiro MF, Cesar JA. Trend and Inequality in Episiotomy in Southern Brazil, 2007-2016: Evidence of Reduced Abusive Practice. Matern Child Health J 2021; 26:1231-1238. [PMID: 34839433 DOI: 10.1007/s10995-021-03291-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study aimed to measure the prevalence, to describe the trend over time, and to evaluate socioeconomic inequalities in the occurrence of episiotomies in 2007, 2010, 2013, and 2016 in the municipality of Rio Grande, in Southern Brazil. METHODS We included all women who had vaginal delivery in each of the studied years. All the information was obtained through a questionnaire applied at maternity wards within 48 h after delivery. The outcome consisted of episiotomy. A chi-square test was used to evaluate the linear trend. Absolute and relative inequalities were assessed from household income and schooling of the women through the Slope Index of Inequality and Relative Index of Inequality, respectively. RESULTS This study included 4,521 parturients. The episiotomy rate in the period fell from 71.0% (95%CI: 68.4-73.5) in 2007 to 40.1% (95%CI: 37.3-42.8) in 2016, and it was more frequent among women with higher income and higher schooling. We observed a reduction in the rate of episiotomy in all income and schooling levels, and this was more evident among women in the lowest socioeconomic levels. Absolute inequality declined, while relative inequality remained unchanged. CONCLUSIONS FOR PRACTICE Despite the significant reduction in the rate of episiotomy, its occurrence remains high. Women with higher income and education, therefore with lower risk for complications during childbirth, were the most frequently submitted to this procedure. Routine use of episiotomy must be reevaluated, especially among pregnant women with better socioeconomic status.
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Affiliation(s)
- Luana P Marmitt
- Universidade Federal do Rio Grande (FURG), Rua General Osorio, Rio Grande, RS, 96201-900, Brazil.
- Universidade do Oeste de Santa Catarina (Unoesc), Rua Getúlio Vargas, 2125-Bairro Flor da Serra, Joaçaba, SC, 89600-000, Brazil.
| | - Marcos F Cordeiro
- Universidade do Oeste de Santa Catarina (Unoesc), Rua Getúlio Vargas, 2125-Bairro Flor da Serra, Joaçaba, SC, 89600-000, Brazil
| | - Juraci A Cesar
- Universidade Federal do Rio Grande (FURG), Rua General Osorio, Rio Grande, RS, 96201-900, Brazil
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Cesar JA, Mendoza-Sassi RA, Marmitt LP. Evolution of care during pregnancy and childbirth in the extreme south of Brazil. Rev Saude Publica 2021; 55:50. [PMID: 34406319 PMCID: PMC8328512 DOI: 10.11606/s1518-8787.2021055003128] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 10/23/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To describe the evolution of care during pregnancy and childbirth among postpartum women living in the municipality of Rio Grande, Southern Brazil, using data from surveys carried out every three years between 2007 and 2019. METHODS Within 48 hours after delivery, a single, standardized questionnaire was applied to all mothers who had children in local hospitals and met the inclusion criteria. Demographic and reproductive characteristics, lifestyle habits, socioeconomic level of the family, and care received during pregnancy and childbirth were investigated. In the analysis, the chi-square test for linear trend was used to assess the distribution of indicators per survey. RESULTS A total of 12,645 parturients were interviewed (98% of the women eligible to participate in the surveys). In the period evaluated, the proportion of births fell 35% among adolescents and increased 25% among women aged 35 years and over. Mothers gained, on average, two years of schooling, and their families experienced an important economic improvement, followed by loss of income in the last survey. Maternal smoking, before and during pregnancy, fell by half. The rate of mothers who started prenatal care in the first trimester and the number of consultations and laboratory tests increased. Almost 60% of prenatal consultations and 80% of births took place in the Brazilian Unified Health System. In 2019, vaginal delivery was once again the most common. The rates of low birth weight (9%) and prematurity (17%) virtually remained unchanged. CONCLUSIONS We found an important change in the reproductive profile and increased coverage of various prenatal care and delivery services. Children continue to be born well, but low birth weight and prematurity remain endemic.
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Affiliation(s)
- Juraci A Cesar
- Universidade Federal do Rio Grande. Faculdade de Medicina. Programa de Pós-Graduação em Saúde Pública. Rio Grande, RS, Brasil
| | - Raul A Mendoza-Sassi
- Universidade Federal do Rio Grande. Faculdade de Medicina. Programa de Pós-Graduação em Saúde Pública. Rio Grande, RS, Brasil
| | - Luana P Marmitt
- Universidade do Oeste de Santa Catarina. Programa de Pós-Graduação em Biociências e Saúde. Flor da Serra, SC, Brasil
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Loret de Mola C, Martins-Silva T, Carpena MX, Del-Ponte B, Blumenberg C, Martins RC, Dias IM, Terribele FB, de Avila AB, Marmitt LP, Meucci R, Cesar JA. Maternal mental health before and during the COVID-19 pandemic in the 2019 Rio Grande birth cohort. Braz J Psychiatry 2021; 43:402-406. [PMID: 33605399 PMCID: PMC8352723 DOI: 10.1590/1516-4446-2020-1673] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/07/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To describe and compare measures of maternal depression, anxiety, and posttraumatic stress symptoms before and during the coronavirus disease 2019 (COVID-19) pandemic in a Brazilian birth cohort. METHODS All hospital births occurring in the municipality of Rio Grande (southern Brazil) during 2019 were identified. Mothers were invited to complete a standardized questionnaire on sociodemographic and health-related characteristics. Between May and July 2020, we tried to contact all cohort mothers of singletons, living in urban areas, to answer a standardized web-based questionnaire. They completed the Edinburgh Postnatal Depression Scale (EPDS) and Generalized Anxiety Disorder 7-item (GAD-7) in both follow-ups, and the Impact of Event Scale (IES) in the online follow-up. RESULTS We located 1,136 eligible mothers (n=2,051). Of those, 40.5% had moderate to severe stress due to the current pandemic, 29.3% had depression, and 25.9% had GAD. Mothers reporting loss of income during the pandemic (57.2%) had the highest proportions of mental health problems. Compared to baseline, the prevalence of depression increased 5.7 fold and that of anxiety increased 2.4-fold during the pandemic (both p < 0.001). CONCLUSION We found a high prevalence of personal distress due to the ongoing COVID-19 pandemic, and a clear rise in both maternal depression and anxiety.
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Affiliation(s)
- Christian Loret de Mola
- Grupo de Pesquisa e Inovação em Saúde, Universidade Federal do Rio Grande (FURG), Rio Grande, RS, Brazil.,Programa de Pós-Graduação em Saúde Pública, FURG, Rio Grande, RS, Brazil.,Programa de Pós-Graduação em Epidemiologia da Universidade Federal de Pelotas (UFPel), Pelotas, RS, Brazil.,Centro de Pesquisas em Desenvolvimento Humano e Violência, UFPel, Pelotas, RS, Brazil.,Universidad Cientifica del Sur, Lima, Peru
| | - Thais Martins-Silva
- Grupo de Pesquisa e Inovação em Saúde, Universidade Federal do Rio Grande (FURG), Rio Grande, RS, Brazil.,Programa de Pós-Graduação em Epidemiologia da Universidade Federal de Pelotas (UFPel), Pelotas, RS, Brazil.,Centro de Pesquisas em Desenvolvimento Humano e Violência, UFPel, Pelotas, RS, Brazil
| | - Marina X Carpena
- Grupo de Pesquisa e Inovação em Saúde, Universidade Federal do Rio Grande (FURG), Rio Grande, RS, Brazil.,Programa de Pós-Graduação em Epidemiologia da Universidade Federal de Pelotas (UFPel), Pelotas, RS, Brazil
| | - Bianca Del-Ponte
- Grupo de Pesquisa e Inovação em Saúde, Universidade Federal do Rio Grande (FURG), Rio Grande, RS, Brazil.,Programa de Pós-Graduação em Epidemiologia da Universidade Federal de Pelotas (UFPel), Pelotas, RS, Brazil
| | - Cauane Blumenberg
- Grupo de Pesquisa e Inovação em Saúde, Universidade Federal do Rio Grande (FURG), Rio Grande, RS, Brazil.,Programa de Pós-Graduação em Epidemiologia da Universidade Federal de Pelotas (UFPel), Pelotas, RS, Brazil
| | - Rafaela C Martins
- Grupo de Pesquisa e Inovação em Saúde, Universidade Federal do Rio Grande (FURG), Rio Grande, RS, Brazil.,Programa de Pós-Graduação em Epidemiologia da Universidade Federal de Pelotas (UFPel), Pelotas, RS, Brazil.,Centro de Pesquisas em Desenvolvimento Humano e Violência, UFPel, Pelotas, RS, Brazil
| | - Ingrid M Dias
- Grupo de Pesquisa e Inovação em Saúde, Universidade Federal do Rio Grande (FURG), Rio Grande, RS, Brazil.,Programa de Pós-Graduação em Saúde Pública, FURG, Rio Grande, RS, Brazil
| | - Flora B Terribele
- Grupo de Pesquisa e Inovação em Saúde, Universidade Federal do Rio Grande (FURG), Rio Grande, RS, Brazil.,Programa de Pós-Graduação em Saúde Pública, FURG, Rio Grande, RS, Brazil
| | - Alice B de Avila
- Grupo de Pesquisa e Inovação em Saúde, Universidade Federal do Rio Grande (FURG), Rio Grande, RS, Brazil.,Programa de Pós-Graduação em Saúde Pública, FURG, Rio Grande, RS, Brazil
| | - Luana P Marmitt
- Programa de Pós-Graduação em Biociências e Saúde, Universidade do Oeste de Santa Catarina, Joaçaba, SC, Brazil
| | - Rodrigo Meucci
- Grupo de Pesquisa e Inovação em Saúde, Universidade Federal do Rio Grande (FURG), Rio Grande, RS, Brazil
| | - Juraci A Cesar
- Grupo de Pesquisa e Inovação em Saúde, Universidade Federal do Rio Grande (FURG), Rio Grande, RS, Brazil
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Cesar JA, Marmitt LP, Carpena MX, Pereira FG, Neto JDM, Neumann NA, Acevedo JD. Maternal Knowledge and Unsafe Baby Sleep Position: A Cross-Sectional Survey in Southern Brazil. Matern Child Health J 2019; 23:183-190. [PMID: 30105515 DOI: 10.1007/s10995-018-2613-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective to evaluate women's knowledge about the best baby sleeping position and to identify factors associated with a greater probability of putting infants to sleep in an unsafe position, in Rio Grande, Southern Brazil. Method This is a cross-sectional population-based study that included all women who bore children in 2013 in this municipality. A single, standardized questionnaire was given within 48 h after delivery in the only two local maternity hospitals. The outcome was that women reported the lateral and the ventral decubitus as the best sleeping positions for babies. A Chi square test was used for proportions and Poisson regression was used with robust variance adjustment in the multivariate analysis. The prevalence ratio was the measure of effect used. Results We included 2624 women in this study. Of these, 82.1% (95% CI 80.6-83.6) stated that the baby should sleep in the lateral or ventral decubitus positions. 76.4% reported having acquired this knowledge from their mothers and 34.7% were willing to adopt the correct (supine) sleeping position for their child if recommended by doctors. The adjusted analysis showed that the lower the schooling of the mothers and the greater the number of people per bedroom and number of children, the greater the probability of women choosing an unsafe baby sleeping position. Conclusions for Practice This study showed that the percentage of women who are unaware of the correct baby sleeping position is very high, that doctors should be convinced to recommend the supine baby sleeping position, and that campaigns on this subject should also include grandparents as a priority intervention group.
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Affiliation(s)
- Juraci A Cesar
- Programa de Pós-graduação em Saúde Pública, Universidade Federal do Rio Grande (FURG), Rio Grande, Rio Grande do Sul, 96200-400, Brazil
| | - Luana P Marmitt
- Programa de Pós-graduação em Ciências da Saúde, Universidade Federal do Rio Grande (FURG), Rio Grande, Rio Grande do Sul, 96200-400, Brazil.
| | - Marina X Carpena
- Programa de Pós-graduação em Saúde Pública, Universidade Federal do Rio Grande (FURG), Rio Grande, Rio Grande do Sul, 96200-400, Brazil
| | - Franciele G Pereira
- Programa de Pós-graduação em Saúde Pública, Universidade Federal do Rio Grande (FURG), Rio Grande, Rio Grande do Sul, 96200-400, Brazil
| | - Jose D Macedo Neto
- Programa de Pós-graduação em Saúde Pública, Universidade Federal do Rio Grande (FURG), Rio Grande, Rio Grande do Sul, 96200-400, Brazil
| | - Nelson A Neumann
- Coordenação Nacional da Pastoral da Criança, Curitiba, Paraná, 80810-900, Brazil
| | - Jayshlyn D Acevedo
- Divisão de População & Saúde, Faculdade de Medicina da Universidade Federal do Rio Grande (FURG), Rio Grande, Rio Grande do Sul, 96200-400, Brazil
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Cesar JA, Marmitt LP, Dziekaniak AC, Leite SS, Leão OA, Sauer JP. Non-performance of urinalysis among pregnant women in Brazil. Int J Health Care Qual Assur 2019; 32:224-232. [PMID: 30859876 DOI: 10.1108/ijhcqa-11-2017-0210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this paper is to measure the prevalence, evaluate the trend and identify the factors associated with the non-performance of qualitative urine test (QUT) among pregnant women living in the extreme south of Brazil between 2007 and 2016. DESIGN/METHODOLOGY/APPROACH All births occurred in the local maternity wards from January 1 to December 31 of 2007, 2010, 2013 and 2016. Mothers were interviewed within 48h after delivery. The outcome was the non-performance of QUT during pregnancy. χ2 test was used to compare proportions and Poisson regression with robust variance adjustment for the multivariate analysis. The effect measure used was the prevalence ratio. FINDINGS Of the 10,331 new mothers identified, 10,004 (96.8 percent) performed at least one prenatal visit. The prevalence of non-performance of QUT was 3.3 percent (95% CI 2.9-3.7 percent), ranging from 1.5 percent in 2007 to 5.3 percent in 2016 ( p<0.001). The analysis showed that not living with a companion, having under four years of schooling, living with seven or more people in the household, having five or more children, having had one to three prenatal visits and not having been supplemented with ferrous sulfate during pregnancy showed a significantly higher prevalence rate to the non-performance of QUT. ORIGINALITY/VALUE The rate of non-performance of this test among pregnant women has clearly increased. Mothers at higher risk of unfavorable outcomes in pregnancy were the ones with the highest probability of not performing QUT. Increasing the number of prenatal visits is a high-impact measure toward the performance of this test.
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Affiliation(s)
- Juraci A Cesar
- Postgraduate Program in Public Health, Faculty of Medicine, Universidade Federal do Rio Grande , Rio Grande, Brazil
| | - Luana P Marmitt
- Postgraduate Program in Public Health, Faculty of Medicine, Universidade Federal do Rio Grande , Rio Grande, Brazil
| | - Alessandra C Dziekaniak
- Postgraduate Program in Public Health, Faculty of Medicine, Universidade Federal do Rio Grande , Rio Grande, Brazil
| | - Sabrina S Leite
- Postgraduate Program in Public Health, Faculty of Medicine, Universidade Federal do Rio Grande , Rio Grande, Brazil
| | - Otávio A Leão
- Postgraduate Program in Public Health, Faculty of Medicine, Universidade Federal do Rio Grande , Rio Grande, Brazil
| | - Jéssica P Sauer
- Postgraduate Program in Public Health, Faculty of Medicine, Universidade Federal do Rio Grande , Rio Grande, Brazil
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