Care provided to children with special health needs in the healthcare system

Paloma Mayara Vieira de Macena Lima1,  Vanessa Medeiros da Nóbrega2, Mariana Matias Santos3, Beatriz Rosana Gonçalves de Oliveira Toso4, Eliane Tatsch Neves5, Neusa Collet6, Elenice Maria Cecchetti Vaz7

1,2,6,7Universidade Federal da Paraíba. João Pessoa (PB), Brasil. 3Universidade Federal de Pernambuco. Recife (PE), Brasil. 4Universidade Estadual do Oeste do Paraná. Cascavel (PR), Brasil. 5Universidade Federal da Santa Maria. Santa Maria (RS), Brasil.

Introduction 

The creation and implementation of public policies focused on children's health, as well as advances in scientific and technological development in the health field, have highlighted a distinct group of children, Children with Special Health Needs (CSHN).1 CSHN are defined as children who are more susceptible to developing physical, behavioral, emotional, and developmental changes due to the presence of chronic conditions and functional limitations.2

In Brazil, the prevalence of CSHN is estimated at 25.3%, with the majority having a constant demand for health services at all levels of care due to chronic conditions, functional limitations, and the need for continuous medication.3 These CSHN may depend on continuous and complex care at different points in the Health Care Network (HCN), which imposes the need for adjustments in the daily lives of family caregivers, who often devote themselves fully to care, giving up personal experiences, self-care, and, in many cases, work.4

Proper coordination of the HCN is essential to ensure comprehensive care for CSHN and to alleviate the burden on their families. However, review studies show that this population faces difficulties in accessing HCN services during their therapeutic journey, which hinders continuity of care.4

Among these difficulties are the lack of professional support from the health network, often for the construction of therapeutic itineraries; delays in scheduling appointments and exams, resulting from long waiting lists; the lack of physical structure in health services to meet the needs of these children; slowness in establishing an early medical diagnosis, associated with professional inability to identify the problem; geographical obstacles related to the distance between the home and health services, combined with a lack of government support for transportation; and the distance between Primary Health Care (PHC) assistance and the needs of CSHN.4-5

In this context, family members assume responsibility for managing care and coordinating the support network for CSHN, but they face different contexts of vulnerability in establishing care flows.5 Vulnerability is understood as a broader view of the susceptibility that individuals or groups have to health problems and damage, considering three dimensions: individual, social, and programmatic.6

The individual dimension refers to the interpersonal relationships that constitute personal identity and impact the quality of understanding of the information received for health care; the social dimension relates to the individual's socioeconomic situations, education, access to material resources, and information; the programmatic dimension is associated with the availability of public policies, health services, and the professional-user relationship.6

An integrative review study highlighted a fragile, fragmented, and incipient HCN in the care of CSHN.7 Furthermore, CSHN's access to health services is slow, leading to the replacement of PHC services with care in emergency care units.8 A broader understanding of the contexts of vulnerability experienced by CSHN enables the discussion of effective strategies for this population group. The family perspective gives voice to individuals who experience, in concrete terms, the positive and negative effects of the HCN on the care of CSHN. Thus, considering the theoretical framework of vulnerability, this study aims to analyze the care provided to CSHN in HCN services from the perspective of family caregivers.

Method

This is a qualitative study with an exploratory and descriptive approach, part of a multicenter study conducted in seven Brazilian states, funded by the National Council for Scientific and Technological Development (CNPq). The description of this study followed the guidelines of the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist9, aiming to ensure methodological rigor.

In the survey of municipalities, research data from the multicenter project that characterized Home Care Services (HCS) in 17 municipalities authorized to provide this service10 were used, which identified that nine municipalities in Paraíba had HCSs that served CSHN during the data collection period. HCS was chosen for data collection because it is a supplementary health service in which CSHN receive continuous monitoring. 

The participants were family caregivers of CSHN children and adolescents and met the following inclusion criteria: age over 18 years; being a family caregiver of a child and/or adolescent with special health needs; being treated by the HCS in the AD2 or AD3 modalities; having received at least five HCS treatments. This frequency of care was important so that participants had experienced home care under the guidance of one of the HCN points. Family members who did not answer the contact telephone numbers provided by the municipalities to the researcher were excluded.

Data collection was carried out between June and September 2021. Telephone contacts were made with the coordinators or professionals of the HCS multidisciplinary team of the nine selected municipalities, requesting the telephone contact information of family members who met the study inclusion criteria. After this contact, it was identified that two municipalities no longer served CSHN, due to their transitional nature.

Nineteen telephone numbers of family members in the seven municipalities served by CSHN were identified and used for initial contact to invite potential participants to the study. After acceptance, a semi-structured interview was scheduled according to the participants' availability and conducted by the principal investigator, a nurse and master's student with experience in qualitative research, under the supervision of the other researchers on the team. Of the 19 family members, three refused to participate in the research for personal reasons, and in one case, telephone contact was not possible. Data collection was completed after all family members were included.

The Free and Informed Consent Term (FICT) was sent in advance via a mobile app, using Google Forms, and, after signing, the telephone interviews began. The Super Recorder or Mimik Lite: Call Recorder digital apps were used to record the telephone calls, which lasted an average of 25 minutes. There was no need to repeat any interviews. When participants indicated difficulty reading the FICT, it was decided to read it together with them so that their acceptance could be recorded on audio. 

The empirical material was interpreted in light of the theoretical framework of vulnerability6 according to Inductive Thematic Analysis (ITA), developed in six flexible and non-sequential stages.11 In the first stage, familiarization with the data, the interviews were listened to, transcribed, and read successively in their entirety, seeking to understand the data as a whole. In the second stage, code generation, the initial codes were identified through units of meaning, organizing the extracts that corresponded to each code. In the third stage, the codes were grouped according to their similarities in content, and potential themes and subthemes were developed.

In the fourth stage, two researchers individually reviewed the analytical construct and then discussed points of divergence in relation to the initial coding and grouping, with a view to refining the analysis process until a consensus was reached, proceeding to name the themes and subthemes. In the fifth stage, a second review of the themes and subthemes was carried out to verify whether they were consistent with the data extracts from the database and the codes and whether they responded to the study objective, culminating in the preparation of a thematic map with a summary of the results. Finally, the sixth stage consisted of the presentation of this study.

In this study, approved by the Research Ethics Committee (REC) under Opinion No. 4,736,299/2021, the anonymity of participants was guaranteed by the following identification in their interview transcripts: the letter “F” followed by the numerical order in which the interviews were conducted for family members; and the letter “C” for the CSHN, followed by the same number that identifies their families.

Results

Interviews were conducted with 15 family members of CSHN, assisted by the HCS in seven municipalities in the state of Paraíba, including 14 mothers and one father. The average age was 34.9 years; 10 family members were single; 12 had completed or incomplete secondary and primary education; 14 family members did not have formal employment, of whom seven were exclusively dedicated to caring for CSHN. Regarding family income, 11 received a minimum wage, and four had incomes ranging from one and a half to two minimum wages. Regarding the CSHN, four were adolescents, and 11 were children, five girls and 10 boys, with special conditions of neurological or genetic origin or resulting from accidents. Finally, the average length of care provided by the HCS was two years. Analysis of the extracts enabled the identification of the themes presented below, summarized with their respective codes in Figure 1.

 

Figure 1 - Thematic map summarizing ITA results, showing identified themes and codes. João Pessoa (PB), Brazil, 2022.

Health vulnerabilities of CHSN resulting from gaps in the HCN

A programmatic vulnerability was identified due to the shortage of specialists in HCN, both in medical specialties and other health professional categories, such as physical therapists and speech therapists, linked to the Expanded Family Health and Primary Care Center (NASF-AB) available in the municipality. This situation has hurt treatment and continuity of care, especially after discharge from the HCS.

"We were paying for [physical therapy], but it became too expensive. [...] we see the orthopedist only once a year, because of the boots he [C2] wears, but we see the orthopedist in a private clinic because there is no orthopedist in the public health system. [...] what C2 needs most is physical therapy [...]. [name of the pediatric neurologist] requested it from Monday to Friday, because now that he's going to undergo Botox treatment, there's no point in my going to do it, for the amount he's asking, 300 reais, and C2 staying still without being able to move, because then the Botox won't do any good." (F2)

This reality has led families to pay for private care, due to the shortage of specialists in HCN, as a strategy to ensure continuity of care with the professional responsible for establishing the diagnosis.

"They are private [follow-up by specialized care] because that is what they have been monitoring since the beginning, such as the neurologist. So, I continued seeing him, because he [the doctor] already knew, he was the one who performed the surgery, so I preferred to keep going to him." (F1)

Some family members reported that medicines, supplements, and supplies should be provided by primary and secondary care services and management bodies. However, obtaining these items is still difficult due to their scarcity in the HCN, which means that they have to be purchased with their own resources, limiting healthcare assistance, since they depend on the coordination and actions of other services that make up the network.

"Now we get [medications] at the [municipal] pharmacy, some of which are controlled substances that he [C11] takes. This month, one of them, which comes from [neighboring city], was not available. [...] diapers too; they haven't given us any for four months. That makes it difficult for us, because we only have one salary. [...] I already took two reports from [name of hospital] about his [C11] nutrition, which is very expensive, because he is fed through a tube, through gastrostomy, and they [Municipal Health Department/MSH] gave us two sets of four cans. And the report from [hospital] says we need 28 cans to get through the month. [...] and the nutritionist [from HCS], poor thing, is caught in the middle because it's not her fault, she just writes the report to make it available." (F11)

"[The professionals at the Family Health Unit] provide [the medications]. Only sleeping pills are not available, so we buy those, but they have everything else, so we can get the medication." (F5)

Expenses related to complementary therapies, medication, supplements, and material supplies aggravate the social vulnerability of families, compromising their financial lives, as most receive only a minimum wage, which is also used to cover household expenses. Given this situation, families feel powerless and incapacitated, having to prioritize which needs of their CSHN will be met.

"Because if we were to buy supplements that the doctor didn't prescribe here. [...] we haven't bought the one he prescribed because we don't have enough money. I have to buy his [C8] medicine that is not available [through the public health system]. [...] with the money my husband earns, we have to do everything; we have to buy his [C8] medicine [when it runs out] and buy diapers." (F8)

"I only received it [the medication] once. I buy everything. [...] it costs around R$200, not to mention when she [C6] gets sick, which is when I spend a lot on medication." (F6)

"[The FHU] does not [provide the medication]. I buy it myself, R$74.50 per box. That's two per month, which comes to almost R$200.00." (F13)

Other setbacks experienced in the coordination of the HCN were associated with the COVID-19 pandemic, during which there was a reduction in the time HCSs spent with CSHNs and their families, followed by an increase in home visits and the cancellation of procedures scheduled in other services in the network. For family members, even though they understood the unusual situation, this hindered the development of the child or adolescent, leaving them dissatisfied.

"In the past, we talked more, exchanged ideas [with HCS] about C4's treatment. Now it's more rushed, but I understand [...]. C4 discharge came because of the pandemic, they explained. There are a lot of people at home with COVID-19 sequelae who need more care than C4. [...] even though it was the only speech therapy service that treated him, they dismissed the speech therapist for C4. [...] this speech therapy issue, because he [C4] doesn't eat with his mouth, and he was progressing very well, then, out of nowhere, they withdrew the speech therapy service. On one hand, I understand why this happened [pandemic], but on the other hand, it makes me sad." (F4)

"Because of the pandemic, [HCS] physical therapy services were suspended, things like that." (F7)

"It was supposed to be removed [use of tracheostomy] after three or four months, but with this whole pandemic, there was no way to go. But we are waiting, Melhor em Casa (Better at Home) [HCS] is arranging it, and we are already waiting for the call from the [referral hospital], so that he [C8] has to go there to do the tests. Now we are waiting for the [referral hospital] to call to schedule the exam for the removal of the tracheostomy." (F8)

It was identified that there is no established link between some CSHN, their families, and Primary Care (PC) services, since PC professionals are not responsible for the comprehensive care of this population nor do they share this care with other services in the network, such as HCS, highlighting programmatic vulnerabilities.

"[...] after Melhor em Casa [HCS], the FHU gave up C10. In the past, they [professionals/FHU] always came, because it's a joint effort, it's supposed to be the FHU and Melhor em Casa." (F10)

"They offered the alternative of FHSC (Family Health Support Centers) [for C4 to continue seeing the speech therapist after being discharged from HCS], which was a service linked to FHU. However, FHU here does not work properly, so this service is also not working. We have the option of looking for a speech therapist, but the cost of transporting C4 is very high. So, HCS was the ideal option." (F4)

The families of CSHN are socially and health vulnerable and face barriers in accessing care for their children's needs. It should be noted that the programmatic vulnerability of these children and adolescents and their families is highly significant in home care due to the various organizational weaknesses of the HCN, which can lead to difficulties in the family's journey in search of quality health care and compromise the continuity of care, as well as the provision of care promptly.

 Actions developed in the HCN for the care of CSHN

The families of CSHN experience situations of assistance and lack of assistance in HCN services. Primary care should be the HCN service that provides assistance to CSHN dependent on AD, with a view to establishing comprehensive care. However, family reports highlight that this service only provides vaccinations and facilitates access to immunobiologicals, reporting that primary care professionals visit the homes of CSHN, avoiding the need for these children to travel due to transportation difficulties.

"They [professionals/FHU come to my house to give me [vaccines]. I only leave the house to go to the neurologist. I don't go to the health center [FHU] or anywhere else [referring to transportation difficulties]." (F8)

In some municipalities, primary care refers patients to the HCN, while in others this responsibility falls to the municipality of reference. The lack of coordination of care by primary care providers highlights the programmatic vulnerability experienced by these families.

"When we need [a referral], we go to the health department. There is a health clinic [FHU] on our street, there is a clinic on every street, and we go there to get the referral." (F12)

"Right here [in the municipality where I live] there are no resources for C3 [...]. The doctor [in the municipality] himself said that to prescribe tests and things like that, I must go to [name of the reference city] to see the doctor there. He said he doesn't do any of that." (F3)

To minimize health vulnerabilities caused by gaps in healthcare provision in the HCN, family members, aware of the health rights of CSHN, demand priority care. 

"[...] It is their duty [health services to provide good care]. [...] C2 has priority; it has to be one of the first [to be seen], so I talked to them there [children's hospital], and when C2 arrives, it is one of the first to be seen. At the health center [FHU], it is the same thing." (F2)

In some municipalities, the CSHN family needs to mobilize to gain access to prescriptions, medications, food supplements, or transportation to travel within the HCN.

"We have to argue [with the Municipal Health Department] to get [C3's medications]. [...] I get the prescription, take it to the [guardianship] council, and the council sends it to the health department, where they get it. [...] transportation is the same thing. Sometimes, his [C3] uncle would put him on his motorcycle to take him to the car stop, because the [Municipal Health Department] said that the car didn't come to the [rural area]. [...] a lot of things here [Family Health Unit] deserve to be improved because when we go after a prescription, the doctor doesn't want to give it to us." (F3)

Professionals working in the HCN have been advising family members to seek out the rights of CSHN, such as Bolsa Família and the Continuous Cash Benefit (CCB), through social assistance services or independently, with the aim of covering the costs of caring for CSHN and minimizing social and programmatic vulnerabilities. However, some families have encountered obstacles in obtaining these benefits.

"The neurologist gave me [the report] because it's his right [C8], but so far I haven't been able to get the CCB [Continuous Cash Benefit]. [...] [The guidance] came from the [hospital] itself, because I saw that it wasn't going to work [...]. Now there will be an assessment on the 19th [of August]. I hope it works out; it's not me who needs it, it's my son who needs it. One salary for everything, and my husband is a patient at the [cancer hospital] and has to spend money; we can't wait for the government, because it takes too long, and if we could afford it, we would have done it already." (F8)

"Her [C14] CCB was when we found out she had a problem where she couldn't see or anything, [...] we went to the CRAS [Centro de Referência de Assistência Social  - Social Assistance Reference Center], and the social worker sent her paperwork [C3] to [name of municipality]. We went to have her [C3] examined, and there she saw the report from the neurologist at FUNAD [Fundação Centro Integrado de Apoio ao Portador de Deficiência - Integrated Support Center for People with Disabilities] in [name of city], which stated that C14 couldn't see." (F14)

"The doctor at the health center [FHU], who was C15's doctor, was the one who referred me, [...] guided me, and I filed the application [for CCB]." (F15)

"The retirement was based on her [C9] report, and I applied to the lawyer. [...] because in her case, she is eligible for retirement because she cannot speak, walk, or leave her bed. She uses a catheter and everything else." (F9)

In one of the municipalities studied, some HCN services were closed due to the COVID-19 pandemic; in this context, the HCS proved essential to ensure the continuity of care for some CSHN.

"She [C1] doesn't have much motor function and really needs physical therapy. So, in the beginning, since I couldn't go out with her [C1] due to the pandemic [COVID-19], we looked for help and went to my mother-in-law, who found HCS. We learned that they [HCS] provided home care, and thank God, it worked out for her [C1] to be cared for at home because we weren't in a position to do so, and it was a huge help." (F1)

Comprehensive healthcare for CSHN has not been effectively implemented, mainly due to problems in coordinating HCN services and care.

Discussion

The HCN of CSHN still perpetuates contexts of social and programmatic vulnerability, given the difficulties listed for the cost of treatment and access to health services and professionals reported by family members participating in the research. Although there are public policies that guarantee children's right to health, such as the Federal Constitution of 198812, the Statute of Children and Adolescents (SCA)13, the Organic Laws of the SUS14-15, the National Policy for Comprehensive Child Health Care (NPCCHC), and the expansion of access to PC actions and services, among others1.

However, despite these advances in public health policies, the context of vulnerability in which CSHN are inserted is still significant, as the model of health care for this population in Brazil is still biological and mechanistic. As a result, we have an HCN that is fragmented in the face of the limitation of PC actions focused only on the immunization program. An international study suggests that family members of CSHN require more qualified health professionals and coordinated, integrated health services to ensure access to other specialized care services.16

Difficulties in accessing, transporting, and traveling to specialized care services in the RAS may be associated with political interference in the process of making these resources available by municipalities. Thus, the establishment of Interfederative Health Consortia (IHC) mitigates these political interferences and expands the population's access to elective health transportation, which enables access to specialized services.17

Furthermore, such difficulties can be minimized by adopting telehealth as a potential strategy to facilitate access to health services and professionals. Recent studies have focused on the benefits of telehealth for CSHN living in rural areas, enabling access to specialized services, avoiding unnecessary travel, and exposure to pathogens.18 However, the advent of telehealth also highlights existing limitations, such as the lack of technological infrastructure in more remote locations, limited digital literacy in health among people with little social support, and the need to ensure hybrid care with in-person support.19

Referrals to different points in the HCN are not always effective, which highlights the low resolution rate of municipal management. These barriers to access make the therapeutic journey of families in search of effective care and the guarantee of the rights of these children and adolescents exhausting.20 In an attempt to meet the demands of CSHN, families move from one city to another, seeking services at all three levels of health care.5 This exposes family caregivers to a context of programmatic, social, and individual vulnerability, due to the lack of guaranteed access to services and insufficient financial resources to afford this journey within the HCN.

Family members constantly seek to guarantee the rights of children and adolescents, either directly through healthcare services or through the mediation of agencies that aim to ensure the fulfillment of these rights.20 This search constitutes a strategy for addressing the vulnerabilities experienced, since the CSHN and their family members participating in this study presented weaknesses related to low income and education, as well as difficulty in accessing health services.4

In this context, it is clear that the FHU is not taking responsibility for sharing care with the HCS, leading to weaknesses in the coordination of care, a result similar to that observed in a study conducted in a health region of Salvador, in the state of Bahia, in which the PC proved unprepared to care for children with congenital Zika virus syndrome after they returned home.21 To fill these gaps, family members seek to pay for private care for the management of invasive devices or care by specialists, due to the lack of these professionals in the SUS.

Even when CSHN have access to one of the health services, such as the HCS, there is no coordination within the health network, although one of the functions of the AD is to establish coordination with the other points of the HCN and assist these families in this process.22 An integrative review pointed out that the gaps in coordination between the AD and the HCN stem from a lack of understanding among professionals about how to coordinate these services, resulting in fragmented care practices.23

In addition, another obstacle to access and coordination of HCN services by CSHN family members is the concentration of health services in urban centers and the poor distribution of financial resources, resulting from chronic underfunding of public health.24 This directly impacts the effective and coordinated functioning of the HCN, affecting those users who seek health care.

It should be noted that, in addition to the obstacles experienced in daily life, the COVID-19 pandemic required adaptations to health services to prevent the spread of the virus. This occurred in line with the international context, in which there was an intensification of biosafety measures and/or the suspension of elective and home health care to prevent the transmission of the virus from one home to another.25 Thus, the pandemic compromised the continuity of care for CSHN at home, given that, in addition to the HCS, other HCN services also canceled appointments, exams, and physical therapy sessions26, exposing them to programmatic, social, and individual vulnerability.

The health vulnerability of families in the HCN is related to the shortage of specialists or professionals working in the rehabilitation process. Therefore, family members believe it is necessary to increase the number of professionals in the HCN to reduce patient overload so that CSHNs have access to all necessary therapies. However, a study conducted with municipal management representatives shows that the insufficient number of professionals in the HCN is related to a growing demand from users with chronic comorbidities and at home, associated with insufficient funding from the federal government.27

Another challenge faced by family members in the HCN is the unavailability of medications, supplements, and supplies for secondary care, which limits the activities of health services and forces family members to purchase them. However, the financial situation of family members is weakened by the abandonment of their jobs to care exclusively for CRIANES28, making it necessary for health professionals to guide these families in seeking their social rights to make funding feasible. Even when guided, some families encounter difficulties in obtaining these rights, requiring them to resort to the courts, initiating a highly bureaucratic and time-consuming process that causes emotional, physical, and financial strain.20 It is important to emphasize the importance of consolidating intersectoral coordination between health and judicial services, under the responsibility of municipal management, through the formation of links and the systematization of work processes.29

In view of the above, there is a clear need to improve health management in municipalities so that they have adequate strategies and tools to provide care for these children at home. The services that make up the municipality's HCN need to establish strategies that facilitate the trajectory of family members who receive home care. This reflects the need for municipal political and administrative management to seek ways to strengthen the state HCN governance system by establishing training and protocols that guide managers' decision-making for the organization of the HCN focused on CSHN.

A study conducted in a health region in the state of Paraná was successful in managing the HCN and implementing the Mais Cuidados, Mais Saúde (More Care, More Health) project through continuing education actions aimed at professionals and service managers, to materialize PC as the organizer of the network responsible for coordinating care.30

Strengthening primary care and the HCS, as well as coordination between these points, is another viable and necessary strategy, as these are services whose operation must be coordinated with the actions and health services of the HCN, so that care and transition from one service to another reflect the power of an effective and decisive HCN for CSHN and their families. These strategies have great potential to minimize the health vulnerabilities experienced by these families in caring for CSHN.

A limitation of the study is that it was conducted during the coronavirus (SARS-CoV-2) pandemic, which interfered with the functioning and continuity of care in the HCN throughout the state. The pandemic exacerbated pre-existing structural gaps in the HCN, which directly affected the care provided to CSHN. Another limitation of this study is the difficulty in validating the interviews by family members after transcription. Although every effort was made to ensure the reliability of the information collected and the accuracy of the analyses, the absence of a validation process by the interviewees may not fully reflect the intentions and experiences of the participants.

Concluding Remarks

Although CSHNs are accompanied by at least one HCN service, limitations persist in accessing the network's actions and services from the perspective of their families. These limitations place them in a context of overlapping social, individual, and programmatic vulnerabilities, evidenced by the fragility of the services that make up the HCN in providing the care and supplies necessary for this population.

The actions and services that complement the HCN to the HCS must consider the process of home care for CSHN, taking into account the vulnerabilities experienced by their families, which requires the strengthening of AD, especially concerning expanding the provision of rehabilitation actions, with a view to avoiding financial impacts on families and the wear and tear resulting from the pursuit of rights in the judicial sphere. The study also highlighted challenges in assisting CSHNs and their families, indicating that, to minimize the situations of vulnerability in which they find themselves, it is necessary to effectively coordinate the actions and services of the HCN, under the joint responsibility of municipal and state health administrations, to ensure adequate assistance.

Understanding the HCN in the context of the studied population represents an advance for the health area, as it gives visibility to the difficulties experienced daily by CSHN and their families, which can support the creation and/or improvement of public health policies aimed at strengthening the political-administrative management of health services in municipalities. Furthermore, this knowledge helps nursing professionals recognize the real health needs of CSHN and their families, favoring the implementation of managerial and care actions capable of ensuring comprehensive care at different points in the HCN.

Authors Contributions

Study design: Paloma Mayara Vieira de Macena Lima; Beatriz Rosana Gonçalves de Oliveira Toso; Neusa Collet; Elenice Maria Cecchetti Vaz. Data collection: Paloma Mayara Vieira de Macena Lima; Mariana Matias Santos. Data analysis and interpretation: Paloma Mayara Vieira de Macena Lima; Vanessa Medeiros da Nóbrega; Mariana Matias Santos. Manuscript writing: Paloma Mayara Vieira de Macena Lima; Vanessa Medeiros da Nóbrega; Mariana Matias Santos; Beatriz Rosana Gonçalves de Oliveira Toso; Eliane Tatsch Neves; Neusa Collet; Elenice Maria Cecchetti Vaz. Critical review of the manuscript: Paloma Mayara Vieira de Macena Lima; Vanessa Medeiros da Nóbrega; Mariana Matias Santos; Beatriz Rosana Gonçalves de Oliveira Toso; Eliane Tatsch Neves; Neusa Collet; Elenice Maria Cecchetti Vaz. Approval of the final version of the text: Paloma Mayara Vieira de Macena Lima; Vanessa Medeiros da Nóbrega; Mariana Matias Santos; Beatriz Rosana Gonçalves de Oliveira Toso; Eliane Tatsch Neves; Neusa Collet; Elenice Maria Cecchetti Vaz.

Conflict of interest

The authors declared that there is no conflict of interest.

Funding

Master's scholarship from the Conselho Nacional de Desenvolvimento Científico e Tecnológico – CNPQ.

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Corresponding Author

Paloma Mayara Vieira de Macena Lima

E-mail: palomamayaravml@gmail.com

The Author(s) 2026.  This work is licensed under Creative Commons Attribution 4.0 International. License text for use: https://creativecommons.org/licenses/by/4.0/deed.pt_BR