Evaluating the homeless population access to mental health services with a validated questionnaire: strengths and challengesAbstract
This article presents the methodological path for developing a structured survey to collect primary data on the vulnerable population, in this case, focused on measuring the people experiencing homelessness (PEH) access to the Psychosocial Care Network (RAPS). The validation process was conducted in Belo Horizonte, Minas Gerais, Brazil, in 2024, and the methodology followed three stages: 1) questions development and definition of the scales used; 2) theoretical and empirical validity tests; 3) quality and reliability tests: completeness and consistency. An questionnaire was assembled with 40 questions divided into three sections: i) sociodemographic characteristics, ii) health issues and patterns of alcohol/other drug use, and iii) experiences of access to mental health services. The final product was a concise research questionnaire directed at the research objectives, language accessible, and culturally adapted to the target population. The questionnaire can be relevant to the data quality and collection of vulnerable populations, considering it can be used for other similar assessments, it could be adapted to specific goals, and the same validation process can be followed to improve data quality standards. The process can qualify discussions on the reality of PEH with the development of focused public policies.
Key words:
Epidemiological surveys; Validation study; Homeless population; Substance-related disorders; Mental health
Resumo
O artigo tem como objetivo apresentar o percurso metodológico da construção de um instrumento voltado à pesquisa de acesso da população em situação de rua (PSR) à Rede de Atenção Psicossocial (RAPS) em Belo Horizonte, Minas Gerais, no ano de 2024. A construção do instrumento ocorreu em três etapas: 1) geração de itens e definição das escalas utilizadas; 2) testes de validade teórica e empírica; 3) testes de qualidade e confiabilidade: completitude e consistência. Foi construído um instrumento com 40 perguntas, divididas em três blocos: i) características sociodemográficas; ii) questões de saúde e padrões de uso de álcool/outras drogas; iii) experiências de acesso aos serviços da saúde mental. O produto final resultou em um instrumento conciso, direcionado aos objetivos, com linguagem acessível e adaptado culturalmente ao público-alvo, sendo importante na produção de dados de qualidade que podem promover discussões mais qualificadas da realidade da PSR, com desenvolvimento de políticas públicas focalizadas.
Palavras-chave:
Inquéritos epidemiológicos; Estudo de validação; População em situação de rua; Transtornos relacionados ao uso de substâncias; Saúde mental
Resumen
Este artículo tiene como objetivo presentar la trayectoria metodológica de la construcción de un instrumento destinado a investigar el acceso de la población sin hogar (PSH) a la Red de Atención Psicosocial (RAPS) en la ciudad de Belo Horizonte, Minas Gerais, Brasil, en el año 2024. El instrumento fue construido en tres etapas: 1) generación de ítems y definición de las escalas utilizadas; 2) pruebas de validez teórica y empírica; 3) pruebas de calidad y confiabilidad: completitud y consistencia. Fue construido un instrumento con 40 preguntas divididas en tres bloques: i) características sociodemográficas; ii) problemas de salud y patrones de consumo de alcohol/otras drogas; iii) experiencias de acceso a servicios de salud mental. El producto final resultó en un instrumento conciso, dirigido a los objetivos, con lenguaje accesible y culturalmente adaptado al público, lo que es importante para producir datos de calidad que puedan promover discusiones más calificadas sobre la realidad de la PSH con el desarrollo de políticas públicas enfocadas.
Palabras-clave:
Encuestas epidemiológicas; Estudio de validación; Población sin hogar; Trastornos relacionados con sustancias; Salud mental
Introduction
The evaluation and monitoring of public policies and interventions targeting specific groups is a growing demand for the production of data related to vulnerable populations, considering ethnicity, gender, and other intersectional factors, which can better support decision-making1.
In Public Health, structured and validated questionnaires are essential tools for collecting information in a standardized manner, allowing the systematic evaluation of data, the longitudinal comparison of information and groups, and the internal and external validity of the study based on the results obtained through their use, with a possible generalization of the results2. Therefore, questionnaires should be built to produce reliable, consistent information, in addition to being culturally adapted to the characteristics of the target population, which is crucial to the quality of studies and the impact of their results. Furthermore, robustness and methodological consistency allow for international recognition of results and better control of research biases. Furthermore, it allows researchers, implementers, and public policy developers to have a more accurate analytical view of the event under study2-4.
Epidemiological studies with people experiencing homelessness (PEH) face several challenges related to the complexity of living on the streets, and especially when elements related to sensitive issues such as mental health and the harmful use of alcohol and other drugs are incorporated5. For example, in the methodological construction of the National Survey on Crack Use, in addition to the initial challenge of measuring the number of PEH in order to allow the construction of a probabilistic sample6, the fear and distrust of the researcher’s approach, and the refusal to participate or omission of information for fear of judgment in an illicit practice, were identified as study limitations.6 Thus, there are significant challenges in developing methodologies and data collection questionnaires that incorporate the heterogeneous nature of PEH and their lifestyles.
Furthermore, the National Demographic Census conducted by the Brazilian Institute of Geography and Economics (BIGE) omits PEH from the national Census because they are not a domiciled population, which requires using local level data from municipal managers, such as the rare PEH census, CadÚnico, and statistical modeling to estimate the frequency of PEH. This data limitation contributes to their invisibility7.
Currently, in Brazil, only one national survey8 shows the sociodemographic profile of PEH, their health and social assistance needs, and access to these services, whose data is now obsolete. Furthermore, municipal census surveys on PEH conducted to date are often criticized by organized civil society for underrepresenting this population and failing to provide parameters that can measure the actual characteristics of this population group9,10. Regarding the data collected from these individuals by the Health sector, most studies found in the literature are qualitative or with small samples, which does not allow adopting their results to draw up a national population profile11.
Given the above, this article aims to present the methodological path of building and validating a structured questionnaire targeting PEH in 2024. The questionnaire sought to investigate the access of these individuals to the services of the mental health network of Belo Horizonte (BH), Minas Gerais, Brazil, aimed at the care of people who make harmful use of alcohol and other drugs.
Presenting the methodological approach to developing a validated questionnaire is crucial to ensuring the study’s transparency and credibility. In this specific case, when developing a research questionnaire aimed at working with PEH, other researchers should understand in detail the steps involved in its construction, validation, and adaptation, given the unique nature of the topic being addressed. This fact strengthens the reliability of the results obtained and contributes to the study’s replicability, allowing other researchers to employ or adapt the questionnaire in different contexts or regions. Furthermore, this procedure highlights the importance of an ethical and thorough approach to research with vulnerable populations, promoting more accurate studies that are sensitive to the specificities of this group. Thus, sharing this methodological approach broadens the work’s impact, encouraging the production of robust and valuable knowledge for future research in the field.
Methods
The structured questionnaire presented in this article was developed to meet the objectives of the research “Analysis of barriers and facilitators of access to equipment of the Psychosocial Care Network (RAPS) for the care of alcohol and other drugs by People Experiencing Homelessness in Belo Horizonte/Minas Gerais”, conducted by the research group on Health Policies and Social Protection (PSPS), of the René Rachou Institute (IRR)/Fiocruz Minas, financed by the Secretariat of Specialized Care (SAES) of the Ministry of Health (MS).
This cross-sectional study collected quantitative primary data and aimed to: (i) sociodemographically characterize PEH who make harmful use of alcohol and other drugs and comparing them with those who do not; (ii) describe the path taken by these people to the municipal RAPS services; and (iii) identify the main facilitators and main barriers to PEH’s access to RAPS services.
The research project was approved by the Institutional Review Board (IRB) of IRR under CAAE 71388523.1.0000.5091 and report 6.580.788 and by the IRB of the Municipal Department of Health of Belo Horizonte, CAAE 71388523.1.3001.5140 and report 6.700.769.
Given the nature of the study and the limited data available on the topic, a team of trained interviewers developed an questionnaire to be administered in public facilities throughout the municipality. The target population was PEH served by the RAPS services within the Unified Health System (SUS) and specialized services within the Unified Social Assistance System (SUAS) in Belo Horizonte. A 40-question questionnaire was developed for this population, encompassing the following sections: a) Sociodemographic characteristics; b) Health issues and patterns of alcohol and other drug use; c) Experiences accessing health services, particularly mental health services (Chart of the Supplementary Material).
The development and validation of the questionnaire followed the following analytical steps: 1) questions development and definition of the scales used (internal multidisciplinary team); 2) validity tests: theoretical validity (experts external to the PSPS) and empirical validity (pilot test); 3) quality tests (completeness and internal consistency).
Results
Stage 1) questions development and scale definition
Initially, a literature search was conducted, including epidemiological studies to map the surveys used and identify questions that could help answer the primary study hypothesis. National surveys were prioritized, followed by state and municipal surveys. The search identified national census of the household population and municipal censuses of people living in Belo Horizonte, Minas Gerais, and São Paulo, São Paulo, Brazil, with PEH, including the National Survey on Crack Use, validated questionnaires analyzing the harmful use of alcohol and other drugs, and municipal studies of PEH living in Belo Horizonte (Chart 1).
Next, we aimed to identify the elements used in the most recent demographic censuses conducted in Brazil (2010 and 2022) to build alternative sociodemographic characterizations of these individuals. In turn, the municipal censuses on PEH conducted in Belo Horizonte (2022) and São Paulo (2021)12,13, were adopted to formulate questions and answers regarding civil documentation, reasons for going to the streets, length of stay on the streets, and city of origin.
This stage allowed for the construction of the sociodemographic characterization section of this study, including, in addition to the points traditionally raised in similar assessments, important and specific elements of the target population of this research. This section includes 17 questions, collecting information on gender, self-identification of race/ethnicity, age, education, sources of income, access to social benefits and civil documentation, interpersonal interaction on the streets and contact with family members, and, finally, reasons for going to the streets and length of time spent homeless. This section corresponds to the specific objective of the primary research, which aimed to compare the sociodemographic characteristics of people who engage in harmful use of alcohol and other drugs with those who do not (section 1, Chart1).
Another important reference for developing the questionnaire was the National Survey on Crack Use6. Conducted through a partnership between the National Drug Secretariat (SENAD) and Fiocruz, among other elements, it aimed to investigate the profile of crack and similar drug users in open drug use scenes in Brazil. The data collection survey used in the study served as an important source for developing the variables in section 2 ( Chart 1), which addresses patterns of use of these substances.
Validated questionnaires were also sought, primarily for the Brazilian context and vulnerable populations, namely the Alcohol Use Disorders Identification Test (AUDIT)14,15 and the Drug Use Disorder Identification Test (DUDIT)15. The AUDIT is an questionnaire developed by the World Health Organization (WHO) that aims to identify patterns of alcohol use and harmful use among the population and is recommended for use by healthcare professionals as a screening tool. As an improvement to the AUDIT, the AUDIT-4 was developed and validated, a shortened version of the questionnaire with four questions16. It was adopted in the questionnaire of the current study, as shown in section 2 (Chart 1).
Based on the AUDIT, the DUDIT is a screening questionnaire that assesses drug use. This questionnaire was developed for use in conjunction with the AUDIT and has been validated with the prison system and health services17. The DUDIT-C is a shortened version of this questionnaire, consisting of the first four questions related to drug use patterns found in the DUDIT. In a Norwegian study, the application of the DUDIT-C, added by question 11, showed a considerable difference in the detection of harmful use compared to the DUDIT-C16. Therefore, the DUDIT-C, with the inclusion of question 11, was used to build the questionnaire (section 2, Chart 1). This section consists of nine questions and relates to health issues and patterns of alcohol and other drug use. It also allows collecting information on previous diagnoses of Noncommunicable Diseases (NCDs) and Sexually Transmitted Infections (STIs); patterns of alcohol and other drug use, and information regarding use frequency, substance type, and amount used, besides allowing the respondent to self-assess whether or not the use of substances is harmful (section 2, Chart 1).
The integrative review “Between the streets and the RAPS: Integrative review on the access of the homeless population to Mental Health Services”11 (our free translation from Portuguese) identified positive and negative elements for access by PEH to mental health services, categorizing them into facilitators and barriers. For each of these categories, subcategories were listed according to the identified elements. The following were identified for the facilitators category: i) relational elements, such as the bond between workers and users; ii) action from an equity perspective, with itinerant work and consideration of the PEH’s lifestyle for the functioning of services; and iii) assistance-related aspects, such as the itinerant and multidisciplinary nature of services. In turn, the following barriers to access were identified: i) discrimination, such as humiliation; ii) rigidity of services, such as bureaucracy and the imposition of abstinence; and iii) service weaknesses, such as difficulties in connecting with the intersectoral network.
The categories listed in the review, as well as information about barriers and facilitators found in the article “Access to health and social protection policies by homeless people during the COVID-19 pandemic: a mixed-methods case study on tailored inter-sector care during a health emergency.”18 (our free translation from Portuguese), were used in the construction of section 3. This section consisted of seven questions about the experiences of access of PEH who make harmful use of alcohol and other drugs to the services that make up the RAPS, the continuity of monitoring in the service, and the barriers and facilitators for access and continuity of care (section 3, Chart 1).
The questionnaire was produced collectively and in multidisciplinary fashion, with the participation of researchers from several fields, including professionals in Health, Humanities and Social Sciences, and Statistics, with previous experience in academic, healthcare, and public management areas in mental health care, health care related to the harmful use of alcohol and other drugs, vulnerable populations, public policy evaluation, epidemiological studies, among others.
This group began developing the questionnaire by reflecting on the points to be covered by the questionnaire based on the study objectives, using the studies shown in Chart 1 as a basis for construction. All questions included in the questionnaire relate to the specific research objectives. Thus, a method of direct identification between the question and objectives was established by constructing an evaluation matrix for each variable, considering the possibilities for statistical analysis and correlations with the study objectives. If this identification did not occur, the question was excluded from the questionnaire, ensuring data collection was more focused on the research proposal.
An important aspect that permeated the entire development process was the concern for coherence, appropriate questionnaire length, and ease of understanding for the target population (using familiar expressions), in order to meet the research objectives while considering the respondents’ availability and attention during the questionnaire’s administration. The sequence of questions was carefully evaluated to foster respondent engagement and confidence and allow for dynamic and fluid administration.
Stage 2 - Theoretical and empirical validation
For theoretical validation, a questionnaire adapted from the DELPHI19 technique was developed, with the questionnaire matrix containing: variable name; question and response options; description of the objective, intent, and/or references for each question; and evaluative questions for the ad hoc consultants. The evaluative questions were: “Are the question and its response options relevant to the study objectives?” and “Is the question clearly stated?”, both followed by the response options “Yes”, “Partially”, and “No”. Finally, the question “Any recommendations?” was an open-ended question for consideration.
After the consultants’ feedback, a consolidated document was created with all contributions, comments, and suggestions for improvement. These suggestions included elements related to the language used in the questions; the inclusion of questions on other topics of individual characterization; and the repositioning of questions within the questionnaire. The response options included considerations from the consultants regarding questions that might cause discomfort to participants; the length of the questionnaire and the time required to complete it; and suggestions for combining similar questions.
Two workshops were held to discuss all suggested changes to the questionnaire. The decision to incorporate the suggestions was based on criteria such as compatibility with the study objectives and maintenance of the questionnaire’s coherence and cohesion. Therefore, suggestions to include topics that were not study objectives or to remove important variables for analysis were not incorporated into the final version of the questionnaire. This step proved important for consolidating a concise, appropriate, coherent, and understandable questionnaire.
The empirical validation stage consisted of a pilot application of the questionnaire. For this purpose, a Specialized Reference Center for People Experiencing Homelessness (Centro Pop) was chosen because it is a dedicated service for PEH, and where research subjects stay long enough to respond to the questionnaire.
Two teams of three to four researchers were formed, responsible for contacting the service management in advance, presenting the study and ethical procedures for conducting the research, and explaining the reasons for the pilot application in this service. After management’s approval, two days were suggested for administering the questionnaire in different shifts. The questionnaire was administered using a hard copy questionnaire, with the trained researchers reading the questions to the respondents and recording their responses.
Thirty questionnaires were administered during the pilot study, 14 on the first day and 16 on the second, with a total of 16 refusals. The main reasons for refusing to participate were being involved in other work activities, such as watching television, being close to the end of the workday, or even simply disinterest. Regarding the duration, the interval was usually 15 to 20 minutes, although some participants who had more information on the topic could speak for up to 30 minutes.
After data collection, we assessed the users’ understanding of the questions; the duration of the questionnaire; the logical sequence of the questions; the respondents’ adherence; possible situations of discomfort; the best environment for approaching and applying the questionnaire; the period of the day with the highest user circulation and the users’ organization times for best application (not coinciding with lunch time at the popular restaurant and closing time of the service).
A meeting was held with all researchers, and feedback from the field was compiled. The following main points were observed: (i) the perception that the questionnaire’s duration was appropriate compared to the initial estimate - an average of 15 minutes; (ii) identification of questions that required alternative questions or the inclusion of instructions for the researches on how they should be asked; (iii) the need to reposition some questions and separate others to facilitate the process for the respondents; (iv) the need to flag conditioning and exclusionary questions in the questionnaire to facilitate the researchers’ management; (v) the perception that users were open to participation; however, some of them needed a more private place to administer the questionnaire; (vi) the perception of the fear of some participants in answering some questions, such as former inmates, highlighting the importance of the field team in reinforcing data anonymity; (vii) the importance of standardizing the methods of administering the questionnaire with the applicators, since different ways of asking could induce the participants in their response; and (viii) the importance of a receptive attitude towards the participant, since the topic is sensitive for some people.
A new version of the questionnaire was structured from the pilot results, as there were significant changes. The 30 questionnaires applied in this stage were discarded and disregarded in the final analysis.
Stage 3 - Quality assessment
The primary outcome variable of the study, which led to the development of the questionnaire presented here, is PEH’s access to RAPS health services. Thus, for sample size calculation, the proportion of respondents in the IV BH Census12 who reported having accessed a psychiatric hospital or CERSAM/CAPS was considered in the analysis regarding “History of institutionalization throughout life in homelessness and by type of institution by gender in the PEH”.12 To this end, a sample size of 318 PEH was calculated, establishing a 95% confidence level with a 5% margin of error. Sample size calculations were performed in R 4.2.2 software, using the sample.size.prop. command. Thus, using the simple random sampling methodology, interviews were conducted with 343 PEH.
The sample included individuals over 18, Portuguese speakers, who could legally represent themselves without the need for a guardian or legal representative, and who were physically able to respond to the questionnaire, meaning they should be alert, lucid, and without severe impairments in their cognitive or communication abilities at the time of the interview. To maximize the response rate, representatives from both the SUS and SUAS institutions participated in defining the most strategic times for data collection at the services, considering their routine and the highest flow of users.
The information collection was distributed through the application of the questionnaire among the nine administrative health regions of the municipality, considering the establishment of PEH in each location, as per the population registered in CadÚnico in September 2021 (Table 1).
The questionnaire was applied from May to June 2024 and then entered into the REDCap software. The questionnaires were double-checked by researchers and randomly reviewed by senior researchers to ensure the reliability of the recorded responses. The database for analysis was then generated, and the reliability of the questions was assessed using completeness and consistency tests for the variables.
Internal consistency was assessed based on the proportion of responses obtained for the multivalued variables, regarding the question on alcohol abuse (Table 2) and other drug use (Table 3). In this case, markings that simultaneously indicated no response or the event under study (“No, I don’t know, I don’t want to answer”) and, at the same time, the presence of the event under study (other possible responses) were considered inconsistent. Only seven questionnaires had inconsistent results, but they were included in the analysis because they indicated the presence of the event under study.
In turn, most variables had response completeness above 91%, and results were considered adequate for inclusion in the inferential analyses. Response completeness was observed for the socioeconomic variables (section 1), and the results are shown in Table 4. The only variable excluded from the inferential tests was “How long have you been in Belo Horizonte?”, which recorded a completeness of only 77.8%.
Discussion
The use of closed-ended questionnaire to collect data is not without its critics. It presupposes that the researcher and respondents share underlying assumptions about language and interpret the statement similarly.2 This understanding of the questions depends, to some extent, on the health literacy of the subjects being studied. Health literacy can be defined as the cognitive and social skills that determine individuals’ motivation and ability to access, understand, and use information in ways that promote and maintain good health21.
Higher health literacy was associated with living in a permanent home, having higher education levels, not having had a mental health diagnosis, and having lower alcohol and other drug use levels22. Meanwhile, low health literacy is related to lower adherence to health prevention and promotion activities, as well as poorer self-management of chronic diseases, higher recurrence of hospitalizations, and a higher risk of comorbidities23.
In a context of social inequalities that directly impact health inequities, health literacy becomes a factor of inclusion or exclusion since it permeates the ability of individuals to make critical decisions about their health24. Adjusting the questionnaires to the PEH’s reading and comprehension level is crucial and, therefore, during the process of validating the questionnaire and analyzing its quality, the language was adapted so that the questions and response options were easy to understand, impacting the study’s internal validity25.
Another limitation identified in studies using structured or semi-structured questionnaires is that closed-ended questions can restrict the depth of participants’ responses26 and, therefore, reduce the quality of the data collected. In developing the questionnaire presented here, we opted to always include the “other” category, allowing participants to provide different responses, which were recorded by trained administrators and then categorized for analysis.
Adopting questions previously validated in different research questionnaires, while still subjecting these to the theoretical and empirical validation phases, allowed us to curb content biases and lack of context for the PEH. The decision to proceed with this cultural adaptation was made considering the guidelines for cross-cultural adaptations, which recommend that this decision should be based on verifying that no existing version of the questionnaire exists for the target population, understanding its context, purpose, characteristics, dimensions, and conceptual equivalence of the construct for the target population, and its suitability for the intended context.
The diversity among vulnerable populations, including from the perspective of the global population, highlights a significant need for cross-culturally validated questionnaires or scales. The translation, adaptation, and validation of a questionnaire or scale for cross-cultural research are time-consuming, require careful planning, and strict methodological approaches to derive a reliable and valid measure of the concept of interest in the target population4.
Peer-to-peer theoretical validation is also used in other studies applying the DELPHI technique, nationally and internationally, to increase the analytical power of the tools developed27-29. It also appears in studies of questionnaires developed for vulnerable populations, as it allows for the necessary contextual and cultural adaptation30. In this study, it was adapted considering the small number of ad hoc experts and the use of only one evaluative round. The technique was adapted considering the difficulty of finding experts on specific topics, as well as the fact that the questions had been previously paired with the research objectives and, therefore, already presented the smallest possible number of variables to the evaluators. However, all considerations were addressed systematically and included or excluded in the workshop according to the criteria presented in the methodology. Other studies focusing on vulnerable populations also made similar methodological choices, noting that calculating coefficients highlighted the questionnaire’s weak items, but independent analysis by category and the judges’ observations were more potent in identifying weaknesses and necessary modifications31.
Regarding empirical validation, based on the pilot test, the results stressed the relevance of evaluating the applicability, clarity, and sequence of questions, whether the response alternatives were sufficient, and application strategies to standardize how to ask questions and address sensitive topics, in agreement with the literature32. We managed to qualify the questionnaire even with a sample of only 30 questionnaires applied, which was defined considering the scarce data to calculate the final sample and the difficulty of accessing our research subject.
A limitation of the current study was the impossibility of people with a life history on the streets participating in the theoretical validation of the questionnaire, which would have helped mainly in the discussion of the language used in the construction of the questionnaire’s questions and answers. Furthermore, this study is strengthened by presenting a questionnaire based on validated questions from other nationally used questionnaires and on important research in the field of PEH, conducted with a probabilistic sample and results with internal and external validity. Furthermore, it is strengthened by the methodological rigor employed in all its stages and the possibility of being used in other Brazilian municipalities with objectives similar to those of our main study.
Final considerations
The provision of the constructed and validated questionnaire aims to encourage its use in different studies, allowing comparability between results nationally, in addition to encouraging other researchers to work with the evaluation theme proposed here.
Research questionnaires targeting PEH and other vulnerable and invisible populations are crucial for producing quality data that can foster evidence-based discussions regarding the needs and demands of these individuals. The questionnaire can be adapted for other research, and the validation process presented here can be used as a parameter for developing other questionnaires, thus strengthening the quality of data related to vulnerable populations and expanding the possibility of developing evidence-based public policies targeted at these groups.
The detailed development and validation of this questionnaire show the complex topics covered and the importance of developing research that is responsible and committed to the methodology used, its results, and social impact. Also noteworthy is that ten years after the commitment to the 2030 Agenda, including the qualification and availability of data for monitoring and evaluating public policies and advancing the “leaving no one behind” goals, significant limitations remain when discussing vulnerable populations. Accelerating the achievement of the Agenda’s goals will require progress in reducing inequities with qualified, replicable, and scalable information.
Acknowledgments
We received funding from the Secretariat of Specialized Care (SAES) of the Ministry of Health to the project entitled “Analysis of barriers and facilitators of access to the Psychosocial Care Network equipment for alcohol and other drug use by the PEH in Belo Horizonte, Minas Gerais.” This article is one of the products of the doctoral research conducted by researcher Rafaela Alves Marinho at the René Rachou Institute/Fiocruz Minas.
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The data sources adopted in the research are indicated in the article’s body.
