Work process and health-disease relationship from the telemarketers’ perception: notes for Occupational Health Surveillance action

Abstract

Introduction  the work process in Call Centers is characterized by repetitive, alienating and intense activities, which strengthens the questioning about the impacts of work on the health of the telemarketer.

Objective  to analyze the work process and the health-disease relationship from the telemarketers’ perception.

Methods  qualitative research, based on the theoretical framework of Psychodynamics of Work. Data collection took place through interviews, which were interpreted according to content analysis.

Results  in the workers’ routine there are protocols to be followed, goals to be achieved, strict control of time, dissatisfaction with the pace of work and difficulties in reconciling work with other activities of personal life. Exposure to ergonomic risks and the presence of signs and symptoms related to voice and hearing impairment, psychological distress and sleep disorders were reported.

Conclusion  health care actions for these professionals must be carried out in an integrated manner between the bodies involved with worker’s health and the institutions/organizations, in the sense of recommending assistance, prevention and promotion, involving the worker in the process of constructing actions that must be based on inter-(trans)-disciplinary and intersectoral approaches.

Work; Health-Disease Process; Telemarketing; Occupational Health; Surveillance of Working Environment

Resumo

Introdução  o processo de trabalho em call centers se caracteriza por atividades repetitivas, alienantes e intensas, o que fortalece os questionamentos acerca dos impactos do trabalho sobre a saúde dos operadores de telemarketing.

Objetivo  analisar o processo de trabalho e a relação saúde-doença na percepção dos operadores de telemarketing.

Métodos  pesquisa qualitativa, embasada no referencial teórico da Psicodinâmica do Trabalho. A coleta dos dados ocorreu por meio de entrevista, sendo interpretados conforme análise de conteúdo.

Resultados  na rotina dos trabalhadores há protocolos a serem seguidos, metas a serem alcançadas, controle rígido do tempo, insatisfação com o ritmo de trabalho e dificuldades em conciliá-lo com demais atividades da vida pessoal. Foram relatadas a exposição a riscos ergonômicos e a presença de sinais e sintomas relacionados ao comprometimento da voz e da audição, ao sofrimento psíquico e alterações do sono.

Conclusão  as ações de atenção à saúde desses profissionais devem ser realizadas de forma integrada entre os órgãos envolvidos com a saúde do trabalhador e as instituições/organizações, no sentido de preconizar a assistência, a prevenção e a promoção, envolvendo os trabalhadores no processo de construção das ações que devem ser pautadas em abordagens inter-(trans)-disciplinares e intersetoriais.

Trabalho; Processo Saúde-Doença; Telemarketing; Saúde do Trabalhador; Vigilância do Ambiente de Trabalho

Introduction

Transformations in the world of work are taking place at an accelerated pace. The expansion and emergence of new means and methods of industrializing and marketing products, combined with the provision of services, have led to a variety of ways of capturing consumers’ attention. The main example of this revolution is information technology and, with it, advances in the telecommunications sector¹.

This scenario gave rise to telemarketing services, making them viable in the capitalist economy by combining technologies. In their practice, they have incorporated taylorist principles based on forms of exhaustive control of time and interactions. Managers seek to align workers’ subjectivity in favor of the companies’ commercial and economic objectives, taking root in a characteristic that has turned telemarketing into an icon of the global process of work intensification²,³.

Telemarketing stands out in terms of customer service, in call centers, where telephone calls are made or received by operators at their workstations, with the aim of supporting sales processes, advertising, customer service, technical support, or other specific activities. It is a sector that acts as a link between a company and its customer base, which is causing a major restructuring in the way these organizations work⁴,⁵.

The conditions and forms of organization of telemarketers’ work include, among other characteristics, high job turnover, the execution of tasks under constant pressure and supervision, the intensity and pace of work, the lack of autonomy, the static overload of body segments, the constant evaluation of performance, the incentive to productivity through the offer of awards, exposure to physical, biological and ergonomic risks, as well as other operational problems characteristic of the work activity⁶.

It is clear from the dynamics presented that telemarketers are vulnerable to occupational illnesses, and that working conditions are related to the high rate of absence from work, even though it is known that there is underreporting and resistance on the part of employers to recognize illness as a result of work⁷,⁸.

Given this scenario, Workers’ Health emerges as a means of analyzing and intervening in the work environment, acting on working conditions and recognizing the determinants of the health-disease process⁹.

Workers must be recognized as subjects with knowledge and not mere consumers of health services. The field of Workers’ Health presupposes the participation of workers in the process of evaluating and controlling accidents at work and is not restricted to the concept of occupational risks and causative agents, but recognizes other determinants of physical and mental suffering, relating them to the production process¹⁰.

The desire to study the work process and health conditions from the point of view of telemarketers arose when the researcher joined the Workers’ Health Surveillance Center (Núcleo de Vigilância em Saúde do Trabalhador). In one particular activity, a call center company was inspected, where factors related to occupational illness were identified, including reports of dissatisfaction with work by the professionals themselves.

Workers’ Health Surveillance (Visat - Vigilância em Saúde do Trabalhador) is part of the Brazilian National Health Surveillance System. Its objectives are to promote health and reduce the morbidity and mortality of the working population, with the support of actions that intervene in the problems and their determinants resulting from development models and production processes¹¹.

The experience triggered a series of questions about how Visat can intervene in this segment. To date, We are not aware of any research with this population in the state of Piauí. With this in mind, in order to qualify Visat’s actions, this study aims to analyze the work process and the health-disease relationship according to the perception of telemarketers.

Methods

Type of study

Exploratory, descriptive study with a qualitative approach, based on the theoretical framework of the Psychodynamics of Work¹².

Place and time of the research

The study was carried out in four call center companies located in a municipality in the state of Piauí, in northeastern Brazil. These institutions were located at strategic points in the city, on the outskirts and in commercial districts. At the time of the research, in 2018, company 1 and its subsidiary (company 3) had a total of 6,000 workers; company 2 had 5,000 employees; and company 4 had 700.

Participants and selection criteria

The participants were telemarketers from these companies. The operator’s job is to listen to requests, suggestions and/or complaints, record them, and provide appropriate guidance to customers.

Participants were of both sexes, over the age of 18, with at least six months’ experience as a telemarketer. The exclusion criteria were being away from the job during the data collection period. Participants were selected for convenience, considering ease of access and availability.

The number of participants was established during the research, with the break point occurring when the answers became repetitive and when the study’s objectives were met: 40 participants took part in the study.

Data collection and analysis

The data was collected through interviews carried out by one researcher, a nurse specializing in occupational health and a master’s student, using a semi-structured script containing the Health Questionnaire for Work Activities in Services (QSATS - Questionário de Saúde de Atividades do Trabalho em Serviços)¹³. The instrument is subdivided into five topics: professional characterization, aspects of work organization, working conditions, family life, and health^d. A pilot test was carried out with four participants to check the clarity of the instrument. The data collected at this stage was not considered in the results. A field diary was used to record important observations and perceptions about the environment.

Before starting the data collection stage, a first contact was made with potential participants. Through the workers’ union, operators were asked to attend a seminar on workers’ health. On this occasion, the researcher introduced herself and explained the research reasons, aims, and objectives. The workers were then invited to take part in the research.

The researcher then began collecting data, going to the companies selected as the research setting. As it was difficult to access the companies’ premises, the workers were approached in their surroundings, in nearby squares, snack bars, restaurants, during break times, at the beginning or end of working hours. The researcher sought to maintain maximum privacy for participants and data confidentiality, despite the circumstantial limitations identified.

The objectives and purpose of the research were presented to the participants, who, upon agreeing to take part, filled in the Free and Informed Consent Form (FICF) in two copies.

Each interview lasted around 30 minutes. The testimonies were collected on audio, then transcribed in full, and submitted to content analysis¹⁴. The interviewees’ statements were identified by the acronym OT (telemarketer).

The results obtained provided input for drawing up an action plan with the aim of developing strategies to minimize the sources of illness, including the risks, exposures, damage, and their consequences for workers’ health.

Ethical aspects

The research was submitted to the Research Ethics Committee of the National School of Public Health/Oswaldo Cruz Foundation (Fiocruz), receiving approval number 2,644,541 on May 9, 2018.

Results and discussion

Forty telemarketers took part in the study, the majority of whom were female (65.0%), with an average age of 27 years, university education in progress (47.5%), and between one and three years in the job (50.0%). The results of the survey were structured according to the QSATS categories.

My work

This topic presents the workers’ point of view on their activities, the operator-customer and operator-company relationships, and how they subjectively process these relationships.

The work schedule is six days on and one day off and every day we have three breaks: two 10-minute and one 20-minute break. I think the breaks are too short. When I see that I’m running out of time, I even stop eating to get to work, so as not to get pressure from the supervisor (OT 06).

My job is to receive complaints. There’s what they call quality control. They take your number and look at your calls that day. If you’re unlucky enough to be drawn and they catch you talking throughout the day, they’ll call you in. You get a warning and a suspension (OT 11).

There’s the supervisor who keeps an eye on the calls you answer. When you’re selling, they put pressure on you. They push you to sell more because of the stipulated target (OT 12).

From the speeches, it is possible to observe elements that make up and circulate between the phases of the Psychodynamics of Work¹². Suffering is one of these elements, appearing when it is no longer possible for the subject to negotiate with the reality imposed by the organization of work¹⁵. The speeches expose the unfeasibility of dialogue in the face of the need to reach increasing targets, insufficient time to meet basic physiological needs, as well as the constant use of punitive power - in the face of the slightest departure from the condition of a worker who faithfully follows their script, regardless of their human condition - with the imminent possibility of dismissal.

Work processes based on the new forms and methods of organization, with constant evaluation for performance and incentives for productivity, leave social relationships more fragile, generating individualism and can consequently contribute to workers’ psychological suffering¹⁶. This situation makes it difficult to build individual and collective defensive strategies, which serve to protect workers from suffering and illness. These strategies facilitate the development of work transformation processes and, at the same time, strengthen cooperative relationships between workers¹³.

In the following statement, a script is described, a strict protocol to be followed, as the worker is constantly evaluated by the supervisor or boss.

There’s constant pressure because there’s the TMA [average service time] issue. We can’t spend too much time with the client. You have to follow the script, you have to follow the protocol. We can’t go off script because we’re evaluated. There’s monitoring, the quality monitoring sector. They monitor our calls (OT 05).

Telemarketing workers “operate”, they don’t carry out any activity, they follow an execution-oriented work model to the letter. In this sense, it is seen as a sector of taylorist rationality that forces workers to carry out their activities in a “robotized” way¹⁷. In telemarketing, we see a large number of workers engaged in production, whose model disregards the quality of the individual who works, as the subject of production, which limits their thinking and creativity, as seen in the report above.

The organization of work in call centers uses regulatory mechanisms to increase productivity. These mechanisms are appropriate when they don’t override workers’ rights and respect for human dignity¹⁸. However, the regulatory mechanisms extracted from the speeches go back to the deterioration of work with excessive working hours, constant pressure, ever-increasing targets, and embarrassment. This scenario corroborates the observation that work in the technology sector is likely to create situations of dependency and exploitation, leading the class into the “cyberproletariat”, a term that refers to the frequent exposure of workers to repetitive, alienating, and intense activities¹⁹.

Also noteworthy is the presence of a silent power applied by those at the top of the hierarchical pyramid in that scenario. This power can be seen in passages such as:

They monitor our calls. On a call, if I don’t say the protocol or don’t say the client’s name, then they give me a low score (OT 05).

There’s too much sales pressure. They stipulate, for example, 14, then you have to deliver 14 or one more than 14. Then, when you deliver less, it’s considered low. Five, six, seven is too low and then we get pressure and they call us to talk. They ask what the problem is or give you a lesson in how to counter-argue in order to sell better (OT 10).

Power should not be interpreted as an intrinsically negative concept. However, it is the way in which it is applied that will define whether its effects will be beneficial or harmful²⁰. In this way, the power present in the workplace and exercised over the participants in this study seems to carry elements that can act negatively on workers due to its coercive nature. On the other hand, it should be noted that it is unknown how this power is exercised over those who are just above the telemarketers in the hierarchical pyramid, which is an important variable.

The workers considered that they suffered situations characteristic of forms of violence from clients and superiors in the course of their work.

Look, I’ve been called names a few times that I didn’t like. It could be considered moral harassment because it’s more from customers (OT 06).

As for the timetable, it’s like this: my timetable is 2:40 p.m. They come in and say: “Look, tomorrow is 5:40. If you don’t want it, ask to leave”. They say: “Yes, when you joined us, didn’t you say that when we needed you, you’d accept?”. We didn’t sign that. There’s no document. Look, when I want to change my schedule I have to sign a document, but they look at us and say: “If you can’t stand it, leave! Ask to leave” (OT 02).

The subjectivity and affections of the customer and the telemarketer interfere in the resolution of the negotiation or sale, so they play an important role in this relationship, in such a way that when the operator is mistreated by the customer, the other operators feel personally affected and this routine leads to stress. Interaction is the human face of the job, with the operator playing the role of the company, as if they were the company itself and not a subject for the customer²¹.

Of course, moral harassment is not a disease, but it can be a triggering factor that compromises the psyche. The practice of moral harassment, as well as exposure to forms of violence or intimidation in telemarketing companies, causes serious problems for the worker who is a victim, leading to illness and often making it impossible for them to return to the job market. Harassment occurs in various forms and at various times, and holding the perpetrator of the damage accountable, whether in or out of property, should serve to correct what has happened, but it should also be educational, so that such practices are banned from employment relationships²².

Regarding violence in the workplace, it is worth highlighting Visat’s actions about reporting cases. These notifications are compulsory and make it possible to see the magnitude of the problem, providing more accurate diagnoses of the working conditions of Brazilian workers, as well as indicators that can support public policies for health care and promotion²³.

Family life, housework, and leisure

It is clear from the testimonies that it is difficult to reconcile work with other personal life activities. Workers therefore seek alternatives in an attempt to maintain personal life activities, as exemplified in the following excerpts:

You can make it compatible, especially with studying. You can do some leisure activities and share them with the house. The family is a bit more complicated, because usually when you’re at home, you’re asleep, right?! (OT 07).

All I want to do on my days off is sleep! [laughs] It’s very hard work. There’s hardly any time to study. It’s the time we have to rest, we can’t study because it’s so hard (OT 09).

Working hours allow us to combine studying and other activities. However, as we often work on Sundays, public holidays, during commemorative periods such as Christmas, Carnaval, and New Year, we miss out on many opportunities to travel, have leisure time, and even spend time with our families (OT 06).

In the speeches, it is possible to identify a synergistic relationship between the worker and the work environment, at the same time as social and family relationships tend to be suppressed. The construction of the worker’s subjectivity is observed from the perspective of the Psychodynamics of Work. As a result of this process, it is plausible to infer the emergence of a subject whose boundaries are limited by the scope and demands of work, often to the detriment of their own needs and personal sphere¹².

The working day, the stress caused by work duties and organizational demands are among the factors that contribute to tensions in the work-family relationship. Research shows that these tensions can lead to physical health problems and dissatisfaction with life, interpersonal conflicts and affective relationships, as well as interfering with dedication to the education and upbringing of children²⁴,²⁵.

The characteristics of telemarketers’ work also limit their availability for rest and leisure time, which can contribute to significant levels of stress, a factor that influences the onset of other occupational diseases, leads to a reduction in the quality of service and productivity, and, as a result, is a justification for workers taking time off work²⁶. It should be noted that workers’ illness is subject to the synergy established between them and the work environment, including the subjectivities carried by each individual²⁷.

My health

The speeches reflected the presence of signs and symptoms that suggest voice and hearing impairment, symptoms associated with the intense pace of work and daily exposure to risk factors that can contribute to workers becoming ill.

I’ve been sick with throat problems, hoarseness, and it started in the call center. I know people who’ve had a stroke, low blood pressure, lots of people with headaches, migraines, and voice problems. There are also many people who have lost part of their hearing. If there’s a lot of “messing” [noise], I feel tinnitus in my ear. Even if I speak at that moment, it bothers me (OT 01).

Lack of voice. I spent two days without a voice, I was hoarse, a week hoarse. Hearing too. There was a time when I even asked to stay at home for a few days because I was hearing tinnitus on this side (one side of the ear), because of the phone calls (OT 02).

The headphone doesn’t bother me. I already hear less out of my left ear, so I don’t change sides, I just stay on the right (OT 15).

The work is very repetitive, very stressful, very tiring, there’s a lot of pressure. From all sides. I usually come home with a headache (OT 08).

The voice is the main working tool in the telemarketing environment. However, operators generally don’t have the proper guidance to use it better, leading to inadequate vocal habits¹⁸. In this sense, it is up to companies to provide workers with an environment with adequate working conditions and which aim to ensure the safety of the individual as a whole, including care for vocal health²⁸.

Current discussions point to the need to include Visat in the field of speech therapy, as an alternative to overcome the health model centered on the problem and direct it towards the identification of social determinants in order to contribute to the prevention of work-related illnesses²⁹.

Hearing damage can also directly affect the health of operators due to the noise to which they are exposed. This situation triggers discomfort, stress, irritability, attention and concentration difficulties, increased blood pressure, psychological effects, interference in communication, and behavioral and sleep changes³⁰.

According to the Regulatory Standard (NR) No. 17 of the Ministry of Labor and Employment, updated in 2021, the acceptable background noise level for acoustic comfort purposes is up to 65 dB(A), equivalent continuous sound pressure level weighted in A and in the Slow (S) response circuit³¹. A study aimed at identifying noise exposure values in this activity showed levels slightly higher than those recommended³².

The interviewees listed the risks associated with the furniture to which they are susceptible in their day-to-day work, which lead them to adopt inappropriate postures as a way of adapting to the situation. As a result, repetitive strain injuries and work-related musculoskeletal disorders (RSI/WMSDs) are common occupational illnesses among this group of workers.

This issue of prevention, we complain, we complain, we ask, but we don’t get an answer to anything. The question of ergonomics... the chairs are all broken, you can ask around. The chairs are too low, I, for example, am tall, and we get a lot of pain (OT 12).

The chairs aren’t comfortable, and I never had the right to a footrest, I asked for it my whole pregnancy, my legs were very swollen, I never had the right (OT 17).

NR No. 17 establishes minimum parameters for worker comfort, safety, health, and efficient performance³¹. When these requirements are not met, workers are susceptible to contracting RSI/WMSDs. These occupational illnesses are responsible for significant numbers of workers taking time off work³³,³⁴.

Not only complaints of physical illness were identified. Working conditions also contribute as a risk factor for the manifestation of psychological distress.

I don’t have any health problems, but I know a lot of people who have psychological problems, such as depression, anxiety, taking controlled medication. They are removed from the service, they go to work in another sector, they stay there or go to the corridors, they can’t even go out. They are not monitored by the doctor there. They go to the psychiatrist and get a medical certificate and wait for the medication to take effect. When they come back, they are discarded (OT 02).

Telemarketing is a good job, but it’s very stressful, my God in heaven! I come home with my patience exhausted. Because of the stress, people get psychologically ill a lot, apart from high blood pressure, that’s what makes operators leave (OT 18).

The day I got sick, it was the supervisor who pushed the bathroom door on my belly, I was 33 weeks pregnant. Because of that I got angry and felt bad. I’ve never been one to explode or speak out, I kept it to myself, and then I got sick at work. Now I’m hypertensive because of the company. I fell ill at work. I take medication all the time, methyldopa, I’m very anxious (OT 17).

For Dejours, mental suffering is rooted in the subjective and the private, and the organization of work is responsible for exploiting the defense mechanisms created to deal with unconscious processes, so the concrete and the social figure as the backdrop to getting sick²¹.

The interviewees’ statements show what Dejours called “defensive ideology”. Defensive ideology is a mechanism developed by workers and aims to replace individual defense mechanisms; to hide, mask or omit the suffering experienced by workers. However, when a worker does not hide their suffering, they are excluded or led to exclusion. The following excerpts exemplify this.

[...] But I know people who have even been off work for six months, I think. Then they went back to work, a nuisance. Then they asked to leave, but they didn’t give their accounts. They claimed there was little time. Then they went crazy, swearing at everyone, saying they were going to hit everyone, the supervisor... and then they were fired for just cause (OT 08).

I don’t have any health problems, but I know a lot of people who have psychological problems, such as depression, anxiety, taking controlled medication. They are removed from the service, they go to work in another sector, they stay there or go to the corridors, they can’t even go out. They are not monitored by the doctor there. They go to the psychiatrist and get a medical certificate and wait for the medication to take effect. When they come back, they are discarded (OT 02).

The working environment in call centers is coercive and stressful by nature. Operators are exposed to constant pressure for productivity, exaggerated control, and a lack of autonomy to carry out their activities. As a result, they tend to develop occupational and emotional illnesses which require analysis and intervention in the organization of work to ensure that they have the conditions to preserve their mental health¹⁵,³⁵.

It is important to note that the National Network for Comprehensive Workers’ Health Care (Renast - Rede Nacional de Atenção Integral à Saúde do Trabalhador) plays a central role in identifying, referring and notifying Work-Related Mental Disorders (WRMD) and the factors that contribute to their occurrence. Compulsory notification is essential for planning Visat’s actions, which are carried out through the Notifiable Diseases Information System (Sinan - Sistema de Informação de Agravos de Notificação)³⁶,³⁷.

In the workers’ routine, complaints related to sleep disorders are also common, mainly due to night work.

I have insomnia because my working hours are late at night until the early hours of the morning. When I get home, I can’t sleep (OT 13).

Night work creates an imbalance in the individual’s circadian rhythm, which causes alterations in the body’s homeostasis, implying psychiatric, metabolic-hormonal, reproductive and cognitive effects, and also contributing to the appearance of various neoplasms³⁸.

At the end of the interview, the participants were asked for suggestions that could make up the proposed action plan. It is pertinent to present some of them:

Improve surveillance. There’s no surveillance there. We need time off, especially to improve our hearing. And also, in terms of the pressure, that’s very bad. The pressure could be improved (OT 10).

They could cut down on the number of calls. If they could at least give us a break of 40 seconds to 1 minute between calls, it would be better (OT 09).

If I could change anything to improve the health of workers, I would try to establish fun activities in the workplace, mainly to get rid of that daily stress (OT 11).

In my opinion, there should be close psychological care (OT 13).

What I see is that there should be more of a motivation policy for employees (OT 14).

It would be good if they put in psychologists, because often the workers get there, they have problems, they develop depression because of the pressure in the workplace, so... if they had psychological assistance, it would be so good!” (OT 05).

In another stage of the study, after the field research, an intervention proposal was developed to be applied in the telemarketers’ workplace. The analysis of the data collected in the interviews provided input for drawing up an action plan which was presented to the research participants at a meeting made possible by the telemarketing union. The partial results of the study are presented below.

The findings presented are part of the perspective of the field of Worker’s Health, as they make it possible to reflect on and seek changes in the work environment of call centers, highlighting the need for workers to participate and express their perception of their work functions and their health conditions, in order to make them protagonists in the process of transforming work.

Conclusion

The study analyzed the work process and the health-disease relationship as perceived by telemarketers. The results reaffirm the literature on workers’ health, despite the specific nature of the jobs performed in call center companies. The testimonies revealed gaps in investment by employers in maintaining and guaranteeing the health of telemarketing workers.

The physical and psychological suffering verbalized by the participants in this study suggests that workers are exposed to a potentially harmful environment. This was based on the participants’ perceptions of voice and hearing impairment, poor posture, discomfort, fatigue, dissatisfaction, devaluation, disrespect, symptoms of anxiety, depression, stress, and sleep disorders. Thus, the work-related malaise experienced by workers is also influenced by the organizational environment.

The workers’ perceptions trigger reflections on the importance of Visat’s work, with a view to committing workers to a leading role in the face of a model of work organization that has contributed to an increase in illness in the category.

Health care actions for telemarketing professionals must be carried out in an integrated manner between the bodies involved in workers’ health and the institutions/organizations, in order to advocate assistance, prevention, and promotion, involving the worker in the process of building these actions, which must be based on inter-(trans)-disciplinary and intersectoral approaches.

The action plan was therefore developed considering strategies for monitoring the physical and mental health and quality of the working environment of telemarketing workers. Interventions aimed at qualifying the companies’ health teams, meetings with supervisors, support groups with workers, integration campaigns, and workplace inspections could initially be developed at local level.

Finally, the possibility of nationwide actions should be considered to carry out surveillance actions covering a greater number of workers in the telemarketing sector throughout the country.

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• Information about academic work:
  This study is based on the master’s thesis by Francisca Zenaide Fernandes Oliveira Nascimento, entitled “ Relação saúde-doença no processo de trabalho de telemarketing: apontamentos para atuação da Vigilância em Saúde do Trabalhador”, presented in 2019 at the Professional Master’s Program in Public Health, in Sérgio Arouca National School of Public Health, Oswaldo Cruz Foundation. Rio de Janeiro, RJ, Brazil.
• Data availability:
  The data cannot be made publicly available due to ethical restrictions.
• Presentation of the study at a scientific event:
  The authors report that the study has not been presented at a scientific event.
• d
  The questionnaires returned to the researcher that were incompletely filled in were considered lost.

• Funding:
  The authors declare that the study was not subsidized.

Edited by

• Editor-in-Chief:
  José Marçal Jackson Filho

Data availability

The data cannot be made publicly available due to ethical restrictions.

Publication Dates

• Publication in this collection
  02 Dec 2024
• Date of issue
  2024

History

• Received
  20 Apr 2023
• Reviewed
  07 Dec 2023
• Accepted
  26 Dec 2023