Rev. Enferm. UFSM, v.12, e37, p.1-17, 2022

https://doi.org/10.5902/2179769268294

ISSN 2179-7692

Submission: 10/27/2021 • Acceptance: 04/27/2022 • Publication: 08/10/2022

Tela de computador com texto preto sobre fundo branco

Descrição gerada automaticamente com confiança média

Experience Report

Experience with social media to promote health actions in older adults during the Covid-19 pandemic

Experiência com mídias sociais para ações em saúde com idosos durante a pandemia Covid-19

Experiencia con redes sociales para la promoción de acciones de salud de ancianos durante la pandemia de Covid-19

Adriana Martins Gallo^I

Juliane Pagliari Araujo^II

Jackeline Tiemy Guinoza Siraichi^III

Djennyfer Abreu de Souza^III

Cristiano Schebeleski Soares^III

Lígia Carreira^I

^I Universidade Estadual de Maringá UEM, Maringá, Paraná, Brasil

^II Instituto Federal do Paraná – Campus Londrina, Londrina, Paraná, Brasil

^III Instituto Federal do Paraná – Campus Astorga, Astorga, Paraná, Brasil

Abstract

Objective: to report the experience of using social media to promote health actions in older adults during the Covid-19 pandemic. Method: this is an experience report of the extension project entitled "Grandma and grandpa wired: connected to the Internet toward quality of life", carried out from April to December 2020, mediated by synchronous and asynchronous interactions, using digital tools and discussed in light of the Active Aging Policy and the Decade of Healthy Aging. Results: the virtual approaches were based on the information and the fight against fake news about Covid-19; emotional support; health promotion; and the use of technology. Conclusion: it was evidenced that the guided use of social media by older adults contributes effectively to the maintenance of social relationships and health promotion in the perspective of healthy aging, even during a health crisis of global repercussion.

Descriptors: Aged; Online Social Networking; Social Media; Healthy Aging; COVID-19

Resumo

Objetivo: relatar a experiência de uso de mídias sociais para ações em saúde com idosos durante a pandemia Covid-19. Método: trata-se de um relato de experiência do projeto de extensão intitulado “Vovôs e vovós conectados: ligados na Internet na qualidade de vida”, realizado de abril a dezembro de 2020, mediado por interações síncronas e assíncronas, utilizando ferramentas digitais e discutido à luz da Política do Envelhecimento Ativo e da Década do Envelhecimento Saudável. Resultados: as abordagens virtuais basearam-se em: informações e combate às fake news sobre Covid-19; apoio emocional; promoção de saúde; e uso de tecnologia. Conclusão: evidenciou-se que o uso orientado de mídias sociais pelos idosos contribui de maneira eficaz para a manutenção das relações sociais e promoção da saúde na perspectiva do envelhecimento saudável mesmo durante uma crise sanitária de repercussão mundial.

Descritores: Idoso; Redes Sociais Online; Mídias Sociais; Envelhecimento Saudável; COVID-19

Resumen

Objetivo: relatar la experiencia del uso de redes sociales para promover acciones de salud de ancianos durante la pandemia de Covid-19. Método: relato de experiencia del proyecto de extensión titulado “Abuela y abuelo cableados: conectados a Internet hacia la calidad de vida”, realizado de abril a diciembre de 2020, mediado por interacciones sincrónicas y asincrónicas, utilizando herramientas digitales y discutido a la luz de la Política de Envejecimiento Activo y la Década del Envejecimiento Saludable. Resultados: los abordajes virtuales se basaron en la información y el combate a fake news sobre Covid-19; soporte emocional; promoción de la salud; y uso de tecnología. Conclusión: se evidenció que el uso de las redes sociales por ancianos contribuye de manera efectiva para el mantenimiento de relaciones sociales y promoción de la salud en la perspectiva del envejecimiento saludable incluso durante una crisis de salud de repercusión mundial.

Descriptores: Anciano; Redes Sociales en Línea; Medios de Comunicación Sociales; Envejecimiento Saludable; COVID-19

Introduction

The world demographic dynamics are characterized by population aging, which has occurred since 1950, standing out nowadays.¹ Projection indicates that by 2030, one in six people will be older adults in the Americas.² The representation of older adults aged 60 years and over in the world went from 5.1% in 1950 to 6.5% in 2020, and it is estimated that the world's population of older adults will reach 22.6% in 2100 and that the percentage of Brazilians aged 65 and over will reach 34.6%.^1,3

The importance of living longer is to add quality to the additional years of life. For this, the process of consolidating opportunities for aging with quality of life and health, participation, and safety was proposed as a policy by the World Health Organization (WHO) in 2005⁴ through the term "active aging", encompassing the behavioral, personal, physical, social, economic, environmental, health systems, social service, cross-cultural, and gender factors.⁵

The WHO, expanding the discussion on aging in society, has adopted and currently supports the policy based on "healthy aging", proclaiming the interstice 2021-2030 as the United Nations Decade for Healthy Aging. The organization also encourages the provision of a longer and healthier life by maintaining the functional capacity of older adults and stimulating well-being in all environments in which they are inserted, as well as in the community, through concerted, catalytic, and collaborative actions of several sectors of society.⁶

The needs of older adults are not only based on the form of care or the ability to be attended to concerning their basic priorities but also on the desire to contribute to society and achieve their personal and well-being goals.⁶ The Statute of older adults is a Brazilian document that discusses and ensures the right to comprehensive health care for older adults, combined with health promotion, prevention, protection, and recovery practices.

Health education, a necessary tool to promote the health of older adults, provides knowledge for the prevention and reduction of diseases and makes the person active throughout the transformation of life and the search for autonomy. In this sense, educational technologies enhance the social and community orientation of care and contribute to the construction of older adults' knowledge and empowerment for self-care.⁷

The inclusion of older adults in the world of digital technology also meets the desire to eliminate stereotypes,⁸ mainly related to ageism, a potential cause of damage, disadvantages, and injustices against this populational group. Strategies including policies and laws, educational activities, and interventions of intergenerational contacts are proposed worldwide to reduce this phenomenon.⁹Unlike some efforts that demonstrate the fragility of old age and the problems people face along with the aging process, the inclusion of older adults in virtual environments is addressed here, considering the opportunities and incitements of aging in the contemporary world related to technology.

The Covid-19 pandemic has brought challenges in many areas of the world, particularly in low- and middle-income countries.⁹ Before that, people of all ages, including older adults, were already diving into the digital world, given the endless opportunities and possibilities that come with network connections. However, it was from this global milestone that the use of technology expanded.¹⁰ At the same time, disparities in access and use of the network became even more evident amid the need for social isolation, indicating that the appropriation of the potential benefits of the Internet is limited among vulnerable segments of the population.¹¹

The impact of social distancing on older adults' physical and mental health has made the use of Internet applications (the so-called "app") an important tool to encourage physical activity and social interaction in this group.¹² The online connections are a window of contact with the world, allowing interaction with family, friends, and the community^13-15 to include older adults in virtual environments, aiming, in addition to those above, the promotion of health and its role in the aging process.

Many terms are used to represent the interactions on the Internet, and in a broad sense, the main objective of social media is the production, dissemination, and sharing of content, which allows the interaction of its audience. In contrast, social relationships gain prominence in social networks. Older adults have limited access to digital technologies and, sometimes, lack the ability to handle such technologies, making them excluded.¹³ Mediated actions aimed at digital inclusion become fundamental and urgent since, in a pandemic, misinformation or excess information can harm human health.¹⁶Given the above, this article aimed to report the experience of using social media to promote health actions in older adults during the Covid-19 pandemic.

Method

This is an experience report, with a descriptive approach, about the experience of using social media with older adults, carried out from April to December 2020, through the extension project entitled " Grandma and grandpa wired: connected to the Internet toward quality of life", discussed in light of the Policy on Active Aging and the Decade of Healthy Aging.⁶

The study was developed in a municipality in the northwest region of Paraná. Following the world trend, in the municipality above, progressive aging has been observed demonstrated by narrowing the base of the age pyramid and the constant widening of the top. The population of this municipality in 2010 was 24,698 inhabitants; of these, 14.4% were 60 years of age or older. In 2020, the numbers rose to 26,209 inhabitants and 19.8% older adults.¹⁷

The face-to-face activities of the extension project above began in March 2019 at the older adults people's coexistence center, which serves an average of 500 people per month, through the agreement signed between the Federal Institute of Paraná and the City Hall. The service was developed based on the demand listed by the center's visitors and project participants, based on the growth of the older adults population in the municipality, and the need to act in the promotion, prevention, and maintenance of the health of older adults, as well as the attribution of solidified values and knowledge. The service is linked to social practices that support the academic training of students who work as extension fellows or volunteers.

It is worth remembering that on December 31, 2019, in Wuhan, China, the new coronavirus, called Sars-CoV-2, which causes the Covid-19 disease, was detected. On January 30, the WHO declared the epidemic an international emergency that remains to this day, causing major global health crisis.⁶ Social distancing measures were adopted to reduce the transmission of the virus around the world, and for older adults, the recommended strategy was selective social distancing, given that they belong to a risk group for developing the severe form of the disease. To this end, states and municipalities issued decrees determining the indefinite closure of places regularly frequented by older adults, such as social centers.

As of April 2020, the extension project underwent adaptations and reinventions to meet the needs of its audience. The activities that until then took place in person at the Living Center for Older Adults started to take place remotely due to the Covid-19 pandemic, and social networks became the project's action scenario. The strategy used to maintain the activities of the extension project during the pandemic and digital support inclusion and the promotion of active and healthy aging was using a personal smartphone with access to social networks.

The study approach was based on the Active Aging Policy framework,⁴ since active aging is related to the longevity of older adults, enhanced social participation, improvements in health and care conditions, and maintenance and optimization of the quality of life,¹⁸ and on the Baseline Report for the Decade of Healthy Aging that supports actions to build a society for all ages to optimize functional capacity and accelerate the impact of this progress on the lives of older people by 2030.⁶

Participants meeting the following criteria were included: being 60 years or older, having a smartphone with an Internet connection, having the WhatsApp application installed on the smartphone, and having accepted to participate in a virtual public group created by the project coordinator for the study's purpose.

Based on the need to reformulate the project to present the contents remotely, meetings by videoconference between professors and students allowed the design of proposals and the schedule. The extension team comprises two scholarship students from the Extension Scholarship Inclusion Program at the Federal Institute of Paraná, a volunteer student, volunteer physical educators, and professors in the following areas: nursing, informatics, pedagogy, physiotherapy, and physical education, who work in several courses. The activities were reorganized by the project coordinator, who was responsible for managing the virtual message group, while the students and other teachers were responsible for constructing and distributing the material. Thus, it was defined that the interaction with older adults would occur daily instead of weekly and that the digital tools would include social media such as WhatsApp, Instagram, and YouTube.

Before the transition from face-to-face to virtual mode, a remote consultation was carried out among the participants. The project coordinator contacted older adults through videoconference, explained the need for changes, explained the applicability of the app, and questioned the interest of older adults in the face of this change. In addition, she explained the possibility of expanding the project with the inclusion of new members, but with the limitation of the number of people anchored to the maximum capacity of WhatsApp. Seniors unanimously accepted the changes, and approximately 100 seniors migrated to the remote system. The participation of older adults was always spontaneous, and there was no pressure for punctuality or engagement.

Virtual communication was designed using appropriate language that was easy to understand for older adults but with a quality and scientific basis, always guided by healthy aging principles. This communication encourages the maintenance of the functional capacity of older adults, especially concerning the possibility of learning and making decisions.⁶

WhatsApp and Instagram were used to communicate with older adults, while YouTube was used for support and consultation of materials. The synchronous interactions lasted approximately one hour, took place every day, were directed by the project coordinator, and took place exclusively in the WhatsApp group, which had the capacity for simultaneous participation of 256 people. The average number of active participants was 95. In this group, various subjects were discussed throughout the day, in the morning, afternoon, and evening, according to weekly planning.

The morning period was intended for health promotion actions, with proposals for physical activities taught in the format of lives and recorded videos and health tips in text format. The afternoon was dedicated to technological inclusion, Covid-19, and combating fake news alternately on weekdays, with guidelines always starting from the context in which older adults are inserted and generating one command at a time. The interventions were made available on YouTube, so there could be later access. The night was dedicated to mental health activities and the stimulation of cognitive capacity, with 10 to 20 images sent through games and hobbies with the possibility of sharing the answers with the group.

On Instagram, a profile called @idoso.conectado was created to systematically and punctually disseminate digital content, always with an informative character. One hundred ninety-one posts were made alluding to the commemorative dates, highlighting the campaigns for the prevention of breast and prostate cancer, suicide prevention, encouraging periodic examinations, and blood donation, in addition to those aimed at maintaining mental health. The content posted on Instagram was configured as a secondary and complementary contribution. In addition to older adults, the above content reached a diverse audience since social media allows visiting the research group's publicly available profile without the need for an administrator's approval for the admission of new members. A quick search of the followers found that they were health professionals, non-governmental organizations, and young people.

Experience report

The virtual approaches were based on four action areas (Figure 1), and the starting point for the characterization of such areas was anchored in the dialogue carried out with older adults and their needs, considering that the moment of seeking, interacting, and investigating is what inaugurates the dialogue of education with the practice of freedom, thus detecting the emergence of significant themes associated with their doubts, anxieties, and hopes.¹⁹

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Figure 1 - Actions conducted with older adults in the extension project. Astorga-PR, 2022.

Source: Prepared by the Authors (2022)/Images: Freepik

The actions of the Decade for Healthy Aging must integrate people who carry out any work, in public or private services, and who make decisions that affect the ability to live well.⁶ The decade's goal is to optimize older people's functional ability. To this end, five interconnected abilities are addressed, which should accompany the daily lives of aging people: the ability to meet basic needs, to continue to learn and make decisions, to be mobile, to build and maintain relationships, and to contribute to society.^2,6

Health education based on knowledge and communication with older adults was conducted in a playful and dialogic way, with activities stimulating reasoning, concentration, and exploring previous experiences on the subject to provide triggers for the beginning of approaches.

The virtual stimuli were carried out to maintain the cognitive abilities of older adults, as well as their appreciation in the face of life in society, with emphasis on the cultural heterogeneity of the group that had a rich influence to guide actions, incorporating older adults without schooling in the same way than the literate. The voice and image tool of the WhatsApp application facilitated the virtual interaction of all members.

In addition to enhancing the integration of older adults and strengthening their proximity to the use of technology, the project addressed areas of work that connected the strategic actions proposed in the report on the Decade of Healthy Aging 2021-2030⁶ with the generating themes presented by older adults in virtual interactions.

Action area 1: Dissemination of information and combating fake news about Covid-19

To carry out actions regarding the dissemination of information and combating fake news about Covid-19, WhatsApp and Instagram were used on alternate days in the afternoon.

The action area above was included in the project due to the pandemic, mainly due to the alarmingly disseminated false information about statistics of contaminated and dead persons, vaccine effectiveness, use of masks, drugs, and alternative treatments. Given the importance of strengthening the dissemination of scientific content on Covid-19, an efficient and accessible language for older adults was prioritized, and for that, updated information from official protocols of the Ministry of Health was provided. The main topics addressed were the need for social distancing, respiratory etiquette, how to use masks correctly, types of masks, and vaccination.

For the information to reach older adults in a clear, objective, and safe way, messages that contained fake news or those that stimulated harmful attitudes to health were filtered to identify inconsistencies. Accompanied by the experience of the Covid-19 pandemic, there is also the problem of the infodemic,^16,20 characterized by the excess of information, sometimes accurate and sometimes not, which make it difficult to identify reputable sources and reliable guidance.

When fake news was identified, the information was blocked by warnings related to the content in question, and the importance of not sharing it with others was used. Encompassing this situation and having knowledge of the dissemination of false websites for registration of those who intended to be vaccinated against the new coronavirus, or even addressing erroneous statistics on side effects of vaccination, official information was sent from the municipalities containing the vaccination schedule corresponding to the age group of the study participants.

Health literacy is essential because it is utilized by people to understand and evaluate information before using it, preventing exposing their health and well-being to inappropriate behaviors.²¹ The understanding that the outbreak and media coverage also shape individual attitudes, stress responses, and health literacy behaviors contribute to a better perception of reality.²⁰

With the same intensity that older adults are encouraged to be autonomous in social networks, there is concern about scams, unnecessary information, and exposure of confidential content such as the number of documents, photos, and codes. There was always caution in the transmission of messages to inform older adults. In addition, we politely called the attention of those who ended up posting false information in the group due to a lack of awareness.

Not only are scientific organizations providing useful resources to reduce misinformation around this critical issue the world is experiencing, but social media entities such as Instagram and Facebook have also made their contribution through reporting and blocking options.²¹

In France, individual initiatives have disseminated booklets with advice on physical activity and exercises for older adults, favoring access to information.⁹ In a related action, members of a health promotion project prepared a booklet on the use of digital technology for older adults at the pandemic moment and made it available on social media and in the Oswaldo Cruz Foundation portal.²²

Action area 2: Emotional or motivational support through proposals for cognitive activities and mental health maintenance

WhatsApp and Instagram were used on alternate nights to carry out actions related to emotional or motivational support through proposals for cognitive activities and mental health maintenance. Notably, the greatest synchronous interaction among older adults occurred on WhatsApp during activities and games involving cognition skills.

The pandemic caused by the new coronavirus can impact and affect people's mental health and psychological well-being due to changes in routines and family relationships, in addition to increasing concerns related to tragedies announced by the media.^15,20

In developing countries, there is a need for measures to help older people stay healthy and active for as long as possible, in line with the Decade of Healthy Aging baseline report.^5-6

In order to stimulate the intrinsic capacity of older adults, actions aimed at emotional or motivational support were given, considering the mention of idleness during the social distancing period. Given the need mentioned above, playful activities such as memory games, riddles, crossword puzzles, the "hangman" game, search for hidden objects, enigmatic letters, and tongue twisters, among others, were sent to the virtual group daily the night time.

In order to provide cognitive stimuli, the participants were encouraged to rescue the affective memory from activities that involved expressing their feelings, such as listening to old songs and sending images of practiced hobbies, for example, plant cultivation, crafts, cooking, and animal care among others, demonstrating their skills and providing a moment of socializing routine experiences voluntarily.

In addition, the inclusion of other recreational and educational activities was developed, such as the collective construction of a recipe book, the exhibition of images of older adults characterized by the June theme, and the stimulus to send a digitized message, voice, or image with votes for the year 2021, as well as the report of what they learned through the project, during the Covid-19 pandemic. These activities were shared initially on WhatsApp and, later, on Instagram.

The strengthening of older adults' connections with the social support network is extremely relevant, even if it does not occur face-to-face, minimizing feelings of loneliness and vulnerability, which can result in altered mood and cognition, modifying the regulation of the body's inflammatory responses, which impair the immune system, the ability to concentrate and sleep habits.^20,23

When planning actions aimed at promoting the mental health of older adults, situations of prolonged stress were considered since they cause an overload of corticosteroids and increase the susceptibility to viral infections, in addition to the biological mechanisms involved in depression and anxiety associated with advanced age, important conditions that aggravate the progression of Covid-19.¹⁵

Action area 3 - Health promotion by encouraging physical activity

The actions related to health promotion by encouragement to perform physical activities were developed using YouTube daily, in the format of lives, but later made available for asynchronous access.

The project valued the maintenance of the functional capacity of older adults by performing physical activities since the change in the routine due to belonging to risk groups made older adults more vulnerable to a sedentary lifestyle. It should be noted that most physical activities used to be carried out in person in an older adults' group held at a living center, but, due to the pandemic, the activities of this group were temporarily suspended. In addition to the emotional damage caused by social distancing, the reduction or complete cessation of physical activities also carries an additional burden that impairs physical health. Older adults in an environment deprived of regular social, cognitive, and sensorimotor stimulation will worsen their health conditions and level of independence.^12,15

Physical activity is important for older adults, especially to maintain independence, mental health, and well-being.¹² Based on the active aging policy's determinants that encompass behavioral and personal factors, the physical trainer participating in the project and invited volunteers proposed a schedule of physical exercises considering the materials and space available at the older adults' homes. The schedule included activities such as dance, gymnastics, and meditations transmitted through lives. During these lives, older adults were encouraged to interact by sending messages in chat mode and even voice messages through the WhatsApp application to strengthen the other areas of action. This stimulus enriched their connection, demonstrating increased satisfaction in their social relationships, even if physically distant.

The fact that people in quarantine lose the possibility of meeting in person and having access to traditional social help causes a stressful phenomenon¹⁵ leading to a significant decrease in the practice of physical activity.¹²The project made it possible to mitigate these impacts by performing bodily activities with the synchronous transmission.

A recent study indicates that strategies to promote psychological well-being should be implemented, such as organizing the routine of daily activities under safe conditions, taking care of sleep, practicing physical activities, and practicing relaxation techniques,²⁰with relevance to the development of intersectoral activities from an approach based on the life course of older adults.⁶

From the perspective above, health tips for improving health and hygiene habits were available through the application's images and texts. The information provided was related to the maintenance of body water balance, daily exposure to the sun, fall prevention measures, adoption of a physical exercise routine, and the functional importance of selecting food, vitamins, and proteins, thus addressing themes that meet the health promotion guidelines contained in the base report of the Decade for Healthy Aging 2021-2030 and the Active Aging Policy.^4,6

Action area 4 - Encouraging the use of technology with guidance on the use of smartphone and messaging applications

WhatsApp, Instagram, and YouTube were used on alternate days in the afternoon to disseminate guidance information on the use of technologies, specifically smartphone and messaging apps.

The Covid-19 pandemic has brought changes in everyday life and challenges for older adults, along with the possibility of closing the gap between the use of technology and the routine of older adults, impacting their way of connecting with others. As a result, digital tools have expanded,¹⁰ making it necessary to create an action area to guide the use of these resources.

The effectiveness of interventions with this type of digital strategy, through the use of virtual social networks, is related to the differences in the educational profile of older adults living in developing countries, such as Brazil, since the low level of education of older adults is still a reality that can influence the planning of the use of new technologies for health education.⁷

It is recognized that literacy and numeracy are basic criteria for messages to be sent and received effectively.²¹ However, it was observed that this scenario could be controversial due to the intuitive interactivity proposed by the applications. Activities involving audiovisual resources were designed to make more older adults participate in the virtual social networks, as these resources allow people with a low schooling level to be included in the group.

Weekly, moments were set aside to clarify doubts regarding smartphone and messaging applications use, which aroused interest and generated participation from all, regardless of education levels. The doubts focused mainly on how to send audio and video messages and capture and share photos, demonstrating the interest of older adults in interacting and virtually maintaining contact with their networks.

The guidelines were recorded in video format, edited, and made available on the YouTube channel. The supporting guidelines providing answers to older adults' questions were disseminated through short duration self-explanatory videos with two minutes on average, created specifically for this audience. In addition, booklets were developed and disseminated using the WhatsApp, Instagram, and Facebook applications (Figure 2) in an accessible and dynamic way, through self-explanatory images with step-by-step guidelines.

Interface gráfica do usuário, Aplicativo

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Figure 2 - Covers of the booklets developed in the extension project. Astorga-PR, 2022.

Source: Prepared by the Authors (2022)/Illustration: Communication/IFPR

For older adults to be dynamically interested in the virtual world, a safe environment was created concerning the use of smartphones and all activities, individually or collectively, according to the level of understanding of each person. The intervention was conducted valuing the process of optimizing opportunities for health, participation, and quality of life improvement, as the Active Aging Policy proposes.⁴ The link between extension actions and the Decade of Healthy Aging took place for supporting the construction of a society for all ages, respecting limitations, and including older adults at the center of their history, as proposed by the WHO.⁶

Some limitations can be mentioned, among them, that the project is carried out in a small municipality in the interior of Paraná, which has important socio-cultural differences and low purchasing power compared to other regions of the country.

The experience reported is an important contribution to professional practice in the field of gerontology regarding multidisciplinary care for this group. From the experiences lived through the action areas covered by the intervention, different domains such as disease prevention, health promotion, education, sociability, maintenance of bonds, active participation, and digital inclusion were connected.

Conclusion

The experiences described indicate an example of successful intervention practice using social media to promote health actions in older adults during the Covid-19 pandemic. Given the importance of virtual tools, keeping older adults engaged in social media encourages the reduction of inequalities in access to technology, being a comprehensive source of knowledge. The expectation is that older people can remain engaged in the online world, but that this does not interfere with face-to-face social and family relationships, and that digital inclusion is optimized and added to the new skills learned.

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Financial support/Acknowledgments:

We thank the Astorga Municipal Living Center for Older Adults staff and all older adults people who helped to provide rich experiences in the project.

We also thank Dr. Simone Roecker for her support at all stages and for valuing the actions of Grandparents and Grandparents Connected.

Finally, we thank the Extension Directorate of the Federal Institute of Paraná (DIEXT-IFPR) for funding the project.

Author Contributions

1 – Adriana Martins Gallo

Corresponding Author

Nurse. Master in Public Health - E-mail: adriana.gallo@ifpr.edu.br