ABSTRACT
Objective
To evaluate the impact of cancer treatment on the health‐related quality of life (HRQoL) of children and adolescents.
Methods
HRQoL self‐perception was assessed using the Pediatric Quality of Life Inventory 3.0 Cancer Module (PedsQL), applied to 103 children and adolescents aged 1 to 18 years, recruited from a hematology and oncology unit of a Brazil public hospital and a support house. Sociodemographic and health data were collected through structured questionnaires, and a dental examination was conducted to assess dental caries. Data were analyzed using SPSS, including descriptive and Chi‐square tests.
Results
Most participants were male (54.4%), aged 1–7 years (55.3%), with a primary diagnosis of hematologic and lymphatic cancer (85.4%). Family income was up to one minimum wage (55.3%), and 70.9% of mothers had at least 8 years of education. Children aged 1–7 scored lower in “Procedural Anxiety” (45.14 ± 40.37) than adolescents (66.67 ± 36.30). Adolescents scored lower in “Nausea” (55.11 ± 30.06) and “Worry” (56.34 ± 38.69) than children. HRQoL scores were associated with age (p < 0.001), maternal education (p = 0.022), brushing frequency (p = 0.046), and decayed teeth (p = 0.001). In the final model, self‐reported HRQoL among children and adolescents aged 8 to 18 years (OR = 4.28; 95% CI: 1.07–17.12) was associated with lower HRQoL.
Conclusion
Anxiety, nausea, and worry negatively impact the health‐related HRQoL of pediatric cancer patients, and sociodemographic factors, such as the child's age, also influence this perception, highlighting the importance of individualized and integrated approaches to care.
Keywords: adolescents, cancer, children, health‐related quality of life, self‐report
1. Introduction
In recent decades, advances in early diagnosis and antineoplastic therapies have significantly increased survival rates for childhood and adolescent cancer, despite the continued rise in the incidence of the disease [1, 2, 3, 4]. Among the most common types are leukemias, lymphomas, and central nervous system tumors. Treatment which may involve surgery, chemotherapy, and radiotherapy often causes significant side effects and impacts not only the body but also the emotional and social well‐being of patients and their families [3, 5].
Given these impacts, health‐related quality of life (HRQoL) has been increasingly recognized as an essential aspect of oncology care [4]. This multidimensional concept reflects the patient's perception of how the disease and its treatment affect their physical, emotional, mental, and social life. In addition to physical repercussions, cancer can compromise the quality of life (QoL) of both the patient and their family, generating fear, insecurity, and frustration due to limitations such as isolation and physical changes [2, 5, 6]. Although several studies have addressed the impacts of cancer on the HRQoL of children and adolescents, many focus on late effects or the survivorship phase. Therefore, it is still necessary to deepen the understanding of the active treatment period and its specific implications, which can support clinical guidelines and public policies that are more responsive to the needs of patients undergoing treatment [4].
In this context, it is crucial to understand the complexity of health and illness perception, as well as the differences determined by age and personal experiences, allowing for the refinement of therapeutic approaches and the improvement of HRQoL in these individuals [7]. Understanding how cancer and its treatment affect the HRQoL of children and adolescents is essential for guiding more individualized clinical practices [8].
In this context, the present study aims to assess this perception using the Pediatric Quality of Life Inventory 3.0 – Cancer Module (PedsQL), an instrument validated in Brazil [9, 10], in order to sensitively capture the effects of treatment across different domains of life and contribute to the improvement of care strategies during treatment. Thus, the objective of this study was to evaluate the effects of cancer treatment on the HRQoL of children and adolescents with cancer, considering their self‐perception through this specific instrument.
2. Methods
2.1. Ethical Considerations
This study was approved by the Research Ethics Committee of the Federal University of Minas Gerais (UFMG) under the Certificate of Ethical Appreciation Presentation (CAAE) number 36138920.2.0000.5149, in accordance with Resolution No. of the Brazilian National Health Council (CNS). Approval was also obtained from the Borges da Costa Outpatient Clinic, which is part of the Hospital das Clínicas complex at the UFMG. Both the children/adolescents and their mothers were informed about the risks and benefits of the study and agreed to participate by signing an informed consent form. Additionally, the children/adolescents provided their assent by signing the Assent Form (TALE), and their mothers/guardians signed the Informed Consent Form (TCLE).
2.2. Study Design and Population
This is an exploratory‐descriptive study with a cross‐sectional design, guided by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [11]. The study was conducted in the city of Belo Horizonte, in the state of Minas Gerais, Brazil. The sample consisted of children and adolescents undergoing cancer treatment at the Borges da Costa Outpatient Clinic. Outpatient Clinic, Hematology and Oncology Unit of the Hospital das Clínicas complex at the UFMG, also located in xxxx. A non‐probabilistic sampling method was used, including participants aged between 1 and 18 years who were receiving care at the study sites between October 2021 and June 2024. On average, twenty children/adolescents are diagnosed with cancer annually at the hospital, and thirty are received at the support house. There were no missing data in the self‐reports from either the children/adolescents or their mothers.
2.3. Pilot Study
A pilot study was conducted with 10% of the sample to assess the efficiency of the data collection methods and instruments. Since no changes to the procedures were necessary, the participants in the pilot study were retained in the final sample, with no exclusions, due to the low prevalence of the disease.
2.4. Clinical Data Collection
Three previously trained and calibrated researchers administered questionnaires on sociodemographic aspects and performed clinical examinations in private rooms, using the dmft/DMFT index to assess dental caries [12] (World Health Organization, 2013). Inter‐ and intra‐examiner agreement was verified using the Kappa test, yielding kappa = 0.92 (intra‐examiner) and kappa = 0.79 (inter‐examiner). According to Siegel and Castellan (1988), these values indicate good to excellent agreement.
2.5. Non Clinical Data Collection—Sample Characteristics and Health Condition Data
The sample characteristics and health condition data related to cancer treatment were collected through a questionnaire directed to the children/adolescents and their mothers/legal guardians, addressing characteristics of the children/adolescents (sex, education level, disease diagnosis, treatment phase, and other problems) and of the mothers/legal guardians (marital status, income, and education level). To assess oral health conditions, clinical examinations were performed on the children and adolescents in private rooms, under artificial light, with the participants seated in chairs facing the examiner. The dmft/DMFT index was used to evaluate dental caries [12].
2.5.1. PedsQL
To assess HRQoL, the Brazilian version of the PedsQL was used [11, 13]. The PedsQL is a multidimensional instrument used to measure the impact of illness and treatment on HRQoL in pediatric patients. It comprises 27 items distributed across eight domains: pain and hurt (2 items), nausea (5 items), procedural anxiety (3 items), treatment anxiety (3 items), worry (3 items), cognitive problems (5 items), perceived physical appearance (3 items), and communication (3 items) [9]. This instrument was developed in age‐adapted versions for children and adolescents in the following age ranges: 5–7 years, 8–12 years, and 13–18 years, as well as for parents of individuals aged 1–4 years, 5–7 years, 8–12 years, and 13–18 years. For children aged 1 to 4 years, there is no self‐report version; only the parents’ perception is considered for this group. To facilitate self‐reporting in children aged 5–7 years, the response scale was simplified to a three‐point scale (0 = never; 2 = sometimes; 4 = almost always), with answers associated with an illustrated scale composed of three facial expressions ranging from a happy face to a very sad face.
Originally, the scales are administered in the form of an interview for children aged 5–7 years, while they are self‐administered by participants in the 8–12 and 13–18 age groups. However, considering that several studies [11, 13] have shown that the mode of administration does not affect the instrument's performance, it was decided to group the age ranges of 1–8 years and 9–18 years and to administer the PedsQL as an interview in all cases, especially due to the homogeneity in age of the children/adolescents included in the present study.
The items were scored inversely and transformed into a scale from 0 to 100 (0 = 100; 1 = 75; 2 = 50; 3 = 25; 4 = 0), where higher scores indicate better HRQoL. The scale scores were calculated as the sum of the items divided by the number of items answered [13].
2.6. Data Analysis
Data organization and statistical analysis were performed using the Statistical Package for Social Sciences (SPSS for Windows, version 21.0, IBM Corp., Armonk, NY, USA). Data distribution and frequency were determined to characterize the sample. Furthermore, in order to test the association between HRQoL and independent variables, analyses were conducted using the Chi‐square test. Binary logistic regression analyses, both unadjusted and adjusted (PR, CI = 95%), were performed to examine the strength of the association between the independent variables and the dependent variable PedsQL. Variables with a p‐value < 0.05 in the final model were considered associated with the study outcome.
3. Results
Table 1 presents the characteristics of the sample, composed of 103 children and adolescents with cancer who participated in the study. Most of the sample was recruited at the hospital (73.8%), were male (54.4%), aged between 1 and 7 years (55.3%), and were students (79.6%). The identified pathological diagnoses were hematologic and lymphatic cancers (85.4%) and other types of cancer (14.6%); the majority of the sample had undergone chemotherapy treatment (67%) and were in a nonintensive treatment phase (53.4%). The questionnaires were answered by the children's/adolescents’ mothers, with a predominance of those who had more than 8 years of education (70.9%). The total family income (55.3%) was less than or equal to one minimum wage (R$1,202.00/month). Regarding oral hygiene habits and caries prevalence, the predominant toothbrushing frequency was more than twice a day (77.7%), while the most common number of decayed teeth was up to two teeth (53.4%).
TABLE 1.
Sample characterization (n = 103).
| Variables | Frequency | |
|---|---|---|
| N | % | |
| Sex | ||
| Male | 56 | 54.4 |
| Female | 47 | 45.6 |
| Study or not | ||
| Yes | 82 | 79.6 |
| No | 21 | 20.4 |
| Age | ||
| 1–7 years | 57 | 55.3 |
| 8–18 years | 46 | 44.7 |
| Mother´s age | ||
| Up to 34 years | 53 51.5 | |
| Over de 34 years | 50 | 48.5 |
| Total income | ||
| ≤ 1minimum wage | 57 | 55.3 |
| >1 minimum wage | 46 | 44.7 |
| Mother´s education | ||
| Up to 8 years of education | 30 | 29.1 |
| More than 8 years of education | 73 | 70.9 |
| Research location | ||
| Hospital | 76 | 73.8 |
| Support Home | 27 | 26.2 |
| Diagnosis of pathology | ||
| Hematological and lymphatic cancer | 88 | 85.4 |
| Other type of cancer | 15 | 14.6 |
| Treatment phase | ||
| Intensive | 48 | 46.6 |
| Non—intensive | 55 | 53.4 |
| Treatment | ||
| Chermotherapy | 69 | 67 |
| Other | 34 | 33 |
| How ofteen do you brush your teeth? | ||
| Up to 2 time | 23 | 22.3 |
| More than 2 times | 80 | 77.7 |
| Number of decayed teeth | ||
| Up to 2 teeth | 55 | 53.4 |
| More than 2 teeth | 48 | 46.6 |
Abbreviations: n, absolute frequency; %, row percentage.
Table 2 presents the results of the descriptive analysis of the means and standard deviations (SD) of the responses to the PedsQL questionnaire, aiming to assess the oral OHRQoL of children/adolescents and their mothers/caregivers. In the proxy reports, it was observed that mothers/caregivers of children aged 1 to 7 years reported the lowest scores in the ‘procedural anxiety’ domain (mean: 35.26; SD ±39.18). For the 8–18 age group, the lowest score reported by mothers/caregivers was in the ‘nausea’ domain (mean: 56.09; SD ±30.12). Regarding self‐reports, children aged 1 to 7 years also showed the lowest score in the ‘procedural anxiety’ domain (mean: 45.14; SD ±40.37), while children/adolescents aged 8 to 18 years reported the lowest score in the ‘nausea’ domain (mean: 55.11; SD ±30.06).
TABLE 2.
Descriptive statistics of PedsQl3.0 scores, as estimated HRQoL (n = 103).
| Children 1–7 | Teenagers 8–18 | |
|---|---|---|
| Domains | Mean (± SD) | Mean (± SP) |
| Pain | 82.29 (26.04) | 73.91 (36.59) |
| Nausea | 81.67 (19.70) | 55.11 (30.06) |
| Procedure—related anxieety | 45.14 (40.37) | 66.67 (36.50) |
| Treatment—related anxiety | 81.25 (27.50) | 74.82 (35.76) |
| Worry | 82.64 (30,48) | 56.34 (38.69) |
| Cognitive problems | 75.36 (32.52) | 64.49 (36.53) |
| Perrception of physical appearance | 85.42 (21.59) | 80.07 (25.42) |
| Communication | 77.08 (29.81) | 57.97 (41.01) |
| Total sum pedsql3.0 | 74.47 (13.31) | 63.93 (20.46) |
Abbreviation: SD, standard deviation.
Table 3, in turn, shows the distribution and association of the study's independent variables. Regarding age, 57% of the children were between 1 and 7 years old (p < 0.001). Most of them brushed their teeth more than twice a day (n = 80; p = 0.046). Additionally, 55% had up to two decayed teeth (p < 0.001). As for the educational level of the mothers/caregivers, 51.5% had up to eight years of schooling (n = 52; p = 0.022). Table 4 presents the logistic regression analysis, in which the final model showed that self‐reporting by children and adolescents aged 8 to 18 years (OR = 4.28; 95% CI: 1.07–17.12) was associated with lower HRQoL.
TABLE 3.
Association between child characteristics, disease clinical status, and impact on HRQoL, with chi‐square analysis (n = 103).
| Variables | Impacto on HRQoL until 67.74(%) | more 67.02 (%) | total n (%) | P‐value * |
|---|---|---|---|---|
| Sex | ||||
| Male | 16 (57.1) | 40 (53.3) | 56 (54.4) | 0.730 a |
| Female | 12 (42.9) | 35 (46.7) | 47 (45.6) | |
| Study or not | ||||
| Yes | 5 (17.9) | 52 (69.3) | 57 (55.3) | 0.000 b , * |
| No | 23 (82.1) | 23 (30.7) | 46 (44.7) | |
| Age | ||||
| 1–7 years | 14 (50) | 39 (52) | 53 (51.5) | 0.857 a |
| 8–18 years | 14 (50) | 36 (48) | 50 (48.5) | |
| Total income | ||||
| ≤ 1minimum wage | 17 (60.7) | 40 (53.3) | 57 (55.3) | 0.503 a |
| >1 minimum wage | 11 (39.3) | 35 (46.7) | 46 (44.7) | |
| Mother´s education | ||||
| Up to 8 years of education | 19 (70.4) | 8 (29.6) | 52 (51.5) | 0.022 * |
| More than 8 years of education | 33 (44.6) | 41 (55.4) | 49 (48.5) | |
| Research location | ||||
| Hospital | 19 (67.9) | 57 (76) | 76 (73.8) | 0.403 a |
| Support home | 9 (32.1) | 18 (24) | 27 (26.2) | |
| Diagnosis of pathology | ||||
| Hematological and lymphatic cancer | 22 (78.6) | 66 (88) | 88 (85.4) | 0.227 a |
| Other type of cancer | 6 (21.4) | 9 (12) | 15 (14.6) | |
| Treatment phase | ||||
| Intensive | 12 (42.9) | 36 (48) | 48 (46.6) | 0.642 a |
| Nonintensive | 16 (57.1) | 39 (52) | 55 (53.4) | |
| Treatment | ||||
| Chermotherapy | 18 (64.3) | 51 (68) | 69 (67) | 0.721 a |
| Other | 10 (35.7) | 24 (32) | 34 (33) | |
| How ofteen do you brush your teeth? | ||||
| Up to 2 time | 10 (35.7) | 13 (17.3) | 23 (22.3) | 0.046 a , * |
| More than 2 times | 18 (64.3) | 62 (82.7) | 80 (77.7) | |
| Number of decayed teeth | ||||
| Up to 2 teeth | 5 (17.9) | 50 (66.7) | 55 (53.4) | 0.000 b , * |
| More than 2 teeth | 23 (82.1) | 25 (33.3) | 48 (46.6) |
P, Probability value.
Pearson's Chi‐square test.
Fisher's Exact Test; Values in parentheses represent row percentages; bold values indicate statistical significance.
TABLE 4.
Logistic regression for association of child characteristics, clinical disease status and impact on HRQoL—PedsQL, child/adolescent self‐report (n = 103).
| Variables | RC not adjusted (95%IC) | p‐value | Adjusted RC (95 % IC) | p‐value |
|---|---|---|---|---|
| Sex | ||||
| Male | 1 | 0.730 | — | — |
| Female | 0.85 (0.35–2.05) | |||
| Study or not | ||||
| Yes | 1 | 0.030* | 1 | 0.311 |
| No | 0.10 (0.13–0.800) | 0.31 (0.31–3.11) | ||
| Age | ||||
| 1–7 years | 1 | 0.000* | 1 | 0.039 |
| 8–18 years | 10.40 (3.51–30.76) | 4.28 (1.07–17.12) | ||
| Total income | ||||
| ≤ 1minimum wage | 1 | 0.503 | — | — |
| >1 minimum wage | 0.73 (0.30–1.79) | |||
| Mother´s education | ||||
| Up to 8 years of education | 1 | 0.000* | 1 | 0.092 |
| More than 8 years of education | 0.33 (0.13–0.84) | 0.39 (0.13–1.16) | ||
| Research location | ||||
| Hospital | 1 | 0.405 | — | — |
| Support home | 1.50 (0.57–3.89) | |||
| Diagnosis of pathology | ||||
| Hematological and lymphatic cancer | 1 | 0.233 | — | — |
| 2.00 (0.64–6.25) | ||||
| Other type of cancer | ||||
| Treatment phase | ||||
| Intensive | 1 | 0.721 | — | — |
| Non‐intensive | 1.18 (0.47–2.94) | |||
| How ofteen do you brush your teeth? | ||||
| Up to 2 time | 1 | 0.051* | 1 | 0.097 |
| More than 2 times | 0.37 (0.14–1.00) | 0.36 (0.11–1.19) | ||
| Number of decayed teeth | ||||
| Up to 2 teeth | 1 | 0.000* | 1 | 0.156 |
| More than 2 teeth | 9.20 (3.12–27.08) | 2.71 (0.68–10.84) |
4. Discussion
The findings of this study revealed that procedure‐related anxiety and nausea were the domains with the greatest negative impact on oral health–related OHRQoL among children and adolescents undergoing cancer treatment. The lower mean scores observed in these domains suggest that both factors significantly influence the perception of well‐being during therapy, underscoring the need for targeted interventions to mitigate these adverse effects. Moreover, older children tended to demonstrate a broader understanding of the disease and its treatment, which led them to experience the side effects and imposed restrictions more consciously. This heightened awareness may intensify feelings of anxiety and discomfort, further compromising quality of life. The consistency between the reports of patients and their caregivers reinforces the reliability of the data and highlights the importance of integrated management strategies that address both the physical symptoms and the psychological challenges associated with cancer and its treatment [12].
Considering the eight domains studied, the Procedural Anxiety domain had the lowest score, indicating lower OHRQoL [14]. In this context, anxiety related to medical procedures is associated with sensations of pain, fear, and unfamiliarity with the environment, which affects not only pediatric patients but also their parents and caregivers, making treatment even more challenging [14, 15]. This finding highlights the importance of managing anxiety associated with medical procedures during cancer treatment. In this regard, the adoption of playful and educational strategies by healthcare professionals may help reduce procedural anxiety. Examples of such measures include patient distractions, positive reinforcement, and sensory explanations about the procedure to be performed [16].
Another major challenge involves concerns related to the illness among adolescents with cancer [17]. Socialization during treatment is difficult due to a lack of autonomy, school limitations, and an exhausting therapeutic routine [17, 18]. Studies show that HRQoL is lower in older adolescents compared to children aged six years or younger [19, 20]. Factors such as the environment, life stage, and complex subjective relationships influence this experience [19, 21]. In this context, it is essential to address the anxiety associated with medical procedures during cancer treatment. This finding highlights the importance of managing this anxiety.
The difference between the age groups of 1–7 years and 8–18 years in the impact of cancer treatment suggests that younger and older children react in distinct ways [12]. Younger children, due to cognitive development, may have more difficulty understanding the treatment, resulting in increased anxiety and fear. These findings indicate the need for specific therapeutic and communication approaches for each age group. Younger children may benefit from playful strategies and simplified explanations, while adolescents may prefer detailed explanations and active involvement in decisions about their treatment [22]. Adapting these approaches can improve cooperation and reduce anxiety, leading to better outcomes in pediatric cancer treatment. On the other hand, older children and adolescents tend to have a greater understanding of the disease and its treatment, which can positively or negatively influence their experience during the therapeutic process [23, 24]. A broader understanding of adverse effects, imposed limitations, and treatment duration can generate greater awareness, but also feelings of distress, frustration, and loss of control. However, this same cognitive capacity favors active engagement in care and adherence to treatment, especially when healthcare professionals adopt open and participatory communication. Thus, promoting dialogue and co‐responsibility in clinical decisions can strengthen the sense of autonomy and contribute to a better quality of life during cancer treatment [24].
Notably, the frequency of tooth brushing in children and adolescents undergoing oncological treatment and their HRQoL highlights the importance of oral hygiene habits for overall health. This result suggests that promoting a higher frequency of tooth brushing may not only improve oral health but also positively influence the HRQoL of these patients, highlighting the relevance of educational interventions aimed at promoting proper oral care practices for broader health benefits [23]. From this perspective, another important finding of our study was the relationship between the number of decayed teeth and the HRQoL of children and adolescents undergoing oncological treatment. Such a result is directly proportional to the presence of oral hygiene habits, meaning that the more adequate and frequent the practice of oral care, the lower the chances of dental caries development, which reinforces the need for such interventions [24].
Several factors may explain the lower number of decayed teeth in children undergoing oncological treatment. First, these children often undergo rigorous medical monitoring, including regular dental care, which leads to greater awareness and practice of proper oral hygiene. Additionally, they and their families receive specific guidance on the importance of oral hygiene during treatment, emphasized by doctors and dentists to prevent further complications [25]. The diet of these children is generally monitored to minimize the intake of cariogenic foods, contributing to a lower incidence of cavities. Some oncological treatments may reduce saliva production, which can lead to a more intense oral care routine to combat dry mouth and its consequences. Additionally, the higher frequency of dental visits to monitor and address potential complications may result in a better overall oral health condition [26].
Furthermore, other findings are related to characteristics such as the education level and family income, which can influence the educational progress of mothers and caregivers, as well as how the family environment can affect health care. Older age and family income below the minimum wage are associated with lower HRQoL in children and adolescents, as well as in their families [4, 27, 28]. A study in the United States reported that higher family income was associated with better HRQoL in children with cancer [23], while a Dutch study found that higher maternal education is a protective factor for HRQoL [29].
The mother's educational level is related to the type of emotional and practical support provided to children during treatment. Mothers with higher levels of education tend to have access to more resources and support networks, as well as being better equipped to cope with the stress and emotional demands of caring for a child with cancer. This support ranges from clear and reassuring explanations to organizing activities that comfort the patient during medical procedures. On the other hand, mothers with lower levels of education may face additional challenges in understanding medical information, affecting treatment adherence and the management of care at home. This underscores the importance of communication strategies tailored to the caregiver's educational level, ensuring that all families receive the necessary support to manage the illness effectively [15, 30]. These findings highlight the need for a personalized approach in medical communication and treatment planning, taking into account the educational level of parents to improve outcomes in pediatric cancer treatment.
The results of this study have clinical implications, suggesting strategies to improve the HRQOL of children and adolescents with cancer and their families. It is crucial to focus not only on physical needs but also on psychological and social aspects, providing individualized and compassionate care. The inclusion of the family in the care process, ensuring the right to information about the treatment and disease, and preparing the child for the procedures, helps reduce traumatic effects and facilitates the relationship between children and mothers. This study faces limitations, such as the small sample size due to the low prevalence of childhood cancer, which affects the confidence interval and the generalization of results in Brazil. More studies in different contexts and with different populations are needed, and longitudinal designs are desirable to infer causality between cancer treatment and quality of life in children and adolescents.
5. Conclusion
This study concludes that procedure‐related anxiety and nausea are the main challenges affecting the health‐related HRQoL of children and adolescents with cancer, as perceived by both patients and their caregivers. These findings highlight the urgent need for targeted interventions that address both physical and psychological symptoms. The results also suggest that older children and adolescents tend to experience a greater impact on HRQoL, likely due to their heightened awareness and understanding of the disease and its treatment. The positive influence of maternal education on understanding and managing the child's medical and emotional needs, together with the role of age in shaping treatment perception and response, reinforces the importance of individualized and age‐appropriate care approaches. Furthermore, maintaining good oral hygiene during treatment is essential to prevent complications such as dental caries, underscoring the relevance of specific oral health strategies to improve the overall HRQoL of pediatric cancer patients.
Author Contributions
Saul M. Paiva conceived, designed and supervised the study and critically edited the manuscript. Anna Vitória M.V. Silva conducted the data collection with the participants, analyzed and interpreted the results and wrote the manuscript. Matheus F. Perazzo supervised the data analysis and critically edited the manuscript. Isabel Z. Freitas conducted the data collection with the participants and assisted in writing the manuscript. Alice M.C. Santos conducted the data collection with the participants and assisted in writing the manuscript. Bernardo V. Pimenta and Bruna P. Guimarães assisted in data collection and contributed to the organization and preliminary analysis of the data.
Consent
The protocol for this study received approval from the Human Research Ethics Committee of the Federal University of Minas Gerais (certificate number: 36138920.2.0000.5149).
Consent for Publication
The manuscript is not being considered for publication by another journal and has not been previously published. All authors made a significant contribution to the manuscript and agree to publish data from this research.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
The authors appreciate the support of the Brazilian fostering agencies Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES [Coordination for the Advancement of Higher Education Personnel]) and Conselho Nacional de DesenvolvimentoCientífico e Tecnológico (CNPq [National Council of Scientific and Technological Development]).
Data Availability Statement
The authors provide all the data used in the research for publication.
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Data Availability Statement
The authors provide all the data used in the research for publication.