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Effect of Satisfaction with Social Support, Food Literacy, and Empowerment concerning the Consumption of Ultra-Processed Foods

Efeito da satisfação com o suporte social, do letramento alimentar e do empoderamento sobre o consumo de ultraprocessados

Efecto de la satisfacción con el apoyo social, la alfabetización alimentaria y el empoderamiento sobre el consumo de alimentos ultraprocesados

Andressa Tavares Gomes1
ORCID: https://orcid.org/0000-0002-5366-2804 E-mail: andressatavaresgom@gmail.com

Paula Karoline Soares Farias2
ORCID: https://orcid.org/0000-0003-0529-2754 E-mail: paulak.soares@hotmail.com

Tatiane Palmeira Eleutério2
ORCID: https://orcid.org/0000-0002-0385-4103 E-mail: tatipeleuterio@gmail.com

Pedro Eleutério dos Santos Neto2
ORCID: https://orcid.org/0000-0002-6205-5205 E-mail: pesneto@yahoo.com.br

Ana Monique Gomes Brito2
ORCID: https://orcid.org/0000-0002-0490-9479 E-mail: anamoniquegomes@gmail.com

Árlen Almeida Duarte de Sousa1,2
ORCID: https://orcid.org/0000-0002-7690-5282 E-mail: arlen.sousa@unimontes.br

Andréa Maria Eleutério de Barros Lima Martins1,2 *
ORCID: https://orcid.org/0000-0002-1205-9910 E-mail: martins.andreamebl@gmail.com

1Postgraduate Program in Health Sciences, State University of Montes Claros (Unimontes), Montes Claros, Minas Gerais, Brazil.
2State University of Montes Claros (Unimontes), Montes Claros, Minas Gerais, Brazil.

*Corresponding address: Andréa Maria Eleutério de Barros Lima Martins. State University of Montes Claros, University Campus Professor Darcy Ribeiro, avenida Rui Braga, sem número, Vila Mauricéia, Montes Claros (MG), Brazil. Zip code: 39401-089. Phone: +55 38 9 9817-2933. E-mail: martins.andreamebl@gmail.com
Abstract
The present study aimed to evaluate the effect of Satisfaction with Social Support (SSS), Food Literacy (FL), and Empowerment (E) concerning the consumption of Ultra-Processed Foods (UPFs) among adults and elderly individuals with Diabetes Mellitus (DM). This is a subset of a larger cross-sectional study conducted between 2016 and 2018. Two out of 73 clusters were randomly selected. Socioeconomic conditions were assessed, and the scales used to evaluate SSS, FL, and E have been previously validated in Brazil. UPF consumption was estimated using a semi-structured food frequency questionnaire. A hypothetical theoretical model was developed. The SPSS and JASP programs were used for data analysis. Structural Equation Modeling estimated the effects of the latent variables SSS, FL, and E on UPF consumption. Bartlett’s test, the Kaiser-Meyer-Olkin (KMO) measure, and the following fit indices were calculated: Chi-square (X²), Chi-square per degrees of freedom ratio (X²/df), Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), Goodness-of-Fit Index (GFI), and Root-Mean-Square Error of Approximation (RMSEA). The average age was 62.25 ± 12.11 years, with the majority being women (68.10%). The fit indices indicated that the hypothetical model is plausible. Thus, SSS does have an effect on UPF consumption mediated by FL and E.
Keywords: Diabetes Mellitus. Health Literacy. Food, Processed.

Resumo
Objetivou-se avaliar o efeito da Satisfação com o Suporte Social (SSS), do Letramento Alimentar (LA) e do Empoderamento (E) sobre o consumo de Alimentos Ultraprocessados (AUPs) em adultos e idosos com Diabetes Melittus (DM). Trata-se de um recorte de um estudo transversal maior conduzido entre 2016 e 2018. Dos 73 conglomerados 2 foram sorteados. Foram avaliadas condições socioeconômicas, as escalas utilizadas para avaliação da SSS, do LA e do E foram previamente validadas no Brasil. O consumo de AUPs foi estimado por meio de Questionário de frequência alimentar semi-estruturado. Foi elaborado um modelo teórico hipotético. Os programas SPSS e JASP foram utilizados. A Modelagem de Equações Estruturais estimou os efeitos das variáveis latentes SSS, LA e E sobre o consumo de AUPs. Estimaram-se os testes de Bartlett, Kayser-Meyer-Otkin e os índices de ajustes: Chi-square (X2), Chi-square per degrees of freedom ratio (X2/g.l); Comparative Fit Index (CFI); Tucker-Lewis Index (TLI); Goodness-of-Fit Index (GFI), e Root-Mean-Square Error of Aproximation (RMSEA). A média de idade foi de 62,25 ±12,11 anos, sendo a maioria mulher (68,10%). Os índices de ajustes provaram que o modelo hipotético é plausível. Assim, a SSS possui um efeito no consumo de AUP mediado pelo LA e pelo E.
Palavras-chaves: Diabetes Mellitus. Letramento em Saúde. Alimentos Ultraprocessados.
 
Resumen
Este artículo tuvo como objetivo evaluar el efecto de la Satisfacción con el Soporte Social (SSS), el Alfabetismo Alimentario (AA) y el Empoderamiento (E) sobre el consumo de Alimentos Ultraprocesados (AUPs) en adultos y ancianos con Diabetes Mellitus (DM). Se trata de un recorte de un estudio transversal más amplio, realizado entre 2016 y 2018. De los 73 conglomerados, se sortearon 2. Se evaluaron las condiciones socioeconómicas, y las escalas utilizadas para la evaluación de la SSS, el AA y el E fueron previamente validadas en Brasil. El consumo de AUPs se estimó mediante un cuestionario de frecuencia alimentaria semiestructurado. Se elaboró un modelo teórico hipotético. Se utilizaron los programas SPSS y JASP. El Modelado de Ecuaciones Estructurales estimó los efectos de las variables latentes SSS, AA y E sobre el consumo de AUPs. Se calcularon las pruebas de Bartlett y Kaiser-Meyer-Olkin, así como los índices de ajuste: Chi-cuadrado (X²), razón Chi-cuadrado por grados de libertad (X²/g.l), Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), Goodness-of-Fit Index (GFI) y Root-Mean-Square Error of Approximation (RMSEA). La edad media fue de 62,25 ±12,11 años, siendo la mayoría mujeres (68,10%). Los índices de ajuste demostraron que el modelo hipotético es plausible. Así, la SSS tiene un efecto en el consumo de AUPs mediado por el AA y el E.
Palabras-clave: Diabetes Mellitus. Alfabetización en Salud. Alimentos Ultraprocesados.

Introduction
In Brazil, the increasing prevalence of Noncommunicable Diseases (NCDs) has been a public health challenge. Most deaths in 2015 were caused by NCDs, leading to a substantial decline in people\'s Quality of Life (QoL), high social costs, and increased government spending on population health1. The consumption of Ultra-Processed Foods (UPFs) is associated with health-related conditions, such as obesity, cardiovascular disease, and diabetes, which are considered NCDs2. Among NCDs, Diabetes Mellitus (DM) stands out as a multifactorial disease caused by a deficiency in insulin production and/or action3. Dietary consumption is considered one of the main modifiable determinants in the control and onset of DM. In recent years, there have been changes in the population\'s eating habits, such as the replacement of unprocessed foods with UPFs2. These foods undergo a high degree of industrialization, with the addition of ingredients and additives, have a long shelf life, are convenient and palatable, and are considered risk factors for DM4-6. However, adopting a healthy diet involves several factors, including environmental and individual factors, including education, income, and culture; in addition to the availability of healthy foods and the advertising of unhealthy foods1,2. Thus, it is necessary for a person with DM to understand the proper management necessary to control the disease.
Health Literacy (HL) refers to the promotion of access to, use of, understanding of, and evaluation of health services, among other organizations or institutions, as well as the ability of people to access, understand, evaluate, and apply information related to health services and health in making decisions relevant to health care, within the realm of humanized care that focuses on the person and not the disease7-13. In Brazilian Portuguese, the term “health literacy” has been translated in various ways, including “alfabetização em saúde”, “letramento em saúde”, “letramento funcional em saúde” and “literacia em saúde”18.
When related to food, HL is called Food Literacy (FL) or Nutritional Literacy14,15. FL focuses on eating habits rather than the specific nutrients present in foods. Recognizing the relevance of HL, the World Health Organization (WHO), in 2008, classified both HL and FL as intermediate determinants of health due to their direct influence on QoL16.
In 2008, the WHO, through the Commission on Social Determinants of Health, listed HL as one of the intermediate determinants of health, given that HL has a direct relationship with people\'s QoL16. In 2010, the WHO provided a conceptual model, devised by Solar and Irwin, which proposes actions to be taken concerning the social determinants of health. In this model, contextual and individual structural determinants that exert an effect on the intermediate determinants of well-being, that is, on QoL among people, were presented17. In 2012, an integrated model of HL was presented, which considers the dimensions related to access, understanding, evaluation, and application of health-related information12, translated into Brazilian Portuguese in 2012, with publication made available in 201419.
The model displays proximal and distal factors that determine or are determined by levels ofHL. The following variables were considered in the model: prior health-related knowledge; skills necessary for self-care; and motivation to access, understand, evaluate, and apply the given information. Access refers to the ability to search for, find, and obtain such information; understanding refers to the ability to comprehend this information; evaluation refers to the ability to interpret, filter, and judge such information; and application refers to the ability to communicate and use or apply the information with a view to maintaining or improving people\'s health conditions. The model also displays factors dynamically associated with HL. Distal determinants are social and environmental; proximal determinants are situational social (social support, family and peer influences, media use, and physical environmental conditions), and personal (age, sex, race, socioeconomic status, marital status, education, occupation, employment, income, and schooling). Other factors possibly associated with HL in a feedback relationship (determinants and consequences) are also presented: use of health services, health costs, health-related behaviors, health outcomes, people\'s participation in health care, empowerment, equity, and health maintenance12,19. In addition to HL, Satisfaction with Social Support (SSS) and empowerment stand out as determinants of well-being or QoL among people.
Social satisfaction with health (SSH), empowerment, and QoL are interconnected and mutually influential. Creating environments that promote empowerment increases health gains for people with NCDs. This is because empowerment promotes autonomy, engagement, and individual emancipation, giving individuals control over their decisions20. SSH has been highlighted as a factor that positively influences NCDs, being considered an indicator of health and well-being in different phases of life21,22. The health status of individuals has been correlated or associated with the level and quality of SSH; the higher and better the SSH, the lower the rates of illness and mortality rates23,24. In 1999, an SSH scale was developed to assess levels of satisfaction with SSH among people with diabetes mellitus (DM)22. In 2014, the SSH scale was cross-culturally validated for Portuguese in Portugal25. It is also well-known that higher levels of self-esteem and empowerment can contribute to the improvement of health indicators, thus mitigating the number of hospitalizations, complications, and deaths related to diseases26. In 2003, at the University of Michigan (USA), a scale was developed to assess levels of empowerment among people diagnosed with DM as a result of the simplification of the previous one, called the “Diabetes Empowerment Scale (DES)”27. This scale allowed for a more concise and comprehensive assessment of the capabilities of people with DM. In 2013, the Center for Health Studies and Research of the University of Coimbra (CEISUC) translated the DES-SF into Portuguese and named it the Diabetes Empowerment Scale28. In Brazil, the version was translated and culturally adapted, and it was named the Diabetes Self-Efficacy Scale - short version (Escala de Autoeficácia em Diabetes - versão curta – EAD-VC). The acronym DES-SF was maintained internationally, since the concept of empowerment supports the hypothesis of this study29.
In this context, it became evident that public administration should invest in increasing levels of HL among people through Health Literacy Organizations (HLOs), as health literacy is an important determinant of health for the population. The essential partnership and engagement of health workers should also be considered, as they are responsible for communicating with the patient, their family members, or caregivers in a simple manner and based on the best scientific evidence. The quality of care provided by health workers is paramount in the process of organizing health services, as well as in increasing levels of HL among people7-13. Health education strategies should be constantly reviewed, especially among health workers who do not have acceptable levels of HL10.
Research elucidating factors that shape food choices related to the consumption of UPFs is rare. In this light, the present study aimed to verify the effect of satisfaction with the health system, food availability, and empowerment concerning the consumption of these foods among people with DM.

Methods
This cross-sectional study is a subset of a larger project conducted between 2016 and 2018 in the municipality of Montes Claros, located in the state of Minas Gerais. The municipality had a population of 414,240 inhabitants, the sixth largest in the state, occupying a territorial area of 3,589.811 km², with a Human Development Index (HDI) of 0.77030.
In the larger study, a sample calculation was made considering a maximum prevalence of 50% for DM in an infinite population, with a 95% confidence interval (95% CI), totaling 384 individuals. For this study, a sample of 10 to 20 people per item answered was considered for psychometric analysis31. The municipal management responsible for the Family Health Strategy (FHS) was contacted to obtain the lists of the hub units of the FHS teams. Therefore, a simple random drawing was conducted among the 73 municipal health units, and four were selected for the study. The managers of the selected units provided lists with the names of people with DM registered and monitored by the teams. The sample was obtained by cluster sampling. All individuals who met the inclusion criteria were previously contacted by community health agents (CHAs) from the FHS and were asked for their consent to provide their address and participate in the research. Data collection took place at the FHS units.
The inclusion criteria for this study were individuals diagnosed with DM registered at the Primary Health Care (PHC) units of the Family Health Strategy (FHS), residing in the urban area of the municipality, and aged 18 years or older. Exclusion criteria included having five or more diagnosed underlying diseases, being bedridden, using a wheelchair and/or other assistive walking devices, having a native language other than Portuguese, and being under the influence of alcohol or other drugs at the time of the interview. It is important to note that the cognitive performance of the elderly was assessed using the Mini-Mental State Examination (MMSE)32. The data were collected by duly trained undergraduate and graduate students.
The sociodemographic questionnaire contained the following variables: age, education (in years of study); sex (female, male); skin color (white, yellow, black, brown, indigenous, no declaration); and marital status (married, single, widowed, common-law marriage). A semi-quantitative food frequency questionnaire (FFQ) was applied, containing data on the consumption of 83 food items, with their respective frequencies (more than three times a day, two to three times a day, once a day, five to six times a week, two to four times a week, once a week, one to three times a week, never or almost never, seasonal consumption) and household measures, considering the methodology proposed in the Longitudinal Study of Adult Health (ELSA)33. The assessment of food consumption was carried out considering the system proposed by Monteiro in 20104-6, whose classification of foods was based on the degree and extent of processing (raw, processed, ultra-processed). Two tables were used: the Brazilian Food Composition Table34 and the food composition table from the Household Budget Survey (Pesquisa de Orçamento Familiar – POF) presented in 2008-200935. Subsequently, the energy consumption of UPFs was estimated. The consumption of macro and micronutrients and the energy value of these nutrients were calculated by converting the frequency of meals and consumption according to household measures of 100g of each food item. Thus, the total energy values were estimated by adding up the calories of the macronutrients (carbohydrates, proteins, and lipids). Subsequently, the energy group was created by adding up the calories of the foods in each group (raw, processed, and ultra-processed), while the percentage of intake was calculated by multiplying by 100 and dividing by the total calories36.
Social satisfaction was estimated using the SSS, which consists of 15 items distributed across four dimensions: five items estimate Satisfaction with Friendships (Satisfação com Amizades – SA); four items, Satisfaction with Intimacy (SI); three items, Satisfaction with Family (SF); and three items, Social Activities (SAs). The items of the instrument formed the latent variable referring to the SSS construct22.
Empowerment was estimated using the Portuguese version of the DES-SF empowerment scale28 since the Brazilian version had not yet been made available during the data collection period29.
FL was assessed using the Food Literacy Scale (FLS) among people diagnosed with Diabetes (FL-D). This scale consists of three dimensions: Access (four items); Comprehension/Evaluation (eight items); and Application or practice related to information (five items).
The data were tabulated and exported to the SPSS computer program37. After this procedure, they were exported to the JASP38 program. Descriptive statistics were calculated in order to arrange, synthesize, and present the data using tables with means (measure of central tendency) and standard deviation (measures of dispersion) for continuous data, along with frequencies and percentages for categorical and ordinal data39.
The following measures were considered for the adequacy of the model fit: Chi-square (X2), Degrees of freedom (df), Chi-square per degree of freedom (X2/df), Comparative Fit Index (CFI) > 0.80, Tucker-Lewis Index (TLI) < 0.80, and Root Mean Square Error of Approximation (RMSEA) 0.08, with a 95% CI <0.0640.41.
Subsequently, to perform the path analysis, the Structural Equation Modeling (SEM) technique was used. This technique was performed in two stages: the first was the measurement model, which related observed variables to latent variables using Confirmatory Factor Analysis (CFA), and the second was the structural model, which related the latent variables to each other and the latent variables to the observed variables.
The SEM aimed to verify the effect of the latent variable SSS on FL-D, as well as from FL-D on empowerment among people diagnosed with DM and the effect of these latent variables on the observed variable of consumption in kilocalories of UPFs. In SEM, latent variables are expressed by ellipses, while observed or measured variables are expressed by rectangles. It analyzes the total effect of the variables, dividing it into direct effect (direct relationship between two variables) and indirect effect (mediation by another variable), represented by directional arrows, which may be bidirectional arrows. This analysis contributes to a better understanding of the relationships between the variables under analysis. Convergent validity was assessed by the factor loading size, which should be >0.40 for samples with 200 people; the internal covariance of construct error was also considered31.
Figure 1

The first step in these analyses was to perform Bartlett\'s sphericity test (which must be significant, p<0.05) and the Kaiser-Meyer-Otkin (KMO) test.
After this procedure, the analysis was performed using the Diagonally Weighted Least Squares (DWLS) estimation method, which is the appropriate estimator for ordinal and nominal categorical data.
All research participants signed the Informed Consent Form. The project was approved by the Research Ethics Committee of the State University of Montes Claros/Unimontes logged under opinion 4.777.302, CAAE: 34687414.0.0000.5146.

Results
The original project included 340 people. However, for this study, data from those who had responded to the questionnaires on the constructs analyzed in that research project were used, totaling a sample of 240, a sufficient number to conduct an exploratory study on the topic. The average age was 62.25 ± 12.11 years, and the average family income was R$ 2,302.31 ± R$ 1,914.27. The majority of the participants were female (68.10%). Almost half reported having brown skin (45.60%) and having a stable partner (54.90%). The average educational levl was 7.74 ± 4.54 years of study. The average consumption of UPFs, in kcal, was 916.47 ± 900.31. Bartlett\'s test of sphericity proved adequate (p < 0.01) for both the FL-D construct and path analysis, and the fit indices demonstrated the plausibility of the model (Table 1).
Table 1

Regarding the construction of the FL-D scale, factor loadings >0.51 were observed in both the observed variables in each dimension and the FL construct with the SSS and empowerment constructs. The same occurred with the other latent variables "Evaluates" and "Practices"
Figure 2 shows the path diagram, with the factor loadings and residuals of the measure according to SEM. When analyzing the diagram, it is evident that SSS generally has high factor loadings (>0.60), both in the observed variables in each dimension and in the latent variables of each dimension with the construct.
Figure 2

The same phenomenon occurred in the factor loadings of the FL-D scores with the latent variable and with the observed variables of empowerment with its latent construct. Moderate and strong factor loadings were also observed between the SSS and FL constructs among people living with DM, as well as between FL and empowerment.
However, the model showed factor loadings <0.20 between the latent constructs and the observed variable kilocalorie consumption in UPFs, indicating that, although the overall model is plausible, the impact of SSS, FL-D, and empowerment on UPF consumption was low.
When analyzing the constructs of LA, empowerment, and social support, ideal factor loading values were observed for most items.

Discussion
This study showed that most participants were elderly people. In fact, population aging is a global trend, and the lack of nutritional knowledge and the influence of food culture and lifestyle habits still lead many elderly people to maintain unhealthy eating patterns. In this light, the need for the prevention and control of diseases associated with diet, such as DM45, is evident.
When analyzing the constructs of FL, empowerment, and SSS, ideal values were observed in most items, since for a sample of 200 individuals a factor loading ≥0.40 is considered adequate31.
Regarding the construction of the FL-D scale, a significant association was observed between the latent variable "access" and FL-D, with high factor loadings (>0.60) both in the variables observed in each dimension and in the latent variables of each dimension with the construct. The same occurred with the other latent variables "Evaluates" and "Practices".
High levels of LS were significantly associated with better knowledge concerning DM (n = 20, r = 0.308, p < 0.001, I 2 = 85%). Access to information about DM care is important, as it implies being aware of risk factors to minimize disease control, understanding it and knowing how the body works, as well as being able to identify symptoms and know-how to act appropriately to control DM46.
Regarding item 11 of the FL-D: Did you understand the information you have already received about nutrition? This refers to the understanding of a wide range of information provided to the patient, such as consent forms and educational materials, which is based on a complex process involving the effective interaction of logic, language, and experience13. When dealing with a patient with DM, this information must be quite clear, since many people cannot discern the meaning of the terms "light" and "diet".
When it comes to item 12 of the same instrument: Can you evaluate the advantages and disadvantages of different dietary treatments, considering the information you have already received? This item refers to the person\'s ability to assess the advantages of consuming or not consuming certain foods, and in this context, an essential aspect is the ability to read food labels. In several countries around the world, food labeling with nutritional information has become a mandatory measure. This initiative aims to increase public awareness of the impact of nutrition on health, especially with regard to the prevention of NCDs such as DM. As a result, consumers are increasingly attentive to food selection and the search for information about its nutritional values, seeking to make more aware and healthier choices47.
Path analysis revealed an inverse, negative relationship between SSS and the consumption of UPFs, as this model represented a negative value of 5%, showing that as SSS decreases, the consumption of UPFs increases.
However, this relationship becomes positive when satisfaction with social support passes through the latent variable FL, representing 10% of the explanation, that is, satisfaction with social support has an effect on the consumption of UPFs, but this effect is indirect, mediated by FL.
Regarding the positive association between FL and the consumption of UPFs, indicating that the higher the FL, the greater the consumption of this type of food, we can observe that HL or FL by itself is not necessarily a promoter of positive changes in an individual\'s eating behavior, as a person may have good HL but not feel empowered to use this knowledge autonomously and assertively in practical situations. This is observed in the present when empowerment is associated with positive changes in the consumption of UPFs, which indicated that the greater the empowerment, the lower the consumption of UPFs. Other studies that verified the impact of HL, aimed at the empowerment of patients, have indeed contributed to improving the self-efficacy, self-management, and self-care of patients with schizophrenia48,49, diabetes50, and various chronic diseases51.
This finding explains the importance of HL by showing that FL, an individual factor, can mediate the relationship between SSS, a social factor, and the consumption of UPFs. Thus, SSS alone was a protective factor against the consumption of UPFs. However, the study showed that the protective effect of SSS was limited to people with empowerment resulting from FL.
FL is the ability to understand and use information about food to make healthy decisions. People with high FL are more likely to understand the benefits of a healthy diet, identify UPFs, and make more appropriate food choices15. However, empowerment resulting from FL is necessary to minimize the consumption of UPFs.
In the context of this study, SSS can be understood as the perception that one receives support from other people to make healthy food choices. This support can be offered by family, friends, health professionals, or other social groups. If empowered, people with FL are better able to understand and use the social support they receive to make healthy food choices. Furthermore, having a support network and feeling satisfied with the support received from healthcare professionals and family members have consistently been shown to be protective factors against distress caused by DM. Elevated levels of glycated hemoglobin, poorer health outcomes, and inadequate self-care behaviors are associated with a higher level of distress caused by the disease23.
Regarding the empowerment scale, an inverse relationship was also observed between the latent variables of empowerment and caloric consumption of UPFs. Empowerment transcends intervention, technique, or strategy; it is a perspective that aims to enable people to transform their behaviors and make choices that are favorable to their health52.
The core purpose of empowerment is to equip the patient with critical thinking skills, enabling autonomous and informed decision-making. Empowerment also helps and encourages people to reflect on their experience in dealing with DM52.
However, when it comes to food, it is important to emphasize that behaviors involving food choices are mediated by several factors that go beyond empowerment, including the feeling of pleasure caused by the ingestion of these products, the influence of commercial entities, as well as socioeconomic factors.
A systematic review encompassing 281 studies from 36 different countries concluded that the pooled global prevalence of food addiction, as measured by the Yale Food Addiction Scale, was 14% in adults and 12% in children53.
Given the above, it was possible to observe that FL is an important strategy to minimize the caloric consumption of UPFs in people living with DM, and it can be promoted through educational and health actions. Research with longitudinal designs to investigate the relationship between empowerment, social support, and UPF consumption may elucidate the observed associations more precisely.
It was also noted that FL in people living with DM is important to minimize the caloric consumption of UPFs, especially when associated with a synergistic effect of SSS.
Thus, the results of this study can provide support for new research related to the topic, in addition to generating knowledge for the development of health policies.

Acknowledgements
The authors wish to thank the National Council for Scientific and Technological Development (CNPq), the Minas Gerais State Research Support Foundation (FAPEMIG), and the Coordination for the Improvement of Higher Education Personnel (CAPES).


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