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Roma mental health: an integrative literature review

Abstract
Background: Roma peoples are considered socioeconomically vulnerable and exposed to historical processes of exclusion and violence, which are still present today. Mental health is an essential component of health, a fundamental human right, and central to the correlations of analyses on poverty, ethnic and racial discrimination, and inequalities. With this integrative review we sought to conceive a state of the art regarding the mental health of the Roma. Method: Our search followed the PRISMA guidelines and was conducted in 6 databases (BVS, ProQuest, PsycInfo, PubMed, Scopus, and Web of Science); 27 articles made the final sample. Seven categories of analysis were constructed: mental disorders, suicide, childhood and adolescence, psychological aspects, risk and protective factors, gender, and mental health promotion. Results: The studies pointed to several situations of vulnerabilities in the experience of Roma peoples regarding mental health. We highlight the exclusionary role of majority supremacist societies in relegating Roma communities to marginalization and invisibility, expressed, for example, through the low scientific production regarding these communities, especially in Latin-American contexts.

Keywords: Romani, gipsies, mental health in ethnic groups

Introduction
An estimated 14 million Roma live in the world, most of them on the European and American continents1. The term gypsy is considered generic and was invented in Europe between the 14th and 15th centuries, when these people arrived in successive migratory waves, probably from India2. The history of these peoples is characterized by the presence of migratory processes and expulsion policies characterized as nomadism3, persecution, slavery, and genocide1. Still today the Roma are socioeconomically vulnerable and often suffer blatant episodes of racism and intolerance4,5.
When we mention Roma peoples, we refer to different groups and cultures, which are reflected in a diversity of terminology. There are terms of external origin, like cigano, tsigan, and zigeneur, which derive from the Greek word atsingani (untouchable) and also terms such as gitano and gypsy derived from Egyptian because Europeans believed that these new arrivals in Europe, from the 10th century onwards, had Egyptian origins1. It is not known exactly how they defined themselves at that time, but it is well-known that some groups self-identified with the externally assigned terms, recognizing themselves even today as, for example, gypsies1.
Considering that names of external origin are often laden with stereotypes, European activist movements and organizations like the United Nations (UN) have proposed replacing the term gypsy with the terms Rom, Roma, or Romani, considering these terms the politically appropriate variants3,6,7. Thus, a diversity of peoples such as the Sinti in Central Europe, the Calon in Spain, Portugal, and Brazil, the Manush in France, and the Travellers in Ireland were included under the umbrella term Roma8. According to the Romani language of the Rom groups, Roma means "people of Romani origin" and names the language of these peoples, including subgroups like the Kalderash, the Matchuaia, the Lovara, and the Curara3.
Regarding the Traveller community, although they are often included in terms considered broader, such as Gypsy and Roma, there may be disagreements about this inclusion because Travellers are not genetically considered to have Indian origin4. Despite this, Travellers are often related to Roma and Gypsies in public policies due to similarities, like a past marked by nomadism, rejection, discrimination, internment, and persecution that led to what is known as the Roma Holocaust, responsible for the deaths of around 500,000 ethnic Roma and Travellers4. Like Roma communities, Travellers are also considered an ethnic minority group who suffer discrimination and lack access to basic rights, including health and housing9.
In relation to the diversity of terms referring to Roma peoples, we chose the term "Gypsy" in the Brazilian version of this article following the decision of researchers who, from a decolonial lens, are attentive to the ways in which people name themselves1,3. In this sense, the current attempt to resolve terminological issues and avoid terms of pejorative origin, such as Gypsy, by using the term Roma, may generate another impasse, which is the use of a term little recognized by the communities themselves, especially those who do not belong to the Roma trunk. Faced with this impasse, the choice of the term Gypsy, in its generic and widely recognized character, was considered preferable. At the same time, mindful of the decisions of European activist movements and relevant organizations such as the UN, we have opted to use the word "Roma" in the English-language version of this article.
Decisions regarding naming are not solely about changing terms. The classifications and identity differentiations of Roma peoples (i.e., the power to name) have historically rested with intellectuals and specialists linked to the standard and educated norm and hegemonic Western science, reflecting a stereotyped social imaginary or a form of self-naming. Stereotyped representation or even complete invisibility are strategies of social exclusion and can greatly affect self-esteem and pride in being Roma, as well as one\'s own ways of naming oneself.
The World Health Organization (WHO) has framed mental health as an essential component of health and a fundamental human right often neglected, even though it is considered a focus of analyses of ethnic and racial discrimination, poverty, violence, and stigmatization, among others, contributing to worsening socioeconomic vulnerabilities and health circumstances10. Some mental health conditions related to socioeconomic inequalities are depression, anxiety, substance use, and suicidal behavior10.
Review studies on the general health of Roma peoples have concluded that there is a lack of research, cultural competence, and visibility on the health needs of these communities. Also reported have been lower life expectancy, higher disease burden, and worse health conditions due to socio-economic disadvantages, inadequate housing, and poor access to health services3,8,11,12.
Considering that Roma peoples are highly diverse in terms of identity and cultural and socio-economic aspects and yet share similarities in relation to historical processes, racialization, discrimination, and socio-economic vulnerability impacting mental health, we aimed to present the state of the art on the mental health of Roma peoples through the following integrative literature review. We asked: a) What scientific knowledge has been produced on the mental health of Roma peoples and which are the determining factors ? b) Are there any studies on suicidal behavior among these peoples? c) What has been produced on the mental health of Roma children and adolescents? d) What mental health interventions have been aimed at Roma peoples?

Method
This integrative review followed the PRISMA (Principal Reporting Items for Systematic Reviews and Meta-Analyses) guidelines13 and the recommendations of Mendes, Campos, and Galvão14. Thus, after choosing our research questions, study objectives, and the descriptors and/or keywords to be used, we searched the following databases14: BVS, ProQuest, PsycInfo, PubMed, Scopus, and Web of Science. The search was carried out on November 14, 2022. Table 1 summarizes the descriptors used and the number of documents found in each database.
Table 1

After the first database searches, when we saw the low number of articles found, we decided not to apply a temporal or territorial filter and then limited the age of the sample or the research method to increase the possibilities of including articles relevant to the research topic. As recommended by past authors14, the inclusion criteria were a) articles investigating issues relevant to the mental health of Roma peoples; b) full text available; and c) peer-reviewed articles. The exclusion criteria were a) articles not referring to the mental health of Roma peoples; and b) articles in languages other than English, Portuguese, Spanish, or French. After collecting the documents, we decided to include articles published from 2012 onwards (i.e., published in the last 10 years) in order to obtain a privileged analysis of the most recent scientific productions.
The articles found were extracted using the Zotero reference management software. A total of 356 articles were found. After excluding duplicates, 198 documents remained. To perform the double-blind analysis, the first and last authors analyzed the titles and abstracts using the Rayyan program. Conflicts and indecisions occurred about whether the included samples were composed of Roma people and whether the studies included assessments related to mental health. In such cases, the full text was read to avoid the exclusion of articles potentially relevant. At this stage, 146 articles were excluded and 52 were selected for full-text reading. After full reading, 27 articles were selected (see Figure 1, illustrating the PRISMA diagram).
Based on the research questions guiding this integrative review, the following categories of analysis14 were constructed: 1) mental disorders, 2) suicide, 3) childhood and adolescence, 4) psychological aspects related to the Roma identity, 5) risk and protective factors, 6) gender issues, and 7) promotion of mental health. Each study was then critically analyzed, the results interpreted, and a synthesis of produced knowledge was prepared14.
Figure 1

Results
All 27 articles included in this review were based on studies on the European continent. The studies mainly occurred in Ireland (n = 10) and the United Kingdom (n = 4), followed by Albania, Germany, Belarus, Bosnia and Herzegovina, Bulgaria, Slovakia, Slovenia, Spain, France, Greece, Hungary, Macedonia, Portugal, Czech Republic, Romania, Serbia, Sweden, Turkey, and Ukraine. Table 2 summarizes the main characteristics of the articles analyzed.
Table 2

In Table 3, we can see the terms used in the articles to designate the Roma people participating in the studies. The term Roma was widely used, followed by the term Traveller. The term Gypsy was used less frequently in this sample of articles.
Table 3

Mental disorders
Five quantitative studies that investigated mental disorders in adult Travellers and Roma peoples were identified. Of these studies, 4 described comparative analyses with groups considered to be in the majority, and 3 found a higher occurrence of mental disorders or their dimensions in Travellers15,16 and Roma17. One study found a greater severity of mental disorders in a sample of non-Roma unemployed people compared to Roma unemployed people, and among both non-Roma and Roma people in this sample of unemployment insurance recipients, higher severity rates were found compared to a control group18.
In Millan\'s19 qualitative study about accommodation, health, and well-being, Gypsies and Travellers had concerns related to suicide and mental health, especially depression and anxiety. In Keogh\'s20 qualitative study, the reasons for seeking mental health services among travelers were depression, anxiety, stress, panic, suicidal behavior, and/or suicide bereavement. Villani\'s21 work on the perception of Irish Travellers in relation to the concept of ‘mental health’ found that the Travellers tended to perceive mental health as equivalent to "depression" or "mental health problems," which was understood as a lack of awareness of the positive dimension of mental health. When the concept of ‘quality mental health’ was properly described, participants associated it with having good social connections and community support and being able to carry out routine activities.
Suicide
Four studies on suicidal behavior were identified. All 4 studies were carried out in Ireland, with one also conducted in the United Kingdom. One of them developed a theoretical argument regarding the impact of anomie and division at the social level on the self-identity of Travellers as factors related to the increase in suicide rates in this community22. Malone\'s23 qualitative study reported on a collaborative research project involving art and science as a way to contribute to raising awareness about suicide and its stigma in a highly marginalized Traveller community who were difficult to reach by mental health programs and who had high suicide rates.
In the quantitative study conducted by Tanner16, based on hospital admission data for suicide in a region of Ireland, it was found that of the total number of suicide admissions, 14.8% were Travellers, showing this a high percentage compared to census data on the Traveller community in the study region. In addition, the study pointed out that the method most used by Travellers, especially men, was hanging. McKey\'s24 research was a rapid literature review with the aim of investigating the literature on mental health and suicide among Irish Travellers and Gypsy Travellers. Only 24 articles were found on the mental health of this community in the last 20 years, with only 5 studies focusing on suicide. In addition, the topic of suicide appeared in interviews with Romany Gypsies and Travellers who reported the following suicide risks: imprisonment, moving into conventional accommodation for the first time, and precarious employment19.
Childhood and adolescence
A total of 7 studies focused on Roma childhood and adolescence. Five of these articles used a quantitative method5,25-28, 1 article used mixed methods29, and 1 article reported a case study30.
Chwastek25 investigated socio-emotional problems related to academic functioning and executive function among Roma migrant children (of this sample, only 10% were born in Germany). These children showed more hyperactivity/inattention, conduct problems, peer problems, and less prosocial behavior compared to a sample of migrant children born in Germany. Also, compared to a sample of refugee children, the Roma migrant children showed more hyperactivity/attention and peer relationship problems.
In Pickett\'s27 study, compared to White British children, Irish Gypsy/Traveller children were more likely to worry all the time about family financial conditions, reported being mean to other people, had difficulties resolving difficult situations, and were less likely to say they had been bullied. Lee5 found that Roma children were more likely to experience internalizing disorders such as phobias, separation anxiety, generalized anxiety disorder, depressive disorder, emotional and peer relationship problems, and anti-social behavior.
In studies specifically including adolescents, no significant differences were found between Roma and non-Roma communities with regard to levels of subjective well-being, developmental resources (e.g., empowerment, boundaries and expectations, social competence, and positive identity), predictors of well-being, internalizing and externalizing disorders, and academic competence26,28,29. Investigating the experience of Egyptian and Roma adolescents in the first wave of COVID-19 in Albania, among the themes that emerged in focus groups, Miconi\'s29 study found difficulties in accessing resources, mental health concerns, and discriminatory experiences.
Henry\'s30 case study was an investigation of the aspects that increased vulnerability in the experience of an 11-year-old Gypsy (Gitane) child diagnosed with autism spectrum disorder and moderate intellectual disability. Some factors were framed as cultural and ethnic aspects that hindered access to care services by Gypsy people with disabilities, such as the frequent discrimination faced by Gypsy people, the experience of uprooting (i.e., the loss of references due to social changes), and the stereotyped representations of Gypsy people presented mainly in media.
Psychological aspects related to Roma identity
Some articles were included because they provided data relating to psychological aspects of the Roma experience. In a study exploring the experiences of vulnerability of Gypsies, Roma, and Travellers in the United Kingdom, 6 categories of analysis were created: 1) vulnerability due to feeling defined and homogenized; 2) feeling pressured to conform to living in a certain way; 3) feeling a split in one\'s identity; 4) feeling a loss of one\'s cultural heritage; 5) feeling discriminated against, persecuted, and threatened; and 6) the perception of powerlessness31.
In another investigation about Travellers\' access to health services, some examples of expressions used to describe feelings and thoughts were feeling under stress, being in a dark place, being "down and out," having bad thoughts, suffering from nerves, having a racing mind, having low self-esteem, having mood swings, and sleeping with difficulty20.
Risk and protective factors
In our sample or articles, risk factors were mentioned more frequently than protective factors. In interviews with Roma and Traveller communities, the following factors were identified: racism, discrimination, inadequate accommodation, unemployment, financial worries, abuse of alcohol and other drugs, rigid gender roles, loss of family members or close people to suicide, lack of social support to talk about feelings and worries, stigma and lack of awareness about mental health, problems in marriage, and poor school performance of children19,20. Protective factors mentioned by Travellers included relationships with friends, having a good relationship with the family, and having an active and structured routine in which it was possible to carry out daily tasks21.
Gender issues
We identified some issues related to the experience of cis Roma women and men regarding mental health. In the sample, there were no studies investigating mental health in LBGTQIAP+ Roma communities.
In interviews with cis Traveller women, an overload of domestic and maternal activities culminated in a lack of time for themselves20, the feeling of division between one\'s cultural identity as a Traveller Gypsy woman and what it was like to be a young woman in society in general31, and women\'s concerns about unbalanced gender roles21 were mentioned. Furthermore, in a study in the context of COVID-19, women Travellers were particularly affected; the women described frustration and worries related to daily challenges during lockdowns32.
Kozubik\'s33 study investigated domestic violence and its consequences for Roma women. Consequences included anxiety and depression, a lack of information on the part of these women about specialized services, and difficulties in accessing these services.
Regarding the experience of cis Roma men, men mentioned difficulties in accessing mental health services23 and effects of a “sexist culture” that was widespread in the Traveller community21, which could create perceived pressure to always be strong and the impossibility of talking about feelings and mental health20.
Mental health promotion
Among possible disorder prevention and mental health promotion strategies aimed at Roma peoples, we identified a nursing linkage project34, an artistic-scientific collaborative project23, and an employability and vocational training program in health mediation35. Based on O\'Sullivan’s34 research on a nursing liaison project to promote Travellers\' mental health in Ireland (TMHLN), we identified some elements that may be relevant to other mental health promotion projects. For example, considering the historically fragile relationships between Traveller communities and majority communities, the team spent time building relationships of trust, a process considered “ongoing.” Cultural competence on the part of the professionals regarding Travellers\' mental health was considered relevant to the implementation of the project. Some actions were designed to avoid stigma associated with mental health and its services, such as the adoption of the term ‘wellness nurse,’ which highlighted a positive aspect of mental health and the development of activities in a community center rather than a classic health center.
Regarding the artistic-scientific collaborative project, once again importance was attributed to the time factor in building mental health interventions with Traveller communities. Malone\'s study23 concluded that such communities can be reached through projects which are developed slowly (e.g., including time dedicated to building relationships of trust with the community). The study highlighted the importance of participants being at the center of projects and co-authors of interventions as ways of building collaborative processes.
Katona35 presented an employability and vocational training program in health mediation for a Roma community in which Roma mediators played an equal role in the primary health care team. Following these mediators over 5 years, a significant improvement was found in the mental health of the mediators who completed vocational training. Employing health mediators in primary health care was concluded to contribute not only to facilitating access to care for vulnerable groups but also to improving the mental health of the mediators themselves who are part of vulnerable groups, as in the case of Roma communities.

Discussion
With this review we aimed to identify the state of the art on Roma mental health. Despite the breadth of the search mechanisms, only 27 relevant articles were found. All the studies were produced on the European continent. In addition, a considerable proportion of studies was developed in Ireland with Traveller communities—groups considered to be of minority status that have historical and socio-economic similarities with the Roma peoples4—which justified the inclusion of this group in this review. Therefore, considering the diversity of Roma communities, there appeared to be a low and restricted production of knowledge on mental health, which is in line with reviews on health in general in these communities8,11,12.
Among the few comparative studies found that considered the presence of mental disorders, we identified 3 that supported the hypothesis that Roma people are more vulnerable in terms of mental health when compared to majority populations15-17. This hypothesis related to the conditions of exclusion and violence imposed by majority populations on Roma peoples throughout history. Thus, mental health suffering can be seen as a marker of a cycle of vulnerability and poverty, violation of basic human rights, and processes of social inequality10.
Some studies contributed to an understanding of mental health from the point of view of the Roma themselves20,21,31. In Villani\'s21 research, positive mental health was associated with being able to rely on a support network and fulfill daily tasks. Such research appeared relevant, especially considering that much of what we know about mental health was drawn from majority populations in Western contexts and tended to focus on individuals’ intrapsychic experiences instead of processes influenced, for example, by community and family issues36.
The development of future studies investigating mental health concepts from the perspective of Roma peoples would enable the possibility of building mental health promotion connected with needs and meanings relevant to these communities, and these would represent culturally competent studies. In this sense, mental health actions can be broad and based on new perspectives, as Katona\'s35 study indicated, in which the path to mental health promotion involves employability in conjunction with vocational training. The intervention presented was in the combined field of health and education, two basic rights relevant to mental health historically denied to Roma peoples.
Considering the articles on suicide, we saw that the production was scarce beyond a few studies in Ireland and the United Kingdom, and a quick review of the literature showed that, even in these regions, there was little scientific production24. Research developed in Ireland has found suicide rates to be high in the Traveller community16,23. The All-Ireland Traveller Health Study (AITHS) found that 11% of deaths in Traveller communities were related to suicide, and suicide among Travellers was found to be 6.6 times more frequent than in the majority population23.
Among the risk factors for suicide reported in Irish Traveller communities were social segregation, ineffective social policies, socio-economic vulnerability, lack of a sense of belonging to both the Traveller culture and the majority culture, identity difficulties, loss of customs and traditions, and a lack of purpose in life22. Stigma in relation to mental health was highlighted as a factor that inhibited Roma from seeking services23,34. According to the AITHS team, racism and a lack of cultural competence within mental health services amplified the stigma related to seeking mental health services, thus increasing the risk of suicide22.
Considering the similarities in historical and social processes experienced by Travellers and other Roma communities, there is a possibility that similar risk factors are also present in communities in other countries inside and outside Europe. Suicide is a tragic outcome from a complex web of risk factors undergirded by psychological suffering37. Therefore, future research into this issue is extremely important to produce appropriate disorder prevention and mental health promotion activities for Roma communities in all their diversity.
Here we emphasize the need for more studies on Roma children and young people, especially considering that the youngest ages are characterized by both vulnerabilities and opportunities in terms of mental health10. Among the strategies recommended by the WHO10 to protect mental health during this period is the implementation of programs in schools, where a large number of children and adolescents can potentially be reached. However, Roma children have experienced a higher risk of school dropout due to various factors, including discrimination by peers and teachers, resulting in Roma parents perceiving school environments as threatening38-40. We thus recommend strategies that include Roma children and adolescents in schools as a way to promote mental health both because it is the preferred space for access to mental health programs and because of the potentially protective role of long-term academic success in dismantling cycles of poverty and vulnerability. ‘Inclusion’ means thinking about both access and the permanence of Roma children and adolescents in schools that do not function as environments which produce experiences of exclusion and racial violence and therefore psychological suffering.
Regarding school dropout, Roma girls have been at higher risk compared to Roma boys38-40. Concerning gender inequality, the present review identified studies indicating a tendency towards rigid gender roles in Roma communities and consequences for both Roma women and men21. In this respect, Garcia-Ramirez\'s41 study protocol challenged the usual ideas that cultural patterns are related to the rigid role of women in Roma communities. Instead, the author’s protocol pointed to a complex intersection of cultural issues and contextual mechanisms of oppression that subject Roma women and girls to violence both systematic and structural.
We also recognized the silence regarding the mental health of LBGTQIAP+ Roma communities per a lack of studies related to this issue. In a document produced by the European Roma Rights Centre (ERRC), these communities were considered to rarely receive adequate attention and were ‘invisibilized’42. The field has also lacked an intersectional analysis, and Roma and LBGTQIAP+ identities have tended to be considered as if they were incompatible and even contradictory42. According to the study conducted by Daniel Backer, the ban on recognizing oneself as, for example, gay and Romani led to losses of connection, where one aspect of identity had to be constantly denied42, which was/is probably reflected in consequences for the mental health of these community members.
One might reflect and question whether there is a premise present in societies (including academic contexts) defining Roma communities as being intrinsically LGBT-phobic, as if this was a cultural issue rather than a systematic and structural one, in a process similar to what is understood about the rigidity of ‘male’ versus ‘female’ gender roles in these communities. To wit, we might usefully claim that the rigidity of gender roles and discrimination against LBGTQIAP+ communities are not specific characteristics of certain groups and peoples, but rather cross-cutting aspects present in different ways in so-called Western and civilized cultures and in cultures considered as a minority. We suggest integrating this aspect into research that works at the intersection between race and gender issues among Roma communities.
Only one study on migratory processes was identified that specifically included a sample of Roma migrant children in Germany25. Most of the Roma families in Europe were found to have European documents that made them ineligible for the support and resources available to asylum seekers and people in situations of refuge, even though the Roma children were living in similar circumstances to refugees.
Moreover, this review drew our attention to the few works that analyzed racial discrimination and xenophobia in relation to Roma communities. Considering that this kind of violence was experienced by a large proportion of poor, working-class, black migrants43, violence in the form of persecution, hatred, and racial violence suffered by the Roma—whether migrants or citizens—is growing in Europe, especially when the violence is exacerbated by policies of extreme right-wing governments44.
Strictly speaking, we wonder how this violence influences the mental health of Roma peoples as they face challenges accessing basic needs (e.g., education, health, housing, and work45), in addition to experiencing racial and xenophobic violence. It therefore appears essential that public health policies, especially primary care services, are designed to help tackle health inequalities and discrimination suffered by these peoples46.

Conclusions
With this review, we corroborated the hypothesis that there is little scientific production on the mental health of Roma peoples, with the few eligible studies found being restricted to the European context. We noticed a relative increase in production since 2020, which may reflect a slow process of change towards achieving more “space” in socio-political and academic settings. The relative slowness of this process might reflect supremacist aspects present in hegemonic non-Roma communities, aspects which result in an unequal division of resources and limit access to basic rights relegating ‘other people’ to processes of marginalization and invisibility.
Overall, the few studies found in this review pointed to the relevance of thinking about the mental health of Roma peoples, given that processes of psychological suffering and vulnerability were noted that require complex and culturally competent interventions. We argue for the need to build culturally and methodologically sensitive scientific studies on the mental health of Roma communities.
We also emphasize the absence of studies published in Latin American contexts, especially in Brazil, despite the wide inclusion of databases (with an emphasis on the use of BVS—a database that brings together scientific work from Latin America and the Caribbean). This result seems to be in line with the health conditions and invisibility of the Roma people in Brazil. In this sense, the Brazilian study by Silva Júnior and Toyansk47 compiled advances in the construction of public policies aimed at the health of these communities. At the same time, they pointed out gaps in the implementation of these policies, with both Roma communities and health professionals unaware of them. There was a lack of data on the Roma in the e-SUS (Brazilian Unified Health System), which made it difficult to build a more accurate picture of the health of these communities, including infant mortality rates, maternal and child mortality rates, life expectancy, and information on the most prevalent diseases or health issues47.
In Brazil, in December 2018, the National Policy for Comprehensive Health Care for the Gypsy/Romani People was published (Decree No. 4.384), which advocates for the development of specific health actions in the light of disadvantages resulting from the experience of discrimination and social exclusion suffered by Roma peoples. Mental disorders and the abuse of alcohol and other drugs, with the need to produce information on health determinants and studies on racism and the health of these peoples in both national and international contexts, are also mentioned48.
For Brazilian Roma, the results of the present literature review are limited and insufficient because they were produced exclusively on the European continent. However, we still consider our review an international contribution that might inform global communities about the mental health of Roma peoples with scientific findings. Granted, our review indicates the need to produce national knowledge in different territorial contexts and to positively influence national health policies.
Indeed, this integrative review was an initial, exploratory investigation with the aim of presenting the state of the art of scientific literature on a neglected subject based on broad questions and the inclusion of secondary studies. We did not, however, evaluate the studies’ methodological quality or meta-analyses, which was a limitation of this work that might inspire future research on this subject.

Author contributions
A. Brandão contributed to the study design, collection and analysis of data, writing, revision of the text, and approval of its final version. A. A. Silva Júnior contributed to drafting and revising the text and approving the final version. J. Balázs contributed to the study’s design, revision of the text, and approval of the final manuscript. C. B. Andrade helped with data collection and analysis, drafting and revising the text, and approving the final manuscript.

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