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1.
Acad Pediatr ; 2024 Jun 07.
Artigo em Inglês | MEDLINE | ID: mdl-38852906

RESUMO

OBJECTIVE: Evaluate the effectiveness of text messages to systematically engage parents/guardians ("caregivers") to reschedule a well-child visit (WCV) that was missed ("no-show") and attend that rescheduled WCV visits. METHODS: Patients <18 years in one of five pediatrics or family medicine clinics, in one health system in the Southeast U.S., were eligible. Patients without a rescheduled WCV after a no-show were randomized into intervention (text messages) or care-as-usual comparison, stratified by language (English/Spanish). Enrollment occurred May-July 2022. Up to three text messages were sent to caregivers one week apart via REDCap and Twilio, advising how to reschedule the missed appointment by phone or health portal. Primary outcomes were (1) rescheduling a WCV within 6 weeks of no-show and (2) completing a rescheduled WCV within 6 weeks. Risk differences (RD) and odds ratios (OR) were used to evaluate the effect of text messages. RESULTS: 720 patients were randomized and analyzed (texts: 361, comparison: 359). The proportion rescheduling WCV after text versus usual care was English: 18.85% vs. 15.02%, respectively, and Spanish: 5.94% vs. 8.14%, with overall RD +1.98% (95% CI: -1.85, 5.81) and OR 1.21 (95% CI: 0.79, 1.84; p-value 0.38). Completed WCV rates in text or usual care were English: 13.08% vs. 6.59%, and Spanish: 5.81% vs. 5.94% with texts associated with RD +2.83% (95% CI: 1.66, 4.00) and OR 1.86 (95% CI: 1.09, 3.19). CONCLUSION: Text message follow-up after a no-show WCV may positively impact attendance at WCVs rescheduled in the subsequent 6 weeks. TRIAL REGISTRATION: ClinicalTrials.gov NCT05086237.

2.
J Agromedicine ; 29(3): 499-503, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38333934

RESUMO

BACKGROUND: Limited research has examined the health implications for youth working in United States tobacco production. Agricultural labor is hazardous, yet youth are legally permitted to be hired as farmworkers. Many youth farmworkers are members of the vulnerable Latino farmworker community. In North Carolina, youth work in many agricultural crops including tobacco. METHODS: A sample of 152 Latino youth farmworkers ages 12-20 years (M = 16.7, SD = 2.0) across 19 North Carolina counties completed a cross-sectional survey and provided saliva samples in 2019. Surveys detailed personal and work characteristics. Saliva samples were analyzed for salivary cotinine and reported in geometric means (ng/ml). Bivariate associations were used to delineate the relationship between personal and work characteristics with salivary cotinine levels. RESULTS: Cotinine levels ranged from 0.05 to 313.5 ng/ml. Older age and working in tobacco were significantly associated with higher salivary cotinine levels. For every one year increase in age, there was a 31% increase in mean salivary cotinine levels (b = 1.31; 95% CI = [1.15-1.50]; p < .0001). Youth tobacco workers' (n = 15) salivary cotinine levels were 890% higher than those not working in tobacco (n = 137) (13.26, 95% CI = [5.95-29.56] ng/ml compared to 1.34, 95% CI = [1.03-1.75] ng/ml (p < .0001)). CONCLUSIONS: Latino youth tobacco workers are exposed to nicotine through their work. This exposure presents serious risk of Green Tobacco Sickness (acute nicotine poisoning) and other health concerns given the growing evidence for risk of epigenetic changes negatively affecting long-term cognitive function. Policy is urgently needed to protect this vulnerable population of adolescent workers.


Assuntos
Cotinina , Fazendeiros , Hispânico ou Latino , Saliva , Humanos , North Carolina , Cotinina/análise , Adolescente , Masculino , Saliva/química , Feminino , Adulto Jovem , Estudos Transversais , Criança , Fazendeiros/estatística & dados numéricos , Exposição Ocupacional/análise , Nicotiana/química
3.
Subst Abuse Treat Prev Policy ; 19(1): 8, 2024 01 18.
Artigo em Inglês | MEDLINE | ID: mdl-38238852

RESUMO

BACKGROUND: Opioid use remains a major public health issue, especially among young adults. Despite investment in harm reduction and supply-side strategies such as reducing overprescribing and safe medication disposal, little is known about demand-side issues, such as reasons for use and pathways to opioid use. Adolescents and young adults who struggle with opioid use disorder (OUD) are multifaceted individuals with varied individual histories, experiences, challenges, skills, relationships, and lives. METHODS: To inform the development of prevention strategies that hold promise for addressing opioid use, this study employs brief structured surveys and semi-structured in-depth interviews with 30 young adults (ages 18-29; 19 female, 23 White, 16 from Suburban areas) in recovery from OUD. For survey data, we used descriptive statistics to summarize the means and variance of retrospectively reported risk and protective factors associated with opioid use. For in-depth interview data, we used a combination of thematic analysis and codebook approaches to generate common themes and experiences shared by participants. RESULTS: Surveys revealed that the most endorsed risk factors pertained to emotions (emotional neglect and emotional abuse) followed by sexual abuse, physical abuse, and physical neglect. Themes generated from qualitative analyses reveal challenging experiences during adolescence, such as unaddressed mental health, social, and emotional needs, which were often reported as reasons for opioid initiation and use. Through surveys and interviews, we also identified positive assets, such as skills and social relationships that were present for many participants during adolescence. CONCLUSION: Implications include the need for universal prevention strategies that include emotion-focused interventions and supports alongside current harm reduction and environmental strategies to regulate prescriptions; the potential utility of more emotion-focused items being included on screening tools; and more voices of young people in recovery.


Assuntos
Analgésicos Opioides , Transtornos Relacionados ao Uso de Opioides , Adolescente , Humanos , Adulto Jovem , Feminino , Analgésicos Opioides/uso terapêutico , Estudos Retrospectivos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Saúde Mental , Fatores de Risco
4.
Environ Justice ; 16(6): 432-439, 2023 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-38074854

RESUMO

Background: Latinx child farmworkers, like all vulnerable youth living in rural communities, experience substantial environmental exposures. Eliminating these exposures and improving environmental justice will benefit from the involvement of these child farmworkers. The aims of this article are to document the environmental self-efficacy of Latinx child farmworkers and to delineate the factors associated with environmental self-efficacy. Methods: A total of 169 North Carolina Latinx child farmworkers completed an interviewer-administered questionnaire in 2018 or 2019 that included the 5-point Self-Efficacy for Environmental Action Scale. Results: Self-efficacy for environmental action was strong among the participants, with a mean score of 3.83 (standard deviation 0.48). Girls had a higher mean score than boys (3.95 vs. 3.77; p = 0.01); each year of educational attainment was associated with a 0.05 score increase (p = 0.03). Discussion: These results indicate that Latinx child farmworker have a strong sense of environmental self-efficacy. Organizations supporting the development of Latinx youth should incorporate issues of environmental justice into their programs.

5.
Prog Community Health Partnersh ; 17(2): 217-225, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-37462550

RESUMO

BACKGROUND: Community-based participatory research (CBPR) facilitates vulnerable communities and scientists collaborating to address pertinent health issues. For Latinx farmworkers, the employment of children and their resulting morbidity and mortality in the hazardous farm environment is a concern. Communicating child farmworker research results to farmworkers and service providers must take into account their language, literacy, and educational characteristics. OBJECTIVES: We describe the collaborative development and dissemination of research findings on child farmworkers by a CBPR partnership with the Latinx farmworker community. METHODS: Key points for communication with infographics were abstracted from peer-reviewed research papers. An iterative process sought community partners' input as the research partners developed the infographics. LESSONS LEARNED: We developed infographics on heat-related illness, education, and musculoskeletal impacts of child labor, guided by published criteria for effective infographics. Efforts to disseminate finished infographics needed greater rigor. CONCLUSIONS: Infographics provide a means to communicate CBPR findings to community members.


Assuntos
Pesquisa Participativa Baseada na Comunidade , Fazendeiros , Criança , Humanos , Pesquisa Participativa Baseada na Comunidade/métodos , Visualização de Dados , Comunicação , Hispânico ou Latino
6.
Front Psychol ; 14: 1188041, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-37496798

RESUMO

Video Review (VR) is a well established educational tool for developing the practice of patient-centered care in family medicine residents. There are a number of behaviorally-based checklists that can be use in both live observation as well as VR of clinical encounters to identify and promote behaviors associated with patient-centered care, most of which also overlap with behaviors associated with Emotional Intelligence (EI). We propose a VR that is structured less on a seek-and-find of clinician behaviors and more as a self-reflective exercise of how the clinician presents in the room alongside how they were feeling during that encounter. We believe that this exercise promotes the first two skills of EI (self-awareness and self-management) and then provides a foundation on which to build the second pair of skills (social awareness and relationship management). This perspective paper offers guidance, including stepwise instruction, on how to facilitate such a VR curriculum.

8.
Fam Syst Health ; 41(2): 207-213, 2023 06.
Artigo em Inglês | MEDLINE | ID: mdl-36227305

RESUMO

INTRODUCTION: Benefits of behavioral health (BH) integrated care (IC) in pediatric primary care have been demonstrated (Asarnow et al., 2015). Pediatric subspecialty care treats patients with high levels of medical and psychosocial vulnerability and complexity (Samsel et al., 2017), underscoring the need for increased IC. Medical provider satisfaction (MPS) with IC is highly relevant for the utilization and expansion of these services. The purpose of this preliminary study was to examine MPS related to BH IC services in a pediatric gastroenterology clinic. METHOD: Eight pediatric gastroenterology providers working in an outpatient clinic completed a 32-item survey (adapted from Corso et al., 2016) assessing their satisfaction with integrated BH care services. Descriptive statistics were utilized to examine and summarize provider satisfaction data. RESULTS: Pediatric gastroenterology medical providers reported high levels of satisfaction with existing IC services and a preference for embedded versus colocated IC. They perceived provider-related and clinical benefits of IC, felt that addressing BH issues is important, and believed IC is a valued service. Medical providers expressed that they wanted expanded IC services, including an embedded psychologist at more locations, BH screenings for younger patients, and an electronic psychosocial screening process. DISCUSSION: The results of this study align with research findings regarding high medical provider satisfaction with IC in primary care and a preference for embedded BH services (Asarnow et al., 2015). While this preliminary study is small in scale, it is an important initial step to better understand MPS with IC in pediatric subspecialty care. (PsycInfo Database Record (c) 2023 APA, all rights reserved).


Assuntos
Prestação Integrada de Cuidados de Saúde , Gastroenterologia , Humanos , Criança , Atenção Primária à Saúde , Instituições de Assistência Ambulatorial , Satisfação Pessoal
10.
Front Psychol ; 13: 840881, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35572230

RESUMO

Community volunteering is an under-utilized, at least under-researched, strategy to supplement existing treatment for affective disorders. We present findings from a feasibility study incorporating community volunteering into clinical treatment for depression and anxiety among adolescents and young adults. This exploratory pilot study had four aims: to investigate recruitment feasibility; to describe participants' experiences with volunteering; to explore psychosocial assets by which volunteering might decrease depressive and anxiety symptoms; and to document preliminary changes in mental health outcomes before and after the volunteering intervention. Interviews and surveys were employed with participants (N = 9; ages 14-20, Mage = 16 years old; eight women and one man) newly diagnosed with: mild to moderate depression (single episode), mild to moderate anxiety, or adjustment disorder. Recruitment was feasible overall, successes and challenges are discussed. Experiences with volunteering were very positive. Qualitative findings revealed perceived positive effects of volunteering on mood and well-being such as helping with social anxiety and being a positive distraction. Qualitative findings revealed several psychosocial assets that improved related to volunteering (e.g., sense of purpose/meaning and sense of community). On average, participants reported a 19% decrease in depressive symptoms from the pre-survey (before volunteering) to the post-survey (after volunteering). Although more research is warranted, the implication of this study for practicing psychologists treating adolescents and young adults for mild to moderate depression and/or anxiety is that they may wish to consider incorporating community volunteer activities into treatment. Volunteering was a desirable activity for interested participants in treatment for affective disorders.

11.
J Occup Environ Med ; 63(12): e838-e845, 2021 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-34860206

RESUMO

OBJECTIVE: Physical demands of work performed by Latinx hired child farmworkers are poorly understood. This paper describes crops, tasks performed, and the most common dimensions of physical demands of work in this population. METHODS: Survey interviews were conducted in 2017 with 202 Latinx children aged 10 to 17 years employed on North Carolina farms. Analysis focused on job characteristics for the past week and included factor analysis of an 18-item questionnaire on physical work demands. RESULTS: The most common crops and tasks reported were topping/suckering tobacco and picking sweet potatoes or berries. Three factors (awkward postures, repetitive motion, strenuous work) accounted for 53% of the variance in physical demands. CONCLUSIONS: Follow-up of hired child farmworkers should be undertaken to understand the long-term effects of physical work demands on their health.


Assuntos
Agricultura , Fazendeiros , Adolescente , Criança , Família , Hispânico ou Latino , Humanos , North Carolina/epidemiologia , Autorrelato
12.
Front Psychol ; 12: 642910, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34025511

RESUMO

Volunteering, or taking part in unpaid work for the benefit of others, can be a powerful positive experience with returns to both individual well-being and community projects. Volunteering is positively associated with mental health in observational studies with community samples but has not been systematically examined as a potential part of treatment interventions with clinical adolescent samples. In this manuscript, we review the empirical evidence base connecting volunteerism to mental health and well-being, outline potential mechanisms based in the theoretical literature from developmental science, and discuss the existing clinical approaches that support community volunteering as a part of treatment. Drawing on this review, we propose that including volunteering as a component of clinical treatment approaches for adolescent depression can be a powerful intervention for adolescents.

13.
Am J Ind Med ; 64(7): 602-619, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34036619

RESUMO

BACKGROUND: Although pesticides have adverse effects on child health and development, little research has examined pesticide exposure among child farmworkers. This analysis addresses two specific aims: (1) describes pesticide exposure among Latinx child farmworkers in North Carolina, and (2) delineates factors associated with this pesticide exposure. METHODS: In 2018 (n = 173) and 2019 (n = 156) Latinx child farmworkers completed interviews and wore silicone wristbands for a single day to measure pesticide exposure. Wristbands were analyzed for 70 pesticides. RESULTS: Most Latinx child farmworkers were exposed to multiple pesticides; the most frequent were pyrethroids (69.9% in 2018, 67.9% in 2019), organochlorines (51.4% in 2018, 55.1% in 2019), and organophosphates (51.4% in 2018, 34.0% in 2019). Children were exposed to a mean of 2.15 pesticide classes in 2018 and 1.91 in 2019, and to a mean of 4.06 pesticides in 2018 and 3.34 in 2019. Younger children (≤15 years) had more detections than older children; children not currently engaged in farm work had more detections than children currently engaged in farm work. Migrant child farmworkers had more detections than nonmigrants. For specific pesticides with at least 20 detections, detections and concentrations were generally greater among children not currently engaged in farm work than children currently engaged. CONCLUSIONS: Children who live in farmworker communities are exposed to a plethora of pesticides. Although further research is needed to document the extent of pesticide exposure and its health consequences, sufficient information is available to inform the policy needed to eliminate this pesticide exposure in agricultural communities.


Assuntos
Exposição Ocupacional , Praguicidas , Adolescente , Agricultura , Criança , Fazendeiros , Humanos , North Carolina/epidemiologia , Exposição Ocupacional/análise , Praguicidas/análise
14.
Am J Ind Med ; 64(7): 620-628, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34002867

RESUMO

BACKGROUND: Although children 10-17 years can be hired to work in agriculture, little research has addressed possible musculoskeletal injuries. Children may be at particular risk for these injuries because of the repetitive and load bearing nature of work tasks. Existing research relies on child workers to self-report musculoskeletal injuries. METHODS: In 2017, 202 Latinx child farmworkers ages 10-17 employed across North Carolina completed survey interviews. In 2018, 145 of these children (94 [64.8%] current farmworkers) completed a physical examination and second interview. The examination obtained findings for upper and lower extremity as well as back injuries. RESULTS: Positive indicators for musculoskeletal symptoms were few in either current or former child farmworkers. The knee was most common site for positive indicators with 15.4% of children having at least one. Combining all anatomical sites, 29.0% of children had at least one positive indicator, with no significant difference between current and former farmworkers. Overall, boys had significantly more indicators of knee injuries than girls (21.3% vs. 4.1%), indicators of ankle injuries were found only in the youngest workers (9.5% of children 11-13 years), and significantly fewer current farmworkers had indicators of lower back injuries than former farmworkers (6.4% vs. 17.7%). CONCLUSIONS: Expectations of injuries come from previous studies using child farmworker self-reports, adult farmworker injury rates, and sports medicine pediatric findings. Hired child farmworkers may not perform activities as repetitious and load-bearing as children in sports training or adult farmworkers. Additional research using physical examination is needed to confirm these findings.


Assuntos
Trabalho Infantil , Migrantes , Adolescente , Agricultura , Criança , Fazendeiros , Feminino , Hispânico ou Latino , Humanos , Masculino , North Carolina/epidemiologia
15.
New Solut ; 31(2): 125-140, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33982609

RESUMO

Children as young as ten-years-old can legally work as hired farm labor in the United States. In North Carolina, many hired children are part of the Latinx farmworker community. Agriculture is a hazardous industry, and child workers experience high rates of injury, illness, and mortality. As part of a community-based participatory research study, we draw from thirty in-depth interviews with Latinx child farmworkers aged ten to seventeen to describe their experiences of personal and observed workplace injury and close calls. Nearly all child workers had experienced or observed some form of injury, with several reporting close calls that could have resulted in severe injury or fatality. Overall, children reported a reactive approach to injury prevention and normalized pain as part of the job. Highlighting Latinx child farmworkers' structural "vulnerability, this analysis contextualizes understanding of workplace injury among this largely hidden population. We offer policy recommendations to protect and support these vulnerable workers.


Assuntos
Traumatismos Ocupacionais , Migrantes , Agricultura , Criança , Fazendeiros , Hispânico ou Latino , Humanos , North Carolina/epidemiologia , Traumatismos Ocupacionais/epidemiologia
16.
Artigo em Inglês | MEDLINE | ID: mdl-33917675

RESUMO

Community-engaged research (CEnR) has emerged within public health and medicine as an approach to research designed to increase health equity, reduce health disparities, and improve community and population health. We sought to understand how CEnR has been conducted and to identify needs to support CEnR within an emerging academic learning health system (aLHS). We conducted individual semi-structured interviews with investigators experienced in CEnR at an emerging aLHS in the southeastern United States. Eighteen investigators (16 faculty and 2 research associates) were identified, provided consent, and completed interviews. Half of participants were women; 61% were full professors of varied academic backgrounds and departments. Interviews were audio-recorded, transcribed, coded, and analyzed using constant comparison, an approach to grounded theory. Twenty themes emerged that were categorized into six domains: Conceptualization and Purpose, Value and Investment, Community-Academic Partnerships, Sustainability, Facilitators, and Challenges. Results also identified eight emerging needs necessary to enhance CEnR within aLHSs. The results provide insights into how CEnR approaches can be harnessed within aLHSs to build and nurture community-academic partnerships, inform research and institutional priorities, and improve community and population health. Findings can be used to guide the incorporation of CEnR within aLHSs.


Assuntos
Equidade em Saúde , Sistema de Aprendizagem em Saúde , Pesquisa Participativa Baseada na Comunidade , Feminino , Humanos , Masculino , Saúde Pública , Sudeste dos Estados Unidos
17.
Artigo em Inglês | MEDLINE | ID: mdl-35692895

RESUMO

Depression, suicidal behaviors and substance use problems frequently co-occur, and treatment for youth with these co-occurring problems is often fragmented and challenging. An integrated cognitive-behavioral treatment approach that builds upon a relapse prevention framework and applies common core skills, language, and approach for treating these related problems may be clinically beneficial. Following a description of the integrated approach, we present results of a pilot trial (n = 13) to examine the acceptability and feasibility of the Cognitive-Behavioral Therapy - Relapse Prevention (CBT-RP) intervention plus enhanced treatment as usual (TAU) compared to enhanced TAU alone. The feasibility of the CBT-RP + TAU intervention was reflected by high rates of retention (86%). The acceptability was reflected in positive evaluations regarding the helpfulness of the intervention by adolescents and families. The majority of youth in both CBT-RP + TAU and TAU alone groups evidenced reductions in depression and suicide ideation from study entry to Week 20. Patterns of reduction were more consistent, however, for youth receiving CBT-RP + TAU, and reductions were slower to emerge for some youth receiving TAU alone. Reductions in alcohol and marijuana problems were similar, but half of the youth in TAU alone (and none in the CBT-RP + TAU group) had emergency department visits related to psychiatric crises or substance related problems. These findings, although based on a small sample, underscore the feasibility and acceptability of an integrated cognitive-behavioral relapse prevention approach for youth with depression, suicide attempt histories, and substance use problems.

18.
J Clin Transl Sci ; 5(1): e200, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-35047212

RESUMO

Health disparities between Appalachia and the rest of the country are widening. To address this, the Appalachian Translational Research Network (ATRN) organizes an annual ATRN Health Summit. The most recent Summit was held online September 22-23, 2020, and hosted by Wake Forest Clinical and Translational Science Institute in partnership with the Northwest Area Health Education Center. The Summit, titled "Community-Engaged Research in Translational Science: Innovations to Improve Health in Appalachia," brought together a diverse group of 141 stakeholders from communities, academic institutions, and the National Center for Advancing Translational Science (NCATS) to highlight current research, identify innovative approaches to translational science and community-engaged research, develop cross-regional research partnerships, and establish and disseminate priorities for future Appalachian-focused research. The Summit included three plenary presentations and 39 presentations within 12 concurrent breakout sessions. Here, we describe the Summit planning process and implementation, highlight some of the research presented, and outline nine emergent themes to guide future Appalachian-focused research.

19.
New Solut ; 30(4): 282-293, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33131378

RESUMO

We examine the educational experience of Latinx hired child farmworkers in North Carolina, using a social justice framework. Qualitative (n = 30) and quantitative (n = 202) data collected among children ten to seventeen years of age revealed elevated rates of grade retention and dropout status. Children reported disruption to their schooling caused by international and interstate migration and intrastate movement. Few worked during school time; nevertheless, children reported missed participation in educational enrichment opportunities and little integration into school life. Schools often failed to accommodate language difficulties and problems caused by migration, and an atmosphere of racism prevailed. Educational programs for children in farmworker families were established during the 1960s. However, they do not meet the needs of hired child farmworkers. Policies to reduce child employment in agriculture and to meet their educational needs are necessary to ensure the education needed for future health and well-being. We discuss the applied implications of findings.


Assuntos
Fazendeiros , Migrantes , Agricultura , Criança , Escolaridade , Hispânico ou Latino , Humanos , North Carolina , Justiça Social
20.
J Occup Environ Med ; 63(1): 38-43, 2021 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-33105405

RESUMO

PURPOSE: This study identifies the menstrual cycle irregularities of Latinx child and adolescent farmworkers. METHODS: Child and adolescent farmworkers aged 13 to 20 years completed questionnaires about menstrual cycle patterns in 2019, and wore silicone passive collection wristbands for pesticide detection in 2018. Menstrual cycle irregularities were determined from the American College of Obstetricians and Gynecologists committee opinion. RESULTS: Half of participants experienced any menstrual cycle irregularity; the most frequent irregularities were cycle length (38.6%) and having gone 90 days or more without a menstrual period (20.4%). Pesticides were detected in 92.9% of the wristbands; most participants were exposed to an endocrine disrupting chemical (EDC) pesticide. CONCLUSION: Half of Latinx children and adolescents hired farmworkers experience irregular menstrual cycles, and most are exposed to EDCs. Inclusion of occupational and menstrual histories in child and adolescent medical visits is critical.


Assuntos
Fazendeiros , Praguicidas , Adolescente , Criança , Família , Feminino , Humanos , Ciclo Menstrual , Distúrbios Menstruais
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