Schools as a health environment: participatory study with educators


Tatiane Marinz de Souza Luquez¹, Vera Maria Saboia¹, Talita Marchióro de Lima Silva¹, Gabriela Oliveira Mayworm Teixeira¹, Crystiane Ribas Batista Ribeiro¹, Donizete Vago Daher¹


1 Federal Fluminense University



Objective: to analyze thematic and pedagogical aspects guiding educational health practices carried out by teachers with students from the sixth year of a Municipal School. Method: research with a qualitative, descriptive approach, based on participatory methodology, such as case study. Data production took place in a municipal school using the Map Falante strategy, in which 12 teachers participated. The data were analyzed using the Thematic Content Analysis technique. Results: two categories originated: The coexistence of traditional and progressive trends; and Environment, hygiene and health-disease interface as central themes in teaching practice. Discussion: educational health practice is still developed in isolation and incipiently. There are misconceptions about the concept of health, as well as the real meaning of the educational process and health literacy. It was evident that there is a predominance of the traditional teaching model in this educational practice.

Descriptors: Health education; Health promotion; School; Nursing.





Schools represent a favorable environment for the encounter between health and education, as well as hosting several initiatives, such as clinical and social diagnosis actions, screening strategies and referral to specialized health services or primary care, as well as education and training and health promotion activities (1).

Health-related issues have long been the subject of discussion and have become mandatory under Article 7 of Law 5,692 of 1971. Previously, health actions were established through schools' first and second degree programs and the aim was to stimulate knowledge and the practice of basic health and body hygiene (2).

In the mid-1990s, this law was repealed by the enactment of Law 9,394 of 1996, called the Education Guidelines and Bases Act - LDB. At the same time, the Ministry of Education (MEC) started to discuss and formulate the National Curriculum Parameters (PCN) for Basic Education (3).

Thus, the teaching of health-related topics is a challenge for education with regard to the possibility of contributing to contextualized, reflective and transformative learning. Transmitting information regarding the functioning of the body and describing characteristics related to the illness process, as well as listing healthy hygiene habits, is not enough for students to develop healthy life attitudes when taking into account aspects of the students' daily lives (4).

Health education is understood as a dialogical action between professionals and students, which creates knowledge and increases the autonomy of people in their care (5). In addition, it should favor access to information, i.e., health literacy, so that it can value and reorient healthy habits, valuing not only the individual and their skills, but also the collective. It is necessary to encourage them to find the solution for personal and collective problems.

However, the objectives achieved through educational health practices carried out by teachers in schools are questioned. Difficulties are encountered in maintaining actions that involve activities about the formation and reorientation of healthy habits. Most of the time, students belong to families with low income and education, who lack financial and social resources capable of providing a better choice, in addition to having little information related to this issue. However, many elementary school teachers develop some type of educational activity in health without considering the context in which this student lives (6).

Regarding the topics covered in health education activities with adolescents, a survey revealed that 43% of students reported that educators did not ask their opinions or needs before performing educational health actions; 25.1% stated that professionals asked students directly about what they wanted to be addressed; 23.9% reported that teachers carried out dynamics to survey the themes; and 18.2% reported using suggestion boxes (7).

With the aim of strengthening health care in the school environment, health and education policies were created for children, adolescents, young people and adults in the Brazilian public education system. The purpose of these governmental initiatives was to unite and connect health and education actions together. In this context, the Health at School Program (PSE) is integrated (8).

The main objectives of this interministerial program are to promote health and a culture of peace, which reinforces the prevention of health problems; articulate the actions of the public health network with the actions of the Basic Education public network for the constitution of conditions for the integral student training; and promoting communication between the areas of education and health, ensuring exchanges (8).

 Educational health practices take on a new character by seeking to overcome the concepts of curative actions aiming at integrality and the intersectoriality of Health and Education. Actions must be contextualized when instructing students to make healthier life choices, within the scope of promotion, prevention and health care (9).

The educational practice in health must be a participative teaching-learning process, which takes place through the understanding and reflection of contents and shared production of knowledge, generating solutions for health problems (10).

 The study is based on concepts by the pedagogue Paulo Freire, such as dialogicity, emancipation, transformation, autonomy and contextualization, thinking about a problematizing education in which the student assumes the role of subject in the teaching-learning process (11).

Therefore, the objective was to analyze thematic and pedagogical aspects guiding educational health practices performed by teachers with sixth-year students from a municipal school.




Research with a qualitative, descriptive approach, based on a case study. The scenario was a municipal school, located in the neighborhood of Caramujo, in the city of Niterói, Rio de Janeiro. Twelve teachers from the sixth grade of elementary school participated in the research.

This institution was chosen because it is one of the schools included in the Health at School Program in that municipality. In addition, the school management has a leadership profile in encouraging the school community to face new challenges, maintains a good relationship with the Family Health Strategy team nearby and demonstrates interest in health issues. The choice for the sixth-year class was because it was the first year in this school, where students are at the beginning of elementary school and, therefore, a new stage in school life.

The following inclusion criteria were adopted for the participants: being a permanent staff teacher at the institution; work with the sixth-grade class; and be present at the time of presenting the research proposal. The exclusion criteria of the participants were teachers who were on sick or vacation leave or who were not present at the presentation of the project to the group.

The first meeting took place in the teachers 'room during a teacher planning meeting, where the proposal was presented and the participants gave suggestions and doubts were clarified. In the end, all teachers approved the research project, showed interest in participating and signed the Free and Informed Consent Form (ICF).

Data production was carried out in October 2016 during class planning, as suggested by the participants, when teachers from different disciplines meet. Three (03) meetings were necessary for data saturation. Data saturation is understood as the moment when it is possible to understand the logic or collectivity under study, thus being able to see the issue from different perspectives and points of view (12).

The Talking Map technique was used was data production, collectively created with the study participants, in a reflexive way, with ideas, beliefs and understandings regarding the phenomenon under study and its context, gathering a set of images, drawings, words and other illustrative tools that reflected the reality experienced, describing the resources of the community, as well as the cultural, social and emotional aspects of the participants (13).

Sheets of brown paper, post-its, markers and pens were made available. Fristly, the participants were instructed on the technique; then, the guiding questions were asked: "In your opinion, how does the relationship between teacher and student occur during Health Education activities?"; “Do you address content related to health issues during your classes? If so, which ones? If not, why?”; "How are health education activities developed with the class?". Soon after, the Talking Maps were prepared, one for each question, with time available for its presentation and discussion, lasting approximately 1 hour.

The entire presentation and discussion process of the speaking map was recorded on an audio device and later transcribed. The teachers participating in the study were identified by the letter P, followed by a number from 1 to 12. The data were analyzed by means of Thematic Content Analysis, which includes pre-analysis and organization of the material; exploratory reading; mapping of major themes and categories that stood out; in addition to interpretation of the results obtained (12).

The study respected the formal requirements contained in the national and international regulatory standards for research involving human beings, in compliance with the resolution of the National Health Council No. 466, of 12/12/12, approved by the Ethics and Research Committee, under No. CAAE: 37709414.8.0000.5243/2016.




After analyzing the data, two categories emerged: The coexistence of traditional and progressive trends; and Environment, hygiene and health-disease interface as central themes in teaching practice. The details of the steps followed in the data analysis are shown in Tables 1 and 2.


Table 01: Category 1 - The coexistence of traditional and progressive trends, 2019, Niterói

 Category 1 - The coexistence of traditional and progressive trends

 Unit of meaning

Context unit

"The integration between teacher and student is one of the most important steps for us to make this construction, bringing them to the subject and themes..."

"Sometimes we just pass the content on and don't bring them into this construction it doesn't make much sense to them..."

"The relationship is sometimes in a dialogical way and at other times in an imperative way, we have to impose ourselves, we have to order, right?"

"The construction of knowledge happens as a dialogue, therefore depending on the attention, disposition, interest and involvement of those who are talking."

"I continue to bet on affection and playfulness"

"That when the teacher is cool, when he respects it, when there is a relationship between the teacher and the students, when they like the teacher, the subject and then the students do not want to insult, abuse...they leave the room talking about the content..."

"It is necessary to work on what they experience, because if we arrive with something that has nothing to do with their experience, it makes no sense..."

On the path of the progressive educational trend

"It's not that we want a robot in the classroom, but sometimes it's such a complicated situation...the students don't understand that something different is a lesson. And they say:" Aren't you going to teach today?"

"We live in a very traditional situation in schools, due to a whole structure that does not help. But when I feel that there is this construction of knowledge, I see that it occurs through dialogue..."

"The big challenge is that you come with a proposal to be a reflective, critical student and then when he" shows up like that ", you come back and want to punish him because you want to have a banking education regime that doesn't exist anymore "

"Class for the student is sometimes content on the board, copied and that movement from board to notebook, board to notebook..."

"Many education professionals also think that class is just a board and a student sitting on the chair and on tasks."

"We expect a student model that we don't have, but that is a model that we have already naturalized as an ideal..."

"Sometimes even when you think about taking...more dynamic things for them, it has no effect... his interest is not my interest and we get frustrated."

"It is this question of frustration, because in the end, you end up falling into sameness... we are always stuck with what we think is right or that student model we want."

"We want to give a different class, but they think it is not a class... so it has been very difficult to teach them, they want something ready."

"If you are going to teach music "it is not a lesson", a film "it is not a lesson"... they still don't understand, they don't understand the purpose of other ways to learn ..."

"In fact, the teacher is also under construction, we see that most teachers come from traditional education..."

Reflections of the traditional educational trend

      Source: Prepared by the Author, 2019.


Table 02: Category 2 - Environment, hygiene and health-disease interface as central themes in teaching practice 2019

Category 2 - Environment, hygiene and health-disease interface as central themes in teaching practice

Unit of meaning

Context unit

"For me everything is health, all my topics I can relate to health, both environment and sexual orientation, drugs, quality of life, which was the theme of the first two months of the sixth year. But we are always working on personal hygiene"

"I worry about personal hygiene issues, brushing my teeth after a meal ..."

"Most of the time I don't work on health issues, because we end up restricting health issues to environmental issues or diseases."

"Now that I've seen this question and I stopped to think, I don't usually approach it at all ..."

"I talk about exposure to garbage, diseases related to the lack of sanitation, exposure to polluted air, we end up talking about what is most there at the moment, for example, the issue of dengue, Zika ..."

"About practicing some physical activity ...”

"Only with the issue of garbage, because it bothers me because it is very close to their reality ... So, I will usually talk about this issue of environmental education"

Priority themes

"The use of resources varies: seminar, research, debate ..."

"I use written texts, oral texts, conversations, exchange of experiences, collective texts..."

"I haven't used any strategy so far"

 “Conducting lectures”

"I usually like to work with music, movies.”

Strategies used

      Source: Elaboração da Autora, 2019.


The coexistence of traditional and progressive trends


When asked about how the teacher-student relationship and the construction of knowledge about health occurs, some teachers stated that the relationship determines the construction of knowledge, and it is not the exclusive responsibility of the teacher to define the contents that will be addressed. The statements below reveal this point of view:

Just passing the content and not bringing them into this construction, it doesn't make much sense to them and they don't understand it so well. You can bring your theme, but building with them always has more effect for learning. (P1)

This relationship happens as a dialogue, so it depends on the attention, disposition, interest and involvement of those who are talking. (P6)


When criticizing the traditional teaching trend, the teacher emphasizes the importance of dialoguing and encouraging students to be critical:

There is a teacher who gets there, passes the material and does not let the student express himself. When he will express himself: “no, it is not right. The right is here in the book ”. So this ends up disturbing the child's reasoning. How is he going to learn to be critical, to have this vision of wanting to give an opinion if the teacher himself is there embarrassing? (P8)

In the following testimony, one of the participants reinforces that one must invest in dynamic and creative methods:

I continue to bet on affection and playfulness. When I come up with a new post, like cutting and pasting, it always works and they leave talking about the content. (P7)


However, some educators revealed that the traditional trend still prevails in educational practice:

Many education professionals think that class is just a board and a student sitting in the chair with a duty to do. (P3)

We live in a very traditional situation in schools, due to a whole structure that does not favor. (P2)

The big challenge is that you come up with a proposal to make a student reflective, participative, critical and then when he “shows up like that”, you come back and want to punish him because you still have a bank school regime. So, in fact, the teacher is also under construction ... (P7)


In other statements, there is some kind of “blaming” the students on the part of some teachers, which justifies the predominance of the traditional tendency in their health education actions. The testimony below reveals such a situation:

I'm going to take a song, I'm going to show a video that for us will be something more concrete, more dynamic, but for them it has no effect, because it depends on their interest, and their interest is not mine and we get frustrated a lot and in the end you end up falling into sameness. (P4)

They are waiting for the answers, they are already used to entering the room, copying and waiting for the teacher to respond, so it has been very difficult to build health knowledge with them, they want something ready. (P5)


In the speech of another teacher, the approximation with the traditional view of education was noteworthy by privileging the linear transfer of content, in which the student is a passive recipient:


We have to impose ourselves, we have to order. I think that the most difficult thing for the teacher is to be able to have this waist game, because we expect a student model that we don't have, but that is a model that we have already naturalized as ideal in every way. (P12)


Environment, hygiene and health-disease interface as central themes in teaching practice


In the educational health practice developed by the study participants, themes related to the environment predominate, which reinforces the view that falling ill is connected to little care for the environment, especially related to the community. The following statements portray this fact:

The issue of garbage bothers me because it is very close to their reality. We look out the window and see what? Garbage right? There, going down the hill. (P9)

I speak of the problem of exposure to garbage (...) diseases related to the lack of sanitation, exposure to polluted air ... and consuming food or water that is not treated. (P6)


Personal hygiene was another content cited by teachers, who recognize that it is essential for healthy living. In practice, they encourage tooth brushing to reduce the risk of tooth decay and reinforce the need for hand washing in order to reduce the risk of infection:

The issue of personal hygiene that bothers me is the tooth brushing part after the meal. Since last year at this school, I teach and provide a space in my class for them to bring the kit, brushes, and go to the bathroom. (P3)

We work a lot on personal hygiene, tooth brushing and hand washing after going to the bathroom. (P7)

Other teachers understand health as the absence of disease, i.e, if there is no disease, the subject is healthy:

Most of the time we end up limiting the health issue to the environmental issue or the disease issue. (P10)

We end up bringing the health issues that are appearing there at the moment, for example, dengue, Zika and yellow fever. (P11)

Only one teacher commented on the topic when presenting a broader vision, focused both on disease prevention and health promotion:

All my topics are closed and related to health ... In this case, addressing both promotion, prevention and treatment. (P1)

The way in which health education practices take place is varied. In general, they consist of lectures, research, seminars, films and music:

The use of resources varies: seminar, research, debate. (P8)

I usually like to work with music, movies. (P11)

So far, I haven't used any strategy. (P3)

Lectures. (P5)




In the educational health practices developed by the study participants, it can be said that the pedagogical trends are articulated and used interchangeably. It is worth mentioning the coexistence of traditional and progressive trends, with a predominance of traditional ways of thinking and doing, i.e., they still prioritize this pedagogical trend.

In the traditional trend, the teacher is seen as the main authority, which determines content from unquestionable truths. The student is considered a passive being, who has little or no freedom in expressing his opinion, becoming a mere depository of knowledge, in which information is not processed, but inserted in his acquired knowledge (14).

In this conception, the contents, the didactic procedures and the teacher-student relationship are not contextualized, since the proposed themes are seen unilaterally. For learning to be meaningful, it is necessary that the individual perceives the relationship between what is learned and their real life, which involves reasoning, analysis, imagination, the relationship between ideas and events.

 The teacher should no longer be recognized as the sole holder of knowledge, in which only he speaks and the students listen. The 21st century teacher must be dynamic, create opportunities for students to think for themselves and discuss their ideas by providing moments to review them, deconstructing hasty opinions, problematizing or proposing alternatives to overcome difficulties (15).

The progressive trend seeks the creation of conditions for critical analysis, in which the human being can be the subject of his own history. Therefore, educators need to reflect on the meaning of education and recognize students' opinions (11).

Education is ethically favorable to updating the human potential to act in the environment in which it lives, enhancing behavioral change, in order to achieve health promotion (16). Many teachers are reluctant to work from a progressive perspective or use different methods to discuss the contents. Thus, most health education practices in schools are based on the traditional teaching trend, closely related to banking education, opposing a broader perspective that seeks to meet progressive conceptions of health and education.

 In this context, it was found that some teachers seek to justify the use of the traditional teaching strand “blaming” students. This is due to the fact that some students behave in a way that is less receptive to other teaching strategies that use music, games and videos. In such cases, teachers end up discouraging and giving up on developing innovative and participatory teaching.

On the other hand, some study participants demonstrated that they seek to update their way of teaching by using music, videos and group dynamics. It is noteworthy that if the school, the research setting, has resources, such as experimentation laboratories and electronic media. It is also recommended to use them, as they diversify the educational practice in health by promoting greater interaction within the school context, which collaborates to make learning effective, motivating and engaging.

 Innovative teaching strategies should favor students' participation in teaching-learning processes, in which the student is committed to his/her learning (17). However, the participants reported that, when using other teaching strategies, students do not show interest in the novelty, which contributes to the failure to achieve the desired results.

When talking about health at school, we think of broader issues that go beyond those contained in the curriculum. It seeks to go beyond the limits of references to sleep, food, hygiene, encompassing the physical structure of the school, good relationships between the participants, harmony with oneself, healthy living in society, sustainable management of the environment, awareness of health policies in the country, the possibility of simple actions carried out by everyone with the aim of collective health (6).

It was observed in the testimonies of the study participants that the concept of health is directly related to the conditions of the environment, an aspect that is emphasized more because it directly affects the lives of students and the community. For there to be benefits for human health and for its promotion, a favorable environment is necessary, where the subjects are aware that, when the environment is damaged, it will cause negative impacts on their own health and the whole community (18).

Health promotion actions are understood to be procedural and aimed at strengthening the autonomy and protagonism of individuals and social groups, based on progressive perspectives, highlighting the development of intersectoral public policies, with a consequent improvement in quality of life (19).

It should be emphasized that the school environment should not be limited to an instrumental space for processing knowledge, since, when the objective is Health Promotion, it is necessary to develop activities of education and critical vision from a dialogical, emancipatory communication, which includes different educators and students so that knowledge is consolidated in an alliance of knowledge that should reflect the better health and transformation of the participants (20).

In this perspective, educational health practices developed in schools should invest in teachers and students as protagonists in the process of producing health knowledge, both individually and collectively, strengthening creativity, reflection and criticism, as well as seeking significant changes in their everyday life.




The study made it possible to analyze the pedagogical aspects and the guiding themes of educational health practices developed by teachers with sixth-year students at a Municipal School in Niterói, Rio de Janeiro.

It was observed that educators recognize their importance in health education activities in the school environment. However, it is a recent process, experienced through actions that are still isolated and incipient, which need to be improved, since there are still mistakes regarding the concept of health and its determinants, as well as with the real meaning of the educational process and health literacy.

By means of analyzing the findings, it was evident that there is a predominance of the traditional teaching model in the development of educational health practices. This fact occurs due to a natural accommodation that the teaching routine imposes and resistance to the use of innovative strategies, both by teachers, managers and students.

It is evident that it is essential for the effectiveness of educational health practices to know the reality experienced by students and to establish social diagnoses that guide the approach to content consistent with the environment in which they live and thus can develop participatory actions that contribute to information, reflection and criticism, which favor the behavioral reorientation of the collective.



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All authors participated in the phases of this publication in one or more steps to follow, according to the recommendations of the International Committee of Medical Journal Editors (ICMJE, 2013): (a) substantial participation in the design or preparation of the manuscript or in the collection, analysis or interpretation of data; (b) preparing the work or conducting a critical review of the intellectual content; (c) approval of the submitted version. All authors declare  that they are responsible for the content related to all aspects of the manuscript submitted to OBJN. They ensure that issues related to the accuracy or completeness of any part of the article have been properly investigated and resolved. Therefore, exempting the OBJN from any joint participation in any misunderstandings on the matter under consideration. All authors declare that they have no conflict of interest, whether financial or relationship, which influences the writing and/or interpretation of the findings.



Received: 08/28/2019

Revised: 04/17/2020

Approved: 04/07/2020