Headache Medicine 2021, 12(2) p-ISSN 2178-7468, e-ISSN 2763-6178

118

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DOI: 10.48208/HeadacheMed.2021.22

Headache Medicine

Original

Headache catastrophization and its relationship with disability,

depression, anxiety, stress and sleep quality

Erlene Roberta Ribeiro dos Santos

, Daniella Araújo de Oliveira

, Antonio Flaudiano Bem Leite

Pedro Augusto Sampaio Rocha Filho

, Marcelo Moraes Valença

Vitória de Santo Antão Academic Center, Collective Health Center;

Physiotherapy Department;

Neurology and Neurosurgery Unit, Federal University

of Pernambuco, Recife, Pernambuco, Brazil.

Abstract

Introduction

Cross-sectional studies on headache have not yet explored the inuence of pain catastrophi-

zing and associations with other psychosomatic comorbidities. The migraine-affected group

of individuals was frequently associated with other clinical conditions such as depression,

anxiety, stress, and poor sleep quality. These conditions exert a signicant inuence on

carrier’s coping with daily pain and helplessness, since disability hampers work and daily

living activities and overly burden individual, their family, society and the health system.

Identifying the elements that contribute to disability is crucial in assisting interventions that

minimize these conditions.

Objective

The aim of this cross-sectional study was to evaluate how the combination of migraine and

catastrophizing, associated with functional disability, depression, anxiety, stress, and sleep

quality in college students, can inuence the perception of pain.

Methods

The 340 participants were selected by drawing lots, in which individuals with primary hea-

daches were assigned. Therefore, the nal analysis sample consisted of 288 individuals. The

sample was divided into Group with migraine and Group with other primary headaches, with

the application of scales: HIT-6 and the scale of pain catastrophizing.

Results

Of the 360 participants, 20 losses were recorded due to inadequate completion of scales,

leaving out 340 participants. Of these, 52/340 (15.25%) did not suffer from headaches.

288/340 (84.7%) participants that reported headaches were included in this study, of whi-

ch 133/288 (46.2%) had migraine, and 155/288 (53.8%) had non-migraine headache.

Women who had migraine attacks were those with the most intense anxious symptoms,

worse sleep quality, and catastrophization. The odds ratio of catastrophizing was higher for

the Migraine Group. Linear and multivariate logistic regression revealed that the greater the

presence of catastrophizing, the greater the occurrence of migraine. Catastrophizing had a

greater power of contribution related to the disability generated by the crises in the group

of migrainous (β = 0.564). The migraine group has a greater perception of pain.

Conclusion

Higher catastrophization was also associated with a greater intensity of depressive and

anxiety symptoms, higher perceived stress, and worse quality of sleep in headache-affected

individuals in our study.

Erlene Roberta Ribeiro dos

Santos

Alto do Reservatório, s/n, Bela

Vista, Vitória de Santo Antão.

55.608.680 - Pernambuco,

Brazil

erlene.santos@ufpe.br

Edited by:

Mario Fernandes Prieto Peres

Keywords:

Catastrophization

Headache

Migraine disorder

Anxiety

Depression

Psychometrics

Pain

Received: April 5, 2021

Accepted: October 11, 2021

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Santos ERR, Oliveira DA, Leite AFB, Rocha Filho PAS, Valença MM

Headache catastrophization and its relationship with disability, depression, anxiety, stress and sleep quality

Introduction

ain catastrophization can be dened as a set of negative

thought

, in which there is an individual’s tendency to

overrate the painful feeling, often feeling unable or prevent-

ed from seeking a solution to relieve suffering. It is under-

stood from the realms of amplication as an exaggerated

perceived pain and rumination as a recurrence of negative

thoughts about pain, helplessness, and lack of support since

the individual feels unable to control the situation.

1,2

Selective attention to body sensations, as in headache,

triggers automatic threatening thoughts that inuence

expectation regarding health and its manifestations:

physiological, such as muscular tension and pain; cognitive,

such as concerns; affective, such as increased anxiety; and

behavioral. These elements enhance threatening thoughts,

contributing to deteriorated anxiety and pain conditions.

Few studies evaluate the occurrence of catastrophization

among individuals with migraine, as well as the association

of migraine with functional disability and other frequent

comorbidities such as depression and anxiety.

2,4-6

When

catastrophizing their pain, these individuals perceive the

painful crises in a more profound and incapacitating way,

which may generate a negative impact on their quality of

life.

4,5

Moreover, the wait for a possible headache attack

is a process that generates high stress, permeated by

catastrophic thoughts, and may exacerbate the expectation

for the next crisis.

2,3

Individuals with migraine affected by the sensation of

the inability to overcome pain become more sensitive to

the onset of other associated clinical conditions, such as

depression and anxiety.

5,6

Furthermore, some psychosocial

factors and their reexes in migraine attacks are still rarely

explored.

This study built on the need to show new evidence on

catastrophization in individuals with migraine and aimed

to evaluate how combined migraine and catastrophization,

associated with other clinical conditions, such as functional

disability, depression, anxiety, stress, and sleep quality in

university students, can inuence pain perception.

Methods

Type of study and participants

This is a cross-sectional study. The population of enrolled

students between 18 and 50 years of age consisted of

1,600 students enrolled at the Academic Center of a

public university located in the city of Vitória de Santo

Antão, Pernambuco, Brazil. The sample consisted of 360

university students in health, with a statistical measure

of reference of frequency 50%, for a maximum value

representative of sample size, a sampling error of 5%, and

a condence level of 95%. There was a loss of 5.6% of the

sample. The power sample end was 95.7% when it was

observed all the statistical measures calculated.

The selection process of the sample units considered the

draw of classes that included more than 30 students from

the Biological Sciences, Physical Education, Nursing,

Nutrition, and Public Health courses, considering 10

classes and all students enrolled. Data collection tools were

applied between January and April 2017. Participants

who did not respond to a minimum of 10% of the questions

on each scale used for data collection were excluded.

The Research Ethics Committee approved the study of

the Health Sciences Center of the Federal University

of Pernambuco (UFPE), Recife (PE), Brazil, under CAAE

57329616.7.0000.5208, receipt nº 061320/2016.

Data collection

The application of the seven self-referred psychometric

scales, i.e., was performed with university students who

accepted to participate in the research in the physical

space of the classrooms. The completion of scales took

about 30 minutes, under the supervision of the lead

researcher.

We collected biodemographic information on sex, age,

weight, and height. The presence of catastrophization was

evaluated with the Pain Catastrophization Thoughts Scale

(PCTS) validated for the Portuguese language

and based

on the Pain Catastrophizing Scale (PCS)

1,6

. The PCTS

measures the realms of rumination and hopelessness of

catastrophization, consisting of 9 items, ranging from 0

to 5 points. No cutoff points are described in the literature

to classify scoring scales. However, higher scores indicate

a more signicant presence of negative thoughts. In this

study, we used a cutoff point of 1.08, which was the mean

of the catastrophization values different zero calculated for

each participant with a headache.

The Headache Impact Test (HIT-6) was used to assess the

disability caused by headache. The combined responses

total a value ranging from 36 to 78. The higher score

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Santos ERR, Oliveira DA, Leite AFB, Rocha Filho PAS, Valença MM

Headache catastrophization and its relationship with disability, depression, anxiety, stress and sleep quality

indicates a more signicant impact of the headache on

daily living. The results were classied as little or no impact:

38 to 49 points; some impact: 50 to 55 points; substantial

impact: 56-59 points; very severe impact: 60 and over.

9,10

We used the criteria of the International Classication of

Headache Disorders (ICHD)

to classify the headache

types; individuals with non-migraine headache and

migraine were divided into two groups and denominated:

Group A (individuals with migraine) and B (students with

other primary headaches).

The Beck Depression Inventory (BDI) is a 21-item

psychometric self-assessment tool and was used to track

the depression symptoms. Each category has four or ve

alternatives, which express the severity levels of depressive

symptoms. The score ranges from zero to three, where

zero is a lack of symptoms and three evidences the

most intense ones. Scores up to 9 points suggest lack of

depression or minimal symptoms; 10 to 18 points, mild to

moderate depression; 19 to 29 points, moderate to severe

depression; 30 to 63 points, severe depression. A score of

21 or more in the inventory is usually representative of a

clinically signicant depression.

12,13

We used the 21-item Beck Anxiety Inventory (BAI) to

elucidate anxiety symptoms. For each question, the

individual should choose one of four levels of anxiety on

a scale ranging from zero to three. The items added can

achieve a total score ranging from 0 to 63, generated from

the sum of the scores of individual items, which allows

classication of anxiety intensity levels as mild, moderate,

or severe.

The Perceived Stress Scale (PSS) was used to evaluate

stress, from 14 questions as answer alternatives, with a

score ranging from 0 to 4 points. The scale total is the

sum of the scores, and scores range from 0 to 56, and the

higher the score, the greater the stress.

15,16

The Pittsburgh Sleep Quality Index was applied to assess

the sleep quality of the previous month. The global score

ranges from 0 to 21 points, and the highest the score, the

worse the quality of sleep. This scale classies participants

as the highest the score, the greater the tendency of bad

sleep quality.

Statistical Analysis

We performed analyses with measures and structuring

elements, differences of means by t-test, chi-square, and

odds ratio, as well as other appropriate statistical tests.

Concerning statistical inferential analyses, simple linear

regression, and generalized multivariate logistic regression

techniques, as well as their analytical protocols

11,18

were

used, evaluating the dependent variables: the presence of

migraine or another type of headache, correlated with the

HIT-6; and independent variables, such as age, sex, and

PCTS, BDI, BAI, PSS and Pittsburgh scales.

Results

The sample was stratied according to the International

Classication of Headache Disorders criteria, third

edition

, based on the denition of two groups. The rst,

classifying the participants with non-migraine headache,

and the second, classifying those with migraine (Figure 1).

Of the 360 participants, 20 losses were recorded due

to inadequate completion of scales, leaving out 340

participants. Of these, 52/340 (15.25%) did not suffer

from headaches. Finally, 288/340 (84.7%) participants

that reported headaches were included in this study, of

which 133/288 (46.2%) had migraine, and 155/288

(53.8%) had non-migraine headache (Figure 1).

Women who had migraine attacks were those with the

most intense anxious symptoms, worse sleep quality, and

catastrophization (Table 1).

Table 2 shows the logistic regression for the occurrence

of migraine between headache-affected individuals.

It is observed that, among all variables in the model,

catastrophization has a more signicant impact on the

changing values of probability of migraine, with an increase

of 5.78 percentage points at every unit variance, with the

other covariates remaining constant, with a statistically

robust estimated association (odds ratio) with migraine.

Depression and perceived stress were covariates that had

a positive association with the occurrence of migraine. On

the other hand, the interaction between catastrophization

and perceived stress expressed a negative coefcient for

a higher probability of occurrence of migraine.

The linear regression in Table 3 shows the association

between the predictive variable, catastrophization, and

other covariates, considering the absence and presence

of migraine. It is noted that each unit variation in the

catastrophization scale (PCTS) increases the impact of

headache (HIT-6), the intensity of depressive (BDI) and

anxiety symptoms (BAI), perceived stress (PSS) and sleep

quality deterioration (Pittsburg Scale). Graphically, when

the adjusted regression lines between migraine and non-

migraine individuals are observed, differences are noted

between the two situations, showing a more signicant

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Headache catastrophization and its relationship with disability, depression, anxiety, stress and sleep quality

Figure 1. Sample characterization

Table 1. Frequency distribution and odds ratio of clinical variables among the 288 university students with non-migraine headache (n=

155) or with migraine (n=133)

Variables Non-migraine-related headache (n=155) Migraine (n=133)

Odds ratio

(95%C.I.)

Age group (yr) n % n %

18-24 72 46.5 69 51.9

0.81 (0.51-1.28) †

25-43 83 53.5 64 48.1

Sex

Male 66/155 42.6 37 27. 9

1.92 (1.17-3.16) †**

Female 89/155 57. 4 96 72.1

Depression BDI

Absence 155 100.0 102 76.7

‡

BDI> 0/155 0.0 31 23.3

Anxiety

Mild 152 98.1 70 52.6 1.00§§***

Moderate 2 1.3 40 30.1 0.02 (0.005-0.098)

Severe 1 0.6 23 1 7. 3 0.02 (0.003-0.151)

Sleep quality

Good (<26) 37 23.8 16 12.1

2.29 (1.21-4.35) †**

Poor (≥26) 118 76.2 117 87. 9

Catastrophization

§§§

Absence 153 98.7 89 66.9 37.44 (10.42-234.6)

Any degree 2 1.3 44 33.1 §***

† χ

test without correction

‡ No odds ratios and no hypothesis testing, due to zero absolute frequency in one of the categories.

§ χ

test with Yates correction, due to the number of observations in one of the categories obtaining an absolute frequency < 5

§§ Linear trend χ

test with extension and Mantel-Haenszel: veries the null hypothesis of increased or decreased odds ratio regarding the

gradual reference of exposure of cases and controls.

§§§ Classication of the PCTS Scale with a cut-off point of 1.08 (mean of values with catastrophization different than zero included in this

research).

*ρ

<0.05

**ρ

<0.01

***ρ

<0.001

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Headache catastrophization and its relationship with disability, depression, anxiety, stress and sleep quality

Table 2. Final model of the multiple logistic regression with variables associated with the presence and absence of migraine

Final model‡ Standardized Coefficient Odds ratios

95%C.I. for OR

Lower Upper

Intercept

α†

-2.866*** 0.057 - -

Catastrophization

†

5.783*** 324.641 12.753 8,264.222

Depression (BDI Scale)

†

0.157*** 1.170 1.031 1.326

Perceived Stress Scale (PSS)

†

0.124*** 1.131 1.059 1.209

Catastrophization and Perceived Stress Scale (PSS) interaction

†

-0.157*** 0.854 0.791 0.923

† α – Intercept or constant and

– Angular or slope coefcient

‡ Statistical decision parameters of the nal model:

a) Omnibus test of coefcient models = 194.682 (

<0.001)

b) Log -2 likelihood = 202.888

c) Cox & Snell R2 = 0.491342044

d) Nagelkerke R2 = 0.656404474

e) Hosmer and Lemeshow test = 14.35 (p=0.073)

***ρ<0.001

Table 3. Multiple linear regression models between catastrophization scale (PCTS) and Headache (Independent variables) and HIT-6, BDI, BAI, Pittsburg

Scale and PSS (Dependent variables)

Dependent

variables

Dependent

variables

HIT6 Depression (BDI) Anxiety (BAI) Stress (PSS) Sleep (Pittsburg Scale)

Model (M) 95%CI

M 95%CI

95%CI

M 95%CI

Intercept (

) † 50.454* 49.621-51.288 0.999* 0.176-1.823 14.229* 13.388-15.069 9.238* 8.053-10.423 4.798* 4.487-5.109

PCTS (

) † 0.045* 0.036-0.054 0.022* 0.014-0.031 0.034* 0.025-0.043 0.043* 0.030-0.056 0.008* 0.005-0.012

Headache (

) 2.449* 1.011-3.887 5.616* 4.195-7.038 4.592* 3.141-6.042 11.041* 8.996-13.086 1.682* 1.146-2.219

-Adjusted

‡

41.1% 37.7% 40.6% 52.2% 30.8%

† α – Intercept or constant and

– Angular or slope coefcient

‡ Statistical decision parameters of the nal model

*ρ<0.001

potential contribution of the scales to the migraine group

(Figure 2). All slope coefcients (β) were positive and

signicant (ρ<0.05) in the multivariate linear regressions

between catastrophization (PCTS) and headache scales

with and without migraine associated with the dependent

variables HIT-6, BDI, BAI, PSS, and Pittsburg Scale.

Table 4 shows the results of the multivariate linear

regression of the impact of headache. Catastrophization

is the variable with the most signicant contribution to the

process of producing disability from headache, with a

strongly signicant β value of 0.564 (ρ<0.001). Covariate

anxiety had a negative slope coefcient with strong

signicance in the context of the contribution of the HIT-6

scale.

Discussion

Our study has shown that catastrophization is associated

with migraine and a more signicant impact of headache.

This corroborates the catastrophic evidence that points to

the realm of hopelessness as the most negative response

to the noxious stimuli generated by pain, and suggests that

this component is the most important predictor of disability

and pain intensity for sufferers.

4-6,8,19

Higher catastrophization was also associated with a greater

intensity of depressive and anxiety symptoms, higher

perceived stress, and worse quality of sleep in headache-

affected individuals in our study. The relationship between

pain intensity, physical disability, and catastrophization

can occur because catastrophic thoughts are oriented

towards the most uncomfortable aspects at the moment

of the painful experience, perceiving it in this way even

more unpleasantly, which may generate less involvement

in physical, social and labor activities, increasing physical

deconditioning, contributing to disability. Also, there is

evidence of the contribution of catastrophic thoughts to

depression, anxiety, and indications that the relationship

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Santos ERR, Oliveira DA, Leite AFB, Rocha Filho PAS, Valença MM

Headache catastrophization and its relationship with disability, depression, anxiety, stress and sleep quality

(A). (B).

(C). (D).

(E).

Figure 2. Multivariate linear regressions charts between PCTS Catastrophization Scale and HIT6 (A), BDI (B), BAI (C), Pittsburg Scale (D)

and PSS (E)

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Headache catastrophization and its relationship with disability, depression, anxiety, stress and sleep quality

between these variables may contribute indirectly to

physical disability.

1,3,5-7,20

Women were more affected by migraine in this study

and were more likely to have this condition than men,

which corroborates most authors in previous studies.

21,22

The signicant involvement of women can be partially

explained by hormonal factors, in which headache plays an

important role and is often potentiated and incapacitating

in specic periods of the menstrual cycle.

21,22

Depression is the comorbidity most frequently cited among

individuals with migraine.

The process of depression can

inuence and enhance catastrophization, enabling an

environment conducive to a favorable cycle of negative

thoughts that interfere with the way crises are addressed,

reducing their capacity for self-pain management.

3,5-7

The presence of anxiety was observed in all participants,

with the highest prevalence classied as severe in the

migraine group. There was a strong tendency to stress that

the higher the degree of anxiety, the greater the likelihood

of catastrophic occurrence in migraine patients, in line

with a previous study.

These associated factors in this

population of university students can interfere signicantly

in productive activities, implying the varying attendance

levels, trouble concentrating, which may inuence the

performance of academic activities.

In this study, the measurement of stress and quality of sleep

is shown for the rst time in migraine-affected subjects, and

these are essential contributors to those suffering from pain.

Emotional stress is reported as one of the main factors that

trigger migraine attacks, and is even correlated with their

duration and intensity. Women suffering from tension-type

headache and migraine have excessive levels of stress,

anxiety, and depression, which directly interfered with the

quality of life and the performance of daily activities.

22,23

When the quality of sleep was evaluated, the proportion

of “poor sleep” was higher and signicant for migraine-

affected individuals, who were more likely to be in this

category, attuned to a previous study that mentions an

association between depression and sleep disorders in

headache-affected patients.

When analyzing the contributions of catastrophic

headaches associated with other clinical conditions, in this

study, we conrmed the signicance of catastrophization

as a strong positive predictor in the occurrence of

migraine, which is in line with previous studies.

5,7

Also,

associations with other clinical conditions may potentiate

functional disability, contributing to deteriorated suffering

in times of crisis or those preceding it. Other studies also

report that patients with chronic daily headache evidence

low concentration and production capacity, anxiety,

depression, and hopelessness, and also overlapping two

or more psychological disorders.

16,22,24

In this same direction, other research identied that

patients diagnosed with migraine were more likely to

show complaints related to mood, irritability, difculties

in performing daily tasks, with impaired functionality and

quality of life aspects.

25,26

This nding considered pain

catastrophization as a process that includes psychosocial

factors and correlates with the individual’s perception of

pain intensity, together with a substantial self-reported

functional disability.

1,2,10,22

Table 4. Final multivariate logistic regression model of the variables associated with the impact on the evaluation of the headache’s disability (HIT6)

Final model‡ Standardized Coefficients

95% CI Limits (

)

Lower Upper

Intercept

† 45.866*** 41.952 49.780

Catastrophization

† 0.564*** 3.811 5.764

Migraine

† 0.064 -0.735 2.489

PSS (Perceived Stress Scale)

† 0.250*** 0.055 0.261

Pittsburgh Scale (Sleep)

† 0.164*** 0.139 0.815

BAI (Anxiety)

† -0.278*** -0.414 -0.139

Age (in years)

† 0.134*** 0.065 0.298

† α – Intercept or constant and

– Angular or slope coefcient

‡ Statistical decision parameters of the nal model:

a) Adjusted R

= 0.477 (Estimate standard error = 4.96), there was no signicant change with the insertion of the migraine variable

b) Lack of Fit Test – ANOVA = 44.64 (

<0.001)

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Headache catastrophization and its relationship with disability, depression, anxiety, stress and sleep quality

Catastrophization is described as a risk factor for pain

progression in individuals suffering from chronic pain.

6,19

The

study showed that among all variables, catastrophization

provides an estimate with a more signicant impact on

the likelihood of migraine. Depression and perceived

stress were covariates with also a positive association for

migraine, corroborating with a previous study.

On the other hand, the interaction between catastrophization

and perceived stress expressed a negative coefcient to

contribute to a higher likelihood of migraine. This is an

atypical nding that diverges from the literature when it

expresses that the presence of both enhances the occurrence

of headaches.

3,23

We highlight the scarce production of studies on the

inuence of catastrophization on patients with migraine,

and this study shows that the variables associated with

the impact on the assessment of headache-triggered

disability from analyses reveal that catastrophization

exerted a signicant inuence on the frequency, duration

and pain sensitivity, more signicant impact and reduced

self-efcacy in the management of migraine crisis, which is

in line with previous studies.

2,4,5,7,27

The migraine-affected group was frequently associated

with other clinical conditions such as depression, anxiety,

stress, and poor sleep quality. These conditions exert a

signicant inuence on carrier’s coping with daily pain

and helplessness

1,5

since disability hampers work and daily

living activities and overly burden individual, their family,

society and the health system. Identifying the elements that

contribute to disability is crucial in assisting interventions

that minimize these conditions.

6,22,27

The main strengths of this study lie in the presentation of an

analysis that raties pain catastrophization as signicant

predictive factor, and when associated with psychosocial

factors such as depression, anxiety, perceived stress, and

sleep quality, tends to deteriorate pain perception. The last

two factors were measured for the rst time in university

students with migraine. An incapacitating condition,

catastrophized migraine negatively reects the quality of

life of sufferers.

As limitations to the analytical study in the measurement

scales, the categorized variables were less sensitive

to variables in a quantitative format. Another point to

highlight is that PCTS questions are not headache-specic,

which has already been mentioned in a previous study.

An important point that should be cited is that, in both

groups, catastrophization, when associated with clinical

conditions such as anxiety, perceived stress, and quality

of sleep, has a signicant inuence on pain perception.

However, in the group of people with migraine, it stands

out with a more substantial impact on the perception of

worsening pain.

Conclusion

In summary, the catastrophization of migraine associated

with other clinical conditions evaluated in this study, such

as depression, anxiety, stress, sleep quality, exerts a very

signicant inuence on the pain-generated disability.

Public Health relevance

• Migraine expresses high magnitude in the global population

that generates disabling processes with considerable impact

on labor and social activities.

• People with migraines are more affected when exposed to

processes that require intellectual capacity and concentration

than the university population.

• The direct cost of migraine admissions in Brazil totals close

to R$2.2 million (around $500,000) annually, with a growing

trend throughout Brazilian regions.

• Migraine also has substantial impacts when associated with

psychosomatic clinical conditions such as catastrophization,

anxiety, stress, and poor quality of sleep, with more frequent

evolution and the perception of the intensity of the crises.

Acknowledgments: We are thankful to the students of the

Centro Acadêmico da Vitória de Santo Antão, UFPE, for their

participation in this study.

Declaration of conflicting interests: The authors declared

no potential conicts of interest with respect to the research,

authorship, and/or publication of this article.

Funding: This study was not funded by anyone institute or

foundation.

Author contributions: ERRS conceptualized the study; ERRS

performed data curation; ERRS, AFBL performed the formal

analysis; ERRS, DAO, MMV made a methodology; ERRS,

AFBL, MMV managed the project; ERRS, MMV oversight

the research activity, planning and execution; ERRS, AFBL

validated the study; ERRS wrote the original draft; ERRS,

MMV, PASRF performed the proofreading and editing.

Erlene Roberta Ribeiro dos Santos

https://orcid.org/0000-0003-3334-3408

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Santos ERR, Oliveira DA, Leite AFB, Rocha Filho PAS, Valença MM

Headache catastrophization and its relationship with disability, depression, anxiety, stress and sleep quality

Daniella Araújo de Oliveira

https://orcid.org/0000-0002-4281-2619

Antonio Flaudiano Bem Leite

https://orcid.org/0000-0003-0211-6608

Pedro Augusto Sampaio Rocha Filho

https://orcid.org/0000-0001-5725-2637

Marcelo Moraes Valença

https://orcid.org/0000-0003-0678-3782

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