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Article History

Received: 21 November 2025

Accepted: 17 March 2026

First Online: 12 May 2026

Data availability

: The data are not publicly available due to privacy or ethical restrictions. The data that support the findings of this study are available from the corresponding author on reasonable request, subject to necessary ethical approval and agreement by the ELSA-Brasil Steering Committee, represented by Maria Inês Schmidt and Bruce B. Duncan. Data are typically shared for the duration of the approved analysis through secure transfer mechanisms.

: The Article Processing Charge (APC) for the publication of this research was funded by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) (ROR identifier: 00x0ma614). This study was funded by the Brazilian National Council for Scientific and Technological Development of the Brazilian Ministry of Science, Technology, and Innovation (grant numbers 405551/2015-0, 405544/2015-4, 405547/2015-3, 405552/2015-7, 405543/2015-8 and 405545/2015-0). MS and BD were supported by research fellowships, and DdP by a post-doctoral fellowship from the Brazilian National Council for Scientific and Technological Development. The article processing charge for the publication of this paper was supported by the Coordination for the Improvement of Higher Education Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – CAPES; identifier ROR: 00x0ma614).

: The authors declare that there are no relationships or activities that might bias, or be perceived to bias, their work.

: MS and BD conceived the idea, designed the study and developed it further with PB. MB contributed to this design, identified analysis priorities and interpreted the data. MS and BD were responsible for securing funding. MS led participant recruitment and clinic visits. JSF organised sample selection and participated in the initial conceptional organisation of the staging schemas. PB conducted the analyses with input from BD. DdP and PB performed the ISSI-2 and cluster analyses. All authors contributed to the drafting and revision of the manuscript, and approved the final version, and MS had final responsibility for the decision to submit for publication. PB and BD vouch for the accuracy and completeness of the data. MS and BD oversaw the conduct of the study, had full access to all the data and take full responsibility for the decision to submit for publication. All authors have read and approved the final manuscript. MS is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.