El desinterés en recibir la vacuna contra el coronavirus en población de 23 ciudades colombianas, julio a diciembre de 2020
Publicado
dic 30, 2021
Almetrics
Dimensions
Google Scholar
##plugins.themes.bootstrap3.article.details##
Resumen
Introducción. La falta de interés de la población en ser vacunada contra el SARS-CoV-2 representa un problema para el manejo de la pandemia. Objetivo. El objetivo fue estimar la falta de interés en recibir la vacuna contra el coronavirus en población de 23 ciudades colombianas, entre julio y diciembre de 2020. Métodos. Se diseñó un estudio descriptivo que empleó información de la Encuesta Pulso Social del DANE en la que se indagó a la población sobre la intención en aplicarse la vacuna y las razones para rechazarla. Se estimaron la prevalencia del desinterés en recibir la vacuna y las diferencias entre las estimaciones de diciembre y julio. Resultados. La prevalencia fue más alta en mujeres, mayores de 54 años, personas sin ninguna escolaridad, hogares con dos personas o menos, grupos pobres y en ciudades como Cali y Bucaramanga. Las diferencias entre diciembre y julio señalaron aumento del desinterés en menores de 25 años y en Santa Marta y Cartagena; el comportamiento del periodo fue ascendente. La principal razón para no querer recibir la vacuna fue la creencia de que esta puede ser insegura debido a los potenciales efectos adversos. Se identificaron variaciones demográficas y geográficas en las prevalencias de no aceptación. Conclusión. Esta investigación puede ayudar a las autoridades de salud a elaborar políticas relacionadas con las estrategias educativas y de comunicación destinadas a aumentar la confianza en la eficacia y seguridad de la vacuna.
Keywords
vaccination, intention, vaccination refusal, vaccine-preventable diseases, COVID-19, Colombiavacunación, intención, negativa a la vacunación, enfermedades prevenibles por vacunación, COVID-19, ColombiaVacinação, intenção, recusa de vacinação, doenças evitáveis por vacina, COVID-19, Colômbia
References
1. Johns Hopkins University. COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). 2021. https://coronavirus.jhu.edu/map.html
2. Gao Q, Bao L, Mao H, Wang L, Xu K, Yang M, et al. Development of an inactivated vaccine for SARS-CoV-2. Science (80). 2020;81(July):77–81. https://doi.org/10.1126/science.abc1932
3. Nuño M, Chowell G, Gumel AB. Assessing the role of basic control measures, antivirals and vaccine in curtailing pandemic influenza: Scenarios for the US, UK and the Netherlands. J R Soc Interface. 2007;4(14):505–521. https://doi.org/10.1098/rsif.2006.0186
4. Malik AA, McFadden SAM, Elharake J, Omer SB. Determinants of COVID-19 vaccine acceptance in the US. EClinicalMedicine. 2020;26:100495. https://doi.org/10.1016/j.eclinm.2020.100495
5. Thunstrom L, Madison A, Finnoff D, Stephe N. Hesitancy towards a COVID-19 vaccine and prospects for herd immunity. SSRN Electron J. 2020.
6. Silverman E. STAT-Harris Poll: The share of Americans interested in getting COVID-19 vaccine as soon as possible is dropping. STAT; 2020. https://www.statnews.com/pharmalot/2020/10/19/covid19-coronavirus-pandemic-vaccine-racial-disparities/
7. Reinhart R. More Americans Now Willing to Get COVID-19 Vaccine. Gallup; 2020. https://news.gallup.com/poll/325208/americans-willing-covid-vaccine.aspx
8. Talev M. Percent who say they are likely to get the first generation COVID-19 vaccine as soon as it is available. Axios. 2020. https://www.axios.com/axios-ipsos-poll-coronavirus-index-vaccine-doubts-e9205f29-8c18-4980-b920-a25b81eebd84.html?mkt_tok=eyJpIjoiTm1Wak56QTBaVGxrTmpGaSIsInQiOiJ3WXdscTJ2NmVGOEpmeUpZdXdXOElZRnR1Umptd3ZkUEpCRzRNUWdYbm5Wa29pOVdMNkxrAllrightsreserved.Noreuse
9. Hamel L, Kirzinger A, Muñana C, Brodie M. KFF COVID-19 Vaccine Monitor: December 2020. KFF. 2020. https://www.kff.org/coronavirus-covid-19/report/kff-covid-19-vaccine-monitor-december-2020/
10. Peretti-Watel P, Seror V, Cortaredona S, Launay O, Raude J, Verger P, et al. A future vaccination campaign against COVID-19 at risk of vaccine hesitancy and politicisation. Lancet Infect Dis. 2020;20(7):769-770. https://doi.org/10.1016/S1473-3099(20)30426-6
11. Ward JK, Alleaume C, Peretti-watel P. The French public’s attitudes to a future COVID-19 vaccine: The politicization of a public health issue. Soc Sci Med J. 2020;265:113414. https://doi.org/10.1016/j.socscimed.2020.113414
12. Neumann-Böhme S, Varghese NE, Sabat I, Barros PP, Brouwer W, van Exel J, et al. Once we have it, will we use it? A European survey on willingness to be vaccinated against COVID-19. Eur J Heal Econ. 2020;21(7):977–982. https://doi.org/10.1007/s10198-020-01208-6
13. Lazarus J V., Ratzan SC, Palayew A, Gostin LO, Larson HJ, Rabin K, et al. A global survey of potential acceptance of a COVID-19 vaccine. Nat Med. 2020;27(February):225–228. http://dx.doi.org/10.1038/s41591-020-1124-9
14. Marcec R, Majta M, Likic R. Will vaccination refusal prolong the war on SARS-CoV-2? Postgrad Med J. 2020;97(August):143–149. https://doi.org/10.1136/postgradmedj-2020-138903
15. Economía Digital. Crece el escepticismo sobre la vacuna: un 47% de españoles no quiere ponérsela. Economía Digital. 2020 Nov 18. https://www.economiadigital.es/politica/crece-escepticismo-la-vacuna-47-espanoles-no-quiere-ponersela_20107279_102.html
16. Organización Mundial de la Salud. Diez cuestiones de salud que la OMS abordará este año. 2021. https://www.who.int/es/news-room/spotlight/ten-threats-to-global-health-in-2019
17. MacDonald NE, SAGE Working Group on Vaccine Hesitancy. Vaccine hesitancy: Definition, scope and determinants. Vaccine. 2015;33:4161–4164. https://doi.org/10.1016/j.vaccine.2015.04.036
18. Bednarczyk RA. Commentary examining the “why” of vaccine hesitancy. Heal Psychol. 2018;37(4):316–317. https://doi.org/10.1037/hea0000596
19. Hornsey MJ, Harris EA, Fielding KS. The Psychological Roots of Anti-Vaccination Attitudes: A 24-Nation Investigation. Heal Psychol. 2018;37(4):307–315. https://doi.org/10.1037/hea0000586
20. Pelullo CP, Della Polla G, Napolitano F, Di Giuseppe G, Angelillo IF. Healthcare workers’ knowledge, attitudes, and practices about vaccinations: A cross-sectional study in Italy. Vaccines. 2020;8(2). https://doi.org/10.3390/vaccines8020148
21. Samoff E, Dunn A, Vandevanter N, Blank S, Weisfuse IB. Predictors of acceptance of hepatitis B vaccination in an urban sexually transmitted diseases clinic. Sex Transm Dis. 2004;31(7):415–420. https://doi.org/10.1097/01.olq.0000130533.53987.78
22. Brewer NT, Hallman WK. Subjective and objective risk as predictors of influenza vaccination during the vaccine shortage of 2004-2005. Clin Infect Dis. 2006;43(11):1379–1386. https://doi.org/10.1086/508466
23. Burgess DC, Burgess MA, Leask J. The MMR vaccination and autism controversy in United Kingdom 1998-2005: Inevitable community outrage or a failure of risk communication? Vaccine. 2006;24(18):3921–3928. https://doi.org/10.1016/j.vaccine.2006.02.033
24. Petts J, Niemeyer S. Health risk communication and amplification: Learning from the MMR vaccination controversy. Heal Risk Soc. 2004;6(1):7–23. https://doi.org/10.1080/13698570410001678284
25. Quinn SC, Thomas T, Kumar S. The anthrax vaccine and research: Reactions from postal workers and public health professionals. Biosecurity and Bioterrorism. 2008;6(4):321–333. https://doi.org/10.1089/bsp.2007.0064
26. Zitner T. Vaccine hesitancy and the unique challenge of COVID-19. Washington, DC; 2020. https://journals.lww.com/ambulatorycaremanagement/Fulltext/2021/01000/COVID_19_and_Vaccine_Hesitancy__A_Challenge_the.10.aspx
27. Silveira MM, Moreira GMSG, Mendonça M. DNA vaccines against COVID-19: Perspectives and challenges. Life Sci. 2021;267(September 2020):118919. https://doi.org/10.1016/j.lfs.2020.118919
28. DANE. Encuesta Pulso Social. 2020 [cited 2021 Jan 20]. https://www.dane.gov.co/index.php/estadisticas-por-tema/encuesta-pulso-social
29. DANE. Metodologia Gran Encuesta Integrada de Hogares. Colección Documentos - Actualización 2009. Bogotá D.C.; 2009. https://www.dane.gov.co/files/investigaciones/fichas/Gran_encuesta_integrada_hogares.pdf
30. DANE. Metodología General Gran Encuesta Integrada de Hogares. Bogotá D.C.; 2016. https://www.dane.gov.co/files/investigaciones/fichas/empleo/metodologia_GEIH-01_V9.pdf
31. Instituto Nacional de Salud. Observatorio Nacional de Salud. Módulo de datos COVID - 2019 en Colombia. 2021. https://www.ins.gov.co/Direcciones/ONS/modelos-covid-19
32. Lin C, Tu P, Beitsch LM. Confidence and receptivity for covid‐19 vaccines: A rapid systematic review. Vaccines. 2021;9:16. https://doi.org/10.3390/vaccines9010016
33. Head KJ, Kasting ML, Sturm LA, Hartsock JA, Zimet GD. A National Survey Assessing SARS-CoV-2 Vaccination Intentions: Implications for Future Public Health Communication Efforts. Sci Commun. 2020;42(5):698–723. https://doi.org/10.1177/1075547020960463
34. Murphy J, Vallières F, Bentall RP, Shevlin M, Mcbride O, Hartman TK et al. Psychological characteristics associated with COVID-19 vaccine hesitancy and resistance in Ireland and the United Kingdom. Nat Commun. 2021;12(29):1–15. http://dx.doi.org/10.1038/s41467-020-20226-9
35. Noordhout CM De, Devleesschauwer B, Salomon JA, Turner H, Cassini A, Colzani E et al. Disability weights for infectious diseases in four European countries: comparison between countries and across respondent characteristics. Eur J Public Health. 2017;28(1):124–133. https://doi.org/10.1093/eurpub/ckx090
36. United States Department of Labor. Unemployment rates and earnings by educational attainment. 2019. https://www.bls.gov/emp/chart-unemployment-earnings-education.htm
37. The Vaccine Confidence Project, London School of Hygiene & Tropical Medicine. The state of vaccine confidence 2015. London; 2015. https://static1.squarespace.com/static/5d4d746d648a4e0001186e38/t/5d75156b63cb4f265725de12/1567954291535/VCP_The-State-of-Vaccine-Confidence_2015.pdf
38. Kennedy J. Populist politics and vaccine hesitancy in Western Europe: an analysis of national-level data. Eur J Public Health. 2019;29(3):512–516. https://academic.oup.com/eurpub/article-abstract/29/3/512/5364298
39. Wang K, Lai E, Wong Y, Fai K, Wai A, Cheung L, et al. Intention of nurses to accept coronavirus disease 2019 vaccination and change of intention to accept seasonal influenza vaccination during the coronavirus disease 2019 pandemic: A cross-sectional survey. Vaccine. 2020;38:7049–7056. https://doi.org/10.1016/j.vaccine.2020.09.021
40. Paul E, Steptoe A, Fancourt D. Attitudes towards vaccines and intention to vaccinate against COVID-19: Implications for public health communications. Lancet Reg Heal - Eur. 2021;1:100012. https://doi.org/10.1016/j.lanepe.2020.100012
41. Ruiz JB, Bell RA. Predictors of intention to vaccinate against COVID-19: Results of a nationwide survey. Vaccine. 2020;39:1080–1086. https://doi.org/10.1016/j.vaccine.2021.01.010
42. Buss LF, Prete CA, Abrahim CMM, Mendrone A, Salomon T, De Almeida-Neto C, et al. Three-quarters attack rate of SARS-CoV-2 in the Brazilian Amazon during a largely unmitigated epidemic. Science (80- ). 2021;371(6526):288–292. https://doi.org/10.1126/science.abe9728
43. Harrison EA, Wu JW. Vaccine confidence in the time of COVID-19. Eur J Epidemiol. 2020;35(4):325–30. https://doi.org/10.1007/s10654-020-00634-3
44. Sherman SM, Smith LE, Sim J, Amlôt R, Cutts M, Dasch H, et al. COVID-19 vaccination intention in the UK: results from the COVID-19 vaccination acceptability study (CoVAccS), a nationally representative cross-sectional survey. Hum Vaccines Immunother. 2020;00(00):1–10. https://doi.org/10.1080/21645515.2020.1846397
2. Gao Q, Bao L, Mao H, Wang L, Xu K, Yang M, et al. Development of an inactivated vaccine for SARS-CoV-2. Science (80). 2020;81(July):77–81. https://doi.org/10.1126/science.abc1932
3. Nuño M, Chowell G, Gumel AB. Assessing the role of basic control measures, antivirals and vaccine in curtailing pandemic influenza: Scenarios for the US, UK and the Netherlands. J R Soc Interface. 2007;4(14):505–521. https://doi.org/10.1098/rsif.2006.0186
4. Malik AA, McFadden SAM, Elharake J, Omer SB. Determinants of COVID-19 vaccine acceptance in the US. EClinicalMedicine. 2020;26:100495. https://doi.org/10.1016/j.eclinm.2020.100495
5. Thunstrom L, Madison A, Finnoff D, Stephe N. Hesitancy towards a COVID-19 vaccine and prospects for herd immunity. SSRN Electron J. 2020.
6. Silverman E. STAT-Harris Poll: The share of Americans interested in getting COVID-19 vaccine as soon as possible is dropping. STAT; 2020. https://www.statnews.com/pharmalot/2020/10/19/covid19-coronavirus-pandemic-vaccine-racial-disparities/
7. Reinhart R. More Americans Now Willing to Get COVID-19 Vaccine. Gallup; 2020. https://news.gallup.com/poll/325208/americans-willing-covid-vaccine.aspx
8. Talev M. Percent who say they are likely to get the first generation COVID-19 vaccine as soon as it is available. Axios. 2020. https://www.axios.com/axios-ipsos-poll-coronavirus-index-vaccine-doubts-e9205f29-8c18-4980-b920-a25b81eebd84.html?mkt_tok=eyJpIjoiTm1Wak56QTBaVGxrTmpGaSIsInQiOiJ3WXdscTJ2NmVGOEpmeUpZdXdXOElZRnR1Umptd3ZkUEpCRzRNUWdYbm5Wa29pOVdMNkxrAllrightsreserved.Noreuse
9. Hamel L, Kirzinger A, Muñana C, Brodie M. KFF COVID-19 Vaccine Monitor: December 2020. KFF. 2020. https://www.kff.org/coronavirus-covid-19/report/kff-covid-19-vaccine-monitor-december-2020/
10. Peretti-Watel P, Seror V, Cortaredona S, Launay O, Raude J, Verger P, et al. A future vaccination campaign against COVID-19 at risk of vaccine hesitancy and politicisation. Lancet Infect Dis. 2020;20(7):769-770. https://doi.org/10.1016/S1473-3099(20)30426-6
11. Ward JK, Alleaume C, Peretti-watel P. The French public’s attitudes to a future COVID-19 vaccine: The politicization of a public health issue. Soc Sci Med J. 2020;265:113414. https://doi.org/10.1016/j.socscimed.2020.113414
12. Neumann-Böhme S, Varghese NE, Sabat I, Barros PP, Brouwer W, van Exel J, et al. Once we have it, will we use it? A European survey on willingness to be vaccinated against COVID-19. Eur J Heal Econ. 2020;21(7):977–982. https://doi.org/10.1007/s10198-020-01208-6
13. Lazarus J V., Ratzan SC, Palayew A, Gostin LO, Larson HJ, Rabin K, et al. A global survey of potential acceptance of a COVID-19 vaccine. Nat Med. 2020;27(February):225–228. http://dx.doi.org/10.1038/s41591-020-1124-9
14. Marcec R, Majta M, Likic R. Will vaccination refusal prolong the war on SARS-CoV-2? Postgrad Med J. 2020;97(August):143–149. https://doi.org/10.1136/postgradmedj-2020-138903
15. Economía Digital. Crece el escepticismo sobre la vacuna: un 47% de españoles no quiere ponérsela. Economía Digital. 2020 Nov 18. https://www.economiadigital.es/politica/crece-escepticismo-la-vacuna-47-espanoles-no-quiere-ponersela_20107279_102.html
16. Organización Mundial de la Salud. Diez cuestiones de salud que la OMS abordará este año. 2021. https://www.who.int/es/news-room/spotlight/ten-threats-to-global-health-in-2019
17. MacDonald NE, SAGE Working Group on Vaccine Hesitancy. Vaccine hesitancy: Definition, scope and determinants. Vaccine. 2015;33:4161–4164. https://doi.org/10.1016/j.vaccine.2015.04.036
18. Bednarczyk RA. Commentary examining the “why” of vaccine hesitancy. Heal Psychol. 2018;37(4):316–317. https://doi.org/10.1037/hea0000596
19. Hornsey MJ, Harris EA, Fielding KS. The Psychological Roots of Anti-Vaccination Attitudes: A 24-Nation Investigation. Heal Psychol. 2018;37(4):307–315. https://doi.org/10.1037/hea0000586
20. Pelullo CP, Della Polla G, Napolitano F, Di Giuseppe G, Angelillo IF. Healthcare workers’ knowledge, attitudes, and practices about vaccinations: A cross-sectional study in Italy. Vaccines. 2020;8(2). https://doi.org/10.3390/vaccines8020148
21. Samoff E, Dunn A, Vandevanter N, Blank S, Weisfuse IB. Predictors of acceptance of hepatitis B vaccination in an urban sexually transmitted diseases clinic. Sex Transm Dis. 2004;31(7):415–420. https://doi.org/10.1097/01.olq.0000130533.53987.78
22. Brewer NT, Hallman WK. Subjective and objective risk as predictors of influenza vaccination during the vaccine shortage of 2004-2005. Clin Infect Dis. 2006;43(11):1379–1386. https://doi.org/10.1086/508466
23. Burgess DC, Burgess MA, Leask J. The MMR vaccination and autism controversy in United Kingdom 1998-2005: Inevitable community outrage or a failure of risk communication? Vaccine. 2006;24(18):3921–3928. https://doi.org/10.1016/j.vaccine.2006.02.033
24. Petts J, Niemeyer S. Health risk communication and amplification: Learning from the MMR vaccination controversy. Heal Risk Soc. 2004;6(1):7–23. https://doi.org/10.1080/13698570410001678284
25. Quinn SC, Thomas T, Kumar S. The anthrax vaccine and research: Reactions from postal workers and public health professionals. Biosecurity and Bioterrorism. 2008;6(4):321–333. https://doi.org/10.1089/bsp.2007.0064
26. Zitner T. Vaccine hesitancy and the unique challenge of COVID-19. Washington, DC; 2020. https://journals.lww.com/ambulatorycaremanagement/Fulltext/2021/01000/COVID_19_and_Vaccine_Hesitancy__A_Challenge_the.10.aspx
27. Silveira MM, Moreira GMSG, Mendonça M. DNA vaccines against COVID-19: Perspectives and challenges. Life Sci. 2021;267(September 2020):118919. https://doi.org/10.1016/j.lfs.2020.118919
28. DANE. Encuesta Pulso Social. 2020 [cited 2021 Jan 20]. https://www.dane.gov.co/index.php/estadisticas-por-tema/encuesta-pulso-social
29. DANE. Metodologia Gran Encuesta Integrada de Hogares. Colección Documentos - Actualización 2009. Bogotá D.C.; 2009. https://www.dane.gov.co/files/investigaciones/fichas/Gran_encuesta_integrada_hogares.pdf
30. DANE. Metodología General Gran Encuesta Integrada de Hogares. Bogotá D.C.; 2016. https://www.dane.gov.co/files/investigaciones/fichas/empleo/metodologia_GEIH-01_V9.pdf
31. Instituto Nacional de Salud. Observatorio Nacional de Salud. Módulo de datos COVID - 2019 en Colombia. 2021. https://www.ins.gov.co/Direcciones/ONS/modelos-covid-19
32. Lin C, Tu P, Beitsch LM. Confidence and receptivity for covid‐19 vaccines: A rapid systematic review. Vaccines. 2021;9:16. https://doi.org/10.3390/vaccines9010016
33. Head KJ, Kasting ML, Sturm LA, Hartsock JA, Zimet GD. A National Survey Assessing SARS-CoV-2 Vaccination Intentions: Implications for Future Public Health Communication Efforts. Sci Commun. 2020;42(5):698–723. https://doi.org/10.1177/1075547020960463
34. Murphy J, Vallières F, Bentall RP, Shevlin M, Mcbride O, Hartman TK et al. Psychological characteristics associated with COVID-19 vaccine hesitancy and resistance in Ireland and the United Kingdom. Nat Commun. 2021;12(29):1–15. http://dx.doi.org/10.1038/s41467-020-20226-9
35. Noordhout CM De, Devleesschauwer B, Salomon JA, Turner H, Cassini A, Colzani E et al. Disability weights for infectious diseases in four European countries: comparison between countries and across respondent characteristics. Eur J Public Health. 2017;28(1):124–133. https://doi.org/10.1093/eurpub/ckx090
36. United States Department of Labor. Unemployment rates and earnings by educational attainment. 2019. https://www.bls.gov/emp/chart-unemployment-earnings-education.htm
37. The Vaccine Confidence Project, London School of Hygiene & Tropical Medicine. The state of vaccine confidence 2015. London; 2015. https://static1.squarespace.com/static/5d4d746d648a4e0001186e38/t/5d75156b63cb4f265725de12/1567954291535/VCP_The-State-of-Vaccine-Confidence_2015.pdf
38. Kennedy J. Populist politics and vaccine hesitancy in Western Europe: an analysis of national-level data. Eur J Public Health. 2019;29(3):512–516. https://academic.oup.com/eurpub/article-abstract/29/3/512/5364298
39. Wang K, Lai E, Wong Y, Fai K, Wai A, Cheung L, et al. Intention of nurses to accept coronavirus disease 2019 vaccination and change of intention to accept seasonal influenza vaccination during the coronavirus disease 2019 pandemic: A cross-sectional survey. Vaccine. 2020;38:7049–7056. https://doi.org/10.1016/j.vaccine.2020.09.021
40. Paul E, Steptoe A, Fancourt D. Attitudes towards vaccines and intention to vaccinate against COVID-19: Implications for public health communications. Lancet Reg Heal - Eur. 2021;1:100012. https://doi.org/10.1016/j.lanepe.2020.100012
41. Ruiz JB, Bell RA. Predictors of intention to vaccinate against COVID-19: Results of a nationwide survey. Vaccine. 2020;39:1080–1086. https://doi.org/10.1016/j.vaccine.2021.01.010
42. Buss LF, Prete CA, Abrahim CMM, Mendrone A, Salomon T, De Almeida-Neto C, et al. Three-quarters attack rate of SARS-CoV-2 in the Brazilian Amazon during a largely unmitigated epidemic. Science (80- ). 2021;371(6526):288–292. https://doi.org/10.1126/science.abe9728
43. Harrison EA, Wu JW. Vaccine confidence in the time of COVID-19. Eur J Epidemiol. 2020;35(4):325–30. https://doi.org/10.1007/s10654-020-00634-3
44. Sherman SM, Smith LE, Sim J, Amlôt R, Cutts M, Dasch H, et al. COVID-19 vaccination intention in the UK: results from the COVID-19 vaccination acceptability study (CoVAccS), a nationally representative cross-sectional survey. Hum Vaccines Immunother. 2020;00(00):1–10. https://doi.org/10.1080/21645515.2020.1846397
Cómo citar
Chaparro Narváez, P. E., & Castañeda Orjuela, C. A. (2021). El desinterés en recibir la vacuna contra el coronavirus en población de 23 ciudades colombianas, julio a diciembre de 2020. Gerencia Y Políticas De Salud, 20, 1–19. https://doi.org/10.11144/Javeriana.rgps20.drvc
Sección
Dossier especial COVID-19
Esta obra está bajo una licencia internacional Creative Commons Atribución 4.0.