Post-Traumatic Stress Associated with Telework-Related Job Limitation in Latin America
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design
2.2. Participants
2.3. Measures
2.4. Data Collection and Procedures
2.5. Statistical Analysis
2.6. Ethical Approval
3. Results
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- Allen, T.D.; Golden, T.D.; Shockley, K.M. How Effective Is Telecommuting? Assessing the Status of Our Scientific Findings. Psychol. Sci. Public Interest 2015, 16, 40–68. [Google Scholar] [CrossRef] [PubMed]
- Herrero, M.T.V.; Alberich, J.I.T.; Vicente, A.T.; de la Torre, M.V.R.I.; García, L.C. El teletrabajo en salud laboral. CES Derecho 2018, 9, 287–297. [Google Scholar] [CrossRef] [Green Version]
- Tellez, J. Teletrabajo. Available online: https://archivos.juridicas.unam.mx/www/bjv/libros/5/2458/43.pdf (accessed on 10 December 2022).
- International Labour Organization. Teleworking during the COVID-19 Pandemic and beyond—A Practical Guide. Available online: https://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---travail/documents/publication/wcms_758007.pdf (accessed on 10 December 2022).
- Castro, R. Teletrabajo: Una Nueva Tendencia de Desarrollo Laboral En El Perú. Available online: https://apps.camaralima.org.pe/repositorioaps/0/0/par/r717_2/inf_esp_ed_dig_717.pdf (accessed on 10 December 2022).
- Valencia Catunta, A.M.C. Aspectos regulatorios del teletrabajo en el Perú: Análisis y perspectivas. Rev. IUS 2018, 12, 203–226. [Google Scholar] [CrossRef] [Green Version]
- León-Jiménez, F.; Vives-Kufoy, C.; Failoc-Rojas, V.E.; Valladares-Garrido, M.J. Mortality in patients hospitalized with COVID-19 in northern Peru. Rev. Med. Chile 2021, 149, 1459–1466. [Google Scholar] [CrossRef]
- Zila-Velasque, J.P.; Grados-Espinoza, P.; Quispe-Chura, K.; Valdiviezo-Morales, C.G.; Diaz-Vélez, C.; Valladares-Garrido, M.J. Prevalence and Factors Associated with Food Insecurity in Eight High-Altitude Cities in Peru during the Second Wave of the COVID-19 Pandemic: A Retrospective, Cross-Sectional Study. BMC Public Health 2022, 22, 1962. [Google Scholar] [CrossRef]
- Vasquez-Elera, L.E.; Failoc-Rojas, V.E.; Martinez-Rivera, R.N.; Morocho-Alburqueque, N.; Temoche-Rivas, M.S.; Valladares-Garrido, M.J. Self-Medication in Hospitalized Patients with COVID-19: A Cross-Sectional Study in Northern Peru. Germs 2022, 12, 46–53. [Google Scholar] [CrossRef]
- Valladares-Garrido, M.J.; Failoc-Rojas, V.E.; Soto-Becerra, P.; Zeña-Ñañez, S.; Torres-Roman, J.S.; Fernández-Mogollón, J.L.; Colchado-Palacios, I.G.; Apolaya-Segura, C.E.; Dávila-Gonzales, J.A.; Arce-Villalobos, L.R.; et al. Clinical-Epidemiologic Variation in Patients Treated in the First and Second Wave of COVID-19 in Lambayeque, Peru: A Cluster Analysis. Int. J. Infect. Dis. 2022, 123, 212–220. [Google Scholar] [CrossRef]
- Díaz-Vélez, C.; Failoc-Rojas, V.E.; Valladares-Garrido, M.J.; Colchado, J.; Carrera-Acosta, L.; Becerra, M.; Paico, D.M.; Ocampo-Salazar, E.T. SARS-CoV-2 Seroprevalence Study in Lambayeque, Peru. June–July 2020. PeerJ 2021, 9, e11210. [Google Scholar] [CrossRef]
- Carhuapoma-Yance, M.; Apolaya-Segura, M.; Valladares-Garrido, M.J.; Failoc-Rojas, V.E.; Díaz-Vélez, C.; Carhuapoma-Yance, M.; Apolaya-Segura, M.; Valladares-Garrido, M.J.; Failoc-Rojas, V.E.; Díaz-Vélez, C. Índice Desarrollo Humano y La Tasa de Letalidad Por Covid-19: Estudio Ecológico En America. Rev. Del Cuerpo Médico Hosp. Nac. Almanzor Aguinaga Asenjo 2021, 14, 362–366. [Google Scholar] [CrossRef]
- Valladares-Garrido, M.J.; Zapata-Castro, L.E.; Picón-Reategui, C.K.; Mesta-Pintado, A.P.; Picón-Reategui, R.A.; Huaman-Garcia, M.; Pereira-Victorio, C.J.; Valladares-Garrido, D.; Failoc-Rojas, V.E. Association between Working Time and Burnout Syndrome in Peruvian Military during the Second Epidemic Wave of COVID-19. Int. J. Environ. Res. Public Health 2022, 19, 13614. [Google Scholar] [CrossRef]
- Aveiro-Róbalo, T.R.; Garlisi-Torales, L.D.; Chumán-Sánchez, M.; Pereira-Victorio, C.J.; Huaman-Garcia, M.; Failoc-Rojas, V.E.; Valladares-Garrido, M.J. Prevalence and Associated Factors of Depression, Anxiety, and Stress in University Students in Paraguay during the COVID-19 Pandemic. Int. J. Environ. Res. Public Health 2022, 19, 12930. [Google Scholar] [CrossRef] [PubMed]
- Santander-Hernández, F.M.; Peralta, C.I.; Guevara-Morales, M.A.; Díaz-Vélez, C.; Valladares-Garrido, M.J. Smartphone Overuse, Depression & Anxiety in Medical Students during the COVID-19 Pandemic. PLoS ONE 2022, 17, e0273575. [Google Scholar] [CrossRef]
- El 42,8% de Las Empresas Mantiene Su Actividad a Pesar de La Crisis Del Covid-19. Available online: https://www-randstad-es.s3.amazonaws.com/wp-content/uploads/2020/04/NdP_Randstad_Impacto-empresas-covid.pdf (accessed on 10 December 2022).
- Camacho, C.M.V.; Vera, M. Teletrabajo: Una Revisión Teórica sobre sus Ventajas y Desventajas. Investigatio 2018, 41–53. [Google Scholar] [CrossRef]
- Efectos Positivos y Negativos Del Teletrabajo Sobre La Salud. Detalle Dcumento. Asesorías Parlamentarias | Biblioteca Del Congreso Nacional de Chile 111. Available online: https://www.bcn.cl/asesoriasparlamentarias/detalle_documento.html?id=73364 (accessed on 10 December 2022).
- Psychiatry.Org—What Is Posttraumatic Stress Disorder (PTSD)? Available online: https://www.psychiatry.org:443/patients-families/ptsd/what-is-ptsd (accessed on 10 December 2022).
- Jalloh, M.F.; Li, W.; Bunnell, R.E.; Ethier, K.A.; O’Leary, A.; Hageman, K.M.; Sengeh, P.; Jalloh, M.B.; Morgan, O.; Hersey, S.; et al. Impact of Ebola Experiences and Risk Perceptions on Mental Health in Sierra Leone, July 2015. BMJ Glob. Health 2018, 3, e000471. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Xu, J.; Zheng, Y.; Wang, M.; Zhao, J.; Zhan, Q.; Fu, M.; Wang, Q.; Xiao, J.; Cheng, Y. Predictors of Symptoms of Posttraumatic Stress in Chinese University Students during the 2009 H1N1 Influenza Pandemic. Med. Sci. Monit. 2011, 17, PH60–PH64. [Google Scholar] [CrossRef] [Green Version]
- del Pérez, C.P.A.; Mendocilla, E.D.A.; Zumaeta, N.V.S.; Huayaney, J.K.C. Prevalencia del Trastorno de Estrés Postraumático en pobladores mayores de 18 años del sector Río Seco del distrito El Porvenir afectados por el fenómeno del Niño Costero en 2017. Rev. Médica Trujillo 2018, 13, 67–74. [Google Scholar]
- Varma, P.; Junge, M.; Meaklim, H.; Jackson, M.L. Younger People Are More Vulnerable to Stress, Anxiety and Depression during COVID-19 Pandemic: A Global Cross-Sectional Survey. Prog. Neuropsychopharmacol. Biol. Psychiatry 2021, 109, 110236. [Google Scholar] [CrossRef]
- Karatzias, T.; Shevlin, M.; Murphy, J.; McBride, O.; Ben-Ezra, M.; Bentall, R.P.; Vallières, F.; Hyland, P. Posttraumatic Stress Symptoms and Associated Comorbidity During the COVID-19 Pandemic in Ireland: A Population-Based Study. J. Trauma. Stress 2020, 33, 365–370. [Google Scholar] [CrossRef]
- Fernandez-Canani, M.A.; Burga-Cachay, S.C.; Valladares-Garrido, M.J. Association between Family Dysfunction and Post-Traumatic Stress Disorder in School Students during the Second COVID-19 Epidemic Wave in Peru. Int. J. Environ. Res. Public Health 2022, 19, 9343. [Google Scholar] [CrossRef]
- Valladares-Garrido, M.J.; Zapata-Castro, L.E.; Peralta, C.I.; García-Vicente, A.; Astudillo-Rueda, D.; León-Figueroa, D.A.; Díaz-Vélez, C. Post-Traumatic Stress Disorder after the 6.1 Magnitude Earthquake in Piura, Peru: A Cross-Sectional Study. Int. J. Environ. Res. Public Health 2022, 19, 11035. [Google Scholar] [CrossRef]
- Valladares-Garrido, M.J.; Zapata-Castro, L.E.; Domínguez-Troncos, H.; García-Vicente, A.; León-Figueroa, D.A.; Zila-Velasque, J.P.; Grados-Espinoza, P.; Astudillo-Rueda, D.; Peralta, C.I.; Díaz-Vélez, C. Mental Health Disturbance after a Major Earthquake in Northern Peru: A Preliminary, Cross-Sectional Study. Int. J. Environ. Res. Public Health 2022, 19, 8357. [Google Scholar] [CrossRef] [PubMed]
- Hernández-Yépez, P.J.; Muñoz-Pino, C.O.; Ayala-Laurel, V.; Contreras-Carmona, P.J.; Inga-Berrospi, F.; Vera-Ponce, V.J.; Failoc-Rojas, V.E.; Pereira-Victorio, C.J.; Valladares-Garrido, M.J. Factors Associated with Anxiety, Depression, and Stress in Peruvian University Students during the COVID-19 Pandemic. Int. J. Environ. Res. Public Health 2022, 19, 14591. [Google Scholar] [CrossRef] [PubMed]
- Valladares-Garrido, M.J.; Picón-Reátegui, C.K.; Zila-Velasque, J.P.; Grados-Espinoza, P.; Hinostroza-Zarate, C.M.; Failoc-Rojas, V.E.; Pereira-Victorio, C.J. Suicide Risk in Military Personnel during the COVID-19 Health Emergency in a Peruvian Region: A Cross-Sectional Study. Int. J. Environ. Res. Public Health 2022, 19, 13502. [Google Scholar] [CrossRef] [PubMed]
- Ponce, V.V.; Garrido, M.V.; Peralta, C.I.; Astudillo, D.; Malca, J.T.; Manrique, E.O.; Quispe, E.T. Factores Asociados al Afrontamiento Psicológico Frente a La COVID-19 Durante El Periodo de Cuarentena. Rev. Cuba. Med. Mil. 2020, 49, 0200870. [Google Scholar]
- Valladares-Garrido, M.J.; Picón-Reátegui, C.K.; Zila-Velasque, J.P.; Grados-Espinoza, P. Prevalence and Factors Associated with Insomnia in Military Personnel: A Retrospective Study during the Second COVID-19 Epidemic Wave in Peru. Healthcare 2022, 10, 1199. [Google Scholar] [CrossRef]
- Vindegaard, N.; Benros, M.E. COVID-19 Pandemic and Mental Health Consequences: Systematic Review of the Current Evidence. Brain Behav. Immun. 2020, 89, 531–542. [Google Scholar] [CrossRef]
- Mingote Adán, J.C.; del Pino Cuadrado, P.; Sánchez Alaejos, R.; Gálvez Herrer, M.; Gutiérrez García, M.D. El Trabajador Con Problemas de Salud Mental: Pautas Generales de Detección, Intervención y Prevención. Med. Segur. Trab. 2011, 57, 188–205. [Google Scholar] [CrossRef] [Green Version]
- de Miquel, C.; Domènech-Abella, J.; Felez-Nobrega, M.; Cristóbal-Narváez, P.; Mortier, P.; Vilagut, G.; Alonso, J.; Olaya, B.; Haro, J.M. The Mental Health of Employees with Job Loss and Income Loss during the COVID-19 Pandemic: The Mediating Role of Perceived Financial Stress. Int. J. Environ. Res. Public Health 2022, 19, 3158. [Google Scholar] [CrossRef]
- Vijayan, M. Impact of Job Stress on Employees Job Performance in Aavin, Coimbatore. J. Organ. Hum. Behav. 2017, 6. Available online: http://www.publishingindia.com/johb/48/impact-of-job-stress-on-employees-job-performance-in-aavin-coimbatore/620/4392/ (accessed on 10 December 2022).
- Mejia, C.R.; Aveiro-Robalo, T.R.; Garlisi Torales, L.D.; Fernández, M.F.; Bonilla-Rodríguez, F.E.; Estigarribia, E.; Coronel-Ocampos, J.M.; Caballero-Arzamendia, C.J.; Torres, R.R.; Conde-Escobar, A.; et al. Basic COVID-19 Knowledge According to Education Level and Country of Residence: Analysis of Twelve Countries in Latin America. Front. Med. 2022, 9, 978795. [Google Scholar] [CrossRef]
- Leiva-Bianchi, M.C.; Gallardo, I. Validación de La Escala Breve Para Diagnosticar Estrés Post-Traumático (SPRINT-E) En Una Muestra de Personas Afectadas Por El Terremoto y Tsunami Del 27-F En Chile. An. Psicol. 2013, 29, 328–334. [Google Scholar] [CrossRef] [Green Version]
- Sandín, B.; Valiente, R.M.; García-Escalera, J.; Campagne, D.M.; Chorot, P. Psychological Impact of the COVID-19 Pandemic: Negative and Positive Effects in Spanish Population during the Mandatory National Quarantine. Rev. Psicopatología Psicol. Clín. 2020, 25, 1e–21e. [Google Scholar] [CrossRef]
- Campos, M.R. Trastorno de estrés postraumático. Rev. Med. Cos. Cen. 2016, 73, 233–240. [Google Scholar]
- Santillán, G.A.H. Trastornos de Ansiedad en consulta externa de Medicina del Centro de Atención Primaria—I Úcupe. Chiclayo. Marzo 2012. Rev. Del Cuerpo Médico Hosp. Nac. Almanzor Aguinaga Asenjo 2013, 6, 14–18. [Google Scholar]
- Bados López, A. Trastorno por Estrés Postraumático: Naturaleza, Evaluación y Tratamiento. 2021. Available online: http://diposit.ub.edu/dspace/handle/2445/115725 (accessed on 10 December 2022).
- Aspectos Psicológicos de Las Enfermedades Cardiacas—Sociedad Española de Cardiología. Available online: https://secardiologia.es/publicaciones/catalogo/libros/5468-aspectos-psicologicos-de-las-enfermedades-cardiacas (accessed on 10 December 2022).
- Stöllberger, C.; Huber, J.O.; Finsterer, J. Antipsychotic Drugs and QT Prolongation. Int. Clin. Psychopharmacol. 2005, 20, 243–251. [Google Scholar] [CrossRef] [PubMed]
- Ruetsch, O.; Viala, A.; Bardou, H.; Martin, P.; Vacheron, M.N. Prise de poids pharmaco-induite par les psychotropes et sa prise en charge: Revue des données de la littérature. L’Encéphale 2005, 31, 507–516. [Google Scholar] [CrossRef] [PubMed]
- Estrés Postraumático y Depresión en Respuesta a un Desastre Natural y su Influencia Sobre Algunos Parámetros Inmunológicos. Available online: https://psiquiatria.com/bibliopsiquis/estres-postraumatico-y-depresion-en-respuesta-a-un-desastre-natural-y-su-influencia-sobre-algunos-parametros-inmunologicos (accessed on 10 December 2022).
Variable | n | % |
---|---|---|
Gender | ||
Female | 727 | 54.7 |
Male | 602 | 45.3 |
Age (years) * | 38 | 27–49 |
Education | ||
High school or less | 45 | 3.4 |
Baccalaureate | 56 | 4.2 |
Technical | 145 | 10.9 |
Superior | 741 | 55.8 |
Postgraduate | 342 | 25.7 |
Profession or occupation | ||
Self-employed ** | 302 | 23.3 |
Teaching ** | 319 | 24.0 |
Health | 149 | 11.2 |
Food ** | 67 | 5.1 |
Economics/administration | 69 | 5.2 |
Safety ** | 47 | 3.5 |
Mining/construction | 42 | 3.2 |
Teleworking by labor constraint | ||
Total telecommuting | 577 | 43.4 |
Regular telework | 557 | 41.9 |
Minimal telework | 195 | 14.7 |
Bereavement/grief for COVID-19 | ||
Close relative died | 72 | 5.4 |
Friend died | 347 | 26.1 |
Comorbidities | ||
Cardiovascular | 99 | 7.5 |
Respiratory | 105 | 7.9 |
Obesity | 128 | 9.6 |
Diabetes Mellitus | 45 | 3.4 |
Infected by COVID-19 | 24 | 1.8 |
Moderate depression or more | 142 | 10.7 |
Moderate anxiety or more | 237 | 17.8 |
Moderate stress or more | 119 | 9.0 |
Post-traumatic stress | 202 | 15.2 |
Variables | Post-Traumatic Stress | p Value | |
---|---|---|---|
No n (%) | Yes n (%) | ||
Telework according to labor limitation | 0.040 | ||
Total TW/Minimum L | 505 (87.5) | 72 (12.5) | |
Partial TW/Intermediate L | 464 (83.3) | 93 (16.7) | |
Minimum TW/Maximum L | 158 (81.0) | 37 (19.0) | |
Gender | <0.001 | ||
Female | 593 (81.6) | 134 (18.4) | |
Male | 534 (88.7) | 68 (11.3) | |
Age (years) * | 39 (27–49) | 32 (25–44) | <0.001 |
Education | 0.409 | ||
High school or less | 38 (84.4) | 7 (15.6) | |
Baccalaureate | 48 (85.7) | 8 (14.3) | |
Technical | 120 (82.8) | 25 (17.2) | |
Higher | 620 (83.7) | 121 (16.3) | |
Postgraduate | 301 (88.0) | 41 (12.0) | |
Profession or occupation | |||
Self-employed ** | 256 (84.8) | 46 (15.2) | 0.951 |
Teaching ** | 261 (81.8) | 58 (18.2) | 0.090 |
Health | 128 (85.9) | 21 (14.1) | 0.690 |
Food ** | 58 (86.6) | 9 (13.4) | 0.677 |
Economics/administration | 62 (89.9) | 7 (10.1) | 0.230 |
Safety ** | 38 (80.9) | 9 (19.2) | 0.443 |
Mining/construction | 33 (78.6) | 9 (21.4) | 0.253 |
Bereavement/grief for COVID-19 | |||
Close relative died | 59 (81.9) | 13 (18.1) | 0.488 |
Friend died | 300 (86.5) | 47 (13.5) | 0.318 |
Comorbidities | |||
Cardiovascular | 94 (95.0) | 5 (5.1) | 0.003 |
Respiratory | 81 (77.1) | 24 (22.9) | 0.023 |
Obesity | 107 (83.6) | 21 (16.4) | 0.689 |
Diabetes Mellitus | 38 (84.4) | 7 (15.6) | 0.946 |
Infected with COVID-19 | 20 (83.3) | 4 (16.7) | 0.840 |
Moderate depression or more | 71 (50.0) | 71 (50.0) | <0.001 |
Moderate or more anxiety | 136 (57.4) | 101 (42.6) | <0.001 |
Moderate or more stress | 46 (38.7) | 73 (61.3) | <0.001 |
Variable | Bivariate Analysis PR 95% CI p Value | Multivariate Analysis PR 95% CI p Value |
---|---|---|
Labor Limitation | ||
Total TW/minimum L | Ref. | Ref. |
Partial TW/Intermediate L | 1.34 (1.02–1.75) 0.033 | 1.24 (1.02–1.52) 0.034 |
Minimum TW/Máximum L | 1.52 (1.16–2.00) 0.003 | 1.42 (1.18–1.69) <0.001 |
Gender | ||
Female | Ref. | Ref. |
Male | 0.61 (0.48–0.78) <0.001 | 0.64 (0.45–0.92) 0.016 |
Age (years) * | 0.98 (0.97–0.99) <0.001 | 0.99 (0.98–1.00) 0.060 |
Education | ||
High school or less | Ref. | - |
Baccalaureate | 0.92 (0.52–1.61) 0.766 | - |
Technical | 1.11 (0.49–2.51) 0.805 | - |
Higher | 1.05 (0.66–1.66) 0.836 | - |
Postgraduate | 0.77 (0.49–1.22) 0.266 | - |
Profession or occupation | ||
Self-employed | 0.99 (0.78–1.26) 0.938 | - |
Teaching | 1.27 (0.94–1.72) 0.117 | - |
Health | 0.92 (0.55–1.53) 0.744 | - |
Food | 0.88 (0.62–1.24) 0.461 | - |
Economics/administration | 0.66 (0.22–1.97) 0.452 | - |
Security | 1.27 (0.76–2.14) 0.366 | - |
Mining/construction | 1.43 (0.97–2.10) 0.068 | - |
Bereavement/grief for COVID-19 | ||
Close relative died | 1.20 (0.98–1.47) 0.075 | - |
Friend died | 0.86 (0.73–1.01) 0.058 | - |
Comorbidities | ||
Cardiovascular | 0.32 (0.15–0.68) 0.003 | 0.35 (0.17–0.73) 0.005 |
Respiratory | 1.57 (1.18–2.09) 0.002 | 1.09 (0.84–1.42) 0.516 |
Obesity | 1.09 (0.85–1.39) 0.498 | - |
Diabetes Mellitus | 1.02 (0.56–1.87) 0.938 | - |
Infected with COVID-19 | 1.10 (0.40–3.00) 0.855 | - |
Moderate depression or more | 4.53 (3.60–5.70) <0.001 | 1.29 (1.03–1.61) 0.025 |
Moderate or more anxiety | 4.61 (4.10–5.18) <0.001 | 2.34 (1.61–3.41) <0.001 |
Moderate or more stress | 5.75 (4.19–7.91) <0.001 | 2.45 (1.46–4.12) 0.001 |
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Briceño, M.; Noblejas, G.; Armada, J.; Serna-Alarcón, V.; Vilela-Estrada, M.A.; Vera-Ponce, V.J.; Valladares-Garrido, M.J.; Mejia, C.R. Post-Traumatic Stress Associated with Telework-Related Job Limitation in Latin America. Int. J. Environ. Res. Public Health 2023, 20, 6240. https://doi.org/10.3390/ijerph20136240
Briceño M, Noblejas G, Armada J, Serna-Alarcón V, Vilela-Estrada MA, Vera-Ponce VJ, Valladares-Garrido MJ, Mejia CR. Post-Traumatic Stress Associated with Telework-Related Job Limitation in Latin America. International Journal of Environmental Research and Public Health. 2023; 20(13):6240. https://doi.org/10.3390/ijerph20136240
Chicago/Turabian StyleBriceño, Mariluz, Grecia Noblejas, Jose Armada, Victor Serna-Alarcón, Martín A. Vilela-Estrada, Víctor Juan Vera-Ponce, Mario J. Valladares-Garrido, and Christian R. Mejia. 2023. "Post-Traumatic Stress Associated with Telework-Related Job Limitation in Latin America" International Journal of Environmental Research and Public Health 20, no. 13: 6240. https://doi.org/10.3390/ijerph20136240