10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-1 Smigelskas K, Lukoseviciute J, Vaiciunas T, Mozuraityte K, Ivanaviciute U, Mileviciute I, Zemaitaityte M. Measurement of health and social behaviors in schoolchildren: randomized study comparing paper versus electronic mode. Zdr Varst. 2019;58(1):1-10. doi: 10.2478/sjph-2019-0001. MEASUREMENT OF HEALTH AND SOCIAL BEHAVIORS IN SCHOOLCHILDREN: RANDOMIZED STUDY COMPARING PAPER VERSUS ELECTRONIC MODE MERITVE ZDRAVSTVENEGA IN SOCIALNEGA VEDENJA PRI ŠOLOOBVEZNIH OTROCIH: RANDOMIZIRANA ŠTUDIJA, KI PRIMERJA UPORABO TISKANIH IN ELEKTRONSKIH VPRAŠALNIKOV Kastytis ŠMIGELSKAS12*, Juste LUKOŠEVIČIUTE2, Tomas VAIČIUNAS12, Kristina MOZURAITYTE1, Urte IVANAVICIUTE1, leva MILEVIČIUTE1, Monika iEMAITAITYTE1 'Department of Health Psychology, Faculty of Public Health, Medical Academy, Lithuanian University of Health Sciences, Tilžes g. 18, Kaunas LT-47181, Lithuania 2Health Research Institute, Faculty of Public Health, Lithuanian University of Health Sciences, Tilžes g. 18, Kaunas LT-47181, Lithuania Received: Mar 19, 2018 Original scientific article Accepted: Nov 13, 2018 ABSTRACT Keywords: school-aged children, health behavior, social support, prevalence, validity, reliability, questionnaire design, Lithuania Introduction: Electronic survey mode has become a more common tool of research than it used to be prevously. This is strongly associated with the overall digitization of modern society. However, the ev'dence on the possible mode effect on study results has been scarce. Therefore, the aim of this study is to investigate the comparability of findings on health and behaviours using a paper-versus-electronic mode of survey with randomization design among schoolchildren. Methods: A randomized study was conducted using a mandatory questionnaire on international Health Beha^our in School-aged Children (HBSC) study in Lithuania, enrolling 531 schoolchildren aged 11-15 years. The questionnaire included health and social topics about physical acti^ty, risk beha^ours, self-reported health and symptoms, life satisfaction, bullying, fighting, family and school environment, peer relationships, electronic media communication, sociodemographic indicators, etc. The schoolchildren within classes were randomly selected for electronic or paper mode. Results: It was found that by study mode differences are inconsistent and in the majority of cases do not exceed 5%-point difference between the modes. The only significant difference was that in the paper survey the participants reported more exercise than in the electronic survey (OR=8.08, P<.001). Other trends were nonsignificant and did not show a consistent pattern - in certain behaviours the paper mode was related to healthier choices, while in others - the electronic. Conclusions: The use of electronic questionnaires in surveys of schoolchildren may provide findings that are comparable with concurrent or prevously conducted paper surveys. Uvod: Uporaba elektronskih vprašalnikov postaja vse bolj pogosto raziskovalno orodje, ki ga omogoča vsesplošna digitalizacija sodobne družbe. Dokazi o morebitnih učinkih elektronskih vprašalnikov na rezultate študije pa so pomanjkljivi. Cilj te študije je raziskati primerljivost dognanj o zdravstvenih vedenjih med šoloobveznimi otroki z uporabo tiskanih vs. elektronskih vprašalnikov. Metode: Randomizirano študijo smo izvajali v Litvi in je vključevala 531 šoloobveznih otrok med 11. in 15. letom starosti. Uporabili smo vprašalnik mednarodne raziskave Z zdravjem povezano vedenje šoloobveznih otrok (Health Behaviour in School-aged Children (HBSC)). Vprašalnik je zajemal vprašanja s področja zdravja in družbe; povpraševal je o fizični aktivnosti otrok, tveganih vedenjih, samoporočanem zdravju in simptomih, življenjskem zadovoljstvu, ustrahovanju, pretepanju, družinskem in šolskem okolju, odnosih z vrstniki, sociodemografskih dejavnikih, komunikaciji po elektronskih medijih itd. Šoloobvezni otroci znotraj razredov so bili naključno izbrani za odgovarjanje na vprašalnike v tiskani in elektronski obliki. Rezultati: Ugotovitve kažejo, da so razlike med obema oblikama vprašalnikov nekonsistentne in v večini primerov ne presegajo 5 % razlike med oblikama. Edina pomembna razlika je, da so v skupini, ki je odgovarjala na tiskani vprašalnik, poročali o več gibanja kot v skupini, ki je uporabljala elektronski vprašalnik (OR = 8,08, P < ,001). Drugi trendi niso znatni in ne prikazujejo konsistentnega vzorca; pri določenih vedenjih so se rezultati tiskanega vprašalnika nagibali k bolj zdravim izbiram, medtem ko so se v nekaterih drugih vedenjih nagibali k bolj zdravim izbiram rezultati elektronskega vprašalnika. Zaključek: Uporaba elektronskega vprašalnika v raziskavah pri šoloobveznih otrocih lahko prinaša rezultate, ki so primerljivi s sočasnimi ali predhodno izvedenimi raziskavami, ki so uporabljale tiskane vprašalnike. 'Corresponding author: Tel. +370 37 242 911; E-mail: kastytis.smigelskas@lsmuni.lt IVI 117 Nacionalni inštitut 1 IM IJb za javno zdravje © Nacionalni inštitut za javno zdravje, Slovenija. IZVLEČEK Ključne besede: šoloobvezni otroci, zdravstveno vedenje, socialna podpora, razširjenost, veljavnost, zanesljivost, oblika vprašalnika, Litva 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 1 INTRODUCTION Information and communication technology has become an ever more demanded working tool to enhance the management, efficiency, and quality of surveys on health and social phenomena. There are several kinds of electronic questionnaires - online access, mobile device administered by the researcher, or computer/ device handled by respondent. The responses can be collected by participant, researcher or a proxy (if a participant is minor). Overall digitization of social life and communication suggests ever-increasing pressure to conduct digital surveys and, therefore, it is essential to assess how reliable and valid the digital methods are and, if they replace paper-and-pencil method, are the findings comparable? The online mode reduces the study costs by saving on the costs of paper and printing as well as from transportation (1). Besides, it ensures quick data with virtually no errors and suggests fewer no-response answers (2). Another important point is that these devices permit automatic checking of responses and complex skip patterns. However, in the digital survey mode, it is essential to ensure who is filling in the questionnaire, which is not always feasible. The literature on the effects of digital-based and computer-adaptive testing suggests that digitization of standardized tests is a precise and appropriate research mode both from a scientific and logistic point of view (3, 4). Nonetheless, some researchers propose that the reliability of data obtained by the web-based approach should be determined (5). There is also a potential for selection bias, where a particular type of participant may be more prone to a particular survey mode (e.g. preference for digital mode among younger, more affluent or educated people). Moreover, in online mode, the participants can be unknown, not meet eligibility criteria or make double entries. Therefore, due to the potential for selection bias a randomized controlled design could be regarded as the main choice in studies on potential mode effects. Even though many studies analysing the issue of mode effect on study results use randomization, quite a lot of them address the issue of response rate foremost, while content-specific comparison receives less attention. Also, such studies rarely investigate younger groups and the majority of them do not use randomization. For example, in the international Health Behaviour in School-aged Children (HBSC) study some countries use mixed mode design for more than a decade, e.g. Belgium (6), but they usually do not randomize the schools or children, leaving the choice of mode up to the school's or child's preference - which may be a subject to bias. Thus, even though research on the validity and reliability of digital versus paper mode is quite extensive, such assessment in adolescents is rarely addressed. Moreover, the randomized approach in the research of mode effect is not always applicable, leaving the findings with a potential for self-selection or school-specific bias. In addition, the health perceptions and behaviours have also been under-investigated from this perspective. Therefore, the objective of our study is to compare the findings from paper and electronic mode using a randomized controlled design among schoolchildren. 2 METHODS 2.1 Study Process and Sample The randomized controlled study was conducted in May 2017 at five secondary schools in Lithuania. All study subjects were informed about the details of the study and that the return of the filled questionnaire will be treated as the informed consent. The anonymity of study participants and confidentiality of the data was ensured. The study was conducted as a pilot project for an oncoming 2018 Health Behaviour in School-aged Children study in Lithuania. The schools were randomly selected from the national schools' list, by choosing the first five schools who agreed to participate in the study. The schools were from the second-largest city, other cities, and one town. In every school, the questionnaire was administered to 5th, 7th, and 9th grades (predominant age of children 11, 13 and 15 years, respectively). Then, the randomization was applied for every class in the school, with one-half of students filling the questionnaire in paper mode and the other half in electronic mode. Every class was randomized to define which half of the students' list filled the online and which the paper version of the questionnaire. Questionnaires (both electronic and paper mode) were administered in school classrooms by trained researchers who complied with written instructions. The electronic version of the questionnaire was uploaded to Google Forms, which was available only to the researchers. During the survey, the researchers shared the web link to study participants. The online questionnaire was filled in on desktop or tablet computers. The places for survey were usually classrooms, computer rooms or libraries. In some cases, the survey of paper and online mode was conducted simultaneously in the same room. Every researcher wrote the notes about the procedure of survey. 2.2 Measurements The tool for the study was based on the then-current version of the standardized international HBSC research protocol (7). The HBSC questionnaire covers a wide range of health and social topics about schoolchildren's physical activity, risk behaviours, self-reported health and symptoms, life satisfaction, bullying, fighting, family, school environment, peer relationships, electronic media 2 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 communication, sociodemographic indicators, etc. Only the mandatory items were included. The sequence, formulation, and overall visualization of items did not differ by mode. Some items of the questionnaire were used from particular scales or subscales: • HBSC symptom checklist, 8 items (7), • Family Affluence Scale, 6 items (8), • Multidimensional Scale of Perceived Social Support: Family, 4 items (9), • Multidimensional Scale of Perceived Social Support: Friends, 4 items (adapted from (9)), • Teacher and Classmate Support Scale: Classmates, 3 items (adapted from (10)), • Teacher and Classmate Support Scale: Teachers, 3 items (adapted from (10)), • Online contact with friends and others, 4 items (11), • Preference for online communication, 3 items (12), • Social media addiction, 9 items (13). 2.3 Data Analysis Data was processed using MS Excel 2010 and analysed using IBM SPSS Statistics, version 20. The descriptive analysis included the calculation of the prevalence of different health behaviours (%). The items were dichotomized based on the cut-offs used in the 2014 Health Behaviour in School-aged Children study report (14). The main purpose of the analysis was to estimate whether various health-related items are similarly distributed among study groups in schoolchildren that filled in the questionnaire in paper-versus-electronic mode. For this, the percentage point differences were calculated, and logistic regression was used with the calculation of certain behaviours' risk when comparing the modes. The differences between the modes were estimated using percentage point difference and odds ratios with the reference group being electronic mode (0R=1.00). Given that despite randomization there were some imbalances between the study groups by gender, grade, and school, these indicators were adjusted for in the multivariate logistic regression model. Due to multiple comparisons of different indicators, the Bonferroni correction was used: in total, 78 variables were compared, so the conventional significance level of P<0.05 was decreased to P<0.001 (0.05/78=0.00064). The P-values between 0.001 and 0.05 were reported as trends. 3 RESULTS The study sample comprised 531 schoolchildren - 261 filled the electronic questionnaire and 270 the paper version. The overall response rate was 83.0% with higher rates among girls and elder schoolchildren. A detailed comparison of study groups by gender, grade, and school are presented in Table 1. Regardless of randomization, there were some differences observed between study groups and since they were definitely random (by design of the study) their statistical significance was not calculated. Table 1. The main characteristics of study sample. Characteristic Electronic Paper n Response mode mode rate Gender Boys 51.4 48.6 255 77.0 Girls 47.3 52.7 275 89.0 Grade 5th 49.7 50.3 187 77.9 7th 48.8 51.2 201 84.1 9th 49.0 51.0 143 88.8 School #1 (large city) 47.3 52.7 74 89.2 #2 (large city) 48.7 51.3 224 94.5 #3 (city) 50.5 49.5 103 60.6 #4 (city) 50.0 50.0 48 80.0 #5 (town) 50.0 50.0 82 91.1 In this study, the internal consistency of scales and subscales was acceptable and the difference between the modes was not more than .07 points - with no consistent superiority of either mode (Table 2). Table 2. Internal consistency of study scales and subscales by survey mode. Scale Number Internal consistency (a) of items Electronic mode Paper mode HBSC symptom checklist 8 .78 .79 Family Affluence Scale 6 .52 .58 Multidimensional Scale of Perceived Social Support: Family 4 .76 .69 Multidimensional Scale of Perceived Social Support: Friends 4 .90 .85 Teacher and Classmate Support Scale: Classmates 3 .77 .70 Teacher and Classmate Support Scale: Teachers 3 .75 .74 Online contact with friends and others 4 .54 .54 Preference for online communication 3 .84 .81 Social media addiction 9 .75 .76 3 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 3.1 Health Behaviours In the field of health behaviours (Table 3), the largest difference depending on survey mode was observed in extensive physical activity - in paper mode, the schoolchildren more frequently reported daily exercise until getting out of breath or sweating (OR=8.08, P<.001). Table 3. Health behaviours of schoolchildren by survey mode. Other indicators had no differences except the trends that students in paper mode more frequently reported, such as having a regular breakfast on weekends (OR=1.93, P=.009). Almost all aspects of health behaviours differed between the survey modes by no more than 5% points. Characteristic Prevalence, % % OR P difference Electronic Paper Eating habits Having breakfast during the weekdays Every day 58.8 62.7 3.9 1.18 .366 Having breakfast during the weekends Every day 79.6 87.7 8.1 1.93 .009 Hav'ng breakfast with parents Every day 41.0 40.7 -.3 1.00 .982 Having dinner with parents Every day 47.1 45.6 -1.5 .96 .816 Eating fruits Every day 41.8 38.5 -3.3 .87 .446 Eating vegetables Every day 32.6 34.2 1.6 1.07 .707 Eating sweets Every day 16.1 13.8 -2.3 .83 .453 Drinking soft drinks Every day 5.4 6.3 .9 1.23 .593 Drinking energy drinks Every day 2.3 .4 -1.9 .16 .097 Health and well-being Subjective health assessment Good 88.5 91.8 3.3 1.59 .132 Life satisfaction 6-10 (10 pts scale) 87.7 85.8 -1.9 .84 .510 Headache Rarely 84.3 82.5 -1.8 .91 .707 Stomach ache Rarely 93.5 93.7 .2 1.04 .912 Backache Rarely 91.6 92.1 .5 1.09 .794 Feeling low Rarely 80.1 81.3 1.2 1.14 .577 Irritability or bad temper Rarely 72.0 76.5 4.5 1.39 .115 Feeling nervous Rarely 70.5 69.7 -.8 1.01 .946 Difficulties in getting to sleep Rarely 79.7 83.2 3.5 1.33 .214 Feeling dizzy Rarely 89.7 89.9 .2 1.08 .798 Brushing the teeth More than once a day 61.3 62.8 1.5 1.05 .809 Body image A bit too thin 11.9 15.0 3.1 .71 .200 A bit too fat 29.1 30.7 1.6 .91 .654 About the right size 59.0 54.3 -4.7 1.00 - Physical activity Physical activity at least 60 minutes 7 days 18.9 20.6 1.7 1.16 .518 per day (last week) Exercise in free time until getting Every day 3.1 19.7 16.6 8.08 <.001 out of breath or sweating Risk behaviour Cigarette smoking (lifetime) Never 73.2 77.8 4.6 1.37 .187 Cigarette smoking (last month) Never 88.1 92.3 4.2 1.75 .097 Alcohol drinking (lifetime) Never 62.8 68.4 5.6 1.37 .129 Alcohol drinking (last month) Never 88.9 88.0 -.9 .89 .706 Cannabis taking (lifetime) Never 94.3 97.0 2.7 2.22 .101 Cannabis taking (last month) Never 98.1 99.2 1.1 2.13 .376 Sexual intercourse No 95.0 93.3 -1.7 .81 .626 4 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 3.2 Social Behaviours and School The selected indicators of social behaviours under study showed slightly bigger differences than health behaviours, though they were inconsistent and nonsignificant (Table 4). Here the trend in paper mode was that the children were more likely to report having friends to share joys and sorrows, but also more cyber-bullying and more treatment-needed injuries (.00125 0.025 Smoking status - MF and SSHF Smoking status - NSMF and SSHF 0.066 -0.411 - Age (p=0.001) and faculty group (p=0.025, all four groups analysed) had a statistically significant influence on smoking status. There were no statistically significant differences in smoking status between students of MF and NMF (p=0.066). When all four faculty groups were included in the analysis, statistically significant differences in smoking status of students from MF and SSHF were discovered, as well as between those attending NSMF and SSHF. An overview of the smoking status of the students by faculty group and gender is presented in Table 3. 14 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 Table 3. Smoking status of students by faculty group and by gender. Faculty Group Smoking status P (Gender/ Smoking status) Non-smokers Ex-smokers Smokers TOTAL n % n % n % n % MF Female 149 71.3 6 2.9 54 25.8 209 8.0 0.224 Male 79 65.8 8 6.7 33 27.5 120 4.6 NMF Female 842 62.6 73 5.4 431 32.0 1346 51.6 0.244 Male 591 63.3 64 6.9 278 29.8 933 35.8 SSHF Female 517 61.3 46 5.5 281 33.3 844 32.4 0.029 Male 230 60.4 36 9.4 115 30.2 381 14.6 NSMF Female 90 68.2 4 3.0 38 28.8 132 5.1 0.587 Male 51 75.0 2 2.9 15 22.1 68 2.6 TESF Female 235 63.5 23 6.2 112 30.3 370 14.2 0.871 Male 310 64.0 26 5.4 148 30.6 484 18.6 TOTAL MF 228 69.3 14 4.3 87 26.4 329 12.6 0.066 TOTAL NMF 1433 62.9 137 6.0 709 31.1 2279 87.4 TOTAL FEMALE 991 63.7 79 5.1 485 31.2 1555 59.6 0.141 TOTAL MALE 670 63.6 72 6.8 311 29.5 1053 40.4 TOTAL 1661 63.7 151 5.8 796 30.5 2608 100.0 The prevalence of smokers was lower among medical students than among non-medical ones (MF: 26.4% vs. NMF: 31.1%), but this difference was not statistically significant (p=0.066). Although the percentage of smokers was higher among women (31.2% vs. 29.5%), the gender difference in smoking status among students was not statistically significant (p=0.141). The analysis of smoking-related experiences and attitudes of students depending on their sociodemographic characteristics, faculty group, and smoking status is depicted in Table 4. 15 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 Table 4. Smoking experiences and attitudes of students by sociodemographic characteristics, faculty group and smoking status. Predictors Experience / Attitude Attendance to Supporting the Compliance There is a Adequate public tobacco industry smoking ban with the sufficiently broad health training is sponsored event smoking ban at debate about provided at my my faculty the harmful effects faculty of smoking at my faculty % p % p %p % p %p Gender Female 18.1 78.8 61.7 11.5 12.2 Male 24.1 °.°01 72.9 25 30.1 <0.001 81.5 0.018 62.8 a091 14.2 0.179 13.5 0.415 Faculty group MF 16.8 83.5 57.2 35.8 41.1 SSHF 22.5 75.1 65.2 8.2 7.5 NSMF 19.6 0.256 81.8 a001 57.7 7 (n/26) 23 23 22 23 20 24 23 20 24 12 20 19 20 25 >7 (%) 88 88 85 88 77 92 88 77 92 46 46 73 77 96 Mean 8.0 8.3 7.7 8.2 7.8 8.6 8.6 7.9 8.7 6.1 8.0 8.0 7.9 8.7 Median 8 9 8 9 9 9 9 8 9 6 9 9 8 9 Legend: N - Number of participants that rated the item >7 out of all 26 participants; Inst - instructions; Ans - Likert scale answers; Q - question In the second Delphi round concerning Q8, the participants proposed 18 alternative translations. We present some of the suggestions in Supplementary material - Table 1. Agreement was reached on a revised translation. 3.3 WAI-SR Physician Scale The first Delphi round for the WAI-SR Family physician scale showed agreement in all but two statements (Q2, Q10). Q2 was rated as adequate by 15/26 (58%) of participants, but Q10 by only 10/26 (38%) participants (Table 2). Table 2. WAI-SR physician scale Likert scores, mean and median - Round 1 (N=26). Results Inst Ans Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 >7 (n/26) 24 25 23 15 20 21 25 23 24 22 22 10 >7 (%) 92 96 88 58 77 81 96 88 92 85 85 38 Mean 8.2 8.5 8.4 6.7 8.0 7.5 9.0 8.5 9.0 9.0 9.0 6.0 Median 8 9 9 8 9 7.5 9 8.5 9 9 9 6 Legend: N - Number of participants that rated the item >7 out of all 26 participants; Inst - instructions; Ans - Likert scale answers; Q - question Numerous alternative translations were again proposed in the second Delphi round - 6 for Q2 and 5 for Q10. Some of these are presented in Supplementary material - Tables 2 and 3. Again, agreement was reached on a revised translation. The Slovene version of the translation for both scales was issued after the second Delphi round (Table 3, Supplementary material - Table 4). Table 3. Mean and median: Patient scale Q8 and Physician scale Q2, Q10 - Round 2. Q8 Q2 Q10 patient scale physician scale physician scale Mean 8.2 8.7 8.2 Median 9 9 8.5 25 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 3.4 Back-Translation Consensus was achieved in two rounds of the agreement process between the two professional translators for both WAI SR scales. Consensus on the back-translation of the scoring key was achieved in four rounds. 3.5 International Cultural Equivalence Evaluation The work on cultural equivalence highlighted three potential problems with translation: In Q10 of the patient scale, "treatment" was translated as "consultation". We concluded that, considering its original use in psychotherapy, the word "treatment" did not relate solely to medical treatment but to the entire process of doctor-patient consultation. For this reason, the translation relates to the entire process of consultation and not only to treatment actions. Also, in the patient scale, Q12 was originally in the active voice, but was translated to the passive voice in the validated Slovene translation. After the cultural check was carried out, the national team agreed that the use of the active voice was more suitable, since it emphasized the patient's active role in the consultation and corresponded to the "shared decision-making" model (Supplementary material - Table 5). In Q8 of the physician scale, the discussion on cultural equivalence revealed that there was a difference between 'the common perception of a goal' (as in the original version) and 'common agreement on the goal' (as translated). We consulted the linguist and appropriately altered the validated translation so that the original meaning of the statement was retained (Supplementary material - Table 6). The final version of the WAI-SR Slovene translation was accepted after the second Delphi round, including these cultural adaptations. 3.6 Validation of the Scoring Key The scoring key contains instructions concerning the evaluation of the scale. The same procedure was used for the translation of the scoring key as for the WAI-SR items. It was validated in the first Delphi round with Q1, Q2, and Q3 each having one evaluation of <7, and all the others (except the last item) >7. Item 11 was adapted after consulting the author of the scale, AO Horvath, who gave additional instructions. 4 DISCUSSION 4.1 Main Findings Only two rounds of the Delphi method were needed to achieve a consensus on the translations of all the items. Cultural equivalence of the back-translation was obtained after some minor adaptations were made. The process showed that a simple literal translation was inappropriate, and rigorous efforts must be made to ensure the meaning and intent of the original items are maintained so the scale remains relevant. 4.2 Validation Process and Comparison to other Countries The equivalence procedure in the translation of the two scales assessing therapeutic alliance was complex and time-consuming, but it served well for the purpose of semantic validation. The same procedure was used to validate and achieve equivalence in the translation of the definition of multi-morbidity (21, 22) and to validate the WAI-SR questionnaire in other countries (23). The translation into Polish showed the feasibility of the procedure, taking only one Delphi round to achieve consensus (23). The advantage of this procedure also lies in the fact that it was simultaneously taking place in several European countries with different linguistic bases, which provided the opportunity to discuss the difficulties national and local research groups met with while translating the original WAI-SR scales. The Delphi method was used to validate the agreed forward translation and has been shown to be suitable for exploring areas where controversy, debate or a lack of clarity exist. Within this process, translations of WAI-SR scales were actively tested in representatives of the target population or language group to determine whether the respondents understood the questionnaire in the same way as the original. We feel that the use of this method for translation was legitimate, since it provided an accurate consensus technique (24). Ideally, every questionnaire translation should undergo a cultural equivalence to identify and resolve any inadequate expressions in the translation, as well as to sort out any other discrepancies between the original items and the back-translated ones. The first steps in the process were inspired by the work of Streiner et al. (25). The standardized approach for the cultural adaptation of patient-measured outcomes was confirmed in recent guidelines (26, 27). In this study, we followed the recommendations at all stages: in the first part of cultural adaptation by using the Delphi method, because we recognized this as the best option given the specifics of our language, social and cultural context, and then by the supervision of the researchers led by the University of Brest, who oversaw the adaptation of the questionnaire 26 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 and the cultural adaptation based on the back-translation. This was to ensure that the items were translated considering their structure as well as the suitability of their content. 4.3 Limitations Given that translation is the most common method for preparing instruments for cross-cultural research, we must be alert to the pitfalls that threaten validity. Firstly, when translating scales such as the WAI-SR, it would be best if the forward translation was carried out by professionals who fit these criteria: familiar with the terminology used in the questionnaire; knowledgeable about the subjects covered; experienced in translating scales from (as here) English; and have Slovene as their native language. The content of the WAI-SR covers the fields of psychology and medicine, and its translation must be understandable by both physicians and patients. In Slovenia, we were unlikely to find a professional translator who would meet all these criteria. Creating a group of two family medicine doctors, a psychologist and a linguist to carry out the forward translation solved this problem. Secondly, we stated that the experts carrying out the consensus procedure consisted of individuals who were fluent in English. However, the method of evaluating fluency in the language is debatable. Proficiency in English was assessed in two ways: one was self-evaluation, and the other was the number of English publications of each of the participants. The latter, in particular, may not be a powerful tool for showing language fluency; however, it was a pragmatic and feasible solution. Thirdly, the Delphi group was not representative of the community of Slovenian family medicine doctors (FMDs) - men were underrepresented and the percentage of the academic FMDs involved was higher than the Slovenian average. But considering that the Delphi method is a qualitative one, population representativeness is not necessary. It is more important that all the characteristics of the participants that can influence decisions regarding validation are represented, such as different ages, location of practice, years of experience and involvement in the academic side of family medicine. Finally, it would have been preferable if the backtranslation had been made by an independent translator fluent in Slovene but whose native language was English. Since no such translators were available, we settled for two independent licensed Slovenian translators who had no previous knowledge of the WAI-SR scale. 5 CONCLUSION At this stage, the WAI-SR and its use in family medicine generally lacks a theoretical background that needs to be discussed and agreed upon in the broader field of family medicine. Given the complexities of patient care in family medicine, the question arises as to whether therapeutic alliance is relatively stable over the course of a relationship between a family doctor and a patient. In addition, if assessing the alliance at one or several points in time, alliance ratings are expected to be associated with morbidity changes over the course of a patient's life, which may fail to capture the short-term impact of alliance on a specific symptom or improvement in their condition. Therefore, the future accuracy of ratings provided by this instrument can be affected by many methodological factors, including the quality of the instrument in terms of validity, reliability, and sensitivity to change. We only described the first phase, where the scale's semantic and cultural equivalence were verified. Further studies will provide results of reliability and item validity analyses. Exploratory principal component analyses are to be conducted to compare response patterns with the hypothesized scale constructs. Four major issues need to be considered in the future: the psychometric properties of the Slovene WAI-SR scale; the appropriateness of the scale for FMDs; practical aspects of scale administration; and the theoretical foundation of scale interpretation within the field of family medicine. CONFLICT OF INTERESTS The authors declare that they have no competing interests. FUNDING The Slovenian part of the study was partly funded by the Slovenian Institute for the Development of Family Medicine. The co-author PS acknowledges financial support from the Slovenian Research Agency, research core funding Research in the Field of Public Health No. P3-0339. The international TATA study was funded by the European General Practice Research Network. ETHICAL APPROVAL The study was approved by the Republic of Slovenia National Medical Ethics Committee at the Ministry of Health, on Dec 15th, 2017, number 0120-397-2016/2. 27 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 ACKNOWLEDGMENTS We thank all the physicians who participated in the study and Ms. Justi Carey for the language editing. We thank to TATA group researchers, who participated in the international translations and are non-author collaborators: Nicola Buono (National Society of Medical Education in General Practice, Caserta, Italy), Radost Assenova (University of Plovdiv, Bulgaria), Krzysztof Buczkowski (Nicolaus Copernicus University in Torun, Poland), Ana Claveria (Universidad de Vigo, Spain); Robert Hoffman (Tel Aviv University, Israel), Djurdjica Lazic (University of Zagreb, Croatia), Heidrun Linger (Hannover Medical School, Germany), Hans Thulesius (Lund University, Sweden). ABBREVIATIONS WAI-SR scale: the Working Alliance Inventory - Short Revised scale FMDs: Family medicine doctors REFERENCES 1. Tammes P, Salisbury C. Continuity of primary care matters and should be protected. BMJ. 2017;356:j373. doi: 10.1136/bmj.j373. 2. Petek D, Künzi B, Kersnik J, Szecsenyi J, Wensing M. Patients' evaluations of European general practice - revisited after 11 years. Int J Qual Health Care. 2011;23:621-8. doi: 10.1093/intqhc/mzr052. 3. Hall MA, Dugan E, Zheng B, Mishra AK. Trust in physicians and medical institutions: what is it, can it be measured, and does it matter? Milbank Q. 2001;79:613-39. doi: 10.1111/1468-0009.00223. 4. Bordin ES. The generalizability of the psychoanalytic concept of the working alliance. Psychother Theory Res Pract. 1979;16:252-60. doi: 10.1037/h0085885. 5. Huff NG, Nadig N, Ford DW, Cox CE. Therapeutic alliance between the caregivers of critical illness survivors and intensive care unit clinicians. 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Luborsky L, Barber JP, Siqueland L, Johnson S, Najavits LM, Frank A, et al The Revised Helping Alliance Questionnaire (HAq-II): psychometric properties. J Psychother Pract Res. 1996;5:260-71. 12. Delsignore A, Rufer M, Moergeli H, Emmerich J, Schlesinger J, Milos G, et al. California Psychotherapy Alliance Scale (CALPAS): psychometric properties of the German version for group and individual therapy patients. Compr Psychiatry. 2014;55:736-42. doi: 10.1016/j.comppsych.2013.11.020. 13. Kim SC, Boren D, Solem SL. The Kim Alliance Scale: development and preliminary testing. Clin Nurs Res. 2001;10:314-31. 14. Shelef K, Diamond GM. Short form of the revised Vanderbilt therapeutic alliance scale: development, reliability, and validity. Psychother Res. 2008;18:33-43. doi: 10.1080/10503300701810801. 15. Saunders SM, Howard KI, Orlinsky DE. The Therapeutic bond scales: psychometric characteristics and relationship to treatment effectiveness. Psychol Assessment. 1989;1:323-30. 16. Pensek L, Selic P. Empathy and burnout in Slovenian family medicine doctors: the first presentation of Jefferson Scale of Empathy results. Zdr Varst. 2018;57:155-65. doi: 10.2478/sjph-2018-0020. 17. Patrick DL, Wild DJ, Johnson ES, Wagner TH, Martin MA. Cross-cultural validation of quality of life measures. In: Orley J, Kuyken W, editors. Quality of life assessment: international perspectives. Heidelberg: Springer Verlag, 1994:19-32. 18. Acquadro C, Jambon B, Ellis D, Marquis P. Language and translation issues. In: Spilker B, editor. Quality of life and pharmacoeconomics in clinical trials. 2nd ed. Philadelphia: Lippincott-Raven, 1996:57585. 19. Herdman M, Fox-Rushby J, Badia X. "Equivalence" and the translation and adaptation of health-related quality of life questionnaires. Qual Life Res. 1997;6:237-47. 20. Skulmoski GJ, Hartman FT, Krahn J. The Delphi method for graduate research. J Inf Technol Educ. 2007;6:2-21. 21. Lazic OK, Le Reste JY, Murgic L, Petricek G, Katic M, OzvaCiC-Adzic Z, et al. Say it in Croatian - Croatian translation of the EGPRN definition of multimorbidity using a Delphi consensus technique. Coll Antropol. 2014;38:1027-32. 22. Le Reste JY, Nabbe P, Rivet C, Lygidakis C, Doerr C, Czachowski S, et al. The European general practice research network presents the translations of its comprehensive definition of multimorbidity in family medicine in ten European languages. PLOS One. 2015;10:e0115796. doi:10.1371/journal.pone.0115796. 23. Le Reste JY, Buczkowski K, Morvan F, Lazic V, Lingner H, Petek D, et al. Translation of a therapeutic alliance scale (The WAI SR) into Polish, TATA EGPRN collaborative study. Abstracts/programme book of the 85th EGPRN meeting, Dublin, 19-22 October 2017. Accessed March 20th, at: https://www.egprn.org/file/3898d1a2-a2f8-479a-899c-c90a1266e949/2017-oct-dublin-ireland-programme.pdf. 24. Linstone HA, Turoff M, editors. The Delphi method: techniques and applications. 2002. Accessed July 17th, 2018 at: http://is.njit.edu/ pubs/delphibook. 25. Streiner DL, Norman GR, Cairney J. Health measurement scales: a practical guide to their development and use. 5th ed. Oxford, New York: Oxford University Press, 2014. 26. Wild D, Eremenco S, Mear I, Martin M, Houchin C, Gawlicki M, et al. Multinational trials - recommendations on the translations required, approaches to using the same language in different countries, and the approaches to support pooling the data: the ISPORP patient-reported outcomes translation and linguistic validation good research practices task force report. Value Health. 2009;12:430-40. doi: 10.1111/j.1524-4733.2008.00471.x. 27. Rabin R, Gudex C, Selai C, Herdman M. From translation to version management: a history and review of methods for the cultural adaptation of the EuroQol five-dimensional questionnaire. Value Health. 2014;17:70-6. doi: 10.1016/j.jval.2013.10.006. 28 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 SUPPLEMENTARY MATERIAL Supplementary table 1. Q8 patient scale translation examples. Q8 patient scale - Q8 patient scale - Q8 patient scale - original statement forward translation alternatives ___and I agree on what is Z___se skupaj dogovarjava o tem, Z____se strinjava, important for me to work on. kaj je zame pomembno, da počnem. na čem moram delati Z____se strinjava/soglašava o tem, kaj je zame pomembno, da počnem. Z_____se strinjava, kaj je zame pomembno, da izboljšam. Supplementary table 2. Q2 physician scale translation examples. Q2 patient scale - Q2 patient scale - Q2 patient scale - original statement forward translation alternatives I am genuinely concerned Blagostanje____je moja for____'s welfare. osrednja skrb. Supplementary table 3. Q10 physician scale translation examples. Skrbi me pacientovo dobro. Dobrobit____je moja osrednja skrb. Moja pristna skrb je dobro počutje____. Q10 patient scale - Q10 patient scale - Q10 patient scale - original statement forward translation alternatives We agree on what is important for____to work on. Z____se skupaj dogovarjava, kaj je zanj(o) pomembno, da počne. Z____se strinjava, na čem mora delati. Z____se strinjava o tem, kakšni ukrepi so pomembni. Z____se strinjava, kaj je zanj(o) pomembno, da izboljša. Supplementary table 4. validated translations: Q8 patient scale and Q2, Q10 physician scale - Round 2. Q8 patient scale - Q2 physician scale - Q10 physician scale - successfully validated translation successfully validated translation successfully validated translation Z se strinjava, kaj Dobrobit je moja Z se strinjava, kaj je je zame pomembno, da izboljšam. osrednja skrb. zanj(o) pomembno, da izboljša. 29 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 Supplementary table 5. Q12 patient scale cultural equivalence. Q12 patient scale -original statemet Q12 patient scale -validated translation Q12 patient scale -after cultural adaptation I believe the way we are working with my problem is correct. Verjamem, da je način obravnave moje težave pravilen. Verjamem, da mojo težavo obravnavava na ustrezen način. Supplementary table 6. Q8 physician scale cultural equivalence. Q8 patient scale -original statemet Q8 patient scale -validated translation Q8 patient scale -after cultural adaptation and I have a common Z se strinjava glede Z enako dojemava perception of his/her goals njegovih/njenih ciljev. njegove/njene cilje. 30 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-31 Stern B, Socan G, Rener-Sitar K, Kukec A, Zaletel-Kragelj L. Validation of the Slovenian version of short Sense of Coherence questionnaire (SOC-13) in multiple sclerosis patients. Zdr Varst. 2019;58(1):31-39. doi: 10.2478/sjph-2019-0004. VALIDATION OF THE SLOVENIAN VERSION OF SHORT SENSE OF COHERENCE QUESTIONNAIRE (SOC-13) IN MULTIPLE SCLEROSIS PATIENTS OVREDNOTENJE SLOVENSKE VERZIJE KRATKEGA VPRAŠALNIKA O OBČUTKU SKLADNOSTI (SOC-13) PRI BOLNIKIH Z MULTIPLO SKLEROZO Biljana STERN12, Gregor SOCAN3, Ksenija RENER-SITAR4, Andreja KUKEC2, Lijana ZALETEL-KRAGELJ2* 'University Clinical Centre Maribor, Department of Neurologic Diseases, Ljubljanska 5, 2000 Maribor, Slovenia 2University of Ljubljana, Faculty of Medicine, Chair of Public Health, Zaloška 4, 1000 Ljubljana, Slovenia 3University of Ljubljana, Faculty of Arts, Department of Psychology, Aškerčeva 2, 1000 Ljubljana, Slovenia 4University of Ljubljana, Faculty of Medicine, Department of Prosthodontics, Hrvatski trg 6, 1000 Ljubljana, Slovenia Received: Jul 6, 2018 Original scientific article Accepted: Dec 19, 2018 ABSTRACT Keywords: multiple sclerosis, Sense of Coherence instrument, reliability, validity, Slovenia Aim: To validate the Slovenian version (SOC-13-SVN) of Sense of Coherence 13-item instrument (SOC-13) in Slovenian multiple sclerosis (MS) patients. Methods: A consecutive 134 Slovenian MS patients were enrolled in a cross-sectional study in 2013. The reliability of the SOC-13-SVN was assessed for internal consistency by Cronbach's alpha coefficient (a), dimensionality by the confirmatory factor analysis (CFA), and criterion validity by Pearson correlation coefficient (r) between SOC-13-SVN global score and MSQOL-54 composite scores - Mental Health Composite score (MHC) and Physical Health Composite score (PHC). Results: For the SOC-13-SVN instrument as a whole, internal consistency was high (atot> =0.88) while it was low for three subscales (a . .... =0.79; a . .... =0.66; a . ,. =0.69). The results of the CFA confirmed a v comprehensibility ' manageability ' meaningfulness ' three-factor structure with good fit (RMSEA=0.059, CFI=0.953, SRMR=0.065), however, the correlations between the factors were very high (r . , ..... =0.938; r . . =0.811; r . =0.930). J 3 v comprehensibility/manageabuity ' comprehensibility/meaningfulness ' manageability/meaningfulness ' The criterion validity analysis showed a moderate positive strength of relationship between SOC-13-SVN global score and both MSQOL-54 composite scores (MHC: r=0.597, p<0.001; PHC: r=0.437, p<0.001). Conclusion: Analysis of some psychometric properties confirmed that this instrument is a reliable and valid tool for use in Slovenian MS patients. Despite the three-dimensional structure of the instrument, the use of the global summary score is encouraged due to the low reliability of the subscale scores and high correlations between them. IZVLEČEK Ključne besede: multipla skleroza, občutek skladnosti, zanesljivost, veljavnost, Slovenija Namen: Ovrednotiti psihometrične lastnosti slovenske verzije (SOC-13-SVN) kratkega vprašalnika o občutku skladnosti s 13 postavkami (SOC-13) pri bolnikih z multiplo sklerozo (MS). Metode: V presečno raziskavo, ki je potekala leta 2013, je bilo vključenih 134 slovenskih bolnikov z MS. Zanesljivost kot notranjo skladnost SOC-13-SVN smo ocenili s Cronbachovim koeficientom alfa (a), komponentno strukturo s potrditveno faktorsko analizo (PFA) in kriterijsko veljavnost s Pearsonovim korelacijskim koeficientom (r) med celokupno vsoto postavk SOC-13-SVN in dveh vsot postavk vprašalnika o kakovosti življenja pri MS (MSQOL-54) - vsoto postavk duševnega zdravja (MHC) in vsoto postavk telesnega zdravja (PHC). Rezultati: Analiza SOC-13-SVN je pokazala, da ima instrument kot celota visoko notranjo skladnost (aslupn = 0,88), medtem ko je bila notranja skladnost za posamezno podlestvico nizka (a ... „ = 0,79; a ... = 0,66; ' '' J J r r 1 razumljivost ' ' upravljivost ' ' a smlelnost = 0,69). Rezultati PFA so potrdili trikomponentno strukturo z dobrim prileganjem (RMSEA = 0,059, CFI = 0,953, SRMR = 0,065), vendar pa je bila korelacija med komponentami zelo visoka (r ,.. „ ,.. . = ' ' '/' r j j r \ razumljivost/upravljivost 0,938; r , = 0,811; r , = 0,930). Rezultati analize kriterijske veljavnosti so pokazali ' ' razumljivost/smiselnost ' ' upravljivost/smiselnost ' ' j j r zmerno moč povezanosti med celokupno vsoto postavk SOC 13-SVN ter MHC in PHC vsotama postavk MSQOL-54 (MHC: r = 0,597, p < 0,001; PHC: r = 0,437, p < 0,001). Zaključek: Analiza nekaterih psihometričnih lastnosti je pokazala, da je SOC-13 SVN zanesljivo in veljavno orodje za uporabo pri slovenskih bolnikih z MS. Čeprav so rezultati potrdili tridimenzionalnost strukture vprašalnika, zaradi nizke zanesljivosti podlestvic in visoke korelacije med njimi priporočamo uporabo orodja kot celote. 'Corresponding author: Tel. + 386 31 662 592; E-mail: Liiana.Zaletel-Krageli@mf.uni-li.si; lnana.krageli@mf.uni-li.si NIJ,, za javno zdravje © Nacionalni inštitut za javno zdravje, Slovenija. 2 Nacionalni inštitut 31 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 1 INTRODUCTION Multiple sclerosis (MS) is a chronic neurological disease starting predominantly in the period of early/middle adulthood (1). It affects patients in a complex way, causing minor or greater disability (2). In MS, the effect of disability in daily living is reported to be greater in comparison to other chronic diseases (3, 4). Additionally, MS is considered as a leading cause of non-traumatic disability (e.g. sensory, motoric, coordination, balance or vision problems, cognitive disturbances, and attention/ memory deficits) in young adults in Europe (5). These facts pose a challenge to clinicians in terms of how to empower MS patients for coping with their illness over the long-term. Sense of coherence (SOC), the core construct of the salutogenetic model (6, 7), developed by the Antonovsky, an Israeli American sociologist, could play an important role in dealing with the disease (7). According to Calandri et al. (8), SOC seems to mediate the adjustment to MS among recently diagnosed patients. The SOC was originally defined by Antonovsky as "a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that (i) the stimuli from one's internal and external environments in the course of living are structured, predictable, and explicable; (ii) the resources are available to one to meet the demands posed by these stimuli; and (iii) these demands are challenges, worthy of investment and engagement" (6). In this context, he also proposed three dimensions/components of the SOC construct: comprehensibility (the ability to understand the situation), manageability (the perception of having resources to cope with the situation), and meaningfulness (the ability to find meaning in the situation) (6). To measure the SOC construct, the Orientation to Life questionnaire was developed (6). The original version consists of 29 (SOC-29), while the abbreviated version consists of 13 items (SOC-13) (6, 7). The comprehensive systematic review of Eriksson & Lindstrom (9) on more than 470 publications showed that, until 2003, the SOC questionnaires had been translated in at least 33 different languages, while a 2017 update revealed that they had been translated in another 16 languages, and used in more than 48 countries in total (7). Both instruments were validated many times in many different population groups, from general population to various groups of patients (e.g. patients with diabetes, cardiovascular diseases, cancer, rheumatoid arthritis, and schizophrenia). The studies evaluated the reliability, mostly in terms of internal consistency, as well as various aspects of validity, e.g. face, criterion, and construct validity (7, 9). The latter was mainly evaluated in terms of the instrument's factor structure (7, 9, 10). Exploratory (EFA) and/or confirmatory factor analysis (CFA) procedures were both applied (7, 10-14), using SPSS software for performing EFA (10, 11), and AMOS (11, 13, 15) or Mplus software (14, 16) for performing CFA procedures, for example. The Slovenian expert group from the Faculty of Medicine, University of Ljubljana, completed the translation/ cultural adaptation of the SOC-29 (SOC-29-SVN) and the SOC-13 (SOC-13-SVN) instruments into the Slovenian language, and made them available for research purposes in 2013 (17). However, they have not been validated in any population group in Slovenia yet. The newest epidemiological data places Slovenia among the countries with the highest MS prevalence worldwide (>100/100,000) (18). In addition, due to a long lifespan, a disability burden of the Slovenian MS patients is very high nowadays (19). Measuring the level of psychosocial dysfunction of MS patients for focused empowerment for a long-term successful coping with this chronic illness is, therefore, mandatory. To our knowledge, the SOC instrument has not been assessed among Slovenian MS patients yet and we could not find information on the validation of SOC questionnaires in the population of MS patients in online biomedical bibliographic/full-text databases. As it is very important to know whether an instrument reliably and validly measures what it intends to measure in a specific population, the aim of the present study was to validate the SOC-13-SVN instrument with the objective of assessing some of its psychometric characteristics in the Slovenian MS patients. 2 METHODS This study was carried out in the frame of a larger research project on the impact of SOC on quality-of-life and a self-perceived health in patients with MS at the Department of Neurology of the University Clinical Centre Maribor (UCCM), Slovenia, in the period of March to December 2013 (20). 2.1 Observed Population All members of the MS patient population, followed-up at the UCCM, which met the inclusion criteria similar to criteria in other MS quality-of-life studies (i.e. MS diagnosis established according to the McDonald's criteria (21), age 18+ years, without MS exacerbation in the last month prior to the scheduled neurological examination, and without chronic co-morbidity), were considered eligible for participating in the aforementioned research project and, consequently, in this study (20). 32 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 2.2 Study Instrument 2.2.1 Description of the SOC 13 Instrument The SOC-13 is an instrument with 13 items, each being scored on a seven-point scale (6) (Table 1). The values can be considered in the analysis with their original (original scoring) or reverse values (reverse scoring) (6) (Table 1). The measure given by the SOC-13 instrument is a summary score, obtained by summing the values of individual responses to all 13 items, ranging from 13-91 points, with higher scores indicating a stronger SOC. Table 1. Sense of Coherence 13-item instrument: items, their placement within three dimensions and scoring (6). Item No. Question* Dimension Scoring Item_1 Do you have the feeling that you don't really care about what goes on around you? Me R (1=Very seldom or never to 7=Very often) Item_2 Has it happened in the past that you were surprised by the behaviour of people whom C R you thought you knew well? (1=Never happened to 7=Always happened) Item_3 Has it happened that people whom you counted on disappointed you? Ma R (1=Never happened to 7=Always happened) Item_4 Until now your life has had: Me O (1=No clear goals or purpose at all to 7=Very clear goals and purpose) Item_5 Do you have the feeling that you're being treated unfairly? Ma O (1=Very often to 7=Very seldom or never) Item_6 Do you have the feeling that you are in an unfamiliar situation and don't know what to C O do? (1=Very often to 7=Very seldom or never) Item_7 Doing the things, you do every day is: Me R (1=A source of deep pleasure and satisfaction to 7=A source of pain and boredom) Item_8 Do you have very mixed-up feelings and ideas? (1=Very often to 7=Very seldom or never) C O Item_9 Does it happen that you have feelings inside you would rather not feel? C O (1=Very often to 7=Very seldom or never) Item_10 Many people - even those with a strong character - sometimes feel like sad sacks (losers) Ma R in certain situations. How often have you felt this way in the past? (1=Never to 7=Very often) Item_11 When something happened, have you generally found that: (1=You overestimated or C O underestimated its importance to 7=You saw things in the right proportion) Item_12 How often do you have the feeling that there's little meaning in the things you do in your Me O daily life? (1=Very often to 7=Very seldom or never) Item_13 How often do you have feelings that you're not sure you can keep under control? Ma O (1=Very often to 7=Very seldom or never) the permission of the copyright holder; C=comprehensibility; Legend: *=the questions from the questionnaire are reprinted with Ma=manageability; Me=meaningfulness; O=original; R=reverse 2.2.2 Translation to Slovenian Language The translation process was performed at the Chair of Public Health, Faculty of Medicine, University of Ljubljana, in the period of September 2012 to March 2013, after obtaining the written permission from the copyright holders of the original SOC-13. The translation was carried out by a specially established group for this task, consisting of well-qualified translators (two medical doctors, both specialists in public health, one medical nurse, and one medical sociologist, all with extensive experience in translating medical texts) and a medical student. Back-translation was carried out by a professional linguist with a university degree in English who had never seen the SOC-13 English version. The group followed 33 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 all the rules of quality translation. Final solutions were accepted with a full agreement of all group members in a final SOC-13-SVN version (17). 2.3 Instrument Administration and other Data Acquisition Participants completed the SOC-13-SVN in the presence of a neurology resident and MS nurse. Assistance in reading/ writing/explanation was provided if required. Along with the SOC-13-SVN, the socio-demographic data (gender: male, female; age; education: primary, secondary, college or higher; employment status: employed, unemployed, retired; marital status: single, married/cohabiting; area of living: rural, urban) were also collected. The clinical data, i.e. MS duration in years, a disease course (primary progressive, secondary progressive, relapsing-remitting), clinical worsening of MS in the past year prior to the neurological examination, excluding the period of 30 days prior to the examination (a relapse of relapsing-remitting type of MS or an increase of the EDSS score by 1 point in progressive type of MS; yes, no), the immunomodulatory therapy (yes, no), and the EDSS score, were extracted from the patients' medical records. Acceptability of the SOC-13-SVN was assessed by calculating a percentage of missing data. 2.4 Psychometric Validation The expectation-maximization technique was used to replace the missing values (22) and the descriptive statistics were utilized to describe the study participants' characteristics. The instrument's reliability was assessed using the internal consistency method. First, the Cronbach's alpha coefficient (a) was calculated for each of the three subscales. Then, these values were combined into the reliability of the total score as described in Nunnally & Bernstein (23). In order to assess the factor structure of the instrument, the CFA was conducted. The robust maximum likelihood estimator (MLM) was used. The criteria for the fit measures were a root mean squared error of approximation (RMSEA) <0.060, a comparative fit index (CFI) >0.950, and a standardized root mean squared residual (SRMR) <0.080 (24). Akaike information criterion (AIC) was used for model comparison. Criterion validity was assessed by calculating the Pearson correlation coefficient between the SOC-13 summary score, the Multiple Sclerosis Quality of Life (MSQOL-54) instrument composite scores (physical (PHC) and the mental health composite (MHC) scores) (25). The statistical analysis was performed with the SPSS software, version 21.0 (SPSS Inc., Chicago, IL, USA), except for the factor analysis in which the lavaan package (26) in the R environment (27) was used. 3 RESULTS 3.1 Study Participants Characteristics Out of 207 MS patients initially considered for inclusion, 57 did not meet the inclusion criteria: 55 (96.5%) had comorbidity and two (3.5%) a recent exacerbation of MS. In total, 134/150 eligible patients participated in the study (response rate: 134/150; 89.3%), while 16 refused. Among the participants, there were 42 males (31.3%) and 92 (68.7%) females. Mean age was 43.2±11.1 years (range: 21-72 years). All other participants' characteristics are presented in Table 2. The mean SOC-13 summary score was 67.8 (13.3; min: 28; max: 91). The characteristics of the individual item values distribution are displayed in Table 3. 3.2 Missing Values Analysis The percentage of missing data was generally low. For 7 items (53.8%) there were no missing data. In the other 6 items the range of missing data was 0.7-3.0% (1 or 0.7% in 3 items, 2 or 1.5% in 1 item, 3 or 2.2% in 1 item, and 4 or 3.0% in 1 item). The highest percentage of missing data was recorded in Item_8 (detailed item description is given in Table 1). 34 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 Table 2. Characteristics of the multiple sclerosis (MS) patients group for validation of Slovenian version of the Sense of Coherence 13-item instrument (n=134). Characteristic Category No. (%) / Median; Min-Max; Q1-Q3 Education Employment status Marital status Area of living Disease duration (years) Disease course Clinical worsening of the disease* Immunomodulatory therapy EDSS Primary Secondary College or higher Employed Unemployed Retired Single Married/cohabiting Rural Urban Primary progressive Secondary progressive Relapsing-remitting No Yes No Yes 16 (11.9) 94 (70.1) 24 (17.9) 63 (47.0) 18 (13.4) 53 (39.6) 44 (32.8) 90 (67.2) 80 (59.7) 54 (40.3) 8; 0-33; 4-12.25 6 (4.5) 23 (17.2) 105 (78.4) 83 (61.9) 51 (38.1) 42 (31.3) 92 (68.7) 3; 0-8; 1.625-4.5 Legend: Q1 - the first quartile; Q3 - the third quartile; *- clinical worsening of the disease in the past year prior to the neurological examination, excluding the period of 30 days prior to the examination (a relapse of relapsing-remitting type of MS or an increase of the EDSS score by 1 point in progressive type of MS); EDSS - Expanded Disability Status Scale score Table 3. Characteristics of the distribution of values of items of the Sense of Coherence 13-item instrument in the validation study in multiple sclerosis patients (n=134). Item Mean Standard Deviation Median Interquartile range tem_1 5.6 1.6 6 4.44-7 tem_2 4.7 1.7 5 3-6 tem_3 4.8 1.7 5 4-6 tem_4 5.7 1.4 6 5-7 tem_5 5.3 1.7 6 4-7 tem_6 5.4 1.6 6 4-7 tem_7 5.4 1.3 6 4-6 tem_8 4.9 1.7 5 4-6.25 tem_9 5.0 1.8 6 4-6.25 tem_10 5.0 1.6 5 4-6 tem_11 5.0 1.5 5 4-6 tem_12 5.7 1.5 6 5-7 tem_13 5.0 1.7 5 4-6.25 35 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 3.3 Psychometric Validation 3.3.1 Reliability For the instrument as a whole, internal consistency was high (atota=0.88) while it was low for three subscales (a, comprehensibility =0.79; a manageability =0.66; a, 'meaningfulness =0.69). 3.3.2 Factor Structure In the CFA, three factor analysis models were defined and tested: the one-factor model, the three-factor model, and a modified three-factor model with correlated uniquenesses. In the third model, we allowed correlated residuals for the Item_2 (comprehensibility dimension) and the Item_3 (manageability dimension), as well as for the Item_4 (manageability dimension) and the Item_13 (meaningfulness dimension) (a detailed description of the items is given in Table 1). The statistical properties of these three models are presented in Table 4. The first two models did not fit well, although the fit of the three-factor model was slightly better compared to the one-factor model. The former model was also to be preferred according to AIC. However, the modified three-factor model exhibited a good fit and was to be clearly preferred according to AIC (Table 4). The Table 5 presents raw (with standard errors) and standardized factor loadings for the modified three-factor model. All loadings were reasonably high, although some items appeared to be better measures of their respective constructs. The correlations between the factors were very high: 0.938 between comprehensibility and manageability dimensions, 0.811 between comprehensibility and meaningfulness dimensions, and 0.930 between manageability and meaningfulness dimensions. 3.3.3 Criterion Validity The analysis showed a moderate positive strength of relationship between SOC-13 score and both MSQOL-54 composite scores (MHC score: r=0.597; PHC score: r=0.437). In both cases, the association was highly statistically significant (p<0.001). Table 4. Comparison of three factor analysis models in the Slovenian version of the Sense of Coherence 13-item instrument validation study in multiple sclerosis patients (n=134). Item X2 df p AIC RMSEA CFI SRMR 1-factor 190.63 65 <0.001 6055.38 0.120 0.786 0.084 3-factor 177.10 62 <0.001 6045.75 0.118 0.804 0.083 Modified 3-factor 87.68 60 0.011 5931.90 0.059 0.953 0.065 Legend: AIC=Akaike information criterion; RMSEA=root mean squared error of approximation, CFI=comparative fit index; SRMR=standardized root mean squared residual Table 5. Factor loadings for the final model in the Slovenian version of the Sense of Coherence 13-item instrument validation study in multiple sclerosis patients (n=134). Item Item Loading (SE) Standardized loading Comprehensibility Item_2 0.804 (0.148) 0.476 Item_6 1.185 (0.126) 0.726 Item_8 1.451 (0.107) 0.834 Item_9 1.370 (0.125) 0.763 Item_11 0.730 (0.140) 0.505 Manageability Item_3 0.693 (0.140) 0.421 Item_5 0.820 (0.149) 0.479 Item_10 0.740 (0.163) 0.467 Item_13 1.325 (0.112) 0.787 Meaningfulness Item_1 0.506 (0.134) 0.319 Item_4 0.890 (0.124) 0.658 Item_7 0.806 (0.105) 0.623 Item_12 1.266 (0.142) 0.855 36 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 4 DISCUSSION Based on the results of this study, we can conclude that the SOC-13-SVN successfully passed the evaluation for cultural equivalence as well as fulfilled the necessary psychometric criteria for being used in the Slovenian MS patients' population. The results of the reliability analysis are consistent with the results reported in other similar studies. In particular, the reliability of the total score obtained in our study is in the upper part of the values range of this measure obtained in other similar studies (range 0.70-0.93) (9, 1012, 15, 16, 28-34). Taking the small number of items into account, it can be considered to be reasonably high and close to the value recommended when making decisions about individuals (23). Analysis of the factor structure has confirmed a three-factor structure of the SOC-13-SVN with good fit. The multidimensionality shown in our study is consistent with the results of a systematic review of Eriksson & Lindstrom (9), who concluded that the SOC seems to be a multidimensional construct. According to that review, factor analysis in a few studies confirmed the unidimensional model, while in others this failed, and two-factor, three-factor, and five-factor models of structure were found (9). However, our three-factor model was modified. Correlated residuals were allowed for two pairs of items, since the items in both pairs have something in common, regardless of whether they belong to different dimensions. In the first pair (Item_2, Item_3), both items address participants' expectations about people who could help them in distress, while in the second pair (Item_4, Item_13), both items are focused on the management of life situations. These results are in line with Antonovsky who stated that items, although theoretically pertaining to one dimension, share elements with items from other dimensions (6). Despite the three-dimensional structure, the use of the single total score is encouraged in our study. The first reason is the high correlations between dimensions and low reliability of the subscale scores were found in our study and the second that the one-factor model was advocated by Antonovsky himself, since the questionnaire was not intended to measure dimensions individually (6, 28). The criterion validity results were also consistent with the results of other similar studies, which used quality-of-life instruments for assessing this aspect of validity (range 0.51-0.77) (9). Finally, if we make a rough comparison of the SOC-13 summary score mean value obtained in our MS patients, this almost coincides with the results of the only similar study that we found, i.e. the study of Broersma et al. (67.5±13.3) (35). This study has some limitations. First, a relatively small number of participants were included in the present study, however, the number was still sufficient to permit fair conclusions. Next, one could argue that no method of measurement of stability of the instrument over time, e.g. the test-retest method, was used in the present study. However, the reliability of any patient-reported outcome measure can be evaluated using measurement stability methods and/or measurement equivalence methods. The later were developed in the social science research for the situations in which it is not possible to perform repeated measurements because the measured phenomenon changes or could change over time (36). As we assumed, based on results of previous studies (37-39), that the phenomenon measured in our study could change over time so, due to specificities of the observed group, only the measures of equivalence were used (36). Finally, not all aspects of validity were analysed in this study, however, we decided to report only usually reported results as in similar studies (9, 10-12, 15, 16, 28-34). The study also has some important strengths. The most important is that this study provided novel knowledge about the psychometric properties of SOC-13 instrument when evaluated in MS patients. Given the results of this study, MS patients could join a number of population groups and settings in which the SOC is or was assessed (7). Moreover, new opportunities are opening toward a more personalized medicine approach in terms of integrating health promotion approaches (i.e. by using SOC for increasing/strengthening interventions (40, 41)) for disease management in MS patients. There are still many challenges in researching the use of SOC-13 in MS patients. It is necessary first to check the dynamics/stability of the SOC in time, especially in those subgroups with more rapidly evolving and/or a more severe form of MS, as well as in those with comorbidity. In the latter group, the SOC has to a certain extent already been studied in MS patients with depressive symptoms (42). Additionally, with a focus on studying the properties of the SOC-13-SVN, further evaluation is needed. Our work can be continued by working on a larger dataset and analysing additional aspects of validity. 5 CONCLUSION The rigorously performed translation process provided a good quality translation of the SOC-13 to Slovenian language. Analysis of its psychometric properties proved that this instrument is a reliable tool for use in Slovenian MS patients. 37 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 ACKNOWLEDGMENTS The authors thank Majda Pahor, Andreja Mihelic-Zajec, Jerneja Farkas-Lainscak, Cita Cvrn, and Breda Vrhunec for their participation in the process of translation of the SOC-13 in Slovenian language, and Tanja Hojs Fabjan for her participation in data acquisition. CONFLICTS OF INTEREST The authors declare no conflict of interest. FUNDING The study received no funding. ETHICAL CONSIDERATIONS The study was approved by the Medical Ethics Committee of Slovenia on July 17, 2012 (approval No. 24k/07/12). REFERENCES 1. World Health Organisation. Neurological disorders: public health challenges. Geneva: WHO, 2006. 2. Benito-Leon J, Manuel Morales J, Rivera-Navarro J, Mitchell A. A review about the impact of multiple sclerosis on health-related quality of life. 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Methodological notes 10. Reliability and validity of measurement (in Slovenian). Ljubljana: University of Ljubljana, FDV, 1995. 37. Karlsson I, Berglin E, Larsson PA. Sense of coherence: quality of life before and after coronary artery bypass surgery - a longitudinal study. J Adv Nurs. 2000;31:1383-92. 38. Forsberg A, Backman L, Svensson E. Liver transplant recipients'ability to cope during the first 12 months after transplantation - a prospective study. Scand J Caring Sci. 2002;16:345-52. 39. Snekkevik H, Anke AG, Stanghelle JK, Fugl-Meyer AR. Is sense of coherence stable after multiple trauma? Clin Rehabil. 2003;17:443-53. doi: 10.1191/0269215503cr630oa. 40. Kahonen K, Naatanen P, Tolvanen A, Salmela-Aro K. Development of sense of coherence during two group interventions. Scand J Psychol. 2012;53:523-7. doi: 10.1111/sjop.12020. 41. Super S, Wagemakers MA, Picavet HS, Verkooijen KT, Koelen MA. Strengthening sense of coherence: opportunities for theory building in health promotion. Health Promot Int. 2016;31:869-78. doi: 10.1093/heapro/dav071. 42. Gottberg K, Einarsson U, Fredrikson S, von Koch L, Holmqvist LW. A population-based study of depressive symptoms in multiple sclerosis in Stockholm county: association with functioning and sense of coherence. J Neurol Neurosurg Psychiatry. 2007;78:60-5. doi: 10.1136/jnnp.2006.090654. 39 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-40 Ferrao AC, Correia P, Ferreira M, Guine RPF. Perceptions towards healthy diet of the Portuguese according to area of work or studies. Zdr Varst. 2019;58(1):40-46. doi: 10.2478/sjph-2019-0005. PERCEPTIONS TOWARDS HEALTHY DIET OF THE PORTUGUESE ACCORDING TO AREA OF WORK OR STUDIES DOJEMANJE ZDRAVE PREHRANE PORTUGALCEV GLEDE NA NJIHOVO PODROČJE DELA ALI ŠTUDIJA Ana Cristina FERRAO1*, Paula CORREIA2, Manuela FERREIRA2, Raquel P. F. GUINÉ2 1Instituto Politécnico de Viseu Escola Superior Agraria de Viseu, Departamento de Indústrias Alimentares, Quinta da Alagoa, Estrada de Nelas, Ranhados, Viseu, 3500-606, Portugal 2CI&DETS/CERNAS Research Centres, Polytechnic Institute of Viseu, Campus Politécnico, Repeses, Viseu, 3500-606, Portugal Received: Jun 14, 2018 Original scientific article Accepted: Jan 3, 2019 ABSTRACT Keywords: food areas, healthy diet, nutrition knowledge, perceptions, survey, Portugal Introduction: A healthy diet is crucial for the maintenance of health. Therefore, the aim of this work is to evaluate the perceptions towards a healthy diet among the participants with work or studies in areas related to diet and nutrition and those who did not. Methods: Anonymous questionnaire data was collected in a cross-sectional study on a non-probabilistic sample of 902 participants living in Portugal. Results: The results showed that the participants' perceptions were, in general, compliant with a healthy diet. However, significant differences were found between gender (p=0.004), between the different civil state groups (p=0.016), between the participants who were responsible for buying their own food and those who were not and also regarding the living environment. The variable area of work or studies also showed significant differences (p=0.001), so that people who had work or studies related to agriculture obtained a higher score. Regarding this variable, the mean values of nutrition and agriculture areas were not statistically different between them, but were statistically different from the mean values of psychology and health areas. The participants who had work or studies in areas showing diet and nutrition-related issues achieved a higher mean score (0.72±0.35) when compared to the participants who did not (0.58±0.30). Conclusion: However, despite the results, it is important to continue developing campaigns that better communicate nutritional aspects, so that people can increase their knowledge on this subject. IZVLEČEK Ključne besede: področje prehrane, zdrava prehrana, znanje o prehrani, dojemanje prehrane, vprašalniki, Portugalska Uvod: Zdrava prehrana je ključnega pomena za ohranjanje zdravja. Zato je cilj te študije oceniti dojemanje zdrave prehrane med v raziskavi sodelujočimi zaposlenimi in študenti, ki so profesionalno povezani s področjem prehrane, in tistimi, ki to niso. Metode: Anonimni podatki iz vprašalnika so bili zbrani v medsektorski študiji z verjetnostnim vzorčenjem 902. sodelujočih, ki prebivajo na Portugalskem. Rezultati: Rezultati so pokazali, da je dojemanje zdrave prehrane med sodelujočimi v študiji na splošno v skladu z zdravo prehrano. Pokazale pa so se izrazite razlike med spoloma (p = 0,004), med različnimi skupinami glede na zakonski stan (p = 0,016), med sodelujočimi, ki so odgovorni za nakup lastne hrane, in tistimi, ki to niso, ter glede na bivalno okolje. Različna področja dela ali študija so prav tako pokazala izrazite razlike (p = 0,001), kar pomeni, da imajo osebe, ki so zaposlene na področju kmetijstva ali študirajo kaj v zvezi s prehrano, na tem področju boljše rezultate. Na podlagi te spremenljivke se povprečne vrednosti iz področja kmetijstva statistično ne razlikujejo med seboj, vendar se statistično razlikujejo od povprečnih vrednosti s področja psihologije in zdravstva. Sodelujoči, ki so profesionalno kakorkoli povezani s prehrano, so dosegli višje povprečne rezultate (0,72 ± 0,35) v primerjavi z ostalimi (0,58 ± 0,30). Zaključek: Kljub tem rezultatom je pomembno, da nadaljujemo s promocijo zdrave prehrane in ljudi izobražujemo in ozaveščamo o pomenu zdrave prehrane. 'Corresponding author: Tel. + 351 232 446 640; E-mail: acristinaferrao@gmail.com 40 M||7 Nacionalni Inštitut IMIJ fc za javno zdravje © Nacionalni inštitut za javno zdravje, Slovenija. 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 1 INTRODUCTION Healthy eating is one of the major factors that contributes to preventing people becoming overweight or obese, as well as a number of non-communicable chronic diseases (NCDs), such as heart diseases, type II diabetes and cancer (1). Eating patterns should consist of various combinations of foods that may differ in macronutrient, vitamin, and mineral compositions. Therefore, in order to follow a healthy diet it is important to emphasise the intake of vegetables, fruits, and whole grains, and to include the consumption of low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts. On the other hand, the intake of sweets, sugar-sweetened beverages and red meats should be limited (2). According to the World Health Organization (3), smoking, physical inactivity, unhealthy diet, and alcohol are strongly associated and causally linked to the incidence of most NCDs. However, choosing to have a healthy diet is not a simple task, because people's food choices constitute more than a simple matter about food nutritional value (4). People's food choices are influenced by many factors, namely biological, health, emotional, social, convenience, price, ethical concerns and nutrition knowledge, among others (5, 6). Nutritional knowledge is influenced by different sociodemographic characteristics, such as age, gender, level of education, and socio-economic status (7). According to the Social Cognitive Theory (8), knowledge is one of the important determinants that contributes to change behaviour. Several studies suggested that there is a positive association between higher nutrition knowledge and the adoption of healthier dietary patterns (9, 10), as well as lower rates of obesity (11-13). However, not all studies have found an association between nutrition knowledge and healthier eating habits (14). Nevertheless, increasing people's nutrition knowledge is still an important health strategy (15). Since the information about Portuguese nutrition knowledge is limited, it is crucial to perform more studies in this area in order to develop and implement more effective programs to encourage the choice of a healthier diet. This study is included in the multinational project entitled "Psycho-social motivations associated with food choices and eating practices (EATMOT)" which intends to perform research about the different psychological and social motivations that determine people's eating patterns in relation to their choices or eating habits. The main goal of this particular study is to compare the perceptions towards a healthy diet between the participants who had work or studies in areas that addressed diet and nutrition-related issues and those who did not have. The study also analyses in what way other sociodemographic factors could influence the participants' perceptions about a healthy diet. 2 MATERIALS AND METHODS 2.1 Instrument For this study, a questionnaire was purposely created to take into consideration a literature review of other existing instruments (16-22). The questionnaire included two parts destined to collect information about several important issues: Part I - Sociodemographic data (1. Age; 2. Gender; 3. Highest level of education completed; 4. Living environment; 5. Civil state; 6. Present professional activity; 7. Area of the professional activity or studies; 8. "Are you responsible for buying the food you eat?"); Part II - Perceptions about a healthy diet (1. "A healthy diet is based on calorie count"; 2. "We should never consume sugary products"; 3. "Fruit and vegetables are very important for a practice of healthy eating"; 4. "A healthy diet should be balanced, varied and complete"; 5. "We can eat everything, as long as it is in small quantities"; 6. "I believe that food produced in a biological way is healthier" and 7. "We should never consume fat products"). In order to measure the perceptions towards a healthy diet, a scale ranging from -2 to +2 was used, which can be interpreted as follows: [-2.0 ; -1.5] perceptions not at all compliant with a healthy diet; [-1.5 ; -0.5] perceptions not compliant with a healthy diet; [-0.5 ; 0.5] perceptions poorly compliant with a healthy diet; [0.5 ; 1.5] perceptions compliant with a healthy diet; [1.5 ; 2.0] perceptions fully compliant with a healthy diet. Then, an average of the scores obtained for all the items included in part II of the questionnaire was calculated. 2.2 Data Collection A descriptive cross-sectional study on a non-probabilistic sample of 902 participants was undertaken. The data was collected from September 2017 to January 2018, among the Portuguese population. The questionnaires were applied online, after informed consent, only to adults (aged 18 or over). All ethical issues were verified when formulating and applying the questionnaire, which was approved by the Ethical Committee with reference no. 04/2017. 2.3 Statistical Analysis For exploratory analysis of the data, several basic descriptive statistical tools were used, for example, the mean and standard deviation. In all tests, the level of significance considered was 5% (p<0.05) and for all data analyses the SPSS software from IBM Inc. (version 24) was used. 41 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 In order to compare the means of two groups, the Student's t-test for independent samples was used and for the comparison of the means of three or more groups one-way ANOVA was used. In the case of ANOVA, to assess the differences between groups the post-hoc Tukey HSD test was used. The Tukey's test, also known as the Tukey's HSD (Honestly Significant Difference) test is a statistical test to find out which means are significantly different from each other, and consists of a single-step multiple comparison procedure, coupled to ANOVA (23). In this test, the difference between means is evaluated to see whether or not it is greater than the standard error (2426). 3 RESULTS AND DISCUSSION 3.1 Sample Characterization Table 1 summarises the demographical data for the sample being studied. This work involved 902 participants aged a minimum of 19 years and a maximum of 80 years, being on average 42±13 years, from which 63.1% were women and 36.9% were men. The average age of men, 44±14 years, was higher than that of women, 41±13 years. As for age, the participants were classified into categories according to: young adults (18< age <30), corresponding to 23.9%; average adults (31< age <50), accounting for 47.3%; senior adults (51< age <64), representing 23.2%; and finally elderly (>65), which accounted for 5.5% of the sample. Concerning the level of education, 71.6% of the participants had a university degree, 28.4% had completed secondary school, and none had the primary school as the highest level of education achieved. Regarding the civil state, most of the participants were married or lived together as a marital couple (63.3%), 23.5% were single, 7.0% were divorced or separated and 6.2% were widowed. As for the living environment, 88.9% of the participants lived in an urban area, 6.5% lived in rural areas and 4.5% lived in a suburban area. Regarding the profession, most of the participants were employed (77.7%), 10.8% were students, 4.3% were working students, 4.0% were retired and 3.2% were unemployed. Table 1. Sociodemographical characterization. Sociodemographic Percentage data (%) Age 18y< age <30y 23.9 31y< age <50y 47.3 51y< age <64y 23.2 Age>65y 5.5 Gender Women 63.1 Men 36.9 Highest level of education Primary school 0.0 Secondary school 28.4 University degree 71.6 Living environment Rural 6.5 Urban 88.9 Suburban 4.5 Civil state Single 23.5 Married/Living 63.3 together Divorced/Separated 7.0 Widow 6.2 Profession Employed 77.7 Unemployed 3.2 Student 10.8 Retired 4.0 Working student 4.3 Area of studies or work Nutrition 3.7 Food 5.3 Agriculture 2.9 Sport 1.0 Psychology 1.2 Health 7.8 Others 78.2 Concerning the participants' professional activity or field of studies, the majority of the participants, 78.2%, did not have any professional activity or field of studies related to any of the options suggested (nutrition, food science, agriculture, sport, psychology, activities related to other health areas), 7.8% had a professional activity or field of studies related to other health areas, 5.3% had a professional activity or field of studies related to food, 3.7% had a professional activity or field of studies related to nutrition, 2.9% had a professional activity or field of studies related to agriculture, 1.2% had a professional activity or field of studies related to psychology and only 1.0% had an activity or studies in the sport area. In general, 20.6% of the participants had a professional activity or field of studies related to areas that addressed diet and nutrition-related issues, against 79.4% who did not. When seen by gender, a higher percentage of women, 24.6%, had a professional activity or field of studies related to that area when compared to men (15.3%). 42 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 When the participants were asked if they were responsible for buying their own food, 97.2% answered yes against only 2.8% that answered no, having a similar percentage for both men and women, 97.0% and 97.4%, respectively. 3.2 Perceptions Towards a Healthy Diet 3.2.1 Individual's Characteristics For the sample at study, the mean score for the participants' perceptions towards a healthy diet was equal to 0.61±0.31, meaning that, in general, the participants' perceptions were compliant with a healthy diet. Table 2 presents the results for the relations between an individual's characteristics and their perceptions towards a healthy diet and, as it can be observed, the mean scores were similar for all age groups and were between 0.5 and 1.0, which means that for those participants the perceptions were compliant with a healthy diet. The results of the ANOVA test revealed that there were no significant differences in the perceptions towards healthy eating among age groups. This finding is consistent with another study, in which it was also shown that nutritional knowledge was not associated with age (27). Regarding gender, it was found that both men and women had perceptions compliant with a healthy diet, with a higher mean score for women (0.63±0.33) when compared to men (0.57±0.28). As was expected, there were found to be significant differences between genders. Previous studies also suggested that women tended to have a higher nutritional knowledge than men (28, 29). As for the civil state, all groups had mean values between 0.5 and 1.5, corresponding to perceptions compliant with a healthy diet in all cases. The results of the ANOVA test showed that there were significant differences between the civil state groups. In fact, living arrangements and marital status have been shown to have a significant effect on a person's health and mortality (30) and, generally, married people tend to have better health profiles than other people, including those who are divorced, separated or widowed (31-33). Table 2. Relations between an individual's characteristics and their perceptions towards a healthy diet (scale from -2=perceptions not at all compliant with a healthy diet to +2=perceptions fully compliant with a healthy diet). Variable Mean±SD P Age group 18y< age <30y 0.61±0.31a 0.4851 31y< age <50y 0.61±0.31a 51y< age <64y 0.61±0.33a Age>65y 0.54±0.26a Gender Women 0.63±0.33 0.0042 Men 0.57±0.28 Civil state Single 0.66±0.33a 0.0161 Married/Living together 0.60±0.31a Divorced/Separated 0.55±0.31a Widowed 0.55±0.21a Highest level of education Secondary school 0.61±0.31 0.9522 University 0.61±0.31 Is responsible for buying the food Yes 0.60 ±0.31 0.0002 No 0.88±0.30 Living environment Rural 0.83±0.35b 0.0001 Urban 0.58±0.30a Suburban 0.86±0.29b 1ANOVA for comparison of 3 or more groups (Level of significance 5%). Mean values with the same letter are not statistically different (p<0.05). 2Student's t-test for independent samples for comparison of 2 groups (Level of significance 5%). 43 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 Regarding the level of education, it was observed that there were no significant differences between the participants who had a university degree and those who had secondary school as their terminal education. In both cases, the mean score was equal to 0.61±0.31, meaning that for those participants the perceptions were compliant with a healthy diet. This finding is not consistent with the ones obtained in previous studies, where it was found that a higher level of education usually corresponds to a better nutritional knowledge (27, 34). The results of the Student's t-test showed that there were significant differences between the participants who were responsible for buying their own food and the participants who were not, with the participants who were not responsible being the ones that obtained the highest mean score (0.88±0.30). However, in both cases the participants' perceptions were compliant with a healthy diet. Concerning the living environment, with a higher mean score came the participants who lived in suburban areas (0.86±0.29), followed by the participants who lived in rural areas (0.83±0.35) and finally the ones who lived in urban areas (0.58±0.30), meaning that for those participants the perceptions were compliant with a healthy diet. Furthermore, there were found to be significant differences in the perceptions towards healthy eating among the participants that lived in different areas. 3.2.2 Professional Characteristics Table 3 presents the relations between professional characteristics and the perceptions towards a healthy diet and, as can be observed, the scores obtained for the perceptions towards a healthy diet according to the professional status were 0.62±0.29 for students, 0.61±0.31 for employed participants, 0.61±0.36 for working students, 0.59±0.39 for unemployed participants and 0.56±0.26 for retired, which means that the participants in all of these professional groups had perceptions compliant with a healthy diet. However, no significant differences were found. According to scientific evidences, an unhealthy diet and adverse effects on health are generally associated with lower incomes, lower education or working in lower status (35, 36). Others studies suggested that students are only slightly aware of nutrition issues and their knowledge and attitudes are average (37). The results also revealed that the participants who had work or studies in areas where diet and nutrition-related issues are addressed had a higher mean score than the participants who did not have (0.72±0.35 and 0.58±0.30, respectively). As it was expected, significant differences were found between these two groups concerning the perceptions towards a healthy diet. Nevertheless, in both cases the participants' perceptions were compliant with a healthy diet. Table 3. Relations between professional characteristics and the perceptions towards a healthy diet (scale from -2=perceptions not at all compliant with a healthy diet to +2=perceptions fully compliant with a healthy diet). Variable Mean±SD p-value Professional status Employed 0.61±0.31a 0.8781 Unemployed 0.59±0.39a Student 0.62±0.29a Retired 0.56±0.26a Working student 0.61±0.36a Work or studies related to food areas Yes 0.72±0.35 0.0002 No 0.58±0.30 Area of studies or work Nutrition 0.83±0.33b 0.0001 Food 0.80±0.28ab Agriculture 0.84±0.37b Sport 0.63±0.36ab Psychology 0.56±0.40a Health 0.55±0.32a Others 0.58±0.30ab 1ANOVA for comparison of 3 or more groups (Level of significance 5%). Mean values with the same letter are not statistically different (p<0.05). 2Student's t-test for independent samples for comparison of 2 groups (Level of significance 5%). 44 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 As for the area of studies or work, the participants who had work or studies related to agriculture were the ones obtaining the highest score (0.84±0.37), followed by the participants who had work or studies related to nutrition (0.83±0.33), the participants who had work or studies related to food (0.80±0.28), the participants who had work or studies related to sport (0.63±0.36), the participants who had work or studies related to other areas (0.58±0.30), the participants who had work or studies related to psychology (0.56±0.40) and finally the participants who had work or studies related to health areas (0.55±0.32). Nevertheless, in all cases the participants' perceptions were compliant with a healthy diet. Furthermore, significant differences were found among the areas of study/work. More specifically, the mean values of nutrition and agriculture areas were statistically different from the mean values of psychology and health areas. Kris-Etherton et al. (38) reviewed the status of nutrition education for healthcare professionals, namely physicians, in the United States, United Kingdom, and also Australia. They concluded that most healthcare professionals are not adequately trained to address diet and nutrition-related issues with their patients. On the contrary, according to the results of the study by Alissa et al. (39), most medical students are aware about the importance of a healthy diet. In another study by Peltzer et al. (40), it was observed that there was no association between risk awareness and health risk behaviour among health science students and there was an inverse association among non-health science students. 4 CONCLUSION This study allowed for the obtaining of important results about people's perceptions towards a healthy diet in a sample of the Portuguese population, namely, in general, the participants' perceptions were compliant with a healthy diet. There were no significant differences in healthy diet perceptions' scores regarding age group, level of education, and professional status. On the other hand, there were significant differences among gender, civil state, the fact that the participants were responsible for buying their own food or not, the living environment and the area of studies or work. Regarding the area of work/studies, the highest score achieved was for the participants who had work or studies in agriculture areas and the lowest for the ones who had work/study in health areas. The mean values obtained for nutrition and agriculture areas were not statistically different between them, but they were statistically different from the scores obtained for psychology and health areas. Overall, the results suggested that the participants who had work or studies in areas where diet and nutrition-related issues are addressed are more aware about some nutritional aspects of their diet than the participants who did not. However, there were no mean scores equal or higher than 1.50, which means that in none of the cases the participants' perceptions were fully compliant with a healthy diet. Therefore, it is crucial to continue developing health promotion projects that allow for increasing people's nutrition knowledge. 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Nurs Health Sci. 2016;18:180-7. doi: 10.1111/ nhs.12242. 46 10.2478/sjph-2019-0012 Ucakar V, Kraigher A. Acceptance of seasonal influenza vaccination among Slovenian physicians, 2016. Zdr Varst. 2019;58(1):47-53. doi: 10.2478/sjph-2019-0006. Zdr Varst. 2019;58(2):91-47 ACCEPTANCE OF SEASONAL INFLUENZA VACCINATION AMONG SLOVENIAN PHYSICIANS, 2016 SPREJEMLJIVOST CEPLJENJA PROTI SEZONSKI GRIPI MED SLOVENSKIMI ZDRAVNIKI, 2016 Veronika UČAKAR1*, Alenka KRAIGHER2 1National Institute of Public Health, Trubarjeva 2, 1000 Ljubljana, Slovenia 2Poljanska 19, 1000 Ljubljana, Slovenia Received: May 28, 2018 Original scientific article Accepted: Jan 7, 2019 ABSTRACT Keywords: influenza, vaccinations, physicians, Slovenia Introduction: Vaccination against seasonal influenza is recommended for all healthcare workers including physicians in Slovenia to protect vulnerable individuals and reduce transmission of influenza viruses. The aim of our study is to determine the uptake of seasonal influenza vaccination among Slovenian physicians, to identify factors associated with that vaccination and assess their attitudes and beliefs regarding vaccination and vaccine-preventable diseases. Methods: A cross-sectional survey was performed among physician members of the Slovenian Medical Chamber. The link to the anonymous web-based questionnaire was sent to 8,297 physicians. We estimated the overall proportion of physicians who vaccinate against influenza, while the possible associations with collected explanatory variables were explored in univariate analyses. Results: The response rate to the survey was 10.8%. 75.9% (95% CI: 73.1-78.7%) physicians vaccinate themselves against influenza (regularly or occasionally) and 24.1% (95% CI: 21.2-26.8%) do not vaccinate (not any more or never). In univariate analysis only, the area of work was statistically significant when associated with vaccinating against influenza (p=0.002). Among physicians who expressed some misconceptions regarding vaccination and vaccine-preventable diseases (it is better to overcome disease naturally as vaccines pose a higher risk than disease) the proportion of vaccinated against influenza was low (43.2%; 95% CI: 27.9-58.4%, 27.3%; 95% CI: 7.1-47.5%). Conclusion: Not trusting in vaccination or professional recommendations regarding vaccination and some misconceptions regarding vaccination and vaccine-preventable diseases may influence the decision to be vaccinated against seasonal influenza among Slovenian physicians. IZVLEČEK Ključne besede: sezonska gripa, cepljenje, zdravniki, Slovenija Uvod: Cepljenje proti sezonski gripi je priporočljivo za zaščito ranljivih posameznikov in zmanjšanje prenosa virusov influence za vse zdravstvene delavce v Sloveniji, vključno z zdravniki. Namen raziskave je bil med slovenskimi zdravniki ugotoviti delež cepljenih proti sezonski gripi, določiti dejavnike, povezane s tem cepljenjem ter oceniti njihov odnos in prepričanja glede cepljenja in bolezni, ki jih preprečujemo s cepljenjem. Metode: Izvedena je bila presečna raziskava med zdravniki, ki so člani Zdravniške zbornice Slovenije. Link do anonimnega spletnega vprašalnika je bil poslan 8.297 zdravnikom. Ocenili smo skupni delež zdravnikov, ki se cepijo proti gripi, morebitno povezanost z izbranimi pojasnjevalnimi spremenljivkami smo proučili z univariatnimi analizami. Rezultati: Stopnja odgovora v raziskavi je bila 10,8 %, 75,9 % (95 % CI: 73,1-78,7 %) zdravnikov se cepi proti gripi (redno ali občasno), 24,1 % (95 % CI: 21,2-26,8 %) pa se jih ne cepi (ne več ali nikoli). V univariatni analizi se je le področje dela izkazalo za statistično značilno povezano s cepljenjem proti sezonski gripi (p = 0,002). Med zdravniki, ki so izrazili nekatera napačna prepričanja v zvezi s cepljenjem in boleznimi, ki jih preprečujemo s cepljenjem (bolje je bolezen preboleti po naravni poti, cepiva predstavljajo večje tveganje kot bolezen), je bil delež cepljenjih proti influenci nizek (43,2 %; 95 % CI: 27,9-58,4 %, 27,3 %; 95 % CI: 7,1-47,5 %). Zaključek: Nezaupanje v cepljenje ali v strokovna priporočila glede cepljenja ter nekatera napačna prepričanja v zvezi s cepljenjem in boleznimi, ki jih preprečujemo s cepljenjem, lahko vplivajo na odločitev o cepljenju proti sezonski gripi med slovenskimi zdravniki. 'Corresponding author: Tel. + 386 1 2441 579; E-mail: veronika.ucakar@nijz.si NIJ,, za javno zdravje © Nacionalni inštitut za javno zdravje, Slovenija. 2 Nacionalni inštitut 47 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 1 INTRODUCTION In Europe, influenza occurs in regular annual epidemics in the winter season. Seasonal influenza epidemics are associated with high morbidity and mortality. Severe illness and complications are more common in certain risk groups, which include those with chronic medical conditions and individuals 65 years of age and above (13). Vaccination is the main public health intervention for preventing influenza (3). To protect vulnerable individuals and reduce influenza virus transmission, vaccination is also recommended for healthcare workers. Immunization protects healthcare workers themselves, and their patients from nosocomial influenza infections. In addition, influenza can disrupt health services and impact healthcare organizations financially. Immunization can reduce staff absences, offer cost savings and provide economic benefits (5). It has also been shown that physicians' knowledge, attitudes and behavior regarding influenza vaccination have a significant impact on the decision-making process of their patients (6). According to the Slovenian national immunization program for employees, vaccination against influenza is performed based on a safety statement with workplace risk assessment, among persons who are exposed to an infection with seasonal influenza virus or can transmit infection to others through their work, in particular for healthcare professionals, including physicians (7). Vaccination providers reported that only about 3,600 health workers were vaccinated against influenza in Slovenia in the 2016/17 season; based on this data, it is estimated that the vaccination uptake for healthcare workers in this season was only around 10% (8). There is no information on the vaccination uptake among individual profiles of health professionals, including physicians, from this routine monitoring data. Studies in Slovenia aiming at explaining predictors for vaccinating against seasonal influenza and also other vaccinations among healthcare workers (including physicians) and among the general population are very scarce (9-12). The aim of our study is to determine the uptake of seasonal influenza vaccination among Slovenian physicians, to identify factors associated with this vaccination and assess their attitudes and beliefs regarding vaccination and vaccine-preventable diseases. 2 METHODS 2.1 Study Population and Data Collection We conducted a cross-sectional survey among Slovenian physicians, who are members of the Slovenian Medical Chamber. Membership of the Medical Chamber is compulsory by law in Slovenia for all physicians working at all levels in public or private healthcare. Data for the current analysis was collected in December and January 2016 as a part of a large interdisciplinary study project about vaccination scepticism in Slovenia. In December 2016, an invitation letter the link to the anonymous web-based questionnaire was sent out by e-mail to all 8,297 physicians listed at the time of the study in the registry of the Slovenian Medical Chamber. We developed the questionnaire after reviewing the literature and pilot-tested it for clarity, length and face validity among several physicians at the National Institute of Public Health. The vaccination status against seasonal influenza was examined with the question "Were you ever vaccinated against seasonal influenza?" and four possible answers "yes, regularly", "yes, occasionally", "yes, but not anymore" and "never". In addition to these responses, individual participants' age, gender, health region and size of place (by number of inhabitants) where workplace is located, area of work, level of healthcare (primary, secondary or tertiary) and previous history of side effects after vaccination were recorded. To assess the attitudes and beliefs toward vaccination in general and vaccine-preventable diseases, the participants were asked of the extent to which they agreed with the given statements and their responses were collected with a five-point scale: completely disagree, mostly disagree, neither disagree nor agree, mostly agree and completely agree. 2.2 Statistical Analysis Statistical analyses were performed using the STATA package version 10.0 (Stata Statistical Software: release 10.0 College Station. TX: Stata Corporation). The responses to questions on seasonal influenza vaccination status were dichotomised, so that participants who regularly or occasionally vaccinate were coded as vaccinate ("1") and participants who do not vaccinate anymore or were never vaccinated were coded as do not vaccinate ("0"), to examine associations between influenza vaccination status and collected explanatory variables (socio-demographic factors, history of side effects after previous vaccinations, attitudes and beliefs toward vaccination and vaccine-preventable diseases). We estimated the overall proportion of Slovenian physicians who vaccinate or do not vaccinate against seasonal influenza with 95% confidence intervals (CI). Possible associations between influenza vaccination status and collected explanatory variables were explored in a univariate analyses by calculating odds ratios (OR) with 95% CI estimates and/ or Pearson's chi-square tests for significance. The level of statistical significance was set at p<0.05. 48 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 3 RESULTS Web-based questionnaires were filled in by 897 out of 8,297 Slovenian physicians (response rate 10.8%). The median age of participants was 41 years (range 25-85 years) and 71.4% were female (Table 1). Most of them (43.5%) were working in the Ljubljana health region, followed by Maribor (13.7%), Celje (9.0%), Kranj (7.5%), Novo mesto (7.0%), Koper (6.8%), Nova Gorica (5.3%), Murska Sobota (3.39) and Ravne (3.2%). According to the area of work, respondents were working in family or general medicine (23.5%), pediatrics or school medicine (17.9%) and internal medicine or infectious diseases (10.8%), while remaining participants (47.8%) listed other areas (mostly gynecology, anasthesiology, psychiatry, and surgery). Almost half of the physicians (42.3%) who participated in the study, performed most of their work at the primary level of healthcare, 29.7% at secondary level, and 28.1% at tertiary level. Out of 894 physicians who reported on their vaccination status against seasonal influenza, 75.9% (95% CI: 73.1-78.7) vaccinate against influenza (regularly or occasionally) and 24.1% (95% CI: 21.2-26.8%) do not vaccinate (not anymore or never). The reasons why they vaccinate themselves were (multiple answers possible) because the free vaccination was offered 32.6% (95% CI: 29.1-36.1%), because of the recommendation to vaccinate 23.7% (95% CI: 20.5-27.0%), for personal protection 83.4% (95% CI: 80.7-86.3%), to protect patients and family members 73.6% (95% CI: 70.4-77.0%) and other (influenza vaccine safe and effective, having complications after influenza, no absence from work due to illness™) 3.8% (95% CI:2.4-5.3%). Physicians who do not vaccinate against influenza stated the following reasons: fear of side effects of the influenza vaccine 11.6% (95% CI: 7.3-15.9%), doubt in the effectiveness of influenza vaccine 37.2% (95% CI: 30.743.7%), not feeling threatened by the disease 47.9% (95% CI: 41.2-54.6%), not having enough information about influenza vaccination 6.0% (95% CI: 2.8-9.2%), having problems after influenza vaccination 10.7% (95% CI: 6.514.9%) and others (never having influenza before, having contraindications for influenza vaccination - autoimmune disease, allergy to egg white, short-term effectiveness of the vaccine and because it is necessary to be vaccinated every year, vaccination organised at an inappropriate time, working with mostly healthy patients™) 19.5% (95% CI: 14.2-24.9%). Influenza vaccination status according to demographic characteristics and history of side effects after previous vaccinations of participants is shown in Table 1. In a univariate analysis only area of work was statistically significant associated with vaccinating against influenza among Slovenian physicians (p=0.002). Physicians who worked in family or general medicine had 1.66 (95% CI: 0.81-1.79) higher odds to vaccinate themselves against influenza, those from paediatrics or school medicine has 2.01 (95% CI: 1.25-3.24) higher odds to vaccinate and those from internal medicine or infectious diseases has 2.52 (95% CI: 1.35-4.73) higher odds to vaccinate in comparison to physicians working in other areas of medicine. 49 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 Table 1. Seasonal influenza vaccination status according to demographic characteristics and history of side effects after vaccination, Slovenian physicians, 2016. Characteristic All Vaccinated* OR 95% CI p N % N % 95% CI All 894 100.0 679 75.9 73.1-78.7 Gender Male 253 28.6 190 75.1 69.7-80.5 1 0.649 Female 632 71.4 483 76.5 73.2-79.9 1.08 0.77-1.52 Age (years) 25-34 305 34.9 239 78.4 73.7-83.0 1 0.605 35-44 187 21.4 138 73.8 67.4-80.2 0.78 0.51-1.20 45-54 166 18.0 123 74.5 67.8-81.3 0.81 0.52-1.26 55-64 150 17.2 112 74.7 67.6-81.7 0.81 0.51-1.29 >65 65 7.4 52 81.2 71.4-91.1 1.20 0.60-2.37 Health region Celje 80 9.0 59 73.7 63.9-83.6 0.22 0.04-1.03 0.092 Koper 60 6.8 48 80.0 69.6-90.4 0.31 0.06-1.53 Kranj 67 7.5 56 84.8 76.0-93.7 0.43 0.09-2.15 Ljubljana 386 43.5 290 75.3 71.0-79.6 0.23 0.05-1.02 Maribor 122 13.7 87 71.3 63.2-79.4 0.19 0.04-0.89 MurskaSobota 35 3.9 31 88.6 77.5-100.0 0.60 0.10-3.59 Nova Gorica 47 5.3 33 70.2 56.6-83.8 0.18 0.03-0.93 Novo mesto 62 7.0 45 73.8 62.4-85.1 0.22 0.04-1.10 Ravne 28 3.2 26 93.0 82.7-100.0 1 Place of work - size <2,000 inhabitants 28 3.1 19 67.7 49.4-86.3 1 0.720 2,000-10,000 inhabitants 171 19.3 133 77.8 71.5-84.1 1.66 0.69-3.98 10,000-100,000 inhabitants 291 32.8 219 75.8 70.8-80.7 1.48 0.64-3.43 >100,000 inhabitants 398 44.8 303 76.3 72.1-80.5 1.53 0.67-3.49 Area of work Family/general medicine 207 23.5 155 74.9 68.9-80.8 1.19 0.81 0.002 Paediatrics/school medicine 158 17.9 131 83.4 77.6-89.3 2.01 -1.79 Internal med./infectious diseases 95 10.8 82 86.3 79.3-93.3 2.52 1.25-3.24 Other 421 47.8 300 71.4 68.1-75.8 1 1.35-4.73 Level of healthcare Primary 363 42.3 275 75.8 71.3-80.2 1 0.438 Secondary 255 29.7 189 74.4 69.0-79.8 0.93 0.64-1.35 Tertiary 241 28.1 190 79.2 74.0-84.3 1.22 0.82-1.80 Had side effects after previous vaccination No 670 75.9 504 75.6 72.3-78.8 1 0.670 Yes 213 24.1 164 77.0 71.3-82.7 1.08 0.74-1.59 "regularly or occasionally against seasonal influenza CI: confidence interval; OR: odds ratio; p: p value. Number of individuals vary according to the number of missing values for individual variables. Table 2 shows the association between seasonal influenza vaccination status and attitudes and beliefs toward vaccination and vaccine-preventable diseases. The proportion of participants who agreed to given statements and vaccinate themselves against influenza differed significantly from participants who disagreed. Among physicians who agreed with statements that they trust in vaccines and vaccinations or that they trust in professional recommendations regarding vaccination, the proportion of those who vaccinate against influenza was higher (79.6%; 95% CI: 76.8-82.4% and 78.8%; 95% CI: 76.081.6%) than among those who expressed distrust (14.3%; 95% CI: 0.5-28.1°% and 13.0°%; 95°% CI: 0-28.0°%). Among physicians who agreed with the statements that it is better to overcome disease naturally, that they are afraid of vaccines' side effects and that vaccines pose a higher 50 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 risk than disease, the proportion of those who vaccinate 7.1-47.5) than among those who expressed disagreement themselves against influenza was lower (43.2%; 95% CI: with dose statements (80.3%; 95% CI: 77.4-83.1%, 80.7%; 27.9-58.4%, 49.1%; 95% CI: 36.0-62.3% and 27.3%; 95% CI: 95% 0:77.9-83.6% and 78.6%; 95% 0:75.8-81.4%). Table 2. Seasonal influenza vaccination status according to attitudes and beliefs toward vaccination and vaccine-preventable diseases, Slovenian physicians, 2016. N All % N Vaccinated* % 95% CI p I fully trust professional recommendations regarding vaccination. agree 825 93.6 650 78.8 76.0-81.6 <0.001 undecided 33 4.1 17 51.5 33.5-69.5 disagree 23 2.6 3 13.0 0.0-28.0 I fully trust in vaccination and vaccines. agree 804 91.3 640 79.6 76.8-82.4 <0.001 undecided 49 5.6 27 55.1 40.7-69.5 disagree 28 3.2 4 14.3 0.5-28.1 By vaccinating the majority, we significantly contribute to the protection of those who cannot be vaccinated. agree 839 95.4 660 78.7 75.9-81.4 <0.001 undecided 21 2.4 2 9.5 0.0-23.2 disagree 19 2.2 6 31.6 8.5-54.6 It's far better to overcome the disease naturally than to be vaccinated. agree 44 5.0 19 43.2 27.9-58.4 <0.001 undecided 96 10.8 56 58.3 48.3-68.4 disagree 745 84.2 598 80.3 77.4-83.1 Because of the way the vaccine works, they will never be completely safe. agree 409 46.3 297 72.6 68.3-76.9 0.001 undecided 139 15.7 97 69.8 62.0-77.5 disagree 336 38.0 278 82.7 78.7-86.8 I'm afraid of vaccination because I'm afraid of the side effects of vaccines. agree 59 6.7 29 49.1 36.0-62.3 <0.001 undecided 75 8.6 38 50.7 39.0-62.2 disagree 743 84.7 600 80.7 77.9-83.6 Vaccination poses a higher risk to the health of the vaccinated person than a disease that can be prevented by vaccination. agree 22 2.5 6 27.3 7.1-47.5 <0.001 undecided 27 3.1 9 33.3 14.3-52.3 disagree 836 94.5 657 78.6 75.8-81.4 It is very important that all healthcare workers are regularly vaccinated against influenza. agree 588 66.6 548 93.2 91.1-95.2 <0.001 undecided 152 17.2 72 47.4 39.3-55.4 disagree 143 16.2 51 35.7 27.7-43.6 The influence of the pharmaceutical industry on the decision-making bodies on vaccines is very high in Slovenia. agree 129 14.6 66 51.2 42.4-59.9 <0.001 undecided 296 33.4 214 72.3 67.7-77.4 disagree 460 52.0 393 85.4 82.2-88.7 "regularly or occasionally against seasonal influenza CI: confidence interval; p: p value. Number of individuals vary according to the number of missing values for individual variables. 51 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 4 DISCUSSION Three quarters of Slovenian physicians who participated in our study reported that they regularly or occasionally vaccinate themselves against seasonal influenza. Physicians who worked in family/general medicine, paediatrics/ school medicine or internal medicine/infectious diseases were more likely to vaccinate themselves against seasonal influenza in comparison to physicians working in other areas of medicine. There was a higher proportion of vaccinated against influenza among physicians who expressed trust in vaccination or professional recommendations regarding vaccination. However, among physicians who expressed some misconceptions regarding vaccination and vaccine-preventable diseases, the proportion of vaccinated against influenza was low. Our study showed that around 75% of physicians who participated in our study reported that they regularly (52%) or occasionally (23%) vaccinate themselves against seasonal influenza. Our results are comparable to the results of the first national survey conducted in 2010 among Slovenian doctors and dentists assessing their uptake of pandemic and seasonal influenza vaccine, where 42% of physicians reported that they were vaccinated against pandemic and seasonal influenza in the last season, and 10% only against seasonal influenza (9). If we compare these results to the results of routine monitoring of seasonal influenza vaccination coverage among healthcare workers in Slovenia, showing that only about 10% of them vaccinate every season (8), we can conclude that the vaccination coverage among physicians is higher than among other profiles of healthcare workers. Therefore, other profiles should be included in similar studies, especially nurses, most of whom have an even higher level of contact with patients. The vaccination coverage of healthcare workers is also not optimal in other European countries. According to the report from the European Center for Disease Control in 2014, 17 countries provided data on vaccination coverage among healthcare workers that ranged from 5.7% to 54.4% (median 26.9%). Among the examined demographic characteristics, only area of work was statistically significant when associated with vaccinating against seasonal influenza in our study. For comparison, in a similar study among Slovenian physicians and dentists from 2010, acceptance of the pandemic and seasonal influenza vaccine was determined by higher age, being an internal medical trainee or specialist, working in a hospital, performing any kind of vaccination, and having a chronic disease. Like in our study, those who declined vaccination believed that they did not need to be vaccinated, had safety concerns and were afraid of side effects (9). Another study performed among the Slovene general population aged 18 and over showed that, in addition to common predictors, a decision in favor of the seasonal and pandemic influenza vaccinations were related to age, gender, chronic illnesses, working in healthcare, trust in media news, and vaccination side-effects in someone close. It was also related to trust in vaccine safety and professional information in favor of vaccination, and the decision of someone close to vaccinate (10). Among the physicians included in our study, some expressed distrust in vaccination or professional recommendations regarding vaccination and some expressed certain misconceptions regarding vaccination and vaccine-preventable diseases. Among these, the proportion of vaccinated against influenza was lower. This is supported with scientific evidence that vaccination is a safe and effective measure that undeniably saves lives and remains one of the most important measures for reducing the burden of communicable diseases (13). For the individual, the risk of damage due to vaccination is significantly lower than the risk of complications due to vaccine-preventable disease (14, 15). There is a lack of acceptance of vaccines by the general population, but physicians also report doubts about risks and usefulness of vaccines or low vaccine acceptance among themselves (16). Physicians with such doubts may hesitate to recommend vaccination to their patients (17). Therefore, the confidence of physicians in the efficacy and safety of vaccines and vaccinations is very important. The gaps were identified in the initial training and the continuous medical education of physicians regarding vaccination in Slovenia and Europe (16, 18, 19). Education on the effectiveness and safety of vaccination should be one of the priority public health measures for improving knowledge and eliminating barriers to vaccination among physicians (16). The limitations of our study include validity constraints of self-reported information, while declaration or desirability biases cannot be excluded. Unfortunately, attitudes and beliefs were not measured specifically for influenza and influenza vaccination but for vaccination and vaccine-preventable diseases in general. The main limitation of our study was the low response rate that limits the generalisability of the results. The anonymity of responders prevented us from sending a reminder letter to the non-responders. There is the possibility of selection bias, if more physicians with a positive opinion on vaccination who vaccinate more were more likely to respond to the survey. If such bias exists, it may lead to an overestimation of the proportion of Slovenian physicians who vaccinate themselves against seasonal influenza. 52 10.2478/sjph-2019-0012 Zdr Varst. 2019;58(2):91-100 5 CONCLUSION Not trusting in vaccination or professional recommendations regarding vaccination and certainly some misconceptions regarding vaccination and vaccine-preventable diseases may influence the decision to be vaccinated against seasonal influenza among Slovenian physicians. It is important that healthcare workers themselves, especially physicians, trust in vaccination and are its promoters, as they can significantly influence beliefs and behaviors associated with the vaccinations of their patients. It is also important for physicians to vaccinate regularly against seasonal influenza because they protect themselves, their family members and their patients against infection. CONFLICT OF INTEREST The authors declare that they have no financial, professional or personal conflicting interests related to this article. FUNDING The study was financed as an interdisciplinary research project [grant number: L7-6806] by the Slovenian Research Agency and co-financed by the Ministry of Health. They were not involved in the study design, data collection, data analysis, and interpretation of results, writing the manuscript or decision to submit the paper for publication. ETHICAL APPROVAL The Republic of Slovenia National Medical Ethics Committee approved the project proposal for the study (Consent number: 127/03/14). REFERENCES 1. Ucakar V, Socan M, Trilar KP. The impact of influenza and respiratory syncytial virus on hospitalizations for lower respiratory tract infections in young children: Slovenia, 2006-2011. Influenza Respir Viruses. 2013;7:1093-102. doi: 10.1111/irv.12134. 2. Socan M, Prosenc K, Ucakar V, Berginc N. 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Pravilnik o določitvi Programa cepljenja in zaščite z zdravili za leto 2018. Uradni list RS. 24(13.4.2018):3635. 8. Učakar V, Jeraj I, Vitek Grgič M. Analiza izvajanja cepljenja v Sloveniji v letu 2016. Accessed April 2nd, 2018 at: http://www.nijz. si/sites/www.nijz.si/files/uploaded/porocilo_cepljenje2016.pdf 9. Sočan M, Erčulj V, Lajovic J. Knowledge and attitudes on pandemic and seasonal influenza vaccination among Slovenian physicians and dentists. Eur J Public Health. 2013;23:92-7. doi: 10.1093/eurpub/ cks006. 10. Podlesek A, Roškar S, Komidar L. Some factors affecting the decision on non-mandatory vaccination in an influenza pandemic: comparison of pandemic (H1N1) and seasonal influenza vaccination. Zdr Varst. 2011;50:227-38. doi: 10.2478/v10152-011-0002-8. 11. Grdadolnik U, Sočan M. The impact of socio-economic determinants on the vaccination rates with rotavirus and human papiloma virus vaccine. Zdr Varst. 2016;55:43-52. doi: 10.1515/sjph-2016-0007. 12. Grgic-Vitek M, Klavs I. 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They should contribute to the conception, design, analysis and interpretation of data, and they should approve the final version of the contribution. ABSTRACT AND KEY WORDS The abstract of the original scientific article should be structured (Introduction, Methods, Results, Conclusions) and of no more than 250 words (Slovenian language abstracts are limited to 400 words). The abstract should be written in third person. The abstract of a original scientific article should state the purpose of the investigation, basic procedures, main findings together with their statistical significance, and principal conclusions. 3 - 10 key words should be cited for the purpose of indexing. Terms from MeSH - Medical Subject Headings listed in Index Medicus should be used. The abstract should normally be written in one paragraph, only exceptionally in several. The author propose the type of the artlice, but the final decision is adopted by the editor on the base of the suggestions of the professional reviewers. REFERENCES We recommend authors to review prior issues of our journal (the last five years) for any relevant literature on their paper's topic. Each mentioning of the statements or findings by other authors should be supported by a reference. References should be numbered consecutively in the same order in which they appear in the text. Reference should be cited at the end of the cited statement. References in text, illustrations and tables should be indicated by Arabic numerals in parentheses ((1), (2, 3), (4-7) etc). References, cited only in tables or illustrations should be numbered in the same sequence as they will appear in the text. Avoid using abstracts and personal communications as references (the latter can be cited in the text). The list of the cited literature should be added at the end of the manuscript. Literature should be cited according to the enclosed instructions that are in accordance with those used by U. S. National Library of Medicine in Index Medicus. The titles of journals should be abbreviated according to the style used in Index Medicus (complete list on the URL address: http://www.nlm.nih.gov). List the names of all authors, if there are six authors or more, list the first six authors than add et al. If the article/book has a DOI number, the author should include it at the end of the reference. EXAMPLES FOR LITERATURE CITATION example for a book: 1. Anderson P, Baumberg P. Alcohol in Europe. London: Institute of Alcohol Studies, 2006. example for the chapter in a book: 2. Goldberg BW. Population-based health care. In: Taylor RB, editor. Family medicine. 5th ed. New York: Springer, 1999:32-6. example for the article in a journal: 3. Florez H, Pan Q, Ackermann RT, Marrero DG, Barrett-Connor E, Delahanty L, et al. Impact of lifestyle intervention and metformin on health-related quality of life: the diabetes prevention program randomized trial. J Gen Intern Med. 2012;27:1594-601. doi: 10.1007/s11606-012-2122-5. example for the article in a journal with no author given: 4. Anon. Early drinking said to increase alcoholism risk. Globe. 1998;2:8-10. example for the article in a journal with organization as author: 5. Women's Concerns Study Group. Raising concerns about family history of breast cancer in primary care consultations: prospective, population based study. Br Med J. 2001;322:27-8. example for the article from journal volume with supplement and with number: 6. de Villiers TJ. The role of menopausal hormone therapy in the management of osteoporosis. Climacteric. 2015; 18(Suppl 2):19-21. doi: 10.3109/13697137.2015.1099806. example for the article from collection of scientific papers: 7. Hickner J, Barry HC, Ebell MH, Ettenhofer T, Eliot R, Sugden K, et al. Suicides and non-suicidal deaths in Slovenia: molecular genetic investigation. In: 9th European Symposium on Suicide and Suicidal Behaviour. Warwick: University of Oxford, 2002:76. example for master theses, doctor theses: 8. Shaw EH. An exploration of the process of recovery from heroin dependence: doctoral thesis. Hull: University of Hull, 2011. example for electronic sources: 9. EQ-5D, an instrument to describe and value health. Accessed January 24th, 2017 at: https://euroqol.org/eq-5d-instruments/. TABLES Type on the place in the text where they belong. Tables should be composed by lines and columns which intersect in fields. Number tables consecutively. Each table should be cited in the text and supplied with a brief title. Explain all the abbreviations and non-standard units in the table. ILLUSTRATIONS Illustrations should be professionally drawn. When preparing the illustrations consider the black-and-white print. Illustration material should be prepared in black-and-white (not in color!). Surfaces should have no tone-fills, hatchings should be chosen instead (in case of bar-charts, so called pie-charts or maps). In linear graphs the individual lines should also be separated by various kinds of hatching or by different markers (triangles, asterisks ... ), but not by color. Graphs should have white background (i. e. without background). Letters, numbers or symbols should be clear, even and of sufficient size to be still legible on a reduced illustration. Freehand or typewritten lettering in the illustration is unacceptable. Each figure should be cited in the text. Accompanying text to the illustration should contain its title and the necessary explanation of its content. Illustration should be intelligible also without reading the manuscript. Ali the abbreviations from the figure should be explained. The use of abbreviations in the accompanying text to the illustration is unacceptable. Accompanying texts to illustrations should be written in the place of their appearing in the text. lf the identity of the patient can be recognized on the photograph, a written permission of the patient for its reproduction should be submitted. UNITS OF MEASUREMENT Should be in accordance with International System of Units (SI). ABBREVIATIONS Avoid abbreviations, with the exception of internationally valid signs for units of measurement. Avoid abbreviations in the title and abstract. The full term for which an abbreviation stands should precede its first use in the text, abbreviation used in further text should be cited in parentheses. EDITORIAL WORK The received manuscript is submitted by the editor to three international professional reviewers. After the reviewing process, the contribution is sent to the author for approval and consideration of corrections. The final copy is than again submitted to the Editorial Office. The Editorial Office allows for a maximum of three revisions to be dealt with. If the third revision of the manuscript does not take into account all the comments of the reviewers, the manuscript will be withdrawn from the editorial process. During the editorial process, the secrecy of the contribution content is guaranteed. All the articles are language edited. Author receives in consideration also the first print, but at this stage corrigenda (printing errors) only are to be considered. Proofreading should be returned in three days, otherwise it is considered that the author has no remarks. The journal office strives for rapid editorial process. Authors should adhere to the deadlines set by them in letters; otherwise it may happen that the article will be withdrawn from the editorial process. Any appeal of the authors deals the Editorial Board of the ZV/SJPH. When the manuscript is accepted for publication, the author must assigns copyright ownership of the material to the National Institute of Public Health as a publisher. Any violation of the copyright will be legally persecuted. ZV/SJPH does not have article processing charges (APCs) nor article submission charges. The author receives one copy of the print issue in which the article is published. Nacionalni inštitut za javno zdravje Trubarjeva 2, 1000 Ljubljana, Slovenija zdrav.var@nijz.si http://www.niiz.si/sl/niiz/reviia-zdravstveno-varstvo ++386 1 2441 543 NAVODILA AVTORJEM Revija: Zdravstveno varstvo (ZV) ISSN 0351-0026 (tiskana izdaja) / Slovenian Journal of Public Health (SJPH) ISSN 1854-2476 (elektronska izdaja) Navodila so v skladu z Uniform Requirements for Manuscripts Submitted to Biomedical Journals. Popolna navodila so objavljena v N Engl J Med 1997; 336: 309-15 in v Ann Intern Med 1997; 126: 36-47 in na spletni strani http://www.icmje.org. ETIČNI STANDARDI Uredništvo sprejema v obdelavo le članke s širšo mednarodno javnozdravstveno tematiko, ki še niso bili in ne bodo objavljeni drugje. Dele članka, ki so povzeti po drugi literaturi (predvsem slike in tabele), mora spremljati dovoljenje avtorja in založnika prispevka, da dovoli naši reviji reprodukcijo. Oddan rokopis morajo prebrati vsi avtorji in se z njegovo vsebino strinjati. Raziskave na ljudeh (vključno s človeškimi materiali in osebnimi podatki) morajo biti izpeljane v skladu s Helsinško deklaracijo in potrjene s strani nacionalne etične komisije. V izjavi na koncu rokopisa morajo avtorji podati izjavo o etiki raziskav na ljudeh, ki mora vsebovati ime etične komisije in referenčno števiko obravnave. Poročanje o raziskavah na ljudeh brez potrdila etične komisije zahteva dodatno razlago v poglavju o metodah dela. Na zahtevo Uredništva je avtor dolžan predložiti vso dokumentacijo o obravnavi raziskovalne etike njegovega rokopisa. Uredništvo si pridržuje pravico, da kontaktira etično komisijo. Prav tako morajo avtorji, ki poročajo o ljudeh ali posredujejo javnosti njihovo slikovno gradivo, pridobiti dovoljenja vseh sodelujočih, da se z vključitvijo v raziskavo strinjajo (v primeru otrok so to starši ali skrbniki). Izjavo o pridobitvi teh dovoljenj morajo avtorji podati v poglavju o metodah dela. Uredništvo si pridržuje pravico vpogleda v to dokumentacijo. Raziskave na živalih morajo biti izpeljane v skladu z navodili "Animal Research: Reporting In Vivo Experiments" (ARRIVE) in potrjene s strani nacionalne etične komisije. V poglavju o metodah dela in v izjavi na koncu rokopisa morajo avtorji podati izjavo o etiki raziskav na živalih z veljavno številko dovoljenja. V izjavi na koncu rokopisa morajo biti zapisani morebitni finančni ali drugi interesi farmacevtske industrije ali proizvajalcev opreme ter inštitucij, povezanih z objavo v ZV/SJPH. Avtorji morajo na koncu rokopisa zapisati sledeče izjave: CONFLICTS OF INTEREST (The authors declare that no conflicts of interest exist.) FUNDING (The study was financed by ... ) ETHICAL APPROVAL (Received from the... ali opis etičnega vidika raziskave) PLAGIATI Kadar uredništvo ugotovi, da je rokopis plagiat, se rokopis takoj izloči iz uredniškega postopka. Plagiatorstvo ugotavljamo s programom za odkrivanje plagiatov CrossCheck plagiarism detection system. ELEKTRONSKA ODDAJA PRISPEVKA Priporočamo uporabo videoposnetka z navodili za avtorje. Prispevke oddajte v elektronski obliki s pomočjo spletne aplikacije Editorial Manager, ki se nahaja na spletnem naslovu http://www.editorialmanager.com/sjph/. V uredništvo sprejemamo po pošti le še Izjave o avtorstvu in avtorskih pravicah, ki zahtevajo lastnoročni podpis. Prosimo, da jih pošljete hkrati z elektronsko oddajo prispevka na naslov: Nacionalni inštitut za javno zdravje, za revijo Zdravstveno varstvo, Trubarjeva 2, 1000 Ljubljana. V spletno uredniško aplikacijo se prijavite kot 'avtor'. Prva prijava zahteva vnos podatkov o avtorju, vse naslednje prijave pa le še vnos podatkov za prijavo, ki jih na svoj elektronski naslov prejmete po prvi prijavi v sistem. Po uspešni prijavi izpolnite vsa zahtevana strukturirana polja. Potrdite izjavo, da vaš prispevek še ni bil objavljen ali poslan v objavo kakšni drugi reviji, da so prispevek prebrali in se z njim strinjajo vsi avtorji, da so raziskave na ljudeh oz. živalih opravljene v skladu z načeli Helsinško-Tokijske deklaracije oz. v skladu z etičnimi načeli. Avtorji, ki v objavo pošiljate raziskovalno delo, opravljeno s pomočjo nekega podjetja, to navedite na koncu rokopisa v izjavi o financiranju. Navedete lahko tudi do dva neželena recenzenta. Polje 'Comments' je namenjeno obveznemu predlogu treh recenzentov z imeni, nazivi, e-naslovi in zaposlitvijo. Navedete lahko tudi do dva neželena recenzenta. Podatke o avtorju in soavtorjih vnesite kar se da natančno in popolno. Naveden naj bo korespondenčni avtor (s polnim naslovom, telefonsko številko in elektronskim naslovom), ki bo skrbel za komunikacijo z uredništvom in ostalimi avtorji. Jezik prispevka je angleščina. Objavljamo izvirne znanstvene članke, sistematične pregledne znanstvene članke, metodologije raziskav in vabljene uvodnike. Pri izvirnih, metodoloških in sistematičnih preglednih znanstvenih prispevkih morajo biti naslov, izvleček in ključne besede prevedeni tudi v slovenščino. Naslov, ključne besede in izvleček se oddajajo dvojezično v angleščini in slovenščini v strukturirana polja. Posebno polje za zapis v drugem jeziku obstaja le za izvleček, preostale podatke vnesite v obeh jezikih v ustrezno isto polje. Prvi izvleček je vselej v angleškem jeziku (do 250 besed - sistem vam besede sproti šteje), drugi pa v slovenskem jeziku (razširjen izvleček - do 400 besed). Po vnosu strukturiranih podatkov oddajte še priponko - rokopis (od 1 Uvod naprej), ki ne sme zajemati podatkov, ki ste jih vnesli že pred tem v strukturirana polja, zlasti ne podatkov o avtorjih. Ime datoteke ne sme vključevati avtorjevih osebnih podatkov, prav tako ne imen ustanov, vključenih v pripravo rokopisa. Grafično in slikovno gradivo je kot ves rokopis v angleškem jeziku. Vključite ga v besedilo na mesto, kamor le-to sodi in ga opremite z naslovom. Oddate torej le en sam dokument, eno priponko. V Wordu uporabite možnost Postavitev strani/Številke vrstic (tako bo na robu vsake vrstice dokumenta dodana številka vrstice). Pri oddaji sledite napotkom, ki vam jih ponuja sistem, pomagate pa si lahko tudi z 'Editorial Manager's Tutorial for Autors'. Sistem najbolje deluje, če uporabljate zadnjo različico Acrobata. Če pri oddajanju rokopisa naletite na nepremostljive težave, se za pomoč obrnite na naslov uredništva: zdrav.var@nijz.si. V nadaljevanju podajamo še nekaj natančnejših napotkov. ROKOPIS Besedila naj bodo napisana z urejevalnikom Word for Windows 97-2003. Robovi naj bodo široki najmanj 25 mm. Znanstveni članki naj imajo naslednja poglavja: uvod, metode, rezultati, razpravljanje in zaključek. Uvodniki in sistematični pregledni članki so lahko zasnovani drugače, vendar naj bo razdelitev na poglavja in podpoglavja jasno razvidna iz velikosti črk naslovov. Poglavja in podpoglavja naj bodo številčena dekadno po standardu SIST ISO 2145 in SIST ISO 690 (npr. 1, 1.1, 1.1.1 itd.). DOLŽINA PRISPEVKOV Zahtevana dolžina prispevka je za vabljen uvodnik od 250 do 1000 besed, za znanstveni članek (originalni, metodološki ali sistematični pregledni) pa od 2000 do 4500 besed s slikovnim gradivom in literaturo vred. Revizija sme obsegati 5000 besed. NASLOV IN AVTORSTVO Naslov v angleškem in slovenskem jeziku naj bo kratek in natančen, opisen in ne trdilen (povedi v naslovih niso dopustne). Navedena naj bodo imena piscev z natančnimi akademskimi in strokovnimi naslovi ter popoln naslov ustanove, inštituta ali klinike, kjer je delo nastalo. Avtorji morajo izpolnjevati pogoje za avtorstvo. Prispevati morajo k zasnovi in oblikovanju oz. analizi in interpretaciji podatkov, rokopis morajo intelektualno zasnovati oz. ga kritično pregledati, strinjati se morajo s končno različico rokopisa. Samo zbiranje podatkov ne zadostuje za avtorstvo. IZVLEČEK IN KLJUČNE BESEDE Izvleček v angleškem in slovenskem jeziku naj bo pri znanstvenem in metodološkem članku strukturiran in naj ne bo daljši od 250 besed v angleščini in 400 besed v slovenščini, izvlečki ostalih člankov so lahko nestrukturirani. Izvleček naj vsebinsko povzema in ne le našteva bistvene vsebine dela. Izogibajte se kraticam in okrajšavam. Napisan naj bo v 3. osebi. Izvleček znanstvenega članka naj povzema namen dela, osnovne metode, glavne izsledke in njihovo statistično pomembnost ter poglavitne sklepe (struktura IMRC - Introduction, Methods, Results, Conclusions). Navedenih naj bo 3-10 ključnih besed, ki nam bodo v pomoč pri indeksiranju. Uporabljajte izraze iz MeSH - Medical Subject Headings, ki jih navaja Index Medicus. KATEGORIJA PRISPEVKA Kategorijo prispevka predlaga z vnosom v ustrezno polje avtor sam, končno odločitev pa sprejme urednik na osnovi predlogov recenzentov. Objavljamo izvirne znanstvene članke, metodološke članke, sistematične pregledne znanstvene članke in vabljene uvodnike. REFERENCE Avtorjem priporočamo, da pregledajo objavljene članke na temo svojega rokopisa v predhodnih številkah naše revije (za obdobje zadnjih pet let). Vsako navajanje trditev ali dognanj drugih morate podpreti z referenco. Reference naj bodo v besedilu navedene po vrstnem redu, tako kot se pojavljajo. Referenca naj bo navedena na koncu citirane trditve. Reference v besedilu, slikah in tabelah navedite v oklepaju z arabskimi številkami ((1), (2, 3), (4-7)). Reference, ki se pojavljajo samo v tabelah ali slikah, naj bodo oštevilčene tako, kot se bodo pojavile v besedilu. Kot referenc ne navajajte izvlečkov in osebnih dogovorov (slednje je lahko navedeno v besedilu). Seznam citirane literature dodajte na koncu prispevka. Literaturo citirajte po priloženih navodilih, ki so v skladu s tistimi, ki jih uporablja ameriška National Library of Medicine v Index Medicus. Uporabljajte numerično citiranje. Imena revij krajšajte tako, kot določa Index Medicus (popoln seznam na naslovu URL: http://www.nlm.nih.gov). Navedite imena vseh avtorjev, v primeru, da je avtorjev šest ali več, navedite prvih šest avtorjev in dodajte et al. Če ima članek/knjiga DOI številko, jo mora avtor navesti na koncu reference. PRIMERI ZA CITIRANJE LITERATURE primer za knjigo: 1. Anderson P, Baumberg P. Alcohol in Europe. London: Institute of Alcohol Studies, 2006. 2. Mahy BWJ. A dictionary of virology. 2nd ed. San Diego: Academic Press, 1997. primer za poglavje iz knjige: 3. Urlep F. Razvoj osnovnega zdravstva v Sloveniji zadnjih 130 let. In: Švab I, Rotar-Pavlič D, editors. Družinska medicina. Ljubljana: Združenje zdravnikov družinske medicine, 2002:18-27. 4. Goldberg BW. Population-based health care. In: Taylor RB, editor. Family medicine. 5th ed. New York: Springer, 1999:32-6. primer za članek iz revije: 5. Florez H, Pan Q, Ackermann RT, Marrero DG, Barrett-Connor E, Delahanty L, et al. Impact of lifestyle intervention and metformin on health-related quality of life: the diabetes prevention program randomized trial. J Gen Intern Med. 2012;27:1594-601. doi: 10.1007/s11606-012-2122-5. primer za članek iz revije, kjer avtor ni znan: 6. Anon. Early drinking said to increase alcoholism risk. Globe. 1998;2:8-10. primer za članek iz revije, kjer je avtor organizacija: 7. Women's Concerns Study Group. Raising concerns about family history of breast cancer in primary care consultations: prospective, population based study. Br Med J. 2001;322:27-8. primer za članek iz suplementa revije z volumnom in s številko: 8. Shen HM, Zhang QF. Risk assessment of nickel carcinogenicity and occupational lung cancer. Environ Health Perspect. 1994;102(Suppl 2):275-82. 9. de Villiers TJ. The role of menopausal hormone therapy in the management of osteoporosis. Climacteric. 2015; 18(Suppl 2):19-21. doi: 10.3109/13697137.2015.1099806. primer za članek iz zbornika referatov: 10. Sugden K, Kirk R, Barry HC, Hickner J, Ebell MH, Ettenhofer T, et al. Suicides and non-suicidal deaths in Slovenia: molecular genetic investigation. In: 9th European Symposium on Suicide and Suicidal Behaviour. Warwick: University of Oxford, 2002:76. primer za magistrske naloge, doktorske disertacije in Prešernove nagrade: 11. Shaw EH. An exploration of the process of recovery from heroin dependence: doctoral thesis. Hull: University of Hull, 2011. primer za elektronske vire: 12. EQ-5D, an instrument to describe and value health. Accessed January 24th, 2017 at: https://euroqol.org/eq-5d-instruments/. TABELE Tabele v angleškem jeziku naj bodo v besedilu prispevka na mestu, kamor sodijo. Tabele naj sestavljajo vrstice in stolpci, ki se sekajo v poljih. Tabele oštevilčite po vrstnem redu, vsaka tabela mora biti citirana v besedilu. Tabela naj bo opremljena s kratkim angleškim naslovom. V legendi naj bodo pojasnjene vse kratice, okrajšave in nestandardne enote, ki se pojavljajo v tabeli. Slike morajo biti profesionalno izdelane. Pri pripravi slik upoštevajte, da gre za črno-beli tisk. Slikovno gradivo naj bo pripravljeno: • črno-belo (ne v barvah!); • brez polnih površin, namesto tega je treba izbrati šrafure (če gre za stolpce, t. i. tortice ali zemljevide); • v linijskih grafih naj se posamezne linije prav tako ločijo med samo z različnim črtkanjem ali različnim označevanjem (s trikotniki, z zvezdicami...), ne pa z barvo; • v grafih naj bo ozadje belo (tj. brez ozadja). Črke, številke ali simboli na sliki morajo biti jasni, enotni in dovolj veliki, da so berljivi tudi na pomanjšani sliki. Ročno ali na pisalni stroj izpisano besedilo v sliki je nedopustno. Vsaka slika mora biti navedena v besedilu. Besedilo k sliki naj vsebuje naslov slike in potrebno razlago vsebine. Slika naj bo razumljiva tudi brez branja ostalega besedila. Pojasniti morate vse okrajšave v sliki. Uporaba okrajšav v besedilu k sliki je nedopustna. Besedila k slikam naj bodo napisana na mestu pojavljanja v besedilu. Fotografijam, na katerih se lahko prepozna identiteta bolnika, priložite pisno dovoljenje bolnika. MERSKE ENOTE Naj bodo v skladu z mednarodnim sistemom enot (SI). KRATICE IN OKRAJŠAVE Kraticam in okrajšavam se izogibajte, izjema so mednarodno veljavne oznake merskih enot. V naslovih in izvlečku naj ne bo kratic. Na mestu, kjer se kratica prvič pojavi v besedilu, naj bo izraz, ki ga nadomešča, polno izpisan, v nadaljnjem besedilu uporabljano kratico navajajte v oklepaju. UREDNIŠKO DELO Prispelo gradivo z javnozdravstveno tematiko mednarodnega pomena posreduje uredništvo po tehnični brezhibnosti v strokovno recenzijo trem mednarodno priznanim strokovnjakom. Recenzijski postopek je dvojno slep. Po končanem uredniškem delu vrnemo prispevek korespondenčnemu avtorju, da popravke odobri in upošteva. Popravljen čistopis vrne v uredništvo po spletni aplikaciji Editorial Manager. Uredništvo dopušča obravnavo največ treh revizij. Če tretja revizija rokopisa ne upošteva vseh pripomb recenzentov, se rokopis umakne iz uredniškega postopka. Sledi jezikovna lektura, katere stroške krije založnik. Med redakcijskim postopkom je zagotovljena tajnost vsebine prispevka. Avtor dobi v pogled tudi prve, t. i. krtačne odtise, vendar na tej stopnji upoštevamo samo še popravke tiskarskih napak. Krtačne odtise je treba vrniti v treh dneh, sicer menimo, da avtor nima pripomb. V uredništvu se trudimo za čim hitrejši uredniški postopek. Avtorji se morajo držati rokov, ki jih dobijo v dopisih, sicer se lahko zgodi, da bo članek odstranjen iz postopka. Morebitne pritožbe avtorjev obravnava uredniški odbor revije. Za objavo članka prenese avtor avtorske pravice na Nacionalni inštitut za javno zdravje kot založnika revije (podpiše Pogodbo o avtorstvu in avtorskih pravicah). Kršenje avtorskih in drugih sorodnih pravic je kaznivo. Prispevkov ne honoriramo in tudi ne zaračunavamo stroškov uredniškega postopka. Avtor dobi izvod tiskane revije, v kateri je objavljen njegov članek.