HEALTH OF THE WORKING-AGE POPULATION ZDRAVJE DELOVNO AKTIVNE POPULACIJE Proceedings Edited by Ana Petelin, Nejc Šarabon and Boštjan Žvanut health of the working-age population zdravje delovno aktivne populacije Univerza na Primorskem ■ Fakulteta za vede o zdravju Università del Litorale ■ Facoltà di scienze del a salute University of Primorska ■ Faculty of health sciences v sodelovanju z / in col aboration with Sveučilište Josipa Jurja Strossmayera u Osijeku ■ Medicinski fakultet Osijek Josip Juraj Strossmayer University of Osijek ■ Faculty of medicine Osijek Univerzitet u Istočnom Sarajevu University of East Sarajevo Inštitut za medicino in šport Institute for medicine and sport Geoplin, d. o. o., Ljubljana Zdravje delovno aktivne populacije Health of the working-age population Edited by Ana Petelin, Nejc Šarabon and Boštjan Žvanut 2017 Contents Eva Boštjančič, Zala Slana 9 Psychophysical workload of workers in Slovenia Marjana Božič, Ksenija Kragelj, Mirko Prosen 23 Retrospective and experiential perception of physical activity during pregnancy on childbirth and postpartum period Anja Brčan, Maruša Kebe, Maša Pintar, Andrej Starc 31 The mammography efficiency in breast cancer detection in women under 50 years of age Melina Colsani, Maša Černelič Bizjak 39 Attending nutrition counsel ing of the working-age subjects Nataša Demšar Pečak 47 The therapeutic approach as an important intervention in the implementation of the program Project learning for young adults (PUM-O) Rok Drnovšek, Marija Milavec Kapun 55 Critical review of viewership and contents of official healthcare organization websites Gašper Grom 63 Ketogenic diet and its impact on mental processes of working population Brigita Jeretina, Katja Krt, Andrej Starc 73 Absenteeism due to mental problems among employees in nursing Sandra Joković, Maja Račić, Jelena Pavlović, Natalija Hadživuković 83 Quality of life of nurses Anita Jug Došler, Ana Polona Mivšek, Petra Petročnik, Teja Škodič Zakšek, Mateja Kusterle Jenko 93 Experience of sexual intercourse in the first year after childbirth: women’s views and attitudes Alexander Kiško, Marika Vereb, Radoslav Dobránsky, Marian Babčák, Lubica Derňarová, Jan Kmec, Jozef Leško, František Neméth, Maria Marcinková, Zuzana Farkašová 103 Prevalence of silent myocardial ischemia in working-age patients with type 2 diabetes mellitus. Sabina Ličen, Igor Karnjuš, Mirko Prosen 113 Ensuring equality through the acquisition of cultural competencies 6 in nursing education: A systematic literature review n Herbert Löllgen, Petra Zupet, Norbert Bachl pulatio 123 Physical activity, physical fitness and prevention: o Role for the working population ge p Polona A. Mivšek, Petra Petročnik, Anita Jug Došler, rking-ao Teja Škodič Zakšek he w 135 The quality of sexual life after experiencing the episiotomy birth f t Teja Novak, Doroteja Rebec ealth o| h 143 Women‘s experiences with perinatal loss of a child Jelena Pavlović, Maja Račić, Nataša Radović, Sandra Joković, pulacije o Natalija Hadživuković 149 Work related stressors and quality of life of nurses ktivne p Tjaša Pogačar, Lučka Kajfež Bogataj elovno a 155 Slovenian workers – is it too hot to work? Andreja Rijavec, David Ravnik, Mirko Prosen zdravje d 165 Characteristics of physical activity among pregnant women Tanja Ritonja, Dragana Pejnović, Lucija Roblek, Andrej Starc 171 The impact of shift work on cardiovascular diseases among nurses Nataša Sedlar Kobe, Alenka Dovč, Andrea Backović Juričan, Jerneja Farkaš Lainščak 179 Association between perceived stress, self-rated health, work productivity and stress management interventions – a study of employees in the Slovenian processing industry Milena Svetlin 189 Fighting stressful situations from the viewpoint of emotional competence Saša Šajn Lekše, Bernarda Lončar, Alenka Žibert, Andrej Starc 199 Stress of conscience as a risk factor for burnout among ICU nurses in University Medical Centre Maribor Tjaša Šapla Troha, Maša Černelič Bizjak 209 Women‘s Quality of Life during the Grief Process after Perinatal Death Martin Vrašec, Matej Voglar 219 Absenteeism in Slovenian railways – comparison between different work groups Milica Vuksanović, Dragica Marić, Jelena Pavlović, Sandra Joković, Natalija Hadživuković 7 227 Presence of professional stress in teaching staff at the Medical faculty in Foca entsntco 237 Thanks to our Conference Sponsors Psychophysical workload of workers in Slovenia Eva Boštjančič, Zala Slana University of Ljubljana, Faculty of Arts, Department of Psychology, Aškerčeva 2, 1000 Ljubljana, Slovenia eva.bostjancic@ff.uni-lj.si; zala.slana@gmail.com Abstract Introduction: The psychophysical workloads with which an individual has to cope on a basis at their workplace are important for the employee as well as the employer. It is important to be aware of them, draw attention to them and strive to reduce their sources. The setting-up of programmes and procedures is an important factor in reducing negative effects on employees, as well as maintaining and increasing employees’ mental and physical health. Methods: This article will present a short self-assessment scale of psychophysical health that enables us to evaluate the appearance of five of the most frequent psychosomatic problems experienced by employees (N = 490). Results: In the research, we will analyse the presence of exhaustion, social behavioural disorders, physical disorders, depressive reactions, and fear and anxiety in different demographic groups and, at the end, we will connect the symptoms with the field of activity. Discussion and conclusions: Research has shown a link between demographic variables and exposure to psychophysical risks. There is a more straightforward connection with education (higher levels of education are connected to lower risk), while the connection with age and gender is not so clear. Psychophysical workloads are more frequent in construction, manufacturing, the information industry and the civil service. Key words: psychophysical workload, health, workers, Slovenia Conditions in working environments today are dependent on wider envi- ronmental as well as social and economic factors. Working conditions comprise physical (e.g. working hours, work equipment) and social fac- tors (e.g., management style, nature of interpersonal relations). All factors (Hupke, 2013, mentions content of work, workload, level of supervision, work- ing hours, the working environment, work equipment, the worker’s role, or- doi: https://doi.org/10.26493/978-961-7023-32-9.9-22 ganisational culture, mutual relations, career development opportunities, and work-life balance) can, to a certain degree, present psychosocial risks to workers. They are among the most important risks related to workplace stress and affect the psychological and physical wellbeing of workers, and have an im- pact on their behaviour. The consequences present themselves indirectly in the costs of treating sick workers and the phenomena of absenteeism and presenteeism, accompanied, in all such cases, by a reduction in productivity and ef- ficiency (Sparks, Faragher and Cooper, 2001). The results of the fourth Euro- pean Working Conditions Survey (Brun and Milczarek, 2007) showed that, in 2005, 20% of workers from the EU and 30% of workers from 10 new Member States believed that their health was being put at risk by stress at the workplace. In 2002, the annual economic cost of workplace stress in the EU was estimat- ed at EUR 20 billion. It is not only the working environment that creates precisely defined con- ditions for the occurrence of health risks on the part of workers; the nature of 10 an individual’s profession is also a factor. We have therefore decided to exam-n ine which demographic groups, which areas of activity and which professions are currently subject to the greatest levels of load and exposed to specific psy-pulatioo chosocial risks in Slovenia. ge p Most common health risks experienced by workers rking-ao Some 25% of the European population suffers from depression (Albreht and he w Turk, 2010), which they characterise as feelings of sadness, loss of interest and f t of the capacity for happiness, feelings of guilt and low self-esteem. The major ealth o negative consequences of depression at the workplace are reduced productiv- | h ity and high incidences of absenteeism and presenteeism (Evans-Lacko et al., 2016). pulacije o Anxiety is defined as a state of unpleasant restlessness and a tension aris-ing from a feeling of threat without a clear awareness of the causes. A cer- ktivne p tain degree of anxiety can have a positive effect on an individual, with im- patience, nervousness and alertness improving a worker’s efficiency. A Dutch elovno a study (Hendriks et al., 2015) has shown that more severe symptoms of anxiety are linked to absenteeism and long periods of absence from work. zdravje d Fatigue at the workplace combines a serious lack of energy with a reduced ability to function, resulting in less energy and motivation to respond to or persist in a certain type of activity or conduct. Three sources of energy are associated with fatigue: physical, psychological and emotional (Frone and Tidwell, 2015). The emotional toll exacted by work is not only expressed in emotional fatigue, but also in physical and psychological fatigue. This indicates that emotional burdens operate more widely and in a more harmful way. As society currently requires ever-greater interaction, cooperation and team work from workers, interest in emotional fatigue has grown in recent times, as a result of the phenomenon of emotional exhaustion (Frone and Tidwell, 2015). Social behavioural disorders at the workplace are most commonly expressed in different forms of violence. Workers may be victims of verbal vi- olence, bullying (mobbing) or even sexual or racial harassment (Fiseković, Trajković, Bjegović-Mikanović and Terzić-Supić, 2015). This is a serious social and health problem and one that affects the psychological and physical health of workers, on their wellbeing, and on their family and working environments. Measuring psychophysical workload Psychophysical workload means increased workload placed on an individu- al. Workload is defined as the physical and mental requirements related to the performance of specific tasks (Gudipati and Pennathur, 2016). The physical volume of work is the measurable part of the physical resources expended in the performance of a specific task. Numerous factors affect this, including the nature of the work, experience, motivation and environmental variables. Tools for assessing physical workload include the use of evaluation techniques, phys-11 ical diagrams, biomechanical analyses, measurements of energy consumption and analyses of the Pain Assessment Scale (Melzack, 1975 in Gudipati and Pen- nathur, 2016). lovenia n s Measuring mental workload is more difficult and is defined as the amount of cognitive work required for a person to complete a specific task within a spe-rkers io cific period (Longo, 2016). In practice, psychophysical measurements such as f w heart rate and brain activity can be employed to measure an individual’s men- tal workload, along with an assessment of task implementation (reaction time, rkload oo etc.) and self-assessment questionnaires (Gudipati and Pennathur, 2016). Problem physical w The purpose of the research was to establish how certain demographic varia- psycho bles affect psychophysical health at work. Borg et al. (2000) found, for example, that women were a higher risk group than men when it came to understanding their own health; they also had fewer opportunities to improve perceptions of their own health. We therefore designed two research questions: - Which demographic groups in Slovenia are currently most exposed to psychophysical risks? - Which professions or professional groups report the highest psychophysical risks? Methods Participants and procedure The questionnaire was completed by 490 workers (366 women and 124 men). Twenty per cent of participants belonged to the first age group (18–26). The highest proportion of participants belonged to the second age group (27–35, 44.5%), while the third age group (36–44) accounted for 20% of participants. The fewest number belonged to the 45 and over age group (15.7% of the sample). University graduates accounted for 35.9% of participants, followed by those who had completed secondary school education (24.1%) and academic technical education (18.4%). Those who had completed primary school, voca- tional secondary school or college accounted for the fewest number of partic- ipants (0.6, 2.2 and 5.7% respectively). A total of 13.1% of participants had completed Master’s or doctoral studies. We classified professions into 21 groups in line with the Standard Classi- fication of Activities from 2008 (SKD, Uradni list RS, 69/07 and 17/08). Twen- ty-two per cent (the highest single proportion) of participants were engaged in professional, scientific and technical activities. Health and social work professions (15.9%) and education (14.3%) were also well represented. Trade and motor vehicle maintenance and repair accounted for 9% of participants, as did other 12 business activities. The data was collected with the help of an online questionnaire in which n all questions had to be answered. We used social networks and the psihologij- pulatio adela.com website to invite participants to take part. o ge p Aids rking-ao We used the Psychophysical Health Scale, SPFZ-2; Majstorović, 2011), which al- he w lows individuals to assess their own psychophysical health. It comprises 15 as-f t sertions within the following five dimensions: physical health complaints (e.g. “Have you suffered from stomach or other digestive complaints in the last four ealth o weeks?”), fear and anxiety (e.g. “ Have you been fearful for no good reason in | h the last four weeks?”), depressive reactions (e.g. “Have you had trouble sleeping in the last four weeks?”), fatigue (e.g. “Have you noticed, in the last four weeks, pulacije o that you are tired for no good reason?”) and social behavioural disorders (e.g. “Have you become intolerant of others in the last four weeks?”). With the help ktivne p of a four-point Likert scale, the individual estimated how many times in the last four weeks they had identified a certain health issue as affecting them (pos-elovno a sible answers are “No”, “Yes, but not often”, “Yes, often” and “Yes, every day”). The reliability of the original scale was 0.85 (Popov et al., 2016) and the reliabil-zdravje d ity of the Slovenian translation was 0.80 (Kuhta, 2016). At the end, the participants inserted further information in the form of their sex, age, level of education completed, profession and group of activities in which they were employed. For the basic overview of data we used simple descriptive statistics ( M, SD) and skewness, kurtosis and Kolmogorov-Smirnov test - to test normality of distribution. Hierarchical regression analysis has been used, where age and education were presented with the aid of »dummy« variables – reference group of edu- cation is primary school education and of age is 18-26 age group. The last two graphs are a simple representation of avarage score on each dimension between different activities (SKD). Results Table 1: Self-assessment of five dimensions of psychophysical health of all participants according to the SPFZ-2 scale. Asymmetry Kurtosis Kolmogorov–Smirnov test Dimension M SD As SE Spl SE Statistics df p Physical health complaints 5.48 1.74 0.86 0.11 0.68 0.22 0.17 489 0 Fear and anxiety 4.27 1.61 1.41 0.11 1.49 0.22 0.25 489 0 Depressive reactions 4.22 1.28 1.28 0.11 2.70 0.22 0.23 489 0 Fatigue 6.02 2.17 0.59 0.11 -0.40 0.22 0.15 489 0 13 Social behavioural disorders 6.21 1.50 0.63 0.11 0.16 0.22 0.18 489 0 lovenia Table 1 shows the average results for all participants across the five di- n s mensions of the Psychophysical Health Scale. They show that the most pro- rkers i nounced dimensions for the participants are fatigue and social behavioural diso f w orders. The lowest average values were in the dimensions of depressive reactions and fear and anxiety. The results are presented below using hierarchical regression analysis for rkload oo all dimensions. All tables are included for the dimensions in which the statistical differences are significant. A model was used that included, step by step, education, followed by age and, at the end, sex. physical w For the dimension of physical health complaints, the hierarchical regres-psycho sion analysis showed that demographic variables explained 3% of the differenc- es, but the variance produced was not statistically characteristic regardless of the predictors included in the model. The demographic variables for the fear and anxiety dimension (Table 2) explain 5% of the differences, where the inclusion of education and age in the model increases the percentage of the variance produced or the differences between people in the dimension in a statistically significant way. With the education variable, there is a statistically significant difference between individuals who have completed secondary school, academic technical, university or doctoral studies. In the fear and anxiety dimension, these individuals differ from those who have completed primary school in a statistically significant way. If we include the predictor of age in the model, we see that the percentage of the variance produced increases significantly. For the dimension of fatigue, the hierarchical regression analysis also shows that demographic variables explain 3% of the differences, but the vari- ance produced is not statistically characteristic regardless of the different inclusion of the predictors in the model. Table 2: Hierarchical regression analysis: prediction of the dimension of fear and anxiety based on education, age and sex. Model 1 Model 2 Model 3 Predictor B SEB β B SEB β B SEB β Education Vocational -0.46 1.05 -0.04 -0.41 1.04 -0.04 -0.56 1.04 -0.05 Secondary -1.81 0.94 -0.48 -1.77 0.93 -0.47 -1.87 0.94 -0.50* College -1.46 0.98 -0.21 -1.42 0.97 -0.20 -1.49 0.97 -0.21 Academic technical -1.81 0.94 -0.43 -1.75 0.94 -0.42 -1.88 0.94 -0.45* 14 University -1.74 0.93 -0.52% -1.76 0.93 -0.52% -1.86 0.93 -0.55* n Master’s -1.48 0.96 -0.25 -1.54 0.96 -0.26 -1.67 0.96 -0.28 Doctorate -2.25 0.98 -0.30* -2.27 0.99 -0.30* -2.28 0.99 -0.31* pulatioo Age ge p 27–35 -0.52% 0.20 -0.16* -0.53 0.20 -0.16* 36–44 -0.16* 0.24 -0.04 -0.19 0.24 -0.05 rking-ao 45 and over -0.42 0.25 -0.10 -0.41 0.25 -0.09 he wf t Sex 0.27 0.17 0.07 0.03 0.05 0.05 -0.05 ealth o| h F 2.18* 2.77* 2.52 Notes: HLM, education and age are presented with the aid of “dummy” variables, where pulacije o the reference group for the first is primary school education and the reference group for the second is the 18–26 age group. * p < 0.05, ** p < 0.01 ktivne p Demographic variables in the depressive reactions dimension (Table 3) ex-elovno a plain 2% of the differences, but the change is not statistically significant. With the inclusion of the variables of age and sex, there are, within Model 3, statis-zdravje d tically significant differences between individuals who have completed voca- tional, academic technical, university and doctoral studies. Individuals who belong to these groups differ significantly from those who have completed pri- mary school in relation to the depressive reactions dimension. Their result for the dimension is 1.74 lower than for those who have completed vocational studies, 1.58 lower than for those who have completed academic technical studies, 1.63 lower than for those who have completed university studies and 1.60 lower than for those who have completed doctoral studies. Table 3: Hierarchical regression analysis: prediction of the dimension of depressive reactions based on education, age and sex. Model 1 Model 2 Model Predictor B SEB β B SEB β B SEB β Education Vocational -1.67 0.83 -0.19* -1.69 0.84 -0.20* -1.74 0.84 -0.20* Secondary -1.35 0.75 -0.45 -1.37 0.75 -0.46 -1.40 0.75 -0.47 College -1.27 0.78 -0.23 -1.3 0.78 -0.24 -1.32 0.78 -0.24 Academic technical -1.49 0.75 -0.45* -1.54 0.76 -0.47* -1.58 0.76 -0.48* University -1.55 0.75 -0.58* -1.59 0.75 -0.60* -1.63 0.75 -0.61* Master’s -1.29 0.77 -0.28 -1.34 0.77 -0.29 -1.38 0.77 -0.30 Doctorate -1.50% 0.78 -0.25 -1.60 0.79 -0.27* -1.60 0.79 -0.27* 15 Age 27–35 -0.01 0.16 0 -0.01 0.16 0 lovenia 36–44 0.09 0.19 0.03 0.08 0.19 0.02 n s 45 and over -0.14 0.20 -0.04 -0.14 0.20 -0.04 rkers i Sex 0.09 0.14 o f w 0.02 0.02 0.02 F 1.03 0.42 0.41 rkload oo Notes: HLM, education and age are presented with the aid of “dummy” variables, where the reference group for the first is primary school education and the reference group for the second is the 18–26 age group. physical w * p < 0.05, ** p < 0.01 psycho The demographic variables for the social behavioural disorders dimension (Table 4) explain 26% of the differences, where the inclusion of all three variables in the model increases the percentage of the variance produced in a statistically significant way. With the inclusion of age and sex (Model 3), statistically significant differences are produced in all education groups. Individuals with an education level above that of primary school more rarely experience social behavioural disorders. The result for individuals in the 45 and over age group is 0.98 higher than that for individuals in the 18–26 age group, which shows that such behaviour is more common in this age group than it is among younger people. It is shown in this dimension that, with the inclusion of all variables, there are significant differences with regard to sex, with women achieving a 0.64 higher result than men, which indicates that there is a statistically significant higher frequency of social behavioural disorders. Table 4: Hierarchical regression analysis: prediction of the dimension of social behavioural disorders based on education, age and sex. Model 1 Model 2 Model 3 Predictor B SEB β B SEB β B SEB β Education Vocational -16.46 1.55 -0.90** -16.36 1.54 -0.90** -16.72 1.54 -0.92** Secondary -16.88 1.39 -2.66** -16.94 1.39 -2.67** -17.18 1.38 -2.71** College -16.43 1.45 -1.41** -16.53 1.44 -1.42** -16.68 1.43 -1.43** Academic technical -16.93 1.40 -2.43** -16.88 1.39 -2.42** -17.19 1.39 -2.46** University -16.85 1.39 -2.99** -16.75 1.38 -2.97** -16.99 1.38 -3.01** Master’s -16.43 1.42 -1.66** -16.40 1.42 -1.66** -16.71 1.42 -1.69** 16 Doctorate -16.58 1.46 -1.33** -16.68 1.46 -1.33** -16.71 1.45 -1.33** Age n 27–35 0.23 0.29 0.04 0.21 0.29 0.04 pulatio 36–44 0.60 0.35 0.09 0.53 0.35 0.08 o ge p 45 and over 0.94 0.37 0.13* 0.98 0.37 0.13* Sex 0.64 0.25 0.10* rking-ao 0.24 0.25 0.26 he wf t F 21.59* 2.74* 6.34* ealth o Notes: HLM, education and age are presented with the aid of “dummy” variables, where | h the reference group for the first is primary school education and the reference group for the second is the 18–26 age group. * p < 0.05, **p < 0.01 pulacije o The tables below show the frequency of psychophysical loads in relation ktivne p to the area of work or activity under the SKD (Uradni list RS, 69/07 and 17/08). Abbreviations are used for groups of activities in the tables for the purpose of elovno a transparency. Physical health complaints (Figure 1) are most frequently reported by par-zdravje d ticipants who perform work in construction ( M = 6.00), followed by financial and insurance activities ( M = 5.79). Participants engaged in electricity, gas and steam supply ( M = 4.67) and cultural, entertainment and recreational activities ( M = 4.91) report the lowest frequency of symptoms of illness. The occurrence of symptoms linked to fear and anxiety is very low in the sample ( M = 4.27). Individuals employed in trade and in motor vehicle maintenance and repair score highest above the average for this dimension ( M = 4.80), followed by those engaged in manufacturing activities ( M = 4.60). The absence of symptoms of fear and anxiety is described within the activity of electricity, gas and steam supply ( M = 3.00). 17 lovenia n s Figure 1: Occurrence of all five psychophysical load dimensions in different activities (SKD). rkers io f w The dimension of fatigue has a high average value in comparison with other dimensions ( M = 6.02). Individuals employed in public administration, defence and compulsory social security activities most frequently report symp-rkload oo toms linked to fatigue ( M = 6.74), followed by those engaged in information and communications activities ( M = 6.58). Symptoms of fatigue are rarely, if ev-er, reported by workers engaged in electricity, gas and steam supply activities physical w ( M = 4.50) and in transport and storage ( M = 5.00). psycho Depressive reactions have the highest average value in comparison with the four other dimensions ( M = 4.22). Symptoms are reported most frequently by those employed in construction ( M = 5,14) and catering and hospitality ( M = 4.50). Never (or rarely) do symptoms occur in trade ( M = 4.11) or in professional, scientific and technical activities ( M = 4.12). In our sample, social behavioural disorders appear with greatest frequency ( M = 6,21). Workers in information and communications activities most frequently report intolerance and avoiding contact with others ( M = 6.92), followed by transport ( M = 6.71). By contrast, workers in catering and hospitality report positive experiences in relationships with others ( M = 5.58). A joint value on the Psychophysical Health Scale is given to enable a com- parison between activities (Figure 2). The overall trend is similar to the trend observed in relation to individual dimensions: issues relating to psychophysical load are most frequently reported by workers in construction ( M = 28.43). Information and communications activities ( M = 27.75), financial and insurance activities ( M = 26.93), trade ( M = 26.80), public administration, defence and so- cial security activities ( M = 26.52), education ( M = 26.51), healthcare ( M = 26.31) and catering and hospitality ( M = 26.25) are all above the average for psychophysical health ( M = 26.23). Participants employed in electricity, gas and steam supply ( M = 22.83) and in cultural, entertainment and recreational activities ( M = 24.82) enjoy the lowest levels of psychophysical risk. 18 n pulatioo ge p rking-ao he wf t Figure 2: Presence of psychophysical load dimensions in different activities. ealth o| h Discussion pulacije o The results show that the most pronounced dimensions for the actively working population are fatigue and social behavioural disorders. Participants therefore ktivne p most frequently report fatigue, a lack of sleep, intolerance and the avoidance of social contact with others. Behaviour linked to the dimensions of depressive elovno a reactions and fear and anxiety is less frequent. Participants rarely mentioned groundless fear, fear of illness, loss of appetite and morbid depressive thoughts. The purpose of the research was to establish a link between demograph- zdravje d ic variables and psychophysical health, i.e those demographic groups currently most exposed to psychophysical risks. The results show that we cannot use demographic variables to explain the differences between people in the dimen- sions of physical health complaints and fatigue. With regard to the dimension of depressive reactions, and despite the fact that the model does not predict discrepancies in individuals’ results in a statistically significant way, we can observe that there are differences in education. Individuals who have completed vocational, academic technical, university or higher studies report depressive symptoms less frequently (difficulties sleep- ing, reduced appetite and loss of a will to live). We can conclude in this case that education is a safety factor, as individuals with a higher level of education are less frequently exposed to depressive feelings. The differences between individuals resulting from demographic vari- ables are statistically important in the dimensions of fear and anxiety and social behavioural disorders. In relation to the dimension of fear and anxiety, there is also a trend for individuals with an education level higher than primary school to suffer significantly less fear and anxiety. There are also significant differences when it comes to age group, with individuals in the 27–35 age experiencing fewer feelings of anxiety than their younger counterparts (18–26). Demographic variables have the greatest explanatory power with regard to the dimension of social behavioural disorders (they explain 26% of the variance). There are statistically significant differences with all three variables of education, age and sex for this dimension. Higher the education is, less symptoms are presented. This once again confirms the trend indicated: education as protec-19 tive factor. There are also significant differences in age, as individuals over the age of 45 experience social behavioural disorders more commonly than those in the 18–26 age group. One can conclude, with regard to the age variable, that lovenia it is about the specificity of the age group in relation to the dimension and not n s the trend: individuals aged between 27 and 35 experience less anxiety, while rkers i social behavioural disorders are more commonly present among the over-45s. o f w The results for the last dimension also show significant differences between the sexes: women report social behavioural disorders more frequently than men, and the difference is statistically significant. This connects with the findings of rkload oo Borg et al. (2000), who found that women were a higher risk group than men when it came to understanding their own health. Given that this connection was evident in only one of the dimensions, we cannot fully support it. physical w The second part of our research question addresses the link between pro- psycho fessional groups/activities and exposure to psychophysical risks. Participants who perform construction work most frequently experience physical health complaints, also employed in finance, insurance and catering and hospitality are more susceptible to feeling unwell. Symptoms linked to fear and anxiety are most frequent in trade and in motor vehicle maintenance and repair. Workers in manufacturing and in information and communications activities are also more highly susceptible to anxiety. Fatigue is most frequently reported by workers in public administration, defence and social security activities, followed by those working in the field of information and communications. De- pressive reactions most frequently appear in construction, followed by catering and hospitality, and finance and insurance. Workers in information and communications activities and in transport most frequently report social behavioural disorders. The overall psychophysical health average shows a similar trend, with the highest level of risk appearing in construction, information and communica- tions, and finance and insurance. Those employed in electricity, gas and steam supply and in cultural, entertainment and recreational activities report the lowest levels of psychophysical risk. Conclusions Demographic variables are significantly linked to exposure to psychophysical risks. We can conclude that education acts as a safety factor, as the results indicate that more highly educated individuals less frequently report psychophys- ical health complaints (feelings of depression, anxiety, social contact issues). Age does not reveal any clear trends in relation to psychophysical health, but there are specificities regarding a specific age group in relation to the dimension. Sex explains the differences between individuals only in one of the di- mensions; therefore, we cannot support the assumption that women are a high- er-risk group when it comes to an understanding of their own health. Of the professional groups or activities in which participants are em- 20 ployed, the research shows that workers in construction are most often ex- n posed to psychophysical risks (they most commonly report physical health complaints and depressive reactions). Psychophysical health problems are also pulatio noted by workers in manufacturing (most commonly fear and anxiety), public o administration, defence and social security (frequently fatigue), and informa- ge p tion and communications (frequently social behavioural disorders). rking-a Despite the suitably large sample, there were too few participants from o some sectors (mining, agriculture, real estate) to enable a proper analysis. If the he wf t research were repeated, one could also ask participants about their status with-in the organisation (management/non-management staff) and on the number ealth o of days of sick leave per year. This information would provide us with an addi- | h tional insight into the issue at hand. The research has drawn attention to the large number of risks to which pulacije o individuals are exposed at work, and could be of value in informing employ- ers of the potential consequences of exposure to various risks among their em- ktivne p ployees. At the same time, the results could raise the awareness of employers in certain sectors: that the working environment is occasionally too demand- elovno a ing and that solutions and measures should be sought in a systematic, planned way (e.g. by adapting the workplace, providing psychological support, and ed- zdravje d ucation and training) to reduce psychophysical risks. References ALBREHT, T. in TURK, E., 2010. Ekonomsko breme duševnih bolezni. Zdra- vstveni vestnik, 78(7/8), 531-536. BORG, V., KRISTENSEN, T.S. in BURR, H., 2000.Work environment and changes in self-rated health: A five year follow-up study. Stress and Health, vol. 16, No 1, pp. 37–47. BRAUNSBERGER, F., HLAVATY, M., SCHLAMBERGER, N. in STEVANO- VIČ, S., 2008. Standardna klasifikacija dejavnosti 2008 [Last accessed: 3. 4. 2017]. Available at: http://www.stat.si/dokument/1209/skd.pdf. BRUN, E. in MILCZAREK, M, 2007. Expert forecast on emerging psychosocial risks relater to occupational safety and health. Belgium: European Agen-cy for Safety and Health at Work. EVANS-LACKO, S., KOESER, L., KNAPP, M., LONGHITANO, C., ZOHAR, J. in KUHN, K., 2016. Evaluating the economic impact of screeningintreat- ment for depression in the workplace. European Neuropsychopharmacol- ogy, vol. 26, No 6, pp. 1004–1013. FISEKOVIĆ, M.B., TRAJKOVIĆ, G.Z., BJEGOVIĆ-MIKANOVIĆ V.M. in TERZIĆ-SUPIĆ, Z.J., 2015. Does workplace violence exist in primary health care? Evidence from Serbia. European Journal of Public Health, vol. 25, No 4, pp. 693–698. FRONE, M.R. in TIDWELL M.C.O., 2015. The meaning in measurement of 21 work fatigue: Development in evaluation of the three-dimensional Work Fatigue Inventory (3D-WFI). Journal of Occupational Health Psychology, lovenia vol. 20, No 3, pp. 273–288. n s GUDIPATI, S. in PENNATHUR, A., 2016. Workload assessment techniques rkers i for job design [Last accessed: 3. 4. 2017]. Available at: http://semac.org. o f w mx/archivos/6-9.pdf. HENDRIKS, S.M., SPIJKER, J., LICHT, C.M.M., HARDEVELD, F. , DE GRAAF, R., BATELAAN, N.M., PENNINX B.W.J.H., AARTJAN T.F. rkload oo in BEEKMAN, A.T.F., 2015. Long-term work disabilityinabsenteeism in anxietyindepressive disorders. Journal of Affective Disorders, No 178, pp. physical w 121–130. HUPKE, M., 2013. Psychosocial risks and workers health. [Last accessed: 3. psycho 4. 2017]. Available at: https://oshwiki.eu/wiki/Psychosocial_risks_and_ workers_health KUHTA, K., 2016. Vpliv delovnega mesta na psihofizično zdravje zaposlenih: diplomska naloga. Ljubljana: Filozofska fakulteta. LONGO, L., 2016. Mental workload in medicine: foundations, applications, open problems, challenges and future perspectives. Dublin: Proceedings of the IEEE Syposium on computer based medical system. MAJSTOROVIĆ, N., 2011. Skala psihofizičkog zdravlja. Unpublished material. MORTENSEN, R., 2014. Anxiety, work and coping. The Psychologist-Manager Journal, vol. 17, No 3, pp. 178–181. POPOV, B., MASTOROVIĆ, N., MATANOVIĆ, J., JELIĆ, D. in RAKOVIĆ, S., 2016. Predictors of employees’ psychophysical health and sickness absen- teeism: Modelling based on REBT framework. Psihologija, vol. 49, No 1, pp. 67–86. SPARKS, K., FARAGHER, B. in COOPER, C.L., 2001. Well-being and occupational health in the 21st century workplace. Journal of Occupational and Organizational Psychology, vol. 74, No 4, pp. 489–509. 22 n pulatioo ge p rking-ao he wf t ealth o| h pulacije o ktivne p elovno a zdravje d Retrospective and experiential perception of physical activity during pregnancy on childbirth and postpartum period Marjana Božič1, Ksenija Kragelj2, Mirko Prosen1 1 University of Primorska, Faculty of Health Sciences, Department of Nursing, Polje 42, 6310 Izola, Slovenia 2 Community Health Centre Tolmin, Prešernova 6/a, 5220 Tolmin, Slovenia bozic.marjanca@gmail.com; kkragelj@gmail.com; mirko.prosen@fvz.upr.si Abstract Introduction: The purpose of the research was to examine the beliefs and experiences of women in the postpartum period on how the physical activity during pregnancy affects the psychological and physical well- being, the outcome of childbirth and the recovery in postpartum period. Methods: The qualitative methodology was used. The purposive sample of 11 women who have given birth in the last year was applied. Their mean age was 27.6 years (s = 4.37); most of them (n = 5) finished upper secondary education; most of them (n = 7) were living in rural areas; more than half of the interviewees were primiparous women (n = 8). Data were collected using a semi-structured interview in January 2017. The data gathered were analyzed with the method of content analysis. Results: The analysis yield three themes, namely (1) the factors that affect the implementation, opportunities, motivation and awareness about the importance of physical activity during pregnancy, (2) the characteristics of performing physical activity in the postpartum period, (3) the implementation of pelvic floor muscle exercise during pregnancy and after childbirth. Discussion and conclusions: The results indicate that women are very aware about the importance of physical activity during pregnancy and its positive impact on childbirth, postpartum period, and psychological and physical well-being. The interviewees were the opinion that physical activity helped to facilitate childbirth and recovery after childbirth. The time taken by the individuals dedicated to physical activity differed between the interviewees. Most women during pregnancy were engaged in physical activity individually. They usually choose walking and swimming. Key words: physical exercise, childbirth outcomes, pelvic floor muscle exercises, qualitative methodology doi: https://doi.org/10.26493/978-961-7023-32-9.23-29 Regular physical activity is one of the most important factors to lead of a healthy way of life. This also the case with the prenatal period, pregnancy time and the postpartum period. Moderate physical exercise is ex- pected to be a part of everyday life of the future mother as long as there are no health or other complications associated with pregnancy. Physically fit and psychologically well prepared women bear their pregnancy better and are better prepared for the birth and also recover after it. A healthy lifestyle for pregnant women – including suitable sport activity as well as a healthy diet – have a positive impact on the growth and development of the fetus, are beneficial to the body and health, and also contribute to an easier childbirth and to get in shape faster after giving birth (Mlakar et al., 2011). A lot of women want to change their physical activity the moment they find out they are pregnant. That is why it is important they get proper ad- vice about doing physical activity during pregnancy. Some of them, especial- ly in the first and last quarter of pregnancy do not have enough will and re- 24 al energy for exercise while others are excessively concerned for the well-being n and health of the fetus. A number of studies have shown that physical activi- ty has beneficial effect on the mental stability of pregnant women, reduces low-pulatioo er back and other joints’ pain, improves sleep, helps to maintain appropriate ge p body weight, increases endurance and strength in labor (Larsson and Lind- qvist, 2005), improves the cardio-vascular and respiratory system function, rerking-ao duces the possibility of developing of pre-eclampsia, gestational diabetes and he w high blood pressure and it also helps to an easier childbirth and reduces the f t number of peripartal complications (Wadsworth, 2007; Lučovnik et al., 2013; Cid and Gonzalez, 2016). Pregnant women who are physically active have less ealth o pregnancy problems, less frequent pain in the pelvic ring and urinary inconti- | h nence (Videmšek et al., 2015). pulacije o Methods ktivne p We used a qualitative research paradigm. The test sample included eleven women who gave birth in the last year. Their average age was 27.6 years. The youngest was 22 years old and the oldest was 35. Five of the participants had elovno a secondary education, two of them higher education, and four had a universi- ty degree. Most of them, i.e. seven participants, lived in rural areas, while four zdravje d lived in the city. For one participant, it was her third childbirth, for two participants it was the second, and for eight it was their first. Regarding the gestational age, ten pregnancies were full-term and one was premature. In the partici- pants who had a vaginal birth, the birth giving lasted 1 to 13 hours. On average, the childbirth lasted 7.3 hours in women giving birth for the first time, 4.5 hours in women giving birth for the second time, and only 1 hour in a woman giving birth for the third time. The method of data collection was a semi-structured interview. We invit- ed the potential participants to take part in the research in writing, with the explanation of the purposes and objectives of the research as well as its methods. We used contacts in our own social network, and with the technique of snow-ball sampling, we reached women who voluntarily accepted the invitation. Ac- cording to their wishes and availability, we agreed on the date, place and time of the interview. The interviews were held in January and February 2017. We took into account the ethical aspects of the research, so all interviewees had to sign the informed consent form before the start of the interview in case they decided to participate. An introductory inquiry on sociodemographic data was followed by an interview which was sound recorded. The average interview lasted 30 minutes. The data obtained through the interview were analysed by content analysis of the text. Results After the initial coding phase of the text in which twenty-two categories were identified, they were combined into three central themes with individual sub-themes that define physical activity during pregnancy. The themes were hier- 25 archically distributed (Table 1), which means that the first topic was support-ed by most statements. And at least the statements of the women participating were the last topic. egnancy pr Table 1: Themes in qualitative analysis. ring Theme Subtopics Number of references ctivity du The influence of the course of pregnan- al a cy on the physical activity during preg- 26 ysic nancy ph Types and opportunities for physical n of The factors that affect the implemen- activity before and during pregnancy 95 tation, opportunities, motivation and rceptio awareness about the importance of pe Accessing information, encouragement physical activity during pregnancy and motivation for physical activity 24 during pregnancy Awareness of the impact of physical ac- tivity on psychological and physical 76 well-being The characteristics of performing phys- Physical activity in the postpartum pe-ical activity in the postpartum period riod 35 The implementation of pelvic floor The gap between the awareness of the muscle exercise during pregnancy and impact of pelvic floor muscle training 24 after childbirth. and its realization Discussion Results of the study showed that women are well informed about the impor- tance of physical activity during pregnancy and are aware of its positive effects on their well-being, the course of pregnancy, the childbirth and the postpar- tum period. Through interviews and their answers gained, we found out that the interviewees did swimming, pilates, cycling on an exercise bike, skiing and hiking during pregnancy. Among the participants walking was dominating, because beside the already mentioned other types of physical activity, walking was chosen by all women. Most of them devoted between 30 and 60 minutes, some also more time, to physical activity depending on the day, their well-be- ing and available time. On average, they were physically active five times a week. We believe that this is a good result according to the issued recommen- dations by American College of Obstetricians and Gynecologists (2002). The same can be confirmed by comparing this qualitative research with a quantita- tive study carried out by Rijavec (2016). In the research, we found that all the interviewees were performing phys- ical activity independently. It seems to us from a medical point of view, this information is worrying because we do not know whether the participants were familiar with it. What they need to be careful about doing and when they need 26 to stop their physical activity. In any case, this could be the research question n for a new research. Gogala (2013) found, that the majority of respondents, 39 (68.4%), during their pregnancy used non-organized forms of physical activ- pulatioo ity, with their family and friends or independently. We also received interest-ge p ing answers on the question where the women got information about the form or type of exercise to perform during the pregnancy. We were surprised by the rking-ao statements of the participants that they found the information themselves us- he w ing various easily accessible sources. At least ten participants confirmed that f t they had access to information via the Internet. We have a question here: »Is the Internet really a right, reliable source of information?« It is often believed ealth o that the answer is affirmative, but it is important to know on which website | h we access the information, otherwise, we could overlook important warnings. At this point, we have identified a gap, so we believe that greater awareness is pulacije o needed, especially at the primary level of health care. Only three interviewees said in their statements that the information was provided by healthcare pro-ktivne p fessionals. In a survey carried out by Gragelj (2014), 27 (54%) of surveyed pregnant women received the most information about exercise during pregnancy elovno a on the Internet and only 6 pregnant women (12%) from health workers at the parent‘s school.. zdravje d Due to an important role of the pelvic floor muscles in the life of every woman, in this research, we tried to determine whether the participants were performing pelvic floor muscle training during pregnancy and whether they were aware of the importance of these muscles. The results show that all the women know the reasons for strengthening the pelvic floor muscles and are aware of how it can affect pregnancy, childbirth, and postnatal period. It was very encouraging to find that seven of them were doing pelvic floor muscle exercises already during the pregnancy. Rijavec (2016) reported that in her study, 35 (76,1%) of the 46 women surveyed performed exercises for strengthening the pelvic floor muscles during pregnancy. The qualitative research confirmed the already known scientific findings: physical activity has beneficial effects on childbirth and postnatal recovery (Blenkuš et al., 2015; Videmšek et al., 2015) – which in this case, was also a subjective opinion of women. Participating women perceived physical activity to be important for an easier birth. Most of the interviewees believed that due to regular physical activity during the pregnancy, they had more power and physical fitness during the birth, which made their birth and the recovery period after that significantly easier and shorter. The type of physical activity pregnant women can attend is organized ex- ercise intended for them. In the results of the research we were surprised by the fact that only two women attended guided exercise during pregnancy but it was not specifically set for pregnant women. In a study conducted by Rijavec (2016), only 9 (19.6%) of the 46 respond- ents decided on organized group exercise during pregnancy. In a study con- ducted by Husić (2015) this type of activity was attended by 6 (15.8%) of the 40 27 respondents. According to the results of these studies, we can conclude that in general, women are generally less likely to have guided exercise in pregnancy. The finding that there is not an organized physical exercise for participating egnancy pregnant women in their hometown or in their immediate area is a concern. pr We believe that in the future organized exercise intended for pregnant women ring should expand and take place in all health centers throughout Slovenia. In Slovenia we have not come across any qualitative research in this field, so we bectivity du lieve that in the future it would be necessary to carry out a similar, more exten-al a sive survey that would allow comparison of results and would thus show the ysic difference between the physical activity of the pregnant women that live in ru-ph ral areas and those who live in the urban environment. n of rceptio Conclusions pe Modern women are very aware of the importance of regular physical activity (especially during pregnancy) and all its positive impacts on psychological and physical well-being, the course of pregnancy, childbirth and postpartum period. They also know that a fit woman will quickly adapt to all the changes that happen in her new period. Physical activity during pregnancy is definitely one of the most impor- tant factors affecting the mental and physical well-being of the mother-to-be, the course of pregnancy, childbirth and postpartum period. All participants showed that with their statements. They were physically active before pregnan- cy and even more committed to and continued it over their expecting period. A detailed analysis of the results has confirmed the fact that health-care workers have known for a long time – physical activity positively affects the well-being of the pregnant women and their health and the fact that pregnant wom- en who take regular exercise feel better. There has been less tension in them. In this emotionally delicate period they were more relaxed, had more strength and energy, and were physically better prepared for childbirth. All of this has consequently led to an easier delivery and faster recovery afterwards. References American College of Obstetricians and Gynecologists, 2002. Exercise during pregnancy and the postpartum period: ACOG Committe Opinion No. 267: Obstetrics & Gynecology, vol. 99, no. 1, pp. 171–173. BLENKUŠ, Š., ČEMAŽAR, V., VIDEMŠEK, M., HADŽIĆ, V., PIRKMAJER, S. and ROTOVNIK-KOZJEK, N., 2015. Pomen telesne dejavnosti v nosečnos- ti. In: NOVAK-ANTOLIČ, Ž., KOGOVŠEK, K., ROTOVNIK-KOZJEK, N. and MLAKAR-MASTNAK, D., eds. Klinična prehrana v nosečnosti. Ljubljana: Center za razvoj poučevanja, Medicinska fakulteta, Univerza v Ljubljani, pp. 145–160. CID, M., and GONZALEZ, M., 2016. Potential benefits of physical activity dur- 28 ing pregnancy for the reduction of gestational diabetes prevalence and n oxidative stress [online]. Early Human Development, vol. 94, pp. 57–62. [viewed 16. 11. 2016]. Available from: http://www.sciencedirect.com/sci- pulatioo ence/article/pii/S0378378216000062 ge p GOGALA, E., 2013. Počutje nosečnic glede na njihovo športno aktivnost: diploma thesis [online]. Ljubljana: Univerza v Ljubljani, Fakulteta za šport, pp. rking-ao 18, 21. [viewed 9. 7. 2017]. Available from: https://www.fsp.uni-lj.si/cobiss/ he w diplome/Diploma22070140GogalaEva.pdf f t GREGELJ, I., 2014. Telesna aktivnost med nosečnostjo: diploma thesis [online]. Murska Sobota: Evropski center Maribor, pp. 38. [viewed 10. 7. 2017] . ealth o| h Available from: http://www.mss.si/datoteke/dokumenti/diplomske/2014/ gregelj_diplomska.pdf pulacije HUSIĆ, T., 2015. Telesna vadba v nosečnosti: diploma thesis [online]. Mario bor: Univerza v Mariboru, Pedagoška fakulteta, Oddelek za predšolsko ktivne p vzgojo, pp. 35, 37, 40, 41. [viewed 7. 6. 2017]. Available from https://dk.um. si/Iskanje.php?type=napredno&lang=slv&stl0=Avtor&niz0=Tama- ra+Husi%C4%87 elovno a LARSSON, L., and LINDQVIST, P.G., 2005. Low-impact exercise during preg- nancy – a study of safety [online]. Acta Obstetricia et Gynecologica Scandi-zdravje d navica, vol. 84, no. 1, pp. 34–38. [viewed 16. 11. 2015]. Available from: http:// onlinelibrary.wiley.com/wol1/doi/10.1111/j.0001-6349.2005.00696.x/full LINDQVIST, M., LINDKVIST, M., EURENIUS E., PERSSON, M., IVARS- SON, A., and MOGREN, I., 2016. Leisure time physical activity among pregnant women and its associations with maternal characteristics and pregnancy outcomes [online]. Sexual & Reproductive Healthcare, vol. 2016, no. 9, pp. 14–20. [viewed 11. 1. 2017]. Availabne from http://www.srh- cjournal.org/article/S1877-5756(16)30026-X/pdf LUČOVNIK, M., BLICKSTEIN, I., STEBLOVNIK; L., VERDENIK, I., TROJNER BREGAR, A., and TUL, N., 2013. Vpliv debelosti pred zanositvi- jo in prekomernega prirasta telesne teže v nosečnosti na izid nosečnos- ti. Ljubljana: Zbornica zdravstvene in babiške nege, Sekcija medicinskih sester in babic, pp. 29–37. MLAKAR, K., VIDEMŠEK, M., VRTAČNIK-BOKAL, E., ŽGUR, L. and ŠĆEPANOVIĆ, D., 2011. Z gibanjem v zdravo nosečnost. Ljubljana: Uni- verza v Ljubljani, Fakulteta za šport, pp. 7 and 20. RIJAVEC, A., 2016. Telesna aktivnost med nosečnostjo: diploma thesis. Izola: Univerza na Primorskem, Fakulteta za vede o zdravju, pp. 26–31. VIDEMŠEK, M., BOKAL-VRTAČNIK, E., ŠĆEPANOVIĆ, D., ŽGUR, L., VIDEMŠEK, N., MEŠKO, M., KARPLJUK, D., ŠTIHEC, J. in HADŽIĆ, V., 2015. Priporočila za telesno dejavnost nosečnic. Zdravniški vestnik, vol. 84, no. 2, pp. 87–98. WADSWORTH, P., 2007. The benefits of exercise in pregnancy [online]. Amer- 29 ican College of Nurse Practitioners, vol. 3, no. 5, pp. 333–339. [viewed 16. 11. 2016]. Available from: http://www.sciencedirect.com/science/article/pii/ S1555415507002127 egnancy pr ring ctivity du al a ysic ph n of rceptiope The mammography efficiency in breast cancer detection in women under 50 years of age Anja Brčan, Maruša Kebe, Maša Pintar, Andrej Starc University of Ljubljana, Faculty of Health Sciences, Zdravstvena pot 5, 1000 Ljubljana, Slovenia anja.brcan@gmail.com; metulj.6@gmail.com; masa.pintar@gmail.com; andrej.starc@zf.uni-lj.si Abstract Around the world and in Slovenia female breast cancer is the most common type of cancer. Based on risk factors the number of patients increases. In 2005 in Slovenia, there were 1111 breast cancer cases, in 2016 the number increased up to 1307 (17.6%). In Slovenia and Europe exists a successful screening breast cancer test program, named DORA. All women between 50 and 69 years are invited in the program to perform a mammography. For women less than 50 years of age several foreign studies revealed that mammography is not the most reliable method for early breast cancer detection. The sensitivity is 61% (< 50 years). In relation to mammography exists a possibility for false positive results. It has been proven that 22% of all diagnoses were pre-diagnosed. This means that women have been exposed to invasive diagnostic procedure, but actually they do not need. For younger women exists a 61.3% of risk for false positive result. And for older women the risk represent 49.7%. For women under 50 years the additional diagnostic methods are the ultrasound and magnetic resonance imaging, also. Descriptive method was used to critically assess Slovenian and English scientific literature. Key words: breast cancer, mammography, screening, DORA Breast cancer (BRC) is the most common type of cancer in women. Inci- dence is higher in the developed world and lower in Africa and Asia (Ed- gar et al., 2013). In 2016, there was 1307 cases of newly discovered BRC in Slovenia, in 2005 the number was 1111. The number of newly discovered diseas- es had increased for 17,6% (CRRS, 2017). Risk factors for BRC are: previous BRC or BRC in family, female gender, age, previous benign breast disease, exposure to ionizing radiation, excessive doi: https://doi.org/10.26493/978-961-7023-32-9.31-38 drinking, smoking and obesity. Big impact on preventing disease have regular physical activity and healthy diet (Primic-Žakelj et al., 2003). Screening test program is the leading measure for detecting BRC around the world for more than 40 years (Roucco, 2016). In Slovenia, there is a nation-al screening test program for BRC since 2008, called DORA (Kadivec and Kra- jc, 2013). All women from 50 and 69 years of age are included in the program (Državni presejalni program za raka dojk, n. d.). Breast tissue consists of two types: glandular tissue (milk lobules and ducts) and fatty tissue. Dense breasts are considered when milk lobules prevails and there is less fatty tissue (Mayo Clinic, 2015). Dense tissue occurs at half of women under 50 years and at one third of women over 50 years. Breast density represents a challenge for radiologists at detecting malignancy, because there is no possibility to differ individual structures or possible disease changes. Breast density is divided into 4 stages: (1) almost entirely fatty tissue, (2) scattered 32 areas of fibroglandular tissue, (3) heterogeneous dense tissue that could cov- er small masses, (4) very dense tissue – can lower mammography sensitivi- n ty (Hooley, 2017). Patients with dense breasts have more biopsies, more false positive results and are frequently exposed to radiation (Roucco, 2016). Dense pulatioo breast tissue is also a risk factor for BRC (Narula, 2016). ge p rking-a Methods o Descriptive method was used with critical assess of professional and scientific he wf t literature in Slovene and English language. Literature was identified by using databases Medline, CINAHL, ScienceDirect and Google Scholar. Bool opera-ealth o tors were used. Searching was limited on articles published between 2001 and | h 2007. Inclusion criteria for literature assess are full articles, articles related to mammography and younger women. Exclusion criteria are studies considering pulacije o women over 50 years of age. We were searching using key words: breast can- cer, mammography, DORA, younger women, screening, overdiagnosis, ultra- ktivne p sound, magnetic resonance. Statistic data was acquired on website of National Cancer Registry RS. Information about screening program DORA on website elovno a of National screening program for breast cancer. Data gathering took place from February to May 2017. zdravje d Results Table 1 shows an overview of 11 studies, that were reviewed. Table 1: Overview of the studies. Author/year Purpose of study Used method Results Magnetic resonance im- Use of imaging diagnos- aging (MRI) has high sen- Sentis, 2010 tic methods for BRC in Literature review sitivity, it detects invasive young women. carcinoma and also carci- noma in situ. To assess sensitivity and specificity of combination of electrical impedance and ultrasound (US) at Combination of electrical BRC detection in young- impedance and US would Wang et al., 2010 er women to calculate rel- Prospective and multicen- be suitable for BRC de- ative risk and find out if tre clinical study tection in younger wom- en regarding to sensitivity 33 there is possible more pre- cise imaging method for and specificity. early BRC detection in tion younger women. etec Ways of diagnosing BRC The best method in wom- d Massat, 2014 in women with dense Literature review en with dense breast tissue er breast tissue. is using MRI. anc US has bigger sensitivi- ty and diagnostic accura- reast c cy than mammography, To compare mammog- specificity is similar. Preci- y in b Ying et al., 2012 raphy and US and their sion of diagnostic US was combination at BRC de- Control group study much better than mam- ficienc tection. mography. Combination of mammography and US increases sensitivity and graphy ef diagnostic accuracy. mo Comparison of diagnostic Combination of two or am efficiency of mammogra- Shao et al., 2013 phy, US, MRI and combi- Prospective study three methods significant- the m nation of those methods at ly improves diagnostic BRC detection. sensitivity for BRC. To research which factors have impact on sensitivity MRI should have been permanent screening Kriege et al.2006 and false positive results at mammography and MRI Multicentric study method for BRC in wom- in women with family ge- en with mutation of gen netic load. BRCA1/2. US also detects chang- Ineffectiveness of mam- es when mammography Brem, 2012 mography in women with Literature review is negative and is success- dense breast tissue. ful at detecting cancer in women with dense breast tissue. Author/year Purpose of study Used method Results To determine character- istic properties of BRC imaging in very young BRC imaging in very women (< 30 years), us- young women shows as ir- An et al., 2015 ing updated BI-RADS. regular mass. Some radio- Further goal is to com- Retrospective study logical tests can be used to pare clinical and imag- detect specific types of tu- ing functions in molecu- mours. lar type tumour in women at that age. To compare clinical exam- ination of breasts, mam- MRI is in most cases bet- ter method than mam- Sardanelli et al., mography, US and MRI at Prospective nonrand- mography, US or combi- 2011 supervising women with high risk factor for he- omized multicenter study nation of both at screening reditary BRC and previ- women with high risk fac- ous BRC. tor for BRC. Common use of tomosin- 34 Comparison of screening, tesis and mammography Chetlen et al., 2015 mammography, tomosin- Literature review increases specificity and n tesis, US, MRI and molec- ular imaging of breasts. decreases the number of false positive results. pulatio Because of indicated biop- o Studying usage of MRI sy in women with palpa- ge p in assessment of palpable Olsen, 2012 breast mass, where mam- Retrospective study ble breast mass is adding mography and US showed MRI just one. more step to rking-a cause more stress and fi- o negative results. nancial load to women. he wf t Since no diagnostic method is perfect, there can also be false positive and false negative results in mammography. False positive result negatively impacts ealth o| h on psychological and emotional state and represents one of the stressors which can temporarily lower the quality of life (Hafslund and Nortvedt, 2009). Nel-pulacije son et al. (2016) have discovered that the most false positive results in younger o women (40–49 years) are because of increased breast density and it decreases with age. Normal mammography result is not a guarantee that a woman does ktivne p not have cancer because some tumours cannot be detected with mammogra- phy. False negative result can cause damage because woman is not treated in elovno a the right time. Cancer can spread and metastasize to the point when treatment cannot be effective anymore (Nass et al., 2001). zdravje d Technologically enhanced methods can detect cancer earlier and where there is none (Nass et al., 2001). It is called prediagnosis, which means that disease is correctly diagnosed but will not cause damage or death to the patient (Glumac, 2012). Prediagnosis is 40–46% more common in women between 40 and 50 years of age. Consequence of prediagnosis is exaggerated intensive treatment (Roucco, 2016). Discussion BRC is difficult to diagnose in younger women (Sentis, 2010). Wang et al. (2010) claim that there is no good strategy for early detection of BRC in younger women. Massat (2014) also claims that they misdiagnosed between 40 and 50% of cancer in younger women which had dense breast tissue using mammography. Mammography is especially unreliable in younger women with small breast and dense tissue. The latter also represents bigger risk for false negative results (Ying et al., 2012; Shao et al., 2013; An et al., 2015). Brem (2012) states that one third of cancers are overlooked in women with dense breast tissue. Several other authors (Kriege et al., 2006; Sardanelli et al., 2011; Ying et al., 2012; An et al., 2015) are discussing about sensitivity of mammography in younger women which results in 33–61%. US is desired to use in women with breast tissue density rate 3–4 and where mammography is negative. 0.6% of BRCs are discovered with that meth- od. Next study showed that 0.3% of BRC is detected with US, especially in those 35 with dense breast tissue. They state that US shows especially invasive small size (< 9 mm) tumours (Shao et al., 2013; Massat, 2014; Chetlen et al., 2015). tion MRI is the most effective method for detecting BRC in dense breast tis- etec d sue (Massat, 2014). Study shows that MRI is the best way for detecting BRC in er women with BRC in family – heredity (Ying et al., 2012). Advantage of MRI is anc high sensitivity (80 – 91%) for BRC detection but it is limited with low specificity. It is especially suitable for women with more than 20% of risk for develop-reast c ment of BRC (Kriege, 2006; Sardanelli et al., 2011; Shao et al., 2013). y in b Authors state that it is crucial to use two or three diagnostic methods to ficienc achieve good sensitivity. Great reliability can be achieved if we combine mam- mography and US (Ying et al., 2012; Sardanelli, 2011; Shao et al., 2013). Because of dense parenchyma tissue in younger women, they advise the use of US and graphy ef mo MRI. Both methods show excellent sensitivity compared to mammography am (An et al., 2015). the m Conclusions BRC is the most common cancer in women. In the past, when BRC awareness was small and there was no screening programs, women had symptoms before the diagnosis. Today we thrive to detect cancer in early phase with screening programs, when there is no symptoms and there is larger possibility for suc- cessful treatment. It is mandatory to take precautions to prevent prediagnosis. Younger women have mostly dense breast tissue which interferes with mam- mogram interpretation which can lead to false positive or false negative results. Possible methods for detecting cancer in younger women are US and MRI with higher sensitivity compared to mammography. Mammography is currently the most used method for BRC detection. Is is important that we are well aware of its limitations. References AN, Y.Y., KIM, S.H., KANG, B.J., PARK, C.S., JUNG, N.Y., KIM, J.Y., 2015. Breast cancer in very young women (<30 years): Correlation of imaging of features with clinicopathological features and immunohistochemical subtypes. European journal of radiology, vol.. 84, no. 10, pp. 1894–1902. BREM, R.M., 2012. Screening whole breast ultrasound: Screening whole breast ultrasound an opportunity to move to personalized, effective breastcan- cer screening. The breast journal, vol. 18, no. 6, pp. 515–516. CHETLEN, A., MARCK, J., CHAN, T., 2016. Breast cancer sreening controver- sies: who, when, why, and how?. Clinical imaging, vol. 40, no. 2, pp. 279– 282. CRRS REGISTER RAKA REPUBLIKE SLOVENIJE, 2017. Incidenčne mere - ocena incidenčnih mer za 2016 [online]. [viewed 14 May 2017]. Avaible from: http://www.slora.si/ocena-letosnje-incidence 36 DRŽAVNI PRESAJALNI PROGRAM ZA RAKA DOJK, n. d. Čemu je namen- n jena DORA? [online]. [viewed 30 May 2017]. Avaible from: https://dora. onko-i.si/cemu_je_namenjena_dora/index.html pulatioo EDGAR, L., GLACKIN, M., HUGHES, C. in ROGERS, K.M.A., 2013. Factors ge p influencing participation in breast cancer screening. British journal of nursing, vol. 22, no. 7, pp. 1021–1026. rking-ao GLUMAC, N., 2012. Prediagnosticiranje. Onkologija, vol. 1, no. 1, pp. 29–32. he w HAFSLUND, B. in NORTVEDT, M., 2009. Mammography screening from the f t perspective of quality of life: review of the literature. Scandinavian jour-ealth o nal of theoretical science, vol. 23, no. 3, pp. 539–547. | h HELLQUIST, B.N., 2014 . Breast cancer screening with mammography of wom- en 40-49 years in Sweden: doctoral thesis [online]. Umeå: Umeå Universi-pulacije o ty, Faculty of Medicine. [viewed 7 May 2017]. Avaible from: http://umu.di- va-portal.org/smash/get/diva2:698751/FULLTEXT01.pdf ktivne p HOOLEY, R.J., 2017. Breast Densitiy Legisation and Clinical Evidence. Radiologic clinics of North America. vol. 55, no. 3, pp. 513–526. elovno a KADIVEC M. in KRAJC M., 2013. Presajalni program DORA za zdravje žensk. In: Matković M., eds. Pacientke z rakom dojk – Trendi in novosti: zdravje d zbornik predavanj /40. Strokovni seminar, Ljubljana, 7. Junij 2013. Lju- bljana: Sekcija medicinskih sester in zdravstvenih tehnikov v onkologi- ji pri Zbornici zdravstvene in babiške nege – Zveza strokovnih društev medicinskih sester, babic in zdravstvenih tehnikov Slovenije, pp. 14-22. KRIEGE, M., BREKELMANS, C.T., OBDEIJN, I.M., BOETES, C., ZONDER-LAND, H.M., MULLER, S.H., KOK, T., MANOLIU, R.A., BESNARD, A.P., TILANUS–LINTHORST, M.M., SEYNAEVE, C., BARTLES C.C., KAA, R., MEIJER, S., OOSTERWIJK, J.C., HOOGERBRUGGE, N., TOLLENAAR, R.A., RUTGERS, E.J., DE KONING, H.J., KLIJN, J.G., 2006. Factors affecting sensitivity and specificity of screening mammog- raphy and MRI in women whit inherited risk for breast cancer. Breast cancer research and treatment, vol. 100, no. 1, pp. 109–119. MASSAT, M.B., 2014. Technology Trends: Calling in reinforcments – Wom- en with dense breasts get help from ultrasound, molecular imaging, and MRI. Applied radiology, vol. 43, no. 9, pp. 34–38. MAYO CLINIC, 2015. Dense breast tissue: what it means to have dense breasts [online]. [viewed 10. 5. 2017 ]. Avaible from: http://www.mayoclinic.org/te- sts-procedures/mammogram/in-depth/dense-breast-tissue/art-20123968 MORRIS, E., FEIG, S.A., DREXLER, M. in LEHMAN, C., 2015. Implications of overdiagnosis: impact on screening mammography practices. Population health management, vol. 18, no. 1, pp. 3–11. NARULA, P.S., 2016. Mammographic density and the rist and detection of breast cancer. International journal od health and life science, vol. 2, no. 2, pp. 48–54. 37 NASS, J.S., HENDERSON, I.C. in LASHOF, J.C., 2001. Mammography and be- yond: developing technologies fort he early detection of breast cancer. tion Washington: National academy press, pp. 15–55. etec NELSON, H.D., O´MEARA, E.S., KERLIKOWSKE, K., BALCH, S. in MI- der GLIORETTI, D., 2016. Factors acssociated with rates of false positive and anc false negative results from digital mammography screening: an analysis of registry data . Annals of internal medicine, vol. 164, no. 4, pp. 226–235. reast c OLSEN, M.L., MORTON, M. J., STAN, D.L., PRUHTI, S., 2012. Is There a Role y in b for Magnetic Resonance Imaging in Diagnosing Palpable Breast Masses When Mammogram and Ultrasound Are Negative?. Journal of women’s ficienc health, vol. 21, no. 11, pp. 1149 – 1154. PRIMIC-ŽAKELJ M., ARKO D., RENER M. in ŽGAJNAR J., 2003. Rak dojk v graphy ef mo Sloveniji: Epidemiologija in presejanje. Zdravniški vestnik, vol. 72, no. 2, am pp. 179-181. the m RUOCCO, M.J., 2016. Improving screening mammography: perspective of a community radiologist. Applied radiology, vol. 45, no. 9, pp. 26–29. SARDANELLI, F., PODO, F., SANTORO, F., MANOUKIAN, S., BERGON- ZI, S., TRECATE, G., VERGNAGHI, D., FEDERICO, M., CORTESI, L., CORCIONE, S. et. al., 2011. Multicenter surveillance of women at high genetic breast cancer risk using mammography, ultrasonography, and contrast– enhanced magnetic resonance imaging (the high berast can- cer risk italian 1 study): final results. Investigative radiology, vol. 46, no. 2, pp. 94–105. SENTIS, M., 2010. Imaging diagnosis of young women with breast cancer. Breast cancer research and treatment, vol. 123, nu. 1, pp. 1–13. SHAO, H., LI, B., ZHANG, X., XIONG, Z., LIU, Y., TANG, G., 2013. Compari- son of the diagnostic efficiency for breast cancer in Chinese women using mammography, ultrasound, MRI, and different comninations of these imaging modalities. Journal of X– ray science and technology, vol. 21, no. 2, pp. 283–292. WANG, T., WANG, K., YAO, Q., CHEN, J.H., LING, R., ZHANG, J.L., DONG, X.Z., FU, F., DOU, K.F., WANG, L., 2010. Prospective study on combina- tion of electrial impedance scanning and ultrasound in estimating risk of development of breast cancer in young women. Cancer investigation, vol. 28, no. 3, pp. 295–303. YING, X., LIN, Y., XIA, X., ZHU, Z., HE, P., 2012. A comparison of mammog- raphy and ultrasound in women with breast disease: a receiveroperating characteristic analysis. The breast journal, vol. 18, no. 2, pp. 130–138. 38 n pulatioo ge p rking-ao he wf t ealth o| h pulacije o ktivne p elovno a zdravje d Attending nutrition counsel ing of the working-age subjects Melina Colsani, Maša Černelič Bizjak University of Primorska, Faculty of Health Sciences, Polje 42, 6310 Izola, Slovenia colsanimelina@gmail.com; masa.cernelic@upr.si Abstract Introduction: Health status and the presence of health problems can be the primary reasons for nutritional-counselling visits. Based on the information that we have gained from the counselling dietitian, from 2009 to 2015, we have analysed the characteristics of subjects who received nutritional counselling. The analysis covered data on health status, anthropometric characteristics, and other physical and psychological problems. Methods: We have analysed data on 863 working-age population (198 men and 665 women, of the average age of 42 years), who visited a nutritional dietitian from 2009 to 2015. Measurements of body composition were collected longitudinally, for each person and for each subsequent nutritional counselling separately. Results: Most of the participants were healthy, and their average age was 42 years. Only a third of them had a BMI belonging to the group of obesity, and 70% of the participants even stood within normal weight body mass index classifications. Dietary counselling is numerically less attended by men. Women are those who have most visits and are present in several sessions. Discussion and conclusions: The initial state of health does not provide information on the nutritional interventions, nor does it forecast the number of consultations. By analysing the data, we have obtained important information on the characteristics of persons attending nutrition counselling, and a better understanding of those factors which could have a major impact on the success or likelihood of a successful outcome of nutritional counselling in the future. Key words: nutritional counselling, successful outcome, body mass index, age, health doi: https://doi.org/10.26493/978-961-7023-32-9.39-46 In 2010, overweight and obesity were estimated to cause 3.4 million deaths and 3.9% of year of life lost. Globally, between 1980 and 2013 the proportion of adults with a body mass index (BMI) greater of 25 increased (Ng et al., 2014). Because of its widely known health risks, obesity has become a major global health challenge, and has led to widespread calls for regular monitoring of nutritional support and more effective intervention (Dansinger et al., 2007). The role of a dietitian is to obtain information from the patient, which will be essential to offer the appropriate nutritional support (National Institute of Health et al., 2000). During the nutritional counselling, it is important to collect anthropometric data, and to identify in a direct or indirect interview the clinical and psychological status of the patient (Gibson, 2005). The skills of dietitians are shown in their capacity of obtaining the required information, but mostly in giving returned information suitable for the patient in the way that nutritional assessment will be even more successful (Lacey and Pritchett, 2003). 40 The establishment and implementation of a standardised nutrition care n process and model were identified as a priority in meeting goals, and in having predictability of nutritional assessment (Lacey and Pritchett, 2003). The aver-pulatioo age effect of dietary counselling on weight changes in adults over time suggests ge p a change of approximatly 2 BMI units over 12 months (Dansinger et al., 2007), while in combination with physical activity the same results are reached after rking-ao 6 months (Marion et al., 2007). However, nutritional assessment is not always he w succesful, and why some people succeed at adopting and sustaining behaviors f t associated with weight control, while others, undergoing similar treatment, do not, remains unknown. Personal factors probably play a very important role in ealth o| h determing success rate (Teixeira et al., 2004). In a descriprive analysis researching the weight loss experience in cor- pulacije o relation with health, Jeffery et al. (2004) found out how people so often fail in mantaining behaviours associated with weight loss (e.g. health nutrition, reg-ktivne p ular physical activity), because they do not find them worth trying. Indeed, some researches have not come to the conclusion of a correlation between mo- tivation and succesful weight loss. This is highlighted by the fact that even 60% elovno a of people who start nutritional assessment do not even finish the process. This shows how motivation is not the only factor which contributes to cost benefit zdravje d evalutations with respect to weight loss (Jeffery et al., 2004). The literature shows many different factors which may have influence on the weight loss process and on the health status of the patient, but it does not define the strength of the influence of every singolar factor. There are different combinations of these factors, and this is the reason why it is not known which one has more relevance on a succesful or unsuccesful outcome of the nutritional assessment. Methods The participants were women and men of different ages, who attended nutri- tional assessment by the nutritional dietitian Lidia Mosca in the period be- tween 2009 and 2015. This nutritional dietitian operates in Italy. The data, which were collected during nutritional assessments, describe patient information. The whole database contains 951 samples, but we only chose those that meet our limitations for analysis. The chosen parametres were demographic data (gender, age) and physical data (body mass – kg, body height – cm, BMI – kg/m², health status). The final database contains information about 863 working-age population (198 men and 665 women), with an average age of 42 years (from 20 to 86 years old; SD = 12.13 years). Measurements of body composition were collected longitudinally, sepa- rately for each person and for each subsequent consultation. The purpose of the analysis was to identify the characteristics of the subjects who attended nutritional counselling depending on their actual attending the counselling, and on 41 their health status, gender, and age. ectsubj s Results age rking-o he wf t ing o unsello n coiti utr attending n Figure 1: Analysis of the consultations from 2009 to 2015. Figure 1 shows the results of the analysis of attendance to every consul- tation from 2009 to 2015. 864 people attended the first consultation, but only 458 participants (53.07 % of the initial number) came to the following consultation. The decline in the percentage of participants who did not return to the next consultation gradually decreased. Most of the participants who attended nutritional counselling did not de- clare any health problem. This is shown in table 1, which analyses of the health status of the attendees of every consultation. Table 1: Physical, psychological, and other health problems of the participants attending consultations from 2009 to 2015. Health status Neuro., Urinary, Emot., C1 N Gast.3 Endoc.4 Neo.7 musc., Derma.9 Comb.12 2 Health (%) (%) (%) Blo.5 (%) Resp.6 (%) (%) bon. repro.10 behav.11 8 (%) (%) (%) (%) (%) % % % % % % % % % % % 1 n = 863 64.07 12.39 2.31 4.28 0.34 0.92 1.96 0.92 0.81 4.63 7.30 2 n = 458 63.31 15.53 2.83 3.71 0.21 0.87 1.31 1.09 0.87 4.14 7.86 3 n = 258 60.64 12.40 3.10 5.42 0.00 0.38 1.93 1.55 1.16 4.65 8.91 4 n = 156 55.76 15.38 3.20 5.76 0.00 0.64 1.28 2.56 0.64 5.12 9.61 5 n = 85 48.23 16.47 3.52 8.23 0.00 1.17 2.35 1.17 1.17 8.23 9.41 6 n = 57 49.12 14.03 0.00 7.01 0.00 1.75 1.75 1.75 1.75 8.77 14.03 42 7 n = 42 45.23 14.28 0.00 9.52 0.00 2.38 2.38 2.38 0.00 7.14 16.66 n 8 n = 34 50.00 14.70 0.00 5.88 0.00 2.94 2.94 2.94 0.00 5.88 14.70 9 n = 25 56.00 12.00 0.00 4.00 0.00 0.00 0.00 0.00 0.00 8.00 16.00 pulatioo 10 n = 21 57.14 14.28 0.00 4.76 0.00 0.00 0.00 0.00 0.00 9.52 0.52 ge p 11 n = 15 53.33 13.33 0.00 6.66 0.00 0.00 0.00 0.00 0.00 13.33 6.66 rking-a 12 n = 10 50.00 20.00 0.00 10.00 0.00 0.00 0.00 0.00 0.00 20.00 0.00 o 13 n = 9 55.55 11.11 0.00 11.11 0.00 0.00 0.00 0.00 0.00 22.22 0.00 he wf t 14 n = 9 55.55 11.11 0.00 11.11 0.00 0.00 0.00 0.00 0.00 22.22 0.00 15 n = 7 71.42 0.00 0.00 14.28 0.00 0.00 0.00 0.00 0.00 14.28 0.00 ealth o| h 16 n = 6 66.66 0.00 0.00 16.66 0.00 0.00 0.00 0.00 0.00 16.66 0.00 17 n = 6 66.66 0.00 0.00 16.66 0.00 0.00 0.00 0.00 0.00 16.66 0.00 pulacije 18 n = 5 60.00 0.00 0.00 20.00 0.00 0.00 0.00 0.00 0.00 20.00 0.00 o 19 n = 2 50.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 50.00 0.00 ktivne p 20 n = 2 50.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 50.00 0.00 21 n = 2 50.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 50.00 0.00 elovno a 22 n = 2 50.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 50.00 0.00 23 n = 2 50.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 50.00 0.00 zdravje d 24 n = 2 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 100.00 0.00 Notes: 1C = consultation; 2N = number of participants; 3Gast.= gastrointestinal diseases; 4Endoc. = endocrine disorders; 5Blo.= blood disease; 6Resp. = respiratory disease; 7Neo. = presence of neoplasm; 8Neuro., musc., bon. = neurological disorders, muscular disorders, bone disease; 9Derma. = dermatology disease; 9Urinary, repro. = urinary disease, reproductive system disease; 11Emot., behav. = emotional lability, behaviour disorders; 21Comb. = combination of more disorders/diseases. Figure 2: Age of the participants on every consultation from 2009 to 2015. Picture 2 represents the average age of the participants who attended nu- tritional counselling in the period between 2009 and 2015. A first consultation was attended by 863 participants, whose average age was 42 years (SD = 12.13 43 years; the youngest being 20 years old; the oldest, 86 years old). ects Our next step was to divide the participants of the first consultation ac- ubj cording to their BMI group. The BMI groups are standardised by the World s age Health Organisation. We calculated the BMI of the participants with anthro- pometric data using the formula (body mass - in kilograms - divided by the rking-o square body weight – in square meters). he w 2% of the participants scored in the BMI group classification of under- f t weight, 36% were in normal range, 32% pre-obese. Obese participants repre- ing o sented 30% of all (class I 20%, class II 7%, class III 5%). unsello Table 2: Division of the attendees of the first consultation (N = 863). n coiti BMI (kg/m²) Classification N % utr Less than 18.49 Underweight 15 2 18.5–24.9 Normal range 307 36 25.0–29.9 Overweight (pre-obese) 277 32 attending n 30.0–34.9 Obese class I 169 20 35.0–39.9 Obese class II 56 7 40.0 or more Obese class III 39 5 TOT 863 100 Discussion The results of the analysis of the attendance of every consultation from 2009 to 2015 shows that only half of the participants who attended the first nutritional counselling came to the second consultation. The decline in the percentage of participants who did not return to the following consultation gradually de- creased, probably due to the higher motivation of the participants who contin- ued the nutritional assessment. However, in the interpretation of the results we also need to consider that the fee charged for the nutritional counselling prob- ably had an impact on the choice of the participants. We found it interesting to investigate the motivational factors of those participants who continued the nutritional assessment for a long period. In the identification of pre-treatment factors related to weight loss in obe- sity treatment, Elfhag and Rössner (2010) found out what could be the strongest factor for predicting the treatment outcome. Several factors have been associated with weight loss and attrition: contrasting feeling about the nutritional assessment, male gender, younger age, fast or slow weight loss (Elfhag and Röss- ner, 2010). Most of these aspects are correlated with psychological factors, such as the impact of a lower quality of life, emotional lability, and eating disorders (Elfhag in Rössner, 2010). Berkatis et al. (2000) investigate gender differences in the utilization of health care services. The study has shown that women had a significantly high- er average number of visits in their primary care clinics and diagnostic ser- vices than men. Our results also show a higher use of nutritional counselling 44 by women. Knowing that most of the participants did not declare any health n problem, we can conclude that probably women care about their future health more than men. pulatioo In a cross-sectional study, Turconi et al. (2012) investigated the anthro- ge p pometric data of the population of northern Italy. Most of the subjects were overweight (average BMI = 28.4 kg/m2), only 30% of the sample had adequate rking-ao dietary status. In our analysis of the BMI classification of the participants, we noticed that the participants were not exclusively obese people (BMI > 30), but he wf t that 70% of the participants had a BMI lower than 30. Thus, the reasons why a normal-weight person decides to attend nutritional counselling include a cur- ealth o rent disease (or prevention of health comorbidities), and nutritional assessment | h for physical activity or for an alternative food regime. In the analysis of health status of the participants we discovered the pres- pulacije o ence of a health problem or pathological state. The health status of the participants was collected by direct interview and not all the participants gave us a ktivne p medical confirmation eventual present disease or health comorbidity. Having many different information about health status, we decided to divide them in elovno a different groups: gastrointestinal disease, endocrine disorders, blood disease, respiratory disease, and presence of neoplasm, neurological disorders, muscu-zdravje d lar disorders, bone disease, dermatology disease, urinary disease and repro- ductive system disease, emotional lability and behavior disorders, combination of more disorders/diseases. Most of the participants who attended nutritional counselling did not declare any health problem. The analysis of the health status of the attendees showed us that the health status does not give a prediction of the duration of the nutritional assessment. We find interesting the fact, why is the prevalence of health attendees so high. A similar phenomenon observed Milunpolo et al. (1997) in Finland population, where noticed a high number of physician con- tacts per year also if the stability of perceived health status was relatively good. In every nutritional counselling represented health people at least half of all participants. This may confirm us that health people and people, who do not have health problems, care more for their health. In the case, we could confirm our hypothesis and observing the low percentage of participants with health comorbidities, it is clear, that the presence of a health disorder or disease is not a factor that have a big influence on motivation during nutritional assessment. In the interpretation of our results of participants gender, anthropomet- ric data and health status looking for those factors which may have influence on the weight loss process, we were interested who mostly attended nutrition- al assessment between young and older people. The results showed us that the participants of the first visit were old from 20 to 86 years. Standard deviation then changed during the next visits and it went nearer to the mean. People, who attended more visits, were older – between 40 and 45 years old. Conclusions 45 Based on our results, we can say that nutritional counselling are mostly visit-ed by people who are in average 42 years old, healthy and with BMI in normal ectsubj range, which means that the participants were not exclusively obese people (BMI s age > 30), but 70% of the participants had a BMI lower than 30. In every nutritional counselling represented health people at least half of all participants. This may rking-o confirm us that health people and people, who do not have health problems, care more for their health. Regarding to our results it is clear, that the presence of a he wf t health disorder or disease is not a factor, which have a big influence on motiva-ing o tion during nutritional assessment. Thus, the reasons why a normal-weight and health person decides to attend nutritional counselling include a current disease unsello (or prevention of health comorbidities), and nutritional assessment for physical n c activity or for an alternative food regime. However, in the interpretation of the oiti results we also need to consider that the fee charged for the nutritional counsel-utr ling probably had an impact on the choice of the participants. References attending n BERKATIS, K.D., AZARI, R., HELMS, L.J., CALLAHAN, E.J., ROBBINS, J.A., 2000. Gender differences in the utilization of health care services. Jour- nal of family practice, vol. 2, no. 49, pp. 147-152. DANSINGER, M.L., TATSIONI, A., WONG, J.B., CHUNG, M. in BALK, E.M., 2007. Meta-analysis: the effect of dietary counseling for weight loss [on- line]. Annals of internal medicine, no. 147, pp. 41-50. [Viewed 27.05.2017]. Available from DOI: 10.7326/0003-4819-147-1-200707030-00007 ELFHAG, K. in RÖSSNER, S., 2010, Initial weight loss is the best predictor for success in obesity treatment and sociodemographic liabilities in- crease risk for drop-out [online]. Patient Education and Counseling, vol. 79, no. 3, pp. 361–366. [Viewed 30.08.2014]. Available from DOI 10.1016/j. pec.2010.02.006. GIBSON, R.S., 2005: Principles of nutritional assessment. 2nd ed. Oxford: University Press, pp. 1-4. LACEY, K., PRITCHETT, E., 2003. Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes management [online]. Journal of the American Dietetic Association, vol. 103, no. 8, pp. 1061–1072. Available from DOI 10.1016/S0002-8223(03)00971-4. MARION, J.F., VANWORMER, J.J., CRAIN, A.L., BOUCHER, J.L., HISTON, T., CAPLAIN, W., BOWMAN, J.D. in PRONK, N.P., 2007. Weight-loss outcomes: a systematic review and meta -analysis of weight-loss clinical trials with a minimum 1-year follow-up [online]. Journal of the Ameri- can dietetic association, vol. 10, no. 107, pp. 1755-1767. [Viewed 27.05.2017]. Available from DOI: 10.1016/j.jada.2007.07.017 MILUNPALO S., VUORI, I., OJA, P., PASANEN, M. in URPONEN, H., 1997. Self-related health status as a health measures: the predictive value of 46 self-reported health status on the use of psysician services and on mortal- ity in the working-age population [online]. Journal of clinical epidemiol- n ogy, vol. 5, no. 50, pp. 517-528. [Viewed 27.05.2017]. Available from https:// pulatio doi.org/10.1016/S0895-4356(97)00045-0 o ge p NATIONAL INSTITUTE OF HEALTH, NORTH AMERICAN ASSOCIA- TION FOR THE STUDY OF OBESITY, NATIONAL HEART, LUNG rking-a AND BLOOD INSTITUTE and NHLBI EDUCATION INITIATIVE, o 2000. The practical guide: Identification, evaluation and treatment of he wf t overweight and obesity in adults [online]. [Viewed 30.10.2015]. Available from http://www.nhlbi.nih.gov/files/docs/guidelines/prctgd_c.pdf ealth o NG, M., FLEMING, in sodel., 2014. Global, regional, and national prevalence | h of overweight and obesity in children and adults during 1980–2013: a sys- tematic analysis for the Global Burden of Disease Study 2013 [online]. pulacije o The Lancet, vol. 384, no. 9945, pp. 766–781. [Viewed 30.08.2014]. Available from DOI 10.1016/S01406736(14)60460-8. ktivne p TEIXEIRA, P. J., GOING, S. B., HOUTKOOPER, L. B., CUSSLER, E. C., MET- CALFE, L. L., BLEW, R. M., SARDINHA, L. B. in LOHMAN, T. G., 2004. elovno a Pretreatment predictors of attrition and successful weight management in women [online]. International Journal of Obesity and Related Metabol- zdravje d ic Disorders: Journal of the International Association for the Study of Obesity,. vol. 28, no. 9, pp. 1124–1133. [Viewed 10.06.2017]. Available from DOI 10.1038/sj.ijo.0802727. TURCONI, G., ROSSI, M., ROGGI, C. in MACCARINI, L., 2012. Nutrition- al status, dietary habits, nutritional knowledge and self care assess- ment in a group of older adults attending community centres in Pavia, Northetn Italy [online]. Journal of human nutrition and dietetics, vol. 1, no. 26, pp. 48-55. [Viewed 10.06.2017]. Available from DOI 10.1111/j.1365-277X.2012.01289.x The therapeutic approach as an important intervention in the implementation of the program Project learning for young adults (PUM-O) Nataša Demšar Pečak The Family Study and Research Centre, Gorazdova 2, 1000 Ljubljana, Slovenia natasa.dp1@gmail.com Abstract This article presents the program Project Learning for Young Adults” (PUM-O), the main purpose of which is to develop the potential of vulnerable young adults for successful integration into education, the development of professional identity and successful integration into the labour market and successful social integration. These young adults have different reasons for abandoning education and lack of work experience therefore; they have difficulties to find employment. Due to the impaired mental health of individuals, the program is the only way out of the current plight and the only possibility of re-control of their lives, as well as successful confrontation with various problems. Because the program is not a therapeutic one and the mentors generally are not therapists, it is extremely important that the mentors in the program, unless they are also therapists, include other relational therapists. With the majority of the participants, their relational needs are not satisfied, so this deficit is reflects in loneliness, dissatisfaction, fear, despair, self-injuring, aimless vegetating, violence, depression and various addictions. Many participants from mentors-therapists for the first time experience safe, compassionate and respectful relations, as well as a sense of acceptance and value, which results in a change of symptomatic deep- rooted patterns of interpersonal interaction. Program participants also experienced a therapeutic approach of mentors-therapists as an important intervention for getting new positive experience on which they acquire functional activity and better contact with themselves. Key words: mental health, young adults, therapeutic approach, intervention, interpersonal relations doi: https://doi.org/10.26493/978-961-7023-32-9.47-53 A publicly valid program of non-formal adult education program “Project learning for young adults (PUM)” in Slovenia was created in the nineties. The program PUM was one of the first publicly approved ed- ucational programs for adults, prepared in accordance with the guidelines of curricular reform of education for adults. The purpose of creating such a pro- gram was mainly reducing social exclusion of the most vulnerable groups of young NEETS (youngsters not employed, educated or trained). Since its incep- tion, the program has developed, supplemented and amended. There have been completed also the evaluation studies in 2002 (Istenič Starčič et al., 2002), and 2010 (Možina et al., 2010) which have demonstrated both the quality as well as the shortcomings of the program and the new needs of young people, especially the new opportunities for developing and completing the program. The purpose and goals of the program PUM-O 48 Based on the experience of many years of the program PUM and based on the new social circumstances a demand for a new program “Project learning for n young adults (PUM-O)” has appeared. It was built at the initiative of the Min- istry of Labour, Family, Social Affairs and Equal Opportunities (MDDSZ) and pulatioo on the basis of the Operational Program for the Implementation of the Europe- ge p an Cohesion Policy in the period 2014-2020. The program is aimed at vulnera- ble groups of young adults from 15 to 26 years who have dropped out of school rking-ao or have not acquired the proper education that would allow them to get the ap- he w propriate employment. f t The PUM-O is formed as an upgrade of previously mentioned PUM pro- ealth o gram, of which it differs considerably. Compared with the PUM program, | h whose main objective was to enable young people to gain experience and skills to continue successfully their education, the main objective of the new pro- pulacije o gram PUM-O is convergence and entry of participants into the labour market. Extending the target group of the program is also reflected in the fact that the ktivne p PUM-O compared with PUM also aims at students who are involved in regu- lar education, but threatened by the risk of dropout. Therefore, we can conclude that the substantial modification of the program PUM is integration of partici-elovno a pants into the labour market. The program is directed markedly to process and provides in-depth cooperation between different resources, allowing partici- zdravje d pants to fulfil their personal career plan (Žalec et al., 2015). As stated by the different authors (Možina et al., 2010), it is a fundamental objective of the program to help young people to gain experience and knowl- edge that would enable them to be successful in further education or the cho- sen career path. It is very important for them to obtain functional knowledge that develops general education: wide horizons and flexibility of thinking, getting a positive learning experience, clearly articulated career aspirations and developing skills in critical and problem-oriented thinking. This program encourages young people in three areas of activity, namely the spread of general education, the formation of professional identity and socio-cultural activities. The importance of the therapeutic approach It is very important for each participant to identify and define his or her fundamental problems, which may show us unconscious and compulsive intergener- ational transmission or intergenerational transmission of behaviour patterns, feelings and beliefs. Intergenerational transmission might thus be defined as instances of social transmission between members of different generations. Martin-Matthews and Kobayashi (2009) state that we can also describe inter- generational transmission as behaviour or tendencies of one generation pass- ing onto the next generation. Intergenerational transmission is one dimension of the larger concept of intergenerational relations. The term intergenerational relation describes a wide range of patterns of interaction among individuals of different generations of the family: for example, among those in older generations, such as parents and grandparents and those in younger generations, such as children and grandchildren. What is transmitted may be intangible and may include beliefs, norms, values, attitudes, and behaviours specific to that fam-49 ily, or may reflect socio-cultural, religious, and ethnically relevant practices n and beliefs (Chen and Kaplan, 2001; Capaldi, Pears, Patterson and Owen, 2003; Martin-Matthews and Kobayashi, 2009). The theory states that parents of one generation have a tendency to repeat nterventio the parenting model which their parents applied on them (Serbin and Karp, 2003). Family researchers have also studied the intergenerational transmis- rtant ipo sion of difficult life course transitions like marital dissolution or divorce. Some mn i members of program for example are also young parents and some of them are s a already divorced. They have similar problems as their parents and grandpar- ents. In particular, studies have found that parental divorce increases the like-pproach a lihood that adult children will experience separation or divorce (Glenn and Kramer 1987; Keith and Finlay 1988; Amato 1996; Demšar Pečak, 2014). It is very important that interventions are held in collaboration with var- herapeutic a ious institutions because in that way the assistance is more effective and espe-the t cially prolonged. For the successful achievements of program mentors need the support of various external institutions and individuals. It is very important that they are all involved in the program as professional team: advisors at the Employment Service, representatives of police, advisers for social work, coun-sellors in schools and mentors in the workplace, doctors, therapists and oth- ers who are closely linked to the individual participants. Thus, the entire team helps participants to the achievement of a career plan. As already mentioned cooperation of the relational therapist is also important for the quality achievement of the individual career goal. The majority of program participants have symptomatic deep-rooted patterns of interpersonal interactions. Therapeutic work with individuals may lead to the gradual change of inappropriate models of interpersonal interactions and thereby the change of the individual’s men- tal structure and regulation of psychobiological conditions (Demšar Pečak and Ovsenik, 2014; Demšar Pečak 2017). Gostečnik (2010, 2011) states that individual fundamental relations, and related basic affects, such as fear, anger, horror, shame, contempt, disappointment as well as emotional calmness and satisfaction learn in the family. These relations are marked forever, because they are internalized in childhood based on mechanism of projection-introjection identification and consolidated based on compulsive repetition. Even Cvetek (2009) mentions that children get the basic patterns, rules for behaviour, emotions the basics of the language and culture skills of expression and thinking in the family. Various authors (Haley, 1987; Minuchin, 1981; Framo, 1992; Boszorome- nyi-Nagy, 1986 and Bowen, 1978, in Gostečnik, 2008, 2010, 2011) focused on co- vert pathological transactions and many times unsolved transfers of painful mental content to a particular individual who has unconsciously adopted this contents. Because of this internalization, he or she becomes identified patient or “scapegoat” of a certain family. The identified patient is therefore an individual who carries and maintains symptomatic patterns of relationships with- 50 in the family through the mechanism of compulsive repetition that is forced n repetition of basic patterns of interpersonal interactions. Framo mentions (i.e.: Gostečnik 2011 p. 180), that certain patterns or family topics skip a whole gen-pulatioo eration, and then mysteriously settle again in the new generation, who do not ge p even know where these painful contents come from. Framo (i.e.: Gostečnik 2011, p. 180) also states how the past can affect the present and how “family rking-ao through several generations develops dysfunctional patterns of behaviour, feel-he w ing, beliefs and above all interpersonal interactions.” f t Therapeutic approach is in the program PUM-O is very important, be- cause in most of the participants’ families’ intergenerational transmission can ealth o| h be found. With the majority of the participants, their relational needs are not satisfied, so this deficit is reflected in loneliness, dissatisfaction, fear, despair, pulacije self-injuring, aimless vegetating, violence, depression and various addictions o (Žvelc, 2016). The acquired patterns can be changed and improved with the professional therapeutic help. Therefore, the therapist also works with the indi-ktivne p viduals as well as the entire group. The therapist uses compassionate approach and addresses inadequate forms of participant’s behaviour models. When we elovno a talk about changing the depth patterns of behaviour, emotions and beliefs we primarily focus on the patterns of the family model from childhood (the rela- zdravje d tionship mother-child). The further emotional, cognitive and inter-relational experience of thinking and response largely depends on the primary relation- ship (Gostečnik, 1997, 2007). With emphatic therapeutic approach and modification of depth patterns of behaviour, emotions and beliefs the participants may respond differently to other co-participants. They also begin to experience and respond differently to the relationships in the home environment. In this way the entire system of interpersonal interaction among participants, as well as the system of interaction between the members of their family can change. The aim of the therapeutic approach is to help the participants find the new functional patterns of behav- iour, emotions and beliefs. That could solve problems which are a result of relationships that occur and transmit from generation to generation. The most of the participants have often regulated psychobiological condition through non-functional forms of behaviour and emotion (e.g. inappropriate communica- tion, violence, self-injuring, various addictions, obsessive-compulsive disorder, suppression of emotions, depression, disinterest). In the evaluation (Možina et al., 2010), it was found out that the partici- pants wish to have more common leisure activities (excursions, holidays, field trips, afternoon activities), extension programs in the afternoons and psychotherapeutic help, also to their parents. In the program they have the feeling of security and belonging, but it can also satisfy their relational needs, which until now they have not been able to satisfy. In achieving career goals of the participants an emphatic therapeu- tic approach is very important because the individuals must first resolve all symptomatic deep-rooted patterns of interpersonal interaction and thereby 51 strengthen appropriate and functional regulation of painful and destructive n affects. Surpassing old rooted patterns means consciously build new relation- ships that will include all of those needs, desires, and feelings the participants in the domestic environment from significant others were not given because nterventio those were not able to or didn`t want to identify them. rtant i On the therapy the participant can exceed the old patterns of behaviour, pom emotions and beliefs and as mentioned by Gostečnik (2007, p. 280), the therapy n i is interactive space in which the therapist must play the role of “good enough s a mother” and establish a “safe space” in which the individual can be able to live again. pproach a Conclusions Based on new pledged foundations of psychic structure and regulation of in- herapeutic a adequate psychobiological condition, the participants can follow their educa- the t tion or employment goals. The old clamps based on the mechanism of projec- tion-introjection identification and consequent compulsive repetition does not force them any longer to a vicious circle of non-functional interpersonal interactions. To achieve its objectives, mentors need support of a variety of professionals. Because the program is not a therapeutic one and the mentors general- ly are not therapists, it is extremely important that the mentors in the program, unless they are also therapists, include other relational therapists. For many participants the program is the only way out of the current hardship and the only possibility of reactivation in everyday life. Many participants in the program PUM-O for the first time experience safe, compassion- ate, predictable and respectful relations. Thus, the participation in the program serves as a safe place, where the participants receive basic security, feeling of understanding, acceptance and value. The participation in program is also a quality platform for further career. References AINSWORTH, M. D., BLEHAR, Mc., WATERS, E., WALL, S. (1987). Patterns of attachment: A psychological study of the strange situation. NY: Erlbaum Associates Pub. AMATO, P. R. (1996). Explaining the Intergenerational Transmission of Di- vorce. Journal of Marriage and the Family 58: 628–641. CAPALDI, D., PEARS, K., PATTERSON, G., OWEN, L. (2003). Continuity of parenting practices across generations in an at-risk sample: A prospec- tive comparison of direct and mediated associations. Journal of Abnor- mal Child Psychology, 31, 127–142. CHEN, Z., KAPLAN, H. (2001). The intergenerational transmission of con- structive parenting. Journal of Marriage and the Family, 63, 17–31. CVETEK, R. (2009). Bolečina preteklosti: Travma, medosebni odnosi, družina, terapija. Celje: Društvo Mohorjeva družba. 52 DEMŠAR PEČAK, N. (2014). Model socialnega marketinga pri reševanju prob- n lemov v partnerskem odnosu: doktorska disertacija. Novo mesto DEMŠAR PEČAK, N., Ovsenik M. (2014). Social Marketing and Intergener- pulatioo ational Dialogue, - A New Research Approach to Resolve Problems in ge p Partner Relationships. Media, culture and public relations 5(2), 147-160 rking-a DEMŠAR PEČAK, N. (2017). Nujnost in pomen terapevtskega pristopa pri izva- o janju programa »Projektno učenje mlajših odraslih (PUM-O). Medsebojni he w odnosi in spremembe v terapiji.VII. kongres zakonskih in družinskih ter- f t apevtov Slovenije 2016. Teološka fakulteta Ljubljana ealth o GLENN, N. D., KRAMER, K. B. (1987). The Marriages and Divorces of the | h Children of Divorce. Journal of Marriage and the Family 49: 811–825. GOSTEČNIK, CH. (1997). Človek v začaranem krogu. Ljubljana: Brat Frančišek pulacije o in Frančiškanski družinski center. GOSTEČNIK, CH. (2007). Relacijska zakonska terapija. Ljubljana: Brat ktivne p Frančišek in Frančiškanski družinski center. GOSTEČNIK, CH. (2008). Relacijska paradigma in travma. Ljubljana: Brat elovno a Frančišek in Frančiškanski družinski center. GOSTEČNIK, CH. (2010). Sistemske terapije in praksa. Ljubljana: Brat Frančišek zdravje d in Frančiškanski družinski center. GOSTEČNIK, CH. (2011). Inovativna relacijska družinska terapija. Ljubljana: Brat Frančišek in Frančiškanski družinski center. ISTENIČ, S.A. (2003). Evalvacija socialno integracijske vloge programa Projektno učenje za mlajše odrasle. Filozofska fakulteta v Ljubljani. Ljubljana. KEITH, V. M., FINLAY, B. (1988). The Impact of Parental Divorce on Chil- dren’s Educational Attainment, Marital Timing, and Likelihood of Di- vorce. Journal of Marriage and the Family 50: 797–809. MARTIN-MATTHEWS, A., KOBAYASHI, K. (2009). Intergenerational Transmission - Cultural Transmission: Values, Norms, And Beliefs, Retrieved. http://family.jrank.org/pages/917/Intergenerational-Transmission.htm MOŽINA, E., JAVRH, P. , KURAN M. , VRBAJNŠČAK, K. , ŠMALCELJ, P., RADOVAN, M. , JAMŠEK D., (2010). Evalvacijska študija. Javno veljav-ni program Projektno učenje za mlajše odrasle (PUM). Program Temelj- no usposabljanje za mentorje (TUM PUM). Andragoški center Sloveni- je. Ljubljana SERBIN, L., KARP, J. (2003). Intergenerational studies of parenting and the transfer of risk from parent to child. Current Directions in Psychological Science, 12, 138–142. ŽALEC, N. (2015). Program Projektno učenje mlajših odraslih PUM-O. Andragoški center Slovenije. Ljubljana ŽVELC, G. (2016). Relacijske potrebe, uglaševanje in prisotnost v psihoterapiji. Medsebojni odnosi in spremembe v terapiji. VII. kongres zakonskih 53 in družinskih terapevtov Slovenije 2016. Teološka fakulteta Ljubljana: 5 n nterventio rtant ipomn is a pproach a herapeutic a the t Critical review of viewership and contents of official healthcare organization websites Rok Drnovšek, Marija Milavec Kapun University of Ljubljana, Faculty of Health Sciences, Zdravstvena pot 5, 1000 Ljubljana, Slovenia rok.drn.zn@gmail.com Abstract Introduction: We all use the World Wide Web to access health-related information regarding disease or healthy behavior. Its wide use and economic efficiency should be considered in preventive healthcare. In this research, we want to determine if the websites of official Slovenian healthcare organizations are suitable for content sharing in health promotion. Methods: Using stratified sampling, we gathered estimations of the average number of daily visitors of websites of Slovenian public healthcare organizations and a subselection from the 200 most visited Slovenian websites to identify those most suitable for health-related topics. Any detected health promotion content was noted. Data was collected between 13th and 15th April 2017. Results: Estimations of average daily visitors from 46 official healthcare organization websites (M=62.5; IQR=100.0) were compared to 34 suitable websites with high viewership nationally (M=10081.5; IQR=6720.9). Official healthcare organization websites included health promotion content as health- education and event information. Discussion and conclusions: As expected, official healthcare organization websites have low viewership nationally and are therefore less suitable for health promotion. Websites owned by pharmacies were visually most sophisticated and included health promotion content most frequently (product marketing). Health promotion should take place on established websites with health-related topics to reach a larger number of people. Key words: health promotion, preventive care, the World Wide Web Modern approaches in healthcare transfer certain amounts of respon- sibility from healthcare professionals to patients themselves, since they are the ones who control the parameters of their disease, avoid harmful behaviours and regularly take prescribed medication in their home doi: https://doi.org/10.26493/978-961-7023-32-9.55-62 environments (Taylor et al., 2014)others lack research explicitly on self-management and, consequently, some patient groups may be overlooked. AIM To undertake a rapid, systematic overview of the evidence on self-management support for LTCs to inform health-care commissioners and providers about what works, for whom, and in what contexts. METHODS Self-management is \u2018the tasks .\u2009.\u2009. individuals must undertake to live with one or more chronic conditions .\u2009.\u2009.\u2009[including] .\u2009.\u2009.\ u2009having the confidence to deal with medical management, role manage- ment and emotional management of their conditions\u2019. We convened an expert workshop and identified characteristics of LTCs potentially of relevance to self-management and 14 diverse exemplar LTCs (stroke, asthma, type 2 diabetes mellitus, depression, chronic obstructive pulmonary disease, chronic kidney disease, dementia, epilepsy, hypertension, inflammatory arthropathies, irritable bowel syndrome, low back pain, progressive neurological disorders and type 1 diabetes mellitus. Each day they make choices about treatment and 56 actively participate in the healthcare process and disease management. Not to n concentrate only on disease, self-management is defined in a broader sense as knowledge, skills and virtues needed to adequately care for one’s health. This pulatioo includes an active and sustainable management of disease and healthy lifestyle ge p choices. Encouraging self-management is also a foundation for patient-centred and patient-centric approaches in healthcare, assuming that patients have an rking-a active role and make their own health-related decisions. Patients are partners o in relationship with healthcare professionals in contrast to a hierarchical re-he wf t lationship in more traditional approaches (Flott et al., 2017). To make patients capable and competent of making informed decisions about their health, it is ealth o necessary that they are well informed (Hibbard et al., 2017). | h Although television, printed media, and the community can all be po- tential sources of information, this article will focus on the world wide web, pulacije o on account of its growing popularity and wide usability. It is designed in a way that enables patients to search for desired information at any given time, which ktivne p makes it useful when looking for information about a specific topic, like a current disease or certain symptoms. Although the World Wide Web is mostly elovno a used by younger generations, many elderly patients use it to gather informa- tion about their health (Medlock et al., 2015)how trustworthy and reliable they zdravje d find these resources, and the difficulties they face in obtaining health-related information. A 41-item survey designed to understand the information-seeking characteristics of older adults was developed and distributed to retirement communities. Some items were taken from the Health Information National Trends Survey. Of 1520 surveys, 403 were returned completed (26.6%, and their numbers are expected to grow in the future. The patient’s information seeking behaviour can generally be divided into (1) seeking self-diagnosis information and (2) seeking information about an already diagnosed condition (Gage and Panagakis, 2012). Seeking self-diagnosis information is less desirable, and is very unreliable, since a non-health profes- sional may have difficulty distinguishing information relevant to their condition. In a study where patients entered their symptoms into the Google search engine, only about 15 % were returned their correct diagnosis as a result (Tang and Ng, 2006). On the other hand, patients with already diagnosed conditions can use search engines to educate themselves about their disease. Many health- care professionals and organisations publish relevant information online, and since many patients already know their diagnosis, they can easily identify contents relevant to them (Promislow et al., 2010)a comprehensive question list was developed in the three following areas: medical information (seven items. It is entirely possible for patients to receive false, deceiving or even harm- ful information online, since massive amounts of information and different sources make it impossible to adequately control their quality (Ellsworth et al., 2016). Patients should therefore always remain in strict co-operation with healthcare professionals before making decisions based on web-gained information. Online sources may have intentions that do not consider an individ- 57 ual’s health a priority, but rather publicity or financial gain. According to a United Kingdom based study, public health interests are likely under-represented, since only 6 % of mastectomy related contents online were published by ebsites healthcare organisations. The rest was published by private companies or pri- n w vate healthcare providers (Light et al., 2014), thus corporative interests should be considered as a possible threat to quality of information. rganizatio Because online information seeking is already present and will most like- ly hold an even greater importance in the near future, this phenomenon must be considered, not only in direct patient-healthcare professional relationship, ealthcare o but also in planning public health strategies. The world wide web can be used as an economically efficient tool for offering health promotion contents to a fficial h vast number of patients and achieve patient empowerment with better health f o outcomes. The World Wide Web ensures that anyone can publish freely, but in reality few healthcare professionals have the knowledge needed to effectively ntents oo create online content. That is why an entry point is required – a website or plat-nd c form that enables an individual to publish content online without any specif- ic knowledge or skills. In this research, we consider the official websites of Slo-ership a venian healthcare organisations as possible entry points for health promotion iew and content sharing. f v eview o Methods A cross-sectional study was conducted in the period between April 13th and 14th critical r 2017. The data acquired is freely available from website traffic estimator services. In this study, alexa.com and hyperstat.com were used to gather data. All public Slovenian healthcare organisations listed by The Health Insurance In- stitute of Slovenia were included in the population. Stratified sampling using country regions as strata offered 60 potential official websites of healthcare organisations. Each website was visually evaluated during data gathering so that presence of health promotion content could be noted. An estimate of the aver- age visitor count per day was gathered for every included website and a list of 200 most visited websites in Slovenia was obtained, of which 34 were identified as suitable for health-related topic implementation. For some of the websites, data was unobtainable due to low visitor counts, which resulted in no data availability in website traffic estimators. Some data was unobtainable due to website design, so an accurate estimate of Slovenian visitors per day could not be obtained for international websites, even if they are frequently accessed from Slovenia. Results A comparison of 46 official websites of Slovenian healthcare organisations and 34 highly visited websites in Slovenia suitable for health-related topics was made in the final analysis. Websites occurring more than once during sampling and websites with inaccessible data were not included in the final analy-58 sis. During stratified sampling healthcare organisations were divided by region n and type of organisation (“Community health centres”, “hospitals”, “pharma- cies”, “social institutions”, “spas”, and “other” (e.g. National Institute for Public pulatio Health and National Laboratory of Health, Environment and Food)). o ge p Health promotion content was categorized as either health education or information about preventive events. The number of websites including either rking-a type of content is presented in Table 1. o he wf t Table 1: Number of included websites featuring health promotion content. ealth o Information about | h Organisation type Health education content preventive events Number of included informing websites pulacije o Community health cen- tre 5 6 10 Hospital 4 4 10 ktivne p Social institutions 1 2 8 Pharmacies 9 4 9 elovno a Spas 0 1 7 Other 1 2 2 zdravje d Sum 20 19 46 Differences in website design were also detected. Pharmacy owned web- sites were visually most appealing and sophisticated. They included a lot of health promotion content and even forums, enabling users to post medicine-re- lated questions to pharmacists. It should be noted that marketing interests are clearly present, since most health promotion content features products that can solve the described medical issue. Spa websites are also visually very appealing, but were lacking health promotion content. Using hyperstat.com, estimates of average unique daily visitors for 46 of- ficial websites owned by health organisations were gathered. Data was used as an indicator for the number of people the published health promotion content may reach. Number of visitors varies according to organisation type, with the largest national reach in the categories “other” and “spa”. The Medians of estimates of daily number of unique visitors according to different types of organisations are shown in Figure 1. Overall the numbers of daily visitors of official healthcare organisations websites are not inconsiderable (M=62.5; IQR=100.0), but their national ranking is lower. Among them nijz.si (owned by The Nation- al Institute for Public Health) ranks the highest, being the 520th most visited in Slovenia. The same data was collected for 34 websites among the 200 most visited in Slovenia (M=10081.5; IQR= 6720.9). Their design enables and often already includes health related topics. The sampled websites are either based in Slovenia or they are international but highly visited in Slovenia. The list included web-based media (24ur.com, rtvslo.si, slovenskenovice.si, etc.), moder- 59 ated and unmoderated forums (over.net, vizita.si, alter.si, etc.), social networks (facebook.com, twitter.com, linkedin.com, etc.) and platforms for free content sharing (youtube.com, blogspot.si, wordpress.com). ebsites n w rganizatio ealthcare o fficial h f o ntents oo Figure 1: Medians of daily numbers of website visitors per organisation nd c type. ership a iew Discussion f v Official websites of healthcare organisations are already used to share health promotion content to some extent. Health education content was detected, and eview o information about preventive events such as parenting school, Nordic walking classes, cheaper vaccination offers, etc. The primary goal of these websites is to critical r inform patients about the working hours and the nature of the healthcare pro- cess in the particular organisation. They effectively serve their purpose, but in health promotion a larger population reach is needed (Korda and Itani, 2013). Since many highly-visited websites include health-related topics we can assume there is a general interest in the population for health-related infor- mation. Even content sharing websites such as youtube.com include numerous health-related videos (Chalil Madathilenstein et al., 2015). Online communities emerge as a result of common interests, goals and values, including the ar-ea of health and illness (Atanasova and Petrič, 2014). These communities ben- efit the patient in ways only possible outside a patient-healthcare professionals relationship since they provide empowerment and sense of participation and af-filiation within the community (Petrovčič and Petrič, 2014). Sadly, these publications and relationships often lack concrete co-operation with healthcare professionals, which is a result of the poor utilisation of the world wide web in public health strategies. Social networks should also be the focus of healthcare professionals, since those platforms enable engagement and continuous sharing of content among users. Social networks can be used for efficient health promotion with an emphasis on behaviour changes and meaningful engage- ment in content design (Korda and Itani, 2013; Kite et al.,2016). Efforts to create, review and efficiently share health related content online should be made to harness what new technologies have to offer. Expert knowledge is wasted when 60 content is shared on websites with inadequate viewership or on leaflets lying n around waiting rooms waiting to be read. The World Wide Web also has potential to reach specific population pulatioo groups. This can be illustrated with pornography addiction, which is becoming ge p prominent in recent years (Beyens et al., 2015). The simplest way of approaching this problem is by strategically placing content online. Since pornography ad-rking-ao diction is most common among men, websites like moskisvet.com (website tai- he w lored for men’s interests) or even adult websites like avanture.net (online dat-f t ing, an affair-based website) can be used in raising awareness of different forms of risky sexual behaviours. To take that approach further, browsing habits of ealth o individuals can be analysed in order to identify and reach individuals at risk | h of developing pornography addiction (adult websites noted excessively in their browsing history). These strategies are already employed in targeted advertis-pulacije o ing, where data is used to profile consumers and deliver specially tailored ad-vertisements to an individual. The same strategies can be adopted for reaching ktivne p patients who can benefit the most from certain health promotion content. We chose pornography addiction as an example after finding that 14 adult content elovno a websites were listed among the 200 most visited websites in Slovenia, with bon-gacams.com ranked 20th and pornhub.com ranked 25th nationally. The same zdravje d approach can be otherwise used in different areas such as pregnancy health- care, early maternity healthcare, eating disorders prevention, depression and internet addiction detection, etc. Health promotion should take place on already established websites in close co-operation with healthcare professionals. A great example of this symbiosis is med.over.net, a website that enables patients to read verified health-related content and connect with healthcare professionals about their own health-related problems. Understanding the world wide web not only as a means of communicating with more patients at the same time, but also as means of communication with a particular population group enables us to better utilise the accessible technology in modern public health. Conclusions This article is based on estimates which can only provide an approximate de- piction of true website viewership. Even so, based on the substantial differenc-es found, a conceptual framework can be provided for a more efficient health promotion contents sharing. Keeping this in mind, healthcare professionals should shift their focus to already established websites that already have a larger audience in order to promote health more efficiently and have a larger im- pact on the health of the population. References ATANASOVA, S. and PETRIČ, G. 2014. Spletne skupnosti: tipologija in temel- 61 jne značilnosti. Družboslovne razprave, vol. 75, pp. 85–106. BEYENS, I., VANDENBOSCH, L. and EGGERMONT, S. 2015. Early adoles- cent boys’ exposure to internet pornography. The Journal of Early Adoles- ebsites cence, vol. 35, no. 8, pp. 1045–1068. n w CHALIL MADATHIL, K., JOY RIVERA-RODRIGUEZ, A., GREENSTEIN, J. S. and GRAMOPADHYE, A. K. 2015. Healthcare information on You- rganizatio Tube: A systematic review. Health Informatics Journal, vol. 21, no. 3, pp. 173–194. ELLSWORTH, B., PATEL, H. and KAMATH, A. F. 2016. Original article: as- ealthcare o sessment of quality and content of online information about hip arthro- scopy. Arthroscopy: The Journal of Arthroscopic and Related Surgery, vol. fficial h f o 32, pp. 2082–2089. FLOTT, K., HOUNSOME, L., VUIK, S., DARZI, A. and MAYER, E. 2017. A pa- ntents o tient-centric approach to improving experience in urological cancer care. o Journal of Clinical Urology, vol. 10, no. 1, pp. 39–46. nd c GAGE, E. A., and PANAGAKIS, C., 2012. The devil you know: parents seeking information online for paediatric cancer. Sociology of Health and Illness, ership a iew vol. 34, no. 3, pp. 444–458. f v HIBBARD, J. H., MAHONEY, E. and SONET, E. 2017. Does patient activation level affect the cancer patient journey? Patient Education and Counseling. eview o vol. 100, no. 7, pp. 1276–1279. KITE, J., FOLEY, B. C., GRUNSEIT, A. C. and FREEMAN, B. 2016. Please li- critical r ke me: Facebook and public health communication [online]. PLOS ONE, vol. 11, no. 9, pp. e0162765. [viewed 15 May 2017]. Available from: https:// doi.org/10.1371/journal.pone.0162765 KORDA, H. and ITANI, Z. 2013. Harnessing social media for health promotion and behavior change. Health Promotion Practice, vol. 14, no. 1, pp. 15–23. LIGHT, A., MUNRO, C., BREAKEY, W. and CRITCHLEY, A. 2014. The Internet: What are our patients exposed to when considering breast recon- struction following mastectomy? The Breast, vol. 23, no. 6, pp. 799–806. MEDLOCK, S., ESLAMI, S., ASKARI, M., ARTS, D. L., SENT, D., DE ROOIJ, S. E. and ABU-HANNA, A. 2015. Health information–seeking behavior of seniors who use the internet: a survey [online]. Journal of Medical In- ternet Research, vol. 17, no. 1, pp. e10. [viewed 8 May 2017]. Available from: https://doi.org/10.2196/jmir.3749 PETROVČIČ, A. and PETRIČ, G. 2014. Dejavniki kolektivnega psihološke- ga opolnomočenja aktivnih uporabnikov spletne zdravstvene skupnosti Med.over.net. Zdravstveno varstvo, vol. 2014, no. 53, pp. 133–143. PROMISLOW, S., WALKER, J. R., TAHERI, M. and BERNSTEIN, C. N. 2010. How well does the Internet answer patients’ questions about inflamma- tory bowel disease? Canadian Journal of Gastroenterology, vol. 24, no. 11, 62 pp. 671–677. n TANG, H. and NG, J. H. K. 2006. Googling for a diagnosis–use of Google as a diagnostic aid: internet based study. BMJ (Clinical Research Ed.), vol. 333, pulatio no. 7579, pp. 1143–1145. o ge p TAYLOR, S. J., PINNOCK, H., EPIPHANIOU, E., PEARCE, G., PARKE, H. L., SCHWAPPACH, A., PURUSHOTHAM, N., JACOB, S., GRIFFITHS, C., rking-ao J., GREENHALGH, T. et al. 2014. A rapid synthesis of the evidence on in- terventions supporting self-management for people with long-term con- he wf t ditions: PRISMS – Practical systematic Review of Self-Management Su- pport for long-term conditions. NIHR Journals Library. ealth o| h pulacije o ktivne p elovno a zdravje d Ketogenic diet and its impact on mental processes of working population Gašper Grom Maksimum, d. o. o., Parmova 51, 1000 Ljubljana grom@maxximum.si Abstract Introduction: Ketogenic diet has been evaluated for wide variety of conditions, although it was initially used for treatment of epilepsy. As alternative dietary pattern it can represent means of better quality of life, improved ability to work and can prevent against cognitive decline, different dementias and more serious forms of neurodegenerative diseases. Methods: This is a systematic review of available literature. Results: As energy substrates and as signaling agents, ketones are potentially usable in mitochondriopathies that come with aging and neurodegenerative diseases, or are a consequence of stroke, trauma. It has antioxidative, antiinflammatory and antiseizure properties, improves bioenergetics of the brain, neuronal plasticity and has epigenetic function. Discussion: Expansion of current nutritional knowledge might be a paradigmatic shift in understanding what is “healthy diet” in general or in terms of segments of population. Key words: ketogenic diet, low carbohydrate, cognitive function, neuroprotective effect Effects of nutrition can most acutely be seen in the working population, as it affects work efficiency and absenteeism; yet the human nutrition, the foundation for chronic noncommunicable diseases and neurodegen- erative diseases (ND) as well, should remain an open discussion in general. Chronic noncommunicable diseases: cardiovascular diseases, cancer, diabetes, musculoskeletal diseases, chronic respiratory diseases and some mental disor- ders, are estimated to represent up to 80 % of deaths worldwide (Nacionalni in- štitut za javno zdravje, 2017). The public health organizations’ recommendations of the past 40 years hardly have any positive effects. High availability of hyperpalatable food, stim-doi: https://doi.org/10.26493/978-961-7023-32-9.63-71 ulating the same reward circuits in the brain as drugs do (Volkow et al., 2012) should be counterweighed with a diet, protective of general and neurological health. Ketogenic diet (KD) has been used with refractory epilepsy in children (Erickson et al., 2017) since 1920’s. Most energy in a KD comes from fat with moderate protein intake and minimal carbs intake – one of the strictest ratios being 90 : 2 : 8 (Oliveira et al., 2017). Most common rule implies 20 to 50 grams of carbs daily (Noakes et al., 2017). This induces ketosis: the liver starts producing ketone bodies (KB) as a metabolite of fats, glucose levels settle down and its concentration normalizes; insulin levels decrease, plasma pH decreases slightly as well (Oliveira et al., 2017). KB become the predominant source of energy for central nervous system (Paoli et al., 2014), musculoskeletal system and the heart (Barbanti et al., 2017). KD surpasses the benefits of high carbohydrate diets (Chang et al., 2017), for example in cancer, diabetes, cardiovascular diseases (Bazzano et al., 2015), AD and multiple sclerosis (Erickson et al., 2017). It’s effi-64 cient for weight loss (Yancy et al., 2010, Bueno et al., 2013), appetite regulation, n glycaemic control (Volek et al., 2009), stabilisation of hyperinsulinemia, im- proving insulin sensitivity and normalizing blood lipid profiles (Chang et al., pulatioo 2017, Noakes et al., 2017, Oliveira et al., 2017). KD has been studied as adjuvant ge p therapy in brain neoplasms. In animal models, KD prolongs survival by anti- oxidant properties and by supressing the tumour growth factors genes (Scheck rking-ao et al., 2012). he w Genesis, transport and oxidation of beta hydroxybutyrate (BoHB), one of f t the most important endogenous KB, are well understood, exact mechanisms however not (Maalouf et al., 2009, McCarty et al., 2015). As direct and indirect ealth o| h histone deacetylase inhibitor, BoHB has epigenetic function (Newman et al., 2014). BoHB also directly inhibits the NLRP3 protein, the main motor of in- pulacije flammatory response in autoimmune and autoinflammatory diseases, diabetes o type 2, AD and atherosclerosis (Youm et al., 2015). ktivne p In this paper we focus on KD as a means of protection for the nervous system and its potential within the realm of mental, cognitive and memory processes. elovno a Methods zdravje d Primary literature for this narrative attempt at a systematic review search was Medline / Pubmed database. A string of keywords using MESH, [tiab] descrip-tor and Boole operators AND, OR and NOT with publication date criteria (2007 and on) and human studies were used. The search string: (ketogenic diet[mesh] OR (ketogenic [tiab] AND diet [tiab]) OR diet carbohydrate restricted [mesh] OR (carbohydrate [tiab] AND restricted [tiab]) OR ketone bodies [mesh] OR (ketone [tiab] AND bodies [tiab]) OR 3-hydroxybutyric acid [mesh] OR beta Hydroxybutyrate [tiab]) AND ((neuroprotection [mesh] OR neuroprotection [tiab] OR neuroprotective [tiab]) OR (cognition [mesh] OR cognition [tiab] OR cognitive function [tiab]) OR (memory [mesh] OR memory [tiab]) OR (memory disorders[mesh] OR (memory [tiab] AND disorders [tiab])) OR (Memory Disorders/diet therapy[Mesh])) NOT epilepsy [mesh]. Google Scholar search results, found by using the string »ketogenic diet, low carbohydrate, cognitive function, memory creation, neuroprotective«, were added to initial Pubmed search. Some results were excluded based on weak connection to the topic. Results Neuronal hypometabolism appears to be foundation in pathogenesis of many ND (Castellano et al., 2015): consequences of metabolic disorders set off in the preclinical stages of the disease. This is a common ground for new therapies for ND, especially in those where neuroprotection is the key (Stafstrom et al., 2012). Ketosis could be the opportunity to open paracrine and autocrine signalling mechanisms to influence cometabolism within the nervous system and tu- mours as a way to achieve therapeutic ends (Puchalska et al., 2017). 65 Mitochondria do not only supply cells with energy; they control the apop- n tosis, calcium levels and production and elimination of reactive oxygen species (ROS) (Milder et al., 2012). Nutrition based therapies are not only an option for pulatioo rare mitochondriopathies but also for a spectrum of ND associated with aging (Procaccio et al., 2014). Mitochondrial dysfunction and the consequential hy- rking po pometabolism of the nervous system that is a part of aging can be a source and f w a consequence of inflammatory processes (Currais, 2015). KD is efficient with ameliorating symptoms of AD, Parkinson’s disease cesses oro and other ND (Hartman, 2012, Liśkiewicz et al., 2012, Mandla et al., 2013). KD can have a profound effect on neuronal plasticity, reduces inflammation, ental p and improves bioenergetics in the brain … (Procaccio et al., 2014). Mitochon- n m drial function is impaired in ND – both systemically as well as in the brain pact o (Wilkins et al., 2017). Nervous system’s glucose dependency poses a risk to cog-m nitive health (Farias et al., 2014). Neurons are adapted to using many differ- ts i ent substrates for energy: glutamine, glutamate, lactate, pyruvate, KB. This nd i is especially useful for people with regular hypoglycaemic episodes (Amaral, iet a 2013), causing cognitive dysfunction, sensory disturbances and memory de- genic d fects (Costantini et al., 2008), verbal memory, digit symbol coding, digit span backwards, and map searching (Page et al., 2009). keto Lack of energy due to hypometabolism and mitochondriopathies can be replaced by KB (Currais, 2015). Nutritional ketosis provides replenishment of the TCA cycle, restoration of neurotransmitter and ion channel function, and enhanced mitochondrial respiration. It helps cellular homeostasis by enabling signal pathways, developed as sensors of the energy state of the cell (Gano et al., 2014). These antiseizure, neuroprotective and antitumor properties of KD are not yet well understood (Maalouf et al., 2009, Thio, 2012). Use of ketosis looks promising most prominently in AD (Grom, 2016). Decrease in glucose utilization has a very early onset with AD – much earli- er before pathologies and symptoms appear – and is much greater than in normal aging (Costantini et al., 2008). The changed metabolic environment rein- forces the disease progression. Normalization of bioenergetics can be efficient in treatment neurological diseases (Masino et al., 2008, Zilberter et al., 2017). AD is the most common type of dementia; it features accumulation of amyloid plaques and hyperphosphorylation of tau protein resulting in inflam- matory response and oxidative stress. The mechanism is not well understood, but it seems that type 2 diabetes (T2D) accelerates these processes. Cerebral at-rophy, hypometabolism of glucose and insulin resistance are featured in both diseases (Verdile et al., 2015). Cognitive decline is directly correlated to the level of glucose hypometabolism (de Leon et al., 1983). Some authors claim that AD is a type 3 diabetes (de la Monte et al., 2008). In animal models of AD, nutritional ketosis can ameliorate the extent of beta amyloid plaque accumulation (Krikorian et al., 2012). However, with pa- 66 tients without ApoE4 allele one of the nutritional options to improve mild cognitive impairments is adding medium chain triglycerides to the diet (Page et n al., 2009, Farias et al., 2014, Sharma et al., 2014, Fernando et al., 2015, Hertz et al., 2015, Ohnuma et al., 2016). pulatioo Even in the excessive ROS model of AD, the KD is still useful as an an- ge p tioxidative therapy. There is mixed evidence about the oxidative stress as the ground for AD in clinical trials, but it is possible that the antioxidant thera-rking-ao pies did not succeed to deliver the antioxidants where they should be delivered he w (Rosini et al., 2014). KD might have been more successful. f t KB help decrease the oxidative stress, while also being a substrate for en- ealth o ergy. Both roles make KB highly neuroprotective agents (Cahill, 2006). KB me- | h diate their antioxidative properties by activation of protective transcription factors (like Nrf2) that increase the production of antioxidants like glutathione pulacije o and other enzymes (Milder et al., 2012). In KD, the metabolism of astrocytes producing purines (ATP and adenos- ktivne p ine) is increased (Masino et al., 2008, Boison, 2013). In animal models there is increased autophagy of neurons in ketotic environment (McCarty et al., 2015). elovno a Balancing excitotoxicity and cell death as a consequence can have a bene- ficial effect with patients who survived ischemic stroke and death of mitochon-zdravje d dria that takes place sometime later after the event. In animal models these devastation to mitochondria can be alleviated by KB (Baxter et al., 2014). Post-operatively, KD could also be used with adult patients who suffered head trau- ma (Prins et al., 2014). Discussion Effects of KD are profound, but also complex. Yet applying any therapeutic means to affect the nervous system is rarely straightforward and simple to ob- serve. Researching the neuroprotective properties of nutrition is by nature re-ductionist, regardless of the mechanism (epigenetic, direct or indirect modu- lation of individual physiological substances). Research is also mostly direct-ed at improving known pathologies. To understand potential preventive effects some backwards deduction should be made. Conclusion Our insight into KD is barely scratching the surface. A lot of research both in humans and in animal models looks promising as expansion of our current nutritional knowledge and potentially as a paradigmatic shift in understand- ing what is “healthy diet” in general. When the nervous system is in question, KD appears to have more ef- ficient bioenergetics. We presented the research that deals with pathologies where the underlying hypometabolism is potentially the key to understand AD, Parkinson’s disease, head trauma etc. Ketosis seems to be especially ben- 67 eficial for mitochondria dysfunction. KB reduce the damaging effect of ROS, n help body’s own antioxidant capacity, while the ketone metabolism itself poses decreased oxidative stress to the tissues. pulatioo Neuroprotective effect of KD for now seems irrefutable, despite the lack of thorough understanding of the underlying mechanisms. Further research, rking po especially in the form of clinical trials, is needed. f w cesses o References ro AMARAL, A.I. 2013. A ketone ester diet exhibits anxiolytic and cognition-spar- ing properties, and lessens amyloid and tau pathologies in a mouse model ental p n m of Alzheimer‘s disease. Journal of Inherited Metabolic Disease, vol. 34, no. 6, pp. 1530-1539. pact om BARBANTI, P. et al. 2017. Ketogenic diet in migraine: rationale, findings and ts i perspectives. Neurological sciences: official journal of the Italian Neurologi-nd i cal Society and of the Italian Society of Clinical Neurophysiology, vol. 38, no. iet a Suppl 1, pp. 111-115. genic d BAXTER, P., CHEN, Y., XU, Y. and SWANSON, R.A. 2014. Mitochondrial dys- function induced by nuclear poly(ADP-ribose) polymerase-1: a treatable keto cause of cell death in stroke. Translational Stroke Research, vol. 5, no. 1, pp. 136-144. BAZZANO, L. et al. 2015. Effects of low-carbohydrate and low-fat diets: a ran- domized trial. The The American Journal of Clinical Nutrition, vol. 102, no. 4, pp. 780-790. BOISON, D. 2013. Adenosine kinase: exploitation for therapeutic gain. Pharmacological Reviews, vol. 65, no. 3, pp. 906-943. BUENO, N., VIEIRA DE MELO, I., LIMA DE OLIVEIRA, S. and DA ROCHA ATAIDE, T. 2013. Very-low-carbohydrate ketogenic diet v. low-fat diet for long-term weight loss: a meta-analysis of randomised controlled trials. The British Journal of Nutrition, vol. 110, no. 7, pp. 1178-1187. CAHILL, G.F., Jr. 2006. Fuel metabolism in starvation. Annual Review of Nutrition, vol. 26, pp. 1-22. CASTELLANO, C. et al. 2015. Lower brain 18F-fluorodeoxyglucose uptake but normal 11C-acetoacetate metabolism in mild Alzheimer‘s disease demen- tia. Journal of Alzheimer‘s Disease, vol. 43, no. 4, pp. 1343-1353. CHANG, C.K., BORER, K. and LIN, P.J. 2017. Low-Carbohydrate-High-Fat Di- et: Can it Help Exercise Performance? Journal of Human Kinetics, vol. 56, pp. 81-92. COSTANTINI, L.C., BARR, L.J., VOGEL, J.L. and HENDERSON, S.T. 2008. Hypometabolism as a therapeutic target in Alzheimer‘s disease. BMC Neuroscience, vol. 9 Suppl 2, pp. S16. CURRAIS, A. 2015. Ageing and inflammation - A central role for mitochondria 68 in brain health and disease. Ageing Research Reviews, vol. 21, pp. 30-42. n DE LA MONTE, S.M. and WANDS, J.R. 2008. Alzheimer‘s Disease is Type 3 Diabetes—Evidence Reviewed. Journal of Diabetes Science and Technology, pulatioo vol. 2, no. 6, pp. 1101-1113. ge p DE LEON, M.J. et al. 1983. Positron emission tomographic studies of aging and Alzheimer disease. AJNR. American Journal of Neuroradiology, vol. 4. rking-ao ERICKSON, N., BOSCHERI, A., LINKE, B. and HUEBNER, J. 2017. Systemat- he w ic review: isocaloric ketogenic dietary regimes for cancer patients. Medi-f t cal Oncology, vol. 34, no. 5, pp. 72. ealth o FARIAS, G.A., GUZMÁN-MARTÍNEZ, L., DELGADO, C. and MACCIONI, | h R.B. 2014. Nutraceuticals: a novel concept in prevention and treatment of Alzheimer‘s disease and related disorders. Journal of Alzheimer‘s Disease, pulacije o vol. 42, no. 2, pp. 357-367. FERNANDO, W.M. et al. 2015. The role of dietary coconut for the prevention ktivne p and treatment of Alzheimer‘s disease: potential mechanisms of action. The British Journal of Nutrition, vol. 114, no. 1, pp. 1-14. elovno a GANO, L.B., PATEL, M. and RHO, J.M. 2014. Ketogenic diets, mitochondria, and neurological diseases. Journal of Lipid Research, vol. 55, no. 11, pp. 2211-zdravje d 2228. GROM, G. 2016. Koristi ketogene diete za starejše: sindromi demence in Alzheimerjeva bolezen. Živeti življenje v varni starosti : zbornik pre- davanj, 2. Kongres gerontološke zdravstvene nege in oskrbe, Portorož, Strokovna sekcija medicinskih sester in zdravstvenih tehnikov v social- nih zavodih, Ljubljana. HARTMAN, A.L. 2012. Neuroprotection in metabolism-based therapy. Epilep- sy Research, vol. 100, no. 3, pp. 286-294. HERTZ, L., CHEN, Y. and WAAGEPETERSEN, H.S. 2015. Effects of ketone bodies in Alzheimer‘s disease in relation to neural hypometabolism, be- ta-amyloid toxicity, and astrocyte function. Journal of Neurochemistry, vol. 134, no. 1, pp. 7-20. KRIKORIAN, R. et al. 2012. Dietary ketosis enhances memory in mild cogni- tive impairment. Neurobiol Aging, vol. 33, no. 2, pp. 425 e419-427. LIŚKIEWICZ, A., JĘDRZEJOWSKA-SZYPUŁKA, H. and LEWIN-KOWA- LIK, J. 2012. Characteristics of ketogenic diet and its therapeutic prop- erties in central nervous system disorders. Annales Academiae Medicae Silesiensis. MAALOUF, M., RHO, J.M. and MATTSON, M.P. 2009. The neuroprotective properties of calorie restriction, the ketogenic diet, and ketone bodies. Brain Research Reviews, vol. 59, no. 2, pp. 293-315. MANDLA, U., SHARMA, P. and SHARMA, V. 2013. Dietary Factors in Alzheimer‘s Disease: A Compilation of Helping Evidences. Internation- al Journal of Research and Development in Pharmacy and Life Sciences, vol. 2, no. 5, pp. 545-552. 69 MASINO, S.A. and GEIGER, J.D. 2008. Are purines mediators of the anticon- n vulsant/neuroprotective effects of ketogenic diets? Trends in Neuroscienc-pulatio es, vol. 31, no. 6, pp. 273-278. o MCCARTY, M.F., DINICOLANTONIO, J.J. and O‘KEEFE, J.H. 2015. Ketosis rking p may promote brain macroautophagy by activating Sirt1 and hypoxia-in- o f w ducible factor-1. Medical Hypotheses, vol. 85, no. 5, pp. 631-639. MILDER, J. and PATEL, M. 2012. Modulation of oxidative stress and mito- cesses o chondrial function by the ketogenic diet. Epilepsy Research, vol. 100, no. ro 3, pp. 295-303. ental p NACIONALNI INŠTITUT ZA JAVNO ZDRAVJE. 2017. Bolezni [ online]: Na-n m cionalni inštitut za javno zdravje. Available at: http://www.nijz.si/sl/po- drocja-dela/nenalezljive-bolezni-in-stanja/bolezni [Accessed 17.6. 2017]. pact om NEWMAN, J.C. and VERDIN, E. 2014. Ketone bodies as signaling metabo- ts i lites. Trends in Endocrinology and Metabolism, vol. 25, no. 1, pp. 42-52. nd i iet a NOAKES, T.D. and WINDT, J. 2017. Evidence that supports the prescription of low-carbohydrate high-fat diets: a narrative review. British Journal of genic d Sports Medicine, vol. 51, no. 2, pp. 133-139. keto OHNUMA, T. et al. 2016. Benefits of use, and tolerance of, medium-chain triglyceride medical food in the management of Japanese patients with Alzheimer‘s disease: a prospective, open-label pilot study. Clinical Interventions in Aging, vol. 11, pp. 29-36. OLIVEIRA, C.L. et al. 2017. A Nutritional Perspective of Ketogenic Diet in Cancer: A Narrative Review. Journal of the Academy of Nutrition and Dietetics. PAGE, K.A. et al. 2009. Medium-chain fatty acids improve cognitive function in intensively treated type 1 diabetic patients and support in vitro synap- tic transmission during acute hypoglycemia. Diabetes, vol. 58, no. 5, pp. 1237-1244. PAOLI, A., BIANCO, A., DAMIANI, E. and BOSCO, G. 2014. Ketogenic diet in neuromuscular and neurodegenerative diseases. BioMed Research International [electronic resource], vol. 2014, pp. 474296. PRINS, M.L. and MATSUMOTO, J.H. 2014. The collective therapeutic poten- tial of cerebral ketone metabolism in traumatic brain injury. Journal of Lipid Research, vol. 55, no. 12, pp. 2450-2457. PROCACCIO, V. et al. 2014. Perspectives of drug-based neuroprotection tar- geting mitochondria. Revue Neurologique, vol. 170, no. 5, pp. 390-400. PUCHALSKA, P. and CRAWFORD, P.A. 2017. Multi-dimensional Roles of Ke- tone Bodies in Fuel Metabolism, Signaling, and Therapeutics. Cell Metab- olism, vol. 25, no. 2, pp. 262-284. ROSINI, M. et al. 2014. Oxidative stress in Alzheimer’s disease: are we connecting the dots? Journal of Medicinal Chemistry, vol. 57, no. 7, pp. 2821-2831. SCHECK, A.C., ABDELWAHAB, M.G., FENTON, K.E. and STAFFORD, P. 70 2012. The ketogenic diet for the treatment of glioma: insights from genet- n ic profiling. Epilepsy Research, vol. 100, no. 3, pp. 327-337. SHARMA, A., BEMIS, M. and DESILETS, A.R. 2014. Role of Medium Chain pulatioo Triglycerides (Axona(R)) in the Treatment of Mild to Moderate Alzheim- ge p er‘s Disease. American Journal of Alzheimer‘s Disease and Other Dementias, vol. 29, no. 5, pp. 409-414. rking-ao STAFSTROM, C.E. and RHO, J.M. 2012. The ketogenic diet as a treatment par- he w adigm for diverse neurological disorders. Frontiers in Pharmacology [elec-f t tronic resource], vol. 3, pp. 59. ealth o THIO, L.L. 2012. Neuroprotection in metabolism-based therapy. Epilepsy Re- | h search, vol. 100, no. 3, pp. 286-294. VERDILE, G., FULLER, S.J. and MARTINS, R.N. 2015. The role of type 2 di- pulacije o abetes in neurodegeneration. Neurobiology of Disease, vol. 84, pp. 22-38. VOLEK, J.S. et al. 2009. Carbohydrate restriction has a more favorable impact ktivne p on the metabolic syndrome than a low fat diet. Lipids, vol. 44, no. 4, pp. 297–309. elovno a VOLKOW, N.D. et al. 2012. Food and drug reward: overlapping circuits in hu- man obesity and addiction. Current Topics in Behavioral Neurosciences, zdravje d vol. 11, pp. 1-24. WILKINS, H.M. and MORRIS, J.K. 2017. New Therapeutics to Modulate Mito- chondrial Function in Neurodegenerative Disorders. Current Pharmaceu- tical Design, vol. 23, no. 5, pp. 731-752. YANCY, W.J. et al. 2010. A randomized trial of a low-carbohydrate diet vs orl- istat plus a low-fat diet for weight loss. A. Archives of Internal Medicine, vol. 170, no. 2, pp. 136-145. YOUM, Y.H. et al. 2015. The ketone metabolite beta-hydroxybutyrate blocks NLRP3 inflammasome-mediated inflammatory disease. Nature Medicine, vol. 21, no. 3, pp. 263-269. ZILBERTER, Y. and ZILBERTER, M. 2017. The vicious circle of hypometabolism in neurodegenerative diseases: Ways and mechanisms of metabolic correction. Journal of Neuroscience Research. 71 n pulatioo rking po f w cesses oro ental p n m pact om ts i nd i iet a genic d keto Absenteeism due to mental problems among employees in nursing Brigita Jeretina1, Katja Krt2, Andrej Starc1 1 Univesrity of Ljubljana, Faculty of Health Sciences, Zdravstvena pot 5, 1000 Ljubljana, Slovenia 2 University Medical Centre Ljubljana, Clinic of Surgery, Zaloška cesta 7, 1000 Ljubljana, Slovenia brigita.jeretina2@gmail.com; katja_krt@hotmail.com; andrej.starc@zf.uni-lj.si Abstract Introduction: Absenteeism is a phenomenon that describes absence at work and is measured as a frequency of missing days at work. It is directly related to consequences such as nursing staff shortage, low employees morale and disruptions in continuity of patient care. Causes of absenteeism are often attributed to mental disorders. In nursing manifestations of mental problems are often caused by the nature of work and working conditions. Methods: In this paper, a descriptive methodology with literature review in Slovenian and English language has been used. Union bibliographic database COBBISS and CINAHL, Medline (PubMed), Cochrane and Springerlink databases have been searched. Results: Many researchers have been studying risk factors which cause and/or influence the absenteeism in nursing. The causes for absenteeism are expected to be overload of work, excessive work demands and job dissatisfaction. Also, depression, anxiety and stress are expected to be recognized as the most frequent mental problems. Discussion: Based on previous findings guidelines for further research on mental health among nurses in Slovenia will be presented. Key words: nurse, absence from work, mental health, job dissatisfaction Absenteesim is a concept by which we define an absence of an employee from the workplace and is measured with the frequency of missing wor- king days. Experts estimate that the rate of absenteeism among heal- th professionals is higher than in other professions. Therefore, identifying and understanding the factors contributing to absenteeism is a particularly challenging for society (Waage and Bjorvatn, 2016). In addition to other factors, the causes of absenteeism are often attributed to mental disorders (Lamont et al., 2016; Perry et al., 2015). When absenteeism arises from mental health problems, employees are usually absent for a longer period of time, and consequently this doi: https://doi.org/10.26493/978-961-7023-32-9.73-81 can lead to permanent incapacity for work (Anema et al., 2006). The very emergence of mental problems in nurses is in many cases the result of the nature of work and working conditions in health care (Mealer et al., 2007). The purpose of the paper is to present the specificity of absentism related to mental health in the field of nursing. The aim of the paper is to answer the following research questions: Is the level of absenteeism in the nursing profession higher compared to other professions? Which factors related to working place influence the frequency of absenteeism in nursing care? What is the impact of mental health on absenteeism in the nursing profession? What impact or consequences ha- ve mental health problems on the individual‘s ability to work in nursing pro- fession? Methods The article used a descriptive method of work with a critical overview of Slo- 74 vene and English professional and scientific literature. The literature search period took place from March to May 2017. The literature search was carried n out using the Slovenian bibliographic-catalog database COBIB.SI and foreign CINAHL and Medline databases (PubMed). The search criteria used the lan- pulatioo guage criterion, but we limited ourselves to articles published in both Slove- ge p nian and English. The applied keywords associated with the Boolean operator AND in English were: absenteeism AND mental disorders AND nursing, ab- rking-ao senteeism AND health care, absenteeism AND nursing home, sickness absen- he w ce AND health care, sickness absence AND mental health AND health care, f t mental health AND stress AND nursing. Slovene literature was searched with the following keywords: absentizem IN zdravstvena nega IN duševne motn- ealth o| h je, absentizem IN depresija, bolniška odsotnost IN duševno zdravje IN zdrav- stvena nega. The result of keyword combinations is a different number of fin- pulacije dings. The selected ones were about the risk factors that lead to absenteeism, o the causes of mental health problems among health professionals and measu- ktivne p res to improve mental health. The exclusion criteria were articles adressing the nursing students. elovno a Table 1: English keyword combinations and number of findings. zdravje d absenteeism absenteeism sickness ab- mental Key words AND men- AND men- absenteeism sickness ab- sence AND health AND (English) tal disorders tal disorders AND nursing sence AND mental health AND nurs- AND nurs- home health care AND health stress AND ing ing care nursing Search results 15 49 64 104 13 112 Used articles 5 2 0 1 4 2 Table 2: Slovene keyword combinations and number of findings. Key words absentizem IN zdravstvena bolniška odsotnost IN (Slovene) nega IN duševne motnje absentizem IN depresija duševno zdravje IN zdravst- vena nega Search results 6 2 2 Used articles 0 1 0 Results Health absenteeism is a serious social problem with many causes and conse- quences. The consequences of absenteeism are present in the case of employees (lower income, lower prospects, job dissatisfaction, loss of working habits), employers (costs for compensation, costs for substitute workers, lower productivity) and at the level of the national economy as a whole (lower gross domestic product) (Vučković, 2010). On the basis of national data from Canada, it is esti-75 mated that, on average, there are up to 1.5 times more probability for absenteeism among health professionals than for other professions (Lamont et al., 2016). Perry and colleagues (2015) studied the mental health of nurses throu- ursing gh a cross-sectional study. From the 382 employees, almost 14 % excluded that s in n they have already been diagnosed with mental disorders such as anxiety and ployee depression in the past. 6 % of nurses state that they are currently using psycho-active drugs. The researchers also found the presence of other symptoms that g em are potentially related to mental health, such as: headache, fatigue, dyspepsia, mons a night sweating, sleeping problems and palpitations. blem The impact of mental health on health and productivity of the working ro population has been underestimated for a long time. The United Kindom De- tal pen partment of Health estimates that 15-30 % of people will have mental health o m problems during their working lives, which are one of the leading causes of ue t morbidity. Mental problems among employees do not only have consequences ism d for the individual, but also affect the productivity of the company, as they le-tee ad to work failure, workplace accidents, absenteeism and employee fluctuation (Harnois and Gabriel, 2000). absen The nursing profession is an emotionally and physically demanding oc- cupation and research suggests that working as a nurse means a high risk of experiencing stress, anxiety, and depression. Authors often report the presen- ce of mental illness, drug abuse, workplace aggression, stress and burnout in nursing care. Mental disorders and burnout are often the result of working, organizational and personal factors (Perry et al., 2015). Researchers from Australia have studied the link between mental health, workplace characteristics and absence from work among nurses and midwives through a cross-sectional study. The survey included 5041 people. They found that the factors related to mental health that contributed to absenteeism among nurses and midwives are: starting a career, multiple work, demanding work, abuse at work, smoking, symptoms of mental disorders, desire for cancellation, use of psychotropic medicines and insomnia. The authors state that on the basis of findings on the connection of mental health with absenteeism in heal- th care system, the specific characteristics of employees could be used as indicators for the early identification of individuals who are at risk of absenteeism (Lamont et al., 2016). There is consensus among experts on the correlation of unfavorable wor- king conditions with the morbidity of the working population. In nursing prac- tice, such unfavorable working conditions include: an intensive working pace, a shortage of human resources and materials, pressure from superiors, low in- come, a two- or three-shift work system, exhaustion as a result of multishifts work and frequent interactions with severe, usually terminal patients (Santa-na et al., 2016). The nurses‘ mental health is particularly affected by work environments where employees lack work autonomy, where they experience low le- vels of support and few opportunities to acquire new knowledge, where a high degree of emotional exhaustion and the occurrence of physical burnout pre- 76 vail, and where employees have poor sleep habits due to multishift work. Men- n tal health consequences are seen in nurses who are under the influence of high expectations and are in conflict working relationships and work in an environ-pulatioo ment where there is a high mortality rate of patients and a high possibility of ge p traumatic events. All these factors have a major negative impact on productivi-ty, absenteeism and presentism, work performance, patient care and patient sa- rking-ao tisfaction (Perry et al., 2015). he w The authors found out that high work demands are associated with emo- f t tional exhaustion, anxiety, depression, and dissatisfaction with work. The ability to control the working environment and social support positively influen- ealth o| h ce the well-being and work satisfaction of nurses and decrease the symptoms of psychological distress and emotional exhaustion. High work demands, throu-pulacije gh the impact on the employees‘ health increase level of absenteeism (Roelen o et al., 2012). ktivne p Clausen and colleagues (2011), through longitudinal research, found out that high working demands are strongly linked to absenteeism in the case of elderly health care providers. On the other hand, positive sources in the work-elovno a place, such as the possibility of influencing on work, higher quality of management and a positive team climate protect individuals from morbidity and con- zdravje d sequently reduce the amount of absenteeism. Roelen and colleagues (2012) add that in addition to all other factors, also the way in which employees are faced with the disease, affects sick leave. It is therefore a phenomenon that arises as a result of the interaction between the personality characteristics, working conditions and the socio-cultural environment. The concern for the health of nurses, the identification of risk factors and mental illnesses is not only important for ensuring the quality of life of nurses in general, but also for maintaining competence that leads to quality tre- atment for patients. Suzuki and colleagues (2005) showed the impact of acci- dents at work (eg. needle injury) on the development of mental disorders and sleep disorders. Xiong and colleagues (2017) investigated whether the injection needle injury affected the development of a mental disorder. There were 302 nurses involved, 162 of them had already had needle injury before. The develo- pment of mental illness was almost twice as likely for nurses exposed to work with blood as in those who were not exposed to work with blood. Also physical symptoms and symptoms of social dysfunction, anxiety and depression were more frequently expressed among nurses exposed to work with blood. It is ne- cessary to provide appropriate psychological support for the stress relief at the workplace. Absenteesim in nursing represents a major economic problem both for the organization and for a personal problem for the individual. Long-term ab- sence can cause many negative consequences, such as exclusion from the wor- kplace and, consequently, social isolation in poverty, therefore recognizing the risk factors for predicting absence from work is very important (Roelen et al., 2015; Roelen et al., 2013). 77 Discussion ursing The average sick leave for a healthcare professional ranges from 12 to 15 days s in n per year per person (Lamont et al., 2016). Waage in Bjorvatna (2016) also points out that absenteeism is more frequent among healthcare workers as a result of ployee illness compared to workers in other sectors. Many authors (Mao et al, 2016; g em Gaudine et al., 2011) note that the rate of absence from all professions is the mon highest in the field of nursing care. s a Lack of employee support, working influences, organizational climate blemro and the ambiguity of the role are associated with the emergence of psychologi- tal p cal problems in nurses. The most common source of poor mental health is wor- en kload pressure (Petterson et al., 1995). The hardship caused by the small role in o m decision-making, low social support at the workplace, and pressures by leaders ue t are linked both to anxiety and to depression (Quine, 1999). ism d To protect and maintain the mental health of nurses and to ensure safe, tee effective and quality patient care, targeted stress relief measures are required absen (Caufigld et al, 2004). Many authors work on the development of strategies for reducing stress among nurses. Some approaches address the problem at the level of the individual, others at the level of the organization, and the authors al-so discuss the combination of both. Mc Vicar (2003) points out that effective approaches ensure better safety and health outcomes of healthcare professio- nals, leading to safe, efficient and quality patient care, and ultimately reducing the economic effects of stress in hospitals, industry and the economy. Deckro and colleagues (2002) represent a program that focuses on an individual in a way to improve the individual‘s ability to successfully meet challenging situations at work by educating about the source of stress and the impact on health, and also acquiring skills and abilities to reduce stress (eg adequate time alloca-tion, relaxation methods). The effects of the program have been shown to redu- ce the symptoms of stress, anxiety and sleep disorders, and positive physical, mental and emotional changes. Implementation of this type of program is not demanding and does not require a financial contribution. On the contrary to programs operating on an individual level, interven- tions at the organization level are focused on reducing stressful working con- ditions. Examples of such interventions include the transformation of jobs, cle-ar definition of job descriptions, the formation of joint staff committees, and the leadership, which increases the involvement of workers and gives them the opportunity to participate in decision-making (Murphy, 1999). As well as programs on an individual level, it is also necessary to adjust organizational adjustments according to a particular job position. The manager can, in cooperation with an expert, diagnose the situation at the level of work units and organization. On the basis of the state of the situation, approaches to prevent or eliminate harmful conditions begin to develop. Such measures include changes in employment according to staff needs, adjustment of working time or shi- 78 fts, inclusion of breaks for rest and ensuring an optimal balance of workloads n (Roberts et al., 2013). pulatioo Conclusion ge p Despite numerous studies and analyzes of the phenomenon of absenteeism, rking-a there are still insufficient studies of its direct association with mental illnesses o in the nursing profession. It is difficult to define causal and consequential con-he w nections between mental disorders and absentism. Even long-term unplanned f t absenteeism due to serious illness can affect the mental health of a nurse, since ealth o longer absenteeism means lower incomes and reduced competence at work. | h According to the findings of many researchers, absenteeism among nurses is influenced by many different factors, usually a combination of the character- pulacije o istics of the working environment and personality traits of an individual. It would be sensible to study and analyze the causes of absenteeism in nurses in ktivne p Slovenia and to compare the results between hospitals and other health institutions of different provincial regions. elovno a References zdravje d ANEMA, J.R., JETTINGHOFF, K., HOUTMAN, L.D, SCHOEMAKER, C.G., BUIJS, P.C. in VAN DEN BERG, R., 2006. Medical care of employees long-term sick listed due to mental health problems: a cohort study to de- scribe and compare the care of the occupational physician and the gen- eral practitioner. Journal of occupational rehabilitation, letn. 16, št. 1, str. 41–52. BEGAT, I., ELLEFSEN, B. in SEVERINSSON, E., 2005. Nurses’ satisfaction with their work environment and the outcomes of clinical nursing super- vision on nurses’ experiences of well‐ being–a Norwegian study. Journal of Nursing Management, letn. 13, št. 3, str. 221–230. CAULFIELD, N., CHANG, D., DOLLARD, M. in ELSHAUG, C., 2004. A review of occupational stress interventions in Australia. International Journal of Stress Management, letn. 11, št. 2, str. 149–166. CLAUSEN, T., NIELSEN, K., GOMES CARNEIRO, I. in BORG, V., 2011. Job demands, job resources and long-term sickness absence in the Danish el- dercare services: a prospective analysis of register-based outcomes. Jour- nal of Advanced Nursing, letn. 68, št. 1, str. 127–136. DECKRO, G.R., BALLINGER, K.M., HOYT, M., WILCHER, M., DUSEK, J., MYERS, P., GREENBERG, B., ROSENTHAL, D.S. in BENSON, H., 2002. The evaluation of a mind/body intervention to reduce psychological dis- tress and perceived stress in college students. Journal of American College Health, letn. 50, št. 6, str. 281–287. GAUDINE, A., SAKS, A.M., DAWE, D. in BEATON, M., 2011. Effects of absen- teeism feedback and goal-setting interventions on nurses‘ fairness per- ceptions, discomfort feelings and absenteeism. Journal of nursing man- 79 agement, letn. 21, št. 3, str. 591–602. HARNOIS, G. in GABRIEL, P., 2000. Mental health and work: impact, issues ursing and good practices. World Health Organization. Geneva, str. 1–4. s in n ISHIKAWA, H., KAWAKAMI, N. in KESSLER, R.C., 2016. Lifetime and 12-month prevalence, severity and unmet need for treatment of common ployee mental disorders in Japan: results from the final dataset of World Men- g em tal Health Japan Survey. Epidemiology and Psychiatric Sciences, letn. 25, mons a št. 3, str. 217–229. blem JENKINS, R. in ELLIOTT, P., 2004. Stressors, burnout and social support: ro nurses in acute mental health settings. Journal of Advanced Nursing, letn. tal p 48, št. 6, str. 622–631. en o m LAMONT, S., BRUNERO, S., PERRY, L., DUFFIELD, C., SIBBRITT, D., GAL- ue t LAGHER, R. in NICHOLLS, R., 2016. “Mental health day” sickness ab- ism d sence amongst nurses and midwives: workplace, workforce, psychosocial tee and health characteristics. Journal of advanced nursing, letn. 73, št. 5, str. 1172–1181. absen LIMA SANTANA, L., MANSANO SARQUISB, L.M., D’ALMEIDA MIRAN- DA, M.F. in ANDRES FELLIC, V.E., 2016. Absenteeism due to mental disorders in health professionals at a hospital in southern Brazil. Revista gaúcha de enfermagem, letn. 37, št. 1, str. 1–8. MAO, F.Q., ZHANG, P., LI, J., WANG, X.M., ZOU, H., GAO, L., YANG, J.H in LI, J.T., 2006. A case-control study on the risk factors of chronic fatigue syndrome in doctors and nurses. Chinese journal of behavioral medical science, letn. 15, št. 4, str. 355–357. McVICAR, A., 2003. Workplace stress in nursing: a literature review. Journal of Advanced Nursing, letn. 44, št. 6, str. 633–642. MEALER, M.L., SHELTON, A., BERG, B., ROTHBAUM, B., in MOSS, M., 2007. Increased prevalence of post-traumatic stress disorder symptoms in critical care nurses. American journal of respiratory and critical care medicine, letn. 175, št. 7, str. 693–697. MURPHY, L.R., 1999. Organisational interventions to reduce stress in health care professionals. In: FRITH-COZENS, J. in PAYNE, R.L., eds. Stress in health professionals: Psychological and organisational causes and interventions. Chichester: John Wiley & Sons, pp. 149–162. PERRY, L., LAMONT, S., BRUNERO, S., GALLAGHER, R. in DUFFIELD, C., 2015. The mental health of nurses in acute teaching hospital settings: a cross-sectional survey. BMC Nursing, letn. 14, št. 15, str. 1–8. PETTERSON, I.-L., ARNETZ, B.B. in ARNETZ, J.E., 1995. Predictors of Job Satisfaction and Job Influence – Results from a National Sample of Swed- ish Nurses. Psychother Psychosom, letn. 64, št. 1, str. 9–19 . 80 QUINE, L., 1999. Workplace bullying in NHS community trust: staff question- n naire survey. BMJ, letn. 318, št. 7178, str. 228–232. ROBERTS, R.K. in GRUBB, P.L., 2014. The Consequences of Nursing Stress pulatioo and Need for Integrated Solutions. Rehabilitation Nursing, letn. 39, št. 2, ge p str. 62–69. ROELEN, C., van RHENEN, W., SCHAUFELI, W., van der KLINK, J., rking-ao MAGERØY, N., MOEN, B., BJORVATN, B. in PALLESEN, S., 2013. Men- he w tal and physical health-related functioning mediates between psycholog- f t ical job demands and sickness absence among nurses. The journal of ad- vanced nursing, letn. 70, št. 8, str. 1780–1792. ealth o| h ROELEN, C.A., van RHENEN, W., GROOTHOFF, J.W., van der KLINK, J.J., ITMANN, U.B. in HEYMANS, M.W., 2012. The development and valida- pulacije tion of two prediction models to identify employees at risk of high sick- o ness absence. European journal of public health, letn. 23, št. 1, str. 128–133. ktivne p ROELEN, C.A.M., HEYMANS, M.W., TWISK, J.W.R., van RHENEN, W., PALLESEN, S., BJORVATN, B., MOEN, B.E. in MAGERØY, N., 2015. Up- dating and prospective validation of a prognostic model for high sickness elovno a absence. International archives of occupational and environmental health, letn. 88, št. 1, str. 113–122. zdravje d SUZUKI, K., OHIDA, T., KANEITA, Y., YOKOYAMA, E. in UCHIYAMA, M., 2005. Daytime sleepiness, sleep habits and occupational accidents among hospital nurses. Journal of Advanced Nursing, letn. 52, št. 4, str. 445–453. VUČKOVIĆ, R., 2010. Obvladovanje zdravstvenega absentizma – izziv za družbo. V: KOS, D., ur. Zdravstveni absentizem v sloveniji. Zbornik prim- erov iz prakse 14 slovenskih podjetij. Ljubljana: Zavod za zdravstveno za-varovanje Slovenije, str. 10–20. WAAGE, S. in BJORVATN, B., 2017. Health, psychosocial and workplace characteristics may identify nurses and midwives at risk of high absenteeism. Evidence-based nursing, letn. 0, št. 0, str. 1–2. WILSON, G.B., 2001. Safer handling practice for nurses: a review of the literature. British Journal of Nursing, letn. 10, št. 2, str. 108–114. XIONG, X., LI, M., JIANG, Y., TONG, X. in PENG, Y., 2017. Study of blood ex- posure-related mental health illness among clinical nurses. Frontiers of Medicine, letn. 11, št. 1, str. 147–151. 81 ursing s in n ployee g em mons a blemro tal pen o m ue t ism d tee absen Quality of life of nurses Sandra Joković, Maja Račić, Jelena Pavlović, Natalija Hadživuković University of East Sarajevo, Faculty of Medicine Foca, Osmana Đikića bb, Foca, Bosnia and Herzegovina sandra.jokovic@hotmail.com; porodicnamedicina@gmail.com; pjelena551@gmail.com; natalijahadživukovic@yahoo.com Abstract Introduction: In modern medical practice, the concept of quality of life has recently gained a great significance and important role in problem analysis in a variety of clinical situations. The aim of this study has been to assess the level of perceived quality of life of nurses. Methodology: The study was designed as a cross-sectional study. The sample of the study consisted of nurses in primary and secondary health care. A sociodemographic questionnaire and questionnaire of health assessment (SF-36) were used for assessment of quality of life. Statistical analysis was done using the SPSSver. 20.0. Results: The highest percentage of respondents (67%) belong to the category of excellent physical functioning. Thirty percent belong to the group that has good physical functioning, whereas only 3% of the subjects have poor physical performance. Fifty-two percent of respondents have excellent social functioning, 47% have a good level of performance, while only two patients have a poor level of social functioning. Thirty percent of respondents have significant limitations due to emotional problems. Disscusion and conclusion: Sociodemographic characteristics significantly affect the quality of life of nurses Key words: quality of life, health, nurses In recent years there has been a great interest in exploring the psychosocial aspects of the work environment of health workers. The reasons for this are the poor financial status, insufficient physical security, working in night shifts, as well as poor working conditions with great physical and mental load (Assalavi et al., 2010; Milošević et al., 2011).Working in nursing job it constantly involves dealing with human needs, problems and suffering, constant inter- action with co-workers, clients and their families, as well as different organizational burden (Golubić and Mustajbegović, 2011). doi: https://doi.org/10.26493/978-961-7023-32-9.83-91 Numerous studies conducted in different countries of the world have shown that the prevalence of work-related stress among nurses is high (Chapman et al., 2010; Iliopoulou and While, 2010; Habazin, 2013). Out of the abo- ve mentioned pathological conditions most often singled out are emotional exhaustion, chronic fatigue, cardiovascular diseases, tumors, and pain in the lower part of the spine (Golubić and Mustajbegović, 2011; Milošević et al., 2011). The workplace and the type of work they do is also an important factor that affects the quality of life and job satisfaction of nurses. A prerequisite for security and satisfaction of a nurse in the workplace is certainly working envi- ronment which meets the expected safety standards, ensures the prevention of injuries and diseases that can occur during the working process, and the- refore ensures the presence of healthy nurses, unencumbered by working con- ditions (Spurgeon, et al., 1997; Jezuit, 2003). Nursing profession because of the patient care that takes place continuously for 24 hours, including work in rotating night shifts, has a significant impact on various aspects of their lives. The 84 system of rotating night shifts is often associated with sleep disorders that can n damage their physical health by increasing the rate of cardiovascular, gastro- intestinal and cancer. Also, working rotating night shifts can negatively affect pulatioo the mental functioning and reduce the concentration which increases the risk ge p of errors in work (Cimete et al., 2003; Lie et al., 2006; Shao, et al., 2010). Great emotional and physical efforts and insufficient rewards are topics that are high rking-a at the priority list of the nursing profession (Golubić and Mustajbegović, 2011). o Therefore, we can say that the quality of life of nurses is a complex entity being he wf t under the influence of and interacting with many aspects of their work envi- ronment and personal lives outside of them. The aim of this study was to assess ealth o the level of perceived quality of life of nurses, as well as to estimate the differen- | h ces in the quality of life of nurses depending on their the place of work (Assalavi et al., 2010; Golubić and Mustajbegović, 2011). pulacije o Methods ktivne p The study was designed as a cross-sectional study. The study involved 200 nur- ses working in primary and secondary health care. Criteria for inclusion in the elovno a study were: respondents who work at least one year and are directly involved in the care and treatment of patients. Criteria for exclusion from the study were: zdravje d respondents who work less than one year, nursing who are not involved in the care and treatment of patients and subjects who did not respond to five or mo- re questions or have circled the same answers to all the questions. The resear-ch was conducted at the University Hospital Foca, Health CenterZvornik and Health Center of East Sarajevo. The survey used: a sociodemographic question- naire, and a questionnaire to assess the health status (Short Form-36 Health Survey SF-36) (Ware et al., 1993; 2000). The socio-demographic questionnaire designed for this study and contains 14 questions relating to the characteristics of the respondents (gender, age, marital status, place of residence, family income, education level of respondents). SF-36 Health Survey is the most commonly used general questionnaire to assess quality of life of patients. The questionnaire is designed for self-assessment of mental and physical health, and social functioning. There are 36 que- stions, of which 35 questions grouped into eight areas: 1. PF-physical functioning − 10 items, 2. RP - role limitation due to emotional problems − 4items, 3. RE- rolls limitation due to emotional problems − 3 items, 4. SF- social functioning) − 2 items, 5. MH mental health − 5 items , 6. The vitality and energy − 4 items, 7. BP bodily pain − 2 items, 8. GH general health perception − 5 items. One question related to the change of health status in relation to the year preceding the survey, ie. whether the current health is better, the same or wor-85 se. For each of the eight domains of the total score ranges from 0 to 100 po- ses ints (percent), wherein 0 is a very low quality of life associated with that domain 100, and is a very positive response and a high level of quality of life. In our f nur study we used linguistic versions of validated questionnaires, translated into fe of li Serbian. Statistical analysis was performed using SPSS ver. 20.0. The chuare test ty o was applied. As the level of statistical significance of differences, p < 0.05, werw uali calculed by using the arithmetic mean and standard deviation. q Results The following tables (Table 1−4) are presenting the results of the research. Table 1: Distribution of respondents according to gender and age. Gender of Age of respondents n (%) respondents Total n (%) χ2 p 20−39 years 40−60 years Men 26 (13) 11 (5.5) 37 (18.5) Women 53 (26.5) 110 (55) 67 (67) 17,987 0,001 Total n (%) 79 (39.5) 121 (60.5) 100 (100) Table 2: Distribution of respondents according to socio-demographic characteristics. Respondents place of work Socio-demographic n (%) characteristics Possible answers Total n (%) χ2 p Primary care Secondary care Married 61 (30.5) 66 (33) 127 (63,5) Not married 17 (8.5) 19 (9,5) 36 (18) Marriage 1.737 0.629 Divorced 12 (6) 9 (4.5) 21 (10.5) Widow/Widower 10 (5) 6 (3) 16 (8) 86 Urban 32 (16) 12 (6) 44 (22) n Place of living 11.65 0.001 Rural 68 (34) 88 (44) 156 (78) pulatioo ge p Secondary school 83 (41.5) 87 (43.5) 170 (85) Educational back- 5.022 0.081 rking-a ground o College 17 (8.5) 13 (6.5) 30 (15) he wf t 1−10 years 30 (15) 37 (18.5) 67 (33.5) ealth o| h Work experience 11−25 years 17 (8.5) 19 (9.5) 36 (18) 11.678 0.432 pulacije o 26−40 years 53 (26.5) 44 (22) 97 (48,5) ktivne p Yes 51 (25.5) 77 (38.5) 128 (64) Working in shifts 14.670 0.023 elovno a No 49 (24.5) 23 (11.5) 72 (36) zdravje d Yes 70 (35) 80 (40) 150 (75) Educative lectures 2.667 0.102 No 30 (15) 20 (10) 50 (25) Table 3: The level of quality of life in the three subscales of the SF-36: physical functioning, the existence of bodily pain and vitality in nurses and technicians who work in primary and secondary health care. Respondents place of work Domains of the SF-36 question- The level of Total n (%) χ2 p naire quality of life Primary care, Secondary care, n (%) n (%) Bad (0−33%) 2 (1) 4 (2) 6 (3) Physical func- Good tioning 9.751 0.008 (33−66%) 40 (20) 20 (10) 60 (30) Excellent (66−100%) 58 (29) 76 (38) 134 (67) Intense (0−33%) 8 (4) 4 (2) 12(6) The existence of Moderate 3.567 0.168 87 physical pain (33−66%) 32 (16) 24 (12) 56 (28) Does not exist ses (66−100%) 60 (30) 72 (36) 132 (66) Bad f nur (0−33%) 2 (1) 8 (4) 10 (5) fe o Good f li Vitality 3.834 0.147 (33−66%) 80 (40) 74 (37) 154 (77) ty o Excellent uali (66−100%) 18 (9) 18 (9) 36 (18) q Table 4: The level of quality of life in the three subscales of the SF-36: social functioning, the existence of limitations due to emotional problems and mental health among nurses and technicians working in primary and secondary health care Domains of the Respondents place of work SF-36 question- The level of Total n (%) χ2 p naire quality of life Primary care, Secondary care, n (%) n (%) Bad (0−33%) / 2 (1) 2 (1) Social Good functioning 4.448 0.108 (33−66%) 42 (21) 52 (26) 94 (47) Excellent (66−100%) 58 (29) 46 (23) 104 (52) Intense (0−33%) 38 (19) 22 (11) 60 (30) The limitation due to emotional Moderate 11.590 0.003 problems (33−66%) 8 (4) 2 (1) 10 (5) Does not exist (66−100%) 54 (27) 76 (38) 130 (65) Domains of the Respondents place of work SF-36 question- The level of Total n (%) χ2 p naire quality of life Primary care, Secondary care, n (%) n (%) Bad (0−33%) / 4 (2) 4 (2) Mental health Good 8.138 0.017 (33−66%) 98 (49) 88 (44) 186 (93) Excellent (66−100%) 2 (1) 8 (4) 10 (5) Discussion In our research, out of nurses of both levels of health care, the best quality of health had the following domains: physical functioning, absence of bodily pain, social functioning, limitations due to physical health problems and lim- itations due to emotional problems. The lower level of quality of the health of 88 our patients is seen in median values of public health, mental health and vitality. n The largest percentage of our respondents, 67% belong to the category of pulatio excellent physical functioning, 30% have a good physical functioning, while on-o ge p ly 3% of respondents have a poor physical functioning. Among the respondents in relation to the place of work was observed statistically significant differen-rking-a ces in terms of physical functioning, with respondents who work in secondary o care showed better physical functioning. In contrast to our research, in a study he wf t conducted in Taiwan on a sample of 1534 nurses, the results showed that nurses who work in outpatient clinics have better physical functioning compared to ealth o nurses working in hospital wards and intensive care units (Shao et al, 2010). Si- | h milar results were obtained in studies in Turkey, where the nurses who worked in an outpatient clinics have a better quality of life in relation to nursing wor-pulacije o king in a surgical departments and operating rooms (Cimete et al, 2003). The limitations due to emotional problems are present in 30% of our respondents, ktivne p moderate limitations has 5% of respondents, while in slightly more than half of the respondents limitations due to emotional problems do not exist. In rela-elovno a tion to the place of work statistically significant difference was observed, with limitations due to emotional problems more common among respondents who work in primary health care. Experiencing positive emotions at work is consi- zdravje d dered an important part of nursing professional life, and has a significant impact on patient safety, quality of services renered, commitment, retention and fluctuation. Many studies alsoconfirmed this fact and point out that experiencing positive emotions at work linked with better health, a higher degree of job satisfaction, responsible behavior at work, higher work performance and quality of work, greater resistance to stress and burnout, rarely change jobs, better relations with other persons, the preferred behavior and thinking, and lower incidence of divorce (Chapman et al., 2010; Golubić and Mustajbegović, 2011; Habazin, 2013). High proportion of respondents assessed their mental health as good.Excellent mental health has 4% of secondary and 1% of primary health care, and poor mental health has 2% of the respondents belonging to secondary health care, while in the primary with poor mental health was not. Next results longitudinal study of 11 countries showed that in all countries there is a significant degree of psychological exhaustion of nursing personnel, in particular in Poland, Slovakia and Germany where they registered the highest scores adverse effects (Cowin, 2002). As regards the existence of pain and vitality of our respondents, it was found that almost two-thirds of our respondents, there is no pain in everyday life, in 28% of the pain there and he is moderate, and 6% of the pain is very strong. Our subjects have the highest percentage of vitality, 18% of the subjects is excellent vitality when in the smallest percentage of the sample is poor viability, wherein between the two groups of subjects in relation to the place of work, no significant difference in terms of the existence of pain, and in terms of vitality. Similar results were obtained in a study conducted by Hassel-89 horm et al.(2005) with the nurses in Germany. The disease is undoubtedly one of the external factors that negatively affect the quality of life of the individual. ses It can be said that the impact of disease on quality of life is multidimensional. f nur The disease not only in terms of affecting the physical symptoms, and thus hin-fe o ders the functioning, but there are present and indirect effects such as a change f li in working ability, the decline in the quality of medical care, the potential isolaty o tion, the increase depending on the other, bad habits,etc. (Knežević et al., 2009; ualiq Buljbašić, 2011). Respondents on both levels of health care have the highest percentage of good and excellent social functioning, while only two patients from secondary care have poor levels of social functioning. Studies dealing with the study of the quality of life highlight the importance of social contacts, and there is a large drop in the quality of life in patients where there is social isolation. Certain contribution to the clarification of the impact of social interaction on the quality of life given by Israeli researchers, who have studied only that component of health and its impact on quality of life (William et al., 1996). Conclusions Respondents expressed the best quality of health in physical functioning, ab- sence of bodily pain and social functioning. The lower level of quality of health of our respondents was noticed in the fields of public health, mental health and vitality. Nurses from primary health care, when compared with their col- leagues from secondary care, assessed their mental health better. On the other hand, nurses from secondary health care expressed better quality of health in physical functioning and limitations due to emotional problems. References ASSALAVI, R.K., APERECIDA, B.D., and GONCALVES, S.B.A., 2010. Evalu- ation of quality of life and depression in nursing technicians and nursing assistants. Rev. Latino-Am Enfermagem, vol. 18, iss. 3, pp. 413−420. BULJAŠIĆ A., 2011. Zastupljenost i utjecaj mobinga na radne aktivnosti medicinskih sestara. HČJZ. CHAPMAN, R., STILES, I., PERRY, L., and COMBS, S,. 2010. Examining the characteristics of workplace in one non-tertiary hospital. J Clin Nurs. vol.19, pp. 479−488. CIMETE, G., GENCALP, N.S., and KESKIN, G.,2003. Quality of life and job satisfaction of nurses. J Nurs Care Qual, vol.18, pp. 151−158. COVWIN, L., 2002. The effects of nurses job satisfaction on retention: an Aus- tralian perspective. J Nurs Admin,vol.32, iss.5, pp. 283−91. HABAZIN, I., 2013. Povezanost emocionalnih s ponašajnim i fiziološkim odgovoroma na posao medicinskih sestara i tehničara u bolničkim us- lovima. Hrvatska revizija za rehabilitaciona istraživanja, vol. 49, iss.1, pp. 37−48. 90 HASSELHORM, H.M., MULLER, B.H., TACKENBERG, P., and BUESCHER n A., 2005. Psychological and physical health among nurses in Europe. NEXT scientific report.University of Wuppertal and University of Wit- pulatioo ten, Germany, pp. 35−37 ge p ILIOPOULOU, K.K., and WHILE, A.E., 2010. Professional autonomy and job satisfaction: survey of critical care nurses in mainland Greece. J Adv rking-ao Nurs,vol.66, pp. 2520−2531. he w JEZUIT, D., 2003. Personalization as it relates to nursesuffering: how managers f t can recognize the phenomenon and assist suffering nurses. Jonas Healthc ealth o Law Ethics Regul, vol.5, pp. 25−28. | h KNEZEVIĆ, B., GOLUBIĆ, R., MILOŠEVIĆ, M., MATEC, L., and MUSTA- JBEGOVIĆ, J., 2009. Zdravstveni djelatnici u bolnicama i stres na radu, pulacije o vol. 51, pp. 85−91. LIE, J.A., ROESSINK J., and KJAERHEIM, K., 2006. Breast cancer and night ktivne p work among Norwegian nurses. Cancer Causes Control,vol. 17, iss.1, pp. 39−44. elovno a MILOŠEVIĆ, M., GOLUBIĆ, R., KNEZEVIĆ, B., GOLUBIĆ, K., BUBAS, M., and MUSTAJBEGOVIĆ, J.,2011. Work ability as a major determinant of zdravje d clin nurs quality of life. J Clin Nurs, vol. 20, pp. 2931−2938. SHAO, M.F., CHOU, Y.C., YEH, M.Y., and TZENG, W.C.,2010. Sleep quality and quality of life in female shift- working nurses. J Adv Nurs, vol. 66, pp. 1565−1572. SPURGEON A., HARRINGTON J.M., and COOPER C.L., 1997. Health and- safety problems associated with long working hours:a review of the cur- rent position. Occupational Environmental Medicine, vol. 54, pp. 367−375. WARE J.E., SNOW K.K., KOSINSKI M., and GENDEK B., 1993. SF-36 Health Survey: Manual and Interpretation Guide. Boston: The Health Institute, New England Medical Center. WARE J.E., SNOW K.K., KOSINSKI M., and GENDEK B., 2000. SF-36 Health Survey: Manual and Interpretation Guide. Lincoln, RI: QualityMetric In-corporatd. WILLIAM, J.S., COHEN, R.D., SHEMA, J.S., and KAPLAN, G.A., 1996. Suc- cessful Ageing: Predicators and Associated Activities. American Journal of Epidemiology. pp. 135−141. 91 ses f nur fe of li ty o ualiq Experience of sexual intercourse in the first year after childbirth: women’s views and attitudes Anita Jug Došler, Ana Polona Mivšek, Petra Petročnik, Teja Škodič Zakšek, Mateja Kusterle Jenko University of Ljubljana, Faculty of Health Sciences, Midwifery Department, Zdravstvena pot 5, 1000 Ljubljana, Slovenia anita.jug@zf.uni-lj.si; polona.mivsek@zf.uni-lj.si; petra.petrocnik@zf.uni-lj.si; teja.zaksek@zf.uni-lj.si; mateja.kusterle.jenko@gmail.com Abstract Introduction: Sexuality after childbirth depends on several factors that may affect a woman at the same time. The aim of the study was to research Slovenian women’s experience of sexual intercourse in the first year after childbirth. Methods: A descriptive and causal – nonexperimental method of empirical research has been used with a scientific literature review. A convenience sample of 3106 women was used and the data was gathered through an online questionnaire tool. The results were analysed with the use of SPSS ver. 20.0 statistical program. Results: Sixty-two percent of couples started with their sexual intercourse 6 to 8 weeks after childbirth. Sixty-two percent of participants reported their satisfaction with sexual intercourse was the same as in the period before childbirth. Thirty-six percent of women reported lower satisfaction with the sexual intercourse after birth. More than half of the women (57 %) had sexual intercourse less frequently after birth. Thirty-five percent of women reported they would like to have sexual intercourse more frequently. The most commonly reported problem after birth was dyspareunia. Discussion and conclusions: The results of the survey suggest some clear recommendations in terms of optimising the couples’ sex life in the period after childbirth and in the first year of the child’s life. Health care professionals have to be knowledgeable to share professional advice in the period after childbirth. Key words: pregnancy, sexuality, sexual intercourse, changes, partnership Sexuality after childbirth depends on several factors that may affect a woman at the same time. In addition to the state of her reproductive organs and stimulation of her genitalia, it involves her desire and motivation for sex- ual intercourse, her general health and quality of life, the relationship with her partner, and emotional readiness to regain sexual intimacy with her partner. doi: https://doi.org/10.26493/978-961-7023-32-9.93-101 It also depends on successful attainment of the maternal role, on the ability to balance the maternal identity with the sexual identity and on the socio-cultural background, sexual habits of the couple before pregnancy and their emo- tional state (Barrett et al., 2000; Rezaee and Kinsberg, 2012; Trutnovsky, 2006) Safe and satisfactory sex life is a basic human right (WHO, 2005). The childbearing period is a very vulnerable time in the sex life of a woman or a couple. Generally, sexual activity and intimacy significantly decrease during pregnancy, which can last up to several months after childbirth (Lee and Yen, 2007; Rezaee and Kinsberg, 2012; Boyd et al., 2013). Sexuality after childbirth includes much more than just a physical act of stimulating the genitalia. Hormonal changes during pregnancy affect the physical wellbeing and the mood of a pregnant woman and therefore the sex life of a couple (Trutnovsky et al., 2006). Avery et al. (2000) concluded that the desire for sexual intercourse between partners decreases after childbirth. Many couples begin with sexual in- tercourse in the first three weeks after childbirth, mostly on the male initia-94 tive, although doctors recommend sexual intercourse as late as after 6 weeks n postpartum. Hormones related to breastfeeding may cause greater dryness of the vagina and consequently lower libido (Barrett et al., 2000). Dyspareunia pulatioo and perineal pain account for common sensations accompanying women af- ge p ter childbirth and generally reduce the frequency of sexual intercourse be- tween partners. Previous studies (Pacey, 2004; Barrett et al., 2000) write about rking-ao a decrease in sexual activity during pregnancy; it being almost non-existent in the immediate postpartum period and then steadily increasing throughout the he wf t first year after childbirth when its frequency is approximately the same as in the time before pregnancy. In many respects, sexual function changes the most ealth o after childbirth (Pacey, 2004). Trutnovsky et al. (2006) in their research noted | h down the following factors that contribute to low sexual activity: sleep deprivation, stress, exhaustion, overload with the newborn care, dyspareunia and pulacije o breastfeeding. During the postpartum period, sexual health problems in wom- en are common. Many experience lower libido and decreased vaginal lubrica- ktivne p tion and frequently have shorter and weaker orgasms. Rathfisch et al. (2010) conducted a study that included healthy pregnant women with low level of risk elovno a that expected to have a vaginal delivery after 38 weeks gestation. Out of 165 women invited to a postnatal check-up 3 months after childbirth, 55 attend- ed. There was a careful gynaecological examination and examination of the zdravje d perineum, performed always by the same gynaecologist, followed by a 20-min- ute interview with each woman individually. The aim of the researchers was to compare sex lives of those women before and after childbirth. The findings re- vealed that women who experienced any perineal trauma, namely episiotomy or rupture, had lower libido, orgasm and sexual satisfaction and experienced more pain during sexual intercourse. Presence of at least one sexual problem (lower libido, decreased sexual arousal, decreased vaginal lubrication, reduced frequency of orgasm, dissatisfaction with sex life and dyspareunia) was statistically significantly more common after childbirth (Rathfisch et al., 2010). The aim and objective of the conducted research was to study Slovenian women’s experience of sexual intercourse in the first year after childbirth. We posed 4 research questions, namely: (1) When did women initiate sexual intercourse after childbirth?, (2) are women equally satisfied with sexual intercourse before and after childbirth?, (3) how often do women have sexual intercourse after childbirth?, (4) do they and if they do, which problems do women most fre- quently encounter during sexual intercourse after childbirth?. Methods The research was based on the quantitative research paradigm, within which a descriptive and causal – nonexperimental method of empirical research was used. It was designed as an online questionnaire tool. Data was gath- ered through a questionnaire preliminarily tested on a pilot sample of ten re- spondents in order to verify comprehensibility of the questions asked. The survey was conducted from January 2013 to September 2015. Apart from de- 95 mographical data, the questionnaire included basic questions in order to study Slovenian women’s experience of sexual intercourse in the first year af- ter childbirth. ttitudes To determine validity (% of variance explained by the first factor) and re- nd as a liability (% of variance explained by common factors) of the measurement in- iew strument, we used the results of factor analysis which showed that our research en’s v instrument is within acceptable limits of validity (first factor explained 23.2% mo variance) and reliability (results of factor analysis revealed 3 factors that explain 60.9% variance). A convenience sample of 3126 women who regionally cover all parts hildbirth: w of Slovenia was used. Altogether, 3106 valid questionnaires were returned, fter c which represents a responsiveness rate of 99.4%. The largest group of wom- en (68%) was between 25 to 35 years old. The majority of women in the sam- ear a ple (58%) achieved a university degree of education. The majority of women irst y gave birth vaginally, namely 82%, the remaining 18% delivered by a caesare- he f an section. n t The ethical aspects of the implementation of the research were provided urse i based on A statement of voluntary participation and protection of personal da-nterco ta. Participation in the survey was voluntary and anonymous. The survey execution was approved by The Department of Midwifery, Faculty of Health Sci- exual i ences in Ljubljana. Data processing was carried out at the level of descriptive f s statistics with calculations of frequencies, percentages and arithmetic mean. The data were processed using the statistical program SPSS 20.0. In order to determine statistically significant differences, we used Chi-square (χ2) test. experience o Where the conditions for χ2- test were not fulfilled, Kullback test was imple- mented. The differences were confirmed as statistically significant at a value of p = 0.05. Results In continuation, the results of the survey are presented in the same order as the preliminary research questions. With the first research question, we wanted to find out when the women started having sexual intercourse for the first time after childbirth (Table 1). We learnt that the majority of the women, 62.9%, started having sexual intercourse 6 weeks to 2 months after the child was born. The mode of delivery (vaginal delivery, caesarean section) did not reveal any statistically significant differences (χ2 = 21.028; g = 1; p = 0.577) Table 1: Initiation of sexual intercourse for women after childbirth. When did you initiate sexual intercourse after childbirth? f, f (%) 1 to 3 weeks after childbirth 3 (0.1) 3 to 6 weeks after childbirth 313 (10) 6 weeks to 2 months after childbirth 1966 (62.9) 96 2 to 6 months after childbirth 656 (21) 6 months to 1 year after childbirth 188 (6) n after 1 year after childbirth or later / Total 3126 (100) pulatioo ge p Note: f: frequency; f (%): percentage With the second research question, we wished to learn if women are rking-ao equally satisfied with sexual intercourse before and after childbirth (Table 2). he w 62% participants reported their satisfaction with sexual intercourse was the f t same as in the period before childbirth. There were 36% of the women who re- ealth o ported lower satisfaction and 2% of the participants who could not assess. None | h of the participants declared to be more satisfied with sexual intercourse after childbirth compared with sexual intercourse before childbirth. Also for this re-pulacije o search question, the mode of delivery did not reveal statistically significant differences (χ2 = 20.927; g = 1; p = 0.713). ktivne p Table 2: Satisfaction of women with sexual intercourse after childbirth elovno a How satisfied are you with sexual intercourse after childbirth? f, f (%) I am more satisfied with sexual intercourse after childbirth than I was before zdravje d childbirth / I am equally satisfied with sexual intercourse after and before childbirth 1938 (62) I am less satisfied with sexual intercourse after childbirth than I was before childbirth 1125 (36) I cannot assess 63 (2) Total 3126 (100) Note: f: frequency; f (%): percentage In addition, we inquired about the frequency of sexual intercourse after childbirth (Table 3). More than a half of the women (57%) have sexual intercourse less frequently after birth. Sexual intercourse is more frequent in 8% of the women. A great percentage of the women (35%) could not give their assessment but would like to have sexual intercourse more frequently. The mode of delivery (vaginal delivery, caesarean section) did not reveal any statistically significant differences (χ2 = 21.966; g = 1; p = 0.875). Table 3: Frequency of sexual intercourse after childbirth How often do you have sexual intercourse after childbirth? f, f (%) After birth, I have more frequent sexual intercourse than before childbirth 250 (8) After birth, I have less frequent sexual intercourse than before childbirth 1782 (57) I cannot assess but I would like to have more frequent sexual intercourse 1094 (35) I cannot assess but I would like to have less frequent sexual intercourse / Total 3126 (100 %) 97 Note: f: frequency; f (%): percentage ttitudes As part of the last research question, we were interested whether women encounter any problems during sexual intercourse after childbirth; and if they nd as a do, which are the most frequent problems. Women report that the most com- iew mon problem accompanying sexual intercourse after birth is dyspareunia (Ta- en’s v ble 4). It represents 32.2% of all answers. The mode of delivery did not reveal mo statistically significant differences (χ2 = 21.103; g = 1; p = 0.943). Table 4: Problems women frequently encounter during sexual intercourse hildbirth: w after childbirth fter c Which of the problems/obstacles did you encounter most frequently during sexual ear a intercourse after childbirth? f, f (%) I perceived changes in my vagina (strange bodily sensations, changed lubrica- irst y tion, etc.) 156 (5) he f Dyspareunia (I feel pain during sexual intercourse) 1007 (32.2) n t Since childbirth, I have been constantly thinking of our baby even during sexu-urse i al intercourse 534 (17.1) Shortage of time 616 (19.7) nterco I had difficulties accepting my changed body after childbirth 438 (14) Our relationship with my partner changed so much after childbirth that it influ-exual i enced our sexual activity 94 (3) f s I did not have any problems/obstacles 281 (9) Other / Total 3126 (100) experience o Note: f: frequency; f (%): percentage Discussion Changes in the period after childbirth can significantly affect the relationship between partners because sexuality plays an important role in their shared life. A childbirth may thoroughly change communication and sex life of a couple and therefore it is very important how partners accept their parent roles and at the same time remain sexual partners to each other. Based on the literature review and our survey we realised that about a third of the women (32.2%) suffer from dyspareunia after childbirth, and the risk is even higher in the presence of former dyspareunia and labour interventions (Buhling et al., 2006; Klein et al., 2009). Woolhouse et al. (2014) discovered that psychological factors also influence the frequency of sexual intercourse and women’s satisfaction with it. Caring for a child can cause stress to a woman. Like others, our research similar-ly confirmed that poor self-image of women after birth can cause lower libido. Namely, quite a percentage of the women (14%) who answered our question- naire had difficulties accepting their changed body after childbirth and some 98 could not stop thinking of their baby during sexual intercourse (17%). n A common challenge that couples face in the postpartum period is a lack of open discussion about sex between partners and a shortage of infor- pulatioo mation available from health care professionals about the spectrum of factors ge p that may influence couple’s sexual function immediately or soon after child- birth. In our research, as much as 35% of the women want to experience sexu- rking-ao al intercourse more often; nevertheless, it is encouraging that as much as 57% he w are satisfied with the frequency of sexual intercourse. Taking into consider- f t ation that as much as 36% of the women report being less satisfied with sex after childbirth, we can assume that the background reasons could be insuffi- ealth o| h cient taking of sexual history and discomfort of women or couples to openly discuss sexuality and the troubles they encounter. Slovenian women rarely at- pulacije tend sex therapy due to the consequences of childbirth on their sex life (Škodič o Zakšek, 2015). Moreover, sexologists are almost non-existent in Slovenia. If we assume this to be a standard part of midwifery treatment, midwives need addi-ktivne p tional knowledge and skills. Only in the past few years, the existing midwife- ry educational system has included emphasis on education about discussion elovno a and treatment of sexuality (Mivšek, 2015). Already during pregnancy women and their partners experience sexuality in different ways which may in turn af-zdravje d fect the first sexual intercourse after childbirth and sex after childbirth in general (Makara-Studzińska et al, 2015). The latter can also affect the child and his or her sexual development (Jug Došler, 2015). In addition, Lee and Yen (2007) call attention to the fact that health care professionals should play a more active role and more openly discuss sexual activity and (lack of) sexual pleasure with both partners during the first postpartum check-up with the gynaecologist. They came to the conclusion that individualised approach is the most ap- propriate form of sex education in the postpartum period. We would like to point out that in Slovenia there is no adequate program for the screening of sex-related problems that could improve the sex life of couples during very vulner- able periods such as pregnancy and postpartum. Gynaecological clinics present a great potential for the introduction of new changes but due to overload of work they often cannot offer sufficient psychosocial help, information and advice to couples about their sex life. Based on the literature review and the survey results, we can summa- rize that the obtained findings bear great importance and that future research on the subject matter is vital because Slovenia lacks empirical research in this field. Research of sexuality opens a new window into the structure, functioning and relationship between partners after childbirth. Therefore, understand- ing of this process is crucial for tackling various problems or for an honest conversation between the couple and health care professionals. Conclusions The survey results represent a starting point for finding solutions in the field of improvement and satisfaction with sex life after childbirth, also in terms 99 of receiving appropriate professional advice, information and assistance from health care professionals. Optimal sexual health is comprised of various phys- ical and psychological factors and calls for an open dialogue that encourages ttitudes women to discuss such sensitive issues openly. Female sexual dysfunction may nd as a be triggered by numerous factors of the endocrine system as well as many psy- iew chosomatic factors accompanied by anatomic changes during pregnancy and en’s v after childbirth, which in turn may also be influenced by mode of delivery. Al-mo most 25% of the women after childbirth report experiencing sexual dysfunc- tions such as low libido, dyspareunia, anorgasmia and difficulty with lubrica- tion. Most of them are related to lactation and/or are side effects of postpartum hildbirth: w depression treatments. They also depend on the amount of rest and the amount of time and space for intimacy. fter c As appears evident from the survey, childbirth and challenges of the ear a postpartum period influence the sex life of couples. In the postpartum peri- irst y od, women should receive enough information from health care professionals he f to live through it more easily. It is a responsibility of health care professionals n t to discuss it with women. Despite an abundance of literature on sexuality, it is urse i limited to longitudinal methodological approaches and validation of standard- ized tools for situation assessments. Alongside, it would be essential to establish nterco quality normative data on female and male sexual function in the postpartum exual i period. We also need more research that would assess male sexual function f s and the role of the partner after childbirth. References experience o AVERY, M.D., DUCKETT, L., FRANTZICH, C.R., 2000. The experience of sexuality during breastfeeding Among primiparous women. Journal of midwifery and women‘s health, vol. 45, no. 3, pp. 228–237. BARRETT, G., PENDRY, E., PEACOCK, J., VICTOR, C., THAKAR, R., MAN-YONDA, I. 2000. Women’s sexual health after childbirth. BJOG, vol. 107, no. 2, pp. 186–195. BOYD, K., CHENEY, B., DAVIS, A., PLUMBO, M., SUNYECZ, J., THOM- AS, M.A., 2013. Postpartum counseling: A quick reference guide for cli- nicians. Association of reproductive health professionals, [Datum dostopa 6. 5. 2017]. Dostopno na: http://www.arhp.org/uploadDocs/QRGpostpar- tum.pdf. BUHLING, K. J., SCHMIDT, S., ROBINSON, J. N., KLAPP, C., SIEBERT, G., DUDENHAUSEN, J. W., 2006. Rate of dyspareu- nia after delivery in primiparae according to mode of delivery. European journal of obstetrics, gynecology, and reproductive biology, vol. 124, no. 1, pp. 42–46. 0 JUG DOŠLER, A. (2015). Raising children for a healthy sexual relationship in 10 adulthood. In: Mivšek, A.P., ed. Sexology in midwifery. Rijeka: Intech. n KLEIN, K., WORDA, C., LEIPOLD, H., GRUBER, C., HUSSLEIN, P., WEN- ZL, R., 2009. Does the Mode of Delivery Influence Sexual Function after pulatio Childbirth. Journal of Womenś health, vol. 18, no. 8, pp. 1227–1231. o ge p LEE, J.T. & YEN, H.W., 2007. Randomized controlled evaluation of a theory-based postpartum sexual health education programme. Journal of Ad- rking-ao vanced Nursing, vol. 60, no. 4, pp. 389–401. he w MAKARA-STUDZIŃSKA, M., PLEWIK, I., KRYŚ, K. M., 2015. Sexual activity f t of women in different trimesters of pregnancy. European Journal of Medi- cal Technologies, vol. 2, no. 7, pp. 1–9. ealth o| h MIVŠEK, A.P., 2015. Do midwives need sexology in their undergraduate study? In: Mivšek, A.P., ed. Sexology in midwifery. Rijeka: Intech. [viewed 8 Ju- pulacije ly 2017]. Available from: https://cdn.intechopen.com/pdfs-wm/47988.pdf o PACEY, S., 2004. Couples and the first baby: responding to new parents’ sex- ktivne p ual and relationship problems. Sexual and Relationship Therapy, vol. 19, no. 3, pp. 223–246. elovno a TRUTNOVSKY, G., HAAS, J., LANG, U., PETRU, E., 2006. Women’s percep- tion of sexuality during pregnancy and after birth. Journal of obstetrics and gynaecology, vol. 46, no. 4, pp. 282–287. zdravje d RATHFISCH, G., DIKENCIK, B. ET AL. (2010). Effects of perineal trauma on postpartum sexual function. Journal of advanced nursing, vol. 66, no. 12, pp. 2640−2649. REZAEE, R. & KINSBERG, S., 2012. How to prepare your patient for the ma- ny nuances of postpartum sexuality. OBG Management, vol. 24, no. 1, pp. 24–38. SERATI, M., SALVATORE, S., SIESTO, G., CATTONI, E., ZANIRATO, M., KHULLAR, V., ET AL., 2010. Female Sexual Function during Pregnan- cy and after Childbirth. The Journal of Sexual Medicine, vol. 7, no. 8, pp. 278–290. ŠKODIČ ZAKŠEK, T. 2015. Sexual Activity during Pregnancy in Childbirth and after Childbirth. In: Mivšek, A.P., ed. Sexology in midwifery. Rijeka: Intech. [viewed 8 July 2017]. Available from: https://cdn.intechopen.com/ pdfs-wm/48023.pdf 110 ttitudes nd as a iew en’s vmo hildbirth: w fter c ear a irst y he f n t urse i nterco exual if s experience o Prevalence of silent myocardial ischemia in working-age patients with type 2 diabetes mellitus Alexander Kiško1, Marika Vereb2, Radoslav Dobránsky3, Marian Babčák1, Lubica Derňarová1, Jan Kmec1, Jozef Leško4, František Neméth1, Maria Marcinková5, Zuzana Farkašová1 1 University in Prešov, Faculty of Health Care; Cardiology Clinic, ProCare Prešov, Prešov, Jurkovičova 19. 08001 Prešov, Slovak Republic. 2 Institute of Nuclear Medicine, Klinikum Kassel, Klinikum Kassel. D-34125 Kassel, Germany. 3 Diabetic & Metabolic Disorders Clinic, ProCare Prešov, Jurkovičova 19. 08001 Prešov, Slovak Republic. 4 VIVAMED ltd, Nuclear Medicine, Hol ého 14. 08181 Prešov, Slovak Republic. 5 Cardiology Clinic, ProCare Prešov, Jurkovičova 19. 08001 Prešov, Slovak Republic. alexander.kisko@unipo.sk; mudr.marika.vereb.@gmail.com; dobranskyrado@gmail.com; babcak@fnsppresov.sk; lubica.dernarova@unipo.sk; kmecj@fnsppresov.sk; lesko@vivamed.sk; frantisek.nemeth@unipo.sk; marcinkova8@gmail.com; zuzana.farkasova@unipo.sk Abstract Introduction: Data confirm a relatively high prevalence of silent myocardial ischemia (SMI) in elderly patients with type 2 diabetes mellitus (T2DM), while no data are available regarding working-age subjects (≤60 years). Methods: Medical records of 192 patients with T2DM aged ≤60 years (110 male patients; 57.3%), who had undergone myocardial perfusion imaging (MPI) between 2010 and 2014 followed by coronary angiography in case of abnormal result, were retrospectively analysed. Results: MPI was positive in 35 patients (18.2%); of those 31 (88.6%) had angiographically confirmed coronary stenosis. The positive predictive value of the MPI for predicting angiographic coronary stenosis in this age subgroup was 88.9%. Univariate analysis revealed post-stress LVEF drop ≥5% (p<0.03) and NT-proBNP levels detected in stress (p<0.05) to be associated with greater risk of ischemia in working- age T2DM patients. In multivariate analysis, LVEF drop ≥5% (p< 0.03) remained an independent predictor of SMI. Conclusion: Prevalence of SMI in diabetic working-age patients was similar to that observed in studies of subjects over 65 years-old. Post- stress LVEF drop ≥5% and NT-proBNP levels can contribute to more precise identification of SMI. Our data suggest that “aggressive” management strategy should be implemented to reduce the risk of cardiac events in T2DM patients of working-age. Keywords: scintigraphy, silent myocardial ischemia, diabetes mellitus doi: https://doi.org/10.26493/978-961-7023-32-9.103-111 Myocardial ischemia is often asymptomatic in patients with type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD) is fre- quently in an advanced stage when it becomes clinically manifested. Silent myocardial ischemia (SMI) is defined as objective evidence of myocardi- al ischemia in the absence of typical chest discomfort or other anginal equiv- alents. It is a common, under-recognized marker of a significant underlying CAD associated with future cardiovascular events and poor prognosis. SMI is an important public health issue, and its early detection may prevent many ep- isodes of sudden cardiac death annually (Cosson et al., 2005; Le Feuvre et al., 2011; Vasiliadis et al., 2014). Diabetic patients have a higher prevalence of SMI and recognised myocardial infarction than patients without diabetes (Mac-Donald et al., 2014). There are some data about the prevalence of SMI in T2DM patients in elderly at high risk for cardiovascular disease (Inoguchi et al., 2000; Faglia et al., 2002; Lima et al., 2004; Mohagheghie et al., 2011; Rawshani et al., 4 2017). However, data about the prevalence of SMI in working-age subgroup of 10 the diabetic population remain limited. n Stress single-photon emission computed tomography (SPECT) is a vali- dated imaging tool providing information on the physiological significance of pulatioo flow-limitation and is also a cost-effective for risk assessment of the major ad-ge p verse cardiac events in the general and diabetic populations. SPECT could ac- curately assess both myocardial perfusion and ventricular function in diabetic rking-ao patients, providing important information for their management and is help- he w ful in these situations (De Keyzer et al., 2011). Moreover, left ventricular (LV) f t function analysis in SPECT can enhances its prognostic and diagnostic ability, particularly in the prediction of SMI (Sharir et al., 1999). We sought to evaluate ealth o the prevalence of SMI detected by SPECT myocardial perfusion imaging (MPI) | h in association with some less recognised diagnostic predictors of it in T2DM asymptomatic patients of working-age. pulacije o Methods ktivne p We retrospectively analysed medical records of 192 (110 male pts; 57.3%) chronologically consecutive asymptomatic working-age (≤60 years) patients with elovno a T2DM, who had undergone MPI subsequently followed by coronary angiog- raphy in case perfusion abnormalities were found. MPI was performed from zdravje d 2010 to 2014 at a single outpatient care centre with nuclear medicine unit, according to the EANM procedural guidelines for stress-rest ECG gated SPECT one-day protocol using 99mTc-tetrofosmin (Verberne et al., 2015). Perfusion images were judged blindly by two specialists independently using the 17-seg- ment ASNC model, and SMI was diagnosed consensually as myocardial per- fusion abnormalities without associated symptoms. Stress (cycle ergometry) and rest myocardial perfusion abnormalities were described as reversible (is- chemia), fixed (scar), or mixed (scar and ischemia). The summed stress score (SSS) and summed rest score (SRS) were obtained, with the summed difference score (SDS) being the difference between the two. A mild ischemic defect was defined as showing the presence of a SDS ≥ 2. A moderate perfusion defect was defined as a SDS ≥ 2 in > 1 segment, and severe perfusion defect was defined as a SDS ≥ 3 in > 1 segment in stress images. Calculation of left ventricular ejection fraction (LVEF) and ventricular volumes was performed by using quantitative software for endocardial and epicardial boundaries automatically tracing. Patients with abnormal MPI were referred for coronary angiography. Angio- graphic images were assessed blindly to the MPI data and significant stenosis was defined as ≥50% for LAD, and ≥75% for other coronary arteries. LV dysfunction was defined as post-stress LVEF drop ≥5% and/or tran- sient ischemic dilatation of LV in stress against rest. The levels of NT-proBNP were measured at rest and within 3 minutes in the early recovery stage of exercise testing. All participants gave written informed consent before enrolment in the study, which was conducted in accord with the principles of the Declaration of Helsinki. All patients were carefully assessed for classic coronary risk factors: 105 age, sex, obesity, smoking, essential hypertension, dyslipidaemia, a family history of CAD, duration of diabetes, diabetic complications (Table 1). atients ge p Table 1: Clinical and laboratory characteristics of the subjects included in the study. rking-ao Clinical and laboratory characteristics Diabetic patients (n=192) n w Age (years) 52.3 ± 6.7 ia i Male (n/%) 110/57.3 schem Obesity (n/%) 151/78.6 Smoking (n/%) 3/1.56 cardial i Hypertension (n/%) 107/55.7 yo Dyslipidaemia (n/%) 140/72.9 Family history of CAD (n/%) 28/14.6 ilent m Duration of diabetes (years) 5.0 ± 3.2 f s Retinopathy (n/%) 20/10.4 Nephropathy (n/%) 13/6.8 Neuropathy (n/%) 7/3.6 prevalence o Glucose (mmol/l) 7.8 ± 2.6 HbA1c (%) 7.2 ±1.3 High-sensitivity CRP (mg/l) 2.2 ±2.3 Total-C (mmol/l) 6.2 ± 3.5 HDL-C (mmol/l) 0.96 ± 0.4 LDL-C (mmol/l) 4.2 ± 1.8 Triglycerides (mmol/l) 3.9 ± 2.4 Note: Data are expressed as the mean ± SD, number and percentage. Continuous variables were expressed as mean values ± standard devia- tion, and frequencies as the number and percentage of patients. Between-group comparisons were made by means of non-parametric Mann–Whitney U test. Bivariate associations were tested using t test and Fisher’s exact test. To identify the factors independently related with SMI univariate and multivariate analysis was performed. P values of <0.05 were considered statistically significant. Statistical analyses were carried out using IBM SPSS Statistics V.19 software. Results MPI results showed that 157 (81,8%) patients had normal myocardial perfusion, while 35 (18.2%) patients showed perfusion defects on MPI (Table 2). In 33(17.2%) cases it was defined as reversible and in 2(1.0%) as mixed. Table 2: MPI results. Result MPI (n=192) 6 Negative (n/%) 157/81.8 10 Positive (n/%) 35/18.2 n Note: Data are expressed as number and percentage. pulatioo ge p 12 (33.4%) out of the 33 reversible perfusion defects were described as mild, 14 (42.4%) – moderate, and 7 (22.2%) – severe. rking-ao 31 (88.6%) patients out of the 35 with abnormal MPI findings represent- ed an abnormal coronary angiography. In 15(48.4%) out of the 31 patients it was he wf t defined as 1 vessel disease, in 10 (32.3%) – 2 vessels disease and in 6 (19.3%) – 3 vessels disease. 9 (29.0%) patients with positive angiographic results represent-ealth o ed diffuse disease and vessel occlusion was detected in 2 (6.5%). Coronary anat- | h omy did not allow any revascularisation procedure in 13 (41.9%) of the patients with abnormal coronary angiography. pulacije o These results emphasize the incremental diagnostic value of MPI for eval- uation of SMI in this specific subgroup of the diabetic population. MPI have ktivne p showed a very good degree of specificity of the test (97.6%) with a positive predictive value of 88.9% for predicting angiographic coronary stenosis (Table3). elovno a Table 3: Evaluation of MPI in predicting angiographic coronary stenosis. zdravje d Statistic Value 95% CI Sensitivity (%) 69.5 61.5–82.6 Specificity (%) 97.6 79.9–99.3 PPV (%) 88.9 73.6–95.6 NPV (%) 50.6 48.9–52.3 Note: PPV: positive predictive value; NPV: negative predictive value; CI: confidence intervals We observed that retinopathy (OR 2.32; 95%-CI: 1.05–5.13; p>0.05), nephropathy (OR 2.12; 95%-CI: 1.0–6.13; p>0.5), and neuropathy (OR 1.70; 95%- CI, 1.07–2.71; p>0.05) were not associated with abnormal MPI. Post-stress LVEF drop ≥5% was observed in 32 (91.4%) patients out of the 35 with abnormal MPI findings. In 29(82.9%) cases it was associated with post- stress transient ischemic dilatation of LV. Patients with LVEF drop ≥5% had higher SDS (p<0.01), but no significant difference in rest LV values (p >0.05) compared to patients without perfusion defects. There was no significant difference between mean rest NT-proBNP lev- el in MPI-negative against MPI-positive subgroups (182±80ng/l vs. 198±60ng/l, p>0.5), but patients with SMI had a significantly higher mean post-stress NT-proBNP level (889±92ng/l vs. 226±80ng/l; p<0.05). Univariate analysis revealed post-stress LVEF drop ≥5% (p<0.03) and NT-proBNP level detected in early recovery stage of stress testing (p<0.05) to 7 be associated with greater risk of ischemia in working-age T2DM pts. In multi- 10 variate analysis, LVEF drop ≥5% (p<0.03) remained to be an independent pre- dictor of SMI. atients ge p Discussion T2DM is a chronic metabolic disease, which results not only in significant di- rking-ao rect medical costs but also in indirect productivity losses due to disability and n w early mortality in working age population. Almost 75% of diabetic decedents ia i without clinical CAD have high-grade coronary atherosclerosis. Autopsy stud- schem ies have identified a high prevalence of coronary atherosclerosis in patients with diabetes, even among those without clinical CAD (Goraya et al., 2002). cardial i The prevalence of SMI in the diabetic population is very variable in the differ-yo ent studies, ranging from 12% to almost 57%, and it is 3 to 6 fold higher than in ilent m asymptomatic non-diabetic population (Inoguchi et al., 2000; Wackers et al., f s 2004; Freeman, 2006; Le Feuvre et al., 2011). Several mechanisms are integrat- ed in the SMI genesis. Endothelial dysfunction secondary to T2DM may play a role, leading to an inappropriate coronary flow response to increasing myocar- prevalence o dial metabolic needs (coronary vascular tone abnormality). It is also due to an increased pain feeling threshold in diabetic patients, probably secondary to an elevated beta-endorphins rate. These two abnormalities are associated with an impaired autonomic nervous system. The patients enrolled in the study were truly asymptomatic, working-age subjects with T2DM, free from known CAD. There were not typical clinical signs of angina at the time of referring patients for MPI. The patients were referred mostly from the clinics for diabetes and metabolic disorders or internal diseases. They were on contemporary medical treatment and were under rea-sonable metabolic control. Yet, 35 patients (18.2%) had evidence of SMI, including 21 with moderate-to-severe reversible perfusion abnormalities and 30 with stress-induced ST-segment changes. The prevalence of perfusion abnormalities in our study was somewhat lower than the 22% observed in the DIAD study (Wackers et al., 2004) but a bit greater than 15,7% obtained in an earlier study from France (Janand-Delenne et al., 1999). However, the lower prevalence reported in this earlier study likely reflects differences in patients selection. Subjects were of younger age, with T1DM and T2DM and perfusion abnormalities were assessed visually with somewhat less sensitive technique. Moreover, im- agings were performed only if the initial exercise ECG stress test was abnormal or equivocal. Thus, patients who would have had perfusion abnormalities were likely missed. On the other hand, it should be noted that the prevalence of perfusion abnormalities in DIAD study is considerably higher than that reported in our study, reflecting the results of adenosine perfusion imaging in a slightly older sample of patients (50-75years). In a recent study of silent CAD detection in a cohort of 102 asymptomat- ic T2DM subjects (57±7years), attending 5 Italian outpatient clinics, a signifi-8 cant higher prevalence of silent CAD was observed in subjects with abnormal 10 vs. normal ECG (23 vs. 4%; P=0.004), but not in subjects with high vs. low pre-n test silent CAD risk (14 vs. 9%; p=0.472). An abnormal ECG was defined to be a strong, independent predictor of silent CAD (OR 8.9; CI 1.27-62.5; p=0.028) in pulatioo T2DM (Vigili de Kreutzenberg et al., 2017). ge p Our second goal was to identify predictors of MPI abnormalities. Demo- graphics, traditional cardiac risk factors, diabetes complications, and biomark-rking-ao ers were analysed. Overall predictors of SMI in working-age cohort of T2DM he w patients were post-stress LVEF drop ≥5% and NT-proBNP levels detected in f t stress. In univariate analysis, only post-stress LVEF drop ≥5% was the factor associated with moderate-to-large perfusion defects abnormalities that raise ealth o| h substantial clinical concern. In working-age patients with diabetes, post-stress LVEF drop showed to be an independent predictor of stress-induced ischemia pulacije and increases the risk of subsequent cardiac events in T2DM patients. However, o a fall in LVEF is detectable also in patients with normal myocardial perfusion. These findings suggest that a post-stress LVEF drop may be related to a spe- ktivne p cific diabetic cardiomyopathy in the absence of myocardial perfusion abnor- malities. Diabetic complications such as retinopathy, nephropathy and neu- elovno a ropathy showed not to be significantly associated with either test abnormality or marked perfusion defects. In addition, traditional cardiac risk factors (male zdravje d gender, hypertension, smoking and family history, or dyslipidaemia), previous- ly reported as risk factors for CAD and poor outcome (De Keyzer et al., 2011) were not associated with SMI in working-age T2DM patients. Conclusions Prevalence of T2DM in working-age population is high and still rising in Eu- rope. Both diabetes and pre-diabetic states are risk factors for CAD. Their emergence starts many years before clinical events appear, developing silently, in parallel with the progression from pre-diabetic status to T2DM (Alegria-Bar-rero, 2014). Our study suggests that 18.2% of asymptomatic working-age pa- tients with T2DM have SMI. More importantly, 13.7% of them have markedly abnormal (moderate-to-severe) myocardial perfusion abnormalities. This jus-tifies screening for SMI by non-invasive and cost-effective technique such as SPECT MPI in subpopulation of T2DM patients of the working-age. LV func- tion testing may have an important role in the SMI risk assessment because of the association shown in the present study between LVEF drop ≥5%, NT-proB- NP levels detected in stress and perfusion defects occurring. The presented da-ta address only the prevalence, severity, and possible predictors of SMI at the time of enrolment into the study and suggest that advanced intervention procedures including “aggressive” drug management should be implemented to reduce the risk of cardiac events in forthcoming future. Follow-up evaluation should allow to define the relationship between abnormal perfusion imaging and the prevalence of cardiac events in asymptomatic T2DM patients of work- ing-age and to evaluate the effectiveness of “aggressive” preventive strategies. 910 Acknowledgment This study was supported in part by a grant from KEGA (Cultural and Edu- atients cational Granting Agency) 066PU-4/2016, Ministry of Education, Science, Re- ge p search and Sports of the SR. The research was designed, conducted, analysed, and interpreted by the authors entirely independently of the funding source. rking-ao n w References ia i ALEGRIA-BARRERO, A., 2014. New insights regarding management of di- schem abetes. An article from the E-journal of the ESC Council for Cardiolo- gy Practice, vol. 12, no. 11. Available from: https://www.escardio.org/ cardial i Journals/E-Journal-of-Cardiology-Practice/Volume-12/New-insights-re- yo garding-management-of-diabetes ilent m COSSON, E., ATTALI, J.R. and VALENSI, P., 2005. Markers for silent myo- f s cardial ischemia in diabetes. Are they helpful? Diabetes Metab. , vol. 31, no. 2, pp.205-213. DE KEYZER, E., KERKHOVE, D., VAN CAMP, G., DE SUTTER, J., ACH- prevalence o TERGAEL, W., KEYMEULEN, B. and WEYTJENS, C., 2011. Screening for silent myocardial ischaemia in patients with type 2 diabetes mellitus: a quest to improve selection of the target screening population. Acta Car- diol., vol. 66, no. 6, pp. 715-720. FAGLIA, E., FAVALES, F., CALIA, P., PALEARI, F., SEGALINI, G., GAMBA, P.L., ROCCA, A., MUSACCHIO, N., MASTROPASQUA, A., TESTORI, G., et al., 2002. Milan Study on Atherosclerosis and Diabetes (Mi SAD). Cardiac events in 735 type 2 diabetic patients who underwent screening for unknown asymptomatic coronary heart disease: 5-year follow-up re- port from the Milan Study on Atherosclerosis and Diabetes (MiSAD). Di- abetes Care, vol. 25, no. 11, pp. 2032-2036. FREEMAN, M., 2006. Myocardial perfusion imaging in diabetes mellitus. Can J Cardiol., vol.22, suppl. A, pp. 22-25. GORAYA, T.Y., LEIBSON, C.L., PALUMBO, P.J., WESTON, S.A., KILLIAN, J.M., PFEIFER, E.A., JACOBSEN, S.J., FRYE, R.L. and ROGER, V.L., 2002. Coronary atherosclerosis in diabetes mellitus: a population-based autopsy study. J Am Coll Cardiol., vol. 40, no. 5, pp. 946-953. JANAND-DELENNE, B., SAVIN, B., HABIB, G., BORY, M., VAGUE, P. and LASSMANN-VAGUE, V., 1999. Silent myocardial ischemia in patients with diabetes: who to screen. Diabetes Care, vol. 22, no. 9, pp. 1396-1400. INOGUCHI, T., YAMASHITA, T., UMEDA, F., MIHARA, H., NAKAGAKI, O., TAKADA, K., KAWANO, T., MURAO, H., DOI, T. and NAWATA, H., 2000. High incidence of silent myocardial ischemia in elderly patients with non insulin-dependent diabetes mellitus. Diabetes Res Clin Pract., vol. 47, no. 1, pp. 37-44. 110 LE FEUVRE, C., JACQUEMINET, S. and BARTHELEMY O., 2011. Myocar- n dial ischemia: a silent epidemic in Type 2 diabetes patients. Future Cardi-ol., vol. 7, no. 2, pp. 183-190. pulatioo LIMA, R.S., DE LORENZO, A., PANTOJA, M.R. and SIQUEIRA, A., 2004. ge p Incremental Prognostic value of myocardial perfusion 99m-techne- tium-sestamibi SPECT in the elderly. Int J Cardiol., vol. 93, no. 2-3, pp. rking-ao 137-143. he w MACDONALD, M.R., PETRIE, M.C., HOME, P.D., KOMAJDA, M., JONES, f t N.P., BECK-NIELSEN, H., GOMIS, R., HANEFELD, M., POCOCK, S.J., CURTIS, P.S., et al., 2011. Incidence and prevalence of unrecognized my- ealth o| h ocardial infarction in people with diabetes: a substudy of the Rosiglita- zone Evaluated for Cardiac Outcomes and Regulation of Glycemia in Di- pulacije abetes (RECORD) study. Diabetes Care, vol.34, no. 6, pp. 1394-1396. o MOHAGHEGHIE, A., AHMADABADI, M.N., HEDAYAT, D.K., POURBE- ktivne p HI, M.R. and ASSADI, M., 2011. Myocardial perfusion imaging using technetium-99m sestamibi in asymptomatic diabetic patients. Nuklear- medicine, vol. 50, no. 1, pp. 3-8. elovno a RAWSHANI, A., FRANZÉN, S., ELIASSON, B., SVENSSON, A.M., MIFTA- RAJ, M., McGUIRE, D.K., SATTAR, N., ROSENGREN, A. and GUDB- zdravje d JÖRNSDOTTIR, S., 2017. Mortality and Cardiovascular Disease in Type 1 and Type 2 Diabetes. N Engl J Med. , vol. 13, no. 15, pp. 1407-1418. SHARIR, T., GERMANO, G., KAVANAGH, P.B., LAI, S., COHEN, I., LEW- IN, H.C., FRIEDMAN, J.D., ZELLWEGER, M.J. and BERMAN, D.S., 1999. Incremental prognostic value of post-stress left ventricular ejection fraction and volume by gated myocardial perfusion single photon emis- sion computed tomography. Circulation, vol. 100, no. 10, pp. 1035-1042. VASILIADIS, I., KOLOVOU, G., MAVROGENI, S., NAIR, D.R. and MIKHA-ILIDIS, D.P., 2014. Sudden cardiac death and diabetes mellitus. J Diabetes Complications, vol. 28, no. 4, pp. 573-579. VERBERNE, H.J., ACAMPA, W., ANAGNOSTOPOULOS, C., BALLINGER, J., BENGEL, F., DE BONDT, P., BUECHEL, R.R., CUOCOLO, A., VAN ECK-SMIT, B.L., FLOTATS, A., et al., 2015. European Association of Nu- clear Medicine (EANM). EANM procedural guidelines for radionuclide myocardial perfusion imaging with SPECT and SPECT/CT: 2015 revi- sion. Eur J Nucl Med Mol Imaging, vol. 42, no. 12, pp. 1929-1940. VIGILI DE KREUTZENBERG, S.,SOLINI, A., VITOLO, E., BOI, A., BAC- CI, S., COCOZZA, S., NAPPO, R., RIVELLESE, A., AVOGARO, A. and BARONI, M.G., 2017. Silent coronary heart disease in patients with type 2 diabetes: application of a screening approach in a follow-up study. J Diabetes Complications, vol. 32, no. 17, pp. 30111-30113. WACKERS, F.J., YOUNG L.H., INZUCCHI, S.E., CHYUN, D.A., DAVEY, 111 J.A., BARRETT, E.J., TAILLEFER, R., WITTLIN, S.D., HELLER, G.V., FILIPCHUK, N., et al., 2004. Detection of Ischemia in Asymptomat- atients ic Diabetics Investigators. Detection of silent myocardial ischemia in ge p asymptomatic diabetic subjects: the DIAD study. Diabetes Care, vol. 27, no. 8, pp. 1954-1961. rking-ao n wia i schem cardial iyo ilent mf s prevalence o Ensuring equality through the acquisition of cultural competencies in nursing education: A systematic literature review Sabina Ličen, Igor Karnjuš, Mirko Prosen University of Primorska, Faculty of Health Sciences, Department of Nursing, Polje 42, 6310 Izola, Slovenia sabina.licen@fvz.upr.si; igor.karnjus@fvz.upr.si; mirko.prosen@fvz.upr.si Abstract Introduction: The number of migrants continues to increase. Appropriate education methods towards the acquisition of cultural competencies of nurses are one of the ways of promoting ethical efficient healthcare systems and services. The research is based on a purposeful literature review where through the discourse of interculturalism available evidence, describing the teaching/learning strategies regarding cross- cultural care and the acquisition of cultural competencies among nursing students, is evaluated. Methods: A systematic literature review following PRISMA guidelines. Results: Four studies that met the criteria has been found which explains the teaching/learning strategies for acquisition of cultural competencies through four different models: Papadopoulos, Tilki and Taylor model for developing cultural competence, Campinha-Bacote‘s model, Leininger‘s Sunrise Model, and 3-dimensional puzzle model of culturally congruent care. Discussion: Although cultural competencies in nursing have long been recognized as essential part of clinical practice, future research should explore additional teaching/learning methods and incorporate evidence based practice and problem-based learning strategies into nursing curriculums to develop cultural competence in nursing. Key words: cross-cultural competencies, transcultural nursing, women’s health, education In 2014, it was estimated that in the European Union immigrated approxi- mately 1.9 million people from non-member countries (Statistics Explained, 2017). However, it is noticeable that over time researchers from nursing and healthcare devoted their attention mainly to the male migrants. Nowadays more attention and research interest is focused on female migrants; although, most of the research highlights the migration process as gender oriented pro- doi: https://doi.org/10.26493/978-961-7023-32-9.113-121 cess and not as much from the nursing or healthcare oriented perspective (Ro-sulnik, 2015). Other research findings suggest that women from culturally diverse background are faced with poor health outcomes, mainly due to in- accessible health services, language and cultural barriers, and finally, institu-tional racism, which is often the result of ignorance of healthcare professionals (Szczepura, 2005). The statistics data is clear that migrant population in the European Un- ion is increasing, which suggests that education in transcultural nursing to allow nurses to provide culturally competent care, is needed. Due to fast-chang- ing multicultural society culturally appropriate nursing will soon be, if it is not already, increasingly important to Slovene nurses too. To prepare nursing students to be effective practitioners in this multicultural society, nursing ed-ucators must design cross-cultural curricula by introducing the transcultur- al nursing curricula in women’s health. One of main goals of such education is to gain cultural competences. The latter is defined as a set of skills that allows 114 individuals to increase their understanding of cultural differences and simi- n larities within, among, and between cultural groups (Mareno and Hart, 2014; Núñez, 2000). Nursing education programmes should provide a foundation of pulatioo such knowledge and prepare graduates to meet the demands of this changing ge p multicultural society (Gebru et al., 2008). However, to define cultural competence, we must first define culture. rking-ao Culture can be defined as the learned and shared knowledge and symbols that he w specific groups use to interpret their experience of reality and to guide their f t thinking and behaviour (Prosen, 2015). The major focus of transcultural nurs- ing is to focus on the humanistic and scientific study of individuals from dif-ealth o| h ferent cultures with consideration to ways in which nurses can assist those individuals meet their health and living needs (Reyes et al., 2013). Thus, cultural pulacije competence can be defined as continual process of striving to become increas- o ingly self-aware, to value diversity, and to become knowledgeable about cultur-al strengths (Bonecutter and Gleeson, 1997). ktivne p Considering the changing demographics in European Union at this pe- riod it is imperative that nurses appreciate the impact of culture on health. elovno a For that reason, the research is based on a purposeful literature review where through the discourse of interculturalism available evidence, describing the zdravje d teaching/learning strategies regarding cross-cultural care and the acquisition of cultural competencies among nursing students, is evaluated. In accordance with the aims and objectives of the research, the following research question was set: What models can we use, from an international perspective, for teach- ing/learning cultural competence related to women’s health? Methods Search strategy A review of the literature was conducted in April 2017 to identify available evidence, describing the teaching/learning strategies in nursing education in order to obtain cultural competencies among nursing students. The search was conducted by using online bibliographic databases such are PubMed, Ci- nahl, and ScienceDirect. For search terms a combination of Medical Subject Headings (MeSH): ‘ transcultural nursing’, ‘ culturally competent care’, ‘ cultural competency’, ‘ cultural diversity’, and ‘ education, nursing’; phrases: Transcultural nursing, Cultural Care, Cultural Competence, Cultural Diversity, Nursing Education; and free text or keywords: Nursing, Transcultural, Culturally Competent, Cultural Care, Culturally Congruent, Cross-Cultural Care, Culturally Competent Health Care, Competency, Cultura l, Cultural Competencies, Cultural Competence, Competence, Cultural Diversities, Multiculturalism*, Cultural Pluralism, Nursing Education, Educations, Nursing, Nursing Educations 115 were identified. n: Study selection ducatio ursing e n n petencies imo ultural cf c n o uisitiocq he a ugh t hro uality tq ensuring e Figure 1: PRISMA search process (Moher et al., 2009) A search was undertaken in each database and to support the relevance to the research purposes, literature published between 2006 and 2017 was extracted. A sample of 3240 papers was obtained. The titles and abstracts were screened by three authors, duplicates were removed and the inclusion criteria (English language, full text availability, and primary study in peer-reviewed journal) were applied. After removal of duplicates, 299 articles were left, of which another 224 were subsequently excluded because of inadequacy in terms of the inclusion criteria based on the purposes of this research. Four studies that met the criteria were finally included in the qualitative analysis. The search process, which used the Preferred Reporting Items for Sys- tematic Reviews and Meta-analyses (PRISMA) (Moher et al., 2009), is outlined in Figure 1. Data extraction 116 Data extraction included author, year, country where the research was con- n ducted, study aim, study design, and study conclusion (Table 1). pulatioo Results ge p The final analysis (Table 1) included 4 studies; one mixed methods two quanti- tative and one narrative article (Figure 1). rking-ao he w Table 1: Study characteristics of included studies. f t Author, year, country Aims Design Findings ealth o To present the cultur- The findings indicat- | h al competence level of Quantitative: pre- and ed that this training in- (Kouta et al., 2016) community nurses be- post-test (n = 92 com- tervention seemed to be pulacije Cyprus fore and after a cultural munity nurses) effective as it increased o competence workshop as nurses’ cultural compe- an intervention. tence levels. ktivne p The evaluation indicat- To determine the effects ed that learning modules of the course on the five Mixed methods: Evaluation forms – (n = focusing on experiential elovno a (Bauer and Bai, 2015) constructs of the Camp- learning activities to ad- United States of America inha-Bacote Model as 34 nursing students) dress constructs of the well as perceived cultur- (The Campinha-Bacote Campinha-Bacote Mod- al competence. Model). el can help develop levels zdravje d of cultural competence. Quantitative: pre- and The results of this re- To assessed the effective- post-test (n = 305 nurs- search indicated that ness of three teaching ing students) compari- case study, tradition- (Lenny and Peng, 2014) methods for develop- sons of all participants al didactic teaching and China ing cultural competency in four areas of cultural self-directed learning all based upon Leininger’s knowledge (Evaluation significantly improved theoretical framework. of Transcultural Nursing the students’ knowledge Competency - ETNC) of transcultural nursing. Author, year, country Aims Design Findings The model describes cul- To describe an emerging tural diversity, cultur- model of culturally-con- Narrative article with al awareness, cultural (Schim and Doorenbos, gruent care and dis- a description of a sensitivity, and cultur- 2010) cuss ways in which it can Three-dimensional al competence variables United States of America guide intervention for Model of Cultural Con- for providers and several nurses, and other health gruence central domains of cul- care workers. tural similarity and dif- ference at the client level. In line with the inclusion criteria for this study, all papers examined one or more of the following: Evidence of Culture and Cultural Competen- cies (Knowledge, Abilities, Sensitivity and Keenness to do it correctly; Becoming aware and conscious), Evaluation of the transcultural nursing competen- cy (Cultural awareness, Compassion, Cultural skills, Cultural competence in practice), and teaching/learning strategies. A broad range of research ap- proaches were used including: (i) quantitative: descriptive evaluation, pre-post 117 survey, longitudinal design, (ii) mixed methods, and (iii) narrative research de-n: sign. Regarding the aims of the research, the following teaching/learning strat- ducatio egies used in selected literature are: ursing e - Papadopoulos, Tilki and Taylor model for developing cultural com- n n petence (PTT model): The model refers to the nurse’s student capac- ity to provide effective health care that takes into consideration the petencies im patient’s cultural beliefs, behaviours and needs in the nursing pro- o cess. The model includes four components of cultural competence: 1) cultural awareness, 2) cultural knowledge, 3) cultural sensitivi- ultural c ty and 4) cultural practice. Further, the PTT model emphasized the f c need for nurses to have both culture specific and culture-generic n o competence (Kouta et al., 2016). uisitio - The process of cultural competence in the delivery of healthcare cq services (Campinha-Bacote’s Model): Campinha-Bacote’s model, he a the process of cultural competence in the delivery of healthcare ser- ugh t vices, includes five constructs: cultural awareness, knowledge, skill, hro encounters, and desire. Campinha-Bacote defined cultural aware- ness as an intentional cognitive process in which providers appre- uality t ciate and gain sensitivity to the values, beliefs, and practices of di- q verse cultures; cultural knowledge as an educational foundation of various world views which includes biocultural ecology and ethnic ensuring e pharmacology; cultural skill as the ability to collect cultural infor- mation regarding health and performing a culturally specific phys- ical assessment; cultural encounters as the way in which healthcare providers directly engage in cross-cultural encounters; and finally, cultural desire as the motivation to want to engage in the process of cultural competence (Bauer and Bai, 2015). - The theory of care diversity and universality (Leininger’s Sunrise Model): The sunrise model, which depicts the theory of cultur- al care diversity and universality, illustrates the concepts, showing culturally congruent care, cultural care maintenance, nursing ac- tions, folk systems, professional healthcare systems, clients, holistic well-being, and numerous cultural factors are all interconnected. In short, nurses who value and practice culturally congruent care can effect positive healthcare changes for clients of various cultures (Lenny and Peng, 2014). - 3-dimensional puzzle model of culturally congruent care: The mod- el is currently described as a 3-dimensional model in which cultur- ally congruent care is the result of nurses and clients working to- gether with cultural respect and humility. This current 3-D model includes two levels: a provider level in which the cultural competen- cies a provider must have to participate in culturally congruent care 118 continue to be represented by the puzzle model developed in 2004, n and a client level. The provider level of the puzzle has 4 components: (i) cultural diversity, (ii) cultural awareness, (iii) cultural sensitivity, pulatioo and (iv) cultural competence behaviours. This level of the model has ge p been more fully articulated elsewhere and has been used as the ba- sis for a Cultural Competence Assessment tool for use with diverse rking-a healthcare providers and professional students (Schim and Dooren- o bos, 2010). he wf t Discussion ealth o| h The studies included in this review focused on teaching/learning strategies regarding cross-cultural care and the acquisition of cultural competencies pulacije among nursing students as well as on the outcomes of improvement of stu- o dents’ knowledge of transcultural nursing. After intervention 25 % of commu- nity nurses who participated in the workshop improved their cultural compe- ktivne p tence level based on the Culturally Competent Tool of the PTT Model (Kouta et al., 2016). While the study did not use qualitative data as a measure of effec-elovno a tiveness, such data, especially regarding nurses’ evaluation of the program and the course work, can further enhance and improve a program and should be zdravje d considered (Kouta et al., 2016). Students in the next study (Bauer and Bai, 2015) significantly improved (p < 0.001) each aspect of the cultural competency model after completion of the course. The total competence score improved from ‘culturally aware’ (score of 68.7 at pre-) to ‘culturally competent’ (score of 78.7 at post-) (The total scale ranges from 25 to 100. A score of 25 to 50 indicates cultural incompetence, a score of 51 to 74 reflects cultural awareness, and a score of 75 to 90 specifies cultural competence, and a score of 91 to 100 designates cultural proficiency). The findings of this study indicated that learning modules focusing on experiential learning activities and designed to address constructs of the Campinha-Bacote Model can help develop levels of cultural competence (Bauer and Bai, 2015). The results of the third study (Lenny and Peng, 2014) revealed that the differences between the pre- and post-test scores were significant for each of the three teaching methods (p < 0.001). The case study method elicited the highest post- test total scores followed by traditional didactic teaching and self-directed learning. Additionally, the case study method resulted in the greatest improvement between the pre- and post-test scores among the three methods, which suggests that the case study method was the most ef- fective instructional approach (Lenny and Peng, 2014). Last study involved in this research (Schim and Doorenbos, 2010) describes cultural diversity, cultur-al awareness, cultural sensitivity, and cultural competence variables for pro- viders and several central domains of cultural similarity and difference at the client level. The model addresses the presence and influence of systemic and organizational elements that create barriers to culturally-congruent care. De- rived from this model, a systematic way to consider interventions is suggested. Overall, the results are consistent with other literature, which common- 119 ly reports high levels of transcultural competences acquisition with the use of similar education approaches (Gallagher and Polanin, 2015; Gebru and Will-n: man, 2003; Loftin et al., 2013; Papadopoulos et al., 2016; Shattell et al., 2013). In this regard, a variety of models describing cultural competence’s multiple di-ducatio mensions it has become a focus of attention over the past several decades (Loftin et al., 2013). Teaching and learning strategies about culturally competent ursing e n n practice in nursing educations are essential to ensure a culturally competent health care workforce (Shattell et al., 2013). In studies of cultural competence education in nursing, findings support that the addition of culturally compe-petencies im tent content increases on culturally competence measures, as students gain ex- o perience during their education (Allen, 2010; Lampley et al., 2008; Majumdar et al., 2004). After the identification of necessary awareness issues, knowledge, ultural c and skills, obtained cultural competences among nursing students should be f c n o assessed thus, the appropriate instruments to measure the obtained compe- tences are required (Ličen and Plazar, 2015). uisitiocq he a Conclusions ugh t Cultural diversity is an issue that faces all healthcare workers today. Globali-hro zation requires that nursing education focuses on culturally competent care. Nurses should be informed about the diverse needs of different patients in or- uality t der to understand and contribute to their satisfaction. Future research should q explore additional teaching/learning methods and incorporate evidence based practice and problem-based learning strategies into nursing curriculums to de- ensuring e velop cultural competence in nursing. References ALLEN, J., 2010. Improving cross-cultural care and antiracism in nursing edu- cation: a literature review. Nurse Education Today, vol. 30, no. 4, pp. 314– 320. BAUER, K. and BAI, Y., 2015. Innovative Educational Activities Using a Mod- el to Improve Cultural Competency among Graduate Students. Procedia - Social and Behavioral Sciences, vol. 174, pp. 705–710. BONECUTTER, F. and GLEESON, J., 1997. Broadening Our View. Journal of Multicultural Social Work, vol. 5, no. 1–2, pp. 99–119. GALLAGHER, R.W. and POLANIN, J.R., 2015. A meta-analysis of educatio- nal interventions designed to enhance cultural competence in professi- onal nurses and nursing students. Nurse Education Today, vol. 35, no. 2, pp. 333–340. 0 GEBRU, K., KHALAF, A. and WILLMAN, A., 2008. Outcome analysis of a re- 12 search-based didactic model for education to promote culturally compe- n tent nursing care in Sweden - a questionnaire study. Scandinavian Jour- nal of Caring Sciences, vol. 22, no. 3, pp. 348–356. pulatioo GEBRU, K. and WILLMAN, A., 2003. A research-based didactic model for ed- ge p ucation to promote culturally competent nursing care in Sweden. Journal of Transcultural Nursing: Official Journal of the Transcultural Nursing Sorking-ao ciety, vol. 14, no. 1, pp. 55–61. he w KOUTA, C., VASILIOU, M. and RAFTOPOULOS, V., 2016. Improving the f t Cultural Competence Level of Community Nurses through an Interven- tion. Journal of Family Medicine, vol. 3, no. 9, pp. id1088. ealth o| h LAMPLEY, T.M., LITTLE, K.E., BECK-LITTLE, R. and XU, Y., 2008. Cultural Competence of North Carolina Nurses: A Journey From Novice to Ex- pulacije o pert. Home Health Care Management & Practice, vol. 20, no. 6, pp. 454– 461. ktivne p LENNY, C.-H. and PENG, Y.-Q., 2014. Efficacies of different methods of te- aching transcultural nursing practice in China. Chinese Nursing Resear- elovno a ch, vol. 1, pp. 17–24. LIČEN, S. and PLAZAR, N., 2015. Identification of nursing competency asses- zdravje d sment tools as possibility of their use in nursing education in Slovenia - A systematic literature review. Nurse Education Today, vol. 35, no. 4, pp. 602–608. LOFTIN, C., HARTIN, V., BRANSON, M. and REYES, H., 2013. Measures of Cultural Competence in Nurses: An Integrative Review. The Scientific World Journal, vol. 2013, pp. e289101. MAJUMDAR, B., BROWNE, G., ROBERTS, J. and CARPIO, B., 2004. Effects of cultural sensitivity training on health care provider attitudes and pa- tient outcomes. Journal of Nursing Scholarship: An Official Publication of Sigma Theta Tau International Honor Society of Nursing, vol. 36, no. 2, pp. 161–166. MARENO, N. and HART, P.L., 2014. Cultural Competency Among Nurses with Undergraduate and Graduate Degrees: Implications for Nursing Education. Nursing Education Perspectives, vol. 35, no. 2, pp. 83–88. MOHER, D., LIBERATI, A., TETZLAFF, J., ALTMAN, D.G. and PRISMA GROUP, 2009. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS medicine, vol. 6, no. 7, pp. e1000097. NÚÑEZ, A.E., 2000. Transforming cultural competence into cross-cultural ef- ficacy in women’s health education. Academic Medicine: Journal of the Association of American Medical Colleges, vol. 75, no. 11, pp. 1071–1080. PAPADOPOULOS, I., SHEA, S., TAYLOR, G., PEZZELLA, A. and FOLEY, L., 2016. Developing tools to promote culturally competent compassion, 1 courage, and intercultural communication in healthcare. Journal of Com- 12 passionate Health Care, vol. 3, pp. 1-10. n: PROSEN, M., 2015. Introducing Transcultural Nursing Education: Implemen- tation of Transcultural Nursing in the Postgraduate Nursing Curricu- ducatio lum. Procedia - Social and Behavioral Sciences, vol. 174, pp. 149–155. ursing e REYES, H., HADLEY, L. and DAVENPORT, D., 2013. A comparative analysis n n of cultural competence in beginning and graduating nursing students. International Scholarly Research Network nursing, vol. 2013, pp. 929764. petencies i ROSULNIK, K.K., 2015. Ženske in migracije. Andragoška spoznanja, vol. 21, no. mo 3, pp. 23–37. SCHIM, S.M. and DOORENBOS, A.Z., 2010. A Three-dimensional Model of ultural c Cultural Congruence: Framework for Intervention. Journal of social work f c in end-of-life & palliative care, vol. 6, no. 3–4, pp. 256–270. n o SHATTELL, M.M., NEMITZ, E.A., CROSSON, N., ZACKERU, A.R., STARR, uisitio S., HU, J. and GONZALES, C., 2013. Culturally competent practice in cq a pre-licensure baccalaureate nursing program in the United States: a he a mixed-methods study. Nursing Education Perspectives, vol. 34, no. 6, pp. ugh t 383–389. hro Statistics Explained, 2017 [online]. Statistika migracij in migrantskega preb- ivalstva. [viewed 5 May 2017]. Available from: http://ec.europa.eu/eu- uality tq rostat/statistics-explained/index.php/Main_Page. SZCZEPURA, A., 2005. Access to health care for ethnic minority populations. Postgraduate Medical Journal, vol. 81, no. 953, pp. 141–147. ensuring e Physical activity, physical fitness and prevention: Role for the working population Herbert Löllgen1, Petra Zupet2, Norbert Bachl3 1 Practice for Sports and Cardiology, University of Mainz, Bermesgasse 32 b, D-42897 Remscheid 2 IMS Institute for Medicine and Sports, Cesta na poljane 24, 1000 Ljubljana, Slovenia 3 Em. Director of the Austrian, Center for Sports sciences and Director of the Dept. Sports and Exercise Physiology, Auf der Schmelz 6, 1150 Wien herbert.loellgen@gmx.de Abstract Introduction: Physical inactivity and increasing daily screen time is an emerging health problem within the working population as well in the general population worldwide. This is called the exercise deficiency syndrom (EDS).On the other hand a large number of single studies as well of meta-analysis strongly support the positive health effects of regular physical activity. Discussion: Regular physical activity (PA) is now widely accepted as one of the most important factors to maintain or improve health and to prevent numerous non-communicable diseases. PA reduces risks of all-cause- and cardiovascular morbidity, mortality. Therefore, PA is a cornerstone in prevention and therapy of many diseases thus improving quality of life and longevity. PA also counteracts the effects of sitting time and sedentary lifestyle (EDS). PA acts like a drug: there are many indications, a non-linear dose- response curve, many somatic and psychosomatic effects, few side effects and contraindications. Similar results can be observed for physical fitness assessed by maximal watt or Vo2 max in exercise testing. PA therefore is the real polypill for prevention and therapy of many diseases. Conclusion: There is now a general agreement and convincing evidence that regular PA including daily life activities are essentials for maintaining health in the working age population. For staying health and preserving health, everybody should reduce or avoid the four main risk factors: no smoking, regular PA, healthy diet and normal body weight. Key words: Physical activity; exercise deficiency syndrom; fitness; exercise prescription; training doi: https://doi.org/10.26493/978-961-7023-32-9.123-134 Regular physical activity and aerobic exercise training are related to a reduced risk of fatal and non-fatal coronary events in healthy individuals, subjects with coronary risk factors, and cardiac patients over a wide age range. A sedentary lifestyle is one of the major risk factors for CVD (Karmali et al., 2013). Physical activity and aerobic exercise training are therefore suggested by guidelines as a very important non-pharmacological tool for primary and secondary cardiovascular prevention (Piepoli et al., 2016, Löllgen et al., 2009). In the EU, 50 % of the citizens are involved in regular aerobic leisure-time, and/or occupational physical activity and the observed increasing prevalence of obesity is associated with a sedentary lifestyle; moreover, probably less than one-third of patients eligible for cardiac rehabilitation are offered this service. Biological rationale Regular aerobic physical activity results in improved exercise performance, 412 which depends on an increased ability to use oxygen to derive energy for work. Primary adaptations occur in the working muscles with increase of mitochon- n dria and improved biochemical substances and enzymes thus improving local muscle endurance properties with increased oxygen extraction in the working pulatioo muscle. This will be the basis for regular physical activity. ge p Moreover, myocardial perfusion can be improved by aerobic exercise, rking-a with an increase in the interior diameter of major coronary arteries, an aug- o mentation of microcirculation, and an improvement of endothelial function. he w Additional reported effects of aerobic exercise are antithrombotic effects that f t can reduce the risk of coronary occlusion after disruption of a vulnerable ealth o plaque, such as increased plasma volume, reduced blood viscosity, decreased | h platelet aggregation, and enhanced thrombolytic ability and a reduction of ar- rhythmic risk by a favourable modulation of autonomic balance (Pescatello pulacije o 2014, Piepoli et al., 2016, Rowe et al., 2014). The preventive effects of regular activity also take place in older adults in ktivne p a similar way as described above with a dependency on activity amount and intensity (Löllgen et al., 2009). Physical activity has positive effects on many elovno a of the established risk factors for CVD therefore reflecting a pleiotropic effect. Physical activity prevents or delayes the development of hypertension in nor- motensive subjects and reduces blood pressure in hypertensive patients (James zdravje d et al., 2014). HDL cholesterol levels are increased, control of body weight is improved, and the risk of developing non-insulin-dependent diabetes mellitus is lowered by activity. Healthy subjects In healthy subjects, growing levels of both physical activity and cardiorespi- ratory fitness are associated with a significant reduction (20 - 30 %) in risk of all-cause and cardiovascular mortality, in anon-linear dose–response fashion (Löllgen et al., 2009, Shiroma et al., 2014) The evidence suggests that risk of dy- ing during a given period continues to decline with increasing levels of physical activity and cardiorespiratory fitness. This is true for both men and women and across a broad range of ages from childhood to the very elderly. These findings are derived from prospective non randomised cohort studies with predefined study groups, with physically active and a control group, a current standard in epidemiological research. Further evidence on the benefit of physical activity are derived from four large meta-analyses (Class I, Evidence A, Grade strong) (Löllgen, 2013, Löllgen et al., 2009) (Figure 1). These meta-analyses have been adjusted for confounding risk factors (i.e. smoking, diet etc.). Sedentary lifestyle In the last years, there is growing evidence that negative effects of sedentary lifestyle is significantly enhanced by sitting time per day, especially the so-called „screen-time”, that is watching TV, PC-work, PC games and surfing the 5 internet. A recent meta-analysis confirmed this to be a significant cofactor for 12 cardiovascular risks (Class I, Level A, Grade strong). Most of the mortality-re-n duction effect seems to rely on a decrease in cardiovascular and CHD mortal- ity. The level of decreased coronary risk attributable to regular physical activi-pulatioo ty is similar to that of other lifestyle factors such as avoiding cigarette smoking or Mediterranean diet. The risk of CVD (including CHD and stroke) or CHD rking po alone is significantly reduced in more physically active or fitter persons, with a relative risk reduction nearly twice as great for cardiorespiratory fitness (CFR) he wr t than for physical activity increase at all percentiles (Kokkinos et al., 2006, Kok-o le f kinos et al., 2016). A possible explanation for the stronger dose–response gra-o dient for fitness than for physical activity is that fitness is measured objectiven: r ly, whereas physical activity is assessed by self-reports and questionnaires that may lead to misclassification and bias towards finding weaker physical activi-reventio ty or health benefit associations (Moore et al., 2012). Altogether, sedentary life nd p style, too much sitting and screen time over hours can be summarized as Exercise Deficiency Syndrom (EDS) as an important risk factor for many diseas-itness a es in the working population. hysical f Physical activity intensity (Dose – response relationship) ctivity, p Some meta-analyses also present data on dose-response relationship for phys- ical activity vs risk reduction. The results of all studies confirm a non-line-ar relationship (Shiroma et al., 2014). The most significant relative decrease of physical a mortality occurs from sedentary lifestyle or inactive phase to low or moderate intensity of physical activity. This then means that little activity is better than nothing. Change from moderate to vigorous activity increases training response and additionally reduces the relative risk for mortality, but to a lesser degree (percentage) than the first (moderate) intensity category. This is emphasized by the flattening of the dose response curve with very vigorous activity. Two re- cent single centred prospective cohort studies confirmed these results show- ing significant increased longevity in the physically active group by about 4 to 7 years. This can be converted to the reciprocal value indicating a mortali-ty reduction with increased amount of activity of about 22 to 40 % (Moore et al., 2012). These studies also underscore the non-linear relationship of mortality reduction with amount of physical activity (Class I, Level A, Grade strong). Training recommendation (FITT): Frequency, intensity, time, and type All health related medical and non-medical societies involved in healthy life style recommend regular physical activity for at least 150 min of moderate intensity on 3 – 5 days a week or at least 75 min /week for vigorous intensity for e.g. 3 days a week for healthy individuals (Class I, level A) (Figure 1). Longer duration and intensity of activities may further increase the health benefits 612 with a lower extent only. Combination of both training modalities are possible. In general, intensity of exercise is superior to duration of exercise to improve n physical capacity (Table 1). Volume in this context is frequency times duration and intensity. Available evidence suggests that the total weekly volume of phys-pulatioo ical activity/aerobic exercise training can be obtained by summing multiple ge p daily bouts of exercise, each lasting ≥10 min. Physical activity/aerobic exercise training should be distributed over most days of the week. rking-ao he wf t ealth o| h pulacije o ktivne p elovno a zdravje d Figure 1: Examples for recommendations for physical activity prescription: Primary prevention and coronary heart disease (Zupet et al., 2015). Types of activity Examples of physical activity/aerobic exercise training involve not only sport-related activities such as hiking, running or jogging, skating, cycling, rowing, swimming, cross-country skiing, and performing aerobic classes, but also lifestyle-common activities such as walking briskly, climbing stairs, and gardening work. In addition, engaging in active recreational pursuits contributes to health effects. Housework no longer has training effects due to the automatic machines used. In the elderly, walking and nordic walking is effective in promoting fitness. Prescription of exercise and physical activity: Frequency, intensity, time and type (FITT) In general, regular physical activity is prescribed like a drug (see below) by frequency, intensity, duration and type of activity (FITT). In addition, progres- 7 sion, and total amount are in use. Examples and criteria for exercise intensity 12 are given in Table 1. For additional extensive fitness, adults may increase their n aerobic activity up to 300 minutes a week of moderate- intensity, or 150 minutes a week of vigorous- intensity aerobic physical activity, thus increasing cardio-pulatioo pulmonary capacity. For long-term development and conservation of health re- lated fitness and risk reduction, moderate intensity recommendations are first rking po line and most important approach (150 m /week of moderate and 75 min / week he w of vigorous exercise). Ratings of perceived exertion related to exercise intensity r to with Borg scale are given in Table 1. It can be easily used by healthy and ill suble f jects. The rate of progression within an exercise program depends on the indi-o n: r vidual’s health and fitness status. To get started, the advice is start low and go slow. Details and comprehensive informations are given in the ACSM Guidelines (Pescatello et al., 2014) and Swedish recommendations (Swedish Nat. Inst. reventio Public health, 2010). Strength training exercises are recommended to perform nd p twice a week (Pescatello et al., 2014). A single exercise session includes warm-itness a ing-up, cooling down and flexibility exercises as part of preventive and reha- bilitation program. For older adult at risk of falls, repeated exercises should be performed to maintain or improve balance and flexibility. hysical f ctivity, p Risk assessment To avoid complications and cardiac events during exercise, healthy subjects should be evaluated prior to engaging in regular physical activity/aerobic exer-physical a cise training. The exercise-related risk of major cardiovascular events in osten-sibly healthy people is exceedingly low, ranging from 1 in 500 000 to 1 in 2 600 000 patient-hours of exercise. As recently proposed for leisure-time sport activities in middle-aged/sen- ior subjects, the risk assessment accuracy should be tailored to the individual’s cardiac risk profile, the current level of habitual physical activity, and the intended level of physical activity/aerobic exercise training, with a more aggres- sive screening (i.e. exercise testing) for people who are sedentary, who are older (> 35ys), who start again with physical activity after long duration of inactivity and/or with cardiovascular risk factors. Significant signs of latent diseases are dyspnoea, chest pain, palpitations, dizziness or even syncope. The current controversy on whether you can do too much of a good thing (i.e. exercise) should be kept in mind, but recent findings and many studies clearly show that the adverse effect of regular physical activity must be rejected due to many bias in the proposed studies (Sanchis-Go- mar 2016). For the moment, there is a clear opinion that positive effects of regular exercise clearly outweigh the small risk, if any, in healthy subjects. Starting slow and go slow is the best advice to avoid a risk, especially in those subjects, which are adults or older adults and start again with exercise training. If maximal stress test is not feasible, a submaximal test such as 6-minutes walking test may be considered, although the correlation between VO peak and distance 8 2 walked are moderate (Pescatello et al., 2014, Liu et al., 2014). Spiro-Ergometry, 12 if available, is nowadays not only helpful but the gold standard for diagnosis of n cardiorespiratory fitness and training counsellation. pulatioo Exercise as a polypill ge p Table 1: Evidence based indications for prescribing regular physical activity rking-ao (Löllgen et al., 2013). he wf t Diseases Level of Evidence Coronary artery disease IA ealth o Artery Hypertension (4-8 mmHg) IA | h Chronic obstructive lung disease IA Heart failure IA pulacije o Cancer (colon, breast, lung) IA Osteoporosis IA ktivne p Metabolic syndrome and Diabetes Mellitus IA Chronic kidney disease IA Peripheral arterial disease IA elovno a Cognitive mental disorder Dementia IB M. Alzheimer IB zdravje d Depression IB Stroke IA Fibromyalgie IA Parkinson’s disease IB Chronic bowel disease IA Bipolar disease IIB Exercise prescription for health concept is similar to prescription of medica- tion during drug therapy. It should also be applied for patients. Exercise as a drug depends on indications, dosage can be choosen individually, there is a (non-linear) dose-response relationship, regular exercise has somatic and psy- chosomatic effects, side effects are possible but rare, and contraindications are all acute diseases (Vina et al., 2012). Consequently, exercise prescription for health has now being introduced in many countries in Europe, North America and Australia /New Zealand. (Zupet et al., 2015; Vina et al., 2012; Löllgen et al., 2015; www.efsma.eu). It is unanimously recommended that regular aerobic exercise is encouraged in patients with heart failure and cardiovascular disease, esp. CAD, to improve functional capacity and symptoms (Class I, Level A, Grade: Strong). Preparticipation examination In patients, generally pre-participation examination is necessary, including stress testing and echocardiography if indicated. Spiroergometry as the gold-en standard improves informations on physical fitness. In patients with CVD, available data now allow definition of anaerobic exercise training weekly vol- 9 ume (frequency, intensity, time) similar to that indicated for healthy subjects 12 (Table 3). This chapter and the following demonstrate the excellent positive ef-n fects of physical activities acting like a drug. Physical activity during rehabilitation after acute myocardial infarction reduces risk for death significantly pulatioo by about 20 to 30 %. Risk for reinfarction does not change. Most studies con- firm that physical training is the most important component of rehabilitation rking po (Class I, level A). In a single randomised controlled trial, which enrolled 100 patients with single vessel coronary artery disease, intensive physical activity he wr t (daily training) had similar or better effect as PCI. o le f A meta-analysis including mainly middle-aged men, most of whom had o n: r a previous acute myocardial infarction and the rest with a previous CABG or percutaneous transluminal coronary angioplasty or affected by stable angina pectoris, showed a 30 % reduction in total cardiovascular mortality for aerobic reventio exercise training programmes of at least 3-months’ duration. This percentage nd p increased to 35 % when only deaths from CHD were considered. Insufficient itness a data were available on to the effects of aerobic exercise training on revascular-ization rates; moreover, aerobic exercise training did show no effect on the occurrence of non-fatal myocardial infarction. hysical f In any case, recent data confirm the existence of an inverse dose–response ctivity, p relationship between cardiovascular fitness (evaluated by treadmill stress testing) and all-cause mortality in large populations of both male and female car- diovascular patients with a history of angiographically documented CHD, my- physical a ocardial infarction, CABG, coronary angioplasty (PCI), chronic heart failure, peripheral vascular disease, or signs or symptoms suggestive of CHD during an exercise testing. The results were the same irrespective of use of beta-block-ing agents. With moderate physical activity, incidence of cardiac arrhythmias may be reduced as has been shown in one single study. So, these findings are significant for working persons returning to work after cardiac events such as myocardial infarction. Risk during training in cardiac diseases In general, the occurrence of major cardiovascular events during supervised aerobic training in cardiac rehabilitation programmes is rare: from 1 in 50 000 to 1 in 120 000 patient-hours of exercise, with fatality incidence ranging be- tween 1 in 340 000 and 1 in 750 000 patient/hours of exercise. The same is also true for patients with chronic heart failure and reduced left ventricular function, New York Heart Association class II–IV symptoms, and treated with op- timal, guideline-based background heart failure therapy. More evidences are needed therefore training supervision is now facilitated by tele monitoring. Heart Failure The effects of aerobic exercise training on cardiac mortality rate in patients with chronic heart failure have been evaluated in a meta-analysis. Overall, 0 moderate to vigorous intensity aerobic exercise training resulted in improved 13 survival in patients with chronic heart failure due to left ventricular systolic n dysfunction, and time to readmission to hospital was also significantly extend-ed. Regular physical activity not only reduces morbidity and rehospitalisation pulatio but also mortality. Left ventricular function increases as shown by V02max o and ejection fraction. Physical capacity thus is improved and quality of life in-ge p creased by 27 % (Edelmann et al., 2011, Kitzmann et al., 2010). rking-a Current multicenter study demonstrated that high intensity interval o training (HIIT) in patients with cardiac failure can be safe and effective in in-he wf t creasing physical capacity (Class II a, Evidence B). During interval exercise, there are short bouts with high intensity (up to 90% of maximal exercise ca-ealth o pacity) alternating with lower recovery periods. This kind of training improves | h cardiorespiratory fitness within short time (some months). HITT can also be combined with endurance training as a kind of basis training. However, one pulacije o large, just finished multicenter study on HITT shows that there is no differ- ence on the long time between endurance training or HIIT (Smartex-Project). ktivne p Therefore, interval training will only be partly integrated into the physical activity program. Endurance training will be the mainstay of training in prima- elovno a ry and secondary prevention. For competitive athletes, such a combination of longer duration endurance training together with longer intervals is well established since long. zdravje d General recommendations for physical activity For long-term development and conservation of health related fitness and risk reduction, moderate intensity recommendations are first line and most impor- tant approach (150 min/week of moderate and 75 min/week of vigorous exer- cise). Ratings of perceived exertion related to exercise intensity are between 11 and 13, they can easily used by healthy and ill subjects. The rate of progression within an exercise program depends on the individual’s health and fitness status. To get started, the advice is start low and go slow. Details and comprehen- sive informations are given in the inte website of EFSMA (www.efsma-scientific. eu), the ACSM Guidelines (Pescatello et al., 2014) and Swedish recommendations (Swedish Nat). On the EFSMA website, detailed recommendations for all diseases and for prevention are listed (Figure 1). Especially, intervention like physical activity improve work life- balance, prevent burn-out or depression and symptoms of fatigue thus enhancing satisfactory of working people. 113 n pulatioo rking po he wr to le fo n: r reventio nd p itness a hysical f ctivity, p physical a Figure 2: Exercise Prescription for Health (Löllgen et al., 2013, Zupet et al., 2015). Population based approaches to physical activities at the workplaces There is a need for comprehensive worksite fitness and wellness programmes together with education in healthy diet and nutrition. Fitness centers at work- site can be considered. Worksite programmes should be well structured to encourage working people to be active even during working time. Use of stair- ways should be encouraged with visible signs and short hints on the health promotion by using staircases instead of elevators. Repeated short time exer- cise bouts (5 – 10 min. duration) during work can also be enough to reduce cardiovascular risk. The non-linear dose–response relationship between CFR and reduction in cardiovascular risk observed in primary prevention also applies to the secondary prevention setting. Advice that every doctor at every contact with a patient should ask for his physical activity improves patient’s adher-ence to an active lifestyle. Role and sustainability of modern technology in improving health and motivating people to more physical activity. This compris- es wearable technology, exergaming and App’s to be downloaded. Conclusion 213 Physical inactivity and sedentary lifestyle are among the three most frequent risk factors for cardiovascular diseases. Conversely, regular physical activity n in prevention, rehabilitation and therapy, reduces cardiovascular morbidity, mortality and disability, improves cardiovascular function and quality of life pulatioo as well as metabolic disorders. Similar effects are observed for hypertension, ge p some central and peripheral diseases and diabetes mellitus. Effects of physi- cal exercise are similar or superior to a single drug therapy. Exercise prescrip-rking-ao tion for health should be used in healthy subjects and in all patients. Due to he w its pleiotropic action, physical activity has to be an essential part of prevention f t and therapy of in- and outpatient’s therapy. Wearable technology will support training recommendations in the near future as do exergaming and many Aps ealth o| h which can be downloaded to the smartphone. pulacije o References EDELMANN, F., GELBRICH, G., DÜNGEN, H.D., FRÖHLING, S., WACH- ktivne p TER, R., STAHRENBERG, R., et al., 2011. Exercise training improves exercise capacity and diastolic function in patients with heart failure and elovno a preserved ejection fraction: results of the Ex-DHF pilot study. J Am Coll Cardiol, vol. 58, pp. 1780–1791. zdravje d JAMES, P.A., OPARIL, S., CARTER, B.L., CUSHMAN, W.C., DENNISON- HIMMELFARB, C., HANDLER, J., et al., 2014. Evidence – based gui- deline for the management of high blood pressure in adults. JAMA, vol. 311, pp. 507-520. KITZMAN, D.W., BRUBAKER, P.H., MORGAN, T.M., STEWART, K.P., LITTLE, W.C., 2010. Exercise training in older patients with heart failu- re and preserved ejection fraction: a randomized, controlled single-blind trial. Circ Heart Fail, vol.3, pp. 657–667. KARMALI, K.N., GOFF jr, D.C., NING, H., LLOYD-JONES, D.M., 2014. A systematic examination of the 2013 ACC/AHA pooled cohort risk assess- ment tool for atherosclerotic cardiovascular disease. J Am Coll Cardiol, vol.60, pp. 959-968. KOKKINOS, P.F., FASELIS, C., MYERS, J., NARAYAN, P., SUI, X., ZHANG, J., et al., 2016: Cardiorespiratory fitness and incidence of major adver- se cardiovascular events in US veterans:Acohort study. Mayo Clin Proc. KOKKINOS, P., PITTARAS, A., MANOLIS, A., PANAGIOTAKOS, D., NARA- YAN, P., MANJOROS, D., et. Al., 2006. Eercise capacity and 24-h blood pressure in prehypertensive man and women. Am J Hypertension, vol. 19, pp. 251-258. LIU, J., SUI, X., LAVIE, C.J., ZHOU, H., PARK, Y., CAI, B., LIU, J., BLAIR, S.N., 2014. Effects of cardiorespiratory fitness on blood pressure trajec- tory with aging in a cohort of healthy men. J Am Coll Cardiol, 2014, vol. 64, pp. 1245-53. LÖLLGEN H., BÖCKENHOFF, A., KNAPP, G., 2009. Primary prevention by 3 physical activity:An updated meta-analysis with different intensity cate- 13 gories. Int.J SportsMed, vol. 30, pp. 213–224. n LÖLLGEN, H., 2013. Bedeutung und Evidenz der körperlichen Aktivität zur pulatio Prävention und Therapie von Erkrankungen (Importance and evidence o of regular physical activity for evention and treatment of diseases). Dtsch rking p med.Wschr, vol. 138, pp. 2253-2259. o LÖLLGEN, H., BÖRJESSON, M., CUMMISKEY, J., BACHL, N., DEBRUYNE, he wr t A., 2015. The Pre-Participation Examination in Sports: EFSMA Statement o on ECG for Pre-Participation Examination. Dtsch Zschr Sportmed, vol. le fo 66, pp.151-155. n: r MOORE, S.C., PATEL, A.V., MATTHEWS, C.E., BERRINGTON DE GON- ZALEZ, A., YIKYUNG PARK, Y., KATKI, H.A., et al., 2012. Leisure Ti- reventio me Physical Activity of Moderate to Vigorous Intensity and Mortality: A nd p Large Pooled Cohort Analysis . Plos one, vol. 9, e1001335. itness a PESCATELLO, L.S., (ED), 2014. ACSM‘s Guidelines for exercise testing and prescription 9th ed, Wolters Kluwer, Baltimore. hysical f PIEPOLI M.F., HOES, A.W., (Chairs), 2016. 2016 European guidelines on car- diovascular disease prevention in clinical practice guidelines. Europ ctivity, p Heart J, vol. 37, pp. 2315–2381. ROWE, G.C., SAFDAR, A., ARANY, Z., 2014. Running Forward.New Fron- tiers in Endurance Exercise Biology. Circulation, vol. 129, pp. 798–810. physical a SANCHIS-GOMAR, F., PEREZ, L.M., JOYNE, M.J., LÖLLGEN, H., LUCIA, A. 2016. Endurance Exercise and the Heart: Friend or Foe? Sports Med, vol. 46, no 4, pp 459-66. SHIROMA, E.J., SESSO, H.D., MOORTHY, M.V., BURING, J.E., LEE, I.M.: Do moderate -intensity and vigorous intensity physical activities reduce mortality rates to the same extent. J Am Heart Ass 2014; vol. 3, e000802. SWEDISH NATIONAL INSTITUTE OF PUBLIC HEALTH. 2010. Physical activity in the prevention and treatment of disease. Professional Associati- ons for physical activity. Stockholm, Sweden, http:/ www.fyss.se VINA. J., SANCHIS–GOMAR, F., MARETINEZ-BELLO, V., GOMEZ-CAB- RERA, M.C., 2012. Exercise acts as a drug; the pharmacological benefits of exercise. Br J Pharmacol, vol. 167, no. 1, pp. 1-12. ZUPET, P., LÖLLGEN, H., DEBRUYNE, A., BACHL, N., CUMMISKEY, J. , 2015. Exercise prescription for health Training recommendations. www. Efsma-scientific.com. 413 n pulatioo ge p rking-ao he wf t ealth o| h pulacije o ktivne p elovno a zdravje d The quality of sexual life after experiencing the episiotomy birth Polona A. Mivšek, Petra Petročnik, Anita Jug Došler, Teja Škodič Zakšek University of Ljubljana, Faculty of Health Sciences, Midwifery Department, Zdravstvena pot 5, 1000 Ljubljana, Slovenia polona.mivsek@zf.uni-lj.si Abstract Introduction: Episiotomy is a surgical cut of the perineum during childbirth to widen the pelvic outlet. The evidence shows women are less interested into sexual intercourse in the period after birth than they were before or during the pregnancy. This is the consequence of the changes in the postpartum period and often affected also by the perineal trauma. The purpose of literature review is to study the connection of perineal trauma on pain during sexual course in the postnatal period. Methods: Descriptive research method has been used, based on the review of relevant national and international literature on the scientific and professional level. The review of the literature took place in the January 2017, with the help of international databases. Searching terms included the following Key words: »episiotomy«, »sexuality«, »postpartum« and »dyspareunia«. The literature searching was limited on the Slovenian and English language and included the relevant papers published between 2007 and 2017. Results: The incidence of episiotomy in Slovenia is lower than 30 % and varies between individual birth hospitals. The first episiotomy is a frequent reason resulting in women’s fear of their first sexual intercourse, mostly the accompanied pain. Discussion and conclusions: The research shows that dyspareunia is more common in women having a vaginal birth, especially if the woman sustained a perineal rupture or episiotomy. Women usually return to their sexual life before the pregnancy after 6-12 months after birth. The quality of sexual life may be affected the whole year after childbirth. Key words: sexuality, postpartum period, perineal trauma, genital pelvic pain doi: https://doi.org/10.26493/978-961-7023-32-9.135-141 Episiotomy is a surgical incision into the perineum in order to assist the birth of a baby (Dahlen, 2015). The correct performance of the cut is of crucial meaning for the future sexual life of the labouring woman. Episiotomy The recommended use is restrictive (only in the case of indications such as foetal distress and the urgent need to finish the labour quickly) (Jiang et al., 2017). In case of the need for episiotomy, the correct timing to perform the procedure is when 3-4 cm of presenting part of the baby is visible in between the contrac-tions. Local anaesthetic should be applied before the procedure (Dahlen, 2015). National Institute for Clinical Excellence - NICE (2017) suggests mediolateral type of episiotomy that must be executed in one clear cut. The recommended length of the incision is 2 and not more than 4 cm. The cut should start at the midpoint of the fourchette, directed mediolateral at a 45-60° angle, toward the 613 ischial tuberosity (Kalis et al., 2017). n If the start of episiotomy is too lateral, Bartholin’s glands can be damaged and if performed too soon, episiotomy can cause more bleeding (Holmes and pulatio Baker, 2006) and the musculus levator ani (Dahlen, 2015) that pays a major role o in the woman’s sexual excitation can be damaged. Episiotomy also weakens ge p perineal muscles (Walsh, 2007) and can predispose woman to perineal trauma, rking-a therefore routines use is not advised (Jiang et al., 2017). o he wf t Dyspareunia Dyspareunia is genital-pelvic pain, evoked by the penetration during the sex- ealth o| h ual intercourse and is classified as a sexual dysfunction by American Psychiatric Association – APA (2013). It can be expressed as a local pain at the vaginal pulacije introitus or a diffuse pain in the pelvis. The nature and intensity of pain var-o ies. Dyspareunia can be primary or secondary and is closely connected to vag- inismus and/or vulvodynia (Edwards and Bowen, 2010; World Health Organ- ktivne p ization - WHO, 2010). The incidence of dyspareunia is increasing (APA, 2013), especially among elovno a young women. Systematic review by Latthe et al. (2006) showed that studies re- port very different rates of dyspareunia. Numbers in the reviewed studies var- zdravje d ied from 8 to 21.8 %. Slovenian online study among women under the age of 30 (N = 408) revealed prevalence of 15.4 % (Kovačič, 2014). The causes for dyspareunia can be physical or psychological (WHO, 2010). In the case of vulvo-vaginal pain are physical causes more common, es- pecially common cause is perineal trauma (Edwards and Bowen, 2010). This can be closely connected with episiotomy. A very important determinant of postpartum sexual function is perineal pain and resultant dyspareunia (Škod- ič Zakšek, 2015). Slovenian online study among 368 women who gave birth in the last 24 months and had episiotomy during it showed that women often postpone first sexual intercourse after the birth due to fear of pain (77 %). 331 of them reported lower sexual desire and among those, 45 % of them identified pain as the most common cause (Grabner, 2015). Therefore authors were interested in investigating the connection be- tween dyspareunia and episiotomy after the childbirth. Methods Descriptive research method has been used, based on the review of relevant na- tional and international scientific literature. The review of the literature took place in the January 2017, with the help of international databases. Searching terms included the following key words: »episiotomy«, »sexu- ality«, »postpartum« and »dyspareunia«. The literature search was limited on the Slovenian and English language and included the relevant papers published between years 2007 and 2017. Later on the search was narrowed to the publica- 713 tions in the last five years in order to get the best and newest evidence. The following databases were searched: CINAHL, Cochrane Library, EI- irth FL Direct, MEDLINE, ScienceDirect, ProQuest, ERIC, Midirs and Embase. y bm We excluded studies of dyspareunia among women after different gy- naecologic operations, with simultaneous mental health problems and stud- pisioto he e ies among women with dyspareunia due to congenital malformations of repro- ductive organs. Excluded were also studies that investigated dyspareunia after the perineal lacerations, vacuum extraction, cesarean cestion or spontaneous delivery with intact perineum. xperiencing t The search returned alltogether 77 references. Studies were sorted accord- fter e ing to exclusion criteria. At the end 14 sources were included in the review (2 ife a from CINAHL, 1 from Cochrane, 2 from EIFL Direct, 3 from Science direct and 6 from Springer). exual lf s Results uality o Sexual disfunctions are more common in postpartum year as in other peri- the q ods of women‘s life (Abdool et al., 2009). Buurman & Lagro-Janssen (2013) have found in their qualitative study 73 % incidence of sexual disfunctions in the puerperium. Their sample was small and one could argue that their research design provide insufficient results. However also Rosen and Pukall (2016) and Khajehei et al. (2015) confirmed high incidence of problems in sexuality in the postpartum period. When comparing the incidence 3-, 6-, and 12- months postpartum it is obvious that the ratio of sexual dysfunctions decline in time after the childbirth (Khajehei et al., 2015). In the case of perineal trauma Williams et al. (2007) found out that wom- en experience in 54,5 % sexual dysfunctions even after 12 months after the birth. Some authors (Doğan et al., 2017) report impact of the episiotomy on sexual desire, arousal and orgasm even 5 years after the birth. On contrary some stud- ies did not found differences in reasuming sexuality postnatally among women with episiotomy or those with intact perineum (Lagana et al., 2015; Kramna and Vrublova, 2016). Dyspareunia is reported by 41 %-67 % of women 2 to 3 months postpar- tum in case of some kind perineal trauma quote Yeniel and Petri (2014). Acele and Karacam (2012) report even higher proportions of postnatal women with dyspareunia – 58,3 %. Necesalova et al. (2016) investigated diferrences in incidence of dyspareunia after mediolateral and lateral episiotomy. Women of both groups reported similar proportions of pain during sexual intercourse – 15,6 % in the group with mediolateral episiotomy and 16,1 % in the group with later- al episiotomy. The studies by Acele and Karacam (2012), Boran et al. (2013) and Sayasneh and Pandeva (2010) confirmed the results of older studies (Rogers et al., 2009; Klein et al., 2009) that episiotomy is more frequently connected to dyspareunia 813 than ruptures of perineum. Statistically significant differences in the incidence of dyspareunia were found with higher age and presence of sexual problems al-n ready in the time of pregnancy (Acele and Karacam, 2012). Women with episi- otomy in general have lower postpartum sexual function on FSF (Female Sex- pulatioo ual Function) Index in comparison to those with no episiotomy (Lukas, 2014). ge p rking-a Discussion o Many postpartum changes may afect sexual health after the birth – even he wf t non-organic. One of those might be also the changes in the relationship after the arrival of the new family member (Simšič, 2009). Physical changes can af- ealth o fect sexuality indirectly (for example higher levels of oestogen or tiredness) | h (Acele and Karacam, 2012) or directly (like perineal trauma) (Luire et al., 2013). Dyspareunia can be also a result of incorrect perineal repair (Dahlen, 2015). pulacije o Women with perineal trauma tend to resume sexual activity later than women with intact perineum (McDonald and Brown, 2013). However women ktivne p in general have decline of sexual life in the postpartum period, no matter what the mode of delivery was, claim Faisal-Cury et al. (2015) and women in gener-elovno a al report dissatisfaction with the sexuality in the postnatal period (Khajehei et al., 2015). zdravje d When looking at the results of the studies that investigated the effect of episiotomy on the prevalence of dyspareunia in puerperium, the evidence are inconclusive. Further meta-synthesis should examine the differences in the proportions of dyspareunia among women with episiotomy, second degree lac- erations or intact perineum. Conclusions Dyspareunia is one variable that may have a negative impact on women’s lives and her partnership, especially if she cannot share her own sexual feelings and difficulties to her partner and health professionals. Through the article we have shown that episiotomy birth may affect woman’s sexual life during the first year postpartum with more frequent pain, sexual dissatisfaction and decreased libido. Perineal trauma affects women’s physical, psychological and social well- being. This is the reason why clinicians, midwives and health care providers need knowledge and skills of sexual postpartum counselling, perinatal clini- cal care and treatment. They should be educated in order to counsel women re- garding the potential postpartum sexual feelings and difficulties and to pro- mote or improve the quality of their sexual functioning and relationship with partner. References ABDOOL, Z., THAKAR, R., SULTAN, A.H., 2009. Postpartum female sexual function. Eur J Obstet Gynecol Reprod Biol. Vol. 145, No. 2, pp.133-7. 913 ACELE, E.O., KARACAM, Z., 2012. Sexual problems in women during the first postpartum year and related conditions . J Clin Nurs. Vol. 21, No. 7-8, pp. irth 929-37. y bm APA, 2013. Diagnostic and statistical manual of mental disorders. 5th ed. (DSM-5). Arlington: American Psychiatric Publishing, pp. 437-40. pisioto he e BORAN, S.U., CENGIZ, H., ERMAN, O., ERKAYA, S., 2013. Episiotomy and the Development of Postpartum Dyspareunia and Anal Incontinence in Nulliparous. Females Eurasian J Med, No. 45, pp.176-80. BUURMAN, M.B., JAGRO-JANSSEN, A.L., 2013. Women‘s perception of xperiencing t postpartum pelvic floor dysfunction and their help-seeking behaviour: a fter e qualitative interview study. Scand J Caring Sci,. Vol. 27, No. 2, pp. 406-13. ife a DAHLEN, H., 2015 Perineal care and repair. In: PAIRMAN, S., PINCOMBE, exual l J., Thorogood, C., TRACY, S., eds. Midwifery: preparation for practice. 3rd f s ed. Sydney: Churchill Livingstone, Elsevier, pp. 693-715. DOĞAN B., GÜN, I., YILMAZ, A., MUHçU, M., 2017. Long-term impacts uality o of vaginal birth with mediolateral episiotomy on sexual and pelvic the q dysfunction and perineal pain. J Matern Fetal Neonatal Med. Vol. 30, No. 4, pp. 457-460. EDWARDS, A., BOWEN, M.L., 2010. Dyspareunia. Pract Nurse. 39 (1):36-30. FAISAL-CURY, A., MENEZES, P.R., QUAYLE, J., MATIJASEVICH, A., DI- NIZ, S.G., 2015. The relationship between mode of delivery and sexual health outcomes after childbirth. J Sex Med. Vol. 12, No. 5, pp. 1212-20. GLOWACKA, M., ROSEN, N., CHORNEY, J., SNELGROVE CLARKE, E., GEORGE, R.B. (2014). Prevalence and Predictors of Genito-Pelvic Pain in Pregnancy and Postpartum: The Prospective Impact of Fear Avoid- ance. The Journal of Sexual Medicine. Vol. 11, No. 12, pp. 3021-34. GRABNER, N., 2015. Spolnost po porodu z epiziotomijo. Diplomsko delo. Lju- bljana: Zdravstvena fakulteta. HOLMES, D., BAKER, P.N., 2006. Midwifery by ten teachers. London: Hodder Arnold, 2006. JIANG, H., QIAN, X., CARROLI, G., GARNER, P., 2017. Selective versus rou- tine use of episiotomy for vaginal birth. Cochrane Database of System- atic Reviews 2017, Issue 2. Art. No.: CD000081. DOI: 10.1002/14651858. CD000081.pub3 KALIS, V., RUSAVY; Z., PRKA, M., 2017. Episiotomy. In: DOUMOUCHTSIS, S., ed. Childbirth Trauma. 1sted. London: Springer-Verlag, pp.69-99. KHAJEHEI, M., DOHERTY, M., TILLEY, P.J., SAUER, R., 2015. Prevalence and risk factors of sexual dysfunction in postpartum Australian women. J Sex Med. Vol. 12, No. 6, pp. 1415-26. KLEIN, K., WORDA, C., LEIPOLD, H., GRUBER, C., HUSSLEIN, P., WENZL, R., 2009. Does the mode of delivery influence sexual function after child- 0 birth? Journal of Womens Health No. 18, pp. 1227–1231. 14 KOVAČIČ, S., 2014. Disparevnija pri mladih ženskah do 30. leta starosti: n Diplomsko delo- Prešernova nagrada študentom. Ljubljana: Zdravstve- na fakulteta. pulatioo KRAMNA, P., VRUBLOVA, Y., 2016. Episiotomy and women’s sexual function ge p 2–5 years after childbirth: A study from the Czech Republic. British Jour- nal of Midwifery. Vol. 24, No. 12, pp. 870-876. rking-ao LAGANA, A.S., BURGIO, M.A., CIANCIMINO, L., SICILIA, A., MAGNO, he w C., BUTTICE, S., TRIOLO, O., 2015. Evaluation of recovery and quality f t of sexual activity in women during postpartum in relation to the differ- ent mode of delivery: a retrospective analysis. Minerva Ginecol. Vol. 67, ealth o| h No. 4, pp. 315-20. LATTHE, P., LATTHE, M., SAY, L., GÜLMEZOGLU, M., KHAN, K.S., 2006. pulacije o WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. BMC Public Health 6, p. 177. ktivne p LUIRE, S., AIZENBERG, M., BOAZ, M., KOVO, M., GOLAN, A., SADAN, O., 2013 . Sexual function after childbirth by the mode of delivery: a prospective elovno a study. Arch Gynecol Obstet, Vol. 288, No. 4, pp. 785–92. LUKAS, E., 2014. Primipara Undergoing Episiotomy had Lower Postpartum zdravje d Sexual Function. INAJOG, Vol. 2, No. 2, pp. 91-95. McDONALD, E.A., BROWN, S.J., 2013. Does method of birth make a differ- ence to when women resume sex after childbirth? BJOG, Vol. 120, No. 7, pp.823-30. NECESALOVA, P., KARBANOVA, J, RUSAVY, Z., PASTOR, Z., JANSOVA, M., KALIS, V., 2016. Mediolateral versus lateral episiotomy and their ef- fect on postpartum coital activity and dyspareunia rate 3 and 6 months postpartum. Sex Reprod Health, No. 8, pp. 25-30. NICE, 2017. Intrapartum care for healthy babies and women. [viewed 12 June 2017]. Available from: https:/ www.nice.org.uk/guidance/cg190 ROGERS, R.G., BORDERS, N., LEEMAN, L.M., ALBERS, L.L., 2009. Does spontaneous genital tract trauma impact postpartum sexual function? Journal of Midwifery & Womens Health. No. 54, pp. 98–103. ROSEN, N.O., PUKALL, C., 2016. Comparing the Prevalence, Risk Factors, and Repercussions of Postpartum Genito-Pelvic Pain and Dyspareunia. Sexual Medicine Reviews, Vol. 4, No. 2, pp. 126–135. SAYASNEH, A., PANDEVA, I., 2010. Postpartum sexual dysfunction: A litera- ture review of risk factors and role of mode of delivery . BJMP. Vol. 3, No. 2, p. 316. SIMŠIČ, B., 2009. Partnerski odnos pred, ob in po rojstvu prvega otroka. Diplomsko delo. Ljubljana: Zdravstvena fakulteta. ŠKODIČ ZAKŠEK, T., 2015. Sexual Activity during Pregnancy in Childbirth and after Childbirth. In: MIVŠEK, A.P., ed . Sexology in midwifery. Rije-ka: Intech, pp. 89-115. 114 YENIEL A.O., PETRI, E., 2014. Pregnancy, childbirth, and sexual function: perceptions and facts. International Urogynecology Journal, vol. 25, No. irth 1, pp. 5-14. y bm WALSH, D., 2007. Evidence-based care for normal labour and birth: a guide for midwives. London: Routledge. pisioto he e WHO, 2010. International statistical classification of diseases and related health problems 10th Revision (ICD-10). [viewed 12 June 2017]. Available from: http:/ apps.who.int/classifications/icd10/browse/2010/en xperiencing t WILLIAMS, A., HERRON-MARKS, S., HICKS, C., 2007. The prevalence of enduring postnatal perineal morbidity and its relationship to perineal fter e trauma. Midwifery No.3, pp.392–403. ife a exual lf s uality o the q Women‘s experiences with perinatal loss of a child Teja Novak1, Doroteja Rebec2 1 Community Health Center Vrhnika, Cesta 6. maja 11, 1360 Vrhnika, Slovenia 2 University of Primorska, Faculty of Health Sciences, Department of Nursing, Polje 42 6310 Izola, Slovenia teja.novak@zd-vrhnika.si; doroteja.rebec@fvz.upr.si Abstract Introduction: Perinatal death is an extremely sensitive area in a parents‘ life since it is considered to be the most painful of losses. From health care professionals it requires expert and compassionate treatment that will help parents in the process of coping with the loss of a child. Health care professionals should be able to listen and to be receptive to parents‘ needs and not become insensitive to their grief. The purpose of the research was to gain insight into the experiences of women in Slovenian maternity hospitals who have experienced the loss of a child in the perinatal period. Methods: A quantitative research approach was based on an online survey convenience sample of women (n = 114) who have experienced the loss of a child in the perinatal period. Women were previously requested to participate via online forums and groups where they also get a link to the online survey. The survey was conducted from January to June 2015. The data were analyzed using basic descriptive statistics. Results: The results showed that the majority of women which have experienced perinatal loss of a child, wants to talk about their experience. Health care professionals have been mostly empathic, respectful and supportive to them in the treatment. Despite the fact that health care professionals are sensitive to the needs and aspirations of women and respect their feelings, their professional behavior in emotionally demanding situations was more reserved, which is against the wishes and women‘s needs. This is sometimes due to the way of working, which allows and encourages more rigid professional behavior. Discussion and conclusions: In the area of perinatal palliative care there is the need to further improve understanding of the needs of grieving parents among health care professionals and additionally trainings to work with bereaved parents. It is also necessary to overcome the shortcomings in the system of treatment to be more supportive to grieving parents. doi: https://doi.org/10.26493/978-961-7023-32-9.143-148 Keywords: perinatal death, needs of grieving mothers, health care professionals, help Death in old age is more widely recognized, but when death and loss re- late to the opposite extreme of age, we are quite uncertain (Mander, 1994). No one expects his child to die before him - we see the death of the child as something that should not have happened and is against natural laws (Globevnik Velikonja, 1997; 2000). Stillbirth is defined as the birth of a child after the 22nd week of pregnan- cy, when child has no signs of life, and at the age of weighing at least 500 grams or the length of his body at least 25 centimeters (Statistical Office of the Republic of Slovenia, n. d.). Barfield (2011) adds that during the perinatal death we al-so count all live births, who died in the first 7 days of life. 4 The health care of a deceased newborn should be directed to the whole 14 family, and requires health professionals to individually address the physical, n emotional, social and spiritual needs of the mother and child or family from the beginning of the delivery process to the adaptation of the entire family pulatio (Skoberne, 1991). In this point, Globevnik Velikonja (1999) adds that the re- o al needs of mourning parents depend on their individual feelings, personality ge p and circumstances of the child‘s death, but nevertheless they all deserve to be rking-a treated with the utmost sensibility. The field of pediatric palliative nursing in o Slovenia is an extremely poorly explored area, therefore, we wanted to gain in-he wf t sight into the experience, feelings and emotions by women who experienced a loss of a child in a perinatal period. Thus, on the basis of their personal expe-ealth o rience, we would highlight and emphasize the advantages or disadvantages of | h treatment by healthcare professionals. pulacije o Methods The research was based on a quantitative research approach. The convenient ktivne p sample included women (n = 114) who experienced a child‘s loss in the per- inatal period. The data were collected using an online survey questionnaire elovno a from January to June 2015. The question sets in questionnaire were related to the display and expression of respect, empathy and emotions, respect for deci- zdravje d sion-making, needs and wishes of mothers, respectful communication, infor- mation, providing psychological assistance, and about respecting the spiritual or cultural needs of mothers by healthcare professionals. Replies were processed using basic descriptive statistics. Results Most women (76%) who experienced a child‘s loss in a perinatal period want- ed to talk about their experiences and would like to speak today. They needed a conversation and it was helpful for them, but many did not dare to ask them or wanted to ask them about it. The results of the research showed that the healthcare professionals were relatively respectful in relation to women, since they largely ensured intimacy of the moment (68%), took into account the needs for respectful, discern- ing and empathic communication and respected the feelings of women (76%), met the need for ‚being listened to‘ at least sometimes (78%) and for psycho- logical assistance (50%), providing information related to child‘s death (50%). In a large proportion (97%), professionals also respected the decisions of the mothers (e.g., about the way of treatment, the place of burial), but in many cases (58%), mothers were also required to make decisions immediately after their birth (e.g., about the name of the child, the manner of burial etc.). The need for information was largely neglected: information about treat- ment after discharge from hospital (31%), about possible consequences requir- ing immediate action (28%), and written information was not provided (42%). In the area of emotional support for women, there were bigger deficits in 5 the respondents‘ responses. The professionals did not meet the needs and ful- 14 filled the wishes of women‘s own choice of the department where they would be accommodated (86%). Most (54%) were not able to spend the first night in the hild hospital with a partner, as well as not to coexist with him throughout the hos-f a c pitalization (61%). They also did not have the opportunity to say goodbye to the ss oo deceased child after 12 hours (82%). In most cases, they were not encouraged to choose the child‘s name (80%), or to see the dead child (57%), to cradle it (56%), or to collect memories of the child (53%). The lack of emotional support also erinatal l shows the answers about receiving attention by healthcare professionals always ith p or sometimes (78%), yet in most cases (73%) they felt alone with their own pain. Comforting touches and time from healthcare professionals received slightly more than half women (56%). xperiences ws e In meeting the spiritual, religious and cultural needs about the method en‘m of childbirth, care or burial, 54% women did not have specific desires, howev- ow er in 24% answers showed that treatment of this area has not been respected. Many of them also received inappropriate ‚comforting‘ comments from pro- fessionals related to the youngness of women and to the possibility of subse- quent pregnancy or to already pre-existing children. According to the majori- ty of respondents (78%), these comments were well-intentioned, but completely unnecessary. Discussion This research shows that in the future more attention should be paid to the needs and desires of women who lost their child in the perinatal period. Many deficits in treatment have been shown in the consideration of women‘s wishes and needs, as well as in informing, in showing compassion and emotional sup- port, and in the sphere of spiritual, religious and cultural needs of women. According to Cehner et al. (2005), healthcare professionals should be more aware of the needs of the grieving woman and family so that they can approach in a more integrated and individual way. Although healthcare professionals were relatively respectful in relation to women and also respected women‘s decisions, they sometimes also required from women to make decisions right after birth. This, in contrast to Skoberne (1991), argues that the mother must not be required to make a decision imme- diately after the child‘s death. If the mother is not prepared yet for taking decisions in a postmortem Therefore, in no way mother should be forced to make decisions in the maternity ward, if she is not prepared yet. The respondents also received too little attention. Healthcare profession- als were not available when they needed help, which also led to bad events. If healthcare professionals do not know how to approach a mournful family, they prefer to withdraw or to comfort in a innapropriate way (Globevnik Velikon- ja, 1997). Grieving parents can be assisted in a better way by those who can give 614 them the opportunity to speak about the loss and recognize that their child existed. n Therefore, healthcare professionals should avoid rigid professional be- pulatio havior, they should be friendly and honest, and if they feel sad, they should o not be ashamed of crying with grieving parents (Skoberne, 1991). The respond- ge p ents also missed a warm and comforting word and respectful communication; on the contrary, some were receiving inappropriate remarks. Skoberne (1997) rking-ao points out that affected parents can be alert and sensitive to every spoken word he w of healthcare professionals; they attach great importance to it, which obliges f t healthcare professionals to be more accountable for what they say (Skoberne, ealth o 1997). It is also important to take into account the individual wishes of a wom- | h an, e.g., the choice of department she will be accommodated. The least that healthcare professionals can do is to offer the woman the option of choosing a pulacije o post delivery period accommodation or to encourage her to decide to stay in a private room at the maternity ward where the whole family will benefit from ktivne p quality health care. It is necessary to take into account the women‘s desire to go to a department that is isolated from the child‘s crying and other mothers (Skoberne, 1997). elovno a Informing women is also problematic area. Women missed the acquaint- ance, help and encouragement in collecting memories of the child, which is zdravje d according to Globevnik Velikonja (1999; 2000) very important because these objects serve as evidence of a child‘s life and offer parents the opportunity to mourn. Since memories of the child all that remains, each one is valuable. The situation is similar with the encouragement of giving a name to the child, cradling a child and to say goodby to deceased child. Skoberne (1997) points out that the healthcare professionals should encourage parents (but not force them) to choose the name of the child, even if it is stillborn or die shortly after birth, to see it and cradle it, to say goodbye, give him their things, take photos, healthcare professionals take photos, or other impressions to have memories. High deficits in treatment are also reflected in the emotional support of women. Skoberne (1997) states that, in general, the best assistance to parents at that time is genuine contact, based on the compassion, understanding and receptivity of an individual, thus emphasizes: „ We should not be afraid to ask them what they feel and whether they want to talk about their distress. Above all, let‘s listen to them. Even our silent presence or touch can be encouraging enough to encourage parents to express grief or help them regulate conflicting feelings they are experiencing“ (Skoberne, 1991, p. 72). Although the research has shown that the spiritual, religious or cultur- al needs of women are not taken into account, it is necessary to think of what the Globevnik Velikonja (1999; 2000) emphasizes that some ritual like baptis-ing the child before death may mean a great deal for parents, so we have to allow them to do so. 147 In Slovenia, the Solzice Association has already changed many things in the field of treatment after perinatal loss of a child. Training in Slovenian ma-hild ternity hospitals should become a constant practice in order to make health- f a c care professionals better trained in dealing with women in case of perinatal ss oo death. New findings based on researching perinatal child loss experiences are so necessary, especially in relation to the Slovenian space Slovenian area. erinatal l ith p Conclusions Although the loss of a child in a perinatal period is more and more common, this topic is still a major taboo. In Slovenia, this is a little researched area, and xperiences w further research are needed. It would also be interesting to compare the treat-s een‘ ment methods in Slovenian maternity hospitals with the aim of transferring mow good practices. There is also a need for improvements in the educational pro- grams themselves, which at this moment perhaps do not offer knowledge in a way that would prepare future healthcare professionals for coping and prop- er handling of such cases. It would be necessary to integrate and to cooperate with associations helping grieving parents. This can be an important source of information and awareness for healthcare professionals of what are needs that grieving parents have at the time of a child loss. Informal forms of edu- cation and lifelong learning as seminars, professional meetings are also wel- come. At the same time, personal involvement and responsibility of each in- dividual healthcare professional is also necessary. Healthcare professionals are the first who have an opportunity to create a memory of a lost child, thus enabling a woman and her family to mourn through the mourning process. There- fore, women who have lost a child in a perinatal period should be listened and helped in a personalized and individualized way. References BARFIELD, W., 2011. Standard Terminology for Fetal, Infant and Perinatal Deaths. Pediatrics, vol. 128, pp. 177–180. CEHNER, M., UREK, P. in ROSEMARIE, F., 2005. Sočutno spremljanje staršev ob smrti otroka v času nosečnosti in po rojstvu. In: FILEJ, B., KVAS, A., KERSNIČ, P., eds. Skrb za človeka: Zbornik predavanj in posterjev 5. Kon- gresa zdravstvene in babiške nege Slovenije, Zveza društev medicinskih sester, babic in zdravstvenih tehnikov Slovenije. Ljubljana: Zbornica zdravstvene in babiške nege Slovenije-Zveza društev medicinskih sester, babic in zdravstvenih tehnikov Slovenije, pp. 181–189. GLOBEVNIK VELIKONJA, V., 1997. Žalujoča družina in njene potrebe. In: BREGANT, L., ed. Strah, bolečina, žalost: kako se z njimi soočata bolnik in zdravstveni delavec v perinatologiji: zbornik referatov, 4. in 5. april 1997, 8 Društvo za pomoč prezgodaj rojenim otrokom in Združenje za perinatalno 14 medicino SZD in Neonatalna komisija pediatrične sekcije SZD. Ljubljana: Društvo za pomoč prezgodaj rojenim otrokom, pp. 38–42. n GLOBEVNIK VELIKONJA, V., 1999. Psihološka pomoč staršem ob otrokovi pulatio smrti. Psihološka obzorja, vol. 8, no. 1, pp. 93−102. o ge p GLOBEVNIK VELIKONJA, V., 2000. Žalovanje po perinatalni izgubi. In: ROMIH, J. and ŽMITEK, A., eds. Na stičiščih psihiatrije in ginekologije: rking-ao zbornik predavanj/Begunje, 22. in 23. oktober 1999. Begunje: Psihiatrična bolnišnica, pp. 89–98. he wf t MANDER, R., 1994. Loss and bereavement in childbearing. Oxford [etc.]: Black-well Scientific, pp. 1–60. ealth o| h SKOBERNE, M., 1991. Umiranje in smrt novorojenčka-izgubljeno upanje in sanje staršev: zdravstvena nega umirajočega novorojenčka in pomoč pulacije staršem v procesu žalovanja. Obzornik zdravstvene nege, vol. 25, no. 1/2, o pp. 67−77. ktivne p SKOBERNE, M., 1997. Spi spokojno, mali otožni deček. Obzornik zdravstvene nege, vol. 31, no. 3−4, pp. 141−145. elovno a Statistical Office of the Republic of Slovenia., n.d. Definicije [online]. [viewed 27 January 2015]. Available from: https://www.stat.si/doc/pub/rr816-2004/ DEFINICIJE_SLO.html zdravje d Work related stressors and quality of life of nurses Jelena Pavlović, Maja Račić, Nataša Radović, Sandra Joković, Natalija Hadživuković University of Sarajevo, Faculty of Medicine, Studentska 5, 73 300 Foca, Republic of Srpska, Bosnia and Herzegovina pjelena551@gmail.com; porodicnamedicina@gmail.com; natasa1 22@live.com; sandra.jokovic@hotmail.com; natalijahadzivukovic@yahoo.com Abstract Introduction: Burnout syndrome is a state of mental and physical exhaustion caused by excessive and prolonged stress. The aim of the research was to determine the influence of stress factors on the quality of life of workers in the surgical and internal medicine department. Methodology: The study was designed as a cross-sectional study with 150 subjects. The research was conducted at the University Hospital Foca, surgical and internal medicine department. We used a sociodemographic questionnaire, a questionnaire to assess the health status and the work related scale of stress. Statistical analysis was performed using the SPSS ver. 24.0. Results: The frequency of the burnout syndrome as a response to chronic stress is high (20%). The lower level of the quality of life of the respondents was found in dimension mental health (49.36%) and vitality (62.93%). Workers on the surgical ward are most obvious overloaded (82.60%) and have a lower quality of life. Disscussion and Conclusion: The most common stress-related factors of workers in the surgical department are overloaded with work, financial constraints, call time, a small number of health care workers. Keywords: professionals, stressful factors, nurses, quality of life In recent years, the greatest attention of the scientific public has been attracted by the number of studies of the influence of stress or stress factors on the health status of employees (Kang et al., 2015; Rybojad et al., 2016).Therefore, the rate of interest in the study of stress and its consequences on employees in the health sector increases (Lin et al., 2015; Kowalczuk and Krajewska-Kulak, 2015). Research of stress in the workplaces in the health sector with the aim of preventing its harmful effects, which lead to lower life quality and reduction of working capacity due to illness, becomes increasingly important (Romano et al, 2015). Neither the students in scientific disciplines are exempt from stress, doi: https://doi.org/10.26493/978-961-7023-32-9.149-154 especially those who are preparing for future positions in the medical profession (Kaewanuchit et al., 2015).In 1984 in the journal Nursing Mirror, Hingly wrote the following: “Nursing is by its very nature, a profession that is experiencing high levels of stress. Nurses are faced with suffering, pain and death; nursing interventions are not appreciative and spirited. Many are, by normal standards, unpleasant, others are degrading and some are scary” (Hingly, 1984, pp.19–22). Some researchers have questioned whether the cited sources of stress in the scientific literature, similar or the same for all nurses employed in hospitals or depend on the type of department. One of the areas of nursing that particularly attract attention of scholars are departments of emergency medicine and intensive care units, departments of surgery and oncology ward. There is agreement that the experience of stress caused by work diminishes the qual- ity of nursing work (reducing the job satisfaction increased psychiatric mor- bidity and may contribute to the occurrence of some forms of physical diseas- 0 es, particularly cardiovascular diseases and musculoskeletal system). Because 15 of the importance and sensitivity of the work performed by nurses, interest in n researching the quality of life and psychosocial aspects of their working en- vironment emerged. Although quality of life and job satisfaction are differ- pulatioo ent constructs, data from the literature show that they are mutually connected ge p and that there are factors that affect both constructs (Stacciarini and Troccoli, 2004). The aim of the research was to determine the influence of stress factors rking-a on the quality of life between patients in the surgical and internal department. o he wf t Methods The study was designed as a cross-sectional study with 150 respondents and ealth o| h was conducted University Hospital Foca surgical and internist wards, in the period from February 2016 to June 2016. Criteria for inclusion in the study pulacije were: respondents who work at least one year and are directly involved in the o care and treatment of patients. Criteria for exclusion from the study were: rektivne p spondents who work less than one year, patients who are not involved in the care and treatment of patients and subjects who did not respond to five or more questions or have circled the same answers to all the questions. The survey elovno a used sociodemographic questionnaire, a questionnaire to assess the health sta- tus (Short Form-36 Health Survey SF-36) (Ware, 1993) and the scale of stress in zdravje d the workplace of hospital health workers ie. modified questionnaire based on the basis of a standardized questionnaire OSQ (Lindblom, 2006).The modifica- tion was made by selecting only a part of the question from the questionnaire, which was supplemented with specific issues related to the health profession. Respondents were offered 37 related to work stressors related to work organi- zation, shift work, career advancement, education, professional requirements, interpersonal communication, communication of healthcare workers with pa- tients, and fear of dangers (Lindblom, 2006).Statistical analysis was performed using SPSS ver. 24.0. The statistical test used was -squared test. As the level of statistical significance of differences, taken a common value of p <0.05. For dis- playing the average values the arithmetic mean and standard deviation were used. The correlation is done with the help of the Pearson and Sperman correlation coefficient test. Results The study included 150 respondents, aged 20 years and over, and the average age was 39.97 years (SD = 12.84). The youngest patient was 20 years old while the oldest participant was 60 years old. The share of the female population in this, as well as in the majority of similar studies were dominant (72%), which is expected, when it comes to the profession. There was a significant difference in terms of age and sex (χ2 = 17,987; p <0.001). More than half of respondents are (66%) while the remaining 34% are not married. Table 1: Arithmetical means and standard deviations domain of the SF- 1 36 questionnaire with nurses and technicians working in surgical and 15 internal medicine department. urses Workplace of respondents f n Mean (SD) ife o Domains of the SF-36 questionnaire Surgery and inter- f l Surgery department Internal medicine department nal medicine de- partment uality o Physical functioning 83.80 (16.78) 86.32(18.39) 85.20 (17.68) nd q Limitation due to physical health 73.13 (36.49) 76.50(37.92) 75.00 (37.20) rs a Body pain 79.55(24.06) 82.40(24.43) 81.13(24.22) tresso General health 69.17(14.83) 72.71(18.63) 71.13 (17.07) elated s Vitality 60.59(13.58) 64.81(13.97) 62.93(13.91) rk ro Social functioning 70.29(24.20) 74.36(26.03) 72.55(25.23) w Limitation due to emotional problems 71.08(16.78) 86.32(18.39) 73.93 (36.26) Mental health 49.94 (6.66) 48.90 (7.05) 49.36 (6.88) Body health component 76.37 (17.73) 79.39 (19.65) 78.04 (18.81) Mental component of health 63.43 (15.37) 66.56 (14.69) 65.16 (15.03) Between the the groups of different places of work no statistically sig- nificant difference in physical function as a measures of physical health, with the largest percentage of respondents (84%) belong to the category of excellent physical function, 14% belong to a group that has a good physical functioning, while only 2% of respondents have a poor physical functioning. Very good functioning 64% of respondents, 26% have a good level of functioning, while 10% of respondents have a poor level of social functioning. Expressed limita- tions due to emotional problems has 27.3% of respondents, moderate limitations has 2.7% of respondents, while the majority of respondents (70%) do not have due to emotional problems. That respondents who work at the surgical department rated stress factors at work with the highest grades in higher percentage compared to respondents who work at the internal department: work overload (82,60%),financial constraints (79,70 %), 24-hour responsibility (73,60%), on- call duty (68,53%), unforeseen situations (50,53%), incurable patients (51,46%), a small number of health workers (48,40%), public criticism (63,43%).Pearson’s correlation coefficient (r) has shown that there is a statistically significant correlation between workplace stress and quality of life of respondents working at the surgical and internal department (r = 0,263; p <0,001). That correlation is low and negative for respondents who fall under the category of those who are more exposed to stress in the workplace show a poorer physical and mental component of life quality (Table 2). 2 Table 2: Correlation coefficients between total stress-related to work and 15 quality of life of the respondents. n pulatioo Stress in the workplace Stress in the workplace ge p and the quality of life The correlation coefficient and the quality of life The quality of life (total score) rking-ao The correlation coeffi- he wf t cient (r) 1 -0.263 Stress in the workplace p 0.001 ealth o (total score) | h Number of respondents 150 150 pulacije o The correlation coeffi- cient(r) -0.263 1 ktivne p The quality of life p 0.001 elovno a Number of respondents 150 150 zdravje d Discussion Our research has shown that healthcare workers show the best quality of health in physical functioning, absence of physical pain, limitations due to physical health problems and limitations due to emotional problems, in social functioning and general health. A lower level of health quality is seen in the me- dian values of mental health and vitality. The most frequent factors of stress in our research: work overload, financial constraints, 24h responsibility, duty, contingency, incurable patients. Respondents who are more exposed to stress in the workplace showed poorer physical and mental component of quality of life According to our research, the level of stress among nurses is very high (60%). The difference was also observed in the view that financial constraints are one of the main stressors. Quality of life is obviously the first psychological category, which does not arise automatically from satisfying certain ba- sic needs, but from the whole psychological structure of the individual inter- acting with the physical and social environment in which he lives. The results of our research have shown that nurses rated their physical health as excellent, while mental health was rated as good. Compared to similar studies, the results of our research were significantly better than the results of the study conducted in Chile (Andrades Barrientos and Valenzuela Suazo, 2007), and lower than the results of the study carried out in Turkey (Cimete, 2003). By analyzing the quality of life domains, it has been found that nurses have shown the best quality of health in physical functioning, absence of physical pain, limitations due to problems in physical health, limitations due to emotional problems, social 315 functioning and general health. Positive emotions at work are associated with better health, a higher degree of job satisfaction, responsible behavior at work, higher work performance and quality of work, greater resistance to stress and ursesf n burnout, less likely to change jobs, better relations with other people (Haba- ife o zin, 2013). f l Conclusions uality o The workplace significantly influences the emergence of stress. Respondents nd q working at the surgical department have a higher level of stress compared to rs a respondents working at the internal department, and there is a significant cor-tresso relation between professional stress and quality of life. Respondents who are more exposed to professional stress show a lower level of physical and mental elated s components of life quality. The most frequent professional stress factors in the rk ro respondents are work overload, financial constraints, 24 hours of responsibili-w ty, on-call duty, unpredictable situations, incurable patients, a small number of health workers and public criticism. References ANDRADES BARRIENTOS, L. and VALENZUELA SUAZO, S., 2007. Qual- ity of life associated factors in Chileans hospitals nurses. Revista Lati- no-Americana de Enfermagem, vol. 15, no. 3, pp. 480−486. CIMETE, G., GENCALP, N.S. and KESKIN, G., 2003. Quality of life and job satisfaction of nurses. Journal of Nursing Care Quality, vol. 18, no. pp.151−158. HABAZIN, I., 2013. The association with emotional behavioral and physiolog- ical response to the work of nurses and technicians in hospitals. Croatian Review of Rehabilitation Research, vol. 49, no.1, pp. 37−48. HINGLY, P., 1984. The humane face of nursing. Nursing Mirror, vol. 159, no. 21, pp. 19−22. KAEWANUCHIT C., MUNTANER C. and ISHA, N., 2015. A Causal relation- ship of occupational stress among university employees. Iranian Journal of Public Health, vol. 44, no. 7, pp. 931−938. KANG, S.H., BOO, Y.J., LEE, J.S., HAN, H.J., JUNG, C.W. and KIM, C.S., 2015. High occupational stress and low career satisfaction of Korean surgeons. Journal of Korean Medical Science, vol. 30, no. 2, pp. 133−139. KOWALCZUK, K. and KRAJEWSKA-KULAK, E., 2015. Influence of selected sociodemographic factors on psychosocial workload of nurses and asso- ciation of this burden with absenteeism at work. Medycyna pracy, vol. 66, no. 5, pp. 615−624. LIN, C., WANG, L. and ZHAO, Q., 2015. Factors related to health-related qual- 4 ity of life among Chinese psychiatrists: occupational stress and psycho- 15 logical capital. BMC health services research, vol. 22, no. 15, pp. 20−27. n RYBOJAD,B., AFTYKA, A., BARAN, M. and RZONCA, P., 2016. Risk fac- tors for posttraumatic stress disorder in Polish paramedics: a pilot study. pulatioo Journal ofEmergencyMedicine, vol.50, no.2, pp. 270−276. ge p ROMANO, M., FESTINI F. and BRONNER, L., 2015. Cross-sectional study on the determinants of work stress for nurses and intention of leaving the rking-ao profession . Professioni Infermieristiche, vol. 68, no.4, pp. 203−210. he w STACCIARINI, J.M.R. and TROCCOLI B.T., 2004. Occupational stress and f t constructive thinking: health and job satisfaction. Journal of Advanced Nursing, vol. 46, no. 5, pp. 480−487. ealth o| h pulacije o ktivne p elovno a zdravje d Slovenian workers – is it too hot to work? Tjaša Pogačar, Lučka Kajfež Bogataj University of Ljubljana, Biotechnical Faculty, Jamnikarjeva 101, 1000 Ljubljana, Slovenia tjasa.pogacar@bf.uni-lj.si; lucka.kajfez.bogataj@bf.uni-lj.si Abstract Introduction: Frequency, duration, and intensity of heat waves have increased in Slovenia (and Europe), so the thermal resilience of workers is being addressed in the European Heat-Shield project (Horizon 2020). Methods: Wet bulb globe temperature (WBGT) index has been chosen to assess the thermal load of workers. Air temperature and relative humidity inside the factory are being measured to calculate WBGT, meteorological data were gained from the Celje station. A survey about heat stress impacts was conducted among workers (in the factory, farmers, tourist guides, in publishing house, at faculty). Results: In the factory reached air temperatures in August 2016 to 33°C, WBGT values were mainly between 20 and 25°C. Workplace temperature is during summer suitable for less than 5% workers in the factory and agriculture, and for 20% office workers. Heat stress has a negative impact on productivity, concentration, and well-being. Thirst, excessive sweating, tiredness, headache, and exhaustion are common (mainly more than 55%), some have already experienced worse health problems (nausea, prickly heat, muscle and heat cramps, fainting, heat stroke). Discussion and conclusions: As heat stress is already causing problems, various solutions for its mitigation will be developed and tested in the next step of the Heat-Shield project. Keywords: heat stress, heat wave, workers, productivity, health, well- being As it states in its Executive Summary, EU funded project Heat-Shield (HS, 2016) addresses the negative impacts of workplace heat stress on the health and productivity of the EU workforce. The main mission of the project is to access the negative impacts of workplace heat stress on the health and productivity of workers in strategic European industries (manufac- doi: https://doi.org/10.26493/978-961-7023-32-9.155-164 turing, construction, transportation, tourism and agriculture) and the poten- tial increase of these impacts as climate change progresses. Results of the project should provide the know-how to the European community ranging from the individual citizen to public and private policymakers towards implement- ing methods and procedures that will secure health and productivity despite aggravated workplace heat levels. According to World Health Organisation (WHO, 2015), it is anticipated that the rising temperatures in Europe during the 21st century will have significant detrimental impacts on the health of local populations – especially in occupational settings – and, as climate change becomes more prevalent, excess heat-related morbidity and mortality will rise between 3% and 6%. Air temperatures in Slovenia have already increased more than in average in Europe, for instance in Ljubljana in the period 1961–2011 by 0.4°C per decade, maxi- mum values and summer averages even more (ARSO, 2014). Under the mod- 6 erate RCP4.5 scenario it can be expected that will the average air temperature 15 in Slovenia in 2011–2040 increase by 1°C regarding the period 1981–2010 and by n another one degree in the next 30-year period (ARSO, 2016). Also, the number of hot days and heat waves is increasing; one example can be seen in Figure 1, pulatioo showing the decadal number of days and average maximum air temperature in ge p heat waves in Bilje in the period 1966–2015. rking-ao he wf t ealth o| h pulacije o ktivne p elovno a zdravje d Figure 1: Decadal number of days (black) and average maximum air temperature (gray) in heat waves (at least 5 consecutive days Tmax ≥ 29.5°C) in years from 1966 to 2015 in Bilje(data: ARSO, 2016). The hottest part of Slovenia is southwest. For example, in Bilje near No- va Gorica in 1960. and 1970. years in average 15 to 30 hot days (maximum dai- ly air temperature equal or higher of 30°C) were detected per year, while in last 15 years there was 35 to 50 hot days per year. In 2003 daily maximum air temperature was higher than 30°C every day between 15 July and 24 August. There is also an increase in the number of tropic nights (minimum daily air tempera- ture does not fall below 20°C), which have a negative effect on sleeping and re-generation after a hot day. The 5-year Heat-Shield project has started in 2016, so it is at the end of its first stage, analyzing current working conditions in the five sectors. Heat stress is readily associated with high environmental temperatures and humidities (Bernard and Cross, 1999), so WBGT (Wet Bulb Globe Temperature) index has been chosen as the most appropriate one to describe working conditions (Gao et al., 2017) and will be used for monitoring, climate change projections and monthly forecasts. Some measurements of conditions in the manufacturing plant are presented, followed by results of heat stress survey among work- ers at various workplaces. Methods Air temperatures are measured every 15 minutes at several workplaces in the 7 manufacturing plant near Celje at 1.5 and 0.05 m height along with relative hu-15 midity at 1.5 m. Measurements are carried out by Jozef Stefan Institute. Tem- rk? perature and relative humidity data for 1 August to 20 August 2016 from one o sensor at 1.5 m were used (the others have not work during last summer yet). o w WBGT index [°C] is calculated using Lemke and Kjellstrom (2012) formula- ot t o h tion, following Bernard and Pourmoghani (1999). For in shadow/indoor condi- ot t tions air temperature (Ta [°C]) and dew point temperature (Td [°C]); calculat- s i ed from relative humidity) is used: rkers – io WBGT=0,67T_pwb+0,33T_a, where T is a psychrometric wet bulb temperature (artificially created condi- pwb tions with a wind speed of 3-5 m/s), determined by iteration from air and dew slovenian w point temperature (equations in McPherson (2008)). Air temperatures at mete- orological station Celje for the same period were obtained from Slovenian En- vironmental Agency. Survey about heat stress at work, symptoms, health problems and their own solutions were made in the year 2016 among 808 workers using compre- hensive questionnaires. Half of them are employed in manufacturing plant, 28% in agriculture (not necessarily their only financial source), 15% of participants work mainly in office (publishing house or Biotechnical Faculty), and 7% of them are tourist guides. Office workers were included for comparison al- though they do not belong in any of five sectors addressed by Heat-Shield. Men are prevailing only among agricultural workers (62%), and women in other groups (65% in manufacturing plant and offices, 52% in tourist guides). Groups are age-homogenous: 25% under 30 years old, 29% from 31 to 40 years, 25% from 41 to 50 years, and 21% over 50 years old. Results and discussion Measurements in the manufacturing plant are showing very high temperatures during summer, but the situation is only a little better during the rest of the year. In the analysed period, the temperatures outside vary from 6 to almost 30°C, but the temperatures at the workplace never fall below 22°C and rise up to 33°C (Figure 2). WBGT values are mainly between 20 and 25°C, which is al- ready high for moderate or heavy work, as heat stress management have to start around WBGT value of 25°C for heavy work (Gao et al., 2017). Workers in this manufacturing plant are reporting thermal discom- fort, especially if they need to wear specific clothes like thick black polo shirts, which are not a part of protective clothing. The effectiveness of our autonomic heat dissipation capacity is related to what type of clothing is worn and the environmental conditions (Lucas et al., 2014). 815 n pulatioo ge p rking-ao he wf t ealth o| h pulacije o Figure 2: Working conditions in the manufacturing plant near Celje: measured air temperature at one workplace at 1.5 m height (T workplace), ktivne p calculated WBGT index (WBGT workplace) and measured air temperature at meteorological station Celje (T outside). elovno a In the manufacturing plant, the cooling system is not efficient enough due to injection molding machines as additional heat sources. For 20% of work- zdravje d ers working conditions during heat waves are perceived as hot, for another 20% too hot, and for 45% extremely too hot (Figure 3). Tourist guides did not an- swer that question as they do not have a permanent workplace. Conditions are certainly better in offices, as 66% workers have air conditioning at their workplace and 11% in the vicinity. However, more than half of them did rate work- ing conditions during heat waves as hot (or worse), and only for 20% workers is the temperature suitable, so air conditioning does not solve the problem as a whole. For 27% of agricultural workers is working outside during heat waves extremely too hot and for 36% too hot. There were no significant variations be- tween age groups even though with the aging of the workforce, it’s resilience to heat stress degrades with further negative effects on health and productivity. 915 rk? o o w ot t o hot ts i Figure 3: Thermal comfort at workplaces during heat waves (754 workers). rkers – io slovenian w Figure 4: Perceived negative impact of hot working conditions during heat waves (808 workers). According to Lucas et al. (2014), occupational heat exposure threatens the health of a worker not only when heat illness occurs but also when a worker’s performance and work capacity is impaired. Figure 4 gives a clear sign, how high is the negative influence of heat stress on various areas, although work- ers in the manufacturing plant and tourist guides did not have a choice of the answer ‘impact on productivity’ due to their working regime. Only 20% office workers and even fewer others think that there is no negative impact of heat. The highest assessed is the negative impact on well-being (60-75%), followed by the negative impact on productivity in agriculture (68%) and by the nega- tive impact on mental concentration in the manufacturing plant (67%) and in offices (56%). 016 n pulatioo ge p rking-ao he wf t ealth o| h Figure 5: Perceived symptoms of heat stress during work in the pulacije o summertime (808 workers). ktivne p The highest negative impact on well-being is well reflected in perceived symptoms of heat stress (Figure 5). Thirst and excessive sweating are common during summertime, but it can be seen that in the office is easier to drink regu-elovno a larly than at other workplaces. Around 60% of workers in each sector are tired because of heat stress, they are reporting also about enhanced stress and dizzi-zdravje d ness (15-30%), and confusion (5-15%). The latest three symptoms are the least expressed at office workers and comparable for the others. Mild effects are certainly more common, but in extreme cases, people can get seriously sick or die. Among 808 workers have 31 already been hospitalized because of heat-induced health problems. The most common health problems in the manufacturing plant are a headache and exhaustion (more than half of the workers), and in other three sectors exhaustion – in agriculture, more than 60%, followed by a headache (Figure 6). In tourism is the next problem prickly heat and in the manufacturing plant nausea or vomiting (more than 20%). There have also already been problems with muscle cramps, fainting, and ex- ceptionally heat cramps or even heat stroke. 116 rk? o o w ot t o hot ts i Figure 6: Heat-induced health problems experienced working during heat waves (808 workers). rkers – io To minimize excessive heat exposure in the workplace, it is recommend- ed that workers and employers regularly review the potential impacts of heat on workers’ health and productivity (Lucas et al., 2014), but this is not yet a slovenian w common practice in Slovenia. There are some instructions published on the La- bor Inspectorate web-site (IRSD, 2015) and for internal use on Chamber of safe-ty and health at work (ZVZD, 2015). However, only workers in the manufactur- ing plant were in majority informed about heat stress impacts (4 out of 5), while 80% of office workers was not informed by the employer, and also 75% of tourist guides and almost 60% of agricultural workers did not get any heat-related warning by advisors. Mainly only agricultural advisors in Southwestern Slovenia have the necessary knowledge on heat stress and important precautions. Anyway, workers try to help themselves by drinking more water (80- 90%). In agriculture, the majority of workers try to adjust their working schedule (70%) and take breaks in a cooler space. In office and in tourism they try to wear appropriate clothes and in tourism also to take breaks in a cooler space (Figure 7). In the manufacturing plant, they have to follow many regulations and fulfill the working norm, so they have much less freedom in the choice of clothing, working schedule and breaks, therefore more than 20% of them an- swered that they cannot do anything to reduce the exposure to heat stress. 216 Figure 7: Workers’ opinion (808), how one can reduce the exposure to heat n stress. pulatioo Conclusions ge p In the field of heat stress negative impacts on workers’ health and productivity is a major need for intersectoral collaboration. The knowledge that we already rking-ao have or that we will obtain in further research needs to be transferred into he w recommendations so that employers can maintain health and productivity of f t their workforce. Among many themes that need to be addressed in the future is also the definition and analysis of heat waves, which is in progress in Slove-ealth o| h nian Environmental Agency and Biotechnical Faculty. Even though summer temperatures do not seem extremely high in Slovenia, workers already report pulacije on heat stress at their workplaces. Climate change will bring a further increase o in a number of hot days, which will worsen the heat stress working problems in Europe and also in Slovenia. ktivne p The survey among 808 workers has shown that there are some symptoms of heat stress very common among workers (thirst, excessive sweating, tired- elovno a ness) and that they usually lead to a headache, exhaustion, nausea or vomiting, and prickly heat. Workers sense the negative impact of heat stress on their well-zdravje d being, mental concentration, and productivity. In some cases, health problems even had to be cured in the hospital. However, apart from some web instruc- tions, there has never been a serious campaign to inform employers and work- ers about heat waves and to propose solutions. This is also one of the further steps in the Heat-Shield project, where we will develop a warning system and test various solutions, depending on workplace specifics. Acknowledgments The work was supported by the European Union Horizon 2020 Research and Innovation Action (Project number 668786: Heat Shield). We are indebted to Profs. Igor Mekjavić, Lars Nybo, Andreas Flouris and Tord Kjellstrom for their assistance. References ARSO, 2014. Klimatološki trendi, Agencija RS za okolje [Date of access 5. 3. 2017]. Available at http://meteo.arso.gov.si/met/sl/climate/trends/ ARSO, 2016. Scenariji podnebnih sprememb, Agencija RS za okolje [Date of access 7. 3. 2017]. Available at http://meteo.arso.gov.si/uploads/probase/ www/climate/PSS/scenariji/letak_RCP45_2070.pdf BERNARD, T.E. and CROSS, R.R., 1999. Case Study Heat stress management: Case study in an aluminum smelter. International Journal of Industrial Ergonomics, no. 23, pp. 609-620. BERNARD, T.E. and POURMOGHANI, M., 1999. Prediction of Workplace Wet Bulb Global Temperature. Applied Occupational and Environmental 316 Hygiene, no. 14, pp. 126-134. GAO, C., KUKLANE, K., ÖSTERGREN, P.O. and KJELLSTROM, T., 2017. Oc- rk? o cupational heat stress assessment and protective strategies in the con- o w text of climate change [in press]. International Journal of Biometeorolo- ot t gy. [Date of access 15. 5. 2017]. Available at DOI 10.1007/s00484-017-1352-y o ho HS (Heat-Shield project), 2016. Available at https://www.heat-shield.eu/ t ts i IRSD (Inšpektorat RS za delo), 2015. Ukrepi delodajalca ob visokih temper- aturah na delovnem mestu [Date of access 3. 4. 2017]. Available at http:// rkers – io www.id.gov.si/fileadmin/id.gov.si/pageuploads/Varnost_in_zdravje_ pri_delu/VISOKE_TEMPERATURE_-_PROMOCIJA/visoke_tempera- ture_na_dm_sj_2015.pdf slovenian w LEMKE, B. and KJELLSTROM, T., 2012. Calculating Workplace WBGT from Meteorological Data: A Tool for Climate Change Assessment. Industrial Health, no. 50, pp. 267-278. LUCAS, R., EPSTEIN, Y. and KJELLSTROM, T., 2014. Excessive occupational heat exposure: a significant ergonomic challenge and health risk for current and future workers. Extreme Physiology and Medicine, no. 3 [Date of access 10. 3. 2017]. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4107471/ McPHERSON, M.J., 2008. Subsurface Ventilation and Environmental Engi- neering, 2nd Ed., Ch. 17. Physiological reactions to climatic conditions. Mine Ventilation Services Inc., Clovis [Date of access 25. 11. 2016]. Avail- able at http://www.mvsengineering.com/index.php?cPath=25 WHO (World Health Organisation), 2015. Available at http://www.euro.who. int/en/health-topics/environment-and-health/occupational-health ZVZD (Zbornica varnosti in zdravja pri delu), 2015. Toplotno okolje na de- lovnem mestu (ZZZS in ZVZD): Neuradni prevod navodil za toplot- no okolje na delovnem mestu HSE, Velika Britanija [Date of access 14. 4. 2017]. Available at: http://www.zbornica-vzd.si/media/Toplotno%20 ugodje-%20UK%20smernice_06_07_2015.pdf 416 n pulatioo ge p rking-ao he wf t ealth o| h pulacije o ktivne p elovno a zdravje d Characteristics of physical activity among pregnant women Andreja Rijavec1, David Ravnik2, Mirko Prosen2 1 Community Health Centre Nova Gorica, Rejčeva ulica 4, 5000 Nova Gorica, Slovenia 2 University of Primorska, Faculty of Health Sciences, Department of Nursing, Polje 42, 6310 Izola, Slovenia andreja.rijavec@gmail.com Abstract Introduction: Moderate physical activity should be a part of every day life during pregnancy of course if the woman does not have any health problems or any complications relating to pregnancy. The aim of the research was to determine how and in which way pregnant women are physical active and if there is any correlation between physical activities during pregnancyregardless of their socio-demographic characteristics. Methods: The nonexperimental empirical method was used. Semi- structured questionnaire was applied on convenience sample of pregnant women (n = 46) who had been attending prenatal education courses in December 2015 and January 2016. The average age of the respondents was 29 years (s = 4.0). The majority of them (39.9%) had completed an upper secondary education; lived in rural areas (63%); were in 29th week of gestation (s = 6) and were primiparous (84.8%). In addition to the basic descriptive statistics Pearson correlation coefficient was used. Results: The results suggest that pregnant women are trying to be physical active during pregnancy, because they are aware of its positive effects on pregnancy, childbirth and know the reasons when physical activity is contraindicated. The majority of them are engaged inphysical activity four times per week; walking is the most common type (54.5%); only 19.6% of pregnant women attend organized physical exercises for pregnant women. Multiparous women compared with primiparous women are more physically active (p = 0.543). Age, levelof education and place of residence are not statistically significantly associated with the implementation of physical activity in everyday life (p>0.05). Discussion and conclusions: One of the most important factors that contribute to a healthy pregnancy, childbirth and postpartum period is physical activity during pregnancy. The results suggest that pregnant women are well aware of these effects, but the implementation of physical activity doi: https://doi.org/10.26493/978-961-7023-32-9.165-170 is not always proportional to this. Organized physical exercises, where established, are insufficient for adequate preparation for childbirth. Key words: physical activity, pregnancy, health, lifestyle, fetus Regular, appropriate and adapted to the appropriate intensity physical ac- tivity is nowadays one of the most important factors of a healthy lifestyle and has an extremely positive effect on the human organism (Videmšek et al., 2015). In addition Videmšek at al. (2015) report that moderate physical activity during pregnancy should also be a part of an expectant mothers‘ every- day life; if the latter does not have any health problems or any complications relating to the pregnancy. Physical activity during pregnancy, initially has a very positive impact on the health of pregnant women and the developing fetus, but it has also proved to be extremely helpful in preparation for childbirth (Videmšek et al., 2015). 616 Blenkuš et al. (2015) claim that various research shows that physical activity during pregnancy reduces the occurrence of certain risk factors, thereby re-n ducing the risk of poor health of pregnant women and the fetus. Physical ac- tivity has a beneficial effect on both the immune system and the mental state pulatioo of pregnant women. ge p In the case of a pregnant, healthy woman, there is almost no reason to rking-a avoid physical activity. If the pregnant woman is both physically and mental- o ly well prepared the birth will be easier and recovery faster. A suitable physical he w activity in combination with a healthy diet has a positive effect on fetal growth f t and development, contributing to better health and to facilitate childbirth and ealth o a faster return to physical fitness after childbirth itself (Mlakar et al., 2011). | h The aim of the research was to determine how much and how physical- ly active womenare during pregnancy, and what connection there is between pulacije o physical activity during pregnancy, and their socio-demographic characteris- tics. ktivne p Methods elovno a Sample description The sample included 46 women.They attended schools for future parents in the zdravje d period from mid-December 2015 till the end of January 2016. The average age of the respondents was 29 years (s = 4.0). From the sample 39.9% had complet- ed secondary education; live in rural areas: 63%; on average, they were 29 weeks intothe pregnancy (s = 6) and primiparous women: 84.8%. Description of the instrument The method of data collection based on a questionnaire consisted of 20 ques- tions mostly closed type. The questions are divided into three sections. The first part of the questionnaire includes demographic information, a second set cov- ers issues relating to the implementation of physical activity during pregnancy,the appropriate choice of activities during pregnancy and knowledge of the positive effects of physical activity during pregnancy and it impact on pregnancy and childbirth.In the third part, the respondents were offered the opportu- nity to express their opinions and feelings. Data processing The survey was conducted between 15/12/2015 and 31/1/2016. Participation was voluntary and anonymous. Participants were presented the aims and objec- tives of the study and given the option of feedback. The data were analysed after the completion of the program using an ex- cel spreadhseet. It was decided that the best way to test the hypotheses was to use Pearson‘s correlation coefficient. The statistical significance level of p < 0.05 was applied. 716 Results en om Our results showed that more than half (69.6%) of women surveyed were al- ready physically active before pregnancy. Before pregnancy, women prefered nant w walking (brisk walking, hiking). This form of activity is carried out by almost reg a third (28.1%) of respondents. This was followed by other types of physical ac-g p tivity, such as jogging, fitness, cycling and aerobics. All these activities, most mon respondents (77.4%) before pregnancy carried out several times a week, while other respondents (13%) were physically active only once a week. Some women ctivity a surveyed were active every day (9.7%). Physical activity was discouraged in 8 pregnant women (17.4%). 33 preg- hysical a nant women (71.7%) confirmed that they were regularly physically active dur- f p ing pregnancy. The type and level of physical activity during pregnancy slightly istics o changed. Still, more than half (54.5%) of the respondents decided to walk. Al- most 20% (19.6%) of women attended an organised exercise for pregnant wom- en, less than 15% of the women conducted yoga and aerobics, ran and swam. On character average they exercise regularly 4 times a week. Runtime exercise is varied from a minimum of 14 minutes to 120 minutes, on average, 48 minutes. The proportion of women who were active once a week before pregnancy, decreased their physical activity during pregnancy, in comparison with proportion of those who were active before pregnancy every day, but during pregnancy they in- creased their physical activity. According to the other results of the study we canadopted certain con- clusions such as: − demographic factors such as age (p = 0.06), education level (p = 0.28) and living environment (p = 0.08) can not affect the physical activity of women; − 71,7% of those women, who parcitipated in the survey and who are physically active during pregnancy, believe that the doing physical activity during pregnancy does not endanger the health of their fe- tus or cause it to be lost, just the opposite; − 100% of women who participated in the survey, believe that physical activity during pregnancy could have a significantly positive impact on the health of the child and themselves, women were generally well aware of the positive effects of doing physical activity during pregnancy to childbirth and fetal development, and the belief that activity during pregnancy harms the health of the fetus is no longer valid; − those women who have already had experiences with pregnancy and childbirth, find it easier to opt for physical activity during preg- nancy and are more physically active (p = 0.54). 816 Discussion n If the results of our research are compared with the results of the survey, which Makara-Studzinska et al. (2013) conducted in Poland, we see that the majori-pulatioo ty of women in the Polish study (71% of respondents) were physically active be-ge p fore pregnancy, the percentage of active of women during pregnancy also in- creased. Before pregnancy, in the Polish study (ibid.), women prefer walking. rking-ao Other practiced aerobics, few werecyclists, attended gym, swimming and run- he w ning. The Polish study also founds that the majority of women surveyed be- f t fore pregnancy were active several times a week, some at least every day. During pregnancy, the degree of physical activity change, as the majority of women ealth o| h were physically active once a week, a few less times a week, but at least every day. pulacije Among the types of physical activity the most popular was walking, o some of the women surveyed had chosen exercise at home, swimming, exercise ktivne p and yoga for pregnant women. Just as in our study, the Polish study of Maka- ra-Studzinska et al. (2013) shows that the relationship between physical activity before and during pregnancy is very low or non-existent. elovno a With results of both studies (our and above mentioned Polish study) we can see the assertion that women,when they are recognising that they are preg- zdravje d nant, stop with physical activities and spend the rest of the pregnancy sitting down because of the convictionthat physical activity during pregnancy causes injury and the loss of a child, it is not valid anymore. If, however, our research compared with the research of Merkxet al. (2017) conducted in the Netherlands, we see that more than half of the 455 healthy pregnant women participating in the survey of Merkx et al., decreased level of physical activity during pregnancy. Less than 5% of the women participating in the study of Merkx et al. (2017), increased physical activity during pregnan-cy. Which means that the results of that research, is in contrast with the results of our research. The results of our study showed that the proportion of wom- en surveyed who have opted for physical activity during pregnancy increased above the proportion of women surveyed who were physically active before pregnancy. It is understood how important it is that pregnant women are properly informed about what is recommended during pregnancy. In conjunction with this, our research found that a 100% of women surveyed are aware of the posi- tive effects of physical activity during pregnancy on pregnancy, childbirth, and on pregnant woman. Conclusions During pregnancy women‘s emotions are more intense, there is a psychological change, and the body makes both visible and invisible changes. Pregnancy is a happy and miraculous event and a lot of things start to change during this pe- riod. When women find out about being pregnant they frequently asked them- 9 selfs what they can do while pregnancy. One of the most important factors 16 affecting the good course of the pregnancy, childbirth and the health of preg- en nant women and children, is definitely a physical activity of pregnant women. om Just a while ago, on the news that they were pregnant, women stopped using all physical activity because they were convinced that physical activity would nant w harm the development of their child and due to pregnancy they were among regg p the most vulnerable groups of women. Since this the world and the way of mon life are constantly changing and new discoveries emerged, this belief has been somehow eradicated in women‘s perception. The results of our research showed ctivity a that women today are well aware of the effects of physical activity during pregnancy on the health of the pregnant woman and the baby, and on pregnan- cy and child birth as well. They know when physical activity is advised during hysical af p pregnancy and when should it be stopped. However, a lot more women choose physical activity during pregnancy precisely with the reason that they will con-istics o tribute to the best possible development of the child, to the health of their own and to the easier and more beautiful course of pregnancy and childbirth. character References BLENKUŠ, Š., ČEMAŽAR, V., VIDEMŠEK, M., HADŽIĆ, V., PIRKMAJER, S. and ROTOVNIK-KOZJEK, N., 2015. Pomen telesne dejavnosti v nosečnos- ti. In: NOVAK-ANTOLIČ, Ž., KOGOVŠEK, K., ROTOVNIK-KOZJEK, N. in MLAKAR-MASTNAK, D., ed. Klinična prehrana v nosečnosti. Lju- bljana: Center za razvoj poučevanja, Medicinska fakulteta, Univerza v Ljubljani, pp. 145−160. MAKARA-STUDZINSKA, M., KRYS-NOSZCZYK, K., STARCZYNSKA, M., SIERON, A. and SLIWINSKI, Z., 2013. Types of physical activity dur- ing pregnancy [online]. Polish annals of medicine, 2013, no. 20, pp. 19−24. [Viewed 19.1.2015]. Available from: http://www.sciencedirect.com/sci- ence/article/pii/S1230801313000052 MERKX, A., AUSEMS, M., BUDE, L., DE VRIES, R. and J. NIEUWENHU-IJZE, M., 2017. Factors affecting perceived change in physical activity in pregnancy [online]. Midwifery, 2017, vol. 51, no. 9, pp. 16−32. [Viewed 5. 6. 2017]. Available from: http://www.midwiferyjournal.com/article/S0266- 6138(17)30352-2/fulltext MLAKAR, K., VIDEMŠEK, M., VRTAČNIK-BOKAL, E., ŽGUR, L. and ŠĆEPANOVIĆ, D., 2011. Z gibanjem v zdravo nosečnost. Ljubljana: Uni- verza v Ljubljani, Fakulteta za šport, pp. 7. VIDEMŠEK, M., BOKAL-VRTAČNIK, E., ŠĆEPANOVIĆ, D., ŽGUR, L., VIDEMŠEK, N., MEŠKO, M., KARPLJUK, D., ŠTIHEC, J. and HADŽIĆ, V., 2015. Priporočila za telesno dejavnost nosečnic. Zdravniški vestnik, vol. 84, no. 2, pp. 87−98. 017 n pulatioo ge p rking-ao he wf t ealth o| h pulacije o ktivne p elovno a zdravje d The impact of shift work on cardiovascular diseases among nurses Tanja Ritonja, Dragana Pejnović, Lucija Roblek, Andrej Starc University of Ljubljana, Faculty of Health Sciences, Zdravstvena pot 5, 1000 Ljubljana, Slovenia tanjaritonja@gmail.com; pejnovic.dragana@gmail.com; lucija.roblek@gmail.com; andrej.starc@zf.uni-lj.si Abstract Shift work is defined as the work, which is time-permanently or frequently disposed outside the standard operating time. It affects the majority of bodily functions which are synchronized with the 24-hour circadian rhythm. The most pronounced impact on sleep, on an autonomous vegetative processes and the ability to work. Nurses in order to ensure quality and continuous care work within these flexible working time, which still remains a necessary form of their work. Numerous studies have shown that age and the years of doing shift work among nurses increases susceptibility to internal desinhronisation and thus to a reduced tolerance for shift work, which is manifested by the appearance of health problems associated with shift work. Neurovegetative reactions in response to the collapse of the circadian rhythm, leading to increased hormonal reactions, which together with other risk factors lead to an increased risk for developing cardiovascular diseases. A review of Slovenian and foreign scientific literature confirm and reduce the existence of evidence to support the theory on the impact of shift work on the incidence of cardiovascular disease in nurses. The findings show solutions, because we are faced with the need to define additional strategies that will reduce the incidence of cardiovascular disease in nurses and the negative consequences in health care institutions and the general public policy. Key words: nurse, shift work, circadian rhythm, cardiovascular disease In recent decades, we are faced with the increasing complexity of health systems (Pryce, 2016) and social and economic requirements to increase 24-hour accessibility of health care (Vetter et al., 2016). Due to the grow- ing demand for continuing care within shift work (Hughes, 2015), currently there is no specific definition of working time in healthcare sector, but it is un-doi: https://doi.org/10.26493/978-961-7023-32-9.171-177 derstood as the work outside the normal daily working hours (Mosendane et al., 2008). As unusual working hours is considered working extended time until the evening and night hours, which lasts more than 8 hours a day (Merijan- tia et al., 2008). These atypical working patterns cause disorders of circadian rhythms (Vimalananda et al., 2015) or disorders in biological rhythm in a period of 24 hours. Circadian rhythm is one of the internal rhythms caused by ex- ternal stimuli (e.g. light) and synchronized with the environment. In humans, the most well-known internal rhythms, are the rhythm of sleeping and wake- fulness, and body temperature rhythm (Špeninger et al., 2009). Abnormal end- ings of sleeping and wakefulness phases cause disturbances in hormones se- cretion (mostly melatonin and cortisol) and increase the risk of cardiovascular disease (CVD) (Anjum et al., 2015), which are the leading causes of death in in-dustrialized countries (Yu et al., 2016), and affects more women than men (Al- lesøe et al., 2010; Gangwisch et al., 2013). In addition to the unbalanced circadi-2 an rhythm in nurses several other risk factors for CVD are included. Lifestyle 17 comes first, including an unhealthy diet, reduced physical activity, excessive n consumption of caffeine and an increased tendency to smoke (Buchvold et al., 2015; Pryce, 2016). The second group includes endocrine disorders and diseases, pulatioo which include obesity, increased blood levels of triglycerides, impaired glucose ge p tolerance and insulin sensitivity. Consequently, it comes to high blood pres- sure and diabetes (Wang et al., 2011; Buchvold et al., 2015). The third group in-rking-a cludes stress, which is a high risk factor, because the 24-hour nursing care for o the patient is very stressful for the nurse (Lo et al., 2010; Roskoden et al., 2017). he wf t The combination of all risk factors, in conjunction with long-term shift work in nurses, increases the chance of myocardial infarction, coronary complications ealth o (Vyas et al., 2012) and stroke (Brown et al., 2009). | h pulacije Methods o We used a descriptive method. We reviewed Slovenian and English scientific ktivne p literature. We used databases CINAHL, PubMed, Medline, Web browser and Google Scholar and we used the following keywords: nurse, shift work, cir- cadian rhythm of cardiovascular disease. Also, we used the following limita- elovno a tions: full-text articles from 2007 to 2017. In the article we included a research conducted in 2004 since its contribution was considered important for our re-zdravje d search. The exclusion criteria were articles with inappropriate content (e.g. did not include women as health care workers and as we said did not include articles which were older than 10 years, not full-text articles). The articles acquired have been systematically analysed. A literature review was conducted from February to May 2017. Results Following the inclusion and exclusion criteria, we obtained 10 journal arti- cles reporting studies which show tangible evidence of the connection between shift work and CVD incidence in nurses. Table 1: Overview of the studies. Author/year Purpose of the research Methodology Results Shift work does not rep- Determination of the in- resent an independ- cidence of health prob- ent risk factor for nurs- Admi et al., 2008 lems and sleep disorders A cross-sectional study es health; failure to adapt among men and women the work schedule does in health care. not cause significant dif- ferences in the perfor- mance of the work. Effect of psychosocial Psychosocial work en- vironment increases the Allesøe et al., 2010 work environment is- chemic heart disease in Cohort study risk of ischemic heart Danish nurses. disease in younger nurs- es (<51years). To evaluate the rela- Nurses working in shifts Brown et al., 2009 tionship between the A prospective cohort shift and night work for study for 15 years or more have 3 women. increased risk of stroke. 17 Relationship shift work with a BMI (body mass Night shift is positive- Buchvold et al., 2015 index), smoking, alcohol A cross-sectional study ly correlated with BMI, urses and caffeine and exercise smoking, alcohol and caffeine and exercise. ng n in Norwegian nurses. om Examine the link be- Among nurses who Jørgensen et al., 2017 tween shift work and the Cohort study perform night and/or evening shift: increased iseases a mortality rate in nurses. risk of mortality. The duration of shift Relationship between work is positively associ- Kim et al., 2013 shift work with a BMI in A cross-sectional study ated with the prevalence Korean nurses. of overweight/obesity in ardiovascular d nurses in Korea. n c The study of circadi- Shift work causes signif- rk o an rhythm as a result of icant changes in the cir- o Morris et al., 2015 shift work and its impact cadian rhythm, which on the occurrence of hy- Experimental study increases the risk of hy- hift w pertension, inflamma- pertension, inflamma- f s tion and CVD. tion and CVD. Physical activity be- pact om tween nurses in relation to the work schedule and the i search for suitable ways Škrbina and Zurc, 2016 of motivating Quantitative cross-sec- Shift work reduces the to help overcome barri- tional study person's motion. ers and promote physical activity purchased under WHO guidelines. The impact of changes Van Amelsvoort et al., in the incidence of risk A prospective cohort Shift workers who smoke 2004 factors for CVD within study have increased BMI and one year. sholesterol levels. Link between shift work Shift work is associat- Vyas et al., 2012 and major vascular A meta-analysis ed with myocardial in- events. farction, stroke and oth- er coronary events. The findings suggest that shift work leads both to physiological and psychological consequences, such as biological rhythm disorders, sleeping disor- ders, health problems, reduced work performance, dissatisfaction at work and social isolation (Admi et al., 2008). Key factors which determine the health of nurses are: gender, age and body weight. The consequences of sleep withdrawal in female nurses are ex- pressed more intensely than in their male counterparts (Admi et al., 2008). Sleep disturbances in nurses with more than 15 working years and with shift work, increase the risk of CVD. In correlation between CVD and shift work: the CVD occur in 23% and rising to 4% every 5 years of age (Brown et al., 2009). The disrupting of circadian rhythm is associated with an unhealthy lifestyle and unhealthy food, smoking, drinking and low physical activity. As a result, the increasing BMI has a negative impact on health (Kim et al., 2013; Buch- vold, 2015). The reducement of physical activity is associated with chronic fatigue, low productivity and quality of work, irreversible impacts on health and 174 quality of life (Škrbina and Zurc, 2016). Shift work increases the risk of CVD in n nurses under 51years of age (Allesøe et al., 2010). The impact of socio-economic status and genetic predisposition contribute to the development of CVD (Mor-pulatioo ris et al., 2015). ge p Some authors do not confirm the thesis that shift work indirectly affects the occurrence of CVD (Van Amersvoort et al., 2004), but introduce the in- rking-ao cidence of different risk factors, which subsequently lead to the formation of he w CVD, most commonly stroke (Brown et al., 2009), ischemic heart disease (Al- f t lesøe et al., 2010), myocardial infarction and other coronary complications (Vyas et al., 2012), which are the main causes of disability (Brown et al., 2009) ealth o| h and mortality among nurses (Brown et al., 2009; Jørgensen et al., 2017). Be- sides all this we must not forget that all of these risk factors are affecting pub-pulacije lic health, public policy and the organization of work in occupational medicine o (Vyas et al., 2012). At the same time, the authors ask, what are the characteristics of nurses who successfully navigate through the challenges of shift work ktivne p (Hughes, 2015). elovno a Discussion The global epidemiological data shows that 30% of the active population works zdravje d in shifts. Shift work is a model of stressors that occur when job requirements do not match the capabilities, resources or needs of the worker and is highly correlated with CVD, irritability, dizziness, sleep disorders and muscle pain. As a result, reduced work productivity deteriorates the health status and quality of life. Therefore, health promotion is becoming an important strategy of many companies. The effort is to integrate targeted programs to change work- ers lifestyles and thus prevent the negative influence of risk factors (Richter et al., 2010). There is a growing need to integrate and implement workshops of healthy lifestyle in the healthcare sector/organizations. The workshop should be focused on nutrition, physical exercise, relaxation techniques and sleep hy- giene. Change in lifestyle and successful adaptation to shift work also depends on an individual’s personality traits and external support. One of the major roles of leadership is to encourage the implementation of healthy lifestyle workshops and regulate schedules to implement strategies to reduce stress in the workplace (Hughes, 2015). Preventing CVD consequently reduces the costs of employees’ absence (Mosca et al., 2007). Conclusions Without systematically planned and organized shift work, modern healthcare systems would not be high-quality and effective. Several scientists explored the link between shift work and the emergence of CVD. They found a positive correlation. Long-term shift work and quick replacement of circadian rhythms have a negative impact on the health and general welfare. However, we must not forget other risk factors and their influence on the development of CVD (Vyas et al., 2012). 175 Based on our findings we propose a research on the relationship with the incidence of shift work CVD in nurses using longitudinal studies. For a certain urses number of nurses the track would be kept from the commencement of their ng no employment until retirement. Sample of nurses from the research would be in- m cluded in the health promotion program, which would measure the effects of the program and the results of both research groups would be the base to plan iseases a further research and action to improve health and psycho-physical well-being of nurses. References ardiovascular d n c ADMI, H., TZISCHINSKY, O., EPSTEIN, R., HARER, P. and LAVIE, P., 2008. rk o Shift work in nursing: is it really a risk factor for nurses' health and pa- o tients' safety? Nursing economics, vol. 26, no. 4, pp. 250–257. hift wf s ALLESØE, K., HUNDRUP, Y.A., THOMSEN, J.F. and OSLER, M., 2010. Psy- chosocial work environment and risk of ischaemic heart disease in wom- pact om en: the danish nurse cohort study. Occupational and environmental med- the i icine, vol. 67, no. 5, pp. 318–322. ANJUM, B., VERMA, N., TIWARI, S., MAHDI, A., SINGH, R., NAAZ, Q., MISHRA, S., SINGH, P., GAUTAM, S. and BHARDWAJ, S., 2015. 24 hours chronomics of ambulatory blood pressure and its relation with cir- cadian rhythm of 6-sulfatoxy melatonin in night shift health care work- ers. International journal of research in medical sciences, vol. 3, no. 8, pp. 1922–1931. BROWN, D.L., FESKANICH, D., SANCHEZ, B.N., REXRODE, K.M., SCHERNHAMMER, E.S. and LISABETH, L.D., 2009. Rotating night shift work and the risk of ischemic stroke . American journal of epidemi- ology, vol. 169, no. 11, pp. 1370–1377. BUCHVOLD, H.V., PALLESEN, S., ØYANE, N.M. and BJORVATN, B., 2015. Associations between night work and BMI, alcohol, smoking, caffeine and exercise--a cross-sectional study. BMC Public health, no. 15, pp. 1112. EUROPEAN OBSERVATORY OF WORKING LIFE (EWCS), 2017. Working time in the european union: Slovenia. [viewed 20 April 2017]. Available from: https:/ www.eurofound.europa.eu/observatories/eurwork/compara- tive-information/national-contributions/slovenia/working-time-in-the-eu- ropean-union-slovenia GANGWISCH, J.E., FESKANICH, D., MALASPINA, D., SHEN, S. and FOR- MAN, J.P., 2013. Sleep duration and risk for hypertension in women: re- sults from the nurses' health study. American journal of hypertension, vol. 26, no. 7, pp. 903–911. HUGHES, V., 2015. Health risk associated with nurse night shift work: a sys- 6 tematic review. GSTF Journal of nursing and health care, vol. 2, no. 2, pp. 17 39–44. n JØRGENSEN, J.T., KARLSEN, S., STAYNER, L., ANDERSEN, J. and ANDER- SEN, Z.J., 2017. Shift work and overall and cause-specific mortality in pulatio the Danish nurse cohort. Scandinavian journal of work, environment & o ge p health, vol. 43, no. 2, pp. 117–126. KIM, M., SON, K., PARK, H., CHOI, D., YOON, C., LEE, H., CHO, E. and rking-ao CHO, M., 2013. Association between shift work and obesity among fe- male nurses: korean nurses' survey. BMC Public health, no.13, pp. 1204. he wf t [viewed 30 April 2017]. Available from: https:/ bmcpublichealth.biomed- central.com/articles/10.1186/1471-2458-13-1204 ealth o| h LO, S.H., LIN, L.Y., HWANG, J.S., CHANG, Y.Y., LIAU, C.S. and WANG, J.D., 2010. Working the night shift causes increased vascular stress and de- pulacije layed recovery in young woman. Chronobiology international, vol. 27, no. o 7, pp. 1454–1468. ktivne p MERIJANTIA, L.T., SAMARA, D.I., TENDEAN, R. and HARRIANTO, R., 2008. The role of night shift work on blood pressure among healthy fe- male nurses. Universa medicina, vol. 27, no. 2, pp. 65–71. elovno a MORRIS, C.J., PURVIS, T.E., HU, K. and SCHEER, F.A., 2016. Circadian mis- alignment increases cardiovascular disease risk factors in humans. Pro- zdravje d ceedings of the national academy of sciences of the united states, vol. 113, no. 10, pp. 1402–1411. MOSENDANE, T.H., MOSENDANE, T.S. and RAAL, F.J., 2008. Shift work and its effects on the cardiovascular system. Cardiovascular journal of Afrca, vol. 19, no. 4, pp. 210–215. MOSCA, L., APPEL, L.J., BENJAMIN, E.J., BERRA, K., CHANDRA-STRO- BOS, N., FABUNMI, R.P., GRADY, D., HAAN, C.K., HAYES, S.N., JU- DELSON, D.R. and at al., 2007. Evidence-based guidelines for cardio- vascular disease prevention in women. Journal of the american college of cardiology, vol. 49, no. 11, pp. 1230–1250. PRYCE, C., 2016. Impact of shift work on critical care nurses. The canadian association of critical care nurses, vol. 27, no. 4, pp. 17–21. RICHTER, K.D., ACKER, J., SCHOLZ, F. and NIKLEWSKI, G., 2010. Health promotion and work: prevention of shift work disorders in companies. The EPMA journal, vol. 1, no. 4, pp. 611–618. ROSKODEN, F.C., KRÜGER, J., VOGT, L.J., GÄRTNER, S., HANNICH, H.J., STEVELING, A., LERCH, M.M. and AGHDASSI, A.A., 2017. Physical ac- tivity, energy expenditure, nutritional habits, quality of sleep and stress levels in shift-working health care personnel. PLOS one, vol. 12, no. 1, pp. 1–21. ŠKRBINA, V. and ZURC, J., 2016. Physical activity of graduated nurses in one- and multiple-shift work. Obzornik zdravstvene nege, vol. 50, no. 3, pp. 193– 7 206. 17 ŠPENINGER, K., KOŠIR, R., FINK, M., DEBELJAK, N. and ROZMAN, D., 2009. Cirkadiani ritem pri ljudeh. Zdravstveni vestnik, vol. 78, no. 11, pp. urses 651–657. ng nom VAN AMELSVOORT, L.G.P., SCHOUTEN, E.G. and KOK, F.J., 2004. Impact of one year of shift work on cardiovascular disease fisk factors. The inter-iseases a national journal of occupational and environmental medicine, vol. 46, no. 7, pp. 699–706. VETTER, C., DEVORE, E.E., WEGRZYN, L.R., MASSA, J., SPEIZER, F.E., KAWACHI, I., ROSNER, B., STAMPFER, M.J. and SCHERNHAMMER, ardiovascular d E.S., 2016. Association between rotating night shift work and risk of cor- n c onary heart disease among women. The journal of the american medical rk o association , vol. 315, no. 16, pp. 1726–1734. o VIMALANANDA, V.G., PALMER, J.R., GERLOVIN, H., WISE, L.A., ROSEN- hift w ZWEIG, J.L., ROSENBERG, L. and RUIZ NARVÁEZ, E.A., 2015. Night- f s shift work an incident diabetes African-American women. Diabetologia, pact o vol. 58, no. 4, pp. 699–706. m the i VYAS, M.V., GARG, A.X., IANSAVICHUS, A.V., COSTELLA, J., DONNER, A., LAUGSAND, L.E., JANSZKY, I., MRKOBRADA, M., PARRAGA, G. and HACKAM, D.G., 2012. Shift work and vascular events: systematic re- view and meta-analysis, British medical journal, vol. 345, no. 7871, pp. 13. YU, E., RIMM, E., QI, L., REXRODE, K., ALBERT, C.M., SUN, Q., WILLETT, W.C., HU, F.B. and MANSON, J.E., 2016. Diet, lifestyle, biomarkers, genet- ic factors and risk of cardiovascular disease in the nurses' health studies. American public health association, vol. 106, no. 9, pp. 1616–1623. WANG, X.S., ARMSTRONG, M.E.G., CAIRNS, B.J., KEY, T.J and TRAVIS, R.C., 2011. Shift work and chronic disease: the epidemiological evidence. Occupational medicine, vol. 61, no. 2, pp. 78–89. Association between perceived stress, self-rated health, work productivity and stress management interventions – a study of employees in the Slovenian processing industry Nataša Sedlar Kobe1, Alenka Dovč2, Andrea Backović Juričan1, Jerneja Farkaš Lainščak3 1 National Institute of Public Health, Trubarjeva cesta 2, 1000 Ljubljana, Slovenia 2 Chamber of Commerce and Industry of Slovenia, Dimičeva ulica 13, 1504 Ljubljana, Slovenia 3 Department of Research, General Hospital Murska Sobota/ National Institute of Public Health, Ulica dr. Vrbnjaka 6, 9000 Murska Sobota/ Trubarjeva cesta 2, 1000 Ljubljana, Slovenia natasa.sedlar@nijz.si; alenka.dovc@gzs.si; andrea.backovic-jurican@nijz.si; jerneja.farkas@sb-ms.si Abstract Introduction: Employees’ high levels of perceived workplace stress has been associated with impaired health and lost productivity due to sickness absenteeism and sickness presenteeism. As a result, there’s been a growing interest in programs and interventions to reduce stress at work among organizations. Methods: The study was conducted as a part of the project Healthy on a square II – workplace health promotion for employees in the chemical and other processing industries, in March 2016 in the sample of N=796 employees in processing industries. The aim of the study was to examine the relationship between employees’ frequency of perceived stress, self-rated health, sickness presenteeism, sickness absenteeism and implemented stress management interventions. Results: The results indicated that higher frequency of perceived stress is associated with poorer self-rated health, higher number of health problems in the past month and more days of sickness absenteeism and sickness presenteeism in the past year. Regarding the implemented activities for managing work-related stress in included organisations, most commonly reported activities were informing employees about work-related stress and its consequences and stress management training provision, while organisational-level interventions were rare. Discussion: The study highlights the need for systematic implementation of stress management interventions and research on their effect on employees’ well-being and work productivity. Key words: stress at work, self-rated health, sickness absenteeism, sickness presenteeism, stress management interventions doi: https://doi.org/10.26493/978-961-7023-32-9.179-188 Stress has been given several definitions, but generally refers to individual’s physical, mental and emotional response to environmental demands or pressures that are perceived as straining or exceeding individual’s per- ceived adaptive capacities (Cohen et al., 1986). So far, a growing body of evidence suggests that excess or long-term stress contributes to impaired physical and psychological health (i.e. Schneiderman et al., 2005). Similarly, impaired employee’s physical and psychological health has been shown to be one of the most undesirable consequences of high-levels of stress at work (i.e. Cox, Grif-fiths and Rial-Gonzales, 2000; Novak, Sedlar and Šprah, 2014; Stansfeld and Candy, 2006). Stress at work gained increased attention among professionals and re- searchers over the last decades, mostly due to its high economic and human costs for organisations. Numerous studies (i.e. Biron et al., 2006; MacGregor, Cunningam and Caverley, 2008) have confirmed that impaired employee’s 0 health and high levels of stress at the workplace result in lost productivity, aris-18 ing from two sources: absenteeism and presenteeism. The first one refers to an n employee’s time away from work due to illness or disability (i.e. Johns, 2003), while the second one occurs when employee comes to work ill and his job per-pulatioo formance is limited in some aspects by a health problem (i.e. Johns 2010). Both ge p outcomes are considered part of a continuum, with presenteeism being placed between full work engagement and absenteeism (Johns, 2009) and employees rking-ao are likely to transit from one to another over time (i.e. Escorpizo et al., 2007). he w To measure work-related stress across various types of jobs and organi- f t zations several self-report instruments have been developed. However, some- times when monitoring stress at work comprehensive scales might not be ac- ealth o| h cepted by the target organisations. Therefore researchers (i.e. Elo et al., 2003) proposed the use of a single-item measure of stress. The scale refers to the gen-pulacije eral experience of stress, not explicitly to work-related stress, but was shown to o be a valid instrument for group-level analysis when monitoring stress at work. In a similar vein, a single-item measure of self-rated health is generally accept-ktivne p ed as an easy to implement and valid indicator to measure individual’s health status (i.e. Borg, Kristensen and Burr, 2000). elovno a Employee’s stress and its negative outcomes have become a concern for many organisations. Therefore there is a growing interest in programs and in- zdravje d terventions to reduce stress at work (González, Cockburn and Irastorza, 2010; Irastorza et al., 2016). Implemented stress management interventions in occu- pational settings most often focus on reducing the presence of work related- stress or aim to minimize the negative outcomes of exposure to these stressors. However, the research shows that their effect most importantly depends on the intervention type (Richardson and Rothstein, 2008). Using a sample of Slovenian industrial workers, our study investigated the relationship between employees’ level of perceived stress in terms of fre- quency, self-rated health, sickness presenteeism, sickness absenteeism and im- plemented stress management interventions in included organisations. Methods Data for his cross-sectional study were collected in March 2016 as part of the project ‘Zdravi na kvadrat II’ (engl.: ‘Healthy on a square II’) – workplace health promotion for employees in the chemical and other processing indus- tries, conducted in 17 Slovenian companies in processing industry ( n=2 small-sized companies (<50 employees); n=11 middle-sized (50-250 employees); n=4 large-sized (>250 employees)). 2-74% of the population size of included organisations completed the self-administered questionnaire. The average age of the final sample ( N=796) was 41 years and there was a slight male predominance (55.2%). Third of the participants reported having completed secondary educational level, while approximately 26% complet- ed vocational and higher vocational educational level/graduate degree. Almost half of the participants reported having sufficient income to meet their (household’s) needs (46.6%), while the rest of the sample reported having (occasional) 1 difficulties. Most of the participants were performing sedentary (43.6%), most-18 ly standing (34.4%) or light physical work (36.5%). Further details are present-ed in Table 1. tion ven Table 1: Socio-demographic characteristics of the sample. t interen Total sample (N=796) Gender (male), n( %) 439 (55.2) anagem Age (years), M± SD 40.9 ± 10.3 Educational level, n(%) tress m Primary or less 92 (11.4) nd s Vocational 205 (25.8) Secondary 267 (33.5) Higher vocational, graduate degree 204 (25.6) Postgraduate degree (master‘s, doctorate) 28 (3.5) ductivity aro Subjective sufficiency of income, n (%) k p Sufficient income to meet (household‘s) needs 371 (46.6) or Occasional difficulties 338 (42.5) Difficulties 87 (10.9) ealth, w Type of work, f (%) h Sedentary work 375 (43.6) Mostly standing 296 (34.4) f-ratedel Light physical work/standing or walking without major physical strain 314 (36.5) Heavy physical work/often lifting or moving heavy things 167 (19.4) tress, s s Forced posture 132 (15.3) Repetitive movements 200 (23.3) ceiveder p Questions regarding socio-demographical data (gender, age, educational een level, subjective sufficiency of income, type of work) comprised the initial sec-etw b tion of the questionnaire. iation Frequency of perceived stress was measured through a question: ‘How of- ten do you feel tense, stressed or under intense pressure?’ (1 – never; 2 – rarely; assoc 3 – sometimes; 4 –often; 5 – every day). Response categories 4 and 5 were used to define groups with high, 3 with medium, and 1 or 2 with low perceived stress levels. Subjective assessment of individual’s health was measured through a question: ‘How would you assess your present health? (1 – very good; 2 – good; 3 – fair; 4 – poor; 5 – very poor). Additionally, respondents were asked to indicate whether they had experienced any of the stated health problems in the previous month (chest pain during physical activity, low back pain, neck/shoulder pain, joint pain, chronic cough and mucus, swollen legs, allergy, constipation, headache, insomnia, depressive symptoms, toothache, urination problems). The total number of reported health problems per participant was calculated. All three questions were adapted from CINDI Health Monitor Core Question- naire (Prättälä et al., 2001). Sickness absenteeism was measured through the question: ‘How many days in the last 12 months have you been absent from work because of sick 2 leave? (ie. Gustafsson and Marklund, 2011). To measure sickness presenteeism 18 the question: ‘Did you go to work even though you should have taken sick leave n during the past 12 months? (yes; no; I have not been sick). If yes, how many times?’ was used (Aronsson et al., 2000). pulatioo Furthermore, management of each included organisation was asked ge p about implemented stress management interventions (i.e. provision of train- ing; a redesign of the work area; for total list see Table 3), adapted from Euro-rking-ao pean Survey of Enterprises on New and Emerging Risks, ESENER (Cox et al., he w 2010). f t Health and safety representative from each organisation was asked to as- ealth o sist with distribution and collection of questionnaires for management and | h employees. Employee participation was voluntary and anonymity guaranteed; the questionnaires were collected immediately after completion and sent to the pulacije o project coordinator. In total, there were 0.2 - 14.8% missing values per variable. Missing data ktivne p were imputed using the EM algorithm, which has been demonstrated to be an effective method of dealing with missing data (Graham, 2009), and all analy- elovno a ses were conducted using a total of 796 participants. Kendall’s tau b rank correlation coefficient was calculated to evaluate the associations between frequen-cy of perceived stress and other variables (health-related characteristics, the zdravje d number of implemented stress management interventions). Multiple linear re- gression was conducted to examine which of the included variables predict fre- quency of perceived stress. All analyses were performed using SPSS V.21 (SPSS, Chicago, Illinois, USA). Results Almost half of the participants (46.0%) reported medium, 28.5% low and 25.5% high perceived stress level. Regarding self-rated health, more than half (62.3%) of the sample reported good or very good, 31.4% fair and 6.3% poor or very poor self-rated health. However, participants on average reported they have experienced three health problems in the last month. Half of the participants report-ed no sickness absenteeism in the past year, 24.0% one to seven days and 21.4% eight to 30 days. Similarly, almost half of the sample (46.0%) reported no sickness presenteeism in the past year, while 33.2% one to seven days and 21.4% eight to 30 days (for details see Table 2). Table 2: Frequency of perceived stress and health-related characteristics/ outcomes of the sample. Total sample (N=796) Perceived stress level, M±SD 3.0 ± 0.9 High, f (%) 203 (25.5) Medium, f (%) 366 (46.0) Low, f (%) 227 (28.5) Self-rated health, M± SD 2.3 ± 0.8 318 Good or very good, f (%) 496 (62.3) Fair, f (%) 250 (31.4) Poor or very poor, f (%) 50 (6.3) tion Number of experienced health problems in the past month, M±SD 3.0 ± 2.3 ven 0-2, f (%) 362 (45.5) t inter 3-6, f (%) 371 (46.6) en 7-10, f (%) 63 (7.9) Sickness absenteeism in the past year (days), M±SD 7.6 ± 19.4 anagem 0 days. f ( %) 400 (50.3) 1-7 days, f ( %) 191 (24.0) tress m 8-30 days, f ( %) 170 (21.4) nd s 31-90 days, f ( %) 29 (3.6) ≥ 91 days, f ( %) 6 (0.8) Sickness presenteeism in the past year (days), M±SD 4.6 ± 7.5 ductivity a 0 days, f ( %) 366 (46.0) ro 1-7 days, f ( %) 264 (33.2) k p 8-30 days, f ( %) 162 (20.4) or 31-90 days, f ( %) 3 (0.4) ≥ 91 days, f ( %) 1 (0.1) ealth, w h **p<0.01 f-ratedel Frequency of perceived stress was significantly associated with self-rat- tress, s ed health ( r=0.29**), number of experienced health problems in the past year s ( r=0.39**), days of sickness absenteeism ( r=0.12**) and sickness presenteeism ceived ( r=0.28**) in the past year. er p Total number of implemented measures to prevent or manage work re- een lated-stress ranged from zero to five ( M± SD=2.2±1.5) in the included organisa-etw b tions and was significantly associated ( r=-0.13**) with frequency of perceived stress. Among the most commonly implemented stress management interven-iation tions were: informing employees about work-related stress and its consequenc- assoc es (58.8%), stress management training provision (35.2%) and informing em- ployees about whom to adress when encountering (work-related) psychosocial problems (23.5%). Organisational-level interventions (ie. changes to working time arrangements or to the way work is organised) were more rare (see Ta- ble 3). Table 3: Implemented stress management interventions in the included work organisations. n (%) of included organisations Informing employees about work-related stress and importance of mental health and their effects on health and safety. 10 (58.8) Provision of training on the prevention of work-related stress. 6 (35.2) Informing employees about whom to address in case of (work-related) psy- chosocial problems. 4 (23.5) 4 Changes to working time arrangements. 2 (11.8) 18 Setting-up of conflict resolution procedure. 2 (11.8) Assessment of work-related stress and psychosocial risk factors in the organ- n isation. 1 (5.9) Changes to the way work is organised. 1 (5.9) pulatio A redesign of the work area. 1 (5.9) o Confidential counselling for employees. 1 (5.9) ge p rking-a Multiple linear regression analysis was used to demonstrate whether the o investigated health-related variables and outcomes significantly contribute to he w the frequency of perceived stress. Results are presented in Table 4. Variables in-f t cluded in the model explained 28% of the variability of the frequency of per- ealth o ceived stress. Having worse self-rated health, having experienced more health | h problem in the past month, being absent from work due to illness more days, being employee of an organisation that has implemented fewer stress manage- pulacije o ment interventions was significantly associated with higher frequency of per- ceived stress even after controlling for organisation, age and gender. ktivne p Table 4: Regression model of frequency of perceived stress (adjusted R2=0.28). elovno a Beta p zdravje d Self-rated health 0.198 <0.001 Number of experienced health problems in the past month 0.322 <0.001 Sickness absenteeism in the past year (days) 0.076 0.015 Sickness presenteeism in the past year (days) 0.059 ns Number of implemented stress management interventions in the organisation -0.071 0.025 Organisation 0.028 ns Age -0.044 ns Gender 0.052 ns Education level 0.184 <0.001 Discussion The results of this study demonstrate the association between higher frequen- cy of perceived stress and worse self-rated health, more health problems in the past month and higher level of sickness absenteeism and sickness presenteeism in the past year. The findings are in line with previous research on the health-and productivity-related consequences of high levels of perceived workplace stress (i.e. Biron et al., 2006; MacGregor et al., 2008; Stansfeld and Candy, 2006). However, days of sickness presenteeism have not significantly contrib- uted to the higher frequency of perceived stress in the regression model. This could be partially explained by the recent meta-analysis of Miraglia and Johns (2016) where various variables pertaining to job demands (constraints on absenteeism, elevated job demands and felt stress etc.) and job and personal re- sources (low support, low optimism etc.) were shown to be more important in explaining presenteeism than absenteeism. A quarter of the sample reported high frequency of perceived stress (Ta- 185 ble 2). This is somewhat similar to the results of the Fifth European Working Conditions Survey, EWCS (EUROFOND, 2012) where 20% of workers report- tion ed a poor mental well-being. Also, the results regarding the frequency of sick-ven ness absenteeism and presenteeism are comparable with those obtained by the t inter most recent EWCS study (EUROFOND, 2017); 50% of the sample reported no en sickness absenteeism (compared to 60% reported in the EWCS), while 46% re- ported no sickness presenteeism (45 % reported in the EWCS). It is interesting, anagem however, that more than half (62.3%) of the participants rated their health as good or very good, while on average reported experiencing three health prob-tress m lems in the last month. A relatively low proportion of the employees rated their nd s health as poor or very poor (6.3%); this is slightly less than estimates obtained in nationwide cross-sectional study by Farkas, Kragelj and Zaletel-Kragelj (2011; ductivity a 9.6%). Yet, these employees are at highest risk for sickness absenteeism or pre-ro senteeism and could benefit the most from interventions targeting their health. k por Our results also indicated that higher frequency of perceived stress is as- sociated with fewer implemented stress management interventions in the or- ealth, w ganisations. According to the research (Richardson and Rothstein, 2008), how- h ever, the effect of interventions most importantly depends on the intervention f-rated type. No conclusions regarding that can be made for our study, as no further el details on the interventions were obtained. Still, similar to the findings of Richardson and Rothstein (2008) included organisations rarely reported implemen- tress, s s tation of organisational-level interventions such as changes to the way work ceived is organised, changes to working time arrangements etc. (Table 3). The high- er p er number of implemented activities for managing work-related stress could, een however, reflect a higher awareness about employees’ mental health and well- etw being, which could partially explain obtained association. b The main limitations of our study pertains the cross-sectional design and iation non-representative sample as the employees’ participation was voluntary. Fur- assoc thermore, despite the satisfactory validity of a single-item measure of stress re- ported by Elo and colleagues (2003), the measure was not additionally validated in our study. Also, the proposed regression model did not control for other working and psychosocial conditions. Conclusions Our study demonstrates that higher frequency of perceived stress in Sloveni- an chemical and other processing industry workers is associated with poor- er self-rated health, higher number of health problems in the past month and higher frequency of sickness absenteeism and sickness presenteeism in the past year. The implemented activities for managing work-related stress in included organisations were relatively rare. Also, guidelines for their systematic implementation and research on their effectiveness are needed in the future. 6 Acknowledgements 18 Project ‘Healthy on a square II’ – workplace health promotion for employees n in the chemical and other processing industries is a collaborative project of Chamber of Commerce and Industry of Slovenia - Association of Chemical In- pulatioo dustries (lead partner), National Institute of Public Health (partner), Olympic ge p Committee of Slovenia - Association of Sports Federations (partner), Sports Association Ljubljana (partner), Trade Union of the Chemical, Non-metal and rking-ao Rubber Industry of Slovenia (partner), financially supported by The Health In- surance Institute of Slovenia. he wf t References ealth o| h ARONSSON, G., GUSTAFSSON, K. and DALLNER, M., 2000. Sick but yet at work. An empirical study of sickness presenteeism. Journal of Epidemiol- pulacije ogy and Community Health, vol. 54, no. 7, pp. 502–509. o BIRON, C., BRUN, J., IVERS, H. and COOPER, C.L., 2006. At work but ill: ktivne p psychosocial work environment and well-being determinants of presen- teeism propensity. JPMH, vol. 5, no. 4, pp. 26–37. elovno a BORG, V., KRISTENSEN, T.S. and BURR, H., 2000. Work environment and changes in self-rated health: a five year follow-up study . Stress Medicine, vol. 16, pp. 37–47. zdravje d BRUN, E. in MILCZAREK. M., 2007. Expert forecast on emerging psychoso- cial risks related to occupational safety and health. Luxembourg: Europe- an Agency for Safety and Health at Work (EU-OSHA). COHEN, S., EVANS, G.W., STOKOLS, D. and KRANTZ, D.S., 1986. Behavior, Health, and Environmental Stress. New York: Plenum press. COX, T., GRIFFITHS, A. and RIAL-GONZALEZ, E., 2000. Research on work related stress. Luxembourg: Office for Official Publications of the European Communities. ELO, A.L., LEPPÄNEN, A. and JAHKOLA, A., 2003. Validity of a single-item measure of stress symptoms. Scandinavian Journal of Work, Environment & Health, vol. 29, no. 6, pp. 444–451. ESCORPIZO, R., BOMBARDIER, C., BOONEN, A., HAZES, J.M.W., LACAILLE, D., STRAND, V. and BEATON, D, 2007 Worker productivi- ty outcome measures in arthritis. Journal of Rheumatology, vol. 34, no. 6, pp. 1372–1380. EUROFOUND, 2012. Fifth European Working Conditions Survey. Luxem- bourg: Publications Office of the European Union. EUROFOUND, 2017. Sixth European Working Conditions Survey 2015. Data visualisation. Available at: https://www.eurofound.europa.eu FARKAS, J., PAHOR, M. and ZALETEL-KRAGELJ, L., 2011. Self-rated health in different social classes of Slovenian adult population: nationwide cross-sectional study. International Journal of Public Health, vol. 56, pp. 7 45-54. 18 GRAHAM, J.W., 2009. Missing data analysis: Making it work in the real world. tion Annual Review of Psychology, vol. 60, pp. 549–576. ven GONZÁLEZ, E. R., COCKBURN, W. and IRASTORZA, X., 2010. European Survey of Enterprises on New and Emerging Risks (ESENER) – Managing t interen safety and health at work. Luxembourg: European Agency for Safety and Health at Work (EU-OSHA). anagem GUSTAFSSON, K. and MARKLUND, S., 2011. Consequences of sickness pres- ence and sickness absence on health and work ability: a Swedish prospec- tress m tive cohort study. International Journal of Occupational Medicine and En- nd s vironmental Health, vol. 24, no. 2, pp. 153–165. IRASTORZA, X., MILCZAREK, M., COCKBURN, W. and EUROPEAN ductivity a AGENCY FOR SAFETY AND HEALTH AT WORK (EU-OSHA), 2016. rok p Second European Survey of Enterprises on new and emerging risks (ESEN- or ER-2) overview report: Managing safety and health at work. Spain: Publication office of the European Agency for Safety and Health at Work ealth, w (EU-OSHA). h JOHNS, G., 2003. How methodological diversity has improved our under- f-rated standing of absenteeism from work. Human Resource Management Re- el view, vol. 13, no. 2, pp. 157–184. tress, s s JOHNS, G., 2009. Absenteeism or presenteeism? Attendance dynamics and employee well-being. In Cartwright, S. and Cooper, C. L., eds. The Ox- ceiveder ford handbook of organizational well-being. Oxford: Oxford University p Press, pp. 7–30. een etw JOHNS, G., 2010. Presenteeism in the workplace: A review and research agen- b da. Journal of Organizational Behavior, vol. 31, pp. 519–542. iation assoc MACGREGOR, J.N., CUNNINGHAM, J.B. and CAVERLEY, N., 2008. Fac- tors in absenteeism and presenteeism: life events and health events. Man- agement Research News, vol. 31, no. 8, pp. 607–615. MIRAGLIA, M. and JOHNS, G., 2016. Going to work ill: A meta-analysis of the correlates of presenteeism and a dual-path model. Journal of Occupation- al Health Psychology, vol. 21, nr. 3, pp. 261–283. NOVAK T., SEDLAR N. and ŠPRAH L., 2013. Doživljanje stresa na delovnem mestu ter sopojavljanje zdravstvenih težav in izgorevanja pri različnih poklicnih skupinah. Zdravstveno varstvo, vol. 52: pp. 292-303. PRÄTTÄLÄ, R., HELASOJA, V., LAAKSONEN, M., LAATIKAINEN, T., NICANDER, P. and PUSKA, P., 2001. Cindi health monitor, proposal for practical guidelines. Helsinki: National Public Health Institute. RICHARDSON, K. M. and ROTHSTEIN, H. R., 2008. The Effects of Worksite 8 Stress Management Intervention Programs: A Systematic Review. Jour- 18 nal of Occupational Health Psychology, vol. 13, pp. 69–93. n SCHNEIDERMAN, N., IRONSON, G., and SIEGEL, S. D., 2005. Stress and health: Psychological, behavioral, and biological determinants. Annual pulatioo Review of Clinical Psychology, vol. 1, pp. 607–628. ge p STANSFELD, S. and CANDY, B., 2006. Psychosocial work environment and mental health - a meta-analytic review. S candinavian Journal Of Work rking-ao Environment & Health, vol. 32, no. 6, pp. 443–462. he wf t ealth o| h pulacije o ktivne p elovno a zdravje d Fighting stressful situations from the viewpoint of emotional competence Milena Svetlin ME SAINE, studio za harmonijo čutenj, Milena Svetlin s.p. zakonska in družinska terapija, Savska cesta 13B, 1230 Domžale, Slovenija milena.svetlin@gmail.com Abstract Introduction: Stress is an important factor in daily life, affecting individual’s health. It is organism’s response to different inner and external factors. The degree to which an individual is capable of dealing with stressful situations is also related to his ability of emotional processing. Emotional competence shows the way a person understands emotions in a certain developmental period, the way he expresses, communicates and integrates them into his self-perception. The aim of our research project was to ascertain the impact of emotional competence upon individual’s strategy of dealing with stressful situations. Methods: We performed a quantitative research. Regarding the calculation of the mutual dependence of degrees of emotional competence (based on the Emotional competence questionnaire) and stress handling strategies (Brief COPE questionnaire), we checked the conditions for the calculation of correlation coefficients and applied Spearman’s rho for the bivariate correlation analysis. The analysis included data on 289 participants. Results: According to the research results every subdimension of emotional competence is related to at least four strategies of stress handling in a statistically significant measure. Correlation between variables is weak (r=0.154), at the level of 1% risk, to strong (r=0.589), at the level of 5% risk. Discussion: Acquisition of emotional competence is a factor affecting the choice of functional strategies of stress handling. Lifelong progress leads to a better emotional condition, which, in turn, sustains active population with the ability of creative performance in the business field, as well as with the feeling of living a full life in private sphere. Key words: stress, stress handling, emotional competence, emotional condition doi: https://doi.org/10.26493/978-961-7023-32-9.189-197 Theoretical Framework Coping with stress is an everyday thing, playing important role in the physical and psychological well-being of a person (Carver, Scheier in Weintraub 1989). Stress is defined as physical response to life situations, as a reaction to physical threats of environment. It is the inner, conditioned reaction of individual to the perceived external pressures, manifested in the form of fight or flight. The individual’s choice of stress handling strategy depends on his dealing with stressful situations and its impact on his health (van Heck in de Ridder 2001). Emotions play key role in individual’s life, representing a significant part in the diversity of everyday life: in the experience of self, mutual relations, workplace, creative processes, sports, etc. (Cvetek 2014, 5). Theories of lifelong emotional development are a relative novelty in the field of psychology of emotions. So far two theories of functional emotional development are known. The first theory is an internalized model of emotional development and emotional 019 regulation by Holodynski and Fridlmeier, focusing mostly on the management of emotions competence. The second theory is Greenspan’s theory of function- n al emotional development, which is somewhat wider and related to the devel- opment of self, consciousness and thinking. Greenspan promoted the idea of pulatioo the higher mental competences (logical thinking and the use of symbols) basi- ge p cally resulting from the transformation of affect, meaning that development of these competences is in fact based on the prior emotional development (Cvet-rking-ao ek 2014, 95). According to Greenspan’s theory sequence of periods in emotional he w development cannot be skipped, every developmental competence comprising f t all the prior ones (Greenspan 1989). If a person fails to develop earlier emotional competences not all is lost for him yet; it just means this person has to make a ealth o conscious effort of returning to the lower developmental grade. Only when the individual manages to develop the lacking comptence can he develop or perfect pulacije | h the following one. According to Greenspan (Cvetek 2014, 95 - 167), the compe- o tences are: emotional steadiness and interest in the world, intimate connect- edness to others, mutual deliberate exchange, mutual social problem solving, ktivne p use of symbolic imagery, emotional logical thinking, comparative emotion- al thinking, differentiation of emotional nuances, reflective emotional think- elovno a ing, consideration of the unconscious, contemplating one’s future, inner emo- tional autonomy, intimate commitment, responsible care for other people and zdravje d emotional parenthood, care for the wider social community, universal love and wisdom (Carver, Scheier in Weintraub 1989). The Present Study The purpose of our research study was to ascertain the impact of emotional competences upon individual’s stress coping strategies. We posed the follow- ing research question: » How dimensions of emotional competences correlate with the utilisation of coping strategies? Methods Participants There were 289 participants in the research project (M=40.24 years, SD=10.9, min=19, max=72), 30 or 10.4% of these were males (M=40.2 years, SD=11.2, min=19, max=72) and 259 oz. 89.6% females (M=39.8 years, SD=10.8, min=19, Max=69). 34 (11.8%) of the participants were single, 114 (39.4%) were married, 80 (27.7%) were not married but had a long-lasting relationship, 7 (2.4%) were in the process of divorce, 35 (12.1%) were divorced, 14 (4.8%) were divorced and in a new relationship, 5 (1.7%) were widowed. 1 (0.3%) participant had primary education, 15 (5.3%) participants had vocational training, 55 (19%) had secondary education, 84 (29.1%) had higher, university education or Bologna first level education, 100(34.6%) had university or Bologna second level education, 31 (10.7%) had specialization or master’s degree, and 3 (1%) participants had doctor’s degree. 37 (12.8%) participants were from the Gorenjska region, 11 (3.8&%) were 1 from the Goriška region, 10 (3.5%) were from the South-Eastern part of Slove- 19 nia, 7 (2.4%) were from the Karst region, 14 (4.8%) were from the Karst-Coastal region, 148 (51.2%) were from the Central Slovenia, 17 (5.9%) were from Podrav-je, 11 (3.8%) from Pomurje, 16 (5.5%) from Savinjska region, 8 (2.8%) from sred-petencemo njePosavje and 7 (2.4%) participants were from Zasavje region. nal c Measures otiomf e Questionnaire of emotional competence of the author Associate Prof. Mateja Cvetek, Ph.D. is a self-assessment questionnaire assessing the developmen- int opo tal degree of one’s emotional competence. The questionnaire is divided in- iew to 8 dimensions: Trust into partner (Cronbach alpha=0.730) (eg.: »When me he v and my partner are faced with a conflict … I know who to ask for help.« ), m tro Mutuality and cooperation between partners (Cronbach alpha=0.940) (eg.: ns f »When me and my partner are faced with a conflict … I feel we are emotion- ally close.«), Understanding and verbal expression of emotions (Cronbach al- ituatio pha=0.757)(eg.: »When me and my partner are faced with a conflict … I can- not find words to express my feelings.«), Comparative emotional reasoning tressful s (Cronbach alpha=0.785) (eg.: »When me and my partner are faced with a con- flict … I can foresee the impact of emotions.«), Emotional oscillations (Cron- bach alpha=0.800) (eg.: »When me and my partner are faced with a conflict fighting s … my emotions are of diverse intensity: from weak to very strong.«), Autono- mous search for new options Cronbach alpha=0.786) (eg.: »When me and my partner are faced with a conflict … I try to learn a lesson from the conflicting situation.«), Autonomous wish for self-improvement (Cronbach alpha=0.729) (eg.: »When me and my partner are faced with a conflict … I strive to improve my conflict management approach.«), Autonomy of judgement (Cronbach al- pha=0.841) (eg.: »When me and my partner are faced with a conflict … I have the feeling of being capable of autonomous decision-making.«). The partici- pants used a 5-grade scale for assessing the statements, i.e.: 1- almost never applies to me (from 0% to 10%), 2 – applies to me rarely ever (from 110% to 35%), 3- applies to me sometimes (from 36% to 65%), 4 – applies to me frequently (from 66% to 90%), 5 – applies to me almost always (from 91% to 100%). Brif COPE is a shortened version of the questionnary COPE Invento- ry (Carver, Scheier in Weintraub 1989); it is a multidimensional self-assess- ment questionnaire for measuring functionality of stress coping responses. The questionnaire is divided into thirteen dimensions: Self-distraction (eg.: » I’ve been turning to work or other activities to take my mind off things.«), Active coping (eg.: »I’ve been concentrating my efforts on doing something about the situation I’m in.«), Denial (eg.: »I’ve been saying to myself “this isn’t real.«), Substance use (eg.: »I’ve been using alcohol or other drugs to make myself feel better.«), Use of emotional support (eg.: »I’ve been getting emotional support from others.«), Use of instrumental support (eg.: »I’ve been getting help and advice from other people.«), Behavioral disengagement (eg.: »I’ve been giving up trying to deal with it. .«), Venting (eg.: »I’ve been saying things to let my unpleas-2 ant feelings escape.«), Positive reframing (eg.: »I’ve been trying to see it in a dif-19 ferent light, to make it seem more positive. .«), Planning (eg.: »I’ve been trying n to come up with a strategy about what to do.«), Humour (eg.: »I’ve been mak- ing jokes about it.«), Acceptance (eg.: »I’ve been accepting the reality of the fact pulatioo that it has happened.«), Religion (eg.: »I’ve been trying to find comfort in my re-ge p ligion or spiritual beliefs.«) and Self-blame (eg.: I’ve been criticizing myself.«). The participants used 4-grade scale for assessment. i.e.: 1- I haven’t been doing rking-ao this at all , 2 – I’ve been doing this a little bit , 3 – I’ve been doing this a medium he w amount , 4 – I’ve been doing this a lot. f t Procedure ealth o| h The questionnaire was published on website links, accessible to a vast number of internet users. The Brif COPE questionnaire is available at the website with pulacije o permission for application, while the permission for the use of the question- naire of emotional competence was acquired through personal communica- ktivne p tion with the author. Statistical processing of the participants’ data was based on the SPSS programme. The first part of the quantitative research comprises basic descriptive statistics with analyses of the participants’ demographic da-elovno a ta, mean, standard deviations, participation shares. In the second part of the research we calculated the relation between degrees of emotional competence zdravje d and stressful situations coping strategies. We checked the conditions for the calculation of the correlation coefficients (One-Sample Kolmogorov-Smirnov Test), applying Spearman’s rho for the bivariate correlation analysis. Results Descriptive Information The descriptive statistics data are presented in Table 1. They show the mini- mum, maximum and average number of points, standard deviation, skewness and kurtosis. Correlation There is a positive correlation link between the competence Trust into the oth-er’s help and the Active coping strategy (p =0.002, r=0.234), Use of instrumental support (p=0.000, r=0.394), Positive reframing (p=0.001, r=0.254) and Acceptance (p=0.020, r=0.181) is weak, while correlation link with the Use of emotion-al support (p=0.000, r=0.411) is medium. There is a weak negative correlation link with Self-distraction (p=0.003, r=0.232), Denial (p=0.001, r=0.256), Self-blame (p=0.001, r=0.265), and medium correlation link with Behavioural dis- engagement (p=0.000, r=0.427). Positive correlation link between the competence Mutual cooperation between partners and Active coping (p=0.024, r=0.175), Positive reframing (p=0.009, r=0.203) and Acceptance (p=0.011, r=0.197) is weak. Also weak and negative is the correlation link with Self-distraction (p=0.022, r=0.177), Deni-al (p=0.017, r=0.185), Behavioural disengagement (p=0.000, r=0.331) and Self- 3 blame (p=0.015, r=0.189). 19 Correlation link between the competence Understanding plus verbal ex- pression and Active coping (p=0.000, r=0.284), Positive reframing (p=0.000, petence r=0.299), Planning (p=0.003, r=0.231), Humour (p=0.022, r=0.178) and Accept- mo ance (p=0.001, r=0.262) is positive and weak. Self-distraction (p0.009, r=0.203), Denial (p=0.000, r=0.309) and Self-blame (p=0.001, r=0.245) have a weak neg-nal c ative correlation. Behavioural disengagement (p=0.000, r=0.409) has a medi- otiom um negative link. f e Correlation link between the competence Comparative emotional think- int opo ing and Active coping (p=0.048, r=0.154), Planning (p=0.011, r=0.196), Humour iew (p=0.025, r=0.174) and Acceptance (p=0.001, r=0.258) is weak positive. Weak he v negative is the link with Denial (p=0.045, r=0.156). m tro The competence Emotional oscillations has a statistically significant weak ns f negative correlation link with the strategies Denial (p=0.014, r=0.190), Behavioural disengagement (p=0.006, r=0.214) and Self-blame (r=0.196). ituatio The competence Autonomous search of new options has a weak positive correlation with Religion (p=0.000, r=0.286) and Self-blame (p=0.000, r=0.286) tressful s and a medium strong one with the subdimensions Planning (p=0.000, r=0.357) and Acceptance (p=0.000, 0.446), as well as a strong correlation with Posi- fighting s tive reframing (p=0.000, r=0.589). There is a weak negative correlation with the subdimension Denial (p=0.003, r=0.233) and Self-blame (p=0.000, r=0.286) and a medium one with Behavioural disengagement (p=0.000, r=0.489). The competence Autonomous wish for self-improvement has a weak pos- itive link with Active coping (p=0.003, r=0.227), Positive reframing (p=0.047, r=0.155) and Religion (p=0.000, r=0.290); it also has a moderate link with Planning (p=0.000, r=0.371). 22 21 20 19 18 17 16 15 4 35 19 14 -0,0 n ** 14 13 ,863 -0,0 pulatio 29 30 52 o 12 0,0 -0,0 0,0 ge p 66). ** 17 ** 11 87 ,209 0,000 -0,0 ,4 rking-a N = 1 ** ** o 34 10 81 77 78 -,3 -0,0 0,0 0,080 -,4 he w ** 5 ** 4 1 ** f t ariable ( 9 80 42 -,258 ,2 -0,00 0,12 0,06 ,3 * ** ** 2 ** ealth o 8 54 5 85 71 28 | h -,1 ,43 -,2 0,08 0,090 0,0 -,3 tudied V 35 ** 31 72 30 f S 7 39 0,0 0,089 ,227 -0,0 0,0 0,110 0,1 -0,0 pulacije o * ** ** 6 ** ** ** 2 73 11 33 89 ,269 ,415 -,16 ,4 -,233 0,080 0,0 0,0 -,4 ktivne p tatistics o 2 ** 3 7 * 7 ** 5 0 36 90 31 58 14 0,08 -,27 -0,09 -0,1 -0,09 -,1 -0,1 -0,09 -0,0 -,2 31 2 ** 25 ** * 7 71 * 30 73 elovno a 4 56 -0,0 ,231 -0,0 ,31 -0,0 ,154 -,1 -0,069 0,0 -0,00 -0,0 escriptive S 2 ** ** ** 3 ** ** ** ** ** 3 75 77 00 7 27 09 09 zdravje d ,3 ,79 ,392 -0,09 ,4 -,20 ,284 -,3 -0,060 0,0 0,0 -,4 nd D ** ** * * 5 2 ** * ** 49 6 72 ** 3 77 5 25 45 -,4 0,099 -,55 ,340 -0,0 ,37 -,1 ,175 -,18 0,00 0,0 0,0 -,331 ** ** ** 1 ** 4 * ** ** ** ** ** 40 28 ** 10 2 4 6 11 27 ,5 ,358 0,11 ,169 ,320 -0,0 ,365 -,23 ,23 -,25 -0,0 ,4 ,394 -,4 - - - orrelations a nd - een n o- p - g a g l- ish n nal en : C w artner sio ci sen nd co et ew o tio g se res ns ous ous w prove y of t otio t l di to p n b tive em pin s strum t easonin nal os or n en ra tio standin otio strac t por en para om om om al f em f in Table 1 al exp ns elf-im t em tance u utuality a otio on on on por nder om nal r ut ns ut en ut ctive co eni se o se o gem Trust in M opera partner U verb of em C tio Em latio A search f tio A for s m A judg Self-di A D Subs U sup U tal sup Behavio ga 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1 **. Correlation is significant at the 0.01 level 22 2 8 9 82 4,16 1,5 *. Correlation is significant at the 0.05 level 0,7 0,00 7 1 4 21 37 2 8 Weak positive link was shown by 0,0 4,16 2,0 0,55 -0,99 the results of the correlation between ** * 8 91 98 20 2 2 8 ,20 -,189 6,22 1,2 -0,3 -0,2 the competence Autonomy of judge- ** 12 ment and strategies Positive reframing 19 75 46 2 8 4 03 ,364 0,0 0,1 4,20 1,7 0,5 -0,6 (p=0.011, r=0.196), Planning (p=0.003, ** ** 4 4 15 3 18 36 95 0 2 8 r=0.229), while the correlation with Ac- 0,0 ,3 ,25 -0,12 6,3 1,26 -0,7 0,79 tive coping (p=0.000, r=0.435) and Ac- ** ** ** 4 7 17 17 ** 66 89 2 8 ceptance (p=0.000, r=0.347) is moder- ,3 ,311 ,554 ,2 -0,109 6,0 1,46 -0,55 -0,0 ate. There is a weak negative correlation * ** * 8 5 16 5 4 34 30 50 2 ,16 8 ,27 0,1 ,170 0,1 0,1 5,46 1,26 -0,12 0,27 with Self-distraction (p=0.047, r=0.154), 8 ** ** ** 71 ** 2 Denial (p=0.000, r=0.285) and Self- 15 21 24 93 95 2 8 6 0,12 -,4 -,269 0,0 -,2 -0,0 ,4 3,8 1,60 0,79 0,181 blame (p=0.000. r=0.286), and a mod- ** 5 7 ** 4 ** 1 14 06 50 6 7 2 8 erate correlation with Behavioural dis- ,4 0,1 ,23 0,118 0,12 ,26 0,099 5,4 1,72 -0,06 -0,89 195 engagement (p=0.000, r=0.328). ** ** 4 ** 1 37 13 38 1 33 2 8 4 0 ,397 0,1 ,20 0,10 0,1 ,240 0,111 5,3 1,7 0,00 -0,8 22 6 76 18 70 2 1 77 50 Discussion petence 12 2 8 m 0,0 0,098 0,0 0,0 0,068 0,0 2,4 1,0 3,1 12,3 o -0,08 According to the results, an individu- ** ** 3 ** ** 11 0 99 49 5 2 8 9 56 68 nal c 0,110 al that trusts into other people’s help -,222 -,23 0,06 -,3 -0,0 ,40 3,2 1,46 1,0 0,5 7 ** actively deals with problem solving in otio 14 ** ** 4 ** 7 37 3 4 23 10 m 10 2 8 ,454 ,52 ,37 0,1 6,3 1,22 f e 0,0 0,06 -,26 -0,5 0,0 stressful situations, seeking help and 2 58 19 7 58 * 6 9 17 emotional support with others. He is int o 9 2 8 0,09 -0,0 0,087 0,013 0,0 ,15 5,3 1,53 -0,0 po -0,0 -0,66 likely to perceive the problem from a * ** ** ** 4 iew 8 78 9 39 47 1 84 47 96 9 52 25 positive point of view and to learn from 0,0 ,196 ,22 0,1 ,3 -0,0 -,2 19,1 3,5 -0,4 0,0 he v the situation. He does not seek dis- 5 * 3 ** ** 7 m t 7 1 56 56 44 90 6 15 traction in work and other activities to ro 0,10 ,155 ,37 -0,0 0,0 ,2 0,11 11,37 1,99 -0,1 -0,37 ** ns f stop reflecting on the problem, neither ** 7 3 6 ** ** 7 40 ** 46 86 3 15 -0,008 ,589 ,35 0,1 ,4 ,268 -,2 10,6 2,66 -0,31 -0,226 does he deny it or despair. He does not 5 * ituatio 4 8 5 43 48 96 blame or accuse himself for the situa- 3 27 ,13 22 -0,1 0,120 -0,118 -0,00 0,0 -0,09 -,1 13 8,45 0,5 -1,33 tion. Mutual cooperation enables him 3 * * ** 41 6 7 40 tressful s 4 9 25 to perceive the problem as a fact that 0,100 0,08 ,196 ,174 ,258 -0,11 -0,1 17,35 3,3 -0,16 -0,0 can be dealt with. ** 3 37 ** ** * ** 2 45 3 4 84 38 0,1 99,2 ,231 ,178 ,26 27 -0,066 -,2 15,1 7,02 0,4 -1,1 Understanding, verbal expressing fighting s 2 1 * 0 4 4 2 ** 3 58 * 77 7 and comparative emotional thinking 12 50 -0,00 ,20 0,12 0,0 ,197 -0,0 -,189 28,7 11,1 0,60 -1,08 enable an individual – apart from ac- ** 1 5 ** 34 25 * 75 5 2 0 77 86 tively confronting the problem – to de- 0,11 ,254 0,1 10 0,0 ,181 0,0 -,26 7,00 2,3 -0,4 -0,7 velop a positive approach to problem, g to plan solutions (also with humour), to minra accept them and live with them. He is ef e g g tance n thus less likely to distract himself with lam um um s tin tive r or io eviation m an ness tosi other activities (cinema, TV, reading, ccep D elig inim axim w Ven Posi Plannin Hu A R Self-b M M Me ur Std. Ske K 16 17 18 19 20 21 22 daydreaming, sleeping, shopping) so as to stop bothering about the problem. He is also less prone to denial and despair. Individuals autonomously seeking new solutions and believing they can still make progress in the field of conflict management, individuals striving to improve their manner of reacting are the ones likely to see a problem from the positive and spiritual side, to plan solutions and live with them in a positive way; they are, however, also less likely to deny the problem and to despair. Greater ability of autonomous judgement can be expected from persons actively dealing with problems, having a positive approach to problem solv- ing, planning, accepting facts and learning from situations. Such persons are less likely to seek distraction elsewhere, to deny problems, despair and blame themselves. Research studies dealing with correlation between emotional compe- 6 tence and stress do not exist. In the research study (Vater in Schröder Abé 2015) 19 it has been ascertained that every factor of a personal characteristic is related to at least one strategy of emotional regulation. Emotional regulation, however, is n the key factor in the development of emotional competence. According to the pulatio research study (Leger et al. 2016) on correlation between personal characteris-o tics and stress differences between personal characteristics affect one’s estimage p tion of potential stressful situation. Interactional and transactional stress models guide much of this personality and stress-related research. These models rking-ao propose that personality is associated with stress in the following ways. First, he w those with certain personality characteristics are more likely to expose them- f t selves to more frequent and severe stressful experiences. Second, individual dif-ealth o ferences in personality traits may influence appraisals of potentially stressful | h circumstances. Last, personality is associated with the effectiveness of the coping responses whereby cognitive and behavioural efforts can prevent, manage, pulacije o or alleviate distress. Results of this study indicate that personality traits are dif-ferentially associated with positive and negative stressor-related affect; neurot-ktivne p icism, conscientiousness and openness to experience uniquely contribute to the degree of stressor-related negative affect, and stressor-related appraisals partially account for this relationship. Only agreeableness relates to the degree elovno a of stressor-related positive affect, but how people appraise their daily stressors are unrelated to this association. These findings suggest that these differences zdravje d in stressor-related affect may serve as one potential mechanism through which personality traits impact health and emphasize the need for future studies to examine not just changes in negative, but also changes in positive affect in response to stress. Conclusions People confront stressful situations in more or less functional ways. Accord- ing to the present research project, emotional maturity and acquisition of emotional competences throughout individual’s life affect the choice of his stress handling strategy. Emotional processing or, rather, the ability of emotional processing, is a new but ever more popular object of empirical research in psy-chotherapy, which is why it makes sense to determine in future, which are the key competences in individual work settings. Research studies will contribute to theoretical knowledge of emotional processes, serving as a basis for the creation of new therapeutic approaches, as well as for a more efficient clinical practice in the field of mental health. Limitations The research study has a few limitations. Research results cannot be compared to results of other research studies, as there are no research studies from the point of view of emotional competence References 719 CARVER, CHARLES S., MICHAEL F. SCHEIER and JAGDISH K. WEIN- TRAUB. 1989. Assessing coping strategies: A theoretically based ap- proach. Journal of Personality and Social Psychology 56, št. 2:267-283. petencem CVETEK, MATEJA. 2014. Živeti s čustvi: čustva, čustveno procesiranje in o vseživljenski čustveni razvoj. V. Ljubljana: Teološka fakulteta. nal c GREENSPAN, STANLEY I. 1989. The development of the ego: Implications for otiom personality theory, psychopathology, and the psychotherapeutic process. f e Madison, CT, US: International Universities Press, Inc. int opo LEGER, KATE A., SUSAN T. CHARLES, NICHOLAS A. TURIANO and DA- iew VID M. ALMEIDA. 2016. Personality and stressor-related affect. Journal he v of Personality and Social Psychology 111, št. 6:917-928. m tro VATER, ALINE, and MICHELA SCHRÖDER ABÉ. 2015. Explaining the link ns f between personality and relationship satisfaction: Emotion regulation and interpersonal behaviour in conflict discussions. European Journal of ituatio Personality 29, št. 2:201-215. tressful s fighting s Stress of conscience as a risk factor for burnout among ICU nurses in University Medical Centre Maribor Saša Šajn Lekše, Bernarda Lončar, Alenka Žibert, Andrej Starc University of Ljubljana, Faculty of Health Sciences, Zdravstvena pot 5, 1000 Ljubljana, Slovenia sasa.sajn.lekse@gmail.com; bernarda.loncar5@gmail.com; ibert.alenka@gmail.com; andrej.starc@zf.uni-lj.si Abstract Introduction: A nurse’s conscience is an important factor in clinical decision-making. Conscience can be clean or troubled; it can warn, encourage or judge. A troubled conscience appears when a person neglects the voice of their own conscience. When related to the quality of the provided service, a troubled conscience can cause stress. Work related stress is defined by endogenous and exogenous factors: the presence of various environmental stressors and the individual’s coping ability. A prolonged period of exposure to stressful situations may lead to occupational burnout. Burnout is a state of physical and emotional exhaustion originating in an individual’s internal processes, but triggered by external burden. Individuals with burnout syndrome exhibit symptoms of depression, anxiety and depersonalisation. Method: A descriptive method was used. A literature search was performed between March and June 2017 in databases CINAHL with full text and MEDLINE. Results: Stress of Conscience Questionnaire appears to be a valid instrument for measuring the stress of conscience in various situations in healthcare. The questionnaire has already been translated into Slovene language and will be applied in a future research within the intensive care units of UKC Maribor. Discussion: A troubled conscience can cause burnout symptoms, especially in intensive care units where patients are monitored constantly by highly trained professional teams. Key words: workplace stress, occupational burnout, intensive care nursing, mental health, nurse. Nurses perform effective professional decision making every day. Not only professional expertise affects their decisions, but also their atti- tudes, values, personality and constraints of healthcare organisation. And yet, sometimes there are adverse consequences. If the outcome is unfortu- doi: https://doi.org/10.26493/978-961-7023-32-9.199-207 nate, severe psychological stress, combined with feelings of guilt and troubled conscience can occur. Conscience and troubled conscience Conscience is an integral part of professional decision-making. At the begin- ning of life, conscience in general is formed through parental values. Religious values and various extrinsic factors are also important. Conscience in relation to established social norms can influence “judgement” which can cause an internal conflict (Thompson et al., 2006; Weinstock, 2014). People describe their conscience as “the voice that tells them what to do.” It guides towards “good” and discourages “evil”. Some religious theories interpret the voice of conscience as the voice of God. The Old Testament argues that a person has two choices. Conscience is God’s emissary or teacher, but man himself must decide between his two tendencies towards good or evil (Fromm, 1987; Wood, 2009). 200 Trstenjak (1971) describes conscience as a compass that directs nurses to- n wards professional goals by protecting against reckless decisions. There are two extremes: dulled conscience, navigating in the wrong direction and extra-sen-pulatio sitive conscience, acting as a brake. Properly formed conscience will not cause o discomfort. Nurses with properly formed conscience constantly receive inter- ge p nal support for their professional conduct. Conscience helps to administer eth-rking-a ical standards to concrete situations. It accompanies every professional deci- o sion. A troubled conscience is sadness in conjunction with the idea of a past he w unexpected event and is a sign of helplessness. Nurses mention a troubled con- f t science when they are not able to provide sufficient high-quality care and when ealth o nurses do something, but at the same time know that this should not be do- | h ne. Troubled conscience is followed by feelings of guilt (De Spinoza, 1988; Kel-ly, 1998; Strandberg and Jansson, 2003; Genuis and Lipp, 2013). pulacije o Stress and occupational burnout ktivne p Stress is defined as a physiological, psychological and behavioural response to stressors. A stressor can be an event, a person or an object (Dernovšek et al., elovno a 2006) which triggers a physiological response. Stress has many negative conno- tations, although positive stress is also possible. Stress becomes negative when zdravje d individuals cannot control the situation or find themselves in distress that is impossible to deal with. Long-term negative stress results in deterioration of health, emotions and behaviour, signalling work overload. (Yehuda 2002; Hafner and Ihan, 2014). In the past, burnout was initially only associated with caring professions (Selič, 2010). Occupational burnout is the result of prolonged workplace stress. The first questionnaire for burnout assessment was developed in 1981, measur- ing three dimensions: emotional exhaustion, depersonalization and personal fulfilment (Maslach and Jackson, 1981; Hafner and Ihan, 2014). Burnout occurs when discrepancies between the nature of work and the nature of man appear. Indicators of discrepancies are: overload, lack of supervision, inadequate financial benefits, absence of strong workplace community, lack of honesty and con- flicts of values. All discrepancies contribute to burnout, and focusing on the individual exclusively will not have the desired effect. Some individuals will seek refuge in their work as a solution to their personal problems. Burnout develops slowly over the years, making it difficult to diagnose and treat. Burnt out individuals are chronically tired, experience headaches, sleep disturbances, vom- iting, changes in nutrition, are alienated from their work and feel that they are becoming less effective, motivated and more cynical. Complete burnout is a state of physical, emotional and mental fatigue and classified as a problem related to life management. Burnout is a gradually expanding disintegration of values, spirit and mood. Depression and anxiety are also common. One of the results of prolonged stress could be a stroke experience, heart attack and sui-cide (Maslach and Leiter, 1997; SZO, 2006; Hafner and Ihan, 2014). 201 Nursing care in intensive care units (ICU) r One of the nursing roles is supporting the treatment plan. Nurses in the ICU aribo are known for their systematic and integrated approaches, which require psy- chophysical abilities and personality traits allowing a responsible attitude to-entre m wards the patient (Kodila, 2008; Makovec, 2009). Healthcare workers need to be highly qualified, requiring theoretical knowledge, responsibility, and expe-edical c rience for an immediate professional response, making the ICU itself a con- stant stressor (Mealer et al., 2007; Polovšak, 2009). The psychological effects of stress are relatively unknown, but are related to the environment where treat-niversity m ment is complex and mortality of patients is high. Consequently, nurses may n u become irritable, depressed and frustrated. Continuous stress and the inabil- urses i ity to adapt can cause burnout symptoms (Badger, 2001; Jonsson et al., 2003; cu n Mealer et al., 2007). ng io Burnout in healthcare systems is often overlooked, because the focus is m on caring, and professionals often do not recognise their own vulnerabilities. ut a The authors are preparing a study on the impact of troubled conscience on urno burnout in a sample of ICU nurses in University Clinical Centre Maribor. The r bo chosen research instrument was the Swedish Stress of Conscience Question- r f naire (Glassberg et al., 2006). The aim of the article is to present results of stud-acto ies that previously used the questionnaire to confirm its usability in Slovenian isk f context. s a r Methods nscience ao A descriptive method was used. A literature search was performed in March f c 2017 in databases CINAHL with Full Text and MEDLINE. We used the exact search phrase “stress of conscience questionnaire”. All studies that included stress o registered nurses were chosen for the review, excluding the validation studies of the questionnaire. The final analysis included 6 studies, as seen in figure 1. Figure 1: Literature search process. Results 220 The following table (table 1) describes the main study characteristics of studies where Stress of Conscience Questionnaire (SCQ) was used to measure the n stress of conscience in healthcare professionals pulatioo Table 1: SCQ study characteristics. ge p AUTHORS AIM METHOD RESULTS rking-ao Most often there is not enough time for quality pa- he wf t tient care. Analysis of the importance Most troubled conscience of the factors that contrib- is caused by the fact that ealth o Glasberg et al., ute to the occurrence of Survey study work is so demanding that | h 2007 burnout of health profes- 423 respondents it leaves too little time for sionals. family. Emotional exhaus- tion and depersonalisation pulacije o can be largely explained by the stress of conscience. ktivne p Stress of conscience can mainly be explained by the perception of con- elovno a science and moral sensitivi- ty. Health workers that can- Exploring the factors that not follow the voice of their contribute to stress of con- own conscience at work zdravje d Glasberg et al., 2008 science or to the stress Same as above experience more stress of caused by a troubled con- conscience. science in health care. Female respondents had significantly higher aver- ages compared to males in items about external de- mands and restrictions in health care. AUTHORS AIM METHOD RESULTS Exploring the connection Not enough time for qual- ity patient care and work Juthberg et al., between the stress of con- Multiple questionnaires is too demanding to leave 2007 science, perceptions of con- science and burnout in car- 146 respondents enough time for family. egivers of the elderly. Private life rarely interferes with work. Exploring the relation- Not enough time for qual- ship between perceptions ity patient care and work Juthberg et al., of conscience, stress of con- Same as above is too demanding to leave 2010 science and burnout in re- Additional statistical anal- enough time for family. lation to occupational be- ysis Private life rarely interferes longing. with work. Not enough time for qual- Testing the Finnish version ity patient care and work Survey study is too demanding to leave Saarnio et al., of SCQ to explore the stress Stratified sampling enough time for family. 2012 of conscience on staff who care for elderly with de- 436 respondents from 45 Health professionals rare- mentia. different institutions. ly avoid patients or relatives 203 who need help. r The variability of SCQ re- aribo Exploring the connection sults is largely influenced Tuvesson et al., between environmental by a sense of moral burden. and individual factors and Multiple questionnaires Higher moral sensitivity entre m 2012 the stress of conscience in 93 respondents has a greater impact during psychiatric nursing. ethical dilemmas, leading to a troubled conscience. edical c Discussion niversity m Nursing is associated with various stressors. In Slovenia, stress and burnout n u has been studied among mental health nurses (Čuk and Klemen, 2010; Peter- urses i ka Novak et al., 2010; Bregar et al., 2011; Nemec and Čuček Trifkovič, 2017), cu n emergency nurses (Kugonič, 2013) and community nurses (Kaučič, 2002). Con- ng i science, troubled conscience and burnout in Slovenian nurses was described by om Pahor and Peternelj in 2003, but the results have not been published. The exist-ut a ing literature also does not offer any research on conscience in ICU nurses, so urno the authors decided to contribute to the field with their own study. Judging by r bo the results of the literature review, the SCQ is suitable for our research. How-r f ever, due to lack of experience in scientific research, the authors were not ful-acto ly prepared for the amount of time needed before the actual start of the study. isk f It seems that stress of conscience is strongest when lack time for quality s a r patient care is present and when the complexity and shift of the job does not allow enough time for family. Troubled conscience appears in situations where nscience a patients are mistreated. On the other hand, avoiding patients or their family o members is not a cause of troubled conscience, because healthcare profession- f c als rarely avoid patients or relatives who need their help. Stress of conscience stress o is an important risk factor for burnout in nurses (Glasberg et al., 2007; Juthberg et al., 2010; Saarnio et al., 2012). Theoretically, we should conclude that nurses often suppress their conscience to allow the working process to contin- ue. This problem should be addressed by leadership of every healthcare institution to ensure the quality of service and preserve nurses’ mental health at the same time. Conclusions Everyday professional demands can become a burden and lead to burnout. Nursing practice is associated with many situations that might cause a trou- bled conscience. Stress of conscience can contribute to burnout. Further re- search in the area would help identify early symptoms of burnout. The authors have drafted a protocol of a quantitative research study, which will be conduct-ed among nurses working in two ICUs in the University medical centre Mar- ibor, currently in the process of obtaining the appropriate permissions. The study is currently in the process of obtaining all necessary permissions before beginning actual data collection. The authors will use a Slovenian version of 204 the SCQ. With our findings we wish to encourage changes which might help to reduce occupational burnout caused by a troubled conscience, and thus to im- n prove the mental health of nurses in the ICU. pulatioo References ge p BADGER, J.M., 2001. Understanding secondary traumatic stress. The ameri- rking-ao can journal of nursing, vol. 101, no. 7, pp. 26–32. he w BREGAR, B., PETERKA NOVAK, J. and MOŽGAN B., 2011. Doživljanje stre- f t sa pri zaposlenih v zdravstveni negi na področju psihiatrije. Obzornik zdravstvene nege, vol. 45, no. 4, pp. 253–62. ealth o| h ČUK, V. and KLEMEN, J., 2010. Izgorevanje osebja v zdravstveni negi na psihiatričnem področju. Obzornik zdravstvene nege, vol. 44, no. 3, pp. pulacije 179–87. o DE SPINOZA, B., 1988. Etika. Ljubljana: Slovenska matica, pp. 246. ktivne p DERNOVŠEK, M.Z., GORENC, M. and JERIČEK, H., 2006. Ko strese stres. Kako prepoznati in zdraviti stresne, anksiozne in depresivne motnje. Lju- elovno a bljanja: Inštitut za varovanje zdravja Republike Slovenije, pp. 8. FROMM, E., 1987. Človekovo srce: njegov demon dobrega in zla. Ljubljana: zdravje d Državna založba Slovenije, pp. 12. GENUIS, S.J. and LIPP, C., 2013. Ethical diversity and the role of conscience in clinical medicine . Internationa journal of family medicine, vol. 2013, pp. 587541. GLASBERG, A.L., ERIKSSON, S. and NORBERG, A., 2007. Burnout and ‘stress of conscience’ among healthcare personnel. Journal of adcanced nursing, vol. 57, no.4, pp. 392–403. GLASBERG, A.L., ERIKSSON, S. and NORBERG, A., 2008. Factors associat- ed with ‘stress of conscience’in healthcare. Scandinavian journal of car- ing sciences, vol. 22, no. 2, pp. 249–258. GLASBERG, A.L., ERIKSSON, S., DAHLQVIST, V., LINDAHL, E., STRANDBERG, G., SÖDERBERG, A., SØRLIE, V. and NORBERG, A., 2006. De- velopment and initial validation of the stress of conscience questionnaire. Nursing ethics, vol. 13, no. 6, pp. 633–648. HAFNER, M. and IHAN, A., 2014. Prebujanje: Psiha v iskanju izgubljene- ga Erosa- psihonevroimunologija. Ljubljanja: Alpha center: Inštitut za preventivno medicino, pp. 83–470. HARPER, D., 2001. “Conscience,” Online Etymology Dictionary. [viewed 6 May 2017]. Available from http://www.etymonline.com/index.php?ter- m=conscience&allowed_in_frame=0. JONSSON, A., SEGESTEN, K. and MATTSSON, B., 2003. Post-traumatic stress among Swedish ambulance personnel. Emergency medicine jour- nal, vol. 20, no. 1, pp. 79–84. JUTHBERG, C., ERIKSSON, S., NORBERG, A. and SUNDIN, K., 2007. Per- ceptions of conscience in relation to stress of conscience. Nursing ethics, 205 vol. 14, no. 3, pp. 329–343. r JUTHBERG, C., ERIKSSON, S., NORBERG, A. and SUNDIN, K., 2010. Per- aribo ceptions of conscience, stress of conscience and burnout among nursing staff in residential elder care. Journal of advanced nursing, vol. 66, no. 8, entre m pp. 1708–1718. edical c KAUČIČ, B.M., 2002. Proces izgorevanja pri članih negovalnega tima v patronažnem varstvu. Obzornik zdravstvene nege, vol. 36, no. 2, pp. 101– 104. niversity m KELLY, B., 1998. Preserving moral integrity: a follow-up study with new gradu- n u ate nurses . Journal of advanced nursing, vol.28, no. 5, pp. 1134–1145. urses i KODILA, V., 2008. Osnovni vodnik po kirurški enoti intenzivnega zdravljen- cu n ja. Priročnik za medicinske sestre in zdravstvene tehnike. Ljubljana: Uni- ng io verzitetni klinični center Ljubljana, pp. 21–35. m KUGONIČ, N., 2013. Sindrom izgorevanja pri zaposlenih v nujni medicinski ut a pomoči. Obzornik zdravstvene nege, vol. 47, no. 3, pp. 268–75. urnor b MAKOVEC, V., 2009. Dokumentiranje in standardi, protokoli zdravstvene or f nege v Enoti intenzivne terapije. In: 18. simpozij intenzivne medicine in 15. seminar intenzivne medicine za medicinske sestre in tehnike zdravst- acto isk f vene nege. Zbornik predavanj. Bled: Slovensko združenje za intenzivno medicino, pp. 174–180. s a r MASLACH, C. and JACKSON, S.E., 1981. The measurement of experienced burnout. Journal of occupational behavior, no. 2, pp. 99–113. nscience ao MASLACH, C. and LEITER, M.P., 1997. Resnica o izgorevanju na delovnem f c mestu. Ljubljana: Educy, pp. 9–19. stress o MEALER, M.L., 2007. Increased prevalence of post- traumatic stress disorder symptoms in critical care nurses. American journal of respiratory and critical care medicine, vol. 175, no. 7, pp. 693–697. NEMEC, U. and ČUČEK TRIFKOVIČ, K., 2017. Stres med zaposlenimi na področju psihiatrične zdravstvene nege. Obzornik zdravstvene nege, vol. 51, no. 1, pp. 9–23. PAHOR, M. and PETERNELJ, K., 2003. Vest, slaba vest in izgorelost pri medi- cinskih sestrah; preliminarna predstavitev mednarodne raziskave. In: KLEMENC, D., KVAS, A., PAHOR, M. and ŠMITEK, J., eds. Zdravstve- na nega v luči etike: Društvo medicinskih sester in zdravstvenih tehnikov Ljubljana, pp. 368–369. PETERKA NOVAK, J., BREGAR, B., MOŽGAN, B. and VAJDA, A., 2010. De- javniki, ki povzročajo stres pri zaposlenih v psihiatrični zdravstveni ne- gi. In: BREGAR, B. and PETERKA NOVAK, J., eds. Kako zmanjšati stres in izgorelost na delovnem mestu: zbornik predavanj z recenzijo / Seminar sekcije medicinskih sester in zdravstvenih tehnikov v psihiatriji, Ljubljana, 12. november 2010. Ljubljana: Zbornica zdravstvene in babiške nege - Zve-206 za strokovnih društev medicinskih sester, babic in zdravstvenih tehnikov Slovenije, pp. 24–29. n POLOVŠAK, S., 2009. Fizične in psihične posledice stresa na delovnem mes- pulatio tu. In: Raznolikost odzivanja na stresne situacije – 4. modul medsebojni o odnosi kot temelj kakovosti v zdravstvu. Logarska dolina: Spes, društvo ge p za kulturo odnosov, pp. 33–36. rking-a SAARNIO, R., SARVIMÄKI, A., LAUKKALA, H. and ISOLA, A., 2012. Stress o of conscience among staff caring for older persons in Finland. Nursing he wf t ethics, vol. 19, no. 1, pp. 104–115. SELIČ, P., 2010. Stres in izgorelost: kako je mogoče razumeti in uporabiti po- ealth o datke o izgorelosti na primarni ravni ravni zdravstvenega varstva. In: | h BREGAR, B., PETERKA NOVAK, J., eds. Kako zmanjšati stres in izgore- lost na delovnem mestu: zbornik predavanj z recenzijo / Seminar sekci- pulacije o je medicinskih sester in zdravstvenih tehnikov v psihiatriji, Ljubljana, 12. november 2010. Ljubljana: Zbornica zdravstvene in babiške nege - Zveza ktivne p strokovnih društev medicinskih sester, babic in zdravstvenih tehnikov Slovenije, pp. 7–18. elovno a STRANDBERG, G. and JANSSON, L., 2003. Meaning of dependency on care as narrated by nurses. Scandinavian journal of caring sciences, vol. 17, no. zdravje d 1, pp. 84–91. SVETOVNA ZDRAVSTVENA ORGANIZACIJA, 2006. Mednarodna klasifi- kacija bolezni in sorodnih zdravstvenih problemov za statistične namene. 2nd ed. Ljubljana: Inštitut za varovanje zdravja Republike Slovenije, pp. 1010. THOMPSON, R.A., MEYER, S. and MCGINLEY, M., 2006. Understanding values in relationships: The development of conscience. Handbook of moral development, pp. 267–297. TRSTENJAK, A., 1971. Človek samemu sebi. Ljubljana: Mohorjeva družba, pp. 50–53. TUVESSON, H., EKLUND, M. and WANN-HANSSON, C., 2012. Stress of Conscience among psychiatric nursing staff in relation to environmental and individual factors. Nursing ethics, vol. 19, no. 2, pp. 208–219. WEINSTOCK, D., 2014. Conscientious refusal and health professionals: does religion make a difference? Bioethics, vol. 28, no. 1, pp. 8–15. WOOD, A.W., 2009. »Kant on conscience«. In: Kantovsky Sbornik. Jubilee edi- tion dedicated to Leonard Aleksandrovich Kalinnikov. [viewed 6 May 2017]. Available from: https://web.stanford.edu/~allenw/webpapers/Kan- tOnConscience.pdf YEHUDA, R., 2002. Post-traumatic stress disorder. The new england journal of medicine, vol. 346, no. 2, pp.108–114. 207 r aribo entre m edical c niversity m n u urses i cu n ng iom ut a urnor bor f acto isk f s a r nscience aof c stress o Women‘s Quality of Life during the Grief Process after Perinatal Death Tjaša Šapla Troha1, Maša Černelič Bizjak2 1 Community Health Center Nova Gorica, Rejčeva 4, 5000 Nova Gorica, Slovenia 2 University of Primorska, Faculty of Health Sciences, Polje 42, 6310 Izola, Slovenia tjasa.troha90@gmail.com; masa.cernelic@fvz.upr.si Abstract Background: Around one fifth of pregnancies worldwide ends in miscarriage, ectopic pregnancy or stillbirth. Women often do not show their feelings after these events; they suppress them or do not talk about their loss. Unresolved grief can affect many aspects of women physical and mental health in all stages of life. Methods: The study included 108 women who experienced perinatal loss. All of them completed the Munich Grief Scale questionnaire and a questionnaire on demographic data. Results: Statistically significant differences in the experience of grief were associated with gestational age of the child (p < 0.01), the age of the mother (p < 0.05) and the time that has elapsed since the child‘s death (p < 0.01). In the clinical setting women judged dealing of health workers, and reported more understanding and compassionate treatment at home. The research was the basis for developing protocols with instructions for handling a situation of stillbirth, focusing on mental well-being of the mother. Discussion and conclusions: The qualification of health professionals is very important. They have the first contact with the mother and at the same time the influence to prevent the pathological processes of bereavement. Careful planning of health care and by using the protocol, nurse can gain an insight into the process of bereavement, and has a tool that focuses on procedures and activities. Keywords: grief, stillbirth, perinatal death, quality of life The loss of a child is one of the hardest events, or namely one of the hard- est and most painful experiences. People often associate grief with a wound that will slowly heal over time and eventually it will be complete- ly healed, but the death of a child is more similar to the loss of a limb or its functioning; namely nothing can heal such a wound completely, in the case of a loss it can only come to the gradual acceptance and adjustment of the irreplace-doi: https://doi.org/10.26493/978-961-7023-32-9.209-217 able and painful loss. The society underestimates the experience in the case of the death of a newborn or in the case of a miscarriage. It is wrongly perceived that grieving is irrelevant in such cases and for that reason parents usually suppress their feelings and do not talk about their loss or ask for help. Perinatal loss therefore defies the modern expectations of a healthy outcome of pregnancy and it was proven to be as important as any other loss of a loved person (Cartwright and Read, 2005). Grieving is a proces where we consciously say goodbye and transform the experience of a loss and integrate it in our life in a manner that we take with us what is important and essential and eventually try to move on. However, this is only possible if we manage to cope with the pain that is present, and we manage to process it in the process of grieving (Simonič, 2006). There are many factors that determine how the grieving person will cope with the loss of a loved one: individual (gender, age, attachment, home envi- 210 ronment), situational (cause of death, manner of receiving the news of the loss) and socio-cultural (accepted form of grief, burial ceremony, stereotypes, taboo n subjects) (Ozbič, 2015); but most certainly strong emotions will always be present. pulatioo ge p Women and Expressing the Feelings in the Grief Process rking-a In the grieving process that usually lasts up to 24 months (Velikonja, 1999), the o reactions of women are in most cases very intensive and long-lasting (Wing he wf t et al., 2001; Ozbič, 2015). In the stage of shock, experiencing depersonaliza- tion is more common for the mothers than the fathers. Right after the death ealth o of the child, intensive distress, depression and grief was observed in moth- | h ers; and all these states could still be observed long after the loss. Besides, in-trusive thoughts, preoccupation, longing and the sense of being more vulner- pulacije o able and anxious are also very frequent (Wing et al., 2001). Anger is intensive at the beginning of a grieving process and starts to slowly fade away over the ktivne p period of two years (Ozbič, 2015). The feeling of guilt is especially present with mothers, when the cause of death is unknown. It can be inward - (they blame elovno a themselves) or outward-oriented (they blame the partner, doctors, God or fate). Searching for causes of death can be realistic (regarding medical conditions that were not in accordance with the imposed regime) or unrealistic (eating zdravje d habits, recreation, sexual intercourse, arguing, thoughts or feelings about the pregnancy). When the intensity of sadness and grief is so strong that an individu- al cannot accept the loss and the grief turns into depression and despair, this is called pathological grief. However, the clinical diagnosis does not know the term ‚pathological grief‘, and therefore the ones that are treated by psychiatrist are diagnosed with depressive episode (Peljhan, 2016). The mentioned states of women reduce their quality of life as well as the lives of close family members that are also dealing with the loss in their own way. The quality of life here refers to the physical and mental well-being. It is based on five factors: functional state of an individual, presence of physical symptoms, emotional and social condition including social relationships and the impact of medical treatment. More and more studies research the link between the quality of life and health and also give opinions and standpoints from the patients‘ point of view (Kopčavar Guček in Franić, 2008). Women‘s quality of life in the grief process after perinatal death is very individually oriented and can be affected by many different factors, among which are also the ones we have already mentioned. It is extremely important that grieving women are given the chance to respectfully and decently grieve; the process should start already in the maternity hospital and continue in their home environment. The key role have the health workers. Methods Sample 211 108 women participated in the survey and the average age in the time of the eath loss was 29.2 (SD = 5.18 years). Participants of the survey were in average 24 weeks pregnant (SD = 9.90 weeks). 34% of the participants, which represented the majority of women participating in the survey, had university degree, i.e. erinatal d they completed the second cycle of the Bologna process. In the time of the loss fter p of the child, 52% of women were married and 48% had a non-marital partner. cess aro Research Tools rief p The initial questionnaire took demographic data, medical history, i.e. how he g many times were the women pregnant before and possible miscarriages or in- duced abortions. The questionnaire also included questions about how they uring t received the news about their child‘s death, the course of stillbirth, the peri-ife df l od after the labor and needs of the grieving mothers or both parents and what they would require afterwards from the health professional in that time. Add- ed were also open-ended questions about their experiences of the treatment uality o s q and handling in the maternity hospital from the time they were accepted in the en‘m hospital until their release and their home environment, the treatment of the ow home care nurse, about expressing their feelings after the loss and their search of the purpose afterwards, impacts of the loss on the relationship with the partner and their other living children and the completed grieving process. Munich Grief Scale Munich Questionnaire consists of 22 questions where participants answered with the Likert five point scale (1 − never, 2 − rarely, 3 − sometimes, 4 − often, 5 − always) and also described how they felt in that moment. The questions are combined into 5 subscales: grief (6 questions), fear of the loss (5 questions), guilt (5 questions), anger (3 questions) and search of the purpose (3 questions). The whole questionnaire consisted of: open-ended questions (15 questions), partially openended questions (1 question) and closed-ended questions (31 questions) and the Munich Grief Scale consisting of 22 closed-ended ques- tions. Processing and Analysis of Data The survey was conducted via web portal 1KA, that was available from the 8th of January 2016 until the 8th of March 2016. The participants agreed to participate in the survey and were explained the purpose and the objectives of the research prior to answering the questions. Data was analyzed with Microsoft Excel and SPSS ver. 20.0. The level of statistical significance was set at 0.05. Results We were interested, whether the time of a miscarriage or stillbirth has any im-212 pact on the level of grief due to the loss of the child. The participants were di-n vided into two groups: women that lost their child before the 22nd week of pregnancy and women that lost their child in the 22nd week or later. pulatioo ge p Table 1: Difference among women and their experiencing of grief regarding gestational age of child. rking-ao Gestational age of the dead t-test he w infant (in weeks) N M SD t df p f t Less than 22 (< 22) 65 3.70 0.54 2.484 106 0.015 More or equal to 22 (≥ 22) 43 3.40 0.70 ealth o| h We found out that regarding the gestational age (less and equal or more pulacije than 22 weeks) there are statistically important differences among women and o their experiencing of grief (Table 1). ktivne p We also wanted to know if experiencing grief might also depend on how much time has passed since the loss. Participants were further divided into two groups: women that lost their child relatively recently (i.e. less than 24 months elovno a ago) and women that experienced the loss more than 24 months ago. zdravje d Table 2: Comparisson considering time passed since the loss of the child. Time passed from the loss of t-test the child (in months) N M SD t df p Less than 24 (< 24) 44 3.80 0.54 -3.919 106 0.002 More or equal to 24 (≥ 24) 64 3.43 0.64 Results (Table 2) showed that how much time had passed from the crit- ical event is a very important factor and has an impact on experiencing grief. Further on, we wanted to find out if the age of the mother at the time of the loss also has an impact on experiencing grief. Participants were divided in-to two groups: on women that were under 30 years old at the time of the loss and on those that were 30 years old or older. Table 3: Comparisson considering the chronological age of mothers in the time of child loss. t-test Chronological age (in years) N M SD t df p Less than 30 (< 30) 60 3.46 0.63 2.297 106 0.024 More or equal to 30 (≥ 30) 48 3.73 0.59 We found out that there are statistically important differences consider- ing the chronological age of mothers in the time of the child loss (Table 3). Further on, we found out that there are no significant differences in expe- 213 riencing grief, other painful feelings, memories or the need to talk about their loss, to cry and miss the child etc. in regard to seeing the child or not seeing it eath after the miscarriage/labor. Whether the medical workers were understanding and sympathetic to erinatal d the mothers during the time they were in the hospital, 58% of the mothers said fter p yes and 42% said no. Out of 108 participants, 68% felt that in their home environment the health professionals (personal doctors, at the gynecologist 3 weeks cess aro after the miscarriage or 6 weeks after the labor and by home care nurses) were understanding and sympathetic towards them, while 32% of the participants rief p said they did not receive adequate treatment by health professionals. he g One of the questions of the questionnaire was regarding the loss of the uring t child and the consequential impact it had on the relationship with their part- ife d ner, which also strongly affects the quality of life during the grieving process. f l As much as 63% of the participants agreed that their relationship with the partner improved, 16% claimed it stayed the same and 21% of women said their re- uality o lationship worsened. s qen‘mow Discussion Grieving is the process of slowly letting go of the emotional attachment to- wards the child. Still, the woman that lost her child is experiencing strong feelings and confusion. Such emotions are present no matter how early the preg- nancy terminated, even if it only lasted a few weeks. Some women do not experience grief right after a miscarriage; however, that does not mean there is something wrong with them or that they are uncaring because every individual reacts differently and the grief and disappointment can also appear at a lat-er time (Zečević et al., 2003). We found out that there are significant differences in experiencing grief due to various factors, namely after the loss of the child, it also depends on how much time had passed from a miscarriage or stillbirth. Women that lost their child in the 22nd week of pregnancy are showing stronger emotions of grief and other painful feelings, memories, a need to talk about their child, to cry and miss it etc. The age of the mothers at the time of the loss also proved to be an im- portant factor because it showed to be an important indicator of experiencing grief with the participants. Namely the grieving process was more intensive with mothers that had perinatal loss at the age 30 or older than mothers that lost their child before reaching 30 years of age. The first group showed more intensive feelings of grief and other painful emotions, memories, a need to talk about their child, to cry and miss it etc. From this we can conclude that the age of the mothers also has an im- pact on the intensity of grief, or how deep it is and therefore the grieving process is also longer. 214 The time that had passed from the loss of the child and to the time the survey was carried out is also one of the important indicators that showed in n which grieving stage the participant was or if she already completed the griev-pulatio ing process. Participants that experienced the loss of their child 24 months ago o are still expected to show certain grieving patterns in comparison to women, ge p who experienced the loss over 24 months ago. When the intensity of grief is so strong that an individual cannot accept the loss, which can eventually lead to rking-ao depression and despair, it is called pathological grief (Peljhan, 2016). Results he w of the conducted survey showed that in average women got pregnant again 15 f t months after the loss. ealth o The results also showed a significant difference in experiencing grief | h among the participants regarding the time that had passed from the loss of the child. Women that experienced the loss of the child 24 months prior to con-pulacije o ducting the research (44 out of 108 participants) showed more intensive emo- tions of grief and other painful feelings, memories, the need to talk about their ktivne p child, to cry and to miss it etc. After the loss it is very important that the parents decide how long they elovno a should wait to get pregnant again. In any case, there is no rule when is the right time, but it is important that the woman lets herself grieve and deals with her zdravje d feelings of the loss. A little over one third of the women participating in the survey were already pregnant again before they answered the questionnaire. Only one participant got pregnant as soon as one month after the loss of her child, which is rather fast. Regarding the theory of the grieving process, an individual after a critical loss barely moves from the stage of shock and realizes the reality of the loss in one month, as the acute stage of the grieving lasts from 2 to 6 weeks (Velikonja, 1999). Among the women participating in the survey the longest time that passed from the loss of the child to another pregnancy was 5 years. It is an interesting fact that Gravensteen et al. (2013) came to completely opposite conclusions regarding holding or seeing the child after stillbirth or miscarriage. Namely they found out that seeing the baby afterwards had a positive effect on the grieving process and therefore they encouraged health workers to prepare the parents to see their child and spend the time with it to say goodbye. However, it is concerning that only 58% of the participants were treat- ed with understanding and sympathy by health workers. From the answers of our participants and other surveys (Baznik, 2005) we can conclude that parents criticized and had a negative experience with health workers after the loss of their child. According to other research, the grieving parents also said they did not get enough information regarding the tests made after the death of their child, the cause of death and the consequences the loss can have on the moth- er and her chances of getting pregnant again. Gravensteen et al. (2013) further on discovered that the majority of women were given support (85.6%) during 215 the labor and were respectfully treated (94.4%) with the stillborn baby by the health workers. eath It is of great importance that the help is offered to the parents‘ right after the loss of their child because it can reduce the risk of a negative outcome. The erinatal d help can be offered by the doctors, nurses and other interdisciplinary mem- bers of the team, including psychologists and social workers (Wing et al., 2001). fter p More sympathy and understanding was given by health workers in the cess a home environments of our participants, as was claimed by 68% of the par- ro ticipants. When asked, what they would require from the health workers in rief p their home environments, women‘s answers varied. Majority claimed that they he g would need more pieces of advice on how to move on and where to look for help further on. This is the role of community nurse that has to document all the ob-uring t servations of a mother after stillbirth. In the case of a problematic outcome that ife df l the home care nurse cannot resolve by her own, a selected doctor, gynecologist or other suitable institution has to be informed (Kraševec, 2002). uality o s qen‘ Conclusion mow In the health care process of the obstetric and gynecological care only emphat-ic healthcare workers should be employed due to special sympathetic treatment women should be given as they are under the influence of many hormones af- ter giving birth. And when we also deal with perinatal death, the health work- ers should, besides being compassionate, also have enough knowledge and willingness to educate themselves further. Additional training is essential for health workers because, firstly they also have to deal with the loss themselves. And secondly, it is their help that is of extreme importance in such critical period for the parents as it can effect and make a difference between a healthy grieving process and an unhealthy one. It is of great importance that the woman and her needs would truly be put first in the postnatal care. One of the participants of the survey wrote that she “would wish that they would think about the particularities” and gave us a great starting point for further research. Namely, the parents should be able to talk to the midwife or a nurse after receiving the sad news, who would explain the course of the labor, important information and encourage the parents to see and hold the baby and even name it, inform them of the grieving process, the nature and process of the bureaucracy and also offer them the time they need to think about their own needs in connection to their dead child, no mat- ter how hard it is for them. When the parents would be given all the informa- tion right after they had received the sad news about the death of their child or already when they are accepted into the hospital for the arranged induced labor, they would cope better after seeing their child and also with their expectations and the reality of the loss. The positive effects of such a talk would later be observed during their grieving process and would also affect their quality 216 of life in the process. We should also be aware of the fact that the grieving pron cess of the parents cannot be alleviated and parents also do not want that from us. Our caring and sensibility that come before realization can help us to un-pulatioo derstand the pain of others, to listen to them and offer them our help (Globev-ge p nik Velikonja, 2000) that is in such times very much needed. Later in the grieving process we should also encourage grieving women rking-ao and other family members to search for additional psychological and therapeu- he w tical help in order to cope more efficiently with their feelings. It would also be f t very wise to integrate women in complementary methods of coping with their grief and other emotions. One of such efficient methods is the EFT (Emotional ealth o Freedom Technique), a technique to achieve emotional freedom (Craig, 2007). | h The EFT is a tool that helps to ease negative emotions and offers many ways to solve emotional problems (Craig, 2007; Fone, 2012). pulacije o References ktivne p BAZNIK, S., 2005 Podpora staršem ob izgubi kritično bolnih otrok v enotah intenzivne zdravstvene nege in terapije. Obzornik zdravstvene nege, letn. elovno a 39, št. 1, str. 47−53. CARTWRIGHT, P., READ, S., 2005. Working with practititioners to develop zdravje d training in peri-natal loss and bereavement: Evaluating three workshops. Nurse Education in Practice, letn. 5, št. 1, str. 266. CRAIG, G., 2007. EFT raziskave [spletni vir]. [Datum dostopa 16. 5. 2017]. Dostopno na http://www.eftuniverse.com/ FONE, H., 2014. (5. NATIS) EFT – Tehnika doseganja čustvene svobode za tele-bane. Ljubljana: Pasadena. GRAVENSTEEN, I. K., HELGADÓTTIR, L. B., JACOBSEN, E. M., RÅDESTAD, I., SANDSET, P. M., EKEBERG, O. 2013. Women‘s experi- ences in relation to stillbirth and risk factors for long-term post-traumat- ic stress symptoms: a retrospective study. BMJ Open. [Datum dostopa: 13.05.2017]. Dostopno na http://bmjopen.bmj.com/content/3/10/e003323 KRAŠEVEC, B., 2002. Zdravstvena nega otročnice. Postojna: Zbornica zdravstvene nege Slovenije – Zveza društev medicinskih sester in zdravstvenih tehnikov Slovenije. KOPČAVAR GUČEK, N., FRANIĆ, D. 2008. Kakovost življenja, svetovanje in hormonsko nadomestno zdravljenje. Zdravniški vestnik, letn. 77, št. 3, str. 73–78. KOROŠEC, M., NOVAK, U., ZEVNIK, H. 2007. Ob izgubi, ki jo doživlja mla- dostnik. Ljubljana: Salve. OZBIČ, P., 2015. Medsebojna podpora partnerjev v procesu žalovanja po otrokovi smrti. Psihološka obzorja, letn. 24, str. 44−56. PELJHAN, M., 2016. Žalovanje, zadovoljstvo z življenjem in partnerski odnos ob zgodnji izgubi otroka: magistrsko delo. Ljubljana: Univerza v Ljublja-217 ni, Teološka fakulteta, magistrski študijski program zakonska in družin- ska terapija. eath SIMONIČ, B., 2006. Prva resnica je rojstvo, zadnja je smrt. Anthropos, letn. 38, št. 1-2(201-202), str. 173−181. erinatal d VELIKONJA, V., 1999. Psihološka pomoč staršem ob otrokovi smrti. Psihološ- ka obzorja, letn. 8, št. 1, str. 93−103. fter p WING, D.G., CLANCE, P.L., BURGE-CALLAWAY, K., ARMISTEAD, L., cess a 2001. Understanding gender differences in bereavment following the ro death of an infant: implications for treatment (Prevedla: Sara Topolovec). rief p Psychotherapy, letn. 38, št. 1, str. 60−73. he g ZEČEVIĆ B, UREK P, KOKOL S, CEHNER M., 2003. Prazna zibka, strto srce: uring t staršem, ki so izgubili otroka med nosečnostjo ali kmalu po porodu. Krško: ife d Društvo Solzice, str. 17, 65. f l uality o s qen‘mow Absenteeism in Slovenian railways – comparison between different work groups Martin Vrašec1, Matej Voglar2 1 Slovenian Railways, Ltd, Kolodvorska 11, 1506 Ljubljana 2 University of Primorska, Faculty of Health Sciences, Polje 42, 6310 Izola martin.vrasec@slo-zeleznice.si; matej.voglar@fvz.upr.si Abstract Introduction: In the working environment there are several (even negative) factors which can affect employees and the consequence is absenteeism. The most often causes of absenteeism in Slovenian Railways Group are musculoskeletal problems, nonworking infections and injuries, and mental and behavioral disturbances. Methods: We observed the percent of absenteeism between four work groups, of which two groups were regular work schedule and two groups were shift-work schedule. The absenteeism was observed between years 2007 and 2015. Regular work schedule employees were office workers and railway infrastructure maintenance workers. Shift-work schedule employees were train drivers and railway wagon inspectors. Results: Using 2-way ANOVA we found the greatest percent of absenteeism in railway infrastructure maintenance workers (6,38 % ± 0,95 %), followed by train drivers (4,49 % ± 1,39 %) office workers (4,23 % ± 0,58 %) and railway wagon inspectors (3,28 % ± 0,62 %). Conclusion: Because we did not have available data on the causes of absenteeism, we can about them only assume on the basis of knowledge of the working environment. In the next survey, we will ask employees about the causes of absenteeism and on the basis of the results we will produce guidelines and recommendations for preventive action. Key words: percent of absenteeism, railway infrastructure maintenance workers, train drivers, office workers, railway wagon inspectors. In working environment, the workers are influenced by several physiological and psychological risk factors. When workers are exposed to those factors for a longer period of time the consequence can be absenteeism. Three main causes for increased absenteeism are I.) incorrect posture and incorrect ma- nipulation with objects, II.) increased body mass and III.) physical inactivity doi: https://doi.org/10.26493/978-961-7023-32-9.219-226 (Albreht, 2016). Epidemiological research has been providing information on causality of infectious diseases and causality of some chronic diseases thus influencing occupational health and safety. Furthermore, epidemiology can ex- plain causality of absenteeism. Absenteeism is expressed in percentage there- fore giving the average fraction of lost working days per person (NIJZ, 2016). Between years 2007 and 2015 the absenteeism in the Slovenian Railways Group was higher in comparison with absenteeism in the Republic of Slovenia (Fig- ure 1) therefore we wanted to examine the absenteeism by different occupation- al subgroups. In our research, we compared absenteeism between four groups of workers of Slovenian Railway Group. The data was acquired from annu- al workers health reports which are every year prepared for the previous year. Current annual reports represent just percent of absenteeism but not the de- tailed information about causality of absenteeism. 220 n pulatioo ge p rking-ao he wf t ealth o| h pulacije o Figure 1: Graphically represented percent of absenteeism between ktivne p Slovenian Railways Group and Republic of Slovenia. Workers from the observed groups were railway maintenance workers, of- elovno a fice workers, train drivers and railway wagon inspectors. Railway maintenance workers and office workers have regular work schedule, while train drivers and zdravje d wagon inspectors work in shift-work schedule. The other difference between groups is the dynamic of their work with railway maintenance and wagon in- spectors having dynamic work while office workers and train drivers have pre- dominantly sedentary work. The health-risk factors in the maintenance work- ers group are lifting and moving heavy objects, work in the forced posture, and exposure to weather conditions. The health-risk factors in the office workers group include prolonged sitting (often in the forced posture) and stress. Train drivers work 8-12 hours and are exposed to prolonged sitting, forced posture and whole-body vibrations, accompanied by stress, exposure to electro-mag- netic fields, sleep deprivation, eating disorders and other (Vrašec, 2015). Wag- on inspectors also work 8-12 hours. They work outside therefore the health-risk factors in this group are exposure to different weather conditions, danger of falls, and asymmetrical posture at work. On the other hand train drivers and wagon inspectors are part of execu- tive railway workers. Executive railway workers are taking an active part in the railway traffic therefore must be at the good health, free of hearing or eyesight troubles, cardiovascular diseases, with settled blood pressure and other. Also, before starting a career, the train driver must perform an ultrasound or ECG which is required in the guidelines of the international association of the railway medical services (van Dijk, Govaart & Voumard, 2007). The goal of our study was to assess if there are statistically significant differences in the absenteeism between these different groups of railway workers. Furthermore the potential effects of sedentary work and shift work on absen- teeism were assessed. We hypothesized that there will be significant difference between different occupations and that shift work and physical work will result 221 in more absenteeism. upsro Methods k gor We observed the incidence among four occupational groups of the Slovenian t w Railways Group, i.e. office workers (regular work schedule, sedentary), main- en tenance workers (regular work schedule, dynamic, heavy duty), train driv- iffer d ers (shift-work schedule, prolonged sitting) and wagon inspectors (shift-work een schedule, dynamic duty). We acquired the data from annual reports on work- etw b ers’ health in the Slovenian Railways Group between years 2007 and 2015. On- ly the data about absenteeism was included. The data for the nursing or attend-parison ance were excluded (E8 by the ICD-10). The average number of employees in om c the observed period was 1590 in the office workers group, 390 in the railway maintenance group, 960 in the train drivers group and 206 in the wagon in- ays – spectors group (table 1). We didn’t find the data for the age, gender and other in ailw the annual reports. ian r SPSS version 20 (SPSS Statistics, IBM, New York, ZDA) has been used loven for the analyses. One-way analysis of variance (1-way ANOVA) was conduct- ed in order to assess the differences between occupational subgroups (dynam- ism in s tee ic regular schedule, sitting regular schedule, sitting shift-work schedule, dynamic shift-work schedule). Two-way analysis of variance (2-way ANOVA) was absen conducted in order to examine the effect of the work schedule and the effect of the dynamics at work (physically active vs. sedentary) and the interaction effect (schedule (2) x dynamic (2)). Statistical significance was set at the p < 0,05. Table 1: The number of employees by the occupation. Occupation Year Maintenance workers Office workers Train drivers Wagon inspectors 2007 473 1670 1038 237 2008 481 1708 1072 228 2009 443 1735 1090 245 The num- 2010 416 1553 958 193 ber of em- 2011 378 1387 917 191 ployees 2012 334 1371 892 195 2013 315 1714 880 192 2014 344 1417 922 190 2015 322 1757 871 180 222 Average 2007-2015 390 1590 960 206 n Results pulatioo ge p rking-ao he wf t ealth o| h pulacije o ktivne p elovno a Figure 2: Graphically represented percent of absenteeism among the zdravje d observed groups. * p < 0,050; ** p < 0,001 Using one-way ANOVA we found significant differences between groups. Maintenance workers have the highest percent of absenteeism (6,38 % ± 0,95 %) which is significantly higher when compared to office workers (4,23 % ± 0,58 %; p < 0,001, F = 2,152), train drivers (4,49 % ± 1,39 %; p < 0,001, F = 1,887) and wagon inspectors (3,28 % ± 0,62 %; p < 0,001, F = 3,102). Significant difference was also found between train drivers and wagon inspectors (p < 0,050, F = 1,214). Between other groups we didn’t find significant differences. Figure 2 represents data graphically. Using two-way ANOVA we first tested the interaction effect between the effect of the work schedule and the effect of the dynamic and the differences by each factor. Comparing by factor dynamic (sedentary vs. physically active) did not show significant differences (p = 0,147, F = 2,208). On the other hand, there were significant differences found when comparing by factor work schedule (regular vs. shift-work) (p < 0,001, F = 20,217). Also we found the significant interaction effect between both factors (p < 0,001, F = 28,456). Discussion We found the highest percent of absenteeism in the railway maintenance group (dynamic, heavy duty, regular schedule) and the lowest percent of absenteeism in the wagon inspectors group (dynamic, shift-work schedule). Train drivers (sitting, shift-work schedule) had lower percent of absenteeism compared with 223 maintenance workers and higher percent compared with office workers (sit- ups ting, regular schedule). The data shows common percent of absenteeism (with- ro out nursing or attendance) and doesn’t include causalities for the absentee- k gor ism. By the factor of dynamics (sedentary vs. physically active) we didn’t find t w significant differences while differences were found by the factor work sched- en ule (regular vs. shift-work), surprisingly showing lower rate of absenteeism in iffer d workers working in shifts. We have also found the significant interaction ef- een fect between both factors indicating that combination of shift work schedule etw b and static work or combination of regular work schedule and heavy duty work can cause higher rate of absenteeism. Moreover, we can assume that heavy du- parison ty work has stronger impact on absenteeism than shift work. om c We acquired information about causalities by National Institute of Pub- lic Health. Most often causalities for absenteeism in the Slovenian Railways ays – Group between years 2007-2015 were musculoskeletal problems, nonworking ailw infections and injuries, and mental and behavioral disturbances, followed by ian r work-related injuries and respiratory diseases. The average number of work-re- loven lated injuries in Slovenian Railways Group was 22 per 1000 employees, which is almost half of that what found Gauchard et al. (2003) in the large French ism in s railway company (~40 work-related injuries per 1000 employees). Gauchard et tee al. (2003) found that more than 15 % of injuries were due to falls. Falls were absen most freequent in train drivers, maintenance workers and production oper- ators (Gauchard et al., 2003; Chau et al., 2004). Mental and behavioral disor- ders were often cause for absenteeism in Chinese executive railway workers (Zhang et al., 2016) and in contrast with our data, they were more comon than musculoskeletal diseases. Compared with our survey in which we observed all employees, Zhang et al. (2016) included just executive railway workers which could contribute to the observed differences. Mental and behavioral disorders are often related with increased workload and shift work, which can cause sleep disturbances and changes in circadian rhythm (Jeon et al., 2013). Furthermore, it can cause fatigue, which can lead to general dissatisfaction. Another stress factors specific for train drivers are accidents with road or railway vehicles and run overs, which often have fatal consequences. Following accidents posttraumatic stress disorder is often seen in train drivers (Doroga & Baban, 2013; Jeon et al., 2013), therefore we have consultants for the first psycho-social aid in the Slovenian Railway Group. It should be noted that physically active employees and those with healthy (settled) lifestyle are more successful in coping stress, PTSD and other risk factors. The highest percent of absenteeism was found in railway infrastructure maintenance workers. We assume that the most probable cause for the absen- teeism in this group were musculoskeletal diseases and work-related injuries. Furthermore, lower education and lower financial income are known to be re- lated with unhealthy habits. In comparison, the office workers have higher in- comes and also it is required at middle school education or higher for office po-4 sition. The risk factors in office workers are prolonged sitting in forced position 22 and stress thus we assume that causes for the absenteeism are musculoskeletal n diseases due to static postures followed by mental and behavioral disorder due to work related stress. In support to this assumption is the fact that office work-pulatioo ers are predominantly women and reports show that women are more often ab- ge p sent due to mental and behavioral disorders compared with male colleagues. The second highest percent of absenteeism was found in train drivers. rking-ao Train drivers work in shift-work schedule which has been shown to be a risk he w factor for sleep disorders, metabolic syndrome and heart diseases (Costa, 2010). f t Other important risk factors are prolonged sitting in restricted position, exposure to whole body vibrations, electromagnetic field and noise. Prolonged sit- ealth o| h ting and exposure to whole body vibrations can cause changes in neuromus- cular functions of the trunk and increase the risk of low back pain (Vrašec, pulacije 2015). However, based on results of previous survey, the train drivers are famil-o iar with guidelines for preventive action at work and in a leisure time (Vrašec, 2015). Furthermore prolonged exposure to noise can cause hear loss therefore ktivne p train drivers are equipped with active silencers. Exposure to electromagnet- ic fields and engine exhaust were recognized as risk factor for cancer develop-elovno a ment. According to aforementioned risk factors and consequences, we assume that train drivers are mostly at risk for developing musculoskeletal disorders zdravje d and metabolism related problems. The lowest percent of absenteeism was found in wagon inspectors, who al- so work in shifts. Wagon inspectors are working outside, exposed to all weather conditions. During 12-hour shift they are mostly walking due to technical examination of the train, testing the break system of the train and other. The path by the track, where wagon inspector walk during work, must be well hardened and well-lighted in all weather conditions. Due to maintenance work or some other unpredictable factor there is a possibility of unpredicted obstacles on the path. During his work the wagon inspector does not watch the path but mostly the train and consequently it can cause slips or falls. Despite mentioned fac- tors we found lowest percent of absenteeism in this group therefore we can assume that regular and moderate physical activity, even at work, can have an important role in health care. Unfortunately, the data on the causes of absen- teeism were not available by separate groups, therefore we can only speculate on the predominant causes based on the knowledge of the working environ- ment. However, more objective validation is necessary therefore we will per- form additional surveys. Conclusion In order to assure better overview on causalities for absenteeism, the renewal of the human resources office information system will be suggested. Renewed system should enable evidence on absenteeism not only by duration but also by causes separately by different occupations. Based on these data we could pre- pare guidelines and recommendations for safer work and for the preventive ac- tion at work and leisure time. All employees, especially executive railway work-225 ers, are well informed about safety at work already before starting the career. Despite this their compliance with recommendations is questionable. In ad- upsro dition to renewal of the human recourses office information system a survey k g should be performed, in which employees could write their most often diseases or t w or disorders. Based on the results of the survey recommendations and guide- en lines for the preventive action at work and in a leisure time could be suggested iffer immediately. Based on the results of this study, we believe that railway infra-d een structure maintenance workers should be the first to be informed with guide- etw lines for the preventive action. This will be implemented as a part of an occu-b pational health promotion which is not just a legal obligation but provides long term benefit for the company and personnel. As Podjed,( 2014) has been shown, parison om we can expect a return of 2,4-4,8 euros for every 1 euro invested in health pro-c motion and that absenteeism decreases 35 % in employees who visit occupa- ays – tional health promotion programs. ailw ian r References loven ALBREHT, T., 2016. Epidemiologija in ergoepidemiologija – Splošna epidemi- ologija. Prosojnice in zapiski predavanj pri predmetu Epidemiologija in ism in s tee ergoepidemiologija, podiplomski magistrski študijski program Aplika- tivna kineziologija. Fakulteta za matematiko, naravoslovje in informaci- absen jske tehnologije. Univerza na Primorskem. CHAU, N., MUR, J.M., TOURON, C., BENAMGHAR, L., and DEHAENE, D., 2004. Correlates of occupational injuries for various jobs in railway work- ers: a case-control study. Journal of Occupational Health, 46(4), 272–280. COSTA, G., 2010. Shift work and health: current problems and preventive ac- tions. Saf Health Work, 1(2), 112–123. DOROGA, C., and BĂBAN, A., 2013. Traumatic exposure and posttraumatic symptoms for train drivers involved in railway incidents. Clujul Medical (1957), 86(2), 144–149. GAUCHARD, G.C., CHAU, N., TOURON, C., BENAMGHAR, L., DE- HAENE, D., PERRIN, P., and MUR, J.M., 2003. Individual characteris- tics in occupational accidents due to imbalance: a case-control study of the employees of a railway company. Occupational and Environmental Medicine, 60(5), 330–335. JEON, H.J., KIM, J.H., KIM, B.N., PARK, S.J., FAVA, M., MISCHOULON, D., … LEE, D., 2014. Sleep quality, posttraumatic stress, depression, and human errors in train drivers: a population-based nationwide study in South Korea. Sleep, 37(12), 1969–1975. https://doi.org/10.5665/sleep.4252 NIJZ – Nacionalni inštitut za javno zdravje, 2016. Pridobljeno na spletnem 6 naslovu http://www.nijz.si/sl/podatki/bolniski-stalez dne 20.12.2016. 22 PODJED, K., 2014. Proaktivni pristop k promociji zdravja na delovnem mes- n tu. Ekonomska demokracija. Pridobljeno 14.3.2016 na spletnem naslovu www.produktivnost.si/wp-content/uploads/2014/09/Proaktivni-pris- pulatio top-k-promociji-zdravja-na-delovnem-mestu-Ekonomska-demokraci- o ge p ja-avg-2014.pdf VAN DIJK, J., GOVAARTS, J., and VOUMARD, P.A., 2007. Vocational reha- rking-ao bilitation of locomotive engineers with ischaemic heart disease. Occupa- tional Medicine (Oxford, England), 57(2), 131–136. https://doi.org/10.1093/ he wf t occmed/kql158 VRAŠEC, M. (2015). Vpliv delovnega mesta strojevodje vlaka na živčno-mišične ealth o| h funkcije trupa v kontekstu tveganja za pojav bolečine v spodnjem delu hr- bta. Diplomska naloga. Fakulteta za matematiko, naravoslovje in infor- pulacije macijske tehnologije. Univerza na Primorskem. Koper. o ZHANG, X., CHEN, G., XU, F., ZHOU, K., and ZHUANG, G., 2016. Health-Re- ktivne p lated Quality of Life and Associated Factors of Frontline Railway Workers: A Cross-Sectional Survey in the Ankang Area, Shaanxi Province, China. International Journal of Environmental Research and Public Health, 13(12). elovno a https://doi.org/10.3390/ijerph13121192 zdravje d Presence of professional stress in teaching staff at the Medical faculty in Foca Milica Vuksanović, Dragica Marić, Jelena Pavlović, Sandra Joković, Natalija Hadživuković University of Sarajevo, Faculty of Medicine, Studentska 5, 73 300 Foca, Republic of Srpska, Bosnia and Herzegovina vuksanovicmilica24@icloud.com; mariceva11@yahoo.com; pjelena551@gmail.com; sandra.jokovic@hotmail.com; natalijahadzivukovic@yahoo.com Abstract Introduction: In recent years, an increasing number of studies deal with the study of the psychosocial aspects of the working-age population. The aim of the research was to examine the level of professional stress in the teaching staff at the Medical Faculty in Foca. Methodology: The study was designed as a cross-sectional study with 47 workers. The survey included faculty members from the Medical Faculty in Foca. We used a sociodemographic questionnaire, a questionnaire to assess health status and Maslach burnout inventory. Statistical analysis was performed with the use of SPSS statistical software package. Results: Most respondents (83%) are under stress, and 42.6% of the respondents identified symptoms of work related burnout. Physical and mental component of quality of life was assessed as “bad” by 2.1 % respondents; their physical and mental health was rated as “well” by 23.4%, and by 74.5%respondents was rated as excellent. Conclusion: Those respondents that rated the presence of burnout symptoms rated also their quality of mental health as lower. Keywords: quality of life, professional stress, health. At the present time the concept of stress is widely used, both in science and in everyday life. There are many definitions of stress dealing with aspects of stress, which are important for the scientific discipline from where they came from, and that immediately indicates the width and impor- tance of this problem. Stress is present in different spheres of human life; there are different patterns and individual consequences (Tennat, 2001). Numerous empirical studies show that the sources of stress on work are many, and that the stress related to work frequently occurs. The most common causes of workplace stress are: lack of control, poor working conditions, too much re- doi: https://doi.org/10.26493/978-961-7023-32-9.227-235 sponsibility, disturbed interpersonal relationships, type of work, tasks that are performed in shifts and those jobs that require extended working hours. The frequency of impacts of negative stress on health and physical disorders goes from 50-70% of the total number of pathogens. There is virtually no area of human activity that is not related to stress and stressful situations. A number of medical experts (Nyssen, et al., 2003) stated that stress plays a major role in the causation of various degenerative diseases such as high blood pressure, heart disease, metabolic disorder and decline in immune capacity of the body. It is very important to develop strategies to control stress, which help to cope with stressful situations and to recognize the situation that the individual cannot influence on (Jackson, 1999).The objective of the research was to examine the level of professional stress of the teaching staff at the Medical Faculty in Foca. Methods 822 The study was designed as a cross-sectional study with 47 respondents, of which 14.9% men and 85.1% women, aged 43.14 ± 9.46 years. The survey includ- n ed the teaching staff from the Medical Faculty in Foca during the period from February to June 2016. The criteria for inclusion in the study were: respondents pulatioo who work and are directly involved in the care and treatment of patients. Crite-ge p ria for exclusion from the study were: respondents who are not involved in the care and treatment of patients and subjects who did not respond to five or more rking-ao questions or have marked the same answers to all the questions. The study in- he w cluded the following instruments: sociodemographic questionnaire, the ques- f t tionnaire for the assessment of the state of health (Short Form 36 Health Sur- vey-SF-36) (Ware, 1993) and Maslach Burnout Inventory (MBI) (Maslach et al., ealth o| h 1996). The sociodemographic questionnaire was created for the purpose of this research and contains 10 questions related to the characteristics of the respond-pulacije ents (gender, age, marital status, place of residence, family income, degree of o education of respondents). ktivne p Maslach Burnout Inventory - The MBI has three structural units and measures the following dimensions: a feeling of emotional exhaustion and overwork, depersonalization, or a sense of discomfort caused by effort and a elovno a sense of competence and job satisfaction. The test consists of 22 claims that are scored in seven categories from 0 to 6 (0 - never, 1 - several times a year or zdravje d less, 2 - once a month or less, 3 - several times a month, 4 - once a week, 5 - several times a week, 6 - every day).The Subscale of Emotional Exhaustion (EE) consists of 9 items, the Subscale of Depersonalization (DP) consists of 5, and 8 items make the subscale of personal fulfilment with job (PA). If the value on test 51 for EE is greater than 26, there is a high risk of burnout syndrome, and / or if the value for the DP test is higher than 9, there is also a high risk of burnout syndrome. A value of less or equal to 18 on the subscale EE represent a small burnout risk, and a value from 19 to 26 is a medium burnout risk. As for the PA subscale, the low burnout risk is greater or equal than 40, the mid risk is from 39 to 34, and the high burnout risk is less or equal to 33, but the general conclu- sion about the presence of burnout syndrome can`t be obtained by observing the PA subscale like isolated case. The subscale PA is relevant only if it is confirmed with an EE or DP scale. The total score is possible in the range 0 -132. MBI has three structural units and measures the following dimensions: a feel- ing of emotional exhaustion and pretensioning job, depersonalization or dis- comfort caused by exertion and a sense of competition and job satisfaction. Statistical analysis was performed using SPSS 24.0 statistical software package. Of the non-parametric statistical tests we used χ2- square test. The correlation is performed using the Pearson correlation coefficient. As the lev-el of statistical significance of differences, its been used a common value of p <0.05. For displaying the average values we used the arithmetic mean and standard-deviation. The data are presented in tables and charts. Results In shifts works 46.8% of respondents and majority (83%) is exposed to stress at 229 work. Professional burnout syndrome was observed in 42.6% of workers, mid- ca dle and high level of emotional exhaustion was observed in 57.5%, deperson- on f alization was observed in 44.7%, while the low and middle level of personal achievements are observed in 61.7% of the respondents. Using the SF-36 ques- aculty i tionnaire that evaluates a common component of physical health, it has been observed that the high level of the Physical Component Summary (PCS)is pres- edical f ent in 74.5 %, of respondents middle level in 23.5%, whereas the low level is ob-he m served in only 2.1% Between groups of respondents with different level of PCS t t highly statistically significant difference was observed (χ2 = 20,228; p = 0.001) taff a comparing to level of emotional exhaustion. Statistically significant number of respondents with high level of PCS (36.2%) was observed comparing to re- eaching s spondents with low level of PCS (0%) (table 1). n t In 74.4% of respondents registered a high level of common mental health tress i components, 23.4% showed a medium level, while only one respondent showed low levels of MCS. Between groups of subjects with different levels of MCS nal s there was a high significant difference compared to the level of emotional ex- fessio haustion (χ2 = 15.276; p = 0.004) and a statistically significant difference com-rof p pared to the level of depersonalization (χ2 = 11,358; p = 0.023), wherein 40.4% of subjects who have a high level of MCS and shows no signs of emotional ex- haustion, while 55.3% of patients with a high level of MCS and shows no signs presence o of depersonalization. Table 2 shows the differences in the average values of the domains of the SF-36 questionnaire for the presence of a professional burnout syndrome. A statistically highly significant difference was observed with re- spect to domain limitations due to emotional problems (t = -3.563, p = 0.002), where the average value of this domain in respondents with present burnout syndromes is significantly lower (66,60 ± 41,92), compared to the scoring state levels of patients where it is not detected burning syndrome (100.00 ± 0.001). Social functioning is at statistically significantly higher level (t = -2.019, p = 0.050) in the patients without the present syndrome (87.03 ± 13.19) compared to those with the present burnout syndrome (78.65 ± 15.21) while differences in relation to domains of physical functioning, vitality, mental health, general health, body pains and limitations due to physical health were not found. Table 1: Emotional exhaustion, depersonalization, personal success and a total score of MBI in regard to the levels of physical health (PCS). PCS (%) Total Subject Level of Burnout Number χ2 p (%) Low level Middle level High level Low level 0 (0) 3 (6.4) 17 (36.2) 20 (42.6) Emotional ex- haustion (De- Middle 0 pressive anxious 20.228 0.001 level 0 (0) 6 (12.8) 18 (38.3) 24 (51.1) 23 syndrome) n High level 1 (1.2) 2 (4.3) 0 (0) 3 (64) pulatioo Low level 0 (0) 7 (14,9) 19 (40,4) 26 (55,3) ge p Depersonaliza- Middle rking-a tion (Lack of em- 9,419 0,051 o pathy) level 1 (2.1) 0 (0) 12 (25,5) 13 (27,7) he wf t High level 0 (0) 4 (8,5) 4 (8,5) 8 (17,0) ealth o| h Low level 1 (2,1) 7 (14,9) 17 (36,2) 25 (53,2) pulacije Personal success Middle o (Achievement) 1,790 0,774 level 0 (0) 1 (2,1) 3 (6,4) 4 (8,5) ktivne p High level 0 (0) 3 (6,4) 15 (31,9) 18 (38,3) With elovno a burnout 1 (2,1) 5 (10,6) 14 (29,8) 20 (42,6) Burn-out syn- syndrome drome measured 1,481 0,477 Without zdravje d using MBI scales burnout 0 (0) 6 (12,8) 21 (44,7) 27 (57,4) syndrome Tabel 2: The arithmetic means and standard deviation of the domains of the SF-36 questionnaire according to the presence of burnout syndrome. Domains of the SF- MBI Mean (SD) 36 questionnaire t p With burnout syndrome Without burnout syndrome Physical func- tioning 87,75 (13,71) 83,51 (18,23) 0,871 0,389 Limitations due to physical health 78,75 (34,67) 91,66 (16,98) -1,535 0,137 Limitations due to emotional prob- 66,60 (41,92) 100,00 (0,001) -3,563 0,002 lems Vitality 60,75 (12,59) 65,18 (9,75) -1,361 0,180 231 Mental health 50,65 (9,46) 47,70 (5,53) 1,340 0,187 cao Social functioning 78,65 (12,21) 87,03 (13,19) -2,019 0,050 n f aculty i Physical pains 42,25 (9,52) 46,14 (8,16) -1,507 0,139 edical f General health 68,25 (14,44) 69,07 (16,67) -0,192 0,849 he mt t MCS 64,04 (12,65) 74,05 (5,63) -3,660 0,003 taff a PCS 69,11 (12,52) 73,46 (8,47) -1,420 0,162 eaching s n t Pearson correlation coefficient show that there is a statistically highly tress i significant positive correlation (r = 0.391; p = 0.007) between the professionnal s al burnout syndrome and age, where older persons are more exposed to a pro- fessio fessional burnout syndrome. The elderly are also significantly more exposed to ro depersonalization (r = -0.321; p = 0.028), while younger people are in positive f p correlation with personal achievement and satisfaction (r = -0.454; p = 0.001). Younger people have a higher quality of mental and physical health, but this presence o positive correlation is not statistically significant. Statistically significant positive correlation was observed regarding the relation of years of service and MBI score (r = 0.377; p = 0.009), where the subjects with higher values of years of service, have a higher value of MBI. High significant negative correlation was observed between the years of service and personal satisfaction (r = -0.395; p = 0.006), while those with lower the years of service have higher levels of personal satisfaction. In terms of shift work there were not found statistically significant correlation compared to other socio-demographic characteristics, professional burnout or quality of life. There is a strong negative high statistical correlation between the professional burnout and mental quality of life of components (r = -0.479; p <0.001), while subjects with diagnosed higher level of professional burnout have a significantly lower quality of mental health. Discussion The largest number of respondents (83%) is exposed to stress at work in our research and professional burnout syndrome was observed in 42.6% of work- ers. In more than half of the respondents is registered a high level of com- mon mental components of health, and social functioning is also significantly higher in patients without the presence of the syndrome while differenc- es from the domain of physical functioning, vitality, mental health, gener- al health, body pains and limitations due to physical health were not found. According to the World Health Organization (1996), every person has the right 2 to a safe workplace and a healthy environment that allow for a normal social 23 and productive life. Therefore, the external and internal factors have a significant role in explaining the quality of life which has been confirmed by numer- n ous studies. Quality of life is a psychological construct, which does not arise automatically from satisfying basic needs, but from the whole psychological pulatioo structure of the individual interacting with the physical and social environ- ge p ment in which he lives (Taillefer, 2003). Felce and Perry (1995) define quality of life as an overall general well-being, which includes objective factors and sub-rking-ao jective evaluation of physical, material, social and emotional well-being, in- he w cluding personal development and meaningful activity (Felce and Perry, 1995). f t According to members of the International Well Being Group’s quality of life is multidimensional term, which is made of: standard of living, health, produc-ealth o| h tivity, the possibility of achieving close contact, security, belonging to the community and a sense of security in the future (World Health Organisation, 1996). pulacije Many studies have shown that the psychological state of anxiety and depres- o sion in particular, appear as mediators of health outcomes and subjective qual-ktivne p ity of life in situations of illness (Costa and McCrae, 1980). In similar studies results of our study were significantly better than the results of a study conducted in Chile (Andrades and Valenyuela, 2007), but low-elovno a er compared to the results of a study conducted in Turkey (Cinnamon, 2003). By analysing the questionnaire, SF-36 the presence of burnout syndrome is zdravje d found among the respondents, particularly with regard to domain limitations due to emotional problems, social functioning and physical functioning. As for the common components of physical and mental health, the difference compared to the PCS was not observed, while the difference between the groups of patients for the presence of syndrome professional burnout highly statistical- ly significant, and mental health of the respondents is at a significantly high-er level in the group without the presence of the syndrome. Experiencing pos- itive emotions at work is considered an important part of nursing professional life, and has a significant impact on patient safety, quality of service, commitment and stay in the organization and the profession. Numerous studies point out those experiencing positive emotions is an important part of nursing professional life, and has a significant impact on the quality of services provided. Positive emotions at work are associated with better health, a higher degree of job satisfaction, responsible behaviour at work, higher work performance and quality of work, greater resistance to stress and burnout, rarely changes of jobs, better relations with other people, desirable behaviour and thoughts and lower incidence of divorce (Golubic and Mustajbegović, 2011). The results of longitudinal Next study from 11 European countries showed that in all countries there is a significant degree of psychological exhaustion of nursing staff, particularly in Slovakia and Germany where they registered the highest scores of negative effects (Stourdeur et al., 2003). The disease is undoubtedly one of the external factors that negatively af- fect the quality of life of the individual. It can be said that the impact of disease on quality of life is multidimensional. The disease not only affects in terms of 3 physical symptoms and thereby interferes with the function, but also there are 23 present indirect effects such as changes in work capacity, decrease in the quality health care, potential isolation, increasing dependence on others, bad habits cao and so on (Hasselkorm, 2005). n f Our research has shown that older people are more exposed to work re- aculty i lated burnout and depersonalization; younger people have a higher quality of mental and physical health, while those with higher values of years of service edical f have a greater value on the MBI scale. Strong negative high statistically signifi-he m cant correlation was found between professional burnout and mental compo- t t nents of quality of life. Higher levels of professional burnout have subjects who taff a have a significantly lower quality of mental health. Professional burnout syn- drome is more than stress conditioned by professional activities; he indicates a state of complete physical and emotional exhaustion caused by excessive and eaching s futile efforts at work. Studies conducted in Finland and Sweden show that the n t burnout syndrome is more expressed with women older than 50 years and that tress i work in none productive sectors. Job satisfaction is considered to be relatively nal s persistent phenomenon that involves affective orientation factors of the work- ing environment. Job satisfaction is an important factor of success at work. Un-fessioro satisfied people transferred their dissatisfaction with the team members and f p to service users, and in the case of health care workers, to patients. With a decrease in job satisfaction it’s also reduced a sense of personal success (achieve-presence o ment). Dimension perception of reduced personal success involves reducing the feelings of competence and achievement at work (Thiruchelvi and Supri- ya, 2012). Conclusions In our study, more than half of respondents (83%) are exposed to stress at work, while the professional burnout syndrome was detected in 42.6% of respondents. Between professional stress and work experience and MBI result, there is a significant correlation. Respondents who have professional burnout syndrome have a lower level of quality of life. References ANDRADES BARRIENTIOS, L. and VALENZUELA SUAZO, S., 2007. Qual- ity of life associated factors in Chileans hospitals nurses. Revista Lati- no-Americana de Enfermagem, vol. 15, no. 3, pp. 480-486. CIMETE, G., GENCALP, N.S. and KESKIN, G., 2003.Quality of life and job satisfaction of nurses. Journal of Nursing Care Quality, vol. 18, no. 4, pp.151-158. COSTA P.T. and MCCRAE R.R. 1980. Influence of extraversion and neurot- icism on subjective well-being: Happy and unhappy people. Journal of Personality and Social Psychology, no.38, no.4, pp. 665‐678. 4 FELCE, R. and PERRY, J., 1995. Quality of life: Its definition and measurement. 23 Research in Developmental Disabilities, vol.16, no.1, pp.51-74. n GOLUBIĆ, Rand MUSTAJBEGOVIĆ, J. 2011. Kvalitet života zdravstvenih djelatnika. In: Vuletić, G. Kvaliteta života I zdravlje. Osijek: Hrvatska na-pulatioo klada za znanost, pp. 220 – 228. [viewed 10 June 2017]. Available from: ge p https://bib.irb.hr/datoteka/592441.KVALITETA_IVOTA_I_ZDRAVLJE. pdf. rking-ao HASSELHORM, H.M., MUELLER, B.H., TACKENBERG, P. and BUESCHER he w A., 2005.Psychological and physical health among nurses in Europe. f t NEXT scientific report. University of Wuppertal and University of Wit- ten, Germany, pp. 35-37. [viewed 10 June 2017] .Availablefrom:https:// ealth o| h www.econbiz.de/archiv1/2008/53604_lifting_bending_tasks.pdf JACSON, S.H., 1999. The role of stress in anaesthetists’ health and well-being. pulacije o Acta anaesthesiologica Scandinavica, vol. 43, no.6, pp. 583-602. MASLACH C, JACKSON S.J., LEITER M.P. 1996. .Maslach Burnout Inventory ktivne p Manual. Mountain View, California: CPP. NYSSEN AS, HANSEZ I, BAELE P, LAMY M and DE KEYSER V., 2003. elovno a Occupational stress and burnout in anaesthesia. British Journal of Anaesthesia,vol.90, no.3, pp.333-337. zdravje d STOURDEUR, S., D’HOOPRE, W., VAN DERHEIJDEN, B., DIBISCEGLIEM- LAINE, M., VAN DER SCHOOT, E. and the NEXT-Study Group, 2003. Leadership, job satisfaction and nurses’ commitment. Working condi- tions and intent to leave the profession among nursing staff in Europe. National institute for working life, Stockholm. [viewed 10 June 2017]. Available from: http:/ www.hosp.ucl.ac.be/recherche/LeaderCommitm.pdf TAILLEFER, M.-C., DUPUIS, G., ROBERGE, M.A., LEMAY, S. 2003.Health-re- lated quality of life models: Systematic review of the literature. Social Indicators Research, vol. 64, no.2, pp. 293-323. TENNAT C., 2001. Work-related stress and depressive disorders. Journal of psychosomatic research, vol. 51, no.5, pp. 697-704. THIRUCHELVI, A. and SUPRIYA, M.V., 2012.An investigation on the me- diating role of coping strategies on locus of control wellbeing relation- ship . The Spanish Journal of Psychology, iss.15, no.1, pp. 156–165. WARE J.E., 1993.SF-36 Health Survey: Manual interpretation guide. Boston, MA: The Health Institute. New England Medical Center. WORLD HEALTH ORGANIZATION, 1996. Programme on mental health. WHOQOL‐BREF Introduction, administration, scoring and generic ver- sion of the assessment. Field Trial Version. 523 caon f aculty i edical f he mt t taff a eaching s n t tress i nal s fessiorof p presence o Thanks to our Conference Sponsors Scientific and Organising Committee would like to thank all the spon- sors whose sponsorship helps to support our conference. 823 n pulatioo ge p rking-ao he wf t ealth o| h pulacije o ktivne p elovno a zdravje d Zdravje delovno aktivne populacije / Health of the Working-Age Population Znanstvena monografija / Proceedings Uredili / Edited by Ana Petelin, Nejc Šarabon and Boštjan Žvanut Recenzenti / Reviewers ■ Katarina Babnik, Urška Bogataj, Ana Petelin, Tamara Poklar Vatovec, Mirko Prosen, Patrik Pucer, Nejc Šarabon, Matej Voglar, Boštjan Žvanut Lektorica/Proofreading ■ Majda Šavle (angleški jezik/english) Oblikovanje in prelom / Design and Typesetting ■ Jonatan Vinkler Izdajatelj / Published by ■ University of Primorska Press Titov trg 4, si-6000 Koper, Koper 2017 Glavni urednik/Editor-in-Chief ■ Jonatan Vinkler Vodja založbe/Managing Editor ■ Alen Ježovnik isbn 978-961-7023-32-9 (www.hippocampus.si/isbn/978-961-7023-32-9.pdf) isbn 978-961-7023-33-6 (www.hippocampus.si/isbn/978-961-7023-33-6/index.html) DOI: https://doi.org/10.26493/978-961-7023-32-9 © 2017 authors Kataložni zapis o publikaciji (CIP) pripravili v Narodni in univerzitetni knjižnici v Ljubljani COBISS.SI-ID=291501824 ISBN 978-961-7023-32-9 (pdf) ISBN 978-961-7023-33-6 (html) Document Outline Petelin, Ana, Nejc Šarabon, Boštjan Žvanut, eds. 2017. Zdravje delovno aktivne populacije ▪︎ Health of the Working-Age Population. Proceedings. Koper: Založba Univerze na Primorskem/University of Primorska Press (Cover) Petelin, Ana, Nejc Šarabon, Boštjan Žvanut, eds. 2017. Zdravje delovno aktivne populacije ▪︎ Health of the Working-Age Population. Proceedings. Koper: Založba Univerze na Primorskem/University of Primorska Press (Title Page) Contents Eva Boštjančič, Zala Slana ⁃ Psychophysical workload of workers in Slovenia Abstract Most common health risks experienced by workers Measuring psychophysical workload Problem Methods Participants and procedure Aids Results Discussion References Marjana Božič, Ksenija Kragelj, Mirko Prosen ⁃ Retrospective and experiential perception of physical activity during pregnancy on childbirth and postpartum period Abstract Methods Results Discussion Conclusions References Anja Brčan, Maruša Kebe, Maša Pintar, Andrej Starc ⁃ The mammography efficiency in breast cancer detection in women under 50 years of age Abstract Methods Results Discussion Conclusions References Melina Colsani, Maša Černelič Bizjak ⁃ Attending nutrition counselling of the working-age subjects Abstract Methods Results Discussion Conclusions References Nataša Demšar Pečak ⁃ The therapeutic approach as an important intervention in the implementation of the program Project learning for young adults (PUM-O) Abstract The purpose and goals of the program PUM-O The importance of the therapeutic approach Conclusions References Rok Drnovšek, Marija Milavec Kapun ⁃ Critical review of viewership and contents of official healthcare organization websites Abstract Methods Results Discussion Conclusions References Gašper Grom ⁃ Ketogenic diet and its impact on mental processes of working population Abstract Methods Results Discussion Conclusion References Brigita Jeretina, Katja Krt, Andrej Starc ⁃ Absenteeism due to mental problems among employees in nursing Abstract Methods Results Discussion Conclusion References Sandra Joković, Maja Račić, Jelena Pavlović, Natalija Hadživuković ⁃ Quality of life of nurses Abstract Methods Results Discussion Conclusions References Anita Jug Došler, Ana Polona Mivšek, Petra Petročnik, Teja Škodič Zakšek, Mateja Kusterle Jenko ⁃ Experience of sexual intercourse in the first year after childbirth: women’s views and attitudes Abstract Methods Results Discussion Conclusions References Alexander Kiško, Marika Vereb, Radoslav Dobránsky, Marian Babčák, Lubica Derňarová, Jan Kmec, Jozef Leško, František Neméth, Maria Marcinková, Zuzana Farkašová ⁃ Prevalence of silent myocardial ischemia in working-age patients with type 2 diabetes mellitus Abstract Methods Results Discussion Conclusions Acknowledgment References Sabina Ličen, Igor Karnjuš, Mirko Prosen ⁃ Ensuring equality through the acquisition of cultural competencies in nursing education: A systematic literature review Abstract Methods Search strategy Study selection Data extraction Results Discussion Conclusions References Herbert Löllgen, Petra Zupet, Norbert Bachl ⁃ Physical activity, physical fitness and prevention: Role for the working population Abstract Biological rationale Healthy subjects Sedentary lifestyle Physical activity intensity (Dose – response relationship) Training recommendation (FITT): Frequency, intensity, time, and type Types of activity Prescription of exercise and physical activity: Frequency, intensity, time and type (FITT) Risk assessment Exercise as a polypill Preparticipation examination Risk during training in cardiac diseases Heart Failure General recommendations for physical activity Population based approaches to physical activities at the workplaces Conclusion References Polona A. Mivšek, Petra Petročnik, Anita Jug Došler, Teja Škodič Zakšek ⁃ The quality of sexual life after experiencing the episiotomy birth Abstract Episiotomy Dyspareunia Methods Results Discussion Conclusions References Teja Novak, Doroteja Rebec ⁃ Women‘s experiences with perinatal loss of a child Abstract Methods Results Discussion Conclusions References Jelena Pavlović, Maja Račić, Nataša Radović, Sandra Joković, Natalija Hadživuković ⁃ Work related stressors and quality of life of nurses Abstract Methods Results Discussion Conclusions References Tjaša Pogačar, Lučka Kajfež Bogataj ⁃ Slovenian workers – is it too hot to work? Abstract Methods Results and discussion Conclusions Acknowledgments References Andreja Rijavec, David Ravnik, Mirko Prosen ⁃ Characteristics of physical activity among pregnant women Abstract Methods Sample description Description of the instrument Data processing Results Discussion Conclusions References Tanja Ritonja, Dragana Pejnović, Lucija Roblek, Andrej Starc ⁃ The impact of shift work on cardiovascular diseases among nurses Abstract Methods Results Discussion Conclusions References Nataša Sedlar Kobe, Alenka Dovč, Andrea Backović Juričan, Jerneja Farkaš Lainščak ⁃ Association between perceived stress, self-rated health, work productivity and stress management interventions – a study of employees in the Slovenian processing industry Abstract Methods Results Discussion Conclusions Acknowledgements References Milena Svetlin ⁃ Fighting stressful situations from the viewpoint of emotional competence Abstract Theoretical Framework The Present Study Methods Participants Measures Procedure Results Descriptive Information Correlation Discussion Conclusions Limitations References Saša Šajn Lekše, Bernarda Lončar, Alenka Žibert, Andrej Starc ⁃ Stress of conscience as a risk factor for burnout among ICU nurses in University Medical Centre Maribor Abstract Conscience and troubled conscience Stress and occupational burnout Nursing care in intensive care units (ICU) Methods Results Discussion Conclusions References Tjaša Šapla Troha, Maša Černelič Bizjak ⁃ Women‘s Quality of Life during the Grief Process after Perinatal Death Abstract Women and Expressing the Feelings in the Grief Process Methods Sample Research Tools Munich Grief Scale Processing and Analysis of Data Results Discussion Conclusion References Martin Vrašec, Matej Voglar ⁃ Absenteeism in Slovenian railways – comparison between different work groups Abstract Methods Results Discussion Conclusion References Milica Vuksanović, Dragica Marić, Jelena Pavlović, Sandra Joković, Natalija Hadživuković ⁃ Presence of professional stress in teaching staff at the Medical faculty in Foca Abstract Methods Results Discussion Conclusions References Thanks to our Conference Sponsors Colophone