ჟურნალი სრული

The Polish Society of Family Medicine
The Association of Friends of Family Medicine & Family Doctors
isSn 1734-3402, eISSN 2449-8580

Family
Medicine
&
Primary Care Review
Quarterly
2019
April–June Central European Journal of Social Sciences and Humanities,
DOAJ, EBSCO, EMBASE/Excerpta Medica, ESCI – Emerging
Sources Citation Index (Web of Science, Clarivate Analytics),
Vol. 21, No. 2

Index Copernicus (ICV 2017: 124.56), ICMJE – International
Committee of Medical Journal Editors, Polish Medical
Bibliography, PMSHE – Polish Ministry of Science and Higher
Education (12 pts), Polish Scholarly Bibliography, Scopus,
Ulrich’s International Periodicals Directory, WorldCat
Scientific Committee Thematic Editors
Prof. Dieter Adam, MD, PhD (Munich, Germany), Allergology, pulmonology, immunology, internal medicine:
Prof. Jiři Beneš, MD, PhD (Prague, Czech Republic), Prof. Rafał Pawliczak, MD, PhD, Medical University of Lodz
Luc van Berkestijn, MD, PhD (Utrecht, Netherlands), Qualitative studies, quality of care, communication:
Jerzy Błaszczuk, MD, PhD, Assoc. Prof. (Wroclaw), Ludmiła Marcinowicz, PhD, Assoc. Prof., Medical University of
Stephan Böse-O’Reilly, MD, PhD (Munich, Germany), Bialystok
Nilzete Liberato Bresolin, PhD (Florianopolis, Brazil),
Walbia Salete Bittencourt Correa, MD, PhD (Florianopolis, Brazil), Infectious diseases in children:
Prof. Olga Fedorciv, MD, PhD (Ternopil, Ukraine), Ernest Kuchar, MD, PhD, Assoc. Prof., Medical University of Warsaw
Prof. George Freeman, MD, PhD (London, United Kingdom), Diagnostics, geriatrics:
Prof. Suleyman Görpelioğlu, MD, PhD (Izmit, Turkey), Bartosz J. Sapilak, MD, PhD, Medical University of Wroclaw
Prof. Hans-Joachim Hannich, MD, PhD (Greifswald, Germany), Physiotherapy:
Wolfgang Hannover, MD, PhD, Assoc. Prof. (Greifswald, Germany), Prof. Jakub Taradaj, PhD, Academy of Physical Education in Katowice
Prof. Steinar Hunskaar, MD, PhD (Bergen, Norway),
Prof. Andrzej Kiejna, MD, PhD (Wroclaw), Family medicine, quality of life, service quality, psychotherapy:
Prof. Ludmila Klimackaya, MD, PhD (Krasnoyarsk, Russia), Donata Kurpas, MD, PhD, Assoc. Prof., Medical University of Wroclaw;
Prof. Jerzy Kołodziej, MD, PhD (Wroclaw), Victoria Tkachenko, MD, PhD, DMSc, Assoc. Prof., Shupyk National
Prof. Piotr Kuna, MD, PhD (Lodz), Medical Academy of Postgraduate Education, Ukraine
Krzysztof Kuszewski, MD, PhD (Warsaw), Forensic medicine, epidemiology, judicature, insurance medicine:
Prof. Andrzej Kübler, MD, PhD (Wroclaw), Robert Susło, MD, PhD, Medical University of Wroclaw
Prof. Radoslav Kveder, MD, PhD (Ljubljana, Slovenia),
Prof. Witold Lukas, MD, PhD (Katowice), Tropical medicine, travel medicine, military medicine:
Prof. Andrzej Mackiewicz, MD, PhD (Poznan), Prof. Krzysztof Korzeniewski, MD, PhD, Military Medical Institute
Christopher Magier, MD, PhD (Newport, United Kingdom), in Warsaw
Prof. Bengt Mattsson, MD, PhD (Gothenburg, Sweden), Neurology:
Prof. John Noble, MD, PhD (Boston, USA), Marta Banach, MD, PhD, Assoc. Prof., Jagiellonian University in Cracow
Prof. Marc Nyssen, MD, PhD (Brussels, Belgium), Nursing, family medicine:
Patricia Owens, MD, PhD (Liverpool, United Kingdom), Barbara Ślusarska, PhD, Assoc. Prof., Medical University of Lublin
Prof. Leszek Paradowski, MD, PhD (Wroclaw),
Prof. Sir Denis Pereira-Gray, MD, PhD (London, United Kingdom), Paediatrics: Prof. Katarzyna Kiliś-Pstrusińska, MD, PhD, Medical
Prof. Tadeusz Płusa, MD, PhD (Warsaw), University of Wroclaw
Prof. Andrzej Radzikowski, MD, PhD (Warsaw), Paediatrics, neonatology:
Prof. Andrzej Rajewski, MD, PhD (Poznan), Barbara Królak-Olejnik, MD, PhD, Assoc. Prof., Medical University
Lindsay Roberts, MD, PhD (Balgowlah Heights, Australia), of Wroclaw
Prof. Zbigniew Rudkowski, MD, PhD (Wroclaw), Polymorphism, biology:
Prof. Bolesław Rutkowski, MD, PhD (Gdansk), Anna Grzywacz, PhD, Assoc. Prof., Pomeranian Medical University
Hogne Sandvik, MD, PhD (Bergen, Norway), in Szczecin
Prof. Janusz Siebert, MD, PhD (Gdansk),
Agnes Sielbert, MD, PhD (Chicago, USA), Telemedicine, geriatrics, internal medicine:
Prof. Wojciech Służewski, MD, PhD (Poznan), Maria Magdalena Bujnowska-Fedak, MD, PhD, Assoc. Prof., Medical
Prof. Jaime Correia de Sousa, MD, PhD (Matosinhos, Portugal), University of Wroclaw
Loreta Strumylaite, MD, PhD (Kaunas, Lithuania), Public health, environmental health, humanities in medicine:
Andrzej Szpakow, MD, PhD (Grodno, Belarus), Bożena Mroczek, PhD, Assoc. Prof., Pomeranian Medical University
Prof. Piotr Szyber, MD, PhD (Wroclaw), in Szczecin
Prof. Barbara Świątek, MD, PhD (Wroclaw),
Prof. Vytautas Usonis, MD, PhD (Vilnius, Lithuania), Editorial Office
Prof. Irma Virjo, MD, PhD (Tampere, Finland),
Prof. Zygmunt Zdrojewicz, MD, PhD (Wroclaw), Department of Family Medicine
Muharem Zildzic, MD, PhD (Tuzla, Bosnia-Herzegovina), Medical University of Wroclaw
Prof. Irena Zimmermann-Górska, PhD (Poznan) Syrokomli 1, 51-141 Wrocław, Poland, Europe
Tel.: +48 71 325-51-26, tel./fax: +48 71 325-43-41
E-mail: fmpcr@familymedreview.org,
Editorial Board www.familymedreview.org
Editor-in-Chief: Contact persons: Bartosz J. Sapilak, MD, PhD, tel.: +48 501 148-503
Donata Kurpas, MD, PhD, Assoc. Prof. E-mail: bartosz.sapilak@umed.wroc.pl
Associate Editors: Marta Kowalewska, tel.: +48 71 326-68-78
Bożena Mroczek, PhD, Assoc. Prof. E-mail: m.kowalewska@fundacjarodzinni.pl
Agnieszka Mastalerz-Migas, MD, PhD, Assoc. Prof.
Scientific Secretary of the Editorial Board:
Bartosz Sapilak, MD, PhD, bartosz.sapilak@umed.wroc.pl
Publisher
Administrative Secretary of the Editorial Board:
Marta Kowalewska, m.kowalewska@fundacjarodzinni.pl
Editorial Staff:
Jarosław Drobnik, MD, PhD, Assoc. Prof.
Anna Grzywacz, MD, PhD, Assoc. Prof. Editorial Office, subscription:
Maria Magdalena Bujnowska-Fedak, MD, PhD, Assoc. Prof. Continuo Publisher
Marek Szewczyk, MD, Lelewela 4/325, 53-505 Wrocław, Poland, Europe
Bożena Ratajczak-Olszewska, MSc, Tel./fax: + 48 71 791-20-30, +48 601 774-733
Katarzyna Szwamel, MSc, PhD E-mail: biuro@continuo.pl, zamowienia@continuo.pl,
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Language Editors Contact person: Jan Kuźma – Publishing Editor, tel. +48 71 791-20-30,
e-mail: wydawnictwo@continuo.pl
Ian Transue, Cleveland, USA (Lingua Lab),
Peter Foulds, London, United Kingdom (Lingua Lab), This is an Open Access article distributed under the terms of the
Stiofán Ó Maoilbhreannain, Dublin, Ireland Creative Commons Attribution-NonCommercial-ShareAlike 4.0
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Statistical Editor org/licenses/by-nc-sa/4.0/).
FM&PCR journal (ISSN 1734-34-02, eISSN 2449-8580) is published
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Contents
91 Preface
ORIGINAL PAPERS
93 Shazan Borajy, Dania Albkhari, Huda Turkistani, Reham Altuwairiqi, Khalid Aboalshamat, Tahir Altaib, Wijdan
Almehman • Relationship of electronic device usage with obesity and speech delay in children
98 Grażyna Dębska, Irena Milaniak, Dorota Domańska, Lucyna Tomaszek • Caregiver burden and the role of social
support in the care of children with cystic fibrosis
104 Sunanda Govinder Thimmajja, Eilean Victoria Lazarus Rathinasamy • Effectiveness of psycho-education on
knowledge regarding schizophrenia and caregivers’ burden among caregivers of patients with schizophrenia
– a randomized controlled trial
112 Maryam Kheiri, Katayon Vakilian • Misconceptions about sexual intercourse during pregnancy: cognitive-behav-
ioral counseling in prenatal care
117 Agata Nowak, Cezary Kucio, Zbigniew Nowak, Thomas Küpper • The effect of hypoxia on exercise tolerance in
individuals after acute coronary syndrome treated with angioplasty combined with coronary stent implantation
– pilot studies
124 Jarosław Pasek, Michał Senejko, Grzegorz Cieślar • Physical possibilities in the treatment of chronic abdominal
pain in patients with peritoneal adhesions
130 Lolita Rapolienė, Lina Gedrimė, Daiva Mockevičienė, Artūras Razbadauskas • Relation of health status with dis-
tress and job-related risk factors
138 Catarina Rocha-Vieira, Gustavo Oliveira, Luciana Couto, Paulo Santos • Impact of loneliness in the elderly in
health care: a cross-sectional study in an urban region of Portugal
144 Nader Saki, Maryam Kardoni, Mehdi Karimi, Amir Mohammad Eghbalnejad Mofrad • Short-term hearing results
in adults after a stapedotomy
149 Zikria Saleem, Mohamed Azmi Hassali, Furqan Hashmi, Faiza Azhar, Hamna Hasan, Saba Zaheer, Inaam Ur Rehm-
an • Assessment of the perception of physicians concerning antibiotic use and resistance along with the factors
influencing the prescription of antibiotics: a situational analysis from Pakistan
158 Inga Šimkutė Karalevičienė, Daiva Mockevičienė, Brigita Kreivinienė • Possibilities for implementation of profes-
sional competencies of physical therapists working in teams of rehabilitation specialists of education and health
protection systems
164 Katarzyna Szwamel, Donata Kurpas • Assessment of the health care system functioning in Poland in light of the
analysis of the indicators of the hospital emergency department (ED) and primary health care (PHC) – proposals
for systemic solutions
174 Nevruz Yildirim Topak, Hakan Demirci • Factors affecting the decision to change the family physician
180 Tengiz Verulava, Dali Beruashvili, Revaz Jorbenadze, Ekaterine Eliava • Evaluation of patient referrals to family
physicians in Georgia
REVIEWS
185 Al Asyary, Yodi Mahendradhata • Unfinished first-line tuberculosis treatment in primary care in Indonesia
CONTINUOUS MEDICAL EDUCATION (CME)
189 Zbigniew Doniec, Agnieszka Mastalerz-Migas, Teresa Jackowska, Ernest Kuchar, Adam Sybilski • ReCOMmenda-
tions for the treatment of INFLUENZA in children for Primary care physiciAnS – COMPAS INFLUENZA
Preface
Colleagues, Readers,
Authors, Reviewers,
Members of the Scientific Committee,
Thematic Editors,
Members of the Editorial Board,
We hope that all our readers had an enjoyable World Family Doctor Day on May 19!
This annual event has been celebrated since 2010, when it was begun by WONCA with the
goal of highlighting the contributions made to health care systems everywhere by family
doctors. It acknowledges the central role of this specialty in delivering personal, and com-
prehensive continuing health care for everyone.
May 19 is also the publication date of this, the second 2019 issue of Family Medicine
& Primary Care Review. With this issue, there are some changes taking place in our pages,
involve both the journal and family medicine itself. In line with the recommendations of the World Health Organization,
family medicine has for last twenty years been performed by specialists and has constituted the foundation of health
care systems everywhere. Yet it also remains a medical specialty and a scientific discipline in its own right, with its own
evidence base, research, clinical activity, and educational aspect, focusing on primary care in every locality. FM&PCR
has also emphasized over the last twenty years that cost-effective, clinically effective health care systems are based on
coordination, versatility, and intradisciplinary co-operation. This issue, which has resulted from cooperation between
family doctors and experts of other disciplines worldwide, continues and advances this mission. Our hope is that it will
help you in your own research projects on the border between family medicine and other specialties, and that it will
also act as a source of practical information, proving useful in everyday practice.
The current issue of FM&PCR preserves the goals of our first issue two decades ago: to publish research into educa-
tion and evidence-based practice, so as to support the everyday practice of ourselves – physicians working in primary
care. Whether we are active in more or less modern healthcare systems, we all nonetheless follow the main principles
of family medicine: coordination, versatility, and effective cooperation with specialists in different fields, always work-
ing to extend patient empowerment and engagement.
This issue includes original papers on the relationship of electronic device usage with obesity and speech delay in
children; caregiver burden and the role of social support in the care of children with cystic fibrosis; effectiveness of
psychoeducation on knowledge of schizophrenia and caregivers’ burden among caregivers of patients with schizophre-
nia; misconceptions about sexual intercourse during pregnancy: cognitive–behavioral counseling in prenatal care; the
effect of hypoxia on exercise tolerance in individuals with acute coronary syndrome treated with angioplasty combined
with coronary stent implantation: a pilot study; physical options in the treatment of chronic abdominal pain in patients
with peritoneal adhesions; relation of health status to distress and job-related risk factors; impact of loneliness in the
elderly in health care: a cross-sectional study of an urban region of Portugal; short-term hearing results in adults who
have undergone stapedotomy; assessment of the perception of physicians concerning antibiotic use and resistance,
along with factors affecting the prescription of antibiotics: a situational analysis from Pakistan; options for implement-
ing the professional competencies of physical therapists working in teams of rehabilitation specialists in education and
health protection systems; assessment of the functioning of the health care system in Poland in light of an analysis of
hospital emergency departments and primary health care: proposed systemic solutions; factors affecting the decision
to change a family physician; evaluation of patient referrals to family physicians in Georgia.
The reviews section contains a paper on unfinished first-line tuberculosis treatment in primary care in Indonesia.
In particular, we suggest that you familiarize yourself with the recommendations for the treatment of Influenza in Chil-
dren for Primary care Physicians (COMPAS INFLUENZA).
We hope to continue to support our authors and to improve the quality of our publication from issue to issue. We
therefore ask you to contribute the results of your research projects. Both our Thematic Editors and the Members of
the Editorial Board will be very happy to help you with your article as it undergoes the review and editorial processes.
We also encourage you to engage with our Editorial Board at the Polish Society of Family Medicine (PSFM) stand during
PSFM conferences, congresses, and conventions, as well as at Continuo Publishing stands at training courses through-
out Poland. The Eighth Congress of the Polish Society of Family Medicine is also happening in Wrocław on 11–13 Octo-
ber 2019; we also recommend the Ninth EURIPA Rural Health Forum in Azores, Portugal, on 7–9 November 2019. The
theme of this year’s Forum is “Isolation and Rural Medicine: Innovation solutions for developing local health services”.
In the last few weeks before the summer, and on behalf of the Editorial Board, we wish you moments of respite
from the ever-increasing demands of everyday life. We also wish you perseverance in your own passion. In particular,
we also hope that you can continue to work on research projects into family medicine, and that these will appear in
FM&PCR over the coming months and years.
Donata Kurpas, MD, PhD, Associate Professor

Wroclaw Medical University
Editor-in-Chief
Family Medicine & Primary Care Review
Family Medicine & Primary Care Review 2019; 21(2): 93–97 https://doi.org/10.5114/fmpcr.2019.84542
ISSN 1734-3402, eISSN 2449-8580

ORIGINAL PAPERS © Copyright by Wydawnictwo Continuo
Relationship of electronic device usage with obesity

and speech delay in children
Shazan Borajy1, A–F, Dania Albkhari2, A–F, Huda Turkistani2, A–F, Reham Altuwairiqi2, A–F,
ORCID iD: 0000-0003-4651-2485
Khalid Aboalshamat3, A–F, Tahir Altaib2, A–F, Wijdan Almehman2, A–F

1
Batterjee Medical College, Jeddah, Saudi Arabia
2
Ministry of Health (MOH), Jeddah, Saudi Arabia
3
Dental Public Health Division, Preventative Dentistry Department, College of Dentistry, Umm Al-Qura University,
Makkah, Saudi Arabia
A – Study Design, B – Data Collection, C – Statistical Analysis, D – Data Interpretation, E – Manuscript Preparation, F – Literature
Search, G – Funds Collection
Summary Background. Smart device usage has become favorable among children worldwide.
Objectives. The study aimed to identify the relation between usage of electronic devices with obesity and speech delay.
Material and methods. A cross-sectional study was conducted among 452 healthy children (18 months to 14 years old) from pediatric
clinics of the Ministry of Health (MOH), Jeddah, Saudi Arabia. Data was collected from June to July 2018. Analysis included linear re-
gression, logistic regression, chi-square, t-test and ANOVA.
Results and discussion. Male participants totalled 57.7% and females 42.3% (mean age 82.27 months) (SD = 40.18). Mean duration
of usage: 3.1 hours (SD = 2.58) per day. Among toddlers only, 31.1% had speech delay. The results showed no relation between the
duration of smart device usage and obesity (p-value = 0.904) or speech delay (p-value = 0.538). Duration of usage was not influenced
by gender or parents’ marital status; however, children who live with both parents spent less time on smart devices than others. The
smart device most used was a tablet (47%), and the main usage was primarily entertainment (60.8%) and games (47.6%). Only 57.8%
reported having parental supervision. Among children, 59.3% eat chips and 48.9% eat candy as snacks during usage. Among parents,
71.5% believe devices reduce children’s physical activities, 64.8% believe that the smart device is a problem, 62.5% of parents should
control time of use, and 60.5% believe that their children are attached to the devices.
Conclusions. There is no association between the duration of using smart devices and obesity, nor speech delay. Future directions and
recommendations should be discussed.
Key words: obesity, child, electronics.
Borajy S, Albkhari D, Turkistani H, Altuwairiqi R, Aboalshamat K, Altaib T, Almehman W. Relationship of electronic device usage with
obesity and speech delay in children. Fam Med Prim Care Rev 2019; 21(2): 93–97, doi: https://doi.org/10.5114/fmpcr.2019.84542.
Background video gaming on children [5]. Only 4% of the extracted studies

assessed the health impact of smart devices, such as phones,
According to the American Academy of Pediatrics, new me- tablets and laptops, on children’s health [5].
dia devices, such as televisions with video gaming, smart tablets Even fewer studies have investigated the relationship be-
and smartphones, now occupy a wide array of children’s lives, tween the use of these new electronic devices and childhood
becoming one of the most influential mediums [1]. According to obesity. A Saudi study found that there was a relationship be-
the Kaiser Family Foundation, American children aged 8 to 10 tween children spending more than two hours per day on smart
years spend, on average, eight hours a day using one of a range devices and body mass index (BMI), indicating that smart device
of electronic items [2]. Even worse, older children and teenag- use may increase the risk of obesity [6]. However, the study did
ers spend more than 12 hours per day on electronic devices [2]. not exclude children with chronic diseases that can significantly
When electronic devices were first invented, they were increase BMI. Furthermore, the data in that study was in a cat-
meant to serve as an end to the communication barriers be- egorical format using two hours as a cutoff point. More accurate
tween settlements often separated by vast distances. It was results can be obtained using a linear regression model when
hard to expect the devastating effects that such devices might
the data being analyzed is in a continuous format.
have on the health of adults and, even more so, on the health
Several other studies have found a significant relationship
of children. In fact, a number of articles in literature on the sub-
between watching TV and a higher BMI in Saudi Arabia [7] and
ject now highlight the importance of policy makers and parents
guiding children’s use of new media devices and social media, in other countries around the world [8–10], where children are
as there is a probability that the child will encounter one of the less active, consume fewer vegetables and eat more high-calorie
many potential negative effects from such use, including eat- food. One study indicated that the time spent actually watching
ing problems, academic challenges or being exposed to unsuit- TV was unrelated to BMI. But rather, the attention given while
able or overtly sexual content [3, 4]. It should be noted that watching TV's was in fact directly related to a higher BMI in
according to a recent systematic review, the majority of these older children [11]. Nevertheless, only one study, conducted in
studies were conducted to assess the negative effects of TV or Al-Agha in 2016, included smart devices in relation to BMI.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International
(CC BY-NC-SA 4.0). License (http://creativecommons.org/licenses/by-nc-sa/4.0/).
94 S. Borajy et al. • Relationship, electronic device, speech delay, children
Moreover, a study of toddlers in Korea indicated that watch- the nearest 0.1 kilogram (kg), using a single scale. Height was
ing TV for more than two hours per day is related to speech measured without shoes and was rounded off to the nearest
delays [12]. Another study in the United States found that chil- centimeter (cm) using a manual scale with a height rod. Weight
dren’s vocabularies and expressions depended mainly on the and height were taken to calculate BMI as a tool for screening
content of TV shows, with some of the effects being positive for obesity, which is defined as weight in kg divided by height
and some negative [13], although other studies indicate that in square meters, bearing in mind that BMI is not considered
watching TV can result in attention problems by the age of 7 as an anthropometric measure in very young children. BMI was
[14]. Again, however, no studies looked at the relationship be- used mainly in its continuous format for more accurate analy-
tween smart devices and speech delays, especially for toddlers. sis. Speech abilities were recorded using speech and language
screening guidelines [15] for normal or delayed speech, as
noted in Table 1, by pediatric residents. It should be noted that
Objectives speech delay assessment was conducted only on toddlers less
than 37 months old.
This study therefore aimed to identify the relationship be-
tween usage of electronic devices and their content with obe-
sity and speech difficulties in kindergartners starting from 18 Table 1. Speech and language screening guidelines for a child
months (1), school aged children – before adolescence (2), and to be classified as delayed speech according to Nelson Textbook
adolescence – less than 18 years of age, in Jeddah, Kingdom of of Pediatrics
Saudi Arabia (KSA). Child’s age Receiving Expressing
in months
Material and methods 15 cannot point or look at

10 objects or less
using less than 3 words
18 cannot keep track with not saying mom, dad or

Participants a simple order or task, any other name
This was a cross-sectional study conducted from June 2018 such as “bring your bag”
to July 2018. Participants were recruited from general pediatric 24 cannot recognize body using less than 25 words
clinics in governmental hospitals in Jeddah, KSA, to investigate parts if named nor can
the relationship between the use of electronic devices and their tell what’s in a picture
content on obesity and speech delays among healthy kinder- 30 does not respond to cannot say a simple
gartners up to adolescent children. A quota sampling technique questions verbally or phrase or sentence of
was used to collect data based on an equal ratio of males and by shaking head or 2 words
females. Only healthy kindergartners and adolescent children nodding
were included. Exclusion criteria included children who were 36 cannot follow orders or does not have 200
younger than 18 months or older than 14 years, as well as those directions of more than or more words in vo-
with chronic illnesses that can significantly affect body weight. 1 step cabulary and would not
Also excluded were children on steroid therapy and children require any prompting
with ADHD; autism; endocrinological disorders; cardiac, renal,
respiratory, liver, neurological or immunological diseases; men- Any recognizable information was excluded so that all col-
tal retardation, developmental delays, hearing impairments lected data and participants were anonymous. Ethical approval
or family history of those same medical issues; and genetic or was obtained from the Saudi Ministry of Health (MOH), Saudi
metabolic disorders that affect body weight. Arabia, Jeddah, on September 19, 2018, with approval number
A sample size calculation formula using a precision degree A00623, which stated its validity for one year and gave approval
of 5%, expected prevalence of 50% and confidence level of 95% for questionnaire distribution and data collection at different gov-
indicated that the minimum requirement for this study was 385 ernmental hospitals. Ethical approval was rechecked by the scien-
participants/parents of children. tific committee and ethical approval committee with rechecking
number: H-02-J-002, with scientific research number: 00957.
Data collection Analyses were conducted using SPSS version 21 (IBM, Ar-
monk, NY, USA), and the linear regression test was used to
Data was collected by medical professionals through a self- analyze the relationship between duration of smart device us-
-reported, hard-copy questionnaire and combined with the age and BMI. t-test and ANOVA were used to compare the du-
child’s measured weight, height and speech ability. After obtain- ration spent on smart devices between different groups, and
ing written consent, the questionnaire was given to parents vis- chi-square was used to compare the content of smart devices
Family Medicine & Primary Care Review 2019; 21(2)
iting pediatric clinics at designated hospitals. The parents were between different groups. Logistic regression was used to find
instructed to answer the questionnaire on their own while the the relationship between smart device use and speech ability.
child’s measurements were being taken by medical profession- Chi-square and Fisher’s exact test were used to compare speech
als. No age criteria were implicated to parents of children who delay with demographic variables. A statistical significance level
agreed to participate in this research. of 0.05 was used.
The questionnaire had four parts, where the first three were
completed by parents. Part one was demographic data collected
through six questions, including age, gender, parents’ educa- Results
tional levels, family income and type of primary caregiver. Part
two comprised nine questions about the child’s electronic de- A total of 452 participants answered the questionnaires,
vice usage. Part three included four questions about the child’s with a mean (m) age of 82.40 months and standard deviation
lifestyle. Finally, the last section, part four, was completed by (SD) of 39.95. Table 2 shows the demographic variables, while
the research team to record the measurements of the child’s Table 3 demonstrates participants’ BMI and lifestyle informa-
weight, height and speech ability. Weight was rounded off to tion for participants.
S. Borajy et al. • Relationship, electronic device, speech delay, children 95
Table 2. Demographic data Among those, 23 children (31.1%) had speech delay. Those chil-
dren (toddlers) had m = 3.31, SD = 2.56 hours of smart device
Demographic Count (%) Mean (SD) usage, which was not significantly different from children older
Gender male 261 than 36 months (m = 3.06, SD = 2.59) after using t-test. Using
(57.74%) chi-square and Fisher’s exact test, the presence of speech delay
female 191 was not significantly different between the demographic vari-
(42.26%) ables, including gender, mother’s educational level, father’s ed-
Mother’s less than high 48 ucational level, family income, children living with both parents
education school (10.62%) or otherwise and the marital status of parents.
level Using a simple linear regression for all participants, there
high school 137
was no significant relationship found between children’s dura-
(30.31%)
tion of smart device usage and BMI (F(1,450) = 0.14, p = 0.904),
college or more 267 nor with number of meals (F(1,450) = 3.39, p = 0.066), but there
(59.07%)
was a significant relationship with the number of snacks per day
Father’s edu- less than high 40 (F(1,450) = 36.66, p < 0.001, R-squared = 0.075). Using logis-
cation level school (8.85%) tic regression, there was no significant relationship (p = 0.565)
high school 100 between children’s duration of smart device usage and speech
(22.12%) delay among children who were 36 months old or younger.
college or more 312 Using the t-test, the duration spent on smart devices was
(69.03%) not found to be significantly different by gender or parent’s
Family in- less than 5,000 86 marital status. However, it was found that children who lived
come (Saudi (equivalent to (19.03%) with both parents spent significantly less time on smart devices
Riyal) 1332.97 USD) (m = 2.95, SD = 2.4) than those who lived with one parent or
5,000–15,000 232 other family member or guardian (m = 4.02, SD = 3.36), (t(75.35)
(equivalent to (51.33%) = −2.45, p = 0.016).
1332.97– The behaviors of children who use smart devices (n = 403)
–39 989 025 USD) and their parents are detailed in Table 4.
more than 15,000 134
(equivalent to 39 (29.65%) Table 4 Behavior of children and parents in using smart devices
989 025 USD) (n = 403)
Child lives both parents 387 No. of those who
with (85.62%) use the device (%)
one parent or 65 Type of used tablet 192 (47.6%)
guardian(s) (14.38%) devices phone 132 (32.8%)
Parents’ married 388
marital status (85.84%) smart tv 141 (35.0%)
divorced/one or 64 Time spent using day 228 (56.6%)
both deceased (14.16%) smart devices night 194 (48.1%)
Siblings 2.53 (1.97)
before bed 131 (32.5%)
Weight (kg) 27.57 (15.95)
Content of smart educational 120 (29.8%)
Height (cm) 116.6 (21.71)
devices used by entertainment 245 (60.8%)
child
Table 3. BMI and lifestyle information for participants songs 157 (39.0%)
games 192 (47.6%)
Count (%) Mean (SD)
BMI 19. 57 (9.17) other 25 (6.2%)
Lifestyle Mean (SD) Parental control yes 233 (57.8%)
Number of 2.77 (0.92) Reason for parents child diversion 135 (33.5%)
meals/day
giving children child entertainment 290 (72.0%)

Number of 1.83 (1.45) smart devices
snacks/day child education 133 (33.0%)
child reward 74 (18.4%)
Physical less than 30 176 (38.94%)
activity/day min
During smart de- soft drinks 62 (15.4%)
more than 276 (61.1%) vice usage, child’s
30 min candy 197 (48.9%)
consumption
chips 239 (59.3%)
The results showed that children’s smart devices usage was the child does not 86 (21.3%)
m = 3.1 hours with SD of 2.58 hours per day. Among the chil- eat snacks during
dren, 403 (89.16%) used smart devices, and 239 (52.88%) of the smart device usage
children used personal smart devices. Among the parents, 355
(78.54%) use their smart devices in front of their children. The Using chi-square, there was no significant difference found
average number of smart devices per family was found to be m between male and female children in regard to the content of
= 4.88, SD = 2.88. smart devices used except for listening to songs, as girls (45%)
When we assessed speech delay, we only included data tended to use smart devices to listen to music more than boys
from children who were 36 months old or younger (n = 74). (27.2%) (χ2(2) = 15.98, p < 0.001).
96 S. Borajy et al. • Relationship, electronic device, speech delay, children
Table 5 details the perceptions and attitudes of parents to- attached to the devices and that they should set specific time
ward their children’s use of smart devices. limits on the use of the devices, this seems to not have been
reflected in their lifestyles. In fact, the average time spent on
Table 5. Perceptions and attitudes of parents toward children smart devices alone was 3.1 hours per day. This was higher than
using smart devices (n = 403) in another study that assessed time spent on interactive screens
in the United States among children from 8 to 18 years of age,
Statement No. agreeing
which averaged around 1.5 hours per day [16]. Our study also
(%)
indicated more mean time spent on electronic devices by tod-
Smart devices are good for educating my child 252 (62.5%) dlers than in the Korean study, which showed results of around
Smart devices can help my child with speech 180 (44.7%) 1.3 hours per day [12]. The time spent in our study was also
greater than that recommended by the American Academy of
Smart devices make my child eat more snack 187 (46.4%)
Pediatrics, which is 1 hour per day for children from 2 to 5 years
Smart device usage decreases my child’s physical 288 (71.5%) of age [17]. This can put more emphasis on the spread of smart
activity device usage among children in Saudi Arabia and highlight the
Smart device usage by my child is a problem 261 (64.8%) need for further studies to assess other hazards that can accom-
pany this behavior, especially when around half of the parents
Parents should allocate specific time limitations 252 (62.5%)
for the use of smart devices
reported that their children had no parental control over smart
device use. In addition, parents might need extra help in finding
My child is attached to smart devices 244 (60.5%) ways to decrease their children’s time spent on smart devices,
which could be provided via programs promoting health and
Discussion through counselors and psychologists.
In addition to Al-Agha et al. [6], our study found no differ-
Our result showed that there was no significant relation- ence in time usage between male and female children. How-
ship between the time spent using smart devices and increased ever, our study added that while the marital status of parents
BMI or speech delays. The duration of smart device usage was did not influence smart device usage, living with both parents
not influenced by gender or parents’ marital status; however, meant the child was less likely to spend more time on smart
children who lived with both parents spent less time on smart devices.
devices than others. The most frequently used smart device was Despite some expectations, the majority of parents report-
a tablet, and the main usage of electronic devices was for entered that the main reason for the child’s use of smart devices was
tainment and games. Only 57.8% had parental control on smart for entertainment and playing games, with less attention spent
device usage. Around half the children ate chips and candy as on educational use. Despite this finding, 62% of the parents be-
snacks during smart device usage. Around 60% of parents believed smart device use was good for educating their children.
lieved that smart device usage is a problem, that parents should This might be taken into consideration for future studies. As one
specify time limits on using the devices and that their children previous study noted, the content type might be a more impor-
are attached to the devices. tant variable to measure than time spent using the device [13].
When we compare our main study results with previous Thus, it could be beneficial for future studies to measure the
studies, we notice a variation in findings. On the one hand, our time spent on different categories of device usage.
results were, to some extent, similar to the previous study by From another perspective, our results showed that around
Bickham et al. [11], where the authors also did not find a rela- half the children consumed chips and candy while using smart
tionship between time spent on devices and BMI. However, they devices. Despite this, we did not find a relationship with obesity,
attributed the increase in BMI to the level of attention paid to but this behavior could be affecting the dental health of chil-
the devices while being used. Furthermore, while Bickham et al. dren. Thus, another future research direction could be to assess
explored TV, video games and computers, they did not make the the relationship between using smart devices and dental care.
distinction of smart devices in particular.
On the other hand, in comparison to a previous Saudi study Implications
[6] where the authors indicated a positive relationship between
electronic device usage and BMI, our results indicated no such Our study showed no significant relationships of children’s
relationship. This might be explained by the previous study [6] use of smart devices to the negative consequences of their use,
not excluding children with chronic diseases that might act as and thus, there is no need to magnify and exaggerate their im-
compounding factors. The authors in that study also measured pact.
the duration of combined use of all electronic devices, including This study was among the few studies that have assessed
regular TV and gaming, in addition to smart devices, whereas the relationship between newly emerging smart device usage
in our study, we focused only on smart devices. Finally, Al-Agha and obesity, but it was the first of its kind to assess the relation-
and colleagues [6] examined the duration of time spent on ship between electronic device usage and speech delay in Saudi
smart devices within a categorical format (less than two hours Arabia. One of the strengths of this study was that it excluded all
and more than two hours), which might result in data distortion, unhealthy patients. The limitations of this study include that it
while in our study, we measured time spent using smart devices used a self-reported questionnaire, which increases the chanc-
using a continuous format and linear regression tests for more es for bias. Additionally, we used a convenience sample, where
accurate results. We argue that our results are more focused random and multicentered samples might generate more reli-
on smart devices, but further studies are needed with different able data.
longitudinal designs to provide more accurate data.
Our study did not find a relationship between the use of
smart devices and speech delays among toddlers, unlike a prior Conclusions
Korean study [12]. This might be because Byeon and Hong in-
cluding watching TV in their assessment. This might also sup- This study concluded that despite the widespread popular
port our suggestion that the nature of smart device usage is belief that excessive use of smart devices can promote child-
different from TV, given that smart devices are more interactive hood obesity and speech development delays, we did not find
than TV and, thus, may have different effects. any statistically significant associations between the duration
Although approximately two-thirds of the parents believed of smart device use and obesity or speech delay. Nonetheless,
that smart device use was a problem, that their children were the children in our study were found to spend more time on
S. Borajy et al. • Relationship, electronic device, speech delay, children 97
smart devices than in other countries and more than the recom- at helping parents add more guidance to their children’s use of
mended time in Saudi Arabia, especially for toddlers. Further these devices.
studies are recommended to generate more generalizable data,
and more studies are needed to focus on smart devices, which Acknowledgments. The authors would like to thank Dalia
seem to be equivalent in importance to TV, which was the focus Aljrary, Shahad AlJifry, Reem Damanhuri, Aohoud AlNafisah,
of most prior research. More programs could also be directed at Shaima Al-Ghuraybi, Hiba Turkustani, and Bashair Al-Jubairy for
increasing awareness of the proper use of smart devices, aimed helping with data collection.
Source of funding: This work was funded from the authors’ own resources.
Conflicts of interest: The authors declare no conflicts of interest.
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Pediatrics-Announces-New-Recommendations-for-Childrens-Media-Use.aspx.
Tables: 5
Figures: 0
References: 17
Received: 20.09.2018
Reviewed: 6.10.2018
Accepted: 14.02.2019
Address for correspondence:

Shazan Borajy, MD
Batterjee Medical College

Jeddah 23819
Jeddah, Saudi Arabia
Tel.: +966566024885
E-mail: shazan.mb@hotmail.com
ISSN 1734-3402, eISSN 2449-8580

Caregiver burden and the role of social support in the care

of children with cystic fibrosis
Grażyna Dębska A, C–G, Irena MilaniakC–F, Dorota Domańska B, F, Lucyna Tomaszek D–F
Faculty of Health and Medical Science, Andrzej Frycz Modrzewski Krakow University, Poland
Summary Background. The effort involved in caring for a patient suffering from cystic fibrosis lies with its parents/caregiver, becom-
ing the cause of excessive burden. In such a situation, social support is an important strategy for coping with chronic illnesses.
Objectives. The aim of the study was to assess the level of burden and social support for parents of children with CF and to establish
a relationship between them.
Material and methods. The study involved 88 parents of patients with cystic fibrosis. The study utilized the standardized Caregiver
Burden Scale (CB) and the Berlin Social Support Scale (BSSS).
Results. The study group experienced an average burden level, which is dependent on the level of education. The highest level of bur-
den was found in two subscales: disappointment and general effort, and the lowest was in the emotional involvement subscale. The lev-
el of support in the studied group was high. The largest was observed in the subscale perceived support and received support, and the
lowest in the subscale seeking support. Analysis of the regression of the dependent variable of the caregiver’s level of burden showed
that the level of burden determines the need for support. It has been observed that as the level of the caregiver’s burden increases,
the need for support also increases. In turn, the smaller the caregiver’s burden, the lower the need for support currently received.
Conclusions. The caregiver burden on the parent of a children suffering from CF and the received social support are important factors
influencing each other in the care of a chronically ill child. This means that the more support received, the lower the sense of burden
the caregiver experiences.
Key words: cystic fibrosis, caregivers, parents, social support.
Dębska G, Milaniak I, Domańska D, Tomaszek L. Caregiver burden and the role of social support in the care of children with cystic fibro-
sis. Fam Med Prim Care Rev 2019; 21(2): 98–103, doi: https://doi.org/10.5114/fmpcr.2019.84543.
Background “caregiving experience” or “caregiving consequences”, present-

ing the possible positive aspects of care [11].
Treatment of cystic fibrosis (CF) is comprehensive and Social support includes the resources and assistance that
multidisciplinary. It includes prophylaxis and treatment of the other people provide. It is a multidimensional concept that can
broncho-pulmonary disease, therapy of pancreatic insufficiency be considered in structural and functional terms. The structural
and treatment of complications and co-morbidities [1]. There ones are actual ties and contacts, i.e. social networks to help peo-
is no doubt that the specific nature of this disease requires ple in a difficult situation. There are three categories of support
ceaseless prevention of its development, constant struggle and sources: personal – these are family, friends and acquaintances or
painstaking routine activities without any visible effects. How- neighbors; formal – these are charities, social welfare and church
ever, thanks to the perseverance and effort of parents, these communities; and professional sources – specialist clinics and
allow for the prolongation of children’s lives and improve their support groups [8–10]. Functional support, on the other hand, is
mental and physical condition [2]. As a result of long-term care, a social interaction taking place in a problem and stress situation.
the parents/caregivers experience resignation, a sense of loneli- The types of support most often distinguished by researchers and
ness, loss of valuable interpersonal contacts, lack of interests, theoreticians are: instrumental, informational, emotional, assess-
dissatisfaction with their own life situation and sometimes even ment, material (factual), evaluative, spiritual, integrating.
negative feelings towards the child [2–4]. This causes stress,
which leads to physical, emotional, mental, social and financial
depletion [4–7]. The burden can be discussed in relation to ob-
Objectives
jective and subjective aspects [5, 6]. Objective or measurable
The aim of the study was:
indicators in the caregiver’s functioning include time and physi-
1) to assess the degree of caregiver burden and level of social
cal effort, chronicity and severity of symptoms, as well as socio-
support of parents of CF patients;
demographic indicators, i.e. gender, education level and earn-
2) establish the relationship between socio-demographic
ings. The subjective approach to burden refers to physical and
mental suffering, as well as emotional and social experiences variables, caregiver burden, as well as experience of social
arising as a result of the child’s illness. It is difficult to verify this support.
type of burden, because it is related to the caregiver’s individual
ways of coping, as well as the level of social support received Material and methods
[8, 9]. Support is a protective factor in the struggle and in over-
coming a difficult situation [8, 10]. Researchers also increasingly The study was conducted between November 2015 and
often reject the concept of burden with care, replacing it with February 2016 in a group of parents of children suffering from
G. Dębska et al. • Caregiver burden social support care of patients with CF 99
cystic fibrosis. The study was approved by the Bioethical Com- tional involvement and Environment. Answers are provided on
mission of the Andrzej Frycz Modrzewski Krakow University, a 4-point estimate scale. The Total Score for the CB Scale and
dated November 19, 2015, opinion No. KBKA/44/O/2015. the 5 subscales is the average score in individual items included
The study group consisted of 88 parents (M = 11.36% (n = 10), in the scale (1 point – 4 points). The obtained results indicate
F = 88.64% (n = 78)) of patients suffering from cystic fibrosis. the following burden categories: low level (1.00–1.99), medium
The average age of the respondents was 39 ± 7.19 years. The level (2.00–2.99), high level (3.0–4.0). A higher number of points
most numerous groups were those aged 35–45 (46%, n = 40) means a higher level of burden. A reliability index was calculat-
and those aged 20–35 (37%, n = 32). The smallest group among ed for the studied population, which was α = 76. The authors of
the respondents was people over 45 (17%, n = 15). Almost half the Polish version agreed do used it in this research [11].
of respondents (n = 41, 46.6%) had secondary education, and 37
people (42%) had higher education. The least numerous group Berlin Social Support Scale (BSSS)
of respondents (n = 10, 11.4%) was people with basic and voca-
tional education. Country dwellers accounted for 47% (n = 41) of The Berlin Social Support Scale originally contained 6 inde-
pendent subscales. For research purposes, 31 questions were
respondents, and city dwellers for 53% (n = 47).
in 4 subscales: Perceived support, Demand for support, Re-
The vast majority (84%, n = 74) of the respondents were
ceived support and Seeking support. Answers are provided on
complete families. 36% (n = 31) of parents have one child; the
a 4-point estimate scale. A higher number of points means more
more numerous group was parents with two children (39%,
social support. A reliability index was calculated for the studied
n = 34). Parents of four children accounted for 8% (n = 7). In
population, which was α = 0.73. The tool is “public domain”, and
contrast, 12 parents (13.7%) took care of two children with cys-
the authors of the Polish version agreed to used it in this re-
tic fibrosis. Of all the parents surveyed, 70% (n = 62) declared search and analyzed only 4 subscales [8, 10].
that the child’s illness influenced their possibility of performing
work. 31.8% (n = 28) use social support. One-third of respon-
Statistical analysis
dents took care of a sick child by themselves, and 58 people
(66%) answered that they could rely on the support of family Statistical analysis of the collected research material in-
members or strangers. Approximately 80% (n = 70) of respon- volved the StatSoft’s statistical package Statistica v. 7.1, as well
dents used help or were involved in self-help associations/or- as Microsoft Excel 2000 and Microsoft Excel 2007. Statistical
ganizations (Table 1). The mean age of children with CF was 10 description methods were used in the presentation of the char-
years, from 1 to 22 years old (± 6). acteristics of the set of measurements for the examined feature
(variable): location measure – arithmetic mean, median m and
Table 1. Characteristics of the study group measures of differentiation – standard deviation (referred to as
sd herein), minimum value (min, first quartile) and maximum
n %
(max, fourth quartile) of a given trait, as well as second and third
Gender quartile. The range of variability (min–max) of the characteris-
Female 78 88.6 tics studied in the paper was marked as scope.
Male 10 11.4 The distribution normality of the variable was verified using
Age the Shapiro–Wilk test. For variables that did not have a normal
20–35 years 32 36.4 distribution, logarithmic transformations were used (e.g. vari-
35–45 years 40 45.5 able: age). In the event that the above transformation provided
Above 45 years 16 18.1 no improvement in the normality of the distribution, non-para-
Education metric tests were used.
Primary and vocational 10 11.4 Statistical inference was performed using the following
Secondary 41 46.6 tests: Friedman’s ANOVA test, Spearman’s test and multiple re-
Bachelor’s and Master’s degrees 37 42.1 gression analysis. Statistically significant results were those with
Place of residence a significance level lower than 0.05.
Village 41 46.6
City up to 100,000 residents 28 31.8 Results
City over 100,000 residents 19 21.6
Family structure The respondents rated their current state of health at 7.22
Complete family 74 84.1 (SD 1.98) points on a 10-point scale (min 1, max 10). In the par-
Single-parent family 14 15.9 ents’ opinion, the health condition of their children in the last
Family economic situation year was stable in most cases (62%, n = 55). Regarding the fre-
Poor, average 49 55.7 quency of stays with the child in the hospital, 60% (n = 53) of
Good, very good 39 44.3 the respondents indicated such need once a year, 27% (n = 24)
Employment status indicated 2–3 times a year, and 8% (n = 7) of parents must take
Full-time job 24 27.3 the child to the hospital more than 3 times a year.
Part-time job 12 13.6 The Total score of the caregivers’ burden in the Caregiver
Unemployed 24 27.3 Burden Scale (CB Scale) was (x = 2.47 ± 0.47). This indicates the
Use of social support 28 31.8 average level of burden in the study group, which concerns
Involvement in self-help associations/orga- 70 79.5 72.73% (n = 63) of respondents. For individual subscales, the
nizations mean burden values were within the average level, except for
the “emotional involvement” subscale, the mean of which (x =
Methods 1.96 ± 0.66) indicates a low level of burden. There were statis-
tically significant differences between individual burden sub-
The study involved the diagnostic survey method. Polish scales (p < 0.05).
versions of self-report tools with proven and good psychomet- The percentage of people with an average level of burden
ric properties were used: Caregiver Burden Scale (CB Scale) [11] for Total score and individual subscales of CB was the highest
and the Berlin Social Support Scale (BSSS) [8, 10]. 56.82% (n = 50) for general effort, 50% (44) for disappointment
The Caregiver Burden Scale includes 22 questions in 5 sub- and environment, and 48.86% (n = 43) for emotional involve-
scales: General strain, Social isolation, Disappointment, Emo- ment, respectively). The highest percentage of people in the
100 G. Dębska et al. • Caregiver burden social support care of patients with CF
Table 2. Level of burden in individual subscales

Caregiver Burden Subscales Min Max Mean SD Level of burden (%)
Low Average High
Total score 1 4 2.47 0.47 13.64 72.73 13.64
General strain 1 4 2.67 0.56 12.50 56.82 30.68
Isolation 1 4 2.32 0.79 32.95 37.50 29.50
Disappointment 1 4 2.74 0.57 7.95 50.00 42.04
Emotional involvement 1 4 1.96 0.66 40.91 48.86 10.23
Environment 1 4 2.06 0.63 38.64 50.00 11.36
Abbreviations: min – minimum, max – maximum, SD – standard deviation.
Table 3. Link between general burden and the caregiver’s level of education – ANOVA (variance analysis)
Variable Total score
No. Total score Total score Degrees F p
(Mean) SD of freedom
Education Primary and vocational 10 2.20 0.42 2 5.49 0.005
Secondary 41 2.38 0.43
Higher 37 2.65 0.47
Abbreviations: No. – number of subjects, SD – standard deviation, F – test F, p – significance.
Table 4. Level of social support in categories

Subscales Min Max Mean SD Level of support (%)
Low Average High
Perceived support 1 4 3.32 0.62 5.68% 15.91% 78.41%
Demand for support 1 4 3.07 0.64 4.54% 29.54% 65.91%
Received support 1 4 3.24 0.68 5.68% 26.14% 68.18%
Seeking support 1 4 2.79 0.77 11.36% 40.91% 47.73%
Total support 1 4 3.18 0.53 2.27% 32.95% 64.77%
Abbreviations: min – minimum, max – maximum, SD – standard deviation.
Table 5. The relationship between social support and the caregiver’s burden
Pair of variables Spearman’s rank order correlation
No. R Spearman t(n - 2) p
Support & Total score CB 88 -0.28 -2.68 0.009
Support currently received & Total score CB 88 -0.16 -1.98 0.04
Abbreviations: R Spearman – Spearman correlation, p – significance.
high burden category concerned disappointment and general level of Total score between caregivers in relation to the level of
effort (with 42.04% (n = 37) and 30.64% (n = 25), respectively). education: F2.85 = 5.49, p = 0.006. The highest level of general
As far as the social isolation subscale was concerned, the per- burden was noted in the group of people with higher education,
centage of responses was similar on each of the burden levels and the lowest in the group of people with basic and vocational
(low, medium and high). Therefore, disappointment and general education. The data acquired showed that the higher the level
effort were considered the most burdensome, while emotional of the caregiver’s education, the greater their sense of burden
involvement and environment – the least burdensome in the (Table 3).
group of respondents (Table 2). Analyzing the support experience of the study group,
The dependence between the caregiver’s burden and the a high level of support was noted for the majority of the group
following variables was analyzed: age, gender, education, place
(64.44%, n = 56) – the general support level result measured by
of residence, family structure, economic situation, the child’s
the BSSS scale was x = 3.18 ± 0.53. The highest level of support
and the caregiver’s health status, age of the sick child and de-
was noted in the subscales support available (x = 3.32 ± 0.62)
gree of involvement in cooperation with associations/organiza-
tions supporting families of CF patients. and support received (x = 3.24 ± 0.68). A high result was also
Among the mentioned variables, the only statistically sig- observed in the demand for support subscale (x = 3.07 ± 0.64).
nificant variable was the relationship between education and The lowest level of support was noted in the seeking support
the degree of burden. The one-way ANOVA analysis (analysis subscale (x = 2.79 ± 0.77) (Table 4).
of variance) was used to examine the dependence between The Spearman’s rank correlation coefficient was utilized in
education and the general care burden. The average level of studying the dependence between the level of the caregiver’s
burden between caregivers belonging to three groups broken general support and general burden (Total score). The result
down by the level of education was compared. The obtained obtained were statistically significant (R Spearman = -0.28,
results showed a statistically significant difference in the mean p = 0.009). This means that the caregiver’s burden is correlated
with the experience of support. A statically significant depen- The above data would suggest that the burden of caring
dence was also found between the support currently received and for a chronically ill child should correlate with one’s economic
the general burden (Total score) (r = -0.16, p < 0.05) (Table 5). situation. However, in an own study, the socio-economic status
As a result of the conducted analyzes, a statistically signifi- was not analyzed using an objective indicator, i.e. the income
cant negative correlation was found between the caregiver’s obtained. Therefore, it is difficult to compare with data from lit-
burden in the social support subscale and the general support erature, where there is evidence that the socio-economic status
subscale: general support (r = -0.23, p < 0.05), support available (SES) of CF patients plays an important role as a factor modifying
(r = -0.20, p < 0.05), seeking support (r = -0.23, p < 0.05). There the course of the disease and prognosis [16]. Studies by Sahni et
was also a negative correlation between the support received al. showed that a lower SES, measured on the basis of average
and the level of general caregiver’s burden and its subscales income and type of health insurance, is an independent risk fac-
(Total score CB r = -0.16, social isolation r = -0.25, disappoint- tor for death in the CF population [16].
ment r = -0.25, emotional involvement r = -0.16, environment On the other hand, failure to show the dependence be-
r = 0.19, p < 0.05). tween the socio-economic status and the caregiver’s burden
Analysis of the regression of the dependent variable of the in the study may result from the fact that in 36% of cases, the
caregiver’s level of burden showed that the demand for support child suffering from CF is the only child in the family. Caring for
and support currently received explain the dependent variable a single child is less financially burdensome than caring for large
in 12% of cases (R = 0.35 R2 = 0.12 F(2.85) = 6.2371, p < 0.003). families. It also seems that the role of support and the ability to
In the case of demand for support, the higher the caregiver’s rely on the help of others is an important factor that helps par-
burden, the greater the demand for support (β = 0.28). In the ents cope with the child’s illness. Majority of the surveyed group
case of currently received support, the smaller the caregiver’s (over 80%) were complete families benefiting from the help of
burden, the lower the need for currently received support self-help associations/organizations. Undoubtedly, the psycho-
(β = -0.32). logical, information and instructional support provided by these
associations/organizations is a huge help for parents and a fac-
tor that reduces the perceived level of burden. They also pro-
Discussion vide an opportunity to contact parents with similar problems
and exchange experiences.
The aim of the conducted research among 88 parents of pa- The average level of burden in the study group may result
tients suffering from cystic fibrosis was to determine the level from the fact that the parents assessed the health of children as
of burden and the degree of social support obtained by the good, and the result of this assessment was: x = 7.22 ± 1.98 (on
caregiver of a chronically ill child, as well as to determine the a scale from 0 to 10). This means that a large group of children
relationship between socio-demographic variables, the parent’s enjoys good health in the opinion of parents, so the burden on
health, the caregiver burden, as wells as asocial support expe- the parent is not high. This condition can be explained by the
rienced. low average age of the respondents’ children (x = 10.4 ± 6.4
Treatment of cystic fibrosis takes place primarily in the years). This was confirmed in a study by Fitzgerald et al. [17],
child’s home. The effort of care rests with parents mainly in ap- which showed that the older the CF patients, the higher the bur-
plying a diet, supply of pancreatic enzymes, vitamins, antibiot- den level. In the same study, the second factor associated with
ics, mucolytics and daily rehabilitation of the respiratory system the higher burden level was Psuedomonas aureginosa infection,
(inhalation, drainage, physiotherapy). This results not only in which indicates disease progression. This thesis was confirmed
the high costs of the treatment itself, but also places a financial by Wojtaszczyk et al. [18] in their work assessing the burden of
burden on parents who give up their professional lives to look caregivers of adult patients with CF, where it was shown that
after their sick child at home [12]. Parents bear the responsibil- along with the deterioration of health, the caregivers experi-
ity for the state of treatment and the child’s improvement, and enced more stress.
the care requirements also increase as the disease progresses. Studying the dependence between the level of general sup-
Uncertainty about the future is becoming a serious issue [13]. port assessed according to the BSSS scale and the caregiver
An analysis of literature suggests that the stress experienced general burden scale (CBS), a significant negative correlation
by the caregivers of chronically ill children leads to the conclu- of these two variables was noticed. This means that the more
sion that this group shows a significantly higher level of stress support received, the lower the sense of burden the caregiver
compared to the caregivers of healthy children. This stress lies experiences. Similar results were found in a study by Parcho-
at the root of neurotic and depressive disorders, or the break- miuk [19], in which, using the same tools (CBS) and (BSSS), it
down of family or marital relationships [14]. was shown that mothers of children with intellectual disability
In an own study, it was shown that education and the as- experience more burden and seek more social support than
sociated greater awareness, together with the need to acquire mothers of healthy children. Moreover, the analyzed literature
knowledge of both the disease and its effects, may be the cause confirms that mothers of sick children show high levels of stress,
of a greater sense of burden. The education level in the study and even depressive disorders [15, 19].
group may also be related to the position held, the type of work Wong and Heriot [20] described the parent’s attitude to-
performed and the responsibility for it, which is associated with wards the child and their illness. It has a huge impact on cop-
greater stress and workload and may affect parental responsi- ing with the child’s disease. The authors note two approaches
bilities. among parents, calling them substitute hope and despair. These
Further analysis showed that despite the fact that the ma- two approaches determine the manner of adapting to living
jority of respondents (n = 49) assessed it as poor and average, with the disease. In one case, anxiety, depression, loss of moti-
the economic situation did not have a significant impact on the vation increase, and in the other, emotional support and hope
level of general burden. This result is surprising, as in an own give strength, reduce the level of anxiety and suffering. Research
study, 70% of respondents declared that the disease affects confirms that the parents’ attitude has a significant impact on
their work performance, with 40.9% working, 13.6% of which the attitude of children. According to the authors, strengthening
work part-time, and one-third of parents declared that they the parents’ substitute hope improves the mental condition of
benefit from social support. Similarly, in a study by Neri et al. sick children [20].
[15], it was shown that the parents of young CF patients (x = 16 One should not overlook the positive features of caring for
± 2.6) declared a lower socio-economic status, giving up their a sick family member, which are very individual and may change
professional work. A higher percentage of parents taking up em- over time. These are a greater sense of satisfaction and per-
ployment compared to own research (54.4%). sonal reward from care. Challenges associated with the struggle
102 G. Dębska et al. • Caregiver burden social support care of patients with CF
with the disease become a source of experience and thus allow 2. Healthcare providers should regularly pay attention to fam-
for a more mature assessment of the world, greater ability to ily caregivers, regardless of the patient’s condition and age.
empathize and can also be a factor in improving relationships
with others or changing one’s system of values [21]. Therefore,
healthcare providers should regularly pay attention to family
Conclusions
caregivers, regardless of the patient’s condition and age.
This study contributes new findings to the sparse literature 1. The burden on the parent of a child suffering from CF was
on caregiver burden of parents of young children with CF. Care- at an average level and was dependent on the level of edu-
giving burden is a relevant and frequent issue among parents of cation. The most burdensome factors proved to be disap-
adolescent patients with cystic fibrosis. pointment and the effort put into care.
2. The burden on the parent of a child suffering from cystic fi-
brosis determined the social support received. As the level
Limitations of the study
of the caregiver’s burden increased, the need for support
The main limitation of this study was the small size of the also increased. In turn, the less the caregiver’s burden, the
study group. This is why our findings may not be internationally lower the need for support currently received.
generalizable. 3. The level of burden was dependent on education and de-
termined the need for social support.
Implications for clinical practice
Acknowledgments. The authors would like to acknowledge
1. The burden on the parent of a child suffering from cystic the participants who took part in this research and who willingly
fibrosis determines the social support received. shared their experience.
Source of funding: The study was financed with the use of funds from the Ministry of Science and Higher Education for scientific and devel-
opment research within the status activity of the Andrzej Frycz Modrzewski Krakow University – Faculty of Medicine and Health Sciences
(number of research task: WZiNM/DS/4/2017-KON).
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Tables: 5
Figures: 0
References: 21
Reviewed: 20.09.2018

Irena Milaniak, RN, MSN, PhD
Wydział Lekarski i Nauk o Zdrowiu
Krakowska Akademia im. Andrzeja Frycza Modrzewskiego
ul. G. Herlinga-Grudzińskiego 1
30-705 Kraków
Polska
Tel/fax: +48 12 252-45-02
E-mail: imilaniak@afm.edu.pl

ISSN 1734-3402, eISSN 2449-8580

Effectiveness of psycho-education on knowledge regarding

schizophrenia and caregivers’ burden among caregivers
of patients with schizophrenia – a randomized controlled trial
Sunanda Govinder Thimmajja1, A–F, Eilean Victoria Lazarus Rathinasamy2, A, C–E
ORCID iD: 0000-0002-9224-2212
1
Department of Psychiatric Nursing, Dharwad Institute of Mental Health and Neurosciences, Dharwad, India
2
Department of Adult and Critical Care, College of Nursing, Sultan Qaboos University, Muscat, Oman
Summary Background. Schizophrenia is one of the commonly occurring disorders, often causing a high degree of disability to the
patients, as well as being stressful to the caregivers.
Objectives. To find the efficacy of psycho-education on knowledge regarding schizophrenia among caregivers and reducing their level
of burden.
Material and methods. A randomized controlled trial was used to assess the effectiveness of psycho-education among caregivers
of patients with schizophrenia. This study was conducted at a selected state government mental hospital in Karnataka, India. 350
caregivers were randomly assigned to study (n = 175) and control groups (n = 175). Both the group subjects were initially assessed for
knowledge and burden. The study group caregivers participated in one or two psycho-education sessions with routine nursing care.
Control group subjects received routine care in the hospital. Post-intervention assessment was done at the end of one-month and
three-month intervals.
Results. At pre-test, the study group caregivers’ mean knowledge scores were mean = 22.93, SD = 17.03, which was improved to mean
= 85.90, SD = 9.51 at the one-month follow-up and mean = 97.94, SD = 4.41 at the three-month follow-up. This improvement was
statistically significant at a 0.01 level when compared to control group caregivers. The study group caregivers’ mean burden scores
that were initially recorded at pre-test mean = 82.37, SD = 10.40 reduced to mean = 49.13, SD = 8.28 at the one-month follow-up and
mean = 40.86, SD = 6.27 at the three-month follow-up. This improvement was statistically significant at a 0.01 level when compared
to control group caregivers.
Conclusions. The study group caregivers showed an improvement in knowledge gain and a reduction in care burden. The present study
findings provided evidence for the role of psycho-education intervention in reducing care burden among caregivers of patients with
schizophrenia and was also found effective in caring for their relatives with appropriate knowledge.
Key words: schizophrenia, caregivers, education.
Govinder Thimmajja S, Lazarus Rathinasamy EV. Effectiveness of psycho-education on knowledge regarding schizophrenia and care-
givers’ burden among caregivers of patients with schizophrenia – a randomized controlled trial. Fam Med Prim Care Rev 2019; 21(2):
104–111, doi: https://doi.org/10.5114/fmpcr.2019.84552.
Background or over 60. Low income is linked to the occurrence of mental dis-
orders, and urban areas are most affected. The overall weighted
Mental illnesses are a global public health concern. Schizo- prevalence for any mental morbidity was 13.7% life-time and
phrenia is one of the top 15 leading causes of disability worldwide 10.6% current mental morbidity [7].
[1]. Estimates of the international prevalence of schizophrenia Indians suffer from severe mental disorders and common
among non-institutionalized persons is 0.33% to 0.75% [2, 3]. mental disorders. The burden of these disorders is likely to in-
The burden of care emerged after the closure of mental hos- crease to 15% by 2020 [8].
pitals when patients were followed-up outside of the hospital While a majority of the population lives in rural areas, 80–
settings [4], and the family members assumed responsibility –90% of the mental disorders among them were not diagnosed
for these patients, thereby becoming the primary caregivers at and left untreated due to lack of knowledge and a negative at-
home [5]. titude towards mental illness. A stigma and negative attitude
Caregiver burden has two dimensions – subjective and ob- towards people with mental illness has been observed among
jective. While the subjective component deals with the extent the general population [9].
to which the burden is felt by the relatives, the objective burden In India, the annual incidence rates of schizophrenia ob-
relates to the ill effects on the household, such as financial diffi- tained were 4.4 and 3.8 per 10,000 for rural and urban areas, re-
culty, effects on health, children and disruption in regular family spectively [10]. More than 70% of mentally-challenged patients
routine due to the patient’s abnormal behavior [6]. live within the family, and the family is the 24/7 care provider.
The media referred to the findings of the report as follows: So, unless the family base is strengthened, the care and rights
“India needs to talk about mental illnesses. Every sixth Indian of mentally ill patients are likely to be compromised irrespective
needs mental health help. 8% of people in Karnataka have men- of the various national programs introduced by the government
tal illnesses. Mental problems are more in the 30–49 age groups of India.
S. Govinder Thimmajja, E. V. Lazarus Rathinasamy • Effectiveness of psycho-education caregivers of patients with schizophrenia 105
Among the many mental illnesses, schizophrenia is a chronic Material and methods
disease that results in a serious form of disability and concerns
not only the patients themselves, but also their family members Design
who assume their care [11]. The burden of those providing care
to patients with chronic diseases is a global problem. Caring for The present study used an experimental pre-post control
such patients requires continuous energy, knowledge, empathy group design with a three-month follow-up.
and economic power, which all influence daily living to a large
extent. While attempting to establish a balance between their Participants
jobs, families and their patient care, usually caregivers will ne-
glect their own physical and mental health [11]. The participants comprised 350 caregivers of patients with
The stigma attached to the mental illness, especially schizo- schizophrenia who were admitted at a selected state govern-
phrenia, often inhibits the family’s willingness to talk about ment psychiatric hospital in Karnataka, India. The subjects were
their thoughts and feelings, and the biological factors of the ill- selected from the in-patient department of the psychiatric hos-
ness interfere with treatment [12]. pital. The participants were randomly assigned to either of the
Family caregivers with a lower education level and increased study or control groups via a computer-generated random se-
family hardiness and those with a higher education level had quence of numbers. The inclusive criteria for selection of sub-
significantly enhanced family functioning. A sense of coherence jects were: the caregivers should be between 15–54 years of
was significantly correlated with family hardiness [13]. age and must be residing with the patients for about six months,
The families who perceived a higher level of caregiver bur- and the schizophrenia patients were diagnosed by a psychiatrist
den were those who lived in a family having poorer functioning, based on ICD-10 criteria.
worse health status and less satisfaction of social support [13].
Treatment of schizophrenia is focused primarily on the man- Study instruments
agement of symptoms with drugs. Rehabilitation and psychoso-
cial interventions are frequently neglected and rarely available. Section A includes socio-demographic details of the partici-
Among psychological interventions, psycho-education is one pants, such as age, gender, relationship with patient, residence,
type of intervention that is used to treat patients with schizo- type of family, education, occupation, income, duration of re-
phrenia, as well as caregivers of patients with schizophrenia. spondent’s relative suffering from schizophrenia and source of
Nurses and mental health professionals need to collaborate information.
with patients and families to educate and assist them in under- Section B included a questionnaire regarding knowledge
standing and coping effectively with mental illnesses. Families on schizophrenia under two areas: 1) General information
often look to nurses for empathy and answers in dealing with of schizophrenia containing 7 items focused on introduction,
these issues. The study showed that 487 family members be- causes, signs and symptoms and course of schizophrenia; and
lieved that the factual information about illness, socialization, 2) Treatment and management of schizophrenia containing
building support in the family and increased understanding and 18 items focused on pharmacological treatment, psychosocial
awareness of the biological basis of mental illness reduced the management and nursing management. The maximum score is
stigma attached to mental illness. A brief psycho-educational in- 25, with 1 mark for each correct answer and 0 marks for each
tervention for relatives is effective in improving relatives’ knowl- wrong answer. Scores between 0–9 (< 35%) indicate inadequate
edge about schizophrenia and reducing re-hospitalization [14]. knowledge, 10–17 (< 65%) moderate knowledge, and 18–25
Caregivers in the intervention group showed significant im- (> 65%) adequate knowledge. Content validity was checked by
provement in knowledge, a reduction in burden while assisting a panel of 12 subject experts. Reliability assessment was done
in daily living (severity) and a reduced defaulter rate in patients’ using the test-retest method. The reliability coefficient for the
follow-up [15]. structured knowledge questionnaire was 0.89 [16].
Many studies have shown that psycho-education interven- Section C included the Burden Assessment Schedule (BAS)
tions may improve patients’ and caregivers’ outcomes, but the [17], which is a standardized tool used in the Indian context
quality of included studies are poor, and it is difficult to draw comprising 20 items representing 5 factors or concerns which
firm conclusions as to the effectiveness of such interventions reflect the caregiver’s main feelings about their care-giving role.
on patients’ and primary caregivers’ outcomes, hence the pres- The 5 factors are: 1) Impact on well-being; 2) Impact on mari-
ent study intended to evaluate the efficacy of psycho-education tal relationships; 3) Appreciation for caring; 4) Impact on rela-
on knowledge regarding schizophrenia and caregiver burden tions with others; 5) Perceived severity of the disease. The BAS
among caregivers of patients with schizophrenia. used a three-point Likert scale to assess the caregiver’s burden
The present study has been taken up against the above in terms of ‘not at all’, ‘to some extent’ and ‘very much’. The
background, with a purpose to measure the effectiveness of highest score is 60. The scores are divided into three levels to
psycho-education on caregivers’ knowledge and burden. We perceive the level of caregiver burden, ranging from low to high.
hypothesized that subjects in the study group will experience Scores between 0–20 denotes low burden, 21–40 denotes aver-
a greater improvement in knowledge regarding schizophrenia age burden, and 41–60 denotes high level. Tools were translated
and a reduction in caregiver burden compared to control group from English to Kannada language by Kannada language experts
subjects during follow-up assessments. Therefore, the aim of and retranslated back to English by English language experts.
the present study is to investigate the effectiveness of psycho-
-education on knowledge regarding schizophrenia and the level Intervention
caregiver burden among caregivers of patients with schizophre-
nia. Psycho-education intervention was developed based on
“A manual on family intervention for the mental health profes-
sional” [18, 19]. This was validated by a panel of subject experts.
Objectives It involves two sessions, each session lasting for 60 to 90 min-
utes. The topics included in psycho-education were – general in-
The aim of the study is to examine the effectiveness of psy- formation on schizophrenia, causes, signs and symptoms, phar-
cho-education on improving knowledge regarding schizophre- macological management, psycho-social management, nursing
nia and reducing caregiver burden among caregivers of patients management and family roles and responsibilities in manage-
with schizophrenia. ment of patients with schizophrenia. It also focused on manage-
106 S. Govinder Thimmajja, E. V. Lazarus Rathinasamy • Effectiveness of psycho-education caregivers of patients with schizophrenia
Assessed eligibility based

on inclusive criteria
(n = 400)
Excluded (n = 50)
• Did not meet inclusion criteria
• Refused to participate
Randomized
(n = 350)
Allocated to study group (n = 175) Allocated to control group (n = 175)

Collected data (pre test) Collected data (pre test)
Attended psycho-education sessions

(n = 175)
Post-test-1 (1-month follow-up) Post-test-1 (1-month follow-up)

Post-test-2 (3-month follow-up) Post-test-2 (3-month follow-up)
Analysis of the data

and interpretation results
Figure 1. Flow chart of the study
ment of stress and the burnout of caregivers of patients with Participants were explained the purpose of the study, nature of
schizophrenia. Psycho-education was translated into the local involvement and number of follow-ups, both in oral and written
language and implemented to the study group by a lecture- form. The researcher obtained written informed consent before
cum-discussion method, one-to-one or in a group in one session proceeding with the study. The respondents were assured ano-
or two sessions with flex charts, a laptop-assisted power point nymity and confidentiality of the information provided by them.
presentation and distributed information brochure.
Data analysis
Data collection
Descriptive and inferential statistics were used to analyze
Study subjects were selected based on inclusive criteria the data, and the results were narrated in the form of tables.
from the in-patient department of a state government psychi-
atric hospital in Karnataka, India. Data was collected from De- Results
cember 2013 to 2015. Initially, the investigator (first author)
approached each participant and assessed them for socio-
-demographic details, knowledge regarding schizophrenia and
Findings related to socio-demographic characteristics
burden level using the above tools. Each participant took 30 Distribution of study subjects based socio-demographic
minutes to complete the questionnaires. Later, the investigator characteristics, majority were belonged to 25–34 years of age
randomly assigned subjects to experimental and control groups group. A majority of n = 115 (65.71%) and n = 112 (64%) respon-
using computer-generated random sequence numbers. The ex- dents were female in the study and control groups, respectively.
perimental group subjects participated in a psycho-education The majority of the [study = 77 (44%) and control = 70 (40%)]
program. The first author provided intervention using a group respondents had a parental relationship with the patient. The
approach and lecture-cum-discussion method. Psycho-educa- majority of the [study = 98 (56%) and control = 96 (54.86%)]
tion was imparted using flex charts and a laptop-assisted power respondents resided in rural areas. 61.7% of the study group
point presentation. At the end of the intervention, each caregiv- and 52.6% of the control group subjects belonged to a joint fam-
er was provided with an information booklet. The control group ily. 42.86% of the study group subjects and 31.43% of the con-
subjects received only routine care in the hospital. A post-test trol group subjects studied up to 10 + 2/Diploma education*.
was conducted at the end of a one-month and two-month pe- 31.43% and 36% of the study and control group subjects respec-
riod. Caregivers in the control group received information book- tively pursued farming. The majority of respondents [study = 40
lets after completion of follow-up assessments (Figure 1).
Ethical consideration * In our country’s education system 10 + 2 means 12th class level of edu-
cation and diploma education means some of the courses are offered
The study was approved by the institutional ethics commit- after 10th class. So, 10 + 2 and diploma education level posses somewhat
tee, and permission was obtained from the hospital authorities. same level of educational status.
Table 1. Distribution of the subjects based on socio-demographic characteristics

Demographic characteristics Study group % Control group % Total %
n = 175 n = 175
Age groups in years
15–24 22 12.57 17 9.71 39 11.14
25–34 68 38.86 47 26.86 115 32.86
35–44 64 36.57 80 45.71 144 41.14
45–54 21 12.00 31 17.71 52 14.86
Gender
Male 60 34.29 63 36.00 123 35.14
Female 115 65.71 112 64.00 227 64.86
Relationship with patient
Spouse 34 19.43 39 22.29 73 20.86
Parent 77 44.00 70 40.00 147 42.00
Siblings 36 20.57 48 27.43 84 24.00
Children 11 6.29 0 0.00 11 3.14
Others 17 9.71 18 10.29 35 10.00
Place of residence
Urban 77 44.00 96 54.86 173 49.43
Rural 98 56.00 79 45.14 177 50.57
Family type
Nuclear 67 38.29 83 47.43 150 42.86
Joint 108 61.71 92 52.57 200 57.14
Education level
Professional 19 10.86 26 14.86 45 12.86
Graduate/postgraduate 27 15.43 12 6.86 39 11.14
10 + 2 and diploma 75 42.86 55 31.43 130 37.14
Primary and higher 31 17.71 34 19.43 65 18.57
No formal education 23 13.14 48 27.43 71 20.29
Occupation
Business/small scale employees 10 5.71 13 7.43 23 6.57
Government employee 42 24.00 20 11.43 62 17.71
Private employee 55 31.43 17 9.71 72 20.57
Farmer/laborer 31 17.71 63 36.00 94 26.86
Unemployed 37 21.14 62 35.43 99 28.29
Annual income in rupees
< 5,500 12 6.86 0 0.00 12 3.43
5,501–10,000 34 19.43 18 10.29 52 14.86
10,001–20,000 40 22.86 10 5.71 50 14.29
20,001–30,000 36 20.57 82 46.86 118 33.71
30,001–40,000 29 16.57 39 22.29 68 19.43
> 41,000 24 13.71 26 14.86 50 14.29
Duration of illness
< 1 year 15 8.57 25 14.29 40 11.43
1–3 years 69 39.43 33 18.86 102 29.14
4–5 years 60 34.29 30 17.14 90 25.71
6+ years 31 17.71 87 49.71 118 33.71
Sources of information
Radio 20 11.43 27 15.43 47 13.43
Television 49 28.00 18 10.29 67 19.14
News papers 21 12.00 6 3.43 27 7.71
Magazines and books 19 10.86 22 12.57 41 11.71

Medical professionals 66 37.71 102 58.29 168 48.00
(22.86%) and control = 82 (46.86%)] belong monthly income Effectiveness of psycho-education on knowledge
status was Rs. 10,001/- to 20,000/- per month. A majority of the level regarding schizophrenia
respondents’ [study = 69 (39.43%) and control = 87 (49.71%)]
patients’ duration of illness was 1–3 years. A majority of respon- The effectiveness of psycho-education on knowledge regard-
dents [study = 66 (37.71) and control = 102 (58.29%)] sought ing schizophrenia was evaluated among caregivers by comparing
pre- and post-test scores, and the significance was tested by using
information from medical professionals. Both groups (study and
the chi-square test (Table 2).
control groups) were comparable in terms of their base-line The results showed that at pre-test level, a majority [study =
characteristics (Table 1). 161 (92.0%) and control = 175 (100%)] had an inadequate level of
knowledge. At post-test-1, a majority of the study [142 (81.1%)]
Intervention effect group participants moved from the inadequate to adequate
knowledge level, but control group participants remained at in-
The intervention effect was tested statistically by using inadequate knowledge (85.1%). These differences were significant
ferential statistical tests, i.e. chi-square, t-test and ANOVA. at a 0.001 level (χ2 = 291.84, df = 2). At post-test-2, the knowledge
level of all the participants in the study group [n = 175(100%)] value (t = 55.1) is significant at a p < 0.01 level. The obtained
moved to adequate level, while the knowledge level of a majority t-test value at pre-test and post-test-1 is (t = -33.77) is significant
[n = 147 (84.0%)] of control group participants remained at an at a level of p < 0.01. The obtained t-test value at pre-test and
inadequate level. The obtained chi-square value (χ2 = 350.000, df post-test-2 is (-34.48) is significant at a level of p < 0.01. The
= 2, p-value = 0.001**) is significant at the level of p < 0.01. compared scores of pre-test, post-test-1, post-test 2, mean, SD,
The effectiveness of psycho-education on the knowledge level df, t-test values in the study and control groups prove the sig-
regarding schizophrenia among caregivers of patients with schizo- nificance of psycho-educational intervention on imparting the
phrenia by comparing pre-test, post-test-1 and post-test-2 scores
knowledge level among study group caregiver compared with
and significance level was tested by using the t-test (Table 3).
control group caregiver knowledge.
The mean and SD at pre-test are (mean = 22.93, SD = 17.03)
(mean = 14.95, SD = 13.75), respectively, in the study and con-
trol groups. The t-test value (t = 4.83) at post-test-1 mean and Effectiveness of psycho-education on caregiver
SD are (mean = 85.90, SD = 9.51) (mean = 30.01, SD = 14.25), burden level
respectively, in the study and control group. The t-test value
(t = 43.16) is significant at a p < 0.01 level. At post-test-2, the Comparison of the level of caregiver burden before and af-
mean and SD are (mean = 97.94, SD = 4.41) (mean = 38.40, SD ter psycho-education at pre-test, post-test-1 and post-test-2 and
= 13.62), respectively, in the study and control group. The t-test significance was tested by using the chi-square test (Table 4).
Table 2. Comparison of knowledge level scores after psycho-education for the study group and control group
Levels of knowledge Study group % Control group % Chi-square Df p
n = 175 n = 175
Pre-test
Inadequate level 161 92.0 175 100.0 14.59 1 0.001
Moderate level 14 8.0 0 0.0
Adequate level 0 0.0 0 0.0
Post-test-1
Inadequate level 0 0.0 149 85.1 291.84 2 0.001**
Post-test-2
Inadequate level 0 0.0 147 84.0 350.00 2 0.001**
Total 175 100.0 175 100.0
Table 3. Significance of findings on knowledge level on effectiveness of psycho-education, n = 175

Variable Group Mean SD t p
Pre-test study group 22.93 17.03 4.83 0.001
control group 14.95 13.75
Post-test-1 study group 85.90 9.51 43.16 0.001**
Post-test-2 study group 97.94 4.41 55.1 0.001**
Pre-test – Post-test-1 study group -62.97 16.91 -33.77 0.001**
control group -15.06 8.13
Pre-test – Post-test-2 study group -75.02 16.46 -34.48 0.001**
control group -23.45 10.98

** 0.01.
Table 4. Comparison of burden levels between study and control group subjects after psycho-education
Levels of burden Study group % Control group % Chi-square df p
n = 175 n = 175
Pre-test
Low level 0 0.0 0 0.0 70.13 1 0.001
Average level 67 38.3 4 2.3
High level 108 61.7 171 97.7
Post-test-1
Low level 115 65.7 0 0.0 277.45 2 0.001**
High level 0 0.0 149 85.1
Table 4. Comparison of burden levels between study and control group subjects after psycho-education
Levels of burden Study group % Control group % Chi-square df p
n = 175 n = 175
Post-test-2
Low level 165 94.3 0 0.0 314.77 2 0.001**
High level 0 0.0 101 57.7
Total 175 100.0 175 100.0
Table 5. Comparison of burden levels between study and control group subjects after psycho-education, n = 175
Variable Group Mean SD t p
Pre-test study group 82.37 10.40 -6.31 0.001
Post-test-1 study group 49.13 8.28 -39.48 0.001**

Post-test-2 study group 40.86 6.27 -49.06 0.001**
Pre-test – Post-test-1 study group 33.24 4.97 65.48 0.001**
Pre-test – Post-test-2 study group 41.51 7.79 47.95 0.001**
Table 6. Group comparison of caregiver burden and knowledge across the time points
Time of assess- Study group Control group Time effect Group effect Time X group effect
ment mean (SD) mean (SD)
Caregiver burden
Pre-test 49.42 (6.23) 52.97 (4.05) F = 4,786.7 F = 1,046.24 F = 1,940.01
Post-test-1 29.48 (4.96) 49.64 (4.57) p < 0.001 p < 0.001 p < 0.001
(1st month) partial eta squared = 0.93 partial eta squared = 0.75 partial eta squared = 0.848
Post-test-2 24.51 (3.76) 46.85 (4.71)
(3rd month)
Caregivers knowledge
Pre-test 5.73 (4.26) 3.74 (3.44) F = 3,179.88 F = 1,306.06 F = 974.91
p < 0.001 p < 0.001 p < 0.001
Post-test-1 21.47 (2.38) 7.50 (3.56) partial eta squared = 0.90 partial eta squared = 0.789 partial eta squared = 0.737
(1st month)
Post-test-1 24.48 (1.10) 9.6 (3.40)
(3rd month)
The analyzed data revealed that at pre-test, a major- the obtained t-test value (t = -39.48, and p = 0.001) and also
ity of study group [n = 108 (61.7%)] and control group [n = with post-test-2 values, mean, SD (mean = 40.86 and SD = 6.27)
171(97.7%)] participants had a high level of burden. At post- of the study group (mean = 78.10 and SD = 7.85) of the control
test-1, the majority of the caregivers n = 115(65.7%) in the study group and the obtained t-test value (t = -49.06) with significance
group showed a reduction in burden level compared to control at a level of p < 0.01. At post-test-1, there was a statistically sig-
group subjects. The obtained chi-square value (χ2 = 277.45, df nificant reduction in the burden level of study group subjects
= 2, p-value = 0.001**) was significant at a p < 0.01 level. At compared with control group subjects (t = -39.48, p = 0.001). At
post-test-2, the majority of subjects in the study group [n = 165 post-test-2, there was also a statistically significant reduction in
(94.3%)] showed lower levels of burden compared to control the burden level among study group participants compared to
group subjects. The obtained chi-square value (χ2 = 314.77, control group participants (t = 47.95, p = 0.001). The compared
df = 2, p-value = 0.001**) is significant at a p < 0.01 level. scores of pre-test, post-test-1, post-test-2, mean, SD, df and
The effectiveness of psycho-education on caregivers, bur- t-test values in the study and control groups proves the signifi-
den level among caregivers of patients with schizophrenia by cance of psycho-educational intervention on reducing the bur-
comparing pre-test, post-test-1 and post-test-2 scores and sig- den level among study group caregivers compared with control
nificance level was tested by using the t-test (Table 5). group caregivers.
The results of the pre-test, mean and SD (mean = 82.37 Repeated measures of ANOVA were conducted to verify the
and SD = 10.40) of the study group and (mean = 88.29 and changes in the outcome variables from baseline to the three-
SD = 6.75) of the control group and the obtained t-test value month follow-up (Table 6).
(t = -6.31, and p = 0.001) were compared with the post-test-1 Repeated measures of ANOVA were conducted to verify
values, mean and SD (mean = 49.13 and SD = 8.28) of the study changes in the outcome variables from baseline to the three-
group and (mean = 82.73 and SD = 7.63) of the control group, month follow-up. There were significant psycho-education ef-
fects in all of the outcome variables between the two groups. is effective in increasing their knowledge about schizophrenia,
Compared with the control group, the study group showed a sta- as well as reducing their burden regarding the care of their
tistically significant decrease in caregiver burden (F = 1,940.01, relatives. The study results also note that the majority of the
p < 0.001, partial eta squared = 0.848) and a statistically signifi- caregivers showed a high level of burden, both in the study and
cant increases in caregiver knowledge (F = 974.91, p < 0.001, par- control groups, before implementing psycho-education to the
tial eta squared = 0.737) over the three-month interval. study group. Finally, the study results identified the need of psy-
cho-education for caregivers to reduce their burden level. The
study highlighted the importance of setting targets for improv-
Discussion ing the functionality of patients in the design and implementa-
tion of rehabilitation and support programs to the caregivers of
Psycho-educational interventions may improve caregiv- patients with schizophrenia. While supporting earlier research
ers’ knowledge of schizophrenia and have a positive impact on recommendations, the present study has attempted to prove
caregivers’ burden level. Many studies thus far have shown that the importance of psycho-educational intervention as one type
these interventions may improve patients’ and caregivers’ out-
of support program for caregivers of patients with schizophre-
comes, but the quality of included randomized controlled trials
nia. In addition to this, there were limited studies focusing on
is poor, and it is difficult to draw firm conclusions as to the ef-
the Indian population. Caregiver education, which proved effec-
fectiveness of such interventions on patients’ and primary care-
tive in other countries, was recommended for application with-
givers’ outcomes, hence the present study intended to evaluate
in the Indian population. Therefore, it was important to test the
the efficacy of psycho-education on knowledge regarding schizo-
efficacy of psycho-education in improving the knowledge about
phrenia and caregiver burden among caregivers of patients
this illness and the ability to reduce the level of burden among
with schizophrenia. In order to achieve the objectives of the
caregivers of patients with schizophrenia. The findings of the
randomized controlled trial, a pre-test, post-test control group
present study have proved the effectiveness of psycho-educa-
as an experimental approach was adapted. The participants
tion on caregivers of patients with schizophrenia. This study has
were randomly assigned to either a study or control group via
provided strong evidence that psychiatric nurses can effectively
a computer-generated random sequence of numbers. The data
implement psycho-education to caregivers and also shows the
was collected with the help of a structured interview schedule
importance of a nurse’s role as a psycho-educator in the mental
of a knowledge assessment questionnaire and a burden assess-
health settings.
ment schedule for 350 caregivers of patients with schizophrenia
who were selected for the study. On the whole, subjects in study
group showed a marked improvement in knowledge scores and
a reduction in burden scores in two follow-ups compared to the The study was limited to caregivers of patients with schizo-
control group which did not receive any psycho-education. This phrenia, so, the study results have limitation in generalization
justifies the efficacy of psycho-education imparting knowledge to other types of the psychiatric conditions, and the long-term
regarding schizophrenia and burden reduction among caregiv- effects could also not be established due to the time constraint.
ers of patients with schizophrenia. The findings of the present
study are in accordance with earlier research studies [20–25],
which have supported that psycho-educational interventions, Conclusions
along with routine treatment, are much more beneficial to the
caregivers of patients with schizophrenia in order to take appro- Psycho-education interventions implemented by psychi-
priate care of their relatives and in reducing their burden level. atric nurses have statistically and significantly increased the
The few studies that were conducted in India so far either knowledge level of caregivers regarding schizophrenia and also
mainly focused on the relationship between first-treatment reduced the caregiver’s burden level among the study group
contacts, supernatural beliefs in caregivers of patients with caregivers compared to control group caregivers, who received
schizophrenia or religious and traditional modes of interven- routine care of the hospital. Based on the findings of the study,
tion, which are still widely practiced, especially in rural areas structured psycho-educational interventions should be consid-
where mental health services are almost non exist. The present ered as an integral component of care to patients with schizo-
study attempted to investigate caregivers’ knowledge on the as- phrenia. The study recommends that mental health settings
pect of the disease and management based on this. Psycho-ed- should compulsorily adapt psycho-education units that specifi-
ucation was provided and tested for effectiveness in the aspect cally function to impart knowledge on mental illnesses to the
of a gain in knowledge level regarding schizophrenia. An earlier relatives and patients who come for treatment. Authorities can
study also supports the present study results that psycho-edu- make available information brochures about mental illnesses to
cational intervention is effective in improving relatives’ knowl- the public, so as to help them in coping better with these ill-
edge about schizophrenia and reducing re-hospitalization. This nesses.
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Tables: 6
Figures: 1
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Sunanda Govinder Thimmajja, MSc(N), PhD, RN, Assoc. Prof.
Department of Psychiatric Nursing
Dharwad Institute of Mental Health and Neurosciences
Belagavi Road, Dharwad 580008
India
Tel.: 9611814496
E-mail: amogh_aniketh@yahoo.com
ISSN 1734-3402, eISSN 2449-8580

Misconceptions about sexual intercourse during pregnancy:

cognitive-behavioral counseling in prenatal care
Maryam Kheiri1, A–G, Katayon Vakilian2, A, D, E
ORCID iD: 0000-0002-6035-0796
1
Nursing and Midwifery School, Arak University of Medical Sciences, Arak, Iran
2
Medical School, Arak University of Medical Sciences, Arak, Iran
Summary Background. The fears, concerns, and negative attitudes of pregnant women towards sex during pregnancy can have
a negative impact on the sexual relationship and sexual performance of couples.
Objectives. We aimed to determine the effects of cognitive-behavioral counseling on misconceptions about sexual intercourse during
pregnancy in pregnant women.
Material and methods. In this randomized educational study, five clinics were randomly selected in Arak, Iran. A total of 20 pregnant
women who met the inclusion criteria were selected from each clinic. The Misconceptions about Sexual Intercourse during Pregnancy
Questionnaire (MSIP-Q) was completed after written informed consent. Finally, twenty-two women with the lowest scores on the
MSIP-Q were selected. Eleven subjects were allocated to the intervention group (cognitive-behavioral counseling), while eleven sub-
jects were assigned to the control group. The questionnaire was also completed by the participants over a three-month interval. For
statistical analysis, descriptive and inferential statistics (student’s t-test, paired t-test and Fisher exact test) were calculated using SPSS
software.
Results. The mean MSIP-Q score was 77.81 ± 10.03 in the intervention group and 71.27 ± 8.29 in the control group before the inter-
vention; no significant difference was found between the groups. On the other hand, the mean MSIP-Q score was 113.3 ± 11.16 in the
intervention group and 76.90 ± 19.07 in the control group following cognitive-behavioral counseling; a significant difference was found
between the two groups (p < 0.001). Based on the findings, no significant difference was reported in the intervention group in the
three-month follow-up; in fact, the effects of training remained stable.
Conclusions. This study showed that there are misconceptions about vaginal intercourse during pregnancy in Iranian women. There-
fore, providing sexual health services and training during pregnancy are necessary at health clinics.
Key words: counseling, pregnancy, women.
Kheiri M, Vakilian K. Misconceptions about sexual intercourse during pregnancy: cognitive-behavioral counseling in prenatal care. Fam
Med Prim Care Rev 2019; 21(2): 112–116, doi: https://doi.org/10.5114/fmpcr.2019.84545.
Background extramarital relations during pregnancy or sexual deviation (e.g.

masturbation, oral sex and anal sex) [1, 2, 8]. Sexual health edu-
Past studies show that most sexual problems during this cation can play a positive role in preventing some of the nega-
period are rooted in the couple’s wrong attitudes, misconcep- tive consequences of sexual activity during pregnancy and can
tions and misunderstandings about the physical and emotional produce positive results, such as a stronger marital relationship,
changes during pregnancy [1, 2]. Sexual and marital relations pleasurable sexual relations and improved confidence and con-
are known to change during pregnancy due to numerous physi- scious decision-making on both personal and interpersonal lev-
cal and psychological transformations. Physiological and ana- els [9]. Since sexual desire and performance are part of pregnant
tomical changes, such as breast tenderness or growth of the women’s health, efforts should be made to correct the negative
abdomen can decrease sexual desire. Psychological factors, attitudes towards sex during pregnancy. Therefore, further iden-
such as changes in women’s mental body image, loss of physi- tification and elimination of dysfunctional attitudes in pregnant
cal attraction to the partner and fear of adverse situations (e.g., women seem necessary for improving their sexual health.
abortion, fetal injury and premature labor) also effect of sexual
intercourse. Negative feelings about sexual intercourse during Objectives
pregnancy can either deepen the marital relationship or lead
to a couple’s separation [3, 4]. On the other hand, according In this study, we aimed to analyze the effects of cognitive-
to published studies, if couples have pleasurable sexual inter- -behavioral counseling on pregnant women’s misconceptions
course during pregnancy, their communication and behaviors about sexual intercourse during pregnancy.
will improve after the infant’s birth [4–7]. Although pregnancy
is an important stage in women’s lives and women need more Material and methods
emotional support during this period, a couple’s in adequate in-
formation about sexual intercourse during pregnancy and their Design and settings
negative attitude towards sexual issues in this period can cause
some problems. These problems include reduced intimacy, The present randomized interventional study was carried
sexual intercourse and libido between the couple, resulting in out in Arak, Iran, in the winter of 2014.
M. Kheiri, K. Vakilian • Misconceptions about sexual intercourse during pregnancy 113
This study was approved under the ethical research num- ing verbal communication, Q&A sessions, photos, videos, Pow-
ber: 93-174-14. erPoint presentations and pamphlets; additionally, a training
manual was given to the participants. The content of the train-
Participants and study design ing sessions is described in Table 1.
The control group received no counseling except for routine
The study population consisted of pregnant women refer- prenatal care by health care workers. After the end of the coun-
ring to health clinics in Arak. seling sessions, the post-test questionnaire on sexual attitude
The inclusion criteria were as follows: was completed by the intervention and control groups, and the
1) no or only one instance of intercourse within 8 weeks MSIP-Q was completed again within a three-month interval by
after pregnancy; pregnant women in the control and intervention groups.
2) no history of untreated sexual problems;
3) no drug addiction; Measure
4) no use of medications affecting the sexual response;
5) absence of sexual restrictions due to medical reasons; The Misconceptions about Sexual Intercourse during Preg-
6) no adverse events over the past 3 months; nancy-Questionnaire (MSIP-Q; 36 questions) was prepared by
7) living with a permanent partner; researchers. It contained two sections; one about demographic
features and the second about misconceptions. A panel consist-
8) intermediate-level education (minimum);
ing of 10 experts in fields of psychology, psychiatry, midwifery
9) age range of 18–35 years;
and gynecology evaluated the content validity of the question-
10) first pregnancy;
naire. The content validity of the scale was evaluated using both
11) gestational age of less than 12 weeks.
qualitative and quantitative methods. The content validity ratio
If the subject had a complicated pregnancy for any reason or
(CVR) and content validity index (CVI) were estimated at 0.62
was unwilling to continue intervention, she was excluded from
and 0.79, respectively. To test the reliability of the question-
the study.
naire, Cronbach’s alpha was also measured (α = 0.86).
Five health clinics in Arak were randomly selected via single-
-stage cluster sampling. In every clinic, 20 pregnant women (total:
100 pregnant women) who met the inclusion criteria were given Statistical analysis
a questionnaire, known as the Misconceptions about Sexual Inter-
The normal distribution of the data related to the indicators
course during Pregnancy-Questionnaire (MSIP-Q; 36 questions).
was assessed, and when the parametric conditions were met,
The researcher in individual interviews with pregnant wom-
t-test and paired t-test were used. The Fisher exact test was also
en obtained a written consent form from eligible subjects will-
used for some demographic variables, using SPSS version 20. In
ing to participate in the study. After providing an explanation
this study, a p-value less than 0.05 was considered statistically
on how to complete the questionnaire, 22 participants who
significant.
obtained the lowest scores on the questionnaires (score: 0-72)
were selected; it should be noted that lower scores indicated
misconceptions about intercourse during pregnancy. They were Results
randomly assigned to 2 groups “A” (11) and “B” (11) by random
blocks. The blocks were ordered and placed in a sealed packet. In order to determine whether the two groups were homog-
Cognitive-behavioral counseling sessions were held weekly in enous in terms of demographic characteristics, the subjects’ his-
eight 90-min sessions. The intervention was implemented us- tory of reproductive/sexual issues was reviewed (Table 2).
Table 1. Content of cognitive-behavioral sessions about women’s misconceptions about sex during pregnancy
Sessions
1 Introduction
Purposes: 1) introducing the participants to each other; 2) attracting the subjects’ cooperation and gaining their confidence;
3) conveying the importance of education to the subjects; 4) specifying the goals of group training; and 5) describing the out-
lines of the meetings for the group members.
2 Does sexual intercourse during pregnancy cause damage to the fetus?
Purposes: 1) being familiarized with the female anatomy; 2) being familiarized with the male anatomy; and 3) introduction to
the female anatomy during pregnancy (e.g. how the fetus grows and what factors influence the safety of the fetus).
3 Does sexual intercourse during pregnancy cause damage to the mother herself?
Purposes: 1) being familiarized with the physiological changes during pregnancy.
4 Is sexual intercourse a sin during pregnancy?

Purposes: 1) overcoming the negative attitudes of pregnant women towards sexual intercourse during pregnancy.
5 Does sexual intercourse during pregnancy improve the mental health of pregnant women?
Purposes: 1) defining mental health; 2) learning about common mental problems during pregnancy; 3) identifying the role
of sexual intercourse in the maintenance and promotion of mental health; 4) introducing the role of sex during pregnancy in
relieving anxiety and psychological perturbations; and 5) establishing the role of sex during pregnancy in improving mental
health and muscle relaxation.
6 Is sexual intercourse enjoyable during pregnancy?
Purposes: 1) learning about the sexual response cycle; 2) learning about sexual disorders and treatments; 3) definition of
sexual pleasure; 4) learning about sensitive and erogenous zones in men and women; and 5) discussing pregnant women’s
mental image of their body.
7 Is sexual intercourse difficult during pregnancy?
Purposes: 1) learning about the common problems during pregnancy and the available treatment options; and 2) providing
training on all sexual positions during pregnancy.
8 Investigating the progress of pregnant women and reassessing their attitudes.
Purposes: 1) reviewing and emphasizing the content of sessions and topics discussed in the past seven weeks.
114 M. Kheiri, K. Vakilian • Misconceptions about sexual intercourse during pregnancy
Table 2. Comparison of demographic information and reproductive/sexual history in the intervention and control groups
Qualitative variables Intervention group Control group *p
n (%) n (%)
Mother’s education
secondary school 3 (27.3) 2 (18.2)
1.00
high school 5 (45.4) 6 (54.7)
academic education 3 (27.3) 3 (27.3)
Spouse’s education
secondary school 4 (36.4) 1 (9.1)
0.161
high school 4 (36.4) 9 (81.8)
academic education 3 (27.2) 1 (9.1)
Mother’s occupation
housewife 8 (72.7) 9 (81.8) 1.00
employee/student 3 (27.3) 2 (18.2)
Spouse’s occupation 3 (27.3) 5 (45.5)
0.659
employee/worker 8 (72.7) 6 (54.5)
Marriage type 6 (54.5) 8 (9.1)
family acquaintance 3 (27.3) 2 (18.2) 0.708
pre-marital relationship 2 (18.2) 1 (9.1)
History of sexual relationship training
yes 4 (36.4) 3(27.3) 1.00
no 7 (63.6) 8 (72.8)
Sexual information sources
books 8 (72.8) 6 (54.5)
family physician 1 (9.1) 2 (18.2) 0.161
radio and tv 0 3 (27.3)
others 2 (18.2) 0
Quantitative variables Intervention group Control group ±p
Mean ± SD Mean ± SD
Mother’s age 22.72 ± 3.95 25.81 ± 3.48 0.135
Duration of marriage (years) 3.54 ± 3.23 5.36 ± 3.41 0.215
Income status (1,000,000 R) 8.68 ± 2.79 8.63 ± 1.28 0.961
Gravid 1.18 ± 0.40 1.27 ± 0.46 0.631
Number of living children 0.18 ± 0.40 0.27 ± 0.46 0.642
± t-test; * Fisher exact test.
Table 3. Comparison of the mean scores of sexual attitude domains after training in the intervention and control groups
Groups Intervention Control *p
domains Mean SD Mean SD
1. Does sexual intercourse during pregnancy cause damage to the fetus? 21.96 2.28 13.59 5.46 0.001
2. Does sexual intercourse during pregnancy cause damage to the mother herself? 13.59 2.69 11.34 3.85 0.001
3. Is sexual intercourse a sin during pregnancy? 18.45 2.20 14.25 4.86 0.008
4. Does sexual intercourse during pregnancy increase the mental health of preg- 18.81 2.99 16.96 3.84 0.230
nant women?
5. Is sexual intercourse enjoyable during pregnancy? 14.16 2.89 12.43 3.64 0.232
6. Is sexual intercourse difficult during pregnancy? 16.34 3.72 8.15 2.75 0.001
Total MSIP-Q score (after the last session) ± 113.36 11.16 76.72 19.07 0.001
Total MSIP-Q score in the three-month follow-up ± 111.73 10.25 69.90 17.63 0.001
After education and three-month follow-up ± p = 0.480
* t-test; ± t2 = 0.48.
Comparison of the two groups in terms of demographic the two groups (p < 0.001), except for two domains, i.e. “sexual
information and reproductive/sexual history showed that they intercourse during pregnancy increases the mental health of
were similar to each other, and there was no significant differ- pregnant women” and “sexual intercourse is enjoyable during
ence between the groups (p > 0.05). pregnancy” (Table 3). The total average MSIP-Q scores were also
In this study, the attitude of pregnant women was catego- significant between the two groups after eight weekly sessions
rized into six domains. Each domain was compared between (p < 0.001). In other words, pregnant women’s misconceptions
the intervention and control groups. Following counseling, all towards sexual intercourse were lower during pregnancy in the
domains of sexual attitude were significantly different between intervention group.
M. Kheiri, K. Vakilian • Misconceptions about sexual intercourse during pregnancy 115
Three months later, sexual misconceptions were re-evalu- that pregnant women's attitude towards sexual activity origi-
ated in both groups. The frequency of coitus was also assessed nates from misconceptions rooted in their misinformation
after three months. The results showed no significant difference [14]. Vakilian et al., in a randomized clinical trial study on 100
in the intervention group after the three-month follow-up, and pregnant women, showed that sexual counseling during preg-
the effect of educational intervention was found to be stable nancy, whereas the control group increased sexual function
(p = 0.480) (Table 3). The mean coitus was also 4.6 ± 1.76 and during pregnancy. They used a cognitive approach for improv-
2.4 ± 1.14, respectively, in the counseling and control groups ing the misbelieves of pregnant women [4]. Contrary to this,
(p = 0.03). Wannakosit and Phupong didn’t report any improvement in
sexual function during education compared to those of the
control group [15]. A systematic review in 56 studies showed
Discussion that couples postpone vaginal intercourse eight weeks after
childbirth and increased their efforts in other sexual behaviors
The present study showed that counseling corrected mis- [16]. A qualitative study on Taiwanese women pointed towards
conceptions about intercourse during pregnancy, such as the a negative experience during vaginal sex, such as dyspareunia,
fear of harm to the fetus, fear of harm to the mother, the sinful uterine discomfort, dry vaginal mucosa, pain in the pelvis and
nature of sex during pregnancy and stress during sexual inter- fatigue [17]. Vakilian et al. pointed out that counseling during
course. pregnancy plays an important role in decreasing the discomfort
A study by Bayrami et al. showed that fear of harm to the of sexual intercourse during pregnancy [4].
fetus and infection was the most common problem, and sexual Today, social and cultural issues, together with inadequate
desire and activity was reduced to 1.61% from 6.58% during sexual training by the healthcare system, are proposed as the
pregnancy in comparison with the pre-pregnancy period [10]. main obstacles against the promotion of knowledge and posi-
In addition, a study conducted by Naim and Bhutton pregnant tive attitudes towards sexual health.
women’s sexual activity showed that 45.4% of the subjects be-
lieved that intercourse is harmful to the fetus, and 22.7% be-
lieved that sexual activity leads to abortion [11]. Conclusions
Undoubtedly, the pattern of changes in sexual activity dur-
ing pregnancy is influenced by misbeliefs and misconceptions This study showed that there are misconceptions about vag-
regarding physical and psychological changes during this period inal intercourse during pregnancy in Iranian women. Therefore,
[8]. Fabamwo and Akinola showed that the most common rea- providing sexual health services and training during pregnancy
sons for abstaining from sex were fear of compilations (35.3%), are necessary at health clinics. In addition, there is a major need
17.6% did not appeal to them, and 8.8% said it is too painful [12]. for providing proper consultation for pregnant women in order
On the other hand, the findings in this study showed a posi- to improve their physical and emotional compliance with chang-
tive role of education in increasing the chance of intercourse es during pregnancy and increase a couple’s sexual knowledge
after three months' education. Pauleta et al. reported that when overcoming their negative attitudes.
13.9% of couples ceased coitus during pregnancy in Taiwan. In
this article, variations in sexual activity, such as manual sex, anal Acknowledgments. This study was extracted from a Mas-
intercourse and coital adjustments were made by couples [13]. ter’s thesis of the Arak University of Medical Sciences (ethical
The pattern of changes in sexual activity during pregnancy code: 93-174-14). Hereby, we would like to thank the research
was found to be related to misconceptions about physical and deputy of the Faculty of Nursing and Midwifery and the Arak
psychological changes during this period. The results of the University of Medical Sciences for the scientific and ethical ap-
mentioned studies, as well as the present research, showed proval of the study and their financial support.
Source of funding: This study was financially supported by the deputy of research of Arak University of Medical Sciences, Arak, Iran.
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Tables: 3
Figures: 0
References: 17
Reviewed: 5.11.2018

Katayon Vakilian, PhD, Assoc. Prof.
Peyambare Azam Campus
Arak University of Medical Sciences
Sardasht street
Arak
Iran
Tel.: 08634173505
E-mail: dr.kvakilian@arakmu.ac.ir
ISSN 1734-3402, eISSN 2449-8580

The effect of hypoxia on exercise tolerance in individuals

after acute coronary syndrome treated with angioplasty
combined with coronary stent implantation – pilot studies
Agata Nowak1, A, B, D–F, Cezary Kucio1, 2, A, D, Zbigniew Nowak1, A, B, D, E, Thomas Küpper3, D, E
ORCID iD: 0000-0002-7083-3185
1
Department of Physiotherapy at the Jerzy Kukuczka’s Academy of Physical Education in Katowice, Poland
2
Multispecialty Hospital in Jaworzno, Poland
3
RTWH Aachen University, Aachen, Deutschland
Summary Background. Currently, there is little documented research evaluating the effect of a high-mountain environment on pa-
tients with ischemic heart disease.
Objectives. The main aim of the study was to assess the effect of normobaric hypoxia on exercise tolerance in patients diagnosed with
stable coronary disease.
Material and methods. 22 men aged 37 to 72 (55.68 ± 9.86 years of age) with coronary disease were qualified. In the pre-study, in
a normobaric normoxia environment, each patient underwent: resting ECG, spiroergometric test using a treadmill, laboratory tests
(gasometry, lactic acid concentration). The patients stayed in the cabinet for 3 hours at the: 1) normoxia, 2) hypoxia (2000 m a.s.l),
3) hypoxia (3000 m a.s.l.) levels. After the 3-hour period, patients underwent a spiroergometric exercise tolerance test combined with
a blood lactic acid concentration test. Venous blood and capillary blood were drawn for gasometry testing purposes.
Results. Under 2000 and 3000 m hypoxia noted a significantly shorter duration of the exercise test, distance travelled and MET values.
An increase in resting blood pH and a decrease of resting and peak pCO2 and pO2 were observed.
Conclusions. As a result of a 3-hour exposure to normobaric hypoxia, the exercise tolerance of patients after acute coronary syn-
drome treated with angioplasty combined with coronary stent implantation decreases. There is no clear information for patients as to
whether high mountain conditions are safe for them. The presented research was a form of introduction to wider and more thorough
experiments that can result in practical information for patients.
Key words: coronary artery disease, hypoxia, angioplasty.
Nowak A, Kucio C, Nowak Z, Küpper T. The effect of hypoxia on exercise tolerance in individuals after acute coronary syndrome treated
with angioplasty combined with coronary stent implantation – pilot studies. Fam Med Prim Care Rev 2019; 21(2): 117–123, doi: https://
doi.org/10.5114/fmpcr.2019.84547.
Background progressing to any type of physical exercise, especially sports

and recreational activities [4–8]. Moreover, the UIAA Medical
Analysis of the existing research on the topic points to the Commission summarizes that patients with stable, well-con-
fact that there are very few documented studies evaluating the trolled CAD without residual ischemia who participate in unre-
effects of a high-mountain environment on patients with coro- stricted physical activity at sea level are probably safe to travel
nary disease. Due to the fact that increasingly more individuals up to 3,000 to 3,500 m with minimal increased risk. Information
decide to spend their free time skiing or mountain hiking, it is on the risks to those with CAD who ascend to altitudes above
to be accentuated that basic safety measures need be taken. 5,000 m is lacking, although there are plenty of anecdotal ex-
These measures apply especially to patients with cardiovascular amples of individuals with stable CAD performing well at these
altitudes [4]. It should be remembered that if an individual suf-
disease. Patients suffering from coronary disease constitute the
fering from coronary disease experiences any type of pain dur-
largest group of cardiovascular patients and therefore are at the
ing the exercise test, then surely this pain is also expected to
highest risk of reacting to temperature and air pressure chang-
occur after reaching even low altitudes, which disqualifies the
es related to altitude. A study conducted in the Alps in 2011
participant from activities in high-mountain environments [3,
showed that individuals with a history of stroke, hypertension
9–11]. It should also be mentioned that this limitation should
or coronary disease engaging in sport activities such as skiing
help the individual avoid visiting a moderate altitude just to
and high-mountain climbing were more likely to experience car-
enjoy scenery without significant physical activity [12, 13]. The
diac arrest while staying in a high-altitude environment [1–3]. It
altitude tolerance of such patients may be tested by breathing
was also suggested that staying at an altitude of 3,500 m a.s.l. in
hypoxic air at rest in well-supervised conditions (e.g. doctor’s
individuals with stable coronary disease and good exercise tol-
practice) [4].
erance, confirmed by an electrocardiographic stress test at sea
Modern interventional cardiology in combination with
level, does not pose a risk of sudden cardiac death [1–3]. Never-
a properly adjusted cardiac rehabilitation protocol enables most
theless, it was recommended that the patient undergoes a 3–5-
patients after acute coronary syndrome to undertake physical
-day adaptation period after reaching each new height before
118 A. Nowak et al. • The effect of hypoxia on exercise tolerance
exercise at a level of a healthy individual without major con- Table 1. Coronary angioplasty with stent implantation in study
traindications. Recommendations regarding physical exercise, participants after acute coronary syndrome
including the type of exercise, its intensity, frequency and work-
load for optimal safety of the patient, can be found in PTK and Artery Number of patients
ESC guidelines [14]. However, in the aforementioned guidelines, LM 5 (22.73%)
no indications can be found regarding staying in higher-tem- RCA 2 (9.1%)
perature and humid environments or in environments where LAD 8 (36.38%)
changes in temperature and air pressure occur, such as the Cx 3 (13.63%)
mountains. Information regarding this topic is of high priority D1 1 (4.54%)
and is more useful than indications regarding physical exercise OM1 1 (4.54%)
LAD + RCA 1 (4.54%)
alone. Physical training has already been widely discussed, and
OM1 + Cx 1 (4.54%)
its benefits on the cardiovascular system have been well proven
[15–17]. LM – left main coronary artery, RCA – right coronary artery, LAD – left
Is it therefore advisable for patients with ischemic heart anterior descending artery, CX – circumflex artery, D1 – first diagonal,
disease to visit the mountainside? Can patients after full revas- OM1 – first obtuse marginal.
cularization safely engage in skiing or trekking? Most recom-
mendations regarding staying at high altitudes for this group Inclusion criteria were:
of patients remain experimental and are not based on scien- • patients after acute coronary syndrome and angioplas-
tific evidence. There is a minor amount of reports, mainly from ty with stent implantation,
the late 1990s, including results of studies conducted directly • patients with stable coronary disease,
at high altitudes on a very limited number of cardiac patients • men aged 35–75 years,
[18–22]. So far, the most comprehensive survey and recom- • patients who underwent model A cardiac rehabilita-
mendations have been given by the Medical Commission of the tion at least 3 months after the occurrence of acute
Union Internationale des Associations d’Alpinisme – UIAA (In- coronary syndrome,
ternational Mountaineering and Climbing Federation) [4]. These • patients who gave their consent to partake in the study.
recommendations are as evidence-based as possible. Exclusion criteria were:
Despite the fact that the above-mentioned studies were • unstable coronary disease,
at a significant risk of complications, promising results were • chronic heart failure during periods of exacerbation,
obtained. Considering the fact that conducting this type of • resistant hypertension,
research requires adequate preparation and medical backup, • abnormal exercise test results,
such as using proper diagnostic equipment, selecting a suitable • peripheral arterial occlusive disease,
group of patients, as well as significant financial means due to • venous thromboemoblism,
travelling to mountainsides or constructing a hypoxic cabinet in • COPD,
• anemia,
order to conduct the study in a laboratory environment, amount
• disorders of locomotor system disabling the patient to
of reports on the topic is exiguous.
take the exercise test,
• lack of consent to partake in the study.
Objectives As a result of the above described method of enrolment,
22 patients with diagnosed and clinically documented coronary
Accordingly, the aim of the following study was to evalu- disease aged 37–72 (55.68 ± 9.86 years of age) were qualified
ate the effect of normobaric hypoxia on exercise tolerance in for the study. In the pre-study, in a normoxia environment, each
patients with coronary artery disease after acute coronary syn- patient underwent the following tests:
drome treated with coronary stent implantation. 1) resting ECG,
2) exercise test combined with spiroergometric test using
a treadmill in accordance with the traditional seven-
Material and methods -grade Bruce Protocol,
3) gasometric test.
The enrolment for the study took place at the AMED (no Each participant entered the hypoxia cabinet 3 times for
explanation for the abbreviation, as it is a proper name) facility a period of 3 hours. The testing took place at the Jerzy Kukucz-
in Katowice, in which the second (ambulatory) stage of cardiac ka’s Academy of Physical Education Cardiovascular Performance
rehabilitation of patients with coronary disease after acute cor- Testing Laboratory. The experiment was conducted in varying
onary syndrome treated with angioplasty combined with coro- oxygen pressure environments:
nary stent implantation was performed (Table 1). • normoxia (resembling the air pressure of 350 m a.s.l.,
To keep the potential risk for the volunteers as low as pos- as in Katowice),
sible, only patients with stable coronary disease treated with • hypoxia (resembling the air pressure of 2,000 m a.s.l.,
model A cardiac rehab (Table 2) were qualified for the experi- as on Kasprowy Wierch),
ment in accordance with the Cardiac Rehabilitation and Exercise • hypoxia resembling the air pressure of 3,000 m a.s.l.,
Physiology Section of the Polish Cardiac Society guidelines [23]. (as in selected tourist resorts in the Alps).
Cardiac rehabilitation of the participants was applied at least In accordance with the study protocol, the patients staying
3 months after acute coronary syndrome (OZW) episode. in the hypoxic cabinet were not informed about the air pressure
Table 2. Model A cardiac rehabilitation of patients with coronary disease

Model Risk Exercise Type of training Frequency Total time Intensity
tolerance
A low > 7 MET continuous endurance train- 5 days a week 90 minutes 60% to 80% of heart rate
> 100 W ing on a cycloergometer or a day reserve or 50% to 70% of
treadmill, resistance training, maximum heart rate
general fitness exercises
A. Nowak et al. • The effect of hypoxia on exercise tolerance 119
they were exposed to (single blind design). During the experi- • peak minute ventilation [VE],
ment, the participants were provided with an unlimited supply • resting and peak heartrate.
of still mineral water.
After the 3-hour cabinet experiment, each of the partici- Gasometric test and lactic acid concentration
pants underwent a spiroergometric exercise test (under hypoxia
conditions) with the use of a treadmill, combined with a blood In order to perform a blood gasometry and lactic acid test,
serum lactate concentration test. Moreover, arterialized capil- the nurse drew approximately 200 µl of blood from the finger-
lary samples (finger puncture) were drawn in order to perform tip. Test material for gasometry was collected in the hypoxia
gasometric lactic acid concentration tests. In order to ensure cabinet twice – the first time at rest and then after the exercise
the safety of the participants during the experiment, a medical tolerance test. The blood gasometry test was performed using
rescue team partook in the study. a Bayer Diagnostics Rapidlab284 device.
Exercise tolerance was evaluated with the use of an elec-
trocardiographic submaximal stress test, during which the tradi- Statistical analysis
tional seven-grade Bruce Protocol was applied.
In order to perform statistical analysis for the study, Open-
As established in the study protocol, the pharmacological
Office 4.0.1, StatSoft Statistica 10 and GraphPad Prism 6.07 soft-
treatment of patients qualified for the study was optimized and
ware were used. The Shapiro–Wilk test and histograms depict-
accordant with the guidelines for coronary disease manage-
ing frequency distribution of the studied variable were used in
ment (Table 3).
order to evaluate the compatibility of empirical distribution of
the studied variables. The homogeneousness of variances was
Table 3. Pharmacological treatment of male participants measured pre-analysis using the Brown–Forsyth test. The sta-
Type of medication Number tistical tools used for verifying the statistical hypotheses were:
of patients • parametric variance analysis with repetitive measure-
β-blockers 15 ments for variables the distribution of which is compat-
ible with normal distribution, and the variances of the
Clopidogrel 5 studied groups are homogenous,
Acetylsalicylicacid (ASA) 16 • Friedman’s non-parametric variance analysis with re-
Atorvastatin 2 petitive measurements for variables the distribution
α-blockers 1 of which is not compatible with normal distribution,
or the variances of the studied groups are not homog-
Vitamin K antagonists 4
enous.
Angiotensin II receptor blockers (ARB) 3 For statistically significant results suggesting that median
Metformin 3 changes in parameter values at varying altitudes differ, the post-
Calcium channel antagonists 2 -hoc Turkey’s test for variables of normal distribution and ho-
mogenous variances and the Dunn–Bonferroni test for variables
Angiotensin II converting enzyme inhibitors (ACEI) 8
exhibiting different than normal distribution and non-homoge-
Diuretics 3 nous variances were used. The accepted level of significance for
the verification of statistical hypotheses amounted to α = 0.05.
Permission of the Bioethics Committee No. 9/2014 at the The presented research lasted from April 2017 to the end
Jerzy Kukuczka’s Academy of Physical Education in Katowice was of the May 2017.
granted for conducting the study.
Results
Data acquisition
In both hypoxic and normoxic environments corresponding
During the spiroergometric exercise test, the following exer- to an altitude of 2,000 and 3,000 meters a.s.l., none of the pa-
cise tolerance values were assessed: tients suffering from coronary disease exhibited adverse symp-
• duration of trial [min], toms requiring the experiment to be aborted.
• distance travelled [m],
• metabolic equivalent [MET], Exercise tolerance
• peak oxygen consumption [VO2peak],
• peak oxygen consumption [VO2peak] per kilogram of In a hypoxic environment responding to an altitude of 2,000
bodyweight, and 3,000 meters a.s.l. (Table 4), in comparison to normoxia, pa-
Table 4. Spiroergometric test results (median ± standard deviation) in patients examined in normoxic and hypoxic environments
responding to altitudes of 2,000 and 3,000 meters a.s.l.
I II III p
Normoxia 350 Hypoxia 2000 Hypoxia 3000
(meters a.s.l. – Katowice) (meters a.s.l.) (meters a.s.l.)
X ± SD X ± SD X ± SD I vs II I vs III II vs III
Test duration [min] 10.70 ± 2.31 9.53 ± 1.72 9.31 ± 2.11 0.001 0.000 0.711
Distance [m] 589.03 ± 199.89 502.70 ± 171.25 467.61 ± 164.13 0.000 0.000 0.498
MET [ml/kg/min] 8.52 ± 1.80 7.10 ± 1.33 6.65 ± 1.27 0.000 0.000 0.034
VE [1/min] 81.92 ± 22.54 74.09 ± 21.29 72.80 ± 21.04 0.244 0.174 0.847
VO2peak [l/min] 2.51 ± 0.64 2.06 ± 0.52 1.86 ± 0.47 0.001 0.000 0.034
VO2peak/kg [ml/min/kg] 29.63 ± 6.44 26.27 ± 8.14 22.04 ± 4.91 0.029 0.000 0.042
Lactates 1 [mmol/l] 1.86 ± 0.77 1.97 ± 0.62 1.50 ± 0.41 0.588 0.059 0.064
Table 4. Spiroergometric test results (median ± standard deviation) in patients examined in normoxic and hypoxic environments
responding to altitudes of 2,000 and 3,000 meters a.s.l.
I II III p
Normoxia 350 Hypoxia 2000 Hypoxia 3000
Lactates 2 [mmol/l] 5.49 ± 2.47 5.30 ± 2.04 4.81 ± 2.09 0.786 0.322 0.432
HRrest [1/min] 69.86 ± 9.08 68.36 ± 8.35 68.27 ± 8.61 0.851 0.822 0.978
HRpeak [1/min] 139.68 ± 15.86 137.40 ± 11.30 134.77 ± 13.04 0.584 0.266 0.475
VE – minute ventilation, MET – metabolic equivalent, HRrest – resting heart rate, HRpeak – peak heart rate; 1 – at rest; 2 – at peak physical effort.
tients with coronary disease exhibited a statistically significant Discussion

decrease in exercise tolerance test duration, distance travelled,
MET values and VO2peak per kilogram of bodyweight. Addition- The evaluation of an organism’s reaction to progressively
ally, a statistically significant decrease in MET values and VO2peak increased physical effort is one of the most important elements
per kilogram of bodyweight was noted in hypoxia responding of cardiac rehabilitation diagnostics. Stimuli in the form of in-
to an altitude of 3,000 meters a.s.l. in comparison to hypoxia creasingly demanding physical exercise may incur various dis-
resembling a height of 2,000 meters a.s.l. However, no similar ease symptoms, such as early symptoms of heart failure, heart
differences were observed as far as exercise tolerance test dura- ischemia indicators or cardiac arrhythmia [23].
tion and distance travelled during the spiroergometric test are The comparison of exercise tolerance test results performed
concerned. in a normoxic environment of 350 meters a.s.l. (Katowice) and
No statistically significant changes in ventilation, resting and those performed in a hypoxic environment of 2,000 and 3,000
intra-workout lactate concentration, as well as resting and intra- meters a.s.l. resulted in various reactions of the participants’ or-
-workout heart rate, were observed (Table 4). ganism, adequate to the given circumstances. Resting heart rate
values, regardless of the air pressure in the cabinet, were similar.
Gasometry The above may have been a result of the applied pharmacologi-
cal therapy. As the altitude increases, the oxygen partial pressure
Blood pH values increased at a statistically significant man- – and therefore in the tissues of the body – is reduced, which
ner in the hypoxic environment responding to an altitudes of may cause decreased exercise tolerance, especially in patients
2,000 and 3,000 a.s.l. No statistically significant changes were with cardio-vascular disease [24]. Beyond the altitude of 1,500
observed in blood pH values between hypoxic environments meters a.s.l., peak exercise tolerance is reduced by 1% with each
of 2,000 meters a.s.l. in comparison to those of 3,000 meters 100 meters travelled [25–30]. The above thesis has also been
a.s.l. No statistically significant effects of hypoxic environments proven by proprietary research. During the exercise test, with
of 2,000 and 3,000 meters a.s.l. on peak physical effort blood each new altitude reached, the duration of the test, as well as
distance travelled, MET and peak oxygen uptake, dropped signifi-
pH values during the spiroergometric test were noted (Table 5).
cantly in comparison to the normoxic environment. An increase
No statistically significant effects of a hypoxic environment
in heart rate related to altitude is one of the organism’s reac-
of 2,000 meters a.s.l. on both resting and intra-workout pCO2
tions to reduced oxygen supply [31]. This phenomenon was also
values were observed. However, in the hypoxic environment of noted in proprietary studies – the patients reached the destined
3,000 meters a.s.l., a statistically significant decrease in both (submaximal) heart rate quicker with each new height above sea
resting and peak pCO2 values in comparison to normoxic and level. Although the differences were not statistically significant,
hypoxic environments of 2,000 meters a.s.l. were observed. the general tendency of the alterations was consistent with the
Resting and peak physical effort values of pO2 decreased sig- observations of other researchers [22, 31, 32].
nificantly in hypoxic environments of 2,000 and 3,000 meters Another observed parameter depicting the exercise toler-
a.s.l. Moreover, significantly lower resting and peak pO2 values ance level of a participant is peak oxygen uptake (VO2) during
were noted in the hypoxic environment of 3,000 meters a.s.l. as submaximal physical effort. At high altitudes, a gradual de-
compared to the environment responding to altitude of 2,000 crease in the human organisms’ oxygen uptake capability oc-
meters a.s.l. (Table 5). curs. In some individuals, this phenomenon can be observed
Table 5. Results of the gasometric test in patients observed in normoxic and hypoxic environments of 2,000 and 3,000 meters a.s.l.
(median ± SD)
I II III p
Normoxia 350 Hipoxia 2000 Hipoxia 3000
pH1 7.37 ± 0.03 7.40 ± 0.02 7.41 ± 0.01 0.001 0.001 0.288
pCO2 1 [mm Hg] 37.55 ± 4.38 37.17 ± 2.98 35.37 ± 3.02 0.744 0.018 0.004
pO2 1 [mm Hg] 69.20 ± 7.35 56.20 ± 4.95 51.26 ± 3.77 0.000 0.000 0.000
pH 2 7.30 ± 0.06 7.33 ± 0.05 7.31 ± 0.09 0.174 0.741 0.512
pCO2 2 [mm Hg] 35.20 ± 3.41 34.20 ± 2.88 32.75 ± 2.86 0.298 0.001 0.036
pO2 2 [mm Hg] 88.64 ± 13.80 72.43 ± 7.73 62.35 ± 7.62 0.000 0.000 0.000
1 – at rest; 2 – at peak physical effort.

even at low altitudes (circa 1,400–1,600 meters a.s.l.). Beyond tate concentration. The athletes presented lower blood lactate
the aforementioned heights, this effect occurs in a linear man- concentration levels in comparison to the control group (7.0
ner: circa 11% with each 1,000 meters a.s.l., while at 8,000, mmol/L and 5 mmol/L, respectively) [44]. The achieved results
peak oxygen uptake amounts only to 20% of the value occurring remain fundamentally in accordance with the results obtained
at sea level [33], beginning above the “threshold altitude” of by other authors conducting studies involving athletes [45, 46].
1,500 m [26–30] At moderate and high altitudes, anaerobic metabolism is acti-
In a study conducted on a group of skiers, a negative cor- vated during relatively less intensive activity.
relation was noted between muscle oxidative metabolism in- In proprietary studies, the only statistically significant dif-
dicators (mitochondrial density, intracellular lipid content) and ferences in blood lactate levels were noted during experi-
VO2max and maximum effort power indicators evaluated with the ments at altitudes of 2,000 and 3,000 meters above sea level.
use of a progressive exercise test in a hypoxic environment [34]. Participants of the study simultaneously took part in a cardiac
Other research aimed at explaining the causes of the decrease rehab program. Most of the patients also engaged in relatively
of VO2max in hypoxemic environment is of interest [35]. In pur- intense physical activity on their own (Nordic walking, cycling,
posefully induced conditions in a hypobaric-hypoxemic cabinet, vivid marching, one of the participants was even a parachute
the effect of various factors likely to impact exercise tolerance jumper) and remained professionally active. It is therefore sug-
with rising hypoxemia were studied. The performed analysis gested that a higher blood lactate concentration may have been
showed that parameters such as sea level VO2max value cause the result of physical activity undertaken a few hours before the
a significant decrease of VO2max in a hypoxemic environment. It testing.
was stated that the greater the initial VO2max level, the greater its Researches report mean resting values of 1.3 mmol/l
decline afterwards. The lactate threshold reached at sea level (± -0.74). a.s.l., while at 3,000 m, a tendency to higher concentra-
shows an inversed relation – the greater the initial value, the tions was measured (1.5 mmol/l (± -0.36; p = 0.0758)), and the
smaller the decline. This finding is somehow difficult to explain. increase was highly significant at 4,560 m (2.2 mmol/l (± -0.74;
The so-called “lactate paradox” can be excluded, since this ef- p = 0.0015)) [26]. It is suggested that individuals inhabiting
fect has been observed at extreme altitudes far beyond 7,000 m low or plain regions and planning to visit high-altitude terrains
only [36]. The indicator causing its decrease during exercise un- should develop at least some degree of adaptation through
til failure is hemoglobin oxygen saturation (SaO2) in hypoxemia; pre-exposure to a hypoxic environment corresponding to 1,500
as far as this indicator is concerned, the greater its reduction, meters a.s.l. This pre-exposure may be performed in a constant
the greater the decrease of VO2max [30]. manner, as well as by using the IHE method (Intermittent Hy-
In proprietary studies, VO2peak given as l/min and ml/min/ poxic Exposure) [47]. The IHE method was first introduced in the
/kg showed statistically significant changes between all levels studies on Finnish athletes as a means of utilizing the ability of
at which the studies were conducted. The achieved results the human organism to adapt to hypoxia without the need of
confirm the thesis that VO2max declines as oxygen pressure de- burdensome and costly travelling. According to these authors,
creases. Similar results were reached in other studies showing the degree of acclimatization incurred by this method is directly
a 7–9% decrease in VO2max with every 1,000 meters a.s.l. [37]. dependent on the altitude a.s.l., as well as the duration of the
A 19% drop in peak VO2max was noted in comparison to the ini- stay. As much as 1 to 2 days spent at an altitude of 2,200 meters
tial value at 540 meters a.s.l. It is to be accentuated that the a.s.l. or 1.5 to 4 hours exposure to a hypoxic environment (cabi-
methodology was similar in these studies in comparison to the net) equivalent to an altitude of 4,000 meters a.s.l. using the
proprietary studies: the experiments were conducted once, and IHE method causes the human respiratory system to adapt. Dur-
the patients’ exposure to a hypoxic environment was constant. ing the IHE procedure, patients remain in hypoxic rooms with
In turn, different results were reached in cases of exposing the reduced oxygen. The air is attenuated with nitrogen, filtrated
participant to a hypoxic environment in intervals [38]. or turned into a hypoxic gas mixture, which in turn resembles
It also needs to be noted that there are reports in which the circumstances equivalent to 2,500 to 3,500 meters a.s.l. An
no significant changes in oxygen uptake in comparison to initial increase in total mitochondrial density as result of consistent cy-
circumstances (normoxia) were noted [39–41]. Moreover, some cloergometric training in a hypoxic environment corresponding
authors achieved results where peak oxygen uptake increased to the height of 3,850 meters a.s.l. is observed [33]. The training
[38, 42]. Such disparities in study results were caused by the was performed for a total of 30 minutes a day, 5 days a week
choice of methodology, time of the patients’ exposure to a hy- for 6 weeks. Moreover, increases in maximal power and VO2max
poxic environment and physical effort intensity applied in a hy- were also noted. However, the latter might be the result of any
poxic environment. type of exercise in a sedentary collective.
During the patients’ stay in the hypoxic cabinet, lactate con- Peripheral blood gasometry was another studied param-
centration at rest, before the stress test and 4 minutes after the eter. Blood was drawn twice: at rest and at peak physical effort.
stress test was assessed. During intense physical exercise, sig- Significant changes were noted between resting blood pH in
nificant amounts of lactates are produced (except at extreme a normoxic environment of 2,000 and 3,000 meters a.s.l.
altitudes far above of 3,000 m, where our actual study was per- Proprietary research showed that resting and peak effort
formed (“lactate paradox”, see above)). Maintaining a produc- pO2 values decreased significantly in a hypoxic environment of
tive exercise metabolism relies on efficient transportation of the 2,000 and 3,000 meters a.s.l. Moreover, a significant decrease in
produced lactate and H+ ions [36]. A lower lactate concentration resting and peak effort pO2 values at an altitude of 3,000 meters
in working muscles reduces the feeling of fatigue and facilitates a.s.l. was noted in comparison to the measurements taken at
longer periods of physical effort. an altitude of 2,000 meters a.s.l. These results remain in accor-
According to reports, the ability to regulate pH levels (H+ ion dance with the aforementioned reports [49]. A significant de-
concentration) in muscle tissue depends on the amount of buff- crease in partial oxygen pressure was noted starting with an al-
ering alkali [43]. A higher level of buffering alkali may be a part titude of 1,500–2,000 meters a.s.l. and did not affect the health
of a fundamental exercise tolerance enhancing mechanism as of the studied group. Similar results were achieved in both the
a result of high-altitude training. A study aiming at evaluating control group and in the group of patients diagnosed with coro-
the effect of normobaric hypoxia on the Finnish national sprint nary disease [48].
team was conducted. It was observed that a 16- to 17-hour stay Results can be found in literature on the topic pointing to
in an environment of 2,200 meters a.s.l. causes raised blood pH a minor decrease of partial oxygen pressure in our study group.
levels. After leaving the cabinet, the members of the group, as The reason for such a result was the short duration of the stay
well as members of the control group, underwent exercise tol- in a hypoxic environment (lasting only 2.5 hours). The analo-
erance tests, which showed significant differences in blood lac- gous results pertained to the partial pressure of carbon diox-
ide (pCO2). The values decreased as the altitude a.s.l. increased Conclusions
[49].
As a result of a 3-hour exposure to normobaric hypoxia, the ex-
Limitations of the study ercise tolerance of patients after acute coronary syndrome treated
with angioplasty combined with coronary stent implantation de-
The presented research is only pilot studies. There is no as- creases. There is no clear information for patients as to whether
sessment of the effect on patients in other high-altitude condi- high mountain conditions are safe for them. The presented re-
tions, such as temperature or pressure. It is important to ex- search was a form of introduction to wider and more thorough
pand the research group in the future. experiments that can result in practical information for patients.
Source of funding: This work was developed under the research grant “Young Scientists”, financed by the Ministry of Science and Higher
Education in the year of 2015.
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Tables: 5
Figures: 0
References: 49
Accepted: 9.10.2018

Agata Nowak, PhD
Akademia Wychowania Fizycznego
im. Jerzego Kukuczki
ul. Mikołowska 72A
40-065 Katowice
Polska
Tel.: +48 501 773-925
E-mail: a.nowak88@gmail.com
ISSN 1734-3402, eISSN 2449-8580

Physical possibilities in the treatment of chronic abdominal

pain in patients with peritoneal adhesions
Jarosław Pasek1, 2, A, B, D–F, Michał Senejko2, A, C, D, F, Grzegorz Cieślar2, A–E
ORCID iD: 0000-0001-6181-337X
1
Institute of Physical Education Tourism and Physiotherapy, University of Jan Długosz in Częstochowa, Poland
2
Department of Internal Medicine, Angiology and Physical Medicine, School of Medicine with the Division
of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
Summary Background. The most intensive pains suffered by patients after surgical interventions are caused by post-operative peri-
toneal adhesions, which are incorrect connective tissue connections formed on or among internal organs and tissues in the abdominal
cavity. These adhesion-related pains are resistant to analgesic treatment and often persist for many years.
Objectives. In this trial, the estimation of the efficacy of combined treatment with the use of two variable magnetic field related thera-
peutic methods (magnetotherapy and magnetostimulation) in the treatment of 119 patients with chronic abdominal pains caused by
numerous post-operative peritoneal adhesions was performed.
Material and methods. 67 patients from the examined group were subjected to two series of 20 daily procedures of exposure to
variable magnetic fields in the form of magnetotherapy and magnetostimulation, while 52 patients from the comparison group were
subjected to sham exposure, during which no magnetic field was generated in the applicators. Prior to the therapeutic cycle and after
its completion, the assessment of pain intensity, with the use of the Visual Analogue Scale (VAS), and subjective estimation of quality
of life, by means of the EuroQol Scale, were performed.
Results. In patients from the examined group, a significant decrease in pain intensity, according to the VAS, and a significant improve-
ment of life quality level, on the EuroQol Scale, in comparison to initial values, was achieved (8.0 ± 1.1 vs 2.3 ± 1.0 points, and 30.2
± 14.1 vs 86.2 ± 8.5 points, respectively (p < 0.05); while in the control group, no statistically significant changes of the estimated pa-
rameters were observed.
Conclusions. Magnetotherapy and magnetostimulation are efficient therapeutic methods in the case of patients with long-lasting ab-
dominal pain related to peritoneal adhesions, enabling an improvement in their life quality (regardless of gender and age). Taking into
account that magnetotherapy and magnetostimulation are not applicable in primary care, family doctors should consider a consulta-
tion with a physical therapy specialist in order to prescribe a cycle of physical treatment with the use of these methods in the case of
such patients with drug-resistant abdominal pain caused by diagnosed postoperative peritoneal adhesions.
Key words: abdominal pain, magnetic fields, tissue adhesions, therapeutics.
Pasek J, Senejko M, Cieślar G. Physical possibilities in the treatment of chronic abdominal pain in patients with peritoneal adhesions.
Fam Med Prim Care Rev 2019; 21(2): 124–129, doi: https://doi.org/10.5114/fmpcr.2019.84548.
Background of these pains is often very difficult and requires the application
of various diagnostic methods, sometimes even repeated hos-
Post-operative adhesions are incorrect connective tissue pitalizations. This influences the economic aspect of treatment,
connections formed on or between internal organs and tissues which calls for even more attention nowadays. Taking into ac-
in the abdominal cavity. They occur in about 5–14% of surgi- count the high costs related to the treatment of these patients,
cal patients. Abdominal adhesions very frequently occur after incurred due to the necessity of performing numerous long-
operations executed in the lower part of the abdominal cavity -lasting, repeated surgeries, and the more frequent occurrence
(surgical interventions affecting intestines, laparoscopy, gyneco- of complications, among them the mechanical obstruction of
logical operations) [1]. Sometimes peritoneal adhesions do not intestines, the fact that the most serious late complications
cause any complications, yet in many cases, the presence of ad- of post-operative adhesions occur in 5% of patients, in recent
hesions causes persistent or recurrent abdominal pains. More- years, there have been increasingly interesting investigations of
over, post-operative adhesions located in the hypogastrium in the mechanisms of formation of adhesions, clinical aspects of
young women can cause infertility [2]. adhesion-related intestinal obstructions, as well as the develop-
Because the internal organs in the abdominal cavity are cov- ment of novel therapeutic methods and prevention procedures
ered by a very thin membrane – the peritoneum – often a slight concerning this pathology [4–6].
lesion in this membrane during a surgical operation increases In modern medicine, there are numerous therapeutic op-
the risk of creation of adhesions [3]. portunities for the treatment of peritoneal adhesions, but they
The consequences of post-operative adhesions can vary are often not sufficiently efficient [3, 7, 8]. In the last decade, an
substantially. Some adhesions can exist without resulting in any increasing application of physical therapeutic methods in medi-
pains for many years. Unfortunately, many surgical patients with cine has been observed, as they can assist the analgesic phar-
multiple adhesions feel chronic or recurrent pains, which are macological treatment more often. One of the physical methods
most often located in the hypogastrium. Diagnosis of the causes applied in the treatment of pain of various origins is therapy us-
J. Pasek, M. Senejko, G. Cieślar • Magnetic fields in peritoneal adhesion treatment 125
ing variable magnetic fields [9]. Depending on the values of the Participants
physical parameters of these fields, especially on the value of
magnetic field induction, as well as the frequency and course of The trial was performed on 119 patients having a mean
impulses of magnetic field, therapeutic methods using variable age of 52.3 ± 16.3 years (min–max: 13–78 years) (85 women
magnetic field are classified in physical medicine as magneto- with a mean age of 51.9 ± 16.2 years and 34 men with a mean
therapy and magnetostimulation. age of 53.5 ± 16.5 years), suffering from severe pains in the ab-
Magnetotherapy is a method in which a variable magnetic dominal cavity caused by numerous post-operative peritoneal
field with a sinusoidal or rectangular course of impulses, having adhesions, resistant to pharmacological treatment, randomly
a frequency below 100 Hz, magnetic field induction in the range divided into 2 groups: the examined group consisting of 67 pa-
0.1 mT to 30 mT and intensity of electric field comparable to tients with a mean age of 52.0 ± 16.2 years (51 women with
terrestrial electric field level is applied. a mean age of 50.6 ± 16.7 years and 16 men with a mean age of
Magnetostimulation, in turn, is a method in which “weak” 56.5 ± 14.2 years) – exposed to a variable magnetic field in the
variable magnetic fields, having a saw-like shape of basic im- form of magnetotherapy and magnetostimulation procedures
pulses, varying in frequency from several to 3,000 Hz and low – and the comparison group consisting of 52 patients with
values of magnetic field induction from 1 pT to 100 μT based on a mean age of 52.8 ± 16.6 years (34 women with a mean age
the mechanism of ion cyclotron resonance is applied [10]. of 53.9 ± 15.8 years and 18 men with a mean age of 52.4 ± 18.3
The biological action of variable magnetic fields related to years) – subjected to sham exposure.
the effect that these fields have on ion currents, as well as upon All patients had been suffering for a few months from severe
particles having a specific magnetic moment, results, among (“unbearable”, as defined by the patients), persistent abdominal
others, in changes of sensitivity threshold for free nerve end- pains related to post-operative peritoneal adhesions, after nu-
ings or cells capable of contracting. Moreover, the ions under merous surgical procedures in the hypogastrium area (gyneco-
the influence of variable magnetic fields gather in the vicinity logical and chirurgical types of operations), and pains that were
of biological barriers, e.g. cell membranes in magnetic field, as resistant to routine analgesic pharmacological treatment.
a result of which ion polarization occurs (in accordance with The number of surgical interventions executed in patients
the phenomenon of ion cyclotrone resonance – ICR) that cause included in the trial is presented on Figure 1A – experimental
a change of the intensity of ion transfer diffusion rate between group and Figure 1B – control group.
the inside area of the cell and the intercellular space, with a sub- A
sequent change in the intercellular concentration of ions as sodi-
um, calcium and potassium. This phenomenon has a significant
influence upon the intensity of numerous metabolic processes
and the speed of nerve conductivity. So far, the biological effects
of magnetic fields that have been confirmed in reliable scientific
research are vasodilatation, angiogenesis, anticoagulation activ-
ity, intensification of the processes of repair and regeneration
of soft and bone tissues, as well as anti-oedemic, anti-spastic,
anti-inflammatory and analgesic effects [10].
The procedures with the use of variable magnetic fields are
well tolerated by patients, and no significant side effects are ob-
served in patients exposed to magnetotherapy and magneto-
stimulation procedures. Sometimes transient, moderate symp-
toms, such as: intensification of pain sensation in the early stage
of the therapeutic cycle, sensation of fatigue, sweating, itching,
tingling sensation and unstable level of arterial blood pressure,
occur, especially in patients with increased activity of the veg-
etative nervous system [10].
The recommended contraindications for magnetotherapy
and magnetostimulation procedures are: neoplastic diseases, Figure 1A. Number of surgical interventions conducted in patients
pregnancy, active form of tuberculosis, hemorrhage from diges- in experimental group
tive and respiratory tract, hyperthyreosis, electronic implants
B
(e.g. pacemakers), as well as acute infectious diseases, e.g. viral,
bacterial and mycotic [10].
Objectives
The aim of the study is to estimate the efficacy of combined
physical treatment with the use of two variable magnetic field
related therapeutic methods (magnetotherapy and magneto-
stimulation) in the treatment of patients with chronic abdomi-
nal pains caused by post-operative peritoneal adhesions.
Material and methods

The study was conducted in accordance with the World
Medical Association Declaration of Helsinki: ethical principles
for medical research involving human subjects (2000), and
its protocol was approved by the Local Ethics Committee of
the Medical University of Silesia in Katowice (2015). All quali-
fied patients signed a written consent for participation in this Figure 1B. Number of surgical interventions conducted in patients
study. in control group
126 J. Pasek, M. Senejko, G. Cieślar • Magnetic fields in peritoneal adhesion treatment
In the objective examination conducted, in all patients, an Results

increase of tension of abdominal integument and distinct mus-
cular defense of the abdominal cavity in painful regions was ob- The results of subjective estimation of pain intensity in VAS,
served. Before qualification to the trial, an ultrasound and CT before and after the end of a cycle of 40 daily procedures of
examination of the abdominal cavity was performed in order to magnetotherapy and magnetostimulation or a cycle of 40 daily
exclude causes of abdominal pains other than peritoneal adhe- in the examined and comparison group, respectively, are pre-
sions. Based on the performed examination in all patients, no sented in Figure 2.
symptoms of active oncological pathology were confirmed.
The criteria of inclusion into the trial were as follows: ultra-
sound and CT examination before the therapy, patients suffering
from abdominal pains for a few months, lack of a positive reaction
to applied analgesic pharmacological treatment, patients after
numerous post-operative surgical operations of the abdominal
and the patients’ agreement for participation in the trial. Exclu-
sion examination criteria were: lack of agreement for participa-
tion in the examination, different causes of pain ailments in the
abdominal cavity, contraindications to magnetic field procedures.
Patients with typical contraindications to magnetotherapy
and magnetostimulation, such as: the presence of neoplasm,
pregnancy, hyperthyroidism, hemorrhage and hemorrhagic dia-
thesis, tuberculosis, generalized infections, the installation of
pace-makers and other electronic implants, were excluded from
the trial.
Magnetotherapy and magnetostimulation protocol

67 patients from the examined group were subjected to
a cycle of 20 daily procedures of magnetotherapy with the use
of the Viofor JPS System (Med & Life, Poland), lasting 12 min- Figure 2. Results of subjective estimation of pain intensity in VAS
before and after the end of a cycle of magnetic field therapy, in the
utes each (sinusoidal course of impulse, frequency: 40 Hz and
examined and comparison group [points]
magnetic field indication: 10 mT), and subsequently – after 4
weeks – to a cycle of 20 daily procedures of magnetostimulation
In the examined group of patients, exposed to variable mag-
with the use of the Viofor JPS System (Med & Life, Poland), last-
netic fields, a significant decrease (by 66.5%) in pain intensity
ing 12 minutes each (ion cyclotron resonance effect, magnetic
– estimated with the use of VAS – was observed in comparison
field intensity increasing cyclically every 12 seconds to a pre-
to the initial value before the beginning of the therapeutic cycle
-selected level of 8, saw-like shape of impulses, frequencies of
(8.0 ± 1.1 vs 2.3 ± 1.0 points, p < 0.05), while in the comparison
basic impulses: 180 and 195 Hz, with intensity level: 8, and mag-
group of patients, subjected to sham exposure, only a slight and
netic field induction: 100 µT). During the procedure, the painful
insignificant decrease in pain intensity was observed in compar-
region of the patient’s body was placed inside a cylindrical appli-
ison to the initial value before the beginning of the therapeutic
cator of devices for magnetotherapy and magnetostimulation,
cycle (8.6 ± 0.8 vs 8.0 ± 0.4 points, p > 0.05).
which generate variable magnetic fields. The results of subjective estimation of pain intensity in VAS
52 patients qualified to the comparison group were sub- before and after the end of a cycle of 40 daily procedures of
jected to a cycle of sham exposures, consisting of two series of magnetotherapy and magnetostimulation or a cycle of 40 daily
20 daily sham exposures to a magnetic field, during which no in the examined and comparison group, respectively, in relation
magnetic field was generated in the applicators of devices for to gender are presented in Table 1.
magnetotherapy and magnetostimulation.
Estimation of pain intensity and Quality of Life Table 1. Results of subjective estimation of pain intensity
in VAS before and after the end of a cycle of magnetic field
Before the beginning and after the end of a full cycle of pro- therapy in the examined and comparison group in relation to
cedures, a subjective assessment of pain intensity felt by the pa- gender [points]
tients during the last two months was performed with the use Group Gender Pain Pain Statistical
of the Visual Analogue Scale (VAS), in which a score of 0 points is intensity in intensity in significance
defined as no pain sensation, while a score of 10 points reflect- VAS before VAS after (p)
ed the highest intensity of pain ever experienced by the patient treatment treatment
in his life; there was also a subjective estimation of patients’ [points] [points]
quality of life, measured with the use of the EuroQol Scale, in Examined men 7.7 ± 0.9 2.2 ± 0.9 p < 0.05
which 0 points stood for the lowest quality of life, and a score of group women 8.1 ± 1.2 2.4 ± 1.0 p < 0.05
100 points reflected the highest quality of life.
Comparison men 8.6 ± 0.9 7.9 ± 0.4 p > 0.05
group
Statistical analysis women 8.6 ± 0.9 8.0 ± 0.5 p > 0.05
All study results, presented as mean value and standard er- In the examined group of patients, exposed to variable
ror of the mean (SEM), were subjected to statistical analysis with magnetic fields, a significant decrease in pain intensity – es-
use of Statistica 7.0 software. The compliance of the distribution timated with the use of VAS – in both genders was observed
of variables with normal distribution was tested by means of the in comparison to the initial value before the beginning of the
Shapiro–Wilk test, and the statistical significance of differenc- therapeutic cycle, while in the comparison group of patients,
es between the values of particular markers, before and after subjected to sham exposure, only a slight and insignificant de-
the therapeutic cycle, was estimated by means of the Mann– crease in pain intensity in both genders was observed in com-
–Whitney U test and the Wilcoxon test. Differences at a level of parison to the initial value before the beginning of the thera-
p < 0.05 were considered statistically significant. peutic cycle.
The results of subjective estimation of pain intensity in VAS The results of self-estimation of quality of life in the Euro-
before and after the end of a cycle of 40 daily procedures of Qol scale before and after the end of a cycle of 40 daily proce-
magnetotherapy and magnetostimulation or a cycle of 40 daily dures of magnetotherapy and magnetostimulation or a cycle of
in the examined and comparison group, respectively, are pre- 40 daily sham-exposures in the examined group and compari-
sented in Table 2. son group, respectively, in relation to gender are presented in
Table 3.
Table 2. Results of subjective estimation of pain intensity in VAS
before and after the end of a cycle of magnetic field therapy in Table 3. Results of self-estimation of quality of life in the
the examined and comparison group in relation to age [points] EuroQol scale before and after the end of a cycle of magnetic
field therapy in the examined and comparison group in relation
Group Age Pain Pain Statistical
to gender [points]
interval intensity in intensity in significance
[years] VAS before VAS after (p) Group Gender Quality of Qual- Statistical
treatment treatment life in ity of life signifi-
[points] [points] EuroQol in EuroQol cance
scale before scale after (p)
Examined 10–30 8.2 ± 1.6 1.9 ± 0.9 p < 0.05
treatment treatment
group 31–60 8.0 ± 1.1 2.5 ± 1.0 p < 0.05 [points] [points]
61–80 7.9 ± 1.0 2.1 ± 0.9 p < 0.05 Examined men 34.7 ± 14.3 85.9 ± 10.2 p < 0.05
Comparison 10–30 8.6 ± 0.5 8.0 ± 0.0 p > 0.05 group women 28.9 ± 13.9 86.4 ± 8.1 p < 0.05
group 31–60 8.5 ± 1.0 8.0 ± 0.5 p > 0.05 Comparison men 24.1 ± 8.6 20.6 ± 6.4 p > 0.05
61–80 8.8 ± 0.8 8.1 ± 0.4 p > 0.05 group women 24.2 ± 8.9 20.9 ± 6.2 p > 0.05
In the examined group of patients, exposed to variable mag- In the examined group of patients, exposed to variable mag-
netic fields, a significant decrease in pain intensity – estimated netic fields, a significant improvement of quality of life – indi-
with the use of VAS – in all age intervals was observed in com- cated by a significant increase in score in the EuroQol scale – in
parison to the initial value before the beginning of the thera- both genders was observed in comparison to the initial value
peutic cycle, while in the comparison group of patients, subject- before the beginning of the therapeutic cycle (30.2 ± 14.1 vs
ed to sham exposure, only a slight and insignificant decrease in 86.2 ± 8.5 points, p < 0.05), while in the comparison group of
pain intensity in all age intervals was observed in comparison to patients, subjected to sham exposure, a slight, yet insignificant
the initial value before the beginning of the therapeutic cycle. deterioration of quality of life in both genders was observed in
The results of self-estimation of quality of life in the EuroQol comparison to the initial value before the beginning of the ther-
scale before and after the end of a cycle of 40 daily procedures apeutic cycle (24.2 ± 8.7 vs 20.7 ± 6.2 points, p > 0.05).
of magnetotherapy and magnetostimulation or a cycle of 40 The results of self-estimation of quality of life in the EuroQol
daily sham-exposures in the examined group and comparison scale before and after the end of a cycle of 40 daily procedures
group, respectively, are presented in Figure 3. of magnetotherapy and magnetostimulation or a cycle of 40
daily sham-exposures in the examined group and comparison
group, respectively, in relation to age are presented in Table 4.
Table 4. Results of self-estimation of quality of life in the

EuroQol scale before and after the end of a cycle of magnetic
field therapy, in the examined and comparison group in rela-
tion to age [points]
Group Age Quality of Quality of Statistical
interval life in the life in the signifi-
[years] EuroQol EuroQol cance
scale before scale after (p)
treatment treatment
[points] [points]
Examined 10–30 28.9 ± 17.6 91.9 ± 6.0 p < 0.05
group 31–60 30.0 ± 14.7 84.5 ± 4.8 p < 0.05
61–80 29.6 ± 12.0 87.3 ± 6.2 p < 0.05
Comparison 10–30 22.5 ± 4.6 21.3 ± 3.5 p > 0.05

group 31–60 25.6 ± 9.7 21.1 ± 7.0 p > 0.05
61–80 22.9 ± 8.5 20.0 ± 6.1 p > 0.05
Figure 3. Results of self-estimation of quality of life in the EuroQol
scale before and after the end of a cycle of magnetic field therapy, In the examined group of patients, exposed to variable mag-
in the examined and comparison group [points] netic fields, a significant improvement of quality of life – indi-
cated by a significant increase in score in the EuroQol scale – in
In the examined group of patients, exposed to variable mag- all age intervals was observed in comparison to the initial value
netic fields, a significant improvement of quality of life – indicat- before the beginning of the therapeutic cycle (30.2 ± 14.1 vs
ed by a significant increase in score in the EuroQol scale – was 86.2 ± 8.5 points, p < 0.05), while in the comparison group of
observed in comparison to the initial value before the begin- patients, subjected to sham exposure, a slight, yet insignificant
ning of the therapeutic cycle (30.2 ± 14.1 vs 86.2 ± 8.5 points, deterioration of quality of life in all age intervals was observed
p < 0.05), while in the comparison group of patients, subjected in comparison to the initial value before the beginning of the
to sham exposure, a slight, yet insignificant deterioration of therapeutic cycle (24.2 ± 8.7 vs 20.7 ± 6.2 points, p > 0.05).
quality of life was observed in comparison to the initial value All patients treated with both therapeutic methods tolerat-
before the beginning of the therapeutic cycle (24.2 ± 8.7 vs 20.7 ed the procedures performed well, and no side-effects of treat-
± 6.2 points, p > 0.05). ment were observed.
128 J. Pasek, M. Senejko, G. Cieślar • Magnetic fields in peritoneal adhesion treatment
Discussion ably related to a subjective placebo effect regarding the psycho-

logical value of participation in a novel physical therapy.
In patients treated with variable magnetic fields, a distinct
Despite conducting intensive clinical and experimental re- reduction of muscular hypertonia in abdominal integument was
search, there is still no generally accepted effective method of also obtained. The mechanism of this antiphlogistic and anti-
treatment for post-operative adhesions found. Pharmacological spastic effect could be related to the positive impact of variable
treatment kindles some hope, but has so far not clearly shown magnetic fields on structures of liquid crystals in muscle mem-
any advantages resulting from its application. In turn, attentive branes, resulting in the change of permeability of membrane ion
anatomical surgery, reliable hemostasis, strict surgical asepsis channels, especially for calcium and natrium ions, and modifica-
and the selection of optimal surgical methods with the application of their penetration between the cytoplasm and extracel-
tion of less invasive procedures leads only to the reduction of lular space, which is responsible for muscular tension. In turn,
number of post-operative complications [11–14]. the regenerative effect of both therapeutic methods is probably
So far, many surgical methods have been described aiming related to the influence of applied variable magnetic fields on
at the prevention of excessive creation of peritoneal adhesions the muscular coat of blood vessels, resulting in decreased ten-
(folding of the intestine wall, splinting of the intestine and leav- sion of smooth muscles and intensification of the angiogenesis,
ing the peritoneum open in the post-operative course), but with subsequent improvement of tissue perfusion [7, 9].
these methods result in the necessity to perform further op-
erational interventiona [15, 16]. This is why the avoidance of
a lesion of the peritoneum during an operation is considered to
be the most efficient method of preventing the creation of post- There were no follow-up observations in this study, but the
-operative adhesions [1, 17]. authors, in order to estimate how long the obtained analgesic
In the present study, we confirmed that the application of effect lasts, in the near future plan to perform a subsequent trial
variable magnetic fields (in the form of two different therapeu- with a follow-up lasting from 1 to 12 months.
tic methods) for the treatment of patients with peritoneal adhe-
sions provides satisfactory therapeutic effects and generally re-
sults in almost complete regression of abdominal pain. Though Conclusions
the therapeutic process was long-lasting and time-consuming,
the obtained effects of treatment significantly contributed to 1. Magnetotherapy and magnetostimulation are efficient ther-
the improvement of the quality of life of patients treated with apeutic methods in patients with long-lasting abdominal
magnetic fields (Quality of Life) [12, 15]. pain related to peritoneal adhesions, enabling the improve-
The observed anti-nociceptive effect was probably caused ment of their quality of life (regardless of gender and age).
by the reduction of nerve impulse conduction in afferent nerve 2. Taking into account that magnetotherapy and magne-
fibers, due to the hyper-polarization of neuron membranes, as tostimulation are not applicable in primary care, family
well as by the increase of synthesis and secretion of endoge- doctors should consider in the case of patients with drug-
nous opiates (beta-endorphins) in the central nervous system, -resistant abdominal pain caused by diagnosed post-oper-
resulting in raising the threshold of pain sensation [8, 17]. ative peritoneal adhesions a consultation with a physical
The slight, and statistically insignificant, decrease in pain therapy specialist in order to prescribe a cycle of physical
intensity observed in patients from the control group was prob- treatment with the use of these methods.
References
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1187–1193.
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132–135.
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11. Rice AD, King R, Reed ED, et al. Manual physical therapy for non-surgical treatment of adhesion-related small bowel obstructions: two
case reports. J Clin Med 2013; 2(1): 1–12.
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16. Alonso Jde M, Alves AL, Watanabe MJ, et al. Peritoneal response to abdominal surgery: the role of equine abdominal adhesions and
current prophylactic strategies. Vet Med Int 2014; 279: 1–8.
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Tables: 4
Figures: 3
References: 17

Jarosław Pasek, PhD
Katedra i Oddział Kliniczny Chorób Wewnętrznych,
Angiologii i Medycyny Fizykalnej
Śląski Uniwersytet Medyczny w Katowicach
ul. Stefana Batorego 15
41-902 Bytom
Polska
Tel.: +48 32 786-16-30
E-mail: jarus_tomus@tlen.pl

ISSN 1734-3402, eISSN 2449-8580

Relation of health status with distress

and job-related risk factors
Lolita Rapolienė1, 3, A–G, Lina Gedrimė2, 3, A–F, Daiva Mockevičienė3, F,
ORCID iD: 0000-0002-5782-0937
Artūras Razbadauskas3, D
1
Klaipėda Seamen’s Health Care Centre, Klaipėda, Lithuania
2
Republic Klaipeda Hospital, Klaipėda, Lithuania
3
Klaipėda University, Klaipėda, Lithuania
Summary Background. Suboptimal health status (SHS) is recognised as a subclinical, reversible stage of a chronic disease. Previous
studies have proposed that SHS may be related to poor lifestyle factors, as well as work-related and study-related stress.
Objectives. The present study was designed to assess the relationship between health status, general distress and job-related risk
factors.
Material and methods. A community-based, cross-sectional study was conducted in a sample of 606 current workers in Klaipeda,
Lithuania, who had no history of clinically diagnosed disease. The SHS score was derived from SHSQ-25; the General Symptom Distress
Scale (GSDS) was used for distress evaluation.
Results. 90% (547) of respondents revealed an optimal health level. The main domains of SHS status were fatigue and mental status.
SHS was related to cardiovascular, digestive and musculoskeletal symptoms, as well as to frequent infections and allergy. SHS was more
prevalent in women. The overall health status depends on the following job-related risk factors: the professional potential to grow, rest,
deadlines, competition, work experience, income, etc.
Conclusions. Health status was related to distress and mainly manifested itself through fatigue, anxiety and sleep disturbances. Resting
hours, professional potential to grow, risk in another person’s life and work in public have a significant influence on SHS.
Key words: health status, risk factors, workload.
Rapolienė L, Gedrimė L, Mockevičienė D, Razbadauskas A. Relation of health status with distress and job-related risk factors. Fam Med
Prim Care Rev 2019; 21(2): 130–137, doi: https://doi.org/10.5114/fmpcr.2019.84549.
Background social inclusion, poverty reduction and environmental protec-

tion. From a health perspective, development can be said to be
In 1948, the WHO defined health as “a state of complete “sustainable” when resources – natural and manufactured – are
physical, mental and social well-being, and not merely the ab- managed by and for all individuals in ways which support the
health and well-being of present and future generations [6].
sence of disease”. By another definition, health is the level of
Determinants of health are the factors that influence how
functional or metabolic efficiency of a living life. In human be-
likely we are to stay healthy or to become ill or injured. There are
ings, it indicates the general condition of a people’s mind, body
three key determinants of health: social determinants, biomedi-
and spirit, usually meaning to be free from illness, stress, in-
cal risk factors and behavioural risk factors. Social determinants
jury or pain [1, 2]. Disease and health are among the most basic
are found in our everyday living and working conditions: these
concepts in modern health care. Rather than a binary distinc-
are the circumstances in which we grow, live, work and age.
tion between health and illness, W. Yuxue proposes a dynamic They include factors such as income, education, employment
transformational model; the intermediate condition between and social support [7, 8]. A person’s health is also influenced by
health and illness that people pass through when they are be- the biomedical factors and health behaviours that are part of
coming ill or regaining their health constitutes the grey zone person’s individual lifestyle and genetic make-up. Behavioural
of subhealth [1, 3, 4]. Prevention and intervention strategies risk factors such as tobacco smoking, risky alcohol consumption,
aimed at SHS are similar to the concept of preventive, predic- using illicit drugs, not getting enough exercise and poor eating
tive and personalised medicine, which is an effective approach patterns can also have a detrimental effect on health and are
to the improvement of health, the prevention of disease and associated with 10 major causes of death [7, 9].
the treatment of early-stage illness [2, 3]. The importance of Previous studies have proposed that SHS may be related to
timely prevention and early detection of disorders is increasing, poor lifestyle factors, such as going to bed late, work-related and
as the global burden of disease is large. The overall total burden study-related stress, physical inactivity and poor diet [2, 10–13].
of disease rates, measured as the number of Disability Adjusted Long-term activation of the stress-response system can
Life Years (DALYs), lost per 100 000 individuals across the world, disrupt almost all of the body’s processes and increase the risk
varies from 40 000 to 70 000 DALYs per 100 000 individuals of public health issue from both health and cost perspectives;
across high-burden countries, particularly in Sub-Saharan Af- stress could enhance the risk of illness of the cardiovascular,
rica [5]. The 2030 Agenda for Sustainable Development frames gastrointestinal, immune and neurologic systems, as well as
health and well-being as both the outcomes and foundations of lead to depression and sleep disorders [14, 16].
L. Rapolienė et al. • Relation of health status with distress and job-related factors 131
Occupational stress with physiological and emotional re- ipate in a continuous experimental study. The study outcomes:
sponses is a major hazard for many workers; it occurs when prevalence of suboptimal health, size and expression of general
workers perceive an imbalance between their work demands distress and their relations to each other including job-related
and their capability and/or resources to meet their demands. factors.
Employees are becoming more frequently exposed to stressful The questionnaire was composed of socio-demographic,
situations, such as overwork, competition and perceived isola- job-related and lifestyle-related questions, as well as 2 scales
tion [15]. The studies of the American Psychological Association (health status and general distress scale). The SHS score was
show that the labour force is now more stressed than at any derived from the data collected in the SHSQ-25. The SHSQ-25
time in the previous decade; continuous psychosocial stress includes 25 items on SHS and is targeted at physiological and
seems to be a part of the everyday reality, especially for white- psychological SHS; it is a reliable and valid instrument for mea-
-collar workers [16]. The CareerCast.com Jobs Rated Job Stress suring sub-health status [16]. The range of the score of the
report endeavours to present the best baseline understanding SHSQ-25 is from 0 to 100 points. 0 points indicate the lowest
of workplace stress, applying 11 factors: travel, career growth level (good health) and 100 points indicate the highest level
potential, physical demands, environmental conditions, hazards of health (poor health). Suboptimal health status is defined as
encountered, meeting the public, competition, risk of death an SHSQ-25 score above 35 points. The higher the score of the
or grievous injury, immediate risk of another’s life, deadlines, SHSQ-25 one gets, the more severe his or her suboptimal health
working in the public eye [17]. status is. The SHSQ-25 highlights the multidimensionality of SHS
What are the ways to determine the difference between by encompassing the following domains: (1) fatigue, (2) cardio-
good health and the beginning of disease? Usually, the limits vascular system, (3) digestive tract, (4) immune system and (5)
between good health and the beginning of disease are not mental status. The SHSQ-25 is short and easy to complete and,
vivid. If there was a possibility to determine this critically vital therefore, is an instrument suitable for use in both large-scale
step from good health and the beginning of disease, and also studies of the general population and a routine health survey.
to take measures, the disease possibly might not develop. How- The General Symptom Distress Scale (GSDS) was used for mea-
ever, “health” is a broad concept and is difficult to capture with suring distress [19] and was chosen due to its adequate internal
any single measure. Health status is mostly measured by using consistency, reliability, good constructional and prognostic va-
pathological and clinical measures and is usually observed by lidity, good correlation with depression and positive and nega-
clinicians or measured using instruments. It can include the tive affects [17]. This short psychometric study allows one to
measurement of signs (temperature, X-ray, blood pressure or assess specific symptoms, rating them against each other, evalu-
heart/breathing rate), symptoms according to diseases-specific ating their strength and control of the situation. The Visual Ana-
checklists or suspected complications, co-morbidity, undergoing logue Scale (VAS) – a psychometric response scale – was used to
medical treatment and others. Numerous generic, disease-spe- measure the intensity and management of distress symptoms
cific and preference-based measures also now exist that tap into as part of GSDS.
the diverse aspects of functioning, well-being, symptom states Data is reported as the mean ± SD for continuous variables,
and subjective perceptions of health. Generic measures tap into or as frequencies in the case of categorical variables. Descrip-
the broad spectrum of health concepts and are intended to be tive statistics and univariate analyses were carried out using
appropriate for groups differing in disease, severity and comor- SPSS V23.0 (SPSS Inc, Chicago, Illinois, USA). Pearson χ2 tests
bidity. Disease-specific tools are designed to be applicable to and independent-sample t-tests were used to compare the in-
specific patient populations, usually defined by disease pathol- dependent variables versus dependent variables. The hypoth-
ogy, and are likely to be sensitive to treatment and natural his- esis about the equality of probability distribution was checked
tory. Preference-based measures are weighted assessments of against the Mann–Whitney–Wilcoxon U nonparametric crite-
health state values with life years, which yield a single aggregate rion, and the corresponding 95% CIs were calculated. To evalu-
score [18]. A number of SHS questionnaires have been estab- ate the interrelations among the factors, the method of logistic
lished and evaluated in China, such as SHMS V1.0, Suboptimal regression was used; p-value < 0.05 was considered to be sig-
Health Status Questionnaire (SHSQ-25) and Multidimensional nificant for all tests.
Sub-health Questionnaire of Adolescents (MSQA).
Objectives Results
In summary, 800 (80%) completed responses were received.
The aim of the present study was to evaluate workers’
606 (75.8%) questionnaires confirmed those eligible by inclu-
health status and to verify its relation with general distress, as
sion criteria. 25 (4.1%) questionnaires were excluded because
well as job-related factors.
of age over 65,50 (8,3%) had been clinically diagnosed with
some disease, 30 (5%) were currently unemployed, 62 (10.2%)
Material and methods did not wish to participate in a continuous study, and 27 (4.5%)
questionnaires were completed inappropriately. Table 1 shows
A community-based, cross-sectional study was conducted the characteristics of participants in the total group and the
in the period of February and March in 2018 in Klaipeda, Lithu- subgroups according to the state of health. The average age
ania. A questionnaire-based survey was carried out with the of participants was 41.1 years, and 78.5% (476) were women.
authorisation of Kaunas Regional Biomedical Research Ethics The majority of respondents had a university degree – 59.1%
Committee (permission No. BE-2-1). During the 2-month study (358), and 34% (208) were married. Work experience was equal
period, a total of 1 000 questionnaires were distributed in to more than 20 years – 38.8% (235), with working from 9 to 12
Klaipeda Seamen’s Health Care Centre Prevention department, hours a day – 44.6% (270) and resting from 7 to 8 hours – 40.8%
and an online survey was sent to the personnel department of (247). The income was from 500 to 1 000 Euros a month – 51.8%
different types of workplaces. The sample size was calculated (314). The biggest part of the respondents were representatives
by an online survey system sample size calculator according to of different kind of specialists – 39.4% (239) with mainly seden-
number of current workers in Klaipeda city, with a 95% confi- tary – 33.8% (205) or sedentary with frequent physical activity
dence level and confidence interval of 3. Inclusion criteria were – 37.8% (229) job characteristics, and the prevalence of stress-
as follows: 18–65 years of age, currently working, no history of -related risk factors at work was from 3.6% (22) of travelling to
clinically diagnosed disease, willingness and possibility to partic- 40.3% (244) of environmental conditions (Table 7).
132 L. Rapolienė et al. • Relation of health status with distress and job-related factors
Table 1. Socio-demographic and work-related characteristics of respondents

Total (n = 606) Optimal (n = 547) Suboptimal (n = 59) p
Age, mean (SD) 41.1 (13.1) 41.3 (13.2) 38.8 (11.8) 0.198*
Gender, n (%) 0.026**
Men 130 (21.5) 124 (22.7) 6 (10.2)
Women 476 (78.5) 423 (77.3) 53 (89.8)
Marital status, n (%) 0.323**
Prefer not to say 279 (46) 250 (45.7) 29 (49.2)
Married 208 (34.3) 194 (35.5) 14 (23.7)
Single 11.9 (7.2) 11.5 (63) 9 (15.3)
Divorced 37 (6.1) 31 (5.7) 6 (10.2)
Widow 10 (1.7) 9 (1.6) 1 (1.7)
Level of education, n (%) 0.553*
Primary education 1 (0.2) – 1 (1.7)
Incomplete secondary education 16 (2.6) 16 (2.9) –
Secondary 91 (15) 82 (15.0) 9 (15.3)
Higher (K12) 76 (12.5) 68 (12.4) 8 (13.6)
High (college level) 58 (9.6) 55 (10.1) 3 (5.1)
High (university level) 358 (59.1) 321 (58.7) 37 (62.7)
PhD 6 (1) 5 (0.9) 1 (1.7)
Work experience, n % 0.426*
Less than 1 year 53 (8.7) 45 (8.2) 8 (13.6)
2–5 years 83 (13.7) 73 (13.3) 10 (16.9)
6–10 years 89 (14.7) 85 (15.5) 4 (6.8)
11–20 years 146 (24.1) 130 (23.8) 16 (27.1)
More than 20 years 235 (38.8) 214 (39.1) 21 (35.6)
Income per month, net, Eur, n (%) 0.324*
Less than 500 157 (25.9) 139 (25.4) 18 (30.5)
500–1 000 314 (51.8) 281 (51.4) 33 (55.9)
1 000–1 500 76 (12.5) 71 (13) 5 (8.5)
1 500–2 000 35 (5.8) 32 (5.9) 3 (5.1)
2 000–2 500 4 (0.7) 4 (0.7) –
2 500–3 000 5 (0.9) 5 (0.9) –
More than 3 000 3 (0.5) 3 (0.5) –
No answer 12 (2) 12 (2.2) –
Working hours per day, n % 0.302*
Less than 8 250 (41.3) 225 (41.1) 25 (4.4)
9–12 270 (44.6) 249 (45.5) 21 (35.6)
13–16 22 (3.6) 16 (2.9) 6 (10.2)
More than 16 20 (3.3) 17 (3.1) 3 (5.1)
Various 44 (7.3) 40 (7.3) 4 (6.8)
Resting hours per day, n % 0.016*
Less than 6 128 (21.1) 106 (19.4) 22 (37.3)
7–8 247 (40.8) 227 (41.5) 20 (33.9)
9–10 127 (21) 115 (21) 12 (20.3)
More than 10 85 (14) 81 (14.8) 4 (6.8)
Various 19 (3.1) 18 (3.3) 1 (1.7)
* By Mann–Whitney U, ** by Pearson chi-square.
The mean SHSQ score result was 20.9 (SD 11.9), with a mini- Table 3. Domains of health status in study groups
mum 0 and maximum 85. Optimal (less than 35 points) health
Health status Total SHSQ, SHS, mean (SD) p

was found in 90.3% (547) of respondents, and study outcome domain mean (SD) (n = 59)
– SHS – was determined in less than in 10% of workers (9.7% (n = 606)
(59) (Table 2).
Fatigue 9.54 (5.54) 19.39 (5.25) < 0.001
Cardiovascular 1.24 (1.60) 3.68 (2.36) < 0.001
Table 2. Health status of respondents system
Health status Frequency % Digestive system 1.31 (1.49) 2.93 (2.10) < 0.001
Optimal 547 90.3 Immune system 2.17 (1.84) 4.10 (2.51) < 0.001
Suboptimal 59 9.7 Mental status 6.64 (4.37) 14.15 (4.02) < 0.001
Considering the perceived symptoms attributable to vari-

Significant differences between groups were noted in gender ous body systems between the health state groups, almost all
(SHS was more observed in women) and resting hours (Table 1). symptoms (except for those attributed to endocrine, respira-
Based on different domains of health assessment, it was tory, urinary-gynaecology, eye and haematology spheres) were
observed that in total SHSQ-25 and SHS, a significantly worse significantly greater in SHS, with the biggest prevalence of car-
state was determined in the area of fatigue and mental system. diovascular, gastrointestinal and musculoskeletal symptoms, as
If compared, all domain values were higher in SHS (Table 3). well as allergy and frequent infections (Table 4).
Table 4. Prevalence of perceived symptoms of respondents attributable to various diseases

Symptoms, n (%) Total (n = 606) Optimal (n = 547) Suboptimal (n = 59) p
Cardiovascular disease 81 (13.4) 67 (12.2) 14 (23.7) 0.014
Musculoskeletal disease 74 (12.2) 62 (11.3) 12 (20.3) 0.045
Gastrointestinal disease 53 (8.7) 40 (7.3) 13 (22) < 0.001
Nervous system disease 29 (4.8) 21 (3.8) 8 (13.6) 0.001
Endocrine system disease 92 (15.2) 82 (15) 10 (16.9) 0.69
Respiratory system disease 23 (3.8) 19 (3.5) 4 (6.8) 0.207
Skin disease 35 (5.8) 27 (4.9) 8 (13.6) 0.007
Ear disease 11 (1.8) 7 (1.3) 4 (6.8) 0.003
Urinary-gynaecological disease 40 (6.6) 35 (6.4) 5 (8.5) 0.542
Eye disease 36 (5.9) 30 (5.5) 6 (10.2) 0.148
Haematological disease 17 (2.6) 16 (2.9) 1 (1.7) 0.587
Allergy 49 (8.1) 40 (7.3) 9 (15.3) 0.034
Frequent infectious diseases 36 (5.9) 24 (4.4) 12 (20.3) < 0.001
Table 5. Pearson correlation of health state and distress parameters

Number of distress symptoms Distress symptom intensity Management of distress symptoms
Health status 0.500 0.585 -0.105
Sig. (1-tailed) < 0.001 < 0.001 0.005
Table 6. Distress parameters in different health status groups

Levene’s t-test
test
Health status Mean (SD) F t df Sig. CI (lower) CI (upper)
Distress symptom optimal (n = 547) 4.3 (2.23) 4.701 -9.548 604 < 0.001 -3.464 -2.262
intensity (VAS) suboptimal (n = 59) 7.2 (1.84)
Distress symptom optimal (n = 547) 6.2 (2.66) 8.841 1.599 604 0.110 -0.130 1.273
management (VAS) suboptimal (n = 59) 5.6 (2.07)
Number of distress optimal (n = 547) 3.5 (2.96) 2.990 -7.211 604 < 0.001 -3.777 -2.160
symptoms suboptimal (n = 59) 6.5 (3.43)
The evaluation of the second outcome – general distress status groups using the t-test, significantly more distress symp-
– by GSDS of all respondents revealed that the respondents toms and bigger intensity were observed in SHS (Table 6).
felt of 3.8 (SD 3.13) symptoms of distress, the overall intensity During the present study, it was determined that despite
of which was 4.6 (SD 2.35) (VAS), and management of these health status, the most commonly experienced distress symp-
equalled to 6.1 (SD 2.6) (VAS). The overall health state corre- toms were fatigue, anxiety and sleep difficulties. All distress
lated with all distress parameters (Table 5). symptoms were significantly more prevalent in the SHS group
When assessing the distress differences in different health (Figure 1).
88.1
79.7 79.7
68.4 59.3
51 54.2
47.5 44.1 45.7
37.1 33.9 35.6 35.6

31.3
22.1
11.7 11.9 15.9 11.7
10.2
3.3
Optimal health Suboptimal health

Figure 1. Distress symptom prevalence according to health state
Table 7. Prevalence of work-related factors in respondent groups

Total (n = 606) Optimal (n = 547) Suboptimal (n = 59) p
Profession, n (%) 0.829
Leader 14 (2.3) 12 (2.2) 2 (3.4)
Specialist 239 (39.4) 210 (38.4) 29 (49.2)
Technicians and junior specialists 10 (1.7) 10 (1.8) 0 (0)
Officials 31 (5.1) 28 (5.1) 3 (5.1)
Service and sales 56 (9.2) 50 (9.1) 6 (10.2)
Qualified specialists in the field of land, forest, fisheries 3 (0.5) 3 (0.5) 0 (0)
Skilled workers and craftsmen 20 (3.3) 18 (3.3) 2 (3.4)
Machine operators 4 (0.7) 4 (0.7) 0 (0)
Unqualified workers 8 (1.3) 8 (1.5) 0 (0)
Armed forces 2 (0.3) 2 (0.4) 0 (0)
Unemployed according to specialty 219 (36.1) 202 (36.9) 17 (28.8)
Character of the work, n (%) 0.334
Mainly sedentary 205 (33.8) 184 (33.6) 21 (35.6)
Sedentary with frequent physical activity 229 (37.8) 210 (38.4) 19 (32.2)
Mainly physical 139 (22.9) 124 (22.7) 15 (25.4)
Physical with frequent intense activity 20 (3.3) 16 (2.9) 4 (6.8)
Stress-related factors at work, n (%)
Competition 141 (23.3) 123 (22.5) 18 (30.5) 0.166
Deadline 223 (36.8) 198 (36.2) 25 (42.4) 0.35
Environmental conditions 244 (40.3) 218 (39.9) 26 (44.1) 0.531
Potential to growth in a professional field 61 (10.1) 49 (9.0) 12 (20.3) 0.006
Facing danger 87 (14.4) 80 (14.6) 7 (11.9) 0.566
Life threatening 33 (5.4) 27 (4.9) 6 (10.2) 0.092
Risk perceived in another person’s life 86 (14.2) 71 (13) 15 (25.4) 0.009
Meetings with public 72 (11.9) 63 (11.5) 9 (15.3) 0.399
Physical requirements 56 (9.2) 49 (9) 7 (11.9) 0.464
Travelling 22 (3.6) 16 (3.3) 4 (6.8) 0.173
Work in publics 114 (18.8) 97 (17.7) 17 (28.8) 0.039
p – by Pearson chi-square.
44.1
42.4 39.9
30.5 36.2
28.8
25.4
22.5 20.3
14.6 15.3 11.9 17.7
11.9 13 11.5
9 10.2 9 6.8
4.9 3.3
Optimal health Suboptimal health
Figure 2. Prevalence of work-related stress factors according to health state
The study showed no significant role of socio-demographic Almost all stress-related work risk factors (except for facing
characteristics such as age, education, marital status, work expe- danger) were more prevalent in the SHS group (Figure 2).
rience, income or working hours in the SHS group. A significant When evaluating the overall health state, there was a signif-
factor was only resting hours (p = 0.016). Nevertheless, shorter icant correlation was identified between the overall health state
work and less income was found in SHS (Table 1). and most of the work-related risk factors (Table 8). Better work
We found no significant effect of profession and characteris- experience, better income and resting time have a positive influ-
tic of work on SHS; however, job-related stress-risk factors such ence on health; intense competition, deadlines, environmental
as potential to grow in a professional field, risk perceived in an- conditions, professional growth potential, risk perceived in an-
other person’s life and work in public have significant influence other person’s life, meetings with public, physical requirements
on SHS (Table 7). and work in public have a negative influence on health.
Table 8. Pearson correlation of work-related factors with health state

Factor Health state p Factor Health state p
Work experience -0.101 0.007 potential for professional growth 0.181 < 0.001
Income -0.085 0.018 risk in another person’s life 0.127 0.001
Resting hours -0.139 < 0.001 meetings with public 0.091 0.013
Competition 0.110 0.03 physical requirements 0.097 0.009
Deadlines 0.116 0.002 work in public 0.138 < 0.001
Environment 0.092 0.012
11.90
10.40
10.60
93.20
87.20
87.80
88.10
85.20
85.5
22.00
19.70
20.00
Suboptimal health Optimal health Total
88.1
Figure 3. Prevalence of behavioural factors according health state [%]
There was no significant difference in health state groups well as behavioural habits. Work-related stress risk factors, such
according to behavioural risk factors. The results showed the as professional potential to grow, risk in another person’s life
prevalence of smoking, which in the total group was 20% (121) and work in public, have a significant influence on SHS, as well
(every day smoking – 8.1% (49) and not different in SHS – 22% as on resting hours.
(13)) (every day smoking – 8.5% (5) (p = 0.652); alcohol use in to- The results of the present study differ from the results in
tal was 85.5% (518) (every day – 0.7% (4)) compared with 88.1% China or the UAE, where the prevalence rate of SHS was 55.9%
(52) (every day – 3.4% (2)) in SHS (p = 0.859); physical activity in (6234) [13] and 52.5% (265) [20]. This reason could be the dif-
total was 87.8% (542) (every day – 11.6% (70)), and in the SHS ferent sample size and the characteristics or different working/
group, it was 93.2% (55) (every day – 15.3% (9)) (p = 0.989), and /studying conditions or different methodology (using median
the application of rehabilitation procedures in total was 10.6% score or > 35 points). In European study samples, the health
(64), and in SHS, it was 11.9% (7) (p = 0.732) (Figure 3). self-rating is better: 8.7% of the participants rated their health
as excellent, 35.8% rated as very good, 45.6% rated as good,
8.9% rated as fair, and 1% as poor [21]. The present study found
Discussion that the mean SHSQ score was 20.9, which was lower than 33.3
in other trials [20]. In a similar age group with less women, the
The aim of this study was to evaluate SHS prevalence and
authors found the mean SHS score among the SHS group was
general distress, as well as the relationship between health 55.73 ± 9.58 (SHS score > 44 and 35.02 ± 6.51 among the con-
status and distress, including job-related factors, so as to ob- trol group (SHS < 44)), respectively [2]. The difference could
tain a more complete profile of the well-being of workers and be explained as follows: the rapid economic progress across
to identify more effective intervention measures. The clinical China and employees becoming more exposed to stressful situ-
study has demonstrated that 90% (547) of respondents had an ations, such as excessive workload, competition and perceived
optimal health level and only 9.7% (59) had SHS. The study par- loneliness [2]. In another trial, the SHS scores of White–Collar
ticipants felt nearly four symptoms of distress on average with 5 Workers (n = 1497), Blue–Collar Workers (n = 507) and College
(VAS) intensity and 6 (VAS) management points. The study has Students (n = 345) were 59.81, 45.28, and 38.96, respectively
shown a reliable connection of overall health status with all pa- [16]. Our results are comparable to Youxin Wang’s (China) sub-
rameters of distress, and SHS with a number of distress symp- optimal health cohort study (COACS), where the prevalence
toms and their intensity. of SHS was 9% (389), using an SHS score of 35 as a threshold,
The main domains of health status in our study were fatigue where women showed a significantly higher prevalence of SHS.
and mental status. SHS was related with cardiovascular, diges- Risk factors for chronic diseases, such as socio-economic status,
tive, musculoskeletal symptoms, frequent infections and allergy. marital status, higher education, physical activity, salt intake,
SHS was more prevalent in woman and did not depend on age, blood pressure and triglycerides, differed significantly between
education (college) and marital status, nor profession, character subjects of SHS (SHS score ≥ 35) and those of ideal health (SHS
of work, income, experience, some job stress-related factors, as score < 35) [22].
The reason for the different results of self-perceived mea- diseases. Distress symptoms, especially fatigue, anxiety and
sures could be the different feelings about subjective health sleep disturbances, must be addressed by effective measures.
(general health, mental health, one’s life stress). People rate In general, the health of a majority of Klaipeda’s workers is
their health in relative terms comparing themselves with others optimal, but distress is prevalent and partly dependent upon
in the community and their expectations [23]. In a 2016 trial (24 specific work stress factors. Pursuant to the findings of the pres-
159 participants), SHS was found in 46% of respondents, and ent study, it is necessary to pay attention to the prevention and
compared with to participants with a healthy lifestyle, subjects lowering of the number of stress symptoms, stress intensity and
with a ‘poor’ lifestyle were at a 43 times higher risk of devel- growing stress management strategies, as well as to evaluate
oping SHS (OR 42.825) [24]. Other researchers also found that workplace safety regarding stress-related risk factors, as they
health status was significantly positively correlated with lifestyle are associated with health status. The guidelines for employers
[11, 13]. Our trial did not show a significant relation with the be- must include improvement of physical working conditions, reg-
havioural habits (we did not take into account nutritional hab- ulation of workload, human effort assessment, healthy working
its), similarly to the UEA (no association with physical activity atmosphere, psychological assistance for workers dealing with
and smoking) [20]. the public and taking responsibility for another person’s life, as
well as a fair and sufficient salary.
The present study identified that overall health status de-
The concepts of health and disease are crucial in defining
pends on job-related risk factors: professional potential to grow,
the aim and the limits of modern medicine. Accordingly, it is
rest, work in public, risk in another person’s life, deadlines, com-
important to understand them, as well as their relationship, in
petition, work experience, physical requirements, environment,
order to find the best tool to assess the health state and be able
meetings with public and income. According to CareerCast, ca- to take preventative measures [27].
reer and money-related issues are two of the leading and most
consistent year-to-year causes of stress [17]. Shorter work ex-
perience (less than 1 year 8.2% vs 13.6%), longer working hours
(13–16 hours in 2.9% vs 10.2%) and smaller income was found The limitation of the study could be unequal distribution of
in SHS. Social determinants can strengthen or undermine the respondents by profession, limited number of job-related fac-
health of individuals and communities. People from poorer so- tors, low prevalence of SHS.
cial or economic circumstances are at greater risk of poor health It would be necessary to perform a much larger-scale study
than people who are more advantaged [7]. In students, factors in order to compare the results with other SHS trials and to be
associated with SHS were age (younger), study year (first years) able to compare the SHS of all country population results, as well
and nationality [21]. The present study found that age (Pearson as with those of other European workers with similar results of
correlation 0.142 (p < 0.001)) and work experience were associ- job-related factors. Further studies could be supplemented with
ated with the overall health state, but not the SHS. questions about possible preventative measures to lower work-
The present research showed the association between dis- -related stress and to increase general health. There is a need for
tress and overall and health state SHS. Fatigue, anxiety and sleep research to compare the different types of work-stress preven-
disturbances were mostly prevalent. According to other stud- tion measures to determine their impact on distress and health
ies, the most frequent symptom of stress was fatigue (90.5%), change. Prevention, prediction and personalisation of medicine
as well as nervousness (81%) and poor sleep (42.9%), and the are the aims of any integrated preventive treatment plan.
correlation between the score for SHS (53.67) and that for ex-
perienced stress (72.67) was statistically significant [16]. Other Conclusions
studies have already identified stress as a key factor contrib-
uting to poor public health [25]. Chronic overwhelming stress 1. SHS prevalence in the study population was 9.7%. The
leads to exhaustion, and this state of exhaustion is marked by main health impairment domains are fatigue and mental
energy depletion and tissue degeneration [26]. In the general disturbances.
population, the major risk factors for SHS included poor stress 2. SHS depends on distress symptom number and intensity.
management, poor self-actualisation, inactivity and poor inter- The main distress symptoms for SHS are fatigue, anxiety
personal relationships [24]. The serum cortisol level was found and sleep disturbances.
to be much higher among the SHS high-score group than that of 3. Health status depends on job-related risk factors: profes-
the low SHS score group. SHS is associated with cardiovascular sional potential to produce, rest, work in public, risk in
risk factors and contributes to the development of cardiovascu- another person’s life, deadlines, competition, work experi-
lar disease. SHS should be recognised in the health care system, ence, physical requirements, environment, meetings with
especially in primary care [11]. Family doctors must pay atten- public and income. The professional potential to grow, the
tion to the number of patients’ complaints and their intensity risk in another person’s life and work in public have a sig-
for further studies concerning SHS or the possible presence of nificant influence on SHS.
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Tables: 8
Figures: 3
References: 27
Received: 8.09.2018
Accepted: 4.12.2018

Lina Gedrimė, MSc
Klaipėda University
Herkaus Manto g. 84
LT-92294 Klaipėda
Lithuania
Tel.: +37068620439
E-mail: linagedrimaite@gmail.com
ISSN 1734-3402, eISSN 2449-8580

Impact of loneliness in the elderly in health care:

a cross-sectional study in an urban region of Portugal
Catarina Rocha-Vieira1, A–F, Gustavo Oliveira2, A, C–F, Luciana Couto1, 3, 4, A, D, E,
ORCID iD: 0000-0002-8147-3197 ORCID iD: 0000-0003-1165-4707 ORCID iD: 0000-0001-6567-993X
Paulo Santos3, 4, A, C–G

ORCID iD: 0000-0002-2362-5527
1
USF Camelias, ACES Gaia, Vila Nova de Gaia, Portugal
2
USF Garcia d’Orta, ACES Porto Ocidental, Portugal
3
MEDCIDS – Department of Medicine of Community, Information and Health Decision Sciences,
Faculty of Medicine of Porto, Portugal
4
CINTESIS – Center for Health Technology and Services Research, University of Porto, Portugal
Summary Background. Loneliness is a subjective, complex and multi-dimensional feeling, having a significant impact on mental
health. It is related to intrinsic and extrinsic factors.
Objectives. The aim of this study is to evaluate the impact of loneliness in elderly patients in medical care.
Material and methods. We conducted a cross-sectional study of a sample of 150 participants, aged ≥ 65 years, interviewed by a struc-
tured questionnaire, including the University of California Los Angeles Loneliness Scale (UCLA-LS), for assessment of loneliness. Other
variables included socio-demographic characterisation and family dysfunction. Total medication prescription and polymedication were
used to assess the medical care assistance profile. Logistic regression was used for multivariate analysis.
Results. The prevalence of moderate to severe loneliness was 36% (95% CI: 28.3–44.2%), higher with ageing, without differences be-
tween gender. The greatest impact in loneliness occurred in the presence of family dysfunction, income dissatisfaction, living alone and
ageing. Being married/in a non-marital partnership and maintaining professional activity appeared as protective factors. The percep-
tion of loneliness was related with polymedication, with higher levels of loneliness matching with higher polymedication.
Conclusions. Loneliness is common in the geriatric population and interferes significantly with health care; thus, it can be considered
a determinant of health. Incorporating this factor into clinical decision reasoning is crucial for better health care.
Key words: geriatrics, loneliness, social isolation, polypharmacy, poverty, family conflict.
Rocha-Vieira C, Oliveira G, Couto L, Santos P. Impact of loneliness in the elderly in health care: a cross-sectional study in an urban region
of Portugal. Fam Med Prim Care Rev 2019; 21(2): 138–143, doi: https://doi.org/10.5114/fmpcr.2019.84550.
Background
proximity to loss. It represents a strong threat to their health
Most of people, if not all, experience feelings of loneliness and quality of life [7]. Several studies associate loneliness with
sometime in their life, without constituting a significant prob- sleep disturbances, depressive symptoms, somatisation, he-
lem or representing a pathological process [1, 2]. Perhaps be- modynamic instability, falls and accidents, as well as to a lower
cause of this, loneliness is still a neglected issue when compared compliance to medical therapy [8–10].
to other social problems [3], despite the growing interest in re- This is particularly relevant if we consider the huge ageing
cent years. of the population, with the number of elderly increasing both in
Loneliness is the result of the discrepancy between desired absolute and relative terms due to better living conditions, the
social relations and those effectively built [4]. It is a subjective, promotion of healthier lifestyles and advances in the prevention
multi-dimensional and complex feeling, with a strong impact of disease. Population-ageing is a reality in western countries,
on mental health, particularly in the elderly. Loneliness can be and the strategies classically outlined to dealing with this do not
determined by intrinsic factors, such as personality or the loss work anymore, especially within the family structure and the
of autonomy, as well as by extrinsic factors, such as poor social disappearance of extended families [11, 12].
networks and deficits in affective standards [3, 4]. The concept of ageing has changed over the time by the
Although it is associated with isolation, loneliness is concep- influence of greater and more profound knowledge of human
tually different, because it derives from the unpleasant percep- anatomy [13].
tion of the lack of a social support network [5, 6]. On the other In a physiological degeneration perspective, ageing is the
hand, isolation corresponds to the perception of a real physical progressive, persistent and age-dependent decline of the intrin-
separation, which can be passive or active. Concurrently, loneli- sic physiological functions of the individual, leading to a reduc-
ness may exist without isolation and isolation without loneli- tion of the reproducibility rate and an increase of mortality [14,
ness [5, 6]. 15]. In the population perspective, ageing is defined as the age-
Although loneliness may exist throughout ones’ lifetime, -related loss of adaptation, caused by the progressive decline of
the elderly are particularly vulnerable due to their fragility and the forces of natural selection [14, 15].
C. Rocha-Vieira et al. • Loneliness in health care 139
Ageing is not a pathological process, but rather an accumu- by patients. We used the Portuguese validated version [27, 28],
lation of progressive changes within the biological, psychologi- containing eighteen questions, each scoring from 1 to 4 points.
cal and social dimensions, evolving over a lifetime from an early The total sum ranges from 18 to 72 points. It always infers some
age, even before birth [16, 17]. Although inevitable, human age- degree of loneliness from 19 points up. This scale allows for
ing is very irregular, with a huge interindividual variation [18]. categorisation at three levels of increasing perception of loneli-
This heterogeneity results from the interaction between sev- ness, from “low level of loneliness” (19–36 points), “moderate
eral intrinsic determinants, such as unique genetic information, level of loneliness” (37–54 points), to “severe level of loneli-
and extrinsic factors, from environment and lifestyle [16, 17]. ness” (55–72 points) [29, 30].
Losses and specific needs affect quality of life and lead to the The number of chronic prescribed medications was assessed
reorganisation of daily routines, many times a real challenge in from the electronic clinical file. Polymedication was defined by
each case, [18] implying the reformulation of each individual’s the chronic consumption of 5 or more drugs a day [31–33].
priorities.
Finding answers for ageing-related problems impose new Ethical aspects
medical, social, cultural, political and financial demands, aiming
to monitor its evolution and to minimise the negative impacts Data was anonymised for analysis. All participants signed
in people. The perspective of ageing as an active process opens the informed consent form, previously to the inclusion. Pro-
opportunities for health [12, 19, 20], increasing participation and cedures were consistent with the Helsinki Declaration and the
security and promoting success in adaptation to changing, in- Oviedo Convention for the protection of human rights and dig-
creasing the perception of well-being and the quality of life [21]. nity of the human being regarding the application of biology and
However, loneliness may compromise this success, leading medicine. The study protocol fell under the supervision and ac-
to a downward spiral, which is hard to stop. ceptance of the Ethical Committee of Portuguese North Health
Administration (process number 96/2017).
Objectives Statistical procedures

The aim of this study is to evaluate the impact of loneliness Data was registered into a digital database using Microsoft™
in people of 65 years of age or older in medical care, searching Excel® 2016 and treated by SPSS® version 22.
for the relationship with socio-demographic factors, comorbidi- We used descriptive and dispersion measures to analyse the
ties and family functioning. A better characterisation of loneli- sample characteristics, calculating the frequency for the cate-
ness in the elderly will contribute to the implementation of pre- gorical and nominal variables, as well as the average, median
vention strategies for better ageing. and standard deviation for the continuous variables.
The sample was compared with the population of the health
centre using the Spearman correlation and the chi-square test
Material and methods for age and gender distribution. The prevalence of loneliness
on the entire population was estimated by direct adjustment
We conducted a cross-sectional study at the Family Health for age and gender. We used the modified Wald method for the
Centre (USF) Camélias, in the north of Portugal, from July to calculation of confidence intervals at a 95% level.
September 2017. Data analysis was performed based on gender (males and
females) and age (categorised into two groups, 65 to 79 years of
Participants age and 80 years of age or more).
For inferential analysis, we used the chi-square test to
Participants were consecutively recruited among patients 65
evaluate the association between categorical variables and the
years of age or older and who went to the primary care setting
t-student in continuous variables, after checking for normal distri-
for a medical or nurse appointment and had agrred to participate.
bution by the Kolmogorov–Smirnov test or nonparametric tests.
The sample size of 150 subjects was calculated based on an
The outcome variable loneliness was dichotomised in no/low
expected prevalence of loneliness in the elderly of about 30% [22]
loneliness (UCLA-LS score lower than 36 points) and moderate/
and a maximum error of 7.5% for a 95% confidence interval [23].
/severe loneliness (ICLS-LS score equal or higher than 36 points).
Participants were asked to fill in a questionnaire, with the
Logistic regression was used in univariate analysis to calculate
aid of the interviewer, if deemed necessary. It included three
the estimate of the odds ratio and in multivariate analysis after
dimensions: socio-demographic characterisation (age, gender,
adjustment for the variables with statistical significance by the
marital status, household size, education, employment status backward stepwise method. We accepted an alpha error of 0.05.
and income satisfaction), family functionality and the percep-
tion of loneliness. Electronic clinical files were checked for
Results
chronic medication.
Two groups were fixed according to age (65–79 years of age
and 80 or more years of age). Household size was categorised by We included 150 elderly patients (61.3% females), with ages
those who live alone, those who live with a partner and those ranging between 65 and 94 years of age (mean age = 74.7 ± 7.5
who had descendants, even those not living with them in the years) and 68.7% below 80 years of age (n = 103). Table 1 shows
same house. Instead of the financial quantification, we asked for the demographic characteristics of the sample. The sample was
the satisfaction with total income, representing the subjective not significantly different to the population of the city of Vila
point of view of participants (Dissatisfied, Average and High). Nova de Gaia, where the health centre was located and where
Family functionality was assessed by the Family APGAR 16% (n = 47 274) of its inhabitants are over 65 years of age [76%
Questionnaire [24]. This test uses five questions about a pa- below 80 years of age (n = 35 941) and 24% over 80 years of age
tient’s perception of family adaptability, partnership, growth, (n = 11 333)], of which 43% (n = 20 233) were males and 57%
affection and resolve. Each of its five questions is ranked from (n = 27 041) were females.
0 to 10 points, and the final score, translated by the sum of the The age groups presented significant differences in marital
partial scores, classifies families as being “severely dysfunction- status and employment, as expected, but also in education and
al” (0 to 3 points), “moderately functional” (4 to 6 points) and income satisfaction. Our population also showed significant
“highly functional” (7 to 10 points) [24, 25]. differences between gender in education and in employment
The University of California in Los Angeles Loneliness Scale status, with males presenting a higher level of education and
(UCLA-LS) [26] evaluated the degree of loneliness experienced greater job permanence.
140 C. Rocha-Vieira et al. • Loneliness in health care
Table 1. Sample socio-demographic characteristics by age group

Age Total
< 80 years ≥ 80 years n = 150 (100%)
n = 103 (68.7%) n = 47 (32.3%)
Gender, n (%)
Male 45 (43.7) 13 (27.7) 58 (38.7)
Female 58 (56.3) 34 (72.3) 92 (61.3)
Marital status, n (%)
Single 6 (5.8) 2 (4.3) 8 (5.3)
Married/non-marital partnership 84 (81.6) 9 (19.1) 93 (62.0)
Divorced 9 (8.7) 3 (6.4) 12 (8.0)
Widowed 4 (3.9) 33 (70.2) 37 (24.7)
Family size, n (%)
Lives with a partner 67 (65.0) 8 (17.0) 75 (50.0)
No descendants 10 (9.7) 4 (8.5) 14 (9.3)
Lives alone 13 (12.6) 20 (42.6) 33 (22.0)
Education, n (%)
< 4 years 2 (1.9) 14 (29.8) 16 (10.7)
Primary education 49 (47.6) 27 (57.4) 76 (50.7)
≤ 9 years 20 (19.4) 1 (2.1) 21 (14.0)
≤ 12 years 24 (23.3) 4 (8.5) 28 (18.7)
College or higher 8 (7.8) 1 (2.1) 9 (6.0)
Employment status, n (%)
Active 41 (39.8) 0 (0.0) 41 (27.3)
Unemployed 1 (1.0) 1 (2.1) 2 (1.3)
Retired 57 (55.3) 41 (87.2) 98 (65.3)
Domestic 4 (3.9) 5 (10.6) 9 (6.0)
Income satisfaction, n (%)
Dissatisfied 23 (22.3) 38 (80.9) 61 (40.7)
Average 76 (73.8) 8 (17.0) 84 (56.0)
High 4 (3.9) 1 (2.1) 5 (3.3)
Family dysfunction (APGAR), n (%)
Severe dysfunction 12 (11.7) 24 (51.1) 36 (24.0)
Moderate dysfunction 8 (7.8) 11 (23.4) 19 (12.7)
Functional 83 (80.6) 12 (25.5) 95 (63.3)
* Chi-square test; NS – non-significant.
The presence of family dysfunction, measured by the Family ried or in a non-marital partnership and maintaining professional
APGAR score, also varied significantly between the age groups, activity appeared to condition lower perception of loneliness.
both in the total score and in the individual analysis of each of
its dimensions (adaptability, partnership, growth, affection and Table 2. Impact of socio-demographic variables and Family
resolve). The group ≥ 80 years of age showed greater severe APGAR on loneliness
dysfunction and less family functionality, without differences OR CI 95% p*
between gender.
Fifty-four of the elderly presented an UCLA-LS score higher Age ≥ 80 years 12.895 5.661–29.374 < 0.001
than 36, representing a perception of moderate to severe loneli- Male 0.616 0.305–1.244 0.175
ness. The prevalence of loneliness in this sample was 36% (95% Married/non-marital 0.063 0.028–0.144 < 0.001
CI: 28.3–44.2%). In the cut-off of 19 points on the UCLA-LS, i.e. partnership
any degree of loneliness perception, the prevalence of loneli- Living with a partner 0.174 0.082–0.369 < 0.001
ness raised to 91.3% (95% CI: 85.6–95.3%).
Having descendants 0.528 0.175–1.595 0.258
A severe level of loneliness was present in 30.7% (95% CI:

23.4–38.7%), 5.3% (95% CI: 2.3–10.2%) expressed a moderate Living alone 19.600 6.882–55.822 < 0.001
level of loneliness, and 55.3% (95% CI: 47.0–63.5%) experienced Education < 9 years 2.489 1.045–5.929 0.040
a low level of loneliness. The remaining thirteen participants (8.7% Maintaining profes- 0.052 0.012–0.224 < 0.001
of the sample: 95% CI: 4.7–14.4%), did not show any level of lone- sional activity
liness. The estimative of prevalence of loneliness for the popula-
Dissatisfaction with 96.591 29.195–319.572 < 0.001
tion of the entire health centre is 36.7% (95% CI: 35.1–38.3%).
income
The degree of loneliness varied with age (greater in the
≥ 80 years of age group) and income satisfaction (greater in Presence of family 2491.000 220.630–28 124.316 < 0.001
more unsatisfied). We noticed a higher tendency in females, dysfunction (APGAR)
though not statistically significant. * Univariate logistic regression; OR – odds ratio; CI – confidence interval;
Table 2 shows the impact of socio-demographic variables in NS – non-significant.
loneliness perception in univariate analysis. The variables were
dichotomised by clinical criteria, using loneliness perception These findings were strengthened in the multivariate anal-
(cut-off > 36) as the outcome. ysis. The presence of severe family dysfunction (OR = 338.18;
An age of ≥ 80 years, living alone, education < 9 years, dissatis- p < 0.001) and dissatisfaction with income (OR = 17.52; p < 0.001)
faction with income and family dysfunction were associated with were significantly associated with the perception of loneliness
a greater perception of loneliness. On the other hand, being mar- by the elderly.
Table 3. UCLA-LS questions whose score was more contributory (white) or more protective (grey) to loneliness, by age group
Age Total p*
< 80 years ≥ 80 years n = 150
n = 103 n = 47
I feel like I’m a part of a group of friends, n (%) < 0.001
“Inverse” question never (4 points) 15 (14.6) 30 (63.8) 45 (30.0)
rarely (3 points) 18 (17.5) 11 (23.4) 29 (19.3)
sometimes (2 points) 37 (35.9) 6 (12.8) 43 (28.7)
frequently (1 points) 33 (32.0) 0 (0.0) 33 (22.0)
I don’t feel intimate with anyone, n (%) < 0.001
never (1 points) 40 (38.8) 0 (0.0) 40 (26.7)
rarely (2 points) 23 (22.3) 1 (2.1) 24 (16.0)
There are people I can turn to, n (%) < 0.001
“Inverse” question never (4 points) 5 (4.9) 2 (4.3) 7 (4.7)
rarely (3 points) 8 (7.8) 17 (36.2) 25 (16.7)
* Chi-square test.
Analysing the different components of UCLA-LS, we can Discussion

verify that the questions mostly counting towards loneliness
perception were “I feel like I’m a part of a group of friends” and Nine out of ten elderly individuals report some level of lone-
“I don’t feel intimate with anyone”, which scored negatively, liness, and more than 1/3 experience loneliness in moderate to
thus increasing the perception of loneliness. The question severe intensity. This is particularly evident in people older than
“There are people I can turn to” scored positively, seeming to 80 years of age, irrespective of gender, where a higher percep-
be protective. The group above 80 years of age showed worse tion of loneliness is also accompanied by family dysfunction.
results in both items (Table 3). Our results are slightly higher than other studies, where
Loneliness interferes with medical care, as seen through loneliness in the elderly varies between 14% and 25% [7, 9, 34].
chronic drug prescriptions. We accepted the definition of poly- Moreover, 22% of our population lives alone, which is close to
medication as the chronic consumption of 5 or more drugs per the USA reality of 26%, but significantly below the European
day. Polymedication was present in 62 patients (41.3%, 95% CI: mean of 32%, climbing to 45% above 80 years of age [5].
33.4–49.7%), more in the group above 80 years of age, with no Although the experience of loneliness is subjective and sin-
differences between gender. Our data showed an increase of gular, there are several significant determinants to the impact
the risk of polymedication in the elderly presenting loneliness on individual perception. Our study shows that the presence
(OR = 46.9; 95% CI: 16.9–130.0; p < 0.001). We also noticed of family dysfunction, according to the Family APGAR, and dis-
a positive correlation between loneliness and number of daily satisfaction with income are major factors in the perception of
chronic drugs (Spearman = 0.706; p < 0.001) (Figure 1). loneliness in the elderly. However, an age ≥ 80 years old, living
12
10
8
Number of drugs
0
No loneliness Low loneliness Moderate loneliness Severe loneliness
Figure 1. Relationship between the level of
Level of loneliness (ES-UCLA) loneliness and the number of drugs
142 C. Rocha-Vieira et al. • Loneliness in health care
alone and education < 9 years are also important contributors. In any case, loneliness is an important issue in the elderly,
On the other hand, having company and maintaining an active and efforts should be made to prevent its occurrence and, if not
professional life are protective factors. possible, to fight it when present. Simple acts such as provid-
When we evaluate the different dimensions of the UCLA-LS, ing company, promoting a healthy and participative family life,
the lack of friends and the lack of intimate relationships were maintaining daily activities to ensure social utility and improving
the main contributors to the perception of loneliness. Converse- social contact using day-care centres are examples of strategies
ly, having someone to turn to in the face of adversity was the that may reduce loneliness, thus improving health outcomes.
factor with the greatest influence on reducing loneliness. Guidelines for the health of the elderly should incorporate
Moreover, loneliness leads to an increase in the demand for social dimensions, such as companionship, adequate income
medical care, as proven by the relation with the great consump- and social utility, as preventive approaches to health. However,
tion of chronic medications, especially in the group over 80 these values are often forgotten in policies, in social frameworks
and even within families [36].
years of age. It is crucial to understand this interaction between
The city of Vila Nova de Gaia, where this study took place,
a social network and health care and to integrate it in health
presents a resident population over 65 years old of 15.4%, slight-
decision-making. We perceive that patients living alone without ly lower than the national statistics of 19.3%, according to of-
a supportive social network appeal to the health system, so- ficial numbers of Census 2011. About 38.7% of elders live alone
maticising their suffering and putting them at risk of overmedi- versus 46.9% throughout the entire country. These differences
calisation. In modern societies, being old is many times also the may condition the possibility to extrapolate data nationwide, but
subject of discrimination and stigma, conditioning individuals' they stress the importance of the conclusions of this study: If
living choices, healthy ageing and their quality of life. more than 1/3 of the elderly show a moderate to severe percep-
We must change mentalities, joining efforts in fighting tion of loneliness, in this urban area, with less elderly, and par-
loneliness in the elderly. Active ageing is defined by the World ticularly less isolated elderly, then, in other regions with worst
Health Organization since 2002 as “the process of developing scenarios, loneliness can be even more evident. Nevertheless,
and maintaining the functional ability that enables wellbeing this is an important limitation that we took into consideration.
as ageing occurs” [35]. Our results confirm that work activity On the other hand, although we used a single scale for
is a protective factor of loneliness. Therefore, political, legisla- the assessment of loneliness, the UCLA-LS is one of the most
tive, social and health measures should stimulate the elderly to valid and robust tools to measure it since it was first published
maintaining a variety of appropriate daily activities even after in 1978 [26]. Moreover, it has also been used in several Portu-
retirement, thus promoting the preservation of social utility and guese studies [28] with good reliability.
protecting against loneliness.
Loneliness requires a global approach to deal with the mul- Conclusions
tifactorial process. Age and its associated losses are important
factors in the increased perception of loneliness, but living This study characterises the impact of loneliness in a Por-
alone, dissatisfaction with income and the presence of family tuguese urban region. Loneliness is a common situation among
dysfunction appear as major associated elements. In this sense, the elderly and impacts medical care, being associated with an
good social and family supportive networks are useful to prevent increased number of daily chronic medications.
loneliness despite ageing. As we have stated, more loneliness Thus, loneliness interferes with health balance. To take good
also means more medical care needs and more chronic medica- care of our elders, we must look for the social framework and
tion taken. Strategies for investment to control loneliness will “prescribe” better family relationships and adequate pensions,
improve health outcomes and reduce the potential harms of aiming to improve the health outcomes and to prevent a pos-
overdiagnosis and polymedication. sible overmedicalisation of ageing.
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Tables: 3
Figures: 1
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Received: 8.10.2018
Reviewed: 1.11.2018

Paulo Santos, MD, PhD, Assoc. Prof.
Department of Medicine of Community,
Information and Health Decision Sciences Faculty of Medicine
University of Porto
Alameda Hernani Monteiro, S/N
4200-319 Porto
Portugal
Tel.: 00351936004916
E-mail: psantosdr@med.up.pt

ISSN 1734-3402, eISSN 2449-8580

Short-term hearing results in adults after a stapedotomy

Nader Saki1, A, B, Maryam Kardoni1, D, E, Mehdi Karimi2, A, C–E,
ORcid id: 0000-0003-4564-6406
Amir Mohammad Eghbalnejad Mofrad2, E, F

1
Hearing Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
2
Student Research Committee, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
Summary Background. A stapedectomy or stapedotomy is known as the best treatment option for patients with otosclerosis. Oto-
sclerosis is a primary disease of the bony labyrinth capsule, which is characterized by one or more localized foci, where bone deposition
occurs repeatedly. The best and most effective treatment option is a stapedectomy or stapedotomy.
Objectives. The present study evaluated the short-term hearing results in patients with otosclerosis after primary stapes surgery.
Material and methods. In this retrospective study, the short-term hearing results of all patients with otosclerosis after a primary sta-
pedotomy admitted to the Ahvaz Emam hospital from 2007 to 2017 was evaluated. Improvement in hearing was evaluated according
to the pre- and post-audiometry results. Air Conduction (AC), Bone Conduction (BC) and Air-Bone Gap (ABG) thresholds were recorded
at 500, 1 000, 2 000 and 4 000 Hz. SPSS software (Version 22.0) was used for statistical analysis.
Results. Of the 413 cases, 231 (55.93%) and 182 (44.07%) were females and males, respectively. The mean age of patients was 39.06
± 11.29 years. The disease in 131 (31.72%) was bilateral. The mean ABG in 341 patients (82.63%) ≤ 10 dB and in 52 patients (12.47%)
was 10–20 dB.
Conclusions. The results of the study showed that a primary stapedotomy is a successful and effective way to improve short-term
hearing results in adults with otosclerosis.
Key words: hearing loss, otosclerosis, audiometry, stapedotomy.
Saki N, Kardoni M, Karimi M, Eghbalnejad Mofrad AM. Short-term hearing results in adults after a stapedotomy. Fam Med Prim Care
Rev 2019; 21(2): 144–148, doi: https://doi.org/10.5114/fmpcr.2018.79991.
Background upper part of fixed stapes, named stapedectomy and stapedot-

omy, respectively [11].
Otosclerosis is a primary disease of the bony labyrinth cap- Previous studies reported the improvement of hearing in
sule [1], which is characterized by one or more localized foci, patients with otosclerosis after a primary stapedectomy [10–
where bone deposition occurs repeatedly. These foci may grad- 13]. However, adverse hearing results have been observed in
ually invade the annular ligament and stapes bone and lead to some patients, especially in patients with an advanced form of
bone ankylosis and reduce or eliminate sound conduction [2]. the disease [3]. A delay in treatment may also lead to progres-
Otosclerosis is a common cause of hearing loss in 15–50 year sion of otosclerosis and permanent deafness. Therefore, the
old patients [3] and is bilateral in most cases (60%) [4]. Oto- disease must be diagnosed at an early stage, and a stapedotomy
sclerosis is a rare clinical disease, which affected 0.5–2% of the or stapedectomy must be performed as a selective treatment
world’s population. This disease is limited to the otic capsules for improvement of hearing [4].
and causse progressive conductive hearing loss, as well as mixed
hearing loss, sensorineural hearing loss and vestibular disorders
[3]. However, the etiological and pathological mechanism of
Objectives
the disease is not clear. Researcher believed that otosclerosis is
The present study was designed to evaluate the results of
a hereditary illness transmitted as an autosomal dominant with
hearing improvement after a stapedotomy in adult patients
incomplete penetrance and a variable expression pattern [5, 6].
One of the main clinical findings in otosclerosis is progres- with otosclerosis and to evaluate the effect of some variables in
sive conductive hearing loss, especially at low frequencis (200– post-surgical hearing results.
–500 Hz), which is sometimes accompanied by sensorineural
hearing loss. Tinnitus is another common symptom of the dis- Material and methods
ease [4–7]. Otosclerosis plaque is mostly (80–95%) found in the
anterior part of the oval window and causes footplate fixation Study design
and hearing loss [6].
The best and most effective treatment option is a stapedec- This is a descriptive study conducted on patients with oto-
tomy or stapedotomy [2, 8]. In the case of hearing loss with sclerosis under surgical treatment at the Ahvaz Imam Khomeini
more than 30 dB and a rinne value, surgery is the only treat- Hospital from 2007–2017. For this purpose, after permission was
ment option [9, 10]. granted by the Ethics Committee of Ahvaz Jundishapur Universi-
Stapes surgery includes total or partial replacement of the ty of Medical Sciences (Ethics code: IR.AJUMS.REC.1396.1051).
N. Saki et al. • Short-term hearing results in adults after a stapedotomy 145
Setting, participants and variables frequency and percentage of frequency were analyzed. Kol-
mogorov–Smirnov and Leven tests were used for normality and
Sampling was done by census method, and inclusion criteria variance homogeneity tests, respectively. To measure the signif-
included all patients between 18–70 years of age with a clinical icance of differences and compare quantitative and qualitative
diagnosis of otosclerosis undergoing stapedotomy surgery for variables, the t-test and chi-squared test were used, respective-
the first time. According to these criteria, the sample size was ly. The paired t-test was used before and after surgery results.
542 patients. Patients with repeated surgery and incomplete The significance level in the tests was considered to be 0.05.
files were excluded from the study. Eventually, pre- and post-
-operative audiograms were available for 413 patients.
In this study, stapedotomy surgery was performed on pa- Results
tients with a teflon piston prosthesis by the same surgeon (first
author). Epidemiologic and clinical data included: age, gender, Descriptive data
unilateral or bilateral involvement and a pre- and post-operative
In the present study, 231 (55.93%) of the patients were fe-
audiogram collected and recorded in the designed form.
male, and 182 (44.07%) of the patients were male. All partici-
pants were 18–67 years of age (mean age 39.06 ± 11.29).
Pure Tone Audiometry (PTA) evaluation
Most of the patients (n = 197; 47.70) were in the 31–40
Improvement in hearing was evaluated according to the age group (Figure 1). The disease in 282 patients (68.28%) was
pre- and post-audiometry results. PTA factors include Air Con- unilateral, and in 131 (31.72), it was bilateral. Surgery was per-
duction (AC), Bone Conduction (BC) and Air-Bone Gap (ABG), formed on the right ear in 249 (60.29%) and on the left ear in
at frequencies of 500, 1000, 2000 and 4000 Hz were evaluated 164 (39.71%) cases. The mean follow-up time after surgery was
before and after surgery (last follow-up session, at least 6 weeks 3.27 months (range 2–7 months).
after surgery). Air-Bone Gap (ABG) was calculated as BC before In all of the mentioned frequencies, the pre- and post-sur-
surgery and AC threshold after surgery. The values expressed gery AC measurement was significantly different (p < 0.05), and
in dB were recorded for the mentioned frequencies. Hearing the highest difference before and after surgery was observed in
loss in the mentioned frequencies was evaluated in five groups: low frequencies (500 and 1 000 Hz) (Table 1).
ABG below 10 dB (excellent outcome), 10–20 dB (acceptable
outcome), 20–30 dB (weak outcome), above 30 dB (very weak Outcome data and main results
outcome) and complete deafness (bad outcome).
In all frequencies except 4000 Hz, the before and after BC
Statistical analysis measurement was significantly decreased (p < 0.05). The high-
est difference before and after surgery was observed at 2000
SPSS software (Version 22.0) was used for statistical analy- Hz. The BC pre- and post-surgery measurement at 4000 Hz was
sis. Descriptive statistics including mean, standard deviation, not significantly different (Table 2).
83
frequency
33
114
34
51 15
8 28 19 9
9 10 Figure 1. Frequency distribution of patients in differ-
age ent age groups by gender
Table 1. Average threshold of Air Conduction (AC) before and after surgery
p Difference After surgery (dB) Before surgery (dB) PTA
0.0001 31.70 ± 12.17 19.89 ± 12.61 51.60 ± 14.03 Hertz 500
0.0001 33.72 ± 12.74 20.64 ± 12.31 54.36 ± 13.57 Hertz 1000
0.0001 28.29 ± 13.52 22.66 ± 12.07 50.96 ± 16.76 Hertz 2000
0.0001 25.85 ± 18.92 28.30 ± 15.64 54.15 ± 19.03 Hertz 4000
Table 2. Average threshold of Bone Conduction (BC) before and after surgery
P-value Difference After surgery (dB) Before surgery (dB) PTA
0.0001 5.00 ± 8.40 15.64 ± 8.69 20.64 ± 10.40 Hertz 500
0.0001 9.04 ± 10.45 17.23 ± 10.97 26.28 ± 11.72 Hertz 1000
0.0001 13.29 ± 12.38 19.68 ± 9.85 32.98 ± 13.81 Hertz 2000
0.084 4.14 ± 16.12 24.68 ± 13.20 28.83 ± 15.88 Hertz 4000
146 N. Saki et al. • Short-term hearing results in adults after a stapedotomy
Table 3. Average Air-Bone Gap (ABG) before and after surgery

p Difference Before surgery (dB) After surgery (dB) PTA
0.0001 27.23 ± 10.77 4.03 ± 6.39 31.28 ± 10.07 Hertz 500
0.0001 24.36 ± 12.23 3.94 ± 6.42 28.30 ± 11.24 Hertz 1000
0.0001 17.02 ± 12.18 2.98 ± 4.50 20.00 ± 11.37 Hertz 2000
0.0001 21.91 ± 13.81 4.15 ± 7.96 26.06 ± 12.85 Hertz 4000
Table 4. Improvement of Air-Bone Gap (ABG) after surgery

Total Hertz 4000 Hertz 2000 Hertz 1000 Hertz 500 ABG result
(82.63) 341 (81.36) 336 (84.75) 350 (82.57) 341 (81.84) 338 0–10 dB
excellent outcome
(12.47) 52 (13.08) 54 (11.38) 47 (12.59) 52 (12.83) 53 11–20 dB
acceptable outcome
(2.72) 11 (3.15) 13 (1.94) 8 (2.66) 11 (3.15) 13 21–30 dB
weak outcome
(1.45) 6 (1.69) 7 (1.21) 5 (1.45) 6 (1.54) 6 very weak outcome
(0.73) 3 (0.73) 3 (0.73) 3 (0.73) 3 (0.73) 3 complete deafness
bad outcome
The difference between pre- and post-surgery ABG was sig- BC at the mentioned frequencies. However, at the 2000 Hz fre-
nificant (p < 0.05), and the highest difference before and after quency, a significant difference between pre- and post-surgery
surgery was observed at low frequencies (500 and 1000 Hz) BC was observed, and the means of BC were 35.75 and 31.97,
(Table 3). After surgery, ABG in 82.63% and 95.1% of patients respectively [22]. The significant decrease in the BC threshold at
reached to below 10 and 20 dB, respectively. Complete deaf- the 2000 Hz frequency led to a reduction in ossicles fluctuations
ness was reported in 3 patients. The best hearing outcomes in otosclerosis and internal stimulation problems, especially at
were observed at 2000 Hz (Table 4). a frequency of 2000 Hz [22]. In the present study, the highest
A significant relationship between improvement in post- rate of improvement in BC was observed at a frequency of 2 000
surgery BC, AC and ABG variables considering age, gender and Hz, which is attributed to Carhart’s notch phenomenon.
involvement (unilateral or bilateral) was not observed in any of A worse BC threshold in the short term after surgery was re-
the frequencies (p > 0.05). ported by Tange and Grolman, which may be caused by cochlear
trauma. However, this did not lead to weaker results [23].
The aim of otosclerosis surgery was improvement of AC and
Discussion ABG closure. Therefore, one of the main evaluation factors in
stapedotomy surgery is AC threshold improvement [16]. In the
In this study, most patient were in the 31–40 age group, and present study, AC hearing improvement at different frequencies
females were more nemerous than males. The results of various was 29.9 dB, which is undoubtedly good and is consistent with
studies indicate a higher incidence of disease in females [1, 5, the results of other similar studies [10, 15, 16]. In our study, the
6, 10, 13–17]. In the present study, unilateral involvement was highest pre- and post-surgery differences were observed at low
observed in 68.28% of cases, and in 60.29% of patients, surgery frequencies (500 and 1000 Hz).
was performed on the right ear. In the study conducted by Saki The mean difference in pre- and post-surgery AC (hearing
et al., most of the patients had unilateral involvement, and only improvement) in the studies conducted by Hossain et al. [10],
in 18.2% of cases was bilateral involvement observed [13]. In Mahafza et al. [16] and Dankuc et al. [22] were 23.58, 24.2 and
some studies, left ear involvement was reported more often 18.67, respectively, which was more significant at low frequen-
[16, 18, 19]. cies. These results suggest the effectiveness of otosclerosis
treatment, especially at low frequencies, which is consistent
Interpretation and generalizability with our results. The biggest improvement in AC threshold was
observed at low frequencies [6]. Overall, the short-term re-
In the present study, BC hearing improvement at different sults of the post-surgery AC were excellent in all research. For
frequencies was 7.9 dB. The audiological evaluation showed example, in the study by Kolo and Ramalingam [3], the mean
different results concerning post-surgery BC. In some studies, difference between pre- and post-surgery AC at the mentioned
constant BC thresholds were reported, while different degrees frequencies was 21.48 dB. This threshold was 21.58 in study of
of progressive sensorineural hearing loss were shown in other Nair et al. [9].
studies. Mahafza et al. reported significant mean differences in In this study, we showed that the differences between pre-
pre- and post-surgery BC (hearing improvement) at 500–4000 Hz and post-surgery ABG at all frequencies was statistically signifi-
frequencies, which was 3.1 dB [16]. Redfors and Möller showed cant, with more differences observed at low frequencies (500,
that post-surgery BC was significantly improved, which equaled 1000 Hz). The benefits of surgery include reduction or closure
6 dB [20]. These findings are consistent with our results. Bernar- of ABG in post-surgery PTA (short term & long term) and hear-
do et al. showed a significant improvement in post-surgery BC ing improvement, which was reported in several studies [6,
at all frequencies except 4000 Hz, and mean improvement at all 24]. Baradaranfar et al. [25] showed that the mean ABG at fre-
frequencies was 4.7 dB [6]. On the other hand, in all audiometry quencies of 500–4000 dB decreased from 41.2 to 12.4 dB three
conducted by Nair et al. [9], Hossain et al. [10] and Quaranta et months after surgery. In the study of Dankuc et al., the mean
al. [21], there was no significant change in BC rates observed differences of pre- and post-surgery ABG at all frequencies was
at the mentioned frequencies. These results are not consistent significant and equal to 19.92 (from 27.12 to 7.5 dB post-sur-
with the findings of our study. gery) [22]. In the study conducted by Kolo and Ramalingam sig-
In the study by Dankuc et al., pre- and post-mean BC at nificant improvement in hearing after the first surgery was ob-
frequencies of 500, 1000 and 4000 Hz was not statistically sig- served, and the mean differences of pre- and post-surgery ABG
nificant, and it was concluded that the surgery had no effect on at frequencies of 0.5, 1, 2 and 4 Hz were significantly decreased
N. Saki et al. • Short-term hearing results in adults after a stapedotomy 147
(from 43.14 to 19.17 dB). Better post-operative hearing results of prosthesis, as well as the severity of the disease [26], but
at lower frequencies can be due to the fact that higher frequen- these factors were not taken into consideration in this study.
cies are usually more affected by the disease process [3]. Our Differences in the results can be attributed to sampling size
results showed significant improvement in hearing, especially and the population studied, the severity of the disease, or even
at low frequencies, which is consistent with previous studies. the surgical technique, and the expertise and experience of the
In the present study, the post-operative ABG threshold in surgeon.
83% of cases reached below 10 dB. The incidence of complete
deafness after primary stapes bone surgery in this study was
lower than other studies (0.4 to 3%) [11, 16, 19]. In the study Conclusions
by Hossain et al., ABG below 10 dB and complete deafness
was 84% and 2%, respectively [10]. Sensorineural hearing loss An improvement in hearing regarding a decrease in AC,
(SNHL) in the study conducted by Nair et al. [9] and Vincent et BC and ABG showed that in 95%, the ABG threshold reached
al. [17] was 1% and 0.7%, respectively. below 20 dB, which indicates successful surgery results in the
Good surgical results (ABG ≤ 10 dB) were below 80% in short term (mean follow-up 3.27 months). Therefore, primary
some studies [14–16, 19]. In the study of Saki et al. [13], ABG be- stapedotomy surgery in patients with otosclerosis is effective in
low 10, between 10–20, above 30 and complete deafness was short-term improvement in adults. Further multi-centered pro-
63.9, 29.9, 2.5 and 1%, respectively. Bagherian [2015] showed spective studies with a larger sample size are recommended un-
a significant decrease in the mean difference between pre- and der standard conditions and with a long-term follow-up period.
post-operative ABG following otosclerosis surgery [18]. Dankuc
et al. showed that an ABG threshold below 20 dB and 10 dB was Acknowledgments. This study was the result of the disserta-
97% and 70%, respectively [22]. In general, good post-operative tion thesis registered in Ahvaz Jundishapur University of Medical
auditory results have been reported in several studies; however, Sciences (AJUMS), Ahvaz, Iran and financially supported by the
some differences in the auditory results of different studies can Vice-Chancellor for Research of the AJUMS and Hearing Research
be related to the size of the sample examined, the size and type Center, AJUMS, Ahvaz, Iran (Registration number: HRC-9680).
Source of funding: This work was funded by the University’s Vice-Chancellor for Research and Hearing Research Center.
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Tables: 4
Figures: 1
References: 27
Received: 3.08.2018

Karimi Mehdi, MD, PhD
Student Research Committee
Ahvaz Jundishapur University of Medical Sciences
Ahvaz
Iran
Tel.: +989379217677
E-mail: omre_man61@yahoo.com
ISSN 1734-3402, eISSN 2449-8580

Assessment of the perception of physicians concerning anti-

biotic use and resistance along with the factors influencing the
prescription of antibiotics: a situational analysis from Pakistan
Zikria Saleem1, 2, 3, A–F, Mohamed Azmi Hassali1, A, C, D, F, Furqan Hashmi2, D–F,
ORCID iD: 0000-0003-3202-6347
Faiza Azhar1–3, D–F, Hamna Hasan2, B–D, Saba Zaheer2, B–D, Inaam Ur Rehman2, D, F
1
School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
2
University College of Pharmacy, University of the Punjab, Lahore, Pakistan
3
Rashid Latif College of Pharmacy, Lahore, Pakistan
Summary Background. Antimicrobial resistance is an emerging problem worldwide, having a negative influence on patient out-
comes. As compared to high and upper middle-income countries, the condition is miserable in low- and middle-income countries,
including Pakistan.
Objectives. This study aims to assess the perception of physicians concerning antibiotic use and resistance, the factors influencing the
prescription of antibiotics and interventions to improve the prescribing behavior in Pakistan.
Material and methods. A cross-sectional survey was performed among physicians practicing in different hospitals of Lahore, Pakistan.
A 60-item survey instrument was developed in consultation with a group of experts after a literature review of previous comparable
studies. The questionnaire was distributed to physicians practicing in different healthcare settings of Lahore, Pakistan.
Results. A total population of 200 physicians filled in the questionnaire, with a response rate of 72.7%. The majority of physicians were
younger (n = 124, 62%), with an age group of 23–29 years. Most of the physicians reported that antibiotics are overused nationally
(n = 190, 95%). However, they did not always agree that antibiotics are overused in their own institutions. A majority of physicians be-
lieved that strong knowledge of antibiotics is important in their career (n = 184, 92%). Of the total, 176 (88%) physicians believed that
inappropriate use of antibiotics is professionally unethical.
Conclusions. Our findings showed that physicians are well aware of the importance of antibiotic resistance and reported that rational
use of antibiotics will aid in resolving this issue. Therefore, the introduction of educational sessions regarding antibiotic use and its re-
sistance and innovative approaches to attract healthcare practitioners’ attention towards antibiotic stewardship programs are urgently
needed.
Key words: drug resistance, microbial, physicians, Pakistan.
Saleem Z, Azmi Hassali M, Hashmi F, Azhar F, Hasan H, Zaheer S, Ur Rehman I. Assessment of the perception of physicians concerning
antibiotic use and resistance along with the factors influencing the prescription of antibiotics: a situational analysis from Pakistan. Fam
Med Prim Care Rev 2019; 21(2): 149–157, doi: https://doi.org/10.5114/fmpcr.2019.84551.
Background sicians, guideline factors, such as guideline characteristics, and

environmental factors, such as lack of resources, lack of time,
To promote appropriate use of drugs, it is essential to col- lack of reimbursement and lack of adequate knowledge [9, 10].
lect data regarding the pattern of drug prescriptions and factors Awareness of antibiotic resistance is increasing among the
affecting prescribing options [1]. Antimicrobial resistance is an general public and medical community, and the impact of re-
emerging public health problem worldwide, having a negative sistance on clinical, as well as economic, outcomes is the main
influence on patient outcomes [2–4]. About 40% of antibiotic issue of ongoing research. Awareness of the impact on antibi-
usage is either inappropriate or unnecessary [5]. The increased otic resistance has several benefits [2]. Firstly, this information
use of antibiotics has led to the initiation of national guidelines regarding antibiotic resistance with respect to patient outcomes
and policies to enhance antibiotic stewardship in many countries may provoke hospitals and healthcare professionals to initiate
[6]. The chief goal of antibiotic stewardship is to improve clinical a multifaceted approach to prevent infections. Secondly, such
outcomes while reducing unintentional outcomes of antibiotic
knowledge can also help policy makers regarding funding of
use that include side effects, selection of microorganisms and
infection control and prevention programs. Thirdly, such infor-
development of resistance [7]. In order to improve organization
of the healthcare system and to change the prescribing behavior mation can also be useful for healthcare practitioners to make
of healthcare practitioners, a multifaceted strategy is favored [7, appropriate choices with respect to antibiotic use according to
8]. Proper recommendations and well-oriented interventions guidelines. Knowledge regarding antibiotic resistance may be
are often insufficient in improving the behavior of physicians substantial in elucidating the prognosis for infected individu-
in clinical settings. The success of the implementation clinical als. Multisite studies have been published regarding physicians’
practice guidelines depends on the consideration of a variety of attitudes towards antibiotic use, as well as the emergence of
barriers. Factors include patient factors, to coordinate with phy- resistance and prescribing behavior in inpatient settings [11,
150 Z. Saleem et al. • The perception of physicians concerning antibiotic use and resistance
12]. A change in prescribing behavior will require changes in the Data analysis
behavior of healthcare practitioners, and thus it is necessary to
figure out what healthcare practitioners know about antibiot- After circulation and collection of the questionnaires from
ics, how they use their knowledge and what factors affect their all physicians, data was organized and compiled. All data was
prescription of antibiotics [13, 14]. analyzed with SPSS software. Descriptive analyses included
percentages for categorical and ordinal data. We tested for as-
sociation among the various variables by using chi-square test.
Objectives A p-value less than 0.05 was considered statistically significant.
The present study is aimed at assessing the perception of

physicians concerning antibiotic use and resistance, the factors Results
influencing prescription of antibiotics and interventions to im-
prove prescribing behavior. Table 1 provides an overview of the basic demographics and
professional profile of participating physicians. A total popula-
tion of 200 participants filled in the questionnaire, with a re-
Material and methods sponse rate of 72.7% from different hospitals in Lahore. Most of
the physicians were younger (n = 124, 62%) in the age group of
Study design, period and setting 23–29 years. Of the total, 118 (59%) respondents had graduated
from public institutions, and the others had graduated from pri-
A traditional paper and pencil cross-sectional, anonymous vate institutions, having between 1–5 years of experience (n =
and voluntary survey was conducted among physicians practic- 108, 54%). Among all the physicians, 73 (36.5%) were medical
ing in different hospitals of Lahore, Pakistan. Lahore is a major officers, while the others include house officers (n = 66, 33%),
metropolitan city of Pakistan with advanced healthcare settings. post graduate residents (n = 39, 19.5%) and consultants (n = 22,
The study was conducted between December 2017 and March 11.0%). More than half of the respondents noted that they had
2018. The study was started after receiving ethics approval from been involved in less than 16 prescriptions of antibiotics in the
the human ethics committee of the University College of Phar- last week (n = 130, 65%) before the survey, while the others pre-
macy, University of the Punjab (HEC/1000/PUCP/1925PhKAP). scribe more than 16 antibiotics per week (n = 70, 35%).
The physicians involve in this survey were qualified as resident
physicians to specialized physicians. Table 1. Demographic characteristics of participating physicians
Survey instrument Demographics n %

Gender
A 60-item survey instrument was developed in consulta- Male 95 47.5
tion with a group of experts after a literature review of previ- Female 105 52.5
ous comparable studies [5, 11–13, 15–20]. The questionnaire Age
consists of 5 sections: the first section consists of demographics 23–29 124 62.0
and the professional profile of the physician; the second section 30–60 76 38.0
consists of perception about antimicrobial use; the third sec- Medical school
tion consists of perception about antimicrobial resistance; the Public 118 59.0
fourth section consists of factors influencing antimicrobial pre- Private 82 41.0
scription; and the fifth section includes interventions to improve
Experience
prescription of antibiotics. For the series of questions regarding
< 1 year 32 16.0
perceptions about antibiotic use and resistance, a 5-item Likert
1–5 year 108 54.0
scale was used, with response options from “strongly disagree”
6–10 year 27 13.5
to “strongly agree”. Whereas, another 5-item scale including
> 10 years 33 16.5
never, rarely, sometimes, often and always was used to explore
factors influencing prescription of antibiotics. Face and content Medical specialty
validity was carried out by experts in the field of quantitative re- General physician 119 59.5
search. Cronbach’s alpha determined the average correlation of Specialized physician 81 40.5
items or internal consistency in the survey instrument to gauge Designation
its reliability (0.761). Before the full-scale study, pilot data was Medical officer 73 36.5
collected from 10 physicians, and changes were made in the House officer 66 33.0
survey instrument by removing any flaws accordingly. Post graduate resident 39 19.5
Consultant 22 11.0
Survey administration Clinical setting
Inpatient 34 17.0
The sample size was calculated by using the Raosoft sample Outpatient 27 13.5
size calculator (n = 268). Questionnaires were distributed to Approximately equal time between both 139 69.5
275 physicians using the non-probability convenience sampling No. of antibiotics prescribed last week
technique. The questionnaire included a detachable cover letter 1–8 72 36.0
consisting of a consent form, which enabled tracking. The cover 8–16 58 29.0
letter, comprised of details about the handling of the survey in- > 16 70 35.0
strument and delinking of identity of respondents, was assured Practice setting
for its anonymity. A hard copy of the survey instrument was Public 71 35.5
distributed to physicians practicing in different healthcare set- Private 42 21.0
tings after receiving approval from each corresponding hospital. Both 87 43.5
The filled in questionnaires were checked thoroughly, and any
Hospital type
incomplete questionnaires were removed. There was no incen-
Secondary 54 27.0
tive for respondents in order to motivate participation.
Tertiary 58 29.0
Teaching 88 44.0
Table 2. Perceptions about antimicrobial use
Questions SA A N DA SD Age Gender Experi- Medical Designa- Clinical Practice Hospital
n (%) n (%) n (%) n (%) n (%) ence specialty tion setting setting type
Antibiotics are overused nationally 92 (46.0) 98 (49.0) 9 (4.5) 1 (.5) 0 – – – – – – – 0.035
Antibiotics are overused in my hospital 48 (24.0) 75 (37.5) 42 (21.0) 29 (14.5) 6 (3.0) – – – – – 0.002 0.010 –
Strong knowledge of antibiotics is impor- 127 (63.5) 57 (28.5) 11 (5.5) 3 (1.5) 2 (1.0) – – – – – – – –
tant in my medical career
I am confident that I use antibiotics opti- 41 (20.5) 102 (51.0) 47 (23.5) 10 (5.0) 0 – – – – – – – 0.013
mally in the ICU
I am confident that I use antibiotics opti- 42 (21.0) 93 (46.5) 51 (25.5) 11 (5.5) 3 (1.5) – – – – – – 0.033 –
mally in a non-ICU setting
I overprescribe antibiotics 20 (10) 58 (29.0) 41 (20.5) 67 (33.5) 14 (7.0) – – – – – – 0.046 –
Other doctors overprescribe antibiotics 35 (17.5) 71 (35.5) 69 (34.5) 23 (11.5) 2 (1.0) – – – – – – – –
Pharmaceutical representatives do not 56 (28.0) 75 (37.5) 39 (19.5) 26 (13.0) 4 (2.0) – – – – – – – –
influence my prescription of antibiotics
Inappropriate use of antibiotics can harm 101 (50.5) 71 (35.5) 25 (12.5) 3 (1.5) 0 – – – 0.044 0.008 - 0.031 0.003
patients
Inappropriate use of antibiotics is profes- 114 (57.0) 62 (31.0) 20 (10.0) 3 (1.5) 1 (.5) – – – – – 0.007 – –
sionally unethical
I prescribe too many anti-microbials 48 (24.0) 57 (28.5) 42 (21.0) 44 (22.0) 9 (4.5) 0.027 0.033 0.013 – – 0.045 – –
because of poor quality anti-microbials
I prescribe anti-microbials according to 48 (24.0) 103 (51.5) 26 (13.0) 18 (9.0) 5 (2.5) – – 0.049 – – – – –
availability in inventory
SA – strongly agree; A – agree; N – neutral; DA – disagree; SD – strongly disagree; significant difference ≤ 0.05 – non significant.
Z. Saleem et al. • The perception of physicians concerning antibiotic use and resistance
151

Family Medicine & Primary Care Review 2019; 21(2) 152
Table 3. Perceptions about antimicrobial resistance

Questions SA A N DA SD Medical Experience Medical Designation Clinical Hospital
n (%) n (%) n (%) n (%) n (%) school specialty setting type
Antibiotic resistance is a significant problem nationally 87 (43.5) 106 (53.0) 5 (2.5) 2 (1.0) 0 – – – – – –
Antibiotic resistance is a significant problem in my 46 (23.0) 104 (52.0) 43 (21.5) 7 (3.5) 0 – – – – – –
hospital
Better use of antibiotics will reduce problems with 96 (48.0) 95 (47.5) 9 (4.5) 0 0 – – – – – –
antimicrobial resistance
Poor hand hygiene causes antibiotic resistance 43 (21.5) 70 (35.5) 51 (25.5) 31 (15.5) 5 (2.5) – – – – – –
Excessive use of antimicrobial in livestock/animal farms 57 (28.5) 79 (39.5) 42 (21.5) 17 (8.5) 5 (2.5) 0.016 – – – – –
can cause resistance
Paying too much attention to advertising causes resis- 23 (11.5) 67 (33.5) 61 (30.5) 40 (20.0) 9 (4.5) – 0.007 – – – 0.027
tance
Lengthy durations of antimicrobial treatments can 59 (29.5) 91 (45.5) 33 (16.5) 14 (7.0) 3 (1.5) 0.033 – 0.015 – – –
result in the development of resistance
Too low doses of antimicrobial treatments can develop 40 (20.0) 91 (45.5) 43 (21.5) 23 (11.5) 3 (1.5) – – – – – –
resistance
Too many broad-spectrum antimicrobial treatments 46 (23.0) 95 (47.5) 44 (22.0) 13 (6.5) 2 (1.0) – – – – – –
can result in the development of resistance
I am concerned about antimicrobial resistance in the 77 (38.5) 97 (48.5) 21 (10.5) 4 (2.5) 1 (.5) – – – 0.021 – –
society
I am concerned about antimicrobial resistance in my 87 (43.5) 85 (42.5) 20 (10.0) 7 (3.5) 1 (.5) 0.038 – – – 0.001 –
hospital
Poor infection control practices increase the spread of 64 (32.0) 103 (51.5) 29 (14.5) 4 (2.0) 0 – – – – – –
antimicrobial resistance
Table 4. Factors influencing antimicrobial prescribing practices
Factors A O S R N Age Gender Medical Experi- Medical Designa- Clinical Practice Hospital
n (%) n (%) n (%) n (%) n (%) school ence specialty tion setting setting type
Antimicrobials can save cost by reducing length of 35 (17.5) 63 (31.5) 63 (31.5) 23 (11.5) 16 (8.0) – – – – – – 0.026 – 0.002
hospitalization
To avoid risk of potential infection 39 (19.5) 67 (33.5) 65 (32.5) 24 (12.0) 5 (2.5) – – – – – – – 0.041 0.031
Antibiotic prophylaxis prevents postoperative 29 (14.5) 81 (40.5) 50 (25.0) 23 (11.5) 17 (8.5) – – 0.043 – – – – – 0.003
infection
Patient demands antibiotics 34 (17.0) 49 (24.5) 61 (30.5) 45 (22.5) 11 (5.5) – – – – – – – – 0.014
Patient is critically ill 42 (21.0) 60 (30.0) 59 (29.5) 27 (13.5) 12 (6.0) 0.016 0.010 – – – – 0.042 0.002 0.031
Patient is immune compromised 38 (19.0) 47 (23.5) 67 (33.5) 37 (18.5) 11 (5.5) – – – – – – – – 0.008
Unexplained fever even if culture results are 15 (7.5) 58 (29.0) 64 (32.0) 47 (23.5) 16 (8.0) – 0.014 – 0.017 0.037 0.029 – – –
negative
Leukocytosis even if culture results are negative 17 (8.5) 45 (22.5) 67 (33.5) 52 (26.0) 19 (9.5) 0.002 0.047 – 0.046 0.000 – – 0.003 0.036
Too much prescribing can increase the risk of C. 19 (9.5) 53 (26.5) 60 (30.0) 50 (25.0) 18 (9.0) – – – 0.000 0.007 – – 0.015 –
difficile colitis
A – always; O – often; S – sometimes; R – rarely; N – never; significant difference ≤ 0.05 – non significant.
153

Table 5. Helpfulness of potential interventions to improve prescription of antibiotics

Interventions SA A N DA SD Medical Experience Practice Hospital
n (%) n (%) n (%) n (%) n (%) school setting type
Pharmaceutical representative 38 (19.5) 94 (47.0) 45 (22.5) 13 (6.5) 10 (5.0) 0.015 0.026 – –
Restricted prescription of all AM 34 (17.0) 103 (51.5) 52 (26.0) 10 (5.0) 1 (0.5) 0.038 – – –
Advice from a pharmacist (hospital/clinical) 52 (26.0) 88 (44.0) 35 (17.5) 20 (10.0) 5 (2.5) – – – –
Advice from infection control/antimicrobial management team 40 (20.0) 122 (61.0) 33 (16.5) 2 (1.0) 3 (1.5) 0.025 0.028 – –
Computer-aided prescribing 48 (24.0) 92 (46.0) 36 (18.0) 19 (9.5) 5 (2.5) – – – –
Availability of resistance data/microbiological data 42 (21.0) 111 (55.5) 43 (21.5) 3 (1.5) 0 – – 0.006 –
Advice from senior colleagues 52 (26.0) 109 (54.5) 28 (14.0) 7 (3.5) 2 (1.0) – – – –
Audit and feedback 44 (22.0) 97 (48.5) 51 (25.5) 8 (4.0) 0 – – – –
Educational sessions 75 (37.5) 90 (45.0) 26 (13.0) 6 (3.0) 3 (1.5) – – – –
Availability of local guidelines 77 (38.5) 91 (45.5) 29 (14.5) 3 (1.5) 0 – – – –
Wait for the microbiology results before treatment 51 (25.5) 82 (41.0) 46 (23.0) 20 (10.0) 1 (.5) – – – –
Rapid and effective diagnostic techniques 80 (40.0) 92 (46.0) 17 (8.5) 9 (4.5) 2 (1.0) – – – 0.001
Ward rotations 48 (24.0) 104 (52.0) 30 (15.0) 13 (6.5) 5 (2.5) – – – –
Off-campus lectures sponsored by pharmaceutical companies 49 (24.5) 86 (43.0) 36 (18.0) 16 (8.0) 13 (6.5) – – – –
Medical journals 67 (33.5) 105 (52.5) 21 (10.5) 6 (3.0) 1 (.5) – – – –
Conferences 76 (38.0) 90 (45.0) 29 (14.5) 5 (2.5) 0 – – – –
Z. Saleem et al. • The perception of physicians concerning antibiotic use and resistance 155
Table 2 depicts the perceptions of physicians concerning antibiotics (n = 140, 70%). A majority of the respondents agreed
antimicrobial use in their daily routine. Most of the physicians with the statements that advice from senior colleagues (n = 161,
were in agreement concerning the statement that antibiotics 80.5%) and audit and feedback (n = 70.5%) are helpful in pre-
are overused nationally (n = 190, 95%), although some physi- scribing antibiotics. Educational sessions (n = 165, 82.5%) and
cians settled in tertiary hospitals remained neutral (p = 0.035). the availability of local guidelines (n = 168, 84%) were thought
A majority of the physicians believed that strong knowledge to be more helpful in prescribing antibiotics. Rapid and effec-
of antibiotics is important in their career (n = 184, 92%). Most tive diagnostic techniques were thought to be an important in-
of the physicians were confident that they use antibiotics op- tervention in prescribing antibiotics by most of the physicians
timally in both ICU (n = 143, 71.5%) and non-ICU settings (n = (n = 172, 86%), while some physicians working in teaching hos-
135, 67.5%), respectively. Almost equal numbers of physicians pitals were significantly in agreement regarding this statement
agreed (n = 78, 39.0%) and disagreed (n = 81, 40.5%) that they (p = 0.001). A majority of the physicians agreed that ward rota-
over-prescribe antibiotics, while some respondents practicing in tions (n = 152, 76%), off-campus lectures sponsored by pharma-
private sectors significantly disagreed that they over-prescribe ceutical companies (n = 135, 67.5%), medical journals (n = 172,
antibiotics (p = 0.046). More physicians agreed that interactions 86%) and conferences (n = 166, 83%) are important and helpful
with pharmaceutical representatives do not influence their an- interventions in prescribing antibiotics.
tibiotic selections (n = 131, 65.5%). Physicians mostly believed
(n = 172, 86%) that inappropriate use of antibiotics can harm Discussion
patients. A majority of physicians agreed (n = 176, 88%) with the
statement that inappropriate use of antibiotics is professionally Antibiotic resistance is a local as well as national issue in
unethical. healthcare settings, resulting in an increase in mortality and
The perceptions of physicians about antimicrobial resis- morbidity rates. This study evaluated physicians’ perceptions
tance in patients is presented in Table 3. A majority of the phy- regarding antibiotic use and resistance and factors affecting
sicians agreed with the statement that antibiotic resistance is antibiotic prescribing behavior. Most of the physicians were in
a significant problem nationally and in their hospitals (n = 193, agreement that antibiotics are overused nationally. Appropriate
96.5% and n = 104, 75%, respectively). According to physicians, use of restricted antimicrobial agents can reduce the overuse of
the appropriate use of antibiotics can reduce problems associ- antibiotics. Occasionally, in order to resolve one issue, it may be
ated with antimicrobial resistance (n = 191, 95.5%). More than replaced by the emergence of another issue. For example, with
half of the physicians agreed that poor hand hygiene is one the restriction of use of cephalosporins in ceftazidime-resistant
of the causes of antibiotic resistance (n = 113, 56.5%). Most Klebsiella, the incidence of imipenem-resistant Pseudomonas
of the physicians believed that long-term therapies of anti- aeruginosa is increased [21]. Antibiotic restriction targets not
microbial agents can result in the development of resistance only the reduction of antibiotic resistance but also reduces
(n = 150, 75%). A majority of the physicians believed that low doses healthcare costs, decreases the length of hospital stay and im-
(n = 131, 65.5%) and the use of broad-spectrum antimicrobials proves patient outcomes [22]. A majority of the physicians be-
(n = 141, 70.5%) can result in the development of resistance. lieved that strong knowledge of antibiotics is important in their
Most of the physicians (n =167, 83.5%) were agreed with the career. Multidisciplinary teams composed of physicians, phar-
statement that poor infection control practices by healthcare macists, microbiologists and infection prevention and control
professionals’ cause spread of antimicrobial resistance. practitioners should initiate antibiotic stewardship programs
Factors influencing antimicrobial prescribing practices are based on ongoing research regarding antibiotic use and resis-
mentioned in Table 4. Some physicians caring for outpatients tance [23].
(p = 0.026) and those from secondary hospitals (p = 0.002) said Most of the physicians believed that they over-prescribe
that quite often antibiotics can save on the cost of treatment antibiotics. Physicians mostly reported that inappropriate or
by reducing the length of hospitalization. Most of the physi- unnecessary use of antibiotics can harm patients. Antibiotic
cians believed that antibiotic prophylaxis often prevents post- management programs have demonstrated substantial health-
operative infection (n = 80, 40.5%), but some physicians who care cost savings as a result of decreased antibiotic usage, thus
graduated from public institutions (p = 0.043) and some working improving patient safety [7]. Inappropriate use of antibiotics is
in a tertiary setting (p = 0.003) showed that antibiotic prophy- professionally unethical. Physicians were mostly in agreement
laxis quite often prevents postoperative infection. According to that they prescribe antibiotics according to their availability in
some physicians from teaching hospitals, sometimes patients inventory. Our findings reported that a majority of the physi-
demands antibiotics (p = 0.014). About 67 physicians (37.5%) cians believed that low doses and the use of broad-spectrum
reported that antibiotics are sometimes prescribed when the antimicrobials can result in the development of resistance.
patient is immune compromised. Male participants (p = 0.014), Within healthcare settings, a minimum demand of antibiotics
physicians having experience greater than 10 years (p = 0.017), sequentially decreases healthcare costs [24]. A majority of phy-
some specialized physicians (p = 0.037) and some post graduate sicians agreed that poor infection control practices by health-
residents (p = 0.029) were more likely to give antibiotics when care professional causes the spread of antimicrobial resistance.
there was an unexplained fever, even if culture results are nega- Male participants, physicians having experience greater than 10
tive. Most physicians agreed that too much antimicrobial pre- years, some specialized physicians and post-graduate residents
scribing can increase the risk of developing Clostridium difficile were more likely to give antibiotics for an unexplained fever
colitis (n = 60, 30%). even if the culture results are negative (p < 0.05). Most physi-
Table 5 overviews the potential interventions to improve cians agree that too frequent anti-microbial prescriptions can
the prescription of antibiotics. A majority of the participants sometimes increase the risk of developing Clostridium difficile
believed that restricted prescription of all antimicrobials is im- colitis. A few studies have reported that antibiotic resistance is
portant in improving the prescription of antibiotics (n = 137, sometimes the most important risk factor for Clostridium dif-
68.5%), while some from private schools particularly agreed ficile infection [25, 26]. The emergence and escalation of resis-
(p = 0.038). Most of the physicians believed that advice from tant pathogens have threatened the efficacy of antibiotics [27].
a hospital or clinical pharmacist is necessary in prescribing an- A majority of the participants believed that restricted prescrip-
tibiotics (n = 140, 70%). A majority of the physicians reported tion of all antimicrobials is important in improvoving prescribing
that advice from the infection control team or antimicrobial antibiotics. Inappropriate prescribing or overuse of antibiotics
management team is helpful in the intervention of prescribing can bring about the emergence of antibiotic resistant pathogens
antibiotics (n = 162, 81%). More physicians were in agreement [28, 29]. In order to optimize the prescribing behavior, a target-
that computer-aided prescribing is very helpful in prescribing ed multidisciplinary approach is needed [30]. The prescribing
156 Z. Saleem et al. • The perception of physicians concerning antibiotic use and resistance
behavior can be affected by professional relationships and the pants, who may not represent the overall population at the dif-
medical hierarchy, resulting in “prescribing etiquette”, including, ferent hospitals surveyed in Lahore, Pakistan. Nevertheless, we
for instance, hesitancy to change a prescription that is written believed that our findings are inspiring and have demonstrated
by practitioners or an inclination to accompany the pattern set a universal substructure for antibiotic restriction policies and
by senior prescribers [31, 32]. About 81% of physicians agreed antibiotic management programs in hospitals and other health-
that advice from the infection control team or antimicrobial care settings.
management team is a helpful intervention in prescribing an-
tibiotics. International efforts are required to hinder the emer-
gence of resistance [33]. Conclusions
More physicians agreed that computer-aided prescribing is
very helpful in prescribing antibiotics. A telephone-based sys- Our findings showed that physicians are well aware of the
tem and computerized system have obvious benefits, requiring importance of antibiotic resistance and reported that rational
organizational devotion towards antibiotic management pro- use of antibiotics will aid in the resolution of this issue. Further-
grams [23]. A majority of physicians believed that educational more, our results showed that most of the physicians believed
sessions and the availability of local guidelines were thought to that antibiotics were used unnecessarily or inappropriately,
be more helpful in prescribing antibiotics. Rapid and effective di- which causes the patient harm. However, they did not always
agnostic techniques were thought to be an important interven- agree that antibiotics are overused in their own institutions. The
tion in prescribing antibiotics by most of the physicians. A ma- initiation of educational programs regarding antibiotic use and
jority of the physicians agreed that ward rotations, off-campus its resistance and innovative approaches to attract healthcare
lectures sponsored by pharmaceutical companies, medical jour-
practitioners’ attention towards antibiotic stewardship are ur-
nals and conferences are important and helpful interventions
gently needed. Strategies such as infection prevention and con-
in prescribing antibiotics. Antibiotic utilization can be improved
trol programs should also be implemented to reduce inappro-
by following multidisciplinary, evidence-based guidelines, which
can be implemented by education and feedback providers [34]. priate use of antibiotics and the spread of nosocomial infection.
An appropriate approach towards refining guideline adherence
Limitations of the study and a set-up for future investigation is required.
This study has some limitations. The primary limitation of Acknowledgments. The authors acknowledge the contribu-
this study was that we cannot rationalize our findings to all hos- tion of the group of experts who formulated the questionnaire
pitals of Pakistan. Another potential limitation was the partici- and all the physicians who showed interest in this research.
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Tables: 5
Figures: 0
References: 34
Accepted: 28.112018

Zikria Saleem, PhD
School of Pharmaceutical Sciences
Universiti Sains Malaysia
Malaysia
Tel.: +92322-9801981
E-mail: xikria@gmail.com

ISSN 1734-3402, eISSN 2449-8580

Possibilities for implementation of professional competencies

of physical therapists working in teams of rehabilitation
specialists of education and health protection systems
Inga Šimkutė Karalevičienė1, A–G, Daiva Mockevičienė1, B–F, Brigita Kreivinienė2, 3 B–F
ORCID iD: 0000-0002-4788-3459 ORCID iD: 0000-0003-3316-096X
1
Department of Holistic Medicine and Rehabilitation, Klaipeda University, Lithuania
2
Department of Social Work, Klaipeda University, Lithuania
3
Dolphin Assisted Therapy Centre of the Lithuanian Sea Museum, Klaipeda, Lithuania
Summary Background. The paper deals with the possibilities for implementation of professional competences of physical therapists
working in different systems of education and health protection with regard to the holistic health concept, psychophysical education
and interdisciplinary collaboration inside rehabilitation teams.
Objectives. The main objective of the study was to compare the possibilities for implementation of professional competences of physi-
cal therapists working in rehabilitation teams of education and health protection systems.
Material and methods. The survey encompassed 200 physical therapists working in the education (n = 98) and health protection
(n = 102) systems of Lithuania. A questionnaire-based method employing closed-type questions was used, which was aimed at reveal-
ing whether implementation of professional competences of physical therapists working in different systems differed.
Results. The competences of communication and collaboration, i.e. interdisciplinary activities inside rehabilitation teams, were more
developed by physical therapists working in the education system (t = 23.483, df = 2, p = 0.001). In the process of physical diagnosis,
physical therapists of the health system make a diagnosis of physical therapy independently. The same statistically significant differ-
ence was also noticed in the aspect of communication of groups of these specialists when psychosocial problems occur, specifically:
t = 14.768, df = 3, p = 0.002. Physical therapists of the education system more actively participate in qualification development, deliv-
ery of talks at conferences and organising health promotion programmes, even though no statistically significant difference was found
(t = 4.830, df = 3, p = 0.185).
Conclusions. The competences of interdisciplinary collaboration are more developed by physical therapists working in the education
system; whereas physical therapists working in the health system are more concerned with the making of a physical therapy diagnosis,
design of a programme and application of more diverse methods.
Key words: clinical competence, physical education and training, rehabilitation.
Šimkutė Karalevičienė I, Mockevičienė D, Kreivinienė B. Possibilities for implementation of professional competencies of physical thera-
pists working in teams of rehabilitation specialists of education and health protection systems. Fam Med Prim Care Rev 2019; 21(2):
Background holistic prevention and education specialists. A changing soci-

etal attitude towards the role of physical therapists stimulates
Throughout Europe, health is perceived as the comprehen- increasing the spread of these specialists in various spheres of
sive spiritual, physical and social welfare of an individual and education and health. Professional regulation of specialist train-
ing ensures practical implementation of the health policy carried
society [1]. The holistic concept of health encompasses the
out by these specialists [8, 9]. The order issued by the Minister
understanding of various health conditions. A contemporary
of Health of the Republic of Lithuania, “A Physical Therapist. The
individual faces many health risk factors every day. The Amster-
Rights, Duties, Competence and Responsibility”, is one of the
dam, Luxembourg Declarations, Ljubljana, Ottawa, Jakarta and
major normative acts defining the most important profession-
European Social Charters emphasise active engagement of social competences of specialists of physical therapy. Meanwhile,
ety members in health maintenance and protection. The order there are no normative acts which regulate the specificity of the
signed by the Minister of Health of the Republic of Lithuania work of physical therapists in the education system.
ensures the right of citizens to have access to rehabilitation ser- Various scientific sources indicate that implementation of
vices [2]. A problematic situation occurs in Lithuania because of the professional competences (knowledge, abilities and skills)
the establishment of the disease treatment paradigm and not of specialists in practice is highly important while seeking to
the accentuation of preventive education [3]. Aiming at a com- meet the modern holistic concept of health protection and
prehensively healthy individual, the systematic development of education [1, 10]. In both health and education areas, physi-
the goals reaching for prevention, education and rehabilitation cal therapy plays an important role; and implementation of the
is necessary [4–6]. Holistic health is grounded on the paradigm competences is highly important and needed [2]. Lithuanian
of psychophysical development, which is important to the exis- scientific research works reveal that physical therapists insuf-
tence of a healthy society [7]. This is the reason why European ficiently implement their competences of communication and
countries, including Lithuania, have an increased demand for collaboration. These issues are dealt with throughout Europe,
I. Šimkutė Karalevičienė, D. Mockevičienė, B. Kreivinienė • Professional competences of physical therapists 159
too; nevertheless, it is noted that there is a lack of scientific re- the specialists’ attitude towards team work [18–20]. The block
search on this topic [10, 11]. Therefore, the current study aims of questions on personal development was designed to find out
at investigating competences sought by specialists working in the possibilities for qualification development of the specialists.
different spheres. The data was processed by employing statistical data analy-
sis. The collected data was analysed and compared by employ-
Objectives ing statistical calculations facilitated by SPPS and MS EXCEL
software. The SPPS software calculated the chi-square criterion
The objective is to reveal the differences for implementa- according to Pearson’s formula. The calculated values: T-value
tion of professional competences of physical therapists working – the value of Pearson’s chi-square criterion, df – number of de-
in institutions of health care and education systems. grees of freedom, Asymp. Sig. (2-sided).
Material and methods Results

The research included a questionnaire-based survey em- Participants
ploying a nominal closed-type questionnaire. The research con-
ducted preserving all requirements of ethics applied for such Physical therapists who participated in the research were
kind of research. The questionnaire was developed operation- gathered from five major cities of Lithuania, as well as remote
alising the object of research, based on scientific literature. The regions (Fig. 1). Those physical therapists were working in the
questionnaire comprises four blocks of questions: demographic, institutions of the education system (n = 98), others – in institu-
special abilities, interdisciplinary collaboration and personal de- tions of the health protection system (n = 102). The majority of
velopment [8, 9, 12–14]. The block of questions on special abili- respondents were up to 40 years of age (Fig. 2), and their dura-
ties sought to examine the making of a physical therapy diagno- tion of work was from 1 to 10 years (Fig. 3). Respondents who
sis, application of methods in practice, etc. [14–17]. The block of participated in the research had two different backgrounds of
questions on interdisciplinary collaboration aimed at analysing physiotherapy program.
percent
35 31.7
30.0 29.3
30
25.7 25.0
25
20
15.7
15
10.7
10.0
10 8.6 8.3
1.77 3.3
5
0
Kaunas Klaipėda Panevėžys Šiauliai Vilnius Other
Physical therapist working in health institutions Figure 1. Distribution of the respondents

Physical therapist working in education institutions according to place of living (%)
percent
50 46.0
45 41.7
40
33.3
35
30 25.9
25 20.1 20.0
20
15
10 4.3 5.0 3.7
5 0.0
0
20-30 31-40 41-50 51-60 61-70
Physical therapist working in health institutions Figure 2. Distribution of the respondents

Physical therapist working in education institutions according to age (%)
160 I. Šimkutė Karalevičienė, D. Mockevičienė, B. Kreivinienė • Professional competences of physical therapists
percent
35 32.1
30 26.7
25.0
25
20.0
16.7 17.1
20
12.9 14.3
15 12.9
10.7
10 6.6
5.0
0
< up to 1 yr. 1-5 yrs. 6-10 yrs. 11-15 yrs. 16-20 yrs. > over 21 yrs.
Figure 3. Distribution of the respondents according
Physical therapists working in health institutions
to duration of work (%)
Physical therapists working in education institutions
Descriptive data the rest (47.9%) had graduated from colleges (Professional Bach-
elors). Only 13.6% of physical therapists holding a Professional
Bachelor’s Degree were working in the education system, and
A questionnaire-based survey was used to find out what the respondents working in the health system distributed even-
study programmes had been completed by the respondents. It ly in terms of their academic degrees. The respondents’ fields of
was found out that 52.1% of the surveyed physical therapists had specialisation were (Fig. 5): orthopaedics, neurology, rehabilita-
completed university studies (Bachelors and Masters, Fig. 4), and tion, surgery, therapy or other.
percent
75.0
80
70
53.5 50.0
60
50
40
26.7
30
20
10 1.4 0.0
0
University University College Professional
Physical therapists working in health institutions Figure 4. Distribution of the respondents according
Physical therapists working in education institutions to educational background (%)
percent
70 63.4
60
50
40 35.0
30
18.3 18.6
20 15.7
11.4 10.7
8.3 8.6
10 3.3 5.0
1.7
0
Therapy
Surgery
Orthopaedics
Neurology
Other
Rehabilitation
Physical therapists working in health institutions Figure 5. Distribution of the respondents according
Physical therapists working in education institutions to their field of specialisation (%)
Outcome data ply stretching exercises, remedial exercises and Bobath in their
work practice; the PNF and Vojta methods are applied less often.
Aiming to evaluate implementation of professional compe- Specialists working in the health system more frequent-
tences of physical therapists, the development of special abili- ly combine methods of physical therapy and physiotherapy
ties (making of a physical therapy diagnosis, design and assess- (t = 37.513, df = 2, p = 0.001).
ment of the effectiveness of individual and group programmes The analysis of interdisciplinary collaboration abilities re-
of physical therapy, application of physical therapy methods and vealed statistically significant differences between the groups
combination of these with physiotherapy, provision of first aid, (t = 42.861, df = 2, p = 0.001). It was found that more physical
compliance with work safety requirements) in work practice therapists working in the education system worked in a team
was analysed. The analysis of characteristics of assessment of and more often communicate with other specialists of an insti-
motor skills did not point out any statistically significant differ- tution to deal with occurring psychological, social and commu-
ence (t = 3.466, df = 3, p = 0.325). A physical therapy diagnosis is nication problems (53.3%); and in the group of those who work
much more often made by specialists working in the health sys- in the health system only, 26.4% (t = 14.768, df = 3, p = 0.002)
tem and by those who graduated from universities (t = 23.483, demonstrated these activities. However, patients are more of-
df = 2, p = 0.001) (Fig. 6). ten taught to use compensatory technology by physical thera-
More than half of physical therapists working in institutions pists working in institutions of the health system (specifically,
of the health protection system (55%) independently design 64.3% and 40.0%; t = 13.965, df = 3, p = 0.003).
individual programmes of physical therapy, and physical thera- The analysis of the aspects of qualification development re-
pists working in the education system do this as follows: 30% vealed that similar amounts of physical therapists participate in
(t = 14.502, df = 2, p = 0.001). events dedicated to qualification development (seminars, train-
Aiming to compare the practical implementation of spe- ing, etc.). Even though more physical therapists working in the
cialists’ functional abilities, frequency of application of various education system take part in conferences on their own initia-
methods in work practice was analysed. The obtained results al- tive, the differences between the groups are insignificant (t =
low us to state that a majority of the respondents constantly ap- 4.830, df = 3, p = 0.185) (Fig. 7).
percent
70 61.6
60
50 40.7
40 32.9
26.7 26.4
30
20 11.7
10
0
Himself/Herself I refer to the conclusions I do not make and do not
made by other specialists form
Figure 6. Distribution of the respondents ac-
Physical therapists working in health institutions
Physical therapists working in education institutions
cording to the making of a physical therapy di-
agnosis (%)
percent 59.3
60
45.0
50
40
28.3
26.7
25.0
30
15.7
20
10
0
Yes, when authorities Yes, on my own initiative No, I did not participate
demanded Figure 7. Distribution of the respondents ac-
Physical therapists working in health institutions cording to participation in seminars and oral
Physical therapists working in education institutions presentations (%)
162 I. Šimkutė Karalevičienė, D. Mockevičienė, B. Kreivinienė • Professional competences of physical therapists
Discussion and respect, as well as collaboration among patient, relatives

who take care of him/her and medical professionals. One of the
This research reveals that despite the area of education, contemporary tendencies deals with an increasing number of
physical therapists working in both education and health pro- countries where physical therapists are allowed to work inde-
tection systems do the same job. However, competences of pendently, without appointments of rehabilitologists. On the
interdisciplinary collaboration are more strongly developed by one hand, it demonstrates their need to expand communica-
physical therapists of the education system. A statistically signif- tion and collaboration with a patient; on the other hand, these
icant difference between both groups of specialists was found in specialists are perfectly able to take the inter-competences of
the process of making a diagnosis (t = 23.483, df = 2, p = 0.001): other specialists and implement them [23], e.g. development of
physical therapists of the health system are more inclined to clinical physical therapy practice at the scientific level is related
diagnose independently. Comparisons of these results with with successful implementation of the dual identity of a physical
other scientific research studies point out that holistic methods therapist [24].
applied by physical therapists while involving other specialists
in practice can significantly improve patients’ health [21], and Limitations of the study
knowledge of communication with a patient and sociocultural
Some limitations of this study should be noted. This re-
aspects are fundamental in the successful process of physical
search did not used a validated questionnaire. Due to the nov-
therapy [22]. A statistically significant difference (t = 14.768,
elty of the study objective, psychosocial aspects are investigated
df = 3, p = 0.002) was calculated in the communication char-
in the professionalisation of physiotherapists. Therefore, the au-
acteristics of these two groups solving psychosocial problems.
thors applied the construction of the questionnaire based on
Even though no statistically significant difference between the
scientific literature. However, the data of this research shows
specialists was found (t = 4.830, df = 3, p = 0.185), it can be
the demand for development of adjacent investigations related
stated that physical therapists working in the education system
to the context of interdisciplinary collaboration of physical ther-
more actively participate in events dedicated to qualification
apists in the future.
development, share experiences, prepare presentations, semi-
nars and design health promotion programmes. These research
findings in Lithuania are closely related to the tendencies of the Conclusions
global manifestations of professional competences of physical
therapists. The modern concept of physical therapy encompass- Implementation of a majority of special competences in
es the specialist autonomisation process and the necessity to practice is much more developed by physical therapists working
develop more awareness in patients [23]. Moreover, the pres- in the health protection system. Physical therapists working in
ent concept of medicine complies with the attitude that team the education system more strongly emphasise team work in
work is more beneficial to the process of patient treatment. their performance jointly with specialists, but also while engag-
Such collaboration is based on an interdisciplinary approach ing the families of patients.
Source of funding: This work was developed using the university’s funds and authors’ own research funds.
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Tables: 0
Figures: 7
References: 24
Received: 1.02.2019
Reviewed: 4.02.2019

Brigita Kreivinienė, PhD, Assoc. Prof.
Dolphin Assisted Therapy Centre of the Lithuanian Sea Museum
Smiltynes str. 3
LT–93100 Klaipėda
Lithuania
Tel.: +37065367047
E-mail: b.kreiviniene@muziejus.lt

ISSN 1734-3402, eISSN 2449-8580

Assessment of the health care system functioning in Poland

in light of the analysis of the indicators of the hospital
emergency department (ED) and primary health care (PHC)
– proposals for systemic solutions
Katarzyna Szwamel1, A–G, Donata Kurpas2, C–E
ORCID iD: 0000-0001-8186-9979
1
Medical School in Opole, Poland
2
Department of Family Medicine, Wrocław Medical University, Poland
Summary Background. In the last three decades, in developed countries, the number of patients reporting to hospital emergency de-
partments has dramatically increased. The number of visits to EDs can be an important indicator of the quality of primary health care.
Objectives. To analyse: 1) the frequency of admissions to EDs, 2) the type and number of medical procedures performed in EDs, and 3)
the type and number of services provided by PHC in the Kedzierzyn-Kozle district.
Material and methods. A retrospective analysis of the statistical data regarding services provided by PHC in the Kedzierzyn-Kozle dis-
trict within the National Health Fund (NHF) and data from the hospital emergency department in Kedzierzyn-Kozle (Opole Province,
Poland).
Results. The results showed an annual increase in the number of hospitalisations (13,815 – 2012, 14,192 – 2013, 15,123 – 2014) and
the number of medical procedures performed in the ED (mainly those from I–III categories), as well as the low rate of admission from
the ED to ICU (Department of Anaesthesiology and Intensive Care). There was an increase in the overall number of consultations given
by a primary health care doctor and the total number of healthcare services provided at night and during holidays.
Conclusions. Reducing the number of non-urgent visits to EDs can be achieved by making efforts to meet the needs of patients at the
level of primary health care, in particular through better coordination of services provided by EDs and PHC and better motivation of
primary care doctors to perform the role of gatekeeper to the health care system.
Key words: delivery of health care, comprehensive health care, professional practice gaps, primary health care, emergency service,
hospital.
Szwamel K, Kurpas D. Assessment of the health care system functioning in Poland in light of the analysis of the indicators of the hospital
emergency department (ED) and primary health care (PHC) – proposals for systemic solutions. Fam Med Prim Care Rev 2019; 21(2):
Background were admitted on days of ED overcrowding experienced a 5%

greater risk of inpatient death, 0.8% longer hospital length of
The last three decades have seen a dramatic increase in the stay and 1% increase in costs per admission [12].
number of patients reporting in developed countries to hospital According to the report entitled Emergency Care Services:
emergency departments (EDs) [1–5]. The low level of satisfac- trends, drivers and interventions to manage the demand con-
tion with the services provided by primary health care staff, dif- cerning health services provided by Emergency Departments
ficulties in making an appointment to a primary health care fa- in 21 OECD countries (Organization for Economic Co-operation
cility, lack of trust and very long waiting time for a visit may lead and Development), in 2011, there were 31 visits to EDs per 100
to reporting to hospital emergency departments in non-urgent inhabitants on average. The highest number of visits (70 visits
situations [6]. The number of visits to EDs can be an important per 100 inhabitants) was recorded in Portugal. Over 40 vis-
indicator of the quality of primary health care [1]. its per 100 inhabitants were reported in such countries as the
ED overcrowding is a situation in which the performance of USA, Spain, Chile, Canada and Greece. It was calculated that in
due functions by emergency departments is difficult because of countries like the Czech Republic, Germany, New Zealand, the
the excessive number of patients awaiting health assessment, Netherlands, Switzerland and Poland, there were less than 20
examination, diagnosis, treatment or discharge in relation to visits per 100 inhabitants [13]. The research carried out by the
the efficiency of the staff employed [7, 8]. This often leads to Health Care Quality Monitoring Centre in Cracow in 223 EDs in
the prolongation of the time patients wait for services provided Poland revealed that the average burden to the ED in Poland os-
by the ED and subsequently results in lowering their satisfaction cillated around the number of 16,000 patients per year. During
with medical care [9]. ED crowding may also be connected with one year, 6 EDs treated over 50,000 patients [14]. Even though
poorer performance and adverse clinical outcomes, including it is true that the problem of the burden of Polish EDs is still
increased mortality [10]. For example, in the study conducted much smaller in comparison to Western European countries or
by Kulstad et al. (2009), ED overcrowding was associated with the USA, it is an important problem [13, 14].
delays in percutaneous coronary intervention for acute myocar- The factors that result in excessive frequent visits to the ED
dial infarction [11]. Sun et al. (2012) showed that patients who include: loneliness, homelessness, alcoholism, the occurrence
K. Szwamel, D. Kurpas • Analysis of the indicators of the emergency department 165
of mental illness (obsessive-compulsive disorder, personality number of patients admitted to the ED and the number of pro-
disorders, depression, schizophrenia, addiction to psychoactive cedures performed in this department are growing year to year
substances), chronic diseases, younger age (from 25–44 years) and that the majority of medical procedures performed in the
or old age (over 65 years), as well as living in close proximity to emergency department are not associated with a sudden health
the ED [15–20]. risk and could be realised on an outpatient basis.
ED overcrowding is partly due to the phenomenon of non-
-urgent visits [21]. These are visits to the ED when patients re-
port health problems that do not cause a threat to their life and
Objectives
do not require immediate treatment; therefore, the decision to
undertake medical care can be safely dismissed in time [22] or The aim of the study was to analyse the benefits provided
when a problem can be solved or the patient’s needs can be by PHC, the frequency of admissions to EDs, the type and num-
met by outpatient care [23]. An international literature review ber of medical procedures performed in the ED in the Kedzie-
performed by Durand et al. demonstrated that 4.8% to 90% of rzyn-Kozle district in the years 2012–2014, as well as to propose
ED patients were potentially non-urgent cases, with a median systemic solutions for the Polish healthcare system in light of
of 32.1% [24]. In the Turkish study, the proportion of ED visits the study results obtained.
for non-urgent conditions was 23.4% [25]. Previous research
showed a non-urgent character of 56% of visits in Belgium, 32% Material and methods
in Australia, 31% in Portugal, 25% in Canada, 20% in Italy, 12%
to 30% in the US and 11.7% to 15% in England [2, 22, 26, 27]. In This study involved a retrospective analysis of the statistical
Polish EDs, 30% to 80% of patients were not eligible for services data from the years 2012-2014 regarding health services provid-
provided in these wards, as they were not in a state of immedi- ed in the Kedzierzyn-Kozle district and data obtained from the
ate health risk [14, 28, 29]. Opole Department of the National Health Fund (NHF), as well as
Apart from non-urgent patients (non-invasive visits, inap- the data from the Asseco Medical Management Solutions com-
propriate ED visits), elderly people are also responsible for the puter system (AMMS) of the Hospital Emergency Department in
phenomenon of ED overcrowding [30]. In this group, ED report- Kedzierzyn-Kozle (Opolskie, Poland) from the years 2012–2014.
ing is related to multiple morbidities, functional limitations, The research covered the number of services provided by PHC
falls, deprivation of needs, lack of care and support, as well as in individual areas of activity, the type and number of proce-
dementia, organic disorders, behavioural changes, aggression, dures performed in the ED, the number of patients’ admissions
depression, self-inflicted injuries, alcohol abuse, polypharmacy, to the ED and the rate of the bed use at the ED. Percentages
urinary tract infections, exacerbating pain, malnutrition and the and rates of dynamics of changes were calculated for the years
need to provide care in the last stage of life [2, 30, 31]. It has 2013/2012, 2014/2013 and 2014/2012. The “patients’ flow in-
been proven that people aged 85 years and over have a 10-fold dicator”, determining how many patients used one hospital bed
greater chance of being hospitalised in the ED compared to in a given time period, was also used. This is calculated as the
those aged 20 to 40 years [32]. Eurostat data showed that the ratio of the number of patients hospitalised and the number of
share of people aged 80 years or above in the EU-28’s popula- beds. The research obtained the approval (No. KB-87/2016) of
tion is projected to more than double between 2017 and 2080, the Bioethics Committee of the Medical University in Wroclaw.
from 5.5% to 12.7% [33]. Taking into account the fact that in
2050, Poland will become one of the European countries with
the most advanced aging of the population, we can expect that Results
the problem of ED reporting in this group of patients may in-
crease [34]. According to Azuma and Ohta, the concept of frailty The number of all patients hospitalised in the years 2012–
may by introduced as an indicator of prognosis and applied in –2014 in the ED in Kedzierzyn-Kozle was 50,693. There was an
relation to the future of emergency medicine [35]. annual increase in the number of hospitalisations, including
A high demand for ED services can be explained by the high 13,815 in 2012, 14,192 in 2013 and 15,123 in 2014. The pa-
expectations of society, both towards access and the level of tients’ flow indicators in ED amounted to: 2,762.17 patients
health services, as well as the convenience and ease of access to (2012), 2,802.50 patients (2013), 2,907.83 patients (2014).
the highly specialised services provided by emergency depart- After ED hospitalisation, some patients were referred to
ments [14, 36–38]. The currently observed rapid medical and hospital wards for further treatment. ED patients most often
technological progress, along with the increasing medical spe- continued treatment in the internal diseases unit (Me = 795,
cialisation and the manner in which health care is organised, min–max, 550– 985), orthopaedic (Me = 453, min–max, 444–
jeopardise the quality and efficiency of health care and make –491), neurological (Me = 423, min–max, 390–433), geriatric
clinical coordination difficult, as patients often observe an ever- (Me = 196, min–max, 192–209) and surgical department (Me
-expanding array of professionals in a variety of different set- = 198, min–max, 177–213). A relatively low admission rate was
tings [38, 39]. Discontinuity of care undermines its effectiveness reported for patients transferred from the ED to ICU (Me = 68,
through misapplied or duplicative treatment. In this situation, min–max, 66–69). The median percentage of admissions from
primary care physicians lose opportunities to educate their pa- the ED to ICU was 2.55% of all admissions to hospital wards,
tients about when it is appropriate to report to emergency de- with the percentage of admissions from the ED to ICU being
partments and to learn about gaps in their own availability that constant at a level of 0.4% of all admissions to the ED in each
may be unnecessarily overused by patients [40]. year in the years 2012–2014.
According to McHale et al., many non-urgent visits to EDs In the analysed period, the number of medical procedures
can be avoided by better patient and community care manage- performed in the ED also increased. In 2013, the number of pro-
ment by a team of professionals at the level of primary health cedures was higher by 5,549 (7.47%) than in 2012, and in 2014,
care [23]. Given the above, the study assumed that both the higher by 9,921 (13.35%) compared to 2012 (Table 1).
Table 1. Number of medical procedures performed in the ED in the years 2012–2014

Years 2012–2014 Difference Dynamics of changes
Year 2012 Year 2013 Year 2014 2013–2012 2014–2012 2013/2012 2014/2012
74,311 79,860 84,232 5,549 9,921 7.47% 13.35%
Table 2. List of medical procedures most often performed at the ED in Kedzierzyn-Kozle in the years 2012–2014
Ordinal Year 2012 Year 2013 Year 2014
number
Name of procedure n Name of procedure n Name of procedure n
1 89.02 Medical consultation, others 16 303 89.02 Medical consultation, others 16 359 89.04 Nurse or midwife care 15 504
2 89.04 Nurse or midwife care 9876 89.04 Nurse or midwife care 11 503 89.00 Medical advice, consultation, assistance 15 222
3 99.18 Injection/infusion of electrolytes 5997 99.18 Injection/infusion of electrolytes 6058 89.71 Evaluation of the patient’s condition in order 7517
to make a decision either to undertake or resign from
emergency medical treatment
4 90.59 Microscopic blood test – other microscopic 4895 90.59 Microscopic blood test – other microscopic examination 5020 99.18 Injection/infusion of electrolytes 6707
examination
5 89.61 Systemic blood pressure monitoring 4407 89.61 Systemic blood pressure monitoring 4979 89.61 Systemic blood pressure monitoring 5262
6 89.79 Physical examination – other 4306 89.521 Electrocardiography, unspecified 4906 89.521 Electrocardiography, unspecified 4432
7 38.99 Venipuncture – other 3959 89.79 Physical examination – other 4289 89.02 Medical consultation, others 2013
8 89.521 Electrocardiography, unspecified 3644 38.99 Venipuncture – other 3725 93.57 Wound dressing – other 1992
9 93.57 Wound dressing – other 1828 93.57 Wound dressing – other 2010 38.93 Venipuncture – other 1454
10 89.522 Electrocardiography with 12 or more leads 1826 88.28 X-ray picture of the ankle/foot 1346 38.99 Venipuncture – other 1453
(with description)
11 88.28 X-ray picture of the ankle/foot 1486 88.23 X-ray of the wrist/hand 1280 89.02 Medical consultation, others 1245
12 86.59 Stitching of the skin and subcutaneous tis- 1132 99.38 Tetanus toxoid administration 1246 99.38 Tetanus toxoid administration 1124
sue elsewhere
13 99.38 Tetanus toxoid administration 1103 86.59 Stitching of the skin and subcutaneous tissue elsewhere 1243 12.02 Removal of a foreign body from the frontal 1046
part of the eyeball (without magnet)
14 88.23 X-ray of the wrist/hand 1054 93.53 Applying plaster immobilisation 1040 12.02 Removal of a foreign body from the frontal 1036
K. Szwamel, D. Kurpas • Analysis of the indicators of the emergency department
part of the eyeball (without magnet)

15 93.53 Applying other plaster immobilisation 928 93.541 Applying the splint with plaster 939 100.43 Infiltrative anaesthesia 910
16 12.02 Removal of a foreign body from the frontal 808 12.02 Removal of a foreign body from the frontal part of the 933 89.79 Physical examination – other 548
part of the eyeball (without magnet) eyeball (without magnet)
17 93.541 Applying the splint with plaster 788 23.0105 Specialist consultation 798 86.59 Stitching of the skin and subcutaneous tissue 533
elsewhere
18 89.00 Medical advice, consultation, assistance 753 23.0401 Superficial local anaesthesia 764 100.43 Infiltrative anaesthesia 521
19 87.031 Head CT with and without contrast 639 87.176 Skull X-ray – review 739 87.031 Head CT with and without contrast 441
20 87.176 Skull X-ray – review 636 88.27 X-ray of the thigh/knee/shank 674 93.53 Applying other plaster immobilisation 366
21 88.27 X-ray of the thigh/knee/shank 621 89.00 Medical advice, consultation, assistance 650 93.541 Applying the splint with plaster 271
22 88.241 X-ray of the upper limb, targeted or 496 87.031 Head CT with and without contrast 647 100.41 Anaesthesia of the peripheral plexi or nerves 244
functional (up to 2 hours)
23 87.440 Chest X-ray 449 87.440 Chest X-ray 587 88.23 X-ray of the wrist/hand 201
24 23.0401 Superficial local anaesthesia 427 88.21 X-ray of the shoulder and arm 376 95.02 Extensive eye examination 198
Table 2. List of medical procedures most often performed at the ED in Kedzierzyn-Kozle in the years 2012–2014
Ordinal Year 2012 Year 2013 Year 2014
number
Name of procedure n Name of procedure n Name of procedure n
25 88.21 X-ray of the shoulder and arm 336 88.22 X-ray of the elbow/forearm 351 98.21 Removal of a superficial foreign body from the 176
eye without incision
26 95.1913 Examination using a slit lamp 318 95.02 Extensive eye examination 306 87.440 Chest X-ray 166
27 87.441 Lung X-ray – other 303 89.522 Electrocardiography with 12 or more leads (with 297 88.27 X-ray of the thigh/knee/shank 157
description)
28 88.22 X-ray of the elbow/forearm 298 88.191 X-ray of the abdominal cavity – review 284 95.1913 Examination using a slit lamp 141
29 100.43 Infiltrative anaesthesia 283 87.441 Lung X-ray – other 282 87.176 Skull X-ray – review 123
30 23.0105 Specialist consultation 272 88.26 X-ray of the pelvis/hip bones – other 280 23.0105 Specialist consultation 119
31 88.26 X-ray of the pelvis/hip bones – other 248 100.43 Infiltrative anaesthesia 270 23.0401 Superficial local anaesthesia 113
32 57.09 Bladder emptying – other 241 57.09 Bladder emptying – other 263 23.0105 Specialist consultation 109
33 88.191 X-ray of the abdominal cavity – review 240 93.964 Oxygen therapy 261 90.59 Microscopic blood test – other microscopic 101
examination
34 95.02 Extensive eye examination 220 95.1913 Examination using a slit lamp 233 88.191 X-ray of the abdominal cavity – review 98
35 87.221 X-ray of the cervical spine – review 203 89.549 Electrocardiographic monitoring – other 218 87.441 Lung X-ray – other 74
36 88.761 Ultrasound of the abdomen and retroperi- 193 87.221 X-ray of the cervical spine – review 211 88.761 Ultrasound of the abdomen and retroperito- 72
toneal space neal space
37 89.549 Electrocardiographic monitoring – other 189 88.761 Ultrasound of the abdomen and retroperitoneal space 200 88.22 X-ray of the elbow/forearm 68
38 93.964 Oxygen therapy 178 87.241 X-ray of the lumbar-sacral spine – review 193 79.02 Closed reduction of a fracture without internal 64
stabilisation – radius/ulna (arm – other)
39 87.241 X-ray of the lumbar-sacral spine – review 163 88.241 X-ray of the upper limb, targeted or functional 175 88.21 X-ray of the shoulder and arm 61
40 87.165 X-ray of the nose 135 99.26 Injection of tranquiliser 142 89.549 Electrocardiographic monitoring – other 60
K. Szwamel, D. Kurpas • Analysis of the indicators of the emergency department
167

168 K. Szwamel, D. Kurpas • Analysis of the indicators of the emergency department
Throughout all these years, in addition to such procedures from 98,931 to 80,137, and by 10.17% compared to 2013, from
as medical consultation and care of a nurse or midwife, the 89,209 to 80,137) and services provided at home (by 23.89% in
most common procedures were: electrolyte injection/infusion, 2014 compared to 2012, from 15,112 to 11,501, and by 10.17%
microscopic blood test, physical examination, systemic blood compared to 2013, from 12,803 to 11,501).
pressure monitoring, electrocardiography, venipuncture, dress-
ing of a wound. Common procedures included: X-ray of the
ankle/foot or wrist and hand, administration of tetanus toxoid,
Discussion
stitching of the skin and subcutaneous tissue, applying plaster
immobilisation, removal of a foreign body from the frontal part Analysis of services provided by the ED and PHC
of the eyeball (without a magnet) (Table 2).
As for the services provided by the PHC, the following were In our study, a three-year follow-up showed, in addition to
analysed: services provided by a primary care physician, nurse an increase in the number of ED hospitalisations, a year to year
and school nurse, as well as healthcare services provided at rise in the number of medical procedures performed in this
night and during holidays. ward. We also showed an increase in the general number of
In the period of the study, a total of 11,033,847 services consultations given by a primary care physician, the number of
were provided by primary health care doctors in the Kedzierzyn- certain services provided by a PHC nurse and school nurse and
-Kozle district (3,621,703 services in 2012, 3,638,745 in 2013, the total number of healthcare services provided at night and
3,773,399 in 2014). There was an increase in the total number during holidays, as well as a decrease in the number of medical
of consultations given by the primary care physician – the num- consultations given at a patient’s home. It should be noted that
ber in 2013 was higher by 3.70% than in 2012, while in 2014, the statistics indicate a gradually decreasing number of inhabitants
number was higher by 4.19% than in 2012. Year to year, there of the Kedzierzyn-Kozle district in the analysed period – in 2012
was an increase in the number of medical consultations given at – 97,879, in 2013 – 97,181, and in 2014 – 96,715 [41].
the primary health care unit to patients for reasons other than In the results of own research, it was shown that the pa-
diabetes and/or cardiovascular diseases (in 2013 – an increase tients’ flow indicator in ED increased every year. Data from the
by 3.38%, and in 2014 – a rise by 5.01%). In addition, in 2014, Central Statistical Office (CSO) shows that the number of people
the number of medical consultations provided to patients in using outpatient services has been steadily increasing in Poland
connection with the treatment of diabetes and/or cardiovas- in recent years. And so, in 2014, in the emergency rooms or Eds,
cular diseases decreased both in terms of the number of ser- medical aid was provided in an outpatient mode to 4.5 million
vices provided at the patient’s home (a decrease by 9.80% from people – i.e. about 200,000 more than in 2013 [42]. In 2015,
15,401 to 13,891) and at the primary health care unit (by 7.17% this number amounted to 4.6 million people [43]. In 2016, it in-
from 969,962 to 900,423). The number of medical consultations creased by 46 thousand people compared to 2015, and in 2017,
provided at the patient’s home for reasons other than diabetes it reached 4.8 million [44]. In turn, other CSO data shows an
and/or cardiovascular diseases has also decreased – by 3.72% in increase in the amount of outpatient advice – the total amount
the years 2012–2014. of medical advice given in Poland in the following years was 300
The total number of services performed by the primary million (2012), 307.4 million (2013) and 311.8 million (2014).
health care nurse was unchanged (1,445,158 – 2012, 1,372,684 However, a relatively stable percentage of advice provided in
– 2013, 1,448,460 – 2014). The number of patronage visits of the PHC was observed (it amounted to 52% of the total number
the primary health care nurse in 2014 decreased by 27.94% of outpatient consultations – 2012, 52.4% – 2013, and 52.3%
compared to 2013 (from 1,571 to 1,132) and by 25.77% in com- – 2014, respectively), while the percentage of advice provid-
parison to 2012 (from 1,525 to 1,132). The number of other ed in specialised care decreased (in year 2012 it amounted to
home visits of the nurse in 2014 fell by 2.12% compared to 2013 48%, in 2013 – 47,6% and in 2014 – 36,6% of the total number
and marginally increased by 0.18% compared to 2012. In addi- of outpatient consultations) [42, 45, 46]. Probably one of the
tion, an analysis of the services provided by the primary health reasons for the increasing burden of ED patients is the difficult
care nurse revealed an increase in the number of rehabilitation availability of specialist consultations at the level of outpatient
services (by 19.96%), the number of injections and treatments care and many months of waiting for such services, while the
carried out based on the order of the health insurance doctor patients’ expectations regarding the scope of provided services
(by 9.31%) and the number of patients who, in the reporting are increasing [47, 48].
period, underwent screening tests (by 11.68%). In view of the results received, an increase in the number
As for the coordination of services provided by the ED and of medical consultations provided to patients within the PHC in
PHC, certain school nurse services are also important, especially the area of the studied district should be considered ineffective
those provided in the field of emergency care and performed in given an increase in demand for lower-rated services provided
children with chronic diseases. The number of emergency care by the ED over the same period of time. If primary health care
services provided by these nurses to students in 2012 amount- physicians had the appropriate financial motivation to improve
ed to 53,509, in 2013 – 49,677, and in 2014 – 50,634; while the the quality of patient care and expand the range of their ser-
number of services and treatments performed in students with vices, and if the patients were satisfied with these services, this
chronic diseases clearly showed an upward trend – in 2012 – would be reflected in a reduction of the number of ED admis-
2,795, in 2013 – 3,941, and in 2014 – 4,121. sions and the type of procedures performed in this department.
Moreover, there was an increase in the total number of Meanwhile, the analysis of the procedures, according to the
healthcare services provided at night and during holidays in codes, clearly showed that among the 40 treatments most fre-
2014 – by 14.4% compared to 2013 (from 215,710 to 245,991) quently performed in the ED, there were no rescue procedures
and by 3.55% in 2014 compared to 2012 (from 237,559 to from higher categories, i.e. IV, V and VI (e.g. patient ventilation,
245,991). At that time, there was an increase in the number cardioversion, pleural drainage, chest drainage, sedation and
of outpatient medical consultations given at night and during intensive supervision, manual resuscitation, endotracheal intu-
holidays (by 22.98% in 2014 compared to 2012, from 117,880 bation, artificial respiration using a face mask or resuscitation
to 144,963, and by 36.45% in 2014 compared to 2013, from mask, insertion of a catheter into the artery, using magnetic res-
106,242 to 144,963) and medical consultations at home (in onance for diagnostics, cardiopulmonary resuscitation in an in-
2014 an increase by 22.39% compared to 2012, from 4,382 to tensive care unit or air transport, etc.). It was demonstrated that
5,363, and by 20.52% compared to 2013, from 4,450 to 5,363). the procedures from categories I, II and III predominated in the
However, there was a decrease in the number of outpatient analysed period. Most of these procedures can be performed in
visits provided by nurses (by 19% in 2014 compared to 2012, the outpatient clinic, e.g. electrolyte injection/infusion, blood
microscopy, systemic blood pressure monitoring, electrocardi- by 2013, the contracts with AOK were signed by another 3,500
ography, venipuncture, dressing of a wound, X-ray of the ankle/ doctors [55].
/foot or wrist/hand, administration of tetanus toxoid, stitching In order to reduce the number of ED visits, it is also im-
of the skin and subcutaneous tissue, applying plaster immobili- portant to seek solutions aimed at coordinating and integrat-
sation. Although these activities are found in the catalogue of ing primary health care and hospital care, including the ED.
rescue procedures and each patient is a separate case requiring Clinical coordination is considered a health policy priority, as its
individual consideration, the fact that mainly procedures from absence can lead to poor quality of care and inefficiency [39].
lower categories are performed at the ED and a small percent- Care coordination is “the deliberate organisation of patient
age of admissions from the ED to ICU (it accounted for 0.4% of care activities between two or more participants involved in
all admissions to the ED in each year in the years 2012–2014 a patient’s care to facilitate the appropriate delivery of health
and was low) may indirectly indicate the burden on the ED with care services” [56]. The rationale for undertaking interventions
non-urgent cases. For comparison, in Norway, the percentage aimed at coordinating and integrating patient and community
of admissions from the ED to ICU is fluctuating around 1% [4], care are, for example, the results of the Commonwealth Fund
and in Denmark, around 1.6% [49]. In the USA, the percentage International Health Policy Survey of 2013 (n = 13,958). The re-
of admissions from the ED to ICU accounted for 1.5% of all ED searchers showed that patients who assessed the level of care
admissions in 2011 [50], and 1.1% in 2015 [51]. coordination as low were more often hospitalised and more fre-
quently reported to the ED in urgent and non-urgent situations
Proposals for systemic solutions compared to those highly evaluating the level of coordination
[57]. The use of one common triage system for patients report-
One of the constructive and rational proposals to solve the ing to emergency departments on their own without a medical
problem of non-urgent ED visits is to make efforts to strengthen referral could be an example of activities undertaken to coordi-
primary health care. According to the report of 2017 entitled nate care between the ED and PHC. Depending on the results of
What is our primary health care and what we need, 64% of the triage, the patient would then go directly to the ED or would be
respondents negatively assessed the functioning of PHC. Every referred to the PHC doctor. This solution was adopted in some
second patient (49%) claimed that his/her doctor was not mo- regions of the Netherlands [58]. On the other hand, Rider et al.
tivated to work with the patients [52]. This may result from the pointed out the need to coordinate activities between the ED
method of financing primary health care, chiefly based on the and PHC, which, in practice, involves the need for communica-
capitation system, which does not encourage PHC workers to tion between the ED physician and the primary care doctor dur-
take full care over patients, thus “pushing them out” to out- ing the discharge of the ED patient in order to optimise further
patient specialist care and hospital wards, including the ED. patient care at the PHC level [59]. Communication and coordi-
Baranowski and Windak believe that the method of PHC fund- nation can help emergency physicians as they formulate plans
ing based on the capitation rate not only does not encourage of care, particularly for patients with chronic illnesses who may
physicians to work more efficiently and to provide high qual- have complex medical histories [40]. Doctors participating in the
ity care, but it is also not a fair way to reward doctors for their study conducted by Rider at al. reported varied expectations
work. Moreover, the size of correctors of capitalization rates is and multiple barriers to effective communication. In addition,
not properly adjusted to patient care expenses [53]. Borek et al. emergency physicians preferred telephone contact synchro-
demonstrated that the capitation rate mechanism as the only nous to the encounter, whereas primary care physicians were
form of PHC financing did not have a beneficial impact on the in favour of using the electronic medical record asynchronous
degree of implementation and quality of preventive care tasks. to the encounter. The researchers indicated a need to optimise
The researchers proved that the mixed system of financing pre- technology for an effective transition of the information from
ventive PHC care (i.e. by means of the capitation rate and the the ED to the outpatient setting [59]. Primary care doctors and
fee for visit) was by far the best, as it had a positive influence home health care providers play a crucial role in the coordina-
both on the quantitative and qualitative parameters assessing tion of care. In the future, primary health care doctors and fam-
the work of PHC staff. In the study cited, the authors showed ily doctors should closely cooperate with the hospital, and the
that compared to doctors and nurses, whose work was financed importance of their role should be more evident [35].
on the basis of the capitation system, the midwife, as the only As mentioned in the introduction, the demographic aging
worker rewarded on the basis of the mixed system, was the of the population will gradually contribute to the growing bur-
most effective and the least-priced representative of the medi- den on the ED concerning elderly people. It is necessary to look
cal personnel, which was beneficial from the perspective of the for constructive systemic solutions for this group of patients.
payer. Physicians, who were paid based on the capitation rate They require comprehensive coverage of their needs, and after
system, implemented only 61% of the visits provided by the reg- hospitalisation, they should be provided with adequate care at
ulation, while the nurse 26% of the visits provided by the regu- home or long-term care. Poor coordination between hospitals
lation. At the same time, the midwife, who was rewarded using and facilities which are responsible for the care of patients after
the mixed system, provided prophylactic visits to over 90% of hospitalisation in the absence of home care may prolong hospi-
children. Borek et al. argue that it would be optimal to abandon talisation and lead to the implementation of unnecessary treat-
the PHC capitation funding system in favour of the mixed sys- ment, which results in higher health care costs. The appropri-
tem, which takes into account the per-visit rate and, preferably, ate allocation of resources between the health and social care
the result (quality assessment parameters) [54]. sectors and the coordination of activities between these sectors
Another interesting solution of PHC financing was intro- can be an effective solution. In many countries, prolonged wait-
duced in Germany. In 2008, the first contract was signed being times for places in long-term care centres incurs hospital
tween AOK Baden-Württemberg and the family doctors’ associ- costs of maintaining additional beds. Efforts aimed at reducing
ation, circumventing national health funds and constructing the care costs are based on the common health and social policy
system of rewarding primary care physicians so as to encourage involving the distribution of financial incentives among health
them to play the role of system gatekeeper. The doctor’s salary care providers [60].
contained several components, i.e. a basic lump sum indepen- Proposals for system solutions should also focus on improv-
dent of the number of contracts, then a lump sum depending ing the quality and accessibility of services offered by healthcare
on the number of contacts, quarterly allowance for the treat- services provided at night and during holidays. Previous studies
ment of chronically ill patients dependent upon the number of have proven that the patient’s attendance rate to EDs correlates
contacts and an allowance depending upon the outcomes. Such negatively with the availability of PHC [1, 2, 13]. However, the
a motivational rewarding method turned out to be beneficial, as insufficient knowledge of patients about the role and principles
of healthcare services provided at night and during holidays and care and community-based health and social services, as well
the poor quality of services offered may contribute to the ex- as to provide patient-centred care [69]. For example, Enard and
cessive use of ad-hoc care in EDs [30, 61]. The Supreme Audit Ganelin found that patient navigation intervention was associ-
Office (2014) reports on many irregularities in the functioning ated with a decreased risk of returning to the ED among less
of healthcare services provided at night and during holidays in frequent primary care–related ED users. The pre/post mean vis-
Poland, such as shortening on-call time and availability for pa- its declined significantly over a 12-month pre/post-observation
tients, understating the number of teams on duty in relation to period among patients who returned to the ED for PCR reasons
the number contracted by the National Health Fund, not per- [70].
forming laboratory and X-ray tests in patients, as well as incor- Winburn et al. conducted a systematic review of literature
rectly placing information about the principles of healthcare aimed at exploring the extent, focus and utilisation of tele-
services provided at night and during holidays [61]. In the time health for pre-hospital emergency care. The results suggest
period examined by the Supreme Audit Office, health care was there are significant opportunities for wider diffusion of tele-
provided in clinics and centres that had a contract with the Na- health in pre-hospital care. The authors concluded that despite
tional Health Fund. In 2017, the reform of the so-called Hospital positive trends, telehealth utilisation in pre-hospital emergency
Network was introduced. One of the purposes of this reform care is fairly limited given the sheer number of EMS agencies
was to relieve EDs at weekends by locating points of healthcare worldwide [71]. In the study of Langabeer et al., patient care
services provided at night and during holidays near to the ED. enabled by telehealth in a pre-hospital environment was more
Patients who report to the hospital are “taken over” by the ED cost-effective alternative compared to the traditional EMS
staff, who makes the initial selection. Depending on the state of ‘treat and transport to ED’ model. The intervention consisted
health, the patient is referred to the ED or to the point of health- of telehealth-based consultation between the patients and an
care service provided at night and during holidays. In Poland, EMS physician to evaluate and triage the necessity for patient
there is a lack of research focused on the effectiveness of this transport to a hospital emergency department (ED). Patients
reform. It is already known that directors of hospitals pointed with non-urgent, primary care-related conditions were then
to the unclear rules of admitting patients, incomplete financ- scheduled and transported by alternative means to an affiliated
ing and lack of money to prepare hospitals for new duties [62]. primary care clinic [72].
Lidal et al. conducted a systematic review to identify available There are also some financial incentives aimed at reduc-
research on the effects of validated triage systems for use in the ing the demand for ED services. One of them is cost sharing,
pre-hospital EMS on health outcomes, patient satisfaction and defined as any kind of out-of-pocket payment for healthcare
patient safety. The authors concluded that there is an evidence services. Cost sharing includes: co-payments (when patients
gap regarding the effects of pre-hospital triage systems and the pay a flat fee for each medical service sought or product pur-
effects of using the same triage system in two or more settings chased), co-insurance (patients pay a fixed percentage of the
of the Emergency Medical Service [63]. cost of care) and deductibles (the amount one must pay out-of-
According to Oregon Primary Care Association, one of the -pocket annually before insurance coverage begins to pay) [30,
methods which could be effective in preventing unnecessary 73]. The aim of cost sharing is to increase the individual respon-
sibility for emergency care and discourage the use of ED services
visits to the emergency room is communicating to patients both
in non-life-threating situations. A breakdown of the cost of visits
before and after they visit the ED about after-hours care, office
to emergency departments was introduced in Belgium, Finland,
hours and what to do if they have an emergency [64]. A system-
Italy, Ireland, Portugal and the US [2]. In a review by Morgan et
atic review of literature conducted by Bahr et al. showed that
al., in nine out of ten studies conducted in the US, a statistically
evidence is inconclusive for the use of phone calls to decrease
significant reduction in the number of visits to SOR ranging from
readmission, emergency department use, patient satisfaction
35% to 50% was found [68].
and scheduled and unscheduled follow-ups [65]. Harrison et al.
Raven et al. evaluated 38 studies and showed that studies
assessed the impact of nurse post-discharge telephone calls on
of ED co-payments had mixed results. In this study, only case
30-day hospital readmission rates. In this study, patients who re-
management consistently reduced ED use. Case management
ceived a call and completed the intervention were significantly
programs employ case managers to assess a patient’s unmet
less likely to be readmitted compared to those who did not [66].
needs and to assist them by delivering care or by communicat-
Ismail et al. conducted a systematic review of UK and interna-
ing and coordinating with health or social service agencies [74].
tional primary care interventions to reduce inappropriate ED at- For example, McCormack et al. implemented a case manage-
tendance. The researchers proved that telephone triage was the ment program within the ED that specifically focused on high
single best-evaluated intervention. This resulted in a negligible ED utilisers who had alcohol dependency concerns and were
impact on ED attendance, but exhibited acceptable patient sat- homeless. Over 6 months, the median ED visit rate dropped
isfaction and clinical safety [67]. from 18.5 to 12 [75]. Previous studies confirmed that case man-
Flores-Mateo et al., investigated the effectiveness of inter-
agement seems to be successful in improving both clinical and

ventions consisting in providing educational guidelines to pa- social outcomes among frequent ED users [30, 76]. It is worth
tients and supporting the development of self-care. The authors mentioned that additional investigation is needed to determine
stated that the most effective is education that relates to a spe- what specific aspects of case management are the most suc-
cific disease entity or a complex multifunctional intervention, cessful and cost effective.
e.g. covering health education, teaching patients how to use the
health care system and social counselling [1]. In the systematic Limitations of the study
review of Morgan et al., five studies concerned the effective-
ness of educational intervention in the US, but only two of them The strength of the study was the critical analysis of the
demonstrated a statistically significant impact of this education objective statistical data obtained in the three-year follow-up.
on the number of applications for EDs. In the case of interven- A limitation of the study was the focus on only ED and PHC in-
tions involving the use of brochures or conducting individual dicators without taking into account the outpatient specialist
educational sessions, a reduction in the number of applications care indicators. Another limitation was the analysis of data from
ranging from 21% to 80% was observed [68]. only one ED, as well as NHF data on the functioning of the PHC
Patient navigation programs may be effective in prevention in only one district. Moreover, the study included only patients
or in reduction of ED use. According to Valaitis et al., the main reporting to the ED in non-urgent situations and focused on el-
goals of patient navigation programs are: to resolve patient derly people, without taking into account the group of patients
barriers to care, to link patients and families to PHC, specialist who, for various reasons, excessively often report to the ED, i.e.
the so-called frequent attenders. Future research should involve tion programs. There is not enough strong evidence for such in-
an analysis of outpatient specialist care data, include informa- terventions as co-payments or the application of telehealth for
tion from several emergency departments located in various pre-hospital emergency care. It is worth considering a change
districts and data from different NHF branches. in the funding mechanism of primary health care, i.e. from the
current capitation system into a mixed system in order to bet-
Conclusions ter motivate primary health care doctors to act as gatekeepers
of the health care system, take full care over patients and pre-
An increase in the number of ED hospitalisations in the vent the phenomenon of “pushing” them to outpatient special-
three-year follow-up and a rise in the number of medical pro- ist care facilities and hospital wards. The financing of PHC in
cedures mainly from I to III categories performed in this ward, a mixed system should be based on combining the capitalisation
along with a small percentage of admissions from the ED to ICU, fee with elements of a fee for the service provided, as well as
may indirectly indicate a burden on the ED, mainly with patients on the payment of bonuses for achieving specific care effects.
reporting in non-urgent health situations. The development of constructive solutions for the ED and PHC
Proposals for systemic solutions aimed at decrease the should be based on periodic monitoring of the level of patient
number of non-urgent visits to the ED should be based mainly satisfaction along with the quality of services provided by PHC,
on: coordinating and integrating primary health care and hos- checking the satisfaction of primary care physicians with meth-
pital care, improving the quality and accessibility of services ods of PHC funding they prefer, systemic solutions proposed by
offered by healthcare services provided at night and during doctors themselves and controlling the level of coordination of
holidays, as well as on case management and patient naviga- services between the ED and PHC.
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Tables: 2
Figures: 0
References: 76

Katarzyna Szwamel, PhD
Państwowa Medyczna Wyższa Szkoła Zawodowa
ul. Katowicka 68
45-060 Opole
Polska
Tel.: +48 605 513-431
E-mail: k.szwamel@interia.pl
ISSN 1734-3402, eISSN 2449-8580

Factors affecting the decision to change the family physician

Nevruz Yildirim Topak B–F, Hakan Demirci A, D–F

ORCID iD: 0000-0003-0434-4807
Department of Family Medicine, University of Health Sciences, Bursa Yüksek Ihtisas Training and Research Hospital,
Bursa, Turkey
Summary Background. Some studies on the decision of patients to choose their primary healthcare physician demonstrate that
the ability to choose their physician is associated with increased patient satisfaction, confidence in the doctor and quality healthcare.
Objectives. The study was aimed at evaluating factors effecting the decision to change the family physician.
Material and methods. In the study, a questionnaire was used to examine the socio-demographic characteristics of the individuals, and
the EUROPEP scale was used to measure the satisfaction with primary health services. Moreover, the Individual Innovativeness Scale
was used in order to evaluate the innovativeness of individuals.
Results. In people who apply to change their family physician, satisfaction with the previous family physician was found to be 69%.
Distance (52.7%), education (25.8%) and gender (16%) were declared as the most important reasons to change the family physician.
An individual’s innovation seeking behavior did not affect on their decisions to change the physician.
Conclusions. In the present study, patient satisfaction was lower than the results reported in previous studies. Distance, education and
gender are at the forefront in family physician preference. Patients prioritize receiving service from trained family physicians. These
issues should be taken into account while planning the future of family practice.
Key words: education, gender identity, physicians, family, patient satisfaction.
Topak NY, Demirci H. Factors affecting the decision to change the family physician. Fam Med Prim Care Rev 2019; 21(2): 173–179, doi:
https://doi.org/10.5114/fmpcr.2019.84554.
Background Organizations, managers, staff and even individuals need

to innovate and adapt innovativeness as a behavior in order
People are healthier in countries where the primary health- to comply with the rapidly changing world and to sustain an
care service is strong [1]. In spite of the fact that health policies individual, organizational and professional life [8, 9]. Innova-
and practices vary throughout the world, family practice consti- tion is the process of embodying a new and valuable idea or
tutes the basic element of healthcare services. A strong primary invention at the right time as a product, process or service and
healthcare service provides a cheaper healthcare service with translating it into social benefit [10, 11]. Personal innovative-
easier accessibility and better satisfaction [2]. ness is considered as an umbrella concept that contains in itself
Individuals are granted the right to choose their physician the characteristics of concepts such as risk-taking, being open
thanks to the health reform in Turkey. Patients who are not to experiences and opinion leadership. Personal innovativeness
pleased with their family physicians have the right to change is also the degree to which individuals in a social system adopt
their physician at the end of a three-month period within the any innovation before others [12]. Individuals in the society are
province due to the current regulations [3]. Moreover, this different from each other in terms of innovation according to
three-month condition is not required for out-of-province pa- their characteristics. This is why individuals can behave differ-
tients or for individuals with privileged excuses (over the age of ently in adopting any innovation, being willing to change and to
65, pregnant, etc.). take risks [13].
Some studies on the decision of patients to choose their
primary healthcare physician demonstrate that the ability to
choose their physician is associated with increased patient Objectives
satisfaction, confidence in the doctor and quality healthcare
[4–6]. Accessibility of healthcare services, type and size of the The study was aimed at evaluating factors effecting the deci-
services, status/experience/quality of the healthcare staff, or- sion to change the family physician.
ganization of the healthcare, treatment expenses and socio-de-
mographic characteristics of the family physicians are effective
in the choice of the physician [3]. Additionally, three variables Material and methods
have been identified in the selection of the family physician:
professional skill, management skill and personal characteris- The research study was performed with the help of 500 vol-
tics. It has been shown that elements including professional skill unteers between the ages of 18–65 who were selected random-
factor have the highest effect, followed by elements constitut- ly from among individuals admitted to the Family Health Center
ing management skills. Personal characteristics have the lowest Unit (#16.02.174) between the dates September 2016 – Febru-
effect [7]. ary 2017 in order to change their family physician.
N. Y. Topak, H. Demirci • Decision to change the family physician 175
The ethics committee of Bursa Yüksek Ihtisas Training and Spearman correlation coefficient was calculated. The SPSS pro-
Research Hospital approved the study. gram was used for statistical analysis (IBM Corp. Released 2012.
In this study, a questionnaire was used to interrogate the IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM
socio-demographic characteristics of the individuals, and the EU- Corp.). p < 0.05 was accepted as statistically significant.
ROPEP scale was used to measure the satisfaction with primary
health services [14]. Moreover, the Individual Innovativeness Scale
was used in order to evaluate the innovativeness of individuals.
Results
The satisfaction status of the individuals with their previous
family physicians was evaluated with the EUROPEP scale, which A total of 469 participants (273 female and 196 male) were
questions 5 different situations in 23 questions, from doctor–pa- included in the study. 31 people who left the survey incomplete
were excluded. The mean age of the participants was calculated
tient relationship to accessibility to the doctor. 3 more questions
as 35.91 ± 12.11. 79.5% of the individuals declared that they
were added to the 23 question EUROPEP scale in the research
were married, 17.5% were single and 3% were divorced or wid-
performed by the Ministry of Health throughout Turkey in order
owed. 84.4% of the individuals indicated that their economic
to measure general satisfaction levels, and a questionnaire of 26
condition was at a medium level. The educational levels of the
questions was applied. The participants were asked to answer
volunteers were classified as high school graduate at maximum
the questions with 6 choices (very bad, bad, normal, good, per-
quantity and post-graduate at minimum quantity (Table 1).
fect, no idea) according to the Likert scale. Patient satisfaction
was analyzed within the aspects of ‘Doctor–patient relation-
ship’, ‘Health Service’, ‘Information and Support’, ‘Health Ser- Table 1. Socio-demographic characteristics of the participants
vice Organization’, ‘Accessibility’ and ‘General Evaluation’ [15]. n = 469
The Individual Innovativeness Scale (IIS), which is a self-re- Gender (Female/Male) 273 (58.20%)/196 (41.80%)
port measuring tool, was used to determine individuals’ general Age (year) 35.91 ± 12.11 (18 : 65)
innovativeness levels and their innovativeness categories [12].
The original questionnaire form contains 20 expressions in to- Age Groups
< 20 26 (5.5%)
tal related to the characteristics of the individuals in 5 different
20–29 133 (28.4%)
categories, from innovative to traditionalist. Each expression
30–39 155 (33%)
in the questionnaire about individual innovativeness is graded
40–49 82 (17.5%)
according to a 5-point Likert scale, from “Strongly Disagree” to
50–59 43 (9.2%)
“Strongly Agree”. Scale items consisted of 12 positive expres- ≥ 60 30 (6.4%)
sions (items 1, 2, 3, 5, 8, 9, 11, 12, 14, 16, 18 and 19) and 8
negative expressions (items 4, 6, 7, 10, 13, 15, 17 and 20). With Marital status
the help of the scale, the innovativeness score is calculated by Married 373 (79.5%)
Single 82 (17.5%)
adding 42 points to the score obtained by subtracting the total
Divorced/widowed 14 (3%)
score of negative items from the total score of positive items.
The lowest grade to be obtained with the help of the scale is 14, Education Level
and the highest score is 94. According to the scores calculated Literate 15 (3.2%)
through the scale, individuals are interpreted as “Innovator” if Primary school 108 (23%)
the score is over 80,“Pioneer” if the score is between 69 and Secondary school 67 (14.1%)
80,“Interrogator” if the score is between 57 and 68,“Skeptical” if High school 146 (31.1%)
the score is between 46 and 56 and “Traditionalist” if the score University 124 (26.4%)
Graduate 9 (1.9%)
is below 46. Moreover, a general evaluation can also be made
on the innovativeness levels of the individuals according to the Economic Status
score calculated with help of the scale. Accordingly, individuals Very low 7 (1.5%)
who get a score higher than 68 are considered to be quite inno- Low 45 (9.6%)
vative, while those with a score lower than 64 are evaluated as Intermediate 396 (84.4%)
low in innovativeness [12]. High 19 (4.1%)
The compatibility of the variables to normal distribution Very high 2 (0.4%)
was analyzed with the Shapiro–Wilk test, and the determiner Data n (%), mean ± standard deviation (minimum : maximum).
was expressed statistically as median (minimum : maximum) or
mean ± standard deviation (minimum : maximum) values. The 69.5% of the participants made the decision of changing
Mann–Whitney U test was used in the comparison of the two their physician themselves. Distance (52.7%), education (25.8%)
groups according to the normality test results, and the Krus- and gender (16%) were declared as the most important reasons
kal–Wallis test was used in case of more than two groups. The to change the family physician (Table 2).
Dunn–Bonferroni approach was used, and multiple comparison
procedures were applied in the sub-group analysis among the
Table 2. Distribution of decisions to change the family physician
groups following the Kruskal–Wallis test. Pearson chi-square
test, Fisher’s exact chi-square test and Fisher–Freeman–Halton Reason for changing the family physician n = 469
tests were used for a comparison of the categorical variables Distance
among the groups. The internal consistency of EUROPEP and Yes 247 (52.7%)
the Individual Innovativeness Scale was analyzed with the Cron- No 222 (47.3%)
bach alpha coefficient. General scale reliability was determined Gender (female physician)
as α = 0.94 in the analysis made to examine the reliability of Yes 75 (16%)
the EUROPEP scale. On the other hand, the results of sub-scale No 394 (84%)
analysis were found to be: α = 0.94 for doctor–patient sub-di-
Religion
mension, α = 0.86 for health services sub-dimension, α = 0.88 Yes 11 (2.3%)
for information and support sub-dimension, α = 0.69 for health No 458 (97.7%)
service organization sub-dimension and α = 0.83 for accessibility
sub-dimension. Scale reliability for the individual innovativeness Training family health center
Yes 121 (25.8%)
questionnaire was α = 0.85. The relationship between continu-
No 348 (74.2%)
ous variables was analyzed with correlation analysis, and the
176 N. Y. Topak, H. Demirci • Decision to change the family physician
Table 2. Distribution of decisions to change the family physician When the questions left unanswered by the participants
were excluded, total satisfaction according to the EUROPEP
Reason for changing the family physician n = 469
scale was 69%. The issues on which satisfaction was maximum
Residential care patient according to the mean scores of the answers given on the
Yes 17 (3.6%) EUROPEP scale questions were: ‘keeping your records and in-
No 452 (96.4%) formation confidential’, ‘listening to you’, ‘physical examina-
Home visit tion’, while ‘being able to speak to the GP on the telephone’
Yes 18 (3.8%) and ‘waiting time in the waiting room’ were issues for which
No 451 (96.2%) dissatisfaction was high (Figure 1, 2).
Q26
Q25
Q24
Q23
Q22
Q21
Q20
Q19
Q18
Q17
Figure 1. Satisfaction ratios according to the EUROPEP
Q16
scale [%]
Q15
Q14
Q1 – making you feel you had time during consultations,
Q2 – interest in your personal situation, Q3 – making it easy
Q13 to talk about your problems, Q4 – involving you in deci-
Q12 sions about medical care, Q5 – listening to you, Q6 – keep-
ing your records and data confidential, Q7 – quick relief of
Q11
your symptoms, Q8 – helping to perform your normal daily
Q10 activities, Q9 – thoroughness, Q10 – physical examination,
Q9 Q11 – offering you services for prevention, Q12 – explaining
the purpose of tests and treatments, Q13 – discussing your
Q8
symptoms and/or illness, Q14 – help in dealing with emo-
Q7 tional problems, Q15 – helping understand the importance
Q6 of following advice, Q16 – knowing what has been done
during previous contacts, Q17 – preparing what to expect
Q5 from specialists, Q18 – the helpfulness of the staff, Q19 –
Q4 getting an appointment that suits you, Q20 – getting through
Good to the practice on the phone, Q21 – being able to speak to
Q3
Moderate the GP on the telephone, Q22 – waiting time in the wait-
Q2 ing room, Q23 – quick service for urgent health problems,
Bad Q24 – general behavior of the doctor in the family practice,
Q1
Q25 – health services in general, Q26 – physical conditions
0 10 20 30 40 50 60 70 80 90 of the family practice.
90
80
70
60
50
40
30
20
10
0
Q1
Q2
Q3
Q4
Q5
Q6
Q7
Q8
Q9
Q10
Q11
Q12
Q13
Q14
Q15
Q16
Q17
Q18
Q19
Q20
Q21
Q22
Q23
Q24
Q25
Q26
Figure 2. Satisfaction ratios of participants according to the EUROPEP scale [%]
Q1 – making you feel you had time during consultations, Q2 – interest in your personal situation, Q3 – making it easy to talk about your problems,
Q4 – involving you in decisions about medical care, Q5 – listening to you, Q6 – keeping your records and data confidential, Q7 – quick relief of your
symptoms, Q8 – helping to perform your normal daily activities, Q9 – thoroughness, Q10 – physical examination, Q11 – offering you services for
prevention, Q12 – explaining the purpose of tests and treatments, Q13 – discussing your symptoms and/or illness, Q14 – help in dealing with emo-
tional problems, Q15 – helping understand the importance of following advice, Q16 – knowing what has been done during previous contacts, Q17
– preparing what to expect from specialists, Q18 – the helpfulness of the staff, Q19 – getting an appointment that suits you, Q20 – getting through
to the practice on the phone, Q21 – being able to speak to the GP on the telephone, Q22 – waiting time in the waiting room, Q23 – quick service
for urgent health problems, Q24 – general behavior of the doctor in the family practice, Q25 – health services in general, Q26 – physical conditions
of the family practice.
The questions that were most often left unanswered were There was no difference among the innovativeness sub-
‘reaching your doctor by phone’, ‘reaching the family health -groups in terms of general satisfaction rates. In the sub-group
center by phone’, ‘doctor informing the patient about expecta- analysis, a difference was detected among the innovativeness
tions from referral to a specialist or hospital’ and ‘keeping your groups in terms of satisfaction with health service organizations.
records and information confidential’ (Figure 3). It was also found that the satisfaction rates of the innovator,
There was no difference between the gender groups in pioneer, interrogator and skeptical groups were higher than that
terms of general patient satisfaction. According to the sub-group of the traditionalist group (p = 0.013, p = 0.008, p = 0.008 and
analysis, the satisfaction rate of male patients was higher than p = 0.047, respectively) (Table 3).
female patients in the sub-groups of doctor–patient relation- There was no difference between general satisfaction
ship, health services, information and support. No difference and satisfaction sub-groups among innovativeness search
was detected among the satisfaction rates of gender groups in sub-groups in terms of age. There was no difference between
terms of health service organization and accessibility. general satisfaction and satisfaction sub-groups in terms of ed-
Among the participants, innovator was determined as 2.3%, ucational level. There was a direct relation between patient ed-
pioneer as 20.4%, interrogator as 57.1%, skeptical as 18.3% and ucation level and innovativeness scale score. As the education
traditionalist as 1.7%. There was no difference among the inno- level increased, the score of the innovativeness scale increased
vativeness groups in terms of gender distribution. (r = 0.34; p < 0.001).
25
20
15
10
0
Q1
Q2
Q3
Q4
Q5
Q6
Q7
Q8
Q9
Q13
Q23
Q10
Q11
Q12
Q14
Q15
Q16
Q17
Q18
Q19
Q20
Q21
Q22
Q24
Q25
Q26
Figure 3. Non-response ratios to the questions of the EUROPEP scale [%]
Q1 – making you feel you had time during consultations, Q2 – interest in your personal situation, Q3 – making it easy to talk about your problems,
Q4 – involving you in decisions about medical care, Q5 – listening to you, Q6 – keeping your records and data confidential, Q7 – quick relief of your
symptoms, Q8 – helping to perform your normal daily activities, Q9 – thoroughness, Q10 – physical examination, Q11 – offering you services for
prevention, Q12 – explaining the purpose of tests and treatments, Q13 – discussing your symptoms and/or illness, Q14 – help in dealing with emo-
tional problems, Q15 – helping understand the importance of following advice, Q16 – knowing what has been done during previous contacts, Q17
– preparing what to expect from specialists, Q18 – the helpfulness of the staff, Q19 – getting an appointment thatsuits you, Q20 – getting through
to the practice on the phone, Q21 – being able to speak to the GP on the telephone, Q22 – waiting time in the waiting room, Q23 – quick service for
urgent health problems, Q24 – general behavior of the doctor in the family practice, Q25 – health services in general, Q26 – physical conditions of
the family practice.
Table 3. Relation between patient satisfaction and innovativeness

Innovator Pioneer Interrogator Skeptical Traditionalist p
n = 11 n = 96 n = 268 n = 86 n=8
Patient Satisfaction (General) 0.089a
Satisfied 7 (63.6%) 32 (33.3%) 83 (31%) 20 (23.3%) 2 (25%)
Unsatisfied 4 (36.4%) 64 (66.7%) 185 (69%) 66 (76.7%) 6 (75%)
Patient Satisfaction 0.060a
(Physician-Patient Relation)
Satisfied 9 (81.8%) 46 (47.9%) 138 (51.5%) 36 (41.9%) 2 (25%)

Unsatisfied 2 (18.2%) 50 (52.1%) 130 (48.5%) 50 (58.1%) 6 (75%)
Patient Satisfaction (Health Services) 0.257a
Satisfied 8 (72.7%) 45 (46.9%) 142 (53%) 42 (48.8%) 2 (25%)
Unsatisfied 3 (27.3%) 51 (53.1%) 126 (47%) 44 (51.2%) 6 (75%)
(Information and Support)
Satisfied 8 (72.7%) 44 (45.8%) 140 (52.2%) 35 (40.7%) 2 (25%)
Unsatisfied 3 (27.3%) 52 (54.2%) 128 (47.8%) 51 (59.3%) 6 (75%)
(Health Service Organization)
Satisfied 7 (63.6%) 47 (49%) 130 (48.5%) 34 (39.5%) 0
Unsatisfied 4 (36.4%) 49 (51%) 138 (51.5%) 52 (60.5%) 8 (100%)
Patient Satisfaction (Accessibility) 0.143a
Satisfied 7 (63.6%) 29 (30.2%) 82 (30.6%) 23 (26.7%) 1 (12.5%)
Unsatisfied 4 (36.4%) 67 (69.8%) 186 (69.4%) 63 (73.3%) 7 (87.5%)
a
– Fisher–Freeman–Halton Test.
178 N. Y. Topak, H. Demirci • Decision to change the family physician
There was no relation between the number of family physi- of the physician, among the non-organizational factors, in their
cian changes and patient satisfaction (p = 0.858) and innovative- decision about family physicians [20, 25]. 25.8% of the patients
ness (p = 0.520). indicated that family medicine residency education in the family
health center positively affected their decision to change physi-
cian.
Discussion In a study performed on prospective teachers, it was shown
that the difference between the individual innovativeness char-
In the current study, we found that patient satisfaction and acteristics of the participants and the current grade they work
individual innovativeness did not have an effect on the decision with is significant. According to this, the mean scale score of
to change family physicians. Distance, education and gender are fourth grade prospective teachers was higher than that of first
at the forefront in family physician preference.
grade prospective teachers [26]. In the current study, the rela-
In this study, the satisfaction rate was 69%. Since the EU-
tion between patient education level and the innovativeness
ROPEP scale does not have a previously determined cut-off
scale score was also in the same direction. The innovativeness
point, general satisfaction was evaluated on an answer basis,
scale score increases as the education level increases. In the
not a mean basis. In previous studies, satisfaction with the fam-
same study, it was shown that there is a positive and medium-
ily medicine system was 89.5% in Bursa, 80.7% in Malatya and
-level relation between the critical thinking tendency of prospec-
87.5% in Gumushane [15–17]. As the volunteers are those who
tive teachers and their individual innovativeness [26]. In our
refer in order to change their family physician, a low level of
study, we did not detect a relation between patient satisfaction
satisfaction can be considered as an expected situation.
and individual innovativeness search with the number of physi-
The factor that patients often consider important in physi-
cian changes.
cian selection is ease of access (practice hours, distance from
home and seeing the doctor without delay). The most highly
disputed issue in the studies is distance or appropriate location.
Strengths and limitations of the study
Another important issue is that patients prefer physicians they The current research is a leading study examining innova-
can reach via their own transport or public transport vehicles tiveness, which may have an effect on the decision to change
[18–20]. Other factors are parking area [19, 20] and transport the family physician. Some limitations of the study can be listed
fee [21, 22]. Other socio-demographic factors that are consid- as follows: the study was applied to patients visiting the family
ered important are age and gender of the physician (whether physician. Hence, satisfaction and innovativeness in this study
the physician is the same gender as the patient). Generally, it refers to the satisfaction and innovativeness of people utilizing
is assumed that the demographic parameters of the physician the family healthcare unit. A control group would be better to
affect the selection of a physician by patients, but other factors compare the results obtained in the study. The single-centered-
are considered more important [23, 24]. However, it is shown ness of the study is another important limitation preventing the
that individuals generally tend to prefer physicians that are the generalizability of the results.
same age and gender as themselves [3]. In the current study,
16% of the participants answered the question “was your deci-
sion of changing the physician affected because the physician Conclusions
was female” with “yes”.
In general, while factors associated with a physician’s indi- Individual innovativeness is not a factor forcing individuals
vidual characteristics (e.g. gender, religion, marital status) are to change their family physician in our region. Distance, edu-
considered relatively unimportant, variables associated with cation and gender are at the forefront in family physician pref-
a physician’s professional expertise (e.g. board certificate or erence. Patients prioritize receiving service from trained fam-
specialist physician) are considered much more [7]. Research ily physicians. These issues should be taken into account while
indicates that individuals are mostly interested in the education planning the future of family practice.
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17. Bostan S, Havvatoğlu K. Europep aile hekimliği memnuniyet ölçeğine göre Gümüşhane aile hekimliği memnuniyet araştırması.
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Tables: 3
Figures: 3
References: 26
Accepted: 4.02.2019

Hakan Demirci, MD
Department of Family Medicine
University of Health Sciences
Bursa Yüksek Ihtisas Training and Research Hospital
Bursa
Turkey
Tel.: 0090536 896 33 30
E-mail: drhakandemirci@hotmail.com

ISSN 1734-3402, eISSN 2449-8580

Evaluation of patient referrals to family physicians in Georgia

Tengiz Verulava1, A–F, Dali Beruashvili2, A–C, Revaz Jorbenadze3, A, D, E,
ORCID iD: 0000-0001-8110-5485 ORCID iD: 0000-0001-8228-5342
Ekaterine Eliava 4, D, E
1
Health Policy and Insurance Institute, School of Business, Ilia State University, Tbilisi, Georgia
2
School of Business, Ilia State University, Tbilisi, Georgia
3
G. Chapidze Emergency Cardiology Center, Tbilisi, Georgia
4
Senamedi Hospital, Senaki, Georgia
Summary Background. Adequate utilization of primary care directly reflects the health status of the population. In Georgia (Repub-
lic), many patients seek care without a referral by a primary-care provider, and as a result, patient referral rates to family physicians are
low. A tendency of patient self-referral behavior may reduce the effectiveness of the healthcare system.
Objectives. The purpose of the research is to study the problem of the low rate of patient referrals to family physicians in Georgia.
Material and methods. Within the quantitative survey, 20 family physicians and 300 patients were interviewed through a semi-struc-
tured questionnaire in different regions of Georgia.
Results. Patient referral rates to family physicians are low. 15% (n = 3) of family physicians recognize that patients often address them
only for a referral to specialists. Only 5% (n = 3) of family physicians provide preventive consultations on occasion and 50% (n = 10) – in
the case of need only. 70% (n = 14) of family physicians think that their remuneration is not adequate for their work and that they work
more than they are paid. 35% (n = 105) of respondents in the case of a health problem address both a family physician and a specialist-
-physician. 42% (n = 126) of patients visit a family physician once a year or do not visit at all, and 47% (n = 141) of patients believe that
the family physician institute needs some changes.
Conclusion. The result suggests that the low rate of patient referrals to family physicians is due to distrust towards family physicians,
which is related to a lack of qualification of physicians and low public awareness of the competence of the family physicians. Due to
inadequate reimbursement, family physicians do not have enough motivation to provide adequate service, and the lack of continuous
professional education negatively affects their professional development. It is recommended to raise public awareness about primary
care, to introduce effective methods for payment of family physicians and to increase the role and affordability of continuous profes-
sional education.
Key words: primary health care, family practice, referral and consultation, Georgia (Republic).
Verulava T, Beruashvili D, Jorbenadze R, Eliava E. Evaluation of patient referrals to family physicians in Georgia. Fam Med Prim Care Rev
2019; 21(2): 180–183, doi: https://doi.org/10.5114/fmpcr.2019.84555.
Background applies to primary health care institutions. Studies show that

the primary healthcare system in Georgia has failed to develop
Health care system orientation to primary care has a posi- under the standards that have been applicable in many devel-
tive effect on the continuity and coordination of medical ser- oped countries for several years [10–12]. This is confirmed by
vices, which simultaneously reduces the cost of unnecessary the fact that the patient referral rate to family physicians is 3.6
specialized services and improves the health of the population. (up to 7.5 in European countries), which is due to the fact that
In a health care system focused on primary health care, the role patients have less motivation to address the primary care physi-
of family physicians as a gatekeeper increases. In such a system, cian for prevention. Patients prefer hospital services [13–15]. It
is obvious that the low development of primary care and family
the patient tries to apply firstly to a family physician, then, if
physician institutes is negatively impacting the health status of
necessary, apply for specialized services to specialists.
the population and health care costs [16–18].
Studies have confirmed that in a health care system where
referral to special medical care is performed through a family
physician, the health care costs decrease [1, 2], and continu- Objectives
ous medical supervision is at a high level. Patients who are un-
der the permanent supervision of a primary care physician are The purpose of the work is to study the problem of the low
less likely to need specialized services or hospitalization [3–5]. rate of patient referrals to family physicians in Georgia. The ob-
The need for urgent medical care is less in patients who utilize jective of the research is to identify the factors that cause low
regular primary health care services [6, 7]. Thus, primary care confidence in family physicians.
is considered as a mechanism for preventing health care costs,
which is important for a low-income country like Georgia [8, 9]. Material and methods
One of the most important components of assessment of
the effectiveness of medical care is the patient referral rate to The research is a cross-sectional study and is concerned
family physicians. It aims to analyze how often the population with the problems in primary care in Georgia (Republic). Within
T. Verulava et al. • Patient referrals to family physicians in Georgia 181
the quantitative survey, 20 family physicians and 300 patients Do you attend educational programs for family
(enrolled in a family physician’s list) were interviewed under physicians?
a semi-structured questionnaire in different cities and regions Yes 3 15
of Georgia. The random selection method was used for selec- No 7 35
tion of the survey contingent. The questionnaire for this study More or less 6 30
was developed based on a review of literature and specificities Not sure 4 25
of the primary health care system in Georgia. After the ques- Do you follow medical news through medical
tionnaire had been built, the information of respondents was journals and articles?
collected by a convenient sampling method. The data was then Yes 10 50
No 0 0
processed by SPSS software. More or less 9 45
The main limitation of the survey is the fact that it was con- Not sure 1 5
ducted in only a few cities/regions due to lack of time.
Do you get updated guidelines via the Internet?
The protocol for the research project was approved by the Yes 7 35
suitably constituted Ethics Committee of the Ilia State Univer- No 6 30
sity, within which the work was undertaken and conforms to the More or less 7 35
provisions of the Declaration of Helsinki of 1995. Not sure 0 0
Physicians have named low pay the reason for low motiva-
Results tion. One of the ways to solve existing primary care problems
is an increase in salaries. The majority (65%, n = 13) think that
Family physicians’ survey results their remuneration is low. In addition, 70% (n = 14) of fam-
ily physicians think that their remuneration is not adequate to
Within the scope of the survey, 20 family physicians were in- their work and that they work more than they are paid.
terviewed. About 60% (n = 12) of respondents serve 10 to 15 The survey found that 60% (n = 12) of family physicians do
patients per day. 15% (n = 3) of family physicians recognize that not have nurses. Considering that nurses play a significant role
in providing services, their absence in the family medicine team
patients often address them only for a referral to specialists. The
negatively affects the quality of service, and therefore the pa-
survey makes it clear that only 5% (n = 3) of family physicians tient’s satisfaction. 50% (n = 10) of family physicians think that
provide preventive consultations on occasion and 50% (n = 10) they are more or less able to improve professionally, but 35%
in the case of need only (Table 1). (n = 7) do not have the opportunity to do so. 35% (n = 7) of re-
spondents cannot participate in educational programs for family
Table 1. Results of the interview with family physicians physicians. 50% (n = 10) of family physicians are familiar with
medicine news through medical journals and articles, and 45%
n %
(n = 9) are more or less familiar. It is noteworthy that respondents
The number of patients received by a family over 51 years of age do not follow the news on the Internet.
physician during a day
Less than 10 1 5 Patient survey results
From 10 to 15 12 60
More than 15 7 35 56% (n = 168) of the interviewed patients were female and
The patients often address the family physicians 44% (n = 132) male. The majority have higher education (73%,
only to receive a referral to a specialist n = 219). The health status of 48% (n = 144) of respondents is av-
Yes 3 15 erage. 35% (n = 105) of respondents in case of a health problem
No 5 25 address both a family physician and a specialist-physician. At the
More or less 11 55 same time, 30% (n = 90) of respondents will directly address the
Not sure 1 5 physician. 42% (n = 126) of respondents visit the family physi-
cian once a year or do not visit at all. When asked if they trust
Do you provide preventive consultations to your the family physician, most of the respondents (36%, n = 108)
patients? were not sure what to answer. The majority of respondents 47%
Sometimes 3 5 (n = 141) believe that the family physician institute needs some
Only in case of need 10 50 changes (Table 2).
I have no time for such consultations 7 35
Assessment of remuneration by the interviewed Table 2. Patient survey results
physicians n %
Low remuneration 13 65 Gender

Satisfactory remuneration 6 30 Female 168 56
Good remuneration 1 5 Male 132 44
Adequacy of remuneration as assessed by the Education
interviewed family physicians Secondary education 81 27
Works more than paid 14 70 Higher education 219 73
Pay is adequate to the work 1 5
Health status
Works somehow less than paid 5 25
Good 120 40
Whether family physicians have nurses? Average 144 48
Yes 8 40 Not satisfactory 36 12
No 12 60
Who will you mainly address in case of health
Do you have career development, professional problems?
improvement opportunity? Family physician 60 20
Yes 0 0 Specialist-physician 90 30
No 7 35 Sometimes a family physician, sometimes
More or less 10 50 a specialist-physician 105 35
Not sure 3 15 Self-medicate 45 15
182 T. Verulava et al. • Patient referrals to family physicians in Georgia
Table 2. Patient survey results viewed and analyzed, and the paths toward a solution are not
n % searched for.
A separate problem is the fact that continuous professional
How often do you address to a family physician education in the country is not mandatory. In addition, for some
during a year?
physicians, the academic and educational programs are not af-
Once or not at all 126 42
fordable, as participation in them is paid.
2–5 72 24
6–8 42 14
The study shows that a family physician’s pay is low, which
9–10 54 18 hinders the development of the family physician institute in
11 and more 6 2 the country. The physician’s financing method is one of the key
leverages to effectively implement health care services. It is
Do you have confidence in your family physician’s advisable to introduce combined methods of pay for primary
qualification?
health care, i.e. funding other than the remuneration method
Yes 101 34
(targeted remuneration and so on). Special attention should be
No 91 30
paid to the methods of incentive remuneration of physicians to
Not sure 108 36
carry out prophylactic measures for beneficiaries.
How would you rate the family physician institute? The patient referral rate to family physicians in Georgia is
Positively 90 30 low. Patients are trying to address specialist-physicians directly,
Requires some changes 141 47 bypassing the family physician. Most rarely address a family
Negatively 54 18
physician for prevention. Family physicians are less likely to take
Not sure 15 5
preventive measures. The low role of a family physician reduces
the effectiveness of medical care, as it is not possible to detect
Discussion illness early by preventive measures. Patient self-referral has
a negative effect on the health of the population, reduces the
The survey has shown that the rate of visiting a family physi- quality of medical care and increases health care costs.
cian in Georgia is lower compared to other countries. A signifi- The low rate of patient referrals to family physicians may be
cant part of the patients visit a family physician once a year or due to a lack of confidence in the quality of medical care. This is
do not visit at all. In the case of health impairment, patients mainly caused by the low qualifications of family physicians. The
try to directly visit the specialist-physician, bypassing the family state and employers are less likely to support the professional
physician. The patient more often applies to specialized medi- growth of family physicians. Accordingly, family physicians do
cal services (hospital, physician specialists) by him/herself. The not have the opportunity to develop and grow professionally.
existing system does not contribute to the reduction of self-re- It is noteworthy that continuous professional education is the
ferral to specialized medical services. country is not mandatory.
It is noteworthy that a greater share of respondents rarely Primary health care reform will not be implemented without
addresses the family physician for consultation with the pur- a properly educated family physician/nurse. In the furtherance
pose of prevention. Family physicians are less likely to take pre- of this goal, the level of professional training should be raised.
ventive measures. This reduces the efficiency of medical care, In this aspect, there are family medicine training centers in the
since early detection of illness cannot be provided by preventive country where family physicians/nurses are trained. However,
measures. The low rate of patient referrals to family physicians most of them are paid trainings and often are not affordable.
in Georgia may be due to a lack of confidence in the quality of With the support of donor organizations, the state should en-
medical care. According to family physicians, the mistrust and sure development of the necessary capacities of primary health
low satisfaction of patients are not only due to them, but also care human resources of appropriate qualifications throughout
due to the fact that patients do not like the infrastructure of the country. The state should also support the continuous medi-
outpatient medical facilities, as well as standing in a queue to cal education of family physicians.
visit the family physician. Another important factor is also the
established stereotype that family physicians are less profes- Conclusions
sional than specialist-physicians. At the same time, according
to family physicians, their load exceeds their pay. It should be The result suggests that the low rate of patient referrals to
taken into consideration that the majority of family physicians family physicians is due to distrust towards family physicians,
do not have a nurse and take on the work themselves. which is related to the lack of qualification of physicians and
The situation is aggravated by the fact that employers are low public awareness of the competence of the family physi-
less likely to support professional growth of family physicians. cians. Due to inadequate reimbursement, family physicians do
Consequently, family physicians do not have the opportunity to not have enough motivation to provide adequate service, and
improve and develop skills, which is very important for people the lack of continuous professional education negatively affects
employed in medicine, as well as in any other field. The study their professional development. It is recommended to raise
shows that the administration of medical facilities is less inter- public awareness about primary care, to introduce effective
ested in the problems of family physicians. Consequently, the methods for payment of family physicians and to increase the
problems are not identified, each particular issue is not re- role and affordability of continuous professional education.
Source of funding: This work was supported by the Shota Rustaveli National Science Foundation of Georgia (grant number FR17_101).
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11(2): 143–150.
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2017; 10(4): 21–28.
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8. Verulava T, Gabuldani M. Accessibility of urgent neurosurgery diseases by the state universal healthcare program in Georgia (country).
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News 2017; 264(3): 135–139.
12. Verulava T, Dangadze B. Health capital and economic growth: evidence from Georgia. Open Public Health J 2018; 11: 401–406.
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Tables: 2
Figures: 0
References: 18

Prof. Tengiz Verulava
Health Policy and Insurance Institute
School of Business
Ilia State University
Kakutsa Cholokashvili Ave 3/5
Tbilisi 0162
Georgia
Tel.: (+995 32) 222 00 09
E-mail: tengiz.verulava@iliauni.edu.ge

ISSN 1734-3402, eISSN 2449-8580

REVIEWS © Copyright by Wydawnictwo Continuo
Unfinished first-line tuberculosis treatment in primary care

in Indonesia
Al Asyary1, 2, A–F, Yodi Mahendradhata3, A, E
ORCID iD: 0000-0003-2150-0429 ORCID iD: 0000-0002-4522-1785
1
Department of Environmental Health, Faculty of Public Health, Universitas Indonesia, Depok, Indonesia
2
Center of Educational and Community Services (P3M), Faculty of Public Health, Universitas Indonesia, Depok,
Indonesia
3
Department of Health Policy and Management, Faculty of Medicine, Public Health, and Nursing,
Universitas Gadjah Mada, Yogyakarta, Indonesia
Summary Background. Unfinished tuberculosis (TB) treatment has slowly but surely become an unexpected event in the disease’s
development into drug-resistant TB. Developing countries, mostly comprised of Asian and Eastern European countries, including Indo-
nesia, have been overwhelmed in preventing drug-resistant TB outcomes and have also failed to avoid the development of this disease.
Objectives. This review discusses the current issue of an unfinished first-line TB treatment strategy in primary care in Indonesia, pre-
senting some relevant strategies in developing countries.
Material and methods. A narrative review approach conducted on all existing evidence in selected scientific bibliographic sources. The
researchers defined the keywords based on the research question as a search strategy.
Results. Scarce resources and limited access, alongside national policy on TB control and management, contribute in different ways to
impede first-line TB treatment in Indonesia. Empowerment of TB patients and their families are considered the best ways to increase
awareness on TB medication in a low- to middle-income setting. The role of the hospital and private practitioner networks in the treat-
ment and management of TB patients is essential for developing active-case-finding-approach programs for TB suspects in primary
care in an Indonesian setting. Contrarily, the potential misunderstandings in TB treatment have led to peculiar events affected by poor
surveillance systems for TB investigation contacts to prevent TB incidences in large populations.
Conclusions. This study addressed the barrier of all stakeholders, particularly primary care, to achieve the Indonesian government’s
goals of TB elimination by 2030 and zero TB findings by 2050.
Key words: tuberculosis, drug resistance, Indonesia, developing countries, primary care.
Asyary A, Mahendradhata Y. Unfinished first-line tuberculosis treatment in primary care in Indonesia. Fam Med Prim Care Rev 2019;
21(2): 185–188, doi: https://doi.org/10.5114/fmpcr.2019.84556.
Background [1], focused on this strategy by committing to a local govern-

ment policy in four provinces in 2012. Previously, drug-resistant
TB surveys began in 2006 in the Jawa Tengah Province, as the
Rationale national TB policy resulting from the estimation of MDR-TB
reached 1.8% of TB incidence and 17.1% of TB default [13].
Multidrug-resistant tuberculosis (MDR-TB) has become
Based on the National Action Plan on Programmatic Manage-
a global social health problem, in which the disease is immune ment of Drug Resistance Tuberculosis (RAN-PMDT), TB-drug re-
to first-line drugs, such as isoniazid and/or rifampicin [1]. MDR- sistance in Indonesia has been affected by (1) poor quality of
-TB has affected more developing countries than developed implementation of DOTs in hospitals and any other health facili-
ones [2–4]. ties except health centers, (2) increase in TB-HIV coinfection, (3)
Unfinished first-line TB treatment has emerged as a large poor surveillance system, and (4) the lack of TB case manage-
proportion of MDR-TB incidences, consisting of failure, default ment for TB-drug resistance facilities [14].
and relapse of TB treatment [3, 5]. Management of TB therapy
on non-directly observed treatments (DOTs) at health facilities Objectives
[3, 6], the lack of a gold standard of drug-susceptibility facilities
for diagnosis [7, 8] and poor TB patient access to medication This study aims to explore a developing country’s strategy of
[5, 8–10] are the main determinant factors for MDR-TB control, unfinished first-line TB treatment in primary care. This narrative
which is more complex in an under-resourced country setting. review particularly examines TB control and management in the
Several developing countries have been encouraging their Indonesian setting.
central governments’ activities and programs through the pri- We examined recent literature on the current issue and
mary care policy related to this agenda [11], including any nec- prospects for the unfinished treatment of TB, with MDR-TB as
essary efforts to prevent TB, such as bacille Calmette–Guerin a common outcome for treatment failure resulting from the
(BCG) vaccination, which is still disputed [12]. Indonesia, which government policy associated with adherence to TB therapy in
ranks 9th out of 27 countries in high-burden MDR-TB diseases numerous studies.
186 A. Asyary, Y. Mahendradhata • National tuberculosis program in Indonesian primary care
Material and methods equate MDR-TB medication [15]. In 2007, assessment results of
implementation of DOTs in 50 hospitals showed a default rate of
TB patients reaching 10% to 20% of category 1 and 6% to 29% of
Eligibility criteria category 2 (Table 1). Otherwise, the average success rate in the
We assemble all existing evidence relevant to TB mitigation hospital was only at 60% out of the 85% national target, which
and control in primary care in Indonesia to identify evidence is less for category 2 at 6.5%. Therefore, more than 90% of TB
gaps, all forms of literature, including published or unpublished patients experiencing default in the hospital had a high risk of
scientific articles or government/institution reports, and other MDR-TB [16].
related eligible documents for review in Bahasa Indonesia or The low success rate of TB treatment was also affected by
English. No publication date or publication status restrictions a poor case holding process that led to a poor compliance rate
were imposed. of TB patient treatment. There was also a lack of family sup-
port and insufficient internal networking between hospitals and
external networking between hospitals and other healthcare
Evidence resources
facilities that implemented DOTs (hospital DOT linkage). Indeed,
In this review, we researched bibliographic sources, i.e. the level of knowledge, attitude and patient behavior also con-
MEDLINE, EMBASE, CINAHL, Cochrane Library, Science Direct, tributed to poor compliance of TB treatment [17].
ProQuest, WHO SEARO database, SCOPUS, Wiley Library, SAGE, Other factors related to inadequate implementation of DOTs
Taylor & Francis, SpringerLink, Hindawi and Directory of Open in hospitals included the use of non-standardized TB drugs. One
Access Journals (DOAJ). We also researched literature not listed study on prescriptions for TB treatment in hospitals found free
in the above bibliographic resources using the Indonesian Portal TB drugs from DOT programs in only 13% of prescriptions; the
Indexing (IPI), and we examined recent literature on the current rest referred to generic brands of TB drugs [19]. The results of
issue and prospects for the unfinished treatment of TB, with a clinical audit in hospitals that have implemented DOT treat-
MDR TB as a common outcome for treatment failure of TB re- ment before also showed an equal pattern of TB drug utilization
sulting from the government policy associated with adherence that is practically non-standardized. Furthermore, inappropriate
to TB therapy in numerous studies. deficiency criteria for doses of TB drugs were found in 69% to
100% of 387 audited hospital medical records [20].
Search strategy Otherwise, the TB drug group that is usually given alongside
first-line TB drugs is quinolone, particularly ciprofloxacin, which
Two researchers defined the keywords based on the re- is available commercially. This study on hospital prescriptions
search question. No years of publication and language restric- showed a general pattern of TB drug combination HRE or HRZE
tion were placed on the search strategy. The team researcher prescription alongside ciprofloxacin (11.6% of category 1 regi-
used the keywords to conduct the search and input the search men and 12.1% of category 2 regimen) or single-regimen cipro-
results into the Mendeley library. Subsequently, we assessed all floxacin (0.75% of category 1 and 7.9% of category 2) [18].
meta-data for each article, including the abstract and full-text, Another threat that surfaced was the unrestricted sale of at
and discuss it to the meeting. least three second-line TB drugs that are freely available on the
commercial market: fluoroquinolone, kanamycin and amikacin.
These drugs are freely accessible and are the most utilized by
Results and discussion healthcare facilities in both hospitals and private practice, with-
out any standard term and regulation practices. Other second-
Poor quality of implementation of DOTs in hospi- -line TB drugs, consisting of ethionamide, protionamide, PAS
tals and in other health facilities and cycloserin, proved ineffective, more expensive and harder
to manage as a short-term package, with worse side effects. It is
Insufficient implementation of DOTs, either in hospitals, essential to prevent resistance to second-line TB drugs. Several
public lung clinics and private health practice, has led to inad- studies have found that in countries where this disease was en-
Table 1. TB cases found that potentially developed into MDR-TB in 20 hospitals and public lung health clinics [18]
Hospitals Lung Hospital Public Lung Health Clinics
2006 2007 2006 2007 2006 2007
No. of treated 1093 1694 451 266 269 167
TB cases
n % n % n % n % n % n %
Category 1 731 66.9 1169 69.0 271 60.1 201 75.6 246 91.4 161 96.4
Failure 9 1.2 10 0.9 0 0.0 0 0.0 4 1.6 5 3.1
Default 149 20.4 143 12.2 0 0.0 0 0.0 27 11.0 17 10.6
Treatment result unrecorded 96 13.1 526 45.0 225 83.0 169 84.1 29 11.8 50 31.1
Category 2 29 66.9 11 69.0 28 60.1 16 75.6 17 91.4 3 96.4
Failure 5 17.2 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0
Default 5 17.2 0 0.0 0 0.0 0 0.0 1 5.9 1 33.3
Treatment result unrecorded 0 0.0 10 90.9 18 64.3 12 75.0 3 17.6 1 33.3
Relapse 21 72.4 9 81.8 10 35.7 6 37.5 17 100.0 1 33.3
Category 1 with smear positive 13 1.2 7 0.4 1 0.2 1 0.4 11 4.1 10 6.0
after intermittent phase
The Public Lung Health Clinics (Balai Pengobatan Penyakit Paru-Paru – BP4).
A. Asyary, Y. Mahendradhata • National tuberculosis program in Indonesian primary care 187
demic, the tuberculosis potentially developed as a genetic mu- condition, distance from the facility and lack of either transpor-
tation of Mycobacterium tuberculosis sp. with a new variant of tation or accommodation funds [24, 25]. Health workers, with an
TB affecting either first-line and second-line TB drug resistance: exceeded workload, tend to care for patients with unaffordable
TB Extra Drug Resistant (XDR) [17]. service. Meanwhile, it potentially decreases treatment adher-
ence, since patients should be coming in every day [23].
Referral laboratory capacities for drug susceptibi- Unfortunately, the PCT strategy lets patients identify pas-
lity tests sively. The period between realizing the symptoms and visiting
healthcare facilities is missed. Therefore, access to healthcare
The laboratory capacity for MDR-TB is the essential compo- is not affected by this approach. However, PCT enables health
nent in facing the challenges of this disease from a diagnosis workers to consider newly diagnosed TB patients as TB incidenc-
standpoint. Laboratory facilities have not been well developed es. Health workers also do not need to worry about being over-
or optimal, as the health system is still being strengthened in whelmed, which could happen when they serve all their TB pa-
several under-resourced countries, including developing coun- tients. PCT supports the increase of access to diagnosis and the
tries. The poor diagnosis system for MDR-TB is affected by the required medication indirectly, as it contributes to improving
unavailability of a laboratory infrastructure, outdated labora- diagnostic procedures and assessments. The key to a PCT strat-
tory guidelines and a quality assurance system fragmented by egy lies in the option of a treatment location and supervision.
limited skilled laborers [21]. Empowerment of TB patients and their families is essential to
In Indonesia, only five laboratories are allowed to run drug cover treatment care, which influences their compliance posi-
susceptibility tests (DSTs), which have been certified by an inter- tively [26]. Prompt diagnosis and treatment leads to compliance
national TB laboratory, the Institute of Medical and Veterinary Sci- and adequate medication based on effective TB control [23].
ence (IMVS), Adelaide, Australia, which both diagnoses and leads
the referral therapy for MDR-TB patients. These laboratories are Limitations of the study and future research
the Microbiology Laboratory of the Faculty of Medicine, Univer-
sity of Indonesia; the Main Health Laboratory Clinic of Surabaya; This narrative review presents the current strategy of the
the Microbiology Laboratory of Persahabatan Hospital; the No- Indonesian government in controlling first-line TB treatment
vartis Eijkmann Hasanuddin Clinical Research Initiatives (NEHCRI) as part of their national priority and strategy. The narrative re-
Laboratory of the Faculty of Medicine, Hasanuddin University; view is not truly useful as scientific evidence, but it would be
and the Health Laboratory Clinic of Bandung. All these laborato- evidence-based [27]. This study was unable to clear the bias
ries have undergone routine external quality assurance by IMVS that caused the absence of systematic selection criteria, but
for first-line and second-line TB drugs in the DST. The capacity of it provides an evidence-based view of the current situation of
DST assessments is still low, i.e. less than 100,000 DSTs annually unfinished TB treatment in developing countries. Thus, further
for all five laboratories. Their limited capacity was affected by studies are needed to set a more systematic approach to this
running-out-of resources, either manpower or others [22]. issue, as well as its potential for MDR-TB disease development
in developing countries.
TB management strategy
Patient-centered tuberculosis (PCT) is a promising strategy Conclusions
for TB medication [23]. It enables the patient to choose the
treatment option or supervision model for drug consumption, The role of hospitals and private practitioner linkages in the
whether in a healthcare facility under health professional super- treatment management of TB patients is critically required. It
vision or at home with relatives who wish to supervise. would be too late if TB control and management begins treat-
Options for treatment location, information related to medi- ment only after the disease has developed into MDR-TB, particu-
cation and tuition from treatment supervisors should increase. larly in under-resourced countries such as Indonesia. Healthcare
Regular training is also needed for health workers to effectively facilities, which are not supported by the TB control strategy,
supervise feasibility strengthening for a successful PCT approach. tend to ignore the International Standard TB Care (ISTC) as its
Furthermore, PCT aims to gain access and compliance to standard procedure for TB control. Poor accessibility by TB pa-
TB treatment, as well as DOTs. TB patients, or their supervisors tients directly causes unfinished TB treatment. Further study is
when they are unable to go to healthcare facilities, can procure necessary to describe and analyze the pattern of unfinished TB
the TB drugs every week in the incentive phase (within the first patients, which is related to the potential of TB to develop into
two months) and every two weeks in the advance phase (in the MDR-TB in developing countries.
last four months). PCT eliminates the workload of health work-
ers when they do not need to supervise the intake of TB drugs Acknowledgments. This review is supported by the Corpo-
of their patients every day. It enables good quality of health pro- rate Social Responsibility of Aneka Tambang (CSR ANTAM) Co.
fessional care [23]. Ltd. Scholarships Grant 2012 (grant No. 5/2012). We would also
In conventional DOT approaches, TB patients are obligated to like to thank the contributors: Prof. Dr. Purwantyastuti, MD,
visit a healthcare facility every day for treatment. In many cases, MSc., Prof. Purnawan Junadi, MD, MPH, PhD. and Dr. Tris Ery-
this is hard for TB patients, as they are affected by their physical ando, MA.
Source of funding: This review is supported by the Corporate Social Responsibility of Aneka Tambang (CSR ANTAM) Co. Ltd. Scholarships
Grant 2012 (grant No. 5/2012).
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Tables: 1
Figures: 0
References: 27
Received: 1.09.2018
Accepted: 7.11.2018

Dr Al Asyary
Department of Environmental Health
Faculty of Public Health
Universitas Indonesia
C Building 2nd Floor
Campus FKM-UI Depok Jawa Barat 16242
Indonesia
Tel./Fax: +6221-7863479
E-mail: al.asyary13@gmail.com, al.asyary@ui.ac.id
ISSN 1734-3402, eISSN 2449-8580

CONTINUOUS MEDICAL EDUCATION (CME) © Copyright by Wydawnictwo Continuo
ReCOMmendations for the treatment of INFLUENZA

in children for Primary care physiciAnS – COMPAS INFLUENZA
Recommendations developed by the following experts: Polish Society of Pediatric Pneumology,
Polish Pediatric Society, Polish Society of Vaccinology, Polish Society of Family Medicine
Zbigniew Doniec1, A, D–F, Agnieszka Mastalerz-Migas2, A, D–F, Teresa Jackowska3, A, D–F,

Ernest Kuchar4, A, D–F, Adam Sybilski5, A, D–F
1
Department of Pneumonology of the Institute of Tuberculosis and Lung Diseases, Regional Department
in Rabka-Zdroj
2
Department of Family Medicine, Wroclaw Medical University
3
Department of Paediatrics, Medical Centre for Postgraduate Education in Warsaw
4
Department of Paediatrics with the Observation Unit of the Medical University of Warsaw
5
Department of Paediatrics and Neonatal Diseases of the Central Clinical Hospital of the Ministry of Interior
and Administration in Warsaw
Summary Influenza is an acute infectious disease of the airways that occurs in every age group. The course of the disease may have
a different severity and clinical picture, from asymptomatic to severe with symptoms of respiratory failure. The possibilities of pan-
demic infections and serious complications throughout the course of influenza distinguish it from other viral respiratory diseases,
prompting us to treat it in a special way. Diagnosis of the disease is usually clinical in nature, and additional studies may be helpful in
clinically relevant cases. The drug recommended for treatment and chemoprophylaxis is oseltamivir. Clinical benefits are greatest if
treatment starts as early as possible, within 48 hours of the first symptoms of influenza. Clinical studies indicate that early treatment
with oseltamivir may shorten the duration of the disease and reduce the risk of its complications. Annual influenza vaccination is the
most effective method of preventing this disease, and the only contraindication to vaccination is the occurrence of an anaphylactic or
other severe allergic reaction after a previous vaccination.
Key words: influenza, children, treatment, vaccinations.
Doniec Z, Mastalerz-Migas A, Jackowska T, Kuchar E, Sybilski A. ReCOMmendations for the treatment of INFLUENZA in children
for Primary care physiciAnS – COMPAS INFLUENZA. Fam Med Prim Care Rev 2019; 21(2): 189–198, doi: https://doi.org/10.5114/
fmpcr.2019.82984.
Background (N1 to N11 subtypes). In humans, three HA subtypes: H1, H2,

H3, and two NA subtypes: N1 and N2, are common. H3N2 was
the subtype of virus A most frequently detected in the years
Influenza is an acute respiratory disease which occurs in 1994–2005 (90.6%), and since the outbreak of the pandemic in
all age groups. The course of the condition may have different 2009 – AH1N1 [1]. Influenza A is infectious to humans and many
severity and clinical picture, from asymptomatic to severe with species of animals; the extent of an epidemic/pandemic is un-
symptoms of respiratory failure [1, 2]. Influenza is one of the predictable and depends on the type of interaction between the
most common acute respiratory diseases of the viral aetiology. virus and the host cells, as well as on ecological factors.
In practice, it is not always properly diagnosed due to numerous Virus B contains only one type of HA and NA belonging to
similarities to the ordinary “common cold”, especially at an early one of two genetic lines: Yamagata or Victoria. In humans, the
stage of the clinical course. The possibilities of pandemic and type B virus causes infections; they usually run in a clinical man-
serious complications distinguish this condition from other viral ner which is indistinguishable from the infections caused by
respiratory diseases [1, 2]. type A viruses [1, 3].
The influenza virus belongs to the Orthomyxoviridae family The influenza A virus is characterised by high antigenic vari-
and has significant affinity for the airway epithelium. In humans, ability of HA and NA proteins, which mainly results from rela-
infections caused by the type A and B virus are important from tively frequent RNA mutations and minor errors accumulated
the clinical point of view, while type C has less epidemiological during RNA copying (antigenic drift or antigenic shift, otherwise
significance. Influenza A and B viruses contain genome (single- known as reassortment) [4]. These changes are caused by the
-stranded, segmented, negative-polarity RNA), protein capsid enzyme responsible for RNA replication (RNA polymerase); new
with antigenic proteins on the surface – neuraminidase (NA), mutations arising from RNA polymerase errors can increase vir-
haemagglutinin (HA) and lipoprotein capsule [3]. ulence, facilitate adhesion of the virus to the respiratory epithe-
Influenza A virus has many subtypes, with differentiation lium and its replication. Because changes in the virus genome
based on HA antigenic properties (H1 to H18 subtypes) and NA are continuous, they allow for the annual spread of the disease
190 Z. Doniec et al. • Recommendations for the treatment of influenza in children
among people who have not acquired immunity as a conse- Reporting the case and a suspicion
quence of contracting influenza in a given season or as a result
of vaccination. The high genetic variability of the influenza A vi- of influenza
rus leads to the formation of new, sometimes very pathogenic
strains. Type B and C viruses have high genetic stability. In the epidemic season, entities providing outpatient health
care services are obliged to make reports on the MZ-55 forms
(weekly and, in the period of significantly higher incidence,
Epidemiology daily). According to the definition adopted for the purpose of
infectious diseases surveillance in European Union countries
Influenza is the most dangerous of common viral respira- (Journal of Laws L 159 of 18.6.2008, p. 46), the reports should
tory infections. In the temperate climate zone, influenza is di- include the cases of flu (diagnosed clinically and/or in labora-
agnosed every year in the winter months. The influenza season tory tests) and all clinically diagnosed flu-like illnesses, as well
in the northern hemisphere falls from October to April, reach- as acute respiratory infections which meet the criteria listed in
ing its peak usually at the end of February [5]. According to the the form. The MZ-55 forms are available on the websites of local
WHO, on average 20–30% of children and 5–10% of adults suf- sanitary and epidemiological stations or can be generated di-
fer from full-blown flu [6]. It is most common among children rectly from a computer program developed for medical entities.
aged 5–14 years, while the risk of severe influenza is the highest Flu, diagnosed clinically and/or in laboratory tests, also re-
in children aged 6 months to 4 years and those chronically ill, quires notification on the ZLK-1 infectious disease report form
especially with neurological disorders which impair ventilation in accordance with the Act of 5th December 2008 on the preven-
and impede expectoration, as well as in patients with chronic tion and control of infections and infectious diseases in humans
lung diseases, for instance bronchopulmonary dysplasia. The (Journal of Laws of 2018, item 151).
ECDC (European Centre for Disease Prevention and Control) esti- It should be noted that correct reporting of all cases of influ-
mates that annually in European Union countries, influenza may enza by all medical entities designated for this purpose (NIZP–
affect 10–30% of the population, with a predominance among –PZH) is crucial for the epidemiological data collected by the
children [7]. On the other hand, a meta-analysis conducted in units to reflect the real situation.
randomised trials shows that in the influenza epidemic season,
an average of 10.5% of school-age children suffer from this Clinical picture
disease, along with as much as 32% of children under 6 years
of age compared to about 2.5% of adults; therefore, children Flu is characterised by a sudden onset, with fever, a feeling
constitute the largest group of the infected and sick [8, 9]. Al- of cold, chills, headache, muscle and joint pain, general malaise,
though flu seasons differ significantly from each other due to no appetite and weakness. The general symptoms are accompa-
the random mutation of influenza viruses, variable circulation nied by dry cough and nasal congestion, sometimes with watery
of the viruses and different effectiveness of vaccines, resulting exudation. The patient may complain of photophobia and other
from the difficulties in the annual adjustment of the vaccine ocular symptoms, such as conjunctival hyperaemia, tearing and
composition, the average pathogenicity of the influenza virus burning eyes, as well as acute retro-bulbar pain (about 20%
is huge. In Poland, several million suspected influenza (flu-like of patients), and he/she may have red face, hot and wet skin.
illness) cases are reported annually, out of which more than ten Sometimes, there is a sore throat, hoarseness, enlarged cervi-
thousand are admitted to hospital, and the number of deaths cal lymph nodes (about 25%), rarely diarrhoea (< 5%); however,
is unknown (official reports list several to 100 deaths per year, the general symptoms usually obscure other ailments. Hearing
while in Poland, the ECDC estimates deaths at 6.000). In 2017, sounds over the lungs are reported in over 20% of patients.
a total of 5 043 491 cases of influenza and suspected flu were Fever is a constant feature of influenza, usually lasting for 3–5
registered in Poland (incidence 13 126.5/100 thousand), 17 118 days, but in approximately 1/5 of patients, fever lasts for 7–10
hospitalisations (0.34%) and 47 deaths. Among children under days or longer. Children run a higher fever than adults, although
the age of 14, 2 269 154 cases of flu and suspected influenza in infants the temperature does not have to rise as high as in
were reported (incidence 39 130.5/100.000), and 9 411 chil- older children and young adults. The temperature usually rises
dren were admitted to hospitals (0.41%), whilst no deaths were rapidly in the first 12 hours of the disease, i.e. at the time when
recorded [10]. The summary of epidemiological data from the the general symptoms appear. A fever can provoke seizures, es-
years 2013–2018 is presented in Tables 1a and 1b. pecially in the first 2 years of life. The most nagging initial com-
Table 1a. Influenza epidemiology: a summary of the last 5 influenza epidemiological seasons in Poland (developed by [10])
Season 2013/2014 2014/2015 2015/2016 2016/2017 2017/2018
Cases 2 761 523 3 774 798 4 069 654 4 844 024 5 385 962
Hospitalisations 9 374 12 227 16 156 16 970 18 561
Hospitalisations/cases (%) 0.33% 0.32% 0.39% 0.34% 0.34%
Deaths 15 11 140 25 47
Table 1b. Deaths depending on the age of the influenza patient (developed in accordance with [10])
Age 0–4 years 5–14 years 15–64 years + 65 years Total
Season
2013/2014 0 1 6 8 15
2014/2015 0 0 9 2 11
2015/2016 3 2 79 56 140
2016/2017 0 0 5 20 25
2017/2018 0 0 20 27 47
Z. Doniec et al. • Recommendations for the treatment of influenza in children 191
plaints are headaches and muscle pain, the severity of which • within the age of 6–59 months;
is usually connected with the height of the fever. Muscle pain • chronically ill with coexisting lung diseases, including
can involve the limbs or long muscles of the back. Joint pain, asthma, cardiovascular system (with the exception of
without arthritis, is equally common. Respiratory symptoms, isolated hypertension), renal, hepatic, neurological, hae-
usually a dry cough and watery nasal discharge, are gener- matological or metabolic disorders, including diabetes;
ally present at the onset of the disease, but these aliments are • with immunodeficiency, including those infected with
usually obscured by the general symptoms. In young children, HIV;
high fever with the accompanying neurological symptoms (en- • receiving aspirin for a long time (increased risk of Reye
cephalopathy or febrile convulsions) may be the only symptom syndrome);
of influenza; a significant percentage of children may develop • staying in long-term care centres;
bronchitis. On the second or third day of the disease, fever and • extremely obese.
other general symptoms begin to subside. In contrast, respira- The most common complications of influenza in children in-
tory symptoms, especially dry cough, become more visible and clude: acute otitis media, bronchitis, primary viral pneumonia,
last usually for 3 to 4 days, though coughing and weakness usu- secondary bacterial pneumonia, tracheitis, subglottic laryngitis,
ally last longer (more than 2 weeks). In some patients, poor mild inflammation of the muscles (usually influenza B, possible
well-being and chronic fatigue may persist for several weeks. It myoglobinuria, occasionally with kidney damage), myocarditis,
should be emphasized that new-borns and infants may also suf- pericarditis and central nervous system complications: fever
fer from influenza; the younger the child, the less specific the convulsions, encephalopathy, transverse myelitis, Guillain–Bar-
symptoms may be. The clinical symptoms of influenza caused by ré syndrome and Reye syndrome [17, 18].
type A and B viruses are similar. Bacterial pneumonia occurs during the recovery from influ-
enza or in the convalescence phase (another episode of fever,
worsening of breathlessness, coughing, weakness after clini-
Diagnosis cal improvement). The most common bacteria responsible for
pneumonia are: S. pneumoniae, S. aureus, H. influenzae and oth-
According to international and national guidelines, clini-
ers. Bacterial superinfections are manifested by deviations in
cal symptoms and physical examination are sufficient to make
complete blood count: leukocytosis > 15 x 103/mm3, especially
a diagnosis in outpatient settings during the epidemic season
an elevated neutrophil count 10 x 103 and high inflammatory
(October–April) [11–13]. The knowledge of the current epide-
marker rates (CRP and procalcitonin). Less common complica-
miological situation, regular reporting of patients with flu-like
tions include: toxic shock syndrome, Goodpasture’s syndrome,
symptoms, reports on increased incidence of flu, as well as in-
anosmia, ageusia (the loss of smell and taste) and balance dis-
formation on contact with a person suffering from influenza con-
orders [19]. The mortality rate among children with influenza
firmed in the medical history, are helpful in diagnosing influenza.
is highest, and complications are most frequent in the first two
Clinical symptoms: general symptoms prevail, sudden on-
years of life; the rates are high in small children and those chron-
set with a high fever > 39°C, highest on the first day, features
ically ill – especially with immunity and neurological disorders
of acute, toxic infection (malaise, significant weakness, chills,
which impair lung ventilation and hinder expectoration of secre-
headaches and muscle pain), muscle and joint pain, dry cough,
tions. Red-flag symptoms indicating possible complications and
less common conjunctivitis, sore throat and wheezing.
Leucopoenia with lymphocytosis in the peripheral blood requiring clinical re-evaluation are presented in Table 2. These
count is helpful in diagnosing influenza. Positive results of Rapid symptoms are an indication for hospitalisation, 24-hour monitor-
Influenza Diagnostic Tests (RIDTs), which detect the A and B virus ing of the patient’s condition, as well as laboratory and imaging
but do not determine the strain, may be helpful in diagnosing tests (chest X-ray, transthoracic ultrasound of the chest).
influenza. The advantage of the tests is the short waiting time
for the result (several minutes) and their high specificity, but Table 2. Red-flag clinical symptoms of influenza indicating pos-
relatively low sensitivity (60–70%), which means that a negative sible complications
test result does not allow for the exclusion of influenza [14]. The • persistent or recurrent high fever or other symptoms after
most accurate method is to identify the genetic material of the 3 days
virus in the material collected from the patient (nose or naso- • symptoms of cardio-respiratory failure: dyspnoea, cyanosis,
pharynx smear, aspirate from the nasal part of the throat, etc.) haemoptysis, chest pain, hypotension, decrease in oxygen
by means of RT-PCR (Reverse Transcriptase Polymerase Chain saturation of haemoglobin
Reaction); however, this should be done no later than on day 7
• symptoms indicating CNS complications: consciousness dis-
from the beginning of the symptoms [15, 16].
turbances, loss of consciousness, pathological drowsiness,
recurrent or sustained seizures, significant weakness, pa-
Differentiation
ralysis or paresis
• signs of severe dehydration: prolonged capillary return, de-
Influenza-like illness caused by other viruses, including RSV, creased activity, dizziness or fainting while trying to get up
atypical pneumonia, viral pharyngitis, sepsis, infectious mono- or reduced diuresis
nucleosis, enterovirus (e.g. Coxsackie), rotavirus and norovirus • laboratory symptoms of secondary bacterial infection
(colloquially, “intestinal flu”).
Symptomatic treatment
Complications
In the majority of healthy people, influenza is a self-limiting,
In the majority of children, flu is uncomplicated, with a high uncomplicated disease [20]. In such cases, symptomatic treat-
fever lasting for 3–4 days, sometimes for 6–8 days. Recovery ment is sufficient (Figure 1) [21]. The strategies for symptomatic
usually occurs after 1–2 weeks. Even in previously healthy chil- treatment of influenza include [13, 22]:
dren, the course of influenza can be serious, with organ com- • proper hydration of the patient – the recommendation
plications or bacterial superinfections, circulatory insufficiency of abundant oral fluid administration, which is crucial
and sudden death. in the course of fever, moisturising of the airways and
The group at higher risk of severe influenza and complica- facilitating the respiration and evacuation of secretions
tions is children: (especially important in children);
Uncomplicated flu-like illness
• symptomatic treatment
without risk factors
• instructing the patient*
• use of antiviral drugs

risk groups • close observation
• instructing the patient*
Figure 1. Initial clinical management in uncom-

• use of antiviral drugs plicated flu-like illness or influenza (according
any deterioration or the lack of • admission to hospital in the to [21])
improvement within 72 hours case of complications and
severe course of the illness * When to report to the doctor again (red-flag flu
symptoms).
• administration of antipyretic drugs and analgesics (ibu- recommended for all people at risk for influenza complications
profen, paracetamol) which reduce chills, muscle pain who are suspected of the disease (even in the case of a mild
and tachycardia due to influenza. However, it should be course) as well as for household members of people at risk for
emphasised that there is no clinical data indicating that influenza complications. According to the recommendations
antipyretic and anti-inflammatory therapy shorten the of the Advisory Committee on Immunization Practices (ACIP)
duration of influenza symptoms. Acetylsalicylic acid is from 2018/2019, these include children < 5 years, especially < 2
not recommended for children under the age of 18 years, all people over 50, patients with chronic respiratory dis-
years due to the possibility of Reye syndrome; eases and those with cardiovascular, metabolic and neurological
• rest and convalescence at home for up to 24 hours af- disorders (Table 4) [35, 36]. At the same time, it should be em-
ter fever has dissipated. This is of particular importance phasised that every patient with the symptoms of confirmed flu
to minimise the complications of influenza, as well as (especially with severe symptoms) can be treated with antiviral
the transmission and spread of the virus [20]; treatment in order to significantly reduce the spread of the virus
• antitussive drugs – in severe, tiring, dry cough [23]; in the population, especially during an epidemic period.
• medicines for reducing swelling of the nasal mucosa
– decongestants, saline solutions. Table 3. Indications for antiviral treatment in children (modified
There are currently no clinical results of the studies con- by authors [35])
ducted in animals or humans indicating a beneficial effect of
Give the medicine to the child (as soon as possible)
natural or herbal therapy in flu. There are no indications and
no herbal, natural or other non-prescription (OTC) preparations Hospitalised with probable influenza
recommended for the symptomatic treatment of influenza in Hospitalised due to severe, complicated or progressive illness as-
adults and children [24]. sociated with influenza, regardless of the duration of symptoms
With suspected flu (with any severity of symptoms) and a high
Causative treatment – antiviral drugs risk of complications
Consider giving the drug
In causative/antiviral treatment of influenza, we use prepa- Any healthy child with suspected flu
rations of neuraminidase inhibitors [13, 25–28]. The neuramini-
A child with suspected influenza who stays with children aged < 6
dase inhibitors registered in Poland are as follows:
months or a person with a disease predisposing to complications
• oseltamivir – oral medicine;
• zanamivir – a drug for inhalation (a medicine not avail-
able in Poland, possible to be brought in as part of Table 4. People from the general population with a higher risk
a target import during an epidemic of influenza). of post-influenza complications and recommendation for anti-
Currently, due to the high level of resistance of AH3N2 and viral therapy (modified by authors according to [35, 36]
AH1N1 type viruses to amantadine, it is not recommended for Recommendation of antiviral treatment in the case of a suspi-
the treatment of influenza [13, 28]. cion or confirmation of influenza infection
Inhibitors of neuraminidase, which is an enzyme necessary Children < 5 years of age, especially < 2 years
for replicated virions to leave the host cell, effectively inhibit the Persons ≥ 50 years of age
spread of the virus in the body and prevent the symptoms of People with chronic diseases of the following systems:
influenza [28]. Oseltamivir is effective against influenza A and B • respiratory (including asthma),
viruses. It is estimated that the resistance of the currently occur- • cardiovascular (excluding isolated hypertension),
ring strains of influenza A to the drug is below 1%. Type B of the • kidneys, liver,
virus is 100% sensitive [29, 30]. • haematological (including sickle-cell disease),
The clinical efficacy of oseltamivir has been confirmed in • metabolic (including diabetes),
many studies. The use of a neuraminidase inhibitor reduces the • neurological (including disorders of the CNS, spinal cord,
severity of influenza symptoms, shortens the duration of fever peripheral nerves, muscles, epilepsy, stroke, mental retar-
and other symptoms, as well as reduces the risk of complica- dation, moderate and severe developmental delays, brain
tions (including the need for taking antibiotics) and hospitalisa- and spinal cord trauma),
tion [20, 31–33]. Antiviral drugs shortened the duration of out- • people in immunosuppression (including due to treatment
patient care and hospital stay in patients with influenza, as well or HIV infection)
as diminished the risk of death [34]. All pregnant women or those in the postpartum period during
The American Academy of Paediatrics (AAP) recommends the flu season
using neuraminidase inhibitors for the treatment and chemo- Extremely obese people BMI > 40
prophylaxis of influenza in children, as they are the best stud-
Persons < 19 years treated for a long time with acetylsalicylic acid
ied antiviral drugs at present. Indications for their use are in-
cluded in Table 3 [35]. Antiviral treatment (oseltamivir) is also People staying in nursing homes
Table 5. Commercial forms of oseltamivir (according to [25–27])

Trade name Pharmaceutical form Registration (treatment, prevention) Responsible entity
Tamiflu* capsules, hard, 30 mg, 45 mg, for the treatment of adults and children, including new- Roche
75 mg (10 in a package) -borns born at term;
in infants below 1 year of age to prevent influenza after
exposure during a pandemic
Ebilfumin* capsules, hard, 30 mg, 45 mg, for the treatment of adults and children, including new- TEVA Pharmaceuticals
75 mg (10 in a package) -borns born at term;
prevention after exposure in people aged 1 year or older;
in infants below 1 year of age for the prevention of influenza
after exposure during a pandemic
Tamivil 75 mg tablets in adults and children over 6 years of age or weighing more Biofarm
(10 in a package) than 40 kg
* Instructions for the preparation of suspension are included in the patient leaflet.
Currently, two preparations of oseltamivir, i.e. Tamiflu and Oseltamivir is administered orally, regardless of meals, al-
Ebilfumin, are registered in Poland. They can be used in treat- though administration with food may improve the gastrointesti-
ment from the first days of life. Tamivil can be applied in children nal tolerance of the drug. In children, the drug should be admin-
over 6 years old, weighing more than 40 kg (Table 5) [25–27]. It istered in the form of a syrup. The suspension may be prepared
should be emphasised that these drugs are not a substitute for from capsules by a pharmacist in a pharmacy (the preferred
the influenza vaccination [35]. way) or, in the absence of such an opportunity, by parents at
In standard therapy, the drug is given twice a day, in equal home. For infants under 1 year of age, it is recommended that
12-hour intervals, for 5 days. In children, the dose depends on the product be prepared in a pharmacy, not at home. The pa-
age and body weight (Table 6). There is no sufficient data on tient leaflet contains detailed instructions on how to prepare
dosage in premature babies, i.e. born before the 36th week of the fluid from capsules [26].
pregnancy. These children may require a different dose due to Oseltamivir is safe and has a small number of side effects.
physiological immaturity [25]. The treatment should last 5 days. These usually included single episodes of symptoms which ap-
It must not be discontinued, even if the symptoms of influenza peared on the first or second day of treatment and resolved
are resolved. spontaneously within 1–2 days [36]. The most common ad-
verse reactions were gastrointestinal symptoms, such as nau-
sea and vomiting (Table 7) [25, 26, 37]. The pharmacokinetic
Table 6. Oral doses of oseltamivir recommended in the treat-
ment and chemoprophylaxis of influenza in Poland (according
mechanisms of oseltamivir, including low protein binding and
to [13, 25–27]) the metabolism which is independent of CYP450 systems and
glucuronidase, are unlikely to cause clinically significant drug
Treatment Prophylaxis interactions [37].
(5 days) (10 days)
Adults 75 mg 2 times daily 75 mg 1 x day
Table 7. Side effects and contraindications to oseltamivir
Children (according to [25–27])
> 12 months*
Side effects Contraindications
≤ 15 kg body mass 30 mg 2 times daily 30 mg 1 x day
Tamiflu • nausea, vomiting and • hypersensitivity to
> 15–23 kg body 45 mg 2 times daily 45 mg 1 x day diarrhoea, oseltamivir phosphate
mass • abdominal pain, or any other compo-
> 23–40 kg body 60 mg 2 times daily 60 mg 1 x day • headaches, dizziness, nent of the drug
mass • insomnia
> 40 kg body mass 75 mg 2 times daily 75 mg 1 x day Ebiflumin • nausea and vomiting, • hypersensitivity to the
Infants 0–12 3 mg/kg body mass 3 mg/kg body mass • headaches, dizziness, active substance or
months per dose per dose 1 x day** • insomnia, any of the excipients
2 times daily • rare: arrhythmias,
disturbances in
* In children, the drug should be administered in the form of a syrup. In consciousness, convul-
Poland, the syrup is unavailable, but it is possible for the pharmacist to sions
prepare a suspension from capsules. If preparation in a pharmacy is not Tamivil • headaches, dizziness, • hypersensitivity to the
possible, the patient can prepare a drug suspension from capsules on • abdominal pain, active substance or
his/her own. For infants below the age of 1 year, it is recommended that • nausea and vomiting, any of the excipients
the product be prepared in a pharmacy, not at home. The preparation
• insomnia,
instructions are included in the patient leaflet.
• rare: arrhythmias,
** Prophylaxis is not recommended in children < 3 months, except for disturbances in
life-threatening situations. There is not enough data available in this consciousness, convul-
regard. sions
Oseltamivir should be administered within 48 hours of the There is no data on the safety and efficacy of oseltamivir
onset of symptoms, preferably as soon as possible. There is no administered in children with renal failure (aged 12 years and
need to obtain a result confirming the presence of the influ- younger). In adolescents (from 13 to 17 years of age) and adults
enza virus infection. In exceptional situations (confirmed severe (especially those over 65 years of age) with renal insufficiency,
flu, late reporting of the patient to a doctor, patient at risk of the dose should be adjusted based on creatinine clearance. For
complications), the drug can be used in the subsequent hours the treatment of patients with creatinine clearance from 10 to
and days of the disease, although the therapeutic effect may be 30 ml per minute, we provide a dose of 75 mg once a day for 5
weaker [35]. days. For the prevention of influenza in patients with creatinine
Pneumonia
mild, moderate severe or worsening
without risk factors groups at risk
• antibiotic ± • admission to hospital • admission to hospital

• oseltamivir • antibiotic ± • antibiotic
• close observation • oseltamivir • oseltamivir
• instructing the patient* • oxygen therapy
Figure 2. Initial clinical management of pneumonia in the course of influenza depending on the indications and clinical situation (modified
by authors [21])
* When the patient should report to the doctor again (red-flag flu symptoms).
clearance from 10 to 30 ml per minute: 30 mg once daily for 10 vir (chemoprophylaxis) may be recommended in order to inhibit
days after exposure or 75 mg once every other day for 10 days the spread of the virus and the development of the disease in
after exposure (5 doses). In patients with hepatic insufficiency, it people after contact with patients suffering from influenza [21].
is not necessary to reduce the therapeutic or prophylactic
1 dose Post-exposure prophylaxis is recommended for unvacci-
[35, 38, 39]. nated children (after contact with a patient with clinically diag-
The medicine should be used to treat and prevent the dis- nosed influenza) [20]:
ease only if reliable epidemiological data indicates that the virus • with a high risk of influenza complications;
is circulating in the environment and the symptoms suggest the • with close contact with sick people (living in the same
presence of flu infection. Protection against influenza lasts only flat);
as long as oseltamivir is administered. It should be emphasised • persons caring for children under 6 years of age, as
that chemoprophylaxis with the drug is not a substitute for vac- these children can not be vaccinated.
cination, which is the most effective form of flu prevention. In exceptional situations, pre-exposure prophylaxis may be
Hospitalisation ought to be considered in the case of a se- used. This is recommended in children at high risk of complica-
vere or worsening course of the disease. In patients at risk, tions (e.g. undergoing immunosuppression), when protection
symptoms of pneumonia are an indication for hospitalisation against influenza is impossible [13].
(Figure 2) [21]. The indications for considering hospitalisation in In addition, CDCs (Centers for Disease Control and Preven-
a patient with influenza are presented in Table 8. A patient with tion) recommend the use of chemoprophylaxis during the sea-
respiratory failure should be transferred to a centre performing son of the illness in the following cases [40]:
extracorporeal transmembrane oxygenation (ECMO). • in children at high risk of influenza complications with-
in 2 weeks after vaccination, when the optimal level of
immunity is not yet reached;
Table 8. When to consider hospitalisation of a patient with
• in unvaccinated family members or health care and care
influenza (modified by authors [22])
facility workers (nurseries, kindergartens) who are in
Indications for hospitalisation permanent or close contact with unvaccinated children
significant dehydration at high risk of influenza complications or unvaccinated
infants and young children up to 24 months of age;

severe or rapidly worsening course of the disease
• as a complement to vaccination in children at high risk
pneumonia in patients at high risk of complications of influenza complications, including immunocompro-
respiratory failure and hypoxia mised individuals who may not develop a sufficient im-
mune response to the vaccine.
circulatory-respiratory disorders
Chemoprophylaxis is not routinely recommended for chil-
disturbances of consciousness dren under 3 months of age due to the lack of data on efficacy
high fever (> 39.5°C), lower body temperature and safety at this age group.
new-born
infant in the first 3–6 months of life
Influenza prevention – vaccinations
Vaccinations are the most effective form of flu prevention
Prophylactic use of antiviral drugs and protection against a severe course of the disease and its
complications [1, 41]. During the flu season, higher incidence
Vaccination against influenza, optimally before, but also rates of epidemic influenza are usually reported in children than
during the flu season, should be recommended for any child in the rest of the population; moreover, the increased morbidity
who has no contraindications. The prophylactic use of oseltami- is accompanied by more severe or fatal complications. Children
spend a lot of time in care facilities (nurseries, kindergartens) activates innate antiviral mechanisms, in particular the produc-
and schools, where there is a greater risk of mutual infection tion of type I interferon [35]. Women who have not received
with influenza. In this group, children under the age of 2 are at vaccination during pregnancy should also be encouraged to be
higher risk of hospitalisation and complications [35]. The effec- vaccinated after childbirth, as soon as possible.
tiveness of vaccination depends on the appropriate adjustment Since the 2017/2018 season, the intramuscular Quadriva-
of the vaccine composition to the strains circulating in the popu- lent Influenza Inactivated Vaccine (QIIV) has been available in
lation in a given season of the illness. Poland. It contains antigens of two types of influenza viruses
According to the Protective Vaccination Program for 2019, A and B [42, 47, 48]. Inactivated influenza vaccines do not con-
flu vaccines are recommended for all healthy children from the tain viruses capable of causing disease, have a well-documented
age of 6 months to the age of 18 years (with special emphasis high safety profile, and their use does not pose any significant
on children from the age of 6 to the end of the 60th month) [42]. health risks [35].
Similar recommendations are made by the AAP, with special One dose of the vaccine should provide protection against
emphasis on children with chronic diseases, which increase the influenza within 2 weeks after vaccination. This protection lasts
risk of influenza complications [35]. These conditions include: for one season. We give one dose of the vaccine to children over
• asthma and other chronic lung diseases, including cys- the age of 8. In children from the age of 6 months up to the age
tic fibrosis; of 8, who are vaccinated for the first time, we give two doses of
• haemodynamically significant heart disease; the vaccine separated by at least 4-week intervals in order to
• immunosuppression; obtain optimal protection against the infection. It is possible to
• HIV infection; co-administer the flu inoculation with other vaccines (adminis-
• hemoglobinopathies (e.g. sickle cell anaemia); tered to another location), in accordance with the general prin-
• illnesses requiring the long-term use of aspirin or med- ciples of vaccine co-administration. In the event of a medical
icines containing salicylates, such as juvenile idiopathic history of febrile seizures, the separate administration of vac-
arthritis or Kawasaki syndrome, which increase the risk cines and/or the prophylactic administration of antipyretics may
of Reye syndrome in the case of influenza infection; be considered [13, 48]. The AAP points out that centres which
• kidney and liver disorders (including chronic renal fail- vaccinate both children and adults should take advantage of the
ure); opportunity, and when vaccinating children, encourage adults
• metabolic diseases, including diabetes; from their environment (home and outside home) to be vac-
• all conditions impairing respiratory functions and in- cinated. This can be done by entering the information about the
creasing the risk of aspiration, such as neurological and possibility of adult vaccinations in the child’s medical records.
neurodevelopmental disorders, spinal cord injuries,
paroxysmal disorders and neuromuscular abnormali-
ties. Contraindications and precautions
The AAP emphasises that in order to prevent transmission
of the infection to children at risk of influenza complications, Rhinitis, cough and other symptoms of the common cold
vaccination should be provided to the following individuals (un- after vaccination may result from accidental coincidence with
less there are contraindications): the infection caused by completely different viruses or bacteria
• family members of children at risk and children young- which often occur in the same season of higher disease inci-
er than 5 years of age (in particular, babies younger dence (i.e. in autumn and winter). A significant reduction in the
than 6 months of age), as well as people taking care of risk of potential adverse post-vaccination reactions is influenced
these children outside home; by a proper qualification for vaccination, including taking medi-
• people in close contact, if they are in a state of immu- cal history, the performance of a physical examination and de-
nosuppression; termination of temporary and permanent contraindications for
• pregnant women, those planning pregnancy and in the vaccinations.
postpartum period or breastfeeding during the influ- Local reactions, such as pain at the site of injection (in 65%
enza season; of people vaccinated), self-limiting redness and oedema lasting
• health care workers; 1–2 days after vaccination, are the most common changes after
• people employed in childcare facilities (nurseries, kin- influenza vaccination [13].
dergartens, schools, sanatoria, etc.). General reactions (usually fever, weakness and muscle
The recommendations of the American Advisory Committee pain) are equally common after the intramuscular administra-
on Immunization Practices (ACIP) also indicate the need to re- tion of influenza vaccines and after the administration of a pla-
duce the risk of exposing children to influenza complications by cebo; they are more frequent in children vaccinated for the first
vaccinating individuals from their immediate environment who time in life [1].
themselves belong to risk groups (Table 4) [36]. In order to re- Mild symptoms of upper respiratory tract infection or aller-
duce influenza virus transmission, it is important to observe the gic rhinitis, with or without fever, are not contraindications to
rules of hand and airway hygiene (cough) among children who the use of influenza vaccines. Feverish children with a moderate
attend kindergarten and school. Similar rules should be applied or severe course of the disease should not be vaccinated until
in the child’s home environment. the symptoms subside.
Studies also show that vaccination of pregnant women re- Children vaccinated against influenza did not have a higher
duces the risk of hospitalisation and influenza complications. risk of Guillain–Barré syndrome (GBS). However, children with
Research conducted in the years 2010–2016 demonstrated that a past history of GBS symptoms within 6 weeks of the influenza
the application of vaccines reduced the number of hospitalisa- vaccination not at high risk for a severe course of influenza and/
tions; the effect was estimated at 40% (95% CI: 12–59%) [43]. /or its complications are not advised to be vaccinated [35].
In addition, maternal vaccination provides protection for babies Like all vaccines, certain components of the preparation
in the first 6 months of life, as they receive antibodies pass- (e.g. chicken egg protein) may cause allergic reactions of varying
ing through the placenta whilst they are too small to receive severity (pruritus, urticaria, angioedema, anaphylactic reaction)
a vaccine [44–46]. Pregnant women can become vaccinated [1, 13, 40].
at any time; vaccination is also safe when breastfeeding, both The qualification for vaccination by a doctor, including the
for mothers and babies. Vaccination given in the third trimes- assessment of allergic reactions after previous vaccinations, is
ter of pregnancy increases the concentration of influenza virus an important element of minimising the risk of an allergic post-
antigen-specific IgA in breast milk; moreover, breastfeeding -vaccination reaction. The reaction may be local (erythema,
oedema and pain) or general (urticaria). An anaphylactic reaction or limitation of the administration to specific medical con-
tion, which is very rare (estimated at approximately 1 case per ditions, are not justified and constitute an unnecessary barrier
1 million of the vaccine doses administered), is the most severe to immunisation [35]. A similar stand is taken by the ACIP [53].
allergic reaction after the administration of the vaccine. An ana- In justified situations (e.g. a patient at risk for severe influenza
phylactic reaction or other serious allergic reactions to any com- complications), the vaccination can be carried out in a hospital
ponent of the vaccine are the only medical contraindications for setting [53]. Detailed indications and contraindications for the
influenza vaccination [35]. vaccines used in Poland can be found in the Summary of Prod-
Children who have previously developed an allergic reaction uct Characteristics (SmPC) [25–27, 54, 55].
to any component of the influenza vaccine should be evaluated In the case of permanent contraindications for influenza
by an allergist in order to determine if a further dose of the vac- vaccination (anaphylaxis with the previous vaccination), the
cine is appropriate. If there was no anaphylactic reaction after patient should be advised on the possibility of vaccinating the
the previous vaccination, the procedure may be performed in closest environment (family, carers) in order to reduce the risk
accordance with the general recommendations, however, with of transmission of the infection (cocoon strategy). If contrain-
the need to exercise particular caution and maintain the re- dications are temporary, the patient should be informed about
quired observation time after the procedure. the earliest possible date of vaccination [35].
Studies show that people with an allergy to chicken egg pro-
tein can safely receive the influenza vaccine exercising standard Summary
precautions; an allergy to eggs, regardless of its severity, is not
a contraindication to vaccination [49–51]. The AAP recommen- 1. Influenza is an acute viral disease with high infectivity and
dations of 2017 stated that [52]: seasonal variability of incidence rates – from local epidem-
• all children with an allergy to chicken egg protein of ics to general pandemics.
any severity may receive the influenza vaccine without 2. The diagnosis of influenza is usually clinical. It may be help-
any additional precautions, except for the rules applied ful to perform a quick test in order to detect the virus, but
for all vaccines; a negative result does not exclude flu.
• the flu vaccine is well-tolerated by people with a histo- 3. Oseltamivir is the recommended drug for the treatment
ry of an allergy to chicken egg protein, regardless of the and prevention of influenza. Clinical benefits are the great-
severity of the allergic reaction observed in the child; est if the treatment starts as early as possible, within 48
• special precautions for patients with an allergy to hours of the first symptoms. Clinical studies indicate that
chicken egg protein are not justified, as the incidence early treatment with oseltamivir may shorten the duration
of an anaphylactic reaction after vaccinating people of the disease and reduce the risk of complications.
with this allergy against influenza is not higher than in 4. Annual vaccination against influenza of children over 6
individuals not suffering from the allergy, nor the in- months and adults is the most effective method of preven-
cidence reported after receiving other commonly rection.
ommended vaccines. 5. Vaccination against influenza is most effective before an
The AAP recommendations of 2018 also emphasise that epidemic season – usually by the end of October, but it is
people with an allergy to chicken egg protein vaccinated against also justified to be given during the whole season of the
influenza are not more susceptible to systemic allergic reactions illness.
than individuals without an allergy to eggs. Precautions, such as 6. Influenza vaccination should involve medical personnel
the choice of a particular vaccine, special periods of observa- and carers of patients at risk.
Source of financing: the work was not financed from external sources.
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Tables: 8
Figures: 2
References: 55

Zbigniew Doniec, MD, PhD, Assoc. Prof.
Klinika Pneumonologii
Instytut Gruźlicy i Chorób Płuc OT w Rabce-Zdroju
ul. Prof. J. Rudnika 3B
34-700 Rabka Zdrój
Polska
Tel.: 18 267-60-60
E-mail: zdoniec@igrabka.edu.pl
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note the examples for format and punctuation to follow:
a) Journal article
• Connors MM. Risk perception, risk taking and risk management among intravenous drug users: implications
for AIDS prevention. Soc Sci Med 1992; 34(6): 591–601.
• Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for
reporting. JAMA 2000; 283: 2008–2012.
b) No author specified or an organization acting as author
• Cancer in South Africa [editorial]. S Afr Med J 1994; 84: 15.
Instruction for Authors 201
• 21st century heart solution may have a sting in the tail. BMJ 2002; 325(7357): 184.
• Diabetes Prevention Program Research Group. Hypertension, insulin, and proinsulin in participants with im-
paired glucose tolerance. Hypertension 2002; 40(5): 679–686.
c) Paper published on the Internet (e.g. from an on-line journal)
• Thomas S. A comparative study of the properties of twelve hydrocolloid dressings. World Wide Wounds [serial
online] 1997 Jul [cited 3.07.1998]. Available from URL: http://www.smtl.co.uk/World-Wide-Wounds/.
d) Library database with DOI
• Banach M, Juranek JK, Antczak J. Neuropatie polekowe. Fam Med Prim Care Rev 2015; 17(4): 284–288, doi:
10.5114/fmpcr/60395 (in Polish).
e) Book/textbook by one or more authors
• Juszczyk J, Gładysz A. Diagnostyka różnicowa chorób zakaźnych. 2nd ed. Warszawa: Wydawnictwo Lekar-
skie PZWL; 1996: 12–30 (in Polish).
• Milner AD, Hull D. Hospital paediatrics. 3rd ed. Edinburgh: Churchill Livingstone; 1997.
f) Book/textbook – joint publication edited by…
• Norman IJ, Redfern SJ, eds. Mental health care for elderly people. New York: Churchill Livingstone; 1996.
g) Book/textbook published by an institution or organization
• NHS Management Executive. Purchasing intelligence. London: NHS Management Executive; 1991.
h) Chapter within a book/textbook
• Krotochwil-Skrzypkowa M. Odczyny i powikłania poszczepienne. In: Dębiec B, Magdzik W, eds. Szczepienia
ochronne. 2nd ed. Warszawa: PZWL; 1991: 76–81 (in Polish).
• Weinstein L, Swartz MN. Pathogenic properties of invading microorganisms. In: Sodeman WA jun, Sodeman
WA, eds. Pathologic physiology: mechanisms of disease. Philadelphia: WB Saunders; 1974: 457–472.
i) Dissertation
• Borkowski MM. Infant sleep and feeding: a telephone survey of Hispanic Americans [dissertation]. Mount
Pleasant (MI): Central Michigan University; 2002.
• Scorer R. Attitudes to dynamic psychotherapy and its supervision among consultant psychiatrists in Wales [dis-
sertation]. London: University of London; 1985.
j) Conference proceedings – publication edited by…
• Harnden P, Joffe JK, Jones WG, eds. Germ cell tumours V. Proceedings of the 5th Germ Cell Tumour Confer-
ence; 2001 Sep 13–15; Leeds, UK. New York: Springer; 2002.
k) Paper in conference/congress proceedings
• Christensen S, Oppacher F. An analysis of Koza’s computational effort statistic for genetic programming. In:
Foster JA, Lutton E, Miller J, Ryan C, Tettamanzi AG, eds. Genetic programming. EuroGP 2002: Proceedings
of the 5th European Conference on Genetic Programming; 2002 Apr 3–5; Kinsdale, Ireland. Berlin: Springer;
2002: 182–191.
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202 Instruction for Authors
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5. Editorial Board contact:

FAMILY MEDICINE & PRIMARY CARE REVIEW
Bartosz J. Sapilak, MD, PhD
Katedra i Zakład Medycyny Rodzinnej
Uniwersytet Medyczny we Wrocławiu
ul. Syrokomli 1
51-141 Wrocław
Poland, Europe
Tel.: +48 71 326-68-72
Tel./fax: +48 71 325-43-41
E-mail: bartosz.sapilak@umed.wroc.pl

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The Polish Society of Family Medicine

The Association of Friends of Family Medicine & Family Doctors

isSn 1734-3402, eISSN 2449-8580

Vol. 21, No. 2

Technical editing and prepress: Anna Derbin, Continuo Publisher

Printing: MCP, Marki; edition: up to 1,000 copies.

CONTINUOUS MEDICAL EDUCATION (CME)

Donata Kurpas, MD, PhD, Associate Professor

ISSN 1734-3402, eISSN 2449-8580

Relationship of electronic device usage with obesity

Khalid Aboalshamat3, A–F, Tahir Altaib2, A–F, Wijdan Almehman2, A–F

Background video gaming on children [5]. Only 4% of the extracted studies

Material and methods 15 cannot point or look at

18 cannot keep track with not saying mom, dad or

giving children child entertainment 290 (72.0%)

Address for correspondence:

Batterjee Medical College

ISSN 1734-3402, eISSN 2449-8580

Caregiver burden and the role of social support in the care

Background “caregiving experience” or “caregiving consequences”, present-

Table 2. Level of burden in individual subscales

Abbreviations: min – minimum, max – maximum, SD – standard deviation.

Abbreviations: No. – number of subjects, SD – standard deviation, F – test F, p – significance.

Table 4. Level of social support in categories

Abbreviations: min – minimum, max – maximum, SD – standard deviation.

Abbreviations: R Spearman – Spearman correlation, p – significance.

Address for correspondence:

Family Medicine & Primary Care Review 2019; 21(2)

ISSN 1734-3402, eISSN 2449-8580

Effectiveness of psycho-education on knowledge regarding

Assessed eligibility based

Allocated to study group (n = 175) Allocated to control group (n = 175)

Attended psycho-education sessions

Post-test-1 (1-month follow-up) Post-test-1 (1-month follow-up)

Analysis of the data

Figure 1. Flow chart of the study

Table 1. Distribution of the subjects based on socio-demographic characteristics

Magazines and books 19 10.86 22 12.57 41 11.71

Table 3. Significance of findings on knowledge level on effectiveness of psycho-education, n = 175

control group -23.45 10.98

Address for correspondence:

ISSN 1734-3402, eISSN 2449-8580

Misconceptions about sexual intercourse during pregnancy:

Background extramarital relations during pregnancy or sexual deviation (e.g.

4 Is sexual intercourse a sin during pregnancy?

± t-test; * Fisher exact test.

Address for correspondence:

ISSN 1734-3402, eISSN 2449-8580

The effect of hypoxia on exercise tolerance in individuals

Background progressing to any type of physical exercise, especially sports

Table 2. Model A cardiac rehabilitation of patients with coronary disease

tients with coronary disease exhibited a statistically significant Discussion

1 – at rest; 2 – at peak physical effort.

Address for correspondence:

ISSN 1734-3402, eISSN 2449-8580

Physical possibilities in the treatment of chronic abdominal

Material and methods

In the objective examination conducted, in all patients, an Results

Magnetotherapy and magnetostimulation protocol

Table 4. Results of self-estimation of quality of life in the

Comparison 10–30 22.5 ± 4.6 21.3 ± 3.5 p > 0.05

Discussion ably related to a subjective placebo effect regarding the psycho-

surgery. JSLS 2016; 20(4): 201–216.

Address for correspondence: