Health Psychology Services for People in Disadvantaged Regions of Hungary: Experiences from the Primary Health Care Development Model Program
Abstract
:1. Introduction
1.1. The Primary Care Development Model in Hungary
1.2. Community Health Psychologists’ Contribution to Primary Care
1.3. The Present Research
2. Study 1
2.1. Overview
2.2. Methods
2.2.1. Participants and Procedure
2.2.2. Materials
2.2.3. Statistical Procedures
2.3. Results
2.4. Short Discussion
3. Study 2
3.1. Overview
3.2. Methods
3.2.1. Participants and Procedure
3.2.2. Materials
3.3. Results
3.4. Short Discussion
4. Study 3
4.1. Overview
4.2. Methods
4.2.1. Participants and Procedure
4.2.2. Materials
4.2.3. Analytical Procedure
4.3. Results
4.3.1. Theme 1—Community Instead of Isolation
And now there is an opportunity, there is a community where they don’t just listen to you, but you even get help, helping sentences, or you see the interested look on the face of the other person, that they don’t just listen, but also care about my problem. They may give advice based on their own experience. (Client)
4.3.2. Theme 2—Autonomy and Activity
I think it would be important for all of us to pass it on and say: ‘yes, this is good, not just because we’re happy and having a good time, but because it takes us further in life, in our attitude towards life.’ (Client)
4.3.3. Theme 3—Openness to Psychological Help and Positive Thinking
We are living now! …a new world has opened up! And it’s such a beautiful thing when a psychologist leads you to find the beauty of your living now. (Client)
4.3.4. Theme 4—Healing Grief and Negative Emotions
…when I started coming here, there was such terrible hatred, anger, and other kinds of negative feelings in my soul towards those who messed me up in the hospital… [but] it disappeared from me, and I put things in a different frame, and that’s what the psychologist taught me. (Client)
4.3.5. Theme 5—The Security of Mental and Somatic Rehabilitation
I [had recently been] operated on and [experienced] all this and other bad things… And then the doctor saw this in my final report, and he told the psychologist, and here, my rehabilitation practically continued with this program.… Here, however, I found a complete cure. First, I was with the psychologist for six sessions, then we asked for six more. (Client)
4.4. Short Discussion
5. General Discussion
Limitations
6. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- Hansen, J.; Groenewegen, P.P.; Boerma, W.G.W.; Kringos, D.S. Living in a Country with a Strong Primary Care System Is Beneficial to People With Chronic Conditions. Health Aff. 2015, 34, 1531–1537. [Google Scholar] [CrossRef]
- Hefford, M.; Crampton, P.; Foley, J. Reducing Health Disparities through Primary Care Reform: The New Zealand Experiment. Health Policy 2005, 72, 9–23. [Google Scholar] [CrossRef]
- Macinko, J.; Starfield, B.; Shi, L. The Contribution of Primary Care Systems to Health Outcomes within Organization for Economic Cooperation and Development (OECD) Countries, 1970–1998. Health Serv. Res. 2003, 38, 831–865. [Google Scholar] [CrossRef] [Green Version]
- Norbury, M.; Mercer, S.W.; Gillies, J.; Furler, J.; Watt, G.C.M. Time to Care: Tackling Health Inequalities through Primary Care. Fam. Pract. 2011, 28, 1–3. [Google Scholar] [CrossRef] [Green Version]
- Bloom, D.E.; Cafiero, E.; Jané-Llopis, E.; Abrahams-Gessel, S.; Bloom, L.R.; Fathima, S.; Feigl, A.B.; Gaziano, T.; Hamandi, A.; Mowafi, M.; et al. The Global Economic Burden of Noncommunicable Diseases; PGDA Working Papers; Program on the Global Demography of Aging: Johannesburg, South Africa, 2012. [Google Scholar]
- Baji, P.; Brodszky, V.; Rencz, F.; Boncz, I.; Gulácsi, L.; Péntek, M. Health status of the Hungarian population between 2000–2010. Orv. Hetil. 2015, 156, 2035–2044. [Google Scholar] [CrossRef] [Green Version]
- Eris, M. Improving Health Outcomes and System in Hungary; OECD: Paris, France, 2012. [Google Scholar]
- Lenard, R. Vulnerability and Chaos in the Hungarian Healthcare System. Heinrich Böll Stift. 2018. Available online: https://www.boell.de/en/2018/05/31/vulnerability-and-chaos-hungarian-healthcare-system (accessed on 17 October 2022).
- Ács, A.; Molnár, E.; Molnár, G.; Balogh, Z. The Care of People Living with Mental Illness in the Hungarian Social Care System: The Process of Deinstitutionalization and the Phenomenon of Stigmatization. DHS 2019, 2, 22–27. [Google Scholar] [CrossRef]
- Swiss Federal Council. Government of Hungary Framework Agreement between the Swiss Federal Council and the Government of Hungary Concerning the Implementation of the Swiss–Hungarian Cooperation Programme to Reduce Economic and Social Disparities within the Enlarged European Union; Swiss Federal Council: Bern, Switzerland, 2017. [Google Scholar]
- Ádány, R.; Kósa, K.; Sándor, J.; Papp, M.; Fürjes, G. General Practitioners’ Cluster: A Model to Reorient Primary Health Care to Public Health Services. Eur. J. Public Health 2013, 23, 529–530. [Google Scholar] [CrossRef] [Green Version]
- Sándor, J.; Kósa, K.; Fürjes, G.; Papp, M.; Csordás, Á.; Rurik, I.; Ádány, R. Public Health Services Provided in the Framework of General Practitioners’ Clusters. Eur. J. Public Health 2013, 23, 530–532. [Google Scholar] [CrossRef] [Green Version]
- Fésüs, G.; Östlin, P.; McKee, M.; Ádány, R. Policies to Improve the Health and Well-Being of Roma People: The European Experience. Health Policy 2012, 105, 25–32. [Google Scholar] [CrossRef]
- Kósa, K.; Sándor, J.; Dobos, É.; Papp, M.; Fürjes, G.; Ádány, R. Human Resources Development for the Operation of General Practitioners’ Cluster. Eur. J. Public Health 2013, 23, 532–533. [Google Scholar] [CrossRef]
- Martos, T.; Sallay, V.; Papp-Zipernovszky, O.; Bodóné Rafael, B.; Pintér, J.N.; Csabai, M. A Praxisközösségi Működés Tapasztalatai az Egészségpszichológus Szemszögéből. Népegészségügy 2017, 95, 52–56. [Google Scholar]
- Saltman, R.; Bankauskaite, V.; Vrangbaek, K. Primary Care in the Driver’S Seat? Organizational Reform in European Primary Care; McGraw-Hill Education: London, UK, 2005; ISBN 978-0-335-21365-8. [Google Scholar]
- Gunn, W.B., Jr.; Blount, A. Primary Care Mental Health: A New Frontier for Psychology. J. Clin. Psychol. 2009, 65, 235–252. [Google Scholar] [CrossRef]
- Haas, L.; Degruy, F. Primary Care, Psychology and Primary Care Psychology. In Handbook of Primary Care Psychology; Haas, L., Ed.; Oxford University Press: Oxford, UK, 2004; pp. 5–20. [Google Scholar]
- Thielke, S.; Thompson, A.; Stuart, R. Health Psychology in Primary Care: Recent Research and Future Directions. Psychol. Res. Behav. Manag. 2011, 4, 59–68. [Google Scholar] [CrossRef] [Green Version]
- World Health Organization. Cancer Control: A Global Snapshot in 2015: Summary of Results from the 2015 WHO NCD Country Capacity Survey; World Health Organization: Geneva, Switzerland, 2016. [Google Scholar]
- World Health Organization. World Health Statistics Overview 2019: Monitoring Health for the SDGs, Sustainable Development Goals; World Health Organization: Geneva, Switzerland, 2019. [Google Scholar]
- Campbell, C.; Cornish, F. Reimagining Community Health Psychology: Maps, Journeys and New Terrains. J. Health Psychol. 2014, 19, 3–15. [Google Scholar] [CrossRef] [Green Version]
- Ádány, R.; Csordás, Á.; Fürjes, G.; Grósz, A.; Gutási, É.; Henter, I.; Kósa, K.; Morvai, G.; Papp, M.; Perczel Forintos, D.; et al. A Praxisközösségek Eljárásrendje; Protocols of the General Practitioners’ Clusters Version 5.0; SH/8/1 Svájci Hozzájárulás Program [Swiss Contribution Program]: Budapest, Hungary, 2015. [Google Scholar]
- Ádány, R. Roma Health Is Global Ill Health. Eur. J. Public Health 2014, 24, 702–703. [Google Scholar] [CrossRef] [Green Version]
- Biddle, L.; Gunnell, D.; Sharp, D.; Donovan, J.L. Factors Influencing Help Seeking in Mentally Distressed Young Adults: A Cross-Sectional Survey. Br. J. Gen. Pract. 2004, 54, 248–253. [Google Scholar]
- Koydemir-Özden, S.; Erel, Ö. Psychological Help-Seeking: Role of Socio-Demographic Variables, Previous Help-Seeking Experience and Presence of a Problem. Procedia Soc. Behav. Sci. 2010, 5, 688–693. [Google Scholar] [CrossRef] [Green Version]
- Picco, L.; Abdin, E.; Chong, S.A.; Pang, S.; Shafie, S.; Chua, B.Y.; Vaingankar, J.A.; Ong, L.P.; Tay, J.; Subramaniam, M. Attitudes Toward Seeking Professional Psychological Help: Factor Structure and Socio-Demographic Predictors. Front. Psychol. 2016, 7, 547. [Google Scholar] [CrossRef] [Green Version]
- Kósa, K.; Katona, C.; Papp, M.; Fürjes, G.; Sándor, J.; Bíró, K.; Ádány, R. Health Mediators as Members of Multidisciplinary Group Practice: Lessons Learned from a Primary Health Care Model Programme in Hungary. BMC Fam. Pract. 2020, 21, 19. [Google Scholar] [CrossRef] [Green Version]
- Rózsa, S.; Szádóczky, E.; Füredi, J. A Beck Depresszió Kérdőív Rövidített Változatának Jellemzői Hazai Mintán. [Psychometric Properties of the Hungarian Version of the Shortened Beck Depression Inventory.]. Psychiatr. Hung. 2001, 16, 384–402. [Google Scholar]
- Goldberg, D.P.; Williams, P. User’s Guide to the General Health Questionnaire; NferNelson: Windsor, ON, Canada, 1988. [Google Scholar]
- Parslow, R.A.; Jorm, A.F. Who Uses Mental Health Services in Australia? An Analysis of Data from the National Survey of Mental Health and Wellbeing. Aust. N. Z. J. Psychiatry 2000, 34, 997–1008. [Google Scholar] [CrossRef]
- Stead, R.; Shanahan, M.J.; Neufeld, R.W.J. “I’ll Go to Therapy, Eventually”: Procrastination, Stress and Mental Health. Pers. Individ. Differ. 2010, 49, 175–180. [Google Scholar] [CrossRef]
- Bartels, S.J.; Coakley, E.H.; Zubritsky, C.; Ware, J.H.; Miles, K.M.; Areán, P.A.; Chen, H.; Oslin, D.W.; Llorente, M.D.; Costantino, G.; et al. Improving Access to Geriatric Mental Health Services: A Randomized Trial Comparing Treatment Engagement With Integrated Versus Enhanced Referral Care for Depression, Anxiety, and At-Risk Alcohol Use. AJP 2004, 161, 1455–1462. [Google Scholar] [CrossRef] [Green Version]
- Bortolotti, B.; Menchetti, M.; Bellini, F.; Montaguti, M.B.; Berardi, D. Psychological Interventions for Major Depression in Primary Care: A Meta-Analytic Review of Randomized Controlled Trials. Gen. Hosp. Psychiatry 2008, 30, 293–302. [Google Scholar] [CrossRef]
- Cape, J.; Whittington, C.; Buszewicz, M.; Wallace, P.; Underwood, L. Brief Psychological Therapies for Anxiety and Depression in Primary Care: Meta-Analysis and Meta-Regression. BMC Med. 2010, 8, 38. [Google Scholar] [CrossRef] [Green Version]
- Chibanda, D.; Weiss, H.A.; Verhey, R.; Simms, V.; Munjoma, R.; Rusakaniko, S.; Chingono, A.; Munetsi, E.; Bere, T.; Manda, E.; et al. Effect of a Primary Care–Based Psychological Intervention on Symptoms of Common Mental Disorders in Zimbabwe: A Randomized Clinical Trial. JAMA 2016, 316, 2618–2626. [Google Scholar] [CrossRef] [Green Version]
- Finney, J.W.; Riley, A.W.; Cataldo, M.F. Psychology in Primary Health Care: Effects of Brief Targeted Therapy on Children’s Medical Care Utilization1. J. Pediatr. Psychol. 1991, 16, 447–461. [Google Scholar] [CrossRef]
- Richards, D.A.; Hill, J.J.; Gask, L.; Lovell, K.; Chew-Graham, C.; Bower, P.; Cape, J.; Pilling, S.; Araya, R.; Kessler, D.; et al. Clinical Effectiveness of Collaborative Care for Depression in UK Primary Care (CADET): Cluster Randomised Controlled Trial. BMJ 2013, 347, f4913. [Google Scholar] [CrossRef] [Green Version]
- Rollman, B.L.; Belnap, B.H.; Mazumdar, S.; Houck, P.R.; Zhu, F.; Gardner, W.; Reynolds, C.F., III; Schulberg, H.C.; Shear, M.K. A Randomized Trial to Improve the Quality of Treatment for Panic and Generalized Anxiety Disorders in Primary Care. Arch. Gen. Psychiatry 2005, 62, 1332–1341. [Google Scholar] [CrossRef] [Green Version]
- Susánszky, É.; Konkoly Thege, B.; Stauder, A.; Kopp, M. A WHO Jól-Lét Kérdőív Rövidített (WBI-5) Magyar Változatának Validálása a Hungarostudy 2002 Országos Lakossági Egészségfelmérés Alapján. Mentálhigiéné Pszichoszomatika 2006, 7, 247–255. [Google Scholar] [CrossRef] [Green Version]
- Carlier, I.V.E.; Meuldijk, D.; Van Vliet, I.M.; Van Fenema, E.; Van der Wee, N.J.A.; Zitman, F.G. Routine Outcome Monitoring and Feedback on Physical or Mental Health Status: Evidence and Theory. J. Eval. Clin. Pract. 2012, 18, 104–110. [Google Scholar] [CrossRef]
- Roe, D.; Mazor, Y.; Gelkopf, M. Patient-Reported Outcome Measurements (PROMs) and Provider Assessment in Mental Health: A Systematic Review of the Context of Implementation. Int. J. Qual. Health Care 2022, 34, ii28–ii39. [Google Scholar] [CrossRef]
- Krueger, R.A. Focus Groups: A Practical Guide for Applied Research; SAGE Publications: New York, NY, USA, 2014; ISBN 978-1-4833-6523-7. [Google Scholar]
- Strauss, A.L.; Corbin, J. Grounded Theory Methodology-An Overview. In Handbook of Qualitative Research; Denzin, N., Lincoln, Y., Eds.; SAGE Publications: New York, NY, USA, 1994. [Google Scholar]
- Ritchie, J.; Spencer, L. Qualitative Data Analysis for Applied Policy Research. In Analyzing Qualitative Data; Routledge: Milton Park, UK, 1994; ISBN 978-0-203-41308-1. [Google Scholar]
- Green, J.; Thorogood, N. Qualitative Methods for Health Research; SAGE: New York, NY, USA, 2018; ISBN 978-1-5264-4880-4. [Google Scholar]
- Wang, J.; Lloyd-Evans, B.; Giacco, D.; Forsyth, R.; Nebo, C.; Mann, F.; Johnson, S. Social Isolation in Mental Health: A Conceptual and Methodological Review. Soc. Psychiatry Psychiatr. Epidemiol. 2017, 52, 1451–1461. [Google Scholar] [CrossRef] [Green Version]
- Sándor, J.; Kósa, Z.; Boruzs, K.; Boros, J.; Tokaji, I.; McKee, M.; Ádány, R. The Decade of Roma Inclusion: Did It Make a Difference to Health and Use of Health Care Services? Int. J. Public Health 2017, 62, 803–815. [Google Scholar] [CrossRef] [Green Version]
- Brannon, L.; Feist, J.; Updegraff, J.A. Health Psychology: An Introduction to Behavior and Health; Cengage Learning: Boston, MA, USA, 2013; ISBN 978-1-285-68707-0. [Google Scholar]
- Regier, D.A.; Narrow, W.E.; Rae, D.S.; Manderscheid, R.W.; Locke, B.Z.; Goodwin, F.K. The de Facto US Mental and Addictive Disorders Service System: Epidemiologic Catchment Area Prospective 1-Year Prevalence Rates of Disorders and Services. Arch. Gen. Psychiatry 1993, 50, 85–94. [Google Scholar] [CrossRef]
- Burton, C.; McGorm, K.; Richardson, G.; Weller, D.; Sharpe, M. Healthcare Costs Incurred by Patients Repeatedly Referred to Secondary Medical Care with Medically Unexplained Symptoms: A Cost of Illness Study. J. Psychosom. Res. 2012, 72, 242–247. [Google Scholar] [CrossRef]
- Reid, S.; Whooley, D.; Crayford, T.; Hotopf, M. Medically Unexplained Symptoms—GPs’ Attitudes towards Their Cause and Management. Fam. Pract. 2001, 18, 519–523. [Google Scholar] [CrossRef] [Green Version]
- Mariman, A.; Vermeir, P.; Csabai, M.; Látos, M.; Weiland, A.; Stegers-Jager, K.M.; Jacobs, M.L.; Vogelaers, D. Perceptions and Attitudes of Health Care Givers and Patients on Medically Unexplained Symptoms: A Narrative Review with a Focus on Cultural Diversity and Migrants. Med. Clin. Res. 2021, 6, 482–486. [Google Scholar]
- Náfrádi, L.; Nakamoto, K.; Schulz, P.J. Is Patient Empowerment the Key to Promote Adherence? A Systematic Review of the Relationship between Self-Efficacy, Health Locus of Control and Medication Adherence. PLoS ONE 2017, 12, e0186458. [Google Scholar] [CrossRef] [Green Version]
- Thornicroft, G.; Deb, T.; Henderson, C. Community Mental Health Care Worldwide: Current Status and Further Developments. World Psychiatry 2016, 15, 276–286. [Google Scholar] [CrossRef] [Green Version]
- Goodie, J.L.; Ware, C.M.; Hunter, C.L. Necessary Training for Psychologists Working in Primary Care Settings. In Handbook of Psychological Assessment in Primary Care Settings; Routledge: Milton Park, UK, 2017; ISBN 978-1-315-65840-7. [Google Scholar]
- Schulte, T.J.; Isley, E.; Link, N.; Shealy, C.N.; Winfrey, L.L. General Practice, Primary Care, and Health Service Psychology: Concepts, Competencies, and the Combined-Integrated Model. J. Clin. Psychol. 2004, 60, 1011–1025. [Google Scholar] [CrossRef]
- Martos, T.; Sallay, V. Enhanced Living Environments from the Viewpoint of Socioecological Psychology. In Enhanced Living Environments: From Models to Technologies; Goleva, R.I., Ganchev, I., Dobre, C., Garcia, N., Valderrama, C., Eds.; Institution of Engineering and Technology: London, UK, 2017; pp. 21–47. ISBN 978-1-78561-211-4. [Google Scholar]
95% C.I. to the OR | |||||
---|---|---|---|---|---|
B | p | OR | Lower | Upper | |
Gender: female (reference: male) | 1.104 | <0.001 | 3.015 *** | 1.823 | 4.987 |
Age (years; reference: 18–24) | 0.182 | ||||
25–44 | 0.337 | 0.403 | 1.401 | 0.636 | 3.086 |
45–64 | 0.008 | 0.985 | 1.008 | 0.440 | 2.310 |
65+ | −0.388 | 0.425 | 0.679 | 0.262 | 1.759 |
Education (reference: maximum 8 years of primary school) | <0.001 | ||||
Secondary without graduation | 1.467 | <0.001 | 4.337 *** | 2.023 | 9.299 |
Secondary with graduation | 1.892 | <0.001 | 6.632 *** | 3.252 | 13.523 |
Higher education | 2.101 | <0.001 | 8.172 *** | 3.655 | 18.272 |
Perceived/subjective financial situation (reference: bad/very bad) | 0.450 | ||||
Optimal | 0.339 | 0.207 | 1.403 | 0.829 | 2.375 |
Good/excellent | 0.306 | 0.413 | 1.358 | 0.652 | 2.829 |
Roma identity: yes (reference: no) | −1.223 | 0.231 | 0.294 | 0.040 | 2.177 |
BMI (reference: no overweight) | 0.701 | ||||
Overweight | −0.200 | 0.433 | 0.819 | 0.497 | 1.349 |
Obese | −0.033 | 0.894 | 0.967 | 0.594 | 1.574 |
SRH (reference: bad/very bad) | 0.014 | ||||
Optimal | 0.264 | 0.380 | 1.301 | 0.723 | 2.343 |
Good/excellent | −0.493 | 0.192 | 0.611 | 0.292 | 1.280 |
How much can you do for your health? (reference: I can do very much) | 0.146 | ||||
I can do much | −0.566 | 0.049 | 0.568 | 0.323 | 0.998 |
I can do little | −0.658 | 0.083 | 0.518 | 0.246 | 1.089 |
There’s nothing I can do | −1.686 | 0.112 | 0.185 | 0.023 | 1.482 |
Systolic blood pressure: high (reference: normal) | 0.429 | 0.085 | 1.536 | 0.943 | 2.502 |
Diastolic blood pressure: high (reference: normal) | −0.017 | 0.950 | 0.983 | 0.581 | 1.663 |
Smoking (reference: not smoking) | −0.298 | 0.208 | 0.743 | 0.467 | 1.180 |
BDI-S (reference: 0–9: normal) | 0.002 | ||||
Mild depression (10–18) | 0.257 | 0.384 | 1.293 | 0.725 | 2.305 |
Moderate depression (19–24) | 1.203 | 0.001 | 3.329 ** | 1.660 | 6.678 |
Severe depression (25+) | 1.307 | 0.002 | 3.694 ** | 1.618 | 8.430 |
GHQ12: high (5+) (reference: 0–4: normal) | 0.773 | 0.015 | 2.167 * | 1.165 | 4.029 |
Constant | −7.321 | <0.001 | 0.001 |
Measurement Point | ||
---|---|---|
T1 | T2 | |
N | 156 | 137 |
Male | 23 | 22 |
Female | 133 | 115 |
Age | 47.5 (15.9) | 47.8 (16.0) |
Individual | 81 | 67 |
Group | 75 | 70 |
T2–T1 (day) | 119.4 (79.8) |
T1 | T2 | t-Rest | p | F-Test+ | p | eta2 | |||
---|---|---|---|---|---|---|---|---|---|
Variable | M | SD | m | SD | |||||
BDI-S | 17.90 | 5.85 | 13.69 | 3.84 | 9.27 | <0.001 | 4.52(131) | 0.035 | 0.033 |
WHO-WBI | 6.63 | 3.22 | 8.96 | 2.63 | −7.51 | <0.001 | 2.32(131) | 0.130 | 0.017 |
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Sallay, V.; Martos, T.; Lucza, L.; Papp-Zipernovszky, O.; Csabai, M. Health Psychology Services for People in Disadvantaged Regions of Hungary: Experiences from the Primary Health Care Development Model Program. Int. J. Environ. Res. Public Health 2023, 20, 3900. https://doi.org/10.3390/ijerph20053900
Sallay V, Martos T, Lucza L, Papp-Zipernovszky O, Csabai M. Health Psychology Services for People in Disadvantaged Regions of Hungary: Experiences from the Primary Health Care Development Model Program. International Journal of Environmental Research and Public Health. 2023; 20(5):3900. https://doi.org/10.3390/ijerph20053900
Chicago/Turabian StyleSallay, Viola, Tamás Martos, Lilla Lucza, Orsolya Papp-Zipernovszky, and Márta Csabai. 2023. "Health Psychology Services for People in Disadvantaged Regions of Hungary: Experiences from the Primary Health Care Development Model Program" International Journal of Environmental Research and Public Health 20, no. 5: 3900. https://doi.org/10.3390/ijerph20053900