Genetic Literacy of pregnant women and their use of prenatal screening and diagnostic tests in Turkey.

This study evaluated how genetic literacy of pregnant women in Turkey affects their use of prenatal screening and diagnostic tests. As a descriptive cross-sectional study, a Participant Identification Form and the Genetic literacy and Comprehension Measure (GLAC) were used to collect data. The sample of study consisted of 189 pregnant women who made regular antenatal care visits in Giresun, Turkey. The mean age was 29.5 ± 5.9 years and mean gestational week was 34.9 ± 5.09. Of the women, 76.7% had undergone prenatal screening tests, and 85.5% of them had learned about the tests from their doctors. The mean GLAC score of familiarity was 3.67 ± 1.78 (out of seven), and the genetic concepts answered correctly were 5.30 ± 1.79 (out of eight). No statistically significant relationship emerged between the women's genetic literacy and their use of prenatal screening or diagnostic tests. However, relationships were statistically significant between the genetic literacy of the women and the educational levels of the women themselves or their spouses, consanguineous marital status, parity, and use of folic acid supplements. Primiparous women who were highly educated, had a highly educated spouse, were not in consanguineous marriages, and had taken folic acid supplements during pregnancy were more literate in genetics. There is a need for more educational opportunities in order for women to increase their familiarity with genetic terms. Educating women will improve their understanding of genetics-related health services and increase their awareness of genetic diseases, which will allow them to take the appropriate actions for primary prevention.

Breast and cervical cancer screening for women with physical disabilities: A qualitative study of experiences and barriers.

AIM: To determine the experiences of women with physical disabilities regarding the barriers to their participation in breast and cervical cancer screening. DESIGN: Qualitative descriptive study. METHOD: Sixteen women who use wheelchairs were recruited. Data were collected via semi-structured face-to-face interviews between January - March 2017. Interviews were transcribed and data were analysed thematically. RESULTS: Three main themes were uncovered: (a) Personal factors; such as lack of knowledge, fear and embarrassment, feeling anxious about the examination process and dependency on others; (b) Environmental and structural factors; and (c) expectations and suggestions of women with disabilities to enable their participation in screening. CONCLUSION: The participation rate of women with physical disabilities in screening is low. The participation of women with disabilities in breast and cervical cancer screening may increase if physical barriers to accessing healthcare services are removed, appropriate and less time-consuming examination conditions are met, and healthcare personnel are informed about the needs of persons with disabilities. IMPACT: Knowing the barriers for women with physical disabilities to participate in cancer screening can help health professionals develop new procedures to increase their participation to cancer screening. Women with physical disabilities encountered various barriers such as; lack of knowledge, fear and embarrassment, feeling anxious about the examination process and dependency on others, access to the healthcare services, environmental, physical limitations, and inadequate knowledge of healthcare professional about their disability. This study will guide healthcare professionals in developing strategies to increase the participation of women with physical disabilities in screening.

Women with Family History of Breast Cancer: How Much Are They Aware of Their Risk?

The aims of this study are to assess knowledge of inheritance characteristics of breast cancer and risk reduction strategies and to determine risk perception and the factors affecting risk perception of women with family history. There is a gap in our understanding of risk perception and knowledge of genetic aspect of breast cancer and risk reduction strategies in women with a family history of breast cancer. The study design is descriptive cross-sectional study. Between January 2015 and 2016 at a training and research hospital in Turkey, 117 women who were the first- and second-degree relatives of breast cancer patients were included in the study. Perceived risk scale, cancer worry chart, and a knowledge assessment form were used to collect data. Of the women, 34.1% were first-degree relatives of a breast cancer patient, and knowledge score was 6.9 ± 2.19 out of 11. Almost half of the women (41.9%) moderately worry about the chances of getting breast cancer, and half of the women (51.3%) ranked their perceived risk as moderate (26-50% out of 100%). There is a significant difference between the perceived risk and educational level, having genetic testing, and a significant relationship between the perceived risk and worry level of women. However, breast cancer screening behavior was not affected by risk perception. The knowledge of women regarding inheritance characteristics of breast cancer and risk reduction strategies was moderate, but still majority of women have moderate or higher level of risk perception and are worried about getting breast cancer. Therefore, interventions should be planned to reduce worry and to increase risk reduction strategies such as screening and other health behaviors in women at risk for breast-ovarian cancer.

The effect of self-administered superficial local hot and cold application methods on pain, functional status and quality of life in primary knee osteoarthritis patients.

AIMS AND OBJECTIVES: To investigate the effect of the self-administered superficial local hot and cold applications on pain, and the functional status and the quality of life in primary knee osteoarthritis patients. BACKGROUND: Superficial local hot and cold application is used as a nonpharmacological method for the treatment of knee osteoarthritis. However, various guidelines for the management of knee osteoarthritis have conflicting recommendation for hot and cold therapy. DESIGN: A randomised clinical trial design. METHODS: The sample consisted of patients (n = 96) who were diagnosed with primary knee osteoarthritis. During the application stage, patients were designated to the hot and cold application groups and administered hot and cold application twice a day for 3 weeks together with standard osteoarthritis treatment. The control group only used standard osteoarthritis treatment. The data were collected with a Descriptive Information Form, a Pain Scale, the WOMAC Osteoarthritis Index, the Nottingham Health Profile (NHP) and a Patient Satisfaction Evaluation Form. Outcome measures included pain intensity, functional status and quality of life. RESULTS: We found decreased primary measurement pain scores and improved functional status scores and quality of life scores after the application programme compared to the pre-application stage in both the hot and cold application groups. Once the application was completed, the pain scores, functional status scores and quality-of-life scores on the second measurements were found to be still statistically lower than the pre-application scores but higher than the first measurement ([p < .001, χ2  = 48.000; p < .001, χ2  = 34.000], [p < .001, χ2  = 22.000; p = .001 χ2 =14.000] and [p = .005, χ2  = 16.000; p = .001, χ2  = 12.500]). There was no difference in the perceived pain, functional status and quality of life between the pre-application, postapplication and 2 weeks postapplication periods of the individuals in three groups (p > .05). CONCLUSION: It was found that both hot and cold application resulted in a mild improvement in pain, functional status and quality of life, but this improvement was not sufficient to create a significant difference between the groups. RELEVANCE TO CLINICAL PRACTICE: This study contributes to the literature on hot and cold application methods as self-management strategies for patients with knee osteoarthritis.

Women's knowledge and use of prenatal screening tests.

AIMS AND OBJECTIVES: The aim of the study was to determine the rate of use of prenatal screening tests and the factors affecting the decision to have a prenatal screening test in pregnant women in Turkey. BACKGROUND: Prenatal genetic screening as an optional service is commonly used to determine a level of risk for genetic conditions in the foetus. DESIGN: A quantitative cross-sectional survey. METHODS: Pregnant women (n = 274) who sought prenatal care from one hospital in Turkey were recruited and asked to complete questionnaires that were developed by the researchers. Descriptive and inferential statistics were used to analyse the data. RESULTS: Almost half (44·2) % of the women were primiparas, and the majority (97·8%) were in the third trimester of pregnancy. Only 36·1% of the women reported that they had prenatal screening by either the double test or triple test. Women had a low level of knowledge regarding prenatal screening: the mean knowledge score was 3·43 ± 3·21 of a possible score of 10. Having consanguineous marriage, a history of spontaneous abortion, a child with genetic disorder, multiparity or a longer marriage duration were positively correlated with accepting a prenatal screening test. CONCLUSIONS: This study has provided baseline data on the uptake and reasons for accepting or declining a prenatal screening in a cohort of Turkish women. There is evidence to suggest that more education is needed to improve knowledge and provide comprehensive nursing care to promote informed consent in this context. RELEVANCE TO CLINICAL PRACTICE: Perinatal nurses are ideally situated to inform pregnant women about prenatal screening tests to improve access to healthcare services and to ensure informed decisions are made by pregnant women and their partners.

Educational needs of nurses to provide genetic services in prenatal care: A cross-sectional study from Turkey.

The latest advances in genetics/genomics have significantly impacted prenatal screening and diagnostic tests. This cross-sectional descriptive study was conducted in inpatient and outpatient obstetric clinics in 24 hospitals in Turkey to determine knowledge of genetics related to prenatal care and the educational needs of perinatal nurses. A total of 116 nurses working in these clinics agreed to participate. The results included the level of knowledge among nurses was not affected by sociodemographic factors. Also, there is a lack of knowledge and interest in genetics among prenatal nurses and in clinical practice to provide education and counseling related to genetics in prenatal settings as a part of prenatal care.

Palliative care needs of patients with gynaecologic cancer.

AIMS AND OBJECTIVES: To identify gynaecologic cancer patients' palliative care needs using the three levels of needs questionnaire. BACKGROUND: Measuring both the burden of symptoms and patient-reported palliative care needs is valuable to improve cancer care. Data representing the palliative care needs of cancer patients in Turkey remain limited. DESIGN: A cross-sectional descriptive study. METHODS: A total of 134 cancer patients were included in the study at an oncology hospital in Turkey. A data collection form, a short-form medical outcomes health survey, and the three levels of needs questionnaire were used to collect data. RESULTS: The mean age of participants was 59 ± 8·76, of 69·4% were diagnosed with ovarian cancer and 52·2% had stage-3-4 cancer. Of patients, 69·3% had no desire for sexual intimacy, 33·5% expressed feeling as though they burden their families and 28·4% feel lonely at some level. The most prevalent problems were tiredness, to feel depressed and problems performing physical activities. The most frequent unmet needs were tiredness (60·5%), feel depressed (47·4%) and lack of appetite (38·5%). CONCLUSIONS: Gynaecologic cancer patients have relatively high prevalence of symptoms and unmet palliative care needs. Health professions mostly were unable to recognise and properly manage tiredness, depression as well as lack of appetite as an integral part of quality cancer care. RELEVANCE TO CLINICAL PRACTICE: Nurses trained in palliative care are needed to evaluate and meet cancer patients' needs regularly to improve quality of palliative care. Nurses should examine the underlying reasons for most prevalent problems and give nursing care accordingly.

Urinary Incontinence in Pregnant Women: Prevalence, Associated Factors, and Its Effects on Health-Related Quality of Life.

PURPOSE: The purpose of this study was to determine the prevalence of and risk factors for urinary incontinence (UI) during pregnancy and to evaluate its effect on health-related quality of life. DESIGN: Descriptive, cross-sectional study. SUBJECTS AND SETTING: The sample of the study comprised 287 pregnant women attending an outpatient clinic located in a research and training hospital in Ankara, Turkey. METHODS: Data were collected using an investigator-developed questionnaire that included 2 validated instruments, the International Consultation on Incontinence Questionnaire Short Form and Incontinence Quality of Life scale. RESULTS: The prevalence of UI in the study population was 21.3% (n = 61). Cumulative scores in pregnant women who "always" experienced UI and those who expressed a "large amount" of UI were lower than women with milder UI. Logistic regression analysis found associations between UI and age in years (odds ratio [OR] = 3.833; 95% confidence interval [CI], 1.763-8.332), parity (OR = 2.539; 95% CI, 1.135-5.675), third trimester versus first trimester (OR = 3.206; 95% CI, 1.178-8.725), and prior use of hormonal contraceptives (OR = 0.209; 95% CI, 0.085-0.513). CONCLUSIONS: Urinary incontinence is prevalent among pregnant women. Age, parity, and gestational week were associated with an increased likelihood of UI during pregnancy. Prior use of contraceptive hormones was associated with a reduced risk of UI during pregnancy.

Interventional Education Methods for Increasing Women's Participation in Breast Cancer Screening Program.

The purpose of this study was to evaluate the impact of the three methods of education-individual, individual with an educational brochure for spouses, and group-on participation on breast cancer screening in Turkey. A total of 550 home visits were made and 446 women were interviewed to accrue 327 women for the study, 26.7% of whom reported receiving a screening mammogram within the past 2 years. Participants were divided into one of the three educational groups, and following the educational session, they were invited to attend a breast cancer screening program. The results indicated that the decision to have a screening mammogram was influenced by the method of education and the knowledge score. Women, who were educated, within a group scored the highest. These results demonstrate that group education is an effective method of increasing breast cancer knowledge and screening awareness.

Evaluating dysmenorrhea in a sample of Turkish nursing students.

The aim of this study was to determine the prevalence and symptoms of dysmenorrhea, its relevant factors, and the rate of seeking medical help in a group of nursing students. A total of 380 students were included in the study. The demographic data questionnaire, a Daily Menstrual Symptom Rating Scale (DMSR), and the Visual Analog Scale for pain (VASP) were used as tools for data collection. The mean age of the participants was 20.31 ± 1.10 years. Most students had experienced dysmenorrhea (84.9%). Menstrual pain was frequently initiated on the first day of menstruation (77.8%). The most commonly reported menstrual problems were irregular menstrual cycles (27.2%) and oligomenorrhea (15.1%). Only 24.1% of students consulted their physicians for dysmenorrhea. The participants who had dysmenorrhea had significantly higher symptom scores than the participants who had not had dysmenorrhea, in terms of decreased activities, tension, hip and abdominal pain, backache, headache, and fatigue. Also, having a sister with dysmenorrhea increased the risk of dysmenorrhea. Although dysmenorrhea is a gynecological problem that is commonly seen in young women and that negatively affects daily activities and school life, the rate of seeking medical help is low. Adolescents should, therefore, be educated and counseled to determine the underlying cause and to increase the use of an effective treatment method. Considering that nurses should be better informed about dysmenorrhea causes and treatment options, a study of nursing students was undertaken.

Evaluation of the quality of life of caregivers in gynecological cancer patients.

The aim of this study was to determine the factors influencing the general quality of life and the quality-of-life subdimensions of family members caring for gynecological cancer patients. This descriptive study was conducted at a training and research hospital in Turkey. A total of 168 caregivers who were family members were included in the study sample. The data collection form and the Caregiver Quality-of-Life Index Cancer Scale were used to collect data. The mean age of family caregivers was 42.6 ± 12.30 and 81% were female. The caregivers had the most problem with coping with the depressive symptoms and the nausea of the patient and with medication use for the patient. Information on care was requested by 35.7%, whereas 70% of this group felt they needed information on every subject regarding disease and its treatment. It is also found that although some factors did not influence the general quality of life of caregivers, they did have a negative effect on various areas such as burden, disruptiveness, positive adaptation, and financial concerns. Health care professions should educate patients and their caregivers who are distant relatives of patient or providing care for older patients especially on medical drug usage after discharge and management of symptoms such as nausea.

Effectiveness of nursing interventions to increase pap smear test screening.

The purpose of this study was to determine the effect of a three-stage nursing intervention to increase Turkish women's participation in Pap smear testing. Knowledge and beliefs about cervical cancer screening and barriers to Pap smears also were explored. In a quasi-experimental study in a target population of 2,500 women, 237 completed pre-test measures to inform the intervention, and an educational brochure was distributed to all 2,500. As a result, 510 women (20.4%) accepted free Pap smears. Of the remaining 1,990 women, 417 were randomly selected for telephone interviews, 302 participated, and 158 of these (52.3%) participated in free Pap smear testing. Of the 144 who did not have Pap smears after participating in telephone interviews, 54 were then interviewed face-to-face, and 20 (37.0%) decided to accept free Pap smears. A total of 668 women had accepted free Pap smears by the end of the intervention period.

Comparison of three different thermometers in evaluating the body temperature of healthy young adult individuals.

The aim of this study was to compare the measurement values obtained with a non-contact infrared thermometer, a tympanic thermometer and a chemical dot thermometer. The research population was composed of students studying in two departments of a university in Ankara. A total of 452 students who fit the inclusion criteria of the study and volunteered to participate were included in the sample. Body temperature measurements with different thermometers were performed by the same researcher at the same room temperature. Data were analyzed in a computerized environment by SPSS 15.0 statistical program pack and Bland-Altman graph. Mean age of healthy young adults participating in the study was 19.66 ± 0.94, and 55.1% of them were female. The agreement limits for non-contact infrared and chemical dot was between -1.30 and 0.32°C; for non-contact infrared and tympanic was between -1.26 and 0.13°C; and for chemical dot and tympanic -0.89 and 0.74°C. It was determined that, although the measurement values of the tympanic membrane and chemical dot thermometers conformed with each other, the conformity of the non-contact infrared thermometer was weak.

Comparison of health-related quality of life of women undergoing robotic surgery, laparoscopic surgery or laparotomy for gynecologic conditions: A cross-sectional study.

OBJECTIVE: To assess and compare the health-related quality of life of women undergoing robotic gynecologic surgery, laparoscopic gynecologic surgery or laparotomy for benign and cancerous conditions. METHODS: Cross-sectional study design was used. The present study was carried out with 240 women, who underwent gynecologic surgery (robotic 48, laparoscopic 96, and laparotomy 96) in a tertiary care hospital. Instruments included a participant description questionnaire and Medical Outcomes Study Short Form-36. The data were collected 4 weeks after surgery, at the first postoperative visit of women to the clinic. Pearson χ2 test, one-way analysis of variance, and regression analysis were used to assess the data. RESULTS: Over half of the women in each group had surgery because of gynecologic cancer. All the subscale scores of Medical Outcomes Study Short Form-36 were significantly higher in the robotic group than the other surgical groups (P < 0.05). Women in the robotic group had better quality of life in terms of both the physical component and the mental component after surgery. CONCLUSIONS: Knowledge of health-related quality of life in the recovery period after surgery is important for healthcare providers to provide adequate preventive measures, information, and follow up.

Health Belief Model Scale for Cervical Cancer and Pap Smear Test: psychometric testing.

AIM: This study is a report of the development and psychometric testing of the Health Belief Model Scale for Cervical Cancer and the Pap Smear Test. BACKGROUND: While the Champion Health Belief Model scales have been tested extensively for breast cancer and screening for this, evaluation of these scales in explaining the beliefs of women with regard to cervical cancer and the Pap Smear Test has only received limited attention. METHODS: This methodological research was carried out in Turkey in 2007. The data were collected with 237 randomly selected women who met the criteria for inclusion and agreed to participate in this study. The Champion Health Belief Model scales were translated into Turkish, adapted for cervical cancer, validated by professional experts, translated back into English and pilot-tested. FINDINGS: Factor analysis yielded five factors: Pap smear benefits and health motivation, Pap smear barriers, seriousness, susceptibility and health motivation. Cronbach's alpha reliability coefficients for the five subscales ranged from 0·62 to 0·86, and test-retest reliability coefficients ranged from 0·79 to 0·87 for the subscales. CONCLUSION: The Health Belief Model Scale for Cervical Cancer and the Pap Smear Test was found to be a valid and reliable tool in assessing the women's health beliefs. Understanding the beliefs of women in respect of cervical cancer and the Pap Smear Test will help healthcare professionals to develop more effective cervical cancer screening programmes.

Women's awareness of the human papilloma virus and related health problems.

AIM: This paper is a report of a study of women's awareness of the human papilloma virus and related health problems. BACKGROUND: Cervical cancer is an important cause of mortality, making up approximately 12% of all cancers in women. Awareness on the part of carriers of human papilloma virus is crucial in preventing transmission of the infection and protecting against cervical cancer. METHOD: The study was performed as a cross-sectional descriptive study. The study consists of 79 human papilloma virus-positive women who had not been diagnosed with cervical cancer and 150 women who had not been diagnosed with human papilloma virus. Data were collected via questionnaires between November 2007 and April 2008. Percentages and chi-square test were used. FINDINGS: A significantly higher percentage of women with positive human papilloma virus knew the definition of human papilloma virus, the fact that it is transmitted via sexual contact and that it can lead to cervical cancer than did women with negative human papilloma virus. It was established that approximately half the women with positive human papilloma virus presented at the hospital with a genital wart. None of the women knew that a Pap smear test was a necessary tool in the prevention of cervical cancer. CONCLUSION: Women with positive human papilloma virus have insufficient knowledge of human papilloma virus, sexually transmitted diseases, the health risks associated with human papilloma virus and the means of preventing these risks. It is therefore necessary to evaluate the education of health workers, and especially of nurses, on human papilloma virus and its prevention.

Prevalence of lower urinary tract symptoms in nurses and civil servants working at a hospital: a cross-sectional study.

BACKGROUND: Lower urinary tract symptoms (LUTS) are common in women and can interrupt daily living activities of the individuals. The study aimed at determining the LUTS prevalence and the influencing factors in nurses and civil servants working at a hospital. METHODS: This cross-sectional and descriptive study was conducted with 158 female nurses and 105 female civil servants. The data were obtained with a data collection form and the Bristol Female Lower Urinary Tract Symptoms-Short Form. RESULTS: This paper exposes that the prevalence of at least one LUTS was 94.2% in nurses and 97.1% in civil servants. The most common LUTS symptoms of nurses and civil servants were urgency (60.1% nurses, 81.9% civil servants) and urge incontinence (59.5% nurses, 81.9% civil servants). Nurses (60.8%) expressed significantly higher rates of having inadequate time going to the toilet due to their work conditions compared to the civil servants (41.9%) (p<0.05). BFLUTS-SF scores in terms of age, BMI, parity, having cesarean and vaginal delivery and urinary incontinence in their previous pregnancies were compared between two groups, statistically significant differences were found (p<0.05). CONCLUSION: Workplace conditions of the health workers should be reorganizing to have healthy urinary habits for preventing them from the development of LUTS.

Case stories and Post-violence behavior of women seeking medical attention at the emergency department due to physical violence.

SUBJECT: The objective of this study is to determine the violence experienced by women who presented to the Emergency Department (ED) due to Intimate Partner Violence (IPV) and their previous experiences of violence. METHOD: The descriptive study was conducted with 96 women. The data was analyzed in SPSS 17.0 statistics package program. FINDINGS: The average age of the women is X = 35.33 ± 11.72, 35.4% of them are in the 31-40 age group, 69.6% are married, 44.8% are high school graduates, 60.4% are unemployed. It was determined that women who were IPV victims were exposed to violence by being beaten (punching, kicking etc.) at the highest rate (82.3%), and nearly half of them (47.9%) were injured in the head and neck regions. The vast majority of women (86.5%) have been subjected to violence before, only %13.5 of them stated that they experienced violence for the first time. It was found that the majority of women (69.8%) continued to live with the perpetrator after violence. Only three of the women (3.4%) attempted to initiate legal action, and the majority (76.5%) did not intend to take legal action. CONCLUSIONS: Healthcare professionals should be aware that most woman presenting to the ED with IPV has a history of violence before it, and that this will probably not be the last. Healthcare professionals should also consider the fact that the victims may be exposed to different types of violence at the same time. It is also recommended that healthcare professionals be trained on policies regarding IPV management and equipped to provide women with the right way out.

Women's breast cancer risk perception and attitudes toward screening tests.

This study's objective is to identify women's breast cancer risk perceptions and their attitudes and knowledge on screening tests. The cross-sectional research. Gulhane Military Medical Academy, Ankara, Turkey. The population of 188 females who applied for gynecological examination. The study employed a semistructured questionnaire form. Questions such as female's demographic data, attitudes based on screening tests of breast cancer, family history, perceived risk breast cancer, and questions with regard to patients' fear of breast cancer were included in the survey. In this study, it is determined that the rates of the women, who conduct breast self-examination (BSE), clinical breast examination (CBE) and mammography at least once, are very low. The reason for not performing the BSE was declared with a rate of 50.8% as "Do not know how to perform." Of the women 20.2% were fully acknowledged about BSE. Nearly half of the women perceived 50% or more risk of developing breast cancer, and this rate increases as they get older. The risk perception and educational status increased CBE and mammography rates and BSE knowledge positively, but because of insufficient BSE application abilities BSE rate cannot increase as expected. It is recommended that nurses put forward the initiatives in training programs to increase women's BSE abilities. In planning such an education program risk perception and information of women about breast cancer should be considered.

Infertility history: is it a risk factor for postpartum depression in Turkish women?

PURPOSE: The aim of this cohort study was to assess postpartum depressive symptoms in women who had been successfully treated for primary infertility at 2 teaching hospitals in Turkey in 2008. METHODS: The study groups comprised 51 fertile and 105 infertile women. The number of participants lost to follow-up was 28 fertile and 8 infertile women. "Descriptive Information Questionnaire" developed by the authors, the adapted "Beck Depression Inventory," and the adapted "Postpartum Depression Scanning Scale" were used to collect data. RESULTS: The probability of developing postpartum depression in the infertile group is 1.352 times higher than that in the fertile group. However, this result cannot be considered to be statistically meaningful. A similar correlation was present between the level of depressive symptoms during pregnancy and in the postpartum period in both the infertile and fertile groups. Additional risk factors such as health issues during pregnancy, the notion that pregnancy causes a decrease in libido and negative body image, the infant's gender, pain from incision or infection, and dyspareunia were manifest in the fertile women, but not in the infertile women. CONCLUSION: A history of infertility is not a major factor in postpartum depression. However, a history of depression may contribute to its development during pregnancy and in the postpartum period. Infertile women who experience severe anxiety and stress could be more prone to depression and should therefore be monitored closely.