Do Swedish rock-climbers exhibit more eating disorder and body dissatisfaction symptoms than non-climbers? A cross-sectional study.

OBJECTIVES: The inclusion of rock-climbing in the Olympic Games has increased participation in the sport and attention to athletes' health. In sports where the importance of low body weight is considerate, there is an increased risk of developing eating disorders (EDs). There is sparse research on EDs among rock-climbers. The primary aim was to map ED symptoms among rock-climbers compared with controls. The secondary aim was to analyze differences in body dissatisfaction. Comparisons between rock-climbing levels and sexes were performed. DESIGN: This is a cross-sectional study in a larger prospective longitudinal study series, CLIMB: Climber's Longitudinal attitudes towards Injury, Mental health and Body image, using baseline data. PARTICIPANTS: Swedish rock-climbers, at an advanced and elite level according to the International Rock Climbing Research Association, participated. Participants were at least 13 years old. 183 rock-climbers partook with a mean age of 29.5 (SD=9.1) with two participants under 15 years old. 180 controls partook with a mean age of 29.0 (SD=8.9). There were no control participants under 15 years of age. PRIMARY AND SECONDARY OUTCOME MEASURES: Data was gathered through a self-report questionnaire collecting the primary outcome measure, ED symptoms (Eating Disorders Examination Questionnaire (EDE-Q) V.6.0) and the secondary outcome measure, body dissatisfaction (Body Shape Questionnaire-8C). RESULTS: There were no differences between rock-climbers and controls regarding ED symptoms. Symptoms were higher among female rock-climbers (26%) than male (5.8%). Regarding body dissatisfaction, the control group reported higher levels compared with rock-climbers. At least a mild concern was observed in 13.3% of male rock-climbers, compared with 47.4% of females. CONCLUSIONS: Although there was no difference in the EDE-Q V.6.0 between rock-climbers and controls, females reported significantly more symptoms than men. Regarding body dissatisfaction, female rock-climbers exhibited higher levels of dissatisfaction than males. Further, higher levels of dissatisfaction were reported in controls, especially in men, where symptoms were three times higher than rock-climbers. TRIAL REGISTRATION NUMBER: NCT05587270.

Trajectories of procrastination among Swedish University students over one academic year: a cohort study.

BACKGROUND: Procrastination is common among university students and associated with adverse outcomes such as physical and mental health problems. According to the Temporal motivation theory procrastination may vary over time depending on the temporal proximity to goals and deadlines. AIMS: To determine if mean procrastination levels among university students varies over an academic year, and if trajectories of procrastination are moderated by gender identity, perfectionistic strivings, and/or perfectionistic concerns. SAMPLE: Swedish university students (n = 1410). METHODS: The cohort was followed with web-surveys at four time-points over one academic year (Late semester, Mid semester, After semester, and Early semester). Generalized Estimating Equations were used to estimate mean levels of self-rated procrastination at the different time-points. RESULTS: We found only small fluctuations in mean procrastination levels over the academic year. Participants with high perfectionistic concerns demonstrated higher mean procrastination levels at all time-points, but neither gender identity, perfectionistic concerns nor perfectionistic strivings affected the slope of the mean procrastination trajectories. CONCLUSIONS: In this cohort of Swedish university students, self-rated procrastination levels were stable over the academic year. Perfectionistic concerns, but not gender identity or perfectionistic strivings, was associated with higher levels of procrastination.

Assessment of eating disorder symptoms, compulsive exercise, body dissatisfaction and depression in Swedish national team gymnasts, with a one-year follow-up.

PURPOSE: The purpose of this study was to explore changes in symptoms of eating disorders, compulsive exercise, and depression, between two assessments 12 months apart, among elite gymnasts. METHOD: Factors related to the development of mental health symptoms in male and female Swedish national team gymnasts were investigated using baseline and 1-year follow-up scores in two subscales of the Eating Disorders Inventory 3; drive for thinness and body dissatisfaction, two subscales of the Compulsive Exercise Test; avoidance and rule-driven behavior and exercise for weight control, and the Montgomery-Åsberg Depression Rating Scale-Self report (MADRS-S). Linear mixed models were used to investigate the influence of drive for thinness, exercise for weight control, avoidance and rule-driven behavior, and MADRS-S on body dissatisfaction. RESULTS: Body dissatisfaction increased from baseline to the follow-up assessment, while drive for thinness and depression remained stable. Symptoms of eating disorders and depression were generally low in this group of elite gymnasts at both assessments. Drive for thinness, exercise for weight control, and symptoms of depression were associated with body dissatisfaction. DISCUSSION: Our findings indicate that there were no significant changes over time in eating disorders and depression symptoms but significant associations with body dissatisfaction. Furthermore, we found independent effects of drive for thinness, exercise for weight control and symptoms of depression for body dissatisfaction.

Sexual harassment, sexual violence and subsequent depression and anxiety symptoms among Swedish university students: a cohort study.

PURPOSE: To determine the gender-specific impact of recent exposure to different forms of sexual harassment and sexual violence (SHV) on depression and anxiety symptoms three, six, and nine months later. METHODS: We recruited 2229 women and 1274 men studying at Swedish universities and followed them with web-surveys every three months over one year. We estimated mean differences (MDs) of depression and anxiety symptoms between exposed and unexposed at each follow-up, adjusting for prior SHV, prior depression and anxiety symptoms and potential confounders. RESULTS: For women, sexual harassment (wide subjective definition) was associated with higher symptom levels of depression (MD 1.0 [95% CI: 0.3; 1.7]) and anxiety (MD 0.8 [95% CI: 0.3; 1.4]) three months later. Unwanted sexual attention was associated with higher symptom levels of anxiety three (MD 0.5 [95% CI: 0.1; 0.8]) and six months later (MD 0.4 [95% CI: 0.0; 0.7]). Exposure to sex against ones will was associated with higher depression symptoms three (MD 1.7 [95% CI: 0.1;3.4]), and six months later (MD 3.1 [95% CI: 1.0; 5.2]). Trends indicated that associations with subsequent mental health differed between forms of SHV among women, and that most associations were more pronounced in temporal proximity to the exposures. For men, we refrain from interpreting the results since they showed high variability and were not robust to sensitivity analyses using multiple imputation to account for missing outcome data. CONCLUSIONS: Among women, several forms of SHV were associated with higher subsequent depression and anxiety symptoms.

Mental health problems, sleep quality and overuse injuries in advanced Swedish rock-climbers - the CLIMB study.

OBJECTIVES: To examine the prevalence of mental health problems (depression, anxiety, and stress), sleep quality, and disability due to overuse injuries in advanced and elite rock-climbers. The rock-climbers were compared to a group of non-climbing controls. METHODS: A self-selected sample of advanced and elite Swedish rock-climbing athletes was recruited through the Swedish Rock-climbing Federation, local rock-climbing gyms and through social media. A control group, matched in size was recruited. Participants in the control group answered an online survey of validated questionnaires, examining symptoms of stress, anxiety, depression, sleep quality. The climbing participants answered the same survey as the non-climbing controls but with additional questions regarding musculoskeletal problems and disabilities related to these. Outcome measures used were the Depression Anxiety Stress Scale, Pittsburgh Sleep Quality Index and The Oslo Sports Trauma Research Center Overuse Injury Questionnaire. RESULTS: A total of 183 participants were included in the rock-climbing group, and 180 participants in the control group. In the rock-climbing group the mean age (SD) was 28.2 (8.3) years among women and 30.5 (9.6) years in men. The mean BMI of women was 21.2 (2.2) and 22.8 (2.1) in men. A total of 30.6% of the rock-climbing group (26.7% of men, 35.9% of women) reported at least moderate levels of symptoms of depression and 23.1% (17.2% men, 30.8% women) at least moderate levels of symptoms of anxiety. A total of 48.4% of rock-climbers (39.1% men, and 61.6% women) reported at least moderate levels of symptoms of stress. Among the rock-climbers, 45.0% reported having poor sleep quality. There were no statistical significant differences (p = 0.052-0.96) in mental health problems or sleeping problems between the rock-climbers and the controls. Among rock-climbers, reports of one-week prevalence of injury related problems was: Finger and hand (49.5%), Shoulder (35.2%), Knee (29.1%), Lumbar back (26.4%), Arm (25.3%), Thoracic back and neck (17.0%), and Foot and lower leg (12.1%). CONCLUSION: The overall results indicate high levels of symptoms of mental health problems and poor sleep quality in both rock-climbers and controls. Although no significant differences between the climbing group and the control group was displayed, symptoms that warrant clinical attention is high. Overuse injuries were commonly reported among the rock-climbers in all examined injury locations. Previous studies reporting mental health problems to be more prevalent among athletes were contradicted in this study. The results display the need for a broader perspective regarding climbers general health and the need to provide structured care and adequate support in order to come to terms with these concerns.

Dietary habits in adolescent male and female handball players: the Swedish Handball Cohort.

Objectives: This cross-sectional study aimed to describe dietary habits in Swedish adolescent handball players and differences with respect to sex and school grade. Methods: Participants in the Swedish Handball Cohort answered a web-survey assessing adherence to sports nutrition recommendations for meal frequency and meal timing, and the Nordic Nutrition Recommendations (NNR) for fruits/vegetables and fish/seafood, food exclusions and use of dietary supplements. Differences with respect to sex and school grade were estimated with generalised linear models, generating prevalence ratios (PR) with 95% CIs. Results: A total of 1040 participants (16.6±0.9 years, 51% males) were included. Overall, 70% and 90%, respectively, met recommendations for meal frequency and meal timing, whereas adherence to recommended carbohydrate intake during training/game was met by 17%. Adherence to the NNR for fruits/vegetables and fish/seafood was met by 16% and 37%, respectively. Twenty-eight per cent reported using dietary supplements. Females reported lower frequency of meals, especially morning snacks (-0.6 days/week (95% CI -0.3 to -0.9)) and evening snacks (-0.8 days/week (95% CI -0.5 to -1.1)), higher prevalence of exclusions due to intolerances (PR 1.66 (95% CI 1.31 to 2.01)) and other reasons (PR 1.36 (95% CI 1.08 to 1.64)), higher adherence to the NNR for fruits/vegetables (PR 2.30 (95% CI 1.98 to 2.62)) and use of micronutrient supplements (PR 1.72 (95% CI 1.43 to 2.00)) compared with males. Only small differences were observed between school grades. Conclusions: Swedish adolescent handball players' dietary habits are fairly in accordance with sports nutrition recommendations but not the NNR. Females appear to display more restrictive habits than males.

Protocol for a 2-year longitudinal study of eating disturbances, mental health problems and overuse injuries in rock climbers (CLIMB).

INTRODUCTION: Rock climbing is a rapidly growing sport in which performance may be affected by participant's weight and leanness, and there may be pressure on athletes with respect to their eating behaviour and body weight. However, there is sparse research performed on climbers, constituting a knowledge gap which the present study aims to fill. The primary outcomes of the study are to examine disordered eating and overuse injuries in rock climbers. Secondary variables are body image, indicators of relative energy deficiency, mental health problems, compulsive training, perfectionism, sleep quality and bone density. METHOD AND ANALYSIS: This prospective longitudinal study aims to recruit Swedish competitive rock climbers (>13 years) via the Swedish Climbing Federation. A non-athlete control group will be recruited via social media (n=equal of the climbing group). Data will be collected using streamlined validated web-based questionnaires with three follow-ups over 2 years. Inclusion criteria for rock climbers will be a minimum advanced level according to International Rock-Climbing Research Association. The non-athlete control group is matched for age and gender. Exclusion criteria are having competed at an elite level in any sport as well as training more often than twice per week. Statistical analyses will include multinominal logistic regression, multivariate analysis of variance (MANOVA) and structural equation modelling (SEM). We will assess effect measure modification when relevant and conduct sensitivity analyses to assess the impact of lost to follow-up. ETHICS AND DISSEMINATION: The Rock-Climbers' Longitudinal attitudes towards Injuries, Mental health and Body image study, CLIMB, was approved by the Swedish ethics authority (2021-05557-01). Results will be disseminated through peer-reviewed research papers, reports, research conferences, student theses and stakeholder communications. TRIAL REGISTRATION NUMBER: NCT05587270.

Preventing Disordered Eating in Teenage Ballet Students: Evaluation of DancExcellent, a Combined CBT and Nutrition Education Intervention.

BACKGROUND: Disordered eating (DE) behaviors are relatively common among high-level dancers, especially in classical ballet. At the same time, interventions aimed at reducing DE behaviors in this population are scarce. METHODS: An 8-week exploratory preventive intervention for DE behaviors was carried out in a high-level ballet school for 40 teenagers aged 12-15 years (77.5% female). Both risk factors (perfectionism) and potentially protective factors (self-esteem, self-compassion) for the development of DE behaviors were considered. The intervention was created specifically for this study and consisted of five cognitive behavior therapy (CBT) workshops and four nutrition workshops. Additional components included newsletters for pupils and educational sessions and social media interactions with staff and parents. The intervention comprised two phases (control and intervention periods), with students acting as their own controls. Standardized questionnaires were completed before and after both phases. RESULTS: Questionnaire results did not indicate any changes in reported perfectionism, self-esteem, or self-compassion, nor were symptoms of DE affected during either the control or intervention periods. CONCLUSIONS: The intervention did not yield any discernible impact. However, it was affected by the onset of the COVID-19 pandemic, which limits our ability to draw conclusions about intervention effectiveness. Evaluations with pupils offer several considerations for future improvements.

Associations Between Procrastination and Subsequent Health Outcomes Among University Students in Sweden.

Importance: Procrastination is prevalent among university students and is hypothesized to lead to adverse health outcomes. Previous cross-sectional research suggests that procrastination is associated with mental and physical health outcomes, but longitudinal evidence is currently scarce. Objective: To evaluate the association between procrastination and subsequent health outcomes among university students in Sweden. Design, Setting, and Participants: This cohort study was based on the Sustainable University Life study, conducted between August 19, 2019, and December 15, 2021, in which university students recruited from 8 universities in the greater Stockholm area and Örebro were followed up at 5 time points over 1 year. The present study used data on 3525 students from 3 time points to assess whether procrastination was associated with worse health outcomes 9 months later. Exposure: Self-reported procrastination, measured using 5 items from the Swedish version of the Pure Procrastination Scale rated on a Likert scale from 1 ("very rarely or does not represent me") to 5 ("very often or always represents me") and summed to give a total procrastination score ranging from 5 to 25. Main Outcomes and Measures: Sixteen self-reported health outcomes were assessed at the 9-month follow-up. These included mental health problems (symptoms of depression, anxiety, and stress), disabling pain (neck and/or upper back, lower back, upper extremities, and lower extremities), unhealthy lifestyle behaviors (poor sleep quality, physical inactivity, tobacco use, cannabis use, alcohol use, and breakfast skipping), psychosocial health factors (loneliness and economic difficulties), and general health. Results: The study included 3525 participants (2229 women [63%]; mean [SD] age, 24.8 [6.2] years), with a follow-up rate of 73% (n = 2587) 9 months later. The mean (SD) procrastination score at baseline was 12.9 (5.4). An increase of 1 SD in procrastination was associated with higher mean symptom levels of depression (ß, 0.13; 95% CI, 0.09-0.17), anxiety (ß, 0.08; 95% CI, 0.04-0.12), and stress (ß, 0.11; 95% CI, 0.08-0.15), and having disabling pain in the upper extremities (risk ratio [RR], 1.27; 95% CI, 1.14-1.42), poor sleep quality (RR, 1.09, 95% CI, 1.05-1.14), physical inactivity (RR, 1.07; 95% CI, 1.04-1.11), loneliness (RR, 1.07; 95% CI, 1.02-1.12), and economic difficulties (RR, 1.15, 95% CI, 1.02-1.30) at the 9-month follow-up, after controlling for a large set of potential confounders. Conclusions and Relevance: This cohort study of Swedish university students suggests that procrastination is associated with subsequent mental health problems, disabling pain, unhealthy lifestyle behaviors, and worse psychosocial health factors. Considering that procrastination is prevalent among university students, these findings may be of importance to enhance the understanding of students' health.

Strengths of associations between depressive symptoms and loneliness, perfectionistic concerns, risky alcohol use and physical activity across levels of sleep quality in Swedish university students: A cross-sectional study.

Previous research shows that sleep quality may interact with some other predictors of depression, such that poor sleep could strengthen the association between these factors and depression. We aimed to determine the presence of statistical interactions between sleep quality and loneliness, risky alcohol use, perfectionistic concerns and/or physical inactivity in relation to depressive symptoms. Further, we aimed to describe the functional form of the statistical interactions and associations. We used a cross-sectional design and included 4262 Swedish university students. All measures were self-reported, sleep quality was measured with the Pittsburgh Sleep Quality Index, and depressive symptoms with the short-form Depression, Anxiety and Stress Scale. Regression models of increasing complexity (linear and non-linear, with and without interactions) were compared to determine the presence of associations and statistical interactions, and to explore the best functional form for these associations and interactions. Out-of-sample R2 from repeated cross-validation was used to select the final models. We found that sleep quality was associated with depressive symptoms in all final models. Sleep quality showed a linear interaction with perfectionistic concerns in relation to depressive symptoms, such that perfectionistic concerns were more strongly associated with depressive symptoms when sleep quality was poor. Loneliness, risky alcohol use and physical inactivity were non-linearly associated with depressive symptoms but did not interact with sleep quality. We concluded that out of the four examined variables, only perfectionistic concerns interacted with sleep quality in relation to depressive symptoms. This interaction was weak and explained little of the overall variance in depressive symptoms.

Lifestyle behaviors in Swedish university students before and during the first six months of the COVID-19 pandemic: a cohort study.

BACKGROUND: Changes in Swedish university students' lifestyle behaviors during the COVID-19 pandemic are unknown. This study aimed to assess physical activity, sitting time, meal frequency and risk substance use (alcohol, tobacco, and illicit use of drugs) in Swedish university students before and during the first six months of the COVID-19 pandemic, for all and stratified by age and sex. METHODS: Data were obtained from the Sustainable University Life cohort study in which web-based surveys were sent to university students repeatedly for one year. Baseline assessment (before the pandemic) was between August 2019-March 2020, follow-up 1 (FU1) between March-June 2020, and follow-up 2 (FU2) between June-September 2020. Participants reported weekly minutes of physical activity, daily sitting hours, meal frequency by weekly intake of different meals, and motivation for eating irregularly, if so. Also, harmful use of alcohol, tobacco and illicit drugs was assessed. Population means and differences with 95% confidence intervals (95% CI) in lifestyle behaviors between time points were calculated with Generalized Estimating Equations. RESULTS: 1877 students (73% women, mean age 26.5 years) answered the baseline survey. Weekly exercise decreased by -5.7 min (95% CI: -10.0, -1.5) and -7.7 min (95% CI: -12.6, -2.8) between baseline and FU1 and FU2, respectively. Weekly daily activities increased by 5.6 min (95% CI: 0.3, 11.7) and 14.2 min (95% CI: 7.9, 20.5) between baseline and FU1 and FU2. Daily sitting time decreased by -1.4 h (95% CI: -1.7, -1.2) between baseline and FU2. Breakfast intake increased by 0.2 days per week (95% CI: 0.1, 0.3) between baseline and FU2. Lunch intake decreased by -0.2 days per week (95% CI: -0.2, -0.1) between baseline and FU1 and by -0.2 days per week (95% CI: -0.3, -0.0) between baseline and FU2. Dinner intake decreased by -0.1 days per week (95% CI: -0.2, -0.0) between baseline and both FU1 and FU2. Only minor differences in risk substance use were observed. Similar changes were observed in analyses stratified by age and sex. CONCLUSIONS: Lifestyle behaviors in Swedish university students slightly improved during the first six months of the COVID-19 pandemic compared to before. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04465435 . 10/07/2020.

Sustainable UNiversity Life (SUN) study: protocol for a prospective cohort study of modifiable risk and prognostic factors for mental health problems and musculoskeletal pain among university students.

INTRODUCTION: Mental health problems and musculoskeletal pain are common health problems among young adults including students. Little is known about the aetiology and prognosis of these problems in university students. We aim to determine the role of personal, sociodemographic, academic and environmental factors for risk and prognosis of symptoms of depression, anxiety and stress as well as musculoskeletal pain in university students. The constructs that will be studied are based on the biopsychosocial model and psychopathology associated with disabling pain. This model acknowledges illness to consist of interrelated mechanisms categorised into biological, psychological, environmental and social cues. METHODS AND ANALYSIS: This cohort study aims to recruit around 5000 Swedish full-time students. Data will be collected using five online surveys during one academic year. A subgroup (n=1851) of the cohort, recruited before the COVID-19 pandemic, receive weekly text messages with three short questions assessing mood, worry and pain, sent through the web-based platform SMS-track . Statistical analyses will include Kaplan-Meier estimates, Cox regression analyses, multinomial logistic regression analyses and generalised estimating equations. We will assess effect measure modification when relevant and conduct sensitivity analyses to assess the impact of lost to follow-up. PROTOCOL AMENDMENTS: Due to opportunity and timing of the study, with relevance to the outbreak of the COVID-19 pandemic, this study further aims to address mental health problems, musculoskeletal pain and lifestyle in university students before and during the pandemic. ETHICS AND DISSEMINATION: The Sustainable UNiversity Life study was approved by the Swedish ethics authority (2019-03276; 2020-01449). Results will be disseminated through peer-reviewed research papers, reports, research conferences, student theses and stakeholder communications. TRIAL REGISTRATION NUMBER: NCT04465435.

Two-year longitudinal case study of intensive exposure treatment in an adolescent girl with social anxiety disorder.

The purpose was to adapt the "Bergen 4-Day Treatment" for severe social anxiety disorder and to study the 28 months follow-up effects for a 16-year-old girl. It was delivered over three full days. At post-treatment, 48% reduction in symptoms, she no longer met the diagnostic criteria for SAD.

Body image and compulsive exercise: are there associations with depression among university students?

PURPOSE: Mental health problems among university students have been reported to be significantly increasing and suggested to be associated with college drop-out. Body dissatisfaction and compulsive exercise are both constructs relevant for mental health problems in general and eating disorders in particular. This study examined associations between body dissatisfaction, compulsive exercise and self-reported symptoms of depression among Swedish university students. METHODS: Participants (n = 4262) are students in an ongoing cohort study, and data from the baseline assessment were used. Four linear regression models were built to explore the associations between body dissatisfaction, compulsive weight control exercise and depressive symptoms. RESULTS: Our findings showed that females reported higher levels of body dissatisfaction than males. Body dissatisfaction and compulsive exercise were associated with self-reported symptoms of depression in this non-clinical population. Results showed that compulsive exercise was negatively associated with reported symptoms of depression, while body dissatisfaction was positively associated with symptoms of depression. CONCLUSION: In line with previous research, there was a gender difference in body dissatisfaction where females displayed higher levels of dissatisfaction than males.  Body dissatisfaction was  positively associated with reported symptoms of depression, suggesting support of previous research indicating body dissatisfaction to increase mental health problems. Compulsive exercise was negatively associated with symptoms of depression suggesting a behavior negatively reinforced, supporting both constructs to be of interest for reported symptoms of depression in a non-clinical population of Swedish university students. LEVEL OF EVIDENCE: III, cohort study. TRIAL REGISTRATION: http://clinicaltrials.gov/ID : NCT04465435.

Depression, anxiety and stress among Swedish university students before and during six months of the COVID-19 pandemic: A cohort study.

AIMS: The COVID-19 pandemic has had a profound effect on societies and citizens worldwide, raising concerns about potential mental health impacts. We aimed to describe trajectories of depression, anxiety and stress symptoms during the COVID-19 outbreak compared to before the outbreak, and to determine if trajectories were modified by pre-pandemic loneliness, poor sleep quality and mental health problems. METHODS: We conducted a cohort study with 1836 Swedish university students entering the study before 13 March 2020, the onset of the pandemic, with follow-ups within three (FU1) and six months (FU2) of the outbreak. Generalized Estimating Equations were used to estimate mean differences in symptom levels over time-periods, and to estimate potential effect modifications. RESULTS: We found small differences in mean levels of the depression, anxiety and stress scale (DASS-21) over time. Compared to before the pandemic, depression increased by 0.25 points of 21 (95% CI: 0.04 to 0.45) at FU1 and decreased by 0.75/21 (95% CI:-0.97 to -0.53) at FU2. Anxiety decreased from baseline to FU1 by 0.09/21 (95% CI: -0.24 to 0.07) and by 0.77/21 (95% CI: -0.93 to -0.61) to FU2. Stress decreased from baseline to FU1 by 0.30/21 (95% CI: -0.52 to -0.09) and by 1.32/21 (95% CI: -1.55 to -1.09) to FU2. Students with pre-pandemic loneliness, poor sleep quality or pre-pandemic mental health problems did not have worse trajectories of mean mental health symptoms. CONCLUSIONS: Symptom levels were relatively stable during the first three months of the pandemic, while there was a slight decrease during the summer months, probably due to seasonality effects.