Tài liệu Registered nurses’ health in community elderly careinSweden ppt

Registered nurses’ health in community elderly
careinSweden
inr_984 409 415
K. Josefsson PHD, RNT
Associate Professor, Senior Lecturer, School of Health, Care and Social Welfare, Mälardalen University, Eskilstuna, Sweden
JOSEFSSON K. (2012) Registered nurses’ health in community elderly care in Sweden. International Nursing
Review 59, 409–415
Aim: To describe registered nurses’ (RNs) ratings of their work-related health problems, sickness presence and
sickness absence in community care of older people. To describe RNs’ perceptions of time, competence and
emotional pressure at work. To describe associations between time, knowledge and emotional pressure with
RNs’ perceptions of work-related health problems, sickness presence and sickness absence.
Background: There is a global nursing shortage. It is a challenge to provide working conditions that enable
RNs to deliver quality nursing care.
Method: A descriptive design and a structured questionnaire were used. 213 RNs in 60 care homes for older
people participated, with a response rate of 62%.
Findings: RNs’ reported work-related health problems, such as neck/back disorders, dry skin/dry mucous
membranes, muscles/joints disorders, sleep disorders and headache. They had periods of fatigue/unhappiness/
sadness because of their work (37%). Most of the RNs felt at times psychologically exhausted after work, with
difficulties leaving their thoughts of work behind. RNs stated high sickness presence (68%) and high sickness
absence (63%). They perceived high time pressure, adequate competence and emotional pressure at work.
There was a weak to moderate correlation between RNs’ health problems and time pressure.
Discussion: We cannot afford a greater shortage of RNs in community care of older people. Politicians and
employers need to develop a coordinated package of policies that provide a long-term and sustainable solution
with healthy workplaces.
Conclusion: It is important to prevent RNs’ work-related health problems and time pressure at work.
Keywords: Community Elderly Care, Positive Practice Environments, Questionnaire, Registered Nurse, Time
Pressure, Work-Related Health Problems
Background
Registered nurses (RNs) are key figures in the community care of
older people (Josefsson 2006). However, there is a global nursing
shortage, that is, an imbalance between demand for employment

and the available supply (Oulton 2006). The factor contributing
to increased demand is an ageing population, since ageing
increases the risk for chronic illness and multimorbidity. By
2050, there will be a greater number of older people than
younger ones in the world (Oulton 2006; United Nations 2009).
Other reasons are unfavourable work environments that include
excessive workloads, inadequate support staff, violence, stress,
burnout, wage disparities and little involvement in decision
making (Fronteira & Ferrinho 2011; Josefsson 2006; Lim et al.
2010; Oulton 2006). RNs’ working conditions must therefore be
addressed in order to retain currently employed RNs, encourage
new RNs to replace those that retire and prevent health problems
for RNs (Eley et al. 2007).
Correspondence address: Karin Josefsson, School of Health, Care and Social
Welfare, Mälardalen University, Box 325, SE-63105 Eskilstuna, Sweden; Tel:
+46-70-6689416; Fax: +46-16-153740; E-mail:
bs_bs_banner
Nurses’ Work-Life Experiences
© 2012 The Author. International Nursing Review © 2012 International Council of Nurses 409
RNs in community care of older people work under psycho-
logical, emotional and time pressures (Josefsson et al. 2007; Lim
et al. 2010) often without support in the form of organized
supervision (Josefsson et al. 2008). Hallin & Danielson (2007a)
found that RNs considered high time pressure a greater obstacle
than difficult work tasks. Time pressure has been shown to occur
frequently in association with burnout in healthcare workers
(Stordeur et al. 2001).
RNs also described their work as varying between stimulating
and strenuous, leaning towards the latter (Hallin & Danielson
2007b). Moreover, RNs were frustrated since they were expected

to ‘be everywhere and know everything’ (Karlsson et al. 2009).
RNs also experienced themselves as ‘lone fixers’ giving rise to a
highly stressful work situation and more complicated roles
(Karlsson et al. 2009).
Nursing is considered a risk profession with high levels of
stress and burnout (Clegg 2001; Garrosa et al. 2008; Ilhan et al.
2008). Work-related stress in the care of older people has been
reported on a worldwide scale (Eley et al. 2007; Hasson & Arnetz
2008; Josefsson et al. 2007). The negative effects of work-related
stress on health have been extensively described (Garrosa et al.
2008; Ilhan et al. 2008; Karasek & Theorell 1990).
One of the leading work stress models is the demand-control-
support model (Karasek & Theorell 1990). The model aids in
understanding the connection between work organization, expe-
rienced stress and health (Josefsson et al. 2007; Tummers et al.
2002). An employee working with demands balanced by a feeling
of high control and the possibility to utilize skills and knowledge
leads to a stimulating work situation. On the other hand, the
experience of high demands imbalanced by low control and no
opportunities to utilize skills creates a highly stressful work situ-
ation, which in the long run, can lead to work-related stress and
unhealthy consequences. Josefsson et al. (2007) showed that RNs
in community care of older people perceived a highly strenuous
work situation characterized by high demands, such as high time
pressure. Therefore, RNs in the long run, placed their mental
health at risk. This could lead to sickness absence and (if other
employment is available) high staff turnover (Karasek & Theorell
1990).
In summary, community care of older people entails high risk
for stressful work, which can predict health problems. However,

there is a paucity of description of RNs’ perceptions of work-
related health problems, sickness presence and sickness absence.
As high work demands such as time, knowledge and emotional
pressure, seem to be central to nursing work, these aspects will be
studied as perceived by RNs, as well as associations between these
demands and health. The current study defines sickness absence
as being off work and sickness presence as being sick but on the
job (Aronsson et al. 2000; Elstad & Vabö 2008).
Aims
To describe RNs’ ratings of their work-related health problems,
sickness presence and sickness absence in community care of
older people. To describe RNs’ perceptions of time, competence
and emotional pressure at work. To describe associations
between time, knowledge and emotional pressure with RNs’ per-
ceptions of work-related health problems, sickness presence and
sickness absence.
Method
Sample
The healthcare system in Sweden consists of 20 county councils
at a regional level and 290 communities at a local level [SALAR
(The Swedish Association of Local Authorities and Regions)
2005]. The communities are responsible for residential care
homes of older people.
The target population consisted of 342 RNs who worked in 60
residential care homes with subunits in the care of older people,
in a large community in Central Sweden. Of the subunits, 33
were in dementia care and 20 were in general elder care where
RNs have to deal with a greater scope of various diagnoses. Seven
residential care homes had subunits both for dementia care and
general care.

In total, n = 213 RNs participated in this study, which com-
prised 62% of the target population. The RNs worked in direct
care, not as nurse managers at any level of management. RNs had
a median age of 51 years (min = 23, max = 76). The median
of the year they qualified nursing examination was 1983
(min = 1956, max = 2002). The majority of RNs were female
(93%). They had worked as RNs 18 years (median; min = 1,
max = 51) and they had worked 2 years at their current work-
place (min = 0.08, max = 40). They had worked 8 years as RN in
elderly care (min = 0.17, max = 30). Most of the RNs were per-
manently employed (86%). Twelve per cent of the RNs were
employed on an hourly contract directly by the organization, and
4% were employed full-time by deputyship or project.
To record the motives of non-respondents (n = 129), a form
was distributed to them, and they were asked to respond to the
following statement: ‘I have not answered the questionnaire
because ’.Non-respondents’ reasons for not participating in
the study were primarily lack of time, too extensive questionnaire
and high workload.
The questionnaire and development
The questions were derived from a questionnaire developed by
Aronsson et al. (1992) and previously used to gain information
about the perceptions of staff about their work situation, own
410 K. Josefsson
© 2012 The Author. International Nursing Review © 2012 International Council of Nurses
health, sickness absence and sickness presence. The question-
naire was designed for physicians in a variety of specializations
and organizational structures. The questions were carefully
selected to suit the aims of this study. Some questions were
modified to apply more specifically to RNs as an occupational

group in the care of older people, for example, years of experi-
ence working as RNs and as RN in elderly care. The logistics of
the questionnaire and the relevance of the questions were trialled
at a seminar; see the procedure.
Three main sections of the questionnaire were developed to
meet the aims of this study. The first section asked for back-
ground characteristics such as age, gender, number of active
years as a RN and year of nursing qualifying examination. The
second section consisted of questions that explored RNs’ percep-
tions of work-related health problems, sickness absence and sick-
ness presence. The questions were presented with a selection of
response categories, which were rated in ordinal scales using a
Likert-type scale, for example, of 1–5 ranged from ‘never’ to
‘most often’. The third section consisted of questions that
explored RNs’ perceptions of time, knowledge and emotional
pressure. The questions were presented with a selection of
response categories, which were rated in ordinal scales using a
Likert-type scale of 1–5 ranged from ‘absolutely too low’ to ‘abso-
lutely too high’. The participants were given an opportunity to
add their comments at the end of the questionnaire.
Procedure
The questionnaire was trialled at a seminar of RNs, psycholo-
gists, physiotherapists, occupational therapists, lecturers and
researchers who were all employed directly or indirectly in com-
munity care of older people. The questionnaire was tested to
assess the logistics and relevance of the questions, the clarity of
interpretation and time needed to complete the questionnaire
(Altman 1997). The questionnaire was also tested by 10 RNs. The
RNs were given an autonomous choice to participate or not. The
questionnaires were distributed personally by the principal

investigator, who participated when the RNs tested and com-
pleted the questionnaire. After that, the RNs and the principal
investigator discussed the questionnaire. Minor modifications
were made primarily to clarify the questions.
Local community managers with supervisory responsibility
for care of older people and the managers for each residential
care homes gave their permission for the study. The target popu-
lation was identified by the managers. The managers provided
the information on the total number of employed RNs and their
names. The principal investigator assured confidentiality. The
postal questionnaires were distributed in sealed envelopes to the
RNs at their work, either by their managers or by the principal
investigator.
The envelope to the RNs included a cover letter explaining the
aim of the study; a statement to convey the study’s importance to
participants; a statement assuring them of confidentiality; infor-
mation that data would be kept protected; and a statement to
encourage their replies (see Cohen et al. 2005). A postage-paid
return envelope was also included. Three reminders were sent
directly to the RNs when necessary.
Data analysis
The software used was Statistical Package for the Social Sciences
(SPSS) for Windows version 17.0 (SPSS Inc., Chicago, IL, USA).
The findings are shown in Table 1 and Supporting Information
Table S1 in absolute frequency (number = n), relative frequency
(%) and in running text. The relative frequency was rounded to
integers (Altman 1997). Median was used to describe the average
value and quartiles were used to describe the spread of data at a
non-parametric level. Spearman’s analysis of rank correlation
(rho) (Altman 1997) was used to measure the associations

between time, competence and emotional pressure with RNs’
perceptions of their own health, sickness presence and sickness
absence. Spearman’s analysis of rank correlation is a non-
parametric measure of statistical dependence between two vari-
ables (Altman 1997). The internal loss of data was minimal and
data was neither replaced nor imputed.
Ethical considerations
This study was approved by the Ethics Committee of Karolinska
Institutet, Stockholm (D. no: 317/02).
The RNs related their perceptions of work-related health, sick-
ness absence and sickness presence. This personal and sensitive
information had to be respected by the investigator. The inves-
tigator strove to prevent discomfort and violation of integrity. All
potential participants were given an autonomous choice to par-
ticipate or not. It was made clear that the investigators did not
work at the request of any of the RNs’ employers.
There was no dependence between investigators and partici-
pants, which could influence the participants. Participants were
informed that returned questionnaires were only to be seen by
the investigators. Participants were thoroughly informed that
their identities was protected, and that collected data was
acquired with no connections between name and work unit.
Information about the possibility of being informed of results
was provided.
Findings
Supporting Information Table S1 provides a summary of the
statistics for RNs’ ratings of work-related health problems
during the past year.
Registered nurses’ health in community elderly 411
© 2012 The Author. International Nursing Review © 2012 International Council of Nurses

At the end of the working day, many RNs expressed difficulty
leaving their thoughts about work behind (daily difficulties,
16%; difficulties some times a week, 23%; difficulties some times
a month, 18%; difficulties once in a while, 38%; no difficulties,
10%).
The majority of the RNs felt at times psychologically
exhausted after work (often 12%; rather often 28%; sometimes
52%; never 8%). Most felt at times physically exhausted after
work (often 15%; rather often 21%; sometimes 51%; never
13%). Thirty-seven per cent of the RNs had episodes of fatigue/
unhappiness/sadness because of their work and found difficul-
ties overcoming these feelings. Of the RNs, n = 213 stated these
episodes occurred several times a year (51%), sometimes (37%)
and rarely (12%). These episodes lasted either always (8%), some
months (4%), some weeks (31%) or some days (57%).
RNs felt, on a scale of 1 (absolutely not) to 5 (yes, without
hesitation), working in care for older people was psychologically
(median 4, inter quartile range 3–5) and physically stressful
(median 4, inter quartile range 3–5) in the long run.
The findings indicated that 68% had worked during the past
year despite feeling that sickness absence was necessary. Accord-
ing to the RNs, this situation arose several times (57%), many
times (9%) and once (34%) during the past year. Sixty-three per
cent of the RNs stated sickness absence during the past year. RNs
stated the number of times they had been on sickness absence
during the past year (0 times, 37%; 1–3 times, 50%; 4–6 times,
9%; 7–10 times, 3%; >10 times, 1%).
The majority of RNs perceived, on a scale of 1 (absolutely too
low) to 5 (absolutely too high), high levels of time pressure at
work (median 4, interquartile range 3–4). The majority of RNs

perceived, on a scale of 1 (absolutely too low) to 5 (absolutely too
high), adequate levels of competence pressure at work (median 3,
interquartile range 3–3). The majority of RNs perceived, on
a scale of 1 (absolutely too low) to 5 (absolutely too high),
adequate levels of emotional pressure at work (median 4, inter-
quartile range 3–4).
Spearman’s P showed a significantly positive correlation
between RNs’ perceived time pressure and 18 of all 19 variables
in Table 1, measured RNs’ perceived work-related health prob-
lems, sickness presence and sickness absence. The associations
varied from weak to moderate. Moreover, Spearman’s P revealed
a significantly positive although weak correlation between RNs’
perceived competence pressure and two of 19 variables (Table 1).
Spearman’s P revealed a significantly positive correlation
between RNs’ perceived emotional demands and 11 of 19 vari-
ables (Table 1). The associations were weak.
Table 1 Correlation coefficients between time, knowledge and emotional pressure perceived by registered nurses (RNs) and their ratings of work-related
health problems during the past year
Variables RNs (n = 213)
Time pressure Competence pressure Emotional pressure
Spearman’s rank
correlation (rho)
Acid indigestion, discomfort or stomach ache 0.261, P < 0.01 0.010 0.118
Gas, stomach ache, diarrhoea 0.229, P < 0.01 0.011 0.253, P < 0.01
Abdominal pain (unrelated to menstruation) 0.327, P < 0.01 0.000 0.226, P < 0.01
Common cold or respiratory tract infection 0.075 0.087 0.090
Dry skin or dry mucous membranes (eyes, nose, mouth, pharynx) 0.140, P < 0.05 0.006 0.099
Headache (unrelated to menstruation) 0.275, P < 0.01 0.035 0.091
Feeling faint 0.247, P < 0.01 0.058 0.233, P < 0.01
Nausea 0.212, P < 0.01 0.146, P < 0.01 0.163, P < 0.01

Neck or back disorders 0.255, P < 0.01 0.006 0.163, P < 0.05
Muscles or joints disorders 0.312, P < 0.01 0.122 0.226, P < 0.01
Sleep disorders 0.275, P < 0.01 0.123 0.187, P < 0.01
Worried and restless 0.333, P < 0.01 0.173, P < 0.05 0.240, P < 0.01
Difficulties leaving thoughts about work behind after the work day 0.369, P < 0.01 0.075 0.167, P < 0.05
Psychologically exhausted after the work day 0.426, P < 0.01 0.023 0.303, P < 0.01
Physically exhausted after the work day 0.142, P < 0.01 0.109 0.073
Episodes of fatigue/unhappiness/sadness, difficult to overcome 0.347, P <
0.01 0.067 0.188, P < 0.01
Sickness presence, that is, worked despite need for sickness absence 0.309, P < 0.01 0.002 0.126
Number of days with sickness absence 0.214, P < 0.01 0.007 0.101
Number of occasions with sickness absence 0.139, P < 0.01 0.022 0.021
412 K. Josefsson
© 2012 The Author. International Nursing Review © 2012 International Council of Nurses
Discussion
The main findings indicated that RNs reported work-related
health problems, sickness absence (63%), sickness presence
(68%) and high time pressure at work. This was a distressing
result since we are experiencing an unprecedented global nursing
shortage (Buchan & Aiken 2008; ICHRN 2007; Oulton 2006).
The nursing shortage is undermining the goals of health systems
globally and challenging nursing’s ability to meet the needs of
the citizens. Moreover, nursing shortages are linked to increased
mortality, staff violence, accidents/injuries, cross infection and
adverse postoperative events (Aiken et al. 2010; Lucero et al.
2010; Oulton 2006). The key reasons for the nursing shortage are
unhealthy work environments and the poor organizational
climate that characterize many workplaces (ICHRN 2007). Thus,
to create healthy workplaces and also retain RNs in active prac-
tice is the key to resolving the present nursing shortage in the

industrialized world and in developing countries.
This study showed that RNs perceived work-related health
problems. Disheartening findings, since perceived ill health
among nursing staff correlated with burnout (Ilhan et al. 2008).
A current study (Fronteira & Ferrinho 2011) showed burnout
and higher work dissatisfaction among RNs working in care for
older people than among RNs working in other areas of practice.
Lim et al. (2010) reported that stressors including shortage of
staff and high work demands can lead to ill health. More, RNs
experienced work dissatisfaction and had intentions to change
profession as a result of work-related stress.
Work-related health problems are most often caused by orga-
nizational factors (Ilhan et al. 2008; Oulton 2006; Peterson
2009). Lack of adequate resources has also been found a major
reason for health problems, such as burnout (Ilhan et al. 2008;
Peterson 2009). Arnetz (2008) showed that 40% of work-related
health problems were explained by organizational factors,
whereas only 10% of work-related health could be explained by
personality factors. Some aspects of personality can play a role in
the process of burnout, especially the positive aspects of person-
ality that can act as a protective factor (Garrosa et al. 2008).
RNs in this study perceived work-related neck or back disor-
ders, dry skin/dry mucous membranes, muscles/joints disorders,
sleep disorders and headache. Muscles/joints disorders have been
confirmed by a current systematic review of experimental and
observational studies on RNs’ physical health (Fronteira & Fer-
rinho 2011). RNs suffered more from musculoskeletal disorders
than other care workers.
RNs’ perceived work-related problems should be considered
from the viewpoint that RNs are the only professional group

with education and certification in advanced nursing. Thus, RNs
are key figures for taking care of seriously ill people, such as older
people with severe dementia and multiple diagnoses, and dying
people in community care (Josefsson 2006). The most important
recommendation for practice is to create healthy workplaces. The
International Council of Nurses described, through ICHRN
(2007), positive practice environments as workplaces that strive
to ensure the health, safety and personal well-being of staff,
support quality patient care and improve the motivation, pro-
ductivity and performance of individuals and organizations.
Improved leadership and organization would not only evidently
decrease sick rates but also improve productivity (Arnetz 2008).
Employers should support RNs, with continuous supervision
focusing on demands and their effect on RNs’ health in commu-
nity care of older people. Moreover, improving RNs’ working
conditions may improve both RNs’ and patients’ satisfaction as
well as the quality of care (McHugh et al. 2011).
This study revealed that health problems are not necessarily
followed by sickness absence, confirmed by Aronsson & Gustafs-
son (2005). Staff may turn up for work despite believing they are
too sick to work. Findings of this study showed that 68% of the
RNs reported attending their workplaces during the past year,
despite feeling so sick that they should have stayed at home.
According to over half of the RNs in this study, the situation of
sickness presence arose several times during the past year. An
explanation might be that professional norms and moral obliga-
tions place pressure on RNs to work even though ill (Crout et al.
2005). RNs might also lower their thresholds for sickness absence
when caregivers are understaffed (Elstad & Vabö 2008; Lim et al.
2010).

This study was in agreement with Aronsson et al. (2000), who
reported that staff providing care or welfare services have an
increased risk for sickness presence. Furthermore, the findings
emphasized that rate of sickness do not always reveal all aspects
of RNs’ perceived health or health problems. Therefore, politi-
cians, employers and nurse managers should take the RNs’ high
sickness presence and sickness absence seriously. The main chal-
lenge for policy makers is to develop a coordinated package of
policies that provide a long-term and sustainable solution with
healthy workplaces (Buchan & Aiken 2008; ICHRN 2007).
Further studies on the health of the nursing staff should concen-
trate not only on sickness absence but on sickness presence as
well (Elstad & Vabö 2008).
Many RNs had difficulties leaving their thoughts behind after
the working day. In addition, the majority of the RNs sometimes
felt psychologically and physically exhausted after work. Findings
indicated that 37% of RNs had work-related periods of fatigue/
unhappiness/sadness from which it was difficult to recover.
These episodes occurred, on average, several times yearly. These
findings have been confirmed by previous studies reporting that
RNs work under physical and emotional pressure in community
care of older people (Hallin & Danielson 2007b; Josefsson et al.
Registered nurses’ health in community elderly 413
© 2012 The Author. International Nursing Review © 2012 International Council of Nurses
2007). It is important to keep work and life in balance. Thus,
employers need to adopt innovative programmes and opportu-
nities that encourage employees to better balance their work days
with their home and family life.
The findings in this study were also in line with previous
reports that nursing is a risk profession with high levels of stress

(Aronsson et al. 2000; Clegg 2001; Fronteira & Ferrinho 2011;
Garrosa et al. 2008; Lim et al. 2010). Garrosa et al. (2008) also
predicted that stress levels in nursing are most likely increasing.
Their assumption was supported by the RNs’ perceptions in this
study, that is to say they felt that working with care of older
people was psychologically and physically stressful in the long
run. Moreover, findings in this study were in line with a recent
report that RNs, regardless of gender, are among the most vul-
nerable occupational groups when it comes to sickness absence
because of mental health problems (AFA Insurances 2006).
This study showed that the majority of RNs perceived high
time pressure at work in the community care of older people.
The result is in accordance with earlier studies (Hallin & Daniel-
son 2007a; Josefsson et al. 2007). A substantial proportion of
RNs stated they were not able to complete their work tasks
during working hours (Josefsson et al. 2007). One major reason
for the time pressure, stated by RNs in care of older people, was
the increasing number of care recipients without a correspond-
ing increase in resources (Swedish Institute of Family Medicine
2003). RNs considered high time pressure as a greater obstacle
than difficult work tasks (Hallin & Danielson 2007a). Time pres-
sure was also the foremost factor for RNs’ work dissatisfaction
(Hasson & Arnetz 2008).
There is presently a shortage of RNs in community care of
older people and a considerable increase is expected in the
number of RNs’ retirements (Josefsson 2006; Oulton 2006). In
light of this and findings in this study, it is especially important to
take RNs’ work-related health problems and the consequences of
RNs’ time pressure at work seriously. Because of the fact that
RNs’ perceived time pressure were significantly correlated with

nearly all (18 of 19) variables measuring RNs’ work-related
health problems. In spite of the fact that the correlations varied
from weak to moderate, this should be taken seriously. For the
sake of safe care, we cannot afford a greater shortage of RNs in
the community care of older people.
Methodological considerations
This study is limited by the lack of description regarding staffing,
such as whether there were numerous unfilled vacancies. Never-
theless, these findings have an important value and are relevant
to clinical practice. Although this applies to most questionnaires,
the use of the questionnaire in which the participants only
answered in those domains determined by the researcher might
be a weakness (Polit & Beck 2008). On the other hand, partici-
pants were given an opportunity to comment at the end of the
questionnaire. The internal loss of data was neither replaced nor
imputed, as the overall percentage of missing data was low. Power
calculation was not used since this study is explorative and
descriptive. Consequently, generalizations beyond this study
should be made with caution. However, the results may reflect
the perceptions of RNs working in similar conditions.
Conclusion
In conclusion, this study highlighted RNs’ work-related health
problems, high sickness presence and high sickness absence in
the community care of older people, as well as perceived time
pressure at work. This study showed that further studies on the
health of the nursing staff should include sickness presence. This
study underlines the importance of taking action to prevent RNs’
work-related health problems and time pressure at work. It
requiresconcertedaction–acombination of strategies globally,
nationally, regionally and locally.

Acknowledgement
I am grateful to the RNs who so willingly agreed to participate in
this study. This research was supported by Mälardalen Univer-
sity, Sweden and a fellowship from Dementia Association – The
National Association for the Rights of the Demented, Sweden.
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Supporting information
Additional Supporting Information may be found in the online
version of this article:
Table S1 Registered nurses’ (RNs’) ratings of work-related
health problems during the past year
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