scholarly journals The Impact of the COVID-19 Pandemic on Stress and Other Psychological Factors in Pregnant Women Giving Birth During the First Wave of the Pandemic

2021 ◽  
Author(s):  
Theresa Hübner ◽  
Tanja Wolfgang ◽  
Ann-Catrin Theis ◽  
Magdalena Steber ◽  
Lea Wiedenmann ◽  
...  
Keyword(s):  
Postpartum Period ◽  
Self Efficacy ◽  
Stress Hormones ◽  
Depression Scale ◽  
Active Coping ◽  
Significant Rise ◽  
Maternal Bonding ◽  
Pregnancy And Postpartum ◽  
Data Survey ◽  
The Impact

Abstract BackgroundThe onset of mental illness such as depression and anxiety disorders in pregnancy and postpartum period is common. The coronavirus induced disease 2019 (COVID-19) pandemic and the resulting public policy responses represent an exceptional situation worldwide and there are hints for adverse psychosocial impact, hence, the study of psychological effects of the pandemic in women during hospitalization for delivery and in the postpartum period is highly relevant. MethodsPatients who gave birth during the first wave of the Corona pandemic in Germany (March to June 2020) at the Department of Obstetrics and Gynecology, University of Würzburg, Germany, were recruited at hospital admission for delivery. Biosamples were collected for analysis of SARS-CoV-2 infection and various stress hormones and interleukin-6 (IL-6). In addition to sociodemographic and medical obstetric data, survey questionnaires in relation to concerns about and fear of COVID-19, depression, stress, anxiety, loneliness, maternal self-efficacy and the mother-child bonding were administered at T1 (delivery stay) and T2 (3-6 month postpartum).ResultsIn total, all 94 recruited patients had a moderate concern of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) at T1 with a significant rise at T2. This concern correlated with low to low-medium general psychosocial stress levels and stress symptoms, and the women showed a significant increase of active coping from T1 to T2. Anxiety levels were low and the Edinburgh Postnatal Depression Scale showed a medium score of 5 with a significant (T1), but only week correlation with the concerns about SARS-CoV-2. In contrast to the overall good maternal bonding without correlation to SARS-CoV-2 concern, the maternal self-efficiency correlated negatively with the obstetric impairment caused by the COVID-19 pandemic. ConclusionObstetrical patients` concerns regarding SARS-CoV-2 and the accompanying pandemic increased during the course of the pandemic correlating positively with stress and depression. Of note is the increase in active coping over time and the overall good mother-child-bonding. Maternal self-efficacy was affected in part by the restrictions of the pandemic.Clinical trial registration: DRKS00022506

Improving the Timely Delivery of Antihypertensive Medication for Severe Perinatal Hypertension in Pregnancy and Postpartum

2021 ◽  
Author(s):  
Patrick Schneider ◽  
Patricia Ann Lee King ◽  
Lauren Keenan-Devlin ◽  
Ann E.B. Borders
Keyword(s):  
Quality Improvement ◽  
Postpartum Period ◽  
Care Team ◽  
Quality Improvement Initiative ◽  
Elevated Blood ◽  
Statistical Process ◽  
Pregnancy And Postpartum ◽  
Blood Pressures ◽  
The Impact ◽  
Timely Delivery

Objective Sustained blood pressures ≥160/110 during pregnancy and the postpartum period require timely antihypertensive therapy. Hospital-level experiences outlining the efforts to improve timely delivery of care within 60 minutes have not been described. The objective of this analysis was to assess changes in care practices of an inpatient obstetrical health care team following the implementation of a quality improvement initiative for severe perinatal hypertension during pregnancy and the postpartum period. Study Design In January 2016, NorthShore University HealthSystem Evanston Hospital launched a quality improvement initiative focusing on perinatal hypertension, as part of a larger, statewide quality initiative via the Illinois Perinatal Quality Collaborative. We performed a retrospective cohort study of all pregnant and postpartum patients with sustained severely elevated blood pressure (two severely elevated blood pressures ≤15 minutes apart) with baseline data from 2015 and data collected during the project from 2016 through 2017. Changes in clinical practice and outcomes were compared before and after the start of the project. Statistical process control charts were used to demonstrate process-behavior changes over time. Results Comparing the baseline to the last quarter of 2017, there was a significant increase in the administration of medication within 60 minutes for severe perinatal hypertension (p <0.001). Implementation of a protocol for event-specific debriefing for each severe perinatal hypertension episode was associated with increased odds of the care team administering medication within 60 minutes of the diagnosis of severe perinatal hypertension (adjusted odds ratio 3.20, 95% confidence interval 1.73–5.91, p < 0.01). Conclusion Implementation of a quality improvement initiative for perinatal hypertension associated with pregnancy and postpartum improved the delivery of appropriate and timely therapy for severely elevated blood pressures and demonstrated the impact of interdisciplinary communication in the process. Key Points

scholarly journals Healthy Habits and Emotional Balance in Women during the Postpartum Period: Differences between Term and Preterm Delivery

Children ◽  
2021 ◽  
Vol 8 (10) ◽  
pp. 937
Author(s):  
Andrea Gila-Díaz ◽  
Gloria Herranz Carrillo ◽  
Silvia M. Arribas ◽  
David Ramiro-Cortijo
Keyword(s):  
Postpartum Depression ◽  
Preterm Delivery ◽  
Postpartum Period ◽  
Depression Scale ◽  
Healthy Food ◽  
P Value ◽  
Healthy Habits ◽  
Food Pyramid ◽  
Term Delivery ◽  
The Impact

Breastfeeding could be considered as a vulnerable period, rising the risk to shift from optimism to pessimism. Preterm delivery is an event that increases postpartum maternal stress and depression, which can have a negative impact on breastfeeding and maternal–filial wellbeing. The adherence to healthy habits may have a positive influence on this vulnerable population. We aimed to analyze the impact of prematurity on maternal psychological aspects during postpartum and to study if adherence to the Healthy Food Pyramid influences psychological variables. Fifty-five breastfeeding women being attended in the Hospital Clínico San Carlos (Madrid, Spain) were recruited during the first day postpartum. The medical data were collected from the obstetrical records. The women answered an auto-administered questionnaire with several sections: sociodemographic characteristics, Perceived Stress Scale (PSS), and Life Orientation Test (LOT), at 14 days and 6 months postpartum, Adherence to the Healthy Food Pyramid Questionnaire (AP-Q) at 28 days postpartum and the Edinburgh Postpartum Depression Scale (EPDS) at 6 months postpartum. The PSS and LOT scores were not statistically different in mothers with preterm compared to term delivery either at 14 days or at 6 months postpartum. Longitudinally, the PSS did not show significant differences, but the LOT score was lower at 6 months compared to 14 days postpartum (p-Value = 0.046). A higher EPDS score was significantly found in mothers with preterm delivery (9.0 ± 4.7) than those with a term delivery (5.4 ± 4.2; p-value = 0.040). A significant and positive correlation was observed between the AP-Q score and LOT both at 14 days and 6 months postpartum. Conclusively, maternal optimism decreases during the postpartum period, women with preterm delivery being at risk of postpartum depression. Furthermore, there is a relationship between optimism and adherence to healthy habits. Healthcare professional counseling is essential during the entire breastfeeding period, particularly in vulnerable mothers with preterm delivery.

Home Telemedicine (CoYoT1 Clinic): A Novel Approach to Improve Psychosocial Outcomes in Young Adults With Diabetes

2019 ◽  
Vol 45 (4) ◽  
pp. 420-430 ◽  
Author(s):  
Marwan Bakhach ◽  
Mark W. Reid ◽  
Elizabeth A. Pyatak ◽  
Cari Berget ◽  
Cindy Cain ◽  
...  
Keyword(s):  
Type 1 Diabetes ◽  
Young Adults ◽  
Self Efficacy ◽  
Group Home ◽  
Depression Scale ◽  
Diabetes Distress ◽  
Control Group ◽  
Distress Scale ◽  
The Impact

Purpose To assess the impact of a home telemedicine clinic model (CoYoT1 Clinic) on psychosocial and behavioral outcomes designed for young adults (YAs) with type 1 diabetes (T1D). Methods YAs self-selected to participate in the CoYoT1 Clinic or serve as a usual care control. CoYoT1 Clinic visits consisted of an individual appointment with a provider and a group appointment with other YAs with T1D using home telemedicine. Psychosocial and behavioral functioning was assessed by 4 measures: Diabetes Distress Scale, Self-Efficacy for Diabetes Scale, Self-Management of Type 1 Diabetes in Adolescence Scale, and Center for Epidemiologic Studies Depression Scale. Results Forty-two patients participated in the CoYoT1 Clinic and 39 patients served as controls. CoYoT1 participants reported lower levels of distress ( P = .03), increased diabetes self-efficacy ( P = .01), and improved ability to communicate with others about diabetes ( P = .04) over the study period compared to controls. YA males in the control group reported increases in depressive symptoms ( P = .03) during the study period, but CoYoT1 participants showed no changes. Conclusion Group home telemedicine for YAs with T1D positively affects diabetes distress, self-efficacy, and diabetes-specific communication. These positive findings have the potential to also affect the YAs’ long-term diabetes outcomes. Further investigation of the model is needed.

scholarly journals Breastfeeding self-efficacy of mothers and relationship with depression risk Annelerin emzirme öz-yeterliliği ve depresyon riski ile ilişkisi

2016 ◽  
Vol 13 (2) ◽  
pp. 3160 ◽  
Author(s):  
Yeşim Aslan ◽  
Emel Ege
Keyword(s):  
Postpartum Depression ◽  
Postpartum Period ◽  
Self Efficacy ◽  
Depression Scale ◽  
Physical And Mental Health ◽  
Symptoms Of Depression ◽  
Consulting Services ◽  
Depression Risk ◽  
Self Sufficiency ◽  
Living Children

A mother primarily should have her own physical and mental health in order to take care a baby in a healthy manner and to breastfeed for long-term. It has been stated that the stress experienced during pregnancy and failing to start providing proper breastfeeding in the postpartum period can affect both providing effective breastfeeding and development of postpartum depression. This study was designed to determine the breastfeeding self-efficacy of mothers and relationship with depression risk. This is a descriptive study was carried out on 265 postpartum women. In collecting the data in the research, a questionnaire prepared using the literature and similar researches made, Postpartum Depression Scale and Breastfeeding-Self Efficacy Scale were used. Mann Whitney U test, Kruskal-Wallis and spearman correlation analysis were used to assess the data. It was determined that the mothers participating in the study received average 58.92 ± 7.61 points from Breastfeeding Self-Efficacy Scale, and  9.58 ± 5.10 points from EPDS.  It was established that the breastfeeding self-efficacy level of the mothers in the postpartum 4-6 week was above average, and one third of the mothers (31.7%) was found to be at risk in terms of depression. It was determined in the study that the variables such as the age of mothers, duration of marriage, pregnancy, childbirth and the number of living children, problems experienced at birth, being satisfied with the baby gender, initial breastfeeding time, regular breastfeeding status and feeling self-sufficient for breastfeeding affected the breastfeeding self-efficacy (p <0.05) and there was no association between the breastfeeding self-sufficiency level and the symptoms of depression (p> 0.05). In line with these results, identifying physical, psychological and social health risks in the early stages from the gestation period, initiating and maintaining breastfeeding can help control the postnatal symptoms of depression. Therefore, empowering the consulting services of health professionals during pregnancy and the postpartum period can be suggested. ÖzetAnnenin bebeğine sağlıklı bir şekilde bakabilmesi ve uzun dönem emzirebilmesi için öncelikle kendi beden ve ruh sağlığının yerinde olması gerekir. Gebelik döneminde yaşanan stres ve doğum sonu dönemde de emzirmenin uygun şekilde başlatılamamasının hem etkili emzirmenin sağlanması hem de doğum sonu depresyon gelişimini etkileyebileceği belirtilmektedir. Bu çalışma annelerin emzirme öz-yeterliliği ve depresyon riski ile ilişkisini incelemek amacı ile yapılmıştır. Tanımlayıcı olarak planlanan çalışmaya doğum sonu 265 kadın dahil edilmiştir. Çalışmada verilerin toplanmasında; literatür bilgilerden ve yapılan benzer nitelikteki araştırmalardan yararlanılarak hazırlanan bir anket formu, Doğum Sonu Depresyon Ölçeği ve Emzirme-Öz Yeterlilik Ölçeği kullanılmıştır. Verilerin değerlendirilmesinde Mann Withney U Testi, Kruskal Wallis ve spearmankorelasyon analizi kullanılmıştır. Çalışmaya katılan annelerin Emzirme Öz-yeterlilik ölçeğinden ortalama 58,92±7,61, EDDÖ’den ise 9,58±5,10 puan aldığı saptanmıştır. Doğum sonu 4-6 haftalık dönemde annelerin emzirme öz-yeterlilik düzeyinin ortalamanın üzerinde olduğu ve annelerin üçte birinin (%31.7) depresyon açısından risk altında olduğu bulunmuştur. Çalışmada annelerin yaş, evlilik süresi, gebelik, doğum ve yaşayan çocuk sayısı, doğumda sorun yaşama durumu, bebek cinsiyetinden memnun olma, ilk emzirme zamanı, düzenli emzirme durumu ve emzirme konusunda kendini yeterli hissetme durumu gibi değişkenlerin emzirme öz yeterliliğini etkilediği (p<0,05)  ve emzirme öz yeterlilik düzeyi ile depresyon semptomları arasında bir ilişki olmadığı belirlenmiştir(p>0,05). Bu sonuçlar doğrultusunda, gebelik döneminden itibaren fiziksel, psikolojik ve sosyal sağlık risklerinin erken dönemde belirlenmesi, emzirmenin başlatılması ve sürdürülmesi ile doğum sonu depresyon semptomlarının kontrolüne yardımcı olabilir. Bu nedenle sağlık profesyonellerinin gebelik ve doğum sonu dönemde danışmanlık hizmetlerinin güçlendirilmesi önerilebilir.

scholarly journals Improving the quality of life in the postpartum period: reduce the incidence of hemorrhoids and its complications

2020 ◽  
pp. 22-25
Author(s):  
Yu.V. Davydova ◽  
◽  
A.O. Ogorodnyk ◽  
A.Iu. Lymanska ◽  
◽  
...  
Keyword(s):  
Quality Of Life ◽  
Postpartum Period ◽  
Clinical Manifestations ◽  
Relevant Information ◽  
Treatment Quality ◽  
Key Words Hemorrhoids ◽  
Pregnancy And Postpartum ◽  
The Impact ◽  
Analyze Data

There are insufficient data in the literature on the actual frequency and prevalence of hemorrhoids among the general population. The incidence of hemorrhoids during pregnancy and in the postpartum period, according to various authors, varies considerably: from a third of women to 86%. The frequency of thrombosis of external hemorrhoids and cracks of the anus in the postpartum period is 25–33%. The aim is to analyze data on the frequency of hemorrhoids during pregnancy and within postpartum period, as well as data on the impact of perianal disorders on the quality of life of women; substantiate recommendations for improving the quality of life of such women. Materials and methods. The analysis of databases from medical research PubMed, MedScape, NCBI by keywords: hemorrhoids, pregnancy, postpartum period, causes, diagnosis, treatment, quality of life. 2000 publications were found, of which, according to relevant information, 4 were selected for analysis. The selection criteria were: cohort of subjects (at least 200 people), prospectiveness of observation (pregnancy and postpartum period), availability of data on medical examination. The information-analytical method and content-analysis are used. Results and conclusions. Hemorrhoids are a frequent complication during pregnancy and in the postpartum period. Perianal disease reduces the quality of life of women during pregnancy and in the postpartum period and requires improved care recommendations. Reparon Herbal, which contains herbal substances and sucralfate, according to the instructions, can be used during pregnancy and in the postpartum period to reduce the clinical manifestations of hemorrhoids, which will improve the quality of life of such women. The authors declare no conflict of interest. Key words: hemorrhoids, pregnancy, postpartum period, causes, diagnosis, treatment, quality of life.

scholarly journals The impact of migration on women’s mental health in the postpartum period

2016 ◽  
Vol 50 (0) ◽  
Author(s):  
Lígia Moreira Almeida ◽  
Cristina Costa-Santos ◽  
José Peixoto Caldas ◽  
Sónia Dias ◽  
Diogo Ayres-de-Campos
Keyword(s):  
Mental Health ◽  
Social Support ◽  
Postpartum Depression ◽  
Perceived Stress ◽  
Psychological Health ◽  
Postpartum Period ◽  
Depression Scale ◽  
Public Hospitals ◽  
Increased Risk ◽  
The Impact

ABSTRACT OBJECTIVE To assess the influence of I mmigration on the psychological health of women after childbirth. METHODS In this cross-sectional study, immigrant and Portuguese-native women delivering in the four public hospitals of the metropolitan area of Porto, Portugal, were contacted by telephone between February and December 2012 during the first postpartum month to schedule a home visit and fill in a questionnaire. Most immigrant (76.1%) and Portuguese mothers (80.0%) agreed to participate and with the visits, thus a total of 89 immigrants and 188 Portuguese women were included in the study. The questionnaire included the application of four validated scales: Mental Health Inventory-5, Edinburgh Postpartum Depression Scale, Perceived Stress Scale, and Scale of Satisfaction with Social Support. Statistical analysis included t-test and Chi-square or Fisher’s test, and logistic regression models. RESULTS Immigrants had an increased risk of postpartum depression (OR = 6.444, 95%CI 1.858–22.344), and of low satisfaction with social support (OR = 6.118, 95%CI 1.991–18.798). We did not perceive any associations between migrant state, perceived stress, and impoverished mental health. CONCLUSIONS Immigrant mothers have increased vulnerabilities in the postpartum period, resulting in an increased risk of postpartum depression and lesser satisfaction with the received social support.

scholarly journals Behavioral Deficits in Juveniles Mediated by Maternal Stress Hormones in Mice

2016 ◽  
Vol 2016 ◽  
pp. 1-13 ◽  
Author(s):  
Jamie Maguire ◽  
Istvan Mody
Keyword(s):  
Mouse Model ◽  
Maternal Depression ◽  
Postpartum Period ◽  
Stress Hormones ◽  
Late Pregnancy ◽  
Wild Type ◽  
Offspring Development ◽  
Pup Survival ◽  
Underlying Mechanisms ◽  
The Impact

Maternal depression has been shown to negatively impact offspring development. Investigation into the impact of maternal depression and offspring behavior has relied on correlative studies in humans. Further investigation into the underlying mechanisms has been hindered by the lack of useful animal models. We previously characterized a mouse model which exhibits depression-like behaviors restricted to the postpartum period and abnormal/fragmented maternal care (Gabrd−/−mice). Here we utilized this unique mouse model to investigate the mechanism(s) through which maternal depression-like behaviors adversely impact offspring development. Cross-fostering experiments reveal increased anxiety-like and depression-like behaviors in mice reared byGabrd−/−mothers. Wild type andGabrd−/−mice subjected to unpredictable stress during late pregnancy exhibit decreased pup survival and depression-like behavior in the postpartum period. Exogenous corticosterone treatment in wild type mice during late pregnancy is sufficient to decrease pup survival and induce anxiety-like and depression-like behaviors in the offspring. Further, the abnormal behaviors in juvenile mice reared byGabrd−/−mice are alleviated by treatment of the mothers with the corticotropin-releasing hormone (CRH) antagonist, Antalarmin. These studies suggest that hyperresponsiveness of the HPA axis is associated with postpartum depression and may mediate the adverse effects of maternal depression on offspring behavior.

Epidemiology of Substance use in Pregnancy

2009 ◽  
Vol 24 (S1) ◽  
pp. 1-1
Author(s):  
M.T. Kumar
Keyword(s):  
Substance Use ◽  
Pregnant Women ◽  
Young Women ◽  
Postpartum Period ◽  
Substance Misuse ◽  
Measurement Techniques ◽  
Alcohol Exposure ◽  
High Rate ◽  
Pregnancy And Postpartum ◽  
The Impact

An understanding of the epidemiology of alcohol and drug use in young women is important to appreciate the considerable morbidity and mortality associated with it and to understand the impact of such use on offspring. Although abstention rates are consistently higher among women than men in general substance misuse is increasing in young women. Differences in definitions, measurement techniques, availability, social acceptability and affordability partly explain the great variability in reported prevalence rates. Alcohol exposure among pregnant women varies from 0.2% to 14.8%. An Australian national survey revealed that nearly half of pregnant and or breast-feeding women up to 6 months postpartum were using alcohol. A Swedish study reported risky use of alcohol during the first 6 weeks of pregnancy, at 15%. Cannabis use among pregnant women varies from 1.8% to 15%. The reported prevalence of opiate use during pregnancy ranges from 1.65 to 8.5%. Cocaine use among pregnant women is reported to be between 0.3% and 9.5. Most pregnant women stop or reduce their substance use during pregnancy and this might be an opportune moment for detection and treatment. Substance use tends to increase sharply in the postpartum period with adverse consequences on mother and baby. Perinatal substance misuse interventions can reduce adverse neonatal outcomes. On the basis of relatively high rate of substance use disorders during pregnancy and postpartum period, effective screening and intervention strategies should be implemented.

Evaluation of an adjustment group forpeople with multiple sclerosis and lowmood: a randomized controlled trial

2011 ◽  
Vol 17 (10) ◽  
pp. 1250-1257 ◽  
Author(s):  
Nadina B Lincoln ◽  
Faye Yuill ◽  
Jessica Holmes ◽  
Avril ER Drummond ◽  
Cris S Constantinescu ◽  
...  
Keyword(s):  
Multiple Sclerosis ◽  
Group Treatment ◽  
Self Efficacy ◽  
Controlled Trial ◽  
General Health Questionnaire ◽  
Depression Scale ◽  
Area Under The Curve ◽  
Low Mood ◽  
The Impact ◽  
Group Allocation

Background: Mood problems affect many people with multiple sclerosis (MS). The aim was to evaluate the effectiveness of a group treatment based on cognitive behavioural principles. Methods: People with MS were screened on the General Health Questionnaire 12 (GHQ-12) and Hospital Anxiety and Depression Scale (HAD). Those identified with low mood were invited to take part in a randomized trial comparing the effect of attending an adjustment group with a waiting list control. Patients allocated to the adjustment group received six 2 h group treatment sessions. Outcomes were assessed 4 and 8 months after randomization, blind to group allocation. Results: Of the 311 patients identified, 221 (71%) met the criteria for low mood and 151 (68%) agreed to take part. Hierarchical regression analyses were conducted to compare the two groups, correcting for baseline mood and disability. At 4 months, group allocation alone was a significant predictor of the primary outcome measure, the GHQ-12. At 8 months, group allocation alone was no longer a significant predictor for GHQ-12 scores, but it was when baseline GHQ-12 and Guy’s Neurological Disability Scale scores were controlled for. Comparison of the area under the curve revealed significant differences between the groups for GHQ-12 ( p = 0.003), HAD Anxiety ( p = 0.013), HAD Depression ( p = 0.004), Beck Depression Inventory ( p = 0.001), MS Self-efficacy ( p = 0.037) and MS Impact Scale Psychological ( p = 0.012). Conclusion: Patients receiving treatment were less distressed and had less depression and anxiety. There was some evidence of improved self-efficacy and a reduction of the impact of MS on people’s lives.

Epidemiology of Substance Use in Pregnancy

2009 ◽  
Vol 24 (S1) ◽  
pp. 1-1
Author(s):  
M.T. Kumar
Keyword(s):  
Substance Use ◽  
Pregnant Women ◽  
Young Women ◽  
Postpartum Period ◽  
Substance Misuse ◽  
Measurement Techniques ◽  
Alcohol Exposure ◽  
High Rate ◽  
Pregnancy And Postpartum ◽  
The Impact

An understanding of the epidemiology of alcohol and drug use in young women is important to appreciate the considerable morbidity and mortality associated with it and to understand the impact of such use on offspring. Although abstention rates are consistently higher among women than men in general substance misuse is increasing in young women. Differences in definitions, measurement techniques, availability, social acceptability and affordability partly explain the great variability in reported prevalence rates. Alcohol exposure among pregnant women varies from 0.2% to 14.8%. An Australian national survey revealed that nearly half of pregnant and or breast-feeding women up to 6 months postpartum were using alcohol. A Swedish study reported risky use of alcohol during the first 6 weeks of pregnancy, at 15%. Cannabis use among pregnant women varies from 1.8% to 15%. The reported prevalence of opiate use during pregnancy ranges from 1.65 to 8.5%. Cocaine use among pregnant women is reported to be between 0.3% and 9.5. Most pregnant women stop or reduce their substance use during pregnancy and this might be an opportune moment for detection and treatment. Substance use tends to increase sharply in the postpartum period with adverse consequences on mother and baby. Perinatal substance misuse interventions can reduce adverse neonatal outcomes. On the basis of relatively high rate of substance use disorders during pregnancy and postpartum period, effective screening and intervention strategies should be implemented.

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