Post-COVID depression among a sample of Egyptian patients and its associated factors

Abstract Background Depression is classified as a mood disorder. It may be described as feelings of sadness, loss, or anger that interfere with a person’s everyday activities. Nowadays, we are in COVID-19 pandemic. From practice after COVID-19 illness resolves, some of the recovering patients return back smoothly to their pre-illness life. Others experience different mood changes. Anxiety and depression are the most common. Those patients with improving general health, radiology, and oxygenation have different somatic complaints such as sensation of dyspnoea. Psychological support and psychiatric evaluation can help them to overcome this situation and get rid of dyspnoea sensation. This work aimed to evaluate the relation between COVID-19 survivors and depression and to how extent this could affect functional status of the study participants. Results This work recruited 102 adult patients as a sample of Egyptians who were positive PCR for SARS-COV2, turned negative and free of symptoms for 1 month or more which include physicians, nurses, employees, and literate health care workers of Ain Shams University hospitals attending chest outpatient clinic for follow-up. The majority were 47.1% in age group (35–55 years), sixty two (60.8%) participants were females, 74.5% had high education, and 24.5% were smokers. The most frequent symptom reported by study participants as the most annoying COVID-19 symptom was fever (32.4%). Beck depression inventory score showed that 59 (57.8%) participants had no depression, 24 (23.5%) had mild depression, 16 (15.7%) had moderate depression, and only 3 (2.9%) participants had severe depression. Logistic regression analysis was done to measure effect of steroid use and grade of dyspnoea on development of moderate or severe post-COVID depression and showed that higher grades of dyspnoea were associated with higher probability of development of moderate or severe post-COVID depression (p value < 0.05). Conclusion As predicted, COVID-19 survivors presented a high prevalence of psychiatric sequelae. Age, sex, and education level were important association factors. Higher educational level was associated with higher score of depression due to increased awareness of the current pandemic issue. Steroids’ use was proposed as a cause of depression since the majority of moderate or severe depression group were on steroids. Higher grades of dyspnoea were associated with higher probability of development of moderate or severe post-COVID depression. It is suggested that COVID-19 survivors should be assessed, to properly diagnose and treat any psychiatric conditions, to reduce the disease burden.

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Stress, anxiety and depression among healthcare workers facing COVID-19 pandemic in Egypt: a cross-sectional online-based study

BMJ Open ◽

10.1136/bmjopen-2020-045281 ◽

2021 ◽

Vol 11 (4) ◽

pp. e045281

Author(s):

Hebatalla Mohamed Aly ◽

Nader Attia Nemr ◽

Rania Mohammed Kishk ◽

Noha Mohamed Abu bakr Elsaid

Keyword(s):

Social Media ◽

Perceived Stress ◽

Healthcare Workers ◽

Severe Depression ◽

Anxiety And Depression ◽

Sociodemographic Characteristics ◽

Cross Sectional ◽

Online Study ◽

High Prevalence ◽

Study Participants

ObjectiveThis study assessed perceived stress, anxiety and depression among healthcare workers facing the COVID-19 pandemic in Egypt.SettingThis was an online study where a Google form was prepared including sociodemographic and occupational data as well as three validated questionnaires to assess perceived stress, anxiety and depression, respectively. The form was distributed online to all social media groups including healthcare workers all across the country, and responses were collected until the sample size of 262.ParticipantsHealthcare workers (physicians, dentists, pharmacists, physiotherapists, nurses, technicians and administrators) working in governmental or educational hospitals from all Egyptian governorates who are members of social media groups. The mean age of participants was 33.4±5.9 years, 70% were women, about 70% were married and 66% were physicians.OutcomesThe frequency of perceived stress, anxiety and depression observed among the study participants according to the results of their questionnaires. Then the frequencies were compared between different sociodemographic characteristics.ResultsOnly 1.3% showed low perceived stress while 98.5% showed moderate to severe stress. About 9.5% did not experience generalised anxiety, while the remaining 90.5% had different degrees of anxiety as mild anxiety showed the highest per cent affecting about 40% of participants followed by moderate anxiety about 32% then severe anxiety, 18.5%. With regard to depression, 94% of participants showed mild to severe depression.ConclusionThis study showed a high prevalence of perceived stress, anxiety and depression among healthcare workers during the COVID-19 pandemic that affected all workers regardless of different sociodemographic characteristics.

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Depression, anxiety and stress among patients with inflammatory bowel disease during the COVID-19 pandemic: Australian national survey

BMJ Open Gastroenterology ◽

10.1136/bmjgast-2020-000581 ◽

2021 ◽

Vol 8 (1) ◽

pp. e000581

Author(s):

Madiha Cheema ◽

Nikola Mitrev ◽

Leanne Hall ◽

Maria Tiongson ◽

Golo Ahlenstiel ◽

...

Keyword(s):

Inflammatory Bowel Disease ◽

Bowel Disease ◽

Severe Depression ◽

Chronic Illnesses ◽

Electronic Survey ◽

Validated Questionnaire ◽

Younger Age ◽

Modifiable Factors ◽

High Prevalence ◽

Inflammatory Bowel

BackgroundThe global COVID-19 pandemic has impacted on the mental health of individuals, particularly those with chronic illnesses. We aimed to quantify stress, anxiety and depression among individuals with Inflammatory bowel disease (IBD) in Australia during the pandemic.MethodsAn electronic survey was made available to IBD patients Australia-wide from 17 June to 12 July 2020. Respondents with an underlying diagnosis of IBD and over 18 years of age were included. A validated questionnaire (Depression, Anxiety, Stress Score-21, DASS21) was used to assess depression, anxiety and stress. Data on potential predictors of depression, anxiety and stress were collected.Results352 participated in the survey across Australia. 60.5% of respondents fulfilled DASS criteria for at least moderate depression, anxiety or stress. 45% reported a pre-existing diagnosis of depression and/or anxiety. Over 2/3 of these respondents reported worsening of their pre-existing depression/anxiety due to the current pandemic. Of those without a pre-existing diagnosis of anxiety or depression, high rates of at least moderate to severe depression (34.9%), anxiety (32.0%) and stress (29.7%) were noted. Younger age (OR 0.96, 95% CI 0.94 to 0.98, p<0.001), lack of access to an IBD nurse (OR 1.81, 95% CI 1.03 to 3.19, p=0.04) and lack of education on reducing infection risk (OR 1.99, 95% CI 1.13 to 3.50, p=0.017) were associated with significant stress, anxiety and/or depression.ConclusionHigh prevalence of undiagnosed depression, anxiety and stress was identified among respondents. Improved access to IBD nurse support and greater attention to education are modifiable factors that may reduce depression, anxiety and/or stress among patients with IBD during the pandemic.

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The psychiatric sequelae of the COVID‐19 pandemic in adolescents, adults, and health care workers

Depression and Anxiety ◽

10.1002/da.23120 ◽

2020 ◽

Author(s):

Stephen Murata ◽

Taylor Rezeppa ◽

Brian Thoma ◽

Laura Marengo ◽

Katie Krancevich ◽

...

Keyword(s):

Health Care ◽

Health Care Workers ◽

Care Workers ◽

Psychiatric Sequelae

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Comparison of prevalence and risk factors of somatization between Chinese health care workers and non-health care workers during COVID-19 outbreak

BMC Psychiatry ◽

10.1186/s12888-021-03294-z ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Xiuli Song ◽

Yongjie Zhou ◽

Wenwang Rao ◽

Xiangyang Zhang

Keyword(s):

Risk Factors ◽

Health Care ◽

Health Care Workers ◽

Online Survey ◽

Medical Service ◽

Multiple Logistic Regression Analysis ◽

Related Factors ◽

Dimension Score ◽

Care Workers ◽

High Prevalence

Abstract Background This study aimed to compare prevalence and risk factors of somatization (SOM) between health care workers and non-health care workers during COVID-19 outbreak in China. Methods From 14 February to 29 March 2020, an online survey was performed in both 605 health care workers and 1151 non-health care workers. Based on the somatization dimension score of the Symptom Checklist-90, participants were divided into non-SOM group and SOM group. Results Health care workers had higher prevalence rate of SOM (p < 0.001) than non-health care workers, with an OR of 1.70 (95% CI, 1.22–2.36, p = 0.002). Multiple logistic regression analysis revealed that in non-health care workers, the risk factors of SOM included other ethnicities, insomnia, and suicide, while in health care workers, the risk factors included working 6–8 h per day, and working ≥10 h per day during COVID-19 outbreak. Conclusions Our research suggests that both non-health care workers and health care workers have a relatively high prevalence of somatization. However, the related factors for somatization in both groups are significantly different, showing that medical service-related factors are associated with somatization in health care workers, while demographic and clinical factors are associated with somatization in non-health care workers.

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AB1034 DEPRESSION AND ANXIETY IN FAMILIAL MEDITERRANEAN FEVER

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2020-eular.5852 ◽

2020 ◽

Vol 79 (Suppl 1) ◽

pp. 1808.2-1809

Author(s):

D. Karatas ◽

Z. Öztürk ◽

D. Cekic ◽

Z. Yuertsever ◽

Ü. Erkorkmaz ◽

...

Keyword(s):

Familial Mediterranean Fever ◽

Severe Depression ◽

Anxiety And Depression ◽

Control Group ◽

Healthy Controls ◽

Depression And Anxiety ◽

Mild Depression ◽

Moderate Depression ◽

Mediterranean Fever

Background:Familial Mediterranean Fever (FMF) is a hereditary autoinflammatory disease characterized by recurrent attacks of fever, peritonitis, pleuritis, arthritis, and skin eruption (1). It is shown by studies that chronic diseases like diabetes mellitus, chronic heart disease, hypertension which other than inflammatory – rheumatologic disease increase depression and anxiety (2). There are a few studies evaluating depression and anxiety in FMF patients, and these results are conflicting (3,4).Objectives:To assess the frequency of depression and anxiety in patients with Familial Mediterranean Fever (FMF)Methods:In this study, 77 FMF patients aged 18 and over who were followed up in Sakarya University Education and Research Hospital, Department of Rheumatology, and 78 healthy volunteers aged 18 and over as thecontrol group. Beck depression scale and Beck anxiety scale were used to depression and anxiety, respectively. Beck’sdepression scale was evaluated as 9 and below normal, 10-16 mild depression, 17-29 moderate depression, 30-63 severe depression. Beck anxiety scale was evaluated as 0-8 normal, 8-15 mild anxiety, 16-25 moderate anxiety, 26 and above severe anxiety.FMF disease severity was determined by Pras scoring.Results:The study group, comprised 77 diagnosed with FMF with a meanage of 37.18 and a control group comprised of 78 healthy controls (C) with a meanage of 35.32 (p=0,058). İn studygroup (P) %63.6, control group (C) %53.8 as female. %36.4 of thestudy group(C), %46.2 of the control group are male. (p=0,216). The prevalence of depression was significantly higher in FMF patients compared to the control group (in order P;C: normal %24,7; %47,4, mild depression: %40.3; %26.9, moderate depression %26; %19.2, severe depression %11.7; %6.4 p<0.015). Similarly in depression results; the prevalence of anxiety was significantly higher in FMF patients compared to the control group (in order P;C normal %23,4; %57.7, mild anxiety %26; %20.5, moderate anxiety %26; %15.4, severe anxiety %24.4; %6.4 p<0,001). Depression status was not correlated with FMF disease severity (p=0.645). A correlation was found between FMF severity and anxiety which it is which was found statistically significant (p=0.005).There was no relationship between erythrocyte sedimentation rate and C-reactive protein with depression and anxiety.Conclusion:Both anxiety and depression frequency are increased in FMF patients compared to healthy controls.References:[1]Livneh A, Langevitz P, Zemer D et al. (1997) Criteria for the diagnosis of familial Mediterranean fever. Arthritis Rheum 40 (10), 1879–85.[2]Alonso J, Ferrer M, Gandek B, Ware JE Jr, Aaronson NK, Mosconi P, Rasmussen NK, Bullinger M, Fukuhara S, Kaasa S, Leplège A, IQOLA Project Group (2004) Health-related quality of life associated with chronic conditions in eight countries: results from the International Quality of Life Assessment (IQOLA) Project. Qual Life Res 13:283–298[3]Makay B, Emiroglu N, Unsal E (2010) Depression andanxiety in children and adolescents with familial Mediterranean fever. Clin Rheumatol 29, 375–9.[4]Giese A, Ornek A, Kilic L, Kurucay M, Sendur S. N., Lainka E, Henning B. F. Anxiety and depression in adult patients with familialMediterranean fever: a study comparing patients living in Germany and Turkey. International Journal of Rheumatic Diseases 2017; 20: 2093–2100Disclosure of Interests:None declared

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AB0167 PECULIARITIES OF INTERACTION OF CHRONIC INFLAMMATION AND DEPRESSION IN RHEUMATOID ARTHRITIS

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2021-eular.3087 ◽

2021 ◽

Vol 80 (Suppl 1) ◽

pp. 1110.1-1110

Author(s):

A. Aleksandrov ◽

N. Aleksandrova

Keyword(s):

Rheumatoid Arthritis ◽

Vitamin D ◽

Inflammatory Cytokines ◽

Depressive Disorders ◽

Severe Depression ◽

Mild Depression ◽

Group Iii ◽

Group I ◽

Severity Of Depression ◽

Pro Inflammatory Cytokines

Background:In patients with rheumatoid arthritis (RA), a high prevalence of depression and anxiety is observed, and the severity of these conditions depends on the degree of vitamin D deficiency. The role of the main mediator, with the help of which psychological and physical stress factors can contribute to the development of depression and systemic diseases, has been attributed to inflammation in recent years.Objectives:to assess the dependence of depressive disorders on vitamin D deficiency and the level of pro-inflammatory cytokines in patients with RA.Methods:88 women with a reliable diagnosis of RA (mean age 54.2 ± 12.0 years old, disease duration 9.0 [3.5; 16.0] years) were under observation. Beck’s depression inventory (BDI-II) was used to assess the presence of depressive symptoms. ELISA test was used to measure serum cytokines (IL-1, IL-6) and serum 25(OH)D levels.Results:The presence of depression was found in 66% of patients with RA. An insufficient level of 25(OH)D (<30 ng / ml) was determined in 89.8% of cases. In RA patients with no signs of depression, the level of 25(OH)D showed maximum values and significantly differed from that in the groups of patients with moderate (p = 0.028) and severe depression (p <0.001). A negative correlation (r = -0.38, n = 88, p <0.05) was established between the level of 25(OH)D and the severity of depression. A positive relationship was also found between 25(OH)D and ESR (r = 0.29, n = 73, p <0.05) and a negative relationship with the number of painful joints (r = -0.29, n = 76, p <0.05). Probably, vitamin D is indirectly involved in inflammatory processes in joints and in central sensitization, which provokes chronic pain and psychological disorders in patients with RA.The level of IL-6 in patients with RA with moderate and severe depression (n=18; 14.6 ± 6.7 pg/ml) significantly exceeded the parameters of patients with RA without depressive disorders (n=30; 9.8 ± 3.7; p = 0.003). There was also a tendency to increase IL-6 in the group of patients with moderate and severe depression compared with patients with mild depression (p = 0.06). IL-1β values significantly increased with the progression of depression (without depression – mild depression, p = 0.034; mild – moderate, p <0.001; moderate – severe depression, p = 0.044). A positive correlation of average severity was revealed between the degree of depression (according to BDI-II) and the dose of glucocorticoids (GC) at the time of the study (r = 0.33, p = 0.002). An increase in the GC dose in the short term can aggravate depressive disorders in RA patients (Table 1).Table 1.Indicators of levels of depression and IL-1β depending on the dose of GCGroup I (n=26), without GCGroup II (n=45),GC <10 mg / dayGroup III (n=17),GC ≥10 mg / dayDepression level according to BDI-II, points (Me [P25; P75])8,5[5;16]14[9;17]19[14;29] *III-IIL-1β level, pg / ml (M ± SD)4,57 ± 1,83*I-II6,04 ± 3,276,52 ± 5,16* - intergroup differences are reliable, p <0.05Patients who used GC in a daily dose of ≥10 mg / day (group III) had a higher degree of depression compared to patients with RA from group I (z = -2.98; p = 0.003). In patients with RA in the first group, the level of IL-1β was significantly higher (pI-II = 0.039) than in patients with GC prescription in minimal doses (up to 10 mg / day) (Table 1). Glucocorticoid hormones suppress pro-inflammatory cytokines. As a rule, this effect is not observed in patients with depression. This fact may indicate a violation of homeostatic mechanisms. IL-1β is thought to be the first step in the pro-inflammatory response to psychological stress and is capable of inducing a subsequent cascade of other inflammatory cytokine responses.Conclusion:Restoring the normal level of 25(OH)D in the blood serum of patients with RA can positively affect psychological indicators by reducing the severity of depression and manifestations of pain. The activation of pro-inflammatory cytokines during stress and depression suggests that suppression of the inflammatory response can also reduce the symptoms of depression in RA patients.Disclosure of Interests:None declared

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Is Chronic Inflammation a Possible Cause of Obesity-Related Depression?

Mediators of Inflammation ◽

10.1155/2009/439107 ◽

2009 ◽

Vol 2009 ◽

pp. 1-4 ◽

Cited By ~ 7

Author(s):

Magdalena Olszanecka-Glinianowicz ◽

Barbara Zahorska-Markiewicz ◽

Piotr Kocełak ◽

Joanna Janowska ◽

Elżbieta Semik-Grabarczyk ◽

...

Keyword(s):

Chronic Inflammation ◽

Severe Depression ◽

Study Groups ◽

Study Group ◽

Serum Concentrations ◽

Obese Women ◽

Adult Obesity ◽

Mild Depression ◽

Depression Level ◽

Possible Cause

Adult obesity has been associated with depression, especially in women. Whether depression leads to obesity or obesity causes depression is unclear. Chronic inflammation is observed in obesity and depression. In 63 obese women without additional diseases depression level was assessed with the Beck's questionnaire. After evaluation of depression level study group was divided into groups according to the mood status (A—without depression, B—mild depression, and C—severe depression), and serum concentration of TNF-α, sTNFs, leptin, and IL-6 were measured by ELISA. No differences in age, body mass, BMI, and body composition were observed in study groups. We did not observe differences of serum concentrations of TNF-α, sTNFRs, leptin, and IL-6 between subgroup A and subgroups B and C. It seems that circulating adipokines did not exert influence on depression levels in obese women.

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Depression and Suicidality in Obese Patients

Psychological Reports ◽

10.2466/06.09.12.15.pr0.108.2.367-368 ◽

2011 ◽

Vol 108 (2) ◽

pp. 367-368 ◽

Cited By ~ 7

Author(s):

David Lester ◽

Maurizio Pompili ◽

Paolo Iliceto ◽

Paolo Girardi

Keyword(s):

Health Professionals ◽

Severe Depression ◽

Obese Patients ◽

Suicidal Risk ◽

High Prevalence

A study of 70 obese patients indicated the presence of severe depression in 32% of the sample and some suicidal risk in 23%. Given this high prevalence, health professionals should always explore the presence of depression and suicidality in obese patients.

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AB1192 THE UNDERWORLD OF DEPRESSIVE SYMPTOMS IN RHEUMATIC DISEASES: OVERLOOKED, UNRECOGNIZED OR UNPERCEIVED?

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2020-eular.1998 ◽

2020 ◽

Vol 79 (Suppl 1) ◽

pp. 1886.2-1887

Author(s):

F. Ingegnoli ◽

T. Schioppo ◽

T. Ubiali ◽

V. Bollati ◽

S. Ostuzzi ◽

...

Keyword(s):

Depressive Symptoms ◽

Rheumatic Diseases ◽

Real Life ◽

Severe Depression ◽

Mild Depression ◽

Cross Sectional ◽

Online Study ◽

Social Burden ◽

Patient Health ◽

The University

Background:The concomitant presence of depressive symptoms and rheumatic diseases (RDs) impose a considerable economic and social burden on the communities as they are associated with numerous deleterious outcomes such as increased mortality, work disability, higher disease activity and worsening physical function, higher pain levels and fatigue. Despite growing interest on depressive symptoms burden in RDs, current patient perception on this topic is unknown.Objectives:Italian patients with RDs were invited to participate in an online study gauging the presence and the perception of depressive symptoms using the Patient Health Questionnaire (PHQ-9).Methods:This was a cross-sectional no-profit online study to screen the presence and the perception of depressive symptoms in RDs patients. All participants gave their consent to complete the PHQ-9 and they were not remunerated. Completion was voluntary and anonymous. The PHQ-9 rates the frequency of symptoms over the past 2 weeks on a 0-3 Likert-type scale. It contains the following items: anhedonia, depressed mood, trouble sleeping, feeling tired, change inappetite, guilt or worthlessness, trouble concentrating, feeling slowed down or restless, and suicidal thoughts. Patients were stratified as: <4 not depressed, 5-9 sub-clinical or mild depression, 10-14 moderate depression, 15-19 moderately severe depression and 20-27 severe depression. The survey was disseminated by ALOMAR (Lombard Association for Rheumatic Diseases) between June and October 2019.Results:192 patients took part in the study: 170 female with median age 50 years. Among respondents only 35 (18.2%) were not depressed. Depression was sub-clinical or mild in 68 (35.4%), moderate in 42 (21.9%), moderately severe in 30 (15.6%), and severe in 17 (8.9%). 16 (8.3%) of respondents declared to have depressive symptoms and 7 of 16 were under psychiatric therapy.Moreover, patients were grouped according to diagnosis.124 respondents had inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis). 23 (18.5%) were not depressed. Depression was sub-clinical or mild in 41 (33%), moderate in 26 (21%), moderately severe in 21 (17%), and severe in 13 (10.5%). Among them, 8 (6.5%) declared to have depressive symptoms depressed and 3 of 8 were under psychiatric therapy.49 respondents had a connective tissue disease or vasculitis. 11 (22.5%) were not depressed. Depression was sub-clinical or mild in 19 (38.8%), moderate in 13 (26.5%), moderately severe in 2 (4%), and severe in 4 (8.2%). Among them, 3 (6%) declared to have depressive symptoms and 1 of 6 were under psychiatric therapy.19 respondents had other rheumatic diseases. 1 (5.3%) was not depressed. Depression was sub-clinical or mild in 8 (42.1%), moderate in 3 (15.8%), moderately severe in 7 (36.8%). Among them, 5 (26.3%) declared to be depressed and 3 of 5 were under psychiatric therapy.Conclusion:Our study confirmed that the overall real-life burden of depressive symptoms is relevant in all RDs. At the same time, these results highlighted that depressive symptoms are overlook by physicians and unperceived by patients since fewer that half of respondents (46.4%) had a clinical depression (PHQ-9>10). These results suggested that screening for depression should form part of the routine clinical assessment of RD patients.Acknowledgments:We thank the Lombard Association of Rheumatic Diseases (ALOMAR) for its contribution to design and disseminate the survey, the group that sustain systemic sclerosis (GILS), and the IT service of the University of Milan.Disclosure of Interests:Francesca Ingegnoli: None declared, Tommaso Schioppo: None declared, Tania Ubiali: None declared, Valentina Bollati: None declared, Silvia Ostuzzi: None declared, Massimiliano Buoli: None declared, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB

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Results of a Survey of Cardiovascular Risk Factor Prevalence Amongst Health Care Workers

Scottish Medical Journal ◽

10.1177/003693300004500308 ◽

2000 ◽

Vol 45 (3) ◽

pp. 84-85 ◽

Cited By ~ 2

Author(s):

S.R. McEwan ◽

N.G. Dewhurst ◽

F. Daly ◽

C.D. Forbes ◽

J.J.F. Belch

Keyword(s):

Risk Factors ◽

Health Care ◽

Cardiovascular Risk ◽

Health Care Workers ◽

Risk Profile ◽

Royal Infirmary ◽

Cardiovascular Risk Profile ◽

Risk Factor Prevalence ◽

Care Workers ◽

High Prevalence

Summary analyses of screening data were used to ascertain the cardiovascular risk profile in a sample of health care workers in Scotland. A sample of NHS staff (298 women and 78 men) were screened during visits to Perth Royal Infirmary (PRI) in 1996 and 1997. Comparisons were made within subsets and with previous screening studies. Health care workers have been a neglected component of the workforce for receiving education about risk factors. The high prevalence of smokers found in this sample should be a cause for concern.

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