Predictors of Work Ability in Individuals With a Common Mental Disorder: Is There an Effect of Metacognitive Beliefs Among Poor Physical Health and Emotional Distress?
Purpose Work ability is a prospective predictor of sick leave, disability pension and unemployment, and has been defined as the balance between human resources and the demands of work, taking into consideration that illness is not equivalent to work disability. In the present study we set out to explore predictors of work ability in a sample of individuals with common mental disorders. In particular, we were interested in exploring metacognitive beliefs as a potential predictor of work ability, as Wells' (2009) metacognitive model of psychological disorder suggests that metacognitions may be an underlying factor in psychological vulnerability generally, and they have been associated with work status in previous studies. Methods One hundred and seventy-seven individuals participated in an online survey and completed a battery of self-report questionnaires. Results Several factors correlated with reduced work ability: physical disorders, emotional distress symptoms and metacognitive beliefs. We found that confidence in memory predicted work ability even when controlling for gender/age, number of physical disorders, and levels of anxiety and depression symptoms. Conclusions This finding suggest that metacognitions of poor memory performance are associated with low work ability among those with common mental disorders, and implies that these should be targeted in treatment with a view to increasing work ability and thus potentially facilitate return to work.
Source: Nordahl H, Wells A, Behaviour Change, Vol. 36 (4), p.252-262, 2019 Dec.
Motivation for return to work and actual return to work among people on long-term sick leave due to pain syndrome or mental health conditions
Purpose The purpose of this study was to investigate associations between motivation for return to work and actual return to work, or increased employability among people on long-term sick leave. Methods Data by responses to questionnaires was collected from 227 people on long-term sick leave (mean = 7.9 years) due to pain syndrome or mild to moderate mental health conditions who had participated in a vocational rehabilitation intervention. The participants' motivation for return to work was measured at baseline. At 12-month follow-up, change in the type of reimbursement between baseline and at present was assessed and used to categorise outcomes as: "decreased work and employability", "unchanged", "increased employability", and "increased work". Associations between baseline motivation and return to work outcome were analysed using logistic and multinomial regression models. Results Motivation for return to work at baseline was associated with return to work or increased employability at 12-month follow-up in the logistic regression model adjusting for potential confounders (OR 2.44, 95% CI 1.25–4.78). Conclusions The results suggest that motivation for return to work at baseline was associated with actual chances of return to work or increased employability in people on long-term sick leave due to pain syndrome or mild to moderate mental health conditions. High motivation for return to work seems to increase the chances of actual return to work or increased employability in people on sick leave due to pain syndrome or mild to moderate mental health conditions. The potential impact of motivation for return to work is suggested to be highlighted in vocational rehabilitation. Rehabilitation professionals are recommended to recognise and take into consideration the patient's stated motivation for return to work. Rehabilitation professionals should be aware of that the patient's motivation for return to work might have an impact on the outcome of vocational rehabilitation. Source: Carlsson L, Lytsy P, Anderzén I, Hallqvist J, Wallman T, Gustavsson C, Disability & Rehabilitation, Vol. 41(25), p.3061-3070, 2019 Dec.
Returning to work after sickness absence due to common mental disorders: study design and baseline findings from an 18 months mixed methods follow-up study in Germany
Purpose With nearly 30 % of the general population experiencing one mental disorder in 12 months, common mental disorders (CMDs) are highly prevalent in Germany and mainly affect the workforce. Therefore, the processes of successfully returning to work (RTW) and achieving a sustainable RTW (SRTW) are important not only for recovery but the prevention of negative consequences like job loss or disability retirement. While factors influencing and predicting the time until RTW are well-investigated in other countries, research on determinants of RTW and SRTW has received little attention in Germany. Consequently, this study aims to investigate the RTW and SRTW processes due to CMDs from the employees´ perspective in Germany. Methods This prospective cohort study uses a convergent parallel mixed methods design with a quantitative sample and qualitative sub-sample. Results Two hundred eighty-six participants of the quantitative study and a sub-sample of 32 participants of the qualitative study were included. The primary outcome of the quantitative study is the time until RTW and full RTW. The secondary outcome is the sustainability of RTW. The following measures will be used to cover work-, RTW- and health-related factors: working time, duration of sickness absences, functional ability, work ability, RTW self-efficacy, social support, work-privacy conflict, job satisfaction, job crafting and depressive symptoms. Quantitative and qualitative data will be integrated at the end. Conclusions The paper provides an overview on study design, recruitment, sample characteristics and baseline findings of an 18 months mixed methods follow-up study in Germany. This study will provide evidence of (S)RTW processes and its influencing factors due to CMDs in Germany and therefore contribute to further improvement of its (S)RTW practices.
Source: Sikora A, Schneider G, Stegmann R, Wegewitz U, BMC Public Health, Vol. 19 (1), p.1-13, 2019 Dec.
Number of Previous Absences Is a Predictor of Sustained Attendance after Return to Work in Workers With Absence due to Common Mental Disorders: A Cohort 3-year Study
Purpose This study evaluated the relationship of the number of previous episodes due to common mental disorders (CMDs) with long-term outcomes and sustainability of attendance after return-to-work (RTW). Methods Participants were assigned to the following three groups: workers having one (Group 1), two (Group 2), and three or more (Group 3) previous episodes. Outcomes were a recurrent absence and the sustainability rate of attendance after RTW. Results The sustainability rate in Group 1 was significantly higher than that in Group 3 throughout the observation period. The sustainability rates for Group 2 were significantly higher than for Group 3 at 30 and 36 months. Conclusions The number of previous episodes was shown to affect sustainability of attendance after RTW due to CMDs, indicating that repeated previous absences are a significant prognostic factor.
Source: Mishima M, Adachi H, Mishima C, Journal of Occupational and Environmental Medicine, 2019 Nov.
Employers' beliefs, knowledge and strategies used in providing support to employees with mental health problems
Purpose Mental health problems are the main cause of sick leave in today's working age population. Employers are responsible for their employees' work environment and preventing work-related illnesses, but their knowledge regarding mental health problems is lacking. Employer beliefs and support strategies need further exploration. Objective To explore employers' beliefs, knowledge and strategies use in providing support to employees with mental health problems. Methods This grounded theory study comprised 24 interviews with employers in a variety of workplaces, and included women and men in large and small organizations in a Swedish context. Results Two categories related to the aims emerged: comprehending mental health problems is complex, and lacking established conditions to support work. The results show that employers seek to support employees with mental health problems but have low expectations and lack knowledge and strategies. Employers acknowledged experiences of inadequate support and collaboration from other actors in the return-to-work (RTW) process. Conclusions To close the service gap and improve the RTW process, employers need to increase their mental health literacy. Other actors need to improve their understanding of employer situations and provide them with necessary support.
Source: Porter S, Lexén A, Bejerholm U, Journal of Vocational Rehabilitation, Vol. 51 (3), p.325-337, 2019.
Exploring the service and knowledge gap between rehabilitation professionals and employers in the return-to-work process of people with mental health problems in Sweden
Purpose Research is needed on how to optimize the return-to-work process for persons with mental health problems. Objective To develop a model that explains how employer and rehabilitation professional mental health literacy may influence strategies used in the return-to-work of persons with mental health problems. Methods A grounded theory study design was used to collect and analyse interview data from 23 employers and 22 rehabilitation professionals. Results The analysis resulted in four categories, illustrated in a conceptual process model: 1) seeing mental health problems through past experiences; 2) separating understandable and incomprehensible mental health problems; 3) balancing safeguarding one's personal interest with providing adequate support; and 4) facing conflicts and uncertainty in employee/service user return-to-work. A positional map of employer/rehabilitation types was created based on level of negative attitudes and uncertainty in supporting employees/service users and the employer in relation to the level of comprehensive understanding of mental health problems. Conclusions Professional mental health literacy needs to be increased. Interventions need to be developed that provide employers with targeted support and knowledge in mental health literacy. Education on how to prevent and detect common mental health problems in the workplace is needed.
Source: Lexén A, Emmelin M, Hansson L, Bejerholm U, Work, 2019 Oct.
Work-directed rehabilitation or physical activity to support work ability and mental health in common mental disorders: a pilot randomized controlled trial
PurposeTo evaluate feasibility and potential effectiveness of work-directed rehabilitation in people with common mental disorders. Design Pilot randomized controlled trial. Setting Primary healthcare, Sweden. Subjects Working adults (n = 42) of mean age 46.2 ± 11.1 years with depression or anxiety disorder. Interventions Eight weeks of work-directed rehabilitation (n = 21) or physical activity (n = 21). Work-directed rehabilitation included sessions with a physiotherapist and/or an occupational therapist, to develop strategies to cope better at work. Physical activity included a planning session and access to a local gym. Main Measures Feasibility: attendance, discontinuation and adverse events. Measurements were the Work Ability Index, the Global Assessment of Functioning, the Montgomery-Asberg Depression Rating Scale, the Beck Anxiety Inventory and the World Health Organization-Five Well-Being Index. Results Attendance to rehabilitation sessions was 88% (n = 147/167) and discontinuation rate was 14% (n = 3/21). No serious adverse events were reported. Within both groups, there was a significant improvement in Work Ability Index score (mean change: 3.6 (95% confidence interval (CI): 0.45, 6.7) in work-directed rehabilitation and 3.9 (95% CI: 0.9, 7.0) in physical activity) with no significant difference between groups. For the other outcomes, significant improvements were found within but not between groups. Per-protocol analysis showed a trend toward the antidepressant effect of work-directed rehabilitation compared to physical activity (mean difference in depression score -3.1 (95% CI: -6.8, 0.4), P = 0.075). Conclusions Work-directed rehabilitation was feasible to persons with common mental disorders and improved their work ability and mental health. Comparable improvements were seen in the physical activity group. Suggested modifications for a larger trial include adding a treatment-as-usual control.
Source: Danielsson L, Waern M, Hensing G, Holmgren K, Clinical Rehabilitation, 2019 Oct.
Work and depression: The moderating role of personality traits
Purpose Some stress theories argue that the effects of stressors are moderated by the individual perception of stressors. Personality traits may thus moderate the relationship between work stressors and depression. Methods This study aims to verify the moderating effect of personality traits on the relationship between work conditions and depression. Multilevel regression analyzes were performed on a sample of 1957 workers employed in 63 Quebec firms. Work variables included skill utilization, decision authority, psychological demands, physical demands, job insecurity, irregular schedule, number of working hours, social support from colleagues and supervisors, and personality traits included self-esteem, locus of control, Big Five. Results and conclusion Certain specific personality traits (self-esteem, locus of control) and general personality traits (openness, extraversion, and conscientiousness) play a moderating role on the relationship between working conditions (skill utilization, physical demands, support from colleagues, job insecurity) and depression. The results of this study may be useful in some human resource management activities, particularly career management, promotions management, and personnel selection. Additional research will, however, be necessary to gain a more complete understanding of the full range of determinants affecting depression.
Source: Parent-Lamarche A, Marchand A, Journal of Workplace Behavioral Health, Vol. 34 (3), p.219-239, 2019 Jul-Sept.
One-year trajectories of mental health and work outcomes post return to work in patients with common mental disorders
Purpose We investigated one-year trajectories of symptom recovery, work functioning and the return to work percentage (RTW%) among patients with common mental disorders (CMDs). Methods Data were used from a cluster-randomised controlled trial evaluating a problem-solving intervention for CMD patients (N = 158) who had returned to work. Information on anxiety and depressive symptoms, work functioning and RTW% was collected at baseline and 3, 6 and 12 months follow-up. Latent class growth analyses were used to identify trajectories for the four outcomes and investigate how these trajectories clustered in higher order latent classes. Additionally, we investigated the relation between patient characteristics and class membership. Results We identified four trajectories for all four outcomes and derived three higher order latent classes: slow recovery (42% [66/158]) (high anxiety and depressive symptoms, moderate to low work functioning and fast RTW); fast recovery (25% [40/158]) (low anxiety and depressive symptoms, high work functioning and fast RTW); and gradual recovery (33% [52/158] (decreasing anxiety and depressive symptoms, increasing or low work functioning and fast RTW). Participants with a higher work engagement and readiness to stay at work were more likely to belong to the fast recovery class. Limitations Due to the relatively small sample size, some trajectories consisted of few participants. Symptom severity was self-reported. Conclusions Many CMD patients experience high levels of mental health symptoms and work functioning problems during the year post RTW. Creating realistic recovery expectations (for both patients and their environments) could be important for successful and sustainable recovery and work participation.
Source: Arends I, Almansa J, Stansfeld SA, Amick BC, van der Klink JJL, Bültmann U, Journal Of Affective Disorders, Vol. 257, p. 263-270, 2019 Jul.
Return-to-Work Coordinators' Practices for Workers with Burnout
Purpose Return-to-work (RTW) coordinators facilitate RTW of workers with work disabilities. However, little is known about RTW coordinators' practices for workers with burnout. The aims of this study were to describe RTW coordinators' activities in supporting workers with burnout during the RTW process, and their experiences with factors influencing the support. Methods Interviews and essay assignments were conducted with 15 RTW coordinators employed in universities and central hospitals in Finland. Data were analyzed using qualitative content analysis. Results RTW coordinators were involved in the RTW process during early intervention, off-work, and work resumption phases. Seven groups of activities were identified: monitoring staff well-being; initiating RTW process; planning RTW; providing tools to support recovery; monitoring progress of the RTW process; supporting re-engagement with work; and monitoring coping with work. RTW coordinators' activities depended on their institutional positions. Factors influencing the support included common understanding about burnout syndrome: co-occurring illnesses, dimensions of burnout, unpredictability of the recovery, personality characteristics, private life psychosocial factors, conflicts within the work community, and openness about burnout and its causes. Conclusions Complexity of the burnout problem challenges the support from the RTW coordinators. Understanding the causes and the consequences of burnout is important for the RTW coordinators to provide adequate and timely support for the workers with burnout in collaboration with the other stakeholders involved in the RTW process. Burnout-, individual-, and work-related factors should be considered in the RTW coordination to prevent and to reduce the negative consequences of burnout.
Source: Kärkkäinen R, Saaranen T, Räsänen K, Journal of Occupational Rehabilitation, Vol. 29 (3), p. 493-502, 2019 Sep.
A return to work program improves parasympathetic activity and psychiatric symptoms in workers on sick leave due to depression
Purpose People with depression have autonomic function disturbances. In Japan, workers who take leave due to depression often undergo a work-focused intervention program called the return to work (RTW) program at a mental health hospital during their leave of absence. However, its biological efficacy remains unclear. We investigated the biological efficacy of the RTW program, including changes in autonomic nervous system (ANS) activity, in workers on sick leave due to depression in Japan. Methods The study involved 104 workers on sick leave due to major depressive disorder or bipolar disorder who underwent the RTW program for 3 months in Yokohama City University Hospital. The ANS activity of all patients was evaluated using heart rate variability at the beginning and end of the 3-month RTW program. Psychiatric symptoms were evaluated using the Montgomery-Åsberg Depression Rating Scale-Japanese (MADRS-J) and Social Adaptation Self-evaluation Scale (SASS). We followed up 3 months after the end of the program and investigated the association between the success in returning to work within 3 months after the end of the RTW program and several factors, including ANS activity, depressive symptoms, and demographic factors. Results Parasympathetic activity was significantly higher and depressive symptom severity was significantly lower at program end than at baseline. Logistic regression analysis showed that the change in depressive symptoms was significantly associated with success in returning to work. Conclusions We suggest that the RTW program improves parasympathetic activity as well as psychiatric symptoms. ANS activity was not a predictor of a successful return to work within 3 months after the end of the program in workers on sick leave due to depression, but further studies with a larger sample size are needed.
Source: Hattori S, Kishida I, Suda A, Kawanishi C, Miyauchi M, Shiraishi Y, Fujibayashi M, Tsujita N, Ishii C, Moritani T, Saigusa Y, Hirayasu Y, Heliyon, Vol. 5 (7) pp. e02151, 2-19 Jul.
Return-to-Work Following Depression: What Work Accommodations Do Employers and Human Resources Directors Put in Place?
Purpose The magnitude of economic and social costs related to common mental disorders has a profound impact on the workplace. Returning to work following depression is, therefore, a major issue for all stakeholders involved (employee, employer, human resources director, union, physician, etc.). Considering their role in the organization, Human Resources Directors (HRD) and employers have a decisive impact on the return-to-work (RTW) process. Purpose This study aims to determine which RTW accommodations are implemented, following depression, by one of the central stakeholders: HRD and employers. Methods 219 HRD/employers participated in a semi-structured telephone interview about RTW of employees after depression. From that interview, the question related to this article was: Do you put in place work accommodations for employees after a sick leave due to depression (yes or no)? If their response was positive, we asked: If yes, what were the work accommodations? Results 170 HRD/employers specified accommodations. The most common categories identified were related to: work schedule, task modifications, job change and work environment change. Accommodations directly related to the employee or the colleagues were considerably less mentioned and those concerning other RTW stakeholders, including supervisor, were almost absent. Conclusions Our results suggest that accommodations directly related to work aspects seemed to predominate in our sample of HRD/employers when an employee returned-to-work following depression. The relational aspect and the involvement of the different stakeholders are also not prioritized to accommodate the RTW. These results contrast with employer best practice guidelines for the RTW of workers with common mental disorders.
Source: Bastien MF, Corbière M, Journal of Occupational Rehabilitation, Vol. 29 (2), p. 423-432, 2019 Jun.
Development and Implementation of a Mental Health Work Rehabilitation Program: Results of a Developmental Evaluation
Purpose Long-term work disability due to common mental disorders (CMDs) is a growing problem. Yet optimal interventions remain unclear and little is known about implementation challenges in everyday practice. This study aimed to support and evaluate, in real time, the development and implementation of a work rehabilitation program (WRP) designed to promote post-CMD return-to-work (RTW). Methods A 2-year developmental evaluation was performed using a participatory approach. At program outset, the researchers held five work meetings to revise the program's logic model and discuss its underlying change theory with clinicians. Data collection tools used throughout the study period were structured charts of activities conducted with workers (n = 41); in-depth interviews with program clinicians and managers (n = 9); and participant observation during work meetings. Quantitative data were analyzed using descriptive statistics. Qualitative data underwent thematic analysis using a processual approach. Results Three types of activity were developed and implemented: individual and group interventions targeting workers, and joint activities targeting partners (physicians, employers, others). While worker-targeted activities were generally implemented as planned, joint activities were sporadic. Analysis of the implementation process revealed five challenges faced by clinicians. Determinants included clinicians, host organization, sociopolitical context and resources provided by the evaluation. Conclusions The program studied is original in that it is based on the best available scientific knowledge, yet adapted to contextual particularities. The identified implementation challenges highlight the need for greater importance to be placed on the external, non-program context to ensure sustainable implementation in everyday practice.
Source: Sylvain C, Durand MJ, Velasquez Sanchez A, Lessard N, Maillette P, Journal of Occupational Rehabilitation, Vol. 29 (2), p.303-314, 2019 Jun.
What are they returning to? Psychosocial work environment as a predictor of returning to work among employees in treatment for common mental disorders: A prospective observational pre–post study
Purpose Long-term sick leave and disabilities due to common mental disorders are challenging for society, employers, and individuals. Hence, we wanted to investigate whether psychosocial work environments experienced by employees undergoing treatment for such disorders was associated with return to work. Methods At the start of treatment, 164 patients responded to questionnaires concerning their psychosocial work environment (the Job Demand–Control–Support model and the Effort–Reward Imbalance model), symptoms (The Clinical Outcomes in Routine Evaluation Outcome Measure) and ability to work (Work Ability Index). In addition, the respondents reported whether they were working or on sick leave at the start and end of their courses of treatment. Their therapists provided information about diagnoses. Results Return to work was associated with control of decisions, support from colleagues, esteem, and job promotion opportunities as measured at the start of treatment. In multivariate analyses, control over decisions and job promotion opportunities continued to predict return to work when adjusted for symptoms, current work ability, and expected future work ability. Conclusions The working conditions that predicted return to work are considered to facilitate work performance and to be sources of motivation, job satisfaction, and job commitment. Consequently, it is important to examine whether this patient group has a favorable working environment and consider changes in the workplace if the environment is not favorable.
Source: Bjørn L, Shiryaeva O, Ruud T, Victor M. PLoS ONE, Vol. 14 (4), p.1-15, 2019 Apr.
Strategies to keep working among workers with common mental disorders - a grounded theory study
PurposeMost people with common mental disorders (CMDs) are employed and working, but few studies have looked into how they manage their jobs while ill. This study explores workers' experiences of strategies to keep working while suffering from CMDs. MethodsIn this grounded theory study, we interviewed 19 women and eight men with depression or anxiety disorders. They were 19-65 years old and had different occupations. Constant comparison method was used in the analysis. ResultsWe identified a core pattern in the depressed and anxious workers' attempts to sustain their capacities, defined as Managing work space. The core pattern comprised four categories describing different cognitive, behavioral, and social strategies. The categories relate to a process of sustainability. Two categories reflected more reactive and temporary strategies, occurring mainly in the onset phase of illness: Forcing the work role and Warding off work strain. The third category, Recuperating from work, reflected strategies during both onset and recovery phases. The fourth category, Reflexive adaptation, was present mainly in the recovery phase and involved reflective strategies interpreted as more sustainable over time. ConclusionsThe results can deepen understanding among rehabilitation professionals about different work-related strategies in depressed and anxious workers. Increased awareness of the meaning and characteristics of strategies can inform a person-oriented approach in rehabilitation. The knowledge can be used in clinical encounters to reflect together with the patient, exploring present options and introducing modifications to their particular work and life context. Implications for rehabilitationSelf-managed work functioning in common mental disorders involves diverse strategies. Strategies interpreted as sustainable over time, seem to be reflective in the sense that the worker consciously applies and adapts the strategies. However, at the onset of illness, such reflection is difficult to develop as the worker might not want to realize their reduced functioning. Rehabilitation professionals' awareness of different strategies can facilitate a person-centered approach and understanding of the vocational rehabilitation process.
Source: Danielsson L, Elf M, Hensing G, Disability & Rehabilitation, Vol. 41 (7), p. 786-795, 2019 Apr.
Occupational health care return-to-work practices for workers with job burnout
PurposeOccupational health care supports return to work in cases of burnout; however, there is little research on return-to-work practices. AimTo describe occupational health care return-to-work practices for workers with burnout and to identify potential for the development of the practices. MethodsOpen-ended interviews and essays were used to collect data from 25 occupational health care professionals. A qualitative content analysis method was used. Results: Occupational health care was involved in the return-to-work support in the off-work, work re-entry and maintenance phases during the return-to-work process. However, occupational health care had no influence in the advancement phase. The key return-to-work actions were: (i) defining burnout, (ii) supporting disengagement from work, (iii) supporting recovery, (iv) determining the return-to-work goal, (v) supporting re-engagement with work, (vi) monitoring the job-person match, (vii) re-evaluating the return-to-work goal, (viii) supporting the maintenance of the achieved return-to-work goal, and, where appropriate, (ix) supporting an alternative return-to-work goal. There were varied return-to-work practices among the occupational health care centers evaluated. ConclusionsThe occupational health care return-to-work practices for workers with burnout are described with recommendations to further develop common practice guidelines.
Source: Kärkkäinen R, Saaranen T, Räsänen K, Scandinavian Journal of Occupational Therapy, Vol. 26 (3), p.194-204, 2019 Apr.
A Preliminary Study of Work-Focused Cognitive Behavioural Group Therapy for Japanese Workers
Purpose In Japan, cognitive behavioural therapy (CBT) has been introduced in the 'Rework Programme', but its impact on return to work (RTW) has not been fully clarified. This pilot study investigated the initial efficacy of a work-focused cognitive behavioural group therapy (WF-CBGT) for Japanese workers on sick leave due to depression. Methods Twenty-three patients on leave due to depression were recruited from a mental health clinic. WF-CBGT including behavioural activation therapy, cognitive therapy, and problem-solving therapy techniques was conducted for eight weekly 150-minute sessions. Participants completed questionnaires on depression and anxiety (Kessler-6), social adaptation (Social Adaptation Self-Evaluation Scale), and difficulty in RTW (Difficulty in Returning to Work Inventory) at pre- and post-intervention time points. Rates of re-instatement after the intervention were examined. Results One participant dropped out, but 22 participants successfully completed the intervention. All scale scores significantly improved after intervention and, except for difficulty in RTW related to physical fitness, all effect sizes were above the moderate classification. All participants who completed the intervention succeeded in RTW. Conclusions Results suggested the possibility that WF-CBGT may be a feasible and promising intervention for Japanese workers on leave due to depression regardless of cross-cultural differences, but that additional research examining effectiveness using controlled designs and other samples is needed. Future research should examine the efficacy of this programme more systematically to provide relevant data to aid in the continued development of an evidence-based intervention.
Source: Ito D, Watanabe A, Takeichi S, Ishihara A, Yamamoto K, Behavioural & Cognitive Psychotherapy, Vol. 47 (2), p.251-256, 2019 Mar.