key: cord-0945945-1gchj06a
authors: Sińska, Beata; Jaworski, Mariusz; Panczyk, Mariusz; Traczyk, Iwona; Kucharska, Alicja
title: The Role of Resilience and Basic Hope in the Adherence to Dietary Recommendations in the Polish Population during the COVID-19 Pandemic
date: 2021-06-19
journal: Nutrients
DOI: 10.3390/nu13062108
sha: 0110fd76aeb4654c4792910aad03d2eaf2c1b6e2
doc_id: 945945
cord_uid: 1gchj06a

(1) Background: The COVID-19 pandemic exerts a negative influence on dietary behaviors, which may lead to health deterioration. Dietary behaviors may be determined by psychological characteristics, such as basic hope and resilience, which facilitate the effective adjustment to new difficult conditions. The professional literature includes no research on the role of basic hope and resilience in the context of undertaken dietary behaviors in the situations of mental load associated with pandemics. The study aimed at the description of the dietary behaviors of individuals with various intensities of the discussed psychological characteristics (basic hope and resilience); (2) The observational cross-sectional online questionnaire study was conducted with the participation of 1082 adult Polish inhabitants. Three psychological scales were used: PSS-10, the Brief Resilient Coping Scale (BRCS) and BHI-12 questionnaire. The assessment of the adherence to dietary recommendations was performed with the present authors’ Dietary Guidelines Adherence Index (DGA Index); (3) Results: The value of DGA Index was variable depending on the psychological profile of study participants. The highest adherence to the principles of appropriate nutrition was observed in individuals characterized by the ability to cope with difficult situations and those who quickly adapted to new changing circumstances. The DGA Index values became poorer with the deterioration of the coping ability as regards stress and mental load; (4) Conclusions: Nutritional education during pandemics should encompass the psychological profile of the patients. It requires the implementation of a different psychodietetic approach which will facilitate a more effective introduction of a well-balanced diet.

The state of epidemic threat was introduced in Poland in the middle of March 2020 because of the COVID-19 pandemic. The first case of SARS-CoV-2 infection was reported in Poland on the 4th of March. The state of epidemic threat was introduced between the 14th and 20th of March, and the state of epidemic emergency was declared on the 20th of March pursuant to a Regulation of the Minister of Health. All Polish universities closed down on the 12th of March. Public gatherings were banned, the movement of persons and access to public spaces were restricted. Tight restrictions which almost completely banned the use of public spaces remained in force until the 20th of April [1] .

The COVID-19 pandemic has considerably changed the functioning of many people, not only in the professional, but also in the private aspect. The rapid transmission of SARS-CoV-2 (Severe acute respiratory syndrome coronavirus 2) [2] contributed to the introduction particular significance in the context of experiencing social isolation combined with stress and anxiety concerning the future.

The present research was conducted with regard to the lack of available studies on the role of basic hope and resilience in the context of undertaken dietary behaviors in the situations of stress and mental load associated with pandemics. The research aimed at developing the characteristics of the dietary behaviors of individuals with various intensities of the discussed psychological traits (basic hope and resilience).

The observational cross-sectional online questionnaire study was conducted in April and May 2020 in the inhabitants of Poland. The inclusion criteria were: respondents aged 18 and older capable of expressing informed consent to participate in the study. Individuals younger than 18 and those who did not consent to participate were excluded from the study. Nonprobability sampling of study participants was used. The sample size for this study was 1082 adult inhabitants of Poland.

The questionnaire was distributed via the Google forms web survey platform. The link to the questionnaire was shared via social media such as Facebook, Instagram, WhatsApp and the personal contacts of study group participants (the snowball method). The method of questionnaire distribution was selected due to the limited possibility of contacting the respondents directly because of the restrictions introduced by the Minister of Health in relation to the COVID- 19 pandemic. An online survey is the recommended approach which facilitates rapid access to the study group while maintaining safety measures in such a situation [21] . The present research lasted from the beginning of April till the end of May 2020. It was a period of sudden changes in lifestyles related to the introduction of hard lockdown (12 March-20 April 2020).

Psychological and nutritional variables were measured during the study. The psychological variables were assessed with the use of the following instruments:

The PSS-10 scale developed by Cohen, Kamarck and Mermelstein [22] . The scale is used to measure the perceived stress level. The present authors used the Polish adaptation of this scale developed by Ogińska-Bulik and Juczyński [13] . The PSS-10 includes 10 questions concerning various subjective feelings associated with problems, personal events, behaviors and coping methods. The test is used to assess the intensity of stress associated with one's life situation over the past month. The scale is characterized by good accuracy and reliability with the Cronbach's alpha coefficient estimated at 0.86 [18] .

The Brief Resilient Coping Scale (BRCS) developed by Sinclair and Wallston [23] which measures resilience as a process. The present authors used the Polish adaptation of this scale developed by Piórowska et al. [12] . The scale consists of only 4 items. The BRCS may be useful in the identification of people who need support to develop their resilience. The accuracy of the scale is satisfactory. However, it requires further analyses. This psychological trait refers to the quality and satisfaction with life. The reliability of the BRCS is satisfactory. The Cronbach's alpha coefficient is 0.625 [12] .

The Polish version of the BHI-12 questionnaire was developed by Trzebiński and Zięba [24] for the measurement of basic hope understood as the belief of an individual concerning the organization and meaning of the world and its agreeableness. Basic hope refers to Erikson's [20] concept of psychosocial development and is defined as general, early formulated conviction that the surrounding reality makes sense and is favorable. It is also a factor determining the constructiveness of human reactions to changes and breakthrough events, especially in situations in which irreversible loss may be incurred.

The BHI-12 questionnaire includes 12 statements and is characterized by good accuracy and reliability with the Cronbach's alpha coefficient estimated at 0.70 [24] .

The assessment of the adherence to dietary recommendations was performed with the present authors' Dietary Guidelines Adherence Index (DGA Index) developed on the basis of current "Healthy nutrition recommendations" for the Polish population published by the National Institute of Public Health-the National Institute of Hygiene [25] . They were developed basing on the review of professional literature concerning the influence of individual dietary components and types of diet on human life and the review of the recommendations of scientific societies dealing with this issue worldwide. Particular attention was paid to domestic and international studies concerning the health status and analyzing the threatening factors, including the results of the Global Burden Diseases Study [26] . Basing on the data we determined the most important diet-related risk factors. Study results were also used to specify the order of factors which contributed to the most considerable reduction in healthy life years in the Polish population. Consistently with study results, diet-related factors were presented in the order starting from ones which were the most significant for maintaining health in the new recommendations. The recommendations were graphically presented as a plate filled with various products with the indication of the recommended portions of individual groups of products in the daily diet. Additionally, groups of products were divided into the following categories: "Eat less", "Eat more" and "Replace" [25] .

Basing on the above described recommendations and thorough literature analysis, a group of experts in dietetics indicated 18 groups of products and the recommended frequency of their consumption. Ten groups included products which should be consumed in higher amounts as they exerted a positive effect on the health (vegetables, fruits, whole grains, dairy products (no added sugar), legumes, fish, unsalted nuts, seeds, white meat, oils/margarines, water), and eight groups-products whose consumption should be limited or replaced with healthier alternatives (red and processed meat, sweets, salty snacks, sweetened drinks, refined grains, fast food, butter/ lard, processed cheese). The groups of products were used to develop a consumption frequency questionnaire. Basing on the questionnaire the respondents selected the frequency of the consumption of the individual groups of products during the pandemic. They could choose the following answers: "a few times a day", "once a day", "a few times a week", "once a week", "1-3 times a month" and "never". One point was scored if the frequency of the consumption of a specific group of products adhered to the recommendations (Table 1 ). If a response revealed no adherence to the recommendations-0 points were scored. DGA Index value was expressed as the total score between 0 and 18 points. Higher DGA Index values were interpreted as a higher degree of adherence to dietary recommendations (0 points-a complete lack of adherence to the recommendations, 18 points-complete adherence to recommendations). The reliability assessment showed a satisfactory level of the internal consistency of the measurement (Cronbach's alpha coefficient estimated at 0.67). The criterion, differential, or convergent validity of the DGA Index was not estimated.

The questionnaire also included questions regarding sociodemographic data, including: age, gender, place of residence, professional activity and the level of education. The Dietary Guidelines Adherence Index is available as supplementary material (See: Supplementary file).

Prior to the study the participants were informed that it was anonymous and the data were confidential. No personal data or computer IP were collected. Due to the anonymous character of the questionnaire and no possibility to follow sensitive data the study required no approval of the Bioethics Committee. 

Quantitative and categorical variables were described with the methods of descriptive statistics. The following measures were determined for quantitative variables: a central tendency (the means and 95% confidence interval, and the median), dispersion (standard deviation, interquartile range), location (upper and lower quartile). The number (N) and frequency (%) were determined for categorical variables.

During the first stage data clustering with k-means method was used to distinguish groups of participants varying in terms of psychological characteristics. The algorithm of 10-fold cross-validation was used, which allows the automatic determination of the number of data clusters. Selecting and distinguishing groups of similar objects in three clusters was performed during the analysis. Non-hierarchical clustering algorithm was implemented on the basis of the values calculated for three indices: stress, basic hope and resilience. Three groups of participants were distinguished: G1 (respondents with a moderate level of basic hope and resilience, but very stressed), G2 (respondents with a moderate level of basic hope and resilience) and G3 (respondents with a high level of basic hope and resilience). In case of groups 2 and 3, the level of stress was typical of the general population in a normal situation. In other words, those two groups were characterized by the level of stress similar to that before the pandemic.

During the second stage of the analysis, a comparison between the distinguished groups was performed depending on the dependent variable: the chi-squared test and one-way analysis of variance (one-way ANOVA) with the post hoc Tukey's HSD (Honestly Significant Difference) test. The effect size of the observed difference was estimated with η 2 assuming the following threshold values: 0.01 = small, 0.06 = medium, 0.13 = large effect size.

All calculations were performed with STATISTICA TM 13.3 software (TIBCO Software, Palo Alto, CA, United States). The p-level of < 0.05 was considered statistically significant in all analyses.

A total of 1082 adult inhabitants of Poland participated in the study. The average age of study participants was 31.6 (SD = 11.98). Women constituted the marked majority of the respondents (N = 934, 86.3%). Selected demographic characteristics of the study group are presented in Table 2 . 

The The level of basic hope measured with the BHI was also slightly over the average noted for the population reference ranges (M = 40.7, SD = 6.03, min-max: 20.0-56.0), which resulted in a slight left-sided asymmetry of distribution (skew: −0.31).

All scores obtained after the measurement with the three psychometric tools were converted to standard ten (sten scores) according to the reference ranges for the Polish population. It constituted the basis for the assignment to groups characterized by various levels of the studied psychological traits (Table 3 ).

Three groups of study participants distinguished with k-means clustering were characterized by the following profile of psychological traits (Table 1) :

Respondents from G1 were characterized by a high intensity of stress, while G2 and G3 individuals were characterized by the levels of stress typical of the general population. However, the level of stress was typical of the conditions prior to the pandemic. In other words, the respondents from groups G2 and G3 did not assess the pandemic situation as a more or less stressful compared to the situation before the pandemic. Moreover, the respondents from G1 were characterized by the moderate levels of basic hope and resilience, i.e., levels typical of the general population. Therefore, this group reflected the attitude of a standard inhabitant experiencing a high level of stress associated with the pandemic. Conversely, G2 reflected the attitude of a standard inhabitant who experienced moderate stress levels which was unrelated to the pandemic. G3 was a specific group of individuals characterized by a high level of basic hope and resilience. It included the respondents who found it very easy to cope with difficult situations and quickly adapted to new changing conditions.

The groups were significantly different as regards three analyzed psychological traits (Table 4) . 

The comparative analysis of three groups of study participants revealed that they were significantly different as regards the adherence to dietary recommendations ( Figure 1 ). Post hoc analysis showed that the average value of DGA Index was significantly higher in G3 compared to G1 (12.6 vs. 11.8; HSD test: p < 0.001) and G2 (12.6 vs. 12.1; HSD test: p = 0.010). However, no significant differences occurred in the average DGA Index between G1 and G2 (11.8 vs. 12.1; HSD test: p = 0.348). Some significant intergroup differences were noted in the assessment of the adherence to dietary recommendations in terms of the frequency of the consumption of individual product groups. The detailed results of comparative analysis were collected in Table 5 . Some significant intergroup differences were noted in the assessment of the adherence to dietary recommendations in terms of the frequency of the consumption of individual product groups. The detailed results of comparative analysis were collected in Table 5. 

The study was conducted to determine the quality of the diet consumed during the pandemic with the assessment of the degree of adherence to the principles of appropriate nutrition (DGA Index). Similarly to other countries, it was recommended to stay at home and avoid social contact as the basic rule of limiting the exposure to the spreading virus during the COVID-19 pandemic in Poland [27] . The limitations resulted both in positive and negative changes in lifestyle and dietary habits [9] . A lot of evidence was collected to demonstrate that healthy lifestyle, including the consumption of appropriate food, played a key role in building resistance to diseases and maintaining good health status. Normal sleep, moderate physical activity, avoiding stress and consuming food rich in nutrients may naturally support the immune system, which is of particular importance in case of viral diseases, such as COVID-19 [28] .

The present study showed that the value of DGA Index varied depending on the psychological profile of study participants. The highest adherence to the principles of appropriate nutrition was observed in case of G3 individuals who were characterized by the ability to cope with difficult situations and quick adaptation to new changing circumstances. The results confirmed the key role of psychological variables in making decisions associated with dietary habits in a difficult situation, such as a pandemic. Particular attention was paid to resilience which determines the ways of coping with difficult situations in life via effective dealing with stress and negative emotions [12] [13] [14] . It was noted that individuals with a high intensity of this psychological trait achieved higher values of DGA Index, i.e., a better degree of adherence to healthy diet. The observations are consistent with the results of psychological research which revealed that high levels of resilience promoted undertaking behaviors that were favorable for one's health [13, 29] , which is of particular importance in the pandemic context. The obtained results were also the first ones to reveal the significance of resilience with reference to dietary behaviors during the pandemic. Notably, high levels of resilience may protect people from "the trap of eating", reduce the tendency towards emotional eating and facilitate the mobilization towards undertaking action in difficult situations [29, 30] .

Basic hope was another analyzed psychological variable. It is one of the most important motivators of human activity which allows the interpretation of current events, especially if a person attempts at predicting their direction and consequences [18, 20, 24] . Considering the characteristics of this psychological variable it was assumed that it would support undertaking health-promoting dietary behaviors during the pandemic. This theoretical assumption was confirmed in the present study which demonstrated that basic hope combined with high resilience contributed to undertaking dietary behaviors adherent to recommendations. No research was published on the analysis of the role of basic hope in the context of dietary behaviors which suggests the necessity to conduct further empirical studies in this area.

The present study indicated the need to analyze the mutual system of psychological characteristics, and not individual traits, with reference to dietary behaviors, because psychological characteristics may appear stronger or weaker when combined. It was demonstrated that stress was not a factor which determined dietary behaviors. American research revealed that stress, especially at the initial stages of the pandemic, exerted no significant influence on changes in dietary habits [31] which is in line with our research. However, some authors emphasized the importance of mental stress on dietary behaviors during the pandemic [32] . Notably, stress may cause an individual response to the change in dietary behaviors. The above mentioned change may be short-term or long-term. It depends on the psychological mechanisms of an individual. Some people may tend to consume higher quantities of food is a stressful situation (about 40% of the general population), while others considerably limit the amount of food consumed (about 40% of the population). It is believed that in case of 20% of the population stress does not contribute to changes in dietary habits [33] . The underlying cause has not been fully elucidated. It is assumed that the emotional status and the psychological profile is of importance here. The level of experienced stress may be modified by the mutual system of traits, such as basic hope and resilience which are psychological characteristics determining the effectiveness of coping with difficult situations. It may be significant in the context of the personalization of dietary counseling. Moreover, personalized counseling should also comprise the aspect of emotional eating which has a negative impact on dietary behaviors during the COVID-19 pandemic [34] .

The study indicated that dietary counseling during difficult and stressful times, e.g., during a pandemic, should encompass the current psychological status of patients/clients. It is particularly important to determine the degree to which the individual copes with the current situation. It was demonstrated that persons with high resilience and basic hope were characterized by the dietary behaviors which were the closest to the recommended ones. However, they did not fully adhere to those recommendations. Therefore, the dietary counseling of such individuals should be based on the identification of the discussed psychological characteristics and strengthening them. Diet interviews should encompass questions concerning the level of perceived stress and behaviors related to emotional eating. It is also important to assess the self-efficacy of clients/patients with regard to the preparation of meals comprising the principles of healthy eating. As regards such a group of individuals, the dietician should use tools aiming at strengthening the sense of accomplishment, emphasize behaviors which are in line with current dietary recommendations and provide support in the modification of behaviors which should be changed. It is a context in which the dietician is a tutor showing the way and the dietician-patient relation is based on partnership.

In case of patients with low or moderate levels of resilience, nutrition education should be focused on to the analysis of methods used by the patient to cope with stress, especially those which are directly related to eating habits. The dietician should also discuss the role of nutrients in strengthening the functioning of the nervous and immune systems and alleviating stress related to the experience of negative events. If a patient cannot cope with stress, the dietician should suggest a psychological consultation and the inclusion of psychological counseling into the therapy, particularly if the problem exceeds the standard competences of the dietician. Notably, strong stress and negative emotions may constitute a significant barrier hindering diet modification in a certain direction. First, the patient should deal with negative experiences effectively in order to be able to undertake actions. Therefore, the dietician should be highly empathic, calm and reactive to every doubt expressed by the patient. It is important to adjust the quantity and quality of information adequately to the emotional status and cognitive capacity of the patient. It is worth remembering that cognitive capacity becomes more modifiable with stronger negative emotions [35] . In other words, a patient who experiences negative emotions will remember much less than one experiencing positive emotions. Moreover, suggested changes may seem more difficult to achieve and one's own capacities may be perceived as poorer than in individuals with positive emotional status. Therefore, the dietician should adjust diet modification using the tools of motivational interviewing which will not only facilitate the reduction of the negative mental status of the patient, but also strengthen the self-evaluation in the patient [36] .

The analysis of the adherence to dietary recommendations should focus on the consumption of individual groups of products, especially those which exert a positive effect on health. International guidelines concerning public health emphasize the significance of diet during epidemics. The diet should be based on fruits, vegetables, whole-grain products, low-fat milk products and healthy fats (olive oil and fish oils). The consumption of sweet drinks and processed food with high energy and salt content should be limited. [37] .

The present study revealed that the frequency of consuming fruits and vegetables consistent with the recommendations was reported in slightly over 50% of the respondents. The percentage of G3 individuals characterized by the appropriate frequency of the consumption of those products was significantly higher compared to the remaining groups. However, it was still lower than the satisfactory level and was only 65%. Fruits and vegetables should be consumed daily in large amounts (min. 400-500 g daily) both fresh and frozen [38] . The favorable effect of fruits and vegetables was noted, for example they reduce the risk of some chronic diseases, such as cardiovascular diseases [39] . The consumption of fruits and vegetables was also investigated in terms of the potential benefits related to respiratory disorders [40] and inflammatory diseases [41] .

The suitable consumption of whole-grain cereal products is an important element of health-promoting diet. The present results indicated that a considerable percentage of the respondents did not consume them at the recommended frequency. The percentage of individuals with the appropriate consumption of whole grains did not exceed 40% in G1 and G2, while in G3 it was significantly higher (47.5%), but still insufficient. The positive influence of whole grains on improving immune function is observed [42] .

Currently available research indicated that vitamin D deficiency was associated with an increased risk of developing COVID-19 [43] . It is even more important to provide its suitable amounts with the diet during the pandemic. It may be achieved by the consumption of larger proportions of its sources-milk products and fish. Our study showed that the recommended level of dairy product consumption was reached by less than half of G1 and G2 respondents (49.2% vs. 45.7%, respectively). The percentage of individuals adhering to the recommendations in group G3 was significantly higher (55.6%), but, still, it could not be assessed as satisfactory. Fish consumption was even lower. The frequency compliant with the recommendations was noted in only one-third of G1 and G2 individuals (31.5 vs. 34.4) , and in less than half of G3 individuals. The suitable frequency of fish consumption is particularly important in the context of viral diseases. It was demonstrated that fish oil increased antiviral response and inhibited virus replication [44] . It is possible that the increased dietary omega-3 consumption or its supplementation may promote the prophylaxis and treatment of COVID-19 via the reduction of the intensity of the inflammation (COVID-19) [45] . Therefore, omega-3 acids may exert a positive effect on inflammatory diseases [46] .

Nuts and seeds are the element of healthy dietary pattern. They are characterized by a high content of unsaturated fatty acids, plant protein, a considerable amount of polyphenols, phytosterols, dietary fiber, and vitamins and minerals (folic acid, vitamin E, selenium, magnesium) [47] , which may have a synergistic action and promote health, also by supporting the immune function. To date, no research has been conducted to assess the possible effect of nut consumption in combating viral or bacterial diseases or the potential complications of such infections [48] .

Regardless of the psychological profile, over 90% of the respondents consumed water at the recommended frequency. Nevertheless, similarly to the remaining recommendations, G3 individuals were characterized by the highest adherence. Proper hydration is essential for healthy life. Water is necessary for maintaining cellular homeostasis. It transports nutrients to cells and removes the waste products of metabolism. Water facilitates the functioning of all transport systems enabling exchange between the cells, interstitial fluid and capillaries. Water supports the maintenance of vascular volume and enables blood circulation, which is essential for the functioning of all body organs and tissues. Therefore, appropriate hydration is necessary to provide the normal activity of the cardiovascular and respiratory systems, the digestive tract, reproductive system, kidneys, liver, brain and the peripheral nervous system [49] . Drinking water may strengthen the adaptive immune response by removing toxins from the body through the kidneys and sweat glands [50] .

As regards unhealthy products, the adherence to recommendations was diversified between groups in case of sweetened drinks. A significantly lower percentage of persons consumed such drinks at a recommended frequency in group G1. The consumption of non-alcoholic beverages containing sugar is considered as the main factor contributing to the epidemic of obesity [51] . Moreover, non-alcoholic beverages reduce the feeling of satiety and the level of perceiving the sweet taste, leading to excessive energy consumption and. As a consequence, body weight increases and the risk of developing type 2 diabetes mellitus is higher [52, 53] .

It is worth noting that undertaking unhealthy eating behaviors (e.g., an increased consumption of high-energy snacks) during the pandemic was associated with the experience of strong negative emotions (e.g., anxiety) and restrictions (e.g., lockdown) [54] . Similar observations were reported by other researchers [32] .

The present research was conducted to analyze the role of basic hope and resilience in the context of undertaken dietary behaviors in the situations of mental load associated with the pandemic. It is a new approach to the issue which has not been discussed in the literature yet.

However, there are some limitations. Firstly, the study did not comprise the changes of dietary behaviors over time. The measurements were performed at one time point. Considering the above, the obtained psychological characteristics should not be discussed in cause-and-effect categories. Moreover, the direction of the changes of dietary behaviors is unknown. Therefore, the determination of the principles of dietary counseling was limited to outlining the methods of cooperation based on the "here and now" approach. The authors also did not aim at the discussion of the psychological traits in the context of causes. The present authors' Dietary Guidelines Adherence Index (DGA Index) developed on the basis of current "Healthy nutrition recommendations" for the Polish population published by the National Institute of Public Health-the National Institute of Hygiene is another important limitation of the study [24] . The index is based on the declarations of the respondents, so it should be interpreted with caution. The researchers did not verify whether the declarations of the respondents regarding their dietary behaviors were true. The principle of confidence was implemented in this study. Potential confounding factors (e.g., smoking status) constitute one of the important limitations of the present study. The study did not involve the analysis of stimulant use by the respondents and their influence on dietary behaviors during the pandemic. Further research should comprise such factors. Moreover, the study was conducted via the Internet, so only respondents with technology access could be included. Women from big cities were the dominant group in the study. Therefore, the interpretation of obtained data in terms of the general population should be rather cautious. Further research should be conducted with a larger percentage of men to verify the obtained correlations.

Nutrition education during pandemics should comprise the psychological profile of the patient. It requires the use of a different psychodietetic approach which may facilitate a more effective introduction of a well-balanced diet. Appropriate dietary habits are more important during pandemics than at any other point of time, due to their role in strengthening the immune system. It is now a priority to have a good life and live in a healthy way. A well-balanced diet concentrated on fruits, vegetables, whole-grain products, plant and animal protein and healthy fats is the best way to obtain all nutrients necessary for good health and appropriate functioning of the immune system. 

The study was conducted according to the guidelines of the Declaration of Helsinki. The authors sought approval from the Ethics Committee of the Medical University of Warsaw to conduct this study. According to the Ethics Committee, "non-interventional studies do not require the opinion of the Ethics Committee in accordance with Art. 37 al of the Pharmaceutical Law Act (Journal of Laws of 2001, No 126, item 1381)". Prior to the study the participants were informed that it was anonymous and the data were confidential. No personal data or computer IP were collected.

Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

The data presented in this study are available on request from the corresponding author. The data are not publicly available due to psychological data.

The authors declare no conflict of interest.

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