European Journal of Cardiovascular Medicine

According to the World Health Organization (WHO) [1], an occupational disease is defined as, “Any disease contracted primarily as a result of exposure to risk factors arising from work activity”. The Occupational Safety and Health Administration (OSHA) [2] regards an occupational disease as, “Any abnormal condition or disorder, other than one resulting from an occupational injury, caused by exposure to factors associated with employment”. The European Agency for Safety and Health at Work (EU-OSHA) [3] further defines that an occupational disease is, “Any illness caused or made worse by workplace factors”.

Occupational diseases in healthcare workers result from workplace exposure and hazards. Healthcare workers play a critical role in public health by providing essential medical care to patients. However, their work environment exposes them to a wide range of occupational hazards that can compromise their health and well-being. From exposure to infectious diseases and hazardous chemicals to physical strain and workplace violence, healthcare workers face numerous risks in the course of their duties. Healthcare workers in areas such as operating, delivery, emergency rooms and laboratories have an enhanced risk of exposure. Cleaners, waste collectors, and others whose duties involve handling blood-contaminated items are also at risk [4]. In spite of this knowledge, the healthcare work environment continues to be neglected by governments and organizations [9]. In fact many healthcare workers have lost track of their own personal health and well-being while striving to do well in their profession.

It is estimated that in India, 17 million occupational non-fatal injuries (17.0% of that in the world) and 45,000 fatal injuries (45.0% of the total deaths due to occupational injuries in the world) occur each year. Out of 11 million cases of occupational diseases in the world, 1.9 million Cases (17.0%) are contributed by India and out of 0.7 million deaths in the world, 0.12 million deaths (17.0%) is contributed by India [8].A study conducted by Amit Kumar and Ansuman Panigrahi in Bhubaneswar, India[10] showed that most healthcare workers reported experiencing occupational health hazards, with 51.7% encountering biological hazards and 75.6% experiencing non-biological hazards. Stress (38.9%), assault (38.4%), needlestick injuries (34.3%), and direct contact with contaminated specimens/body fluids (32.6%) were the most frequently experienced occupational hazards.

In the present study area there was no study addressing occupational hazards among healthcare workers. The objective is to study the occupational hazards among healthcare workers and possible remedial measures in a tertiary care hospital, Secunderabad.

An Institution based cross-sectional study was conducted among healthcare workers in a tertiary care hospital, Telangana, India. The study population consisted of doctors, nurses, and laboratory technicians of various departments in the above-mentioned hospital in Telangana with a total of more than 1000 healthcare workers. The sample size calculated statistically by using OpenEpi software was 297 healthcare workers (doctors, nurses, and laboratory technicians) from various specialties. A sample of 300 healthcare workers was randomly selected with proportional representation of the size of each professional category. The study tool for data collection consisted of a pre-designed, pre-tested, semi-structured questionnaire given to the study population with prior informed consent.

Inclusion criteria & Exclusion criteria: To ensure specificity and exclude irrelevant studies, we chose healthcare workers (willing to give the informed consent) working in the hospital for more than 1 year. Healthcare workers who were unavailable /unable to participate at the time of data collection and who had pre-existing medical and mental disorders before joining the hospital were excluded from the study.

Questionnaire: The questionnaire consisted of closed and open questions, categorized into seven sections to achieve the objectives of the study. Section one of the questionnaire covered socio-demographic characteristics of the healthcare workers, which included age, sex, occupation, speciality, and years of experience in healthcare. Section two of the questionnaire covered biological hazards exposure experienced by the healthcare workers, which included infectious agent’s exposure, needle stick injuries, and sharps injuries. Section three of the questionnaire covered chemical hazards exposure experienced by the healthcare workers, which included chemical exposure and respiratory conditions. Section four of the questionnaire covered physical hazards exposure experienced by the healthcare workers, which included eye conditions, noise exposure, dermatological conditions, and radiation exposure. Section five of the questionnaire covered ergonomic hazards exposure experienced by the healthcare workers, which included musculoskeletal discomfort and pain. Section six of the questionnaire covered psychosocial hazards exposure experienced by the healthcare workers, which included violence, assault, and shift work. Section seven of the questionnaire covered general health and well-being of the healthcare workers, which included mental health issues, substance misuse, overall general rating of the institution in terms of providing adequate protection from occupational hazards, and overall general rating of their health and well-being.

Data Collection: The timeline of the study was from February 2023 to April 2023, with data collection taking place in the month of March 2023.The Institutional Ethics Committee approved this study. Data was collected manually after taking oral consent from the participants who were well aware of the study. No personally identifiable data was collected to maintain confidentiality. Data collection and analysis was performed with Google productivity and collaboration tools.

SOCIO-DEMOGRAPHIC CHARACTERISTICS: The study population consisted of healthcare workers of various departments working in a tertiary care hospital, Telangana. The following Table-1 provides the summary of socio-demographic characteristics collected.

Table 1: Socio-Demographic Characteristics

OCCUPATIONAL HAZARDS

The International Labour Organization (ILO)[5] Categorizes occupational hazards that affect healthcare workers as:

• Biological Hazards
• Chemical Hazards
• Physical Hazards
• Ergonomic Hazards
• Psychosocial Hazards

BIOLOGICAL HAZARDS: The prevalence of biological hazards among the healthcare workers was 284 (94.7%). This consisted of infectious agent’s exposure, needle stick injuries and sharps injuries. 271 (90.3%) of the healthcare workers were exposed to infectious agents with the majority being air-borne (78.5%) followed by droplet (72.2%) as shown in Figure 1. TB, MRSA, HIV, hepatitis B, hepatitis C, conjunctivitis, URTI (consisting of common cold, pharyngitis, tonsillitis, acute rhinitis, etc.), contact dermatitis, COVID-19, etc. were the commonly mentioned infections healthcare workers were exposed to.

Figure 1: Infectious agent’s exposure among healthcare workers. (n=270)

The prevalence of needle stick injuries and sharps injuries is shown in Figure 2. Out of the 208 (69.3%) healthcare workers who experienced injuries most were not serious and many took remedial actions.

Figure 2: Needle sticks injuries and sharps injuries among healthcare workers. (n=300)

CHEMICAL HAZARDS: The prevalence of chemical hazards among the healthcare workers was 162 (54.0%).Around 134 (44.7%) were exposed to harmful chemicals. Healthcare workers were found to be frequently exposed to formalin, fumigatory substances (formaldehyde, sodium hypochlorite, peroxide), and anesthetic gasses upon accidental leakage. Dizziness, giddiness, headache, skin allergies, burning sensation of eyes, nose, and throat were the major adverse effects suffered by them due to exposure to the above mentioned chemicals. 55 (18.3%) healthcare workers who had respiratory conditions such as asthma, bronchitis, emphysema, and allergic rhinitis were found to have aggravated symptoms due to harmful chemical exposure; mainly formalin.

PHYSICAL HAZARDS: The prevalence of physical hazards among the healthcare workers was 274 (91.3%). The following physical hazards were studied:

Eye Conditions - 221 (73.7%) experienced eye conditions such as eye strain and eye pain during work. Night duty, long work hours, exposure to formalin, performing time consuming surgeries, and looking through the microscope for a long time were the major reasons for eye conditions among healthcare workers.

Noise Exposure - 152 (50.7%) experienced discomfort due to occupational noise exposure. Squabbles among patients and their attendants, sounds from old machines (processing machines like auto analyzers, ICU machines, etc.) were the major causes of occupational noise exposure among healthcare workers. Healthcare workers working in the orthopedics operation theater experienced discomfort due to noise from air powered and electric drills.

Dermatological Conditions - 160 (53.3%) experienced skin conditions such as dermatitis, eczema, and allergic reactions during work. Glove powder from latex gloves and spirit were the major causes of dermatological conditions among healthcare workers.

Radiation Exposure - 113 (37.7%) were frequently exposed to radiation in their work environment. The following Table 2 provides the summary of radiation exposure data collected. Inadequate number of lead aprons, heaviness of the lead aprons, and not providing new lead aprons were the common issues raised by healthcare workers working in radiation exposed areas such as operation theaters. Radiologists mentioned that they were made to wear a dosimeter which measures their ionizing radiation exposure.

Table 2: Radiation Exposure

ERGONOMIC HAZARDS: The prevalence of ergonomic hazards among the healthcare workers was 251 (83.7%).Ergonomics is “the concept of designing the working environment to fit the worker, instead of forcing the worker to fit the working environment” [16]. The study focused mainly on musculoskeletal discomfort and pain. The prevalence of areas of musculoskeletal discomfort and pain is shown in Figure 3. 275 (91.7%) of the healthcare workers said that no ergonomic remedial measures were implemented by the institution.

PSYCHOSOCIAL HAZARDS: The prevalence of psychosocial hazards among the healthcare workers was 291 (97.0%). 209 (69.7%) reported that they experienced incident(s) of violence or assault from colleagues, patients and their attendants. 140/209 (69.0%) healthcare workers said that the incident(s) affected them mentally for a certain period of time. The prevalence of the nature of assault is shown in Figure 4. 254 (84.7%) said that they frequently worked either for long hours or did night shifts. 273 (91.0%) said that they experienced fatigue and sleep disturbance due to their work schedule.

GENERAL HEALTH AND WELL-BEING: The study included the following aspects to understand the general health and well-being of the healthcare workers:

MENTAL HEALTH ISSUES - 272 (90.6%) healthcare workers experienced mental health issues attributed to inadequate infrastructure and management, difficulty with clinical cases, job constraints, and lack of job satisfaction. The prevalence of various mental health issues experienced by the healthcare workers is shown in Figure 5. Rest, frequent short breaks, spending time with family and friends, listening to music, exercise, travel, etc. were the common ways in which most of the healthcare workers coped up with their mental health issues. A significant number of healthcare workers said that they got used to their mental health issues

SUBSTANCE MISUSE - 34 (11.3%) healthcare workers said that they consumed substances to cope up with their mental health and work. The commonly consumed substances were Selective Serotonin Reuptake Inhibitors (SSRIs) like Sertraline (Zoloft), Escitalopram (Lexapro), Fluoxetine (Prozac), Citalopram (Celexa), and Norepinephrine-Dopamine Reuptake Inhibitors (NDRIs) like Bupropion(Wellbutrin),Amineptine (Survector), Desoxypipradrol (2-DPMP), Dexmethylphenidate (Focalin). A few healthcare workers also mentioned that they smoked cigarettes and consumed alcohol to cope up with their mental health conditions.

IN GENERAL - Healthcare workers were asked to rate the institution in terms of providing adequate protection from occupational hazards and their general health and well-being. The following Table 3 provides the summary of data collected.

Finally, healthcare workers were asked if they had any occupational concerns. A serious need for increase in workforce and decrease in workload by dividing work appropriately was expressed. Improvement in overall hygiene; provision of basic amenities like adequate workspaces, good wash areas and restrooms, sleep arrangements, better isolation wards, new and updated equipment (PPE kits, lead aprons, microscopes, instruments, machines, etc.) were the major concerns expressed.

Table 3: General Health and Well-Being

Figure 3: Areas of musculoskeletal discomfort and pain among healthcare workers. (n=228)

Figure 4: Nature of assault among healthcare workers. (n=208)

Figure 5: Mental health issues experienced among healthcare workers. (n=300)

Despite a high prevalence of occupational hazards among healthcare workers, more than a third failed to recognize immediate health consequences and impact. Upon probing, many were able to identify the hazards. This study highlights gaps between training, perceived importance, and actual practice of occupational risk control and management among healthcare workers.Majority of the healthcare workers had 1-5 years of experience which was in accordance with a study conducted by Minikumary C. K. et al. in Bhubaneswar, India [11].

Table 4: Speciality and Biological Hazards.

BIOLOGICAL HAZARDS: The study revealed a high prevalence of biological hazards exposure (94.7%) among healthcare workers which was higher than that of a study conducted by Amit Kumar and Ansuman Panigrahi in Bhubaneswar, India (51.7%) [10]. This indicates that health safety practices, Infection Prevention and Control (IPC) were inadequate in the hospital.Exposure to infectious agents (90.3%) was the most prevalent biological hazard. Irrespective of the speciality, healthcare workers were prone to air-borne infections. Table 4 correlates between the speciality and the biological hazards that healthcare workers were prone to mainly and in particular.

Though the healthcare workers were exposed to various infectious agents, they mentioned that the Hospital Infection Control Committee was taking adequate care of them by making sure they were vaccinated through programs in accordance with the immunization schedule (Ex. Hepatitis B, HPV, etc.). As seen in Figure 2, needle stick injuries (64.0%) were more prevalent than sharps injuries (29.0%). The incidence of needle stick injuries among healthcare workers was found to be 7.0% in General Surgery, 3.0% in Obstetrics and Gynecology, and 1.3% in Pediatrics. These findings were lower than those in a study conducted by Vincenzo Bianco et al. [12] in a Southern Italian Tertiary Hospital (14.21% in General Surgery, 9.00% in Obstetrics and Gynecology, and 6.49% in Pediatrics).

CHEMICAL HAZARDS: In chemical hazards, formalin was found to be the most mentioned chemical that healthcare workers were exposed to which was in accordance with a study conducted by J J Gestal in Spain [13]. Pathologists and Forensic pathologists in particular were prone to formalin exposure. Formalin is used as a preservative, fixative, and disinfectant. Formalin has always been the gold standard for more than 100 years as a fixative in laboratories (pathology, microbiology, etc.).

PHYSICAL HAZARDS: Night duty and long work hours were the major reasons for eye conditions among healthcare workers. Pathologists and microbiologists in particular experienced eye conditions while looking through the microscope for a long time. Healthcare workers working in the orthopedics operation theater experienced discomfort due to noise from air powered and electric drills. These findings were corroborated by a study conducted by A. Vijendren et al. in the UK [14]. The prevalence of dermatological conditions (53.3%) among healthcare workers was more than the reported prevalence of irritant contact dermatitis in a study conducted by K T Kim et al. in the US (21.8%) [15]. It was surprising to find that 94.1% of the radiologists suffered from dermatological conditions due to glove powder in latex gloves. Many surgeons and nurses working in the operation theater where ionizing radiation was used, mentioned about an inadequate number of lead aprons and how they were not protected from radiation completely.

ERGONOMIC HAZARDS: Out of the 300 healthcare workers, 251 (83.7%) reported that they suffered from musculoskeletal discomfort and pain which was higher in prevalence than that reported in a study conducted by Ksenia A. Aaron in the US (69.7%) [16]. Lumbar back pain was the most prevalent musculoskeletal pain which was in accordance with a study conducted byA. Vijendren et al. in the UK [14]. The prevalence of lumbar back pain was more in females while males suffered mostly due to long standing hours.

PSYCHOSOCIAL HAZARDS: Majority of the healthcare workers experienced verbal abuse (66.7%) from patients and their attendants mainly which was in accordance with a study conducted by Sandro Vento et al. [17]. The healthcare workers said that they were initially affected emotionally by the verbal assaults but they got used to it later and started acting accordingly without getting emotional. Prevalence of psychosocial hazards (97.0%) was the highest among all the hazards.

GENERAL HEALTH AND WELL-BEING: The prevalence of anxiety, depression, and burnout was found to be more among the 20-35 years age group which was in accordance with a study conducted by Jenny Firth-Cozens in England [18]. The incidence of stress among healthcare workers (80.3%) was a little higher than that of a study conducted by Shibu Sasidharan and Harpreet Singh Dhillon among healthcare workers in a COVID-19 intensive care unit (71.0%) in Haryana, India [19]. Substance misuse (11.3%) was rather lower than that of a study conducted by George A Kenna and David C Lewis in the US (25.0%) [20]. Majority of the healthcare workers were able to control and cope up with their mental health without consumption of any substance.

Overall, the healthcare workers were fairly satisfied with the support systems provided by the institution, but expressed dissatisfaction with other aspects like inadequate infrastructure, management, and the system to report workplace grievances. A serious need for increase in workforce and decrease in workload by dividing work appropriately was expressed. Improvement in overall hygiene; provision of basic amenities like adequate workspaces, good wash areas and restrooms, sleep arrangements, better isolation wards, new and updated equipment (PPE kits, lead aprons, microscopes, instruments, machines, etc.) were the major concerns expressed. Most of the equipment was mentioned to be old and not up to standards

LIMITATIONS & STRENGTHS: A possible limitation of this study was sampling bias though the traditional method of data collection was followed. The study was also limited in the sample selection. Although the study was conducted among healthcare workers, it was limited in showing the strength of such association due to sample size for exposure and category of worker. Hesitation among healthcare workers in reporting substance misuse and providing negative responses was noticed. Many healthcare workers repeatedly expressed fear of disclosure of their data. Factors outside the workplace, such as personal health habits and environmental factors can confound results and make it difficult to isolate the effects of occupational hazards.  Strength of this study was that the study population consisted mainly of doctors (61.3%) and nurses (31%) who provided critical insight about the occupational hazards they were exposed to. Thanks to their honest responses, the primary objectives of the study could be achieved

There is a high prevalence of occupational hazards among healthcare workers in the tertiary care hospital, Telanagana. These hazards vary in prevalence, severity, and impact depending on factors such as the healthcare setting, patient population, and organizational policies. Effective management of occupational hazards among healthcare workers requires a multifaceted approach that includes comprehensive training in health safety practices, Infection Prevention and Control (IPC), increase in workforce and decrease in workload by dividing work appropriately. Additionally, ongoing research, collaboration and adherence to regulatory standards are essential to ensure the safety and well-being of healthcare workers.By recognizing the diverse nature of occupational hazards in healthcare and implementing targeted preventive measures, the government and the society can work together to create safer work environments and better protect those who dedicate their careers to caring for others.

RECOMMENDATION: Comprehensive training, provision of appropriate Personal Protective Equipment (PPE), upgraded technology and engineering controls will reduce biological hazards.Provision of better grossing stations with good exhaust fans in the pathology and forensic laboratories will reduce formalin levels present in the air. While using formaldehyde, sodium hypochlorite, peroxide, and other disinfectants to disinfect wards and operation theaters, it is advisable to facilitate as much ventilation as possible by opening doors and windows to reduce the concentration of chemicals in the air. It is advisable to fumigate wards and theaters when no one is present to avoid the after effects of chemical exposure among healthcare workers and patients. Healthcare workers who disinfect the wards and operation theaters should wear adequate eye and body protection.

Allergy due to glove powder present in latex gloves was the major reason for dermatological conditions among healthcare workers. Nitrile gloves are known to not cause allergies. Nitrile gloves were found to be more effective than powdered latex gloves in a study done by M Mansouri et al. [21]. While wearing hand gloves, instead of wearing two pairs of powdered latex gloves, it is advisable to first wear a pair of nitrile gloves and then wear a pair of latex gloves as the second pair.Exposure to ionizing radiation can cause skin and blood damage, cataract, infertility, birth defects, and cancer. It is important to provide adequate eye protection equipment and lead aprons to all the healthcare workers working in operation theaters during procedures which require radiation. It is also critically important to note that the lead apron must cover the thyroid gland and the head in addition to the chest and abdomen.

To reduce ergonomic hazards, it is important for the institution to implement ergonomic remedial measures such as creating ergonomic awareness along with providing ergonomic equipment and furniture.To reduce incidence of violence or assault among healthcare workers, it is important to increase and tighten security in and around the hospital.To reduce mental health issues, healthcare workers should not be subjected to heavy workload. Work hours can be reduced by increasing the staff. Healthcare workers should work in a friendly and motivating environment. If not given importance, work related stress may lead to burnout and further health complications.

FUNDING: No financial support was received for this study

CONFLICT OF INTEREST: There are no potential conflicts of interest with respect to the research, authorship, and publication of this article

1. World Health Organisation (WHO), 2021. Occupational and Work-Related Diseases.
2. Occupational Health and Safety (OSHA) (2021). Occupational Safety and Health Act of 1970.
3. EU-OSHA. (2021). Work-Related Diseases.
4. World Health Organization. AIDE-MEMOIRE: For a strategy to protect health workers from infection with blood borne viruses. 2003.
5. International Labour Organization (ILO). (2018). International labour standards on occupational safety and health.
6. National Cancer Institute: Formaldehyde and Cancer Risk.
7. Government of India, Ministry of Health and Family Welfare Statistics Division; Rural Health Statistics, 2018-2019.
8. Employee State Insurance Corporation Occupational Disease Centre. Burden of Occupational Injuries in India.
9. Lipscomb J, Rosenstock L. Healthcare workers: Protecting those who protect our health. Infection Control and Hospital Epidemiology.1997; 18: 397-399.
10. Kumar, A., Panigrahi, A. Occupational health hazards among health care personnel working in public health facilities in Bhubaneswar, India. J Public Health (Berl.) 29, 633–639 (2021).
11. Minikumary CK, Pillai JSK, Mondal R. A study on occupational safety and health among workers at a tertiary care hospital at south India. Int J Community Med Public Health 2023;10:254-7.
12. Bianco V, Spera AM, Maraolo AE, Parente S, Donno D, Schiano Moriello N, Tosone G. Risk of professional accidental exposure to biological agents in health care workers: a retrospective analysis carried out in a southern Italian tertiary hospital. Infez Med. 2019 Mar 1;27(1):40-45. PMID: 30882377.
13. Gestal JJ. Occupational hazards in hospitals: accidents, radiation, exposure to noxious chemicals, drug addiction and psychic problems, and assault. Br J Ind Med. 1987 Aug;44(8):510-20. doi: 10.1136/oem.44.8.510. PMID: 3307896; PMCID: PMC1007869.
14. Vijendren A, Yung M, Sanchez J. Occupational health issues amongst UK doctors: a literature review. Occup Med (Lond). 2015 Oct;65(7):519-28. doi: 10.1093/occmed/kqv088. Epub 2015 Jul 14. PMID: 26175495.
15. Kim KT, Wellmeyer EK, Miller KV. Minimum prevalence of latex hypersensitivity in health care workers. Allergy Asthma Proc. 1999 Nov-Dec;20(6):387-91. doi: 10.2500/108854199778251780. PMID: 10624496.
16. Aaron KA, Vaughan J, Gupta R, Ali N-E-S,Beth AH, Moore JM, et al. (2021) The risk of ergonomic injury across surgical specialties. PLoS ONE 16(2): e0244868.
17. Vento S, Cainelli F, Vallone A. Violence Against Healthcare Workers: A Worldwide Phenomenon With Serious Consequences. Front Public Health. 2020 Sep 18;8:570459. doi: 10.3389/fpubh.2020.570459. PMID: 33072706; PMCID: PMC7531183.
18. Firth-Cozens J. Source of stress in women junior house officers. BMJ. 1990 Jul 14;301(6743):89-91. doi: 10.1136/bmj.301.6743.89. PMID: 2390589; PMCID: PMC1663442.
19. Sasidharan S, Dhillon HS. Stress and burnout among health-care workers in the coronavirus disease 2019 intensive care unit. Int J Crit Illn Inj Sci. 2021 Oct-Dec;11(4):257-261. doi: 10.4103/ijciis.ijciis_45_21. Epub 2021 Dec 18. PMID: 35070917; PMCID: PMC8725809.
20. Kenna GA, Lewis DC. Risk factors for alcohol and other drug use by healthcare professionals. Subst Abuse Treat Prev Policy. 2008 Jan 29;3:3. doi: 10.1186/1747-597X-3-3. PMID: 18230139; PMCID: PMC2265282.
21. Mansouri M, Tidley M, Sanati KA, Roberts C. Comparison of blood transmission through latex and nitrile glove materials. Occup Med (Lond). 2010 May;60(3):205-10. doi: 10.1093/occmed/kqp196. Epub 2010 Jan 22. PMID: 20097745.
22. Nazanin Izadi and Reza Piruznia. Occupational Health Hazards among Health Care Workers. Public H Open Acc 2017, 2(1): 000120.
23. Che Huei L, Ya-Wen L, Chiu Ming Y, Li Chen H, Jong Yi W, Ming Hung L. Occupational health and safety hazards faced by healthcare professionals in Taiwan: A systematic review of risk factors and control strategies. SAGE Open Med. 2020 May 18;8:2050312120918999. doi: 10.1177/2050312120918999. PMID: 32523695; PMCID: PMC7235655.
24. Mohanty A, Kabi A, Mohanty AP. Health problems in healthcare workers: A review. J Family Med Prim Care. 2019 Aug 28;8(8):2568-2572. doi: 10.4103/jfmpc.jfmpc_431_19. PMID: 31548933; PMCID: PMC6753812.
25. Owie HO, Apanga PA (2016) Occupational Health Hazards Prevailing among Healthcare Workers in Developing Countries. J AIDS Clin Res 7: 596. doi:10.4172/2155-6113.1000596.
26. Shanafelt TD, Noseworthy JH. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 2017 Jan;92(1):129-146. doi: 10.1016/j.mayocp.2016.10.004. Epub 2016 Nov 18. PMID: 27871627.
27. Shevchenko MV, Yurochko TP, Hrechko II. Factors of working environment influencing occupational stress among primary health care doctors in Ukraine. Wiad Lek. 2019;72(5 cz 2):1038-1042. PMID: 31175740