Background: During the current COVID-19 pandemic, alcohol, and tobacco are the most available substances for managing stress and can induce a risk of addiction. KANOPEE is a smartphone application available to the general population using an embodied conversational agent (ECA) to screen for experiences of problems with alcohol/tobacco use and to provide follow-up tools for brief intervention.Objectives: This study aimed to determine if the smartphone KANOPEE application could identify people at risk for alcohol and/or tobacco use disorders in the context of the current COVID-19 pandemic, to assess adherence to a 7-day follow-up use diary, and to evaluate trust and acceptance of the application.Methods: The conversational agent, named Jeanne, interviewed participants about perceived problems with the use of alcohol and tobacco since the pandemic and explored risk for tobacco and alcohol use disorder with the five-item Cigarette Dependence Scale (CDS-5) and “Cut Down, Annoyed, Guilty, Eye-opener” (CAGE) questionnaire and experience of craving for each substance. Descriptive, univariate, and multivariate analyses were performed to specify personalized associations with reporting a problem with alcohol/tobacco use; descriptive analysis reported the experience with the intervention and acceptance and trust in the application.Results: From April 22 to October 26, 2020, 1,588 French participants completed the KANOPEE interview, and 318 answered the acceptance and trust scales. Forty-two percent of tobacco users and 27% of alcohol users reported problem use since the pandemic. Positive screening with CDS-5 and CAGE and craving were associated with reported problem use (p < 0.0001). Lockdown period influenced alcohol (p < 0.0005) but not tobacco use (p > 0.05). Eighty-eight percent of users reported that KANOPEE was easy to use, and 82% found Jeanne to be trustworthy and credible.Conclusion: KANOPEE was able to screen for risk factors for substance use disorder (SUD) and was acceptable to users. Reporting craving and being at risk for SUD seem to be early markers to be identified. Alcohol problem use seems to be more reliant on contextual conditions such as confinement. This method is able to offer acceptable, brief, and early intervention with minimal delay for vulnerable people. Since December 2019, cases of severe acute respiratory syndromes due to Coronavirus 2 (SARS-CoV-2) also named COVID-19 , 4. It iTobacco and alcohol are the most accessible substances worldwide  and remaRecently, concern was expressed about the increase in tobacco use and relapse among smokers due to the decrease or absence of usual sources of regulation . In peopDuring the development of an addiction, use is no longer contextual and can continue outside of the stressful period in which it began. Independent of these environmental factors, individual factors contribute to alcohol and tobacco use. These include use disorders, mental disorders, and individual responses to stress . To reduThe current COVID-19 crisis requires new means for identification of health status, while maintaining the principles of reducing person-to-person contact and contamination. In this context, a proactive approach to monitoring alcohol and tobacco use in the general population is essential. Protocols may be oriented toward the development of virtual and/or distant resources and the reduction of face-to-face visits . During KANOPEE is the first application of embodied conversational agents (ECAs), otherwise named virtual agents, whose intended purpose is to detect and prevent problems with tobacco and alcohol use as well as sleep disorders related to the COVID-19 pandemic –25. It cKANOPEE was launched during the COVID-19 pandemic to respond to the immediate needs of addressing the mental health of the French population in that context. In this first report on the use of the KANOPEE smartphone application for alcohol and tobacco assessment, our objectives were to identify people at risk for alcohol and/or tobacco use disorders and to determine if the application could determine personalized risk factors associated with reporting problems with alcohol/tobacco use. This was operationalized as examining if self report of problems with alcohol/tobacco use during current COVID-19 pandemic were associated with being at risk of SUD, reporting tobacco/alcohol craving, being a COVID-19 healthcare worker, and being confined due to pandemic lockdown restrictions. Moreover, characteristics of the follow-up respondents were studied to examine the profile of users of the diary. Lastly, trust toward the virtual agent and acceptance of the overall system were measured, and we analyzed if user characteristics influenced attitude toward the virtual agent.Data were collected from users of the KANOPEE application, downloaded voluntarily between April 22 and October 26, 2020. Respondents were anonymous and had to meet the following inclusion criteria: be of legal age (18 years old and over), have used tobacco or alcohol at least once in the past 12 months, and have completed the screening interview for tobacco and alcohol use disorder . The approval of the scientific committees of the University of Bordeaux was obtained as well as the agreement with respect to the General Data Protection Regulations (GDPR) by the French authorities (CNIL). Informed consent was obtained directly on the app by all participants who downloaded the application.KANOPEE is a smartphone application developed by the University of Bordeaux (SANPSY CNRS USR 3413) in partnership with CHU Bordeaux and CH Charles Perrens. It is available for Android and Apple IOS and for free download since April 2020. It provides weekly interactions with a virtual agent named Jeanne, proposing a screening evaluation assessing lifetime and current (past year) alcohol and tobacco use, craving for alcohol and tobacco, and risk of SUD. Furthermore, Jeanne inquires about experiencing problems with alcohol or tobacco use since the COVID-19 epidemic.For users identified as “at risk” , a daily use diary was proposed.The diary was designed to help the user to monitor craving and daily alcohol and tobacco intake and to confront it by self-determined daily use objectives. The diary was initially available as a downloadable printable version and then was integrated within the application in an update . After 7 days and then every 7 days thereafter, a follow-up evaluation with Jeanne asked participants on whether the application and diary were helpful. After 2 weeks of use, the application questioned participants on whether direct contact with a healthcare worker was required.Age, gender, level of education, and socio-professional category (SPC) collected as sociodemographic data.Period of confinement: according to the date of the initial KANOPEE interview. In France, the period of confinement was from April 22, 2020, to June 1, 2020, and the post-confinement period was from June 2, 2020, onward.COVID-19 healthcare worker: provided by answering yes to the question “Are you currently involved in the care of patients infected with COVID-19?”Reported problem with alcohol/tobacco use during the epidemic: provided by answering yes to the question “In the context of the COVID-19 epidemic, did you feel that your situation with respect to tobacco/alcohol has worsened?”Risk of SUD: Screening questionnaires were previously adapted to be performed by an ECA .Acceptance and trust questionnaires: After the interviews with the virtual agent, users could complete two assessments on the application. The French version of the Acceptability E-scale  and standard deviations (SD) and categorical variables by frequencies and percentages (%). The dependent variable was the reported problem with alcohol/tobacco use due to the epidemic, and explanatory variables were to present a risk of SUD, craving, using the application during the period of confinement, and being a COVID-19 Healthcare worker. Analyses were carried out separately for tobacco and alcohol users. Descriptive and univariate analyses were first conducted.We described continuous variables by means . The proportion of the explained variance of multivariate models was examined with the R2(U) value. Univariates analyses were also conducted to identify variables associated with completing follow-up assessments and finding the application and diary helpful. Lastly, to investigate factors associated with acceptance and trust, we conducted univariate analyses with Pearson correlation analyses between two continuous variables  and performed mean comparisons  to analyze the variation in AES and ETQ scores regarding categorical variables .To determine risk factors for p ≤ 0.05.Analyses were performed using the JMP Pro 14® software. The significance threshold was set at From April 22, 2020, to October 26, 2020, 1,588 subjects downloaded the application and answered at least one interview on tobacco and/or alcohol from the KANOPEE application .M = 43.56, SD = 13.67), mostly women , and half had a high level of education (≥12 years) . Two-thirds  responded during the confinement period . One hundred twenty-seven (8%) subjects reported being COVID-19 healthcare workers.The sample mean age was 44 years old  reported tobacco use during the past year, and among them, 83.85% (N = 592) reported craving for tobacco. The mean CDS-5 score was 13.34 (SD = 5.69), and 496 (70.16%) tobacco users were at risk of tobacco use disorder (CDS-5 score > 9). Almost the entire sample reported past-year alcohol use , and among them, 28.17% (N = 416) reported craving for alcohol. The mean CAGE score was 0.95 (SD = 1.67), and 482 (32.61%) alcohol users were at risk of alcohol use disorder (CAGE score > 1).Regarding tobacco and alcohol use, half of the sample (N = 177) were at risk for both alcohol and tobacco use disorder (CDS-5 score > 9 and CAGE > 1).Six hundred and fifty-five subjects (41.25%) used both substances, and 11% (N = 297) than that of alcohol users  reported a problem use since the context of the epidemic.A higher proportion of current tobacco users  was associated with more frequent reports of problem with alcohol/tobacco use (p < 0.0001). Being a COVID-19 healthcare worker increased the risk of reporting a problem with alcohol use during the current epidemic (p = 0.0463) but did not increase the risk to report a problem with tobacco use. There was no significant difference between the proportion of those who reported a problem with alcohol/tobacco use according to period of use of the application (during the confinement period or after) .Results of univariate analyses  suggest p < 0.0001) and experiencing craving .Multivariate analysis  showed tp < 0.0001), experiencing craving , and being currently in a period of confinement .For alcohol, reporting problem use was associated with being at risk of alcohol use disorder  = 0.1074] and around 15% of reporting alcohol problem use [R2(U) = 0.1511].The whole model explained approximately 11% of the variations of reporting tobacco problem use [N = 38) found the application and the diary helpful .There was no difference in terms of age, gender, socio-professional categories, and level of education between the initial and follow-up samples (p < 0.05) and to complete it outside of the confinement period (p < 0.05). For alcohol, subjects who filled the 7-day evaluation were more likely to report a use disorder risk (p = 0.0175) and craving for alcohol (p = 0.0034). For tobacco, subjects who filled the 7-day evaluation were more likely to report tobacco problem use (p = 0.0434).COVID-19 healthcare workers were more likely to fill the 7-day follow-up evaluation (p = 0.0300).Compared to the initial sample, reporting that the application and diary were helpful was more frequent for those who reported a tobacco problem use  users answered the acceptance and trust questionnaires .Acceptance of the overall system (AES score) was rated very positively, with 87.4% (278/318) of users being “very satisfied” with the usability of the system, and 80.0% (267/318) of users rating the virtual agent more than 3 out of 5 for satisfaction. Regarding trust (ETQ score), Jeanne was perceived as trustworthy to perform medical interviews. Indeed, 95.9% (305/318) of users “somewhat agreed” or “totally agreed” that she was benevolent, and 81.44% (259/318) of users had a positive attitude toward her credibility .r = 0.564; p < 0.001).Interestingly, correlation analyses revealed that both subscores of ETQ were positively correlated with both subscores of AES, with high coefficients of correlation, suggesting that the more Jeanne was perceived credible and benevolent, the more the whole application was found usable and satisfactory . Similarly, users with a higher familiarity with technologies found KANOPEE more usable .Regarding the influence of user characteristics, correlation analyses revealed a positive relation between the usability subscore of AES and education level, suggesting that users with a higher education level found KANOPEE more usable  did not reach a significant level of correlation between any of the subscores of AES and ETQ, suggesting that the attitude toward Jeanne and the application was not influenced by these factors.The KANOPEE smartphone application was designed to address the general population's mental health needs in the context of the current pandemic. In this study, we focused on the application's ability to access those at risk to report problem with alcohol/tobacco use, in view of facilitating early access to personalized prevention. In this report of an initial sample of 1,588 participants covering the first French general population confinement, 42% of tobacco users (297/708) and 28% of alcohol users  reported problem use due to the pandemic context. Self-report of craving and screening for SUD diagnosis by the KANOPEE application were the most consistent associated risk factors to report problem with alcohol/tobacco use. The application's self-help daily diary was used by those with increased risk, and overall, 46% reported it was helpful.Alcohol use was reported by almost the whole sample, while a little less than half used tobacco in the past 12 months. Compared to the French general population, our sample had more smokers. In 2019, 30.4% of people aged 18–75 years reported smoking tobacco  comparedCurrent tobacco users were more frequently identified as being at risk of an SUD diagnosis (around 70% with CDS-5) than alcohol users (around 33% with CAGE), and they were more likely to report a problem of use since the context of the epidemic. It is known that smoking tobacco is more addictive than drinking alcohol . Thus, eReporting a problem with alcohol use since the epidemic was more frequent among those who completed the application during the period of the first lockdown in France, which was not the case for tobacco users. Alcohol use may be more influenced by immediate contextual variations than tobacco use. Our results suggest that the KANOPEE application was able to show that if smoking may not be influenced by periods of confinement, in opposition to drinking alcohol, the overall impact of the epidemic was more important for tobacco users. Previous studies reported no or little change in tobacco use or request for support since the beginning of COVID-19 while one-half of alcohol users reported a change in alcohol use , 37, andOn another note, characteristics associated with the use of the diary were to be a COVID-19 healthcare worker, using the application out of the confinement period, reporting a tobacco problem use, being at risk of alcohol/tobacco use disorder, and reporting craving for alcohol. Ultimately, the only characteristic related to being most helped by the application was reporting a problem with tobacco use. Thus, even if the addictive core (being at risk of use disorder and presence of craving) is associated with follow-up completion, it is the subjective report of a problem use that is associated with the feeling of being helped by the KANOPEE application. This result is therefore promising for the use of KANOPEE by tobacco users , and further studies could explore why problems with tobacco use is associated with helpfulness of the diary.In this study, craving appeared to represent a marker of risk for reporting a problem with alcohol/tobacco use as much as screening with CDS-5 and CAGE. Research exploring the different SUD diagnostic criteria has reported craving as among the most consistently frequent and discriminant criteria across different SUDs, including alcohol and tobacco , 39. ThuLastly, regarding acceptance and trust measures, we reproduced in the general population previous results observed in a hospital setting , suggestSome limitations must be acknowledged. First, this study was conducted in a sample recruited through a mobile application and not through face-to-face data collection. As a result, it is possible that some of the data could be erroneous . Nevertheless, previous studies from general-population internet-based surveys have shown that the data generated may be reliable . FurtherOverall, for the first time, our data suggest that the KANOPEE application was able to access, within the French general population, a group at risk of experiencing problems with alcohol and tobacco use in the context of the COVID-19 epidemic. Our results are consistent with other reports that the epidemic has increased alcohol and tobacco misuse for some users, and in addition, we were able to characterize potential risk markers for prevention and early intervention: reporting craving and screening for risk of SUD. The promotion of KANOPEE takes place in the context of a growing demand for the use of digital technology  in the context of the pandemic. More research is needed to confirm the markers for risk of experiencing problem use with alcohol and tobacco and to determine if the early monitoring with the diary is effective as an early intervention.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their digital informed consent to participate in this study.MA was the PI for the application of KANOPEE to substance use and addiction and obtained funding. PP was the overall PI of the KANOPEE project and obtained funding. LF, FS, and LD analyzed the data. LF and MA drafted the initial manuscript. LD, FS, EB, J-MA, and J-AM-F provided methodological support, critical revision, and editing of the manuscript. ES provided technical support on data and application. All authors significantly contributed to the manuscript and approved the final version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Background: There are more and more foreigners in Poland who become clients of the Polish healthcare system. They use, among others, emergency medical services provided by healthcare professionals: doctors, nurses, and paramedics. Skillful care for culturally different patients requires cultural competencies and cultural intelligence to ensure good quality of care and cultural safety. The study aimed to measure and assess the cultural competencies and cultural intelligence of medical professionals working in hospital emergency departments (HEDs) and hospital emergency rooms (HERs) in Małopolska, a region in southern Poland. Methods: The following questionnaires were used in the study: the Cross-Cultural Competence Inventory (CCCI), the Cultural Intelligence Scale (CQS), and Questionnaire on Attitudes Towards Culturally Divergent People. In total, 709 medical professionals participated in the study, including 363 nurses, 223 paramedics, and 123 doctors. Results: Cultural intelligence—the overall score and the scores on the metacognitive, cognitive, motivational, and behavioral subscales were significantly higher among HED and HER doctors. Cultural competencies—the overall score and the score on the cultural adaptation subscale were also significantly higher among HED and HER doctors. The CCCI and CQS scores were influenced by selected variables: taking care of and close interactions with representatives of other cultural circles; staying outside Poland for more than a month. Doctors were the group of medical professionals that were most tolerant and most positive towards people from other cultures. Conclusions: The research results confirm the positive impact of contact of medical professionals with people from other cultures on their cultural competencies and cultural intelligence. They indicate the need for training in acquiring cultural competencies and developing cultural intelligence, especially among nurses. They demonstrate the need to raise awareness among HED and HER medical professionals about issues in intercultural care and to increase diversity efforts, especially among nurses. More and more foreigners in Poland become clients of the Polish healthcare system and use, among others, emergency medical services, also known as emergency care. Hence, healthcare professionals such as doctors, nurses, and paramedics in hospital emergency departments (HEDs) and hospital emergency rooms (HERs) provide assistance to an increasing number of people from other countries and cultural environments who represent different beliefs, practices, customs, and value systems. The literature emphasizes that, in such situations, cultural competencies and cultural intelligence play an important role ,7,8,9,10According to the estimates of the Central Statistical Office (GUS) of 31 December 2019, the number of foreigners living in Poland was 2,106,101  . This isThe National Health Fund (NHF) does not have nationwide data and does not keep complete statistics on the treatment of foreigners and their use of medical services in the Polish healthcare system, including units of the Polish Emergency Medical Services (PRM) system . FurtherPolish Emergency Medical Services (PRM) is a system established in Poland in order to provide medical services to people experiencing a sudden health emergency. PRM provides medical rescue operations. The system consists of outgoing medical rescue teams (ZRM): S-type ambulances , P-type ambulances (basic), N-type ambulances , T-type ambulances (transport), Helicopter Emergency Medical Service (HEMS), and hospital emergency departments (HEDs). HEDs are supported by hospital emergency rooms (HER). The PRM employs system doctors, paramedics, and system nurses .Cultural difficulties that arise in the process of building relations between medical personnel and a foreign patient are greater, the lower the degree of cultural competence of the treating and being treated and a positive or negative attitude towards people who are culturally different . TraininSkillful treatment of patients who are different in terms of culture, ethnicity, or religion requires appropriate preparation. Medical professionals, including professionals providing services in the field of emergency medicine, should acquire and develop basic cultural competencies and cultural intelligence already during studies. Cultural competencies and cultural intelligence should be developed at the undergraduate and postgraduate level in three areas: affective, cognitive, and behavioral. The first area relates to overcoming stereotypes and the belief that someone’s worldview is the most important and building a positive image and attitude towards people from other cultures. The second area is knowledge concerning the influence of religion and culture on people’s behavior in times of health and illness problems. The third area relates to verbal and non-verbal communication skills . Only siCultural competencies  are defined as a set of uniform attitudes, behaviors, and principles of medical professionals, thanks to which it is possible to work effectively with people from different cultures. Cultural intelligence is the ability of an individual to understand, correctly infer, function, manage, and deal with situations characteristic of cultural diversity.There is a need to conduct research that provides information on the cultural competencies and cultural intelligence of healthcare professionals working in the PRM system who are the first to provide help to foreigners . Using sThe study aimed to measure and assess the cultural competencies and cultural intelligence of medical professionals working in hospital emergency departments (HEDs) and hospital emergency rooms (HERs) in Małopolska, a region in southern Poland.The researchers reviewed the cities and hospitals with HEDs and HERs in Małopolska, a region in southern Poland. A list of 31 centers, i.e., 21 HEDs and 10 HERs, was created. Written requests were sent to the management boards of these institutions asking for permission to conduct research; consent was obtained to conduct research in 19 HEDs and 6 HERs. The criterion for inclusion in the research was that the respondent had an employment contract with an HED or HER. The exclusion criteria were other forms of employment in HED, HER, or employment in medical rescue teams (EMS). A list was prepared of 1052 healthcare professionals who were employed in these facilities and met the above criteria: 308 doctors, 439 nurses, and 305 paramedics. During the recruitment period (September–December 2020), the researchers distributed three printed research tools to all 1052 healthcare professionals. Some of the respondents, i.e., 320 people, did not consent to participation in the research; some, i.e., 23 people, returned not fully completed research tools. Finally, fully completed research tools were analyzed from a sample of 709 people, which constitutes 67% of the entire possible research group: 123 doctors, 363 nurses, 223 paramedics.M = 40.38, SD = 11.56; 1 participant did not indicate their age). All but two participants indicated Polish nationality. No incentive was offered for participation in the study. In general, the pool consisted of the three following groups of participants: (1) nurses (N = 363), (2) medics (N = 122), and (3) paramedics (N = 223). This pool was specifically used in the analyses of the CQS and the Positive/Negative Attitude Towards Culturally Divergent People Questionnaire. However, as recommended by the author of the original scale [M = 38.21, SD = 11.32). Finally, nurses had the most extensive work experience  compared to medics  and paramedics , F = 103.38, p = 0.001, η2 = 0.23. Most of the participants (45%) were recruited from small towns ; 26% came from middle-sized cities ; 29% were from big cities .A total of 709 individuals participated in the study  aged 20–70 . CCCI is a broad, multidimensional instrument for the detailed and comprehensive measurement of cultural competence. It also touches on deeper layers: attitudes related to cultural sensitivity/awareness, cultural skills, and the application and use of cultural knowledge. CCCI measures three aspects of cultural competence: cognitive, emotional, and behavioral. This is particularly important considering the fact that the most commonly used definition of cultural competence relates directly to three areas: knowledge—providing culturally specific information; skills—involving multicultural interventions; attitudes—cultural empathy, openness, curiosity, tolerance, lack of prejudice in interpersonal relationships, awareness of one’s own value system and its limitations, awareness of different perspectives, and hierarchies of values, norms, and patterns of behavior [behavior . The insAnswers were provided with the use of a 6-point Likert scale, where 6 meant “I strongly agree” and 1 meant “I strongly disagree”. Cultural competence helps achieve effective communication with people of different cultures. CCCI obtained satisfactory psychometric properties and reliability  ,38,39,40Cultural Intelligence Scale (CQS). CQS is a slightly different concept: it is not as deep as CCCI; it is more focused on examining knowledge, including meta-level knowledge; it is less focused on attitude  and behavior. Similarly to other types of intelligence, cultural intelligence is understood as the ability to adapt to the surrounding environment and to interpret unknown and ambiguous behavior. It is defined as the ability to function effectively in an environment that is culturally different from ours [rom ours . CQS conrom ours ,47,48,49rom ours .The Positive/Negative Attitude Towards Culturally Divergent People Questionnaire. This questionnaire was adapted from previous studies  and consisted of questions relating to the two main research areas: (1) participants’ attitudes to and experience of interacting with people from diverse cultural backgrounds; (2) their attitudes towards refugees. For the former, participants were asked whether they (a) had lived abroad for at least 1 month (Yes/No); (b) have had close relationships with culturally diverse people (Yes/No); (c) had treated or cared for culturally diverse patients/clients in the past (Yes/No). Regarding the latter, participants were instructed to think of refugees coming to Poland and to answer whether they should be accepted by the Polish government and granted free education. We also asked about past attendance of any course/workshop/seminar oriented towards development of cross-cultural competencies/skills (Yes/No). The total summary of Yes answers in this area may be treated as an indicator of a strong positive attitude towards culturally divergent people.do you have a close relationship with any culturally diverse people) were used as between-subjects factors. For all statistical analyses reported below, the level of significance was set at p < 0.05, and the effect size was measured by partial eta-squared (ηp2).STATISTICA software  was used for statistical analysis. Specifically, we conducted a series of one-way ANOVAs on the total score in the CCCI and CQS  to find differences between the studied groups  treated as a between-subjects variable. Finally, to further verify whether participants who demonstrate positive relationships with and/or a positive attitude towards foreign populations, minorities, and migrants perform higher on the CQS and CCCI , we used a series of two-way ANOVAs: total score of CQS and CCCI was used as an outcome variable; group  and attitude . The study was developed and conducted in accordance with (1) the principles of Good Scientific Practice; (2) the Act of 10 May 2018, on the protection of personal data; (3) the principles of the Helsinki Declaration; and (4) the Regulation of the European Parliament, and of the Council (EU) 2016/679 of 27 April 2016, on the protection of individuals with regard to the processing of personal data. The study participants were provided with all the necessary information about the study, its purpose, and its procedure. Each participant received oral and written information about the purpose of the study and that participation was voluntary. Importantly, all participants were guaranteed the right to withdraw from participation in the study at any time without giving a reason or suffering any consequences. Submitting the completed questionnaires was tantamount to consent to participation in the study. Written consent for participation was obtained prior to data collection. In order to maintain anonymity, identification marks were provided on the research instruments. The data were anonymized by randomization, i.e., random separation of data to eliminate the close relationship between the data and a specific natural person, and coding, i.e., changing the values of variables from real to fictitious.p = 0.008). However, the differences between nurses and paramedics (p = 0.111) and between paramedics and medics (p = 0.238) were not statistically significant. As shown in p = 0.002) and paramedics (p = 0.001). At the same time, paramedics scored the highest on the Determination and Tolerance scales compared to nurses  and medics . Finally, nurses scored lowest on the Self-presentation scale compared to both groups . We did not observe any significant group effect for the Mission and Engagement subscales.The overall means of the CCCI  across groups are provided in pNurses = 0.001, pParamedics = 0.013), (2) Motivational CQ , (3) Behavioral CQ . At the same time, compared to paramedics and/or medics, nurses scored worse on (1) CQS overall scores (pParamedics = 0.001), (2) Metacognitive CQ (pMedics = 0.008), (3) Cognitive CQ (pParamedics = 0.001), (3) Motivational CQ (pParamedics = 0.004).The overall means for the CQS  across groups are provided in F = 3.98, p = 0.019, ηp2 = 0.01, and (2) having previous experience with culturally divergent healthcare, F = 9.99, p = 0.002, ηp2 = 0.03. A post hoc test indicated that nurses performed significantly lower on the CCCI scale compared to medics (p = 0.007) and individuals who had previous experience in taking care of culturally diverse people compared to those without such an experience scored significantly higher on the CCCI scale. We repeated similar analyses for the CQS. Similarly to the previous analyses, the main effects of group  = 16.26, p = 0.001, ηp2 = 0.04) and of previous multicultural healthcare experience  = 5.21, p = 0.023, ηp2 = 0.01) were statistically significant. Specifically, nurses scored significantly worse in the CQS compared to paramedics (p = 0.001) and medics (p = 0.001). At the same time, compared to individuals who did not declare previous cross-cultural healthcare experience, those who did have this experience scored significantly higher on the CQS (p = 0.026). The group by previous experience interaction was not statistically significant.We analyzed the differences across groups in the overall CCCI and CQS scores between people who declared providing professional healthcare to culturally different people in two separate factorial ANOVAs: the overall score in the CCCI or CQS was used as an outcome variable; group  and past experience with professional healthcare of culturally diverse individuals (Yes vs. No) were used as between-subject factors. First, regarding CCCI, we observed significant main effects for (1) group, F = 15.22, p = 0.001, ηp2 = 0.04) and CQS  = 28.89, p = 0.001, ηp2 = 0.04). In addition, those who had lived abroad for at least 1 month also scored significantly higher on CCCI  = 5.98, p = 0.015, ηp2 = 0.02) and CQS  = 31.86, p = 0.001, ηp2 = 0.04). There were no significant group by the multicultural relationship interaction for any of these analyses. In none of the analyses was there any significant group in the multicultural relationship. As the majority of the participants did not declare any previous attendance of cross-cultural training/workshops , we were not able to analyze the differences between participants on the CQS and CCCI in this regard.We repeated these analyses for individuals who had had close relationships with culturally diverse people and had lived abroad for at least 1 month. Those who fulfilled these criteria scored higher on both CCCI  = 22.32, p = 0.001, ηp2 = 0.06). A post hoc test revealed that medics obtained the highest score on the positive attitude towards refuges , compared to nurses  and paramedics .Finally, we analyzed the difference between groups in the total score on the Positive/Negative Attitude Towards Culturally Divergent People Questionnaire towards refuges (second area of the questionnaire). The main group effect was significant , also known as cultural intelligence (CQ) , are conCultural awareness is the ability of healthcare personnel to understand and respond to the unique cultural needs of HED and HER patients. According to the American College of Emergency Physicians, doctors should consider a patient’s culture in relation to their history and present symptoms. The treatment plan should contain elements of culture and be mutually agreed upon by the patient and the doctor. This organization also notes the dependence of healthcare quality on doctors’ scientific competencies and cultural awareness. Healthcare professionals should receive cultural awareness training in order to provide high-quality care in the emergency room. They should also encourage patients and their representatives to raise cultural issues that affect their care. Information resources should be made widely available to HED staff so that they can ensure that they appropriately respond to the needs of all patients, regardless of their origin .Language barriers, socio-economic conditions, religious values, and cultural practices can be an obstacle to delivering high-quality care to an increasingly diverse patient population. These obstacles contribute to the difference in healthcare delivery. Improving cultural competencies is mentioned as part of the solution when it comes to reducing disparities. An emergency department is an environment in which cultural sensitivity is especially needed. It is often the primary healthcare facility for neglected ethnic and racial minorities. HED is a place where help is provided to a large number of patients in highly time-pressured conditions. The emergency medicine literature says little about differences in healthcare and cultural competencies. Padela and Punekar (2009) present three clinical scenarios that illustrate the challenges in providing equitable medical services to minority populations in the United States. One episode describes a Latino woman with shortness of breath; the second presents a Cambodian refugee with hemoptysis who does not speak English; the third describes a Muslim woman with a tingling left leg. Using these cases as an illustration, these authors propose three processes that can improve the quality of care provided to minorities: (a) increasing cultural awareness and reducing healthcare provider bias; (b) adjusting to patients’ preferences and needs in the field of medical procedures; (c) increasing the diversity of providers to increase the level of tolerance, awareness, and understanding of other cultures, and patient–doctor relationships that are more compatible with racially and/or ethnically diverse patients .In Poland, patients from different cultural contexts are a new phenomenon. Therefore, medical professionals working in HED and HER may not have the experience, knowledge, skills, or culturally sensitive attitudes to deal with culturally different patients. Cooperation with patients during accident or illness is challenging due to the misfortune that affects them and the accompanying emotions and stress. A patient from a different culture may not speak Polish or English, and medical professionals usually do not know the patient’s native language. In such circumstances, it will be dependent on the awareness of medical professionals regarding interactions between people from different cultures, their sensitivity to the patient brought up in a different culture, and knowledge about a given culture whether the patient will find themself in a new situation, whether they will gain the patient’s trust and give him or her optimal medical assistance. Knowledge about behaviors related to the health of representatives of different cultures, their response to stress, their methods of communication, and their approach to using professional healthcare, including in emergency situations, is the basis for acquiring practical cultural competencies and cultural intelligence and using these when providing medical services to patients from different ethnic, national, or religious groups. Pre- and postgraduate education programs should include multicultural content. Medical students should be prepared theoretically and practically to help culturally different patients; therefore, education programs should teach attendees to take into account patients’ expectations that arise as a result of socio-cultural factors during medical rescue operations (MCR).The analysis of the literature on the subject shows that intercultural competencies in Poland are measured among students of medicine and nursing as well as working doctors and nurses more often than among paramedics but not as often as in America or Western Europe ,29,33,54In the presented research, people (most often doctors) with close relationships, experience in providing care to people from different cultural areas, and a positive attitude towards culturally different people obtained higher scores in terms of cultural intelligence and cultural competencies.The strength of this study is the diagnosis of cultural competencies and cultural intelligence among medical professionals in HEDs and HERs. The main limitation of this study is that it was conducted in one province that is relatively not very diversified in terms of religion and culture. Thus, the possibility of generalizing the results is limited. The hindering factors in this study could be, for example, the size and representativeness of the sample, the fact that the research was conducted during the COVID-19 epidemic, the impact of the social approval variable, because, as E. Zasępa writes after Karyłowski, it is saturated with tools measuring feelings and moral behavior  and the The results may be helpful in practice and suggest that attention should be paid to improving the cultural competencies and cultural intelligence of medical staff in HEDs and HERs, changing attitudes towards culturally different people. They indicate that the content, methods, and forms of educational programs should be so designed and attractive as to change not only the knowledge, but also the skills and attitudes of medical professionals in the provision of culturally adequate care.The research results confirm the positive impact of contact of medical professionals with people from other cultures on their cultural competencies and cultural intelligence. They indicate the need for training in acquiring cultural competencies and developing cultural intelligence, especially among nurses. They demonstrate the need to raise awareness among HED and HER medical professionals about issues in intercultural care and to increase diversity efforts, especially among nurses.


Introduction: Social isolation is a modifiable risk factor for negative health outcomes among older adults. This work assessed the relationship between geography  and social isolation in a cohort of older drivers.Methods: The AAA LongROAD cohort with 2,989 older adult drivers from across the country were included. Social isolation was measured at baseline and at two subsequent annual follow-ups using PROMIS v2.0 Social Isolation 4a. The effect of geographic location with social isolation was assessed through with multivariable regression using a generalized estimating equation model.Results: The rate of social isolation in urban areas was 21% lower  compared to non-urban areas after adjusting for covariates, though not significant.Discussion: Social isolation is a predictor of poor health outcomes and geographic considerations have been lacking in the literature. The panel data in this analysis provides more evidence for causality though the under-representation of non-urban areas potentially reduces the power for the results.Conclusions: It is important to understand the needs and risk of social isolation in various geographic settings to ensure resources and interventions are appropriately modified for a greater public health impact. The older adult population in the United States (US) is steadily growing, with adults over 65 projected to outnumber those under 18 for the first time in US history . The rapWe assessed if geography was associated with social isolation with a more precise measure of social isolation to build on this conversation in the literature. Social isolation is a more objective and comprehensive domain compared to loneliness. Along with mortality, social isolation is associated with increased medical costs , 8.To date there has not been consensus on whether social isolation varies by geography. A study measuring prevalence of social isolation found no difference between urban and non-urban areas in the adjusted model where social isolation was measured as physical separation . A subseOther research has shown that older adults utilize health care services more than younger patients, and particularly for older adults experiencing loneliness, interactions with the health system can be very important for social and physical health . Rural dUsing the AAA Longitudinal Research on Aging Drivers (AAA LongROAD) cohort, we assessed the rate of social isolation among older adults using precise measures normed to the US average. The Patient-Reported Outcomes Measurement Information System (PROMIS) measure for social isolation is a concise and validated measure developed by the National Institutes of Health. It was derived from a loneliness scale which is more focused on the feeling of distress that is associated with social isolation vs. loneliness , 15. We The study population is from the AAA LongROAD prospective cohort study. Participants ranged from 65 to 79 years old at baseline and were recruited in one of five sites across the US: Ann Arbor, MI, Baltimore, MD, Cooperstown, NY, Denver, CO, and San Diego, CA. To be included in the study, participants had to reside in one of the above-referenced locations for 80% of the year, have a valid driver's license and have no major cognitive deficits. A total of 2,990 were enrolled in the cohort; more detailed methods are described in the LongROAD methods paper (2). Because we are assessing population averages, participants needed at least one measure of social isolation across the three time intervals (baseline 7/7/2015 to second year follow-up 6/8/2019); one participant did not meet this criterion and was excluded. The study population for this analysis was 2,989.The self-reported PROMIS v2.0 Social Isolation 4a data was collected at baseline and annually . This meGeography based on address of primary residence was dichotomized to urban and non-urban using Rural Urban Commuting Area (RUCA) codes. The original ten RUCA codes based on census tract, population density, and commuting were categorized into urban , suburban 1.3, 2.2), and rural (>2.2) for the LongROAD study. For this analysis, the categories were dichotomized into urban and non-urban, the latter including the suburban population due to the small sample size. Potential confounders were age group, gender , race/ethnicity, marital status, education, measures of health and driving exposure . Marriag, 2.2, an2 and T-tests. To account for correlation from repeated measures within individuals, a generalized estimating equation (GEE) was used to assess the rate of social isolation using an identity link, Gaussian distribution and unstructured correlation structure. Life satisfaction and social role were highly correlated with one another and therefore excluded from modeling to increase the model's precision. Their collinearity approached 0.4. Time-varying covariates included in the model were age, race/ethnicity, marital status, education, depression, physical function, hearing and driving exposure.Baseline characteristics were stratified by exposure status, i.e., urban or non-urban, and compared using χThe population in this analysis was predominantly white (85.5%), married (66.0%) and held advanced degrees (40.8%) . Below ap = 0.04), race and ethnicity (p < 0.01), marital status (p < 0.01), education (p < 0.01), hearing (p = 0.04) and miles driven per week (p < 0.01). Depression, vision and hearing were significantly related to social isolation and also included in the full model.Of the 2,989 participants 13.2% reported social isolation at baseline and the average T-score measures was 42.9, lower than average social isolation. A T-score of 50 is the mean and a T-score of 40 indicates one standard deviation below the mean corresponding with less social isolation. Variables from univariate testing as seen in 2= 384.7, p-value < 0.01). Gender and vision were excluded as they did not contribute to the adjusted rate ratio.Participants in urban areas appeared to be 28% less likely to be socially isolated than participants in non-urban areas in the unadjusted model  . That gaSocial isolation is gaining increased attention as a predictor of poor health outcomes, now associated with increased risk of death and increased Medicare expenses, although geographic considerations have been lacking in this literature , 23. DisThese results align with a larger cross-sectional study in that social isolation was not significantly different between urban and non-urban areas . Cudjoe A strength of this study is the increased precision of the PROMIS Social Isolation SFv2.0 short form which is normed to US census data allowing for increased comparability. Panel data from three time periods provided more evidence for causality. A limitation was that the sample is not demographically diverse, although it was not designed to be a nationally representative sample. Alternate transportation use was excluded in this analysis as it was not operationalized to include rideshare but could be a potential confounder when assessing geographic differences . The subThe importance of social isolation is gaining more traction in research and it will be important to have a nuanced understanding of the experience in the geographically diverse areas of the US to ensure effective policies are implemented. Although geographic differences in social isolation were not statistically significant in this analysis, the evidence can build on the conversation in the literature regarding social isolation and rurality. This research was done prior to the COVID-19 pandemic; more research is needed to better understand the effect the pandemic may have had on social isolation, specifically older adults. Geographic location could potentially play a greater role in the setting of a pandemic and it needs further analysis.Restrictions apply to the availability of these data. Data are available from the author with permission from the AAA Foundation for traffic safety and upon execution of a data use agreement.The studies involving human participants were reviewed and approved by IRB of the Columbia University Medical Center (IRB-AAAN9950). The patients/participants provided their written informed consent to participate in this study.TM and LL: conceptualization, formal analysis, and writing—original draft preparation. TM, LL, GL, and DS: methodology. TM, DS, CD, MB, LM, DE, VJ, LH, and GL: data curation. TM, LL, DS, CD, MB, LM, DE, VJ, LH, and GL: writing—review and editing. TM: supervision. All authors have read and agreed to the published version of the manuscript.This work was supported by the AAA Foundation for Traffic Safety. This research was supported in part by Grant 1 R49 CE002096- 01 from the Centers for Disease Control and Prevention, National Center for Injury Prevention and Control to the Center for Injury Epidemiology and Prevention at Columbia University.Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health and Centers for Disease Control and Prevention.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


P > 0.05); 1 week, 2 weeks, and 3 weeks after treatment, the visual analogue scale (VAS) pain scores of the experimental group were significantly lower (P < 0.05); and the total incidence rate of adverse reactions was remarkably lower in the experimental group (P < 0.05). On the basis of targeted nursing intervention, applying silver-zinc bacteriostatic cream obtains an obviously better clinical efficacy than silver sulfadiazine ointment in treating second-degree burn and works better in promoting wound healing, relieving pain sensation, and reducing adverse reactions.Second-degree burn is the most common type of burn wound in the clinics, which presents a deeper wound, skin blisters, white or red bottom, and thick and clear fluid inside, is sensitive to tenderness, and turns white by compression . The aim of this study is to explore the efficacy of applying silver-zinc bacteriostatic cream to patients with second-degree burn under targeted nursing intervention and its effect on wound healing rate. A total of 110 patients with second-degree burn treated in our hospital from January 2019 to June 2021 were selected as the research object for the retrospective study. Between the experimental group and the control group, no statistical differences in patients' general information were observed ( Second-degree burn is the most common type of burn wound in the clinics, which presents a deeper wound, skin blisters, white or red bottom, and thick and clear fluid inside, is sensitive to tenderness, and turns white by compression , 2. The n = 55) and the experimental group . The study was approved by the hospital ethics committee.A total of 110 patients with second-degree burn treated in our hospital from January 2019 to June 2021 were selected as the research object for the retrospective study. The targeted nursing intervention was conducted to all patients, and according to the treatment methods, the patients were divided into the control group  After admission, the patients' wounds were cleaned immediately, i.e., first flushing the wound with normal saline, then repeatedly cleaning it with diluted hydrogen peroxide aqueous solution three times, wiping the wound, and disinfecting with povidone-iodine solution for 3 min, and treatments such as fluid infusion and analgesia were performed –10. (2) For patients in the control group, the wound was applied with the proper amount of silver sulfadiazine ointment  for 1.5 mm thick and then covered and fixed with sterile gauze, and the fresh dressing was changed once in one or two days. For patients in the experimental group, the wound was applied with silver-zinc bacteriostatic cream prepared by our hospital (5% of sulfadiazine zinc and 1% of sulfadiazine silver) for 1.5 mm thick and then covered and fixed with sterile gauze, and the fresh dressing was changed once in one or two days. The time of medication was decided according to the patients' condition.The general information mainly included the patients' age, gender, etiological factors of burn, depth of burn, and burn position. The observation indexes for basic clinical situation mainly included the time of antibiotic treatment, hospitalization time, and wound healing time .Wound healing rate = /initial wound area × 100%. To calculate the area, the wound was fully covered with sterile plastic film to get the contour and then scan to the computer.The proper amount of secretions on the patients' wounds was taken by sterile throat swab and sent to the laboratory department of our hospital for bacterial culture, and the positive cases were counted. The pain intensity of wound was evaluated by the visual analogue scale (VAS) on a scale of 0–10, with 0 points indicating no pain and 10 points indicating unbearable severe pain. According to the examination results of indicators such as routine blood tests and hepatic and kidney function and combined with the clinical manifestation, the incidence of adverse reactions in patients was evaluated.n(%)) and , items included were enumeration data and measurement data, which were expressed by (P > 0.05), which met the criteria for the controlled study   .P < 0.05)  .P < 0.05), and at the 3rd week, the positive rate of the experimental group was 0, which was lower than the control group, but with no significant between-group difference (P > 0.05)  .P < 0.05)  .P < 0.05)  .Silver sulfadiazine has been a classic topical drug used in the clinics to treat burn wounds. It mainly contains sulfadiazine and silver ion, so it has the antibacterial action of sulfadiazine and the astringency of silver salt and a powerful inhibitory effect on both Gram-positive coccus and Gram-negative bacillus –20. But P < 0.05), and from day 3 to day 21 of treatment, the wound healing rates of superficial and deep second-degree burn patients were significantly higher in the experimental group than in the control group (P < 0.05). Compared with the study conducted by Quang Hieu Tran et al. [P < 0.05), and at the 3rd week, the positive rate of the experimental group was 0, which was lower than the control group, but with no significant between-group difference (P > 0.05), demonstrating that both silver sulfadiazine and silver-zinc bacteriostatic cream had the antibacterial effect, but the latter worked faster and reduced the irritation of silver sulfadiazine on wounds. Compared with the control group, the VAS pain scores of patients after 1 week, 2 weeks, and 3 weeks of treatment of the experimental group were significantly lower (P < 0.05); and the total incidence rate of adverse reactions was significantly lower in the experimental group than in the control group (P < 0.05), proving that silver-zinc bacteriostatic cream could protect the burn wounds and prevent excessive evaporation of water, cell dehydration, and tissue fracture, thereby, reducing the pain sensation for patients. Although the adverse reaction rate of silver-zinc bacteriostatic cream is lower, attention should be paid to the prevention and treatment of adverse reactions such as wound deepening and high fever, which can be reduced by strengthening targeted nursing intervention for adverse reactions.By summarizing and analyzing the previous research experience, the advantages and disadvantages of the existing silver preparations for the treatment of burn wounds have been clarified, so the silver-zinc bacteriostatic cream made by our hospital was used for treating patients with second-degree burn, which obtained a better efficacy, with the results concluded as follows. The time of antibiotic treatment, hospitalization time, and wound healing time of patients were significantly shorter in the experimental group than in the control group (n et al. , the wouIn conclusion, on the basis of targeted nursing intervention, applying silver-zinc bacteriostatic cream obtains an obviously better clinical efficacy than silver sulfadiazine ointment in treating second-degree burn and works better in promoting wound healing, relieving pain sensation, and reducing adverse reactions. But this study still has the following problems. It was a single center pharmaceutical study, and the sample size was small because of the limited cost of analysis. The long-term follow-up mechanism was not established for the patients, and thus, long-term efficacy analysis of topical medication was lacking.


Thus far, data on sleep disorders among prison officers (POs) have been scarce. Research allows us to relate this problem to occupational stress, which POs experience every day. The aim of the current study was to analyze the scale, predictors, and impact of select factors on the relationship between insomnia and occupational burnout. This study was carried out on a sample of 376 Indonesian and 288 Polish POs using the Athens Insomnia Scale (AIS), the Coping Orientation to Problems Experienced (COPE) inventory, and the Oldenburg Burnout Inventory (OLBI). Results showed that 43.4% of the Polish sample exhibited early symptoms of insomnia, compared to 26.1% of the Indonesian sample. Sleep disorders had a significant role in developing occupational burnout. In both samples, coping strategies such as help-seeking and engagement were revealed to have a mediating role in the relationship between insomnia and occupational burnout dimensions. For the total sample and for the Polish sample, the coping strategy of help-seeking was the only predictor of insomnia. Discrepancies  were observed between the current results and earlier studies. The current study’s limitations were discussed and new solutions were proposed. Sleep is necessary for human functioning. The latest research shows that around one-third of the general population suffers from some form of sleep disorder. However, among penitentiary personnel, this figure is over 40% ,2. SleepPoor sleep quality is also related to numerous physical and mental health problems, which has been documented in workplace and organization psychology research. Sufficiently meeting the need for sleep facilitates professional activity. The literature notes that one of the factors of the development and maintenance of insomnia is multi-shift work ,18,19,20The negative impact of low sleep quality on the health and workplace effectiveness of various occupational groups has been shown to be so severe that discontinuing research in this direction is unjustifiable. Moreover, the results provoke discussions on possible solutions aiming to improve sleep quality among night shift workers, particularly those who are responsible for public safety, as low sleep quality is related to a higher frequency of workplace errors .Workplace conditions have a documented effect on employee health. Depending on their characteristics, this effect can be positive or negative . If workThe most popular theory of occupational burnout, developed by Maslach and colleagues, defines it as a syndrome comprised of emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment . It has A consistent relationship between occupational burnout and insomnia has been established ,32. The Analogously to studies on insomnia, analyses of occupational burnout prevalence have been carried out on medical personnel and school staff ,41,42,43The specifics and nature of a given job might constitute a significant burden for the employees. These are often the constant features of the job, for example, time pressure in medical professions or strict security measures in the uniformed services. Research points towards new possibilities of application, including significant improvements for employees. Thus far, it has been shown that personality factors influencing the development of occupational burnout include high anxiety, low resilience, external locus of control, avoidant style of coping with stress, low self-esteem, and high job motivation, among others .Penitentiaries are closed and guarded facilities for individuals serving prison sentences. They are also the job environment of penitentiary personnel who are responsible for executing temporary arrests and enforcing appropriate restrictions, carrying out interventions directed at the inmates, and guaranteeing their laws and appropriate living conditions. The characteristic aspects of prison service workers are: working in a uniformed formation, an authoritarian style of management, a paramilitary nature, formalism of activity, and risk of aggression on the part of the inmates. These specifics are sources of stress. Thus far, it has been shown that stressors also include both social contacts between the POs as well as interactions with the inmates ,47. EmpiPenitentiary personnel experience the mental and physical effects of stress. This influences their judgments of life and job satisfaction. Occupational stress and burnout are also more frequent among penitentiary personnel than the general population ,53,54,55Measurements of sleep disorders among all penitentiary personnel  showed a higher incidence compared to other occupational groups . TherapeStudies also show differences in health dependent on the occupation within penitentiary facilities. Compared to healthcare, administration, or socioeducational workers in penitentiaries, prison guards responsible for maintaining safety experience more mood and anxiety disorders. Years of job experience were also related to the intensity of mental health symptoms in a sample of French penitentiary personnel . PersonnAs was already shown, penitentiary personnel are at risk of experiencing occupational burnout. Studies carried out in China indicate that such factors as job stress, job dangerousness, or male gender influence the intensity of occupational burnout symptoms. On the other hand, role clarity reduces burnout symptoms . MoreoveThere is a well-founded view in psychology that studying stress should also include studying individual behaviors in stressful situations. Thus far, studies on penitentiary personnel have shown that employees who frequent religious services experience mood disorders less frequently . Using sThe functioning of penitentiary systems is related to the directions of national criminal policy. In turn, social pathologies are related to socioeconomic conditions . The curhttp://garuda.ristekbrin.go.id/ (accessed on 4 February 2021) with the keyword “insomnia” show that studies were mainly conducted among students and the elderly. Studies of insomnia or sleep disturbances among workers are very limited. No studies among POs have been found, either in Poland or Indonesia. Moreover, Indonesia lacks specialist facilities dedicated to PO mental health. General health facilities, including hospitals, can be accessed through health insurance. However, in Poland, specialist Mental Health Centers for the Prison Service offer individual therapy, crisis interventions, therapy for PTSD, and personnel assessment and recruitment.Few studies have concerned insomnia among both countries’ populations, including those occupational groups who are tasked with protecting citizens’ safety and realizing other basic functions of the state. Study results suggest that self-reported insomnia is a common problem in the general Polish population. The prevalence of sleep complaints was 50.5%  among group of 2413 participants . A study-The role of strategies of coping.-The role of organizational factors, that is, penitentiary unit type  and single- or multi-shift work.-The role of individual factors such as gender and age.The aim of the current study was to examine the phenomenon of insomnia and its relationship with occupational burnout in a sample of Polish and Indonesian POs. The analysis included:-What is the intensity of occupational burnout among POs? Are there differences between the Polish and Indonesian samples?-Do coping strategies, organizational factors, and individual factors differentiate insomnia levels?-Are there differences between the samples?-Which of the considered variables are predictors of insomnia intensity among POs in each sample?The following research questions were formulated:The study was carried out in compliance with the Declaration of Helsinki and the standards of the Ethical Code of the Polish Psychological Association. The study was approved by the Ethics committee of the Faculty of Psychology, Kazimierz Wielki University in Bydgoszcz, Poland, on 28 February 2020. Consent was also given by the managers of each penitentiary facility taking part in the study, as well as by their supervisory bodies: The District Inspectorate of the Prison Service in Poland and the Directorate General of Corrections, Ministry of Law and Human Rights, Republic of Indonesia.The POs’ participation in the study was voluntary and anonymous. Questionnaires were placed in commonly accessible rooms. The questionnaires were supplemented with a description of the study and its aims, as well as a written request to fill them out and insert them in a specially prepared container. The description also informed the participants that the questionnaires were entirely anonymous and their results would only be used for the purpose of the current study. The data collection method resulted in a sample which was not random, since the questionnaires were only filled out by interested participants. However, this data collection method was optimal because it allowed the participants’ full anonymity and privacy to be maintained.(1)The Athens Insomnia Scale (AIS) by Soldatos, Dikeos, and Paparrigopoulos. This is an eight-item scale measuring insomnia symptoms . The sca(2)(a)Exhaustion due to intense physical, mental, and emotional effort, the effect of chronic workplace stress related to job demands;(b)Distancing from work (described as disengagement from work by Demerouti and Bakker), its purpose, and its character .The Oldenburg Burnout Inventory (OLBI) by Demerouti and Bakker . This quThe following measures were used:Answers are given on a four-point Likert-type scale, where 1 denotes “I agree” and 4—“I disagree”. The sum of the item scores divided by their number gives the total subscale scores in a range of 1–4. The higher the scores, the higher the severity of the two components of occupational burnout—exhaustion and distancing from work. The Polish part of the study used the adaptation of the OLBI by Baka and Basińska (2016) . The Cro(3)Coping Orientation to Problems Experienced (COPE) by Carver, Scheier, and Weintraub .The Cronbach’s α reliability coefficient for the Polish and Indonesian versions of the exhaustion subscale was 0.73 and 0.80, respectively, and 0.69 and 0.75, respectively, for the distancing subscale.The engagement coping style: acceptance, positive reinterpretation, active coping, planning, restraint coping, and suppression of competing activities.The disengagement coping style: religion, mental disengagement, behavioral disengagement, and denial.The help-seeking style: seeking instrumental support, seeking emotional support, and venting of emotions.This questionnaire measures strategies of coping with stress. It is a self-report measure consisting of 60 items. Responses are given on a four-point Likert-type scale, where 1 denotes “I usually do not do this at all” and 4—“I usually do this a lot”. The questionnaire distinguishes 15 coping strategies. The current study used a three-factor classification , accordiThe Polish part of the study used the adaptation of the COPE by Juczyński and Ogińska-Bulik (2009) . The Crot test or Mann–Whitney’s U test were used. To estimate the relationships between the quantitative variables, Pearson’s correlation analysis was carried out. To compare the correlation coefficients in the two groups, Fisher’s test was used. To examine the mediating role of coping strategies in the relationship between insomnia and occupational burnout, a mediation analysis was carried out using the PROCESS macro 3.5 . Insomnia levels were higher among the Polish  than the Indonesian POs . An analysis using the cut-off point for early symptoms of insomnia on the AIS showed that 26.1% of the Indonesian sample and 43.4% of the Polish sample met the cut-off point.Next, using the independent-samples To assess the relationship between coping styles and insomnia levels, a Pearson’s correlation analysis was carried out. The analysis was carried out for the total sample, as well as separately for the Polish and Indonesian samples. The analysis showed a weak, negative relationship between insomnia levels and engagement in the total sample, as well as a weak, negative relationship between insomnia levels and help-seeking. This means that the more frequent the use of engagement and help-seeking coping styles, the lower the insomnia levels.An analysis using Fisher’s test to compare the correlation coefficients showed statistically significant differences between Polish and Indonesian POs in terms of engagement and help-seeking. The intergroup differences in disengagement were not statistically significant. In the Polish sample, insomnia levels were weakly and negatively correlated with engagement and help-seeking. No relationship between insomnia levels and disengagement was observed. In the Indonesian sample, the only statistically significant relationship occurred between insomnia levels and disengagement. It was weak and positive, which means that the higher the frequency of using this coping style, the higher the insomnia levels. Detailed results of the analyses are shown in U test, insomnia levels were compared between the POs working in a multi-shift system and those who did not. The analysis showed that multi-shift workers in the total sample reported higher insomnia levels. Analogous differences were observed in the Polish sample. The effect size for these differences was weak. In the Indonesian sample, the differences in insomnia levels between POs working in the multi-shift system and those who did not were not statistically significant. The results are presented in Using Mann–Whitney’s Additionally, Polish and Indonesian POs’ insomnia levels were compared separately for those working in the multi-shift system and those working single shifts. The analysis showed that both among multi-shift workers and among single-shift workers, higher insomnia levels were reported by Polish POs. The effect size for the differences was moderate. The results of the analysis are shown in p = 0.266, r = 0.04) as well as within the Polish  and Indonesian samples . Nonetheless, insomnia levels among Polish POs, both those working in semi-open and closed facilities  were higher than among Indonesian POs in those facility types .Next, analogous analyses were carried out for POs working in semi-open and closed facilities. The analysis did not show statistically significant differences in insomnia levels between the facility types, both for the total sample . Fisher’s test showed statistically significant differences between the samples in the relationship between age and insomnia . A weak and positive relationship between age and insomnia was observed in the Polish sample . The higher the Polish POs’ age, the higher their insomnia levels. On the other hand, in the Indonesian sample, this relationship was not statistically significant .The relationship between age and insomnia was not statistically significant in the total sample  are mediators in the relationship between insomnia levels and occupational burnout, a mediation analysis was carried out using Hayes’ PROCESS macro 3.5 (2017). To estimate the statistical significance of the indirect effects, the analyses were carried out using the bootstrapping method with a sampling of 5000 to estimate the percentile confidence intervals for the effects. When the confidence interval between the upper and lower bounds was above 0, the effect was not statistically significant. However, when it did not cross the 0 value, that is, when both bounds of the confidence interval were positive and negative, the effect was statistically significant. A total of six models were analyzed. The detailed results of the analyses are discussed below.Model 1:The mediating role of engagement in the relationship between insomnia and exhaustion.F(2.783) = 177.54; p < 0.001 and it explained 31.2% of the variance in exhaustion. The first analyzed model considered the mediating role of engagement for the relationship between insomnia and exhaustion as a dimension of occupational burnout. The model had a good fit to data, b = −0.13; SE = 0.02; β = −0.20; p < 0.001; Path A). As insomnia increased by one unit of measurement, engagement decreased by 0.13 units. The direct relationship between insomnia and exhaustion was positive —as insomnia increased by one unit, exhaustion increased by 0.05 units. The relationship between engagement and exhaustion with the inclusion of insomnia  was negative—the higher the engagement, the lower the exhaustion. The relationship between insomnia and exhaustion with the inclusion of engagement  was also statistically significant and positive—as insomnia increased, together with including the coping strategies, exhaustion increased by 0.05 units.The analysis showed a negative relationship between insomnia and engagement . This means that engagement weakened the positive relationship between insomnia and exhaustion, though it remained statistically significant .To test whether the indirect effect of engagement was statistically significant, an additional bootstrapping analysis was carried out. It showed that the effect was significant (Model 2:The mediating role of engagement in the relationship between insomnia and distancing from work.F(2.783) = 154.10; p < 0.001, and it explained 28.2% of the variance in distancing. The second analyzed model included the mediating role of engagement in the relationship between insomnia and distancing from work as a dimension of occupational burnout. The analyzed model had a good fit to data, b = −0.13; SE = 0.02; β = −0.20; p < 0.001; Path A). As insomnia levels increased by one unit of measurement, engagement levels lowered by 0.14 units. The direct relationship between insomnia and distancing was positive —as insomnia levels increased by one unit of measurement, distancing increased by 0.05 units. The relationship between insomnia and distancing with the inclusion of engagement was also statistically significant and positive —as insomnia levels increased, with the inclusion of coping styles, distancing increased by 0.05 units.The analysis showed a negative relationship between insomnia and engagement . This means that engagement weakened the positive relationship between insomnia and distancing, although it remained statistically significant .To test the statistical significance of the indirect effect, an additional bootstrapping analysis was carried out. It showed that the effect was significant (Model 3:The mediating role of disengagement in the relationship between insomnia and exhaustion.F(2.783) = 127.28; p < 0.001, and it explained 24.5% of the variance in exhaustion. The third analyzed model included the mediating role of disengagement for the relationship between insomnia and exhaustion as a dimension of occupational burnout. The analyzed model had a good fit to data b = −0.02; SE = 0.01; β = −0.04; p = 0.245; Path A).The analysis showed a lack of relationship between insomnia and disengagement —as insomnia levels increased by one unit of measurement, exhaustion increased by 0.05 units. The relationship between disengagement and exhaustion with the inclusion of insomnia was negative —the higher the disengagement, the lower the exhaustion. The relationship between insomnia and exhaustion with the inclusion of disengagement as a coping style was statistically significant and positive —as insomnia increased, with the inclusion of disengagement, exhaustion increased by 0.05 units of measurement.The direct relationship between insomnia and exhaustion was positive . This means that disengagement was not a significant mediator in the relationship between insomnia and exhaustion.To test the statistical significance of the indirect effect of coping styles, an additional bootstrapping analysis was carried out. It showed that the effect was not statistically significant (Model 4:The mediating role of disengagement in the relationship between insomnia and distancing from work.F(2.783) = 138.93; p < 0.001, and it explained 26.2% of the variation in distancing. The fourth model included the mediating role of disengagement in the relationship between insomnia and distancing from work as a dimension of occupational burnout. The analyzed model had a good fit to data, b = −0.02; SE = 0.01; β = −0.04; p = 0.245; Path A). The direct relationship between insomnia and distancing from work was positive —as insomnia levels increased by one unit of measurement, distancing increased by 0.05 units. The relationship between disengagement and distancing with the inclusion of insomnia was negative —the higher the disengagement, the lower the distancing. The relationship between insomnia and distancing with the inclusion of disengagement was positive —as insomnia increased, with the inclusion of disengagement, distancing lowered by 0.05 units.The analysis showed a lack of relationship between insomnia and disengagement . Disengagement was not a significant mediator in the relationship between insomnia and distancing from work.To test the statistical significance of the indirect effect of disengagement, an additional bootstrapping analysis was carried out. It showed a lack of statistical significance of the indirect effect (Model 5:The mediating role of help-seeking in the relationship between insomnia and exhaustion.F(2.783) = 168.82; p < 0.001, and it explained 30.1% of the variance in exhaustion. The fifth analyzed model included the mediating role of help-seeking in the relationship between insomnia and exhaustion as a dimension of occupational burnout. The analyzed model had a good fit to data, b = −0.10; SE = 0.01; β = −0.25; p < 0.001; Path A). As insomnia levels increased by one unit of measurement, the use of the help-seeking coping strategy decreased by 0.10 units. The direct relationship between insomnia and exhaustion was positive —as insomnia levels increased by one unit of measurement, exhaustion increased by 0.05 units. The relationship between help-seeking and exhaustion with the inclusion of insomnia was negative —the higher the use of help-seeking as a coping strategy, the lower the exhaustion. The relationship between insomnia and exhaustion with the inclusion of help-seeking as a coping strategy was positive —as insomnia levels increased, with the inclusion of help-seeking, exhaustion increased by 0.05 units.The analysis showed a negative relationship between insomnia and help-seeking . This means that help-seeking was a significant mediator in the relationship between insomnia and exhaustion. Additionally, the relationship between the explanatory and the explained variables remained statistically significant—a partial mediation effect.To test the statistical significance of the indirect effect of help-seeking, an additional bootstrapping analysis was carried out. It showed that this effect was statistically significant  = 164.68; p < 0.001, and it explained 29.6% of the variance in distancing. The last analyzed model included the mediating role of active coping in the relationship between insomnia and distancing from work as a dimension of occupational burnout. The analyzed model had a good fit to data, b = −0.10; SE = 0.01; β = −0.25; p < 0.001; Path A). As insomnia levels increased by one unit of measurement, the frequency of using this coping strategy decreased by 0.10 units. The direct relationship between insomnia and distancing was positive —as insomnia levels increased by one unit of measurement, distancing increased by 0.05 units. The relationship between help-seeking and distancing with the inclusion of insomnia was negative —the higher the frequency of using the help-seeking coping style, the lower the distancing. The relationship between insomnia and distancing with the inclusion of help-seeking was statistically significant and positive —as insomnia increased, with the inclusion of the help-seeking coping strategy, distancing increased by 0.05 units of measurement.The analysis showed a negative relationship between insomnia and help-seeking . This means that the coping strategy of help-seeking weakened the relationship between insomnia and distancing, although it remained statistically significant .To test the statistical significance of the indirect effect of help-seeking, an additional bootstrapping analysis was carried out. It showed that the effect was statistically significant  estimation. The analysis included a total of 751 cases after excluding missing data.2/df = 2.65; CFI = 0.976; RMSEA = 0.047; SRMR = 0.047, and it explained a total of 7% of the variance in insomnia levels. A detailed analysis showed a lack of statistically significant relationships between insomnia and age , penitentiary unit type , engagement , and disengagement . Significant relationships were observed between insomnia and gender, help-seeking, and multi-shift work. Help-seeking  and multi-shift work  were negatively related with insomnia, meaning that the higher the frequency of using help-seeking as a coping strategy, the lower the insomnia levels, while multi-shift work increased insomnia levels. Gender  was positively related to insomnia, which indicates that men experienced higher insomnia levels. After including additional covariations between the variables on the basis of the modification indexes, the analyzed model achieved a good fit to data, χn = 288) and Indonesian (n = 376) samples. To compare the models between the groups, the software created by Gaskin and Lim (2018) was used [2 = 19.24; df = 7; p = 0.007; ΔNFI = 0.018. Thus, it can be assumed that the intergroup differences for the analyzed model are significant. To test whether the analyzed model differed depending on the sample country, additional analyses were carried out separately for the Polish . However, these data come from a phone interview study, which limits their interpretation [In the current study, men reported higher insomnia levels. Male gender was also one of the predictors of insomnia in the total sample. The results of the Indonesian sample were in line with previous Indonesian studies in showing that gender does not have a statistically significant influence, although younger men (15–34 years) report higher insomnia levels than older men (45+ years) ,107. Howretation .The current study also confirmed the relationship between sleep disorders and occupational burnout, including physical, mental, and emotional exhaustion, and distancing from work. These results are in line with previous studies . Thus faThe literature review above showed that insomnia causes numerous negative health consequences. These can impact the capacity to cope with stress and inhibit adaptive behaviors. A lack of appropriate coping skills can lead to worsened mental, social, and professional functioning in penitentiary personnel ,120. DivThe current results allow for underscoring the role of multi-shift work in the development of sleep disorders. It is known that some employees cannot adjust to multi-shift work and are thus at risk for shift work disorder (SWD) . Its sym-Scientific advances allow occupational burnout to be linked with sleep disorders. Experiences of stress are considered to factor into the etiology of these two phenomena. Nevertheless, data on the role of coping strategies in the relationship between occupational burnout and insomnia have been scarce thus far.-Insomnia among Polish and Indonesian prison officers has not been examined thus far. The current study shows that its incidence is higher in Poland, while over 1/4 of the Indonesian sample reported results indicating early insomnia symptoms. Sleep disorders were revealed to influence the development of occupational burnout.-The mediating role of such coping strategies as help-seeking and engagement in the relationship between insomnia and occupational burnout dimensions has been confirmed for the total sample. Both in the total sample, as well as in the Polish sample, help-seeking was the only coping strategy predicting insomnia.-Age, gender, and multi-shift work differences exist between the current comparison of the two countries and the results of previous studies.-The current study should be followed up with further studies, which should include more precise measurement tools for sleep difficulties. This is because sleep disorders can significantly impact the work functioning of penitentiary personnel.On the basis of the current study, analysis, and discussion of the results, it can be concluded that:The current results can constitute a significant argument for health promotion campaigns highlighting sleep hygiene directed at penitentiary personnel. They also have potential value for the managers of penitentiary institutions who are responsible for general work safety and hygiene. Well-rested employees are more engaged. The current results also highlight the issue of multi-shift work. Organizing shift changes such that they will interfere in employee health to the least extent possible seems to be the only solution. This has not been taken into consideration thus far in the Polish and Indonesian penitentiary systems. Coping skills trainings have been shown to positively impact adaptability, facilitate more effective coping, and reduce anxiety levels among students and other nonclinical groups ,136,137.The limitations of the current study stem in part from its choice of diagnostic tools. Following the grouping of coping styles into three groups by Gutiérrez et al. , the COPA research model created for the purposes of future studies would allow for measuring the frequency of health behaviors, including the general category of preventive behaviors. A study on a sample of telecommunication company employees and nurses showed that insomnia symptoms were related to alcohol use, with the highest insomnia levels being reported by high-risk drinkers, smokers, and individuals consuming more than three cups of coffee per day ,142. StrA review of studies on treatments for insomnia shows evidence for the effectiveness of cognitive-behavioral therapy  . During