The characteristics of young pre-licensed drivers: Evidence from the New Zealand Drivers Study

Aim

The aim of this study was to identify demographic and behavioural factors associated with pre-licensed driving.

Method

A cohort comprising 3526 newly licensed drivers aged 15–24 years old from throughout New Zealand completed a questionnaire which sought information on pre-licensed driving behaviour and factors thought to be related to this.

Results

Almost half of the participants had driven on-road prior to passing their learner license theory test; 14% had driven more than 20 times; and 7.5% had driven more than 200 km. Multivariate logistic regression showed the results differed depending on the outcome examined. In general pre-licensed driving was significantly higher among males, among Māori, those living in a rural area, and those living in an area of high deprivation. Furthermore, those who drove pre-licensed were more likely to engage in other risky behaviours such as hazardous drinking and cannabis use, and have medium to high scores for sensation seeking and aggression/hostility.

Conclusion

The young people who were pre-licensed drivers displayed a range of demographic and behavioural characteristics that indicate they may be at higher crash risk than their peers who did not drive before licensing. Identifying those who drive before licensing and targeting road safety interventions towards this group may help reduce the high crash risk among novice drivers.     

Reductions in transport mortality in Australia: Evidence of a public health success

Objective

To describe trends in transport mortality for a range of common transport types in Australia over a 30-year period (1975–1977 to 2005–2007).

Methods

Mortality data on all-cause and transport-related causes of death were supplied by the Australian Institute of Health and Welfare (AIHW). Mortality rates, expected number of deaths and probabilities of death were compared for three time periods: 1975–1977, 1990–1992 and 2005–2007.

Results

There were significant decreasing trends between 1975–1977 and 2005–2007 in all-cause and most other transport mortality types for both men and women. There were significant reductions in the contribution of transport-related mortality to all-cause mortality; however the difference in mortality between men and women (higher for men) changed little over the evaluated period.

Conclusions

Between 1975–1977 and 2005–2007 there were marked reductions in key causes of transport-related mortality amongst Australian adults, and the reductions in transport-related mortality exceeded reductions in all-cause mortality. The reductions could be attributed to better preventive measures and improved medical treatment for people involved in transport crashes. Although there is scope for further improvement, the reductions are evidence of a success in the prevention of crashes and the medical treatment of crash victims.     

The effects of health status, distress, alcohol and medicinal drug use on subsequent motor vehicle injuries

Objective

The purpose of this study was to examine the effects of health factors and substance use on subsequent motor vehicle collision (MVC) injuries of three different age groups, using the longitudinal dataset from the Canadian National Population Health Survey (NPHS) for the years 1994–2002.

Methods

Path analysis technique was used to determine the relations between MVC injury and four risk factors: binge drinking; health status; distress; and medication use. The three demographic variables, age at ‘baseline’, sex, and immigration status were added into the model as control variables. Three age groups were examined: young = 12–29.9; middle-aged = 30–59.9 and old = 60–85 years of age. The total sample size was 16,093.

Results

A lower percentage of males, older persons, immigrants, and non-binge drinkers reported a subsequent MVC injury, as did respondents reporting better health and lower distress scores. Medication use was associated with higher subsequent MVC injuries. Path analysis found that among younger individuals, the variable binge drinking, was the only significant risk factor associated with subsequent injuries. In contrast, among middle-aged individuals, the variable medication use, was the only statistically significant risk factor for subsequent injuries. No variables were significant risk factors of injuries for older individuals.

Conclusions

Various demographic and risk factors were found to influence injuries among a nationally representative sample of Canadians. Reported binge drinking among young individuals and medication use among middle-aged individuals were found to be risk factors for subsequent MVC injury. These findings support the need for continued focus on alcohol, drugs and traffic safety.     

Predictive factors of chronic post-traumatic stress disorder 6 months after a road traffic accident

Background

This study sets out to identify risk factors for post-traumatic stress disorder (PTSD) after a road traffic accident with a view to improving prevention.

Methods

The study used a prospective cohort of road traffic accident casualties. All subjects over 15 years of age were recruited in the course of an interview conducted while they were receiving care in a hospital of the Rhône area administrative département. Six months after their accident, they answered a self-administered postal questionnaire that included the Post-traumatic Check-List Scale (PCLS) in order to evaluate PTSD. Multivariate logistic regression analysis was conducted to compare those subjects with a PCLS score of 44 or over with those with a lower score, in order to identify factors that might be associated with PTSD.

Results

592 subjects (out of 1168) returned the 6-month questionnaire and 541 completed the PCLS test. One hundred subjects had a PCLS score ≥44, suggesting PTSD, and 441 subjects did not. The factors associated with PTSD were initial injury severity, post-traumatic amnesia, the feeling of not being responsible for their accident and persistent pain 6 months after it. A lower odds-ratio was associated with users of two-wheel than four-wheel motor vehicles (OR = 0.4; 0.2–0.9).

Conclusion

Besides predictive factors for PTSD (injury severity, post-traumatic amnesia and the feeling of not being responsible for their accident), our study suggested a reduced risk of PTSD among two-wheel motor vehicle users.     

Unsupervised driving by learner licence holders: Associated characteristics and crash risk

Aims

To determine: (a) the association between socio-demographic, and behavioural factors and compliance with supervised driving condition as a learner licensed driver, (b) whether unsupervised driving as a learner licence holder was associated with elevated crash risk while holding a learner licence.

Study design

The study population was the New Zealand Drivers Study (NZDS) cohort, a prospective cohort study designed to explore the relationship between a comprehensive range of driving and traffic safety related factors and subsequent traffic crashes and convictions among newly licensed drivers.

Results

Thirty-one percent of the study sample was non-compliant at least once with the supervised driving condition. Many socio-demographic and behavioural risk factors were independently associated with unsupervised driving. The strength of the associations was greatest for those with relatively high levels of unsupervised driving (13+ trips). High distance driven showed the strongest relationship: RR 8.91 (95% CI 5.27–15.07). Unsupervised driving was associated with increased risk of crash: 1–12 trips: RR 1.84 (1.29–2.61), and 13+ trips: RR 2.71 (1.94–3.80).Given that a significant portion of learner licence holders report driving unsupervised and those that violate this condition the most are more likely to crash, evaluation of strategies designed at improving compliance with learner licence supervised driving condition should be a research priority.     

Pre-licensed driving experience and car crash involvement during the learner and restricted,licence stages of graduated driver licensing: Findings from the New Zealand Drivers Study

Objective

The aim of this study was to determine whether pre-licence driving experiences, that is driving before beginning the licensing process, increased or decreased crash risk as a car driver, during the learner or the restricted licence stages of the graduated driver licensing system (GDLS).

Method

Study participants were 15–24 year old members of the New Zealand Drivers Study (NZDS) – a prospective cohort study of newly licensed car drivers. The interview stages of the NZDS are linked to, the three licensing stages of the GDLS: learner, restricted and full. Baseline demographic (age, ethnicity, residential location, deprivation), personality (impulsivity, sensation seeking, aggression) and, behavioural data, (including pre-licensed driving behaviour), were obtained at the learner licence interview. Data on distance driven and crashes that occurred at the learner licence and restricted licence stages, were reported at the restricted and full licence interviews, respectively. Crash data were also obtained from police traffic crash report files and this was combined with the self-reported crash data. The analysis of the learner licence stage crashes, when only supervised driving is allowed, was based on the participants who had passed the restricted licence test and undertaken the NZDS, restricted licence interview (n = 2358). The analysis of the restricted licence stage crashes, when unsupervised driving is first allowed, was based on those who had passed the full licence test and completed the full licence interview (n = 1428).

Results

After controlling for a range of demographic, personality, behavioural variables and distance driven, Poisson regression showed that the only pre-licence driving behaviour that showed a consistent relationship with subsequent crashes was on-road car driving which was associated with an increased risk of being the driver in a car crash during the learner licence period.

Conclusion

This research showed that pre-licensed driving did not reduce crash risk among learner or restricted licensed drivers, and in some cases (such as on-road car driving) may have increased risk. Young people should be discouraged from the illegal behaviour of driving a car on-road before licensing.     

Increased patterns of risky behaviours among helmet wearers in skiing and snowboarding

Background

There has been an ongoing debate as to whether wearing helmets in skiing and snowboarding increases the risk tolerance of participants.

Objective

To investigate the roles of demographic and personality variables, and helmet usage in predicting risk taking behaviours in a cross-sectional sample of intermediate and proficient skiers and snowboarders.

Methods

Risk taking in skiing was measured using a validated 10-item self-report measure which was designated as the outcome variable in a three step hierarchical regression. Independent predictors included age, sex, education, sport, ability, helmet usage, and personality traits that have been associated with risk taking: impulsivity and sensation seeking.

Results

In the final regression model, helmet use significantly predicted variance in risk taking (standardized β = .10, p = .024), and the relationship remained after accounting for variance due to demographic variables and general trait measures. The partial relationship between risk taking and sex, ability, impulsivity, and sensation seeking were also significant (p < .05).

Conclusion

High sensation seeking, high impulsivity, male sex, and proficiency were associated with increased patterns of risky behaviours in skiers and snowboarders, and after accounting for these factors, helmet use was a significant predictor of risk taking. The relationship between helmet use and risk taking was modest suggesting that the costs of increased risk taking is not likely to outweigh the protective benefits of a helmet.     

Supervisor vs. employee safety perceptions and association with future injury in US limited-service restaurant workers

Objectives

Many studies have found management commitment to safety to be an important construct of safety climate. This study examined the association between supervisor and employee (shared and individual) perceptions of management commitment to safety and the rate of future injuries in limited-service restaurant workers.

Methods

A total of 453 participants (34 supervisors/managers and 419 employees) from 34 limited-service restaurants participated in a prospective cohort study. Employees’ and managers’ perceptions of management commitment to safety and demographic variables were collected at the baseline. The survey questions were made available in three languages: English, Spanish, and Portuguese. For the following 12 weeks, participants reported their injury experience and weekly work hours. A multivariate negative binomial generalized estimating equation model with compound symmetry covariance structure was used to assess the association between the rate of self-reported injuries and measures of safety perceptions.

Results

There were no significant relationships between supervisor and either individual or shared employee perceptions of management commitment to safety. Only individual employee perceptions were significantly associated with future employee injury experience but not supervisor safety perceptions or shared employee perceptions.

Conclusion

Individual employee perception of management commitment to safety is a significant predictor for future injuries in restaurant environments. A study focusing on employee perceptions would be more predictive of injury outcomes than supervisor/manager perceptions.     

Work characteristics associated with injury among light/short-haul transport drivers

Introduction

This study aims to describe the hazard environment facing drivers of light freight vehicles and short-haul transport drivers and to examine the relationships between hazard exposure and injury.

Methods

Drivers (n = 321) of rigid vehicles up to 12 tonnes Gross Vehicle Mass working within a 100 km radius of their base across the Australian state of New South Wales were surveyed regarding their experience of occupation-specific hazards and their experience of workplace injury in the past year.

Results

Principal components analysis identified four clusters of hazards corresponding to those associated with work organisation, vehicles, road and access, and interpersonal conflict. In logistic regression analysis, work organisation and vehicle-related hazards, explained unique variance in the experience of injury in the past year. However, frequent stress replaced work organisation when included as a predictor in the analysis.

Conclusions

Drivers’ most common safety concern (road and driving issues) reflected the frequency of their exposure to road and access hazards but did not parallel their injury experience. Examination of the hazards most strongly associated with injury suggest that industry risk management efforts should target work organisation and vehicle-related hazards, and particularly work practices that engender frequent stress among drivers.     

Fitness-to-drive after mild traumatic brain injury: Mapping the time trajectory of recovery in the acute stages post injury

Introduction

Little is known about the trajectory of recovery in fitness-to-drive after mild traumatic brain injury (mTBI). This means that health-care professionals have limited evidence on which to base recommendations to this cohort about driving.

Objective

To determine fitness-to-drive status of patients with a mTBI at 24 h and two weeks post injury, and to summarise issues reported by this cohort about return to driving.

Method

Quasi-experimental case-control design. Two groups of participants were recruited: patients with a mTBI (n = 60) and a control group with orthopaedic injuries (n = 60). Both groups were assessed at 24 h post injury on assessments of fitness-to-drive. Follow-up occurred at two weeks post injury to establish driver status.

Main Measures

Mini mental state examination, occupational therapy-drive home maze test (OT–DHMT), Road Law Road Craft Test, University of Queensland-Hazard Perception Test, and demographic/interview form collected at 24 h and at two weeks.

Results

At the 24 h assessment, only the OT–DHMT showed a difference in scores between the two groups, with mTBI participants being significantly slower to complete the test (p = 0.01). At the two week follow-up, only 26 of the 60 mTBI participants had returned to driving. Injury severity combined with scores from the 24 h assessment predicted 31% of the variance in time taken to return to driving. Delayed return to driving was reported due to: “not feeling 100% right” (n = 14, 23%), headaches and pain (n = 12, 20%), and dizziness (n = 5, 8%).

Conclusion

This research supports existing guidelines which suggest that patients with a mTBI should not to drive for 24 h; however, further research is required to map factors which facilitate timely return to driving.     

Beachgoers’ beliefs and behaviours in relation to beach flags and rip currents

Background

Coastal drownings claim on average 82 people per year in Australia. Beach flags are a primary safety strategy used on beaches. They are located away from rip currents, which are the main beach hazard affecting swimmers. Little is known about the behavioural and motivational factors associated with people choosing where to swim in relation to flags and rips.

Aims

To assess the beliefs and behaviours of beachgoers in relation to beach flags and rip currents.

Methods

Beachgoers at beaches in NSW were interviewed about their swimming beliefs and behaviours. They were asked to indicate on pictures depicting beach scenarios involving beach flags and fixed rip currents, where they would and would not swim. Logistic regression analysis was undertaken to determine predictors of correct and incorrect swimming behaviour.

Results

Beachgoers who are aged from 30 to 49 years (OR 0.34, 95% CI 0.16, 0.74, p = 0.006) are less likely to choose to swim between the flags than other swimmers. In addition, beachgoers who are at the beach with children are significantly more likely to choose to swim between the flags (OR 2.74, 95% CI 1.39, 5.40, p = 0.004). Beachgoers with basic knowledge about rip currents are significantly more likely to swim away from the rip (OR 11.59, 95% CI 5.89, 22.81, p < 0.001).

Discussion and conclusions

Ocean swimmers aged from 30 to 49 years may choose to swim outside the flags, though they may not necessarily be swimming in the rip. Swimming outside of the flags may be linked with experience. The flags appear to be attractive to parents and carers of children. Whilst the flags indicate a relatively safe area of the beach, it is still vitally important for parents and carers to supervise children in this area. Basic rip current knowledge is an essential component in developing national interventions aimed at reducing coastal drowning. Beachgoers clearly need to know what a rip looks like in order to actively avoid swimming in it.     

Motorcycle right-of-way accidents--a literature review

The most typical automobile–motorcycle collision take places when an automobile manoeuvres into the path of an approaching motorcycle by violating the motorcycle's right of way (ROW).

Aim

The present paper provides a comprehensive review of past research that examined motorcycle ROW accidents.

Methods

Articles and publications were selected for relevance and research strength through a comprehensive search of major databases such as Transportation Research Information Services (TRIS), Compendex, and Medline.

Results

Two major causes of such a crash scenario are the lack of motorcycle conspicuity and motorist's speed/distance judgment error, respectively. A substantial number of studies have manipulated physical characteristics of motorcycles and motorcyclists to enhance conspicuity, along with research addressing motorists’ gap-acceptance behaviours and arrival time judgments when confronting motorcycles. Although various conspicuity aids have proven effective, some researchers reported that motorcyclist's/motorcycle's brightness per se may be less important as a determinant of conspicuity than brightness contrast between the motorcyclists and the surroundings. Larger vehicles tended to be judged to arrive sooner than motorcycles. Such a speed/distance judgment error is likely attributable to some psychological effects such that larger automobiles appear more threatening than motorcycles. Older motorists particularly have difficulties in accurately estimating the distance and the speed of an approaching motorcycle. Research examining the effects of conspicuity measures on motorists’ speed/distance judgments when confronting motorcycles has been rather inconclusive.

Conclusions

Past research offers valuable insight into the underlying motorcycle ROW crash mechanisms. However, with ageing society and a rapid change in traffic composition (e.g., more larger motorcycles) in recent years, prior research findings should be updated. The present study finally provides recommendations for future research on motorcycle ROW accidents.     

Alcohol-related traffic accidents with fatal outcomes in the city of Sao Paulo

Aims

The aims of the present study were to characterize fatal traffic accident victims in a major urban center in Brazil and their association with alcohol consumption.

Methods

Cross-sectional study of 907 fatal traffic accident victims in Sao Paulo, in 2005.

Results

Adult males between the ages of 25 and 54 represented the majority of cases with positive blood alcohol concentrations (BAC). Overall, males had a higher proportion of BAC and mean BAC than females. Pedestrians, particularly those with no detectable BAC, were typically older than other victims. Most accidents (total and BAC-positive) happened on weekends between midnight and 6 a.m. Considering all victims, 39.4% were positive (BAC over 0.1 g/l). When only drivers (automobile, motorcycle and bicycle) were evaluated, 42.3% had BAC over the legal limit (0.6 g/l).

Conclusions

Alcohol is associated with nearly half of all traffic accident deaths in the city of Sao Paulo, especially for days and times associated with parties and bars (weekends between 12 a.m. and 6 a.m.).     

Powered two-wheeler drivers’ crash risk associated with the use of bus lanes

Context

Authorizing powered two-wheeler drivers to drive in lanes reserved to buses is a measure that is sometimes mentioned to improve mobility conditions for these users. But what effect would this measure have on the safety of these users and on the safety of the other users with whom they share the traffic space?

Objective

The objective of this study is to contribute elements to help answer this question. More precisely, the objective is to estimate the risk of having an accident per kilometer driven by powered two-wheeler drivers who drive in bus lanes and to compare this risk with that of powered two-wheeler drivers who drive in general traffic lanes.

Method

Using the bodily injury accidents recorded by the police over two years on 13 roads in the city of Marseille and a campaign of periodical observations of powered two-wheeler traffic, we estimated the risk per kilometer driven by powered two-wheeler drivers who drive in bus lanes and compared it with that of drivers who do not drive in them.

Results

The results show that the risk for powered two-wheeler drivers who drive in bus lanes of being involved in a bodily injury accident is significantly higher than the risk run by drivers who drive in general traffic lanes. For the 13 roads studied, it is on average 3.25 times higher (95% CI: 2.03; 5.21).

Conclusion

In the current situation, powered two-wheeler drivers who drive in bus lanes are less safe than those who drive in general traffic lanes. The analysis of police reports suggests that part of this increased risk comes from collisions between automobile drivers turning right and powered two-wheelers driving in the bus lane who continue straight ahead.     

An example of the usefulness of joinpoint trend analysis for assessing changes in traffic safety policies

Aim

To show the usefulness of joinpoint trend analysis for assessing changes in traffic safety policies.

Methods

Trends in driver death rates from traffic injury stratified by alcohol involvement in Spain during 2001–2011 were characterized with joinpoint regression to observe how changes in these rates match in time with the implementation of traffic regulations and interventions.

Results

Both alcohol-related (blood alcohol concentration >0.3 g/l) and non-alcohol-related rates decreased similarly (10–11% annually) during 2001–2011, although the former showed an earlier (2003 joinpoint) acceleration of the downward trend than the latter (2006 joinpoint); both joinpoints matched in time with relevant road safety interventions.

Conclusions

These results, which are consistent with results from previous analytical studies, show that joinpoint trend analysis, although not valid for causal inference, is useful for assessing changes in traffic safety policies. This methodology can be easily extended to other risk factors, such as excessive speeding or not wearing a seat belt.     

The association of activity level, parent mental distress, and parental involvement and monitoring with unintentional injury risk in fifth graders

Objective

Extend findings with young children by examining the strength of association of activity level, parent mental distress, and parental involvement and monitoring with fifth graders’ unintentional injuries.

Methods

Ordinal logistic regression models were used to predict unintentional injury frequency among 4745 fifth-graders. Examined predictors included demographics, parent reports of mental distress, temperamental activity level (tendency to be fidgety, restless, and constantly in motion), and parental involvement and monitoring in adolescents’ lives.

Results

Higher levels of both activity level and parent mental distress predicted more frequent injuries.

Conclusions

As has been found with younger children, unintentional injuries in fifth graders are associated with both parent and child characteristics. The result is discussed in the context of adolescent development. Implications include those for injury prevention (multi-dimensional prevention strategies that incorporate environmental modifications as well as training of youth and parents) and future research (study of potential mechanisms behind injury risk behavior via longitudinal and experimental research; study of injury risk during this phase of child development).     

Effects of graduated driver licensing on licensure and traffic injury rates in Upstate New York

Objective

In 2003, New York State implemented an enhanced graduated driving licensing (GDL) program that requires extended supervised driving and a passenger restriction. This study examines its safety benefit in 55 Upstate New York counties.

Methods

We analyzed fatal/incapacitating traffic injury data among 16-, 17- and 21-24-year olds for the years 2001 and 2005 using the negative binomial model. To adjust for trends in the traffic injury rate, the relative rate ratio (rRR) of 16- and 17-year olds relative to 21-24-year olds was estimated.

Results

GDL implementation was associated with a 31% reduction in the driver injury rate (rRR 0.69, 95% confidence interval (CI) 0.49-0.96), but not with any statistically significant change in the passenger injury rate (rRR 1.19, 95% CI 0.77-1.84), or pedestrian and bicyclist injury rate (rRR 1.53, 95% CI 0.89-2.62) among 16-year olds. Sixteen-year olds experienced a 21% decline in licensure rates between 2001 and 2005. GDL implementation had no appreciable impact on driver injury and licensure rates for 17- and 21-24-year olds.

Conclusions

GDL implementation is associated with a significant reduction in licensure and driver injury rate among 16-year olds. GDL implementation does not have a statistically significant impact on passenger, pedestrian, and bicyclist injury rates for 16-year olds.     

Predictors of driving after alcohol and drug use among adolescents in Valencia (Spain)

Background

Driving under the influence of alcohol and drugs has been identified as a risk factor for road traffic crashes. We have assessed the prevalence and predictor factors for driving after alcohol and drug use by adolescents.

Methods

A cross-sectional survey involving 11,239 students aged 14–18 years from 252 private and public schools in the Valencia region of Spain was conducted. The prevalence and predictors of driving after alcohol use, alcohol and drug use, or drug use during the previous 6 months were measured.

Results

Of the students who reported driving (20%), 45.1% indicated driving after alcohol and drug use. The consumption of various drugs was higher among students who drove a vehicle compared with those who did not. The likelihood of driving after consuming alcohol, or alcohol and drugs, increased in line with the number of standard drink units per week, reports of any lifetime alcohol- or drug-related problems, and poor family relationship. In addition, masculine gender and early alcohol use increased the likelihood of driving after consuming alcohol.

Conclusions

Driving after alcohol and drug use is quite prevalent among adolescents in the Valencia region of Spain. There is a need for implementation of targeted policies for adolescents. This should focus on education and information on alcohol/drug use and driving.     

Outcomes one year after a road accident: Results from the ESPARR cohort

Objective

Reducing the rates of death, trauma and sequelae associated with road accidents is the prime goal of road safety authorities, and success requires having data on victims’ outcomes in the long term. The present study examined the outcome of adult road accident victims one year after their accident.

Design

A follow-up study.

Methods

The cohort comprised 886 injured road-accident victims, aged ≥16 years, and living in the Rhône administrative Département, France (taken from the ESPARR Cohort). Data were collected on victim characteristics at the time of crash, and self-reported outcomes one year later. The population of respondents at the one-year questionnaire follow-up was divided into two categories according to injury severity, as mild-to-moderate (M.AIS < 3) or severe (M.AIS 3+). Qualitative variables were compared between these 2 groups using Chi² or Fisher exact tests.

Results

At one year post-accident, 45% of the mild-to-moderate injury group versus only 20% of severely injured subjects reported full recovery of health (p < 0.001). 20% of the cohort, as a whole, reported permanent pain. More than half of the severely injured subjects reported that the accident had had an impact on the everyday life of their family; this was twice as many as in the mild-to-moderate injury group (55% vs. 22%). Most of the severely injured reported impact on leisure, projects and emotional life: 20% reported relational difficulties in the couple, 16% reported impaired sexual life, and the rate of separation was significantly higher than in the mild-to-moderate injury group (5% vs. 1%; p < 0.001). Mean time off work was significantly longer in the severe injury group: 245 ± 158 days vs. 75 ± 104 days (p < 0.001); and 32% of the severe injury group (p < 0.001) who had stopped work had not returned at 1 year, compared to 5% of the mild-to-moderate injury group.

Conclusions

One year after a road accident, the consequences for victims remain significant. In terms of physical impact, pain frequently persists, impairing daily life for many. There is an elevated rate of chronic PTSD (post-traumatic stress disorder) and a non-negligible impact on affective and occupational life.