PromisesEditorialTeam, Author at Promises Healthcare - Page 2 of 27
ENQUIRY
My partner may be a Porn Addict – What should I do?

My partner may be a Porn Addict – What should I do?

Written by: Andrew da Roza, Addictions Therapist, Sex Addiction Specialist

With the introduction of the fast speed Internet, a new addiction was born – Internet porn addiction. 

One client who has fallen down the “Rabbit Hole” of porn addiction reports: 

“I saw porn in Manga mags and comics when I was in my early teens and occasionally saw a porn mag. 

It wasn’t until the fast speed Internet came in and I could stream videos on my mobile phone and iPad, that I started to watch it regularly. After a year or so, I started to watch it every day at home, when I was alone. 

Later on, I started watching it in the bathroom of the office; then at my desk, and finally, in public places and on public transport – I am amazed I wasn’t caught by someone!”

Some clients come to therapy to kick the porn habit because they recognize that they have a problem. They have been “caught” multiple times by their partner – always promising to stop. 

Or they may have inadvertently left sites open on the family computer. Some even get called in by HR at work and asked to explain the hundreds of times they have logged into porn sites, which the IT department has uncovered.   

Others don’t see they have a problem – even when their experiencing porn-related erectile dysfunction, anejaculation, or loss of libido and intimacy with their partners and spouses. 

They may simply consider this distressing, though natural, change in their relationship – a product of familiarity and boredom.  

As it turns out – they may be quite wrong – because there is nothing “natural” about porn. It’s toxic and it can effectively hijack intimate relationships, which could otherwise have been healthy and fulfilling.

Clients with porn use compulsivity often say:

“I wouldn’t have come to therapy unless my partner had given me an ultimatum – “get help or we break up!”.

And it’s also common to hear: 

“At first I thought I would just see a therapist once or twice to appease her, and let her know I want us to stay together”. 

However, after discussing in therapy how long a client has been using porn, how frequently they were using it, where they were using it – and the type of porn they have digressed to watching – they often realize all the risks they are taking with their relationships, marriage, families, and their jobs or their studies.

One client reports:
“the therapists gave me a detailed questionnaire. I was staggered by the report that came out. Seeing my behaviour over the last few years, what motivated me to do it, and how it changed me and my relationships, I became really worried.”

“I hadn’t realized that because of porn, I was losing interest in sex with her, I wasn’t present for my family, and I was getting irritated, restless and discontent at home and at work.

I thought that my problem with my sex drive and erections was our relationship – not the porn.”

These revelations, and many more, may be tough for a person with porn compulsion but at least they may be motived to take recovery actions. 

But what about the partner or spouse? They may be feeling frustrated, angry, fearful and ashamed. They may be devastated. 

They may be confused when friends, relatives and the community at large believe that porn is the “new norm” and that “boys will be boys”. 

What can they do? 

While relationships are all as different and unique as the people in them, there may be some common actions that spouses and partners may wish to consider. 

These include:

  • Attend therapy with the person who has porn use compulsivity – and learn about Internet porn addiction. How it arises; what it looks like; is the behaviour compulsive – or is it a moral issue, a lack of discipline, selfishness – or have they just stopped loving or desiring me?
    In a couples’ session, you can also learn what the recovery actions are, what it takes to succeed in recovery, and how you will know that he is in recovery – and will he ever do it again?

 

  • Read about porn addiction and how porn changes the brain. There are many good websites with excellent information. Fight the “New Drug”, “NoFap”, and “Your Brain on Porn” are but a few sites with good articles and videos. Robert Weiss, Paula Hall and Stephanie Carnes also have helpful YouTube videos.   

 

  • Insist that your partner initiates a regularly weekly couples’ check-in session; in which he shares: what actions he taken in his recovery that week and what he has learned; what actions he hasn’t done and why; what he will do next week; and what help he needs from you – and you always have the right to say “no”, or “yes, but…”. 

 

  • Judge his recovery only by his actions – not by his promises, intentions, desires or apologies. What he says is important – but what he actually does, is definitive.    

 

  • Create physical, emotional, spiritual and sexual boundaries with him – and have consequences that you apply – without fail – whenever those boundaries are breached. 

   

  • Stay connected with others about how you are doing and don’t isolate – but be cautious who you tell about his porn compulsion; only choose a few trustworthy friends or relations. Do not talk to everyone, including your children, when you are angry, in a rage, frustrated – or to retaliate – you are very likely to regret it later.

    If you think an age-appropriate disclosure is beneficial for the children, work on a script together; and allow the person with the porn compulsion to deliver it. It is their responsibility to hold themselves accountable for their actions.

 

  • Take really good care of yourself. Treat yourself kindly and compassionately.  Eat three healthy meals a day; sleep seven to eight hours; exercise regularly; take up yoga, Tai Chi and meditation. There are a wealth of Apps and YouTube videos out there – Calm, HeadSpace and Insight Timer are popular meditation Apps. Spend time with friends and family; take up new interests and hobbies – seek to relax and allow joy into your life. 

 

  • Porn blocking software administration. If you are open to it, you may be asked to be the security administrator for the porn blocking software that will prevent porn from being seen on his devices and the family computer. Consider carefully whether this would cause you more distress – or whether you wish to support him by ensuring that the security blocking software is in place.  

 

  • Consider seeing your own therapist – sometimes porn and deceit can be felt as profoundly as a relationship betrayal. It takes time and help to get through the trauma.

    Some partners feel shame, and some question whether they are the cause of the porn compulsion. Some partners are confused and devastated by all the lies and deceit. They don’t know what is real anymore. Talking to a supportive therapist can help you through this.

 


Photo by Grzegorz Walczak on Unsplash

How Do You Find The Right Therapist For You

How Do You Find The Right Therapist For You

For many individuals, therapy is a rather intense and personal topic, and it could have taken them a lot of courage to finally seek the help that they need. Keeping this in mind, it is exceptionally crucial that one finds the right therapist, for there’s a pre-existing implicit clinical belief that the level of treatment effectiveness is greatly dependent on the therapist-client fit. Of course, every client would love to be able to – ideally – find that one therapist whom they can fully open up to from the very beginning, but in reality, that may not be the case. At times, it is necessary to assess your relationship with your therapist and evaluate if there’s the good rapport you need for your sessions to be a success. Ultimately, it boils down to whether you feel a steady, reliable and safe connection with the therapist, and whether you are making the progress you hope for. 

To give you some background, studies over the years have shown that the more similar the therapist and the client, the higher the rate of recovery. As an example, an assessment instrument entitled the “Structural Profile Inventory(SPI)”, which measures seven “independent yet interactive” variables (behaviours, affects, sensory imagery, cognition, interpersonal, drugs/biological factors or BASIC-ID), showed that client-therapist similarity on the SPI predicted a better psychotherapy outcome for the client as measured by differences pre- and post-treatment on the Brief Symptom Inventory. Moreover, the demographic similarity between therapist and client facilitates positive perceptions of the relationship in the beginning stages of treatment, enhances commitment to remaining in treatment, and at times can accelerate the amount of improvement experienced by clients. More precisely, it can be said that age, ethnicity, and gender similarity have been associated with positive client perceptions of the treatment relationship. With gender and cultural similarities appearing the most strongly preferred among clients, these domains generally enhance clients’ perceptions of their therapists’ level of understanding and empathy, and as a result, sessions are judged to be more advantageous and worthwhile. However, besides these, there are also other means to assess your “fit” with your therapist, and we’re here to discuss just that.

First and foremost, consider if you are seeking help in the right place. Does the therapist you are looking at specialise in the area you are seeking help for? Before we can even touch on the topic of interpersonal therapist-client fit, it is important for you to take the time to do some research on various therapists’ profiles – in other words, to sift through and read up on their respective areas of expertise. Typically, therapists would have their area(s) of specialisation up on their online profile directories. It would be clearly indicated if they specialise in areas such as substance abuse, family therapy, or even anger management. It goes without saying that, for example, it would be inappropriate to consult a psychologist who specialises in child psychology when you’re clearly looking for someone who can help you with your substance-use addiction. With that said, it is to no one’s benefit for you to rush into therapy blindly. 

Once you have chosen the potential therapist that you are most likely to want to have see you through your road to recovery, another essential question you should ask yourself is whether you are comfortable with their suggested mode of therapy. During consultations, you will have the opportunity to enquire about their recommended techniques or treatment methods that will be explored during your subsequent sessions. If you are uncomfortable with any particular process, giving honest feedback and exploring other methods is always an option. However, at any point, you also have the right to seek other therapists who may be able to help you in other ways that don’t put you in a tight spot. After all, therapy is all about having a safe and comfortable space for you to sort out your difficulties. 

When assessing your interpersonal connection with your therapist, make sure to trust your gut. This way, you’ll also be able to track your progress better and to seek alternative help if required. Some questions you can ask yourself are:

  1. Am I satisfied with the current balance of talking and listening with my therapist?
  2. Is my overall therapy experience safe, warm, and validating? 
  3. Am I fully assured that I’m in a non-judgemental space where I can be fully honest?
  4. How much has the therapist helped me to gain greater insight into my own behaviour and thoughts so far? 
  5. Am I becoming more capable of coping (independently) with stressful or triggering situations over time?
  6. Am I noticing more positive changes in myself, as compared to when I first started therapy?

As mentioned, a major deciding factor should also be on whether you find yourself noticing positive changes in your thought cycles and behaviour after a couple of sessions. At the end of the day, therapy should be about working towards achieving your desired outcome, and should definitely not be limited to weekly venting sessions. Although venting and letting out hard feelings can provide temporary relief, it fosters a client’s dependence on the therapist over time and further reinforces the client’s problems. Therapy should instead help you to feel more confident that you’ve developed the relevant skill sets in order to cope with whatever emotional challenges that brought you to seek therapy in the first place.

Naturally, there’s no guarantee that we will find chemistry with the first therapist we meet. The chemistry between people varies, and sometimes it’s just not possible for us to force it. Thus, it is important to remember that a lack of fit between therapist and client is no one’s fault. However, remember that the ball is in our court, and it is within our control to start looking in the right place for the sake of our own well-being.


 1 Herman, S.M. (1998). The relationship between therapist-client modality similarity and psychotherapy outcome. Journal of Psychotherapy Practice and Research, 1998 Winter; 7(1): 56-64.

2 Luborksky, L., Crits-Christoph, P., Alexander, L., Margolis, M., & Cohen, M. (1983). Two Helping alliance methods for predicting outcomes of psychotherapy: A counting signs vs. a global rating method. Journal of Nervous and Mental Disease, 171, 480-491.

3 Jones, E. E., (1978). Effects of race on psychotherapy process and outcome: An exploratory investigation. Psychotherapy: Theory, Research and Practice, 15, 226-236.

4 Blase, J. J. (1979). A study of the effects of sec of the client and sex of the therapist on clients’ satisfaction with psychotherapy. Dissertation Abstracts International, 39, 6107B-6108B.

Beutler, L.E., Clarkin, J., Crago, M. and Bergan, J., 1991. Client-therapist matching. Pergamon general psychology series, 162, pp.699-716. (Accessed 30/08/2020)

https://www.counsellingconnection.com/index.php/2019/12/03/assessing-therapist-client-fit/ (Accessed 30/08/2020)

https://www.nytimes.com/roomfordebate/2013/02/14/think-like-a-pope-knowing-when-to-quit/when-to-quit-therapy (Accessed 30/08/2020)

Photo by Cytonn Photography on Unsplash

Addictions in the Digital Age: Technology – The Accelerator of both the Problem and the Solution

Addictions in the Digital Age: Technology – The Accelerator of both the Problem and the Solution

Written by: Andrew da Roza, Addictions Therapist, Sex Addiction Specialist

Ever since people first crushed and fermented grapes, the dark hand of alcoholism has been present. When the first games of chance and competition were born – so too was the addiction to gambling.  

We can well imagine that abusing cannabis came, even as it was used for medicinal and religious purposes in the 3rd millennium BC. 

And breathing in the toxic smoke from burning tobacco was a daily human habit, well before Christopher Columbus landed in the Americas in 1492 and brought it back to Europe. 

But now, in our digital age, technology has accelerated our addictions.

And the stress and isolation brought to us by COVID-19 have pushed many to addictions they never thought they had.  

Alcohol and cigarettes can be delivered to our doors from digital orders placed on mobile phones. The Dark Web and chemistry have conspired to create hazardous new psychoactive substances that pose as cannabis, available with a few keystrokes on a laptop. An Internet poker or roulette game can be found 24 hours a day, every day of the year. The Internet has sped us down the path of over-shopping, over-eating, and over-playing competitive games.

Ever adaptable and flexible, the Internet has even created new addictions – such as Internet pornography and anonymous sex “dating”. 

If we are unlucky enough to fall down these digital “rabbit holes”, what are the results? Alice’s Wonderland? Or: failing health and finances; anxiety; depression; isolation, fractious and failing relationships, lost schooling and jobs; self-harm; and suicidal thoughts. “Jails, institutions and death” – as Alcoholics Anonymous warn us. A life without meaning, purpose or dignity.

But just as addictions have been accelerated by technology and new ones invented, technology has also enabled us to make recovery more convenient, available, cheaper, effective, and timely. 

The longest journey for people suffering from addictions has been from the “bottle” to the therapy room. Any number of “barriers” stood in the way. Not enough time, not enough money, not enough knowledge of which therapist to see or what recovery involves. 

But the biggest barrier of all to entering recovery was shame.

Now, therapy can be done on the Internet: information about therapists can be Googled; prices compared; social service agencies offering low-cost therapy or even free therapy can be found, and rich information and video testimonies on the recovery journey can be reviewed.  

Best of all, Zoom therapy can be conducted with a therapist “once removed” from the personal space of the client by computer screens – and in the comfort of the client’s own living room or bedroom. Clients could even maintain much of their anonymity. In this safe space, shame may deign to take a back seat.

With digital recovery free from barriers, even if the sufferer is still reluctant to seek help, they may be more inclined to reflect on why they remain reluctant to get and receive help. If they do start to reflect honestly – they have started their first step on their recovery journey. 

But more can be done with digital recovery. 

I would submit that the next significant step in using the Internet to accelerate recovery is to bring the therapist to the clients where they are – on the sites that feed their addictions and perpetuate their suffering.

A therapist could join as a “player” in Animal Crossing, Fornite, a poker or roulette game. They can then engage suffering players in unthreatening and therapeutic conversations. Perhaps PornHub will produce an avatar “ambassador” – a therapist who guides users through a porn compulsiveness assessment? Perhaps the GrabEats avatar therapist will help customers with alcohol and calorie counts, consumption and portion control, alcohol use and dietary information – and motivational conversations to help customers build their resolve.     

Engaging suffering people in their digital space opens a whole new avenue for the helping professional to guide someone towards a path of meaning and purpose.

Therapists may wish to think “Digital” – and harness the power of technology to enrich people’s lives – even if technology can also impoverish them. 


Photo by Taras Shypka on Unsplash

Alcohol Use Disorder Diagnosis & Treatment

Alcohol Use Disorder Diagnosis & Treatment

What comes to mind when someone mentions alcohol? For many, alcohol is often associated with the temporary avoidance of daily struggles. Whether or not we have the habit to drink, it is a known fact that people may tend to have “blackouts” whenever they’re really drunk – and are unable to recall anything during these periods of time. As for young adults, perhaps it could also be attributed to their keen desire to look “cool” and to show off their high alcohol tolerance to their friends. However, alcohol can be addictive, and frequent heavy drinkers run the risk of becoming alcohol-dependent and hence developing alcohol use disorders. But what actions can we take if we find ourselves constantly wanting to submit to such an altered state of being, and seeing the appeal in losing control of ourselves as a form of escapism?

 

What is an Alcohol Use Disorder?

According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; 

DSM–5; American Psychiatric Association, 2013), an alcohol use disorder is essentially characterised by “a problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following, occurring within a 12-month period”: 

  1. Alcohol is often taken in larger amounts or over a longer period than was intended.
  2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
  3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
  4. Craving, or a strong desire or urge to use alcohol.
  5. Recurrent alcohol use resulting in a failure to fulfil major role obligations at work, school, or home.
  6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
  7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
  8. Recurrent alcohol use in situations where it is physically dangerous.
  9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
  10. Tolerance.
  11. Withdrawal.

In regards to the disorder’s severity, it is safe to say that an individual categorised under the ‘mild severity’ category would display two to three of the above symptoms, while those under ‘Moderate’ would display four to five. For persons who develop six or more of such symptoms, they would, unfortunately, be diagnosed to be severely alcohol-dependent. 

In the development of alcohol abuse, we need to recognise that the physiological and psychological reward system in our brains are what contributes to the clouding of negative consequences and effects associated with alcohol dependence and addiction. In other words, the possibility for change is tough, and the learnt habit can be hard to kick. Positive and negative reinforcements play a major role, especially in the beginning stages of alcohol abuse. Positive reinforcement occurs when the chances of an individual performing an activity (in this case, drinking) is heightened due to his previous experience of feeling rewarded by the “high” he or she obtains when getting drunk. On the contrary, negative reinforcement occurs when the probability of alcohol-seeking behaviour increases upon allowing the drinker to avoid certain situations or negative stimuli. Therefore, it can be said that alcohol abuse is fuelled by the physiological and psychological reward system, thus increasing one’s motivation to consume more alcohol, though sometimes a little too much. 

Alcohol addiction can be greatly detrimental to our lifestyles, as well as to our physical and mental health. Known to be a depressant, alcohol can have a significant impact on our brain’s activity. If you’re drinking unhealthy levels of alcohol in an attempt to manage other mental health conditions such as anxiety or depression, stop it immediately! Alcohol affects neurotransmitters in your brain, potentially worsening your pre-existing condition. As such, it is crucial that we help people with alcohol use disorders to move past their addiction to a more fulfilling lifestyle. 

 

What forms of treatment can I consider?

Alcohol abuse can be treated with psychiatric or psychological intervention, sometimes a combination of both. 

When it comes to psychiatric medications, psychiatrists may prescribe medications used primarily to treat alcohol withdrawal by targeting the GABA neurotransmitters in the brain, allowing the brain to restore its natural balance when the person abstains from alcohol. Another common medication prescribed mainly affects the individual’s alcohol metabolism. The drug increases the concentration of acetaldehyde, a product formed when alcohol is broken down. The buildup of this acetaldehyde induces undesirable effects such as vomiting, hence holding the person back from consuming large amounts of alcohol. However, despite these drugs being the commonly prescribed medications, it is extremely dangerous for one to source and consume them without first consulting a professional psychiatrist. Everyone’s case is different, and people may have differing medication needs. 

Another form of treatment one can consider is Cognitive Behavioural Therapy (CBT). CBT is an effective method which focuses on helping one identify and uproot negative or irrational thoughts and/or behaviours. Being highly solution-focused, such forms of therapy can include trying to help these individuals to recognise situations in which they are inclined to drink, and how they can better repress themselves. As such, the main goal would be for these people to recognise their problematic behaviour, and subsequently cut down on and adhere to healthy alcohol consumption levels. Since the impact of alcohol abuse is usually not limited to the individual, family therapy may also be recommended at times, especially if the individual’s alcoholic behaviour causes others distress. 

All in all, alcoholism is not a matter to be taken lightly, as alcohol can certainly bring harm to both our physical and mental health if not consumed in moderation or at healthy levels. Do seek treatment immediately if you find that your alcohol-use patterns are interfering with your quality of life, or if you constantly find yourself craving higher doses each time.

 


References

1 DiClemente, C.C.. (2006). Addiction and change. How addictions develop and addicted people recover. New York, NY: The Guilford Press.

2 Gilpin, N.W., & Koob, G.F. (2008). Neurobiology of alcohol dependence. Focus on motivational mechanisms. Alcohol Research & Health, 32, 1850195. 

 

Drinking & Alcohol-Related Harm Among Young Adults Especially Since COVID Measures

Drinking & Alcohol-Related Harm Among Young Adults Especially Since COVID Measures

With economic growth and increased globalisation, alcohol consumption generally increases as it gets more affordable and popular as a drink for celebratory or social occasions, and even for stress-relief. This same trend has been observed in Singapore – where the per capita alcohol consumption in Singapore has nearly trebled from 2005 to 2015, and a study released in 2016 estimated the prevalence of binge drinking in Singapore to be 9.6 per cent of the population. Among young adults in the recent decade or so, the number of alcohol-related incidents including verbal abuse, physical abuse, domestic violence, as well as property damage and vandalism have also increased. According to the Institute of Mental Health, a nation-wide study in 2010 found that one in 19 of those aged 18 to 34 struggle with alcohol dependence, abuse and disorders. The study also highlighted that the chances of alcohol-use disorders in this age group were twice that of age groups above 35. In this article, we will thus explore why drinking is becoming more prevalent, and the types of alcohol-related harm that young adults are increasingly vulnerable to. 

 

For sure, individuals don’t become an alcohol addict overnight – they usually start with binge drinking, which is the worrying trend among young adults. Binge drinking is defined as the heavy consumption of alcohol within a short span of time with the intention of being inebriated. Binge drinking can be classified under mainly two categories: extensive drinking on a single occasion, or continuous drinking over days or weeks. It isn’t a rare sight to see youths gathering on a Friday night or weekends to go clubbing – places where most drinks have high alcohol content. Even with the COVID19 pandemic at present, young adults can still be seen to gather in small groups to drink and socialise. As a matter of fact, more people have turned to drinking in order to cope with the COVID19 situation. On a global scale, studies have shown that alcohol sales and consumption has risen. As an example, according to a recent study conducted by the USA Nielsen Company, there has been a 240% increase in internet alcohol sales, including hard liquor. Needless to say, it is not surprising that more Singaporeans would pick up drinking in order to cope with their unpleasant emotions and distress as well.

 

Frequent binge drinking may lead to alcohol dependence or addiction, especially when these individuals start consuming larger amounts of alcohol in order to obtain the same “high”. So why are more young adults exposed to alcohol drinking? Firstly, Singapore’s progress and prosperity have brought about lifestyle changes of youths and young adults compared to their parents’ generation. The increasing independence and thrill-seeking behaviours of these younger people might also include experimenting with alcohol. Secondly, globalisation has undermined many of the traditional controls on alcohol, making it widely available and aggressively marketed and promoted throughout society. 

 

People who begin drinking early in life run the risk of developing serious alcohol problems, including alcoholism, later in life. They also are at greater risk for a variety of adverse consequences and poor performance in school or at work. 

 

Overall, alcohol-related harm doesn’t merely include alcohol poisoning or eventual liver failure. Rather, it can also refer to:

  • Other related long-term diseases due to chronic heavy drinking
  • Unintended sexual behaviours, including sexual assault
  • Accidents such as those caused by drunk-driving
  • Suicide
  • Crime, including violent crimes and homicide

 

To reiterate, binge drinking can very well lead to alcoholism and it shouldn’t be taken too lightly. Identifying people at greatest risk can help stop problems before they develop. Young people are at greater risk of alcohol-related harm than adults. Excessive alcohol drinking as a teenager can greatly increase the risk of damage to the developing brain and also lead to problems with alcohol later in life. For those of you that find yourselves increasingly inclined to drink high amounts of alcohol, do consider taking proactive steps to reduce your intake. It may require strong willpower and determination initially, but things will be easier once you take the first step. Go for alcohol addiction treatment therapy or counselling,  if it can give you the push you need to counter your drinking habits, or connect with like-minded people through peer support groups such as Alcoholics Anonymous. By curbing and reducing your alcohol consumption to safe levels, you will be doing both your physical and mental health a favour.

 


References:

Dr. Barry L. Jackson, 2016, Drinking & Alcohol-Related Harm Among Young Adults, video recording, Mental Health Academy 

<https://www.mentalhealthacademy.co.uk/dashboard/catalogue/drinking-and-alcohol-related-harm-among-young-adults?start=true> (Accessed 13/08/2020)

https://www.straitstimes.com/singapore/alcohol-abuse-worse-among-younger-people (Accessed 13/08/2020)

https://www.imh.com.sg/wellness/page.aspx?id=1224 (Accessed 14/08/2020) 

Chodkiewicz J., Talarowska M., Miniszewska J., Nawrocka N. (2020) ‘Alcohol Consumption Reported during the COVID-19 Pandemic: The Initial Stage’, Int. J. Environ. Res. Public Health 2020, 17(13), 4677; https://doi.org/10.3390/ijerph17134677  (Accessed 22/08/2020)