Research Article
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The Levels of Depression, Anxiety and Stress of Patients and Associated Factors in the COVID-19 Pandemic

Year 2023, Volume: 7 Issue: 2, 78 - 88, 07.08.2023

Abstract

It was aimed to examine the depression, anxiety and stress levels of patients during the COVID-19 epidemic and to reveal the associated factors. A total of 291 patients who applied to the university hospital in Kahramanmaraş for treatment were included in this cross-sectional study. The research was carried out between 27 January-10 February 2022. The scale developed by Henry and Crawford (2005) was used to measure the depression, anxiety and stress levels of the participants. In data analysis, t test, analysis of variance test and descriptive statistics were used. It was determined that the depression, anxiety and stress levels of the participants were moderate. Women, those with chronic illnesses and individuals who stated that they regularly followed the news about the epidemic stated higher levels of depression, anxiety and stress. It has been determined that the depression and stress levels of the individuals who regularly smoke and are single are higher. In addition, it was observed that the levels of anxiety and depression were lower in patients who stated that they trusted the vaccine and did sports regularly. With these results, some antecedent factors that should be taken into account in order to improve the mental health of patients in pandemics have been revealed.

References

  • Akova, İ., Kılıç, E., & Özdemir, M. E. (2022). Prevalence of burnout, depression, anxiety, stress, and hopelessness among healthcare workers in COVID-19 Pandemic in Turkey. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 59(1), 1-11. https://doi.org/10.1177/00469580221079684
  • Alan, H., Gumus, E., & AK, H. S. (2021). " I'm a hero, but…": An evaluation of depression, anxiety, and stress levels of frontline healthcare professionals during COVID-19 pandemic in Turkey. Perspectives in Psychiatric Care, 57(3), 1126-1136. https://doi.org/10.1111/ppc.12666
  • Aslan, I., Ochnik, D., & Çınar, O. (2020). Exploring perceived stress among students in Turkey during the COVID-19 pandemic. International Journal of Environmental Research and Public Health, 17(23), 1-5. https://doi.org/10.3390/ijerph17238961
  • Bareeqa, S. B., Ahmed, S. I., Samar, S. S., Yasin, W., Zehra, S., Monese, G. M., & Gouthro, R. V. (2021). Prevalence of depression, anxiety and stress in china during COVID-19 pandemic: A systematic review with meta-analysis. The International Journal of Psychiatry in Medicine, 56(4), 210-227. https://doi.org/10.1177/0091217420978005
  • Cenat, J. M., Blais-Rochette, C., Kokou-Kpolou, C. K., Noorishad, P.-G., Mukunzi, J. N., McIntee, S.-E., Dalexis, R. D., Goulet, M.-A., & Labelle, P. R. (2021). Prevalence of symptoms of depression, anxiety, insomnia, posttraumatic stress disorder, and psychological distress among populations affected by the COVID-19 pandemic: A systematic review and meta-analysis. Psychiatry research, 295(1), 1-10. https://doi.org/10.1016/j.psychres.2020.113599
  • Cortés-Álvarez, N. Y., Piñeiro-Lamas, R., & Vuelvas-Olmos, C. R. (2020). Psychological effects and associated factors of COVID-19 in a Mexican sample. Disaster medicine and public health preparedness, 14(3), 413-424. https://doi.org/10.1017/dmp.2020.215
  • Effati-Daryani, F., Zarei, S., Mohammadi, A., Hemmati, E., Ghasemi Yngyknd, S., & Mirghafourvand, M. (2020). Depression, stress, anxiety and their predictors in Iranian pregnant women during the outbreak of COVID-19. BMC psychology, 8(1), 1-10. https://doi.org/10.1186/s40359-020-00464-8
  • Elbay, R. Y., Kurtulmuş, A., Arpacıoğlu, S., & Karadere, E. (2020). Depression, anxiety, stress levels of physicians and associated factors in Covid-19 pandemics. Psychiatry research, 290(1), 1-5. https://doi.org/10.1016/j.psychres.2020.113130
  • Erdoğan, S., Can, A. A., Abiç, A., & Yilmaz, D. V. (2022). Examination of individuals' depression, anxiety, and stress levels during the COVID-19 pandemic in Turkey. Archives of Psychiatric Nursing, 41(1), 96-102. https://doi.org/10.1016/j.apnu.2022.07.021
  • Gasteiger, N., Vedhara, K., Massey, A., Jia, R., Ayling, K., Chalder, T., Coupland, C., & Broadbent, E. (2021). Depression, anxiety and stress during the COVID-19 pandemic: results from a New Zealand cohort study on mental well-being. BMJ open, 11(5), 1-8. https://doi.org/10.1136/bmjopen-2020-045325
  • Hajure, M., Tariku, M., Mohammedhussein, M., & Dule, A. (2020). Depression, anxiety and associated factors among chronic medical patients amid COVID-19 pandemic in Mettu Karl Referral Hospital, Mettu, Ethiopia, 2020. Neuropsychiatric disease and treatment, 16(1), 1-14. https://doi.org/10.2147/NDT.S281995
  • Henry, J. D., & Crawford, J. R. (2005). The short‐form version of the Depression Anxiety Stress Scales (DASS‐21): Construct validity and normative data in a large non‐clinical sample. British Journal of Clinical Psychology, 44(2), 227-239. https://doi.org/10.1348/014466505X29657
  • Hosen, I., Al-Mamun, F., & Mamun, M. A. (2021). Prevalence and risk factors of the symptoms of depression, anxiety, and stress during the COVID-19 pandemic in Bangladesh: a systematic review and meta-analysis. Global Mental Health, 8(1), 1-10. https://doi.org/10.1017/gmh.2021.49
  • Hosseinzadeh-Shanjani, Z., Hajimiri, K., Rostami, B., Ramazani, S., & Dadashi, M. (2020). Stress, anxiety, and depression levels among healthcare staff during the COVID-19 epidemic. Basic and Clinical Neuroscience, 11(2), 163-168. https://doi.org/10.32598/bcn.11.covid19.651.4
  • Hou, F., Bi, F., Jiao, R., Luo, D., & Song, K. (2020). Gender differences of depression and anxiety among social media users during the COVID-19 outbreak in China: a cross-sectional study. BMC public health, 20(1), 1-11. https://doi.org/10.1186/s12889-020-09738-7
  • Jeong, H., Yim, H. W., Song, Y.-J., Ki, M., Min, J.-A., Cho, J., & Chae, J.-H. (2016). Mental health status of people isolated due to Middle East Respiratory Syndrome. Epidemiology and Health, 38(1), 1-4. https://doi.org/10.4178/epih.e2016048
  • Khademian, F., Delavari, S., Koohjani, Z., & Khademian, Z. (2021). An investigation of depression, anxiety, and stress and its relating factors during COVID-19 pandemic in Iran. BMC Public Health, 21(1), 1-7. https://doi.org/10.1186/s12889-021-10329-3
  • Maunder, R., Hunter, J., Vincent, L., Bennett, J., Peladeau, N., Leszcz, M., Sadavoy, J., Verhaeghe, L. M., Steinberg, R., & Mazzulli, T. (2003). The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. Canadian Medical Association Journal, 168(10), 1245-1251.
  • Okuhara, T., Ishikawa, H., Okada, M., Kato, M., & Kiuchi, T. (2019). Newspaper coverage before and after the HPV vaccination crisis began in Japan: a text mining analysis. BMC Public Health, 19(1), 1-15. https://doi.org/10.1186/s12889-019-7097-2
  • Özdin, S., & Bayrak Özdin, Ş. (2020). Levels and predictors of anxiety, depression and health anxiety during COVID-19 pandemic in Turkish society: The importance of gender. International Journal of Social Psychiatry, 66(5), 504-511. https://doi.org/10.1177/0020764020927051
  • Palgi, Y., Bergman, Y. S., Ben-David, B., & Bodner, E. (2021). No psychological vaccination: Vaccine hesitancy is associated with negative psychiatric outcomes among Israelis who received COVID-19 vaccination. Journal of Affective Disorders, 287(1), 352-353. https://doi.org/10.1016/j.jad.2021.03.064
  • Pieh, C., Budimir, S., & Probst, T. (2020). The effect of age, gender, income, work, and physical activity on mental health during coronavirus disease (COVID-19) lockdown in Austria. Journal of Psychosomatic Research, 136(1), 1-11. https://doi.org/10.1016/j.jpsychores.2020.110186
  • Rehman, U., Shahnawaz, M. G., Khan, N. H., Kharshiing, K. D., Khursheed, M., Gupta, K., Kashyap, D., & Uniyal, R. (2021). Depression, anxiety and stress among Indians in times of Covid-19 lockdown. Community Mental Health Journal, 57(1), 42-48. https://doi.org/10.1007/s10597-020-00664-x
  • Salazar, A., Palomo-Osuna, J., de Sola, H., Moral-Munoz, J. A., Dueñas, M., & Failde, I. (2021). Psychological impact of the lockdown due to the COVID-19 pandemic in university workers: Factors related to stress, anxiety, and depression. International Journal of Environmental Research and Public Health, 18(8), 4367- 4375. https://doi.org/10.3390/ijerph18084367
  • Simegn, W., Dagnew, B., Yeshaw, Y., Yitayih, S., Woldegerima, B., & Dagne, H. (2021). Depression, anxiety, stress and their associated factors among Ethiopian University students during an early stage of COVID-19 pandemic: An online-based cross-sectional survey. PloS one, 16(5), 1-5. https://doi.org/10.1371/journal.pone.0251670
  • Stainback, K., Hearne, B. N., & Trieu, M. M. (2020). COVID-19 and the 24/7 news cycle: Does COVID-19 news exposure affect mental health? Socius, 6(1), 1-15. https://doi.org/0.1177/2378023120969339
  • Stanton, R., To, Q. G., Khalesi, S., Williams, S. L., Alley, S. J., Thwaite, T. L., Fenning, A. S., & Vandelanotte, C. (2020). Depression, anxiety and stress during COVID-19: associations with changes in physical activity, sleep, tobacco and alcohol use in Australian adults. International Journal of Environmental Research and Public Health, 17(11), 1-14. https://doi.org/10.3390/ijerph17114065
  • Venanzi, L., Dickey, L., Green, H., Pegg, S., Benningfield, M. M., Bettis, A. H., Blackford, J. U., & Kujawa, A. (2022). Longitudinal predictors of depression, anxiety, and alcohol use following COVID‐19‐related stress. Stress and Health, 38(4):674-691. https://doi.org/10.1002/smi.3125
  • Verma, S., & Mishra, A. (2020). Depression, anxiety, and stress and socio-demographic correlates among general Indian public during COVID-19. International Journal of Social Psychiatry, 66(8), 756-762. https://doi.org/10.1177/0020764020934508
  • World Health Organization (WHO). (2022). WHO Coronavirus (COVID-19) Dashboard. https://covid19.who.int/ adresinden 3 Eylül 2022 tarihinde alınmıştır.
  • Yılmaz, Ö., Boz, H., & Arslan, A. (2017). Depresyon anksiyete stres ölçeğinin (DASS 21) Türkçe kısa formunun geçerlilik-güvenilirlik çalışması. Finans Ekonomi ve Sosyal Araştırmalar Dergisi, 2(2), 78-91. https://dergipark.org.tr/en/pub/fesa/issue/30912/323190
  • Zandifar, A., Badrfam, R., Yazdani, S., Arzaghi, S. M., Rahimi, F., Ghasemi, S., Khamisabadi, S., Mohammadian Khonsari, N., & Qorbani, M. (2020). Prevalence and severity of depression, anxiety, stress and perceived stress in hospitalized patients with COVID-19. Journal of Diabetes & Metabolic Disorders, 19(2), 1431-1438. https://doi.org/10.1007/s40200-020-00667-1

COVID-19 Pandemisinde Hastaların Depresyon, Anksiyete ve Stres Düzeyleri ve İlişkili Faktörler

Year 2023, Volume: 7 Issue: 2, 78 - 88, 07.08.2023

Abstract

Bu çalışma ile COVID-19 salgın sürecinde hastaların depresyon, anksiyete ve stres düzeylerini incelemek ve ilişkili faktörleri ortaya koymak amaçlanmıştır. Bu kesitsel nitelikteki çalışmaya Kahramanmaraş ilindeki üniversitesi hastanesine tedavi için başvuran toplam 291 hasta dahil edilmiştir. Araştırma 27 Ocak-10 Şubat 2022 tarihleri arasında gerçekleştirilmiştir. Katılımcıların depresyon, anksiyete ve stres düzeylerini ölçmek için Henry ve Crawford (2005) tarafından geliştirilen ölçek kullanılmıştır. Veri analizinde, t testi, varyans analizi testi ve tanımlayıcı istatistikler kullanılmıştır. Katılımcıların depresyon, anksiyete ve stres düzeylerinin orta şiddette olduğu tespit edilmiştir. Kadınlar, kronik rahatsızlığı olanlar ve salgın ile ilgili haberleri düzenli olarak takip ettiğini belirten bireyler daha yüksek depresyon, anksiyete ve stres düzeyi belirtmiştir. Düzenli olarak sigara içtiğini belirten ve bekar olan bireylerin depresyon ve stres düzeylerinin daha yüksek olduğu tespit edilmiştir. Ayrıca, aşıya güvendiğini belirten ve düzenli olarak spor yapan hastalarında anksiyete ve depresyon düzeylerinin daha düşük olduğu görülmüştür. Bu sonuçlar ile pandemilerde hastaların ruh sağlığını iyileştirmek için dikkate alınması gereken bazı öncül faktörler ortaya konulmuştur.

References

  • Akova, İ., Kılıç, E., & Özdemir, M. E. (2022). Prevalence of burnout, depression, anxiety, stress, and hopelessness among healthcare workers in COVID-19 Pandemic in Turkey. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 59(1), 1-11. https://doi.org/10.1177/00469580221079684
  • Alan, H., Gumus, E., & AK, H. S. (2021). " I'm a hero, but…": An evaluation of depression, anxiety, and stress levels of frontline healthcare professionals during COVID-19 pandemic in Turkey. Perspectives in Psychiatric Care, 57(3), 1126-1136. https://doi.org/10.1111/ppc.12666
  • Aslan, I., Ochnik, D., & Çınar, O. (2020). Exploring perceived stress among students in Turkey during the COVID-19 pandemic. International Journal of Environmental Research and Public Health, 17(23), 1-5. https://doi.org/10.3390/ijerph17238961
  • Bareeqa, S. B., Ahmed, S. I., Samar, S. S., Yasin, W., Zehra, S., Monese, G. M., & Gouthro, R. V. (2021). Prevalence of depression, anxiety and stress in china during COVID-19 pandemic: A systematic review with meta-analysis. The International Journal of Psychiatry in Medicine, 56(4), 210-227. https://doi.org/10.1177/0091217420978005
  • Cenat, J. M., Blais-Rochette, C., Kokou-Kpolou, C. K., Noorishad, P.-G., Mukunzi, J. N., McIntee, S.-E., Dalexis, R. D., Goulet, M.-A., & Labelle, P. R. (2021). Prevalence of symptoms of depression, anxiety, insomnia, posttraumatic stress disorder, and psychological distress among populations affected by the COVID-19 pandemic: A systematic review and meta-analysis. Psychiatry research, 295(1), 1-10. https://doi.org/10.1016/j.psychres.2020.113599
  • Cortés-Álvarez, N. Y., Piñeiro-Lamas, R., & Vuelvas-Olmos, C. R. (2020). Psychological effects and associated factors of COVID-19 in a Mexican sample. Disaster medicine and public health preparedness, 14(3), 413-424. https://doi.org/10.1017/dmp.2020.215
  • Effati-Daryani, F., Zarei, S., Mohammadi, A., Hemmati, E., Ghasemi Yngyknd, S., & Mirghafourvand, M. (2020). Depression, stress, anxiety and their predictors in Iranian pregnant women during the outbreak of COVID-19. BMC psychology, 8(1), 1-10. https://doi.org/10.1186/s40359-020-00464-8
  • Elbay, R. Y., Kurtulmuş, A., Arpacıoğlu, S., & Karadere, E. (2020). Depression, anxiety, stress levels of physicians and associated factors in Covid-19 pandemics. Psychiatry research, 290(1), 1-5. https://doi.org/10.1016/j.psychres.2020.113130
  • Erdoğan, S., Can, A. A., Abiç, A., & Yilmaz, D. V. (2022). Examination of individuals' depression, anxiety, and stress levels during the COVID-19 pandemic in Turkey. Archives of Psychiatric Nursing, 41(1), 96-102. https://doi.org/10.1016/j.apnu.2022.07.021
  • Gasteiger, N., Vedhara, K., Massey, A., Jia, R., Ayling, K., Chalder, T., Coupland, C., & Broadbent, E. (2021). Depression, anxiety and stress during the COVID-19 pandemic: results from a New Zealand cohort study on mental well-being. BMJ open, 11(5), 1-8. https://doi.org/10.1136/bmjopen-2020-045325
  • Hajure, M., Tariku, M., Mohammedhussein, M., & Dule, A. (2020). Depression, anxiety and associated factors among chronic medical patients amid COVID-19 pandemic in Mettu Karl Referral Hospital, Mettu, Ethiopia, 2020. Neuropsychiatric disease and treatment, 16(1), 1-14. https://doi.org/10.2147/NDT.S281995
  • Henry, J. D., & Crawford, J. R. (2005). The short‐form version of the Depression Anxiety Stress Scales (DASS‐21): Construct validity and normative data in a large non‐clinical sample. British Journal of Clinical Psychology, 44(2), 227-239. https://doi.org/10.1348/014466505X29657
  • Hosen, I., Al-Mamun, F., & Mamun, M. A. (2021). Prevalence and risk factors of the symptoms of depression, anxiety, and stress during the COVID-19 pandemic in Bangladesh: a systematic review and meta-analysis. Global Mental Health, 8(1), 1-10. https://doi.org/10.1017/gmh.2021.49
  • Hosseinzadeh-Shanjani, Z., Hajimiri, K., Rostami, B., Ramazani, S., & Dadashi, M. (2020). Stress, anxiety, and depression levels among healthcare staff during the COVID-19 epidemic. Basic and Clinical Neuroscience, 11(2), 163-168. https://doi.org/10.32598/bcn.11.covid19.651.4
  • Hou, F., Bi, F., Jiao, R., Luo, D., & Song, K. (2020). Gender differences of depression and anxiety among social media users during the COVID-19 outbreak in China: a cross-sectional study. BMC public health, 20(1), 1-11. https://doi.org/10.1186/s12889-020-09738-7
  • Jeong, H., Yim, H. W., Song, Y.-J., Ki, M., Min, J.-A., Cho, J., & Chae, J.-H. (2016). Mental health status of people isolated due to Middle East Respiratory Syndrome. Epidemiology and Health, 38(1), 1-4. https://doi.org/10.4178/epih.e2016048
  • Khademian, F., Delavari, S., Koohjani, Z., & Khademian, Z. (2021). An investigation of depression, anxiety, and stress and its relating factors during COVID-19 pandemic in Iran. BMC Public Health, 21(1), 1-7. https://doi.org/10.1186/s12889-021-10329-3
  • Maunder, R., Hunter, J., Vincent, L., Bennett, J., Peladeau, N., Leszcz, M., Sadavoy, J., Verhaeghe, L. M., Steinberg, R., & Mazzulli, T. (2003). The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. Canadian Medical Association Journal, 168(10), 1245-1251.
  • Okuhara, T., Ishikawa, H., Okada, M., Kato, M., & Kiuchi, T. (2019). Newspaper coverage before and after the HPV vaccination crisis began in Japan: a text mining analysis. BMC Public Health, 19(1), 1-15. https://doi.org/10.1186/s12889-019-7097-2
  • Özdin, S., & Bayrak Özdin, Ş. (2020). Levels and predictors of anxiety, depression and health anxiety during COVID-19 pandemic in Turkish society: The importance of gender. International Journal of Social Psychiatry, 66(5), 504-511. https://doi.org/10.1177/0020764020927051
  • Palgi, Y., Bergman, Y. S., Ben-David, B., & Bodner, E. (2021). No psychological vaccination: Vaccine hesitancy is associated with negative psychiatric outcomes among Israelis who received COVID-19 vaccination. Journal of Affective Disorders, 287(1), 352-353. https://doi.org/10.1016/j.jad.2021.03.064
  • Pieh, C., Budimir, S., & Probst, T. (2020). The effect of age, gender, income, work, and physical activity on mental health during coronavirus disease (COVID-19) lockdown in Austria. Journal of Psychosomatic Research, 136(1), 1-11. https://doi.org/10.1016/j.jpsychores.2020.110186
  • Rehman, U., Shahnawaz, M. G., Khan, N. H., Kharshiing, K. D., Khursheed, M., Gupta, K., Kashyap, D., & Uniyal, R. (2021). Depression, anxiety and stress among Indians in times of Covid-19 lockdown. Community Mental Health Journal, 57(1), 42-48. https://doi.org/10.1007/s10597-020-00664-x
  • Salazar, A., Palomo-Osuna, J., de Sola, H., Moral-Munoz, J. A., Dueñas, M., & Failde, I. (2021). Psychological impact of the lockdown due to the COVID-19 pandemic in university workers: Factors related to stress, anxiety, and depression. International Journal of Environmental Research and Public Health, 18(8), 4367- 4375. https://doi.org/10.3390/ijerph18084367
  • Simegn, W., Dagnew, B., Yeshaw, Y., Yitayih, S., Woldegerima, B., & Dagne, H. (2021). Depression, anxiety, stress and their associated factors among Ethiopian University students during an early stage of COVID-19 pandemic: An online-based cross-sectional survey. PloS one, 16(5), 1-5. https://doi.org/10.1371/journal.pone.0251670
  • Stainback, K., Hearne, B. N., & Trieu, M. M. (2020). COVID-19 and the 24/7 news cycle: Does COVID-19 news exposure affect mental health? Socius, 6(1), 1-15. https://doi.org/0.1177/2378023120969339
  • Stanton, R., To, Q. G., Khalesi, S., Williams, S. L., Alley, S. J., Thwaite, T. L., Fenning, A. S., & Vandelanotte, C. (2020). Depression, anxiety and stress during COVID-19: associations with changes in physical activity, sleep, tobacco and alcohol use in Australian adults. International Journal of Environmental Research and Public Health, 17(11), 1-14. https://doi.org/10.3390/ijerph17114065
  • Venanzi, L., Dickey, L., Green, H., Pegg, S., Benningfield, M. M., Bettis, A. H., Blackford, J. U., & Kujawa, A. (2022). Longitudinal predictors of depression, anxiety, and alcohol use following COVID‐19‐related stress. Stress and Health, 38(4):674-691. https://doi.org/10.1002/smi.3125
  • Verma, S., & Mishra, A. (2020). Depression, anxiety, and stress and socio-demographic correlates among general Indian public during COVID-19. International Journal of Social Psychiatry, 66(8), 756-762. https://doi.org/10.1177/0020764020934508
  • World Health Organization (WHO). (2022). WHO Coronavirus (COVID-19) Dashboard. https://covid19.who.int/ adresinden 3 Eylül 2022 tarihinde alınmıştır.
  • Yılmaz, Ö., Boz, H., & Arslan, A. (2017). Depresyon anksiyete stres ölçeğinin (DASS 21) Türkçe kısa formunun geçerlilik-güvenilirlik çalışması. Finans Ekonomi ve Sosyal Araştırmalar Dergisi, 2(2), 78-91. https://dergipark.org.tr/en/pub/fesa/issue/30912/323190
  • Zandifar, A., Badrfam, R., Yazdani, S., Arzaghi, S. M., Rahimi, F., Ghasemi, S., Khamisabadi, S., Mohammadian Khonsari, N., & Qorbani, M. (2020). Prevalence and severity of depression, anxiety, stress and perceived stress in hospitalized patients with COVID-19. Journal of Diabetes & Metabolic Disorders, 19(2), 1431-1438. https://doi.org/10.1007/s40200-020-00667-1
There are 32 citations in total.

Details

Primary Language Turkish
Subjects Health Care Administration
Journal Section Research Article
Authors

Fedayi Yağar 0000-0002-3436-6583

Early Pub Date July 24, 2023
Publication Date August 7, 2023
Published in Issue Year 2023 Volume: 7 Issue: 2

Cite

APA Yağar, F. (2023). COVID-19 Pandemisinde Hastaların Depresyon, Anksiyete ve Stres Düzeyleri ve İlişkili Faktörler. Kırşehir Ahi Evran Üniversitesi Sağlık Bilimleri Dergisi, 7(2), 78-88.

The journal is indexed in Sobiad Citation Index, Turkish Education Index and Turkey Citation Index.