key: cord-1001627-44jqkx7w
authors: Rosales-Vaca, Kimberly Massiel; Cruz-Barrientos, Oscar Ivan; Girón-López, Samara; Noriega, Sayra; More-Árias, Adriana; Guariente, Suzana Maria Menezes; Zazula, Robson
title: Mental health of healthcare workers of Latin American countries: a review of studies published during the first year of COVID-19 pandemic
date: 2022-03-07
journal: Psychiatry Res
DOI: 10.1016/j.psychres.2022.114501
sha: 656f335fb59e0b3e94dad41a66e11583ae27d6e7
doc_id: 1001627
cord_uid: 44jqkx7w

OBJECTIVE: Identify and review articles that evaluated mental health of HCW of Latin American countries (except Brazil), published during the first year of COVID-19 pandemic. METHOD: We systematically searched EMBASE, PsycINFO, Scopus, PUBMED/ Medline, Web of Science, PePSIC, and Scielo for articles published during the first year of the COVID-19 pandemics. Two independent researchers reviewed titles and abstracts and then, for eligible studies, extracted data from full texts. Outcomes included mental health variables, country where the study was conducted, period of data collection, healthcare professional categories, study design, mental health measurements and main outcomes. The quality and risk assessment was also performed. RESULTS: Out of 248 records identified, 24 initially were assessed for eligibility. From those, 17 studies matched eligibility criteria and were included in the review. Higher scores of anxiety were reported in different studies, as well as an increased level of depression among HCW. Being a female, younger age, and closer distance of the epicenter of the outbreak increased the likelihood to develop mental health disorder. Concerns and fear related to COVID-19 have a greater impact on stress, anxiety, and depression symptoms. CONCLUSION: Our findings highlight that COVID-19 pandemic had been worse for HCW from Latin America, showing the harmful effects of burnout on their health. Greater psychological distress, as well as anxiety and depression had been experienced by HCW from Latin America in their fight against COVID-19, demonstrating the importance of psychological well-being policies for them during and post- the pandemic.

Coronavirus disease 2019 (COVID-19) emerged in December 2019 in China, where it was identified for the first time and from where it spread quickly worldwide. The disease was declared a global pandemic in March 2020. Since then, many regions and countries worldwide have been experiencing cycles of outbreaks and an increasing number of infections and deaths. After a year from the declaration of COVID-19 as a global pandemic, the cumulative number of infections was almost 120 million and deaths exceeds 2,6 million worldwide 1 . In general, infected persons could develop a wide range of severity, from severe to mild symptoms or even being asymptomatic, which could still transmit the virus to other people. The average time from exposure to the virus to the beginning of the symptoms is around five days, and most individuals who develop symptoms do so within 11.5 days of infection 2 . In general, the most common symptoms of the COVID-19 are fever, shortness of breath, sore throat, and dry cough 3 . Although most of the patients are considered to show a favorable prognosis, both elderly and those with chronic conditions are more susceptible to develop a severe condition. Those patients might require intensive care unit admission and are likely to suffer substantial sequelae 2 .

Currently, more than 200 countries worldwide have been affected by COVID-19 and their health systems are suffering to deploy technical and human resources to minimize the spread of the virus and its respective morbidity and mortality 4 

America was confirmed in Brazil at the end of February of 2020 5, 6 . Even with late identification of its first case and death, when compared with the rest of the world, the region had become one of the world epicenters of the disease during the first year of the pandemic, and since then has been in an epidemiological emergency 7 . According to the Pan American Health Organization (PAHO), the region surpassed 1 million deaths as of May 21, 2021 8 . The reported number of healthcare workers (HCWs) who had been infected with the virus in the region was approximately 1.8 million, and almost 9000 had died 9 .

One of the key points in this context is related to mental health, which has been a concern among researchers, HCW, and governmental leaders, particularly in low-and middle-income countries 10 . Several studies have been describing the impacts of the COVID-19 and measures to minimize its spread on mental health 11-14 , in particular among HCWs, which were considered, at the same time, as essential workers during the pandemics and one of the most affected groups. In addition, they also may be considered as one of the most vulnerable groups to develop mental disorders, such as depression, anxiety, or stress 15 . The most common factors that contribute to mental health deterioration are excessive working journeys and shifts, employment contracts, insufficient personal protective equipment (PPE), and continuous exposure to a new virus, which may represent a risk for their health [16] [17] [18] [19] .

However, even with a high prevalence and mortality of the COVID-19 in Latin America and the known effects of the pandemic on the mental health of HCWs, there were only a few studies published reporting their mental health during the first year of the COVID-19 pandemics. Although there have been published several reviews determining the psychological impact, as well as the prevalence of anxiety, depression, and stress symptoms among HCW worldwide [20] [21] [22] [23] [24] , to our knowledge, there was no published review identifying mental health outcomes nor as describing their main characteristics among HCWs from Spanish-speakers from Latin American countries, which makes the present review more relevant. Then, considering the effect of the COVID-19 pandemic, its consequences on mental health, the lack of studies focusing on mental health of HCWs from this region, and the fact that Latin America has become one of the epicenters of the disease since its outbreak, the current review aimed to identify and review articles that evaluated mental health of HCWs of Latin American countries (except Brazil) published during the first year of COVID-19 pandemic.

Mental health of healthcare workers of Latin America

An integrative review was performed, aiming to identify and review articles published during the first year of COVID-19 pandemics, since its outbreak in the region (from March 2020 to March 2021). There was no previous published protocol.

We systematically searched seven electronic databases: EMBASE, PsycINFO, 

The present study included only studies published during the first year since the COVID-19 outbreak in the region (from March 2020 to March 2021), which were written either in English or Spanish. Additionally, a broad eligibility criterion was used to capture all potential studies, based on PECO model 25 described as follow: (a) population: HCWs from Latin American countries (only Spanish speakers' countries); (b) exposure: the main exposure was the COVID-19 pandemics since its outbreak in the region; (c) control: there were no specific inclusion or exclusion criteria for a comparison group in the selected studies;

(d) outcomes: one or more aspects of mental health (either as primary or secondary outcomes) of the selected population.

All studies were imported into Mendeley (version 1.19.8), where they were screened independently by the first and the second authors (KMRV and OICB). During this first screening process, both researchers assessed the eligibility based on the titles and abstracts.

Then, during the second screening process, both researchers independently read abstracts and full-texts and, if the latter were not available online, corresponding authors were contacts.

Unclear articles and disagreements between researchers were discussed by both researchers with co-authors and the supervisor.

The first and second authors independently extracted relevant data from the selected articles based on an extraction form, which was developed based on the objectives of the current review. The extraction form contained the following information: article code, title, authors, DOI number, primary aim, country of data collection, sample size, the average age of participants (or any related information), professional categories, general measures, mental health measurements/ inventories, COVID related measurements/ questionnaires, main outcomes, COVID related outcomes, and conclusions.

A qualitative analysis was performed, in which the evidence was summarized and organized around the following topics: primary aim, variables assessed, study designs, sample population and country in which the study was conducted, mental health and COVID-19 measurements, and main outcomes. Quality and risk assessment was also assessed by two independent researchers (SMMG and RZ) using the STROBE checklist for cohort, casecontrol, and cross-sectional studies (combined) (to see all available checklists https://www.strobe-statement.org/index.php?id=available-checklists). All items and subitems from the checklists were assessed and rated as 0, if the information was not reported, 1, if the information was reported in the study, and X, if the information was not applicable, reaching a maximum of 34 points. Then, final scores were converted into percentages concerning the relation to the number of assessed items (rated as 0 or 1), ranging from 0% to 100%. It is important to highlight that STROBE analysis were only descriptive, and all eligible studies were included in the final review.

Out of 248 records identified, 24 initially matched eligibility criteria and were assessed for eligibility. Then, seven studies were later excluded after a discussion with coauthors, and the supervisor and 17 were finally included in the review. The PRISMA flow diagram was presented in Figure 1 . HCWs, such as anxiety and depressive symptoms, stress, distress, and/or sleep aspects (see Table 1 for more information).

Additionally, nine studies assessed the frequency of generalized anxiety disorder symptoms, eight of them using the 7-Item Generalized Anxiety Disorder Scale (GAD-7) and one using Generalized Anxiety Disorder Scale-2 (GAD-2). Depression was assessed by 12 studies, most of them using different versions of the Patient Health Questionnaire (PHQ-9).

Four studies evaluated aspects related to post-traumatic stress disorder (PTSD) among those professionals, whereas burnout symptoms were specifically assessed by three studies. A single study aimed to show the impact of belief in conspiracy theories as a negative predictor of mental health among HCWs whereas another study aimed to estimate the long-term impact of compulsory social isolation on the psychological well-being of HCWs.

When COVID-19 specifically was taken into account, five studies included either instruments or isolated questions to assess COVID-19 related aspects, such as fear, coping needs, and conspiracy theories. With regards to non-modifiable factors, such as age, sex, demographic characteristics, and professional category, all studies collected those data and analyzed their association to mental health variables. Studies included in this current review were conducted in the following countries:

Colombia, Ecuador, Mexico, Argentina, Paraguay, and Peru. Although the study conducted by Guiroy and colleagues 26 collected data from 13 different countries of the region (including Brazil), there were reported less than two participants from seven different countries of the region and only five participants from one of the countries, in comparison with the whole sample (n = 204). Regarding study design, 15 of 17 studies included in the review were identified as cross-sectional studies (most of them were conducted through online surveys).

The study conducted by Miguel-Puga and colleagues 27 and Rodante and colleagues 28 , were identified as cohort studies.

Concerning the target population, HCWs from multiple areas were included, from specialist doctors to technicians, nurses, pharmacists, and laboratory workers. Out of four studies included in their sample administrative and support personnel who were working in hospital settings [29] [30] [31] [32] , whereas one study also included volunteers 31 . From all studies, one of them did not specify each professional category included in its sample, classifying all participants only as HCWs 33 . Although most studies specified the number of HCWs of each category, some of them analyzed data together, grouping different professional categories into one group. A large range of sample sizes was also observed among studies. The largest sample size was identified in the study conducted by Robles and colleagues 34 (n = 5938), whereas the smallest was found in the study conducted by Chavez and colleagues 35 (n = 125) (see Table 2 ). 

Anxiety symptoms were evaluated in 13 of the selected studies, using instruments such as 7-Item Generalized Anxiety Disorder (GAD-7), used in eight of the studies, and the State-Trait Anxiety Inventory (STAI) used in two of the studies. Generalized Anxiety Disorder Scale-2 (GAD-2) was used only by Mamani-Benito and colleagues 36 Table 2 ).

In general, all studies identified high frequencies of HCWS reporting mental health problems. Out of 12 studies evaluated one or more aspects related to anxiety, and the frequency of participants reporting anxiety ranged from 10.6% in the study conducted by Robles and colleagues 34 to 76.5% in the study conducted by Giardino and colleagues 32 depressive symptoms. They also found that moderate and severe depressive symptoms were more associated with female gender (p = 0.005) and onsite work (p = 0.005). Finally, in the study conducted by Rodante and colleagues 28 , 50.7% of all professionals met the criteria for major depressive disorders in the first data collection while 61.4% met the criteria in the second one, conducted around two months from the first collection, demonstrating an increase in depression among participants throughout the pandemic.

Although stress was investigated by six studies, each of them evaluated different aspects of this variable, using a wide range of instruments (See Table 2 ). The study conducted by Pazmiño-Erazo and colleagues 37 PTSD was the focus of four studies: Robles and colleagues 34 , who identified 29.4% of all participants with PTSD symptoms, Pazmiño-Erazo and colleagues 37 , who identified PTSD symptoms among 43.8% of the participants of their study, and Villalba-Arias and colleagues 39 found the prevalence of 7.2%. Additionally, Miguel-Puga and colleagues 27 did not report the frequency of participants who met the criteria for any of the disorders investigated, such as depression, anxiety, or stress. However, they identified that pre-existing depression and anxiety symptoms, as well as acute stress or anxiety increase the likelihood to develop PTSD. Finally, it is important to highlight that each study adopted different criteria to classify if their sample were able to or not to meet criteria for anxiety, depression, or stress. Out of three studies investigated COVID-19 aspects related to mental health, such as fears and concerns 18,29,36 . Mamani-Benito and colleagues 36 found that concerns related to COVID-19 impact both anxiety and depression, which might increase psychological discomfort. On the other hand, they also found that concerns related to COVID-19 had a minimal impact on professional self-efficacy. García-Reyna and colleagues 29 found similar outcomes, associating fear of COVID-19 with either depression or anxiety. They also identified higher levels of fear among administrative staff than both nursery and medical personnel. In Monterrossa-Castro and colleagues 18 study, 98% of those participants with Mental health of healthcare workers of Latin America generalized anxiety disorder symptoms also were being afraid of losing life because of COVID-19.

The quality and risk assessments of studies included in the present review ranged from 55.2% to 90.0%. The average value was 76.8%. The inter-rater reliability was К = 0.88 (SD = 0.01, p < 0.001 [95% CI = 0.84, 0.92]). The final quality and risk assessment ratings could be seen in Table 3 . Table 3 . Quality and risk assessment for each item according to STROBE checklist [Insert Table 3 approximately here]

Mental health of healthcare workers of Latin America

The main findings of the present study support studies published before theCOVID-19 pandemic, reporting that the mental health of HCWs was poorer than the mental health of general population. However, the situation had worsened during the first year of COVID-19, particularly in Latin American countries, such as Colombia, Ecuador, Argentina, Peru, Paraguay, Chile, and Mexico. According to studies included in the review, frequent factors that affected the mental health of HCWs during this period were anxiety, stress, fatigue, depression, and burnout. One of the variables that were reported in the studies was the capacity of public healthcare systems to treat patients with COVID-19. Given the imminent collapse of the health systems throughout Latin America, it had been necessary to increase the number of healthcare workers and maximize their service capacity 6, 42 . There is broad consensus that these professionals, while responding to social changes and emotional stressors, also faced an increased risk of exposure to illness, extreme workloads, moral dilemmas 43 , violence, and stigmatization 7, 29 . A similar study conducted among HCWs in the Philippines found a higher score (19.92).

Additionally, it is important to highlight the stigmatization suffered by HCWs in some areas, as reported by García-Reyna and colleagues 29 , in Mexico, and by Mamani-Benito and colleagues 36 , in Peru, which could deeply impact their mental health. In the same direction, we found that some studies identified that pre-existing anxiety, depression, or stress disorders could have contributed to the presentation of more severe mental health symptoms as well as the development of mental disorders among those professionals. In a study conducted among Mexican HCWs, the development of PTSD was related to pre-existing anxiety, depression, and acute stress and pre-existing resilience skills could be understood as protective factors to minimize the development of this disorder 40 . Several studies record PTSD symptoms related to a high degree of anxiety and depression, as well as exhaustion among HCWS 27,34,45-47 . According to Walton and colleagues 48 , mental health disorders have negative impacts not only on HCWs but also on patients and the entire population. We can reaffirm that the negative influence of these disorders during a peak of inpatient admissions at COVID-19 may contribute to the development of PTSD symptoms in frontline HCWs 27 . Similar outcomes were identified by Maiorano and colleagues 49 , who reported the protective role of resilience skills and behaviors as a prevention to the development of mental disorders, in particular PTSD. According to Blekas and colleagues 50 , HCWs that reported higher levels of negative mental health symptoms, such as insomnia, depression, and anxiety, were more likely to present PTSD in comparison with those who did not report those symptoms. Restrepo-Martinez and colleagues 41 also found that HCWs who presented moderate to severe levels of either depression or anxiety during COVID-19 were more likely to report appetite problems, sleep problems, and suicide ideation. In their study, 6.4% of all women and 6.6% of all men who presented moderate to severe levels of either depression or anxiety reported suicidal ideation.

When sociodemographic variables were taken into account, significant correlations were identified in each of the studies reviewed. In general, gender and age were identified as risk factors either to develop mental disorders or present worsened mental health outcomes.

In the study conducted by Chapa-Koloffon and colleagues 40 , younger and female professionals were more likely to develop PTSD in comparison with male participants from the same sample. Similarly, the study conducted by Guiroy and colleagues 26 identified higher levels of depression, anxiety, and hypochondria among women in comparison to men, as well as lower age as a significant predictor in the development of this disorder. According to them, higher rates of depression during the COVID-19 pandemic were associated with lower age professionals and the female gender. Similar outcomes were found by Samaniego and colleagues 38 , who found higher distress, anxiety, and depressive symptoms among younger HCWs. However, it is important to noteworthy that the study conducted by Guiroy and colleagues 26 investigated only spine surgeons and administered a single instrument, which could be a limitation in further analysis. Additionally, the latter study did not mention if the professionals were directly involved in the treatment of COVD-19 patients during the first outbreak or when the pandemic worsened in the region.

Furthermore, the fact of being a woman is another factor associated with the presence of mental disorders, as shown by Chapa-Koloffon and colleagues 40 and Guiroy and colleagues 26 , and found in systematic reviews and meta-analysis including HCWs worldwide 51, 52 . This is a concern, as more than 70% of HCWs, including those who work in healthcare institutions are women, and even so, the inequality between them and male professionals is enormous 53 . In Argentina, for example, female HCWs were more likely to work more overtime in comparison with their male colleagues, regardless of the salary difference. Additionally, it is important to highlight that in the context of the pandemic, female HCWs are exposed to countless forms of violence in their workplace, on the street, and even in their own homes due to stigmatization and unsympathetic reactions driven by the fear of COVID-19 42 . On the other hand, only Chavez and colleagues 35 found in their study that be man would be a significant risk factor for anxiety. However, they presented a small sample size, as well as a convenience sample, which were limitations of their study and do not allow the generalizability of their outcomes. Despite being the most important force of action in the healthcare system around the world, female HCWs are at a great disadvantage both in terms of their physical and mental health, as well as their social and economic wellbeing. Our outcomes in the present review show that their reality is not different among Latin American countries, as reported by different studies included in this current review.

Additionally, both psychosocial and demographic factors have also been associated with a greater number of mental disorders, such as anxiety disorder. In Colombia, four of ten clinical profiles present symptoms of anxiety 18 . According to a recent meta-analysis including 19 studies worldwide, the average prevalence of GAD was 32% among HCWs, lower than found in most studies included in this review 24 . The most common factors associated with poorer mental health outcomes were long working shifts, fear of being exposed or infected by COVID-19, unavailability of PPE, patient demands, lack of effective treatment against COVID-19, death of colleagues after exposure to COVID-19, social distancing, and isolation from their loved. Similar outcomes were found in different countries, such as the United Kingdom, as reported by Greene and colleagues 54 .

However, due to the lack of resources and the limited number of HCWs, we could hypothesize that the situation is worse throughout Latin American countries. García-Reyna and colleagues 29 found lower fear of COVID-19 scores in the general Italian population in comparison with Mexican HCWs, which could indicate the role of fear among the latter group during the pandemic. In addition, the number of HCWs who died of COVID-19 is greater in Latin America in comparison to the rest of the world. According to Agren 55 , by August 2020 Mexico led the rank of HCWs who died from COVID-19. Out of 55.8% of all HCWs in Mexico had lost a family member, a colleague, or a close person to the disease, which might affect their mental health, increase their fear, and the risk to develop mental disorders, such as PTSD, or even commit suicide 30 . A recent meta-analysis showed that fear of COVID-19 among HCWs was strongly associated with anxiety, traumatic stress, and distress and moderately associated with depression and stress 23 .

Regarding burnout outcomes among HCW, we might conclude based on studies we included in the current review that they were related to some variables such as long working Although differences in mental health outcomes of HCWs were clear among studies included in the current review, it is not possible to compare them directly due to the fact that studies were different in their methods. Additionally, HCWs categories were very dissimilar across studies and, in some of them, all categories were grouped together in their analysis. In those studies, it is not possible to compare different HCWs categories regarding their mental health outcomes. When fear of COVID-19 was taken into account, García-Reyna and colleagues 29 found that administrative personnel working in hospital settings presented higher levels of fear of COVID-19 than both nursery and medical personnel. Yáñes and colleagues 31 found that those professionals working closer to COVID-19 epicenters presented higher levels of anxiety and depression than those working far from it.

Regarding the quality and risk assessment, it was only descriptive. There was no inclusion or exclusion criteria related for acceptance of the studies, and eligible studies were included in the final review. The average value was 76.8%, demonstrated that most of the articles followed most of good practices in the reporting of studies. However, some points should be mentioned, such as the fact that most of studies did not describe how sample size was calculated, how missing data were addressed, and analytical methods taking in account sampling strategies. One possible explanation is the fact that those studies were conducted mostly based on online surveys, with convenience samples.

We consider this study of valuable academic relevance as it is the first of its kind. A review might be appropriate because it is a broader method in comparison with other studies that also focus on the mental health of HCWs in Latin American. An important point to clarify is the deliberate exclusion of Brazil in this review. Although it could be considered a limitation, it would be very difficult to fit the study to the reality of a continental country that, in addition to having a linguistic, cultural, and demographic difference, also has a universal public healthcare system that is different from healthcare systems of other Latin-American countries. In a rapid search, the number of studies conducted in Brazil during the first year of the COVID-19 pandemic was larger than the number of studies conducted throughout all Spanish-speakers' countries of Latin America. In addition, the country has been experiencing an overwhelming political crisis since the beginning of the pandemic. Finally, it is important to noteworthy that quarantines and effective closure measures were not implemented widely in Brazil as a national health policy to cope with COVID-19 crises, contrasting with most Spanish-speakers countries of Latin America, which implemented this measure. The absence of effective measures to prevent and minimize the infection led the country to a rapid increase in the number of infections and deaths. With this, it is not our intention to express that the rest of Latin America acted in better ways to confront the COVID-19 pandemic, simply the political reality of this country has been more difficult to handle than in the rest of Latin America during this period of emergency health. Considering that different countries and regions worldwide adopted distinctive strategies against COVID-19, might be interesting to conduct future reviews comparing the mental health of HCW from different regions, as well as how different approaches to the pandemic worldwide impact the mental health of depression symptoms might get worse over time, from mild to moderate, or even to severe. In this context, stress related to work, with long working hours, the limited availability of PPE, inefficient routine biosecurity protocols, and poor sleep quality are variables that could be related to higher psychological distress and might contribute to the increased depression among HCWs 43 . We can also affirm that there would be an association between the presence of anxiety and depression symptoms as risk factors for the development of PTSD in the long term. Both depression and anxiety could also be impacted by concerns and fear of COVID-19, showing the effects of the disease on mental health of HCW 29, 36 .

The most relevant factors associated with the presence of mental disorders are, according to our review, the professional specialty of the HCWs, age, and gender. We also identified that the mental health of HCWs worsened according to the distance from the epicenter of the pandemic. In general, increased levels of GAD prevailed in more populated cities, where the level of contagion was higher, and the demand for hospital service exceeded the capacity of the healthcare systems 31 . These findings allow us to understand the need for early mental health screening in HCW during periods of public health emergencies and highlight the importance of timely psychosocial interventions directed for those individuals.

It is fundamental to change the perception of COVID-19 through psychological interventions and adaptation strategies to different scenarios, aiming to reduce symptoms associated with mental disorders. Therefore, we conclude that it is essential to know the epidemiological behavior of each mental disorder and the variables associated with the increase in its incidence among HCW, in particular in Spanish-speakers Latin-American countries. Notes. *Only in the studies conducted in two or more countries; ** Medical personnel (physicians and medical residents), administrative personnel (archive, office, and administration personnel), and non-clinical hospital personnel with direct contact with COVID-19 (laboratory, pharmacy, cleaning, kitchen, nutrition, radiology, security, and psychology personnel)

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The authors have declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

The authors have declared no funding in this article.Mental health of healthcare workers of Latin America

Chapa-Koloff on et al. 40 1 1 1 1 1 1 0 X 0 1 1 0 0 1 1 0 X 0 0 X X 1 0 X 1 0 X X 0 1 1 1 0 X 57.7Chavez et al. 35 1 1 1 0 1 1 1 X 1 1 0 0 0 1 0 0 X 0 0 0 X 1 0 X 1 1 1 X 1 1 1 1 1 1 65.5Chen et al. 33 1 1 1 0 1 1 0 X 1 1 0 0 1 1 1 0 X 0 0 X X 1 0 X 1 1 1 X 1 1 1 1 1 1 71.4Garcia-Reyna et al. 29 1 1 1 1 1 1 1 X 1 1 1 1 1 1 1 0 X 1 1 1 X 1 0 X 1 1 1 X 1 1 1 1 1 0 89.7Giardin o et al. Yáñes et al. 31 1 1 1 1 1 1 1 X 1 1 0 0 1 1 1 0 X 0 1 0 X 1 0 X 1 1 1 X 1 1 1 1 1 1 79.3Note. STROBE checklist for cohort, case-control, and cross-sectional studies (combined) (to see the full checklist: https://www.strobe-statement.org/index.php?id=available-checklists)