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Kardiyovasküler Hastalıklara Bağlı Ölümleri Etkileyen Faktörlerin Belirlenmesi: OECD Ülkeleri Üzerinde Bir Araştırma

Year 2021, Volume: 12 Issue: 2, 340 - 345, 01.04.2021

İlknur Arslan Çilhoroz , Yasin Çilhoroz

https://doi.org/10.31067/acusaglik.849024

Abstract

Amaç:Küresel anlamda ortalama yaşam süresinin uzamasıyla birlikte kronik hastalıklar olarak da bilinen bulaşıcı olmayan hastalıkların görülme sıklığı artmıştır. Dolayısıyla bu hastalıklara bağlı ölümler de giderek artış göstermiştir. Bu çalışmada, bulaşıcı olmayan hastalıklardan biri olan kardiyovasküler hastalıklara bağlı ölümleri en fazla etkileyen yaşam tarzı faktörleri üzerine bir inceleme yapmak amaçlanmıştır.
Yöntem:Bu amacı gerçekleştirmek için kardiyovasküler hastalıkları en fazla etkileyen yaşam tarzı faktörleri olan sigara içme, alkol kullanma ve obezite oranı bağımsız değişken olarak ve kardiyovasküler hastalıklara bağlı gerçekleşen toplam ölümler bağımlı değişken olarak belirlenmiştir. Bu değişkenlere ilişkin veriler Dünya Sağlık Örgütü ve Ekonomik Kalkınma ve İşbirliği Örgütü veri tabanlarından elde edilmiştir.
Bulgular:Gerçekleştirilen En Küçük Kareler regresyon analizi sonucunda sigara içme ve alkol kullanma değişkenlerinin kardiyovasküler hastalıklara bağlı ölümler üzerinde anlamlı ve pozitif yönlü etkisin olduğu bulunmuştur. Yani, sigara içme ve alkol kullanma miktarı arttıkça kardiyovasküler hastalıklara bağlı ölümlerde de artış meydana gelmektedir.
Sonuç:Bu bakımdan, bireylerin sigara ve alkol kullanımını azaltmasına yönelik uygulamalar yapılarak kardiyovasküler hastalıklara bağlı ölümlerin azaltılması mümkün olabilecektir.

Keywords

Sigara içme Alkol kullanma Obezite Kardiyovasküler hastalıklar OECD

References

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  • 2. WHO. World Health Organization. The world health report 2008: primary health care now more than ever. Geneva:WHO Publication, 2008: 8.
  • 3. Ezzati M, Pearson-Stuttard J, Bennett JE, Mathers CD. Acting on non-communicable diseases in low-and middle-income tropical countries. Nature 2018;559:507-516.
  • 4. İlgün G, Konca M. The effect of alcohol, cigarette consumption and obesity on the life expectancy at birth. Journal of behavioral health 2019;8:1-6.
  • 5. Eryurt MA, Menet MG. Noncommunicable diseases among Syrian refugees in Turkey: An emerging problem for a vulnerable group. Journal of immigrant and minority health 2020;22:44-49.
  • 6. Kim HC, Oh SM. Noncommunicable diseases: current status of major modifiable risk factors in Korea. Journal of preventive medicine and public health 2013;46;165.
  • 7. WHO. World Health Organization. (Noncommunicable Disesases. https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases. Erişim Tarihi: 21.01.2020.
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  • 16. Townsend N, Wilson L, Bhatnagar P, Wickramasinghe, K, Rayner M, Nichols M. Cardiovascular disease in Europe: epidemiological update European heart journal 2016;37;3232-3245.
  • 17. Bonnet F, Irving K, Terra JL, Nony P, Berthezène, F, Moulin P. Anxiety and depression are associated with unhealthy lifestyle in patients at risk of cardiovascular disease. Atherosclerosis 2005;178:339-344.
  • 18. Lee, Douglas S et al.Trends in risk factors for cardiovascular disease in Canada: temporal, socio-demographic and geographic factors. Cmaj 2009;181: E55-E66.
  • 19. Sumartono W, Sirait AM, Holy M, Thabrany H. (2011). Smoking and socio-demographic determinant of cardiovascular diseases among males 45+ years in Indonesia. International journal of environmental research and public health 2011;8:528-539.
  • 20. Havranek EP et al. Social determinants of risk and outcomes for cardiovascular disease: A scientific statement from the American Heart Association. Circulation, 2015;132:873-898.
  • 21. Wang Y, Zhou S, Lei S, Hao L, Sun D, Hu H. (2020). Vitamin D deficiency and cardiovascular diseases. Science of advanced materials 2020;12(1);27-37.
  • 22. Örs S.H. Yetişkin kadınların kardiyovasküler risk faktörleri, bilgi düzeyleri ve sağlığı geliştirme davranışları. Yüksek lisans tezi, Muğla sıtkı koçman üniversitesi, Muğla:2018.
  • 23. Öz Ş. Üniversite öğrencilerinin sağlıklı yaşam biçimi davranışları ve kardiyovasküler risk faktörleri bilgi düzeylerinin belirlenmesi. Yüksek lisans tezi, Ankara yıldırım beyazıt üniversitesi, Ankara:2018.
  • 24. Oğuz S, Erguvan B, Ünal G, Bayrak B, Çamcı G. Üniversite öğrencilerinde kardiyovasküler hastalıklar risk faktörleri bilgi düzeyinin belirlenmesi. MN kardiyoloji, 2019;26:184-191.
  • 25. Keleşoğlu A. bir araştırma hastanesi aile hekimliği polikliniğine başvuran erişkin bireylerde kardiyovasküler riskin belirlenmesi kardiyovasküler hastalık risk faktörleri bilgi düzeyinin değerlendirilmesi. Tıpta uzmanlık tezi, Erciyes üniversitesi, Kayseri:2018.
  • 26. Karabacak M. Ailesel akdeniz ateşi hastalarının kardiyovasküler mortalite riskinin karotis intima media kalınlığı ve kardiyovasküler risk skoru yöntemleri ile belirlenmesi. Uzmanlık tezi, Marmara üniversitesi, İstanbul:2016.
  • 27. Türkmen E, Badır A, Ergün A. Koroner arter hastalıkları risk faktörleri: primer ve sekonder korunmada hemşirelerin rolü. ACU sağlık bilimleri Dergisi, 2012;3:223-231.
  • 28. Kara S, Arslan B, Mergen H, Öngel K. Aile hekimliği polikliniklerinde kardiovasküler risk faktörlerinin değerlendirilmesi. İzmir tepecik eğit hastan derg 2012;22:163-169.
  • 29. Sungur M. S.B.Ü. okmeydanı eğitim ve araştırma hastanesi hürriyet eğitim aile sağlığı merkezine kayıtlı 40 yaş üstü kadın hastaların kardiyovasküler risk düzeyleri ve risk faktörlerinin değerlendirilmesi. Tıpta uzmanlık tezi, Sağlık bilimleri üniversitesi, İstanbul:2018.
  • 30. Uçar C. Aile hekimliği polikliniğine başvuran 45 yaş ve üzeri bireylerde kardiyovasküler risklerin araştırılması ve risk skorlaması. Uzmanlık tezi, Akdeniz üniversitesi, Antalya:2018.
  • 31. Eray A, Ateş E, Set T. (2018). Yetişkin bireylerde kardiyovasküler hastalık riskinin değerlendirilmesi. Türkiye aile hekimliği dergisi 2018;22:12-19.
  • 32. Alpar R. Uygulamalı istatistik ve geçerlik-güvenirlik: spor, sağlık ve eğitim bilimlerinden örneklerle (3. Baskı). Ankara: Detay yayıncılık 2018:384-430.
  • 33. Dehesh T, Dehesh P, Gozashti MH. Metabolic factors that affect health-related quality of life in type 2 diabetes patients: a multivariate regression analysis. Diabetes, metabolic syndrome and obesity: Targets and therapy 2019;12:1181.
  • 34. Moody C. Basic econometrics with STATA. Economics Department. College of William and Mary, 2009.
  • 35. Sheytanova T. The accuracy of the Hausman Test in panel data: A Monte Carlo study. Master thesis, Örebro university, Öebro, 2015.
  • 36. Haskell WL. Cardiovascular disease prevention and lifestyle interventions: Effectiveness and efficacy. Journal of cardiovascular nursing 2003;18:245-255.
  • 37. Silagy C, Muir J, Coulter A, Thorogood M, Roe L. Cardiovascular risk and attitudes to lifestyle: What do patients think? BMJ 1993;306:1657-60.
  • 38. Hayano J et al. Short-and long-term effects of cigarette smoking on heart rate variability. The American journal of cardiology 1990;65:84-88.
  • 39. Sisa I. Gender differences in cardiovascular risk assessment in elderly adults in Ecuador: Evidence from a national survey. Journal of investigative medicine 2019;6:736-742.
  • 40. Man RE et al. Prevalence, determinants and association of unawareness of diabetes, hypertension and hypercholesterolemia with poor disease control in a multi-ethnic Asian population without cardiovascular disease. Population health metrics, 2019;17:17.
  • 41. Mamani-Ortiz Y et al. Prevalence and determinants of cardiovascular disease risk factors using the WHO STEPS approach in Cochabamba, Bolivia. BMC public health 2019;19:786.
  • 42. Britton A, McKee M. The relation between alcohol and cardiovascular disease in Eastern Europe: Explaining the paradox. Journal of epidemiology & community health 2000;54:328-332.
  • 43. Hubert HB, Feinleib M, McNamara PM, Castelli WP. Obesity as an independent risk factor for cardiovascular disease: A 26-year follow-up of participants in the Framingham Heart Study. Circulation 1983;67:968-977.
  • 44. Dowse Gary K et al. Changes in population cholesterol concentrations and other cardiovascular risk factor levels after five years of the noncommunicable disease intervention programme in Mauritius. Mauritius non-communicable disease study group BMJ 1995;311:1255-9.
  • 45. Isomaa BO et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes care 2001;24;683-689.
  • 46. Romero-Corral A et al. Association of bodyweight with total mortality and with cardiovascular events incoronary artery disease: A systematic review of cohort studies. Lancet 2006;368:666–678.
  • 47. Oreopoulos A, Padwal R, Kalantar-Zadeh K, Fonarow GC, Norris CM, McAlister FA. Body mass index and mortality in heart failure: A meta-analysis. American heart journal 2008;156:13-22.
  • 48. Lavie CJ, McAuley PA, Church TS, Milani RV, Blair SN. Obesity and cardiovascular diseases: Implications regarding fitness, fatness, and severity in the obesity paradox.J Am Coll Cardiol. 2014;63:1345–1354.
  • 49. Cooney JK, Ahmad YA, Moore JP, Sandoo A, Thom JM. The impact of cardiorespiratory fitness on classical cardiovascular disease risk factors in rheumatoid arthritis: A cross-sectional and longitudinal study. Rheumatology international, 2019;39:1759-1766.
  • 50. Akcay M, Yuksel S. Smoking and cardiovascular diseases. J Exp Clin Med. 2017;34:21–5.
  • 51. Kycina P, Murin J. Alcoholic cardiomyopathy and cardiovascular events-an insight from the Liptov region. Bratislavske lekarske listy 2013;114:337-341.
  • 52. Murray R. P., et al. Alcohol volume, drinking pattern, and cardiovascular disease morbidity and mortality: Is there a U-shaped function?. American Journal of Epidemiology 2002;155:242-248.
  • 53. Lakka H. M et al. The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men. Jama 2002;288:2709-2716.
  • 54. Ritchie SA, Connell JM. The link between abdominal obesity, metabolic syndrome and cardiovascular disease. Nutr Metab Cadiovasc Dis 2007;17:319–326.

Determination of Factors Affecting Deaths Due to Cardiovascular Diseases: A Research on OECD Countries

Year 2021, Volume: 12 Issue: 2, 340 - 345, 01.04.2021

İlknur Arslan Çilhoroz , Yasin Çilhoroz

https://doi.org/10.31067/acusaglik.849024

Abstract

Purpose:With the average life expectancy increased globally, the incidence of non-communicable diseases, also known as chronic diseases, has increased. Therefore, deaths due to these diseases have increased gradually. In this study, it was aimed to make an examination on lifestyle factors affecting deaths due to cardiovascular diseases which is one of the noncommunicable diseases.
Patients and Methods:To achieve this aim, smoking, alcohol use and obesity rate which are the lifestyle factors affecting cardiovascular diseases the most, as independent variables and total deaths due to cardiovascular diseases as dependent variable were determined. Data on these variables were obtained from the World Health Organization and Economic Development and Cooperation Organization databases.
Results:As a result of the Ordinary Least Squares regression analysis performed, it was found that smoking and alcohol use variables had a significant and positive effect on deaths due to cardiovascular diseases. So, as the amount of smoking and alcohol use increases, deaths due to cardiovascular diseases also increase.
Conclusion:In this regard, it will be possible to reduce the deaths due to cardiovascular diseases by making implementations for reducing the smoking and alcohol use of individuals.

Keywords

Smoking Alcohol use Obesity Cardiovascular diseases OECD

References

  • 1. SB. Türkiye’de bulaşıcı olmayan hastalıklar ve risk faktörleri ile mücadele politikaları. Ankara: Sağlık Bakanlığı yayınları, 2011: 15.
  • 2. WHO. World Health Organization. The world health report 2008: primary health care now more than ever. Geneva:WHO Publication, 2008: 8.
  • 3. Ezzati M, Pearson-Stuttard J, Bennett JE, Mathers CD. Acting on non-communicable diseases in low-and middle-income tropical countries. Nature 2018;559:507-516.
  • 4. İlgün G, Konca M. The effect of alcohol, cigarette consumption and obesity on the life expectancy at birth. Journal of behavioral health 2019;8:1-6.
  • 5. Eryurt MA, Menet MG. Noncommunicable diseases among Syrian refugees in Turkey: An emerging problem for a vulnerable group. Journal of immigrant and minority health 2020;22:44-49.
  • 6. Kim HC, Oh SM. Noncommunicable diseases: current status of major modifiable risk factors in Korea. Journal of preventive medicine and public health 2013;46;165.
  • 7. WHO. World Health Organization. (Noncommunicable Disesases. https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases. Erişim Tarihi: 21.01.2020.
  • 8. WHO. World Health Organization. Noncommunicable diseases. http://www.euro.who.int/en/health-topics/noncommunicable-diseases.Erişim Tarihi: 21.01.2020.
  • 9. OECD. Applying modeling to improve health and economic policy decisions in the Americas: the case of noncommunicable diseases. Pan American Health Organization, 2015.
  • 10. Unicef. Non-communicable diseases. https://www.unicef.org/health/non-communicable-diseases. Erişim Tarihi: 21.01.2020.
  • 11. Tunstall-Pedoe H, Woodward M, Tavendale R, A'Brook R, McCluskey MK. Comparison of the prediction by 27 different factors of coronary heart disease and death in men and women of the Scottish heart health study: Cohort study. BMJ 1997; 315: 722-9.
  • 12. Mozaffarian D, Wilson PW, Kannel WB. Beyond established and novel risk factors: Lifestyle risk factors for cardiovascular disease. Circulation 2008;117:3031-3038.
  • 13. NCD Countdown Contributors. NCD Countdown 2030: worldwide trends in non-communicable disease mortality and progress towards Sustainable Development Goal target 3.4. The lancet 2018;392:1072-1088.
  • 14. WHO. World Health Organization Cardiovascular Diseases. https://www.who.int/health-topics/cardiovascular-diseases/#tab=tab_1. Erişim Tarihi: 30.01.2020.
  • 15. Nhung, Nguyen Thi Trang, et al.Exposure to air pollution and risk of hospitalization for cardiovascular diseases amongst Vietnamese adults: Case-crossover study. Science of The Total Environment 2020;703:134637.
  • 16. Townsend N, Wilson L, Bhatnagar P, Wickramasinghe, K, Rayner M, Nichols M. Cardiovascular disease in Europe: epidemiological update European heart journal 2016;37;3232-3245.
  • 17. Bonnet F, Irving K, Terra JL, Nony P, Berthezène, F, Moulin P. Anxiety and depression are associated with unhealthy lifestyle in patients at risk of cardiovascular disease. Atherosclerosis 2005;178:339-344.
  • 18. Lee, Douglas S et al.Trends in risk factors for cardiovascular disease in Canada: temporal, socio-demographic and geographic factors. Cmaj 2009;181: E55-E66.
  • 19. Sumartono W, Sirait AM, Holy M, Thabrany H. (2011). Smoking and socio-demographic determinant of cardiovascular diseases among males 45+ years in Indonesia. International journal of environmental research and public health 2011;8:528-539.
  • 20. Havranek EP et al. Social determinants of risk and outcomes for cardiovascular disease: A scientific statement from the American Heart Association. Circulation, 2015;132:873-898.
  • 21. Wang Y, Zhou S, Lei S, Hao L, Sun D, Hu H. (2020). Vitamin D deficiency and cardiovascular diseases. Science of advanced materials 2020;12(1);27-37.
  • 22. Örs S.H. Yetişkin kadınların kardiyovasküler risk faktörleri, bilgi düzeyleri ve sağlığı geliştirme davranışları. Yüksek lisans tezi, Muğla sıtkı koçman üniversitesi, Muğla:2018.
  • 23. Öz Ş. Üniversite öğrencilerinin sağlıklı yaşam biçimi davranışları ve kardiyovasküler risk faktörleri bilgi düzeylerinin belirlenmesi. Yüksek lisans tezi, Ankara yıldırım beyazıt üniversitesi, Ankara:2018.
  • 24. Oğuz S, Erguvan B, Ünal G, Bayrak B, Çamcı G. Üniversite öğrencilerinde kardiyovasküler hastalıklar risk faktörleri bilgi düzeyinin belirlenmesi. MN kardiyoloji, 2019;26:184-191.
  • 25. Keleşoğlu A. bir araştırma hastanesi aile hekimliği polikliniğine başvuran erişkin bireylerde kardiyovasküler riskin belirlenmesi kardiyovasküler hastalık risk faktörleri bilgi düzeyinin değerlendirilmesi. Tıpta uzmanlık tezi, Erciyes üniversitesi, Kayseri:2018.
  • 26. Karabacak M. Ailesel akdeniz ateşi hastalarının kardiyovasküler mortalite riskinin karotis intima media kalınlığı ve kardiyovasküler risk skoru yöntemleri ile belirlenmesi. Uzmanlık tezi, Marmara üniversitesi, İstanbul:2016.
  • 27. Türkmen E, Badır A, Ergün A. Koroner arter hastalıkları risk faktörleri: primer ve sekonder korunmada hemşirelerin rolü. ACU sağlık bilimleri Dergisi, 2012;3:223-231.
  • 28. Kara S, Arslan B, Mergen H, Öngel K. Aile hekimliği polikliniklerinde kardiovasküler risk faktörlerinin değerlendirilmesi. İzmir tepecik eğit hastan derg 2012;22:163-169.
  • 29. Sungur M. S.B.Ü. okmeydanı eğitim ve araştırma hastanesi hürriyet eğitim aile sağlığı merkezine kayıtlı 40 yaş üstü kadın hastaların kardiyovasküler risk düzeyleri ve risk faktörlerinin değerlendirilmesi. Tıpta uzmanlık tezi, Sağlık bilimleri üniversitesi, İstanbul:2018.
  • 30. Uçar C. Aile hekimliği polikliniğine başvuran 45 yaş ve üzeri bireylerde kardiyovasküler risklerin araştırılması ve risk skorlaması. Uzmanlık tezi, Akdeniz üniversitesi, Antalya:2018.
  • 31. Eray A, Ateş E, Set T. (2018). Yetişkin bireylerde kardiyovasküler hastalık riskinin değerlendirilmesi. Türkiye aile hekimliği dergisi 2018;22:12-19.
  • 32. Alpar R. Uygulamalı istatistik ve geçerlik-güvenirlik: spor, sağlık ve eğitim bilimlerinden örneklerle (3. Baskı). Ankara: Detay yayıncılık 2018:384-430.
  • 33. Dehesh T, Dehesh P, Gozashti MH. Metabolic factors that affect health-related quality of life in type 2 diabetes patients: a multivariate regression analysis. Diabetes, metabolic syndrome and obesity: Targets and therapy 2019;12:1181.
  • 34. Moody C. Basic econometrics with STATA. Economics Department. College of William and Mary, 2009.
  • 35. Sheytanova T. The accuracy of the Hausman Test in panel data: A Monte Carlo study. Master thesis, Örebro university, Öebro, 2015.
  • 36. Haskell WL. Cardiovascular disease prevention and lifestyle interventions: Effectiveness and efficacy. Journal of cardiovascular nursing 2003;18:245-255.
  • 37. Silagy C, Muir J, Coulter A, Thorogood M, Roe L. Cardiovascular risk and attitudes to lifestyle: What do patients think? BMJ 1993;306:1657-60.
  • 38. Hayano J et al. Short-and long-term effects of cigarette smoking on heart rate variability. The American journal of cardiology 1990;65:84-88.
  • 39. Sisa I. Gender differences in cardiovascular risk assessment in elderly adults in Ecuador: Evidence from a national survey. Journal of investigative medicine 2019;6:736-742.
  • 40. Man RE et al. Prevalence, determinants and association of unawareness of diabetes, hypertension and hypercholesterolemia with poor disease control in a multi-ethnic Asian population without cardiovascular disease. Population health metrics, 2019;17:17.
  • 41. Mamani-Ortiz Y et al. Prevalence and determinants of cardiovascular disease risk factors using the WHO STEPS approach in Cochabamba, Bolivia. BMC public health 2019;19:786.
  • 42. Britton A, McKee M. The relation between alcohol and cardiovascular disease in Eastern Europe: Explaining the paradox. Journal of epidemiology & community health 2000;54:328-332.
  • 43. Hubert HB, Feinleib M, McNamara PM, Castelli WP. Obesity as an independent risk factor for cardiovascular disease: A 26-year follow-up of participants in the Framingham Heart Study. Circulation 1983;67:968-977.
  • 44. Dowse Gary K et al. Changes in population cholesterol concentrations and other cardiovascular risk factor levels after five years of the noncommunicable disease intervention programme in Mauritius. Mauritius non-communicable disease study group BMJ 1995;311:1255-9.
  • 45. Isomaa BO et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes care 2001;24;683-689.
  • 46. Romero-Corral A et al. Association of bodyweight with total mortality and with cardiovascular events incoronary artery disease: A systematic review of cohort studies. Lancet 2006;368:666–678.
  • 47. Oreopoulos A, Padwal R, Kalantar-Zadeh K, Fonarow GC, Norris CM, McAlister FA. Body mass index and mortality in heart failure: A meta-analysis. American heart journal 2008;156:13-22.
  • 48. Lavie CJ, McAuley PA, Church TS, Milani RV, Blair SN. Obesity and cardiovascular diseases: Implications regarding fitness, fatness, and severity in the obesity paradox.J Am Coll Cardiol. 2014;63:1345–1354.
  • 49. Cooney JK, Ahmad YA, Moore JP, Sandoo A, Thom JM. The impact of cardiorespiratory fitness on classical cardiovascular disease risk factors in rheumatoid arthritis: A cross-sectional and longitudinal study. Rheumatology international, 2019;39:1759-1766.
  • 50. Akcay M, Yuksel S. Smoking and cardiovascular diseases. J Exp Clin Med. 2017;34:21–5.
  • 51. Kycina P, Murin J. Alcoholic cardiomyopathy and cardiovascular events-an insight from the Liptov region. Bratislavske lekarske listy 2013;114:337-341.
  • 52. Murray R. P., et al. Alcohol volume, drinking pattern, and cardiovascular disease morbidity and mortality: Is there a U-shaped function?. American Journal of Epidemiology 2002;155:242-248.
  • 53. Lakka H. M et al. The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men. Jama 2002;288:2709-2716.
  • 54. Ritchie SA, Connell JM. The link between abdominal obesity, metabolic syndrome and cardiovascular disease. Nutr Metab Cadiovasc Dis 2007;17:319–326.
There are 54 citations in total.

Details

Primary Language English
Subjects Health Policy
Journal Section Research Articles
Authors

İlknur Arslan Çilhoroz

Yasin Çilhoroz

Publication Date April 1, 2021
Submission Date February 7, 2020
Published in Issue Year 2021Volume: 12 Issue: 2

Cite

EndNote Arslan Çilhoroz İ, Çilhoroz Y (April 1, 2021) Determination of Factors Affecting Deaths Due to Cardiovascular Diseases: A Research on OECD Countries. Acıbadem Üniversitesi Sağlık Bilimleri Dergisi 12 2 340–345.
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