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Functional status related to post-COVID 19 Syndrome in the nursing sta of a Second Level
Hospital in Quito-Ecuador
Estado funcional relacionado con el Sídrome post-COVID 19 en el personal de enfrmería en un Hospital
de Segundo Nivel de Quito-Ecuador
Cuenca-Jumbo T., Loachamin-
Quinatoa D., Pastuña-Doicela
R., Armas-Freire P., Functional
status related to post-COVID 19
Syndrome in the nursing sta of
a second Level Hospital in Quito-
Ecuador.. INSPILIP. 2024; Vol.
8, Núm. 25.
Scientic journal INSPILIP.
Volume 8, number 25; May -
August 2024.
The author declares that there are no
personal or commercial associations
that could result in a conict of
interest in connection with this
article.
All ethical principles of research
have been adhered to, including
obtaining necessary authorizations
from the institution where the study
was conducted, permission to use
the data, and informed consents. For
observational studies and clinical
trials, authorization from relevant
ethics committees (such as CEISH,
ARCSA, Environment, etc.) was
obtained according to the study
category. Additionally, licenses
to publish images of individuals
appearing in the manuscript have
been secured.
Therefore, INSPILIP holds no
responsibility for any impacts on
third parties. The responsibility for
the content of this publication lies
solely with the authors, and neither
INSPI as the publishing entity nor the
Editor bears any responsibility.
Patricio Vega Luzuriaga
EDITOR-IN-CHIEF
Teresa Daniela Cuenca-Jumbo
a
, tdcuenca@uce.edu.ec
Dylan Javier Loachamin-Quinatoa
a
, djloachaminq@uce.edu.ec
iD
Rosa Pastuña-Doicela
b
, rhpastuna@uce.edu.ec
iD
Paulina Isabel Armas-Freire
b
,
*
piarmas@uce.edu.ec
a. Ministry of Public Health, Quito-Ecuador.
b. Central University of Ecuador, Faculty of Medical Sciences, Nursing Major, Quito- Ecuador.
Correspondence: Paulina Isabel Armas Freire Email: piarmas@uce.edu.ec
Identication of the responsibility and contribution of the authors: The authors declare their
specic contributions to the study as follows: The original idea and planning of the study (TC, DL,
PA), execution of the study, analysis and interpretation of the results (TC, DL, PA, RP), writing of
the article (TC, DL, PA).
Admission date: 05/02/2024.
Approval date: 26/04/2024.
Publication date: 05/05/2024.
iD
Original Article:
Open Access
Abstract
Citation
Introduction: Nurses are on the front line ghting against the COVID-19 and are at
high risk of infection by direct patient care. Multiple factors determine the severity
of this disease and along with persistent symptoms due to subsequent infection,
aect the functional status of the infected nurses. General Objective: To determine
the functional status related to the post-COVID-19 in direct patient care nurses at
Hospital General Docente de Calderón during 2022. Method: The research has a
quantitative approach with a descriptive, observational and cross-sectional design
which determined the functional status related to the post-COVID 19 syndrome in
142 respondents. For this purpose it was used the Spanish version of Post COVID
19 Functional Status Scale, previously validated. Results: The average age of
the participants was 36.8 years, 110 women and 32 men. Regarding functional
limitations, 54.9 % had no limitations, 16.9 % had minimal limitations, 5.6 % had
mild limitations, 12.7 % had moderate limitations and 9.9 % had severe limitations.
By exploring possible associations between variables, a signicant relationship
(p<0.005) was found between functional status with age and the number of infections.
Conclusions: Although the largest percentage does not present functional limitations,
it is worth noting that the 45.1 % of nurses and auxiliary nurses, with minimal
or severe functional limitations, continue to work in areas of medium or greater
complexity. It constitutes an important input for the improvement of occupational
health.
Keywords: Functional Status. Nursing Sta. Post-Acute COVID-19 Syndrome.
iD
DOI: 10.31790/inspilip.v8i25.615
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Resumen
Introducción: El personal de enfermería se
encuentra en primera línea en la lucha contra la
COVID-19 y presenta un alto riesgo de infección.
Múltiples factores determinan la severidad de la
enfermedad y junto a los persistentes síntomas
subsecuentes, comprometen el estado funcional
del personal contagiado. Objetivo General:
Determinar el estado funcional relacionado
al síndrome post-COVID-19 en el personal de
enfermería en un Hospital General de Quito,
Ecuador 2022 Diseño y Método: Se realizó
un estudio de enfoque cuantitativo con un
diseño descriptivo, observacional y de corte
transversal, el cual determinó el estado funcional
relacionado al síndrome post-COVID- 19 en
142 encuestados mediante la Escala Funcional
Post-COVID 19 versión en español, previamente
validada. Resultados: El promedio de edad de los
participantes fue de 36,8 años, la muestra estaba
conformada por 110 mujeres y 32 hombres. En
cuanto a las limitaciones funcionales se encontró
que el 54.9 % no presenta limitaciones, el 16,9
% limitación mínima, el 5,6 % limitación leve, el
12,7 % limitación moderada y el 9,9 % limitación
severa. Se encontró relación signicativa
(p<0.005) entre el estado funcional con la edad y
el número de contagios. Conclusiones: Si bien, el
mayor porcentaje del personal de enfermería no
presenta limitación funcional, llama la atención
el 45,1 % con limitaciones funcionales entre
mínimas y severas que laboran en áreas de mayor
complejidad, lo que se debe considerar para el
mejoramiento de la salud laboral.
Palabras claves: Estado Funcional. Personal de
Enfermería. Síndrome post-agudo de COVID-19.
I
Introduction
Coronavirus disease (COVID-19) is caused
by Severe Acute Respiratory Syndrome
Coronavirus-2 (SARS-CoV-2) (1). The rst case
reported in Ecuador occurred on February 29,
2020, in a 71-year-old woman whose death was
recorded on March 13, 2020 (2). The American
continent is characterized by its heterogeneity in
sociocultural, political, and economic aspects,
which translates into limitations in healthcare
structures, resource management, and a scarcity
of healthcare personnel (3). Consequently, the
pandemic exposed disparities in the quality, cost,
and accessibility of healthcare (4).
At the onset of the COVID-19 pandemic, there was
a simultaneous lack of knowledge about the virus,
protocols, and personal protective equipment,
coupled with long and exhausting work hours.
This created signicant physical and emotional
stress for healthcare personnel, particularly nurses,
leading to a chronic and unsustainable increase in
workload (5).
The pandemic had a severe impact on the nursing
team, who were on the front lines providing direct
care to patients from the onset of the pandemic (6).
They faced increased workloads and a reduction
in available sta, which resulted in them having to
work under greater pressure than usual and often
in deance of safe work procedures and practices
(7).
As a result, the importance of occupational health
was recognized as a signicant aspect of this new
reality which makes it necessary to know and
analyze the evolution of the disease, the risk of
exposure for professionals and workers in health
centers where they play a crucial role in the care
of aected patients (8).
For this reason, this study aims to determine
the functional status related to post-COVID-19
syndrome in the direct care nursing sta who work
at Hospital General Docente de Calderón during
2022. Additionally, it pretends to characterize the
direct care nursing sta post-COVID-19; to analyze
their physical, mental and social functional status
and to explore possible associations between the
variables studied.
Subjects and methods: A quantitative,
observational, descriptive and cross-sectional
study was carried out. For this purpose,
institutional approval was obtained from the
Hospital Docente de Calderón, all participants
signed the informed consent form, and data
anonymity was guaranteed. The data collection
instrument was the Post-COVID 19 Functional
Scale, Spanish version (Chile).
The population consisted of direct care
nursing sta, both professional and auxiliary
who worked at the Hospital during 2022. It
comprised 455 professionals (316 nurses and
139 auxiliary nurses). The sample was selected
by non-probabilistic, intentional or convenience
sampling, which made it possible to contemplate
the target population. For this purpose, the report
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of COVID-19 infections from the Occupational
Health Area was considered and were conrmed by
PCR or antigen test; therefore, an initial sample of
202 participants was estimated.
The inclusion criteria were: nursing personnel
working at the Hospital General Docente Calderón,
agreed to participate voluntarily in this study,
perform direct patient care, and have a conrmed
COVID-19 infection by any diagnostic method with
more than 6 months since recovery. The exclusion
criteria included nursing personnel who were not
infected with COVID-19 or whose diagnosis was
presumptive.
The following variables were taken into account:
Post-COVID-19 Syndrome, Functional status,
Age, Sex, Comorbidities, Exposure Time/Workday,
COVID-19 Morbidity, Nursing sta, Immunization,
Personal protective equipment.
Techniques and instruments: Participants were
asked to provide information on socio-demographic
characteristics and medical history (age, sex,
pre-existing comorbidities, exposure time/workday,
COVID-19 morbidity, nursing role classication,
number of immunizations and access to personal
protective equipment, service where they works,
number of contagions, most serious contagion).
The Post-COVID-19 Functional Status (PCFS)
Scale for adult survivors of COVID-19 was used
as an objective tool when evaluating patients with
post-COVID-19 syndromes (9). This ordinal scale
assesses the totality of functional limitations Post
COVID-19 (9). The Leiden group, Netherlands,
proposed this scale with the purpose of evaluating
patients after hospital discharge, at 4 and 8 weeks
to maintain a follow-up in their recovery, and
at 6 months to evaluate the functional sequelae.
Therefore,
the PCFS scale maintains its usefulness both at
the time of hospital discharge and for monitoring
functional status after discharge (10). The description
of each grade of the scale is detailed in Annex 1,
Chile version (11).
Semantic validation of the PCFS was performed by
means of a written survey for each of the judges. Six
health professionals participated: 3 nursing graduates
and 3 nursing assistants who met the following
inclusion criteria: knowledge of the subject,
experience in the application of the scale, more than
5 years of professional practice and experience at
providing direct care to patients with COVID-19.
The experts evaluated the content of the scale with its
6 dimensions in the categories of: clarity, coherence
and relevance for which a Likert-type response
format with 5 response alternatives was used.
The average score for each item, according to the
experts, was greater than 4, it corresponds to a clear
and precise question for measuring the phenomenon
under study. It was decided not to use the rst
question, "Did the patient die after the diagnosis
of COVID-19?," because it generated confusion in
the response. In addition, words such as "you" were
modied to "for you"; "local shopping" to "store" in
the dimensions of basic activities of daily living and
instrumental activities of daily living.
The reliability and validity of the instrument were
assessed through a pilot test administered to a total
of 25 health professionals, including nurses and
nursing assistants, who worked in a clinic in Quito.
The statistical analysis was performed using SPSS
statistical software for Windows (Version 26.0, IBM
Inc., Armonk, NY, USA). The construct validity of
the PCFS scale was evaluated using Cronbach's α
coecient, yielding a result of 0.935 which permits
considering the scale as highly reliable and suitable
for its application. Each item was individually
evaluated, with a Cronbach's alpha greater than
0.9 and coecients ranging from 0.918 to 0.948.
It proved that each of the questions are highly
reliable and at the same time allowed modications
to be made to the approach of the aforementioned
questions.
Data processing and analysis: Once the results of
the physical surveys were obtained, the data were
exported to an Excel database, cleaned and transferred
to the statistical program IMB SPSS version 26 for
comprehensive analysis of each variable's behavior.
To ensure data condentiality, codes were assigned
to each survey conducted for every participant,
eectively safeguarding their identity and personal
information.
For data analysis, descriptive statistics were employed
to address the research objectives. The qualitative
variables (sex, personnel, service, availability of
PPE, immunization, comorbidity, contagion, contact
time, COVID morbidity) were analyzed through
frequencies and percentages, while the age variable
was analyzed through mean and standard deviation.
Age was represented by ranges and comorbidity
and immunization were represented by absolute
frequencies.
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For the tabulation and descriptive analysis of data,
Microsoft Oce Excel 2016 was used alongside
SPSS version 26 statistical software.
Ethical principles: The present study was
submitted for review to obtain ethical approval
by the Ethics Committee for Research on Human
Beings of the Universidad Central del Ecuador, with
approval code: 011-G-FCM-2023. Additionally,
approval was obtained from the public institution
where the study was conducted (Annex 2).
Throughout the research process, the present study
consistently adhered to the principles of bioethics
endorsed by the CEISH, as well as national and
international legislation and regulations in force,
such as the Declaration of Helsinki.
The benets derived from this research directly
impacted the participants by providing valuable
insights into post-COVID-19 functional status,
and thus contributed with evidence that contributes
to the occupational health of this important group.
Informed Consent: Before administering the
instrument to the nursing professionals, their
consent to participate in the study was obtained.
The purpose of the research and their contribution
to it were clearly explained. Additionally, they
were assured that refusal to participate would
not result in any detrimental eects for either the
participants or the researchers.
Of the planned sample of 202 participants, 60
individuals did not meet the inclusion criteria.
Additionally, some participants refused to
participate in the study and did not sign the
informed consent form. Consequently, the results
presented here reect the data from the 142
participants who did meet the inclusion criteria
and agreed to participate. These results will be
described in accordance with the objectives of the
present study.
Sociodemographic Characteristics:
The surveyed population exhibited a feminization
trend, with 110 women and 32 men participating.
The mean age of the participants was 36.88 years,
with a standard deviation of 8.59 years. The age
range of the participants was 25 to 64 years,
categorizing them as a young working population.
Approximately 74.6% of the participants were
nursing professionals engaged in direct patient
care duties.
Regarding the work characteristics, most of
the nursing personnel carried out their current
activities in the Hospitalization service (43.0%,
n=61), followed by the Critical Areas service
(40.8%, n=58). It is noteworthy that 93% of the
participants had access to personal protective
equipment (PPE) during the pandemic. Regarding
work shifts, there was a greater exposure time to
the virus during 12-hour shifts (47.2%, n=67),
followed by 24-hour shifts (43.7%, n=62). These
extended work hours are considered signicant
risk factors for COVID-19 infection among the
nursing sta.
Regarding the characteristics associated with
the infection, approximately 58.8% of the
participants were infected with COVID-19 at
least once. Among these, 81% (n=115) indicated
that this was their most severe infection. The
severity of the infection reached a moderate level
of morbidity in 48.6% (n=69) of these cases.
About 66.9 % had no previous comorbidities.
The highest percentage of morbidity corresponds
to respiratory disease with 14.1 % (n=20).
Regarding COVID-19 immunizations, 64.8 %
(n=92) of the nursing sta had the second booster
as shown in Table No. 1.
Results
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Post-COVID-19 functional status scale:
Most of the participants (54.9%) maintain a range
without functional limitations (Grade 0), 16.9%
have a minimal functional limitation (Grade 1),
12.7% have a moderate functional limitation
(Grade 3), while 5.6% maintain a slight functional
limitation (Grade 2). It should be noted that 9.9%
have a severe functional limitation (Grade 4),
considering this population as vulnerable, as can
be seen in Table 2.
Introducci
Relationship of Variables:
Before exploring the relationship of variables, the
Kolmogorov-Smirnov normality test was applied
to determine the distribution of the data, given that
the sample size was greater than 50. The results
obtained were p=0.001, indicating that the data
did not follow a normal distribution; therefore,
non-parametric statistics were used.
A result is statistically signicant when it is not
likely to have been due to chance, as indicated by
the p-value. However, considering only the p-value
in the study is limiting and can result in a loss of
signicant data. Therefore, other factors were
also taken into account. One such factor is sex,
which is important due to the feminization of the
profession. It was observed that, across dierent
grades, males were the least aected. Additionally,
within grade 4, no dierences were seen between
the activities of the nursing personnel.
The Hospitalization service maintains a high mean
in relation to functional limitations, considering
this group as vulnerable compared to other services.
Despite not nding a signicant relationship
between access to personal protective equipment
and the degree of limitation, it is important to
highlight it due to its relationship with the exposure
time to the virus, particularly during 12-hour shifts
among the personnel. Regarding comorbidities,
it is noteworthy that about 11 professionals had
a respiratory disease prior to infection. Finally,
immunizations for the year 2022 were available up
to the fourth dose, but only 56 professionals had
received the second booster to prevent the severity
of the disease, as shown in Table 3.
Table 3: Relationship between the sociodemographic
characteristics and the Functional Status Scale.
ón
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To explore possible relationships between
sociodemographic characteristics and the
Post-COVID-19 functional status scale, bivariate
analysis was used, which showed a signicant
positive relationship (p= 0.037) between age and
functional status, indicating that the greater the
age, the greater the degree of functional status
impairment. Likewise, a signicant positive
relationship (p=0.001) was found between the
number of infections and functional status, which
shows that the greater the number of infections, the
greater the functional limitation, as can be seen in
Table 4.
To explore possible relationships between
sociodemographic characteristics and the
Post-COVID-19 functional status scale, bivariate
analysis was used, which showed a signicant positive
relationship (p=0.037) between age and functional
status, indicating that greater age is associated with
a higher degree of functional status impairment.
Likewise, a signicant positive relationship
(p=0.001) was found between the number of
infections and functional status, demonstrating that
a higher number of infections correlates with greater
functional limitation, as can be seen in Table 4.
A signicant bilateral relationship between the
dierent dimensions of the Post-COVID-19
functional status scale could also be evidenced,
where a higher or lower score acquired in the
physical (p=0.216) and emotional (p=0.290)
dimensions determines an equal alteration in the
social dimension, as can be seen in Table 5.
Table 5: Relationship of the Dimensions of the
Functional Status Scale Post-COVID-19
Discussion
The primary objective of this study was to determine
the functional status associated with post-COVID-19
syndrome among direct care nursing sta at a General
Hospital in Quito, Ecuador, in the year 2022. The
study evaluated a cohort of 142 health professionals,
comprising nursing assistants and graduates who
met the specied inclusion criteria.
It was found that following COVID-19 infection,
54.9% of participants reported no functional
limitations (Grade 0), while 45.1% experienced
some degree of functional limitation. Specically,
16.9% had minimal functional limitation (Grade
1), 12.7% had moderate functional limitation
(Grade 3), and 5.6% had mild functional limitation
(Grade 2). Notably, 9.9% of participants reported
severe functional limitation (Grade 4), indicating
vulnerability within this population.
The results obtained are compared with those of
the study "Prevalence of Functional Limitation
in COVID-19 Recovered Patients Using the Post
COVID-19 Functional Status Scale," conducted in
Nepal by Pant et al. In their study, it was observed
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that more than 56.6% of patients, including health
personnel, reported no limitations (12). Similarly,
in the study "Evaluation of the Post-COVID-19
Functional Status (PCFS) Scale in a cohort of
patients recovering from hypoxemic SARS-CoV-2
pneumonia" conducted in France by Benkalfate N
et al., 88% did not experience functional limitations
(13). These studies underscore the scale's adequate
semantic and cultural validation in their respective
languages, suggesting that the results obtained
were reliable. Thus, these ndings indicate that the
outcomes of our study are consistent with existing
research.
The association between sociodemographic
characteristics and the Post-COVID-19 functional
status scale was assessed through bivariate
analysis, revealing distinct patterns among the
study population. Age and the number of infections
emerged as signicant factors inuencing functional
status.
The study found an average age of 36.8 years,
indicating a predominantly young working
population. This aligns with national statistics from
the National Survey of Employment, Unemployment,
and Underemployment (ENEMDU), which reports
that 70.25% of workers in this sector are under 50
years old (14). The analysis revealed a signicant
positive relationship between age and functional
status, suggesting that as age increases, there is a
greater degree of functional impairment. This trend
may be inuenced by the inclusion of younger
participants, given that the hospital sta averages 8
years of service and is considered relatively young.
Additionally, younger individuals may generally
experience better outcomes compared to older adults
following COVID-19 infection (12).
In analyzing the relationship between the number
of infections and functional status, a signicant
positive correlation was identied, indicating
that higher infection rates correlate with greater
functional limitations. Studies indicate that nearly
90% of COVID-19 cases manifest clinical symptoms
characteristic of the infection, and persistent
symptoms may lead to further deterioration in
functional status. This can include declines in
pulmonary function, mental health issues, and
varying degrees of impact on quality of life, aecting
long-term physical, mental, social, and cognitive
well-being (12).
A statistically signicant result indicates that the
observed eect is unlikely to be due to chance
(p-value). However, relying solely on this value in
the study can be limiting and may lead to a loss of
important data. It's also important to consider the
potential impact of sex, given the feminization of the
profession. Evidence suggests that women may be
disproportionately aected by post-acute COVID-19
syndrome, with sequelae more frequently observed
among female patients (15).
In Ecuador, women constitute 65.8% of health
personnel (14). Therefore, it's important to note
that a profession is considered feminized when the
percentage of women exceeds 55% of the workforce
compared to men (16). In this study, 77.46% (110
individuals) of the surveyed population were
women, while 22.54% (32 individuals) were men.
This underscores the persistence of a patriarchal
social model dating back to the 19th century, which
normalized the notion that nursing should exclusively
be a female domain due to their nurturing role, akin
to mothers caring for their children. This perception
entrenched women in roles seen as extensions of
their domestic duties (17)."
According to the most recent data from the Statistical
Registry of Health Resources and Activities of the
Ecuadorian Institute of Statistics and Census, there
are a total of 25,900 nurses and 17,560 auxiliary
nurses nationwide (18). Approximately 74.6%
of these professionals are directly involved in
patient care. The Hospitalization service stands
out with a signicant proportion of nursing sta
experiencing various levels of functional limitations,
highlighting this group's vulnerability compared
to other services. In our current investigation, a
majority of nursing personnel (43.0%, n=61) are
assigned to the Hospitalization service. This area
was notably impacted due to the continuous inux
of COVID-19 patients requiring extended hospital
stays, necessitating increased stang levels (19).
Although no signicant relationship was found
between access to personal protective equipment
and the degree of functional limitation, it is crucial
to highlight this nding due to its association with
the duration of virus exposure. The study revealed a
predominance of extended work shifts, particularly
12-hour shifts (47.2%, n=67) and 24-hour shifts
(43.7%), which correlate with prolonged exposure
to COVID-19. Consequently, these extended
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shifts were considered signicant risk factors for
COVID-19 infection.
Furthermore, Linh T. Phan et al. highlighted that
inadequate use of personal protective equipment
(PPE) poses signicant risks; incorrect removal
procedures were reported in 90% of cases, including
issues with sequence, technique, and selection
of appropriate PPE (20). During the COVID-19
pandemic, Hoedl et al. emphasized the widespread
use of face masks and gloves in nursing practice,
with face mask usage being mandatory (21). In the
current study, 93% (n=132) of participants reported
access to PPE, indicating some shortcomings in
timely access to these devices for all personnel.
Regarding immunizations, by 2022, boosters up to the
fourth dose were available. However, in the present
study, only 64.8% of professionals had received
the second booster to mitigate disease severity.
This contrasts with ndings from a study involving
28,356 participants, which demonstrated a decrease
in the likelihood of prolonged COVID-19 symptoms
following vaccination (22). This discrepancy may be
attributed to inadequate awareness among surveyed
personnel regarding the importance of booster doses.
Dierent phenotypes of post-COVID-19 conditions
may exist, although the exact causes, management,
and outcomes remain unknown (23). This study
revealed a signicant bilateral relationship among
the various dimensions of the Post-COVID-19
functional status scale. Notably, higher or lower
scores in the physical (p=0.216) and emotional
(p=0.290) dimensions corresponded to similar
alterations in the social dimension.
In the context of the physical dimension, these
symptoms are more prevalent, as highlighted in the
literature, which underscores their high frequency
and heterogeneity following COVID-19. Studies
have documented a wide range of symptoms
persisting up to six months after the acute phase
of the illness (24). While many of these symptoms
may resolve over time, some are enduring and
can profoundly impact daily life (25). Therefore,
timely consideration of these symptoms is crucial
to prevent their progression into chronic conditions
with signicant implications for quality of life,
economics, and public health (13)
In the context of the emotional dimension, healthcare
workers often experience ongoing pressure (26).
They frequently report high emotional exhaustion,
depersonalization, and low professional fulllment,
which are compounded by factors such as
decision-making under moral duress in critical work
situations (26). Moreover, the severity of COVID-19
patient conditions, increased workload, and human
resource shortages have consistently compromised
the emotional well-being of healthcare workers (27).
Therefore, emotional support for healthcare workers
is essential to address these challenges.
Peer review
The manuscript underwent blind peer review and
was promptly approved by the Editorial Team of the
INSPILIP journal.
Los datos que sustetan este manuscrito estn
disponibles bajo requisicin al autor correspondiente.
Availability of Data and Materials
The data supporting the ndings of this study are
available upon request from the corresponding
author.
Conicts of Interest
The authors declare that they have no conicts of
interest.
Authors' Contributions
All authors equally contributed to the dierent
phases of the research process.
Acknowledgments
We are grateful to the Nursing Major of the Faculty
of Medical Sciences of the Universidad Central del
Ecuador, who gave their support to the realization of
this project.
We thank Hospital General Docente de Caldern and
its authorities for allowing this research to be carried
out.
Previous presentations or publications
This research has not been previously published or
presented at any conferences.
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