Abstract
Background
The Ferrer-Urbina’s Multidimensional Scale of Sexual Self-Concept is newly designed and consists of an appropriate number of items. This scale has not been previously utilized in Iran. Thus, the present study aimed to evaluate the validity and reliability of its Persian version in Iran.
Methods
This cross-sectional psychometric validation study was conducted in 2025 on 160 married men and women living in Urmia. The content validity was assessed quantitatively and qualitatively. Also, Convergent validity was performed by calculating the correlation coefficient between the Snell and MSSSC sexual self-concept questionnaires. Confirmatory factor analysis was employed to determine the construct validity. The reliability of the questionnaire was also tested using the internal consistency method, along with calculating the Cronbach's alpha coefficient. Data were analyzed using IBM SPSS (v.27) and MPLUS (v.8.3), with a significance level set at p < 0.01.
Results
The factor loadings for 16 items were calculated between (0.99–0.4), indicating a good correlation between the items, so there was no need to remove any items. Cronbach's alpha and McDonald's omega coefficients were estimated for the entire scale (α = 0.949, ώ = 0.948) as well as its dimensions. CFA confirmed excellent model fit (CFI = 0.987, TLI = 0.984, RMSEA = 0.057.90% Cl [0.081,0.112]). The reliability of this scale was examined using the test–retest method and the Cronbach's alpha value was 0.946.
Conclusion
The Persian version of the Ferrer-Urbina Multidimensional scale of sexual self-concept with 16 items is psychometrically sound, culturally valid tool for assessing sexual self-concept in Iran.
Keywords: Construct validity, Convergent validity, Internal reliability, Temporal reliability, Sexual self-concept
Background
Sexual self-concept is a key component of sexual health which forms the core of individuals' sexual desires and orientations. Sexual self-concept is also closely linked to an individual's physical and mental health and overall well-being [1, 2]. Sexual self-concept, as an emotional phenomenon, helps an individual achieve awareness, acquire identity, and self-evaluate their sexual life. It is influenced by a variety of factors, including cognition, beliefs, and the environment, and is related to an individual's sexual experiences and behaviors [3, 4]. It guides individuals to their sexual desires and tendencies, which have been formed throughout the process of socio-emotional development along with sexual schemas [4, 5].
The structure of sexual self-concept is strongly influenced by social representations [6]. Over the past decades, researchers have used or even designed various scales to measure and identify sexual self-concept and its dimensions, as well as to examine the significance of this variable. For example, Sullivan et al. developed a scale in the United States that consists of 34 items. They showed that their tool is beneficial for assessing adolescent girls' perceptions of their sexual orientation and can be used, to some extent, in studies related to health and decision-making in high-risk situations [7].
Vickberg and Deaux also designed a 39-item scale to examine sexual self-concept and believed that their instrument could be used as a suitable option for studying women's sexual self-concept [8].Also, Snell designed a 100-item questionnaire to measure sexual self-concept, which was an essential step towards paying attention to sexual desires in individuals [9].
The scales mentioned include a large number of questions, which can create challenges in the process of investigating the problem. In other words, lengthy questionnaires make participants feel fatigued, making subjects reluctant to continue filling out the questionnaires. As a result, it can lead to poor data collection and an increase in the rate of non-completion of the questionnaires [10–12]. Also, most questionnaires on sexual self-concept are old and may not be suitable for new conditions; that is, they are not adapted to today's culture, language, and social changes, and repeated use of an instrument can reduce research innovation [13, 14].Therefore, the existence of a new and valid tool with an appropriate number of items seems essential.
Accordingly, in the present study, the Multidimensional Scale of Sexual Self-Concept (MSSSC) of Urbina et al. will be psychometrically tested. The scale in question specifically measures sexual self-concept. This scale is a 16-item instrument with four subscales, including sexual self-esteem, sexual self-efficacy, assertive sexual behaviors, and Assertive sexual communication, with each subscale containing four items [15]. For example, the sexual self-esteem subscale refers to an individual's emotional response to the assessment of sexual thoughts, feelings, and behaviors; this component can be determined by the images and values that an individual has regarding their sexual attractiveness and aptitude [16].
The sexual self-efficacy subscale is a multidimensional construct which includes beliefs about one's ability to perform sexually, desirability for a romantic partner, and evaluation of one's abilities as well as competencies in sexual behaviors, leading to better socio-psychological functioning in life [17].Further, the assertive sexual behaviors subscale refers to the ability to initiate sexual activities, reject unwanted sexual activities, and agree to desired sexual behaviors. Ultimately, Assertive sexual communication is also referred to as social skills which improve communication, interests, and the needs of a sexual partner [15]. Thus, considering what was raised in the statement of the problem, the present study will ascertain psychometrically evaluate the Ferrer-Urbina’s Multidimensional scale of sexual self-concept for Iranian population.
Methods
The present study is a cross-sectional methodological psychometric investigation aimed at validating the Ferrer-Urbina Multidimensional scale of sexual self-concept (MSSSC). The statistical population consisted of married men and women covered by comprehensive health centers in Urmia. The sample size was determined according to the number of items. The MSSSC questionnaire consists of 16 items, so 10 people were considered for each item, for a total of 160 [18]. Considering a 15% dropout rate [19], the total score was estimated to be 184. To conduct the study, Urmia city was first divided into two districts. A list of comprehensive health service centers was then prepared for each district. Subsequently, a comprehensive health service center was randomly selected from each district. Then, 92 married women and 92 married men from each center were randomly selected for the study. They were randomly selected. The R computer power software for RMSEA was applied. The results indicate an acceptable power (0.794) for the study's sample size (n = 160) [20].
The study entry requirements included being a resident of Urmia, being covered by a comprehensive health center, and having no cognitive or psychological problems.
In the present study, two questionnaires were used: 1- the Persian version of Snell Multidimensional Sexual Self-Concept Questionnaire (MSSCQ) [21]. 2-The Ferrer-Urbina MSSSC was first designed by Urbina et al. in 2019. This 16-item questionnaire contains four dimensions of sexual self-concept, including sexual self-esteem, sexual self-efficacy, assertive sexual behavior, and Assertive sexual communication. It was first administered to 792 men and women living in Chile [15]The MSSSC scale is a four-point Likert scale scored from one "strongly disagree" to four "strongly agree", with each of the four dimensions having four specific items. Higher scores reflect higher levels of sexual self-concept. The total score of MSSSC is obtained by summing up the scores of all items. The questionnaire enjoys suitable validity, and the total reliability of the test, as measured by Cronbach's alpha, is reported to be above 0.80. The reliability of all subscales is also above 0.80 [22].
In the first stage of the research, after obtaining consent from Dr. Ferrer-Urbina, the MSSSC questionnaire was received and translated from the original language into Persian by two individuals. Next, the initial translations were combined into a single translation. Again, the final version translated from the target language into the original language was returned and revised. This work was performed by four translators, including one language specialist, one translator familiar with the concepts, one specialist in questionnaire translation, and one translator as a coordinator, who were fluent in both the original and target languages.
A qualitative and quantitative evaluation of face validity was performed by nine psychologists. They ascertained the importance of the questions using a five-point Likert scale, which ranged from "very important" to "not at all important." Then, the CVR was computed using the following formula:
 |
In which” ne” stands for the number of experts who chose the “item is necessary” option, while” n” represents the total number of experts. Then, the resulting value was compared with the calculated one in Lawshe’s (1975) Table [23]. The scores on the "very important" scale varied between 77.78 and 100%, demonstrating that the questions were generally deemed important. Overall, 90.27% of the respondents rated the questions as "very important."
To quantitatively inspect the content validity (CVR), experts responded to each item of the tool in three ranges: essential, useful but not essential, and not essential. The CVR ratio of each question was then compared with the Lawshe CVR, whereby the CVR ratio of the questions was estimated to be 0.91.
For calculating the CVI, the evaluators commented on each item of the tool used, regarding the three criteria of relevance or specificity, simplicity and fluency, and clarity or transparency, based on a 4-point Likert scale. For instance, for the criterion of "relevance", the options were not relevant = 1, relatively relevant = 2, relevant = 3, and completely relevant = 4, after which the validity index was calculated according to the formula below [24–26]:
 |
According to Lawshe's table, if the items were < 0.7, the item was removed; if it was between 0.7 and 0.79, it required revision. Items with a CVI value of ˃0.79 are considered acceptable [27]. Therefore, the simplicity, relevance, and clarity indices of the Persian version of the MSSSC scale were estimated to be 0.94, 0.99, and 0.95, respectively. Considering these two indices, no question was eliminated.
The structural validity of the questionnaire was ascertained using confirmatory factor analysis to determine whether the items considered for the dimensions of the questionnaire really represent those dimensions and how accurately they introduce them. The model fit of the Persian version of the Urbina Multidimensional scale of sexual self-concept was evaluated through confirmatory factor analysis using SPSS V27 and MPLUS software. Since there is no general agreement among structural equation experts about which of the fit indices provides a better estimate of the model, it has been proposed to report a combination of three to four indices. As a result, in the present study and in line with factor analysis studies the following were used: the fit indices, ratio of chi-square to degrees of freedom (X2.DF), root-mean-square error of estimation index (RMSEA), comparative fit index (CFI), the comparative fit index (TLI) [28, 29]. Fit indices such as the Tuker-lewis index (TLI), incremental fit index (IFI), comparative fit index (CFI), the root mean square error of approximation (RMSEA) are less affected by disturbing and external factors, and the result obtained is more indicative of a defect in the model fit; that is, if there is no proper fit in the analysis, it is owing to the nature of the model and is less affected by disturbing and external factors [30, 31].
The Persian version of Snell Sexual Self-Concept Questionnaire was employed to examine the convergent validity. The Snell Sexual Self-Concept Questionnaire was developed by William Snell [32] and the Persian version has 78 items and 18 components. The questionnaire items are scored based on a five-point Likert scale (completely applies to me, score 5, somewhat applies to me, score 4, I cannot confirm or deny it (no opinion), score 3, almost does not apply to me, score 2, does not apply to me at all, score 1). The developers of this scale have stated that the content validity of the questionnaire is appropriate. Tarnas [33] obtained the reliability of the questionnaire and its components as 0.94 using Cronbach's alpha method.
To scrutinize the internal reliability of the instrument, the McDonald Omega reliability coefficient and Cronbach's Alpha were utilized. The main advantage of Omega compared to Cronbach's Alpha is that Omega also considers the strength of the relationship between items [34–37]. Also, to assess the reliability of the instrument over time, the test–retest test was applied, which indicates the repeatability of an indicator, thus showcasing the extent to which the results of measuring a quantity in the same sample but at two different times are consistent [38, 39].
In inferential statistics, according to structural equation experts, the confirmatory factor analysis method based on the structural equation model was employed to examine and confirm the subscales of the questionnaire, i.e., to confirm the construct (factor) validity of the questionnaire. The internal consistency (consistency) of the questionnaire was specified by determining the Cronbach's alpha coefficient, where the temporal reliability (response stability) of the questions was determined by specifying the correlation coefficient in the test–retest method. The correlation coefficient was also utilized to estimate the convergence validity of the two scales. To perform statistical calculations, two software packages, SPSS version 27 and MPLUS version 8.3, were used.
Results
The demographic characteristics of participants are displayed in Table 1. To achieve acceptable convergent validity, measures that claim to capture the same construct should correlate at a value of at least 0.5 [40]. Convergent validity was determined by calculating the Pearson’s correlation coefficient. The correlation between the total score of the Multidimensional scale of sexual self-concept and each of the subscales of the MSSSC with the Persian version of snell sexual self concept questionnaire was considered strong. Additionally, a positive correlation was observed between the two questionnaires at a significant level of p = 0.01 (Table 2).
Table 1.
Mean and standard deviation of demographic characteristics of participants
| Gender | AGE | marriage age | marriage duration | children number |
|---|---|---|---|---|
| female(n = 91) | 31 ± 9.1 | 22.23 ± 3.2 | 8.8 ± 9.6 | 1.16 ± 1.2 |
| Male (n = 69) | 39.6 ± 9.5 | 26.7 ± 3.9 | 13 ± 9.8 | 1.6 ± 1.2 |
| Total(n = 160) | 34.7 ± 10.2 | 24.2 ± 4.1 | 10.6 ± 9.9 | 1.4 ± 1.2 |
Table 2.
Correlation between urbina's multidimensional sexual self-concept questionnaire and persian version snell’s sexual self-concept questionnaire
| Total-M | SSE | SSF | ASB | ASC | Total-S | |
|---|---|---|---|---|---|---|
| Total- M | 1 | |||||
| SSE | .563* | 1 | ||||
| SSF | .647* | .769* | 1 | |||
| ASB | .502* | .612* | .682* | 1 | ||
| ASC | .697* | .777* | .865* | .668* | 1 | |
| Total-S | .675* | .878* | .927* | .836* | .928* | 1 |
SSE Sexual-self-esteem, SSF Sexual self efficacy, ASB Assertive sexual behavior, ASC Assertive sexual communication, Total- M Multidimensional of sexual self-concept,Total-S Snell Sexual Self-Concept, * = p < 0.01
The internal reliability of the questionnaire was considered using Cronbach's alpha and McDonald's omega coefficients. Regarding the interpretation of alpha and omega, the suggested value is as follows: excellent (˃0.9), good (0.7 to 0.9), acceptable (0.6 to 0.7), poor (0.5 to 0.6), and unacceptable (< 0.5) [41–44]. Therefore, both Cronbach's alpha and McDonald's omega have been higher than 0.7, demonstrating excellent reliability of the instrument (Table 3).
Table 3.
Internal reliability coefficient for the Urbina Multidimensional Sexual Self-Concept subscales
| Sub scales | Item | mean | SD | Cronbach’s Alpha | Total Cronbach | McDonald’s omega | total omega |
|---|---|---|---|---|---|---|---|
| se1 | 2.45 | 0.76 | 0.89 | 0.9 | |||
| se2 | 3.1 | 0.77 | 0.70 | 0.77 | |||
| Sexual-self esteem | se3 | 3.18 | 0.83 | 0.72 | 0.82 | 0.75 | 0.83 |
| se13 | 2.99 | 0.75 | 0.71 | 0.79 | |||
| se12 | 9.35 | 3.97 | 0.86 | 0.86 | |||
| se14 | 9.28 | 4.01 | 0.86 | 0.89 | 0.86 | 0.88 | |
| Sexual self efficacy | se15 | 9.27 | 4.02 | 0.84 | 0.84 | ||
| se16 | 9.56 | 4.03 | 0.87 | 0.87 | |||
| se4 | 3.01 | 0.78 | 0.85 | 0.85 | |||
| Assertive sexual behavior | se6 | 2.61 | 0.89 | 0.77 | 0.84 | 0.79 | 0.85 |
| se7 | 2.64 | 0.89 | 0.79 | 0.80 | |||
| se8 | 2.64 | 0.88 | 0.78 | 0.80 | |||
| se5 | 3.03 | 0.83 | 0.89 | 0.89 | |||
| se9 | 3.08 | 0.83 | 0.87 | 0.87 | 0.90 | ||
| Assertive sexual communication | se10 | 3.16 | 0.79 | 0.86 | 0.90 | 0.87 | |
| se11 | 3.15 | 0.78 | 0.86 | 0.86 | |||
| Multidimensional of sexual self-concept | MSSSC | 47.51 | 9.68 | 0.95 | 0.95 |
SD Standard deviation
Confirmatory factor analysis was employed to examine the latent factors in the instrument. High values of factor loading (e.g., greater than 0.7) reveal a strong correlation between the variable and the factor, while lower values (less than 0.3) may indicate a weak relationship [45, 46]. They may not be included in the final model. Based on Table 4, all options have high factor loadings and were included in the model. In testing the reliability of this scale using the test–retest method, the Cronbach's alpha value was 0.946.
Table 4.
Standardized factor loadings for Urbina's Multidimensional Sexual Self-Concept items by subscale
| Items | Estimate | S.E | Est/S.E | P-Value | |
|---|---|---|---|---|---|
| se1 | 0.40 | 0.076 | 5.3 | 0.0001 | |
| Sexual Self-Esteem | se2 | 0.95 | 0.021 | 45.2 | 0.0001 |
| se3 | 0.92 | 0.023 | 40 | 0.0001 | |
| se13 | 0.92 | 0.022 | 42 | 0.0001 | |
| se12 | 0.85 | 0.033 | 25.7 | 0.0001 | |
| Sexual Self-Efficacy | se14 | 0.90 | 0.023 | 39.1 | 0.0001 |
| se15 | 0.95 | 0.017 | 55.8 | 0.0001 | |
| se16 | 0.84 | 0.036 | 23.3 | 0.0001 | |
| se4 | 0.99 | 0.031 | 32.0 | 0.0001 | |
| Assertive Sexual Behavior | se6 | 0.74 | 0.042 | 17.6 | 0.0001 |
| se7 | 0.77 | 0.041 | 18.7 | 0.0001 | |
| se8 | 0.76 | 0.04 | 19 | 0.0001 | |
| se5 | 0.88 | 0.024 | 36.6 | 0.0001 | |
| Assertive sexual communication | se9 | 0.87 | 0.031 | 28 | 0.0001 |
| se10 | 0.91 | 0.019 | 47.8 | 0.0001 | |
| se11 | 0.91 | 0.024 | 37.9 | 0.0001 |
S.E standard error, Est/S.E estimate ÷ standard error
Experts have provided different cut-off criteria for fit indices. For instance, in comparative fit indices and Tucker-Lewis index (CFI, TLI), whose range of variation is between zero and one, values ˃0.85 reflect relative fit, values ˃0.90 indicate good fit, and values ˃0.95 represent excellent fit of the model [47]. For the root mean square error of estimation (RMSEA) index, values ≤ 0.06 reveal good fit, 0.06 to ≤ 0.08 demonstrate acceptable and reasonable fit, 0.08 and ≤ 0.1 represent moderate fit, and ˃0.1 indicate poor fit. In the case of the index (X2.DF), there is no agreement on acceptable values [48]. Some researchers consider values < 5 to be appropriate for it. Thus, according to Table 5, RMSEA, CFI, and TLI indicate that the model has an acceptable fit.
Table 5.
Fit indices of the confirmatory factor analysis model
| Index name | Amount obtained | Indicator abbreviation |
|---|---|---|
| Root Mean Square Error of Approximation | RMSEA | 0.057 |
| Comparative fit index | CFI | 0.987 |
| Tucker-Lewis fit index | TLI | 0.984 |
| Chi-square coverage area | X2 | 11,139.72 |
| Degrees of freedom | df | 120 |
| Significance level | p | 0.0001 |
| Confidence interval | CI (Lower – Upper) | 0.081–0.112 |
| Sample size | N | 160 |
RMSEA Root Mean Square Error of Approximation, CFI Comparative Fit Indices, TLI Tucker-Lewis fit index, CI Confidence Interval
Figure 1 displays the confirmatory factor structure of the 4-factor model of the Persian version of the Multidimensional scale of sexual self-concept, along with standardized factor loadings. In the analysis of CFA, it was found that most factor loadings are ˃ 0.50 [49]. However, one factor has a loading that falls below this threshold (0.404). Actual research indicates that while factor loadings should ideally be at least 0.30 [50], this minimum can vary based on the specific context. For a stronger association, it is preferable to have factor loadings of 0.45 or higher, as these levels suggest a more meaningful relationship between the variable and the factor. Therefore, in the current model all factor loadings were statistically significant.
Fig. 1.
Structural model of the Persian version of the Urbina multidimensional scale of sexual self-concept among married men and women in Urmia city. *SSE ASC, ASB, and SSF represent the subscales of sexual self-esteem, sexual self-efficacy, assertive sexual behavior, and Assertive sexual communication, respectively
Discussion
The present study was undertaken to normalize the multidimensional sexual self-concept scale of Ferrer-Urbina et al. (2019) in Iranian society. This scale is considered one of the important tools in measuring sexual self-concept and its various dimensions. The results obtained from the Iranian society indicate desirable and acceptable content validity. In this regard, the Chilean elderly version of SSC [51] reported results slightly higher than those obtained in the current study. This may reflect age-related differences, cultural perceptions, and variations in the evaluations of expert panels.
Furthermore, this research utilized convergent validity. Convergent validity assesses the quality of a measurement tool, which usually consists of a series of question-statements. A measurement tool demonstrates strong convergent validity if the question-statements (or alternative measures) related to each latent variable are interpreted by the respondents in the same manner as intended by the creators of those question-statements [52, 53]. In inspecting the convergent validity, the correlation of the total scale and dimensions of the Persian version of multidimensional scale of sexual self-concept with Persian version of the Snell sexual self-concept questionnaire had desirable and significant values, suggesting that the present tool has had appropriate and high convergent validity.
Further, in examining the reliability of this scale using the test–retest method [54], the Cronbach's alpha value was 0.946, representing high reliability. For this reason, the Persian adaptation of the Multidimensional scale of sexual self-concept is recognized as a valid and dependable instrument for assessing sexual self-concept, aligning with Ferrer-Urbina's original scale [15].
Additionally, confirmatory factor analysis was employed to examine the construct validity, where the factor loadings for 16 items were calculated within (0.99–0.4), indicating appropriate correlation of the items with common factors, and there was no need to remove any items. Cronbach's alpha and McDonald's omega coefficients were calculated for the entire scale and its dimensions, aligning with the results of the study by Ferrer-Urbina et al. [15]. The purpose of Cronbach's alpha is to measure the internal consistency of a scale [55]. Finally, the Omega coefficient was considered because it provides a comprehensive assessment of reliability. Omega coefficients are less likely to be misinterpreted and provide detailed outputs about the reliability of measures because of the transparent relationship between them. The selected analyses were therefore useful in enhancing the scale [56, 57].
In fact, sexual self-concept is a cognitive indicator which refers to the dimensions and aspects of individuals' sexuality and is known as the core of sexual desires. It also plays a significant role in sexual performance and predicting sexual outcomes. Thus, it seems appropriate as a valid and reliable tool which can accurately measure sexual self-concept and its dimensions as well as help improve our knowledge and understanding of this component [58, 59]. Although another scale of sexual self-concept has been validated in Iran in the past, the importance of revision is owing to the outdatedness of the scales and the growing socio-cultural changes in society. It is necessary to identify and update new questionnaires in the field of sexual self-concept. Furthermore, since Ferrer-Urbina’s scale was created recently and has only been applied in Chile, a more thorough analysis might be possible if it were applied in other nations as well.
The study had several limitations that should be acknowledged. Firstly, the present study has its non-generalizability to rural areas. It is recommended that the present scale be used as a new tool in other urban areas of West Azerbaijan Province. Secondly, fifteen percent of participants withdrew from the study. One reason for this could be that, in sensitive research topics such as sexuality, this implies that participants reveal private information, which leads to people not answering questions or leaving the research. That brings this to a close by using a larger sample of participants; further research could avoid this issue. Third, this study did not examine sexual self-concept in men and women separately. To obtain more precise and broadly applicable results, it is recommended that future researchers investigate this variable by accounting for gender differences.
Conclusions
It can be stated that the 16-item Persian version of Ferrer-Urbina Multidimensional scale of sexual self-concept has greater strengths compared to previous standardized sexual self-concept questionnaires in Iran, including the small number of items, being newer, high accuracy of questions, and capturing the participants' mental and physical exhaustion caused by the high number of questions. Another advantage of this questionnaire, unlike the original tool developed by Urbina and validated in the HIV-infected population, is that it can be applied to both healthy married men and women. In light of the aforementioned, psychologists can provide better services by using this scale to gain a more thorough understanding of their clients' sexual behaviors in healthcare settings.
Acknowledgements
The authors wish to thank all those who participated in this study or helped this study in any way.
Abbreviations
- MSSSC
Multidimensional scale of sexual self-concept
- CVR
Content validity Ratio
- CVI
Content validity index
- SPSS
Statistical package for social science
Authors’ contributions
DY planned the study and wrote the manuscript; MA, AA&NZ helped to plan the study and support the manuscript review; DY and NZ conducted the data analysis; DY made contribution to items creations and data collection; DY, MA, AA&NZ made contribution to the literature review and summarization. All authors read and approved the final manuscript.
Funding
The author(s) declare that no financial support was received for the research, authorship, and or publication of this article.
Data availability
All data generated or analyzed during this study are not publicly available due the restrictions from the ethics committee, but are available upon a reasonable request from the corresponding author.
Declarations
Ethics approval and consent to participate
This study was approved by The Ethics Council in Tehran University (approval number: IR.UT.PSYEDU.REC.1404.017). The participants were given full explanation about the study's aims and methods, as well as assurances that their participation was entirely voluntary and their information was Confidential. Written Informed consent was obtained from all subjects. All methods were performed by relevant guide lines and regulations including the Declaration of Helsinki.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
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Data Availability Statement
All data generated or analyzed during this study are not publicly available due the restrictions from the ethics committee, but are available upon a reasonable request from the corresponding author.