Nurse Caring Patient Scale (NCPS): Cross-Cultural Validation and Psychometric Testing of the Portuguese Version in Puerperal Context

Abstract

AIM

This study aimed to adapt and validate the Nurse Caring Patient Scale (NCPS) in a puerperal context to the European Portuguese.

Method

This research was a methodological study. The participant sample comprised 100 puerperal women, with an average age of 31.3 years (SD = 5.65), who attended a public hospital in southern Portugal. The instrument, originally consisting of 22 items, underwent translation, back translation, and semantic and colloquial conciliation. Ethical aspects have been respected.

Results

Factor analysis with varimax rotation revealed a set of 17 items with factor weights greater than .400. Three factors emerged, which explain 65.537% of the variance, namely “Being-at-the-Moment” (8 items), “Responsibility-for-the-Other” (5 items) and “Care-Diligent” (4 items). Reliability through Cronbach’s alpha coefficient in the total scale was .881, and in the subscales, ranged from .713 to .938. Precision was analyzed using the split-half method, reaching an alpha with Spearman-Brown correction of .900. The convergent validity between the instrument versus the discrete variable Care-Offered showed, in the total scale, a Spearman rho of .851 and in the subscales between .528 and .616. In the discriminating validity, the Mann–Whitney test revealed that Portuguese women, vis-à-vis foreign women significantly value the dimensions “Being-at-the Moment” and “Responsibility-for-the-Other” (p < .05), while in the “Care-Diligent” component, there are no significant differences (p > .05).

Conclusion

The European Portuguese version of the NCPS, in an obstetric context, has reliability and validity. A further study in a random sample and validation in other Lusophone countries will be appropriate.

Introduction

Care, in the practice of nursing, contains and transmits the ontological essence of the profession. Care conceives and explains the inherent nature of nursing through the provider–beneficiary relationship (Hansen & Jørgensen, 2020). This relationship is fundamental in the context of pregnancy–puerperal care (Darbyshire & Oerther, 2020; Power, 2015). Both for reasons of learning of maternage (Jeong & Kim, 2020), and for anatomical constraints dictated by bipedalism in the face of greater fetal robustness (Rosenberg & Trevathan, 2005, 2014), as well as for reasons of puerperal fragility (Negron et al., 2013), the need for support for women is justified (Darbyshire & Oerther, 2020).

Care is the first gesture of human existence (Santos et al., 2017), and professional care, offered by specialists, especially midwives, constitutes a valuable resource in healthcare. It displays the area of knowledge, defends the autonomy of the profession, its science and art (Power, 2015). These professionals exhibit skills to which puerperal women are sensitive, since they become the beneficiaries, analyzing or judging the proficiency of the care providers (Della-Monica & Connell, 2007; Power, 2015).

The professional skills of midwives are appreciated by the puerperal women both for instrumental reasons, as for their knowledge, availability, and readiness, and out of respect for the culture of origin of women, among others. On the theme of care skills, Nola Della-Monica elaborated a medium-range theory where he defines three components. Component one, labeled “presence and concern for others,” component two, referring to “respect for the person,” and component three, reporting to “competent and experienced care” (Della-Monica & Connell, 2007). The theory supports the Nurse Caring Patient Scale (NCPS), which addresses the competence of professionals from the perspective of the care beneficiary. As far as was possible, it is not validated in the Portuguese language, nor in the obstetric, puerperal, or other areas of action of midwives. This study aimed to adapt and validate the Portuguese NCPS in a puerperal context.

Researh Questions

Is the NCPS an instrument valid and reliable for Portuguese puerperal women?

Method

Study Design

This is a methodological study.

Sample

The participants were selected by convenience sampling, and were puerperal women attending a hospital in the South of Portugal. The estimated sample size was a minimum of four cases per NCPS item (Reeve et al., 2013). The inclusion criteria were written and spoken knowledge of Portuguese and age 16 years or older. Individuals who had undergone an obstetric urgency in peripartum phase were excluded. One hundred questionnaires were applied, and all 100 were completely filled.

The study was carried out in an academic context, to acquire a master’s degree in Maternal Health and Obstetrics Nursing (EVEN), which in the European domain is equivalent and designated as Matron, Sage-femme, and Midwife (Directive 2005/36/EC of the European Parliament and the Council of 7 September; M10; point 5.5.2 Midwife’s training titles).

Data Collection

The self-completed questionnaire was presented in paper format. The potential participants were invited at approximately 12 hours postpartum. In the approach, the research context was verbally explained. The women who showed willingness to participate were given the questionnaire in an opaque envelope. Completed questionnaires were collected at the end of the shift. The questionnaires were applied from March 10, 2019 to August 31, 2019.

Data Collection Tool

The questionnaire presented four sections. The first contained sociodemographic data (e.g., age, educational qualifications, household and employment situation). The second section was related to data from the pregnancy–puerperal cycle (e.g., type of delivery, pregnancy planning, number of children, and sex of the new born).

The Nurse Caring Patient Scale

The third section featured the NCPS (Della-Monica & Connell, 2007). The NCPS is a 22-item instrument, which focuses on the perspective of the user/patient/patients on the competence of nursing caregivers. Likert-scaled responses are scored from 0 (none) to 5 (always). In the original study, the scale has three dimensions: (a) Presence and Concern for the other (Cronbach’s alpha .89; 10 items: 1, 5, 16, 17, 25, 29, 38, 44, 48, 49); (b) Experience and Competence (Cronbach’s alpha .77; 5 items: 23, 27, 34*, 45, 46*), and (c) Respect for the Person (Cronbach’s alpha .73; 7 items: 2*, 3, 6, 9, 15*, 20*, 24*). The total score and subscales are obtained by calculating the mean.

In the third section, 10 variables were presented, which were dichotomized as 0 (no) and 1 (yes). They were reported to the perspective of the participants, stating the following indicators of care: (1) available time of the nurse to care of them, (2) concern for the patient, (3) provision in pain relief, (4) knowledge about the situation, (5) interaction with the patient, (6) communication with the patient, (7) active listening, (8) reassuring attitude, (9) offer of help, and (10) therapeutic touch. The sum generated a discrete variable called Care-Offered.

Statistical Analysis

Data analysis was done using the IBM Statistical Package for the Social Sciences (IBM SPSS Corp., Armonk, NY, USA) Software, Version 24. A 95% CI and significance level p < .05 were considered.

Statistical operations refer to descriptive, observed frequencies and percentages, as well as measures of central tendency. The factorial structure was analyzed, as well as other appropriate tests of validity and reliability, respectively (Almeida & Freire, 2017; Field, 2018; Moreira, 2009; Polit & Beck, 2020).

Ethical Considerations

The present study obtained approval from the Ethics Committee for Research in the Areas of Human Health and Well-being of the University of Évora (Registration NO 44989).

In respect of intellectual property (Della-Monica & Connell, 2007) and the obituary dating back to November 2014, permission was requested from the spouse of the original investigator. The spouse’s response by e-mail, addressed to the first author on February 28, 2019, granted permission to use the instrument. Written consent was obtained from participants.

Results

Language Validation

The linguistic validation process followed the guiding procedures (Almeida & Freire, 2017; Polit & Beck, 2020) described below. The initial translation was performed by a teacher and a nurse independently, both with mastery of the English language. The two translations underwent a conciliation process, with discussion between the two translators and one of the current authors. A professional back-translated version was requested, and the scale was placed under the consideration of a nursing professor, who made minor changes in colloquial adjustment. In a last procedure, the authors of the current research and the translators reconciled arguments and arrived at a final version. A group of ten women were pretested. A cognitive debriefing followed, which produced no changes in the instrument.

Sociodemographic and Obstetric Characteristics

Among the 100 participants, the mean age was 31.3 (SD = 5.65). The frequencies and percentages of the characteristic variables in the sociodemographic and obstetric scope were observed (Table 1). The indicators of the discrete variable, Care-Offered, are shown in Figure 1, with an average of 6.73 (SD = 2.37).

Table 1.

Sociodemographic, Obstetric Characteristics of the Participants and Indicators of Care-Offered

Variables	Categories	n (%)
Age (in years)	<18	3 (3)
	19–29	28 (28)
	30–34	43 (43)
>35	26 (26)
Nationality	Portuguese	92 (92)
	Brazilian	5 (5)
Angolan	3 (3)
Marital status	Single	26 (26)
	Married	71 (71)
Divorced	3 (3)
Schooling	First cycle	3 (3)
	Second cycle	21 (21)
	High school	41 (41)
	Degree	26 (26)
Mastership	9 (9)
Number of children	1 Child	57 (57)
	2 Children	32 (32)
3 or more	11 (11)
Family	Alone	6 (6)
	Couple	35 (35)
	With children	9 (9)
With a partner	50 (50)
Employment	Homemaker	57 (57)
	Unemployed	29 (29)
Seasonal work	14 (14)
Pregnancy planning	Yes	79 (79)
No	21 (21)
Birth type	Vaginal	49 (49)
	Vaginal-instrumental	21 (21)
Cesarean	30 (30)
Newborn’s gender	Female	40 (40)
Male	60 (60)
Total		100 (100)

Figure 1.

The Indicators of the Discrete Variable, Care-Offered.

Structural Validation

Factorial analysis on main components (FAMC) was performed with varimax rotation, forcing three factors, like in the original study (Della-Monica & Connell, 2007). Factorial weight equal to or greater than .40 was considered. Seven items had weight in more than one factor. Those whose difference was less than .100 (items 23, 44, and 46) were removed. AFCP was made, maintaining varimax rotation forced to three factors. Two items were revealed, whose factorial load difference was less than .100 (items 27 and 45), were removed and varimax rotation was made to three factors (Table 2). The instrument now has 17 items. The commonalities range from .788 to .362.

Table 2.

Component Loadings After Third Factorial Analysis with Varimax Rotation

	Rotated Component Matrixa
1	2	3
16. Os enfermeiros estavam presentes quando eu realmente precisava de um 16-My nurses were there when I really needed a nurse.	.866
17. Os enfermeiros estavam preocupados com o que eu estava a passar 17-The nurses were concerned about what I was going through as a patient.	.842
29. Os enfermeiros estavam disponíveis sempre que eu chamava por um 29-My nurses were available whenever I called for a nurse.	.834
38. Os enfermeiros confortaram-me quando eu precisei 38-The nurses comforted me when I needed it.	.814
25. Os enfermeiros estabeleceram uma ligação comigo 25-My nurses connected with me.	.803
48. Os enfermeiros foram pacientes comigo 48-The nurses were patient with me.	.783
49. Os enfermeiros foram amigáveis 49-The nurses were friendly.	.750	.471
9. Os enfermeiros ouviam-me 9-The nurses listened to me.	.700	.422
1. Os enfermeiros sabiam o que eu precisava 1-The nurses knew what I needed.		.782
3. Os enfermeiros trataram-me com respeito 3-The nurses treated me with respect.		.721
2. Os enfermeiros fizeram-me sentir como um objeto em vez de uma pessoa*2-The nurses made me feel like an object instead of a person.*		−.713
5. Eu podia confiar nos enfermeiros que cuidavam de mim 5-I could trust the nurses who cared for me.		.696
6. Os enfermeiros trataram-me como pessoa e não como doente 6-The nurses treated me as a person rather than an illness.		.552
20. Os enfermeiros eram indelicados comigo*20-The nurses were unkind to me.*			.794
34. Os enfermeiros eram incompetentes nos meus cuidados*34-The nurses were incompetent with my care.*			.761
24. Os enfermeiros eram insensíveis quando entravam no meu quarto*24-The nurses were unfeeling when they came into my room.*			.680
15. Os enfermeiros tratavam as máquinas no meu quarto em vez de mim*15-My nurses treated the machines in my room instead of me.*			.605

Note: Extraction Method: Principal Component Analysis.

Rotation Method: Varimax with Kaiser Normalization.

^aRotation converged in five iterations.

^*Reversed items.

The explained variance of the first factor is 42.21%, explaining the set of the three factors by 65.53% of the total variance of the measure (Table 3).

Table 3.

Total Variance Explained with 17 Items

Component	Initial Eigen Values			Extraction Sums of Squared Loadings			Rotation Sums of Squared Loadings
Total	% of Variance	Cumulative %	Total	% of Variance	Cumulative %	Total	% of Variance	Cumulative %
1	7.176	42.212	42.212	7.176	42.212	42.212	5.659	33.287	33.287
2	2.418	14.221	56.433	2.418	14.221	56.433	3.159	18.585	51.872
3	1.548	9.104	65.537	1.548	9.104	65.537	2.323	13.665	65.537
4	.963	5.664	71.201
5	.744	4.379	75.580
6	.638	3.751	79.331
7	.558	3.282	82.613
8	.545	3.205	85.818
9	.459	2.703	88.521
10	.393	2.314	90.834
11	.379	2.227	93.062
12	.328	1.927	94.988
13	.278	1.635	96.623
14	.246	1.445	98.068
15	.181	1.066	99.133
16	.100	.590	99.723
17	.047	.277	100.000

Note: Extraction Method: Principal Component Analysis.

The interpretation of the organization of the factors in the round matrix suggests the following. Component 1: consisting of eight items (9, 16, 17, 25, 29, 38, 48, and 49), suggesting the meaning of “Being-at-the-Moment” (Hemberg & Wiklund Gustin, 2020). Component 2, with five items (1, 2, 3, 5, and 6), suggesting the meaning of “Responsibility-for-the-Other” (Hemberg & Wiklund Gustin, 2020). Component 3, consisting of four items (15, 20, 24, and 34), suggesting the meaning of “Care-Diligent” (Griffith, 2020).

For better clarification of the construct, parallel­ analysis was used through syntax. The empirical own values of the matrix were considered in relation to the random data. Three factors emerged, whose magnitude of variance was higher in the empirical matrix, revealing a three-dimensional instrument (Figure 2).

Figure 2.

Parallel Analysis of the Variance of Empirical and Random Factors.

Reliability Analysis

The reliability of the NCPS in the current version with 17 items, was observed through the item-total correlations and Cronbach’s alpha coefficient. The item-total correlations ranged from .893 to .866. Cronbach’s alpha coefficient of the total scale was .881. In the subscales, the highest Cronbach’s alpha coefficient was in the “Being-at-the-Moment” component (.938), followed by “Responsibility-for-the-Other” (.764) and “Care-Diligent” (.713), as shown in Table 4.

Table 4.

Total Correlations and Cronbach’s Alpha of the Nurse Caring Patient Scale

Component	Description	Corrected Item-Total Correlation	Cronbach’s Alpha if Item Deleted	Cronbach’s Alpha
1	Being-at-the-Moment
	16. My nurses were there when I really needed a nurse.	.607	.871	.938
	17. The nurses were concerned about what I was going through as a patient.	.725	.867
	29. My nurses were available whenever I called for a nurse.	.594	.872
	38. The nurses comforted me when I needed it.	.550	.873
	25. My nurses connected with me.	.669	.869
	48. The nurses were patient with me.	.765	.867
	49. The nurses were friendly.	.777	.867
	9. The nurses listened to me.	.751	.866
2	Responsibility-for-The-Other
	1. The nurses knew what I needed.	.300	.882	.764
	3. The nurses treated me with respect.	.659	.872
	2. The nurses made me feel like an object instead of a person.*	.558	.874
	5. I could trust the nurses who cared for me.	.630	.873
	6. The nurses treated me as a person rather than an illness.	.435	.878
3	Care-Diligent
	20.The nurses were unkind to me.*	.453	.879	.713
	34.The nurses were incompetent with my care.*	.096	.893
	24.The nurses were unfeeling when they came into my room.*	.471	.877
	15.My nurses treated the machines in my room instead of me.*	.200	.886

A split-half test was performed to evaluate the accuracy of the instrument, introducing even items versus odd items. Cronbach’s alpha value in the first half was .728, and in the second half it was .852, with the correlation coefficient between forms being .818. The alpha value with Spearman-Brown correction was .900.

Construct Validity

In construct validity, the NCPS sections requiring facial and content validity were filled in 10–12 minutes, without any questioning.

Before continuing the analysis, a Kolmogorov–Smirnov test was performed with Lilliefors correction, to test the normality of the NCPS variable and the three components. It was observed that the NCPS has normal distribution (KMO = .083; p = .087), but component 1, “Being-at-the-Moment” (p = .014), component 2, “Responsibility-for-the-Other” (p < .001), or component 3, “Care-Diligent” (p < .001) do not follow normal distribution. Thus, non-parametric analysis was chosen in the following operations.

In convergent validity, the association was strong and significant between the discrete variable Care-Offered versus the total NCPS (n = 100; rs = .851 p < .001), component 1, “Being-at-the-Moment” (n = 100; rs = .735 p < .001), component 2, “Responsibility-for-The-Other” (n = 100; rs = .616 p < .001), or component 3, “Care- Diligent” (n = 100; rs = .528 p <.001).

The discriminant validity was verified through a Mann–Whitney U test, which, in the “Being-at-the-Moment” component, a higher average of ordering was observed in the Portuguese participants (n = 92; Mean Rank = 52.57) than in foreign ones (n = 8; Mean Rank = 26.69) with significant differences (U = 177.500; Z = −2.427; p = .015). The same was observed in the “Responsibility-for-The-Other” component, with a higher average, also in the Portuguese participants (n = 92; Mean Rank = 52.23) than in the foreign participants (n = 8; Mean Rank = 30.62), maintaining significant differences (U = 209.000; Z = −2.058; p = .040).

However, in component 3, “Care-Diligent,” although without significant differences (U = 478.500; Z = 1.444; p = .149), the highest mean of ordination was in foreign participants (n = 8; Average Rank = 64.31 versus n = 92; Average Rank = 49.30, respectively). Considering the total scale, the differences are not significant (U = 222.500; Z = −1.850; p = .064), although the highest average of ordering is in the Portuguese participants (n = 92; Average Rank = 52.08 versus n = 8; Average Rank = 32.31, respectively).

Discussion

Considering the current sample size, the number of cases may be controversial, and necessitates a discussion. Some studies consider two to four subjects per item (Reeve et al., 2013). On the other hand, the criterion of 5–10 cases per item is the most observed quantification in validation studies (Polit & Beck, 2020). Although the sample size may skew the results, there is no consensus or minimum standard when the sample is centered on patients/patients (Reeve et al., 2013). In validation studies, the number of cases can reach two or four per item (Anthoine et al., 2014). Safeguard, the verification of assumptions, ensured the sample adequacy in the current study.

The request for permission from the original authors is an open discussion. There is no consensus (Hays et al., 2018), but it is a practice of courtesy, ensuring ethical principles, based on respect for the intellectual property of the original author. The fact that the author of the NCPS (Della-Monica & Connell, 2007) was deceased was not an obstacle, ensuring the continuity of the study of the construct and respect for her memory.

Structural Validation

After confirming the adequacy of the sample, the structural validation analysis had a KMO above .500 (2018). Varimax rotation was applied, given the multidimensional perspective of the original study, as it was important to maximize high correlations and minimize low correlations. The orthogonal solution underlined the independence of the manifest variables (Field, 2018; Dancey & Reidy, 2019; Moreira, 2009). The variance explained in the three-component model does not reach 75%, but exceeded minimums of 50% (Dancey & Reidy, 2019; Field, 2018). The results contribute to the original study (Della-Monica & Connell, 2007), occurring in the current highest percentage of explained variance.

“Be-at-the-moment” component: The interpretation of the items suggests the patient’s perspective on care readiness. It reveals the perception of immediacy and professional availability to offer care. The concept of “Being-at-the-Moment,” by making the patient the center of care, creates in the component a space for active listening about the lived experience (Hemberg & Wiklund Gustin, 2020). Sometimes, it is the moments of silence, the therapeutic touch, or the urge to feel accompanied. The “Being-at-the-Moment” component is part of special moments in life, as it is to accompany in labor, the birth of a child. In fact, the obstetric dilemma resulting from bipedalism (Rosenberg & Trevathan, 2005, 2014) leads to feelings of insecurity in women. Thus, the availability of the professional perhaps underlines, in an obstetric framework, the beneficiary–caregiver link in the singular and unrepeatable “Being-at-moment.”

“Responsibility-for-the-Other” component: In this set of six items, the patient’s perception is revealed, in view of the fulfillment of the Legis Artis by the professional, in the autonomy that is proper to her (Zolkefli et al., 2020). It recognizes, perhaps, that trust in the professional leads to expectations of competent performance. Safety in care, in the patient’s view, will be in professional knowledge, because they dominate matters which respond to individual needs (Hemberg & Wiklund Gustin, 2020), particularly in each singular experience that is lived by each woman in the obstetric context.

“Diligent-Care” component: Although the component may be cumbersome, it is necessary to consider it in the instruments that treat the perception of puerperal women. Being diligent, is reported to be the careful and attentive look, with the intention of identifying the needs and concerns of patients. Diligent nurses are fundamental to the success of care (Power, 2015; Watkins et al., 2016), particularly in a limited situation, in a crisis environment (Ivry et al., 2019), underlining patient-centered care. On the other hand, negligence refers to not using care which one would, prudently and courteously, in similar circumstances (Weld & Garmon Bibb, 2009). Inattention and indolence are examples of neglect, and are characteristics different from lack of expertise, which refers to lack of technique (Griffith, 2020). Negligence is considered a violation of human rights, disrespecting the patient’s need for compassion and dignity (Reader & Gillespie, 2013). Negligence is subject to litigation, and is an important reason for abandoning the profession of midwifery, of one’s own free will or by legal imposition. Cases of negligence litigation are part of the public domain and lead to feelings of insecurity in obstetric users (Robertson & Thomson, 2016).

The use of parallel analysis through syntax is not frequent in validation studies. In the present case, the first validation of the NCPS for the Portuguese European Commission required this commitment to clarify the factoriality of the instrument. The three factors are independent in orthogonal rotation.

Reliability

The reliability analysis revealed results approximated to the original study (Della-Monica & Connell, 2007), but slightly lower. The results suggest that the agreement between the items, displayed by Cronbach’s alpha coefficient, is adequate, although the number of factors has been decreased. This slight drop was expected, since with fewer items, the coefficient scores tend to decrease (Dancey & Reidy, 2019; 2018). In the item-total correlations, the values were satisfactory and proved the measurement of the same construct.

After a single application of NCPS, the accuracy of the instrument was observed through the split-half test with Spearman-Brown correction, without retesting, The alternating order of even/odd items ensured the reduction of the position effect (Maroco & Garcia-Marques, 2006).

Some authors argue that retesting may bring greater divergence in responses compared to the split-half analysis, because it is subject to memory bias that the researcher does not control. This effect is mainly present in variables like those in the current study, such as perceptions, opinions, or attitudes (Moreira, 2009).

Validation

The convergent validation, observed through Spearman’s rho, between NCPS and Care-Offered, shows adequate association coefficients. The expected positive association was about .600 (Almeida & Freire, 2017; Field, 2018), although the “Care-Diligent” component was lower.

The discriminating validity observed through non-parametric tests has curious results, since they tend to differentiate between Portuguese and foreign participants. This suggests that the phenomena in the obstetric field are lived with a cultural burden to consider. Portuguese women value above all the dimensions of “Being-at-the-Moment” and “Responsibility-for-the-Other”, while foreign women tend to value the “Care-Diligent” component. Thus, comes the idea of the vulnerability of ethnic minorities in health systems. These results agree with other studies, where worse experiences of foreign women in maternity care are observed (Raleigh et al., 2010). The posture in care or communication with the obstetric patient are still weaknesses in the health services. This is contradictory to the spirit of the National Health Service, which in its own document (Information Circular No. 12/DQS/DMD of May 7, 2009), disclosing the equality of care between national women and immigrants, who, as beneficiaries for reasons of maternity or reproductive health, receive free care in the country.

Conclusion and Recommendations

The results show that NCPS is a reliable and valid measure that can be applied in a puerperal context, in Portuguese. The validated components implied restructuring of the instrument, applying it to Portuguese culture. The “Being-at-the-Moment” component is based on the recognition of a beneficiary–caregiver relationship, on the readiness to respond to women’s needs. The “Responsibility-for-The-Other” component implies the recognition by the patient of professional autonomy, of the ability to make appropriate decisions, according to knowledge in the area. The “Care-Diligent” component reveals the importance of the patient feeling recognized as a natural person and user with her own right. Such components, in the perception of the puerperal, are particularly important, as they will be linked to memories of personal history, in the sublime moments of life.

An instrument is available that allows the development of the theme in the Portuguese. It contributes to the approach of the construct in the clinic, simultaneously offers opportunity for further research, and a moment of learning is realized in the second cycle of nursing education. It will be useful to conduct studies in a larger, random sample, covering women from other parts of the country and in other Lusophone obstetric contexts. A validated version will bring in conditions to study the subject in different regions and larger groups.

Ethics Committee Approval

This study was approved by Ethics Committee for Research in the Areas of Human Health and Welfare at the University of Évora (Approval Date: 4/12/2018 Approval No: 44989).

Informed Consent

Written informed consent was obtained from women participants.

Author Contributions

Concept – A.G., M.S.S.; Design – A.F., M.S.S.; Supervision – A.F.; Resources – A.G.; Materials – A.F., M.S.S.; Data Collection and/or Processing – A.G., A.F.; Analysis and/or Interpretation – A.G., M.S.S.; Literature Search – A.G., A.F., M.S.S.; Writing Manuscript – A.G., M.S.S.; Critical Review – A.G., A.F., M.S.S.

Funding Statement

The authors declared that this study has received no financial support.