Introduction
According to the world cancer statistics, cancer cases
9.6 million cancer deaths and 18.1 million new cases
occur annually.[] The International Agency for Research
on Cancer estimates that cancer cases will rise to
22 million by 2030.[] It is reported that the prevalence
of cancer in the world is 20%. It is 270/100 thousand
in males, 173/100 thousand in females, and 222/100
thousand in the total population in Turkey. According to the 2009 data of the National Cancer Report of the
Turkish Academy of Sciences, it is stated that nearly
160,000-180,000 new cancer diagnoses are made every
year in Turkey and these values are above the world average.[] The prevalence of mental disorders in cancer
patients varies between 30% and 60%.[-]
Individuals diagnosed with cancer can be diagnosed
with adjustment disorders, depressive syndromes,
panic disorder, phobias, and post-traumatic
stress disorder (PTSD) during the illness, and they may experience emotional problems such as social isolation,
insecurity, lack of empathy, impending death/
guilt thought, dysphoric mood similar to depression,
and loss of sleep quality.[-]
Life-threatening diseases are evaluated under the title
of PTSD in DSM-5 diagnostic criteria. Due to being
life-threatening, the diagnosis of cancer is a cause of
mental trauma.[-] Traumas negatively can affect
the individual's sense of security, sense of control, self-
-regulation, interpersonal relationships, and stress responses
and can reveal mental health problems.[,]
In a study conducted with cancer patients, the rate of
PTSD was found to be 19%. In the present study, the
PTSD ratio of patients receiving chemotherapy was
higher than those who did not.[] Cognitive functions
and cognitions are important in patients diagnosed
with cancer. Cancer-related cognitive impairment is
one of the important issues affecting the quality of life.
The clinical prevalence of cognitive impairment due to
cancer diagnosis and especially cancer treatment varies
between 17% and 75%. Despite the high prevalence of
cognitive impairment, diagnosis and treatment remain
largely inadequate.[]
Cognitions in trauma and cancer disease processes
are similar, and these cognitions are listed as intense
fear and helplessness.[] Cognition is a process including
the interpretation of sensory inputs, their storage in
memory, and their re-evaluation as a result of a critical
and logical approach.[]
The emergence of a traumatic experience devastates
the most basic beliefs of the person, basic assumptions
about the world, oneself, and others.[] While individuals
struggle with trauma (diagnosing cancer and
receiving cancer treatment), they realize a cognitive,
emotional, and behavioral transformation.[] Traumas
negatively affect an individual's assumptions and
basic beliefs. It is stated that traumatic events negatively
affect individuals" sense of bonding, meaning, control,
and existing coping mechanisms and cause the person
to experience extreme helplessness and horror.[] At
the point of giving meaning to the difficult event and
making sense of the sensations, the individual's "assumptions
about the world" come to the fore. World
assumptions are defined as "a concept implicating the
safety and well-being of the person."[]
Individuals suffering from cancer are defined as a
special group in need of nursing care.[,] In the relevant
study, the cancer patients considered the nursery
as a fundamental and valuable contribution to their
well-being.[] Nevertheless, it was also reported that
nurses who constantly communicate with the patients focus on the increase of the nursery quality of the individuals
who are diagnosed with cancer.[] Consultation-
liaison psychiatry (CLP) is one of the substantial
approaches to psychosocial care. CLP nurse is a fundamental
mental health professional who undertakes an
active role in evaluating and managing both the mental
and emotional problems caused by physical symptoms
and the effective cognitive and perceptual processes in
the emergence of these problems. Thus, this study aims
to evaluate the traumatic cognitions that can lead to
mental disorders in cancer cases and the assumptions
of patients who can change with the disease process,
about themselves, events, and the world.
Study Questions
• What are the traumatic cognitions of cancer patients
and their assumptions about the world?
• Is there a relationship between cancer patients"
traumatic cognitions and their assumptions about
the world?
• What are the factors that affect cancer patients" traumatic
cognition and assumptions about the world?
Methods
Sample and Recruitment
This is a single-center, descriptive, and correlationseeking
study. The target population of the study consists
of all patients hospitalized in Ankara University
Faculty of Medicine Cebeci Application and Research
Hospital Oncology and Hematology Departments. No
sampling selection was made, and all cancer patients
between the ages of 18 and 65 who consent to participate
in the study and hospitalized in Ankara University
Medical Faculty Cebeci Application and Research
Hospital Oncology and Hematology departments between
May 2016 and January 2017 were included in the
study. The sample was selected by simple random sampling.
The sample of the study was 249 patients. There
is no data loss in this study.
Post hoc power analysis was performed to determine
the adequacy of the sample size. In the power
analysis made considering the correlation coefficient
of 0.565 between the total scores of the scales, it was
determined that the study with 95% confidence (1-α),
249 sample numbers had 100% test power (1-Β). This
result indicates that the sample is sufficient.
Inclusion Criteria
Being between 18 and 65 years old, being diagnosed
with cancer for at least 6 months, being inpatient, being literate, conscious patients, Turkish speaking patients,
and patients without communication problems were
included in the study.
Exclusion Criteria
Being younger than 18, older than 65, not being diagnosed
with cancer, not receiving inpatient treatment,
patients diagnosed by a psychiatrist, patients with
autoimmune disease, patients receiving high-dose
chemotherapy, and being illiterate were excluded from
the study.
Data Collection Procedure
The data were collected using the "Personal Information
Form," "Post-Traumatic Cognitions Scale (PTCS),"
and "World Assumptions Scale (WAS)."
Introductory Information Form: It is a form consisting
of ten questions about the sociodemographic
and disease characteristics of the participants.
PTCS
This is a seven-point Likert scale consisting of 36 items
and it has been developed to evaluate traumatic cognitions
considered effective in the emergence and duration
of PTSD. The score interval of the scale is between 36
and 252. Higher scores on the scale indicate an increase
in negative cognitions about the traumatic experience.
[] It was adapted to Turkish by Yetkiner (2010).[]
The scale has three sub-scales: Negative cognitions
about oneself, negative world cognitions, and self-reproach.
Cronbach alpha reliability coefficient of PTCS
was found 0.95 for the whole scale, 0.95 for the "negative
cognitions about oneself" sub-scale, and 0.89 for the
"negative cognitions about the world" sub-scale. In this
study, the Cronbach alpha reliability coefficient of PTCS
was found to be 0.96 for the whole scale, 0.95 for the
"negative cognitions about oneself" sub-scale, 0.85 for
the "negative cognitions about the world" sub-scale, and
0.82 for the "self-reproach" sub-scale.
WAS
The scale was developed by Janoff-Bulman (1989) in
a seven-factor structure with 32 items to measure the
basic assumptions about the world of individuals with
and without traumatic life events. The internal consistency
coefficients of the original form of the scale
ranged from 0.66 to 0.76 for the sub-scales.[] The
scale was adapted to Turkish by Yılmaz (2008) and the
number of items in the scale was decreased to 25, and
the factor number was decreased to 6. This is a sixpoint Likert scale.[] This scale has six sub-scales,
namely, belief in personal fortune, belief in the goodness
of the world, belief that events can be controlled
in advance, belief that life is based on chance, positive
self-belief, and belief that the world is fair. İtems 5, 13,
and 24 are reverse coded in the Turkish version. The
analysis result of the adaptation study stated that the
Cronbach alpha reliability coefficient varied between
0.81 for the whole scale and 0.63?0.85 for the sub-scales.[] In this study, the Cronbach alpha reliability
coefficient of the scale ranged from 0.90 for the "total
world assumptions" and between 0.58 and 0.85 for the
relevant sub-dimensions.
Ethical Approach
The study was conducted in Ankara University Medical
Faculty Cebeci Application and Research Hospital
Oncology and Hematology Departments under
the written consent obtained from Ankara University
Faculty of Medicine Dean's Office (dated 16.02.2016,
numbered 93984376-044/E.7794). Ethics committee
approval was obtained from the Ordu University Ethics
Committee (dated 01.04.2016, numbered 2016/18).
The present study was explained to the participants
and written consents of the participants were obtained
from the individuals.
Data Analysis
The compliance of the data to normal distribution was
tested with the Shapiro-Wilk test. Mann?Whitney
U-test was used to compare abnormally distributed
features in two independent groups, and the Kruskal-
Wallis test and all pairwise multiple comparison tests
were used for comparison of more than two independent
groups. Correlation between numerical scales
was tested with the Spearman correlation coefficient.
Cronbach alpha coefficients were calculated to ensure
validity and reliability. Mean±standard deviation for
numerical scales, number, and % values for categorical
scales was provided as descriptive statistics. A statistical
package program was used for the statistical analysis
and p<0.05 was considered statistically significant.
There is no data loss in this study.
Results
According to the results obtained, of the participants,
34% are 55?65 years old, 52% are male, 71% are married,
33% are high school graduates, and social security of
49% of the patients is SSK. Of the participants, 52% had
not received any help for their mental problems before, 33% were diagnosed with acute/chronic leukemia, 83%
did not have a stem cell transplant, and 96% did not have
an organ transplant. The average age of the participants
is 46.03±13.15; the year of diagnosis is 2.63±3.42 years
and varies between 0 and 20 years (Table 1).
Table 1 Distribution of descriptive characteristics of the participants
The difference between the mean scores of the "selfblame"
sub-scale of the PTCS was statistically significant in terms of age groups (p<0.05). A significant difference
is found regarding the 45-54 age groups.
Table 2 shows the comparison of the mean scores of
the post-traumatic cognitions sub-scale of the participants
according to the distribution of disease characteristics.
These data indicate that the difference between
the total score of the PTCS and the mean scores of all sub-scales is statistically significant in terms of the participant
diagnoses (p<0.05). It was determined that the
disease group with the highest mean total score on the
PTCS was breast-lung cancer, and the lowest was lymphoma.
In terms of getting help for mental problems,
both the PTCS total score average and the difference
between the mean scores of all sub-scales are statistically
significant (p<0.05). PTCS total score averages of
the patient group who received help for their mental
problems were determined to be higher.
Table 2 Comparison of post-traumatic cognitions scale (PTCS) sub-dimension mean scores according to the distribution
of disease characteristics of the participants (n=249)
In terms of years of diagnosis, the difference between
the total score of the PTCS and its sub-scales
"negative cognitions about oneself" and "negative
cognitions about the world" is statistically significant
(p<0.05). The significant difference is due to the group,
whose year of diagnosis is between 1 and 5 years. In
terms of receiving stem cell transplants, the difference between the mean total score of the PTCS and the
"negative cognitions about the world" scale mean score
is statistically significant (p<0.05). It was determined
that the significant difference was caused by the group
without stem cell transplantation.
In terms of having organ transplants, the PTCS total
score mean and the difference between "negative
cognitions about oneself " and "negative cognitions
about the world" sub-scale mean scores are statistically
significant (p<0.05). It was determined that the significant
difference was caused by the group having organ
transplantation.
Table 3 shows the comparison of the WAS total score
and sub-scale mean scores according to the descriptive
characteristics of the participants. Accordingly, in terms
of the gender of the participants, the "belief that events
can be controlled in advance" scale mean scores was found to be statistically significant (p<0.05). In terms
of the marital status of the participants, the difference
between the scale means score of "world assumptions,"
"belief in the goodness of the world," and "belief that
events can be controlled in advance" is statistically significant
(p<0.05). In terms of the social security of the
participants, only the "belief that the world is fair" scale
of the scale of world assumptions showed a statistically
significant difference (p<0.05).
Table 3 Comparison of the world asumptions scale (WAS) sub-dimension mean scores according to the descriptive characteristics of the participants (n=249)
Table 4 shows the comparison of the total mean
scores of the WAS and the mean scores of its sub-scales
according to the distribution of the disease characteristics
of the participants. According to these data, the
total mean scores of the WAS, "belief in personal fortune,"
"belief in the goodness of the world," and "belief
that the world is fair" in terms of the diagnoses of the
participants, showed a statistically significant difference
(p<0.05). The significant difference is due to the group,
whose year of diagnosis is between 1 and 5 years. The
disease group with the lowest total means score on the
scale is lung-breast cancer, while the disease group with
the highest total mean score is multiple myeloma (MM).
Table 4 Comparison of the sub-dimension mean scores of the world assumptions scale (WAS) according to the distribution of the disease characteristics of the participants
(n=249)
In terms of getting help for the mental problems
of the participants, scale mean scores of "belief in
the goodness of the world" and "positive self-belief "
showed a statistically significant difference (p<0.05).
The total score averages of the WAS of the patient
group who received help for their mental problems
were found to be lower. In terms of the participants
having organ transplants, the mean score of the "positive
self-belief " scale showed a statistically significant
difference (p<0.05). The mean scale scores of those
who had organ transplants were found to be lower.
According to Table 5, a moderate negative correlation
between the total score of the WAS and the total
score of the PTCS, negative cognitions about oneself,
and the negative cognition about the world sub-scale
in the negative direction was determined, and a weak
correlation with the self-blame sub-scale was detected
(p<0.05). In terms of the PTCS total score of belief in
personal fortune sub-scale, a moderate negative correlation
was found between negative cognitions about oneself
and negative cognitions about the world, and a weak
correlation with the self-blame sub-dimension (p<0.05).
Post-traumatic cognitions total score of the positive self-
-belief sub-scale and negative cognitions about oneself
were moderately significant negatively; negative cognitions
about the world sub-scale and self-blame sub-scale
were negatively weakly correlated (p<0.05).
Table 5 Relationship between post-traumatic cognitions scale (PTCS), world assumptions scale (WAS), and sub-dimension
mean scores
Table 5 shows the total mean scores of the PTCS
and the WAS. According to these data, the participants obtained 134.53±38.36 total points from the PTCS;
they obtained 70.77±24.18 points from the "negative
cognitions about oneself " sub-scale, 37.51±9.63 from
the "negative cognitions about the world" sub-scale,
and 16.84±6.67 from the "self-blame" sub-scale. For
the WAS, participants received 87.95±16.84 points as a
total score; they got 12.30±5.44 from the "belief in personal
fortune" sub-scale, 16.14±6.29 from the "belief in
the goodness of the world" sub-scale, 20.20±4.34 from
the "belief that events can be controlled in advance"
sub-scale, 12.51±4.28 from the "belief that life is based
on chance" sub-scale, 17.42±3.26 from the "belief in
positive memory" sub-scale, and 9.36±3.62 from the
"belief that the world is fair" sub-scale.
Discussion
Mental health issues are common in cancer patients,
with a frequency varying between 30% and 60% [-]
When the meaning attributed to cancer by the individual
interacts with the meaning, he/she attributed to the
world, events, his/her self (world assumptions), and
negative cognitions (being traumatic); these mental
health issues can worsen and can become chronic.
The mean PTCS total score in this study was found
to be 134.53±38.36, "negative cognitions about oneself"
at 70.77±24.18, "negative cognition about the world" at
37.51 ± 9.63, and "self-blame" at 16.84±6.67. In a study
conducted with individuals with various traumatic experiences,
including cancer patients; for the PTCS, the
mean score was 121.05±40.45, "negative cognitions
about oneself" was 3.51±1.29, "negative cognitions
about the world" scale mean score was 4.84±1.26, and
"self-blame" scale mean score was 2.70±1.90.[] According
to a study conducted with women who were
subjected to partner abuse and endured traumatic experiences,
the mean score of the "self-blame" scale was
found to be 18.75±7.75, and the mean score of "negative
cognition of oneself" was found to be 72.66±29.61.
[] According to a study carried out with veterans who
were experienced military trauma, the PTCS total score
was 129.2±41.8.[] In a study of stillbirth women, the
mean score of "negative cognitions about oneself" was
64.12±31.44, the mean score of the "self-blame" scale
was 14.60±7.33, and the mean score of "negative cognitions
about the world" was 22.74±11.17.[33] Studies
in the literature and the results obtained from this study
indicate that cancer patients have higher mean scores
in terms of traumatic cognitions and sub-scales compared
to individuals with other traumatic experiences.
The difference is considered to be because the experience of suffering from cancer may involve more than
one trauma during the diagnosis and treatment process,
some of which are complex and repetitive, and cancer
is perceived as an "internal" threat rather than external
risks resulting from attacks and natural disasters.[,]
The uncertainty, fear of potential mortality in the future,
and the risk of cancer recurrence or metastasis
may lead the individual diagnosed with cancer to experience
constant fear, anxiety, and panic.[-] Thus,
cancer trauma differs from other types of trauma, and
it is thought that this circumstance may be the reason
why individuals diagnosed with cancer experience more
negative cognitions. Sheerin et al. (2018)[] found that
the mean score of "negative cognitions about oneself"
was 42.84±19.74, the mean score of "self-blame" was
9.4±5, and the mean score of "one"s negative cognitions
about the world" was 29.33±9.17 in his study with victims
of war trauma. Chung and Reed (2017)[] found
that the mean score on the "negative cognitions about
oneself" scale was 64.12±31.44, the mean score on the "self-blame" scale was 14.60±7.33, and the mean score
on the "negative cognitions of the person about the
world" scale was 14.60±7.33. When the mean scores of
the scales from both types of research are compared, it
is clear that the people in our study have more negative
thoughts. This disparity is thought to be because the
cancer experience may include multiple traumas during
the diagnosis and treatment process, some of which are
complex and repetitive, and that cancer is perceived as
an "internal" threat in contrast to external threats such
as terrorist attacks and natural disasters.[,] Furthermore,
due to the uncertainty of the illness"s future, the
potential fear of death, and the chance of recurrence or
metastasis, an individual diagnosed with cancer may experience
persistent worry, anxiety, and panic.[-]
In this study, the year of diagnosis was found to
have a statistically significant difference in, both posttraumatic
cognitions total score and "negative cognitions
about oneself " and "negative cognitions about
the world" sub-scale mean scores (p<0.05). In a study with lung cancer patients, a higher rate of depression
was discovered during the first 0-5 years.[] In another
study on the subject, the duration of exposure
to traumatic experience was found to be statistically
insignificant (p>0.05).[] In this study, it is thought
that the reason for the significant difference appearing
within 1-5 years is the diagnosis of cancer and the difficulties
of adjusting to the process in the early years.
In this study, patients with organ transplants had a
higher total score on the PTCS, and patients with stem
cell transplants had greater world assumptions than
those who had not undergone any transplant surgery.
In a study of stem cell transplant patients, it was discovered
that the rates of sadness (43.3%) and PTSD
(28.4%) increased in the first six months. These data
suggest that stem cell and organ transplantation have a
deleterious impact on cognition, perception, and mental
health.[]
The overall score of the participants on the PTCS, as
well as the mean scores of all sub-scales, was found to
be statistically significant (p<0.05) for all diagnoses in
this study. Lung-breast cancer was the diagnosis group
with the most unfavorable cognition. In this study, the
"belief in the goodness of the world" sub-scale was
16.14±6.29, the "belief in the world is fair" sub-scale
was 9±3.62, the "belief in the ability to control events
in advance" sub-scale was 20. 20±4.34, the "belief in
personal fortune" sub-scale was 12.30±5.44, "belief in
life is based on chance" sub-scale was 12.51±4.28, "positive
self-belief " was 17.42±3.26, and WAS total score
was 87.95±6.84. A statistically significant difference
was found between the diagnoses of the participants
and the mean scores of the PTCS total, all sub-scales
of PTCS, and the sub-scales of WAS regarding belief in
personal luck, belief in the goodness of the world, and
belief that the world is fair (p<0.05). In a study conducted
with patients diagnosed with cancer, the "belief
in the goodness of the world" sub-scale was 19.1±4.1,
the "belief in the fairness of the world" sub-scale was
11.2±4.7, the "belief that events could be controlled
in advance" sub-scale was 12.9±4.1, the "belief in personal
fortune" sub-scale was 18.0±4.7, the "belief that
life-based on chance" sub-scale was 15.1±4.4, and "optimistic
self-belief " was 21.3±3.8 points.[] In relation
to the subject, the study of Yom Kippur conducted
on prisoners of war yielded the world assumption scale
total score of 118.36±17.03. A difference was found between
the diagnosis groups according to the WAS total
score, "benevolence of the world," "meaningfulness
of the world," and "self-worth sub-dimension" scores
(p<0.01).[] In their study with war victims, "belief in the goodness of the world" was 24.12±3.85, "belief
in the fairness of the world" was 23.6±8.48, "belief that
events can be controlled in advance" was 10.92±3.15,
"belief in personal fortune" was 16.28±3.58, "belief
that life is based on chance" was 22.62±5.16, and "positive
self-belief " was 19.56±3.4 points.[] These studies
show that being a cancer patient has a significant
negative impact on one"s assumptions about the world.
In the literature, it is stated about the issue that it may
be related to the fact that cancer is inherently a lifethreatening
disease suggesting the consciousness of
death; the experience of suffering from cancer also entails
that there is uncertainty about prognosis, optimal
treatment, the likelihood of nonresponse to treatment,
and possible future effects; and it is stated that it may
be correlated to the progression of the disease and the
constant presence of fear of relapse.[,]
The overall score of the participants on the PTCS,
as well as the mean score of all sub-dimensions, was
statistically significant for all diagnoses (p<0.05) in
this study. Lung-breast cancer received the maximum
negative cognition score of 158.61±36.65 points; while
lymphoma received the lowest score of 113.05±30.43
points. El-Jawahri et al. (2015)[] found that using
cognitive behavioral therapy techniques to patients
during their hospitalization helped lessen sadness and
PTSD symptoms within 6 months after transplantation
in their study with cancer patients who got stem cell
transplantation. Both investigations show that they are
related.
The belief level of men (x±SD: 20.7±64.28) that
events can be controlled ahead of time was found to
be significantly greater than that of women (x±SD:
19.58±4.35) in this study, with a statistical difference
(p<0.05). According to Erkmen"s (2017) research with
trauma victims, men"s "belief in the goodness of the
world" is significantly higher than women"s, men"s belief
in the controllability of events is significantly higher
than women"s, and men"s belief in the fairness of the
world is significantly higher than women"s (p<0.05).
[46] Tüfekçi (2011) found that males have considerably
greater levels of belief in the goodness of the world, belief
in the fairness of the world, belief in personal luck,
and believe in control than females in his study of people
who had a traffic accident regarding the world. It
can be seen that the substantial difference in favor of
men found in this study between world assumptions
and gender is consistent with the findings of other investigations.[] This assessment also highlights the
fact that the interaction between worldview beliefs,
which have been shown to play a role in mental health, and the structural factors that contribute to inequity in
gender roles and women"s powerlessness, is a different
issue that needs to be addressed.
Post-traumatic cognitions of organ transplant participants
had a mean total score of 162.44±28.07 for
those who had the transplant, 133.48±38.34 for those
who did not, 88.561±5.68 for those who had "negative
cognitions about oneself," and 70.10±24.21 for
those who did not have a "negative cognition about
the world" in this study. Those with "cognition" scored
43.67±6.42, while those without scored 37.28±9.66.
Those who had their organs transplanted scored
higher than those who did not. According to Dew et
al. (2015),[] sadness increases the chance of organ
transplant rejection. In this regard, the findings of this
and previous investigations are similar.
In the present study, a moderate negative correlation
was found between the WAS and the PTCS, "negative
cognitions about oneself " and "negative cognitions
about the world," and a weak correlation with "selfblame"
(p<0.05). A weak negative correlation with the
PTCS, "negative cognitions about oneself " and "negative
cognitions about the world" with belief in the fairness
of the world, and a very weak negative correlation
with "self-blame" was found in a study of people who
had been through various traumas, including cancer
patients (p<0.05).[]
The outcomes of this study are likely to broaden the
role of mental health nurses in cancer patients" psychosocial
care and contribute to an improvement in
cancer patients" quality of life and psychosocial adjustment
to the condition.
Conclusion
In the present study, it was determined that the traumatic
cognition and world assumptions of the individuals
diagnosed with cancer were negatively affected,
especially in the 1st years of diagnosis. For this reason,
actions such as mental assessment, counseling, and
psychosocial support should be initiated as of the moment
of informing patients in centers providing care
for cancer patients. It can also be seen that it is important
to carry out the disease and treatment process in
co-operation with CLP.
As more than half of the participants (52%) did not
receive any help for their mental problems, the traumatic
cognition of the individuals who received help
was higher and their world assumptions were negative.
It is important to provide psychological support to cancer
diagnosed patient groups in a long-term, planned, and structured way by including traumatic cognitions
and world assumptions.
The data that support the findings of this study are
available from the corresponding author upon request
and will be provided if the manuscript is accepted for
publication.
Note: The study has been produced from the master's thesis.
Acknowledgements: The authors would like to thank the
cancer patients who participated in this study.
Peer-review: Externally peer-reviewed.
Conflict of Interest: The authors declare that they have no
conflict of interest.
Ethics Committee Approval: The study was approved by
the Ordu University Ethics Committee (No: 2016/18, Date:
01/04/2016).
Financial Support: The author(s) received no financial support
for the research, authorship, and/or publication of this
article.
Authorship contributions: Concept - Ö.K., N.G.; Design -
N.G.; Supervision - N.G.; Funding - None; Materials - Ö.K.;
Data collection and/or processing - Ö.K.; Data analysis and/
or interpretation - Ö.K., N.G.; Literature search - Ö.K., N.G.;
Writing - Ö.K., N.G.; Critical review - N.G.
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