Anxiety, depression, and knowledge level in postpartum women during the COVID‐19 pandemic – Guvenc – – Perspectives in Psychiatric Care

[ad_1]

1 INTRODUCTION

The new type of coronavirus infection (COVID‐19), whose agent is SARS‐CoV‐2, has spread very rapidly after the first case in Wuhan, the center of Hubei Province of China, and it has now become a pandemic.¹ Over 11 million people worldwide and more than 250,000 people in Turkey have been affected by COVID‐19.^{2, 3} The spread of the pandemic to these dimensions has resulted in social distance practices, causing a change in the daily functioning and standard behavior patterns of individuals in many parts of the world.⁴

Rapid transmission of COVID‐19, high mortality rates in risky groups, lack of effective treatments, and massive quarantine measures have led to fear, anxiety, depression, and sleep problems in humans.⁵ Risks associated with COVID‐19 infection have also been reported to affect pregnant women and women in the postpartum period.^6–8 During the pandemic period, women’s visits to the hospitals to receive antenatal care, deliveries at the hospitals, revisits for postpartum follow‐ups after the discharge, problems related to maintaining physical distance in the postpartum period, and keeping the mothers and babies in quarantine in suspicious cases pose a risk in terms of the transmission of COVID‐19 infection to the woman and her family. In particular, adapting to the dynamic process in the postpartum period, with a change in living conditions due to the pandemic, also negatively affects the mother’s psychology.^{4, 9, 10}

Physiological and psychological processes experienced in the first few weeks after delivery affect the mental health of the mother and increase the risk of postpartum depression (PPD). The incidence of PPD ranges from 6.9% to 12.9% in high‐income countries and more than 20% in some low‐ or middle‐income countries.¹¹ PPD frequency in Turkey ranges from 4.8% to 51.3%, depending on the used diagnostic method, scanning time, and sample size.^12–16 According to the results of a recent meta‐analysis, the prevalence of PPD in Turkey has been reported as 23.8%.¹⁷ It is perceived that the incidence of PPD, an important concern in the postpartum period, increased due to the psychological burden that increased due to the pandemic. In a limited number of recent studies, it has been reported that anxiety and depression levels increase in women in the postpartum period.^{9, 18–20}

PPD observed in a new mother causes a lack of interest toward the family and opposing feelings toward her baby, which may lead to growth and development retardation, in addition to cognitive, behavioral, social, and psychological problems later in life in children.²¹ The American College of Obstetrics and Gynecology (ACOG) recommends that women should be screened at least once in the perinatal period using a standardized, approved scale for symptoms of depression and anxiety (Edinburgh Postnatal Depression Scale (EPDS), Beck Depression Inventory I–II, etc.).²² On the basis of the increasing number of problems that may affect women in the postpartum period during the pandemic period, we aimed to evaluate anxiety, depression, and knowledge level in postpartum women during the COVID‐19 pandemic.

2 METHOD

2.1 Design and participants

This descriptive and cross‐sectional study was carried out from May to July 2020 in Ankara, Turkey. Offıcially, on March 11, 2020, the COVID‐19 pandemic started in Turkey. Women who gave birth in the training and research hospital where the study was conducted after March 15, 2020 (who were in the 4‐ to 6‐week postpartum period and agreed to participate in the study) constituted the sample of the study. Out of 276 women who had given birth in the period when the study was carried out, 216 were reached. Four patients did not want to participate in the study. Finally, the data of 212 women were analyzed (response rate: 78.26%). After the data collection, a power analysis was conducted to determine the level of statistical power and estimate the minimum sample size needed.²³ The 212 women were sufficient at the 0.05 level of error with a 95% confidence interval and 90% power according to the post hoc statistical power analysis.

2.1.1 Inclusion criteria

Women who were in the postpartum period of 4–6 weeks, who could speak and understand Turkish, had a telephone number to communicate, and were willing to participate in the study were included in the study.

2.2 Materials

“Participant Information Form,” “Knowledge Assessment Form Regarding the COVID‐19 Pandemic Process,” “State‐Trait Anxiety Inventory‐I (STAI‐I),” and “EPDS” were used in data collection.

2.3 Participant Information Form

This form, developed by the authors, consisted of three parts. In the first part, questions about age, educational status, working status, income level, how she feeds her baby, whether she shares the same house with healthcare personnel, and the sociodemographic data about family type were asked. The second part consisted of questions about obstetric history (delivery type, number of pregnancy and birth, number of alive children, stillbirths, etc.) and medical history (presence of chronic disease in the mother). In the third part, there were questions about how the pandemic process affected her mental health, whether the type of birth was affected by this process, the conditions she was affected by in the postnatal period, the sources of knowledge about the pandemic, the presence of COVID‐19 infection in herself or her family, the fear of virus infection to herself or her baby, and the fear of infecting virus to her baby during breastfeeding.

2.4 Knowledge Assessment Form Regarding the COVID‐19 Pandemic Process

The form, developed by the authors in accordance with the relevant literature,^{1, 18, 24, 25} consisted of three parts. In the first part, five semi‐structured statements were presented evaluating attitudes and behaviors toward breastfeeding. Participants were asked to answer each statement as “Yes,” “No,” änd “I do not know,” and each correct answer was scored as 1 point. The total score that could be obtained from the first part was between 0 and 5. In the second part, there are 12 statements questioning general knowledge, such as the transmission routes of COVID‐19 infection, symptoms, and risk groups. Participants get 1 point for each correct answer 0 points for the wrong answer and “I do not know” option. The total score to be obtained from the second form varies between 0 and 12 points. In the third part, there were total five semi‐structured statements regarding the general attitudes and behaviors of the individual in the pandemic process. There were “Yes,” “No,” and “I do not know options” for each question.

2.5 COVID‐19 transmission fear and risk perception forms

This form consisted of a Visual Analog Scale (VAS). The VAS was used for determining perceptions of fear of being infected with COVID‐19, fear of COVID‐19 transmission to the baby, fear of COVID‐19 transmission to the baby during breastfeeding, and risk perception. The VAS for fear of COVID‐19 consisted of a 10‐cm horizontal scale with the descriptors 0 (no fear) on the left and 10 (maximal fear) on the right. Participants were asked to mark their current level of perceived fear along the scale.

2.6 State‐Trait Anxiety Inventory‐I

STAI‐I was developed by Spielberger in 1964 and revised in 1983.²⁶ It was adapted for the Turkish context by Oner and Le Compte.²⁷ The scale consists of 20 items, and it is a 4‐point Likert‐type scale. The total score ranges between 20 and 80 points, and higher scores indicate higher anxiety levels.^{26, 27} Cronbach’s alpha value for STAI‐I was found between 0.83 and 0.87. In this study, Cronbach’s alpha value of the STAI‐I was 0.92.

2.7 Edinburgh Postnatal Depression Scale

EPDS, developed in 1987 by Cox and Murray to evaluate PPD, consists of 10 items and is a 4‐point Likert‐type scale. The scores that can be obtained from this scale range between 0 and 30. The cutoff point of 13 or higher scores are considered as the probable risk for the presence of PPD. Cox and Murray have reported Cronbach’s alpha value of 0.87 for EPDS. In the Turkish validity and reliability study conducted by Engindeniz,²⁸ it has been reported that Cronbach’s alpha value was 0.79. In this study, Cronbach’s alpha value was determined as 0.85.

2.8 Data collection

To collect the research data, women in the postpartum period were contacted by phone. The purpose of the study was explained to the participants by phone, and an online survey was sent to the mobile phones of women who agreed to participate in the study. Written information was given about the study at the beginning of the survey. The survey took about 15 min to answer.

2.9 Ethical considerations

Before the onset of the study, ethics committee approval and necessary permissions were obtained from the institution where the study was conducted (May 9, 2020, 2020/166). All of the participants were informed about the purpose of the study and their written consents were obtained.

2.10 Statistical analysis

The data were evaluated using the IBM SPSS 24.0 statistics package. The suitability of continuous variables to normal distribution was evaluated by the Kolmogorov–Smirnov test. Data included descriptive statistics; the number (n) and percentage (%) for the variables determined by counting are shown as mean ± standard deviation (X ± SS); and median and minimum–maximum (min–max) values for variables are determined by measurements. Χ² test was used to detect significant differences between the nondepression group and the depression group. The t‐test and one‐way analysis of variance test were used to compare continuous and nominal measures. Pearson’s correlation coefficients were calculated to assess the correlations. A p < 0.05 value was accepted as statistically significant.

3 RESULTS

A comparison of depression rates according to sociodemographic and obstetric variables of women is shown in Table 1. The mean age of women was 29.49 ± 5.01. No statistical difference was found between women’s age, pregnancy number, delivery number, educational status, living with health personnel at home, chronic illness status, and delivery type according to depression status. There was a statistically significant difference between women’s employment and depression status (p = 0.001). The depression rate of the women who were not employed was lower than employed women (Table 1).

Table 1.
Comparison of depression according to sociodemographic and obstetrics variables

			No depression (EDPS < 13)			Depressive (EDPS ≥ 13)
			N = 140 (66.0%)			N = 72 (34.0%)
Characteristics, N = 212	Mean	±SD	Mean	±SD		Mean	±SD	t	pa
Age	29.49	5.01	29.44	5.52		29.57	4.43	−0.17	0.86
Number of pregnancy	2.00	1.16	1.99	1.15		2.03	1.18	−0.24	0.80
Number of delivery	1.76	0.86	1.74	0.88		1.79	0.82	−0.39	0.69
	n	%	n	%		n	%	χ2	pb
Educational status
Elementary	37	17.5	22		59.5	15	40.5	3.52	0.17
High school	61	28.8	46		75.4	15	24.6
University and higher	114	53.8	72		63.2	42	36.8
Employment
Employed	79	37.3	41		51.9	38	48.1	11.22	0.001
Not employed	133	62.7	99		74.4	34	25.6	11.22	0.001
Living with health personnel at home
Yes	16	9.4	13		61.9	8	38.1	0.178	0.42
No	191	90.1	127		66.5	64	33.5	0.178	0.42
Chronic illness status
Yes	26	12.3	14		53.8	12	46.2	1.96	0.18
No	186	87.7	126		67.7	60	32.3	1.96	0.18
Delivery type
Vaginal	102	48.1	69		67.6	33	32.4	0.27	0.66
Caesarean	110	51.9	71		64.5	39	35.5	0.27	0.66

Abbreviation: EPDS, Edinburgh Postnatal Depression Scale.
^at‐test.
^bΧ² test.

Women feared mostly for being infected with the virus (66%), and they had worries concerning their family’s health (60%). Feeling upset (46.2%) and worries related to the future (43.9%) were the other most common factors affecting the women during the COVID‐19 pandemic (Figure 1).

Women’s perceptions and attitudes in the postpartum period regarding COVID‐19 [Color figure can be viewed at wileyonlinelibrary.com]

A statistically significant difference was found between the status of the women having relatives who had tested positive for coronavirus and the rates of depression (p = 0.002).

The rate of experiencing depression for women who had their relatives tested positive for coronavirus was found to be higher. A statistically significant difference was found between women’s status for being affected by the pandemic process and their rates of experiencing depression (p < 0.001). Women who stated that they were very much affected by the pandemic process had a higher rate of depression (Table 2).

Table 2.
The affection status of women from the pandemic process and their depression experiencing status due to the diagnosis of COVID‐19 of their relatives

			No depression (EDPS < 13)		Depressive (EDPS ≥ 13)
			N = 140 (66.0%)		N = 72 (34.0%)
Characteristics, N = 212	n	%	n	%	n	%	χ2	pa
The status of having their relatives tested positive for coronavirus
Yes	10	4.7	2	20.0	8	80.0	9.91	0.002
No	202	95.3	138	68.3	64	31.7
The impact status due to the pandemic process on mental health
Very affected	64	30.2	28	43.8	36	56.3	24.81	<0.001
Affected to a certain extent	126	59.4	91	72.2	35	27.8
Not affected	22	10.4	21	95.5	1	4.5

Note: The bold values indicate statistically significant at p < 0.05.
Abbreviation: EPDS, Edinburgh Postnatal Depression Scale.
^aΧ² test.

A comparison of women’s depression, anxiety, information, fear, and risk perception scores related to COVID‐19 of women according to depression status is presented in Table 3. There was a statistically significant difference between the EDPS scores of women and depression status (p < 0.001). EDPS scores were found to be higher in women who had depression. There was a statistically significant difference between the anxiety scores of women and depression status (p < 0.001). Anxiety scores were found to be higher in women who had depression. We did not find statistically significant differences between the COVID‐19 knowledge and COVID‐19 breastfeeding knowledge scores of women and depression status (p > 0.05). There were statistically significant differences between considering themselves in the high‐risk group (p < 0.001), fear about being infected with COVID‐19 for themselves (p = 0.01) and for their babies (p = 0.01), and the depression status of women. There was a statistically significant difference between fear about their babies getting infected with COVID‐19 from breastfeeding and the depression status of women (p = 0.03). Women who were afraid about their babies getting infected with COVID‐19 from breastfeeding had higher EDPS scores (Table 3).

Table 3.
Comparison of women’s depression scores with STAI‐I, COVID‐19 knowledge, COVID‐19 breastfeeding, knowledge, and fear scores

		No depression (EDPS < 13)		Depressive (EDPS ≥ 13)
Characteristics (N = 212)	Mean ± SD	N = 140 (66.0%)		N = 72 (34.0%)		t	pa
Depression	10.42 ± 5.81	6.97	3.23	17.13	3.29	−2.152	<0.001
STAI	42.69 ± 9.93	39.10	8.49	49.68	8.79	−8.48	<0.001
COVID‐19 knowledge score	9.69 ± 1.94	9.72	1.96	9.62	1.92	0.36	0.71
COVID‐19 breastfeeding knowledge score	3.79 ± 0.97	3.70	0.99	3.97	0.90	−1.88	0.06
Considering themselves in the high‐risk group being infected with COVID‐19	3.41 ± 2.63	2.92	2.52	4.36	2.60	−3.89	<0.001
Fear of being infected with COVID‐19	7.49 ± 2.76	7.14	2.92	8.17	2.31	−2.58	0.01
Fear of COVID‐19 transmission to the baby	8.38 ± 3.62	8.07	2.74	8.97	1.75	−2.52	0.01
Fear of COVID‐19 transmission to the baby during breastfeeding	4.80 ± 2.81	4.38	3.55	5.67	3.65	−2.16	0.03

Note: The bold values indicate statistically significant at p < 0.05.
Abbreviations: EPDS, Edinburgh Postnatal Depression Scale; STAI‐I, State‐Trait Anxiety Inventory‐I.
^at‐test.

A correlation between STAI, EDPS, COVID‐19 knowledge scores, COVID‐19 breastfeeding knowledge scores, and fear scores of women is presented in Table 4. There was a statistically significant correlation between STAI and EDPS scores of women (p < 0.001). STAI scores of women increased with the increase in EDPS scores. There was no correlation found between knowledge scores (COVID‐19 and breastfeeding) and STAI, and EDPS scores. There were statistically significant correlations between fears of women and STAI and EDPS scores (p < 0.05). STAI and EDPS scores of women increased as their fear scores about being infected with COVID‐19, transmission to the baby, and fear of COVID‐19 transmission to baby during breastfeeding increased (Table 4).

Table 4.
Correlation between STAI‐I, EPDS, COVID‐19 knowledge scores, COVID‐19 breastfeeding knowledge scores, and fear scores of women

	STAI‐I		EDPS		COVID‐19 knowledge score		COVID‐19 breastfeeding knowledge score		Fear of being infected with COVID‐19		Fear of COVID‐19 transmission to the baby		Fear of COVID‐19 transmission to the baby during breastfeeding
Scales	r*	p	r*	p	r*	p	r*	p	r*	p	r*	p	r*	p
STAI‐I			0.56	<0.001	−0.07	0.91	0.10	0.12	0.34	<0.001	0.31	0.001	0.24	0.002
Depression	0.56	<0.001			−0.41	0.55	0.04	0.53	0.31	0.002	0.31	0.002	0.24	0.001
COVID‐19 knowledge score	−0.07	0.91	−0.41	0.55			0.31	<0.001	0.06	0.36	0.07	0.27	−0.08	0.92
COVID‐19 breastfeeding knowledge score	0.10	0.12	0.04	0.53	0.31	<0.001			0.07	0.28	0.03	0.66	−0.14	0.05
Fear of being infected with COVID‐19	0.34	<0.001	0.31	0.002	0.06	0.36	0.07	0.28			0.73	<0.001	0.51	<0.001
Fear of COVID‐19 transmission to the baby	0.31	0.001	0.31	0.002	0.07	0.27	0.03	0.66	0.73	<0.001			0.039	<0.001
Fear of COVID‐19 transmission to the baby during breastfeeding	0.24	0.002	0.24	0.001	−0.08	0.92	−0.14	0.05	0.51	<0.001	0.39	<0.001

Note: The bold values indicate statistically significant at p < 0.05.
Abbreviations: EPDS, Edinburgh Postnatal Depression Scale; STAI‐I, State‐Trait Anxiety Inventory‐I.
* Pearson’s correlation test.

4 DISCUSSION

In this study, we aimed to assess anxiety, depression, and knowledge level in postpartum women during the COVID‐19 pandemic. We found that 34.0% of women were under risk in terms of PPD. Similar rates have been reported in a limited number of studies conducted in different countries during the COVID‐19 pandemic.^{20, 29} In a study conducted by Sun et al.²⁰ in Wuhan with 2883 women, 33.71% of the participants had depression symptoms, including 27% with mild depression, 5.24% with moderate depression, and 1.46% with severe depression.²⁹ They examined the relationship between COVID‐19 and depression levels of women and found that 34% of women who were in the postpartum period of 0–18 months suffered from depression.

In studies conducted before the pandemic, PPD rates have been reported as 19%–25% in middle‐income countries and 7%–15% in developed countries.^{30, 31}

Our research showed that the COVID‐19 pandemic increased the risk of PPD, in parallel with other studies conducted during the pandemic. Additionally, in studies conducted during the COVID‐19 pandemic, women in the antenatal period have been found to have high levels of anxiety and depression.^{18, 19, 32, 33} As the reflection of the problems experienced in the antenatal period to the postpartum period is almost inevitable, the antenatal and postpartum periods cannot be considered separately from each other. It is estimated that women who experience anxiety due to the COVID‐19 pandemic, in addition to general stresses from the pregnancy period, have a higher risk for PPD.³⁴ It could be speculated that the high risk of PPD of the women found in our study could be attributed to their pregnancy and delivery coinciding with the pandemic process.

Again, we found that among the sociodemographic characteristics of women, only their employment status affected the risk of PPD. Working women have a higher risk of depression. In the literature, there are various studies stating that employment status does not affect PPD,^{13, 35} nonworking women have a higher risk of PPD symptoms,^36–38 and mothers working in the private sector constitute a risk factor for PPD.³⁹ The uncertainty of the process and the concerns about working in the future may influence these results.

In our study, it was determined that obstetric characteristics do not affect the risk of PPD. In the literature, some studies concluded that delivery method, which is one of the obstetric characteristics, may increase the risk of PPD,^{38, 40} whereas other studies showed that they were not related.^41–43 We found that women were most afraid of COVID‐19 transmission to themselves, to their babies, and to their families during the pandemic. In addition, women wanted to be discharged from the hospital immediately after delivery, avoided going to the hospital for postpartum controls, and stated that they did not accept visitors in the postpartum period. The reason for this behavior of women was their fear of transmission of the infection. We found that women who were afraid of transmission of COVID‐19 infection to themselves or their babies had a higher risk of PPD. Additionally, the PPD risks and anxiety levels of the women participating in the study increased with the increase in fear of COVID‐19 transmission to themselves or their babies in the hospital and elsewhere. Again, our study found that women who feared COVID‐19 transmission during breastfeeding had a higher risk of PPD.

Pregnant and postpartum women who have been infected with COVID‐19 and deceased were reported in the literature,^44–46 and such news has been (and is) frequently reported in the media. It could be considered that this type of news also affects women negatively. Studies show that fears experienced during the COVID‐19 pandemic have negative psychological consequences.^47–49 Our research results showed that fears experienced due to the pandemic process increase both the risk of PPD and the level of anxiety. We also found that women whose relatives were diagnosed with coronavirus had a higher risk of PPD. This may be due to the increased likelihood of infection being transmitted to them.

In our study, women’s anxiety levels were found to be moderate according to the STAI‐I scores. However, women with a high risk of PPD had higher anxiety levels, and as their anxiety levels increased, their risk of PPD also increased. Studies show that anxiety experienced during the pandemic process is an important risk factor in the development of PPD.^{19, 29, 34} In a study conducted by Cameron et al.,²⁹ a relationship was found between experiencing mental health problems and experiencing depression in women who are in the postpartum period of 0–18 months.

In our study, no relationship was found between women’s knowledge level about COVID‐19 and their knowledge about breastfeeding during the pandemic, their PPD risks, and anxiety levels. No other study was encountered in the literature evaluating the perceptions and knowledge levels of postpartum women regarding breastfeeding during the COVID‐19 pandemic. The importance of obtaining knowledge from healthy sources of information during the pandemic process and applying it to health institutions when necessary has been emphasized.⁵⁰ In our study, the fact that the knowledge about the pandemic process was not obtained from the professional sources may be considered effective in the absence of a relationship between women’s knowledge levels and PPD risks and anxiety levels.

In this study, we found that women who considered themselves in the risky group and who stated that they were psychologically affected by the pandemic were at higher risk for PPD.²⁹ Also, a relationship was found between experiencing mental health problems and experiencing depression in women who were in the postpartum period of 0–18 months. Our research results suggest that the subjective well‐being of women in the postpartum period should also be evaluated.

4.1 Limitations

The study has some limitations. First, the design of the study is cross‐sectional; therefore, it could not show cause and effect relationships. Further studies using a longitudinal study design are recommended. Second, the study data were collected from postpartum women who gave birth in a single tertiary hospital. Therefore, the study results cannot be generalized. Another limitation is that the data were collected through a web‐based online survey and based on women’s self‐reports, which might result in self‐report bias. Finally, the vast majority of the participants’ educational level was high school and higher. This is one of the potential limitations of administering an online survey. Future research with the postpartum women should consider data collection methods that allow for the participation of individuals with a lower education level.

4.2 Implications for nursing practice

Nurses are key health professionals who are often in contact with women in the perinatal and postpartum periods. This is an important opportunity to screen women for PPD and plan implementation of preventative and treatment options. During the COVID‐19 pandemic, there is an increase in the existing risk of PPD. Therefore, early detection and appropriate and timely intervention to prevent or detect PPD are crucial to the well‐being of a woman and her family. Due to the COVID‐19 pandemic, women may not reach out to the healthcare services as much as they did before the pandemic. Therefore, providing an opportunity to reach out to e‐health services or online access to healthcare services may be an alternative way to detect and effectively manage women experiencing PPD.

Women’s anxiety levels and fear regarding COVID‐19 had an impact on PPD. Decreasing the anxiety levels and fear regarding COVID‐19 of women may be an important step to prevent PPD during the pandemic. In the perinatal period, and before hospital discharge postpartum, women should be educated about available services if symptoms develop and of the serious implications of untreated PPD and how they may reach out to healthcare services during the pandemic.

5 CONCLUSION

The COVID‐19 pandemic has increased the incidence of depression in women in the postpartum period. It has been found that women’s anxiety levels and their fear of COVID‐19 infection have an impact on their depression experience. No relationship was determined between women’s knowledge of COVID‐19 and their depression experience. It is perceived that the high level of PPD during the pandemic process is also related to the stresses exposed during pregnancy. For this reason, it is recommended to plan care of women starting from the antenatal period and to particularly make interventions to reduce their anxiety levels and fears. To achieve this, it may be suggested to create online materials and psychological support lines for the needs of women in both antenatal and postpartum periods.

ACKNOWLEDGMENTS

The authors would like to thank all participants for their contribution to the study. This study received no specific grant from any funding agency in the public, commercial, or not‐for‐profit sectors.

CONFLICT OF INTERESTS

The authors declare that there are no conflict of interests.

AUTHOR CONTRIBUTIONS

Gulten Guvenc, Fulden Ozkececi, İlknur Yesilcinar, Emine Öksüz, Coşkun F. Ozkececi, and Dilek Konukbay made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data. Gulten Guvenc, Fulden Ozkececi, İlknur Yesilcinar, Emine Öksüz, Coşkun F. Ozkececi, Dilek Konukbay, Gulsah Kok, and Kazım E. Karasahin were involved in drafting the manuscript or revising it critically for important intellectual content. Gulten Guvenc, Fulden Ozkececi, İlknur Yesilcinar, Emine Öksüz, Coşkun F. Ozkececi, Dilek Konukbay, Gulsah Kok and Kazım E. Karasahin gave final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content. Gulten Guvenc, Fulden Ozkececi, İlknur Yesilcinar, Emine Öksüz, Coşkun F. Ozkececi, Dilek Konukbay, Gulsah Kok, and Kazım E. Karasahin agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.