A Scoping Review of the Maternal Role at Older Age; Perceptions and Occupations
Abstract
:1. Introduction
2. Materials and Methods
2.1. Eligibility Criteria (Study Selection)
2.2. Information Sources and Search Strategy (Identifying Relevant Studies)
2.3. Data Items and Data Collection Process
2.4. Charting the Data
3. Results
3.1. Occupations within the Maternal Role of Older Women
3.2. Perceptions and Attitudes of Older Women toward the Maternal Role
4. Discussion
Limitations and Strengths
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Appendix A
SECTION | ITEM | PRISMA-ScR CHECKLIST ITEM | REPORTED ON PAGE # |
TITLE | |||
Title | 1 | Identify the report as a scoping review. | 1 |
ABSTRACT | |||
Structured summary | 2 | Provide a structured summary that includes (as applicable): background, objectives, eligibility criteria, sources of evidence, charting methods, results, and conclusions that relate to the review questions and objectives. | 1 |
INTRODUCTION | |||
Rationale | 3 | Describe the rationale for the review in the context of what is already known. Explain why the review questions/objectives lend themselves to a scoping review approach. | 1–2 |
Objectives | 4 | Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g., population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives. | 2 |
METHODS | |||
Protocol and registration | 5 | Indicate whether a review protocol exists; state if and where it can be accessed (e.g., a Web address); and if available, provide registration information, including the registration number. | N/A |
Eligibility criteria | 6 | Specify characteristics of the sources of evidence used as eligibility criteria (e.g., years considered, language, and publication status), and provide a rationale. | 2 |
Information sources | 7 | Describe all information sources in the search (e.g., databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed. | 2–3 |
Search | 8 | Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated. | 2–3 |
Selection of sources of evidence | 9 | State the process for selecting sources of evidence (i.e., screening and eligibility) included in the scoping review. | 3 |
Data charting process | 10 | Describe the methods of charting data from the included sources of evidence (e.g., calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators. | 3 |
Data items | 11 | List and define all variables for which data were sought and any assumptions and simplifications made. | 3 |
Critical appraisal of individual sources of evidence | 12 | If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate). | N/A |
Synthesis of results | 13 | Describe the methods of handling and summarizing the data that were charted. | 3 |
RESULTS | |||
Selection of sources of evidence | 14 | Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram. | 4 |
Characteristics of sources of evidence | 15 | For each source of evidence, present characteristics for which data were charted and provide the citations. | 5–7 |
Critical appraisal within sources of evidence | 16 | If done, present data on critical appraisal of included sources of evidence (see item 12). | N/A |
Results of individual sources of evidence | 17 | For each included source of evidence, present the relevant data that were charted that relate to the review questions and objectives. | 7–9 |
Synthesis of results | 18 | Summarize and/or present the charting results as they relate to the review questions and objectives. | 9 |
DISCUSSION | |||
Summary of evidence | 19 | Summarize the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups. | 9 |
Limitations | 20 | Discuss the limitations of the scoping review process. | 10 |
Conclusions | 21 | Provide a general interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps. | 10 |
FUNDING | |||
Funding | 22 | Describe sources of funding for the included sources of evidence, as well as sources of funding for the scoping review. Describe the role of the funders of the scoping review. | 11 |
References
- Beard, J.R.; Officer, A.M.; Cassels, A.K. The world report on ageing and health. Gerontologist 2016, 56, S163–S166. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Hocking, C. Contribution of occupation to health and well-being. In Willard & Spackman’s Occupational Therapy; Boyt Schell, B.A., Gillen, G., Scaffa, M.E., Cohn, E.S., Eds.; Lippincott Williams & Wilkins: Philadelphia, PA, USA, 2013; pp. 73–75. [Google Scholar]
- Martin, M.; Weibel, R.; Rocke, C.; Boker, S.M. Semantic Activity Analytics for Healthy Aging: Challenges and Opportunities. IEEE Pervasive Comput. 2018, 17, 73–77. [Google Scholar] [CrossRef]
- Smallfield, S.; Molitor, W.L. Participation and Leisure Engagement for Community-Dwelling Older Adults: A Systematic Review. Am J Occup Ther. 2018, 72, 190020. [Google Scholar]
- Stav, W.B.; Hallenen, T.; Lane, J.; Arbesman, M. Systematic Review of Occupational Engagement and Health Outcomes Among Community-Dwelling Older Adults. Am. J. Occup. Ther. 2012, 66, 301–310. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- World Health Organization. Global Strategy and Action Plan on Ageing and Health; WHO: Geneva, Switzerland, 2017. [Google Scholar]
- WFOT. Definitions of Occupational Therapy; WFOT, 2013; Available online: https://wfot.org/resources/definitions-of-occupational-therapy-from-member-organisations (accessed on 23 November 2021).
- American Occupational Therapy Association. Occupational Therapy practice framework: Domain & process 3rd Edition. Am. J. Occup. Ther. 2014, 68, 1–48. [Google Scholar]
- Craig, B.M.; Donovan, K.A.; Fraenkel, L.; Watson, V.; Hawley, S.; Quinn, G.P. A Generation of Childless Women: Lessons from the United States. Women’s Health Issues 2014, 24, e21–e27. [Google Scholar] [CrossRef]
- Monte, L.M.; Ellis, R.R. Fertility of Women in the United States: 2012. In Population Characteristics; US Census Bureau: Suitland, MD, USA, 2014; pp. 1–26. Available online: https://www.census.gov/content/dam/Census/library/publications/2014/demo/p20-575.pdf (accessed on 23 November 2021).
- Evans, K.L.; Millsteed, J.; Richmond, J.E.; Falkmer, M.; Falkmer, T.; Girdler, S.J. The impact of within and between role experiences on role balance outcomes for working Sandwich Generation Women. Scand. J. Occup. Ther. 2018, 26, 184–193. [Google Scholar] [CrossRef]
- Laney, E.K.; Hall, M.E.L.; Anderson, T.L.; Willingham, M.M. Becoming a mother: The influence of motherhood on woman’s identity development. Identity An. Int. J. Theory Res. 2015, 15, 126–145. [Google Scholar] [CrossRef]
- Avrech Bar, M.; Jarus, T. The effect of engagement in everyday occupations, role overload and social support on health and life satisfaction among mothers. Int. J. Environ. Res. Public Health 2015, 12, 6045–6065. [Google Scholar]
- Koniak-Griffin, D.; Logsdon, M.C.; Hines-Martin, V.; Turner, C.C. Contemporary mothering in a diverse society. J. Obstet. Gynecol. Neonatal Nurs. 2006, 35, 671–678. [Google Scholar] [CrossRef]
- Primeau, L. Divisions of household work, routines, and child care occupations in families. J. Occup. Sci. 2000, 7, 19–28. [Google Scholar] [CrossRef]
- Dunbar, S.B.; Roberts, E. An exploration of mothers’ perceptions regarding mothering occupations and experiences. Occup. Ther. Health Care 2006, 20, 51–73. [Google Scholar] [CrossRef] [PubMed]
- Sethi, C. Mothering as a relational role: Re-evaluating everyday parenting occupations. J. Occup. Sci. 2019, 27, 158–169. [Google Scholar] [CrossRef]
- Avrech Bar, M.; Forwell, S.; Backman, C.L. Ascribing meaning to occupation: An example from healthy, working mothers. OTJR Occup. Particip. Health 2016, 36, 148–158. [Google Scholar] [CrossRef] [PubMed]
- Dillaway, H.E. Good Mothers Never Wane: Mothering at Menopause. J. Women Aging 2006, 18, 41–53. [Google Scholar] [CrossRef]
- Dunkle, R.E.; Ingersoll-Dayton, B.; Chadiha, L.A. Support for and From Aging Mothers Whose Adult Daughters are Seriously Mentally Ill. J. Gerontol. Soc. Work. 2015, 58, 590–612. [Google Scholar] [CrossRef]
- Gueta, K.; Tam, S. Intensive-invisible mothering: The experiences of mothers of adult children with dual diagnosis. Int. J. Ment. Health Nurs. 2019, 28, 997–1007. [Google Scholar] [CrossRef]
- Kim, H.W.; Greenberg, J.S.; Seltzer, M.M.; Krauss, M.W. The role of coping in maintaining the psychological well-being of mothers of adults with intellectual disability and mental illness. J. Intellect. Disabil. Res. 2003, 47, 313–327. [Google Scholar] [CrossRef]
- Poole, J.L.; Willer, K.; Mendelson, C. Occupation of Motherhood: Challenges for Mothers With Scleroderma. Am. J. Occup. Ther. 2009, 63, 214–219. [Google Scholar] [CrossRef] [Green Version]
- Weitz, T.; Estes, C.L. Adding Aging and Gender to the Women’s Health Agenda. J. Women Aging 2001, 13, 3–20. [Google Scholar] [CrossRef] [PubMed]
- Peters, S.A.E.; Woodward, M.; Jha, V.; Kennedy, S.; Norton, R. Women’s health: A new global agenda. BMJ Glob. Health 2016, 1, e000080. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Munn, Z.; Peters, M.D.J.; Stern, C.; Tufanaru, C.; McArthur, A.; Aromataris, E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med. Res. Methodol. 2018, 18, 143. [Google Scholar] [CrossRef]
- Arksey, H.; O’Malley, L. Scoping studies: Towards a methodological framework. Int. J. Soc. Res. Methodol. 2005, 8, 19–32. [Google Scholar] [CrossRef] [Green Version]
- Tricco, A.C.; Lillie, E.; Zarin, W.; O’Brien, K.K.; Colquhoun, H.; Levac, D.; Straus, S.E. PRISMA Extension for scoping reviews (PRISMA-ScR): Checklist and explanation. Ann. Intern Med. 2018, 169, 467–473. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Peters, M.D.; Godfrey, C.M.; Khalil, H.; McInerney, P.; Parker, D.; Soares, C.B. Guidance for conducting systematic scoping reviews. Int. J. Evid. Based Health 2015, 13, 141–146. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Levac, D.; Colquhoun, H.; O’Brien, K.K. Scoping studies: Advancing the methodology. Implement Sci. 2010, 5, 69. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Bromberg, E.M. Mother-Daughter Relationships in Later Life. J. Gerontol. Soc. Work. 1983, 6, 75–92. [Google Scholar] [CrossRef]
- Henwood, K.L. Women and later life: The discursive construction of identities within family relationships. J. Aging Stud. 1993, 7, 303–319. [Google Scholar] [CrossRef]
- Blieszner, R.; Usita, P.M.; Mancini, J.A. Diversity and Dynamics in Late-Life Mother-Daughter Relationships. J. Women Aging 1996, 8, 5–24. [Google Scholar] [CrossRef]
- Francis-Connolly, E. It Never Ends: Mothering as a Lifetime Occupation. Scand. J. Occup. Ther. 1998, 5, 149–155. [Google Scholar] [CrossRef]
- Martini, T.S.; Grusec, J.E.; Bernardini, S.C. Perceptions of help given to healthy older mothers by adult daughters: Ways of initiating help and types of help given. Int. J. Aging Hum. Dev. 2003, 57, 237–257. [Google Scholar] [CrossRef] [PubMed]
- Suitor, J.J.; Pillemer, K.; Sechrist, J. Within-Family Differences in Mothers’ Support to Adult Children. J. Gerontol. Ser. B 2006, 61, S10–S17. [Google Scholar] [CrossRef]
- Suitor, J.J.; Sechrist, J.; Pillemer, K. When Mothers Have Favourites: Conditions under Which Mothers Differentiate among Their Adult Children. Can. J. Aging La Rev. Can. Du Vieil. 2007, 26, 85–99. [Google Scholar] [CrossRef] [PubMed]
- Forssén, A.S.K.; Carlstedt, G. “You Really Do Something Useful with Kids”: Mothering and Experienced Health and Illness in a Group of Elderly Swedish Women. Health Care Women Int. 2008, 29, 1019–1039. [Google Scholar] [CrossRef]
- Schwarz, B.; Albert, I.; Trommsdorff, G.; Zheng, G.; Shi, S.; Nelwan, P.R. Intergenerational Support and Life Satisfaction: A Comparison of Chinese, Indonesian, and German Elderly Mothers. J. Cross-Cult. Psychol. 2010, 41, 706–722. [Google Scholar] [CrossRef]
- Schwarts, Y.; Ayalon, L. The experiences of older mothers following the return of an adult child home. J. Aging Stud. 2015, 33, 47–57. [Google Scholar] [CrossRef] [PubMed]
- To, C.W.-C. Sibling structure, distributive norms, and negotiation for mothers-in-law’s assistance in rural South China. J. Aging Stud. 2015, 32, 59–70. [Google Scholar] [CrossRef]
- Lee, Y.-S. Is giving or receiving psychologically beneficial to older mothers in South Korea? Importance of marital status. J. Women Aging 2016, 29, 137–149. [Google Scholar] [CrossRef]
- Bangerter, L.R.; Polenick, C.A.; Zarit, S.H.; Fingerman, K.L. Life Problems and Perceptions of Giving Support: Implications for Aging Mothers and Middle-Aged Children. J. Fam. Issues 2018, 39, 917–934. [Google Scholar] [CrossRef] [Green Version]
- Woolley, M.E.; Greif, G.L. Mother-in-Law Reports of Closeness to Daughter-in-Law: The Determinant Triangle with the Son and Husband. Soc. Work 2018, 64, 73–82. [Google Scholar] [CrossRef]
- Francis-Connolly, E. Toward an Understanding of Mothering: A Comparison of Two Motherhood Stages Elizabeth. Am. J. Occup. Ther. 2000, 54, 281–289. [Google Scholar] [CrossRef] [Green Version]
- Kielhofner, G.; Burke, J.P. A Model of Human Occupation, Part Conceptual Framework and Content. Am. J. Occup. Ther. 1980, 34, 572–581. [Google Scholar] [CrossRef] [Green Version]
- Kielhofner, G. The model of human occupation. In Conceptual Foundations of Occupational Therapy Practice, 4th ed.; Kielhofner, G., Ed.; F.A Davis: Philadelphia, PA, USA, 2009; pp. 147–174. [Google Scholar]
- Shloim, N.; Hugh-Jones, S.; Rudolf, M.C.J.; Feltbower, R.G.; Lans, O.; Hetherington, M.M. “It’s like giving him a piece of me.”: Exploring UK and Israeli women’s accounts of motherhood and feeding. Appetite 2015, 95, 58–66. [Google Scholar] [CrossRef]
- Roccas, S.; Sagiv, L. Personal Values and Behavior: Taking the Cultural Context into Account. Soc. Pers. Psychol. Compass 2009, 4, 30–41. [Google Scholar] [CrossRef]
- Rudnicka, E.; Napierała, P.; Podfigurna, A.; Męczekalski, B.; Smolarczyk, R.; Grymowicz, M. The World Health Organization (WHO) approach to healthy ageing. Maturitas 2020, 139, 6–11. [Google Scholar] [CrossRef] [PubMed]
- World Health Organization. ICF: International Classification of Functioning, Disability and Health; WHO: Geneva, Switzerland, 2001. [Google Scholar]
- Dawson-Townsend, K. Social participation patterns and their associations with health and well-being for older adults. SSM -Popul. Health 2019, 8, 100424. [Google Scholar] [CrossRef]
- Lam, J.; Bolano, D. Social and productive activities and health among partnered older adults: A couple-level analysis. Soc. Sci. Med. 2019, 229, 126–133. [Google Scholar] [CrossRef] [PubMed]
- Moieni, M.; Irwin, M.R.; Seeman, T.E.; Robles, T.F.; Lieberman, M.D.; Breen, E.C.; Okimoto, S.; Lengacher, C.; Arevalo, J.M.; Olmstead, R.; et al. Feeling needed: Effects of a randomized generativity intervention on well-being and inflammation in older women. Brain Behav. Immun. 2020, 84, 97–105. [Google Scholar] [CrossRef]
- Moieni, M.; E Seeman, T.; Robles, T.F.; Lieberman, M.D.; Okimoto, S.; Lengacher, C.; Irwin, M.R.; Eisenberger, N.I. Generativity and Social Well-Being in Older Women: Expectations Regarding Aging Matter. J. Gerontol. Ser. B 2021, 76, 289–294. [Google Scholar] [CrossRef] [PubMed]
- Yuen, H.K.; Huang, P.; Burik, J.K.; Smith, T.G. Impact of Participating in Volunteer Activities for Residents Living in Long-Term-Care Facilities. Am. J. Occup. Ther. 2008, 62, 71–76. [Google Scholar] [CrossRef] [Green Version]
- Gimigliano, F.; Negrini, S. The World Health Organization “Rehabilitation 2030: A call for action”. Eur. J. Phys. Rehabil. Med. 2017, 53, 155–168. [Google Scholar] [CrossRef] [PubMed]
- Cogan, A.M.; Carlson, M. Deciphering participation: An interpretive synthesis of its meaning and application in rehabilitation. Disabil. Rehabil. 2017, 40, 2692–2703. [Google Scholar] [CrossRef] [PubMed]
First Author and Year of Publication | Study Purpose | Discipline/ Country | Study Methodology/Tools | Participants |
---|---|---|---|---|
Bromberg 1983 [31] | To determine whether quality of mother–daughter relationship is related to mutual support given with respect to support given by daughters to mothers. | Social Work/United States | Quantitative | Older mothers (n = 75), widowed, Jewish. Age 65 and up |
Henwood 1993 [32] | To investigate experiences, identities and relationships of mothers and daughters in a family life framework | Social Sciences/United Kingdom | Qualitative/semi structured interviews | Mothers (n = 60) aged > 50, who have adult daughters (age-up to early 40s) |
Blieszner 1996 [33] | To explore relationships of older mothers and daughters, identify predictors of relationship quality and describe satisfactions and complaints related to the relationships | Gerontology/United States | Mixed methods/Structured interviews including 11 indicators of relationship interaction and quality and nine indicators of parent-child demographic characteristics | Older mothers (n = 15). Mean age 72, age range 66–85 |
Francis-Connolly 1998 [34] | To examine the mothering occupation and experience across life course | Occupational Therapy/USA | Qualitative/Semi structured interviews and focus groups | Mothers (n = 17), aged 32–83 with 1–8 children |
Martini 2003 [35] | To explore the ways in which support from daughters to mothers is initiated and given and the types of support given from the perspective of mothers, and to explore the perspective of daughters in relation to their mothers’ feelings | Psychology/Canada | Quantitative | Older mothers (n = 43), age range 60–89, mean age 73. Adult daughters (n = 43) age range 29–67, mean age 44. |
Suitor 2006 [36] | To explore the extent of within-family differences in older mothers’ support to children, and explain differences using factors drawn from between-family designed studies. | Sociology/United States | Quantitative | Older mothers (n = 556). Age range 65–78 (mean age—70.9; SD—3.1) |
Suitor 2007 [37] | To identify factors that distinguish between mothers who report having a favorite child and mothers that report equal preference among all their children | Sociology/ United States | Quantitative | Older mothers (n = 566), age range 65–75 (mean age 70.9; SD—3.1). |
Forssen 2008 [38] | To describe the mothering work and mothers’ perceived important conditions for doing it. To examine relations between mothering work and perceived health across mothers’ life course | Public Health/Sweden | Qualitative/Open interviews | Older Swedish mothers (n = 20). Age range 63–83 |
Schwarz 2010 [39] | To explore and compare relations between mothers’ life satisfaction and support provided to adult children among Chinese, Indonesian, and German women. | Psychology/China Indonesia Germany | Quantitative/Structured interviews | Older mothers (n = 406). mean age of rural Chinese mothers—64.69, urban Chinese mothers—68.04, rural Indonesian mothers—58.00, urban Indonesian mothers—67.16, German elderly mothers—69.57. |
Schwarts 2015 [40] | To describe mothers’ experience of maternal role to co-residing adult children who have returned to live at parents’ home. | Social Work/Israel | Qualitative/In-depth, semi-structured interviews | Mothers (n = 14). Aged 58–74 with adult children (aged 30–40) who returned to live at home. |
To 2015 [41] | To examine patterns of mother’s support distribution to their sons and daughters-in-law, the factors affecting them and changes over time | Sociology/China | Qualitative/Semi structured interviews | Older mothers (n = 34) aged 49–76. Married, including co-residing mothers- and daughters-in-law. |
Lee 2017 [42] | To understand intergenerational financial transfers and subjective well-being of older mothers | Sociology/ South Korea | Quantitative/General life satisfaction estimation on a 0–100 scale; structured interviews—intergenerational economic exchange questions | Mothers (n = 803), with at least one married child living separately, age > 45, married mean age 57, widowed mean age 68.9 |
Bangerter 2018 [43] | To examine support given in context of life problems as perceived by mothers and their middle-aged children | Gerontology/United States | Quantitative/Frequency of support given-the Intergenerational Support Scale (ISS; Fingerman et al., 2009). Perceptions of support given by two single item questions | Mother–child dyads (n = 226), mothers mean age 75.04 years, children mean age 49.57 years |
Woolley 2018 [44] | To explore the perspective of mothers-in-law of interactions with and feelings toward their daughters-in-law, and the son’s role in those interactions. | Social Work/United States | Quantitative | Older mothers (n = 267), from various races and religions, who’s sons are married to a living daughter in law. Age mean 63, (SD = 10; range: 37–88) |
Instrumental Activities of Daily Living | Social Participation | ||
---|---|---|---|
Occupations (n = 12) | Perceptions (n = 7) | Occupations (n = 8) | Perceptions (n = 5) |
Assistance with daily chores [31,37,39,40,41] | Supporting children as part of motherhood [36,39,40,42,43] | Sharing enjoyable activities with children [32,38] | Valuing close relationships [32,37,38] |
Providing financial support [36,39,42,43] | Feeling rewarded by supporting children [38] | Open, frequent communication with children [35,40,44] | Close relationships reconcile earlier hardship of motherhood [38] |
Caring for children [34,39,43] | Ambivalence towards exchanged support [31,33,35] | Sharing thoughts and opinions with children [33,37] | Viewing children in-law as part of the relationship with children [44] |
Caring for grandchildren [38,41] | Visiting children and sharing holiday rituals [31] | ||
Exchanged support [32,33,35] |
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. |
© 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Maman, R.; Rand, D.; Avrech Bar, M. A Scoping Review of the Maternal Role at Older Age; Perceptions and Occupations. Int. J. Environ. Res. Public Health 2022, 19, 492. https://doi.org/10.3390/ijerph19010492
Maman R, Rand D, Avrech Bar M. A Scoping Review of the Maternal Role at Older Age; Perceptions and Occupations. International Journal of Environmental Research and Public Health. 2022; 19(1):492. https://doi.org/10.3390/ijerph19010492
Chicago/Turabian StyleMaman, Ruth, Debbie Rand, and Michal Avrech Bar. 2022. "A Scoping Review of the Maternal Role at Older Age; Perceptions and Occupations" International Journal of Environmental Research and Public Health 19, no. 1: 492. https://doi.org/10.3390/ijerph19010492
APA StyleMaman, R., Rand, D., & Avrech Bar, M. (2022). A Scoping Review of the Maternal Role at Older Age; Perceptions and Occupations. International Journal of Environmental Research and Public Health, 19(1), 492. https://doi.org/10.3390/ijerph19010492