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Damgalanmaya Karşı Savunmasız Sağlık Çalışanlarının, COVID-19 Hastalarına Yönelik Yaklaşımlarının Değerlendirilmesi

Year 2022, Volume: 5 Issue: 2, 153 - 165, 15.08.2022
https://doi.org/10.54803/sauhsd.1067517

Abstract

Amaç: Damgalanmaya karşı savunmasız sağlık çalışanlarının damgalanma deneyimleri ve COVID (+) olgulara yönelik yaklaşımlarını değerlendirmek amaçlanmıştır.
Yöntem: Araştırmaya, çevrimiçi anket yöntemiyle 151 sağlık çalışanı alınmıştır. G*POWER 3.1.9.7 programıyla yapılan analizde, etki büyüklüğü 0,569, alfa 0,05 alındığında örneklem büyüklüğü 151, gücü 0,99 olarak belirlenmiştir. Veriler, “Tanımlayıcı Bilgi Formu”, “COVID-19 Tanılı Bireylere Yaklaşımlar Anketi” ile toplanmış; sayı ve yüzdelik dağılımlarla ifade edilmiştir. Anlamlı ilişkileri belirlemede ki-kare bağımsızlık testi kullanılmıştır.
Bulgular: Katılımcıların yaş ortalaması 30,89±8,39, %68,2’si kadın, %59,6’sı hemşiredir. %66,9’u damgalandığını düşünse de sağlık çalışanı olmaları sebebiyle damgalananlar %22,5; COVID (+) hastalarla çalıştığı bilinen ortak alanlarda damgalananlar %47,7’dir. COVID (+) hastayla çalıştığı için damgalanmayla hastalığı gizleme arasında anlamlı fark bulunamamıştır. Sağlık çalışanı olduğu için dışlandığını düşünenler; COVID-19 olan bireylerin cahil, ihmalkar olduğunu bildirmişlerdir.
Sonuç: Damgalanma deneyimleri, COVID (+) olan insanlara yönelik olumsuz duygu ve düşünceleri arttırmış ancak tedavi süreçlerinin profesyonel olarak sürdürülmesini engellememiştir. Sadece sağlık çalışanı olduğu için dışlandığını düşünen fakat damgalanmayanlar, içselleştirilmiş damgalanmayı düşündürmektedir ve ayrıntılı çalışmalara ihtiyaç duyulmaktadır.

References

  • 1. Zhong BL, Luo W, Li HM, Zhang QQ, Liu XG, Li WT, et al. Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: A quick online cross-sectional survey. Int J Biol Sci, 2020;16(10):1745-1752.
  • 2. World Health Organization. 2019-ncov outbreak is an emergency of international concern. https://www.euro.who.int/en/health-topics/health-emergencies/international-health-regulations/news/news/2020/2/2019-ncov-outbreak-is-an-emergency-of-international-concern (Erişim Tarihi: 9 Ekim 2021)
  • 3. World Health Organization. WHO director–general’s opening remarks at the media briefing on COVID-19-11 March 2020. https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020 (Erişim Tarihi: 9 Ekim 2021)
  • 4. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study. Lancet. 2020;395(10223):507-513.
  • 5. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497–506.
  • 6. Ren L, Wang YM, Wu ZQ, Xiang ZC, Guo L, Xu T, et al. Identification of a novel coronavirus causing severe pneumonia in human: A descriptive study. Chin Med J. 2020;13(9):1015-1024.
  • 7. Alamri HS, Algarni A, Shehata SF, Al Bshabshe A, Alshehri NN, ALAsiri AM, et al. Prevalence of depression, anxiety, and stress among the general population in Saudi Arabia during COVID-19 pandemic. Int J Environ Res Public Health. 2020;17(24):9183.
  • 8. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 Coronavirus Disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health. 2020;17(5):1729.
  • 9. Vujčić I, Safiye T, Milikić B, Popović E, Dubljanin D, Dubljanin E, et al. Coronavirus Disease 2019 (COVID-19) epidemic and mental health status in the general adult population of Serbia: A cross-sectional study. Int J Environ Res Public Health. 2021;18(4):1957.
  • 10. Forte G, Favieri F, Tambelli R, Casagrande M. COVID-19 pandemic in the Italian population: Validation of a Post-Traumatic Stress Disorder Questionnaire and prevalence of PTSD symptomatology. Int J Environ Res Public Health. 2020;17(11):4151.
  • 11. Sun L, Sun Z, Wu L, Zhu Z, Zhang F, Shang Z, et al. Prevalence and risk factors for acute posttraumatic stress disorder during the COVID-19 outbreak. J Affect Disord. 2021;283:123-129.
  • 12. Xiang YT, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry. 2020;7(3):228-229.
  • 13. Roberto KJ, Johnson AF, Rauhaus BM. Stigmatization and prejudice during the COVID-19 pandemic. Administrative Theory&Praxis. 2020;42(3):364-378.
  • 14. Latner JD, Stunkard AJ. Getting worse: The stigmatization of obese children. The Obesity Society. 2003;11(3):452-456.
  • 15. Courtwright A, Turner AN. Tuberculosis and stigmatization: Pathways and interventions. Public Health Rep. 2010;4(4):34-42.
  • 16. Stewart MC, Keel PK, Schiavo RS. Stigmatization of Anorexia Nervosa. Int J Eat Disord. 2006;39(4):320-325.
  • 17. Crisp AH, Gelder MG, Rix S, Meltzer HI, Rowlands OJ. Stigmatisation of people with mental illnesses. Br J Psychiatry. 2000;177:4-7.
  • 18. Cho H, Li W, Cannon J, Lopez R, Song CC. Testing three explanations for stigmatization of people of Asian descent during COVID-19: Maladaptive coping, biased media use, or racial prejudice? Ethn Health. 2020;26(1):94-109.
  • 19. Oaten M, Stevenson RJ, Case TI. Disease avoidance as a functional basis for stigmatization. Philos Trans R Soc Lond B Biol Sci. 2011;366(1583):3433-3452.
  • 20. Frost DM. Social stigma and its consequences for the socially stigmatized. Social and Personality Psychology Compass. 2011;5(11):824-839.
  • 21. Villa S, Jaramillo E, Mangioni D, Bandera A, Gori A, Raviglione MC. Stigma at the time of the COVID-19 pandemic. Clin Microbiol Infect. 2020;26(11):1450-1452.
  • 22. Ng E. The pandemic of hate is giving COVID-19 a helping hand. Am J Trop Med Hyg. 2020;102(6);1158-1159.
  • 23. Taylor S, Landry CA, Rachor GS, Paluszek GS, Asmundson GJG. Fear and avoidance of healthcare workers: An important, under-recognized form of stigmatization during the COVID-19 pandemic. Journal of Anxiety Disorders. 2020;75:102289.
  • 24. Singh R, Subedi M. COVID-19 and stigma: Social discrimination towards frontline healthcare providers and COVID-19 recovered patients In Nepal. Asian J Psychiatr. 2020;53:102222.
  • 25. Bagcchi S. Stigma during the COVID-19 pandemic. Lancet Infect Dis. 2020;20(7):782.
  • 26. Vani P, Banerjee D. “Feared and avoided”: Psychosocial effects of stigma against health-care workers during COVID-19. Indian J Soc Psychiatry. 2021;37(1):14-18.
  • 27. Belice T, Çiftçi D, Demir İ, Yüksel A. COVID-19 and stigmatisation of healthcare providers. EUREKA: Health Sciences. 2020;(6):3-7.
  • 28. Kotera Y, Ozaki A, Miyatake H, Tsunetoshi C, Nishikawa Y, Tanimoto T. Mental health of medical workers ın Japan during COVID-19: Relationship with loneliness, hope and self-compassion. Curr Psychol. 2021:1-4.
  • 29. Janitra FE, Melastuti E, Yusuf AH, Fadhilah H, Wibawa YA. Perceived stigma, psychological response, and nurse coping in the COVID-19 pandemic in Indonesia. Jurnal Keperawatan Padjadjaran. 2021;9(1):10-17.
  • 30. Zandifar A, Badrfam R, Khonsari NM, Mohammadi MR, Asayesh H, Qorbani M. Prevalence and associated factors of Posttraumatic Stress symptoms and stigma among health care workers in contact with COVID-19 patients. Iran J Psychiatry. 2020;15(4):340-350.
  • 31. Türkiye Psikiyatri Derneği. COVID-19 ve Damgalama. https://psikiyatri.org.tr/uploadFiles/243202019327-DamgalanmaCOVID.pdf (Erişim Tarihi: 9 Ekim 2021)
  • 32. Dye TD, Alcantara L, Siddiqi S, Barbosu M, Sharma S, Panko T, et al. Risk of COVID-19-related bullying, harassment and stigma among healthcare workers: An analytical cross-sectional global study. BMJ Open. 2020;10(12):e046620.
  • 33. Lee N, Lee HJ. South Korean nurses’ experiences with patient care at a COVID-19-Designated Hospital: Growth after the frontline battle against an infectious disease pandemic. Int J Environ Res Public Health. 2020;17(23):9015.
  • 34. Mostafa A, Sabry W, Mostafa NS. COVID-19-related stigmatization among a sample of Egyptian healthcare workers. PloS One. 2020;15(12):e0244172.
  • 35. World Health Organization. WHO Coronavirus (COVID-19) dashboard. https://covid19.who.int/ (Erişim Tarihi: 9 Ekim 2021)
  • 36. Cherlin EJ, Allam AA, Linnander EL, Wong R, El-Toukhy E, Sipsma H, et al. Inputs to quality: Supervision, management, and community involvement in health facilities in Egypt in 2004. BMC Health Serv Res. 2011;11:282.
  • 37. Ertem M. COVID-19 pandemisi ve sosyal damgalama. İzmir Kâtip Çelebi Üniversitesi Sağlık Bilimleri Fakültesi Dergisi. 2020;5(2):135-138.
  • 38. Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Brain Behav Immun. 2020;88:901-907.
  • 39. Ugidos C, López-Gómez A, Castellanos MÁ, Saiz J, González-Sanguino C, Ausín B, et al. Evolution of intersectional perceived discrimination and internalized stigma during COVID-19 lockdown among the general population in Spain. Inter J Soc Psychiatry. 2022;68(1):55-63.
  • 40. Johnson SU, Ebrahimi OV, Hoffart A. PTSD symptoms among health workers and public service providers during the COVID-19 outbreak. PloS One. 2020;15(10):e0241032.
  • 41. Dubey S, Biswas P, Ghosh R, Chatterjee S, Dubey MJ, Chatterjee S, et al. Psychosocial impact of COVID-19. Diabetes Metab Syndr. 2020;14(5):779-788.
  • 42. Quinn DM, Chaudoir SR. Living with a concealable stigmatized identity: The impact of anticipated stigma, centrality, salience, and cultural stigma on psychological distress and health. J Pers Soc Psychol. 2009;97(4):634-651.
  • 43. Yebei VN, Fortenberry J, Ayuku DO. Felt stigma among people living with HIV/AIDS ın rural and urban Kenya. Afr Health Sci. 2008;8:97-102.
  • 44. Sajjad M, Qayyum S, Iltaf S, Khan RA. ‘The best interest of patients, not self-interest’: How clinicians understand altruism. BMC Med Educ. 2021;21(1):477.
  • 45. Chopra KK, Arora VK. COVID-19 and social stigma: Role of scientific community Indian J Tuberc. 2020;67(3):284-285.

Evaluation of the Approaches of Health Workers Who are Vulnerable to Stigma Towards COVID-19 Patients

Year 2022, Volume: 5 Issue: 2, 153 - 165, 15.08.2022
https://doi.org/10.54803/sauhsd.1067517

Abstract

Aim: It was aimed to evaluate the stigmatization experiences and approaches of healthcare professionals who are vulnerable to stigma towards COVID (+) cases.
Method: 151 health workers were included in the study by online survey method. In the analysis made with the G*POWER 3.1.9.7 program, the effect size was 0.569, and when the alpha was 0.05, the sample size was 151 and the power was 0.99. The data were collected with the “Descriptive Information Form”, “Approaches to Individuals Diagnosed with COVID-19 Questionnaire”; expressed as numbers and percentages. Chi-square independence test was used to determine significant relationships.
Results: The mean age of the participants was 30.89±8.39 years, 68.2% were women and 59.6% were nurses. Although 66.9% think that they are stigmatized, 22.5% of them are stigmatized because they are health workers; Those stigmatized in common areas known to work with COVID (+) patients are 47.7%. There was no significant difference between stigmatization and hiding the disease, since it works with a COVID (+) patient. Those who think that they are excluded because they are health workers; reported that individuals with COVID-19 are ignorant and negligent.

Conclusion: Stigma experiences increased negative feelings and thoughts towards people with COVID (+), but did not prevent professional continuation of treatment processes. Those who think that they are excluded but not stigmatized just because they are health workers suggest internalized stigma and detailed studies are needed.

References

  • 1. Zhong BL, Luo W, Li HM, Zhang QQ, Liu XG, Li WT, et al. Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: A quick online cross-sectional survey. Int J Biol Sci, 2020;16(10):1745-1752.
  • 2. World Health Organization. 2019-ncov outbreak is an emergency of international concern. https://www.euro.who.int/en/health-topics/health-emergencies/international-health-regulations/news/news/2020/2/2019-ncov-outbreak-is-an-emergency-of-international-concern (Erişim Tarihi: 9 Ekim 2021)
  • 3. World Health Organization. WHO director–general’s opening remarks at the media briefing on COVID-19-11 March 2020. https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020 (Erişim Tarihi: 9 Ekim 2021)
  • 4. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study. Lancet. 2020;395(10223):507-513.
  • 5. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497–506.
  • 6. Ren L, Wang YM, Wu ZQ, Xiang ZC, Guo L, Xu T, et al. Identification of a novel coronavirus causing severe pneumonia in human: A descriptive study. Chin Med J. 2020;13(9):1015-1024.
  • 7. Alamri HS, Algarni A, Shehata SF, Al Bshabshe A, Alshehri NN, ALAsiri AM, et al. Prevalence of depression, anxiety, and stress among the general population in Saudi Arabia during COVID-19 pandemic. Int J Environ Res Public Health. 2020;17(24):9183.
  • 8. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 Coronavirus Disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health. 2020;17(5):1729.
  • 9. Vujčić I, Safiye T, Milikić B, Popović E, Dubljanin D, Dubljanin E, et al. Coronavirus Disease 2019 (COVID-19) epidemic and mental health status in the general adult population of Serbia: A cross-sectional study. Int J Environ Res Public Health. 2021;18(4):1957.
  • 10. Forte G, Favieri F, Tambelli R, Casagrande M. COVID-19 pandemic in the Italian population: Validation of a Post-Traumatic Stress Disorder Questionnaire and prevalence of PTSD symptomatology. Int J Environ Res Public Health. 2020;17(11):4151.
  • 11. Sun L, Sun Z, Wu L, Zhu Z, Zhang F, Shang Z, et al. Prevalence and risk factors for acute posttraumatic stress disorder during the COVID-19 outbreak. J Affect Disord. 2021;283:123-129.
  • 12. Xiang YT, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry. 2020;7(3):228-229.
  • 13. Roberto KJ, Johnson AF, Rauhaus BM. Stigmatization and prejudice during the COVID-19 pandemic. Administrative Theory&Praxis. 2020;42(3):364-378.
  • 14. Latner JD, Stunkard AJ. Getting worse: The stigmatization of obese children. The Obesity Society. 2003;11(3):452-456.
  • 15. Courtwright A, Turner AN. Tuberculosis and stigmatization: Pathways and interventions. Public Health Rep. 2010;4(4):34-42.
  • 16. Stewart MC, Keel PK, Schiavo RS. Stigmatization of Anorexia Nervosa. Int J Eat Disord. 2006;39(4):320-325.
  • 17. Crisp AH, Gelder MG, Rix S, Meltzer HI, Rowlands OJ. Stigmatisation of people with mental illnesses. Br J Psychiatry. 2000;177:4-7.
  • 18. Cho H, Li W, Cannon J, Lopez R, Song CC. Testing three explanations for stigmatization of people of Asian descent during COVID-19: Maladaptive coping, biased media use, or racial prejudice? Ethn Health. 2020;26(1):94-109.
  • 19. Oaten M, Stevenson RJ, Case TI. Disease avoidance as a functional basis for stigmatization. Philos Trans R Soc Lond B Biol Sci. 2011;366(1583):3433-3452.
  • 20. Frost DM. Social stigma and its consequences for the socially stigmatized. Social and Personality Psychology Compass. 2011;5(11):824-839.
  • 21. Villa S, Jaramillo E, Mangioni D, Bandera A, Gori A, Raviglione MC. Stigma at the time of the COVID-19 pandemic. Clin Microbiol Infect. 2020;26(11):1450-1452.
  • 22. Ng E. The pandemic of hate is giving COVID-19 a helping hand. Am J Trop Med Hyg. 2020;102(6);1158-1159.
  • 23. Taylor S, Landry CA, Rachor GS, Paluszek GS, Asmundson GJG. Fear and avoidance of healthcare workers: An important, under-recognized form of stigmatization during the COVID-19 pandemic. Journal of Anxiety Disorders. 2020;75:102289.
  • 24. Singh R, Subedi M. COVID-19 and stigma: Social discrimination towards frontline healthcare providers and COVID-19 recovered patients In Nepal. Asian J Psychiatr. 2020;53:102222.
  • 25. Bagcchi S. Stigma during the COVID-19 pandemic. Lancet Infect Dis. 2020;20(7):782.
  • 26. Vani P, Banerjee D. “Feared and avoided”: Psychosocial effects of stigma against health-care workers during COVID-19. Indian J Soc Psychiatry. 2021;37(1):14-18.
  • 27. Belice T, Çiftçi D, Demir İ, Yüksel A. COVID-19 and stigmatisation of healthcare providers. EUREKA: Health Sciences. 2020;(6):3-7.
  • 28. Kotera Y, Ozaki A, Miyatake H, Tsunetoshi C, Nishikawa Y, Tanimoto T. Mental health of medical workers ın Japan during COVID-19: Relationship with loneliness, hope and self-compassion. Curr Psychol. 2021:1-4.
  • 29. Janitra FE, Melastuti E, Yusuf AH, Fadhilah H, Wibawa YA. Perceived stigma, psychological response, and nurse coping in the COVID-19 pandemic in Indonesia. Jurnal Keperawatan Padjadjaran. 2021;9(1):10-17.
  • 30. Zandifar A, Badrfam R, Khonsari NM, Mohammadi MR, Asayesh H, Qorbani M. Prevalence and associated factors of Posttraumatic Stress symptoms and stigma among health care workers in contact with COVID-19 patients. Iran J Psychiatry. 2020;15(4):340-350.
  • 31. Türkiye Psikiyatri Derneği. COVID-19 ve Damgalama. https://psikiyatri.org.tr/uploadFiles/243202019327-DamgalanmaCOVID.pdf (Erişim Tarihi: 9 Ekim 2021)
  • 32. Dye TD, Alcantara L, Siddiqi S, Barbosu M, Sharma S, Panko T, et al. Risk of COVID-19-related bullying, harassment and stigma among healthcare workers: An analytical cross-sectional global study. BMJ Open. 2020;10(12):e046620.
  • 33. Lee N, Lee HJ. South Korean nurses’ experiences with patient care at a COVID-19-Designated Hospital: Growth after the frontline battle against an infectious disease pandemic. Int J Environ Res Public Health. 2020;17(23):9015.
  • 34. Mostafa A, Sabry W, Mostafa NS. COVID-19-related stigmatization among a sample of Egyptian healthcare workers. PloS One. 2020;15(12):e0244172.
  • 35. World Health Organization. WHO Coronavirus (COVID-19) dashboard. https://covid19.who.int/ (Erişim Tarihi: 9 Ekim 2021)
  • 36. Cherlin EJ, Allam AA, Linnander EL, Wong R, El-Toukhy E, Sipsma H, et al. Inputs to quality: Supervision, management, and community involvement in health facilities in Egypt in 2004. BMC Health Serv Res. 2011;11:282.
  • 37. Ertem M. COVID-19 pandemisi ve sosyal damgalama. İzmir Kâtip Çelebi Üniversitesi Sağlık Bilimleri Fakültesi Dergisi. 2020;5(2):135-138.
  • 38. Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Brain Behav Immun. 2020;88:901-907.
  • 39. Ugidos C, López-Gómez A, Castellanos MÁ, Saiz J, González-Sanguino C, Ausín B, et al. Evolution of intersectional perceived discrimination and internalized stigma during COVID-19 lockdown among the general population in Spain. Inter J Soc Psychiatry. 2022;68(1):55-63.
  • 40. Johnson SU, Ebrahimi OV, Hoffart A. PTSD symptoms among health workers and public service providers during the COVID-19 outbreak. PloS One. 2020;15(10):e0241032.
  • 41. Dubey S, Biswas P, Ghosh R, Chatterjee S, Dubey MJ, Chatterjee S, et al. Psychosocial impact of COVID-19. Diabetes Metab Syndr. 2020;14(5):779-788.
  • 42. Quinn DM, Chaudoir SR. Living with a concealable stigmatized identity: The impact of anticipated stigma, centrality, salience, and cultural stigma on psychological distress and health. J Pers Soc Psychol. 2009;97(4):634-651.
  • 43. Yebei VN, Fortenberry J, Ayuku DO. Felt stigma among people living with HIV/AIDS ın rural and urban Kenya. Afr Health Sci. 2008;8:97-102.
  • 44. Sajjad M, Qayyum S, Iltaf S, Khan RA. ‘The best interest of patients, not self-interest’: How clinicians understand altruism. BMC Med Educ. 2021;21(1):477.
  • 45. Chopra KK, Arora VK. COVID-19 and social stigma: Role of scientific community Indian J Tuberc. 2020;67(3):284-285.
There are 45 citations in total.

Details

Primary Language Turkish
Subjects Nursing
Journal Section Research Article
Authors

Sevgi Köroğlu 0000-0002-8060-9216

Gülgün Durat 0000-0002-9889-3622

Publication Date August 15, 2022
Submission Date February 3, 2022
Published in Issue Year 2022 Volume: 5 Issue: 2

Cite

APA Köroğlu, S., & Durat, G. (2022). Damgalanmaya Karşı Savunmasız Sağlık Çalışanlarının, COVID-19 Hastalarına Yönelik Yaklaşımlarının Değerlendirilmesi. Sakarya University Journal of Holistic Health, 5(2), 153-165. https://doi.org/10.54803/sauhsd.1067517