Araştırma Makalesi
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The Relationship Between Chronic Disease Self-Management and Well-Being in Hemodialysis Patients/Hemodiyaliz Hastalarında Kronik Hastalık Öz Yönetimi ve İyilik Hali Arasındaki İlişki

Yıl 2023, , 87 - 98, 31.05.2023
https://doi.org/10.47565/ndthdt.2023.71

Öz

Amaç Hemodiyaliz tedavisi gören hastalarda öz yönetim ile iyilik hali arasındaki ilişkiyi ve ilişkili sosyodemografik ve klinik özellikleri değerlendirmek amacıyla yapıldı.
Yöntem: Araştırma, Eylül-Aralık 2022 tarihleri arasında İzmir ilinde üç hemodiyaliz merkezinde tedavi gören, araştırmaya dahil edilme kriterlerine uyan 261 hasta ile tanımlayıcı olarak yapıldı. Araştırmanın verileri; “Sosyodemografik Veri Formu”, “PERMA Ölçeği” ve “Kronik Hastalık Öz Yönetim Ölçeği” ile yüz yüze görüşme yolu ile toplandı. Araştırmanın yürütülmesi için etik kurul izni alındı. Verilerin istatistiksel analizinde sayı, yüzde, ortalama, standart sapma, Mann Whitney U/Kruskal Wallis H testleri ve Spearman korelasyon analizi kullanıldı.
Bulgular: PERMA Ölçeği ortalama puanı 7.21±1.31 ve öz yönetim ölçeği ortalama puanı 3.31±0.35 idi. Psikolojik iyi oluş algısı yüksek, beslenme sorunu olmayan ve fiziksel sorunlarla tamamen baş edebilen hastaların hem kendini yönetme hem de iyilik hali daha yüksektir (p<0.05). Öz yönetim ve iyilik hali arasında pozitif bir ilişki vardı (r: 0.385, p<0.01).
Sonuç: Çalışmanın sonuçları, hemodiyaliz hastalarının orta düzeyde hastalık özyönetimi ve yüksek iyilik haline sahip olduklarını desteklemektedir. Bunun yanı sıra, hastalık öz yönetimi arttıkça hastaların iyilik halinin arttığı belirlenmiştir.

Kaynakça

  • 1. Homaie Rad E, Mostafavi H, Delavari S, Mostafavi S. Health-related quality of life in patients on hemodialysis and peritoneal dialysis: a Meta-Analysis of Iranian Studies. Iran J Kidney Dis. 2015;9(5):386-93.
  • 2. US Renal Data System 2019 Annual Data Report: Epidemiology of Kidney Disease in The United States. [Cited 2020 May 12]. Available From: Https://Www.Usrds.Org/2019/Download/USRDS_2019_ES_Final.Pdf. Erişim: 20.11. 2022.
  • 3. Kılıç SP. Kidney failure and care management, Internal Medicine Nursing with Case Scenarios, Istanbul Medical Bookstore, 2019, Chapter: 10.4, 487-501.
  • 4. Gong Y, Zhao Y, Ran L, Liu Y. Comparison between hemodialysis and peritoneal dialysis in the risks for disease activity in LN-ESRD patients: A systematic review and meta-analysis. Altern Ther Health Med. 2022;28(6):144-9.
  • 5. Liew A. Perspectives in renal replacement therapy: Haemodialysis. Nephrology (Carlton). 2018; 4:95-99.
  • 6. Bello AK, Okpechi IG, Osman MA, Cho Y, Htay H, Jha V, et al. Epidemiology of haemodialysis outcomes. Nat Rev Nephrol. 2022;18(6):378-95.
  • 7. Almutary H. Psychosocial Aspects in Hemodialysis. Updates on Hemodialysis [Working Title] [Internet]. 2023 Jan 16; Available from: http://dx.doi.org/10.5772/intechopen.109592.
  • 8. Xie C, Li L, Li Y. Learned helplessness in renal dialysis patients: concept analysis with an evolutionary approach. Patient Prefer Adherence. 2022; 16:2301-12.
  • 9. Debnath S, Rueda R, Bansal S, Kasinath BS, Sharma K, Lorenzo C. Fatigue characteristics on dialysis and non-dialysis days in patients with chronic kidney failure on maintenance hemodialysis. BMC Nephrol. 2021, 22, 1–9. DOI: 10.1186/s12882-021-02314-0.
  • 10. Cho OH, Hong I, Kim H. Effect of uncertainty in ıllness and fatigue on health-related quality of life of patients on dialysis: a cross-sectional correlation study. Healthcare (Basel). 2022;10(10):2043. DOI: 10.3390/healthcare10102043.
  • 11. Post A, Tsikas D, Bakker SJL. Creatine is a conditionally essential nutrient in chronic kidney disease: a hypothesis and narrative literature review. Nutrients. 2019;11(5):1044. DOI: 10.3390/nu11051044.
  • 12. Taylan S. , Özkan İ. Hemodiyaliz hastalarında görülen semptom kümelerinin cinsel işlev ile ilişkisi. Nefroloji Hemşireliği Dergisi. 2020; 15(2): 91-100 DOI: 10.47565/ndthdt.2020.9
  • 13. Niu Q, Zhao X, Gan L, Liang X, Ni Z, Chen X, et al. Physical function and clinical outcomes in hemodialysis patients: china dialysis outcomes and practice patterns study. Kidney Dis (Basel). 2021;7(4):315-322. DOI: 10.1159/000513897
  • 14. Post A, Tsikas D, Bakker SJL. Creatine is a conditionally essential nutrient in chronic kidney disease: a hypothesis and narrative literature review. Nutrients. 2019;11(5):1044. DOI: 10.3390/nu11051044.
  • 15. Seraji M, Shojaeizadeh D, Rakhshani F. Well-being in hemodialysis patients. Iran J Public Health. 2018;47(8):1222-3.
  • 16. Myers JE, Sweeney TJ, Witmer JM. Thewheel of wellnesscounselingforwellness: A holistic model fortreatmentplanning. Journal of Counseling& Development. 2000; 78: 251-266. DOI: 10.1002/j.1556-6676.2000.tb01906.x.
  • 17. Bottomley A. The cancer patient and quality of life. Oncologist. 2002;7(2):120-5. DOI: 10.1634/theoncologist.7-2-120
  • 18. Miller WR, Lasiter S, Bartlett Ellis R, Buelow JM. Chronic disease self-management: a hybrid concept analysis. Nurs Outlook. 2015;63(2):154-61. DOI: 10.1016/j.outlook.2014.07.005.
  • 19. Donald M, Kahlon BK, Beanlands H, Straus S, Ronksley P, Herrington G, et al. Self-management interventions for adults with chronic kidney disease: a scoping review. BMJ Open. 2018;8(3): e019814. DOI: 10.1136/bmjopen-2017-019814.
  • 20. Wang SL, Kung LF, Chen TH, Hsiao SM, Hsiao PN, Chiou CJ. Construction and Validation of a Chronic Kidney Disease Self-Care Scale. Hu Li Za Zhi. 2016;63(4):90-9. DOI:10.6224/JN.63.4.90
  • 21. Grady PA, Gough LL. El automanejo de las enfermedades crónicas: un método integral de atención [Self-management: a comprehensive approach to management of chronic conditions]. Rev Panam Salud Publica. 2015;37(3):187-94.
  • 22. Chrvala CA, Sherr D, Lipman RD. Diabetes self-management education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control. Patient Educ Couns. 2016;99(6):926-43. DOI: 10.1016/j.pec.2015.11.003.
  • 23. Koetsenruijter J, van Eikelenboom N, van Lieshout J, Vassilev I, Lionis C, Todorova E, et al. Social support and self-management capabilities in diabetes patients: An international observational study. Patient Educ Couns. 2016;99(4):638-643. DOI: 10.1016/j.pec.2015.10.029.
  • 24. Butler J, Kern ML. The PERMA-Profiler: A brief multidimensional measure of flourishing. International Journal of Wellbeing. 2016; 6(3): 1-48.
  • 25. Demirci I, Eksi H, Dinçer D, Kardas S. The five-dimensional model of well-being: The validity and reliability of the Turkish version of the PERMA Scale. The Journal of Happiness & Well-Being. 2017;5(1):60-77.
  • 26. Ngai SS, Cheung C, Ng Y, Tang H, Ngai H, Wong KH. Corrigendum to “development and validation of the chronic illness self-management (CISM) scale: Data from a young patient sample in Hong Kong” [Child. Youth Serv. Rev. 114 (2020) 105077]. Children and Youth Services Review. 2020;116:105181.
  • 27. Öztürk YE, Yeşildal M, Arık Ö, Fidan Y. Kronik hastalık öz yönetim ölçeğinin türkçe geçerlilik güvenilirliği. Journal of Academic Value Studies. 2021;7(3): 375-381.
  • 28. Hong SA, Peltzer K. Dietary behaviour, psychological well-being and mental distress among adolescents in Korea. Child Adolesc Psychiatry Ment Health. 2017;11:56.
  • 29. Wammerl M, Jaunig J, Mairunteregger T, Streit P. The German version of the PERMA-Profiler: evidence for construct and convergent validity of the PERMA theory of well-being in German speaking countries. Journal of Well-Being Assessment. 2019;3(2); 75-96.
  • 30. Kabadaş A. (2020) Tip II diyabet tanısı almış bireylerin sosyodemografik özellikleri ve hastalıkla yaşam deneyimleri açısından iyi oluş düzeylerinin incelenmesi. Ondokuz Mayıs Üniversitesi Sağlık Bilimleri Enstitüsü Hemşirelik Ana Bilim Dalı. Yayınlanmamış Yüksek Lisans Tezi. Ondokuz Mayıs Üniversitesi.
  • 31. Camitan DS 4th, Bajin LN. The Importance of well-being on resiliency of filipino adults during the COVID-19 enhanced community quarantine: a necessary condition analysis. Front Psychol. 2021;12:558930. DOI: 10.3389/fpsyg.2021.558930.
  • 32. Batista de Lima ME, Eleuteri S. Increasing patient motivation and adherence to nutritional care: The ımportance to overcome psychological barriers. In Interdisciplinary Nutritional Management and Care for Older Adults. 2021;135-146.
  • 33. Ryff CD. Psychological well-being revisited: advances in the science and practice of eudaimonia. Psychother Psychosom. 2014;83(1):10-28. DOI: 10.1159/000353263.
  • 34. Lovett N, Lovett T. Wellbeing in education: staff matter. International Journal of Social Science and Humanity. 2016;6(2):107-112.
  • 35. Yıldız K, Dirik D. The Role of perceived self-efficacy in the relationship between perceived social support and coping styles with stress. SPORT METER Journal of Physical Education and Sport Sciences.2019;17(2):132-144.
  • 36. Simon N, Roberts NP, Lewis CE, van Gelderen MJ, Bisson JI. Associations between perceived social support, posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD): implications for treatment. Eur J Psychotraumatol. 2019;10(1):1573129.
  • 37. Cacciatore J, Thieleman K, Fretts R, Jackson LB. What is good grief support? Exploring the actors and actions in social support after traumatic grief. PLoS One. 2021;16(5):e0252324.
  • 38. Capistrano RL, Sousa AR, Araújo IF, Almeida ES, Menezes HF, Silva RA, et al. Stigma perceived by men on hemodialysis. Acta Paul Enferm. 2022;35:eAPE039008234. DOI: 10.37689/acta-ape/2022AO0082349
  • 39. Lu M, Yang Y, Wang G, Wang H, Feng D. Effects of perceived stigma on depressive symptoms and demoralization in maintenance hemodialysis patients: Self-warmth and Self-coldness as Mediators. Mindfulness. 2022;1-12. DOI: 10.1007/s12671-022-02011-5
  • 40. Nath SD, Jamshed KM, Shaikh JM. The impact of the COVID-19 pandemic on subsistence consumers' well-being and coping strategies: Insights from India and Bangladesh. J Consum Aff. 2022;56(1):180-210. DOI: 10.1111/joca.12440
  • 41. Borrelli S, Provenzano M, Gagliardi I, Michael A, Liberti ME, De Nicola L, et al. Sodium ıntake and chronic kidney disease. Int J Mol Sci. 2020 Jul 3;21(13):4744. DOI: 10.3390/ijms21134744.
  • 42. Canaud B, Chazot C, Koomans J, Collins A. Fluid and hemodynamic management in hemodialysis patients: challenges and opportunities. J Bras Nefrol. 2019;41(4):550-559. DOI: 10.1590/2175-8239-JBN-2019-0135.

The Relationship Between Chronic Disease Self-Management and Well-Being in Hemodialysis Patients

Yıl 2023, , 87 - 98, 31.05.2023
https://doi.org/10.47565/ndthdt.2023.71

Öz

Aims: To appraise the relation between self-management and well-being and related sociodemographic and clinical features in patients receiving hemodialysis treatment.
Methods: The study was carried out with 261 patients who were treated at three hemodialysis centers in Izmir between September and December 2022 and who met the criteria for inclusion. The data of the research; “Sociodemographic Data Form”, “PERMA Scale” and “Chronic Illness Self-Management Scale” were collected through face-to-face interviews. Ethics committee approval was obtained to conduct the study. Number, percent, mean, standard deviation, Mann Whitney U/Kruskal Wallis H tests and Spearman correlation analysis were used in the statistical analysis of the data.
Results: The PERMA Scale mean score was 7.21±1.31 and the self management scale mean score was 3.31±0.35. Patients who have a high perception of psychological well-being, who have no problems with diet and who can cope with physical problems completely have higher levels of both self-management and well-being (p<0.05).There is a positive relationship between self-management and well-being (r: 0.385, p<0.01).
Conclusion: Results supported that hemodialysis patients were found to have moderate disease self-management and high well-being. In addition, it was determined that as the disease self-management increased, the well-being of the patients increased.

Kaynakça

  • 1. Homaie Rad E, Mostafavi H, Delavari S, Mostafavi S. Health-related quality of life in patients on hemodialysis and peritoneal dialysis: a Meta-Analysis of Iranian Studies. Iran J Kidney Dis. 2015;9(5):386-93.
  • 2. US Renal Data System 2019 Annual Data Report: Epidemiology of Kidney Disease in The United States. [Cited 2020 May 12]. Available From: Https://Www.Usrds.Org/2019/Download/USRDS_2019_ES_Final.Pdf. Erişim: 20.11. 2022.
  • 3. Kılıç SP. Kidney failure and care management, Internal Medicine Nursing with Case Scenarios, Istanbul Medical Bookstore, 2019, Chapter: 10.4, 487-501.
  • 4. Gong Y, Zhao Y, Ran L, Liu Y. Comparison between hemodialysis and peritoneal dialysis in the risks for disease activity in LN-ESRD patients: A systematic review and meta-analysis. Altern Ther Health Med. 2022;28(6):144-9.
  • 5. Liew A. Perspectives in renal replacement therapy: Haemodialysis. Nephrology (Carlton). 2018; 4:95-99.
  • 6. Bello AK, Okpechi IG, Osman MA, Cho Y, Htay H, Jha V, et al. Epidemiology of haemodialysis outcomes. Nat Rev Nephrol. 2022;18(6):378-95.
  • 7. Almutary H. Psychosocial Aspects in Hemodialysis. Updates on Hemodialysis [Working Title] [Internet]. 2023 Jan 16; Available from: http://dx.doi.org/10.5772/intechopen.109592.
  • 8. Xie C, Li L, Li Y. Learned helplessness in renal dialysis patients: concept analysis with an evolutionary approach. Patient Prefer Adherence. 2022; 16:2301-12.
  • 9. Debnath S, Rueda R, Bansal S, Kasinath BS, Sharma K, Lorenzo C. Fatigue characteristics on dialysis and non-dialysis days in patients with chronic kidney failure on maintenance hemodialysis. BMC Nephrol. 2021, 22, 1–9. DOI: 10.1186/s12882-021-02314-0.
  • 10. Cho OH, Hong I, Kim H. Effect of uncertainty in ıllness and fatigue on health-related quality of life of patients on dialysis: a cross-sectional correlation study. Healthcare (Basel). 2022;10(10):2043. DOI: 10.3390/healthcare10102043.
  • 11. Post A, Tsikas D, Bakker SJL. Creatine is a conditionally essential nutrient in chronic kidney disease: a hypothesis and narrative literature review. Nutrients. 2019;11(5):1044. DOI: 10.3390/nu11051044.
  • 12. Taylan S. , Özkan İ. Hemodiyaliz hastalarında görülen semptom kümelerinin cinsel işlev ile ilişkisi. Nefroloji Hemşireliği Dergisi. 2020; 15(2): 91-100 DOI: 10.47565/ndthdt.2020.9
  • 13. Niu Q, Zhao X, Gan L, Liang X, Ni Z, Chen X, et al. Physical function and clinical outcomes in hemodialysis patients: china dialysis outcomes and practice patterns study. Kidney Dis (Basel). 2021;7(4):315-322. DOI: 10.1159/000513897
  • 14. Post A, Tsikas D, Bakker SJL. Creatine is a conditionally essential nutrient in chronic kidney disease: a hypothesis and narrative literature review. Nutrients. 2019;11(5):1044. DOI: 10.3390/nu11051044.
  • 15. Seraji M, Shojaeizadeh D, Rakhshani F. Well-being in hemodialysis patients. Iran J Public Health. 2018;47(8):1222-3.
  • 16. Myers JE, Sweeney TJ, Witmer JM. Thewheel of wellnesscounselingforwellness: A holistic model fortreatmentplanning. Journal of Counseling& Development. 2000; 78: 251-266. DOI: 10.1002/j.1556-6676.2000.tb01906.x.
  • 17. Bottomley A. The cancer patient and quality of life. Oncologist. 2002;7(2):120-5. DOI: 10.1634/theoncologist.7-2-120
  • 18. Miller WR, Lasiter S, Bartlett Ellis R, Buelow JM. Chronic disease self-management: a hybrid concept analysis. Nurs Outlook. 2015;63(2):154-61. DOI: 10.1016/j.outlook.2014.07.005.
  • 19. Donald M, Kahlon BK, Beanlands H, Straus S, Ronksley P, Herrington G, et al. Self-management interventions for adults with chronic kidney disease: a scoping review. BMJ Open. 2018;8(3): e019814. DOI: 10.1136/bmjopen-2017-019814.
  • 20. Wang SL, Kung LF, Chen TH, Hsiao SM, Hsiao PN, Chiou CJ. Construction and Validation of a Chronic Kidney Disease Self-Care Scale. Hu Li Za Zhi. 2016;63(4):90-9. DOI:10.6224/JN.63.4.90
  • 21. Grady PA, Gough LL. El automanejo de las enfermedades crónicas: un método integral de atención [Self-management: a comprehensive approach to management of chronic conditions]. Rev Panam Salud Publica. 2015;37(3):187-94.
  • 22. Chrvala CA, Sherr D, Lipman RD. Diabetes self-management education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control. Patient Educ Couns. 2016;99(6):926-43. DOI: 10.1016/j.pec.2015.11.003.
  • 23. Koetsenruijter J, van Eikelenboom N, van Lieshout J, Vassilev I, Lionis C, Todorova E, et al. Social support and self-management capabilities in diabetes patients: An international observational study. Patient Educ Couns. 2016;99(4):638-643. DOI: 10.1016/j.pec.2015.10.029.
  • 24. Butler J, Kern ML. The PERMA-Profiler: A brief multidimensional measure of flourishing. International Journal of Wellbeing. 2016; 6(3): 1-48.
  • 25. Demirci I, Eksi H, Dinçer D, Kardas S. The five-dimensional model of well-being: The validity and reliability of the Turkish version of the PERMA Scale. The Journal of Happiness & Well-Being. 2017;5(1):60-77.
  • 26. Ngai SS, Cheung C, Ng Y, Tang H, Ngai H, Wong KH. Corrigendum to “development and validation of the chronic illness self-management (CISM) scale: Data from a young patient sample in Hong Kong” [Child. Youth Serv. Rev. 114 (2020) 105077]. Children and Youth Services Review. 2020;116:105181.
  • 27. Öztürk YE, Yeşildal M, Arık Ö, Fidan Y. Kronik hastalık öz yönetim ölçeğinin türkçe geçerlilik güvenilirliği. Journal of Academic Value Studies. 2021;7(3): 375-381.
  • 28. Hong SA, Peltzer K. Dietary behaviour, psychological well-being and mental distress among adolescents in Korea. Child Adolesc Psychiatry Ment Health. 2017;11:56.
  • 29. Wammerl M, Jaunig J, Mairunteregger T, Streit P. The German version of the PERMA-Profiler: evidence for construct and convergent validity of the PERMA theory of well-being in German speaking countries. Journal of Well-Being Assessment. 2019;3(2); 75-96.
  • 30. Kabadaş A. (2020) Tip II diyabet tanısı almış bireylerin sosyodemografik özellikleri ve hastalıkla yaşam deneyimleri açısından iyi oluş düzeylerinin incelenmesi. Ondokuz Mayıs Üniversitesi Sağlık Bilimleri Enstitüsü Hemşirelik Ana Bilim Dalı. Yayınlanmamış Yüksek Lisans Tezi. Ondokuz Mayıs Üniversitesi.
  • 31. Camitan DS 4th, Bajin LN. The Importance of well-being on resiliency of filipino adults during the COVID-19 enhanced community quarantine: a necessary condition analysis. Front Psychol. 2021;12:558930. DOI: 10.3389/fpsyg.2021.558930.
  • 32. Batista de Lima ME, Eleuteri S. Increasing patient motivation and adherence to nutritional care: The ımportance to overcome psychological barriers. In Interdisciplinary Nutritional Management and Care for Older Adults. 2021;135-146.
  • 33. Ryff CD. Psychological well-being revisited: advances in the science and practice of eudaimonia. Psychother Psychosom. 2014;83(1):10-28. DOI: 10.1159/000353263.
  • 34. Lovett N, Lovett T. Wellbeing in education: staff matter. International Journal of Social Science and Humanity. 2016;6(2):107-112.
  • 35. Yıldız K, Dirik D. The Role of perceived self-efficacy in the relationship between perceived social support and coping styles with stress. SPORT METER Journal of Physical Education and Sport Sciences.2019;17(2):132-144.
  • 36. Simon N, Roberts NP, Lewis CE, van Gelderen MJ, Bisson JI. Associations between perceived social support, posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD): implications for treatment. Eur J Psychotraumatol. 2019;10(1):1573129.
  • 37. Cacciatore J, Thieleman K, Fretts R, Jackson LB. What is good grief support? Exploring the actors and actions in social support after traumatic grief. PLoS One. 2021;16(5):e0252324.
  • 38. Capistrano RL, Sousa AR, Araújo IF, Almeida ES, Menezes HF, Silva RA, et al. Stigma perceived by men on hemodialysis. Acta Paul Enferm. 2022;35:eAPE039008234. DOI: 10.37689/acta-ape/2022AO0082349
  • 39. Lu M, Yang Y, Wang G, Wang H, Feng D. Effects of perceived stigma on depressive symptoms and demoralization in maintenance hemodialysis patients: Self-warmth and Self-coldness as Mediators. Mindfulness. 2022;1-12. DOI: 10.1007/s12671-022-02011-5
  • 40. Nath SD, Jamshed KM, Shaikh JM. The impact of the COVID-19 pandemic on subsistence consumers' well-being and coping strategies: Insights from India and Bangladesh. J Consum Aff. 2022;56(1):180-210. DOI: 10.1111/joca.12440
  • 41. Borrelli S, Provenzano M, Gagliardi I, Michael A, Liberti ME, De Nicola L, et al. Sodium ıntake and chronic kidney disease. Int J Mol Sci. 2020 Jul 3;21(13):4744. DOI: 10.3390/ijms21134744.
  • 42. Canaud B, Chazot C, Koomans J, Collins A. Fluid and hemodynamic management in hemodialysis patients: challenges and opportunities. J Bras Nefrol. 2019;41(4):550-559. DOI: 10.1590/2175-8239-JBN-2019-0135.
Toplam 42 adet kaynakça vardır.

Ayrıntılar

Birincil Dil İngilizce
Konular Hemşirelik
Bölüm Makale
Yazarlar

Özkan Uğuz 0000-0002-9410-9511

Satı Doğan 0000-0002-9935-3265

Yayımlanma Tarihi 31 Mayıs 2023
Yayımlandığı Sayı Yıl 2023

Kaynak Göster

Vancouver Uğuz Ö, Doğan S. The Relationship Between Chronic Disease Self-Management and Well-Being in Hemodialysis Patients. NefroHemDergi. 2023;18(2):87-98.

Nefroloji Hemşireliği Dergisi/ Journal of Nephrology Nursing Creative Commons Lisansı Creative Commons Atıf-GayriTicari-Türetilemez 4.0 Uluslararası Lisansı ile lisanslanmıştır.