Sistematik Derlemeler ve Meta Analiz
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Prekonsepsiyonel Bakımda Mobil Aplikasyonların Etkinliğinin Değerlendirilmesi: Bir Sistematik Derleme

Yıl 2024, Cilt: 7 Sayı: 3, 853 - 865
https://doi.org/10.38108/ouhcd.1379709

Öz

Amaç: Bu çalışmanın amacı prekonsepsiyonel bakımda kullanılan mobil aplikasyonların etkinliğini incelemektir.
Yöntem: Bu sistematik derleme çalışması için Google Scholar, PubMed, Cochrane, Science Direct, ProQuest Central ve Web of Science elektronik veri tabanları, makaleler için herhangi bir tarih sınırlaması yapılmadan İngilizce dilinde 07 Haziran-10 Temmuz 2022 tarih aralığında taranmıştır. Taramalar, “mobile”, “mobile intervention”, “mobile health”, “mHealth”, “mobile application” “preconception” anahtar kelimeleri kullanılarak yapılmıştır. Çalışma PRISMA-P kontrol listesine göre raporlandırılmıştır.
Bulgular: Sistematik derlemeye 3’ü randomize kontrollü, 1’i yarı deneysel ve 2’si karma yöntem olmak üzere toplam 6 çalışma dahil edilmiştir. Çalışmaların örneklem grubunu 16-49 yaş aralığındaki toplam 1017 kadın ve 36 erkek birey oluşturmuştur. Dahil edilen çalışmalarda DeDi torRi, PADI, MAMA-EMPOWER ve üç çalışmada Smarter Pregnancy isimli mobil aplikasyon geliştirilerek prekonsepsiyonel bakıma yönelik etkinliği değerlendirilmiştir. Çalışmalarda prekonsepsiyonel bakıma ilişkin geliştirilen mobil aplikasyonların bireylerde sağlıklı yaşam tarzı değişiklikleri oluşturduğu ve anne adaylarının gebeliğe yönelik bilgi düzeylerini artırdığı görülmüştür. Dahil edilen çalışmalarda geliştirilen mobil aplikasyonlar ile, sağlıksız beslenmenin, sigara içme alışkanlıklarının, düşük riskinin, perinatal ve neonatal bakımın tıbbi maliyetlerinin azaldığı görülmüştür.
Sonuç: Genel olarak mobil aplikasyonlar gebeliğe uyumu artırmış, maliyeti düşürmüş, düşük riskini azaltmıştır. Bu olumlu sonuçların yanında mobil aplikasyonların küçük örneklem gruplarında çalışılmış olması sonuçların genellenebilirliğini etkilemektedir. Mobil aplikasyonların daha büyük örneklem grupları ile üreme çağındaki hem kadın hem erkek bireyler üzerinde değerlendirilmesi önerilebilir.

Etik Beyan

Sistematik derlemeye ilişkin veriler literatür taraması ile elde edildiği için etik kurul onayına ihtiyaç duyulmamıştır. Araştırma protokolü, sistematik derleme ve meta-analiz araştırmalarını kayıt altına alan “PROSPERO” veri tabanına CRD42022338106 kayıt numarası ile kaydedilmiştir.

Destekleyen Kurum

Yoktur

Proje Numarası

Yoktur

Teşekkür

Yoktur

Kaynakça

  • Abriyani NNY, Sunarsih T, Rosida L. (2022). Increased knowledge and attitudes of preconception care using the Dedi Torri application. Indonesian Journal of Obstetrics and Gynecology, 10(1), 31-36.
  • Acar Z, Oskay Ü. (2021). Perinatal dönemde kullanılan mobil sağlık uygulamaları ve hemşirenin rolleri. Journal of Education and Research in Nursing, 18(4), 451–456.
  • Baysoy NG, Özkan S. (2012). Gebelik öncesi (prekonsepsiyonel) bakım: Halk sağlığı perspektifi. Gazi Medical Journal, 23(3), 77-90.
  • Centers for Disease Control and Prevention (CDC) 2022 Before Pregnancy. Erişim tarihi:13.04.2022, https://www.cdc.gov/preconception/
  • Degu Ayele A, Temesgen Ayenew N, Getnet Kassa B, Getie Teffera A, Nibret Mihretie G, Dagnew Yehuala E et al. (2022). Preconception care utilization and its associated factors among women in Debre Tabor Town northwest Ethiopia: Community Based Cross-Sectional Study. SAGE Open, 12(2), 21582440221097392.
  • Doğaner G, Gölbaşı Z. (2011). Prekonsepsiyonel danışmanlık. Sürekli Tıp Eğitim Dergisi, 20(5), 215-221.
  • Floyd RL, Johnson KA, Owens JR, Verbiest S, Moore CA, Boyle C. (2013). A national action plan for promoting preconception health and health care in the United States (2012–2014). Journal of Women's Health, 22(10), 797-802.
  • Formda Kal Türkiye 2015. Erişim tarihi:13.02.2023, https://apps.apple.com/tr/app/formda-kal-t%C3% BCrkiye/id964427903?l=tr
  • Gökdemir F, Eryilmaz G. (2017). Prekonsepsiyonel sağlık hizmetleri. Türkiye Klinikleri J Obstet Womens Health Dis Nurs-Special Topics, 3(3), 204-12.
  • Guo H, Zhang Y, Li P, Zhou P, Chen LM, Li SY. (2019). Evaluating the effects of mobile health intervention on weight management, glycemic control and pregnancy outcomes in patients with gestational diabetes mellitus. Journal of Endocrinological Investigation, 42(6), 709-714.
  • Hong QN, Pluye P, Fàbregues S, Bartlett G, Boardman F, Cargo M et al. (2018). The mixed methods appraisal tool (MMAT) version 2018 for information professionals and researchers. Education for Information, 34(4), 285-291. http://mixedmethod sappraisaltoolpublic.pbworks.com/w/file/fetch/127916259/MMAT_2018_criteria -manual_2018-08-01_ENG.pdf
  • JBI. (2020a). Checklist for quasi-experimental studies (non-randomized experimental studies). Critical Appraisal Tools For Use in JBI Systematic Reviews. Joanna Briggs Instıtue. Erişim tarihi:10.06.2022, https://jbi.global/critical-appraisal-tools
  • JBI. (2020b). Checklist for randomized controlled trials. Critical Appraisal Tools For Use in JBI Systematic Reviews. Joanna Briggs Instıtue. Erişim tarihi:10.06.2022, https://jbi.global/critical-appraisal -tools.
  • Kennedy M, Kumar R, Ryan NM, Bennett J, Fuentes GLH, Gould GS. (2021). Codeveloping a multibehavioural mobile phone app to enhance social and emotional well-being and reduce health risks among Aboriginal and Torres Strait Islander women during preconception and pregnancy: a three-phased mixed-methods study. BMJ Open, 11(11), e052545.
  • Kılıç T. (2016). E-sağlık ve teletıp Hollanda ve dünyadan iyi uygulama örnekleriyle. İstanbul: Az Yayıncılık, s. 39-105.
  • Kördeve MK, Uzun B, Ünal E. (2017). Merkezi hastane randevu sisteminin işleyişi üzerine bir alan araştırması. Uluslararası Sağlık Yönetimi ve Stratejileri Araştırma Dergisi, 3(2), 52-61.
  • Lieto AD, Campanile M, Falco MD, Carbone IF, Magenes G, Signorini MG et al. (2011). Prenatal Telemedicine: A New System for Conventional and Computerized Telecardiotocography and Tele-Ultrasonography. Graschew G, Roelofs TA, editors. Advances in Telemedicine: Applications in Various Medical Disciplines and Geographical Regions, InTech, p. 121-154.
  • Liu C, Zhu Q, Holroyd AK, Seng KE. (2011). Status and trends of mobile-health applications for IOS devices: A developer’s perspective. The Journal of Systems and Software, 84(11), 2022-2033.
  • Maslowsky J, Frost S, Hendrick CE, Cruz FOT, Merajver SD. (2016). Effects of postpartum mobile phone-based education on maternal and infant health in Ecuador. International Journal of Gynecology & Obstetrics, 134(1), 93-98.
  • Merkezi Hastane Randevu Sistemi (MHRS). Erişim tarihi:13.01.2023, https://www.mhrs.gov.tr/
  • Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M et al. (2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Reviews, 4(1), 1-9.
  • Nijerya Demografik ve Sağlık Araştırmaları Raporu 2018. Erişim tarihi:13.01.2023, https://www.dhs program.com/pubs/pdf/FR359/FR359.pdf
  • Nwolise CH, Carey N, Shawe J. (2021). Preconception and diabetes information (PADI) app for women with pregestational diabetes: a feasibility and acceptability study. Journal of Healthcare Informatics Research, 5(4), 446-473.
  • Oostingh EC, Ophuis RH, Koster MP, Polinder S, Lingsma HF, Laven JS et al. (2019). Mobile health coaching on nutrition and lifestyle behaviors for subfertile couples using the smarter pregnancy program: model-based cost-effectiveness analysis. JMIR mHealth and uHealth, 7(10), e13935.
  • Rabie NZ, Sandlin AT, Barber KA, Ounpraseuth S, Nembhard W, Magann EF et al. (2017). Teleultrasound: how accurate are we?. Journal of Ultrasound in Medicine, 36(11), 2329-2335.
  • Salem A, Lacour O, Scaringella S, Herinianasolo J, Benski AC, Stancanelli, G et al. (2018). Cross-sectional survey of knowledge of obstetric danger signs among women in rural Madagascar. BMC Pregnancy and Childbirth, 18(1), 1-9.
  • Schweers J, Khalid M, Underwood H, Bishnoi S, Chhugani M. (2016). Mlabour: Design and evaluation of a mobile partograph and labor ward management application. Procedia Engineering, 159, 35-43.
  • Signorini MG, Lanzola G, Torti E, Fanelli A, Magenes G. (2018). Antepartum fetal monitoring through a wearable system and a mobile application. Technologies, 6(2), 44.
  • Silva BMC, Rodrigues JJPC, Canelo F, Lopes IMC, Lloret J. (2019). Towards a cooperative security system for mobile-health applications. Electronic Commerce Research, 19, 629-654.
  • Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M et al. (2016). ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. British Medical Journal, 355.
  • Sterne JA, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I et al. (2019). RoB 2: a revised tool for assessing risk of bias in randomized trials. British Medical Journal, 366.
  • Türkiye İstatistik Kurumu (TÜİK) 2020 Hane Halkı Bilişim Teknolojileri (BT) Kullanım Araştırması. Erişim tarihi:05.05.2022, https://data.tuik.gov.tr/ Bulten/Index?p=Hanehalki-Bilisim-Teknolojileri-(BT)-Kullanim-Arastirmasi-2020-33679
  • Türkiye Nüfus ve Sağlık Araştırması (TNSA) 2018 Analiz ve Raporu. Erişim tarihi:13.02.2023, https://hips.hacettepe.edu.tr/tr/2018_tnsa_analiz_ve_rapor-56
  • Van Dijk MR, Koster MP, Oostingh, EC, Willemsen SP, Steegers EA, Steegers-Theunissen RP. (2020). A mobile app lifestyle intervention to improve healthy nutrition in women before and during early pregnancy: Single-center randomized controlled trial. Journal of Medical Internet Research, 22(5), e15773.
  • Van Dijk, MR, Koster MP, Rosman AN, Steegers-Theunissen RP. (2017a). Opportunities of mhealth in preconception care: preferences and experiences of patients and health care providers and other involved professionals. JMIR mHealth and uHealth, 5(8), e7834.
  • Van Dijk, MR, Oostingh EC, Koster MP, Willemsen SP, Laven JS, Steegers-Theunissen RP. (2017b). The use of the mhealth program smarter pregnancy in preconception care: Rationale, study design and data collection of a randomized controlled trial. BMC Pregnancy and Childbirth, 17(1), 1-7.
  • Woldaregay AZ, Issom DZ, Henriksen A, Marttila H, Mikalsen M, Pfuhl G, Sato K, Lovis C, Hartvigsen G. (2018). Motivational factors for user engagement with mHealth apps. Blobel B, Yang B, editors. Studies in Health Technology and Informatics. Amsterdam: IOS Press, p.151-157.
  • World Health Organization (WHO) 2014 Reducing maternal and child mortality in Zanzibar: Wired Mothers. Erişim tarihi:01.12.2023, https://iris.who .int/bitstream/handle/10665/184986/WHO_RHR_14.33_eng.pdf

Evaluation of the Effectiveness of Mobile Applications in Preconception Care: A Systematic Review

Yıl 2024, Cilt: 7 Sayı: 3, 853 - 865
https://doi.org/10.38108/ouhcd.1379709

Öz

Objective: This study aims to determine the effectiveness of mobile applications used in preconception care.
Methods: For this systematic review, electronic databases of Google Scholar, PubMed, Cochrane, Science Direct, ProQuest Central, and Web of Science were searched in English between 07 June and 10 July 2022, without any date limitation for the articles. Searches were made using the keywords "mobile," "mobile intervention," "mobile health", "mHealth", "mobile application" and "preconception". The study was reported according to the PRISMA-P checklist.
Results: A total of 6 studies, 3 randomized controlled, 1 quasi-experimental, and 2 mixed methods were included in the systematic review. The sample group of the studies consisted of 1017 female and 36 male individuals between the ages of 16-49. In the included studies, DeDi-torRi, PADI, MAMA-EMPOWER, and three studies, the Smarter Pregnancy mobile application was developed, and its effectiveness for preconception care was evaluated. Studies show it has been seen that mobile applications developed for preconception care create healthy lifestyle changes in individuals and increase the knowledge level of expectant mothers about pregnancy. Mobile applications developed in the included studies showed that unhealthy diet, smoking habits, miscarriage risk, and medical costs of perinatal and neonatal care were reduced.
Conclusion: In general, mobile applications have increased compliance with pregnancy, reduced cost, and reduced the risk of miscarriage. Evaluating mobile applications on larger sample groups and male and female individuals of reproductive age may be recommended.

Proje Numarası

Yoktur

Kaynakça

  • Abriyani NNY, Sunarsih T, Rosida L. (2022). Increased knowledge and attitudes of preconception care using the Dedi Torri application. Indonesian Journal of Obstetrics and Gynecology, 10(1), 31-36.
  • Acar Z, Oskay Ü. (2021). Perinatal dönemde kullanılan mobil sağlık uygulamaları ve hemşirenin rolleri. Journal of Education and Research in Nursing, 18(4), 451–456.
  • Baysoy NG, Özkan S. (2012). Gebelik öncesi (prekonsepsiyonel) bakım: Halk sağlığı perspektifi. Gazi Medical Journal, 23(3), 77-90.
  • Centers for Disease Control and Prevention (CDC) 2022 Before Pregnancy. Erişim tarihi:13.04.2022, https://www.cdc.gov/preconception/
  • Degu Ayele A, Temesgen Ayenew N, Getnet Kassa B, Getie Teffera A, Nibret Mihretie G, Dagnew Yehuala E et al. (2022). Preconception care utilization and its associated factors among women in Debre Tabor Town northwest Ethiopia: Community Based Cross-Sectional Study. SAGE Open, 12(2), 21582440221097392.
  • Doğaner G, Gölbaşı Z. (2011). Prekonsepsiyonel danışmanlık. Sürekli Tıp Eğitim Dergisi, 20(5), 215-221.
  • Floyd RL, Johnson KA, Owens JR, Verbiest S, Moore CA, Boyle C. (2013). A national action plan for promoting preconception health and health care in the United States (2012–2014). Journal of Women's Health, 22(10), 797-802.
  • Formda Kal Türkiye 2015. Erişim tarihi:13.02.2023, https://apps.apple.com/tr/app/formda-kal-t%C3% BCrkiye/id964427903?l=tr
  • Gökdemir F, Eryilmaz G. (2017). Prekonsepsiyonel sağlık hizmetleri. Türkiye Klinikleri J Obstet Womens Health Dis Nurs-Special Topics, 3(3), 204-12.
  • Guo H, Zhang Y, Li P, Zhou P, Chen LM, Li SY. (2019). Evaluating the effects of mobile health intervention on weight management, glycemic control and pregnancy outcomes in patients with gestational diabetes mellitus. Journal of Endocrinological Investigation, 42(6), 709-714.
  • Hong QN, Pluye P, Fàbregues S, Bartlett G, Boardman F, Cargo M et al. (2018). The mixed methods appraisal tool (MMAT) version 2018 for information professionals and researchers. Education for Information, 34(4), 285-291. http://mixedmethod sappraisaltoolpublic.pbworks.com/w/file/fetch/127916259/MMAT_2018_criteria -manual_2018-08-01_ENG.pdf
  • JBI. (2020a). Checklist for quasi-experimental studies (non-randomized experimental studies). Critical Appraisal Tools For Use in JBI Systematic Reviews. Joanna Briggs Instıtue. Erişim tarihi:10.06.2022, https://jbi.global/critical-appraisal-tools
  • JBI. (2020b). Checklist for randomized controlled trials. Critical Appraisal Tools For Use in JBI Systematic Reviews. Joanna Briggs Instıtue. Erişim tarihi:10.06.2022, https://jbi.global/critical-appraisal -tools.
  • Kennedy M, Kumar R, Ryan NM, Bennett J, Fuentes GLH, Gould GS. (2021). Codeveloping a multibehavioural mobile phone app to enhance social and emotional well-being and reduce health risks among Aboriginal and Torres Strait Islander women during preconception and pregnancy: a three-phased mixed-methods study. BMJ Open, 11(11), e052545.
  • Kılıç T. (2016). E-sağlık ve teletıp Hollanda ve dünyadan iyi uygulama örnekleriyle. İstanbul: Az Yayıncılık, s. 39-105.
  • Kördeve MK, Uzun B, Ünal E. (2017). Merkezi hastane randevu sisteminin işleyişi üzerine bir alan araştırması. Uluslararası Sağlık Yönetimi ve Stratejileri Araştırma Dergisi, 3(2), 52-61.
  • Lieto AD, Campanile M, Falco MD, Carbone IF, Magenes G, Signorini MG et al. (2011). Prenatal Telemedicine: A New System for Conventional and Computerized Telecardiotocography and Tele-Ultrasonography. Graschew G, Roelofs TA, editors. Advances in Telemedicine: Applications in Various Medical Disciplines and Geographical Regions, InTech, p. 121-154.
  • Liu C, Zhu Q, Holroyd AK, Seng KE. (2011). Status and trends of mobile-health applications for IOS devices: A developer’s perspective. The Journal of Systems and Software, 84(11), 2022-2033.
  • Maslowsky J, Frost S, Hendrick CE, Cruz FOT, Merajver SD. (2016). Effects of postpartum mobile phone-based education on maternal and infant health in Ecuador. International Journal of Gynecology & Obstetrics, 134(1), 93-98.
  • Merkezi Hastane Randevu Sistemi (MHRS). Erişim tarihi:13.01.2023, https://www.mhrs.gov.tr/
  • Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M et al. (2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Reviews, 4(1), 1-9.
  • Nijerya Demografik ve Sağlık Araştırmaları Raporu 2018. Erişim tarihi:13.01.2023, https://www.dhs program.com/pubs/pdf/FR359/FR359.pdf
  • Nwolise CH, Carey N, Shawe J. (2021). Preconception and diabetes information (PADI) app for women with pregestational diabetes: a feasibility and acceptability study. Journal of Healthcare Informatics Research, 5(4), 446-473.
  • Oostingh EC, Ophuis RH, Koster MP, Polinder S, Lingsma HF, Laven JS et al. (2019). Mobile health coaching on nutrition and lifestyle behaviors for subfertile couples using the smarter pregnancy program: model-based cost-effectiveness analysis. JMIR mHealth and uHealth, 7(10), e13935.
  • Rabie NZ, Sandlin AT, Barber KA, Ounpraseuth S, Nembhard W, Magann EF et al. (2017). Teleultrasound: how accurate are we?. Journal of Ultrasound in Medicine, 36(11), 2329-2335.
  • Salem A, Lacour O, Scaringella S, Herinianasolo J, Benski AC, Stancanelli, G et al. (2018). Cross-sectional survey of knowledge of obstetric danger signs among women in rural Madagascar. BMC Pregnancy and Childbirth, 18(1), 1-9.
  • Schweers J, Khalid M, Underwood H, Bishnoi S, Chhugani M. (2016). Mlabour: Design and evaluation of a mobile partograph and labor ward management application. Procedia Engineering, 159, 35-43.
  • Signorini MG, Lanzola G, Torti E, Fanelli A, Magenes G. (2018). Antepartum fetal monitoring through a wearable system and a mobile application. Technologies, 6(2), 44.
  • Silva BMC, Rodrigues JJPC, Canelo F, Lopes IMC, Lloret J. (2019). Towards a cooperative security system for mobile-health applications. Electronic Commerce Research, 19, 629-654.
  • Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M et al. (2016). ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. British Medical Journal, 355.
  • Sterne JA, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I et al. (2019). RoB 2: a revised tool for assessing risk of bias in randomized trials. British Medical Journal, 366.
  • Türkiye İstatistik Kurumu (TÜİK) 2020 Hane Halkı Bilişim Teknolojileri (BT) Kullanım Araştırması. Erişim tarihi:05.05.2022, https://data.tuik.gov.tr/ Bulten/Index?p=Hanehalki-Bilisim-Teknolojileri-(BT)-Kullanim-Arastirmasi-2020-33679
  • Türkiye Nüfus ve Sağlık Araştırması (TNSA) 2018 Analiz ve Raporu. Erişim tarihi:13.02.2023, https://hips.hacettepe.edu.tr/tr/2018_tnsa_analiz_ve_rapor-56
  • Van Dijk MR, Koster MP, Oostingh, EC, Willemsen SP, Steegers EA, Steegers-Theunissen RP. (2020). A mobile app lifestyle intervention to improve healthy nutrition in women before and during early pregnancy: Single-center randomized controlled trial. Journal of Medical Internet Research, 22(5), e15773.
  • Van Dijk, MR, Koster MP, Rosman AN, Steegers-Theunissen RP. (2017a). Opportunities of mhealth in preconception care: preferences and experiences of patients and health care providers and other involved professionals. JMIR mHealth and uHealth, 5(8), e7834.
  • Van Dijk, MR, Oostingh EC, Koster MP, Willemsen SP, Laven JS, Steegers-Theunissen RP. (2017b). The use of the mhealth program smarter pregnancy in preconception care: Rationale, study design and data collection of a randomized controlled trial. BMC Pregnancy and Childbirth, 17(1), 1-7.
  • Woldaregay AZ, Issom DZ, Henriksen A, Marttila H, Mikalsen M, Pfuhl G, Sato K, Lovis C, Hartvigsen G. (2018). Motivational factors for user engagement with mHealth apps. Blobel B, Yang B, editors. Studies in Health Technology and Informatics. Amsterdam: IOS Press, p.151-157.
  • World Health Organization (WHO) 2014 Reducing maternal and child mortality in Zanzibar: Wired Mothers. Erişim tarihi:01.12.2023, https://iris.who .int/bitstream/handle/10665/184986/WHO_RHR_14.33_eng.pdf
Toplam 38 adet kaynakça vardır.

Ayrıntılar

Birincil Dil Türkçe
Konular Halk Sağlığı Hemşireliği
Bölüm Sistematik Derleme
Yazarlar

Lütfiye Parlak 0000-0001-8481-3874

Pınar Duru 0000-0002-3471-1383

Özlem Örsal 0000-0002-4494-8587

Proje Numarası Yoktur
Erken Görünüm Tarihi 12 Kasım 2024
Yayımlanma Tarihi
Gönderilme Tarihi 22 Ekim 2023
Kabul Tarihi 30 Ocak 2024
Yayımlandığı Sayı Yıl 2024 Cilt: 7 Sayı: 3

Kaynak Göster

APA Parlak, L., Duru, P., & Örsal, Ö. (2024). Prekonsepsiyonel Bakımda Mobil Aplikasyonların Etkinliğinin Değerlendirilmesi: Bir Sistematik Derleme. Ordu Üniversitesi Hemşirelik Çalışmaları Dergisi, 7(3), 853-865. https://doi.org/10.38108/ouhcd.1379709