Unraveling the Link Between Childhood Psychological Maltreatment and Mental Well-Being: The Serial Mediation Role of Family Belongingness,Family Coherence,and Loneliness

Abstract

Childhood psychological maltreatment has a significant impact on family-related factors and adult mental health, emphasizing the importance of investigating its effects and developing appropriate interventions. Loneliness is also an important factor that needs further exploration in relation to these variables. This study aims to gain a better understanding of the relationship between these variables and to examine the role of family belongingness, family sense of coherence, and loneliness as chain mediators between childhood psychological maltreatment and adult mental well-being. Data from 369 participants residing in 46 different cities in Turkey were analyzed. The participants were selected to represent a diverse range of backgrounds and living conditions, predominantly female (n = 282, 76.4%) and well educated (n = 300, 81.3%). A structural mediation model was used to analyze the data. The variables of childhood psychological maltreatment, family belongingness, family sense of coherence, loneliness, and adult mental well-being were measured and examined for their relationships. The findings of the study indicated that family belongingness, family sense of coherence, and loneliness mediate the association between childhood psychological maltreatment and adult mental well-being. Childhood psychological maltreatment poses a risk to a positive family sense of coherence and family belongingness, while loneliness emerges as a significant factor affecting adult mental well-being. These findings highlight the importance of addressing childhood maltreatment and promoting family support and coherence to enhance mental well-being in adulthood. Further research and interventions in this area are warranted.

Keywords

psychological maltreatment family belongingness family sense of coherence loneliness mental well-being

Introduction

The family is the primary and most fundamental social environment for a child's psychological development, playing a crucial role in the formation of an individual's overall personality (Bronfenbrenner, 1986). The child's individual development within the context of the family is heavily influenced by the parents’ manners and behaviors (Glaser, 2002). Psychological maltreatment focuses on these parenting behaviors and parent–child relationships, which influence a child's emotional, mental, cognitive, and relational construct adversely. It refers to the damaging attitude and behavior of caregivers toward a child, which contains emotional and psychological abuse and neglect (McGee & Wolfe, 1991). Spurning, isolating, terrorizing, corrupting/exploiting, denying emotional responsiveness, and neglecting mental health, medical, and educational needs are core components of psychological maltreatment (ASPAC, 1995). In the long term, psychological maltreatment has shown disruptive effects on individuals such as cannabis abuse (Abajobir et al., 2017), a propensity for antisocial behavior (Braga et al., 2018), and poor and dysfunctional emotion regulation (Gruhn & Compas, 2020). Examining individuals in precarious living conditions revealed that they had a history of maltreatment and were exposed to intimate partner violence (Chen & Chu, 2021). In addition, there are some clinical outcomes such as depression, substance abuse, anxiety, and psychopathological disorders caused by exposure to childhood maltreatment (Xiao et al., 2021).

Psychological maltreatment poses a significant threat as it fails to meet the emotional needs of love, belonging, and acceptance (Hart et al., 1997). It has been noted that psychological maltreatment is closely intertwined with family dynamics (Glaser, 2002; Hart & Brassard, 1987), suggesting its potential impact on family belongingness. Belongingness refers to the attachment and acceptance from others, encompassing an individual's inclination to nurture and safeguard social relationships (Baumeister & Leary, 1995). Theorists emphasize the innate human need for belongingness (Maslow, 1968), portraying it as an adaptive drive for social connections (Kelly, 2001). Research has shown that individuals who have experienced rejection tend to recall social events, regardless of their positive or negative nature (Gardner et al., 2000). In essence, fostering a sense of belongingness leads to heightened attentiveness to social information relevant to others.

The family serves as the primary source of the sense of belongingness, and family belongingness plays a pivotal role in shaping an individual's psychosocial well-being (Baumeister & Leary, 1995). Research by Ngai and Ngu (2013) has shown that perceived social support significantly enhances family belongingness, reduces symptoms of depression during the transition to motherhood, and improves overall life quality. Moreover, family belongingness has been found to promote proactive measures in response to COVID-19, with participants displaying heightened dedication and a sense of connection to their family members (Marinthe et al., 2022). Moreover, fostering a sense of family belongingness plays a crucial role in preventing suicidal ideation and mitigating the risk of suicidal behavior (Parra et al., 2021).

One characteristic of family belongingness is the cultivation of a sense of teamwork within the family, which fosters higher motivation for collaborative decision-making (Kelley & Thibaut, 1978; Marinthe et al., 2022). The existence of rules and their applicability in the family are the features that show the existence of family coherence. At this point, it can be said that family coherence and family belongingness are related. Family coherence was derived from the concept of personal sense of coherence. A sense of coherence states a person's perspective on life and being able to take a stance in the face of a difficult situation. Just as there is a personal sense of coherence, there is also a family sense of coherence that shapes the family's relationship with the outside world (Antonovsky, 1987). Comprehensibility, manageability, and meaningfulness are three components of the sense of coherence. Comprehensibility is the cognitive component of the sense of coherence and refers to internal and external stimuli that could be understandably perceived. Manageability pertains to the behavioral aspect, encompassing the recognition of resources to cope with challenging situations. Lastly, meaningfulness represents the motivational component, reflecting the belief that efforts invested in life are valuable and life itself is worth living, as opposed to viewing life and its struggles as futile (Eriksson, 2017).

Family coherence is the perception of high comprehensibility, meaningfulness, and manageability in one's family. Children and adolescents with a family sense of coherence can cope better with stressful events and situations because they believe that the effort they will make to cope is meaningful (Antonovsky, 1987). It has been observed that children who have a family sense of coherence also have more positive and satisfactory friendship relationships (Idan et al., 2017). Therefore, one's sense of family coherence could be a protective variable against loneliness. Studies revealed that the children of parents who have a sense of coherence feel less lonely (Idan et al., 2017).

Loneliness is characterized by the feeling of being isolated from others, the lack of numbers, or the poor quality of existing and desired relationships (Peplau & Perlman, 1982). Loneliness is a factor that affects depression and anxiety problems (Moeller & Seehuus, 2019), and these effects have been found to be long term in longitudinal studies (Jose & Lim, 2014; Vanhalst et al., 2012). Studies have shown that loneliness has an indirect negative effect on the academic outcomes of young people and adolescents. It predicts procrastination and low academic achievement (Freyhofer et al., 2021). Research has shown that it is important to reduce the loneliness levels of individuals because of its unfavorable consequences. Family coherence is thought to be a concept that will reduce loneliness. As mentioned above, the sense of family coherence expresses the cooperation, solidarity, trust, and togetherness of family members. On the other hand, the factors that determine loneliness are the satisfaction of the relationship and the perception of the person towards this satisfaction, rather than the number of people with whom a relationship is established (Heinrich & Gullone, 2006). Individuals who grow up and live in families with a sense of coherence can establish healthy relationships.

Mental well-being is used instead of the concept of positive mental health and shows the psychological and emotional functionality of individuals (Tennant et al., 2007). In addition to a healthy body and mind, mental well-being has a wide scope that includes features such as trust in interpersonal relationships, openness to interaction, ability to maintain relationships, striving for success and achieving success, and getting satisfaction from life (Beiser, 1974). The objective of improving well-being by actively engaging individuals of all ages in various aspects of life, including individual, social, and academic domains, has gained momentum in the field through research efforts. These definitions suggest that mental well-being is more than just not being ill and is characterized by a holistic framework (Stewart-Brown, 2013). At this point, WHO (2014) emphasizes the social determinants of mental health. Highlighting the positive correlation between mental health and well-being, the assertion is made that fostering healthy parental behaviors and cultivating social support networks can promote mental well-being. Therefore, the main objective of this study was to explore the extent to which mental well-being can be explained by psychological maltreatment, family belongingness, family coherence, and loneliness as interpersonal factors.

The Present Study

Negative parental attitudes and adverse childhood experiences can have long-lasting impacts on individuals’ lives, affecting their present circumstances and future trajectories (Lowell et al., 2014). This study focuses on the psychological maltreatment experienced during childhood and adolescence and its influence on the mental well-being of adults. Additionally, the roles of family belongingness, family sense of coherence, and loneliness in this relationship are examined. Previous research has explored the relationship between belongingness and loneliness, revealing conflicting notions (Yildiz, 2016). However, the potential contribution of family sense of coherence in this relationship remains unexplored in the literature. Furthermore, the unique value of this study lies in investigating these variables together, providing a comprehensive understanding of the association between psychological maltreatment and well-being. Therefore, the hypotheses (H) of this study are presented below.

H1: Family belongingness, family coherence, and loneliness have mediating roles in the relationship between childhood psychological maltreatment and mental well-being.

Method

Study Procedures

All studies included in this research adhered to the principles outlined in the Helsinki Declaration of 1975, as revised in 2000. Approval for the study was obtained from the Yıldız Technıcal University Scientific Research and Ethical Review Board. Data were collected from voluntary participants through an online survey. Participants were provided with informed consent and had the freedom to discontinue their participation at any time. The data collection process was carried out by the researchers.

Participants

The study included a total of 369 participants residing in 46 different cities in Turkey. The average age of the participants was 22.10 years (SD = 5.27 years, range: 18–61 years). Of the participants, 282 identified as women and 87 as men. The majority of participants (n = 300, 81.3%) were university students. In terms of socio-economic status (SES), 59 participants (16%) had a low SES, 228 participants (61.8%) had a middle SES, and 82 participants (22.3%) had a high SES. Regarding the number of siblings, most participants reported having two (n = 167, 45.3%) or three (n = 110, 29.8%) siblings. Table 1 shows further information about the participants.

Table 1.

Participants’ Characteristics.

Variable	Frequency	%
Gender
Female	282	76.4
Male	87	23.6
Educational status
High school or below	14	3.8
University	335	90.8
Master/PhD	20	5.4
Employee status
Employee	95	74.3
Unemployed	274	25.7
Perceived socio-economic status
Poor	59	16.0
Moderate	228	61.8
Good	82	22.2

Measures

Psychological maltreatment questionnaire. PMQ was developed by Arslan (2015, 2017) to measure the psychological maltreatment of individuals by their parents. The two-dimensional scale comprises 12 items (e.g., “My parent gives me offensive, hurtful nicknames”) rated on a 4-point Likert scale, with 1 (almost never) and 4 (almost always). The score range of the scale is from 12 to 48. Higher scores show a higher level of psychological maltreatment. Cronbach's α was found to be 0.81. (Arslan, 2015; 2017).

The family sense of coherence scale. The original scale was developed by Antonovsky and Sourani (1988) to measure the family's perception of the world as comprehensible, meaningful, and manageable. Sagy (1998) reformed it into a 12-item short form (e.g. “Is there a feeling in your family that everyone understands everyone else well?”). It comprises three dimensions and had good internal consistency (Cronbach's α = 0.81). The scale is rated on a 7-point Likert with 1 (often) and 7 (rarely or never). The score ranges from 7 to 84. The higher score obtained from the scale means the level of family sense of coherence increases. The Turkish adaptation of the scale was performed by Çeçen (2007). Cronbach's α was found to be 0.80 in the adaptation study.

Family sense of belongingness scale. The scale was developed by Mavili et al. (2014). The two-dimensional scale includes 17 items (e.g., “I strongly feel an attachment to my family”). It is rated on a 5-point Likert scale with 1 (totally disagree) and 5 (totally agree). The total score obtained from the scale is 17–85. The higher score indicates a higher family sense of belongingness. Cronbach's α was found to be 0.94.

UCLA loneliness scale short form. Russell et al. (1978) originally developed the scale, and it included 20 items. The short form of the scale was developed by Hays and DiMatteo (1987). The uni-dimensional scale comprises 8 items (e.g., “There is no one I can turn to”) rated on a 4-point Likert scale, with 1 (never) and 4 (always). The total score obtained from the scale is 8 to 32. The higher scale obtained from the scale indicates higher loneliness. The scale was adapted into Turkish by Doğan et al. (2011). Cronbach's α was found to be 0.71.

Warwick–Edinburgh mental well-being scale short form. The scale was developed by Tennant et al. (2007) to measure the mental well-being of individuals. The short form of the scale was developed by Haver et al., (2015). The uni-dimensional scale comprises 7 items (e.g., “I have been feeling optimistic about the future”) rated on a 5-point Likert scale, with 1 (none of the time) and 5 (all of the time). The total score obtained from the scale is 7 to 35. A higher score indicates higher mental well-being. Internal consistency was calculated for two samples. Cronbach's α was found to be 0.84 for the Norway sample and 0.86 for the Sweden sample. The Turkish version of the scale was validated by Demirtaş and Baytemir (2019).

Data Analysis

Descriptive statistics were performed using IBM SPSS Statistics 26.0 and JASP 0.16.4. Skewness and kurtosis values were controlled for parametric tests. Pearson's correlation coefficients and reliabilities (Cronbach's α, McDonald's omega ω, and Guttman's lambda λ⁶) were calculated as preliminary analyses. The mediation roles of family belongingness, family sense of coherence, and loneliness were investigated between psychological maltreatment and mental well-being via structural equation modeling (SEM). SEM was conducted in AMOS Graphics. A two-step approach was used to discover research questions from the point of view of Anderson and Gerbing's (1988) recommendations. Firstly, the measurement model was tested. Secondly, the hypothetical model was tested. Standardized Root Mean Square Residual, Root Mean Square Error Approximation, Comparative Fit Index, Normed Fit Index, Goodness of Fit Index, and Incremental Fit Index were accepted as the model fit indexes. In the relevant literature, the values of SRMR and RMSEA should be smaller than 0.08 and the values of CFI, NFI, GFI, and IFI should be greater than 0.90 (Hoyle & Panter, 1995). Gender and socio-economic status were controlled as covariates. To evaluate the significance of the mediating variable, we used a bootstrapping method with 5,000 samples, which allowed us to generate 95% confidence intervals (CIs) for the indirect effects. Following Hayes’ (2018) recommendations, we considered indirect effects to be statistically significant if their bootstrapped 95% CIs did not include zero. We used the specific indirect effects estimation and plugin proposed by Gaskin et al. (2020) to evaluate the specific indirect effects and their significance. This method enables a more precise estimation of the specific indirect effects and their statistical importance.

Results

Descriptive Statistics and Correlation Analyses

Descriptive statistics, reliabilities, and correlations among variables are presented in Table 2. Considering Nunnally and Bernstein's (1994) recommendation, it can be stated that the alpha, omega, and lamp reliability coefficients of all variables are above 0.70 and acceptable. As expected, all variables were significantly related to each other. Psychological maltreatment was significantly and negatively related to family belongingness (r = −.65, p < .01), family sense of coherence (r = −.67, p < .01), mental well-being (r = −.33, p < .01), positively related to loneliness (r = .40, p < .01).

Table 2.

Correlations and Descriptive Statistics Among the Variables.

Variable	Correlations				Descriptive Statistics and Reliabilities
	1	2	3	4	Mean	SD	Skewness	Kurtosis	α	ω	λ⁶
1. Psychological maltreatment	–				20.56	7.04	0.925	0.401	0.90	0.90	0.91
2. Family belongingness	−.65**	–			62.88	8.10	−0.814	0.453	0.75	0.82	0.88
3. Family sense of coherence	−.67**	.72**	–		54.79	12.59	−0.318	−0.227	0.86	0.86	0.87
4. Loneliness	.40**	−.30**	−.38**	–	13.25	4.96	1.023	0.384	0.85	0.86	0.85
5. Mental well-being	−.33**	.32**	.45**	−.54**	25.56	5.68	−0.434	−0.220	0.87	0.88	0.87

Note. ** p < .01.

Structural Equation Modeling

Measurement model. The measurement model consisted of five latent variables (psychological maltreatment, family belongingness, family sense of coherence, loneliness, and mental well-being) and 11 observed variables. It showed good fit indices: χ²_{(34, N = 369)}= 97,830, p < .001; SRMR = 0.032; RMSEA = 0.071; CFI = 0.975; NFI = 0.962; GFI = 0.955; IFI = 0.975. Factor loadings ranged from 0.477 to 0.947 and were significant. Therefore, all indicators were representative of their latent variables.

Structural model. It was found to have acceptable fit indices of the full mediation model, which is based on the theoretical perspective. The model (Figure 1) showed a good fit to the data: χ²_{(52, N} _= 369)= 167.719, p < .001; SRMR = 0.640; RMSEA = 0.078; CFI = 0.955; NFI = 0.937; GFI = 0.938; IFI = 0.956. The mediation model showed that lower psychological maltreatment predicted higher family belongingness (γ = −0.76, p < .01) and higher family sense of coherence (γ = −0.29, p < .01). Additionally, a higher level of family belongingness was associated with a higher level of family sense of coherence (γ = −0.64, p < .05) and a higher level of mental well-being (γ = 0.21, p < .01). As expected, a higher family sense of coherence predicted lower loneliness (γ = −0.42, p < .01), and lower loneliness predicted a higher level of mental well-being (γ = −0.51, p < .01).

Figure 1.

The result of final serial multiple mediational model, **p < .01.

According to the bootstrap analysis, the study discovered a direct negative impact of psychological maltreatment during childhood on mental well-being. The total effect showed a coefficient of B = −0.320, p < .001. When the mediators were taken into account, the coefficient was still statistically significant, although reduced (direct effect, B = −0.300, p < .05). The study found a significant mediating pathway between childhood psychological maltreatment, family belongingness, family sense of coherence, and mental well-being (β = −0.048, bootstrapping CI = [−0.110, −0.009]), supporting a serial mediation relationship. The values showing the mediation effect of this and other paths are given in Table 3.

Table 3.

Indirect Effect of Childhood Psychological Maltreatment on Mental Well-Being via Family Belongingness, Family Sense of Coherence, and Loneliness.

Path	Coefficient	95%CI
Path	Coefficient	LL	UL
Childhood PM → family SoC → mental WB	−0.050	−0.108	−0.013
Childhood PM → loneliness → mental WB	−0.107	−0.194	−0.025
Childhood PM → family belongingness → family SoC → mental WB	−0.089	−0.171	−0.035
Childhood PM → family SoC → loneliness → mental WB	−0.027	−0.078	−0.004
Childhood PM → family belongingness → family SoC → Loneliness → mental WB	−0.048	−0.110	−0.009
Total effect	−0.320	−0.405	−0.232
Direct effect	−0.300	−0.400	0.001

Note. CI=confidence interval; LL=lower limit; UL=upper limit; PM=psychological maltreatment; SoC=sense of coherence; WB=well-being.

Discussion

Childhood and adolescent experiences are an internal representation of the establishment of balance in intrapersonal and interpersonal relationships in later life stages. Hence, it is important to investigate what protective factors can reduce the negative effects of childhood psychological maltreatment (Reyome, 2010). It has been investigated what the mediating roles of family belongingness, family sense of coherence, and loneliness are in the relationship between psychological maltreatment and mental well-being.

The full mediation model was supported as hypothesized. Psychological maltreatment significantly predicted family belongingness. The need to belong develops in a family-centered manner, especially during childhood, and this is more possible if the family context provides an environment of consistency and trust (Allen et al., 2022). It is also related to affectionate and positive relationships (Baumeister & Leary, 1995). Psychological maltreatment is the untrustworthy, devaluing, and unloving demeanor of parents (Hart & Brassard, 1987). Due to its features, it does not offer a secure environment for the formation of a sense of family belongingness. Therefore, it can be said based on the findings that individuals who do not experience maltreatment can develop a sense of family belongingness. Previous studies demonstrated that psychological maltreatment impaired general belonging (Arslan, 2022). Psychological maltreatment also predicted the family sense of coherence. Psychological maltreatment is reflected in the parent's inconsistent, unpredictable, and unbalanced behavior. They do not put clear and open boundaries for their children (Glaser, 2002). Thus, family dynamics are built on uncertainty and insecurity in terms of the child (Hart & Brassard, 1987). The fact that the child is a victim of psychological maltreatment may manifest itself as a lack of sense of coherence toward his family.

Another significant relationship is the path from family belongingness to the family sense of coherence. Baumeister and Leary (1995) stated that individuals who need to belong desire consistent and predictable relationships, free from uncertain or disappointing relationships. Thus, they can meet their need for belonging by feeling secure. Positive family relationships were found to be a predictor of the family sense of belongingness of adolescents (Margalit & Eysenck, 1990). On the other hand, social support and strong emotional bonds are supporting factors for developing a family sense of coherence (Mittelmark & Bauer, 2022). The family's acting in a body and meeting on a common ground create the feeling of a family sense of coherence (Eriksson, 2017). The increase in the feelings of closeness, togetherness, and acceptance toward one's family may contribute to a higher level of family sense of coherence. Furthermore, it has been found out that with the increase in the sense of coherence in adolescents, their physical and psychological health increases (Garcia-Moya et al., 2013).

Bronfenbrenner (1986) proposed that positive contextual characteristics are protective factors for young individuals. Family sense of coherence has been identified as a protective feature for both family and individual well-being during challenging situations (Idan et al., 2017). Loneliness is regarded as a stress-inducing factor, and the family is believed to play a role in protecting against loneliness (de Jong Gierveld, 1998). Previous studies have shown that a higher sense of coherence is associated with lower levels of loneliness (Al-Yagon & Margalit, 2006), and it directly and negatively correlates with social and emotional loneliness in clinical samples (Drageset et al., 2012). Sagy and Dotan (2001) reported that a family sense of coherence enhances coping skills in maltreated children, indicating that having clear rules and attainable goals within the family contributes to children's confidence in dealing with problems. Results of the current study suggest that individuals with a stronger sense of coherence may be less prone to experiencing loneliness by enhancing their competence and coping abilities. Building and maintaining satisfactory relationships with others are among the factors that positively influence mental health (Diener et al., 2018). In conclusion, this study demonstrates that childhood psychological maltreatment has a detrimental role on adults’ sense of family belonging and cohesion, which in turn contributes to increased feelings of loneliness and ultimately a decline in their mental well-being. Our findings indirectly provide new insights into how well-being can be reduced due to maltreatment, taking existing research findings one step further. Besides, the relationships between the variables examined provide new perspectives on both mental health and family studies. Culturally specific interpretations are crucial in understanding this exposure. According to Sunar and Fisek (2005), despite a trend toward increasing autonomy and independence among young adults in Turkish culture, there remains a contemporary shift where they continue to maintain financial and emotional ties with their families even after marriage. Kagitcibasi (2005) suggested that individuals navigate this changing landscape by becoming more autonomous-related. Considering these cultural dynamics, experiencing maltreatment within the family may diminish the perceived value and meaning of the family concept for individuals. Failure to cope with the effects of maltreatment may result in adverse outcomes, such as weakened mental well-being, which can manifest as loneliness. Given this cultural perspective, empirical studies that address well-being within the family context are necessary. This study serves as a bridge for future research in this evolving field.

Limitations

This study has several limitations. Firstly, cross-sectional data was utilized, which hinders the establishment of causal relationships between variables. Future research should consider employing experimental or longitudinal designs to explore causality. Secondly, the majority of participants were single university students, limiting the generalizability of the findings. It would be valuable to replicate the study with diverse populations, including married individuals and different cultures. Thirdly, the study's limitation is the predominance of women, constituting 75% of the sample. Future research endeavors may seek to achieve a more balanced gender distribution. Additionally, alternative sampling techniques could be employed to enhance the representativeness of the sample. Fourthly, qualitative studies can be designed to reflect the experiences of the participants in depth. Lastly, the use of self-reported scales introduces subjectivity, as the findings rely solely on individuals’ perceptions. To address this limitation, the development of dyadic self-report scales or the integration of qualitative methods could provide a more comprehensive understanding of the subject matter. Furthermore, future studies could consider incorporating relationship satisfaction or spouse support as a dependent variable to further expand the scope of the research.

Implications

This study offers valuable suggestions for professional counseling groups. Its findings highlight the significant role that childhood psychological maltreatment plays in the current mental well-being of individuals. To promote healthy mental development, it is crucial for parents to distinguish between maltreatment and non-maltreatment behaviors, acquiring the necessary skills to engage with their children appropriately. Individuals who experienced childhood parental maltreatment may struggle to establish family cohesion and a sense of belonging in their own marriages. During the premarital process, counselors can assist clients in acquiring these qualities by employing an instructive approach. Counselors with a systemic approach play a prominent role in understanding individuals within the family system and fostering insight. Therapists should consider these insights when working with clients who may have difficulty being active, productive, and experiencing positive emotions in life. Marriage and family counselors can actively contribute to this process by facilitating the acquisition of skills that enhance a sense of family belonging and coherence. These skills may include spending quality time together, making collective decisions, and fostering an environment where family members feel comfortable expressing their views. Additionally, these developments during family counseling may potentially reduce feelings of loneliness in individuals grappling with such issues.

Footnotes

Availability of Data and Material

Data will be available on request.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval

The study protocol has been approved by Yildiz Technical University Scientific Research and Ethical Review Board (Report Number: 20221201728). The study was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its following updates.

Consent to Participate

Informed consent was obtained from all the individual participants that were included in the study.

ORCID iD

Zahide Gul Karaagac

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