Keywords
Issue: Volume 65 - Issue 1 - January 2019 ISSN 2640-5245
Index: Wound Manage Prev. 2019;65(1):20–27.
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Abstract
Research related to the design and development of new incontinence containment products for women is scarce. Purpose: The purpose of this 2-part study was to 1) develop a new incontinence containment product for fecal incontinence and 2) examine the effect of this new product on the occurrence of incontinence-associated dermatitis (IAD). Methods: In part 1, a new incontinence containment product was designed, developed, and trialed among 10 healthy female volunteers. The product was comprised of a double layer of polypropylene nonwoven fabric and 100% cotton interlock fabric with a 3-ply 100% cotton interlock fabric added into the perianal section. Participants wore the product for 8 hours and were asked to defecate into the product and evaluate its comfort, ability to contain liquids and protect privacy, any personal allergic reaction, and air permeability. In part 2, after any product modifications, 12 bedridden women treated in the neurology unit of a hospital in western Turkey who had an indwelling urinary catheter and fecal incontinence and who did not have diabetes mellitus, a darkly pigmented area in the perianal area, pressure injury, or erythema were randomized to 2 groups (study product and control, a premium adult diaper) and monitored for 8 days for the development and severity of perineal dermatitis (scored from 0 [no erythema] to 4 [broken, abraded skin]) using a skin assessment tool. Any type of erythema was considered IAD. Skin care (cleansing with a washcloth and water) was provided daily and after each defecation to all study participants. Data were collected via paper-and-pencil completion of the perineal skin integrity assessment and patient observation forms and entered into and analyzed by a computerized statistical program. Fisher’s exact test and the chi-squared test were used to analyze the difference in IAD incidence and severity between the 2 groups, and the Mann Whitney U test was used to detect differences in the number and consistency of defecations. Results: No statistically significant differences were noted among the characteristics of the 12 participants (6 in each group) except for age; patients in the study product group were significantly older (70.66 ± 10.36 vs 52.20 ± 16.78 years; P <.05. Four (4) patients in the study group exhibited 13 areas of perineal dermatitis (degree 1 = 6 areas; degree 2 = 6 areas; degree 3 = 1 area; and degree 4 = 0); 1 patient in the control group had 4 areas with degree 1. Conclusion: This prototype product is not sufficient to be used in clinical practice in patients with fecal incontinence, but further study in a larger population is warranted.
Introduction
Urinary and fecal incontinence affect many people and are common and embarrassing health problems.1,2 Prevalence and review studies show urinary incontinence affects quality of life1,3,4 and causes isolation and depression, and fecal incontinence can cause psychosocial problems such as loss of self-esteem, progressive isolation, and social stigmatization as well as reducing quality of life,5,6 burdening patients and the community with high costs.6 Urinary incontinence prevalence has been shown to be between 12% and 49.7%1,7-12 and fecal incontinence has a prevalence of between 2% and 16.9%.1,6,12-14 Relevant reviews15,16 have found urinary and fecal incontinence in older community-dwelling people can lead to admittance to long-term care institutions.
According to descriptive and review studies17-21 both urinary and fecal incontinence may lead to incontinence-associated dermatitis (IAD), an inflammatory skin disease18 characterized by the clinical evolution of skin damage associated with moisture18 as a result of chronic or repeated exposure of the skin to urine or fecal matter.4,17 A descriptive review and prevalence study involving acute care patients17 notes IAD presents as redness with or without blistering, erosion, or loss of skin barrier function. IAD causes discomfort and stress for patients19 and is a serious and common problem in many health care settings17,18 impacting patients’ well-being.18 According to a review of IAD prevention and management by Beeckman et al,18 health care professionals working in many health institutions struggle to provide optimal care to maintain patients’ skin health.18
When IAD develops, risk of infection, length of hospitalization, and morbidity increase, and patients are at greater risk of developing pressure injury; as shown in prevalence and review studies,17,19 factors that have been shown to increase the risk for occurrence of IAD include decreased mobility, pain, fever, the use of incontinence containment products that facilitate continuous exposure to moisture, changes in the skin due to the use of steroids, aging, frequent urination or defecation, friction, increased skin pH, overhydration, irritants, diet, antibiotic use, diarrhea, and medical conditions. Beeckman et al18 concluded IAD can be avoided and alleviated with appropriate and timely skin cleansing.
Literature Review
In a descriptive prevalence study,17 a randomized controlled trial,22 2 reviews,18,23a clinical study,24 a longitudinal repeated-measures study,25 and a prospective multicenter study,26 IAD prevalence has been found to be between 3.4% and 83.3%. This research17,25,26 also examined the relationship between incontinence and IAD or/and skin injury in different inpatient environments and described different methods for the prevention or treatment of IAD. For example, incontinence rates and prevalence of IAD or skin injury were surveyed17 in 608 acute care patients >4 years of age at 2 hospitals using an instrument designed and tested by a research team as part of a pilot study. The overall prevalence of incontinence was 19.7%; fecal incontinence was more frequent (17.6%) than urinary incontinence across genders and different age groups. IAD was present in 20% of patients who were incontinent (21.5% of patients with fecal incontinence and 13.5% with urinary incontinence). The highest prevalence was found in the oldest (80+ years) age group. The authors concluded fecal incontinence was associated with a higher rate of skin injury.17 Long et al25conducted a longitudinal, repeated-measures study among 171 patients at least 18 years of age admitted to 4 long-term acute care units of a hospital. Patients were examined using the Braden Scale and Hospital Survey on Incontinence and the Perineal Skin Injury Instrument within 24 hours of admission and re-evaluated weekly until discharge using the same tool. Overall, 31.6% of the patients were women and 31% were older than 65 years, their mean length of stay was 15 days, 57.3% were fecally incontinent, and 43.3% had an indwelling catheter. IAD prevalence on admission was 22.8%. In their quasi-experimental study, Bliss et al26 compared the efficacy of 4 different regimens for preventing IAD in 16 nursing home residents who were incontinent and free of skin damage; 80% of the participants were women and 26% were >90 years of age. The researchers observed perineal skin for frequency, type, and severity of skin damage over a 6-week period. Skin damage developed in 4.6%, the prevalence of IAD was 3.5%, and 31% of the participants had IAD. The rate and severity of IAD were found to be low with close monitoring and the use of a defined skin care regimen that included a pH-balanced cleanser and moisture barrier.
Beeckman et al18 recommended using a skin protectant to protect against IAD for at-risk patients along with cleaning the skin with soap and water after each incontinence episode. The authors concluded IAD can be prevented and treated with proper and well-timed skin cleansing. In a review of IAD-related literature, Gray et al23 concluded a small amount of important evidence exists related to assessing, preventing, and treating IAD, and further studies to evaluate the effect of different interventions on IAD are needed. Driver24 determined the rate of skin breakdown in adult patients with fecal incontinence who had indwelling urinary bladder catheters and no skin breakdown at the time of admission. The study was conducted in 2 phases: the first focused on the nurses’ rates of use of a no-rinse cleanser and a zinc oxide barrier, and the second took the results of the first phase to develop a new treatment protocol. Of the 131 patients enrolled in phase 1, 16 were incontinent of stool, and 8 of 16 patients developed perineal dermatitis. Perineal dermatitis did not develop in any patients who were fecally continent. Of the 177 patients enrolled in phase 2, 16 had fecal incontinence and a methicone cleaner/barrier product was applied to every patient after each incontinence episode. Skin breakdown developed in 3 of the 16 patients. The researchers concluded outcomes were better in patients who were treated with the cleaner/barrier product.24
Few studies relate to new incontinence containment products. Palmieri et al21examined 120 patients (65 men, 55 women; 45 to 96 years of age) in 2 inpatient care settings over an 8-year period with regard to the use of a bag that isolated the anus and perianal area. The patients were divided into groups according to the duration of anal bag use and were evaluated at each bag change by a team of 4 nurses and 8 physicians using a questionnaire and a scale for skin reaction to the adhesive. Feelings and perceptions of the patients also were assessed. Most of the patients (91.76%) tolerated the bag well, it was not painful to remove and apply (100%), no adverse reactions to the product occurred, and no pressure injuries developed in patients who were at high risk.
The effect of perianal pouches (n = 15) and adult containment briefs (n = 15) on the incidence of IAD was examined in a randomized controlled study by Denat and Khorshid,22 conducted among neurology and neurosurgery patients with fecal incontinence and indwelling urinary catheters. Perineal cleaning was performed daily and as necessary, and the skin was observed and evaluated daily using a Perineal Skin Integrity Assessment Form. A statistically significant difference in IAD occurrence was noted between patients in the perianal pouch group (66.7%) and those managed using containment briefs (100%). The authors concluded perianal pouches are more effective than adult containment briefs for the prevention of IAD. A review2 of randomized or quasirandomized studies involving absorbent products determined gender was a significant variable. From among the disposable designs, the more expensive pull-up and T-shaped diaper designs were not better overall but they were better than a diaper insert, making them the most cost-effective disposable designs for men for both day and nighttime wear. For women, disposable pull-ups were better overall than the other designs, but they are expensive. Washable diapers were the cheapest but were unacceptable to most women at any time, but some study participants, particularly men living at home, preferred them at night; for this group, washable diapers were a cost-effective option. The authors concluded people have varying preferences for absorbent product design, and no single design was best for women.2
Beguin et al4 developed a diaper as part of their study to test how a new diaper design affected parameters of the epidermal barrier. The authors measured the product and corneometry (ie, hydration level) of the skin of 13 healthy human volunteers (4 women, 9 men; mean age 50.6 ± 2.1 years) under the supervision of a dermatologist. The authors also examined the effect of this product on IAD among 12 female long-term/rehabilitation patients (4 experiencing their first episode and 8 having recurrent IAD) with a mean age of 83.9 ± 6.7 years with preexisting IAD; the authors observed skin symptoms for 21 days. The researchers concluded briefs that can help support epidermal barrier function can create an acidic surface pH on the absorbing part of the diaper and that using breathable materials inside panels can reduce the negative effects of incontinence on skin health.4
pH rises to the base level as urea in urine is converted to ammonia in the presence of stool bacteria; as a result, diapers can be a causative factor in promoting perineal dermatitis.16 Today, many strategies are used for the prevention of IAD. These include avoidance or minimization of exposure to stool or urine and implementation of a skin care program consisting of cleansing, moisturization, the application of skin protectants or moisture barriers, and the maintenance of optimal skin pH in the diaper area in-between and after an incontinent episode.18,20,27 Health professionals must be aware of the utilization and features of these management methods.16
Researchers have conducted studies related to the effects of different productson the occurrence of IAD.4,21,22,28 In a blinded, randomized clinical 3-part study, Baldwin et al29 examined disposable diapers designed to provide a zinc oxide and petrolatum-based formulation continuously to the skin. In the first part of the study, children wore a single diaper for 3 hours or multiple diapers for 24 hours; after use, samples from the stratum corneum were taken from each child and analyzed for the presence of zinc oxide/petrolatum. Zinc oxide was analyzed using inductively coupled plasma atomic emission spectrometry; total ointment was measured by gas chromatography analysis of stearyl alcohol. The second part of the study was performed on adults and evaluated the prevention of skin irritation and barrier damage by a standard skin irritant. In the third part of the study, the effect of a zinc oxide and petrolatum-based formulation on skin erythema and diaper rash in 268 infants was evaluated over a 4-week period. The zinc oxide and ointment formulation transferred effectively from the diaper to the children’s skin in the first study. Exposure to the formulations directly on adult skin before an irritant challenge was associated with a reduction in skin barrier damage and erythema. Wearing a diaper with zinc oxide and ointment formulation reduced skin erythema and diaper rash compared to the control product. The authors concluded the diaper had positive clinical utility.29 A small number of publications relate to the physical features and absorbance capacity of incontinence products in adults.4,21,22,29
The purpose of this study was to develop a new incontinence containment product to contain fecal incontinence and to examine the effect of this new product on the prevention of perineal dermatitis. The research question was, Are there differences in the incidence of IAD in patients with fecal incontinence using a new incontinence containment product versus those using adult diapers?
Methods
Design. A randomized controlled clinical trial was conducted between February 2013 and July 2015 at a university in western Turkey.
Part 1: Prototype development and testing.
Prototype development. The data of the first part of the study were collected between February 2 and February 28, 2015. After the first author took a 1-semester course in medical wear at the Textile Engineering Department of the Institute of Science and Technology, Izmir, Turkey, a faculty member from the Department of Textile Engineering of the university’s Faculty of Engineering was consulted to help develop a new incontinence containment product. Diaper manufacturers were asked via telephone and email to provide samples, which were tested in the experimental laboratories of the Textile and Apparel Research and Application Center of the Institute of Science and Technology for air permeability, surface friction, and thickness. The materials that gave the best results after the analysis were used as the raw material for the care prototype.
The incontinence containment product prototype was designed and manufactured using a double layer of polypropylene nonwoven fabric and a 100% cotton interlock fabric. Additionally, a 3-ply 100% cotton interlock fabric was used in the perianal section of the new product. Three different sizes (40–80 kg) were produced. The goal was to construct an incontinence containment product that accommodated the patient’s size and that increased air permeability by using a nonwoven material. The authors also wanted to avoid the mixing of urine and feces in order to prevent a rise in the pH of the diaper area. At this stage, experiments of wearing this prototype product were conducted with healthy volunteer study participants.
Participant sample (healthy individuals). When the prototype was first developed, experiments were conducted among 10 healthy volunteer study participants who were at least 18 years of age and who agreed to wear the product for 8 hours. Participants were recruited by physicians working in the faculty of occupational health and safety unit of the university where health status is periodically checked; inclusion criteria stipulated participants be healthy and free of dermatological disease.
Participants were asked to wear this product and conduct clothing experiments. They were requested to defecate while wearing the product then asked about any discomfort during this period and to answer questions about the product. A questionnaire was developed based on the literature.2,4,18,28 Expert opinion was obtained from research team members (a textile academician, a dermatologist, and 2 nurse academicians). The questionnaire consisted of 9 multiple choice and open-ended questions. Participants also were asked to evaluate the product in terms of clothing comfort features (fabric type, product model, easy wearing and removal, type of fastening, whether it held liquids, protection of privacy, whether it elicited an allergic effect, and whether it was air-tight), and they completed a questionnaire relating to the features of the new diapers. Face-to-face interviews were conducted by first author. Participant skin was checked by the fourth author for any reaction in terms of allergic contact dermatitis or irritant contact dermatitis. The incontinence containment product prototype could be modified at this point according to these results. Women who did not complete the 8-hour period of the clothing experiment were excluded from the study. In the case of any reaction, the participant was examined by the dermatologist.
Part 2: The effect of the incontinence containment product on perineal dermatitis.
Participant sample. The second part of the study was conducted between April 2 and July 3, 2015. Once the prototype was developed and the clothing experiments had been conducted in healthy women, a sample consisting of 12 female bedridden patients from the neurology unit of a hospital in western Turkey who had fecal incontinence was enrolled. Patients >18 years of age with intact perineal and perianal skin and an indwelling urethral catheter who agreed to participate were eligible for the study. Patients who had diabetes mellitus (diabetic neuropathy causes weakness in tissue tolerance and the development of perineal dermatitis26), a darkly pigmented perineal area, pressure injuries or erythema, or who did not agree to participate in the study were excluded.
Procedure. Patients were randomized into experimental product and control diaper groups according to age by flipping a coin. In the control group, an adult diaper (Pads, Linea Tena, SCA, Hygiene, Göteborg, Sweden) a premium quality adult diaper, was chosen for use as a result of analysis conducted at the Textile Faculty laboratories and because it was similar to the products normally used in the population. This diaper consists of 3 layers: the outer layer is made of polyethylene film, the middle layer is made of superabsorbent polymer, and the inner layer is made of nonwoven polypropylene fabric. Patients were provided either the new incontinence containment product prototype or the control diaper and monitored for the development of perineal dermatitis for 7 days. A Patient Identification Form, a Perineal Skin Integrity Assessment Form, and a Patient Observation Form were used for data collection. Perineal care was given to patients in both groups twice a day and after each defecation. The diaper or the new incontinence containment product was changed after each perineal care session. The skin care included cleaning perineal areas with water using a washcloth. The diaper and new incontinence containment devices of patients in both groups were changed every day and after each defecation.
The Patient Identification Form consisted of 5 questions including age, medical diagnosis, degree of activity, presence of chronic disease, body mass index, and method of nutrition. These data were obtained from the medical records of the hospital and were recorded by the first author at the beginning of the study.
The Perineal Skin Integrity Assessment Form was used to evaluate and record the skin integrity. The visual scale based on the International Contact Dermatitis Score and that was utilized in a study by Fader et al30 was used to grade the severity of IAD. The visual scale gives a score from 0 to 4; a score of 0 indicates no erythema, 1 indicates mild erythema, 2 indicates moderate erythema, 3 indicates more intense erythema, and 4 indicates broken, abraded skin. In this study, a score of 1 was considered IAD.30 These evaluations were approved by the fourth author (a dermatologist) on the study team.
Seven (7) measurement sites assessed included the sacrum, left buttock, right buttock, right groin, left groin, left thigh, and right thigh. To evaluate skin integrity, patient perineal skin condition was observed and recorded daily by the first researcher using the Perineal Skin Integrity Assessment Form. The number of defecations were observed and recorded daily on the Patient Observation Form. The main study outcomes were IAD, defined as an erythema score of 1 or more in the skin of the buttock, sacrum, thigh, and groin. Patients who developed IAD were dismissed from the study and control diaper groups, and treatment with an ointment containing Hamamelis virginiana (witch hazel) distillate was ordered by the physician.
Ethical considerations. This study was formally approved by the Turkish Ministry of Health and the ethics committee of the hospital. Insurance policies were prepared for each patient attending the study (Number 481360). Information about the research was given to the patients who met the criteria or to their relatives, and written informed consent to participate in the study was obtained.
Data analysis. Data were collected from the perineal skin integrity assessment form and patient observation form and manually entered into and analyzed using IBM SPSS Statistics, version 22 (IBM Corp, Armonk, NY) software. Statistical significance was accepted as P <.05. In order to denote IAD severity, the number of dermatitis areas and the number of days at which dermatitis occurred were tabulated. The Fisher exact test and the chi-squared test were used to evaluate the difference in the incidence of IAD between the 2 groups, and the Mann-Whitney U test was used to detect any significant differences in the number of defecations and the consistency of feces between the 2 groups.
Results
Nineteen (19) women were eligible to participate in the study; 4 with diabetes mellitus were excluded in terms of study ınclusion criteria, 2 were discharged before the end of 7 days (end of study), and 1 patient did not agree to participate. Thus, 12 patients completed the follow-up incontinence containment product assessments — 6 were randomly allocated to the diaper group and 6 to the new incontinence containment product group. The mean patient age was 52.50 ± 16.78 years in the diaper (control) group and 70.66 ± 10.36 years in the new product (study) group (P <.05). Statistical analysis found no difference between the study and control groups according to the chronic disease status, allergies, mobility status, body mass index, and feeding route of the patients (P >.05). Patient characteristics are summarized in Table 1.
The groups did not show any significant difference in terms of the mean number of defecations for 7 days (P >.05) For example, on the first day, the mean number of patient defecations was 1.16 in the control group and 2.00 for the study group 2 (see Table 2). Dermatitis developed in 1 patient in the control group; IAD was found in 4 areas in this patient, but it was of the least severity. Dermatitis developed in 4 patients in the new incontinence containment product. The patients in this study were only fecally incontinent, and no patients had soft/more liquid stool. IAD was found in 13 areas: 46.15% had an IAD score of 1, 46.15% had a score of 2, and 7.70 % had a score of 3. Four (4) patients in the study group had IAD in more than 1 area. The patients in the new incontinence containment product group (the study group) were found to have a higher incidence of IAD than those in the diaper group (the control group), but this difference was not statistically significant (P >.05) (see Table 3). No women experienced any skin reaction during the wearing experiments (see Table 4).
Discussion
IAD occurs when skin is exposed to urine or stool. The affected skin becomes inflamed and erythematous, and erosion of superficial layers may occur.20Existing incontinence containment products should be evaluated for functionality and, if possible, they should be redesigned.32 This study is the first trial in Turkey to evaluate a newly developed incontinence containment product with new physical features; the study was also the first to examine the effect of this product on IAD.
This study found no statistical difference in the incidence of the development of dermatitis between the new incontinence containment product and the marketed incontinence product (P >.05). However, the proportion of areas with more severe dermatitis was higher in the study group. The results may be related to the higher proportion of elderly patients in the study product group than in the diaper group; the average age of patients in the new incontinence containment product group was 70.66 ± 10.36 years, whereas the average age of patients in the diaper group was 52.50 ± 16.78 years. Elderly skin is more fragile and vulnerable to injury1; inflammatory processes are less efficient and cell-mediated immunity is weakened in aged skin,2 so skin repair is slower.4,33 The observed difference also may be related to the absorption features of the incontinence containment product.
Few studies have evaluated the effect of new absorbent products for incontinence or diapers on the occurrence of IAD. Denat and Khorshid22 found a perianal pouch was more effective than adult containment briefs for the prevention of IAD. In the study by Beguin et al,4 adult incontinence briefs that reduced pH at the surface of the skin and had higher air permeability were developed and tested. The researchers also conducted a single group before-after study with 12 patients in which IAD was resolved in 8 participants (67%). In the study by Palmieri et al21 that evaluated the efficacy of repeated bag changes, the majority of patients (92.77%) found the anal bag comfortable.
The results of these studies are different from the results of the current study because of methodological variances. The pH is raised to a basic level as urea in urine is converted to ammonia in the presence of stool bacteria.16 The new incontinence containment product was designed as a simple product with increased permeability to air by using a nonwoven material and a special design to collect stool without mixing stool and urine in order to reduce the risk of pH increase on the skin. For this reason, the study was implemented among patients with an indwelling urethral catheter; thus, it was not possible to determine whether the incontinence care products could be used comfortably on a patient without an indwelling urethral catheter or whether these products would be effective in preventing IAD or to compare current study findings to those in the literature. Current results also may be due to other factors. The inner layer of the new incontinence product may have functioned as an absorbent layer because it was made from 100% cotton interlock fabric, and a 3-ply 100% cotton interlock fabric was used in the perianal section of the new product. Also, the air permeability of the 100% cotton interlock fabric may have been affected as a result. In addition, the patients in this study were only fecally incontinent, and no patients had soft/more liquid stool. Although this prototype product can be used as an alternative to any diaper, it is not of sufficient quality to be used in clinical practice in patients with fecal incontinence.
Limitations
This study had several limitations. The sample of patients examined in the current study was small owing to time restrictions of patient insurance policies. Also, the unwillingness of patients to participate in the study limited the number of patients who were enrolled in the study. The small sample of the study may have been insufficient to detect statistical differences. Because funds reserved for this study were limited and the cost was considerable, only IAD due to fecal incontinence was observed in this study. In the future, studies should be implemented to examine the effects of both urinary and fecal incontinence. Also, this study was implemented with female patients because the incontinence containment product was designed for women. A new incontinence containment product also should be designed for men.
Another important limitation of this study was that a superabsorbent polymer could not be added to the prototype product because of technical limitations, limited financial support, and limited time for implementing the research. Therefore, superabsorbent polymer should be added to any prototype incontinence containment product. Finally, the authors had planned to observe and monitor patients for 15 days, but this was not done for reasons relating to the patients’ disease and hospitalization. Seven (7) days is too short a period to draw conclusions about the effects of incontinence containment products. Patients should be monitored and observed for a long duration.
Many of these limitations can be explained by administrative and insurance restrictions. In Turkey, the ethics committee approves any study that has no CE (European Conformity) certificate after approval from the Ministry of Health and after patients who will be included in the research are insured. This type of health insurance is provided only by international companies and at prohibitively high cost. In addition, this insurance cost increases according to the duration of data collection in the study and the number of patients included. These limitations and the long duration of correspondence did not allow sufficient time to collect data and had to comply with the periods specified in the insurance policy.
Conclusion
A new incontinence containment prototype product for fecal incontinence was developed and its effect on IAD in women examined. No statistically significant difference in terms of preventing dermatitis was noted between the newly developed incontinence containment product and the diapers used in the control group, but the sample size was small and study duration may have been too short to evaluate actual differences. New types of incontinence care products should be designed and developed, and studies should be implemented to examine their effects on IAD. The prototype incontinence containment product should be improved, especially in terms of its absorptivity. The researchers found the absorptive quality was not sufficient for the new product to be used in clinical practice in patients with fecal incontinence. Further randomized controlled trial studies with more participants, patients who are incontinent of urine and feces and do not have a urinary catheter, and a longer observation period are warranted in order to bring new products to market.
Disclaimer
The majority (67%) of research expenses were paid by Fund of Academic Staff Training Program, and the first and second authors paid the remainder.
Affiliations
Dr. Leblebicioğlu is a research assistant and Dr. Khorshid is a professor/lecturer, Fundamentals of Nursing Department, Faculty of Nursing; Dr. Öndogan is a professor/lecturer, Faculty of Engineering, Textile Department; and Dr. Öztürk is a professor/physician, Faculty of Medicine, Dermatology Unit, Ege University İzmir, Turkey.
Correspondence
Please address correspondence to: Hülya Leblebicioğlu, RN, PhD(c); email: 该Email地址已收到反垃圾邮件插件保护。要显示它您需要在浏览器中启用JavaScript。.
