{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,4]],"date-time":"2026-05-04T23:30:10Z","timestamp":1777937410538,"version":"3.51.4"},"reference-count":58,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2023,6,14]],"date-time":"2023-06-14T00:00:00Z","timestamp":1686700800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"national funds through FCT\u2014Funda\u00e7\u00e3o para a Ci\u00eancia e a Tecnologia, I.P.","award":["UIDB\/05704\/2020"],"award-info":[{"award-number":["UIDB\/05704\/2020"]}]},{"name":"national funds through FCT\u2014Funda\u00e7\u00e3o para a Ci\u00eancia e a Tecnologia, I.P.","award":["UIDP\/05704\/2020"],"award-info":[{"award-number":["UIDP\/05704\/2020"]}]},{"name":"national funds through FCT\u2014Funda\u00e7\u00e3o para a Ci\u00eancia e a Tecnologia, I.P.","award":["CEECINST\/00051\/2018"],"award-info":[{"award-number":["CEECINST\/00051\/2018"]}]},{"name":"Scientific Employment Stimulus-Institutional Call","award":["UIDB\/05704\/2020"],"award-info":[{"award-number":["UIDB\/05704\/2020"]}]},{"name":"Scientific Employment Stimulus-Institutional Call","award":["UIDP\/05704\/2020"],"award-info":[{"award-number":["UIDP\/05704\/2020"]}]},{"name":"Scientific Employment Stimulus-Institutional Call","award":["CEECINST\/00051\/2018"],"award-info":[{"award-number":["CEECINST\/00051\/2018"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Spiritual care is an important dimension of palliative care (PC) and a facet of holistic care that helps ill people find meaning in their suffering and lives. This study aims to: (a) develop and test the psychometric properties of a new instrument, Perceived Barriers to Spiritual Care (PBSC); (b) explore participants\u2019 perceptions of how prevalent those (pre-identified) barriers are; and (c) examine the association of their personal and professional characteristics with those perceptions. A descriptive cross-sectional study was carried out using a self-reporting online survey. In total, 251 professionals registered with the Portuguese Association of Palliative Care (APCP) completed the study. The majority of respondents were female (83.3%), nurses (45.4%), had more than 11 years of professional experience (66.1%), did not work in PC (61.8%), and had a religious affiliation (81.7%). The psychometric assessment using PBSC provided sound evidence for its validity and reliability. The three most common perceived barriers were late referral for palliative care (78.1%), work overload (75.3%), and uncontrolled physical symptoms (72.5%). The least commonly perceived barriers were different spiritual beliefs among professionals (10.8%), differences between the beliefs of professionals and patients (14.4%), and the shame of approaching spirituality in a professional context (26.7%). The findings show there is some relationship between sex, age, years of professional experience, working in PC, having a religious affiliation, the importance of spiritual\/religious beliefs, and responses to the PBSC tool. The results highlight the importance of advanced training in spirituality and intervention strategies. Further research is needed to properly study the impacts of spiritual care and establish outcome assessments that accurately reflect the effects of the various spiritual care activities.<\/jats:p>","DOI":"10.3390\/ijerph20126121","type":"journal-article","created":{"date-parts":[[2023,6,14]],"date-time":"2023-06-14T02:01:40Z","timestamp":1686708100000},"page":"6121","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":21,"title":["Perceived Barriers to Providing Spiritual Care in Palliative Care among Professionals: A Portuguese Cross-Sectional Study"],"prefix":"10.3390","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1080-9535","authenticated-orcid":false,"given":"Carlos","family":"Laranjeira","sequence":"first","affiliation":[{"name":"School of Health Sciences, Polytechnic of Leiria, Campus 2, Morro do Lena, Alto do Vieiro, Apartado 4137, 2411-901 Leiria, Portugal"},{"name":"Centre for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Rua de Santo Andr\u00e9\u201466\u201368, Campus 5, 2410-541 Leiria, Portugal"},{"name":"Comprehensive Health Research Centre (CHRC), University of \u00c9vora, 7000-801 \u00c9vora, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9035-8548","authenticated-orcid":false,"given":"Maria Anjos","family":"Dixe","sequence":"additional","affiliation":[{"name":"School of Health Sciences, Polytechnic of Leiria, Campus 2, Morro do Lena, Alto do Vieiro, Apartado 4137, 2411-901 Leiria, Portugal"},{"name":"Centre for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Rua de Santo Andr\u00e9\u201466\u201368, Campus 5, 2410-541 Leiria, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5021-773X","authenticated-orcid":false,"given":"Ana","family":"Querido","sequence":"additional","affiliation":[{"name":"School of Health Sciences, Polytechnic of Leiria, Campus 2, Morro do Lena, Alto do Vieiro, Apartado 4137, 2411-901 Leiria, Portugal"},{"name":"Centre for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Rua de Santo Andr\u00e9\u201466\u201368, Campus 5, 2410-541 Leiria, Portugal"},{"name":"Group Innovation & Development in Nursing (NursID), Center for Health Technology and Services Research (CINTESIS@RISE), 4200-450 Porto, Portugal"}]}],"member":"1968","published-online":{"date-parts":[[2023,6,14]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Sawatzky, R., Porterfield, P., Lee, J., Dixon, D., Lounsbury, K., Pesut, B., Roberts, D., Tayler, C., Voth, J., and Stajduhar, K. (2016). Conceptual foundations of a palliative approach: A knowledge synthesis. BMC Palliat. Care, 15.","DOI":"10.1186\/s12904-016-0076-9"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"197","DOI":"10.1177\/0269216313493685","article-title":"White paper defining optimal palliative care in older people with dementia: A Delphi study and recommendations from the European Association for Palliative Care","volume":"28","author":"Radbruch","year":"2014","journal-title":"Palliat. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"428","DOI":"10.1016\/j.jpainsymman.2017.07.028","article-title":"State of the Science of Spirituality and Palliative Care Research Part I: Definitions, Measurement, and Outcomes","volume":"54","author":"Steinhauser","year":"2017","journal-title":"J. Pain Symptom Manag."},{"key":"ref_4","unstructured":"Worldwide Palliative Care Alliance [WPCA] (2014). Global Atlas of Palliative Care at the End of Life, WHO."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Gijsberts, M.-J.H.E., Liefbroer, A.I., Otten, R., and Olsman, E. (2019). Spiritual Care in Palliative Care: A Systematic Review of the Recent European Literature. Med. Sci., 7.","DOI":"10.3390\/medsci7020025"},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Rego, F., Gon\u00e7alves, F., Moutinho, S., Castro, L., and Nunes, R. (2020). The influence of spirituality on decision-making in palliative care outpatients: A cross-sectional study. BMC Palliat. Care, 19.","DOI":"10.1186\/s12904-020-0525-3"},{"key":"ref_7","first-page":"86","article-title":"Spiritual care in palliative care: Working towards an EAPC Task Force","volume":"18","author":"Nolan","year":"2011","journal-title":"Eur. J. Palliat. Care"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Best, M.C., Vivat, B., and Gijsberts, M.-J. (2023). Spiritual Care in Palliative Care. Religions, 14.","DOI":"10.3390\/rel14030320"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"591","DOI":"10.1590\/0034-7167.2016690324i","article-title":"Palliative care and spirituality: An integrative literature review","volume":"69","author":"Evangelista","year":"2016","journal-title":"Rev. Bras. Enferm."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1109","DOI":"10.1001\/jamainternmed.2013.903","article-title":"Provision of Spiritual Support to Patients with Advanced Cancer by Religious Communities and Associations with Medical Care at the End of Life","volume":"173","author":"Balboni","year":"2013","journal-title":"JAMA Intern. Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"445","DOI":"10.1200\/JCO.2009.24.8005","article-title":"Provision of Spiritual Care to Patients with Advanced Cancer: Associations with Medical Care and Quality of Life Near Death","volume":"28","author":"Balboni","year":"2010","journal-title":"J. Clin. Oncol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"519","DOI":"10.1017\/S1478951515001236","article-title":"Creating a safe space: A qualitative inquiry into the way doctors discuss spirituality","volume":"14","author":"Best","year":"2016","journal-title":"Palliat. Support. Care"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"L\u00f3pez-Tarrida, \u00c1.D.C., de Diego-Cordero, R., and Lima-Rodr\u00edguez, J.S. (2021). Spirituality in a Doctor\u2019s Practice: What Are the Issues?. J. Clin. Med., 10.","DOI":"10.3390\/jcm10235612"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"371","DOI":"10.1017\/S1478951504040490","article-title":"Spiritual issues and needs: Perspectives from patients with advanced cancer and nonmalignant disease. A qualitative study","volume":"2","author":"Grant","year":"2004","journal-title":"Palliat. Support. Care"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"753","DOI":"10.1177\/0269216310375860","article-title":"Review: The understanding of spirituality and the potential role of spiritual care in end-of-life and palliative care: A meta-study of qualitative research","volume":"24","author":"Edwards","year":"2010","journal-title":"Palliat. Med."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1712","DOI":"10.1111\/ppc.12979","article-title":"The relationship between the individualized care perceptions and spiritual care perceptions of nurses","volume":"58","author":"Kaya","year":"2022","journal-title":"Perspect. Psychiatr. Care"},{"key":"ref_17","unstructured":"National Coalition for Hospice and Palliative Care (2018). Clinical Practice Guidelines for Quality Palliative Care, National Coalition for Hospice and Palliative Care. [4th ed.]."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"3609","DOI":"10.1111\/jocn.15411","article-title":"Spiritual care provision to end-of-life patients: A systematic literature review","volume":"29","author":"Batstone","year":"2020","journal-title":"J. Clin. Nurs."},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Vivat, B., Lodwick, R., Merino, M.T.G.-B., and Young, T. (2023). What Do Palliative Care Professionals Understand as Spiritual Care? Findings from an EAPC Survey. Religions, 14.","DOI":"10.3390\/rel14030298"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"575","DOI":"10.4103\/ijnmr.ijnmr_422_21","article-title":"Barriers to Providing Spiritual Care from a Nurses\u2019 Perspective: A Content Analysis Study","volume":"27","author":"Momeni","year":"2022","journal-title":"Iran. J. Nurs. Midwifery Res."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"344","DOI":"10.1016\/j.jclinepi.2007.11.008","article-title":"The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies","volume":"61","author":"Altman","year":"2008","journal-title":"J. Clin. Epidemiol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"149","DOI":"10.3389\/fpubh.2018.00149","article-title":"Best Practices for Developing and Validating Scales for Health, Social, and Behavioral Research: A Primer","volume":"6","author":"Boateng","year":"2018","journal-title":"Front. Public Health"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"400","DOI":"10.1016\/j.jpainsymman.2013.09.020","article-title":"Nurse and Physician Barriers to Spiritual Care Provision at the End of Life","volume":"48","author":"Balboni","year":"2014","journal-title":"J. Pain Symptom Manag."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Egan, R., Llewellyn, R., Cox, B., MacLeod, R., McSherry, W., and Austin, P. (2017). New Zealand Nurses\u2019 Perceptions of Spirituality and Spiritual care: Qualitative Findings from a National Survey. Religions, 8.","DOI":"10.3390\/rel8050079"},{"key":"ref_25","unstructured":"Polit, D.F., and Beck, C.T. (2016). Nursing Research: Generating and Assessing Evidence in Nursing Practice, Lippincott Williams and Wilkins. [10th ed.]."},{"key":"ref_26","unstructured":"Ranganathan, S., Gribskov, M., Nakai, K., and Sch\u00f6nbach, C. (2019). Encyclopedia of Bioinformatics and Computational Biology, Elsevier."},{"key":"ref_27","unstructured":"Mar\u00f4co, J. (2021). An\u00e1lise Estat\u00edstica com o SPSS Statistics, Edi\u00e7\u00f5es Report Number. [8th ed.]."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"34","DOI":"10.1080\/13561820.2021.1890006","article-title":"The role of gender, profession and informational role self-efficacy in physician\u2013nurse knowledge sharing and decision-making","volume":"36","author":"Durand","year":"2022","journal-title":"J. Interprof. Care"},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Tao, Z., Wu, P., Luo, A., Ho, T.-L., Chen, C.-Y., and Cheng, S.-Y. (2020). Perceptions and practices of spiritual care among hospice physicians and nurses in a Taiwanese tertiary hospital: A qualitative study. BMC Palliat. Care, 19.","DOI":"10.1186\/s12904-020-00608-y"},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"de Diego-Cordero, R., L\u00f3pez-Tarrida, C., Linero-Narv\u00e1ez, C., and Gonz\u00e1lez-Serna, J.M.G. (2023). \u201cMore Spiritual Health Professionals Provide Different Care\u201d: A Qualitative Study in the Field of Mental Health. Healthcare, 11.","DOI":"10.3390\/healthcare11030303"},{"key":"ref_31","first-page":"A25","article-title":"P-46 Barriers towards providing effective spiritual care to palliative care patients","volume":"11","author":"Abbas","year":"2021","journal-title":"BMJ Support. Palliat. Care"},{"key":"ref_32","first-page":"597","article-title":"Review of a Study on Late Referral to a Palliative Care Consultation Service: Length of Stay and In-Hospital Mortality Outcomes","volume":"6","author":"Fink","year":"2015","journal-title":"J. Adv. Pract. Oncol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"18","DOI":"10.12968\/ijpn.2017.23.1.18","article-title":"New Zealand palliative care nurses experiences of providing spiritual care to patients with life-limiting illness","volume":"23","author":"Walker","year":"2017","journal-title":"Int. J. Palliat. Nurs."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"e03312","DOI":"10.1590\/s1980-220x2017007403312","article-title":"Spirituality in palliative care: Experiences of an interdisciplinary team","volume":"52","author":"Arrieira","year":"2018","journal-title":"Rev. Esc. Enferm. USP"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"206","DOI":"10.4037\/ajcc2016276","article-title":"Critical Care Nurses\u2019 Perceived Need for Guidance in Addressing Spirituality in Critically Ill Patients","volume":"25","author":"Canfield","year":"2016","journal-title":"Am. J. Crit. Care"},{"key":"ref_36","first-page":"150","article-title":"Spirituality, religion and palliative care","volume":"3","author":"Richardson","year":"2014","journal-title":"Ann. Palliat. Med."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1177\/1542305019890120","article-title":"Challenges and Enablers of Spiritual Care for Family Members of Patients in the Intensive Care Unit","volume":"74","author":"Ordons","year":"2020","journal-title":"J. Pastoral. Care Counsel."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"122","DOI":"10.1016\/j.jpainsymman.2018.03.009","article-title":"Spiritual Distress Within Inpatient Settings\u2014A Scoping Review of Patients\u2019 and Families\u2019 Experiences","volume":"56","author":"Ordons","year":"2018","journal-title":"J. Pain Symptom Manag."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"323","DOI":"10.1093\/sw\/swx036","article-title":"Social Workers\u2019 Perceived Barriers to and Sources of Support for Integrating Clients\u2019 Religion and Spirituality in Practice","volume":"62","author":"Oxhandler","year":"2017","journal-title":"Soc. Work."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Fang, M.L., Sixsmith, J., Sinclair, S., and Horst, G. (2016). A knowledge synthesis of culturally- and spiritually-sensitive end-of-life care: Findings from a scoping review. BMC Geriatr., 16.","DOI":"10.1186\/s12877-016-0282-6"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"2126","DOI":"10.1111\/j.1365-2702.2012.04180.x","article-title":"Spirituality and spiritual caring: Nurses\u2019 perspectives and practice in palliative and acute care environments","volume":"21","author":"Ronaldson","year":"2012","journal-title":"J. Clin. Nurs."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"e261","DOI":"10.1016\/j.jpainsymman.2021.03.013","article-title":"The Content, Teaching Methods and Effectiveness of Spiritual Care Training for Healthcare Professionals: A Mixed-Methods Systematic Review","volume":"62","author":"Jones","year":"2021","journal-title":"J. Pain Symptom Manag."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1035","DOI":"10.1016\/j.jpainsymman.2017.11.015","article-title":"Toward a Fully Fledged Integration of Spiritual Care and Medical Care","volume":"55","author":"Kruizinga","year":"2018","journal-title":"J. Pain Symptom Manag."},{"key":"ref_44","doi-asserted-by":"crossref","unstructured":"Moniz, J.B. (2023). Secularization in Europe: Causes, Consequences, and Cultural Diversity. Religions, 14.","DOI":"10.3390\/rel14030423"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"244","DOI":"10.1080\/13674676.2019.1590806","article-title":"Addressing the spiritual domain in a plural society: What is the best mode of integrating spiritual care into healthcare?","volume":"22","author":"Liefbroer","year":"2019","journal-title":"Ment. Health Relig. Cult."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"779","DOI":"10.3389\/fpsyg.2015.00779","article-title":"Gender roles and traits in stress and health","volume":"6","author":"Mayor","year":"2015","journal-title":"Front. Psychol."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"7","DOI":"10.5498\/wjp.v6.i1.7","article-title":"Gender differences in caregiving among family-caregivers of people with mental illnesses","volume":"6","author":"Sharma","year":"2016","journal-title":"World J. Psychiatry"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"78","DOI":"10.1177\/08258597221120707","article-title":"Gender Disparities in End of Life Care: A Scoping Review","volume":"38","author":"Wong","year":"2023","journal-title":"J. Palliat. Care"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"250","DOI":"10.1097\/JNR.0b013e318236cf78","article-title":"Exploration of Clinical Nurses\u2019 Perceptions of Spirituality and Spiritual Care","volume":"19","author":"Wu","year":"2011","journal-title":"J. Nurs. Res."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"114","DOI":"10.1177\/0898010119882153","article-title":"How Nurses Understand Spirituality and Spiritual Care: A Critical Synthesis","volume":"38","author":"Cooper","year":"2020","journal-title":"J. Holist. Nurs."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"3102","DOI":"10.1111\/j.1365-2702.2011.03778.x","article-title":"Turkish nurses\u2019 perceptions of spirituality and spiritual care","volume":"20","author":"Ozbasaran","year":"2011","journal-title":"J. Clin. Nurs."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"594","DOI":"10.3390\/rel6020594","article-title":"Spiritual Care Education of Health Care Professionals","volume":"6","author":"Baldacchino","year":"2015","journal-title":"Religions"},{"key":"ref_53","doi-asserted-by":"crossref","unstructured":"Hu, Y., Jiao, M., and Li, F. (2019). Effectiveness of spiritual care training to enhance spiritual health and spiritual care competency among oncology nurses. BMC Palliat. Care, 18.","DOI":"10.1186\/s12904-019-0489-3"},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"1132584","DOI":"10.3389\/fpsyg.2023.1132584","article-title":"An in-depth introduction to arts-based spiritual healthcare: Creatively seeking and expressing purpose and meaning","volume":"14","author":"Laranjeira","year":"2023","journal-title":"Front. Psychol."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"933767","DOI":"10.3389\/fpsyg.2022.933767","article-title":"Exercising Hope in Palliative Care Is Celebrating Spirituality: Lessons and Challenges in Times of Pandemic","volume":"13","author":"Laranjeira","year":"2022","journal-title":"Front. Psychol."},{"key":"ref_56","doi-asserted-by":"crossref","unstructured":"Sarri\u00f3n-Bravo, J.A., Gonz\u00e1lez-Agu\u00f1a, A., Abeng\u00f3zar-Muela, R., Renghea, A., Fern\u00e1ndez-Batalla, M., Santamar\u00eda-Garc\u00eda, J.M., and Ruiz-Moral, R. (2022). Competence in Spiritual and Emotional Care: Learning Outcomes for the Evaluation of Nursing Students. Healthcare, 10.","DOI":"10.3390\/healthcare10102062"},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"184","DOI":"10.1001\/jama.2022.11086","article-title":"Spirituality in Serious Illness and Health","volume":"328","author":"Balboni","year":"2022","journal-title":"JAMA"},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"1083","DOI":"10.1111\/jonm.13538","article-title":"Managing holistic nursing practice: The need for spiritual care competence in health care practice","volume":"30","author":"Dobrowolska","year":"2021","journal-title":"J. Nurs. Manag."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/20\/12\/6121\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T19:54:29Z","timestamp":1760126069000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/20\/12\/6121"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,6,14]]},"references-count":58,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2023,6]]}},"alternative-id":["ijerph20126121"],"URL":"https:\/\/doi.org\/10.3390\/ijerph20126121","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,6,14]]}}}