1
|
Guerrero-Gaviria D, Acosta-Pardo C, Carreño-Moreno S. Validity and Reliability of the Preparedness for Care Scale in Family Caregivers of People with Chronic Illness in Colombia. HISPANIC HEALTH CARE INTERNATIONAL 2025:15404153251342741. [PMID: 40420699 DOI: 10.1177/15404153251342741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2025]
Abstract
BACKGROUND Family caregivers assume their role suddenly and in many cases without the necessary preparation and resources for these responsibilities. Preparedness for Caregiving Scale measures the level of preparedness perceived by the family caregiver to assume the responsibilities of the role. Aim: To assess the validity and reliability of the Preparedness for Caregiving Scale (PCS) in family caregivers of people with chronic illness in Colombia by analyzing its psychometric properties. Methods: Psychometric validation study, conducted in 2022 with 109 family caregivers of people with chronic diseases. Convenience sampling was used. Validity was established by exploratory factor analysis and divergent validity was assessed using ZARIT. Results: Exploratory and confirmatory factor analysis validate the unifactorial structure of PCS. Divergent validity was established with a Pearson correlation of -0.247. PCS has internal consistency, Cronbach's alpha = 0.925. The stability of the scale showed significant correlations between items, with a total correlation of 0.585. Conclusion: The validation of the scale in caregivers of people with chronic diseases in Colombia demonstrates validity and reliability for its use in the Colombian context. More studies are needed to measure caregiving preparedness in different caregivers and to develop interventions focused on caregiver preparedness.
Collapse
Affiliation(s)
- Daniel Guerrero-Gaviria
- School of Nursing, Purdue University, West Lafayette, Indiana, USA
- College of Nursing, Universidad Nacional de Colombia - Sede Bogotá, Bogota, Colombia
| | - Camilo Acosta-Pardo
- College of Nursing, Universidad Nacional de Colombia - Sede Bogotá, Bogota, Colombia
| | - Sonia Carreño-Moreno
- College of Nursing, Universidad Nacional de Colombia - Sede Bogotá, Bogota, Colombia
| |
Collapse
|
2
|
Martínez-Tofé J, Santolalla-Arnedo I, Gea-Caballero V, Durante A, Martínez-Sabater A, Sánchez-Barba M, Di Nitto M, Sanchez-Conde P, Gónzalez-Fernández S, Ruíz de Viñaspre-Hernández R, Juárez-Vela R, Soto-Ruiz N. Psychometric Properties of the Spanish Version of the Caregiver Contribution to Self-Care of Diabetes Inventory (CC-SCODI). NURSING REPORTS 2025; 15:129. [PMID: 40333084 PMCID: PMC12029930 DOI: 10.3390/nursrep15040129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2025] [Revised: 04/09/2025] [Accepted: 04/10/2025] [Indexed: 05/09/2025] Open
Abstract
Background: The Caregiver Contribution to Self-Care of Diabetes Inventory (CC-SCODI) is an instrument grounded in the middle-range theory of self-care of chronic illness. It is designed to measure how caregivers support individuals with diabetes mellitus in carrying out self-care activities. Effective tools are essential for clinicians and researchers to evaluate factors influencing self-care, including caregivers' contributions. This study aimed to assess the reliability and validity of the Spanish translation of the CC-SCODI. Methods: A total of 201 caregivers of individuals with Type 1 Diabetes Mellitus (T1DM) and Type 2 Diabetes Mellitus (T2DM) were recruited for participation in this cross-sectional study. Participants were selected through convenience sampling at a university hospital. Before administration, the survey questions were translated and culturally adapted to ensure appropriateness for both patients and caregivers. Confirmatory factor analysis (CFA) was performed on each of the CC-SCODI subscales using models fitted to the relevant indices. Results: The initial construction of the four-dimensional tool was verified. The internal consistency of the four subscales was assessed using Cronbach's α to measure the caregiver contribution to patients' self-care maintenance (α = 0.725), self-care monitoring (α = 0.728), self-care management (α = 0.729), and caregiver self-efficacy in contributing to patient self-care (α = 0.921). Model fit indices demonstrated a chi-square value of 1.028 with 773 degrees of freedom. CFA indicated an excellent model fit, confirming the reliability and validity of the proposed structure. Conclusions: The internal consistency and reliability of the Spanish version of the CC-SCODI were deemed adequate. Due to its strong psychometric properties, this instrument is considered appropriate for evaluating the contribution of caregivers to the self-care behaviors of Spanish-speaking individuals with diabetes.
Collapse
Affiliation(s)
- Jesús Martínez-Tofé
- Doctoral Program in Health Sciences, Public University of Navarra, 31008 Pamplona, Spain;
- GRUPAC Research Group in Care, Faculty of Health Sciences, University of La Rioja, 26004 Logroño, Spain; (I.S.-A.) (R.R.d.V.-H.)
| | - Iván Santolalla-Arnedo
- GRUPAC Research Group in Care, Faculty of Health Sciences, University of La Rioja, 26004 Logroño, Spain; (I.S.-A.) (R.R.d.V.-H.)
| | - Vicente Gea-Caballero
- Faculty of Health Sciences, International University of Valencia, 46002 Valencia, Spain;
| | - Angela Durante
- Health Science Interdisciplinary Center, Sant’Anna School of Advanced Studies, 56127 Pisa, Italy;
- Fondazione Toscana Gabriele Monasterio, 54100 Pisa, Italy
| | - Antonio Martínez-Sabater
- Faculty of Health Sciences, University of Valencia, 46010 Valencia, Spain;
- Nursing Care and Education Research Group (GRIECE), GIUV2019-456, Nursing Department, Universitat de Valencia, 46010 Valencia, Spain
- Care Research Group (INCLIVA), Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain
| | - Mercedes Sánchez-Barba
- Department of Statistics, Faculty of Medicine, University of Salamanca, 37007 Salamanca, Spain
| | - Marco Di Nitto
- Department of Health Sciences, University of Genoa, Via A. Pastore 1, 16132 Genoa, Italy;
| | - Pilar Sanchez-Conde
- University Hospital of Salamanca, 37007 Salamanca, Spain;
- Faculty of Medicine, University of Salamanca, 37007 Salamanca, Spain;
| | | | | | - Raúl Juárez-Vela
- GRUPAC Research Group in Care, Faculty of Health Sciences, University of La Rioja, 26004 Logroño, Spain; (I.S.-A.) (R.R.d.V.-H.)
| | - Nelia Soto-Ruiz
- Department of Health Sciences, Public University of Navarra, 31008 Pamplona, Spain;
- IdiSNA—Navarra Institute for Health Research, 31008 Pamplona, Spain
| |
Collapse
|
3
|
Espadas-Calzado E, Esteban-Burgos AA, Capilla-Díaz C, Puente-Fernández D, Martí-García C, Montoya-Juárez R. Assessment of Competencies and Ability to Care for the General Population: Design and Validation of the Spanish COMCAPCARE Scale. West J Nurs Res 2025; 47:47-54. [PMID: 39588761 DOI: 10.1177/01939459241302568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2024]
Abstract
BACKGROUND As the population ages, the demand for social and health systems grows, especially due to chronic diseases and dependency. Informal caregivers, particularly women, face significant burdens including physical, emotional, and financial strain. Current caregiving assessment tools focus on those already in caregiving roles or health professionals, with no tools for the general population without prior caregiving experience. PURPOSE This study aimed to develop and validate the Spanish COMCAPCARE scale, which assesses the skills and abilities necessary to care for dependent individuals, including those nearing the end of life, among individuals without prior caregiving experience. METHODS A scale validation study was conducted. A Delphi panel of 13 experts developed an 18-item scale, which was administered to 253 participants over the age of 18 who had not previously served as primary caregivers. Main measurements were psychometric analyses, including principal components analysis (PCA) and reliability testing using Cronbach's alpha and intraclass correlation coefficient. Correlation with a single-item self-assessment of caregiving competence was verified through Spearman's rho. RESULTS A total of 253 participants (73.9% women) with a mean age of 33 years (SD 13.7) participated. The scale identified 3 factors: financial and work situation (4 items), adaptability (8 items), and care and communication (6 items). The total scale demonstrated high reliability (α = 0.84) and significant correlations between the scale's total score and a single-item self-assessment of caregiving competence (r = 0.693, P < .001). CONCLUSIONS The Spanish COMCAPCARE scale provides a reliable and valid tool for assessing caregiving competencies in the general population without caregiving experience.
Collapse
Affiliation(s)
| | - Ana Alejandra Esteban-Burgos
- Department of Nursing, Faculty of Health Sciences, University of Jaén, Jaén, Spain
- Instituto de Investigación Biosanitaria (ibs.GRANADA), Granada, Spain
| | - Concepción Capilla-Díaz
- Instituto de Investigación Biosanitaria (ibs.GRANADA), Granada, Spain
- Department of Nursing, Faculty of Health Sciences, University of Granada, Granada, Spain
| | - Daniel Puente-Fernández
- Instituto de Investigación Biosanitaria (ibs.GRANADA), Granada, Spain
- Department of Nursing, Faculty of Health Sciences, University of Granada, Granada, Spain
| | - Celia Martí-García
- Instituto de Investigación Biosanitaria (ibs.GRANADA), Granada, Spain
- Universidad de Málaga, Facultad de Ciencias de la Salud, Málaga, Spain
| | - Rafael Montoya-Juárez
- Instituto de Investigación Biosanitaria (ibs.GRANADA), Granada, Spain
- Department of Nursing, Faculty of Health Sciences, University of Granada, Granada, Spain
| |
Collapse
|
4
|
Gutierrez-Baena B, Gilart E, Romero-Grimaldi C. Factors Associated with and Predictive Model for Resilience in Family Caregivers of Care-Dependent Adults. NURSING REPORTS 2024; 14:3476-3487. [PMID: 39585144 PMCID: PMC11587463 DOI: 10.3390/nursrep14040253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 10/24/2024] [Accepted: 11/08/2024] [Indexed: 11/26/2024] Open
Abstract
Background: Caring for dependent people is an intense task that leads family caregivers to suffer physical or mental pathologies. Resilience is a protective factor that makes an individual more resistant to adverse events. Some characteristics of the caregiver or the care provided predispose the caregiver to be less resilient. Knowing these characteristics will allow us to detect vulnerable caregivers. Aim: The aim of this study was to explore the factors associated with caregiver resilience and establish a predictive model, including the relationship between preparedness, burden, resilience, and anxiety. Materials and Methods: The study design was descriptive, observational, and cross-sectional, with purposive sampling. The sample included 172 family caregivers of care-dependent patients in Spain. Questionnaires were administered to assess caregiver resilience, anxiety, burden, and the preparedness of care-dependent patients. Correlation, univariate, and multiple linear regression analyses were performed to identify the factors associated with resilience. Results: We found that there is a correlation between resilience, preparation, and burden. Factors related to resilience include age, the caregiver's health status, kinship, childcare, and state aid granted. Caregiver preparedness is the factor that most predicts caregiver resilience in our model. Caregivers with high levels of resilience also demonstrated high levels of preparedness and experienced less burden than those with low levels of resilience. Conclusions: These findings emphasize the relevance of improving the preparation of family caregivers to increase their resilience and, at the same time, the quality of care provided.
Collapse
Affiliation(s)
- Belen Gutierrez-Baena
- Nursing Faculty Salus Infirmorum, University of Cadiz, 11001 Cadiz, Spain;
- Hospital “Viamed Bahía de Cadiz”, 11130 Cadiz, Spain
| | - Ester Gilart
- Department of Nursing and Physiotherapy, University of Cadiz, 11009 Cadiz, Spain;
| | - Carmen Romero-Grimaldi
- Nursing Faculty Salus Infirmorum, University of Cadiz, 11001 Cadiz, Spain;
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, 28029 Madrid, Spain
| |
Collapse
|
5
|
Medina V, Watts A, Fracachán-Cabrera M, Hazlewood C, Ramirez-Mantilla M, Vidoni ED, Perales-Puchalt J. Analysis of the intensity of engagement with CuidaTEXT, a text message intervention for dementia caregiver support among Latinos/as. ETHNICITY & HEALTH 2024; 29:924-945. [PMID: 39107055 PMCID: PMC11560709 DOI: 10.1080/13557858.2024.2387111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 07/27/2024] [Indexed: 08/09/2024]
Abstract
OBJECTIVES To examine the associations between participant intensity of engagement with a text message intervention, CuidaTEXT, and socio-demographic factors, acceptability measures, and clinical outcomes among Latino/a caregivers of individuals with dementia. METHODS CuidaTEXT is a six-month, bilingual, and bidirectional intervention. We enrolled 24 Latino/a caregivers in a one-arm feasibility trial. Participants received approximately one automatic daily text message and could engage with the intervention by texting specific keywords (e.g. STRESS to receive messages about stress-coping), and by chat-texting with a live coach. We used metrics and psychometric scales to quantify variables. RESULTS Participants sent a total of 1847 messages to CuidaTEXT. Higher intensity of engagement was associated with higher intervention satisfaction (r = 0.6, p = 0.007), as were several other acceptability outcomes. We found no associations between intensity of engagement with CuidaTEXT and sociodemographic or clinical outcomes (p > 0.05). CONCLUSION Encouraging more intense engagement with CuidaTEXT might lead to higher levels of satisfaction with the intervention. However, it is possible that those who are highly satisfied, engage more intensely with CuidaTEXT. Future research should determine the directionality of these associations to optimize text message interventions. CLINICAL IMPLICATIONS Creating more opportunities to increase the intensity of text message engagement with caregiver support interventions may improve caregiver satisfaction with them.
Collapse
Affiliation(s)
- Valerie Medina
- Department of Psychology, University of Kansas, Lawrence, KS
| | - Amber Watts
- Department of Psychology, University of Kansas, Lawrence, KS
- University of Kansas Alzheimer’s Disease Research Center, Fairway, KS
| | | | | | | | - Eric D. Vidoni
- University of Kansas Alzheimer’s Disease Research Center, Fairway, KS
- University of Kansas Medical Center, Kansas City, KS
| | - Jaime Perales-Puchalt
- University of Kansas Alzheimer’s Disease Research Center, Fairway, KS
- University of Kansas Medical Center, Kansas City, KS
| |
Collapse
|
6
|
Kian A, Sharif-Nia H, Hejazi S. The Farsi version of Caregiver Preparedness Scale in Iranian family caregivers of the older adults undergoing hemodialysis: a psychometric study. BMC Geriatr 2024; 24:512. [PMID: 38867155 PMCID: PMC11170810 DOI: 10.1186/s12877-024-05103-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 05/23/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND Enhancing preparedness of family caregivers and support for caregiving is essential for the mutual benefit of both caregivers and the well-being of those under their care. This study aimed to translate and evaluate psychometric properties of the Caregiver Preparedness Scale among family caregivers of older adults undergoing hemodialysis. METHODS In this methodological study, 400 family caregivers of older adult patients undergoing hemodialysis enrolled to the study via convenience sampling method. The study was conducted in two stages: translation and psychometric evaluation. At first, the translation of the scale was done using Beaton et al. method. In the psychometric evaluation stage, quantitative face validity, content validity, item analysis and construct validity of the scale were evaluated. The internal consistency of the scale was assessed through the calculation of Cronbach's alpha, McDonald's omega, and average inter-item correlation coefficients. RESULTS All items had an impact score greater than 1.5. The content validity ratio and the kappa coefficient for all items were above 0.75. In the item analysis, item 2, which had a correlation with the total score of less than 0.3, was removed. Following exploratory factor analysis, only one factor composed of all items (7 items) was extracted, explaining 75.7% of the total variance. This model had acceptable fit indices in confirmatory factor analysis. Cronbach's alpha and omega of 0.95 and an average inter-item correlation of 0.75 were obtained. CONCLUSIONS The study results demonstrated that the Caregiver Preparedness Scale exhibits appropriate psychometric properties. Geriatric nurses can utilize this Scale for assessment of caregivers. This assessment can aid in decision-making regarding educational programs aimed at enhancing family caregiver preparedness.
Collapse
Affiliation(s)
- Arash Kian
- Student Research Committee, Department of Nursing, Bojnurd School of Nursing, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Hamid Sharif-Nia
- Psychosomatic Research Center, Mazandaran University of Medical Sciences, Sari, Iran
- Department of Nursing, Amol Faculty of Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari, Iran
| | - Sima Hejazi
- Department of Nursing, Bojnurd School of Nursing, North Khorasan University of Medical Sciences, Shahriar Ave, Bojnurd, Iran.
| |
Collapse
|
7
|
Perales-Puchalt J, Ramírez-Mantilla M, Fracachán-Cabrera M, Vidoni ED, Ellerbeck EF, Ramírez AS, Watts A, Williams K, Burns J. A text message intervention to support latino dementia family caregivers (CuidaTEXT): feasibility study. Clin Gerontol 2024; 47:50-65. [PMID: 36268684 PMCID: PMC10119327 DOI: 10.1080/07317115.2022.2137449] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To test the feasibility, acceptability, and preliminary efficacy of CuidaTEXT: a bidirectional text message intervention to support Latino dementia family caregivers. METHODS CuidaTEXT is a six-month, bilingual intervention tailored to caregiver needs (e.g., education, problem-solving, resources). We used convenience sampling and reached 31 potential participants via clinics, registries, community promotion, and online advertising. We enrolled 24 Latino caregivers in a one-arm trial and assessed feasibility, acceptability, and preliminary efficacy within six months. RESULTS None of the participants unsubscribed from CuidaTEXT and 83.3% completed the follow up survey. Most participants (85.7%) reported reading most text messages thoroughly. All participants reported being very or extremely satisfied with the intervention. Participants reported that CuidaTEXT helped a lot (vs not at all, a little, or somehow) in caring for their care recipient (71.4%; n = 15), for themselves (66.7%; n = 14), and understanding more about dementia (85.7%; n = 18). Compared to baseline, at six months caregiver behavioral symptom distress (0-60) decreased from 19.8 to 12.0 and depression (0-30) from 8.8 to 5.4 (p < .05). CONCLUSIONS CuidaTEXT demonstrated high levels of feasibility, acceptability, and preliminary efficacy among Latino caregivers. CLINICAL IMPLICATIONS CuidaTEXT's feasibility and potential for widespread implementation holds promise in supporting Latino caregivers of people with dementia.
Collapse
Affiliation(s)
- Jaime Perales-Puchalt
- Department of Neurology, University of Kansas Alzheimer's Disease Research Center, Fairway, Kansas, USA
- Department of Population Health, University of Kansas Medical Center, Kansas, Kansas, USA
| | | | | | - Eric D Vidoni
- Department of Neurology, University of Kansas Alzheimer's Disease Research Center, Fairway, Kansas, USA
- Department of Population Health, University of Kansas Medical Center, Kansas, Kansas, USA
| | - Edward F Ellerbeck
- Department of Population Health, University of Kansas Medical Center, Kansas, Kansas, USA
| | - A Susana Ramírez
- Department of Public Health, University of California, Merced, California, USA
| | - Amber Watts
- Department of Neurology, University of Kansas Alzheimer's Disease Research Center, Fairway, Kansas, USA
- Department of Psychology, University of Kansas, Lawrence, Kansas, USA
| | - Kristine Williams
- Department of Neurology, University of Kansas Alzheimer's Disease Research Center, Fairway, Kansas, USA
- School of Nursing, University of Kansas Medical Center, Kansas, Kansas, USA
| | - Jeffrey Burns
- Department of Neurology, University of Kansas Alzheimer's Disease Research Center, Fairway, Kansas, USA
- Department of Population Health, University of Kansas Medical Center, Kansas, Kansas, USA
| |
Collapse
|
8
|
Gutierrez-Baena B, Romero-Grimaldi C. Predictive model for the preparedness level of the family caregiver. Int J Nurs Pract 2022; 28:e13057. [PMID: 35388583 PMCID: PMC9285821 DOI: 10.1111/ijn.13057] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 03/14/2022] [Accepted: 03/24/2022] [Indexed: 11/26/2022]
Abstract
Background Many caregivers are insufficiently prepared, and little is known about measures that can be employed to enhance their preparedness. Aim The aim of this study was to explore the factors associated with caregiver preparedness and establish a predictive model including the relationship between preparedness, burden, resilience and anxiety. Design A cross‐sectional design was used. Methods The sample included 172 family caregivers who were selected from one private hospital and daytime nursing centres. Caregivers were recruited from 2018 to 2019; they completed assessments for caregiver preparedness, anxiety, resilience and burden. A multiple linear regression analysis was performed to identify the factors associated with preparedness. Results Preparedness was significantly associated with high levels of resilience and a low level of burden, while it was not associated with anxiety. Caregivers' gender, experience and cohabitation status were the main predictors. Resilience is an explanatory factor for caregiver preparedness in the predictive model. Conclusion The demographic variables related to preparedness can be used to guide efforts to meet the needs of vulnerable caregivers. A caregiver's preparedness depends on their level of burden and resilience. Nursing interventions focused on these aspects could make the caregiver's role easier and improve the quality of care provided. What is already known about this topic?
Many caregivers are inadequately prepared for this role, and ensuring adequate preparedness is important for family caregivers. Preparedness and factors predictive of this in Spanish family caregivers have not been well‐documented. Resilience, burden and anxiety affect caregivers, but the degree to which they influence caregivers' preparation levels is unknown.
What is the contribution of this paper?
Specific factors influence the preparedness of family caregivers. Men and caregivers who do not cohabit in the same household with the care‐dependent person may present greater deficits in preparedness. Moreover, poor health and lack of experience in caring can result in inadequate caregiving performance. Readiness, resilience and burden are significantly related, and the best predictor of family caregivers' preparedness is resilience. Resilience leads to greater preparedness in caregivers, and better‐prepared caregivers experience a lighter burden.
What are the implications of this paper?
Knowing the factors associated with preparedness in advance will allow health‐care professionals to prevent deficits in vulnerable family caregivers. Resilience is a decisive factor which prevents negative consequences such as low preparedness. A resilient coping style can diminish the burden and promote successful adaptation in caregivers.
Collapse
Affiliation(s)
- Belen Gutierrez-Baena
- Nursing Faculty Salus Infirmorum, University of Cadiz, Cadiz, Spain.,Hospital Viamed Bahia de Cádiz, Chiclana de la Frontera, Cadiz, Spain
| | - Carmen Romero-Grimaldi
- Nursing Faculty Salus Infirmorum, University of Cadiz, Cadiz, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain
| |
Collapse
|